Antegrade Blood Flow Research Articles

Ultrasonographic and functional evaluation of forearm circulation with occluded radial artery

Abstract Introduction The transradial approach (TRA) has gained popularity in cardiology procedures. This study aims to evaluate forearm and hand arterial circulation in radial artery (RA) occlusion (RAO) patients after coronary angiography (CAG) and percutaneous coronary interventions (PCI). The ulnar (UA) and anterior interosseous artery (AIA) can compensate for RAO. Methods A prospective, observational study was conducted on 40 RAO patients after CAG/PCI. Ultrasonographic and functional evaluation (Barbeau test) of collateral circulation through AIA or UA were performed. Statistical analyses were applied to evaluate various Doppler ultrasound parameters and the anatomical characteristics of the RAO. Results The RAO group mean age was 71.22 ± 9.99 years, and 45% were male. RA, UA, and AIA showed significant differences in peak systolic velocity, end-diastolic velocity, arterial diameter, total flow volume, and stroke volume (p < 0.01). Pulse quality over RA and UA also differed significantly (p < 0.0001). Blood flow direction in the distal RA segment divided patients into an antegrade flow group (50%) from AIA and a retrograde flow group (50%) from UA. The Barbeau test results varied among RAO patients, with type D being the most common. Anatomical locations of RAO included the anatomical snuffbox (10%), wrist (60%), and forearm (30%). The logistic regression model revealed that the Barbeau test results on Finger 2 (p=0.0006, OR=0.1398) and Finger 4 (p=0.004, OR 0.2843) were significant predictors for the occurrence of antegrade or retrograde blood flow in the distal RA when RAO occurred. Furthermore, when the RA was occluded, the study revealed that a palpable pulse over the RA was still possible in 15% of cases. Conclusion Ultrasonographic evaluation and the Barbeau test can assess collateral circulation and predict blood flow patterns in RAO patients. Further research is needed to validate these findings, explore additional factors influencing collateral circulation and access route selection, and investigate the clinical implications of different RAO anatomical locations in cardiology procedures.Radial Artery OcclusionThe pulse quality over RA/UA with RAO

Two hundred and twenty-nine cases of bidirectional cavopulmonary anastomosis with and without antegrade pulmonary blood flow, a single-center experience.

Bidirectional cavopulmonary anastomosis is palliative surgical procedure for stepwise adaptation of the ventricle by time-phased relief of blood volume from the single functional ventricle. There still exists a controversial question regarding maintaining additional antegrade pulmonary blood flow. We retrospectively reviewed the surgical cases of 261 patients who underwent bidirectional cavopulmonary anastomosis in our institution from 2012 to 2022 with special regard to antegrade pulmonary blood flow as our preferred strategy. The mean age at the time of surgery was 33.1 months (range 2.9-192 months), and the mean weight was - 7.6 kg (range 3.9-38 kg). Furthermore, we divided all the patients into two groups: in group 1 (n = 182) - patients who underwent bidirectional cavopulmonary anastomosis with antegrade pulmonary blood flow, and in group 2 (n = 47) - patients without antegrade pulmonary blood flow. The mean follow-up time was 56 months (range 24-120 months). Mortality rate was 4.8 % (n = 11) in the past 10 years. Statistical difference between groups was in the following positions: group 2 had less ICU stay (p < 0.000125) and hospital stay (p < 0.017110); group 1 had a longer duration of pleural effusion (p < 0.000003) and amount of drainage output (p < 0.007), also demonstrated higher oxygen saturation (p < 0.000264) and Glenn shunt pressure (p < 0.002) after the surgery; but there was no difference in oxygen saturation after 6, 12, and 24 months; mortality in both groups has no statistic difference. Considering our experience, we take a stand on the controlled to antegrade pulmonary blood flow strategy during bidirectional cavopulmonary anastomosis.

Outcomes of fenestrated frozen elephant trunk technique in 150 patients with acute type A aortic dissection

