Novel Use of Dual Guiding Catheters Technique to Prevent Distal Embolization and Slow Flow during PCI of Coronary Stent Thrombosis

Despite having an incidence of 0.5 to 2%, stent thrombosis has an in-hospital mortality of 15% and myocardial infarction (MI) incidence of 67%. Even with the usage of thrombus aspiration devices and microvasculature vasodilators such as nitroprusside, verapamil, adenosine, and Gp2b/3a inhibitors, the angiographic result of percutaneous coronary intervention of coronary stent thrombosis remains frequently suboptimal due to distal embolization and subsequent slow flow. We describe a novel use of dual guide catheter technique, where one guide acts as conduit for thrombus aspiration catheter and the other for distal placement of balloon trap to prevent distal embolization while managing a case of coronary stent thrombosis to improve the angiographic outcome in this scenario.

766 Distal embolization protection systems. A rare complication

Aims The no reflow phenomenon is a not rare complication that occurs in up to 30% of patients with acute coronary syndrome undergoing myocardial reperfusion by percutaneous coronary intervention. The use of coronary artery thrombus aspiration or distal embolization protection systems has reduced the risk of distal embolization and no-reflow phenomenon. Methods and results We describe the case of a 77 year old female suffering from hypertension presented at our emergency department for inferior STEMI. An urgent coronary angiography was performed, showing a three-vessel coronary artery disease with right coronary artery sub-occluded in the middle segment (culprit lesion), with a voluminous endoluminal minus image, as intracoronary thrombosis. Before performing the coronary angioplasty, a Spider FX3 filter was placed on the distal segment of the right coronary artery; thrombus aspiration was performed, which was ineffective, then angioplasty and Zotarolimus eluting stent implantation in the mid segment of the right coronary artery. After stent implantation, an image of minus was highlighted inside the basket of the filter, as a migrated and incarcerated thrombotic formation; then, the filter was removed. During the removal of the filter, longitudinal crush of the distal portion of the stent is caused, with limitation of the downstream flow, in the absence of haemodynamic instability. The stent was recrossed with Fielder XT guidewire supported by Turnpike LP Microcatheter. Multiple dilations werenperformed with semi-compliant and non-compliant increasing-caliber balloons and then Zotarolimus eluting stent implantation, in partial overlap with the distal portion of the previously implanted stent, with TIMI flow 3. The echocardiogram showed a normal global systolic function, with alterations in regional kinetics. On the 6th day, angioplasty and Zotarolimus eluting stent implantation was performed on the mid-proximal segment of the left anterior descending artery. During the hospitalization the patient was stable and has been discharged in good condition on the ninth day. Conclusions The interest of this case is the evidence of a rare complication related to the use of distal embolization protection system, probably due to an incomplete closure of the filter before removal, due to the high amount of thrombotic material inside it. The rapid recrossing of the stent after the longitudinal crush, the angioplasty and the second stent implantation, led to a quick flow restoration, without haemodynamic and clinical consequences on the patient's outcome.

Brachial artery aneurysm as a late complication of arteriovenous fistula

Introduction: Brachial artery aneurysm (BAA) is a rare late complication of arteriovenous fistula (AVF). It brings the risk of peripheral embolism and hand ischemia and is defined by brachial artery diameter above 10 mm or by regional dilatation by >50%. BAA is described in the literature in closed radiocephalic arteriovenous fistulas after kidney transplantation. The aim of the study was to analyze the prevalence of BAA and of their more dangerous forms. Method: A observational one center study performed on patients after kidney transplantation with AVF or arteriovenous graft (AVG). We invited all patients followed up for kidney transplantation in our center. Arterial diameter greater than 10 mm was considered as a brachial artery aneurysm to simplify the detection and evaluation of aneurysms. Results: About 162 patients with AVF after kidney transplantation were examined between 4/2018 and 4/2020. Brachial artery aneurysm was detected in 34 patients (21%) with AVF or AVG, of them 7 had confirmed wall thrombi. AVF flow volume of more than 1500 ml/min increased the risk of BAA development by 4.54x. Eight aneurysms were treated surgically. After this surgery, the primary patency was 87.5% in 12 months. Conclusion: Brachial artery aneurysm was relatively frequent in our study compare to the literature. Aneurysm or dilatation of the brachial artery is more frequent in functional AVFs. Surgical correction is necessary in cases of complicated aneurysms to prevent distal embolization.

