Arterial Stasis Research Articles

A Continuous Red Eye: Case Report of Indirect Carotid Cavernous Fistula

Abstract
 Introduction : Carotid cavernous fistula (CCF) is a type of arteriovenous shunt in the cavernous sinus. Indirect CCF symptoms are not typical that can outwit us. Ocular manifestations occur because of venous and arterial stasis around the eye and orbit. The aim of this report is to increase awareness of the existence of other causes if there is no improvement after treatment.
 Case Illustration : A 59-year-old male presented with prolong conjunctival hyperemia on both eyes for two months that been diagnosed and treated as conjunctivitis. The ophthalmologic examination showed dilated episcleral vessels on both eyes with no evidence of infection and inflammation, this became a suspicion about the existence of a suppression from retro orbital region. The magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) brain examination were performed anda right CCF was diagnosed. The patient was referred to interventional neurology, digital subtraction angiography (DSA) examination showed a fistula in the right cavernous sinus and embolization was conducted.
 Discussion : The patient categorized as spontaneous, low flow, indirect CCF Barrow type D. On this type of CCF conjunctival injection is often the most prominent feature, and patients are commonly treated for other conditions, such as conjunctivitis, before a correct diagnosis is made.
 Conclusion : Carotid cavernous fistula can be characterized by the insidious onset of symptoms, diagnosis is based on the angiographic examination. When a sign suggestive of orbital or cavernous sinus pathology is present, a more thorough examination is crucial. Early diagnosis and appropriate management are essential to avoid vision and life threatening complications.

Vortex-assisted resin y90 delivery via 175 cm Truselect microcatheter: case factors for high residual despite double-flush protocol.

To report efficiency of resin y90 delivery using SIROS via 175 cm TruSelect microcatheter with double-flush protocol (40 ml dextrose total). IRB-approved retrospective review of all patients undergoing SIROS injection of y90 Sir-Spheres via TruSelect from 2019 through 2022 at one quaternary-care academic institution, including medical records. Included were 48 infusions in 25 patients across 11 cancer histologies. Mean planned, delivered, and residual activities were 28 ± 17, 27 ± 17, 1.1 ± 0.56 mCi respectively (mean residual 4.9% ± 2.8%) across flex-dosing precalibrations including 1-day, 2-day, and 3-day SIROS (4/51, 16/51, and 28/51). Mean liver treatment volume was 483 ± 306 ml with target dose mean of 128 ± 26 Gy in non-segmentectomy cases; Radiation segmentectomy was performed in 15/48 (31%). Arterial stasis was documented in 9/48 (19%) of cases. Use of a 3-day precalibrated SIROS dose, use of activity <10 mCi, treatment of smaller liver volumes (<200 ml) and documentation of stasis were associated with higher residual activity (P = 0.025, P = 0.0007, P = 0.0177, and P = 0.049, respectively) were associated with higher residuals. Combining the new technologies of SIROS and the Truselect microcatheter with a double-flush protocol yielded <10% residual in 94% of y90 infusions. Future studies may clarify if the predictors of high residual dose seen here may warrant microcatheter-specific considerations for dosimetry or dose preparation at the Radiopharmacy level.

Introduction of prostate artery embolization (PAE) in Sweden

Background: Transurethral resection of the prostate (TURP) is ‘Gold Standard’ treatment for moderate-to-severe lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH) with bladder-outlet obstruction (BOO). However, TURP is associated with a risk of complications, so minimally invasive methods have been developed. Prostate artery embolization (PAE) is a new minimally invasive procedure. This study reports the outcomes of PAE when introduced in a ‘real life’ clinical setting in a Swedish County hospital.Methods: A prospective, single-center, single-arm study in a consecutive vascular-anatomy ‘all comers’ population, eligible for TURP or adenomaenukleation, but unsuitable for this, treated with PAE from January 2015 to June 2018. Defined improvement of IPSS/QoL scores, or freedom from urinary catheter if previous urinary catheter-dependent, or clean intermittent catheterization (CIC) were considered as clinically successful treatments. PAE was performed until arterial stasis using the Perfected technique. Most patients were treated during a day-care procedure.Results: Of 37 treated men, bilateral PAEs were achieved in 32 patients, unilateral PAEs in four patients, and bilateral failure in one patient due to difficult vascular anatomy. Clinically successful treatment was achieved in 84%, without serious adverse events.Conclusions: PAE was introduced in Sweden, showing PAE as a novel and good minimally invasive alternative in treatment of symptomatic BPH, possible to perform as a day-care procedure.

