RESUMEN
BACKGROUND: Patients with atrial fibrillation are frequently nonadherent to oral anticoagulants (OACs) prescribed for stroke and systemic embolism (SSE) prevention. We quantified the relationship between OAC adherence and atrial fibrillation clinical outcomes using methods not previously applied to this problem. METHODS AND RESULTS: Retrospective observational cohort study of incident cases of atrial fibrillation from population-based administrative data over 23 years. The exposure of interest was proportion of days covered during 90 days before an event or end of follow-up. Cox proportional hazard models were used to evaluate time to first SSE and the composite of SSE, transient ischemic attack, or death and several secondary outcomes. A total of 44 172 patients were included with median follow-up of 6.7 years. For direct OACs (DOACs), each 10% decrease in adherence was associated with a 14% increased hazard of SSE and 5% increased hazard of SSE, transient ischemic attack, or death. For vitamin K antagonist (VKA) the corresponding increase in SSE hazard was 3%. Receiving DOAC or VKA was associated with primary outcome hazard reduction across most the proportion of days covered spectrum. Differences between VKA and DOAC were statistically significant for all efficacy outcomes and at most adherence levels. CONCLUSIONS: Even small reductions in OAC adherence in patients with atrial fibrillation were associated with significant increases in risk of stroke, with greater magnitudes for DOAC than VKA. DOAC recipients may be more vulnerable than VKA recipients to increased risk of stroke and death even with small reductions in adherence. The worsening efficacy outcomes associated with decreasing adherence occurred without the benefit of major bleeding reduction.
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Anticoagulantes , Fibrilación Atrial , Cumplimiento de la Medicación , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Masculino , Femenino , Estudios Retrospectivos , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Anciano , Cumplimiento de la Medicación/estadística & datos numéricos , Administración Oral , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Persona de Mediana Edad , Factores de Tiempo , Anciano de 80 o más Años , Resultado del Tratamiento , Embolia/prevención & control , Embolia/epidemiología , Embolia/etiología , Factores de Riesgo , Ataque Isquémico Transitorio/epidemiología , Ataque Isquémico Transitorio/prevención & controlRESUMEN
The management of embolic acute limb ischaemia commonly involves determining aetiology and performing emergency invasive procedures. This detailed study aimed to determine the impact of manipulation of anticoagulation in the aetiology of emboli in acute limb ischaemia and determine the efficacy of primary anticoagulation therapy vs. invasive interventions. Material and methods: Data collection was conducted at a single institution on a cohort of patients presenting consecutively with embolic acute limb ischaemia over one year. Two groups were compared, one receiving anticoagulation as primary therapy with those undergoing invasive treatment as the internal comparison group. Results: A likely haematological causation was identified in 22 of 38 presentations, related to interruption of anticoagulation in cardiac conditions, the majority atrial fibrillation (n=12), or hypercoagulable states (n=10). Limb salvage was pursued in 36 patients employing anticoagulation (n=19) or surgical embolectomy (n=17) as the primary therapy in upper and lower limbs (n=17 vs n=19 respectively). Despite delays often well beyond six hours and a range of ischaemic severity in both groups, 35 of 36 patients achieved full or substantive restoration of function with improved perfusion. Regarding anatomical distribution of arterial disease and therapy, three patients with multi-level disease proceeded to embolectomy following anticoagulation. Embolectomy was undertaken most often for proximal emboli and more profound paralysis. Conclusions: Anticoagulation and coagulopathy are commonly implicated in the aetiology of arterial emboli, with omission of effective anticoagulation in atrial fibrillation being associated in almost 1/3 of presentations. Whilst more profound limb paralysis and proximal or multi-level disease tended to be managed surgically, primary anticoagulation therapy alone or with a secondary embolectomy was effective across the spectrum of ischaemia severity and despite significant delays beyond guideline recommendations.
