Failure Of Recanalization Research Articles

Improvement of Cerebral Glucose Metabolism in Symptomatic Patients With Carotid Artery Stenosis After Stenting.

Neurocognitive performance among patients with carotid artery stenosis or occlusion may deteriorate because of chronic cerebral hypoperfusion. Carotid artery stenting (CAS) has been reported to improve cerebral perfusion and neurocognitive function. The purpose of the study was to evaluate cerebral metabolism using F-fluorodeoxyglucose (FDG) positron emission tomography (PET) after CAS. Nineteen consecutive patients (15 men, 69 ± 13 years) with carotid artery stenosis or occlusion and cerebral ischemia detected on brain perfusion computed tomography (CT) or magnetic resonance imaging (MRI) were enrolled. Four patients had bilateral lesions, and 15 subjects had previous ischemic stroke. Neurocognitive function (NCF) assessments and brain FDG PET scans were performed before and 19 ± 7 (12-31) months after the procedure. The procedural success rate of CAS was 70%. Two patients were excluded from the study because of procedural complications. No new cerebral ischemic events or neurologic deaths occurred during follow-up of 44 ± 11 (15-54) months. Significant improvements were observed in the Mini-Mental State Examination (before, 26.06 ± 3.32 versus after, 28.13 ± 2.8; P = 0.0016), the verbal fluency test (26.81 ± 7.82 versus 30.75 ± 9.58; P = 0.0378), and marginal upgrading in the Alzheimer Disease Assessment Scale-Cognitive Subtest (7.19 ± 7.59 versus 5.63 ± 5.90; P = 0.0523). Six of 9 patients who underwent successful CAS showed improvement of cerebral glucose metabolism. Of the 4 patients with recanalization failure, 2 exhibited decline in ipsilateral glucose metabolism. Cerebral FDG metabolism improved in patients with successful CAS (P = 0.038), although there was a weak correlation between interval change of NCF tests and brain FDG metabolism. Successful CAS may improve long-term cerebral glucose metabolism and neurocognitive function in patients with chronic severe carotid stenosis or occlusion.

Retrograde puncture assisted hepatic vein recanalization in treating Budd-Chiari syndrome with segmental obstruction of hepatic vein.

This study aimed at investigating the feasibility and effectiveness of retrograde puncture assisted hepatic vein (HV) recanalization in management of Budd-Chiari syndrome (BCS) patients with segmental obstruction of HV. From May 2011 to August 2014, 76 BCS patients with obstruction of HV were treated by routine transjugular HV recanalization in our center. Among them, 17 patients with segmental obstruction (obstruction length >1cm) of HV experienced failure of the routine transjugular HV recanalization and underwent retrograde puncture assisted HV recanalization. Data on technical success, clinical success and follow-up were collected and analyzed retrospectively. Retrograde puncture assisted HV recanalization was technically successful in 14 of 17 (82%) patients. Of these 14 patients, 12 patients underwent HV balloon dilation, and 2 patients underwent HV stent insertion. No procedure-related complications occurred in any of our patient. Clinical success was achieved in all of the 14 patients who experienced technical success. The mean HV pressure decreased from 43.6±6.7 cmH2O before treatment to 18.4±4.8 cmH2O after treatment (P<0.001). BCS-related symptoms began to improve on the next day following the treatment. During 4-43months (mean 17.4±10.8months) of follow-up, three patients experienced re-obstruction of HV. Retrograde puncture assisted HV recanalization is a simple, safe, and effective treatment for BCS patients with segmental obstruction of HV. It can serve as an additional treatment option for patients who experience the technical failure of routine transjugular HV recanalization.

Acute reperfusion therapy and stroke care in Asia after successful endovascular trials.

