Arterial Segments Research Articles

Drug Loss at Arterial Bends Can Dominate Off-Target Drug Delivery by Paclitaxel-Coated Balloons

Background/Objective: Paclitaxel-coated balloons (PCBs) can deliver efficacious drug concentrations to treated arterial segments but are known to exhibit high tracking losses. We aimed to define the governing factors impacting tracking loss and to contrast its drug distribution consequences with those of PCB inflation at the treatment site. Methods: Four naïve and four in-stent restenosis (ISR) porcine superficial femoral arteries (SFA) were treated with PCBs, and plasma samples were collected post-tracking and post-inflation. Animals were sacrificed <1 h post-intervention, and local, upstream, and downstream tissues were collected for paclitaxel quantification. Computationally driven quantitative benchtop-tracking and frictional PCB-sliding experiments modeled paclitaxel loss and delivery to upstream tissue. Results: Paclitaxel concentrations in plasma peaked pre-inflation and declined 30-fold immediately post-inflation. Correspondingly, losses of 30% and 1% of nominal PCB load were measured in vitro during, respectively, tracking over single bend and during device insertion. Mean paclitaxel concentrations were equally high at ISR and naïve SFA treatment sites (56,984 vs. 79,837 ng/g, p > 0.99) and ranged from 9 to 89 ng/g in tissues downstream of these treatment sites. Sampling of non-target upstream iliac artery tissues revealed paclitaxel concentration of 4351 ± 4084 ng/g. Benchtop sliding of PCB samples onto ex vivo porcine artery samples exhibited efficient, pressure independent frictional paclitaxel transfer (124 µg at 0.05 atm vs. 126 µg at 0.1 atm, p > 0.99). Conclusions: PCB interactions at porcine vessel bends led to premature tracking loss, resulting in peak plasma concentrations exceeding post-inflation concentrations, and delivery to upstream tissue that is plausibly explained as arising from efficient friction-mediated coating transfer.

Coronary Endothelial Dysfunction and Vasomotor Dysregulation in Myocardial Bridging

Myocardial bridging (MB), a congenital variant where a coronary artery segment is tunneled within the myocardium, is increasingly recognized as a contributor to coronary endothelial and vasomotor dysfunction. Beyond the hallmark systolic compression observed on angiography, MB disrupts endothelial integrity, impairs the release of vasoactive substances, and induces vasomotor abnormalities. These effects exacerbate ischemic symptoms and predispose to atherosclerosis in the proximal segment, particularly in conditions such as ischemia/myocardial infarction with nonobstructive coronary arteries. Recent studies underscore MB’s association with coronary vasospasm, microvascular endothelial dysfunction, and adverse cardiovascular outcomes, including sudden cardiac death. These findings highlight the interplay between MB’s structural anomalies and functional impairments, with factors such as the bridge’s length, depth, and orientation influencing its hemodynamic significance. Advances in imaging and coronary physiology assessment, including acetylcholine testing and stress diastolic fractional flow reserve/iFR/RFR, have enhanced diagnostic precision. This review explores the multifaceted impact of MB on coronary physiology, emphasizing its role in endothelial dysfunction and vasomotor regulation. Recognizing MB’s contribution to cardiovascular disease is essential for accurate diagnosis and tailored management strategies aimed at mitigating ischemic risk and improving patient outcomes.

Association of iliofemoral calcium score and major vascular complications within the first year after lower limb endovascular revascularization

The accumulation of calcium load in peripheral lower extremity arteries has been associated with increased severity of peripheral artery disease (PAD) and mortality. While calcium scores are commonly calculated from non-contrast computed tomography (CT) scans, patients with PAD often undergo contrast-enhanced CT scans. This study aims to explore the association between a length-adjusted calcium score (LACS) of the iliofemoral arteries, determined through pre-intervention contrast-enhanced CT, and major adverse events in patients with chronic limb-threatening ischemia (CLTI). A cohort of CLTI patients subjected to endovascular revascularization between 2005 and 2017 at a tertiary referral center were categorized into 2 groups. The complication group experienced one of the composite outcomes (reintervention, above-the-ankle amputation, and/or all-cause mortality within 1year of the primary endovascular procedure), while control patients did not encounter this composite endpoint. Patients from the complication group were matched one-to-one with controls based on sex and Fontaine classification. LACS was calculated (Ca volume[mm3]/length[cm]) at 3 arterial segments; 1. the common iliac artery (CIA), 2. the external iliac artery and common femoral artery (EIA+CFA), and 3. the superficial femoral artery plus the popliteal artery (SFA+PA). Binary logistic regression analysis was conducted to investigate the association between LACS in the different arterial segments and the occurrence of the composite binary outcome (complication and control) and LACS of the different segments, adjusting influences of age, sex, BMI >25, Fontaine classification, diabetes mellitus type 1 & 2, chronic kidney disease stage, and hemodialysis treatment. Sixty-four CLTI patients were included in this study (complication group [n=32], and control group [n=32]). A significant difference (higher LACS was found for the complication group in the CIA, the SFA+PA, as well as the total trajectory. CLTI patients with high LACS in the SFA+PA or the total trajectory were more likely to suffer adverse events (SFA+PA: OR: 1.010, 95% CI: 1.000-1.020, P=0.04; Total LACS: OR: 1.008, 95% CI: 1.000-1.017, P=0.05). Patients with a high calcium load in the ilio-femoral arteries are at increased risk of major adverse events during 1year after endovascular revascularization. The calcium score, derived from contrast-enhanced CT scans, holds potential utility in decision making for CLTI patients.

