ST-Segment Elevation Myocardial Infarction on the Line: Inadvertent Arterial Infusion of Vasopressors Causing Acute Myocardial Infarction.

Central venous catheters (CVCs), regarded as lines of life, are helpful in hemodynamic monitoring and delivering medications to patients. However, there are several complications that can result from the placement of CVCs. This includes accidental arterial puncture, which has a temporal association with hemorrhage, hematoma, and stroke. Infusion of vasopressors through such a mispositioned arterial CVC further increases the risk of these complications with potential end-organ ischemia. Here, we discuss the case of a 76-year-old woman who developed a myocardial infarction, heart failure, and subarachnoid hemorrhage following the arterial infusion of vasopressors through a malpositioned CVC.

CLINICAL MEMORY OF COVID-19 PANDEMIC: A COMPARATIVE ANALYSIS OF CLINICAL AND ANGIOGRAPHIC CHARACTERISTICS OF PATIENTS WITH ACUTE CORONARY SYNDROME

Objectives: To describe the clinical characteristics and angiographic features of COVID-19 patients presenting with acute coronary syndrome (ACS) and to compare with non-COVID-19 ACS patients presenting simultaneously. Methodology: In a case control design, data were extracted from a prospectively collected COVID-19 and NCDR registry. All ACS patients who underwent cardiac catheterization from April 2020 to May 2021 were included. All of the patients were taken to the Cath lab for diagnostic coronary angiography and possible percutaneous intervention. Demographic and clinical characteristics, angiographic features, and in-hospital outcomes were compared between ACS patients with and without COVID-19. Results: A total of 4027 COVID-19 negative patients, and 80 COVID-19 positive were included. Total of 83% in COVID-19 and 88% in non-COVID-19 group had ST elevation myocardial infarction. Majority of the COVID-19 positive patients had sub-optimal TIMI flow grade (<III) post procedure and had a high thrombus burden (11.2% vs. 2.9%;p<0.001). Majority of the patients who had COVID-19 and ACS required mechanical circulatory support (48.8% vs. 0.3%;p<0.001). The mortality rates were also higher in COVID-19 positive group (38.8% vs. 1.3%;p<0.001). Among the COVID-19 positive patients 66.3% (53) had high thrombus burden (≥4 grade), intervention was performed in 73.7% (59). Post-intervention myocardial blush grade ≤2 was observed in 57.6% (34), slow flow in 85.3% (29), and phasic flow possibly due to elevated LVEDP in 41.2% (14) patients. Conclusion: COVID-19 patients with ACS had a higher severity of illness at presentation and worse outcomes as compared to simultaneously presenting non-COVID patients. © 2023 The authors.

COVID-19 infected ST-Elevation myocardial infarction in India (COSTA INDIA).

OBJECTIVE: To find out differences in the presentation, management and outcomes of COVID-19 infected STEMI patients compared to age and sex-matched non-infected STEMI patients treated during the same period. METHODS: This was a retrospective multicentre observational registry in which we collected data of COVID-19 positive STEMI patients from selected tertiary care hospitals across India. For every COVID-19 positive STEMI patient, two age and sex-matched COVID-19 negative STEMI patients were enrolled as control. The primary endpoint was a composite of in-hospital mortality, re-infarction, heart failure, and stroke. RESULTS: 410 COVID-19 positive STEMI cases were compared with 799 COVID-19 negative STEMI cases. The composite of death/reinfarction/stroke/heart failure was significantly higher among the COVID-19 positive STEMI patients compared with COVID-19 negative STEMI cases (27.1% vs 20.7% p value = 0.01); though mortality rate did not differ significantly (8.0% vs 5.8% p value = 0.13). Significantly lower proportion of COVID-19 positive STEMI patients received reperfusion treatment and primary PCI (60.7% vs 71.1% p value=< 0.001 and 15.4% vs 23.4% p value = 0.001 respectively). Rate of systematic early PCI (pharmaco-invasive treatment) was significantly lower in the COVID-19 positive group compared with COVID-19 negative group. There was no difference in the prevalence of high thrombus burden (14.5% and 12.0% p value = 0.55 among COVID-19 positive and negative patients respectively) CONCLUSIONS: In this large registry of STEMI patients, we did not find significant excess in in-hospital mortality among COVID-19 co-infected patients compared with non-infected patients despite lower rate of primary PCI and reperfusion treatment, though composite of in-hospital mortality, re-infarction, stroke and heart failure was higher.

