Distal Embolization Research Articles

Lower extremity pseudoaneurysms and their interventional radiological management: a pictorial review.

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

Carotid artery stenting using a 7 French Optimo balloon guide catheter combined with a distal filter.

Carotid artery stenting (CAS) by proximal occlusion of the common carotid artery (CCA) using a balloon guide catheter (BGC) is a simple proximal protection method to prevent distal embolism, however, it requires at least an 8 French (F) system. A 7 F Optimo BGC is the smallest BGC with an inner lumen diameter of 0.071 inches, and which permits the passage of a 5 F carotid stent. We retrospectively investigated the clinical results and the safety of CAS by using a 7 F Optimo BGC combined with a distal filter. One-hundred carotid arterial stenosis patients were treated with CAS using combined protection of a 7 F Optimo BGC and a distal filter. The BGC was navigated from the femoral and radial arteries in 85 and 15 patients, respectively. The 7 F Optimo BGC was successfully navigated into the CCA in all patients, and the technical success rate of CAS was 100%. Major adverse events of any death, stroke, or myocardial infarction within 30-day after the procedure were observed in one (1%). Post-procedural diffusion-weighted magnetic resonance imaging revealed high signals in 21% of the patients, all of whom were asymptomatic. The 7 F Optimo is the smallest BGC to achieve CAS using a proximal protection system. The combined use of a 7 F Optimo BGC and a distal filter is effective for navigating the BGC and distal embolic protection.

Comparative Outcomes of Interventions for Femoropopliteal Chronic Total Occlusion Versus Non-Chronic Total Occlusion Lesions From the Multicenter XLPAD Registry.

Background Endovascular intervention of femoropopliteal chronic total occlusions (CTOs) is technically more complex. However, there is lack of comparative analysis between CTO and non-CTO femoropopliteal interventions. Methods and Results We report procedural details and outcomes of patients treated for femoropopliteal CTO and non-CTO lesions in the XLPAD (Excellence in Peripheral Artery Disease) registry (NCT01904851) between 2006 and 2019. Primary outcomes were procedural success and 1-year major adverse limb events, a composite of all-cause death, target limb revascularization, or major amputation. Analysis included 2895 patients (CTO: n=1516 patients; non-CTO: n=1379 patients) with 3658 lesions (CTO: n=1998 lesions; non-CTO: n=1660 lesions). Conventional balloon angioplasty (20.86% versus 33.48%, P<0.001) or drug-coated balloon angioplasty (1.26% versus 2.93%, P<0.001) were more frequent in the non-CTO group, whereas bare-metal stents (28.09% versus 20.22%, P<0.001) or covered stents (4.08% versus 1.83%, P<0.001) were more frequent in the CTO group. Debulking procedures were more commonly performed in the non-CTO group (41.44% versus 53.13%, P<0.001), despite a similar degree of calcification between the 2 groups. Procedural success was higher in the non-CTO group (90.12% versus 96.79%, P<0.001). Procedural complications were higher in the CTO group (7.21% versus 4.66%, P=0.002), mainly due to excess distal embolization (1.5% versus 0.6%, P=0.015). Adjusted 1-year major adverse limb events were higher in the CTO group (22.47% versus 18.77%, P=0.019), driven mainly by target limb revascularization (19.00% versus 15.34%, P=0.013). Conclusions Procedural success is lower for endovascular treatment of femoropopliteal CTO compared with non-CTO lesions. CTO lesions are associated with higher rates of periprocedural complications and reinterventions after 1 year.

