Outcome Of Thrombolysis Research Articles

Comparative outcomes of catheter-directed thrombolysis versus AngioJet pharmacomechanical catheter-directed thrombolysis for treatment of acute iliofemoral deep vein thrombosis

ObjectiveThe objective of this study was to compare the outcomes of pharmacomechanical thrombolysis and thrombectomy (PCDT) plus catheter-directed thrombolysis (CDT) vs CDT alone for the treatment of acute iliofemoral deep vein thrombosis (DVT) and summarize the clinical experience, safety outcomes, and short- and long-term efficacy. MethodsWe performed a 4-year retrospective, case-control study. A total of 95 consecutive patients with acute symptomatic iliofemoral deep vein thrombosis (DVT) with a symptom duration of ≤7 days involving the iliac and/or common femoral veins underwent endovascular interventions. The patients were divided into two groups according to their clinical indications: PCDT plus CDT vs CDT alone. Statistical analyses were used to compare the clinical characteristics and outcomes between the two groups. Additionally, the patients were followed up for 3 to 36 months after treatment, and the proportions of post-thrombotic syndrome (PTS) and moderate to severe PTS were analyzed using the Kaplan-Meier survival method. ResultsA total of 95 consecutive patients were analyzed in this retrospective study, of whom, 51 underwent CDT alone and 44 underwent PCDT plus CDT. Between the two groups, in terms of immediate-term efficacy and safety, significant differences were found in the catheter retention time (60.64 ± 12.04 hours vs 19.42 ± 4.04 hours; P < .001), dosages of urokinase required (5.82 ± 0.81 million units vs 1.80 ± 0.64 million units; P < .001), the detumescence rate at 24 hours postoperatively (48.46% ± 8.62% vs 76.79% ± 7.98%; P = .026), the descent velocity of D-dimer per day (2266.28 ± 1358.26 μg/L/D vs 3842.34 ± 2048.02 μg/L/D; P = .018), total hospitalization stay (6.2 ± 1.40 days vs 3.8 ± 0.70 days; P = .024), number of postoperative angiograms (2.4 ± 0.80 vs 1.2 ± 0.30; P = .042), and grade III venous patency (>95% lysis: 54.5% vs 68.6%; P = .047). Furthermore, during the follow-up period, significant differences were found in the incidence of PTS (Villalta scale ≥5 or a venous ulcer: 47.0% vs 27.7%; P = .037), and the incidence proportion of moderate to severe PTS at 12 months (15.7% vs 4.5%; P = .024) and 24 months (35.3% vs 11.4%; P = .016). ConclusionsCompared with CDT alone, in the iliofemoral DVT subgroup with a symptom duration of ≤7 days, PCDT plus CDT could significantly relieve early leg symptoms, shorten the hospitalization stay, reduce bleeding complications, promote long-term venous patency, and decrease the occurrence of PTS and the incidence proportion of moderate to severe PTS. Thus, the short- and long-term outcomes both support the superiority of PCDT plus CDT vs CDT in this subgroup.

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis

There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT+SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT+SA and 8,239 SA alone) patients were included. Compared with SA, CDT+SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p=0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p=0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p=0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p=0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p=0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p=0.08). In conclusion, CDT+SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.

Pre-morbid frailty is associated with poor outcome after thrombolysis in older patients with ST-elevation Myocardial Infarction

