Influence of inframalleolar modifier P0/P1 on wound healing in bypass surgery vs endovascular therapy in patients with chronic limb-threatening ischemia.

OBJECTIVE: This study aimed to compare the influence of inframalleolar (IM) P0/P1 on wound healing in bypass surgery vs endovascular therapy (EVT) in patients with chronic limb-threatening ischemia (CLTI). METHODS: We retrospectively analyzed the multicenter data of patients who underwent infra-inguinal revascularization for CLTI between 2015 and 2022. IM P represents target artery crossing into foot, with intact pedal arch (P0) and absent or severely diseased pedal arch (P1). The endpoints were wound healing, limb salvage (LS), and postoperative complications. RESULTS: We analyzed 66 and 189 propensity score-matched pairs in the IM P0 and IM P1 cohorts, respectively. In the IM P0 cohort, the 1-year wound healing rates were 94.5% and 85.7% in the bypass surgery and EVT groups, respectively (P = .092), whereas those in the IM P1 cohort were 86.2% and 66.2% in the bypass surgery and EVT groups, respectively (P < .001). In the IM P0 cohort, the 2-year LS rates were 96.7% and 94.1% in the bypass surgery and EVT groups, respectively (P = .625), and those in the IM P1 cohort were 91.8% and 81.5% in the bypass surgery and EVT groups, respectively (P = .004). No significant differences were observed between the bypass surgery and EVT in terms of postoperative complication rates in either the IM P0 or P1 cohorts. CONCLUSIONS: Bypass surgery facilitated better wound healing and LS than EVT in patients with IM P1. Conversely, no differences in wound healing or LS were observed between groups in patients with IM P0. Bypass surgery should be considered a better revascularization strategy than EVT in patients with tissue loss and IM P1 disease.

Global Limb Anatomic Staging System Inframalleolar Modifier Predicts Limb Salvage and Wound Healing in Patients with Chronic Limb Threatening Ischaemia Undergoing Endovascular Infrainguinal Revascularisation.

OBJECTIVE: This study aimed to analyse the influence of the Global Anatomic Staging System (GLASS) and inframalleolar (IM) disease on the treatment outcomes of patients with chronic limb threatening ischaemia (CLTI) who undergo endovascular treatment (EVT) METHODS: Data of patients who underwent infrainguinal endovascular therapy (EVT) for CLTI between 2015 and 2019 at two centres were analysed retrospectively. The endpoints were major amputation, major adverse limb events (MALE), and wound healing. RESULTS: Overall, 276 patients and 340 limbs were analysed. The number of revascularisations for an infrapopliteal lesion was 48 (70.6%), 63 (63.0%), and 142 (82.6%) in the GLASS I, GLASS II, and GLASS III stages, respectively (p < .001). There was no statistically significant difference in limb salvage among the GLASS stages (p = .78). The limb salvage rates at one year were 94.6%, 88.0%, and 70.0% in the IM P0 P1, and P2 groups, respectively (p < .001). Multivariable analysis showed that Wound, Ischemia, and foot Infection (WIfI) stage, and IM grade were risk factors for major amputation. The freedom from MALE rates at two years were 60.5%, 45.3%, and 41.1% in the GLASS I, II, and III stages, respectively (p = .003) and 64.1%, 43.5%, and 18.4% in the IM P0, P1, and P2 groups, respectively (p < .001). Multivariable analysis demonstrated that WIfI stage, GLASS stage, IM grade, and infrapopliteal revascularisation were risk factors for MALE. There was no significant difference in wound healing among GLASS I - III (p = .75). The wound healing rates at 365 days were 78.6%, 68.6%, and 42.0% in the IM P0, P1, and P2 groups, respectively (p = .065). Multivariable analysis showed that WIfI stage and IM P2 were risk factors for incomplete wound healing. CONCLUSION: GLASS IM was associated with major amputation, MALE, and wound healing, while GLASS stage was associated with only MALE.

