Tissue Plasminogen Activator Infusion Research Articles

Acute Sinister in Stent Thrombosis in Endovascular Stenting in SVC Syndrome Secondary to Fibrosing Mediastinitis: Emergent Catheter-Directed Thrombolysis and Outcome—A Case Report

AbstractA 40-year-old woman presented with a 4-week history of headache, facial swelling, and dyspnea. Computed tomography (CT) scan of the chest showed marked narrowing of the superior vena cava (SVC) with surrounding hypodense soft tissue and prominent collateral circulation in mediastinum, and the diagnosis of fibrosing mediastinitis was made. Biopsy suggested active fungal infection and she was treated with oral antifungal therapy. She reported persistent symptoms even after medical management; hence, she was taken for endovascular treatment with placement of a 16 × 60 mm stent (Optimed sinus-XL) in SVC. The patient complained of aggravation in symptoms immediately the next day, and a diagnostic venogram revealed acute total in-stent thrombosis. On an emergency basis, the patient was taken for catheter-directed thrombolysis (CDT) with tissue plasminogen activator (tPA) infusion. She was followed up with CT after1 year, which showed patent stent and no residual or recurrent thrombosis. She is on follow-up with marked relief in symptoms and improved quality of life. Catheter-directed thrombolysis is an emergent treatment modality with limited albeit growing evidence to treat acute in-stent thrombosis. CDT with tPA can be used to effectively treat acute thrombosis with promising results.

Systemic Thrombolysis of Acute Portal Venous System Thrombosis in Patients with Liver Cirrhosis: A Pilot Study

Background The prevalence of Portal Vein Thrombosis (PVT) is highly variable at different stages of liver disease: in compensated patients 10%, in decompensated patients 17%, in acute decompensated cirrhosis 9%, and in post-liver transplantation patients 2-26%. Aim The aim of the study was to assess the efficacy and safety of systemic thrombolysis in acute portal vein thrombosis in patients with liver cirrhosis. Methods A total of 10 compensated cirrhotic patients with acute portal vein thrombosis were examined by abdominal ultrasonography with color Doppler and Contrast-enhanced computerized tomography. Continuous intravenous infusion of recombinant tissue plasminogen activator(r-tPA.) and Low molecular weight heparin (LMWH) was used to treat all patients for a maximum of 7 days. Patients were followed up for improvement of clinical symptoms and radiological by abdominal ultrasound with color Doppler and contrast-enhanced computerized tomography. Results The regimen of therapy was found to be well-tolerated by all the patients. At the end of the seven days, six patients (60%) had full recanalization of the portal vein, while three had partial recanalization (30%) and no recanalization in only one patient (10%). Conclusion The preliminary data indicate that systemic thrombolytic therapy combined with low molecular weight heparin for the treatment of PVT appears to be safe and effective over a few days with no clinically significant side effects.

THU153 Deep Vein Thrombosis As The Presenting Symptom In An Adolescent With New-Onset Type 2 Diabetes

