Recanalization Rate Research Articles

Normobaric hyperoxia combined with endovascular treatment for acute ischaemic stroke in China (OPENS-2 trial): a multicentre, randomised, single-blind, sham-controlled trial.

Endovascular treatment improves the recanalisation rate for patients with acute ischaemic stroke; however, even with endovascular treatment, approximately half of patients do not have a favourable functional outcome. We aimed to evaluate the effect of normobaric hyperoxia combined with endovascular treatment on functional outcomes up to 90 days after treatment in patients who had an acute ischaemic stroke with large-vessel occlusion. In this multicentre, randomised, single-blind, sham-controlled trial, patients aged 18-80 years presenting within 6 h of acute ischaemic stroke attributed to large-vessel occlusion in anterior circulation, who were candidates for endovascular treatment, were recruited from 26 comprehensive stroke centres in China. Eligible patients were randomly assigned (1:1), with an Interactive Web Response System on the basis of a minimisation process to balance assignment at each participating site both overall and according to age, sex, occlusion location, and use of intravenous thrombolytics, to receive either normobaric hyperoxia combined with endovascular treatment or sham normobaric hyperoxia combined with endovascular treatment. Participants and assessors were blinded to treatment assignment. Normobaric hyperoxia treatment involved inhaling 100% oxygen at a flow rate of 10 L/min through a non-rebreather mask for 4 h, or an inspiratory oxygen fraction (FiO2) of 1·0 in participants for whom intubation was necessary. Sham treatment was 100% oxygen delivered at a flow rate of 1 L/min or an FiO2 of 0·3. The primary outcome was the comparison of the ordinal scores on the modified Rankin Scale (mRS) at 90 days assessed in the intention-to-treat population (including all patients randomly assigned to treatment). Safety was assessed in all patients who received any oxygen therapy. This trial is registered with ClinicalTrials.gov, NCT04681651, and is now complete. Between April 22, 2021, and Feb 5, 2023, 473 patients were screened, of whom 282 were randomly assigned to either normobaric hyperoxia plus endovascular treatment (n=140) or sham normobaric hyperoxia plus endovascular treatment (n=142; intention-to-treat population). The median age was 65 years (IQR 57-71), 75 (27%) of 282 participants were female, 207 (73%) were male, and 282 (100%) of participants were of Chinese Han ethnicity. At 90 days, the median score on the mRS for the normobaric hyperoxia group was 2 (IQR 1-4) and it was 3 (1-4) in the sham normobaric hyperoxia group (adjusted common odds ratio 1·65 [95% CI 1·09-2·50]; p=0·018). At 90 days, 14 (10%) of 140 patients in the normobaric hyperoxia group and 17 (12%) of 142 in the sham normobaric hyperoxia group died (adjusted risk difference -0·02 [95% CI -0·09 to 0·06]) and 28 (20%) and 33 (23%) had serious adverse events (adjusted risk difference -0·03 [-0·12 to 0·07]). In patients with acute ischaemic stroke caused by large-vessel occlusion in the anterior circulation who were candidates for endovascular treatment, normobaric hyperoxia yielded superior functional outcomes at 90 days compared with the sham normobaric hyperoxia, without raising safety concerns. Beijing Municipal Education Commission, Beijing Municipal Finance Bureau, and National Natural Science Foundation of China.

Clinical outcomes following treatment for small saphenous vein insufficiency: An AVLS PRO venous registry study.

