Search Results (32)

Background: Acute portal vein thrombosis (aPVT) is a severe complication of the splanchnic venous system, often associated with portal hypertension, intestinal ischemia, and hepatic dysfunction. Anticoagulation is the first-line therapy but is frequently insufficient in advanced Yerdel grade III–IV cases, where recanalization rates remain low. Endovascular interventions have emerged as alternative therapeutic strategies in selected patients. Methods: We present three cases of patients with Yerdel grade III–IV aPVT who underwent endovascular management. The techniques included: (1) transhepatic aspiration thrombectomy combined with intra-thrombus thrombolysis using alteplase (Actilyse); (2) combined aspiration thrombectomy, intra-thrombus thrombolysis with alteplase, portal vein stenting, and transjugular intrahepatic portosystemic shunt (TIPS) creation; and (3) transsplenic aspiration thrombectomy followed by angioplasty, stent placement, and TIPS creation in a post-liver transplant patient. Results: All procedures were technically successful, achieving complete or near-complete recanalization of the portal venous system. Restoration of patency in the extrahepatic portal circulation was confirmed, and portal pressures were reduced in the TIPS-assisted case. No major periprocedural complications occurred. Clinical outcomes included preservation of transplant candidacy and graft salvage. Conclusions: Endovascular therapy may be an option in selected patients with acute portal vein thrombosis. Careful patient selection and an individualized technical approach are essential. Full article

Adventitial cystic disease (ACD) is a rare vascular condition, representing approximately 0.1% of all vascular diseases, with about 325 cases reported in the literature since its first description in 1947, including 72 venous cases. This study aims to highlight the diagnostic and therapeutic challenges of venous ACD, which is frequently misdiagnosed as deep vein thrombosis (DVT), femoral varices, aneurysms, venous tumors, or lymphadenopathy due to its rarity. Clinical, imaging, and treatment data from reported cases of venous adventitial cystic disease (VACD) were reviewed. The disease most commonly involved the common femoral vein (56%) and external iliac vein (24%), with less frequent involvement of the saphenous and popliteal veins (7%). Symptoms commonly mimic deep vein thrombosis (DVT), with unilateral swelling resulting from progressive cyst enlargement and subsequent venous luminal stenosis. Doppler ultrasound typically shows a hypoechoic lesion in the venous wall with preserved flow and normal D-dimer levels, while CT angiography and MRI confirm an adventitial cyst occupying ≥ 90% of the lumen without thrombus. Surgical intervention, particularly transadventitial cyst evacuation with excision, is the preferred method of treatment due to lower recurrence rates (7–20%) as compared to cyst aspiration and drainage with higher recurrence (83.3%). These findings highlight the need for heightened clinical suspicion and advanced imaging to optimize the diagnosis and management of venous ACD and reduce misdiagnosis and recurrence. Further studies are needed to optimize diagnostic protocols and treatment strategies, but the limited number of cases hampers meaningful scientific research. Full article

Objective: The AXS Vecta 46 intermediate catheter (Stryker) features a large inner diameter, enabling effective aspiration, combined with a small outer diameter and soft distal-tip flexibility, which allows for safe tracking through more tortuous and smaller arterial segments to target medium vessel occlusions non-traumatically. The efficacy of the Vecta 46 in the spectrum of large and medium vessel occlusions has not been well elucidated in the literature. Methods: This retrospective cohort study included patients who underwent MT for acute ischemic stroke at our institution between July 2022 and June 2024. The outcomes of patients treated with Vecta 46 were compared to those of all other catheters used at the institution. Results: The distribution of aspiration and stent retriever attempts in Vecta 46 procedures versus non-Vecta 46 procedures was significantly different (p = 0.00325). Aspiration was attempted 1.66 ± 0.936 times in the Vecta 46 group and 1.12 ± 0.650 times in the non-Vecta 46 group (p = 0.00135). More mechanical thrombectomies with the Vecta 46 included aspiration of a secondary thrombus (p = 0.0314), despite no difference in the distribution of the primary or secondary occlusion location. There were no statistically significant differences in recanalization success (p = 0.800), recanalization time (p = 0.245), procedure duration (p = 0.580), discharge modified Rankin Score (p = 0.875), or intracranial hemorrhage rate (p = 0.720) between non-Vecta 46 and Vecta 46 procedures. Conclusions: Vecta 46 has similar safety and functional outcomes compared to other endovascular treatment options despite procedural differences. Full article

