Control Angiography Research Articles

Percutaneous Patent Ductus Arteriosus (PDA) closure: When and how to close Coil VS Occluder “step by step” cases report

Background: The PDA defines the pathological persistence after the birth of a fetal physiological communication between the aorta and the pulmonary artery frequently encountered in preterm infants and whose clinical and hemodynamic consequences depend on the importance of the shunt directly bound to the diameter of the canal. Percutaneous closure is the most frequent management modality with excellent immediate and long-term results (two modes of closure: using coil or Occluder). The surgery remains reserved for complex anatomies or associated with other surgical congenital anomalies. Case presentation: We detail in this document the two methods of percutaneous closure step by step illustrated by pediatric cases. The first case concerns a 7 years old girl of 17 kg weight with a history of heart murmur that presented in the TTE a PDA estimated at 1mm with LV dilation. The second case concerns a 12 years old girl of 30 kg weight with also a history of heart murmur that presented on TTE a PDA of 4.5mm with LV dilation. Therapeutic intervention: In the first case, we perform a closure with coil 5/5 by a unique femoral arterial approach as a standardized attitude in our center avoiding additional venous access. For the second case, we opted for closure with prosthesis N° 6/8 by a double femoral approach (arterial and venous access). Outcomes: The follow-up was favorable for both patients, with total sealing of the defect immediately after the procedures that persist during the 6 months of control. Conclusion: The closure of PDA in children is a challenging procedure whose safety requires a good pre-and per-procedural evaluation allowing the right choice of the method and size of the closing device. The respect of the different closure stages and the critical per procedural ultrasound and angiographic control reduce the rate of complications making this technique accessible and safe. In our series of 108 PDA closures by Coil in children, the unique femoral arterial approach is the standardized attitude in the first line in all patients avoiding additional venous access, which allows the Coil release in the basic technique while the arterial access allows opacification and measurement of the channel. The unique arterial approach has reduced the risk of local complications at the puncture site and the duration of the procedure without difference in closure efficiency and embolization risk. In our series of 92 PDA closures by Occluder in children the double femoral approach is the standardized attitude for all patients, the venous access allows the device release while the arterial access allows opacification/ measurement of the channel and control device deployment.

A novel histological occlusion classification for coiled aneurysms based on multiphoton microscopy.

Intracranial aneurysm (IA) coiling remains the most commonly used endovascular approach for ruptured and unruptured IA, and recanalization is a common drawback that impairs treatment success. Angiographic occlusion and aneurysm healing are not synonymous, and histological evaluation of embolized aneurysms remains a challenge. We propose here an experimental study of coil embolization in animal models by multiphoton microscopy (MPM) in comparison with conventional histological staining. The purpose of his work is to analyze coil healing process using histological sections of aneurysms. Based on a rabbit elastase model, 27 aneurysms were fixed, embedded in resin, and cut in thin histological sections 1 month after coils implantation and after angiographic control. Hematoxylin and eosin (H&S) staining were realized. Non-stained adjacent slices were imaged for multiphoton excited autofluorescence (AF) and second-harmonic generation (SHG) to construct three-dimensional (3D) projections of sequentially and axially acquired images. The contrast provided by the combination of these two imaging modalities can be used to distinguish five levels of aneurysm healing, based on a combination of thrombus evolution and increased extracellular matrix (ECM) deposit. RDPC:\Users\SHAHUL\RDP6|We have established a novel histological scale from a rabbit elastase aneurysm model after coiling with a classification of five different stages thanks to nonlinear microscopy. This classification is an actualized tool in order to obtain a more precise evaluation of occlusion device efficacy in the scope of new innovative microscopy for research.

Using Intravascular Ultrasound as Experience in a Comorbid Patient of High Surgical Risk

Intravascular ultrasound examination (ICSI) allows to assess the nature of atherosclerotic plaque, the degree of significance and extent of stenosis, as well as to monitor the position of the stent in the lumen of the coronary artery. Insufficient opening of the stent, unrecognized during angiographic control, can lead to thrombosis or restenosis in the early or long term. The clinical case presented in the publication demonstrates the difference between the results of fluoroscopycontrolled stenting and ICSI-controlled stenting during percutaneous coronary intervention (PCI) in a high-risk surgical patient with significant concomitant pathology.

