Fresh Thrombus Research Articles

Unstable Angina Caused by Honeycomb-Like Coronary Lesion Identified with Use of Optical Coherence Tomography

A 67-year-old man had angina and dyspnea for several weeks during exercise and rest, and he came to our hospital for coronary angiography. He had mild ST-segment variability, without necrosis markers. Cardiac ultrasonograms revealed moderate mitral regurgitation, preserved ejection fraction, and a posterior-wall infarction scar despite no history of infarction.Coronary angiograms, which revealed no obvious culprit lesion, showed mild focal stenosis in the proximal right coronary artery, distal chronic occlusion of a small left circumflex coronary artery, and mild stenosis and haziness in the mid left anterior descending coronary artery (LAD) (Fig. 1). Suspecting thrombus in the mid LAD, we performed optical coherence tomography (OCT) (Fig. 2A). The OCT showed irregular honeycomb-like channels connecting the proximal and distal lumina, smooth appearance of the channels' inner surface and the separating septa, no visible fresh thrombus, and only a small plaque burden at the lesion site (Fig. 2B–E). We thought that the guidewire might have passed into a false lumen of a spontaneous dissection, so we advanced another guidewire, parallel to the first, to ensure entry into the distal true lumen.Given the patient's clinical instability, we performed angioplasty and implanted a bare-metal stent. Afterwards, OCT confirmed good distal flow without residual stenosis and showed a well-apposed stent, mild intima prolapse through the struts (Fig. 3A), and almost complete collapse of the parallel channels (Fig. 3B). Two years later, the patient was asymptomatic and well.Lesions of this type were previously associated with recanalized thrombus.1,2 They were compared with Swiss cheese,1 or, when channels were spread over a larger area, with a honeycomb—a term coined by Toutouzas and colleagues.2In our patient, the small plaque burden at the lesion site seen on coronary angiography suggested an organized coronary embolus, but OCT revealed a recanalized thrombus. This rare case highlights the need to recognize the limits of angiography and to use complementary imaging methods, especially when angiographic appearance is discordant with clinical status.

P1259 When it rains, it pours: Late presentation STEMI in a patient with intricate symptomatology due to concomitant acute pancreatitis and pneumonia

Abstract Background ST segment elevation acute myocardial infarction and acute pancreatitis are diagnostic and therapeutic emergencies. The concomitance of these two pathologies produces intricate and confusing symptoms leading to late presentation. Clinical Case Description- We present the case of a 62-year-old male patient, non-smoker, admitted in the emergency department for intense, continuous epigastric pain with posterior radiation and dyspnea, started four days before. On admission we found hemodynamic stability, lung crackles in the ½ inferior of the right lung, SaO2= 94% under 3l/min O2, normal cardiac sounds, HR 102/min, mitral systolic murmur, BP 145/80mmHg, abdominal pain on palpation. Lab tests revealed elevated cardiac troponin values and detection of a fall of cTn values in dynamics (hs-cTnI 30372ng/l, TnI 73ng/ml), but also high serum transaminases, amylase and lipase (1278 U/l), with high inflammatory markers, leukocytosis and neutrophilia. ECG showed sinus rhythm, QRS axis 0 degrees, ST segment elevation in V1-V4, ST segment depression DI, aVL, negative and biphasic T waves in V5-V6, DI, DII, aVL, Q wave in DIII, aVF and poor R wave progression V1-V4. Admission echocardiography revealed dilated left cavities with severe left ventricular systolic dysfunction (EF 20%), akinesia of the anterior and inferolateral walls, moderate mitral and tricuspid regurgitation, grade III diastolic dysfunction and possible pulmonary arterial hypertension. Coronary angiography revealed distal stenosis of the left main, involving the bifurcation, 80% ostial LAD stenosis, proximal LAD occlusion, 30% ostial LCX. PCI with DES of the proximal LAD, and left main–LDA junction with overlapping was performed successfully. Abdominal echography showed increased volume of the pancreas and significant decrease in echogenicity. Abdominal CT scan assessed inflammatory changes in pancreas and peripancreatic fat (grade C Balthazar score), superior mesenteric artery partial thrombosis and alveolar consolidation in the right lung. Echocardiography reassessment four days later revealed a fresh apical thrombus of the left ventricle. He received treatment with low molecular weight heparin, dual antiplatelet therapy statin, loop diuretic, aldosterone antagonist, digoxin, antibiotics and food restriction with gradual oral realimentation. He needed positive inotropic support for the first 4 days from a total of 28 days of hospitalization. Conclusions ECG changes and prothrombotic status can occur in patients with acute pancreatitis. The diagnosis and management of STEMI concomitant with acute pancreatitis can be challenging. The multimodality imaging and interdisciplinary approach individualized to the patient’s clinical situation is important, especially when having safety concerns about the revascularization therapy, antiplatelet and anticoagulant therapy. Abstract P1259 Figure.

