Acute aortic occlusion: A narrative review for emergency clinicians.

INTRODUCTION: Acute aortic occlusion (AAO) is a rare but serious condition associated with significant morbidity and mortality. OBJECTIVE: This review provides an emergency medicine focused evaluation of AAO, including presentation, assessment, and emergency department (ED) management based on current evidence. DISCUSSION: AAO refers to obstruction of blood flow through the aorta due to either thrombosis or embolism. This condition primarily affects older adults ages 60-70 with cardiovascular comorbidities and most commonly presents with signs and symptoms of acute limb ischemia, though the gastrointestinal tract, kidneys, and spinal cord may be affected. The first line imaging modality includes computed tomography angiography of the chest, abdomen, and pelvis. ED resuscitative management consists of avoiding extremes of blood pressure or heart rate, maintaining normal oxygen saturation and euvolemic status, anticoagulation with heparin, and pain control. Emergent consultation with the vascular surgery specialist is recommended to establish a plan for restoration of perfusion to ischemic tissues via endovascular or open techniques. High rates of baseline comorbidities present in the affected population as well as ischemic and reperfusion injuries place AAO patients at high risk for complications in an immediate and delayed fashion after surgical management. CONCLUSIONS: An understanding of AAO can assist emergency clinicians in diagnosing and managing this rare but devastating disease.

Simulation of transportation of acute stroke patients in border regions.

Determining the optimal transportation for each stroke patient is critically important to achieve the best possible outcomes. In border regions the next comprehensive stroke center may be just across an international border, but bureaucratic and financial hurdles may prevent a simple transfer to the next stroke center. We hypothesized that in regions close to international borders, patients may benefit from an "open border, closed transfer scenario", meaning that patients in whom a large vessel occlusion (LVO) is detected in the primary stroke center will benefit from a transfer to the nearest stroke center offering endovascular thrombectomy-even if this may be across a national border. We used the Swiss-German-French trinational region as an example for a region with several international borders within close proximity to one another, and compared two feasible scenarios; (a) a "closed borders, open transfer" scenario, where the patient is transported to any center in the same country, (b) an "open border, closed transfer" scenario, where patients are always transported to the nearby primary stroke center first and then to the nearest comprehensive stroke center in either the same or a neighboring country and (c) and "open borders, open transfer" scenario. The outcome of interest was the predicted probability of acute ischemic stroke patients to achieve a good outcome using a conditional probability model which predicts the likelihood of excellent outcome (modified Rankin scale score of 0-1 at 90 days post-stroke) for patients with suspected LVO. Results were modeled in a virtual map from which the ideal transport concept emerged. For an exemplary LVO stroke patient in Germany, the probability of a good outcome was higher in an open border, closed transfer scenario than with closed borders, open transfer (33.1 vs. 30.1%). Moreover, time to EVT would decrease from 232 min in the first scenario to 169 min in an open border, closed transfer scenario. The catchment area of the University Hospital Basel was almost double the size in an open border, closed transfer scenario compared to closed borders (1674 km2 vs. 2897 km2) and would receive transfers from 3 primary stroke centers in other countries (2 in Germany and 1 in France). Stroke patients showed a higher likelihood of good outcome in the "open border" scenarios without transfer restrictions to a specific healthcare system. This probably has implications for stroke treatment in all border regions where EVT eligible stroke patients may benefit from transport to the closest EVT capable center whenever possible, regardless of whether this hospital is located in the same or a neighboring country/jurisdiction.

Effect of Hand Dominance on Radial Artery Spasm and Occlusion: A Prospective Observational Study.

Transradial access has become the most commonly used method for cardiac catheterization. Many medical and technical applications have been proposed to reduce TRA complications. The aim of this study is to examine the effect of hand dominance on radial artery spasm and radial artery occlusionin subjects undergoing CC via TRA. Between April 2020 and August 2022, 1713 subjects who underwent CC via TRA were included in the study. Patient data were obtained in terms of hand dominance of the catheterized side and RAS and RAO during a 1-month follow-up period. RAS was seen in 9.6% of the subjects. The RAS in patients catheterized by the dominant hand was significantly higher than that performed by the non-dominant hand (12 vs 7.8%; P = .004). RAO was seen in 1% of the subjects. RAO was significantly higher in the spasm side than in the no-spasm side (3 vs .8%; P = .009). Hand dominance was determined as an independent predictor of radial artery spasm (P = .006). In our study, RAS and RAO were more common on the dominant hand side than on the non-dominant side. Choosing the non-dominant hand for TRA for CC may reduce the incidence of RAS and RAO.

