Chemical Thrombolysis Research Articles

Morbimortality and determinants of reperfusion in ischemic stroke.

Cerebrovascular accident (or stroke) and ischemic heart disease are the the major causes of death in the world. It is estimated that about 85% of strokes are ischemic in origin. Reperfusion therapy in the acute phase of ischemic stroke with a recombinant human tissue plasminogen activator is effective, but some factors influence the success of this treatment. The aim of this study was to evaluate clinical aspects and possible determinants for reperfusion after venous thrombolysis. This is a retrospective, cross-sectional, observational study based on a review of hospital records of inpatients diagnosed with ischemic stroke treated with intravenous thrombolysis, the main outcome being reperfusion or not. Data from this study revealed a predominance of females in the group of reperfused patients and males in the non-reperfused group, both maintaining moderate severity on the National Institutes of Health Stroke Scale and admission without statistical significance (p>0.18). In addition, the mean admission severity score was 13.2 for the group of reperfused patients and 14.2 for those not reperfused, and the mean ejection fraction of both groups was within normal functionality, with a mean of 0.50 for reperfused patients and 0.62 for non-reperfused patients. We found an association between successful venous chemical thrombolysis reperfusion and lower mortality in patients with acute stroke.

Epidemiology, Diagnosis, and Treatment of Portal Vein Thrombosis

In recent years, the incidence of portal vein thrombosis (PVT) in patients with cirrhosis has increased; the thrombosis ranges from asymptomatic partial to complete occlusion. Treatment is difficult. Anticoagulation therapy may be the optimal first-line treatment for patients with acute PVT who lack variceal bleeding or mesenteric ischemia. Minimally invasive treatment options include mechanical thrombectomy, chemical thrombolysis, and stent placement. However, the effectiveness and timing of anticoagulation and interventional therapies remain unclear.

THE SURGEON'S PERSPECTIVE ON PORTAL VEIN THROMBOSIS IN PATIENTS WITH LIVER CIRRHOSIS

The article discusses the key aspects of the etiology, diagnosis, and treatment of portal vein thrombosis in patients with liver cirrhosis. The prevalence of portal vein thrombosis in individuals with liver cirrhosis ranges from 0.6 % to 26 %, with a higher incidence observed in those with decompensated cirrhosis. Symptoms of portal vein thrombosis are often nonspecific. Approximately one-third of patients with this condition experience no symptoms, and the detection of a thrombus is usually an incidental finding during computed tomography or ultrasound examinations.
 Acute portal vein thrombosis is characterized by abdominal pain in the right upper quadrant, non-bloody diarrhea, or acute intestinal obstruction when there is symptomatic dilatation of the superior mesenteric vein. On the other hand, chronic portal vein thrombosis manifests through signs of portal hypertension, such as esophageal and gastric bleeding, deterioration of portal gastropathy, splenomegaly, pancytopenia, and significant ascites.
 The first-line treatment for portal vein thrombosis involves the use of direct and indirect anticoagulants. However, their administration necessitates careful consideration of the risk of intraluminal bleeding, the severity of cirrhosis, and the potential benefits of portal vein recanalization. Mechanical thrombectomy can serve as an alternative to long-term anticoagulant therapy for portal vein thrombosis. In cases of portal vein thrombosis in patients with cirrhosis, after mechanical thrombectomy and thrombolysis, the placement of transjugular intrahepatic portosystemic shunt (TIPS) is often performed.
 To conclude, portal vein thrombosis frequently occurs in patients with liver cirrhosis, and its appearance is challenging to predict due to its multifactorial nature. The preferred initial treatment for acute portal vein thrombosis, in the absence of intraluminal bleeding or intestinal ischemia, involves the use of direct and indirect anticoagulants. Minimally invasive surgical options, such as mechanical thrombectomy, chemical thrombolysis, and TIPS placement (with or without variceal embolization), are currently available. However, due to the heterogeneous nature of the existing data and the lack of randomized controlled trials, definitive recommendations regarding the optimal treatment strategy are not yet available.
 Keywords: cirrhosis, coagulopathy, portal hypertension, portal vein thrombosis, anticoagulants.

