Use Of Mechanical Thrombectomy Research Articles

Pretreatment predictors of very poor clinical outcomes in medium vessel occlusion stroke patients treated with mechanical thrombectomy.

Acute ischemic stroke (AIS) from primary medium vessel occlusions (MeVO) is a prevalent condition associated with substantial morbidity and mortality. Despite the common use of mechanical thrombectomy (MT) in AIS, predictors of poor outcomes in MeVO remain poorly characterized. In this prospectively collected, retrospectively reviewed, multicenter, multinational study, data from the MAD-MT (Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy) registry were analyzed. The study included 1568 patients from 37 academic centers across North America, Asia, and Europe, treated with MT, with or without intravenous tissue plasminogen activator (IVtPA), between September 2017 and July 2021. Among the 1568 patients, 347 (22.2%) experienced very poor outcomes (modified Rankin score (mRS), 5-6). Key predictors of poor outcomes were advanced age (odds ratio (OR): 1.03; 95% confidence interval (CI): 1.02 to 1.04; p < 0.001), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (OR: 1.07; 95% CI: 1.05 to 1.10; p < 0.001), pre-operative glucose levels (OR: 1.01; 95% CI: 1.00 to 1.02; p < 0.001), and a baseline mRS of 4 (OR: 2.69; 95% CI: 1.25 to 5.82; p = 0.011). The multivariable model demonstrated good predictive accuracy with an area under the receiver-operating characteristic (ROC) curve of 0.76. This study demonstrates that advanced age, higher NIHSS scores, elevated pre-stroke mRS, and pre-operative glucose levels significantly predict very poor outcomes in AIS-MeVO patients who received MT. These findings highlight the importance of a comprehensive risk assessment in primary MeVO patients for personalized treatment strategies. However, they also suggest a need for cautious patient selection for endovascular thrombectomy. Further prospective studies are needed to confirm these findings and explore targeted therapeutic interventions.

Predictors of In-Hospital Mortality after Thrombectomy in Anterior Circulation Large Vessel Occlusion: A Retrospective, Machine Learning Study.

Despite the increased use of mechanical thrombectomy (MT) in recent years, there remains a lack of research on in-hospital mortality rates following the procedure, the primary factors influencing these rates, and the potential for predicting them. This study aimed to utilize interpretable machine learning (ML) to help clarify these uncertainties. This retrospective study involved patients with anterior circulation large vessel occlusion (LVO)-related ischemic stroke who underwent MT. The patient division was made into two groups: (I) the in-hospital death group, referred to as miserable outcome, and (II) the in-hospital survival group, or favorable outcome. Python 3.10.9 was utilized to develop the machine learning models, which consisted of two types based on input features: (I) the Pre-MT model, incorporating baseline features, and (II) the Post-MT model, which included both baseline and MT-related features. After a feature selection process, the models were trained, internally evaluated, and tested, after which interpretation frameworks were employed to clarify the decision-making processes. This study included 602 patients with a median age of 76 years (interquartile range (IQR) 65-83), out of which 54% (n = 328) were female, and 22% (n = 133) had miserable outcomes. Selected baseline features were age, baseline National Institutes of Health Stroke Scale (NIHSS) value, neutrophil-to-lymphocyte ratio (NLR), international normalized ratio (INR), the type of the affected vessel ('Vessel type'), peripheral arterial disease (PAD), baseline glycemia, and premorbid modified Rankin scale (pre-mRS). The highest odds ratio of 4.504 was observed with the presence of peripheral arterial disease (95% confidence interval (CI), 2.120-9.569). The Pre-MT model achieved an area under the curve (AUC) value of around 79% utilizing these features, and the interpretable framework discovered the baseline NIHSS value as the most influential factor. In the second data set, selected features were the same, excluding pre-mRS and including puncture-to-procedure-end time (PET) and onset-to-puncture time (OPT). The AUC value of the Post-MT model was around 84% with age being the highest-ranked feature. This study demonstrates the moderate to strong effectiveness of interpretable machine learning models in predicting in-hospital mortality following mechanical thrombectomy for ischemic stroke, with AUCs of 0.792 for the Pre-MT model and 0.837 for the Post-MT model. Key predictors included patient age, baseline NIHSS, NLR, INR, occluded vessel type, PAD, baseline glycemia, pre-mRS, PET, and OPT. These findings provide valuable insights into risk factors and could improve post-procedural patient management.