Bypass Surgery Provides Better Outcomes Compared with Endovascular Therapy in the Composite Endpoint Comprising Relief from Rest Pain, Wound Healing, Limb Salvage, and Survival after Infra-inguinal Revascularisation in Patients with Chronic Limb Threatening Ischaemia.

OBJECTIVE: The present study aimed to determine the factors related to relief from rest pain, wound healing, major adverse limb events (MALEs), and prognosis after infrainguinal revascularisation in patients with chronic limb threatening ischaemia (CLTI). METHODS: The data of patients who underwent infrainguinal revascularisation for CLTI between 2010 and 2020 was analysed retrospectively. The endpoint was the composite of relief from rest pain, wound healing, MALE, or death. RESULTS: A total of 234 limbs in 187 patients with CLTI were analysed. Of the 234 limbs, 149 (63.7%) underwent bypass surgery and 85 (36.3%) underwent endovascular therapy (EVT). The event free survival rates with respect to the composite endpoint at two years were 30.4% in the EVT and 48.5% in the bypass groups, respectively (p = .005). The event free survival rates at two years were 56.7% in bypass surgery and 29.5% in EVT in the indeterminate subgroup (p = .051). Multivariable analysis revealed that age (hazard ratio [HR] 1.03; 95% confidence interval [CI] 1.01 - 1.05; p < .001), coronary artery disease (CAD) (HR 1.45; 95% CI 1.01 - 2.07; p = .042), haemodialysis (HR 1.74; 95% CI 1.22 - 2.48; p = .002), Wound, Ischaemia and foot Infection stage (HR 1.34; 95% CI 1.07 - 1.68; p = .012), Global Limb Anatomical Staging System stage (HR 1.31; 95% CI 1.01 - 1.72; p = .043), EVT (HR 1.90; 95% CI 1.31 - 2.74; p < .001), Geriatric Nutritional Risk Index (HR 0.98; 95% CI 0.97 - 0.99; p = .021), and non-ambulatory status (HR 1.89; 95% CI 1.31 - 2.74; p < .001) were risk factors for the composite endpoint. CONCLUSION: Bypass surgery is superior to EVT with respect to the composite endpoint including relief from rest pain, wound healing, MALE, or death. Bypass surgery may be considered as the treatment of choice, instead of EVT, in patients in the indeterminate group according to the Global Vascular Guidelines preferred revascularisation method.

Angiographic flow velocity predicts lower limb outcomes after endovascular therapy: Application of the frame count method.

INTRODUCTION: Several factors related to lesion characteristics and endovascular therapy (EVT) procedures have been reported to affect primary patency after EVT. However, it is unknown why these factors were associated with primary patency. We hypothesized patency failure was related to poor blood flow in affected arteries. METHODS: This retrospective study included 131 consecutive patients who had received EVT with bare metal stents for peripheral artery disease caused by femoropopliteal artery lesions. Based on the tertile post-EVT flow velocity of the superficial femoral artery (SFA), patients were divided into high (n = 43), middle (n = 44), and low (n = 44) flow velocity groups. Flow velocity was measured using the frame count method. We measured incidence of major adverse limb events (MALE), composed of target lesion revascularization (TLR), non-TLR, and major amputation. RESULTS: At a median follow-up period of 22.7 months, MALE had occurred in 7 (16.3%), 10 (22.7%), and 29 (65.9%) of patients from the high, middle, and low SFA flow velocity groups, respectively (p < 0.001). Kaplan-Meier analysis showed incidence of MALE was significantly higher in the patients of low SFA flow velocity (log-rank test χ2 = 38.8, p < 0.001). Multivariate analysis found low SFA flow velocity to be an independent predictor for MALE (hazard ratio: 4.42; 95% CI: 2.27 to 8.60; p < 0.001) as was ankle-brachial index. CONCLUSION: Post-EVT SFA flow velocity for femoropopliteal artery lesions treated with bare metal stents is an independent predictor of limb patency. The frame count method for assessing arterial flow velocity is convenient and has potential for wide applications in EVT.

