Distal Vessels Research Articles

The pitfalls and challenges in the diagnosis and treatment of patients with carotid near-occlusion: a narrative review.

Carotid near-occlusion (CNO) is defined as a severe stenosis of the internal carotid artery (ICA) resulting in a reduction in the distal diameter. It is a specific type of carotid stenosis accounting for 34% of the patients with symptomatic carotid stenosis ≥50%. The current guidelines recommend the best medical treatment (BMT) as the treatment of choice. Therefore, it is of the utmost importance to accurately diagnose CNO to avoid unnecessary surgical treatment. Although imaging can detect the majority of cases, there are still a few cases that remain unexplained. The purpose of this review is to discuss the mechanism of stroke, diagnostic imaging, and therapeutic approaches in patients with CNO and to examine the importance of diagnostic imaging in determining the treatment and prognosis of patients with CNO. The PubMed database was searched for clinical studies on CNO published in English from 1950 to 2024. The selected literature was screened for articles related to the formation mechanism of CNO, clinical diagnosis, and the latest developments in treatment methods. The primary mechanisms of stroke in CNO include embolism and hypoperfusion. Imaging techniques such as computed tomography angiography (CTA) and digital subtraction angiography (DSA) can identify most instances of CNO; however, anatomical variations may pose challenges in accurately diagnosing this condition. Currently, revascularization offers limited benefits for patients with CNO. According to the 2023 European Society for Vascular Surgery (ESVS) guideline update, BMT is the preferred treatment for CNO, and patients with CNO and distal vessel collapse with recurrent carotid territory symptoms may be considered for revascularization after multidisciplinary team discussion. The diagnosis of CNO based on feature interpretation necessitates a cautious approach. It is imperative to conduct large prospective clinical trials to identify the optimal treatment for patients with various types of CNO.

Soft partial release of non-aggressive stent retriever technique for very distal arterial occlusion stroke.

Endovascular thrombectomy (EVT) for very distal vessel occlusion (DVO) stroke is increasingly performed but there is insufficient evidence on the efficacy and safety of distal EVT techniques. We hypothesized that the technique of soft partial release of non-aggressive stent retrievers (SPORNS) reduces friction on the perforating vessels during thrombectomy and thereby reduces bleeding complications. Retrospective study including consecutive DVO patients who were treated with the SPORNS technique between 1 January 2022 and 31 December 2022 at two tertiary stroke centers. DVOs were defined as isolated occlusions of the M3 and M4 segments of the middle cerebral artery, occlusions of the A2 and A3 segments of the anterior cerebral artery, and occlusions of the P2 and P3 segments of the posterior cerebral artery or of the superior cerebellar artery. The technique is described in detail and procedural and clinical outcomes are given. Twenty-four patients were treated with the SPORNS technique of whom 22 (92%) had complete or near complete recanalization (eTICI 2c/3). National Institutes of Health Stroke Scale (NIHSS) decreased from a median of nine (IQR 7-13) at admission to three (1-5) at discharge and 18 patients (75%) achieved a good outcome (modified Rankin scale 0-2) at day 90 post-stroke. Two patients (8%) had a small subarachnoid hemorrhage and two patients (8%) had a symptomatic intracerebral hemorrhage on follow-up imaging. For the treatment of very distal arterial occlusions, the SPORNS technique employing a soft partial release of a non-aggressive stent retriever is safe and effective for the thrombectomy of small clots. The technique potentially yields a lower rate of subarachnoid hemorrhages while achieving an excellent rate of complete and first-pass recanalization.

Relationships Among Capillary Refill Time, Peripheral Blood Flow Rate, and Fingertip Temperature: Advances in Peripheral Artery Contractility Diagnosis.

Capillary refill time (CRT) is a widely used noninvasive measure of cardiovascular health. Despite its widespread diagnostic utility, it has several limitations, particularly its low sensitivity for certain conditions, because factors such as the contraction and relaxation of distal blood vessels can influence CRT readings. This study was performed to explore the relationships between CRT and distal blood flow. The right hand of each of 10 healthy adult volunteers was cooled to induce blood vessel contraction. CRT, fingertip temperature, and blood flow rate were measured using a custom device, a thermometer, and a laser Doppler blood flow meter, respectively, before and after cooling. Hand cooling significantly decreased blood flow rate and increased CRT. A robust inverse correlation was observed between blood flow rate and CRT, supporting a model where CRT is the time required for blood to flow through a cylindrical pipe. Furthermore, CRT showed a significant negative correlation with fingertip temperature. Most participants had high correlation coefficients, although two showed lower values. However, all data points exhibited a linear relationship, with the slopes of the regression lines between CRT and temperature varying among participants. These results suggested that the slope between CRT and fingertip temperature indicates individual differences in arterial contractility. These findings could improve the diagnostic utility of CRT in assessing vascular health, including arterial age and Raynaud's phenomenon, based on the contractility of peripheral arteries.