Symptomatic intracerebral hemorrhage in proximal and distal medium middle cerebral artery occlusion patients treated with mechanical thrombectomy

BackgroundAcute ischemic stroke (AIS) caused by distal medium vessel occlusions (DMVOs) represents a significant proportion of overall stroke cases. While intravenous thrombolysis (IVT) has been a primary treatment, advancements in...

Evaluating high-flow oxygen therapy after mechanical thrombectomy under general anesthesia in acute ischemic stroke: A retrospective single-center study

BackgroundThe use of mechanical thrombectomy for acute intracranial vascular occlusion under general anesthesia with endotracheal intubation is well-established as a safe and effective method. However, the process of extubation post-surgery presents challenges for certain patients. This retrospective study assesses the safety and efficacy of combining mechanical ventilation with high-flow oxygen inhalation as an interim strategy, while also examining its impact on long-term clinical outcomes. MethodsThis research enrolled 119 patients with acute intracranial large vessel occlusion who underwent mechanical thrombectomy under general anesthesia with tracheal intubation between January 2020 and November 2023. Participants were categorized into two groups: Group 1 (n=55), which received high-flow oxygen (HFO) post-extubation, and Group 2 (n=64), which was treated with routine oxygen supplementation (RO). The study compared reintubation and tracheotomy rates between these groups to determine safety and effectiveness. Additionally, it analyzed long-term clinical outcomes by comparing NIHSS and mRS scores before treatment and at 90-day follow-up. ResultsThe reintubation rate post-extubation was significantly lower in the HFO group (12.7 %, n=7) compared to the RO group (31.2 %, n=20, p=0.016). The incidence of tracheotomy within 7 days was also reduced in the HFO group compared to the RO group (7.3 %, n=4 vs 20.3 %, n=13, p=0.043). Moreover, a greater proportion of patients in the HFO group achieved mRS scores of 0–2 at 90 days post-stroke than those in the RO group (60 %, n=33 vs 40.6 %, n=26, p=0.035). The median NIHSS score at 90 days was more favorable in the HFO group than in the RO group (6, IQR [1–18] vs 8, IQR [1–20], p=0.005). ConclusionThe study suggests that high-flow oxygen therapy after mechanical thrombectomy under general anesthesia with tracheal intubation may lessen the need for reintubation and tracheotomy, potentially leading to improved long-term prognosis.

Trends in Percutaneous Device Use for the Treatment of Venous Thromboembolism Over Time in the PINC AI Healthcare Database and the National Inpatient Sample

The number of different methodologies of reperfusion therapy to treat venous thromboembolism (VTE) has increased substantially. Nevertheless, investigation of data representativeness and device-level usage in administrative databases has been limited. Using the National Inpatient Sample (NIS) and the PINC AI Healthcare Database (PHD), all hospital encounters with a diagnosis code of VTE were identified between 1/1/2016 and 12/31/2020. Patient demographics and trends in treatment modalities were evaluated over time. An algorithm was developed to identify specific devices used for VTE treatment in the PHD cohort. 145,870 VTE patients treated with reperfusion therapy were identified in the NIS (Pulmonary embolism (PE): 88,725; isolated DVT (iDVT): 57,145) and 39,311 in the PHD (PE: 25,383; iDVT: 13,928). Patient demographics were qualitatively similar in the NIS and PHD. Over time, there was a significant increase in the use of mechanical thrombectomy (MT) in the PE and iDVT populations (p<0.05 in both databases) with catheter directed thrombolysis (CDT) use plateauing in PE (p=0.83 and p=0.14 in NIS and PHD respectively) and significantly decreasing for the iDVT population (p<0.05 in both databases). In the PHD cohort, specific reperfusion devices were identified in 14,105 patients (PE: 9,098; iDVT: 5,007). In conclusion, the use of MT for the treatment of VTE has increased over time, while rates of CDT therapy have remained stagnant or decreased. Further research is needed to understand the uptake of these treatment modalities as well as the unique abilities of the PHD to study specific device therapy in the VTE population.

