BACKGROUND: A third of endovascularly treated patients with stroke experience incomplete reperfusion (expanded Thrombolysis in Cerebral Infarction [eTICI] <3), and the natural evolution of this incomplete reperfusion remains unknown. We systematically reviewed the literature and performed a meta-analysis on the natural evolution of incomplete reperfusion after endovascular therapy. METHODS: A systematic review of MEDLINE, Embase, and PubMed up until March 1, 2024, using a predefined strategy. Only full-text English-written articles reporting rates of either favorable (ie, delayed reperfusion (DR) or no new infarct) or unfavorable progression (ie, persistent perfusion deficit or new infarct) of incompletely reperfused tissue were included. The primary outcome was the rate of DR and its association with functional independence (modified Rankin Scale score, 0-2) at 90 days postintervention. Pooled odds ratios with 95% CIs were calculated using a random-effects model. RESULTS: Six studies involving 950 patients (50.7% female; median age, 71 years; interquartile range, 60-79) were included. Four studies assessed the evolution of incomplete reperfusion on magnetic resonance imaging perfusion imaging, while 2 studies used diffusion-weighted imaging and noncontrast computed tomography imaging, where new infarct was used to denote unfavorable progression. Five studies defined incomplete reperfusion as eTICI 2b50 or 2c. DR occurred in 41% (interquartile range, 33%-51%) of cases 24 hours postintervention. Achieving DR was associated with a higher likelihood of functional independence at 90 days (odds ratio, 2.5 [95% CI, 1.9-3.4]). CONCLUSIONS: Nearly half of eTICI <3 patients achieve DR, leading to favorable clinical outcomes. This subgroup may derive limited or potentially harmful effects from pursuing additional reperfusion strategies (eg, intra-arterial lytics or secondary thrombectomy). Accurately predicting the evolution of incomplete reperfusion could optimize patient selection for adjunctive reperfusion strategies at the end of an intervention. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT05499832.
- MeSH
- endovaskulární výkony * metody MeSH
- ischemická cévní mozková příhoda * chirurgie diagnostické zobrazování terapie MeSH
- lidé středního věku MeSH
- lidé MeSH
- reperfuze metody MeSH
- senioři MeSH
- trombolytická terapie metody MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- systematický přehled MeSH
Ischemic stroke is a common and serious condition. Timely restoration of cerebral perfusion is crucial for improving patient outcomes and reducing economic impacts. For three decades, alteplase has been the only established pharmacological treatment, often combined with endovascular therapy. Tenecteplase, a newer generation of fibrinolytic therapy, is recommended by the ESO 2023 guidelines as a suitable alternative to alteplase, particularly if treatment is initiated within 4.5 hours of symptom onset. Tenecteplase offers higher fibrin specificity, lower binding to PAI-1, and a longer plasma half-life compared to alteplase, allowing for single bolus administration. Clinical studies have shown that tenecteplase 0.25 mg/kg achieves better recanalization and clinical improvement without increased risk of bleeding. It is equally effective and safe as alteplase, with meta-analyses indicating improved recanalization and clinical outcomes at a lower risk of bleeding. Tenecteplase is a suitable alternative for treating iNCMP, especially within 4.5 hours of symptom onset. Its single bolus administration simplifies hospital management and improves the logistics of transporting patients to specialized centers.
- MeSH
- fibrinolýza účinky léků MeSH
- ischemická cévní mozková příhoda * diagnóza farmakoterapie MeSH
- klinická studie jako téma MeSH
- lidé MeSH
- reperfuze klasifikace metody MeSH
- tenektepláza * aplikace a dávkování farmakologie terapeutické užití MeSH
- tkáňový aktivátor plazminogenu farmakologie terapeutické užití MeSH
- trombolytická terapie klasifikace metody MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
BACKGROUND: We evaluated the association of reperfusion quality and different patterns of achieved reperfusion with clinical and radiological outcomes in the ESCAPE NA1 trial. METHODS: Data are from the ESCAPE-NA1 trial. Good clinical outcome [90-day modified Rankin Scale (mRS) 0-2], excellent outcome (90-day mRS0-1), isolated subarachnoid hemorrhage, symptomatic hemorrhage (sICH) on follow-up imaging, and death were compared across different levels of reperfusion defined by expanded Treatment in Cerebral Infarction (eTICI) Scale. Comparisons were also made between patients with (a) first-pass eTICI 2c3 reperfusion vs multiple-pass eTICI 2c3; (b) final eTICI 2b reperfusion vs eTICI 2b converted-to-eTICI 2c3; (c) sudden reperfusion vs gradual reperfusion if >1 pass was required. Multivariable logistic regression was used to test associations of reperfusion grade and clinical outcomes. RESULTS: Of 1037 included patients, final eTICI 0-1 was achieved in 46 (4.4%), eTICI 2a in 76 (7.3%), eTICI 2b in 424 (40.9%), eTICI 2c in 284 (27.4%), and eTICI 3 in 207 (20%) patients. The odds for good and excellent clinical outcome gradually increased with improved reperfusion grades (adjOR ranging from 5.7-29.3 and 4.3-17.6) and decreased for sICH and death. No differences in outcomes between first-pass versus multiple-pass eTICI 2c3, eTICI 2b converted-to-eTICI 2c3 versus unchanged eTICI 2b and between sudden versus gradual eTICI 2c3 reperfusion were observed. CONCLUSION: Better reperfusion degrees significantly improved clinical outcomes and reduced mortality, independent of the number of passes and whether eTICI 2c3 was achieved suddenly or gradually.