ObjectiveThe fenestrated frozen elephant trunk (FET) technique provides proximalization of distal anastomosis and antegrade blood flow into supra-aortic vessels through fenestration in a FET. We investigated the outcomes of the fenestrated FET technique in acute type A aortic dissection. MethodsWe evaluated 150 patients who underwent arch repair using the fenestrated FET technique for acute type A aortic dissection between July 2014 and January 2023. FET was deployed under hypothermic circulatory arrest and manually fenestrated under direct vision on the supra-aortic vessel aspect. Fenestration was performed for the left subclavian artery alone in 139 patients, 2 supra-aortic vessels in 9 patients, and total supra-aortic vessels in 2 patients. Fixation around fenestration site for endoleak prevention was performed in 48 patients. ResultsThe overall 30-day mortality rate was 4.7% (7 out of 150). Two patients developed paraparesis. Adequate blood flow into the supra-aortic vessels through fenestrations were confirmed in all patients at discharge. The false lumen thrombosis rate at the distal edge of FET was 96.6%. The median follow-up period was 28 months. The 1-year and 3-year overall survival rate was 89.1% and 84.5%, respectively. During the follow-up period, neither fenestration occlusion nor stroke was noted in the cerebral area perfused via the fenestration. Distal stent graft-induced new entry was noted in 2 patients. ConclusionsThe fenestrated FET technique is a straightforward and secure procedure for selected patients with acute type A aortic dissection. This technique can facilitate arch repair.

Outcomes of Patients Undergoing the Kawashima Procedure at an Early Age: A Single Center Experience.

Previous reports have demonstrated the safety and efficacy of performing early Kawashima procedure (KP). Despite this, more recent studies have shown that the average age at the time of operation remains greater than one year of age. We report our experience with performing KP at an earlier age than previously reported. A retrospective review was completed of patients undergoing KP at a single center (January 2000 to June 2020). Clinical outcomes were examined. Initial palliation was performed in 11 out of 12 patients. Age and weight at time of KP were 8.25 months (6.4-9.7) and 7.7 kg (6.5-8.6). Intensive care unit stay was 3.16 days (1-12), overall length of stay was 9.5 days (3-22). There was one unplanned reoperation, and no mortality in the cohort. Discharge oxygen saturation was 88% (80%-98%). Seven patients developed pulmonary arteriovenous malformations (PAVMs) with six proceeding to hepatic vein incorporation (HVI). Interval time to development of PAVMs was 42.3 months (16-121). Four of the 12 patients were left with antegrade pulmonary blood flow (PBF) and three (75%) remain without PAVMs. Median follow-up was 10 years (1.5-22) with 11 of 12 (91.67%) survival for the cohort. The KP can be done at a younger age than previously reported with adequate early and late results. Most patients will go on to develop PAVMs and require HVI but leaving patients with some antegrade PBF is likely protective but will need further investigation to show definitive benefit.

The use of neuromuscular electrical stimulation to elicit muscle contractions does not impair the hyperemic response compared to volitional contractions

Abstract Purpose Electrical stimulation-induced muscle contractions in individuals with paralyzed muscles are often associated with early onset fatigue. We examined whether electrical stimulation (ES) of the quadriceps muscle results in vasoconstriction and a reduction in blood flow which may contribute to this early onset fatigue. Methods Seventeen young individuals completed 40 ES isometric contractions (stimulation frequency of 75 Hz, pulse duration of 400 μs, on-off ratio 6.0-20s) and force matched voluntary (VOL) isometric contractions. Isometric force, heart rate, blood pressure, superficial femoral diameter and blood velocity were measured at baseline and during exercise (contractions 1,5,10,15,20,25,30,35, and 40). Net, antegrade, and retrograde blood flow, and conductance were quantified. Two-way, within-subjects ANOVAs were used to evaluate diameter, blood flow and conductance. Results Diameter was not different between ES and VOL (p = 0.57). Net blood flow increased during both conditions with the greatest blood flow occurring during ES compared to VOL (p ≤ 0.01). ES showed a greater increase antegrade and reduced retrograde flow compared to VOL. After the twentieth contraction, ES also elicited greater conductance than VOL (p ≤ 0.049). Conclusion The use of neuromuscular electrical stimulation to elicit muscle contractions does not result in vasoconstriction or a reduced hyperemic response compared to volitional contractions.

Communicating Arteries and Leptomeningeal Collaterals: A Synergistic but Independent Effect on Patient Outcomes after Stroke.

The collateral system is a compensatory mechanism activated in the acute phase of an ischemic stroke. It increases brain perfusion to the hypoperfused area. Arteries of the Willis' circle supply antegrade blood flow, while pial (leptomeningeal) arteries direct blood via retrograde flow. The aim of our retrospective study was to investigate the relationship between both collateral systems, computed tomography perfusion (CTP) values, and functional outcomes in acute stroke patients. Overall, 158 patients with anterior circulation stroke who underwent mechanical thrombectomy were included in the study. We analyzed the presence of communicating arteries and leptomeningeal arteries on computed tomography angiography. Patients were divided into three groups according to their collateral status. The main outcomes were the rate of functional independence 3 months after stroke (modified Rankin scale score, mRS) and mortality rate. Our study suggests that the collateral status, as indicated by the three groups (unfavorable, intermediate, and favorable), is linked to CT perfusion parameters, potential recuperation ratio, and stroke outcomes. Patients with favorable collateral status exhibited smaller core infarct and penumbra volumes, higher mismatch ratios, better potential for recuperation, and improved functional outcomes compared to patients with unfavorable or intermediate collateral status.