Needle fenestration of popliteal artery covered stent graft to salvage inadvertent stent misdeployment

Endovascular methods have transformed treatment of lower extremity peripheral arterial disease but can still present technical challenges. We report the case of a 69-year-old man with rest pain who underwent superficial femoral artery recanalization with covered stents. During completion angiography, the distal stent was discovered to have been misdeployed into an anterior geniculate branch overlying the behind-the-knee popliteal artery. Subsequently, an endovascular reentry device was used to fenestrate the stent posteriorly to enter the lumen of the popliteal artery. Cutting balloons were used to enlarge the fenestration in the stent fabric, with placement of an additional 6× 50-mm covered stent bridging from the popliteal artery into the fenestrated misdeployed covered stent. Completion angiography demonstrated no evidence of distal embolization and patent two-vessel runoff. The patient had an uncomplicated recovery and at 2 years of follow-up remained asymptomatic with documented popliteal stent patency.

Single-center Experience with JETi Hydrodynamic Thrombectomy System for Arterial Occlusions of the Extremities

Percutaneous aspiration thrombectomy is a new modality for treating patients with acute limb ischemia (ALI). We report our experience and outcomes using the JETi hydrodynamic thrombectomy system (Abbott Vascular, Abbott Park, IL) to treat acute arterial occlusions of the extremities. This a single-center retrospective review of patients with acute occlusions of peripheral arteries or grafts treated with the JETi from September 2020 to December 2022. JETi was used either as primary intervention or as an adjunct to treat distal vessel thrombus after proximal open thrombectomy. The primary outcome for success was defined as >50% luminal opening post-intervention. Indications, limb salvage, and major adverse events were reviewed. The JETi was used in 59 procedures (56 acute lower extremity ischemia [ALEI], three acute upper extremity ischemia [AUEI]) to treat 124 arteries in 57 patients. Mean age was 62 years (range, 29-95 years), and 49% were male. The mean duration of symptoms before hospitalization was 4.8 days (range, 0 hours to 21 days) for ALEI. The primary outcome was achieved in 102 of 124 (83%) arteries by JETi alone. Additional modalities including open thrombectomy, angioplasty, and stenting were used in five arteries to achieve the primary outcome. Seventeen arteries failed to achieve primary outcome with JETi with or without an adjunct. Reasons for failure were attributed to small artery size and chronic nature of the clot. Complete luminal patency with JETi thrombectomy alone was achieved in 52 arteries (42%). Additionally, 55 arteries underwent additional procedures (angioplasty and stenting) to restore complete luminal patency, which was successfully achieved in 49 vessels (89%) (Table). Average estimated blood loss in JETi-only procedures was 335 mL and 384 mL in those who underwent adjunctive procedures to achieve the primary outcome. Complications included distal embolization (5), access site hematoma (3), and acute kidney injury (AKI) (8). Two AKIs were attributed to rhabdomyolysis with creatine phosphokinas >10,000 IU/L; none of whom needed dialysis. There was a single 30-day mortality. Six patients required major limb amputations within 30 days – two after unsuccessful recanalization and one each for severe gangrene despite restoration of in-line flow, reocclusion of a distal bypass graft, recurrent ALEI postoperative day 15 with non-viable muscle on exploration, and a delayed compartment syndrome diagnosis. Success of the JETi to remove the targeted clot was 83%. The JETi system is an efficacious and safe tool for use in the treatment of acute artery occlusion.TableJETi thromboembolectomy technical success outcomes by vessel/graft intervened uponName of artery/graftNo. of each vesselJETi >50%JETi + adjunctive >50%JETi 100%JETI + adjunctive 100%JETI 4- adjunctive 50% <X <100%Aorta000000Common iliac660150External iliac642150Common femoral440310Superficial femoralI8170313IProfunda iroris220100Popliteal20I80882Anterior tibial16111840Tibioperoneal trunk13110821Peroneal artery13100910Posterior tibial1382631Femoral-anterior tibial bypass330030Femoral-popliteal bypass55004lAxillary femoral bvpass110100Axillary200000Subclavian110100Brachial110100124101552496 Open table in a new tab

