Distal Artery Research Articles

Endovascular treatment of non-acute symptomatic anterior circulation distal medium artery disease

Objective: To examine the clinical effect of endovascular treatment for patients with non-acute symptomatic anterior circulation distal medium artery disease (aDMAD). Methods: This is a retrospective case series study.Retrospective analysis was conducted on the clinical data of 28 patients(29 lesions) with non-acute symptomatic aDMAD who underwent endovascular treatment at the Department of Neurosurgery,Beijing Hospital from May 2018 to March 2024. There were 15 males and 13 females,with an age of (63.4±10.2) years (range:36 to 82 years). The course of disease were more than 72 hours of all the patients. Confirmed by digital subtraction angiography,the lesion was located in distal anterior circulation and (or) medium arteries. Among them, 21 lesions (72.4%) located at middle cerebral artery and 8 lesions (27.6%) located at anterior cerebral artery.The median degree of stenosis before surgery (M(IQR)) was 90%(23%) (range:70% to 100%).After standardized drug treatment,there was still a transient ischemic attack or cerebral infarction in the vascular related area.The therapeutic effects and complications were analyzed,and the differences in the occurrence of target vessel restenosis under different interventional treatment methods were collected. Results: A total of 28 patients with 29 lesions underwent endovascular treatment, with a treatment success rate of 96.6% (28/29). The course of disease was 60(66)days (range:9 to 210 days). Simple plain balloon angioplasty was performed in 12 cases (13 lesions), drug-coated balloon (DCB) angioplasty in 7 cases (7 lesions), and stent placement in 9 cases (9 lesions). The median degree of stenosis after surgery was 20%(39%) (range:0 to 50%). There was no new cerebral infarctions,cerebral hemorrhages,or other complications during the perioperative period.Imaging follow-up was conducted on 23 lesions for 12(15)months(range:3 to 34 months),with 10 cases (43.5%) of restenosis,3 cases (13.0%) of symptomatic restenosis,and 4 cases (17.4%) of re-treatment. There were no new cases of cerebral hemorrhage or death during the follow-up process.The restenosis rate was 6/10 for the conventional balloon group,1/6 for the DCB group, and 3/7 for the stent group; the rate of symptomatic restenosis was 1/10 for the conventional balloon group,0/6 for the DCB group, and 2/7 for the stent group. Conclusions: Endovascular treatment for non-acute symptomatic aDMAD is relatively effective,but there is a high rate of restenosis postoperatively. DCB may reduce the occurrence of postoperative restenosis.

Molecular Pathophysiology of Chronic Thromboembolic Pulmonary Hypertension: A Clinical Update from a Basic Research Perspective

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but severe condition characterized by persistent obstruction and vascular remodeling in the pulmonary arteries following an acute pulmonary embolism (APE). Although APE is a significant risk factor, up to 25% of CTEPH cases occur without a history of APE or deep vein thrombosis, complicating the understanding of its pathogenesis. Herein, we carried out a narrative review discussing the mechanisms involved in CTEPH development, including fibrotic thrombus formation, pulmonary vascular remodeling, and abnormal angiogenesis, leading to elevated pulmonary vascular resistance and right heart failure. We also outlined how the disease’s pathophysiology reveals both proximal and distal pulmonary artery obstruction, contributing to the development of pulmonary hypertension. We depicted the risk factors predicting CTEPH, including thrombotic history, hemostatic disorders, and certain medical conditions. We finally looked at the molecular mechanisms behind the role of endothelial dysfunction, gene expression alterations, and inflammatory processes in CTEPH progression and detection. Despite these insights, there is still a need for improved diagnostic tools, biomarkers, and therapeutic strategies to enhance early detection and management of CTEPH, ultimately aiming to reduce diagnostic delay and improve patient outcomes.

Fractional flow reserve measurement using dynamic CT perfusion imaging in patients with coronary artery disease

Fractional flow reserve measurement using dynamic CT perfusion imaging in patients with coronary artery disease

