Complete Reperfusion Research Articles

Clinical Results of the Advanced Neurovascular Access Catheter System Combined With a Stent Retriever in Acute Ischemic Stroke (SOLONDA).

Background:The Advanced Neurovascular Access (ANA) thrombectomy system is a novel stroke thrombectomy device comprising a self-expanding funnel designed to reduce clot fragmentation by locally restricting flow while becoming as wide as the lodging artery. Once deployed, the ANA device allows distal aspiration combined with a stent retriever to mobilize the clot into the funnel where it remains copped during extraction. We investigated the safety and efficacy of ANA catheter system.Methods:SOLONDA (Solitaire in Combination With the ANA Catheter System as Manufactured by Anaconda) was a prospective, open, single-arm, multicenter trial with blinded assessment of the primary outcome by an independent core lab. Patients with anterior circulation vessel occlusion admitted within 8 hours from symptom onset were eligible. The primary end point was successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b–3) with ≤3 passes of the ANA device in combination with stent retriever, before the use of rescue therapy in the intention to treat population. Primary predefined analysis was noninferiority as compared to the performance end point observed in HERMES (High Effective Reperfusion Using Multiple Endovascular Devices).Results:After enrollment of 74 patients, an interim analysis was conducted, and the trial Steering Committee decided to terminate recruitment due to safety and performance objectives were reached. Mean age was 71.6 (SD 8.9) years, 46.6% women and median National Institutes of Health Stroke Scale on admission 14 (interquartile range, 10–19). Successful reperfusion within 3 passes before rescue therapy was achieved in 60/72 (83.3% [95% CI, 74.7%–91.9%]) with a rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 2c–3) of 60% (95% CI, 48.4%–71.1%; 43/72 patients). After noninferiority was confirmed (P<0.01), the ANA device also showed superiority in the rate of successful reperfusion with ≤3 passes (P=0.02). First-pass successful recanalization rate was 55.6% (95% CI, 44.1%–67.0%), with a first-pass complete recanalization rate of 38.9% (95% CI, 27.6%–50.1%). Rescue therapy to obtain a modified Thrombolysis in Cerebral Infarction score 2b–3 was needed in 12/72 (17%) patients. At 90 days, the rate of favorable functional outcome (modified Rankin Scale score 0–2) was 57.5% (95% CI, 46.2%–68.9%), and the rate of excellent functional outcome (modified Rankin Scale score 0–1) was 45.2% (95% CI, 33.8%–56.6%). The rate of severe adverse device related was 1.4%.Conclusions:In this clinical experience, the ANA device achieved a high rate of complete recanalization with a preliminary good safety profile and favorable 90 days clinical outcomes.Registration:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04095767.

Effect of Intravenous Alteplase on Functional Outcome and Secondary Injury Volumes in Stroke Patients with Complete Endovascular Recanalization.

Intravenous thrombolytic therapy with alteplase (IVT) is a standard of care in ischemic stroke, while recent trials investigating direct endovascular thrombectomy (EVT) approaches showed conflicting results. Yet, the effect of IVT on secondary injury volumes in patients with complete recanalization has not been analyzed. We hypothesized that IVT is associated with worse functional outcome and aggravated secondary injury volumes when administered to patients who subsequently attained complete reperfusion after EVT. Anterior circulation ischemic stroke patients with complete reperfusion after thrombectomy defined as thrombolysis in cerebral infarctions (TICI) scale 3 after thrombectomy admitted between January 2013–January 2021 were analyzed. Primary endpoints were the proportion of patients with functional independence defined as modified Rankin Scale (mRS) score 0–2 at day 90, and secondary injury volumes: Edema volume in follow-up imaging measured using quantitative net water uptake (NWU), and the rate of symptomatic intracerebral hemorrhage (sICH). A total of 219 patients were included and 128 (58%) patients received bridging IVT before thrombectomy. The proportion of patients with functional independence was 28% for patients with bridging IVT, and 34% for patients with direct thrombectomy (p = 0.35). The rate of sICH was significantly higher after bridging IVT (20% versus 7.7%, p = 0.01). Multivariable logistic and linear regression analysis confirmed the independent association of bridging IVT with sICH (aOR: 2.78, 95% CI: 1.02–7.56, p = 0.046), and edema volume (aOR: 8.70, 95% CI: 2.57–14.85, p = 0.006). Bridging IVT was associated with increased edema volume and risk for sICH as secondary injury volumes. The results of this study encourage direct EVT approaches, particularly in patients with higher likelihood of successful EVT.