Assessing donor-recipient arterial pressure dynamics in STA-MCA bypass for moyamoya disease

BackgroundIn bypass surgery for moyamoya disease (MMD), the superficial temporal artery’s (STA) pressure needs to surpass that of the cortical M4 recipient of the middle cerebral artery (MCA), boosting cerebral blood flow into the MCA and enhancing cerebral circulation. This study investigates the STA-MCA arterial pressure parameters and gradients during bypass surgery, aiming to deepen our understanding of hemodynamic shifts pre- and post-operation.MethodsDSA imaging data were prospectively collected from patients diagnosed with bilateral MMD who underwent STA-MCA bypass surgery between 2022 and 2023 and stratified according to the Suzuki stage. The mean arterial pressure (MAP) of the donor and recipient arteries was directly measured during the STA-MCA bypass procedure, and these data were statistically analyzed and evaluated.ResultsAmong 48 MMD patients, Suzuki grading revealed that 43.8% were in early stages (II and III), while 56.2% were in advanced stages (IV, V, and VI). Predominantly, 77.1% presented with ischemic-type MMD and 22.9% with hemorrhagic type. Pre-bypass assessments showed that 62.5% exhibited antegrade blood flow direction, and 37.5% had retrograde. The mean recipient artery pressure was 35.0 ± 2.3 mmHg, with a mean donor-recipient pressure gradient (δP) of 46.4 ± 2.5 mmHg between donor and recipient arteries. Post-bypass, mean recipient artery pressure increased to 73.3 ± 1.6 mmHg. No significant correlation (r = 0.18, P = 0.21) was noted between δP and Suzuki staging.ConclusionOur study elucidated that cerebral blood pressure significantly decreases beyond the moyamoya network at the distal M4 segment. Furthermore, we observed bidirectional flow in MCA territories and a significant positive pressure gradient between the STA and M4 segments. The lack of correlation between Suzuki stages and M4 pressures indicates that angiographic severity may not reflect hemodynamic conditions before surgery, highlighting the need for customized surgical approaches.

The American Association for Thoracic Surgery (AATS) 2024 expert consensus document: Management of neonates and infants with Ebstein anomaly

ObjectivesSymptomatic neonates and infants with Ebstein anomaly (EA) require complex management. A group of experts was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic focusing on risk stratification and management. MethodsThe EA Clinical Congenital Practice Standards Committee is a multinational and multidisciplinary group of surgeons and cardiologists with expertise in EA. A citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to EA. The search was restricted to the English language and the year 2000 or later and yielded 455 results, of which 71 were related to neonates and infants. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of members votes with at least 75% agreement on each statement. ResultsWhen evaluating fetuses with EA, those with severe cardiomegaly, retrograde or bidirectional shunt at the ductal level, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or fetal hydrops should be considered high risk for intrauterine demise and postnatal morbidity and mortality. Neonates with EA and severe cardiomegaly, prematurity (<32 weeks), intrauterine growth restriction, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or cardiogenic shock should be considered high risk for morbidity and mortality. Hemodynamically unstable neonates with a circular shunt should have emergent interruption of the circular shunt. Neonates in refractory cardiogenic shock may be palliated with the Starnes procedure. Children may be assessed for later biventricular repair after the Starnes procedure. Neonates without high-risk features of EA may be monitored for spontaneous closure of the patent ductus arteriosus (PDA). Hemodynamically stable neonates with significant pulmonary regurgitation at risk for circular shunt with normal right ventricular systolic pressure should have an attempt at medical closure of the PDA. A medical trial of PDA closure in neonates with functional pulmonary atresia and normal right ventricular systolic pressure (>20-25 mm Hg) should be performed. Neonates who are hemodynamically stable without pulmonary regurgitation but inadequate antegrade pulmonary blood flow may be considered for a PDA stent or systemic to pulmonary artery shunt. ConclusionsRisk stratification is essential in neonates and infants with EA. Palliative comfort care may be reasonable in neonates with associated risk factors that may include prematurity, genetic syndromes, other major medical comorbidities, ventricular dysfunction, or sepsis. Neonates who are unstable with a circular shunt should have emergent interruption of the circular shunt. Neonates who are unstable are most commonly palliated with the Starnes procedure. Neonates who are stable should undergo ductal closure. Neonates who are stable with inadequate pulmonary flow may have ductal stenting or a systemic-to-pulmonary artery shunt. Subsequent procedures after Starnes palliation include either single-ventricle palliation or biventricular repair strategies.