Endovascular revascularization of vertebrobasilar tandem occlusions in comparison to isolated basilar artery occlusions: A multi-center experience.

Acute basilar artery occlusion (BAO) is a severe disease that is associated with an 85% mortality rate if untreated. Several studies have analyzed the use of mechanical thrombectomy (MT) in the different scenarios of BAO. However, the results remain conflicting and the role of MT as standard of care for vertebrobasilar tandem occlusions (VBTO) has not been confirmed. Our goal was to assess technical feasibility, safety, and functional outcome of endovascular treatment of VBTO in comparison to isolated BAO (IBAO). We retrospectively reviewed all prospectively collected patients with acute BAO from six tertiary centers between September 2016 and November 2021. Patients were subsequently divided into two groups: VBTO and IBAO. Baseline data, procedural details, and outcomes were compared between groups. A total of 190 patients were included, 55 presenting with a VBTO and 135 with IBAO. Successful recanalization was equally common in both groups (89.1% and 86.0%). Rates of favorable functional outcome (modified Rankin Scale: 0-2) were higher in patients with VBTO compared to IBAO (36.4% vs. 25.2%, p = 0.048) and mortality was lower (29.1% vs. 33.3%). However, these associations faded after adjustment for confounders (adjusted odds ratio [aOR] 0.86, 95% CI 0.35-2.05; aOR 0.93, 95% CI 0.35-2.45). Rates of symptomatic intracranial hemorrhage did not differ between the groups (VBTO: 7.3% vs. IBAO: 4.2%; p = 0.496). Endovascular treatment of VBTO is technically feasible and safe with similar rates of successful recanalization, favorable functional outcome, and mortality to those in patients with IBAO.

Systematic Review and Case of Thrombectomy for Pediatric Stroke Due to Myxoma Embolism

BackgroundStroke presentation secondary to a cardiac myxoma thromboembolism are rare in the pediatric population. Because of its rarity, the reported cases in the literature are primarily case reports. Additionally, general pediatric stroke management lacks evidence-based guidelines because of its low incidence and lack of clinical trials. In pediatric strokes identified from a cardiac myxoma, the incidence favors boys with classical presentation of unilateral weakness and aphasia. We present a pediatric patient who presented with stroke-like symptoms secondary to an intracranial embolus from a previously undiagnosed cardiac myxoma. MethodsWe performed a systematic review by searching PubMed, Google Scholar, Web of Science, and Embase databases for cases of pediatric myxoma causing stroke (n=2431) and identified 19 reported uses of surgical management in treating pediatric patients who present with stroke symptoms secondary to a cardiac myxoma thromboembolism. ResultsThe most common imaging modality was MRI in 42% of cases, CT in 36.8%, followed by CTA in 31.6% of cases. Of these 19 children treated with procedures, 36.8% of pediatric patients aged between 4 and 14 years underwent neurosurgery (n=7). ConclusionsWe describe an urgent mechanical thrombectomy, share preoperative and postoperative images and pathology slides confirming a stroke from myxoma origin. We provide added insight in the safe use of mechanical thrombectomy as treatment for pediatric strokes secondary to a thromboembolism.

Influence of Activated Protein C Resistance on Short-Term Hospital Outcomes Following Admission for Acute Ischemic Stroke in the United States