Abstract Disclosure: F.I. Cooper: None. S. Gurnurkar: None. M. Carakushansky: None. Introduction The prothrombin G20210A mutation occurs in a small portion of the population, but usually does not become apparent unless the individual exhibits another risk factor for clotting (such as diabetes in adulthood). In this case report, we discuss a 15-year-old male with extensive deep vein thrombosis (DVT) in the setting of hyperglycemia and a newly-discovered prothrombin G20210A mutation. Case Presentation A previously healthy, obese 15-year-old male presented to the emergency department with two days of left hip pain radiating down to the left calf, and one day of left calf swelling. The patient denied prolonged immobility, recent infections, or recent vaccinations. There was strong maternal family history of diabetes but no history of thrombosis. D-dimer was 2013 ng/mL (0-500 ng/mL). A Computed Tomography of the abdomen and pelvis with contrast revealed thrombi in the inferior vena cava, left common iliac, left external iliac, left internal iliac and left common femoral veins. Initial labs were remarkable for unexpected significant hyperglycemia-- random serum glucose 317 mg/dl (<140 mg/dl).He was started on unfractionated heparin infusion as well as Lantus and Humalog insulins. An echocardiogram did not reveal pulmonary embolism or right heart strain. Hemoglobin A1C was 11.8% (3.4-5.6%) and C-peptide was detectable at 1.2 ng/mL (1.1-4.4 ng/mL), suggesting type 2 diabetes (in addition to negative anti-GAD 65 and islet cell antibody titers, in this child with a BMI of 34 kg/m2). The patient underwent image-guided thrombolysis and thrombectomy from the popliteal vein to the left iliac vessels and received continuous infusion of heparin and tissue plasminogen activator (TPA). As the clot improved over the subsequent days, he underwent image-guided angioplasty and removal of the popliteal sheath. He was then transitioned to enoxaparin and discharged on day 10 of hospitalization. His blood sugars responded well to insulin therapy (85-308 mg/dl). The patient received a staged thrombophilia workup. A heterozygous mutation was found in factor II (prothrombin G20210A) gene which is associated with a 2-4 fold increased risk of venous thromboembolism. The patient was discharged on enoxaparin, as well as Lantus and Humalog. He is followed by the Hematology and Endocrinology departments. Conclusion In this case, we presented the first written occurrence of DVT in a pediatric patient with type 2 diabetes. Our patient’s hyperglycemia caused by his new onset type 2 diabetes may have led to onset of an extensive DVT thrombosis at an usually young age, since he had an underlying prothrombin G20210A mutation. Our case also illustrates the need for a multidisciplinary approach (involving endocrinology, hematology, pediatric intensive care, and interventional radiology) for successful outcomes in these patients. Presentation: Thursday, June 15, 2023

Rescue treatment with tPA for refractory thromboembolism during stent-assisted coiling of a ruptured intracranial aneurysm: A case report

Thromboembolic complications during stent-assisted coiling of ruptured intracranial aneurysms are major complications that can cause serious neurological deficits. Management strategies include medical thrombolysis, mechanical thrombectomy with suction aspiration or stent retrieval, and rescue stenting. The existing literature suggests that tissue plasminogen activator agents should be used cautiously because of the high risk of severe bleeding at the aneurysm. We present the case of a ruptured anterior communicating artery aneurysm. Acute in-stent thrombosis occurred during the stent-assisted coiling of the aneurysm. Rescue therapy with tirofiban, suction aspiration, and rescue stenting was attempted; however, these methods failed. Finally, tissue plasminogen activator infusion was performed, which successfully dissolved the thrombus and restored blood flow. Follow-up brain computed tomography revealed no increase in hemorrhage volume.

Transcatheter closure of patent foramen ovale using the Cocoon occluder: A multicenter retrospective study

BackgroundThe Cocoon patent foramen ovale (PFO) occluder is a new device especially designed for transcatheter closure of PFO. This occluder has some distinctive structural modifications aimed at reducing the risk of major complications of transcatheter PFO closure. In this report we present our initial experience to evaluate the efficacy and safety of the Cocoon PFO occluder in 253 patients who underwent transcatheter PFO closure. MethodsThe study cohort included 253 patients (median age 45 years) with embolic stroke of undetermined source who underwent attempted transcatheter closure of PFO for secondary prevention of paradoxical embolism. Patients were enrolled retrospectively from five sites in Greece and one in Romania between December 2016 and January 2021, and the median follow-up period was 28 months (range 12–48 months). Clinical and laboratory data from each participating center were sent to an electronic registry for evaluation and statistical analysis. ResultsThe Cocoon PFO occluder was permanently implanted in all patients. At 6 months, complete occlusion of PFO was observed in 251/253 (99.2%) patients. Three (1.2%) patients had a trivial residual shunt. Thrombus formation on the device, which was successfully treated with recombinant tissue plasminogen activator infusion, was observed in one (0.4%) patient. No other complications occurred. During a median follow-up period of 28 months, 3 (1.2%) patients, aged 64–67 years, developed new onset paroxysmal atrial fibrillation. No neurologic events, cardiac erosions, allergic reactions to nickel, or thrombus formation occurred. ConclusionThe Cocoon PFO occluder is an effective and safe device that adds to our armamentarium for transcatheter closure of PFO.

Low-dose thrombolytic therapy versus unfractionated heparin in patients with intermediate-high risk pulmonary embolism.

