ВЛИЯНИЕ РАЗЛИЧНЫХ ОПЕРАТИВНЫХ ВМЕШАТЕЛЬСТВ НА ПОКАЗАТЕЛИ АПОПТОЗА СОСУДИСТОЙ СТЕНКИ У ПАЦИЕНТОВ С АТЕРОСКЛЕРОЗОМ ПЕРИФЕРИЧЕСКИХ АРТЕРИЙ

To compare the outcomes of IV thrombolytics (tissue plasminogen activator or tPA) with endovascular treatment (intra-arterial tPA ± mechanical thrombectomy) in dialysis patients who suffered from acute ischemic stroke. Observational study. Data analysis from Nationwide Inpatient Sample (NIS 2005- 2010) including dialysis patients presenting with acute ischemic stroke, either treated with IV thrombolytics or endovascular treatment. Baseline characteristics, in-hospital complications, and discharge outcomes were compared between the two groups. We determined the effect of endovascular treatment on in-hospital mortality, disability at discharge, and post-thrombolytic intracerebral hemorrhages (ICH) after adjusting for potential confounders using multivariate analysis. Of the 2 313 dialysis patients with ischemic stroke, 1 398 (60%) received IV thrombolytics and 915 (40%) were treated with endovascular treatment. The in-hospital mortality rate and moderate-to-severe disability were lower in dialysis patients receiving endovascular treatment (7.6% vs. 14.5% p = 0.04) and (30% vs. 52% p = <.0001), respectively. After adjusting for age, gender, and potential confounders, endovascular treatment was associated with lower in-hospital mortality (OR 0.5, 95% CI 0.2-0.9) and moderate-to-severe disability (OR 0.3, 95% CI 0.2-0.5). The odds of both in-hospital mortality and moderate to severe disability were lower with endovascular treatment in dialysis patients. Such data support the preferential use of endovascular treatment in this patient population.

BackgroundThe management of acute ischemic stroke due to isolated posterior cerebral artery occlusion (iPCAO) remains a topic of debate. This study investigates the efficacy and safety of endovascular treatment (EVT)...

Restenosis of the reconstruction zone is one of the main postoperative complications of vascular reconstructions, which develops in 18–40% of cases and leads to an increase in the risk of limb loss to 20–25%. The search for new markers for predicting the development of this complication is an urgent problem today.Aim of study. To assess the dynamics of markers of apoptosis and cell proliferation at different times after endovascular intervention and their role in the development of restenosis of the reconstruction zone in patients with peripheral arterial disease (PAD).Material and methods. The clinical study included 30 patients with PAD stage III disease. After further examination, the patients underwent endovascular intervention on the arteries of the femoral-popliteal segment. If restenosis developed, the patients were re-operated. In patients before surgery, within the first hour, and then on days 1, 7, 14, 21, 30 after the operation, venous blood was taken to determine the markers Bax, sFas, PDGF BB using enzyme immunoassay.Results. After endovascular intervention, the first wave of apoptosis was triggered with an increase in the amount of proapoptotic protein Bax (p=0,00003) from 1 to 24 hours, followed by a decrease by day 7 (p=0.0008) compared to the amount on day 1. The PDGF BB level increased from day 1 after surgery (p=0.03) with maximum values on day 7 (p=0.0002) compared to the level on day 1. Then the second wave was triggered with a peak decrease in the level of the apoptosis inhibitor sFas on day 21 (p=0.002). After 9-12 months, restenosis of the intervention zone with a return of limb ischemia developed in 10 patients. During the first hour (p=0.004) in patients with restenosis, the level of Bax protein was significantly increased, with an increase in the level of PDGF BB by day 7 (p=0.011), and sFas by day 21 (p=0.0001), PDGF BB by the end of 1 month (p=0.004) compared to values in patients without this complication.Conclusion. 1. Endovascular intervention causes two waves of apoptosis in the postoperative period. The first wave is associated with an increase in Bax protein in the first hours, followed by an increase in PDGF BB on day 7. The second wave of apoptosis is due to a decrease in the inhibitor of apoptosis — sFas for 21 days against the background of the shift of the PDGF BB to the initial level. 2. An increase in Bax protein within the first hours after surgery in the course of PDGF BB growth on day 7 with an increased amount of sFas on day 21 leads and PDGF BB by the end of 1 month leads to the development of restenosis of the intervention area.