[Bilateral sub-acute upper limb ischemia revealing Horton's disease, a rare presentation : A case report and literature review]. / Ischémie subaiguë bilatérale des membres supérieurs révélant une Maladie de Horton, une présentation assez rare : à propos d'un cas et revue de la littérature.

STUDY'S GOAL: Our goal is to enrich the medical literature by sharing our experience in managing a case of sub-acute upper limb ischemia that revealed Horton's disease. This is particularly relevant given the current lack of well-established guidelines. INTRODUCTION: Acute upper limb ischemia is rarely seen in Horton's disease. CASE REPORT: We present a case of a 63-year-old female patient with sub-acute ischemia in both upper limbs, accompanied by jaw claudication and absence of bilateral temporal pulses. The CT Angiography scan revealed bilateral occlusions and stenosis of the axillary and sub-clavier arteries, as well as involvement of the external carotid arteries and its branches. The Arteriography confirmed abnormalities in the medium-sized arteries of the supra-aortic trunks. The histopathology examination of the temporal artery biopsy was negative. The patient received emergency corticosteroid therapy followed by an immunosuppressant. Due to the improved clinical condition of the upper limbs, surgical intervention was not performed.

Transradial or Transulnar Long Sheath Access to the Brachial Artery Allows for Neuroendovascular Procedures in Patients with Radial or Ulnar Artery Occlusion.

BACKGROUND: Transradial access is an important tool for many neuroendovascular procedures. Occlusion of the radial or ulnar artery is not uncommon after transradial or transulnar access and can present a challenge for patients requiring repeat angiography. METHODS: Between March 2022 and June 2023, patients undergoing transradial or transulnar angiography who were found to have a radial artery occlusion or ulnar artery occlusion were identified. Repeat catheterization of the occluded artery was attempted using a 21-gauge single wall puncture needle and a 0.021-inch wire to traverse the occlusion and insert a 23-cm sheath into the brachial artery. RESULTS: A total of 25 patients undergoing 26 angiograms during the study period were found to have a radial artery occlusion or ulnar artery occlusion. Successful repeat catheterization of the occluded artery was achieved in 21 of 26 cases (80.7%). Outer diameter sheath size ranged from 5 Fr (0.0655 inch) to 8 Fr (0.1048 inch). No access complications were encountered. Number of prior angiograms, time since prior angiogram, and prior angiogram procedure time were associated with lower likelihood of successful access. CONCLUSIONS: Transradial or transulnar neuroangiography through an occluded radial or ulnar artery is safe and feasible by traversing the occlusion into the brachial artery with a 23-cm sheath. Repeat catheterization is most successful in patients with an arterial occlusion <6 months old. This technique is important in patients who have limited options for arterial access, avoiding access site complications inherent in transfemoral access, and in patients who specifically require radial or ulnar artery access.

Safety and efficacy of mechanical aspiration thrombectomy for patients with acute lower extremity ischemia.

