Failure Of Recanalization Research Articles

Posterior circulation tandem occlusions: Classification and techniques

BackgroundPosterior circulation tandem occlusions are poorly characterized in current literature. Data regarding endovascular approaches and outcomes in this patient subgroup is extremely limited. MethodsWe conducted a retrospective analysis of a prospectively maintained database and identified 17 patients with posterior circulation tandem occlusions who underwent mechanical thrombectomy between 2014 and 2019. ResultsOf 17 patients with posterior circulation tandem occlusion, the mean age was 55.76 ± 11.8 with 35.3% female. The mean NIHSS score on presentation was 17.2 ± 9.2. Tissue plasminogen activator was administered in 7 (41.2%) patients, stent-retrievers alone were used in 2 (11.8%), aspiration catheters alone were used in 2 (11.8%), a combination was used 12 (70.6%), and a self-expandable stent in 5 (29.4%). The mean number of device passes was 2.24 ± 2.02, recanalization failure occurred in 4 (23.5%) patients, the mean time from stroke onset to puncture was 6.9 ± 2.4 h, and the mean time from puncture to recanalization was 59.3 ± 26.6 min. Postprocedural symptomatic ICH occurred in 1 (5.9 %) patient, periprocedural ICH/SAH occurred in 2 (11.8%), periprocedural distal emboli occurred in 0 (0%), periprocedural vessel dissection occurred in 1 (5.9%), and periprocedural vessel perforation occurred in 1 (5.9%) patient. TICI score>2b was achieved in 13 (76.5%) patients. An improvement in NIHSS>3 at discharge occurred in 10 (58.8%) patients, and good outcomes (mRS score < 2) occurred in 7 (41.2%). The mean length of stay was 11.6 ± 12.2 days, and the mortality rate was 41.2%. ConclusionEndovascular intervention with mechanical thrombectomy is safe and feasible in patients with posterior circulation tandem occlusions.

Retained second twin secondary to an undiagnosed bicornuate uterus in a poorly supervised labour: A case report

Congenital anomalies of the uterus may result from maldevelopment, abnormal fusion or failure of recanalisation of the paramesonephric (Müllerian) ducts. They are uncommon and are associated with various fertility and pregnancy outcomes. Uterine anomalies have been associated with infertility and pregnancy-related complications. Some cases of successful pregnancies among women with a bicornuate uterus have been reported. However, successful twin pregnancy in a bicornuate uterus is very rare. We report the case of a 24-year-old primigravida who presented with a retained second twin secondary to an undiagnosed bicornuate uterus. An abdominal examination revealed an enlarged abdomen with the uterus tilted to the right and also a palpable firm mass on the left iliac fossa. The retained foetus was presenting cephalic, and the foetal heart rate was 118 bpm. A diagnosis of a retained second twin secondary to a suspected uterine anomaly and suspected foetal distress was made. An emergency caesarean section revealed two horns of the uterus, each having a fallopian tube, an ovary and a cervix. Both cervices opened into one vagina. A 3.0 kg live male baby was successfully delivered through a transverse incision on the lower segment of the right horn of the uterus. The client had an uneventful recovery and was discharged home together with her babies after 4 days. In conclusion, congenital anomalies of the uterus should be considered in cases of a retained second twin. A prompt and accurate diagnosis followed by appropriate management will go a long way in ensuring a good outcome, as was had in this case.

Superior Vena Cava Obstruction Secondary to Prolonged Calcium Therapy: A Benign Etiology, Managed by Vein Graft Bypass Surgery

We like to report this case of a 28-year-old lady, who had celiac disease and developed complete Superior Vena Cava Obstruction secondary to prolonged corrective calcium therapy for refractory Hypocalcemia through the central venous line. Usually Superior Vena Cava Syndrome (SVCS) due to Superior Vena Cava obstruction (SVCO) has infective and malignant etiologies. Our case is a rare and benign cause, managed surgically after failed endovascular recanalization by the interventional radiologist.