The treatment effect of endovascular therapy for chronic limb-threatening ischemia with systemic sclerosis.

Systemic sclerosis (SSc) is a collagen disease with immune abnormalities, vasculopathy, and fibrosis. Ca blockers and prostaglandins are used to treat peripheral circulatory disturbances. Chronic limb-threatening ischemia (CLTI) is a disease characterized by extremity ulcers, necrosis, and pain due to limb ischemia. Since only a few patients present with coexistence of CLTI and SSc, the treatment outcomes of revascularization in these cases are unknown. In this study, we evaluated the clinical characteristics and treatment outcomes of seven patients with CLTI and SSc, and 35 patients with uncomplicated CLTI who were hospitalized from 2012 to 2022. A higher proportion of patients with uncomplicated CLTI had diabetes and male. There were no significant differences in the age at which ischemic ulceration occurred, other comorbidities, or in treatments, including antimicrobial agents, revascularization and amputation, improvement of pain, and the survival time from ulcer onset between the two subgroups. EVT or amputation was performed in six or two of the seven patients with CLTI and SSc, respectively. Among those who underwent EVT, 33% (2/6) achieved epithelialization and 67% (4/6) experienced pain relief. These results suggest that the revascularization in cases with CLTI and SSc should consider factors such as infection and general condition, since revascularization improve the pain of these patients.

Short-term efficacy of stenting as a rescue therapy for acute atherosclerotic occlusion in anterior cerebral circulation.

Purpose: The study aimed to explore the efficacy and safety of the Neuroform EZ stent in treating acute anterior circulation large artery occlusion. Methods: The clinical data of 42 consecutive patients with acute anterior circulation large atherosclerotic occlusion who were treated with the Neuroform EZ stent from January 2018 to August 2019 in our stroke care center, including baseline characteristics, images, therapeutic condition, and follow-up data were retrospectively analyzed. Results: There were 42 mechanical thrombectomy (MT) failure cases of intracranial atherosclerotic stenosis with rescue Neuroform EZ stent implantation, of which 78.6% (33/42) had a good prognosis and 88.1% (37/42) showed no re-stenosis at follow-up. The average time from puncture to recanalization is 79.50 ± 14.19 min. The successful rate of intraoperative stent release is 97.6%, while there is one case of stent displacement, three cases of thrombus escape, and six cases of hemorrhage. Conclusion: Rescue therapy of the Neuroform EZ stent for acute anterior circulation large atherosclerotic occlusion can archive good short-term imaging and clinical results, while long-term follow-up is still needed to verify.

Staged Hybrid Techniques With Straightforward Bypass Surgery Followed by Flow Diverter Deployment for Complex Recurrent Middle Cerebral Artery Aneurysms.

BACKGROUND: Recurrent complex middle cerebral artery (MCA) aneurysms after combined clipping and endovascular surgery are challenging, and if conventional techniques are adapted, advanced surgical, endovascular, and a combination of both techniques are often required. For such complex aneurysms, safe and effective straightforward techniques for all neurovascular surgeons are warranted. We describe the details of staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment in a patient with complex MCA aneurysm. ILLUSTRATIVE CASE: A 69-year-old woman presented with left recurrent large MCA aneurysm enlargement 25 years after direct surgery and coil embolization for ruptured aneurysm. The recurrent MCA aneurysm had large and complex morphology and was adhering to the brain tissues. Therefore, it was unsuitable to treat such aneurysm with conventional surgical and endovascular techniques with a high risk of morbidity. We performed (1) M2 ligation following superficial temporal artery-M2 bypass and (2) flow diverter deployment assisted with coil packing in two sessions. Three months after the second session, the aneurysm was completely occluded with endothelialization of the neck. Angiographic findings revealed no recurrence 12 months after the treatment. CONCLUSIONS: Staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment may be a safe and effective treatment for complex recurrent MCA aneurysms.