Compared to the great saphenous vein, there is a relative paucity of data in the literature focused on treating the small saphenous vein (SSV). Our goal was to evaluate and analyze national registry data related to the diagnosis and treatment of the SSV and identify practice patterns and clinical outcomes. Subjects undergoing SSV interventions between April 2014 and March 2023 were identified in the AVLS PRO Venous Registry. Data points included Clinical, Etiological, Anatomical, Pathological (CEAP) classifications; Venous Clinical Severity Score (VCSS), Venous Quality of Life (VVSymQ®) instrument scores, Heaviness, Aching, Swelling, Throbbing, Itching (HASTI) symptoms, and Short Form Health Survey (SF-36.) Duplex ultrasound findings included vein diameter, length, and the overall recanalization rate. A total of 92,175 SSV interventions were identified. Over two-thirds of subjects presented with a CEAP classification of C3 (31%) and C4 (C4 40%). Clinical results demonstrated significant improvement immediately after treatment in the first month and maintained beneficial results at 1year or longer (p < 0.001.) This improvement was reflected in the significant decrease in VCSS scores (6 ± 3.4 to 5 ± 2.9; p < 0.0001), VVSymQ (9.5 ± 6.0 to 5.9 ± 4.4; p < 0.0001), and HASTI (9.4 ± 5.9 to 6.6 ± 5.2; p < 0.0001). The recanalization rate at any follow-up was 3%; 48% of those occurring within the first year. Predictors associated with recanalization were larger vein diameter (mean 4.0mm, 95% CI 3.9-4.1, p < 0.0001) and shorter SSV length (mean 15.27mm, 95 % CI 14.4-16.1, p < 0.0001). Treatment of SSV insufficiency improved clinical outcomes by both patient and physician-derived outcome measures. Only 3% of SSV demonstrated recanalization, and nearly half occurred within the first year following the procedure. Predictors of recanalization included larger pre-procedure vein diameters and treatment of a shorter length of SSV.

Comparison of Direct Oral Anticoagulants for Treatment of Cerebral Venous Thrombosis - A Retrospective Cohort Study.

Limited available evidence comparing DOACs with warfarin suggests efficacy and safety of DOACs for CVT. We aimed to evaluate whether a specific DOAC is preferred for the treatment of CVT. This retrospective cohort study included adult patients with CVTs between September 2018 and September 2022 treated with a DOAC. The primary outcome was rate of partial or complete recanalization. Secondary outcomes included rate of recurrent VTE, CVT extension, major or clinically relevant non-major bleeding, and death within 180 days after DOAC initiation. Of 31 patients with CVT, 21 received apixaban, 7 received rivaroxaban, and 3 received dabigatran. Among those with repeat imaging, the primary composite outcome occurred in 100%, 80%, and 100% for each group, respectively (P = 0.34). One patient had extension of CVT while on apixaban and one patient had increased midline shift while on rivaroxaban. No other secondary outcomes were observed. There do not appear to be significant efficacy or safety differences between DOACs when used for CVT treatment, though larger studies are needed to validate these findings.

Magnesium Sulfate in the Management of Acute Ischemic Stroke: A Review of the Literature and Future Directions.

The management of acute ischemic stroke (AIS) was revolutionized within the last 15 years with the introduction of mechanical thrombectomy (MT) to standard of care. Despite the success of mechanical thrombectomy (MT) in achieving high recanalization rates for large vessel occlusion, functional independence post-treatment remains suboptimal. The current limitations of MT prompt evaluation of the role of adjunctive pharmacologic neuroprotective therapies to prevent excitotoxicity, cellular apoptosis, and inflammation that cause irreversible neuronal damage during AIS. Magnesium (MgSO4) provides an attractive neuroprotectant profile, having many different effects, and is inexpensive, readily available, and has a long-established safety and tolerability profile in the management of myocardial infarction and eclampsia. This gap between technical success and patient outcomes is largely due to the inability to fully protect brain tissue from infarction during ischemia. MgSO4 has shown promise in preclinical studies for its neuroprotective properties, including blocking NMDA receptors, increasing cerebral blood flow, and stabilizing ion channels. However, clinical trials, such as FAST-MAG and IMAGES, failed to demonstrate significant benefits when MgSO4 was administered intravenously, due to delayed drug administration or delivery to target tissue. These trials highlighted the need for faster, more targeted drug delivery. Intra-arterial (IA) administration of MgSO4 via the catheter used in MT could address these limitations by delivering high doses directly to ischemic brain tissue, potentially enhancing neuroprotection while reducing systemic exposure. Preclinical studies and some clinical trials have demonstrated the safety and feasibility of IA, but not IA MgSO4. Further investigation is needed to assess its efficacy. While past trials have not succeeded, IA administration of neuroprotective agents like MgSO4 may improve functional outcomes in stroke patients post-MT. Ongoing and future studies will determine if this approach can effectively complement reperfusion strategies, potentially ushering in a new era of stroke care.