P1309 A jellyfish in the sea

Abstract Background The unexpected presence of a left ventricular (LV) mass is always a cause of concern for physicians. This is especially so in the presence of a cerebrovascular accident and a recent cardiac event, where the hunt for a cardioembolic source begins. We describe a case of an unusual presentation of a LV thrombus masquerading as a cystic mass, where diagnosis was confirmed with multimodality imaging tools. Purpose A 58 year old Thai male first presented to the emergency department with left brachio-facial syndrome secondary to a right pre-central gyrus stroke. He had chest pain 2 days prior, and was pain free on admission. An electrocardiogram done showed an evolved anterior myocardial infarction. Methods and Results A transthoracic echocardiogram performed on the 4th day of admission revealed a mildly impaired left ventricular systolic function with an ejection fraction of 45%, and wall motion abnormalities in the left anterior descending artery territory. There was an apical gelatinous-like, cystic and mobile mass with soft flexible walls, measuring 2.4 X 2.1cm. Differentials at this point included cystic thrombus, hydatid cyst, capillary haemangioma and intracardiac tumour. A cardiac MRI was performed which showed an irregular apical mass with features suggestive of fresh thrombus. The mass demonstrates hyperintensity T1-w FSE sequences (with and without fat sat), increased hyperintensity in T2-w triple IR FSE, with no increased uptake in first pass perfusion, T1-w post contrast, or early and late gadolinium enhancement images. A repeat transthoracic echocardiogram done 11 days after anticoagulation showed a 50% reduction in the size of the mass. See images below for more information. Conclusion In the era of early primary percutaneous coronary intervention and anticoagulation following an acute myocardial infarction (AMI), LV thrombus is an uncommon complication. It can occur within 2 weeks after an AMI, where increased blood stasis from dyskinesia or akinesia of associated wall segments, and a hypercoagulable state increases the risk of thrombus formation. A literature search has shown that presentation of the thrombus as a cystic mass is rare as well. As such, early diagnosis allowing for early treatment, especially when systemic embolism of thrombus is suspected, is important. Other causes of cystic LV thrombus do need to be considered in the relevant clinical context. These include infectious causes such as hydatid cyst, capillary hemangioma or intracardiac tumour, which are less likely given the history and investigation results. In this case, a trial of therapy with anticoagulation reduced the size of the cystic mass, and along with imaging findings, confirmed the diagnosis of a cystic LV thrombus. Abstract P1309 Figure. TTE and MRI heart

2D-shear wave elastography in the prediction of type II endoleaks after endovascular aneurysm repair

Purpose To evaluate the usefulness of 2D-shear wave elastography (2D-SWE) in the prediction of type II endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA). Material and methods Twenty-nine patients underwent EVAR for AAA, and 2D-SWE was performed after EVAR. Follow-up contrast-enhanced CT and ultrasonography were performed to evaluate endoleaks in all patients. The median follow-up period was 12 months (range, 3–12 months). Patients were divided into two groups: one with an endoleak (endoleak group) and another without it (control group). We compared the elasticity index (EI) of intraluminal thrombus (ITL) and fresh thrombus (FT) between the two groups. Results Type II endoleaks were confirmed in five of the 29 patients (endoleak group), and there were no endoleaks in the other 24 (control group). ILT was observed in 21 patients of the control group and in all patients of the endoleak group. There was a difference only in EI of ILT; the mean EI (± standard deviation) of ILT was 89 ± 16 kPA in the control group and 113 ± 25 kPA in the endoleak group (p=.037). Conclusions High EI of ILT may predict the occurrence of type II endoleaks after EVAR of AAA.

