Arch Artery Research Articles

Endovascular treatment for carotid stenosis developing after neck radiotherapy

Aims: One of the causes of carotid stenosis is radiation therapy to the neck area. Cervical irradiation is frequently used in the treatment of head and neck cancers. However; the ionizing effect of radiation causes arteritis, which can lead to acceleration of fibrosis or atherosclerosis, thrombosis, stenosis, or occlusion. Carotid stenosis due to radiation is relatively rare. Accordingly, in this study, our aim was to assess the feasibility, safety and preliminary efficacy of endovascular therapy for carotid stenosis developing after neck radiotherapy. Methods: This study was a retrospective review of a prospectively maintained database of a consecutive unselected group of symptomatic and asymptomatic patients with carotid artery stenosis developing after neck radiotherapy. Data was collected from 2017 to 2023. A total of 17 patients who developed carotid stenosis due to neck radiotherapy were included in the study. Neck irradiation was applied in 76.5% of cases due to laryngeal cancer. All statistical analysis was performed using R version 4.2.1 (The R Foundation for Statistical Computing, Vienna, Austria; https://www.r-project.org). Univariate analysis was performed using ?2 and Wilcoxon tests. Cumulative survival estimates were assessed using the life-table method. Results: One patient had a technical failure due to a difficult aortic arch. Because of the degree of stenosis (40?) was not serious in conventional angiography of 2 patients, medical follow-up was decided. 3 patients were admitted to the emergency department due to acute ischemic stroke. Endarterectomy was performed in 4 patients due to the complex structure of the aortic arch and carotid arteries for carotid artery stending. The number of patients with stenosis in the right carotid was 10, while the number of patients with stenosis in the left carotid was 7. No restenosis was observed in patients with stent placement in follow-up carotid Doppler and CT angiography performed 3 months later. Additionally, no new neurodeficit was observed in the neurological examinations 3 months later. Conclusion: This retrospective study demonstrates that endovascular treatment for carotid stenosis developing after neck radiotherapy is safe, effective and reliable.

Performance Assessment of an Electrostatic Filter-Diverter Stent Cerebrovascular Protection Device: Evaluation of a Range of Potential Electrostatic Fields Focusing on Small Particles.

Silent Brain Infarction (SBI) is increasingly recognized in patients with cardiac conditions, particularly Atrial Fibrillation (AF) in elderly patients and those undergoing Transcatheter Aortic Valve Implantation (TAVI). While these infarcts often go unnoticed due to a lack of acute symptoms, they are associated with a threefold increase in stroke risk and are considered a precursor to ischemic stroke. Moreover, accumulating evidence suggests that SBI may contribute to the development of dementia, depression, and cognitive decline, particularly in the elderly population. The burden of SBI is substantial, with studies showing that up to 11 million Americans may experience a silent stroke annually. In AF patients, silent brain infarcts are common and can lead to progressive brain damage, even in those receiving anticoagulation therapy. The use of cerebral embolic protection devices (CEPDs) during TAVI has been explored to mitigate the risk of stroke; however, their efficacy remains under debate. Despite advancements in TAVI technology, cerebrovascular events, including silent brain lesions, continue to pose significant challenges, underscoring the need for improved preventive strategies and therapeutic approaches. We propose a device consisting of a strut structure placed at the base of the treated artery to model the potential risk of cerebral embolisms caused by atrial fibrillation, thromboembolism, or dislodged debris of varying potential TAVI patients. The study has been carried out in two stages. Both are based on computational fluid dynamics (CFD) coupled with the Lagrangian particle tracking method. The first stage of the work evaluates a variety of strut thicknesses and inter-strut spacings, contrasting with the device-free baseline geometry. The analysis is carried out by imposing flow rate waveforms characteristic of healthy and AF patients. Boundary conditions are calibrated to reproduce physiological flow rates and pressures in a patient's aortic arch. In the second stage, the optimal geometric design from the first stage was employed, with the addition of lateral struts to prevent the filtration of particles and electronegatively charged strut surfaces, studying the effect of electrical forces on the clots if they are considered charged. Flowrate boundary conditions were used to emulate both healthy and AF conditions. Results from numerical simulations coming from the first stage indicate that the device blocks particles of sizes larger than the inter-strut spacing. It was found that lateral strut space had the highest impact on efficacy. Based on the results of the second stage, deploying the electronegatively charged device in all three aortic arch arteries, the number of particles entering these arteries was reduced on average by 62.6% and 51.2%, for the healthy and diseased models respectively, matching or surpassing current oral anticoagulant efficacy. In conclusion, the device demonstrated a two-fold mechanism for filtering emboli: (1) while the smallest particles are deflected by electrostatic repulsion, avoiding micro embolisms, which could lead to cognitive impairment, the largest ones are mechanically filtered since they cannot fit in between the struts, effectively blocking the full range of particle sizes analyzed in this study. The device presented in this manuscript offers an anticoagulant-free method to prevent stroke and SBIs, imperative given the growing population of AF and elderly patients.