Abstract TMP82: First line aspiration versus stent retriever for posterior circulation stroke; A meta-analysis

Introduction: Aspiration and stent retriever thrombectomy are the primary approaches for endovascular management of posterior circulation stroke. However, the optimal first-line choice of surgical technique remains unclear. This study aims to conduct a systematic review and meta-analysis comparing first-line aspiration with stent retriever thrombectomy in terms of recanalization rates, complications, and clinical outcomes. Methodology: This systematic review and meta-analysis followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Databases searched included PubMed, Embase, Web of Science, Cochrane, and ClinicalTrials.gov, focusing on studies comparing the efficacy and safety of first-line aspiration versus stent retriever thrombectomy for posterior circulation stroke. Data analysis was performed using RevMan version 5.4.1, with statistical significance set at p &lt; 0.05. Result: A total of 21 studies, including 2,521 patients, were analyzed. First-line aspiration demonstrated a significant advantage in terms of successful recanalization (OR = 1.36; 95% CI: 1.04–1.76; p = 0.002) and complete recanalization (OR = 1.41; 95% CI: 0.91–2.20; p = 0.03), both favoring aspiration over the stent retriever technique. Additionally, first-line aspiration was associated with a significantly lower overall complication rate (OR = 0.58; 95% CI: 0.40–0.85; p = 0.005) and a shorter procedural time (SMD = -0.60; 95% CI: -0.81 to -0.40; p &lt; 0.005). However, there were no statistically significant differences between the two techniques in the first pass effect (OR = 1.41; 95% CI: 0.95–2.09; p = 0.09), the need for rescue therapy (OR = 1.01; 95% CI: 0.71–1.44; p = 0.96), 90-day all-cause mortality (OR = 0.95; 95% CI: 0.71–1.27; p = 0.72), and 90-day favorable functional outcome (OR = 1.17; 95% CI: 0.97–1.41; p = 0.11). Conclusion: This meta-analysis suggests that first-line aspiration may offer advantages over stent retrievers for posterior circulation stroke, particularly in terms of recanalization success and procedural safety. However, no significant differences were observed in key clinical outcomes such as mortality and favorable recovery.

Impact of carotid artery tortuosity on mechanical thrombectomy outcomes: A systematic review.

Carotid artery tortuosity (CAT) may complicate mechanical thrombectomy (MT), potentially causing delays or preventing recanalization. However, the relationship between CAT and MT outcomes remains largely unexplored. This systematic review aims to evaluate the existing evidence regarding the impact of CAT on MT outcomes. Following PRISMA guidelines, a systematic literature search was conducted using MEDLINE, EMBASE, Web of Science, Cochrane, and Scopus databases. Studies providing data for MT outcomes based on CAT status were included. Outcomes of interest included successful recanalization, first-pass efficacy (FPE), procedure time, functional independence, and procedure-related complications. Our search identified nine studies with 2737 patients. Three studies employed DSA to assess tortuosity, whereas the remaining six studies preferred CTA. In seven studies, CAT was associated with prolonged procedure times. In five studies, successful recanalization rates were significantly lower in CAT patients as compared to patients with non-tortuous arteries. Two studies showed that CAT could alter FPE or successful recanalization rates of first-line MT techniques. No study found statistically significant relationships between CAT and functional independence. Three studies examined the association between CAT and safety outcomes, and only one study found increased intracranial hemorrhage rates in patients with CAT. All nine studies employed different CAT criteria. Despite the vast MT literature, the number of studies reporting CAT status remains low. CAT may affect procedure time and technical outcomes of MT. Therefore, employing a uniform CAT definition and reporting CAT more frequently can provide insights into management of patients with acute large vessel occlusions.

Clinical and angiographic outcomes of intracranial aneurysms treated with low-profile braided or laser-cut stents: a propensity score-matched analysis.

To compare the embolization outcomes and complications of the LEO Baby and Neuroform Atlas stents in the endovascular treatment of intracranial wide-neck aneurysms. We identified patients with intracranial aneurysms treated with LEO Baby (n=163) or Atlas (n=65) stent-assisted coiling between October 2018 and February 2023. A retrospective analysis of demographics, aneurysm characteristics, embolization outcomes, and procedure-related complications was performed. Propensity score matching analysis with a ratio of 1:2 was used to balance the patient selection bias that existed between the two cohorts. Compared to the Atlas cohort, the LEO Baby cohort had a higher rate of immediate successful embolization (95.6% vs. 78.5%, P<0.001) and a lower rate of incomplete embolization at midterm follow-up (4.0% vs. 18.6%, P=0.006), but there was no significant difference for either after matching for a 1:2 propensity score (P=0.091 and P=0.081, respectively). Procedure-related complications were 10.4% (17/163) in the LEO Baby cohort and 7.7% (5/65) in the Atlas cohort. At midterm angiographic follow-up, recanalization occurred in 0.8% (1/124) of the LEO Baby cohort and 4.7% (2/43) of the Atlas cohort. Complication and recanalization rates for both stents were not statistically different before (P=0.701 and P=0.332, respectively) and after (P>0.999 and P>0.999, respectively) propensity score matching. Both LEO Baby and Atlas are safe and effective in the treatment of intracranial aneurysms, and they are similar in terms of aneurysm embolization outcomes and complication rates.

