Intraarterial infusion of low-dose streptokinase after acute thromboembolization of the right renal artery

Acute arterial thromboembolization is a well-recognized complication following myocardial infarction. Intraarterial infusion of thrombolytic agents is a relatively new method of treating such thromboembolic occurrences. We describe a patient who was successfully treated with low-dose, intraarterial streptokinase infusion following occlusion of the right renal artery 1 week after an acute myocardial infarction.     

Methodology and results of intravenous thrombolysis in acute myocardial infarction

For the vast majority of patients with acute myocardial infarction, intravenous thrombolysis is at present the only therapeutic approach aimed at early reperfusion of the ischemic myocardium. Rapid recanalization of the infarct-related coronary artery is achieved in at least 50–60% of the patients by short-term high-dose infusions of streptokinase or urokinase with a low risk of bleeding. A substantial reduction of infarct size, however, can be expected in only a minority of patients, mostly in those who are treated very early. The effects of intravenous thrombolysis on early and late mortality from acute myocardial infarction are still equivocal; more conclusive data may be expected from ongoing randomized trials.     

Effects of intracoronary thrombolysis on global left ventricular function assessed by an automated edge detection technique

Three hundred and two patients with acute myocardial infarction were enrolled in a randomized multicenter trial to compare conventional treatment with attempted recanalization by intracoronary streptokinase. In a subgroup of patients, the effects of thrombolysis on left ventricular function were evaluated within 48 hr, at 2 wk, and at 3 mo after admission. Global left ventricular ejection fraction (LVEF) was obtained by radionuclide angiography and analyzed with an automatic detection program. Paired data were determined in 160 patients (control 78, thrombolysis 82) within 48 hr and at 2 wk, and in 143 patients (control 71, thrombolysis 72) at 48 hr, 2 wk, and 3 mo. It was shown that LVEF significantly improved in the thrombolysis group as compared with controls both at 2 wk (delta LVEF thrombolysis 3.9 +/- 7.9%, p less than 0.001 compared with delta LVEF control 0.6 +/- 9.7%, p = N.S.) and at 3 mo (delta LVEF thrombolysis 3.1 +/- 12.4%, p less than 0.05 compared with delta LVEF control 2.1 +/- 12.2%, p = N.S.). When patients were divided according to infarct site, however, significant improvement at 3 mo was only observed in the patients with anterior infarction (delta LVEF thrombolysis 5.5 +/- 13.1%, p less than 0.05 compared with delta LVEF control 3.3 +/- 10.4%, p = N.S.). It was shown that acute intervention with intracoronary streptokinase has a potentially favorable and lasting effect on left ventricular function in patients with anterior myocardial infarction. This improvement might be related to the rather rapid administration of thrombolytic therapy with a median time of approximately 4 hr after onset of symptoms.     

Local intraarterial thrombolysis in vertebrobasilar thromboembolic disease

The poor prognosis of basilar artery occlusion is well known. Systemic anticoagulation rarely prevents a lethal outcome. A new therapeutic approach involves selective perfusion of streptokinase through the vertebrobasilar artery via a coaxial catheter system. Three of five reported cases demonstrated successful vascular recanalization with clinical improvement.     

Spontaneous splenic rupture associated with thrombolytic therapy and/or concomitant heparin anticoagulation

Two cases of spontaneous splenic rupture in connection with thrombolytic therapy and concomitant heparin anticoagulation are reported. One patient was being treated for peripheral arterial graft occlusion using intraarterial urokinase, the other received intravenous infusion of streptokinase for acute myocardial infarction. Neither patient had a condition predisposing to splenic rupture. Although rare, previous reports of spontaneous splenic rupture associated with thrombolytic therapy and/or anticoagulation have been reported. Splenic rupture as a complication of thrombolytic therapy and/or anticoagulation should be considered when unexplained abdominal symptoms, hypotension, or blood loss is encountered.     

Intravenous streptokinase therapy in acute myocardial infarction: Assessment of therapy effects by quantitative 201Tl myocardial imaging (including SPECT) and radionuclide ventriculography

To evaluate a potential beneficial effect of systemic streptokinase therapy in acute myocardial infarction, 36 patients treated with streptokinase intravenously were assessed by radionuclide ventriculography and quantitative ²⁰¹Tl myocardial imaging (including SPECT) in comparison with 18 conventionally treated patients. Patients after thrombolysis had significantly higher EF, PFR, and PER as well as fewer wall motion abnormalities compared with controls. These differences were also observed in the subset of patients with anterior wall infarction (AMI), but not in patients with inferior wall infarction (IMI). Quantitative ²⁰¹Tl imaging demonstrated significantly smaller percent myocardial defects and fewer pathological stress segments in patients with thrombolysis compared with controls. The same differences were also found in both AMI and IMI patients. Our data suggest a favorable effect of intravenous streptokinase on recovery of left ventricular function and myocardial salvage. Radionuclide ventriculography and quantitative ²⁰¹Tl myocardial imaging seem to be reliable tools for objective assessment of therapy effects.     

