Percutaneous Thrombectomy Using Angiovac System as a Diagnostic and Therapeutic Tool in Managing Right Atrial Mass in a High-Risk Patient

Background Right atrial (RA) masses often pose a dilemma in accurate diagnosis and management. We describe a challenging case of a large mobile RA mass in a febrile cancer patient. Case A 36-year-old female with newly diagnosed breast cancer on chemotherapy for 4 months via Port-A-Cath presented initially with COVID-19 pneumonia but continued to have persistent fever and dyspnea. A CT of the chest ruled out pulmonary embolism but showed an incidental RA mass. Echocardiography confirmed a large (2.7 x 1.6 cm), pedunculated mobile mass in the RA, attached to the free wall near the Eustachian valve (Fig.1). For a suspected thrombus, anticoagulation was initiated and a percutaneous thrombectomy using AngioVac was attempted. The mass was tightly attached to the atrial wall and too large to suction, resulting in only partial extraction of multiple tumor-like masses. Decision-making In addition to catheter-related thrombus and COVID-19 infection-related thrombus in transit, possibilities of myxoma, metastasis and fungal vegetation were considered due to its atypical features. A week later, pathology confirmed the diagnosis of an organized thrombus. Surgery was deferred and instead a repeat AngioVac using a larger aspiration catheter successfully aspirated the entire RA mass without complications. Conclusion Percutaneous aspiration of RA masses can prove to be of both diagnostic and therapeutic use, especially in high-risk patients. It can help avoid invasive surgical intervention in clinical dilemmas. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

ACUTE STROKE MANAGEMENT DURING COVID-19 PANDEMIC

INTRODUCTION: In the coronavirus disease 2019 (COVID-19) pandemic, there may be a decrease in the number of acute stroke intervention and acute treatment, and delays in treatment periods. In this study, it was aimed to compare the clinical features of patients presenting with acute stroke during the COVID-19 pandemic and in the pre-pandemic period. METHODS: Patients hospitalized with the diagnosis of cerebrovascular disease (CVD) between January 01, 2019 and May 31, 2021 were included in the study. Demographic characteristics and stroke risk factors of the patients were recorded. Stroke type and ischemic disease subtypes were determined, and patients' admission National Institutes of Health Stroke Scale (NIHSS) score, symptom-door time, door-consultation time, door-to-door Needle time and door-groin puncture time, intravenous tissue type plasminogen activator (IV tPA) and endovascular thrombectomy (EVT) applications were recorded. Discharge modified Rankin Scale (mRS) and NIHSS scores and mortality rates were evaluated. Patients hospitalized in two separate periods of 14 months each were compared by dividing them into pre-pandemic and pandemic periods. RESULTS: Before COVID-19, 316 patients (female 45.25%, age: 66.75±13.68 years) and during the pandemic period 341 (female 41.94%, age: 68.34±13.55 years) patients were included in the study. During the pandemic period, an increase in the number of hemorrhagic CVD and transient ischemic attacks, a decrease in the number of ischemic stroke and cerebral venous thrombosis (CVT) hospitalizations, a decrease in cardioembolic strokes and an increase in lacuner ischemic CVD subtypes were observed (p<0.01). The number of large vessel atherosclerosis, IV tPA and EVT were found to be similar before and after the pandemic. In the pandemic period, although it did not reach statistical significance compared to the pre-pandemic period, prolongation was recorded in the symptom-door, door-consultation, door-needle and door-groin puncture times (p>0.05). The COVID-19 test was positive after hospitalization in 5 (1.8%) patients with ischemic stroke hospitalized during the pandemic period. During the pandemic period, admission NIHSS, discharge NIHSS and mRS scores and mortality rates were found to be significantly higher between hemorrhagic and ischemic stroke patients (p<0.01). DISCUSSION AND CONCLUSION: The COVID-19 pandemic adversely affects the management of acute stroke. The duration of acute stroke treatment is delayed due to pre-hospital and in-hospital reasons. With the heavy burden of stroke during the pandemic period, poor clinical outcome and high mortality are observed.

