Modified Coronary Pharmaco-Mechanical Thrombectomy Technique.
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ABSTRACT:
SUBMITTER: Lichaa H
PROVIDER: S-EPMC11307672 | biostudies-literature | 2022 Mar-Apr
REPOSITORIES: biostudies-literature
Publications
Modified Coronary Pharmaco-Mechanical Thrombectomy Technique.
Journal of the Society for Cardiovascular Angiography & Interventions 20220301 2
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Project description:Background and purposeThe impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke.MethodsWe performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay.ResultsAmong 1174 patients, 441 (37.6%) underwent general anesthesia and 733 (62.4%) underwent conscious sedation. Using an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% confidence interval, 1.9%-11.0%) and 8.4 days longer length of stay (95% confidence interval, 2.9-14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent 1 death. Our results were robust in sensitivity analysis with mixed effects regression and propensity score-adjusted regression models.ConclusionsUsing a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case-fatality and length of stay. These considerations should be taken into account when standardizing acute stroke care.
| S-EPMC5263179 | biostudies-literature
Project description:BackgroundPoor myocardial reperfusion due to distal embolization and microvascular obstruction after percutaneous coronary intervention is associated with increased risk of morbidity and mortality. Prior trials have not shown a clear benefit of routine manual aspiration thrombectomy. Sustained mechanical aspiration may mitigate this risk and improve outcomes. The objective of this study is to evaluate sustained mechanical aspiration thrombectomy before percutaneous coronary intervention in high thrombus burden acute coronary syndrome patients.MethodsThis prospective study evaluated the Indigo CAT RX Aspiration System (Penumbra Inc, Alameda CA) for sustained mechanical aspiration thrombectomy before percutaneous coronary intervention at 25 hospitals across the USA. Adults presenting within 12 hours of symptom onset with high thrombus burden and target lesion(s) located in a native coronary artery were eligible. The primary end point was a composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or new or worsening New York Heart Association class IV heart failure within 30 days. Secondary end points included Thrombolysis in Myocardial Infarction thrombus grade, Thrombolysis in Myocardial Infarction flow, myocardial blush grade, stroke, and device-related serious adverse events.ResultsFrom August 2019 through December 2020, a total of 400 patients were enrolled (mean age 60.4 years, 76.25% male). The primary composite end point rate was 3.60% (14/389 [95% CI, 2.0-6.0%]). Rate of stroke within 30 days was 0.77%. Final rates of Thrombolysis in Myocardial Infarction thrombus grade 0, Thrombolysis in Myocardial Infarction flow 3, and myocardial blush grade 3 were 99.50%, 97.50%, and 99.75%, respectively. No device-related serious adverse events occurred.ConclusionsSustained mechanical aspiration before percutaneous coronary intervention in high thrombus burden acute coronary syndrome patients was safe and was associated with high rates of thrombus removal, flow restoration, and normal myocardial perfusion on final angiography.
| S-EPMC9944712 | biostudies-literature
Project description:There is little guidance in the literature on which thrombectomy technique is preferred in patients with acute ischemic stroke and concomitant aneurysms. Here, we present the case of a 58-year-old female with an acute ischemic stroke requiring emergent thrombectomy that was complicated by the presence of multiple, nonruptured intracranial aneurysms. Imaging confirmed an occlusion of the right middle cerebral artery and multiple nonruptured intracranial aneurysms. The patient was administered intravenous recombinant tissue plasminogen activator and the thrombus was aspirated via a direct aspiration first pass technique (ADAPT). Her symptoms improved significantly postoperatively with a consequent National Institutes of Health Stroke Scale (NIHSS) score of 0. The purpose of this case report is to give an overview and compare various techniques that can help guide the physician for safe, early revascularization while reducing recanalization time in patients having an ischemic stroke who also harbor intracranial aneurysms.
