Jaw Pain and Heart Attack: Understanding the Connection and Symptoms
Type B Aortic Dissection Presenting As Sudden-Onset, Sharp Back Pain
CASE PRESENTATIONA woman in her mid 70s with a past medical history of hypertension and hyperlipidemia presented to the emergency department (ED) with acute-onset, sharp upper back pain she described as "tearing." She also endorsed intermittent numbness of her bilateral lower extremities and mild abdominal pain. The pain was characterized as severe and radiated to her right chest and had been constant since it began 1 hour prior. The patient had no history of back pain or any recent injuries or falls. Her vital signs were significant for normal sinus rhythm of 70 bpm and a blood pressure (BP) of 195/102 mm Hg. She was combative and appeared in acute distress, asking for pain medications.
1. Highlight PointPatients with type B aortic dissection (TBAD) most commonly present with abrupt-onset, sharp, severe pain located in either the chest, back (classically midscapular), or abdomen. The pain is often characterized as a ripping or tearing pain. Up to 20% of TBAD patients describe migrating pain with propagation of the dissection throughout the aorta. Other hallmarks of the presentation include long-standing hypertension and hyperlipidemia. Obtaining a thorough medical, surgical, social, and family history is essential. Previous cardiac or vascular interventions may influence the treatment strategy. A social history of illicit drug use is not uncommon. Family history must be screened for any connective tissue disorders or history of aortic dissection or aneurysm. Although connective tissue disorders are not immediately high on the differential, aortic disease often has some genetic component.
Most urgent cares facilities or EDs start with a chest x-ray, which may demonstrate a widened mediastinum or enlarged cardiac silhouette, but this is nonspecific. The first-line modalities to diagnose an aortic dissection are CT and MRI. MRI is more expensive, less time efficient, and often less available, so CTA is generally the gold standard. Echocardiography, particularly transesophageal echocardiography, can also be used, although this is invasive, less detailed, not available in some centers, and is not the first-line test. However, an echocardiogram should be obtained before any operative intervention. Once the diagnosis of TBAD has been confirmed, lab tests should be comprehensive and help determine if there is any evidence of end-organ malperfusion. Lab testing should include a complete blood count, coagulation studies, comprehensive metabolic panel, lactate, and arterial blood gas. Other testing that should be performed includes electrocardiogram, as myocardial infarction can be seen in up to 10% of TBAD patients.1
CASE CONTINUEDA CTA of the chest, abdomen, and pelvis was obtained, which demonstrated a TBAD beginning just distal to the origin of the left subclavian artery (LSA)and involving 60% of the lower thoracic and upper abdominal aorta, ending just proximal to the aortoiliac bifurcation (Figure 1). The mesenteric and renal arteries were supplied by the true lumen with no radiographic evidence of malperfusion. Laboratory testing was normal. Upper extremity, femoral, and pedal pulses were 2+ and equal bilaterally.
Figure 1. CTA demonstrating a TBAD in the descending thoracic aorta with a classic double barrel. The true lumen is the smaller lumen (A). Three-dimensional reconstruction demonstrating the extent of the TBAD from the distal arch down to the abdominal aorta (B).
β-blockers are the first-line drug of choice for TBAD. They have a negative inotropic and chronotropic effect. This results in a prolonged diastolic filling time and increased left ventricular end-diastolic volume, which lowers BP and heart rate.
2. Highlight PointMedical therapy is the first-line intervention for patients with TBAD. The main goal is impulse control—specifically, BP control with systolic BP between 100 and 120 mm Hg and heart rate control, ideally < 60 bpm. This reduces aortic wall shear stress to minimize dissection propagation. After β-blockade, peripheral vasodilators such as nitroprusside or calcium channel blockers are given if needed. For patients without malperfusion who can be managed medically, the optimal treatment and monitoring involves intensive care unit (ICU) admission, hourly neurovascular checks, and intravenous drips to manage BP until impulse control can be achieved with oral medications.
