Collateral System Research Articles

“What IVC?”: Deep Vein Thrombosis in the Context of IVC Dysgenesis

Among young, otherwise healthy adults with unprovoked deep vein thrombosis (DVT), uncommon causes like variation in the normal sequential development of the inferior vena cava (IVC), must be explored. Anomalous IVC conditions are estimated to occur in up to 9% of the general population, with the rarest anomaly being IVC agenesis at 0.0005% - 1% general population prevalence. DVTs are more likely to develop in this population due to venous stasis from decreased venous return, even with the formation of extensive collateral veins. Herein, the authorial team presents a 22-year-old patient with leg pain and swelling who was found to have acute DVT, and, incidentally, the absence of the suprarenal IVC with a robust collateral system on further imaging studies. The morbidity of DVTs in this population is very high, and attention should be given to young patients who present with new-onset DVT in the setting of normal coagulation studies and lack of personal or family history of clotting disorders, as the need for specialized imaging such as venograms is necessary to secure the proper diagnosis.

Transdural Collateral Circulation Indicates Cerebral Ischemia in Moyamoya Disease

Moyamoya disease (MMD) is an idiopathic occlusive cerebrovascular disorder. The development of collateral circulation originates from the dural and pial collaterals. Currently, the clinical significance of transdural collateral in MMD has not been established. We sought to study the relationship between transdural collateral circulation and the side of relative cerebral ischemia in MMD. Data from MMD patients were collected at Xiangya Hospital from January 2016 to April 2022. A collateral circulation grading system with scores was established, the dominant side of transdural collateral with a higher point. Cerebral perfusion was used to identify the side of relative cerebral ischemia. A total of 102 patients were recruited. Results of digital subtraction angiography showed that 74 (72.5%) patients had transdural collaterals. The transdural collaterals were more common in patients with infarctions than in those with headaches or transient ischemic attacks (P= 0.0074). The dominant side for the formation of transdural collateral circulation was more easily found at the side of relative cerebral ischemia (P < 0.0001). Additionally, the side of the brain with a higher score of transdural collaterals was more likely to experience relative cerebral ischemia (P < 0.0001). There was no significant difference in the formation of transdural collateral circulation between ischemic and hemorrhagic MMD patients. Transdural collateral circulation was common in MMD patients. The transdural collaterals were associated with the occurrence of infarction. Transdural collaterals were well established on the cerebral ischemic side, which indicated higher ischemic levels in the ipsilateral than contralateral side.

Pharmacobotanical study of Psychotria carthagenensis Jacq. (Rubiaceae), a species known as toxic and medicinal

Psychotria carthagenensis (Rubiaceae), popularly known as “erva-de-rato”, is known as poisonous, and its leaves are used as a constituent of “ayahuasca”. An anatomical study of its leaves was carried out to define parameters to support its taxonomy and quality control of ethnodrugs. Transverse and paradermic sections of petioles and leaf blades were made following the usual techniques of botanical anatomy. All semi-permanent laminas were then analyzed and photographed by light microscopy. Leaf blades were also studied with the support of the scanning electron microscope. Psychotria carthagenensis has hypostomatic epidermis, 1-2-stratified, in cross section, with three types of stomata (paracytic, anisocytic and anomocytic), and predominantly straight anticlinal cell walls, in frontal view, and glandular-peltate trichomes on both surfaces, the cuticle is smooth and thickened. The leaf edges are acute, mesophyll dorsiventral with the palisade parenchyma 1-seriate, and spongy parenchyma 4-seriate. The midrib is flat-convex with 4 bundles; petiole is semicircular with lateral projections with 9 vascular bundles. Midrib and petiole have collateral vascular system. Anisocytic and anomocytic stomata, glandular-peltate trichomes, petiole with the central bundle invaginate at the end, the syntopism of epicuticular waxes are distinctive parameters for P. carthagenensis, which support the standardization of its leaves used as medicines, in addition to contributing to the systematic of the Psychotria genus.

