Reasons for Failed Mechanical Thrombectomy in Posterior Circulation Ischemic Stroke Patients

Background and Purpose

To determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation.

Methods

Retrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT.

Results

Patients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups.

Conclusion

Failure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.

Mechanical Thrombectomy with Intraoperative Local Thrombolysis Versus Mechanical Thrombectomy with Continuous Thrombolysis for Treatment of Cerebral Venous Sinus Thrombosis: A Systematic Review of 82 Cases

OBJECTIVE

The first-line treatment of cerebral venous sinus thrombosis (CVST) is systemic anticoagulation. However, patients with severe or a clinically worsening condition might benefit from mechanical thrombectomy (MT) combined with intraoperative thrombolysis (IOT) or MT with continuous thrombolytic infusion (CTI). The present study compared the efficacy and safety of these 2 endovascular therapeutic methods by performing a systematic review of the literature.

METHODS

The present systematic review was conducted to identify all cases of CVST treated with MT+IOT or MT+CTI/MT+IOT+CTI reported in PubMed and Ovid. The recanalization rates, outcomes, operation-related complications, sequelae, and postoperative hemorrhage rates were evaluated.

RESULTS

A total of 28 studies, including 82 patients, met the inclusion criteria. Alone, MT+IOT was performed in 42 patients (51%), and MT+CTI/MT+IOT+CTI was performed in 40 patients (49%). Overall, outcomes data were available for 69 patients, of whom 57 (82%) had had a good outcome and 12 (18%) had had a poor outcome or had died. Recanalization data were available for 68 patients. Of these patients, 28 (41%) had had complete recanalization, 40 (59%) had had partial, and no patient had had no recanalization. Operation-related complications occurred in 5 patients (6%), and 3 patients (4%) developed postoperative intracerebral hemorrhage. However, no significant differences were found in the recanalization rate or prognosis between the MT+IOT and MT+CTI/MT+IOT+CTI groups.

CONCLUSIONS

The results from our review suggest that MT with local thrombolysis is relatively safe, with no significant differences in efficacy and safety between MT+IOT alone and MT+CTI/MT+IOT+CTI. However, randomized controlled studies are required to provide a definitive answer on its use for CVST.

Transjugular local thrombolysis with/without TIPS in patients with acute non-cirrhotic, non-malignant portal vein thrombosis

BACKGROUND & AIMS

Therapeutic anticoagulation is the standard treatment in patients with acute non-cirrhotic portal vein thrombosis (PVT). In critically ill patients, anticoagulation only may not suffice to achive rapid and stable recanalization. This study evaluates efficacy and safety of transjugular interventional therapy in acute non-cirrhotic PVT.

METHODS

This retrospective study includes 17 consecutive patients with acute noncirrhotic, non-malignant PVT. Main indication for interventional therapy was imminent intestinal infarction (n=10). Treatment consisted of a combination of transjugular thrombectomy, local fibrinolysis and - depending on thrombus resolution - transjugular intrahepatic portosystemic shunt.

RESULTS

Recanalization was successful in 94.1%. One- and two-year secondary PV patency rates were 88.2%. Major complications (n=3) resolved spontaneously in all but one patient (heparin induced thrombocytopenia type 2 with intestinal infarction). Symptoms improved in all patients. However, segmental bowel resection had to be performed in two (11.8%). During a median follow-up of 28.6 months, no patient experienced portal hypertensive complications. Presence of JAK2 V617F mutation predicted both short-term and long-term technical success.

CONCLUSIONS

Transjugular recanalization is safe and effective in patients with acute non-cirrhotic, non-malignant PVT. It should be considered especially in patients with imminent bowel infarction and low likelihood of recanalization following therapeutic anticoagulation. Patients with JAK2 mutation ought to be followed meticulously.