Search Results (20)

Ischemic stroke following percutaneous coronary intervention (PCI) is a rare complication, with an overall incidence of 0.56%. Most embolic strokes result from the dislodgement of atherosclerotic plaques, thrombi formed on catheter surfaces, procedural maneuvers, or, less commonly, air or metallic emboli originating from fractured guidewires. We present a unique case of stroke following PCI due to a previously unreported mechanism—arterial tunica media embolization associated with arterial access. A 57-year-old female presented with chest pain at rest and with exertion, accompanied by episodes of anxiety and fluctuating blood pressure, for which coronary angiography was performed, revealing 90–99% stenosis of the left anterior descending artery and necessitating PCI. During the procedure, the patient developed an eye deviation, aphasia, and left-sided hemiparesis. Cerebral angiography identified a M2 segment occlusion of the right middle cerebral artery (MCA) and a subocclusion of the right anterior cerebral artery (ACA). Thrombectomy was performed, retrieving two white, tubular emboli resembling fragments of a vessel wall, histologically confirmed to be arterial tunica media. While PCI is associated with a low complication rate, its increasing frequency necessitates awareness of emerging complications. This case underscores a previously undocumented potential embolic complication arising from the performance of PCI. Full article

Background and Objectives: Acute limb ischemia (ALI) is a life-threatening vascular emergency that requires immediate intervention to restore perfusion and prevent limb loss or mortality. Management strategies primarily include thrombolysis and surgical revascularization, each with distinct risks and benefits. This review evaluates and compares the outcomes of thrombolysis and surgical revascularization in ALI management, emphasizing their efficacy, safety, and patient selection criteria. Materials and Methods: A systematic review was conducted in adherence to PRISMA guidelines, analyzing data from 15 studies, including randomized controlled trials and large retrospective analyses, encompassing over 3500 patients with varying demographics and clinical presentations. Study quality was assessed using the Cochrane risk of bias tool and the Newcastle–Ottawa Scale. Results: Thrombolysis, utilizing agents such as urokinase or recombinant tissue plasminogen activator (rt-PA), demonstrated limb salvage rates up to 90% in acute cases, with 30-day mortality rates of 4–6%. It was particularly effective in patients with embolic occlusions or short symptom durations. However, bleeding complications associated with thrombolysis were reported in up to 47% of cases. Conversely, surgical revascularization remains crucial for those with advanced ischemia or contraindications to thrombolysis, offering reliable perfusion restoration but with higher perioperative morbidity, especially in older patients with significant comorbidities. Recent advancements, including hybrid approaches combining catheter-directed thrombolysis with percutaneous mechanical thrombectomy, have shown promise in improving outcomes by reducing procedure times and enhancing clot resolution. Conclusions: While thrombolysis and surgical revascularization are effective, optimizing patient selection remains a key challenge. Future research should focus on refining treatment algorithms, investigating novel thrombolytic agents, and expanding the role of minimally invasive techniques to improve long-term outcomes while mitigating complications such as bleeding and reperfusion injuries. Full article

Percutaneous treatment of highly thrombotic coronary lesions is demanding, due to worse acute and long-term clinical outcomes. In this report, we describe a case series of six patients with ST-segment elevation myocardial infarction and high-thrombus-burden coronary lesions. All patients were treated with the AngioJet Solent^® Dista catheter, a rheolytic thrombectomy device designed for peripheral use. The catheter effectively reduced the thrombus burden in all cases, achieving satisfactory final angiographic results. One case of no-reflow was observed following lesion dilatation prior to thrombectomy, but no other major in-hospital adverse events occurred. At mid-term follow-up, all patients remained free from angina. These preliminary findings suggest that this approach could represent a promising option for managing highly thrombotic coronary lesions, but further studies with larger populations and long-term follow-up are needed to confirm these results. Full article

Mortality rates from pulmonary embolism (PE) remain significant, highlighting the need for alternative treatment strategies beyond traditional anticoagulation. Percutaneous interventions, including mechanical thrombectomy and catheter-directed thrombolysis, are emerging as promising options. Given the complex pathophysiology and unique risk profiles of these patients, meticulous multidisciplinary planning is essential. Anesthesiologists play a central role in coordinating care and managing perioperative risks to improve outcomes. This article provides insights into best safety practices and shares experiences from a leading quaternary center. It offers guidance for anesthesia providers to proactively engage in comprehensive risk stratification, participate in multidisciplinary discussions, and support robust contingency planning for managing PE patients undergoing percutaneous interventions in non-operating room anesthesia settings. Full article