Intracranial aneurysms - a battle against time

Introduction: Intracranial aneurysms consist in abnormal dilatation of the cerebral arteries, most frequently asymptomatic, with symptoms appearing in the case of aneurysm rupture. From an imaging point of view, a cranial CT scan shows the subarachnoid haemorrhage caused by aneurysm rupture and the “gold standard” for aneurysm diagnosis is cerebral angiography.
 Case presentation: A 49 years-old female, Ukrainian refugee, presented with a unique comitial crisis and chronic headache. Following an MRI performed in Kiev, it was decided to perform a bilateral carotid and vertebral angiography in our clinic. Clinical and imagistic results showed a giant left middle cerebral artery aneurysm. Postoperative, the patient had a favourable neurological recovery, with no neurological deficits. Additionally, control angiography and CT scan highlight complete occlusion of the aneurysm and no complications.
 Conclusions: Cerebral aneurysms represent a high-risk vascular condition that needs a CT scan and angiography to be precisely diagnosed, surgical clipping should be performed as soon as possible.

Descriptive and prognostic study at 5 years of percutaneous coronary intervention by long active stents ≥ 40 mm

The treatment of long coronary lesions often requires long stents, which carries a higher risk of stent thrombosis, restenosis and major adverse cardiac events. Our objective is to evaluate the clinical and angiographic results, immediate, in the medium and in the long-term of the coronary angioplasties with very long active stents ≥ 40 mm. We carried out a retrospective, multicenter, descriptive and prognostic study, during a period of 5 years between January 2015 and January 2020 in four Tunisian centers, including all patients who underwent coronary angioplasty with an active stent ≥ 40 mm in length. Four hundred and eighty patients were included. Our population was at high cardiovascular risk: the mean age was 62.45 years with a sex ratio of 3.40. The most frequent cardiovascular risk factors were as follows: arterial hypertension: 61.1%, diabetes: 56.6% and tobacco: 60.5%. The most common clinical presentation was acute coronary syndromes in 69.70%. The artery most frequently stented with a very long stent was the anterior interventricular artery in 49.4%. The treated lesions were complex: 23.5% were calcified, 8.7% were total chronic occlusions and 25% had bifurcations. The average length of the implanted stents was 47.72 mm. The long coronary lesion required an overlap by a 2nd stent in 16.45% of the interventions. Angiographic and clinical success was observed in 96% and 95% of cases respectively. Seventeen cases of per-procedural complications were recorded during the procedure (3.55%). Angiographic control was only performed during the follow-up in 21.7% of patients. The stent thrombosis rate was 0.83%. The incidence of MACE, TVR and TLR and was 16.3%, 9.2% and 7.9%, respectively. Diabetes appeared to be predictive factors of TLR (survival without TLR at 12 months = 99% vs. 93.7%; P = 0.01). The study of the characteristics lesion showed that ostial lesions and bifurcation lesions are predictive factors for increased TLR (ostial lesion: survival without TLR at 5 years = 78.2% vs. 87.4%; P = 0.001/bifurcation lesion: survival without TLR at 5 years = 84% vs. 92.7%; P = 0.03). Coronary stenoses requiring treatment with long stents are generally associated with high cardiovascular risk and complex atheromatous disease. They can be revascularized with a long active stent (≥ 40 mm) with an acceptable MACE, TLR, TVR and thrombosis rate.

Acute coronary syndrome in a young patient with ECG presentation of acute inferior myocardial infarction and acute thrombosis of left main stem coronary artery

Introduction. The left main stem (MS) coronary artery (CA) (MSCA) thrombosis is a rare but potentially lethal manifestation of acute coronary syndrome. The standard approach in treating such patients is the primary percutaneous coronary intervention (pPCI) or CA bypass graft surgery. In some cases, depending on the morphological appearance of the thrombus, findings and flow rates assessed on coronary angiography (CAn), clinical conditions, and cardiologist?s experiences, another possible method of treatment can be the conservative approach using antithrombotic therapy. Case report. A 37-year-old male was admitted to the emergency room with symptoms of an acute myocardial infarction with an ST elevation in diaphragmal localization. Using an emergency CAn, we have visualized a thrombus at the ostial and proximal part of the left MSCA, with no complete obstruction of the blood flow. Initially, dual antithrombotic therapy (ticagrelor and acetylsalicylic acid) was applied, and in the further procedure, it was decided to introduce glycoprotein IIb/IIIa platelet receptor inhibitor (tirofiban) as an intracoronary bolus (0.3 ?g/kg) and later as a continuous infusion (0.1 ?g/kg/min). Four days later, a control CAn and intravascular echocardiography were performed, and it was decided to continue the treatment using conservative therapy without a pPCI procedure. The patient was discharged in good condition with no signs of illness on the eighth day after hospital admission for home recovery, with planned frequent follow-ups in the future. Conclusion. In the case of non-obstructive thrombotic masses without significant atherosclerotic stenotic lesions, conservative treatment modality with the use of aggressive antithrombotic therapy may be considered.

