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Objective: Since the last decade, the notion of minimally invasive cardiac surgery (MICS) has gained worldwide rapid popularity. Bangladesh is not far from mastering this technique due to the increasing interest of both patients and surgeons. Meanwhile, during this COVID-19 era could it help patients, remains the main question. In this context, we have operated on a total of 523 patients from October 2020 to November 2021 including, 89 patients who were MICS and among them, 17 were coronary artery bypass grafting. Method(s): We have included all patients who underwent minimally invasive coronary artery surgery in our hospital from October 2020 to November 2021 irrespective of single (MIDCAB) / multi-vessel disease (MICAS) or combined valve replacement with coronary revascularization. Data were collected from the hospital database, telephone conversations, and direct clinic visits. All data were analyzed statistically and expressed in the form of tables. Result(s): In the last 14 months of pandemics we have operated on a total of 89 MICS patients, among them 10 were Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), 6 were double or triple vessels coronary artery surgery (MICAS), 1 patient underwent upper-mini aortic valve replacement along with coronary revascularization. One of our patients needed re-exploration for chest wall bleeding on the same day. Mean ICU and hospital stay in our series were less than conventional revascularization. There was no in-hospital or 30 days' mortality in our series. Conclusion(s): Cardiac surgery these days is headed toward less invasive approaches with the aid of technology, advanced instruments, and pioneer's lead. But from our in-hospital results we conclude that by avoiding median sternotomy, these minimal invasive revascularization techniques can provide hope to the patients by alleviating symptoms with restored vascularity, reduced morbidity, preventing sudden cardiac death. Health costs reduction with shorter hospital and ICU stay are the added benefits.
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Protein S is a multifunctional plasma protein, whose deficiency, results in a rare congenital thrombophilia, inherited in an autosomal dominant pattern. It can aggravate the hypercoagulable state of pregnancy, when it presents in parallel with the condition, leading to adverse maternal outcomes and foetal loss. A 35-year-old female third gravida having previous 2 deliveries by Lower Segment Caesarean Section (LSCS) presented to emergency at 10 weeks pregnancy with chief complaints of pain and swelling in left thigh since 4-5 days. After thorough investigations and work-up, the patient was diagnosed with Protein S deficiency. She was managed conservatively and was delivered by elective LSCS with bilateral tubal ligation at 38 weeks of gestation with good foetal and maternal outcomes.The rarity of Protein S deficiency along with the successful outcome of the pregnancy makes this a unique case.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.
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The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.Copyright © 2020 Wolters Kluwer Medknow Publications. All rights reserved.
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Background: Lockdowns and mask wearing have impacted infectious disease patterns during the COVID-19 pandemic. We investigated changes in the use of bronchoscopy and the results of routine microbiology in bronchial lavage. Method(s): We included bronchoscopies from 2017-2021 at the LMU University Department of Pulmonology. In this we present an initial cohort comparing bronchoscopies in 2017-2018 to the initial phase of the COVID-19 pandemic in 2020. Comparisons used chi-squared and Fischer's exact tests in SPSS. Result(s): We analysed 480 bronchoscopies from before and 85 during the COVID-19 pandemic. Mean age: 62.6 y (+/-14.1) before vs. 55.2 y (+/-16.3) during the pandemic (p<0.001). Indication for bronchoscopy: secretions/atelectasis (n=122), suspected tumor (n=89) and intervention/therapy (n=80) before;suspected tumor (n=30), respiratory deterioration after lung transplant (n=19) and infection (n=7) during the pandemic. Staphylococcus aureus and Pseudomonas aeruginosa were common in both groups. Frequencies of EBV (p<0.001), CMV (p=0.003) and HHV6 (p<0.001) differed significantly. Conclusion(s): There were clinically relevant differences in the use of bronchoscopy before vs. during the COVID-19 pandemic: pandemic patients were younger and interventions such as bronchial stenting and recanalisation less common. Bacterial results were similar but the frequency of common viruses differed. The effect of lockdowns, mask wearing and social distancing on bronchial microbiology in patients with lung cancer or chronic lung disease will be investigated in further detail in this cohort. Clinical relevant differences may support continued mask wearing in some high-risk situations post-pandemic.