Collateral Circulation and BNP in Predicting Outcome of Acute Ischemic Stroke Patients with Atherosclerotic versus Cardioembolic Cerebral Large-Vessel Occlusion Who Underwent Endovascular Treatment

The aim of this study was to verify the value of collateral circulation and B-type natriuretic peptide (BNP) in predicting clinical outcomes of patients with acute ischemic stroke (AIS) and their biomarker value for stroke subtypes before endovascular treatment (EVT). In this retrospective study, 182 patients who underwent EVT for unilateral anterior circulation large-vessel occlusion between March 2016 and January 2022 were analyzed. The modified collateral circulation scoring system on four-dimensional computed tomography angiography (4D CTA-CS) was used to assess collateral status, and stroke subtypes were determined according to the TOAST classification criteria. Patients were divided into good (mRS ≤ 2) and poor outcome (mRS > 2) groups based on their modified Rankin Scale (mRS) score at 3 months. 4D CTA-CS was an independent predictor of the clinical outcome for all AIS patients (odds ratio = 0.253; 95% CI, 0.147-0.437; p < 0.001), CE stroke patients (odds ratio = 0.513; 95% CI, 0.280-0.939; p = 0.030), and LAA stroke patients (odds ratio = 0.148; 95% CI, 0.049-0.447; p = 0.001). The BNP was a biomarker for clinical outcome prediction in CE (odds ratio = 1.004; 95% CI, 1.001-1.008; p = 0.005) but not in LAA patients. Combined with BNP, 4D CTA-CS improved predictive values for clinical outcomes (p < 0.05). Collateral status and BNP could be used as independent predictors of clinical outcomes in AIS patients and could determine stroke subtypes (CE stroke or LAA stroke). In addition, the model of 4D CTA-CS combined with BNP was the most effective in predicting clinical outcomes compared with collateral status or BNP alone.

Perspectives.

![Figure][1]</img> Title: Power of Cerebral Blood Supply. A significant amount of cardiac output supplies brain parenchyma and the entire blood supply of the brain depends only on 2 paired arteries. However, the intracranial arterial collateral system is not that simple. I wanted to emphasize the

Anatomic Leaf Structure of 'Sunrise Solo' and 'Golden THB' Papaya Plants

Papaya (Carica papaya L.) stands out as a strong economic driver, being one of the fruit trees that most contribute to the total volume of brazilian production. The description of leaf characteristics allows to understand structures that act in resistance to pathogens, relationships with water resources and photosynthetic of plants, in addition to contributing to genetic improvement programs. However, there are few studies that attempt to describe the leaf anatomy of the different papaya cultivars. Thus, this study aims to describe the main leaf structure of papaya cultivars Sunrise Solo and Golden THB. The leaves were collected in the municipalities of São Mateus and Aracruz, located in the north of the State of Espírito Santo, using transversal and paradermic sections and the usual techniques of plant histology. Both cultivars presented uni-stratified epidermis, followed by palisade chlorophyll parenchyma and lacunous with collateral vascular system. Calcium oxalate druses were more observed in the Sunrise Soil cultivar. The differences between cultivars were in the number of layers of mesophyll tissues.

PERLINDUNGAN HUKUM BAGI KREDITUR ATAS SAHAM TANPA WARKAT (SCRIPLESS) SEBAGAI OBJEK JAMINAN GADAI

Scripless shares are one of the objects of collateral as regulated in article 60 section (2) of UUPT. Collateral provides guarantee for repayment of debts to creditors as regulated in article 1150 of the Indonesian civil code. Yet, scripless shares collateral is different from general collateral, where the object of collateral is not on the creditor, and the value of shares changes anytime. This study aims to explain the legal protection for the creditor on scripless shares collateral. Based on findings, the author found that the current regulations have not yet provided maximum legal protection for the creditor in the scripless shares collateral system. KSEI only acts as the depositor of the collateral object and not obliged to guarantee the fulfillment of the creditor’s rights. Thus, when the blocking of collateral shares is lifted, KSEI does not have to ensure that the rights of creditors have been fulfilled. Based on the findings, the author suggests a regulation that obliges KSEI to ensure the creditor’s rights have been fulfilled to be made, before unblocking the collateral objects.

