Incidence Of Distal Embolization Research Articles

Invasive Management of Vertebrobasilar Artery Stenosis and Occlusion: A Meta-Analysis on Efficacy and Safety Endpoints.

Vertebrobasilar angioplasty and stenting or mechanical thrombectomy (MT) using a stent retriever or suction thrombectomy are effective interventions in managing acute ischemic stroke caused by vertebrobasilar artery occlusion (VBAO). This study aims to investigate the safety and efficacy of self-expanding stents and balloon angioplasty in managing ischemic stroke. We reviewed the literature for relevant clinical trials and included those reporting the following primary outcomes: successful recanalization, favorable clinical outcome, and stenosis degree change. We included 24 studies (858 patients). In the subgroup analysis, participants were divided into three main subgroups based on the type of intervention: mechanical thrombectomy (MT), percutaneous transluminal angioplasty and stenting (PTAS), and MT+PTAS. Regarding overall mortality, the incidence was 34.5%, 9.9%, and 28.9% in the MT, PTAS, and MT+PTAS groups, respectively. The incidence of arterial dissection was 3.6% in the MT group, 3.1% in the PTAS group, and 16.7% in the MT+PTAS group. Incidence of distal embolization, MT, PTAS, and MT+PTAS groups had 3.4%, 5.8%, and 9.5% incidence rates, respectively. Favorable clinical outcomes were reported in 42.8% of subjects in the MT+PTAS group, 64.7% in the PTAS group, and 39.2% in the MT group. The incidence of intracranial hemorrhage was 5.2%, 4.5%, and 15.3% in the MT, PTAS, MT + PTAS groups, respectively. The incidence of successful recanalization was 85.3% in the MT group, 99.4% in the PTAS group, and 92.7% in the MT+PTAS group. Our analysis concludes that PTAS is the most effective intervention for VBAO and is associated with a lower rate of mortality compared to mechanical thrombectomy alone.

Application and value of excimer laser ablation in the treatment of lower limb atherosclerotic obliterans

Objective: To evaluate the results of excimer laser ablation (ELA) in the treatment of lower limb atherosclerotic obliterans (ASO). Methods: From June 2019 to March 2020, patients who underwent ELA combined with drug-coated balloon (DCB) for lower limb atherosclerotic obliterans (ASO) were enrolled. Demographics, lesion characteristics, procedure-related outcomes and complications were collected and analyzed. Results: Thirty patients were enrolled, including 21 males and 9 females. The mean age was (76.5±10.5) years. The mean lesion length was (11.7±6.4) cm. A total of 41 lesions, including in-stent restenosis (ISR) in 12 (29.3%), chronic totally occlusion (CTO) at initial treatment in 24 (58.5%), and severe stenosis in 5 (12.2%) patients. Sixteen (51.6%) patients were classified as Peripheral Arterial Calcium Scoring System (PACSS) category 4. The technical success rate was 93.5%. Incidence of distal embolization and bailout stenting was 12.9% and 6.5%, respectively. The mean follow-up time was (6.6±3.0) months. Ankle-brachial index (ABI) was significantly increased from 0.43(0.32,0.55) preoperatively to 0.91(0.87,1.01) postoperatively (Z=-5.43, P<0.01) and 0.82(0.73,1.02) (Z=-3.99, P<0.01) three months after surgery. The 3-month major-amputation free survival rate was 96.7%, primary patency rate was 100%, the target lesion reintervention (TLR) rate was 0 and ulcer healing rate was 76.9%. Conclusion: Debulking of ELA is feasible and effective for both ISR and CTO at initial treatment, providing a new option for DCB preparation and reducing stent implantation.