Predictive accuracy of an ADC map for hemorrhagic transformation in acute ischemic stroke patients after successful recanalization with endovascular therapy.

Background: Hemorrhagic transformation (HT) of acute ischemic stroke (AIS) is associated with poor outcome. Previous studies only reported the association of mean ischemic severity or total infarct volume with HT after endovascular therapy (EVT). We aimed to investigate the predictive value of preoperative apparent diffusion coefficient (ADC) map for HT by combinated ischemic severity and corresponding volume in AIS after successful recanalization with EVT. Methods: We retrospectively analyzed 119 consecutive cases of AIS with large vessel occlusion of anterior circulation within 24 hours after symptom onset and successful recanalization after EVT. All cases had baseline magnetic resonance imaging (MRI), follow-up computed tomography (CT), and magnetic resonance angiography (MRA) or computed tomography angiography (CTA). Volumes of ADC <0.6×10-3, 0.5×10-3, 0.4×10-3, and 0.3×10-3 mm2/s, baseline characteristics and outcomes of patients with and without HT identified by European Collaborative Acute Stroke Study (ECASS) were compared. The optimal ADC and volume threshold for predicting HT were analyzed using receiver operating characteristic (ROC) curve, and multivariate logistic regression analysis were performed with clinical characteristics and volumes of optimal ADC threshold to determine risk factors for HT. Results: Among 119 patients, 42 patients had HT on follow-up CT, including 24 hemorrhagic infarct (HI) cases and 18 parenchymal hematoma (PH) cases. The optimal volumes were 6.46 mL with ADC <0.4×10-3 mm2/s for predicting both HT and PH, with a larger area under curve (AUC) of 83.3% for HT than that for PH of 80%. In logistic regression analysis, intravenous tissue plasminogen activator (IV tPA) treatment, atrial fibrillation, and volume of ADC <0.4×10-3 mm2/s were identified as independent predictors for HT and volume of ADC <0.4×10-3 mm2/s had the highest odds ratio (OR) value. Conclusions: The combination of ischemic severity and corresponding volume in ADC map may predict HT after thrombectomy. In addition to the total infarct volume, volume with severe ischemia should be taken into consideration in preoperative patient selection.

No sex difference was found in the safety and efficacy of intravenous alteplase before endovascular therapy.

Background and purpose: Prior studies on sex disparities were post-hoc analyses, had limited treatment modalities, and had controversial findings. Our study aimed to examine whether sex difference modifies the effect of intravenous alteplase before endovascular therapy. Methods: We conducted a multicenter prospective cohort study of 850 eligible patients with acute ischemic stroke who underwent endovascular therapy. A propensity score was utilized as a covariate to achieve approximate randomization of alteplase pretreatment. The baseline characteristics of women and men were compared. Logistic regression with interaction terms, adjusted for potential confounders, was used to investigate the effect of sex on the prognosis of bridging therapy. Results: In comparison to men, women were older [78.00 (70.00-84.00) vs. 67 (61.00-74.00), P < 0.001], had more atrial fibrillation (61.4 vs. 35.2%, P < 0.001), had a lower ASPECTS [10.00 (8.00-10.00) vs. 10 (9.00-10.00), P = 0.0047], and had a higher NIHSS score [17.00 (14.00-20.00) vs. 16 (13.00-19.00), P = 0.005]. Women tended to receive less bridging therapy (26.3 vs. 33%, P = 0.043) and more retrieval attempts [2.00 (1.00-2.00) vs. 1 (1.00-2.00), P = 0.026]. There was no sex difference in functional independence at 90 days after bridging therapy (OR 0.968, 95% CI 0.575-1.63), whereas men benefited more after EVT alone (OR 0.654, 95% CI 0.456-0.937). There were no sex-treatment interactions observed regardless of the location of the occlusion. There were no significant sex differences in all safety outcomes. Conclusion: Our study could not confirm that sex modifies the treatment effect of intravenous alteplase before endovascular therapy. At the same time, we advocate for women to seek timely medical treatment.