Pulmonary embolism (PE) is a life-threatening medical condition caused by the thrombotic occlusion of one or more branches of the lung vasculature, which represents the third most common cause of cardiovascular mortality after myocardial infarction and stroke. PE treatment requires a tailored approach based on accurate risk stratification and personalized treatment decision-making. Anticoagulation is the cornerstone of PE management, yet patients at higher clinical risk may require more rapid reperfusion therapies. In recent years, transcatheter treatment has emerged as a valuable option for patients with intermediate–high or high-risk PE who have contraindications to systemic thrombolysis. Recent advancements in catheter-directed therapies, such as catheter-directed thrombolysis (CDT) and catheter-directed mechanical thrombectomy (CDMT), provide minimally invasive options for swift symptom relief and hemodynamic stabilization. This review aims to provide a practical approach for optimal patient selection and management for PE percutaneous therapies, supported by a thorough evaluation of the current evidence base supporting these procedures. A focus on post-procedural management, the prevention of recurrence, and monitoring for long-term complications such as chronic pulmonary hypertension and post-PE syndrome is also specifically tackled. Full article

Introduction: Infectious catheter-related right atrial thrombus (CRAT) is a potentially fatal but often underestimated contingency associated with central venous catheter (CVC) in patients on hemodialysis. Management guidelines for CRAT are lacking, and its occurrence poses clinical challenges. Here, we describe the case of an infectious CRAT in a young patient on hemodialysis with peculiar clinical complications and perform a literature review. Case presentation and literature review: A 30-year-old man on hemodialysis after bilateral nephrectomy due to polycystic disease presented with hyperpyrexia resistant to broad-spectrum antibiotics. A pleural empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) was diagnosed. Since fever persisted despite targeted antibiotic therapy, a transthoracic echocardiogram to exclude infective endocarditis was performed, showing a right atrial thrombus. CVC was promptly removed and the thrombus was aspirated through a percutaneous retrieval system. The thrombus cultural exam resulted positive for MRSA. After performing an extensive literature review, we could not find another case reporting the concomitance of these two rare complications. Conclusions: CRAT is a life-threatening complication in hemodialysis patients. While various treatment options exist, evidence-based guidelines are lacking, leading to individualized management strategies. Minimizing CVC use remains the best option for preventing such a complication. Full article

Acute pulmonary embolism (PE), often resulting from deep vein thrombosis (DVT), is the third most frequent cause of cardiovascular death and is associated with increasing incidence, causing considerable morbidity and mortality. This review aims to evaluate the efficacy, safety, and outcomes of treatment options in the management of acute PE and DVT, encompassing both established and emerging technologies, such as catheter-directed thrombolysis, aspiration thrombectomy, and other endovascular techniques. A comprehensive literature review was conducted, assessing clinical studies, trials, and case reports that detail the use of percutaneous interventions for PE and DVT and analyzing the advantages and disadvantages of each percutaneous system. Several percutaneous treatments have shown promising results, especially in cases where rapid thrombus resolution is critical, such as in high- and intermediate–high-risk patients. The incidence of major complications, such as bleeding, remains a consideration, though it is generally manageable with proper patient selection and technique. It is fundamentally important to tailor the specific treatment strategy to the clinical and anatomical characteristics of each patient. Percutaneous treatments for acute PE and DVT represent valuable options in the therapeutic arsenal, offering enhanced outcomes in appropriately selected patients. Ongoing advancements in technology and technique, along with comprehensive clinical trials, are essential to further define the role and optimize the use of these interventions. Full article