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Introduction: Cerebral venous sinus thrombosIs (CVST) is a rare condition compared to other categories encountered in stroke medicine.It occurs more frequently in patients with conditions that predispose them to other venous thrombosis, such as thrombophilias, acute malignancies, nephrotic syndrome, and COVID-19. CVST was identified as one of the rare causative of stroke. The exact mechanism of the stroke is not fully understood. However, a commonly agreed pathophysiology is that a dysfunction in arachnoid granulation can lead to sinus occlusion. Subsequently, this leads to a reduction in cerebral fluid drainage, which can increase intracranial pressure, causing capillary hypertension, cerebral oedema, decrease in cerebral perfusion pressure and venous haemorrhage. The European Stroke Organisation (ESO) supports using both MRI/MR Venogram and CT venogram as modalities for diagnosis of CVST, with no particular preference of one over the other. The standard practice in the management of cerebral venous sinus thrombosis includes treating the clot and its precipitating factors and treating the sequela of the clot as in the case we are reporting. Yet, there is no clinical guideline for the more aggressive measures to break down the clot in either AHA or European Stroke Organization, but they are used in clinical practice, with promising results in certain cases. Our case is an example of a successful mechanical thrombectomy with a lifesaving outcome. Method(s): We are reporting an unusual case of a 27- year- old lady who presented to the hyperacute stroke unit with dense right- sided weakness and expressive dysphasia. After an initial CT (Computerised Tomography) scan confirming extensive cerebral venous sinus thrombosis, she went for urgent mechanical thrombectomy. The clinical assessment after the procedure showed significant recovery in power of the right limbs and speech. She was discharged 7 days later with near full recovery. Venous thrombectomy is a rarely performed procedure. However, in this case, it was potentially lifesaving and resulted in an excellent clinical outcome. Result(s): An MRI/MRV follow up in a month demonstrated that the lesion on left centrum semiovale had regressed compared to the first scan. Also, there was some evidence of recanalization of her transverse sinuses. She was assessed by the therapist two months from the event. The patient reported some word finding difficulties and clumsiness in the right hand and leg. However, no further major event since her thrombectomy, and now aiming to get back to work. Conclusion(s): Mechanical thrombectomy in cerebral venous sinus thrombosis can be an effective, life-saving, and safe procedure with an extremely rewarding outcome. It should be considered in patients with acute neurological deterioration despite anticoagulant therapy.
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Introduction: Although AVFs are preferred vascular access for hemodialysis, tunneled cuffed catheters(TCC) are increasingly being used as dialysis access in certain clinical situations such as in AVF failure or lack of suitable vessels for AVF creation or bridge to living donor transplant. Aim and objective of this study was to study the characteristics of the population having benefited from tunneled cuffed catheters, to identify the different indications as well as the complications secondary to tunneled cuffed catheters in hemodialysis patients and to determine the catheter and patient survival rate and the factors associated with complications and survival. Method(s): This was an retrospective Observational study done after institutional ethics committee approval. All data was captured using standard proforma. The data was tabulated using MS excel and all results projected in form of bar graphs, pie charts, histograms or tables. Kaplan- meier analysis was used for survival. All patients included in the study consented for the procedure as well as collection of data. 527 TCC placement were done in 498 patients by nephrologists without fluoroscopy in a percutaneous fashion between jan 2021 to march 2022. Minimum follow up was 12 months. 37 patients lost to follow up. Result(s): 316 (68.5%) were males and mean age was 48.3+/-12.6 years. Staggered tip MAHURKAR MaxidTM Covidien, was used in every patient. Most common native kidney disease was cresentic GN 176(38.1%). Most common Site of TCC was right internal jugular 88.9%(441/496), followed by left internal jugular 10.48%(52/496), femoral TCC done in 0.6%. Mean blood flow achieved was 311+/- 32ml/min. Most common indication of TCC placement was starting of HD after 1/2 temporary access- 162(32.66%), followed by awaiting Maturation of autogenous AVF 66 (13.3%) and awaiting living-related transplantation 54(10.88%). Total catheter related infective episodes (CRBSI) were 229 (1.07 episodes/1000catheter days),Exit site infection was in 57 cases (0.26 /1000 catheter days), Tunnel infection was in 51(0.19/1000 catheter days), Infective endocarditis was seen in 3 cases. Catheter loss due to CRBSI was 23 (12.16%). Most common organism was Enterococci (29.7%), followed by s.aureus (24.32%). Most common immediate complication was tunnel bleeding (5.9% ), followed by improper tip position 4.68%. Late complications due to TCC thrombosis/ fibrin sheath was 74(15.07%). Recanalisation with urokinase was successful in 36.84%. Central venous stenosis was in 26 cases. successful recanalisation after central venoplasty was 16/19 (84.21%). Mean catheter survival was 201.9 +/- 114.9 days (3day to 12 months). Catheter survival at the end of 3 months was 75.76%, at 6 months 63.4%, at 12months 32.17%. Patient survival at 6 months was 86.7%, at 12 months- 77.5%. Most common cause of death was unrelated to TCC - cardiovascular cause (77.6%). Direct TCC related death was in 5 cases. Most common cause of catheter drop out was patient death (33.03%), followed by maturation of AVF (22.82%), catheter thrombosis/fibrin sheath (22.2%). [Formula presented] Conclusion(s): Though AVF is the best access, for late unplanned HD initiation in many CKD patients, TCC insertion becomes next best option. In access crisis patients, TCC may remain one feasible option for bridge to available live donor transplant. With strict asepsis protocol and technical aptitude TCC placement is safe with few side effects. No conflict of interestCopyright © 2023
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Background: This case highlights how coronary pathology presents in vasculitis. Case presentation: A 49-year-old male, never-smoker presented to our hospital for a series of Acute Coronary Syndromes (ACS). The first in October 2019;angiogram revealed diffuse aneurysms and clot in the right coronary artery (RCA) and stenosis in the posterolateral branch (PLB). Post aspiration thrombectomy, and drug eluting stent (DES) to the PLB, patient was discharged on standard ACS meds. Coagulopathy workup was unremarkable. Follow up in November 2020, the patient was recommended reducing ticagrelor to 60mg twice daily (bid). The second ACS, one year later, revealed severe in-stent restenosis of the PLB stent. Patient had 2 DES placed in the PLB and was discharged on escalated therapy of rivaroxaban 2.5mg bid, and ticagrelor 90mg bid. Two months later the patient had COVID-19;during that admission he had two ACS events. The first showing mid-RCA stenosis and thrombosis of the same PLB;this was treated with only angioplasty. The next day, he had repeat ACS showing thrombosis of the RCA, but despite multiple attempts RCA recanalization was unsuccessful and discharged on medical therapy only. During clinic follow up, May 2022, the patient revealed that he had Kawasaki's disease as a kid. Conclusion(s): Coronary aneurysms are high risk because of slow flow and endothelial dysfunction that makes balloon dilation, stent sizing, and post interventional medical therapy difficult. Currently no standard guidelines exist to help providers treat this population. It may be beneficial to regularly follow up, monitor inflammatory markers (ESR, CRP correlated well with interleukin 6 and 8), and use CT or PET to follow active vasculitis and changes in aneurysms. Kawasaki's disease is a vasculitis of small and medium-sized vessels and often presents in childhood. Prospective studies show that patients with coronary aneurysms tend to have systemic artery aneurysms, so it is important to screen other arterial beds. Valvular disease has also been found to co-exist in patients with vasculitis, and pre-existing disease should be followed with echocardiography.
