Contrast Angiography Research Articles

Abstract WMP49: Occult Contrast Retention Post-thrombectomy On 24-hour Follow-up CT: Associations And Impact On Imaging Analysis

Introduction: CT performed 24h post-treatment is widely used to assess radiological outcomes in stroke studies. Even without visible hyperattenuation, occult angiographic contrast may persist in the brain and confound Hounsfield Unit-based imaging metrics such as Net Water Uptake (NWU), a measure of cerebral edema based on tissue hypoattenuation. We aimed to assess (1) the presence of retained contrast post-thrombectomy on 24h CT by comparing NWU measurements with and without adjustment for iodine using dual energy CT (DECT), (2) factors associated with amount of retention, and (3) its impact on the accuracy of NWU. Methods: In a prospective study of patients with anterior circulation large vessel occlusion who had post-thrombectomy follow-up DECT performed 24h post-treatment from two Comprehensive Stroke Centres (November 2021 to May 2022), NWU was calculated by interside comparison of Hounsfield Units of the infarct lesion and its mirror homolog. Retained contrast was quantified by the difference in NWU values with and without adjustment for iodine. We tested correlation between NWU and tissue swelling using relative hemispheric volume (rHV) and midline shift (MLS). Patients with visible hyperdensities from hemorrhagic transformation or visible contrast retention, and bilateral infarcts were excluded. Results: Of 125 patients analysed (median age 71 [IQR 61-80], baseline NIHSS 16 [IQR 9.75-21]), reperfusion (eTICI 2b-3) was achieved in 120 patients (96.8%). NWU measured with iodine adjustment was significantly higher than NWU measured without adjustment (17.1% vs 10.8%, p<0.001). In multivariable median regression analysis, age (p=0.031), number of passes (p<0.001) and having CT perfusion at baseline (p=0.008) were independently associated with amount of retained contrast. NWU measured with iodine adjustment correlated with rHV (p=0.043) and MLS (p=0.033), but NWU without adjustment did not (rHV p=0.350; MLS p=0.347). Conclusion: Occult angiographic iodine contrast significantly affects NWU on CT at 24h. Our data suggest adjustment for retained iodine using DECT is required for accurate NWU measures post-thrombectomy. Future studies analysing CT post-thrombectomy should consider the significance of occult contrast retention.

Intravascular Ultrasound Guidance in Percutaneous Mechanical Thrombectomy: A Single-Center Experience From the FLASH Registry

BackgroundTraditionally, iodinated contrast is utilized during catheter-based mechanical thrombectomy for pulmonary embolism (PE). Recently, there have been disruptive contrast shortages. Furthermore, contrast can cause contrast-induced acute kidney injury especially in patients with pre-existing chronic kidney disease, necessitating an alternative imaging method. We present utilization and feasibility of an intravascular ultrasound (IVUS)-guided strategy for mechanical thrombectomy in PE from the FLASH registry. MethodsIn this FLASH patient subset, IVUS was used to image the pulmonary arteries (PAs) before and after mechanical thrombectomy with the FlowTriever System at one study site comprising three hospitals. The Philips Visions PV 0.035” IVUS catheter was used for all the IVUS-guided cases in a standardized manner. ResultsBetween July 2019 and December 2021, 26 FLASH patients enrolled at this site underwent IVUS-guided thrombectomy. Most patients (96.2 %) had intermediate-risk PE and 3.8 % had high-risk PE. The mean baseline composite RV/LV ratio was 1.36 ± 0.27 and the mean simplified Pulmonary Embolism Severity Index (sPESI) score was 1.9 ± 1.2. A decreasing trend in contrast agent volume usage was observed over time and several later procedures were performed with IVUS guidance alone. Mean PA pressure significantly decreased immediately following thrombectomy from 34.8 ± 8.3 to 25.5 ± 7.3 mmHg (p < 0.0001). Systolic PA pressure also significantly decreased immediately from 55.4 ± 13.9 to 39.5 ± 12.5 mmHg (p < 0.0001). Significant improvements were seen in echocardiographic assessments of RV function at a mean 87-day follow-up compared with baseline. ConclusionsIn conclusion, the use of IVUS guidance with minimal or no angiographic contrast during mechanical thrombectomy for acute PE is technically feasible.

