Collateral Supply Research Articles

Signal variance-based collateral index in DSC perfusion: A novel method to assess leptomeningeal collateralization in acute ischaemic stroke

As a determinant of the progression rate of the ischaemic process in acute large-vessel stroke, the degree of collateralization is a strong predictor of the clinical outcome after reperfusion therapy and may influence clinical decision-making. Therefore, the assessment of leptomeningeal collateralization is of major importance. The purpose of this study was to develop and evaluate a quantitative and observer-independent method for assessing leptomeningeal collateralization in acute large-vessel stroke based on signal variance characteristics in T2*-weighted dynamic susceptibility contrast (DSC) perfusion-weighted MR imaging (PWI). Voxels representing leptomeningeal collateral vessels were extracted according to the magnitude of signal variance in the PWI raw data time series in 55 patients with proximal large-artery occlusion and an intra-individual collateral vessel index (CVIPWI) was calculated. CVIPWI correlated significantly with the initial ischaemic core volume (rho = −0.459, p = 0.0001) and the PWI/DWI mismatch ratio (rho = 0.494, p = 0.0001) as an indicator of the amount of salvageable tissue. Furthermore, CVIPWI was significantly negatively correlated with NIHSS and mRS at discharge (rho = −0.341, p = 0.015 and rho = −0.305, p = 0.023). In multivariate logistic regression, CVIPWI was an independent predictor of favourable functional outcome (mRS 0–2) (OR = 16.39, 95% CI 1.42–188.7, p = 0.025). CVIPWI provides useful rater-independent information on the leptomeningeal collateral supply in acute stroke.

Abstract WP167: Is There a Distinct Phenotype for Non-Asian Moyamoya Patients?

Background and Purpose: Idiopathic moyamoya syndrome (IMMS) is a progressive narrowing of the anterior circulation arteries resulting in the development of a tenuous collateral blood supply which is prone to rupture or thrombosis. IMMS has mostly been studied in East Asian populations where it was first described, with limited data describing this syndrome in non-Asians. We aimed to describe IMMS patients in New York and identify differences between Asians and non-Asians in this population. Methods: Using the New York State Department of Health Statewide Planning and Research Cooperative System database from 2000-2014 we identified all newly diagnosed cases of IMMS (ICD-9 437.5) in adults aged 18 and older. We excluded patients with down syndrome, neurofibromatosis type 1 and sickle cell disease. We compared patient demographics, comorbidities and extracranial-intracranial revascularization (ECIC) rates for IMMS patients that self-identified with Asian race/ethnicity vs those who did not. Results: All IMMS diagnoses occurred in urban hospitals. There were 554 IMMS patients in total; 89.4% (n=495) were non-Asian while only 10.6% (n=59) were Asian. A smaller proportion of non-Asian IMMS patients were diagnosed in smaller, non-academic hospitals compared to Asians (3.8% vs 10.2%, p=0.03) (Table). Both groups showed comparable rates of characteristics and comorbidities. Stroke risks following IMMS diagnosis were similar for both Asians and non-Asians (13.6% vs 22.4%, p=0.1); strokes occurred later for non-Asian patients with ECIC than in those without (2.1 + 2.8 vs 1.4 + 2.1 years, p=0.04). No subsequent strokes occurred in Asians after ECIC. Conclusion: Individuals of non-Asian origin account for almost 90% of IMMS diagnoses in New York State, but they are infrequently diagnosed in small, non-academic hospitals. Further research is needed to identify a distinctive phenotype and genotypic profile of IMMS in non-Asians.

