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mechanical thrombectomy - Top 30 Publications

Middle Cerebral Artery Occlusion by an Intraluminal Suture Method.

Stroke represents the most common fatal neurological disease especially in highly developed countries. Even today, treatment options are very limited. The development of new therapeutic approaches replies, to a great extent, on experimental rodent models of focal cerebral ischemia. Since ~80% of ischemic strokes occur in the area of middle cerebral artery (MCA), a number of these stroke models are based on this artery. The intraluminal monofilament model of MCA occlusion involves the insertion of a surgical filament inside the external carotid artery and its extension into the internal carotid artery until the tip occludes the source of the MCA-thus arresting blood flow with resultant infarction in the MCA area. This technique can be utilized to model both permanent and transient occlusions. A major advantage of this technique is that it does not require craniectomy, which may affect intracranial pressure and temperature. Although the restored blood flow is unlike the pathophysiology of spontaneous human stroke, it more closely mimics the therapeutic state of mechanical thrombectomy which is increasingly being applied to patients with stroke.

PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy - evaluation of a double embolic protection approach in endovascular stroke treatment.

Stent retriever-based mechanical thrombectomy (MT) for emergent large vessel occlusions (ELVO) is often complicated by thrombus fragmentation causing distal embolization and embolization to new vascular territories. Well-established embolic protection approaches include proximal flow arrest and distal aspiration techniques during stent retriever maneuvers. Aiming at the reduction of thrombus fragmentation during MT we evaluated a technical approach combining proximal balloon occlusion together with direct thrombus aspiration during MT: the PROTECT technique.

Collaterals Predict Outcome Regardless of Time Last Known Normal.

Recent studies suggest that patients with large-vessel ischemic strokes (large-vessel occlusion [LVO]) with favorable imaging may benefit from mechanical thrombolysis even when treated outside the standard 6-hour window. However, many patients in these studies presented with unknown times of onset. We compare outcomes in thrombectomy patients treated at less than versus greater than 6 hours from last known well (LKN), and evaluate whether "unknown time of onset" alters prognosis.

Successful Reperfusion With Intravenous Thrombolysis Preceding Mechanical Thrombectomy in Large-Vessel Occlusions.

Although current guidelines advocate pretreatment with intravenous thrombolysis (IVT) in all eligible patients with acute ischemic stroke with large-vessel occlusion before mechanical thrombectomy, there are observational data questioning the efficacy of this approach. One of the main arguments in favor of IVT pretreatment is the potential for tissue-type plasminogen activator-induced successful reperfusion (SR) before the onset of endovascular procedure.

Carotid Artery Stenosis Contralateral to Acute Tandem Occlusion: An Independent Predictor of Poor Clinical Outcome after Mechanical Thrombectomy with Concomitant Carotid Artery Stenting.

Cerebral ischemic strokes due to extra-/intracranial tandem occlusions (TO) of the anterior circulation are responsible for causing mechanical thrombectomy (MT). The impact of concomitant contralateral carotid stenosis (CCS) upon outcome remains unclear in this stroke subtype.

Definition and treatment of stroke over the centuries.

Stroke was already diagnosed in the ancient times. For hundreds of years the treatment of this disease has changed radically. According to the current WHO definition, stroke is a clinical syndrome caused by focal or generalized brain injury that lasts more than 24 hours or leads to death and has no other cause than vascular. Stroke constitutes a big social and economic problem, as it can lead to death or disability. In the highly developed countries stroke is the third most common cause of adult deaths, the second leading cause of dementia, and the most common cause of disability. The consequences of stroke also include epilepsy and depression. In the twentieth century, stroke was only treated symptomatically and rehabilitation was limited to passive exercises. The first breakthrough in ischemic stroke therapy was the introduction of aspirin (ASA), followed by intravenous thrombolysis using recombinant tissue plasminogen activator (rtPA), initially available in our country only in the drug programs, and since 2009 it has been reimbursed by the National Health Fund (NFZ). Gradually invasive stroke treatment has been developed. Mechanical thrombectomy is currently only performed in selected centers, giving hope for more effective stroke treatment. The purpose of this work was to show how stroke treatment has changed over the centuries.

Mechanical thrombectomy and rescue therapy for intracranial large artery occlusion with underlying atherosclerosis.