Comparative efficacy and safety of stent retrievers as a bailout strategy following failed contact aspiration technique in acute stroke thrombectomy

BackgroundThe contact aspiration (CA) technique is often used to perform endovascular thrombectomy (EVT) for acute ischemic stroke (AIS); however, rescue strategies are necessary if CA fails to achieve recanalization. This...

Outcomes and safety of mechanical thrombectomy, alteplase, and conventional medical care in the treatment of acute M2 segment middle cerebral artery occlusion: a comparative study

BackgroundData on mechanical thrombectomy (MT) to treat M2 occlusions of the middle cerebral artery (MCA) are sparse. We report the outcome and safety of MT versus intravenous recombinant tissue plasminogen activator (IV rTPA) versus conventional medical treatment (CMT) of acute ischemic stroke (AIS) due to occlusion of the M2 segment of the MCA. This prospective longitudinal intervention study compared the outcomes and safety of MT, rTPA, and CMT in M2 occlusion AIS patients. National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale (mRS), and recanalization rate assessed outcomes.Results74 AIS patients were recruited (23 MT, 23 rTPA, 28CMT). MT group had significantly higher admission NIHSS (p = 0.018) and mRS (p = 0.023) than rTPA. At 24 h, NIHSS improved more with MT and rTPA than CMT (p < 0.0001). At 3 months, mRS were better with MT and rTPA versus CMT (p < 0.0001). Successful recanalization occurred in 73.9% of the MT group. 69% of the MT group required stent retrieval plus aspiration thrombectomy, and 60.9% required ≥ 3 trials, but outcomes did not differ by technique or number of trials. A good outcome (mRS 0–2) at 3 months was achieved in 69.6% MT versus 65.2% rTPA versus 7.1% CMT (p < 0.0001). Symptomatic intracranial hemorrhage (sICH) rates were slightly, but insignificantly, higher with CMT. Mortality did not significantly differ between groups.ConclusionsFor M2 occlusions, MT and rTPA achieved better early and 3-month outcomes than CMT; however, MT was not superior to rTPA. MT of M2 is feasible and effective, with a lower hemorrhage rate than rTPA and CMT.Trial registration: This study was prospectively registered in the clinical trial with ClinicalTrials.gov ID (NCT05091320). The link: https://clinicaltrials.gov/study/NCT05091320

Efficacy and Safety of Endovenous Microwave Ablation versus Endovenous Laser Ablation for Varicose Veins in Chronic Great Saphenous Vein Insufficiency: A Meta-Analysis.

Although guidelines have established endovenous laser ablation (EVLA) as the first-line option for patients with varicose veins (VVs) in chronic Great saphenous vein (GSV) insufficiency, however, Chronic Vein Insufficiency (CVI) remains a significant healthcare burden. Endovenous microwave ablation (EMA) is a promising alternative. This review aims to analyze the Endovenous Microwave Ablation versus Endovenous Laser Ablation for Varicose Veins in Chronic Great Saphenous Vein Insufficiency METHODS: Randomized controlled trials (RCTs) and cohort studies across PubMed, Scopus, Science Direct, and the Cochrane Library up to November 11, 2024 was searched. Risk of bias was evaluated using Cochrane Risk of Bias Tool for RCT and Newcastle-Ottawa Scale (NOS) for Cohort studies. Meta-analysis was done using RevMan 5.4.0 using an inverse-variance random-effects model with Duval and Tweedie trim-and-fill sensitivity analysis. Overall, a total of 2 RCTs and 1 cohort study included. In treating GSV VVs, EMA has proven to have shorter duration of operation significantly compared to EVLA (MD: -6.62 [95% CI: -11.91, -1.32, p = 0.01]) although heterogeneity is high. EMA have similar profiles in efficacy compared to EVLA (Aberdeen score of QoL, VAS Score, length of hospital stays, and recanalization rate in 6-months). In terms of safety, the incidence of ecchymosis was found to be lower in the EMA group compared to the EVLA group significantly (OR: 0.58). Other safety profiles were found to be similar. EMA might lower operating time, potentially reducing procedure risks, and is equally effective as EVLA in treating VVs in chronic GSV insufficiency. Further research comparing these techniques with extended follow-up periods (over 12 months) and standardized study methodologies are still needed.

