Distal Arterial Occlusions Research Articles

Human “live cadaver” neurovascular model for proximal and distal mechanical thrombectomy in stroke

BackgroundPreclinical testing platforms that accurately replicate complex human cerebral vasculature are critical to advance neurointerventional knowledge, tools, and techniques. Here, we introduced and validated a human “live cadaveric” head-and-neck neurovascular...

Should Primary Stroke Centers Perform Advanced Imaging?

Should Primary Stroke Centers Perform Advanced Imaging?

Comparison of Two Pre-Hospital Stroke Scales to Detect Large Vessel Occlusion Strokes in Australia: A Prospective Observational Study

Aims The Hunter-8 and the ACT-FAST are stroke scales used in Australia for the pre-hospital identification of large vessel occlusion (LVO) stroke but have not previously been compared. Moreover, their use in identifying distal arterial occlusions has not previously been assessed. We therefore aimed to describe the area under the receiver operating curve (AUC) of the Hunter-8 versus the ACT-FAST for the detection of classic LVO. Methods Both scales were performed on consecutive patients presenting with stroke-like symptoms within 24 hours of symptom onset presenting to the emergency department at a tertiary referral hospital between June 2018 and January 2019. The AUC of the Hunter-8 and the ACT-FAST was calculated for the detection of LVO using different definitions [classic LVO (proximal segment of the middle cerebral artery (MCA-M1), terminal internal carotid artery (T-ICA), or tandem occlusions) and extended LVO (classic LVO plus proximal MCA-M2 and basilar occlusions)]. Results Of 126 suspected stroke patients, there were 24 classic LVO and 34 extended LVO. For detection of classic LVO, the Hunter-8 had an AUC of 0.79 and the ACT-FAST had an AUC of 0.77. For extended LVO, the AUC was 0.71 and 0.70 respectively. Conclusion Both scales represent a significant opportunity to identify patients with proven potential benefit from thrombectomy (classic LVO), however M2 and basilar occlusions may be more challenging to identify with these scales.

Time-to-Maximum of the Tissue Residue Function Improves Diagnostic Performance for Detecting Distal Vessel Occlusions on CT Angiography.

Detecting intracranial distal arterial occlusions on CTA is challenging but increasingly relevant to clinical decision-making. Our purpose was to determine whether the use of CTP-derived time-to-maximum of the tissue residue function maps improves diagnostic performance for detecting these occlusions. Seventy consecutive patients with a distal arterial occlusion and 70 randomly selected controls who underwent multimodal CT with CTA and CTP for a suspected acute ischemic stroke were included in this retrospective study. Four readers with different levels of experience independently read the CTAs in 2 separate sessions, with and without time-to-maximum of the tissue residue function maps, recording the presence or absence of an occlusion, diagnostic confidence, and interpretation time. Accuracy for detecting distal occlusions was assessed using receiver operating characteristic analysis, and areas under curves were compared to assess whether accuracy improved with use of time-to-maximum of the tissue residue function. Changes in diagnostic confidence and interpretation time were assessed using the Wilcoxon signed rank test. Mean sensitivity for detecting occlusions on CTA increased from 70.7% to 90.4% with use of time-to-maximum of the tissue residue function maps. Diagnostic accuracy improved significantly for the 4 readers (P < .001), with areas under the receiver operating characteristic curves increasing by 0.186, 0.136, 0.114, and 0.121, respectively. Diagnostic confidence and speed also significantly increased. All assessed metrics of diagnostic performance for detecting distal arterial occlusions improved with the use of time-to-maximum of the tissue residue function maps, encouraging their use to aid in interpretation of CTA by both experienced and inexperienced readers. These findings show the added diagnostic value of including CTP in the acute stroke imaging protocol.

Endovascular therapy in the distal neurovascular territory: results of a large prospective registry

BackgroundThere is a paucity of data regarding mechanical thrombectomy (MT) in distal arterial occlusions (DAO). We aim to evaluate the safety and efficacy of MT in patients with DAO and...

Percutaneously created sutureless anastomosis.

