Fresh Thrombus Research Articles

Proximal protection in recanalization of totally occluded saphenous vein grafts in acute coronary syndrome

Percutaneous treatment of old, degenerated saphenous vein grafts (SVG) is associated with a high likelihood of major adverse cardiac events. When an acute coronary syndrome (ACS) develops in a patient with old SVG, fresh thrombus may superimpose on an old, degenerative atheroma: a sudden increase in the athero-thrombotic burden ensues with consequent, frequent total occlusion of the lumen. In this scenario, transluminal recanalization of the graft is usually associated with the highest chance of distal embolization and no-reflow and positioning of an embolic protection device (EPD) is almost mandatory. However, distal EPD are difficult to place when the vessel is totally occluded and do not completely avoid distal embolization. We report two cases of totally occluded SVG in patients admitted for ACS that were recanalized with the aid of a proximal EPD system with angiographic and clinical success.

335 Sensitivity and specificity of post-resuscitation ECG for the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrests

Coronary angioplasty can decrease mortality in patients with acute myocardial infarction (AMI) and out-of-hospital cardiac arrest (OHCA). Sensitivity (Se) and specificity (Sp) of electrocardiogram (ECG) for AMI diagnosis in these patients are debated. to determine the Se and Sp of immediate post-resuscitation ECG for AMI diagnosis in patients resuscitated from an OHCA. We screened in a prospective single centre study, 210 consecutive patients admitted for OHCA regardless of ECG abnormalities and medical history, between January 2002 and June 2008. All patients underwent coronary angiogram with angioplasty on arrival at the hospital. Exclusion criteria were: obvious non-cardiac cause of OHCA, age <18 or >90 years, unstable or absence of return of spontaneous circulation. AMI was characterized at angiography by a significant stenosis (>80% lumen diameter) and TIMI 3 or 2 flow with intracoronary fresh thrombus, or TIMI 1 or 0 flow due to an occlusion easily crossed by a guide wire. Results are expressed as mean ± SD [range]. Among the 170 patients included, 77% were male and mean age was 58 ± 13 [26-90]. On post-resuscitation ECG, 41% presented with ST segment elevation, 15% with ST depression only (≥1mm), 12% with large QRS complex only (>120 ms with left bundle branch block or atypical morphology), and 32% with no significant ECG changes. AMI was diagnosed in 38% of the patients: in 76% of the patients with ST segment elevation, in 15% with ST depression, in 15% with large QRS, and in 0% with none of the above. Se and Sp for AMI diagnosis of ST elevation, ST elevation or depression and ST elevation or depression or large QRS were 88% and 83%, 95% and 63%, 100% and 46% respectively. ST elevation on ECG after a resuscitated OHCA has a moderate Se and Sp for AMI diagnosis. The combined criterion of ST elevation or depression or large QRS has 100% sensitivity in our study and could identify all patients with AMI in the setting of OHCA.

Meckel's Diverticulum Ischemia Caused by Thromboembolism after Coronary Artery Bypass Grafting

A 75-year-old woman underwent emergency coronary artery bypass surgery after acute anterior wall myocardial infarction. Because of the presence of a local peritonitis, an emergency laparotomy was performed in which necrotizing Meckel's diverticulum was found and resected. Microscopically, sections through the diverticulum revealed a fresh thrombus occluded the arterial lumen of diverticulum. The patient had an uneventful postoperative course. We believe that the cause of Meckel's diverticulum ischemia was the development of atrial fibrillation with left atrium thrombus formation followed by embolic obliteration of Meckel's diverticulum feeding artery.

