Angiographic Appearance Research Articles

Angiographic classification of chronic subdural hematoma.

<p>Chronic subdural hematoma (cSDH) is a challenging pathology with high recurrence rate after surgical treatment and may seriously affect the patient&rsquo;s quality of life. Membrane formation with angiogenesis plays an important role in the evolution of the disease, providing a promising target for endovascular therapy. Our goal is to categorize angiographic patterns of chronic subdural hematoma for standardized reporting purposes.</p>. <p>In our retrospective analysis of prospective data collection, we analyzed angiographic properties of all high recurrence risk patients with cSDH, who were treated by embolization in our hospital between February 2019 and June 2020. Altogether 17 patients were included in the analysis.&nbsp;</p>. <p>Based on superselective angiography of the middle meningeal artery (MMA) in the two standard, AP and lateral views, three distinct categories of dural supply were defined: normal vascular pattern (Grade I), cottonwool appearance without enlargement of the MMA branches (Grad II) and strong cottonwool like staining with dilatative remodelling of the MMA branches (Grade III).</p>. <p>The proposed grading system of the angiographic appearance of cSDH, representing the pathophysiological evolution of the disease should be correlated to therapeutic success rates and could be applied in future clinical studies.</p>.

Aspects of Coronary Angiography in Diabetic Patients at the CHU Mother and Child Luxembourg in Bamako

&amp;lt;i&amp;gt;Introduction&amp;lt;/i&amp;gt;: Type 2 diabetes is on the increase in Africa as a result of the epidemiological transition. Cardiovascular complications, particularly ischemic complications, are common in diabetic patients. They are life-threatening. It is important to identify the angiographic appearance of the coronary arteries in diabetic patients in order to guide treatment. &amp;lt;i&amp;gt;Objective&amp;lt;/i&amp;gt;: to identify the results of coronary angiography in diabetic patients. &amp;lt;i&amp;gt;Patients and method&amp;lt;/i&amp;gt;: Descriptive, cross-sectional study with retrospective recruitment over a three-year period from September 2019 to August 2022. All diabetic patients who underwent coronary angiography at the CHU mother child Luxembourg in Bamako were included. &amp;lt;i&amp;gt;Results&amp;lt;/i&amp;gt;: We enrolled 371 patients out of 985 during the study period, i.e. a hospital frequency rate of 37.66%. The mean age of the patients was 60.76 +/- 10.26 years, with extremes of 32 and 84 years. They were predominantly male, with a sex ratio of 1.45. The predominant functional signs were typical chest pain (39.4%), atypical chest pain (27.8%) and dyspnea (13.2%). The predominant risk factors were hypertension (74.7%), sedentary lifestyle (48.8%) and smoking (17.5%). The indications for coronary angiography were chronic coronary syndrome (55%) and acute coronary syndrome (45%). Coronary angiography was pathological in 78.4% of patients, with tritruncular lesions in 38% and bi-truncal lesions in 21%. Lesions were located on the common trunk in 5.4%, on the anterior interventricular in 59.8%, on the right coronary in 51.8% and on the circumflex in 47.4%. &amp;lt;i&amp;gt;Conclusion&amp;lt;/i&amp;gt;: Ischemic heart disease is common in diabetic patients with tri- and bi-truncular lesions.

Twenty-five-year trends in incidence, angiographic appearance, and management of spontaneous coronary artery dissection