Background and Objective: Although extracorporeal membrane oxygenation (ECMO) is an essential life-saving technique for patients with refractory cardiopulmonary shock, it can be fatal in certain cases. Case Presentation: A 19-year-old girl treated with ECMO presented with acute limb ischemia 2 days after cannula removal. The decannulation was performed percutaneously by an interventional cardiologist, and the vascular surgery department was consulted after the patient developed symptoms. The first suspected diagnosis was thrombosis due to incorrect use of the closure device. However, the artery had ruptured due to the insertion of a catheter with a cannula that was larger than the patient’s artery. Management and Outcome: Fortunately, excessive bleeding due to the size-mismatched cannula was prevented by an unintentional complication of the closing device, which saved the patient’s life. She underwent a right common femoral artery thrombectomy and patch angioplasty. Hospital guidelines have changed regarding the surgical removal of ECMO cannulas. Discussion: This report aims to highlight the importance of two aspects that are critical to a successful outcome: individualized cannula selection followed by precise insertion and removal and postoperative evaluation of a patient’s final status. Full article

Renal vein thrombosis (RVT) is a relatively uncommon condition that is most frequently observed in individuals with nephrotic syndrome. While rare, pyelonephritis (PN) may serve as a predisposing factor for secondary RVT. In such cases, one should consider the possibility of RVT when patients fail to respond to appropriate antibiotic treatment. Typically, these patients require additional anticoagulation therapy for a duration of 3 to 6 months, with a generally favorable prognosis. In this report, we present the case of a 74-year-old female who developed RVT due to Klebsiella pneumoniae PN. Additionally, we reviewed 11 cases of PN complicated by RVT, which were documented in the PubMed database over a span of 40 years, emphasizing key elements in diagnostic and therapeutic approaches. Lastly, we elaborated upon the role of thrombo-inflammation, especially in the context of sepsis. Full article

Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI. Full article

The healthcare industry is one application for data envelopment analysis (DEA) that can have significant benefits for standardizing health service delivery. This narrative review focuses on the application of DEA in emergency departments (EDs) and the management of emergency conditions such as acute ischemic stroke and acute myocardial infarction (AMI). This includes benchmarking the proportion of patients that receive treatment for these emergency conditions. The most frequent primary areas of study motivating work in DEA, EDs and management of emergency conditions including acute management of stroke are sorted into five distinct clusters in this study: (1) using basic DEA models for efficiency analysis in EDs, i.e., applying variable return to scale (VRS), or constant return to scale (CRS) to ED operations; (2) combining advanced and basic DEA approaches in EDs, i.e., applying super-efficiency with basic DEA or advanced DEA approaches such as additive model (ADD) and slack-based measurement (SBM) to clarify the dynamic aspects of ED efficiency throughout the duration of a first-aid program for AMI or heart attack; (3) applying DEA time series models in EDs like the early use of thrombolysis and percutaneous coronary intervention (PCI) in AMI treatment, and endovascular thrombectomy (EVT) in acute ischemic stroke treatment, i.e., using window analysis and Malmquist productivity index (MPI) to benchmark the performance of EDs over time; (4) integrating other approaches with DEA in EDs, i.e., combining simulations, machine learning (ML), multi-criteria decision analysis (MCDM) by DEA to reduce patient waiting times, and futile transfers; and (5) applying various DEA models for the management of acute ischemic stroke, i.e., using DEA to increase the number of eligible acute ischemic stroke patients receiving EVT and other medical ischemic stroke treatment in the form of thrombolysis (alteplase and now Tenecteplase). We thoroughly assess the methodological basis of the papers, offering detailed explanations regarding the applied models, selected inputs and outputs, and all relevant methodologies. In conclusion, we explore several ways to enhance DEA’s status, transforming it from a mere technical application into a strong methodology that can be utilized by healthcare managers and decision-makers. Full article