To investigate the safety and efficacy of mechanical thrombectomy plus rescue therapy for intracranial large artery occlusion (ILAO) with underlying intracranial atherosclerosis (ICAS).

Thromboembolic Risk of Endovascular Intervention for Lower Extremity Deep Venous Thrombosis.

This study evaluated the risk of thromboembolism during endovascular interventions in patients with symptomatic lower extremity deep vein thrombosis (DVT) METHODS: Clinical records of all patients who underwent endovascular interventions for symptomatic lower extremity DVT from 2001 to 2017 were retrospectively analyzed using a prospectively maintained database. Only patients who received an IVC filter were included in the analysis. Trapped intra-filter thrombus was assessed for procedural-related thromboembolism. Clinical outcomes of thrombus management and risk for thromboembolism risk were analyzed.

Specific Factors to Predict Large-Vessel Occlusion in Acute Stroke Patients.

The effectiveness of thrombectomy for acute ischemic stroke has been established, and earlier treatment produces better outcomes. If possible to identify large-vessel occlusion (LVO) at the prehospital phase, eligible patients can be shipped directly to a hospital that can perform thrombectomy. The purpose of this study was to determine factors that are specific to LVO and can be known before hospital arrival.

DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores) and DWI-FLAIR (Diffusion-Weighted Imaging-Fluid Attenuated Inversion Recovery) Mismatch in Thrombectomy Candidates: An Intrarater and Interrater Agreement Study.

We aimed to study the intrarater and interrater agreement of clinicians attributing DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores) and DWI-FLAIR (Diffusion-Weighted Imaging-Fluid Attenuated Inversion Recovery) mismatch in patients with acute ischemic stroke referred for mechanical thrombectomy.

Microsurgical Clipping of a Giant Middle Cerebral Artery Aneurysm with Successful Postoperative Endovascular Mechanical Thrombectomy for Treatment of Emergent Large Vessel Occlusion.

Giant intracranial aneurysms (>25mm) are uncommon. These lesions typically manifest clinically due to mass effect, acute hemorrhage, or thromboembolic events. To minimize the chances of poor clinical outcome, detailed operative planning and fully integrated considerations and collaboration among neurosurgical and endovascular techniques are essential prior to microsurgical clipping of ruptured giant aneurysms.

The organisation of the acute ischemic stroke management: key notes of the Italian Neurological Society and of the Italian Stroke Organization.

The main aim of acute ischemic stroke treatment is the as much possible prompt, safe and effective arterial recanalisation, in order to restore reperfusion into the ischemic brain area. The procedures obtaining this result are rapidly evolving and in the last years, we observed new evidences that affirmed the therapeutical benefit of the concomitant treatment using endovenous thrombolysis and mechanical thrombectomy in selected patients with ischemic stroke. However, all treatments are time-sensitive and the main limitation for their application is represented by the time. For this reason, the optimisation of the acute stroke management that includes a pre-hospital and an in-hospital phase is essential to reduce the avoidable delay, increasing the number of patients potentially treatable. The purpose of this document is to define the main elements and to suggest the principal key points constituting the optimal pathway of stroke management in Italian care settings, in line with the recommendations coming from the current national and international guidelines.

Fibrin Clot Architecture in Acute Ischemic Stroke Treated With Mechanical Thrombectomy With Stent-Retrievers - Cohort Study.

The composition of intra-arterial clots might influence the efficacy of mechanical thrombectomy (MT) in ischemic stroke (IS) due to the acute occlusions within large cerebral arteries. The aims were to assess the factors associated with blood clot structure and the impact of thromboembolus structure on MT using stent-retrievers in patients with acute large artery IS in the anterior circulation.Methods and Results:In an observational cohort study, we studied the components of intra-arterial clots retrieved from large cerebral arteries in 80 patients with acute IS treated with MT with or without i.v. thrombolysis (IVT). Histology of the clots was carried out without knowledge of the clinical findings, including the treatment methods. The components of the clots, their age, origin and semi-quantitative graded changes in the architecture of the fibrin components (e.g., "thinning") were compared via neuro-interventional, clinical and laboratory data. The most prominent changes in the architecture of the fibrin components in the thromboemboli were associated with IVT (applied in 44 patients; OR, 3.50; 95% CI: 1.21-10.10, P=0.02) and platelet count (OR, 2.94; 95% CI: 1.06-8.12, P=0.04).