Patients with intermediate-high risk pulmonary embolism (PE) who have acute right ventricular dysfunction and myocardial injury without overt hemodynamic compromise may be candidates for thrombolytic therapy (TT). In this study, we aimed to compare the clinical outcomes of low-dose prolonged TT and unfractionated heparin (UFH) in intermediate-high risk PE patients. This study enrolled 83 (female: 45 [54.2%], mean age: 70.07±10.7 years) retrospectively evaluated patients with the diagnosis of acute PE who were treated with low-dose and slow-infusion of TT or UFH. The primary outcomes of the study were de-fined as a combination of death from any cause and hemodynamic decompensation, and severe or life-threatening bleeding. Secondary endpoints were recurrent PE, pulmonary hypertension, and moderate bleeding. The initial management strategy of intermediate-high risk PE was TT in 41 (49.4%) patients and UFH in 42 (50.6%) cases. Low-dose prolonged TT was successful in all patients. While the frequency of hypotension decreased significantly after TT (22 vs. 0%, P<0.001), it did not decrease after UFH (2.4 vs. 7.1%, p=0.625). The proportion of hemodynamic decompensation was significantly lower in the TT group (0 vs. 11.9%, p=0.029). The rate of secondary endpoints was significantly higher in the UFH group (2.4 vs. 19%, P=0.016). Moreover, the prevalence of pulmonary hypertension was significantly higher in UFH group (0 vs. 19%, p=0.003). Prolonged TT regimen with low dose, slow infusion of tissue plasminogen activator was found to be associated with a lower risk of hemodynamic decompensation and pulmonary hypertension in patients with acute intermediate-high-risk PE compared to UFH.

Fixed-Dose Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Pulmonary Embolism Associated with COVID-19.

Background. Fixed-dose ultrasound-assisted catheter-directed thrombolysis (USAT) rapidly improves hemodynamic parameters and reverses right ventricular dysfunction caused by acute pulmonary embolism (PE). The effectiveness of USAT for acute PE associated with coronavirus disease 2019 (COVID-19) is unknown. Methods and results. The study population of this cohort study consisted of 36 patients with an intermediate-high- or high-risk acute PE treated with a fixed low-dose USAT protocol (r-tPA 10–20 mg/15 h). Of these, 9 patients tested positive for COVID-19 and were age–sex-matched to 27 patients without COVID-19. The USAT protocol included, beyond the infusion of recombinant tissue plasminogen activator, anti-Xa-activity-adjusted unfractionated heparin therapy (target 0.3–0.7 U/mL). The study outcomes were the invasively measured mean pulmonary arterial pressure (mPAP) before and at completion of USAT, and the National Early Warning Score (NEWS), according to which more points indicate more severe hemodynamic impairment. Twenty-four (66.7%) patients were men; the mean age was 67 ± 14 years. Mean ± standard deviation mPAP decreased from 32.3 ± 8.3 to 22.4 ± 7.0 mmHg among COVID-19 patients and from 35.4 ± 9.7 to 24.6 ± 7.0 mmHg among unexposed, with no difference in the relative improvement between groups (p = 0.84). Within 12 h of USAT start, the median NEWS decreased from six (Q1–Q3: 4–8) to three (Q1–Q3: 2–4) points among COVID-19 patients and from four (Q1–Q3: 2–6) to two (Q1–Q3: 2–3) points among unexposed (p = 0.29). One COVID-19 patient died due to COVID-19-related complications 14 days after acute PE. No major bleeding events occurred. Conclusions. Among patients with COVID-19-associated acute PE, mPAP rapidly decreased during USAT with a concomitant progressive improvement of the NEWS. The magnitude of mPAP reduction was similar in patients with and without COVID-19.

Comparison of Outcomes Following Physician Directed Bolus vs. Strict Infusion Protocol of Tissue Plasminogen Activator for Thrombolytic Treatment of Pump Thrombosis