Peptide Receptor Radionuclide Therapy Using 90Y- and 177Lu-DOTATATE Modulating Atherosclerotic Plaque Inflammation: Longitudinal Monitoring by 68Ga-DOTATATE Positron Emissions Tomography/Computer Tomography.

Background: Atherosclerosis and its sequels, such as coronary artery disease and cerebrovascular stroke, still represent global health burdens. The pathogenesis of atherosclerosis consists of growing calcified plaques in the arterial wall and is accompanied by inflammatory processes, which are not entirely understood. This study aims to evaluate the effect of peptide receptor radionuclide therapy (PRRT) using 90Y- and 177Lu-DOTATATE on atherosclerotic plaque inflammation. Methods: Atherosclerotic plaques in 57 cancer patients receiving PRRT using 90Y- and 177Lu-DOTATATE were longitudinally monitored by 68Ga-DOTATATE PET/CT. The target-to-background ratio (TBR) and overall vessel uptake (OVU) were measured in eight distinct arterial regions (ascending aorta, aortic arch, descending aorta, abdominal aorta, both iliac arteries, and both carotid arteries) to monitor calcified plaques. Results: PET/CT analysis shows a positive correlation between calcified plaque scores and the 68Ga-DOTATATE overall vessel uptake (OVU) in cancer patients. After PRRT, an initially high OVU was observed to decrease in the therapy group compared to the control group. An excellent correlation could be shown for each target-to-background ratio (TBR) to the OVU, especially the ascending aorta. Conclusions: The ascending aorta could present a future reference for estimating generalized atherosclerotic inflammatory processes. PRRT might represent a therapeutic approach to modulating atherosclerotic plaques.

Left aortic arch and aberrant right subclavian artery in children: spectrum of symptoms and response to surgical intervention.

Children with left aortic arch and aberrant right subclavian artery may present with either respiratory or swallowing symptoms beyond the classically described solid-food dysphagia. We describe the clinical features and outcomes of children undergoing surgical repair of an aberrant right subclavian artery. This was a retrospective review of children undergoing repair of an aberrant right subclavian artery between 2017 and 2022. Primary outcome was symptom improvement. Pre- and post-operative questionnaires were used to assess dysphagia (PEDI-EAT-10) and respiratory symptoms (PEDI-TBM-7). Paired t-test and Fisher's exact test were used to analyse symptom resolution. Secondary outcomes included perioperative outcomes, complications, and length of stay. Twenty children, median age 2 years (IQR 1-11), were included. All presented with swallowing symptoms, and 14 (70%) also experienced respiratory symptoms. Statistically significant improvements in symptoms were reported for both respiratory and swallowing symptoms. Paired (pre- and post-op) PEDI-EAT-10 and PEDI-TBM-7 scores were obtained for nine patients, resulting in mean (± SD) scores decreasing (improvement in symptoms) from 19.9 (± 9.3) to 2.4 (± 2.5) p = 0.001, and 8.7 (± 4.7) to 2.8 (± 4.0) p = 0.006, respectively. Reoperation was required in one patient due to persistent dysphagia from an oesophageal stricture. Other complications included lymphatic drainage (n = 4) and transient left vocal cord hypomobility (n = 1). Children with a left aortic arch with aberrant right subclavian artery can present with oesophageal and respiratory symptoms beyond solid food dysphagia. A thorough multidisciplinary evaluation is imperative to identify patients who can benefit from surgical repair, which appears to be safe and effective.