Why we don’t need hepatic artery reconstruction during DP-CAR? experience of 20 modified appleby procedures

Background: Distal pancreatectomy with celiac artery resection (DPCAR) is in use for borderline-resectable pancreatic cancer. It is believed that considerable reduction of the liver arterial supply after DPCAR may cause severe liver ischemia. Although the artery reconstruction is not a problem anymore the decision to reconstruct artery has to be justified To study liver collateral arterial supply after temporary CHA, right gastroepiploic and accessory/replaced left hepatic arteries (a/rLHA). Methods: Arterial anatomy, diameters of CHA, proper hepatic (PHA), gastroduodenal(GDA) and pancreatoduodenal arteries(PDA) were registered before surgery in 110 consecutive patients with pancreatic body/tail cancer(n35), gastric cancer with pancreatic involvementn30) and liver tumors(n45)by CT. For DPCAR(n20) these data were obtained after surgery as well. Diameters of peripancreatic arteries and mean systolic blood velocity in hepatic arteries before and after CHA clamping were measured intraoperatively by Doppler ultrasound. Results: Pulse disappeared in 19 (17 %) cases after clamping of CHA,RGEA and aLHA/rLPA. Collateral arterial blood flow in the liver parenchyma was revealed in all cases. DPCAR led to increase of GDA, rRHA, PDA and RGEA blood flow in 0,9-12 times Conclusion: Doppler ultrasound is a reliable modality for intraoperative assessment of liver arterial blood supply after DPCAR; Hepatic artery reconstruction may be necessary after DPCAR in case of disappearance of arterial US signal upon the liver parenchyma.

Popliteal Vascular Injuries

Background: Injury of the popliteal vessels is one of the most limb-threatening peripheral vascular injuries. The high morbidity after popliteal vascular injury can be explained by the fact that the popliteal artery is an end artery with an insufficient collateral supply; in addition, the popliteal vein provides the bulk of lower leg and foot drainage. Delays in diagnosis and interference in addition to associated complex tissue injuries would be associated with high amputation rate. However, high level of suspicion with early recognition and management by multidisciplinary team are necessary to optimize limb salvage. The aim of this review is to discuss the different factors that may affect the morbidity, incidence, presentation and diagnostic tools, various management options, and outcome of popliteal vascular injury.

Popliteal Vascular Injuries

Background: Injury of the popliteal vessels is one of the most limb-threatening peripheral vascular injuries. The high morbidity after popliteal vascular injury can be explained by the fact that the popliteal artery is an end artery with an insufficient collateral supply; in addition, the popliteal vein provides the bulk of lower leg and foot drainage. Delays in diagnosis and interference in addition to associated complex tissue injuries would be associated with high amputation rate. However, high level of suspicion with early recognition and management by multidisciplinary team are necessary to optimize limb salvage. The aim of this review is to discuss the different factors that may affect the morbidity, incidence, presentation and diagnostic tools, various management options, and outcome of popliteal vascular injury.

Collateral Uterine Arterial Supply in the Setting of Various Uterine Pathologies

AbstractIn most patients, bilateral uterine arteries supply the uterus exclusively. However, collateral arterial supply to the uterus has been described, predominantly in the context of uterine artery embolization (UAE) for fibroid treatment. This may lead to incomplete embolization, which can impact clinical outcomes. Therefore, identification of potential collateral supply to the uterus is essential for achieving optimal clinical results. The authors report three cases of collateral uterine arterial supply from the ovarian and round ligament arteries in the setting of uterine arteriovenous fistula (uAVF), postpartum hemorrhage (PPH), and symptomatic fibroids. Aortography from the level of the renal arteries was performed for initial evaluation of uterine arterial supply in all patients and identified hypertrophied, tortuous ovarian artery collaterals. Selective angiography of the external iliac artery was required to identify round ligament collateral uterine supply. Three-dimensional cone beam computed tomography (CT) was also used to visualize vascular distribution of bilateral uterine arteries and an ovarian collateral feeding a uAVF. In regard to outcomes, identification of collateral uterine arterial supply allowed for single-session complete embolization in fibroid patients with collateralized round ligament or ovarian arteries and in the PPH patient in disseminated intravascular coagulation with predominantly ovarian artery supply to the uterus. Identification of collateral uterine arterial supply facilitated technical success in all patients. In the setting of various uterine pathologies, identification of collateral uterine arterial supply is essential to optimize clinical success of UAE.

Indirect revascularization with the dural inversion technique for pediatric moyamoya disease: 20-year experience.