P12 COMPLEX LEAD EXTRACTION: A PERCUTANEOUS MULTIDISCIPLINARY APPROACH

Abstract Introduction The infection represents one of the most serious complications of implantable cardiac systems (ICDs and PMs) and is associated with increased mortality and significant expenditure of financial resources. The incidence, which ranges from 0.6 to 3.4%, depends by the patient characteristics, the type of implanted system, and from other factors related to the procedure itself. When diagnosed, it is recommended extraction of the system. A 77–year–old patient, hypertensive, obese, former tobacco user, suffering from chronic ischemic heart disease and carrier of bicameral PM since 2019 for BAV grade III. In June 2022 decubitus of the PM pocket. Considering the negativity of coltural tests and the absence of fever, it was decided to use a conservative approach by doing a curettage of the pocket and by repositioning the device at the submuscular level. After about a month, a reappearance of decubitus with exposure of the PM case occurred, therefore, a complete extraction of the leads and removal of the device was performed. The surgery, performed under general anaesthesia, was complicated by the fracture of both leads at the level of the anonymous vein. With the introduction of dedicated ligature through the right femoral vein, it was possible to successfully extract the ventricular lead stump. During the recapture of the atrial stump, a migration of the stump into the right ventricle and then into the pulmonary circulation to a terminal branch of the right pulmonary artery occurred. The recovery of such stump was possible with the help of interventional radiologists and through the use of a dedicated material (“Gooseneck ligature catheter”). Subsequent implantation of temporary PM by the right jugular given the absence of underlying spontaneous rhythm. Conclusions CIED extraction surgery is burdened with a high risk of complications even serious ones, including lead rupture and distal fragment embolization. A multidisciplinary approach with shared choices and techniques allowed the resolution percutaneous resolution of a complex picture.

P36 A CHALLENGING CASE OF MINOCA

Abstract Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) accounts for 5–6% of all myocardial infarctions. The causes that can lead to this diagnosis are many and not always clearly identifiable; in fact, despite optimal work–up, the cause of MINOCA remains undetermined in 8–25% of patients and diagnosis represents a real challenge for the cardiologist clinician. Because patients with MINOCA have clinical outcomes comparable to those with myocardial infarction with obstructive coronary artery disease, they should undergo a careful diagnostic work–up in order to set up a therapy related to the specific diagnosis. Introduction A 51–years old woman presented to the emergency room after a sudden onset of an oppressive, prolonged and non–radiating chest pain, with gradual resolution after intravenous nitroderivates therapy. Smoking was the only cardiovascular risk factor. A recent uncomplicated COVID 19 infection (2 months before hospital admission) was the only event reported in clinical history. Physical examination was unremarkable with the exception of an apical mid–end systolic murmur. The electrocardiogram was normal and the Troponin T peak was 391 pg/ml. An echocardiogram showed a normal biventricular function without alterations of segmental kinetics and mitral valve prolapse with moderate degree regurgitation. The patient was admitted to the Intensive Care Unit department and underwent a coronary angiography study with evidence of main epicardial coronaries free from stenosing atherosclerotic lesions. In addition, a cardiac magnetic resonance (CMR) was performed before discharge, with evidence of normal biventricular systolic function in the presence of limited area of ​​late enhancement with ischemic pattern at the level of the middle segment of the inferolateral wall of the left ventricle without edema. In the light of the clinical instrumental picture, a diagnosis of MINOCA was made. Discussion This clinical case is an example of how sometimes the cause relating to a MINOCA cannot always be well identified. However, the multi–imaging approach and in particular the resonance allowed to identify a localized area of ​​late enhancement with an ischemic type pattern. The origin of the ischemia could be dated from a picture of distal embolization, from a microvascular disease or from a myocardial stretching due to prolapse.