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Anticoagulantes , Embolectomía , Embolia , Isquemia , Recuperación del Miembro , Humanos , Anticoagulantes/uso terapéutico , Anticoagulantes/efectos adversos , Femenino , Masculino , Anciano , Embolectomía/efectos adversos , Isquemia/tratamiento farmacológico , Isquemia/diagnóstico , Resultado del Tratamiento , Embolia/etiología , Embolia/prevención & control , Embolia/diagnóstico , Enfermedad Aguda , Persona de Mediana Edad , Anciano de 80 o más Años , Factores de Tiempo , Factores de Riesgo , Estudios Retrospectivos , Enfermedad Arterial Periférica/tratamiento farmacológico , Enfermedad Arterial Periférica/diagnóstico , Recuperación de la FunciónAsunto(s)
Embolia , Humanos , Resultado del Tratamiento , Embolia/etiología , Embolia/diagnóstico por imagen , Embolia/terapia , Masculino , Cianoacrilatos/administración & dosificación , Cianoacrilatos/efectos adversos , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/efectos adversos , Anciano , Femenino , Adhesivos Tisulares , Persona de Mediana EdadRESUMEN
There is insufficient data on systemic embolic events (SSEs) in patients with ischemic left ventricular aneurysm (LVA) concerning the impact of anticoagulation therapy. In this retrospective cohort study with 1043 patients with ischemic LVA, SSEs occurred in 7.2% over 2.4 years. After adjusting for relevant factors, the use of anticoagulants was independently associated with a lower incidence of SSE (3.1% vs. 9.0%, P < 0.001; subdistribution hazard ratios (SHR) 0.21, 95% confidence intervals (CI) 0.10-0.44, P < 0.001), with no significant difference in net adverse clinical events (NACEs) (10.6% vs. 13.3%, P = 0.225). Specifically, anticoagulation in patients with apical segment akinesis significantly reduced SSEs (3.9% vs. 13.6%, P = 0.002) and NACE rates (7.8% vs. 19.4%, P = 0.002). Major bleeding rates did not significantly differ between groups (5.6% vs. 3.5%, P = 0.111). These findings highlight the SSE risk in ischemic LVA and suggest potential benefits of anticoagulation, particularly in those with apical segment akinesis. These findings need to be validated in independent datasets.
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Anticoagulantes , Aneurisma Cardíaco , Humanos , Estudios Retrospectivos , Anticoagulantes/uso terapéutico , Masculino , Femenino , Anciano , Persona de Mediana Edad , Pronóstico , Aneurisma Cardíaco/tratamiento farmacológico , Aneurisma Cardíaco/epidemiología , Ventrículos Cardíacos/patología , Ventrículos Cardíacos/efectos de los fármacos , Ventrículos Cardíacos/fisiopatología , Isquemia Miocárdica/tratamiento farmacológico , Isquemia Miocárdica/epidemiología , Factores de Riesgo , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Embolia/epidemiología , Embolia/tratamiento farmacológicoRESUMEN
BACKGROUND: Patients with atrial fibrillation and severe chronic kidney disease have higher risks of bleeding, thromboembolism, and mortality. However, optimal anticoagulant choice in these high-risk patients remains unclear. METHODS AND RESULTS: Using deidentified electronic health records from the Optum Labs Data Warehouse, adults with atrial fibrillation and severe chronic kidney disease (estimated glomerular filtration rate <30 mL/min per 1.73 m2) initiating warfarin, apixaban, or rivaroxaban between 2011 and 2021 were included. Using inverse probability of treatment weighting, adjusted risks of major bleeding, stroke/systemic embolism, and death were compared among agents. A total of 6794 patients were included (mean age, 78.5 years; mean estimated glomerular filtration rate, 24.7 mL/min per 1.73 m2; 51% women). Apixaban versus warfarin was associated with a lower risk of major bleeding (incidence rate, 1.5 versus 2.9 per 100 person-years; subdistribution hazard ratio [sub-HR], 0.53 [95% CI, 0.39-0.70]), and similar risks for stroke/systemic embolism (incidence rate, 1.9 versus 2.4 per 100 person-years; sub-HR, 0.80 [95% CI, 0.59-1.09]) and death (incidence rate, 4.6 versus 4.5 per 100 person-years; HR, 1.03 [95% CI, 0.82-1.29]). Rivaroxaban versus warfarin was associated with a higher risk of major bleeding (incidence rate, 4.9 versus 2.9 per 100 person-years; sub-HR, 1.65 [95% CI, 1.10-2.48]), with no difference in risks for stroke/systemic embolism and death. Apixaban versus rivaroxaban was associated with a lower risk of major bleeding (sub-HR, 0.53 [95% CI, 0.36-0.78]). CONCLUSIONS: These real-world findings are consistent with potential safety advantages of apixaban over warfarin and rivaroxaban for patients with atrial fibrillation and severe chronic kidney disease. Further randomized trials comparing individual oral anticoagulants are warranted.