SURGICAL CHALLENGES IN CLIPPING LARGE ANEURYSMS IN DISTAL ARTERIAL TERRITORIES

Background By distal arterial territories we mean the arteries located after the main bifurcations of the cerebral arteries. They can occur at multiple sites throughout the course of distal arteries, but most often are found after the bifurcation of the M1 segment of the middle cerebral artery. Methods A retrospective review of 18 consecutive patients with large aneurysms located in distal arterial territories, treated by surgical clipping between 2019-2023, was performed. We consider aneurysm larger than 10 mm in diameter as large aneurysm. The data of all our consecutive patients were searched to obtain patient characteristics, details of the aneurysm size and orientation, treatment details, complications and follow up. At admission, the clinical condition of all patients was classified according to the Hunt and Hess scale. Clinical outcome was graded according to the modified Rankin scale. The follow-up period varied widely from 6 to 54 months (mean 24 months). Results Surgical clipping was performed for all aneurysms; only in 2 cases the aneurysm was unruptured. Three patients presented with significant hematoma which required the evacuation of the clot. Most large aneurysms were located in M2 or M3 segments of the MCA (16 patients). Post-operative control angiography was performed in 11 patients (61%), from which we reported a full occlusion of the aneurysm in 10 patients (90%). No perioperative mortality was recorded. The outcome was graded mRankin 0–2 in 83% of the cases (15 patients) at the end of the first postoperative months, and 94.4% (17 patients) at six months follow-up. The most important improvement was recorded for patients graded mRankin 1-2 at the first month follow-up. Conclusions The large size of the aneurysm, the size of the neck, as well as the reduced diameter of the parent vessel, represent important trials for the neurosurgeon in the correct clipping of the aneurysm. In some cases, sectioning of the aneurysm dome was necessary for successful clipping.

Abstract 4146316: Venous Remodeling and Occlusion Accompany Arterial Pathology in Patients with Chronic Limb Threatening Ischemia

Background: Chronic limb threatening ischemia (CLTI) is defined as the presence of peripheral artery disease (PAD) in combination with rest pain or tissue loss and represents advanced arterial occlusive disease. Little is known about associated venous pathology as prior pathologic reports were limited to evaluation of maximally diseased arterial lesions. Objectives: To characterize arterial and venous histopathology in patients with CLTI. Methods: Tissue containing peripheral arteries and veins from the femoropopliteal to distal tibial arteries was harvested from 10 patients who underwent amputation for CLTI (Fig 1). Vessels were sectioned at 0.5 cm intervals, and histopathologic features were catalogued across 535 arterial and 493 venous sections. Results: Consistent with PAD, atherosclerotic lesions were more prevalent in proximal than distal arteries; 81.8% (27/33) femoropopliteal sections compared to 26.6% (134/502) of tibial sections. Severe stenosis (>90%) was noted in 21.9% (117) of sections and was associated with atherosclerosis (pathological intimal thickening, fibroatheroma, fibrocalcific or fibro-osseous lesions) in 10.3% (12), luminal thrombi in 68.4% (80), or both in 21.4% (25) of arterial sections. In all patients and in 99.0% (488/493) of venous sections, irrespective of the degree of arterial luminal stenosis, adjacent large (≥1000µm) and small diameter veins revealed marked thickening of the vessel wall comprised of fibrosis and smooth muscle hyperplasia (Fig 2). While large veins retained luminal patency, small veins exhibited severe luminal stenosis or obliteration. Venous thrombosis was uncommon, occurring in 3.0% (15/493) of sections. Conclusions: Venous remodeling with stenosis and occlusion is highly prevalent and coincides with arterial disease pathology in patients with CLTI. This novel finding of previously underappreciated and severely altered venous pathology suggests a possible additional mechanism for limb ischemia in CLTI.

Abstract 4136511: Targeting ATP Citrate Lyase: A Novel Therapeutic Strategy for Vascular Remodeling in Pulmonary Hypertension

Introduction: Pulmonary arterial hypertension (PAH) is a vascular remodeling disease characterized by a progressive obliteration of distal pulmonary arteries (PA), which is driven by a cancer-like pro-proliferative phenotype of smooth muscle cells (SMCs). A metabolic shift towards glycolysis and changes in the epigenetic landscape contribute to this abnormal phenotype. ATP Citrate Lyase (ACLY) is an enzyme that plays a role in promoting the Warburg effect, lipid synthesis, and chromatin remodeling in cancer. However, its role in PAH remains unknown. We hypothesized that ACLY is upregulated in PAH and supports the abnormal phenotype of PAH-PASMCs . Methods/Results: To investigate this hypothesis, we measured ACLY expression in human distal pulmonary arteries and isolated PASMCs from PAH patients (immunoblot/Immunofluorescence). We found increased expression and activation of ACLY in PAH-PASMCs, with preferential localization in the nucleus. Inhibition of ACLY using BMS-303141 or siACLY decreased PAH-PASMCs proliferation (Ki67/MCM2, PLK1, PCNA) and survival (Annexin V/SURVIVIN). ACLY inhibition also reduced glycolysis markers and increased mitochondrial respiration. Additionally, the inhibition of ACLY lowered cholesterol levels and lipid droplet accumulation in PAH-PASMCs. Further analysis showed that ACLY promotes nuclear acetyl-CoA production, leading to acetylation of specific histone proteins and GCN5-mediated transcriptional activation of genes involved in cell cycle progression. The transcription factor FOXM1 appeared to mediate this genetic signature. In vivo , pharmacological inhibition of ACLY using BMS-303141 significantly improved pulmonary vascular remodeling (Elastica Van Gieson staining, EVG) and right ventricular function (RVSP, mPAP, TAPSE, S-Wave, SV by echocardiography and right heart catheterization) in Su/Hx-challenged rats with established PAH. SMC-specific Acly K.O mice were protected against Su/Hx-induced PAH. Consistently, tamoxifen-induced SMC-specific Acly deletion improved hemodynamics parameters in Su/Hx mice. These therapeutic effects were associated with a reduced acetylation of H3K27 and H3K9 (IF). Ex vivo , inhibition of ACLY attenuated vascular remodeling (EVG) in human precision cut lung slices exposed to a growth factor cocktail. Conclusion: Our study reveals that ACLY plays a critical role in vascular remodeling in PAH and its pharmacological inhibition may represent a novel and attractive avenue as therapeutic treatment.

