Association Between Time to Endovascular Therapy and Outcomes in Patients With Acute Basilar Artery Occlusion.

OBJECTIVE: To characterize the association of onset to puncture time (OPT) with clinical outcomes among patients with acute basilar artery occlusion receiving endovascular therapy (EVT) in clinical practice. METHODS: Using the EVT for Acute Basilar Artery Occlusion (BASILAR) study, we identified consecutive patients with acute basilar artery occlusion receiving EVT in 47 comprehensive stroke centers in China from January 2014 to May 2019. The primary outcome was favorable functional outcome (defined as modified Rankin Scale score [mRS] 0-3) at 90 days. Secondary outcomes included function independence (mRS 0-2), mortality, and symptomatic intracerebral hemorrhage. The associations of OPT with clinical outcomes were analyzed using multivariable logistic regression (OPT as a categorical variable) and restricted cubic spline regression (OPT as a continuous variable). RESULTS: Among 639 eligible patients, the median age was 64 years, and median OPT was 328 minutes (interquartile range 220-490). Treatment within 4-8 hours and 8-12 hours was associated with lower rates of favorable outcome (adjusted odds ratio, 0.63 [95% confidence interval (CI), 0.40-0.98] and 0.47 [95% CI, 0.23-0.93], respectively) compared with treatment within 4 hours. Restricted cubic spline regression analysis showed that the OPT had L-shaped associations with favorable outcome (p nonlinearity = 0.028) and functional independence (p nonlinearity = 0.025), with significant benefit loss throughout the first 9 hours, but then appeared relatively flat. The odds of mortality increased relatively for OPT up to 9 hours, but then leveled off (p nonlinearity = 0.042). The association between symptomatic intracerebral hemorrhage and OPT was not significant. CONCLUSION: Among patients with acute basilar artery occlusion in routine practice, earlier treatment with EVT was associated with better outcomes throughout the first 9 hours after onset, but benefit may sustain unchanged afterwards. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for patients with acute ischemic stroke due to basilar artery occlusion, earlier EVT is associated with better outcomes.

Quantitative Profiling of Oxylipins in Acute Experimental Intracerebral Hemorrhage.

Oxylipins are a series of bioactive lipid metabolites derived from polyunsaturated fatty acids that are involved in cerebral homeostasis and the development of intracerebral hemorrhage (ICH). However, comprehensive quantification of the oxylipin profile in ICH remains unknown. Therefore, an ICH mouse model was constructed and liquid chromatography tandem mass spectrometry was then performed to quantify the change in oxylipins in ICH. The expression of the oxylipin relative enzymes was also reanalyzed based on RNA-seq data from our constructed ICH dataset. A total of 58 oxylipins were quantifiable and the levels of 17 oxylipins increased while none decreased significantly in the first 3 days following ICH. The most commonly increased oxylipins in ICH were derived from AA (10/17) and EPA (4/17) followed by LA (2/17) and DHA (1/17). 18-HEPE from EPA was the only oxylipin that remained significantly increased from 0.5 to 3 days following ICH. Furthermore, 14 of the increased oxylipins reached a peak level on the first day of ICH, and soon decreased while five oxylipins (PGJ2, 15-oxo-ETE, 12-HEPE, 18-HEPE, and 5-oxo-ETE) had increased 3 days after ICH suggesting that the profile shifted with the progression of ICH. In our constructed RNA-seq dataset based on ICH rats, 90 oxylipin relative molecules were detected except for COX. Among these, Cyp4f18, Cyp1b1, Cyp2d3, Cyp2e1, Cyp1a1, ALOX5AP, and PLA2g4a were found up-regulated and Cyp26b1 was found to decrease in ICH. In addition, there was no significant change in sEH in ICH. This study provides fundamental data on the profile of oxylipins and their enzymes in ICH. We found that the profile shifted as the progression of ICH and the metabolism of arachidonic acid and eicosapentaenoic acid was highly affected in ICH, which will help further studies explore the functions of oxylipins in ICH.