OBJECTIVE: Acute limb ischemia (ALI) is associated with high rates of amputation and consequent morbidity and mortality. The objective of this study is to report on the safety and efficacy of aspiration thrombectomy using the Indigo Aspiration System in patients with lower extremity (LE) ALI. METHODS: The STRIDE study was an international, multicenter, prospective, study that enrolled 119 participants presenting with LE-ALI. Patients were treated firstline with mechanical thrombectomy using the Indigo Aspiration System, before stenting or angioplasty, or other therapies as determined by treating physician. The primary end point was target limb salvage at 30 days after the procedure. Secondary end points within 30 days included technical success, defined as core laboratory-adjudicated Thrombolysis in Myocardial Infarction (TIMI) 2/3 flow rate immediately after the procedure, changes in modified Society for Vascular Surgery runoff score, improvement of Rutherford classification compared with before the procedure, patency, rate of device-related serious adverse events, and major periprocedural bleeding. Secondary end points that will be evaluated at 12 months include target limb salvage and mortality. RESULTS: Of the 119 participants enrolled at 16 sites, the mean age was 66.3 years (46.2% female). At baseline (n = 119), ischemic severity was classified as Rutherford I in 10.9%, Rutherford IIa in 54.6%, and Rutherford IIb in 34.5%. The mean target thrombus length was 125.7 ± 124.7 mm. Before the procedure, 93.0% (of patients 107/115) had no flow (TIMI 0) through the target lesion. The target limb salvage rate at 30 days was 98.2% (109/111). The rate of periprocedural major bleed was 4.2% (5/119) and device-related serious adverse events was 0.8% (1/119). Restoration of flow (TIMI 2/3) was achieved in 96.3% of patients (105/109) immediately after the procedure. The median improvement in the modified Society for Vascular Surgery runoff score (before vs after the procedure) was 6.0 (interquartile range, 0.0-11.0). Rutherford classifications also improved after discharge in 86.5% of patients (83/96), as compared with preprocedural scores. Patency at 30 days was achieved in 89.4% of patients (101/113). CONCLUSIONS: In the STRIDE (A Study of Patients with Lower Extremity Acute Limb Ischemia to Remove Thrombus with the Indigo Aspiration System) study, aspiration thrombectomy with the Indigo System provided a safe and effective endovascular treatment for patients with LE-ALI, resulting in a high rate (98.2%) of successful limb salvage at 30 days, with few periprocedural complications.

Aortic endarterectomy in patients with severe multivessel paravisceral and aortoiliac occlusive disease.

OBJECTIVE: Aortic endarterectomy (AE), once a treatment of choice for aortoiliac occlusive disease, is now rarely performed in favor of endovascular procedures or open aortobifemoral bypass. However, in select patients with paravisceral or aortoiliac occlusive disease, AE remains a viable alternative for revascularization, either as a primary procedure or after prior interventions have failed. Here, we evaluated outcomes for an extended series of patients undergoing paravisceral or aortoiliac endarterectomy, demonstrating that these procedures can be an excellent alternative with acceptable morbidity and mortality in properly selected patients. METHODS: A single institution retrospective review of 20 patients who underwent AE from 2017 to 2023 was performed. RESULTS: Five patients (25%) underwent paravisceral endarterectomy and 15 (75%) underwent aortoiliac endarterectomy. There were no perioperative mortalities. One paravisceral patient died 3 months postoperatively from complications of pneumonia. Three patients in the paravisceral group required reinterventions; one acutely due to thrombosis of the superior mesenteric artery (SMA) requiring extension of the endarterectomy and patch angioplasty on postoperative day 0, one due to stenosis at the distal edge of the endarterectomy 1 month postoperatively, successfully treated with SMA stenting, and one at 10-month follow-up due to SMA stenosis at the distal aspect of the endarterectomy, also successfully treated with SMA stenting. With these reinterventions, the 1-year primary patency in the paravisceral group was 40%, primary-assisted patency was 80%, and secondary patency was 100%. In the aortoiliac group, 1-year primary, primary-assisted, and secondary patency were 91%, 91%, and 100%, respectively. One patient developed iliac thrombosis 10 days postoperatively owing to an intimal flap distal to the endarterectomy site. She and one other patient, a young man with an undefined hypercoagulable disorder, ultimately required neoaortoiliac reconstructions at 18 and 32 months postoperatively, respectively (the latter in the setting of stopping anticoagulation). The remaining 13 patients experienced no complications. All patients had rapid resolution of clinical symptoms, and median postoperative ankle-brachial indexes of 1.06 on the right and 1.00 on the left, representing a median improvement from preoperative ankle-brachial indexes of +0.59 on the right and +0.56 on the left (P < .01 and P < .01). CONCLUSIONS: In this series of 20 patients undergoing paravisceral and infrarenal aortoiliac endarterectomy, AE was associated with no perioperative mortality, relatively low and manageable morbidity, and excellent clinical outcomes in patients with both paravisceral and aortoiliac occlusive disease. SMA-related early reintervention was not uncommon in the paravisceral group, and attention should be given particularly to the distal endarterectomy site. AE remains a viable treatment for severe multivessel paravisceral or aortoiliac occlusive disease isolated to the aorta and common iliac arteries in select patients.

