Distal Vessels Research Articles

A topological data analysis study on murine pulmonary arterial trees with pulmonary hypertension

Pulmonary hypertension (PH), defined by a mean pulmonary arterial blood pressure above 20 mmHg in the main pulmonary artery, is a cardiovascular disease impacting the pulmonary vasculature. PH is accompanied by chronic vascular remodeling, wherein vessels become stiffer, large vessels dilate, and smaller vessels constrict. Some types of PH, including hypoxia-induced PH (HPH), also lead to microvascular rarefaction. This study analyzes the change in pulmonary arterial morphometry in the presence of HPH using novel methods from topological data analysis (TDA). We employ persistent homology to quantify arterial morphometry for control and HPH mice characterizing normalized arterial trees extracted from micro-computed tomography (micro-CT) images. We normalize generated trees using three pruning algorithms before comparing the topology of control and HPH trees.This proof-of-concept study shows that the pruning method affects the spatial tree statistics and complexity. We find that HPH trees are stiffer than control trees but have more branches and a higher depth. Relative directional complexities are lower in HPH animals in the right, ventral, and posterior directions. For the radius pruned trees, this difference is more significant at lower perfusion pressures enabling analysis of remodeling of larger vessels. At higher pressures, the arterial networks include more distal vessels. Results show that the right, ventral, and posterior relative directional complexities increase in HPH trees, indicating the remodeling of distal vessels in these directions. Strahler order pruning enables us to generate trees of comparable size, and results, at all pressure, show that HPH trees have lower complexity than the control trees.Our analysis is based on data from 6 animals (3 control and 3 HPH mice), and even though our analysis is performed in a small dataset, this study provides a framework and proof-of-concept for analyzing properties of biological trees using tools from Topological Data Analysis (TDA). Findings derived from this study bring us a step closer to extracting relevant information for quantifying remodeling in HPH.

Evaluation of left ventricular function in patients with coronary slow flow: A systematic review and meta-analysis.

Coronary slow flow (CSF) is an angiographic finding defined as delayed distal vessel perfusion without severe stenosis of the epicardial coronary arteries. However, definite alterations in left ventricular (LV) function in patients with CSF remains inconsistent. This study aimed to clarify the changes in LV function in patients with CSF and explore the factors that may influence LV function. PubMed, Embase, and Cochrane Library databases were systematically searched. Standardized mean differences and 95% confidence intervals (CI) for the LV function parameters were calculated. Subgroup analysis, meta-regression analysis, and correlation analysis were performed to explore the factors influencing LV function. Twenty-two studies (1101 patients with CSF) were included after searching three databases. In patients with CSF, LV ejection function in patients with CSF was marginally lower (61.8%; 95% CI: 61.0%, 62.7%), global longitudinal strain was decreased (-18.2%; 95% CI: -16.7%, -19.7%). Furthermore, left atrial diameter, left atrial volume index, and E/e' were significantly increased, while E/A and e' were significantly decreased. The mean thrombolysis in myocardial infarction frame count (TFC) was linearly associated with LV function; the larger the mean TFC, the greater the impairment of LV function. Left ventricular systolic and diastolic functions were impaired in patients with CSF, and this impairment was aggravated with increasing mean TFC.

Intra-Arterial Thrombolysis is Associated with Delayed Reperfusion of Remaining Vessel Occlusions following Incomplete Thrombectomy.

Intra-arterial thrombolytics may be used to treat distal vessel occlusions, which cause incomplete reperfusion following mechanical thrombectomy. Because immediate reperfusion after intra-arterial thrombolytics occurs rarely, the aim of this study was to assess the delayed effect of intra-arterial thrombolytics using follow-up perfusion imaging. We included patients from a prospective stroke registry (February 2015 to September 2022) who had undergone mechanical thrombectomy and had incomplete reperfusion (expanded TICI 2a-2c) and available 24 hour perfusion imaging. Perfusion imaging was rated as delayed reperfusion if time-sensitive perfusion maps did not show wedge-shaped delays suggestive of persisting occlusions corresponding to the post-mechanical thrombectomy angiographic deficit. Patients treated with intra-arterial thrombolytics were compared with controls using multivariable logistic regression and inverse probability of treatment weighting matching for baseline differences and factors associated with delayed reperfusion. The median age of the final study population (n = 459) was 74 years (interquartile range, 63-81 years), and delayed reperfusion occurred in 61% of cases. Patients treated with additional intra-arterial thrombolytics (n = 40) were younger and had worse expanded TICI scores. After matching was performed, intra-arterial thrombolytics was associated with higher rates of delayed reperfusion (adjusted OR = 2.7; 95% CI, 1.1-6.4) and lower rates of new infarction in the residually hypoperfused territory after mechanical thrombectomy (adjusted OR = 0.3; 95% CI, 0.1-0.7). No difference was found in the rates of functional independence (90-day mRS, 0-2; adjusted OR = 1.4; 95% CI, 0.4-4.1). Rescue intra-arterial thrombolytics is associated with delayed reperfusion of remaining vessel occlusions following incomplete mechanical thrombectomy. The value of intra-arterial thrombolytics as a potential therapy for incomplete reperfusions after mechanical thrombectomy should be assessed in the setting of randomized controlled trials.

