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Kaddoura R, Mohamed Ibrahim MI, Al-Badriyeh D, Omar A, Al-Kindi F, Arabi AR. Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials. PLoS One 2022; 17:e0263270. [PMID: 35512007 PMCID: PMC9071172 DOI: 10.1371/journal.pone.0263270] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Thrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden. OBJECTIVES This meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI). METHODS A comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)). RESULTS Twelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85-7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60-8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48-11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13-0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes. CONCLUSIONS Compared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Amr Omar
- Department of Cardiothoracic Surgery/Cardiac Anesthesia, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fahad Al-Kindi
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Rahman Arabi
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Enzyme Therapy: Current Challenges and Future Perspectives. Int J Mol Sci 2021; 22:ijms22179181. [PMID: 34502086 PMCID: PMC8431097 DOI: 10.3390/ijms22179181] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 12/18/2022] Open
Abstract
In recent years, enzymes have risen as promising therapeutic tools for different pathologies, from metabolic deficiencies, such as fibrosis conditions, ocular pathologies or joint problems, to cancer or cardiovascular diseases. Treatments based on the catalytic activity of enzymes are able to convert a wide range of target molecules to restore the correct physiological metabolism. These treatments present several advantages compared to established therapeutic approaches thanks to their affinity and specificity properties. However, enzymes present some challenges, such as short in vivo half-life, lack of targeted action and, in particular, patient immune system reaction against the enzyme. For this reason, it is important to monitor serum immune response during treatment. This can be achieved by conventional techniques (ELISA) but also by new promising tools such as microarrays. These assays have gained popularity due to their high-throughput analysis capacity, their simplicity, and their potential to monitor the immune response of patients during enzyme therapies. In this growing field, research is still ongoing to solve current health problems such as COVID-19. Currently, promising therapeutic alternatives using the angiotensin-converting enzyme 2 (ACE2) are being studied to treat COVID-19.
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Agarwal SK, Agarwal S. Role of Intracoronary Fibrinolytic Therapy in Contemporary PCI Practice. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:1165-1171. [PMID: 30685340 DOI: 10.1016/j.carrev.2018.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/15/2018] [Accepted: 11/26/2018] [Indexed: 11/13/2022]
Abstract
Plaque rupture or plaque erosion leads to intracoronary thrombus formation resulting in coronary artery occlusion and ST-segment elevation myocardial infarction. Early restoration of blood flow in occluded coronary artery is the mainstay of therapy and it can be achieved by either thrombolytic therapy or primary percutaneous coronary intervention (P-PCI) or a combination of these two in many different ways. It has been proved that primary PCI is better than thrombolytic therapy in establishing early and effective recanalization of infarct related artery, reducing major adverse cardiovascular events (MACE) and increasing survival. There have been tremendous advances in PCI techniques over the years with newer stents, thrombectomy devices, and adjunctive pharmacotherapy. However, intracoronary thrombus continues to be the bane of interventional cardiologists. Failure of recanalization, suboptimal results, distal embolization, no reflow and impaired myocardial perfusion are some of the unresolved difficulties, regularly seen during PCI of patients with large intracoronary thrombus burden indicating an unmet need. This review focuses on emerging evidence about the usefulness of intracoronary thrombolytic therapy as an adjunct to PCI in patients with large intracoronary thrombus burden.
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Affiliation(s)
- Sanjeev Kumar Agarwal
- Department of Cardiology, Rashid Hospital, PO Box 4545, Dubai, United Arab Emirates.