Abstract 11104: Percutaneous Embolization of Extensive Collateral Vessels for Hemoptysis in Pulmonary Aspergilloma

Introduction: Pulmonary aspergillomas form due to fungal colonization in patients with immunocompromise and underlying cavitary lung disease. They can present with hemoptysis due to erosion of pulmonary vessels and formation of collaterals. Arterial embolization of bronchial vessels is considered first line treatment due to effectiveness and minimal invasiveness. We present one patient with need for extensive embolization treatment for persistent hemoptysis. Case: 53yo woman with pulmonary sarcoidosis and bilateral pulmonary aspergilloma presented to our institution for lung transplant evaluation. She had persistent hemoptysis for years after being diagnosed. She previously had bronchial artery embolization at outside hospital but had persistent symptoms severely limiting her functional status. She continued to have active hemoptysis during the admission, including on arrival to procedure. Angiography demonstrated extensive collateral vessels from systemic arterial to pulmonary circulation including several large branches originating from the subclavian arteries, internal mammary arteries and dorsal scapular arteries. There was leak through multiple previously embolized arteries, with active extravasation of contrast. Initial large collaterals were embolized using Medtronic MVP micro-vascular plugs (3Q, 5Q, 7Q) and smaller collaterals from intercostal arteries embolized using Penumbra Ruby Coil. She had improvement following the first procedure, but had persistent hemoptysis requiring repeat procedures to address more collateral and native vessels prior to resolution of symptoms. Conclusions: This patient with bilateral pulmonary aspergilloma had previous unsuccessful coil embolizations and complex collateral vessel system that resulted in severe recurrent bleeds. We successfully treated this patient’s persistent massive hemoptysis after extensive embolizations during multiple challenging procedures.

ROLE OF ACCOUNTS RECEIVABLE IN ACCOUNTING (FINANCIAL) STATEMENTS

Receivables in the financial statements are an important element that reflects the amount of an organization's funds diverted from turnover, those that are expected to be received in the near future. At the same time, receivables differ in terms of maturity, quality and it is necessary to analyze them in order to understand what share of the total amount of debt will actually return to the turnover of the organization. For analysis, you need to set up the accounting and analytical collateral system so that the entire accounts receivable management system is tailored to the needs of the users of this information. Understanding how much funds we actually have to pay off accounts payable, we can ensure the timely repayment of the organization's debts and improve solvency indicators. The organization's revenue reflects the amount of funds invested in production and commercial operations taking into account the profit received, therefore, its financial stability depends on the speed of the refund. Thus, accounts receivable management is a process aimed at improving its quality, return rate and more efficient use of funds. Performance indicators of accounts receivable reflect the speed of their circulation; their calculation and correct interpretation are an important element of analysis. The article provides an example of how the change in receivables affects the key performance indicators of the organization. Using this method, you can in practice calculate the performance indicators of the use of receivables for making decisions regarding their optimization.

Surgical technique for preservation of extrathoracic collateral networks in thoracoabdominal aortic surgery.

Surgical technique for preservation of extrathoracic collateral networks in thoracoabdominal aortic surgery.

A Novel Clinically Based Classification System for the Profunda Femoris Artery and the Circumflex Femoral Arteries

The profunda femoris artery (PFA) supplies important collateral branches to both the ipsilateral internal iliac artery and the distal superficial femoral artery (SFA). The size and patency of these collateral pathways can determine the risk of pelvic malperfusion, spinal cord ischemia, and lower extremity limb loss following vascular interventions. Despite its importance, the anatomy of the PFA is rarely characterized in clinical studies involving the pelvic or lower extremity circulation. This discussion may be limited by the lack of a comprehensive classification system. Our objective was to describe the most common PFA anatomic variants and present a classification system based on its branching patterns. We dissected 155 fixed and nonfixed femoral artery systems from 88 cadavers. Seventy-seven female and 78 male femoral exposures were performed. Vessel diameters, branch configurations, and relative distances between the inguinal ligament, PFA, lateral circumflex femoral artery (LCFA), and medial circumflex femoral artery (MCFA) were recorded. The mean diameters of the common femoral artery, SFA, and PFA were 10.3mm, 8.0mm, and 6.9mm in males and 8.9mm, 6.9mm, and 6.1mm in females, respectively (P<0.05). The mean distances from the inguinal ligament for PFA, MCFA, and LCFA were 41mm, 41.7mm, and 52.5mm, respectively. No significant differences were noted relative to laterality or fixation. We developed a clinically applicable classification system based on the orientation of the PFA, LCFA, and MCFA. Six PFA, 5 LCFA, and 5 MCFA variations were identified and ranked by frequency. The 5 most common combinations accounted for 56.1% of our cadaver series. The anatomic orientation of the PFA and its branches is highly variable. We propose a novel classification system of this rich collateral system to facilitate consistent communication in academic and clinical vascular surgery.

