Arterial Embolism Research Articles

Academician Viktor Sergeyevich Savelyev (1928–2013) (on the 95th anniversary of his birth)

Outstanding surgeon, scientist, teacher and organizer of healthcare, founder of a large surgical school, Hero of Socialist Labor (1988), academician of the USSR Academy of Medical Sciences (1974), RAMS (1991) and RAS (1997), laureate of the USSR State Prize (1975), the State Prize of the Russian Federation (1992), Demidov Prize (2002) and the A. N. Bakulev Prize (2002), Professor Viktor Sergeevich Savelyev was born on February 24, 1928 in the village of Pakhotny Ugol of the Bondarsky district of the Tambov region in the family of Sergei Dmitrievich Savelyev, a wood sawmill worker, and Olga Kuzminichna, a housewife. In 1945, Viktor Sergeevich entered the 2nd Moscow Medical Institute (now the Pirogov Russian National Research Medical University). After graduating in 1951, he studied in residency at the Department of Faculty Surgery, which was headed by the academician A. N. Bakulev, and was stayed at the department as an assistant. After defending his PhD thesis in 1955, he was appointed a teacher. In 1959, V. S. Savelyev successfully defended his doctoral dissertation, in 1961, he passed the academic title of Professor, in 1967, he was elected the head of the Department of Faculty Surgery. Viktor Sergeevich fully became the successor of A. N. Bakuleva and made the very great contribution to the development of domestic cardiac surgery. The works of V. S. Savelyev played a huge role in the formation and rapid development of vascular surgery. The clinic he headed has accumulated the world’s largest experience in the treatment of acute thrombosis and embolism of the main arteries. Viktor Sergeevich is rightfully one of the founders of modern Russian phlebology. He also made a significant contribution to the development of surgery of the stomach, intestines, bile ducts and pancreas. He was one of the first in the country to use organ-preserving operations on the stomach for complicated duodenal ulcer. Many of Viktor Sergeevich’s works were devoted to various aspects of postoperative management of patients, infusion therapy and parenteral nutrition, pathogenesis, diagnosis and treatment of sepsis. V. S. Savelyev and his students made a significant contribution to the development of abdominal endoscopy. V. S. Savelyev was a major organizer of domestic healthcare, for 34 years he held the post of the chief surgeon of the Ministry of Health of Russia. He was the Chairman of the Scientific Society of Surgeons of Russia (ROH), founder and president of the Russian Association of Phlebologists, editor-in-chief of journals «Thoracic and Cardiovascular Surgery» and «Phlebolymphology». Under his leadership and with his participation as the scientific consultant, 70 doctoral and 180 candidate dissertations were defended. He was the author and co-author of more than 500 scientific papers, including 24 monographs and manuals. The academician Viktor Sergeevich Savelyev died on December 25, 2013 and was buried in Moscow at the Troyekurovo Cemetery.

Computer tomography perfusion patterns in iatrogenic cerebral arterial gas embolism: A retrospective cohort study

PurposeCerebral arterial gas embolism (CAGE) occurs when air or medical gas enters the systemic circulation during invasive procedures and lodges in the cerebral vasculature. Non-contrast computer tomography (CT) may not always show intracerebral gas. CT perfusion (CTP) might be a useful adjunct for diagnosing CAGE in these patients. MethodsThis is a retrospective single-center cohort study. We included patients who were diagnosed with iatrogenic CAGE and underwent CTP within 24 h after onset of symptoms between January 2016 and October 2022. All imaging studies were evaluated by two independent radiologists. CTP studies were scored semi-quantitatively for perfusion abnormalities (normal, minimal, moderate, severe) in the following parameters: cerebral blood flow, cerebral blood volume, time-to-drain and time-to-maximum. ResultsAmong 27 patient admitted with iatrogenic CAGE, 15 patients underwent CTP within the designated timeframe and were included for imaging analysis. CTP showed perfusion deficits in all patients except one. The affected areas on CTP scans were in general located bilaterally and frontoparietally. The typical pattern of CTP abnormalities in these areas was hypoperfusion with an increased time-to-drain and time-to-maximum, and a corresponding minimal decrease in cerebral blood flow. Cerebral blood volume was mostly unaffected. ConclusionCTP may show specific perfusion defects in patients with a clinical diagnosis of CAGE. This suggests that CTP may be supportive in diagnosing CAGE in cases where no intracerebral gas is seen on non-contrast CT.

