LEA 38. Retrograde Use of the Outback Re-entry Catheter in Complex Infrainguinal Arterial Recanalization

Background: Data on arterial recanalization after IV t-PA treatment are rare. IMS-3 allows the study of variables affecting arterial recanalization after IV t-PA in acute ischemic stroke patients with CTA-proved major artery occlusions. Methods: Of 656 acute ischemic stroke patients in IMS-3, 306 were examined with baseline CTA and randomized either to IV t-PA (N=95) or to IV t-PA followed by digital subtraction angiography (DSA) and endovascular therapy (EVT) (N=211). Comparison of baseline CTA to DSA within 5 hours of stroke onset assessed early arterial recanalization after IV t-PA. A central core lab categorized DSA vessel occlusion as “no, partial, or complete”. We studied the association between arterial occlusion sites on baseline CTA with early recanalization for the endovascular group and analyzed its impact on clinical outcome at 90 days. Results: In the EVT group, 22 patients (10.4%) had no CTA intracranial occlusions, but 1 extracranial occlusion; 42 patients (19.9%) had occlusions of intracranial internal carotid artery (ic-ICA); 10 patients (4.7%) had tandem occlusions of the cervical ICA and middle cerebral artery (MCA); 95 patients (45.0%) had MCA-trunk (M1) occlusions, 33 patients (15.6%) had M2 occlusions, 3 patients (1.4%) had M3/4 occlusions, and 6 patients (2.8%) occlusions within posterior circulation. Partial or complete recanalization occurred in 28.6% of patients before DSA and was marginally associated with occlusion site (p=0.0525) (8 patients (19.0%) with ic-ICA occlusion, 0 patients with tandem ICA/MCA occlusions, 34 patients (35.8%) with M1 occlusions, 11 patients (33.3%) with M2 occlusions, 0 patients with M3/4 occlusions, and 1 patient (16.7%) with occlusion within posterior circulation). Three CTA negative patients had intracranial occlusions on DSA. Thirty-two patients (59.3%) with early recanalization achieved mRS of 0-2 at 90 days compared to 51 patients (38.4%) without early recanalization (p=0.0099). There was no relationship between early recanalization and time to IV t-PA or mean t-PA dose. Conclusion: Before EVT, IV rt-PA may facilitate arterial recanalization and better clinical outcome in about one third of patients.

Download Full-text

Abstract W P11: A Clinical Scale to Predict Futile Arterial Recanalization in Acute Stroke Patients with Anterior Circulation Arterial Occlusion Treated with Endovascular Therapies.

Stroke ◽

10.1161/str.45.suppl_1.wp11 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Natalia Perez de la Ossa ◽

Maria Hernández-Pérez ◽

Monica Millán ◽

Meritxell Gomis ◽

Elena López-Cancio ◽

...

Keyword(s):

Acute Stroke ◽

Scale Score ◽

Endovascular Therapy ◽

Univariate Analysis ◽

Arterial Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

History Of ◽

Stent Retrievers ◽

Arterial Recanalization

Introduction: Futile arterial recanalization (FAR), considered as a lack of functional recovery despite complete recanalization, is observed in up to 30-50% of acute stroke patients treated with endovascular therapy. We aimed to develop a prognostic scale based on baseline clinical and radiological factors to predict FAR. Methods: Prospective analysis of consecutive stroke patients with anterior circulation occlusion treated with endovascular therapy (97% mechanical thrombectomy with stent-retrievers). Complete recanalization was considered as a TICI 2b-3. FAR was defined as a modified Rankin scale >2 at 90 days in patients with complete recanalization. Baseline factors associated with FAR were detected on univariate analysis and were used to compose the predictive scale. Results: From a total of 229 patients with anterior arterial occlusion, 166 (72.5%) achieved complete recanalization. FAR was observed in 80/166 (48.2%). Factors significantly associated with FAR were included to compose the predictive scale as follow: Age (scoring 0 if ≤70 and 1 if >70 years old), history of diabetes mellitus (0 if absent, 1 if present), history of hypertension (0 if absent, 1 if present), NIHSS (1 if NIHSS ≤10, 2 if NIHSS 10-19, 3 if NIHSS>19), ASPECTS (1 if ASPECTS 9-10, 2 if ASPECTS 7-8, 3 if ASPECTS<7) and i.v tPA use (0 if yes, 1 if not). The higher the scale score, the higher the risk of FAR (Figure). The scale showed a good predictive value of FAR (c-statistics 0.71). A scale score <5 was associated with a low rate of FAR (25%) whereas a score >7 increased FAR up to 86%. Conclusion: We developed a simple scale that can easily predict futile arterial recanalization (FAR) in stroke patients with large arterial occlusion treated with endovascular therapies. A larger validation study is necessary to confirm the utility of this predictive scale.

