Endovascular treatment for acute ischemic stroke in patients with tandem lesion in the anterior circulation: analysis from the METRICS study.

BACKGROUND: Acute ischemic stroke (AIS) due to anterior circulation tandem lesion (TL) remains a technical and clinical challenge for endovascular treatment (EVT). Conflicting results from observational studies and missing evidence from the randomized trials led us to report a recent real-world multicenter clinical experience and evaluate possible predictors of good outcome after EVT. METHODS: We analyzed all AIS patients with TL enrolled in the prospective national study METRICS (Mechanical Thrombectomy Quality Indicators Study in Czech Stroke Centers). A good 3-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS), achieved recanalization using the Thrombolysis In Cerebral Infarction (TICI) scale and symptomatic intracerebral hemorrhage (sICH) according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria. RESULTS: Of 1178 patients enrolled in METRICS, 194 (19.2%) (59.8% males, mean age 68.7±11.5 years) were treated for TL. They did not differ in mRS 0-2 (48.7% vs 46.7%; p=0.616), mortality (17.3% vs 22.7%; p=0.103) and sICH (4.7% vs 5.1%; p=0.809) from those with single occlusion (SO). More TL patients with prior intravenous thrombolysis (IVT) reached TICI 3 (70.3% vs 50.8%; p=0.012) and mRS 0-2 (55.4% vs 34.4%; p=0.007) than those without IVT. No difference was found in the rate of sICH (6.2% vs 1.6%; p=0.276). Multivariate logistic regression analysis showed prior IVT as a predictor of mRS 0-2 after adjustment for potential confounders (OR 3.818, 95% CI 1.614 to 9.030, p=0.002). CONCLUSION: Patients with TL did not differ from those with SO in outcomes after EVT. TL patients with prior IVT had more complete recanalization and mRS 0-2 and IVT was found to be a predictor of good outcome after EVT.

Mechanical Thrombectomy Quality Indicators Study in Czech Stroke Centers: Results of the METRICS Study.

BACKGROUND AND PURPOSE: Rigorous and regular evaluation of defined quality indicators is crucial for further improvement of both technical and clinical results after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Following the recent international multi-society consensus quality indicators, we aimed to assess trend in these indicators on national level. MATERIAL AND METHODS: The prospective multicenter study (METRICS) was conducted in Czech Republic (CR) in year 2019. All participating centers collected technical and clinical data including defined quality indicators and results were subsequently compared with those from year 2016. RESULTS: In the 2019, 1375 MT were performed in the CR and 1178 (86%) patients (50.3% males, mean age 70.5 ± 13.0 years) were analyzed. Recanalization (TICI 2b-3) was achieved in 83.7% of patients and 46.2% of patients had good 3-month clinical outcome. Following time intervals were shortened in comparison to 2016: "hospital arrival - GP" (77 vs. 53 min; p<0.0001), "hospital arrival - maximal achieved recanalization" (122 vs. 93 min; p<0.0001), and "stroke onset - maximal achieved recanalization" (240 vs. 229 min; p p<0.0001). More patients with tandem occlusion were treated in 2019 (7.8 vs. 16.5%; p<0.0001) and more secondary transports were in 2019 (31.3 vs. 37.8%; p=0.002). No difference was found in 3-month clinical outcome and in the rate of periprocedural complications. Results of the METRICS study met all criteria of multi-society consensus quality indicators. CONCLUSION: Nationwide comparison between 2016 and 2019 showed improvement in the key time intervals, but without better overall clinical outcomes after MT.

Mechanical Thrombectomy for Acute Ischemic Stroke in Czech Republic: Technical Results from the Year 2016.