The use of furosemide during Intravenous Immunoglobulin therapy should not always be considered contraindicated

AimsEndothelial damage in acute respiratory distress syndrome (ARDS) increases capillary permeability, resulting in an increase in free lung fluid, interstitial pulmonary edema, and ventilation-perfusion imbalance. Due to their high osmolarity, Intravenous Immunoglobulin (IVIG) treatment may deepen hypoxemia by increasing lung fluid leakage. Adding furosemide to IVIG treatment in ARDS secondary to COVID-19 (CARDS) cases may increase treatment tolerance and success. Materials and methodsIn our study, we aimed to measure the effectiveness of this treatment combination in CARDS cases and to report the observed complications. Patients who were followed up in the 34-bed adult COVID intensive care unit between March 2020/2021 and who received IVIG, high-dose corticosteroid, and furosemide combination therapy were included in the study. Patients' age, gender, comorbidities, Acute Physiology, and Chronic Health Assessment II (APACHE-II), and Sequential Organ Failure Assessment (SOFA) scores were recorded. The day IVIG duration of treatment, additional medical treatments, respiratory support treatments, laboratory examinations, the percentage of involvement of lung lesions (Covid Visual Assessment Scale), clinical outcomes, and treatment complications were recorded. ResultsCombination therapy with found to improve respiratory failure in 50 % of patients. Troponin elevation was found in two patients, femoral artery embolism in one patient, and thrombosis in the femoral vein in one patient. In addition to IVIG treatment, the administration of two doses of immune plasma increased the chance of discharge (P = 0.037) ConclusionIn severe viral ARDS refractory to standard therapy, using furosemide in addition to IVIG therapy has an acceptable side-effect profile and may increase treatment success. Furosemide given during IVIG therapy should not be considered a contraindication in every patient.

Endovascular repair for abdominal aortic aneurysms involving visceral arteries: Effectiveness and contributing factors

ObjectiveAbdominal aortic aneurysms (AAA) involving branches of the visceral arteries mainly refer to AAA with flat renal artery (neck length ≤5 mm) or beyond the renal artery, and the branch of the visceral arteries needs to be reconstructed during treatment. Endoluminal repair (EVR) surgery refers to the isolation of AAA with less surgical trauma through vascular puncture, guidewire, catheter, stent and double suturer technology. However, postoperative endoleak is a complication specific to open surgery. This study aimed to analyze the efficacy of EVR for AAA involving visceral vessels (AAA-Vs) and the factors influencing the occurrence of postoperative endoleak. MethodsA total of 106 patients with AAA-Vs in our hospital during the period of January 2018 to January 2022 were distinguished as the observation group (received EVR, n = 48) and the control group (received laparotomy, n = 58). The operation time, intraoperative bleeding, intraoperative blood transfusion, postoperative intensive care unit (ICU) observation time, postoperative food-taking time, first time out of bed, hospital stay, complications and the one-year mortality of two groups were compared. According to the occurrence of postoperative endoleak, the patients underwent endoluminal repair surgery were graded as non-endoleak group (n = 39) and endoleak group (n = 9). The clinical data, including aneurysm anatomical conditions (proximal neck length, neck diameter, proximal neck angle), tumor shape (normal, calcification, mural thrombus), and internal iliac artery embolism of two groups were compared. Logistic regression analysis was employed to analyze the risk factors of endoleak after EVR of AAA. ResultsThe operation time, intraoperative blood loss, intraoperative blood transfusion, postoperative ICU observation time, postoperative food-taking time, first time out of bed and hospitalization days were sharply lower in the observation group than the control group (P < 0.001). There existed no significant difference in the proportion of pulmonary complications, cardiac complications and electrolyte disorders between two groups (P > 0.05). The observation group had much lower incidence of incision infection complications than the control group (P < 0.05). The one-year mortality rate in the observation group was 10.42 %, markedly lower than 25.86 % in the control group (P < 0.05). The incidence of endoleak in the observation group was 18.75 %, while no internal endoleak occurred in the control group (P < 0.05). The proportion of male patients, smoking history, internal iliac artery embolism, and the level of tumor neck length and proximal tumor neck angle in the endoleak group were memorably higher in comparison with the non-endoleak group (P < 0.05). Logistic regression analysis revealed that the length of the neck and the angle of the proximal neck were independent risk factors for postoperative endoleak of AAA (P < 0.05). In conclusionEVR was effective for AAA-Vs with the advantages of small trauma, rapid recovery, low complication rate and high safety. The diameter of the aneurysm neck and the angle of the proximal aneurysm neck were the risk factors for the occurrence of endoleak after EVR. It was necessary to fully evaluate the aneurysm before operation to help reduce the incidence of endoleak.

Application of Sofia Plus catheter tip shaping in the treatment of acute middle cerebral artery occlusion: A case control study.

