Emergent Stent Placement Research Articles

Effects of Emergent Carotid Stenting Performed before or after Mechanical Thrombectomy in the Endovascular Management of Patients with Tandem Lesions: A Multicenter Retrospective Matched Analysis.

Mechanical thrombectomy (MT) along with emergent carotid stent placement (eCAS) has been suggested to have a greater benefit in patients with tandem lesions (TL), compared with other strategies of treatment. Nonetheless, there is no agreement on whether the intracranial occlusion should be treated before the cervical ICA lesion, or vice versa. In this retrospective multicenter study, we sought to compare clinical and procedural outcomes of the 2 different treatment approaches in patients with TL. The prospective databases of 17 comprehensive stroke centers were screened for consecutive patients with TL who received MT and eCAS. Patients were divided in 2 groups based on whether they received MT before eCAS (MT-first approach) or eCAS before MT (eCAS-first approach). Propensity score matching was used to estimate the effect of the retrograde-versus-anterograde approach on procedure-related and clinical outcome measures. These included the modified TICI score 2b-3, other procedure-related parameters and adverse events after the endovascular procedure, and the ordinal distribution of the 90-day mRS scores. A total of 295 consecutive patients were initially enrolled. Among them, 208 (70%) received MT before eCAS. After propensity score matching, 56 pairs of patients were available for analysis. In the matched population, the MT-first approach resulted in a higher rate of successful intracranial recanalization (91% versus 73% in the eCAS-first approach, P = .025) and a mean shorter groin-to-reperfusion time (72 [SD, 38] minutes versus 93 [SD, 50] minutes in the anterograde approach, P = .017). Despite a higher rate of efficient recanalization in the MT-first group, we did not observe a significant difference regarding the ordinal distribution of the 90-day mRS scores. Rates of procedure-related adverse events and the occurrence of both parenchymal hemorrhage types 1 and 2 were comparable. Our study demonstrates that in patients with TL undergoing endovascular treatment, prioritizing the intracranial occlusion is associated with an increased rate of efficient MT and faster recanalization time. However, this strategy does not have an advantage in long-term clinical outcome. Future controlled studies are needed to determine the optimal treatment technique.

Self-expandable metallic stent as bridge to surgery vs. emergency resection in obstructive right-sided colon cancer: a systematic review and meta-analysis.

Emergency resection is common for malignant right-sided obstructive colon cancer. As there is evidence showing a potential benefit of self-expandable metal stents as a bridge to surgery, a new debate has been initiated. The aim of this study was to compare self-expandable metal stents with emergency resection in right-sided obstructive colon cancer. A systematic search was conducted accessing Medline/PubMed, Scopus, Embase, and the Cochrane Database of Systematic Reviews. Studies reporting either emergency surgery or stent placement in right-sided obstructive colon cancer were included. Stent or emergency resection in right-sided obstructive colon cancer. Morbidity rate, mortality rate, stoma rate, laparoscopic resection rate, anastomotic insufficiency rate, success rate of stent. A total of 6343 patients from 16 publications were analyzed. The stent success rate was 0.92 (95% CI, 0.87 to 0.95) with perforation of 0.03 (95% CI, 0.01 to 0.06). Emergency resection was performed laparoscopically at a rate of 0.15 (95% CI, 0.09 to 0.24). Primary anastomosis rate in emergency resection was 0.95 (95% CI, 0.91 to 0.97) with an anastomotic insufficiency rate of 0.07 (95% CI, 0.04 to 0.11). The mortality rate after emergency resection was 0.05 (95% CI, 0.02 to 0.09). Primary anastomosis and anastomotic insufficiency rate were similar between the two groups (RR: 1.02; 95% CI, 0.95 to 1.1; p = 0.56 and RR: 0.53; 95% CI, 0.14 to 1.93; p = 0.33). The mortality rate in emergency resection was higher compared to stent (RR: 0.51, 95% CI 0.30 to 10.89, p = 0.016). No randomized controlled trials are available. Stent is a safe and successful alternative to emergency resection and may increase the rate of minimally invasive surgery. Emergency resection, however, remains safe and did not result in higher rate of anastomotic insufficiency. Further high-quality comparative studies are warranted to assess long-term outcomes.