Background The endovascular treatment of acute cerebral ischemia has been proven beneficial without major safety concerns. To date, the role of endovascular treatment in patients treated with oral anticoagulants, which may be associated with periprocedural intracranial bleeding, remains uncertain. Aims The objective of the current analysis is to evaluate the safety of endovascular treatment in patients treated with oral anticoagulants. Methods The ENDOSTROKE-Registry is a commercially independent, prospective observational study in 12 stroke centers in Germany and Austria collecting pre-specified variables about endovascular stroke therapy. Results Data from 815 patients (median age 70 (interquartile range (IQR) 20), 57% male) undergoing endovascular treatment with known anticoagulation status were analyzed. A total of 85 (median age 76 (IQR 8), 52% male) patients (10.4%) took vitamin-K-antagonists prior to endovascular treatment. Anticoagulation status as measured with international normalized ratio was above 2.0 in 31 patients. Intracranial hemorrhage occurred in 11.8% of patients taking vitamin-K-antagonists compared to no-vitamin-K-antagonists (12.2%, p = 0.909). After adjustment for confounding factors which were unbalanced at univariate level such as NIHSS and age, anticoagulation status was not found to significantly influence clinical outcome (modified Rankin Scale 3-6) and occurrence of intracranial hemorrhage in a multivariate logistic regression analysis. Conclusion Prior use of vitamin-K-antagonists was not associated with a higher rate of periprocedural intracranial hemorrhage after endovascular treatment or worse outcome. Endovascular treatment should be considered as an important treatment option in patients taking vitamin-K-antagonists.

BackgroundSymptomatic intracranial hemorrhage (sICH) is a devastating complication of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) and is associated with high risk of disability and mortality. This study intended to evaluate the predictors of sICH after EVT in patients with large vessel occlusion (LVO)-induced AIS.MethodsWe conducted a retrospective review on consecutive AIS patients who underwent EVT in our University hospital between January 2019 and August 2020. The patients were classified into two groups based upon the occurrence of sICH. The main outcomes were the occurrence of sICH using the Heidelberg Bleeding Classification and functional condition at 90 days. Multivariate logistic regression analysis and receiver operating characteristics (ROC) curves were used to identify independent predictors of sICH after EVT.ResultsThree hundred and 69 patients were enrolled in the study, of which 16.8% (n = 62) developed sICH. Favorable neurological outcome was lower in patients with sICH than in patients without sICH (6.5 vs. 43.3%; P < 0.001), with the overall mortality being 112 (30.4%) at 90 days post- EVT. Results from univariate analysis showed significant differences between the two groups in the prevalence of diabetes, initial Alberta Stroke Program Early CT Score (ASPECTS) score, National Institutes of Health Stroke Scale (NIHSS) score after operation, the levels of fasting blood glucose (FBG), neutrophil to lymphocyte ratio (NLR), platelets (PLT), and thrombin time (TT) at admission. Multivariate logistic regression analysis showed that FBG ≥ 7.54 mmol/L (OR: 2.765; 95% confidence interval [CI]: 1.513–5.054), NLR ≥ 5.48 (OR: 2.711; 95% CI: 1.433–5.128), TT at admission ≥ 16.25 s (OR: 2.022; 95% CI: 1.115–3.667), and NIHSS score within 24 h after the operation ≥ 10 (OR: 3.728; 95% CI: 1.516–9.170) were independent predictors of sICH. The combination of NLR ≥ 5.48, FBG ≥ 7.54 mmol/L, TT at admission ≥ 16.25 s, and NIHSS score within 24 h after the operation ≥ 10 generated an optimal prediction model (AUC: 0.723).ConclusionHigher levels of FDG, NLR, TT at admission, and NIHSS score after operation were associated with sICH after EVT in patients with LVO-induced AIS.

BackgroundRecanalization status is the strongest predictor of clinical outcome in patients undergoing endovascular treatment (EVT). Although the time to reperfusion remains crucial even with EVT, the previous meta-analysis demonstrated that...