Thrombus Size and Doppler Embolic Signal Intensity

Background: Migration of thrombus through the cerebral arteries is a common cause of stroke. Thrombus emboli can be detected non-invasively using Doppler ultrasound, but even where the embolus composition is known, there is currently no method for estimating the size of an embolus based on the returned ultrasound signal. Here we report the results of in vitro experiments investigating the relationship between size and embolic signal intensity for fresh thrombus emboli with a view to estimating the sizes of thrombi detected following carotid surgery. Method: Thrombi were formed from whole blood using the ‘Chandler loop’ method under flow conditions similar to those associated with arterial thrombus formation in vivo. A total of 390 Doppler embolic signals were then measured from 37 pieces of thrombus circulated in a pulsatile closed-flow circuit. The dimensions of each of the thrombi were measured before and after circulation using an optical microscope. Relationships between thrombus size and embolic signal properties were then investigated using standard statistical methods with a view to size estimation of thrombi during clinical monitoring. Results: Although embolic signals generally became more intense with increasing thrombus size, strong oscillations due to resonance effects were observed. Pearson tests revealed strong positive correlations between embolus diameter, signal intensity and duration (r > 0.8, p ≤ 0.01). Conclusions: This study provides experimental evidence supporting theoretical predictions relating Doppler embolic signal intensity to thrombus size. In our discussion, we tentatively suggest how this information might be used to size emboli in clinical practice.

Fibulin-1 and fibrinogen in human atherosclerotic lesions

Fibulin-1 is a fibrinogen-binding blood protein and a component of many extracellular matrices (ECM) including those of blood vessels. In this study, the deposition patterns of fibulin-1 and fibrinogen were examined in human coronary artery atherosclerotic lesions excised by atherectomy from 20 patients. Fibulin-1 deposition was found to be closely overlapping with fibrinogen located within the atherosclerotic lesions and in regions containing fresh thrombi. Pronounced intracellular fibulin-1 immunostaining was apparent in lesion areas rich in macrophages and foam cells, although THP-1 macrophages and foam cells were found not to express fibulin-1. Strong ECM deposition of fibulin-1 was observed in acellular atheromatous and myxomatous regions. By contrast, fibulin-1 was present at relatively low levels in the ECM associated with smooth muscle cells within and outside of lesions and was not detected in sclerotic regions. These results reveal the pattern of fibulin-1 within human atherosclerotic lesions and highlight the potential for fibulin-1, perhaps derived from the blood and acting in conjunction with fibrinogen, to play a role in the etiology and cardiovascular disease progression, particularly with respect to thrombotic aspects of atherosclerosis.