Introduction: In recent years, the association of frailty has been established with a poor outcome after percutaneous intervention following an acute cardiovascular event. However, a larger proportion of the world population is unable to access the prohibitively expensive tertiary cardiac care and receives the more readily available, affordable and acceptable thrombolytic therapy in emergency situations. The current study was designed to explore the association of pre-morbid frailty with immediate and short-term outcome of thrombolysis in older subjects presenting with ST-elevation myocardial infarction to our hospital. Methods: This was an observational prospective cohort study completed between 2015 and 2017 at a tertiary care teaching hospital in Delhi. Patients older than 60 years who presented to the hospital with ST-elevation myocardial infarction and underwent successful thrombolysis were included for the study. Complications such as bleeding, reperfusion reactions and allergic reactions were recorded whenever these were observed. In addition, complications such as re-infarction, stroke, cardiac arrest, cardiogenic shock and death were also recorded. In addition, a short-term outcome in terms of discharge, death, recovery was noted. A pre-morbid frailty score was historically computed with inputs from the patients and their primary caretakers using a deficit count approach on a pre-defined list of fifty self-reported deficits. The descriptive statistical analysis comprised of calculating means (standard deviations) and proportions (frequencies and percentages). The association of premorbid deficit score with thrombolysis success and other variables was tested by calculating mean ranks, and Mann Whitney U test was used as a statistical test of significance. Spearman correlation coefficient was used to determine the association between frailty and complications and morbidity and mortality indicators. Univariable logistic regression models were used to evaluate independent variables associated with outcome of thrombolysis to further explore the association between frailty and outcome. Independent variables found significantly associated with poor outcome were entered into a multivariable logistic regression model (forward) in addition to those considered scientifically relevant. Results: In the present study, we found a significant association between a higher pre-morbid frailty status assessed by an interview-based deficit count score and poorer outcome of thrombolysis. Every unit increment in the frailty deficit count score on a scale of 50 points increased the odds of failed thrombolysis by 1.14 times. Frailty was also associated with an increased risk of reperfusion arrhythmias and cardiac arrest following thrombolysis. Additionally, we noted that higher the deficit score, lesser the resolution of ST segment on ECG, 90 minutes following thrombolysis. Conclusions: Our study indicates that frailty determined by a premorbid count of health deficits is associated with the outcome of thrombolysis following myocardial infarction in older patients. The patients with greater count of deficits have a higher chance of failure. Our findings will help informed decision-making while managing older patients presenting with myocardial infarction and in-turn improve morbidity and mortality.

Outcomes of catheter-directed thrombolysis versus systemic thrombolysis in the treatment of pulmonary embolism: a meta-analysis.

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) versus systemic thrombolysis (ST) in the treatment of pulmonary embolism (PE). The Cochrane Library, PubMed, and Embase databases were searched to collect the literature on the comparison of the results of CDT and ST in the treatment of PE from the beginning of their records to May 2020, and meta-analysis was performed by STATA software (version 15.1). Using standardized data-collection forms, the authors screened the studies and independently extracted data, and assessed the quality of the studies using the Newcastle-Ottawa Scale for cohort studies. Cohort studies that examined the following results were included in the current study: in-hospital mortality, all-cause bleeding rate, gastrointestinal bleeding rate, intracranial hemorrhage rate, the incidence of shock, and hospital length of stay. A total of eight articles, with 13,242 participants, involving 3962 participants in the CDT group and 9280 participants in the ST group were included. CDT compared with ST in the treatment of PE can significantly affect in-hospital mortality rate [odds ratio (OR) = 0.41, 95% CI: 0.30-0.56, P < 0.05], all-cause bleeding rate (OR = 1.20, 95% CI: 1.04-1.39, P = 0.012), gastrointestinal bleeding rate (OR = 1.43, 95% CI: 1.13-1.81, P = 0.003), the incidence of shock (OR = 0.46, 95% CI: 0.37-0.57, P < 0.05), and hospital length of stay [standard mean difference (SMD) = 0.16, 95% CI: 0.07-0.25, P < 0.05]. However, there was no significant effect on intracranial hemorrhage rate in patients with PE (OR = 0.70, 95% CI: 0.47-1.03, P = 0.070). CDT is a viable alternative to ST in the treatment of PE, as it can significantly reduce in-hospital mortality rate, all-cause bleeding rate, gastrointestinal bleeding rate, and incidence of shock. However, CDT may prolong hospital length of stay to a certain extent. Further research is needed to evaluate the safety and efficacy of CDT and ST in the treatment of acute PE and other clinical outcomes.

Energy spectrum CT index-based machine learning model predicts the effect of intravenous thrombolysis in lower limbs.

To develop a noninvasive machine learning (ML) model based on energy spectrum computed tomography venography (CTV) indices for preoperatively predicting the effect of intravenous thrombolytic treatment in lower limbs. A total of 3492 slices containing thrombus regions from 58 veins in lower limbs in a cohort of 18 patients, divided in good and poor thrombolysis prognosis groups, were analyzed. Key indices were selected by univariate analysis and Pearson correlation coefficient test. A support vector machine classifier-based model was developed through ten-fold cross validation. Model performance was assessed in terms of discrimination, calibration, and clinical usefulness at both per-slice and per-vessel levels. Continuous variables and categorical variables were compared between good and poor thrombolysis prognosis group by Mann-Whitney U-test and chi-square test, respectively. A nomogram was built by integrating clinical factors and the energy spectrum CTV index-based score calculated by the model. Six indices selected from 192 indices were used to build the predictive model. The ML model achieved area under the curves (AUCs) of 0.838 and 0.767 [95% CI (confidence interval), 0.825-0.850, 0.752-0.781] in the training and validation datasets at the per-slice level, and the per-vessel level AUCs were 0.945 and 0.876 (95% CI, 0.852-0.988, 0.763-0.948) in the training and validation datasets, respectively. The nomogram showed better performance with the per-vessel level AUC, accuracy, sensitivity and specificity, yielding 0.901(95% CI, 0.793-0.964), 86.2%, 87.9% and 84.0% in the validation dataset, respectively. There was no significant difference in the vessel distribution between good and poor thrombolysis prognosis groups (chi-square test, p=0.671). The energy spectrum CTV index-based ML model achieved favorable effectiveness in predicting the outcome of vessel-level intravenous thrombolysis. A nomogram integrating clinical factors, and risk score calculated by the developed model showed improved performance and had potential to be used as a noninvasive preoperative tool for clinicians.

Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion

Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. Mechanical thrombectomy with or without IVT. Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.

Pharmacoinvasive Therapy in Treating Acute STEMI Patients in Covid-19 Era

Background: Treating acute ST segment elevated myocardial infarction (STEMI) patients by primary PCI (pPCI) has dramatically fallen globally in covid era as there is chances of potential threat of spreading COVID among the non-COVID patients. Thereby, thrombolysis of acute STEMI patient in grey zone till COVID RT PCR report to come, was the mode of treatment of acute myocardial infarction patient in our hospital. We have carried out this prospective observational study to see the outcomes of thrombolysis and subsequent intervention. Methods: STEMI patient who presented to our emergency department with chest pain and ECG and hs-Troponin-I evidenced acute STEMI, were enrolled in the study. Total 139 patients enrolled (Male:120, Female :54); average age for Male: 54 yrs., female was: 56yrs. All patients were admitted in the grey zone of CCU where thrombolysis was done. COVID-19 patients were excluded from intervention and managed conservatively. Covid Negative patients were kept transferred to CCU green zone. On average 2.1 days after Fibrinolysis, elective PCI carried out. Data analysis from 48 patients who underwent pharmacoinvasive therapy was done. Results: Among the study population, Covid-19 positive was in 11 (7.9%) patients and Covid-19 was negative in 128 (92.1%) patients. Primary PCI was performed in 7 (5.03%) patients. Rest of the patients were managed by Pharmacoinvasive therapy. Thrombolysis by Tenecteplase (TNK) was done in 89 (64%) patients, and by Streptokinase in 25 (17.9%) patients, 18 (12.9%) patients did not receive any thrombolysis due to late presentation. Chest pain to needle time was 7.2 ±12.7hrs., thrombolysis to balloon time was 117.5 ±314.8hrs. More than 50% stenosis resolution observed in 20 (41.6%) patients, chest pain resolution within one hour of thrombolysis observed in 21 (43.8%) patients. Ten (20.8%) patients developed. Door to needle time was 30 mins. Total, 88 stents were deployed in 83 territories. CABG was recommended for 7 (5.03%) patients. Stented territory was LAD 37 (45.7%) and RCA 32 (39.5%) and LCX 12 (14.8%). Conclusion: In the era of COVID-19, in this prospective cohort study, on acute STEMI patient management, we found that Pharmacoinvasive therapy, reduced patients’ symptoms and ST resolution occurred partially. Cardiovasc j 2023; 15(2): 136-143

Thrombolysis Outcomes in Acute Ischaemic Stroke Patients with Pre-Existing Cognitive Impairment.

Thrombolysis treatment for ischaemic stroke in patients with pre-existing disabilities, including cognitive impairment, remains controversial. Previous studies have suggested functional outcomes post-thrombolysis are worse in patients with cognitive impairment. This study aimed to compare and explore factors contributing to thrombolysis outcomes, including haemorrhagic complications, in cognitively and non-cognitively impaired patients with ischaemic stroke. A retrospective analysis of 428 ischaemic stroke patients who were thrombolysed between January 2016 and February 2021 was performed. Cognitive impairment was defined as a diagnosis of dementia, mild cognitive impairment, or clinical evidence of the condition. The outcome measures included morbidity (using NIHSS and mRS), haemorrhagic complications, and mortality, and were analysed using multivariable logistic regression models. The analysis of the cohort revealed that 62 patients were cognitively impaired. When compared to those without cognitive impairment, this group showed worse functional status at discharge (mRS 4 vs. 3, p < 0.001) and a higher probability of dying within 90 days (OR 3.34, 95% CI 1.85-6.01, p < 0.001). A higher risk of a fatal ICH post-thrombolysis was observed in the cognitively impaired patients, and, after controlling for covariates, cognitive impairment remained a significant predictor of a fatal haemorrhage (OR 4.79, 95% CI 1.24-18.45, p = 0.023). Cognitively impaired ischaemic stroke patients experience increased morbidity, mortality, and haemorrhagic complications following thrombolytic therapy. However cognitive status is not independently predictive of most outcome measures. Further work is required to elucidate contributing factors to the poor outcomes observed in these patients and help guide thrombolysis decision-making in clinical practice.