Treatment of ruptured aneurysms of the choroidal collateral system in moyamoya disease: a systematic review and data analysis.

Moyamoya disease (MMD) is a chronic, progressive steno-occlusive condition of the distal internal carotid arteries of unknown etiology. Collateral arterial networks typically develop in MMD, bypassing the steno-occlusion. Aneurysms arising on the collateral networks are a known source of hemorrhage. The choroidal collateral system is the most common location for collateral pathway aneurysms in MMD and associated hemorrhage. The authors performed data collection and analysis to further elucidate the best treatment approaches for ruptured aneurysms of the choroidal collateral system in MMD, which as yet remain unclear. A comprehensive data collection and analysis of case reports and case series with ruptured choroidal collateral artery aneurysms (CCAAs) was performed. PRISMA guidelines for systematic reviews were followed and the Medline, Embase, and Scopus databases were searched for relevant studies. A database was created including patients with ruptured CCAA in MMD. Original data from case series were included whenever possible. A previously unreported case of a ruptured choroidal artery aneurysm in MMD treated by the authors was also included. The database comprised 72 patients with ruptured CCAA in MMD. The most common clinical symptoms were headache, nausea, and vomiting (39%). Initially, a conservative treatment approach was chosen in 29% of cases but led to rehemorrhage in 40% of cases; 63% of these rehemorrhages occurred during the first 35 days. Endovascular treatment seemed a safe option for aneurysm exclusion, mainly through parent vessel sacrifice, but had a treatment failure rate of 21%, due to inadequate access. Aneurysm treatment with revascularization as the initial treatment strategy led to aneurysm regression in 82% with no reported rehemorrhage. Aneurysm exclusion through open surgery was effective but was associated with a relatively high complication rate (25%). Outcome after rupture of CCAA was poor, with 41% of patients deceased or permanently disabled. Overall, patient outcomes were better in the endovascular and revascularization treatment group than in the conservative treatment group. Rupture of CCAA in MMD is associated with high morbidity and rerupture rate requiring urgent treatment.

Association of BIRC5 Gene Polymorphism with the Collateral Circulation and Severity of Large Artery Atherosclerotic Stroke.

