Proximal Occlusion Research Articles

Abstract 23: Effect Of Intravenous Tirofiban Vs Placebo On First-pass Effect In Endovascular Stroke Thrombectomy: Insights From The Rescue Bt Randomized Clinical Trial

Background: First-pass effect (FPE) defined as a complete or near-complete reperfusion achieved after a single thrombectomy pass is predictive of favorable outcome in acute ischemic stroke (AIS) patients with large vessel occlusion. It remains uncertain whether intravenous tirofiban is effective to improve the rate of FPE in anterior circulation strokes. Methods: RESCUE-BT (A randomized controlled trial of intravenous tirofiban or placebo prior to endovascular thrombectomy for large vessel occlusion stroke) enrolled 948 patients with proximal intracranial large vessel occlusion presenting within 24 hours of time last known well to receive intravenous either tirofiban or placebo before endovascular thrombectomy. Patients who did not treated with endovascular thrombectomy were excluded from this cohort. The endpoint was FPE, which defined by extended thrombolysis in cerebral infarction (eTICI) scale 2b, 2c or 3 after the first pass. A modified Poisson regression analysis was performed to assess the association between intravenous tirofiban treatment and FPE. Results: Twenty-two patients were excluded for not treating with endovascular thrombectomy. The remaining 926 patients were included (mean age, 66 years; 380 [41.0%] women), with 450 in the tirofiban and 476 in the placebo group, respectively. Among them, an FPE was achieved in 141 patients (31.3%) of the tirofiban group vs 114 patients (23.9%) of the placebo group. The adjusted risk ratio for FPE with tirofiban vs placebo was 1.24 (95%CI, 1.02-1.52). Conclusions: Treatment with intravenous tirofiban before endovascular thrombectomy significantly increased the incidence of FPE in acute ischemic stroke patients with large vessel occlusion presenting within 24 hours of time last known well.

Abstract 49: Association Of Intravenous Thrombolysis And Pre-interventional Reperfusion: A Post-hoc Analysis Of The Swift Direct Trial

Background: One potential benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is pre-interventional reperfusion. Currently, there is a paucity of data regarding the occurrence of pre-interventional reperfusion in patients randomized to IVT or no-IVT before MT. Methods: SWIFT DIRECT was a randomized controlled trial including acute ischemic stroke IVT-eligible patients being directly admitted to a comprehensive stroke center, with allocation to either MT alone or IVT + MT. Primary endpoint of this analysis was the occurrence of pre-interventional reperfusion defined as pre-interventional expanded Thrombolysis in Cerebral Infarction score ≥2a. The effect of IVT and potential treatment effect heterogeneity were analyzed using logistic regression analyses. Results: Out of the 396 patients analyzed, pre-interventional reperfusion occurred in 20 (10.0%) of patients randomized to IVT+MT, and 7 (3.6%) of patients randomized to MT alone. Receiving IVT favored the occurrence of pre-interventional reperfusion (aOR 2.91 [95% CI 1.23 - 6.87]). There was no IVT treatment effect heterogeneity on the occurrence of pre-interventional reperfusion with different strata of Randomization-to-Groin-Puncture (p for interaction=0.33), although the effect tended to be stronger in patients with Randomization-to-Groin-Puncture >28 minutes (aOR 4.65 [95% CI 1.16 - 18.68]). There were no significant difference in rates of functional outcomes between patients with and without pre-interventional reperfusion. Conclusion: Even for patients with proximal large vessel occlusions and direct access to MT, IVT leads towards an absolute increase of 6.9% (95% CI 1.7-12.2%) in the rates of pre-interventional reperfusion. The effect of IVT tended to be more pronounced when Randomization-to-Groin-Puncture intervals were longer, but this heterogeneity did not reach statistical significance.

Abstract TMP68: Core/perfusion Mismatch In Acute Ischemic Stroke With M2 Occlusion: Prevalence And Associated Factors.