The current status of and prospects for acute stroke care in Asia in the situation where both intravenous thrombolysis and endovascular therapies have been recognized as established strategies for acute stroke are reviewed. Of 15 million people annually having stroke worldwide, ≈9 million are Asians. The burdens of both ischemic and hemorrhagic strokes are severe in Asia. The unique features of stroke in Asia include susceptibility to intracranial atherosclerosis, high prevalence of intracerebral hemorrhage, effects of dietary and lifestyle habits, and several disorders with genetic causes. These features affect acute stroke care, such as the dosage of alteplase for thrombolysis and consideration of bleeding complications during antithrombotic therapy. Acute endovascular thrombectomy, as well as intravenous thrombolysis, is relatively prevalent in East Asia, but most of the other Asian countries need to develop their human resources and fundamental medical infrastructure for stroke care. A limitation of endovascular therapy in East Asia is the high prevalence of intracranial atherosclerosis that can cause recanalization failure and require additional angioplasty or permanent stent insertion although intracranial stenting is not an established strategy. Multinational collaboration on stroke research among Asian countries is infrequent. Asians should collaborate to perform their own thrombolytic and endovascular trials and seek the optimal strategy for stroke care specific to Asia.

Retraction note: Meta-analysis of the effect of percutaneous coronary intervention on chronic total coronary occlusions.

Coronary chronic total occlusion (CTO) is the last stage of coronary artery atherosclerosis. Percutaneous coronary intervention (PCI) is a therapeutic procedure used to recanalize vessels with total occlusion. However, successful recanalization of CTO is still not optimal, and the key influence factors are still uncertainty. Therefore, a scientific evaluation on the effective of PCI for CTO treatment is necessary. Relevant studies of PCI treatment for CTO were examined. Data were extracted and assessed by two independent clinical experts. Embase, PubMed and Medline et al. were used as database. The main research key words include “CTO”, “PCI”, “Stent”, “Reopen”, “long-term”, “follow-up” and “outcome”. Quality assessment was carried out according to the Cochrane Handbook. The selected data were pooled and analyzed using fixed-effect model and random-effect model. Heterogeneity was assessed using the I 2 test, Q test, L’abbe and Galbraith. Comprehensive Meta -Analysis 2.0 and Metanalysis 1.0 were used for statistics analysis in this research. A total of 16 articles involving 6695 cases in successful CTO recanalization (CTO success group) and 2370 cases in failed CTO recanalization(CTO failure group) were included in this research. Low CTO success was associated with elder age, previous coronary artery bypass graft surgery (CABG) history, multi-vessel diseases and right coronary artery disease lesion. Six follow-up variables including major adverse cardiac events (MACE), recurrent myocardial infarction (MI), all-cause death, incidence of angina, subsequent CABG and cumulative survival rate were found significantly reduced associated with CTO success. Clinical baseline characteristics such as age, previous CABG history and lesion baseline characteristics such as lesion length, multi-vessel diseases might be important factors influencing the successful rate of CTO recanalization. Compared to CTO failure patients, all six follow-up variables showed advantage for CTO success patients.

Platelet rich clots are resistant to lysis by thrombolytic therapy in a rat model of embolic stroke.

BackgroundEarly recanalization of occluded vessels in stroke is closely associated with improved clinical outcome. Microbubble-enhanced sonothrombolysis is a promising therapy to improve recanalization rates and reduce the time to recanalization. Testing any thrombolytic therapy requires a model of thromboembolic stroke, but to date these models have been highly variable with regards to clot stability. Here, we developed a model of thromboembolic stroke in rats with site-specific delivery of platelet-rich clots (PRC) to the main stem of the middle cerebral artery (MCA). This model was used in a subsequent study to test microbubble-enhanced sonothrombolysis.MethodsIn Study 1 we investigated spontaneous recanalization rates of PRC in vivo over 4 hours and measured infarct volumes at 24 hours. In Study 2 we investigated tPA-mediated thrombolysis and microbubble-enhanced sonothrombolysis in this model.ResultsStudy 1 demonstrated stable occlusion out to 4 hours in 5 of 7 rats. Two rats spontaneously recanalized at 40 and 70 minutes post-embolism. Infarct volumes were not significantly different in recanalized rats, 43.93 ± 15.44% of the ischemic hemisphere, compared to 48.93 ± 3.9% in non-recanalized animals (p = 0.7). In Study 2, recanalization was not observed in any of the groups post-treatment.ConclusionsSite specific delivery of platelet rich clots to the MCA origin resulted in high rates of MCA occlusion, low rates of spontaneous clot lysis and large infarction. These platelet rich clots were highly resistant to tPA with or without microbubble-enhanced sonothrombolysis. This resistance of platelet rich clots to enhanced thrombolysis may explain recanalization failures clinically and should be an impetus to better clot-type identification and alternative recanalization methods.Electronic supplementary materialThe online version of this article (doi:10.1186/s13231-014-0014-y) contains supplementary material, which is available to authorized users.