Mechanical thrombectomy in elderly stroke patients with low ASPECTS: insights from STAR

BackgroundThe elderly population (≥80 years) were underrepresented in recent trials of endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion acute ischemic stroke (LVO-AIS) with low Alberta Stroke Program Early...

Safety and Efficacy of Thrombectomy for Distal Medium Vessel Occlusions of the Middle Cerebral Artery.

Mechanical thrombectomy (MT) for distal medium vessel occlusions (DMVOs) in the middle cerebral artery (MCA) is less established than for large vessel occlusions. This study evaluates the safety and efficacy of MT in DMVOs, comparing it with M1-segment occlusions. This retrospective study analyzed 218 patients who underwent MT for isolated M1 (n=123) or distal M2+M3 (n=35) occlusions between January 2020 and August 2023. Outcomes included procedural complications, hemorrhagic events, reperfusion rates, and clinical severity and disability at admission and discharge. Multivariate logistic regression identified predictors of favorable outcomes (modified Rankin Scale≤2) at discharge. Median admission National Institutes of Health Stroke Scale (NIHSS) scores were higher in the M1 group (13, interquartile range [IQR]: 8) compared to the distal M2+M3 group (8, IQR: 7; P<0.001), with significant improvements at discharge in both groups (6 [IQR: 8] for M1 and 2.5 [IQR: 5] for M2+M3; P=0.025). Favorable outcomes were more frequent in the M2+M3 group (50.0%) compared to M1 (28.1%; P=0.023). Recanalization rates (modified Thrombolysis in Cerebral Infarction≥2b) were excellent (>90% in both groups; P=0.300). Procedural complications were rare, with vessel perforations occurring infrequently (M1: 1.6%; M2+M3: 2.9%; P=0.531). Symptomatic intracranial hemorrhage rates were similarly low (2.4% vs. 2.9%; P=0.889). Multivariate analysis identified younger age (P=0.045) and lower NIHSS (P=0.061) as predictors of favorable outcomes in distal occlusions. MT is safe and effective for DMVOs of the MCA, demonstrating significant improvements in clinical outcomes and comparable complication rates to MT for M1-segment occlusions. Given the typically less severe presentations in DMVO and similar risk profiles, careful patient selection and individualized treatment remain critical.

Artificial biomarker-based feedback-regulated personalized and precise thrombolysis with lower hemorrhagic risk.

The body weight-based thrombolytic medication strategy in clinical trials shows critical defects in recanalization rate and post-thrombolysis hemorrhage. Methods for perceiving thrombi heterogeneity of thrombolysis resistance is urgently needed for precise thrombolysis. Here, we revealed the relationship between the thrombin heterogeneity and the thrombolysis resistance in thrombi and created an artificial biomarker-based nano-patrol system with robotic functional logic to perceive and report the thrombolysis resistance of thrombi. The nano-patrols are contrallable and are able to accomplish thrombolysis resistance-matched personalized and precise therapy according to the feedback signal from artificial biomarkers. This nano-patrol system depicted more enhanced thrombolytic efficiency (elevated by 25%) than alteplase for mini pig model and clinical thrombi and achieved recanalization in thrombotic model where alteplase encountered failure. Moreover, the nano-patrol remarkably reduced the infarct volume and the hemorrhagic transformation risk (0.12-fold of alteplase) of cerebral thrombosis. Therefore, we developed a unique tool for diagnosing thrombolysis resistance and achieving personalized and precise thrombolysis.

Medium vessel occlusions in the drip-and-ship model: Clinical vs. hub CTP-supported decision making.