OBJECTIVENumerous surgical procedures facilitate revascularization of the ischemic brain in patients with moyamoya disease. Dural inversion is a technique in which flaps of dura mater centered around the middle meningeal artery are inverted, encouraging the formation of a rich collateral blood supply. This procedure has been used in combination with encephaloduroarteriosynangiosis for more than 20 years at the authors' institution for the treatment of pediatric moyamoya disease. The objective of this study was to describe the clinical and radiographic outcomes for a cohort of consecutive pediatric moyamoya patients undergoing dural inversion.METHODSClinical and radiographic data on patients who had undergone dural inversion in the period from 1997 to 2016 were reviewed. Univariate and multivariate logistic regression and Kaplan-Meier analyses were performed to assess the risk of postoperative stroke, functional outcome, and the angiographic degree of revascularization.RESULTSDural inversion was performed on 169 hemispheres in 102 patients. Median follow-up was 4.3 years. Six patients (3.6% of hemispheres) suffered postoperative ischemic or hemorrhagic stroke. Overall mortality was 1.0%. Good postoperative neurological status (modified Rankin Scale [mRS] score ≤ 2) was observed in 90 patients (88%); preoperative and postoperative mRS scores showed significant improvement (p < 0.001). Eighty-six percent of hemispheres had Matsushima grade A or B revascularization. Younger age was associated with postoperative stroke and poor functional outcome. Patients with secondary moyamoya syndrome had a significantly worse radiographic outcome. The cumulative 5-year Kaplan-Meier risk for stroke was 6.4%.CONCLUSIONSDural inversion is a useful technique of cerebral revascularization in pediatric moyamoya disease. A 20-year experience demonstrates the safety and efficacy of this technique with a relatively low rate of postoperative stroke, good functional outcomes, and favorable angiographic results.

Upper Gastrointestinal Bleeding From Ischemic Gastropathy After TACE Therapy

Transarterial chemoembolization (TACE) therapy is used in the treatment of unresectable hepatocellular carcinomas. TACE involves the injection of a chemotherapeutic agent into the hepatic artery which results in decreased blood supply to the liver tumor and resultant tumor cell death. Rare complications of TACE therapy including hepatic artery occlusion, tumor rupture, liver abscess, and ischemic injury related to non-target embolization. GI bleeding due to ischemic gastropathy, however, is rare due to the extensive collateral blood supply of the stomach. A 63 year-old male with hepatitis C and alcoholic cirrhosis complicated by esophageal varices, hepatic encephalopathy, and hepatocellular carcinoma was admitted for his fourth TACE therapy. The patient developed abdominal discomfort and hematemesis the following day. Patient was tachycardic during episodes of hematemesis but was otherwise stable with no transfusion requirements. Upper endoscopy later that day revealed non-bleeding small esophageal varices and extensive areas of blackened mucosa from the proximal stomach to duodenum with nodularity, tissue friability, erosions, and adherent clots. Mucosal changes were most pronounced in the mid and distal stomach. Diffuse erosions were also noted in the proximal duodenum, but there was a discrete transition point to normal mucosa between the 2nd and 3rd portions of the duodenum. Hematemesis was thought to be related to severe inflammation and friability in stomach and proximal duodenum, and patient had clinical improvement with supportive care. Gastrc biopsies demonstrated fibrinoid change of lamina propria, glandular atrophy, and purulent exudate consistent with ischemic gastritis. Duodenal biopsies also demonstrated focal fibrinoid change of lamina propria and glandular atrophy also consistent with ischemia. This case was discussed with interventional radiology, and previously treated branches of the right and left hepatic artery had appeared atretic. Visualization of the hepatic lesion was therefore limited, and the decision was made to treat non-selectively via the left hepatic and middle hepatic artery which likely resulted in embolization of vasculature supplying the stomach and proximal duodenum. Most patients have resolution of symptoms with supportive care. PPI therapy has also been suggested to promote mucosal healing. Patients would benefit from monitoring after TACE therapy especially if less-selective embolization is performed.2338_A Figure 1 No Caption available.2338_B Figure 2 No Caption available.2338_C Figure 3 No Caption available.