Background: The benefit of mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with M2 occlusion is uncertain. Observational studies suggest that perfusion imaging may help select optimal M2 candidates for MT. We aimed to study the prevalence and factors associated with core/perfusion mismatch, as assessed by both CT and MRI, in an unselected population of AIS with M2 occlusion. Methods: Retrospective observational study including AIS patients with M2 occlusion and baseline perfusion imaging (MRI or CT) performed within 24hrs from last seen well. To avoid selection bias, patients were selected from the prospective registries of 3 centers with systematic use of perfusion imaging, including both MT-treated and untreated patients. Core/perfusion mismatch was defined as mismatch ratio (Tmax>6s/ core volume) >1.8 and mismatch volume (Tmax>6s - core volume) >15mL. Results: Overall, 156 and 196 patients were included in the MRI and CT cohorts, respectively. Last-seen-well to imaging time was 5.6hrs (IQR 3.9-9.7) and 3.5hrs (1.5-9.8) in the MRI and CT cohorts, and 103/156 (66%) and 134/196 (68%) had proximal M2 occlusions (the remainder had distal M2 occlusions). Median ASPECT score was 7 (5-8) and 8 (7-9), and core/perfusion mismatch was present in 70/156 (45%) and 167/196 (85%) patients. In both cohorts, mismatch was less frequent in distal M2 occlusions and among patients with lower ASPECTS (Figure). Multivariable analysis showed higher ASPECT scores (OR=3.09, 95%CI=2.11-4.52, P <0.001 and OR=2.41, 95%CI 1.63-3.58, P <0.001 in the MRI and CT cohorts) and proximal M2 occlusion (with distal M2 as a reference: OR=3.94, 95%CI=1.68-9.26, P =0.002 and OR=32.78, 95%CI 8.36-128.47, P <0.001 in the MRI and CT cohorts) were independently associated with core/perfusion mismatch. Conclusion: Perfusion imaging may be useful in triaging M2 patients, particularly for those with ASPECT score <8 and distal M2 occlusions. This has implication for trials.

Abstract WP140: Coma As A Presentation For Large Vessel Occlusion Stroke

Introduction: Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. While coma has been studied in the context of traumatic brain injury, the epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke. Methods: Individuals who presented with LVO were identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a: responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic. Results: A total of 28/638 (4.4%) patients with large vessel occlusion stroke were identified as presenting with coma. The median age was 65 (IQR 48-78), and 57% were female. The median NIHSS was 32 (IQR 29-34). Occlusion locations included basilar (10), vertebral (2), P1 posterior cerebral (2), internal carotid (4), M1 middle cerebral (6), and M2 middle cerebral arteries (4). In all 14 patients with anterior LVO, the acute LVO was unilateral. Of these 14, 6 had evidence of acute or chronic stroke involving the contralateral hemisphere; 1 experienced seizure; 1 experienced cardiac arrest; and 1 had chronic occlusion of the contralateral ICA. Overall, 20/28 died during the admission. Of those who died, 9 presented with anterior LVO and 11 with posterior LVO. Eight patients were treated with EVT. For those not treated, reasons included established infarct with ASPECTS <6 (11), delayed presentation (2), pre-stroke disability and goals of care (3), and absence of intracranial proximal occlusion on repeat imaging (2). Conclusions: It is not uncommon for patients with LVO stroke to present with coma, and 65% of patients not treated with EVT had delayed presentations or large established infarcts, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Further study of these patients may shed light on the pathophysiology of coma. Efforts to improve early diagnosis and care are crucial given their poor outcomes.

Assessing the Efficacy of Mechanical Thrombectomy in Patients with an NIHSS < 6 Presenting with Proximal Middle Cerebral Artery Vessel Occlusion as Compared to Best Medical Management