CASE CONTINUEDThe patient was started on esmolol and nicardipine infusions and admitted to the ICU for monitoring. A radial arterial line was placed for hemodynamic monitoring. Pain was controlled with an oral pain regimen. Over 2 days, the esmolol and nicardipine infusions were able to be weaned off as an oral regimen of carvedilol, amlodipine, and captopril was added with appropriate impulse control. A repeat CTA 48 hours after the initial showed a stable dissection with no further propagation. The patient was then discharged home with plans for close follow-up with cardiac surgery and cardiology and repeat imaging at 1, 3, 6, and 12 months after discharge. The patient was counseled on BP control and warning signs of dissection propagation, to avoid strenuous exercise and heavy weight lifting, and when to seek medical care.
Approximately 55% of patients present with uncomplicated TBAD. Uncomplicated TBAD means there is no evidence of organ malperfusion, aortic rupture, or "high-risk" features for impending rupture.
High-risk features include an entry tear ≥ 10 mm, a primary entry tear at greater curve of distal aortic arch, short proximity of the entry tear to LSA ostium, maximum aortic diameter ≥ 40 mm, maximum false lumen diameter ≥ 22 mm, and bloody pleural effusion.
3. Highlight PointFor uncomplicated TBAD patients, aggressive medical therapy is usually sufficient. However, a complicated TBAD must be managed surgically with either thoracic endovascular aortic repair (TEVAR) or open repair. TEVAR is considered the treatment of choice when feasible.
CASE CONCLUSIONThe patient did well; however, her 1-year repeat imaging showed aneurysmal degeneration of her descending thoracic aorta. She underwent a percutaneous TEVAR with a thoracic branched endograft (TBE) with a 12-mm subclavian stent. A TBE device was used due to the inadequate landing zone distal to the LSA. She did well and was discharged on postoperative day 1 in good condition.
4. Highlight PointPatients must be counseled on all possible complications. For TEVAR, major complications include spinal cord ischemia, stroke, acute kidney injury, propagating a retrograde aortic dissection, endoleak, and access-related complications (femoral injury, femoral pseudoaneurysm, limb ischemia).
DISCUSSIONThe treatment of TBAD is complex and requires an understanding of the natural history and pathophysiology in order to apply the correct treatment algorithm (Figure 2). The providers must be facile with optimizing medical therapy as well as open and endovascular surgery to provide a tailored approach to each patient.
Figure 2. Treatment algorithm for TBAD. HTN, hypertension.
This case presentation discusses a patient with an uncomplicated TBAD who then had aneurysmal degeneration requiring a surgical intervention. This is not uncommon, and aortic disease must be thought of as a chronic, often progressive disease that requires regular follow-up. Furthermore, although medical management is the gold standard for an acute uncomplicated TBAD, the frequency of secondary interventions is high, reportedly between 20% and 50%.2 Therefore, there is a trend toward the prophylactic use of TEVAR for uncomplicated dissections. Two randomized trials have studied this, including the ADSORB trial, which randomized patients with acute uncomplicated TBAD to either medical therapy or medical therapy with TEVAR.3 With a follow-up of 1 year, improved aortic remodeling was observed in the TEVAR group, and the trial concluded that prophylactic TEVAR can be safely adopted for uncomplicated TBAD.4
The INSTEAD trial studied subacute and chronic TBADs and randomized patients to medical therapy versus medical therapy plus TEVAR. Long-term results demonstrated improved aortic remodeling with true lumen expansion and false lumen reduction at 5 years postoperatively. Notably, medical therapy alone demonstrated increased maximum aortic diameter with minimal aortic remodeling, and 16% of patients in the medical therapy arm required crossover to TEVAR because of adverse events.5 More studies are needed before recommending prophylactic TEVAR, but the data suggest it is safe and effective.