Effects of early myocardial reperfusion and perfusion on myocardial necrosis/dysfunction and inflammation in patients with ST-segment and non-ST-segment elevation acute coronary syndrome: results from the PLATelet inhibition and patients Outcomes (PLATO) trial.

AimsRestoration of myocardial blood flow and perfusion during percutaneous coronary intervention (PCI) measured using Thrombolysis in Myocardial Infarction (TIMI) flow grade (TFG) and perfusion grade (TMPG) is associated with improved outcomes in acute coronary syndrome (ACS). Associations between TFG/TMPG and changes in biomarkers reflecting myocardial damage/dysfunction and inflammation is unknown.Methods and resultsAmong 2606 patients included, TFG was evaluated in 2198 and TMPG in 1874 with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment ACS (NSTE-ACS). Biomarkers reflecting myocardial necrosis [troponin T (TnT)], myocardial dysfunction [N-terminal prohormone brain natriuretic peptide (NT-proBNP)], inflammation [interleukin-6 (IL-6) and C-reactive protein (CRP)], and oxidative stress/ageing/inflammation [growth differentiation factor-15 (GDF-15)] were measured at baseline, discharge, and 1- and 6-month post-randomization. Associations between TFG/TMPG and changes in biomarker levels were evaluated using the Mann–Whitney–Wilcoxon signed test. In total, 1423 (54.6%) patients had STEMI and 1183 (45.4%) NSTE-ACS. Complete reperfusion after PCI with TFG = 3 was achieved in 1110 (85.3%) with STEMI and in 793 (88.5%) with NSTE-ACS. Normal myocardial perfusion with TMPG = 3 was achieved in 475 (41.6%) with STEMI and in 396 (54.0%) with NSTE-ACS. Levels of TnT, NT-proBNP, IL-6, CRP, and GDF-15 were substantially lower at discharge in patients with complete vs. incomplete TFG and STEMI (P < 0.01). This pattern was not observed for patients with NSTE-ACS. Patients with normal vs. abnormal TMPG and NSTE-ACS had lower levels of NT-proBNP at discharge (P = 0.01).ConclusionsSuccessful restoration of epicardial blood flow in STEMI was associated with less myocardial necrosis/dysfunction and inflammation. Attainment of normal myocardial perfusion was associated with less myocardial dysfunction in NSTE-ACS.

Ovine Iliac Vein Model for Endovascular Thrombectomy of Acute Deep Venous Thrombosis

An ovine iliac vein thrombosis model was devised to test a wall-contacting rotational thrombectomy device. Thrombosis was successfully induced in 9 sheep with an average clot length of 31 mm ± 12 and >60% vessel occlusion on angiography. The thrombus was subsequently removed, maintaining normal intraoperative pulmonary arterial pressure (5.9 mm Hg ± 3.6) and complete distal reperfusion after thrombectomy. Additionally, the sheep were without signs of vascular trauma or embolic complications on gross necropsy and histopathologic analysis. The findings from this study support the use of an ovine iliac deep vein thrombosis model for testing of a lower extremity thrombectomy device.

Frailty in people over 80 years after an ischemic stroke treated with mechanical thrombectomy

IntroductionAlthough the advanced age is not an exclusion criterion for the stroke treatments, is characterized by a frailty state that affected the evolution and prognosis in such patients. ObjectivesTo describe the possibility of a relation between frailty in elderly people (≥ 80 years old) after mechanical thrombectomy, and clinical severity, and to describe stroke clinical features. MethodsObservational study in people over 80 year-old who suffered an ischemic stroke and underwent to mechanical thrombectomy, between February and October 2018. Data about cardiovascular risk factors, medical treatment, stroke episode and frailty were collected. ResultsThe sample was constituted by 65 people. A 72% suffered hypertension and 43% atrial fibrillation. A 75% did not take anticoagulants. A 82% did not suffer complications with the procedure, and a complete arterial reperfusion was achieved in 83%. A 27.69% (n = 28) was not fragile. There was statistical association between age and frailty (P = .003). DiscussionIn our sample, the neurological and functional state caused by the stroke were more severe (described by the NIHS and Rankin modified scales score), but the recovery after hospital discharge was more positive. Elderly survivor patients were characterized as no fragile. The recovery after a stroke should be measured in functionality and quality of life terms, and not only using the age data.