Clot-in-transit (CIT) is a free-floating thrombus in the right heart and can enter pulmonary circulation at any moment. Possible treatments include anticoagulation, systemic thrombolysis, surgical embolectomy, and endovascular catheter-based therapies. The optimal treatment is still undetermined, heavily relying on clinical judgment and multidisciplinary team discussion. We report a case of a 70-year-old woman presenting with tachydyspnoea following recent abdominal surgery, who was diagnosed with massive bilateral pulmonary embolism (PE) complicated by a clot-in-transit. Point-of-care ultrasonography revealed a large mobile thrombus in the right atrium with severe right ventricular dysfunction. Due to haemodynamic instability and a contraindication for systemic thrombolysis, mechanical thrombectomy was performed. A large thrombotic burden was aspirated from the right heart and pulmonary arteries, resulting in haemodynamic stabilization and recovery of right ventricular function. The patient remained stable throughout hospitalization and was discharged on oral anticoagulation therapy with complete recovery on follow-up. This case highlights several points. Firstly, CIT is a rare finding but should be considered in patients with massive pulmonary embolism and shock. Furthermore, POCUS is essential for diagnosing CIT. Finally, mechanical thrombectomy is a valuable therapeutic option in high-risk PE patients with contraindications to systemic thrombolysis and haemodynamic instability. Further studies are needed to establish adequate guidelines for the optimal management of CIT patients. Full article

Background: The mechanisms underlying fibrinolysis failure in patients with STEMI who are undergoing a pharmacoinvasive strategy appear to be multifactorial and may be associated with the thrombus’s architecture and composition. Objective: We aimed to compare the thrombus composition in patients with STEMI who were undergoing rescue percutaneous coronary intervention (rPCI) versus primary PCI (pPCI) using optical microscopy (OM) and scanning electron microscopy (SEM). Methods: Fifty-three patients were prospectively enrolled, with twenty-five undergoing rPCI and twenty-eight undergoing pPCI. After thrombus aspiration, each harvested fragment was divided into two pieces: one was analyzed using OM with a 60× magnifying lens on hematoxylin–eosin-stained samples, and the other with SEM at 5000× magnification. Results: Patients who underwent rPCI had significantly higher C-reactive protein levels and a longer ischemic interval at admission compared to those treated with pPCI (9.92 h [range: 1.58–106.17] vs. 2.14 h [range: 0–48]; p < 0.001). Optical microscopy analysis revealed that thrombi from rPCI patients exhibited a significantly higher erythrocyte area percentage (18.36% [range: 0.3–50.08] vs. 0.91% [range: 0–70.1]; p = 0.001), a lower fibrin content as assessed by optical microscopy (79.49% [range: 49.2–98.25] vs. 94.43% [range: 29.19–99.92]; p = 0.006), and a greater amount of cholesterol crystals as measured by SEM (1.73 μm² [range: 0–18.51] vs. 0.08 μm² [range: 0–0.71]; p < 0.001). Conclusions: The thrombus composition of patients with STEMI who are undergoing rPCI had higher amounts of erythrocytes and cholesterol crystals and a lesser area occupied by fibrin compared to those undergoing pPCI. The composition of thrombi in rPCI could potentially contribute to the failure of fibrinolytic therapy within a pharmacoinvasive strategy. Full article