Physician Modification of a Custom-Made Fenestrated Endograft By Closure of a Fenestration With Bovine Patch.

Ruptured mycotic pararenal aortic aneurysms are rare and serious condition that requires prompt treatment. Open surgery with aortic resection and in-situ or extra-anatomic reconstruction is the standard treatment. The aim of this technical note is to report urgent endovascular treatment using a readily available custom-made device (created for another patient), with a back-table modification using pericardium patch and a new fenestration. In preoperative measurements on centerline-based workstation, aortic diameter in proximal and distal landing zone and target vessel position matched the measurements of graft plan of custom-made device (CMD) besides left renal artery. To address current patient`s anatomy, closure of the nonsuitable fenestration with pericardial patch and creation of new fenestration (1 cm above and 1:15 hours posterior to original fenestration) for the respective target vessel have been performed. Postoperative computed tomography angiography (CTA) scan showed complete exclusion of aneurysm, perfused target vessels, and no endoleak. Under resistance-based antibiotic therapy, the patient was asymptomatic and showed normal infection parameters in blood samples postoperatively. In the hands of an experienced endovascular aortic surgeon modification of a custom-made device is a quick and feasible technique in this emergency situation. Long-term follow-up must confirm the durability and reliability of this new technique. The described technique of modification of a custom-made endograft can provide an alternative endovascular treatment option for urgent complex abdominal aortic pathologies. Compared to the current available treatment modalities, like physician modified endografts, off-the-shelf branched devices, parallel grafts and in-situ fenestration, it can save considerable time and provides reasonable sealing in ruptured cases. The technique offers a valuable add-on to the armamentarium of experienced endovascular physicians.

Significance of marginal vessels in differentiating peripheral small-cell lung cancer and benign lung tumor.

Some peripheral small cell lung cancers (pSCLCs) and benign lung tumors (pBLTs) have similar morphological features but different treatment and prognosis. To determine the significance of marginal vessels in differentiating pSCLCs and pBLTs. A total of 57 and 95 patients with pathological confirmed nodular (≤3 cm) pSCLC and pBLT with similar morphological features were enrolled in this study retrospectively. The patients' clinical characteristics and computed tomography (CT) features of tumors and marginal vessels (vessels connecting with tumors) were analyzed and compared. Compared with pBLTs, pSCLCs had a larger diameter (P = 0.001) but lower enhancement (P = 0.015) and fewer had calcification (P = 0.013). Compared with pBLTs, more lesions had proximal (70.2% vs. 22.1%) and distal (59.6% vs. 4.2%) marginal vessels in pSCLCs (each P < 0.0001). In addition, in pSCLCs, the numbers of proximal (1.3 ± 1.4 vs. 0.3 ± 0.6), distal (2.4 ± 3.1 vs. 0.1 ± 0.5), and total (3.6 ± 3.5 vs. 0.4 ± 1.0) marginal vessels were all more than those in pBLTs (each P < 0.001). Receiver operating characteristic curve analysis revealed the positive distal marginal vessel sign had the highest specificity (95.8%), and the number of total marginal vessels had the best performance in discriminating pSCLC from pBLT (cutoff value = 1.5, AUC = 0.80, 95% CI = 0.72-0.89, sensitivity = 70.2%, and specificity = 91.6%). For peripheral solid nodules similar to pBLTs but without any calcification, the possibility of pSCLC should be considered if they have multiple marginal vessels (≥2), especially the distal ones.

Bipolar Cautery in Aneurysms: Effective but Underutilised Technique

ABSTRACT Background: Bipolar cautery for aneurysms is an effective technique, described in the literature about 50 years back by Yasargil, however, there is an inadequacy of articles highlighting the technique. Materials and Methods: Operative videos of aneurysm surgeries were analysed to select the videos/photographs which can help readers to understand the technical nuances of using bipolar cautery during aneurysm surgeries. Cautery was used after the completion of sharp dissection around the neck and demarcation of proximal and distal vessels in non-giant aneurysms. Cautery setting was kept around 10%–20% of the maximum. Blunt tip forceps were used with continuous irrigation. A shaft instead of the tip of the cautery was used. Results: Bipolar cautery resulted in the shrinkage of the wall of the aneurysm. It had a similar effect on the neck, fundus or transition zone between the neck and fundus. It helped in controlling the bleeding from the fundus even during intraoperative rupture of the aneurysms. Even the flimsy wall of the fundus shrunk, which prevented their rupture during dissection. It was very useful to make giant aneurysm fundus shrink to a smaller size providing space for dissection. The wide neck could be modified to a desirable shape for easier clip applications. Conclusion: Fear of intraoperative rupture by cautery appears misconceived. It causes shrinkage of the wall of the aneurysm, can stop bleeding from the fundus and can change the shape of the neck fundus, which helps clipping the aneurysms easily.

