Baseline Blood Pressure Effect on the Benefit and Safety of Intra-Arterial Treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands)

Background and Purpose—

High blood pressure (BP) is associated with poor outcome and the occurrence of symptomatic intracranial hemorrhage in acute ischemic stroke. Whether BP influences the benefit or safety of intra-arterial treatment (IAT) is not known. We aimed to assess the relation of BP with functional outcome, occurrence of symptomatic intracranial hemorrhage and effect of IAT.

Methods—

This is a post hoc analysis of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands). BP was measured at baseline, before IAT or stroke unit admission. We estimated the association of baseline BP with the score on the modified Rankin Scale at 90 days and safety parameters with ordinal and logistic regression analysis. Effect of BP on the effect of IAT was tested with multiplicative interaction terms.

Results—

Systolic BP (SBP) had the best correlation with functional outcome. This correlation was U-shaped; both low and high baseline SBP were associated with poor functional outcome. Higher SBP was associated with symptomatic intracranial hemorrhage (adjusted odds ratio, 1.25 for every 10 mm Hg higher SBP [95% confidence interval, 1.09–1.44]). Between SBP and IAT, there was no interaction for functional outcome, symptomatic intracranial hemorrhage, or other safety parameters; the absolute benefit of IAT was evident for the whole SBP range. The same was found for diastolic BP.

Conclusions—

BP does not affect the benefit or safety of IAT in patients with acute ischemic stroke caused by proximal intracranial vessel occlusion. Our data provide no arguments to withhold or delay IAT based on BP.

Clinical Trial Registration—

URL: http://www.isrctn.com . Unique identifier: ISRCTN10888758.

Collateral Status on Baseline Computed Tomographic Angiography and Intra-Arterial Treatment Effect in Patients With Proximal Anterior Circulation Stroke

Background and Purpose—

Recent randomized trials have proven the benefit of intra-arterial treatment (IAT) with retrievable stents in acute ischemic stroke. Patients with poor or absent collaterals (preexistent anastomoses to maintain blood flow in case of a primary vessel occlusion) may gain less clinical benefit from IAT. In this post hoc analysis, we aimed to assess whether the effect of IAT was modified by collateral status on baseline computed tomographic angiography in the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN).

Methods—

MR CLEAN was a multicenter, randomized trial of IAT versus no IAT. Primary outcome was the modified Rankin Scale at 90 days. The primary effect parameter was the adjusted common odds ratio for a shift in direction of a better outcome on the modified Rankin Scale. Collaterals were graded from 0 (absent) to 3 (good). We used multivariable ordinal logistic regression analysis with interaction terms to estimate treatment effect modification by collateral status.

Results—

We found a significant modification of treatment effect by collaterals ( P =0.038). The strongest benefit (adjusted common odds ratio 3.2 [95% confidence intervals 1.7–6.2]) was found in patients with good collaterals (grade 3). The adjusted common odds ratio was 1.6 [95% confidence intervals 1.0–2.7] for moderate collaterals (grade 2), 1.2 [95% confidence intervals 0.7–2.3] for poor collaterals (grade 1), and 1.0 [95% confidence intervals 0.1–8.7] for patients with absent collaterals (grade 0).

Conclusions—

In MR CLEAN, baseline computed tomographic angiography collateral status modified the treatment effect. The benefit of IAT was greatest in patients with good collaterals on baseline computed tomographic angiography. Treatment benefit appeared less and may be absent in patients with absent or poor collaterals.

Clinical Trial Registration—

URL: http://www.trialregister.nl and http://www.controlled-trials.com . Unique identifier: (NTR)1804 and ISRCTN10888758, respectively.

Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial

IMPORTANCE

Intra-arterial treatment (IAT) for acute ischemic stroke caused by intracranial arterial occlusion leads to improved functional outcome in patients treated within 6 hours after onset. The influence of treatment delay on treatment effect is not yet known.

OBJECTIVE

To evaluate the influence of time from stroke onset to the start of treatment and from stroke onset to reperfusion on the effect of IAT.