P3717More fresh thrombi in cardio embolic than vascular related acute vessel syndromes

Abstract Background Acute thrombotic occlusion may lead to major life threatening syndromes such as ST elevation myocardial infarction (STEMI) or stroke. In the majority, the underlying pathophysiology may be related to local vascular factors or thrombotic emboli. Thrombus composition might be indicative of underlying etiology and affect therapeutic considerations. Comparison of thrombi of patients suffering from both these acute syndromes has not been made yet. In this study, we compared the “age” of thrombi of patients with STEMI and acute large vessel occlusion related stroke (LVOS). Methods and results A total of 126 consecutive patients underwent thrombectomy for either STEMI (n=51) or LVO (n=75). All STEMI patients had vascular related occlusions. Causes of LVOS were classified according to the TOAST criteria; i.e. large artery atherosclerosis (LAA), cardio embolic (CE), other determined and embolic stroke of unknown source. Aspirated material was histopathological ordered as fresh (<1 day old), lytic (1–5 days old) or organized (>5 days old). In general, thrombi of patients with LVOS were fresher compared to thrombi of STEMI patients (p=0,04). This difference is can be attributed mainly to CE patients, which had significantly younger thrombi (p=0.001). Thrombi of LAA had comparable age with thrombi of STEMI (Figure). Conclusion Thrombi of cardio embolic stroke are fresher compared to that of thrombi of atherosclerotic related stroke. The latter have thrombi with comparable age of that with thrombi of ST elevation myocardial infarction. These findings may have therapeutic implications in anti-thrombotic therapies.

Treating Intimal Injury to the Graft Hepatic Artery by Intraoperative Fluorescence Vascular Stenting.

Early hepatic artery (HA) thrombosis and primary graft failure contribute greatly to the mortality of patients after liver transplantation. Herein, we present the treatment of intimal injury of HA by intraoperative fluorescence vascular stenting. A sample of 471 patients receiving liver transplantations underwent arterial anastomosis. Six patients (1.3%) were found to have early HA thrombosis. Two patients had thrombi that were impenetrable with a guide wire. Intimal injury on both the graft and the donor sides of the HA was found after thrombectomy. We performed anastomosis between unhealthy graft vessels and healthy recipient vessels. Intraoperative angiography was done immediately because of the guide wire being easier to insert through a fresh thrombus, and a long endovascular stent was inserted to bypass the injured vessels. The proper HA was reconstructed under microscopy. Three days after reconstruction, an angioplasty showed no dissection, stenosis, or pseudoaneurysm of the HA. Unexpectedly, these 2 patients survived well with acceptable graft functionality, one based on a 32-month follow-up and the other based on a 2-month follow-up. Anastomosis of the intimally injured graft artery followed by immediate endovascular angioplasty with stenting to bypass the injury zone is an efficacious and tolerable procedure.

Focal Aneurysm Wall Enhancement on Magnetic Resonance Imaging Indicates Intraluminal Thrombus and the Rupture Point

The precise mechanism of aneurysm wall enhancement (AWE) in ruptured intracranial aneurysms on magnetic resonance vessel wall imaging (VWI) remains unclear. We explored patterns of VWI findings and correlations with intraoperative or histopathologic aneurysm wall architecture. Twenty-four patients were evaluated by VWI before microsurgical clipping or endovascular coiling. The patterns of AWE were categorized, and the contrast ratio of AWE area was measured relative to the pituitary stalk. A total of 13 aneurysms were microsurgically inspected of the aneurysm wall and 4 were available for histopathologic evaluation. AWE was identified in 20 of 24 ruptured aneurysms. Among these 20 aneurysms, AWE was focal in 15 and circumferential in 5. Focal AWE showed significantly higher contrast ratio than circumferential AWE (P= 0.002). Histopathologic studies suggested that focal AWE indicating contrast ratio over 0.1 could be associated with fresh intraluminal thrombus at the rupture site. On the contrary, circumferential AWE suggested potential wall thickening with abundant neovascularization and inflammatory cells. Two AWE patterns were seen in ruptured intracranial aneurysms. Focal AWE on magnetic resonance imaging might indicate the presence of intraluminal thrombus, and detection of this sign could be useful for identification of the rupture point before treatment.