A clinically relevant model of focal embolic cerebral ischemia by thrombus and thrombolysis in rhesus monkeys.

Over decades of research into the treatment of stroke, nearly all attempts to translate experimental treatments from discovery in cells and rodents to use in humans have failed. The prevailing belief is that it might be necessary to pretest pharmacological neuroprotection in higher-order brains, especially those of nonhuman primates (NHPs). Over the past few years, chemical thrombolysis and mechanical thrombectomy have been established as the standard of care for ischemic stroke in patients. The spotlight is now shifting towards emphasizing both focal ischemia and subsequent reperfusion in developing a clinically relevant stroke model in NHPs. This protocol describes an embolic model of middle cerebral artery occlusion in adult rhesus monkeys. An autologous clot is combined with a microcatheter or microwire through endovascular procedures, and reperfusion is achieved through local intra-artery thrombolysis with tissue plasminogen activator. These NHP models formed relatively stable infarct sizes, delivered predictable reperfusion and survival outcomes, and recapitulated key characteristics of patients with ischemic stroke as observed on MRI images and behavioral assays. Importantly, treated animals could survive 30 d after the surgery for post-stroke neurologic deficit analyses. Thus far, this model has been used in several translational studies. Here we describe in detail the teamwork necessary for developing stroke models of NHPs, including the preoperation preparations, endovascular surgery, postoperation management and histopathological analysis. The model can be established by the following procedures over a 45-d period, including preparation steps (14 d), endovascular operation (1 d) and evaluation steps (30 d).

Liver Transplantation After Acute Portal Vein Thrombosis: Case Report

Portal vein thrombosis is a relatively frequent complication in patients with liver cirrhosis. Its detection and management are essential to avoid worsening portal hypertension or liver function complications. This complication can also negatively impact or even preclude liver transplant. We report the case of a patient who presented with acute portal vein thrombosis, which allowed the diagnosis of liver cirrhosis and hepatocarcinoma within the Milan criteria. Chemical thrombolysis was performed with a mechanical aspiration of the thrombus, and in a second moment, the patient was submitted to a liver transplant. Advances in the therapeutic approach to portal vein thrombosis and surgical techniques have allowed the condition to no longer be an absolute contraindication to liver transplantation. Diagnosis in the acute phase is associated with greater therapeutic success, aiming to avoid the extension of thrombosis and achieve portal vein recanalization.

Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective.

This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided. Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation. Computerized literature search as well as discussion with experts in the field. Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.

HSPA12B Expression as an Epigenetic Signature Following Ischemic Stroke: Heat Shock Protein Mini Review

Stroke is a cardiovascular condition that caused by a clot or obstruction that prevents blood from flowing to the brain. Neural cells within the occluded area undergo cell death within minutes, and the results are often permanent, making stroke one of the leading causes of serious longterm disability. Stroke is a complex disorder that requires innovative solutions to attenuate the effects of stroke and improve clinical outcomes. Traditionally, stroke treated by relieving vascular occlusions and restoring blood flow to the infarcted tissue (necrotic tissue; core infarct) and the surrounding tissue at risk (penumbra). This technique known as thrombolysis, utilizing both chemical and mechanical modes. Chemical thrombolysis utilizes a catheter that administers medication to the clot site, which includes a multitude of treatments that include intravenous (IV) thrombolysis with recombinant tissue plasminogen activator, or rTPA, and intra-arterial (IA) therapies that aim to directly remove the occlusive clot and reestablish blood flow through recanalization.

Mechanical thrombectomy and intravascular imaging for cerebral venous sinus thrombosis: a preclinical model.