Acute Limb Ischemia Following a Mild Case of COVID-19.

Coronavirus disease 2019 (COVID-19) was a novel virus that originated in China in November 2019 and is most known for its respiratory compromise; however, many patients have experienced vascular thrombosis as sequelae of COVID-19. It is thought that the virus causes endothelial cell damage and increased platelet and leukocyte adhesion, causing a hypercoagulable state. While the most common presentation of hypercoagulability associated with COVID-19 is venous thrombosis, there are reports of patients who present with acute limb ischemia. We present a case of acute leg ischemia in an otherwise asymptomatic patient with no atherosclerotic risk factors.

Impact of Patient Transferto an External ICU Hospital for Post-Operative Monitoring after EndovascularIntervention

Objective: To assess safety and outcomes of immediate post-operative transferring of endovascular thrombectomy (EVT) patients to an external hospital ICU. Background: Due to the COVID-19 pandemic, hospital patient volumes increased significantly, resulting in a shortage of ICU beds in various NYC hospitals including the Mount Sinai Hospital system. Patients in the system were often transferred within the network after mechanical thrombectomy was complete if bed availability at EVT site was unavailable. Design/Methods: Reviewed all consecutive EVT cases from January1 2020 - July 31 2021 at the Mount Sinai System for intersystem transfers. Out of the 353 thrombectomy cases that took place between this time frame, 27 patients were transferred to an outside ICU hospital. Patient demographics, co-morbid stroke risk factors (hypertension, diabetes, hyperlipidemia), stroke metrics such as modified rankin score, NIHSS, and TICI score were evaluated for each patient. Key safety outcomes were symptomatic hemorrhage (sICH), groin hematoma requiring manual compression, and unanticipated extubation or hemodynamic instability within the first 24 hours of transfer. Symptomatic ICH was defined as new intracranial hemorrhage associated with NIHSS increase >4 points. Results: Transferred patients were mostly male (n=18) with a mean age was 67.9 years. Twenty- five out of 27 (92.6%) patients achieved a TICI core of 2b or higher. Major neurological improvement, defined as an NIHSS of 0-1 or ≥ 8 point improvement at 24 hours, was achieved in 51.8% of transfer patients. sICH occurred in 3 out of 27 (11%) of patients. There were no unexpected extubation or hemodynamic instability within the first 24hours. All transfer cases had a mRS of 0-3 upon discharge. Conclusions: Transfer post EVT to an outside hospital for close ICU monitoring is associated with 11% sICH risk without any apparent cardiopulmonary risk.

Pediatric Cerebral Infarction associated with recent SARS-CoV-2 mild infection treated with intravenous thrombolysis and endovascular thrombectomy

Objective: N/A Background: Acute ischemic stroke is a major cause of disability worldwide in adults and children. It is a common disease after middle age but uncommon in the pediatric population. Disabling arterial ischemic strokes due to acute intracranial large vessel occlusion within 3-4 weeks of SARS-CoV-2 (COVID-19) infection have been described. Design/Methods: N/A Results: A 15-year-old boy presented with sudden onset right-sided weakness and expressive aphasia witnessed by mother. He presented within 50 minutes of symptom onset to the regional ER facility. Around 4 weeks ago, patient had mild SARS-Cov-2 infection with flu-like symptoms and mild chest pain that worsened with exertion lasting 3-4 days. Neurological examination revealed diminished fluency, anomia, and right upper extremity drift. Initial non contrast computed tomography (CT) demonstrated hyperdense left middle cerebral artery (MCA) sign with subtle loss of gray/white matter differentiation in the left anterior insula. Aphasia and right-sided weakness worsened as he was coming back from CT 2 hours after symptom onset. Intravenous Tenecteplase was administered. CT angiography of head/neck confirmed left proximal M2 occlusion with no arterial dissection. Patient underwent successful mechanical thrombectomy. Three days later his deficits completely resolved. Transthoracic echocardiography with contrast bubble study was unremarkable. Laboratory workup demonstrated mildly low ATIII, positive Factor V Leiden screen with negative genetic testing, positive SARS coronavirus-2 IgG, mildly low PTT. Remaining coagulopathy workup was unremarkable. Conclusions: To our knowledge this is the first case of large vessel occlusion in a pediatric patient treated successfully with both intravenous thrombolysis and mechanical thrombectomy associated with recent SARS-Cov-2 infection. The AIS etiology in our case remains uncertain as abnormal laboratory findings do not explain this presentation. There is high clinical suspicion of an embolic event as possible explanation, possibly related to SARS-CoV-2 postinfectious stage.