In conclusion, optimal medical therapy is the treatment of choice for patients with uncomplicated TBAD. In these patients, prophylactic TEVAR may be considered to reduce late aortic-related adverse events and aortic-related death. In uncomplicated TBAD, it is beneficial to delay TEVAR up to 90 days to reduce early adverse events. Finally, rigorous follow-up is imperative. If follow-up imaging demonstrates any disease progression or aortic degeneration, TEVAR or open surgery is likely indicated. For patients with a complicated TBAD, intervention is warranted. TEVAR is the gold standard if feasible.6
Jason Zakko, MD, MSCardiothoracic Surgery FellowUniversity of Colorado Anschutz Medical CenterAurora, Coloradojason.Zakko@cuanschutz.EduDisclosures: None.
T. Brett Reece, MDProfessor of SurgeryDivision of Cardiothoracic SurgeryUniversity of Colorado Anschutz Medical CenterAurora, ColoradoDisclosures: Consultant to Gore & Associates, Terumo, and Biostable.
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Neurovascular Catheters Market Size Is Expanding To USD 11.64 Billion By 2033
Precedence Research
The global neurovascular catheters market size is calculated at USD 5.91 billion in 2024 and is expected to attain around USD 11.64 billion by 2033 with a CAGR of 7.82% from 2024 to 2033.
Los Angeles, April 17, 2024 (GLOBE NEWSWIRE) -- According to Precedence Research, the global neurovascular catheters market size was evaluated at USD 5.47 billion in 2023 and it is expanding around USD 10.88 billion by 2032. The utilization of catheters in treating a spectrum of neurovascular conditions, such as cerebral aneurysms and ischemic stroke, contributes significantly to the expansion of the neurovascular catheters market. These advanced catheters play a pivotal role in addressing conditions affecting the blood vessels supplying the brain and spine. The increasing incidence of such neurological disorders underscores the demand for innovative medical devices like microcatheters. Consequently, this demand acts as a substantial growth factor for the neurovascular catheters market, propelling its expansion and attracting investments in research, development, and market penetration strategies.
Market Overview
The neurovascular catheters market is experiencing rapid growth due to their pivotal role in treating conditions affecting blood vessels within the brain through minimally invasive procedures. These catheters are inserted via femoral or brachial arteries and manually navigated to deliver treatment to the brain, eliminating the need for invasive skull and brain tissue incisions. However, challenges arise from the reduction of blood vessel diameter and increased tortuosity in deep brain vessels, limiting procedure effectiveness. Despite these challenges, neurovascular catheters have revolutionized patient treatment worldwide, advancing healthcare in this critical field.
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They enable minimally invasive treatments in a complex anatomical area, significantly enhancing patient outcomes. Neurovascular catheters cater to a wide range of conditions, including cerebral aneurysms, ischemic stroke, and other ailments affecting blood vessels supplying the brain and spine. While there have been notable advancements in catheter design and development, ongoing innovation focuses on pushing the boundaries of miniaturization. Continued miniaturization reduces patient risk and trauma while facilitating the use of new medicines and diagnostic technologies. Smaller microcatheters pave the way for new types of treatments, expanding the scope of possibilities in neurovascular interventions.
Story continues
In May 2023, EOSolutions declared the full commercial launch of the Dr. Banner balloon guide catheter,
In March 2022, Shockwave Medical unveiled the global launch of a new peripheral intravascular lithotripsy catheter
Key Insights
The U.S. Neurovascular catheters market size was estimated at USD 1.35 billion in 2023
The U.S. Neurovascular catheters market size is expected to hit around USD 3.04 billion by 2033 and growing at a CAGR of 8.44% from 2024 to 2033.
North America led the global market with the highest market share of 35.14% in 2023.
Europe region is estimated to expand the fastest CAGR between 2024 and 2033.
By Type, the equipment segment has held the largest market share of 35% in 2023.
By Type, the microcatheters segment is expected to grow at a remarkable CAGR during the forecast period.
By End-use, the hospital segment captured the biggest revenue share of 56% in 2023.
By Application, the human tissues segment registered the maximum market share of 34% in 2023.
By End-use, the ambulatory surgical centers segment is expected to expand at the fastest CAGR over the projected period.
