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PubMed2002

Nonocclusion and spontaneous recanalization rates in acute ischemic stroke: a review of cerebral angiography studies.

BACKGROUND: Spontaneous recanalization is an understudied phenomenon in stroke. It is often overestimated by nonocclusion rates. The heterogeneity of the causes and manifestations of stroke and of the studies assessing vascular patency has created difficulties in assigning accurate rates of its incidence. METHODS: Systematic review of published articles about cerebral angiography in stroke. RESULTS: Lack of anticipated occlusions (nonocclusion rates) was noted in 28% of patients in suspected vessels 6 hours after stroke onset, whereas documented occlusions were noted in 17% of patients who underwent spontaneous lysis at 6 to 8 hours. At 3 to 4 days, the nonocclusion rate was 50% of studied vessels. CONCLUSIONS: In the first 6 to 8 hours from stroke onset, spontaneous recanalization occurs in approximately 17% of patients, whereas nonocclusion exists in about 28% of patients and up to 50% by 4 days after stroke.

Acute Disease↗

PubMed2004

Factors affecting the angiographic recanalization and early clinical improvement in middle cerebral artery territory infarction after thrombolysis.

BACKGROUND: Factors affecting the angiographic recanalization (AR) and clinical improvement (CI) still remain unclear in patients receiving thrombolytic therapy. OBJECTIVES: To elucidate factors related to AR and early CI in patients with middle cerebral artery (MCA) or internal carotid artery (ICA) occlusion. DESIGNS: Retrospective study. SETTING: Department of Neurology, Asan Medical Center, Seoul, South Korea. PATIENTS: We studied 42 patients who (1) underwent diffusion-weighted magnetic resonance (MR) imaging and MR angiography within 6 hours after onset, (2) had MCA territory infarction, (3) had nonvisualization of the MCA or the ICA on initial MR angiography, (4) were treated with thrombolytics, and (5) underwent follow-up MR imaging and MR angiography at day 2 or 3. RESULTS: Successful AR and CI were achieved in 31 and 16 patients, respectively. Angiographic recanalization was related to CI (P<.01), lower follow-up National Institutes of Health Stroke Scale scores (P<.05), the absence of a dominant ipsilateral posterior cerebral artery (P<.01) on initial MR angiography, and the sparing of the internal capsule on both initial (P<.05) and follow-up (P<.01) MR imaging. Clinical improvement was associated with the absence of ICA (vs MCA) flow signals (P<.05), the sparing of the internal capsule (P<.01), and marginally, with the infarct volume change (P = .06). CONCLUSIONS: In patients with MCA or ICA occlusion, CI after thrombolysis is related to the AR and the sparing of the critical motor pathway. The presence of a dominant ipsilateral posterior cerebral artery may predict poor AR after thrombolysis.

Aged↗

PubMed1981

Percutaneous transluminal recanalization of complete iliac artery occlusions.

Percutaneous transluminal recanalization of ten complete iliac artery occlusions were attempted using the Grüntzig balloon catheter. The procedure was successful in eight of the ten occlusions, including all seven in which only one of the common or external iliac arteries was obstructed. Follow-up for periods of three to 13 months (average, eight months) showed continued patency in all cases. Although the long-term results remain to be determined, our preliminary results suggest that transluminal recanalization of complete obstruction of the iliac arteries is an alternative to surgery.

Aged↗

PubMed1998

Crosswire for recanalization of total occlusive coronary arteries.