TGF-ß Signaling Induces the Expression of OPN in Blood Vessel Endothelial Cells.

BACKGROUND: The mechanism of blood vessel formation and degeneration still remains unclear. Transforming growth factor-ß1 (TGF-ß1) signaling is a critical pathway in this progression and can induce multiple biological effects. Osteopontin (OPN) is involved in mineral metabolism and the inflammatory response associated with vascular calcification. METHODS: To identify the relationship between TGF-ß signaling pathway and OPN, we stimulated human vascular endothelial cells (HVECs) and human aortic endothelial cells (HAECs) using various concentration of TGF-ß1 in vitro. RESULTS: As assessed by flow cytometry and western blots, apoptosis levels were significantly increased with TGF-ß1 treatment. We also demonstrated that OPN increased in vitro with TGF-ß signaling by western blot and quantitative real time polymerase chain reaction (qRT-PCR) analyses. The inhibitory phosphorylation of endothelial nitric-oxide synthase (eNOS) (Thr495) was also up-regulated by TGF-ß signaling. Meanwhile, the anti-inflammatory factor Nrf2 and the activating phosphorylation of eNOS (Ser1177) were down-regulated. CONCLUSIONS: Taken together, our findings demonstrate that TGF-ß signaling can induce the expression of OPN, which may play an important role in the dysfunction of the vascular wall.

Mechanical Thrombectomy Using Solitaire in Acute Ischemic Stroke Patients with Vertebrobasilar Occlusion: A Prospective Observational Study.

BACKGROUND: The safety and effectiveness of endovascular mechanical thrombectomy in patients with acute vertebrobasilar occlusion (VBO) are debatable and undergoing evaluation. We report the clinical outcome and prognostic factors in a prospective cohort of acute ischemic stroke patients with VBO. METHODS: In total, 48 consecutive patients with acute VBO underwent mechanical thrombectomy using Solitaire. We analyzed clinical and imaging data and searched for predictors of good clinical outcome (modified Rankin scale score: 0-3). RESULTS: The median prethrombectomy National Institutes of Health Stroke Scale score was 22.0. The median duration from symptom onset to recanalization was 493.5 minutes. A total of 35.4% of the patients received rescue therapy. Recanalization (modified Thrombolysis In Cerebral Infarction: 2b-3) was successful in all patients. Clinically relevant intracranial hemorrhage was observed in 2 patients. After 90 days, good outcomes were obtained in 27 patients. The baseline National Institutes of Health Stroke Scale score, posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS), anesthesia type, and posterior communicating artery (PComA) patency were significantly associated with outcomes at 90 days in univariate analysis. Multivariate logistic regression indicated that high pc-ASPECTS at admission and PComA patency were independent predictors of good outcome at 90 days. CONCLUSIONS: Up to 60.4% of the patients reached good outcomes after endovascular treatment and 35.4% of the patients received rescue therapy, suggesting that mechanical thrombectomy using Solitaire in patients with stroke with VBO is safe and effective and that rescue therapy is readily required and employed. High baseline pc-ASPECTS and PComA patency were associated with better outcomes after thrombectomy in these patients.

Diagnosis and endovascular treatment of iliac venous compression syndrome.