<h3>Purpose</h3> There is a lack of consistent approach to pump thrombosis (PT) in ventricular assist device (VAD) supported patients. Previously, bolus thrombolysis was administered at physicians' discretion, guided by changes in pump parameters. More recently, we adopted a strict protocol with invasive haemodynamic monitoring to target mean arterial pressure <80mmHg and continuous infusion of tissue plasminogen activator (tPA) to achieve sustained normalisation of pump flow and power derivatives. We compare outcomes following bolus protocol (BP) and strict infusion protocol (SIP). <h3>Methods</h3> Single-centre retrospective analysis of all patients treated with thrombolysis for VAD PT between 2007-2020. Patients divided into two cohorts (BP and SIP) based on PT treatment. Baseline demographics, antithrombotic therapy, pump parameters and biochemistry were collected prior to PT event, at diagnosis and following thrombolysis. Outcomes reported included need for repeated thrombolysis doses, post thrombolysis major bleeding and death, and survival to transplant. <h3>Results</h3> Mean age 51.7y, 23.5% female. All supported with Medtronic HVAD. 21 PT events in 17 patients; 10 patients with 11 cases in BP group, 7 patients with 10 cases in SIP group. SIP group had more pre-implant renal dysfunction (mean GFR 54 vs. 81ml/min/1.73m2, p=0.017), and lower stable post-implant MAP (mean 72 vs. 76, p=0.05). Repeated thrombolytic doses were never required following SIP vs. 70% following BP (p=0.01). No patients required pump exchange, however 1 in each group required urgent heart transplant listing. Numerically fewer post thrombolysis major bleeds (2 vs. 3) and deaths (0 vs. 3) following SIP compared with BP. All SIP patients survived to transplant, compared with 70% of BP patients(figure 1). <h3>Conclusion</h3> SIP is safe for treatment of PT in VAD supported patients, with excellent associated survival to transplant, and trend towards improved post-thrombolysis outcomes.

756 Self-Inflicted Frostbite with Dry Ice: A Case Report

IntroductionFrostbite (FB) is a severe form of cold injury that may result in significant morbidity. Freezing causes formation of ice crystals and protein denaturation leading to cellular damage and tissue necrosis. Although commonly affecting populations who live and work or become stranded in cold environments, the true prevalence is unknown due to lack of standardized reporting. Dry ice is a solid form of carbon dioxide commonly found in the food industry, that can reach temperatures as cold as -110 degrees Fahrenheit and can be purchased at local department stores. Exposure to dry ice is an unusual cause of FB injury that could occur anywhere, especially in warmer climates. Healthcare professionals practicing in warmer climates may be unprepared to assess and treat patients with such injuries.MethodsWe describe a case of self-inflicted FB injury to the bilateral lower extremities (BLE) following intentional submersion in dry ice who presented to a Southern U.S. Burn Unit.ResultsA 20-year-old man with self-diagnosed Body Integrity Identity Disorder (BIID) sustained a 12% TBSA FB injury to his BLE following intentional submersion in dry ice for an estimated 4 hours (Figure 1). He presented to the Burn Center from an outside facility approximately 12 hours post injury with initial rewarming having already occurred. He immediately underwent catheter directed intra-arterial thrombolysis with tissue plasminogen activator (TPA) for leg length preservation. TPA infusion was initiated at 16 hours post-injury for a total infusion time of 24 hours. Wound care consisted of gentle twice daily cleansing with silver sulfadiazine and mafenide acetate creams. The patient ultimately required bilateral below the knee amputations which successfully healed with minimal autografting to the distal limbs. He was formally diagnosed with schizophrenia by our behavioral health team and initiated on risperidone. He underwent aggressive physical therapy and was discharged home with his parents after 21 days. He underwent weekly mental health follow up appointments and has been seen regularly in our burn and rehabilitation clinic.ConclusionsThis unusual case is one of few to describe Grade 4 FB after exposure to dry ice and highlights that severe FB may occur in any climate and can cause severe morbidity. Severe cold injury management is important for burn care professionals to maximize tissue and limb preservation.

Thrombolysis or Surgery in Patients With Obstructive Mechanical Valve Thrombosis: The Multicenter HATTUSHA Study