Minor acute ischemic stroke (AIS) patients-defined by an NIHSS score < 6-presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have shown that several patients afflicted with MCA-LVO in this subgroup experience cognitive and functional decline. Although mechanical thrombectomy (MT) is the standard of care for patients with an NIHSS score of 6 or higher, treatment in the minor stroke subgroup is still being explored. The purpose of this preliminary study is to report our center's experience in evaluating the potential benefit of mechanical thrombectomy (MT) in minor stroke patients when compared to medical management (MM). We performed a retrospective study with two comprehensive stroke centers within our hospital enterprise of consecutive patients presenting with minor AIS secondary to MCA-LVO (defined as M1 or proximal M2 segments of MCA). We subsequently evaluated patients who received MT versus those who received MM. Between January 2017 and July 2021, we identified 46 AIS patients (11 treated with MT and 35 treated with MM) who presented with an NIHSS score < 6 secondary to MCA-LVO (47.8% 22/46 female, mean age 62.3 years, range 49-75 years). MT was associated with a significantly lower mRS at 90 days (median: 1.0 [IQR 0.0-2.0] versus 3.0 [IQR 1.0-4.0], p = <0.001), a favorable NIHSS shift (-4.0 [IQR -10.0--2.0] versus 0.0 [IQR -2.0-1.0], p = 0.002), favorable NIHSS shift dichotomization (5/11, 45.5% versus 3/35, 8.6%, p = 0.003) and favorable mRS dichotomization (7/11, 63.6% versus 14/35, 40.0%, p = 0.024). In our center's preliminary experience, for AIS patients presenting with an NIHSS score < 6 secondary to MCA-LVO, MT may be associated with improved clinical outcomes when compared to MM only.

Enhanced Drug Delivery for Cardiac Microvascular Obstruction with an Occlusion-Infusion-Catheter

Microvascular Obstruction (MVO) is a common consequence of acute myocardial infarction. MVO is underdiagnosed and treatment is often nonspecific and ineffective. A multi-scale in-vitro benchtop model was established to investigate drug perfusion in MVO affected microcirculation. The central element of the benchtop model was a fluidic microchip containing channels with diameters between 555 and 50 μm representing 2% of the microvascular tree fed by the left anterior descending artery (LAD). The outlets of the chip could be closed to mimic MVO. Two methods for intracoronary infusion of pharmacologic agents (simulated by dye) to regions with MVO were investigated using an occlusion-infusion catheter. The first case was a simple, bolus-like infusion into the LAD, whereas the second case consisted of infusion with concomitant proximal occlusion of the LAD phantom with a balloon. Results show that local dye concentration maxima in the chip with MVO were 2.2–3.2 times higher for the case with proximal balloon occlusion than for the conventional infusion method. The cumulated dose could be raised by a factor 4.6–5.2. These results suggest that drug infusion by catheter is more effective if the blood supply to the treated vascular bed is temporarily blocked by a balloon catheter.

Prediction of Functional Outcome in Stroke Patients with Proximal Middle Cerebral Artery Occlusions Using Machine Learning Models.

At present, clinicians are expected to manage a large volume of complex clinical, laboratory, and imaging data, necessitating sophisticated analytic approaches. Machine learning-based models can use this vast amount of data to create forecasting models. We aimed to predict short- and medium-term functional outcomes in acute ischemic stroke (AIS) patients with proximal middle cerebral artery (MCA) occlusions using machine learning models with clinical, laboratory, and quantitative imaging data as inputs. Included were consecutive AIS patients with MCA M1 and proximal M2 occlusions. The XGBoost, LightGBM, CatBoost, and Random Forest were used to predict the outcome. Minimum redundancy maximum relevancy was used for selecting features. The primary outcomes were the National Institutes of Health Stroke Scale (NIHSS) shift and the modified Rankin Score (mRS) at 90 days. The algorithm with the highest area under the receiver operating characteristic curve (AUROC) for predicting the favorable and unfavorable outcome groups at 90 days was LightGBM. Random Forest had the highest AUROC when predicting the favorable and unfavorable groups based on the NIHSS shift. Using clinical, laboratory, and imaging parameters in conjunction with machine learning, we accurately predicted the functional outcome of AIS patients with proximal MCA occlusions.

Impact of target vessel on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention.