Incidence of Distal Embolization during Peripheral Intervention using the NAV-6 Embolic Protection System

Purpose: To compare the rates of embolic debris (ED) generation during lower extremity arterial interventions and evaluate the safety and efficacy of the using an embolic protection device (EPD). Methods: This was a single-center retrospective review of 111 patients (114 vessels) having undergone peripheral arterial intervention with the use of an EPD (Emboshield NAV-6 device). A database was created through review of the electronic health record and images in PACS. The presence of ED was determined through visual inspection after retrieval of the device or from filling defects identified during digital subtraction angiography with the device deployed. Descriptive statistics were used to report the demographic and clinical information. Relative frequencies of debris generation were determined for vessel type, trans-atlantic inter-society consensus (TASC) classification, and type of intervention. Differences in frequencies between groups weer evaluated with the Chi-square test, and associations were examined using the logistic regression analysis. Results: Of the 114 vessels treated, 16 (14%) demonstrated true distal embolization (DE) past the filter basket and 58 (51%) demonstrated generation of ED as determined by filling of the filter basket. This was significantly higher in patients undergoing atherectomy (70%) compared with those undergoing thrombolysis (38%) or angioplasty with or without stenting (29%) (P &lt; 0.001). Of those patients undergoing atherectomy, laser atherectomy had the lowest rate of DE (26%) compared with either orbital (67%) or directional atherectomy (57%) (P &lt; 0.05). In regression analysis, atherectomy was the only factor with significant association with detection of ED (odds ratio: 4.52, P &lt; 0.0001). There was no statistically significant difference in the frequency of debris generated based on vessel type or TASC classification. Conclusion: The frequency of ED is higher in patients undergoing atherectomy versus patients undergoing lysis or percutaneous transluminal balloon angioplasty with or without stenting. Laser atherectomy has a lower frequency of debris generation when compared to either orbital or directional atherectomy.

Effectiveness of Revive SE in the RAPID registry : Revive Acute Ischemic Stroke Patients ImmeDiately (RAPID) Prospective Multicenter Trial.

The prospective, multicenter Revive Acute ischemic stroke Patients ImmeDiately (RAPID) trial was carried out to evaluate the real-world safety and efficacy of the Revive SE stent retriever. From January 2017 the study planned to enroll 100 patients with acute ischemic stroke who were treated with the Revive SE as afirst pass. The study primary outcomes were rates of favorable reperfusion using the modified thrombolysis in cerebral infarction score [mTICI] 2b/3 and rates of favorable outcome with the modified Rankin Scale (mRS) ≤2 at 3months. The secondary outcomes were time interval from puncture to vascular reperfusion, number of passes by Revive SE stent-retriever, incidence of distal embolization and into new territories and rate of symptomatic intracranial hemorrhage (SICH) within 24 h post intervention. A total of 100 treated patients (mean age: 65.6 ± 11.3 years) were enrolled. The median National Institutes of Health Stroke Scale before the procedure was 16. Target vessel occlusions were as follows: middle cerebral artery (MCA) M1 in 48, M2 in 6, anterior cerebral artery (ACA) in 3, internal carotid artery (ICA) in 22, basilar artery (BA) in 17, and vertebral artery (VA) in 4. Reperfusion rate with Revive SE without rescue devices was 69%. Reperfusion rate with Revive SE only was 83.3% in MCA M2, followed by 82.4% in BA. Thromboembolic complications and SICH developed in 10% and 2% of patients, respectively. Overall, a satisfactory reperfusion was achieved in 92% and a favorable outcome at 90days in 48%. Use of the Revive SE for thrombectomy appeared to be effective and safe but these findings need be confirmed in larger clinical trials (RAPID ClinicalTrials.gov number, NCT03007082).

