Abstract:

Aim: was to evaluate immediate and long-term results of using the catheter-directed thrombosis (CDT) in patients with acute iliofemoral thrombosis.

Materials and methods: the study included 26 patients (9 men and 17 women aged 31-70) with primary or iliofemoral thrombosis, which was made by CDT Assessment of immediate results was conducted and long-term results were tracked after 12 months.

Results: technical success of treatment was achieved in 22 (84,6%) patients. In 7 (26.9%) patients after the completion of CDT, hemodynamically significant stenoses were identified and addition stenting of iliac veins were performed. Preservation of primary permeability after 12 months was observed in 26 patients (96.2%). The presence of pathological venous reflux was observed in 6(23.1%) cases. Development of post-thrombotic disease (PTD) of mild and medium severity was observed in 7 (26.9%) patients.

Conclusion: catheter-directed thrombolysis in combination with traditional anticoagulant therapy is a safe and effective method of treatment in patients with acute iliofemoral thrombosis, and allows quickly to restore venous patency and also to reduce risk of development and severity of clinical manifestation of PTD.

References

1.      Vedantham S, Thorpe PE, Cardella JF, Grassi CJ, Patel NH, Ferral H, et al. Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. Journal of Vascular and Interventional Radiology. 2006; 17: 435-48.

2.      Henke PK, Comerota AJ. An update on etiology, prevention, and therapy of postthrombotic syndrome. Journal of Vascular Surgery. 2011; 53: 500-509.

3.      Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed Thrombolysis for Lower Extremity Deep Venous Thrombosis: Report of a National Multicenter Registry. Radiology. 1999; 11: 39-49.

4.      Kahn SR, Partsch H. Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. Journal of Thrombosis and Haemostasis. 2009; 7: 879-83.

5.      Comerota AJ, Kamath V. Thrombolysis for iliofemoral deep venous thrombosis. Expert Review of Cardiovascular Therapy. 2013; 12:1631-1638.

6.      Semba CP, Dake MD. Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis. Radiology. 1994; 191: 487-494.

7.      Vedantham S., Sista A.K., Klein S.J., Nayak L., Razavi M.K., Kalva S.P., et al. Quality Improvement Guidelines for the Treatment of Lower-Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. Journal of Vascular and Interventional Radiology. 2014; 25: 1317-1325.

8.      Vedantham S, Goldhaber S, Julian J. ATTRACT Trial Investigators. Pharmacomechanical catheter-directed thrombolysis deep-vein thrombosis. N Engl J Med. 2017; 23: 2240-2252.

9.      Kolbel T, Alhadad A, Acosta S, Lindh M, Ivancev K, Gottsдter A. Thrombus Embolization Into IVC Filters During Catheter-Directed Thrombolysis for Proximal Deep Venous Thrombosis. Journal of Endovascular Therapy. 2008; 15: 605-613.

Abstract:

The article presents an analysis of the choice of strategy for the treatment of ischemic stroke in the acute period, based on literature review.

Aim: was to develop the concept of effective thromboextraction (TE), based on the evaluation of factors influencing results of reperfusion treatment of ischemic stroke (IS), methods of endovascular restoration of cerebral blood flow

Materials and methods: meta-analysis of 44 sources of domestic and foreign literature is performed. The analysis of factors limiting the effectiveness of various reperfusion approaches and the analysis of modern methods of thrombectomy are performed.

Results: it is established, that SMAT (Solumbra) and PROTECT techniques have an advantage in comparison with aspiration approaches to thrombectomy in reducing the period to full reperfusion; methods with temporary occlusion of the source vessel (BGC) SAVE and PROTECT significantly reduce the risk of stroke spread to new vascular areas of the brain and increase the frequency of successful recanalization.

Conclusion: at present time, the PROTECT is the most effective technique in the frequency of successful recanalization, the degree and speed of achieved reperfusion, as well as in the prevention of distal embolization. Extrapolation of experience and principles from other sections of interventional radiology, development of new methods and strategies of brain reperfusion, depending on the morphology of thromboembolism, its size, localization and extent may contribute to improving results of endovascular treatment of ischemic stroke.

References

1.      Newsletter of the WHO №317, 2015 January.

2.      Jansen O., von Kummer R., Forsting M. et al. Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. AJNR Am J Neuroradiol. 1995; Nov-Dec; 16(10): 1977-86.

3.      Furlan A., Higashida R., Wechsler L. et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999 Dec; 282(21): 2003-11.