Association of Pretreatment Perfusion Imaging Parameters With 90-Day Excellent Functional Outcomes in Anterior Circulation Distal Medium Vessel Occlusion Stroke.

Acute ischemic strokes caused by distal medium vessel occlusions (DMVO) represent a significant proportion of all stroke cases, yet the predictors of excellent functional outcomes in these patients remain poorly understood. This study aims to identify pretreatment computed tomography perfusion (CTP) parameters associated with excellent functional outcomes, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days, in patients with anterior circulation DMVO. We conducted a retrospective multicenter study involving patients with anterior DMVO, from three stroke centers within the Johns Hopkins Medical Enterprise. Baseline demographic, clinical, and imaging data were collected, with CTP parameters analyzed using RAPIDAI software. Univariable and multivariable logistic regression models were used to identify predictors of excellent outcomes. Receiver operating characteristic (ROC) curves were constructed to assess the predictive accuracy of CTP parameters. Among the 82 patients (median age, 71 years; 57% female), occlusions were located in the M2 segment in 89%, M3 in 8.5%, and A2 in 2.4%. IVT was administered to 37% of patients, and EVT was attempted in 59%. Excellent outcomes at 90 days were achieved in 45% of patients. In univariate analysis, white race (OR, 4.14; 95% CI, 1.66-10.9; P=0.003), higher CBV index (OR per 0.1-unit change, 1.45; 95% CI, 1.08-2.05; P=0.022), and lower relative cerebral blood flow (rCBF < 20%) volumes (OR, 0.91; 95% CI, 0.81-0.98; P=0.038) were significantly associated with excellent outcomes. In multivariate analysis adjusting for age, sex, race, IVT administration, EVT attempted, dyslipidemia, and premorbid mRS, higher CBV index remained a significant independent predictor (OR per 0.1-unit change, 1.72; 95% CI, 1.14-2.81; P=0.017), and lower rCBF < 20% volume was associated with better outcomes (OR, 0.91; 95% CI, 0.80-0.98; P=0.05). The multivariate model demonstrated good predictive performance (area under the ROC curve, 80%; 95% CI, 70%-90%; P < 0.001). In patients with anterior circulation DMVO, a higher CBV index on pretreatment CTP is an independent predictor of excellent functional outcomes at 90 days. These findings suggest that CTP parameters, particularly the CBV index, may be useful in prognostic assessment for this stroke population. Further studies are needed to validate these results and optimize therapeutic approaches. ABC＝ definition; XYZ＝ definition.

The Current Status of Endovascular Treatment for Extracranial Vertebral Artery Stenosis in Japan: A Subanalysis of the Japanese Registry of Neuroendovascular Therapy 4.

Endovascular treatment (EVT) is a potential therapeutic option for extracranial vertebral artery (VA) stenosis; however, its efficacy or optimal procedures remain unknown. This study aimed to investigate the recent status of EVT for extracranial VA stenosis in Japan using a nationwide registry. We conducted a post hoc analysis of the Japanese Registry of Neuroendovascular Therapy 4 that enrolled patients who underwent EVT at 166 hospitals in Japan from 2015 to 2019. The outcomes of this study were as follows: procedural success indicating that the planned procedure was completed, modified Rankin Scale (mRS) score at 30 days, and procedure-related complications evaluated according to the procedure during EVT (percutaneous transluminal angioplasty vs. stenting and with or without the use of embolic protection devices [EPDs]). Of 308 eligible patients, 301 (95%) were treated for atherosclerotic stenosis, predominantly by stenting (74%). EPDs were used in 43%, primarily with the distal balloon (63%). The proportion of procedural success was 98%. Functional independence (mRS of 0-2) at 30 days was achieved in 80% of the total cohort, and there were no differences between patients treated with or without stenting or EPDs (74% vs. 82%, p = 0.12, and 80% vs. 80%, p = 0.93). Procedural complications occurred in 28 (9.1%) patients similarly in each group, with distal embolism and vessel dissection being common. In conclusion, EVT is a reasonable option for extracranial VA stenosis as a daily clinical practice. This study emphasizes the potential of EVT in managing extracranial VA stenosis and the need for further research to refine treatment strategies.

