Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection.Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b−3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0–2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle–Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I2 statistic. Subgroup and sensitivity analyses were also performed.Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40–0.99, p = 0.04]. 90-day favorable outcome (mRS 0–2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58–0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups.Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results.Systematic Review Registration: “PROSPERO” database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.

Outcomes of Side to End versus End to End Colorectal Anastomosis in Non-emergent Sigmoid and Rectal Cancers. Randomized Controlled Clinical Trial.

Purpose The outcomes of open side-to-end colorectal anastomosis versus open end to end colorectal anastomosis in non-emergent sigmoid and rectal cancers open surgery in adults were compared. Methods A randomized controlled trial on individuals with sigmoid and rectal cancers was conducted between September 2016 and September 2018. Results The majority of the participants in the study were between the ages of 50 and 70 years, with a mean age of 62.58±12.3 years in the side-to-end anastomotic group (SEA group = group A = antegrade approach) and 61.03±13.98 years in the end-to-end anastomotic group (EEA group = group B = retrograde approach), respectively. Except for the operative time, intraoperative data revealed no significant differences between the studied groups, and the SEA group revealed that the mean anastomotic time was significantly shorter. Perioperative blood loss, length of stay, reoperation, inpatient death, infection, and bleeding were all revealed to be significantly associated with leakage in univariate analysis. In a multivariate analysis of anastomotic leaks, infection was the only independent predictor. There is a statistically significant change regarding the range of bowel frequency in the EEA group only (p = 0.04). There is a statistically significant difference regarding incontinence for Flatus in the SEA group only (p = 0.00). A statistically significant change in both groups regards incontinence for liquid stools (p = 0.00) and clustering of stools (p = 0.00 and p = 0.043). The quality of life (QOL) in the SEA group significantly dropped at 6 months and returned to baseline after that as regards PWB, FWB, and CCS with no difference as regards SWB & EWB, while in the EEA group, the exact change happened only as regard PWB & FWB, but SWB and CCS percentage did not return to baseline. Conclusion The SEA group offers a safe and approach alternative to the EEA group.

Arterial Thrombosis Induced By Coagulopathy Due To Coronavirus Infection Concomitant With Heparin Resistance: A Case Report

Background : A newly emerging pandemic of Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory coronavirus 2 is responsible for significant morbidity and mortality worldwide. As one of the effects is hematological changes related to the COVID-19 infection causing patient tend to thrombosis than hemorrhagic. Current review of evidence and statements on management of coagulopathy and thrombotic complications related to this novel disease is needs to be explored Case : Male 53 years old referred from Private Hospital, due to Severe pneumonia due to COVID-19 and Acute Limb Ischemia. This patient was assessed as Pneumonia COVID-19 severe with acute limb ischemia bilateral grade IIB and performed bilateral surgical thrombectomy with antegrade approach using fogarty catheter with the result was thrombus 10cm along the left femoral artery and thrombus 2cm in the right femoral artery. Discussion : With consideration of atherosclerotic diseases in this patient, we decided to give rivaroxaban as an anticoagulant combined with aspilet and statin high dose. But due to lack of source in our hospital, and patient also denied for further management, treatment for the patient cannot be optimal, so the patient discharge with unresolved limb ischemia. Conclusion : This case showed that the increase risk of heparin resistance in SARS-CoV-2 patient, it is recommend- ed to monitor heparin activity of UFH treatment based on anti-Xa levels instead of aPTT alone.

ULSOSEAL Technique: A Unique Technique to Achieve Hemostasis Using ExoSeal in High-Risk Patients after Common Femoral Artery Puncture