Combined Direct Endarterectomy and Fogarty Thrombectomy with Endovascular Therapy for Subacute Occlusion of the Superficial Femoral Artery.

A 78-year-old woman with a prior history of a right femoropopliteal bypass 5 years before and a coronary artery bypass graft 3 months before was admitted for a non-healing ulcer on her right foot. A computed tomography angiogram revealed occlusion of her superficial femoral artery (SFA) from its orifice to the anastomotic site of the bypass graft. The lesion was thought to consist of a partial atherosclerotic plaque with a large number of relatively fresh thrombi, referring to an angiogram of her lower extremity 3 months ago. We recanalized the occlusive SFA by Fogarty thrombectomy, and endovascular therapy preceded by direct SFA endarterectomy.

Higher lactate and purine metabolite levels in erythrocyte-rich fresh venous thrombus: Potential markers for early deep vein thrombosis

BackgroundThrombolytic therapy is effective in fresh deep vein thrombosis (DVT) although the benefit may fall below the risk of bleeding in non-fresh thrombosis. Markers reflecting fresh DVT have not been established. The present study aims to identify metabolites reflecting fresh venous thrombus and their role in thrombus formation. MethodsMetabolites of rabbit venous blood and jugular venous thrombus 4 h after thrombus induction were analysed using electrophoresis-time of flight mass spectrometry. The effects of the altered metabolites on blood coagulation and platelet aggregation were assessed by using rotation thromboelastometry and platelet aggregometer. Cellular contents and glucose transporter (Glut)-1 expression in aspirated human DVT samples were pathologically analysed. ResultsMetabolome analysis identified 226 metabolites (133 cationic and 93 anionic metabolites). Largely altered 18 metabolites (thrombus/blood ratio: >5 or <0.5) included glycolytic metabolites, redox-related metabolites, purine nucleotides and tryptophan metabolites. Among the metabolites with >5-fold increase, lactic acid was most abundant and guanine modestly enhanced whole blood clotting with thromboelastometry. Lactic acid and adenosine monophosphate inhibited collagen-induced platelet aggregation. Human DVTs were rich in erythrocytes expressing Glut-1. The erythrocyte content and Glut-1 expression were negatively correlated with the time after onset of DVT. ConclusionsGlycolysis-, purine-, and redox-related metabolites may reflect fresh erythrocyte-rich venous thrombus, and altered metabolites may affect venous thrombus formation. An increased level of lactate may reflect active glycolysis of thrombus cellular components, predominantly erythrocytes.

Abstract 44: Histopathological Interpretation of Vessel Wall Imaging of Intracranial Aneurysms

Background and purpose: It remains a challenge to predict unruptured intracranial aneurysms (UIAs) that are prone to rupture. MR- Vessel wall imaging (VWI) is a current topic whether it could predict unstable aneurysms. We investigated the correlations between aneurysm wall imaging findings and aneurysmal risk factors with a focus on the histopathological vessel wall architecture to clarify the interpretation of VWI of intracranial aneurysms. Methods: A total of 117 intracranial aneurysms, including 21 ruptured and 96 UIAs were investigated by VWI and visualization of the aneurysm wall enhancement (AWE) was evaluated. Univariate analysis was performed to assess the correlation between VWI findings and the PHASES score (calculating patient demographic and aneurysm morphologic risk factors). Fifteen intracranial aneurysms, including 6 ruptured and 9 UIAs were available for histopathological examination. Results: In UIAs, AWE was identified in 30 of 96 UIAs (31%). The PHASES score was associated with AWE (9.1 ± 0.7 versus 6.0 ± 0.3, p= 0.001). Histopathological studies revealed that wall thickening accompanied by atherosclerosis, neovascularization, and macrophage infiltration corresponded to AWE. The thicken wall was characterized by loss of mural cells and mucinous degeneration as well. On contrary, AWE was identified in 17 of 21 ruptured aneurysms (81%). Three AWE patterns (focal, circumferential, and both) were identified in ruptured ones. Histopathological studies revealed that focal AWE was associated with very thin aneurysm wall and fresh intraluminal thrombus at the rupture site, whereas circumferential AWE suggested wall thickening with abundant neovascularization and inflammatory cells. Conclusions: In the present study, one-third of UIAs showed AWE and might not provide informative rupture risk estimation beyond PHASES score at this moment. However, VWI of intracranial aneurysms can detect what is going on in the aneurysm wall. Histopathological interpretation of VWI in ruptured aneurysms differed from that of UIAs, especially in focal AWE. Focal AWE could identify the intraluminal thrombus suggesting rupture site of the wall before treatments.