Abstract 4141481: Outcomes of the upfront two stent strategies for bifurcation percutaneous coronary interventions: Insights from PROGRESS-BIFURCATION registry

Background: Upfront two-stent techniques are often used in bifurcation percutaneous coronary interventions (PCI), but there is controversy about optimal strategy selection. Methods: We examined the clinical, angiographic characteristics, and long-term outcomes of 206 bifurcation PCIs using the double kissing (DK) crush or the culotte techniques in 192 patients between 2014-2023 from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (NCT05100992). For the long-term outcomes adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using the mixed effects Cox proportional hazards model. Results: DK crush was more commonly used (70.4%). Patients in the culotte group had similar baseline characteristics with the DK crush group. Lesions treated with culotte were more likely to be in the left anterior descending (54.1% vs. 35.9%, p&lt;0.001) and circumflex arteries (21.3% vs. 9.0%, p&lt;0.001), had smaller proximal (3.50 [3.00, 3.75] vs. 3.50 [3.30, 4.00] mm, p=0.032) and distal (3.00 [2.75, 3.00] vs. 3.00 [3.00, 3.50] mm, p=0.047) main vessel diameters, and were less likely to have severe calcification (6.6% vs. 32.4%, p&lt;0.001). Technical success (96.7% vs. 98.6%, p=0.583), procedural success (93.1% vs. 93.9%, p=0.758), and in-hospital major adverse cardiovascular events (MACE) (3.4% vs. 6.1%, p=0.726) were similar in both groups. During a mean follow-up of 38-month, 32 (28.3%) patients experienced MACE. On multivariable analysis, culotte was associated with similar MACE (aHR 1.19; 95%CI 0.78-1.80; p=0.680), mortality (aHR 1.11; 95%CI 0.68-1.79; p=0.810), and target vessel PCI revascularization (aHR 0.58; 95%CI 0.30-1.13; p=0.460) compared with DK crush (Figure). Conclusions: Bifurcation PCI with DK crush and culotte had similarly high technical and procedural success, low in-hospital MACE, and long-term outcomes.

Abstract 4141480: Gender differences in bifurcation percutaneous coronary interventions: Update from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION)

Background: Gender differences on short and long-term outcomes following bifurcation percutaneous coronary intervention (PCI) have received limited study. Research Questions: To examine gender differences in outcomes of bifurcation PCI. Methods: We examined the angiographic, procedural characteristics, and outcomes of 1084 bifurcation PCIs (1076 patients) performed at five centers between 2013-2024 from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION). Results: Women represented 25.19% of the entire study population. They were older (68.37±12.34 vs 66.09±11.54; p=0.001), less likely to be currently smokers (13.7% vs 20.4%; p=0.014), with higher left ventricular ejection fraction (%) (55.46±13.27 vs 53.16±12.55; p&lt;0.001) and lower baseline creatinine (0.85 vs 1.00; p&lt;0.001). Lesion characteristics were mostly similar, with slightly lower proximal and distal main vessel diameter in women. Their proximal main vessel was more likely to be left anterior descending artery (46.5% vs 39.4%; p=0.030) and less likely to be right coronary artery (10.3% vs 16.1%; p=0.030), compared to men. Technical success was similar (94.5% vs 94.6%; p=0.952), while procedural success was lower (89.6% vs 94.1%; p=0.011). In-hospital major adverse cardiac events (MACE) were more common in women (8.5% vs 4.2%; p=0.007), which presented with increased in-hospital mortality (4.1% vs 0.6%; p&lt;0.001), stroke (1.8% vs 0.1%; p=0.005) and bleeding (1.8% vs 0.2%; p=0.013). Their PCIs required equal procedure time, but lower fluoroscopy time, contrast volume and air kerma radiation dose. Female gender was independently associated with higher in-hospital major adverse cardiac events (MACE) (odds ratio (OR) 2.21; 95%CI 1.23-3.95; p=0.008) and lower procedural success (OR 0.56; 95%CI 0.32-1.00; p=0.044). Follow-up data were available for 733 patients (68.12%). The incidence of follow-up MACE was significantly higher in women (hazard ratio (HR) 1.36; 95%CI 1.02-1.81; p=0.038), while on adjusted mixed Cox proportional hazards analysis female gender was associated with higher follow-up MACE (HR 1.58; 95%CI 1.08-2.30; p=0.018). The incidence of follow-up mortality was similar between genders (HR 1.17; 95%CI 0.78-1.77; p=0.45). Conclusions: Bifurcation PCI can be accomplished with high technical success in women, but higher in-hospital and follow-up MACE, compared to men.

Incidence of Angiographic Deterioration Following Inframalleolar Angioplasty and Its Impact on Outcomes in Patients With Chronic Limb-Threatening Ischemia Requiring Repeat Intervention.

Clinical impact of inframalleolar (IM) angioplasty in patients with chronic limb-threatening ischemia (CLTI) is still controversial. This single-center, retrospective study included 168 patients with CLTI and tissue loss who underwent angioplasty for IM lesions. Angiographic follow up was performed at reintervention between April 2010 and December 2020. The outcome measure was the incidence of angiographic deterioration characterized by severe restenosis or occlusion of mildly stenotic lesions, occlusion of severely stenotic lesions, or extension of the occlusion length at reintervention. Angiographic deterioration was observed in 47.7% of patients, with the majority attributed to occlusion in severely stenotic lesions. Multivariate analysis revealed that a distal reference vessel diameter ≤1.0 mm in the initial angioplasty (hazard ratio 1.91 [95% confidence interval 1.20-3.04]; P=0.006) was significantly associated with angiographic deterioration of IM lesions at reintervention. Angiographic deterioration occurred in approximately half of the patients with CLTI who underwent IM angioplasty and reintervention.

