Artery Patency Research Articles

Occlusion type and posterior communicating artery patency may predict favorable outcome after endovascular thrombectomy in selective basilar top occlusion.

The top of the basilar artery is a five-branched junction, consisting of two superior cerebellar arteries (SCAs), two posterior cerebellar arteries (PCAs), and the basilar artery itself. This study aimed to investigate prognostic factors in patients with selective acute basilar top occlusion managed with mechanical thrombectomy, focusing on occlusion type and posterior communicating artery (PCoA) patency. Eligible patients who underwent endovascular treatment (EVT) for acute basilar top occlusion were reviewed. Patterns of basilar top occlusion were categorized as types I-III according to whether the SCA and PCA were visible on angiography. The PCoA was categorized as hypoplastic or non-visible (type I), normal patency but non-visible PCA through PCoA flow (type II), and fetal type (type III). Good outcomes were observed in 50% (21/42) and mortality in 11.9% (5/42) of the cases at 90 days. Patients with good outcomes showed lower baseline National Institutes of Health Stroke Scale (NIHSS) score (P = 0.001) and a higher proportion of type III basilar top occlusion (P = 0.004) and type III PCoA (P = 0.001). Multivariable logistic analysis showed that baseline NIHSS score [odds ratio (OR), 0.84; 95% confidence interval (CI), 0.73-0.97; P = 0.017) and type III PCoA (OR, 21.54, 95% CI, 1.33-347.97; P = 0.031) were independent predictors of good functional outcomes. A low initial NIHSS score and good PCoA patency were independent predictors of favorable clinical outcomes after EVT in patients with acute basilar top occlusion. Furthermore, the favorable outcome group showed a high proportion of type III basilar top occlusions.

Single-branched stent-graft with on-table fenestration for endovascular repair of primary retrograde type A aortic dissection: A multicenter retrospective study.

This study aims to evaluate the feasibility, efficacy, and safety of a single-branched stent-graft with on-table fenestration for primary retrograde type A aortic dissection (RTAD) during thoracic endovascular aortic repair (TEVAR). From January 2019 to December 2021, 36 patients with primary RTAD from five tertiary hospitals received medical management in the acute phase. They underwent TEVAR with a proximal zone 1 landing for aortic arch reconstruction in the subacute phase, using a fenestration technique on a single-branched stent-graft. Nearly 2 weeks after admission, computed tomography angiography (CTA) was re-examined to evaluate the thrombosis status of retrograde false lumen (FL). The primary outcomes were technical success, patency of the target branch arteries, and absence of type Ia endoleaks. The second outcomes were stent-graft-related complications and all-cause mortality. The mean age was 56.2 ± 11.3 years, and 29 (80.6%) were male. After a median interval of 18.0 [interquartile range (IQR), 17.0-20.3] days of medical treatment, the partial and complete thrombosis of proximal FL rates increased to 52.8% and 47.2%, respectively. One patient (2.8%) experienced postoperative type Ia endoleaks, and was successfully re-treated using coli and Onyx glue. The median hospital stay was 20.5 (IQR, 18.0-23.0) days. The overall technical success rate was 100%. The median follow-up time was 31.5 (IQR, 29.8-34.0) months. There was one death (2.8%) due to gastrointestinal bleeding. Distal aortic segmental enlargement (DASE) occurred in two (5.6%) patients. No major complications or recurrent dissections in the proximal landing zone were recorded during follow up. The retrograde FL in primary RTAD could realize partial or complete thrombosis after medical management in the acute phase, and it might be regarded as a valid proximal landing zone for endovascular repair. The single-branched stent graft with on-table fenestration performed in the subacute phase may be feasible strategy in selective primary RTAD patients.