Posterior cerebral artery occlusion: clinical, computed tomographic, and angiographic correlation.

The distribution of low-density areas on computed tomography (CT) suggested occlusions in the proximal half of the circummesencephalic portion in 38 patients with posterior cerebral artery (PCA) occlusion. Correlation between clinical, CT, and angiographic findings in 24 cases showed that occlusion was most common in the crural segment. Clinical manifestations and infarction extension varied widely among proximal occlusions. In cases with good collateral filling, the infarction was restricted to the thalamus; in those with poor filling, it involved most of the PCA's territory, and hemorrhagic transformation occasionally ensued. Discrepancies between findings were ascribed to dislodging of emboli or thrombi, recanalization, and transient obscuration of the infarction on CT.     

An Unusual Complication Following Transarterial Chemoembolization: Acute Myocardial Infarction

Transarterial chemoembolization has been widely used to treat unresectable hepatocellular carcinoma. Various complications have been reported, but they have not included acute myocardial infarction. Acute myocardial infarction results mainly from coronary artery occlusion by plaques that are vulnerable to rupture or from coronary spasm, embolization, or dissection of the coronary artery. It is associated with significant morbidity and mortality. We present a case report that describes a patient with hepatocellular carcinoma who underwent transarterial chemoembolization and died subsequently of acute myocardial infarction. To our knowledge, there has been no previous report of this complication induced by transarterial chemoembolization for hepatocellular carcinoma. This case illustrates the need to be aware of acute myocardial infarction when transarterial chemoembolization is planned for the treatment of hepatocellular carcinoma, especially in patients with underlying coronary artery disease.     

多巴酚丁胺超声心动图检测存活心肌的局限性研究

目的利用小剂量多巴酚丁胺超声心动图（LDDE）识别存活心肌,并对冠脉再通术前后心脏收缩功能进行对比研究,阐述多巴酚丁胺（Dobu）超声心动图检测存活心肌的局限性。方法选择急性前壁心梗（AMI）4周后左前降支（LAD）完全闭塞或濒临闭塞病变,拟行介入性治疗（PCI）的患者20例,PCI术前进行LDDE,根据收缩性储备功能（CR）分组：有CR组和无CR组,对术前静息、术前小剂量Dobu、术后静息状态下进行左室舒张末容积指数（EDVI）、左室收缩末容积指数（ESVI）、室壁运动积分指数（WMSI）、左室射血分数（LVEF）进行分组对比分析。结果 LDDE术前判断无收缩功能的心肌（无CR组）,PCI术后部分恢复收缩功能（占32%）,其LVEF术前、术后对比亦有明显差异（P〈0.05）。结论多巴酚丁胺超声心动图术前检测存活心肌具有一定的局限性。     

Effect of progenitor cells on myocardial perfusion and metabolism in patients after recanalization of a chronically occluded coronary artery.

Even after recanalization of a chronic total coronary occlusion, functional recovery is incomplete and parts of the myocardium remain hypoperfused. In this randomized, placebo-controlled, and double-blinded study, we investigated relative changes in myocardial perfusion and glucose metabolism induced by intracoronary administration of blood-derived circulating progenitor cells (CPCs), compared with the natural course in a control group after recanalization of total coronary occlusion. METHODS: After recanalization of total coronary occlusion, 26 patients were randomly assigned to the CPC treatment or placebo group. Regional myocardial perfusion and glucose metabolism were assessed by 99mTc-tetrofosmin SPECT and 18F-FDG PET at baseline (after recanalization of total coronary occlusion) and 3 mo after the administration of 69 +/- 14 x 10(6) CPCs or cell-free serum, respectively. Segments were classified as "normal," "perfusion-metabolism mismatch" (dysfunctional segments with a 99mTc-tetrofosmin-18F-FDG mismatch), or "scar." RESULTS: In contrast to the placebo group, CPC administration resulted in a significant decrease in the number of segments with a perfusion-metabolism mismatch, from 3.0 +/- 0.5 to 1.7 +/- 0.6 segments (P < 0.05 vs. baseline). Of the normal segments at baseline, 2.7% in the CPC group and 30% in the placebo group revealed a perfusion-metabolism mismatch at follow-up after 3 mo (P < 0.05 vs. placebo). CONCLUSION: Intracoronary administration of CPCs significantly reduces the amount of myocardium with a perfusion-metabolism mismatch and prevents areas with normal perfusion and metabolism after recanalization of total coronary occlusion from becoming dysfunctional during the next 3 mo. These results show that PET and SPECT can be used to monitor the effect of progenitor cells on myocardial integrity. More important, they provide evidence supporting expansion of the use of progenitor cell treatment to chronic coronary artery disease.     

