Double Solitaire Mechanical Thrombectomy in Acute Stroke: Effective Rescue Strategy for Refractory Artery Occlusions?

BACKGROUND AND PURPOSE:Mechanical thrombectomy by using a single stent retriever system has demonstrated high efficacy for recanalization of large-artery occlusions in acute stroke. We aimed to evaluate the feasibility, safety, and efficacy of a novel double Solitaire stent retriever technique as an escalating treatment for occlusions that are refractory to first-line single stent retriever mechanical thrombectomy.MATERIALS AND METHODS:All patients treated with the double stent retriever technique by using the Solitaire system were retrospectively selected from 2 large neurointerventional centers. Time to recanalization, angiographic (TICI) and clinical outcomes (mRS), and complications were assessed.RESULTS:Ten patients (median NIHSS score, 16; mean age, 70 years) with MCA M1 segment (n = 5) and terminal ICA (n = 5 including 2 ICA tandem) occlusions were included. Prior single stent retriever mechanical thrombectomy had been performed in 9 patients (median number of passes, 3). Median time to recanalization was 60 minutes (interquartile range, 45–87 minutes). Procedure-related complications occurred in 1 patient; overall mortality was 20%. Recanalization of the target vessel (TICI 2b/3) was achieved in 80%. Good clinical outcome (mRS 0–2) was 50%.CONCLUSIONS:In this preliminary feasibility study, the double Solitaire stent retriever technique proved to be an effective method for recanalization of anterior circulation large-artery occlusions refractory to standard stent retriever mechanical thrombectomy.

In acute ischemic stroke, recanalization of an occluded cerebral artery is strongly linked with improved clinical outcome and reduced mortality.¹ The potential of IV thrombolysis for achieving successful vessel recanalization is significantly limited by the extent of clot burden in proximal cerebral artery occlusions.² With the recent introduction of stent retrievers (SR) for mechanical thrombectomy (MT), fast, safe, and efficient large-artery recanalization treatment can be achieved, and their superiority over older MT devices has been demonstrated in randomized controlled trials.^3,4Despite considerable recanalization rates of 61%–86% (Thrombolysis in Myocardial Infarction/TICI scores of ≥2/2b),^3–5 up to 33.3% of patients are still left without sufficient recanalization after standard SR MT.⁶ In these refractory cases, different rescue treatments have been proposed with variable rates of success.^4,5,7–10 These include local intra-arterial fibrinolysis, MT with the Penumbra device (Penumbra, Alameda, California), mechanical thrombus disruption, thromboaspiration through a distal-access catheter (DAC), balloon angioplasty, and/or stent placement.Here, we describe a novel escalating strategy for MT by using 2 Solitaire SR devices (Covidien, Irvine, California), hence termed the “double Solitaire SR technique,” for proximal anterior circulation occlusions that are refractory to first-line single SR MT. In a retrospective series of patients from 2 large neurointerventional centers, we assessed the feasibility, safety, and angiographic and clinical outcomes of this technique.     

Does Mechanical Thrombectomy in Acute Embolic Stroke Have Long-term Side Effects on Intracranial Vessels? An Angiographic Follow-up Study

Purpose

Mechanical thrombectomy (mTE) proved to be effective treating acute vessel occlusions with an acceptable rate of procedural complications. Potential long-term side effects of the vessel wall trauma caused by mechanical irritation of the endothelium are unknown up to now.

Methods

From a retrospectively established database of 640 acute stroke treatments, we selected 261 patients with 265 embolic vessel occlusions treated successfully by mTE without permanent implantation of a stent. Analysis comprised the type of devices used and the number of passes performed. Digital subtraction angiography immediately after treatment was evaluated for vasospasm, dissection, and extravasation. Control angiographic images were evaluated for any morphological change compared to the immediate posttreatment angiographic run.

Results

Recanalization was achieved with a median of one (range 1–10) mTE maneuvers. Vasospasm occurred in 69 territories (26.0 %) and was treated with glyceroltrinitrate in three. Dissection was observed in one vessel (0.4 %). Intraprocedural hemorrhage in two patients (0.8 %) was either wire or device induced. Follow-up digital subtraction angiography was available for 117 territories after a median of 107 days, revealing target vessel occlusion in one segment (0.9 %) and a de novo stenosis of four segments (3.4 %). All findings were clinically asymptomatic. Posttreatment vasospasm was more frequent in patients with de novo stenosis and occlusion (p = 0.038).

Conclusion

De novo stenoses and occlusions occur in a small proportion of patients after mTE. Because all lesions were clinically asymptomatic, this finding does not affect the overall benefit of the treatment. Vasospasm may predict late vessel wall changes.     

The Use of the “Preclosure” Technique for Antegrade Aspiration Thrombectomy with Large Catheters in Acute Limb Ischemia

Purpose

This study was designed to assess retrospectively short- and mid-term outcomes of the use of a suture-mediated closure device to close the antegrade access in patients undergoing percutaneous aspiration thrombectomy with large catheters for acute leg ischemia.