To explore the safety and efficacy of Sofia Plus distal access catheter tip shaping for treatment of acute middle cerebral artery embolism. This single-center retrospective study involved patients eligible for acute embolic middle cerebral artery occlusion from January 2020 to October 2021. They were divided into a shaping and non-shaping group according to whether the Sofia Plus catheter tip was shaped intraoperatively. Baseline data, preoperative Alberta Stroke Program Early Computed Tomography (ASPECT) score, National Institutes of Health Stroke Scale (NIHSS) score, onset-to-admission time, admission-to-puncture time, Sofia Plus-clot time, puncture-to-reperfusion time, surgical approach, and use of a stent for rescue thrombectomy were compared between the 2 groups. Postoperative symptomatic intracerebral hemorrhage and the modified Rankin scale score at the 90-day follow-up were observed. In total, 54 patients were enrolled in this study (shaping group, 26 patients; non-shaping group, 28 patients). Their mean age was 64.8 ± 14.6 years, and the proportion of men was 68.5% (37/54). Successful recanalization was achieved in all patients. There were no differences in the baseline data (age, sex, history, pre-admission ASPECT score, or NIHSS score) between the shaping and non-shaping groups. Patients treated with a shaped Sofia Plus catheter had a shorter Sofia Plus-clot time [median (25th, 75th percentile: 4 (4, 7) vs 10.5 (5.25, 14) min, P = .006] and puncture-to-reperfusion time [16.5 (12, 30.5) vs 26 (16.25, 38.25) min, P = .036]. There were significant differences in the surgical approaches between the 2 groups. The rates of a favorable outcome (57.7% vs 64.3%, P = .62) and postoperative symptomatic intracerebral hemorrhage (7.7% vs 3.6%, P = .60) were not significantly different between the groups. Sofia Plus catheter tip shaping improved catheter trafficability and reduced the operative time. It was safe and effective for treatment of acute middle cerebral artery thrombotic occlusion.

Impact of atrial fibrillation on mortality and non-fatal cardiovascular outcomes in 152 638 patients admitted with congestive cardiac failure: a statewide population-linkage study

Abstract Background Congestive cardiac failure (CCF) and atrial fibrillation (AF) frequently co-exist, cause and exacerbate each other. Prior studies on the impact of AF in CCF patients yielded mixed findings. Purpose This study aims to examine the impact of AF on long-term outcomes including MACE (major adverse cardiovascular events defined as all-cause mortality and major cardiovascular outcomes including myocardial infarction, ischaemic stroke, CCF or revascularization) and other non-fatal vascular or bleeding outcomes in patients admitted with CCF. Methods Hospitalised patients in New South Wales (NSW), the largest state of Australia, from 1 July 2003 to 31 March 2021 with a primary diagnosis of CCF were identified from the statewide Admitted-Patient-Data-Collection database, stratified by AF (Prior-AF or New-AF during index CCF admission) and No-AF status, with follow-up until 31 March 2022. A linkage look-back to year-2001 was performed to identify prior-AF history. In addition to MACE, non-fatal outcomes assessed included recurrent admission with AF, haemorrhagic stroke, peripheral arterial thromboembolism, pulmonary embolism, and bleeding. Multivariable Cox regression was performed to assess the impact of AF on MACE. To account for the competing risk of death and assess the impact of AF on non-fatal cardiovascular outcomes, Fine-Gray competing risk analysis was performed. Results The cohort comprised 152 638 admitted CCF patients (median age: 80.4 years; 51.4% males): New-AF, n=16 371 (10.7%); Prior-AF, n=56 546 (37.0%) (Table 1). During a median follow-up of 2.5 years, compared to No-AF CCF patients, those with New-AF or Prior-AF had significantly higher rates of MACE (New-AF: 81.7% vs Prior-AF: 86.3% vs No-AF: 78.5%) driven by all-cause mortality (New-AF: 71.6% vs Prior-AF: 76.5% vs No-AF: 66.2%) (both logrank P&amp;lt;0.001). However, after adjusting for differences in baseline characteristics and admission year-groups, New-AF and Prior-AF status had differential impact on MACE compared to No-AF patients (adjusted hazard ratio [aHR]=0.93, 95% confidence interval [CI]=0.91-0.94; aHR=1.14, 95%CI=1.13-1.16 respectively; both P&amp;lt;0.001). Results were similar for all-cause death (aHR=0.94 and aHR=1.16 respectively; both P&amp;lt;0.001). Competing risk analyses showed that rehospitalisation for ischaemic stroke, AF, haemorrhagic stroke, peripheral arterial thromboembolism and bleeding were significantly higher in CCF patients with New-AF and Prior-AF (P&amp;lt;0.001), after adjusting for age, sex, referral source, year-groups, intensive-care-unit admission and Charlson comorbidities index (Table 2). Conclusion This study shows that AF status has a differential impact on clinical outcomes in patients admitted with CCF. Drivers behind this difference in outcomes require further study and strategies should be developed to minimise the risk of adverse clinical outcomes in this vulnerable group of patients.Table 1.Baseline characteristicsTable 2.Non-fatal CV outcomes

The impact of Covid-19 on mortality and clinical characteristics in hospitalized patients with peripheral artery disease in the year 2020