Quantification of Activity Lost to Delivery-System Residual and Decay in Yttrium-90 Radioembolization

PurposeTo measure the decay activity loss and delivery system residual activity loss of yttrium-90 (Y90) radioembolization treatments across resin and glass microsphere activities. Materials and MethodsFor Y90 administrations between December 2009 and June 2017 at the study institution, the prescribed activity, prepared activity, and delivered activity were recorded. Six hundred sixty-two administrations were reviewed—345 glass (0.21–8.52 GBq) and 317 resin (0.18–3.28 GBq). Twenty-five patients (all resin) were excluded for arterial stasis or catheter clogging. The percentage and actual losses of activity lost to decay and to delivery system residual were calculated for glass and resin microspheres. ResultsThe median time between activity premeasurement and administration was 2.20 hours, resulting in a median activity lost to decay of 0.030 GBq or 2.35%, with no significant difference observed between glass and resin despite differences in preparation (P = .0697). Resin showed significantly higher activity lost to delivery system residual than glass (0.039 GBq vs 0.010 GBq, 3.01% vs 0.61%, P < .001). The percent activity lost to residual varied with activity prepared, with a maximum of 20.1% and 16.2% for the smallest activities of resin and glass, respectively. ConclusionsResidual activity loss differs between glass and resin microspheres. For resin microspheres in particular, percent residual activity loss increases with lower prepared activities. Protocols for activity calculation and preparation, patient dosimetry, and regulatory compliance must take these losses into consideration prospectively.

C1-esterase inhibitor treatment: preclinical safety aspects on the potential prothrombotic risk.

Human plasma-derived C1-esterase inhibitor (C1-INH) is an efficacious and safe treatment for hereditary angioedema. However, thrombotic events in subjects treated with C1-INH at recommended or off-label, high doses have been reported. In this study, we addressed the potential prothrombotic risk of C1-INH treatment in high doses using a non-clinical rabbit model. Following intravenous infusion of C1-INH to rabbits at doses up to 800 IU/kg, the exposure and the pharmacodynamic efficacy of C1-INH in rabbits were confirmed by activity measurements of C1-esterase, and coagulation factors XIa and XIIa, respectively. Potential prothrombotic effects were assessed following induction of venous and arterial thrombosis using in vivo models of venous and arterial stasis, complemented by various in vitro assays of coagulation markers. Administration of C1-INH at doses up to 800 IU/kg did not potentiate thrombus formation during venous stasis. In contrast, inhibition of arterial occlusion was observed upon C1-INH administration when compared with isotonic saline treatment, indicating antithrombotic rather than prothrombotic activity of high dose C1-INH treatment in vivo. This was further confirmed in vitro by decreased thrombin generation, increased activated partial thromboplastin time, clotting time and clot formation time, and inhibition of platelet aggregation. No relevant changes in fibrinolysis or in the levels of thrombin-antithrombin complexes, and prothrombin fragment 1+2 were observed upon high dose C1-INH treatment. The data suggest that treatment of healthy rabbits with high doses of C1-INH could potentially inhibit coagulation and thrombus formation rather than induce a prothrombotic risk.

ULTRASONOGRAPHY OF THE HIP JOINT EXAMINATION HIP JOINT IN THE ASSESSMENT OF THE EFFECTIVENESS OF TREATMENT IN CHILDREN WITH LEGG-CALVE-PERTHES DISEASE AND HIP OSTEOARTHRITIS

We performed dynamic hip doppler ultrasonography in children with Legg-Calve-Perthes disease (LCPD) in order to determine the effectiveness of the conservative and surgical treatment. The study included children aged from 3 to 7 years old with LCPD who had pain in the hip joints during admission. We assessed the structural changes in the head of the femur and the hip joint (B-mode), when the Doppler study analyzed diameter of enveloping hip vessels, blood velocity and resistance index. The study found that severe pain and contracture of the hip during admission appeared as a manifestation of concomitant hip osteoarthritis. On admission all patients had signs of arterial spasm and venous stasis in the hip joints, which determined the administration of a comprehensive arthrologic, osteogenesis stimulating and angioprotective therapy, according to the data of dynamic ultrasound.