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Background: We report on a patient with a branch retinal artery occlusion (RAO) and its recanalization based on multimodal retinal and angiographic images after he was administered the first dose of the SARS-CoV-2 mRNA vaccine. Case summary: A 64-year-old man complained of a right, painless, inferior field defect 3 days after the first dose of BNT162b2 vaccination. Fundus examination revealed decolorization of the right upper macula, including microthrombi in the superior proximal branch of the retinal artery. Optical coherence tomography angiography revealed upper macular hypoperfusion. Fluorescein angiography revealed prolonged arteriovenous transit to the macula. After paracentesis with antiplatelet medications, the artery was recanalized as the thrombi dissolved, and the right visual field was recovered. Re-occlusion did not occur during the 3 months after the second mRNA vaccination. Conclusion: Non-embolic thrombotic RAO may develop shortly after the SARS-CoV-2 mRNA vaccine. Ophthalmologists should consider RAO as a possible post-vaccination adverse event. The temporal association between mRNA vaccination and RAO onset with evidence of microthrombi might provide additional clues to elucidate the unpredictive arterial thrombosis following SARS-CoV-2 mRNA vaccination.
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BACKGROUND: Catheter directed thrombolysis (CDT) proved to be effective treatment in deep venous thrombosis (DVT), However, there is some concerns about the associated bleeding risk. We assessed the safety and efficacy including technical and clinical success in resolution of iliofemoral DVT after one session treatment with penumbra aspiration mechanical thrombectomy catheter as an alternative CDT. METHOD(S): This is a retrospective study that was conducted on patients presented to Aseer Central Hospital and Saudi German Hospital in Saudi Arabia from January 2019 to December 2020 with symptomatic acute iliofemoral DVT. Patients were treated with Indigo continuous aspiration mechanical thrombectomy 8 system (Penumbra Inc, Alameda, CA, USA). Secondary end point was treatment complications, DVT recurrence and postphlebetic syndrome occurrence within 1 year follow-up. RESULT(S): Our study included twenty-three patients with sixteen females (59.6%) and seven males (30.4%) with a median age of 38 years (18-60years). Indication for treatment was primary DVT in seventeen patients (73.9%), recurrent DVT in six patients (26.1%). Provoked DVT was present in fifteen patients (65.2%) with nine of them was tested positive for COVID-19 while non provoked DVT in eight patients (4.8%). Seven patients (30.4%) had underlying May-Thurner Syndrome after thrombus removal and needed stenting for left common iliac vein (CIV) and two patients (8.7%) with recurrent DVT has significant residual Left common iliac vein stenosis that needed stenting. Two patient (8.7%) have thrombosis extending to inferior vena cava. Initial technical success using Penumbra was 82.6%. All patients in whom aspiration thrombectomy was not successful underwent further treatment with CDT which was successful in further three cases with failure in one case making overall technical success was 95.7%. Recurrent iliac occlusion after successful recanalization was seen in two patients (8.7%) at 6 months follow up. One patient (4.3%) developed pulmonary embolism that required full anticoagulation with no further treatment. No patient develops postphlebetic syndrome at 1 year follow-up. CONCLUSION(S): Penumbra aspiration thrombectomy catheter was safe, effective and promising technique in treatment of acute iliofemoral DVT and allowed definitive treatment in one session with no need for the use of thrombolysis in the majority of cases with no risk for bleeding complications, shorter hospital stay, no need for ICU admission and lower cost. COVID infection does not seem to alter the outcome. Copyright © 2022 EDIZIONI MINERVA MEDICA.