| | - Shubham Agarwal
- Department of Internal Medicine, Rashid Hospital, Dubai, United Arab Emirates
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Greco C, Pelliccia F, Tanzilli G, Tinti MD, Salenzi P, Cicerchia C, Schiariti M, Franzoni F, Speziale G, Gallo P, Gaudio C. Usefulness of local delivery of thrombolytics before thrombectomy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (the delivery of thrombolytics before thrombectomy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention [DISSOLUTION] randomized trial). Am J Cardiol 2013; 112:630-5. [PMID: 23711809 DOI: 10.1016/j.amjcard.2013.04.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 04/22/2013] [Accepted: 04/22/2013] [Indexed: 11/19/2022]
Abstract
Thrombus aspiration during percutaneous coronary intervention can result in improved rates of normal epicardial flow and myocardial perfusion, but several unmet needs remain. The purpose of the Delivery of thrombolytIcs before thrombectomy in patientS with ST-segment elevatiOn myocardiaL infarction Undergoing primary percuTaneous coronary interventION (DISSOLUTION) trial was to evaluate the hypothesis that local delivery of thrombolytics can enhance the efficacy of thrombus aspiration in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. A total of 102 patients with ST-segment elevation myocardial infarction and angiographic evidence of massive thrombosis in the culprit artery were randomly assigned to receive a local, intrathrombus bolus of 200,000 U of urokinase (n = 51) or saline solution (n = 51) by way of an infusion microcatheter, followed by manual aspiration thrombectomy. The end points included the final Thrombolysis In Myocardial Infarction flow grade and frame count, myocardial blush grade, 60-minute ST-segment resolution >70%, and major adverse cardiac and cerebrovascular events, defined as the death, reinfarction, stroke, or clinically driven target vessel revascularization at 6 months. The use of intrathrombus urokinase was associated with a significantly higher incidence of Thrombolysis In Myocardial Infarction flow grade 3 (90% vs 66%, p = 0.008) and lower postpercutaneous coronary intervention Thrombolysis In Myocardial Infarction frame count (19 ± 15 vs 25 ± 17, p = 0.033). The postprocedural myocardial perfusion was significantly increased with the use of urokinase (myocardial blush grade 2 or 3, 68% vs 45%, p = 0.028), with more patients showing ST-segment resolution >70% (82% vs 55%, p = 0.006). At 6 months of follow-up, the patients treated with intrathrombus urokinase showed a better major adverse cardiac event-free survival (6% vs 21%; log-rank p = 0.044). In conclusion, local, intrathrombus delivery of thrombolytics before manual thrombectomy improved the postprocedural coronary flow and myocardial perfusion and the 6-month clinical outcomes.
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Affiliation(s)
- Cesare Greco
- Department of Heart and Great Vessels Attilio Reale, Sapienza University, Rome, Italy
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Rathi S, Latif F, Emilio Exaire J, Hennebry TA. Use of simultaneous angioplasty and in situ thrombolysis with a specialized balloon catheter for peripheral interventions. J Thromb Thrombolysis 2008; 28:77-82. [DOI: 10.1007/s11239-008-0286-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2008] [Accepted: 10/06/2008] [Indexed: 10/21/2022]
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Xavier AR, Farkas J. Catheter-based recanalization techniques for acute ischemic stroke. Neuroimaging Clin N Am 2005; 15:441-53, xii. [PMID: 16198951 DOI: 10.1016/j.nic.2005.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Recent advances in endovascular interventional therapies have revolutionized the management of acute ischemic stroke. For patients who present with occluded circle of Willis vessels, timely and successful arterial recanalization is the best predictor of clinical improvement. Diagnostic neuroimaging has advanced noninvasive tools--namely, transcranial Doppler, CT angiography, and MR angiography--to screen individuals with acute neurologic syndromes rapidly for arterial occlusion, and hence to exclude from treatment those who are unlikely to benefit from or could be harmed by arterial recanalization strategies. Intra-arterial thrombolysis has been proven to be of benefit in large clinical trials. Moreover, the US Food and Drug Administration has recently approved the use of a mechanical clot retrieval device for acute embolic stroke, and a number of other similar strategies are under various stages of investigation. This article reviews the diagnostic and interventional approach to the management of large vessel embolic stroke.