Abstract Background The Covid-19 pandemic developed its full destructive capacity and caused over 6.6 million confirmed deaths worldwide in the year 2020. This retrospective study aimed to examine the effects of Covid-19 on the mortality and clinical characteristics of peripheral artery disease (PAD) patients because these chronically ill patients are at risk for arterial embolic vascular complications and a fatal outcome. Methods and results From a German nationwide registry of 2020 all patients hospitalized with PAD (n=173.075) were compared in four different groups. The first group had no additional diabetes mellitus type 2 or Covid-19 (n=110.531), the second diabetes mellitus but no Covid-19 (n=59.991), the third diabetes mellitus and Covid-19 (n=1497) and the fourth no diabetes mellitus but Covid-19 (n=1056). Mortality rates in all PAD patients without Covid-19 were low and ranging between 1.1-3.6%, depending on PAD classification. However, PAD patients with Covid-19 had significantly higher mortality rates of 11.1-12.6%. Clinical characteristics and the Charlson- comorbidity index surprisingly revealed that PAD patients with Covid-19 but without diabetes mellitus presented more complications such as higher rates of stroke (1.4%), cardiogenic shock (3.3%), chronic kidney failure with GFR &amp;lt; 15 ml/min (10.5%) and prolonged ventilation time &amp;gt;48 hours (4.4%). Conclusion Covid-19 massively increased death rates in PAD patients in the year 2020. Neither disease severity of different stages of PAD nor additional diabetes mellitus had an effect on in-hospital mortality. One explanation of this finding might be that the risk for arterial embolism increases after a Covid-19 infection and thus leads to higher mortality rates in PAD patients, who are in danger for vascular/embolic complications. Our study reveals the importance of preventing the spread of Covid-19 disease, especially in the case of patients with atherosclerotic diseases.

Acute Mesenteric Ischemia: Basic concepts, Diagnosis, Treatment Options and Outcomes.

Acute mesenteric ischemia (AMI) is a group of diseases in which blood flow to the intestine is interrupted by occlusive or nonocclusive causes that include mesenteric arterial embolism, mesenteric arterial thrombosis, and mesenteric venous thrombosis. AMI risk factors include advanced age, Caucasian race, history of systemic arterial hypertension, arterial fibrillation, chronic kidney disease, and congestive heart failure. The clinical triad is characterized by the sudden onset of severe abdominal pain accompanied by gastrointestinal symptoms in the presence of an identified embolic source. Diagnosis is commonly made using computed tomography angiography, where the obstruction is observed directly in occlusive causes. Treatment involves fluid resuscitation and restoring mesenteric artery circulation using endovascular or surgical procedures. The mortality rate varies depending on the patient's clinical history and treatment approach, with a higher risk associated with open surgery. Lifelong anticoagulation or antiplatelet therapy may be necessary to prevent recurrence. Follow-up evaluations are recommended to monitor for restenosis and to prevent acute myocardial infarction.

A patient with acute myocardial infarction with acute lower extremity arterial embolization underwent amputation under general anesthesia.

Acute peripheral and coronary artery embolism are common complications of diabetes mellitus and greatly affect the clinical outcome of patients with diabetes; however, there are few reports about the symptoms and prognosis of patients with acute myocardial infarction (AMI) and concurrent acute lower extremity arterial embolism (ALEAE). A 44-year-old man with a history of 4 years of type 1 diabetes was admitted to hospital after suddenly experiencing severe pain in his right lower limb and feeling tightness in the left anterior chest area. Ultrasonography revealed distal occlusion of the right superficial femoral artery, and an electrocardiogram showed acute anterior interstitial myocardial infarction. After conservative treatment for 2 days, the patient had severe necrosis of the lower limbs and secondary injury of multiple organs. Haemodialysis and heparin anticoagulant therapy were performed before amputation. Twelve days after the operation, the patient's condition was stable, and he was transferred out of the intensive care unit. If patients with ALEAE miss the opportunity for early treatment, even with AMI, emergency amputation under general anaesthesia is the right strategy to save lives.

Treatment results of acute arterial obstruction of the lower limbs during advanced stages of ischemia

Objective. To analyze the immediate results of treatment of patients with acute arterial obstruction of the lower limbs during advanced stages of ischemia.Material and methods. The results of a comprehensive examination and treatment of 244 patients (135 men, 109 women, average age 67,2±8,4 years) with acute arterial obstruction of lower limbs were analyzed. Acute thrombosis was observed in 105 (43,1%) patients and embolism of the main arteries in 139 (56,9%) patients. 197 (80.7%) patients had ischemia of one (102 left, 95 right lower limbs) and 38 (15.6%) of both lower limbs. In 244 patients acute ischemia was noted in a total of 281 lower extremities. 86.9% of patients were hospitalized 24 hours after the onset of the disease. In 190 cases the affected limbs had II degree ischemia (54 cases (19,2%) of IIA degree, 136 (48,4%) IIB degree), and 91 (32,4%) patients had ischemia of III degree.Results and discussion. The main component of the operation for vascular embolism was thromboembolectomy (n=110), which in 56 cases was supplemented by vessel reconstruction (n=13), fasciotomy (n=34), and necrectomy (n=12). Primary amputation of the limb was performed in 13 cases. Conservative angiotropic therapy was performed in 16 cases.In acute thrombosis of lower limb arteries, conservative treatment was performed in 28 cases, primary limb amputation was performed in 10 cases, thrombectomy with a local reconstruction of the vessel (n=31), also with bypass (n=14), with reconstruction and fasciotomy of the tibia (n=13) and with reconstruction and necrectomy (n=7) were performed in 93 cases.Conclusion. Despite the delayed treatment in 67.6% of cases, the acute ischemia presented less severely, suggesting that the level of obstruction is more influential than the timing of the onset in the development of ischemic limb injuries. The choice of treatment method and extent at advanced stages of limb ischemia primarily depends on the degree and severity of ischemic disorders. The outcomes of treatment were less satisfactory in acute arterial thrombosis than in embolism, largely due to chronic obliteration of the distal arterial channel.