Abstract WMP48: Prediction of Irregular Plaque Protrusion After Stenting by Magnetic Resonance Imaging Plaque Characterization

Background: One disadvantage of carotid artery stenting (CAS) is a high incidence of distal embolism (DE) during or after the procedure. Also, irregular plaque protrusion (PP) after stent placement has been suggested as one of the major causes of post procedural ischemic complications. The aim of this study was to evaluate the relationship between unstable plaque identified on black-blood magnetic resonance imaging (BB-MRI) and the occurrence of irregular PP after CAS using optical frequency domain imaging (OFDI). Materials and Methods: We enrolled 41 patients who underwent CAS with OFDI image acquisition. We measured signal intensity ratios (SIR) from T1 weighted images of all carotid plaques. The plaque with high SIR is considered as unstable plaque with intraplaque hemorrhage (IPH) according to previously published criteria. Cross-sectional OFDI images were evaluated at every 0.125-mm intervals within the stented segments, and assessed the relationships among the occurrence of irregular PP (I-PP), smooth PP (S-PP) or non-PP, and SIR measured by MRI. Results: PP and I-PP were detected in 34 cases (83%) and in 20 cases (49%), respectively. There were two minor strokes in the I-PP group. There was a positive correlation between PP volume and SIR (r=0.47, p&lt;0.01). The SIR was significantly higher in the I-PP group than the S-PP or non-PP groups [I-PP vs. S-PP or non-PP: 1.67 (IQR: 1.39-1.9) vs. 1.36 (IQR: 1.25-1.62), p&lt;0.01]. From analysis of receiver operating characteristic curves, a SIR of 1.57 on BB-MRI was the most reliable cutoff values for predicting I-PP. In multivariate logistic regression analysis, the independent predictor of I-PP was SIR (p=0.012) even after adjusted by plaque volume. Conclusions: Quantitative tissue characterization of carotid plaques using BB-MRI was useful to predict I-PP. These data suggest that identification of carotid plaque components such as IPH by BB-MRI before CAS may improve the clinical outcome of this procedure.

Outcomes of direct stenting in patients with ST-elevated myocardial infarction.

We compared direct stenting (DS) with conventional stenting (CS) - i.e., stenting after predilation - during primary percutaneous coronary intervention (P-PCI) in terms of procedural results and long-term mortality in patients with ST-elevated myocardial infarction (STEMI). We retrospectively analyzed 2306 patients (mean age 59years, 22% female) who underwent P‑PCI within 12 h of symptom onset. Patients were then followed up prospectively for clinical events. Patients were divided into aDS group (n= 597) and aCS group (n= 1709). The CS group was further divided into aCS-1 group (baseline thrombolysis in myocardial infarction [TIMI] flow grade≥ 1) and aCS-2 group (baseline TIMI flow grade 0). Main outcome measures were postprocedural myocardial reperfusion and all-cause mortality in long-term follow-up. Patients in the DS group had ahigher percentage of final TIMI-3 flow, myocardial blush grade3 and complete ST-segment resolution, better left ventricular ejection fraction, and alower incidence of distal embolization compared with CS patients. In-hospital (1.5 vs. 4.6%, respectively, p= 0.001) and long-term all-cause mortality (8.8 vs. 17.0%, respectively, p< 0.001) were significantly lower in the DS group than in the CS group. Kaplan-Meier survival analysis showed similar survival rates in the DS and CS-1 groups (log-rank p= 0.40), but significantly worse survival in the CS-2 group than in the other groups (log-rank p< 0.001). After adjusting for risk factors, DS was not found to be apredictor of long-term mortality. DS in P‑PCI was associated with better postprocedural angiographic results and long-term survival. However, the DS group had similar in-hospital and long-term mortality to matched patients in the CS group.

New Endovascular Technique to Prevent Distal Embolism for Iliofemoral Occlusive Disease: Reverse Flow Aspiration With Proximal Sheath Blockage