4.      Domashenko M.A., Maksimova M.Yu., GafarovaM.E. i dr. Personifikatsiya podkhodov k reperfuzionnoj terapii ishemicheskogo insul'ta [Personification of approaches to reperfusion therapy of ischemic stroke.] Annaly klinicheskojI experimental'noj nevrologii. 2017; 11(1): 7-13.

5.      Domashenko M.A., Panova K.V., Murtazalieva D.M. i dr. Personifikatsiya tromboliticheskoj terapii patsientov s ishemicheskim insulom [Personification of thrombolytic therapy in patients with ischemic stroke.] Medica mente. 2017; 3(1): 45-48.

6.      Emberson J. et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. - 2014; 384(9958): 1929-1935.

7.      Fransen P.S., Berkhemer O.A., Lingsma H.F. et al. Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurol. 2016 Feb; 73(2): 190-196.

8.      Seet R.C., Rabinstein A.A. Symptomatic intracranial hemorrhage following intravenous thrombolysis for acute ischemic stroke: a critical review of case definitions. Cerebrovasc Dis. 2012; 34: 106-114.

9.      Yaghi S., Eisenberger A., Willey J.Z. Symptomatic intracerebral hemorrhage in acute ischemic stroke after thrombolysis with intravenous recombinant tissue plasminogen activator: a review of natural history and treatment. JAMA Neurol. 2014; 71(9): 1181-1185.

10.    Yaghi S., Boehme A.K., Dibu J. et al. Treatment and Outcome of Thrombolysis-Related Hemorrhage: A Multicenter Retrospective Study. JAMA Neurol. 2015; 72(12): 1451-1457.

11.    Hacke W., Kaste M., Bluhmki E. et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008; 359: 1317-1329.

12.    Nikoubashman O., Reich A., Pjontek R. et al. Postinterventional subarachnoid haemorrhage after endovascular stroke treatment with stent retrievers. Neuroradiology. 2014; Dec; 56(12): 1087-1096.

13.    Kornienko V.N., Pronin I.N. Diagnosticheskaya nejroradiologiya. [Diagnostic Neuroradiology]. Moscow. 2006: 1317 [In Russ].

14.    Urbach H. et al. Local intra-arterial thrombolysis in the carotid territory: does recanalization depend on the thromboembolus type? Neuroradiology 2002; 44: 695-699.

15.    Riedel C.H., Zimmermann P., Jensen-Kondering U. et al. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011;Jun; 42(6):1775-1777.

16.    Del Zoppo C.J. et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann. Neurol. - 1992, 32: 78-86.

17.    Mori E. et al. Intravenous recombinant tissue plasminogen activator in acute carotid territory stroke. Neurology, 1992; 42: 976-982.

18.    Shamalov N.A. Optimizatsiya reperfusionnoj terapii u patsientov s ishemicheskim insultom. Diss. dokt. med. nauk [Optimization of reperfusion therapy in patients with ischemic stroke. Dr. med. sci. diss.]. Moscow. 2012: 47 [In Russ].

19.    Lansberg M.G. et al. Risk factors of symptomatic intracerebral hemorrhage after tPA therapy for acute stroke. Stroke. - 2007; 38: 2275-2278.

20.    Bracard S., Ducrocq X., Mas J.L., et. al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016; Oct; 15(11): 1138-1147.

21.    Powers W.J., Rabinstein A.A., Ackerson T. et al. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2018 Mar; 49(3): 46 - 99.

22.    Eva A. Mistry, Akshitkumar M. Mistry, Mohammad Obadah Nakawah, Mechanical Thrombectomy Outcomes with and without Intravenous Thrombolysis in Stroke Patients. Stroke. 2017 Sept; 48(9): 2450-2456.

23.    Kaesmacher J., Boeckh-Behrens T., Simon S. et al. Risk of Thrombus Fragmentation during Endovascular Stroke Treatment. AJNR Am J Neuroradiol. 2017 May; 38(5): 991-998.

24.    Nikoubashman O., Reich A., Pjontek R. et al. Postinterventional subarachnoid haemorrhage after endovascular stroke treatment with stent retrievers. Neuroradiology. 2014 Dec; 56(12): 1087-1096.

25.    Kang D.H., Park J. Endovascular Stroke Therapy Focused on Stent Retriever Thrombectomy and Direct Clot Aspiration: Historical Review and Modern Application J Korean Neurosurgical Society 2017 May; 60(3): 335-347.

26.    Kang D.H., Hwang YH., Kim YS. et al. Direct thrombus retrieval using the reperfusion catheter of the penumbra system: forced-suction thrombectomy in acute ischemic stroke. AJNR Am J Neuroradiol. 2011 Feb; 32(2): 283 - 287.