Abstract Number ‐ 90: Bailout Technique for Entangled Stentriever and Carotid Stent during Tandem Large Vessel Occlusion Endovascular Therapy

Introduction Tandem occlusions represent 10–20% of all acute ischemic stroke patients.1 Endovascular Thrombectomy (EVT) for this subset of patients is more challenging given the proximal underlying steno occlusive disease. Emergent carotid artery stenting could achieve a considerably high chance of reperfusion and functional independence.2 Methods This is a case report of a 73‐year‐old woman who presented with left MCA syndrome‐NIHSS 13 found to have left ICA/MCA tandem occlusions. EVT was pursued, initial angiographic run of the left common carotid artery demonstrated severe stenosis at the origin of left cervical ICA which harbors a mid‐cervical ICA loop and proximal left MCA occlusion. Following our retrograde revascularization approach, an intracranial pass using an embotrap 5mm x 37 mm stent retriever (SR) was attempted however given proximal cervical ICA tortuosity and underlying proximal stenosis, the stability of triaxial system prevented optimal placement of the SR and achieving intracranial reperfusion. An antegrade revascularization approach was then pursued with uneventful cervical ICA angioplasty followed by extracranial carotid closed cell Xact stent placement. A stable triaxial system was navigated through the stented cervical ICA. An ideal SR pass was performed. Upon retrieving the clot‐incorporated SR with the intention to fully retrieve the SR into the locally placed aspiration catheter (AC) in the supraclinoid ICA under continuous aspiration, the triaxial system collapsed into the distal CCA, likely due to the mid cervical ICA loop, leading to entanglement of the proximal end of SR and distal ICA stent (Figure1‐A). Large thrombus was recovered from the AC aspirate. Results Numerous attempts to disentangle the SR from the ICA stent including attempts to re‐sheath the SR with different size microcatheters and guide catheters were unsuccessful. The cervical ICA lumen remained patent without evidence of dissection or residual thrombus however, the presence of SR pusher‐wire would preclude safe termination of the procedure. Surgical bailout with emergent carotid endarterectomy and removal of the stent/SR metal mesh was considered.3,4 However, given the high surgical risk with recent intravenous load of antithrombotics for emergent stent placement, this option was deemed as a last resort. We decided to attempt safe separation of the SR from its pusher wire and leave behind the patent ICA stent/SR in place. A gradual pulling pressure was applied to the SR wire while maintaining adjacent microwire access and fully inflated Viatrac 5mm x 30 mm extracranial balloon over the entangled portion to ensure continuous vascular access (Figure1‐B). The SR wire was then separated from the SR and fully retracted outside the body (Figure1‐C). Delayed angiographic runs continued to demonstrate full patency of the ICA lumen (Figure1‐D). No residual dissection, spasm or thrombus noted. Patient was discharged home with NIHSS of 3. Conclusions Exposure to EVT technical complications and bailout techniques are of utmost importance.

Reducing the rate of negative ureteroscopy: predictive factors and the role of preoperative imaging.

The aim of this study was to investigate factors that may predict a negative ureteroscopy (URS) performed for ureteric calculi in prestented patients and to assess preoperative imaging in reducing the rate of negative URS. Data were collected on emergency stent placement for a ureteric calculus from April 2011 to February 2016 (Group A) and October 2016 to October 2019 (Group B). Data included patient demographics, indication for a stent, stone characteristics, baseline bloods, urine culture, readmission, negative URS rate and the use of pre-URS imaging. Multivariate logistic regression was used for statistical analysis. Of 257 patients who underwent emergency stent insertion, 251 underwent deferred URS for a ureteric calculus and 6 avoided URS due to pre-URS imaging. Indications for stent were pain (42%), sepsis (39%) and acute kidney injury (19%). Mean stone size was 7.8mm, mean stone density was 699 Hounsfield units (HU) and the stone locations were upper (62%), mid (13%) and lower ureter (25%). The overall negative URS rate was 12%. The negative URS rate was lower in patients with pre-URS imaging compared with those with none, 6% and 14%, respectively (OR=2.33, 95% CI: 0.69-7.56, p=0.2214). Logistic regression analysis indicated stone size as the only significant predictor of a negative URS, where the greater the size of the stone the less likely URS would be negative (β=0.75, 95% CI: 0.60-0.94 p=0.011). Utilising pre-URS imaging can lead to a reduction in negative URS rate. Stone size <5mm appears to be the subgroup most likely to benefit from imaging.