Endovascular mechanical thrombectomy in large vessel occlusion ischemic stroke presenting with low NIHSS: a systematic review and meta-analysis.

Mechanical thrombectomy has become the standard of care for management of most large vessel occlusion (LVO) strokes. When patients with LVO present with minor stroke symptomatology, no consensus on the role of mechanical thrombectomy exists.

Complications of endovascular treatment for acute ischemic stroke: Prevention and management.

Endovascular mechanical thrombectomy (MT) for the treatment of acute stroke due to large vessel occlusion has evolved significantly with the publication of multiple positive thrombectomy trials. MT is now a recommended treatment for acute ischemic stroke. Mechanical thrombectomy is associated with a number of intra-procedural or post-operative complications, which need to be minimized and effectively managed to maximize the benefits of thrombectomy. Procedural complications include: access-site problems (vessel/nerve injury, access-site hematoma and groin infection); device-related complications (vasospasm, arterial perforation and dissection, device detachment/misplacement); symptomatic intracerebral hemorrhage; subarachnoid hemorrhage; embolization to new or target vessel territory. Other complications include: anesthetic/contrast-related, post-operative hemorrhage, extra-cranial hemorrhage and pseudoaneurysm. Some complications are life-threatening and many lead to increased length of stay in intensive care and stroke units. Complications increase costs and delay the commencement of rehabilitation. Some may be preventable; the impact of others can be minimized with early detection and appropriate management. Both neurointerventionists and stroke specialists need to be aware of the risk factors, strategies for prevention, and management of these complications. With the increasing use of mechanical thrombectomy for the treatment of acute ischemic stroke, incidence and outcome of complications will need to be carefully monitored by stroke teams. In this narrative review, we examine the frequency of complications of MT in the treatment of acute ischemic stroke with an emphasis on periprocedural complications. Overall, from recent randomized controlled trials, the risk of complications with sequelae for patient from mechanical thrombectomy is ∼15%. We discuss the management of complications and identify areas with limited evidence, which need further research. Search strategy and selection criteria Relevant evidence was found by searches of Medline and Cochrane Library, reference list, cross-referencing and main journal content pages. Search terms included "brain ischemia", "acute ischemic stroke", "cerebral infarction" AND "mechanical thrombectomy", "endovascular therapy", "endovascular treatment", "endovascular embolectomy", "intra-arterial" AND "randomized controlled trial", "non-randomised trials", "observational studies" AND "complications", "procedural complications", "peri-procedural complications", "device-related complications", "management", "treatment", "outcome". The search included only human studies, and was limited to studies published in English between January 2014 and November 2016. The final reference list was selected on the basis of relevance to the topics covered in the Review. Guidelines for management of acute ischaemic stroke by the American Heart Association, the European Stroke Organisation, multi-disciplinary guidelines and the National Institute for Health and Care Excellence (NICE) were also reviewed.

Mechanical cerebral thrombectomy in a BiVAD patient awaiting cardiac transplantation.

Physicians are not well informed about the new guidelines for the treatment of acute stroke.

Treatment of cerebrovascular disease has advanced rapidly in the last two decades. Recent data has added challenges to the treatment of ischemic stroke in the acute phase.

Endovascular Renal Artery Stent Retriever Embolectomy in a Young Patient With Cardiac Myxoma: Case Report and Review of the Literature.

Cardiac myxomas are common tumors of the heart with disproportionate impact on young patients, occasionally with dramatic systemic dissemination of tumor emboli with catastrophic multiorgan system ischemia. The coincident comorbidities can increase the risk of traditional treatments for tumor embolus in each region.

How to Escape Stentriever Wedging in an Open-cell Carotid Stent during Mechanical Thrombectomy for Tandem Cervical Internal Carotid Artery and Middle Cerebral Artery Occlusion.

We present 2 cases of complicated mechanical thrombectomy involving tandem cervical internal carotid artery and middle cerebral artery occlusion using the Solitaire FR stent and simultaneous carotid stent angioplasty. During the procedures, the Solitaire stents containing the thrombus were wedged into the open-cell carotid stents, which were already deployed for proximal flow restoration. We describe the methods used to avoid and overcome such complications.