Hemostasis after transradial coronary intervention by rotary compression device with sterile gauze is associated with more adverse events: a retrospective study.

OBJECTIVE: We investigated the relationship between using a rotary compression device (RCD) with or without sterile gauze and adverse events in transradial access (TRA) for coronary intervention. METHODS: In this study involving 933 patients at Yueyang Hospital, we recorded TRA-related adverse events, such as bleeding, forearm hematoma, swollen palms, radial artery occlusion (RAO) and others. Logistic regression was applied to assess the association. RESULTS: Of the 933 patients (66.7% males, average age 67.8 years), 511 used RCD with sterile gauze, whereas 422 used RCD without sterile gauze. The most common adverse events were radial artery hemorrhage (7.4%), hand swelling (4.8%) and RAO (4.6%). Logistic regression analysis revealed that the use of RCD with sterile gauze was associated with a higher prevalence of adverse events [odds ratio (OR), 1.74; 95% confidence interval (CI), 1.22-2.49), even with the adjustment of potential confounders (OR, 1.71; 95% CI, 1.19-2.45). Moreover, patients who used RCD with sterile gauze exhibited an increased risk of radial artery hemorrhage (OR, 1.83; 95% CI, 1.07-3.12), swelling of the hand (OR, 1.96; 95% CI, 1.02-3.75) and RAO (OR, 3.17; 95% CI, 1.49-6.72). CONCLUSIONS: The use of RCD with sterile gauze in TRA is associated with a higher incidence of adverse events.

The Role of Hyperdense Basilar Artery Sign in Predicting Outcome of Acute Basilar Artery Occlusion within Twelve Hours of Onset.

BACKGROUND: The correlation between hyperdense basilar artery sign (HDBAS) and outcome after acute basilar artery occlusion (ABAO) is debated. Our objective was to determine the usefulness of HDBAS in predicting the outcomes of patients with ABAO after endovascular treatment (EVT), intravenous thrombolysis (IVT), and best medical treatment (BMT). METHODS: The study participants were selected from the ATTENTION trial. The primary outcome of the study was a 90-day modified Rankin Scale (mRS) score, and the secondary outcome was the recanalization rate, any intracranial hemorrhage, and 90-day mortality. RESULTS: The study comprised 276 participants, with cohorts for EVT (n = 188), IVT (n = 82), and BMT (n = 88). In the EVT cohort, HDBAS was not associated with 90-day mRS score (adjusted odds ratio [OR], 0.87; 95% confidence interval [CI], 0.51-1.48; P = 0.6029), the recanalization after 24 hours of onset (adjusted OR, 0.76; 95% CI, 0.30-3.61; P = 0.9422), and 90-day mortality (adjusted OR, 0.77; 95% CI, 0.41-1.46; P = 0.4238). In the IVT cohort, HDBAS was not associated with a 90-day mRS score (adjusted OR, 0.69; 95% CI, 0.31-1.56; P = 0.3742), the recanalization after 24 hours of onset (adjusted OR, 2.24; 95% CI, 0.47-10.78; P = 0.3132), and 90-day mortality (adjusted OR, 0.64; 95% CI, 0.26-1.57; P = 0.3264). Similarly, in the BMT cohort, HDBAS was not associated with 90-day mRS score (adjusted OR, 1.11; 95% CI, 0.47-2.63; P = 0.8152), the recanalization after 24 hours of onset (adjusted OR, 1.27; 95% CI, 0.40-4.02; P = 0.6874), and 90-day mortality (adjusted OR, 1.17; 95% CI, 0.46-2.96; P = 0.748). CONCLUSIONS: HDBAS may not be a reliable predictor of outcomes for patients with ABAO, regardless of whether they received EVT, IVT, or BMT.