Accurate and robust segmentation of cerebral distal small arteries by DVNet with dual contextual path and vascular attention enhancement

Accurate and robust segmentation of cerebral distal small arteries by DVNet with dual contextual path and vascular attention enhancement

Abstract TMP79: Post Thrombectomy Transcranial Doppler Parameters and Clinical Outcomes

Introduction: Previous evidence indicated that transcranial doppler (TCD) parameters were associated with functional outcome in large vessel occlusion stroke (LVOS) patients who undergo mechanical thrombectomy (MT). We aim to 1) evaluate if TCD-derived pulsatility index (PI) and mean flow velocity (MFV) may predict clinical outcomes in LVOS after successful MT reperfusion, and to 2) assess if the PI is different in patients that received intravenous thrombolysis (IVT), indicating potential beneficial impact on microvascular reperfusion. Methods: This is a retrospective analysis of consecutive patients treated with MT for AIS secondary to a middle cerebral artery (MCA) M1 segment or intracranial internal carotid artery terminus (ICA) LVO. The study period spanned from January 1, 2018, to June 12, 2024; we only included patients with excellent reperfusion, defined as thrombolysis in cerebral infarction [TICI] grade 2c-3, who had TCD studies within 24 hours of their procedure. Patients without TCD studies, or with a poor temporal window were excluded. Ipsilateral and contralateral MFV and PI were collected for both the MCA and anterior cerebral artery (ACA). The primary outcome was the correlation between 3-month functional outcomes, assessed using the modified Rankin Scale (mRS), and the collected TCD parameters. Statistical correlations were performed using Pearson correlation. Results: Out of 1962 patients treated within the study period, 703 had MCA-M1 or i-ICA occlusions and TICI 2c-3, and only 229 had TCD within 24h and a good temporal window. Median age was 64.5 (IQR 56-75.5) years and 126 patients (55%) were males, 187 (81.7%) had an MCA-M1 and 42 (18.3%) an ICA-T occlusion. The median ASPECTS score was 8 (IQR 7-9) and the rate of IVT was 29.3%. Functional independence and mortality at 90 days were 49.3% and 14.4%, respectively. There was no association between MCA MFV (linear correlation coefficient -0.016;p=0.88) or PI (-0.08;p=0.47) and mRS at 90 days. The mean PI in patients that received IVT and did not receive IVT was comparable (mean 1.24 [SD0.06] vs 1.73 [SD0.54];p<0.001; adjusted for hypertension and occlusion location). Conclusion: In a homogeneous population of i-ICA/MCA-M1 occlusion with full reperfusion, TCD-derived parameters were not found to be associated with clinical outcomes. The PI was comparable between patients with and without IVT, and the finding substantiates the suggestion of IVT-related microvascular clearance.

Point-of-care ultrasound of the common carotid arteries for detection of large vessel occlusion stroke: Results of the POCUS-LVO study.