Catheter-Directed Therapy for Pulmonary Embolism: Patient Selection and Technical Considerations.

Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with cardiogenic shock and may be of benefit in select normotensive patients with right heart strain. Percutaneous catheter-based techniques (catheter-directed mechanical thrombectomy, clot maceration, and/or pharmacologic thrombolysis) as an alternative or adjunct to systemic thrombolysis can rapidly debulk central clot in patients with shock. Catheter-directed thrombolysis, which uses a low-dose intraclot prolonged thrombolytic infusion, is a promising but insufficiently studied therapy for patients presenting with acute intermediate-risk PE.

Thrombectomy Using "Clamping Embolus with Semi-Retrieval" Technique in Acute Ischemic Stroke.

Embolization of thrombus fragments in new or downstream vascular territories is a potential adverse event in neurothrombectomy, requiring additional repeated thrombectomy attempts. This study aims to describe technical results of the thrombectomy with clamping embolus technique (TCET) method in acute ischemic stroke. This study also aims to evaluate the efficiency of mechanical thrombectomy by TCET, and to compare it with conventional stent retriever thrombectomy (CSRT).

Dual Mechanical Thrombectomy for Recanalization of a Resistant Acute Posterior Circulation Stroke.

A 71-year-old man with acute basilar artery occlusion was referred for endovascular treatment 6 hours after the onset of stroke with a Glasgow Coma Score of 3 and National Institutes of Health Stroke Scale of 27. A cerebral arteriogram revealed occlusion of the left vertebral artery proximally and thromboembolic occlusion of the basilar tip. Direct aspiration and mechanical thrombectomy with various stent retrievers failed to reconstitute arterial flow in the basilar artery. Thrombolysis in cerebral infarction 2b recanalization was achieved only after placement of double Catch Mini stent retrievers through 2 microcatheters, on both side branches of the basilar bifurcation in a kissing fashion and retrieving them simultaneously. It was possible to perform this maneuver through a single distal access catheter without any complications. On follow-up the patient awakened and was able to follow commands on his right side. To our knowledge, dual mechanical thrombectomy with stent retrievers has not been reported in the posterior circulation previously. This technique may be useful in retrieving thrombi located at major intracranial bifurcations of the posterior circulation which do not recanalize with standard mechanical thrombectomy procedures. Although bilateral access to the basilar artery through both vertebral arteries is an advantage in posterior circulation for this technique, dual mechanical thrombectomy can also be performed through a unilateral access.

Recommendations for Mechanical Thrombectomy in Patients with Acute Ischemic Stroke : A Clinical Guide by the Hellenic Stroke Organization.

This document presents the consensus recommendations of the Hellenic Stroke Organization which can be of assistance to the treating stroke physicians.

Combined interventional and surgical treatment of tandem middle cerebral artery embolus and internal carotid artery occlusion: case report.

Tandem internal carotid artery (ICA) origin occlusion and middle cerebral artery (MCA) thromboembolism is a life-threatening condition with poor neurological outcome. The authors report on a patient presenting with acute ischemic stroke from a tandem ICA and MCA occlusion with penumbra. Emergency MCA mechanical thrombectomy was performed through percutaneous cervical ICA access due to the inability to cross the cervical carotid occlusion. Emergency carotid endarterectomy to reperfuse the poorly collateralized hemisphere and repair the ICA access site was performed 2 hours after completion of tissue plasminogen activator (tPA) infusion. This case illustrates the shortest reported interval between tPA infusion and open surgical intervention for carotid revascularization, as well as the role of direct carotid artery access for mechanical thrombectomy. The authors also describe the use of a temporizing femoral artery-to-ICA shunt to maintain cerebral perfusion in the setting of ICA occlusion.

Mechanical thrombectomy performs similarly in real world practice: a 2016 nationwide study from the Czech Republic.

Randomized clinical trials have proven mechanical thrombectomy (MT) to be a highly effective and safe treatment in acute stroke. The purpose of this study was to compare neurothrombectomy data from the Czech Republic (CR) with data from the HERMES meta-analysis.

Is bridging therapy still required in stroke due to carotid artery terminus occlusions?

Studies comparing endovascular stroke treatment using mechanical thrombectomy (MT) with or without prior IV tissue plasminogen activator (tPa) have included only 30% of internal carotid artery terminus occlusions (ICA-O), a known predictor of recanalization failure with IV tPa.