The effect of nursing management in different levels and areas in emergency treatment of patients with acute ST segment elevation myocardial infarction

Objective: Study on the effect of nursing management in different levels and areas in emergency treatment of patients with acute ST segment elevation myocardial infarction. Methods: 200 patients with acute ST segment elevation myocardial infarction admitted by our hospital from January 2018 to October 2019 were divided into observation group and control group according to the nursing mode of patients, with 100 cases in each group. The patients in the control group were given routine emergency care, and the patients in the observation group were given graded and partitioned nursing management. Result: The time of emergency treatment, coronary angiography and stent placement were compared between the two groups. The results showed that the time of observation group was significantly shorter than that of control group (P &lt; 0.05). The results showed that the time of the observation group was significantly shorter than that of the control group (P &lt; 0.05). The incidence of complications was 11.00% in the control group and 1.00% in the observation group. There was statistical significance between the two groups (P &lt; 0.05). The nursing satisfaction of the control group was 80.00%, and that of the observation group was 96.00%. There was statistical significance between the two groups (P &lt; 0.05). Conclusion: The application effect of grading and zoning nursing management in the first aid of patients with acute ST segment elevation myocardial infarction is better. It can effectively shorten the waiting time of patients, reduce nursing complications, improve nursing satisfaction, and effectively improve the effect of first aid, which is worth popularizing.

Safety and Efficacy of Direct Angioplasty in Acute Basilar Artery Occlusion Due to Atherosclerosis.

Background and Purpose: Endovascular treatment (EVT) is one of the promising treatment options in patients with intracranial atherosclerotic disease (ICAD)-related basilar artery occlusion (BAO). In this study, we compared the safety and efficacy of direct angioplasty (DA) with stent-retriever thrombectomy (SRT) with or without rescue treatment in ICAD-related BAO.Methods: We retrospectively evaluated 187 patients who underwent EVT for BAO from January 2012 to July 2018. We identified patients who underwent EVT due to ICAD-related BAO. Patients who accepted SRT with or without rescue treatment were classified into the SRT group. Patients treated with DA with or without stent placement were classified into DA group. Clinical and laboratory findings and outcomes were compared between groups.Results: A total of 108 patients were enrolled, among them 77 underwent SRT and 31 underwent DA; 61 (79.2%) SRT group patients underwent angioplasty with or without stent placement. Compared with patients in the SRT group, those in the DA group experienced a significantly shorter procedure time [60 min (60–120 min) vs. 120 min (60–120 min); p = 0.038] and a lower number of device passes [2 passes (1–2 passes) vs. 3 passes (2–4 passes); p < 0.001]. No significant differences in balloon angioplasty (35.5 vs. 22.1%; p = 0.150), emergent stent placement (64.5 vs. 57.1%; p = 0.481), successful recanalization (93.5 vs. 85.7%; p = 0.340), embolization in distal or new territory (3.2 vs. 9.1%, p = 0.314), and reocclusion (22.6 vs. 9.1%; p = 0.109) among DA and SRT groups were found. Additionally, no differences in symptomatic intracranial hemorrhage incidence [adjusted odds ratio (OR), 0.74; 95% CI, 0.06–9.44; p = 0.815], functional independence (adjusted OR, 1.44; 95% CI, 0.50–4.16; p = 0.497), and mortality rate (adjusted OR, 0.36; 95% CI, 0.06–2.04; p = 0.247) were noted among groups.Conclusions: In certain patients with ICAD-related BAO, DA may shorten procedure time and reduce required device passes compared to SRT. In this study, DA was retrospectively found to be of similar safety and efficacy as SRT.