Early arterial stasis during resin-based yttrium-90 radioembolization: incidence and preliminary outcomes

ObjectivesThis study was conducted to determine the incidence of early stasis in radioembolization using resin yttrium-90 (Y-90) microspheres, to evaluate potential contributing factors, and to review initial imaging outcomes. MethodsPatients in whom early stasis occurred were compared with those in whom complete delivery was achieved for tumour type and vascularity, tumour:normal liver ratio (T:N ratio) at technetium-99m-macroaggregated albumin (Tc-99m-MAA) angiography, previous intra-arterial therapy, and infusion site (left, right or whole liver). Tumour response was evaluated at 3 months and defined according to whether a partial response and stable disease versus progressive disease were demonstrated. ResultsA total of 71 patients underwent 128 Y-90 infusions in which 26 (20.3%) stasis events occurred. Hypervascular and hypovascular tumours had similar rates of stasis (17.4% versus 27.8%; P = NS). The mean ± standard deviation T:N ratio was 3.03 ± 1.54 and 3.66 ± 2.79 in patients with and without stasis, respectively (P = NS). Stasis occurred in 14 of 81 (17.3%) and 12 of 47 (25.5%) infusions following previous intra-arterial therapy and in therapy-naïve territories, respectively (P = NS). Early stasis occurred in 15 of 41 (36.6%) left, 10 of 65 (15.4%) right and one of 22 (4.5%) whole liver infusions (P < 0.001). Rates of partial response and stable disease were similar in the stasis (88.3%) and non-stasis (76.0%) groups (P = NS). ConclusionsEarly stasis occurred in approximately 20% of infusions with similar incidences in hyper- and hypovascular tumours. Whole-liver therapy reduced the incidence of stasis. Stasis did not appear to affect initial imaging outcomes.

Abstract No. 205: Early arterial stasis preventing complete dose delivery during resin based Y90 radioembolization: Incidence and preliminary outcome

Use of SIR-Spheres can be complicated by arterial stasis limiting dose delivery. The purpose of this study is to determine the incidence of early stasis during radioembolization, evaluate potential contributing factors, and determine whether initial imaging outcomes are affected.

Pure Ethiodized Oil-based Transcatheter Ablative Therapy in Normal Rabbit Kidneys and Kidneys Inoculated with VX-2 Carcinoma

To evaluate the efficacy of ablation with selective arterial injection of pure ethiodized oil followed by arterial occlusion with 9:1 ethanol-Ethiodol mixture (EEM) and coil placement in normal rabbit kidneys and kidneys inoculated with VX-2 carcinoma. All experiments were conducted with Animal Care and Use Committee approval. In six rabbits (group 1), one kidney was embolized with pure Ethiodol until capillary stasis, followed by injection of 9:1 EEM until arterial stasis and then coil placement into the main renal artery. In 12 other rabbits, one kidney was inoculated with VX-2 tumor. Ethiodol and EEM embolization and coil placement followed 7days later (group 2, n=6) or 11-14 days later (group 3, n=6). Kidneys were evaluated (angiography, computed tomography, macro- and microscopy) 7days after treatment. Capillary stasis was achieved in groups 1, 2, and 3 with (mean±standard deviation) 0.47±0.03, 0.53±0.02, and 0.56±0.04 ml of pure Ethiodol, followed by 0.47±0.05, 0.42±0.03, and 0.38±0.04 ml of EEM, respectively, which caused complete arterial occlusion in 17 of 18 kidneys. In group 1, all but one kidney showed at least 95% generalized coagulative necrosis. In group 2, all six kidneys exhibited 100% coagulative necrosis, with no viable tumor present. In group 3, 100% coagulative necrosis was present in all kidneys, with a small viable tumor in one. In the rabbit, selective arterial injection of pure Ethiodol can cause complete renal parenchyma and tumor ablation when it is followed by prompt, contiguous, and permanent occlusion of the arterial compartment.

