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Epistaxis is not uncommon, with up to 60% of the population suffering from at least one episode in their lifetime and as many as 6% presenting for medical attention. An analysis of emergency room (ER) visits in the United States between 2009 and 2011 identified 1.2 million encounters for epistaxis, accounting for 0.32% of ER visits. Approximately 6% of patients will require more aggressive, invasive management in the form of transnasal ligation of the sphenopalatine artery or endovascular embolization. This article reviews the epidemiology, rationale for endovascular treatment, strategy for treatment, endovascular technique, postprocedural follow-up, and complications and their management.

J INTRODUCTION Tube feeding has been practiced for more than 400 years (1). In addition to feeding, gastrointestinal (GI) access can be used for decompression in cases of enteral obstruction. Temporary access can be achieved with a nasogastric (NG), oral gastric (OG), nasojejunal (NJ), or oral jejunal (OJ) feeding tube. These tubes can be placed “blindly” at the bedside, with the use of image guidance (eg, fluoroscopy, ultrasound), or with the use of endoscopic guidance. Unfortunately, natural orifice tubes often fail because of clogging as a result of their relatively small diameter or inadvertent dislodgement (2). More permanent enteral access can be obtained

To compare the clinical and angiographic outcomes of endovascular treatment of symptomatic intracranial stenosis between octogenarian and younger patients.Data for 244 consecutive patients (173 men; mean age 61.6 years) who underwent angioplasty and/or stenting for intracranial atherosclerotic disease at 5 specialized centers were pooled. Baseline, 30-day, and follow-up clinical and angiographic information were collected. Rates of clinical and angiographic endpoints were compared between patientsor=80 years old versus those80 years.Patientsor=80 years (n = 15) were more likely to be hypertensive (87% versus 69%) and have underlying coronary artery disease (73% versus 36%, p0.05) compared to younger patients (n = 229). The rate of periprocedural stroke and/or death was 3-fold higher among patients agedor=80 years compared with those80 years (20% versus 7%, p = 0.11). No recurrent stroke or death (excluding periprocedural events) was observed during follow-up in the octogenarian group. In patients who had follow-up angiography, a similar rate ofor=50% restenosis was observed among patients agedor=80 years and those aged80 years (25% versus 29%, p0.1).The 3-fold higher periprocedural death and/or stroke rate suggests cautious use of intracranial angioplasty and/or stent placement in octogenarians.

Background and Purpose— We sought to compare the clinical outcomes between primary angioplasty and stent placement for symptomatic intracranial atherosclerosis. Methods— We retrospectively analyzed the clinical and angiographic data of 190 patients treated with 95 primary angioplasty procedures and 98 intracranial stent placements (total of 193 procedures) in 3 tertiary care centers. Stroke and combined stroke and/or death were identified as primary clinical end points during the periprocedural and follow-up period of 5 years. The rates of significant postoperative residual stenosis (≥50% of greater stenosis immediately after the procedure) and binary restenosis (≥50% stenosis at follow-up angiography within 3 years) were also compared. The comparative analysis was performed after adjusting for age, sex, and center. Results— Fourteen procedures in the angioplasty-treated group (15%) and 4 in the stent-treated group (4.1%) had significant postoperative residual stenosis (relative risk [RR]=2.8, 95% CI, 0.85 to 9.5, P =0.09, for the adjusted model). There were 3 periprocedural deaths (1.5%), 1 in the angioplasty group (1.1%) and 2 in the stent-treated group (2.0%) and 14 periprocedural strokes (7.3%), 7 periprocedural strokes in each group (7.4% and 7.1%, respectively; hazard ratio=1.1; 95% CI, 0.57 to 1.9, P =0.85). Angiographic follow-up was available for 134 procedures (66 angioplasty-treated and 68 stent-treated cases). Forty-eight procedures (36.1%) had evidence of binary restenosis (25 of 66 angioplasties, 23 of 68 stents, P =0.85). Binary restenosis-free survival at 12 months was 68% for the angioplasty-treated group and 64% for the stent-treated group. There was no difference in follow-up survival (stroke, or stroke and/or death) between the angioplasty-treated and the stent-treated groups (hazard ratio=0.54; 95% CI, 0.11 to 2.5, P =0.44 and hazard ratio=0.50; 95%, CI 0.17 to 1.5, P =0.22, respectively, after adjusting for age, sex, and center). The stroke- and/or death-free survival at 2 years for the angioplasty-treated group and the stent-treated group was 92±4% and 89±5%, respectively. Conclusions— Stent treatment for intracranial atherosclerosis may lower the rate of significant postoperative residual stenosis compared with primary angioplasty alone. No benefit of stent placement over primary angioplasty in reducing stroke or stroke and/or death could be identified in this study.

STROKE is the third leading cause of death and the leading cause of adult disability in North America, Europe, and Asia (1,2). Intracranial cerebral atherosclerosis accounts for approximately 8 to 10% of all ischemic strokes with a higher reported incidence in the Asian, African, and Hispanic descent populations (3–5). Risk factors include insulin-dependent diabetes mellitus, hypercholesterolemia, hypertension, and cigarette smoking (6–8). In the United States, it is estimated that 40,000 to 60,000 new strokes per year are due to intracranial cerebral atherosclerosis.