BackgroundSpontaneous coronary artery dissection (SCAD) has been described as an infrequent cause of acute coronary syndrome (ACS). Knowledge about the disease is still limited and SCAD might still be underdiagnosed. ObjectivesTrends in incidence, presentation, angiographic appearance, management, and outcomes of SCAD over 25 years were analyzed. MethodsPatients with SCAD between 1997 and 2021 at the University Hospital Zurich, Switzerland, were included. Incidences were assessed as total numbers and proportions of ACS cases. Clinical data were collected from medical records and angiographic findings were reviewed. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, cardiac arrest, SCAD recurrence or progression, other myocardial infarction, and stroke. ResultsOne hundred fifty-six SCAD cases were included in this study. The incidence increased significantly in total (p < 0.001) and relative to ACS cases (p < 0.001). This was based on an increase of shorter lesions (p = 0.004), SCAD type 2 (p < 0.001), and lesions in side branches (p = 0.014), whereas lesions in the left main coronary artery and proximal segments were decreasing (p-values 0.029 and < 0.001, respectively). There was an increase in conservative therapy (p < 0.001). The rate of MACE (24%) was stable, however, there was a reduced proportion of patients with a need for intensive care treatment (p = 0.017). ConclusionsSCAD represents an important entity of ACS that still might be underappreciated. The increasing incidence of SCAD is likely based on better awareness and familiarity with the disease. A lower need for intensive care treatment suggests positive effects of the increasing implementation of conservative management.

Coronary vasculopathy due to moyamoya disease

Moyamoya disease is a rare disorder associated with progressive intracranial arterial stenosis with fragile, small collateralization that gives an angiographic appearance of a puff of smoker or, in Japanese, “moya-moya”. We report a case of coronary artery ostial occlusive disease as an extracranial manifestation of Moyamoya. In the case, we demonstrate that thigh risk features of cardiac positron emission tomography (PET) that ultimately lead to the diagnosis of coronary artery occlusion.

Abstract 539: Mini-swine Model Of Hindlimb Ischemia On A Background Of Metabolic Syndrome Mimics Peripheral Artery Disease And Claudication

Background: There is an ongoing need for an animal model of PAD that is similar to the human patients in its size, anatomy, physiology, comorbidities and suitability for invasive/non-invasive testing and treatment. Methods: Three months old Ossabaw swine (N=9) were fed a high fat/fructose/sodium diet for 8 weeks. Right hindlimb ischemia was then induced (N=6, 2 female) using Right Superficial Femoral Artery (RSFA cutdown, right external iliac artery endovascular (R EIA) coil embolization/occlusion and RSFA resection (T0) vs sham (N=3, 1 female). At 4 weeks (T4), all swine underwent R carotid cutdown, 2-D angiography, and bilateral(b/l) gastrocnemius open biopsy. At 8 weeks (T8) swine underwent L carotid cutdown, 2-D angiography, b/l sampling of the gastrocnemius. During all procedures, b/l ankle brachial indices (ABIs), and tissue oximetry on the calf and thigh were measured. All swine underwent weekly measurement of their treadmill walking distance. Gastrocnemius muscle mitochondrial respiration was measured with an Oroboros Oxygraph-2k. Results: Blood draws showed hyperlipidemia and hyperglycemia in all swine at T0, T4, and T8 after a 12-hour fasting period. Hindlimb ischemia lowered right-sided ABIs at T4 and T8 by 45 and 39% (p&lt;0.001) , and tissue oximetry on R calf (28 and 18% p&lt;0.01) and thigh (22 and 18% P&lt;.01 ) with no differences in the sham. Ischemia reduced treadmill times from T0 to T8 from 24 to 9.4 minutes (p&lt;0.01) vs sham increase from 23.3 to 32.2 (p&lt;0.09) . R internal Iliac artery had the largest growth of cross-sectional area at T4 and T8 (111.7 and 115.2%) compared to L EIA (40.6 and 46.1% - p&lt; 0.02 and &lt;0.5 ) and aorta (14.5 and 29% p &lt;0.02 and &lt;0.02 ). R profunda artery angiographic appearance was delayed at T4, which improved at T8 after normalization of the timing ratio from right to left (3.25 vs 2.3 p&lt;0.008 ). Mitochondrial oxygen consumption in the ischemic right gastrocnemius was consistently lower ex-vivo (21.96±6.41 vs 15.11±11.1 p&lt;0.03 ) with no differences in the sham. We had no fatalities. Discussion: We present a porcine model of hindlimb ischemia (iliofemoral artery occlusion) which recapitulates key aspects of the pathophysiology of human PAD/ claudication, and can support the development of new therapies for PAD.