Objectives The collateral circulation near the cerebral artery occlusion can contribute to the relief of the symptoms and signs of stroke. Genetic factors play a decisive role in the difference in collateral circulation. Survivin, encoded by the baculoviral inhibitor of apoptosis (IAP) repeat-containing 5 gene (BIRC5), plays an important role in maintaining long-term endothelial integrity and homeostasis and as an angiogenic factor in the treatment of vascular diseases. We hypothesized that genetic variations in the BIRC5 gene may contribute to severity by influencing the collateral circulation. This study aimed at examining how the polymorphism of the BIRC5 gene correlated with the collateral circulation and severity of large artery atherosclerotic stroke. Methods This study enrolled 428 patients with large artery atherosclerotic stroke. There are no statistical differences in age, sex, social behavior, such as smoking and drinking, between the groups classified by the collateral circulation and by the severity of stroke (P > 0.01). Direct sequencing was performed for the genotyping of single nucleotide polymorphism (SNP) of BIRC5 (rs2071214). The enrolled patients were divided into several subgroups based on the collateral flow grading system from the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR), the results of the National Institutes of Health Stroke Survey (NIHSS) (6 as a threshold), and the score of the modified Rankin scale (mRS) (for the prediction of prognosis, 2 as a threshold). Differences among subgroups were identified through logistic regression. Results The analysis of collateral circulation revealed the significant correlation of SNP of rs2071214 with the development of poor collateral circulation of large artery atherosclerotic stroke in the additive model (GG vs. AA, odds ratio (OR) = 3.592, 95% confidence interval (CI) = 1.410–9.150, and P=0.007) and the recessive model (GG vs. AA/GA, OR = 3.313, 95% CI = 1.420–7.727, and P=0.006). The analysis of stroke severity exposed the significant role of the SNP of rs2071214 in increasing stroke severity in the dominant model (GA/GG vs. AA, OR = 1.658, 95% CI = 1.017–2.703, and P=0.043) and the additive model (GA vs. AA, OR = 1.717, 95% CI = 1.021–2.888, and P=0.042). However, the analysis of the short-term outcome indicated that three genetic models were not associated with short-term outcomes in the additive model (GA vs. AA, P=0.815, GG vs. AA, and P=0.336), the dominant model (GA/GG vs. AA and P=0.589), and the recessive model (GG vs. AA/GA and P=0.342). Conclusion Our findings identified the SNP of rs2071214 of the BIRC5 gene as a risk factor for the poor compensatory ability of collateral circulation and a predictor of stroke severity in large artery atherosclerotic stroke, which suggested that the SNP of rs2071214 can serve as an innovative therapeutic target for patients with acute ischemic stroke.

Mobile Money Services: An Enabler of Development Processes in Africa

Access to finance has been a major constraint in a lot of developing countries, especially in Africa. This research seeks to explore the role of mobile money in the development of the financial sector and its role in enforcing financial inclusiveness by making banking easily accessible and convenient. We look at data of сountries which operate mobile money credit facilities. Looking closely at how these loan services are increasing financial accessibility and the intensity of entrepreneurship, we hypothesize that mobile money positively influences entrepreneurship and domestic saving by providing an avenue for financial inclusiveness. To explore our objectives, we use panel data consisting of developing countries. With repeated observations of enough cross-sections, panel data analysis permits us to study the dynamics of change with time series. Our data consists of 28 developing countries from the year 2010 to 2018. Our results indicated a positive effect of mobile money registered accounts on new business density and positive effect of transactional volume on domestic savings. We realized that the mobile money system has increased people's confidence in saving and investment since their money is easily accessible with just a click away. People now feel much safer, and this system is educating more people rapidly in developing the culture of saving. This improves how banks treat their clients in rural communities and it also creates employment for young graduates. Access to loans has become much easier by replacing the collateral system with the credit score system. We also realized that since there are no regulations regarding access to loans, mobile money operators seem to take advantage of the people by taking interest rates of more than 10% per month.

EVALUATING THE EFFECTIVENESS OF SUPPORTIVE TREATMENT BY MOXA ROLLER ON SOME TRADITIONAL WIND-COLD DISEASES

Background: According to traditional medicine, the wind-cold agent is a common clinical cause, may appear in such diseases as: lumbar pain, neck shoulder pain, and flu… The wind-cold agent enters the meridian and collateral system, skin and hair on the body, lead to blood stasis due to qi stagnation cause pain and affect the patient’s quality of life. The moxa roller method is a form of moxibustion, which based on the use of a warm heat. The use of moxa roller is a new method in clinical to make moxibustion in patients more convenient and effective. Materials and method: 30 patients were diagnosed with lumbar pain and neck shoulder pain according to wind-cold traditional disease, treatment at Thua Thien Hue Traditional Medicine Hospital with supportive of moxa roller. The study was designed by method of prospective study, assessed the results before and after treatment. Results: Neck shoulder treatment: the rate good and very good accounts for 78.6%, lumbar pain treatment: the rate good and very good accounts for 87.6%. The general treatment effect is good and very good accounting for 83.4%. The change compared to before treatment was statistically significant with p &lt; 0.05. Conclusion: Practising moxibustion by moxa roller supportive treatment of some diseases by wind-cold results in high clinical effectiveness. Key words: lumbar pain, neck shoulder pain, moxa roller, wind-cold.