Sequential Hemodynamic Analysis of Ruptured Posterior Communicating Artery Aneurysms Treated With Coil Embolization and Delayed Flow Diversion.

Computational fluid dynamics has advanced our knowledge of the pathogenesis of intracranial aneurysms and the dynamic changes observed after treatment. Herein, we analyze hemodynamic changes throughout the intervention stages for ruptured posterior communicating artery (PComA) aneurysms, treated with acute coiling and delayed flow diversion (FD). We performed a retrospective analysis of ruptured PComA aneurysms treated with the acute coiling and delayed FD strategy between June 2013 to November 2022, using 3-dimensional reconstructions of digital subtraction angiographies. Hemodynamic simulations using ANSYS® calculated aneurysmal and adjacent arteries' wall shear stress (WSS), aneurysmal low shear areas (LSA), and mean velocities in the distal arteries. Six of the 22 patients were selected for computational fluid dynamics analysis, including 4 females and 2 males with a median age of 60 years. The average aneurysm volume was 984.12 mm3, with an average surface area of 386.11 mm2; LSA was 22.90%, and the average WSS was 3.39 Pa. The 2 largest aneurysms also had the highest LSA values. After coiling, there was a reduction in the aneurysmal volume (-78.42%) and the average surface area (-55.28%), and aneurysmal WSS increased to 6.10 Pa (+79.90%). WSS values for the middle cerebral artery (MCA) increased to 10.76 Pa, while anterior cerebral artery (ACA) increased to 7.51 Pa. Complete occlusion was achieved with delayed FD at a median follow-up of 19.7 months. After FD, average WSS increased to 14.94 Pa for the MCA (+70.64%) and to 10.82 Pa for the ACA (+30.10%). The mean MCA velocity increased to 43.04 cm/s (+36.85%), and 3 cases showed an increase in ACA velocities. LSA may have triggered rupture for the PComA aneurysms analyzed. After coiling, average WSS increased in the aneurysm wall and downstream vessels in the majority of cases analyzed. Delayed FD caused hemodynamic disturbances distal to deployment, reflected in the sequential increase in the WSS and velocities in both the ACA and MCA.

Abstract 4138674: Long-acting CRF2 receptor agonist, COR-1389, improves cardiopulmonary function in the rat model of Sugen plus hypoxia-induced pulmonary hypertension and right heart failure

Introduction: Urocortin-2 (UCN-2), a peptide which is part of the corticotropin-releasing factor (CRF) family, functions as an autocrine and paracrine factor, exerting its effects on cardiac and pulmonary function through agonism of CRF2 receptors. Although acute administration of UCN-2 has shown promise by improving heart and lung function in conditions like heart failure (HF) and pulmonary hypertension (PH), its limited stability impedes its chronic therapeutic use. Hypothesis: In this study, we explored the efficacy of COR-1389, a potent, selective and long-acting CRF2 agonist peptide, in the Sugen 5416 (VEGFR2 inhibitor, Su) combined with hypoxia (Hx) rat model of PH and right heart failure (RHF). Methods: To this aim, male adult Sprague Dawley rats were divided into three groups: Control rats (normoxia) were compared with rats injected subcutaneously with 20 mg/kg Sugen 5416 and exposed to chronic hypoxia for 3 weeks, followed by 2 weeks of normoxia. At 5 weeks, control rats and one SuHx group received subcutaneously vehicle (control and SuHx), while the third group received COR-1389 at a dose of 100 μg/kg every 4 days subcutaneously for 3 weeks (SuHx + COR-1389). At 8 weeks, cardiac and pulmonary hemodynamic functions of the three groups were evaluated using echocardiography and right heart catheterization, and heart and lung tissue were evaluated by histology and immunohistochemistry. Results: Compared to controls (n=10), SuHx exhibited increased mean pulmonary arterial pressure (mPAP), right ventricle (RV) hypertrophy (Fulton Index/body weight), muscularization of distal pulmonary arteries, RV fibrosis and cardiomyocyte hypertrophy, alongside reduced RV systolic function (Tricuspid Annular Plane Systolic Excursion, TAPSE) and cardiac output (CO). Conversely, compared to the SuHx + vehicle group (n=11), curative treatment with COR-1389 for 3 weeks in SuHx rats (n=13) led to enhanced RV systolic function (TAPSE) and CO, together with reductions in mPAP, RV hypertrophy, muscularization of pulmonary arteries, RV fibrosis and cardiomyocyte hypertrophy. Systolic blood pressure remained unchanged across all groups. Conclusion: These findings indicate that COR-1389 ameliorates the deteriorating cardiopulmonary parameters observed in the SuHx model and represents a promising approach for the treatment of PH and RHF.