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SESSION TITLE: Great Procedural Cases: Fire, Ice, Struts, Valves, and Glue SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: While rarely reported, there has been an increasing incidence of tracheobronchial mucormycosis in patients infected with COVID-19, especially when associated with uncontrolled diabetes mellitus. We describe a complex case of central airway obstruction due to mucormycosis that was managed with a custom 3D printed silicone Y-stent. CASE PRESENTATION: A 54-year-old woman with diabetes, prior COVID-19 infection, presented with dyspnea and cough. She underwent a CT chest which showed left lower lobe atelectasis and left main stem bronchus (LMSB) obstruction. Bronchoscopy showed a large exophytic mass extruding from the LMSB. There was necrosis leading to a fistula between the left and right mainstem bronchi distal to the carina. Pathology of the mass showed necrotic bronchial mucosa and cartilage with invasive mucormycosis. She underwent placement of a 10X40mm covered stent in LMSB. However, due to granulation tissue and recurrent mucus plugging, she needed a bronchoscopy every 3-4 weeks and multiple stent revisions. Despite these interventions, her respiratory symptoms did not change significantly. Ultimately, her airway was also complicated by tracheobronchomalacia (TBM) of the right main stem bronchus (RMSB). Subsequently a custom printed 3D silicone Y-stent from VisionAir was placed that allowed successful recanalization of LMSB and management of the TBM of RMSB simultaneously. The patient reported significant improvement in respiratory symptoms. She was maintained on Isavuconazole for mucormycosis suppression therapy DISCUSSION: Mucormycosis infections commonly occur in the pulmonary or rhino-cerebral region with high morbidity and mortality. Mucor can involve the major airways as well as rarely invade the tracheal cartilage leading to TBM. There is often granulation tissue, gray-white mucoid material, with edematous and necrotic airway. This can be associated with complex central airway obstruction. While the covered tracheobronchial stent (Bonastent) allowed us to recanalize LMSB, it was complicated by obstructive granulation tissue formation and mucous plugging requiring frequent stent revision to maintain stent patency. At the same time, the TBM in the right airway was contributing significantly to dyspnea and cough. While a standard silicon Y stent was considered for the management of bilateral mainstem bronchi disease, due to the significant distortion in airway anatomy this was not an ideal option. By using the VisionAir stent, we placed a custom stent that would best fit her airway anatomy. The patient had sustained improvement in her symptoms for several months following the procedure. CONCLUSIONS: This is the first case report of a custom designed and 3D printed stent for the treatment of benign central airway obstruction caused by tracheobronchial mucormycosis. Custom stents are a promising tool to individualize and tailor intervention for patients with complex airway anatomy. Reference #1: Tracheal Mucormycosis Pneumonia: A Rare Clinical Presentation. Satyawati Mohindra, Bhumika Gupta, Karan Gupta and Amanjit Bal. Respiratory Care November 2014, 59 (11) e178-e181 Reference #2: Keshishyan S, DeLorenzo L, Hammoud K, Avagyan A, Assallum H, Harris K. Infections causing central airway obstruction: role of bronchoscopy in diagnosis and management. J Thorac Dis. 2017;9(6):1707-1724. doi:10.21037/jtd.2017.06.31 Reference #3: Leon CA, Inaty H, Urbas A, Grafmeyer K, Machuzak M, Sethi S, Gildea T. Early outcomes with 3D printing and airway stents. CHEST 2019 annual meeting s. DISCLOSURES: No relevant relationships by Sisir Akkineni No relevant relationships by Kelly Daymude No relevant relationships by Wissam Jaber No relevant relationships by Abesh Niroula
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SESSION TITLE: Pulmonary Procedures: Creativity and Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Recent advances in the management of airway disorders have provided additional therapeutic options for pathology, such as central airway obstruction (CAO). Symptomatic CAO has been managed by bronchoscopic interventions with a high risk of airway compromise and respiratory failure. Other alternatives such as mechanical and jet ventilation may not ensure adequate respiratory support during the procedure and cause delays in life-saving treatments. Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used as an adjunct to preserve safety during these airway interventions [1,2]. We present a case of complete tracheal occlusion successfully intervened using VV ECMO support. CASE PRESENTATION: The patient is a 55-year-old male with a history of ventilator-dependent respiratory failure s/p tracheostomy, secondary to post COVID-19 fibrosis, who presented from a long-term acute care facility with worsening hypoxemia. The patient was transferred to the intensive care unit, where he underwent flexible bronchoscopy via the tracheostomy lumen, which did not reveal a patent airway. Orotracheal intubation was unsuccessful as there was complete occlusion of the airway below the vocal cords with abundant granulation tissue. Interventional pulmonology was consulted, and emergent recanalization of the airway with rigid bronchoscopy-mediated debulking was performed. Due to the severity of hypoxemia, cardiothoracic surgery was consulted, and the patient was placed on VV ECMO to support further intervention. The patient was intubated with EFER-DUMON 13 mm rigid bronchoscope. Complete recanalization was achieved using a rigid barrel and forceps with patency of both mainstems and all segmental bronchi. There were no postprocedural complications, and the patient returned to his baseline ventilator settings. DISCUSSION: VV ECMO has been used as an adjunct to preserve safety during high-risk bronchoscopic interventions, primarily in CAO. Acute respiratory decompensation remains a feared complication during these interventions in cases of CAO. Initiating ECMO before these interventions may reduce the incidence of respiratory failure and airway compromise. In a case series, ECMO has been described by Stokes et al. as a supportive measure facilitating such interventions [3]. Further guidelines are required to standardize ECMO initiation as procedural support during airway interventions. CONCLUSIONS: Planned