Although the majority of patients with cerebral venous sinus thrombosis (CVST) will improve with anticoagulation therapy, a portion of patients will either present in a comatose state or continue to deteriorate clinically despite early anticoagulation. In these cases, along with treating the underlying thrombophilia, timely thrombolysis may be beneficial. Repurposed arterial thrombectomy devices may not perform as expected in the cerebral venous sinus, and there are currently no preclinical endovascular thrombectomy (EVT) models for CVST. Contrary to arterial stroke research, preclinical models utilized to test various endovascular techniques and devices are lacking. The purpose of this research was to develop a reliable preclinical animal model for the testing of endovascular strategies to treat CVST. Five consecutive male Yorkshire swine weighing 45 kg were utilized. Thrombosis of the superior sagittal sinus was induced with a bovine thrombin injection via a microcatheter under distal balloon occlusion for 15 minutes. Combined arterial injections and superselective sinus injections confirmed the extent of thrombosis. EVT was subsequently performed using a second-generation stent retriever, followed by intravascular optical coherence tomography (OCT) imaging to assess the luminal environment after thrombectomy. Thrombosis of the superior sagittal sinus, EVT, and subsequent OCT imaging were technically successful in 4 of the 5 swine. Recanalization of the sinus with a second-generation stent retriever was successful after one attempt in 3 of 4 swine (75%), and 1 swine required two attempts. OCT imaging after thrombectomy revealed regions of residual sinus luminal thrombus despite complete angiographic recanalization. Thrombosed bridging cortical veins were also observed before draining into the sinus, along with patent cortical veins. The authors describe a preclinical model to assess endovascular techniques and devices for the treatment of CVST. Repurposed devices from arterial stroke may not perform as expected, given the unique features of venous sinus thrombosis. Residual bridging cortical vein thrombus and residual sinus thrombus, visualized on intravascular OCT, may be present despite complete sinus recanalization on angiography, and this may be the etiology of the poor clinical outcome despite technical success. In the setting of bridging cortical vein thrombus after successful sinus thrombectomy, direct chemical thrombolysis may be warranted to dissolve the remaining clot. This model may be helpful in developing and testing a new generation of devices designed specifically for CVST treatment.

Suction Thrombectomy of Large-Volume Iliocaval Deep Venous Thrombosis in Patients Contraindicated for Chemical Thrombolysis

Suction Thrombectomy of Large-Volume Iliocaval Deep Venous Thrombosis in Patients Contraindicated for Chemical Thrombolysis

Perioperative and long-term outcomes after percutaneous thrombectomy of arteriovenous dialysis access grafts

ObjectiveMaintenance of functional arteriovenous grafts (AVGs) for dialysis is difficult secondary to low primary patency, need for reinterventions, and limited alternative dialysis access options. We assessed our experience with percutaneous thrombectomy for treatment of occluded AVGs. MethodsWe performed a retrospective analysis of all percutaneous thrombectomies for AVGs from 2015 to 2017. These were generally performed using mechanical thrombectomy and occasional chemical tissue plasminogen activator thrombolysis, over-the-wire balloon embolectomy for inflow, and adjunctive inflow and outflow interventions as necessary. Perioperative outcomes, long-term patency, reinterventions, and need for new permanent access placement were analyzed. ResultsThere were 218 percutaneous thrombectomies performed on 86 AVGs in 77 patients. Approximately half (53.2%) of the patients were male and 68.8% were black. Mean age was 61.1 ± 13.0 years. At the time of thrombectomy, 73.8% underwent venous outflow interventions and 4.5% underwent arterial inflow interventions. Within 30 days, 24.8% of declotted grafts underwent repeated percutaneous thrombectomy, 14.3% required tunneled dialysis catheter placement, 4% developed minor access site or graft infections, and one patient underwent surgical arterial thrombectomy for arm ischemia. There were no venous thromboembolic, cardiopulmonary, or cerebrovascular complications or clinically significant pulmonary embolism. At 1 year and 3 years after percutaneous thrombectomy, freedom from repeated thrombosis was 37% and 18%, respectively, and freedom from new dialysis access placement was 66% and 51%, respectively. Overall patient survival was 82% at 3 years. ConclusionsPercutaneous thrombectomy of AVGs is safe and is associated with acceptable patency rates. This minimally invasive method extends AVG use for these high-risk patients with limited dialysis access options.