Abstract 4124604: Finding the Right Course: Unknown Source of Hemorrhage Following Endocardial-Epicardial Ablation for Ventricular Tachycardia

Background: Epicardial radiofrequency ablation via percutaneous access is a common technique for ventricular tachycardia (VT) ablation. Rapid identification of and response to complications can reduce morbidity and mortality. Objective: We present a case of epicardial VT ablation complicated by a distal left internal mammary artery (LIMA) transection secondary to subxiphoid sheath insertion. Report: A 66-year-old man with hypertrophic cardiomyopathy was referred for endo-epicardial ablation of recurrent VT. Pericardial access was obtained using coronary vein exit and carbon dioxide insufflation technique. An 8.5F sheath was advanced over an indwelling pericardial wire, and ablation was performed. Following ablation, 400cc of blood was aspirated from the pericardial space after replacing the 8.5F sheath with a standard pericardial drain. Urgent angiography revealed intact coronary arteries, coronary sinus (CS) and LIMA. The 8.5F sheath was re-introduced and bleeding ceased. CT scan revealed no myocardial or great vessel damage. Mild pericardial drainage continued overnight. The next day, IR angiography demonstrated transection of the distal LIMA from the indwelling sheath. The patient underwent placement of a back-up pericardial drain, followed by coil embolization of the injured artery without complication (Fig). Conclusion: This case highlights the importance of maintaining a broad differential during apparent complications of epicardial access and the importance of staying close to midline for epicardial puncture given anatomic variability. The differential for acute blood loss and pericardial effusion following epicardial ablation includes 1) coronary artery damage, 2) CS damage, 3) extracardiac vascular injury, and 4) right ventricular injury. When extracardiac vascular injury is suspected, multidisciplinary collaboration is essential.

Abstract 4115642: Resonance Sonomanometry in an Early Prototype Device Effectively Measures Continuous, Noninvasive Blood Pressure

Background: Nearly half of American adults have hypertension; however, reliable, continuous, noninvasive blood pressure (BP) measurement (cNIBP) for inpatient and outpatient use is not currently available. This study evaluated a new method for cNIBP measurement called resonance sonomanometry (RSM). RSM derives blood pressure using first-principles physics, is applicable to any artery, and requires no calibration, blood vessel deformation, or dependence on demographic inputs. Methods: A prospective, observational feasibility study was undertaken to compare carotid artery BP measurements with a prototype ultrasound-based cNIBP device incorporating RSM, to arterial catheter BP measurements in the radial arteries of 60 test subjects. Catheter measurements were obtained from a distal peripheral artery (radial), oscillometric cuff from the brachial artery, and RSM was obtained from a central artery (carotid). This study was the first-in-human study for the RSM method in comparison to arterial catheters. Results: RSM-induced arterial resonance was observed in all tested subjects. For each of the subjects, the arterial resonant frequency increased with increasing BP during systole, and decreased with diastole (consistent with the cardiac cycle), as predicted by the physical model. RSM-derived BP traces were qualitatively similar to catheter data, exhibiting features such as the dicrotic notch. The RSM method yielded similar diastolic BP (DBP), but lower systolic BP (SBP) compared to the arterial catheter, likely due to expected peripheral pulse amplification. RSM DBP was not significantly different from the catheter (+1.5mmHg, p = 0.187), while BP cuff DBP was significantly different from the catheter (−4.3mmHg, p=0.002). There were significant differences in the catheter to RSM SBP (34.1 mmHg, p < 0.01), consistent with the aforementioned expectations from a central-versus-peripheral continuous pressure measurement. Conclusions: RSM is a novel BP measurement technique that could enable cNIBP measurements with accuracy required in hospitals. While the data are promising, significant future work remains. The study was meant to test the RSM method, not the device or form factor. Consequently, the form factor will need to be improved prior to clinical use. The prototype was designed for manual operation; thus, future work will also be needed to enhance the ability of the device to autonomously locate and track the artery for ease of use.