preprocedural ECMO initiation can prevent respiratory emergencies and allow therapeutic high-risk airway interventions. The choices for this patient were stark- either airway recanalization without ECMO bridge with a risk of hypoxic brain injury vs. VV ECMO support and curative airway intervention. In the absence of large-scale data and based on local availability of excellent ECMO support and Interventional Pulmonology, the latter approach was used, leading to successful and safe airway recanalization. Reference #1: Zapol WM, Wilson R, Hales C, Fish D, Castorena G, Hilgenberg A et al.Venovenous bypass with a membrane lung to support bilateral lung lavage. JAMA 1984;251:3269–71. Reference #2: Fung R, Stellios J, Bannon PG, Ananda A, Forrest P. Elective use of venovenous extracorporeal membrane oxygenation and high-flow nasal oxygen for resection of subtotal malignant distal airway obstruction. Anaesth Intensive Care 2017;45:88–91. Reference #3: Stokes JW, Katsis JM, Gannon WD, Rice TW, Lentz RJ, Rickman OB, Avasarala SK, Benson C, Bacchetta M, Maldonado F. Venovenous extracorporeal membrane oxygenation during high-risk airway interventions. Interact Cardiovasc Thorac Surg. 2021 Nov 22;33(6):913-920. doi: 10.1093/icvts/ivab195. PMID: 34293146;PMCID: PMC8632782 DISCLOSURES: No relevant relationships by Vatsal Khanna No relevant relationships by Anurag Mehrotra No relevant relationships by Trishya Reddy No relevant relationships by Bernadette Schmidt
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Objectives: Paraplegia is known to complicate extensive iliocaval and lower extremity deep vein thrombosis (DVT) in rare instances. The most common pathophysiology is ischemia from severe venous hypertension in phlegmasia cerulea dolens. Less understood, however, is paresis or paraplegia in the absence of ischemia. We present a case of paraplegia in extensive iliocaval and lower extremity DVT without ischemia, which was successfully treated by percutaneous pharmacomechanical therapy. Methods: A 46-year-old African American woman with a history of hypertension, insulin-dependent diabetes mellitus, indwelling inferior vena cava filter since 2005, and recent coronavirus disease 2019 diagnosis, presented with acute abdominal pain with severe bilateral lower extremity edema, pain, and paresis. She was found to have bilateral iliocaval to tibial DVT (Fig 1). The patient was noted to have multiphasic arterial waveforms on ankle-brachial index and duplex ultrasound examination. Paresis quickly progressed to flaccid bilateral lower extremity paralysis. Neurologic workup was unrevealing. Despite her symptoms, thrombolytic therapy was delayed due to severe menstrual bleeding requiring a blood transfusion. Therapeutic anticoagulation was initiated. Results: On hospital day 10, the patient underwent 24-hour catheter-directed thrombolysis via bilateral popliteal vein access. Bilateral mechanical thrombectomy was then performed, achieving recanalization of the bilateral lower extremities, iliac veins, and inferior vena cava with minimal residual thrombus (Fig 2). The patient's edema and sensorimotor function immediately improved and never incurred lower extremity tissue ischemia. She was discharged on lifelong rivaroxaban. With physical therapy, the patient ambulated independently at 1 month postoperatively. Venous duplex ultrasound examination revealed continued iliocaval and lower extremity patency at 6 months postoperatively. Conclusions: We postulate that this patient suffered lower extremity paralysis secondary to cauda equina syndrome. Pharmacomechanical thrombectomy is a pragmatic means that reestablishes venous patency and relieves venous hypertension. This pathophysiology and its treatment should be considered in extensive iliocaval DVT and lower extremity neurologic compromise despite duration of paralysis. [Formula presented] [Formula presented]
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Background: The novel coronavirus disease 2019 (COVID-19) has rapidly spread worldwide and created a tremendous threat to global health. Growing evidence suggests that patients with COVID-19 have more severe acute ischemic stroke (AIS). However, the overall efficacy and safety of recanalization therapy for AIS patients infected by the SARS-CoV-2 virus is unknown. Methods: The PRISMA guideline 2020 was followed. Two independent investigators systematically searched databases and ClinicalTrials.gov to identify relevant studies published up to 31 March 2022. AIS patients who received any recanalization treatments were categorized into those with COVID-19 and those without COVID-19. The main efficacy outcomes were patients' functional independence on discharge and successful recanalization, and the safety outcomes were in-hospital mortality and symptomatic intracranial hemorrhage. Subgroup analyses were implemented to assess the influence of admission National Institutes of Health Stroke Scale and different recanalization treatments on the outcomes. STATA software 12.0 was used for the statistical analysis. Results: This systematic review and meta-analysis identified 10 studies with 7,042 patients, including 596 COVID-19 positive patients and 6,446 COVID-19 negative patients. Of the total patients, 2,414 received intravenous thrombolysis while 4,628 underwent endovascular thrombectomy. COVID-19 positive patients had significantly lower rates of functional independence at discharge [odds ratio (OR) 0.30, 95% confidence interval (CI) 0.15 to 0.59, P = 0.001], lower rates of successful recanalization (OR 0.40, 95% CI 0.24 to 0.68, P = 0.001), longer length of hospital stay (weighted mean difference 5.09, 95% CI 1.25 to 8.94, P = 0.009) and higher mortality rates (OR 3.38, 95% CI 2.43 to 4.70, P < 0.0001). Patients with COVID-19 had a higher risk of symptomatic intracranial hemorrhage than the control group, although the difference did not reach statistical significance (OR 2.34, 95% CI 0.99 to 5.54, P = 0.053). Conclusions: Compared with COVID-19 negative AIS patients who received recanalization treatments, COVID-19 positive patients turned out to have poorer outcomes. Particular attention needs to be paid to the treatments for these COVID-19 patients to decrease mortality and morbidity. Long-term follow-up is necessary to evaluate the recanalization treatments for AIS patients with COVID-19. Systematic review registration: https://inplasy.com/inplasy-2022-4-0022/, identifier: INPLASY202240022.