Purpose: To report the safety and efficacy of a new technique to prevent distal embolism during treatment of iliofemoral occlusions: reverse flow aspiration with proximal sheath blockage (ReFLAP). Method: Between October 2013 and December 2014, 90 patients (mean age 74 years; 66 men) were prospectively enrolled in a study to evaluate the ReFLAP technique during treatment of 110 occlusions in the iliac artery (72, 65%) or superficial femoral artery (SFA; 38, 35%). The mean occlusion lengths of iliac and SFA lesions were 79 and 179 mm, respectively. The concept of ReFLAP is to aspirate debris after balloon dilation using reverse flow through collaterals without antegrade flow. The main endpoints were the incidence of distal embolization, amputation, complications, and the ReFLAP capture rate, which was visually estimated during aspiration using 4 prespecified grades (0, none; 1, foamy debris; 2, small particles; 3, massive particles). Results: ReFLAP was successful in 105 (95.4%) of the 110 lesions attempted; the 5 failures were due to severe vessel tortuosity or calcification. The incidences of distal embolization and amputation were both 0. Minor complications unrelated to ReFLAP were observed in 8 patients. The ReFLAP procedure aspirated debris in 57 (54%) of the 105 lesions. Aspirated material, including marked clots (grades 2 and 3), was confirmed in 40 (38%) of the lesions. The distribution of aspiration grades was significantly different between iliac and SFA lesions (p=0.02). Conclusion: Our results suggest that the ReFLAP endovascular technique to prevent distal embolization during iliofemoral occlusive disease treatment is simple, safe, and effective.

Impact of intracoronary eptifibatide on the right ventricular function in patients with acute inferior myocardial infarction

Background and aim Distal embolization during primary percutaneous coronary intervention of the proximal right coronary artery (RCA) leads to impairment of flow of right ventricular (RV) branches and RV dysfunction. Glycoprotein IIb/IIIa receptor antagonists improve microcirculation and decrease the incidence of distal embolization. In the present study we aimed to assess RV function in patients with acute inferior ST-segment elevation myocardial infarction who received intracoronary (i.c.) bolus eptifibatide, and to compare them with patients who received a standard intravenous (i.v.) dose. Patients and methods Sixty-six patients with acute inferior myocardial infarction who underwent primary percutaneous coronary intervention and whose culprit lesion was RCA proximal to major RV branch were included in the present study. Patients were divided into two groups. In the first group, 36 patients received double bolus intracoronary eptifibatide followed by i.v. infusion. In the second group, 30 patients received standard i.v. dose. Forty-eight hours after the index procedure, all the patients underwent standard echocardiography assessment of RV function using conventional two-dimensional and tissue Doppler imaging. Results There were no significant differences regarding baseline characteristics, final Thrombolysis In Myocardial Infarction (TIMI) flow, and left ventricular systolic function between the two groups. RV function indices, including tricuspid annular plane systolic excursion, myocardial performance index-tissue Doppler imaging, and RV fractional area change, were significantly better in patients who received i.c. bolus eptifibatide (P Conclusion I.c. double bolus eptifibatide followed by i.v. infusion was found to be superior to the standard i.v. dose with respect to RV function in patients with acute inferior ST-segment elevation myocardial infarction due to proximal RCA occlusion.

Insight into the Periprocedural Embolic Events of Internal Carotid Artery Angioplasty

Thromboembolism is a major risk of carotid angioplasty and stenting (CAS). Although the incidence of distal embolism has been documented by MRI and TCD studies, the mechanisms and management of this complication are rarely reported. Here we describe four patients with periprocedural embolic events to demonstrate the mechanisms of thromboembolism in CAS. Different remedies were applied to these patients according to the underlying mechanisms of thromboembolism and good clinical outcomes were achieved.

Association between carotid plaque composition assessed by multidetector computed tomography and cerebral embolism after carotid stenting