Prognosis of Proximal and Distal Vertebrobasilar Artery Stent Placement.

Vertebrobasilar artery stent placement (VBS) is potentially effective in preventing recurrent posterior circulation strokes; however, the incidences of in-stent restenosis and stented-territory ischemic events based on the location of stent placement have rarely been investigated. We aimed to investigate the characteristics and prognosis of VBS between intracranial and extracranial. This study was single-center retrospective cohort study, and we obtained medical records of patients who underwent VBS. We compared clinical and periprocedural factors between extracranial and intracranial VBS. The primary outcomes included the incidence of in-stent restenosis (>50% reduction in lumen diameter) and stented-territory ischemic events. We compared the incidence of in-stent restenosis and stented-territory ischemic events by using Kaplan-Meier curves. Of the 105 patients, 41 (39.0%) underwent extracranial VBS, and 64 (61.0%) underwent intracranial VBS. During the follow-up, the incidences of in-stent restenosis and stented-territory ischemic events were 15.2% and 22.9%, respectively. The procedure time was longer (47.7 ± 19.5 minutes versus 74.5 ± 35.2 minutes, P < .001), and the rate of residual stenosis (≥30%) just after VBS was higher (2 [4.9%] versus 24 [37.5%], P < .001) in intracranial VBS than in extracranial VBS. Also, the incidences of in-stent restenosis were significantly higher in intracranial VBS than in extracranial VBS (4.9% versus 21.9%, P = .037). On the other hand, the incidences of stented-territory ischemic events (7.3% versus 32.8%, P < .001) were significantly higher in intracranial VBS than in extracranial VBS. The main mechanisms of stroke were artery-to-artery embolism (2 [66.7%]) in extracranial VBS, and artery-to-artery embolism (9 [42.9%]) and branch atheromatous disease (8 [38.1%]) in intracranial VBS. The Kaplan-Meier curve demonstrated a higher incidence of in-stent restenosis and stented-territory ischemic events in intracranial VBS than in extracranial VBS (P = .008 and P = .002, respectively). During the follow-up, the incidence of in-stent restenosis and stented-territory ischemic events was higher in patients with intracranial VBS than in those with extracranial VBS. The higher rates of postprocedural residual stenosis might have contributed to the increased risk of in-stent restenosis. Furthermore, prolonged procedure time and additional stroke mechanism, including branch atheromatous disease, might be associated with a higher risk of stented-territory ischemic events in intracranial VBS.

Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use?

Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era. This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis. Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction. These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.

OA27 A Thrombus Tale

Abstract Introduction Non catheter related arterial thrombosis is very rare in children. Our patient had a peripheral arterial thrombus with no risk factors apart from a background of recurrent Henoch-Schönlein Purpura (HSP). He had no history of trauma. Thrombosis as a complication of HSP is extremely rare with onlyeight case reports so far in children and among those eight, there is only one resembling our case with an arterial thrombus. We considered other causes of thrombosis and screened our patient for thrombophilia, infection and malignancy. Case description Our patient, a 12-year-old boy with a background of recurrent HSP for the last two years, presented with a rash on the left 2nd toe followed by blackish discolouration of the distal part of the same toe, a few days later. His initial presentation with purpuric rash, arthralgia, and abdominal pain was diagnosed as HSP and he required no intervention required for this. He continued to have regular flares of his HSP every six weeks, and these were self-limiting. His last flare was in February 2024. In April 2024, his feet appeared dusky and mottled. He presented to his local hospital with a rash on the tip of his left 2nd toe which turned gangrenous. He was otherwise systemically well. He was initially treated with antibiotics and acyclovir as a swab from the lesions grew staphylococcus aureus and the rash was bullous initially. He was referred to our tertiary rheumatology and haematology teams at Nottingham due to worsening ischemia and an absent left dorsalis pedis pulse. His examination revealed normal blood pressure, mottled, dusky lower legs, warm left foot with a faint petechial rash near left malleolus, absent left Dorsalis pedis pulse and an ischemic tip of left 2nd toe. Bilateral femoral and upper limb pulses were well felt. His respiratory, cardiovascular, abdomen &amp; musculoskeletal examination were normal apart from an antalgic gait. His clotting and thrombophilia screen including antiphospholipid screen was normal. His D dimer was raised at 1894ug/l. A duplex scan of his left leg showed occlusions in the distal anterior and posterior tibial artery as well as in the dorsalis pedis artery with no emboli. His inflammatory markers and autoantibodies were normal. Infection screen including mycoplasma, CMV, EBV and ASOT titres were all negative. Echo was normal. A skin biopsy from the toe revealed IgA vasculitis. Discussion We had a multidisciplinary team (MDT) discussion with haematology, vascular surgery and dermatology. As per the MDT discussion, he was given a pulse of intravenous methylprednisolone after careful consideration weighing the risk versus benefit of steroids adding to the pro thrombotic state versus active vasculitis causing narrowing of the arteries. He was also commenced on Aspirin at 1 mg/kg/day. There was marked improvement in his symptoms with improvement in the discolouration and pain, his d-dimer reduced, and he was able to mobilise comfortably. We felt that active vasculitis could be causing the vascular event. As immunology screen was negative and the skin biopsy was confirmatory of HSP. There was no thrombus specifically mentioned in the duplex but with D-dimer being raised it was a reasonable assumption was that there was a thrombus occluding the peripheral arteries. As his HSP was recurring quite frequently and was bothersome, as well as the thought that the recurrences might contribute to further vascular events and complications, we started our patient on Azathioprine. We have also sent genetic tests and awaiting a catheter angiogram to complete the investigation process. Key learning points • Consider vasculitis as one of the differentials in a child with unexplained venous or arterial thrombosis. • In a child with recurrent HSP, keep an open mind for rare complications that may occur. • Recurrent HSP in an older child may need immunosuppression. • Treatment considerations in a case with vasculitis with a thrombus has to be in close connection with haematology to decide on anticoagulation and its implications on the young person and their lifestyle. • Should there be any other investigations done or alternative diagnosis though of at this point?