Abstract TMP67: Predictors Of Unfavourable Events Despite Successful Mechanical Thrombectomy In The Extended Window

Background: Futile recanalization (FR) and symptomatic intracranial hemorrhage (sICH) are adverse outcomes after otherwise successful mechanical thrombectomy (MT). The aim of this study was to evaluate independent predictors of these unfavourable events in the extended time window and to compare imaging modalities (non-enhanced CT (NCCT) alone vs. CT perfusion vs. MRI) regarding patient selection. Methods: The CT for Late EndovasculAr Reperfusion (CLEAR) study was a multicenter, retrospective study of stroke patients undergoing thrombectomy in the extended time window. The primary endpoint of this study was the proportion of patients with FR, defined as a patient with large vessel occlusion achieving near-complete or complete reperfusion (TICI 2c/3) with a 90-day mRS score between 3 and 6. The secondary safety endpoints included the predictors of mortality and symptomatic intracranial hemorrhage. Inclusion criteria for this analysis were baseline NIHSS ≥6, internal carotid artery, M1 or M2 segment occlusion, prestroke modified rankin scale (pmRS) 0-2, time last seen well (TLSW) to treatment 6-24 hours, and mTICI 2c-3. Results: Of 2304 patients in the CLEAR study, 715 patients were included in this analysis. Of these, 364 patients (50.9%) showed FR, 37 patients (5.2%) suffered sICH and 127 patients (17.8%) died within 90 days. Old age, higher baseline NIHSS, higher prestroke disability, transfer to a comprehensive stroke center from another site, and a longer interval from TLSW to puncture were identified as positive predictors of FR. Hypertension was an independent predictor of sICH. The imaging modality (NCCT vs. CT perfusion vs. MRI) was not associated with FR, sICH, or mortality. Conclusions: Older age, higher baseline NIHSS, higher prestroke disability, transfer patients, and a longer interval from TLSW to puncture were predictors of FR in the extended window. Hypertension was a predictor of sICH in successfully reperfused patients. Neither MRI or CT perfusion was superior in predicting FR and sICH compared to NCCT alone. NCCT together with CTA may be sufficient for patient selection in the extended time window. Trial Registration: ClinicalTrials.gov Identifier: NCT04096248

Abstract WP159: Effect Of Multiple Passes During Mechanical Thrombectomy On Clinical Outcomes

Introduction: Reperfusion with mechanical thrombectomy improves outcomes in patients with Large Vessel Occlusion Acute Ischemic Stroke (LVO-AIS). The technical goal of thrombectomy is reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b. Here we investigate if procedures requiring multiple passes to achieve complete reperfusion (MP mTICI 3) result in better outcomes compared to procedures stopped after achieving mTICI 2b-2c on the first pass (FP mTICI 2b-2c). Methods: Using data from the COMPLETE registry (a global prospective study of LVO-AIS patients who underwent mechanical thrombectomy using the Penumbra System), we grouped patients into MP mTICI 3 and FP mTICI 2b-2c. Functional independence (mRS 0-2) at 90 days, all-cause mortality at 90 days, device-related serious adverse events (SAE) ≤ 24 hours, procedure-related SAEs ≤ 24 hours, embolization to new or previously uninvolved territories (ENT), symptomatic intracranial hemorrhage (sICH) ≤ 24 hours, vessel perforation, vessel dissection, and length of stay were compared. Results: Of the 650 patients in the COMPLETE registry, 215 were included in this subgroup analysis; 111 were categorized as MP mTICI 3, and 104 as FP mTICI 2b-2c. The MP mTICI 3 group has fewer M1 occlusions (48% vs 67%, p = 0.004) and more ICA-T occlusions (19% vs. 9%, p = 0.032). The groups were otherwise well matched with respect to age, sex, medical history, pre-procedure ASPECTS, NIHSS, IV tPA use, onset-to-puncture time, and occlusion etiology. Outcomes are shown in table 1. Conclusions: In this exploratory subgroup analysis, we found that procedures requiring multiple passes to achieve complete revascularization were not associated with improved outcomes compared to procedures stopping after achieving mTICI 2b-2c on the first pass.

Modeling Large Vessel Occlusion Stroke for the Evaluation of Endovascular Therapy According to Thrombus Composition.