C21 A FLOATING THROMBUS IN THE ASCENDING AORTA, AS A COMPLICATION OF A PERCUTANEOUS CORONARY ANGIOGRAPHY

Abstract Free–floating thrombus of the ascending aorta is a rare disease entity which carries a potential risk of distal embolization with catastrophic consequences. We present the case of a 46–year–old patient with floating thrombus in the ascending aorta, likely caused by catheter injury, after a percutaneous coronary angiography with stent implantation at the circumflex artery and no antiplatelet agents. A 46–year–old female patient was admitted to the emergency room with acute chest pain radiating to the left arm for the past 3 days. She reported a history of cigarette smoking and a ST–elevation myocardial infarction with stent implantation at the level of the circumflex artery about 1 month before. The patient was not taking any antiplatelet therapy for explicit refusal. Transthoracic echocardiography showed an isoechoic lesion in the ascending aorta and no other abnormalities of the cardiac structure and function and of the valve systems. Transoesophageal echocardiography confirmed the presence of a coarse (17 mm 14 mm) isoechoic formation, with a large base of implantation at the level of the non–coronary aortic cusp, extending approximately 45 mm into the aortic vessel with a floating attitude (Panels A–C). Computed tomography angiography showed a pedunculated mass measuring 22 mm 22 mm 45 mm in ascending aortic lumen (Panels D and E). Intact intima and normal size of ascending aorta with no signs of aortic dissection or intramural haematoma were also reported. The patient underwent a thrombectomy (Panel F) and aortic replacement. A histopathologic examination revealed the mass to be a fibrin thrombus. The post–operative course was uneventful. No recrudescence or concomitant visceral or vascular embolism was observed. The patient was discharged with dual antiplatelet agents.

Impact of stent-retriever tip design on distal embolization during mechanical thrombectomy: a randomized in vitro evaluation

BackgroundRepeated number of passes, clot fragmentation, and distal embolization during mechanical thrombectomy (MT) lead to worse clinical outcomes in acute ischemic stroke. This study aimed to assess the recanalization and...

Drug-loaded balloon with built-in NIR controlled tip-separable microneedles for long-effective arteriosclerosis treatment

Drug-eluting balloon (DEB) angioplasty has emerged as an effective treatment for cardiovascular and cerebrovascular diseases. However, distal embolism and late lumen restenosis could be caused by drug loss during DEB handling and rapid drug metabolization. Here, a drug-loaded balloon equipped with tip-separable microneedles on the balloon surface (MNDLB) was developed. Inbuilt near-infrared (NIR) ring laser inside the catheter inner shaft was introduced to activate the biodegradable microneedle tips for the first time. The drug-loaded tips thus could be embedded in the vasculature and then released antiproliferative drug - paclitaxel slowly via polymer degradation for more than half a year. A significant increase in drug delivery efficiency and superior therapeutic effectiveness compared with the standard DEB were demonstrated using an atherosclerosis rabbit model.

Hemodynamic Changes in Patients with Chronic Internal Carotid Artery Occlusion After Recanalization.

This study aimed to investigate the feasibility and clinical efficacy of endovascular recanalization in patients with chronic internal carotid artery occlusion (CICAO) and explore the application value of computed tomography perfusion (CTP) in endovascular recanalization. This non-randomized controlled study included 41 patients with CICAO. All patients received active medical treatment. In this study, patients with successful endovascular recanalization and those who refused endovascular recanalization were included in the recanalization and medication groups, respectively. Before and 90 days after treatment, cognitive function was evaluated using the Montreal Cognitive Function Assessment, and neurological function was evaluated using the National Institutes of Health Stroke Scale and modified Rankin scale. For patients with successful endovascular recanalization, brain CTP imaging was performed to evaluate hemodynamic changes in patients with CICAO before and three days after treatment. Overall, 41 symptomatic patients with CICAO were included, and 20 patients received endovascular recanalization therapy, with a success rate of 60% (12/20). The perioperative complication rate was 15% (3/20); there were no events such as hyperperfusion, distal embolism, vascular rupture, or cerebral hemorrhage, and no stroke-related or death-related events. Patients were divided into a medication group (n=21) and recanalization group (n=12). After 90 days of follow-up, patients in the recanalization group showed greater improvement in overall cognitive and neurological function. In addition, successful endovascular recanalization significantly improved cerebral blood perfusion on the occluded side of patients with CICAO. Successful recanalization can effectively improve the overall cognitive and neurological functions of patients in the short term. CTP can be used to quantitatively evaluate not only the cerebral hemodynamic changes after internal carotid artery occlusion but also the improvement of cerebral blood perfusion after successful endovascular recanalization, which provides a reliable method for postoperative follow-up.