| S-EPMC5929888 | biostudies-other
Project description:BackgroundRapid reperfusion is an important predictor of neurologic recovery in acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with mechanical thrombectomy (MT). We present a single-institution retrospective observational study of the ThrOmbectomy withOut Flushes or AnestheSia Teams (TOOFAST) technique, which eliminates continuous heparinized saline flushes and employs conscious sedation (CS) to streamline MT preparation.MethodsRetrospective review of prospectively collected data for AIS-LVO patients at our comprehensive stroke center from January 1, 2020, to December 31, 2023. Patients were >18 years with premorbid modified Rankin Scale (mRS) <3. Cases were performed under CS without continuous pressurized heparinized saline flushes or anesthesiologist involvement. Cases were categorized as presenting to the emergency department or from inpatient units (in-house), outside hospital transfers, or those undergoing hyperacute MRI.ResultsAmong 947 total cases, 638 were analyzed. 374 (58.6%) were in-house activations, 205 (32.1%) were transfers, and 59 (9.2%) underwent hyperacute MRI. Median presenting National Institutes of Health Stroke Scale (NIHSS) was 15 (interquartile range (IQR) 9-20) and 34.7% of patients received intravenous thrombolysis. Median arrival-to-access and NIR-to-access times for in-house activations were 67 (IQR 56-80) and 39 (IQR 29-48) minutes, respectively. Embolization to new territory occurred in 11 (1.7%) patients while vascular perforation occurred in 9 (1.4%). Median NIHSS shift from admission to discharge was -9 (IQR -15 to -5). At 90 days, 46.5% (106/228) remained mRS <3.ConclusionsThe TOOFAST technique may result in rapid access times with a profile of safety, procedural parameters, and neurologic outcomes comparable to published trial standards.
| S-EPMC11869227 | biostudies-literature
Project description: Not available
| S-EPMC8878942 | biostudies-literature
Project description:ObjectivesTo introduce a modified rotational atherectomy (RA) procedure and investigate the early and midterm outcomes of the RA-facilitating diversified percutaneous coronary intervention (PCI) in a large group of aged patients with higher cardiovascular risk.BackgroundPrevious studies about the outcomes of RA were limited with small sample size and low-risk population.MethodsBetween January 2013 and November 2015, 1169 consecutive patients treated with modified RA-facilitated PCI were retrospectively enrolled, including de novo calcified lesions and in-stent restenosis. Patients were regularly followed up for at least 1 year. Major adverse cardiac events (MACE) were analyzed for all participants by different strategies. Cox regression analysis was performed to identify risk factors for the events.ResultsThe median age of patients was 75 years, with 11.7% of patients on maintenance hemodialysis. Most lesions (99.9%) were complex (American Heart Association type B2/C), and 68.3% were treated with RA + drug-eluting-stent (DES). Successful angiography was achieved in 97.8% cases, with 1.7% (20/1169) experiencing coronary perforation (including guidewire perforation). The incidence of MACE was 20.5% and 26.8% at 1-year and 2-year follow-up and were mainly driven by target lesion revascularization (TLR) (10.3% and 12.5%, respectively). The strategy of RA + DES had the lowest 2-year MACE, compared with the RA + drug-coated balloon and RA + plain old balloon angioplasty (14.5%, 30.5%, and 26.0%, respectively).ConclusionsThe modified RA technique is a safe and effective tool in the contemporary PCI era, even in high-risk patients. The TLR rate was relatively high but acceptable in such complex lesions.