An exploration of the early discharge approach for low-risk STEMI patients following primary percutaneous coronary intervention.

Recently, there has been growing interest in the early discharge strategy for low-risk patients who have undergone primary percutaneous coronary intervention (PCI) to treat ST-segment elevation myocardial infarction (STEMI). So far findings have suggested there are multiple advantages of shorter hospital stays, including that it could be a safe way to be more cost- and resource-efficient, reduce cases of hospital-acquired infection and boost patient satisfaction. However, there are remaining concerns surrounding safety, patient education, adequate follow-up and the generalisability of the findings from current studies which are mostly small-scale. By assessing the current research, we describe the advantages, disadvantages and challenges of early hospital discharge for STEMI and discuss the factors that determine if a patient can be considered low risk. If it is feasible to safely employ a strategy like this, the implications for healthcare systems worldwide could be extremely beneficial, particularly in lower-income economies and when we consider the detrimental impacts of the recent COVID-19 pandemic on healthcare systems.

Thrombolysis in STEMI in the era of COVID - Holding fort in cardiologist deficit locales.

During the COVID-19 pandemic, the pharmaco-invasive approach in the management of ST Elevation Myocardial Infarction (STEMI) played a vital role in saving many lives. A retrospective observational study was conducted wherein 134 patients presenting with STEMI between (Dec 2019-Mar 2022) were thrombolysed with either streptokinase or tenecteplase in a centre where primary PCI was not available. There was no significant difference in the outcomes and their predictors between the SK and TNK groups. A prospective study with a larger sample size in the Indian population will be able to provide more substantial and promising results for further interventions.

The Clot Thickens: COVID-19-Related ST-Elevation Myocardial Infarction in the Setting of Recent Boosters.

The coronavirus disease of 2019 (COVID-19) has an array of pathological effects that continue to be discovered. Vaccines against COVID-19 have quickly emerged as our main tool. However, the thrombotic risk of both the virus and the vaccine is yet to be established, let alone together. In this case report, we present a case involving a recently diagnosed COVID-19 patient who developed an ST-elevated myocardial infarction (STEMI) after receiving his booster shot. Our aim is to highlight the standard of treatment outcomes in COVID-19-associated clots, familiarize ourselves with the complexity of the clot burden in a COVID-19-associated STEMI, and illustrate the potential role of the cumulative pro-thrombotic effects of a recent COVID-19 booster with a concomitant symptomatic COVID-19 infection.

Cardiac Arrest Secondary to Inferior ST-Segment-Elevation Myocardial Infarction in Patient with Paroxysmal Nocturnal Hemoglobinuria and COVID-19 Infection.

Patients with paroxysmal nocturnal hemoglobinuria (PNH) have transient attacks of complement-mediated hemolysis and thrombosis that can be spontaneous or secondary to precipitating factors such as infections. We present a case of a 63-year-old male patient with a medical history of PNH who presented with typical chest pain, fever, cough, jaundice, and dark-colored urine. On examination, he was hemodynamically stable but had conjunctival icterus. A few minutes after presentation, the patient suffered a ventricular fibrillation cardiac arrest and then achieved a return of spontaneous circulation after receiving two defibrillator shocks. EKG showed inferior wall ST-segment elevation myocardial infarction. Labs showed hemoglobin of 6.4 g/dl, elevated cardiac markers, serum lactate dehydrogenase, and indirect bilirubin. Serum haptoglobin was < 1 mg/dl. His COVID-19 polymerase chain reaction test was positive. Immediately, the patient received 2 units of packed RBCs and underwent a coronary angiogram (CA), which revealed total proximal occlusion of the right coronary artery. He underwent successful percutaneous coronary intervention (PCI), and two drug-eluting stents were placed. His peripheral blood immunophenotyping and flow cytometry showed loss of glycosylphosphatidylinositol-linked antigens and decreased expression of CD 59/14/24. He was started on ravulizumab, a humanized monoclonal antibody complement five inhibitor. Both PNH and COVID-19 increase the risk of thrombosis. Endothelial injury and cytokine storm increase the risk of thrombosis in COVID-19 patients, whereas the activation of the coagulation system and the impairment of the fibrinolytic system by complement cascade leads to thrombosis in PNH patients. Regardless of which pathway leads to coronary artery thrombosis, CA and PCI can be life-saving.