Preoperative assessment for vascular access: Vascular mapping and handgrip strength.

Reliable vascular access (VA) is required for patients receiving chronic hemodialysis (HD) treatment. Vascular mapping using duplex doppler ultrasonography (DUS) can aid in planning VA construction. Greater handgrip strength (HGS) was found to be associated with more developed distal vessels both in chronic kidney disease (CKD) patients and healthy individuals, and patients with lower HGS had worse morphologic vessel characteristics and were, therefore, less likely to construct distal VA. This study aims to describe and analyze clinical, anthropometric, and laboratory characteristics of patients who underwent vascular mapping prior to VA creation. Prospective analysis. Adult patients with CKD referred for vascular mapping, at a tertiary center, between March 2021 and August 2021. Preoperative DUS by a single experienced nephrologist was carried out. HGS was measured using a hand dynamometer, and PAD was defined as ABI < 0.9. Sub-groups were analyzed according to distal vasculature size (<2 mm). A total of 80 patients were included, with a mean age of 65.7 ± 14.7 years; 67.5% were male, and 51.3% were on renal replacement therapy (RRT). Twelve (15%) participants had PAD. HGS was higher in the dominant arm (20.5 ± 12.0 vs 18.8 ± 11.2 kg). Fifty-eight (72.5%) patients had vessels smaller than 2 mm in diameter. There were no significant differences between groups concerning demographics or comorbidities (diabetes, HTN, PAD). HGS was significantly higher in patients with distal vasculature greater than or equal to 2 mm in diameter (dominant arm: 26.1 ± 15.5 vs 18.4 ± 9.7 kg, p = 0.010; non-dominant arm: 24.1 ± 15.3 vs 16.8 ± 8.6, p = 0.008). Higher HGS was associated with more developed distal cephalic vein and radial artery. Low HGS might be an indirect sign of suboptimal vascular characteristics, which might help predict the outcomes of VA creation and maturation.

Pressure Clamping During Ocular Perfusions Drives Nitric Oxide-Mediated Washout.

The aim of this study was to test the hypothesis that nitric oxide (NO) mediates a pressure-dependent, negative feedback loop that maintains conventional outflow homeostasis and thus IOP. If true, holding pressure during ocular perfusions will result in uncontrolled production of NO, hyper-relaxation of the trabecular meshwork, and washout. Paired porcine eyes were perfused at constant pressure of 15 mmHg. After 1 hour acclimatization, one eye was exchanged with N5-[imino(nitroamino)methyl]-L-ornithine, methyl ester, monohydrochloride (L-NAME) (50 µm) and the contralateral eye with DBG, and perfused for 3 hours. In a separate group, one eye was exchanged with DETA-NO (100 nM) and the other with DBG and perfused for 30 minutes. Changes in conventional outflow tissue function and morphology were monitored. Control eyes exhibited a washout rate of 15% (P = 0.0026), whereas eyes perfused with L-NAME showed a 10% decrease in outflow facility from baseline over 3 hours (P < 0.01); with nitrite levels in effluent positively correlating with time and facility. Compared with L-NAME-treated eyes, significant morphological changes in control eyes included increased distal vessel size, number of giant vacuoles, and juxtacanalicular tissue separation from the angular aqueous plexi (P < 0.05). For 30-minute perfusions, control eyes showed a washout rate of 11% (P = 0.075), whereas DETA-NO-treated eyes showed an increased washout rate of 33% from baseline (P < 0.005). Compared with control eyes, significant morphological changes in DETA-NO-treated eyes also included increased distal vessel size, number of giant vacuoles and juxtacanalicular tissue separation (P < 0.05). Uncontrolled NO production is responsible for washout during perfusions of nonhuman eyes where pressure is clamped.

Pretreatment brain CT perfusion thresholds for predicting final infarct volume in distal medium vessel occlusions.