COVID-19 infection complicated with acute pulmonary embolism treated with percutaneous pulmonary artery thrombectomy: a case report.

Background: Coronavirus disease 2019 (COVID-19) disease is a highly prothrombotic state. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are observed with increased incidence in patients infected with the severe acute respiratory syndrome coronavirus 2 virus. Case summary: A 57-year-old male patient with a recent COVID-19 infection complained of leg swelling shortly after his COVID ward discharge. A few days later he was hospitalized with acute massive PE and DVT of his left leg was diagnosed. In another facility, as the first line of treatment, the PE was managed with catheter-directed therapy (CDT) using thrombus defragmentation via 5F (French) Pigtail catheter and supraselective application of 40 mg alteplase. Following the procedure, in addition, 50 mg alteplase was also applied as a 1 hour systemic infusion. Despite the haemodynamic stabilization of the patient, he remained persistently symptomatic and tachycardic. Three days later-in our institution, a second computed tomography pulmoangiography revealed massive thrombotic masses mainly in the left pulmonary artery. Successful percutaneous thrombus aspiration was conducted. The procedure was uneventful with an immediate drop of systolic pulmonary artery pressure from 68 to 47 mmHg and relief of the patient's symptoms. Discussion: In the era of the COVID-19 pandemic, physicians have to remain vigilant of its potential thrombotic complications, the most commonly observed being DVT and PE. We demonstrated the efficacy of percutaneous thrombus aspiration in a patient with acute COVID-19-associated PE, after initial CDT with thrombus defragmentation and high-dose tissue plasminogen activator was implemented with a suboptimal result.

Endovascular Thrombectomy for Large Vessel Occlusions in Covid-19 Patients: Technical Challenges and Lessons

INTRODUCTION: Covid 19 infections has been shown to be associated with a range of thromboembolic disease that has implications for the neuro-endovascular management of large vessel occlusions. METHODS: Five consecutive Covid-19 positive patients presented with large vessel occlusions to our institution. Covid-19 testing was performed using nasal swab. All thrombectomy cases was performed under general endotracheal anesthesia using a stent-aspiration combination as primary thrombectomy technique. The technical details of each case and the angiographic outcome are described. Routine labs including D-dimer, platelet count, coagulation panel (aPTT, INR), Interleukin 6 (IL-6), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) were evaluated in all patients. Rotational thrombelastography (ROTEM) was performed on the patients' blood samples to assess real-time clot formation/dissolution properties. RESULTS: Four patients had anterior circulation large vessel occlusions and one patient had both anterior and posterior circulation occlusions. Mean age was 52.8 years and 80% were males. TICI 3 revascularization was achieved in one patient, TICI 2B achieved in two patients and TICI 2A in two patients. In our cohort, patients were on average 52.8 years old and presented with a median NIHSS of 27. All our patients had very proximal occlusions. Three patients presented with intra-cranial ICA occlusions. Two patients presented with a tandem carotid bulb thrombus in conjunction with an intracranial vessel occlusion. One patient had an ICA terminus occlusion with a concomitant basilar occlusion. Second, the intravascular clots in all our patients were prone to fragment and migrate into both new vascular territories and into distal downstream vasculature. Distal emboli into a different territory (anterior cerebral artery occlusion) was seen in two two of our five patients (40%) and distal emboli into a downstream territory was seen in all five patients (100%). An average of 2.7 pstent-retriever passes was needed to achieve a final TICI revascularization of IIb or better. CONCLUSION: Covid-19 patients are predisposed to a hypercoagulable state. When presenting with large vessel occlusions, these patients present unique challenges that make successful revascularization difficult.