Aneurysm of the primitive trigeminal artery: a clinical case and a literature review

Background. The primitive trigeminal artery is a fetal anastomosis connecting carotid and vertebrobasilar basins during embryonic period of development. After birth, this artery in the child is obliterated and reduced in most cases. Sometimes the obliteration does not occur and as a result the aneurysms may be formed on this artery (due to change in ordinary hemodynamics in carotid basin), as a consequence, it produces a risk of subarachnoid hemorrhage that sharply worsens prognosis of the disease outcome. The usual microsurgical treatment methods of aneurysms of such localization are of little use and are highly traumatic due to the very “low” location of the neck, because the surgery may need extended basal accesses requiring resection of skull base bones. Also, an “open” surgery produces risks of perforating arteries injury that often extend from trigeminal artery and feed the brain stem, the injury will immediately result in brain ischemic damage. That is why the preferred method for treatment of that kind of pathology may include endovascular intervention both of non‑reconstructive type employing microcoils only and those of reconstructive requiring implantation of assisting or flow‑redirecting stents.Aim. To demonstrate a case of successful treatment of patient with a primitive trigeminal artery aneurysm.Materials and methods. A woman, who was admitted to clinic with complaints of convergent strabismus, undergone surgery for large aneurysm located on primitive trigeminal artery. CT brain angiography revealed large aneurysm of primitive trigeminal artery on the right, the result was later confirmed by data of selective cerebral subtraction angiography. Taking into account oculomotor disorders in the patient, it was decided to refrain from microcoils use due to risk of the mass‑effect preservation. Under double disaggregant therapy (ticagrelor 90 mg twice daily + acetylsalicylic acid 100 mg once daily in the evening) and monitoring the functional activity of platelets, a flow‑deflecting stent was implanted into the right internal carotid artery.Results. The patient was discharged from hospital on the 1st day after the surgery and returned to work. A control angiography performed 3 years later revealed a total shutdown of the aneurysm from bloodstream as well as a partial regression of oculomotor disorders. Intravascular treatment in this situation served as an effective method of choice and made it possible to reliably turn off the aneurysm from bloodstream without impairing the functional outcome of patient’s treatment.Conclusions. It can be assumed that intravascular intervention in case of such aneurysms serves as an effective method of choice as minimally invasive and low‑traumatic surgery in the treatment of patients with that type of pathology.

Snare-Dragging Technique to Target the Hypogastric Artery in an Iliac Bifurcation Dissection

Purpose: To describe snare-assisted vessel targeting to selectively overcome a dissection in the iliac bifurcation and gain antegrade access to the hypogastric artery (HA). Technique: The technique is demonstrated in a 64-year-old woman with an asymptomatic Crawford type III thoracoabdominal aneurysm. A 2-stage endovascular repair, consisting of a thoracic endovascular aortic repair (TEVAR) and a branched endovascular aortic repair was planned. In the control angiography after TEVAR, a disrupted plaque with consequent dissection in the right iliac bifurcation was detected. The perfusion of the common iliac artery and external iliac artery resulted impaired. The targeting of the right HA through a contralateral antegrade approach failed, whereas an ipsilateral retrograde approach was possible but unsuitable for therapeutic purposes. Using the catheter of the retrograde ipsilateral access, a snare from a contralateral crossover was cached and dragged into the HA, allowing the targeting of the vessels and further endovascular therapy with angioplasty and stenting. Follow-up 8 months postoperatively demonstrated the patency of the stents and well-preserved perfusion in the right iliac bifurcation. Conclusion: The snare-dragging technique can be used to gain access to vessels presenting challenging conformations or dissections. This application may be a valuable support for complex endovascular treatment in a variety of patients. Clinical Impact The snare-dragging technique can be used to gain access to vessels presenting challenging conformations or dissections. It allows the catheterization to be establish from the easiest and safest approach and then “transferred” from one access to the other. It avoids the risk of repeated loss of catheterization due to unstable and unfavorable working angles, and it saves time and radiation. It permits different material combinations, adapting to the available resources and materials. We believe that the current technique may increase the strategy spectrum available for endovascular therapy and complex endovascular procedures.