Intraoperative Invasive Coronary Angiography after Coronary Artery Bypass Grafting.

The aim of this study was to prospectively evaluate the feasibility and safety of intraoperative invasive coronary angiography (ICA) following coronary artery bypass grafting using a mobile angiography C-arm. Between August 2020 and December 2021, 18 patients were enrolled for intraoperative ICA following coronary artery bypass grafting. After skin closure, ICA was performed including angiography of all established bypass grafts via a mobile angiography system by an interventional cardiologist. Data on graft patency, stenosis, and kinking were assessed. Grafts were rated on an ordinal scale ranging from very poor (1) to excellent (5). Furthermore, the impact of ICA compared with flow measurement was assessed using the ordinal Likert scale ranging from (I) worse to (V) much better. The ICA was considered better (V) compared with transient flow measurement in 38 (93%) and comparable (III) in 3 (7%) distal anastomoses. ICA impacted clinical or surgical decision-making in three patients (17%). In one patient, dual antiplatelet therapy for 6 months was initiated and rethoracotomy was needed in two (11%) patients with bypass graft revision and additional bypass grafting for graft occlusion. There were no cerebral and distal embolic events or access vessel complications observed and no postoperative acute kidney injury occurred. Intraoperative angiography after coronary bypass grafting is safe. Using a mobile angiographic device, graft patency, and function assessment was superior to transit time flow measurement leading to further consequences in a relevant number of patients. Therefore, it has the potential to reduce postoperative myocardial injury and improve survival.

Endovascular thrombectomy for distal medium vessel occlusions: A literature review

BackgroundThere is a lack of substantial evidence supporting the safety and effectiveness of endovascular thrombectomy in treating distal medium vessel occlusions (DMVOs). ObjectiveTo summarize the current evidence regarding endovascular thrombectomy for DMVOs. MethodsWe conducted a narrative review of key articles related to the diagnosis and management of DMVOs. We manually searched PubMed and Google Scholar from January 2010 to July 2023, and only included articles published in the English language. ResultsWhile diagnosing and treating DMVOs is tricky due to access limitations and potential limited benefit from mechanical clot removal, recent improvements in catheter and retrieval technology suggest that endovascular thrombectomy might be a potential treatment option. However, more high-quality research is needed to confirm its effectiveness for DMVOs. ConclusionExperts disagree on how to classify DMVOs and what the best mode of endovascular treatment is.

Mechanical Thrombectomy for Treatment of Acute Cerebral Infarction due to Distal Medium Vessel Occlusions: A Retrospective Cohort Study.

Mechanical thrombectomy (MT) is standard of care for acute cerebral infarction (ACI) due to large vessel occlusions. However, its clinical efficacy in patients with ACI due to distal medium vessel occlusions (DMVOs) remains unclear. This study evaluates the efficacy and safety of MT in patients with ACI due to DMVOs. Totally, 306 patients with ACI at a very early stage were assigned into DMVOs-MT, M1-MT, and DMVOs-intravenous thrombolysis (IVT) groups. These groups were compared regarding baseline data, recanalization rate, location of vessel occlusions, number of thrombectomy, first-pass recanalization, mRS scores, NIHSS scores, 90-day mRS scores, incidence of adverse events, and mortality. Risk factors for poor prognosis of patients with DMVOs following MT were analyzed. DMVOs-MT and M1-MT groups showed comparable first-pass recanalization rates, recanalization rates, and NIHSS score reduction ratios, with marked differences in location of vessel occlusions. Versus DMVOs-IVT, DMVOs-MT had increased differences between pre- and post-treatment NIHSS scores and between pre-treatment NIHSS scores and NIHSS scores at discharge and elevated NIHSS reduction ratios. The poor prognosis rate of DMVOs-MT group was insignificantly different from that of M1-MT group but lower than that of DMVOs-IVT group. Adverse events and mortality incidences were comparable among the three groups. Diabetes, first-pass recanalization, and pre-treatment NIHSS scores were independent risk factors for poor prognosis in DMVO patients after MT. MT is as effective and safe in patients with DMVOs as in patients with M1 occlusions. In patients with DMVOs, MT has higher efficacy and safety than IVT.

Role of Hypoperfusion Intensity Ratio in Vessel Occlusions: A Review on Safety and Clinical Outcomes.