Distal arterial occlusions can cause measurable changes in the flow wave profile in proximal segments of the feeding artery. Our objective was to study the diagnostic accuracy of point-of-care ultrasound (POCUS) of the common carotid arteries (CCA) for detection of anterior circulation large vessel occlusion (ac-LVO) in patients with suspected stroke. We conducted a prospective, single-center, observational study of adult patients with suspected stroke admitted in the emergency department. Flow wave profiles of both CCAs were generated by non-specialists using POCUS as soon as possible after admission. ac-LVO was defined as an internal carotid artery or M1 occlusion in CT- or MR-angiography. The diagnostic performances for detection of ac-LVO using flow wave parameters were calculated. Among 283 patients recruited during a 10-month period, 257 patients (91%) had CCA ultrasound images of sufficient quality and were included for analysis. The mean age was 75 years (IQR 62-83), 131 were female (51.0%), median baseline NIHSS was 2 (IQR 0-5). The most frequent final diagnosis was ischemic stroke (49.4%), ac-LVO was present in 30 patients (11.9%). The median duration of POCUS was 3 min (IQR 2-5). Among all flow wave parameters, the highest diagnostic accuracy for ac-LVO detection was found for end-diastolic velocity difference between sides (AUC = 0.90, 95%CI = 0.85-0.93), with a specificity of 83% (95%CI = 78-88%) at a predefined sensitivity threshold of 80%. POCUS of the CCA in patients with suspected stroke can predict the presence of ac-LVO. These results need to be replicated in a prehospital setting.

The Role of Immune Cells in Moyamoya Disease

Moyamoya disease (MMD) is a rare progressive cerebrovascular disorder characterized by the stenosis or occlusion of the terminal segments of the internal carotid arteries, leading to the development of abnormal collateral vascular networks. These networks are a compensatory mechanism for reduced blood flow to the brain. Despite extensive research, the exact etiology of MMD remains unknown, although recent studies suggest that immune system dysfunction plays a critical role in its pathogenesis. In particular, the involvement of immune cells such as T cells, macrophages, and dendritic cells has been increasingly recognized. These immune cells contribute to the inflammatory process and vascular remodeling observed in MMD patients, further complicating the disease’s progression. Inflammation and immune-mediated damage to the vessel walls may accelerate the narrowing and occlusion of arteries, exacerbating ischemic events in the brain. Additionally, studies have revealed that certain genetic and environmental factors can influence immune system activation in MMD, linking these pathways to disease development. This review aims to provide a comprehensive overview of the immune mechanisms at play in MMD, focusing on how immune cells participate in vascular injury and remodeling. Understanding these immunological processes may offer new therapeutic targets to halt or reverse disease progression, potentially leading to more effective treatment strategies for MMD.

Multilevel lesions of lower extremities arteries: choosing the optimal surgical approach

INTRODUCTION. One of the important problems in cardiovascular surgery is the multilevel lesions of the lower extremity arteries. We presented the results of treatment of multilevel arterial lesion.METHODS AND MATERIALS. We analyzed the treatment results of 90 patients with combined lesions of the aortofemoral and femoral-popliteal segment of type TASC C and D. The patients were divided into 2 groups and 2 subgroups. Group 1 consisted of patients who underwent combined multilevel interventions, in turn, group 1 was divided into 2 subgroups according to the type of interventions. Group 1A – closed remote endarterectomy (RE) from the iliac arteries + femoral-popliteal (tibial) bypass surgery. Group 1B – aorto (iliac) – femoral bypass + RE from the arteries of the femoral-popliteal segment. Group 2 consisted of patients who underwent combined aorto (iliac) femoral + femoral-popliteal (tibial) bypass surgery.RESULTS. There were no registered cases of shunt thrombosis in the early postoperative period in group 1, whereas in group 2, both aorto-femoral and femoral-popliteal shunt thrombosis occurred in three cases (12%) in the early postoperative period. In group 1, 1 episode of bleeding was registered that required revision, in group 2, no bleeding was registered. In groups 1 and 2, 1 case of myocardial infarction (MI) was registered in the early postoperative period (p=0.301), one patient in group 2 had a stroke with regression of symptoms in the postoperative period. There were no deaths or amputations in the early postoperative period in group 1. In group 2, two patients (8%) underwent amputation in the early postoperative period, one patient died in the postoperative period. The primary patency in group 1A by 12, 24 and 60 months was 95 %, 76 % and 63 % respectively, in group 1B by 12, 24 and 60 months was 86 %, 86 % and 81 %, respectively, in group 2 by 12, 24 and 60 months was 100 %, 100 % and 85 %, respectively (p=0.368). Secondary patency in group 1A by 12 months was 77 %, by 24 months was 77 % and by 60 months was 52 %. In group 1B – by 12 months – 100 %, by 24 months – 67 %. In group 2 – by 12 months and 24 months – 50 % (p =0.983).CONCLUSIONS. Thus, if it is impossible to perform hybrid procedures, combined interventions for multi-level lesions of lower extremity arteries is an acceptable alternative to multi-level bypass. There was no difference in long-term patency between the compared methods of interventions, but the presence of fatal complications in the group of multilevel bypass indicates the advantage of a less invasive approach.