We aimed to assess the relationship between atherosclerotic carotid plaque composition analyzed using multidetector computed tomography (MDCT) and the appearance of new ischemic lesions detected by diffusion-weighted images (DWI) after carotid artery stenting (CAS). We quantitatively and qualitatively analyzed plaque characteristics in carotid arteries using MDCT before CAS in 19 patients. Carotid plaques were expediently subdivided into four components with Hounsfield unit (HU) values of <0, 0-60, 60-130, and >600. The incidence of distal embolism was evaluated with DWI. Pearson's correlation analyses were used to assess the association between plaque composition and the incidence of cerebral embolization. Fifteen patients (79%) demonstrated new DWI lesions after CAS. High-signal DWIs were noted as follows: one in six patients, 2 ~ 5 in five patients, 6 ~ 10 in two patients, and >10 in two patients. The mean volumes of the plaque components for HU < 0, 0-60, 60-130, and >600 were 5.4, 200, 260, and 59mm(3), respectively. There was a strong correlation between the number of high-signal DWI lesions in the ipsilateral side and the plaque volume of HU < 0 (r = 0.927; P < 0.0001). There was a moderate correlation between the number of high-signal DWI lesions and the plaque volume of HU 0-60 (r = 0.568; P = 0.0099) and the sum total of HU < 0 and HU 0-60 (r = 0.609; P = 0.0047). Quantitative and qualitative tissue characterization of carotid plaques using MDCT might be a useful predictor for silent ischemic lesions after CAS.

Aspiration of embolized thrombus during primary percutaneous coronary intervention

During percutaneous coronary intervention for acute myocardial infarction, distal embolization of thrombus and plaque material often occurs, despite the use of thrombectomy and aspiration catheters. Large embolized thrombi can cause occlusion of distal coronary vessels for which angioplasty most often leads to no more than poor results. We describe the successful use of an aspiration catheter to treat distally embolized thrombus, to optimize coronary reperfusion therapy, and to improve salvage of myocardial tissue. We discuss the manifestation and incidence of distal embolization and show its clinical relevance.

Assessing a strategy of initial stand-alone extractional atherectomy followed by staged stent placement in degenerated saphenous vein graft lesions

To assess whether a staged strategy (initial stand alone transluminal extraction atherectomy and coumadin therapy followed by stenting six weeks later) could reduce ischemic complications in degenerated saphenous vein graft (SVG) interventions, we studied 72 patients undergoing percutaneous interventions of degenerated SVG. Patients were divided into two groups; 28 were treated with a staged strategy (group I) and 44 with similar lesion characteristics were treated with a definitive initial procedure with transluminal extraction atherectomy ± adjunctive balloon angioplasty and stenting (group II). Procedural success, major in-hospital complications (death, Q-wave myocardial infarction, and emergent coronary bypass surgery), and incidence of distal embolization were compared between the 2 groups. Procedural success was lower (92% vs 100%, p = 0.14) and major in-hospital complications were higher (0% vs 11%, p = 0.14) in group II. Distal embolization occurred in 11% of the patients in group I compared with 23% of the patients in group II (p = 0.19). At 6 week follow-up (group I), 9 patients (33%) had negative symptoms, 11 (41%) underwent stent implantation, 3 (11%) did not require any further therapy (without significant stenosis), and 4 (14%) had total occlusions. We therefore conclude that this staged strategy in degenerated SVG appears to reduce distal embolization but most importantly avoids major in-hospital complications, including any deaths either at the time of initial procedure or during the 6-week follow-up period.

Prevention of distal embolism during arterial reconstruction

Distal embolization of fragmented laminated thrombus and atheroma producing peripheral ischemia or gangrene is an underemphasized complication of arterial reconstruction. A set of techniques has been developed to minimize this important complication. To assess their effectiveness, the incidence of distal embolism in patients undergoing resection of abdominal aortic aneurysm with and without the use of these techniques was studied. In the 434 patients who underwent elective resection of abdominal aneurysm, measures to prevent distal embolism were used in all cases. The incidence of distal embolism was only 0.23 per cent (1 of 434), in contrast to reported incidences of up to 11 per cent. In the 21 patients who underwent emergency resection of ruptured aneurysm, these techniques were not used due to the need for early proximal control for resuscitation; distal embolism of atheromatous material occurred in 2 cases, an incidence of 9 per cent. The application of these techniques to other peripheral vascular procedures has resulted in similar low rates of postoperative distal ischemia.