Anisodine hydrobromide injection promotes neural remodeling and recovery after ischemic stroke in mice.

Anisodine hydrobromide injection has shown promising therapeutic effects in treating patients with cerebral infarction, improving recovery of neurological function during the post-cerebral infarction period. However, the effects of anisodine hydrobromide on brain recovery and neuroplasticity are unclear. This study explores the therapeutic effects and underlying mechanisms of anisodine hydrobromide in mice experiencing the chronic phase of an ischemia stroke. The electrocautery method established a distal middle cerebral artery occlusion (MCAO) model in healthy male C57BL/6 mice. Neurological deficits were evaluated using Golgi and immunofluorescence staining to measure the effects of anisodine hydrobromide on neural proliferation, migration and remodeling. DAPT (dipeptidic γ-secretase-specific inhibitor) was employed to explore the involvement of the Notch signaling pathway post-anisodine hydrobromide treatment. Compared to the control and MCAO groups, mice treated with anisodine hydrobromide showed improved post-stroke neurological function, increased neurite intersections, and dendritic spine density in the peri-infarct cortex. Anisodine hydrobromide also promoted neural cell regeneration which is dendritic and axonal structures and synaptic vesicle protein restructuring. Gap43, NGF, Notch1, and Hes1 protein level increased significantly in the ANI group provided inhibitor DAPT was absent. Anisodine hydrobromide can promote neurological function, neurotrophic factors, and neuroplasticity. Notch signaling pathways also impact the effects of anisodine hydrobromide on neural plasticity in ischemia stroke.

Impact of the thin-walled sheath on the distal radial artery occlusion: a randomized trial

Abstract Background Distal transradial access (dTRA) has been increasingly accepted as an alternative to the transradial access (TRA) for coronary angiography (CAG) and/or percutaneous coronary intervention (PCI). Although the dTRA has been significantly associated with better patient comfort, shorter haemostasis time, and fewer vascular access-related complications, such as haematoma and proximal radial artery occlusion (pRAO), it has also been associated with an increased risk of distal radial artery occlusion (dRAO). Purpose The aim of the present study was to investigate whether the 6-Fr thin-walled sheath was superior to the conventional radial sheath with respect to the incidence of distal radial artery occlusion (dRAO) at 24 h after CAG and/or PCI via dTRA. Methods A prospective, single-centre trial of patients who were randomized to undergo CAG and/or PCI with either a 6-Fr thin-walled sheath or a 6-Fr conventional sheath. The primary endpoint was the incidence of dRAO at 24 h postoperatively, as evaluated by Doppler ultrasound. The second endpoints included the puncture success rate, puncture time, the incidence of pRAO, pain during the sheath placement, and other vascular-associated complications. Results A total of 620 patients were included in the study. The mean age of the patients was 66.6± 9.7 years (median age 69.0 years [interquartile range 60.0- 74.0 years]), and 66.3% were men. The baseline patient and procedural characteristics were similar between the two groups. For the primary endpoint, the incidence of dRAO at 24 h after the procedure was 1.0% (3/314) in the thin-walled sheath group and 3.6% (11/306) in the conventional sheath group (RR= 0.266, 95%CI= 0.075-0.943, P= 0.027) according to the intention-to-treat (ITT) analysis. For secondary endpoints, the incidence of pRAO was 0.3% (1/314) in the thin-walled sheath group and 2.3% (7/306) in the conventional sheath group (P= 0.029). No significant difference was observed between the thin-walled sheath and the conventional sheath groups regarding the puncture success rate (92.4% vs. 92.5%, P= 0.952). The severity of pain experienced during the sheath placement was similar between the two groups (VAS 2 vs. 2 P=0.426). Other secondary endpoints, including procedural outcomes and other puncture-related outcomes and access-related complications, were not significantly different between the two groups. Conclusion A thin-walled sheath can reduce the incidence of early-term dRAO in patients who underwent CAG and/or PCI via the dTRA.The primary endpoint of the trial