Classic surgical thrombectomy of the aorta and iliac arteries through an incision in the groin vessels harbors the risk of embolization to the viscero-renal as well as hypogastric arteries, while percutaneous endovascular thrombectomy techniques can lead to peripheral embolization to the lower limbs. Therefore, we describe a novel, percutaneous technique that tackles the above issues. Furthermore, we also present our initial experience using the technique. The principle of the technique is to percutaneously place large-bore sheaths in the iliac arteries that deliberately occlude the latter to protect the lower limbs from embolization. Through one of these sheaths, over wire Fogarty^® catheters can be placed and inflated in the ostia of the coeliac trunk, superior mesenteric artery, renal arteries, and hypogastric arteries as needed. A large thrombectomy balloon catheter is then used to bring any aorto-iliac thrombus into the sheaths, whereafter the thrombus is removed from the sheaths by simply deflating their valves. Additional endovascular procedures of the aorto-iliac branches can be performed as needed. We report nine procedures in 8 patients (4 males and 4 females) with a median age of 63 (53–68.5). Additional endovascular procedures were performed in 6 (66.7%) procedures. All but one procedure were technically successful, and all patients had palpable foot pulses on completion of the procedures, while no patient had clinical signs of peripheral embolization. This technique is a very valid addition to the vascular surgeon’s armamentarium when treating aorto-iliac thrombotic events because it is minimally invasive while still protecting against embolization and offering the flexibility to perform a wide range of additional endovascular procedures where needed. Full article

A 64-year-old male patient was admitted to the catheterization laboratory with a suspected myocardial infarction and in cardiogenic shock. Upon further investigation, a massive bilateral pulmonary embolism with signs of right heart dysfunction was discovered, leading to a decision to perform a direct interventional treatment with a thrombectomy device for thrombus aspiration. The procedure was successful in removing almost the entirety of the thrombotic material from the pulmonary arteries. The patient’s hemodynamics stabilized and oxygenation improved instantly. The procedure required a total of 18 aspiration cycles. Each aspiration contained approx. 60 mL blood amounting to a total of approx. 1080 mL of blood. During the procedure, a mechanical blood salvage system was used to resupply 50% of the blood via autotransfusion that would otherwise have been lost. The patient was transferred to the intensive care unit for post-interventional care and monitoring. A CT angiography of the pulmonary arteries after the procedure confirmed the presence of only minor residual thrombotic material. The patient’s clinical, ECG, echocardiographic, and laboratory parameters returned to normal or near normal ranges. The patient was discharged shortly after in stable conditions on oral anticoagulation. Full article

Lower extremity deep vein thrombosis (DVT) leads to significant morbidity including pain, swelling, and difficulty walking in the affected limb. If left untreated, DVT increases the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE), and post thrombotic syndrome (PTS). The objective of this review was to identify catheter-directed interventions and their success rates for the treatment of lower extremity DVT. A comprehensive search of current and emerging catheter-directed interventions for lower extremity DVT treatment was conducted in PubMed and Google Scholar. Clinical trials, retrospective and prospective observational studies, and case reports were identified to classify percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), and pharmacomechanical CDT (PCDT) devices based on their mechanism of action and indication of use. Catheter-directed interventions such as PMT, CDT, and PCDT offer an alternative therapeutic strategy for DVT management, particularly in patients with limb-threatening conditions and absolute contraindications to anticoagulants. Currently, there are limited guidelines for the use of mechanical and pharmacomechanical devices because of the lack of clinical evidence available for their use in treatment. Future studies are required to determine the short and long-term effects of using catheter-directed interventions as well as their effectiveness in treating acute versus subacute and chronic DVT. Full article

There is a discrepancy between epicardial vessel patency and microcirculation perfusion in a third of patients treated with percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Optimization with aspiration thrombectomy (AT) may reduce distal embolization and microvascular obstruction. The effect of AT in the treatment of STEMI is debatable. The purpose of this study was to use cardiac magnetic resonance (CMR) to determine whether AT influences microvascular obstruction (MVO), infarct size and left ventricular (LV) remodelling in STEMI patients. Sixty STEMI patients with a thrombus-occluded coronary artery were randomized in a 2:1 fashion to receive PCI proceeded by AT (AT + PCI group), or PCI only. MVO, myocardial infarct size and LV remodelling were assessed by CMR during the index hospitalization and 6 months thereafter. The majority of patients had a large thrombus burden (TIMI thrombus grade 5 in over 70% of patients). PCI and AT were effective in all cases. There were no periprocedural strokes. CMR showed that the addition of AT to standard PCI was associated with lesser MVO when indexed to the infarct size and larger infarct size reduction. There were less patients with left ventricle remodelling in the AT + PCI vs. the PCI only group. To conclude, in STEMI patients with a high thrombus burden, AT added to PCI is effective in reducing infarct size, MVO and LV remodelling. Full article