27.    Hwang YH., Kang D.H., Kim YW. et al. Outcome of forced-suction thrombectomy in acute intracranial internal carotid occlusion. J Neurointervent Surg. 2013; 5 (Suppl 1): 81-84.

28.    Turk AS, Spiotta A, Frei D, et al. Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy. J Neurointervent Surg. 2014 Apr; 6(3): 231-237.

29.    Lee D.H., Sung J.H., Kim S.U. et al. Effective use of balloon guide catheters in reducing incidence of mechanical thrombectomy related distal embolization. Acta Neurochirurgica 2017 Sept; 159(9): 1671-1677.

30.    Kang D.H., Kim YW., Hwang YH. et al. Switching strategy for mechanical thrombectomy of acute large vessel occlusion in the anterior circulation. Stroke. 2013; Dec; 44(12): 3577-3579.

31.    Deshaies EM. Tri-axial system using the Solitaire-FR and Penumbra Aspiration Microcatheter for acute mechanical thrombectomy. J Clin Neurosci. 2013; 20(9): 1303-1305.

32.    Humphries W., Hoit D., Doss V.T. et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg. 2015; 7(2): 90-94.

33.    Lee J.S., Hong J.M., Lee S.J. et al. The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion. Acta Neurochir (Wien) 2013; 155(4): 635 - 641.

34.    Jadhav A.P, Aghaebrahim A., Horev A. et. al. Jovina, Stent Retriever-Mediated Manual Aspiration Thrombectomy for Acute Ischemic Stroke. Interv Neurol. 2017 Mar; 6(1-2): 16 - 24.

35.    Maegerlein C., Mцnch S., Boeckh-Behrens T. et al. PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy - evaluation of a double embolic protection approach in endovascular stroke treatment. J Neurointerv Surg. 2017; 0: 1 - 5.

36.    Maus V., Behme D., Kabbasch C. et al. Maximizing First-Pass Complete Reperfusion with SAVE. Clin Neuroradiol. 2017 Feb 13. doi: 10.1007/s00062-017-0566-z.

37.    Wiesmann M., Brockmann M.A., Heringer S. et al. Active push deployment technique improves stent/vesselwall interaction in endovascular treatment of acute stroke with stent retrievers. J Neurointerv Surg. 2017 Mar; 9(3): 253 - 256.

38.    Nikoubashman O., Alt J.P, Nikoubashman A. et al. Optimizing endovascular stroke treatment: removing the microcatheter before clot retrieval with stent-retrievers increases aspiration flow. J Neurointerv Surg. 2017 May; 9(5): 459-462.

39.   Volodyukhin M.U., Novozhilova A.A. Sposob vosstanovleniya krovotoka pri sochetannom tromboze vnutrennej sonnoj I srednej mozgovoj arterij [A method for restoring of blood flow in a combined thrombosis of the internal carotid and middle cerebral artery]. Patent RF №2629046, 2016.

40.    Volodyukhin M.U. Rentgenendovaskulyarnyj metod vosstanovleniya cerebral'nogo krovotoka pri ostroy tandemnoj okklyuzii vnutrennej sonnoj arterii s razvitiem embolii v srednyuyu mozgovuyu arteriyu. [Endovascular method of cerebral blood flow restoration in acute tandem occlusion of the internal carotid artery with embolism development in the middle cerebral artery.] Kazanskij meditsinskijzhurnal. 2016; 97(3): 457-460.

41.    Noser EA, Shaltoni HM, Hall CE, et al. Aggressive mechanical clot disruption: a safe adjunct to thrombolytic therapy in acute stroke? Stroke 2005; 36: 292-296.

42.    Nakano S., Iseda T., Yoneyama T. et al. Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: an alternative option to intra-arterial thrombolysis. Stroke 2002; 33: 2872-2876.

43.    Qureshi AI, Siddiqui AM, Suri MF. et al. Aggressive mechanical clot disruption and low-dose intra-arterial third-generation thrombolytic agent for ischemic stroke: a prospective study. Neurosurgery 2002; 51: 1319-1329.

44.    von Gadow N., Nikoubashman O., Freiherr J. et al. Endovascular stroke treatment now and then-procedural and clinical effectiveness and safety of different mechanical thrombectomy techniques over time. Quant Imaging Med Surg. 2017 Feb; 7(1): 1-7.