USE OF THE STERI-STRIPS IN ACHIEVING RADIAL ARTERIAL ACCESS HEMOSTASIS

Objectives: The compression duration of the radial artery remained a key concern after coronary angiography (CA) and interventions via trans-radial access (TRA). We evaluate the impact of application of steri-strips along with conventional pneumatic trans-radial (TR) band on duration of compression required for hemostasis after diagnostic CA.
 Methodology: In this open labeled randomized clinical trial, total of 209 patients who underwent diagnostic CA were randomized in 1:1 ratio into TR band with steri-strips (treatment) and conventional TR band alone (control) for achieving hemostasis. All patients were followed for 1 month. The primary endpoint was the duration of application of TR band and secondary endpoints were radial artery occlusion (RAO) and major bleeding.
 Results: 106 patients received steri-strip along with TR band and 103 patients received TR band alone. The median duration of application of TR band was 60 [IQR: 60-60] min in the treatment group and 250 [IQR: 240-360] min in the control group; p≤0.001. The major bleed requiring reapplication of TR band was 9.4% vs. 4.9%; p=0.364 and hematoma (type I only) was 7.5% vs. 9.7%, p=0.578 in the treatment and control group respectively. Radial artery was palpable in 95.3% vs. 85.4%; p=0.016 after 24 hours and 96.2% vs. 88.3%; p=0.0.032, at 1 month in the treatment and control arm respectively.
 Conclusion: Use of steri-strips is helpful in significantly reducing the compression duration of TR band and improving the patency of radial artery after diagnostic angiography with no significant rise in hematoma or major bleeding complications. Keywords: Steri-strips, radial artery, pneumatic TR band, coronary angiography, radial artery patency, radial artery occlusion.

Analysis of Spinal Ischemia after Frozen Elephant Trunk for Acute Aortic Dissection: An Observational, Single-Center Study.

This observational study aimed to evaluate the perioperative risk factors for spinal cord ischemia (SCI) in patients who underwent aortic repair with the frozen elephant trunk technique (FET) after acute aortic Stanford A dissection. From May 2015 to April 2019, 31 patients underwent aortic arch replacement with the FET technique, and spinal ischemia was observed in 4 patients. The risk factors for postoperative SCI were analyzed. The mean age of patients with acute aortic dissection was 57.1 years, and 29.4% were female. Four patients developed SCI. There were no significant differences in characteristics such as age and body mass index. The female gender was associated with most of the SCI cases in the univariate analysis (75%, p = 0.016). Known perioperative and intraoperative risk factors were not related to postoperative SCI in our study. Patients who developed SCI had increased serum postoperative creatinine levels (p = 0.03). Twenty-four patients showed complete false lumen thrombosis up to zones 3-4, five patients up to zones 5-6 and two patients up to zones 7-9, which correlates with the postoperative development of SCI (p = 0.02). The total number of patent intercostal arteries was significantly reduced postoperatively in SCI patients (p = 0.044). Postoperative acute kidney injury, the reduction in patent intercostal arteries after surgery and the extension of false lumen thrombosis up to and beyond zone 5 may play a significant role in the development of clinically relevant spinal cord injury after FET.

Fenestrated/branched endovascular aortic repair using unilateral femoral access in patients with iliac occlusive disease

ObjectiveFenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging owing to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease. MethodsWe performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with unilateral iliofemoral occlusive disease were included in the analysis. All patients had one patent iliac artery that was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (stroke, spinal cord injury, dialysis or decrease in the glomerular filtration rate of more than 50%, bowel ischemia, myocardial infarction, or respiratory failure), primary iliac patency, and freedom from reinterventions. ResultsThere were 959 patients treated with F/BEVAR. Of these, 15 patients (1.56%; mean age, 74 years; 80% male) had occluded iliac arteries and 1 patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (n = 8) or juxtarenal abdominal aortic aneurysm (n = 7). Brachial access was used in 14 of the 15 patients and preloaded systems in 7 of the 15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were seven physician-modified endovascular grafts, seven custom-made devices, and one off-the-shelf device used. Thirteen patients (87%) had distal seal using aortouni-iliac stent grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in two patients and six patients had a prior FCB. Technical success was 100%. There were no intraoperative complications or early lower extremity ischemic complications, and all FCB were preserved. There was one mortality (7%) within 30 days owing to retrograde type A dissection. Major adverse events occurred in 20% of patients. The median follow-up was 12 months (range, 0-85 months). Two patients (13%) required three reinterventions. One patient required proximal stent graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an aortouni-iliac graft (21 months) and thrombolysis of that extension (50 months). At last follow-up, all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no r-intervention. The overall survival rate was 60%, without aortic-related deaths. ConclusionsAlthough challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications, but satisfactory outcomes.

Aspirin versus aggressive antiplatelet therapy for acute carotid stenting plus thrombectomy in tandem occlusions: ETIS Registry results

BackgroundPatients treated with acute carotid stenting (CAS) may have higher odds of a favorable outcome than those treated without CAS during thrombectomy in tandem occlusions. Antiplatelet therapy is associated with...