Segmentation of coronary artery and calcification using prior knowledge based deep learning framework.

Computed tomography angiography (CTA) is used to screen for coronary artery calcification. As the coronary artery has complicated structure and tiny lumen, manual screening is a time-consuming task. Recently, many deep learning methods have been proposed for the segmentation (SEG) of coronary artery and calcification, however, they often neglect leveraging related anatomical prior knowledge, resulting in low accuracy andinstability. This study aims to build a deep learning based SEG framework, which leverages anatomical prior knowledge of coronary artery and calcification, to improve the SEG accuracy. Moreover, based on the SEG results, this study also try to reveal the predictive ability of the volume ratio of coronary artery and calcification for rotational atherectomy (RA). We present a new SEG framework, which is composed of four modules: the variational autoencoder based centerline extraction (CE) module, the self-attention (SA) module, the logic operation (LO) module, and the SEG module. Specifically, the CE module is used to crop a series of 3D CTA patches along the coronary artery, from which the continuous property of vessels can be utilized by the SA module to produce vessel-related features. According to the spatial relations between coronary artery lumen and calcification regions, the LO module with logic union and intersection is designed to refine the vessel-related features into lumen- and calcification-related features, based on which SEG results can be produced by the SEGmodule. Experimental results demonstrate that our framework outperforms the state-of-the-art methods on CTA image dataset of 72 patients with statistical significance. Ablation experiments confirm that the proposed modules have positive impacts to the SEG results. Moreover, based on the volume ratio of segmented coronary artery and calcification, the prediction accuracy of RA is 0.75. Integrating anatomical prior knowledge of coronary artery and calcification into the deep learning based SEG framework can effectively enhance the performance. Moreover, the volume ratio of segmented coronary artery and calcification is a good predictive factor forRA.

The relationships between non-invasive myocardial work indices, myocardial blood flow and viability determined by PET

Abstract Backgrounds Myocardial work (MW) indices are new echocardiography parameters of left ventricular (LV) performance that consider afterload and global longitudinal strain analysis. However, the relationships between MW indices, myocardial perfusion and viability remain unclear after acute myocardial infarction (AMI). Aims To evaluate relationships between echocardiographic MW indices, myocardial blood flow and viability based on positron emission tomography (PET) in patients with AMI. Methods Thirty prospectively recruited patients (64±9 years, 90% males) underwent PET scans 7.7±3.8 days after primary percutaneous coronary intervention (PCI) for ST-elevation AMI. Global and segmental absolute myocardial blood flow (MBF) and perfusable tissue fraction (PTF) at rest were assessed using 15O-water PET. Myocardial segments were graded as viable or non-viable using the previously defined PTF cut-off value of 0.69 per segment (reference). LV function was evaluated by transthoracic echocardiography on the day of the PET scan (baseline) and at 6 months follow-up. MW index (MWI), constructive MW (CMW), MW efficiency (MWE), and myocardial wasted work (MWW) were measured. The myocardial area at risk (AAR) is based on the culprit coronary arterial segment, determined from the invasive coronary angiography. Two segments remote from the AAR were considered as the remote area. Results At baseline, resting global MBF was 0.84±0.19 ml/g/min, global MWI 1327± 334.9 mm Hg %, global MWE 87% [IQR 83- 92], global CMW 1649.8±415.9 mm Hg %, and global MWW 210.9±133.7 mm Hg %. There was a positive correlation between global MBF and CMW (r=0.42, p=0.02), whereas MWI, MWE, and MWW were not correlated with MBF. However, none of the MW indices correlated with MBF corrected for rate pressure product. In the AAR, MWI and MWE correlated with regional MBF (r= 0.53, p= 0.003, and r= 0.59, p<0.001) and PTF (r= 0.41, p = 0.03, and r= 0.65, p<0.001. Figure 1). The average ejection fraction was similar at baseline and after 6 months (55.8±66.9 vs. 57.5±67.3 %, p=0.2). Of the 156 segments in the AAR, 114 were viable and 42 were non-viable based on based on PTF. There was no difference in MW indices between viable and non-viable segments in the AAR at baseline. However, viable segments in the AAR showed improved MWI, MWE, CMW, and MWW at 6 months compared to baseline (P<0.001, P=0.02, P<0.001, and P<0.001, respectively), whereas there was no change in non-viable segments (Table 1). Moreover, MWI in the remote area increased at 6-month follow-up (p <0.001). Conclusions Although echocardiographic MWE was not associated with global MBF, it correlated with residual myocardial blood flow and PTF in the AAR after reperfused AM. Furthermore, echocardiographic MW indices improved in viable segments of the AAR at the 6-month follow-up. Our results provide evidence that myocardial viability is an important determinant of MWE measured by echocardiography.