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Anticoagulantes , Fibrilación Atrial , Embolia , Hemorragia , Pirazoles , Piridonas , Insuficiencia Renal Crónica , Rivaroxabán , Accidente Cerebrovascular , Warfarina , Humanos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/mortalidad , Femenino , Masculino , Anciano , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/mortalidad , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Warfarina/efectos adversos , Warfarina/uso terapéutico , Rivaroxabán/efectos adversos , Rivaroxabán/uso terapéutico , Rivaroxabán/administración & dosificación , Embolia/prevención & control , Embolia/epidemiología , Embolia/etiología , Pirazoles/efectos adversos , Pirazoles/uso terapéutico , Piridonas/efectos adversos , Piridonas/uso terapéutico , Piridonas/administración & dosificación , Administración Oral , Medición de Riesgo , Anciano de 80 o más Años , Factores de Riesgo , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Incidencia , Inhibidores del Factor Xa/efectos adversos , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/administración & dosificaciónRESUMEN
Multivalvular endocarditis is a rare and potentially fatal complication that can occur in people who inject drugs. Currently, there are few cases that have been studied or reported in literature. A complication of this manifestation that worsens prognosis and treatment is the distribution of septic emboli throughout the body which highlights the dissemination of the infection. There are no specific guidelines on the treatment of multivalvular endocarditis, but its complexity can present challenges in administering medical and surgical treatment. In this case of a 37-year-old man with infective endocarditis of 3 valves, a comprehensive work-up found septic emboli in the lungs, kidneys, ribs, spine, and brain with ophthalmologic involvement that resulted in visual impairment. This case highlights important complications that can occur with septic emboli and management of these issues using a multidisciplinary approach including the treatment of substance use disorder.
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Endocarditis Bacteriana , Infecciones Estafilocócicas , Staphylococcus aureus , Humanos , Masculino , Adulto , Infecciones Estafilocócicas/tratamiento farmacológico , Endocarditis Bacteriana/tratamiento farmacológico , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/complicaciones , Staphylococcus aureus/aislamiento & purificación , Antibacterianos/uso terapéutico , Abuso de Sustancias por Vía Intravenosa/complicaciones , Embolia/etiologíaAsunto(s)
Prótesis Valvulares Cardíacas , Corazón Auxiliar , Humanos , Resultado del Tratamiento , Cateterismo Cardíaco/instrumentación , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Masculino , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Embolia/etiología , Embolia/diagnóstico por imagen , Embolia/terapia , Migración de Cuerpo Extraño/etiología , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/terapia , Anciano , Femenino , EmbolectomíaRESUMEN
PURPOSE: Acute ischemic stroke is a leading cause of death and morbidity worldwide. Despite advances in medical technology, nearly 30% of strokes result in incomplete vessel recanalization. Recent studies have demonstrated that clot composition correlates with success rates of mechanical thrombectomy procedures. To understand clot behavior during thrombectomy, which exerts considerable strains on thrombi, in vitro studies must characterize the rate-dependent high-strain behavior of embolus analogs (EAs) with different formation conditions, which can be used to fit models of hyper-viscoelasticity. METHODS: In this study, the effect of collagen infiltration as a carotid-induced collagen-rich thrombosis surrogate is considered as a contributor to embolus analog high-strain stiffness, when compared to 40% hematocrit EAs. RESULTS: EA high-strain stiffnesses, characterized on a uniaxial load frame, increase by an order of magnitude for collagenous clot analogs. Chandler loop analogs show high-strain stiffnesses and clot compositions commensurate with previous reports of stroke patient clots, and collagenous clots show significant increase in stiffness when compared to stroke patient clots. Finally, hyper-viscoelastic curve fitting demonstrates the asymmetry between tension and compression. Nonlinear, rate-dependent models that consider clot-stiffening behavior match the high strain stiffness of clots fairly well. Furthermore, we demonstrate that the stability of the elastic energy needs to be considered to obtain optimal curve fits for high-strain, rate dependent data. CONCLUSION: This study provides a framework for the development of dynamically formed EAs that mimic the mechanical and structural properties of in vivo clots and provides parameters for numerical simulation of clot behavior with hyper-viscoelastic models.