Abstract 9618: Prolonged Arterial Phase is the Culprit Pathology in Patients With Chest Pain, Elevated Troponin Level, Abnormal Thallium Scan and Patent Coronary Arteries: An Angiographic, Machine Learning Analysis for a Personalized Preventive Medicine Approach

Introduction: Many patients with acute coronary syndrome (ACS) presented with elevated troponin level and reversible changes in the thallium scan. When they patients underwent coronary angiogram, the results showed patent coronary arteries. WHY? Hypothesis: Could abnormal coronary flow explain ACS, abnormal thallium and patent coronary arteries? Methods: Patients with newly diagnosed ACS and abnormal Thallium scan underwent a new dynamic coronary angiogram. 10 patients without ACS, normal EF and no coronary artery disease served as control. In this new technique, the contrast and blood flow were recorded at 15 images per second. The first image was of the index artery completely filled with contrast. The subsequent images showed the blood in white color moving in over a background of black contrast. The arterial phase started when the blood began moving in and ended when the contrast disappeared from the distal arterial vasculature as the contrast was replaced by blood. The machine learning (ML) program had 2 models (built on Python). Model 1 was built based on U-net and Densenet-121 for vessel segmentation. Model 2 was used for classification of flow. The model 2 was trained based on the convolutional neural network. The data to be collected was the duration of the arterial phase and the recurrence of ACS within one year follow-up Results: 45 patients with ACS (elevated troponin level (50-100mg), reversible stress thallium), underwent coronary angiogram. The angiograms of 10 control patients showed a normal arterial phase (AP) of 1.56 sec. It was prolonged at 2.5sec in 45 patients with ACS (p<0.05). After 1 year follow-up, 35 patients had no further ACS if their LDL cholesterol was well controlled (<75mg%), blood pressure (BP<130mmHg) and the patients stopped smoking. In 10 patients who continued to have uncontrolled LDL, high BP and especially smoking, they developed ACS including death. Conclusions: In ACS patients, a prolonged arterial phase associated with reversible change in nuclear scan and normal coronary arteries identified the patients of high risk. Aggressive treatment of risk factors protected these patients of new ACS. Failure to control risk factors lead to repeat ACS. New trials are needed to confirm and guide new personalized medicine approach.

Five-year outcomes of physician-modified endografts for repair of complex abdominal and thoracoabdominal aortic aneurysms

ObjectiveThere is paucity of data on the durability of physician modified endografts (PMEGs) for complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) despite widespread use. The aim of this study was to evaluate and compare the early and long-term outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) for CAAAs and TAAAs using PMEGs. MethodsWe reviewed clinical data and outcomes of patients treated by FB-EVAR using PMEGs for CAAAs (defined as short-neck infrarenal, juxtarenal, and pararenal AAAs) and TAAAs between 2007 and 2019. All patients were treated by a dedicated team with extensive manufactured device experience. Endpoints included 30-day mortality and major adverse events, patient survival and freedom from aortic-related mortality (ARM), freedom from secondary intervention, target artery (TA) patency, and freedom from TA endoleak and TA instability. ResultsOf 645 patients undergoing FB-EVAR, 156 patients (24%) treated with PMEG (121 males; mean age, 75 ± 8 years) were included. There were 89 CAAAs, 33 extent IV TAAAs and 34 extent I to III TAAAs. A total of 452 renal-mesenteric targets (3.1 ± 1.0 vessels/patient) were incorporated. Patients with TAAAs had significantly (P < .05) larger aneurysms (73 ± 11 vs 68 ± 14 mm), more TAs incorporated (3.4 ± 0.9 vs 2.8 ± 1.0), and more often had previous aortic repair (54% vs 27%). Technical success was higher in patients treated for CAAAs (99% vs 91%; P = .04). Thirty-day and/or in-hospital mortality was 5.7% and was significantly lower for CAAAs compared with TAAAs (2% vs 10%; P = .04), with three of nine early mortalities (33%) among patients treated emergently. After a mean follow-up of 49 ± 38 months, there were 12 aortic-related deaths (7.6%), including nine early deaths (5.7%) from perioperative complications and three late deaths (1.9%) from rupture. At 5 years, patient survival was 41%. Patients treated for CAAAs had higher 5-year freedom from ARM (P = .016), TA instability (P = .05), TA endoleak (P = .01), and TA secondary interventions (P = .05) with a higher, but non-significant, freedom from sac enlargement ≥5 mm (P = .11). Primary and secondary TA patency was 91% ± 2% and 99% ± 1%, respectively. Sac regression ≥5 mm occurred in 67 patients (43%) and was associated with increased survival (hazard ratio, 0.54; 95% confidence interval, 0.37-0.80) compared with those without sac regression. ConclusionsFB-EVAR using PMEGs was performed with acceptable long-term outcomes. Overall patient survival was low due to significant underlying comorbidities. Patients treated for CAAAs had higher freedom from ARM, TA instability, TA endoleak, TA secondary interventions, and a trend towards higher freedom from sac enlargement compared with patients treated for TAAAs. Sac regression was associated with improved patient survival.