More than 40% of endovascular therapy (EVT) fail to achieve complete reperfusion of the territory of the occluded artery in patients with acute ischemic stroke (AIS). Understanding factors influencing EVT could help overcome its limitations. Our objective was to study the impact of thrombus cell composition on EVT procedures, using a simulation system for modeling thrombus-induced large vessel occlusion (LVO) in flow conditions. In an open comparative trial, we analyzed the behavior of size-standardized platelet-rich and red blood cells (RBC)-rich thrombi during simulated stent retriever-mediated EVT procedures. Sixteen simulated EVT procedures were performed (8 RBC- vs. 8 platelet-rich thrombi). Platelet-rich thrombi were associated with a higher number of stent retriever passes (p = 0.03) and a longer procedure duration (p = 0.02) compared to RBC-rich thrombi. Conversely, RBC-rich thrombi released more embolic fragments than platelet-rich thrombi (p = 0.004). Both RBC-rich and platelet-rich thrombi underwent drastic compaction after being injected into the in vitro circulation model, and histologic analyses showed that these EVT-retrieved thrombi displayed features comparable to those previously observed in thrombi from patients with AIS patients having LVO, including a marked structural dichotomy between RBC- and platelet-rich areas. Our results show that the injection of in vitro-produced thrombi in artificial cerebrovascular arterial networks is suitable for testing recanalization efficacy and the risk of embolization of EVT devices and strategies in association with thrombus cell composition.

Impact of Number of Passes Before Rescue Therapy in Thrombectomy for Basilar Artery Strokes

Background When standard endovascular thrombectomy techniques fail to achieve a successful recanalization, it is often necessary to use rescue therapies (RTs). RTs are more commonly used in basilar artery occlusions and conventionally thought to represent “a last resort option.” We sought to study the outcomes of basilar artery occlusion patients who received RT, and further hypothesize that the number of instrumental passes before initiation of RT may be associated with increased risk for poor clinical outcomes. Methods We performed a retrospective analysis of the ETIS (“Endovascular Treatment in Ischemic Stroke”) registry. Our primary analysis included 277 patients who underwent thrombectomy for basilar artery occlusion, of whom 74 patients (26.7%) who received RT, defined as the use of intra‐arterial drugs, angioplasty, or stenting. Primary outcome measures included successful or complete reperfusion (final modified thrombolysis in cerebral infarction ≥2b or 3), functional independence (modified Rankin scale of 0–2), and mortality at 3 months. Results RT patients were more likely to have an atherosclerotic cause than non‐RT patients (46/74 [62.2%] versus 38/203 [18.7%]), were more likely to die (42/74 [56.8%] versus 73/203 [36.0%]), and were less likely to achieve functional independence (12/74 [16.2%] versus 84/203 [41.4%]). In the RT cohort, 17 of 74 patients (23.0%) had 1 pass before RT initiation, and 8 of 17 (47.1%) achieved a modified Rankin scale score of 0 to 2 at 3 months, with a mortality rate of 23.5% (4/17). The chance of achieving good clinical outcome decreased with each additional pass, whereas mortality increased. The odds of mortality at 3 months were highest in the &gt;3 passes group, with an odds ratio of 10.29 (95% CI, 2.42–43.81) compared with 1 pass. None of the 25 patients with &gt;3 passes before RT achieved 3‐month functional independence. Conclusions There is a significant correlation between the number of passes before initiation of RT and 3‐month clinical outcomes in basilar artery occlusion patients.

POSC294 The Environmental Impact of the First Pass Effect in Mechanical Thrombectomy in the NHS

First Pass Effect (FPE), a measure of the ability of a mechanical thrombectomy (MT) device to restore complete or near-complete reperfusion (mTICI 2c-3) in a single pass of the device through a clot, is an independent predictor of good functional outcome. FPE results in improved clinical outcomes and healthcare resource utilisation. We aim to appraise the environmental impacts of the reductions in healthcare resource utilisation with FPE.

Clinical Impact of Large Vessel Occlusion Achieved First Pass Effect with Stent Retriever Alone: A Single-Center Retrospective Analysis.