The efficacy and safety of intravenous thrombolysis with tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis.

We aimed to evaluate the available evidence on the efficacy and safety outcomes of intravenous tenecteplase (TNK) compared with intravenous alteplase(ALT) for patients with acute ischemic stroke (AIS) in randomized controlled trials (RCTs). The MEDLINE/PubMed, Embase, Springer, Web of Science, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of TNK versus ALT among AIS patients in these English and Chinese electronic databases from inception dates to August 1, 2022. This meta-analysis followed PRISMA guidelines. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) and mortality at 90days. The secondary outcomes included successful recanalization, early neurologic improvement < 48h, any intracranial hemorrhage (ICH), and symptomatic ICH. The follow-up time of all studies was at least 3months. A total of nine RCTs involving 1958 patients in TNK group and 1731 patients in ALT group were finally included. For the efficacy outcomes, there were no significant differences between the two groups in terms of mRS score 0 ~ 2 (RR 1.00; 95% CI 0.88-1.13; P = 0.96), mRS score 0 ~ 1 (RR 1.03; 95% CI 0.96-1.10; P = 0.36), successful recanalization (RR 1.25; 95% CI 0.88-1.76; P = 0.21), and early neurologic improvement < 48h (RR 1.08; 95% CI 0.92-1.26; P = 0.37). Similar results were seen for the safety outcomes, which have no statistical differences in terms of any ICH (RR 1.01; 95% CI 0.72-1.41; P = 0.96), symptomatic ICH (RR 1.19; 95% CI 0.81-1.76; P = 0.37), and mortality at 90days (RR 0.99; 95% CI 0.83-1.19; P = 0.94). Overall, the efficacy and safety outcomes of intravenous thrombolysis with TNK versus ALT for AIS were not statistically different. However, TNK at a dose of 0.25mg/kg may be a reasonable alternative to ALT for thrombolysis.

Interaction between intravenous thrombolysis and clinical outcome between slow and fast progressors undergoing mechanical thrombectomy: a post-hoc analysis of the SWIFT-DIRECT trial

BackgroundIn proximal occlusions, the effect of reperfusion therapies may differ between slow or fast progressors. We investigated the effect of intravenous thrombolysis (IVT) (with alteplase) plus mechanical thrombectomy (MT) versus...

Clinical outcomes of ultrasound-assisted coagulation monitoring-adjusted catheter-directed thrombolysis for acute pulmonary embolism

BackgroundUltrasound-assisted catheter-directed thrombolysis (USAT) may reverse right ventricular dysfunction due to acute pulmonary embolism (PE) with a favorable safety profile. MethodsWe studied intermediate-high- and high-risk acute PE patients who underwent USAT at the University Hospital Zurich, 2018–2022. The USAT regimen included alteplase 10 mg per catheter over 15 h, therapeutic-dosed heparin, and dosage adaptations based on routinely monitored coagulation parameters, notably anti-factor Xa activity and fibrinogen. We focused on the mean pulmonary arterial pressure (mPAP) and the National Early Warning Score (NEWS) before and after USAT, and reported the incidence of hemodynamic decompensation, PE recurrence, major bleeding, and death over 30 days. ResultsWe included 161 patients: 96 (59.6 %) were men and the mean age was 67.8 (SD 14.6) years. Mean PAP decreased from a mean of 35.6 (SD 9.8) to 25.6 (SD 8.2) mmHg, whereas the NEWS decreased from a median of 5 (Q1-Q3 4–6) to 3 (Q1-Q3 2–4) points. No cases of hemodynamic decompensation occurred. One (0.6 %) patient had an episode of recurrent PE. Two (1.2 %) major bleeding events occurred, including one (0.6 %) intracranial, fatal hemorrhage in a patient with high-risk PE, severe heparin overdosing, and a recent head trauma (with negative CT scan of the brain performed at baseline). No other deaths occurred. ConclusionsUSAT resulted in a rapid improvement of hemodynamic parameters among patients with intermediate-high risk acute PE and selected ones with high-risk acute PE, without any recorded deaths related to PE itself. A strategy including USAT, therapeutic-dosed heparin, and routinely monitored coagulation parameters may partly explain the overall very low rate of major bleeding.