The effect of the size of the new contour neurovascular device for altering intraaneurysmal flow.

Recently, a novel intrasaccular device (contour neurovascular system, contour) was introduced to treat intracranial aneurysms. Contour is placed at thе aneurysm neck and reduces the intraaneurysmal blood inflow. Contour comes in a range of sizes to target different aneurysms. The efficiency of altering flow with contour and the effect of device size have not yet been investigated. Therefore, we studied the effect of the device size with patient-based aneurysm models using 2D digital subtraction angiography (DSA). Three patient-based aneurysm models with necks ranging from 2.7 to 9.7 mm were produced, providing standardized testing conditions. Contours with diameters of 5, 11, and 14 mm were implanted into the models, four of each size. 2D DSA images were acquired before and after implanting contour (15 frames/s, manual contrast injection). After injecting angiographic contrast agent, the DSA signal was recorded over time to calculate the contrast washout time (WOT), which is a measure of flow diversion efficiency. All contour devices caused contrast agent stasis and increased WOT in aneurysm sac (p-value = 0.0005). The median relative WOT was largest for 5-mm contour (6.6 ± 3.2) and similar for 11-mm contour (3.4 ± 2.6) and 14-mm contour (3.2 ± 3.8). The implantation procedure might affect WOT values even for contours of the same size; the overall relative WOT ranged between 1.5 and 10.89. The 5-mm contour showed the longest WOT value in our study, while no apparent difference between 11-mm contour and 14-mm contour was found.

Doppler ultrasound in the assessment of blood supply to choroidal melanoma: parallels with contrast angiography and histography

Evaluation of blood supply to choroidal melanoma based on comparison of Doppler characteristics of blood flow with angiographic variant of angioarchitectonics and densitometric parameters of the tumor. The study was performed in 135 patients (135 eyes) with choroidal melanoma. The initial prominence of the tumors varied from 0.6 to 15.2 mm (mean 5.07±3.58 mm), the diameter of the tumor base varied from 4.1 to 22 mm (mean 10.97±3.62 mm). Taking into account the biometric characteristics of choroidal melanoma, all patients were divided into 3 groups: «small» (n=49), «medium» (n=34) and «large» (n=52). In addition to standard diagnostic examination, the following instrumental methods for assessing the blood supply of choroidal melanoma were carried out: angiography with indocyanine green, optical coherence tomography angiography, ultrasound in color Doppler mapping mode, ultrasound histography. Comparative analysis of Doppler ultrasound and contrast angiography data in assessing the blood supply of choroidal melanoma established that the first angiographic type, presented by straight and parallel vessels (65%, p=0.037), is characteristic for hypovascular and avascular masses, the second type - for hypervascular choroidal melanomas, in which the new vessels can take the form of arches, loops and nets (68%, p=0.027). The study of densitometric characteristics in choroidal melanoma of various sizes indicates a natural decrease in the acoustic density of the tumor tissue with increase in the prominence of the mass, while there are significant differences in the acoustic density values in hypo/avascular (36.53±5.37 dB) and hypervascular variants (29.28±4.53 dB) of blood supply to tumor tissue. The obtained data on acoustic density of choroidal melanoma can be used in clinical practice for indirect assessment of the nature of blood supply to choroidal melanoma.

Drug-eluting, balloon-expandable, bioresorbable vascular scaffolds reduce neointimal thickness and stenosis in an animal model of percutaneous peripheral intervention