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Colágeno , Elasticidad , Embolia , Accidente Cerebrovascular Isquémico , Colágeno/química , Accidente Cerebrovascular Isquémico/fisiopatología , Viscosidad , Estrés Mecánico , Animales , Ensayo de Materiales , Fenómenos Biomecánicos , TrombosisRESUMEN
Ballistic embolism represents an unusual complication of vascular by a flying object injury. Because embolus is remote from injury site, the occurrence of missile embolus may be overlooked and lead to delay in diagnosis of significant ischemia or embolism. We herein report a successful surgical removal of a rare missile embolus from the upper arm in the right ventricle. A 44-year-old man visited our hospital because of pulsatile bleeding from the left upper arm due to injury by a flying metal fragment of a hammerhead. Chest roentgenogram and computed tomography (CT) scan 9 days after the injury demonstrated a missile embolus in the right ventricle, which was thought to be ballistic embolism of the metal fragment. We underwent surgical removal of the retained object under cardiopulmonary bypass uneventfully, and discharged home ten days later.
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Embolia , Ventrículos Cardíacos , Humanos , Masculino , Adulto , Ventrículos Cardíacos/cirugía , Ventrículos Cardíacos/diagnóstico por imagen , Embolia/cirugía , Embolia/diagnóstico por imagen , Embolia/etiología , Tomografía Computarizada por Rayos X , Cuerpos Extraños/cirugía , Cuerpos Extraños/complicaciones , Cuerpos Extraños/diagnóstico por imagenRESUMEN
Objective: Photoelectric volumetric tracing (PPG) exhibits high sensitivity and specificity in flap monitoring. Deep learning (DL) is capable of automatically and robustly extracting features from raw data. In this study, we propose combining PPG with 1D convolutional neural networks (1D-CNN) to preliminarily explore the method's ability to distinguish the degree of embolism and to localize the embolic site in skin flap arteries. Methods: Data were collected under normal conditions and various embolic scenarios by creating vascular emboli in a dermatome artery model and a rabbit dermatome model. These datasets were then trained, validated, and tested using 1D-CNN. Results: As the degree of arterial embolization increased, the PPG amplitude upstream of the embolization site progressively increased, while the downstream amplitude progressively decreased, and the gap between the upstream and downstream amplitudes at the embolization site progressively widened. 1D-CNN was evaluated in the skin flap arterial model and rabbit skin flap model, achieving average accuracies of 98.36% and 95.90%, respectively. Conclusion: The combined monitoring approach of DL and PPG can effectively identify the degree of embolism and locate the embolic site within the skin flap artery.