Chronic thromboembolic pulmonary hypertension in Austria and Japan

ObjectiveChronic thromboembolic pulmonary hypertension (CTEPH) is characterized by one or more of the following features: intraluminal thrombus organization, fibrous stenosis, and complete obliteration of major pulmonary arteries, amenable to significant improvement by pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty, and medical treatments with vasodilators. Because treatment practices and outcomes differ in Europe versus Japan, we hypothesized that population-based characteristics of pulmonary vascular phenotypes may exist in Austria compared with Japan. The objectives of this study were to analyze clinical characteristics, hemodynamics, and PEA specimens in consecutive patients with CTEPH undergoing PEA in Austria and Japan. MethodsClinical features, hemodynamics, and PEA specimens were collected and analyzed in patients with CTEPH undergoing PEA, and clinical features and hemodynamics were collected and analyzed in patients with not-operated CTEPH and in patients with nonthromboembolic pulmonary arterial hypertension. ResultsApart from key differences between Austrian and Japanese patients regarding body size, lung function vital capacity, cardiac output, and serum high-density lipoprotein levels, Austrian patients were more likely to be obese, have greater hematocrits and greater white blood cells counts, greater C-reactive protein levels, and significantly elevated serum myeloperoxidase levels compared with Japanese patients with CTEPH. Analysis of PEA specimens demonstrated more proximal thrombus and more fresh red thrombus components in Austrian patients. ConclusionsThis study documents an inflammatory thrombotic phenotype in Austrian compared with Japanese patients with CTEPH that may be a determinant of differential treatment outcomes.

Relationship between histopathological features of aspirated thrombi and long-term left ventricular function in patients with ST-segment elevation myocardial infarction.

This study was an investigation of the severity of inflammation (SOI) in aspirated material and thrombus age to examine any association with pre-discharge and long-term left ventricular (LV) function after ST-elevation myocardial infarction (STEMI). The study group comprised 25 patients with STEMI from whom an occlusive thrombus was aspirated from the infarct-related artery with a 7-F catheter. The SOI in the aspirate was determined according to the mean leukocyte count in 5 high-power magnification fields and graded as mild in the presence of ≤100 leukocytes per field or significant if there were >100 leukocytes per field. The thrombi were categorized as fresh or lytic/organized (L/O) using predefined criteria. Echocardiographic assessment was performed prior to discharge and at 1 year. Adverse left ventricular remodeling (LVR) was defined as a 20% increase in LV end-diastolic volume in comparison with baseline values. LVR was observed in 8 patients. The mean leukocyte count of the aspirate (127.5±86.0 vs 227.2±120.7; p=0.026) and frequency of significant inflammation (35% vs 75% p=0.046) were significantly higher in the group with LVR. The serum high-sensitivity C-reactive protein (hsCRP) level was significantly correlated with the leukocyte count of the aspirate (r=0.532; p=0.006). An L/O thrombus was related to better pre-discharge and long-term LV volumes and ejection fraction values compared with a fresh thrombus. A significant increase in the leukocyte count in the aspirate and a fresh thrombus might predict long-term LV functional deterioration irrespective of the clinical and procedure-related characteristics. In addition, serum markers of inflammation, like hsCRP, might also reflect the intensity of the local inflammatory response at the site of occlusion.

Catheter-directed intra-arterial thrombolysis for lower extremity arterial occlusions.

