Thrombectomy-Capable Stroke Centre-A Key to Acute Stroke Care System Improvement? Retrospective Analysis of Safety and Efficacy of Endovascular Treatment in Cardiac Cathlab.

The optimal structure of the acute ischaemic stroke treatment network is unknown and eagerly sought. To make it most effective, different treatment and transportation strategies have been developed and investigated worldwide. Since only a fraction of acute stroke patients with large vessel occlusion are treated, a new entity-thrombectomy-capable stroke centre (TCSC)-was introduced to respond to the growing demand for timely endovascular treatment. The purpose of this study was to present the early experience of the first 70 patients treated by mechanical means in a newly developed cardiac Cathlab-based TCSC. The essential safety and efficacy measures were recorded and compared with those reported in the invasive arm of the HERMES meta-analysis-the largest published dataset on the subject. We found no significant differences in terms of clinical and safety outcomes, such as early neurological recovery, level of functional independence at 90 days, symptomatic intracranial haemorrhage, parenchymal haematoma type 2, and mortality. These encouraging results obtained in the small endovascular centre may be an argument for the introduction of the TCSC into operating stroke networks to increase patient access to timely treatment and to improve clinical outcomes.

Neurointerventional tools and techniques for coronary thrombus removal. A case-based review.

Due to the negative results of randomized aspiration thrombectomy studies, its role in myocardial infarction has been limited to high thrombus burden and/or failed vessel recanalization, with little technological advancement over the last years. In contrast, there has been rapid progress in mechanical thrombectomy in stroke, which is understandable as most ischemic cerebrovascular accidents have an embolic etiology.We present three transradial procedures wherein neurointerventional catheters were used as a first-line device for en bloc removal of large clots lodged distally in tortuous coronary anatomy. First-pass reperfusion was achieved in all the cases, without dissection, distal embolization, or the no reflow phenomenon. Learning objective: In the case of large clots, where coronary aspiration devices fail, neurointerventional catheters may be considered as a rescue strategy. They provide large aspiration lumen and excellent trackability with atraumatic design. Many other neurointerventional techniques can be easily adopted into the coronary armamentarium, possibly increasing the safety and efficacy of thrombus aspiration.

Forewarned Is Forearmed: Machine Learning Algorithms for the Prediction of Catheter-Induced Coronary and Aortic Injuries.

Catheter-induced dissections (CID) of coronary arteries and/or the aorta are among the most dangerous complications of percutaneous coronary procedures, yet the data on their risk factors are anecdotal. Logistic regression and five more advanced machine learning techniques were applied to determine the most significant predictors of dissection. Model performance comparison and feature importance ranking were evaluated. We identified 124 cases of CID in electronic databases containing 84,223 records of diagnostic and interventional coronary procedures from the years 2000-2022. Based on the f1-score, Extreme Gradient Boosting (XGBoost) was found to have the optimal balance between positive predictive value (precision) and sensitivity (recall). As by the XGBoost, the strongest predictors were the use of a guiding catheter (angioplasty), small/stenotic ostium, radial access, hypertension, acute myocardial infarction, prior angioplasty, female gender, chronic renal failure, atypical coronary origin, and chronic obstructive pulmonary disease. Risk prediction can be bolstered with machine learning algorithms and provide valuable clinical decision support. Based on the proposed model, a profile of 'a perfect dissection candidate' can be defined. In patients with 'a clustering' of dissection predictors, a less aggressive catheter and/or modification of the access site should be considered.

Acute ischemic stroke treatment model for Poland in the mechanical thrombectomy era - which way to go?

The interventional treatment of acute ischemic stroke with large vessel occlusion has revolutionized patient care in recent years. The Mechanical Thrombectomy Pilot Program in Poland is due to end soon. It seems the right time to summarize the achievements and name the problems of a centralized stroke care system and decide what future model of treatment and transportation to implement. In order to provide the best care for our patients, it is crucial to establish the actual needs in stroke and tailor the mechanical thrombectomy system structure accordingly. The analysis of data from well-organized health systems in the world suggests that to deliver adequate numbers of mechanical thrombectomy to stroke patients in Poland, we would need to at least double the number of procedures currently performed. To achieve this, an essential system reorganization and adjustments are required, with special emphasis on the number of mechanical thrombectomy centers and transportation models. The strengths and weaknesses of two dominant transportation models (mothership and drip-and-ship) are herein discussed, and a proposal on how to build an efficient and cost-effective mechanical thrombectomy stroke network in Poland is put forward. The article is an invitation to open an interdisciplinary discussion on the best treatment model of acute ischemic stroke patients requiring mechanical thrombectomy in Poland.

Catheter-induced coronary artery and aortic dissections. A study of the mechanisms, risk factors, and propagation causes.