Abstract 1122‐000122: The Role of the Venous System in Infarct Burden in Patients with Acute Ischemic Stroke

Introduction : Acute ischemic stroke (AIS) is a leading cause of disability internationally. Most therapies focus on intra‐arterial treatment to improve post‐stroke deficits and neurologic status. However, if a relationship between venous anatomy and post‐stroke deficits or infarct size can be shown, then venous augmentation strategies represent a possibility for future interventions as an adjunct to intra‐arterial treatment. Methods : We retrospectively reviewed all ischemic infarcts at our institution that underwent thrombectomy from January 2018 – October 2020. From these, we selected cases that were demonstrated as M1 occlusions on intra‐procedural angiogram and those who had a CT Head obtained within six hours of the patient’s last known normal (LKN). Patients without a CT Head or CT Angiogram of their head were excluded. Using axial and sagittal reconstructed views of 0.9mm slices, cross‐sectional area measurements were taken of the superior sagittal sinus 1cm above the Torcula, in three locations of the ipsilateral and contralateral transverse sinus, in three locations of the ipsilateral and contralateral sigmoid sinus, and of the ipsilateral and contralateral internal jugular vein (IJV) at the external surface of the skull. For the transverse and sigmoid sinuses, the three measurements were averaged together. These measurements were then compared against patient’s Alberta Stroke Program Early CT Score (ASPECTS). Results : 77 patients were identified in the study period. Average ASPECTS was 8.9, ranging from 5–10. There were three patients included with ASPECTS &lt; 6. Average ipsilateral transverse sinus area was 34.4mm ± 3.34, average ipsilateral sigmoid sinus area was 32.8mm ± 2.74, average ipsilateral IJV area was 46.9 mm ± 5.00. Correlation tests to identify relationships between venous sinus area and ASPECTS was unremarkable (ipsilateral transverse sinus p = 0.574, ipsilateral sigmoid sinus p = 0.548, ipsilateral IJV p = 0.798). When assessed as a ratio of ipsilateral venous sinus area to contralateral sinus area to assess correlation with ASPECTS, results were unremarkable (transverse sinus p = 0.891, sigmoid sinus p = 0.292, IJV p = 0.499). Conclusions : Venous sinus size was not found to be predictive or associated with predominantly favorable ASPECTS for strokes found within six hours. We believe this may be due to our cohort lacking significant numbers of patients with low ASPECTS, yielding a false negative result. We are currently expanding this project to include a comparable number of patients with ASPECTS &lt; 6 to determine the role of venous collateral system in infarct progression.

Assessment of Collaterals Using Multiphasic CT Angiography in Acute Stroke

The aim of the research was to compare the efficiency of multiphase and single-phase computed tomography (CT) angiography in assessing the leptomeningeal collaterals and in predicting the long-term clinical outcome as well as the risk of hemorrhagic transformation. A prospective study was conducted from October 2016 to May 2018 in consecutive patients who presented within 8 hours of the onset of acute anterior circulation ischemic strokes, with NIHSS (National Institutes of Health Stroke Scale) scores ≥5. They underwent triple-phase cerebral CT angiography, and the collaterals were assessed separately using both single-phase and multiphase techniques. The ability of the collaterals to predict the 24-hour CT ASPECTS (Alberta Stroke Program Early CT score), risk of cerebral hemorrhagic transformation, and 90-day clinical outcome was assessed. Fifty-six patients, which included 42 with an involvement of the middle cerebral artery and 14 with mixed occlusions, were assessed. In the multivariate logistic analysis, multiphase CT angiography collateral grading is one of the independent predictors of favorable outcomes. Area under the curve (AUC) was 0.853 (95% confidence interval [CI; 0.73, 0.97]) for multiphase CT collateral scoring in predicting the long-term functional independence, whereas single-phase CT (sCT) scoring displayed an AUC value of only 0.609 (95% CI [0.43, 0.78]). Eighty-two percent of the patients with good multiphase CT collaterals were functionally independent. CT ASPECTS at 24 hours was significantly better in patients with a good multiphase CT collateral score than in those with a good single-phase score. None of the patients with good collaterals in multiphase CT angiography had a significant hemorrhagic transformation. Good multiphase CT collaterals demonstrated 78% sensitivity, 81% specificity, and 80% accuracy in predicting the functional outcome. Multiphase CT collateral system was superior to single-phase angiography in predicting the long-term functional outcomes. Prediction of the hemorrhagic transformation risk was also observed to be better for multiphase CT.