The Impact of the COVID-19 Pandemic on Coronary Interventional Cardiology Activity in King Abdulaziz Medical City: A Retrospective Study.

BACKGROUND: The COVID-19 pandemic has decreased the number of patients undergoing coronary interventional procedures. This study aimed to identify the impact of the COVID-19 pandemic on the volume of patients and the types of interventional cardiology procedures performed at King Abdulaziz Cardiac Center (KACC) in Riyadh, Saudi Arabia. METHODS: A retrospective chart review was undertaken with a sample size of 301 patients aged over 18 years, who underwent various cardiac interventions at King Abdulaziz Cardiac Center (KACC) between March 15, 2019, and February 29, 2020 (prior to the pandemic, group A), and between March 1, 2020, and March 15, 2021 (during the pandemic, group B). The BESTCare 2.0 system (ezCaretech, Seoul, South Korea) was used to collect data, Microsoft Office Excel (Microsoft® Corp., Redmond, WA) was utilized for data entry, and the Statistical Package for Social Sciences software (IBM SPSS Statistics, Armonk, NY) was employed for data analysis. RESULTS: There was a 21.4% decrease in the number of procedures performed during the pandemic. The largest age group within the population was ≥60 years, comprising 43.5% and 52.3% of groups A and B, respectively. Most patients had a body mass index (BMI) of >30, i.e., 43.5% of patients before the pandemic and 47.7% after the pandemic. In group A, 39.9% were smokers and 60.6% in group B. The prevalence of hypertension and obesity was higher in group B, i.e., 77.3% and 42.3%, respectively. The incidence of ST-elevation myocardial infarction (STEMI) was 39.9% in group A and 39.4% in group B. For non-ST-elevation myocardial infarction (NSTEMI), the comparable statistics were 56.5% and 49.2%, respectively. In groups A and B, readmission frequencies were 17.9% and 20%, respectively. CONCLUSION: The study indicates a minor decline in the number of percutaneous coronary interventions (PCIs) conducted in the interventional cardiology department of King Abdulaziz Cardiac Center (KACC) immediately following the COVID-19 outbreak, reflecting a steady activity in the center.

A Case of Pure Pericarditis Associated With COVID-19: Application of Classical Clinical Evaluation for Differential Diagnosis.

Pericarditis of varying severity is being recognized as a rare complication of the COVID-19 infection. We present a patient with an electrocardiogram (EKG) and physical exam findings that initially seemed to most likely be pericarditis related to the COVID-19 infection. The differential diagnosis was a bit difficult because it included ST-segment elevation myocardial infarction (STEMI) due to some EKG changes and early repolarization changes that were rather robust. Treatment options for STEMI could cause severe harm if the process turned out to be pericarditis. Treatment options for pericarditis could cause severe harm if the process turned out to be STEMI. And treatment options for early repolarization might be no treatment at all, which could cause harm if the process turned out to be STEMI or pericarditis. In this case, a correct diagnosis was very important to ensure a good clinical outcome. We would like to share our thought processes in the management of this case.

The Impact of Emergency Department Arrival Time on Door-to-Balloon Time in Patients with ST-Segment Elevation Myocardial Infarction Receiving Primary Percutaneous Coronary Intervention.

