To our knowledge，there are reports of repeated MT in patients with AIS[3, 6]. However, no patients with AIS complicated with uremia undergoing repeated MT treatments in a short time were reported. We report this uremia patient who underwent MT twice in 15 days, hoping to provide a reference for the clinic.
This patient was admitted to the hospital twice in the time window of intravenous thrombolysis (IVT), but no IVT was performed. Studies show patients with renal failure has higher occurrence of spontaneous intracerebral hemorrhage, cerebral microbleeds, or hemorrhagic transformations after AIS. There is still controversy about whether to give IVT for AIS patients with renal dysfunction. The Japanese guidelines state that stroke patients with severe renal disorder should be given IVT cautiously. Because further evidence of IVT safety in patients with renal failure is needed, and the clinical presentation of patients suggest LVO, we skipt IVT and directly underwent MT.
Renal clearance is the main elimination route of contrast, however, for patients with renal failure, their kidneys do not have the function of metabolic contrast agents. Due to renal failure of the patient, the metabolism of the contrast must rely on hemodialysis, so it is still necessary to pay attention to the dose of contrast, meanwhile control the drip rate and rehydration volume, to prevent excessive cardiac load. Despite that repeated thrombectomy may lead to more severe disruption of the vascular endothelium, thereby increasing the risk of complications such as vasospasm, arterial dissectionas well as intracranial hemorrhage，and renal failure also increases the risk of intracranial hemorrhage, MT may still be a better choice due to the benefits of opening blood vessels.
Anticoagulant therapy is the key to preventing thromboembolic events in patients with AF. However, there are still controversies about anticoagulant therapy in patients with concomitant AF and chronic renal failure. Giving anticoagulants to elderly with AF and renal failure was related to higher risk of ischamic stroke and haemorrhage but a paradoxical lowered rate of all cause mortality. Therefore, the treatment must be carefully selected according to the patient's condition. The patient is not older and has two thromboembolic events in a short period of time, so the benefits of anticoagulant therapy may be greater than the risk of bleeding. The patient was finally given oral warfarin to maintain INR fluctuations of 2-3, and no thromboembolic events and adverse bleeding reactions occurred during 4 months follow up.
In conclusion, it may be safe and effective to perform two MTs in patients with uremia and AF who have two cardiogenic strokes in a short period of time. For these patients, it may be beneficial to give anticoagulant therapy after careful assessment of the patient's condition, which needs further evidence from large sample studies.