The Effectiveness of Additional Treatment Modalities after the Failure of Recanalization by Thrombectomy Alone in Acute Vertebrobasilar Arterial Occlusion.

ObjectiveAcute vertebrobasilar artery occlusion (AVBAO) is a devastating disease with a high mortality rate. One of the most important factors affecting favorable clinical outcome is early recanalization. Mechanical thrombectomy is an emerging treatment strategy for achieving a high recanalization rates. However, thrombectomy alone can be insufficient to complete recanalization, especially for acute stroke involving large artery atheromatous disease. The purpose of this study is to investigate the safety and efficacy of mechanical thrombectomy in AVBAO.MethodsFourteen consecutive patients with AVBAO were treated with mechanical thrombectomy. Additional multimodal treatments were intra-arterial (IA) thrombolysis, balloon angioplasty, or permanent stent placement. Recanalization by thrombectomy alone and multimodal treatments were assessed by the Thrombolysis in Cerebral Infarction (TICI) score. Clinical outcome was determined using the National Institutes of Health Stroke Scale (NIHSS) at 7 days and the modified Rankin Scale (mRS) at 3 months.ResultsThrombectomy alone and multimodal treatments were performed in 10 patients (71.4%) and 4 patients (28.6%), respectively. Successful recanalization (TICI 2b-3) was achieved in 11 (78.6%). Among these 11 patients, 3 (27.3%) underwent multimodal treatment due to underlying atherosclerotic stenosis. Ten (71.4%) of the 14 showed NIHSS score improvement of >10. Overall mortality was 3 (21.4%) of 14.ConclusionWe suggest that mechanical thrombectomy is safe and effective for improving recanalization rates in AVBAO, with low complication rates. Also, in carefully selected patients after the failure of recanalization by thrombectomy alone, additional multimodal treatment such as IA thrombolysis, balloons, or stents can be needed to achieve successful recanalization.

Endovascular recanalization of a thrombosed native arteriovenous fistula complicated with an aneurysm: technical aspects and outcomes.

ObjectiveTo evaluate the technical aspects and outcomes of endovascular recanalization of a thrombosed native arteriovenous fistula (AVF) complicated with an aneurysm.Materials and MethodsSixteen patients who had a thrombosed AVF complicated with an aneurysm (two radiocephalic and 14 brachiocephalic) were included in this study. Recanalization procedures were performed by mechanical thrombectomy using the Arrow-Trerotola percutaneous thrombectomy device and adjunctive treatments. We evaluated dose of thrombolytic agent, underlying stenosis, procedure time, technical and clinical success, and complications. The primary and secondary patency rates were calculated using the Kaplan-Meier analysis.ResultsThe thrombolytic agents used were 100000 U urokinase mixed with 500 IU heparin (n = 10) or a double dose of the mixture (n = 6). The thrombi in aneurysms were removed in all but two patients with non-flow limiting residual thrombi. One recanalization failure occurred due to a device failure. Aspiration thrombectomy was performed in 87.5% of cases (n = 14). Underlying stenoses were found in the outflow draining vein (n = 16), arteriovenous anastomosis or juxtaanastomosis area (n = 5), and the central vein (n = 3). Balloon angioplasty was performed for all stenoses in 15 patients. Two patients with a symptomatic central vein stenosis underwent insertion of a stent after balloon angioplasty. Mean procedure time was 116.3 minutes. Minor extravasation (n = 1) was resolved by manual compression. Both technical and clinical success rates were 93.8% (n = 15). The primary patency rates at 3, 6, and 12 months were 70.5%, 54.8%, and 31.3%, respectively. The secondary patency rates at 3, 6, and 12 months were 70.5%, 70.5%, and 47.0%, respectively.ConclusionThrombosed AVF complicated with an aneurysm can be successfully recanalized, and secondary patency can be prolonged with endovascular treatment.