Efficacy comparison of transcatheter aorticorenal ganglion ablation and renal denervation in a hypertensive canine model

Abstract Background Transcatheter renal sympathetic denervation (RDN) has been proposed to be an adjunctive treatment in uncontrolled hypertension. However, non-responders to RDN were not rare. Considering the lack of a procedure endpoint and the limitation of anatomic-based ablation strategy, incomplete or futile denervation may contribute to non-responsiveness. Aorticorenal ganglion (ARG) is a purely sympathetic ganglion that projects to the proximal and distal renal artery, forming the peri-arterial nerve network. Ablation of this ganglion results in significant renal denervation. However, it remains unknown whether ARG ablation has a superior effect in lowering blood pressure (BP) compared to RDN. Purpose The aim of the study was to determine whether ARG ablation improved the BP-lowering effect compared to RDN in a hypertensive canine model. Methods A total of 21 male Chinese Kunming dogs were included and randomized into three groups: ARG ablation group (n=7), RDN group (n=7) and control group (n=7). In the ARG ablation group, anatomically based high-frequency stimulation (HFS) was performed in the aorta and inferior vena cava (IVC) under the guidance of 3D anatomical construction (Figure 1A). ARG ablation sites were identified by HFS-induced BP elevation response (&amp;gt;10mmHg) and renal artery vasoconstriction (Figure 1B). In the RDN group, HFS-guided ablation was conducted at the positive site (BP elevation response &amp;gt;5mmHg) from the distal to proximal renal artery. Endpoint of the procedure was defined as the elimination or attenuation of BP elevation induced by HFS. BP was assessed at baseline and 4 weeks after the procedure. Results The left ARG ablations were performed at the inferior aspect of superior mesenteric artery (4/7), the abdominal aorta (2/7) and the proximal renal artery (1/7), while the right ARG ablations were performed at the posterior aspect of the IVC (6/7) and the ostium of the left renal vein (1/7). The gross anatomy of bilateral ARGs was shown in Figure 1C. The hemodynamic response to ARG stimulation was significantly greater than that of renal artery stimulation (40.0±13.4 vs 13.3±3.7 mmHg, Figure 2A, B); meanwhile, ARG ablation is more effective in blunting the BP elevation response compared to RDN (30.7±11.7 vs 9.6±2.6, P=0.001, Figure 2A, C). With a 4-week follow-up, ARG ablation demonstrated a greater systolic BP-lowering effect than RDN (-29.6±12.0 vs -15.3±6.9 mmHg, P=0.018, Figure 2D). No complications were found during the procedure or follow-up. Conclusion Our study suggests that ARG ablation could lead to a more efficient BP-lowering effect compared to RDN, which provides a novel paradigm for autonomic modulation in the treatment of hypertension.Figure 1Figure 2

The Neck-Crossing Technique Using the Low-Profile Distal Access Catheter in Flow Diverter Placement for Dissecting Posterior Cerebral Artery Aneurysm: A Case Report

AbstractWe report a case in which a novel distal access catheter proved successful in the placement of a flow diverter for a challenging distal cerebral artery lesion. We discuss the advantages and pitfalls of this technique and considerations for its use. A 74-year-old female presented with intermittent headaches, and was diagnosed with a dissecting aneurysm at the proximal right posterior cerebral artery with a sharp bleb, measuring 9.8 mm in diameter. Given the complex vascular anatomy, stent-assisted coil embolization was initially considered but deemed high risk for dual catheter for jailing technique with 6-Fr size guiding catheter due to the tortuosity and stenosis of the parent vessel. Therefore, we opted for flow diverter treatment, which presented its challenges during delivery. By employing a low-profile distal access catheter, Phenom Plus (outer diameter: 4.2-Fr. inner diameter: 1.13 mm; Medtronic, Minneapolis, Minnesota, United States), with a minimal ledge between it and the delivery catheter, Phenom 27 (outer diameter: 2.8-Fr, 0.91 mm; Medtronic), we successfully crossed the neck of the aneurysm with Phenom Plus and placed the flow diverter. While acknowledging potential risks, this case demonstrates the value of the neck-crossing technique using a low-profile distal access catheter as an alternative option for treating challenging peripheral artery aneurysms with flow diverters. This technique offers promise in specific situations where conventional methods pose challenges.