The frozen elephant trunk: seeking a more definitive treatment for acute type A aortic dissection.

Conventional treatment for type A aortic dissection includes replacement of the ascending aorta with an open distal anastomosis in the hemiarch position. The frozen elephant trunk (FET) is a hybrid technique that extends the repair to the descending thoracic aorta. The goal is to improve resolution of malperfusion syndrome and to induce positive aortic remodelling and reduce the need for reintervention on the downstream aorta. We aim to summarize the data on the short and long-term outcomes of this technique. A thorough search of the literature was conducted isolating all articles dealing with aortic remodelling after the use of FET in case of type A acute aortic dissection. Keywords 'aortic dissection', 'frozen elephant trunk', 'aortic remodelling' and 'false lumen thrombosis' were used. Data for type B and chronic aortic dissections were excluded. FET use favourably influences aortic remodelling. The main advantages lie in the exclusion of distal entry tears in either the aortic arch or descending aorta thus restoring antegrade blood flow in the true lumen and inducing false lumen thrombosis. False lumen thrombosis is not only induced at the level of the stent deployment but also lower in the distal descending aorta. Moreover, it offers an adequate landing zone in the mid-descending aorta for second-stage endovascular or open surgical aortic repair, if needed. FET can be advantageous in the treatment of acute type A aortic dissection dealing with extended aortic pathology.

Efficacy of intentional undersized thoracic endovascular repair for Stanford type B aortic dissection

ObjectiveThoracic endovascular aneurysm repair (TEVAR) is widely used for the treatment of aortic dissection. Endograft oversizing is a risk factor for stent graft-induced new entry tears and retrograde type A aortic dissection. However, there is no clear consensus on the optimal graft size selection for Stanford type B acute or subacute aortic dissection (TBAD). Herein, we examined the safety and efficacy of TEVAR using an intentionally undersized endograft to treat TBAD. MethodsThis retrospective chart review study included 82 patients who underwent TEVAR for acute or subacute Stanford TBAD between 2015 and 2022. We measured the true lumen diameter just distal to the subclavian artery and opted for a stent graft of the same diameter. In instances where deformation resulting from false lumen pressure displacement was pronounced, we measured the diameter at the site just proximal to the subclavian artery. Patients’ characteristics, procedural, in-hospital, and follow-up data, and aortic remodeling were analyzed. The aortic diameter was analyzed using one-way analysis of variance followed by Dunnett’s test. Survival and freedom from reintervention were estimated using Kaplan-Meier curves. ResultsThe follow-up rate was 98.4%. The mean age was 58.3 ± 12.3 years, and 76 were men (92.7%). The mean diameters of the stent graft and native proximal landing zone were 30.9 ± 3.2 mm and 30.8 ± 3.0 mm, respectively. The oversize rate of the stent graft in relation to the native proximal aortic diameter was 0.3% ± 4.7%. In-hospital mortality was observed in one patient, retrograde type A aortic dissection in one patient, distal stent graft-induced new entry tear in zero patients, and type 1a endoleak in 22 patients (26.8%). Type 1a endoleaks, characterized by antegrade false lumen blood flow originating from the primary entry, in 12 patients spontaneously disappeared within 1 year of follow-up. According to aortic remodeling, 59 patients (86.8%) achieved complete aortic remodeling at the aortic arch level and 51 (75.0%) at the eighth thoracic vertebral level. The diameters of the aortic arch and descending aorta were significantly reduced compared with the postoperative measurements (P <.001). Survival rates were 97.5% and 93.6% at 1 and 3 years, respectively. Freedom from reintervention was 84.7% and 84.7% at 1 and 3 years, respectively. ConclusionsIntentionally undersized TEVAR was safe and achieved acceptable aortic remodeling despite a high rate of type 1a endoleaks. A type 1a endoleak was acceptable as it primarily diminished during the mid-term follow-up.

