Efficacy of peripheral interventional radiologists performing endovascular stroke therapy guided by CT perfusion triage of patients.

PURPOSE: To assess safety and efficacy of intraarterial mechanical thrombectomy for treatment of ischemic stroke in a community hospital by peripheral interventional radiologists employing computed tomography (CT) perfusion imaging for patient selection. MATERIALS AND METHODS: Forty patients, 11 men (27.5%) and 29 women (72.5%), were treated between February 2008 and October 2011. Eligible patients had a National Institutes of Health Stroke Scale (NIHSS) score greater than 8 and diagnosis of large-vessel ischemic stroke by head CT angiogram, and met previously reported CT perfusion imaging triage criteria. RESULTS: The baseline NIHSS score was 18.0 ± 7.9 (range, 8-35). Sixteen patients (40%) had a baseline NIHSS score greater than 20. Symptom onset was unknown in five patients. Symptom onset to device time in the remaining 35 patients was 254.8 minutes ± 150.9 (range, 75-775 min). A total of 65% of patients showed thrombolysis in cerebral infarction (TICI) 2a, 2b, or 3 flow following the procedure. Symptomatic intracranial hemorrhage was seen in four patients (10.0%). At 90 days, 32 patients (80%) were alive and eight (20%) had died. The modified Rankin scale (mRS) score at 90 days was no more than 2 in 20 patients (50.0%). The mean mRS score at 90 days was 2.9 ± 2.0 (range, 0-6). NIHSS score at 90 days was 5.1 ± 6.1 (range, 0-24). In patients with successful recanalization (ie, TICI 2 or 3 flow), a good clinical outcome (ie, mRS score ≤ 2) was achieved in 65.3% of patients (mean, 2.4 ± 1.9; range, 0-6), and 90-day mortality rate was 15.4%, compared with 28.6% in patients with TICI 0/1 flow. CONCLUSIONS: Peripheral interventional radiologists who use CT perfusion imaging for patient triage can have good neurologic outcomes and provide sustainable, safe, and complete around-the-clock coverage for endovascular stroke treatment.

Thrombolysis of acute peripheral arterial and venous occlusions with tenecteplase and eptifibatide: a pilot study.

PURPOSE: To prospectively assess the feasibility, risk profile, and effect on fibrinogen levels of combination tenecteplase (TNK) and eptifibatide in transcatheter thrombolysis for peripheral arterial and venous thromboocclusive disease. MATERIALS AND METHODS: Sixteen consecutive patients (seven men, nine women) seen at our institution between March and August 2002 with arterial (n = 11) or venous (n = 5) thromboocclusive disease were treated with TNK (5-mg bolus and 0.25-mg/h infusion) and eptifibatide (180- micro g/kg bolus and 1- micro g/kg/min infusion). Informed consent was obtained. Technical success was defined as restoration of antegrade flow and more than 95% removal of thrombus. Clinical success in arterial cases was defined as immediate limb salvage and relief of ischemic rest pain, and in venous cases as resolution or improvement in extremity pain and swelling. Major bleeding was defined as an intracranial bleeding episode, bleeding resulting in death, or bleeding requiring transfusion, surgery, or cessation of thrombolytic therapy. RESULTS: Technical success was achieved in 10 of 11 arterial cases (91%) and in four of five venous cases (80%). Clinical success was achieved in nine of 11 arterial cases (82%) and in four of five venous cases (80%). The mean duration of thrombolysis was 12.1 hours +/- 5.8 (range, 2-22 hours), requiring a total TNK dose of 8.0 mg +/- 1.5 (range, 4.0-10.5). A major bleeding episode occurred in one of 16 patients (6.3%) as a result of slow oozing from a femoral groin access site and required transfusion of 2 U of packed red blood cells. There were no deaths, intracranial hemorrhages, remote sites of bleeding, or minor bleeding complications. The serum fibrinogen level decreased to a mean of 59.3% +/- 34.6 of baseline. CONCLUSION: In this initial study, the combination of TNK and eptifibatide was shown to be feasible for peripheral arterial and venous thrombolysis.

Thrombolysis of occluded peripheral arteries and veins with tenecteplase: a pilot study.

PURPOSE: To prospectively assess the feasibility, risk profile, and effect on fibrinogen levels of tenecteplase in transcatheter thrombolysis for peripheral arterial and venous occlusive disease. MATERIALS AND METHODS: Between March 2001 and January 2002, 18 consecutive patients (14 men, four women) with arterial (n = 13) or venous (n = 5) occlusive disease were treated with tenecteplase infusions of 0.25 mg/h. Technical success was defined as restoration of antegrade flow and removal of more than 95% of thrombus. Clinical success was defined in arterial cases as immediate limb salvage and relief of ischemic rest pain and in venous cases as resolution or improvement in extremity pain and swelling. Major bleeding was defined as an intracranial bleeding episode, bleeding that resulted in death, or bleeding that required transfusion, surgery, or cessation of thrombolytic therapy. RESULTS: Technical success was achieved in all 18 patients (100%). Clinical success was achieved in 11 of 13 arterial cases (85%) and in four of five (80%) venous cases. The mean duration of thrombolysis treatment was 21.5 hours +/- 6.2 (range, 7-35 h), with total tenecteplase doses of 7.1 mg +/- 4.3 (range, 1.75-18.75 mg). Major bleeding occurred in one patient (5.5%) because of slow oozing from bilateral femoral groin access sites, which caused a 25% decrease in hematocrit level. There were no deaths, intracranial hemorrhages, remote sites of bleeding, or minor bleeding complications. The serum fibrinogen level dropped to a mean of 77.4% +/- 19.2% of baseline. CONCLUSION: In this initial study, tenecteplase was shown to be a feasible treatment for peripheral arterial and venous thrombolysis with only moderate effect on fibrinogen levels.