Antegrade pedal approach for recanalizing occlusions in the opposing circulatory pathway of the foot when a retrograde puncture is not possible.

To describe a novel technical strategy to approach below-the-ankle chronic total occlusions after failed antegrade recanalization in patients who are not candidates for retrograde puncture. After a failure of antegrade recanalization of the tibial and foot vessels, an antegrade pedal access can be performed in the pedal or plantar artery. After crossing the plantar arch and the occlusions in the opposing circulation pathway of the foot, a rendezvous with the antegrade catheter is performed, followed by final angioplasty and hemostasis. An antegrade pedal approach to the opposing circulation in the foot may be considered for below-the-ankle recanalization after standard antegrade recanalization failure in patients who are not candidates for a retrograde puncture.

Minimally invasive and rapid surgical embolectomy (MIRSE) as rescue treatment following failed endovascular recanalization for acute ischemic stroke.

An intra-arterial (IA) mechanical thrombectomy has increased the recanalization rates for acute occlusion of proximal intracranial arteries. However, the current failure rate of endovascular recanalization remains at approximately 10%, resulting in the need for surgical rescue treatment. The authors applied a minimally invasive and rapid surgical embolectomy (MIRSE) as a final rescue treatment after the failure of endovascular recanalization, and investigated the incidence, technical feasibility, and treatment results. For two years, from 2012 to 2013, a total of 131 patients with acute occlusion of proximal intracranial arteries underwent an IA mechanical thrombectomy using a Penumbra System and a Solitaire stent, yet ten (7.6%) patients still experienced final recanalization failure. Four (40%) of these ten patients subsequently underwent a MIRSE consisting of a superciliary keyhole approach, arteriotomy to remove the embolus, and arteriotomy repair techniques using aneurysm clips as the final repair material, or a temporary compartmentalizing clip. Four patients aged 39 to 78 years with an embolic occlusion in the middle cerebral artery (n = 1) and internal carotid artery (n = 3) were treated using a MIRSE. Complete recanalization was achieved in all four patients, and the time from skin incision to reperfusion was 40-50 minutes. The modified Rankin Scale (mRS) scores at 3 months after surgery were 1 (n = 2), 2 (n = 1), and 3 (n = 1), respectively. A MIRSE can be an effective rescue treatment after the failure of endovascular recanalization therapies for acute occlusion of proximal intracranial arteries if the patient is within the therapeutic time window.

Combined Transmesenteric and Transhepatic Recanalization of Chronic Portal and Mesenteric Vein Occlusion to Treat Bleeding Duodenal Varices

Two patients presented with bleeding duodenal varices secondary to mesenteric and portal vein chronic occlusion. After a failed transhepatic recanalization, a combined transmesenteric and transhepatic approach was used to recanalize the chronic portal and mesenteric venous obstruction. The occluded segment was treated with transmesenteric stent placement in one patient and stent placement and coil embolization of varices in the second patient. Follow-up imaging and endoscopy showed decompression of the duodenal varices in both patients and absence of further bleeding episodes.

Instant Reocclusion following Mechanical Thrombectomy of in situ Thromboocclusion and the Role of Low-Dose Intra-Arterial Tirofiban