Left gastric artery to Aortic anastomosis for the management of Coeliac Artery Stenosis during pancreaticoduodenectomy

Introduction: Coeliac artery stenosis (CAS) is rarely of consequence due to rich collateral supply from the superior mesenteric artery (SMA) via the pancreatic head. Pancreaticoduodenectomy (PD) in CAS disrupts these collaterals and puts the liver, stomach and spleen at risk of ischemia. Methods and results: A 56-year-old male, presented with obstructive jaundice for 3 weeks. Computed-tomography (CT) scan revealed an operable periampullary tumor with CAS due to compression by the median arcuate ligament(MAL) with multiple collaterals in pancreatic head and prominent GDA. After an unsuccessful attempt at coeliac axis endo-vascular stenting, he was planned for PD. Intra-operative MAL release failed to restore good flow in common hepatic (CHA) and splenic arteries (SpA), as confirmed by Doppler with a GDA clamp. We decided to use left gastric artery(LGA) for arterial reconstruction, disconnected it from the stomach with its origin intact and anastamosed to supracoeliac aorta (Figure 1). Doppler with a GDA clamp confirmed good filling of CHA and SpA via LGA. GDA was ligated and PD was completed. The patient had an uneventful recovery except for a biochemical pancreatic leak and discharged on POD 10. Conclusion: CAS during PD, confirmed by a decrease in CHA flow with a GDA clamp, needs additional procedures to restore blood flow to liver, stomach and spleen. Anastamosing LGA to supra-coeliac aorta is a simple reconstruction technique to achieve this.

ВАСКУЛОЕНДОТЕЛІАЛЬНИЙ ФАКТОР РОСТУ А ТА ПОЛІМОРФІЗМ G634C ГЕНА ВЕФР-A У ХВОРИХ ІНФАРКТОМ МІОКАРДА В ГОСТРИЙ ТА ВІДДАЛЕНИЙ ПЕРІОДИ

&#x0D; &#x0D; &#x0D; Vascular endothelial growth factor A (VEGF-A) promotes the survival of endothelial cells during acute myocardial infarction, accelerates the development of collateral blood supply to ischemic myocardium, and affects the size diminishing of the necrotic lesion area. The synthesis of the VEGF- A in response to standard stimuli is different between people that is genetically determined. The aim was to study the association of polymorphous variants of the VEGF-A gene (G634C) with the dynamics of structural and functional parameters of left ventricle in patients with acute ST elevation myocardial infarction (STEMI) during a 6-month period.A significantly higher VEGF-A concentration was determined in the carriers of the GG genotype compared to the GC genotype (p = 0.047) in the acute period. It has been established that the genotype GC in patients with acute myocardial infarction ST-elevation (STEMI) is associated with more pronounced changes in the left ventricular geometry during the acute period. The GC genotype is associated with a better blood pressure control and a decrease in the left ventricle mass after 6 months’ observation.&#x0D; &#x0D; &#x0D;

Protective effect of electroacupuncture preconditioning at zúsānlĭ (足三里 ST36) on mitochondria in the intestinal ischemia/reperfusion injury