Abstract 12986: Internal Iliac Artery Occlusion With the Amplatzer Vascular Plug During Endovascular Repair of Large Abdominal Aortic Aneurysm

Background: Retrograde blood flow from the internal iliac artery resulting in a type II endoleak is a challenging complication of endovascular aorto-iliac aneurysm repair. Several methods have been developed to address this concern. We present a case where the Amplatzer vascular plug was used to embolize the internal iliac artery in a patient undergoing aorto-iliac stent-grafting with extension of the graft into the external iliac artery. Case: A 67-year-old male presented with abdominal pain. Abdominal contrast computed tomography confirmed a large infrarenal abdominal aortic aneurysm (AAA) measuring 100 mm across, extending into the common iliac artery on the right and the external iliac artery on the left, with perianeurysmal fat stranding indicating impending rupture. The patient was taken emergently to the operating room. Vascular access was obtained through bilateral common femoral arteries. The left internal iliac was occluded with an Amplatzer 16 mm by 12 mm vascular plug, with excellent angiographic apposition. A bifurcated aorto-iliac graft was then sequentially deployed to repair the aneurysm. Final angiography showed patent renal arteries with no endoleak. The patient was discharged home the following day. Discussion: Embolization of the internal iliac artery is indicated in endovascular aorto-iliac aneurysm repair to prevent endoleak formation. Traditionally performed with coils, the Amplatzer vascular plug has emerged as a safe and effective alternative, with the added advantage of recoverability prior to definitive release. Conclusion: Endovascular repair of an AAA must consider the complication of endoleak formation. In this case, the use of an Amplatzer vascular plug was successful in preventing a type II endoleak from the internal iliac artery. Panel A. 3D reconstruction of aneurysm anatomy; Panel B. Angiogram showing final result of endovascular repair with successful occlusion of the left internal iliac artery

Abstract 14141: A Novel Endothelial Function Test in Predicting Late Coronary In-Stent Restenosis

Introduction: Endothelial dysfunction is related with in-stent restenosis (ISR) of prior drug-eluting stents (DES) implanted more than 1 year ago (late ISR). EndoPAT is a novel non-invasive test quantifying endothelial function as reactive hyperemia peripheral arterial tonometry index (RHI). Hypothesis: EndoPAT is a potential predicting test for late ISR. Methods: We conducted a case control study on 186 patients with coronary DES implanted more than 1 year ago in a single medical center. Those who had contraindications to EndoPAT test, acute myocardial infarction, coronary artery bypass graft (CABG), chronic kidney disease (CKD) stage III and above, active infection and rheumatologic disease or acute decompensated heart failure were excluded. Patients were divided into ISR and non-ISR group based on coronary angiography. EndoPAT test was done at 24 to 48 hours prior to catherization. LnRHI is an index after natural log transformation of RHI. A receiver operative characteristic (ROC) curve analysis was used to determine the sensitivity and specificity of LnRHI for predicting late ISR. Results: ISR group had significantly more patients with history of ISR or triple-vessel disease, longer stent length and fewer totally occlusive lesions than non-ISR group. LnRHI was significantly lower in ISR group than in non-ISR group (0.66 vs 0.50, p&lt;0.01). Patients with diffuse ISR had lower LnRHI than those with focal ISR (0.40 vs 0.55, p=0.03). Patients without ISR but undergoing revascularization had lower LnRHI than those with patent coronary arteries (0.56 vs 0.70, p=0.02). Endothelial function quantified by LnRHI was an independent risk factor for ISR (LnRHI/0.1, OR=0.79, 95% CI 0.64-0.97, p=0.03). The ROC curve analysis showed LnRHI of 0.44 had a sensitivity of 81.7% and specificity of 53.8% for predicting late ISR. Conclusions: Endothelial dysfunction measured by EndoPAT had a clinical potential for predicting the development of late ISR.