There is limited information on the impact of the target vessel on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 11,580 CTO PCIs performed between 2012 and 2022 at 44 centers. The most common CTO target vessel was the right coronary artery (RCA) (53.1%) followed by the left anterior descending artery (LAD) (26.0%) and the left circumflex artery (LCX) (19.8%). RCA CTOs were longer and more complex, with a higher Japanese CTO score compared with LAD or LCX CTOs. Technical success was higher among LAD (88.8%) lesions when compared with RCA (85.7%) or LCX (85.8%) lesions (P less than .001). The incidence of major adverse cardiovascular events (MACE) was overall 1.9% (n = 220) and was similar among target vessels (P=.916). There was a tendency toward more frequent utilization of the retrograde approach for more proximal occlusions in all 3 target vessels. When compared with all other RCA lesions combined, distal RCA lesions had higher technical success (87.7% vs 85.3%; P=.048). Technical success was similar between various locations of LAD CTOs (P=.704). First/second/third obtuse marginal branch had lower technical success when compared with all other LCX lesion locations (82.7% vs 86.8%; P=.014). There was no association between MACE and CTO location in all 3 target vessels. LAD CTO PCIs had higher technical and procedural success rates among target vessels. The incidence of MACE was similar among target vessels and among various locations within the target vessel.

High-flow Bypass with Proximal Artery Occlusion as a Therapeutic Option for Recurrent Large Internal Carotid Paraclinoid Aneurysm after Endovascular Surgery

High-flow Bypass with Proximal Artery Occlusion as a Therapeutic Option for Recurrent Large Internal Carotid Paraclinoid Aneurysm after Endovascular Surgery

Gaze Weakness Neglect and Speech: An Acute Stroke Scale for Large Vessel Occlusion in the Emergency Department for Faster Treatment

Background: Despite the advancement in acute ischemic stroke with large vessel occlusion (LVO), golden time is lost in assessment lengthy neurological examination and redundantly in the Emergency department, often after emergency medical service prehospital stroke scale evaluation indicating possible LVO. A simple acute ischemic stroke scale (AISS) of the cortical representations of the anterior circulation can rapidly predict LVO, saving precious time to initiate early intravenous tissue plasminogen activator and endovascular mechanical thrombectomy. We proposed an ASIS in the emergency department called Gaze Weakness Neglect Speech (GWNS) to evaluate its feasibility and predictability for the detection of LVO in anterior circulation in the emergency department. Additionally, to evaluate if time can be gained that has been lost in obtaining National Institute of Health stroke Scale (NIHSS) and computed tomographic angiography (CTA), avoiding unnecessary radiation. Methods: This is a prospective observational study. An institutional review board permission was obtained, and patient enrollment started in January 2020 and ended in January 2021. Consecutive patients from January 2020 to September 2021 were selected from the database. The GWNS stroke scale was used by stroke and vascular neurologist during the emergency triage. The GWNS stroke scale scores range from 0 to 4 (1 for positive 0 for negative). The GWNS stroke scale assesses gaze deviation or gaze preference (G), presence of any weakness (W), neglect/disregard (N), and any speech impairment (S). Demographic data, CTA/cerebral angiographic data, and scores from NIHSS were also collected. The collected data was analyzed by a biostatistician to determine the association between the GWNS scale score and LVO. Results: In our study,109 qualifying patients were selected. Fifty-eight patients had GWNS stroke scale score of 3 or 4, with 57 having confirmed LVO and 1 presenting after a seizure. The GWNS stroke score ≥3 (0.86) correlated with LVO better than NIHSS (0.67), regardless of hemisphere side involvement. The GWNS stroke scale score of ≥3 also was effective in detection of proximal and distal blood vessels occlusion in the anterior circulation (Internal carotid artery, middle cerebral artery and its branches). A GWNS stroke scale score of ≥3 with presence of gaze was the most predictive for LVO (0.9) followed by neglect/disregards (0.8). The time to obtain GWNS stroke scale was 1.5 minutes (range 1-3) and time to obtain/interpretation CTA was 41.3 +/- 7.4 minutes after emergency department arrival (range: 29-51 minutes). Conclusions: Our Gaze Weakness Neglect Speech stroke scale can be performed rapidly in the emergency department and is highly predictive of LVO in the internal carotid artery, middle cerebral artery and middle cerebral branches. A GWNS stroke scale score of ≥3 is highly predictive of LVO, especially when gaze or neglect is present. Patients can potentially bypass CTA or advanced imaging in future studies, saving precious time and millions of brain cells for better outcome.

How stroke care has changed in Slovakia in the last 5 years.