A retrospective study on the management of massive hemoptysis by bronchial artery embolization: risk factors associated with recurrence of hemoptysis

BackgroundMassive hemoptysis is a life-threatening condition that requires immediate treatment. This study aimed to retrospectively analyze the outcome of bronchial artery embolization (BAE) for massive hemoptysis, as well as potential factors that may contribute to the recurrence of hemoptysis after BAE.MethodsA total of 105 patients with massive hemoptysis treated with BAE were analyzed.ResultsThe immediate control rate of bleeding was 84.8% (67/79); however, during the 36-month follow-up, 45.3% (29 out of 64) of the patients had recurrent hemoptysis after BAE. Comorbidities, pituitary hormone treatment, the angiographic appearance of artery dilation and hypertrophy, and the materials used for BAE were significantly correlated with the success rate of the BAE, while lack of pituitary hormone treatment and existence of arterio-arterial or arteriovenous fistula were risk factors for the recurrence of hemoptysis after BAE. Only a small proportion of patients (9/105, 8.6%) had mild complications after BAE treatment.ConclusionFindings suggest that BAE continues to be an effective treatment for massive hemoptysis in emergency settings. Moreover, the treatment of underlying pulmonary diseases and comorbidities is important to increase BAE’s success rate of BAE and decrease the risk of recurrent hemoptysis after BAE.

Symptomatic and asymptomatic carotid near-occlusions have very similar angiographic appearance on CT-angiography

The aim of this study was to compare the angiographic appearance of symptomatic and asymptomatic carotid near-occlusion. We have found no such previous study. The study hypothesis was that among symptomatic patients with ≥ 50% carotid stenosis, near-occlusion is more common and near-occlusions are more severe than among asymptomatic persons with ≥ 50% carotid stenosis. We reassessed consecutive CTAs from 4042 persons, 645 had ≥ 50% carotid stenosis, and 385 (60%) symptomatic. Near-occlusion was similarly common in symptomatic (105, 27%) and asymptomatic (56, 24%) cases. Among near-occlusions, the angiographic appearance was very similar between symptomatic and asymptomatic cases: mean stenosis lumen diameter (0.7 mm), distal ICA diameter (2.1 mm), and ECA ratio (0.79) were the same in both groups. Mean ICA ratio (0.46 and 0.48) and share of full collapse was very similar (45% and 42%). These findings add to the pathophysiological understanding of carotid near-occlusion.

Intrasaccular neck-bridging: A technical note on Nautilus-assisted coiling of wide-necked cerebral aneurysms. Feasibility study, immediate and early angiographic results.

Various adjunctive devices have been reported to be helpful during the endovascular coiling of complex, wide-necked cerebral aneurysms. This study aimed to describe the utilization of a recently introduced intrasaccular neck-bridging implant specifically designed to facilitate coil embolization. We retrospectively reviewed eight consecutive patients who underwent treatment for intracranial aneurysms with the Nautilus intrasaccular bridging system between February 2022 to May 2022. We evaluated the angiographic appearances of treated aneurysms at the end of the procedure and early follow-up, the clinical status and complications. Eight patients with eight cerebral aneurysms (3 men and 5 women, mean age 52.8 years (range 39-66) were analyzed. Five of the treated aneurysms were managed in an acute case scenario. There were no technical difficulties while executing the technique. No other procedural adverse events were documented. Immediate complete occlusion of the aneurysm was seen in 6 patients, neck remnant in 1 and stable aneurysm reperfusion in one case. Early radiological follow-up was available in five patients, and the observed occlusion rates were - RR class I in all radiologically screened aneurysms. Nautilus-assisted coil embolization represents a rapid and safe solution for complex cerebral aneurysms. In our opinion this device symbolizes a significant step forward in treating intracranial aneurysms. We believe that the technique's actual value consists of the fact that the device is fully compatible with the modern low-profile microcatheter technology and does not involve the need for antiplatelet medications.