John D. Barr, MD, John J. Connors, III, MD, David Sacks, MD, Joan C. Wojak, MD, Gary J. Becker, MD, John F. Cardella, MD, Bohdan Chopko, MD, PhD, Jacques E. Dion, MD, Allan J. Fox, MD, Randall T. Higashida, MD, Robert W. Hurst, MD, Curtis A. Lewis, MD, MBA, Terence A.S. Matalon, MD, Gary M. Nesbit, MD, J. Arliss Pollock, MD, Eric J. Russell, MD, David J. Seidenwurm, MD, and Robert C. Wallace, MD, for the ASITN, ASNR, and SIR Standards of Practice Committees

Intracranial embolization and resultant ischemic stroke are the primary risks of carotid angioplasty and stenting. Emboli are generated in all cases of angioplasty and stenting; most of these are of little or no clinical significance. There are several other technique-related sources of emboli, most of which are preventable. There are several angiographic and clinical signs of intracranial embolus. Astub of vessel or filling defect is not reliably seen. It is important to assess the extent of these collaterals and the status of the lenticulostriate arteries arising from the proximal middle cerebral artery; they determine the time available for rescue. The first clinical indication of a problem is often a change in the patient's mental status. Focal neurological deficits will not be recognized unless serial neurological examinations are performed. Once it has been determined that an event has occurred, general supportive and monitoring measures should be undertaken. It is important to exclude recent silent infarct, as fibrinolysis is contraindicated in that setting. After this has been excluded, systemic heparinization and definitive therapy (local intracranial intra-arterial thrombolysis and/or mechanical disruption or thrombus) can be undertaken.

A meta-analysis was performed to assess randomized controlled trials comparing local endovascular therapy (with and without intravenous thrombolysis) versus standard care (intravenous thrombolysis alone when appropriate) for acute ischemic stroke. Local endovascular therapy showed a significant improvement in functional independence versus standard care (odds ratio, 1.779; 95% confidence interval, 1.262-2.507; P.001). This benefit strengthened further on subgroup analyses of trials in which a majority of cases used stent retrievers, trials with intravenous thrombolysis use in both arms when appropriate, and trials that required preprocedural imaging of all patients. There were no significant differences between arms in terms of mortality, hemicraniectomy, intracranial hemorrhage, and cerebral edema rates (P.05). In conclusion, in the treatment of acute ischemic stroke, local endovascular therapy leads to improved functional independence compared with standard care.

Objective Stent-assisted coiling of intracranial aneurysms is performed by placing a microcatheter through a stent's interstices or jailing the microcatheter between the stent and the artery. Both approaches impede manipulation of the microcatheter during coiling. We describe a modified jailing technique that improves catheter maneuverability and report the safety and efficacy of the method for the treatment of complex, wide-necked aneurysms. Methods The semi-jailing technique involves the partial deployment of a retrievable stent, bridging part of the aneurysm neck while leaving space to maneuver the microcatheter. Twenty-two complex, wide-necked aneurysms, including 3 ruptured and 5 dissecting, were treated using the semi-jailing technique (15 women; mean age, 55.2 years). Results The semi-jailing technique was successfully applied in all cases. Immediate posttreatment angiograms showed total occlusion of the aneurysm in 17 cases (77%), neck remnant in 3 cases (14%), and aneurysm dome filling in 2 cases (9%). Follow-up angiography available in 10 patients at an average of 8.5 months showed progressive occlusion in 1 aneurysm and 7 remained occluded. In 2 cases of dissecting aneurysms, retreatment was required. No permanent periprocedural morbidity was encountered. One patient died of complications secondary to intracranial hemorrhage 6 days after treatment. In 2 cases (9%), thromboembolic events after final stent placement were successfully treated with intraarterial thrombolysis. No delayed stent migration was seen. Conclusion Semi-jailing is a safe and effective stent-assisted coiling technique that facilitates treatment of complex, wide-necked aneurysms.