Clinical-applied anatomy of the carpal tunnel regarding mini-invasive carpal tunnel release

BackgroundCarpal tunnel release is a widely performed procedure. Despite a high success rate, iatrogenic neurovascular injuries can occur which lead to a painful and unsatisfying outcome. This study conducted a detailed examination of the anatomy of the carpal tunnel and the proximity of neurovascular structures that are particularly susceptible to injury, especially in the context of minimally invasive carpal tunnel release procedures.Patients and methodsThe anatomy of the carpal tunnel of 104 wrists of 52 body donors was examined. The precise anatomical location and the presence of variations were recorded for the median nerve, ulnar nerve, ulnar artery and Berrettini branch. The distance between the median nerve, the ulnar artery, the ulnar nerve, and the Berrettini branch was measured in a proximo-distal and radio-ulnar direction in relation to the distal ulnar end of the carpal tunnel.ResultsThe authors identified four main dangerous anatomical situations. (1) A proximal separation of the Long-Finger/Ring-Finger branch of the median nerve together with a narrow safe-zone; (2) an ulnar take-off of the recurrent muscle branch of the median nerve with a close radio-ulnar distance to the distal ulnar end of carpal tunnel; (3) an ulnar arterial arch lying close to the transverse carpal ligament; and (4) a proximal Berrettini branch also lying close to the latter. All situations are illustrated by photographs. Additionally, the authors present a sonographic carpal tunnel assessment protocol in order to reduce the risk of injury of any neurovascular structure in the proximity of the carpal tunnel.ConclusionCertain patients may inherently face an increased risk of neurovascular injuries during minimally invasive carpal tunnel releases due to their anatomical variations. Four potentially risky scenarios were clearly illustrated. Consequently, one may consider conducting a preoperative ultrasound assessment of neurovascular structures at risk, when endoscopic or ultrasound-guided tunnel release are planned. In high-risk patients, open surgery should be preferred.Level of evidenceII.

Chemoradiotherapy treatment increases cardiac and aortic [18F]FDG uptake ratios in lung cancer patients

[18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) is an indispensable non-invasive imaging tool to aid diagnosis, prognostication, and therapeutic monitoring in oncology, but it can also evaluate cardiovascular inflammation1,2. Previously, cardiac metabolic changes using [18F]FDG with chemoradiotherapy have been explored3 but changes in the rest of the cardiovascular system remain undetermined. To investigate the cardiovascular metabolic changes pre- and post-chemoradiotherapy in stage 3b non-small cell lung cancer (NSCLC) patients. A retrospective analysis of 26 patients (43-82 years) with stage 3b NSCLC from the American College of Radiology Imaging Network (ACRIN 6668) trial was performed3. All available pre- and post-treatment imaging were retrieved from the Cancer Imaging Archive (TCIA)4 and regions of interest for the left ventricle and calcified large arteries were contoured on all PET-CT scans using PMOD version 4.0 software. The mean, maximum standard uptake value (SUVmean and SUVmax) and target-to-background ratio (TBR) were quantified on PMOD. At approximately 14 weeks post-chemoradiotherapy, there was a higher SUVmean (mean difference 0.81, p=0.01) and SUVmax (mean difference 2.20, p=0.006) in the left ventricle compared with pretreatment scans. TBR for aorta was higher post-treatment (mean difference 0.06, p=0.005). However, SUVmean for carotid arteries and right brachiocephalic artery was reduced post-chemoradiotherapy (mean difference 0.15, p=0.008 and mean difference 0.28, p=0.03). A reduction in SUVmax was also seen for aortic arch (mean difference 0.58, p=0.03) and right brachiocephalic artery (mean difference 0.42, p=0.03 and mean difference 0.42, p=0.03). Cardiovascular glucose metabolism is selectively increased in the left ventricle and aorta post-chemoradiotherapy. Changes in glucose metabolism of atherosclerotic plaques vary across different vessels throughout the body. Please click on the 'PDF' for the full abstract!

Non-contrast-enhanced MR-angiography of Extracranial Arteries in Acute Ischemic Stroke at 1.5 Tesla Using Relaxation-Enhanced Angiography Without Contrast and Triggering (REACT).

To evaluate anovel flow-independent sequence (Relaxation-Enhanced Angiography without Contrast and Triggering (REACT)) for imaging of the extracranial arteries in acute ischemic stroke (AIS) at 1.5 T. This retrospective single-center study included 47AIS patients who received REACT (scan time: 3:01 min) and contrast-enhanced MRA (CE-MRA) of the extracranial arteries at 1.5 T in clinical routine. Two radiologists assessed scans for proximal internal carotid artery (ICA) stenosis, stated their diagnostic confidence and rated the image quality of cervical arteries, impact of artifacts and image noise. Apparent signal- and contrast-to-noise ratios (aSNR/aCNR) were measured for the common carotid artery and ICA. REACT achieved asensitivity of 95.0% and aspecificity of 97.3% for ICA stenoses in high agreement with CE-MRA (κ = 0.83) with equal diagnostic confidence (p = 0.22). Image quality was rated higher for CE-MRA at the aortic arch (p = 0.002) and vertebral arteries (p < 0.001), whereas REACT provided superior results for the extracranial ICA (p = 0.008). Both sequences were only slightly affected by artifacts (p = 0.60), while image noise was more pronounced in CE-MRA (p < 0.001) in line with higher aSNR (p < 0.001) and aCNR (p < 0.001) values in REACT for all vessels. Given its good diagnostic performance while yielding comparable image quality and scan time to CE-MRA, REACT may be suitable for the imaging of the extracranial arteries in acute ischemic stroke at 1.5 T.