Quantitative CT perfusion (CTP) thresholds for assessing the extent of ischemia in patients with acute ischemic stroke (AIS) have been established; relative cerebral blood flow (rCBF) <30% is typically used for estimating estimated ischemic core volume and Tmax (time to maximum) >6seconds for critical hypoperfused volume in AIS patients with large vessel occlusion (LVO). In this study, we aimed to identify the optimal threshold values for patients presenting with AIS secondary to distal medium vessel occlusions (DMVOs). In this retrospective study, consecutive AIS patients with anterior circulation DMVO who underwent pretreatment CTP and follow-up MRI/CT were included. The CTP data were processed by RAPID (iSchemaView, Menlo Park, CA) to generate estimated ischemic core volumes using rCBF <20%, <30%, <34%, and <38% and critical hypoperfused volumes using Tmax (seconds) >4, >6, >8, and >10. Final infarct volumes (FIVs) were obtained from follow-up MRI/CT within 5days of symptom onset. Diagnostic performance between CTP thresholds and FIV was assessed in the successfully and unsuccessfully recanalized groups. Fifty-five patients met our inclusion criteria (32 female [58.2%], 68.0±12.1years old [mean±SD]). Recanalization was attempted with intravenous tissue-type plasminogen activator and mechanical thrombectomy in 27.7% and 38.1% of patients, respectively. Twenty-five patients (45.4%) were successfully recanalized. In the successfully recanalized patients, no CTP threshold significantly outperformed what is used in LVO setting (rCBF<30%). All rCBF CTP thresholds demonstrated fair diagnostic performances for predicting FIV. In unsuccessfully recanalized patients, all Tmax CTP thresholds strongly predicted FIV with relative superiority of Tmax >10seconds (area under the receiver operating characteristic curve=.875, p=.001). In AIS patients with DMVOs, longer Tmax delays than Tmax >6seconds, most notably, Tmax >10seconds, best predict FIV in unsuccessfully recanalized patients. No CTP threshold reliably predicts FIV in the successfully recanalized group nor significantly outperformed rCBF<30%.

Impact of left coronary artery bifurcation angle on computed tomography derived fractional flow reserve in normal coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Computed-tomography (CT) derived fractional-flow-reserve (FFRCT) decreases from the proximal to the distal part of vessel due to the influence of various factors. The energy loss due to the bifurcation angle may potentially contribute to a progressive FFRCT decline. However, the association of the bifurcation angle with FFRCT is still not entirely understood. Purpose This study aimed to investigate the impact of various bifurcation angles on FFRCT decline below the clinically crucial pathological value of 0.80 in normal coronary arteries. Methods A total of 83 consecutive patients who underwent both CT angiography including FFRCT and invasive coronary angiography, resulting in normal coronary arteries were evaluated. ΔFFRCT was defined as the magnitude of the change in FFRCT from the proximal to the distal vessel in the left anterior descending (LAD) and left circumflex (LCX). Both LAD angle and LCX bifurcation angle were measured as the crossing angle between the centrelines of the left main trunk and each coronary artery (LAD or LCX) on the 3-dimensional volume rendered image of the coronary artery tree (Figure 1). Vessel length, lumen volume, non-calcified plaque volume, and calcified plaque volume were assessed. Results Bifurcation angle was significantly lower in LAD angle (LAD angle, 31.1 ± 6.6°; LCX angle, 42.8 ± 14.9°, p &amp;lt; 0.0001). FFRCT showed a continuous gradual decline from the proximal to the distal in both LAD (from 0.95 ± 0.03 to 0.81 ± 0.06) and LCX (from 0.96 ± 0.03 to 0.88 ± 0.06). ΔFFRCT was significantly greater in LAD angle (LAD angle, 0.13 ± 0.06; LCX angle, 0.08 ± 0.05, p &amp;lt; 0.0001) ΔFFRCT was significantly correlated with each bifurcation angle (LAD angle, r = 0.35, p = 0.001; LCX angle, r = 0.26, p = 0.02) and vessel length (LAD angle, r = 0.30, p = 0.005; LCX angle, r = 0.49, p &amp;lt; 0.0001) (Figure 2A). In LAD, vessel length was the strongest predictor for distal FFRCT of ≤ 0.80 (β-coefficient = 0.56, p = 0.0002), immediately followed by the bifurcation angle (β-coefficient = 0.24, p = 0.02). The bifurcation angle was a good predictor for a distal FFRCT ≤ 0.80 (LAD angle, cut-off 31.0°, AUC 0.70, 95% CI 0.58–0.83, sensitivity 74%, specificity 68%; LCX angle, cut-off 52.6°, AUC 0.86, 95% CI 0.76–0.96, sensitivity 88%, specificity 85%) (Figure 2B). Conclusions The change in FFRCT depended on the bifurcation angle. In normal coronary arteries, vessel length was the most influential factor on FFRCT, immediately followed by the bifurcation angle.