Biomarkers of Technical Success After Embolectomy for Acute Stroke

Purpose of the ReviewStent retrievers and large-bore aspiration catheters have doubled substantial reperfusion rates compared to first-generation devices. This has been accompanied by a 3-fold reduction in procedural time to revascularization. To measure future thrombectomy improvements, new benchmarks for technical efficacy are needed. This review summarizes the recent literature concerning biomarkers of procedural success and harm and highlights future directions.Recent FindingsExpanded Treatment in Cerebral Ischemia (eTICI), which incorporates scores for greater levels of reperfusion, improves outcome prediction. Core laboratory–adjudicated studies show that outcomes following eTICI 2c (90%–99% reperfusion) are superior to eTICI 2b50 and nearly equivalent to eTICI 3. Moreover, eTICI 2c improves scale reliability. Studies also confirm the importance of rapid revascularization, whether measured as first pass effect or procedural duration under 30 minutes. Distal embolization is a complication that impedes the extent and speed of revascularization, but few studies have reported its per-pass occurrence. Distal embolization and emboli to new territory should be measured after each thrombectomy maneuver. Collaterals have been shown to be an important modifier of thrombectomy benefit. A drawback of the currently accepted collateral grading scale is that it does not discriminate among the broad spectrum of partial collateralization. Important questions that require investigation include reasons for failed revascularization, the utility of a global Treatment in Cerebral Ischemia scale, and the optimal grading system for vertebrobasilar occlusions.SummaryEmerging data support a lead technical efficacy endpoint that combines the extent and speed of reperfusion. Efforts are needed to better characterize angiographic measures of treatment harm and of collateralization.

Abstract 1122‐000204: Risk of Distal Embolization in Large Vessel Occlusion Strokes Treated with Tenecteplase

Introduction : The use of IV thrombolytics and concomitant intra‐arterial therapy (IAT) in large artery occlusion (LVO) has become standard of care in acute ischemic strokes. Distal embolization may limit the efficacy of revascularization with IAT. Distal embolization may occur spontaneously or secondary to IV thrombolytics. Our objective was to compare rates of distal embolization in subjects who received IV alteplase (tPA) or IV tenecteplase (TNK) followed by EVT. Methods : Electronic medical records of subjects with acute ischemic stroke secondary to MCA occlusion who received TNK or tPA and underwent IAT therapy were reviewed. Digital subtraction images were reviewed to evaluate for distal embolization prior to revascularization. To confirm distal embolization, pre‐procedure CT angiogram or CT head hyperdense sign were reviewed. Z score for 2 population proportions was used to compare rates of distal embolization in tPA and TNK subjects. Social Science Statistics was used for data analysis. Results : From June 2020 to May 2021, 29 subjects received IV thrombolytics (tPA n = 12; TNK n = 17) followed by IAT. Five subjects were excluded from the TNK group with tandem and/or ICA occlusion. Twelve patients in each group with MCA occlusions (M1 or proximal M2 occlusions were compared). Difference in distal embolization rates had a trend towards statistical significance (z = ‐1.2649; p = 0.10383). Conclusions : The exclusion of tandem and/or ICA occlusions due to small sample size was a significant limitation of the study that affects generalizability to the strokes secondary to LVO. The trend towards statistical significance in higher distal embolization rates in subjects receiving TNK warrants larger, prospective studies to validate results.

Presentation, Diagnosis and Management of Innominate Artery Thromboembolism

Purpose: Acute thromboembolic disease of the innominate artery (IA) poses a unique set of therapeutic challenges, owing to its contribution to both the cerebral and upper extremity circulation, and risks of distal embolization via the carotid and subclavian arteries, respectively. Herein, we present a 74-year-old female who presents with acute IA thrombus treated successfully with right axillary and common carotid exposure and aspiration catheter-directed mechanical thrombectomy (CDT). Furthermore, an emerging use of CDT and its application in acute thromboembolism are outlined. Case report: A 74-year-old female with history of right lung transplant for pulmonary fibrosis with severe pulmonary hypertension, and stage IIIA left lung adenocarcinoma status post left lower lobectomy undergoing adjuvant chemotherapy presented with acute IA thrombus and right-sided stroke. She was treated successfully with right axillary and common carotid exposure and aspiration CDT. Computed tomography angiography performed 1 month postoperatively confirmed patent IA with no evidence of residual or recurrent thrombus. Conclusion: There are currently no standard guidelines on the management of acute IA thromboembolism, with mostly individual cases reported in the literature describing this rare entity. Nevertheless, this unique clinical entity mandates expeditious diagnostic and therapeutic approaches in order to avoid permanent neurologic deficits from distal embolization. Our case demonstrates that aspiration CDT may be an effective treatment modality for patients with acute IA thrombus.