Trajectories and determinants of myocardial work indices in patients with acute myocardial infarction after primary percutaneous coronary intervention

Abstract Backgrounds The myocardial work indices (MW indices) are novel echocardiographic parameters that quantify myocardial deformation and concomitant left ventricular pressure. However, there is little current data on trajectories and determinants of MW indices after acute myocardial infarction (AMI). Purpose We aimed to evaluate the trajectories of myocardial work indices and their relationship with left ventricle (LV) functional recovery and remodelling in patients with AMI after primary percutaneous coronary intervention (PCI). Methods Thirty-one prospectively recruited patients (28 men; mean age, 64 ± 9 years) underwent transthoracic echocardiography 7.7±3.8 days after PCI for the first ST-elevation AMI. LV function was evaluated at baseline and the 6-month follow-up. MW index (MWI), constructive MW (CMW), myocardial wasted work (MWW), MW efficiency, and (MWE) were measured globally and segmentally. The myocardial area at risk (AAR) and the remote area were based on the culprit coronary arterial segment, determined from the invasive coronary angiography. Levels of troponin T and NT-proBNP were assessed. Results The mean LV end-diastolic volume (EDV), LV end-systolic volume (ESV), LV ejection fraction (EF), and global longitudinal strain were similar at baseline and the 6-month follow-up (94.7±27.7 vs 93.6±30.1 ml, p=0.7, 42.7±17.1 vs. 40.8±19.1 ml, p=0.4, 55.8±6.9 vs. 57.5±7.3%, p=0.2, and -14.9±4.6 vs. -15.4±3.9%, p=0.3, respectively). The global MWI, MCW, MWW and were significantly improved at the 6-month follow-up (p<0.001, p<0.001, p=0.002, and p=0.03, respectively). Furthermore, in AAR, regional MWI, MCW, and MWW values significantly improved at the 6-month follow-up (all p<0.001), whereas no changes in MWE were observed . MWI and MCW significantly improved in the remote areas (p<0.001, and p=0.02, respectively) , but other indicators remained unchanged (Table 1). The global MWI and MCW values at baseline were inversely correlated with peak levels of troponin T (r= - 0.60, p<0.001, and r= -0.52, p= 0.002, respectively) and NT-proBNP (r= -0.49, p= 0.007, and r= -0.47, p=0.01, respectively). Furthermore, the global MWI and MCW showed a significant positive correlation with EF at baseline (r= 0.66, p<0.001, and r= 0.56, p<0.001, respectively) and 6-month follow-up (r= 0.68, p<0.001, and r= 0.69, p<0.001, respectively), but a negative correlation with ESV (Figure 1). However, there was no significant correlation between MW indices and EDV. Conclusion Patients with AMI who underwent primary PCI showed improved global and regional LV performance 6 months post-infarction, as demonstrated by MW indices. Decreased global MWI and MCW are associated with higher baseline levels of NT-proBNP, higher baseline levels of troponin T, reduced EF, and increased end-systolic volume. These results provide evidence that MW indices are potential markers of the severity of myocardial injury and remodelling after AMI.

The liver’s dilemma: sensing real danger in a sea of PAMPs: the (arterial) sinusoidal segment theory

The liver is susceptible to viruses and bacterial infections, tumors, and sterile tissue damage, but immunological danger recognition in the liver is highly unconventional. When analyzing innate and adaptive immunity in the organ, the valid concepts that guide danger recognition and immune response in the periphery should be put aside. In the liver, the vascular anatomy is a game changer, as about 80% of the blood that percolates the organ arrives from the hepatic portal vein, draining blood rich in molecules from the intestinal flora. This 24/7 exposure to high amounts of pathogen-associated molecular pattern (PAMPs) molecules results in hepatic immunological tolerance. In the liver, dendritic, Kupffer (KC), liver sinusoidal endothelial cells (LSECs), and even hepatocytes express PD-L1, a T lymphocyte downregulatory molecule. Most cells express Fas-L, IL-10, TGF-β, low levels of co-stimulatory molecules, lack of or have low levels of MHC-I and/or MHC-II expression. Moreover, other negative regulators such as CTLA-4, IDO-1, and prostaglandin E2 (PGE2) are regularly expressed. Then, how can real danger be discerned and recognized in this sea of PAMPs? This is an open question. Here, we hypothesize that conventional immunological danger recognition can occur in the liver but in specific and minor arterial sinusoidal segments,. Then, in the portal triad, where the hepatic artery ramificates into the stroma and carries arterial blood with no gut-derived PAMPs, there is no evolutive or environmental pressure for immunosuppressive pathways, and conventional immunological danger recognition could occur. Therefore, in arterial sinusoidal segments with no sea of PAMPs, the liver could recognize real danger and support innate and adaptive immunity.