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Introduction: Chronic extrahepatic non-tumoral thrombotic portal vein occlusion in non-cirrhotic patients is a rare condition, affecting 5-10% of patients with portal hypertension. Presentation of case: The present study reports the case of a young patient without previous comorbidities who presented with portal hypertension secondary to chronic extrahepatic non-tumoral thrombotic occlusion of the portal vein. He underwent portal recanalization with a 12 × 80 mm nitinol self-expandable stent and embolization of esophagogastric varices with fibrous springs and cyanoacrylate via transparieto-hepatic access. Immediate resolution of the trans-lesion pressure gradient was obtained transoperatively, while complete remission of esophagogastric varices was verified by endoscopic control during outpatient follow-up. Discussion: Chronic portal vein occlusion is associated or not with liver cirrhosis. The chronic phase is characterized by cavernomatous transformation of the portal vein, which consists of the formation of multiple collaterals that bypass the lesion. This phase usually courses with portal hypertension and consequent variceal gastrointestinal bleeding. Decompression of the portal system through direct recanalization (angioplasty with stenting) is one therapeutic options. Conclusion: We conclude that, in the present case, resolving portal hypertension by direct portal recanalization was a good therapeutic option, as it decompressed the portal system while maintaining the hepatopetal flow.
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Background The COVID-19 pandemic has impacted every aspect of our current lives. Therefore, it is important to identify whether there is a change in the number of mechanical thrombectomy (MT) cases that could be attributed to COVID- 19 shutdowns. Methods This is a retrospective cohort study utilizing a prospectively maintained institutional database that tracks MT data at our institution. The study date ranges from August 21, 2018 to October 20, 2021. Patients were dichotomized by the arrival date of March 19, 2020 into pre-and post-COVID-19 shutdown groups. Stroke-onset-to-arrival time is defined as the patient's last known normal to when they arrived at our institution. We utilized univariate analyses to assess MT differences between three settings, 'drip and ship', emergency department, and in-patient admission. Results Of the 544 patients during this time period, 289 (53.1%) presented during the pre-COVID-19 shutdown timepoint while 255 (46.9%) presented after. Of the 289 pre-COVID-19 patients, 158 (54.7%) arrived by 'drip & ship', 120 (41.5%) presented to the emergency department, and 11 (3.8%) had a stroke in the in-patient setting. Of the 255 post-COVID-19 shutdown patients, 197 (77.3%) arrived by 'drip & ship', 41 (16.1%) presented to the emergency department, and 17 (6.7%) had a stroke in the inpatient setting. The changes in presentation location between the pre-and post-COVID-19 shutdown timepoint were statistically significant (p<0.001). Among the 'drip and ship' patients, the onset-to-arrival time to our institution lengthened from 386.2 to 488.6 minutes after the COVID- 19 shutdown (p=0.002) while the onset-to-arrival times did not significantly differ for emergency department and inpatient admits (p>0.05). The arrival-to-puncture time increased from 107.1 minutes to 133.0 minutes after COVID-19 shutdowns for those presenting to the emergency department (p<0.001) while there was no significant difference between 'drip and ship' and in-patient times (p>0.05). The onset-to-recanalization time significantly increased for 'drip and ship' patients from 487.5 to 604.1 minutes after COVID-19 shutdowns (p=0.0037) while the difference was not significant for those presenting to the emergency department. Conclusion There appears to be a 3-fold decrease in MT presenting to the emergency department at our institution since the COVID-19 shutdown while 'drip and shipped' and inpatient admits have increased slightly. For patients admitted to the emergency department, there was a statistically significant ∼25-minute increased arrival-to-puncture time after COVID- 19 shutdowns. Further monitoring of presentation over the next year as the pandemic wanes will be revealing to any lasting impact on patient triage and treatment based on the COVID-19 pandemic.