Donor great vessel free arterial grafts for complex reconstruction during pediatric heart transplantation

ObjectivePrior studies suggest that prolonged donor heart warm ischemia time increases heart transplant mortality. Patients with single-ventricle heart disease requiring transplant with concomitant aortic arch or central pulmonary artery reconstruction present technical challenges that extend donor warm ischemia time using conventional techniques. Studies in larger pediatric and adult patients with single-ventricle anatomy have described the use of prosthetic material for concomitant great vessel reconstruction. We have used donor free arterial grafts to simplify concomitant great vessel reconstructions and reduce warm donor ischemia time in small patients with single-ventricle physiology undergoing heart transplant. The purpose of this study is to review our results in these patients. MethodsChildren with single-ventricle heart disease who underwent free donor arterial graft great vessel reconstruction at heart transplant were identified, divided into aortic arch and central pulmonary artery groups, and retrospectively reviewed. Warm and total ischemia times were recorded contemporaneously at transplant. ResultsFifteen pediatric patients with single-ventricle physiology underwent donor free arterial graft great vessel reconstructions (9 aortic arch, 6 pulmonary artery). Mean donor warm and total ischemia times for the entire cohort were 52.8 ± 10.7 and 341.7 ± 41.2 minutes. Two patients required postoperative extracorporeal membrane oxygenation. Hospital survival was 94% (1 death). There were no late deaths, and 2 patients had late retransplant. There were no early or late aortic or pulmonary artery obstructions, reinterventions, or complications at median follow-up of 14.2 years (interquartile range, 4.2-16.3 years). ConclusionsDonor free arterial grafts for concomitant great vessel reconstruction during heart transplant in small, single-ventricle patients reduces warm ischemia time, simplifies technical demands, and preserves growth potential.

Relationship Between Quantitative Tracheal Geometry and Clinical Course in Various Types of Vascular Ring.

To investigate the relationship between quantitative tracheal geometry and clinical course among various types of vascular ring and to identify factors correlating with symptom presentation. Patients with vascular ring diagnosed between April 2010 and December 2022 were included. All the patients were classified as type 1 (complete double aortic arch); type 2 (incomplete double aortic arch); type 3 (circumflex aorta); type 4 (right aortic arch and aberrant left subclavian artery with a left retroesophageal diverticulum of Kommerell); or type 5 (mirror-imaged right aortic arch with retroesophageal aortic diverticulum). Their clinical characteristics and quantitative variables on computed tomography (CT) were compared. Of the 50 patients enrolled, those with type 1 tended to have a smaller luminal tracheal diameter at the level of the ring. The median symptom-free survival time was shortest in this group (16.0days [95% confidence interval (CI): 9.4-51.0]), followed by type 3 (138.0days [95% CI: 0.0-851.4]). Type 1 (hazard ratio [HR]: 9.0; 95% CI: 2.3-35.0; P = 0.001), type 3 (HR: 4.2; 95% CI: 1.4-13.2; P = 0.013), and the percentage of tracheal narrowing in the anteroposterior projection (HR: 0.87; 95% CI: 0.78-0.96; P = 0.008) were significantly associated with symptom presentation in the time-dependent course. The aortic arch encircling the entire circumference in type 1 and high-pressure vasculature in front of the vertebral body in types 1 and 3 may contribute to raising the risk of symptom presentation.

Common Arterial Trunk Repair at the Red Cross War Memorial Hospital, Cape Town: A 20-Year Review of Surgical Practice and Outcomes.

