Surgical management and outcomes of renal tumors with inferior vena cava extension among children: a single center retrospective study from Pakistan.

OBJECTIVE: The aim of this study was to assess management and determine outcomes of renal tumors with inferior vena cava (IVC) and intracardiac (IC) extension in a tertiary care center in Pakistan. METHODS: A retrospective chart review was conducted at the Aga Khan University Hospital, Karachi, Pakistan. All patients from 1 to 18 years of age with renal tumors with intravascular extensions, surgically managed from January 1988 till June 2016, were included. Data was extracted by reviewing medical records, and the tumor details, treatment and outcomes were analyzed. RESULTS: A total of 18 patients out of the total 61 patients with renal tumors, presented with IVC and/or IC extension, with the majority involving the right kidney. Mean age was 5.9 (SD:4.9) and a female preponderance (56%) was seen. Wilms tumor (77%) was the most common tumor type, with the level of tumor extension into IVC predominantly being below the diaphragm (55.5%). Fourteen patients received preoperative chemotherapy, with tumor regression, seen in 10. Most patients underwent thrombectomy through the renal vein (56%). Regarding outcomes, frequency of mortality and morbidity was 1 and 2, respectively, with 7 patients having no recurrent 5 years post-surgery. CONCLUSION: A greater incidence (29.5%) of IVC and or IC Tumor extension was found compared to existing literature, which could likely be due to a higher referral rate to the center. Moreover, this is a single-center study and so a multi-center study is crucial to form an assessment of surgical management in resource-limited settings. Our study is the first from Pakistan on this particular renal tumor presentation. Considering the varying case presentations and surgical techniques used, further studies are needed to standardize surgical management and optimize patient outcomes.

The effect of Clot Burden Score on clinical outcomes in acute ischemic stroke patients with atrial fibrillation treated with endovascular thrombectomy.

BACKGROUND: The Clot Burden Score (CBS) is used to assess thrombus length. The influence of CBS on functional outcome was barely analyzed in patients with acute ischemic stroke (AIS) with atrial fibrillation (AF). PURPOSE: To assess the association between CBS and clinical outcomes in large vessel occlusion (LVO)-related patients with AF who have undergone endovascular thrombectomy (EVT). MATERIAL AND METHODS: A total of 160 patients with AF were enrolled between January 2021 and April 2023. The CTA-CBS score was used to quantify the thrombus burden. The primary outcome was the modified Rankin scale (mRS) score at 90 days. A multivariate logistic regression model was used to identify prognostic predictors and determine the correlation between CTA-CBS and clinical outcomes. RESULTS: In the multivariable logistic regression, younger age, smaller clots, and better collateral status were the favorable prognosis factors. The odds ratios (OR) were 0.956 (95% confidence interval [CI] = 0.924-0.988, P = 0.008), 1.29 (95% CI = 1.110-1.499, P < 0.001), and 1.706 (95% CI = 1.065-2.731, P = 0.026), respectively. A smaller clot correlated with better outcomes OR of 1.29 (95% CI = 1.110-1.499, P < 0.001) for the entire cohort, 1.395 (95% CI = 1.142-1.702, P < 0.001) for bridging the EVT subgroup, and 1.171 (95% CI = 0.866-1.582, P = 0.305) for direct EVT subgroup. CONCLUSIONS: In LVO-related AIS patients with AF treated with EVT, lower CBS is associated with poorer functional outcomes. Notably, CBS acts as a prognostic imaging biomarker in the direct EVT subgroup and does not in bridging the EVT subgroup.

Making Neuroendovascular Therapy for Cerebrovascular Disease Using Distal/Trans-radial Artery Access Safer.