Efficacy and safety of embolo-sclerotherapy of arteriovenous malformations with foam sodium tetradecyl sulphate.

To evaluate the efficacy and safety of embolo-sclerotherapy (EST) particularly with foamed sclerotherapy in the treatment of arteriovenous malformations (AVMs). All patients with AVM who underwent interventional therapy i.e. EST from January 1st, 2015 - December 31st, 2019 were identified through a prospective database. Types of AVM were classified according to Schobinger's classification. The outcome measures assessed efficacy and complications. The former was divided into four groups: no response, mild response, moderate response, and complete response.. Complications were defined as any tissue or functional damage, distal embolization or tissue reaction. Continuous variables were compared using analysis of variance (ANOVA) F test and discrete variables were analysed using χ2 tests. P<0.05 was considered significant. A total of 65 patients were included. There was no statistical difference amongst the volume of foam STS 3% or alcohol used across all types of AVM. Overall, majority of patients (86.2%) reported some degree of improvement following interventional therapy. Six (9.2%) patients experienced complications including necrosis and amputation. The proportions of complication were significantly different across the categories (P=0.009). Patients with type III AVM seemed to report more complications than others. Foam sclerotherapy was clinically effective and safe for patients with AVM. This study showed that foam sclerotherapy with STS 3% provided a safe and efficacious alternative sclerosant to ethanol despite it was not often reported to be used to treat AVM. However, a combination of embolic agents is likely required to treat type IV AVMs.

Is There an Advantage of Ultrathin-Strut Drug-Eluting Stents over Second- and Third-Generation Drug-Eluting Stents?

In patients undergoing percutaneous coronary intervention, the second-generation drug-eluting stents (DES) are considered the gold standard of care for revascularization. By reducing neointimal hyperplasia, drug-eluting coronary stents decrease the need for repeat revascularizations compared with conventional coronary stents without an antiproliferative drug coating. It is important to note that early-generation DESs were associated with an increased risk of very late stent thrombosis, most likely due to delayed endothelialization or a delayed hypersensitivity reaction to the polymer. Studies have shown a lower risk of very late stent thrombosis with developing second-generation DESs with biocompatible and biodegradable polymers or without polymers altogether. In addition, research has indicated that thinner struts are associated with a reduced risk of intrastent restenosis and angiographic and clinical results. A DES with ultrathin struts (strut thickness of 70 µm) is more flexible, facilitates better tracking, and is more crossable than a conventional second-generation DES. The question is whether ultrathin eluting drug stents suit all kinds of lesions. Several authors have reported that improved coverage with less thrombus protrusion reduced the risk of distal embolization in patients with ST-elevation myocardial infarction (STEMI). Others have described that an ultrathin stent might recoil due to low radial strength. This could lead to residual stenosis and repeated revascularization of the artery. In CTO patients, the ultrathin stent failed to prove non-inferiority regarding in-segment late lumen loss and showed statistically higher rates of restenosis. Ultrathin-strut DESs with biodegradable polymers have limitations when treating calcified (or ostial) lesions and CTOs. However, they also possess certain advantages regarding deliverability (tight stenosis, tortuous lesions, high angulation, etc.), ease of use in bifurcation lesions, better endothelialization and vascular healing, and reducing stent thrombosis risk. In light of this, ultrathin-strut stents present a promising alternative to existing DESs of the second and third generation. The aims of the study are to compare ultrathin eluting stents with second- and third-generation conventional stents regarding procedural performance and outcomes based on different lesion types and specific populations.