Intraoperative contrast-enhanced cone beam CT allows visualization of the ‘dark side’ of the clot and improves mechanical thrombectomy performance

BackgroundVisualization of the clot is key to the endovascular treatment of ischemic stroke, but identification of the distal part of the clot and distal arteries during mechanical thrombectomy (MT) remains...

Intercoronary communication: a rare coronary anomaly.

Intercoronary communication also known as coronary arcade or coronary cascade is a rare coronary artery anomaly with an incidence of only 0.002% in patients undergoing angiography. This case emphasizes the importance of recognizing this rare anomaly and highlights its clinical significance. We report a case of intercoronary communication in a 56-year-old female who presented with acute chest pain and ST-segment depression in the lateral leads. High-sensitivity troponin-T was elevated and transthoracic echocardiography revealed normal left ventricular function with no regional wall motion abnormality. Hence, the diagnosis of acute coronary syndrome - non-st-elevation myocardial infarction was considered. Coronary angiography revealed a 95% focal stenosis in the major obtuse marginal artery (OM). The right coronary artery (RCA) angiogram revealed a single abnormal channel communicating the right posterolateral branch (PLV) and the distal left circumflex artery (LCX) with retrograde opacification of the proximal LCX, left main coronary artery (LMCA) and left aortic sinus. After she underwent revascularization with the drug-eluting stent to the OM. CT-coronary angiography confirmed the presence of intercoronary communication (ICC) between the right posterolateral branch and the distal LCX artery. No active intervention was done for the ICC. Over a year of follow-up, our patient remained asymptomatic. Angiographically and anatomically, collaterals and intercoronary communications should be differentiated. Obstructive coronary artery disease leads to the development of collaterals, which are typically less than 1mm in diameter, multiple and tortuous. However, ICC tends to be single and straight, usually seen without obstructive disease with unidirectional or bidirectional flow. Histologically, collaterals consist of endothelium supported by poorly organized collagen, muscle and elastic fibers. Meanwhile, ICCs resemble epicardial vessels in that they have a well-defined muscular layer. This case emphasizes the importance of recognizing this rare coronary anomaly and distinguishing it from collaterals to help in accurate diagnosis. Although they can provide an efficient blood supply to the jeopardized myocardium and can aid as a channel during coronary interventions, they can also cause myocardial ischemia by coronary steal.

Feasibility of transcranial Doppler to evaluate vasculopathy among survivors of childhood brain tumors exposed to cranial radiation therapy.

The ability of transcranial Doppler (TCD) to detect asymptomatic cerebrovascular disease among childhood brain tumor survivors following exposure to cranial radiation therapy has not been established. Survivors of childhood brain tumors, more than 3years since diagnosis and exposed to greater than 30Gy cranial radiation, underwent a history and physical exam, laboratory biomarkers of cerebrovascular disease (cholesterol, high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), high-sensitivity CRP, hemoglobin A1C, apoprotein A, and apoprotein B), and a TCD evaluation of their cerebral arteries. In all 165 cerebral arteries from 13 patients (medulloblastoma=10; germ cell tumor=3; females=5; mean age at diagnosis=8.0years; mean age at time of study=20.9years) were examined. Twenty-eight of 165 (17%) were considered abnormal by pre-specified criteria. Total 114 cerebral arteries from 13 patients were assessed for greater than 50% stenosis velocities. Arteries most likely to be considered abnormal included the distal bilateral vertebral arteries (right 38%, left 30%), basilar artery 30%, bilateral siphon internal carotid arteries (right 30%, left 23%), bilateral middle cerebral arteries (23% bilaterally), and bilateral anterior cerebral arteries (7% bilaterally). Two vessels had mean flow velocities consistent with 50% stenosis (1.8%). No vessels were found to have greater than 80% stenosis. TCD may be a useful and practical tool to examine asymptomatic cerebrovascular disease among childhood brain tumor survivors after exposure to cranial radiation therapy. Posterior circulation vessels appear to have the highest burden of disease in this group of brain tumor survivors, a majority of whom had medulloblastoma.