Influence of pre-stroke dependency on safety and efficacy of endovascular therapy: A systematic review and meta-analysis.

Background and purpose: In the landmark trials studying endovascular thrombectomy (EVT), pre-stroke dependent (PSD) patients were generally excluded. This systematic review and meta-analysis aimed to compare the safety and efficacy of EVT between PSD and pre-stroke independent (PSI) patients. Methods: We searched CENTRAL, Embase, and Ovid MEDLINE up to 11 November 2021 for studies assessing PSD and PSI patients, which were separately defined as pre-stroke mRS score >2 or >1, and ≤2 or ≤1 accordingly. Two authors extracted data and assessed the risk of bias. A meta-analysis was carried out using the random-effects model. Adjusted OR and 95% CI were used to estimate adjusted pool effects. The main outcomes included favorable outcomes, successful recanalization, symptomatic intracranial hemorrhage, and 90-day mortality. Results: A total of 8,004 records met the initial search strategy, and ten studies were included in the final decision. Compared with PSImRS≤2, PSDmRS>2 had a lower favorable outcome (OR 0.51; 95% CI, 0.33-0.79) and higher 90-day mortality (OR 3.32; 95% CI, 2.77-3.98). No significant difference was found in successful recanalization and sICH. After adjustment, only 90-day mortality (aOR 1.99; 95% CI, 1.58-2.49) remained significantly higher in PSDmRS>2. Compared with PSImRS≤1, PSDmRS>1 had lower 90-day mortality (OR, 3.10; 95% CI, 1.84-5.24). No significant difference was found regarding the favorable outcome, successful recanalization, and sICH. After adjustment, no significant difference was found in a favorable outcome, but a higher rate of 90-day mortality (aOR, 2.13; 95% CI, 1.66-2.72) remained in PSDmRS>1. Conclusions: PSD does not innately influence the EVT outcomes regarding sICH and favorable outcomes but may increase the risk of 90-day mortality. Until further evidence is available, it is reasonable to suggest EVT for patients with PSD.

Accuracy of quantitative vessel analysis in endovascular treatment for femoropopliteal lesions.

BACKGROUND: Our aim was to evaluate the accuracy of quantitative vessel analysis (QVA) in measuring the reference vessel diameter (RVD) of femoropopliteal lesions. METHODS: Between October 2014 and September 2015, 30 consecutive femoropopliteal lesions in 25 patients who underwent endovascular therapy (EVT) under intravascular ultrasound (IVUS) guidance were analyzed. RVDs measured using QVAsheath (calibrated using a 6-Fr sheath in the common femoral artery) and QVAruler (calibrated using a ruler on the angiography table) were compared to those obtained using IVUS as the reference values. RESULTS: The mean QVAsheath-measured RVD was significantly larger than the mean IVUS-measured RVD (5.34±1.29 vs. 5.07±1.20 mm, P=0.001). In contrast, mean QVAruler-measured RVD was 4.60±1.04 mm, which was significantly smaller than both the mean IVUS- and mean QVAsheath-measured RVD (both P<0.001). Bland-Altman analysis revealed that the 95% limits of agreement versus IVUS ranged from -0.94 to 1.49 mm for QVAsheath and -1.69 to 0.76 mm for QVAruler, respectively. Agreement with tolerance of ±1.00 mm accounted for 88% of QVAsheath and 83% of QVAruler (P=0.60). The difference between QVA- and IVUS-measured RVDs was inversely correlated with the distance from the table (P=0.029 for QVAsheath and P=0.003 for QVAruler). CONCLUSIONS: The accuracy of both QVAsheath and QVAruler in measuring RVD were similarly suboptimal. Over- and under-estimation of RVD is not rare in QVA.