Coronary angioplasty of total occlusions is technically difficult and is associated with limited success rates. The procedural outcome is mainly determined by the underlying pathological process. Recanalization of total occlusions is aimed at finding the passage with least resistance, without causing dissection or perforation. Several techniques have been advocated to improve the overall success rate. Recently, a new 0.014" Nitinol wire (Crosswire, Terumo) has been introduced as a tool, to achieve higher success rates for total occlusion angioplasty. The wire consists of an extremely flexible Nitinol-core, a platinum/iridium coil at the distal tip, and a hydrophilic polymer coating. Balloon angioplasty was attempted in 30 totally occluded coronary arteries with mean age of occlusion being 5 +/- 4 months (range 2-14 months). The initial five procedures were performed following failure of the conventional angioplasty guidewires. Subsequently, Cross-wire was used electively in all the cases. The lesion was crossed successfully in 90% (27/30) cases. Dissection of the coronary artery with subintimal entry was seen in two (7%) cases, and the rest (three cases) could not be crossed. Balloon angioplasty and stenting (n = 21) were performed with good immediate angiographic results. There were no myocardial infarctions or deaths. Fourteen of 16 patients, who had completed 6 months follow-up, were asymptomatic. Angiographic evidence of in-stent restenosis was demonstrable in one case. Successful recanalization of total coronary occlusions by using Cross-wire can be expected in 83% cases, with reasonable safety.

Adult↗

PubMed1999

Adjunctive abciximab improves outcomes during recanalization of totally occluded saphenous vein grafts using transluminal extraction atherectomy.

Degenerative disease of aortocoronary saphenous vein grafts is a major cause of late morbidity and mortality in patients after coronary bypass surgery. We previously described a technique for recanalization of totally occluded grafts using extraction atherectomy (TEC) as a primary modality. While success was comparable to overnight urokinase, distal embolization, no-reflow, and non-Q myocardial infarction were common. Recently, abciximab has been used adjunctively in angioplasty and stenting with a reduced incidence of periprocedural complications. In order to determine whether abciximab can reduce the incidence of distal embolization, no-reflow, and myocardial infarction during TEC in totally occluded saphenous vein grafts, we compared patients treated with adjunctive abciximab with control subjects not receiving the drug. Male patients with previous coronary bypass surgery, class III-IV angina, and totally occluded saphenous vein grafts serving a vascular territory with ischemia not approachable by standard catheter-based techniques underwent TEC with or without adjunctive abciximab. Recanalization of the graft was achieved in 8/10 (80%) of subjects without abciximab, but complete success was achieved in only 5/10 (50%). In contrast, all procedures in the abciximab group were completely successful, without embolization or no-reflow. Our results suggest that TEC with adjunctive abciximab may be a highly effective approach for management of totally occluded saphenous vein grafts.

Abciximab↗

PubMed2000

Initial experience with a hydrophilic-coated guidewire for recanalization of chronic coronary occlusions.

Chronic coronary occlusions are still a therapeutic challenge to the interventional cardiologist. New techniques such as laser wire have improved recanalization rates, but outcomes are still far from satisfactory. We report the results of a nonrandomized single-center investigation using a hydrophilic-coated guidewire (Terumo Crosswire). Between September 1996 and September 1998, 107 chronic occlusions in 106 patients were approached when previous attempts with conventional guidewires failed. Median occlusion duration in these cases was 4 months (range, 0.5-122); mean occlusion length was 19 +/- 11 mm (range, 5-60). Forty-five (42%) of these attempts were successful. Attempts were successful in 42% in the left anterior descending artery, in 30% in the left circumflex artery, in 48% in the right coronary artery, and in 43% in coronary artery bypass grafts. Success rates ranged from 56% for occlusions of less than 4-month duration to 18% for occlusions of more than 36-month duration. The success rate in TIMI 1-flow lesions was significantly higher than in TIMI 0 flow lesions, 85% vs. 36%. In a multivariate regression analysis, TIMI flow grade and occlusion age were independent predictors of success. There were no deaths or Q-wave myocardial infarctions; two cases of hemopericardium were treated successfully. In five cases, pericardial contrast staining due to vessel perforation occurred. Our results indicate that the Crosswire is an effective tool in the treatment of chronic coronary occlusions, even when recanalization attempts with conventional guidewires fail. Cathet. Cardiovasc. Intervent. 49:45-50, 2000.

Adult↗

PubMed1991

New option for balloon recanalization of total coronary occlusions.