DESIGN, SETTING, AND PARTICIPANTS

The Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) was a multicenter, randomized clinical open-label trial of IAT vs no IAT in 500 patients. The time to the start of treatment was defined as the time from onset of symptoms to groin puncture (TOG). The time from onset of treatment to reperfusion (TOR) was defined as the time to reopening the vessel occlusion or the end of the procedure in cases for which reperfusion was not achieved. Data were collected from December 3, 2010, to June 3, 2014, and analyzed (intention to treat) from July 1, 2014, to September 19, 2015.

MAIN OUTCOMES AND MEASURES

Main outcome was the modified Rankin Scale (mRS) score for functional outcome (range, 0 [no symptoms] to 6 [death]). Multiple ordinal logistic regression analysis estimated the effect of treatment and tested for the interaction of time to randomization, TOG, and TOR with treatment. The effect of treatment as a risk difference on reaching independence (mRS score, 0-2) was computed as a function of TOG and TOR. Calculations were adjusted for age, National Institutes of Health Stroke Scale score, previous stroke, atrial fibrillation, diabetes mellitus, and intracranial arterial terminus occlusion.

RESULTS

Among 500 patients (58% male; median age, 67 years), the median TOG was 260 (interquartile range [IQR], 210-311) minutes; median TOR, 340 (IQR, 274-395) minutes. An interaction between TOR and treatment (P = .04) existed, but not between TOG and treatment (P = .26). The adjusted risk difference (95% CI) was 25.9% (8.3%-44.4%) when reperfusion was reached at 3 hours, 18.8% (6.6%-32.6%) at 4 hours, and 6.7% (0.4%-14.5%) at 6 hours.

CONCLUSION AND RELEVANCE

For every hour of reperfusion delay, the initially large benefit of IAT decreases; the absolute risk difference for a good outcome is reduced by 6% per hour of delay. Patients with acute ischemic stroke require immediate diagnostic workup and IAT in case of intracranial arterial vessel occlusion.

TRIAL REGISTRATION

trialregister.nl Identifier: NTR1804.

A randomized trial of intraarterial treatment for acute ischemic stroke

BACKGROUND

In patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion, intraarterial treatment is highly effective for emergency revascularization. However, proof of a beneficial effect on functional outcome is lacking.

METHODS

We randomly assigned eligible patients to either intraarterial treatment plus usual care or usual care alone. Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intraarterially within 6 hours after symptom onset. The primary outcome was the modified Rankin scale score at 90 days; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death). The treatment effect was estimated with ordinal logistic regression as a common odds ratio, adjusted for prespecified prognostic factors. The adjusted common odds ratio measured the likelihood that intraarterial treatment would lead to lower modified Rankin scores, as compared with usual care alone (shift analysis).

RESULTS

We enrolled 500 patients at 16 medical centers in The Netherlands (233 assigned to intraarterial treatment and 267 to usual care alone). The mean age was 65 years (range, 23 to 96), and 445 patients (89.0%) were treated with intravenous alteplase before randomization. Retrievable stents were used in 190 of the 233 patients (81.5%) assigned to intraarterial treatment. The adjusted common odds ratio was 1.67 (95% confidence interval [CI], 1.21 to 2.30). There was an absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate of functional independence (modified Rankin score, 0 to 2) in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage.

CONCLUSIONS

In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation, intraarterial treatment administered within 6 hours after stroke onset was effective and safe. (Funded by the Dutch Heart Foundation and others; MR CLEAN Netherlands Trial Registry number, NTR1804, and Current Controlled Trials number, ISRCTN10888758.).

Use of flow-diverting stents to treat para-anastomotic iliac artery aneurysms after previous open aortic prosthetic reconstruction

PURPOSE

To present a series of para-anastomotic iliac artery aneurysms treated with flow-diverting stents.