Restoration of Bile Outflow and Liver Revascularization After Cholecystectomy with Damage to the Hepaticocholedochus and Thrombosis of the Right Hepatic Artery

The problem of iatrogenic damage to the extrahepatic bile ducts during cholecystectomy remains relevant. Insufficient experience of the surgical team, limited knowledge of the topographic anatomy of the subhepatic space, especially in conditions of perivesical inflammatory infiltrate, poorly timed access conversion are some of the main reasons.The results of treatment of these patients depend on the timing of recognition of the injury, the type of the injury, the characteristics of reintervention, and timely reconstructive surgery performed in a specialized center. Up to 30 % of damage occurs due to combined injury to the extrahepatic bile ducts and afferent vessels of the liver, which aggravates the course of the disease.We report a clinical case of a female patient. The fragment of the hepaticocholedochus was excised during a planned cholecystectomy. In the same clinic, the primary reconstructive operation was performed (drainage of the hepaticocholedochus using a Kehr’s drain). Afterwards, an external fistula of the common hepatic duct was formed. The reconstructive operation was performed 4 days after the initial operation, in a specialized department of the regional clinical hospital. Relaparotomy was performed. In a dense inflammatory infiltrate during mobilization of the suspected hepaticocholedochus, a Kehr’s drain was identified, which distal branch was not located in the lumen of the bile duct. Thrombosis of the right hepatic artery was diagnosed. The Kehr’s drain was removed, the lobar ducts were identified to their confluence, and the confluence was preserved. The distal stump was sutured. Next, arteriotomy and thrombectomy were performed, and adequate retrograde and antegrade blood flow was recoverd. A hepaticoenteroanastomosis has been formed. The patient was discharged with recovery. When examined after 2 months, the condition was satisfactory. Timely diagnosis of thrombosis of the right hepatic artery, adequate revascularization and biliary reconstruction made it possible to avoid liver necrosis and achieve a good treatment outcome.

Compatibility of the semijailing technique with extremely soft i-ED coils for ruptured blood blister-like and dissecting aneurysms: patient series.

Optimal treatment options for ruptured blood blister-like aneurysms (BBAs) and dissecting aneurysms (DAs) have not yet been established. Endovascular treatment may achieve vessel reconstruction with the preservation of antegrade blood flow; however, securing curative hemostasis at the fragile rupture point remains a major concern. Two ruptured BBAs and two ruptured DAs treated by stent-assisted coiling with the semijailing technique in the last 2 years are described herein. The devices used were braided stents and i-ED coils, which are new low-memory shape and extremely soft coils. Neither rebleeding nor ischemic complications were observed. All patients had a favorable outcome and showed no recurrence after treatment. All aneurysms were treated without ischemic complications or rebleeding. The good compatibility of braided stents and the new concept coils in stent-assisted coiling by the semijailing technique provides insight into these intractable hemorrhagic vascular pathologies.

Laparoscopic median arcuate ligament section for median arcuate ligament compression syndrome initially detected as splenic infarction: a case report

BackgroundMedian arcuate ligament compression syndrome (MALS) causes upper abdominal pain and at times hemodynamic abnormalities in the pancreaticoduodenal region.Herein, we present a case of a 70 year-old man, initially diagnosed with splenic infarction and was successfully treated laparoscopically.Case presentationA 70-year-old man with abdominal pain admitted to our hospital. Abdominal-enhanced computed tomography revealed a poorly contrasted area in the spleen and stenosis at the root of the celiac artery. Arterial dilatation was observed around the pancreaticoduodenal arcade, however, no obvious aneurysm formation or arterial dissection was observed. Abdominal-enhanced magnetic resonance imaging indicated the disappearance of the flow void at the root of the celiac artery. The patient had no history of atrial fibrillation and was diagnosed with splenic infarction due to median arcuate ligament compression syndrome. We performed a laparoscopic median arcuate ligament section with five ports. Intraoperative ultrasonography showed a retrograde blood flow in the common hepatic artery and the celiac artery. After releasing the compression, the antegrade blood flow from the celiac artery to the splenic artery, and the common hepatic artery were visualized using intraoperative ultrasonography. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 9. Postoperative computed tomography a month after surgery revealed no residual stenosis of the celiac artery or dilation of the pancreaticoduodenal arcade. Furthermore, the poorly contrasted area of the spleen improved.ConclusionsReports indicate that hemodynamic changes in the abdominal visceral arteries due to median arcuate ligament compression are related to the formation of pancreaticoduodenal aneurysms. In this case, median arcuate ligament compression syndrome caused splenic infarction by reducing blood flow to the splenic artery.

Utility of Balloon Occlusion Testing in Determining Fontan Suitability Among Patients with Elevated Pulmonary Artery Pressure and Additional Antegrade Pulmonary Blood Flow.