In 9 out of 12 patients with a total coronary occlusion but definite signs of viable myocardium a new approach for the recanalization procedure was successfully employed: Following recanalization using an on-the-wire 2.0 or 2.5 mm angioplasty catheter, a standard coronary guidewire was placed along the angioplasty catheter. After withdrawal of the catheter, over-the-wire angioplasty with an appropriately sized balloon was performed for final dilatation. Pending further studies in a larger patient population, this new method may offer an alternative approach for revascularization of total coronary occlusions.

Aged↗

PubMed1995

Recanalization of totally occluded saphenous vein grafts using local urokinase delivery with the Dispatch catheter.

Current techniques for the percutaneous revascularization of totally occluded vein grafts are limited by a low initial success rate, a significant incidence of distal embolization, and a high rate of early graft reclosure. This case report describes two patients in whom graft recanalization was attempted with the combined use of balloon angioplasty/intra-graft stent placement and local urokinase delivery using a new angiotherapy catheter. Successful recanalization was achieved in both patients without major complications, in spite of a large thrombus burden as demonstrated by angiography.

Angioplasty, Balloon, Coronary↗

PubMed2004

Improved recanalization of chronic total coronary occlusions using an optical coherence reflectometry-guided guidewire.

Successful percutaneous therapy of chronic total occlusions is limited predominantly by the inability to cross the lesion. We report our experience of 29 chronic total occlusions (CTOs) that could not be crossed with conventional wires and subsequently underwent attempted recanalization facilitated using a wire navigated with optical coherence reflectometry. Mean length of occlusion was 22.1 mm (range, 4.5-88.7 mm). Successful recanalization was achieved in a further 15 (51.7%), with no complications of tamponade, myocardial infarction, or death. These results demonstrate that this wire can be a useful tool in addition to conventional wires in the treatment of CTO.

Aged↗

PubMed2006

Controlled blunt microdissection for percutaneous recanalization of lower limb arterial chronic total occlusions: a single center experience.

BACKGROUND: Percutaneous techniques for the revascularization of symptomatic lower limb arterial chronic total occlusions (CTOs) remain suboptimal due to difficulty in safely and reliably crossing these heavily calcified lesions using standard guidewire and balloon technology. OBJECTIVES: The objective of this prospective study was to evaluate the technical success and safety of controlled blunt microdissection (CMD) for the treatment of resistant peripheral CTOs. METHODS: This series enrolled 36 patients (26 men; mean age 67 +/- 12 years), with 44 symptomatic CTOs (2 terminal aortic, 24 iliac, 16 femoral, and 2 popliteal), which had previously failed conventional percutaneous revascularization. CMD was carried out using a specialized prototype catheter. Actuation of the hinged jaws of this CMD catheter created a channel within the occluded arterial segment for guidewire passage, and subsequent angioplasty and stenting using standard procedures. The problem of subintimal CMD catheter passage, creating an eccentric channel, was addressed using a second novel device, the true-lumen reentry (LRE) catheter, which allowed reentry into the downstream lumen. RESULTS: Procedural success, evaluated angiographically, was achieved in 40 (91%) of the 44 CTOs. Fourteen (35%) of these 40 successful recanalizations required guidewire redirection, using the LRE catheter for lesion traversal. There were no complications related to CMD per se; although one patient experienced acute in-stent thrombosis, managed successfully with intra-arterial thrombolysis. CONCLUSIONS: We therefore conclude that CMD can be used safely and successfully to facilitate recanalization of resistant CTOs in the pelvic and lower limb arteries.

Aged↗

PubMed1986

Mechanical emergency recanalization of the left main coronary artery.

Acute occlusion of the left main coronary artery is normally fatal. According to the literature, only a few cases have been treated by intracoronary thrombolysis; the prolonged period of ischemia, however, resulted in severe left ventricular dysfunction and numerous complications. Therefore, effort should be directed to recanalize the left main coronary artery within the shortest possible interval. We followed this approach in a case of acute occlusion of a subtotal stenosis of the left main coronary artery which could be mechanically reopened and dilated within a few minutes. The intervention resulted in immediate reversal of profound cardiogenic shock and complete restoration of normal left ventricular function. At hospital discharge, the patient was asymptomatic with a negative bicycle stress test. Immediate mechanical recanalization and angioplasty appear to be a feasible approach in life-threatening coronary occlusion.