Validation of UniverSeg for Interventional Abdominal Angiographic Segmentation.

Automatic segmentation of angiographic structures can aid in assessing vascular disease. While recent deep learning models promise automation, they lack validation on interventional angiographic data. This study investigates the feasibility of angiographic segmentation using in-context learning with the UniverSeg model, which is a cross-learning segmentation model that lacks inherent angiographic training. A retrospective review, after IRB approval, identified 234 patients who underwent interventional fluoroscopy of the celiac axis with iodinated contrast from January 1, 2019, to December 31, 2022. From 261 acquisitions, 303 maximum contrast images were selected, each generating a 128 × 128 pixel partition for arterial detail analysis and binary mask creation. Image-mask pairs were divided into three classes of 101 pairs each, based on arterial diameter and bifurcation number. UniverSeg was tested class independently in a fivefold nested cross-validation. Performance analysis for in-context learning determined average model convergence for class sizes from 1 to 81 pairs. The model was further validated by repeating the tests on the inverse segmentation task. Dice similarity coefficients for decreasing diameters were 78.7%, 72.5%, and 59.9% (σ = 5.96, 7.99, 14.29). Balanced average Hausdorff distances were 0.86, 0.71, and 1.16 (σ = 0.37, 0.52, 0.68) pixels, respectively. Inverted mask testing aligned with UniverSeg expectations for out-of-context problem sets. Performance improved with support class size, vessel diameter, and reduced bifurcations, plateauing to within ± 1.34 Dice score at N = 51. This study validates UniverSeg for arterial segmentation in interventional fluoroscopic procedures, supporting vascular disease modeling and imaging research.

Detecting asymptomatic cement pulmonary embolisms following vertebral augmentation using dual-energy computed tomography pulmonary angiography.

Dual-energy computed tomography (DECT) pulmonary angiography can reliably detect cement pulmonary embolisms (CPEs) and parenchymal perfusion defects. This prospective observational study investigated CPEs in asymptomatic patients using DECT. We enrolled 42 patients who underwent vertebroplasty or received cement screws for vertebral augmentation, examining them using spinal computed tomography and DECT pulmonary angiography. An iodine map was employed to identify perfusion defects. We recorded the number, location, and perfusion defects of each CPE, and the vertebral cement distribution and perivertebral venous leakage patterns of prevertebral, paravertebral, epidural, and inferior vena cava leaks at each treated level. The presence of CPEs and perfusion defects was correlated with clinical factors and perivertebral venous leakage patterns in patient- and level-based analyses. Seven patients had 19 CPEs among them: fourteen in subsegmental arteries, two in segmental arteries, two in lobar arteries, and one in the main pulmonary artery. Twelve CPEs identified in four patients had corresponding perfusion defects on an iodine map. Patient-based univariable and multivariable logistic regression revealed that prevertebral leakage was significantly associated with the presence of CPEs (P<0.05). Prevertebral leakage was significantly associated in the univariable analysis with the presence of perfusion defects (P=0.025). In mixed-model univariable level-based logistic regression, prevertebral leakage was significantly associated with the presence of CPEs (P=0.04). CPEs frequently occur following vertebral augmentation, are associated with substantial prevertebral venous leakage, and predominantly occur in the subsegmental pulmonary artery. They do not always cause perfusion defects.

Novel anatomical variations of the internal thoracic artery: implications for coronary artery bypass grafting surgery and autologous breast reconstruction.

The unique structure and location of the internal thoracic artery make it an ideal conduit for coronary artery bypass grafting surgery and autologous breast reconstruction. Variants with different characteristics have the potential to impact surgical success. This report presents a female body donor with a novel bilateral variation of the internal thoracic artery. The vessel arose from third segment of the subclavian artery, distal to it coursing deep to the anterior scalene muscle, and then proceeded to course anterior to the first rib, instead of posteriorly. This variation could detract from the desirability of the internal thoracic artery as a graft. Tractioning the artery over the first rib may render it too stenotic for surgical utility. In an individual who has undergone autologous breast reconstruction, this variation may prohibit adequate length preservation for use in subsequent coronary artery bypass grafting. Also, in the setting of thoracic outlet syndrome, this arterial variation may cause unforeseen complications post-grafting.