Meniscus Sign in Patients with Anterior Circulation Large Vessel Occlusion Stroke does not Predict Outcome

PurposeThe angiographic appearance of the occlusion site was suggested to influence outcomes of stroke patients with large vessel occlusion (LVO) who undergo endovascular treatment (EVT). We aimed to study the impact of the meniscus sign (MS) on outcomes of stroke patients with anterior circulation LVO.MethodsBased on two prospective registries of acute ischemic stroke, we selected patients with carotid‑T, M1 or M2 occlusion who underwent EVT. Clinical characteristics and outcomes were collected from the registries or from individual records. Two independent observers blinded to outcomes assessed the presence of MS in digital subtraction angiography before thrombectomy. Angiographic and clinical outcomes of patients with and without MS were compared.ResultsWe included 903 patients, with median age of 78 years, 59.8% were male, median baseline NIHSS was 14 and 39.5% received intravenous thrombolysis. Patients with MS (n = 170, 18.8%) were more frequently female, presented with higher NIHSS scores and more frequently underwent intravenous thrombolysis. Presence of MS was significantly associated with cardioembolic etiology. Successful reperfusion, number of passes, first pass effect, procedural time, symptomatic intracerebral hemorrhage, in-hospital mortality and favorable 3‑month functional outcome were similar in the groups of patients with and without MS. In the multivariable analyses, MS was not associated with successful reperfusion (odds ratio, OR = 1.08, 95% confidence interval, CI = 0.76–1.55), first pass effect (OR = 0.96, 95%CI = 0.48–1.92) or favorable 3‑month outcome (OR = 1.40, 95%CI = 0.88–2.24).ConclusionThe presence of MS in acute ischemic stroke patients with anterior circulation large vessel occlusion who undergo EVT does not appear to influence angiographic or clinical outcomes.

Stroke Recurrence in Children with Vertebral Artery Dissecting Aneurysm.

Pediatric vertebral artery dissecting aneurysm is a subtype of vertebral artery dissection that can be challenging to diagnose and may be associated with stroke recurrence. This study examines the presenting features, clinical outcomes, and recurrence risk in a cohort of children with vertebral artery dissection, comparing those with aneurysms with those without. The medical records of children evaluated for vertebral artery dissection were retrospectively reviewed for neurologic presentation, treatment, stroke recurrence, and angiographic appearance of dissection. Cohort patients were categorized into 2 groups based on the presence or absence of a vertebral artery dissecting aneurysm and compared via the Fisher exact test, Student t test, and log-rank analyses. P < .05 was deemed statistically significant. Thirty-two patients met the inclusion criteria, including 13 with vertebral artery dissecting aneurysms. Five cases of vertebral artery dissecting aneurysm were missed on the initial evaluation and diagnosed retrospectively. All patients received antiplatelet or anticoagulation therapy at the time of diagnosis. Children in the vertebral artery dissecting aneurysm group were more likely to present with stroke (P = .059), present at a younger age (P < .001), and have recurrent stroke (P < .001) compared with the group of children with vertebral artery dissection without an aneurysm. After surgery, no patients with vertebral artery dissecting aneurysm experienced recurrent stroke (P = .02). Vertebral artery dissecting aneurysm is often missed on the initial diagnostic evaluation of children presenting with stroke. In children with vertebral artery dissection, the presence of an aneurysm is associated with stroke presentation at a younger age and stroke recurrence.

499 What light through yonder window breaks? Benefits of optical coherence tomography (OCT) in a case of spontaneous coronary artery dissection