Transcatheter occlusion of pulmonary arterial circulation and collateral supply: failures, incidents, and complications

Failures and complications were analyzed retrospectively in 45 patients treated with embolotherapy or occlusion of pulmonary arterial circulation. Pulmonary arterial branches were occluded with steel coils in 19 patients with pulmonary arteriovenous malformations, 17 with hemoptysis of pulmonary artery (PA) origin, and one with massive parenchymal shunt. Bronchial arterial supply to the lung was embolized with small particles in eight cases of hemoptysis and systemic to pulmonary arterial antegrade shunt secondary to chronic thromboembolism. Asymptomatic incidents included catheterization failures, vascular damage, partial occlusion, partial recanalization of the thrombus, ectopic deposition of a coil, and delayed bacterial contamination of the thrombus. A few cases of transient clinical and radiologic signs of pulmonary infarction were observed after complete occlusion of the PA and bronchial artery embolization. This complication was never observed after complete occlusion of main right or left PA, inferior right or left PA, or segmental branches. The management and prevention of these complications, the role of bronchial arterial collateral pathways, and the importance of the site of PA occlusion in the development of pulmonary infarction are discussed.     

Targeting and Recanalization after Embolization with Calibrated Resorbable Microspheres versus Hand-cut Gelatin Sponge Particles in a Porcine Kidney Model

PurposeTo report on polyethylene glycol hydrogel-based resorbable embolization microspheres (REM) that were synthesized to resorb in < 24 hours, before inflammation and vascular remodeling, to achieve a complete arterial recanalization and to compare targeting and recanalization of REM of 300–500 µm, 500–700 µm, and 700–900 µm with hand-cut gelatin sponge particles (GSP).Materials and MethodsEight pigs underwent polar renal artery embolization with REM or GSP. Angiograms were obtained before embolization and 10 minutes and 7 days after embolization before pigs were sacrificed to determine the occlusion level, the percentage of occlusion, and the recanalization rate for each product. The distribution of embolic material was assessed in pathology, and infarction rate of the kidneys was measured.ResultsREM of 300–500 µm occluded more distal vessels than REM of 500–700 µm and 700–900 µm. At day 7, the recanalization rate was complete for the larger REM, whereas it was about 60% for the two smaller sizes. REM were completely degraded, with no residual material or inflammation. GSP occluded more proximal arteries than REM of 700–900 µm, were partly degraded at day 7, and were accompanied by a foreign body reaction in proximal and distal arteries. GSP recanalized at 79%. The infarction rate was higher with the two smaller sizes of REM and with GSP than with the largest REM.ConclusionsREM of different sizes targeted different occlusion levels in kidney arteries. GSP provided an extended occlusion level without actual targeting. Regardless of embolic material used, angiographic recanalization of renal arteries depended on the extent of necrosis. REM of 700–900 µm demonstrated the lowest infarction rate and the best recanalization rate.     

Short-duration, high-dose urokinase infusion for recanalization of occluded saphenous aortocoronary bypass grafts

Thrombolytic recanalization of arterial bypass grafts has been pursued aggressively in the peripheral circulation but not in the coronary circulation. In an attempt to apply peripheral transcatheter thrombolytic techniques to the coronary circulation, nine patients with 10 occluded saphenous aortocoronary bypass grafts underwent recanalization procedures using a short-duration, high-dose urokinase infusion. Urokinase was infused at the occluded graft orifice at a rate of 600 units/min. The average infusion time was 1 hr, 26 min. The average urokinase dose was 435,000 units. Graft recanalization was achieved in eight (80%) of 10 grafts, although only six (60%) of 10 grafts were widely patent at the end of the procedure. All successfully recanalized grafts required balloon angioplasty of underlying stenoses. No complications, specifically myocardial infarction or cerebrovascular accident, were encountered. We have shown that occluded aortocoronary bypass grafts can be recanalized successfully by using a short-duration, high-dose urokinase infusion. It appears that, with attention given to angiographic techniques that minimize clot manipulation, recanalization can be accomplished safely in a majority of cases.     