BACKGROUND: Only the incidence, management, and prognosis of catheter-induced coronary artery and aortic dissections have been systematically studied until now. We sought to evaluate their mechanisms, risk factors, and propagation causes. METHODS: Electronic databases containing 76,104 procedures and complication registries from 2000-2020 were searched and relevant cineangiographic studies adjudicated. RESULTS: Ninety-six dissections were identified. The overall incidence was 0.126%, and 0.021% for aortic injuries. The in-hospital mortality rate was 4.2%, and 6.25% for aortic dissections. Compared to the non-complicated population, patients with dissection were more often female (48% vs. 34%, p = 0.004), with a higher prevalence of comorbidities such as hypertension (56% vs. 25%, p < 0.001) or chronic kidney disease (10% vs. 4%, p = 0.002). They more frequently presented with acute myocardial infarction (72% vs. 43%, p < 0.001), underwent percutaneous coronary intervention (85% vs. 39%, p < 0.001), and were examined with a radial approach (77% vs. 65%, p = 0.011). The most prevalent predisposing factor was small ostium diameter and/or atheroma. Deep intubation for support, catheter malalignment, and vessel prodding were the most frequent precipitating factors. Of the three dissection mechanisms, 'wedged contrast injection' was the commonest (the exclusive mechanism of aortic dissections). The propagation rate was 30.2% and led to doubling of coronary occlusions and aortic extensions. The most frequent progression triggers were repeat injections and unchanged catheter. In 94% of cases, dissections were inflicted by high-volume operators, with ≥ 5-year experience in 84% of procedures. The annual dissection rate increased over a 21-year timespan. CONCLUSIONS: Catheter-induced dissection rarely came unheralded and typically occurred during urgent interventions performed in high-risk patients by experienced operators.

Delayed presentation of left main coronary artery dissection due to catheter ablation in a patient with bicuspid aortic valve. Coincidence or manifestation of inherent vulnerability?

Left main coronary artery (LMCA) injury is an uncommon complication of catheter ablation. Due to the large myocardial area at risk, its presentation is usually acute with a dramatic course and life-threatening sequelae. Increased susceptibility to spontaneous coronary artery dissection has recently been implied in patients with bicuspid aortic valve (BAV). We present the first case of iatrogenic coronary dissection in a BAV patient, with an atypically delayed manifestation. The patient sustained ablation catheter-induced mechanical damage of LMCA due to its inadvertent penetration during the attempts to cross the aortic valve. After three days of recurring chest pain, he was readmitted with anterior myocardial infarction and imminent cardiogenic shock, and underwent emergent coronary stenting. Literature review suggests that in BAV inherent susceptibility to both spontaneous and iatrogenic coronary dissection may exist. Therefore, we advocate that in BAV extreme caution should be exercised during electrophysiological procedures involving the coronary artery cannulation for tagging or pace mapping, or when the left ventricle is to be entered retrogradely, and likewise in percutaneous coronary interventions. Such patients may be doubly predisposed to iatrogenic injury; firstly, by more difficult catheter manipulation in the malformed aortic cusps, and secondly, by the underlying vulnerability of coronary ostia. .

Analysis of reported cases of left main coronary artery injury during catheter ablation: In search of a pattern.

INTRODUCTION: Left main coronary artery (LMCA) injury is a rare but potentially fatal complication of catheter ablation. Due to LMCA large perfusion area, its occlusion is usually a dramatic event. METHODS AND RESULTS: Reports of LMCA injury complicating catheter ablations from 1987 to 2018 were searched in electronic databases. Twenty-two cases of serious LMCA damage have been identified. Additionally, four reports of direct mechanical trauma involving major LMCA branches induced by inadvertent catheter insertion have been studied. Typically 86% LMCA injury presented as an acute/subacute complication of retrograde ablation in left ventricle/left ventricular outflow tract or aortic cusps. In at least 86% of patients with an in-hospital presentation, the LMCA trauma manifested dramatically as a life-threatening arrhythmia, cardiogenic shock, or severe hypotension requiring vasopressors. In-hospital mortality rate was 32%. Direct stenting has been found to be the most successful strategy. CONCLUSION: LMCA injury, even if initially asymptomatic with normal angiographic appearance, may cause delayed flow deterioration, requiring prolonged monitoring and extended follow-up. Special caution should be given to the prevention whereas survival depends on prompt detection and treatment.

Successful primary PCI in a patient with single coronary artery.

Sudden occlusion of the only patent coronary artery is usually a devastating event. We describe the case of a successful percutaneous recanalization of a single coronary artery originating at the right sinus of Valsalva.

Percutaneous evacuation of detached hydrophilic coating of jailed guidewire.

Continuous technological development and modern construction of guidewires make percutaneous interventions safer than ever. Complications associated with device failure are rare and most of them may be avoided. We describe a case where hydrophilic coating of a jailed guidewire was peeled off in the coronary tree and successfully retrieved in percutaneous fashion.