OBJECTIVES: To report *The first two authors contributed equally to this work. our clinical experience on diagnostic criteria and endovascular management in patients with iliac venous compression syndrome. METHOD: Between July 2013 and May 2015, 85 consecutive patients with suspected iliac venous compression syndrome were evaluated by transfemoral venography and intravascular ultrasonography. Venographic evidence of iliac venous occlusion, stenosis, or pelvic collateral vessels, and the degree of stenosis as examined with intravascular ultrasonography were recorded. The endovascular procedure, complications, clinical outcome, and the Venous Clinical Severity Score were evaluated before and after the intervention. RESULTS: Of the 85 limbs, 66 cases of iliac venous compression syndrome were confirmed and 19 cases were excluded. In all of the 66 patients, we successfully performed endovascular intervention (22 balloon dilations, 44 balloon dilations + stenting). Two patients with stent implantation developed acute lower extremity deep vein thrombosis, resulted in successful lysis of the thrombus with catheter-directed thrombolysis. CONCLUSIONS: The presence of intraluminal spurs and pelvic collateral vessels represents not only pathological and anatomical changes by long-term mechanical compression, but also indicators of the severity of iliac venous compression syndrome. The degree of stenosis cannot accurately represent the severity and treatment of iliac venous compression syndrome, especially in the right iliac vein. Endovascular intervention is a safe and effective treatment that reduces lower extremity symptoms. Full and intentional dilation of the intraluminal spurs is an important technical aspect, which is often ignored.

Mid-term outcome of endovascular treatment for acute lower extremity deep venous thrombosis.

Purposes of the study To evaluate the benefit of stenting the iliac vein in patients with residual iliac vein stenosis treated with catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis. Procedures In this randomized prospective study, patients with a first-time acute lower extremity deep venous thrombosis that had persisted <14 days were treated with catheter-directed thrombolysis. After catheter-directed thrombolysis, patients with >50% residual iliac vein stenosis were randomly divided into two groups: catheter-directed thrombolysis + Stent Group and catheter-directed thrombolysis Alone Group. Patients received urokinase thrombolysis and low-molecular-weight heparin/oral warfarin during the hospitalization period and were administrated oral warfarin after discharge. Cumulative deep vein patency, the Clinical Etiology Anatomic Pathophysiologic classification system, the Venous Clinical Severity Score and the Chronic Venous Insufficiency Questionnaire score were evaluated. Findings The cumulative deep vein patency rate was 74.07% in the catheter-directed thrombolysis + Stent Group and 46.59% in the catheter-directed thrombolysis Alone Group. The mean postoperative Clinical Etiology Anatomic Pathophysiologic classification and Venous Clinical Severity Score was significantly lower in the catheter-directed thrombolysis + Stent Group than in the catheter-directed thrombolysis Alone Group. The mean postoperative Chronic Venous Insufficiency Questionnaire score was significantly higher in the catheter-directed thrombolysis + Stent Group than the catheter-directed thrombolysis Alone Group. Conclusions Placement of an iliac vein stent in patients with residual iliac vein stenosis after catheter-directed thrombolysis for acute lower extremity deep venous thrombosis increases iliac vein patency and improves clinical symptoms and health-related quality of life at mid-term follow-up compared to patients treated with catheter-directed thrombolysis alone.

Biocompatibility of porcine small intestinal submucosa and rat endothelial progenitor cells in vitro.

OBJECTIVE: This study investigated the biocompatibility of the small intestinal submucosa (SIS) and endothelial progenitor cells (EPCs) by co-cultivating EPCs and SIS in vitro and observing EPC growth on the SIS. METHODS: The porcine SIS was prepared and bone marrow mononuclear cells (BMMNCs) were isolated from 3 or 4-week old male SD rats. Cellular morphology was observed by light microscopy and scanning electron microscopy (SEM) and viabilities by the MTT assays. Endothelial progenitor cells (EPCs) were phenotyped by immunocytochemistry, immunofluorescence microscopy and flow cytometry. Vascular lumen formation was evaluated by the Matrigel tube formation assays. EPCs were seeded onto the SIS and production of angiogenin-1 and endothelial cell growth factor (VEGF) by EPCs was examined by ELISA and immunoblotting assays. RESULTS: Light microscopy and SEM showed that the mechanically and chemically treated small intestinal submucosa was composed of cell-free extracellular matrix. Immunohistochemistry, and flow cytometry revealed that the EPCs expressed appropriate surface markers including CD34, CD133, and VEGFR-2. Furthermore, the EPCs formed lumen-like structures and the SIS significantly enhanced the growth of EPCs in vitro. CONCLUSION: SIS has good biocompatibility with EPCs. SIS pre-seeded with EPCs can be potentially applied as an alternative scaffold material in artificial blood vessel prosthesis.