Download Full-text

FIBRINOGEN DOSAGE AS A SYSTEMIC MARKER OF UNSUCCESSFUL INTRAVENOUS STREPTOKINASE IN ACUTE MYOCARDIAL INFARCTION

10.1055/s-0038-1642987 ◽

1987 ◽

Author(s):

Ch Col-De Beys ◽

E Lavenne-Pardonge ◽

M Moriau ◽

J Renkin ◽

J Col

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Coronary Occlusion ◽

Plasminogen Activators ◽

Clot Lysis ◽

Thrombin Time ◽

Intravenous Streptokinase ◽

Method Of Determination ◽

Arterial Recanalization

Whether failure to timely recanalize coronary artery with intravenous streptokinase (SK) is related to inadequate fibrinolysis remains controversial. Since coagulation might also interfere with the course of clot lysis, this relation was investigated in 27 patients (pts) pretreated with heparin (10.000 IU bolus). 500.000 to 1.500.000 IU SK were infused in 45 min, 160 ± 60 min after the onset of infarct.Angiographic control, performed 219 ± 199 min after SK, showed persistent coronary occlusion in 5 pts (0CC) and patency in 22 (PAT), unrelated to SK dosage. One to 3 hours post SK, fibrinogen (Fg) (Clauss Method) was undetectable in all 22 PAT and 4/5 0CC. However, Fg (and clottable breakdown products) assessed by Gram's method* was detected in all 5 OCC and 3/22 PAT (164 ± 89 VS 13 ± 38 mg %, p < 0.005). Prolongation of thrombin time (neutralized with protamine) was limited in OCC, compared to PAT (59 ± 6 VS 96 ± 11 sec, p < 0.005), supporting the hypothesis of the presence of clottable material in OCC. These results were accompanied by slight differences of ELT (< 20 min in 2/5 OCC VS 21/22 PAT) and non significant differences in plasminogen (1.78 ± 1 VS 2.18 ± 1.1 mg/dl ; NS), α2 antiplasmin (1.7 ± 1.7 VS 3.9 ± 6.9 % ; NS), plasmin (12 ± 4 VS 16 ± 11 mm2 ; NS) and plasminogen activators (95 ± 41 VS 105 ± 23 mm2 ; NS).Conclusion : at similar systemic lytic activity induced by SK, failure of arterial recanalization was associated wih an apparent incomplete fibrinogenolysis (and fibrinolysis) in 20 % of the patients.*Gram H.C. - A new method of determination of the fibrin percent in blood and plasma - J Biol Chem 49 : 279 - 295 (1921)mean ± SD

Download Full-text

Gender Differences in tPA-Related Arterial Recanalization

Stroke ◽

10.1161/01.str.0000190010.73274.e0 ◽

2005 ◽

Vol 36 (12) ◽

pp. 2529-2530 ◽

Cited By ~ 4

Author(s):

David M. Kent ◽

Michael D. Hill

Keyword(s):

Gender Differences ◽

Arterial Recanalization

Download Full-text

Subintimal Arterial Recanalization Using the Bull’s-Eye Technique

10.1093/med/9780199986071.003.0015 ◽

2018 ◽

Author(s):

S. Lowell Kahn

Keyword(s):

Specific Target ◽

Arterial Recanalization ◽

Bull's Eye

Antegrade retrograde revascularization is invaluable to the interventionalist, but is commonly complicated by the two catheters/wires lying in different planes and/or lumens relative to one another. This chapter describes the “bull’s-eye” technique with use of the Outback® LTD® Re-Entry Catheter (Cordis Corp., Milpitas, CA) steered toward a specific target, most commonly a snare to connect the two accesses. Although a snare the most commonly used target, this technique has been employed using a balloon or catheter as the target for the Outback®. This technique is widely applicable for large (aortic) to small (tibial) vessel revascularizations. It has also been employed successfully with challenging chronic central and peripheral venous occlusions.