This study describes the 20-year experience of managing common arterial trunk (CAT) in a low-and-middle-income country and compares the early and medium-term outcomes following the transition from conduit to nonconduit repair at the Red Cross War Memorial Children's Hospital. Single-center retrospective study of consecutive patients aged less than 18 years who underwent repair of CAT from January 1999 to December 2018 at the Red Cross War Memorial Children's Hospital. Patients with interrupted aortic arch or previous pulmonary artery banding were excluded. Fifty-four patients had CAT repair during the study period. Thirty-four (63.0%) patients had a conduit repair, and 20 (37.0%) patients had a nonconduit repair. There were two intraoperative deaths. Thirty-day in-hospital mortality was 22.2% (12/54). Overall, in-hospital mortality was 29.6% (16/54). Eight (21.1%) late mortalities were observed. The actuarial survival for the conduit group was 77.5%, 53.4%, and 44.5% at 6, 12, and 27 months, respectively, and the nonconduit group was 58.6% at six months. The overall freedom from reoperation between the conduit group and nonconduit group was 66.2% versus 86.5%, 66.2% versus 76.9%, and 29.8% versus 64.1% at 1, 2, and 8 years, respectively. The outcomes following the transition to nonconduit repair for CAT in a low- and middle-income setting appear to be encouraging. There was no difference in mortality between conduit and nonconduit repairs, and importantly the results suggest a trend toward lower reintervention rates.

A novel technique for NO.253 lymph node dissection and left colic artery preservation to avoid potential postoperative internal hernia in laparoscopic radical resection for rectal cancer

BackgroundThe preservation of the left colic artery (LCA) has emerged as a preferred approach in laparoscopic radical resection for rectal cancer. However, preserving the LCA while simultaneously dissecting the NO.253 lymph node can create a mesenteric defect between the inferior mesenteric artery (IMA), the LCA, and the inferior mesenteric vein (IMV). This defect could act as a potential “hernia ring,” increasing the risk of developing an internal hernia after surgery. The objective of this study was to introduce a novel technique designed to mitigate the risk of internal hernia by filling mesenteric defects with autologous tissue.MethodsThis new technique was performed on eighteen patients with rectal cancer between January 2022 and June 2022. First of all, dissected the lymphatic fatty tissue on the main trunk of IMA from its origin until the LCA and sigmoid artery (SA) or superior rectal artery (SRA) were exposed and then NO.253 lymph node was dissected between the IMA, LCA and IMV. Next, the SRA or SRA and IMV were sequentially ligated and cut off at an appropriate location away from the “hernia ring” to preserve the connective tissue between the “hernia ring” and retroperitoneum. Finally, after mobilization of distal sigmoid, on the lateral side of IMV, the descending colon was mobilized cephalad. Patients’preoperative baseline characteristics and intraoperative, postoperative complications were examined.ResultsAll patients’ potential “hernia rings” were closed successfully with our new technique. The median operative time was 195 min, and the median intraoperative blood loss was 55 ml (interquartile range 30–90). The total harvested lymph nodes was 13.0(range12−19). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 8.0 days. One patient had an injury to marginal arterial arch, and after mobolization of splenic region, tension-free anastomosis was achieved. No other severe postoperative complications such as abdominal infection, anastomotic leakage, or bleeding were observed.ConclusionsThis technique is both safe and effective for filling the mesenteric defect, potentially reducing the risk of internal hernia following laparoscopic NO.253 lymph node dissection and preservation of the left colic artery in rectal cancer surgeries.

Combined Color-Doppler Flow and Angio Planewave UltraSensitive™ Imaging for Analysis of Hemodynamic Characteristics of Normal Upper Limb Arteries

BackgroundTo evaluate the hemodynamic characteristics of normal upper extremity arteries from the brachial artery to the fingertip arterioles.MethodsWe analyzed the characteristics and changes in the regularities of ultrasonic parameters in the upper extremity arteries of 104 healthy volunteers using color Doppler flow imaging and Angio Planewave UltraSensitive™ imaging. The measured ultrasonic parameters included the vessel diameter, blood-flow spectrum waveform, peak systolic velocity, end-diastolic velocity, resistance index, pulsatility index, ratio of PSV to EDV, blood-flow volume, along with systolic acceleration of each BA, radial artery, superficial palmar arch artery, palmar proper digital artery, and third-grade artery arch of the fingernail bed.ResultsFrom BA to FN3AA, the diameter, PSV, RI, S/D, VFlow, and slope of the artery significantly decreased (P < 0.001), and size of the parameters significantly correlated with the anatomic position of the arteries. The blood-flow spectrum gradually changed from various waveforms to fixed monophasic waves. There was a linear relationship between the distribution of monophasic waveforms and arterial groups (R = -0.453; P < 0.001). When the blood-flow spectrum of BA and RA showed a monophasic waveform, their branch arteries showed the same. The waveforms of PPDA and FN3AA were also monophasic.ConclusionRegular changes in the blood-flow spectrum waveform and hemodynamic parameters are related to the anatomic position of the upper limb arteries. CDFI combined with Angio PLUS accurately and systematically evaluates the hemodynamic characteristics of the upper extremity arteries.