The first pass effect (FPE), which means the achievement of complete or near-complete reperfusion of large vessel occlusion (LVO) in the first pass, is one of the goals of mechanical thrombectomy (MT). However, the impact of FPE on the prognosis has not been assessed for Japanese patients with various degrees of independence before the onset of LVO. The purpose of this study was to investigate the prognostic effects of FPE in a comprehensive stroke center in Japan, which includes patients in a variety of self-independence states with different comorbidities before stroke onset. Between April 2017 and March 2020, 151 patients who underwent MT with a stent retriever (SR) alone as initial strategy for anterior circulation (internal carotid artery terminal, M1, M2) LVO at our hospital and finally achieved modified treatment in cerebral infarction (mTICI) 2b-3 were analyzed. Forty-eight patients in whom first pass mTICI 2c-3 was achieved were classified into the FPE+ group, and the other 103 patients were classified into the FPE- group. We compared the characteristics and clinical outcomes between patients with and without FPE, and estimated the odds ratio for outcomes after adjusting for confounders. The puncture-reperfusion time was shorter (20 vs. 35 minutes; p <0.01), and cardiogenic embolism was more common (81.3 vs. 60.2%; p = 0.01) in the FPE+ group. The FPE was significantly associated with good neurological outcome after 3 months (p <0.01; adjusted odds ratio [aOR], 3.87; 95% confidence interval [CI], 1.69-9.38), reduction in all intracranial hemorrhage (p <0.01; aOR, 0.24; 95% CI, 0.10-0.54), and symptomatic intracranial hemorrhage (p = 0.04; aOR, 0.16; 95% CI, 0.01-0.98). The FPE with an SR alone improved the neurological prognosis in a Japanese patient group.

PREDICTIVE ROLE OF INFARCT RELATED ARTERY IN ACUTE RIGHT VENTRICULAR INFARCTION DIAGNOSED USING ELECTROCARDIOGRAPHY

Right coronary artery (RCA) emerged as infarct related artery (IRA) in patients with right ventricular myocardial infarction (RVMI), which is followed by some degree of RV dysfunction. The aim of our study was to identify significant predictors of IRA among angiographic and/or echocardiographic data of RV dimension and/or function in patients with acute RVMI. Out of 122 hospitalized patients with acute inferior myocardial infarction, on the basis of ECG criteria RVMI was diagnosed in 58/47.5% patients. Coronary angiography was applied in 52/89,6% immediately after admission and conventional 2D echocardiography was performed in all referred patients in order to assess right heart dimensions and function according to the professional association recommendations. RCA emerged as IRA in 49/84,5 % of patients with echocardiographicaly diagnosed RVMI. Patients with RCA stenosis/occlusion had 4.9 times higher risk for RVMI presence (OR=4.941; 95%CI: 1.727-14.136; p=0.003) than those without and had significantly worse echocardiographic assessed RV global and/or regional systolic function. Logistic stepwise regression analysis confirmed the significant role of&nbsp; enlarged RV dimension (OR=1.1; 95%CI: 1.023-1.182; p=0.010), RCA stenosis/occlusion presence (OR=4.8; 95%CI: 1.649-14.199; p=0.004) and/or LAD stenosis/occlusion absence (OR=0.18; 95%CI: 0.067-0.476; p=0.001) in prediction of RVMI. The optimal sensitivity of the model was 90% and specificity 75%.&nbsp;RCA and conversely lack of LAD stenosis/occlusion presence along with some of the echocardiographic parameters showing RV dysfunction increased the odds for RVMI. Applying immediate and complete reperfusion of RCA is of a great importance for recovery of RV function. Key words: right myocardial infarction, right coronary artery, right ventricular dysfunction, reperfusion.

Prognostic factors of cerebral revascularisation in acute ischemic stroke at Hanoi Heart Hospital

Background: Considering the effectiveness of treatment for acute ischemic stroke (AIS)patients, the most expected method is immediate revascularization using intravenous thrombolysis or mechanical thrombectomy, or both methods. Objective: “Find factors related to post-treatment outcomes of acute ischemic stroke patients undergoing cerebral revascularization”. Method: Cross-sectional, prospective, descriptive analysis with convenient sample size. Results: From February 2018 to August 2021, 83 patients were hospitalized with a diagnosis of acute ischemic stroke or acute ischemic stroke and had cerebral revascularision either by thrombolysis or mechanical devices or both. 6.02% of them had cerebral thrombosis with mechanical devices and stenting of cerebral/carotid arteries. Mean age was 66.37±11.82 (range 31to 91 years). Mean NIHSS score was 12.57±6.70. The rate of complete recanalization was 91.56%. The mRS score of 0-2 points accounted for 48.19% at the time of discharge and 54.21% at 30 days after discharge. The rate of death or severe illness at discharge accounted for 14.45%. 30 days all-cause mortality after discharge accounted for 25.3%. Conclusion: The rate of complete reperfusion in patients with acute cerebral infarction at Hanoi Heart Hospital and good recovery rate is quite high. Factors that related to the treatment efficacy of patients with acute ischemic stroke were NIHSS score, ASPECT score, occlusion site, pre-reperfusion parenchymal damage and the selection of appropriate reperfusion measures.

Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke.

Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT. We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0-2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups. The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group (p < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group (p < 0.05). The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

Effect of blood pressure variability in the randomized controlled BP TARGET trial.

The Blood Pressure Target in Acute Ischemic Stroke to Reduce Hemorrhage After Endovascular Therapy (BP TARGET) trial evaluated whether an intensive systolic blood pressure (SBP) target resulted in reduced rates of intracranial hemorrhage (ICH) after successful endovascular therapy (EVT) but did not assess the effect of blood pressure variability (BPV) on functional outcomes and ICH occurrence. We sought to evaluate this question in the BP TARGET trial. We performed a post hoc analysis of the BP TARGET trial and included patients with at least 50% of blood pressure (BP) recordings during the first 24 h after EVT. BPV parameters were SBP and diastolic BP (DBP) coefficient of variation (CV), standard deviation (SD), maximum-minimum (max-min), successive variation (SV), and time rate. The primary outcome was favorable functional outcome (3-month modified Rankin Scale between 0 and 2); the secondary outcome was the rate of ICH at 24h. We included 290 patients (mean number of BP measures = 30.4, SD=8.0). BPV parameters (SBPSD , SBPmax-min , SBPCV ) were higher in the intensive SBP target group. Only DBP BPV parameters were associated with worse functional outcomes in the unadjusted model (DBPSD , DBPmax-min , DBPCV , and DBPSV ), but not after adjustment. Higher SBPmax-min was associated with worse functional outcomes in Thrombolysis in Cerebral Infarction 2B patients (odds ratio [OR]=0.62, 95% confidence interval [CI] = 0.38-1.02), but not in patients with complete reperfusion (OR=1.27, 95% CI = 0.80-2.02, p for heterogeneity (phet =0.037). None of the BPV parameters was associated with ICH, regardless of the randomization group or the reperfusion grade. BPV was significantly higher in the intensive SBP target group but was not associated with functional outcome or ICH.

Prevalence and Significance of Impaired Microvascular Tissue Reperfusion Despite Macrovascular Angiographic Reperfusion (No-Reflow).

The relevance of impaired microvascular tissue-level reperfusion despite complete upstream macrovascular angiographic reperfusion (no-reflow) in human stroke remains controversial. We investigated the prevalence and clinical-radiologic features of this phenomenon and its associations with outcomes in 3 international randomized controlled thrombectomy trials with prespecified follow-up perfusion imaging. In a pooled analysis of the Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA; ClinicalTrials.gov NCT01492725), Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK; NCT02388061), and Determining the Optimal Dose of Tenecteplase Before Endovascular Therapy for Ischaemic Stroke (EXTEND-IA TNK Part 2; NCT03340493) trials, patients undergoing thrombectomy with final angiographic expanded Treatment in Cerebral Infarction score of 2c to 3 score for anterior circulation large vessel occlusion and 24-hour follow-up CT or MRI perfusion imaging were included. No-reflow was defined as regions of visually demonstrable persistent hypoperfusion on relative cerebral blood volume or flow maps within the infarct and verified quantitatively by >15% asymmetry compared to a mirror homolog in the absence of carotid stenosis or reocclusion. Regions of no-reflow were identified in 33 of 130 patients (25.3%), encompassed a median of 60.2% (interquartile range 47.8%-70.7%) of the infarct volume, and involved both subcortical (n = 26 of 33, 78.8%) and cortical (n = 10 of 33, 30.3%) regions. Patients with no-reflow had a median 25.2% (interquartile range 16.4%-32.2%, p < 0.00001) relative cerebral blood volume interside reduction and 19.1% (interquartile range 3.9%-28.3%, p = 0.00011) relative cerebral blood flow reduction but similar mean transit time (median -3.3%, interquartile range -11.9% to 24.4%, p = 0.24) within the infarcted region. Baseline characteristics were similar between patients with and those without no-reflow. The presence of no-reflow was associated with hemorrhagic transformation (adjusted odds ratio [aOR] 1.79, 95% confidence interval [CI] 2.32-15.57, p = 0.0002), greater infarct growth (β = 11.00, 95% CI 5.22-16.78, p = 0.00027), reduced NIH Stroke Scale score improvement at 24 hours (β = -4.06, 95% CI 6.78-1.34, p = 0.004) and being dependent or dead at 90 days as assessed by the modified Rankin Scale (aOR 3.72, 95% CI 1.35-10.20, p = 0.011) in multivariable analysis. Cerebral no-reflow in humans is common, can be detected by its characteristic perfusion imaging profile using readily available sequences in the clinical setting, and is associated with posttreatment complications and being dependent or dead. Further studies evaluating the role of no-reflow in secondary injury after angiographic reperfusion are warranted. This study provides Class II evidence that cerebral no-reflow on CT/MRI perfusion imaging at 24 hours is associated with posttreatment complications and poor 3-month functional outcome.