Acute pulmonary embolism (APE) represents a significant cause of morbidity and mortality worldwide, requiring rapid and precise diagnosis and effective therapy strategies. Computed Tomography Pulmonary Angiography (CTPA) is currently the gold standard technique for diagnosing PE; however, it presents some disadvantages, including limited sensitivity in detecting sub-segmental emboli and contrast-related risks. Recent advancements in imaging technologies, including Dual-Energy Computed Tomography (DECT) and Photon Counting (PC), offer improved sensitivity and specificity for APE and perfusion abnormalities detection. Digital Dynamic Radiography (DDR) perfusion imaging represents a novel imaging that allows pulmonary perfusion assessment without contrast medium administration, able to detect anomalies at the patient’s bedside, representing a promising advancement, particularly for critically ill or contrast-allergic patients. In parallel, interventional radiology has become integral to APE management, particularly for high-risk and intermediate–high-risk patients, with evolving intravascular treatment techniques such as catheter-directed thrombolysis, mechanical thrombectomy, and thrombus aspiration. This narrative review provides an overview of the latest developments in APE diagnostic imaging and interventional radiology, contextualizing them within current guideline recommendations for endovascular treatment. Full article

Inflammation contributes to myocardial injury in ST-elevation myocardial infarction (STEMI). Interleukin-6 receptor (IL-6R) inhibition has been shown to mitigate myocardial injury and reduce levels of the prothrombotic and inflammatory mediator, neutrophil extracellular traps (NETs). The enzyme peptidylarginine deiminase 4 (PAD4) is central in NET formation. We hypothesized that PAD4 links IL-6R activation and NET formation. Methods: We conducted thrombus aspiration and peripheral blood sampling in 33 STEMI patients. In thrombi and leukocytes, we quantified the mRNA of IL-6, IL-6R, and PAD4. In peripheral blood, the protein levels of IL-6, IL-6R, PAD4, dsDNA, H3Cit, MPO-DNA, and troponin T were quantified. Results: In thrombi and circulating leukocytes, PAD4 mRNA was associated with IL-6R mRNA (thrombi: β = 0.34, 95% CI [0.16–0.53], p = 0.001, circulating leukocytes: β = 0.92, 95% CI [0.07–1.77], p = 0.036). There were no correlations between PAD4 and IL-6 in thrombi and leukocytes. The protein levels of IL-6R were associated with the NET marker H3Cit (r_s = 0.40, p = 0.02). In thrombi, PAD4 mRNA was associated with high levels of troponin T (β = 1.15 95% CI [0.27–2.04], p = 0.013). Conclusion: We demonstrate an association between PAD4, IL-6R, and troponin release in STEMI patients. Our findings indicate a PAD4-mediated connection between IL-6R and NET formation and highlight PAD4 as a potential treatment target for mitigating inflammation and myocardial injury in STEMI. 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

Background: ST-segment elevation myocardial infarction (STEMI) remains a leading cause of mortality worldwide, primarily caused by acute thrombosis over atherosclerotic plaques. Simultaneous acute thrombosis in two coronary arteries is an exceptionally rare event. This report highlights a unique case of STEMI associated with cardiogenic shock due to dual coronary artery thrombosis and provides insights from a literature review on this rare condition. Methods: We report the case of a 58-year-old male with a history of hypertension, type II diabetes, and heavy smoking, who presented with a two-day history of chest pain and cardiogenic shock. Diagnostic evaluation included an electrocardiogram showing ST-segment elevation in AVR and ischemia, along with echocardiography revealing severe left ventricular dysfunction (ejection fraction 20%). Emergency coronary angiography was performed to identify the underlying pathology. Additionally, a literature review was conducted to analyze the characteristics and outcomes of similar cases of dual coronary artery thrombosis. Results: Coronary angiography identified significant occlusions in the proximal circumflex branch and the left anterior descending artery (LAD), a combination rarely reported in the literature. Our review confirmed that dual thrombosis involving the LAD and right coronary artery (RCA) is the most frequently described presentation of this condition, while simultaneous CFX and LAD thrombosis is exceedingly rare. Most reported cases, including ours, were associated with cardiogenic shock, highlighting the severity of this clinical entity. Despite successful thrombus aspiration and stenting, our patient experienced severe complications, including infections, pleural effusions, and paralytic ileus, ultimately requiring evaluation for left ventricular assist device implantation. Conclusions: This case underscores the complexity and critical challenges of managing STEMI with cardiogenic shock due to simultaneous coronary thrombosis. The findings from our literature review suggest the need for heightened clinical awareness and tailored revascularization strategies. Further studies are warranted to optimize management approaches and improve outcomes in such rare and high-risk scenarios. 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