| S-EPMC7007738 | biostudies-literature
Project description:BackgroundThere is no established technique for managing large thrombus burden (LTB) in patients with acute coronary syndrome (ACS).AimsThe aim of this study was to assess the safety and efficacy of the NeVa (Vesalio) mechanical thrombectomy device (MTD) in ACS patients with LTB.MethodsConsecutive patients with ACS and LTB were treated with the NeVa MTD as the primary vessel recanalisation and thrombus removal modality, followed by conventional intervention. We further developed a bench model and applied to a subset of patients, a vacuum-assisted aspiration technique, exploiting 6 Fr-compatible conventional guiding catheter extensions, as an adjudicative manoeuvre to the use of stent-based MTD. A core laboratory reviewed the angiographic images for procedural complications, Thrombolysis In Myocardial Infarction (TIMI) flow, myocardial blush grade (MBG) and TIMI thrombus grade (TTG).ResultsBetween November 2019 and March 2021, 61 patients underwent thrombectomy with the NeVa device. Non-flow limiting and reversible coronary spasm occurred in 14 (23%) patients. One patient (#10) suffered from side branch embolisation, which was successfully treated with the NeVa, triggering the development of a vacuum-assisted aspiration technique in a bench model, which was then applied to the subsequent 51 patients. No other device-related complications occurred. After NeVa use, TIMI flow <3 decreased from 68.3% at baseline to 10.3% (p<0.001), MBG <2 from 65% to 27.6% (p<0.001), TTG ≥3 from 96.7% to 43.2% (p<0.001), respectively.ConclusionsIn patients with LTB, the NeVa MTD was safe and associated with high rates of vessel recanalisation and thrombus removal. The concomitant use of vacuum-assisted aspiration has potential to improve the effectiveness and safety of the technique.
| S-EPMC9912965 | biostudies-literature
Project description:BackgroundWe aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT's safety with IVT treatment.MethodsThis is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality.ResultsOf 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P=0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P=0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P=0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P=0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P=0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups.ConclusionsOur study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days.
| S-EPMC10599264 | biostudies-literature
Project description:BackgroundDespite improvement in available tools and techniques, procedural complications like coronary perforation can occur during percutaneous coronary intervention (PCI). Severe proximal coronary perforations are usually caused by balloon and vessel size mismatch but can also occur with appropriately sized balloons or stents if the coronary vessel has very eccentric calcification or if there is negative remodelling of the vessel.Case summaryA 74-year-old man with a history of type II diabetes mellitus, hypertension, and chronic coronary syndrome (previous PCI 10 years before) presented with unstable angina of 2 weeks of duration. Coronary angiography revealed a patent stent in left anterior descending artery, significant disease in left circumflex artery and diffuse calcified lesion in dominant right coronary artery (RCA). During angioplasty of RCA, the patient developed severe Ellis grade III perforation, which was successfully managed with modified double guiding catheter 'Ping Pong' technique. In this technique, the already engaged 7 French (F) Amplatz Left 1 guide catheter was used to deliver the bulky covered stent in highly tortuous and calcified RCA while a second 6F guide catheter (Judkin Right) introduced through contralateral femoral access was used for introducing the balloon, which initially sealed the perforation and subsequently acted as a distal anchor to provide strong support to deliver the covered stent.ConclusionIn a case of severe coronary perforation, modified Ping Pong technique using a small-sized second guide catheter complimentary to the first guide catheter, can be used to deploy bulky covered stent.
| S-EPMC8189299 | biostudies-literature
Project description:In ischemic stroke patients undergoing endovascular treatment (EVT), we aimed to test the hypothesis that cerebral microbleeds (CMBs) are associated with clinical outcomes, while estimating the mediating effects of hemorrhagic transformation (HT), small-vessel disease burden (white matter hyperintensities, WMH), and procedural success. From a multicenter EVT registry, patients who underwent pretreatment MR imaging were analyzed. They were trichotomized according to presence of CMBs (none vs. 1-4 vs. ≥ 5). The association between CMB burden and 3-month mRS was evaluated using multivariable ordinal logistic regression, and mediation analyses were conducted to estimate percent mediation. Of 577 patients, CMBs were present in 91 (15.8%); 67 (11.6%) had 1-4 CMBs, and 24 (4.2%) had ≥ 5. Increases in CMBs were associated with hemorrhagic complications (β = 0.27 [0.06-0.047], p = 0.010) in multivariable analysis. The CMB effect on outcome was partially mediated by post-procedural HT degree (percent mediation, 14% [0-42]), WMH (23% [7-57]) and lower rates of successful reperfusion (6% [0-25]). In conclusion, the influence of CMBs on clinical outcomes is mediated by small-vessel disease burden, post-procedural HT, and lower reperfusion rates, listed in order of percent mediation size.
| S-EPMC8901625 | biostudies-literature