Abstract 14711: Radial Artery Patency Following Distal Transradial Access in Patients With Advanced Chronic Kidney Disease

Background Radial artery occlusion (RAO) with transradial access is reported in 6-9% of patients with advanced chronic kidney disease (CKD) and may preclude the creation of an arteriovenous fistula for dialysis. Distal transradial access (dTRA) has lower rates of RAO compared with proximal transradial access but studies excluded patients with advanced CKD. Methods: We sought to define procedure characteristics and RAO rates with dTRA in CKD. Patients who underwent cardiac catheterization with dTRA from 01/01/2019 to 01/01/2022 with follow-up of radial artery patency by reverse Barbeau or repeat access of the artery were included. Results: A total of 68 patients with a median age of 60 (IQR 54-69), 50 (74%) males were included. A total of 44 (65%) were on hemodialysis. Of the procedures, 59 (87%) were diagnostic and 9 (13%) were PCIs. Access was ultrasound guided, a majority (79%) were right dTRA and all had spasmolytic therapy and patent hemostasis. Sheaths were 5 French short (7 cm) in 40 (59%) and 6 French short in 28 (41%). Mean contrast volume was 20+/-11 ml for diagnostic procedures and 91+/-53 ml for PCIs. Mean radiation exposure was 290+/-156 mGy for diagnostic procedures and 1692+/-961 mGy for PCIs. Mean fluoro time was 5+/-4 mins for diagnostic procedures and 24+/-13 mins for PCIs . Of 9 patients with PCIs, mean number of stents was 2+/-1 and atherectomy was used in 2 (22%) PCIs. The median number of diagnostic catheters was 1(IQR 1-2) and median guides was 1(IQR 1-1) in PCIs. Radial arteries were patent in 68 (100%) at follow-up. (Figure 1) Conclusions: Our cohort demonstrates safety of dTRA in patients with advanced CKD with high rates of radial artery patency.

Rare presentation of Waldenström’s macroglobulinaemia requiring bilateral above-knee amputations: a case report

BackgroundWaldenström’s macroglobulinaemia is a rarely encountered B-lymphocytic malignancy. Waldenström’s macroglobulinaemia-associated paraproteinaemia is linked to an increase in serum viscosity, which results in a hypercoagulable state. Burning bilateral foot pain in a man with alcohol dependence and controlled atrial fibrillation presenting to the emergency department was attributed to peripheral neuropathy, given satisfactory angiographic evidence of bilateral foot arterial blood supply. Subsequently, his presentation as an emergency with acute bilateral critical lower limb ischemia that was managed by bilateral above-knee amputations, prompted a wider search for other etiologies. We present a hitherto unreported case of Waldenström’s macroglobulinaemia-related acute bilateral lower limb ischemia, which required bilateral above-knee amputations.Case presentationA 50-year-old Caucasian man, who was an alcohol dependent heavy smoker, presented with burning pain in his right foot that was deemed to be related to alcoholic neuropathy. A computerized tomographic angiogram demonstrated an occluded right distal anterior tibial artery but a patent posterior tibial artery supplying the foot arch, findings that were associated with noncritical ischemia. After multiple presentations within a week, he was admitted following sudden clinical deterioration with acute confusion, hyponatremia, and bilateral foot pain. Over the course of 24 hours, the patient deteriorated rapidly, with bilateral lower limb ischemia requiring bilateral above-knee amputations. Subsequent investigations revealed a diagnosis of Waldenström’s macroglobulinaemia.ConclusionsTo the best of our knowledge, this is the only reported case of Waldenström’s macroglobulinaemia-induced bilateral lower limb ischemia requiring major bilateral amputations.

Volumetric analysis of effectiveness of embolization for preventing type II endoleaks following endovascular aortic aneurysm repair

ObjectiveThe presence of endoleak was associated with the failure of endovascular aortic aneurysm repair (EVAR) treatment. The key to eliminating type II endoleak has shifted from reintervention to prevention. This study aimed to evaluate the effectiveness and safety of applying fibrin sealant to prevent type II endoleak in conjunction with EVAR. MethodsAll patients with abdominal aortic aneurysm who underwent EVAR from June 2019 to July 2021 were reviewed. Patients were grouped as Group A: standard EVAR with preemptive embolization and Group B: standard EVAR alone. The primary endpoint was the incidence of type II endoleak. The secondary endpoints were aneurysm sac regression, the inferior mesenteric artery patency, the numbers of patent lumbar arteries, and all-cause mortality. ResultsA total of 104 patients were included in Group A, and 116 were included in Group B. Technical success rate was 100%. The overall incidence of type II endoleak in Group A was significantly lower than that in Group B (4.8% vs 19.0%). The mean time of freedom from type II endoleak was 22.71 months for Group A (95% confidence interval, 21.59-23.83 months) and 19.89 months for Group B (95% confidence interval, 18.08-21.70 months). The Kaplan-Meier estimate of freedom from type II endoleak showed a significantly longer duration of freedom from type II endoleak in Group A (81.0% vs 95.2%). Group A showed a continuous sac regression tendency. In Group B, the sac volume decreased within 12 months but increased by 3.07 cm3 at 24 months. No complications were noted in both groups. ConclusionsNonselective preemptive embolization with porcine fibrin sealant during EVAR was safe and effective in preventing type II endoleak in the short and mid-term. Preemptive embolization can lead to a significantly higher sac regression rate. Larger patient populations and longer follow-ups with randomized control designed trials are expected to verify the long-term effectiveness and safety of preemptive embolization in preventing type II endoleak.