Initial Single-Center Experience With the Knickerbocker Technique During Thoracic Endovascular Aortic Repair to Block Retrograde False Lumen Flow in Patients With Type B Aortic Dissection

Objective: Effectiveness of thoracic endovascular aortic repair in type B aortic dissection is impaired by persistent retrograde false lumen flow via distal re-entry tears. Controlled, stentgraft-assisted balloon dilatation of the true lumen at its lower end, or Knickerbocker technique, may block retrograde false lumen flow and consequently improve effectiveness by inducing immediate thrombosis along the entire descending thoracic aorta. Materials and Methods: A single-center retrospective analysis was performed for all consecutive patients with aortic dissection treated with the Knickerbocker technique to block retrograde false lumen flow. Results: Eleven patients were included for analysis. Intraoperative control angiography showed successful occlusion of the false lumen at the level of balloon dilatation in 9 out of 11 patients (82%). There was one perioperative mortality (9%), due to stroke. There were 2 early reinterventions, due to retroperitoneal bleeding and due to chyle leakage in the neck after left subclavian artery bypass. Median clinical follow-up duration was 6 (interquartile range [IQR] 2–11] months. There were 2 deaths during follow-up, one at 2 months after TEVAR from unknown cause of death, and one after 11 months due to rupture of an ascending aortic pseudoaneurysm. The Knickerbocker technique led to positive aortic remodeling. At 3 months follow-up, 100% of patients showed complete false lumen thrombosis in the thoracic aorta proximal to the level of balloon dilatation, with decreasing false lumen diameters (100%) and stable (44%) or decreasing (56%) total aortic diameters. In most patients, the false lumen distal to the stentgraft (i.e. at visceral level) remained patent (11% false lumen thrombosis rate), leading to ≥2 mm dilatation at this level (78% of patients) and in the infrarenal abdominal aorta (56% of patients) at 3 months postoperatively. No distal stent-graft-induced new entry tears were noticed during follow-up. Conclusion: The Knickerbocker technique is feasible and effective, leading to positive aortic remodeling of the aorta covered by stentgraft in all of a small cohort of patients. Clinical Impact Persistent, retrograde false lumen perfusion from distal re-entries following thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection, may lead to progressive, aneurysmal dilatation. Controlled, stent graft-assisted balloon dilatation of the true lumen in the distal descending aorta (i.e. Knickerbocker technique) during TEVAR effectively excludes the false lumen from persistent flow resulting in positive aortic remodeling in our small cohort of patients, and hence potentially eliminates the risk of late post-dissection aneurysm formation in the descending thoracic aorta.

Combining transradial access and sheathless femoral access for complex iliac artery chronic total occlusions

BackgroundThe transradial approach (TRA) is associated with fewer serious access site-related complications compared with the transfemoral or transbrachial approach. However, TRA has associated problems in complex aortoiliac (AI) lesions, including the procedural difficulty. A bidirectional approach was used combining TRA with a sheathless technique for femoral artery (FA) puncture to treat complex AI lesions, as a minimally-invasive approach. This report describes a representative cases with AI chronic total occlusion in which the combination of TRA and a sheathless technique for FA puncture was useful for guidewire crossing.Case presentationCase 1 was a 71-year-old man with intermittent claudication (IC). Control angiography showed total occlusion of the left common iliac artery (CIA) ostium to the distal external iliac artery (EIA). Guidewire externalization was achieved by combining TRA using a 6Fr guiding sheath and a sheathless technique for the left FA. Two nitinol stents were deployed in the CIA to EIA. Case 2 was a 63-year-old man with IC. Control angiography revealed total occlusion of the right CIA ostium to the common femoral artery (CFA) with severe calcification. The antegrade wire could not pass through the CTO lesion because of the calcified CFA occlusion. A 21-G metal needle was used to penetrate the CFA calcification through the distal true lumen of the CFA, and the wire was inserted into the EIA for wire externalization. Three nitinol stents were deployed in the CIA to EIA, and a drug-coated balloon was dilated in the CFA with hemostasis of the distal puncture site. In both cases, the retrograde puncture site was hemostatic during the procedure and postoperative bed rest was not required.ConclusionsTRA combined with a sheathless technique from the FA has the potential to treat AI complex lesions in a less invasive manner.