Incomplete or failed thrombectomy in acute stroke patients with Alberta Stroke Program Early Computed Tomography Score 0-5 - how harmful is trying?

It is currently unknown whether mechanical thrombectomy (MT) for ischaemic stroke patients with low initial Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is clinically beneficial or even harmful. The purpose of this study was to investigate whether failed or incomplete MT in acute large vessel occlusion stroke with an initial ASPECTS≤5 is associated with worse clinical outcome compared to patients not undergoing MT. This observational cohort study included a consecutive sample of patients with anterior circulation stroke and initial ASPECTS≤5 admitted between March 2015 and August 2019. Failed recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) score 0-2a, and incomplete recanalization as TICI 2b. Clinical outcome was assessed using the modified Rankin Scale (mRS) at 90 days defining very poor clinical outcome as mRS>4. One hundred and seventy patients were included. Ninety-nine patients underwent MT and 71 patients received best medical treatment only. Clinical outcome after failed or incomplete MT (TICI 0-2b) was significantly better compared to patients with medical treatment only (median mRS 5, interquartile range 4-6 vs 5-6, P=0.03). In multivariable logistic regression analysis, failed or incomplete MT (TICI 0-2b) showed a significantly reduced likelihood for very poor outcome (odds ratio 0.39, 95% confidence interval 0.19-0.83, P=0.01). Failed MT (TICI 0-2a) was not associated with a worse outcome compared to best medical treatment. Patients with failed or incomplete recanalization results (TICI 0-2b) showed a reduced likelihood for very poor outcome compared with those who did not receive MT. Evidence from randomized trials is needed to confirm that even failed or incomplete MT is not harmful in these patients.

Fetoscopic Balloon Dilation and Cricotracheal Resection for Laryngeal Atresia in CHAOS.

View Supplementary Video 1 Laryngoscope, 131:660–662, 2021

Congenital Pharyngeal Web in an Adult: Treatment of a Rare Clinical Anomaly by Coblation

INTRODUCTION TO THE TOPICPrevious reports of congenital pharyngeal webs, although rare, have been described in children. Clinical presentation varies, ranging from aspiration to intermittent airway obstruction, and most commonly, dysphagia. In this case report, the authors describe an unusual finding of a hypopharyngeal web in an adult patient. This patient had no prior history of chemoradiotherapy, malignancy, or total laryngectomy, all of which have been associated with acquired pharyngeal stenosis, supporting that this finding was of congenital origin. After a review of the possible embryological developmental abnormalities, the hypothesis is that of gut recanalization failure during development.CASE PRESENTATIONWe present a case of a woman in her mid-40’s with a history of solid food dysphagia resulting in a 20 kg weight loss over three months. The patient denied dysphagia progressing to liquids, pain with swallowing, and a history of alcohol or tobacco use. Upon examination of the larynx via laryngoscope, a congenital hypopharyngeal web was identified. Successful excision of the web via coblation restored proper drainage of the pyriform sinus into the esophagus and resulted in markedly improved swallowing function and weight gain.CONCLUSIONSPharyngeal webs are rare findings, particularly in adult patients. These congenital anomalies can be safely and effectively treated endoscopically via coblation.

A Quantitative Method for Prediction of True Lumen Recanalization in Chronic Total Occlusion of the Superficial Femoral Artery