Feasibility and safety of ADAPT in acute distal posterior cerebral artery occlusions

PurposeThe direct aspiration first pass technique (ADAPT) is an effective and safe endovascular treatment for distal medium vessel occlusions (DMVO) of the anterior circulation. Clinical experience with ADAPT in the distal posterior circulation, however, is still limited and published data is scarce. In this original work, feasibility, safety and efficacy of ADAPT with distal access catheters (DAC) for treatment of acute distal posterior cerebral artery occlusions (DPCAOs) is evaluated. MethodAll acute ischemic stroke patients between 2017 and 2022 with primary or secondary DPCAOs in the P2 or P3 segment, that underwent thrombectomy of the DPACO using ADAPT with DACs as frontline therapy, were identified. Demographic data, recanalization rates, procedural safety, and clinical outcome were assessed. ResultsTwenty-four patients with primary (n = 6) or secondary (n = 18) DPCAOs (P2: 21/24; P3: 3/24) were included. Median NIHSS score at admission was 14.5 (IQR 9.5). In all cases, the DPCAO could be reached with the DAC. Successful revascularization (DMVO-p-TICI ≥ 2b) with ADAPT was achieved in 79.2% (19/24), including a first pass effect of 62.5% (15/24), leading to complete recanalization (DMVO-p-TICI 3). Median number of passes was 1 (range 1–2). No complications related to distal PCA aspiration thrombectomy occurred. Median NIHSS and mRS scores at discharge were 4 (IQR 8) and 3 (IQR 2), respectively. ConclusionsADAPT appears to be feasible, safe and effective for the treatment of acute DPCAOs in the setting of different occlusion patterns. High revascularization rates without procedural complications can be achieved. Further studies are needed to consolidate these results.

#3866 PREOPERATIVE ASSESSMENT FOR VASCULAR ACCESS: VASCULAR MAPPING AND HANDGRIP STRENGTH

Abstract Background and Aims A reliable vascular access (VA) is required for patients receiving chronic hemodialysis (HD) treatment. VA choice is complex and must consider patient characteristics, predicted patency and risk of primary failure. Vascular mapping (VM) by duplex doppler ultrasonography (DUS) can aid in the planning of which VA to place. Peripheral artery disease (PAD) is associated with higher AVF failure and can be assessed by calculating the ankle-brachial index (ABI). Muscle strength is independently associated with mortality risk and can be evaluated with handgrip strength (HGS). This study aims to describe and analyze clinical anthropometric and laboratory characteristics of patients referred for vascular mapping prior to VA creation and to correlate VM data, HGS, and ABI. Method Prospective analysis of all adult patients with CKD who were referred for VM, at a tertiary center, between March 2021 and August 2021. No patients were excluded. Preoperative DUS by a single experienced nephrologist was carried out. HGS was measured using a Hand Dynamometer and PAD was defined as ABI&amp;lt;0.9. According to distal vasculature size (&amp;lt;2mm) sub-groups were analyzed. Results 80 patients were included and 67.5% were male, mean age 65.7 ± 14.7 years and 51.3% were on Renal Replacement Therapy (RRT). Twelve (15%) participants had PAD. HGS was higher in dominant arm (20.5 ± 12.0 kg vs 18.8 ± 11.2 kg). Fifty-eight (72.5%) patients had vessels smaller than 2 mm in diameter. There were no significant differences between groups concerning demographic and comorbidities (diabetes, PAD). HGS was significantly higher in patients who had vessels greater than or equal to 2 mm in diameter (26.1 ± 15.5 kg vs 18.4 ± 9.7 kg, p = 0.010). Conclusion Greater HGS was associated with more developed distal vessels. Low HGS might be an indirect sign of poor vascular characteristics, which might help predict the outcomes of VA creation and maturation.

Haemostatic efficacy and inflammatory response of a novel beta-chitin patch in a cerebral small vessel injury model – A pilot study

ObjectiveRapid and efficacious haemostasis is paramount in neurosurgery. Assessing the efficacy and short- and long-term safety of haemostatic agents utilised within cerebral tissue is essential. This pilot study investigates the haemostatic efficacy and long-term safety of a novel beta-chitin patch against traditionally used agents, bipolar and Floseal, within cerebral tissue. MethodsEighteen Merino sheep underwent standardised distal cortical vessel injury via temporal craniotomy. Sheep were randomised to receive 2 mls Floseal, 2 cm novel beta-chitin patch, or bipolar cautery to manage bleeding. All sheep underwent cerebral magnetic resonance imaging (MRI) at three months, before euthanasia and brain harvesting for histological assessment. ResultsBeta-chitin demonstrated a trend towards a faster mean time to haemostasis (TTH) compared to Floseal (223.3 ± 199 s v. 259.8 ± 186.4 s), albeit non-significant (p = 0.234). Radiologically, cerebrocortical necrosis (p = 0.842) and oedema (p = 0.368) were noted slightly more frequently in the beta-chitin group. Histologically, severe fibrotic (p = 0.017) and granulomatous changes at the craniotomy sites were only present in the beta-chitin group (p = 0.002). Neuronal degeneration was seen in all with Floseal, but beta-chitin showed a trend towards more severe reaction when present. Bipolar use predominantly showed an inflammatory cortical reaction with substantial microvascular proliferation, and Floseal showed worse severity and depth of subpial oedema, however no statistical significance was reached. ConclusionAll haemostats controlled bleeding, with beta-chitin demonstrating a non-inferior TTH compared to Floseal. However, it resulted in intense granulomatous and fibrotic changes, including degenerative neuronal reactions. More extensive studies are needed to assess these trends, to make further clinical inferences.