Immediate and middle term outcome of symptomatic spontaneous isolated dissection of the superior mesenteric artery.

PURPOSE: Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare but fatal condition. Herein, we report the therapeutic outcome of a contemporary series of 12 patients with SIDSMA who were treated with conservative, anticoagulation, or endovascular therapy. METHODS: Revascularization was measured according to recanalization of the primary arterial occlusive lesion and reperfusion was measured by flow through the occluded vessel. Pain was evaluated by using the visual analog scale (VAS) at admission and at each follow-up visit. RESULTS: Type I SIDSMA was seen in 3 (25%) patients, type IIa in 4 (33.3%) patients, and type IIb in 5 (41.7%) patients. No patient had type III SIDSMA. The false lumens were patent in 6 (50%) patients. Partial thrombosis in the false lumen was demonstrated in CT scans in 5 (41.7%) patients and total thrombosis in 1 (8.3%) patient. Four (33.3%) patients received conservative therapy, and 2 (16.7%) patients received anticoagulation therapy. All six patients resumed normal blood flow in the SMA. The remaining six patients received endovascular stenting. After stent placement, excellent distal blood flow was restored. Abdominal pain was completely resolved in all patients except in one patient. No complications associated with SMA dissection occurred. CONCLUSION: If bowel perfusion is not compromised and the SMA aneurysm is not likely to rupture in patients with a symptomatic SIDSMA, conservative, or anticoagulation therapy can be considered. If patient has sustained intestinal ischemic symptoms, and severe compression of the true lumen, or dissecting aneurysm likely to rupture, endovascular therapy, or surgery should be adopted.

Endovascular treatment of Budd-Chiari syndrome with hepatic vein obstruction in China.

UNLABELLED: Abstract Purpose: To evaluate characteristics of obstructions of the hepatic veins (HVs) in Chinese patients, technical aspects of puncture of the HVs, short- and mid-term outcomes, and complications of endovascular treatment. PATIENTS AND METHODS: Forty-eight HV patients with different degrees of symptoms and signs of portal hypertension were enrolled in our study. Endovascular treatments with balloon and stents were performed. Catheter-directed thrombolysis (CDT) was performed in patients with thrombosis in the HVs. For patients with lesions of both the HVs and the inferior vena cava (IVC), balloon expansions or stenting were performed at the IVC lesions also. RESULTS: Endovascular treatments were successful in 43 patients. The technically success rate was 89.6% (43/48). Fifteen patients underwent solely balloon expansions, 28 patients had balloon expansions and stentings, 5 patients underwent CDT, and 3 patients had implanted stents in the IVC lesions at the same time. The symptoms of portal hypertension were alleviated in 39 patients postoperatively. In the other 4 cases portal hypertension was mildly alleviated at discharge. Thirty-nine of the 43 patients were followed up for an average of 24±1.3 months (range, 6-62 months). Ascites were completely resolved in 32 cases, with a small amount of ascites in 4 patients and moderate to massive amounts in 3 patients. Hepatomegaly and splenomegaly completely disappeared in 30 patients and still could be touched in 6 patients. The HVs were patent in 29 patients. Restenosis and re-occlusion of the HVs appeared in 4 cases. All patients were successfully treated by endovascular treatments. CONCLUSIONS: Endovascular treatments for patients with obstruction of the HVs have a high technical success rate, fewer complications, and better short- and mid-term clinical outcome. The key to successful endovascular treatment is successful puncture of HVs. For patients who have occlusive lesions of HVs combined with occlusive IVC, recanalization of the lesions of the HVs could achieve good results.