Abstract Aims Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial walls, creating a false lumen. SCAD is an infrequent and often missed diagnosis especially in women presenting with acute coronary syndrome and in the majority of cases angiography alone could be insufficient for identification. Methods and results A 43-year-old woman presented to the Emergency Department of Fondazione Policlinico Universitario A. Gemelli IRCCS (Rome, Italy) for oppressive acute chest pain radiated to the right jaw, resolved spontaneously within a few minutes. Physical examination, including cardiovascular evaluation, was normal. High-sensitivity troponin was 152 ng/l and 250 ng/l in two serial determination (reference range, 0.0–37 ng/l). EKG showed sinus rhythm with no significant ST-segment alterations. Echocardiography revealed preserved biventricular systolic function with mild hypokinesia of the apical segments of the left ventricle. A diagnosis of NSTEMI was made based on clinical and laboratory parameters. Thus, urgent coronary angiography was performed, which demonstrated a single vessel disease with an eccentric, and angiographically complex stenosis of the proximal left anterior descending (LAD) artery with an image of plus compatible with a plaque ulceration. In order to define the extension of the disease and ostium involvement for a better procedural planning, OCT imaging was performed. Surprisingly, OCT showed a intramural haematoma extending from the ADA ostium to the proximal tract (approximately 22 mm) with ulceration in the body, minimal lumen area (MLA) 2.0 mm2 and evidence of normal trilaminar structure of the vessel both on downstream and upstream of the lesion. The angiographic features were compatible with type 2A SCAD. The therapeutic management was conservative with continuation of the double antiplatelet therapy and remote CT monitoring. Three days later, because of a new onset of chest pain and slight elevation of the ST segment on EKG, was performed a coronarographic control: the angiographic appearance of the lesion was substantially unchanged; OCT showed unmodified longitudinal extension of the lesion (about 22 mm) and relative increase in the endoluminal caliber compared to the previous examination (MLA 4.0 mm2).After 2 weeks, coronary CTA control was carried out, which documented the stability of the intramural hematoma in the proximal LAD, extended for 22 mm and with a maximum thickness of 2 mm, determining lumen narrowing of 40–45% The patient was discharged on medical therapy and no events occurred during the follow-up. Six month later, repeat CTA showed a complete resorption of the intramural haematoma. Conclusions In this case we highlight the utility of intravascular imaging, in particular OCT, in the evaluation of angiographic lesions of non-univocal interpretation and how its use can change the management and prognosis of ACS patients. Furthermore, the spontaneous resolution of the clinical and anatomical scenario through conservative treatment additionally confirms spontaneous healing as the natural history of SCAD and foreground the role of precise diagnosis (and intravascular imaging showed to improve it) for therapy shift and calibration.

734 Have I lost my large rupture cavity? The fingerprint of atherosclerotic plaque healing detected by serial optical coherence tomography imaging

Abstract A 64-year-old man, prior smoker, with a history of paroxysmal atrial fibrillation was referred to our hospital due to worsening dyspnoea, progressively worsening angina, and a positive stress EKG testing. Coronary angiography (CAG) showed an angiographically intermediate stenosis of the mid left anterior descending (LAD) artery and a focal, complex lesion of the distal right coronary artery (RCA) (Figure 1A and B, red arrow). Treatment of the LAD stenosis was deferred based on a negative fractional flow reserve value (i.e. 0.85). Optical coherence tomography (OCT) imaging (ILUMIEN OPTIS, Abbott Vascular, Santa Clara, CA) was performed to better characterize the RCA lesion, which disclosed a ruptured thin-cap fibroatheroma (TCFA) with a large ‘empty’ cavity (Figure 1C–G, red arrows) and overlying ‘layered’ tissue (Figure 1H, white arrowheads). Based on these OCT findings, suggestive of initial plaque healing, and on a large residual lumen dimension (i.e. minimum lumen area, MLA, at the rupture site: 7.7 mm2), this lesion was not treated with percutaneous coronary intervention. The patient was discharged on aspirin, edoxaban, metoprolol, rosuvastatin, and ezetimibe, and remained clinically stable for more than 1 year. Due to angina recurrence, a new CAG was performed 18 months after the first admission, revealing a progression of the mid LAD stenosis that was treated with a 2.5/28 mm drug-eluting stent, and an improvement of the RCA lesion angiographic appearance (smooth contour) (Figure 1A′–B′). RCA OCT imaging was repeated demonstrating a complete healing of the large rupture cavity with all the hallmarks of the reparative process (Figure 1C′–H′): (1) re-established fibrous cap integrity and smooth vessel lumen profile; (2) thickening of the fibrous cap and reduction of lipid burden (i.e., transformation of TCFA into thick-cap fibroatheroma, ThCFA); (3) replacement of the ‘empty’ cavity with new ‘granulation tissue’; (4) initial calcification of the plaque; (5) heterogeneous signal-rich layers with distinct optical-signal intensity (layered, ‘onion-like’ pattern); and (6) mild lumen narrowing (MLA at the rupture site: 6.9 mm2).