Intracranial Carotid Occlusions

PurposeSpecific decisions made by neurointerventionists are often lost behind the data of large-scale trials, and many of these studies have taken place before the development of new techniques and devices. This study compares the stent-retriever assisted vacuum-locked extraction (SAVE) technique with a direct aspiration first pass (ADAPT), as well as the use of a balloon guide catheter (BGC), in intracranial internal carotid artery (IC-ICA) occlusions.MethodsObservational and retrospective study from an Italian hospital, including patients who underwent thrombectomy for IC-ICA occlusion between 1 January 2019 and 31 March 2021.ResultsOut of 91 IC-ICA occlusions, the ADAPT was the first choice in 20 (22%) and the SAVE in 71 (78%). A BGC was used in 32 (35%) cases, always in conjunction with the SAVE technique. The use of SAVE technique without BGC was associated with the least risk of distal embolization (DE) in the territory occluded (44% vs. 75% when ADAPT technique was used; p = 0.03) and achieved first pass effect (FPE) more frequently (51% vs. 25%, p = 0.09). When the SAVE technique was used, BGC (BGC-SAVE) compared to no BGC (NoBGC-SAVE) was associated with a tendency for less DE (31% vs. 44%, p = 0.3), more FPE (63% vs. 51%, p = 0.5), the same median number of passes (1, p = 0.8) and similar groin-to-recanalization times (36.5 vs. 35.5 min, p = 0.5), none of which reached statistical significance.ConclusionOur findings support the use of SAVE technique for IC-ICA occlusions; the added benefit of BGC compared to long sheaths was not remarkable in this sample.

Efficacy and Safety of Anticoagulant Therapy in COVID-19-Related Pulmonary Embolism with Different Extension.

Pulmonary embolism (PE) has been associated with SARS-CoV-2 infection, and its incidence is highly variable. The aim of our study was to describe the radiological and clinical presentations, as well as the therapeutic management, of PEs that occurred during SARS-CoV-2 infection in a cohort of hospitalized patients. In this observational study, we enrolled patients with moderate COVID-19 who developed PE during hospitalization. Clinical, laboratory, and radiological features were recorded. PE was diagnosed on clinical suspicion and/or CT angiography. According to CT angiography results, two groups of patients were further distinguished: those with proximal or central pulmonary embolism (cPE) and those with distal or micro-pulmonary embolism (mPE). A total of 56 patients with a mean age of 78 ± 15 years were included. Overall, PE occurred after a median of 2 days from hospitalization (range 0-47 days) and, interestingly, the majority of them (89%) within the first 10 days of hospitalization, without differences between the groups. Patients with cPE were younger (p = 0.02), with a lower creatinine clearance (p = 0.04), and tended to have a higher body weight (p = 0.059) and higher D-Dimer values (p = 0.059) than patients with mPE. In all patients, low-weight molecular heparin (LWMH) at anticoagulant dosage was promptly started as soon as PE was diagnosed. After a mean of 16 ± 9 days, 94% of patients with cPE were switched to oral anticoagulant (OAC) therapy, which was a direct oral anticoagulant (DOAC) in 86% of cases. In contrast, only in 68% of patients with mPE, the prosecution with OAC was indicated. The duration of treatment was at least 3 months from PE diagnosis in all patients who started OAC. At the 3-month follow-up, no persistence or recurrence of PE as well as no clinically relevant bleedings were found in both groups. In conclusion, pulmonary embolism in patients with SARS-CoV-2 may have different extensions. Used with clinical judgment, oral anticoagulant therapy with DOAC was effective and safe.