Aortic Arch:Embryology and Remodeling

A right aortic arch and aberrant subclavian artery result from an interruption in the remodeling of the pharyngeal arch arteries. We occasionally encounter this anatomical variation during angiography. Patients with disorders such as Down syndrome and congenital heart disease show a high incidence of an aberrant right subclavian artery, and this anomaly can cause symptomatic esophageal or tracheal compression. The root of the aberrant artery may show dilatation(referred to as a Kommerell diverticulum), dissection, intramural hematoma, or rupture necessitating cardiac intervention using a surgical or endovascular approach. Neurointerventionalists should have working knowledge of the anatomy to rapidly understand the anatomy and ensure a safe procedure. A left transradial approach should be considered if prior knowledge of the aberrant subclavian anatomy is available.

A case of Kommerell diverticulum in adolescence presented with dysphagia

BackgroundKommerell diverticulum (KD) with right aortic arch and aberrant left subclavian artery (ALSCA) is a rare congenital aortic anomaly. To improve organ compression symptoms and avoid rupture of aneurysms in adulthood (19 years old–), surgical treatment is considered the only curative option. However, in childhood (–18 years old), several problems regarding approach and technique selection have been reported. Surgical treatment for KD in infancy (birth–2 years old) has been reported recently, but rarely in adolescence (13–19 years old). We herein report a case of KD in which the patient underwent graft replacement during adolescence. Case presentationA 13-year-old boy was admitted to our hospital presenting with dysphagia and body weight loss. Esophagography showed upper esophageal stenosis caused by extrinsic compression. Contrast-enhanced computer tomography showed saccular aneurysm formation of KD with right aortic arch (RAA) and ALSCA. Elective surgery including KD resection and graft replacement of the descending aorta was performed via right thoracotomy under partial extracorporeal circulation. The ALSCA was reconstructed by graft interposition. No postoperative complication was observed. Follow-up esophagography showed no residual stenosis.ConclusionWe experienced a case of KD with dysphagia and weight loss in adolescence, which was successfully treated with surgery. Graft replacement could be an effective treatment option, facilitating recovery even during the growth period.

Persistent right aortic arch and aberrant left subclavian artery in a dog

A 1.5-year-old male German Shepherd dog was referred to a Teaching Veterinary Hospital with a chronic history of regurgitation and a previous presumptive diagnosis of megaesophagus. An esophagogram showed partial esophageal dilation, suggesting one vascular ring anomaly. Computed tomography identified a persistent right aortic arch (PRAA) and an aberrant left subclavian artery (ALSA). The patient underwent thoracotomy, ligamentum arteriosum ligation, and debridement of the periesophageal region. The ligation of the ALSA was not carried out because the esophagus was observed to be released entirely during the surgical intervention. Therefore, intervention on the subclavian artery was not necessary. Clinical follow-up occurred on seven, 14, and 30 postoperative days. The dog improved, showing only sporadic regurgitations. Clinical history and complementary exams were essential to establish a diagnosis. The liberation of the esophageal transit during surgery contributed to the decision not to perform the ALSA ligation.