Detecting lesion-specific ischemia in patients with coronary artery disease with computed tomography fractional flow reserve measured at different sites

ObjectivesWhether a stenosis can cause hemodynamic lesion-specific ischemia is critical for the treatment decision in patients with coronary artery disease (CAD). Based on coronary computed tomography angiography (CCTA), CT fractional flow reserve (FFRCT) can be used to assess lesion-specific ischemia. The selection of an appropriate site along the coronary artery tree is vital for measuring FFRCT. However the optimal site to measure FFRCT for a target stenosis remains to be adequately determined. The purpose of this study was to determine the optimal site to measure FFRCT for a target lesion in detecting lesion-specific ischemia in CAD patients by evaluating the performance of FFRCT measured at different sites distal to the target lesion in detecting lesion-specific ischemia with FFR measured with invasive coronary angiography (ICA) as reference standard.MethodsIn this single-center retrospective cohort study, a total of 401 patients suspected of having CAD underwent invasive ICA and FFR between March 2017 and December 2021 were identified. 52 patients having both CCTA and invasive FFR within 90 days were enrolled. Patients with vessels 30%-90% diameter stenosis as determined by ICA were referred to invasive FFR evaluation, which was performed 2–3 cm distal to the stenosis under the condition of hyperemia. For each vessel with 30%–90% diameter stenosis, if only one stenosis was present, this stenosis was selected as the target lesion; if serial stenoses were present, the stenosis most distal to the vessel end was chosen as the target lesion. FFRCT was measured at four sites: 1 cm, 2 cm, and 3 cm distal to the lower border of the target lesion (FFRCT-1 cm, FFRCT-2 cm, FFRCT-3 cm), and the lowest FFRCT at the distal vessel tip (FFRCT-lowest). The normality of quantitative data was assessed using the Shapiro–Wilk test. Pearson's correlation analysis and Bland–Altman plots were used for assessing the correlation and difference between invasive FFR and FFRCT. Correlation coefficients derived from Chi-suqare test were used to assess the correlation between invasive FFR and the cominbaiton of FFRCT measred at four sites. The performances of significant obstruction stenosis (diameter stenosis ≥ 50%) at CCTA and FFRCT measured at the four sites and their combinations in diagnosing lesion-specific ischemia were evaluated by receiver-operating characteristic (ROC) curves using invasive FFR as the reference standard. The areas under ROC curves (AUCs) of CCTA and FFRCT were compared by the DeLong test.ResultsA total of 72 coronary arteries in 52 patients were included for analysis. Twenty-five vessels (34.7%) had lesion-specific ischemia detected by invasive FFR and 47 vesseles (65.3%) had no lesion-spefifice ischemia. Good correlation was found between invasive FFR and FFRCT-2 cm and FFRCT-3 cm (r = 0.80, 95% CI, 0.70 to 0.87, p < 0.001; r = 0.82, 95% CI, 0.72 to 0.88, p < 0.001). Moderate correlation was found between invasive FFR and FFRCT-1 cm and FFRCT-lowest (r = 0.77, 95% CI, 0.65 to 0.85, p < 0.001; r = 0.78, 95% CI, 0.67 to 0.86, p < 0.001). FFRCT-1 cm + FFRCT-2 cm, FFRCT-2 cm + FFRCT-3 cm, FFRCT-3 cm + FFRCT-lowest, FFRCT-1 cm + FFRCT-2 cm + FFRCT-3 cm, and FFRCT-2 cm + FFRCT-3 cm + FFRCT-lowest were correatled with invasive FFR (r = 0.722; 0.722; 0.701; 0.722; and 0.722, respectively; p < 0.001 for all). Bland–Altman plots revealed a mild difference between invasive FFR and the four FFRCT (invasive FFR vs. FFRCT-1 cm, mean difference -0.0158, 95% limits of agreement: -0.1475 to 0.1159; invasive FFR vs. FFRCT-2 cm, mean difference 0.0001, 95% limits of agreement: -0.1222 to 0.1220; invasive FFR vs. FFRCT-3 cm, mean difference 0.0117, 95% limits of agreement: -0.1085 to 0.1318; and invasive FFR vs. FFRCT-lowest, mean difference 0.0343, 95% limits of agreement: -0.1033 to 0.1720). AUCs of CCTA, FFRCT-1 cm, FFRCT-2 cm, FFRCT-3 cm, and FFRCT-lowest in detecting lesion-specific ischemia were 0.578, 0.768, 0.857, 0.856 and 0.770, respectively. All FFRCT had a higher AUC than CCTA (all p < 0.05), FFRCT-2 cm achieved the highest AUC at 0.857. The AUCs of FFRCT-2 cm and FFRCT-3 cm were comparable (p > 0.05). The AUCs were similar between FFRCT-1 cm + FFRCT-2 cm, FFRCT-3 cm + FFRCT-lowest and FFRCT-2 cm alone (AUC = 0.857, 0.857, 0.857, respectively; p > 0.05 for all). The AUCs of FFRCT-2 cm + FFRCT-3 cm, FFRCT-1 cm + FFRCT-2 cm + FFRCT-3 cm, FFRCT-and 2 cm + FFRCT-3 cm + FFRCT-lowest (0.871, 0.871, 0.872, respectively) were slightly higher than that of FFRCT-2 cm alone (0.857), but without significnacne differences (p > 0.05 for all).ConclusionsFFRCT measured at 2 cm distal to the lower border of the target lesion is the optimal measurement site for identifying lesion-specific ischemia in patients with CAD.