Role of Vascular Smooth Muscle Cell Phenotype Switching in Arteriogenesis.

Arteriogenesis is one of the primary physiological means by which the circulatory collateral system restores blood flow after significant arterial occlusion in peripheral arterial disease patients. Vascular smooth muscle cells (VSMCs) are the predominant cell type in collateral arteries and respond to altered blood flow and inflammatory conditions after an arterial occlusion by switching their phenotype between quiescent contractile and proliferative synthetic states. Maintaining the contractile state of VSMC is required for collateral vascular function to regulate blood vessel tone and blood flow during arteriogenesis, whereas synthetic SMCs are crucial in the growth and remodeling of the collateral media layer to establish more stable conduit arteries. Timely VSMC phenotype switching requires a set of coordinated actions of molecular and cellular mediators to result in an expansive remodeling of collaterals that restores the blood flow effectively into downstream ischemic tissues. This review overviews the role of VSMC phenotypic switching in the physiological arteriogenesis process and how the VSMC phenotype is affected by the primary triggers of arteriogenesis such as blood flow hemodynamic forces and inflammation. Better understanding the role of VSMC phenotype switching during arteriogenesis can identify novel therapeutic strategies to enhance revascularization in peripheral arterial disease.

A-60 Case of Moyamoya Syndrome in Haitian Female without Known Risk Factors

Abstract Objective Moyamoya is a rare, progressive cerebrovascular disorder characterized by carotid artery stenosis or occlusion. Tiny “moyamoya” blood vessels open at the brain base to compensate, often resulting in large vessel ischemic strokes or from hemorrhage of moyamoya vessels. Peak incidence in adults is 30 to 50 years old and 30% progress bilaterally. 54 year-old right-handed Black Haitian female with 13 years of education presented with new stroke, now diagnosed with bilateral moyamoya syndrome. Premorbid history includes hypertension, Type II Diabetes Mellitus, patent foramen ovale, and malignant phyllodes breast tumor treated by resection and local radiation. Presents with no traditional risk factors for moyamoya (e.g., brain radiation, sickle cell disease, neurofibromatosis). Method Five years previously patient experienced multi-focal embolic MCA strokes from left internal carotid occlusion attributed to hypercoagulability of malignancy, returning to previous activities except driving. Present perfusion CT showed complete occlusion of bilateral cavernous carotid arteries. Diagnostic angiogram showed collateral system via PCA-MCA pial-pial collaterals in parieto-occipital-temporal regions, and leptomeningeal collaterals to ACA territory. She underwent bilateral STA-MCA direct bypass. Results Acute neuropsychological testing conducted in Haitian Creole by native-speaking trainee showed expressive aphasia, orientation to person and situation, ability to follow 1-step commands, moderately impaired naming of familiar objects, reduced sustained attention. Also left hemiparesis, right gaze preference, and left homonymous hemianopsia. Conclusions The present case study delineates development of secondary moyamoya in a Black Haitian woman without known risk factors, resulting in significant cognitive-linguistic deficits consistent with brain findings. Limitations include lack of validated measures in Haitian Creole.

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks.

Simple SummaryCholangiocarcinoma (CCA) is the second most common liver primary malignancy and its gold-standard treatment is surgery. Unfortunately, CCA is seldom amenable to curative resection due to late-stage diagnosis and frequent major vascular invasion. Major vascular invasion has historically been considered a contraindication to resection, but lately aggressive surgeries for CCA with vascular involvement have been shown to improve outcomes. The purpose of this review is to provide a comprehensive and up to date summary of the strategies for CCA resection, focusing on the surgical techniques and results of complex procedures with tumour vascular involvements. The current review shows that satisfactory results can be achieved in patients with CCA and tumoral vascular invasion by aggressive surgical resection and challenging vascular reconstruction, ensuring a meticulous evaluation of patients in a multidisciplinary setting by experienced hepatobiliary surgeons.Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.