Introduction: Activated protein C (APC) plays a crucial role in breaking down factor Va and VIIIa, preventing excessive blood clotting. APC resistance occurs when protein C is unable to degrade these factors, leading to a higher risk of thrombosis. This condition can be either hereditary or acquired, with the most common cause being the factor V Leiden mutation. While previous studies have indicated that APC resistance increases the likelihood of acute ischemic stroke (AIS), their specific outcomes have not been extensively studied. Our research aims to bridge this gap via a national study. Methods: We used hospital records via the National Inpatient Sample (NIS) for our study. It consists of de-identified in-patient data, released on an annual basis by HCUP, AHRQ, and collaborating hospitals. Patients admitted with a primary diagnosis of AIS were recruited. We excluded all hospitalizations of ages &amp;lt;18 years. The impact of APCR status on outcomes and in-hospital complications such as acute kidney injury (AKI), myocardial infarction (MI), thrombolysis, mechanical thrombectomy (MT), vasopressor use, seizures, unfavorable discharge (discharge to another center such as short-term hospital, skilled nursing facility, intermediate care facility, and another type of facility) was studied using multivariable regression analysis, while adjusting for the impact of several potential patient and hospital characteristics. Results: Our selection criteria identified 2631890 admissions for AIS between 2016-2020, including 5910 (0.2%) patients also reporting a diagnosis of APCR (Table 1). In addition, APCR patients were younger (mean age 60.1 vs. 70.1 years, p&amp;lt;0.01) with a lower mean Charlson Comorbidity Index (CCI) score (3.50 vs. 3.87, p&amp;lt;0.01), and showed higher odds of a history of prior stroke (19.3% vs. 15.4%, aOR 1.482, 95% CI 1.387-1.584, p&amp;lt;0.01). While both groups were primarily covered by Medicare (65.0% in non-APCR group and 47.3% in APCR patients), a higher proportion of patients with APCR were also covered by private insurance (33.0% vs 19%, p&amp;lt;0.01). The APCR group also showed a higher prevalence of Whites (85.9% vs. 68.2%, p&amp;lt;0.01). Most cases in both cohorts were treated in Urban teaching centers. While higher prevalences of smoking(43.2% vs. 39.8%, p&amp;lt;0.01), obesity (20.3% vs. 14.5%, p&amp;lt;0.01), and drug abuse (4.4% vs. 2.8%, p&amp;lt;0.01) were seen in APCR patients, they also expressed fewer cases of cirrhosis (0.3% vs. 0.7%, p&amp;lt;0.01), diabetes (30.6% vs 39.2%, p&amp;lt;0.01), hypertension (51.9% vs 58.2%, p&amp;lt;0.01), chronic kidney disease (13.7% vs 18.3%, p&amp;lt;0.01), atrial fibrillation (18.8% vs 24.9%, p&amp;lt;0.01), and lipid disorder (53.8% vs 60.3%, p&amp;lt;0.01). After careful adjustments of confounders, APCR patients showed a higher use of mechanical thrombectomy (aOR 1.523, 95% CI 1.374-1.689, p&amp;lt;0.01) and vasopressor use (aOR 1.877, 95% CI 1.435-2.455, p&amp;lt;0.01) and also reported higher odds of seizures (aOR 1.413, 95% CI 1.265-1.578, p&amp;lt;0.01) and unfavorable discharge (aOR 1.065, 95% CI 1.006-1.128, p=0.03). However, lower odds of acute kidney injury (aOR 0.87, 95% CI 0.794-0.952, p&amp;lt;0.01) and death(aOR 0.708, 95% CI 0.597-0.838, p&amp;lt;0.01) were noted. No differences in events of MI (aOR 1.161, 95% CI 0.994-1.358, p=0.06) and thrombolysis (aOR 0.94, 95% CI 0.863-1.024, p=0.159) use were seen between the two groups. Conclusion: The study reported higher short-term outcomes, including increased use of mechanical thrombectomy and vasopressors and higher odds of seizures and unfavorable discharge in APCR patients with acute stroke. However, no similar increased odds of in-patient death, acute kidney injury, thrombolysis, and myocardial infarction were noted. While the impact of APCR on stroke recurrence has been highly debated in prior studies, our analysis provides a novel update showing an increased risk of subsequent stroke in patients with a history of stroke. Encouraging more extensive studies in a clinical setting, with larger groups of people and more extended observation periods, can provide a clearer understanding of the situation and thus improve their long-term outcomes.