Mechanical thrombectomy (MT) for medium vessel occlusions (MeVO) is emerging as a promising treatment in acute stroke. We aim to evaluate the utility of additional imaging (CTP) in patients with MeVOs who received thrombolysis at a spoke hospital and were transferred to the hub. This was a retrospective review of prospectively collected data from April 2018 to June 2023. Patients were transferred to one of the following destinations: CT scanner for a perfusion scan, directly to the angiography suite, or admitted to the neurological intensive care unit (NICU). We compared baseline characteristics, MT times, radiographic and clinical outcomes between the group that was initially transferred to CTP vs. the group that was not initially transferred to CTP. Seventy-eight MeVO patients who received IV thrombolysis and were transferred to our comprehensive stroke center were included in the analysis. Forty patients went directly to CTP, thirty went directly to the angiography suite (DTA), and eight were transferred to the NICU. 67.5% of patients presenting to CTP did not subsequently go to the angiography suite. The CTP and non-CTP groups did not differ significantly in terms of demographics, rates of successful recanalization, complications, and clinical outcomes at 90 days. The CTP group had significantly longer median door-to-groin times and median door-to-recanalization times. Mechanical thrombectomy should be considered in stroke patients with confirmed medium vessel occlusions who receive thrombolysis. CTP utilization may lead to lower angiography utilization and longer door-to-procedure times but does not significantly affect long-term outcomes.

Dumbbell-shaped thrombectomy device for cerebral venous sinus thrombus removal with controllable axial and longitudinal maneuverability

Abstract Cerebral venous sinus thrombosis (CVST) is frequently observed in younger adults and features in large thrombus volume. Due to the triangular-like cross-sectional shape and large diameter of superior sagittal sinus, all the commercially available artery stent retrievers are not suitable for venous vessels. In this study, a dumbbell-like stent was designed and fabricated by 3D braided technology using NiTi wires, which was manually rotatable and stretchable with controlled length/diameter ratios (2.6 to 14.0) and reciprocating maneuverability. Computational modeling and an in vitro study were conducted to evaluate the mechanical properties of this device and its ability to trap and remove thrombi from occluded venous vessels was verified using a swine model. And a single-center retrospective clinical study of 10 patients using the Venus-TD to treat patients with CVST was conducted. Pre/postoperative thrombus volume in ten patients was quantitively analyzed (12855.3 ± 6417.1 vs. 2373.1 ± 2759.0 mm³, P &amp;lt; 0.001) with a high recanalization rate, yielding favorable clinical outcomes. This study offers a novel treatment option for patients with extensive CVST.

Microsurgical clipping remains a viable option for the treatment of coilable ruptured middle cerebral artery aneurysms in the endovascular era.

Although many institutions increasingly perform endovascular coiling instead of microsurgical clipping as the primary treatment for ruptured aneurysms, there remains ongoing debate regarding the optimal treatment strategy for ruptured middle cerebral artery (MCA) aneurysms. Therefore, we compared the outcomes of clipping and coiling for treating ruptured MCA aneurysms. A total of 155 ruptured MCA aneurysms that were deemed eligible for both clipping and coiling were retrospectively reviewed. We compared patient characteristics, radiological results, clinical outcomes, and perioperative complications between patients who received clipping and those receiving coiling. Furthermore, we analyzed the potential risk factors for perioperative complications that differed between the two groups. 59 (38.1%) aneurysms were treated using coiling, and 96 (61.9%) received clipping. The clipping group showed a significantly higher rate of immediate complete occlusion and a lower rate of neck remnants compared with the coiling group (p = 0.006). These radiological results persisted at the 12-month angiographic follow-up, with a significantly higher complete occlusion rate (p = 0.038) and a lower recanalization rate (p = 0.033) in the clipping group. The clinical outcomes were comparable between the two groups. Patients treated with coiling showed a higher rate of permanent shunting than those treated with clipping (18.6% vs. 8.3%, p = 0.058). Coiling was independently associated with shunt-dependent hydrocephalus in multivariate analysis. Microsurgical clipping provides comparable clinical outcomes, better occlusion, and superior durability for treating ruptured MCA aneurysms compared with endovascular coiling. Therefore, clipping remains a viable option for treating ruptured MCA aneurysms, even in aneurysms suitable for coiling.

Effect of Intravenous Alteplase Before Endovascular Thrombectomy on Outcome After Unsuccessful Recanalization in the DIRECT-MT Trial.