Stenting of iliac vein obstruction following catheter-directed thrombolysis in lower extremity deep vein thrombosis.

BACKGROUND: Catheter-directed thrombolysis (CDT) for deep venous thrombosis (DVT) of the lower extremity has good effect, but whether iliac vein stent placement after thrombolytic therapy is still controversial. The goal of this study was to evaluate the efficacy of stent placement in the iliac vein following CDT in lower extremity DVT. METHODS: This was a single-center, prospective, randomized controlled clinical trial. After receiving CDT, the major branch of the distal iliac vein was completely patent in 155 patients with lower extremity DVT, and 74 of these patients with iliac vein residual stenosis of >50% were randomly divided into a control group (n = 29) and a test group (n = 45). In the test group, stents were implanted in the iliac vein, whereas no stents were implanted in the control group. We evaluated the clinical indicators, including patency of the deep vein, C in CEAP classification, Venous Clinical Severity Score (VCSS), and Chronic Venous Insufficiency Questionnaire (CIVIQ) Score. RESULTS: All patients had postoperative follow-up visits for a period of 6-24 months. Venography or color ultrasound was conducted in subjects. There was a significant difference between the patency rate at the last follow-up visit (87.5% vs. 29.6%) and the 1-year patency rate (86.0% vs. 54.8%) between the test and control groups. The change in the C in CEAP classification pre- and post-procedure was significantly different between the test and control groups (1.61 ± 0.21 vs. 0.69 ± 0.23). In addition, at the last follow-up visit, VCSS and CIVIQ Score were both significantly different between the test and control groups (7.57 ± 0.27 vs. 0.69 ± 0.23; 22.67 ± 3.01 vs. 39.34 ± 6.66, respectively). CONCLUSION: The stenting of iliac vein obstruction following CDT in lower extremity DVT may increase the patency of the deep vein, and thus provides better efficacy and quality of life.

[Analysis of cause and treatment of acute limb ischemia complicated in peripheral endovascular interventions].

OBJECTIVE: To discuss the cause and treatment of acute limb ischemia in endovascular therapy of the lower extremity arterial occlusive disease. METHODS: Clinical data of 54 cases of acute limb ischemia in the endovascular treatment of 685 cases of lower extremity arterial occlusive disease from June 2003 to April 2012 was analyzed retrospectively. There were 43 male and 11 female patients, with a mean age of 72.3 years (ranging from 56 to 82 years). The major causes which resulted in acute limb ischemia included: arterial embolization of 43 cases, arterial thrombosis of 8 cases, arterial dissection of 3 cases. The acute limb ischemia occurred in the process of balloon angioplasty/stent in 36 cases, catheter-directed thrombolysis in 17 cases, Silverhawk atherectomy in 1 cases. Thirty-two cases were treated by endovascular treatment, 9 cases by surgical procedures (bypass or embolectomy), 13 cases by the combination of endovascular therapy and surgical procedures. RESULTS: Treatment were successfully accomplished in 50 of 54 cases, and failed in 4 cases which had surgical amputation. There were no deaths in all the patients. Forty-five of 54 cases were followed up for the average of 40.3 months. Six cases had ischemic symptoms recurrence in 43 artery embolization patients, in whom 4 cases were cured by endovascular treatment, 2 cases were cured by toe amputation. One case of bypass anastomotic stenosis and one case of stent restenosis were successfully cured by endovascular treatment in 8 arterial thrombosis patients. One cases of below-knee artery stent occlusion in 3 arterial dissection patients was cured by medical treatment. Four cases of amputation patients were followed up in good condition. CONCLUSIONS: Most patients of acute limb ischemia complicated in endovascular therapy could be treated by endovascular therapy. Surgical procedures in time is still the best choice for the patients in whom the endovascular therapy was not satisfied.

[Endovascular therapy of superior mesenteric artery embolism].