Appropriate and adequate cognitive and technical training, proficiency and experience are essential for the safe performance of procedures that confer significant risk to patient well-being. This principle is the foundation of all medical education and is especially important when considering the cerebral vasculature, for which stroke is a defined risk for every endovascular procedure. Despite recent advances in noninvasive diagnostic neuroimaging, diagnostic cervicocerebral angiography remains the cornerstone and “gold standard” for the evaluation and treatment of patients with cerebrovascular disease.1 In addition to a high level of technical expertise, performance and interpretation of diagnostic cervicocerebral angiography requires in-depth cognitive knowledge of related neurological pathophysiology, neurovascular anatomy and pathology, and an understanding of the full range of neurodiagnostic possibilities. Expert diagnostic cervicocerebral angiography is the foundation for safe and successful cervicocerebral endovascular intervention, including carotid artery angioplasty and stenting for atherosclerosis, interventional stroke therapy, intracranial angioplasty and stenting, and embolization of cerebral aneurysms, epistaxis and vascular malformations. All of these procedures are increasing in volume and complexity with recent technological advances that further mandate the need for adequate cognitive acumen and technical skills. To ensure proper outcomes, formal neuroscience training, adequate procedural training and sufficient experience are all essential for competency in diagnostic cervicocerebral angiography and interventional procedures, including carotid stenting. These concepts have been delineated in training requirements by the Accreditation Council for Graduate Medical Education (ACGME) and by previously published official society statements. The purpose of this document is to define the minimum training and experience necessary to provide adequate quality of patient care for extracranial cerebrovascular interventions, particularly carotid artery stenting. Hospital credentialing is the mechanism by which competence is ensured. ### Risks of diagnostic cervicocerebral angiography. Stroke is recognized as the most disabling and costly of all medical conditions.2 Stroke is also the most feared of all iatrogenic medical and procedural …

Background and Purpose— Medical treatment of symptomatic intracranial stenosis carries a high risk of stroke. This study was done to evaluate the clinical and angiographic outcomes after intracranial angioplasty for this disease. Methods— A total of 120 patients with 124 intracranial stenoses were treated by primary angioplasty. All patients had neurologic symptoms (stroke or transient ischemic attack) attributable to intracranial stenoses ≥50%. Angiograms were evaluated before and after angioplasty for the degree of stenosis. Results— Pretreatment stenoses varied from 50% to 95% (mean 82.2±10.2). Post-treatment stenoses varied from 0% to 90% (mean 36.0±20.1). There were 3 strokes and 4 deaths (all neurological) within 30 days of the procedure, giving a combined periprocedural stroke and death rate of 5.8%. A total of 116 patients (96.7%) were available for a mean follow-up time of 42.3 months. There were 6 patients who had a stroke in the territory of treatment and 5 additional patients with stroke in other territories. Ten deaths occurred during the follow-up period, none of which were neurological. Including the periprocedural stroke and deaths, this yielded an annual stroke rate of 3.2% in the territory of treatment and a 4.4% annual rate for all strokes. Conclusion— Intracranial angioplasty can be performed with a high degree of technical success and a low risk of complications. Long-term clinical follow-up of intracranial angioplasty patients demonstrates a risk of future strokes that compares favorably to patients receiving medical therapy.

Developed by a Collaborative Panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology

Object. A retrospective analysis of a 9-year experience with balloon angioplasty for intracranial atherosclerotic stenosis was undertaken with the goals of illustrating development of a safe technique for treatment of intracranial atherosclerotic disease and reporting the immediate results in this series of patients.Methods. Three distinct periods are defined, based on the technique used. In the early period, in which eight patients were treated, the angioplasty balloon size approximated the vessel size, but was always smaller. Angioplasty was moderately rapid and brief (15–30 seconds). Clinical improvement occurred in seven (87.5%) of eight patients, dissection without consequence occurred in four (50%) of eight, and residual stenosis greater than 50% was found in three (37.5%) of eight. No neurological complications occurred.In the middle period, in which 12 patients were treated, the balloon size approximated the vessel size, but oversizing by up to 0.25 mm was permitted. Angioplasty was extremely rapid and brief. Angiographically visible dissection occurred in nine (75%) of 12 patients, necessitating urokinase infusion in five (41.7%) of 12 and producing abrupt occlusion in one (8.3%) of 12, resulting in death. Occlusion secondary to the recrossing of the lesion occurred in one (8.3%) of 12, resulting in stroke. Good outcome was eventually achieved in 10 (83.3%) of 12.In the current period, in which 50 patients have been treated, the balloon is always undersized and inflation is extremely slow (several minutes). Dissection occurred in seven (14%) of 50 patients, necessitating fibrinolysis in two of 50 (4%, both uneventful) and producing no abrupt occlusion or stroke. Residual stenosis greater than 50% occurred in eight (16%) of 50, with no stenosis greater than 70%. Late restenosis occurred in four (9%) of 44 and successful repeated angioplasty was performed in all four. One guidewire vessel perforation occurred (2%), resulting in the patient's death. Good angiographic and short-term clinical outcome was achieved in the other 49 patients (98%).Conclusions. Extremely slow balloon inflation combined with balloon undersizing results in decreased intimal damage, decreased acute platelet/thrombus deposition, and decreased acute closure. This technique sometimes yields suboptimal angiographic results but achieves the clinical goal safely. Intracranial angioplasty can be safely performed using this technique and modern equipment.

2. Treatment modalities for ESRD patients. United States Renal Data System. Am J Kidney Dis 1998;32(suppl): 550-559. Summary In most patients, catheters are a bridge to a more permanent form of replaced renal function. A large bore, high flow, cuffed, tunneled catheter is strongly preferred. Current data does not favor anyone tunneled or non-tunneled catheter over another. The role of dialysis ports in the clinical mix is stilI in evaluation. The right internal jugular vein is strongly preferred for vein access. Fluoroscopy and ultrasound are valuable aids for device placement.