Endovascular Therapy for Acute Stroke

Stroke is the most common cause of permanent disability, the second most common cause of dementia, and the fourth most common cause of death in the Western world. Recently, based on positive multicenter randomized clinical trials, endovascular therapy for acute stroke has undergone a revolution. Routine mechanical thrombectomy in addition to intravenous thrombolysis has been shown to provide excellent outcomes for patients with proximal anterior circulation occlusions. This procedure reduces disability and benefits are seen across a wide range of age and initial stroke severity. Important features that affect treatment decisions include time of presentation, the patient's clinical status, imaging characteristics, and lab tests. Under optimal conditions, it should be available to patients 24/7, similar to systems offering prompt percutaneous coronary interventions to patients with acute ST-segment elevation myocardial infarctions

Efficacy and safety of routine aspiration thrombectomy during primary PCI for ST-segment elevation myocardial infarction: A meta-analysis of large randomized controlled trials

Background: Recent randomized controlled trials (RCTs) have questioned the clinical efficacy and safety of routine aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI). A systematic synthesis of these randomized data is hence very timely to address this clinical equipoise. Methods: We performed a meta-analysis of the larger (>150 patients) RCTs that compared AT with only primary PCI. Procedural endpoints were myocardial blush grade (MBG) score of 0 or 1 and ST-segment resolution (STR) >50%. Midterm endpoints were mortality, reinfarction, target vessel revascularization, and stroke >30 days after the procedure. Results: We identified 11 large RCTs, with 10,309 patients randomized to AT and 10,296 to routine strategy (RT). While AT was associated with significantly improved myocardial perfusion, as demonstrated by the MBG score (OR = 0.69; p = 0.010), and improved rates of STR >50% (OR = 1.41; p = 0.006), there were no differences in mortality (OR = 0.89; p = 0.76), reinfarction (OR = 0.9; p = 0.47), target vessel revascularization (TVR; OR = 1.06; p = 0.67), and stroke rates (OR = 1.49; p = 0.29) >30 days after the procedure. Conclusion: Our meta-analysis of 20,605 patients who participated in large RCTs demonstrates improved MBG scores and STR >50% with AT compared with only PCI, but no differences were observed in mortality, reinfarction, TVR, and stroke rates at 30 days. Our study supports the latest ACC/AHA/SCAI focused update document that recommends against the routine use of AT during primary PCI. Keywords: Aspiration thrombectomy, Manual thrombectom

Percutaneous Muscular Ventricular Septal Defect Closure with 2D Transthoracic Echocardiography: Can We Sufficiently Visualize It?

Ventricular septal defect (VSD) is one of the most common congenital heart diseases worldwide today. Although the majority close spontaneously, transcatheter VSD closure is a common option for symptomatic patients with suitable anatomy in adult age. Although transesophageal echocardiography (TEE) and intracardiac echocardiography are the most common imaging modalities for the procedure, in patients with poor TEE images, Transthoracic echocardiography (TTE) can be used as a reliable alternative. Here we present an adult patient with pulmonary hypertension associated with a muscular VSD which was closed percutaneously using 2-dimensional TTE because of poor TEE images

SCAI expert consensus statement: Evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (Endorsed by the Cardiological Society of India, and Sociedad Latino Americana de Cardiologıa Intervencionista).

In the United States alone, there are currently approximately 14.5 million cancer survivors, and this number is expected to increase to 20 million by 2020. Cancer therapies can cause significant injury to the vasculature, resulting in angina, acute coronary syndromes (ACS), stroke, critical limb ischemia, arrhythmias, and heart failure, independently from the direct myocardial or pericardial damage from the malignancy itself. Consequently, the need for invasive evaluation and management in the cardiac catheterization laboratory (CCL) for such patients has been increasing. In recognition of the need for a document on special considerations for cancer patients in the CCL, the Society for Cardiovascular Angiography and Interventions (SCAI) commissioned a consensus group to provide recommendations based on the published medical literature and on the expertise of operators with accumulated experience in the cardiac catheterization of cancer patients

Safety and Efficacy of Stent Retrievers for the Management of Acute Ischemic Stroke: Comprehensive Review and Meta-Analysis

OBJECTIVES: This study sought to evaluate the safety and efficacy of stent retriever for the management of acute ischemic stroke. BACKGROUND: Stroke is the third leading cause of death and the most common cause of disability in the United States. Early reperfusion has been associated with favorable outcomes. Stent retrievers are novel endovascular devices that provide vessel recanalization via thrombus retrieval mechanical thrombectomy. METHODS: The authors performed a literature search using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from May 2005 to May 2015. Randomized controlled trails (RCTs) comparing endovascular therapy (ET) with the use of retrievable stents against standard therapy (ST) for the management of acute stroke were included. RESULTS: Five RCTs (the MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT studies) with 634 patients in the ET group and 653 patients in the ST group met inclusion criteria. The frequency of a low 90-day modified Rankin Score (0 to 2) in the intervention group was 42.6% compared with 26.1% in the control group (odds ratio: 2.43; 95% confidence interval [CI]: 1.9 to 3.09; p \u3c 0.0001). The frequency of intracranial bleeding was 4.2% in the ET group compared with 4.3% in the ST group (risk ratio: 1.08; 95% CI: 0.64 to 1.82; p = 0.78). 90-day mortality was 15.1% in the ET group compared with 18.7% in the ST group (risk ratio: 0.81; 95% CI: 0.58 to 1.12; p = 0.19). There was no evidence of significant heterogeneity or publication bias for any of the endpoints. CONCLUSIONS: On the basis of the results of this meta-analysis of RCTs, ET with stent retrievers appears as a safe and effective therapeutic option for acute ischemic stroke due to large vessel occlusion