Chest pain and small red cells: size does matter

A 63-year-old woman was admitted to our hospital in June, 2008, with a 24-h history of central chest pain radiating to her neck. In the 7 days before admission, she had experienced intermittent chest tightness without any obvious precipitating cause. Her medical history was unremarkable. She did not smoke and was on no regular medication. There were no abnormalities on clinical examination. ECG showed inversion of T waves in leads III, V2, and V3. Serum troponin T concentration after 12 h was 1·22 μg/L (normal range [NR] 0–0·01 μg/L) indicating an inferior non-STelevation myocardial infarction. We started our patient on aspirin, clopidogrel, and dalteparin. Serum cholesterol was slightly high (5·3 mmol/L; normal up to 5 mmol/L) but no additional risk factors for coronary artery disease were evident. Blood tests showed haemoglobin 137 g/L (NR 120–160 g/L), leuco cytes 14·5×109/L (NR 4–11×109/L), neutrophils 12×109/L (NR 2·0–7·5×109/L), and platelets 614×109/L (NR 150–400×109/L), with normal eosinophil (0·08×109/L; NR 0–0·4×109/L) and basophil counts (0×109/L; NR 0–1×109/L). C-reactive protein concentration was 4 mg/L (normal up to 5 mg/L). After 24 h, leucocyte count had normalised, and the platelets decreased to 528×109/L. Coronary angiography showed normal left coronary arteries. The right coronary artery was dominant with a long layer of fresh thrombus in the proximal/mid vessel (fi gure A), clearly the cause of her symptoms. Because of the risk of distal embolisation, angioplasty was deferred and the patient was started on an infusion of the glycoprotein IIb/IIIa inhibitor, tirofi ban. Repeat angiography after 72 h of tirofi ban showed almost complete resolution of the thrombus (fi gure B) and we managed our patient conservatively thereafter, with the initiation of dual antiplatelet therapy. On closer scrutiny of the presenting blood count, despite normal haemoglobin and packed-cell volume, there was micro cytosis with reduced mean corpuscular volume (74·5 fL; NR 80–96 fL) and hypochromia (mean corpuscular haemoglobin 23 pg; NR 27–32 pg). The serum ferritin concentration (12 μg/L; NR 13–150 μg/L) confi rmed iron defi ciency. This conclusion was supported by the microscopic appearance of the blood, which showed anisopoikilocytosis with microcytic hypochromic cells, elliptocytes, and pencil cells (fi gure C). In addition, platelet anisocytosis and giant platelets were seen (fi gure D). Paradoxically, despite iron defi ciency, there was erythrocytosis (red cell count 5·96×1012/L; NR 3·8–4·8×1012/L) indicating loss of homoeostatic control of erythropoiesis. The suspicion of an iron-defi cient myelo proliferative disorder underlying the myocardial infarction was confi rmed by the presence of a heterozygous mutation (V617F) in the JAK2 gene, detected in 90–95% of patients with myeloproliferative polycythaemia. We started our patient on hydroxy carbamide, resulting in satisfactory control of the platelet count. When last seen in May, 2009, our patient was asymptomatic with no further angina. Myeloproliferative disorders are associated with thrombotic complications with predominance of arterial over venous events. The recognition of the somatic mutation JAK2V617F in most patients with myeloproliferative polycythaemia has improved the diagnostic accuracy and bone-marrow examination is not mandatory. Diagnosis of myeloproliferative polycyth ae mia is therefore straight forward in the setting of an elevated haemoglobin and packed-cell volume. Some patients may present with a normal haemoglobin and only subtle changes in red cell indices, as a result of iron-defi ciency; identifi cation of these patients is important because of the potential for life-threatening thrombosis through mechanisms independent of haemoglobin and packedcell volume. Despite iron defi ciency, these patients should not be given iron-replacement therapy unless closely supervised, because it could stimulate a rapid and potentially catastrophic increase in haemoglobin.

Correlation of Intravascular Ultrasound Findings With Histopathological Analysis of Thrombus Aspirates in Patients With Very Late Drug-Eluting Stent Thrombosis

Intravascular ultrasound of drug-eluting stent (DES) thrombosis (ST) reveals a high incidence of incomplete stent apposition (ISA) and vessel remodeling. Autopsy specimens of DES ST show delayed healing and hypersensitivity reactions. The present study sought to correlate histopathology of thrombus aspirates with intravascular ultrasound findings in patients with very late DES ST. The study population consisted of 54 patients (28 patients with very late DES ST and 26 controls). Of 28 patients with very late DES ST, 10 patients (1020+/-283 days after implantation) with 11 ST segments (5 sirolimus-eluting stents, 5 paclitaxel-eluting stents, 1 zotarolimus-eluting stent) underwent both thrombus aspiration and intravascular ultrasound investigation. ISA was present in 73% of cases with an ISA cross-sectional area of 6.2+/-2.4 mm(2) and evidence of vessel remodeling (index, 1.6+/-0.3). Histopathological analysis showed pieces of fresh thrombus with inflammatory cell infiltrates (DES, 263+/-149 white blood cells per high-power field) and eosinophils (DES, 20+/-24 eosinophils per high-power field; sirolimus-eluting stents, 34+/-28; paclitaxel-eluting stents, 6+/-6; P for sirolimus-eluting stents versus paclitaxel-eluting stents=0.09). The mean number of eosinophils per high-power field was higher in specimens from very late DES ST (20+/-24) than in those from spontaneous acute myocardial infarction (7+/-10), early bare-metal stent ST (1+/-1), early DES ST (1+/-2), and late bare-metal stent ST (2+/-3; P from ANOVA=0.038). Eosinophil count correlated with ISA cross-sectional area, with an average increase of 5.4 eosinophils per high-power field per 1-mm(2) increase in ISA cross-sectional area. Very late DES thrombosis is associated with histopathological signs of inflammation and intravascular ultrasound evidence of vessel remodeling. Compared with other causes of myocardial infarction, eosinophilic infiltrates are more common in thrombi harvested from very late DES thrombosis, particularly in sirolimus-eluting stents, and correlate with the extent of stent malapposition.