Methods

Between November 2005 and February 2010, a suture-mediated active closure system (ProGlide^® 6F, Abbott) was placed before arterial sheath (mean 9 F, range 6–12 F) introduction in 101 patients (74 men, 73 %, mean age 70.1 ± 12.6 years standard deviation). Data regarding mortality, complications, and factors contributing to vascular complications at the access site was collected for 6 month after the intervention to detect device-related problems. As a coincidence, 77 patients had follow-up visits for a duplex ultrasound.

Results

There were a total of 19 vascular complications (19 %) at the puncture site, all of which were of hemorrhagic nature and none of which consisted of vessel occlusion. Two major outcome complications (2 %) occurred. A retroperitoneal hematoma and a serious inguinal bleeding required additive treatment and did not result in permanent sequelae. Nine cases involved death of which eight were not attributable to the closure and one remained unclear. Successful closure was achieved in 95 patients (94 %); additional manual compression was sufficient in the majority of the remaining patients. Numerous factors contributing to vascular complications were encountered.

Conclusions

With acceptable short- and mid-term outcomes, the “preclose” technique can be a reliable option for the closure of a large antegrade femoral access even for patients at a high risk of vascular complications, such as those undergoing aspiration thrombectomy.     

Neurointerventional Treatment in Acute Stroke. Whom to Treat? (Endovascular Treatment for Acute Stroke: Utility of THRIVE Score and HIAT Score for Patient Selection)

Purpose

Intra-arterial therapy (IAT) is used increasingly as a treatment option for acute stroke caused by central large vessel occlusions. Despite high rates of recanalization, the clinical outcome is highly variable. The authors evaluated the Houston IAT (HIAT) and the totaled health risks in vascular events (THRIVE) score, two predicting scores designed to identify patients likely to benefit from IAT.

Methods

Fifty-two patients treated at the Stavanger University Hospital with IAT from May 2009 to June 2012 were included in this study. We combined the scores in an additional analysis. We also performed an additional analysis according to high age and evaluated the scores in respect of technical efficacy.

Results

Fifty-two patients were evaluated by the THRIVE score and 51 by the HIAT score. We found a strong correlation between the level of predicted risk and the actual clinical outcome (THRIVE p = 0.002, HIAT p = 0.003). The correlations were limited to patients successfully recanalized and to patients <80 years. By combining the scores additional 14.3 % of the patients could be identified as poor candidates for IAT. Both scores were insufficient to identify patients with a good clinical outcome.

Conclusions

Both scores showed a strong correlation to poor clinical outcome in patients <80 years. The specificity of the scores could be enhanced by combining them. Both scores were insufficient to identify patients with a good clinical outcome and showed no association to clinical outcome in patients aged ≥80 years.     

Outcomes of Endovascular Treatment and Open Repair for Renal Artery Aneurysms: A Single-Center Retrospective Comparative Analysis

Purpose

To compare outcomes of endovascular repair and open repair in treatment of renal artery aneurysms (RAAs).

Is Uterine Artery Embolization for Patients with Large Myomas Safe and Effective? A Retrospective Comparative Study in 323 Patients

PurposeTo evaluate the effectiveness, safety, and complications of uterine artery embolization (UAE) in women with large fibroid tumors.Materials and MethodsFrom January 2005 to February 2011, 323 patients underwent UAE for symptomatic uterine leiomyomas without adenomyosis and were included in this study. Patients were divided into two groups: those with a large tumor burden (group 1; n = 63), defined as a dominant tumor with a longest axis of at least 10 cm or a uterine volume of at least 700 cm³; and the control group (group 2; n = 260). Tumor infarction and volume reduction were calculated based on magnetic resonance imaging findings. Symptom status was assessed with a visual analog scale. Postprocedure complications and repeat interventions were recorded. The data were analyzed with appropriate statistical tests.ResultsNo significant differences were seen between the two groups in volume reduction of dominant tumors (46.5% in group 1 vs 52.0% in group 2; P = .082) or percentage volume reduction of the uterus (40.7% in group 1 vs 36.3% in group 2; P = .114). Also, no significant differences were seen between the two groups regarding satisfaction scores at immediate or midterm follow-up (P = .524 and P = .497) or in the presence of procedure-related complications (P = .193).ConclusionsUAE outcomes in large fibroid tumors were comparable to those in smaller tumors, without an increased risk of significant complications. Tumor size may not be a key factor in predicting successful outcomes of UAE.     

Clinical Significance of Acute Phase Hyperglycemia in Patients with Severe Head Injury

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Carotid Artery Stent Placement and Carotid Endarterectomy: A Challenge for Urgent Treatment after Stroke—Early and 12-Month Outcomes in a Comprehensive Stroke Center

Purpose

To compare feasibility, 12-month outcome, and periprocedural and postprocedural risks between carotid artery stent (CAS) placement and carotid endarterectomy (CEA) performed within 1 week after transient ischemic attack (TIA) or mild to severe stroke onset in a single comprehensive stroke center.