Endovascular Mechanical Thrombectomy and On-Site Chemical Thrombolysis for Severe Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare cause of cerebral infarction. Once patients survive the acute phase, long-term prognosis is generally satisfactory. CVST patients who harbored risk factors known for poor prognosis (e.g., deterioration of consciousness/neurological functions and seizures) were oftentimes unresponsive to systemic heparin treatment. The advantage of combined endovascular mechanical thrombectomy (EMT) and on-site chemical thrombolysis (OCT) plus systemic heparin for CVST over the heparin treatment alone has not been proved. A retrospective study was conducted to analyze consecutive patients with CVST from 2005 to 2015. Patients having clinical improvement or stable disease after heparin treatment were in I/S group; patients having continuous deterioration of consciousness/neurological functions and refractory seizures (despite the use of multiple anti-epileptic drugs) after heparin treatment were in D group. EMT and OCT were indicated for patients in D group. Imaging studies and medical records were reviewed for statistical analysis. Safety issues included new-onset/progression of symptomatic intracerebral hemorrhages (ICH) or procedure-related complications. Total thirty patients were included (I/S group = 16; D group = 14). In D group, the mean time frame from the start of heparin treatment to the endovascular treatment was 3.2 days. Compared with I/S group, all patients in D group had complete stenosis of the sinuses, with higher initial mRS, lower initial GCS, and more seizures (p = 0.006, 0.007, and 0.031, respectively), but no significant differences in the mRS at discharge (p = 0.504). Shorter length of thrombosis and lower initial mRS were associated with better outcomes (p = 0.009 and 0.003, respectively). Thrombosis involving the superior sagittal sinus (SSS) was associated with bad outcomes (p = 0.026). There were two patients (6.7%) with worsening symptomatic ICH, one in each group, managed surgically. The overall mortality of the study was 6.7% (2/30). Combined EMT and OCT after heparin treatment for severe CVST were reasonably safe, which might be considered as a salvage treatment in severe CVST patients who are unresponsive to heparin with heavy clot burden involving SSS in the acute phase. However, further studies are needed to confirm its efficacy and validity.

1993 Diagnosis and Management of Porto-Porto Varices in a Patient With Prior Orthotopic Liver Transplant

INTRODUCTION: Gastrointestinal variceal bleeding is a frequent complication in patients with liver disease. Small bowel varices represent a less common source of bleeding, and are often challenging to manage due to their location. We describe a case of bleeding small bowel porto-porto varices in a young patient status-post orthotopic liver transplant. CASE DESCRIPTION/METHODS: An 18-year-old-female patient presented with melanotic stools and a presyncopal episode. Her medical history was significant for iron deficiency anemia and biliary atresia. Associated surgical history included hepatoportoenterostomy in infancy and orthotopic liver transplantation at age two. Admission labs were significant for hemoglobin (Hgb) of 4.0 g/dL. Hepatic enzymes, INR and platelets were within normal limits. Initial colonoscopy and EGD were revealing for hematin in the cecum and colon. CT enterography showed smaller collateral veins draining into a large superior mesenteric collateral vein. This finding was confirmed by triple phase CT angiography, which also demonstrated chronic occlusion of the portal vein. The collaterals provided bypass of the thrombosed portal vein, and also included jejunal submucosal porto-porto varices. As the patient’s hemoglobin continued to drop despite blood transfusions, recanalization of the portal vein was attempted by Interventional Radiology (IR). The portal vein was stented, resulting in reduced flow through collateral vessels. The patient was taken back to the IR suite three days later as she had recurrent melena and Hgb drop. The stent had thrombosed, and a combination of chemical and mechanical thrombolysis was used to restore flow. Coil embolization of three collateral vessels from the SMV was also performed. A contrasted CT scan of the abdomen three days later revealed a patent stent with significant improvement in jejunal porto-porto varices. At her last clinic appointment two months after discharge, the patient denied further bleeding. DISCUSSION: This case illustrates the diagnostic and therapeutic challenges in patients with small bowel varies. This case is noteworthy as it highlights a type of collateralization, porto-porto varices, which have not been well described. Furthermore, this case occurred in a population not frequently studied: patients who previously underwent orthotopic liver transplant for biliary atresia. Recognition and appropriate treatment of associated liver conditions is crucial to increasing survival in this group.