Histopathological Features of Aspirated Thrombi after Primary Percutaneous Coronary Intervention in Patients with ST-Elevation Myocardial Infarction

BackgroundPlaque disruption with superimposed thrombus is the predominant mechanism responsible for the onset of acute coronary syndromes. Studies have shown that plaque disruption and thrombotic occlusion are frequently separated in time. We established the histopathological characteristics of material aspirated during primary percutaneous coronary intervention (PCI) in a large consecutive ST-elevation myocardial infarction (STEMI) population.Methodology/Principal FindingsThrombus aspiration during primary PCI was performed in 1,362 STEMI patients. Thrombus age was classified as fresh (<1 day), lytic (1–5 days), or organized (>5 day). Further, the presence of plaque was documented. The histopathological findings were related to the clinical, angiographic, and procedural characteristics. Material could be aspirated in 1,009 patients (74%). Components of plaque were found in 395 of these patients (39%). Fresh thrombus was found in 577 of 959 patients (60%) compared to 382 patients (40%) with lytic or organized thrombi. Distal embolization was present in 21% of patients with lytic thrombus compared to 12% and 15% of patients with fresh or organized thrombus.Conclusions/SignificanceMaterial could be obtained in 74% of STEMI patients treated with thrombus aspiration during primary PCI. In 40% of patients thrombus age is older than 24 h, indicating that plaque disruption and thrombus formation occur significantly earlier than the onset of symptoms in many patients.

Endovascular Treatment for Iliac Vein Compression Syndrome: a Comparison between the Presence and Absence of Secondary Thrombosis

ObjectiveTo evaluate the value of early identification and endovascular treatment of iliac vein compression syndrome (IVCS), with or without deep vein thrombosis (DVT).Materials and MethodsThree groups of patients, IVCS without DVT (group 1, n = 39), IVCS with fresh thrombosis (group 2, n = 52) and IVCS with non-fresh thrombosis (group 3, n = 34) were detected by Doppler ultrasonography, magnetic resonance venography, computed tomography or venography. The fresh venous thrombosis were treated by aspiration and thrombectomy, whereas the iliac vein compression per se were treated with a self-expandable stent. In cases with fresh thrombus, the inferior vena cava filter was inserted before the thrombosis suction, mechanical thrombus ablation, percutaneous transluminal angioplasty, stenting or transcatheter thrombolysis.ResultsStenting was performed in 111 patients (38 of 39 group 1 patients and 73 of 86 group 2 or 3 patients). The stenting was tried in one of group 1 and in three of group 2 or 3 patients only to fail. The initial patency rates were 95% (group 1), 89% (group 2) and 65% (group 3), respectively and were significantly different (p = 0.001). Further, the six month patency rates were 93% (group 1), 83% (group 2) and 50% (group 3), respectively, and were similarly significantly different (p = 0.001). Both the initial and six month patency rates in the IVCS patients (without thrombosis or with fresh thrombosis), were significantly greater than the patency rates of IVCS patients with non-fresh thrombosis.ConclusionFrom the cases examined, the study suggests that endovascular treatment of IVCS, with or without thrombosis, is effective.

No fate but what we make: a case of full recovery after out-of-hospital cardiac arrest

An 80 years old man suffered a cardiac arrest shortly after arrival to his local health department. Basic Life Support was started promptly and nine minutes later, on evaluation by an Advanced Life Support team, the victim was defibrillated with a 200J shock. When orotracheal intubation was attempted, masseter muscle contraction was noticed: on revaluation, the victim had pulse and spontaneous breathing.Thirty minutes later, the patient had been transferred to an emergency department. As he complained of chest pain, the ECG showed a ST segment depression in leads V4 to V6 and laboratorial tests showed cardiac troponine I slightly elevated. A coronary angiography was performed urgently: significant left main plus three vessel coronary artery disease was disclosed.Eighteen hours after the cardiac arrest, a quadruple coronary artery bypass grafting operation was undertaken. During surgery, a fresh thrombus was removed from the middle left anterior descendent artery. Post-operative course was uneventful and the patient was discharged seven days after the procedure. Twenty four months later, he remains asymptomatic.In this case, the immediate call for the Advanced Life Support team, prompt basic life support and the successful defibrillation, altogether, contributed for the full recovery. Furthermore, the swiftness in the detection and treatment of the acute reversible cause (myocardial ischemia in this case) was crucial for long-term prognosis.