Aged↗

PubMed1986

Argon laser recanalization of three totally occluded human right coronary arteries.

We report the successful recanalization, in vivo, of three totally occluded human right coronary arteries with an argon laser catheter during coronary artery bypass surgery. The laser catheter and technique of laser recanalization are described. At 15 days postoperatively, two of the laser-treated arteries were reoccluded angiographically. The third patient refused postoperative angiography.

Cardiac Catheterization↗

PubMed1993

Coronary artery rupture during transluminal coronary recanalization and angioplasty in a case of acute myocardial infarction and shock.

Percutaneous transluminal coronary angioplasty (PTCA) is a widely performed and effective therapy for coronary artery disease. Evolution of the dilatation instruments during the last decade has led to an increased success rate of PTCA and to the development of newer techniques such as recanalization of totally occluded coronary arteries. We report a case of coronary artery recanalization complicated by fatal coronary artery rupture.

Aged↗

PubMed1996

Peripheral artery recanalization in humans using balloon and laser angioplasty.

The treatment of patients with complex peripheral arterial disease and those who have had previous unsuccessful attempted revascularization procedures can be clinically challenging. Initial treatment was begun using therapy by percutaneous balloon and laser angioplasty, then proceeding to bypass surgery if severe ischemia persisted. Both percutaneous and cut-down approaches were used to access totally occluded arteries. An attempt was made to cross the occlusion mechanically with either a guide wire or an activated laser probe. If laser recanalization was not successful, the patient underwent bypass surgery or was managed with medication unless an amputation was necessary. Following initial screening of 381 patients, 115 procedures were performed on 103 patients. In 31 procedures (28 patients), only balloon angioplasty was performed. In 84 procedures (75 patients), laser recanalization was attempted: 55 percutaneously and 29 by cut-down. Overall technical success (crossing the obstruction without perforation) was 86/115 (75%). Technically successful procedures were characterized by shorter arterial occlusions than were technical failures (8.4 +/- 1 cm vs. 14.3 +/- 1.9 cm; p < 0.004). Clinical success (residual stenosis < 50%, symptom relief, improved ankle brachial index > or = 0.15, and no complications) was achieved in 22/31 (71%) of balloon angioplasty procedures alone. The stenoses decreased from 98 +/- 4% to 31 +/- 24%, p < 0.00001. Combined percutaneous laser and balloon angioplasty had a technical success of 36/55 (65%). Stenoses were reduced from 99 +/- 2% to 56 +/- 14% after laser angioplasty, to 30 +/- 15% after balloon angioplasty, p < 0.0001. Laser angioplasty performed via a cut-down had a clinical success of 9/29 (31%). However, major complications were rare. Device staging for treatment of peripheral vascular disease provides additional options for patients who are at high surgical risk and/or in whom standard therapy has failed.

Adult↗

PubMed1985

Complete patency in thrombus-occluded arteries two weeks after laser recanalization.

The potential problem of rethrombosis after laser recanalization was studied in 16 thrombus-occluded canine femoral arteries. Balloon de-endothelialization and thrombin-human blood injection produced adherent, completely occlusive thrombi 4.13 +/- 1.54 cm in length; laser exposure of the thrombi occurred at 18.35 +/- 22.1 hours. The argon laser catheter was introduced via a proximal arteriotomy and a power of 3.83 +/- 0.58 W delivered for 411.3 +/- 296.87 seconds. Follow-up period was 14 days. All arteries were patent immediately after and 14 days following lasing, as demonstrated by angiography. There was no vessel perforation. Seven of the dogs were maintained on aspirin and dipyridamole 4 days before and throughout the study, but there were no differences in thrombus length, laser power, or duration of laser exposure between these dogs and those receiving no anti-platelet therapy. Control thrombosed arteries (without laser energy application) showed no autolysis within 14 days in all dogs and up to 95 days in three dogs followed for this period of time. These data show that rethrombosis of totally occluded, thrombosed arteries is not present up to 2 weeks later after laser recanalization, with or without the aid of anti-platelet therapy.