Abstract 11716: Patent Foramen Ovale Closure vs Medical Therapy in Patients ≥ 60 Years of Age With Ischemic Stroke: A Retrospective Cohort Study

Background: The benefit of patent foramen ovale (PFO) closure in patients aged ≥60 years with ischemic stroke is uncertain. Purpose: We conducted a retrospective cohort study to compare the outcomes of PFO closure vs medical therapy in this population. Methods: Using the TriNetX research database we identified patients ≥ 60 years with PFO who had an ischemic stroke from 2016 to 2021. Patients were divided into two groups: those undergoing PFO closure within 3 months of the stroke and those who received medical therapy only. Subgroup analyses was performed by age group (60 to 70 and ≥71). Propensity score matching was used to control for age, sex, hypertensive diseases, CKD, diabetes, dyslipidemias, ischemic heart disease, tobacco use, and neoplasms. Outcomes were measured from 1 month to 3 years after the index event and included all-cause mortality, new onset AF/flutter, arterial embolism, and services associated with stroke/embolism (thrombolysis, thrombectomy, administration of thrombolytics, and imaging of head and neck). Results: PFO closure was associated with lower number of services used in stroke/embolism (HR 0.57, 95%CI 0.42-0.78), a similar association was seen in those in the 60-70 age group (HR 0.539, 95%CI 0.373,0.78) but not in those ≥71 years. Arterial embolism was seen in 3.14% of the patients who received antiplatelets or anticoagulants only, but none of the patients who underwent PFO (Table 1) . Conclusions: PFO closure was associated with lower number of services used in stroke/embolism in patients aged ≥60 years with ischemic stroke. Our study could have been underpowered to find differences amongst those ≥71 years old. None of the patients who underwent PFO closure developed arterial embolism. PFO closure may be beneficial for older patients with ischemic stroke and warrant further investigation

Abstract 13708: Analyzing Outcomes of Atrial Septal Defect Closure in Patients With Ischemic Stroke and Thrombophilia

Introduction: Evidence on outcomes of ASD closure after a stroke in patients with thrombophilia is limited.: We illustrate differences in long-term outcomes amongst patients diagnosed with a stroke and thrombophilia, who underwent ASD closure up to 3 months after the stroke versus those who did not. Methods: We queried the TriNetX research database to identify adult patients with thrombophilia and ASD who had an ischemic stroke from 2016 to 2021. Patients were divided into two groups: those undergoing percutaneous transcatheter ASD closure within 3 months of the stroke and those who received medical therapy only. Subgroup analyses was performed comparing ASD closure with patients who received either anticoagulation or antiplatelets, and of those with a specific diagnosis of PFO. Propensity score matching (PSM) was used to control for age, sex, hypertensive diseases, CKD, diabetes, dyslipidemias, ischemic heart disease, and tobacco use. Outcomes were measured from 1 month to 3 years after the index event and included all-cause mortality, new onset Atrial fibrillation/flutter, arterial embolism, and services associated with stroke/arterial embolism namely thrombolysis, thrombectomy, and imaging (CT, CTA, MRI, MRA) of head and neck. Results: Patients with thrombophilia undergoing ASD closure after a stroke had lower all-cause mortality compared to medical therapy [HR 0.35, 95%CI 0.165 - 0.764]. This association persisted on subgroup analysis comparing ASD closure to antiplatelet use only [HR 0.392, 95% CI 0.163,0.947] (Table 1). Conclusions: ASD closure was associated with lower mortality in patients with thrombophilia and ischemic stroke. There was no statistical difference in incidence of A.fib/flutter, arterial embolism, or services associated to stroke/embolism. There were no differences in outcomes in patients with a specific diagnosis of PFO.