Background: An in situ thromboocclusion (IST) is defined as an infarct extensively involving all or most of a stenosed arterial territory, which is one major stroke mechanism related to intracranial atherosclerosis (ICAS). We focused on ISTs occurring in major cerebral arteries and analyzed their rate of instant reocclusion during mechanical thrombectomy (MT) compared with non-ISTs. Also, we introduced a treatment strategy of low-dose intra-arterial tirofiban administration to prevent such reocclusion following repeat recanalization, and evaluated its safety and efficacy. Methods: We analyzed 168 consecutive patients treated with MT over a 2-year period from May 2011 to April 2013. During MT, if angiography following a successful recanalization showed stenosis at the occlusion site, we performed additional angiographic runs every 10 min for 30 min after the recanalization. Then, if angiography revealed reocclusion, we performed a repeat recanalization, using the same MT technique but additionally followed by low-dose intra-arterial tirofiban infusion. Time-of-flight MR angiography or CT angiography was performed to confirm any underlying ICAS at the occlusion site 5-7 days after the procedure. The patients who had confirmed underlying ICAS were included in the IST cohort. Results: Of 168 enrolled patients, we excluded 36 who could not be checked for underlying ICAS at the occlusion site for one of the following reasons: recanalization failure (n = 11), rescue stenting after tirofiban failure (n = 5) and lack of follow-up vascular imaging (n = 20). The incidence of IST was 30.3% (40/132). All IST patients were confirmed to have underlying ICAS by follow-up vascular imaging. Instant reocclusion after successful recanalization was significantly more frequent in the IST cohort [26/40 (65%) vs. 3/92 (3.3%); p < 0.001]. Regarding the efficacy of low-dose intra-arterial tirofiban infusion, 85.7% of the reocclusion patients finally achieved a thrombolysis in cerebral infarction score 2/3 recanalization, but in the remaining 14.3% of the cases, the condition was refractory to the procedure and required rescue stenting. There were no cases of symptomatic intracranial hemorrhage following the procedure. Conclusions: In situ thromboocclusion was characterized by a significantly higher chance of instant reocclusion during MT. In such cases, low-dose intra-arterial tirofiban administration may be effective and safe. However, future confirmation by prospective multicenter trials seems necessary.

PWE-148 Long Term Outcomes Of Percutaneous Recanalisation For Budd-chiari Syndrome (bcs): Our Experience In Birmingham, Uk

IntroductionPatients with BCS and short stenosis of the hepatic vein or the upper IVC can be treated with recanalisation by percutaneous venoplasty ± hepatic vein stent insertion. Recent data suggests...

Natural history of deep vein thrombosis in children.

To determine the natural history of deep vein thrombosis in children presented with a first episode in the lower extremity veins. Children with objective diagnosis of acute deep vein thrombosis were followed up with ultrasound and clinical examination. Risk factors and clinical presentation were prospectively collected. The prevalence of recurrent deep vein thrombosis and the development of signs and symptoms of chronic venous disease were recorded. There were 27 children, 15 males and 12 females, with acute deep vein thrombosis, with a mean age of 4 years, range 0.1-16 years. The median follow-up was 23 months, range 8-62 months. The location of thrombosis involved the iliac and common femoral vein in 18 patients and the femoral and popliteal veins in 9. Only one vein was affected in 7 children, two veins in 14 and more than two veins in 6. Recurrent deep vein thrombosis occurred in two patients, while no patient had a clinically significant pulmonary embolism. Signs and symptoms of chronic venous disease were present at last follow-up in 11 patients. There were nine patients with vein collaterals, but no patient developed varicose veins. Reflux was found in 18 veins of 11 patients. Failure of recanalization was seen in 7 patients and partial recanalization in 11. Iliofemoral thrombosis (p = 0.012) and failure to recanalize (p = 0.036) increased significantly the risk for developing signs and symptoms. Children with acute proximal deep vein thrombosis develop mild chronic venous disease signs and symptoms at mid-term follow-up and are closely related with iliofemoral thrombosis and failure to recanalization.

Transpopliteal stenting of femoral occlusions in patients with critical limb ischemia using a 4-French system.