BACKGROUND AND PURPOSE: Experienced multidisciplinary stroke team and well-organized hospital management are considered necessary to achieve good results after mechanical thrombectomy (MT) in acute ischemic stroke patients. We analyzed the technical results of MT performed in the Czech Republic in the year 2016 to provide relevant data for further quality improvement. MATERIAL AND METHODS: All centers performing MT in the CR were called for detailed technical and clinical data from year 2016, which were anonymously analyzed and relevant technical key time intervals were compared. Clinical outcomes were assessed according to the HERMES meta-analysis. RESULTS: In the 2016, 1053 MTs were performed in the CR. Of 15 dedicated centers, the data from 12 centers and from 886 (84%) patients (49.2% males, mean age 69.8 ± 12.3 years) were analyzed. The overall median of time from hospital arrival to groin puncture (GP) was 77 min with a range from 40 to 109 min among individual hospitals, from GP to first passage of stent retriever 20 (15-40) min and from GP to maximal reached recanalization 42 (33-80) min. The median of recanalization time was 240 (219-320) min. The recanalization (TICI 2b-3) was achieved in 81.7% of patients, 44.1% of patients had a good 3-month clinical outcome and 6.3% suffered from symptomatic intracerebral hemorrhage. Peri-procedural complications were recorded in 89 (10%) patients. CONCLUSION: Despite achieved good overall results, a great variability in some of the analyzed key time intervals among individual centers performing MT warrants further quality improvement.

Contribution of Computed Tomographic Angiography to Pretreatment Planning of Radio-embolization of Liver Tumors.

Transarterial radio-embolization (TARE) using yttrium-90 microspheres is a promising method based on the brachytherapeutic effect of radionuclide with beta-minus decay dissolved in solid microparticles applied directly to tumor-supplying arteries. This treatment is complex, as well as logistically and technically extremely demanding and must be planned in detail. The visualization of the vascular supply of the liver and the possible parasitic supply of the tumor is essential not only for indication of the procedure and correct identification of the arteries to which the microspheres will be applied, but also for prevention of non-target deposition of radioactive material. This review addresses the use of computed tomographic angiography in the preparatory phase of TARE.

Portal Vein Embolization with Contralateral Application of Stem Cells Facilitates Increase of Future Liver Remnant Volume in Patients with Liver Metastases.

OBJECTIVES: This study aimed to evaluate the progress of future liver remnant volume (FLRV) in patients with liver metastases after portal vein embolization (PVE) with the application of hematopoietic stem cells (HSCs) and compare it with a patients control group after PVE only. METHODS: Twenty patients (group 1) underwent PVE with contralateral HSC application. Subsequently, CT volumetry with the determination of FLRV was performed at weekly intervals, in total three weeks. A sample of twenty patients (group 2) who underwent PVE without HSC application was used as a control group. RESULTS: The mean of FLRV increased by 173.2 mL during three weeks after the PVE/HSC procedure, whereas by 98.9 mL after PVE only (p = 0.015). Furthermore, the mean daily growth of FLRV by 7.6 mL in group 1 was significantly higher in comparison with 4.1 mL in group 2 (p = 0.007). CONCLUSIONS: PVE with the application of HSC significantly facilitates growth of FLRV in comparison with PVE only. This method could be one of the new suitable approaches to increase the resectability of liver tumours.

Predictive Value of Growth Factors and Interleukins for Future Liver Remnant Volume and Colorectal Liver Metastasis Volume Growth Following Portal Vein Embolization and Autologous Stem Cell Application.

BACKGROUND: Liver metastases occur in 60-80% of patients with colorectal carcinoma. The only potentially curative method is surgical resection, with an operability of 20-25%. The main reason for such low resectability is insufficient future liver remnant volume (FLRV). Portal vein embolization (PVE) alone is associated with failure in up to 40% of patients. A new method that could lead to acceleration of FRLV growth appears to be combination of PVE and application of hematopoietic stem cells (HSCs). The aim of our study was to evaluate the importance of growth factors and interleukins for FLRV growth after PVE and HSC application and also their possible effect on growth of colorectal liver metastases. PATIENTS AND METHODS: From June 2010 to July 2014, PVE was combined with application of adult HSCs in 16 primarily inoperable patients with colorectal liver metastases. We determined the serum levels of growth factors [hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF), insulin-like growth factor 1 (IGF-1), insulin-like growth factor binging protein 3 (IGF-BP3), epidermal growth factor (EGF), transforming growth factor (TGFα), tumor necrosis factor (TNF)] and interleukins (IL2, -6, -8 and -10) at given time intervals by immunoanalytic methods. The growth of FLRV was evaluated by multidetector computed tomography at intervals of 1 week until sufficient growth of FLRV. RESULTS: We were able to perform radical surgery in 13 primarily inoperable patients (81.4%). The average FLRV growth was 23.1% (range=21.9-38.6%); from an initial FLRV of 30.5% (range=20.6-39%) to 40.1% (range=29-48%) before resection. The combination of levels of EGF, HGF, VEGF, IGF, TGFα and IL2,-6,-8 appears to be crucial for predicting operability. IL8 was statistically significant for the growth of colorectal liver metastases, and TGFα, IL2, and IL8 are important for a longer disease-free interval.