C92. Successful Percutaneous Coronary Intervention (PCI) in Rare Case of Anomalous Aortic Origin of the Right Coronary Artery from the Opposite Sinus (AAORCA) Presenting as Inferior ST Elevation Myocardial Infarction (STEMI)

Abstract Background AAORCA from opposite sinus is a rare congenital anomaly that can present with symptoms similar to coronary artery disease, even sudden cardiac death. AAORCA with Inferior STEMI is a rare combination situation. Management of acute myocardial infarction with AAORCA is not well established and still debatable. Case Summary We presented a case 61 years old aged male with STEMI and AAORCA. He admitted to our hospital with complaint of retrosternal chest pain with ST segment elevation in inferior lead thus we diagnosed as Inferior STEMI. He underwent an emergency coronary angiography (CAG) that showed anomalous of right coronary artery (RCA) and total occlusion of the proximal RCA with atherosclerotic lesion. Stent then implanted at proximal of RCA. Further work-up by Computed Tomography Angiography (CTA) revealed an AAORCA with interarterial course. Discussion AAORCA with interarterial course that presents as inferior STEMI is a rare case. Diagnosis requires CAG and coronary CTA to identify anatomy and physiology so revascularization can be carried out appropriately. It is still arguable whether atherosclerosis or the interarterial course of AAORCA that caused acute MI. There is evidence that anomalous coronary arteries doesn’t increase atherosclerosis risk than normal. Total occlusion located at the distal to interarterial course reinforce that atherosclerosis may be the possible cause of acute MI. PCI could be the preferred choice in patients with inferior STEMI accompanied by AAORCA with evidence of atherosclerotic lesion, because may result in complete reperfusion and good clinical outcome.

C92. Successful Percutaneous Coronary Intervention (PCI) in Rare Case of Anomalous Aortic Origin of the Right Coronary Artery from the Opposite Sinus (AAORCA) Presenting as Inferior ST Elevation Myocardial Infarction (STEMI)

Abstract Background AAORCA from opposite sinus is a rare congenital anomaly that can present with symptoms similar to coronary artery disease, even sudden cardiac death. AAORCA with Inferior STEMI is a rare combination situation. Management of acute myocardial infarction with AAORCA is not well established and still debatable. Case Summary We presented a case 61 years old aged male with STEMI and AAORCA. He admitted to our hospital with complaint of retrosternal chest pain with ST segment elevation in inferior lead thus we diagnosed as Inferior STEMI. He underwent an emergency coronary angiography (CAG) that showed anomalous of right coronary artery (RCA) and total occlusion of the proximal RCA with atherosclerotic lesion. Stent then implanted at proximal of RCA. Further work-up by Computed Tomography Angiography (CTA) revealed an AAORCA with interarterial course. Discussion AAORCA with interarterial course that presents as inferior STEMI is a rare case. Diagnosis requires CAG and coronary CTA to identify anatomy and physiology so revascularization can be carried out appropriately. It is still arguable whether atherosclerosis or the interarterial course of AAORCA that caused acute MI. There is evidence that anomalous coronary arteries doesn’t increase atherosclerosis risk than normal. Total occlusion located at the distal to interarterial course reinforce that atherosclerosis may be the possible cause of acute MI. PCI could be the preferred choice in patients with inferior STEMI accompanied by AAORCA with evidence of atherosclerotic lesion, because may result in complete reperfusion and good clinical outcome.

