Purpose
The first-pass effect during mechanical thrombectomy improves clinical outcomes regardless of first-line treatment approach, but current success rates for complete clot capture with one ...attempt are still less than 40%. We hypothesize that the ThrombX retriever (ThrombX Medical Inc.) can better engage challenging clot models during retrieval throughout tortuous vasculature in comparison with a standard stent retriever without increasing distal emboli.
Materials and Methods
Thrombectomy testing with the new retriever as compared to the Solitaire stent retriever was simulated in a vascular replica with hard and soft clot analogs to create a challenging occlusive burden. Parameters included analysis of distal emboli generated per clot type, along with the degree of recanalization (complete, partial or none) by retrieval device verified by angiography.
Results
The ThrombX device exhibited significantly higher rates of first-pass efficacy (90%) during hard clot retrieval in comparison with the control device (20%) (
p
< 0.009), while use of both techniques during soft clot retrieval resulted in equivalent recanalization. The soft clot model generated higher numbers of large emboli (>200 μm) across both device groups (
p
= 0.0147), and no significant differences in numbers of distal emboli were noted between the ThrombX and Solitaire techniques.
Conclusions
Irrespective of clot composition, use of the ThrombX retriever demonstrated high rates of complete recanalization at first pass in comparison with a state-of-the-art stent retriever and proved to be superior in the hard clot model. Preliminary data suggest that risk of distal embolization associated with the ThrombX system is comparable to that of the control device.
INTRODUCTION: We studied the relationship of acute ischemic stroke (AIS) large-vessel occlusion clot composition with vessel recanalization and preprocedure imaging.
SUBJECTS AND METHODS: Individual ...clots from AIS patients who underwent mechanical thrombectomy (MT) between September 2016 and September 2018 were examined. Clot composition was analyzed histologically through a trichrome staining and image segmentation, and the area occupied by red blood cells (RBCs), fibrin, or mixed composition was quantified.
RESULTS: Forty-three patients (65.4 ± 12.7 years, 39% of females) who underwent 92 retrieval passes (mean 2.14, range 1-6) were included in this study. Fibrin (44%) occupied the greatest area, followed by mixed composition (34%) and RBCs (22%). A stent retriever was deployed in 81% of cases, 20 patients (47%) achieved first-pass efficacy (FPE) (thrombolysis in cerebral infarction TICI 2b-3 after first pass), 41 (95%) achieved successful revascularization (TICI 2b-3), and 21 (49%) had good outcome (modified Rankin Scale mRS ≤2) at 90 days. Hyperdense artery sign (HAS) on initial computed tomography was correlated with mixed clot composition (P = 0.01) and lack of fibrin content (P = 0.03). In the univariate analysis, FPE was associated with RBC clot area, atrial fibrillation, and occlusion location but not with fibrin clot area, mixed clot area, stroke etiology, thrombectomy technique, distal emboli, or 90-day mRS. In the multivariate analysis, FPE was significantly correlated with low RBC clot area (odd ratio = 0.96, confidence interval 0.92.99, P = 0.034) but not with atrial fibrillation or location.
CONCLUSION: Our results suggest that HAS is correlated with mixed clot composition and lower fibrin content and that lower RBC clot composition is associated with FPE in patients undergoing MT.
Despite high recanalization rates achieved with endovascular treatment of acute ischemic strokes, around 50% of eligible patients will not achieve a good outcome. Parameters that may determine ...patient outcomes include: time from puncture to recanalization, the collateral status, the anesthesia regimen, blood pressure management, and distal emboli. Characterization of distal emboli generated during mechanical thrombectomy has been performed in previous studies.
To further investigate the risk of distal embolization associated with microcatheter navigation across the clot.
A contrast-enhanced clot analog was used in an in vitro model that mimicked a middle cerebral artery occlusion within a complete circle of Willis vascular replica. The clot was crossed with one of the following microcatheters: Pro18, XT-27 or 3MAX. The emboli generated during the procedure were collected and measured.
The use of Pro18 and XT-27 resulted in a significant reduction of visible particles (size ≥500 µm) as compared with the 3MAX catheter (P<0.003). For the size range between 8 and 200 µm, there was a trend for Pro18 to generate fewer particles (-18%) than XT-27 but without statistical significance (P>0.05). In comparison with previously published data, acquired under the same conditions, it was found that the clot crossing maneuver accounts approximately for 12% of the total number of small emboli (<200 µm) induced during a stent retriever-mediated mechanical thrombectomy procedure via a balloon guide catheter.
The clot crossing maneuver has a significant effect on the total number of small particles induced during mechanical thrombectomy. Smaller microcatheter sizes should be favored when possible.
Neo-intimal hyperplasia (NIH) is frequently observed after flow-diverter stent (FDS) implantation. Although mostly asymptomatic, this vascular response can sometimes lead to delayed ischemic strokes. ...This study intended to evaluate the factors potentially influencing the rates of NIH following FDS treatment.
All aneurysm treatments performed with a Pipeline embolization device (PED) or a SILK stent from May 2011 to May 2015 were collected in a prospectively maintained database. Patient demographics, clinical, and angiographic outcomes including both digital subtraction angiography and C-arm cone-beam CT were registered. Two blind reviewers rated the presence of NIH on a binary scale (present/absent).
From 148 patients, 63 datasets were available for analysis. Inter-reader agreement was excellent (Kappa=0.88). NIH was positively correlated with smoking, dyslipidemia, and high blood pressure, but not with aneurysm characteristics. At early follow-up (<12 months), NIH was more frequently associated with the use of the SILK stent (68%) rather than the PED (38%): P<0.02. At long-term follow-up, the NIH rate in the total population dropped from 55% to 26% with no more significant difference between the two stents. The complete occlusion rate as seen in early follow-up was higher in the SILK group with 76% vs 65% but without statistical significance (P=0.4).
NIH is a dual-vessel reaction after FDS implant. When planning a treatment in locations at risk of ischemic complications if severe NIH would occur, then the stent design should be considered. However, minimal NIH might also be needed as it is involved in aneurysm healing. Before treatment patients should be recommended best medical management of their cardiovascular risks factors to prevent an excessive NIH reaction.
Metformin is the first-line treatment for type 2 diabetes (T2D) in youth but with limited sustained glycemic response. To identify common variants associated with metformin response, we used a ...genome-wide approach in 506 youth from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study and examined the relationship between T2D partitioned polygenic scores (pPS), glycemic traits, and metformin response in these youth. Several variants met a suggestive threshold (P<1×10−6), though none including published adult variants reached genome-wide significance. We pursued replication of top nine variants in three cohorts, and rs76195229 in ATRNL1 was associated with worse metformin response in the Metformin Genetics Consortium (n = 7,812), though statistically not being significant after Bonferroni correction (P=0.06). A higher β-cell pPS was associated with a lower insulinogenic index (P=0.02) and C-peptide (P=0.047) at baseline and higher pPS related to two insulin resistance processes were associated with increased C-peptide at baseline (P=0.04,0.02). Although pPS were not associated with changes in glycemic traits or metformin response, our results indicate a trend in the association of the β-cell pPS with reduced β-cell function over time. Our data show initial evidence for genetic variation associated with metformin response in youth with T2D.
Position statement: Policies to support family caregivers Perez, G. Adriana; Rose, Karen Moomaw; Caceres, Billy A. ...
Nursing outlook,
May-June 2018, 2018 May - Jun, 2018-05-00, 20180501, Letnik:
66, Številka:
3
Journal Article
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