Evolution of Reperfusion Therapies for Acute Brain and Acute Myocardial Ischemia

Abstract

Beginning in the early 1980s, clinical trials have tested iteratively improving acute reperfusion interventions for both myocardial infarction and ischemic stroke. In both circulatory beds, treatments have evolved in a similar pattern, beginning with intravenous fibrinolytics, followed by intraarterial fibrinolytics, then mechanical endovascular therapies, and finally exploration of combined intravenous and catheter treatments. 1,2 However, in important ways, therapies in the different vascular beds have evolved distinctively. For example, primary stenting has become a mainstay of acute coronary reperfusion, reflecting its efficacy in treating target atherosclerotic plaques with supervening thrombi, whereas mechanical retrieval and aspiration techniques are the leading endovascular therapies for cerebral ischemia, because of their appropriateness for target embolic thrombi residing in relatively normal recipient vessels.Even more importantly, the technical efficacy of lytic and mechanical treatments in achieving reperfusion has evolved at different rates in the cerebral and cardiac circulatory beds. However, the difference in success rates of reperfusion treatments for brain and heart have not been previously systematically characterized and quantified. We therefore undertook a formal systematic analysis of reperfusion efficacy over the past 30 years of cerebral and cardiac revascularization strategies. Methods Search and Inclusion CriteriaA systematic search was performed to identify all multi-arm trials of coronary revascularization for acute myocardial infarction and multicenter trials of cerebral revascularization for acute ischemic stroke (AIS) with reperfusion assessed by catheter angiography. Medline was searched from 1950 to 2010: (1) crossing the terms Background and Purpose-Early reperfusion is the most effective therapy for both acute brain and cardiac ischemia.However, the cervicocephalic circulatory bed offers more challenges to recanalization interventions. The historical development of reperfusion interventions has not previously been systematically compared. Methods-Medline search identified all multi-arm, controlled trials of coronary revascularization for acute myocardial infarction and multicenter trials of cerebral revascularization for acute ischemic stroke reporting angiographic reperfusion rates. Results-Thirty-seven trials of coronary reperfusion enrolled 10 908 patients from 1983 to 2009, and 10 trials of cerebral reperfusion enrolled 1064 patients from 1992 to 2009. Coronary reperfusion trials included 10 of intravenous fibrinolysis alone, 8 combined intravenous fibrinolysis and percutaneous transluminal coronary angioplasty with or without stenting, 3 intra-arterial fibrinolysis, and 16 percutaneous transluminal coronary angioplasty with or without stenting. Cerebral reperfusion trials included 1 of intravenous fibrinolysis alone, 3 intra-arterial fibrinolysis, 3 endovascular device alone, and 3 of endovascular treatment ± intravenous fibrinolysis. In both circulatory beds, endovasc...

Symptom Differences and Pretreatment Asymptomatic Interval Affect Outcomes of Stenting for Intracranial Atherosclerotic Disease

“…Multiple factors must be considered in the design of the SAMMPRIS trial and its implications for future investigation. 46 The SAMMPRIS trial made no distinction between pathophysiologic causes of symptoms. Our series shows that nonhypoperfusion lesions have higher risk of death at the point of last contact after stent placement.…”

Stent Retriever-Mediated Manual Aspiration Thrombectomy for Acute Ischemic Stroke

“…Historically, this has led to significantly lower rates of recanalization. Between 2005 and 2009, cardiac reperfusion rates were 78.6-86.1% for complete to near-complete reperfusion compared to 23.4-61.1% for cerebral reperfusion [13]. Two trials [14,15] comparing stent retriever devices to the Merci device revealed significantly higher rates of complete or near-complete reperfusion (68-69%) compared to the Merci clot retrieval device (30-44%).…”

Endovascular Therapy for Stroke

“…30,31 Historically, improvements in reperfusion rates in acute coronary ischemia have followed a stepwise trajectory of intravenous thrombolytics to intra-arterial thrombolytics to balloon angioplasty, stents, manual thrombus aspiration catheters, and drug-eluting stents. [75][76][77] During this period of growth from the early 1980s to the present, complete reperfusion rates increased at a rate of 3.0%/y, 78 which coincided with a significant reduction in the risk-standardized mortality rates of patients with acute myocardial infarction in the United States. 79 Over the last decade, complete recanalization rates and acute ischemic stroke (AIS).…”

“…From 1992 to 2009, complete reperfusion rates for treatment of ischemic strokes increased at 0.9%/y, 78 with subsequent symptom onset-to-treatment times hovering at 4 to 5 hours in all endovascular trials to date. [20][21][22][36][37][38] Indeed, improved reperfusion rates must come hand in hand with improvements in system processes, thereby creating the optimal environment for new devices to affect changes in patient outcomes.…”