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Screen Shot of New Medical Video Center

The MUSC Health Medical Video Center is now available online at MUSCHealth.org/medical-video. It profiles cutting-edge surgical procedures and innovative treatments available at MUSC Health and is intended for a health care audience. Its initial areas of focus are cardiology, oncology, neuroscience, and pediatrics. The site contains educational (and explicit) surgical video and photography.

 

Summary: Investigators at the Medical University of South Carolina report impressive 90-day outcomes in patients with large-vessel ischemic stroke who underwent thrombectomy using a direct-aspiration, first pass technique.

In an article published online April 16, 2016 by the Journal of Neurointerventional Surgery (doi: 10.1136/neurintsurg-2015-012211), investigators at the Medical University of South Carolina (MUSC) report promising 90-day outcomes for stroke patients with large-vessel clots who underwent thrombectomy or clot removal using the direct-aspiration, first pass technique (ADAPT).  Approximately 58% of stroke patients with a large-vessel clot removed using the technique achieved a good outcome at 90 days, defined as a Modified Rankin Score (mRS) of 0 to 2.

ADAPT aims to remove the clot in its entirety with a large-diameter aspiration catheter in a single pass. In contrast, stent retrievers, currently considered standard of care, frequently fragment the clot for removal and can require several passes.

ADAPT was developed by MUSC Health neuroendovascular surgeons M. Imran Chaudry, M.D., Alejandro M. Spiotta, M.D., Aquilla S. Turk, D.O., and Raymond D. Turner, M.D., all co-authors on the April 2016 Journal of Neurointerventional Surgery article. MUSC Health neurosurgery resident Jan Vargas, M.D., is first author on the article.

“The goal in ADAPT is to take the largest-bore catheter available up to the blood clot and put suction where it’s blocked and pull it out of the head to reestablish flow in that blood vessel,” said Turk. If the first-pass attempt is unsuccessful, stent retrievers can still be used to remove the clot.

In the article, the investigators report the results of a retrospective study of 191 consecutive patients with acute ischemic stroke who underwent ADAPT at MUSC Health. In 94.2% of patients, blood vessels were successfully opened—by direct aspiration alone in 145 cases and by the additional use of stent retrievers in another 43 cases. Good outcomes at 90 days (mRS, 0-2) were achieved in 57.7% of patients who were successfully revascularized with aspiration alone and in 43.2% of those who also required a stent retriever. The average time required to reopen the blocked blood vessels was 37.3 minutes—29.6?minutes for direct aspiration alone and 61.4 minutes for cases that also required stent retrievers. Patients presented for thrombectomy on average 7.8 hours after stroke onset.

These results confirm the promise of ADAPT, which was first described by the MUSC Health team in a seminal 2014 article in the Journal of Neurointerventional Surgery. Since the publication of that article, a number of single-center series studies have reported impressive recanalization times (the time it takes to open the blood vessel) and good neurological outcomes with ADAPT using a large-bore catheter, suggesting that it could offer an alternative approach to stent retrievers for mechanical thrombectomy.

Stent retrievers have been considered standard of care for stroke patients since the publication in the October 2015 issue of Stroke of a scientific statement on thrombectomy by the American Heart Association. That statement recommended rapid clot removal in addition to tissue plasminogen activator (tPA), a clot-busting drug that can minimize stroke complications if administered in a tight time window. The recommendation was based on the promising findings of five large clinical trials comparing treatment with tPA alone versus treatment with tPA plus thrombectomy using stent retrievers in large-vessel clots: MR CLEAN, EXTEND-IA,  ESCAPE, SWIFT PRIME, and REVASCAT.

A definitive answer as to whether ADAPT could likewise become standard of care for stroke patients with large-vessel clots will require clinical trials comparing the efficacy of the direct aspiration technique versus stent retrievers in this population of stroke patients.

The MUSC Health neuroendovascular surgery team is currently running the COMPASS trial (COMParison of ASpiration vs Stent retriever as first-line approach; Clinicaltrials.gov identifier NCT02466893) in conjunction with colleagues Dr. J. Mocco of Mount Sinai and Dr. Adnan Siddiqui of the University of Buffalo. The trial is randomizing patients to either ADAPT or a stent retriever as the initial thrombectomy technique. The trial, scheduled to enroll 270 patients, has enrolled 90 patients in the past year at ten sites in the United States.