Management of tandem occlusions in patients who receive rtPA.

Tandem occlusions exist in 17-32% of large vessel occlusion (LVO) strokes. A significant concern is bleeding when carotid stenting is performed in tandem with thrombectomy due the administration of antiplatelet agents such as glycoprotein IIb/IIIa inhibitors (GP2b3aI) after receiving rtPA, but data are limited in this setting. A mutlicenter, retrospective chart review was conducted at two comprehensive stroke centers to assess the safety and efficacy of using GP2b3aI to facilitate carotid stent placement simultaneously with endovascular thrombectomy in patients who have received rtPA. Overall, 32 patients were included in this study, with average age of 66.3 ± 10.4years and predominantly male (87.5%). The cause of stroke was mostly large artery atherosclerosis (59.4%) and the thrombectomy target vessels were typically first- or second segment middle cerebral artery (37.5% and 31.3%). Time from symptom onset to rtPA bolus was 1.8h [interquartile range (IQR) 1.5-2.7], rtPA bolus to first pass was 2h [IQR 1.5-3.1], rtPA bolus to GP2b3aI bolus was 2h [IQR 1.6-3.5], and rtPA bolus to aspirin and clopidogrel administration was 4.3h [IQR 2.6-8.9] and 6.6h [IQR 4.5-11.6] respectively. No patients had acute in-stent thrombosis or post-op bleeding from the access site. Two patients (6.3%) had significant hemorrhagic conversion. The use of GP2b3aI in the setting of tandem occlusions that required emergent stent placement post-rtPA appears safe and effective. Given the small sample size, these findings should be interpreted cautiously, and need to be confirmed in a larger patient population.

Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1

Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1. Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy. Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment. Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.

S1961 Mediastinal Tuberculosis: A Rare Cause of Spontaneous Esophageal Perforation

INTRODUCTION: Esophageal perforation secondary to mediastinal tuberculosis is a rarely documented medical occurrence. We describe a patient admitted with sudden onset chest pain, followed by hematemesis, who was found to have a spontaneous esophageal perforation with mediastinal aspirates growing Mycobacterium tuberculosis (TB). CASE DESCRIPTION/METHODS: A 53 year old male with past medical history of atrial fibrillation on long term anticoagulation presented to the emergency department with sudden onset chest pain. His chest pain was followed by sudden hematemesis. Chest computed tomography (CT) revealed extensive pneumomediastinum consistent with esophageal perforation with mediastinal lymphadenopathy (Figure 1). Barium esophagram confirmed evidence of a large distal esophageal perforation (Figure 2). The patient underwent emergent esophageal stent placement and open repair of perforation. There was no reported evidence of mediastinal granuloma or fistula leading to the esophagus at the level of perforation. Mediastinal fluid cultures later returned positive for Mycobacterium tuberculosis. DISCUSSION: Esophageal perforation confers a high mortality risk to affected patients. Therefore, swift diagnosis and identification of underlying cause is important. We present a case of esophageal perforation thought to be secondary to tuberculosis induced mediastinal lymphadenopathy (1,2). It is believed that over time, persistent lymphadenopathy erodes though the esophageal wall leading to perforation. Though esophageal complications are only present in 0.15% of patient with active tuberculosis, it is important to identify tuberculosis as a potential cause of spontaneous perforation in at risk populations (3). Failure to confirm this diagnosis may lead to inadequate treatment and exposure to staff and community.Figure 1.: CT revealing mediastinal perforation with free air surrounding esophagus (arrow).Figure 2.: Esophagram revealing contrast (arrow) leaking into mediastinal cavity confirming esophageal perforation.

Emergent Stenting for Obstructive Nephrolithiasis During the COVID-19 Pandemic Compared to the Prepandemic Era.