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Regional Stance
In North America, particularly in the United States, the neurovascular catheters market is dominated by significant players, with ASAHI FUBUKI Catheters emerging as a notable contender. These catheters are designed to guide interventional devices for neurovascular therapy, addressing lesions or procedural sites through percutaneous intravascular procedures within the neurovasculature. The prevalence of neurovascular diseases in the US underscores the critical need for advanced treatment approaches. Specialists in the region offer a comprehensive range of treatments, including open micro neurosurgery and endovascular surgery, leveraging tiny instruments and microscopes to address conditions affecting small blood vessels directly.
In Canada, the Canadian Neurovascular Health Society plays a crucial role in enhancing the lives of individuals impacted by neurovascular conditions. As a volunteer-driven, non-profit charitable society, it focuses on support, research, and education initiatives. Through the provision of information and support, the society aims to raise awareness among healthcare professionals and advocate for neurovascular treatment. Research efforts contribute to the understanding of neurovascular conditions, while educational forums facilitate knowledge dissemination. In Canada, a multidisciplinary approach involving interventional cardiology, vascular surgery, interventional radiology, and neurosurgery specialists is pivotal in managing patients with vascular diseases. Each specialty claims expertise and unique advantages in treating specific patient cohorts, contributing to comprehensive patient care across the region.
In November 2023, the first patient was enrolled in the STORM-PE RCT, which evaluated Penumbra's latest computer-assisted vacuum thrombectomy, Lightning Flash, for the treatment of acute pulmonary embolism.
In April 2024, FDA 510(k) clearance for the AlphaVac F18 system for the treatment of pulmonary embolism (PE) was announced by AngioDynamics, Inc.
In April 2024, Concept Medical announced that it had received FDA investigational device exemption (IDE) approval to commence a clinical study for its MagicTouch AVF sirolimus-coated balloon catheter for managing stenotic arteriovenous fistula (AVF) lesions.
In the Asia Pacific region, particularly in India, the medical devices sector is poised for rapid growth, projected to exhibit the highest rate during the forecast period. The Indian medical devices sector is a crucial component of the country's healthcare industry, driven by increasing demand for healthcare infrastructure, preventive testing, and the expansion of healthcare services and insurance programs. Growth in this sector is underpinned by the adoption of new technologies, making it highly capital-intensive with extended gestation periods. Continuous training of healthcare providers is essential to integrate these new technologies effectively.
The fourth-largest medical devices market in Asia, after Japan, China, and South Korea, India's industry is significantly reliant on imported medical devices, with about 75-80% of sales stemming from imports. However, the presence of numerous multinational companies underscores the sector's global significance. Neurointervention, focusing on neurovascular diseases affecting the brain, head-and-neck, and spine, represents a rapidly evolving medical field. In countries like Korea, indices reflecting neurointerventional activities continue to surge annually, reflecting the growing importance and adoption of advanced medical technologies in the region.
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Report Highlights
By Type
In the neurovascular catheters market, the embolization catheter segment stands out as the dominant player. Vascular embolization devices, a key subset within this segment, serve the purpose of controlling hemorrhaging caused by aneurysms, certain tumors (such as nephroma, hepatoma, uterine fibroids), and arteriovenous malformations. Notably, this category excludes cyanoacrylates and other embolic agents acting through polymerization or precipitation. Neurovascular embolization devices, a specialized type within this segment, are specifically designed to permanently occlude blood flow to cerebral aneurysms and cerebral arteriovenous malformations. Through catheter embolization procedures, embolic agents—either medications or synthetic materials—are delivered through a catheter into the targeted blood vessel, effectively halting blood flow to the designated area. This minimally invasive treatment modality offers a means to block one or more blood vessels or abnormal vascular channels, providing a versatile solution for various neurovascular conditions. Thus, catheter embolization plays a pivotal role in the realm of neurovascular interventions, offering effective and efficient management of critical medical situations.