BackgroundProsthetic valve thrombosis (PVT) is one of the life-threatening complications of prosthetic heart valve replacement. Due to the lack of randomized controlled trials, the optimal treatment of PVT remains controversial between thrombolytic therapy (TT) and surgery. ObjectivesThis study aimed to prospectively evaluate the outcomes of TT and surgery as the first-line treatment strategy in patients with obstructive PVT. MethodsA total of 158 obstructive PVT patients (women: 103 [65.2%]; median age 49 years [IQR: 39-60 years]) were enrolled in this multicenter observational prospective study. TT was performed using slow (6 hours) and/or ultraslow (25 hours) infusion of low-dose tissue plasminogen activator (t-PA) (25 mg) mostly in repeated sessions. The primary endpoint of the study was 3-month mortality following TT or surgery. ResultsThe initial management strategy was TT in 83 (52.5%) patients and surgery in 75 (47.5%) cases. The success rate of TT was 90.4% with a median t-PA dose of 59 mg (IQR: 37.5-100 mg). The incidences of outcomes in surgery and TT groups were as follows: minor complications (29 [38.7%] and 7 [8.4%], respectively), major complications (31 [41.3%] and 5 [6%], respectively), and the 3-month mortality rate (14 [18.7%] and 2 [2.4%], respectively). ConclusionsLow-dose and slow/ultraslow infusion of t-PA were associated with low complications and mortality and high success rates and should be considered as a viable treatment in patients with obstructive PVT.

Adjunctive Catheter-Directed Thrombolysis during Primary PCI for ST-Segment Elevation Myocardial Infarction with High Thrombus Burden.

Background: High coronary thrombus burden has been associated with unfavorable outcomes in patients with ST-segment elevation myocardial infarction (STEMI), the optimal management of which has not yet been established. Methods: We assessed the adjunctive catheter-directed thrombolysis (CDT) during primary percutaneous coronary intervention (PCI) in patients with STEMI and high thrombus burden. CDT was defined as intracoronary infusion of tissue plasminogen activator (t-PA; monteplase). Results: Among the 1849 consecutive patients with STEMI, 263 had high thrombus burden. Moreover, 41 patients received t-PA (CDT group), whereas 222 did not receive it (non-CDT group). No significant differences in bleeding complications and in-hospital and long-term mortalities were observed (9.8% vs. 7.2%, p = 0.53; 7.3% vs. 2.3%, p = 0.11; and 12.6% vs. 17.5%, p = 0.84, CDT vs. non-CDT). In patients who underwent antecedent aspiration thrombectomy during PCI (75.6% CDT group and 87.4% non-CDT group), thrombolysis in myocardial infarction grade 2 or 3 flow rate after thrombectomy was significantly lower in the CDT group than in the non-CDT group (32.2% vs. 61.0%, p < 0.01). However, the final rates improved without significant difference (90.3% vs. 97.4%, p = 0.14). Conclusions: Adjunctive CDT appears to be tolerated and feasible for high thrombus burden. Particularly, it may be an option in cases with failed aspiration thrombectomy.

Tissue plasminogen activator for the treatment of adults with critical COVID-19: A pilot randomized clinical trial

Tissue plasminogen activator for the treatment of adults with critical COVID-19: A pilot randomized clinical trial

The Japan Neurosurgical Database: Statistics Update 2018 and 2019.

Each year, the Japan Neurosurgical Society (JNS) reports up-to-date statistics from the Japan Neurosurgical Database regarding case volume, patient demographics, and in-hospital outcomes of the overall cohort and neurosurgical subgroup according to the major classifications of main diagnosis. We hereby report patient demographics, in-hospital mortality, length of hospital stay, purpose of admission, number of medical management, direct surgery, endovascular treatment, and radiosurgery of the patients based on the major classifications and/or main diagnosis registered in 2018 and 2019 in the overall cohort (523283 and 571143 patients, respectively) and neurosurgical subgroup (177184 and 191595 patients, respectively). The patient demographics, disease severity, proportion of purpose of admission (e.g., operation, 33.9–33.5%) and emergent admission (68.4–67.8%), and in-hospital mortality (e.g., cerebrovascular diseases, 6.3–6.5%; brain tumor, 3.1–3%; and neurotrauma, 4.3%) in the overall cohort were comparable between 2018 and 2019. In total, 207783 and 225217 neurosurgical procedures were performed in the neurosurgical subgroup in 2018 and 2019, respectively, of which endovascular treatment comprised 19.1% and 20.3%, respectively. Neurosurgical management of chronic subdural hematoma (19.4–18.9%) and cerebral aneurysm (15.4–14.8%) was most common. Notably, the proportion of management of ischemic stroke/transient ischemic attack, including recombinant tissue plasminogen activator infusion and endovascular acute reperfusion therapy, increased from 7.5% in 2018 to 8.8% in 2019. The JNS statistical update represents a critical resource for the lay public, policy makers, media professionals, neurosurgeons, healthcare administrators, researchers, health advocates, and others seeking the best available data on neurosurgical practice.