Mechanical thrombectomy for acute pulmonary embolism in lung transplant recipients

The rates of pulmonary embolism (PE) are high among lung transplant (LT) recipients. Management is challenging because of elevated bleeding risks and inadequacy of conventional PE risk stratification tools. New percutaneous large bore mechanical thrombectomy catheters are being increasingly used effectively to debulk thrombus and restore flow immediately. We describe the use of mechanical thrombectomy (MT) in 8 LT recipients. All patients were diagnosed with intermediate/high-risk proximal PE involving the allograft and underwent successful MT within 30hours of diagnosis. Estimated blood loss was between 200 and 450cc, with 3 patients requiring blood transfusions. Improvement in heart rate and oxygenation was seen in all 8 patients after the procedure. In the 30days after MT, 7 of 8 patients survived. One patient died from major bleeding occurred 16 days after MT and 5 days after venoarterial extracorporeal membrane oxygenator decannulation. Mechanical thrombectomy may provide a feasible management strategy in select LT recipients with pulmonary embolism.

Cardiovascular collapse during mechanical thrombectomy for acute pulmonary embolism and the role of extracorporeal membrane oxygenation in patient rescue

BackgroundDriven by the ability to avoid thrombolytics and provide a one stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for the treatment of intermediate-to-high risk pulmonary embolism (PE). This study investigated the incidence and outcomes of cardiovascular collapse during MT procedures and demonstrates the role of extracorporeal membrane oxygenation (ECMO) in salvaging patients. MethodsThis single-center retrospective review included patients with PE undergoing MT with the FlowTriever device between 2017 and 2022. Patients presenting periprocedural cardiac arrest were identified and their perioperative characteristics and postoperative outcomes were evaluated. ResultsA total of 151 patients with a mean age of 64 ± 14 years who presented with intermediate-to-high risk PE received LBAT procedures during the study period. The simplified PE severity score was ≥1 in 83% of cases and the average RV/LV ratio was 1.6 ± 0.5, with and elevated troponin in 84%. Technical success was achieved in 98.7% and a significant decrease in pulmonary artery systolic pressure (PASP) was observed (37 mm Hg vs 56 mm Hg; P < .0001). Intraoperative cardiac arrest occurred in nine patients (6%). These patients were more likely to present PASP of ≥70 mm Hg (84% vs 14%; P < .001), were more hypotensive upon admission (systolic of 94 ± 14 mm Hg vs 119 ± 23 mm Hg; P = .004), presented lower oxygen saturation levels (87 ± 6% vs 92 ± 6%; P = .023) and were more likely to present with a history of recent surgery (67% vs 18%; P = .004). Four patients were rescued successfully with ECMO and their residual PE was subsequently removed before discharge by surgical embolectomy in two of the four cases and repeat MT in the other two. All five patients (3%) who did not receive ECMO support expired intraoperatively. The overall 30-day mortality was 8% with no death occurring in patients who were salvaged with ECMO. ConclusionsLarge-bore aspiration thrombectomy for acute PE is associated with favorable technical outcomes, but the concern for acute cardiac decompensation is non-negligible in patients presenting with high-risk features and a PASP of ≥70 mm Hg. ECMO can help to salvage some of these patients and should be considered in the treatment algorithms of patients deemed at high risk.

March 2023 Stroke Highlights.

March 2023 Stroke Highlights.