ObjectiveRecanalization with balloon angioplasty and/or self-expanding stents (SES) has become the endovascular treatment of choice for symptomatic femoropopliteal occlusive disease. These strategies generate suboptimal clinical results, however, because they fail to expand the artery fully and ineffectively prevent recoil, neointimal hyperplasia, and restenosis. Balloon-expandable stents, given their greater radial force and rigid structure, represent a more effective treatment strategy, but only short lengths can be implanted safely in arteries that deform and bend with skeletal motion. The purpose of this preclinical experiment was to test the hypothesis that simultaneous implantation of a series of short, resorbable, balloon-expandable, paclitaxel-eluting scaffolds would prevent neointimal hyperplasia and stenosis compared with SES in an animal model of percutaneous femoropopliteal intervention. MethodsWe extruded 6 × 60 mm Efemoral Vascular Scaffold Systems (EVSS) from copolymers of poly-L-lactic acid, coated with paclitaxel 3 μg/mm2, crimped onto a single delivery balloon, and implanted percutaneously into the iliofemoral arteries of eight Yucatan mini-swine. We implanted 7- to 8-mm × 60 mm SES into the contralateral experimental arteries. The animals were serially imaged with contrast angiography and optical coherence tomography after 30, 90, 180, 365, and 730 days. The primary end point of this study was neointimal morphometry over time. Secondary end points included acute deformation and angiographic and optical coherence tomography-derived measurements of chronic vascular response. ResultsOver the 2-year study period, one SES was found to be completely occluded at 90 days; all EVSS were widely patent at all time points. Arteries treated with SES exhibited profound neointimal hyperplasia with in-stent stenosis. In contrast, arteries treated with EVSS exhibited only modest vascular responses and minimal stenosis. After 2 years, the mean neointimal thickness (0.45 ± 0.12 vs 1.31 ± 0.91 mm; P < .05) and area (8.41 ± 3.35 vs 21.86 ± 7.37 mm2; P < .05) were significantly decreased after EVSS implantation. By 2 years, all scaffolds in all EVSS-treated arteries had resorbed fully. ConclusionsIn this preclinical animal model of peripheral endovascular intervention, the EVSS decreased neointimal hyperplasia and stenosis significantly compared with SES, then dissolved completely between the first and second years after implantation.

The incidence and clinical characteristics of pulmonary embolism in oncologic patients

BackgroundFor various types of cancer in oncologic patients, the clinical features of pulmonary embolism (PE) are unknown. The purpose of the study is to identify pulmonary embolism incidence and type among oncologic patients along with evaluating any associated clinical variables.Patients and methodsA prospective cohort study was conducted on 540 patients who had various types of cancers and attended to a 1-day care unit of oncology in King Fahd Hospital, Kingdom of Saudi Arabia. Chest CT with contrast and CT pulmonary angiography was applied when indicated.ResultsThis study was conducted on 540 patients who have different types of cancers; among them, 24 (4.44%) developed PE. Pulmonary embolism was reported in 50% of patients who had seminoma and germ cell tumor, while in cancer larynx, it was represented in 33.4% of them. Moreover, PE was less common among patients who had cancer colon, prostate, and breast (6.68%, 4.7%, and 2.54%, respectively). Seven patients with PE (1.3%) were diagnosed incidentally during cancer staging, while 17 patients (3.14%) had symptomatic PE. Eighty-four percent of the PE cases were diagnosed within the first 6 months of cancer diagnosis, while 4/24 (16%) of the PE cases were diagnosed throughout patient follow-up within the first year of diagnosis. Chest pain and dyspnea were the common presentations in confirmed PE either symptomatic or incidental group.ConclusionsLow-risk PE was the most frequent degree; massive and sub-massive PE was uncommon in oncologic patients. Dyspnea and chest discomfort are concerning signs of PE in cancer. Meticulous care during the first 6 months for cancer patients to pick up pulmonary embolism is recommended.

Isolated Third Cranial Nerve Palsy: Aetiology - Clinical Profile and Recovery at a Tertiary Neuro-ophthalmology Centre on the East Coast Peninsular of Malaysia