Clinical expert consensus document on standards for lower extremity artery disease of imaging modality from the Japan Endovascular Treatment Conference.

Imaging modalities have developed to provide precise information in the assessment of lower extremity artery disease (LEAD), including both quantitative measurements and morphological assessment. However, a lack of standardization for the evaluation methods introduces inconsistency and potential risk. This consensus document from Japan Endovascular Treatment Conference (JET) summarizes the methods of measurement and assessment of intravascular ultrasound (IVUS), optical frequency domain imaging (OFDI), and angioscopy. We propose standardized approaches for the evaluation of these modalities in endovascular therapy (EVT).

Changes of Health-Related Quality of Life Within the 1st Year After Stroke-Results From a Prospective Stroke Cohort Study.

Introduction: As prospective data on long-term patient-reported outcome measures (PROMs) to assess Health related Quality of Life (HRQoL) after stroke are still scarce, this study examined the long-term course of PROMs and investigated influential factors such as recanalization therapies. Materials and Methods: A total of 945 (mean age 69 years; 56% male) stroke patients were enrolled with a personal interview and chart review performed at index event. One hundred forty (15%) patients received thrombolysis (IVT) and 53 (5%) patients received endovascular therapy (ET) or both treatments as bridging therapy (BT). After 3 and 12 months, a follow-up was conducted using a postal questionnaire including subjective quality of life EQ-5D-5L (European Quality of Life 5 Dimensions). At all time-points, Modified Rankin Scale (mRS) was additionally used to quantify functional stroke severity. Differences between therapy groups were identified using post-hoc-tests. Linear and logistic regression analyses were used to identify predictors of outcomes. Results: Recanalization therapies were associated with significant improvements of NIHSS (National Institutes of Health Stroke Scale [regression coefficient IVT 1.21 (p = 0.01) and ET/BT 7.6; p = 0.001] and mRS (modified Rankin Scale) [regression coefficient IVT 0.83; p = 0.001 and ET/BT 2.0; p = 0.001] between admission and discharge compared to patients with stroke unit therapy only, with a trend toward improvement of EQ-5D after 12 months [regression coefficient 4.67 (p = 0.17)] with IVT. HRQoL was considerably impaired by stroke and increased steadily in 3- and 12-months follow-up in patients with (mean EQ-5D from 56 to 68) and without recanalization therapy (mean EQ-5D from 62 to 68). In severe strokes a major and significant improvement was only detected during period of 3 to 12 months (p = 0.03 in patients with and p = 0.005 in patients without recanalization therapy). Conclusions: Despite significant and continuous improvements after stroke the HRQoL after 12 months remained below the age-matched general population, but was still unexpectedly high in view of the accumulation of permanent disabilities in up to 30% of the patients. Especially in severe strokes, it is important to evaluate HRQoL beyond a 3-months follow-up as improvements became significant only between 3 months and 1 year.

Modeling Large Vessel Occlusion Stroke for the Evaluation of Endovascular Therapy According to Thrombus Composition.

More than 40% of endovascular therapy (EVT) fail to achieve complete reperfusion of the territory of the occluded artery in patients with acute ischemic stroke (AIS). Understanding factors influencing EVT could help overcome its limitations. Our objective was to study the impact of thrombus cell composition on EVT procedures, using a simulation system for modeling thrombus-induced large vessel occlusion (LVO) in flow conditions. In an open comparative trial, we analyzed the behavior of size-standardized platelet-rich and red blood cells (RBC)-rich thrombi during simulated stent retriever-mediated EVT procedures. Sixteen simulated EVT procedures were performed (8 RBC- vs. 8 platelet-rich thrombi). Platelet-rich thrombi were associated with a higher number of stent retriever passes (p = 0.03) and a longer procedure duration (p = 0.02) compared to RBC-rich thrombi. Conversely, RBC-rich thrombi released more embolic fragments than platelet-rich thrombi (p = 0.004). Both RBC-rich and platelet-rich thrombi underwent drastic compaction after being injected into the in vitro circulation model, and histologic analyses showed that these EVT-retrieved thrombi displayed features comparable to those previously observed in thrombi from patients with AIS patients having LVO, including a marked structural dichotomy between RBC- and platelet-rich areas. Our results show that the injection of in vitro-produced thrombi in artificial cerebrovascular arterial networks is suitable for testing recanalization efficacy and the risk of embolization of EVT devices and strategies in association with thrombus cell composition.