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Affiliation(s)
- Andrew R Xavier
- Department of Neurosciences, University of Medicine and Dentistry-New Jersey Medical School, Newark, NJ, USA
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Xavier AR, Siddiqui AM, Kirmani JF, Hanel RA, Yahia AM, Qureshi AI. Clinical potential of intra-arterial thrombolytic therapy in patients with acute ischaemic stroke. CNS Drugs 2003; 17:213-24. [PMID: 12665395 DOI: 10.2165/00023210-200317040-00001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Acute ischaemic stroke is a leading cause of mortality and morbidity around the world. An arterial occlusive lesion is found in the majority of patients with acute ischaemic stroke, and recanalisation has been shown to result in a better clinical outcome. The only widely approved recanalisation strategy is the use of intravenous alteplase (recombinant tissue-type plasminogen activator; tPA) within 3 hours of stroke onset. However, this therapy has limitations, and alternative or supplemental recanalisation strategies need to be considered in a large number of patients with acute ischaemic stroke. One such promising strategy is intra-arterial thrombolysis. This article reviews the pharmacology of the various drugs used for intra-arterial thrombolysis in the setting of acute ischaemic stroke and the results of the clinical trials that have studied their benefit. Three generations of thrombolytic agents have been available for clinical use so far. The first-generation agents such as streptokinase and urokinase were the first to be studied in acute stroke, and a number of positive case reports and series of their intra-arterial use have been reported from around the world. Second-generation products include alteplase and pro-urokinase. The clinical benefits of intra-arterial pro-urokinase were recently proven in a randomised, placebo-controlled study. Third-generation agents, such as reteplase, lanoteplase and tenecteplase, offer superior recanalisation rates with limited systemic adverse effects and might prove to be the agents of choice for intra-arterial acute stroke thrombolysis in the future. The exact administration regimens as well as the identification of patient sub-populations most likely to benefit from intra-arterial thrombolysis are subjects of current investigations, and hopefully firmer guidelines will be established in the next few years, once the results of the clinical trials are available.
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Affiliation(s)
- Andrew R Xavier
- Department of Neurology and Neurosciences, University of Medicine and Dentistry of New Jersey - New Jersey Medical School, Newark, New Jersey 07103, USA
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Chamberlain J. Transforming growth factor-beta: a promising target for anti-stenosis therapy. CARDIOVASCULAR DRUG REVIEWS 2002; 19:329-44. [PMID: 11830751 DOI: 10.1111/j.1527-3466.2001.tb00074.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Transforming growth factor-beta (TGF-beta) is the general name for a family of cytokines which have widespread effects on many aspects of growth and development. The TGF-beta isoforms are produced by most cell types and exert a wide range of effects in a context-dependent autocrine, paracrine or endocrine fashion via interactions with distinct receptors on the cell surface. TGF-beta is involved in the wound healing process and, thus plays a significant role in the formation of a restenotic lesion after percutaneous transluminal coronary angioplasty (PTCA) or stenting. Perhaps because of its wide-ranging effects, TGF-beta is usually released from cells in a latent form, and its activation and signaling are complex. Manipulation of the TGF-beta1, TGF-beta2, and TGF-beta3 isoforms by inhibiting their expression, activation, or signaling reduces scarring and fibrosis in animal models. However, to date, few have reached clinical trial. This review summarizes current knowledge on the activation and signaling of TGF-beta, and focuses on the anti-TGF-beta strategies which may lead to clinical applications in the prevention of restenosis following PTCA or stenting.
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Affiliation(s)
- J Chamberlain
- Cardiovascular Research Group, Section of Medicine, University of Sheffield, Clinical Sciences Centre, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK.