Abstract 17671: Comparative Analysis of Warfarin and Direct Oral Anticoagulants for the Treatment of Left Ventricular Thrombus

Introduction: This study aims to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) in the treatment of left ventricular thrombus (LVT). Warfarin has been shown to be an effective treatment in mitigating thrombotic events; however, numerous limitations exist, including the need for frequent monitoring and increased risk of side effects. Despite this, insight into DOAC use for the treatment of LVT remains limited. Thus, this study seeks to investigate the safety and efficacy of DOACs as a potential alternative to warfarin for the treatment of LVT. Hypothesis: DOACs decreases the risk of adverse events compared to Warfarin in patients with LVT. Methods: A retrospective cohort study was conducted using a federated realtime database called TriNetX which is comprised of over 100 million patient records. ICD-10 diagnostic codes and national drug codes were used to stratify adults by warfarin or DOAC treatment within 3 months of an initial LVT diagnosis. A 1:1 matched propensity score analysis was conducted, adjusting for comorbidities and demographics, to calculate adjusted Risk Ratios (aRR) with 95% CI. 90-day risk for mortality, stroke, need for blood transfusion, hemorrhage, and arterial embolism &amp; thrombosis were examined. Results: In a matched sample of 11,206 patients in each cohort, patients with LVT who took warfarin within 3 months of initial diagnosis is at higher risk for stroke (aRR[95%CI]=1.44(1.34,1.55)], need for blood transfusion [1.29(1.11,1.51)], hemorrhage [1.56(1.35,1.8)], and arterial thromboembolism [1.28(1.13,1.45)] than LVT patients who took a DOAC. Risk for death was non-significant between cohorts. Conclusions: The findings from this large electronic medical record patient cohort establish higher rates of adverse events for patients with LVT treated with warfarin versus DOAC, with no statistically significant difference in therapeutic efficacy.

Abstract 14729: Association of Iliac Artery Non-Calcified Plaque Volume and Acute Limb Ischemia: Insights From the VOYAGER PAD Angiographic Core Lab

Introduction/Background: Acute limb ischemia (ALI) is a severe complication of peripheral artery disease. Lipid lowering and antithrombotic therapies reduce ALI but pathologic studies have described thrombus in distal arteries without plaque, suggesting that artery to artery embolism from proximal (aortic-iliac) athero-thrombosis may be a key driver. Research Questions/Hypothesis: We hypothesized that the burden and character of atherosclerosis in the iliac arteries of patients with PAD would be associated with long term risk of ALI. Methods: VOYAGER PAD enrolled 6,554 patients with PAD and collected 2,200 baseline angiograms in 1,664 patients including 400 CT angiograms enabling plaque characterization. A case-control of 9 who had ALI during follow up and 9 controls were matched on anatomic and patient characteristics, type of index revascularization and disease pattern. Images were read by a blinded, independent imaging core lab. Results/Data: Of the 9 ALI cases, 45% had iliac artery occlusion and 55% had distal artery occlusion. Plaque characteristics were different in cases relative to controls including significantly greater non-calcified plaque volume (OR 2.36, 95% CI 1.05 - 9.38, p=0.03) as well as similar trends for low attenuation plaque (OR 1.65, 95% CI 0.89 - 4.72, p=0.05), and plaque burden (OR 1.16, 95% CI 1.00 - 1.25, p=0.03, Figure). In patients who experienced ALI, there was a trend for greater non-calcified plaque in the limb that experienced the ALI relative to the contra-lateral limb (index 7.2 vs contra-lateral 5.4, p=0.08). Conclusions: In a case-control series, total non-calcified plaque volume and overall plaque burden in the iliac arteries were associated with future ALI over 3 years. Based on the observations in this case-control, we are now analyzing plaque and outcomes in the full cohort. These data are hypothesis generating and suggest that plaque characteristics may be associated with ALI and may serve a surrogate marker of risk.

Abstract 12186: A Challenging Case of Acute Superior Mesenteric Artery Embolism Diagnosed by Gastroscopy

Introduction: Acute superior mesenteric artery (SMA) occlusion is one of the most lethal causes of acute abdomen that we often experience but mistake for gastrointestinal diseases. The golden time for revascularization in cases of SMA main trunk occlusion is within 5 hours of onset, requiring prompt diagnosis and treatment. We describe a challenging case of acute SMA embolism diagnosed by gastroscopy. Case Summary: A 66-year-old man with a history of hypertension presented to the emergency department for marked epigastric pain after eating raw seafoods. On arrival, electrocardiogram showed atrial flutter with no significant ST-segment changes. Despite the elevation of white blood cell count and lactate dehydrogenase in blood exam, computed tomography (CT) indicated no findings to cause his symptoms. Emergency gastroscopy performed on suspicion of anisakiasis demonstrated pallor findings with hematologic material in the duodenum, suggesting intestinal ischemia (Figure A). Since contrast-enhanced CT revealed an occlusion of SMA (Figure B), we diagnosed acute SMA embolism based on the finding of atrial flutter without anticoagulation. After discussion among cardiologists and gastroenterology surgeons, we selected to perform endovascular treatment. The epigastric pain was improved after reperfusion using a self-expandable stent, but flared up as oral intake progressed. Follow-up CT suggested ischemic enteritis of the proximal jejunum, leading to conduct laparoscopic partial jejunectomy. He was discharged 18 days after the operation with the ability to eat a normal diet. Conclusions: This case highlights that we should keep in mind SMA embolism when examining acute abdomen patients with atrial fibrillation or flutter without anticoagulation.