An 80-year-old male diabetic patient with end-stage renal disease was evaluated for decreasing access flow and difficult cannulation of his established percutaneous arteriovenous fistula (pAVF), created 6 months ago with the Ellipsys vascular access system (Avenu Medical, San Juan Capistrano, Calif).1Mallios A. Jennings W.C. Boura B. Costanzo A. Bourquelot P. Combes M. Early results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System.J Vasc Surg. 2018; 68: 1150-1156Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Mallios A. Fonkoua H. Allouache M. Boura B. Percutaneous arteriovenous dialysis fistula.J Vasc Surg. 2020; 71: 1395Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Mallios A. Bourquelot P. Franco G. Fonkoua H. Allouache M. Boura B. et al.Mid-term results of percutaneous arteriovenous fistula creation with the Ellipsys vascular access system, technical recommendations and an algorithm for maintenance.J Vasc Surg. 2020 Apr 7; ([Online ahead of print])Abstract Full Text Full Text PDF Scopus (26) Google Scholar The patient's ipsilateral hand was cool without distal pulses. Percutaneous transluminal angioplasty of the pAVF anastomosis had only modestly improved access flow because of significant diffuse arterial calcifications. Bilateral distal arterial occlusions were present and the pAVF remained dysfunctional. Further and more aggressive attempts with percutaneous transluminal angioplasty were thought likely to result in severe hand ischemia (steal syndrome); therefore, arterial inflow proximalization was established using a 4- to 7-mm graft (W. L. Gore & Associates, Flagstaff, Ariz) with a lateral axillary artery anastomosis and an end-to-end outflow anastomosis to the mature cephalic vein, ligating the distal pAVF inflow site. An excellent thrill was recovered immediately over the entire length of the cephalic vein in the arm. Distal circulation improved substantially. A/Cover, B, and Video 1 show a perioperative view of the percutaneously created Ellipsys anastomosis between the proximal radial artery and perforating vein of the elbow. To our knowledge, this is the first direct visualization of an Ellipsys pAVF anastomosis in a human. The anatomic configuration and natural course of the pAVF are apparent along with the absence of suture or fibrosis, yielding a shape similar to surgical proximal radial artery AVFs described by Jennings et al.4Jennings W. Mallios A. Mushtaq Proximal radial artery arteriovenous fistula for hemodialysis vascular access.J Vasc Surg. 2018; 67: 244-253Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar C (medial view), D (anterior view), and Video 2 show the ligated pAVF anastomosis. Need for ligation of a pAVF has been a concern of some critics because of the multiple venous branches. This report demonstrates that in the rare case in which ligation is necessary, an Ellipsys pAVF may be easily ligated without consequence or technical challenges. The patient's informed consent was obtained before submission of this manuscript. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkM2YxZjljYzQzMTczOTJhZDVmYzdiMjVmYjJmMDc3YSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjU5NjgwMTEyfQ.P2iwekbqoGENyxeFwVBltgYalZQe974yt_1Pylg0oqw2wFHO3H5CWSPevIxJUo12W3mIV07CWaNMIpXXz890jVkEezWvpGPFAxKusFybJG_J-dUhtw2jZOOPABJPZG57mLmCApG-jTPEMAHW9pySwjjAkCUSrKAtXkkDyhYRg9KC4hAUWNilnBi-_azL08GN--bXaVldB4WfATLWRNN0AD8X_3mTXzlx_QakMBjMTbIc_JlN1rqNjO2zj3X2xxIyscs4nu7HNDe4Yl8ALcJg4rbz3dXNZm9xYBzLti2FU-yetHtrydtcxMLAVp3Fyk5IF4QMtPBmJ6GImX4mAYjwgg Download .mp4 (0.98 MB) Help with .mp4 files Video 1Perioperative view of the percutaneously created Ellipsys anastomosis between the proximal radial artery and perforating vein of the elbow.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4Yjk0MWI1ZWQwOTI1YzFjNmE0ZTAyMTJkN2YyODFjNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjU5NjgwMTEyfQ.HCPbtwp0lEn6tVnP5ipUjgo9Onu8BqDai6EaTcoSnwhdy1nK0swZeXM-bhdYhkOHKJoygNoK2-KvvS0ogyTxmhdk4F4pH_uKLQ0aBVKS1U7mXOouNT7J4OYjQRKkWFFxHaJWdePogqOgipV0cU_g0q4Mvzdqrwz-NM5QJTjg-rCAciba72xGohrwgvkUD24fZ21KOdzuGHnQD3HJlUmu5pbDBMCl6oLq5Uq970eaiRxZt66Y9ky_xXvbywthSc5h81x5QAqsGyLpDWA7oyrVn61ol7zdANzYpKlKsL9YKEgXAoBS8SNAMubTKpBlYIGCQrUtMDl602MclcggLFcrRA Download .mp4 (0.63 MB) Help with .mp4 files Video 2Ligated percutaneous arteriovenous fistula anastomosis.