Distal Target Vessel Quality and Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention

BackgroundDistal vessel quality is a key parameter in the global chronic total occlusion (CTO) crossing algorithm. ObjectivesThe study sought to evaluate the association of distal vessel quality with the outcomes of CTO percutaneous coronary intervention. MethodsWe examined the clinical and angiographic characteristics and procedural outcomes of 10,028 CTO percutaneous coronary interventions performed at 39 U.S. and non-U.S. centers between 2012 and 2022. A poor-quality distal vessel was defined as <2 mm diameter or with significant diffuse atherosclerotic disease. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke. ResultsA total of 33% of all CTO lesions had poor-quality distal vessel. When compared with good-quality distal vessels, CTO lesions with a poor-quality distal vessel had higher J-CTO (Japanese chronic total occlusion) scores (2.7 ± 1.1 vs 2.2 ± 1.3; P < 0.01), lower technical (79.9% vs 86.9%; P < 0.01) and procedural (78.0% vs 86.8%; P < 0.01) success, and higher incidence of MACE (2.5% vs 1.7%; P < 0.01) and perforation (6.4% vs 3.7%; P < 0.01). A poor-quality distal vessel was independently associated with technical failure and MACE. Poor-quality distal vessels were associated with higher use of the retrograde approach (25.2% vs 14.9%; P < 0.01) and higher air kerma radiation dose (2.4 [IQR: 1.3-4.0] Gy vs 2.0 [IQR: 1.1-3.5] Gy; P < 0.01). ConclusionsA poor-quality distal vessel in CTO lesions is associated with higher lesion complexity, higher need for retrograde crossing, lower technical and procedural success, higher incidence of MACE and coronary perforation, and higher radiation dose.

P71: Use of Veno-Arterial Extracorporeal Membrane Oxygenation and Impella for Cardiogenic Shock due to Cocaine Abuse

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella left ventricular assist device individually offer cardiovascular support for cardiogenic shock patients. Each modality has its own benefits and downfalls. We present a case in which a patient developed cocaine-induced coronary vasoconstriction resulting in cardiogenic shock with rapid systemic decompensation. We employed VA-ECMO and subsequent Impella to recover the patient. Methods: A 26-year-old male with a history of Graves’ Disease and chronic cocaine abuse presented to the ED with chest pain following cocaine ingestion. EKG showed sinus tachycardia and ST-elevations throughout, suspicious of coronary vasospasm. Labs showed an acute kidney injury as well as shock liver. Bedside echocardiogram (ECHO) revealed a severely depressed left ventricular ejection fraction (LVEF) of <10%. He was hemodynamically unstable for coronary catheterization and was emergently cannulated for VA-ECMO via the right femoral artery and left femoral vein. After we gained stability and slowly weaned the inotropic support. A follow-up ECHO revealed a dilated left ventricle and biventricular failure. With better hemodynamics, we did a catheterization showing coronary vasoconstriction, “clamping down” of distal vessels. (Figure 1) Due to the left ventricular dilation and its poor contractility, we decided to place an Impella. Results: The patient was supported on VA ECMO for 4 days, at which his LVEF recovered to 30-35%. The Impella device remained for an additional 3 days as his labs and hemodynamics improved. His LVEF at Impella removal was 40%. The patient was discharged in 14 days with a normal LVEF. Conclusion: One of the major downfalls of VA-ECMO is the lack of left ventricular unloading resulting in increased afterload and hindering recovery. An Impella can be used to help vent the left ventricle. This combination has been shown in several studies to improve outcomes in patients with acute coronary syndrome. The technique was employed with successful cardiac recovery in a patient who developed cardiogenic shock from coronary vasospasm from cocaine use.Figure 1. Coronary angiography showing coronary vasoconstriction due to cocaine use

Endovascular Versus Medical Management of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study.