Posterior tibial vein approach to catheter-directed thrombolysis for iliofemoral deep venous thrombosis

ObjectiveDeep venous thrombosis (DVT) remains a significant cause of morbidity in the American population. Catheter-directed thrombolysis for acute iliofemoral DVT is an effective therapy not only to restore venous patency but also to reduce the development of post-thrombotic syndrome (PTS), especially in patients with extensive thrombosis involving the iliac and femoral venous segments. We hypothesized that delivery of thrombolytics through an access site in a vein distal to the segments containing thrombus would provide the greatest short- and long-term therapeutic clinical benefit with similar safety and efficacy. MethodsAll patients treated at a single institution between 2009 and 2016 undergoing mechanical and chemical thrombolysis for iliofemoral DVT were retrospectively reviewed. Patients were divided into groups by access site, including contralateral and ipsilateral femoral vein, popliteal vein, and posterior tibial vein (PTV). Preoperative demographics, intraoperative data, and postoperative outpatient charts were analyzed. Primary end points included evidence of incompetence after the procedure by duplex ultrasound assessment and development of complications of PTS as defined by the Villalta scale. ResultsFifty-eight patients underwent mechanical and chemical thrombolysis, and 51 patients met the inclusion criteria. Thrombolysis access was through PTV (n = 27), popliteal vein (n = 20), or femoral vein (n = 4). More patients were female (55%), and the mean age was 57 years. Forty patients had unilateral DVT, whereas 11 patients had bilateral involvement. After lysis, 44 patients underwent percutaneous venous angioplasty and 11 patients underwent venous stenting in the acute setting. Although not statistically significant, mean operative times were slightly longer in the posterior tibial approach (156.7 minutes vs 130.6 minutes; P = .08), and mean fluoroscopy time was higher in the posterior tibial group (18.1 minutes vs 14.3 minutes; P = .17). Overall 90-day morbidity was 9.8%, and no deaths were recorded. Patency of the deep venous system was similar between the posterior tibial and the popliteal or femoral approach (95% vs 88%; P = .29); 21.6% developed symptoms of PTS. There was no difference for development of PTS between posterior tibial and popliteal or femoral approaches (22% vs 20.8%; P = .52). There was no difference in development of chronic nonocclusive DVT (37% vs 35%; P = .61). Median follow-up was 8.7 months (range, 0.4-58.9 months). ConclusionsThe PTV approach to catheter-directed thrombolysis is a safe and sensible option for the treatment of iliofemoral and femoropopliteal DVT. A larger cohort will be necessary to demonstrate superiority of tibial vein access in the treatment of iliofemoral DVT with popliteal involvement.

Correlation between pre-admission blood pressure and outcome in a large telestroke cohort

BackgroundTelemedicine rapidly connects patients, with acute ischemic stroke symptoms, with neurovascular specialists for assessment to reduce chemical thrombolysis delivery times. Management of AIS includes maintaining target systolic blood pressures (SBP). In this retrospective study, we assess the efficacy of the telestroke (TS) system at a primary stroke center and the prognostic value of SBP throughout the transportation process. MethodsPatients presenting with acute-onset neurological symptoms to the TS hospitals network, over a 5-year period, were assessed. Those with a confirmed diagnosis of AIS were included. We examined demographics, presenting-NIHSS, last SBP before transfer from the network hospital and continuous BP during transport, stroke risk factors, hospital-course, door-to-needle (DTN) time, treatments, and modified Rankin Scale(mRS). Multivariate analysis was conducted to evaluate the prognostic value of SBP on stroke outcome. ResultsOf 2,928 patients identified, 1,353 were diagnosed with AIS. Mean age was 66.6 years (SD = 15.4), 47.6% female. Most cases affected the MCA(44.5%). Mean presenting-NIHSS was 8.67(SD = 8.38) and mean SBP was 148 mmHg(SD = 25.39). 73.2% treated using a standard protocol, 23.7% given IVrt-PA, and 6.8% received mechanical thrombectomy(MT). Mean DTN was 96 min(SD = 46; 27.3% <60 min). Age, presenting-NIHSS and pre-existing hypertension were associated with higher mortality and/or higher mRS. SBP was not associated with higher mortality and morbidity. ConclusionsThis study displays better clinical outcomes at latest follow-up when compared to current international TS studies. SBP during transportation to the hub hospital did not prove to be a useful prognostic metric. However, future studies should address the limitations of this study to confirm these findings.