Low profile sheaths in pediatric neurointervention: a multicenter experience

BackgroundPediatric neurointervention is challenged by the appropriateness of adult catheters and devices. This multicenter report on the smallest groin access sheaths offers technical notes and clinical outcomes in the pediatric neurointerventional population.MethodsAll pediatric neurointerventional cases from 2019 to 2021 were reviewed for use of a 3.3F Pediavascular or a 4F Merit Prelude Ideal low profile sheath. Hospital records were reviewed for complications and technical notes and compared with arterial groin access with the 4F Terumo Pinnacle in infants less than 1 year old, before the low profile sheaths at one author’s institution were introduced.ResultsFrom January 1, 2019 to March 31, 2021 there were 347 procedures performed at Boston Children’s Hospital and University of Wisconsin. Forty-four procedures in 26 patients were identified in which a 3.3F (38 cases, 20 patients) or 4F (6 cases, 6 patients) sheath was used. The average age was 2.2 years (1.5 days to 18 years). Retinoblastoma intra-arterial chemotherapy infusion (18 of 44) was the most common indication. The remaining procedures comprised vein of Galen embolization (12), diagnostic cerebral angiography (13), and one preoperative tumor embolization. Morbidity included a groin hematoma and decreased pulses (4.5%). No major groin complications occurred. There was no statistically significant difference compared with the historical cohort (132 procedures), which had seven instances of decreased pulses (5.3%, p>0.05).ConclusionThe 3.3F Pediavascular and 4F Merit Prelude Ideal sheaths are easily incorporated into the pediatric neurointerventionalist’s armamentarium for infants and readily accommodate various microcatheters for distal embolization and catheterization.

Rotational atherectomy in a dire situation: a case report

Background Traditionally rotablation is considered as contraindicated in presence of visible thrombus or dissection. However, clinical situations may force us to undertake rotablation in presence of thrombus or dissection. We report a case of coronary rotablation done successfully in setting of acute thrombotic occlusion over an underlying non-healed dissection. Case summary A non-dilatable lesion in proximal left anterior descending (LAD) artery after rotablation with a 1.5 mm burr resulting in non-flow limiting Type A dissection with TIMI3 flow was left on conservative management to allow it to heal. But the patient developed ST-elevation myocardial infarction on the 9th post-intervention day due to thrombotic occlusion of the LAD at the site of dissection. At this time, we were compelled to do rotablation as a lifesaving procedure in presence of both thrombus and underlying dissection with a successful outcome. Discussion Rotablation in presence of dissection can lead to entrapment of the flap in the rotating burr leading to progression of dissection distally or sometimes there can be subintimal tracking of burr leading to perforation. In thrombotic lesions, rotablation can cause further increase in platelet activation and aggregation by the spinning burr or distal embolization of the thrombotic material promoting slow or no flow. In this unusual case with limited options for achieving successful revascularization, some out of the box steps were taken with all recommended precautions and successful outcome achieved.

Intravascular Ultrasound Assessment and Correlation With Angiographic Findings of Arterial Dissections Following Auryon Laser Atherectomy and Adjunctive Balloon Angioplasty: Results of the iDissection Auryon Laser Study

Background Femoropopliteal arterial angiographic dissections with the use of the Auryon laser atherectomy system (previously the B-laser) have been infrequent and non–flow limiting. However, the pattern of these dissections (depth and arc) using intravascular ultrasound remains unknown. Materials and Methods We prospectively enrolled 29 patients in the iDissection Auryon study. The primary objective was to define the occurrence of new adventitial injury with intravascular ultrasound (IVUS). Secondary objectives included distal embolization and bailout stenting as judged by the operator because of 30% or more residual narrowing and/or NHLBI (National Heart, Lung, and Blood Institute) angiographic dissection C and higher. Core laboratory analysis was carried on all cases except for 1 patient (that crossed over to Jetstream atherectomy). Dissections were classified according to the iDissection classification as involving the intima (A), media (B), and adventitia (C) and ≤ 180-° arc (1) or >180-° arc (2). Overall, 22 of 29 patients had an embolic filter (per protocol). Results Median lesion and treated lengths were 100.0 and 150.0 mm, respectively. Vessel diameter by IVUS was 6.5 ± 1.5 mm. Chronic total occlusion (CTO) was present in 24.1% of cases. The arc of calcium was: no calcium in 27.6%, <90° in 13.8%, 90° to 180° in 20.7%, and >180° in 34.4%. Lesion severity was reduced to a median of 14% post laser and adjunctive percutaneous transluminal angioplasty (PTA) from a baseline of 76%. Bailout stenting occurred in 6 of 28 (21.4%) patients (3 for dissections, 2 for residual >30%, and 1 for both) and primary stenting in 1 of 28 (3.6%). By IVUS, there were 9 new dissections post laser (1 adventitial; 3≥180°) and 21 new dissections post laser and PTA (3 adventitial; 1≥180°). No distal embolization requiring treatment was seen and no macrodebris ≥2 mm was recovered in the filters. Conclusion The Auryon laser atherectomy system had minimal rate of adventitial injury despite complex disease with relatively low bailout stent rate and no clinically significant macrodebris.