This study aimed to assess the safety and feasibility of the ULtrasound-guided uSe Of exoSEAL technique (ULSOSEAL technique) in patients at a high risk of complications following the use of ExoSeal. ExoSeal is a novel, completely extravascular hemostatic device that can treat punctures of the common femoral artery; however, it is not preferable for use in cases that require hemostasis of complex puncture sites. From November 2019 to August 2020, the ULSOSEAL technique was performed in 35 patients with implanted stents (6 patients, 17%), severe calcification (32 patients, 91%), and plaque (7 patients, 20%) around the puncture site; the presence of these conditions is usually undesirable when using ExoSeal. The antegrade approach was used in 22 patients (71%). The size of the ExoSeal used was 5 Fr (13 patients, 37%), 6 Fr (21 patients, 60%), and 7 Fr (1 patient, 2%). Technical success was achieved in 34 patients (97%), while ExoSeal malfunction occurred in 1 patient. There was no incidence of vessel occlusion, pseudoaneurysm, arteriovenous fistula, infection, and secondary bleeding. One patient developed a hematoma (>5 cm in size); however, it occurred before the use of ExoSeal due to side leakage from the inserted sheath. The ULSOSEAL technique was safe and feasible for hemostasis in patients who were considered unsuitable for the ExoSeal device.

Fluoroscopy-guided percutaneous antegrade approach for ureteral stent placement in children: a single-center experience

Background Although there are many studies on percutaneous nephrostomy in urinary obstruction management in pediatric patients, there is a limited number of studies on percutaneous antegrade ureteral stenting (PAUS) on this issue. Purpose To evaluate the results of fluoroscopy-guided percutaneous antegrade approach for ureteral stent placement through the nephrostomy route in children. Material and Methods Between October 2005 and June 2019, the medical records of children who underwent PAUS through the nephrostomy route were reviewed retrospectively. Demographic data of the patients, technical and clinical success rates, technical details, and complications of the procedure were recorded. Patients were divided and evaluated into groups according to etiology. Categorical data were analyzed by using the Pearson chi-square test. Results In total, 31 patients (19 boys, 12 girls; age range = 2 months–18 years; mean age = 7.4 ± 6.01 years) and 42 procedures were included in the study. The most common underlying diseases were ureteropelvic junction obstruction (16 stents, 38.1%) and vesicoureteral reflux (13 stents, 31%). The technical and clinical success rates were 97.6% and 90%, respectively. Clinical failure (10%) was not related to gender, underlying diseases, and stent size ( P > 0.05). Mean stent dwelling time was 96.43 ± 58.1 days. Complications were urinary tract infection (two procedures), stent migration (two procedures), early occlusion (one procedure), and contrast material leak after balloon dilation (one procedure). The complication rate was 14.6%. No procedure-related death was observed. Conclusion PAUS through the nephrostomy route in children is an effective and reliable method when surgical treatment is not feasible.

Jejunal Hemolymphangioma in a Patient Presenting with Gastrointestinal Bleeding

Background: Hemolymphangioma is rarely found in the small intestine. There have only been eight reports of hemolymphangiomas arising in the small intestine to date. The first patient was reported by Fang et al.in 2012. A small intestinal hemolymphangioma may lead to anemia and gastrointestinal bleeding. Case Presentation: We report a case of jejunal hemolymphangioma in a 49-year-old man. The patient presented with melena and anemia. He underwent double-balloon enteroscopy (DBE) via the antegrade approach, which demonstrated a 3.0 cm segment of jejunum with nearly 75% of the circumferential lesion with blood remnant. The raised soft lesion was in the middle of the jejunum with white patches on the surface of the mucosa. Endoscopic biopsy was not performed to avoid secondary bleeding. The patient underwent laparotomy, and partial small intestine resection was performed. A 5.0cm segment of jejunum was resected with primary anastomosis. The patient had an uneventful postoperative recovery. Macroscopic pathological examination showed a cavernous, soft and compressible tumor. Microscopic examination showed a tumor that was composed of blood and lymphatic vessels mainly located in the submucosa. The definitive histological diagnosis was jejunal hemolymphangioma. During a follow-up of 2 years, there was no further gastrointestinal bleeding. Conclusion: Small intestinal hemolymphangioma is a rare benign tumor of which clinical manifestations are nonspecific, and accurate preoperative diagnosis is challenging. Endoscopic biopsy is not recommended for hemolymphangioma of the gastrointestinal tract due to the risk of severe bleeding. Complete surgical resection of the hemolymphangioma is considered the most effective treatment for small intestinal hemolymphangioma.