Abstract:

Thrombolytic therapy (TLT) is the most efficient method of reperfusion therapy in ischemic stroke (IS), considerably increasing the number of patients with good functional restoration obtained. Carrying out selective intraarterial TLT (IA TLT) is feasible within the framework of a wider therapeutic window (up to 6-8 hours from the onset of the disease) under angiographic control and a possibility of individual dosing of a fibrinolytic employed. The present study demonstrated high efficiency of selective IATLT based on two clinical examples of patients presenting with IS. In the first case, a 55-year-old male patient with occlusion of M1 segment of the right median cerebral artery (MCA) and a baseline NIH score equalling 13 underwent IA TLT preformed 7 hours after the onset of IS, which led to complete recanalization of the vessel after 40 minutes, and resulted in a considerable clinical improvement (8 points by the NIH scale after TLT). The second case describes a 64-year-old female patient presenting with segment C7 stenosis of the left internal carotid artery and occlusion of segment M1 2 of the left MCA (20 points by the NIH scale). Carrying out IA TLT also promoted restoration of the blood flow after 60 minutes and restoration of the disordered functions (NIHSS score 14). Hence, the described examples demonstrate high efficacy of intra-arterial thrombolysis in management of patients with ischemic stroke.

Reference

1.     Гусев Е.И., Скворцова В.И., Киликовский В.В., Стаховская Л.В., Айриян Н.Ю.«Проблема инсульта в Российской Федерации». Качество жизни. 2006; (13): 10- 14.

2.     European Stroke Initiative Recommendations for stroke Management - Update 2003. Cerebrovasc Dis. 2003; 16:311-337.

3.     del Zoppo G. J., Higashida R.T., Furlan A.J., Pessin M.S., Rowley H.A., Gent M. PROACT: A Phase II Randomized Trial of Recombinant Pro-Urokinase by Direct Arterial Delivery in Acute Middle Cerebral Artery Stroke. Stroke. 1998; 29: 4 - 11.

4.     Arnold M., Schroth G., Nedeltchev K., Loher T.J., Stepper E, Remonda L., Sturzenegger M., Mattle H. Intra-arterial thrombolysis in 100 patients with acute stroke due to middle cerebral artery occlusion. Stroke. 2002; 33: 1828-1833.

5.     Arnold M., Nedeltchev K., Mattle H.P., Loher T.J., Stepper E, Schroth G., Brekenfeld C., Sturzenegger M., Remonda L. Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T-occlusions. J. Neurol Neurosurg Psychiat. 2003; 74: 739-742.

6.     Lee D.H., Jo K.D., Kim H.G., Choi S.J., Jung S.M., Ryu D.S., Park M.S. Local intra-arterial urokinase thrombolysis of acute ischemic stroke with or without intravenous abciximab: a pilot study. J. Vasc Interv Radiol. 2002; 13: 769 - 774.

7.     ThОron J., Coskun O., Huet H., Oliveira G., Toulas P., Payelle G. Local intra-arterial thrombolysis in the carotid territory. Interventional Neuroradiology. 1996; 2: 111 - 126.

8.     Zeumer H., Freitag H.J., Zanella E, Thie A., Arning C. Local intra-arterial fibrinolytic therapy in patients with stroke: urokinase versus recombinant tissue plasminogen activator (rt-PA). Neuroradiology. 1993; 35: 159- 162

9.     Lisboa C., Borko D. Jovanovic, Mark J.Alberts. Analysis of the Safety and Efficacy of Intra-Arterial Thrombolytic Therapy in Ischemic Stroke. Stroke. 2002; 33: 2866.

10.   Волынский Ю.Д., Гаврилов А.В. Оценка гемодинамики и перфузии на основе компьютерного анализа ангиографических изображений. Материалы конференции «Современные технологии в клинической медицине» Санкт-Петербург. 2003; 151 - 152.

11.   Волынский Ю.Д., Гаврилов А.В. Рентгеновидеоденситометрия - метод оценки кровотока по плечеголовным и внутримозговым сосудам. Материалы конференции «Повреждения и заболевания шейного отдела позвоночника». 2004; 9-11.

Abstract:

In clinical practice, ischemic stroke still remains a difficult problem, being in most leading causes of death. Development of new treatments, founding of new therapeutic algorythmes and untiringly technical progress in sphere of instrumental support of operation-room allow to proceed endovascular intervention in group of patients with cardioembolic stroke.

Case report presents successful endovascular treatment of patient from cardio-surgical department of Belgorod Region Clinical Hospital named after St. loasaf, with cardioembolic stroke, onset in preoperative period (before aorto-coronary bypass).