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Introduction Cerebral venous thrombosis (CVT) may occur due to a number of common etiologies such as thromboembolism, atherosclerotic disease, or small vessel disease. When these are ruled out or considered unlikely, a hypercoagulability workup is performed. We describe a series of 30 patients with CVT and medical and/or genetic basis for the underlying hypercoagulable state and thrombophilia. Methods A retrospective review of all CVT cases treated with venous thrombectomy between June 2016 and August 2021 was performed within our institutional, neuroendovascular database. Results Of the 30 patients identified, 18 were associated with a hypercoagulable state and/or thrombophilia. Underlying illness was present in seven (36.8%) patients due to polycythemia vera, systemic lupus erythematosus, a combination of nephrotic syndrome and morbid obesity, a combination of rheumatoid arthritis and diabetes, chronic rejection of a small bowel transplant further complicated by acute renal failure and ARDS, a combination of diabetes, DVT, and a dyslipidemic state, and Covid-19. Hypercoagulable states were identified in seven (36.8%) patients due to elevated Factor VIII (1/ 7), antiphospholipid syndrome (3/7), and Protein S deficiency (3/7). Genetic thrombophilia was identified in four (16.4%) patients in the form of a heterozygous Factor V mutation in R506Q (2/4), a heterozygous Prothrombin Factor II mutation in G20210A (1/4), and a homozygous 4G/4G promoter Plasminogen Activator inhibitor I deletion mutation (1/4). Overall, no subset of hypercoagulability (I.e. mutation, disease, transient state) nor hypercoagulability overall was predictive of outcome as measured by recanalization, discharge disposition, or reocclusion likelihood. Conclusion The most common cause of hypercoagulability was underlying disease or transient antiphospholipid syndrome/elevated pro-coagulation factor. While we are unable to report hypercoagulability as a predictive variable of outcome in our cohort, we outline the presence of various coagulopathies within this medically refractory, CVT cohort. While CVT may occur due to many common pathologies, in cases where the cause is unknown a hypercoagulability workup my shed light on mitigating factors underlying the thrombosis.
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Introduction: Aortic aneurysmal disease is an evolving pathology: when treating an aortic aneurysm, we must consider the possibility of a thoraco-abdominal evolution aneurysm, which might lead to further treatments. In case of challenging anatomies (narrow aortic lumen at the level of visceral arteries, aortic wall thrombus, true lumen in an aortic dissected aneurysm, and focal aortic narrow diameter), unfavourable both for fenestrated endovascular aneurysm repair (FEVAR) and branched endovascular aneurysm repair (BEVAR), an inner branched custom made device could represent a potential feasible solution. Inner branched endografts have a typical configuration that combines the advantageous characteristics of both fenestrated and side branched endografts, thus showing advantages over other custom made grafts. Our study aimed to investigate the potential role of this technique in a broad variety of aortic anatomies unfavourable for FEVAR and BEVAR, in patients who received different previous aortic treatments. Methods: In our institution, between July 2018 and July 2020, 20 consecutive patients underwent a FEVAR/BEVAR procedure to treat complex abdominal aortic aneurysm or thoracic aortic aneurysm. Nine patients who were deemed untreatable with a fenestrated/branched graft due to aortic anatomy and/or previous treatments were treated with a custom made, four inner branch E-xtra design endograft (I BEVAR). All patients were treated for a complex aortic abdominal and thoraco-abdominal aneurysm: two patients were previously treated with frozen elephant trunk and TEVAR;three patients were previously treated with TEVAR;and one with TEVAR + abdominal aortic surgical treatment. Two patients received abdominal aortic surgical treatment only. The last patient was previously treated with EVAR, which was then complicated with a type 1A endoleak (EL). Five of six TEVARs were placed before BEVAR as staged procedures, to decrease spinal cord ischaemia risk. All patients had a lumbar cerebrospinal fluid drainage during the BEVAR procedure. In total, the bridging stents placed included 43 balloon expandable and four self-expandable stents. Results: In our experience, all cases were treated with a four inner branch endograft with a total revascularisation of 36 target vessels. Technical success was achieved in all nine cases (100%), with precise deployment of the inner branched endograft and effective engagement and bridging of all branches. Major clinical complications occurred in three (33%) patients: one case of continuous veno-venous haemofiltration treatment for a transient acute renal failure in a chronic renal disease;one case of hepatic decompensation in patient with a chronic cirrhosis, which led to liver failure (Child Pugh C10, MELD 19, still under medical treatment);and one patient with a pulmonary infection disease (COVID-19 related), which then resolved. No patient suffered spinal cord ischaemia. The mean follow up was 12.8 months ± 6.79 months, with an estimated one year survival rate of 89%. One patient with a thrombophilic disorder died on postoperative day 48 as a result of multiple organ failure after acute four inner branches simultaneous occlusion. During follow up, the target vessel primary patency rate was 89%, associated with four (11%) bridging stent ELs. At 30 days, computed tomography angiography detected five BS ELs in four patients: one type III BS EL (2.7%), and four type I BS ELs (11%). Re-intervention was needed in one patient (11%) with a type III and I BS EL associated with an aneurysm sac enlargement treated with bridging stent relining in the left renal artery and superior mesenteric artery. Conclusion: Our experience shows the feasibility of treating complex aortic anatomies with an inner branched graft in patients which were anatomically unfit for FEVAR/BEVAR treatment, allowing complex visceral vessels recanalisation and an adequate sealing. When a re-intervention is needed, we have to consider that previous surgical and endovascular treatments modify the aortic anatomy, and the graft deploy ent may be tougher, with a higher risk of malrotation. Inner branched endograft could be a valid option in case of complex anatomies, but long term follow up is needed.