COVID-19 has rapidly evolved into a global pandemic. In an attemp to reduce transmission, patients were advised to avoid in-person medical evaluations when possible. Accordingly, we hypothesize that fewer patients have sought care and undergone treatment for emergent urological conditions such as nephrolithiasis. We performed a retrospective chart review of patients undergoing emergent ureteral stent placement for obstructive nephrolithiasis from March 15, 2020 through May 31, 2020 and compared them to similar patients from a year earlier. We found that notably fewer patients underwent emergent stent placement during the COVID-19 era and that these patients were notably sicker. These findings suggest that indirect sequelae of the pandemic include delays in seeking care for conditions unrelated to the virus. Strategies such as increased use of in-office stenting and improved patient counseling may help reduce delays in care and improve clinical outcomes for patients with nephrolithiasis during subsequent peaks in the ongoing pandemic.

Carotid Stenting and Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Tandem Occlusions: Antithrombotic Treatment and Functional Outcome.

There is no consensus on the optimal antithrombotic medication for patients with acute ischemic stroke with anterior circulation tandem occlusions treated with emergent carotid stent placement and mechanical thrombectomy. The identification of factors influencing hemorrhagic risks can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to investigate the impact of medical therapy on functional and safety outcomes in patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions. A multicenter retrospective study on prospectively collected data was conducted. Only patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions of the anterior circulation were included. Univariate and multivariate analyses were performed on preprocedural, procedural, and postprocedural variables to assess factors influencing clinical outcome, symptomatic intracranial hemorrhage, stent patency, and successful intracranial vessel recanalization. Ninety-five patients with acute ischemic stroke and tandem occlusions were included. Good clinical outcome (mRS ≤ 2) at 3 months was reached by 33 (39.3%) patients and was associated with baseline ASPECTS ≥ 8 (OR = 1.53; 95% CI, 1.16-2.00), ≤2 mechanical thrombectomy attempts (OR = 0.71; 95% CI, 0.55-0.99), and the absence of symptomatic intracranial hemorrhage (OR = 0.13; 95% CI , 0.03-0.51). Symptomatic intracranial hemorrhage was associated with a higher amount of intraprocedural heparin, ASPECTS ≤ 7, and ≥3 mechanical thrombectomy attempts. No relationships among types of acute antiplatelet regimen, intravenous thrombolysis, and symptomatic intracranial hemorrhage were observed. Patients receiving dual-antiplatelet therapy after hemorrhagic transformation had been ruled out on 24-hour CT were more likely to achieve functional independence and had a lower risk of symptomatic intracranial hemorrhage. During carotid stent placement and mechanical thrombectomy for tandem occlusion treatment, higher intraprocedural heparin dosage (≥3000 IU) increased symptomatic intracranial hemorrhage risk when the initial ASPECTS was ≤7, and mechanical thrombectomy needs more than one passage for complete recanalization. Antiplatelets antiplatelets use were safe, and dual-antiaggregation therapy was related to better functional outcomes.

Timing of Definitive Operative Intervention in Cases of Obstructing Colon Cancers Following Emergent Stent Placement: A Retrospective Review

Timing of Definitive Operative Intervention in Cases of Obstructing Colon Cancers Following Emergent Stent Placement: A Retrospective Review

Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience.

Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results A total of 63 patients with a median age of 67 years (range 33-84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1-29). Median time from stroke onset to recanalization was 408 minutes (range 165-1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15-202 minutes] vs. 130 minutes [range 60-280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of ≥2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0-2) after three months. Conclusions Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high technical success, reasonable clinical outcomes and acceptable rates of symptomatic intracranial haemorrhage in carefully chosen patients which are triaged interdisciplinary based on clinical and computed tomography imaging criteria. This warrants further study in a randomised prospective trial.