This study aimed to examine a quantitative method for evaluating calcification in failure in recanalization (FR) in endovascular treatment of superficial femoral artery (SFA) chronic total occlusion, and to investigate the possibility of using a formula to predict the incidence of true lumen recanalization (TR) in such cases. Patients who met the inclusion criteria were retrospectively analyzed in our center from January 2012 to September 2017. A Calcification Lesion Analyzing and Scoring System (CLASS) was established to quantify the characteristics of calcification in SFA computed tomography slices, which were ranked as grade 1-4 and class A-E. Corresponding scores were obtained, and the Cumulative Calcification Score (CCSO) of occlusive SFA was calculated on the basis of CLASS. The factors correlating to FR and the formula for predicting TR were evaluated. A total of 215 patients were included in this study. There were 150 cases of TR and 65 cases of subintimal recanalization; 12 (5.6%) cases had FR. The maximum CLASS of occlusion was correlated with FR. Not only the formula including Trans-Atlantic Inter-Society Consensus II grade and CCSO but also the formula including occlusion length and CCSO predicted the incidence of TR well. The degree of the most severe calcification in occlusive lesions clearly affects success in recanalization. Two quantitative formulas that combine occlusion length or Trans-Atlantic Inter-Society Consensus II grade with CCSO can predict TR in endovascular treatment of SFA lesions with chronic total occlusion.

A case report of thrombolysis resistance: thrombus ultrastructure in an ischemic stroke patient

BackgroundFollowing acute ischemic stroke (AIS), approximately half of patients do not achieve recanalization after intravenous administration of tissue plasminogen activator (rt-PA). Thrombolysis resistance is a possible reason for recanalization failure. Thrombolysis resistance is likely related to the ultrastructure and composition of the thrombus. However, there is a paucity of published information on the relationship between thrombus ultrastructure and thrombolysis resistance.Case presentationTwo patients who underwent mechanical thrombectomy were observed within 4.5 h after stroke onset. One patient failed to respond to rt-PA (defined as thrombolysis resistant), and the other patient did not receive rt-PA treatment (non-rtPA). In each patient, the occluded artery was the internal carotid artery or middle cerebral artery. According to the Trial of ORG 10172 in Acute Stroke Treatment classification, both patients had large atherosclerotic cerebral infarction. By scanning electron microscopy (SEM) and transmission electron microscopy (TEM), we found that the thrombus structure was significantly different between the two patients.ConclusionGrid-like dense fibrin, compressed polyhedral erythrocytes, and large accumulation of neutrophils may be characteristics of thrombolysis resistant thrombi.

Subarachnoid Contrast Accumulation and Alberta Stroke Program Early Computed Tomography Score Applied to Contrast Accumulation After Thrombectomy as Predictors of Symptomatic Hemorrhage

Areas of contrast accumulation (CA) are commonly found on routine computed tomography (CT) performed immediately after thrombectomy. In the present study, we investigated the types of CA associated with the different outcomes, including symptomatic intracranial hemorrhage (sICH). The present study analyzed the data from 145 patients with anterior circulation stroke who had undergone non-contrast-enhanced conventional CT immediately after thrombectomy. The following variables were investigated: collateral status, failure of recanalization, Alberta stroke program early CT score (ASPECTS) applied to CA lesions and diffusion-weighted imaging infarct lesions, and sICH. Of the 145 patients, 102 (70.3%) had CA lesions. All types of CA (any CA, cortical CA, subarachnoid CA, and CA ASPECTS) were significantly associated with poor outcomes (modified Rankin scale score >2). In particular, subarachnoid CA (odds ratio, 23.994; 95% confidence interval, 4.696-122.589) and CA ASPECTS (odds ratio, 0.550; 95% confidence interval, 0.404-0.750) were independently associated with sICH. Patients with subarachnoid CA had poorer collateral status and a larger final infarct size than those without subarachnoid CA, although the initial National Institutes of Health stroke scale score and recanalization rate were comparable between the 2groups. A CA ASPECTS of ≤5 predicted sICH with a sensitivity of 66.7% and a specificity of 92.6% (area under the curve, 0.854). Our data suggest that a subarachnoid CA location and CA ASPECTS are predictors of sICH. In particular, a subarachnoid location of CA might signify damage of the subarachnoid collateral arteries, leading to a larger infarct.