Objective: This study aimed to study the aetiologies, clinical profile and recovery of isolated third cranial nerve palsy (ITCNP) patients, at a tertiary neuro-ophthalmology center on the East Coast Peninsular of Malaysia. Material and Methods: This was a retrospective study, involving 33 patients with newly diagnosed ITCNP, who were treated at the Hospital of the Universiti Sains, Malaysia; from January 2018 to December 2019, with a follow up period ranging from 18 to 24 months. The demographic data, clinical features and aetiologies of the patients were analysed. Results: Patients’ ages ranged from 14 to 79 years (mean: 48, 50 years of age). The main aetiology was microvascular ischemia (39.4%), followed by trauma (30.3%), aneurysm (15.2%), tumour (9.1%) and undetermined cause (6.1%). Neuroimaging was performed for those indicated cases; with either computed tomography (CT), CT angiography, digital subtraction angiography, magnetic resonance imaging (MRI) with contrast or MRI angiography. Two-thirds of the patients (66.7%) had periorbital pain, which included 30.8% of patients with microvascular ischemia and 60.6% had pupil involvement; which was also found in 23.1% of patients with microvascular ischemia. Complete external third nerve palsy occurred in 18.2% of patients, and aberrant regeneration was observed in 36.4% of patients. Complete recovery occurred in 48.5%, of all patients, having microvascular ischemia and undetermined causes. Conclusion: The aetiologies, clinical profile and recovery of ITCNP patients in our institution are comparable to those reported in other previous studies. Patients with microvascular ischemia may also demonstrate periorbital pain and anisocoria. Neuroimaging remains the gold standard and the best tool via which to exclude other sinister and lifethreatening aetiologies.

A Case of Spontaneous Isolated Superior Mesenteric Artery Dissection in a Patient With Celiacomesenteric Trunk Anomaly

Celiacomesentric trunk (CMT) is a rare vascular anomaly with a common origin for the celiac artery and superior mesenteric artery. To our knowledge, this is the first case of superior mesenteric artery (SMA) dissection in patients with CMT. Here, we discuss a case of a 65-year-old male with acute-onset epigastric pain who was found to have SMA dissection with CMT. He was treated conservatively with symptomatic improvement. Diagnostic imaging studies include computed tomography (CT) scanning of the abdomen with or without contrast and CT angiography. Management options include a conservative approach, endovascular repair, and surgical management based on the classification/location of the dissection.

Intraoperative Flow Measurement as a Quality Control during Carotid Endarterectomy in a Teaching Hospital Setting

Background: To evaluate the technical results of an arterial repair, a variety of intraoperative imaging and assessment techniques can be used during carotid endarterectomy (CEA). The aim of the study was to evaluate the usefulness of intraoperative ultrasound flow measurement as a quality control after primary CEA in a teaching hospital setting. Methods: Over 36 months, 107 consecutive CEAs were performed at our institution. Retrospectively acquired demographics, intraoperative flow measurements, duplex results, revisions, and surgical outcomes were reviewed. Postoperative 30-day transient ischemic attack (TIA), stroke, and death rates were analyzed. Results were compared with ultrasound flow measurement and duplex ultrasonography. Results: From March 2012 to March 2015, 107 primary consecutive CEAs were performed in 107 patients (71% male, 29% female), whose age ranged from 51 to 81 years with a mean age of 68 ± 4 years. Associated risk factors included diabetes for 89 (83%), smoking for 92 (86%), hypertension for 94 (87.8%), chronic renal insufficiency for 71 (66%), and coronary artery disease for 57 (53%) of the patients. Early postoperative duplex scans in all 107 patients showed no significant changes from intraoperative findings. The ipsilateral stroke and death rate in this study was 0 (0/107) and the 30-day death and stroke rate was also 0 (0/107), with no significant difference between trainees and senior surgeons. Three patients (2.8%) had flow &lt; 100 mL/Min and two of them were revised after completion of contrast angiography. Conclusions: The findings of this study indicate that the intraoperative flow measurement is an alternative method for detecting technical errors and a tool for quality-control imaging. Especially for trainees, it makes sense to ensure effectiveness of the procedure upon its completion and to assess the technical adequacy of CEA.