Carotid Artery Stenting for Acute Ischemic Stroke Patients after Intravenous Recombinant Tissue Plasminogen Activator Treatment

We herein report three ischemic stroke patients who underwent emergency carotid artery stenting after receiving intravenous tissue plasminogen activator (t-PA) treatment. All patients received antiplatelet medications immediately before stent placement for loading as well as dual antiplatelet therapy after stenting. Under high-dose and dual antiplatelet therapy, none of the three patients showed symptomatic intracranial hemorrhaging. However, one case showed reocclusion of the placed stent after acute thrombosis. As a result, new treatment strategies for the use of antiplatelet agents during emergency stent placement must be developed, particularly for patients who have received intravenous t-PA therapy.

Many Benefits to Managing My Own Care

Many Benefits to Managing My Own Care

Emergency Stenting of the Extracranial Internal Carotid Artery in Combination with Anterior Circulation Thrombectomy in Acute Ischemic Stroke: A Retrospective Multicenter Study.

Several small case series reported a favorable clinical outcome for emergency stent placement in the extracranial internal carotid artery combined with mechanical thrombectomy in acute stroke. The rate of postinterventional symptomatic intracranial hemorrhages was reported to be as high as 20%. Therefore, we investigated the safety and efficacy of this technique in a large multicentric cohort. The data bases of 4 German stroke centers were screened for all patients who received emergency stent placement of the extracranial internal carotid artery in combination with mechanical thrombectomy of the anterior circulation between 2007 and 2014. The primary outcome measure was the rate of symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study III criteria; secondary outcome measures included the angiographic revascularization results and clinical outcome. One hundred seventy patients with a median age of 64 years (range, 25-88 years) were treated. They presented after a median of 98 minutes (range, 52-160 minutes) with a median NIHSS score of 15 (range, 12-19). Symptomatic intracranial hemorrhages occurred in 15/170 (9%) patients; there was no statistically significant difference among groups pertaining to age, sex, intravenous rtPA, procedural timings, and the rate of successful recanalization. In 130/170 (77%) patients, a TICI score of ≥ 2b could be achieved. The in-hospital mortality rate was 19%, and 36% of patients had a favorable outcome at follow-up. Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is effective and safe. It is not associated with a significantly higher risk of symptomatic intracranial hemorrhage compared with published series for mechanical thrombectomy alone.

Endovascular treatment of severe acute basilar artery occlusion

Severe acute basilar artery occlusion (BAO) has a high mortality rate but as yet no effective treatment has been developed. This study aimed to evaluate the feasibility and safety of combined mechanical thrombectomy, intra-arterial thrombolysis, and emergent stent placement for patients with severe acute BAO. Eighteen patients who were unconscious after confirmed onset of BAO and who were given arterial interventional treatment from March 2011 to June 2013 at our department were included in this study. The mean age was 59.56years (range: 31–76years) and patients were in a critical physical condition upon admission, and had a mean National Institutes of Health Stroke Scale (NIHSS) score of 25.94 (range: 18–35). All patients were treated with mechanical thrombectomy, 10 of whom received mechanical thrombectomy only. Of the others, eight were also treated with intra-arterial thrombolysis, three were treated with emergent stent placement, and 17 were treated with recanalization with an achieved recanalized rate of 94.4%. The average number of passes through the stent was 1.5 (range: 1–3) and five patients died (27.8%). Thirteen patients survived, and the mean NIHSS score was 6.54 (range: 0–16). Seven patients showed a modified Rankin Scale score ⩽2, and the rate of good prognoses was 38.9%. In the treatment of patients with severe acute BAO, intra-arterial mechanical thrombectomy combined with thrombolysis or stent placement are effective strategies to restore blood flow and preserve life, and these strategies have a low incidence of complications.

Duodenal ulcer penetration into the superior mesenteric artery after percutaneous transluminal angioplasty and stent placement for acute mesenteric ischemia: report of a case

A 78-year-old male presented with the chief complaints of abdominal pain and vomiting. Contrast-enhanced computed tomography and abdominal angiography showed occlusion of the superior mesenteric artery due to thrombosis, and emergency percutaneous transluminal angioplasty and stent placement were carried out. Two months later, stent thrombosis developed, and a second stent was placed. Eight months later, he complained of general fatigue and anorexia. Gastrointestinal endoscopy revealed a duodenal ulcer at the third portion close to the superior mesenteric artery. Thirteen days after conservative management, duodenal ulcer penetration into the superior mesenteric artery with subsequent air embolism developed, and the patient died of multiple organ failure.