Sex Differences in Outcomes of Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Preadmission Use of Antiplatelets.

To compare safety and functional outcomes of intravenous thrombolysis (IVT) between females and males with acute ischaemic stroke (AIS) in relation to preadmission use of antiplatelets. Multicentre cohort study of patients admitted from 1 January 2014 to 31 January 2020 to hospitals participating in the Swiss Stroke Registry, presenting with AIS and receiving IVT. Primary safety outcome was in-hospital symptomatic intracerebral haemorrhage (sICH). Primary functional outcome was functional independence at 3 months after discharge. Multivariable logistic regression models were fitted to assess the association between sex and each outcome according to preadmission use of antiplatelets. The study included 4996 patients (42.51 % females, older than males, median age 79 vs 71 years, p < 0.0001). Comparable proportions of females (39.92 %) and males (40.39 %) used antiplatelets before admission (p = 0.74). In total, 3.06 % females and 2.47 % males developed in-hospital sICH (p = 0.19), with similar odds (adjusted odds ratio, [AOR] 0.93, 95 % confidence interval, [CI] 0.63-1.39). No interaction was found between sex and preadmission use of either single or dual antiplatelets in relation to in-hospital sICH (p = 0.94 and p = 0.23). Males had higher odds of functional independence at 3 months (AOR 1.34, 95 % CI 1.09-1.65), regardless of preadmission use of antiplatelets (interaction between sex and preadmission use of either single or dual antiplatelets p = 0.41 and p = 0.58). No sex differences were observed in the safety of IVT regarding preadmission use of antiplatelets. Males showed more favourable 3-month functional independence than females; however, this sex difference was apparently not explained by a sex-specific mechanism related to preadmission use of antiplatelets.

Outcomes in minor stroke patients treated with intravenous thrombolysis.

Our study aimed to describe the short-, medium-, and long-term outcomes of intravenous thrombolysis in minor stroke, and to explore the relationship between thrombolysis and clinical outcomes. Our study included ischemic minor stroke patients (National Institutes of Health Stroke Scale score ≤ 5) within 4.5h from symptom onset from the Third China National Stroke Registry (CNSR-III) between August 2015 and March 2018. The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0-1 at 3months. The secondary outcomes included mRS score of 0-1 at discharge, 6months, and 1year. The safety outcomes were symptomatic intracerebral hemorrhage (sICH) at 24-36 h and all-cause mortality. The association between intravenous thrombolysis and clinical outcomes was studied using multivariable models. A total of 1905 minor ischemic stroke patients were included. Overall 527 patients (28%) received intravenous t-PA (IV t-PA) and 1378 patients (72%) in the non-IV t-PA group. Of them, 18.85% (359/1905) participants had a disabled outcome (defined as mRS score ≥ 2) at discharge, 12.8% (242/1885) at 3months, 13.9% (262/1886) at 6months, and 13.9% (260/1871) at 1year. In multivariable analysis, IV t-PA was associated with favorable functional outcomes at discharge (adjusted odds ratio [aOR] 1.49; 95% confidence interval [CI] 1.13-1.96; p=0.004), 3months (aOR 1.51; 95% CI 1.09-2.10; p=0.01), 6months (aOR 1.64; 95% CI 1.19-2.27; p=0.003), and 1year (aOR 1.52; 95% CI 1.10-2.10; p=0.01). Symptomatic ICH occurred in 3 (0.6%) patients in IV t-PA versus 2 (0.1%) in the non-IV t-PA group. No significant differences were found in all-cause mortality between the two groups. Intravenous t-PA may be safe and effective in minor stroke (NIHSS ≤ 5) within a 4.5-h window and further randomized controlled trials are warranted.

Predictors of Early Neurological Improvement and Its Relationship to Thrombolysis Treatment and Long-Term Outcome in the WAKE-UP Study