Effects of Early Changes in Blood Pressure During Intravenous Thrombolysis on the Prognosis of Acute Ischemic Stroke Patients.

Background: Intravenous thrombolysis (IVT) therapy is currently one of the best medical treatments available for patients with acute ischemic stroke. Studies have shown that blood pressure (BP) changes in patients treated with IVT are significantly correlated with prognosis.Objective: Our study aimed to determine the relationship between BP changes during recombinant tissue plasminogen activator (rt-PA) infusion and the 3-month prognosis evaluated using the modified Rankin Scale (mRS) and determine the factors influencing BP changes during rt-PA infusion.Methods: Consecutive patients who were treated with IVT and admitted to our stroke center between May 2015 and October 2017 were analyzed retrospectively. Patients were divided into two groups according to their 3-month prognosis status: patients with mRS ≤ 2 were defined as “favorable outcome group” and those with mRS ≥ 3 as “unfavorable outcome group”. First, the factors affecting prognosis after thrombolysis were analyzed. Second, we analyzed the relationship between BP and the prognosis. BP was taken before and at regular intervals of 15 min during the rt-PA infusion (1 h). The average value of BP during thrombolysis was calculated and compared to the baseline BP. BP decrease was defined as the difference between the baseline BP and the average BP, provided it was greater than 0 mmHg. Third, univariate and multivariate analyses were performed to identify factors that may contribute to BP decrease.Results: In total, 458 patients were included. Patients with a lower baseline National Institute of Health Stroke Scale (NIHSS) score (8.25 ± 5.57 vs. 13.51 ± 7.42, P < 0.001), a higher Alberta Stroke Program Early CT Score (ASPECTS; 8.65 ± 1.82 vs. 8.13 ± 2.00, P = 0.005), decreased BP during thrombolysis (69.4% vs. 59.8%, P = 0.037), and steady BP (SD < 10 mmHg) were more likely to have a favorable outcome (73.9% vs. 60.6%, P = 0.019). High baseline BP (OR > 1), hypertension history (OR < 1), and baseline ASPECTS (OR > 1) were independent factors of BP change during thrombolysis.Conclusion: Patients with decreased or steady BP during thrombolysis were more likely to have a favorable outcome. Baseline ASPECTS, baseline NIHSS score, and hypertension history influenced BP changes during thrombolysis.

A Stepwise Approach to Left Ventricular Assist Device Pump Thrombosis

Pump thrombosis (PT) is a detrimental complication of left ventricular assist device (LVAD) therapy. There is no consensus on optimal PT treatment. The aim of this study was to present a treatment strategy for patients with PT. The hospital records of patients who underwent isolated LVAD implantation between May 2013 and October 2018 were retrospectively evaluated. Pump thrombosis was suspected in the setting of impaired flow/power parameters and haemolysis. Protocols for the management of suspected PT varied by patient presentation. Parameters that increased the PT risk were investigated by dividing the patients into two groups according to the presence of PT. Preoperative and operative data were analysed. Pump thrombosis was observed in 20 of 81 patients. All patients with PT presented elevated lactate dehydrogenase levels and higher power and/or low-/high-flow alarm at admission. All patients were treated initially with intravenous unfractionated heparin infusion; three patients did not require further treatment, one patient died due to sudden cardiac arrest, and three patients underwent urgent surgery for LVAD exchange. Thirteen (13) patients received tissue plasminogen activator infusion; eight were discharged without any signs of thrombosis, and three were bridged to transplant. One (1) major bleeding event leading to death was observed. Freedom from second PT was found in 91% cases at 6 months and in 68.2% at 1 year. We found that a larger left ventricle and the type of pump determined the risk of PT. Low-dose thrombolytic therapy should be considered as a feasible treatment option for patients with PT.