Small versus large-sized drug-eluting beads (DEBIRI) for the treatment of hepatic colorectal metastases: a propensity score matching analysis.

PURPOSE: To compare the feasibility, safety, and efficacy with small and large irinotecan drug-eluting beads (DEBIRI) for treating hepatic colorectal metastases. METHODS: Using our prospectively maintained, multi-center, intra-arterial therapy registry, we identified 196 patients treated with a combination of large beads (100-300 to 500-700 µm) and patients treated with a combination of small beads (70-150 to 100-300 µm). To minimize selection bias, a propensity score analysis was performed to compare both groups. RESULTS: Unadjusted analysis consisted of 196 and 30 patients treated with large and small beads, respectively. The adjusted analysis consisted of 19 patients each. Unadjusted analysis showed decreased all-grade (p = <0.001) and high-grade adverse effects (p = 0.02) in the small bead group, with a persisting trend toward decreased overall side effects in the adjusted analysis favoring small beads (p = 0.09) The adjusted analysis showed the percentage dose delivered (delivered dose/intended dose) was significantly greater in the small bead group compared to the large bead group (96 vs 79 %; p = 0.005). There were also a lower percentage of treatments terminating in complete stasis in the adjusted analysis (0.0035). Adjusted analysis also showed increased objective response rate (ORR) at 12 months (p = 0.04), with a corresponding trend also seen in the unadjusted analysis (0.09). CONCLUSION: Smaller beads result in increased dose delivery probably due to less propensity to reach complete stasis. It may also lead to more durable long-term efficacy. Smaller beads also demonstrate similarly low toxicity compared to large-sized beads with a trend toward less toxicity.

Portal vein embolisation with application of haematopoietic stem cells in patients with primarily or non-resectable colorectal liver metastases.

BACKGROUND: Insufficient future liver remnant volume (FLRV) is the main cause of low resectability of liver metastases from colorectal cancer (CLMs). One option for enhancing FLVR growth is the use of portal vein embolisation (PVE) with the application of autologous haematopoietic stem cells (HSCs). PATIENTS AND METHODS: PVE with the application of HSCs was used in 11 patients (group 1) with primarily non-resectable CLMs due to insufficient FLRV without signs of extrahepatic metastases. The control group (group 2) consisted of 14 patients in whom only PVE was performed. We evaluated the product quality, FLRV growth, CLM volume, median survival and progression-free survival (PFS). RESULTS: Product quality was achieved in all collections. In all group-I patients, sufficient FLRV growth occurred within three weeks. In the first and second weeks, FLRV increased optimally in most patients (p<0.006). In 13 out of the 14 group-2 patients, optimum FLVR growth was observed within three weeks following PVE (p<0.002). More rapid FLVR growth was observed in group 1 patients (p<0.01). CLM volume was significantly increased in both the group-2 (p<0.0005) and group-1 (p<0.008) patients at the time of liver resection. There was no significant difference in the growth of the CLM volume between the groups (p<0.18). The median survival was 7.3 and 6.8 months for group 1 and 2 patients, respectively, and the two-year PFS was 28% and 22% (p<0.18), respectively. CONCLUSION: PVE with HSC application is a promising method for effectively stimulating FLRV growth in patients with primarily non-resectable CLMs.

Phlegmasia cerulea dolens as a complication of a severe form of acute hemorrhagic-necrotizing pancreatitis.

Phlegmasia cerulea dolens is an extreme form of deep venous thrombosis with a proximal localization of the blockage, most frequently in the ileofemoral area. Symptoms are graded as follows: swelling of the entire extremity, pain, and cyanosis. This form of the disease is rare, occurring most frequently in the terminal stage of malignancies. Diagnosis of phlegmasia usually causes no problems because the proper diagnosis is usually revealed during clinical examination and confirmed by imaging techniques. The authors present a case report of phlegmasia cerulean dolens and discuss the options for treatment.