Catheter-directed intra-arterial thrombolysis (CDT) is a rational treatment method in patients with acute/subacute and even some chronic occlusions of lower extremity arteries and bypass grafts having salvageable limb ischemia. Immediate vessel patency can be achieved with an acceptable complication rate in many patients, especially those with fresh thrombus or emboli. It can be also an adjuvant treatment modality for endovascular interventions for chronic occlusions. There is no standard method of CDT including thrombolytic agent dose and technique. Selection of treatment strategy should be based on individual judgment based on viability of limb, lesion characteristics, and risks of hemorrhage.

Shear wave elasticity imaging for residual endoleak and thrombus characterisation after endoleak embolisation following endovascular aneurysm repair: a canine animal study

BackgroundTo evaluate residual endoleak and thrombus organisation with shear wave imaging (SWI) after endoleak embolisation through an animal study.MethodsThis prospective experimental study involved eight dogs with creation of 16 iliac aneurysms and type I endoleak after endovascular aneurysm repair (EVAR). Embolisation agents were injected into the sac to seal endoleak. SWI and colour flow Doppler ultrasound (DUS) were performed at implantation, one week, and one and three months after implantation; for three dogs, SWI and DUS were also performed six months after implantation. Digital subtraction angiography and contrast-enhanced computed tomography were performed at sacrifice. Macroscopic and histopathological analyses were processed to identify regions of interest (ROIs) for endoleak, fresh thrombus, organised thrombus and embolisation agent, where SWI elasticity moduli were compared.ResultsAt sacrifice, nine aneurysms had residual endoleak, while seven were sealed. Ten had a fresh and 15 had an organised thrombus. SWI was able to detect all endoleaks, including two cases undetected with DUS. Elasticity moduli of 0.2 kPa ± 0.1 kPa (mean ± SD), 9.5 kPa ± 3.3 kPa, 48.1 kPa ± 21.3 kPa and 44.9 kPa ± 23.7 kPa were found in the ROIs positioned in endoleaks, fresh thrombi, organised thrombi and embolisation agent, respectively. Elasticity values of endoleak and fresh thrombus were lower than those of organised thrombi and embolisation agent (p < 0.001). Stiffness of fresh thrombus at one week (8.7 kPa ± 3.6 kPa) increased at three months (30.2 kPa ± 13.8 kPa), indicating thrombus maturation (p < 0.001).ConclusionsIn a dog model of iliac EVAR, SWI was able to identify endoleak, thrombus maturation and embolising agents after endoleak embolisation.

Chronic aortiс dissection: pathomorphological characteristics.

Background. Chronic aortic dissection (CAD) is a poorly understood vascular pathology. Etiology, pathogenesis, pathomorphological and clinical changes are not fully elucidated. The presence of open questions in their morphogenesis and pathomorphological picture creates difficulties in clinical diagnosis and gives rise to discussions in the choice of treatment. Objective – determinate pathomorphological changes of CAD. Methods. The analysis of 31 cases of surgical material for patients undergoing surgery on CAD was conducted. Among the operatives men dominated – 22 (70.9%), women were nine (29.1%). The age of patients ranged from 47 to 59 years. Aortic preparations were painted hematoxylin-eosin, resorcinol-fuchin for Chart, picrofuscin for Weigert, trichrome Mason. Results. The cavity of the dissection looked like a two-channel, located on the verge of adventitia and mediums, filled with blood convections, with the spread of hemorrhagic infiltration to periadventicial fatty tissue. The new pseudo-channel in one third of cases contained blood convection and fresh thrombi, and the old one was completely covered with endothelium with neointimal formation. In the media were detected massive elastolysis with contours of hyperchromic elastic fibers with signs of hyperlastosis, multiple thin layers of connective tissue fibers located between randomly scattered smooth muscle cells and collagen fibers, deeper definitions of massive enlargement of connective tissue. Conclusions. In the pathomorphological study of CAD, connective tissue remodeling of the aorta in the form of randomly located immature mesenchymal cells in combination with muscular and connective tissue transformation was revealed. The processes of vascular remodeling can provide the relative clinical stability of HRAA.