Distal arterial occlusions in patients with mild strokes – is endovascular therapy superior to thrombolysis alone?

Background and PurposeSafety and efficacy of endovascular thrombectomy (EVT) in patients with mild stroke syndromes is unclear, especially in distal vessel occlusions. MethodsWe analysed in our stroke database (HeiReKa) between 2002 and April 2019 safety and efficacy of EVT compared to intravenous thrombolysis (IVT) in patients with occlusions distal to the M1 segment of the middle cerebral artery and the top of the basilar artery who presented with a National Institute of Health Stroke Scale (NIHSS) below 6. Excellent (good) outcome was defined as modified rankin scale (mRS) 0-1 (0-2) or return to baseline mRS (good) after 3 months. Safety endpoints were mortality after 3 months and intracranial hemorrhage according to the Heidelberg Bleeding Classification (HBC). ResultsOf 4167 patients 94 met the inclusion criteria. Sixty-four patients were allocated to the IVT group and 30 to the EVT group of which 15 also received IVT; three patients (4.6%) in the IVT group received rescue EVT. Baseline characteristics did not differ but more M2 occlusions were found in the EVT group (93.3% vs. 64.1%, p = 0.02). Intracranial bleeding occurred more often in EVT patients (HBC class 2: 13.3% vs. 1.6%, p = 0.01). Excellent and good outcome were not significantly different (75% vs. 70%, p = 0.65 and 87.5% vs. 73.3%, p = 0.14). Mortality was significantly lower in IVT patients (1.6% vs. 13.3%, p = 0.04). ConclusionRates of excellent and good outcome after IVT or EVT were almost similar, but safety parameters were increased after EVT. EVT may be considered in selected patients after careful risk/benefit analysis.

A comparative analysis of 3MAX aspiration versus 3 mm Trevo Retriever for distal occlusion thrombectomy in acute stroke

BackgroundAlthough aspiration and stent retriever thrombectomy perform similarly in proximal occlusions, no comparative series are available in distal occlusions. We aimed to compare the 3 mm Trevo Retriever against the...

Single-center experience using the 3MAX or 4MAX reperfusion catheter for the treatment of acute ischemic stroke with distal arterial occlusions in patients not eligible for intravenous fibrinolysis.

In acute stroke, distal cerebrovascular occlusions can be linked to severe clinical symptoms, and treatment by mechanical thrombectomy may have an important clinical impact. When intravenous fibrinolytic therapy is firmly contraindicated, it remains the only treatment option. A total of 42 patients with isolated distal arterial occlusions and absolute contraindication for intravenous fibrinolytic therapy were retrospectively included. Mechanical thrombectomy was performed using Penumbra 4MAX or 3MAX aspiration catheters. When aspiration alone did not result in successful revascularization, a stent retriever was added. Direct thromboaspiration was the first treatment option in all patients. 16.7% of cases required the additional use of a stent retriever. A TICI score ≥ 2b reperfusion at the end of the procedure was obtained in 76.2% and a Rankin Score of 2 or less at 90days in 45.7%. Two hemorrhagic complications were observed. Direct thromboaspiration appears a safe technique in acute isolated distal arterial occlusions. In a cohort of patients with absolute contraindication for intravenous fibrinolytic therapy, a significant percentage achieved good revascularization.

Single-Center Experience Using the 3MAX Reperfusion Catheter for the Treatment of Acute Ischemic Stroke with Distal Arterial Occlusions.