Neuroendovascular therapy using distal/trans-radial artery access (d/TRA) has attracted attention as a less invasive procedure. We have selected dTRA or TRA in all cases of carotid artery stenting (CAS). In recent years, TRA has been actively selected for mechanical thrombectomy for acute ischaemic stroke (MT for AIS) and Onyx embolisation for arteriovenous malformations. We compared the patient background, surgical strategy, perioperative complications, and outcome in 41 patients who underwent CAS in the first period (Apr 2017-Feb 2019) and 12 patients in the second period (Apr 2020-Feb 2022) avoiding trans-femoral artery access (TFA) as possible. We compared the patient background, surgical strategy, perioperative complications, and outcome in 46 patients who underwent MT for AIS via TFA from Apr 2022 to Dec 2022 as the first period and five patients who underwent MT for AIS via TRA from Jan 2023 to Sep 2023 as the second period. Concerning CAS, the second period included significantly more symptomatic cases, with a higher rate of edaravone use to prevent hyperperfusion and a significantly smaller sheath diameter. In the second period, CAS was performed in severe conditions; nevertheless, there was no significant difference between the two groups in terms of either the ratio of cases detected by postoperative diffusion-weighted imaging positive or the ratio of cases with puncture site-related complications (PSCs). Concerning MT for AIS, there were no significant differences between the two groups with the patient backgrounds. The percentage of effective reperfusion, time from puncture to recanalisation, and outcome in the second period were all non-inferior to those in the first period when conventional MT for AIS was performed. Even though we introduced d/TRA in patients with cognitive decline and inability to remain at rest during the perioperative period, we completely avoided PSCs via d/TRA. In particular, cerebral hyperperfusion syndrome after CAS and ischaemia-reperfusion injury or re-occlusion after MT were rare but critical perioperative complications, and near-infrared spectroscopy (NIRS) may be used to monitor these problems. We introduced intensive evaluation by NIRS if we had time to spare.

[Role of mechanical thrombectomy in the management of acute pulmonary embolism]. / Place de la thrombectomie dans le traitement de l'embolie pulmonaire aiguë.

Venous thromboembolism disease complicated by pulmonary embolism is a common cause of admission to emergencies and critical care unit. It is burdened by high mortality in the absence of early and appropriate treatment. Rapid diagnosis, anticoagulation to avoid recurrence and, in case of hemodynamic instability, use of systemic fibrinolysis are the corner stones of its management. For several years, interventional radiology techniques have been developed to treat the most critical patients in addition to or instead of systemic fibrinolysis. Among these techniques, mechanical thrombectomy deserves to be integrated into our therapeutic arsenal. We propose here an original decision-making algorithm integrating this technique based on a review of the literature, with the support of multidisciplinary team for the management of pulmonary embolism in our department.

La maladie thromboembolique veineuse compliquée d'une embolie pulmonaire est une cause fréquente d'admission aux urgences et en soins intensifs. Elle est grevée d'une mortalité élevée en l'absence d'un traitement précoce et adapté. Sa prise en charge repose sur un diagnostic rapide, une anticoagulation pour éviter la récidive et, pour les patients présentant une instabilité hémodynamique, le recours à une fibrinolyse systémique. Depuis plusieurs années, des techniques de radiologie interventionnelle ont été élaborées pour traiter les patients les plus sévèrement atteints en complément ou en alternative de la fibrinolyse. Parmi ces techniques, la thrombectomie mécanique, au vu de son essor récent, mérite d'être intégrée dans notre arsenal thérapeutique. Nous proposons un algorithme décisionnel original intégrant cette technique, basé sur une revue de la littérature et utilisé avec l'appui d'une équipe pluridisciplinaire de prise en charge de l'embolie pulmonaire dans notre institution.

Endovascular thrombectomy after anterior circulation large vessel ischemic stroke: an updated meta-analysis.