ObjectiveThe study explored the effect of applying electroacupuncture (EA) preconditioning at ST 36 on mitochondria in rats with intestinal ischemia/reperfusion injury. MethodsForty SD rats were divided into four sets: sham operation group (sham group); intestinal ischemia/reperfusion group (I/R group); EA preconditioning at ST 36 followed by intestinal ischemia/reperfusion injury (ST 36 + I/R group); EA preconditioning at the lateral site away from ST36 0.5 cm followed by intestinal ischemia/reperfusion injury (N + I/R group). For the sham group, the rats were opened abdominal cavity for 3 h and 20 min and their abdominal cavities were covered with wet gauze avoiding drying and kept on the thermostat at 37 °C. For the ischemia/reperfusion (I/R) group, rats were anaesthetised and their abdominal cavities were opened to expose jejunum segments. The segment's collateral blood supply was restricted by bilateral ligation of the intestine. Next, one of the branches of a mesenteric artery was occluded with a thread for 20 min and then the thread was released after such ischemia conditions, keeping reperfusion for 3 h. For the ST36 + I/R group, the electroacupuncture at ST36 was first performed, then the intestinal ischemia/reperfusion model was constructed. For the N + I/R group, electroacupuncture at non ST36 acupoint, which is away from ST36 about 0.5 cm, and then the intestinal ischemia/reperfusion model was performed. Measurements of the levels of inflammatory markers tumour necrosis factor α (TNFα) and interleukin-1 beta (IL-1β), cytochrome c (CYCS), and the mitochondrial membrane pro-apoptotic protein (BAX), anti-apoptotic protein Bcl-2 were performed. ResultsCompared to I/R group, the intensity of cytoplasmic CYCS in intestinal tissues was significantly decreased in the ST 36 + I/R group (1.65 vs. 0.18, p < 0.05). Compared to N + I/R group, the intensity of cytoplasmic CYCS in intestinal tissues was also dramatically declined in the ST 36 + I/R group (1.37 vs. 0.18, p < 0.05). The level of CYCS in mitochondria in rats in the ST 36 + I/R group were appreciably increased than those of rats in the I/Rgroup (1.42 vs. 0.06, p < 0.05), and CYCS in mitochondria was also largely expressed in ST36 + I/R group than N + I/R group (1.42 vs. 0.08, p < 0.05). Bcl-2 was shown to be elevated in the ST 36 + I/R group than I/R group (1.01 vs. 0.10) and N + I/R group (1.01 vs. 0.09, all p < 0.05), whereas BAX expression was greatly decreased in the ST36 + I/R group than I/R group (0.11 vs. 0.78 ) and N + I/R group (0.11 vs. 0.87, all p < 0.05). ConclusionThe results suggest the EA intervention has a protective effect upon mitochondria, preventing CYCS release and the subsequent activation of downstream apoptosis pathway. It is proposed that patients due to undergo gastrointestinal surgery get benefit from EA preconditioning at ST 36.

Syndrome du marteau hypothénarien : à propos d’un cas de récidive après traitement chirurgical

Hypothenar hammer syndrome is a rare entity secondary to ulnar artery damage in the wrist, affecting mainly those exposed to repeated hand-palm trauma. Surgery is discussed in case of severe symptoms, resistant to medical treatment, and/or when anatomical lesions with emboligenic potential are demonstrated in the radiological exams. In this case, resection of the pathological zone with revascularization by autologous vein graft is the best option. We report the case of a 60-year-old patient who had a recurrence of symptoms more than 10 years after the completion of a surgical treatment. There was an aneurysmal thrombosed vein graft with extensive thrombus extending from the ulnar artery upstream of the Guyon's canal to the superficial palmar arch. The digital revascularization was provided by the radial superficial palmar arch and the presence of a collateral vascular supply. This late complication was responsible for compression of the ulnar nerve in Guyon's canal. A new surgery was performed consisting of the resection of the thrombosed zone, including the vein graft, without vascular reconstruction given the good vascularization of all the fingers, and release of the ulnar nerve to the wrist. The operative follow-up was uneventful with the disappearance of pain and sensory-motor deficits. Good digital vascularization was confirmed by imaging at 3 months postoperatively; nerve recovery by electromyogram at 6 months with normal conduction.

Spontaneous posterior spinal artery infarction: An under-recognized cause of acute myelopathy.

Spinal cord infarctions (SCIs) predominantly affect the anterior spinal artery (ASA) territory and manifest with acute weakness and loss of pain and temperature sensation. In comparison, posterior spinal artery (PSA) infarctions are more rare,1 possibly due to paired PSAs with increased collateral arterial supply; the diagnosis may also be underrecognized.1–5 Reports on clinical and radiologic features and outcomes of PSA infarcts are scant. We sought to describe all PSA infarcts seen at Mayo Clinic (1997–2017) to improve the understanding and awareness of this uncommon myelopathy. All patients consented to use of their medical records for research.