P023 A case of ANCA-associated vasculitis with possible IgG4-related disease

Abstract Background/Aims IgG4-related disease (IgG4-RD) and granulomatous polyangiitis (GPA) have apparent different pathology. There are infrequent reports of the two conditions occurring simultaneously. We add to the literature by describing a patient who appears to have both conditions. Methods A 65-year-old male presented with low back pain radiating to the perineum. His past history included T2DM, CABG and ablation for AF. Initial investigations showed a CRP of 102mg/ml and an eGFR of &amp;gt; 90ml/hr. A CT urogram revealed possible aortitis. A dedicated aortogram showed a cuff of added tissue around the infrarenal aorta and iliac arteries. A whole aortogram showed an increase in the abnormal tissue and detected a left upper lobe cavitating lesion. A PET-CT scan showed activity in the infrarenal aortic tissue, with focal uptake in the aortic arch and right superficial femoral artery. Several pleural based and parenchymal lesions showing moderate increased FDG activity were seen. A CT scan of the sinuses showed multifocal sinonasal mucosal thickening without bony erosions. C-ANCA was positive at 1/40, with raised PR3 of 32U/ml and IgG4 of 2.2g/L. Other immunoglobulin levels were normal and IGRA was negative. A biopsy of the lung lesion showed necrotising granulomatous inflammation and surrounding palisading histocytes, withno vasculitic element. Treatment with prednisolone 40mg daily and methotrexate 15mg weekly was started. A quick symptomatic improvement followed. CRP fell to 14mg/ml within two months. It was discussed in the national IgG4-RD MDT, and the consensus was that he had features of both GPA and IgG4-RD. A follow-up CT scan showed reduction in the volume of para-aortic tissue, with regression of some lesions in the chest, while others increased. However, he remains well with a normal CRP, stable renal function and normal urinalysis. His latest IgG4 level dropped to 0.67 g/L. Results The ANCA positivity and lung biopsy findings satisfy classification criteria of GPA. While aortic involvement is not commonly seen in GPA; it is typical of IgG4-RD; however, its diagnostic criteria require a confirmatory biopsy. This is challenging due to the risk of sampling around the aorta and ureters. Our case fulfils criteria for ‘possible’ IgG4-RD. In retrospect, an earlier PET CT scan may have spared the patient several CT scans. Conclusion The co-existence of IgG4-RD and ANCA-associated vasculitis may be more common than might be expected. Our case highlights the usefulness of early PET-CT scanning in rheumatic conditions. It is important to check ANCA in suspected IgG4-RD cases. It is possible that future AI programmes may help clinicians better judge the timing of investigations that may be more expensive, invasive or have increased radiation exposure in such complex cases. Finally, the usefulness of a national MDT for IgG4-RD is highlighted. Fortunately, treatment modalities are similar for both conditions. Disclosure H. Eltahir: None. M. Lloyd: None.

Buffering Mechanism in Aortic Arch Artery Formation and Congenital Heart Disease.

The resiliency of embryonic development to genetic and environmental perturbations has been long appreciated; however, little is known about the mechanisms underlying the robustness of developmental processes. Aberrations resulting in neonatal lethality are exemplified by congenital heart disease arising from defective morphogenesis of pharyngeal arch arteries (PAAs) and their derivatives. Mouse genetics, lineage tracing, confocal microscopy, and quantitative image analyses were used to investigate mechanisms of PAA formation and repair. The second heart field (SHF) gives rise to the PAA endothelium. Here, we show that the number of SHF-derived endothelial cells (ECs) is regulated by VEGFR2 (vascular endothelial growth factor receptor 2) and Tbx1. Remarkably, when the SHF-derived EC number is decreased, PAA development can be rescued by the compensatory endothelium. Blocking such compensatory response leads to embryonic demise. To determine the source of compensating ECs and mechanisms regulating their recruitment, we investigated 3-dimensional EC connectivity, EC fate, and gene expression. Our studies demonstrate that the expression of VEGFR2 by the SHF is required for the differentiation of SHF-derived cells into PAA ECs. The deletion of 1 VEGFR2 allele (VEGFR2SHF-HET) reduces SHF contribution to the PAA endothelium, while the deletion of both alleles (VEGFR2SHF-KO) abolishes it. The decrease in SHF-derived ECs in VEGFR2SHF-HET and VEGFR2SHF-KO embryos is complemented by the recruitment of ECs from the nearby veins. Compensatory ECs contribute to PAA derivatives, giving rise to the endothelium of the aortic arch and the ductus in VEGFR2SHF-KO mutants. Blocking the compensatory response in VEGFR2SHF-KO mutants results in embryonic lethality shortly after mid-gestation. The compensatory ECs are absent in Tbx1+/- embryos, a model for 22q11 deletion syndrome, leading to unpredictable arch artery morphogenesis and congenital heart disease. Tbx1 regulates the recruitment of the compensatory endothelium in an SHF-non-cell-autonomous manner. Our studies uncover a novel buffering mechanism underlying the resiliency of PAA development and remodeling.

Acto3D: an open-source user-friendly volume rendering software for high-resolution 3D fluorescence imaging in biology.

Advances in fluorescence microscopy and tissue-clearing have revolutionised 3D imaging of fluorescently labelled tissues, organs and embryos. However, the complexity and high cost of existing software and computing solutions limit their widespread adoption, especially by researchers with limited resources. Here, we present Acto3D, an open-source software, designed to streamline the generation and analysis of high-resolution 3D images of targets labelled with multiple fluorescent probes. Acto3D provides an intuitive interface for easy 3D data import and visualisation. Although Acto3D offers straightforward 3D viewing, it performs all computations explicitly, giving users detailed control over the displayed images. Leveraging an integrated graphics processing unit, Acto3D deploys all pixel data to system memory, reducing visualisation latency. This approach facilitates accurate image reconstruction and efficient data processing in 3D, eliminating the need for expensive high-performance computers and dedicated graphics processing units. We have also introduced a method for efficiently extracting lumen structures in 3D. We have validated Acto3D by imaging mouse embryonic structures and by performing 3D reconstruction of pharyngeal arch arteries while preserving fluorescence information. Acto3D is a cost-effective and efficient platform for biological research.