- MeSH
- lidé středního věku MeSH
- lidé MeSH
- reperfuze * metody MeSH
- senioři MeSH
- subarachnoidální krvácení terapie diagnostické zobrazování mortalita MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- randomizované kontrolované studie MeSH
BACKGROUND: Incomplete reperfusion (IR) after mechanical thrombectomy (MT) can be a consequence of residual occlusion, no-reflow phenomenon, or collateral counterpressure. Data on the impact of these phenomena on clinical outcome are limited. METHODS: Patients from the ESCAPE-NA1 trial with IR (expanded Thrombolysis In Cerebral Infarction (eTICI) 2b) were compared with those with complete or near-complete reperfusion (eTICI 2c-3) on the final angiography run. Final runs were assessed for (a) an MT-accessible occlusion, or (b) a non-MT-accessible occlusion pattern. The primary clinical outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Our imaging outcome was infarction in IR territory on follow-up imaging. Unadjusted and adjusted incidence rate ratios (aIRR) with 95% confidence intervals (95% CI) were obtained. RESULTS: Of 1105 patients, 443 (40.1%) with IR and 506 (46.1%) with complete or near-complete reperfusion were included. An MT-accessible occlusion was identified in 147/443 patients (33.2%) and a non-MT-accessible occlusion in 296/443 (66.8%). As compared with patients with near-complete/complete reperfusion, patients with IR had significantly lower chances of achieving mRS 0-2 at 90 days (aIRR 0.82, 95% CI 0.74 to 0.91). Rates of mRS 0-2 were lower in the MT-accessible occlusion group as compared with the non-MT-accessible occlusion pattern group (aIRR 0.71, 95% CI 0.60 to 0.83, and aIRR 0.89, 95% CI 0.81 to 0.98, respectively). More patients with MT-accessible occlusion patterns developed infarcts in the non-reperfused territory as compared with patients with non-MT occlusion patterns (68.7% vs 46.3%). CONCLUSION: IR was associated with worse clinical outcomes than near-complete/complete reperfusion. Two-thirds of our patients with IR had non-MT-accessible occlusion patterns which were associated with better clinical and imaging outcomes compared with those with MT-accessible occlusion patterns.
- MeSH
- cerebrální infarkt diagnostické zobrazování terapie MeSH
- lidé středního věku MeSH
- lidé MeSH
- prospektivní studie MeSH
- reperfuze * metody MeSH
- senioři MeSH
- trombektomie metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- randomizované kontrolované studie MeSH
BACKGROUND: Surgical factors and direct cytotoxicity of bile salts on cholangiocytes may play a role in the development of ischemic cholangiopathy (IC) after liver transplantation (LTx). There is no validated consensus on how to protect the bile ducts during procurement, static preservation, and LTx. Meanwhile, IC remains the most troublesome complication after LTx. AIM: To characterize bile duct management techniques during the LTx process among European transplant centers in cases of donation after brain death (DBD) and circulatory death (DCD). METHOD: An European Liver and Intestine Transplant Association-European Liver Transplant Registry web survey designed to conceal respondents' personal information was sent to surgeons procuring and/or transplanting livers in Europe. RESULTS: Sixty-five percent of responses came from large transplant centers (>50 procurements/y). In 8% of DBDs and 14% of DCDs the bile duct is not rinsed. In 46% of DBDs and 52% of DCDs surgeons prefer to remove the gallbladder after graft reperfusion. Protocols concerning preservation solutions (nature, pressure, volume) are extremely heterogeneous. In 54% of DBDs and 61% of DCDs an arterial back table pressure perfusion is performed. Steroids (20%-10%), heparin (72%-60%), prostacyclin (3%-7%), and fibrinolytics (4%-11%) are used as donor-protective interventions in DBD and DCD cases, respectively. In 2% of DBD and 6% of DCD cases a hepatic artery reperfusion is performed first. In 4% of DBD and 6% of DCD cases, fibrinolytics are administered through the hepatic artery during the bench and/or implantation. CONCLUSION: This European web survey shows for the first time the heterogeneity in the management of bile ducts during procurement, preservation, and transplantation in Europe. In the context of sharing more marginal liver grafts, an expert meeting must be organized to formulate guidelines to be applied to protect liver grafts against IC.