The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.

8mm Conduit Outperforms 6mm Conduit in Extra-anatomic Bypass

Extra-anatomic bypass is an important tool in relieving supra-inguinal occlusive disease. These bypasses are frequently conducted with prosthetic material, commonly available in 6-mm and 8-mm sizes. Previous studies have demonstrated infra-inguinal bypass has improved patency when graft size is 6 mm or greater. This study aimed to examine outcomes of 6-mm vs 8-mm prosthetic graft use in extra-anatomic bypasses. A retrospective analysis of the Vascular Quality Initiative supra-inguinal database (2010-2022) was conducted. Patients undergoing either axillary-femoral or femoral-femoral prosthetic bypass with available conduit size data were included. Primary endpoints included graft patency and major adverse limb events (MALE). A logistic regression analysis was performed of demographic and operative variables to determine if any factors contributed to the selection of graft size. Then, multivariable Cox regression analysis was conducted in groups based on prosthetic diameter (6 mm vs 8 mm), controlling for these factors. Seven mm was excluded from formal regression analysis due to small sample size but included in survival curves to demonstrate the stepwise impact of graft size. A total of 6463 patients were included for analysis; 2355 axillary-femoral bypasses and 4128 femoral-femoral bypasses. Of these, 1071 patients underwent bypass with 6-mm graft, and 5392 patients underwent bypass with 8-mm graft. Significant predictors (P < .05) of 8-mm graft use in both types of extra-anatomic bypass included male gender, body mass index (BMI) of 25-35 kg/m2, and common femoral as distal target when compared to profunda, superficial femoral artery, and other distal vessels. The most significant predictor (P < .001) of improved primary patency in both types of extra-anatomic bypass examined was larger conduit diameter (8 mm vs 6 mm axillary-femoral hazard ratio [HR], 0.5; femoral-femoral HR, 0.66). Cox regression curves by graft size were generated for both axillary-femoral and femoral-femoral bypasses (Figs 1 and 2), which demonstrated significantly higher primary patency in patients with 8-mm bypasses over time. Improved performance in 8-mm graft compared with 6-mm graft was additionally demonstrated in primary-assisted patency, secondary patency, and MALE regression curves with P < .001 for both axillary-femoral and femoral-femoral bypasses. In this retrospective analysis of extra-anatomic bypasses, 8-mm grafts had significantly improved patency rates and fewer MALE when compared with 6-mm grafts over time. Male sex and body mass index were associated with larger diameter bypass use; after controlling for these preoperative factors, 8-mm grafts still outperformed 6-mm grafts. Vascular surgeons should be cognizant of the potential implications in limb salvage when selecting prosthetic graft for extra-anatomic bypass.Fig 2Primary patency of axillary-femoral bypass over time by graft size.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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

Assessment of the risk factors determining the prognosis of major and minor limb amputations in patients with diabetic foot ulcers.

Diabetes mellitus (DM) is a major global health problem, and its incidence is growing. Depending on this increase, the number of diabetes-related complications will also rise. This study aimed to determine the risk factors associated with major and minor amputations resulting from diabetes. Patients diagnosed with diabetic foot complications (n = 371) and hospitalized between January 2019 and March 2020 were retrospectively evaluated using information obtained from the database of Diabetic Foot Wound Clinic. Examination of the data identified 165 patients for inclusion in the study, who were stratified into major amputation (group 1, n = 32), minor amputation (group 2, n = 66) and non-amputation (group 3, n = 67) groups. Of the 32 patients who underwent major amputations, 84% had a below-knee amputation, 13% had an above-knee amputation and 3% had knee disarticulation. At the same time, 73% of 66 patients who underwent minor amputation had a single-finger amputation, 17% had a multiple-finger amputation, 8% had a transmetatarsal amputation, and 2% had Lisfranc amputation. Laboratory results showed high acute phase protein and low albumin (ALB) levels in patients from group 1 (p < 0.05). Although Staphylococcus aureus was found to be the most common infectious agent, Gram-negative pathogens were dominant (p < 0.05). Also, there was a significant cost difference between the groups (p < 0.05). Furthermore, those aged over 65 had a high Wagner score, high Charlson Comorbidity Index (CCI), long diabetic foot ulcer (DFU) duration, and high white blood cell (WBC) count, all of which were risk factors for major amputation (p < 0.05). This study demonstrated an increased Wagner staging and incidence of peripheral neuropathy (PN) and peripheral arterial disease (PAD) in major amputation patients. In addition, the rate of distal vessel involvement was high in major amputation patients, with elevated acute phase proteins and low ALB levels crucial in laboratory findings.