Association between high-sensitivity C-reactive protein levels and clinical outcomes in acute ischemic stroke patients treated with endovascular therapy.

BACKGROUND: Increasing evidence demonstrates that high-sensitivity C-reactive protein (hs-CRP) is an independent prognostic predictor in acute ischemic stroke (AIS) patients. The purpose of this study is to investigate the association between hs-CRP levels and clinical outcomes in AIS patients receiving endovascular therapy (EVT). METHODS: This observational study was based on a prospective registry study. AIS patients receiving EVT from December 2012 to January 2019 were included. The modified Rankin Scale (mRS) scores at the 90-day and long-term follow-up were evaluated as clinical outcomes. Multivariable logistic regression analysis was conducted to adjust for confounders. Receiver operating characteristic (ROC) curve analysis was performed based on significant predictors of favorable outcomes in the logistic regression analysis. Patients were divided into two groups according to the cutoff value. Clinical outcomes were compared between groups. Survival probability was assessed using Kaplan-Meier survival analysis. RESULTS: Multivariable logistic regression analysis of the 362 enrolled AIS patients demonstrated that age (P=0.030), National Institutes of Health Stroke Scale (NIHSS) score (P=0.023), hs-CRP levels (P<0.001), and symptomatic intracranial hemorrhage (sICH) (P=0.006) were independently predictive of favorable outcomes. ROC curve analysis indicated that the hs-CRP level was predictive of favorable outcomes at the 90-day follow-up with a cutoff value of 8.255 mg/L. The mRS scores between patients with hs-CRP <8.255 mg/L and patients with hs-CRP ≥8.255 mg/L at the 90-day [2 (IQR, 1-2) vs. 4 (IQR, 3-6), P<0.001] and long-term follow-up [1 (IQR, 0-2) vs. 4 (IQR, 2-6), P<0.001] were significantly different. Patients with hs-CRP ≥8.255 mg/L had significantly increased risk of poor clinical outcomes at the 90-day and long-term follow-up compared with those with hs-CRP <8.255 mg/L (P<0.001 each). CONCLUSIONS: Elevated hs-CRP levels were associated with poor clinical outcomes in AIS patients receiving EVT.

Added Prognostic Value of Hemorrhagic Transformation Quantification in Patients With Acute Ischemic Stroke.