Therapeutic alternatives for subacute peripheral arterial occlusion. Comparison by outcome, length of stay, and hospital charges.

Thrombolytic therapy using streptokinase or urokinase has been shown to be a viable alternative to surgical thrombectomy in patients with subacute peripheral arterial occlusion. Urokinase is associated with higher success and lower complication rates than streptokinase, but the cost of urokinase is at least seven times higher. To address questions of utility and effectiveness in the treatment of subacute peripheral arterial occlusions, the authors designed a retrospective study of patients treated either by surgical thrombectomy (n = 70), thrombolysis with streptokinase (n = 19), or thrombolysis with urokinase (n = 22). Outcome of therapy, length of hospital stay, and total hospital charges in the three groups were examined. Treatment successes in the three groups, defined as complete clearing of the occluded segment with patency maintained for 60 days, were 76% for thrombectomy, 32% for streptokinase, and 64% for urokinase. Total duration of hospitalization was 21.1, 21.3, and 11.5 days (P less than .05), respectively. Mean charges for thrombolytic agents were $690 for streptokinase and $6429 for urokinase. Mean total hospital charges, however, were $25,978 for streptokinase, $22,203 for urokinase, and $25,336 for thrombectomy (P = NS). The higher cost of urokinase, then, accounted for the similar total charges, despite the shortened length of stay. These results suggest that urokinase is cost-effective compared to streptokinase for subacute peripheral arterial occlusion. Compared to thrombectomy, thrombolysis with urokinase has a marginally lower patency rate at 60 days, but a significantly shorter length of hospital stay.     

急性缺血性脑卒中急诊介入开通治疗的临床观察

目的探讨急诊行介入开通术治疗急性缺血性脑卒中（AIS）的有效性、安全性及个体化治疗方案。 方法收集31例经DSA提示为脑动脉主干血管闭塞、行急诊介入开通术的AIS患者的临床资料并进行回顾分析,评估该手术方式的技术成功率、疗效及风险。 结果31例患者中获得血管再通的24例,技术成功率达77.42%（24/31）,其中19例达到术后即刻血管完全再通（TICI 3级）,5例部分再通（TICI 2级）。获得血管再通的24例中,8例采用接触溶栓法,16例采用机械开通如球囊扩张、自膨式支架置入或Solitaire取栓中的一种或几种获得。术后死亡7例（7/31,22.58%）,其中因颅内出血死亡2例（2/31,6.45%）,1例溶栓后,1例机械取栓后,出血均发生在术后12 h内;因大面积梗死致亡5例（5/31,16.13%）,2例因血管部分开通后再次急性血栓形成,3例因血管未开通而闭塞症状逐渐加重死亡。90天随访中达到预后良好（MRS≤2分）的患者占51.61%（16/31）,其中血管获得完全再通的患者预后良好率达78.95%（15/19）,术前DSA证实有侧支代偿的患者预后良好率达57.89%（11/19）。 结论急诊行介入开通术治疗AIS是可行、有效、较安全的,并有可能成为急性脑动脉主干血管闭塞患者的首选治疗方式。     

Phase 3 study of beta-methyl-p-(123I)-iodophenyl-pentadecanoic acid, a myocardial imaging agent for evaluating fatty acid metabolism--a multi-center trial]

A multi-center trial of beta-methyl-p-(123I)-iodophenyl-pentadecanoic acid (123I-BMIPP) was performed to assess its clinical usefulness in the evaluation of myocardial fatty acid metabolism in 587 patients with various heart diseases. 123I-BMIPP showed relatively decreased uptake compared with 201Tl in the myocardial lesions of 62% of patients with ischemic heart disease (IHD), 39% of those with cardiomyopathy and 32% of those with other heart diseases. In case of myocardial infarction, less uptake of 123I-BMIPP (Type B) than 201Tl was more frequently seen in patients with successful recanalization than in those without recanalization. The patients with matched distribution of the two tracers (Type E) increased in the direct proportion to the interval between the onset of myocardial infarction and the radionuclide studies. The uptake of 123I-BMIPP correlated well with myocardial viability evaluated by 201Tl exercise-redistribution studies. Type B was frequently seen in the areas with 201Tl redistribution, while Type E was seen in the fixed defect areas. In the other heart diseases studied, Type E was observed in approximately 60% of patients with dilated or secondary cardiomyopathies. Type B was seen in about 45% of patients with valvular heart diseases and myocarditis. Various types of mismatch between the two tracers were demonstrated in hypertrophic cardiomyopathy and hypertensive heart disease. It is concluded that 123I-BMIPP is a safe and useful agent for the diagnosis of various heart diseases, since it reflects myocardial fatty acid metabolism.     