Introduction: The aims of this study were to evaluate the relationship of clinical and imaging baseline factors and treatment on the occurrence of early neurological improvement (ENI) in the WAKE-UP trial of MRI-guided intravenous thrombolysis in unknown onset stroke and to examine the association of ENI with long-term favorable outcome in patients treated with intravenous thrombolysis. Methods: We analyzed data from all patients with at least moderate stroke severity, reflected by an initial National Institutes of Health Stroke Scale (NIHSS) score ≥4 randomized in the WAKE-UP trial. ENI was defined as a decrease in NIHSS of ≥8 or a decline to zero or 1 at 24 h after initial presentation to the hospital. Favorable outcome was defined as a modified Rankin Scale score of 0–1 at 90 days. We performed group comparison and multivariable analysis of baseline factors associated with ENI and performed mediation analysis to evaluate the effect of ENI on the relationship between intravenous thrombolysis and favorable outcome. Results: ENI occurred in 93 out of 384 patients (24.2%) and was more likely to occur in patients who received treatment with alteplase (62.4% vs. 46.0%, p = 0.009), had smaller acute diffusion-weighted imaging lesion volume (5.51 mL vs. 10.9 mL, p ≤ 0.001), and less often large-vessel occlusion on initial MRI (7/93 [12.1%] versus 40/291 [29.9%], p = 0.014). In multivariable analysis, treatment with alteplase (OR 1.97, 95% confidence interval [CI] 0.954–1.100), lower baseline stroke volume (OR 0.965, 95% CI: 0.932–0.994), and shorter time from symptom recognition to treatment (OR 0.994, 95% CI: 0.989–0.999) were independently associated with ENI. Patients with ENI had higher rates of favorable outcome at 90-day follow-up (80.6% vs. 31.3%, p ≤ 0.001). The occurrence of ENI significantly mediated the association of treatment with a good outcome, with ENI at 24 h explaining 39.4% (12.9–96%) of the treatment effect. Conclusion: Intravenous alteplase increases the odds of ENI in patients with at least moderate stroke severity, especially when given early. In patients with large-vessel occlusion, ENI is rarely observed without thrombectomy. ENI represents a good surrogate early marker of treatment effect as more than a third of good outcome at 90 days is explained by ENI at 24 h.

Short-Term Complications and Outcomes in Pharmaco-Mechanical Thrombolysis First and Catheter-Directed Thrombolysis First in Patients with Acute Lower Limb Ischemia

Pharmaco-mechanical thrombolysis (PMT) has emerged as a treatment option in patients with acute lower limb ischemia (ALI), especially Rutherford IIb (motor deficit) for rapid revascularization, but supportive data is scarce. The aim of the present study was to compare the effects of thrombolysis, complications, and outcomes of PMT first versus catheter-directed thrombolysis (CDT) first in a large cohort of patients with ALI. All endovascular thrombolytic/thrombectomy events in patients with ALI performed between January 1st, 2009, and December 31st, 2018 (n=347) were included. Successful thrombolysis/thrombectomy was defined as complete or partial lysis. Reasons for using PMT were described. Complications such as major bleeding, distal embolization, and new onset of renal impairment, and major amputation and mortality at 30days were compared between PMT (AngioJet) first and CDT first groups in a multivariable logistic regression model with adjustment for age, gender, atrial fibrillation, and Rutherford IIb. The most common reason for initial use of PMT was the need for rapid revascularization, and the most common reason for use of PMT after CDT was the insufficient effect of CDT. Presentation of Rutherford IIb ALI was more common in the PMT first group (36.2% vs. 22.5%, respectively, P=0.027). Among the 58 patients receiving PMT first, 36 (62.1%) were terminated within a single session of therapy without need of CDT. The median duration of thrombolysis was shorter (P<0.001) for the PMT first group (n=58) compared to the CDT first group (n=289) (4.0hr vs. 23.0hr, respectively). There was no significant difference in amount of tissue plasminogen activator given, successful thrombolysis/thrombectomy (86.2% and 84.8%), major bleeding (15.5% and 18.7%), distal embolization (25.9% and 16.6%), major amputation or mortality at 30-days (13.8% and 7.7%) in the PMT first compared to the CDT first group, respectively. The proportion of new onset of renal impairment was higher in the PMT first compared to the CDT first group (10.3% vs. 3.8%, respectively), and the increased odds (odds ratio 3.57, 95% confidence interval 1.22-10.41) were maintained in the adjusted model. In Rutherford IIb ALI, no difference in rate of successful thrombolysis/thrombectomy (76.2% and 73.8%), complications or 30-day outcomes was found between PMT first (n=21) and CDT (n=65) first group. PMT first appears to be a good treatment alternative to CDT in patients with ALI, including Rutherford IIb. The found renal function deterioration in the PMT first group needs to be evaluated in a prospective, preferably randomized trial.

High ratio of C-reactive protein to albumin is associated with hemorrhagic transformation and poor functional outcomes in acute ischemic stroke patients after thrombolysis.