The endothelium and thrombotic risk in heart failure

Thromb Haemost 2009; 102: 185–187 Chronic heart failure (HF) is increasingly recognised as a syndrome which confers a considerable prothrombotic risk. Whilst the annual incidence of venous thromboembolism is about 0.1% in general population, prospective observational studies have shown that thromboembolic events would occur in 1.7–2.7% of patients with HF each year (1). Indeed, a retrospective analysis of the Studies of Left Ventricular Dysfunction (SOLVD) trials reported that the annual incidence of thrombotic events (including strokes, pulmonary emboli and peripheral emboli) in patients with ventricular dysfunction and sinus rhythm was 1.8% in men and 2.4% in women (2). Furthermore, patients with HF generally suffer more severe strokes that are associated with high mortality rate (3). However, even this high prevalence of thromboembolic events may just represent the tip of the iceberg. Indeed, more than 30% of patients with HF, irrespective of its aetiology, may experience ‘silent’ asymptomatic thromboembolic strokes detected by brain magnetic resonance imaging (4). In addition to the risk of venous thromboembolism, patients with HF also have a high (and often underestimated) risk of arterial thrombosis. The risk of sudden cardiac death, often attributable to acute arterial thrombosis, is 6– to 9-fold higher in those with HF compared to the general population (5). In the Assessment of Treatment with Lisinopril and Survival (ATLAS) study, fresh coronary thrombus was found in more than 30% of such sudden death cases (6). Both acute myocardial infarction and unstable angina are independent risk factors for death in patients with congestive HF (7). Why does HF confer a prothrombotic state? HF is associated with abnormalities of flow (low cardiac output, impairment of intracardiac haemodynamics, dilated cardiac chambers, stasis of blood in peripheral vascular beds, etc), vessel wall (endothelial damage/ dysfunction), and abnormalities of blood constituents (abnormalities of platelets and haemorrheology). Thus HF fulfils all of Virchow's triad of characteristics of a prothrombotic state, which promote the risk of thrombosis and unsurprisingly, the risk of thromboembolic complications rises accordingly the degree of left ventricular contractility impairment (2). Given that endothelial dysfunction is commonly seen in HF pathophysiology, the contribution of the endothelium to thrombosis may be especially important in patients with HF. Endothelium and thrombogenic alterations in heart failure

Gradenigo Syndrome

Gradenigo Syndrome

Atherosclerotic Peripheral Vascular Disease Symposium II

Percutaneous intervention for peripheral artery disease has evolved from balloon angioplasty for simple focal lesions to multimodality techniques that enable treatment of severe arterial insufficiency. This technological expansion comes without a standard approach or algorithm, which makes the decision-making process more subjective than objective. Nevertheless, clinical tools are available that can have a favorable effect on patient care, and these promote usage. So, when are standard endovascular techniques (such as balloon and stents) good enough, and when are the latest advances (eg, atherectomy, drug-eluting stents) more appropriate? This section will address these questions for acute limb ischemia (ALI) and chronic critical limb ischemia (CLI). It will also delineate the problem of restenosis, particularly of the superficial femoral artery (SFA), and describe treatment alternatives. The discussion will review the role of drug-eluting stents, atherectomy devices, reentry catheters, and brachytherapy, as well as their potential complications and appropriate remedies. Treatment algorithms for aortoiliac and infrainguinal disease are provided in Figures 1 through 3⇓⇓. Figure 1. Treatment algorithm for acute lower-limb ischemia. *Short infusion of thrombolytic therapy proximal to occlusion can be used to facilitate wire traversal. Figure 2. Simplified treatment algorithm for symptomatic aortoiliac disease in patients deemed candidates for revascularization. In patients with multilevel disease, the aortoiliac segment should be addressed first. TASC indicates TransAtlantic Inter-Society Consensus; AI, aortoiliac; PTA, percutaneous transluminal angioplasty; PE, physical examination; ABI, ankle-brachial index; and U/S, ultrasound. Figure 3. Simplified treatment algorithm for symptomatic infrainguinal peripheral arterial disease, assuming concomitant aortoiliac disease has been treated and the patient is an acceptable candidate for revascularization. *Alternative therapies to PTA include cryotherapy, atherectomy (directional, rotational, ablative), and cutting balloon. †Alternative stent options include stent (graft, balloon expanding, and self expanding) and drug-eluting stent. PTA indicates percutaneous transluminal angioplasty; TASC, TransAtlantic Inter-Society Consensus; PE, physical examination; …