Simultaneous depiction of clot and MRA using 1 min phase contrast angiography in acute ischemic patients

[Background and Purpose] Clot location and range predict clinical outcomes for acute ischemic stroke (AIS). We developed a new technique for visualizing occlusion clots, namely, the DEpicting blood clot and MRA using Phase contrast angiography with Image Calculation for Thrombectomy (DEPICT) method. The purpose of this study was to assess the clinical usefulness of DEPICT.[Methods] We used DEPICT in 36 AIS patients to obtain MRA and black blood images with 1-min phase contrast angiography (PCA). We created the black blood images by subtracting the MRA from the T1WI using the source image of PCA. We evaluated the motion artifact, detectability of clot, and precision in location and range compared these to that of susceptibility vessel sign in T2*WI and measured contrast ration (CR) of clot between the cistern and brain tissue. Motion artifact was visually evaluated using a 3-point scale. Detectability and precision of the location and range of occlusion clots were assessed by comparison with findings from digital subtraction angiography (DSA). Gwet's AC1 and kappa statistics were used to assess inter-observer agreement.[Results] DEPICT showed significant robustness for motion artifact compared with T2*WI (p = 0.0026, Wilcoxon signed-rank test). DEPICT showed 100% detectability for the clot. Further, DEPICT showed higher Gwet's AC1 and kappa statistic values with DSA than T2*WI. CR demonstrated a positive value.[Conclusions] DEPICT technique based on 1-min PCA offers both MRA and black blood T1W images that can be used to accurately evaluate both location and range of the clot.

Renal Function After Transcatheter Piccolo Patent Ductus Arteriosus Closure With Contrast Angiography in Extremely Premature Infants

Transcatheter patent ductus arteriosus (PDA) device closure is increasingly performed in extremely premature infants. Contrast angiography improves the procedural safety and effectiveness by precise anatomic delineation. Contrast nephropathy is a concern in clinically ill premature infants, especially with the presence of renal insufficiency. We hypothesized that the benefit of transcatheter PDA closure outweighs the harm of contrast nephropathy in extremely premature infants. A total of 160 infants underwent successful transcatheter (n=59) and surgical (n=101) PDA closure at a median age of 26 (7 to 78) days. The surgical group had a lower procedural weight (870 vs 960 g, p=0.014). In the transcatheter group, serum creatinine decreased from 0.48 to 0.45 mg/100 ml at 24 hours (p=0.003, n=59) and decreased further to 0.37 mg/100 ml at 5 to 7 days after closure (p &lt;0.001). Median contrast amount was 1.9 ml/kg (0.6 to 6.1). In 8 infants with pre-existing renal insufficiency who underwent transcatheter closure, serum creatine significantly improved from 1.44 to 1.36 mg/100 ml at 24 hours and 0.79 mg/100 ml at 5 to 7 days after closure (p &lt;0.001). There was no difference in improvement of serum creatinine between transcatheter and surgical closure groups. In conclusion, despite the use of contrast, serum creatinine significantly improved with transcatheter PDA closure even in infants with pre-existing renal insufficiency. Contrast angiography should not be discouraged for transcatheter PDA closure because of the concern for contrast nephropathy in extremely premature infants.

The Complication Of Decrease In Aorto-Mesenteric Angle And Distance Its Diagnosis And Treatment: Case Report

Introduction. Wilkie syndrome is a pathological manifestation caused by an abnormal disorder of the superior mesenteric artery arising from the abdominal part of the aorta. As a result, the distal part of the duodenum is compressed between the abdominal aorta, spine, and SMA, which creates a hindrance for the passage of himus in the duodenum, creating a mechanical obstruction.Aim: To draw the surgeons’ attention towards the possibility of developing a rare complication of decreased aorto-mesenteric angle and the distance, highlighting the challenges in diagnosis and treatment.Materials and methods. This article presents a clinical case of WS diagnosed in the surgical department of the BSMU clinic. We hereby discuss the case report of a 28-year-old patient diagnosed at the initial stage of WS. The patient had been suffering from the symptoms of WS since 2018 but wasn’t able to identify the disease, but when he came to the surgical department of BSMU clinic based on the results of abdominal CT-scan with combined contrast of the stomach and duodenum per os with water-soluble contrast and computer angiography of the mesenteric vessels, the diagnosis was confirmed. The patient was treated with the duodenojejunostomy (laparoscopic Strong’s operation).Results and discussion. Absence of timely diagnosis of this disease can lead to life-threatening complications, and early diagnostics is complicated by similarity of initial manifestations with other gastropancreaticoduodenal diseases. One of the most promising approach in the diagnosis of Wilkie syndrome is the use of abdominal CT-scan with combined contrasting of the stomach and duodenum per os with water-soluble contrast and computer angiography of vessels. In the present clinical case due to the given combination of methods we can assess functional state of the stomach and duodenum, clearly visualize not only the organs topography but also estimate the aorto-mesenteric angle and distance, which can further determine the type and tactics of initial stage treatment, which we decided to perform surgery (laparoscopic Strong’s operation). The postoperative period was without complications. The patient noted an improvement in the state and the relief of pain in the epigastrium and was discharged after 9 days of hospitalization in satisfactory condition.Conclusion. For diagnosis and treatment in time as well as prevention of possible complications, it is necessary to improve surgeons’ information about this pathology, which if diagnosed and treated late can lead to severe, life-threatening complications up to death. The diagnosis at the initial stages, specifically with the assistance of computer tomography with contrast, angiography, and treatment in a timely manner, can preserve life and prevent the possible outcomes of fatal complications.

Ankle Hemodynamic Index to Assess the Severity of Peripheral Arterial Disease Compared to Ankle Brachial Index

Aims: The goal of this study is to assess the diagnostic efficacy of the “ankle-brachial index, ankle hemodynamic index (Tanno et al, 2016) correlated with the Rutherford grading of lower limb ischemia” in patients with angiographically proven peripheral artery disease as assessed by either CT or contrast angiography of the lower extremities as imaging modalities. Methods: This observational cross-sectional study included 100 participants with proven peripheral artery disease who were referred to Nasr city health insurance hospital's vascular department and outpatient clinic. Results: Study participants ranged in age from 35-86. The mean age of the participants was 63.6 ± 10.5 years. They were 70 males (70%) and 30 females (30%). The ankle-brachial index value ranged from 0.6 up to 1.3 for all of the participants that were evaluated, with a mean of 1 and a standard deviation of 0.2. Ankle hemodynamic index ranged from 17 to 73, with 17 being the lowest possible value and 73 being the highest possible value. The mean ankle hemodynamic index was 41.2 ± 13.4. Ankle hemodynamic index and Rutherford grade have an extremely statistically significant positive correlation. Conclusion: In conclusion, the AHI was shown to be substantially positively connected with the severity of PAD as assessed by Rutherford grading, but the ABI was found to be non-significantly associated with Rutherford grading. We also discovered that Rutherford grade was linked to HbA1C, Hb, CRP, and ankle DBP. Keywords: Peripheral artery disease, ankle hemodynamic index, Rutherford grading, ankle-brachial index.

The ascending aorta valve-sparing prosthetics with abnormal location of the coronary artery circumflex

Highlights. The combination of congenital aortic valve insufficiency and abnormal coronary artery discharge is rare. Taking into account the fact that coronary angiography is not indicated for young patients, there may be a risk of injury to the coronary artery during the correction of aortic malformation. The published case indicates the need for routine coronary angiography for all patients, regardless of their age, who are going to have aortic valve surgery.Background. Anomalous origin from right sinus and pathway of circumflex coronary artery can complicate aortic valve and root procedures. Computed tomography scan with contrast and selective angiography help to recognize the malformation and protect circumflex artery. Herein we present the case of valve sparing root replacement in patient with bicuspid regurgitant aortic valve and anomalous origin of circumflex artery.

Abstract No. 369 Facilitating lower dose quantitative DSA: a technique for simultaneous acquisition of blood velocity and vessel morphology during angiographic imaging

An interleaved x-ray imaging technique was developed to capture diagnostic quality angiographic images and contrast media kinetics in a single scan, while reducing patient radiation and contrast dose. This study assessed the accuracy of arterial velocity calculations using quantitative DSA (qDSA) and the interleaved technique.

PO-707-08 ANTIDROMIC LEFT PERICARDIOPHRENIC VEIN ACCESS FOR DEPLOYMENT OF A PHRENIC NERVE STIMULATOR: LESSONS LEARNED FROM COMPLEX CORONARY SINUS LEAD IMPLANTATION

Left pericardiophrenic vein (PPV) access is required to deploy over-the-wire phrenic nerve stimulator leads for implantable sleep apnea therapy devices. Coursing along the left lateral aspect of the pericardium, the left PPV is accompanied by the left phrenic nerve and terminates superiorly at the left brachiocephalic vein (BCV) and inferiorly at the left inferior phrenic vein. A superior approach may be complicated by congenital atresia, tortuous anatomy, or iatrogenic dissection. We report a novel approach to PPV access using retrograde wire externalization and antidromic lead placement derived from complex coronary sinus (CS) access techniques. Recognize techniques for complex vascular access for phrenic nerve stimulators and cardiac implantable electronic devices (CIED). The right chest was prepared for subclavian vein access and pre-pectoral generator implant. A 7 French (Fr) delivery sheath and inner 5 Fr Merit CS vertebral vein selector were used to engage the left BCV. Contrast angiography and a 0.014 mm angioplasty wire were used to identify the PPV. Repeated attempts to engage the tortuous vein were associated with proximal dissection. An alternative approach with inferior PPV access was selected. The sheath and vein selector were positioned within the left hepatic vein and the left phrenic vein for angiography. The angioplasty wire was advanced retrogradely into the PPV and left subclavian vein followed by an additional support wire. A separate 7 Fr sheath was placed in the right subclavian vein and a 4 Fr snare was used to secure and externalize the distal angioplasty wire. The wire was used as a rail to advance the phrenic nerve stimulator anterogradely into the PPV. Lead deployment was successful and phrenic nerve stimulation thresholds were satisfactory. Antidromic posterolateral cardiac vein access has been well described for complex coronary sinus lead implantation. The technique may be applied to extracardiac vascular anatomy for challenging PPV lead implantation. This case highlights the technical expertise and anatomical familiarity needed to optimize cardiac implantable electronic device implantation.

The Woven EndoBridge (WEB) device: feasibility, techniques, and outcomes after FDA approval.

Wide-neck bifurcation cerebral aneurysms have historically required either clip ligation or stent- or balloon-assisted coil embolization. This predicament led to the development of the Woven EndoBridge (WEB) aneurysm embolization system, a self-expanding mesh device that achieves intrasaccular flow disruption and does not require antithrombotic medications. The authors report their operative experience and 6-month follow-up occlusion outcomes with the first 115 aneurysms they treated via WEB embolization. The authors reviewed the first 115 cerebral aneurysms they treated by WEB embolization after FDA approval of the WEB embolization device (from February 2019 to January 2021). Data were collected on patient demographics and clinical presentation, aneurysm characteristics, procedural details, postembolization angiographic contrast stasis, and functional outcomes. A total of 110 patients and 115 aneurysms were included in our study (34 ruptured and 81 unruptured aneurysms). WEB embolization was successful in 106 (92.2%) aneurysms, with a complication occurring in 6 (5.5%) patients. Contrast clearance was seen in the arterial phase in 14 (12.2%) aneurysms, in the capillary phase in 16 (13.9%), in the venous phase in 63 (54.8%), and no contrast was seen in 13 (11.3%) of the aneurysms studied. Follow-up angiography was performed on 60 (52.6%) of the aneurysms, with complete occlusion in 38 (63.3%), neck remnant in 14 (23.3%), and aneurysmal remnant in 8 (13.3%). Six (5.5%) patients required re-treatment for persistent aneurysmal residual on follow-up angiography. The WEB device has been successfully used for the treatment of both unruptured and ruptured wide-neck bifurcation aneurysms by achieving intrasaccular flow diversion. Here, the authors have shared their experience with its unique technical considerations and device size selection, as well as critically reviewed complications and aneurysm occlusion rates.

Patient-Specific Computer Simulation to Predict Conduction Disturbance With Current-Generation Self-Expanding Transcatheter Heart Valves

BackgroundPatient-specific computer simulation may predict the development of conduction disturbance following transcatheter aortic valve replacement (TAVR). Validation of the computer simulations with current-generation devices has not been undertaken. MethodsA retrospective study was performed on patients who had undergone TAVR with a current-generation self-expanding transcatheter heart valve (THV). Preprocedural computed tomography imaging was used to create finite element models of the aortic root. Procedural contrast angiography was reviewed, and finite element analysis performed using a matching THV device size and implantation depth. A region of interest corresponding to the atrioventricular bundle and proximal left bundle branch was identified. The percentage of this area (contact pressure index [CPI]) and maximum contact pressure (CPMax) exerted by THV were recorded. Postprocedural electrocardiograms were reviewed, and major conduction disturbance was defined as the development of persistent left bundle branch block or high-degree atrioventricular block. ResultsA total of 80 patients were included in the study. THVs were 23- to 29-mm Evolut PRO (n = 53) and 34-mm Evolut R (n = 27). Major conduction disturbance occurred in 27 patients (33.8%). CPI (28.3 ± 15.8 vs. 15.6 ± 11.2%; p < 0.001) and CPMax (0.51 ± 0.20 vs. 0.36 ± 0.24 MPa; p = 0.008) were higher in patients who developed major conduction disturbance. CPI (area under the receiver operating characteristic curve [AUC], 0.74; 95% CI, 0.63-0.86; p < 0.001) and CPMax (AUC, 0.69; 95% CI, 0.57-0.81; p = 0.006) demonstrated a discriminatory power to predict the development of major conduction disturbance. ConclusionsPatient-specific computer simulation may identify patients at risk for conduction disturbance after TAVR with current-generation self-expanding THVs.

Bridging the macro to micro resolution gap with angiographic optical coherence tomography and dynamic contrast enhanced MRI

Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) is emerging as a valuable tool for non-invasive volumetric monitoring of the tumor vascular status and its therapeutic response. However, clinical utility of DCE-MRI is challenged by uncertainty in its ability to quantify the tumor microvasculature (mu mathrm{m} scale) given its relatively poor spatial resolution (mm scale at best). To address this challenge, we directly compared DCE-MRI parameter maps with co-registered micron-scale-resolution speckle variance optical coherence tomography (svOCT) microvascular images in a window chamber tumor mouse model. Both semi and fully quantitative (Toft’s model) DCE-MRI metrics were tested for correlation with microvascular svOCT biomarkers. svOCT’s derived vascular volume fraction (VVF) and the mean distance to nearest vessel (overline{mathrm{DNV} }) metrics were correlated with DCE-MRI vascular biomarkers such as time to peak contrast enhancement (r=-0.81 and 0.83 respectively, P<0.0001 for both), the area under the gadolinium-time concentration curve (r=0.50 and -0.48 respectively, P<0.0001 for both) and {k}_{trans} (r=0.64 and -0.61 respectively, P<0.0001 for both). Several other correlated micro–macro vascular metric pairs were also noted. The microvascular insights afforded by svOCT may help improve the clinical utility of DCE-MRI for tissue functional status assessment and therapeutic response monitoring applications.

Strategies for Renal Protection in Cardiovascular Interventions.

Coronary artery disease is highly prevalent in chronic kidney disease (CKD) and is a risk factor for contrast-associated acute kidney injury (CA-AKI), a complication of cardiovascular procedures that require contrast administration (e.g., coronary angiography, percutaneous coronary intervention [PCI]). CA-AKI has a major impact on morbidity, mortality, and healthcare resource utilization. The incidence of CA-AKI is particularly high in patients with pre-existing CKD, advanced age and comorbidities that increase the likelihood of CKD. The focus of the present review is to provide a brief overview on the assessment of the risk for and prevention of CA-AKI in patients undergoing angiography and PCI, including recognition of the important patient- and procedure-related factors that may contribute to CA-AKI. Preventive and treatment strategies, the mainstay of which is volume repletion by normal saline, are briefly discussed. The main focus of the review is placed on technical details of contrast minimization techniques, including ultra-low contrast angiography and zero-contrast PCI. Operator competence in such techniques is important to ensure that procedural challenges in patients with CKD, like vessel calcification, multivessel disease and complex anatomical subsets, are effectively addressed by PCI while minimizing the risk of CA-AKI.