3:00 PM Abstract No. 42 Analysis of microchannel recanalization with orbital atherectomy in failed standard recanalization of TASC-II D aortoiliac occlusive disease

Endovascular treatment of TASC II D aorto-iliac lesions now an accepted form of revascularization. We sought to analyze the technical and clinical outcomes of microchannel recanalization and orbital atherectomy (MCOA) in TASC II D aorto-iliac lesions refractory to standard recanalization techniques. Nineteen patients from 2016-2018 with symptomatic TASC-II D aortoiliac occlusive disease (AIOD) prohibitive for open bypass underwent traditional or MCOA recanalization. In four patients, native microchannels were probed and traversed with a 0.014 wire. The atherectomy crown was tracked over wire and orbital atherectomy was initiated with the 1.25 crown starting at the lowest revolution and continued until the microchannel is sufficiently large to track a 1.2 mm balloon for angioplasty. Serial microchannel angioplasty with exchange for stiffer and/or larger profile wires and balloons was achieved until a covered stent could be safely deployed across the target lesion. Technical and clinical outcomes including lesion characteristics, survival, limb salvage, patency, and change in clinical symptoms were analyzed. Both groups had similar Rutherford scores, ABI, and presence of outflow lesions. All MCOA patients presented with long segment unilateral CIA occlusion with contralateral CIA stenosis. In MCOA cases, there were no intraoperative ruptures or dissections. There were many similar metrics and outcomes between traditional recanalization versus MOCA: procedure time (150.3 min vs. 183.0 min, P = 0.41), primary patency rate (86.7% vs. 75.0%, P = 0.53), long-term (2.5 years) clinical symptoms improvement (86.7% vs. 75.0%, P = 0.53), and median all outcome progression free survival (1919 days vs. 1928 days, P = 0.62). Short-term (30 day) clinical symptoms improvement and limb salvage rate was equal between traditional recanalization versus MCOA (100% vs. 100%, P = >0.999). Native microchannel recanalization with subsequent orbital atherectomy is an option in high-risk patients with TASC II D aorto-iliac disease who have failed traditional prodding recanalization. Further work in proper patient selection and safe utilization of atherectomy devices in the CIA is needed.

Predictors of Good Outcomes in Patients with Failed Endovascular Thrombectomy.

ObjectiveEndovascular thrombectomy (EVT) fails in approximately 20% of anterior circulation large vessel occlusion (AC-LVO). Nonetheless, the factors that affect clinical outcomes of non-recanalized AC-LVO despite EVT are less studied. The purpose of this study was to identify the factors affecting clinical outcomes in non-recanalized AC-LVO patients despite EVT.Materials and MethodsThis was a retrospective analysis of clinical and imaging data from 136 consecutive patients who demonstrated recanalization failure (modified thrombolysis in cerebral ischemia [mTICI], 0–2a) despite EVT for AC-LVO. Data were collected in prospectively maintained registries at 16 stroke centers. Collateral status was categorized into good or poor based on the CT angiogram, and the mTICI was categorized as 0–1 or 2a on the final angiogram. Patients with good (modified Rankin Scale [mRS], 0–2) and poor outcomes (mRS, 3–6) were compared in multivariate analysis to evaluate the factors associated with a good outcome.ResultsThirty-five patients (25.7%) had good outcomes. The good outcome group was younger (odds ratio [OR], 0.962; 95% confidence interval [CI], 0.932–0.992; p = 0.015), had a lower incidence of hypertension (OR, 0.380; 95% CI, 0.173–0.839; p = 0.017) and distal internal carotid artery involvement (OR, 0.149; 95% CI, 0.043–0.520; p = 0.003), lower initial National Institute of Health Stroke Scale (NIHSS) (OR, 0.789; 95% CI, 0.713–0.873; p < 0.001) and good collateral status (OR, 13.818; 95% CI, 3.971–48.090; p < 0.001). In multivariate analysis, the initial NIHSS (OR, 0.760; 95% CI, 0.638–0.905; p = 0.002), good collateral status (OR, 14.130; 95% CI, 2.264–88.212; p = 0.005) and mTICI 2a recanalization (OR, 5.636; 95% CI, 1.216–26.119; p = 0.027) remained as independent factors with good outcome in non-recanalized patients.ConclusionBaseline NIHSS score, good collateral status, and mTICI 2a recanalization remained independently associated with clinical outcome in non-recanalized patients. mTICI 2a recanalization would benefit patients with good collaterals in non-recanalized AC-LVO patients despite EVT.

