Percutaneous Large-Bore Pulmonary Thrombectomy with the FlowTriever Device: Initial Experience in Intermediate-High and High-Risk Patients

OBJECTIVES

This retrospective cohort study investigates outcomes of patients with intermediate-high and high-risk pulmonary embolism (PE) who were treated with transfemoral mechanical thrombectomy (MT) using the large-bore Inari FlowTriever aspiration catheter system.

MATERIAL AND METHODS

Twenty-seven patients (mean age 56.1 ± 15.3 years) treated with MT for PE between 04/2021 and 11/2021 were reviewed. Risk stratification was performed according to European Society of Cardiology (ESC) guidelines. Clinical and hemodynamic characteristics before and after the procedure were compared with the paired Student's t test, and duration of hospital stay was analyzed with the Kaplan-Meier estimator. Procedure-related adverse advents were assessed.

RESULTS

Of 27 patients treated, 18 were classified as high risk. Mean right-to-left ventricular ratio on baseline CT was 1.7 ± 0.6. After MT, a statistically significant reduction in mean pulmonary artery pressures from 35.9 ± 9.6 to 26.1 ± 9.0 mmHg (p = 0.002) and heart rates from 109.4 ± 22.5 to 82.8 ± 13.8 beats per minute (p < 0.001) was achieved. Two patients died of prolonged cardiogenic shock. Three patients died of post-interventional complications of which a paradoxical embolism can be considered related to MT. One patient needed short cardiopulmonary resuscitation during the procedure due to clot displacement. Patients with PE as primary driver of clinical instability had a median intensive care unit (ICU) stay of 2 days (0.5-3.5 days). Patients who developed PE as a complication of an underlying medical condition spent 11 days (9.5-12.5 days) in the ICU.

CONCLUSION

In this small study population of predominantly high-risk PE patients, large-bore MT without adjunctive thrombolysis was feasible with an acceptable procedure-related complication rate.

Inter- and Intrareader Agreement of NI-RADS in the Interpretation of Surveillance Contrast-Enhanced CT after Treatment of Oral Cavity and Oropharyngeal Squamous Cell Carcinoma

BACKGROUND AND PURPOSE

The Neck Imaging Reporting and Data System was introduced to assess the probability of recurrence in surveillance imaging after treatment of head and neck cancer. This study investigated inter- and intrareader agreement in interpreting contrast-enhanced CT after treatment of oral cavity and oropharyngeal squamous cell carcinoma.

MATERIALS AND METHODS

This retrospective study analyzed CT datasets of 101 patients. Four radiologists provided the Neck Imaging Reporting and Data System reports for the primary site and neck (cervical lymph nodes). The Kendall's coefficient of concordance (W), Fleiss κ (κ_F), the Kendall's rank correlation coefficient (τ_B), and weighted κ statistics (κ_w) were calculated to assess inter- and intrareader agreement.

RESULTS

Overall, interreader agreement was strong or moderate for both the primary site (W = 0.74, κ_F = 0.48) and the neck (W = 0.80, κ_F = 0.50), depending on the statistics applied. Interreader agreement was higher in patients with proved recurrence at the primary site (W = 0.96 versus 0.56, κ_F = 0.65 versus 0.30) or in the neck (W = 0.78 versus 0.56, κ_F = 0.41 versus 0.29). Intrareader agreement was moderate to strong or almost perfect at the primary site (range τ_B = 0.67-0.82, κ_w = 0.85-0.96) and strong or almost perfect in the neck (range τ_B = 0.76-0.86, κ_w = 0.89-0.95).

CONCLUSIONS

The Neck Imaging Reporting and Data System used for surveillance contrast-enhanced CT after treatment of oral cavity and oropharyngeal squamous cell carcinoma provides acceptable score reproducibility with limitations in patients with posttherapeutic changes but no cancer recurrence.

[Initial Clinical Experiences Using Ocriplasmin for the Treatment of Vitreomacular Traction with or without a Macular Hole]

PURPOSE

In vitreomacular traction (VMT), there is abnormal adhesion between the vitreous cortex and the retina, especially in the fovea. Symptoms of VMT include metamorphopsia and a decrease in visual acuity. Since 2013, ocriplasmin (Jetrea®) has been approved for treatment of symptomatic vitreomacular traction with or without macular holes (≤ 400 µm).

METHODS

We retrospectively examined twenty-three eyes of twenty-one patients who underwent intravitreal ocriplasmin treatment for symptomatic vitreomacular traction with or without macular holes. Best corrected visual acuity and central retinal thickness (CRT) were measured in advance and after ocriplasmin treatment. The numbers of resolved vitreomacular traction and closed macular holes were documented.

RESULTS

Vitreomacular traction was resolved in eight of twenty-three eyes (34.8 %); in fifteen eyes (65.2 %) it was persistent and two of four macular holes were found closed. The average best corrected visual acuity was 0.39 ± 0.25 logMAR at baseline and 0.41 ± 0.24 logMAR at the first follow-up visit after injection (p = 0.613). The average CRT was 453.3 ± 172.7 µm at baseline, with a slight decrease to 412.0 ± 212 µm (p = 0.124).