Percutaneous Suction Thrombectomy Is a Viable Alternative for Patients With Contraindications to Chemical Venous Thrombolysis

Percutaneous Suction Thrombectomy Is a Viable Alternative for Patients With Contraindications to Chemical Venous Thrombolysis

Endovascular treatments for cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) is an uncommon but potentially fatal condition. CVST usually occurs young adults with a female predominance. The current mainstay for treating CVST is anticoagulation with heparin. However, more aggressive interventions, endovascular treatment as an example, may be indicated in selected patients who are non-responsive to heparin and other anticoagulants. Endovascular approaches include catheter-based local chemical thrombolysis, balloon angioplasty and mechanical thrombectomy, all of which may rapidly recanalize the occluded venous sinus, restore the blood flow, reduce the increased intracranial pressure, and subsequently relieve the corresponding symptoms. However, as an invasive strategy, endovascular procedures per se may cause complications, such as intracranial hemorrhage, vessel dissection and pulmonary embolization, which may substantially decrease the benefit-risk ratio of the treatment. Due to the rareness of the condition and the limited indication of this invasive strategy, safety and efficacy of endovascular procedures in treating CVST are less feasible to be evaluated in large randomized clinical trails. Therefore, the evidences for justifying this treatment strategy are largely derived from case reports, cohort studies and clinical observations.

Chemical characteristics and antithrombotic effect of chondroitin sulfates from sturgeon skull and sturgeon backbone

Chondroitin sulfates (CSs) were extracted from sturgeon skull and backbone, and their chemical composition, anticoagulant, anti-platelet and thrombolysis activities were evaluated. The average molecular weights of CS from sturgeon skull and backbone were 38.5kDa and 49.2kDa, respectively. Disaccharide analysis indicated that the sturgeon backbone CS was primarily composed of disaccharide monosulfated in position four of the GalNAc (37.8%) and disaccharide monosulfated in position six of the GalNAc (59.6%) while sturgeon skull CS was primarily composed of nonsulfated disaccharide (74.2%). Sturgeon backbone CS showed stronger antithrombotic effect than sturgeon skull CS. Sturgeon backbone CS could significantly prolong activated partial thromboplastin time (APTT) and thrombin time (TT), inhibited ADP-induced platelet aggregation and dissolved platelet plasma clots in vitro. The results suggested that sturgeon backbone CS can be explored as a functional food with antithrombotic function.

Comparative Analysis of Endovascular Stroke Therapy Using Urokinase, Penumbra System and Retrievable (Solitare) Stent.

BackgroundHigher reperfusion rates have been established with endovascular treatment for acute ischemic stroke patients. There are limited data on the comparative performance of mechanical thrombectomy devices. This study aimed to analyse the efficacy and safety of the stent retriever device (Solitaire stent) by comparing procedure time, angiographic outcome, complication rate and long term clinical outcome with previous chemical thrombolysis and mechanical thrombectomy using penumbra system.MethodsA retrospective single-center analysis was undertaken of all consecutive patients who underwent chemical thrombolysis and mechanical thrombectomy using Penumbra or Solitaire stent retriever from March 2009 to March 2014. Baseline characteristics, rate of successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b-3), symptomatic intracerebral hemorrhage, procedure time, mortality and independent functional outcomes (mRS ≤2) at 3 month were compared across the three method.ResultsOur cohort included 164 patients, mechanical thrombectomy using stent retriever device had a significant impact on recanalization rate and functional independence at 3 months. In unadjusted analysis mechanical thrombectomy using Solitaire stent retriever showed higher recanalization rate than Penumbra system and chemical thrombolysis (75% vs. 64.2% vs. 49.4%, p=0.03) and higher rate of functional independence at 3 month (53.1% vs. 37.7% vs. 35.4%, p=0.213). In view of the interrelationships between all predictors of variables associated with a good clinical outcome, when the chemical thrombolysis was used as a reference, in multiple logistic regression analysis, the use of Solitaire stent retriever showed higher odds of independent functional outcome [odds ratio (OR) 2.62, 95% confidence interval (CI) 0.96-7.17; p=0.061] in comparison with penumbra system (OR 1.57, 95% CI 0.63-3.90; p=0.331).ConclusionOur initial data suggest that mechanical thrombectomy using stent retriever is superior to the mechanical thrombectomy using penumbra system and conventional chemical thrombolysis in achieving higher rates of reperfusion and better outcomes. Randomized clinical trials are needed to establish the actual benefit to specific patient populations.