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Aprendizaje Profundo , Fotopletismografía , Colgajos Quirúrgicos , Conejos , Animales , Colgajos Quirúrgicos/irrigación sanguínea , Redes Neurales de la Computación , Monitoreo Fisiológico , Periodo Posoperatorio , EmboliaRESUMEN
BACKGROUND: Apixaban, rivaroxaban, and warfarin have shown benefit for preventing major ischemic events, albeit with increased bleeding risk, among patients in the general population with atrial fibrillation (AF). However, data are scarce in patients with cirrhosis and AF. OBJECTIVE: To compare the effectiveness and safety of apixaban versus rivaroxaban and versus warfarin in patients with cirrhosis and AF. DESIGN: Population-based cohort study. SETTING: Two U.S. claims data sets (Medicare and Optum's de-identified Clinformatics Data Mart Database [2013 to 2022]). PARTICIPANTS: 1:1 propensity score (PS)-matched patients with cirrhosis and nonvalvular AF initiating use of apixaban, rivaroxaban, or warfarin. MEASUREMENTS: Primary outcomes included ischemic stroke or systemic embolism and major hemorrhage (intracranial hemorrhage or major gastrointestinal bleeding). Database-specific and pooled PS-matched rate differences (RDs) per 1000 person-years (PY) and Cox proportional hazard ratios (HRs) with 95% CIs were estimated, controlling for 104 preexposure covariates. RESULTS: Rivaroxaban initiators had significantly higher rates of major hemorrhagic events than apixaban initiators (RD, 33.1 per 1000 PY [95% CI, 12.9 to 53.2 per 1000 PY]; HR, 1.47 [CI, 1.11 to 1.94]) but no significant differences in rates of ischemic events or death. Consistently higher rates of major hemorrhage were found with rivaroxaban across subgroup and sensitivity analyses. Warfarin initiators also had significantly higher rates of major hemorrhage than apixaban initiators (RD, 26.1 per 1000 PY [CI, 6.8 to 45.3 per 1000 PY]; HR, 1.38 [CI, 1.03 to 1.84]), particularly hemorrhagic stroke (RD, 9.7 per 1000 PY [CI, 2.2 to 17.2 per 1000 PY]; HR, 2.85 [CI, 1.24 to 6.59]). LIMITATION: Nonrandomized treatment selection. CONCLUSION: Among patients with cirrhosis and nonvalvular AF, initiators of rivaroxaban versus apixaban had significantly higher rates of major hemorrhage and similar rates of ischemic events and death. Initiation of warfarin versus apixaban also contributed to significantly higher rates of major hemorrhagic events, including hemorrhagic stroke. PRIMARY FUNDING SOURCE: National Institutes of Health.
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Anticoagulantes , Fibrilación Atrial , Inhibidores del Factor Xa , Hemorragia , Cirrosis Hepática , Pirazoles , Piridonas , Rivaroxabán , Warfarina , Humanos , Warfarina/efectos adversos , Warfarina/uso terapéutico , Piridonas/efectos adversos , Piridonas/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Rivaroxabán/efectos adversos , Rivaroxabán/uso terapéutico , Pirazoles/uso terapéutico , Pirazoles/efectos adversos , Masculino , Femenino , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Anciano , Cirrosis Hepática/complicaciones , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/efectos adversos , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Estados Unidos/epidemiología , Puntaje de Propensión , Persona de Mediana Edad , Accidente Cerebrovascular Isquémico/prevención & control , Accidente Cerebrovascular Isquémico/epidemiología , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/epidemiología , Estudios de Cohortes , Embolia/prevención & control , Embolia/etiología , Embolia/epidemiologíaRESUMEN
We describe the case of a male heavy machinery operator who presented from work with a rapidly evolving spinal cord syndrome. Spinal MRI revealed thoracic vertebral body and cord infarction and evolving mild disc prolapse attributed to fibrocartilaginous disc embolism (FCDE). FCDE should be considered as one of the aetiological mechanisms of acute spinal cord infarction in pile-driver/heavy machinery operators, especially in association with adjacent vertebral body infarction and intervertebral disc prolapse. Magnetic resonance imaging (MRI) changes may evolve, warranting early follow-up MRI in appropriate cases.
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Embolia , Infarto , Imagen por Resonancia Magnética , Médula Espinal , Humanos , Masculino , Infarto/diagnóstico por imagen , Infarto/etiología , Embolia/diagnóstico por imagen , Embolia/diagnóstico , Embolia/etiología , Médula Espinal/diagnóstico por imagen , Médula Espinal/irrigación sanguínea , Médula Espinal/patología , Cuerpo Vertebral/diagnóstico por imagen , Adulto , Vértebras Torácicas/diagnóstico por imagen , Enfermedades de los Cartílagos/diagnóstico por imagen , Desplazamiento del Disco Intervertebral/diagnóstico por imagen , Desplazamiento del Disco Intervertebral/complicacionesRESUMEN
Bullet embolization is a rare and potentially life-threatening complication of gunshot wounds, particularly in lowpowered and small-caliber bullets. When these small bullets enter a large elastic vessel, they have the potential to leave a small entrance hole that can form a traumatic pseudoaneurysm. These pseudoaneurysms, which may be life-protecting at first, may rupture and lead to exsanguination if not found. We report an interesting case of an 18-year-old male gunshot victim where a bullet formed an aortic pseudoaneurysm and subsequently embolized and present a review of the literature regarding bullet embolization and traumatic pseudoaneurysms.