There are still some patients with acute anterior circulation large vessel occlusion stroke experienced unsuccessful recanalization after endovascular thrombectomy (EVT). The efficacy of intravenous alteplase before thrombectomy for such patients is unknown. We performed this study to investigate whether prior intravenous alteplase could affect the outcome of patients with unsuccessful recanalization. This is a post-hoc analysis of the DIRECT-MT trial (direct intraarterial thrombectomy in order to revascularize acute ischemic stroke patients with large vessel occlusion efficiently in Chinese Tertiary Hospitals: a multicenter randomized clinical trial). Patients with final extended thrombolysis in cerebral infarction score of 0-2a were included. Patients with successful recanalization (modified treatment in cerebral ischemia 2b-3) or could not be assessed for modified treatment in cerebral ischemia were excluded. The primary outcome was the 90-day modified Rankin Scale (mRS) score, while secondary outcomes included 90-day functional independence (mRS 0-2), recanalization (modified arterial occlusive lesion) rates at 24-72 hours by computed tomography angiography, infarction volume on computed tomography, and rates of symptomatic intracranial hemorrhage and asymptomatic intracranial hemorrhage. Among 656 randomized patients, 92 patients with unsuccessful recanalization were included, of which 55 patients underwent EVT alone (EVT group) and 37 patients underwent EVT preceded by intravenous alteplase (combination group). No statistically significant difference in the 90-day mRS score was observed between the 2 groups (adjusted common odds ratio= 1.65; 95% confidence interval, 0.76 to 3.59). The volume of infarction, the proportion of 90-day functional independence, recanalization rates at 24-72 hours, rates of symptomatic intracranial hemorrhage, and rates of asymptomatic intracranial hemorrhage were similar in both groups. We found no evidence that prior intravenous alteplase could affect the clinical or imaging outcome in patients with acute anterior circulation large vessel occlusion stroke and unsuccessful recanalization after EVT.

Administration of anticoagulation strategies for portal vein thrombosis in cirrhosis: network meta-analysis.

Evidences for anticoagulation strategies in cirrhotic with portal vein thrombosis (PVT) are still insufficient. This study aims to comprehensively compare the therapeutic effects of different therapeutic therapeutic measures in individuals suffering from cirrhosis with PVT, with the ultimate goal of providing evidence-based recommendations for thrombolytic therapy in this population. Starting from 20 October 2023, a comprehensive search about therapeutic strategies for portal vein thrombosis in cirrhosis was conducted on PubMed, EMBASE, and Cochrane Library. 19 studies were eventually incorporated into this study. Comparison with control in network meta-analysis, direct oral anticoagulants (DOACs) (RR = 2.15, 95%CI: 1.33, 3.48), LMWH (RR = 1.41, 95%CI: 1.01, 1.99), TIPS (RR = 5.68, 95%CI: 2.63, 12.24), warfarin (RR = 2.16, 95%CI: 1.46, 3.21), EBL plus propranolol (RR = 2.80, 95%CI: 1.18, 6.60), LMWH-DOACs sequential (RR = 7.92, 95%CI: 2.85, 21.99) and LMWH-warfarin sequential (RR = 2.26, 95%CI: 1.16, 4.42) significantly improved the incidence of complete recanalization. The anticoagulation drugs were ranked based on their SUCRA values, with the LMWH-DOACs sequential (92.7%), TIPS plus warfarin (91.3%), and TIPS (80.3%) emerging as the top three effective treatments. In this study, active anticoagulants were recommended for cirrhosis with PVT. The TIPS plus warfarin, LMWH-DOACs sequential, and TIPS improved the complete recanalization rate most effectively, and the EBL plus propranolol, heparin plus DOACs plus warfarin, and DOACs were highly recommended for increasing the incidence of partial recanalization. Warfarin and TIPS were recommended for reducing the frequency of bleeding events, while LMWH plus warfarin and DOACs proved to be most effective in decreasing the rate of major bleeding events. Warfarin, heparin plus DOACs plus warfarin, and DOACs demonstrated the most significant reduction in mortality rates, highlighting its potential as an effective intervention. TIPS plus warfarin, LMWH-DOACs sequential, and TIPS were recommended for reducing the occurrence of PVT expansion. Heparin plus DOACs plus warfarin was recommended for reducing the occurrence of hepatic encephalopathy, and protocols that involve TIPS were generally associated with a higher risk of hepatic encephalopathy. However, a longer follow-up period is necessary to comprehensively evaluate the efficacy of active anticoagulants therapy in patients with PVT in cirrhosis.

Experience With Dabigatran on Rate of Portal Vein Thrombosis Recanalization, Disease Progression and Survival.