Background: Recent trials have demonstrated a reduction in death or disability with endovascular treatment in patients with acute ischemic strokes. However, readmission rates and predictors are not known. Objective: To identify rates and factors associated with 30-day readmission after endovascular treatment in ischemic stroke patients. Methods: Nationwide Readmissions Data (NRD) between 2010 and 2017 was utilized to identify endovascular treatment in acute ischemic stroke patients using ICD-9 and ICD-10 codes. We used hierarchical logistic regression model to identify factors associated with 30-day readmissions. Results: Among 17, 562 acute ischemic stroke patients who survived to discharge after endovascular treatment, 2334 (13.29%) were readmitted within 30-days. Age =&gt; 65 years (odds ratio [OR]: 1.23, 95% confidence interval [CI]: 1.09 to 1.39, p =0.0005), chronic kidney disease (OR: 1.28, 95%CI: 1.12 to 1.47, p = 0.0004), congestive heart failure (OR: 1.25, 95%CI: 1.13 to 1.39, p &lt;.0001), post procedure intracranial hemorrhage (OR: 1.09, 95%CI: 0.99 to 1.20, p = 0.04) and diabetes mellitus (OR: 1.09, 95%CI: 0.99 to 1.20, p = .09) during the index hospitalization were associated with readmission within 30 days. Conclusion: In this large nationally representative study, nearly one in 10 patients were readmitted within 30 days after discharge in acute ischemic stroke patients undergoing endovascular treatment. Medical comorbidities and post procedure intracranial hemorrhage were associated with 30-day readmission.

To date, only uncontrolled studies have evaluated the efficacy and safety of endovascular treatment (EVT) in patients with cerebral venous thrombosis (CVT), leading to the lack of recommendations on EVT for CVT. To evaluate the efficacy and safety of EVT in patients with a severe form of CVT. TO-ACT (Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis) was a multicenter, open-label, blinded end point, randomized clinical trial conducted in 8 hospitals in 3 countries (the Netherlands, China, and Portugal). Patients were recruited from September 2011 to October 2016, and follow-up began in March 2012 and was completed in December 2017. Adult patients with radiologically confirmed CVT who had at least 1 risk factor for a poor outcome (mental status disorder, coma state, intracerebral hemorrhage, or thrombosis of the deep venous system) were included. Data were analyzed according to the intention-to-treat principle from March 2018 to February 2019. The trial was halted after the first interim analysis for reasons of futility. Patients were randomized to receive either EVT with standard medical care (intervention group) or guideline-based standard medical care only (control group). The EVT consisted of mechanical thrombectomy, local intrasinus application of alteplase or urokinase, or a combination of both strategies. Patients in the intervention group underwent EVT as soon as possible but no later than 24 hours after randomization. Primary end point was the proportion of patients with a good outcome at 12 months (recovered without a disability; modified Rankin Scale [mRS] score of 0-1). Secondary end points were the proportion of patients with an mRS score of 0 to 1 at 6 months and an mRS score of 0 to 2 at 6 and 12 months, outcome on the mRS across the ordinal continuum at 12 months, recanalization rate, and surgical interventions in relation to CVT. Safety end points included symptomatic intracranial hemorrhage. Of the 67 patients enrolled and randomized, 33 (49%) were randomized to the intervention group and 34 (51%) were randomized to the control group. Patients in the intervention group vs those in the control group were slightly older (median [interquartile range (IQR)] age, 43 [33-50] years vs 38 [23-48] years) and comprised fewer women (23 women [70%] vs 27 women [79%]). The median (IQR) baseline National Institutes of Health Stroke Scale score was 12 (7-20) in the EVT group and 12 (5-20) in the standard care group. At the 12-month follow-up, 22 intervention patients (67%) had an mRS score of 0 to 1 compared with 23 control patients (68%) (relative risk ratio, 0.99; 95% CI, 0.71-1.38). Mortality was not statistically significantly higher in the EVT group (12% [n = 4] vs 3% [n = 1]; P = .20). The frequency of symptomatic intracerebral hemorrhage was not statistically significantly lower in the intervention group (3% [n = 1] vs 9% [n = 3]; P = .61). The TO-ACT trial showed that EVT with standard medical care did not appear to improve functional outcome of patients with CVT. Given the small sample size, the possibility exists that future studies will demonstrate better recovery rates after EVT for this patient population. ClinicalTrials.gov Identifier: NCT01204333.

Background and PurposeCerebral microbleeds (CMBs) are generally considered markers of hemorrhagic and ischemic stroke and are predictors of hemorrhagic complications after a stroke. However, the potential impact of CMB presence...

A systematic review and meta-analysis of primary bypass surgery compared with bypass surgery after endovascular treatment in peripheral artery disease patients