Challenging the Myth: Directional Atherectomy—A Reply

‘‘Challenging the myth’’ is a new column we have introduced to stimulate discussions among our readers to give their ideas and thoughts about controversial principles and issues. The content of these short commentaries will be influenced by individual and sometimes subjective thoughts and conclusions. However, these opinions should not be published without the opportunity for others to give an alternative view if they so wish. Therefore, we also intend to create space in the journal where authors can provide opposing viewpoints. Jim Reekers starts this series by challenging the myth of atherectomy and points out that there was never any proof that atherectomy works better than balloon angioplasty, neither in cohort series nor in randomized trials, and I have to agree that he is right. Nevertheless, we need atherectomy. Many interventional radiologists missed the old Simpson atherectomy catheter when it disappeared because there was no better tool for debulking eccentric calcified plaques, especially from the popliteal artery in the P2 segment. Therefore, despite the fact that no statistical benefit was proven over PTA, atherectomy is a valuable and helpful tool although it is not required on a frequent basis. Clearly, this should be the approach regarding how we should view the new atherectomy device, i.e., as a tool and not as miraculous new weapon. It might be a mistake to advertise the device as something revolutionary that will drastically change long-term results in peripheral angioplasty. However, the new atherectomy device is a helpful new instrument that is much more versatile than the old Simpson device. The new atherectomy device is useful to remove organized as well as fresh thrombus. The device works on calcified material (although not as well as the Simpson device), and it can debulk eccentric plaques from small arteries without a significant risk of dissection. It is also useful to remove dissections after balloon angioplasty, which otherwise require stent implantation. It can be used on tight and fibrous lesions, such as anastomotic strictures in bypasses, and helps to clean restenosed stents by removing neointimal tissue (not officially, but I swear it works). It is therefore a useful tool especially in delicate areas, such as close to the groin or in the popliteal artery. Professor Reekers is correct in that there is no proof that the device creates better follow-up results than angioplasty alone, although in the registry there was some interest in the fact that diabetic patients had improved patency compared with diabetic patients treated with alternative techniques. However, all of this remains to be proven in a randomized trial. I know that Professor Reekers loves cooking to a great degree. He would love to have such a new multifunctional tool in his kitchen to help him out in technically challenging situations. This is exactly the way I am looking at this new device. If it proves to be better than angioplasty, that’s great. If it fails, I would not be surprised, but I would still like the device as a valuable tool in particular acute situations. Professor Reekers says myths in interventional radiology sometimes are challenged twice. However, he forgets the example of femoral stenting, which was abandoned once but has definitely changed our approach to femoral disease in a second run after the introduction of nitinol stents. D. Vorwerk (&) Department of Radiology, Klinikum Ingolstadt, Krumenauerstrasse 25, Ingolstadt 85049, Germany e-mail: dierk.vorwerk@klinikum-ingolstadt.de

Fresh thrombus formation in left atrial appendage after temporary suspension of warfarin treatment in a patient with mitral stenosis and atrial fibrillation

A 61-year-old woman underwent a transoesophageal echocardiogram (TOE) for further assessment of her rheumatic mitral stenosis 2 days after a right and left heart catheterisation and coronary angiogram. She was...