In patients with acute ischemic stroke, hemorrhagic transformation (HT) is a common complication after intravenous thrombolysis (IVT). In this study, we evaluated the relationship between the ratio of C-reactive protein to albumin (CAR) before thrombolysis, HT, and functional outcomes in patients with acute ischemic stroke. We retrospectively analyzed data from 354 patients who received thrombolytic therapy at the Second Affiliated Hospital of the Wenzhou Medical University in China between July 2014 and May 2022. CAR was measured on admission, and HT was identified by cranial computed tomography (CT) within 24-36 h after treatment. Poor outcome was defined as a score on the modified Rankin Scale (mRS) > 2 at discharge. The multivariate logistic regression model was used to investigate the association between CAR, HT, and poor outcome after thrombolysis, respectively. A total of 354 patients were analyzed, and their median CAR was 0.61 (interquartile range, 0.24-1.28). CAR was significantly higher in the 56 patients (15.8%) who experienced HT than in those who did not (0.94 vs. 0.56, p < 0.001), and the 131 patients (37.0%) who experienced poor outcome than in those who did not (0.87 vs. 0.43, p < 0.001). Multivariate logistic regression indicated that CAR was an independent risk factor for both HT and poor outcome. The risk of HT was significantly higher among patients whose CAR fell in the fourth quartile than among those with CAR in the first quartile (OR 6.64, 95% CI 1.83 to 24.17, p = 0.004). Patients with CAR in the third quartile were more likely to experience poor outcome (OR 3.35, 95% CI 1.32 to 8.51, p = 0.01), as were those in the fourth quartile (OR 7.33, 95% CI 2.62 to 20.50, p < 0.001), compared to patients with CAR in the first quartile. High ratio of C-reactive protein to albumin in individuals with ischemic stroke is associated with an increased risk of HT and poor functional outcomes after thrombolysis.

Thrombus Signal on T1-Weighted Black-Blood MR Predicts Outcomes of Catheter-Directed Thrombolysis in Acute Deep Vein Thrombosis.

Catheter-directed thrombolysis (CDT) is an effective therapy for acute deep vein thrombosis (DVT). However, predicting the CDT outcomes remains elusive. We hypothesized that the thrombus signal on T1-weighted black-blood magnetic resonance (MR) can provide insight into CDT outcomes in acute DVT patients. A total of 117 patients with acute iliofemoral DVT were enrolled for T1-weighted black-blood MR before CDT in this prospective study. Based on the signal contrast between thrombus and adjacent muscle, patients were categorized into the iso-intense thrombus (Iso-IT), hyper-intense thrombus (Hyper-IT), and mixed iso-/hyper-intense thrombi (Mixed-IT) groups. Immediate treatment outcome (i.e., vein patency) and long-term treatment outcome (i.e., the incidence rate of postthrombotic syndrome) were accessed by the same expert. Histological analysis and iron quantification were performed on thrombus samples to characterize the content of fibrin, collagen, and the ratio of Fe3+ to total iron. Compared to Mixed-IT and Hyper-IT groups, the Iso-IT group had the best lytic effect (90.5 ± 1.6% vs. 78.4 ± 2.6% vs. 46.5 ± 3.3%, p < 0.001), lowest bleeding ratio (0.0 vs. 11.8 vs. 13.3, p < 0.001), and the lowest incidence rate of postthrombotic syndrome on 24 months (3.6 vs. 18.4 vs. 63.4%, p < 0.001) following CDT. The Iso-IT group had a significantly lower ratio of Fe3+ to total iron (93.1 ± 3.2% vs. 97.2 ± 2.1%, p = 0.034) and a higher content of fibrin (12.5 ± 5.3% vs. 4.76 ± 3.18%, p = 0.023) than Hyper-IT. Thrombus signal characteristics on T1-weighted black-blood MR is associated with CDT outcomes and possesses potential to serve as a noninvasive approach to guide treatment decision making in acute DVT patients. · Thrombus signal on T1-weighted black-blood MR is associated with lytic therapeutic outcome in acute DVT patients.. · Presence of iso-intense thrombus revealed by T1-weighted black-blood MRI is associated with successful thrombolysis, low bleeding ratio, and low incidence of the postthrombotic syndrome.. · T1-weighted thrombus signal characteristics may serve as a noninvasive imaging marker to predict CDT treatment outcomes and therefore guide treatment decision making in acute DVT patients..

Clinical outcomes of AngioJet pharmacomechanical thrombectomy versus catheter-directed thrombolysis for the treatment of filter-related caval thrombosis.