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Aneurisma Falso , Arteria Femoral , Heridas por Arma de Fuego , Humanos , Aneurisma Falso/etiología , Aneurisma Falso/terapia , Aneurisma Falso/diagnóstico por imagen , Masculino , Heridas por Arma de Fuego/complicaciones , Adolescente , Arteria Femoral/lesiones , Arteria Femoral/diagnóstico por imagen , Embolia/etiologíaRESUMEN
BACKGROUND: Infective endocarditis (IE) is a dangerous and lethal illness with high mortality rates. One of the main indications for surgery according to the guidelines is prevention of embolic events. However, uncertainty remains concerning the timing of surgery and the effect of early surgery in combination with antibiotic therapy versus antibiotic therapy alone in IE patients with a vegetation size > 10 mm. METHODS: We conducted a comprehensive review by searching the PubMed, MEDLINE, and EMbase databases. Titles and abstracts were screened, and studies of interest were selected for full-text assessment. Studies were selected for review if they met the criteria of comparing surgical treatment + antibiotic therapy to antibiotic therapy alone in patients with vegetations > 10 mm. RESULTS: We found 1,503 studies through our database search; nine of these were eligible for review, with a total number of 3,565 patients. Median age was 66 years (range: 17-80) and the median percentage of male patients was 65.6% (range: 61.8 - 71.4%). There was one randomised controlled trial, one prospective study, and seven retrospective studies. Seven studies found surgery + antibiotic therapy to be associated with better outcomes in patients with IE and vegetations > 10 mm, one of them being the randomised trial [hazard ratio = 0.10; 95% confidence interval 0.01-0.82]. Two studies found surgery + antibiotic therapy was associated with poorer outcomes compared with antibiotic therapy alone. CONCLUSION: Overall, data vary in quality due to low numbers and selection bias. Evidence is conflicting, yet suggest that surgery + antibiotic therapy is associated with better outcomes in patients with IE and vegetations > 10 mm for prevention of emboli. Properly powered randomised trials are warranted.
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Embolia , Endocarditis , Humanos , Endocarditis/cirugía , Endocarditis/complicaciones , Endocarditis/prevención & control , Embolia/prevención & control , Embolia/etiología , Antibacterianos/uso terapéutico , Masculino , AncianoRESUMEN
BACKGROUND: Left ventricular (LV) thrombus is not common but poses significant risks of embolic stroke or systemic embolism. However, the distinction in embolic risk between nonischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM) remains unclear. METHODS AND RESULTS: In total, 2738 LV thrombus patients from the JROAD-DPC (Japanese Registry of All Cardiac and Vascular Diseases Diagnosis Procedure Combination) database were included. Among these patients, 1037 patients were analyzed, with 826 (79.7%) having ICM and 211 with NICM (20.3%). Within the NICM group, the distribution was as follows: dilated cardiomyopathy (DCM; 41.2%), takotsubo cardiomyopathy (27.0%), hypertrophic cardiomyopathy (18.0%), and other causes (13.8%). The primary outcome was a composite of embolic stroke or systemic embolism (SSE) during hospitalization. The ICM and NICM groups showed no significant difference in the primary outcome (5.8% vs. 7.6%, p = 0.34). Among NICM, SSE occurred in 12.6% of patients with DCM, 7.0% with takotsubo cardiomyopathy, and 2.6% with hypertrophic cardiomyopathy. Multivariate logistic regression analysis for SSE revealed an odds ratio of 1.4 (95% confidence interval [CI], 0.7-2.7, p = 0.37) for NICM compared to ICM. However, DCM exhibited a higher adjusted odds ratio for SSE compared to ICM (2.6, 95% CI 1.2-6.0, p = 0.022). CONCLUSIONS: This nationwide shows comparable rates of embolic events between ICM and NICM in LV thrombus patients, with DCM posing a greater risk of SSE than ICM. The findings emphasize the importance of assessing the specific cause of heart disease in NICM, within LV thrombus management strategies.