Comparison of Arterial Line Patency in Heparinized Normal Saline with Normal Saline Flushing Among Critically ill Patients: A Literature Review

Hemodynamic monitoring in critically ill patients is often invasive, using an arterial line. The monitoring accuracy is highly dependent on the patency of the arterial line, which is often compromised by artery blockages. So far, heparin in normal saline is believed to prevent these complications compared to normal saline alone. This study aimed to compare the effectiveness of normal saline flushing with heparin with normal saline use on arterial line patency. The method of the study was a review. Keywords were compiled using words such as critical care unit, heparinized saline, normal saline, and arterial line patency with boolean operators. Searched extensively through PubMed, Science Direct, and Google Scholar, Data were analyzed using the extraction table and presented with qualitative analysis. The initial search identified 370 articles. Seven articles were obtained after being selected through the duplication, title, abstract, and inclusion-exclusion criteria. All articles mentioned that there was no significant difference between the use of normal saline added with heparin with normal saline on arterial line patency. Based on the study, it can be concluded that the use of normal saline alone as an arterial line flush is recommended because it reduces the risk of Heparin-Induced Thrombocytopenia, allergy to heparin, bleeding and is economically more cost-saving. Abstrak: Pemantauan hemodinamik pada pasien kritis seringkali dilakukan secara invasif, menggunakan jalur arteri. Keakuratan pemantauan sangat tergantung pada patensi arterial line , yang seringkali terganggu oleh penyumbatan arteri. Sejauh ini, heparin dalam salin normal diyakini dapat mencegah komplikasi tersebut dibandingkan dengan pemberian normal salin saja. Penelitian ini bertujuan untuk membandingkan efektivitas flushing menggunakan normal saline ditambah heparin dengan penggunaan normal salin terhadap kepatenan arterial line. Penelitian ini merupakan literatur review . Kata kunci dikompilasi menggunakan critical care unit, heparinized saline, normal saline, dan arterial line patency yang dikombinasikan menggunakan boolean operator . Hasil-hasil penelitian dicari secara ekstensif melalui PubMed, Science Direct, dan Google Scholar, data dianalisis menggunakan tabel ekstraksi dan disajikan menggunakan analisis kualitatif. Pencarian awal berhasil mengidentifikasi 370 artikel. Tujuh artikel kemudian diperoleh setelah melalui seleksi menggunakan kriteria duplikasi, judul, abstrak, dan inklusi-eksklusi. Semua artikel menyebutkan bahwa tidak ada perbedaan yang signifikan antara penggunaan normal saline ditambah heparin dengan normal saline terhadap kepatenan arterial line . Berdasarkan penelitian dapat disimpulkan bahwa penggunaan flushing menggunakan normal salin saja direkomendasikan karena mengurangi risiko trombositopenia yang diinduksi heparin, alergi terhadap heparin, perdarahan dan dilihat dari biaya, lebih ekonomis.

Repair of coronary artery ostium with a ring-shaped bovine pericardial patch.

As an approach to coronary artery ostial injury in type A aortic dissection and infective endocarditis, we describe a technique of coronary ostial repair using a ring-shaped bovine pericardial patch. The inner and outer rims of the patch were sutured to the involved coronary ostium (to close the ostial tear) and to the aortic wall (to cover the sinus), respectively. Four patients were successfully managed and computed tomographic coronary arteriogram at follow-up showed patent coronary ostia and arteries. The favourable preliminary results imply that this technique is a simple, safe and effective approach to coronary ostial repair in patients with type A aortic dissection or infective endocarditis.