Improving mechanical thrombectomy time metrics in the angiography suite: Stroke cart, parallel workflows, and conscious sedation.

Purpose Earlier reperfusion of large-vessel occlusion (LVO) stroke improves functional outcomes. We hypothesize that use of a stroke cart in the angiography suite, containing all commonly used procedural equipment in a mechanical thrombectomy, combined with parallel staff workflows, and use of conscious sedation when possible, improve mechanical thrombectomy time metrics. Methods We identified 47 consecutive LVO patients who underwent mechanical thrombectomy at our center, retrospectively and prospectively from implementation of these three workflow changes (19 pre- and 28 post-). For each patient, last known normal, NIHSS, angiography suite in-room time, type of anesthesia, groin puncture time, on-clot time, recanalization time, LVO location, number of passes, device(s) used, mTICI score, and outcome (mRS) were recorded. Between-group comparisons of time metrics and multivariate regression were performed. Results Stroke cart, parallel workflows, and primary use of conscious sedation decreased in-room time to groin puncture (-21.3 min, p < 0.0001), in-room to on-clot time (-24.1 min, p = 0.001), and in-room to reperfusion time (-29.5 min, p = 0.01). In a multivariate analysis, endotracheal intubation and general anesthesia were found to significantly increase in-room to on-clot time ( p = 0.01), in-room to reperfusion time ( p = 0.01), and groin puncture to on-clot time ( p = 0.05). The number of patients achieving a good outcome (mRS 0-2), however, did not significantly differ between the two groups (9/18 (47%) vs 14/28 (50%), p = 0.60). Conclusions Use of a stroke cart, parallel workflows by neurointerventionalists, technologists, and nursing staff, and use of conscious sedation may be useful to other institutions in efforts to improve procedural times.

Imaging assessment of acute ischaemic stroke - a review of radiological methods.

Acute ischaemic stroke is the second largest cause of death worldwide and a cause of major physical and psychological morbidity. Current evidence based treatment includes intravenous thrombolysis (IVT) and mechanical thrombectomy (MT), both requiring careful patient selection and to be administered as quickly as possible within a limited time window from symptom onset. Imaging plays a crucial role identifying patients who may benefit from MT or IVT whilst excluding those that maybe harmed. For IVT, imaging must as a minimum exclude haemorrhage, stroke mimics and provide an estimate of non-viable brain. For MT, imaging must in addition detect and characterise intra-arterial thrombus and assess the intra and extracranial arterial architecture. More advanced imaging techniques maybe used to assess more accurately the volume of non-viable and potentially salvageable brain tissue. It is highly likely that further research will identify patients who would benefit from treatment beyond currently accepted time windows for IVT (4.5h) and MT (6h) and patients with an unknown time of symptom onset. Current evidence indicates that best outcomes are achieved when treatment is instituted as soon as possible after symptom onset. A rapid, efficient imaging pathway including interpretation is fundamental to achieving optimal outcomes. This review summarises current techniques for imaging assessment of acute stroke, highlighting the strengths and limitations. The optimum pathway is a balance between diagnostic information, local resources, specialisation and the time taken to acquire, process and interpret the data. As new evidence emerges it is likely that the minimum required imaging data will change.

Significances and Outcomes of Mechanical Thrombectomy for Acute Infarction in Very Elderly Patients: A Single Center Experience.

Mechanical thrombectomy is increasingly being used for the treatment of acute ischemic stroke. The population over 80 years of age is growing, and many of these patients have acute infarction; however, these patients are often excluded from clinical trials, so the aim of this study was to compare the functional outcomes and complication rates in very elderly patients (age ≥80 years) and aged patients (60-79 years) treated with mechanical thrombectomy.

Effectiveness and Safety of Mechanical Thrombectomy with Stent Retrievers in Basilar Artery Occlusion: Comparison with Anterior Circulation Occlusions.

Acute basilar artery occlusion (BAO) is associated with severe neurological dysfunction and high mortality rates. The benefits of mechanical thrombectomy in BAO have not been explored in recent clinical trials. Therefore, we analyzed outcomes of stent retriever mechanical thrombectomy for BAO, and compared with anterior circulation occlusions (ACO).