CONCLUSION

Intravitreal injection of ocriplasmin appears is an experimental therapy in patients with symptomatic vitreomacular traction. Patient selection seems to be critically important for the therapeutic outcome, whereas greater age, specific VMT morphology and missing chromatopsia seem to be negative predictors.

[Methotrexate in Atypical Non-Arteritic Ischemic Optic Neuropathy]

Background: Optic nerve disease can occur from a variety of different causes, with vascular, inflammatory or toxic pathologies. In such cases, it is hardly possible to clarify the aetiology. These diseases of the optic nerve are usually accompanied by progressive loss of visual field and visual impairment. Patient: We report a case of a 74-year-old woman complaining of loss of visual acuity, visual and blurred vision in the left eye in 2010. We made the diagnosis of non-arteritic ischemic optic neuropathy (NAION). With steroid therapy, there was an improvement in both visual acuity and visual field defects. But if an attempt was made to reduce steroids, her condition progressed. Except for a very small optic disk and arterial hypotension, there were no typical risk factors for NAION. We started treatment with methotrexate (MTX), with a starting dose of 10 mg per week, and observed the patient over two years. Results: Using MTX therapy, the swelling of the optic nerve head and visual field loss were reversible, so we increased the dose of MTX up to 15 mg/week. Steroid therapy could be stopped and the patient's visual acuity and visual field have now been stable for two years. There was no visible pallor in the optic nerve head, as normally occurs after AION, so we considered different underlying pathologies, including autoimmune disease. There were no adverse events with MTX therapy. Conclusion: If the course of the disease is atypical, the pathology may include an autoimmune component. Immunosuppressive MTX therapy may be started in order to avoid long-term steroid use. It may then be possible to maintain a stable visual field and prevent remitting episodes.

[Effectiveness of Intravitreal Aflibercept Injections in Patients who had Received 10 and More Ranibizumab Injections in Advance]

BACKGROUND

Since 2007, the standard treatment for age related macular degeneration has been intravitreal injection of ranibizumab. However, despite continuous treatment, some patients fail to achieve remission or stabilisation of the disease. Since 2012, the recombinant fusion protein aflibercept has been available as an alternative treatment. In this study, we investigated whether patients who appear to be resistant to ranibizumab would benefit from treatment with aflibercept.

METHODOLOGY

This retrospective study covered 83 eyes of 81 patients, for whom treatment switch from ranibizumab to aflibercept was indicated. Inclusion criteria were an age ≥ 50 years and at least 10 ranibizumab injections before a switch to aflibercept. Patients with severely impaired visual acuity were excluded. Primary outcomes were improvement or loss of visual acuity (VA) and evaluation of central macular thickness (CMT) via SD-OCT. Secondary endpoints were percentage of eyes without activity of the choroidal neovascular membrane after aflibercept injections and loss or gain of letters on the visual chart. Statistical analysis was performed using SPSS.

RESULTS

VA was 0.83 ± 0.34 logMAR before the first aflibercept injection, with a slight but not statistically significant improvement up to 0.79 ± 0.33 logMAR after the third aflibercept injection (p = 0.205). On the other hand, there was a clear reduction of CMT in OCT, from 451.4 ± 263.0 to 288.2 ± 128.2 µm (p = 0.0001). Overall, 73 % of eyes exhibited better or stable VA and 27 % of eyes lost VA. Interestingly, eyes with worse initial VA gained greater benefit from the switch to aflibercept (p = 0.001).

CONCLUSION

A switch to aflibercept may lead to stabilisation of choroidal neovascularisation and thus stabilise the visual acuity for patients who appear to be no longer responsive to treatment with ranibizumab.

[The determination of a gross utilization of 15N-lysine in laboratory rats. 2. Comparative testing with an antibiotic supplement to the diet]

Wistar rats of a live weight of about 100 g received in 26 groups (4 animals/group) diets, each with a different lysine content. The rations given supplied the animals with 75%, 100% or 125% lysine of the calculated requirement. The source of protein in the diets was: barley (B), wheat (W), wheat gluten (WG), isolated soybean protein (assay protein) (S) or soybean meal (SM). For WG and S only the lysine levels 100% and 125% (SM = 116% and 125%) could be achieved. All diet groups were fed for 10 days with and without antibiotics (7 g Nebacitin/kg feed-DM). During the 7-day-period of the main experiment all 24 rations were supplemented with 0.5 g 15N-lysine/kg DM (48.3 atom-% 15N-excess, alpha-aminogroup 95% 15N-labelled). The nitrogen balance was improved only after feeding antibiotics with the diet S 100. It may be supposed that Nebacitin saved the second limiting amino acid methionine against microbial degradation in the digestion tract. The biological value (BV) of feed-proteins declined in the case of the diets B and W in the presence of antibiotics because the absorbed nitrogen was higher, this calculation basis for BV was therefore also higher without an improvement of the N-utilization. The 15N-excretion in faeces was significantly lower after feeding the diets B, W and WG with antibiotics. The 15N-excretion in urine was elevated in the most cases of the antibiotic supplement. The determination of a gross utilization of lysine and 15N-lysine resp. in relation to the lysine retention (availability) was not possible, neither using a labelling of diets with 15N-lysine.