The hypoperfusion intensity ratio (HIR) is a quantitative metric used in vascular occlusion imaging to evaluate the extent of brain tissue at risk due to hypoperfusion. Defined as the ratio of tissue volume with a time-to-maximum (Tmax) of >10 seconds to that of >6 seconds, HIR assists in differentiating between the salvageable penumbra and the irreversibly injured core infarct. This review explores the role of HIR in assessing clinical outcomes and guiding treatment strategies, including mechanical thrombectomy and thrombolytic therapy, for patients with large vessel occlusions (LVOs). Evidence suggests that higher HIR values are associated with worse clinical outcomes, indicating more severe tissue damage and reduced potential for salvage through reperfusion. Additionally, HIR demonstrates predictive accuracy regarding infarct growth, collateral flow, and the risk of reperfusion hemorrhage. It has shown superiority over traditional metrics, such as core infarct volume, in predicting functional outcomes. HIR offers valuable insights for risk stratification and treatment planning in patients with LVOs and distal medium vessel occlusions (DMVOs). Incorporating HIR into clinical practice enhances patient care by improving decision-making processes, promoting timely interventions, and optimizing post-intervention management to minimize complications and improve recovery outcomes.

Prognostic outcome of ACS in HTX patients after PCI

Abstract Background Cardiovascular disease (CVD) is the leading cause of mortality and morbidity worldwide, particularly in countries with limited access to healthcare [1,2]. Acute coronary syndrome is a collective term for several clinical conditions resulting from narrowing or occlusion of the coronary arteries [3,4]. Another group of patients affected by cardiovascular disease are those who have undergone heart transplantation. Long-term survival after transplantation is limited by cardiac allograft vasculopathy, a condition that affects the coronary arteries of the donor heart and causes diffuse narrowing [5,6]. Our retrospective analysis aims to compare the prognostic outcomes of HTX patients with ACS who underwent PCI with patients without a history of HTX. Results A total of 3194 patients with ACS were enrolled, of whom 1.16% (37) had a previous heart transplant. Patients with prior transplantation were on average younger (52.54 ± 15.13 vs. 69.76 ± 12.16, p &amp;lt; 0.001), had less dyspnea (p &amp;lt; 0.001) and a different distribution of ACS types (p &amp;lt; 0.001), as shown in Figure 1. There were no differences in sex (p = 0.287), BMI (p = 0.123), hypertension (p = 0.557), diabetes mellitus (p = 0.188) and previous myocardial infarction (p = 0.681). The majority of HTX patients were diagnosed with ISHLT CAV III (58.54%) and the average time to PCI was 12 years after transplantation. Multi-vessel disease was more common in HTX patients (p &amp;lt; 0.001). In addition, calcification was less frequent in the HTX group than in the control group (p &amp;lt; 0.001), and the lesion morphology was more diffuse in the HTX group (p &amp;lt; 0.001). On the other hand, there was no difference in the distribution of target vessels (p = 0.424), with the left anterior descending being the most frequently treated coronary artery, followed by the left circumflex and right coronary arteries. HTX patients received more stents (p &amp;lt; 0.001). There was also a difference in post-procedural TIMI flow achieved (p = 0.047), with less TIMI 3 flow achieved after PCI in the HTX group (80% vs. 93.59%). Technical success was less likely to be achieved in the HTX group (62.50% vs. 96.29%, p &amp;lt; 0.001), as was procedural success (47.06% vs. 89.68%, p &amp;lt; 0.001). There was no difference in the incidence of complications, which include perforation and bleeding (p = 0.284). All-cause mortality at three years (39.02% vs. 17.50%, p &amp;lt; 0.001), stroke (7.32% vs. 1.59%, p = 0.035) and myocardial infarction (p = 0.026) were higher in the HTX group. Over a period of three years, MACCE was more likely to occur in the HTX sub-group, which is shown graphically in Figure 2. Conclusion Interventional treatment of ACS in HTX patients is an option with a complication rate comparable to non-HTX patients and with a lower technical and procedural success - partly due to the diffuse nature of CAV and the involvement of distal and microvascular vessels. Overall MACCE and survival are inferior to the control population.Figure 1Figure 2