TRATAMIENTO ENDOVASCULAR CON COILS DE ANEURISMA DE ARTERIA COMUNICANTE ANTERIOR, CONTROL ANGIOGRAFICO Y EVOLUCION SEGÚN DENSIDAD DE EMPAQUETAMIENTO: SERIE DE CASOS

Objective: The goal of this study is to present the outcomes of endovascular treatment performed on a group of patients diagnosed with ruptured aneurysms in the anterior communicating artery. The effectiveness of the treatment will be assessed based on the degree of packing observed in both immediate and subsequent angiography control. Methods: An observational, retrospective, and descriptive study was conducted at the Guillermo Almenara Hospital to analyze the treatment outcomes of patients with ruptured anterior communicating artery aneurysms, who were solely treated through embolization with coils (without stent or balloon) in the year 2021 and 2022. The degree of packing of the aneurysms was measured and analyzed using the AngioCalc program, while data analysis was performed using Excel. Results: Three patients with ACom aneurysm were successfully treated using only coils for embolization. Among them, two patients had a Fisher IV subarachnoid hemorrhage (SAH) while one patient had a Fisher III SAH. The volume of the aneurysm was 12.78 mm3 for patient A, 51.65 mm3 for patient B, and 34.06 mm3 for patient C. The degree of packing of the aneurysm was calculated using a formula and found to be 23.79%, 28.7%, and 34.06% for patients A, B, and C respectively. These values were all greater than 24%. The immediate angiography results were classified as RR II for patients A and B, and RR IIIA for patient C. Subsequent angiographic control results were classified as RR IIIA for patient A, RR II for patient B, and RR IIIB for patient C. All patients had a favorable outcome. Conclusions: The degree of coil packing affects the evolution of an embolized aneurysm, therefore serial angiographic monitoring is necessary to detect recurrence and perform additional endovascular treatment if needed. Keywords: Aneurysm, Ruptured, Subarachnoid Hemorrhage, Angiography, Embolization, Therapeutic. (Source: MeSH NLM)

A simple technique to obtain postprocedural antegrade angiographic control in single-access Impella-protected PCI.

A simple technique to obtain postprocedural antegrade angiographic control in single-access Impella-protected PCI.

Embolization for Type Ia Endoleak after EVAR for Abdominal Aortic Aneurysms: A Systematic Review of the Literature.

(1) Successful endovascular repair for abdominal aortic aneurysms is based on the complete exclusion of the aneurysm sac from the systemic circulation. Type Ia endoleak (ELIA) is defined as the persistent perfusion of the aneurysm sac due to incomplete proximal sealing between aorta and endograft, with a consequent risk of rupture and death. Endoleak embolization has been sporadically reported as a viable treatment for ELIA. (2) A systematic literature search in PubMed of all publications in English about ELIA embolization was performed until February 2022. Research methods and reporting were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data regarding patient numbers, technical success (endoleak absence at control angiography), reinterventions, clinical and imaging follow-up, and outcomes were collected and examined by two independent authors. (3) Twenty-one papers (12 original articles, 9 case reports) reported on 126 patients (age range 58–96 years) undergoing ELIA embolization 0–139 months after the index procedure. Indication for embolization was most often founded on unfavorable anatomy and patient comorbidities. Embolic agents used include liquid embolic agents, coils, plugs and combinations thereof. Technical success in this highly selected cohort ranged from 67–100%; the postprocedural complication rate within 30 days was 0–24%. ELIA recurrence was reported as 0–42.8%, with a secondary ELIA-embolization-intervention success rate of 50–100%. At a follow-up at 0–68 months, freedom from sac enlargement amounted to 76–100%, freedom from ELIA to 66.7–100%. (4) Specific literature about ELIA embolization is scant. ELIA embolization is a valuable bailout strategy for no-option patients; the immediate technical success rate is high and midterm and long-term outcomes are acceptable.

Endovascular treatment of intracranial aneurysms using the Derivo Embolization Device: a multicenter experience

BackgroundFlow diversion is the first-line treatment for several types of intracranial aneurysms. We report on a large series of patients treated with the Derivo Embolization Device who underwent a 1-year...