BACKGROUND: Endovascular thrombectomy (EVT) has emerged as the established standard of care for the treatment of anterior circulation large-vessel occlusion (LVO). However, its benefits remain unclear in specific patient populations. Herein, we present an updated systematic review and meta-analysis aimed at thoroughly assessing the effectiveness and safety of combining EVT with medical treatment (MT) compared with MT alone. METHODS: This systematic review was performed in accordance with the PRISMA guideline. The MEDLINE, Embase, and Cochrane databases were systematically searched to identify relevant articles published until December 30, 2023. The inclusion criteria restricted articles to randomized clinical trials (RCTs). We pooled odds ratios (OR) and their respective 95% confidence intervals (CIs). RESULTS: Fifteen RCTs involving 3897 patients were included in the study. EVT plus MT was associated with a significant reduction in disability at 90 days (OR = 1.91, [1.61-2.26]), improved functional independence (modified Rankin Scale [mRS] 0-2) (OR = 2.19 [1.81-2.64]), excellent functional outcomes (mRS 0-1) (OR = 2.37, [1.45-3.87]), improved independent ambulation (mRS 0-3) (OR = 2.17, [1.75-2.69]), and higher rates of partial/complete recanalization (OR = 2.18, [1.66-2.87] compared with EVT. Efficacy outcomes for both large and small infarct cores were statistically favorable following EVT. Safety outcomes showed comparable rates, except for intracerebral and subarachnoid hemorrhage, which favored MT alone. CONCLUSION: This meta-analysis supports the use of EVT plus MT as the standard of care for acute ischemic stroke patients with LVO of any infarct core size, as it offers substantial improvements in functional outcomes and recanalization. Safety considerations, particularly the risk of hemorrhage, warrant careful patient selection. These findings provide valuable insights for optimizing stroke management protocols and enhancing patient outcomes.

Does Ischemic Core Volume Modify the Treatment Effect of Endovascular Thrombectomy?

Imaging-based selection has become integral in guiding endovascular thrombectomy for large vessel occlusive stroke, driven by positive trial outcomes incorporating parenchymal and perfusion imaging criteria. While small-moderate core trials transformed acute reperfusion therapy, uncertainties persisted for large ischemic strokes. This was recently addressed in several treatment trials which demonstrated a benefit of endovascular thrombectomy in patients with large ischemic strokes, defined by parenchymal and/or perfusion imaging. Although individual trials suggest treatment benefits regardless of core size, patient-level meta-analyses are essential to clarify this relationship. Our aim was to summarize the imaging ramifications of the major endovascular thrombectomy trials of the past decade focusing on the interaction between the core and the treatment effect, to assist in the design of future meta-analyses. The core-treatment relationship that will be investigated in these meta-anlalyses will likely have major implications in our systems of care designs and in determining the utility of imaging-based selection.

Correspondence: Microsurgical thrombectomy: Where the ancient art meets the new era.

Surgical thrombectomy remains a feasible technique in an accurately selected patient population with large vessel occlusion, even though endovascular mechanical thrombectomy is the gold standard. It especially warrants consideration in cases where the endovascular approach is unfeasible or fails. The current extension in the therapeutic window of time in mechanical thrombectomy also provides opportunities to open thrombectomy. To support our view, we present a case of a patient who suffered an ischemic stroke. Intravenous thrombolysis proved ineffective and mechanical thrombectomy was impossible due to extreme tortuosity of the internal carotid artery. Therefore, surgical thrombectomy was performed. The patient underwent successful recovery and states a great satisfaction. To improve efficiency and outcomes, a properly organised and trained surgical team with plentiful neurovascular experience is necessary. Finally, open thrombectomy is the most effective approach to completely restore luminal patency compared to the endovascular approaches yet risks due to the operation should be taken into account.

Removal of an intra-aortic thrombus.