Comprehensive classifications for the endovascular recanalization of vertebral artery stump syndrome

Backgroundand purpose: To share our single-center vertebral artery stump syndrome (VASS) treatment experience and assess the role of comprehensive classification based on anatomic development, proximal conditions, and distal conditions (PAD). Materials and methodsData were retrospectively collected from patients who underwent endovascular thrombectomy (EVT) at the Stroke Center of the First Hospital of Jilin University between January 2016 and December 2021. Among patients with acute ischemic stroke in the posterior circulation, those with acute occlusion of the intracranial arteries and occlusion at the origin of the vertebral artery confirmed by digital subtraction angiography were selected. The clinical data were summarized and analyzed. ResultsFifteen patients with VASS were enrolled in the study. The overall success rate of surgical recanalization was 80%. The successful proximal recanalization rate was 70.6%, and the recanalization rates for P1, P2, P3, and P4 were 100%, 71.4%, 50%, and 66.67%, respectively. The mean operation times for the A1 and A2 types were 124 and 120 ​min, respectively. The successful distal recanalization rate was 91.7%, and the recanalization rates for types D1, D2, D3, and D4 were 100%, 83.3%, 100%, and 100%, respectively. Five patients experienced perioperative complications (incidence rate: 33.3%). Distal embolism occurred in three patients (incidence rate: 20%). No dissection or subarachnoid hemorrhage occurred in any patient. ConclusionEVT is a technically feasible treatment for VASS, and comprehensive PAD classification can, to a certain extent, help initially estimate the difficulty of surgery and provide guidance for interventional procedures.

Penumbra Indigo Percutaneous Aspiration Thrombectomy System in the treatment of Aortic Endograft Iliac Limb Occlusion: Results from an Italian Multicentre Registry

This study aimed to evaluate the safety and effectiveness of the Penumbra Indigo percutaneous aspiration thrombectomy (PAT) system in the clinical presentation of iliac limb occlusion (ILO) after endovascular aortic repair (EVAR). A retrospective, observational, multicentre study conducted in eight Italian vascular centres. Consecutive patients presenting with ILO after EVAR were eligible. To assess vessel revascularisation, Thrombo-aspiration In Peripheral Ischaemia (TIPI) classification (score 0-3) was used at presentation (t1), after PAT (t2), and after adjunctive procedures (t3). Successful revascularisation was considered TIPI 2-3 (near complete or complete). Primary intra-operative outcomes were technical success (TS) of Indigo PAT and combined TS of PAT associated with adjunctive procedures when needed. Primary follow up outcomes were safety and effectiveness at one, six, and 12 months. From September 2019 to December 2021, there were 48 ILO and 17 patients (35%) [median age 75 years, IQR 71, 83 years; male, 14 (82%); urgent, 8 (47%)] were treated and enrolled. The median time after primary EVAR was 24 months (IQR 0, 42 months). The median clot age from ILO diagnosis to PAT was three days (IQR 1, 12 days). Ten patients (59%) presented with limb threatening ischaemia. At t1, TIPI 0 and 1 was present in 13 (76%) and four (24%) cases, respectively. At t2, primary TS (TIPI 2-3) was achieved in 14 cases (82%) after Indigo PAT (p < .001). Fifteen patients (88%) required adjunctive procedures (14 re-linings, one surgical patch angioplasty). At t3, combined TS was achieved in 16 cases (94%). Intra-operative complication included one (6%) distal embolisation, treated successfully. The 30 day mortality was one case (6%) due to pneumonia. At one, six, and 12 months, clinical success was 100% without ILO recurrence. The median follow up was 23 months (IQR 11, 41 months): at 18 months, survival and freedom from re-intervention were 91 ± 8% and 90 ± 9%, respectively. This study reports for the first time the efficacy and safety of Penumbra Indigo PAT for ILO after EVAR, with promising technical and clinical success up to one year.

Chronic Complete Distal Aortic Occlusion and Pulmonary Embolism—Atypical Antiphospholipid Syndrome?

Complete aortic occlusion is a rare pathology with various possible etiologies. According to current data, it is most frequently caused by atherosclerosis. However, thrombosis or vasculitis could also be involved. We present the case of a 42-year-old female with chronic complete distal aortic occlusion, associated pulmonary embolism and positive antiphospholipid antibodies. The patient had an obstetric history suggestive of antiphospholipid syndrome (APS). She presented with typical intermittent claudication symptoms persisting for approximately five years at the time of admission. Arteriography revealed complete infrarenal aortic occlusion and the presence of collateral arteries. Aortoiliac bypass surgery was performed. This case emphasizes an unusual, yet possible, etiology of chronic aortic occlusion-most probably, combining atherosclerosis and chronic thrombosis-in a relatively young patient, in which the diagnosis was significantly delayed due to the peculiar association of traits.