Door-to-balloon (DTB) time significantly affects the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). The effects of temporal differences in emergency department (ED) arrival time on DTB time and on different segments of DTB time remain inconclusive. Therefore, we performed a retrospective study in a tertiary hospital between January 2013 and December 2021 and investigated the relationship between a patient's arrival time and both their DTB time and different segments of their DTB time. Of 732 STEMI patients, 327 arrived during the daytime (08:01-16:00), 268 during the evening (16:01-24:00), and 137 at night (00:01-08:00). Significantly higher odds of delay in DTB time were observed during the nighttime (adjusted odds ratio (aOR): 2.87; 95% confidence interval (CI): 1.50-5.51, p = 0.002) than during the daytime. This delay was mainly attributed to a delay in cardiac catheterization laboratory (cath lab) activation-to-arrival time (aOR: 6.25; 95% CI: 3.75-10.40, p < 0.001), particularly during the 00:00-04:00 time range. Age, sex, triage level, and whether patients arrived during the COVID-19 pandemic also had independent effects on different segments of DTB time. Further studies are required to investigate the root causes of delay in DTB time and to develop specific strategies for improvement.

Impact of COVID-19 on percutaneous coronary intervention utilization and mortality in New York.

BACKGROUND: COVID-19 has disrupted the care of all patients, and little is known about its impact on the utilization and short-term mortality of percutaneous coronary intervention (PCI) patients, particularly nonemergency patients. METHODS: New York State's PCI registry was used to study the utilization of PCI and the presence of COVID-19 in four patient subgroups ranging in severity from ST-elevation myocardial infarction (STEMI) to elective patients before (December 01, 2018-February 29, 2020) and during the COVID-19 era (March 01, 2020-May 31, 2021), as well as to examine the impact of different COVID severity levels on the mortality of different types of PCI patients. RESULTS: Decreases in the mean quarterly PCI volume from the prepandemic period to the first quarter of the pandemic ranged from 20% for STEMI patients to 61% for elective patients, with the other two subgroups having decreases in between these values. PCI quarterly volume rebounds from the prepandemic period to the second quarter of 2021 were in excess of 90% for all patient subgroups, and 99.7% for elective patients. Existing COVID-19 was rare among PCI patients, ranging from 1.74% for STEMI patients to 3.66% for elective patients. PCI patients with COVID-19 and acute respiratory distress syndrome (ARDS) who were not intubated, and PCI patients with COVID-19 and ARDS who were either intubated or were not intubated because of Do Not Resuscitate//Do Not Intubate status had higher risk-adjusted mortality ([adjusted ORs = 10.81 [4.39, 26.63] and 24.53 [12.06, 49.88], respectively]) than patients who never had COVID-19. CONCLUSIONS: There were large decreases in the utilization of PCI during COVID-19, with the percentage of decrease being highly sensitive to patient acuity. By the second quarter of 2021, prepandemic volumes were nearly restored for all patient subgroups. Very few PCI patients had current COVID-19 throughout the pandemic period, but the number of PCI patients with a COVID-19 history increased steadily during the pandemic. PCI patients with COVID-19 accompanied by ARDS were at much higher risk of short-term mortality than patients who never had COVID-19. COVID-19 without ARDS and history of COVID-19 were not associated with higher mortality for PCI patients as of the second quarter of 2021.

Impact of COVID-19 on Acute Myocardial Infarction Care.

The global health crisis caused by the COVID-19 pandemic has evolved rapidly to overburden health care organizations around the world and has resulted in significant morbidity and mortality. Many countries have reported a substantial and rapid reduction in hospital admissions for acute coronary syndromes and percutaneous coronary intervention. The reasons for such abrupt changes in health care delivery are multifactorial and include lockdowns, reduction in outpatient services, reluctance to seek medical attention for fear of contracting the virus, and restrictive visitation policies adopted during the pandemic. This review discusses the impact of COVID-19 on important aspects of acute MI care.

Comparison of STEMI Door-To-Device Time During the COVID-19 Crisis in a New Jersey Inner City Community Hospital.