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OBJECTIVE: We aimed to evaluate door-to-puncture time (DPT) and door-to-recanalization time (DRT) without directing healthcare by neuro-interventionalist support in the emergency department (ED) by workflow optimization and improving patients' outcomes. METHODS: Records of 98 consecutive ischemic stroke patients who had undergone endovascular therapy (EVT) between 2018 to 2021 were retrospectively reviewed in a single-center study. Patients were divided into three groups: pre-intervention (2018-2019), interim-intervention (2020), and post-intervention (January 1st 2021 to August 16th, 2021). We compared door-to-puncture time, door-to-recanalization time (DRT), puncture-to-recanalization time (PRT), last known normal time to-puncture time (LKNPT), and patient outcomes (measured by 3 months modified Rankin Scale) between three groups using descriptive statistics. RESULTS: Our findings indicate that process optimization measures could shorten DPT, DRT, PRT, and LKNPT. Median LKNPT was shortened by 70 min from 325 to 255 min(P < 0.05), and DPT was shortened by 119 min from 237 to 118 min. DRT shortened by 132 min from 338 to 206 min, and PRT shortened by 33 min from 92 to 59 min from the pre-intervention to post-intervention groups (all P < 0.05). Only 21.4% of patients had a favorable outcome in the pre-intervention group as compared to 55.6% in the interventional group (P= 0.026). CONCLUSION: This study demonstrated that multidisciplinary cooperation was associated with shortened DPT, DRT, PRT, and LKNPT despite challenges posed to the healthcare system such as the COVID-19 pandemic. These practice paradigms may be transported to other stroke centers and healthcare providers to improve endovascular time metrics and patient outcomes.
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COVID-19 , Ischemic Stroke , Stroke , Humans , Ischemic Stroke/surgery , Pandemics , Punctures , Retrospective Studies , Stroke/therapy , Thrombectomy , Time-to-Treatment , Treatment Outcome , WorkflowABSTRACT
Background and purpose: Inevitable lockdown scenario during the first wave of COVID-19 pandemic led to different approaches of medical care system worldwide. During this period, health care services faced the problem of time, place and human resources management. However, in spite of redirecting health forces to fight this new and unknown virus in all countries, the need of routine treatment of all the other emergencies according to the guidelines remained present. The aim of our study was to analyse the acute stroke care in Croatia during first wave of Covid pandemic. Materials and methods: In order to achieve the rate of stroke patients admitted to hospital care in dedicated hospital stroke units and centers, we have gathered the data from four Croatian University Hospitals. We analyzed the number of hospitalized stroke patients from 1th of February to 1th of May 2020 and the proportions of patients treated with recanalization therapy. Results: Our results showed a slight decrease of number of all neurological patients who arrived to the Emergency Unit. In 2019 recanalization therapy was given to 158 patients (19%) vs 177 (26%) in 2020. Thrombolysis alone was given to 72 (9%) of patients in 2019 and to 68 (10%) of patients in 2020, while thrombectomy (with or without thrombolysis) has been performed to 86 (10%) vs 109 (16%) patients in 2019 and 2020 respectively. Conclusion: In conclusion, we did not notice less severe stroke patients or lower level of stroke care in University Hospitals.
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Backgound and aims: Stroke is a time dependent medical emergency. The incorporation of the EMS team to the Stoke Code (SC) might improve the number and timing of recanalization. We will review the EMS times, type of acute cerebrovascular syndrome, rate of recanalization and characterization of mimics. Methods: Observational, analytic, retrospective cross-sectional study based on electronic records. From 11/2018 to 6/2021. n= 452. Data was transferred to MS Excel and analyzed with Epi Info v. 7.2.2.1 and JASP 0.14.1 for analysis of related variables we used ttest for paired variables. Results: n=452. Acute Cerebrovascular Syndromes 54.5%(206). Alternative diagnosis 45.5%(246). Acute Ischemic Stroke (AIS) 31,2%(141), Hemorrhagic Stroke 11% (33). TIA 7,3% (32). Recanalization rate AIS 55%. Alternative diagnosis group: Sepsis 11.8%(53), Conversive syndrome 7,1%(32), Seizure 4,6%(21) Trauma 4,4% (20), Vertigo 3,3% (15), Pharmacological/Alcohol toxicity 2.87% (13), Hypoglycemia (2%) 9. The mean medical time is 32 minutes. The mean transport time is 17minutes. Interestingly, the mean Medical Time from November 2018 to March 2020 (COVID-19 pandemic declaration) was 26 minutes and from April 2020 to June 2021 was 38 minutes, a 12-minute difference with significative difference (p<0.001). Transport times show only 2 minutes of difference with no statistical difference. Conclusions: This is one of the largest observational studies with identification of the final diagnosis of patients and the treatment modality. In our sample, we identify an important quantity of mimics and a very high recanalization ratio for AIS. We also describe the worsening in medical times after the COVID-19 lockdown in Argentina.