颈内动脉系统脑梗死责任血管自发性再通的MRA研究

目的探讨颈内动脉系统脑梗死责任血管自发性再通发生率、发生时间、梗死模式以及再通机制。方法回顾性收集了2015年5月—2016年5月共441例就诊于天津医科大学总医院的脑梗死病例,其中男279例,女162例,年龄31~90岁,平均(63.17±10.10)岁。所有脑梗死病人均进行了常规MRI、DWI及MRA检查。依据MRA上显示梗死灶责任血管有无狭窄将全组病人分为再通组和非再通组。2组间病人年龄、自发病初至MRA检查时间差异的比较采用双样本t检验,病人性别、病变侧别及其他临床资料的组间比较采用χ2检验。结果 441例病人中有300例(68.03%,男192例,女108例)存在责任血管狭窄或闭塞,为非再通组;141例(31.97%,男87例,女54例)未见责任血管狭窄或闭塞,为再通组。脑梗死后血管自发性再通的发生率为31.97%。2组间病人年龄、性别、病变侧别及其他临床资料的差异均无统计学意义(均P0.05)。再通组的自发病至MRA检查时间明显小于非再通组(P=0.002)。2组病人中单一梗死模式均较混合梗死模式多见,其中穿支动脉供血区梗死模式最多见。再通组病人3 d内再通比例为90.07%,3~7 d再通比例为9.93%。结论闭塞血管自发性再通率约为30%,再通多发生在脑梗死前3 d内,再通比例达90.07%,终末支小血管再通率高。了解脑梗死后脑血管自发性再通有助于避免过激治疗。     

Hyperacute therapy of ischemic stroke: intravenous thrombolysis

Stroke is the third most common cause of death in the United States following heart disease and cancer. Following the success of thrombolysis for myocardial infarction in the early 1990s, major trials for evaluation of this new therapeutic approach for ischemic stroke were initiated. The majority of ischemic strokes are due to occlusion of a cerebral vessel by a blood clot. Occlusion of a cerebral blood vessel leads to a core of infracted tissue surrounded by a relatively hypoperfused but viable brain tissue (the ischemic penumbra), which can be potentially salvaged by rapid recanalization of the target vessel. The underlying rationale for introduction of thrombolytic drugs is the lysis of an obliterating thrombus and reestablishment of blood flow. In this article we review the major intravenous thrombolysis trials leading to approval of intravenous recombinant tissue plasminogen activator, the only FDA approved treatment available today for acute ischemic stroke.     

Patent foramen ovale,paradoxical embolism and fatal coronary obstruction

A 75-year-old woman was admitted to the emergency room with chest pain and vomiting. An electrocardiogram and laboratory results were suggestive for myocardial infarction of the posterior cardiac wall. Echocardiography was indicative of aortic dissection, and a CT scan of the thoracic arteries showed a massive pulmonary thromboembolism and thrombotic occlusion of the right coronary artery (RCA). The woman died shortly after admission. Autopsy confirmed the presence of thromboemboli in the right pulmonary artery and its lobar branches. Also, the anterior aortic sinus was filled with a 9 cm long thromboembolus that extended into the RCA, making it dilated and completely occluded. Another 3.5 cm long thromboembolus extended from the beginning of the left subclavian artery. A patent foramen ovale (PFO) was present. On the posterior wall of the left ventricle, there was an area suggestive of myocardial infarction, and histopathological examination confirmed that it was 24–48 hours old. The coronary circulation was “co-dominant”. The sources of thrombotic masses were the deep veins of the lower limbs. The cause of death was myocardial infarction, caused by RCA occlusion with thromboembolus originating from the deep veins of the left lower leg after paradoxical embolism via PFO. This case illustrates that although deep venous thrombosis, pulmonary thromboembolism, and PFO are not rare findings at autopsy, their combination could be a relatively rare cause of fatal coronary artery occlusion after paradoxical embolism.