- MeSH
- cholangitida etiologie MeSH
- ischemie etiologie MeSH
- lidé MeSH
- odběr tkání a orgánů škodlivé účinky metody MeSH
- perfuze škodlivé účinky metody MeSH
- pooperační komplikace etiologie MeSH
- přežívání štěpu MeSH
- průzkumy a dotazníky MeSH
- reperfuze škodlivé účinky metody MeSH
- transplantace jater škodlivé účinky MeSH
- uchovávání orgánů škodlivé účinky metody MeSH
- žlučové cesty krevní zásobení transplantace MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Evropa MeSH
BACKGROUND AND AIM: Thromboembolic disease is the third most common cardiovascular disorder and deep vein thrombosis carries the risk of pulmonary embolism (PE). Questions related to reperfusion after PE remain, especially risk factors. Incomplete reperfusion after PE is closely related to the development of chronic thromboembolic pulmonary hypertension. The aim of this study was to determine the relation between reperfusion after PE in the long term over a period of 24 months, laboratory results and clinical risk factors found during the initial PE event. PATIENTS AND METHODS: 85 consecutive patients with a first episode of acute PE, diagnosed at 4 cardiology clinics, were followed up using clinical evaluation, scintigraphy and echocardiography (6, 12 and 24 months after the PE. 35 patients were in the low risk category (41%), 42 (49%) in the intermediate risk group and 8 (9%) in the high risk category. RESULTS: Perfusion defects persisted in 20 patients (26%) after 6 months, in 19 patients (25%) after 12 months and in 14 patients (19%) after 24 months. The incidence was more frequent in older patients, with more serious (higher risk) PE, increased right ventricular internal diameter during the initial episode, and more significant tricuspid insufficiency in the initial echocardiography. Notably, higher hemoglobin levels were also shown as a significant risk factor. The presence of perfusion defects after 24 months correlated with a concurrent higher pulmonary pressure but not with either patient function or adverse events (recurrence of PE, re-hospitalization or bleeding). In 3 cases (4% of patients), long-term echocardiographic evidence of pulmonary hypertension was detected. CONCLUSION: Even after 24 months from acute PE with adequate anticoagulation treatment, incomplete reperfusion was found in 19% of patients with a corresponding risk of chronic thromboembolic pulmonary disease and hypertension.
- MeSH
- antikoagulancia terapeutické užití MeSH
- CT angiografie MeSH
- dospělí MeSH
- echokardiografie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- multimodální zobrazování MeSH
- následné studie MeSH
- perfuzní zobrazování MeSH
- plicní embolie diagnostické zobrazování farmakoterapie MeSH
- prospektivní studie MeSH
- reperfuze metody MeSH
- rizikové faktory MeSH
- senioři MeSH
- trombolytická terapie metody MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
UNLABELLED: Backround. Intermittent claudication is a classic symptom of peripheral arterial disease. It is mainly treated conservatively but if this fails, a form of revascularization is indicated. The revascularization in chronic occlusion of femoropopliteal region is currently performed by two basic methods: the standard method of surgical bypass and the newer miniinvasive alternative represented by the endovascular method. The treatment of patients with solely claudication and long occlusion of femoropopliteal region remains controversial. The aim of this minireview was to determine whether surgical bypass is still the best method of choice in a time of endovascular techniques. METHODS: A MEDLINE search for original and review articles using key terms, intermittent claudication and long femoropopliteal oclusion. RESULTS AND CONCLUSION: No ideal treatment for long occlusions of the femoropopliteal segment has been established to date. It is clear that the role of endovascular techniques in the treatment of SFA occlusions is increasing. It remains that, lower risk patients with claudication should be examined to assess the quality of veins suitable for revascularization and bypass should be selected as the first method of choice.