A 70-year-old female patient was referred from a peripheral hospital to our department with an incidental finding of an intra-aortic mass. Chest access was gained by a median sternotomy, and visualization of the intra-aortic mass was achieved using epiaortic ultrasound. After systemic heparinization, arterial cannulation was performed in the distal aortic arch. The right atrium was cannulated; the patient was cooled to a target temperature of 22°C. With the patient under hypothermic circulatory arrest, a transverse aortotomy was performed 3 cm proximal to the brachiocephalic trunk, and prompt removal of the tumour was achieved. After establishing antegrade cerebral perfusion, proper visualization of the aortic wall was achieved, and no pathological alterations of the aortic wall were encountered. After closure of the aorta and complete rewarming, the patient was easily weaned from cardiopulmonary bypass. Chest closure was performed in the usual fashion. The postoperative course was uneventful, and the histopathological diagnosis was thrombus formation. Consequently, the patient was placed on lifelong phenprocoumon therapy.

In acute ischemic stroke with a large core infarct, endovascular thrombectomy reduced disability at 90 d.

SOURCE CITATION: Costalat V, Jovin TG, Albucher JF, et al; LASTE Trial Investigators. Trial of thrombectomy for stroke with a large infarct of unrestricted size. N Engl J Med. 2024;390:1677-1689. 38718358.

[Successful endovascular treatment of proximal deep vein thrombosis following May-Thurner syndrome]. / Uspeshnoe lechenie proksimal'nogo tromboza glubokikh ven nizhnikh konechnostei na fone sindroma Meya-Ternera endovaskulyarnymi tekhnologiyami.

We present two clinical cases of successful endovascular treatment of proximal deep vein thrombosis following May-Thurner syndrome. In the first case, 2-day regional catheter thrombolysis, percutaneous mechanical thrombectomy and venous stenting were required to restore hemodynamics in the left lower limb. In the second case, regional catheter thrombolysis continued for 3 days with subsequent thrombotic mass lysis. However, iliac vein was severely narrowed that required venous stenting. Long-term results were favorable in both cases. Venous outflow has become almost normal after endovascular treatment. The patients' ability to work has been restored.

Endovascular management of acute stroke.

Stroke related to large vessel occlusion is a leading cause of disability and death worldwide. Advances in endovascular therapy to reopen occluded arteries have been shown to reduce patient disability and mortality. Expanded indications to treat patients with large vessel occlusion in the late window (>6 h from symptom onset), with basilar artery occlusion, and with large ischaemic core at presentation have enabled treatment of more patients with simplified imaging methods. Ongoing knowledge gaps include an understanding of which patients with large ischaemic infarct are more likely to benefit from endovascular therapy, the role of endovascular therapy in patients who present with low National Institutes of Health Stroke Scale scores or medium or distal vessel occlusion, and optimal management of patients with underlying intracranial atherosclerotic disease. As reperfusion can now be facilitated by intravenous thrombolysis, mechanical thrombectomy, or both, the development of cytoprotective or adjunctive drugs to slow infarct growth, enhance reperfusion, or decrease haemorrhagic risk has gained renewed interest with the hope to improve patient outcomes.

Delayed door to puncture time during off-duty hours is associated with unfavorable outcomes after mechanical thrombectomy in the early window of acute ischemic stroke.