Abstract 16065: AICD Lead Endocarditis With Large Vegetation Complicated by Septic Pulmonary Embolism

Introduction: Infective endocarditis of an automatic implantable cardioverter-defibrillator (AICD) lead is a rare and serious complication. Less than 4% of AICD related endocarditis cases are caused by Enterococcus faecalis . Herein, we report a rare case of a patient with an infected AICD lead and a large vegetation caused by Enterococcus faecalis . Case Presentation: A 66-year-old male with a history of mitral valve replacement, heart failure with reduced ejection fraction status post AICD and hypertension presented with loss of appetite, subjective fevers and chills. Initial vitas were significant for tachycardia and tachypnea. Physical examination revealed lethargy and an irregular rate and rhythm. Initial labs showed an elevated WBC count, elevated C-reactive protein, elevated D-dimer, negative procalcitonin, negative High-sensitivity troponins and elevated BNP. Electrocardiogram showed atrial fibrillation. Echocardiogram showed an EF of 25-30% with a vegetation on the right ventricular lead. A CT angiogram chest was done and showed a right pulmonary artery embolism. Blood cultures were positive for Enterococcus faecalis . The patient was started on IV antibiotics, anticoagulation and he underwent open removal of the AICD along with multiple vegetations with the largest being 3.5cm. He recovered well post-operatively. Discussion: Cardiac device endocarditis is a difficult to manage condition that has been increasing in incidence over the years. Persistent infection is a problem faced when a patient has AICD endocarditis since these infections are typically resistant to many antibiotics necessitating surgical removal of the AICD. Patients that present with large vegetations larger than 2.5cm are at highest risk of complications. These complications include septic pulmonary emboli as seen in our patient, pulmonary abscess formation and pneumonia. Early diagnosis and lead extraction has been related to the highest reduction in mortality.

Increased Risk of Thrombosis in Patients with Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome (PCOS) is the most common endocrine-metabolic disorder in reproductive age women, with an estimated prevalence of 6-12% of assigned female at birth women in the US. We identified a pattern in our coagulation diagnostic management team, wherein women with PCOS had increased rates of and repeated histories of thrombotic events, such as strokes, heart attacks, pulmonary embolisms, and deep vein thromboses. However, clinical coagulation assays on these PCOS patients with repeated thrombotic events were all within the normal reference range. Our goal was to investigate the validity of this pattern and its occurrence in both local and national populations. This was accomplished by 1) Determining the incidence rate of thrombosis in PCOS and 2) Analyzing clinical presentations of thrombosis in PCOS. Methods/Study populations : Analyses on the rate of thrombotic events in PCOS patients locally at UTMB and in the US were performed on the TriNetX health research network. Using the incidence and prevalence and compared outcomes analytic functions on TriNetX, we determined the rate of thrombosis from 2013-2018 and explored patient characteristics. We further analyzed thrombosis in PCOS with the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) method. Through the compare outcomes analysis on the TriNetX platform, we looked at PCOS and control patients who experienced thrombotic events between 2013-2018 and analyzed clinical presentations that occurred in the 90 days prior to the index event. Patient queries included the diagnostic code for PCOS, ICD10 E28.2, women age 15-75, who had a clinical encounter since 2013. Exclusion criteria included inherited thrombotic disorders, smoking history, and human immunodeficiency virus. Events of interest included myocardial infarctions, cerebral infarctions, pulmonary embolisms, arterial embolisms and thrombosis, and portal vein thromboses. Statistical analysis: For evaluating statistical significance of the rate of thrombosis, we performed a compare outcome analysis on the UTMB network, with propensity score matching for current age. A Kaplan-Meier Analysis and a student's t-test were performed on the number of instances/events, and statistical significance was defined as a p-value &amp;lt;0.0001. Results:Between 2013-2018, the incidence rate of thrombosis in PCOS patients was 4.35% with 5.36% prevalence, this was statistically significantly higher than the control cohort at 2.66% incidence and 3.5% prevalence. The incidence rate of thrombosis in PCOS increased dramatically in post-menopausal women. Of the 60 outcomes investigated, 24 were determined to be statistically significant between control and PCOS, 22 symptoms and 2 procedures. Discussion: This is the first study to analyze the rate of thrombotic events in PCOS. We identified significant presentations and gaps that could assist in the early detection of thrombotic events in PCOS. However, the mechanisms of thrombosis in PCOS are unknown and are poorly detected with current clinical assays. Future studies will examine clinical assays in the detection of thrombosis in PCOS and investigate thrombotic mechanisms in PCOS.