Fast-track thrombolysis protocol for acute limb ischemia

ObjectiveCatheter-directed thrombolysis in the treatment of acute lower extremity arterial occlusions often requires several interventional sessions to generate successful outcomes. It is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the fast-track thrombolysis protocol for arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. MethodsA retrospective study of 42 patients who were treated for acute limb ischemia at our institution by FTTP-A from January 2014 to February 2019 was performed. FTTP-A includes periadventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanical rheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and (if deemed necessary) placement of a stent in an area of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus is cleared, patients are prescribed an oral anticoagulant agent. ResultsPrimary FTTP-A (50 total interventions) was performed in 42 patients. The median age of patients was 67.2 ± 12.2 years (range, 41-98 years), and 54.8% were male; 59.5% of the procedures were performed on the left lower extremity. Initial arterial access was obtained through the common femoral artery in 39 of 42 cases (92.9%); in the remaining 3 cases, it was obtained in a left bypass access site, a right femoral-popliteal graft, and a right femoral-femoral graft. The mean operative time was 148.9 ± 62.9 minutes (range, 83-313 minutes), and the mean volume of tissue plasminogen activator infused was 9.7 ± 4.0 mg (range, 2-20 mg). The median cost including medications and interventional tools was $4673.19 per procedure. The mean postoperative LOS was 3.1 ± 4.5 days (range, 1-25 days). Median postoperative LOS was 1 day. Mean postoperative follow-up was 27 ± 19.2 months (range, 0-62 months). Single-session FTTP-A was successful in 81% (n = 34/42) of patients; the remaining 8 patients (19%) required a single additional session. Of the 42 patients, 34 (81%) required arterial stenting. Periprocedural complications consisted of one patient with hematuria, which resolved, and one patient with thrombocytopenia, which resolved. No patients experienced rethrombosis within 30 days of FTTP-A. During the 5-year study period, there was no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. ConclusionsFTTP-A appears to be a safe, efficacious, and cost-effective procedure in the resolution of acute lower extremity arterial occlusions.

Clinical features and efficacy of reperfusion therapy in minor ischemic stroke patients with atrial fibrillation.

The efficacy of reperfusion therapy (RT) using intravenous infusion of recombinant tissue plasminogen activator and/or endovascular therapy for minor ischemic stroke (MIS) has not yet been established. The present study aimed to elucidate the clinical features of MIS patients with atrial fibrillation (AF) and examine whether they could be potential candidates for RT. Data of MIS patients, defined as those with a score ≤ 5 on the National Institute of Health Stroke Scale, were extracted from patients admitted to our hospital between 2006 and 2018, and clinical characteristics were compared between the AF and non-AF groups. Thereafter, the impact of RT on outcomes in the AF- group was evaluated using the modified Rankin scale (mRS) score 3months after onset and compared to that of standard medical therapy (SMT) using propensity score matching (PSM). Of 10,483 stroke patients, 3003 were shortlisted, and 457 AF patients and 2546 non-AF patients were finally selected. Patients in the AF group had more RT (13.3% vs. 5.7%, p < 0.001) than those in the non-AF group. Using PSM, 53 patients each were extracted from the AF-RT and AF-SMT groups. The frequencies of mRS = 0 or 1 for the AF-RT and AF-SMT groups were 69.8% and 64.2% (p = 0.536), respectively, with a significant difference in mRS = 0 (56.5% vs. 34.0%, p = 0.019). The present study found that MIS patients with AF underwent more RT than those without AF and that RT compared favorably with SMT for them; further study is warranted to examine whether these patients could be good candidates for RT.

Abstract TP170: Dihomo-Gamma-Linolenic Acid Decreases Hemorrhagic Complications in Acute Ischemic Stroke