Abstract 6181: ST Segment Resolution and Pathological Findings of Aspirated Materials in Patients with ST Elevation Acute Myocardial Infarction

Early resolution of ST-segment elevation (STR) is a potent predictor of better clinical outcome after PCI in ST elevation acute myocardial infarction (STEMI). The aim of this study was to determine the association of aspirated materials and serial change of ST elevation. We studied 150 consecutive STEMI patients with assessable ECG recording, in whom standard PCI was performed with the adjunctive use of aspiration thrombectomy. STR(+) was defined as more than 50% resolution of ST-segment elevation at 60min after PCI. Aspirated materials were pathologically classified into thrombus only group (fresh, lytic, or organized) or thrombus and atheroma complex group, and compared between STR(+) and STR(−). TIMI flow grade, IVUS findings after aspiration(ruptured plaque, calcification, thrombus and echo signal attenuation), area under the curve (AUC) of CK-MB release, and pathological findings were also compared between the two groups. Seventy-six patients (50.6%) showed STR and 74 patients didn’t. RCA culprit lesion was significantly more frequent in STR(+)(P&lt;0.05). There was no significant difference in other patient characteristics or IVUS findings in the present cohort. AUC of CK-MB was lower in STR(+)(p=0.02). TIMI 3 flow was more frequently achieved in STR(+)(p&lt;0.05). Fresh thrombus was more frequent in STR(+)(p&lt;0.05), whereas atheromatous component and lytic or organized thrombus were frequently observed in STR(−)(p&lt;0.05). Culprit lesions in STEMI, when atheroma and thrombus complex with lytic or organized thrombus was aspirated, caused more myocardial damage and less frequent STR.

Presence of Older Thrombus Is an Independent Predictor of Long-Term Mortality in Patients With ST-Elevation Myocardial Infarction Treated With Thrombus Aspiration During Primary Percutaneous Coronary Intervention

Routine thrombus aspiration is frequently used during primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction to prevent distal embolization. Recently, evidence of clinical benefit was published. In 50% of the ST-elevation myocardial infarction patients with an onset of symptoms <12 hours before, thrombi were shown to be >1 day old. This observation illustrates that plaque rupture and coronary occlusion are significantly separated in time. In the present study, we correlate the presence of fresh versus older thrombus with long-term mortality. Thrombus aspiration was performed in 1315 patients treated with primary percutaneous coronary intervention with 3 devices (Rescue, Export, and Proxis). Aspirated material was fixed in formalin and processed for histopathology. If possible, thrombus age was classified as either fresh only (<1 day) or older (>1 day). We identified fresh thrombus in 552 patients and older thrombus in 372 patients. The cumulative Kaplan-Meier estimate of all-cause mortality at 4 years was significantly higher in patients with older thrombus (16.0%) compared with patients with fresh thrombus (7.4%), with a hazard ratio of 1.82 (95% confidence interval, 1.17 to 2.85; P=0.008). Multivariate analysis identified the presence of older thrombus, in addition to other established predictors, as an independent predictor (hazard ratio, 1.83; 95% confidence interval, 1.14 to 2.93; P=0.01) of long-term mortality. Our study demonstrates that the presence of older thrombus, in addition to other established predictors, is an independent predictor of long-term mortality in patients with ST-elevation myocardial infarction treated with thrombus aspiration during primary percutaneous coronary intervention.