Pure Ethiodized Oil as a Capillary Embolic Agent with and without Ethanol-ethiodol Mixture in the Rabbit Kidney: Embolic Efficacy and Temporal Histopathologic Findings

To determine the extent of ablation and the temporal histopathologic findings associated with selective arterial injection of pure Ethiodol in the normal rabbit kidney, with or without arterial occlusion of the main renal artery. In 19 rabbits, 27 kidneys were embolized by injecting 0.6 mL of pure Ethiodol into the main renal artery to achieve capillary stasis. A 9:1 ethanol-ethiodized oil mixture was then injected into 17 of the 27 kidneys until complete arterial stasis was accomplished. Macro- and microscopic evaluation was performed 10 minutes to 6 weeks and 60 minutes to 1 week, respectively, for kidneys with and without arterial occlusion. Ethiodol followed by ethanol-Ethiodol mixture (mean +/- standard deviation, 0.37 mL +/- 0.03) caused complete and permanent arterial stasis in all 17 kidneys. Thrombosis of the large arteries occurred initially. Ischemic coagulative necrosis of renal tubules and damage to glomeruli were detected 2 hours after embolization. Within 24 hours, the glomeruli and most tubules of the cortex and medulla were necrotic. Without arterial occlusion, the arteriocapillary bed of the kidneys was completely patent, with normal contrast medium excretion. Ethiodol was observed in glomeruli and interstitial capillaries from 60 minutes to 1 week and caused mild acute glomerulitis from day 1. The lesions were confined to the glomeruli, and no significant parenchymal changes were observed. In the rabbit, selective arterial injection of pure Ethiodol produces complete renal ablation within 24 hours if prompt and permanent occlusion of the arterial compartment guarantees its permanent capillary retention.

Marked Impairment of Protease-Activated Receptor Type 1-Mediated Vasodilation and Fibrinolysis in Cigarette Smokers: Smoking, Thrombin, and Vascular Responses In Vivo

We sought to test the hypothesis that cigarette smoking adversely alters protease-activated receptor type 1 (PAR-1)-mediated vascular effects in vivo in humans. Distinct from its role in the coagulation cascade, thrombin exerts its major cellular and cardiovascular actions via PAR-1. The activation of PAR-1 causes endothelium-dependent arterial vasodilation and the release of endogenous fibrinolytic factors. Forearm blood flow was measured with venous occlusion plethysmography in 12 cigarette smokers and 12 age- and gender-matched nonsmokers during intrabrachial infusions of PAR-1-activating-peptide (SFLLRN; 5 to 50 nmol/min), bradykinin (100 to 1,000 pmol/min), and sodium nitroprusside (2 to 8 mug/min). Plasma tissue plasminogen activator (t-PA) and plasminogen-activator inhibitor 1 antigen and activity concentrations were measured throughout the experiment. All agonists caused dose-dependent increases in forearm blood flow (p < 0.0001 for all). Although bradykinin and sodium nitroprusside caused similar vasodilation, SFLLRN-induced vasodilation was attenuated in smokers (p = 0.04). Smokers had modest reductions in bradykinin-induced active t-PA release (reduced by 37%, p = 0.03) and had a marked impairment of SFLLRN-induced t-PA antigen (p = 0.02) and activity (p = 0.006) release, with a 96% reduction in overall net t-PA antigen release. The use of SFLLRN also caused similar (p = NS) increases in inactive plasminogen-activator inhibitor 1 in both smokers and nonsmokers (p <or= 0.002 for both). Cigarette smoking causes marked impairment of PAR-1-mediated endothelial vasomotor and fibrinolytic function. Relative arterial stasis and near abolition of t-PA release will strongly promote clot propagation and vessel occlusion. These findings suggest a major contribution of impaired endothelial PAR-1 action to the increased atherothrombotic risk of cigarette smokers.

Proximal deep venous thrombosis following PTA of the superficial femoral artery – an obligation to disclose a complication that is rarely taken into account

We report two cases of femoral vein thrombosis after arterial PTA and subsequent pressure stasis. We discuss the legal consequences of these complications for information policies. Because venous thrombembolism following an arterial PTA might cause serious sequel or life threatening complications, there is a clear obligation for explicit information of the patients about this rare complication.