Heparin reversal for coronary artery perforation

Abstract Background/Introduction In the management of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI), heparin reversal can provide hemostatic effects but raises concerns about potential coronary thrombosis if an intracoronary artery guidewire or balloon is in place. Purpose We aimed to evaluate the safety and efficacy of heparin reversal during device insertion for CAP. We also aimed to determine the optimal target activated clotting time (ACT) to maintain when performing heparin reversal. Methods We analyzed cases of CAP which occurred during PCI procedures in a single center from January 2006 to October 2023. Patients were assigned to two groups according to whether they received heparin reversal with a device in place. The safety outcome was the periprocedural myocardial infarction (creatine kinase-MB &amp;gt;5 times the upper normal limit), and the efficacy outcome was successful hemostasis at the end of the procedures (complete absence of CAP on angiography). Results Among the 22,368 cases, 368 (1.6%) developed CAP, consisting of main vessels 45%, distal vessels 43%, and collateral vessels 12%. Heparin reversal with a device in place was implemented in 211 (57%) cases. Of these, 16 (7.6%) experienced coronary thrombosis. After adjusting covariates by the multivariable logistic regression model, heparin reversal with a device in place was significantly associated with a higher incidence of periprocedural myocardial infarction (11% vs 4.5%; adjusted OR: 3.11; 95% CI: 1.24–7.78; P = 0.015) and a higher rate of successful hemostasis (91% vs 73%; adjusted OR: 2.78; 95% CI: 1.27–6.09; P = 0.011). In the analysis of cases where minimum ACT value was available (n = 251), this value was significantly correlated with coronary thrombosis (r = −0.16, P = 0.012). When the cutoff values of minimum ACT were set at 200, 150, and 120 seconds as a binomial variable, the correlation coefficient was r = −0.08 (P = 0.158), r = −0.16 (P = 0.009), r = −0.20 (P = 0.001), respectively. Conclusions Heparin reversal after CAP with an intracoronary artery device in place was significantly associated with a higher incidence of periprocedural MI but also a higher rate of successful hemostasis. A minimum ACT value &amp;lt;150 seconds was significantly correlated with coronary thrombosis. These results propose a novel algorithm for CAP management strategies.Management algorithm for CAP

Embolic myocardial infarction. Clinical characteristics, etiology, and prognosis

Abstract Introduction A small proportion of acute myocardial infarctions (AMI) are of embolic origin. There is limited information about the actual causes of these AMIs, the population they affect, and their prognosis. Purpose The purpose of this study is to describe the clinical characteristics of embolic myocardial infarction (EMB-AMI) and compare them with atherosclerotic myocardial infarction (ATH-AMI). Methods Retrospective observational study of patients admitted for AMI at our centre (2010-2022). Clinical characteristics, ethology, and prognosis are described, and the EMB-AMI cohort is compared with the ATH-AMI cohort. Results Out of 6046 AMIs, 75 (1.2%) were EMB-AMI. Cardiovascular risk factors were similarly distributed in both groups, except for a higher rate of smokers, males, and older age in the ATH-AMI group (figure 1). Additionally, EMB-AMIs more frequently presented as ST-elevation myocardial infarctions. Hospital mortality for EMB-AMI and ATH-AMI was 10.7% vs. 6.2% (p=0.177), and the rate of mechanical complications was higher in the EMB-AMI group (6.7% vs. 1.8%, p=0.009). Of the EMB-AMIs, 8 (10.7%) had other systemic emboli during admission, including a 5.3% of strokes (vs. 1.4% in the ATH-AMI group, p=0.021). In EMB-AMIs, coronary embolism was multivessel in 8 (10.7%) patients, 46 (61.3%) had distal vessel involvement, and 66 (88.0%) had initial TIMI 0 flow. Thrombectomy was performed in 51 (68%) patients, with 82% of them being successful. However, final TIMI was 0-1 in 36 (48%) patients and 3 in 32 (42.7%) patients. Angioplasty was performed in 12 (16.0%) patients. In 52 (67.5%) EMB-AMI patients, atrial fibrillation (AF) was diagnosed at some point during follow-up, and in 43 (57.3%), embolism was exclusively attributed to AF. Nine (12.0%) embolisms were attributed to prosthetic thrombosis, although thrombosis was confirmed by imaging in only one third of cases. Six (8%) embolisms were attributed to endocarditis, and 5 (6.7%) to patent foramen ovale. Rest of embolism causes detected are outlined in figure 2. During a mean follow-up of 44.8 months, 11 patients experienced new embolic events in the EMB-AMI cohort: 7 strokes, 2 probable coronary embolisms, and 2 systemic embolisms. Twenty-seven (36.0%) patients died during follow-up (38.4% of whom from cardiac causes), and 18 (24.0%) were admitted for heart failure. Conclusions EMB-AMI exhibits specific clinical characteristics distinct from ATH-AMI, with varied etiologies, with atrial fibrillation being the most common cause. These AMIs are associated with a higher incidence of complications, including mechanical complications of myocardial infarction and recurrence of embolic events.Characteristics and outcomesEmbolic source

Predictors and Outcomes of Excellent Recanalization Versus Successful Recanalization After Thrombectomy in Proximal and Distal Medium Vessel Occlusion Strokes: A Multinational Study