Interventional therapy for iliac vein compression syndrome and secondary thrombosis

Objective To evaluate the value of interventional therapy in treatment of iliac compression syndrome (ICS) and subsequent venous thrombosis. Methods Examined by DSA, 125 cases were diagnosed of iliac vein compression and subsequent thrombosis. In 39 cases of ICS ( group 1 ), left: right = 4.6: 1. In 86 cases of ICS complicated with subsequent thrombosis (group 2), left: right = 4.7: 1. The patients of iliac vein compression and compression-related iliac vein stenosis or occlusion without fresh thrombus were treated by percutaneous transluminal angioplasty (PTA) and self-expandable stenting. In those cases with fresh thrombosis the inferior vena cava filter were inserted before thrombosis suction, mechanical thrombus ablation, PTA, stenting and transcatheter thrombolysis. The Chi-square test for comparison of proportions was used to test statistical significance. Results In 39 cases of ICS, 38 cases were treated by PTA and stenting. In 86 cases of deep vein thrombosis complicated with ICS, 83 cases were treated by various interventional therapy. There was no significant difference in the efficiency of intraluminal treatment between the two groups at discharge (97.4% and 96.5%, X2 =0.000,P >0.05) and at 6 months follow-up(96.3% and 90.2%, X2 = 0.266, P > 0.05 ), the difference in excellent-good rate of the two groups was significant at discharge (94.9% and 79.1%, X2=3.879, P <0.05) and at 6 months follow-up (92.6% and 68.6% ,X2 =4.441,P <0.05). Conclusions Interventioual treatment for ICS and secondary thrombosis is safe and effective. Key words: Iliac vein; Vein thrombosis; Radiology, interventional

A potential thrombus diagnosis reagent based on P-selectin monoclonal antibody SZ-51 light chain

Introduction P-selectin is a well characterized platelet adhesion molecule that can shift from the secretory granules to the surface of activated platelets, which makes it a potential target in thrombus diagnosis and therapy. SZ-51 is a monoclonal antibody against P-selectin. Materials and methods To build a potential thrombus diagnosis reagent, we expressed the light chain of SZ-51 (SZ-LC) in P. pastoris and the protein was highly purified by the procedure combining nickel affinity purification, Q-column and Superdex 75 column chromatography. The purified recombinant SZ-LC was labeled with 99mTc and used for blood clearance, in vitro platelet binding and dog thrombus binding assay. Results and conclusion The yield of SZ-LC by the expression and purification method reached above 70 mg/L culture. We found that the nucleotide from 99mTc-SZ-LC was removed quickly through animal kidney, and 99mTc-SZ-LC could bind specifically to the activated human platelet in vitro. More importantly, with this recombinant protein, we successfully detected the fresh thrombus that was induced in dog vein. These results suggested that the recombinant SZ-LC expressed by P. pastoris was functional active and a potential reagent for thrombus diagnosis.

Periprocedural Stroke and Cardiac Catheterization

Case presentation : During cardiac catheterization, a 65-year-old man suddenly complained of nuchal pain, vertigo, and nausea and rapidly became unconscious, presumably from a stroke. The operator was unsure what type of imaging and management should be undertaken in this infrequent clinical setting. He paged the neurologist, asking him to urgently provide a strategy for diagnosis and management. Although the overall rate of stroke after left heart catheterization or percutaneous coronary intervention (PCI) is low, ranging from 0.2% to 0.4% (Tables 1 and 2⇓),1–5 it is the most debilitating complication from the patient’s perspective, associated with a high rate of morbidity and mortality (Figure 1).1–8 In 20 679 consecutive patients who underwent PCI in a large-volume center, stroke occurred in 0.44%.4 Multivariate analysis has shown that the occurrence of stroke was more frequently associated with diabetes mellitus, hypertension, prior stroke, or renal failure and was independently associated with in-hospital death. Patients who suffered a stroke had previously undergone longer cardiac catheterization procedures, using more contrast, were more likely to have had the procedure for urgent reasons, and to have had intraaortic balloon counterpulsation, a procedure that is itself known to increase the risk of stroke.9 Possible explanations for this latter characteristic include the greater propensity for hemodynamic compromise in these patients, which may increase the risk of ischemic stroke, and less meticulous care in advancing the catheter through the aorta during urgent PCI, which increases the risk of embolization by scraping of aortic plaques with subsequent embolization of debris to the brain. Indeed, scraping of aortic plaques occurs in >50% of PCI cases and more frequently with large than with small catheters.10 Cerebral microembolism is thought to be the main mechanism of periprocedural ischemic stroke occurring with PCI. This finding is supported …