Case study scrub nurse role in aorto-bifemoral reconstruction with transbrachial balloon endoclamping technique.

INTRODUCTION: Aortoiliac arterial disease is a chronic progressive disease which is characterized by steno-occlusive changes in the aorta and iliac arteries. The gold standard for the treatment of patients with the advanced stage of the disease is aorto-bifemoral reconstruction. Patients with circumferential juxtarenal calcifications of the aorta bear a high risk of intraoperative complications, due to difficult cross-clamping in such zones. CASE REPORT: We present a case of a 73-year-old patient who has been admitted due to left leg rest pain and second toe ulceration. Multislice computed tomography showed significant stenosis of the aortoiliac segment with a circumferentially calcified abdominal aorta. Aortobifemoral reconstruction was performed featuring endoluminal occlusion of the aorta using a balloon catheter which was placed through the left brachial artery. The procedure and the postoperative course were uneventful, and the patient was discharged on the sixth postoperative day. CONCLUSION: The hybrid endovascular and open surgery technique presented emerged as a valid alternative for selected high-risk patients. Scrub nurses should be familiarized with endovascular techniques and tools and be aware of the measures to be protected from the harmful effects of ionizing radiation.

Predictive factors of poor outcome and mortality among anterior ischaemic stroke patients despite successful recanalisation in China: a secondary analysis of the CAPTURE trial.

OBJECTIVES: This work aimed to analyse the risk factors for poor outcomes and mortality among patients with anterior large vessel occlusion (LVO) ischaemic stroke, despite successful recanalisation. SETTING AND PARTICIPANTS: This study conducted a secondary analysis among patients who underwent successful recanalisation in the CAPTURE trial. The trial took place between March 2018 and September 2020 at 21 sites in China. The CAPTURE trial enrolled patients who had an acute ischaemic stroke aged 18-80 years with LVO in anterior circulation. INTERVENTIONS: Thrombectomy was immediately performed using Neurohawk or the Solitaire FR after randomisation in CAPTURE trial. Rescue treatment was available for patients with severe residual stenosis caused by atherosclerosis. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary goal was to predict poor 90-day survival or mortality within 90 days post-thrombectomy. Univariate analysis, using the χ2 test or Fisher's exact test, was conducted for each selected factor. Subsequently, a multivariable analysis was performed on significant factors (p≤0.10) identified through univariate analysis using the backward selection logistic regression approach. RESULTS: Among the 207 recruited patients, 79 (38.2%) exhibited poor clinical outcomes, and 26 (12.6%) died within 90 days post-thrombectomy. Multivariate analysis revealed that the following factors were significantly associated with poor 90-day survival: age ≥67 years, internal carotid artery (ICA) occlusion (compared with middle cerebral artery (MCA) occlusion), initial National Institutes of Health Stroke Scale (NIHSS) score ≥17 and final modified Thrombolysis in Cerebral Infarction (mTICI) score 2b (compared with mTICI 3). Additionally, the following factors were significantly associated with mortality 90 days post-thrombectomy: initial NIHSS score ≥17, ICA occlusion (compared with MCA occlusion) and recanalisation with more than one pass. CONCLUSIONS: Age, NIHSS score, occlusion site, mTICI score and the number of passes can be independently used to predict poor 90-day survival or mortality within 90 days post-thrombectomy. TRIAL REGISTRATION NUMBER: NCT04995757.

Unusual approach to popliteal vein bypass graft stenosis following failed angioplasty in popliteal entrapment syndrome.

Popliteal artery entrapment syndrome (PAES) is where the popliteal artery is compressed-typically by the medial head of the gastrocnemius muscle. PAES is typically treated surgically with popliteal artery release with or without bypass. Graft stenosis is a recognised complication of vein grafts. These are normally treated endovascularly. Endarterectomy of venous graft stenosis may be a useful tool in selected cases, where an endovascular approach was unsuccessful. Long-term follow-up of graft stenosis endarterectomy will allow us to determine effectiveness of this method of treatment where other options have failed.

Superior cerebellar artery occlusion remaining after thrombectomy for acute basilar artery occlusion.