In the neurovascular catheters market, the microcatheters segment is poised for substantial growth during the forecast period. Microcatheters, characterized by their small diameter, play a crucial role in minimally invasive procedures by facilitating the delivery of devices with precision. Their compact design makes them particularly adept at navigating the intricate vasculature of the human body, enabling clinicians to reach challenging anatomical locations effectively.
Microcatheters have demonstrated notable utility in percutaneous coronary intervention (PCI), where they provide crucial support in addressing calcified lesions and vessel angulation, enhancing the success rates of otherwise complex procedures. Moreover, various types of microcatheters can be tailored to specific neurovascular applications, depending on the condition being treated. For instance, occlusion balloon catheters are commonly employed in the treatment of cerebral aneurysms, while stent delivery catheters find utility in addressing ischemic stroke cases. This versatility underscores the significance of microcatheters in modern healthcare, where they enable clinicians to offer targeted and effective interventions for a wide range of neurovascular conditions. As such, the anticipated growth of the microcatheters segment reflects the increasing adoption and recognition of their instrumental role in advancing minimally invasive treatment modalities in neurovascular medicine.
By Application
In the neurovascular catheters market, the brain aneurysms segment emerges as the dominant player. Recent advancements in endovascular devices have paved the way for the utilization of intermediate catheters (IMCs) in coil embolization procedures for cerebral aneurysms. These specialized catheters are engineered to offer optimal tracking and a stable platform within tortuous vessels, achieved through a combination of a bendable distal tip and a supportive proximal shaft. Endovascular treatment modalities involve accessing the aneurysm site by threading a small plastic tube, known as a catheter, through the artery. This catheter is then meticulously advanced into the brain arteries, enabling precise intervention at the site of the aneurysm.
By leveraging IMCs, clinicians can navigate the intricate vasculature of the brain with enhanced precision and stability, facilitating effective coil embolization procedures. This application insight underscores the critical role of catheter technology in the management of brain aneurysms, where precise navigation and stability are paramount for successful treatment outcomes. The utilization of IMCs represents a significant advancement in endovascular procedures, offering clinicians the tools necessary to address complex neurovascular conditions with improved efficacy and patient outcomes.
By End Use
In the neurovascular catheters market, the hospital segment emerges as the dominant end-use sector, having already secured a significant share. Neurovascular surgery, a critical branch of medicine encompassing the diagnosis, treatment, and prevention of diseases affecting the brain and spinal cord, is predominantly conducted within hospital settings. These procedures target various conditions such as stroke, brain aneurysms, arteriovenous malformations (AVMs), and brain tumors. Utilizing a catheter-based approach, neurovascular surgery allows for the diagnosis and treatment of conditions affecting the brain and spinal cord through minimally invasive techniques.
By accessing the patient's vascular system through a small incision in the groin area, surgeons can significantly reduce the need for open surgery and minimize recovery time, leading to enhanced patient outcomes. Endovascular neurosurgery, a key technique employed within hospital settings, is particularly effective in treating aneurysms, AVMs, and specific types of stroke. This approach, termed endovascular, involves procedures conducted within blood vessels, enabling precise intervention while minimizing trauma to surrounding tissues. The widespread adoption of endovascular techniques within hospitals underscores the importance of minimally invasive approaches in improving patient care and outcomes in neurovascular surgery.
In the neurovascular catheters market, the ambulatory surgical centers (ASCs) segment is poised to emerge as the most attractive end-use sector. ASCs represent a modern advancement in healthcare delivery, offering surgical care without the need for hospitalization. These centers provide patients with cost-effective and time-saving solutions while embracing the latest technologies in medicine. ASCs offer a wide range of surgical services, covering specialties such as general surgery, orthopedic surgery, ophthalmology, pain management, and more.
The convenience and efficiency offered by ASCs make them increasingly appealing to patients seeking outpatient surgical procedures. Moreover, the streamlined processes and focus on specialized care contribute to enhanced patient satisfaction and improved treatment outcomes. As ASCs continue to evolve and expand their capabilities, they are expected to play a significant role in driving the adoption of neurovascular catheters. Their emphasis on providing high-quality surgical care in a convenient and cost-effective manner aligns well with the demands of modern healthcare consumers.