Usefulness of thrombosis and inflammation biomarkers in chronic thromboembolic pulmonary hypertension-sampling plasma and surgical specimens.

Chronic thromboembolic pulmonary hypertension (CTEPH) results from persistent pulmonary vascular obstructions, presumably due to inflammatory thrombosis. Because estimates of thrombus volume at diagnosis have no predictive value, we investigated the role of the thrombosis marker, D-dimer, and the inflammation marker, C-reactive protein (CRP), for predicting outcomes in CTEPH. A total 289 consecutive patients with CTEPH were followed for 57 (median 45 to 69) months. One hundred fifty-seven of these patients underwent surgical pulmonary endarterectomy (PEA). D-dimer and CRP were collected at the time of CTEPH diagnosis and their impact on outcome was analyzed using Cox and logistic regression models. Their association with thrombus composition was analyzed utilizing HistoQuest. D-dimer and CRP levels were separately and independently predictive of death or need for lung transplantation (p = 0.012 and p = 0.025, respectively). For example, 5-year survival was 90% (confidence limits 84% to 96%) in patients with D-dimer levels <0.5 µg/ml and CRP <1 mg/dl at diagnosis, as compared with 50% (36% to 64%) for patients with D-dimer ≥0.5 µg/ml and CRP ≥1 mg/dl (p < 0.001). D-dimer and CRP both decreased significantly after PEA (p < 0.01). The amount of fresh red thrombus in thrombendarterectomy specimens correlated positively with D-dimer levels at diagnosis (r = 0.37, p = 0.003). D-dimer and CRP at the time of diagnosis are independent and significant predictors of outcome in CTEPH, available at the time of diagnosis. This observation suggests an important role for fibrin turnover and inflammation in the pathogenesis of CTEPH and the associated complications.

Volume of mural thrombus plays a role in the elevation of inflammatory markers after endovascular aortic repair

BackgroundAlthough systemic inflammatory responses are common after endovascular aortic repair (EVAR), its etiology remains uncertain. It is normally well tolerated and has a benign course. This study was undertaken to investigate the possible etiology of post-EVAR inflammation by measuring volumes of chronic mural thrombus and fresh thrombus.MethodsThe subjects of this study included 34 patients who underwent EVAR from February 2012 to July 2017. Inflammatory markers in all the patients were evaluated before surgery, using the highest value among the laboratory data up to 5 days after surgery, and postoperative computed tomographic angiography (CTA) was taken for all of them before their discharging. Volumes of mural thrombus and fresh thrombus were calculated by CTA. The mean interval from surgery to immediate postoperative CTA was estimated as 6.8 ± 4.0 days.ResultsAfter undergoing EVAR, white blood cell (WBC) (p < 0.01), C-reactive protein (CRP) (p < 0.01) and erythrocyte sedimentation rate (ESR) (p = 0.01) were significantly elevated. Two groups were defined according to the post-implantation syndrome (PIS) by the criteria of systemic inflammatory response syndrome (SIRS);no significant differences were observed in any factors between the two groups. Classification of two groups by the criteria of increasing WBC and CRP revealed that inflammatory markers were significantly enhanced as the volume of mural thrombus increased (p = 0.03). However, no significant risk factor was found in view of aneurysmal growth after EVAR.ConclusionVolume of mural thrombus is an important risk factor for the elevation of inflammatory markers after EVAR.

Catheter-Directed Thrombolysis Versus Pharmacomechanical Thrombectomy for Upper Extremity Deep Venous Thrombosis: A Cost-Effectiveness Analysis