Most recent guidelines recommend the use of stent retriever devices in endovascular treatment of acute ischemic stroke with large vessel occlusion (LVO). Recently published data reported convincing results with thromboaspiration devices such as the Penumbra System (Penumbra, Alameda, CA, USA) combined with supple reperfusion catheters by using the ADAPT (ADirect Aspiration First-Pass Thrombectomy) technique. The aim of this study was to report our initial experience with the 3MAX (3.8 F) reperfusion catheter for the recanalization of distal intracranial arteries. From August 2015 to December 2016, 32consecutive patients (16females, 50%; mean age= 67.4± 18.7years, range: 22-91) for 38distal occlusions underwent mechanical thrombectomy (MT) by thromboaspiration using the 3MAX. Median NIHSS score at admission was 14 (IQR: 9-19). Distal occlusions were distributed as follows: M2 (n: 23), M3 (n: 6), P1 (n: 3), P2 (n: 2), P3 (n: 2), A3 segment (n: 1) and superior cerebellar artery (n: 1). In 1/38 (2.6%) target artery, the 3MAX could not be navigated. Of the 37 (59.5%) remaining arteries, 22 were successfully reperfused (TICI 2b/3) after ADAPT with the 3MAX alone. Additional stent retriever thrombectomy allowed a76.3% final reperfusion rate. Good functional outcome (mRS ≤2) was obtained in 45.5% of patients at 3months. Three (9.4%) 3MAX-related complications occurred: 2emboli to new territory (ENT) and one vascular perforation. The 3MAX is well-navigable in distal arteries making it useful as afrontline technique. However, the reperfusion rate with the 3MAX catheter alone seems lower than the ones reported with stent retrievers for such distal occlusions.

Sympathectomie thoracique

Upper thoracic sympathectomies, performed most of the time by coelioscopy, have become mildly aggressive interventions. Such procedure is primarily indicated for palmar and axillary hyperhidroses; it is also indicated in case of collagenosis-related disabling syndromes of Raynaud's disease, causalgias, distal arterial occlusions with thrombotic or embolic digital lesions, and lesions due to Buerger's disease. Thoracotomy is considered only in case of thoracoscopy failure or infeasibility. Other accesses are far less utilized. Ablation of the 2 nd and 3 rd thoracic sympathetic ganglia is sufficient for hand lesions; in case of axillary hyperhidrosis, further exeresis of the 4 th and 5 th ganglia is necessary. The only disadvantage related to this indication is the frequent postoperative compensatory hypersudation that involves both the thorax and the lumbar area, but which doesn't constitute a real complaint for the patients.

Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet.

To describe our experience with surgical therapy for upper extremity ischemia incident to emboli from aneurysms of the subclavian artery. Retrospective review case series. Vascular surgery practice at a university hospital-based tertiary referral center. All patients treated for upper extremity ischemia caused by embolism from a subclavian artery aneurysm from January 1, 1990, to July 31, 1996. All patients underwent detailed history and physical examination, screening for immunologic and hypercoaguable disorders, noninvasive vascular laboratory evaluation, and arteriography of the aortic arch in both arms and hands. Surgical treatment consisted of rib excision or fracture plating, aneurysm excision, and interposition vein grafting, with additional saphenous vein bypasses to brachial or forearm arteries as needed to provide uninterrupted circulation to the wrist. Twelve patients (6 males; mean age, 37 years) were treated. All had episodic upper extremity ischemia with an initial misdiagnosis of primary vasospastic disorder. Rest pain and/or ischemic ulceration developed in 3. Duration of symptoms before correct diagnosis averaged 7 months (range, 1-36 months). All patients had bony abnormalities of the thoracic outlet (8 cervical ribs, 3 abnormal first ribs, and 1 unstable clavicular fracture). All aneurysms contained intraluminal thrombus, and all patients had multiple ipsilateral distal arm, forearm, and/or hand arterial occlusions indicating chronic and repeated embolization. All patients underwent aneurysm excision and interposition vein grafting, with additional vein bypass to the brachial (3 patients) and/or forearm arteries (5 patients). Mean follow-up was 18 months (range, 2 weeks to 63 months). Eleven patients had complete symptomatic relief, and 1 patient improved. All subclavian interposition grafts remained patient. Two distal bypass grafts occluded in patients with preoperative arteriograms demonstrating no patient forearm arteries. There has been no limb loss. Hand ischemia caused by embolization from a subclavian artery aneurysm occurs in young patients without atherosclerosis and is frequently misdiagnosed as vasospasm. Despite advanced disease and multiple chronic distal arterial occlusions, surgical treatment by resection of bony abnormalities, aneurysm excision and grafting, and distal bypass grafting produces excellent results.