An Alternative Treatment of Stump Occlusion of the Superficial Femoral Artery with Percutaneous Direct Puncture Followed by Antegrade Recanalization

IntroductionThe purpose of the study was to evaluate the efficacy and safety of the “percutaneous direct puncture of occluded superficial femoral artery (SFA)” technique for recanalization of SFA, after failure of antegrade recanalization in patients with limited access to retrograde popliteal and crural arteries. Material and methodsBetween April 2014 and November 2017, 10 patients with CLI (Critical limb ischemia) underwent endovascular recanalization with direct percutaneous puncture of occluded SFA after failed antegrade recanalization. All patients had a long segment (39,9 ± 2.8 cm) occluded SFA without stump causing failed antegrade recanalization with a cannulated guidewire in the SFA origin. After unsuccessful attempts with the antegrade approach, the retrograde direct puncture technique of the occluded SFA was performed and followed by antegrade recanalization. Patients were followed up clinically with Doppler ultrasonography and according to the Rutherford scale at 1, 3, 6 and 12 months after discharge. ResultsTechnical success was achieved in 8/10 patients (80%).The mean follow-up period was 25,1 ± 9,6 months. One patient underwent major amputation, resulting in 90% limb salvage rate at 12 and 24 months. Amputation-free survival estimated by Kaplan-Meier analysis was 60% at 12 and 24 months. Primary patency rates were 62.5% at 12 and 24 months and secondary patency rates were 87.5% at 12 and 24 months. ConclusionTreatment of SFA occlusions without a stump in CLI patients via the percutaneous direct puncture of occluded SFA approach improved technical success and clinical recovery, especially in cases unsuitable for conventional antegrade and retrograde approaches.

Combined use of the Solitaire AB stent and Navien delivery catheter for mechanical thrombectory of acute vertebrobasilar artery occlusion

Objective: To investigate the efficacy and safety of mechanical thrombectory with a tri-axial system of the solitaire AB stent through a Navien delivery catheter to treatment acute vertebrobasilar artery occlusion. Methods: The clinical data of 16 consecutive patients with acute ischemic stroke of vertebrobasilar artery occlusion treated with the Solitaire AB device from March 2016 to March 2018 in Department of Neurosurgery, the First Affiliated Hospital, Medical College of Shihezi University, were extracted and then retrospectively analyzed.Recanalization rate as well as complications after treatment were analysized. Also, neurological functions of the patients before and after operation 1 weeks, measured by National Institute of Health stroke scale (NIHSS) score were compared via t test and the clinical outcomes were assessed by modified Rankin score (mRS) at 90 days after operation. Results: There were 10 male and 6 female patients with a median age of 59 years (ranging from 45 to 78 years).Fourteen patients resulted in successfully recanalization, and 2 cases failed both of whose onset to sheath mean time were 8.5 hours.The NIHSS score at 7 days was 13±7, which was significantly decreased compared to the admission NIHSS score 24±4 (P=0.000).No symptomatic intracranial hemorrhage case was found after operation.At 90 days, 8 patients achieved good outcome (mRS 0 to 2), one patient died (mRS 6),two patients moderately seriously disabled (mRS 4).Three patients resulted in moderate outcome (mRS 3).In 3 cases of death,2 patients died due to failure in recanalization,another patient died of severe pulmonary infection. Conclusion: The results suggest that this technique of a tri-axial system used of the Solitaire AB stent through a Navien delivery catheter can effectively retrieve clots from the occlusive artery and improves functional outcome in patients with acute ischemic stroke of vertebrobasilar artery.