Surgical treatment of distal cerebral aneurysms

Background. Distal cerebral aneurysms are very rare. To date, there are very few publications on distal cerebral aneurysms and they are mostly limited to clinical case series.Aim. To analyze anatomical characteristics of distal cerebral aneurysms and surgical outcomes, as well as to identify risk factors for a poor outcome and develop a treatment algorithm on this basis; to determine the role of neuronavigation and revascularization in the surgical treatment of distal cerebral aneurysms.Materials and methods. We performed a retrospective analysis of surgical outcomes of 153 patients with distal cerebral aneurysms treated in N.V. Sklifosovsky Research Institute for Emergency Medicine (Moscow Healthcare Department) between January 1, 2000 and December 31, 2019.Results. Distal cerebral aneurysms were identified in 4.5 % cases of all cerebral aneurysms; 81.7 % of patients with distal cerebral aneurysms were admitted to the hospital with ruptured aneurysms. The most frequent locations of distal cerebral aneurysms were pericallosal and middle cerebral arteries. Distal cerebral aneurysms were usually small (77.5 %), had a wide neck (31.8 %), and fusiform structure (15.7 %). Aneurysm clipping was performed in 74.5 % cases; parent artery trapping, in 23.5 % of patients; revascularization, in 5.9 % of patients. The main risk factors for a poor outcome included aneurysm size and location, patient grade on the modified scale of the World Federation of Neurosurgical Societies (mWFNS), and presence of severe vasospasm.Conclusion. The developed surgical algorithm for distal cerebral aneurysms (based on the assessment of a poor outcome risk factors, the use of neuronavigation, arterial patency control, and revascularization) could improve surgical outcomes of patients with distal cerebral aneurysms.

Default distal radial approach for all coronary procedures – a prospective study

Abstract Background Radial artery approach for coronary interventions has substantially improved the outcome especially in acute coronary syndrome patients. However, radial artery occlusion is the achilles' heel of such an approach. Purpose To obviate such problems, distal radial artery (DRA) approach is evolving but technical challenge is the small size of the artery. We looked at the feasibility, safety and advantages of it. Methods Patient population included any patient requiring a diagnostic or percutaneous coronary interventions (PCI) in our catheterization laoratory from March 2020 to March 2022. A primary operator performed all procedures as default, if the patient had a palpable DRA. After local anaesthesia infiltration, using seldinger technique and micropuncture kit, 5 to 7F hydrophilic sheaths were introduced and a cocktail of verapamil and heparin was given routinely. Sheaths were removed immediately after procedure but dedicated side specific compression devices were used but removed 45 min after diagnostic and 2 hours after PCI. Clinical patency of radial artery was assessed at discharge and follow up. Results A total of 682 procedures were performed (50% were diagnostic). Out of all PCIs 59% were for ACS). Elective PCIs included very complex cases including PCI for bifurcation, left main and rota assisted complex PCIs. 651 patients had right distal radial approach and 28 had left. Mean age of patients were 66.8±12.9 years (26 to 97). Females constituted 218 (32%). Mean time from 1st needle puncure to successful vascular access took 1.2±0.8 min (20 sec to 6 min). Average attempts to obtain successful vascular access was 1.3±0.7 (1 to7 attempts). There were 15 failures (2%) to obtain DRA access requiring change over to 6 ipsilateral radial, 2 ulnar, 4 contralateral distal radial, 2 femoral and 1 brachial access. Interestingly, in 5 different occaisions previous procedure related occluded radial arteries were recanalized through this access. Most importantly, no case of radial artery occlusion was encountered at discharge or at follow up by clinical examinations. No other vascular complications were encountered except mild transient bruising in 6 cases and early small hematoma in 3 cases. Patient's comfort, nursing staffs' satisfaction and trend towards early discharges were also noticed. There was a distinct improvement in obtaining faster access with lower failure rates by the operator after initial 90, especially after 150 procedures. Conclusions A default approach through distal radial artery in anatomical snuff box for all coronary interventions is feasible, safe and possibly superior to conventional radial access with better patient comfort and caring staff's satisfaction. Though learning curve is longer and more challenging, success rates were much higher and vascular access was faster after initial phase. Clinically radial artry occlusion was not seen but needs further study and more objective evidence. Funding Acknowledgement Type of funding sources: None.

Relationship between microvascular obstruction and infarct size assessed early after primary PCI and all-cause mortality, reinfarction and hospitalization for heart failure