Intraoperative Fibrinolytic Therapy for Salvage of Limbs With Acute Arterial Ischemia: An Adjunct to Thromboembolectomy

The purpose of this prospective study was to determine the value of intraoperative intra-arterial fibrinolytic therapy (IIFT) in patients with acute arterial ischemia as an adjunct to mechanical thromboembolectomy. Sixty-six femoropopliteal or distal acute arterial occlusions were assessed by means of arteriography and Doppler imaging pre- and postoperatively. Two groups of patients were compared: one (n = 35) in which mechanical thromboembolectomy was applied as the single technique and another (n = 31) in which 250,000 IU of urokinase diluted in 250 ml of normal saline solution was instilled at the end of mechanical thromboembolectomy over a 30-minute period with the arterial inflow occluded. Candidates for IIFT were selected according to a nonrandomized method. Intraoperative arteriography showed residual thrombus in 20 (30.3%) patients and unsuspected arterial lesions in 23 (34.8%). Thrombosis recurrence was associated with residual thrombus (p < 0.001) and amputation (p < 0.001). The ankle/brachial index increased significantly (p < 0.05) in the patients who received IIFT (0.88 +/- 0.03) in comparison with those who underwent mechanical thromboembolectomy (0.75 +/- 0.05). Although the percentages of distal revascularization and amputation did not differ significantly between the two groups, quantitatively the results were better in the IIFT group (80.65% success and 9.68% failure) compared to the mechanical thromboembolectomy group (60% success and 22.86% failure). There was no bleeding due to IIFT. Significant variables in our study were diabetes (p < 0.05), the time period of 12 to 24 hours before the surgery (p < 0.05), and the severity of the ischemia in association with rest pain (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracic outlet syndrome

Eleven patients with vascular sequelae of thoracic outlet syndrome were operated on at the University of California, San Francisco, during the past 17 years. Five patients presented with episodes of ischemia of the arm and hand secondary to microemboli released from subclavian arterial lesions produced by chronic compression at the thoracic outlet. Treatment consisted of arterial reconstruction, removal of the compressive structure, and cervical sympathectomy to relieve or lessen distal ischemia. Four of the five patients had good or excellent results; one patient required amputation of the forearm. The results were inversely proportional to the extent of distal arterial embolic occlusions present at the time of surgical treatment. Six patients presented with symptoms of chronic venous hypertension. Four of the six had subclavian venous thrombosis and were treated by transaxillary resection of the first rib to decompress the collateral veins within the costoclavicular space. All four were symptomatically improved. Two patients had venous hypertension due to extrinsic compression of the subclavian vein. One patient became asymptomatic and the other was markedly improved after resection for external compression. In this small series transaxillary resection of the first rib has resulted in symptomatic improvement in chronic venous hypertension of the arm.

Dorsalis pedis artery in bypass grafting

For many years, arterial reconstructive procedures designed to treat arterial occlusive disease involving the lower extremities were limited to the femoral and popliteal vessels. Arterial bypass procedures involving anastomoses below the knee were thought to be impossible because of the small size of the vessels involved and the limited runoff. However, as technics of vascular surgery have improved and as surgeons have become more familiar with the handling of smaller vessels, successful treatment of more distal arterial occlusions has been possible. Morris et al [I ] in 1959 described the first anastomosis of arterial grafts to the distal popliteal vessel below the knee. Two years later, McCaughan [2] described the first group of patients who had bypass grafts to vessels below the popliteal trifurcation. It soon became apparent that vessels distal to the popliteal artery would support inserted autogenous saphenous vein grafts [3-101. Thereafter, the frequency of arterial bypass grafting to the anterior tibial, posterior tibial, and peroneal arteries in the calf region increased rapidly. More recently, refinements in surgical technics for suturing vessels 2 mm in diameter have resulted in favorable patency rates for arterial anastomoses at the ankle and below [11-141. This report is an analysis of sixteen patients in whom the dorsalis pedis artery was utilized for the distal anastomosis in bypass grafting for arterial occlusive disease.