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Bases de Datos Factuales , Isquemia Miocárdica , Sistema de Registros , Trombosis , Humanos , Femenino , Masculino , Anciano , Persona de Mediana Edad , Trombosis/epidemiología , Isquemia Miocárdica/epidemiología , Isquemia Miocárdica/diagnóstico , Japón/epidemiología , Factores de Riesgo , Embolia/epidemiología , Embolia/complicaciones , Ventrículos Cardíacos/diagnóstico por imagen , Cardiomiopatías/epidemiología , Anciano de 80 o más AñosRESUMEN
Coexistence of pulmonary embolism (PE) and arterial thrombosis in a single patient is rare. Management of such cases is challenging because there is no unified standard on how to treat this type of disease. We herein report a case involving a 73-year-old man who was admitted to the hospital because of a 2-day history of chest tightness. Pulmonary computed tomography angiography revealed a filling defect of the main pulmonary artery and bilateral branches as well as a left subclavian artery embolism. AngioJet mechanical thrombectomy (Boston Scientific, Marlborough, MA, USA) was used to treat the PE, and this was combined with left brachial artery incision and thrombectomy for treatment of the left subclavian artery embolism. The patient recovered well after the operation. The prognosis was good after 9 months of regular follow-up. AngioJet mechanical thrombectomy combined with left brachial artery incision thrombectomy may be a feasible treatment option for cases of PE combined with left subclavian artery embolism.
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Embolia Pulmonar , Arteria Subclavia , Trombectomía , Humanos , Masculino , Anciano , Embolia Pulmonar/cirugía , Embolia Pulmonar/complicaciones , Trombectomía/métodos , Arteria Subclavia/cirugía , Arteria Subclavia/diagnóstico por imagen , Angiografía por Tomografía Computarizada , Resultado del Tratamiento , Embolia/cirugía , Embolia/complicaciones , Embolia/etiologíaRESUMEN
BACKGROUND: Tandem lesions consist of cervical internal carotid artery (ICA) stenosis or occlusion, most commonly of atherosclerosis or dissection etiology, plus a large vessel occlusion. In this study, we compare outcomes in patients with atherosclerosis versus dissection of the cervical ICA. METHODS: This multicenter retrospective cohort study includes data from tandem lesion patients who underwent endovascular treatment from 2015 to 2020. Atherosclerosis was defined as ICA stenosis/occlusion associated with a calcified lesion and dissection by the presence of a tapered or flame-shaped lesion and intramural hematoma. Primary outcome: 90-day functional independence (modified Rankin Scale score, 0-2); secondary outcomes: 90-day favorable shift in the modified Rankin Scale score, modified Thrombolysis in Cerebral Infarction score 2b-3, modified Thrombolysis in Cerebral Infarction score 2c-3, symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, distal embolization, early neurological improvement, and mortality. Analysis was performed with matching by inverse probability of treatment weighting. RESULTS: We included 526 patients (68 [59-76] years; 31% females); 11.2% presented dissection and 88.8%, atherosclerosis. Patients with dissection were younger, had lower rates of hypertension, hyperlipidemia, diabetes, and smoking history. They also exhibited higher rates of ICA occlusion, multiple stents (>1), and lower rates of carotid self-expanding stents. After matching and adjusting for covariates, there were no differences in 90-day functional independence. The rate of successful recanalization was significantly lower in the dissection group (adjusted odds ratio, 0.38 [95% CI, 0.16-0.91]; P=0.031), which also had significantly higher rates of distal emboli (adjusted odds ratio, 2.53 [95% CI, 1.15-5.55]; P=0.021). There were no differences in other outcomes. Acute ICA stenting seemed to increase the effect of atherosclerosis in successful recanalization. CONCLUSIONS: This study reveals that among patients with acute stroke with tandem lesions, cervical ICA dissection is associated with higher rates of distal embolism and lower rates of successful recanalization than atherosclerotic lesions. Using techniques to minimize the risk of distal embolism may mitigate this contrast. Further prospective randomized trials are warranted to fully understand these associations.