In many patients with critical limb ischemia (CLI), transfemoral endovascular recanalization is the preferred treatment. Transpopliteal treatment may be used in patients with inaccessible groins. This retrospective study regards transpopliteal stenting of superficial femoral artery (SFA) occlusions using a 4F system. Eleven patients (4 male and 7 female [mean age 77years]) underwent 12 attempts of transpopliteal recanalization of long SFA occlusions (Trans-Atlantic InterSociety Consensus B through D). All patients had CLI (Rutherford 4 to 6) and were nonoperable due to poor general condition. Indications for transpopliteal access were proximal/flush SFA occlusions (n=5), failure of antegrade recanalization (n=4), infected femoral-femoral crossover bypass (n=2), and occlusion of both the native SFA and the femoral-popliteal bypass (n=1). The popliteal artery was punctured under ultrasound guidance. Occlusions were recanalized subintimally, and 4F compatible stents were implanted. Technical success rate (<30% residual stenosis) was achieved in 83% of cases. In two patients, stent dislocation occurred while the sheath was removed. One arteriovenous fistula was successfully treated with additional stenting. During 6-month follow-up, there were no major amputations, and three patients died from nonrelated causes. Fifty percent of patients alive after 6months improved to Rutherford score ≤3. The duplex restenosis (>50%) rate at 6months was 50%. Transpopliteal primary stenting of complex SFA lesions in CLI for a temporary bypass is now technically feasible using a 4F system. Technical results are promising. Clinical results after 6months are acceptable when taking into consideration that this approach may be the last option for limb salvage.

RETRACTED ARTICLE: Meta-analysis of the effect of percutaneous coronary intervention on chronic total coronary occlusions

Background and purposeCoronary chronic total occlusion (CTO) is the last stage of coronary artery atherosclerosis. Percutaneous coronary intervention (PCI) is a therapeutic procedure used to recanalize vessels with total occlusion. However, successful recanalization of CTO is still not optimal, and the key influence factors are still uncertainty. Therefore, a scientific evaluation on the effective of PCI for CTO treatment is necessary.MethodsRelevant studies of PCI treatment for CTO were examined. Data were extracted and assessed by two independent clinical experts. Embase, PubMed and Medline et al. were used as database. The main research key words include “CTO”, “PCI”, “Stent”, “Reopen”, “long-term”, “follow-up” and “outcome”. Quality assessment was carried out according to the Cochrane Handbook. The selected data were pooled and analyzed using fixed-effect model and random-effect model. Heterogeneity was assessed using the I2 test, Q test, L’abbe and Galbraith. Comprehensive Meta -Analysis 2.0 and Metanalysis 1.0 were used for statistics analysis in this research.ResultsA total of 16 articles involving 6695 cases in successful CTO recanalization (CTO success group) and 2370 cases in failed CTO recanalization(CTO failure group) were included in this research. Low CTO success was associated with elder age, previous coronary artery bypass graft surgery (CABG) history, multi-vessel diseases and right coronary artery disease lesion. Six follow-up variables including major adverse cardiac events (MACE), recurrent myocardial infarction (MI), all-cause death, incidence of angina, subsequent CABG and cumulative survival rate were found significantly reduced associated with CTO success.ConclusionsClinical baseline characteristics such as age, previous CABG history and lesion baseline characteristics such as lesion length, multi-vessel diseases might be important factors influencing the successful rate of CTO recanalization. Compared to CTO failure patients, all six follow-up variables showed advantage for CTO success patients.

Successful pregnancy by direct intraperitoneal insemination in an infertile patient with failure of recanalization of isthmic stenosis after laparoscopic radical trachelectomy

Radical trachelectomy is a promising fertility-sparing treatment for patients with early stage cervical cancer who want to preserve their fertility. However, isthmic stenosis occurs frequently in patients who received radical trachelectomy and it is one of the causes of infertility following radical trachelectomy. Moreover, despite the treatment for recanalization of isthmic stenosis, recanalization can fail or isthmic stenosis can recur. Herein we report a successful pregnancy and birth by direct intraperitoneal insemination in an infertile woman with failure of recanalization of isthmic stenosis after laparoscopic radical trachelectomy.