BACKGROUNDS: The impact of off-duty hours mechanical thrombectomy on outcomes remains a subject of controversy. The impacts of off-duty hours on procedures are influenced by various factors, but the most critical one is the time delay in initiating the procedure after the patient's arrival at the emergency room. Recently, a report suggested that the impact of time delay on post-procedural outcomes is evident in patients who arrive at the emergency room within 6 h of symptom onset, referred to as the "early window." We hypothesized that the impact of procedure delays on outcomes during off duty-hours would be most significant within this early window. This study aimed to investigate the impact of door-to-puncture time (DTPT) delays in patients who underwent mechanical thrombectomy for acute ischemic stroke (AIS) during off-duty hours in both the early and late time windows. METHODS: We investigated patients who presented to the emergency center between 2014 and 2022. Among a total of 6,496 AIS patients, we selected those who underwent mechanical thrombectomy within 24 h of the onset of acute anterior circulation occlusion. The eligible patients were divided into two groups: those who arrived within 6 h of symptom onset and received the procedure within 8 h (early window), and those who received the procedure between 8 h and 24 h after symptom onset (late window). The study assessed the association between the onset to puncture time in each group and poor outcomes, measured by the modified Rankin scores(mRs) at 90 days. Furthermore, the study analyzed the impact of receiving the procedure during off-hours in both the early and late windows on outcomes. Specifically, the analysis focused on the impact of delayed DTPT in patients during off-duty hours on outcomes measured by the 90-days mRS. RESULTS: Among the eligible patients, a total of 501 AIS patients underwent mechanical thrombectomy for acute anterior circulation occlusion within 24 h. Of these, 395 patients (78.8%) fell into the early window category, and 320 patients (63.9%) underwent the procedure during off-duty hours. In the early window, for every 60-minute increase in OTPT, the probability of occurrence a poor outcome at 90 days significantly increased in the fully adjusted model (OR = 1.21; 95% CI, 1.02 to 1.43; p = 0.03). In the early window, delayed procedures during off-duty hours (exceeding 103 min of DTPT) were identified as an independent predictor of poor outcomes (OR = 1.85; 95% CI, 1.05 to 3.24; p = 0.03). However, in the late window, there was no association between DTPT and outcomes at 90 days, and the impact of DTPT delays during off-hours was not observed. CONCLUSIONS: Through this study, it became evident that the impacts of off-duty hours in mechanical thrombectomy were most pronounced in the early window, where the impact of time delay was clear. Therefore, it is believed that improvements in the treatment system are necessary to address this issue.

Adjunctive Intravenous Argatroban or Eptifibatide for Ischemic Stroke.

BACKGROUND: Intravenous thrombolysis is a standard treatment of acute ischemic stroke. The efficacy and safety of combining intravenous thrombolysis with argatroban (an anticoagulant agent) or eptifibatide (an antiplatelet agent) are unclear. METHODS: We conducted a phase 3, three-group, adaptive, single-blind, randomized, controlled clinical trial at 57 sites in the United States. Patients with acute ischemic stroke who had received intravenous thrombolysis within 3 hours after symptom onset were assigned to receive intravenous argatroban, eptifibatide, or placebo within 75 minutes after the initiation of thrombolysis. The primary efficacy outcome, the utility-weighted 90-day modified Rankin scale score (range, 0 to 10, with higher scores reflecting better outcomes), was assessed by means of centralized adjudication. The primary safety outcome was symptomatic intracranial hemorrhage within 36 hours after randomization. RESULTS: A total of 514 patients were assigned to receive argatroban (59 patients), eptifibatide (227 patients), or placebo (228 patients). All the patients received intravenous thrombolysis (70% received alteplase, and 30% received tenecteplase), and 225 patients (44%) underwent endovascular thrombectomy. At 90 days, the mean (±SD) utility-weighted modified Rankin scale scores were 5.2±3.7 with argatroban, 6.3±3.2 with eptifibatide, and 6.8±3.0 with placebo. The posterior probability that argatroban was better than placebo was 0.002 (posterior mean difference in utility-weighted modified Rankin scale score, -1.51±0.51) and that eptifibatide was better than placebo was 0.041 (posterior mean difference, -0.50±0.29). The incidence of symptomatic intracranial hemorrhage was similar in the three groups (4% with argatroban, 3% with eptifibatide, and 2% with placebo). Mortality at 90 days was higher in the argatroban group (24%) and the eptifibatide group (12%) than in the placebo group (8%). CONCLUSIONS: In patients with acute ischemic stroke treated with intravenous thrombolysis within 3 hours after symptom onset, adjunctive treatment with intravenous argatroban or eptifibatide did not reduce poststroke disability and was associated with increased mortality. (Funded by the National Institute of Neurological Disorders and Stroke; MOST ClinicalTrials.gov number, NCT03735979.).

Multi-Target and Multi-Phase Adjunctive Cerebral Protection for Acute Ischemic Stroke in the Reperfusion Era.