Image Caption: Left: Frontal view of the skull showing occlusion of the right internal carotid artery (ICA) beginning at the level of the vertical petrous potion (arrow). Right: Frontal view of the skull after thrombectomy shows the revascularization of the ICA and the distal arteries supplying the right side of the brain.

Dr. Vincent Pellegrini, Chair of the Department of Orthpaedics, leading a revision hip replacementFigure 1 Logo

Join Dr. Vincent Pellegrini, Chair of the Department of Orthopedics at MUSC Health, on April 26 at 8 pm as he leads a virtual grand rounds on revision hip replacement on the free case-sharing app Figure 1 (http://figure1.com, app available on iOS and Android). Annotated surgical photos highlighting key moments in this complex surgery will drop one by one, with Dr. Pellegrini available live online to answer questions and respond to comments. Follow @MUSChealth on the app to participate in this event and see photographs from other complex and innovative surgeries at MUSC Health.

Placement of a single, coated, self-expanding metallic stent achieved similar rates of resolution of benign pancreatobiliary strictures as placement of multiple plastic stents, the current standard of care, and required fewer sessions of endoscopic retrograde cholang­iopancreatography, according to the results of a randomized controlled trial led by an endoscopist at the Medical University of South Carolina and reported in the March 22 JAMA.

Pictured above: MUSC Health endoscopist Gregory A Coté, M.D., performing ERCP

Placement of a single covered, self-expanding metallic stent (cSEMS) via endoscopic retrograde cholang­iopancreatography (ERCP) resolved benign obstructions of the pancreatic and biliary ducts as well as placement of multiple plastic stents, the current standard of care, and required fewer ERCP sessions, according to the results of a randomized controlled trial reported in the March 22, 2016 issue of the Journal of the American Medical Association. These findings will change practice in the opinion of Gregory A. Coté, M.D., an endoscopist at the Digestive Disease Center at the Medical University of South Carolina, lead author of the article, and the national principal investigator for the eight-center study. B. Joseph Elmunzer, M.D., of the MUSC Digestive Disease Center is also a co-author.

“For appropriately selected patients who are presenting the first time with a blockage, many endoscopists will change their strategy and use these newer stents, in an effort to reduce the total procedures that are required,” says Coté.

For now, the use of cSEMS (pictured below right) in benign biliary strictures would be off-label, as they have been approved by the U.S. Food and Drug Administration only for the treatment of malignant pancreatobiliary strictures, such as those which develop in the setting of unresectable pancreatic cancer.

Left untreated, benign biliary strictures can lead to jaundice, cholangitis (i.e., infection of the bile duct), and secondary biliary cirrhosis. Benign strictures most often occur after liver transplantation and gallbladder surgery or as a result of chronic pancreatitis. ERCP is preferred to surgery in these patients because it is less invasive.

ERCP is an endoscopic procedure in which a camera is introduced through the mouth and advanced first to the proximal duodenum and then, using endoscopy and fluoroscopy, into the pancreatic and bile ducts.  Although highly effective, three to four ERCP sessions are typically required to fully stretch the blockage and minimize the chance of recurrence once the stents are removed.  Because ERCP is not without its risks—complications include pancreatitis, infections, bowel perforation, and bleeding—minimizing the number of sessions needed to successfully treat the stricture benefits patients. Coté designed the trial to determine whether using the larger cSEMS could successfully treat benign strictures with fewer ERCP sessions. cSEMS are coated to prevent in-growth of tumor or other tissue and to facilitate removal.

The primary endpoint of the trial, which enrolled 112 patients, was the rate of benign stricture resolution after no more than 12 months of stenting. cSEMS were found to be noninferior to plastic stents for achieving stricture resolution and they did so more quickly (181 vs. 225 days) and with fewer ERCP sessions (2.14 vs. 3.24). It should be noted that the study had careful enrollment criteria; patients with small (<6 mm) bile ducts and those with intact gall bladders were excluded. “We were careful not to cross the gall bladder insertion into the bile duct in patients who still have their gall bladder because you don’t want to block the gall bladder and potentially create a new problem,” says Coté.

The procedure can be performed by anyone proficient in ERCP but best results will likely be seen when it is performed by a high-volume provider (2-3 ERCPs per week) who is comfortable placing and removing cSEMS.

“We can’t universally change practice based on these findings, but, in appropriately selected patients with benign pancreatobiliary strictures, deployment of cSEMS via ERCP should be first-line treatment,” says Coté.