Background: For acute ischemic stroke (AIS) patients with anterior circulation occlusion, local anesthesia can significantly shorten the time from endovascular treatment to recanalization. Objective: To investigate the application of individualized sedation and analgesia nursing in endovascular treatment (EVT) of patients with anterior-circulation AIS. Methods: From October 2019 to October 2020, all of 78 patients who underwent EVT with anterior-circulation AIS were retrospectively collected. Before interventional preoperative, doctors and nurses cooperated to comprehensively evaluate the patient's condition. Based on fully considering patients' respiratory function, hemodynamic status and pathological and physiological status, individualized sedation and analgesia targets were formulated. The nurses dynamically assessed the patients' sedation score with Sedation-Agitation Scale (SAS) and analgesia score with Critical-Care Pain Observation Tool (CPOT), monitored the depth of sedation and analgesia in real time, adjusted the drug dose, and maintained the ideal sedation and analgesia state of the patients. During the operation, we actively prevented and dealt with the occurrence of adverse reactions such as hypersedation and respiratory depression, and placed oropharyngeal airway to improve ventilation for patients with retroglossal drop and respiratory depression. Results: The SAS score of 78 patients was 5.8±3.7 while entering the operating room. Among them, 71 patients were treated with the midazolam with an average dose of 5.3±2.7 mg, as well as the SAS score of 3.3±1.8 during the operation, and the other 7 patients were cooperated with consciously. Sixty patients were sedated with fentanyl solution at an average dose of 0.38±0.22mg, and the CPOT score was 4.8±3.2 during the operation. The other 18 patients did not use analgesics. The time of Door to Recanalization (D2R) in 78 patients was 50.8±28.6 min. During the operation, there was good cooperation between doctors and nurses, no case of intracranial hemorrhage and no case died. Conclusion: In the EVT of the anterior-circulation AIS patients, medical cooperation developed individualized sedation and analgesia, and the nurses dynamically evaluated the sedation and analgesia score of the patients. By monitoring the depth of sedation and analgesia in real time to adjust the dosage of drugs, patients can maintain in a moderate sedation and analgesia state to ensure the safety of EVT performed.

Background and Purpose- Previous studies suggest that intracranial carotid artery calcification (ICAC) volume might influence the clinical outcome of patients after endovascular treatment (EVT) for acute ischemic stroke. Importantly, ICAC can be subtyped into a medial or intimal pattern that may differentially influence the effect of EVT in patients with acute ischemic stroke. Methods- All 500 patients included in the MR CLEAN (Multicenter Randomized Clinical trial of Endovascular treatment for acute ischemic stroke in the Netherlands) were evaluated. Volume (mm3) and location pattern (tunica intima or tunica media) of ICAC could be determined on baseline noncontrast computed tomography in 344 patients. Functional outcome at 90 days was assessed with the modified Rankin Scale. Next, we investigated the association of ICAC volume and pattern with functional outcome using adjusted ordinal logistic regression models. Effect modification by EVT was assessed with an interaction term between treatment allocation and ICAC aspect. Results- We found evidence for treatment effect modification by ICAC pattern ( P interaction=0.04). Patients with predominantly medial calcification had better functional outcome with EVT than without this treatment (adjusted common odds ratio, 2.32; 95% CI, 1.23-4.39), but we observed no effect of EVT in patients with predominantly intimal calcifications (adjusted common odds ratio, 0.82; 95% CI, 0.40-1.68). We did not find an association of ICAC volume with functional outcome (adjusted common odds ratio per unit increase ICAC volume 1.01 (95% CI, 0.89-1.13). Moreover, we found no evidence for effect modification by ICAC volume ( P interaction=0.61). Conclusions- The benefit of EVT in acute ischemic stroke patients with a medial calcification pattern is larger than the benefit in patients with an intimal calcification pattern. Clinical Trial Registration- URL: http://www.trialregister.nl . Unique identifier: NTR1804. URL: http://www.isrctn.com . Unique identifier: ISRCTN10888758.

Predicting futile recanalisation following endovascular treatment (EVT) in patients with large core infarctions is crucial for guiding clinical decisions, optimising perioperative management and improving healthcare resource allocation. This study aimed to compare four machine learning (ML) algorithms and identify the most effective model for preinterventional prediction of futile recanalisation. Patients achieving successful reperfusion (expanded Thrombolysis in Cerebral Infarction Score≥2b) from the EVT in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core trial were stratified into two groups: no-futile recanalisation (90-day modified Rankin Scale (mRS) 0-3) and futile recanalisation (mRS 4-6). The least absolute shrinkage and selection operator regression method was used for feature selection, and four ML algorithms, including logistic regression, support vector machine (SVM), decision tree and random forest, were applied. Model performance was evaluated using receiver operating characteristic curves, calibration plots and decision curve analysis. Feature importance was ranked using SHapley Additive exPlanation (SHAP) values. Among 146 patients, 74 experienced futile recanalisation. Eight predictors were identified and ranked by SHAP analysis from highest to lowest importance: sex, age, National Institutes of Health Stroke Scale, glucose, systolic blood pressure, neutrophil-to-lymphocyte ratio, fibrinogen and occlusion site. Among the four models, the SVM model achieved the highest area under the curve of 0.891 (95% CI 0.837 to 0.945), along with good calibration (Hosmer-Lemeshow test, p=0.103) and clinical utility. The SVM model emerges as the optimal predictive tool for futile recanalisation following EVT in patients with large core infarction. Nevertheless, external validation is required to confirm its performance before clinical application. NCT04551664.