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Kanamasa K, Inoue Y, Otani N, Naito N, Morii H, Ikeda A, Taniguchi M, Ishida N, Hayashi T, Ishikawa K. tPA via infusion catheters followed by continuous IV infusion for 3 days prevents intimal hyperplasia after balloon injury. Angiology 2001; 52:819-25. [PMID: 11775623 DOI: 10.1177/000331970105201203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A rabbit model was used to examine the effects of tissue plasminogen activator (tPA) on development of intimal hyperplasia following balloon injury. Thirty-two hereditary hypercholesterolemic (KHC) rabbits underwent percutaneous transluminal coronary artery balloon catheterization and injury to the common iliac artery, after which they were divided into four groups: untreated (control); Dispatch catheterized-30 minutes local saline delivery [D(+)-tPA(-)]; D(+)-30 minutes local tPA delivery (0.6 mg/kg) [D(+)-tPA(30 min)]; and D(+)-30 minutes local tPA + 3 days intravenous infusion (0.6 mg/kg/24 h) [(D(+)-tPA(30 min + 3 d)]. Twenty-eight days later, the intimal cross-sectional areas of all three Dispatch catheterized groups were significantly smaller than those of control groups, as were the intimal/medial area ratios. Moreover, the intima/media ratios of the D(+)-tPA(30 min + 3 d) group were significantly smaller than those of the D(+)-tPA(-) group. Thus, local delivery of tPA via Dispatch catheters followed by continuous intravenous infusion of tPA for 3 days prevented intimal hyperplasia after angioplasty.
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Affiliation(s)
- K Kanamasa
- The First Department of Internal Medicine, Kinki University School of Medicine, Osaka, Japan.
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Qureshi AI, Ringer AJ, Fareed M, Suri K, Guterman LR, Hopkins LN. Acute Interventions for Ischemic Stroke: Present Status and Future Directions. J Endovasc Ther 2000. [DOI: 10.1583/1545-1550(2000)007<0423:aifisp>2.0.co;2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Qureshi AI, Ringer AJ, Suri MF, Guterman LR, Hopkins LN. Acute interventions for ischemic stroke: present status and future directions. J Endovasc Ther 2000; 7:423-8. [PMID: 11032263 DOI: 10.1177/152660280000700512] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A I Qureshi
- Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA.
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Roy S, Laerum F, Brosstad F, Kvernebo K, Sakariassen KS. Selective venous thrombolysis with the nipple-balloon catheter: comparative evaluation in vivo. J Vasc Interv Radiol 1999; 10:817-24. [PMID: 10392954 DOI: 10.1016/s1051-0443(99)70121-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To compare in an animal model of deep vein thrombosis, an intramural drug delivery catheter, the nipple-balloon catheter, with an occlusion balloon-infusion guide wire system. MATERIALS AND METHODS Ten juvenile pigs were used for the study. Deep vein thrombosis was induced in both hind limbs by using a previously described technique. Heparin was administered 30 minutes later (2,500 IU intravenously) and bilateral thrombolysis was attempted with use of 8 mg of alteplase as a 0.25 mg/mL solution containing heparin 50 IU/mL (n = 10) and sodium/meglumine ioxaglate 40 mgI2/mL (n = 5). In one limb, the external iliac vein was endoluminally occluded, and 0.8 mL of alteplase was administered every 3 minutes through a multisideport infusion wire placed coaxially through the balloon catheter. On the other side, a nipple-balloon catheter was used: alteplase was injected as two 0.4-mL aliquots every 3 minutes in overlapping segments of the vessel. Blood samples were taken at predetermined intervals to determine the partial thromboplastin time and plasma fibrinogen concentration. At autopsy, the thrombus mass in the iliofemoral veins was measured, and the extent of residual thrombosis in the venous tributaries was graded at four sites. The heart and the lungs were also examined for thromboemboli (n = 5). Venous specimens were then subjected to X-ray fluorescence spectrometry to determine iodine content (n = 5). RESULTS Bilateral thrombolysis could be successfully completed in all animals. No procedural problem associated with the use of the nipple-balloon catheter was encountered. The mass of residual thrombus in the axial veins was significantly lower in this group (P = .005). The drug delivery system used did not appreciably influence thrombolysis in the tributaries. Signs of macroscopic damage to the veins were not observed in any animal. None of the venous specimens had detectable levels of iodine. Small thromboemboli were found in the pulmonary circulation in three of five animals. Fibrinogen levels did not decrease during the procedure. CONCLUSIONS The significantly lower residual thrombus burden associated with use of the nipple-balloon catheter suggests that the device may have the potential to be an effective delivery system for selective thrombolysis in veins.
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Affiliation(s)
- S Roy
- Institute for Surgical Research, National Hospital, Oslo, Norway
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