Safety of double and a half layered esophagojejunal anastomosis in radical gastrectomy: A prospective, multi-center, single arm trial

Safety of double and a half layered esophagojejunal anastomosis in radical gastrectomy: A prospective, multi-center, single arm trial

Zone 2/3 lesion and emergency repair as potential mortality predictors of TEVAR for thoracic aortic pseudoaneurysm

ObjectiveThoracic aortic pseudoaneurysm (TAP) is an uncommon but life-threatening condition. The present study aimed to investigate the early and midterm clinical outcome of TAP patients following TEVAR and identify potential mortality predictors.MethodsWe retrospectively reviewed a series of 37 eligible patients with TAP admitted to our hospital from July 2010 to July 2020. We explored their baseline, perioperative and follow-up data. Fisher exact test and Kaplan–Meier method were applied for comparing difference between groups.ResultsThere were 29 men and 12 women, with the mean age as 59.5 ± 13.0 years (range 30–82). The mean follow-up period was 30.7 ± 28.3 months (range 1–89). For early outcome (≤ 30 days), mortality happened in 3 (8.1%) zone 3 TAP patients versus 0 in zone 4 (p = 0.028); postoperative acute arterial embolism of lower extremity and type II endoleak respectively occurred in 1(2.7%) case. For midterm outcome, survival at 3 months, 1 year and 5 years was 88.8%, 75.9% and 68.3%, which showed significant difference between zone 2/3 versus zone 4 group (56.3% vs. 72.9%, p = 0.013) and emergent versus elective TEVAR group (0.0% versus 80.1%, p = 0.049). Previous stent grafting or esophageal foreign body with Aortoesophageal fistula (AEF), and systemic vasculitis, as etiologies, resulted in encouraging immediate outcome but worse midterm prognosis.ConclusionTAP lesions at zone 2/3 and emergent TEVAR predict worse midterm outcomes compared to zone 4 lesions and elective TEVAR. The outcomes are also mainly restricted by the etiology of the TAP.

Resveratrol reduces ROS-induced ferroptosis by activating SIRT3 and compensating the GSH/GPX4 pathway

BackgroundIntestinal ischemia-reperfusion injury occurs in acute intestinal obstruction, intussusception, acute mesenteric artery embolism, and other diseases and can lead to local intestinal necrosis, distant organ involvement, or systemic reactions, with high morbidity and mortality. Ferroptosis plays a crucial role in intestinal ischemia-reperfusion injury, and inhibition of ferroptosis may provide new approaches for treating the disease. SIRT3 protects cells from oxidative stress and may be involved in the process of ferroptosis. We hypothesized that resveratrol, an agonist of SIRT3, could ameliorate intestinal ischemia-reperfusion injury by compensating the GSH/GPX4 pathway.MethodsIntestinal ischemia-reperfusion (I/R) and Caco-2 hypoxia-reoxygenation models were established. Transmission electron microscopy was used to assess mitochondrial function; the Chiu’s score was used to evaluate the degree of intestinal mucosal injury based on HE staining; and Western blot was used to detect the SIRT3/FoxO3a pathway, tight junction proteins and ferroptosis-related protein expression. Sirt3-/- C57, shSIRT3-Caco-2 cells and siFoxO3a-Caco-2 cells were established. C11-BODIPY was used to detect lipid peroxide in cells; FD4 and IFABP were used to detect intestinal permeability; MitoSOX was used to detect ROS levels; and MitoTracker and immunofluorescence colocalization were used to detect SIRT3 levels.ResultsIn the intestinal I/R model, I/R injury occurs mainly during the reperfusion period and leads to ferroptosis through the GSH/GPX4 pathway. Resveratrol could reduce ferroptosis and ameliorate I/R injury by activating SIRT3. In Sirt3-/- mice, more intestinal mucosal cells underwent ferroptosis, I/R injury was more severe, and resveratrol lost the ability to ameliorate I/R injury. In addition, hypoxia-reoxygenation increased RSL3-induced ferroptosis sensitivity in Caco-2 cells in vitro. In the presence of shSIRT3 or RSL3 alone, resveratrol could ameliorate Caco-2 ferroptosis, but not RSL3-induced shSIRT3-Caco-2 ferroptosis. Furthermore, resveratrol might activate the SIRT3/FoxO3a pathway, increase the expression of SOD2 and catalase, and inhibit ROS generation, thus reducing lipid peroxidation and ferroptosis.ConclusionTo date, this is the first study to show that resveratrol ameliorates intestinal ischemia-reperfusion injury by activating SIRT3 and reducing ferroptosis. Resveratrol can reduce intestinal ischemia-reperfusion injury by activating the SIRT3/FoxO3a pathway, increasing the expression of SOD2 and catalase, reducing ROS and LPO production, compensating for the GSH/GPX4 pathway and inhibiting ferroptosis.Graphical abstractResveratrol increases the expression of SOD2 and catalase, reduces the production of ROS and LPO, compensates for the GSH/GPX4 pathway and inhibits ferroptosis by activating the SIRT3/FoxO3a pathway