Abstract Number ‐ 122: Minimally symptomatic left M1 occlusion from carotid web

Introduction Minimally symptomatic large vessel occlusion (LVO) is an area of prognostic and management uncertainty. Current guidelines recommend thrombectomy only for patients with NIHSS of 6 or greater when additional timeline and imaging criteria are met. However, patients with initial mild or rapidly improving symptoms with LVO can eventually deteriorate, raising the question of whether all patient with acute LVO should be offered thrombectomy. Methods We present a case of minimally symptomatic M1 occlusion due to ipsilateral carotid web managed without thrombectomy. Results A 42‐year‐old woman with Systemic Lupus Erythematosus (SLE) and hypertension presented to an outside hospital with sudden transient left monocular vision loss, aphasia, right‐side weakness, and dizziness. At the time of presentation (1h from LKW) exam revealed only mild aphasia (NIHSS 1) with normal blood pressure. CTA demonstrated left M1 occlusion with reconstitution of flow at the M2 bifurcation. She was given IV Alteplase and transferred to our center. On 7 h from LKW repeat imaging demonstrated persistence of the left M1 occlusion with an ipsilateral near‐occlusion suspicious for carotid web at the ICA origin, but exam was without deficit. She was monitored closely for neurological deterioration, but remained without significant symptoms. MRA taken the next day demonstrated complete recanalization of the left M1. She was taken to the angiography suite on an outpatient basis for stenting of the carotid web at the origin of the internal carotid artery. Initial diagnostic angiogram revealed near occlusion of the ICA at the origin with post‐stenotic dilation, which was treated with angioplasty and stenting with distal embolic protection. She has remained stable to 8‐month follow‐up with no recurrent stroke. Conclusions Minimally symptomatic LVO presents significant endovascular management uncertainty. While clinical trials support the use of mechanical thrombectomy for significantly symptomatic patients, there is no consensus to guide treatment decisions for patients with minimal symptoms. This uncertainty is driven at least in part by an inability to reliably distinguish between patients who are likely to progress and would benefit from intervention before their collateral circulation fails, and those who will recanalize or develop a compensated chronic occlusion. In this case, our patient received tPA and saw symptom improvement, but this did not remove her M1 occlusion. Angiographic investigation was limited as the patient was asymptomatic, however non‐invasive imaging revealed robust collateralization including reconstitution of MCA flow and left ICA injection failed to opacify the ipsilateral ACA despite patency in recent CT angiography, indicating a right to left flow dominance in circle of Willis collaterals. We opted for close monitoring with follow‐up imaging and outpatient correction of the carotid web, which resulted in a positive outcome. More work is needed to establish criteria to predict which patients with minimally symptomatic LVO are likely to progress.

Cardiovascular Collapse During Mechanical Thrombectomy for Acute Pulmonary Embolism: The Role of Extracorporal Membrane Oxygenation in Patient Rescue

Driven by the ability to avoid thrombolytics and provide a one-stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for the treatment of massive or submassive pulmonary embolism (PE), as well as their widespread adoption by different levels of health care organizations. This study investigated the incidence and outcomes of severe cardiovascular collapse during MT procedures.

Fibrin-Targeted Nanoparticles for Finding, Visualizing and Characterizing Blood Clots in Acute Ischemic Stroke.

Recanalization of the occluded artery is the gold standard treatment for acute ischemic stroke, which includes enzymatic fibrinolytic treatment with the use of recombinant tissue plasminogen activators (rtPAs) to disrupt the occluding clot, the use of mechanical thrombectomy to physically remove the clot, or a combination of both. Fibrin is one of the main components of blood clots causing ischemic stroke and is the target of rtPA upon activation of plasminogen in the clot. In addition, fibrin content also influences the efficacy of mechanical thrombectomy. Current imaging methods can successfully identify occlusions in large vessels; however, there is still a need for contrast agents capable of visualizing small thrombi in ischemic stroke patients. In this work, we describe the synthesis and the in vitro characterization of a new diagnostic nanoparticle, as well as the in vivo evaluation in an animal model of thromboembolic stroke. Gd-labeled KCREKA peptides were synthesized and attached onto the surface of PEGylated superparamagnetic nanoparticles. Magnetic resonance imaging (MRI) of blood clots was performed in vitro and in vivo in animal models of thromboembolic stroke. KCREKA-NPs were synthesized by attaching the peptide to the amino (N) termini of the PEG-NPs. The sizes of the nanoparticles, measured via DLS, were similar for both KCREKA-NPs and PEG-NPs (23 ± 4 nm, PDI = 0.11 and 25 ± 8 nm, PDI = 0.24, respectively). In the same line, r2 relaxivities were also similar for the nanoparticles (149 ± 2 mM Fe s−1 and 151 ± 5 mM Fe s−1), whereas the r1 relaxivity was higher for KCREKA-NPs (1.68 ± 0.29 mM Fe s−1 vs. 0.69 ± 0.3 mM Fe s−1). In vitro studies showed that blood clots with low coagulation times were disrupted by rtPA, whereas aged clots were almost insensitive to the presence of rtPA. MRI in vitro studies showed a sharp decrease in the T1 × T2 signals measured for aged clots incubated with KCREKA-NPs compared with fresh clots (47% [22, 80] to 26% [15, 51]). Furthermore, the control blood showed a higher value of the T1 × T2 signal (39% [20, 61]), being the blood clots with low coagulation times the samples with the lowest values measured by MRI. In vivo studies showed a significant T1 × T2 signal loss in the clot region of 24% after i.v. injection of KCREKA-NPs. The thrombus age (2.5% ± 6.1% vs. 81.3% ± 19.8%, p < 0.01) confirmed our ability to identify in vivo fresh blood clots. In this study, we developed and tested a dual MRI nanoparticle, acting as T1 and T2 contrast agents in MRI analyses. The developed KCREKA-NPs showed affinity for the fibrin content of blood clots, and the MRI signals provided by the nanoparticles showed significant differences depending on the clot age. The developed KCREKA-NPs could be used as a tool to predict the efficacy of a recanalization treatment and improve the triage of ischemic stroke patients.