Materials and methods: patient A., 59 years, diagnosis: «Ischemic heart disease. Exertional angina FC II. Post-infarction cardiosclerosis. (AMI in September 2014). Stenosis of coronary arteries according to coronary angiography (CAG), hemodynamically significant. Hypertensive heart disease III st., 2 degree, with the defeat of the heart and blood vessels of the brain, with the achievement of target blood pressure (BP). Diabetes mellitus type 2, the second insulin-depended, stage subcompensation. Risk factor 4. congestive heart failure 2a class, functional class III. Chronic gallstone disease. Chronic calculous cholecystitis without exacerbation». 05.02.15 - onset of ischemic stroke in left hemisphere of brain. Patient urgently underwent: multislice computed tomography (MSCT), MSCT-angiography of main brain arteries, direct angiography of main brain arteries. Survey showed: occlusion of proximal third of left common carotid artery (CCA) with TICI-0 blood flow; left middle cerebral artery (MCA) and anterior cerebral artery (ACA) were filled threw anterior communicating artery (ACoA) from right internal carotid artery (ICA). Patient underwent: recanalization of occlusion, thrombectomy from left CCA, stenting of CCA-ICA segment, selective thrombolythic therapy into left MCA.

Results: «Time-To-Treatment» was 4 hours 15 minutes. Made endovascular treatment leaded to regression of neurological deficit.

Conclusions: the use of endovascular methods in patients with cardioembolic stroke car decrease neurological deficit and increase quality of life of patients in this group.  

References 

1.    «10 ведущих причин смерти в мире». ВОЗ. Информационный бюллетень №310 от 05.2014.

2.    Parfenov V.A., Khasanov D.R.. Ishemicheskiy insult. [Ischemic stroke.] «Medicinskoe informacionnoe agenstov». 2012; 298 [In Russ].

3.    Fonyakin A.V., Geras'kina L.A. Profilaktika ishemicheskogo insulta. Rekomendacii po antitromboticheskoy terapii. [Prophylaxis of ischemic stroke. Recommendations for antithrombotic therapy] (Pod redaktsiei Z.A. Suslinoy). M: IMA-PRESS. 2014; 72.

4.    Michael J. Schneck et al. Overview cardioembolic stroke. Section 20.01.2015 http://emedicine. medscape.com /article/1160370-overview#aw2aab6b2

5.    Wilterdink J.L., Furie K.L., Easton D. Cardiak evaluation of stroke patients. Neurology 1998; 51(3): 23-26.

6.    Petty G.W., Brown R.D., Whisnant J.P. et al. Ischemic stroke subtypes. A populationbased study of functional outcome, survival and recurrence. Stroke. 2000; 31: 1062-1068.

7.    Kelley R.E., Minagar A. Cardioembolic Stroke: An Update. South Med J. 2003; 96(4): 343-349.

8.    Secades J.J. Citicoline: pharmacological and clinical review, 2010 update / J. Secades. Revista de Neurologia. 2011; 52(2): 1-62.

9.    Kuznetsov V.V., Egorova M.S., Fibrillyacia predserdiy kak patogeneticheskiy mekhanizm razvitiya kardioembolicheskogo insulta. [Atrial fibrillation - a pathogenetic mechanism of cardioembolic stroke.] Nevrologia. Kardiologia. 2011; 4(150): 46-49 [In Russ].

10.  Mooe Th., Tienen D., Karp K., et al. Long-term follow-up of patients with anterior miocardial infarction complicated by left ventricular thrombus in the thrombolytic era. Heart. 1996; 75(3):252-6.

11.  Vereshagin N.V., Piradov M.A., Suslina Z.A. (red). Insul’t. Principi diagnostiki, lecheniya I profilaktiki. [Stroke: principles of diagnosis, treatment and prophylaxis.]. M, Intermedika, 2002; 208.

12.  Suslina Z.A., Vereshagin N.V., Piradov M.A., Podtipi ishemicheskikh narusheniy mozgovogo krovoobrasheniya: diagnostika i lechenie. [Subtypes of ischemic cerebrovascular disorder: diagnosis and treatment]. Consilium medicum. - 2001; 3(5): 218-221.

13.  Albers G.W., Comess K.A., De Rook F.A. et al. Transesophageal echocardiographic findings in stroke subtypes. Stroke. 1994; 25: 23-28.

14.  Akhmedov A.D-O. Karotidnaya endarterektomiya u bol’nikh s visokim khirurgicheskim riskom. [Carotid endarterectomy in patients with high operation risk]. Diss. kand.med. Mos