We assessed clinical, procoagulant and genetic risk factors and clinical outcomes in dabigatran-treated patients with non-tumoural acute and acute-on-chronic portal vein thrombosis (PVT). Patients with a new diagnosis of non-tumoural acute and acute-on-chronic PVT between January 2021 and January 2024 (aged ≥ 18 years) in those without/with cirrhosis (Child-Pugh (CP)-A/B/C ≤ 10) were started on dabigatran and followed and compared with those on vitamin K antagonist (VKA) and untreated individuals. Dabigatran was prescribed in 119 patients with PVT type 1 (61, 51.3%), type 2 (34, 28.6%), type 3 (24, 20.2%); 72 (60.5%) with cirrhosis [CP-A (27, 37.5%), CP-B (43, 59.7%) and CP-C10 (2, 2.8%)]. Procoagulant factors noted were JAK2V617F (10.1%), CALR (2.5%) and factor V Leiden (1.6%) mutations, antiphospholipid syndrome (APS, 15.2%), isolated Protein C (14.3%) and Protein S (16.8%) deficiency. 28 patients who declined anticoagulation/were unable to come for follow-up, and six with CP-C received VKA. Overall recanalization rate (RR) on dabigatran was 56 (47.1%); 25 (21%) complete recanalization, 31 (26%) partial recanalization and 63 (52.9%) stable PVT over median follow-up of 32 months. Patients not anticoagulated had a spontaneous RR in 21.4% (28 patients; p = 0.005 compared with dabigatran group) and none recanalized on VKA. On multivariable analysis, predictors of recanalization on dabigatran were Factor VIII Antigen level (FVIII:Ag, HR 0.6; 95% CI 0.3-0.9, p = 0.032), non-occlusive PVT (HR 3.5, 95% CI 1.9-5.6, p = 0.025) and acute PVT (HR 2.1; 95% CI 1.5-3.2, p = 0.003). Mortality was 14 (11.8%). On dabigatran, 47% of 119 patients achieved portal vein recanalization over 32 months of follow-up which was higher than the spontaneous RR (21.4%) in an untreated cohort. High Factor VIII:Ag was a predictor of non-recanalization. Dabigatran was safe in cirrhosis (CP-A and B) while further work is needed in CP-C.

Hydrogel coils in intracranial aneurysm treatment: a multicenter, prospective, randomized open-label trial.

Studies have demonstrated the effectiveness of hydrogel-coated coils (HGCs) to achieve the composite endpoint of decreased recanalization rates and greater safety. Herein, the authors aimed to assess the true ability of second-generation HGCs to prevent recanalization. This randomized controlled study, the HYBRID (Hydrocoil Versus Bare Platinum Coil in Recanalization Imaging Data) trial, comparing HGCs with bare platinum coils (BPCs), was conducted in 43 Japanese institutions. The aneurysm diameter range was 7-20 mm. HGCs were used in 4 patients in the BPC arm, and at least one HGC was used in each patient in the HGC arm, excluding 3 patients. Additionally, an HGC length ≥ 50% of the length of all the coils used was strongly recommended. The primary endpoint was recanalization 1 year after embolization, according to core laboratory evaluation. Angiographic change was also classified as further thrombosis, unchanged, or recanalization. Changes in cases with both initial and 1-year posttreatment angiographic images were compared. In the post hoc analysis, major recanalization was defined as any change, from complete occlusion or a neck remnant at the end of the procedure to body filling (BF) on the 1-year posttreatment angiogram or any increase in the size of BF in patients with BF at the end of the procedure, and its rate was compared between the two treatment arms. Recruitment ended when 432 patients were randomized; 217 and 215 patients were allocated to the HGC and BPC arms, respectively. The recanalization rates in the HGC and BPC arms were 3.3% and 7.1%, respectively (risk difference -3.8%, 95% CI -8.6 to 0.5), with no statistically significant difference (p = 0.083). Regarding aneurysm occlusion within 1 year, there was significantly more thrombosis and less recanalization in the HGC group (p = 0.043). The major recanalization rates were 2.3% and 6.6% in the HGC and BPC arms, respectively, with a significant difference between the two (p = 0.036). The study results did not confirm the effectiveness of second-generation HGCs using recanalization imaging data. However, these coils may induce more thrombosis and less recanalization for medium-sized cerebral aneurysms. Clinical trial registration no.: UMIN000006748 (www.umin.ac.jp/ctr/).