Outcomes of Surgical and Mechanical Thrombectomy in Massive Saddle Pulmonary Embolism: A National Perspective.

Introduction Saddle pulmonary embolism (PE) is a type of central PE that involves the bifurcation of the pulmonary arteries. First-line treatment is usually systemic thrombolytics, but surgical and mechanical thrombectomy (ST and MT) are used for patients with contraindications to thrombolytics or right heart strain. This study compares surgical and mechanical thrombectomy trends and outcomes in patients with saddle PE. Methods The data was extracted from the National In-Patient Sample (NIS) from 2016-2018 using the International Classification of Diseases-10-Clinical Modification (ICD-10-CM) diagnosis codes. We used the Cochrane-Armitage trend test to analyze the trends of ST and MT and the chi-square test for statistical analyses. A two-tailed p-value of <0.05 was considered statistically significant. Results The overall trend of MT in saddle PE rose from 2016 to 2018, while ST remained stable. Around 95% of patients undergoing ST/MT were emergent admissions, with 82.5% occurring in teaching hospitals. Patients of age >65 years and more with comorbidity burdens were more likely to undergo MT over ST. In-hospital mortality after ST was 15.1%, and after MT was 11.1% (p:<0.001). The most common complications after ST were congestive heart failure (CHF) and atrial fibrillation (AF), and after MT were vascular events and CHF. Conclusion The use of mechanical thrombectomy has steadily increased during the study period. ST is more common in large/teaching hospitals, weekend admissions, and patients transferred from other facilities. MT is more common in elderly patients with a higher comorbidity burden. Patients who underwent MT had lowermortality, length of hospital stay, and post-procedural complications.

Outcomes of COVID-19 patients with STEMI undergoing primary PCI

Abstract Introduction and aim Coronavirus disease (COVID-19) has substantial impact on acute myocardial infarction (AMI) clinical course and outcome. In Poland during early phase of COVID-19 pandemic a network of dedicated hospitals was set to treat SARS-Cov2 positive patients. There is scarce data on STEMI patients outcome treated in this setting. Our aim was to compare outcomes of STEMI patients treated with primary PCI in hospitals dedicated to treat COVID-19 and referral high volume haemodynamic centres. Methods Study was a retrospective analysis of 115 consecutive COVID-19 patients with STEMI, treated with primary PCI, admitted to 4 high volume centres (2 referral hospitals and 2 COVID dedicated sites) in southern Poland between May 2020 and November 2021. Data was obtained from patients' electronic medical records. Results Detailed characteristics are presented in Table 1 and 2. In general in all hospitals, patients were similar in terms of age (median 69 y.o., IQR: 60–73), with similar profile of comorbidities. All patients used acetylsalicylic acid and unfractioned heparin. In referral centres, as compared with COVID-19 dedicated sites, there was a higher use of mechanical thrombectomy (p&amp;lt;0.001) and adenosine (p&amp;lt;0.001). Overall mortality rate was higher in COVID-19 centres (50% vs 25%, p=0.008). Detailed results are presented in Table 3. Conclusions There is a significantly higher mortality in COVID patients who develop STEMI than in patients with STEMI who were tested positive on admission. Patients in COVID-19 hospitals had higher levels of CRP and NT-proBNP at baseline. There are substantial differences in treatment of patients in referral centres and COVID dedicated hospitals. Funding Acknowledgement Type of funding sources: None.

Advances in Percutaneous Management of Pulmonary Embolism.