Introduction: Dihomo-gamma-linolenic acid (DHLA) is an omega-6 essential fatty acid related to thrombotic diseases. There are many reports about the ratio of eicosapentaenoic acid to arachidonic acid which associates with coronary and brain ischemia. But there is no report focusing on DHLA and acute ischemic stroke (AIS). We report a new correlation between DHLA and hemorrhagic complications (HC). Method: We conducted a retrospective single center case-controlled study in Japan. Among all cases of AIS from January 2015 to May 2019, we selected those who had intravenous infusion of tissue plasminogen activator (tpa) with or without endovascular treatment (EVT). Tpa was administered at 0.6mg / kg according to guidelines in Japan. Intracranial hemorrhage confirmed by imaging within 24 hours after tpa was defined as HC. We considered the patient background including lipids and outcomes: mRS0-2 after 90 days, recurrence within 30 days, any complications. We also divided all cases into two groups; the presence (A) or absence (B) of HC, and examined factors that contribute to HC. Lipid fractions (DHLA, AA, EPA, docosahexaenoic acid) were measured before tpa. Result: In the eligible 111 patients, 59 were male, and the median age was 77.4±11.5 years old. There were 30 cases of HC (A); HC within infarction (14), beyond or other than infarction (7), SAH associated with EVT (9), traumatic (0). There were significant differences between two groups: age(median, A:85.0, B:75.0[p&lt;0.001]), Alb(median, A:3.70, B:3.95mg/dL[p=0.0172]), D dimer (median, A:1.95, B:1.10μg/mL[p=0.0254]), DHLA (A:32.0, B:43.5μg/mL[p=0.0295]), eGFR (median A:54.9, B:64.0 [p=0.0129]), and NIHSS (median A:17.5, B:9.0 [p&lt;0.001]). The mRS0-2 after 90 days was 7/30 (23.3%) in A, and 51/81(62.9%) in B [p&lt;0.001].There were no significant differences in clinical type of AIS, lipids other than DHLA, and recurrence of stroke within 30 days. Conclusion: DHLA, age, D dimer, and renal function were significantly associated with HC in resuscitation therapy for AIS. The prognosis was poor in cases of HC. We emphasize DHLA as a new finding. DHLA may be related to vascular vulnerability. There is a possibility that early improvement of DHLA can reduce HC, lead to good prognosis, and decrease the cost.

Abstract TP159: Unilateral Spatial Neglect as an Independent Prognostic Factor for Poor Fim Efficiency in Patients With Mild to Moderate Ischemic Stroke

Background and Purpose: Unilateral spatial neglect (USN) is often observed in ischemic stroke patients suffered their right parietal lobe. USN is an obstacle to undergo rehabilitation smoothly, then might influence the recovery of activities of daily living (ADL) after stroke. We aimed to clarify the association between the presence of USN after ischemic stroke and the ADL improvement. Methods: Consecutive patients with first-ever ischemic stroke and left limb paralysis who admitted to within 7 days from onset during February 2011 and March 2019 were included. Patients met the following criteria were excluded: mRS ≥3 before onset, NIHSS &gt;15 on admission, without left limb paralysis, and missing NIHSS or functional independence measure (FIM) score on admission. Multiple regression analysis was performed to investigate the association between FIM efficiency score of acute phase and following factors: age, sex, acute reperfusion therapy (using an intravenous infusion of recombinant tissue plasminogen activator and/or endovascular therapy), FIM score on admission, and other clinical characteristics. All data were collected retrospectively using our electrical health record. Results: 721 ischemic stroke patients with left limb paralysis (320 women, median age 76) were included. Median FIM efficiency score was significantly lower in patients with USN than without USN (n=240, 481; 0.83 vs 1.63, respectively). Multiple regression analysis showed that USN, age, and acute reperfusion therapy were significant prognostic factors of FIM efficiency (coefficient and 95% confidence interval [CI]: -0.135 [-0.771 to -0.153], -0.106 [-0.022 to -0.002], and 0.224 [0.136 to 0.305], respectively). Conclusions: USN significantly influence the recovery of ADL after ischemic stroke. Clinicians should adequately evaluate USN after stroke and undergo USN-specific rehabilitation for them to optimize the effect of post-stroke rehabilitation. USN-specific rehabilitation might lead to better FIM efficiency.

Organizing Healthcare for Optimal Acute Ischemic Stroke Treatment.

Stroke is a major health-care problem that represents a leading cause of death and also the top cause of disability in adulthood. In recent years there has been a significant paradigm shift in treatments for acute ischemic stroke to favor earlier reperfusion therapy, mainly using the systemic infusion of recombinant tissue plasminogen activator. Subsequent trials found that combining this treatment with endovascular therapy was effective in selected patients. The increased complexity of acute stroke treatments has resulted in a substantial reorganization of stroke care. This review reports on the evolution of acute ischemic stroke treatment and describes the main organizational models based on the hub-and-spoke system. The lack of evidence for comparisons of the effectiveness of different paradigms means that some decision-analysis models predicting the best organizational pathways are also reported, with a particular emphasis on the workflow timing in the prehospital and in-hospital settings. Major benchmarks and performance measures are also reported, focusing on the timing of interventions and rates of process indicators. Finally, future directions are illustrated, including using telemedicine for stroke, mobile stroke units, and artificial intelligence and automated machines to produce software for detecting large-vessel occlusion.