Although stroke patients in Slovakia had been treated according to European recommendations, no network of primary and comprehensive stroke centers had been officially established; the ESO recommended quality parameters had not been fulfilled. Therefore, the Slovak Stroke Society decided to change the stroke management concept and introduced mandatory evaluation of quality parameters. This article focuses on key success factors of the change in stroke management in Slovakia and presents the 5-year results and perspectives for the future. We processed data from the stroke register at the National Health Information Center, which is mandatory in Slovakia for all hospitals designated as primary and secondary stroke care centers. Since 2016, we have started to change stroke management. New National Guideline for Stroke Care was prepared in 2017 and published in 2018 as a Recommendation of the Ministry of Health of the Slovak Republic. The recommendation included pre-hospital as well as in-hospital stroke care, a network of primary stroke centers (hospitals administering intravenous thrombolysis - 37), and secondary stroke centers (hospitals treating with intravenous thrombolysis + endovascular treatment (ET) - 6). A stroke priority was instituted, having equally high priority as myocardial infarction. More efficient in-hospital workflow and pre-hospital patient triage shortened the time to treatment. Prenotification became mandatory in all hospitals. Non-contrast CT, and CT angiography is mandatory in all hospitals. In patients with suspected proximal large-vessel occlusion the EMS stays at the CT facility in primary stroke centers until the CT angiography is finished. If LVO is confirmed, the patient is transported to an EVT secondary stroke center by the same EMS. From 2019 all secondary stroke centers offer endovascular thrombectomy in a 24/7/365 system. We consider the introduction of quality control one of the most critical steps in stroke management. The result of these activities is 25.2% of patients treated with IVT and 10.2% by endovascular treatment, and median DNT 30 min. Number of patients screened for dysphagia increased from 26.4% in 2019 to 85.9% in 2020. In the most of the hospitals the proportion of ischemic stroke patients discharged with antiplatelets and in case of AF with anticoagulants was >85%. Our results indicate that it is possible to change stroke management at a single hospital and national level. For continuous and further improvement, regular quality monitoring is necessary; therefore, the results of stroke hospital management are presented regularly once a year at national and international level. Collaboration with the "Second for Life" patient organization is very important for the "time is brain" campaign in Slovakia. Due to the change in stroke management over the last 5 years, we have reduced the time for acute stroke treatment and improved the proportion of patients with acute treatment, and in this area, we have achieved and exceeded the goals of the Stroke Action Plan for Europe for 2018-2030. Nevertheless, we still have many insufficiencies in stroke rehabilitation and post-stroke nursing that need to be addressed.

Neurointerventional Advances in 2022

Neurointerventional Advances in 2022

Motion artifact correction for cone beam CT stroke imaging: a prospective series

BackgroundImaging assessment for acute ischemic stroke (AIS) patients in the angiosuite using cone beam CT (CBCT) has created increased interest since endovascular treatment became the first line therapy for proximal...

Polyvinylpyrrolidone-Coated Catheters Decrease Astrocyte Adhesion and Improve Flow/Pressure Performance in an Invitro Model of Hydrocephalus.

The leading cause of ventricular shunt failure in pediatric patients is proximal catheter occlusion. Here, we evaluate various types of shunt catheters to assess in vitro cellular adhesion and obstruction. The following four types of catheters were tested: (1) antibiotic- and barium-impregnated, (2) polyvinylpyrrolidone, (3) barium stripe, and (4) barium impregnated. Catheters were either seeded superficially with astrocyte cells to test cellular adhesion or inoculated with cultured astrocytes into the catheters to test catheter performance under obstruction conditions. Ventricular catheters were placed into a three-dimensional printed phantom ventricular replicating system through which artificial CSF was pumped. Differential pressure sensors were used to measure catheter performance. Polyvinylpyrrolidone catheters had the lowest median cell attachment compared to antibiotic-impregnated (18 cells), barium stripe (17 cells), and barium-impregnated (21.5 cells) catheters after culture (p &lt; 0.01). In addition, polyvinylpyrrolidone catheters had significantly higher flow in the phantom ventricular system (0.12 mL/min) compared to the antibiotic coated (0.10 mL/min), barium stripe (0.02 mL/min) and barium-impregnated (0.08 mL/min; p &lt; 0.01) catheters. Polyvinylpyrrolidone catheters showed less cellular adhesion and were least likely to be occluded by astrocyte cells. Our findings can help suggest patient-appropriate proximal ventricular catheters for clinical use.

Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions

ObjectivesParadoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up. Materials and methodsWe prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death. Results36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89). ConclusionsIHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.

806 BRIDGING COLLATERALS OF CHRONICALLY OCCLUDED LEFT INTERNAL MAMMARY ARTERY BYPASS GRAFT TO LEFT ANTERIOR DESCENDING ARTERY

Abstract Methods and results The internal mammary artery (IMA) is the conduit of choice to bypass the left anterior descending (LAD) coronary artery in patients eligible for coronary artery bypass grafting (CABG). In case of graft occlusion, it is still not clear whether it is better to revascularize the graft or the recipient native vessel, on top of optimal medical therapy. A 55-year-old man, with prior CABG, underwent urgent coronary angiography for an acute coronary syndrome. LAD CTO, severe proximal circumflex artery stenosis, and mild atherosclerosis of the right coronary artery were found. Moreover, a proximal occlusion of the venous graft to the obtuse marginal branch and LIMA CTO within the body of the graft were shown as well. Surprisingly, many well-developed bridging collaterals, arising close to the proximal cap of the LIMA occlusion, supplied the bloodstream circulation distal to the occlusion within the LIMA. At that time, a left main–proximal circumflex artery stenting was performed (3.5×24-mm Xience Sierra, Abbott) because that was judged the culprit lesion. One month later the patient still complained of effort angina and dyspnoea despite optimized antianginal medical therapy. The patient was scheduled for elective antegrade LIMA CTO PCI, considered the most appropriate treatment strategy. Indeed, the presence of a prior stent implanted in the left main– circumflex artery would have made difficult a proximal cap negotiation and its penetration by guidewires in case of antegrade LAD CTO PCI. Thus, the LIMA CTO negotiation was initially attempted with a Fielder FC guidewire (Asahi Intecc) and a supporting Corsair Pro (Asahi Intecc) microcatheter. The polymeric soft wire prolapsed preferentially into the bridging collaterals without the chance to engage the CTO proximal cap. Finally, a moderate-weight hydrophilic GAIA second (Asahi Intecc) succeeded in cap penetration and final CTO crossing. After lesion predilatation with a 2.0×15-mm balloon (Emerge, Boston Scientific), 2 overlapped stents, respectively 2.75×44 mm and 3.0×18 mm (VIVO ISAR, Translumina) were deployed and postdilated by a 3.0×15-mm non-compliant balloon (Accuforce, Terumo). The final result was deemed very satisfactory with a TIMI 3 flow. Conclusions Many studies showed that IMA has active biological functions, providing a sort of protection against atherosclerosis and self-reparative properties. These biological properties might justify the IMA high long-term patency rates as CABG conduits. The development of bridging collaterals in this patient, represents a clear proof of the LIMA self-reparative properties. Whereas bridging collaterals are a common feature of coronary CTO, their development in a LIMA bypass graft represents a unique finding which requires further investigation.

110 ANEURYSMECTOMY AND SURGICAL ABLATION: WHEN?

Abstract A 60-year-old man with a previous myocardial infarction was admitted to our ICU for acute pulmonary edema in the context of an acute antero-lateral non-ST elevation myocardial infarction. Echocardiography showed severe left ventricular (LV) dilatation with extensive wall motion abnormalities, large apical aneurysm and severe systolic dysfunction. Coronary angiography showed a triple-vessel disease with proximal occlusion of the left anterior descending artery. During the hospitalization, multiple episodes of drug-resistant monomorphic ventricular tachycardias occurred, requiring repeated DC Shock. After Heart Team discussion, the patient underwent coronary artery bypass grafting, LV restoration according to the procedure described by Guilmet and surgical cryoablation. The Guilmet septoexclusion is indicated when the interventricular septum is more involved than the free wall. After aneurysm incision, cryolesions were applied at the septum and at the transitional zone of the scar and viable tissue. Thus, the anterior free wall was sewn obliquely to the septum. Finally, the edges of the incision, anterior and septal, were sewn together to assure a definitive hemostasis (overcoat technique). After surgery, an implantable cardioverter-defibrillator was implanted in secondary prevention. The postoperative course and subsequent cardiological follow-up were characterized by a gradual clinical improvement with mild increasing in LV function and reduction in ventricular arrhythmias. Nowadays, combined aneurysmectomy and endocardial ablation are rarely performed, but should be considered in patients with LV aneurysm who manifest drug-resistant ventricular arrhythmias. Encircling cryoablation in a remodelled ventricle is safe and effective in reducing ventricular arrhythmias which are a negative prognostic factor.