- MeSH
- arteria femoralis chirurgie MeSH
- arteria poplitea chirurgie MeSH
- cévní protézy MeSH
- cévy - implantace protéz metody MeSH
- endovaskulární výkony metody MeSH
- intermitentní klaudikace chirurgie MeSH
- lidé MeSH
- reperfuze metody MeSH
- výkony cévní chirurgie metody MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- přehledy MeSH
The evolution of reperfusion therapy in acute myocardial infarction and acute ischaemic stroke has many similarities: thrombolysis is superior to placebo, intra-arterial thrombolysis is not superior to intravenous (i.v.), facilitated intervention is of questionable value, and direct mechanical recanalization without thrombolysis is proven (myocardial infarction) or promising (stroke) to be superior to thrombolysis-but only when started with no or minimal delay. However, there are also substantial differences. Direct catheter-based thrombectomy in acute ischaemic stroke is more difficult than primary angioplasty (in ST-elevation myocardial infarction [STEMI]) in many ways: complex pre-intervention diagnostic workup, shorter time window for clinically effective reperfusion, need for an emergent multidisciplinary approach from the first medical contact, vessel tortuosity, vessel fragility, no evidence available about dosage and combination of peri-procedural antithrombotic drugs, risk of intracranial bleeding, unclear respective roles of thrombolysis and mechanical intervention, lower number of suitable patients, and thus longer learning curves of the staff. Thus, starting acute stroke interventional programme requires a lot of learning, discipline, and humility. Randomized trials comparing different reperfusion strategies provided similar results in acute ischaemic stroke as in STEMI. Thus, it might be expected that also a future randomized trial comparing direct (primary) catheter-based thrombectomy vs. i.v. thrombolysis could show superiority of the mechanical intervention if it would be initiated without delay. Such randomized trial is needed to define the role of mechanical intervention alone in acute stroke treatment.
- MeSH
- akutní nemoc MeSH
- cévní mozková příhoda terapie MeSH
- fibrinolytika terapeutické užití MeSH
- infarkt myokardu terapie MeSH
- intravenózní infuze MeSH
- klinické zkoušky jako téma MeSH
- kombinovaná terapie MeSH
- koronární angioplastika metody MeSH
- lidé MeSH
- reperfuze metody MeSH
- trombektomie metody MeSH
- trombolytická terapie metody MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- přehledy MeSH
BACKGROUND: Numerous acute reperfusion therapies (RPT) are currently investigated as potential new therapeutic targets in acute ischemic stroke (AIS). We conducted a comprehensive benefit-risk analysis of available clinical studies assessing different acute RPT, and investigated the utility of each intervention in comparison to standard intravenous thrombolysis (IVT) and in relation to the onset-to-treatment time (OTT). METHODS: A comprehensive literature search was conducted to identify all available published, peer-reviewed clinical studies that evaluated the efficacy of different RPT in AIS. Benefit-to-risk ratio (BRR), adjusted for baseline stroke severity, was estimated as the percentage of patients achieving favorable functional outcome (BRR1, mRS score: 0-1) or functional independence (BRR2, mRS score: 0-2) at 3 months divided by the percentage of patients who died during the same period. RESULTS: A total of 18 randomized (n = 13) and nonrandomized (n = 5) clinical studies fulfilled our inclusion criteria. IV therapy with tenecteplase (TNK) was found to have the highest BRRs (BRR1 = 5.76 and BRR2 = 6.82 for low-dose TNK; BRR1 = 5.80 and BRR2 = 6.87 for high-dose TNK), followed by sonothrombolysis (BRR1 = 2.75 and BRR2 = 3.38), while endovascular thrombectomy with MERCI retriever was found to have the lowest BRRs (BRR1 range, 0.31-0.65; BRR2 range, 0.52-1.18). A second degree negative polynomial correlation was detected between favorable functional outcome and OTT (R (2) value: 0.6419; P < 0.00001) indicating the time dependency of clinical efficacy of all reperfusion therapies. CONCLUSION: Intravenous thrombolysis (IVT) with TNK and sonothrombolysis have the higher BRR among investigational reperfusion therapies. The combination of sonothrombolysis with IV administration of TNK appears a potentially promising therapeutic option deserving further investigation.
- MeSH
- cévní mozková příhoda terapie MeSH
- fibrinolytika terapeutické užití MeSH
- hodnocení rizik MeSH
- ischemie mozku terapie MeSH
- klinické zkoušky jako téma MeSH
- lidé MeSH
- reperfuze metody MeSH
- tkáňový aktivátor plazminogenu terapeutické užití MeSH
- ultrazvuková terapie metody MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- přehledy MeSH
- Klíčová slova
- sulodexid (Vessel Due F),
- MeSH
- antikoagulancia terapeutické užití MeSH
- dolní končetina krevní zásobení patologie MeSH
- glykosaminoglykany aplikace a dávkování terapeutické užití MeSH
- lidé středního věku MeSH
- lidé MeSH
- posttrombotický syndrom * farmakoterapie prevence a kontrola MeSH
- reperfuze metody MeSH
- warfarin terapeutické užití MeSH
- žilní trombóza diagnóza etiologie farmakoterapie terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH