Complete Angiographic Resolution Research Articles

Cough-induced Bilateral Vertebral Artery Dissections in an Active Duty Service Member with Complete Angiographic Resolution (P8-5.005)

Cough-induced Bilateral Vertebral Artery Dissections in an Active Duty Service Member with Complete Angiographic Resolution (P8-5.005)

Predictors of angiographic resolution in patients with presumed reversible cerebral vasoconstriction syndrome.

Reversible cerebral vasoconstriction syndrome is a complex neurovascular syndrome that presents with varying neurological deficits as well as segmental vasoconstriction of the small and medium cerebral arteries. There is limited literature on pathologies that mimic reversible cerebral vasoconstriction syndrome, so this study aims to understand what factors may impact the angiographic confirmation of reversible cerebral vasoconstriction syndrome on follow-up and play a role in establishing the diagnosis. The Clinical Research Data Warehouse at this institution was employed to search the medical records for patients with diagnosis and treatment of reversible cerebral vasoconstriction syndrome between January 2010 and May 2021. After screening, 32 patients met the inclusion criteria for a presumed diagnosis of reversible cerebral vasoconstriction syndrome with both angiography on presentation and at three-month follow-up after treatment. Patients were divided into two categories: those with complete angiographic resolution, versus partial or no improvement on follow-up. Clinical and radiographic data were analyzed. Patients who had partial or no resolution were more likely to have a history of hypertension (p = 0.001), higher systolic blood pressure on admission (p = 0.047), and present with a recurrent thunderclap headache (p = 0.038). Binary logistic regression selected for hypertension (odds ratio [OR] 18.35 [95% CI, 1.37-245.1]) as predictive of not having reversible cerebral vasoconstriction syndrome, as can be seen by partial or no resolution on follow-up angiography (p = 0.028). Complete resolution on follow-up angiography is a distinguishing factor of reversible cerebral vasoconstriction syndrome. Our analysis revealed that a history of hypertension is the most significant predictor of confirming that a patient may not have reversible cerebral vasoconstriction syndrome. This is due, in part, to increased atherosclerotic or hypertensive cerebral arterial changes, which can mimic reversible cerebral vasoconstriction syndrome and present as partial or no resolution on angiography.

De novo brain AVM following radiotherapy for cerebral cavernous malformation in a child: A 15-year clinical course.

Multiple de novo brain arteriovenous malformations (bAVM) have been reported in the literature, raising questions about the contended purely congenital nature of these lesions. We present the 15-year course of a pediatric patient, who initially presented at age 5 with a thalamic cavernous malformation and was treated with radiosurgery, and then subsequently developed a thalamic de novo bAVM immediately adjacent to the initial lesion location, discovered 2years later. Treatment of the bAVM entailed two transarterial embolizations and one radiosurgery session which ultimately led to complete angiographic resolution. Finally, this patient's course was complicated by intraparenchymal hemorrhage and acute obstructive hydrocephalus, and further imaging revealed two newly formed cavernous malformations, also associated with the initial lesion's location, that have remained stable since their formation. This case likely represents the second-hit model for the formation of vascular malformations, as sparsely supported by the current literature. According to this, genetically aberrant, yet quiescent, brain areas might promote the de novo formation of vascular malformations after brain injury, including radiation.

Long-Term Results of Combination Treatment with Single-Dose Ranibizumab plus Photodynamic Therapy for Retinal Angiomatous Proliferation

Purpose: To present functional and anatomic outcomes of combination therapy with ranibizumab and photodynamic therapy (PDT) in a series of retinal angiomatous proliferation (RAP) cases. Methods: A total of 17 eyes of 17 patients with RAP were included. Thirteen eyes were treatment naïve and 4 were already on ranibizumab monotherapy. Combined treatment with single-dose ranibizumab and PDT was performed on all treatment-naïve cases. Follow-up was performed every month for 6–38 months, using optical coherence tomography and indocyanine green angiography when necessary. Results: Overall, 6 out of 7 treatment-naïve cases with stage I or II disease manifested complete angiographic resolution of the hot spot with a single injection of ranibizumab plus PDT. In stage III disease, 7 out of 10 eyes showed persistent leakage immediately after the combined treatment. The rate of hot spot occlusion was found to correlate with the stage of disease (p = 0.05). There was a significant improvement in posttreatment BCVA for all patients regardless of disease stage (p = 0.02), which was more evident in the earlier stages. Improvement was also greater for treatment-naïve patients (p = 0.03). The posttreatment improvement in BCVA was strongly correlated with hot spot occlusion (p < 0.001). Conclusions: Single-dose modified anti-VEGF treatment in combination with PDT may provide long-term regression at the initial stages of RAP.

Spontaneous coronary artery dissection and takotsubo syndrome: An often overlooked association; review.

Spontaneous coronary artery dissection (SCAD) and takotsubo syndrome (TS) are two cardiovascular syndromes with predilection for women. Both conditions may be preceded by an emotional stress or, for the affected individual, an unusual severe physical exercise. "Restitution ad integrum" occurs in most cases suffering from SCAD or TS with complete angiographic resolution of the dissected vessel and left ventricular dysfunction respectively. Recently, many cases, which were initially diagnosed as TS because of typical left ventricular ballooning pattern showed to have SCAD, have been reported; these cases were deemed to be "SCAD misdiagnosed as TS". The left ventricular wall motion abnormality has been attributed to the ischemia caused by SCAD-affected coronary vessel especially in the left anterior descending artery (LAD) with "wrap-around course". However, the left ventricular ballooning pattern have occurred in patients with SCAD in non-long-wrap-around LAD and SCAD in other coronary branches where coronary ischemia on its own cannot explain the left ventricular ballooning. In this review, sufficient data supporting the evidence for the possibility of coexistence of SCAD and TS is provided. Misdiagnosis of the association of the two conditions may result in mismanagement of the patient with undesirable consequences. Furthermore, the causal links between SCAD and TS is discussed.

Intra-arterial versus intravenous abciximab therapy for thromboembolic complications of neuroendovascular procedures: case review and meta-analysis

BackgroundAbciximab is used to treat thromboembolic complications of neuroendovascular procedures, but outcomes of treatment are not well defined.ObjectiveTo examine the angiographic and clinical outcomes based on route of abciximab administration...

Endovascular Treatment of Traumatic Carotid Cavernous Fistula with Balloon-Assisted Sinus Coiling

This study aimed to propose an alternative treatment for carotid cavernous fistula (CCF) using the balloon-assisted sinus coiling (BASC) technique and to describe this procedure in detail. Under general anesthesia, we performed the BASC procedure to treat five patients with traumatic CCF. Percutaneous access was obtained via the right femoral artery, and a 7F sheath was inserted, or alternatively, a bifemoral 6F approach was accomplished. A microcatheter was inserted into the cavernous sinus over a 0.014-inch microwire through the fistulous point; the microcatheter was placed distal from the fistula point, and a "U-turn" maneuver was performed. Through the same carotid access, a compliant balloon was advanced to cross the point of the fistula and cover the whole carotid tear. Large coils were inserted using the microcatheter in the cavernous sinus. Coils filled the adjacent cavernous sinus, respecting the balloon. Immediate complete angiographic resolution was achieved, and an early angiographic control (mean = 2.6 months) indicated complete stability without recanalization. The clinical follow-up has been uneventful without any recurrence (mean = 15.2 months). An endovascular approach is optimal for direct CCF. Because the detachable balloon has been withdrawn from the market, covered stenting requires antiplatelet therapy and its patency is unconfirmed, but cavernous sinus coiling remains an excellent treatment option. Currently, there is no detailed description of the BASC procedure. We provide detailed angiograms with suitable descriptions of the exact fistula point, and venous drainage pathways. Familiarity with these devices makes this technique effective, easy and safe.

Clinical and angiographic results of patients with dural arteriovenous fistula

Endovascular embolization has been regarded as the primary treatment for dural arteriovenous fistula (dAVF). The aim of this study was to describe our experience with treatment and outcomes for patients with dural AVF, and to determine optimal treatment modalities. Between November 2007 and March 2011, 43 patients with dAVF (14 cavernous sinus, 20 transverse-sigmoid sinus, and nine patients with other types) were admitted to our Institute for treatment. For cavernous sinus dAVF, transvenous embolization was attempted as the first-line treatment with residual AVF obliterated by transarterial embolization (TAE), except for three patients who were treated conservatively. For transverse-sigmoid sinus dAVF, TAE was the primary treatment method. Nine of 14 (64.3%) patients with cavernous sinus dAVF had complete angiographic resolution. For transverse-sigmoid sinus dAVF, 14 of 17 (82.4%) patients were treated by TAE using Onyx Liquid Embolic System (eV3 Neurovascular, Irvine, CA, USA). Nine of these patients (64.3%) were angiographically cured or improved clinically with no serious complications, and the other five (35.7%) patients showed significant reductions in arteriovenous shunt. The other nine dAVF were treated by TAE or surgical disconnection depending upon the accessibility of the lesion and risk of complications. Six of nine (66.7%) patients had complete angiographic obliteration or clinical improvement. With developments in diagnostic tools and endovascular interventions, dAVF have become an important neurovascular issue. The results of this study suggest that a new approach to treatment of dAVF is needed.

Resolution of Pulmonary Embolism on CT Pulmonary Angiography

The objective of our study was to retrospectively determine the rate of resolution of pulmonary emboli (PEs) in individual vessels and the rate of complete resolution of PEs on CT angiography. Follow-up CT pulmonary angiograms, obtained during the period from January 2006 through May 2009, of 69 patients with acute PE from two hospitals were assessed. Initial and follow-up CT angiograms were reread together by one radiologist at both of the hospitals. Images were obtained using a 10-, 16-, 40-, or 64-MDCT angiography unit with a 0.5-mm collimation, 1.25- to 2.0-mm reconstruction, 0.3- to 0.5-second rotation time, and 7.5-mm/rotation table speed. All CT angiograms were obtained using a PE protocol. Follow-up CT angiograms were obtained in 35 men and 34 women who ranged in age from 17 to 92 years (mean age, 58 +/- 17 [SD] years). Complete CT angiographic resolution of PE was seen in six of 15 patients (40%) 2-7 days after diagnostic imaging. After day 28, complete resolution occurred in 17 of 21 patients (81%). The main pulmonary arteries showed complete PE resolution during days 2-7 in seven of nine patients (78%) and after day 28 in 34 of 36 (94%). The lobar pulmonary arteries showed complete resolution of PE during days 2-7 in 23 of 33 patients (70%) and after 28 days in 44 of 48 (92%). The segmental pulmonary arteries showed complete resolution during days 2-7 in eight of 21 patients (38%) and after day 28 in 38 of 38 (100%). Most patients (81%) showed complete resolution of PE on CT angiography after 28 days. PEs resolved faster in the main and lobar pulmonary arteries than in the segmental branches.

Reconstructive endovascular treatment of ruptured blood blister–like aneurysms of the internal carotid artery

Ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) are rare but carry a high rate of morbidity and mortality. Furthermore, BBAs are very difficult to treat surgically as well as endovascularly. The authors present their experience in treating BBAs with reconstructive endovascular methods. Nine ruptured BBAs in 9 consecutive patients (2 men and 7 women; mean age 50 years, range 42-57 years) were treated using reconstructive endovascular methods between January 2006 and November 2007. Treatment methods and angiographic and clinical outcomes were retrospectively evaluated. All 9 BBAs were initially treated with stent-assisted coil (SAC) embolization. This was followed by a second stent insertion using the stent-within-a-stent (SWS) technique in 3, covered stent placement in 3, and SAC embolization alone in 3. All 3 patients who underwent SWS placement had excellent outcomes (Glasgow Outcome Scale Score 5) with complete angiographic resolution of the BBAs. There were no treatment-related complications in the SWS group. Two of the 3 patients who received covered stents had excellent outcomes (Glasgow Outcome Scale Score 5) and complete occlusion of the BBA was achieved. The remaining patient who received a covered stent died of ICA rupture during the procedure. Aneurysm regrowth without rebleeding occurred in the 3 patients who underwent SAC embolization. Two of the 3 recurrent BBAs were treated with coil embolization with a second stent insertion, and as a result these belonged to the SWS group. The other recurrent BBA was treated with a covered stent. Of the 8 surviving patients, 5 underwent SWS, and 3 underwent covered stent placement. All surviving patients had excellent outcomes during the clinical follow-up period (mean 11 months, range 4-26 months); complete BBA resolution and smooth reconstruction of the affected ICA segment was shown on follow-up angiography. In the present study, the SWS and covered-stent techniques effectively prevented rebleeding and regrowth of the BBA without sacrifice of the ICA. The SWS and covered-stent techniques can be considered an alternative treatment option for BBAs in selected patients in whom ICA sacrifice is not feasible. Stent-assisted coiling alone seems insufficient to prevent BBA regrowth.

Spontaneous coronary artery dissection in the postpartum period.

Spontaneous coronary artery dissection is a very uncommon cause of acute coronary syndrome. It occurs predominantly in young to middle-aged women during or after pregnancy. The aetiology remains uncertain. Possible factors are hormonal changes, haemodynamic stress and changes in autoimmune status. In case of single-vessel dissection and normal blood flow, conservative treatment often leads to complete angiographic resolution. This case report describes the clinical presentation, diagnosis and therapy of spontaneous coronary artery dissection in a 37-year-old woman in the postpartum period. (Neth Heart J 2008;16:412-4.).

Cutting Balloon Angioplasty for Carotid In‐Stent Restenosis: Case Reports and Review of the Literature

Percutaneous stenting techniques are becoming more commonly used for treatment of carotid artery disease. One outcome of particular concern is in-stent restenosis. Indications for treatment of in-stent restenosis are not clearly defined. Use of traditional balloon angioplasty with or without stent placement is still considered the first option. Cutting balloon angioplasty has recently been used as an alternative treatment option for revascularization of in-stent restenosis with higher procedural success rates and without the use of additional stents. We report our experience with cutting balloon angioplasty in treating 2 patients with carotid in-stent restonosis, and review previous cases reported in the literature. A total of 16 patients have been treated with cutting balloon angioplasty. Among 11 patients for whom the clinical and angiographic information were available, 63% of patients were asymptomatic at the time of treatment, and more than 90% of patients showed either complete angiographic resolution or residual stenosis of less than 30%. Additional stent placement or angioplasty was required in only half of the patients, and 1 patient had recurrent stenosis. The review suggests that the procedure is safe and effective.

Complete angiographic resolution of spontaneous coronary artery dissection associated with sleep deprivation

We describe a case of complete angiographic resolution of spontaneous coronary artery dissection associated sleep deprivation with a successful medical management. A 40-year-old woman presented to our emergency department with squeezing chest pain following 72 h sleep deprivation. Coronary angiography demonstrated longitudinal dissection of the middle part of the diagonal artery with TIMI III flow to the distal part of the vessel. The dissected vessel was small to intervene so we decided to treat it conservatively with antiplatelet agents and heparin. She remained free of chest pain during the hospitalization period and was discharged in good condition. We continued to treat her in the outpatient clinic with antiplatelet agents and the patient no longer complained of chest pain. At six months, coronary angiography demonstrated complete resolution of the previously dissected coronary artery.

Endovascular Reconstruction with the Neuroform Stent as Monotherapy for the Treatment of Uncoilable Intradural Pseudoaneurysms

Intradural pseudoaneurysms have a malignant natural history and can be difficult to treat if parent vessel deconstruction is not feasible. These lesions often involve a long arterial segment and lack a defined saccular component that would safely accommodate the introduction of embolization coils. The current report describes the successful endovascular treatment of these lesions using a strategy of Neuroform stent reconstruction. A retrospective review of the prospectively maintained Neuroform databases from our two institutions identified all intracranial aneurysms treated with the Neuroform stent alone, without embolization coils. The clinical charts, procedural data, and angiographic results were reviewed. Over a 38-month study period (10/02-2/06), 266 aneurysms were treated with the Neuroform stent. Of these, 10 were small "uncoilable" intradural pseudoaneurysms associated with subarachnoid hemorrhage. These lesions were treated using a strategy of endovascular stent reconstruction of the diseased vascular segment with one or more Neuroform stents (without concomitant coil embolization). Seven pseudoaneurysms were treated in the context of acute or subacute subarachnoid hemorrhage, and three were associated with a remote history of subarachnoid hemorrhage. Periprocedural complications occurred in two patients (clinically silent, intraprocedural thromboembolic event successfully treated with intra-arterial abciximab, symptomatic postprocedural stent thrombosis with successful thrombolysis, and excellent neurological recovery). Both complications occurred in patients with ruptured aneurysms and could be attributed to inadequate platelet inhibition at the time of the initial procedure. Follow-up conventional angiographic examinations were available for all 10 patients with pseudoaneurysms (1-18.5 mo; average, 9.0 mo). In nine cases, the aneurysms improved at follow-up, with either complete (n = 5) or near complete (n = 4) resolution. In one case, short-term follow-up (1 mo) demonstrated no significant change. No patient has rehemorrhaged after treatment. Endovascular Neuroform stent reconstruction represents an optimal strategy for the management of intradural pseudoaneurysms that require a constructive treatment strategy and are too small to accommodate the introduction of embolization coils. Nine out of 10 patients in the current series treated with this strategy demonstrated some degree of endovascular remodeling with either complete (n = 5) or partial (n = 4) angiographic resolution at follow-up. No rehemorrhages were encountered. Adequate antiplatelet therapy, even in the setting of acute subarachnoid hemorrhage, is prerequisite for the avoidance of thromboembolic complications.

The Role of Serum Endothelin-1 Level in the Etiopathogenesis of Central Serous Chorioretinopathy

To assess the role of serum endothelin-1 (ET-1) in the pathogenesis of central serous chorioretinopathy (CSC). Prospective, case control study. The serum ET-1 levels of 21 otherwise healthy patients who received a diagnosis of acute CSC (group 1) were measured with the enzyme-linked immunosorbent assay (ELISA) method at the initial visit, at the one month follow-up examination, and after complete angiographic resolution of the leakage. Nine patients with a previous diagnosis of CSC (group 2), 10 patients from the outpatient clinic (group 3), and 14 hospital employees (group 4) were also included. The serum ET-1 levels in group 1 revealed neither correlation with the disease activity nor significant difference from the levels in groups 2 and 4. However, serum ET-1 levels in group 3 were statistically higher than the levels in groups 1 and 4. These findings suggest no role of serum ET-1 in pathogenesis of CSC in otherwise healthy subjects.

Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment

Background Less is known about characteristics, treatment and follow-up of patients with spontaneous coronary artery dissection (SCAD) without associated pregnancy or underlying atherosclerosis. Methods We reviewed 5054 consecutive coronary angiographies for SCAD in patients without atherosclerosis or associated pregnancy and performed follow-up angiography in eligible patients. Results SCAD were assessed in five patients (mean age 44±8.7 years). Interestingly, all were premenopausal women. Three had no cardiovascular risk factors, whereas two were previous smokers and one had slightly elevated cholesterol levels. Clinical presentation was acute myocardial infarction in four cases and unstable angina pectoris in one of them. Dissection was localized in the left anterior descending artery (LAD) in three cases and in the first marginal branch of the left circumflex artery in two cases. Three patients were treated conservatively with antithrombotic therapy and beta-blocker, whereas in one patient rescue-PCI with stenting of the ostium of the LAD was performed after failed thrombolysis. The fifth woman with dissected proximal LAD underwent CABG. Follow-up angiographies after 5.9±4.4 months showed complete angiographic resolution of the dissection in the medically treated patients and a perfect angiographic result of the stented LAD. All patients were free of symptoms after a mean follow-up of 13±10 months. Conclusions Idiopathic SCAD is a rare cause of acute coronary syndrome in premenopausal women. In case of single vessel dissection and normal blood flow of the dissected vessel, medical treatment with aspirin, clopidogrel and beta-blockade leads to complete angiographic resolution within a few months.

Ketorolac treatment of pseudophakic cystoid macular edema identified more than 24 months after cataract extraction

Objective To evaluate whether ketorolac ophthalmic drops prescribed four times a day can be associated with improved visual acuity and prompt resolution of edema for patients with pseudophakic cystoid macular edema identified more than 24 months after cataract surgery. Design Prospective, nonrandomized, comparative (subject self-controlled) trial. Participants The records of nine patients who had pseudophakic cystoid macular edema more than 24 months after cataract surgery at the time treatment commenced were identified at the Wilmer Retinal Vascular Center from September 1, 1996, through March 1, 1997. Main outcome measures Best-corrected visual acuities measured on a retroilluminated Bailey-Lovie chart approximately every 3 months, contact lens biomicroscopy, and fluorescein angiography following ketorolac. Intervention Commercially available ketorolac ophthalmic drops 0.5% were prescribed for the affected eye four times a day for at least 3 months and continued until edema resolved. Results Ten eyes of nine patients were identified more than 24 months after cataract extraction (median, 59 months). Seven eyes (70%) improved (mean, +3.2 lines; range, +1 to +13 lines), including six by 2 or more lines 3 months after treatment initiation. Two eyes (20%) were unchanged, and one eye (10%) was 1 line worse. All seven eyes that improved 1 line or more had some or complete angiographic resolution of fluorescein dye leakage. In these seven eyes, ketorolac was discontinued when dye leakage completely resolved or failed to continue to improve on periodic 3-month follow-up examinations. In all seven eyes, recurrence of edema was noted within 3 months after ketorolac was stopped. Conclusions Chronic pseudophakic cystoid macular edema identified more than 24 months after cataract surgery can improve with topical ketorolac but probably requires persistent use.

Successful reversal of cardiogenic shock precipitated by saphenous vein graft distal embolization using aspiration thrombectomy

A 74-year-old male had cardiac catheterization complicated by embolization of a thrombotic proximal saphenous vein graft lesion. Cardiogenic shock ensued. Successful aspiration thrombectomy was performed using a 7F multipurpose guiding catheter advanced to the site of obstruction. There was complete angiographic resolution and reversal of cardiogenic shock.

Transvenous embolization of dural caroticocavernous fistulae: technical considerations

Sixteen patients with symptomatic dural caroticocavernous fistulae were treated by transvenous embolization, via the jugular vein and inferior petrosal sinus. The fistula was occluded by thrombogenic coils. Complete resolution of symptoms and signs was achieved in 14 patients, and complete angiographic resolution was also obtained in 14 patients. Failures to achieve angiographic cure were attributed to failure to reach the fistula within the cavernous sinus precisely. Factors which make placement of the catheter at the fistula difficult are trabeculae within the cavernous sinus, a specific configuration of the superior ophthalmic vein and venous thrombosis. To improve the efficacy of transvenous embolization, every possible venous route to the cavernous sinus therefore should be tried, to facilitate reaching the fistula and the possibility of transvenous embolization should not be thwarted by venous thrombosis.

Spontaneous Healing of a Traumatic Thoracic Aortic Tear:

A patient with deceleration trauma of the thoracic aorta causing significant intimal disruption is described in whom complete angiographic resolution was documented during a period of medical management. Review of the literature, along with our experience, suggests that traumatic aortic disruption constitutes a spectrum of injury rather than an all-or-none phenomenon. Immediate surgery, especially in multiply injured patients, may be delayed or even postponed indefinitely if the injury is relatively limited.