The structure of aspirated coronary thrombus in ST-segment elevation myocardial infarction (STEMI) is still being studied. Our aims were to characterize coronary thrombi of different ages, focusing on the appearance of activated protein C (APC/PC) and its relation to the elements of neutrophil extracellular traps (NETs), and the factors closely related to fibrin as factor XIII (FXIII) and α2 plasmin inhibitor (α2-PI). The thrombi of n = 24 male patients with atherosclerotic coronary plaque rupture related to native coronary artery occlusion were selected for histopathology analysis. Thrombus age was distinguished as fresh, lytic, and organized, and then analyzed by immunofluorescent staining and confocal microscopy. FXIII was present at a high level and showed a high degree of co-localization with fibrin in all stages of thrombus evolution. The amount of α2-PI was low in the fresh thrombi, which increased significantly to the lytic phase. It was evenly distributed and consistently associated with fibrin. APC/PC appeared in the fresh thrombus and remained constant during its evolution. The presence of NET marker and CD66b was most dominant in the lytic phase. APC/PC co-localization with the elements of NET formation shows its role in NET degradation. These observations suggest the importance of searching for further targeted therapeutic strategies in STEMI patients. 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

Despite growing evidence over the last few years of the efficacy and safety of direct thrombus aspiration using a large bore distal access catheter as a type of mechanical thrombectomy procedure in acute stroke large-vessel occlusion patients, the experience and evidence of this technique for managing thromboembolic complications in endovascular aneurysm treatment is still limited and little research is available regarding this topic. We present a case of a thromboembolic occlusion of the left middle cerebral artery during the preprocedural angiograms of a large and fusiform left internal carotid artery aneurysm. This complication was successfully managed by navigating an already-placed distal access catheter intended for support during the opening of the flow-diverting stent; therefore, the thrombus was manually aspirated for two minutes, and Thrombolysis in Cerebral Infarction (TICI) scale 3 flow was restored. This case should encourage the use of a distal access catheter, already placed for aneurysm treatment, to perform zero-delay direct thrombus aspiration as a rescue approach for thromboembolic complications during endovascular treatments. 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

Background: Basilar artery occlusion (BAO) is a serious disease with a poor prognosis if left untreated. Endovascular therapy (EVT) is the most effective treatment that is able to reduce mortality and disability. Treatment results are influenced by a wide range of factors that have not been clearly identified. In the present study, direct aspiration was chosen as a first-line treatment. The safety and effectiveness of direct aspiration in BAO were determined, and factors affecting patient outcomes were identified. Methodology: Data for patients with BAO treated between November 2013 and December 2021 were evaluated using a database. The association between clinical and procedural parameters and functional outcome was assessed. Results: A total of 89 patients with BAO were identified. Full recanalization was achieved in 69.7% of cases and partial recanalization in 19.1%. Intracranial hemorrhage was detected in 11 (12.4%) patients, of which, eight (9.0%) patients experienced symptomatic intracranial hemorrhage. Patients with good outcomes presented with milder strokes (mean NIHSS score of 12.58 vs. 24.00, p < 0.001), had higher collateral scores (6.79 vs. 5.88, p = 0.016), more often achieved complete recanalization (87.9% vs. 58.9%, p = 0.009), and more often experienced early neurological improvement (66.7% vs. 26.8%, p < 0.001). On the contrary, patients with worse outcomes had higher serum glucose levels (p = 0.05), occlusion of the middle portion of the basilar artery (MAB) (30.3% vs. 53.6%, p = 0.033), longer thrombus lengths (10.51 vs. 16.48 mm, p = 0.046), and intracranial hemorrhage (p = 0.035). Conclusions: The present study results suggest that direct aspiration is a safe and effective treatment for patients with BAO. We identified several factors affecting the patients’ outcome. Full article