Background Acute ischemic stroke arising from medium vessel occlusions (MeVO) poses substantial challenges in treatment and management. This study aims to elucidate the outcomes and factors contributing to achieving excellent recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] 2c–3) versus successful recanalization (mTICI 2b) in patients with MeVO stroke undergoing mechanical thrombectomy (MT). Methods We conducted a multinational study analyzing data from the MAD‐MT (Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy) registry, encompassing 37 centers across North America, Asia, and Europe, collected between September 2017 and July 2023. The study included acute ischemic stroke patients with MeVO treated with MT, with or without intravenous thrombolysis, who achieved mTICI 2b–3 post‐MT. Results Among 1463 patients with successful recanalization (mTICI 2b–3), 523 achieved mTICI 2b recanalization, and 940 achieved mTICI 2c–3. Distal occlusions exhibited higher odds of excellent recanalization compared with proximal MeVO vessel occlusions (odds ratio, 1.58; 95% CI, 1.17–2.15; P = 0.003). Cardioembolic stroke pathogenesis was associated with a higher likelihood of excellent recanalization (1.67; 95% CI, 1.07–2.59; P = 0.018). Patients achieving mTICI 2c–3 recanalization demonstrated lower initial National Institutes of Health Stroke Scale scores, significant improvements in postprocedural National Institutes of Health Stroke Scale shift, and a higher percentage of favorable 90‐day outcomes compared with those with mTICI 2b. However, no significant difference in 90‐day mortality rates was observed. Conclusion This study underscores that among patients with MeVO stroke with successful recanalization (mTICI 2b–3) there is higher likelihood of achieving excellent recanalization (mTICI 2c–3) in distal occlusions and cardioembolic pathogenesis. mTICI 2c–3 scores post‐MT correlate with improved clinical outcomes compared with mTICI 2b, affirming the superiority of excellent recanalization over successful recanalization in patients with MeVO stroke. Further prospective studies and randomized controlled trials are warranted for validation.

Data-Driven Prognostication in Distal Medium Vessel Occlusions Using Explainable Machine Learning.

Distal medium vessel occlusions (DMVOs) are estimated to cause acute ischemic stroke (AIS) in 25-40% of cases. Prognostic models can inform patient counseling and research by enabling outcome predictions. However, models designed specifically for DMVOs are lacking. This retrospective study developed a machine learning model to predict 90-day unfavorable outcome [defined as a modified Rankin Scale (mRS) score of 3-6] in 164 primary DMVO patients. A model developed with the TabPFN algorithm utilized selected clinical, laboratory, imaging, and treatment data with the Least Absolute Shrinkage and Selection Operator feature selection. Performance was evaluated via 5-repeat 5-fold cross-validation. Model discrimination and calibration were evaluated. SHapley Additive Explanations (SHAP) identified influential features. A web application deployed the model for individualized predictions. The model achieved an area under the receiver operating characteristic curve of 0.815 (95% CI: 0.79-0.841) for predicting unfavorable outcome, demonstrating good discrimination, and a Brier score of 0.19 (95% CI: 0.177-0.202), demonstrating good calibration. SHAP analysis ranked admission National Institutes of Health Stroke Scale (NIHSS) score, premorbid mRS, type of thrombectomy, modified thrombolysis in cerebral infarction score, and history of malignancy as top predictors. The web application enables individualized prognostication. Our machine learning model demonstrated good discrimination and calibration for predicting 90-day unfavorable outcomes in primary DMVO strokes. This study demonstrates the potential for personalized prognostic counseling and research to support precision medicine in stroke care and recovery. DMVO = Distal medium vessel occlusion; AIS = acute ischemic stroke; mRS = modified Rankin Scale; SHAP = SHapley Additive Explanations; NIHSS = National Institutes of Health Stroke Scale; ST = stroke thrombectomy; TRIPOD = Transparent Reporting of Multivariable Prediction Models for Individual Prognosis or Diagnosis; CT = computed tomography; CTP = CT perfusion; MRI = magnetic resonance imaging; CTA = CT angiography; DVT = deep vein thrombosis; PE = pulmonary emboli; TIA = transient ischemic attack; BMI = body mass index; ALP = alkaline phosphatase; ALT = alanine transaminase; AST = aspartate aminotransferase; NCCT-ASPECTS = Alberta Stroke Program Early CT Score; IVT = intravenous thrombolysis; mTICI = modified thrombolysis in cerebral infarction; ER = emergency room; kNN = k-nearest neighbor; LASSO = Least Absolute Shrinkage and Selection Operator; PDPs = partial dependence plots; ROC = receiver operating characteristic; PRC = precision-recall curve; AUROC = area under the ROC curve; AUPRC = area under the PRC; CI = confidence interval.

Endovascular therapy versus medical management in isolated posterior cerebral artery acute ischemic stroke: A multinational multicenter propensity score-weighted study.