Apple peel atresia: a case report

A 3 days old child presented with chief complaints of bilious vomiting and abdominal distention since few hours duration. Prenatal history revealed mother to be polyhydraminos and pregnancy induced hypertensive was on treatment with labetolol. Baby was a term, emergency lscs delivery. On examination baby was active, alert and with fair hydration. On per abdominal examination abdomen was distended and dilated bowel loops were seen. On per rectal wash pale jelly stools were expelled. Baby was taken up for emergency laprotomy and found to be having illeal atresia for which resection and anastamosis is done. Post operatively baby was doing well with satisfactory weight gain. Intestinal atresias are the major cause of intestinal obstruction in cases of neonates. They may be illeal or duodenal atresia. It is hypothesized to be occurring due intrauterine vascular assault and failure of recanalization. Babies present with vomiting and abdominal distention with mother having a positive history of polyhydraminos. On examination there will be abdominal distention with dilated bowel loops. X-rays would show dilated bowel loops and ultrasound shows decreased peristalisis in the bowel loops. Emergency laprotomy and surgical resection is the treatment of choice.

Angiographical Jaggy Sign of Remnant M2 Occlusion during Acute Mechanical Thrombectomy

Background and purpose: During mechanical thrombectomy for acute main trunk occlusion, we sometimes encounter difficult situation; 1 M2 branch of the middle cerebral artery is successfully recanalized, while the other remains occluded. In this study, we focused on the angiographical findings of remnant occlusion. Methods: Among 83 patients who underwent mechanical thrombectomy for the acute internal carotid artery or proximal middle cerebral artery (M1) occlusion, 25 patients (30%) intraoperatively exhibited the remnant M2 occlusion, in spite of the recanalization of the other M2. We classified the angiographical findings of the remnant M2 occlusion and examined the clinical features, prognosis, and complications, in relation to additional thrombectomy. Results: The remnant M2 occlusion was classified into stump type (40%, 10 cases), round deficit type (28%, 7 cases), and jaggy type (32%, 8 cases). Multivariate analysis suggested that noncardioembolic stroke may lead to jaggy type remnant occlusion with marginal significance (P = .051). Additional thrombectomy for the remnant M2 occlusion resulted in failed recanalization in 6% in the nonjaggy (stump or round deficit) type, whereas in 50% in the jaggy type groups (P = .023). Symptomatic intracranial hemorrhage occurred in 6% in the nonjaggy and 38% in the jaggy groups (P = .081), and poor outcome at discharge in 29% and in 50%, respectively. Conclusions: Angiographical jaggy sign in the remnant M2 occlusion suggests the pre-existing or procedure-related pathology, such as atherosclerosis, vasospasm, or arterial dissection. Additional thrombectomy should be carefully determined, as which might lead to adverse events and poor outcomes.

Clinical and Radiological Predictors of Recanalization after IV rt-PA in Patients of Acute Ischemic Stroke