113 The Use of Machine Learning of Carotid Web Angioarchitecture for Predicting Stroke Risk

INTRODUCTION: Carotid webs (CWs) are a known mechanism for stroke in young adults without other vascular risk factors. Altered hemodynamics distal to the web may cause flow stagnation with the potential for distal embolization of clots. Although there are some computational flow models studies of CW, currently there are no well-described CT angiographic features to predict stroke risk. METHODS: Anatomical data of the internal carotid artery (ICA), common carotid artery (CCA), the CW and its “distal pouch” angioarchitecture was gathered as part of a retrospective cohort study from symptomatic (stroke) and asymptomatic (non-stroke) patients. Principal component analysis was applied to anatomical and angioarchitectural features, and the two components were plotted to investigate whether the stroke and non-stroke patients were easily separable. We built a predictive model of stroke risk using these features with Firth regression to reduce bias related to small datasets. RESULTS: The first two principal components of the anatomical and angioarchitectural features clearly distinguish between stroke patients and non-stroke patients. The firth regression and 5-fold cross validation revealed that CCA web “pouch” angle (p=.014), ICA web “pouch” tip angle (p=.023), CCA web “pouch” tip angle (p = .017), and ICA web “pouch” angle (p = .016) are the most important features to model and assess stroke risk. Conversely, CCA and ICA anatomy (diameter and angle) on their own were not found to be risk factors for stroke. Overall, pouch angles in respect to flow trajectory in the CCA and in the ICA are significant risk factors as compared to vessel sizes and flow relationships between them. CONCLUSIONS: This study demonstrates that carotid web angioarchitecture and carotid anatomy data from diagnostic angiography may be used to assess stroke risk, allowing physicians to tailor care for each patient according to risk stratification.

Clinical Characteristics of Patents who Developed Slow Flow/ no-reflow After Post-dilatation with Non-compliant Balloon during Primary Percutaneous Coronary Intervention

Objectives: Post-dilatation with non-compliant (NC) balloons is a commonly used strategy to improve inadequate stent expansion but this strategy carries an increased risk of slow flow/no-reflow (SF/NR) due to distal embolization. Therefore, our objective was to evaluate the demographic, clinical, angiographic, and procedure characteristics among patients undergoing primary percutaneous coronary intervention (PCI) who developed slow flow/no-reflow (SF/NR) after post-dilatation with non-compliant (NC) balloons. Methodology: In this cross-sectional observational study, we included consecutive patients with SF/NR after post-dilatation using NC balloon post stent deployment during primary PCI. The demographic, clinical, angiographic, and procedure characteristics were evaluated. Results: In the sample of 107 patients, male were 77.6% (83) and mean age was 56.94 ± 10.47 years. The median chest pain to ER (emergency room) arrival time was 292 [180-394] minutes. A majority of the patients (66.4%) had multi-vessel disease. Mean length NC balloon was 10.57±1.98 mm and diameter was 3.5±0.26 mm. The mean number of inflation were 3.62±1.08, at mean maximal pressure of 20.43±2.49 mmHg, proximal edge pressure of 19.25±2.74 mmHg, and distal edge pressure of 14.64±2.01 mmHg. A total of 5.6% (6) patients developed adverse events and final TIMI (thrombolysis in myocardial infarction) III flow was achieved in 89.7% (96) of the patients. Conclusion: SF/NR after post-dilatation during primary PCI is associated with a significant rate of adverse events and sub-optimal (&lt;III) final TIMI flow. The detrimental effects of high pressure, short length, and increased number of inflations on post NC SF/NR need further investigations.