Ethiodized oil-ethanol capillary embolization in rabbit kidneys: temporal histopathologic findings.

To determine the temporal histopathologic findings associated with selective arterial injection of a 1:1 ethiodized oil-ethanol mixture (EEM) in normal rabbit kidney followed by administration of pure ethanol into the main renal artery. In five rabbits, the EEM was injected sequentially into each segmental renal artery of the right kidney until capillary stasis occurred. Pure ethanol was then injected into the main renal artery to achieve complete arterial stasis. Before sacrifice, the left kidney in each animal was acutely (ie, with a short follow-up period) embolized by using the same technique. The 10 kidneys of the five rabbits were evaluated microscopically at 1 (n = 3), 1(1/2) (n = 1), and 3 hours (n = 1) and 1 (n = 1), 3 (n = 1), 5 (n = 1), 7 (n = 1), and 14 days (n = 1) after embolization. Injection of the EEM (mean volume, 0.46 mL +/- 0.14 [SD]) followed by ethanol alone (mean volume, 0.25 mL +/- 0.09) led to complete stasis in all kidneys. There was no recanalization in the chronically (ie, with a longer follow-up period) embolized kidneys. Microscopically, uniform distribution of the EEM was evident in all slices at all time points. From 1 to 3 hours, sloughing of endothelium, formation of thrombi, and deposition of eosinophilic material along the renal, interlobar, and arcuate arteries were observed, without evidence of parenchymal damage. Within 24 hours, complete coagulative necrosis of the entire kidney occurred as a result of an occluding thrombus in the main renal artery. Analysis at subsequent time points revealed liquefaction of necrotic tissue and replacement with granulation tissue. In the rabbit, selective renal arterial injection of EEM followed by administration of ethanol produces vascular endothelial damage initiating thrombosis that results in renal infarction and ablation within 24 hours.

Endovascular Microcoil Gene Delivery Using Immobilized Anti-adenovirus Antibody for Vector Tethering

Endovascular microcoils are widely used in interventional procedures to treat cerebral aneurysms. In the present study we report for the first time successful use of an endovascular microcoil as a gene delivery system. Anti-adenoviral monoclonal antibodies were covalently attached to the collagen-coated surface of either platinum or polyglycolic acid microcoils. These antibodies were used to tether replication-deficient adenovirus (Ad-GFP [encoding green fluorescent protein] or Ad-LacZ [encoding beta-galactosidase]). Cell culture studies with rat arterial smooth muscle cells (A10) assessed transduction on or near the coil. Platinum coils coated with Ad-GFP were implanted into the ligated common carotid artery (CCA) of adult rats in a model of arterial stasis and pressurization. After 7 days, CCA segments were harvested, and coils were removed for histopathology and GFP expression studies, while organs were evaluated by polymerase chain reaction to assess viral biodistribution. In cell culture studies, GFP-positive smooth muscle cells were detected only on the platinum coil surface, while LacZ-positive cells were detected only on the polyglycolic acid coil surface, thus demonstrating localized gene delivery. After 7-day implantation, GFP (according to fluorescence microscopy and confirmed with immunohistochemistry) was detected on the harvested platinum coil and in the organizing thrombus within the CCA but not in the arterial wall. Morphometric analyses revealed that 13.3+2.0% of cells within the organized thrombus were transduced with Ad-GFP via the gene delivery system. However, arterial smooth muscle cells were negative for GFP according to fluorescence microscopy and immunohistochemistry. Ad-GFP was not detectable by polymerase chain reaction in lung, liver, or kidney. It is concluded that catheter deployment of platinum or biodegradable gene delivery endovascular microcoils represents an interventional device-based gene therapy system that can serve as a suitable platform for either single or multiple gene therapy vectors.

Transcutaneous PO2 response to transient arterial occlusion in peripheral vascular disease detected by heating power oximeter.

Transcutaneous PO2 (TcpO2) was measured in 30 patients with peripheral arterial obstructive disease (PAOD) and in 30 age-matched controls in the hand and foot using a heating power electrode oximeter (HP-E). The HP-E was connected with a software modified monitor to simultaneously record changes in arterial stasis in the skin (TcpO2 mm Hg) and in the underlying tissue 3.5 to 4 mm from the HP-E (TcpO2 mW). In the hands of patients with PAOD, the following was found, lower mean values of the rest flow (R-F) and of the recovery area (Rc-Ar); delayed appearance of both a PO2 decrease after the start of stasis (ODT) and the increased value after the cuff deflation (ORT); and little relevance of flow changes in the tissues under the HP-E. In the foot homolateral to the obstructive lesion, the hemodynamic effects of the stasis were not consistently a result of circulatory insufficiency. In light-medium PAOD the correlation was more significant with the walking-free distance (WFD). However in severe PAOD, the perfusion was usually depressed and the variable values tended to flatten. This study confirmed the diagnostic reliability of this test in PAOD patients. Furthermore simultaneous exploration of two microvessel levels increased its diagnostic possibilities.

Salvage of Superficial Palmar Avulsion

Avulsion injuries of the hand caused by moving rollers usually create a distally or, less commonly, a laterally based skin flap. Progressive necrosis in the distant part of the flap usually occurs because of arterial insufficiency and venous stasis over the next 2 to 3 weeks. From 1991 to 1994, we applied the concept of the "arterialized venous flap" to salvage the palmar tissue by revascularizing the superficial palmar venous network with an arterial anastomosis in eight patients. Six of the flaps survived completely and two had a small strip of marginal necrosis which healed secondarily. When compared with conventional methods, this method can remarkably improve the circulation of the flap and provide a better cosmetic and functional result for the highly specialized palmar tissue.

Topical metronidazole for arterial insufficiency ulcers

The use of topical metronidazole has been limited to the treatment of acne rosacea, infected foot ulcers associated with diabetes mellitus, varicose veins, postirradiation ulcers, and dental conditions since the Food and Drug Administration approved the drug in 1988. Because of this agent's apparent effectiveness in treating anaerobic bacterial infections in such ulcers, the authors believed that treatment of arterial insufficiency ulcers with a solution of topical metronidazole would be a rational approach. They describe a 30-year-old man in whom bilateral lower extremity cellulitis developed as a result of arterial insufficiency. The patient's ulcers were unresponsive to intravenously administered antibiotics and whirlpool therapy. However, when a topical solution of metronidazole was administered, the ulcers began to heal and epithelialization at the ulcer sites occurred. The authors review others' studies concerning clinical use of topical metronidazole and suggest that further study is warranted. To the authors' knowledge, topical metronidazole solution for the treatment of arterial insufficiency and venous stasis ulcers has not been previously reported.

Magnetic Resonance Imaging of the Extremities

In a resistive magnetic resonance imaging system, the T1 and T2 values of muscle and fat were calculated in 2 volunteers, at rest and during venous and arterial stasis, postischemic hyperemia and dehydration. The values found at rest were reproducible from one occasion to another and there were no significant differences between values in the arms and legs. Dehydration induced a slight increase in the T2, otherwise there was no change during stasis, hyperemia or dehydration.

Correlation of intra-arterial contrast stasis with flow patterns at constrictions, branches and bends: An experimental model

Flow patterns at bends and branches have been studied in an easily constructed open channel model so as to determine whether zones of stasis and poor mixing at constrictions, bends and branches can be correlated with certain arteriographic appearances. At bends, spiral flow lines and static zones occur which resemble those seen occasionally in the aortic arch and carotid siphon. At branches, stasis occurs on the outer walls of the branch mouths both in the experiments and arteriography, and constrictions easily produce downstream stasis, previously demonstrated in both arteries and open-channel experiments. Upstream stasis, not previously recorded, can also occur in arteries and model associated with severe constrictions. Occasionally stasis may extend along the whole length of one wall of a vessel when there is a downstream constriction, resembling arteriographic appearances seen in the internal carotid artery in patients with raised intracranial pressure, in those undergoin hyperventilation and also in coronary and other arteries. Despite known rheological differences between blood and water, the experimental findings are thought to be meaningful, and to indicate that there are within arteries, areas where turbulent mixing forces are weak or absent, resulting in arterial stasis.