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Urinary Catheters Market - The global urinary catheters market size reached USD 5.90 billion in 2023 and is projected to surpass around USD 10.15 billion by 2033 with a CAGR of 5.57% from 2024 to 2033.
Drug-Eluting Balloon Catheters Market - The global drug-eluting balloon catheters market size was recorded at USD 1.11 billion in 2022 and is estimated to hit around USD 3.15 billion by 2032, growing at a registered CAGR of 11.1% during the forecast period from 2023 to 2032.
Neonatal Intensive Care Units (NICU) Catheters Market - The NICU catheters market size was estimated at US$ 390 million in 2022 and is expected to hit around US$ 650.53 million by 2032. It is poised to grow at a CAGR of 5.30% from 2023 to 2032.
Market Dynamics
Driver
Innovative Stroke Thrombectomy Device
The introduction of the Advanced Neurovascular Access (ANA) catheter system presents a significant driver for the growth of the neurovascular catheters market. This novel stroke thrombectomy device features a self-expanding funnel component designed to mitigate side effects caused by clot fragmentation by locally restricting blood flow while adapting to the diameter of the lodging artery. Upon deployment, the ANA catheter facilitates distal aspiration combined with a stent retriever (SR), effectively mobilizing the clot into the funnel where it remains trapped and protected during extraction.
In both in vitro phantom and swine models mimicking human neurovascular anatomy, the ANA catheters have demonstrated superior recanalization rates compared to SR in combination with a distal aspiration catheter or a balloon guiding catheter. This innovative solution addresses critical needs in stroke treatment, propelling the demand for neurovascular catheters and contributing to market growth.
Restraint
Challenges in Microcatheter Manufacturing
Manufacturers of microcatheters encounter significant obstacles, particularly in bonding the multiple specialized layers of the device. A critical challenge, known as 'delamination', arises when these layers separate due to differing chemistries. Despite advancements, the final step in production—removing heat shrink from the device, remains problematic. Traditional methods involving skiving tools or razor blades often result in damage to these small and delicate devices. These manufacturing constraints pose limitations to the expansion of the neurovascular catheters market.
Opportunity
Advancements in Preventing Spinal Cord Ischemia Management
Recent years have witnessed impactful advances in preventing spinal cord ischemia during thoracoabdominal aortic repair, with a notable adoption of precision medicine concepts. The treatment of thoracoabdominal aortic aneurysms increasingly involves custom-made devices tailored to individual patient anatomy. Moreover, various strategies to prevent, detect, and treat spinal cord ischemia are being recommended on a personalized basis. These include novel surveillance techniques like near-infrared spectroscopy, the utilization of spinal catheters, staged procedures, and minimally invasive segmental artery coil embolization. These developments present significant opportunities in the neurovascular catheters market, as the demand for specialized catheters tailored to individual patient needs continues to rise.
In January 2023, Fluidx unveiled a new embolic for neurovascular use.
In April 2024, the FDA announced a new recall of neurovascular catheters built by a subsidiary of Johnson & Johnson.
Recent Developments
In February 2024, Philips launched the new Azurion neuro biplane system at ECR2024 to speed up and improve minimally invasive diagnosis and treatment of neurovascular patients.
In April 2022, Penumbra announced the European launch of the Indigo System with Lightning 7 and Lightning 12 Intelligent Aspiration, according to HMP Global Learning Network.
Key Players in the Neurovascular Catheters Market
Medtronic
Stryker
Terumo Corporation
Integer Holdings Corporation
Penumbra, Inc.
Johnson & Johnson Services, Inc.
Integra LifeSciences Corporation
Acandis GmbH
Spiegelberg GmbH & Co. KG
Market Segmentation
By Type
Microcatheters
Balloon Catheters
Access Catheters
Embolization Catheters
Others
By Application
By End Use
By Geography
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