Analysis of Distal Protection Debris to Identify High Risk Peripheral Interventions

Purpose Distal embolization (DE) of plaque or thrombus is a well-recognized cause of iatrogenic injury during percutaneous peripheral interventions. Several devices are available to help mitigate this and prevent potential distal ischemia. This study evaluated the incidence of DE during percutaneous intervention with the use of the Emboshield NAV-6 embolic protection system (Abbott Vascular, Abbott Park, Illinois). The relative incidence of DE during chemical thrombolysis (intra-arterial TPA), atherectomy, and treatment of in-stent restenosis (ISR) was analyzed. Material and Methods The NAV-6 was used over a 46-month period in 69 patients undergoing lower extremity arterial intervention. A database was generated through utilization of the Hi-IQ inventory management system. A retrospective analysis of this database was performed reviewing both the intervention notes stored in the EMR and the case images stored in PACS. The relative incidence of DE during chemical thrombolysis (intra-arterial TPA), atherectomy, and treatment of ISR was analyzed and compared to DE rates during procedures not involving one of the above categories. Retrieved DE was determined through identification of visible contents within the NAV-6 basket either upon visual inspection following capture and removal or inferred from identification of filling defects during DSA with the device deployed. Results Interventions were performed in 34 native vessels, 6 bypass grafts, and 29 vessels that had been stented previously. NAV-6 devices were placed immediately distal to the arterial lesion in all cases. Twenty-four were treated with intra-arterial TPA either prior to the case during overnight thrombolysis or during the case via pulse-spray thrombolysis. Of the 24 patients treated with TPA, 12 had DE retrieved through the NAV-6 (50%). Twenty patients were being treated with atherectomy (including laser, directional, and rotational) with 10 having DE retrieved through the NAV-6 (50%). Nineteen patients were being treated for ISR with or without complete thrombosis with 9 having DE retrieved through the NAV-6 (47%). Twenty-one patients had treatment not involving TPA, ISR, or atherectomy. Of those 21 patients, DE was retrieved through the NAV-6 in 4 patients (19%). 8 patients had DE despite NAV-6 use (12%) with 6 of the 8 being secondary to an over-filled filter basket. There were no cases of hemodynamically significant arterial spasm or dissection with the use of NAV-6. There was 1 device malfunction where the NAV-6 fractured during retrieval. All but 1 patient had preserved or improved runoff at the end of the case. Conclusions The overall incidence of DE during lower extremity arterial intervention was 30%. Treatment of ISR, treatment with atherectomy, or use of intra-arterial TPA was associated with an increased incidence of DE (47%, 50%, and 50%, respectively) when compared with treatment not involving one of these techniques (19%). The incidence of DE despite use of NAV-6 was 12%. These findings validate the continued use of NAV-6 during lower extremity arterial interventions particularly in the settings of ISR, atherectomy, or use of intra-arterial TPA.

Novel Treatment Techniques for Recanalization of Femoral-Popliteal Deep Venous Occlusion From Chronic Thrombosis

Patients with postthrombotic syndrome due to previous femoral-popliteal deep venous thrombosis often experience lifestyle-limiting lower-extremity pain and swelling. Conservative treatment options include compression stockings and lymphedema massage, but in many cases these treatments only temporarily and partially improve symptoms. Ultrasound and venography in patients with postthrombotic syndrome often show only partial recanalization of the femoral vein with significant collateral vein formation. These abnormal veins are insufficient for adequate venous drainage from the lower extremity as evidenced by the patient's continued symptoms. Recanalization of the occluded or partially occluded femoral vein using prolonged venoplasty, with or without chemical thrombolysis, combined with optimizing anticoagulation and conservative treatment measures, results in lasting improvement in symptoms for a high percentage of patients.