To investigate the incidence and impact of superior cerebellar artery (SCA) occlusion remaining after thrombectomy for acute basilar artery occlusion (BAO). We retrospectively analyzed data from 116 patients who underwent thrombectomy for BAO. The patency of SCA was assessed on final angiograms. Clinical and radiologic data of the patients were retrieved from a prospectively collected database and analyzed. All patients underwent pretreatment and follow-up DWI to detect new infarctions in SCA territory. Ten patients (8.6%) had SCA occlusions on final angiograms. Of these, two patients had bilateral occlusions. A new infarction with a diameter ranged from 4 to 11 mm in corresponding SCA territory occurred in 5 of 10 patients. No patients with SCA occlusions experienced symptomatic cerebellar hemorrhage or malignant cerebellar infarction. Nine of 12 SCA occlusions showed spontaneous recanalization on follow-up CT angiography. Four of 10 patients showed 90-day favorable outcome (mRS 0-3) and 90-day mortality occurred in one patient. SCA occlusions remaining after thrombectomy for acute BAO had a benign clinical course. Most of these lesions recanalized spontaneously. Our study suggests that attempts to recanalize remnant SCA occlusion may be unnecessary after basilar artery thrombectomy.

Dynamic and visual nomograms to online predict unfavorable outcome of mechanical thrombectomy for acute basilar artery occlusion.

BACKGROUND: The evidence of mechanical thrombectomy (MT) in basilar artery occlusion (BAO) was limited. This study aimed to develop dynamic and visual nomogram models to predict the unfavorable outcome of MT in BAO online. METHODS: BAO patients treated with MT were screened. Preoperative and postoperative nomogram models were developed based on clinical parameters and imaging features. An independent dataset was collected to perform external validation. Web-based calculators were constructed to provide convenient access. RESULTS: A total of 127 patients were included in the study, and 117 of them were eventually included in the analysis. The nomogram models showed robust discrimination, with an area under the receiver operating characteristic (ROC) of 0.841 (preoperative) and 0.916 (postoperative). The calibration curves showed good agreement. The preoperative predictors of an unfavorable outcome were previous stroke, the National Institutes of Health Stroke Scale (NIHSS) at admission, and the posterior circulation Alberta Stroke Program Early Computed Tomography Score (pc-ASPECTS). The postoperative predictors were previous stroke, NIHSS at 24 h, and pc-ASPECTS. CONCLUSION: Dynamic and visual nomograms were constructed and validated for the first time for BAO patients treated with MT, which provided precise predictions for the risk of an unfavorable outcome. The preoperative model may assist clinicians in selecting eligible patients, and the postoperative model may facilitate individualized poststroke management.

Basilar artery bifurcation anatomy as a determinant of recanalization and stroke outcome: Basilar artery bifurcation anatomy and stroke outcome.

OBJECTIVES: Thrombectomy improves outcomes in patients with basilar artery (BA) occlusion. We hypothesized that the anatomic configuration of the BA bifurcation, classified as T- or Y-shaped, may impact the outcome as a T-shaped BA would involve more deep penetrating arteries of the midbrain and thalamus. MATERIALS AND METHODS: In this 2-center retrospective cohort study, we included patients with stroke due to distal BA occlusion and performed blinded classification of their BA distal bifurcation as either T- or Y-shaped. The primary outcomes were favorable outcome at 90-days (modified Rankin Scale 0 - 2) and successful recanalization (TICI scores 2B or 3). RESULTS: 70 patients (mean age 66 years, 36% women) were included. 38 had T- and 32 had Y-shaped bifurcations. Baseline characteristics were similar for both groups, including demographics, onset to arterial puncture time, baseline NIHSS, THRIVE score, posterior circulation collateral score, and presence of tandem occlusion. Comparing the T- to the Y- shape, there was no difference in the likelihood of successful recanalization (RR: 1.02, CI: [0.86-1.21], p=1.00) nor 90-day favorable mRS (0-2) score (RR: 0.58, CI: [0.25-1.32]; p=0.18). Similarly, mortality at 30 and 90-days were not significantly affected by the type of bifurcation. CONCLUSIONS: The configuration of the basilar artery does not significantly impact on recanalization success or stroke outcome in our study. Further studies are needed to confirm our observations.