Gubernaculum Testis and Cremasteric Vessels Preservation During Laparoscopic Orchidopexy for Intra-Abdominal Testis: Effect on Testicular Atrophy Rates

PurposeGubernaculum-sparing laparoscopic orchidopexy (GSLO) - which involves anatomical delivery of the testis through the internal inguinal ring (IIR) - has been proposed as an alternative to Conventional Laparoscopic Fowler-Stephens Orchidopexy (CLO) maximizing collateral blood supply and potentially reducing atrophy rates. Herein, we test this hypothesis by comparing the 2 techniques. Materials and MethodsThe primary (dependent) outcome of this study was the rate of testicular atrophy, which was defined as palpation of a nubbin or the inability to palpate a testis (complete atrophy) on postoperative physical examination at 3 and 12 months. Doppler ultrasound was obtained routinely to further confirm the diagnosis of testicular atrophy. The following independent variables were captured: age at surgery, type of procedure (CLO vs. GSLO), surgical approach (single vs. 2-stage), location of IAT (high vs. low), and patency of the IIR ResultsMean and median age at surgery were 25.7±13.3 and 22 months respectively. Laparoscopy was carried-out for NPT, showing: vanishing IAT in 120 (29%), peeping testes in 80 (19%) and IAT in 212 (51%; 104-low and 108-high). A 1-stage procedure was performed in 44(21%) cases and 2-stage in 168 (79%). CLO was undertaken in pts 46 (22%) and GSLO in 166(78%), based on surgeon preference. The overall atrophy rate was 6.6% (14/212). 13 of 46 testes atrophied after CLO vs 1 of 166 following GSLO (28.3% vs 0.6%, p=<0.01). ConclusionsGSLO is a feasible alternative to CLO. Our findings suggest that preservation of additional vascular supply to the testis (cremasteric vessels and deferential artery as opposed.

Hypothenar hammer syndrome: A case of a late complication after surgery

Hypothenar hammer syndrome is a rare condition secondary to ulnar artery damage in Guyon's canal, affecting mainly those exposed to repeated palm trauma. Surgery is discussed in cases of severe symptoms that are resistant to conservative treatment, and/or when anatomical lesions with high embolism potential are discovered during imaging exams. Resection of the pathological zone with revascularization by autologous vein graft is the best option. We report the case of a 60-year-old patient who had a recurrence of symptoms more than 10 years after this type of surgical treatment was performed. There was an aneurysmal thrombosed vein graft with extensive thrombus from the ulnar artery upstream to Guyon's canal to the superficial palmar arch. Finger revascularization was provided by the superficial branch of the radial artery and the presence of a collateral vascular supply. This late complication was responsible for compression of the ulnar nerve in Guyon's canal. A new surgery was performed to resect the thrombosed zone, including the vein graft, without vascular reconstruction due to the good vascularization of all the fingers, and to release the ulnar nerve at the wrist. The postoperative course was uneventful with the disappearance of pain and sensory-motor deficits. Good finger vascularization was confirmed by imaging at 3 months postoperative; nerve conduction was normal at 6 months on electroneuromyography.

Risk of Branch Occlusion and Ischemic Complications with the Pipeline Embolization Device in the Treatment of Posterior Circulation Aneurysms.

Flow diversion with the Pipeline Embolization Device is increasingly used for endovascular treatment of intracranial aneurysms due to high reported obliteration rates and low associated morbidity. While obliteration of covered branches in the anterior circulation is generally asymptomatic, this has not been studied within the posterior circulation. The aim of this study was to evaluate the association between branch coverage and occlusion, as well as associated ischemic events in a cohort of patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. A retrospective review of prospectively maintained databases at 8 academic institutions from 2009 to 2016 was performed to identify patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. Branch coverage following placement was evaluated, including the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and posterior cerebral artery. If the Pipeline Embolization Device crossed the ostia of the contralateral vertebral artery, its long-term patency was assessed as well. A cohort of 129 consecutive patients underwent treatment of 131 posterior circulation aneurysms with the Pipeline Embolization Device. Adjunctive coiling was used in 40 (31.0%) procedures. One or more branches were covered in 103 (79.8%) procedures. At a median follow-up of 11 months, 11% were occluded, most frequently the vertebral artery (34.8%). Branch obliteration was most common among asymptomatic aneurysms (P < .001). Ischemic complications occurred in 29 (22.5%) procedures. On multivariable analysis, there was no significant difference in ischemic complications in cases in which a branch was covered (P = .24) or occluded (P = .16). There was a low occlusion incidence in end arteries following branch coverage at last follow-up. The incidence was higher in the posterior cerebral artery and vertebral artery where collateral supply is high. Branch occlusion was not associated with a significant increase in ischemic complications.