Western Moyamoya Phenotype: A Scoping Review.

Moyamoya, a rare angiographic finding, is characterized by chronic and progressive stenosis at the terminal end of the internal carotid artery, followed by collateralization of the cerebral vasculature at the base of the skull. Coined by Suzuki and Takaku in 1969, the term “moyamoya” means a “puff of smoke” in Japanese, a reference to the angiographic appearance of moyamoya collateralization. Moyamoya is most commonly found in East Asian countries, where much governmental and civilian effort has been expended to characterize this unique disease process. However, despite its rarity, the occurrence of moyamoya in Western countries is associated with significant divergence regarding incidence, gender, sex, age at diagnosis, clinical presentation, and outcomes. Here, we attempted to review the Western literature on moyamoya presentation using the PubMed database to characterize the Western phenotype of moyamoya. We were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). We reviewed papers generated from a search with keywords “moyamoya case report,” those reported from a Western institution, and those reported on a relevant association. Our scoping review demonstrated various clinical associations with moyamoya. Moreover, we summarized the demographic profile and clinical symptomatology, as well as reported disease associations to better elucidate the Western phenotype of moyamoya.

Seurat Spleen: A Pathognomonic Sign in Angiography

Splenic injury commonly occurs following abdominal trauma and can result in severe complications and death if it goes unrecognized. The Seurat spleen is a term used to describe the angiographic appearance of splenic injury following blunt trauma, given its resemblance to the pointillistic artwork of French neo-impressionist Georges Seurat. We present a case of a 43-year-old man who presented following a motor vehicle collision and was found to have multiple punctate foci of contrast extravasation in the spleen consistent with the Seurat spleen angiographic sign. This angiographic pattern can be used as a pathognomonic sign to identify splenic injury, with early identification crucial to preventing further complications of the injury.

Clinical presentation of simple and combined or syndromic arteriovenous malformations

ObjectiveArteriovenous malformations of the lower extremities (AVMLE) can present as simple or complex combined or syndromic forms (eg, Parkes Weber Syndrome). We aimed to characterize the differences in clinical presentation and natural history of these potentially life- and limb-threatening congenital vascular malformations. MethodsWe conducted a retrospective analysis of a consecutive series of patients with AVMLE who presented to a tertiary referral center in Switzerland between 2008 and 2018. Clinical baseline characteristics, D-dimer level, and course were summarized and differences between simple, non-syndromic and combined or syndromic AVMLE determined. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. ResultsOverall, 506 patients were prospectively enrolled in the Bernese Congenital Vascular Malformation Registry, 31 (6%) with AVMLE. There were 16 women and 15 men, with a mean age of 18 years at first diagnosis (range, 1 month to 72 years). Simple AVMLE was present in 22 (71%) and combined or syndromic AVMLE with limb overgrowth in 9 patients (29%), respectively. Common symptoms and signs were pain (n = 25; 81%), swelling (n = 21; 68%), and soft tissue hypertrophy (n = 13; 42%). Among combined or syndromic patients, three patients died from wound infection with sepsis or disseminated intravascular coagulation with bleeding complications (intracranial hemorrhage and bleeding from extensive leg ulcers). Combined or syndromic patients presented more often with bleeding (67% vs 5%; P < .001), malformation-related infection (44% vs 5%; P = .017) and leg length difference (56% vs 14%; P = .049). D-dimer levels were elevated (mean, 17,256 μg/L; range, 1557-80,000 μg/L) and angiographic appearance showed complex, mixed type of AVMs, including interstitial type IV, in all patients with combined or syndromic AVMLE. ConclusionsPatients with congenital simple AVMLE most often present with benign clinical features and rarely with complications related to hemodynamic changes. Patients with combined or syndromic AVMLE often face serious outcomes dominated by complications other than direct high-flow-related heart failure.