Cracking the Code of Calcification: How Presence and Burden among Intracranial Arteries Influence Stroke Incidence and Recurrence.

Intracranial atherosclerosis accounts for about 8% of all strokes in Western societies but the influence of arterial calcification on plaque instability is a topic on ongoing debate. Explore the association between the presence and burden of calcium in atherosclerotic plaques among intracranial arteries with the risk of clinical or silent stroke events through a systematic review and meta-analysis. Adhering to PRISMA guidelines, studies from PubMed and Embase were analyzed up to May 2024. Adult populations undergoing CT/CTA scans for symptomatic and asymptomatic atherosclerosis among intracranial vessels. Statistical analyses were performed to identify the impact of calcium presence and relative burden on stroke incidence or recurrence. Risk of bias was evaluated with QUADAS-2 criteria while GRADE system was used to assess quality of evidence. The study synthesized data from 8 longitudinal studies, creating two different models: Calcium presence (heterogeneity: Q 9.19; I2 42.61%) and calcium burden (heterogeneity: Q 6.01; I2 0.01%). As for calcium presence and stroke events, 6839 patients were considered, and two statistical models were made. Our analysis established a significant association between the presence of calcium and stroke events. [OR= 1.54, 95% CI 1.06, 2.24, p=0.001]. A subsequent effect size analysis showed a similar correlation's strength [OR = 1.56, 95% CI 1.11, 2.19, p = 0.001]. As for calcium burden and stroke events, 4885 patients were considered with effect size analysis establishing a positive correlation [OR = 1.31, 95% CI, 1.17, 1.46, p =< 0.001). A decrease in correlation strength was found between calcium presence [OR = 1.56] and burden [OR = 1.31] with stroke events. Despite strict exclusion criteria, heterogeneity across studies and between different statistical models of the present study persisted. Valuable data loss among excluded studies could have affected the findings of this meta-analysis. Unified calcium scoring pattern and individual arterial segment analysis was not widely adopted by included literature. Our meta-analysis showed a weak, yet present association between presence and burden of calcification among intracranial arterial vessels and clinical or silent stroke events. Considering the high prevalence of intracranial calcification in the general population, widespread intracranial calcium assessment for stroke prediction has currently poor evidence. Investigation on specific intracranial vessels or exploration of newer calcium patterns could be essential to enhance the predictive accuracy of calcification in stroke incidence or recurrence. IAC = Intracranial Arterial Calcification; HU = Hounsfield Unit; RE = Random Effect.

A nuanced scrutiny of the segmental renal artery spectral Doppler in "Pickering" the right diagnosis.

Approximately 5-10% of patients with hypertension have secondary hypertension. We describe a case of secondary hypertension from bilateral renal artery stenosis (RAS): "Pickering syndrome." This is a case of hypertension secondary to bilateral RAS which provides an opportunity to review secondary hypertension with a specific focus on RAS, in terms of when to consider work up, causes of secondary hypertension, diagnostic testing, and treatment.

Analysis of clinical features and prognostic factors of focal cerebral arteriopathy in children