Embolization of the Superior Rectal Arteries for Hemorrhoidal Disease: Prospective Results in 25 Patients

PurposeTo evaluate efficacy and safety of superior rectal artery embolization of hemorrhoidal disease as a first-line invasive treatment. Materials and MethodsThis prospective study was conducted between 2014 and 2015 on 25 consecutive patients (16 men and 9 women with a mean age of 53 y [range, 30–76 y]) with grade II–III hemorrhoids refractory to medical treatment. A transfemoral superselective superior rectal artery branch embolization was performed using 2- and 3-mm diameter microcoils. Over the following 12 months, clinical outcomes were evaluated using the French bleeding score, Goligher prolapse score, visual analog scale (VAS) score for pain, quality-of-life score. The primary endpoint was relief of symptoms by 12 months based on a 2-point minimum improvement on VAS score and bleeding score. ResultsAt 12 months after embolization, clinical success was obtained in 18 patients (72%), 8 of whom had 2 embolizations. VAS score decreased from 4.6 to 2.3 (P < .01), and bleeding score decreased from 5.5 to 2.3 (P < .01). Quality-of-life and prolapse scores also showed improvement (P < .05), and no patients experienced any early or late complications. Complete clinical failure was observed in 7 patients. After coil embolization, the collateral supply to the hemorrhoidal cushions was significantly related to any recurrence (P = .001). ConclusionsHemorrhoidal artery coil embolization was found to be a safe and effective treatment for grade II–III hemorrhoids.

Extrahepatic Collateral Artery Extravasation in Patients with Ruptured Hepatocellular Carcinoma

This report describes 3 patients with previously untreated hepatic tumors who underwent embolization for the treatment of extravasation from extrahepatic arteries. Although development of extrahepatic collateral blood supply is well known, its importance in the presentation of rupture of liver tumors may be underrecognized. Findings that suggest bleeding from extrahepatic arteries include a discrepancy in the pattern of extravasation on computed tomography vs hepatic angiography and a lack of stabilization of vital signs after embolization of hepatic arteries. To achieve successful hemostasis in embolization, the potential involvement of such extrahepatic arteries should be accurately recognized, suggestive imaging findings considered, and the occult vessels selected and embolized.

Abstract No. 510 Extrahepatic collateral supply of hepatocellular carcinoma by the omental artery: detection with automatic software

Abstract No. 510 Extrahepatic collateral supply of hepatocellular carcinoma by the omental artery: detection with automatic software

Area at risk and collateral circulation in a first acute myocardial infarction with occluded culprit artery. STEMI vs non-STEMI patients

BackgroundIt is unclear why among patients with first acute myocardial infarction and an occluded culprit artery only some present ST segment elevation. In fact, there is no study that compares the angiographic area at risk and the collateral circulation in first NSTEMI vs STEMI patients. Methods and results205 patients admitted for myocardial infarction with occluded culprit artery were included, 132 STEMI and 73 NSTEMI. Demographic data, the area at risk determined by the BARI score and collateral supply by the Rentrop score from the 2 groups were compared. NSTEMI patients showed lower peak Tn I than STEMI in the overall group but also in the 3 subsets with different culprit arteries (p < .001). They also presented a higher rate of left circumflex coronary artery (CFX) as culprit artery (52% vs 14%, p < .001), smaller BARI score area of the culprit artery (5.4 vs 7.6, p < .001), and higher frequency of well-developed collaterals (Rentrop score ≥ 2, 1.82 vs 0.41, p < .001). The latter was also higher in each of the 3 different culprit arteries (p = .002–<0.001) Among 38 NSTEMI patients with CFX occlusion, 20 with ≥1 mm ST depression in V2 to V4 (possible posterior infarction) showed a similar Rentrop score than the 18 with other ECG changes but lower Tn I peak (p = .012). ConclusionsIn first acute myocardial infarction with an occluded culprit artery NSTEMI patients – including those with possible posterior infarction – present smaller infarct size and higher collateral blood supply than STEMI patients in each of the 3 main culprit arteries.