Mechanical thrombectomy in acute ischemic stroke with tandem occlusions: impact of extracranial carotid lesion etiology on endovascular management and outcome

OBJECTIVE Different etiologies of extracranial internal carotid artery steno-occlusive lesions (ECLs) in patients with acute ischemic stroke (AIS) and tandem occlusion (TO) have been pooled together in randomized trials. However, carotid atherosclerosis (CA) and carotid dissection (CD), the two most common ECL etiologies, are distinct nosological entities. The authors aimed to determine if ECL etiology has impacts on the endovascular management and outcome of patients with TO. METHODS A multicenter, retrospective study of prospectively collected data was conducted. AIS patients were included who had TO due to internal CA or CD and ipsilateral M1 middle cerebral artery occlusion and underwent endovascular treatment (EVT). Comparative analyses including demographic data, safety, successful recanalization rates, and clinical outcome were performed according to EVT and ECL etiology. RESULTS In total, 214 AIS patients with TOs were included (77.6% CA related, 22.4% CD related). Patients treated with a retrograde approach were more often functionally independent at 3 months than patients treated with an antegrade approach (OR 0.6, 95% CI 0.4–0.9). Patients with CD-related TOs achieved 90-day clinical independence more often than patients with CA-related TOs (OR 1.4, 95% CI 1.1–2.0). Emergency stenting use was associated with good 3-month clinical outcome only in patients with CA-related TOs (OR 1.4, 95% CI 1.1–2.1). Symptomatic intracranial hemorrhage (sICH) occurred in 10.7% of patients, without differences associated with ECL etiology. CONCLUSIONS ECL etiology impacts both EVT approach and clinical outcome in patients with TOs. Patients with CD-related TO achieved higher 3-month functional independence rates than patients with CA-related TOs. A retrograde approach can be desirable for both CA- and CD-related TOs, and emergency stenting is likely better justified in CA-related TOs.

The Role of Antegrade Ureterolithotripsy in the Treatment of Large Impacted Proximal Ureteral Stones

The objective: optimization of approaches to the choice of endoscopic ureterolithorpsy method in the presence of large stones of the proximal ureter. Materials and methods. For the period 2017–2020 y. the study included 136 patients with large stones of the proximal ureter, who were performed one of two methods of ureterolithotripsy: rULT (group I) or m-aULT (group II). In group I 73 (53,7%) patients were operated, in group II – 63 (46,3%) patients. The age of patients ranged from 18 to 81 years, the average age was 52,7 years (54±10,5). The age of patients in group II ranged from 25 to 77 (63±10,5) years; the size of a concrement from 10 to 20 (14±3,5 mm). In group I, the age of patients ranged from 18 to 91 (63,5±10 years); the size of a concrement from 7 to 20 (12±5,5 mm). Results. The average time of m-AULT was 58,5±15,4 min, while the status of stone free was achieved in all 100% of patients. The operation ended with the installation of nephrostomy drainage in 11 (17,5%) cases, nephrostomy drainage and internal ureteral JJ-stent – in 33 (52,4%), in 19 (30,2%) cases – tubeless drainage method with the installation of ureteral stent. And the total percentage of stenting in staghorn stones of the proximal ureter, after lithotripsy and litholapaxy was 82,6% (52 patients). RULT surgery in 92% (67 patients) of cases ended with drainage of the kidney by JJ-stent, in 6 (8%) patients the operation ended without drainage. Conclusions. Analyzing the results, it was noted that the antegrade approach is a safe and effective method of treatment for proximal ureterolithiasis in the group with large stones of the proximal ureter, where the effectiveness of RULT (SFR up to 86,3±3,9%) is significantly inferior to AULT, and minimizing the size of instruments m-aULT) reduces the number and degree of complications associated with the size of the coiled tract, while providing a high level of SFR (96,8±4,4%).

Mastering retrograde coronary chronic total occlusion intervention in 2021

Chronic total occlusion recanalization still represents the last frontier in percutaneous coronary intervention. Retrograde recanalization is one of the most significant amendments of the technique, and has recently become an essential complement to the classical antegrade approach. It has a high success rate with a low complication profile, despite frequent utilization in the most complex patients. Since its initial description, important iterations have occurred and made the technique safer, faster and more successful.