Introduction: Carotid artery dissection (CAD) and atherosclerotic carotid artery occlusion (ACAO) are major causes of a tandem occlusion in patients with intracranial large vessel occlusion (LVO). Presence of tandem occlusions may hamper intracranial access and potentially increases the risk of procedural complications of endovascular treatment (EVT). Our aim was to assess neurological, functional and technical outcome and complications of EVT for intracranial LVO in patients with CAD in comparison to patients with ACAO and to patients without CAD or ACAO.Methods: We analyzed data of the MR CLEAN trial intervention arm and MR CLEAN Registry, acquired in 16 Dutch EVT-centers. Primary outcome was the change in stroke severity by comparing the National Institute of Health Stroke Scale (NIHSS) score at 24–48 h after treatment vs. baseline. Secondary outcomes included reperfusion rate and symptomatic intracranial hemorrhage (sICH). We compared outcomes and complications between patients with CAD vs. patients with ACAO and patients without CAD or ACAO.Results: In total, we identified 74 (4.7%) patients with CAD, 92 (5.9%) patients with ACAO and 1398 (89.4%) patients without CAD or ACAO. Neurological improvement at short-term after EVT in patients with CAD was significantly better compared to ACAO (resp. mean −5 vs. mean −1 NIHSS point; p = 0.03) and did not differ compared to patients without CAD or ACAO (−4 NIHSS points; p = 0.62). Rates of successful reperfusion in patients with CAD (47%) was comparable to patients with ACAO (47%; p = 1.00), but was less often achieved compared to patients without CAD or ACAO (58%; p = 0.08). Occurrence of sICH did not differ significantly between CAD patients (5%) and ACAO (11%; p = 0.33) or without CAD/ACAO (6%; p = 1.00).Conclusion: EVT in patients with intracranial LVO due to CAD results in neurological improvement comparable to patients without tandem occlusions. Therefore, carotid artery dissection by itself should not be a contraindication for endovascular treatment in stroke patients with intracranial large vessel occlusion. Although more challenging endovascular procedures are to be suspected in both patients with CAD or ACAO, accurate distinction between CAD and ACAO might influence clinical decision making as better clinical outcome can be expected in patients with CAD.

Purpose Hyperspectral imaging (HSI) and thermal imaging allow contact-free tissue perfusion measurements and may help determine the effect of endovascular treatment (EVT) in patients with peripheral arterial disease. This study aimed to detect changes in perfusion with HSI and thermal imaging peri-procedurally and determine whether these changes can identify limbs that show clinical improvement after 6 weeks. Methods Patients with Rutherford class 2–6 scheduled for EVT were included prospectively. Hyperspectral imaging and thermal imaging were performed directly before and after EVT. Images were taken from the lateral side of the calves and plantar side of the feet. Concentrations of (de)oxyhemoglobin, oxygen saturation, and skin temperature were recorded. Angiographic results were determined on completion angiogram. Clinical improvement 6 weeks after EVT was defined as a decrease ≥ one Rutherford class. Peri-procedural changes in perfusion parameters were compared between limbs with and without good angiographic results or clinical improvement. To identify limbs with clinical improvement, receiver operating characteristic (ROC) curves were used to determine cutoff values for change in HSI. Results Included were 23 patients with 29 treated limbs. Change in HSI values and temperature was not significantly different between limbs with good and poor angiographic results. Change in peri-procedural deoxyhemoglobin, determined by HSI, at the calves and feet was significantly different between limbs with and without clinical improvement at 6 week follow-up (p=0.027 and p=0.017, respectively). The ROC curve for change in deoxyhemoglobin at the calves showed a cutoff value of ≤1.0, and ≤−0.5 at the feet, which were discriminative for clinical improvement (sensitivity 77%; specificity 75% and sensitivity 62%; specificity 88%, respectively). Conclusions HSI can detect changes in perfusion at the calves after EVT in patients with Rutherford class 2–6. Peri-procedural deoxyhemoglobin changes at the calves and feet are significantly different between limbs with and without clinical improvement. Decrease in deoxyhemoglobin directly after EVT may identify limbs that show clinical improvement 6 weeks after EVT.