Download Full-text

Response by Darcourt and Cognard to Letter Regarding Article, “Predictive Value of Susceptibility Vessel Sign for Arterial Recanalization and Clinical Improvement in Ischemic Stroke”

Stroke ◽

10.1161/strokeaha.119.025115 ◽

2019 ◽

Vol 50 (5) ◽

Author(s):

Jean Darcourt ◽

Christophe Cognard

Keyword(s):

Ischemic Stroke ◽

Clinical Improvement ◽

Predictive Value ◽

Arterial Recanalization

Download Full-text

Intravenous Administration of Standard Dose Tirofiban after Mechanical Arterial Recanalization is Safe and Relatively Effective in Acute Ischemic Stroke

Aging and Disease ◽

10.14336/ad.2018.0922 ◽

2019 ◽

Vol 10 (5) ◽

pp. 1049 ◽

Cited By ~ 3

Author(s):

Zhe Cheng ◽

Xiaokun Geng ◽

Jie Gao ◽

Mohammed Hussain ◽

Seong-Jin Moon ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Administration ◽

Standard Dose ◽

Arterial Recanalization

Download Full-text

Depletion of circulating α2-antiplasmin by intravenous plasmin or immunoneutralization reduces focal cerebral ischemic injury in the absence of arterial recanalization

Blood ◽

10.1182/blood.v97.10.3086 ◽

2001 ◽

Vol 97 (10) ◽

pp. 3086-3092 ◽

Cited By ~ 32

Author(s):

Nobus Nagai ◽

Maria De Mol ◽

Berthe Van Hoef ◽

Maria Verstreken ◽

Désiré Collen

Keyword(s):

Antibody Fragment ◽

Ischemic Injury ◽

Neutralizing Antibody ◽

Human Beings ◽

Fab Fragment ◽

Single Bolus ◽

Arterial Recanalization ◽

Cerebral Ischemic Injury ◽

Cerebral Ischemic ◽

Single Bolus Injection

Abstract In the absence of arterial recanalization, thrombolytic agents induce a dose-related extension of focal cerebral ischemic injury (FII) in experimental animals. However, FII is smaller in mice lacking α2-antiplasmin (α2-AP), the physiologic inhibitor of plasmin, suggesting its depletion might reduce FII in the absence of reperfusion. Therefore, the effect of human plasmin (Pli), human miniplasmin (mPli), and an Fab fragment neutralizing murine α2-AP (Fab-4H9) on FII after middle cerebral artery (MCA) ligation was studied in mice and in hamsters. In BALB/c mice, the median FII after 24 hours was 28 μL (range, 20-34) (n = 10) with saline and 23 μL (range, 17-26) (n = 9) with a single bolus of 0.07 mg Pli, given after MCA ligation (P = .010), which reduced α2-AP to 44% and fibrinogen from 0.75 to 0.44 g/L. FII was 20 μL (range, 13-26) (n = 6, P = .025) with 0.2 mg mPli and was 24 μL (range, 20-27) (n = 6,P = .020) with 1.7 mg Fab-4H9. Neuronal atrophy and reduction of laminin immunoreactivity were comparably observed in the infarct area after saline and Pli. In hamsters, a single bolus injection of 1 mg Pli, after MCA ligation, depleted α2-AP and fibrinogen and reduced FII at 24 hours from 20 μL (range, 9.9-38) (n = 6) to 7.0 μL (range, 0.44-31) (n = 7,P = .032). Thus, reduction of circulating α2-AP, with a single bolus of plasmin or of a neutralizing antibody fragment, significantly reduced FII after MCA ligation in mouse and hamster models, suggesting that, provided these observations can be extrapolated to human beings, transient depletion of circulating α2-AP might reduce ischemic stroke in the absence of reperfusion.

Download Full-text