Transpedal access after failed anterograde recanalization of complex below‐the‐knee and femoropoliteal occlusions in critical limb ischemia

Successful angioplasty is one of the main factor of limb salvage during critical limb ischemia. In complex femoropopliteal to infrapopliteal occlusions, an anterograde recanalization attempt can fail in up to 20% of the cases. The purpose of this dual center pilot study was to evaluate the acute success and clinical impact of retrograde transpedal access for retrograde below-the-knee and femoropopliteal chronic total occlusions after failed anterograde attempt and to access the late complications at the puncture site. The clinical and angiographic data of 51 consecutive patients with CLI treated by retrograde transpedal recanalization between 2010 and 2011 were evaluated in a pilot study. We have examined the 2-month and 1 year major adverse events (MAEs) and clinical success. In all cases after failure of the anterograde recanalization of occluded below-the-knee segments due to unsuccessful penetration or failed re-entry, the anterior tibial or posterior tibial artery was punctured under fluoroscopic guidance and retrograde recanalization was performed. Direct revascularization was tried firstly following the angiographic zones, but in failed cases indirect revascularization was carried out with increasing the collateral flow to the wound. Successful direct retrograde revascularization was achieved successfully in 40 patients (78.4%) and indirect revascularization was done in 10 patients (19.6%). Revascularization was failed in one patient (2%). MAE at 2 and 12 months follow-up was 6 (11.7%) and 11 (24%). Limb salvage at 2 and 12 months was 93% and 82.3%, respectively. Balloon angioplasty was performed in all interventions and provisional stenting was done in 34 patients (66.7%). One major and three minor vascular complications occurred after the procedure. The mean basal and control creatinine level was 120.9 ± 133.4 and 123.8 ± 131.3 μmol/L (P = 0.83) after the procedure. Failed antegrade attempts to recanalize CTO-s of femoropopliteal and infrapopliteal vessels can be salvaged using a retrograde transpedal access, with a low acute and late complication rate. This technique could be valuable for patients with critical limb ischemia due to femoropopliteal and infrapopliteal occlusions.

Feasibility of Ambulatory Percutaneous Femoral Access without the Use of Arterial Closure Systems

To evaluate the feasibility of early ambulation in patients treated for peripheral occlusive lesions by femoral percutaneous access, without the use of closure systems and the application to ambulatory practice. This single-center observational exploratory study was undertaken among 99 consecutive patients between August 1-December 31, 2011 (mean age: 72years; 72 men) who were treated by percutaneous femoral route for peripheral arterial lesions. All the patients had a manual compression then pressure bandage. A clinical evaluation was carried out after 4hours, seeking a local or a general complication and checking the procedure. Rising and walking in the unit of hospitalization were authorized in the absence of complication as of 4 hours postoperatively. All patients remained in hospital for at least 1 night, with a clinical revaluation before discharge. All patients were contacted by telephone at postoperative day 7 in order to verify the absence of local complications. All the individual factors and those related to the procedure were analyzed. With criteria of complications related to the gesture, 72 patients (72.7%) were considered ready to be discharged as of postoperative hour 4. Among the 27 patients who were not able to leave, 7 presented with an early local complication without reoperation, and 20 could not walk because of a necrotic lesion (n=8), their advanced age (n=4), morbid obesity (n=2), or a choice of the surgeon in charge (n=6). Twenty-five patients could, however, stroll after 12 hours. The mean duration of hospitalization was 1.3days (range: 0-10days). Two patients required distal amputation during the same hospitalization, and 1underwent a femoropopliteal bypass after failure of a femoropopliteal recanalization. With univariate analysis, the treatment by anticoagulants and the duration of the hospitalization were the only factors significantly related to the impossibility of early ambulation. The occurrence of complications was linked with the experience of the surgeon, the age of the patient, and the female sex. Three patients, including 2 regarded as ready to walk by postoperative hour 4, were rehospitalized after 1 week for reoperation because of 1 major hematoma and 2 femoral false aneurysms. Percutaneous endovascular surgery by the femoral route without using an arterial closure system is feasible in an ambulatory practice in nearly 75% of cases. Particular monitoring must be done in the oldest patients, women, and those treated with anticoagulants.