Stroke remains the leading cause of death and disability in some countries, predominantly attributed to acute ischemic stroke (AIS). While intravenous thrombolysis and endovascular thrombectomy are widely acknowledged as effective treatments for AIS, boasting a high recanalization rate, there is a significant discrepancy between the success of revascularization and the mediocre clinical outcomes observed among patients with AIS. It is now increasingly understood that the implementation of effective cerebral protection strategies, serving as adjunctive treatments to reperfusion, can potentially improve the outcomes of AIS patients following recanalization therapy. Herein, we reviewed several promising cerebral protective methods that have the potential to slow down infarct growth and protect ischemic penumbra. We dissect the underlying reasons for the mismatch between high recanalization rates and moderate prognosis and introduce a novel concept of "multi-target and multi-phase adjunctive cerebral protection" to guide our search for neuroprotective agents that can be administered alongside recanalization therapy.

Bibliometric analysis of renal cell carcinoma with venous tumor thrombus.

Objectives: To identify the cooperation of authors, countries, institutions and explore the hot spots regarding research of renal cell carcinoma with venous tumor thrombus. Methods: Relevant articles were obtained from the Web of Science Core database (WoSC) from 1999 to 2024. CiteSpace was used to perform the analysis and visualization of scientific productivity and emerging trends. Network maps were generated to evaluate the collaborations between different authors, countries, institutions, and keywords. Results: A total of 2180 related articles were identified. We observed an increased enthusiasm in related fields during the past two decades. The USA dominated the field in all countries, and the University of Miami was the core institution. Ciancio G might have a significant influence with more publications and co-citations. Current research hotspots in this field mainly included thrombectomy, tyrosine kinase inhibitors, immune checkpoint inhibitors, vena cava inferior, and microvascular invasion. Thrombectomy complications, thrombectomy survival outcome, and preoperative neoadjuvant immunotherapy represented the frontiers of research in this field, undergoing an explosive phase. Conclusion: This is the first bibliometric study that comprehensively visualize the research trends and status of RCC with VTT. We hope that this work will provide new ideas for advancing the scientific research and clinical application.

Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in Early and Late Time Windows.

BACKGROUND AND OBJECTIVES: This study aimed to compare outcomes of low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) patients with stroke who underwent mechanical thrombectomy (MT) within 6 hours or 6 to 24 hours after stroke onset. METHODS: A retrospective cohort study was conducted using data from a large multicenter international registry from 2013 to 2023. Patients with low ASPECTS (2-5) who underwent MT for anterior circulation intracranial large vessel occlusion were included. A propensity matching analysis was conducted for patients presented in the early (<6 hours) vs late (6-24 hours) time window after symptom onset or last known normal. RESULTS: Among the 10 229 patients who underwent MT, 274 met the inclusion criteria. 122 (44.5%) patients were treated in the late window. Early window patients were older (median age, 74 years [IQR, 63-80] vs 66.5 years [IQR, 54-77]; P < .001), had lower proportion of female patients (40.1% vs 54.1%; P = .029), higher median admission National Institutes of Health Stroke Scale score (20 [IQR, 16-24] vs 19 [IQR, 14-22]; P = .004), and a higher prevalence of atrial fibrillation (46.1% vs 27.3; P = .002). Propensity matching yielded a well-matched cohort of 84 patients in each group. Comparing the matched cohorts showed there was no significant difference in acceptable outcomes at 90 days between the 2 groups (odds ratio = 0.90 [95% CI = 0.47-1.71]; P = .70). However, the rate of symptomatic ICH was significantly higher in the early window group compared with the late window group (odds ratio = 2.44 [95% CI = 1.06-6.02]; P = .04). CONCLUSION: Among patients with anterior circulation large vessel occlusion and low ASPECTS, MT seems to provide a similar benefit to functional outcome for patients presenting <6 hours or 6 to 24 hours after onset.