As the novel COVID-19 pandemic was on the rise, its impact on the healthcare system was devastating. Patients became more reluctant to present to the hospital and elective procedures were being postponed for patient safety. We wanted to assess the effects of the COVID-19 pandemic on the door-to-device time in our small community hospital in the heart of Trenton, New Jersey. We created a retrospective study that evaluated all STEMI cases that presented to our institute from January 2018 until the end of May, 2021. Our primary outcome was the door-to-device time. Secondary outcomes were the length of hospital stay, ICU admission, length of ICU stay, cardiac arrest, and death during the hospitalization. We studied 114 patients that presented with STEMI to our emergency department, 77 of these patients presented pre-COVID-19, and 37 presented during the pandemic. Our median door-to-device for STEMI cases pre-COVID-19, and during the pandemic were 70 min (IQR 84-57) and 70 min (IQR 88-59) respectively with no significant difference found (P-value 0.55, Mann Whitney Test). It is, however, interesting to note that the number of STEMI admissions significantly decreased during the pandemic era. There are limitations to our study, most noticeably the number of STEMI cases at our small community hospital which limits its generalizability. Moreover, we did not assess other comorbidities which might have confounded our outcomes and we were also unable to follow patients post-discharge to assess the long-term sequela of their STEMI admission. Therefore, more dedicated studies of this clinical conundrum are required to further assess and implement guidelines for the future.

Recovery From the Impact of COVID-19 on Treatment Times and Clinical Outcomes of Patients With ST-Segment Elevation Myocardial Infarction: An Interim Analysis.

BACKGROUND: Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. METHODS: Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. RESULTS: For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). CONCLUSION: COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.

COVID-19 pandemic affects STEMI numbers and in-hospital mortality: results of a nationwide analysis in Germany.

BACKGROUND: The COVID-19 pandemic led to extensive restrictions in Germany in 2020, including the postponement of elective interventions. We examined the impact on ST-elevation myocardial infarction (STEMI) as an acute and non-postponable disease. METHODS: Using German national records, all STEMI between 2017 and 2020 were identified. Using the number of STEMI cases between 2017 and 2019, we created a forecast for 2020 and compared it with the observed number of STEMI in 2020. RESULTS: From 2017 to 2020, 248,062 patients were treated for STEMI in Germany. Mean age was 65.21 years and 28.36% were female. When comparing forecasted and observed STEMI in 2020, a correlation can be seen: noticeable fewer STEMI were treated in those weeks respectively months with an increasing COVID-19 hospitalization rate (monthly percentage decrease in STEMI: March - 14.85%, April - 13.39%, November - 11.92%, December - 22.95%). At the same time, the crude in-hospital mortality after STEMI increased significantly at the peaks of the first and second waves (relative risk/RR of monthly in-hospital mortality: April RR = 1.11 [95% CI 1.02; 1.21], November RR = 1.13 [1.04; 1.24], December RR = 1.16 [1.06; 1.27]). CONCLUSION: The COVID-19 pandemic led to a noticeable decrease in the number of STEMI interventions in Germany at the peaks of the first and second waves in 2020, corresponding to an increase in COVID-19 hospitalizations. At the same time, in-hospital mortality after STEMI increased significantly in these phases. Impact of the COVID-19 pandemic on STEMI numbers and in-hospital mortality in Germany. Relative difference between forecasted and observed STEMI numbers (above figure), the relative risk of in-hospital mortality (middle figure) as well as number of new hospital admissions for COVID-19 per million inhabitants according to Roser et al.27 (bottom figure).

Impact of COVID-19 Pandemic on Patients with ST-Segment-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest.