AbstractBackground and Aim: Acute Ischemic Stroke (AIS) is defined as a focal neurological deficit lasting for more than 24 hours with no cause other than that of vascular origin. Stroke is the third commonest cause of mortality after cardiac disease, cancer and the first cause of disability. Current treatment for AIS includes thrombolytic drugs such as rt-PA which dissolve occlusive blood clots and reversing the ischemia in salvageable area of the penumbra adjacent to irreversible infracted area. The purpose of this study is to assess the predictors of recanalization after treatment via rt-PA.Aim of Study: Was to assess the clinical and radiological predictors of the recanalization after IV thrombolytic therapy in patients of AIS.Subjects and Methods: This study was conducted in the Departments of Neuropsychiatric and Radiology, Tanta Uni-versity on 25 patients of AIS in the period between August 2016 and February 2017. They were classified into 2 groups according to the successful recanalization or not. All patients were subjected to full history taking, neurologic examination including evaluation by National Institute of Health Stroke Scale (NIHSS), laboratory investigations, neuroimaging including: Computed Tomography (CT), Transcranial Doppler Ultrasound (TCD) and CT angiography which were done with follow-up 24 hours later.Results: The mean age of the group of successful recanal-ization was 62.12±13 while in the group of failed recanalization was 69.21±10. Smoking and DM were significantly higher among patients with failed recanalization while cardiac prob-lems were significantly more common in patients with suc-cessful recanalization. In addition, the recanalization was associated with significant improvement in stroke severity. Distal MCA occlusion had a better chance of recanalization via rt-PA than proximal MCA occlusion.TCD had 81.25% sensitivity and 100% specificity compared to CTA.Conclusion: IV rt-PA is an effective treatment of AIS. Earlier rt-PA timing of administration and lower NIHSS were significant predictors for successful recanalization. TCD is an easy, fast and feasible tool to assess the occluded vessels with near results to CTA.

04:12 PM Abstract No. 168 M2 Frontal and Parietal Division Angles Impacting Success of Mechanical Thrombectomy

Vessel anatomy is the cornerstone of endovascular therapy, including in mechanical thrombectomy (MT). The horizontally orientated M1 segment of the MCA commonly terminates in a bifurcation. The M2 segment is made up of a frontal division coursing cephalic to supply the frontal convexity and a parietal division which appears as a continuation of the M1 coursing inferiorly to supply the temporoparietal lobes. We have demonstrated the rate of successful reperfusion following MT is significantly greater in parietal division than frontal division occlusions (unpublished work). Our current hypothesis is that the differences in success are due to a less obtuse angle of the frontal versus parietal division. A single-center retrospective study was conducted to identify isolated frontal and parietal M2 branch occlusions from September 2012 to April 2018. Occlusions involving the M1 segment, distal MCA (M3 and M4 divisions), ACA, ICA and posterior cerebral circulation were excluded. 3D renderings from preprocedural CT angiography of the head (MRA reformats were used for a single patient) were utilized to assess vessel anatomy. The angle between the conterminous segment of the distal M1 and of each M2 division were measured from the healthy non-occluded side. The angle between the M1 and parietal division was designated M1/parietal angle. A second angle between the M1 and frontal division was designated M1/frontal angle. Twenty nine out of 364 endovascularly treated cases had isolated parietal or frontal M2 occlusions. Of these, 23 met our criteria; 17 subjects were in the parietal cohort and 6 subjects in the frontal cohort. Mean age of patients was 67.7. There was a larger mean M1/parietal angle than M1/frontal angle in the parietal cohort (146.2° vs 116.3, p = <0.0001) and frontal cohort (147.7 vs 116.5, p = 0.013). A less obtuse angle of the frontal M2 division can account for an increased failure of recanalization. Although it may be difficult to determine the angle on the occluded side due to nonvisualization of the vessel, angle measurement on the healthy side correlates with success of mechanical thrombectomy.

Homemade Device to Facilitate Percutaneous Venous Arterialization in Patients With No-Option Critical Limb Ischemia

Purpose: To describe a maneuver to facilitate percutaneous arteriovenous fistula creation during venous arterialization procedures in patients with no-option critical limb ischemia. Technique: Following a failed arterial recanalization attempt, a balloon catheter is passed up to the tip of the guidewire. Venous access is gained distally, a 4-F sheath is antegradely passed, and a 4-mm GooseNeck snare is advanced through it. A fluoroscopic view that overlaps the snare and the inflated balloon is obtained. If the vein remains anterior with respect to the artery, a needle is inserted across the vein, passing through the snare loop and puncturing the intra-arterial balloon. A wire is inserted and placed inside the punctured balloon. The balloon is retrieved and the wire externalized through the femoral access. A catheter is advanced antegradely over this wire from the artery into the vein. If the vein remains posterior to the artery, a needle is inserted, puncturing the balloon and thereafter the vein (crossing through the snare). A wire is inserted, captured by the snare, and externalized through the vein sheath. A catheter is finally advanced over this wire from the vein into the artery. Conclusion: This maneuver is a simple alternative to create an arteriovenous fistula during venous arterialization procedures in patients with no-option critical limb ischemia.