Comparison of Ultrasound-Accelerated versus Pigtail Catheter–Directed Thrombolysis for the Treatment of Acute Massive and Submassive Pulmonary Embolism

Purpose

To compare the technical and clinical effectiveness of ultrasound-accelerated endovascular thrombolysis (USAT) versus pigtail catheter–directed thrombolysis (PCDT) for the treatment of acute pulmonary embolism (PE).

Data Bank and Consulting System for Medical Management of Patiens with Acute Radiation Sickness

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Whole-body MRI at 1.5 T and 3 T compared with FDG-PET-CT for the detection of tumour recurrence in patients with colorectal cancer

The purpose of this study was to assess the diagnostic accuracy of whole-body MRI (WB-MRI) at 1.5 T or 3 T compared with FDG-PET-CT in the follow-up of patients suffering from colorectal cancer. In a retrospective study, 24 patients with a history of colorectal cancer and suspected tumour recurrence underwent FDG-PET-CT and WB-MRI with the use of parallel imaging (PAT) for follow-up. High resolution coronal T1w-TSE and STIR sequences at four body levels, HASTE imaging of the lungs, contrast-enhanced T1w- and T2w-TSE sequences of the liver, brain, abdomen and pelvis were performed, using WB-MRI at either 1.5 T (n = 14) or 3 T (n = 10). Presence of local recurrent tumour, lymph node involvement and distant metastatic disease was confirmed using radiological follow-up within at least 5 months as a standard of reference. Seventy seven malignant foci in 17 of 24 patients (71%) were detected with both WB-MRI and PET-CT. Both investigations concordantly revealed two local recurrent tumours. PET-CT detected significantly more lymph node metastases (sensitivity 93%, n = 27/29) than WB-MRI (sensitivity 63%, n = 18/29). PET-CT and WB-MRI achieved a similar sensitivity for the detection of organ metastases with 80% and 78%, respectively (37/46 and 36/46). WB-MRI detected brain metastases in one patient. One false-positive local tumour recurrence was indicated by PET-CT. Overall diagnostic accuracy for PET-CT was 91% (sensitivity 86%, specificity 96%) and 83% for WB-MRI (sensitivity 72%, specificity 93%), respectively. Examination time for WB-MRI at 1.5 T and 3 T was 52 min and 43 min, respectively; examination time for PET-CT was 103 min. Initial results suggest that differences in accuracy for local and distant metastases detection using FDG-PET-CT and WB-MRI for integrated screening of tumour recurrence in colorectal cancer depend on the location of the malignant focus. Our results show that nodal disease is better detected using PET-CT, whereas organ disease is depicted equally well by both investigations.     

Functional limits of stability and standing balance in people with Parkinson’s disease with and without freezing of gait using wearable sensors

BackgroundPeople with from Parkinson’s disease (PD) and freezing of gait (FoG) have more frequent falls compared to those who do not freeze but there is no consensus on which, specific objective measures of postural instability are worse in freezers (PD + FoG) than non-freezers (PD-FoG).Research questionAre functional limits of stability (fLoS) or postural sway during stance measured with wearable inertial sensors different between PD + FoG versus PD-FoG, as well as between PD versus healthy control subjects (HC)?MethodsSixty-four PD subjects with FoG (MDS-UPDRS Part III: 45.9 ± 12.5) and 80 PD subjects without FoG (MDS-UPDRS Part III: 36.2 ± 10.9) were tested Off medication and compared with 79 HC. Balance was quantified with inertial sensors worn on the lumbar spine while performing the following balance tasks: 1) fLoS as defined by the maximum displacement in the forward and backward directions and 2) postural sway area while standing with eyes open on a firm and foam surface. An ANOVA, controlling for disease duration, compared postural control between groups.ResultsPD + FoG had significantly smaller fLoS compared to PD-FoG (p = 0.004) and to healthy controls (p < 0.001). However, PD-FoG showed similar fLoS compared to healthy controls (p = 0.48). Both PD+FoG and PD-FoG showed larger postural sway on a foam surface compared to healthy controls (p = 0.001) but there was no significant difference in postural sway between PD+FoG and PD-FoG.SignificancePeople with PD and FoG showed task-specific, postural impairments with smaller fLoS compared to non-freezers, even when controlling for disease duration. However, individuals with PD with or without FoG had similar difficulties standing quietly on an unreliable surface compared to healthy controls. Wearable inertial sensors can reveal worse fLoS in freezers than non-freezers that may contribute to FoG and help explain their more frequent falls.     

Comparative study of on-pump and off-pump coronary bypass surgery for patients with triple coronary artery disease

Minimalinvasivesurgeryhasbecomepopularsince2 0thcentury .Withregardtocoronaryarterybypasssurgery,avoidingcardiopulmonarybypass(CPB)hasavitalsignificanceoftheminimalinvasivesurgery ,foritcanavoidtheischemia reperfusioninjuryandaseriesofpathophysiologicaldisordersoftheorgansbroughtbytheCPB .SinceBenettiandBuffolo[1-2 ] firstreportedtheirexperiencesofoff pumpCABG ,(OPCAB) ,quiteafewliteratureshavecomparedtheeffectbetweenOPCABandconventionalon pumpCABG (CCABG ) .Forthedifferenceofpatie…