Stent Retrievers in Acute Ischemic Stroke: Complications and Failures during the Perioperative Period

Stent retriever-assisted thrombectomy promotes high recanalization rates in acute ischemic stroke. Nevertheless, complications and failures occur in more than 10% of procedures; hence, there is a need for further investigation. A total of 144 patients with ischemic stroke presenting with large-vessel occlusion were prospectively included. Patients were treated with stent retriever-assisted thrombectomy ± IV fibrinolysis. Baseline clinical and imaging characteristics were incorporated in univariate and multivariate analyses. Predictors of recanalization failure (TICI 0, 1, 2a), and of embolic and hemorrhagic complications were reported. The relationship between complication occurrence and periprocedural mortality rate was studied. Median age was 69.5 years, and median NIHSS score was 18 at presentation. Fifty patients (34.7%) received stand-alone thrombectomy, and 94 (65.3%) received combined therapy. The procedural failure rate was 13.9%. Embolic complications were recorded in 12.5% and symptomatic intracranial hemorrhage in 7.6%. The overall rate of failure, complications, and/or death was 39.6%. The perioperative mortality rate was 18.4% in the overall cohort but was higher in cases of failure (45%; P = .003), embolic complications (38.9%; P = .0176), symptomatic intracranial hemorrhages (45.5%; P = .0236), and intracranial stenosis (50%; P = .0176). Concomitant fibrinolytic therapy did not influence the rate of recanalization or embolic complication, or the intracranial hemorrhage rate. Age was the only significant predictive factor of intracranial hemorrhage (P = .043). The rate of perioperative mortality was significantly increased in cases of embolic and hemorrhagic complications, as well as in cases of failure and underlying intracranial stenoses. Adjunctive fibrinolytic therapy did not improve the recanalization rate or collateral embolic complication rate. The rate of symptomatic intracranial hemorrhage was not increased in cases of combined treatment.

Factors Associated with Early Recanalization Failure following Intravenous rt-PA Therapy for Ischemic Stroke

Background: Although intravenous recombinant tissue-type plasminogen activator (rt-PA) therapy can be effective for ischemic stroke, a considerable percentage of patients do not receive any benefit as a result of early recanalization failure. We aimed to investigate the factors associated with early recanalization failure following intravenous rt-PA therapy. Methods: Patients with acute ischemic stroke and internal carotid artery (ICA) or middle cerebral artery occlusion on initial magnetic resonance angiography (MRA) who received intravenous rt-PA therapy within 3 h of stroke onset and underwent follow-up MRA within 8 h after treatment were enrolled. Baseline characteristics, stroke features, onset to treatment time, initial National Institutes of Health Stroke Scale (NIHSS) score, initial Alberta Stroke Programme Early CT Score on diffusion-weighted imaging-ASPECTS (Alberta Stroke Program Early Computed Tomography Score), the presence of ICA or M1 origin (the residual length <5 mm) (ICA/M1 origin occlusion), initial vital signs, and laboratory findings were recorded. Early recanalization on the follow-up MRA within 8 h was evaluated by modified Mori grade: grade 0, no reperfusion; grade 1, movement of thrombus; grade 2, partial recanalization, and grade 3, complete recanalization. Results: Seventy subjects (35 women, 77 ± 12 years) were enrolled. The median (interquartile range: IQR) NIHSS score was 18 (12.5-24), and the mean onset to treatment time was 141 ± 54 min. ICA was occluded in 29%, M1 origin in 17%, M1 middle in 13%, M1 distal in 26% and M2 in 15%. The median (IQR) pretreatment diffusion weighted imaging-ASPECTS was 8 (6-9), and follow-up time of MRA was 65 min (59-70) after rt-PA therapy. Thirty-two subjects (46%) showed modified Mori grade 0; 10 (14%), grade 1; 9 (13%), grade 2, and 19 (27%), grade 3. Multivariate analyses revealed ICA/M1 origin occlusion (OR 3.71, 95% CI 1.03-14.87, p = 0.044), and C-reactive protein (per 0.1-mg/dl increment, OR 1.19, 95% CI 1.03-1.44, p = 0.013) were independently associated with subjects with no recanalization (grade 0-1), whereas age (per years old, OR 0.93, 95% CI 0.86-0.99, p = 0.014) and high-density lipoprotein cholesterol (per 1-mg/dl increment, OR 0.94, 95% CI 0.89-0.98, p = 0.004) were inversely associated with those. Conclusion: ICA/M1 origin occlusion and C-reactive protein were positively and high-density lipoprotein cholesterol was negatively associated with early recanalization failure.