In individuals with a single ventricle undergoing evaluation before Fontan surgery, the presence of excessive pulmonary blood flow can contribute to increased pulmonary artery pressure, notably in those who had a Glenn procedure with antegrade pulmonary flow. 28 patients who had previously undergone Glenn anastomosis with antegrade pulmonary blood flow (APBF) and with elevated mean pulmonary artery (mPAP) pressure > 15mmHg in diagnostic catheter angiography were included in the study. After addressing other anatomical factors that could affect pulmonary artery pressure, APBF was occluded with semi-compliant, Wedge or sizing balloons to measure pulmonary artery pressure accurately. 23 patients (82% of the cohort) advanced to Fontan completion. In this group, median mPAP dropped from 20.5 (IQR 19-22) mmHg to 13 (IQR 12-14) mmHg post-test (p < 0.001). Median PVR post-test was 1.8 (IQR 1.5-2.1) WUm2. SpO2 levels decreased from a median of 88% (IQR 86%-93%) pre-test to 80% (IQR 75%-84%) post-test (p < 0.001). In five patients, elevated mPAP post-test occlusion on diagnostic catheter angiography led to non-completion of Fontan circulation. In this group, median pre- and post-test mPAP were 23mmHg (IQR 21.5-23.5) and 19mmHg (IQR 18.5-20), respectively (p = 0.038). Median post-test PVR was 3.8 (IQR 3.6-4.5) WUm2. SpO2 levels decreased from a median of 79% (IQR 76%-81%) pre-test to 77% (IQR 73.5%-80%) post-test (p = 0.039). Our study presents a specialized approach for patients initially deemed unsuitable for Fontan due to elevated pulmonary artery pressures. We were able to successfully complete the Fontan procedure in the majority of these high-risk cases after temporary balloon occlusion test.

The burden of cardiovascular disease in South Asia: the need for effective treatment

Dear Ma'am, Cardiovascular disease (CVD) is rapidly becoming the leading cause of death worldwide (1). According to global health projections, it will remain the number one cause of death in 2030. The Asian region has been shown to have a higher cardiovascular disease burden than Western countries, and most of this burden is borne by economically disadvantaged people mainly located in South Asian regions such as Pakistan. (1). A large-scale survey conducted in 53 cities in Punjab, Pakistan, found that 17.5% of the population suffered from cardiovascular disease (2). Mechanical thrombectomy is a minimally-invasive procedure where a specialized interventional radiologist utilizes specific equipment to remove a blood clot from an artery in a patient's body. This procedure treats arterial blockages caused by blood clots such as Deep Vein Thrombosis (DVT), Ischemic Stroke, etc (3). MegaVac, a part of mechanical thrombectomy, is the newest technique for the removal of blood clots from arteries. It is an invasive procedure that ensures the complete removal of clots from the occluded artery. The biggest advantage of this technique over typical clot removal is that it prevents embolus formation, which can occlude smaller arteries. The MegaVac Thrombectomy System is an intravascular mechanical thrombectomy and aspiration device with a single use that includes a thrombowire with an embolectomy component. A distal silicone-coated nitinol braid used in the SafeSealTM technology of the MegaVac Catheter swells to momentarily obstruct antegrade blood flow. The braid is expanded by the inner and outer coaxial shafts of the catheter body, briefly occluding the channel and enabling aspiration. SafeSeal funnel is activated by the assembly of the proximal handle. A nitinol embolectomy component that is part of the thrombowire can be used to draw material in the direction of the MegaVac catheter when it is inflated by the proximal actuation handle (4). Thrombectomy is a common and effective procedure for clot removal but in Pakistan thrombectomy is not as common compared to developed countries, primarily due to two reasons. First, Mechanical thrombectomy is exclusively available in four hospitals nationwide, with only one public hospital in Lahore providing this procedure (5). Second, it is an expensive procedure that ranges from 1700$ to 5000$ depending on the severity of the patient and the complexity of the procedure. Health Departments of Pakistan should provide this facility in more public hospitals so it becomes accessible to more people.

Abstract 13267: Early Predictors of High-Risk Lymphatic Subtypes on T2-Weighted MRI in Patients After Superior Cavopulmonary Connection

Introduction: Lymphatic subtype as determined by T2-weighted MRI (T2-CMR) after superior cavopulmonary connection (SCPC) is known to predict clinical outcome after Fontan. Factors related to lymphatic subtype development are not well understood. This study aims to identify early predictors of high-risk lymphatic subtypes. Methods: Retrospective cohort study of consecutive patients with pre-Fontan T2-CMR from 2017 to 2021. Patients divided into two groups based on lymphatic subtype: Group 1 - subtypes 1, 2, and 3; Group 2 - subtypes 3+ (defined as type 3 with history of chylothorax) and 4. Pearson’s chi square, Fisher’s exact, Wilcoxon rank sum, univariate and multivariate logistic regression analysis were performed. Results: We identified 171 patients. The groups differed significantly in total hospital, ICU, and chest tube days, number of catheterizations and number of cardiac surgeries (Table 1). Moderate or greater atrioventricular valve regurgitation (Mod+ AVVR), increased catheterizations and increased chest tube days were associated with high-risk lymphatic subtype. Maintenance of antegrade pulmonary blood flow at the time of SCPC was not significant (Table 2). In multivariate analysis, Mod+ AVVR and number of chest tube days remained in the model after adjusting for other covariates. Overall model significance was 0.007 with an area under the curve of 0.777. Conclusions: Mod+ AVVR and increased chest tube days are predictive of high-risk lymphatic subtype. Further study is needed to determine if lymphatic subtype is acquired via clinical exposure or whether native lymphatic subtype may be predictive of clinical course even prior to cavopulmonary connection.