Image quality and related outcomes of the ShuntScope for catheter implantation in pediatric hydrocephalus—experience of 65 procedures

PurposeVentricular catheter implantation in pediatric hydrocephalus can become a highly challenging task due to abnormal anatomical configuration or the need for trans-aqueductal stent placement. Transluminal endoscopy with the ShuntScope has been invented to increase the rate of successful catheter placements. This study aims to evaluate ShuntScope’s image qualities and related surgical outcomes in the pediatric population.MethodsA retrospective analysis of all pediatric patients undergoing ventricular catheter placement using the ShuntScope from 01/2012 to 01/2022 in the author’s department was performed. Demographic, clinical, and radiological data were evaluated. The visualization quality of the intraoperative endoscopy was stratified into the categories of excellent, medium, and poor and compared to the postoperative catheter tip placement. Follow-up evaluation included the surgical revision rate due to proximal catheter occlusion.ResultsA total of 65 ShuntScope-assisted surgeries have been performed on 51 children. The mean age was 5.1 years. The most common underlying pathology was a tumor- or cyst-related hydrocephalus in 51%. Achieved image quality was excellent in 41.5%, medium in 43%, and poor in 15.5%. Ideal catheter placement was achieved in 77%. There were no intraoperative complications and no technique-related morbidity associated with the ShuntScope. The revision rate due to proximal occlusion was 4.61% during a mean follow-up period of 39.7 years. No statistical correlation between image grade and accuracy of catheter position was observed (p-value was 0.290).ConclusionThe ShuntScope can be considered a valuable addition to standard surgical tools in treating pediatric hydrocephalus. Even suboptimal visualization contributes to high rates of correct catheter placement and, thereby, to a favorable clinical outcome.

Influence of prior intravenous thrombolysis in patients treated with mechanical thrombectomy for M2 occlusions: insight from the Endovascular Treatment in Ischemic Stroke (ETIS) registry

BackgroundIntravenous thrombolysis (IVT) for patients treated with mechanical thrombectomy (MT) for proximal occlusions has recently been questioned through randomized trials. However, few patients with M2 occlusions were included. We investigated...

Treatment of Vascular Injury During Balloon Pulmonary Angioplasty in Patients With Chronic Thromboembolic Pulmonary Hypertension.

Treatment strategy for vascular injury during balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) was uncertain. This study aimed to identify an optimal therapeutic strategy for vascular injury during BPA in patients with CTEPH. This study reviewed 207 patients with CTEPH and 956 BPA procedures between November 1, 2012 and November 30, 2015. Patients who were diagnosed with vascular injury during BPA, which was defined as angiographic signs or sudden respiratory and hemodynamic defects were included in this study. The study investigated the safety and efficacy of the hierarchically systematic treatment strategy including gelatin sponge embolization (GSE). More than one-half of the 79 patients and 133 procedures with vascular injury were improved by general treatment with reversal of heparin and high-flow oxygen administration. The investigators performed conventional treatment of proximal vessel occlusion using a guiding or balloon catheter in 47 procedures (35%) in which the culprit vessels could be detected under patients' stable conditions. In 32 procedures (24%) without detected culprit lesions or improvement by conventional treatment, GSE could significantly improve patient condition. The treatment strategy obtained successful bailout in 98% of procedures with vascular injury. No patients who underwent GSE died within 30days after the treatment. There was no significant difference in cumulative mortality rate (median follow-up: 6.6years) between groups with or without GSE (15.6% vs 8.2%; adjusted HR: 1.47; 95%CI: 0.25-8.69; P = 0.67). Treatment strategy including GSE would be promising for vascular injury during BPA in patientswith CTEPH.