Spontaneous Coronary Artery Dissection: A Case Series of 8 Patients with Literature Review

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndromes, affecting a mainly female population with few cardiovascular risk factors, with an incidence of 0.07–0.2% of all angiograms and 2–4% of angiograms performed for acute coronary syndrome (ACS) .It is defined by a spontaneous, non-traumatic and non-iatrogenic separation of the coronary wall, in the absence of an associated atheromatous lesion. The pathophysiology is heterogeneous, including hormonal influences, arteriopathies, and precipitating intense physical or emotional stressors. Methods and results: Between 2018 and 2020, 8 cases of SCAD were collected from a database our cardiology unit. The mean age was 46 years with a female exclusive and 47% of patients were under 50 years old. Three patients (37.5%) had no cardiovascular risk factor (CVRF). One patient had SCAD in a peripartum setting with a personal and a family history of fibromuscular dysplasia. All our patients were admitted for ACS, the half of them presented a ST-segment elevation myocardial infarction (STEMI), and the other half presented non-STEMI. In all de cases the diagnosis was confirmed by angiography alone. All patients were managed with conservative approach in the early and late phases. The anterior interventricular artery (AIV) was most frequently involved in 62.5% of cases. No endocoronary imaging was required; 37.5% were classified as Type 1, 37.5% as Type 2 and 50% as type 4. No lesions were classified as Type 3. The cardiac computed tomography angiography (CCTA) control was performed in 62.5% between 1 and 6 months. The extracoronary workup was performed in 37.5% of the cases and revealed lesions in 66% of the cases. Conclusion: The data from this study are consistent with the literature, and involvement of the left coronary artery and left main coronary artery were highly prevalent. Clinicians must be aware of angiographic appearances of SCAD for prompt diagnosis and management......

Treatment of Iatrogenic Coronary Artery Dissection in Resource Constraint in Cath-Lab, A Retrospective Study

Introduction: Coronary Artery Dissection is a well-known serious complication of invasive procedures (e.g. coronary angiography, balloon angioplasty and surgical cardioplegia) and is due to mechanical injury of the arterial wall by interventional devices used during procedures needing skilled operator to manage it timely. Objective: We wanted to look at these large tears that can dramatically affect blood flow and result in severe complications to understand where they happen most and how efficient are we at managing them for our patients in limited resources of the Cath-labs in developing countries. Methods: We reviewed the record of 28 (3.4%) cases of large dissection found in 806 patients who underwent coronary angioplasty in Cath lab of Cardiology Department of Dow University of Health Sciences Karachi. We analyzed as per American College of Cardiology/American Heart Association (ACC/AHA) criteria of the type of lesion, chronic total occlusion, calcification, intra-procedural dissection, and vessel site, related complications and management strategies. Results: Among the 806 patients that underwent per-cutaneous coronary intervention during 3 years (2014-2017) period at Cath-lab of Cardiology Department of Dow University of Health Sciences Karachi, 28 (3.4%) patients were found to have extensive dissection. Out of 10 patients who had immediate angioplasty and stenting for closure of dissection 8 patients were successfully treated and 2 (7.1) died during procedures. 8 (28.5%) needed immediate coronary artery bypass surgery. 10 (35.7%) out of the 28 (3.4%) patients were managed by further hospitalization with medical treatment out of them 3 patients needed angioplasty procedures. There were no late deaths. Conclusion: Coronary artery dissection remains a common occurrence during PCI since pre-stent procedures and clinical sequelae have been minimized by the routine use of coronary stents. Rapid recognition and attention to the angiographic appearance of the dissection is essential to the successful management of this complication. None the less, patients with extensive dissection who are free from the manifestation at the end of the procedure can be managed conservatively. Attempts should be made to stabilize extensive dissection during coronary angioplasty so that surgical intervention can be delayed or avoided altogether if possible.

Spontaneous Coronary Artery Dissection: Pitfalls of Angiographic Diagnosis and an Approach to Ambiguous Cases.