Introduction and Aim: Hemorrhagic transformation (HT) frequently occurs after acute ischemic stroke and negatively influences the functional outcome. Usually, HT is classified by its radiological appearance. Discriminating between the subtypes can be complicated, and interobserver variation is considerable. Therefore, we aim to quantify rather than classify hemorrhage volumes and determine the association of hemorrhage volume with functional outcome in comparison with the European Cooperative Acute Stroke Study II classification. Patients and Methods: We included patients from the MR CLEAN trial with follow-up imaging. Hemorrhage volume was estimated by manual delineation of the lesion, and HT was classified according to the European Cooperative Acute Stroke Study II classification [petechial hemorrhagic infarction types 1 (HI1) and 2 (HI2) and parenchymal hematoma types 1 (PH1) and 2 (PH2)] on follow-up CT 24 h to 2 weeks after treatment. We assessed functional outcome using the modified Rankin Scale 90 days after stroke onset. Ordinal logistic regression with and without adjustment for potential confounders was used to describe the association of hemorrhage volume with functional outcome. We created regression models including and excluding total lesion volume as a confounder. Results: We included 478 patients. Of these patients, 222 had HT. Median hemorrhage volume was 3.37 ml (0.80-12.6) and per HT subgroup; HI1: 0.2 (0.0-1.7), HI2: 3.2 (1.7-6.1), PH1: 6.3 (4.2-13), and PH2: 47 (19-101). Hemorrhage volume was associated with functional outcome [adjusted common odds ratio (acOR): 0.83, 95% CI: 0.73-0.95] but not anymore after adjustment for total lesion volume (acOR: 0.99, 95% CI: 0.86-1.15, per 10 ml). Hemorrhage volume in patients with PH2 was significantly associated with functional outcome after adjusting total lesion volume (acOR: 0.70, 95% CI: 0.50-0.98). Conclusion: HT volume is associated with functional outcomes in patients with acute ischemic stroke but not independent of total lesion volume. The extent of a PH2 was associated with outcome, suggesting that measuring hemorrhage volume only provides an additional benefit in the prediction of the outcome when a PH2 is present.

Diagnostic and Therapeutic Approaches in the Management of Infrapopliteal Arterial Disease.

Chronic limb-threatening ischemia represents end-stage peripheral artery disease. It is underdiagnosed; it relies on clinical symptoms and traditional noninvasive tests, which significantly underestimate the severity of disease. Innovative techniques, approaches, technologies, and risk-assessment tools have significantly improved our ability to treat these patients and to better understand their complex disease process. For patients with chronic limb-threatening ischemia considered without options, the reengineering of deep venous arterialization procedures has shown promising results. Finally, the creation of interactive and multidisciplinary teams in centers of excellence is of paramount importance to significantly improve the care and outcomes of these patients.

Morphologic Changes of the Femoropopliteal Arterial Segment with Knee Flexion after Endovascular Therapy.

Objective: The purpose of this study is to investigate morphologic changes of the femoropopliteal arterial segment (FPAS) with knee flexion after endovascular therapy (EVT). Methods: From July 2012 to January 2015, EVT was performed on 12 limbs in 12 consecutive patients who had obliterative lesions in the FPAS. After the implantation of nitinol stents, angiography was performed with the knee in both extension and flexion to investigate morphologic changes of the FPAS. Results: On angiography, the distal end of the implanted stent was placed at various distances (5-10 cm in two cases, 10-15 cm in nine cases, and 15-20 cm in one case) above the knee joint line with the knee in extension. In all cases, although the popliteal artery was highly bent with the knee in flexion, the FPAS morphology was highly variable. However, the most proximal bending point of the FPAS was about 10 cm above the knee joint line. In one case, the artery was occluded at the distal part of the stent 16 months later, probably due to EVT. Conclusion: In EVT of the FPAS, it is important to consider the characteristics and position of the stent to prevent complications.

Hybrid Operations in Patients with Peripheral Arterial Disease.

In this seminar, I would like to discuss the recent hybrid operations in patients with peripheral arterial diseases. Hybrid is generally defined as combinations of different types of things. In the surgical community, it is loosely defined as therapy combining open surgery (OS) and endovascular therapy (EVT). In practice, combination surgery of diseased inflow vessels by EVT and outflow vessels by OS is a typical example, namely, the combination therapy of thromboendarterectomy (TEA) for common femoral artery and EVT (PTA and stenting) for iliac artery in patients with PAD (ilio-femoral lesions). Also, there is the potential of various combinations of OS and EVT for complex lesions. Unfortunately, we do not have specific guidelines for hybrid therapy of PAD, but in clinical practices, justified decision-making for surgical indication is strictly required. I emphasize that the cardiovascular surgeon (or vascular specialist) must have the ability of decision-making for suitable combination therapy of OS and EVT which adheres to existing specific guidelines. (This is a translation of Jpn J Vasc Surg 2017; 26: 275-283.).