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE with hemodynamic compromise (massive/high-risk PE). A significant number of patients are not candidates for systemic thrombolysis due to the bleeding risk associated with thrombolytics. Historically, surgical pulmonary embolectomy (SPE) was recommended for massive PE with hemodynamic compromise for these patients. In the last decade, catheter-directed thrombolysis (CDT) has largely replaced SPE in the patient population with intermediate risk PE (submassive), defined as right heart strain (as evidenced by right ventricle enlargement on echocardiogram and/or computed tomography, usually along with elevation of troponin or B-type natriuretic peptide). Use of CDT increased in the last few years due to high incidence of PE in hospitalized patients with coronavirus disease 2019 pneumonia, and the use of mechanical thrombectomy (initially reserved for those with contraindications to thrombolysis) has also grown. In this article, we discuss the value of the PE response team, our approach to management of submassive (intermediate risk) and massive (high risk) PE with systemic thrombolytics, CDT, mechanical thrombectomy, and surgical embolectomy.

Change of mortality of patients with acute ischemic stroke before and after 2015.

IntroductionAdvances in the diagnosis and management of acute ischemic stroke (AIS) and the increased use of mechanical thrombectomy (MT) have improved the quality of care and prognosis of patients with AIS since 2015. We investigated the changing trends in mortality of patients with AIS in Korea before and after 2015.Materials and methodsA retrospective cohort study was conducted using combined anonymized data from the Acute Stroke Assessment Registry of Korea and the Health Insurance Review & Assessment Service database. Patients with ischemic stroke with precise onset time and initial National Institute of Health Stroke Scale records were included.ResultsPatients receiving MT treatment increased from 256 (2.7%) pre-2015 to 1,037 (3.9%) post-2015 (p < 0.001). Overall mortality significantly decreased from pre-2015 to post-2015. In pre-2015, intravenous thrombolysis (IVT) administered within 2 h significantly reduced 3-month mortality when compared with non-IVT. While, in post-2015, IVT administered within 2 h significantly reduced the 3-month, 1-year, 2-year, and 4-year mortality (p < 0.05). MT only reduced 1-year mortality pre-2015; however, MT significantly reduced the 3-month, 1-year, and 2-year mortality post-2015 (p < 0.05). Post-stroke antiplatelet and anticoagulant drugs significantly reduced the 3-month, 1-year, 2-year, and 4-year mortality post-2015.DiscussionSince 2015, faster IVT has significantly reduced the short- and long-term mortality in patients with AIS; MT reduced the 3-month, 1-year, and 2-year mortality. Post-stroke antithrombotic medication has significantly lowered the 2- and 4-year mortality since 2015.ConclusionsChanging trends in AIS management since 2015 have improved the prognosis of patients with AIS.

Type of anaesthesia for acute ischaemic stroke endovascular treatment.

Type of anaesthesia for acute ischaemic stroke endovascular treatment.

Availability of tracheal shift in the chest X-ray image as pre-treatment evaluation of mechanical thrombectomy.

The use of mechanical thrombectomy (MT) for treatment of acute large vessel occlusion has recently increased. Prompt and timely guiding catheter (GC) induction is necessary to improve prognosis of MT and reduce the time for recanalization. However, difficulties in GC induction are encountered in some patients. This GC induction depends mainly on the aortic arch structure. Therefore, this study focused on assessing presence of tracheal shift on chest X-ray images as pre-treatment evaluation method for GC induction due to its wide availability as an indicator for status of the mediastinum. We retrospectively examined 33 patients who underwent MT at our facilities between April 2017 and March 2021. The patients were divided into two groups according to presence or absence of tracheal shift on chest X-ray images. Background characteristics and treatment courses in these two groups were compared. Among 33 patients, tracheal shift was observed on the chest X-ray images of 14 patients. Furthermore, tracheal shift was positively correlated with the time of GC induction (32.9 min vs. 11.6 min, [p < 0.05]) and the female sex (p = 0.03). Additionally, tracheal shift exhibited correlations with multiple risk factors of atherosclerosis (p = 0.04). In patients with tracheal shift, GC induction could be expectedly difficult. Therefore, advanced disinfection of the right upper arm and affected side of the neck during MT in preparation for changing an approach route is required.