Abstract TP11: National Trends in Utilization and Outcomes of Emergent Carotid Artery Stent Placement in Acute Ischemic Stroke Patients

Background: Subsequent to recent trials of carotid artery stent placement (CAS), emergent stent placement in acute ischemic stroke is being considered more frequently as part of the endovascular treatment. Objective: To evaluate trends in utilization of emergent CAS in acute ischemic stroke and to compare rates of death and disability with those treated with endovascular treatment without CAS. Methods: We obtained data for patients admitted to hospitals in the United States between 2004 to 2009 with a primary diagnosis of ischemic stroke using the Nationwide inpatient sample, a nationally representative data of acute care hospitalizations. We determined the rate of utilization of emergent CAS as part of endovascular treatment and outcomes according to use of emergent CAS or not. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition. Results: Of the 12,720 patients who underwent endovascular treatment, 1000 patients had emergent CAS (mean age 65 ± 12.8 years). The estimated number of patients undergoing emergent CAS increased by 7 fold (46 in 2004 to 336 in 2009). The rates of intracranial hemorrhage remained unchanged throughout the 6 years. The rates of none-minimal disability were significantly higher (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.3-3.1, p value=0.001) and in-hospital mortality was significantly lower [OR 0.6, 95% CI 0.4-0.9, p value=0.009] among patients who underwent endovascular treatment with emergent CAS after adjusting for potential confounders. Conclusion: There has been a significant increase in the proportion of acute ischemic stroke patients receiving emergent CAS with high rates of favorable outcomes and low rates of in-hospital mortality.

Abstract TP12: Safety of Antiplatelet Agents within 24 hours of Intra-arterial Thrombolytic Administration in Acute Ischemic Stroke Patients

Background: Current American Heart Association guidelines recommend withholding all antiplatelet use within 24 hours of thrombolytic use because of concerns regarding an increased risk of intracerebral hemorrhage (ICH). The increased use of emergent thrombectomy, angioplasty, and stent placement in endovascular treatment of acute stroke has prompted a reconsideration of antiplatelet use within 24-hour period. Objective: To determine if there is an increased rate of poor outcomes and ICH in acute ischemic stroke patients that undergo intra-arterial thrombolysis (IAT) and are started on antiplatelets within 24 hours of thrombolytics. Methods: All IAT treated acute ischemic stroke patients identified through a prospective database maintained from two comprehensive stroke centers over a 6-year period. Patients’ clinical characteristics, timing of antiplatelet agents, rates of poor outcome at discharge (modified Rankin score [mRS] of &gt;3) and ICH were obtained and analyzed. Results: Among the total 115 patients that underwent IAT, 65 patients (mean age 60 ± 16.4; 60% men) were started on antiplatelet agents within 24 hours. 43 (66%) patients were started on single antiplatelet, 19 (29%) on dual antiplatelet, and 3 (4.7%) on triple antiplatelet agents within 24 hours of IAT. The proportion of patients with admission NIHSS score&gt;20 was similar in patients who received antiplatelet agents within 24 hours versus those who received them after 24 hours (22% versus 24%, p=0.8) Compared with patients in whom antiplatelets were started after 24 hours, there was no significant difference in the rates of post-procedure ICH (20% versus 9%, p=0.09) and in-hospital mortality (12% versus 12%, p=0.9) in patients started on antiplatelets within 24 hours. There was no significant difference in the rates of poor outcomes (64% versus 71%, p=0.5) between the two groups. Conclusions: Despite the existing recommendation advising against the initiation of antiplatelet agents within 24 hours of thrombolysis, there seems to be no significant risk of increased ICH or mortality with such a practice in IAT cases. Larger prospective studies are needed to identify the benefit of early initiation of antiplatelet agents before broad use is implemented.