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20 Papers for FRCS (Plus a Few More)
Published in James Michael Forsyth, How to Be a Safe Consultant Vascular Surgeon from Day One, 2023
As combinations of clot removal strategies are now frequently used in clinical practice, it also included studies where adjunctive thrombus removal techniques such as thrombectomy, balloon maceration, balloon venoplasty, aspiration, stenting etc., were used in combination with thrombolysis, provided they were compared to standard anticoagulation alone.
Stroke
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Mechanical thrombectomy is also called angiographically directed intraarterial removal of a thrombus or embolus, which uses a stent retriever device. This is done in larger stroke centers if the patient has had a recent large-vessel occlusion within the anterior circulation. It is not used in place of IV recombinant tPA within 4.5 hours of symptom onset for patients that are eligible and have had an acute ischemic stroke. The newer stent retrievers can reestablish perfusion in 90%–100% of cases. Today, clinical and imaging findings suggesting many tissues being at risk for infarction can justify mechanical thrombectomy later.
Blood Pressure Control in Acute Stroke
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
Blood pressure management during mechanical thrombectomy and type of anesthesia is also controversial. Because general anesthesia (GA) might have a greater propensity to cause a lower blood pressure and retrospective studies have shown that patients receiving GA have worse neurological outcomes compared to patients who have received conscious sedation (monitored anesthesia care, MAC), many neuro-interventional radiologists prefer MAC for these procedures. However, the SIESTA trial randomized patients with an acute ischemic stroke in the anterior circulation to MAC or GA [5]. Early outcome (24 hours) was no different between the two group although complications including hypothermia, delayed extubation, and pneumonia were more frequent in the GA group. There was no difference in mortality between the two groups at 3 months but more patients in the GA group were functionally independent at that time. In a small, single-center prospective trial comparing MAC to GA, there was no difference in neurological impairment (modified Rankin Scale score) at 3 months and no difference in hospital mortality despite a greater percentage of patients with a mean arterial blood pressure (MAP) 20% lower than the baseline MAP in the GA group [6]. A greater percentage in patients in the GA group required vasopressor support to maintain the MAP.
Extracorporeal membrane oxygenation for large pulmonary emboli
Published in Baylor University Medical Center Proceedings, 2023
Timothy J. George, Jenelle Sheasby, Rahul Sawhney, J. Michael DiMaio, Aasim Afzal, Dennis Gable, Sameh Sayfo
Acute pulmonary embolism (PE) is a common and growing problem.1 Large submassive and massive PE large enough to cause significant obstruction of the pulmonary arteries can cause hypoxia, hypercapnia, right ventricular failure, and hemodynamic instability.1,2 In some cases, patients will suffer cardiovascular collapse requiring cardiopulmonary resuscitation (CPR). In patients requiring CPR, in-hospital mortality is high, ranging from 25% to 80%.2–5 Although the first line of therapy consists of anticoagulation, treatment options include systemic thrombolysis, directed thrombolysis, percutaneous thrombectomy, and open surgical embolectomy. These therapies have been employed with varying degrees of success in different clinical situations.
Efficacy and safety of mechanical thrombectomy in acute stroke patients with pre-morbid disability
Published in Expert Review of Medical Devices, 2022
Aravind Ganesh, Joachim Fladt, Nishita Singh, Mayank Goyal
As for patients with more significant disability (mRS≥3), we recommend pursuing a case-by-case approach to the use of acute stroke therapies, using shared decision-making with patients and/or their family members (Figure 1). In such discussions, it is important to acknowledge the spectrum of good and bad outcomes that may be achieved in these patients, disclosing the uncertain state of the evidence, and adopting patient-centered care strategies whenever possible. This includes taking into account each patient’s long-term goals of care. In addition, thrombectomy techniques and skills have improved drastically over the last few years, ensuring higher rates of successful reperfusion and better safety. Add-on therapies for neuroprotection-like nerenitide have shown promising results in preliminary large trials and are being studied further. Thus, overall acute care in stroke continues to improve which will in turn lead to better stroke outcomes and care in all patients presenting with stroke including those with preexisting disability.
Simulation of stent retriever thrombectomy in acute ischemic stroke by finite element analysis
Published in Computer Methods in Biomechanics and Biomedical Engineering, 2022
Ronghui Liu, Chang Jin, Lizhen Wang, Yisong Yang, Yubo Fan, Weidong Wang
High stress in the clot was mainly concentrated on the surface interacting with the stent retriever along the clot length from proximal to distal. This feature allows the full-length of the thrombus to be retrieved. Different types of mechanical thrombectomy devices may have different interaction areas with a clot. For first-generation mechanical thrombectomy devices (Merci retriever, Concentric Medical), the interaction site is primarily focused on the distal end of a clot (Mordasini et al. 2013). However, for the aspiration catheter, the proximal surface of a clot is the main interacting area. The interaction mechanism between a clot and different types of thrombectomy devices needs to be further investigated. Moderate stress may contribute to clot engagement. However, increased stress, especially for the model with a 10 mm clot and 0.3 friction coefficient, may imply a higher risk of clot fragmentation and distal embolization.