Spontaneous coronary artery dissection (SCAD) is a pathophysiologically distinct cause of acute coronary syndromes (ACS). It is increasingly recognized that optimal management is different from that for atherosclerotic ACS and that a SCAD diagnosis has specific long-term prognostic and therapeutic implications. Accurate diagnosis is therefore essential to ensure the best treatment of patients. At present this relies on the recognition of typical features of SCAD identified on invasive coronary angiography. Although most SCAD can be readily distinguished angiographically from alternative causes of ACS, false positive and false negative diagnoses remain common. In particular, sometimes non-SCAD presentations, including atherothrombosis, takotsubo cardiomyopathy, coronary embolism, coronary vasospasm, contrast streaming, and myocardial infarction with nonobstructive coronary arteries, can mimic angiographic features usually associated with SCAD. The authors present the combined experience from European and US SCAD referral centers reviewing the classical angiographic appearances of SCAD, presenting potential diagnostic pitfalls and exemplars of SCAD mimickers. The authors further review the benefits and limitations of intracoronary imaging in the context of SCAD. Finally, the authors discuss the investigation of ambiguous cases and an approach to minimize misdiagnosis in difficult cases.

Virtual test occlusion for assessing ischemic tolerance using computational fluid dynamics.

Background: Ischemic tolerance has been evaluated by the balloon test occlusion (BTO) for cerebral aneurysms and tumors that might require parent artery occlusion during surgery. However, because of its invasiveness, a non-invasive evaluation method is needed. In this study, we assessed the possibility of virtual test occlusion using computational fluid dynamics (CFD) as a non-invasive alternative to BTO for evaluating ischemic tolerance.Methods: Twenty-one patients who underwent BTO were included in the study. Virtual test occlusion was performed using CFD analysis, and the flow rate (FR) and wall shear stress (WSS) of the middle cerebral artery on the occlusion side were calculated. The correlations between these parameters and examination data including the parameters of computed tomography perfusion during BTO were assessed and the cutoff value of CFD parameters for detecting the good collateral group was calculated.Results: The FR was strongly correlated with mean transit time (MTT) during BTO and moderately correlated with collateral flow grade based on angiographic appearance. The WSS was moderately correlated with collateral flow grade, mean stump pressure (MSP), and MTT. Furthermore, the FR and WSS were strongly correlated with the total FR and the diameters of the inlet vessels. The cutoff value of FR for detecting the good collateral group was 126.2 mL/min, while that of the WSS was 4.54 Pa.Conclusion: The parameters obtained through CFD analysis were correlated with collateral flow grade and MSP in addition to MTT. CFD analysis may be useful to evaluate ischemic tolerance as a non-invasive alternative to BTO.

Transpleural systemic artery-to-pulmonary artery communications in the absence of chronic inflammatory lung disease. A case series and review of the literature

To describe the causes and computed tomography (CT) and angiographic appearances of transpleural systemic artery-to-pulmonary artery shunts in patients without chronic inflammatory lung disease and determine their best management. All patients referred to a tertiary referral unit between January 2009 and January 2020 in whom a diagnosis of a systemic-to-pulmonary artery communication without underlying chronic inflammatory lung disease was subsequently made have been included in this report. Medical records and imaging findings were reviewed retrospectively. Ten patients (male: female ratio=7:3; median age 42 years [range 22-70 years]) with systemic artery-to-pulmonary artery shunts without chronic inflammatory lung disease were identified. Five were misdiagnosed as having a pulmonary arteriovenous malformation and had been referred for embolisation. In six patients, there was either a history of accidental or iatrogenic thoracic trauma or of inflammatory disease involving the pleura, and in two patients, in whom a previous medical history could not be obtained, there were CT features suggesting previous pleural inflammatory disease. Two shunts were thought to be congenital. All individuals were asymptomatic other than one with localised thoracic discomfort that dated from the time of surgery. All patients were managed conservatively and have remained well with a median follow-up of 4.5 years (range 1-11.3 years). Localised transpleural systemic artery-to-pulmonary artery shunts in the absence of chronic inflammatory lung disease are usually related to previous thoracic trauma/intervention or abdominal or pulmonary sepsis involving a pleural or diaphragmatic surface. Congenital shunts are rare. The present study and much of the literature supports conservative management.