CASE REPORTS

Three patients (2 men, 1 woman; ages 70, 73, and 78 years) with previous open aortoiliac reconstructions received a 12-mm-diameter Cardiatis Multilayer Stent to treat 4 para-anastomotic iliac artery aneurysms in an attempt to preserve their ipsilateral hypogastric arteries. After 1-year follow-up, all aneurysms were successfully excluded, with complete sac thrombosis in three and partial thrombosis in one. The diameter of the aneurysm was reduced in all by a median 6 mm. At 1 year, patency of the hypogastric artery was maintained in only the patient with partial sac thrombosis. No patient developed buttock claudication.

CONCLUSION

The use of flow-diverting stents for para-anastomotic iliac artery aneurysms resulted in reduction of iliac aneurysm diameter. However, intended patency of the ipsilateral hypogastric artery was not always observed. The feasibility of the technique has therefore not been shown for this specific indication.

Endovascular Repair of a Streptococcus pneumonia-Induced Aortitis Complicated by an Iliacocaval Fistula

Purpose: To describe the successful endovascular treatment and follow-up of a patient with a Streptococcus pneumonia-induced right iliacocaval fistula. Case report: A 82-year-old man was diagnosed with a right iliacocaval fistula, as a result of Streptoccocus pneumoniae infection of the distal aorta and proximal right common iliac artery. After antibiotic treatment, he was initially unsuccessfully treated with balloon expandable covered stents. Then, the fistula was excluded by an aortamonoiliac endograft to the left common iliac artery, and occluders in the distal and proximal right common iliac artery followed by a femoral–femoral crossover bypass. Postoperatively patient was treated with prolonged antibiotics. After a follow-up of 20 months, there are no signs of active infection, endoleak, or fistula, both clinically and on 2-deoxy-2-[F18]fluoro-d-glucose positron emission tomography/computed tomography. Conclusion: In selected patients, complicated infectious disease of the aorto-iliac tract may be treated successfully with an endograft and prolonged antibiotics.

Endovascular repair of a ruptured type II renal artery aneurysm using an endograft

BACKGROUND

The purpose of this study was to describe a case of an endovascular exclusion of a ruptured type II renal artery aneurysm in a hemodynamically unstable patient using an endograft.

METHODS AND RESULTS

A 73-year-old woman, with an extensive medical history, presented with a sudden onset of abdominal pain and hypovolemic shock. A computed tomography scan showed a massive right-sided retroperitoneal hematoma and a type II aneurysm of the right renal artery just proximal to the bifurcation. Angiography demonstrated active contrast extravasation from the aneurysm. The aneurysm was excluded using a 5-cm long, 6-mm wide endograft. After a 6-month interval, duplex ultrasonography showed a patent endograft and normal perfusion of the renal parenchyma in the lower and middle pole, with a glomerular filtration rate of 75 mL/min.

CONCLUSION

Endovascular exclusion using an endograft may provide a safe and rapid alternative to surgery to treat ruptured renal artery aneurysms in a selected group of patients.

Dutch randomized trial comparing standard catheter-directed thrombolysis versus ultrasound-accelerated thrombolysis for thromboembolic infrainguinal disease (DUET): design and rationale

BACKGROUND

The use of thrombolytic therapy in the treatment of thrombosed infrainguinal native arteries and bypass grafts has increased over the years. Main limitation of this treatment modality, however, is the occurrence of bleeding complications. Low intensity ultrasound (US) has been shown to accelerate enzymatic thrombolysis, thereby reducing therapy time. So far, no randomized trials have investigated the application of US-accelerated thrombolysis in the treatment of thrombosed infra-inguinal native arteries or bypass grafts. The DUET study (Dutch randomized trial comparing standard catheter-directed thrombolysis versus Ultrasound-accElerated Thrombolysis for thrombo-embolic infrainguinal disease) is designed to assess whether US-accelerated thrombolysis will reduce therapy time significantly compared with standard catheter-directed thrombolysis.

METHODS/DESIGN

Sixty adult patients with recently (between 1 and 7 weeks) thrombosed infrainguinal native arteries or bypass grafts with acute limb ischemia class I or IIa, according to the Rutherford classification for acute ischemia, will be randomly allocated to either standard thrombolysis (group A) or US-accelerated thrombolysis (group B). Patients will be recruited from 5 teaching hospitals in the Netherlands during a 2-year period. The primary endpoint is the duration of catheter-directed thrombolysis needed for uninterrupted flow in the thrombosed infrainguinal native artery or bypass graft, with outflow through at least 1 crural artery.