COVID-19 in interventional radiology: management of the angiography room

One of the most significant challenges that the COVID-19 pandemic has created is the intervetional radiology practice. In order to guarantee the best patient care and avoid contamination of the operators, it was necessary to carry out specific management of the complex angiographic rooms. This work aims to guide healthcare professionals in the safe execution of interventional radiology procedures on COVID-19 patients using suitable management strategies, guidelines and recommendations available, creating an appropriate work environment. Research and revision work, targeted at COVID-19 patients, made use the main scientific literature databases of guidelines and scientific articles promoted or edited by international scientific societies. After identifying and separating the pathways for infected patients and defining the dressing and undressing areas of the operators, a check-list was created to prepare the angiographic room and the surrounding spaces. The set-up includes removal of all non-essential mobile devices for the expected procedure and preparation of the sterile angiographic table with the necessary material and drugs. It is also necessary placement of containers for infected waste inside the room; cover of contrast injector, angiographic controls and patient monitoring devices; finally covering with clean sheets everything that cannot be moved. The standardization of operating procedures, staff training and the analysis of critical issues encountered lay the foundations for definition of best practices adaptable to different work environments.

COVID-19 in interventional radiology: management of the angiography room

One of the most significant challenges that the COVID-19 pandemic has created is the intervetional radiologypractice. In order to guarantee the best patient care and avoid contamination of the operators, it was necessary tocarry out specific management of the complex angiographic rooms.This work aims to guide healthcare professionals in the safe execution of interventional radiology procedures onCOVID-19 patients using suitable management strategies, guidelines and recommendations available, creating anappropriate work environment.Research and revision work, targeted at COVID-19 patients, made use the main scientific literature databases ofguidelines and scientific articles promoted or edited by international scientific societies.After identifying and separating the pathways for infected patients and defining the dressing and undressing areasof the operators, a check-list was created to prepare the angiographic room and the surrounding spaces. The setup includes removal of all non-essential mobile devices for the expected procedure and preparation of the sterileangiographic table with the necessary material and drugs. It is also necessary placement of containers for infectedwaste inside the room; cover of contrast injector, angiographic controls and patient monitoring devices; finallycovering with clean sheets everything that cannot be moved. The standardization of operating procedures, stafftraining and the analysis of critical issues encountered lay the foundations for definition of best practices adaptableto different work environments.

OCT-guided left-main PCI, a retrospective single-center analysis

Abstract Funding Acknowledgements Type of funding sources: None. Background It is known that PCI is associated with non-optimal stent implantation utilizing angiography for only left main lesions as well as for bifurcation lesions and is characterised by a high risk of adverse long-term effects. The use of OCT for the left main stent makes it easier to enhance the effective implantation of stents and enhance the results of patients. Methods A single-center randomised study was performed to demonstrate the benefit of stent implantation under OCT control in the left main bifurcation lesions compared to standard implantation under angiographic control. The follow-up period was 1 year, and the study included 68 patients with 1:1 randomization. The final composite points were: cardiac death, ischaemia, or myocardial infarction. All patients were elective, with moderate to high-functional class of angina pectoris. PCI was done using one or two stents, using OCT or without OCT to perform kissing dilation and proximal optimization technique. Results As a result of the data review of 68 patients with or without OCT using PCI of left main bifurcation lesions, the primary endpoint parameters in the non-OCT group were 17.8% and 6% for the OCT group. In 43.1 % of cases, a single-stent technique was used rather than a two-stent when using OCT. In the OCT group, additional stent optimisation is 40% more common. In 96.7 % of cases, a 9-month follow-up in the OCT group showed complete or partial endothelization of the stent struts, allowing earlier termination of DAPT, which is critical in patients at high risk for significant bleeding. Conclusions The perioperative results of PCI for left main bifurcation can be improved by the use of OCT using regulated factors for optimal stent implantation. As a result, in patients with atrial fibrillation and a high risk of painful bleeding, the long-term effects of treatment are increased , the time to take DAPT is decreased and the number of implantable stents is decreased, which is significant.