Objective: To summarize the clinical characteristics of focal cerebral arteriopathy (FCA) in children, and to analyze its influencing factor of prognosis. Methods: A retrospective cohort study was conducted. Clinical data from 40 children with FCA who were hospitalized at the Department of Neurology, Beijing Children's Hospital, Capital Medical University, from September 2015 to August 2024 were collected. A centralized follow-up was conducted in October 2024 via outpatient clinics or the internet. The pediatric stroke outcome measure (PSOM) was used to evaluate their outcomes. Based on the PSOM, the children were further divided into a group with normal neurological function and another group with abnormal neurological function. Differences between groups were analyzed using the Mann-Whitney U test and Fisher exact test. Univariate Logistic regression analysis was performed to identify the influencing factors for neurological outcomes in children with FCA. Results: A total of 40 children were included, with 20 males and 20 females, and the onset age of 9.2 (6.8, 12.5) years. Among them, 12 cases (30%) had a history of varicella within 1 year before onset. There were 23 cases (58%) presenting with transient ischemic attack (TIA) or recurrent fluctuating symptoms of onset, while 3 cases (8%) developed progressive stroke within the first month of onset. The M1 segment of the middle cerebral artery was the most commonly affected vascular site, with a total of 16 cases (40%). Arterial occlusion occurred in 8 cases (20%). Lumbar puncture was completed in 36 children, and white blood cell counts in cerebrospinal fluid was increased in 6 cases. All 23 patients who completed magnetic resonance vessel wall imaging (VWI) showed circular enhancement of the arterial wall. A total of 28 patients (70%) received antiplatelet or anticoagulation therapy, and 16 patients (40%) received hormone therapy. At admission, the pediatric National Institute of Health Stroke Scale (PedNIHSS) score was 6.0 (2.0, 8.8) points, which decreased to 0.5 (0, 3.0) points at discharge. The follow-up duration was 1.6 (0.8, 4.9) years, with 1 case lost to follow-up. There was 1 case presenting with recurrence course manifesting as TIA. Among the 39 cases who completed the follow-up, 23 cases (59%) were assessed as neurologically normal by PSOM, while 16 cases (41%) were assessed as neurologically abnormal. Among the 29 cases who completed the imaging review, magnetic resonance angiography (MRA) review in 23 cases indicated stability or improvement in the original arterial stenosis, with 6 cases experiencing transient worsening of arterial stenosis early in the disease course (within 2 months), which later improved. Arterial stenosis progression occurred in 6 cases at the final review of 29 cases who completed the imaging review, with 1 case developing progressive cerebral arteriopathy. The proportion of patients with headache, altered consciousness, and aphasia in the abnormal neurological function group, as well as the PedNISS scores at admission and discharge, were all higher than those in the normal neurological function group (all P<0.05). Univariate Logistic regression analysis revealed that only a PedNISS score>6 points at onset was an influencing factor for abnormal neurological function (OR=20.58, 95%CI 3.93-107.70, P<0.001). Conclusions: Childhood FCA often presents with fluctuating onset, and the proximal segment of the middle cerebral artery is frequently affected. Progression of arterial stenosis is common within 2 months of the disease course, but clinical progression and new ischemic lesions are uncommon. Most patients have a favorable long-term prognosis. PedNIHSS score>6 points at admission is related to abnormal neurological function outcomes.

Iatrogenic pseudoaneurysm formation of the anterior cerebral artery following placement of an external ventricular drain: illustrative case.

External ventricular drains (EVDs) provide an invaluable diagnostic method for accessing cerebrospinal fluid and therapeutically treating elevated intracranial pressure. Although complications including hemorrhage and infection have been well documented, the formation of iatrogenic pseudoaneurysms following EVD placement has rarely been reported. The authors present a case of this exceedingly rare complication of iatrogenic pseudoaneurysm formation following EVD placement. In this report, the authors document the formation of a pseudoaneurysm within the A4 segment of the anterior cerebral artery in a 77-year-old female following frontal EVD placement, which was promptly recognized and successfully embolized endovascularly. They discuss the suspected pathophysiology, given the literature citing similar complications, and the differing management strategies following the discovery of iatrogenic pseudoaneurysms. Although rare, iatrogenic vascular injury following EVD placement or removal should not be overlooked. If hemorrhage following catheter placement or manipulation develops, suspicion for iatrogenic vascular injury should be high, and appropriate vascular imaging should be performed. As reported here, prompt treatment with endovascular embolization provides a safe and effective means to prevent future rupture and worsening hemorrhage. This case and the literature review emphasize the importance of rapid diagnosis of postprocedural pseudoaneurysm formation and treatment to prevent continued secondary brain injury. https://thejns.org/doi/10.3171/CASE24558.

Intentional staged embolization via the "highway bypass" using a radial artery graft for a large posterior circulation aneurysm: illustrative case.

The presence of significant tortuosity in access routes to aneurysms can interfere with catheter guidance and manipulation and significantly impact treatment strategies. In this report, the authors combined intentional staged aneurysm embolization with the construction of a new direct access route, which they call a "highway bypass," for a symptomatic posterior circulation cerebral aneurysm that was difficult to access with a catheter. Notably, the highway bypass is used for catheter passage, and technical tips should be considered. The patient had a symptomatic unruptured cerebral aneurysm in the first segment of the left posterior cerebral artery with bilateral internal carotid artery occlusion and severe tortuosity of the bilateral vertebral arteries. The highway bypass using a radial artery graft was performed in the first stage; in the second stage, the aneurysm was accessed using the graft, and embolization was performed. The catheter was passed through the graft without complications. The aneurysm was successfully embolized, no ischemic lesions were found in the postoperative images, and the patient was discharged without worsening neurological findings. Intentional staged aneurysm embolization combined with the highway bypass effectively treats aneurysms that are difficult to access. Anastomoses should be designed to allow catheters to pass through the graft. https://thejns.org/doi/10.3171/CASE24527.