OBJECTIVE: To explore the safety and immediate efficacy of endovascular treatment for superior mesenteric artery embolism. METHODS: From November 2007 to October 2012, 18 cases of superior mesenteric artery embolism were treated by thrombus extraction and/or catheter-directed thrombolysis. There were 13 males and 5 females with an age range of 44-91 years. The concurrent conditions included atrial fibrillation (n = 8) and rheumatic valve disease (n = 3). All diagnoses were made with abdominal enhanced computed tomography (CT) examination. Embolism was predominantly located at 3 to 10 cm away from opening. The procedures included thrombus extraction plus system thrombosis (n = 3), thrombus extraction and catheter-directed thrombolysis (n = 6), catheter-directed thrombolysis (n = 5) and thrombus extraction, catheter-directed thrombolysis and PTA (n = 2). RESULTS: The technical success rate was 100%. Two cases had new embolism in popliteal artery. Another case with peritoneal irritation syndrome died after automatic discharge. The other 17 patients obtained satisfactory results and were followed up after 6 months by color Doppler ultrasound or abdominal enhanced CT. It showed that superior mesenteric arteries were unobstructed, but local stenosis occurred in 2 cases. CONCLUSION: Endovascular interventional therapy is both safe and efficacious in the treatment of superior mesenteric artery embolization. And its immediate effect is satisfactory.

Endovascular treatment of iliac vein compression syndrome.

BACKGROUND: Iliac vein compression syndrome (IVCS), the symptomatic compression of the left common iliac vein between the right common iliac artery and the vertebrae, is not an uncommon condition. The aim of this research was to retrospectively evaluate long-term outcome and the significance of endovascular treatment in patients with left IVCS. METHODS: Between January 1997 and September 2008, 296 patients received interventional therapy in the left common iliac vein. In the second stage, 170 cases underwent saphenous vein high ligation and stripping. Two hundred and thirty-one cases were followed up over a period of 6 to 120 months (average 46 months) and evaluated for symptom improvement with color ultrasound and ascending venography. RESULTS: The stenotic or occlusive segments of the left iliac vein were successfully dilated in 285 cases, of whom 272 received stent implantation therapy. Most of the patients achieved satisfactory results on discharge. During the follow-up period, varicose veins were alleviated in 98.7% of the patients, and leg swelling disappeared or was obviously relieved in 84% of cases. About 85% of leg ulcers completely healed. The total patency rate was 91.7% as evaluated with color ultrasound and 91.5% with ascending venography. CONCLUSIONS: Endovascular treatment of IVCS provides effective symptomatic improvement and good long-term patency in most patients.

Radical correction of Budd-Chiari syndrome.

BACKGROUND: Interventional therapy is widely accepted as the first choice for the treatment of the Budd-Chiari syndrome, but the use of radical correctional therapy should not be discarded. This study describes radical correction by controlling bleeding from distal end of pathological segment of the inferior vena cava (IVC) and discusses potential surgical errors and postoperative complications. METHODS: Of the 216 patients in the study, 78 were treated with simple membranectomy, 64 with dissection of the pathological segment of the IVC and vascular prosthesis or pericardial patch plasty, 60 with resection of the pathological segment of the IVC and orthotopic graft transplantation with vascular prosthesis, and 14 with resection of the occlusive main hepatic vein and its upper IVC, hepatic venous outflow plasty and vascular prosthesis orthotopic graft transplantation from the hepatic venous entrance to the IVC of right atrial ostium. RESULTS: Except 14 cases who were discharged after hepatic vein outflow plasty, four cases died postoperatively, and 198 patients were discharged without complications. The symptoms of 15 patients were relieved partially and 2 without any change. There were no deaths intraoperatively. Of the 112 cases who were followed up for 72 months, 13 suffered from a relapse. CONCLUSIONS: Radical correction is a beneficial therapy in the treatment of Budd-Chiari syndrome.