Anatomical Modifications After Stent Implantation: A Comparative Analysis Between CGuard, Wallstent, and Roadsaver Carotid Stents

Purpose: Carotid revascularization can be associated with modifications of the vascular geometry, which may lead to complications. The changes on the vessel angulation before and after a carotid WallStent (WS) implantation are compared against 2 new dual-layer devices, CGuard (CG) and RoadSaver (RS). Materials and Methods: The study prospectively recruited 217 consecutive patients (112 GC, 73 WS, and 32 RS, respectively). Angiography projections were explored and the one having a higher arterial angle was selected as a basal view. After stent implantation, a stent control angiography was performed selecting the projection having the maximal angle. The same procedure is followed in all the 3 stent types to guarantee comparable conditions. The angulation changes on the stented segments were quantified from both angiographies. The statistical analysis quantitatively compared the pre-and post-angles for the 3 stent types. The results are qualitatively illustrated using boxplots. Finally, the relation between pre- and post-angles measurements is analyzed using linear regression. Results: For CG, no statistical difference in the axial vessel geometry between the basal and postprocedural angles was found. For WS and RS, statistical difference was found between pre- and post-angles. The regression analysis shows that CG induces lower changes from the original curvature with respect to WS and RS. Conclusion: Based on our results, CG determines minor changes over the basal morphology than WS and RS stents. Hence, CG respects better the native vessel anatomy than the other stents. Level of Evidence: Level 4, Case Series.

CONTINUOUS INTRAVENOUS NIMODIPINE APPLICATION FOR PREVENTION OF VASOSPASM BEFORE ENDOVASCULAR TREATMENT OF RUPTURED CEREBRAL ANEURISMS

Early recognition of vasospasm (VS) in patients with aneurismal subarachnoid hemorrhage (aSAH) is an imperative for timely treatment and prevention of delayed cerebral ischemia (DCI). VS, the pathologic response of the vascular damage in aSAH, is the main risk factor for irreversible brain damage. The first step in successful solving of aneurismal bleeding is prevention and treatment of VS. The aim of this study is to determine whether medical treatment with continuous infusion of intravenous Calcium blocker Nimodipine, without radiology verified VS will impact the degree of arterial vasoconstriction during the endovascular aneurismal treatment (EVT). A total of 20 patients with aSAH, confirmed by CT-angiography and hospitalized in UC for Neurosurgery were included in the study. In 10 patients, a continuous iv Nimodipine infusion was initiated on admission, the other half remained on their own antihypertensive therapy. If signs of VS or neurologic deterioration had developed, iv vasodilator therapy would have been initiated. Control angiography and immediate EVT were performed on the 4th day of admission at Radiology Institute. Using angiography, the vascular diameter was measured and compared with the same vessel diameter on CTA, to determine whether iv Nimodipine is effective in the pretreatment period. In 8 of 10 treated patients with iv Nimodipine, VS resolved in preEVT period. Among the patients from the non-treated group, 1 had developed DCI, 1 had no VS, 6 had persistent and in 2 patients VS resolved spontaneously. The conclusion is that continuous iv Nimodipine in preEVT period has vasodilatory potency on the vascular pool. Key words: Aneurismal subarachnoid hemorrhage, vasospasm, intravenous Nimodipine, endovascular treatment

A Rare Case of Coronary Artery Fistula on Vieussens Arterial Ring

Coronary artery fistulas represent an abnormal communication between coronary circulation and heart chambers or any segment of pulmonary or systemic circulation, without an intervening capillary network. Seldom, this connection can arise on a conotruncal anastomotic variant linking the anterior descending artery and the right coronary artery or a conus artery originating from the right coronary sinus, known as Vieussens’ arterial ring. Here we discuss a case of a 73-yearold man undergoing a coronary CT angiography because of recurrent chest pain and cardiovascular risk factors; the exam showed multiple aneurismatic sacs on a Vieussens arterial ring, associated with a fistulous connection between one of the aneurysms and the main pulmonary artery, highlighted by an hyper dense jet of contrast medium within its lumen. We spotted also enlarged right and left pulmonary arteries and right ventricular dilatation, with a mild hemodynamic overload on echocardiographic evaluation. A coronary angiography confirmed the findings shown by CT scan. After a multidisciplinary discussion, the interventional cardiology team decided to close the fistulous connection. Therefore, in a subsequent procedure the malformation was treated by catheterizing the branch stemming from the anterior descending artery and placing embolization coils in the first aneurysmatic sac and in the vessel itself; the same treatment was performed on the branch originating from the right coronary sinus. Final angiographic control showed complete exclusion of the saccular aneurysms from the circulation and closure of the associated fistula. There was no peri or post-procedural complication.