Association of Oral Anticoagulant Therapy with the Prevalence and Severity of Vascular Calcification among Patients with Atrial Fibrillation: A Cohort Study.

Many patients with atrial fibrillation (AF) requiring long-term use of oral anticoagulants (OACs) are at high risk for vascular calcification and anticoagulation therapy with warfarin exacerbate vascular calcification. However, the effect of nonvitamin K agonists on vascular calcification has not been clearly investigated. This study explored the effects of dabigatran etexilate, rivaroxaban, and warfarin on vascular calcification among 1527 patients with AF. Demographics, comorbidities, laboratory test data, medications, and the prevalence and severity of vascular calcification in different vascular beds were compared. After propensity score matching, the incidence of vascular calcification in the rivaroxaban and warfarin group was significantly higher than that in the nonanticoagulant group, while there was no difference between the dabigatran etexilate group and the nonanticoagulant group. Similarly, we found that the rivaroxaban group had more severe calcification in the overall vascular level (P < 0.001), thoracic aorta (P < 0.001), aortic arch (P = 0.001), and left common carotid artery (P = 0.005) than the nonanticoagulant group. In addition, in the left common carotid artery, there was more severe calcification in the rivaroxaban group than that in the dabigatran group (P = 0.005). Our results suggest that rivaroxaban can significantly increase both the incidence and severity of vascular calcification among patients with AF, while dabigatran etexilate has no such effect. Many patients with AF requiring long-term use of OACs are at high risk for vascular calcification. This is the first study to conduct a head-to-head comparison of the effects of dabigatran etexilate and rivaroxaban on vascular calcification. Rivaroxaban, rather than dabigatran etexilate, promotes vascular calcification in patients with AF, providing important implications to aid clinicians in their choice for OAC selection, especially those at high risk for vascular calcification.

FETAL ANATOMY OF THE ARTERIES OF THE DORSUM OF THE HAND

Fetal anatomy of the upper extremity in today’s understanding is a set of morphological methods for studying the structure and topography of the structures of its separate areas in human fetuses from the standpoint of the norm and taking into account the forms of individual anatomical variability. Also, in recent decades, microsurgical anatomy has gained intensive development, in particular the hand, which allows studying the structure and topography of small anatomical structures – blood vessels and nerves, muscle tendons, their layer-by-layer relationship in normal anatomical formation, and pathological deviations depending on the needs of microsurgery.The purpose of the study was to fi nd out the sources of blood supply, topography, and branching areas of the arteries of the back of the hand in human fetuses. The study was conducted on the preparations of 18 human fetuses aged from 4 to 10 months using macromicroscopic preparation, injection of arterial vessels, and morphometry.In human fetuses, the arteries of the back of the hand are arranged in two layers. The surface layer of the arterial vessels of the back of the hand, as a rule, is formed by the radial and anterior interosseous arteries, and (or), less often, by the ulnar or posterior interosseous arteries without the formation of arterial arches or nets. The deep layer of the arteries of the back of the hand mostly forms the back carpal arch and is inseparably connected both with the arteries of the superfi cial layer of the back of the hand and with the palmar arterial arches.The arteries of the deep layer of the back part of the hand are mostly (69.5 % of cases) represented by the back arterial arch: 1) radial-i nterosseous; 2) radial-i nterosseous-ulnar; 3) radial- ulnar; in 25 % of observations – with the posterior carpal arterial network. In 5.5 % of cases, the posterior carpal arch or posterior carpal mesh was absent, and duplication of the deep palmar arterial arch was found. Variability of the sources of formation, the degree of development, and the number of dorsal common digital arteries were revealed in human fetuses.Own dorsal digital arteries, except for the arteries of the thumb, as a rule, reach only the level of the middle phalanx of the fi ngers, and then they become thinner, or end in the periosteum or arterial arch-shaped anastomoses of the fi rst interphalangeal joint, or end in the palmar digital arteries, which provide blood supply to the back surface of the distal parts of the fi ngers of the brush.