Abstract 089: A Case of Complicated Dissection: Vertebral Artery Sacrifice for Recurrent Stroke Prevention

Introduction Posterior circulation strokes account for 20% of ischemic strokes (1). Optimal management for posterior circulation strokes has been studied less than for anterior circulation strokes (2). Endovascular parent vessel sacrifice is an established technique used to treat vascular pathologies. There is limited evidence for parent artery sacrifice for recurrent strokes and there is no current guideline for standard of care. Methods '‐ Results 51‐year‐old gentleman with history of tobacco use presented with left homonymous hemianopsia, onset 1.5 hours prior to arrival. CT brain showed no bleed and patient received IV tissue‐plasminogen activator (tPA). CT angiography (CTA) demonstrated occlusion of the right posterior cerebral artery (PCA) and dissection of the left vertebral artery (V2 segment) with distal reconstitution. He underwent emergent thrombectomy for right P2 thrombus with complete reperfusion TICI 3 (Thrombolysis in Cerebral Infarction Score). Less than 24 hours later, he developed a right homonymous hemianopsia, and was found to have a new occlusion of the left P1 segment of the left PCA. Emergent thrombectomy was performed with complete reperfusion (TICI3). MRI brain demonstrated bilateral PCA territory infarcts. Within 12 hours of the second thrombectomy, his neurological exam deteriorated, and interval imaging revealed a basilar trunk thrombus, for which he underwent a successful endovascular thrombectomy complete reperfusion (TICI3). His antiplatelet regimen was optimized with Aspirin. Heparin was considered as treatment but was not provided because of the hemorrhagic conversion of his ischemic strokes. Given the persistent recurrence of thromboemboli in the posterior circulation despite being on optimal medical management, and evidence of hemorrhagic conversion, a decision was made to perform endovascular coil embolization of the left vertebral artery V2 segment at the site of dissection. Angiographic imaging demonstrated antegrade blood flow through the dissection as the source of recurrent embolic strokes. Six Stryker Target coils were deployed spanning the region of dissection within the left V2 segment via a right radial access with the guide catheter in the right vertebral artery. Post coil embolization angiographic runs demonstrated complete occlusion of the left vertebral V2 segment at the region of dissection which was confirmed via a left vertebral injection from a left femoral arterial access. There was preservation of ascending cervical collaterals beyond the dissection with patency of the contralateral vertebral artery supplying the intracranial circulation. Following embolization, repeat imaging showed no new infarcts and no new or worsening hemorrhage. He was continued on Aspirin monotherapy. It is notable that though his neurological exam deteriorated during each recurrent thromboembolic event, his neurologic exam at the time of discharge significantly improved with NIHSS of 3. He is currently being followed at our neuroscience institute. Conclusion Cervical arterial dissections pose increased risk for ischemic strokes (3). Vertebral artery dissection accounts for approximately 2%, of which, 10‐25% occur in middle‐aged and younger patients (4). This is a case of a young patient that exemplifies a successful role for vertebral artery sacrifice with coil embolization to prevent recurrent thromboembolic posterior circulation strokes. However controlled studies are needed for safety and efficacy of these interventions.

Strategy of delayed intervention without stent implantation in myocardial infarction with ST segment elevation caused by massive thrombosis of the infarct-related artery