Abstract Background Rapid reperfusion of the epicardial coronary artery by primary percutaneous coronary intervention (PCI) is the guideline-recommended treatment for ST-segment elevation myocardial infarction (STEMI). However, in a substantial proportion of patients, despite restored patency of the epicardial coronary artery, perfusion to the distal coronary microvasculature is not fully achieved. The principal cause of this phenomenon is severe microvascular dysfunction or loss of integrity leading to microvascular obstruction (MVO). Objectives Aim of the research was to understand the relationship between microvascular obstruction (MVO) and/or infarct size (IS) and/or left ventricular ejection fraction (LVEF) assessed early after PCI in STEMI patients and subsequent all-cause mortality, reinfarction, and hospitalization for heart failure (HF). Methods A literature review was performed with no restrictions in terms of geography or design of study. Publications related to the validation and/or comparison of methods to quantify microvascular obstruction or infarct size were discarded. Results Search criteria yielded 23 references. After exclusion of validation studies, 13 publications were retained. Most of these papers were authored by the same group of investigators. A pooled patient-level analysis from 10 randomized primary PCI trials (total 2,632 patients) established that IS was strongly associated with all-cause mortality and hospitalization for HF but not significantly related to subsequent infarction. Pooled analysis of patient data from 7 of these 10 randomized primary PCI studies showed that MVO was also significantly associated with all-cause mortality and hospitalization for HF but not related to subsequent infarction. 5 of these 10 randomized primary PCI trials allowed categorization of patients by time of the day of the primary PCI intervention. No association was found between the time of day and IS, MVO, or prognosis after STEMI. A similar analysis concluded that recent smoking was unrelated to IS or MVO but was associated with a worse prognosis after primary PCI in STEMI. No correlation was established between body mass index and IS, MVO or LVEF, or one-year rates of death or HF hospitalization. A sub-study of a nationwide randomized investigation in Denmark assessed the impact of age of STEMI on IS and LVEF and the composite endpoint of death and re-hospitalization for HF. Patients &amp;lt;60 had smaller final infarcts and higher LVEF, but after adjusting for confounders, age did not remain significantly associated with IS and LVEF. During 4-year follow-up, the composite endpoint depended on both age and IS. Conclusions MVO and IS assessed early after primary PCI in STEMI are strongly associated with death and hospitalization for HF within one year. Innovative technologies that limit IS by improving microcirculation function during STEMI are of great individual and socioeconomic value. Funding Acknowledgement Type of funding sources: Private company.

Stenting of critical aortic coarctation in neonates between 600 and 1,350 g. Using a transfemoral artery approach. A single center experience.

BackgroundStenting of aortic coarctation (CoA) in newborns with a very low bodyweight remains rare and challenging. In this study we aim to highlight on two points: first the feasibility of CoA stenting in such babies and second the importance of using echocardiogram for guiding the intervention without the need for contrast agent.MethodsBetween 2020 and 2022 three preterm babies with very low (VLWB) and extremely low weight (ELWB) underwent CoA-stenting in our center. The weight of the patients at time of intervention was 1,350, 1,200, and 600 g, respectively. The femoral artery was chosen in all patients as vascular access. Transthoracic echocardiography, sonography of the femoral arteries and head ultrasound were applied for follow up.ResultsAll three interventions were successfully done, with no complications. Coronary stents were implanted. In one Patient (1,350 g) the stent was inserted without sheath. In two patients with renal failure, the stenting was performed under echocardiography-guidance without contrast agent. The follow up showed a preserved function of the left ventricle in all patients. No relevant gradient was reported and no stent re-intervention was required. Sonographic follow up showed a patent femoral artery in all patients. Two patients were operated 73 and 110 days after stenting, and the stents were successfully removed. In the third patient the intervention was performed 130 days ago and he is waiting for the operation.ConclusionCoA-stenting in VLWB and ELWB is feasible and can bridge them to the next surgery without complications. Echocardiography-guided CoA-stenting in VLWB is a considerate option especially in patients with renal failure. Accessing the femoral artery by experienced doctors, using local anesthesia before the puncture and before removing the sheath might help to protect the vessel from stenosis or occlusion.

The choice of bridging stents in fenestrated endovascular aortic repair

PURPOSE: To study the medium and long-term patency and endoleak rate of visceral arteries in fenestrated endovascular aortic repair (fEVAR), and explore the strategies for bridging stent selection. METHODS: The clinical data of 44 patients with thoracoabdominal aneurysms, infrarenal short-necked aortic aneurysms and aortic dissection involving the visceral artery treated using fEVAR were reviewed. The indications for stents for different visceral vessels were evaluated. RESULTS: A total of 104 target vessels were revascularized with 7 scallops and 97 fenestrations. Among them, 12 were without stents and 92 were bridged with 96 stent-grafts, including 28 uncovered stents and 68 covered stents. The success rate of the one-time placement of bridging stents was 95.7% (88/92). The overall Type-I endoleak rate was 2.9% (3/104), and the overall visceral stent patency rate was 97.1%. The receiver operating characteristic curve revealed that the critical distances between the celiac trunk artery, superior mesenteric artery (SMA), renal artery, and aneurysm were 10.25 mm, 4.3 mm, and 10.05 mm, respectively, for selecting covered stents or uncovered stents and 12.4 mm for SMAs with or without stents. CONCLUSION: The branch-to-aneurysm distance may be important for bridging stents choice in fEVAR.