The inferior vena cava filter is utilized worldwide to intercept thrombi and to reduce the risk of fatal pulmonary embolism (PE). However, filter-related thrombosis is a complication of filter implantation. Endovascular methods such as AngioJet rheolytic thrombectomy (ART) and catheter-directed thrombolysis (CDT) can treat filter-related caval thrombosis, but the clinical outcomes of both treatment modalities have not been determined. To compare the treatment outcomes of AngioJet rheolytic thrombectomy vs catheter-directed thrombolysis in patients with filter-related caval thrombosis. In this single-center retrospective study, 65 patients (34 males and 31 females; mean age: 59.0 ± 13.43 years) with intrafilter and inferior vena cava thrombosis were enrolled between January 2021 and August 2022. These patients were assigned to either the AngioJet group (n = 44) or the CDT group (n = 21). Clinical data and imaging information were collected. Evaluation measures included thrombus clearance rate, periprocedural complications, urokinase dosage, incidence of PE, limb circumference difference, length of stay, and filter removal rate. Technical success rates were 100% in the AngioJet and CDT groups. In the AngioJet group, grade II and grade III thrombus clearance was achieved in 26 (59.09%) and 14 (31.82%) patients, respectively. In the CDT group, grade II and grade III thrombus clearance was accomplished in 11 (52.38%) patients and 8 (38.10%) patients, respectively (P > 0.05).The peridiameter difference of the thigh was significantly reduced in patients from both groups after treatment (P < 0.05). The median dosage of urokinase was 0.08 (0.02, 0.25) million U in the AngioJet group and 1.50 (1.17, 1.83) million U in the CDT group (P < 0.05). Minor bleeding was shown in 4 (19.05%) patients in the CDT group, and when it was compared with that in the AngioJet group, the difference was statistically significant (P < 0.05). No major bleeding occurred. Seven (15.91%) patients in the AngioJet group had hemoglobinuria and 1 (4.76%) patient in the CDT group had bacteremia. There were 8 (18.18%) patients with PE in the AngioJet group and 4 (19.05%) patients in the CDT group before the intervention (P > 0.05). Computed tomography angiopulmonography (CTA) showed that PE was resolved after the intervention. New PE occurred in 4 (9.09%) patients in the AngioJet group and in 2 (9.52%) patients in the CDT group after theintervention (P > 0.05). These cases of PE were asymptomatic. The mean length of stay was longer in the CDT group (11.67 ± 5.34 d) than in the AngioJet group (10.64 ± 3.52 d) (P < 0.05). The filter was successfully retrieved in the first phase in 10 (47.62%) patients in the CDT group and in 15 (34.09%) patients in the AngioJet group (P > 0.05).Cumulative removal was accomplished in 17 (80.95%) out of 21 patients in the CDT group and in 42 (95.45%) out of 44 patients in the ART group (P > 0.05). The median indwelling time for patients with successful retrieval was 16 (13139) d in the CDT group and 59 (12231) d in the ART group (P > 0.05). Compared with catheter-directed thrombolysis, AngioJet rheolytic thrombectomy can achieve similar thrombus clearance effects, improve the filter retrieval rate, reduce the urokinase dosage and lower the risk of bleeding events in patients with filter-related caval thrombosis.

Clinical and radiological outcomes of adjuvant catheter-directed thrombolysis of acute iliofemoral venous thrombosis compared to standard anticoagulant therapy: a randomized controlled study

Clinical and radiological outcomes of adjuvant catheter-directed thrombolysis of acute iliofemoral venous thrombosis compared to standard anticoagulant therapy: a randomized controlled study

CATHETER DIRECTED THROMBOLYSIS IN ACUTE LIMB ISCHEMIA PATIENTS. A SINGLE CENTER’S EXPERIENCE

The aim: This study evaluates catheter-directed thrombolysis (CDT) outcomes in patients with acute lower limb arterial thrombosis and acute limb ischemia. Materials and methods: 53 patients (17 females, 36 males, aged 53-76) were studied. 57% had femoropopliteal and below-the-knee (BTK) thromboocclusion, 43% had BTK thromboocclusion. Symptoms included pain, pallor, edema, and cyanosis. Exclusions criteria: contracture, recent surgeries, bleeding. Results: In 29 (97%) patients regression of lower-limb ischemia rate by 1-2 stages according to the Rutherford classification were observed. One patient (3%) did not exhibit any regression in the degree of lower-limb ischemia, experiencing increasing pain and decreased sensitivity in the lower limb, leading to the development of contracture in the ankle joint and subsequent lower limb amputation over 7 days. Among 12 (40%) patients, after performing follow-up arteriography of the lower limb, angioplasty was performed on the diagnosed steno-occlusive lesions in the revascularized segment with secondary angioplasty. Within a year, one (3%) patient experienced recurrent thrombosis of the lower limb arteries with subsequent revascularization. Conclusions: CDT is recommended for ALI Patients with arterial thrombooclusion.