Aim. TIntroduction. To evaluate in-hospital angiographic and five-year posthospital clinical outcomes of percutaneous intervention strategy without stent implantation with immediate coronary artery stenting technique in STEMI patients with massive coronary thrombosis.Material and methods. The study enrolled 116 patients with primary STEMI myocardial infarction with the signs of massive thrombosis in the lumen of the main epicardial coronary artery with TIMI thrombus grade greater than 3 after antegrade blood flow restoration. In the 1st group of delayed intervention at the primary stage the blood flow was restored by small diameter balloon inflation and/ or manual vacuum thrombus aspiration until stable TIMI grade 3 blood flow was achieved, at control CAG on day 5-6 in 36 people the stent was not implanted due to insignificance of infarct-related coronary artery stenosis (stenosis less than 50% according to QCA). Immediate stent implantation was performed in 78 patients (group 2). The primary endpoint was the incidence of adverse cardiovascular events, including total mortality, recurrent myocardial infarction, repeated revascularization of the infarct-responsive artery. Secondary endpoint: frequency of achieving optimal myocardial perfusion as measured by angiography – TIMI blood flow and Myocardial Blush Grade.Results. The median follow-up period was 47 months. The incidence of the primary end point (MACE) was 15,8% in group 1 and 23,1% in group 2, with no statistically significant difference (p=0,408). Overall mortality (10,5% and 11,7%), the rate of repeat myocardial infarction (2,6% and 5,1%), and the rate of repeat target vessel revascularization (2,6% and 6,4%) were without significant advantage between subgroups. Optimal reperfusion (TIMI-3 and Myocardial Blush Grade 2-3 after primary procedure was achieved in significantly (p=0,02) more patients in group 1 (89%) than in group 2 (69,2%) ST segment resolution ≥70% after intervention was achieved in 87% of cases in group 1 and in 64,1% of cases in group 2 (p=0,011).Conclusion. In STEMI patients with massive coronary thrombosis, the method of delayed percutaneous intervention increases the rate of achieving optimal blood flow and allows avoiding stent implantation in the infarct-related artery in 50% of cases as compared to the method of immediate stenting. Both methods have comparable hospital and five-year clinical risks.

Transverse-Sigmoid Sinus Dural Arteriovenous Fistula Concurrent With Bilateral Venous Sinus Occlusion.

Dural arteriovenous fistula (DAVF) is a relatively rare type of cerebrovascular malformation with unknown pathogenesis. Here, the authors report a patient with DAVF in the left transverse-sigmoid sinus (Cognard type III) combined with occlusions of the left sigmoid sinus and right transverse sinus. The authors describe and discuss their successful treatment approach, with the aim to improve the management of this rare disorder. A 59-year-old man presented with dizziness, headache, vomiting, and unsteady gait. His digital subtraction angiography evaluation indicated DAVF in the left transverse-sigmoid sinus (Cognard type III) combined with occlusions of the distal 1/3 of the left sigmoid sinus and the proximal one-third of the right transverse sinus. After balloon angioplasty and stenting, blood flow was restored in the occluded sinuses. The DAVF was treated by embolization. The patient had a satisfactory recovery with significantly improved clinical symptoms. In patients with transverse-sigmoid sinus DAVF, satisfactory venous reflux should be ensured. In patients with concurrent DAVF and sinus stenosis or occlusion, it is important to reestablish antegrade venous blood flow first. It is feasible and safe to simultaneously embolize DAVF after the venous reflux can be reestablished.

Does leaving native antegrade pulmonary blood flow at the time of the superior cavopulmonary connection impact long-term outcomes after the Fontan?

ObjectivesAntegrade pulmonary blood flow (APBF) may be left or eliminated at the time of the superior cavopulmonary connection (SCPC). Our aim was to assess the impact of leaving native APBF at the SCPC on long-term Fontan outcomes. MethodsIn the Australia and New Zealand Fontan Registry (1985-2021), 587 patients had pre-existing native APBF at the SCPC. At the SCPC, 302 patients had APBF eliminated (APBF−) and 285 patients had APBF maintained (APBF+). The incidence of Fontan failure (composite end point of Fontan takedown, transplant, plastic bronchitis, protein losing enteropathy and death) and atrioventricular (AV) valve repair/replacement post SCPC was compared between the 2 groups. ResultsSex, predominant-ventricle morphology, isomerism, primary diagnosis, and age/type of Fontan were similar between groups. APBF− versus APBF+ had a higher incidence of arch obstruction/coarctation (17% vs 7%) and previous pulmonary artery band (54% vs 45%) and a lower rate of Fontan fenestration (27% vs 41%). The risk of Fontan failure was similar between the 2 groups (hazard ratio [HR], 1.01; 95% confidence interval [CI], 0.58-1.78; P = .96). The risk of AV-valve repair/replacement was greater in APBF+ versus APBF– (HR, 2.32; CI, 1.13-4.75; P = .022). The risk of AV-valve repair/replacement remained after adjustment for arch obstruction/coarctation, previous pulmonary artery band and Fontan fenestration (HR, 2.27; CI, 1.07-4.81; P = .033). ConclusionsMaintaining APBF at the time of the SCPC does not impact the risk of Fontan failure but may increase the incidence of AV-valve repair and/or replacement post-SCPC.