OR3. Admission blood glucose and ischemic time are associated with successful fibrinolysis in combined assessment of ST-segment resolution, myocardial infarction flow grade, and myocardial perfusion grade

Abstract Background and Aims Fibrinolytic therapy (FT) is the alternative recommendation in patients with ST-segment elevation myocardial infarction (STEMI) if primary percutaneous coronary intervention (PCI) could not be perfomed timely at initial presentation. Successful revascularization of occluded infarct-related coronary arteries depends on complex mechanisms of hemodynamic, clinical, biochemical, and mechanical parameters. This study aimed to find out predictors of complete reperfusion after FT based on Thrombolysis in Myocardial Infarction (TIMI) 3 flow, Myocardial Blush Grade (MBG) 3, and ST-segment resolution. Method and Results This retrospective study was held in Saiful Anwar, Malang Hospital during 2017-2021, including total of 142 patients. All patients received FT and coronary angiographic evaluation post-FT. Those were divided into 3 groups, which included R0,1 (0/1 highest measure of reperfusion), R2 (2 highest measures of reperfusion), and R3 (3 highest measures of reperfusion). Admission blood glucose (ABG) (OR 0.99 [95%CI -0.16;-0.001]; p = 0.025), ischemic time (OR 0.82 [95%CI -0.491;-0.137]; p = 0.001), and triglycerides (OR 0.98 [95%CI 0.23;-0.006]; p = 0.001) were negatively correlated to the complete restoration of reperfusion (R3). ABG&amp;lt;140 mg/dL (AUC 0.701 [95%CI 0.612-0.790]; p = 0.000) and ischemic time&amp;lt;5 hours (AUC 0.742 [95%CI 0.645-0.839]; p = 0.000) were significant predictors for R ≥ 2. Coronary characteristics were not related to measure of reperfusion (p = 0.25). Conclusion ABG&amp;lt;140 mg/dL and ischemic time&amp;lt;5 hours are important predictors of successful reperfusion post FT (R ≥ 2), along with triglycerides. Early assessment of patients who are likely to have low parameter reperfusion (R &amp;lt; 2) would help promptly preparing for primary PCI.

Abstract 14089: Phase Shift Microbubbles for the Treatment of Microvascular Obstruction

Introduction: Microvascular obstruction (MVO) following coronary intervention is a common problem associated with worse clinical outcome, and has no consistent therapy. We are developing a new technique termed sonoreperfusion (SRP), to restore microvascular patency. This entails the use of ultrasound (US) to cause microbubble (MB) cavitation to dissolve microthrombi; this MB cavitation creates shear stress, activates nitric oxide release, and results in thrombolysis. In this pilot study, to further optimize SRP, we have used Phase Shift Microbubbles (PSMBs) (Microvascular Therapeutics, Inc). Owing to their much smaller size relative to standard MBs (~400 nm vs 3 μm) and greater microthrombus penetration, we will test the hypothesis that PSMBs attain successful reperfusion of MVO, and ultimately, will provide more rapid SRP, in our model of MVO. Methods: MVO of the rat ( n =3) hindlimb was created by direct injection of microthrombi into the left femoral artery, followed by infusion of therapeutic PSMBs. Definity MBs (Lantheus Medical Imaging) were infused through the jugular vein for contrast enhanced ultrasound imaging (CEUS). A transducer was positioned vertically above the hindlimb for therapeutic US pulses during concomitant administration of PSMBs. CEUS cine loops with burst replenishment were obtained at baseline (BL), 10 min post MVO, and after each of the two SRP treatment sessions (TX1, TX2) and analyzed (MATLAB). Results: Fig. 1 depicts a typical example demonstrating successful creation of MVO and complete reperfusion after SRP treatment. Data are expressed as mean ± standard error. Blood volume (dB) at BL (15.3 ± 1.1), MVO (5.2 ± 1.3), TX1 (19.8 ± 2.4), TX2 (17.9 ± 1.8) and flow rate (dB/sec) at BL (2.7 ± 0.4), MVO (0.2 ± 0.1) TX1 (2.1 ± 0.5), TX2 (2.7 ± 0.4). Conclusions: US targeted PSMB cavitation causes successful rapid reperfusion of rat hindlimb following MVO. Studies to explore the underlying molecular mechanisms associated with SRP of PSMBs are underway.