Patients with ST-segment-elevation myocardial infarction (STEMI) treated during the COVID-19 pandemic might experience prolonged time to reperfusion. The delayed reperfusion may potentially aggravate the risk of out-of-hospital cardiac arrest (OHCA) in those patients. Limited access to healthcare, more reluctant health-seeking behaviors, and bystander readiness to render life-saving interventions might additionally contribute to the suggested change in the risk of OHCA in STEMI. Thus, we sought to explore the effects of the COVID-19 outbreak on treatment delay and clinical outcomes of patients with STEMI with OHCA. Overall, 5,501 consecutive patients with STEMI complicated by OHCA and treated with primary percutaneous coronary intervention with stent implantation were enrolled. A propensity score matching was used to obviate the possible impact of non-randomized design. A total of 740 matched pairs of patients with STEMI and OHCA treated before and during the COVID-19 pandemic were compared. A similar mortality and prevalence of periprocedural complications were observed in both groups. However, patients treated during the COVID-19 outbreak experienced longer delays from first medical contact to angiography (88.8 (±61.5) vs. 101.4 (±109.8) [minutes]; p = 0.006). There was also a trend toward prolonged time from pain onset to angiography in patients admitted to the hospital in the pandemic era (207.3 (±192.8) vs. 227.9 (±231.4) [minutes]; p = 0.06). In conclusion, the periprocedural outcomes in STEMI complicated by OHCA were comparable before and during the COVID-19 era. However, treatment in the COVID-19 outbreak was associated with a longer time from first medical contact to reperfusion.

A Rare Case of ST-Segment Elevation Myocardial Infarction and Left Ventricular Thrombus in a Dextrocardia Patient With COVID-19 Infection.

Acute coronary syndrome (ACS) is an increasingly common finding among patients presenting with Coronavirus Disease 2019 (COVID-19) pneumonia. While cardiovascular disease alone remains one of the most common causes of death among COVID-19 patients in the United States, its heightened prevalence with COVID-19 pneumonia has been well documented. Here we present the case of a 58-year-old male with an extensive cardiac history including coronary artery disease (CAD) with multiple drug-eluting stents (DES) placed and an episode of cardiac arrest requiring implantable cardioverter defibrillator (ICD) placement. He presented to the Emergency Department originally complaining of chest pain, shortness of breath, and fatigue, and was found to be positive for COVID-19 pneumonia. Cardiac catheterization demonstrated extensive CAD and evaluation for coronary artery bypass grafting (CABG) was warranted. Shortly after, the patient experienced an acute thrombotic episode in the left anterior descending (LAD) coronary artery and underwent successful emergent high-risk percutaneous coronary intervention (PCI) with DES placement. The patient was also found to have a left ventricular thrombus requiring anticoagulation. Despite his complex course, the patient had a very favorable outcome.

The Profile and All-Cause In-Hospital Mortality Dynamics of St-Segment Elevation Myocardial Infarction Patients during the Two Years of the COVID-19 Pandemic.

During the coronavirus pandemic 2019 (COVID-19), some studies showed differences in the profile of subjects presenting with acute coronary syndromes as well as in overall mortality due to the delay of presentation and other complications. The purpose of this study was to compare the profile and outcomes, with emphasis on all-cause in-hospital mortality, of ST-elevation myocardial infarction (STEMI) subjects presenting to the emergency department during the pandemic period compared with a control group from the previous year, 2019. The study enrolled 2011 STEMI cases, which were divided into two groups-pre-pandemic (2019-2020) and pandemic period (2020-2022). Hospital admissions for a STEMI diagnosis sharply decreased during the COVID-19 period by 30.26% during the first year and 25.4% in the second year. This trend was paralleled by a significant increase in all-cause in-hospital mortality: 11.5% in the pandemic period versus 8.1% in the previous year. There was a significant association between SARS-CoV-2 positivity and all-cause in-hospital mortality, but no correlation was found between COVID-19 diagnosis and the type of revascularization. However, the profile of subjects presenting with STEMI did not change over time during the pandemic; their demographic and comorbid characteristics remained similar.

Novel application of large bore aspiration in the treatment of COVID-19 associated acute limb ischemia using the penumbra CAT 12 lightning aspiration system.

COVID-19 associated cardiovascular complications have been well documented throughout the pandemic and are associated with higher rates of morbidity and mortality. Hypercoagulable states resulting from systemic inflammation have been associated with increasing incidences of acute myocardial infarctions (AMI) and acute limb ischemia (ALI). Herein, we present a case of AMI complicated by ALI in a patient with COVID-19 in which aspiration thrombectomy using the Penumbra CAT 12 thrombectomy catheter was used in the management of acute popliteal artery occlusion.