DISCUSSION

The DUET study is a randomized controlled trial that will provide evidence of whether US-accelerated thrombolysis will significantly reduce therapy time in patients with recently thrombosed infrainguinal native arteries or bypass grafts, without an increase in complications.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN72676102.

Central venous catheter related thrombosis in haematology patients and prediction of risk by screening with Doppler-ultrasound

Patients with a central venous catheter (CVC) who receive intensive chemotherapy or a stem cell transplantation for haematological disease are at risk for developing CVC-related thrombosis. To study the incidence of thrombosis, 105 consecutive patients underwent serial Doppler-ultrasound and we evaluated whether clinically manifest thrombosis could be predicted by screening with Doppler-ultrasound. Patients with subclavian or jugular inserted CVCs were clinically assessed each day for signs and symptoms of thrombosis. Additional Doppler-ultrasound screens were performed weekly by an independent physician in all patients until CVC removal. Doppler-ultrasound recordings were assessed by two blinded observers. In cases of clinically suspected thrombosis, the attending physicians followed routine diagnostic and therapeutic procedures. The overall cumulative incidence of CVC-related thrombosis was 28.6% (30 of 105 patients). Of the 30 patients with thrombosis, 26 had subclinical thrombosis by Doppler-ultrasound, nine of whom developed clinically manifest thrombosis later. Four patients had clinically manifest thrombosis without prior abnormal Doppler-ultrasound. In cases of subclinical thrombosis the risk of developing symptomatic disease increased sevenfold (34.6% vs. 5.1%). Doppler-ultrasound screening may be useful to identify those patients that are at high and low risk for clinically manifest CVC-related thrombosis.

Prospective study of renal insufficiency after bone marrow transplantation

Since more and more children survive allogeneic bone marrow transplantation (BMT), knowledge of acute and late complications becomes increasingly important. Besides the major complications [(opportunistic) infections, veno-occlusive disease, graft versus host disease, and recurrence of primary disease], acute and chronic renal insufficiency are significant post-transplant complications that may contribute to transplant-related mortality. To elucidate risk factors for acute and chronic renal insufficiency post BMT, we performed a prospective study of all 66 children who received a BMT in a 2-year period at our institution; 21% had acute renal insufficiency post BMT. Risk factors for acute renal insufficiency were veno-occlusive disease, high cyclosporin serum levels, and foscarnet therapy. Of surviving patients, 11% developed chronic renal insufficiency 1 year post BMT. Acute renal insufficiency was the sole predictor of chronic renal insufficiency. In contrast to studies in adults, we did not find total body irradiation to be a risk factor for chronic renal insufficiency. Future long-term studies are needed to assess incidence and morbidity of chronic renal insufficiency in children following allogeneic BMT.

Delayed pseudoaneurysm after renal artery angioplasty

PURPOSE

To report delayed pseudoaneurysm formation after percutaneous renal artery angioplasty.

CASE REPORTS

A 56-year-old woman succumbed to complications of a ruptured right juxtarenal aortic pseudoaneurysm 2 years after right renal artery stenting for renal impairment. The juxtarenal aorta had been normal on aortography at the time of angioplasty. She gave a history of right-sided back pain that started within 8 months of the angioplasty. A 21-year-old woman with left renal artery stenosis due to fibromuscular dysplasia was treated with balloon angioplasty, after which there was evidence of active extravasation. The completion angiogram, after a period of observation, documented cessation of the leak. Follow-up angiography because of persisting hypertension disclosed a large, asymptomatic, intrarenal pseudoaneurysm that was repaired with bench surgery and autotransplantation.

CONCLUSIONS

We advise that patients with symptoms referable to the site of renal artery intervention and those who have had complicated interventions should have follow-up imaging to exclude pseudoaneurysm formation.