Endovascular recanalization of the symptomatic non-acute occlusion of large intracranial artery of circulation: preliminary study

Objective To investigate the feasibility, safety and efficacy of endovascular recanalization of the symptomatic occlusion of large intracranial artery in anterior circulation. Methods From October 2015 to December 2017, 13 patients with symptomatic non-acute occlusion of large intracranial artery in anterior circulation were enrolled into this study and underwent endovascular recanalization. The initial procedural results, including the rate of successful recanalization and perioprocedural complications, and angiographic and clinical follow-up results were collected. The functional outcome was evaluated at discharge and 90 days. Results Recanalization was successful in 11 out of 13 patients. Perioperative complications occurred in 8 cases, including distal embolization in 7 cases (3 with symptom and 4 without), in which intracerebral hemorrhage associated with embolectomy was found in 1 case; and distal embolization concomitant with artery dissection in 1 case. At discharge, the symptoms of 10 out of 11 patients with successful recanalization were improved and 1 was unchanged; one of 2 patients with recanalization failure was aggravated and 1 was unchanged. After the procedure, 1 patient with successful recanalization, but complicated with intracerebral hemorrhage associated with embolectomy was lost at follow-up, thus angiographic follow-up was available in the remaining 10 patients. Of the 10 patients, 1 patient developed in-stent restenosis at 12 months and 9 patients had no hemodynamic stenosis/reocclusion. The clinical follow-up was available in 12 patients. No recurrence of TIA or stroke was found in 9 cases with successful recanalization except for 1 case who developed in-stent stenosis and suffered from TIA. At the follow-up of 90 days, 10 patients with successful recanalization showed good function (mRS: 0-2), 2 patients with recanalization failure were deteriorated. Conclusions In strictly selected patients with symptomatic non-acute occlusion of large intracranial artery in anterior circulation, endovascular recanalization was feasible and safe, which may improve patients' symptoms in a short term and reduce the recurrence rate of stroke, but its definite efficacy needs to be confirmed by studies with larger sample and longer follow-up. Key words: Intracranial arterial diseases; Arterial occlusive diseases; Radiology, interventional; Endovascular recanalization, non-acute

Role of Intracoronary Fibrinolytic Therapy in Contemporary PCI Practice.

Plaque rupture or plaque erosion leads to intracoronary thrombus formation resulting in coronary artery occlusion and ST-segment elevation myocardial infarction. Early restoration of blood flow in occluded coronary artery is the mainstay of therapy and it can be achieved by either thrombolytic therapy or primary percutaneous coronary intervention (P-PCI) or a combination of these two in many different ways. It has been proved that primary PCI is better than thrombolytic therapy in establishing early and effective recanalization of infarct related artery, reducing major adverse cardiovascular events (MACE) and increasing survival. There have been tremendous advances in PCI techniques over the years with newer stents, thrombectomy devices, and adjunctive pharmacotherapy. However, intracoronary thrombus continues to be the bane of interventional cardiologists. Failure of recanalization, suboptimal results, distal embolization, no reflow and impaired myocardial perfusion are some of the unresolved difficulties, regularly seen during PCI of patients with large intracoronary thrombus burden indicating an unmet need. This review focuses on emerging evidence about the usefulness of intracoronary thrombolytic therapy as an adjunct to PCI in patients with large intracoronary thrombus burden.