Upper extremity deep vein thrombosis represents (UEDVT) 2-3% of all deep vein thrombosis. Catheter directed thrombolysis (CDT) was replaced largely by pharmacomechanical thrombolysis (PMT) in our institution. In this study we compared the immediate and 1-year results as well as the total hospital costs between CDT and PMT in the treatment of UEDVT. From 2006 to 2013, 55 patients with UEDVT were treated with either CDT or PMT at Helsinki University Hospital. Of them, 43 underwent thoracoscopic rib resection later to relieve phlebography-confirmed vein compression. This patient cohort was prospectively followed up with repeated phlebographies. CDT was performed to 24 patients, and 19 had PMT with a Trellis™ device. Clinical evaluation and vein patency assessment were performed with either phlebography or ultrasound 1 year after the thrombolysis. Primary outcomes were immediate technical success, 1-year vein patency, and costs of the initial treatment. The immediate overall technical success rate, defined as recanalization of the occluded vein and removal of the fresh thrombus, was 91.7% in the CDT group and 100% in the PMT group (n.s.). The median thrombolytic time was significantly longer in CDT patients than that in PMT patients (21.1 vs. 0.33hr, P<0.00001). There were no procedure-related complications. The 1-year primary assisted patency rate was similar in both the groups (91.7% and 94.7%). There were no recurrences of clinical DVT. The hospital costs for the acute period were significantly lower in the PMT group than those in the CDT group (medians: 11,476 € and 5,975 € in the CDT and PMT groups, respectively [P<0.00001]). The clinical results of the treatment of UEDVT with CDT or PMT were similar. However, PMT required shorter hospital stay and less intensive surveillance, leading to lower total costs.

Ultrasound Elastography for Determination of the Age of Venous Thrombi. Evaluation of Thrombus Evolution in Patients After Sclerotherapy.

SummaryBackgroundVenous thrombosis is a multicausal disease involving intravenous clot formation. It may occur spontaneously or after provoking events, such as traumatic injuries to the pelvis, upper and lower extermities, immobilization, intravascular procedures, including venous catheterization or injection. Color Doppler ultrasonography is a rapid and non-invasive technique for evaluation of venous disease. It is a very sensitive method for detection of thrombi, but has some limitations, e.g. inability to distinguish between an old and fresh thrombus. Elastography as a method for evaluation of tissue elasticity and allows more accurate assessment of venous thombosis. The thrombus solidifies significantly during the process of remodeling, thereby changing elasticity, while the tissues located around the vessel remain unchanged. Moreover, the homogeneity of the thrombus is also changed. These factors allow for exact determination of the age of the thrombus depending on changes of its elasticity.Material/MethodsThe object of this study was to assess thrombus age in patients with saphenous vein insufficiency treated with sclerotherapy. We examined 34 patients, 30 women and 4 men, aged 18–62 years. All short-listed patients with initial 7–8 mm vessel diameter underwent treatment with 3% Aetoxysklerol mixed with CO2 and other respiratory gases. Data acquisition was performed using an Esaote MyLab Twice device with LA523 linear probe.ResultsOn the sixth day after the treatment 31 patients presented uniform, hypoechogenic thrombus in B-mode image. Ultrasound-based elasticity images (elastography) showed significant predominant red and green areas. Blue area was either invisible or appeared in insignificant grade on examined area. The mosaic image of colors appeared on 2 patients. On the fourteenth day of study 21 patients still presented hypoechogenic thrombus, whereas mixed echogenicity of thrombus appeared on 11 patients.On 28 examined patients mosaics of red, green and blue colors were observed, with blue color significantly predominating over red color. 3 patients presented mosaics of colors without a predominate color.ConclusionsElastography as a method of thrombus evaluation, provides information about relative shrinkage of blood clot. It seems that elasatography can improve accurate assessment of the exact age of thrombus.

Activatable magnetic resonance nanosensor as a potential imaging agent for detecting and discriminating thrombosis.

The early detection and accurate characterization of life-threatening diseases such as cardiovascular disease and cancer are critical to the design of treatment. Knowing whether or not a thrombus in a blood vessel is new (fresh) or old (constituted) is very important for physicians to decide a treatment protocol. We have designed smart MRI nano-sensors that can detect, sense and report the stage or progression of cardiovascular diseases such as thrombosis. The nanosensors were functionalized with fibrin-binding peptide to specifically target thrombus and were also labelled with fluorescent dye to enable optical imaging. We have demonstrated that our nanosensors were able to switch between the T1 and T2 signal depending on thrombus age or the presence or absence of thrombin at the thrombus site. The developed nanosensors appeared to be non-toxic when tested with Chinese Hamster Ovarian cells within the tested concentrations. The working principle demonstrated in this study can be applied to many other diseases such as cancer.