Figure 1 Live Event wth Dr. Satish Nadig January 27 at 8 pm

MUSC Health transplant surgeon Satish N. Nadig, M.D., Ph.D., will lead a virtual ground rounds on kidney transplant on January 27 at 8pm EST on Figure 1 (https://figure1.com/), a case-sharing app for healthcare professionals. Download the free app on iOS or Android to follow along in real time.

During the live event, 10-12 preloaded  photos of a recent kidney transplant surgery at MUSC Health will drop one at a time, and Dr. Nadig will be available virtually to answer questions from those in attendance. The transcript of the event will then  be posted to the app.

To learn more about Figure 1, see http://abcnews.go.com/Health/figure-app-instagram-doctors/story?id=30160402.

Watchman deviceMUSC Health is the first hospital in South Carolina to offer a left atrial appendage (LAA) closure device that reduces stroke risk for high-risk patients with non-valvular atrial fibrillation. The WATCHMAN™, (Boston Scientific Corporation, Marlborough, MA) approved by the U.S. Food and Drug Administration in March 2015, is intended for percutaneous transcatheter closure of the LAA. Six of these devices have been implanted at MUSC Health by Frank A. Cuoco, M.D., MBA, Director of the Cardiac Electrophysiology Lab. “In atrial fibrillation, most blood clots that are responsible for stroke form in the LAA,” he says. “Implanting this device has been shown to be equivalent to warfarin for overall stroke prevention and superior to warfarin for reduction of bleeding and overall cardiovascular mortality.” Six weeks after implantation, patients are able to stop warfarin. They remain on clopidogrel and aspirin for 6 months while the device completely seals, and then require only aspirin going forward. This therapy offers a proven alternative to patients who cannot or do not want to use warfarin to reduce their risk of stroke.

leddy and surgery team preparing prosthesisIn May 2015, an 8-year-old boy from Columbia, SC became the second child in the state to receive an extendible implant that replaced the leg bone that osteosarcoma had destroyed.  Orthopaedic oncologist Lee Leddy, M.D., Associate Professor in the Department of Orthopaedics at MUSC Health, performed the surgery, removing the cancerous bone (and its growth plate) and replacing it with a device designed to be lengthened over time to ensure that both legs will be of equal length. During follow-up visits every four to six weeks, the boy will place his leg into a doughnut-shaped magnet that will drive a gearbox to extend the prosthesis nine centimeters, the remainder of the boy’s projected growth.

Prior to this technology, options for a child whose growth plate had to be removed due to cancer were amputation; rotationplasty, in which the child’s ankle is substituted for the knee joint; or implants that required repeated surgeries to lengthen the prosthesis.  With this device, future operations are not necessary. More than 100 procedures have been completed in the U.S. with this device, but only two in South Carolina, both by Leddy at MUSC Health.

Leddy says this prosthesis is a dramatic improvement over the ways doctors previously met the challenges of limb salvage surgery in the skeletally immature patient. “Being able to reliably lengthen the extremity without surgery is a major advantage,” he says. “However, it is important to realize how critical the team approach is when treating these complex problems.”

The team of specialists who collaborated on these complex cases included musculoskeletal radiologists who interpreted radiographs and magnetic resonance imaging reports,  pathologists who evaluated biopsy tissues, sarcoma-trained surgical oncologists who helped resect the cancer and reconstruct the extremity, operating room nurses, oncologists who made recommendations regarding chemotherapy, and physical therapists who worked with the patients to help return them  to their active lives.

Leddy says that assuming a good response to chemotherapy and physical therapy, these patients can expect a full recovery. 

Photo provided by Sarah A. Pack

Scientists and engineers at the Institute for Applied Neurosciences at MUSC Health have developed a device that detects mild traumatic brain injury, also known as concussion.  Previously, there was no objective way to identify concussion, leaving clinicians and athletic trainers with only subjective measures of altered behavior or cognitive function.  The Blink Reflexometer uses stimuli to trigger a blink and a high-speed camera to collect data on the body’s response to these stimuli.  When a blow to the head occurs on the athletic field or battlefield, for example, trained personnel can use this device to stimulate and record a blink, then compare the person’s data to his or her baseline measurement (recorded previously in the Blink Reflexometer). The technology is now being refined into a hand-held device and the research team is collecting baseline measurements on football players from The Citadel and Charleston Southern University. Clinical trials will continue through Fall 2015. This device is expected to be commercially available by approximately 2017. 

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