Animals↗

PubMed1988

Histopathology of human laser thermal angioplasty recanalization.

Laserprobe thermal-assisted balloon, angioplasty (LTBA) has demonstrated promising initial clinical results in recanalizing stenotic or occluded superficial femoral and popliteal arteries. Over the past year we have obtained six specimens of laserprobe thermal (LT) and LTBA treated total occlusions (avg. length 12 cm) for histopathologic examination from patients who were treated for limb salvage. Three tissue specimens were obtained acutely, and one was obtained at 6, 8, and 13 days, respectively, after laser angioplasty at the time of revision for complications or failed procedures. Serial histologic sections of the treated LT segments demonstrated recanalization of atherosclerotic lesions to approximately 60-70% of the probe diameter. The LT channels were lined by a thin layer of carbonized or coagulated tissue and several layers of cell necrosis. The histology of the thermal injury was similar regardless of whether it was produced by the heated metal cap or by free argon laser energy. Stellate balloon angioplasty fractures were frequently filled with thrombus. Analysis of these human LT and LTBA specimens revealed that the thermal device produces a confined injury through the path of least resistance. Balloon dilatation produces fragmented cracks in the vessel wall, which appear to be more thrombogenic than the carbonized LT surface. With improved guidance methods, LTBA shows potential for continuing development.

Aged↗

PubMed1992

Intravascular ultrasound guided holmium:YAG laser recanalization of occluded arteries.

Current angioplasty devices are limited by arterial wall dissection and perforation, and by early recurrence from inadequate debulking of lesions. This study evaluated intravascular ultrasound (IVUS) as guidance for concentric laser recanalization of arterial occlusions. Twelve, 2-4-cm-long canine iliac artery occlusions were treated at 2 weeks (organizing thrombus) to 12 weeks (firm fibrous lesions) using a Holmium:YAG laser (2,100 nm wavelength) in free running mode, FRM, (250 musec pulse, 5 Hz), n = 9; and Q-switched mode, QSM (200 ns pulse, 6 Hz), n = 3. A 200 microns (n = 2) or 600 microns (n = 10) optic fiber was centered in the artery coaxial to a 5Fr rotating A scan IVUS probe. The fiber was positioned in the center of the artery distal to the lesion and slowly advanced through the obstruction. In 8 occlusions the same fiber was used as a guidewire for passage of either a 1.6-mm-(n = 2) and/or 3.0-mm (n = 6) diameter multifiber catheter (19 x 100 and 19 x 200 microns fibers, respectively) using FRM energy to further debulk the lesion. In all cases, IVUS guidance enabled concentric initial recanalization of occlusions, although 3 vessel perforations resulted from fiber deviation off the center of the lumen at a distance of 2 to 4 cm from the IVUS imaging element. Both QSM and FRM modes ablated tissue, with FRM modes producing more tissue fragmentation and thermal effect. IVUS images accurately diagnosed the location of lesions compared to angioscopic views and pathologic analysis of the specimens.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Laser↗

PubMed1978

Infarction and circulation in cerebrum. Effect of recanalization and/or collateral circulation on the lesion and prognosis.

Findings of computed tomography (CT) and angiography in supratentorial cerebral infarction associated with complete stroke were compared with regard to prognosis. It was found that the extent of low-density areas on CT was perfectly in accordance with the areas of occluded arteries on angiograms. However, the low-density areas on CT were always smaller than the areas involved angiographically when early recanalization and/or collateral circulation were carried out within 2 to 3 days of onset. It was also found that smaller low-density areas only had favorable effect. We concluded that the prognosis was better with early recanalization and/or collateral circulation, despite the general acceptance of its poor prognostic implication.

Adult↗