A meta-analysis and systematic review of endovascular thrombectomy versus medical management for acute basilar artery occlusion.

OBJECTIVE: Acute basilar artery occlusion (BAO) is a devastating neurologic event. As endovascular thrombectomy (EVT) became more prevalent for anterior circulation strokes, investigations were conducted in the posterior circulation. Its success in improving outcomes compared to standard medical therapy (SMT) after BAO has been debated. METHODS: We conducted a systematic review and meta-analysis of all randomized controlled trials (RCTs) and observational cohort studies evaluating EVT compared to SMT in acute BAO. We queried PubMed, Embase, and Cochrane for studies. Primary outcome was good functional outcome at 90 days (modified Rankin scale (mRS) ≤ 3). We analyzed studies for risk of bias (ROB) and calculated pooled risk ratios (RRs), odds ratios (ORs), and mean differences (MDs) with 95% confidence intervals (95%CI) using the random effects model for our primary outcome and secondary positive outcomes and harms. RESULTS: We identified four RCTs (991 patients randomized) and three cohort studies (1030 patients treated in-trial) that fit inclusion criteria. Three RCTs had low ROB, one had serious ROB. One cohort study had high ROB, one had moderate ROB, and one had low ROB. EVT was statistically significantly more associated with good functional outcome than SMT in RCTs (RR=1.54, 95%CI=1.16-2.04, p = 0.003) and trended towards significance in cohort studies (RR=2.64, 95%CI=0.87-8.00, p = 0.09). Mean mRS at 90 days was lower in EVT patients in RCTs (MD=-0.65, 95%CI=-1.07--0.22, p = 0.003) though not cohort studies (MD =-0.84, 95%CI=-2.48-0.79, p = 0.31). Symptomatic intracerebral hemorrhage (sICH) was statistically significantly associated with EVT in RCTs (OR=6.36, 95%CI=2.24-18.07, p < 0.001) and statistically non-significantly in cohort studies (OR=4.51, 95CI=1.00-20.33, p = 0.05). Mortality at 90 days was statistically lower with EVT than with SMT in both RCTs (OR=0.76, 95%CI=0.65-0.88, p < 0.001) cohort studies (OR=0.36, 95%CI=0.26-0.50, p < 0.001) CONCLUSION: EVT is associated with greater rates of good functional outcomes and lower rates of death and disability despite higher rates of periprocedural sICH.

Diagnostic performance of contrast-enhanced ultrasound in diagnosing hepatic artery occlusion after liver transplantation: A systematic review and meta-analysis.

INTRODUCTION: Hepatic artery occlusion (HAO) is a significant complication post-liver transplantation. Doppler ultrasound (DUS) has been widely used as an initial screening test for detecting HAO; however, its performance is often not sufficient. Although other diagnostic tests such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), and angiogram are more accurate, they are invasive and have several limitations. Contrast-enhanced ultrasound (CEUS) is an emerging tool for detecting HAO; however, the results from previous studies were limited due to a small number of patients. Therefore, we aimed to evaluate its performance by performing a meta-analysis. METHOD: We performed a systemic review and meta-analysis of studies evaluating the performance of CEUS for the detection of HAO in an adult population. A literature search of EMBASE, Scopus, CINAHL, and Medline was conducted through March 2022. Pooled sensitivity, specificity, log diagnostic odd ratio (LDOR), and area under summary receiver operating curve (AUC) were calculated. Publication bias was assessed by Deeks' funnel plot. RESULT: Eight studies were included, with 434 CEUS performed. Using a combination of CTA, MRA, angiography, clinical follow-up, and surgery as the gold standard, the sensitivity, specificity, and LDOR of CEUS for detection of HAO were .969 (.938, .996), .991 (.981, 1.001), and 5.732 (4.539, 6.926), respectively. AUC was .959. The heterogeneity between studies appeared universally low, and no significant publication bias was found (p = .44). CONCLUSION: CEUS appeared to have an excellent performance for the detection of HAO and could be considered as an alternative when DUS is non-diagnostic or when CTA, MRA, and angiogram are not feasible.