Despite the proven effectiveness of endovascular therapy (EVT) in acute ischemic strokes (AIS) involving anterior circulation large vessel occlusions, isolated posterior cerebral artery (PCA) occlusions (iPCAo) remain underexplored in clinical trials. This study investigates the comparative effectiveness and safety of EVT against medical management (MM) in patients with iPCAo. This multinational, multicenter propensity score-weighted study analyzed data from the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. We included iPCAo patients treated with either EVT or MM. The primary outcome was the modified Rankin Scale (mRS) at 90 days, with secondary outcomes including functional independence, mortality, and safety profiles such as hemorrhagic complications. A total of 177 patients were analyzed (88 MM and 89 EVT). EVT showed a statistically significant improvement in 90-day mRS scores (OR = 0.55, 95% CI = 0.30-1.00, p = 0.048), functional independence (OR = 2.52, 95% CI = 1.02-6.20, p = 0.045), and a reduction in 90-day mortality (OR = 0.12, 95% CI = 0.03-0.54, p = 0.006) compared to MM. Hemorrhagic complications were not significantly different between the groups. EVT for iPCAo is associated with better neurological outcomes and lower mortality compared to MM, without an increased risk of hemorrhagic complications. Nevertheless, these results should be interpreted with caution due to the study's observational design. The findings are hypothesis-generating and highlight the need for future randomized controlled trials to confirm these observations and establish definitive treatment guidelines for this patient population.

More severe cerebral small vessel disease associated with poor leptomeningeal collaterals in symptomatic intracranial atherosclerotic stenosis.

We investigated the association between cerebral small vessel disease (CSVD) and ipsilateral leptomeningeal collateral (LMC) status in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). In 108 patients with 50-99% symptomatic intracranial internal carotid artery or M1 middle cerebral artery stenosis, 4 CSVD imaging markers (lacunes, cerebral microbleeds, enlarged perivascular spaces [EPVSs], and white matter hyperintensities [WMHs]) were assessed in MRI. Score of 0 or 1 was assigned to each marker and added up as a summary CSVD score (ranging 0-4) to reflect an overall CSVD burden. Ipsilateral LMC status was assessed by determining the laterality of distal vessels in anterior and posterior cerebral artery territories on CT angiography. Moderate-to-severe EPVSs (adjusted odds ratio [aOR] = 4.15; p = 0.031) and WMHs (aOR = 5.90; p = 0.010), and higher summary CSVD score (aOR = 1.66; p = 0.030) were independently associated with poor LMCs. There was significant interaction between stenosis percentage in sICAS and summary CSVD score on poor LMCs (p = 0.022 for interaction), when higher CSVD score was significantly associated with poor LMCs in patients with severe sICAS (aOR = 2.84; p = 0.011) but not in those with moderate sICAS. The findings indicated possibly adverse effect of CSVD on the recruitment or development of LMCs in sICAS patients, especially in patients with severe sICAS.

The Vecta 46 intermediate catheter for mechanical thrombectomy of distal medium vessel occlusions: A single-center experience.

With emerging evidence supporting the clinical efficacy and safety of mechanical thrombectomy (MT) for distal medium vessel occlusions (DMVOs), MT devices specifically designed to navigate through smaller caliber and more delicate tortuous distal cerebrovasculature are required. This study describes our single-center experience using the AXS Vecta 46 intermediate catheter for first-line thromboaspiration of DMVOs. We identified all patients who underwent MT using the Vecta 46 for first-line thromboaspiration for primary or secondary DMVOs. We collected baseline clinical data, angiographic and clinical outcomes, as well as procedural complications. The primary outcome in question was the rate of successful recanalization, which was defined as a modified Thrombolysis in Cerebral Infarction score of ≥2b. We identified 43 patients who underwent MT using the Vecta 46 catheter for thromboaspiration of 54 DMVOs. Intervened vessels included the M2 (23/54), M3 (19/54), and M4 (6/54) branches of the middle cerebral artery, A2 (1/54), A3 (1/54), and A4 (1/54) branches of the anterior cerebral artery, and P1 (1/54), P2 (1/54), and P4 (1/54) branches of the posterior cerebral artery. The median number of passes for primary DMVOs was 2 (IQR: 1-3) and 1 (IQR: 1-1.25) for secondary DMVOs. The rate of successful recanalization was 100% (18/18) for primary DMVOs and 80.6% (29/36) for secondary DMVOs. First-pass effect (FPE) was noted in 55.6% (30/54) of all primary and secondary DMVO cases. Improved short-term clinical outcomes were observed in both the primary (National Institute of Health Stroke Scale [NIHSS] shift: -5 [IQR: -14.25 to -0.25]) and secondary (NIHSS shift: -5 [IQR: -10 to -2]) DMVO groups. A total of six patients died during their hospitalization, though none were deemed procedural-related. Our study demonstrates the safety and efficacy of the Vecta 46 intermediate catheter for thromboaspiration of both primary and secondary DMVOs, achieving high rates of successful recanalization and FPE.