Emergent Angiography Research Articles

Association between admission blood pressure and spontaneous reperfusion and long-term prognosis in STEMI patients: an observational and multicenter study

BackgroundThis study aims to assess the associations of admission systolic blood pressure (SBP) level with spontaneous reperfusion (SR) and long-term prognosis in ST-elevation myocardial infarction (STEMI) patients.MethodsData from 3809 STEMI patients who underwent primary percutaneous coronary intervention within 24 h, as recorded in the Chinese STEMI PPCI Registry (NCT04996901), were analyzed. The primary endpoint was SR, defined as thrombolysis in myocardial infarction grade 2–3 flow of IRA according to emergency angiography. The second endpoint was 2-year all-cause mortality. The association between admission BP and outcomes was evaluated using Logistic regression or Cox proportional hazards models with restricted cubic splines, adjusting for clinical characteristics.ResultsAdmission SBP rather than diastolic BP was associated with SR after adjustment. Notably, this relationship exhibits a nonlinear pattern. Below 120mmHg, There existed a significant positive correlation between admission SBP and the incidence of SR (adjusted OR per 10-mmHg decrease for SBP ≤ 120 mm Hg: 0.800; 95% CI: 0.706–0.907; p<0.001); whereas above 120mmHg, no further improvement in SR was observed (adjusted OR per 10-mmHg increase for SBP >120 mm Hg: 1.019; 95% CI: 0.958–1.084, p = 0.552). In the analysis of the endpoint event of mortality, patients admitted with SBP ranging from 121 to 150 mmHg exhibited the lowest mortality compared with those SBP ≤ 120mmHg (adjusted HR: 0.653; 95% CI: 0.495–0.862; p = 0.003). In addition, subgroups analysis with Killip class I-II showed SBP ≤ 120mmHg was still associated with increased risk of mortality.ConclusionThe present study revealed admission SBP above 120 mmHg was associated with higher SR,30-d and 2-y survival rate in STEMI patients. The admission SBP could be a marker to provide clinical assessment and treatment.Trial registrationClinicalTrials.gov (NCT04996901), 07/27/2021.

Endovascular treatment of contained ruptured internal thoracic artery aneurysm mimicking a tumor in a patient with neurofibromatosis type 1: a case report

BackgroundAn internal thoracic artery aneurysm (ITAA) is an exceedingly rare condition, with approximately two-thirds of reported cases being iatrogenic pseudoaneurysms. The remainder are attributed to various causes, including vasculitis, connective tissue disease, and neurofibromatosis type 1 (NF-1). NF-1 is an autosomal dominant disorder characterized by distinct clinical manifestations that occasionally include life-threatening vascular complications. Although NF-1 patients may develop various vascular abnormalities, ruptured ITAA is rarely reported, with only seven published cases.Case presentationA 32-year-old man with NF-1 consulted for a three-day history of persistent left back and upper arm pain. Initial chest radiography indicated left pleural effusion and an opacity at the left lung apex. Computed tomography scan revealed a mass in the left upper mediastinum that was initially suspected to be a tumor. Subsequent contrast-enhanced computed tomography revealed the mass to be a subclavian artery aneurysm. Detailed contrast-enhanced computed tomography with 1-mm slices was performed for surgical planning, identifying the mass as a left ITAA with contained rupture. Given the risk of re-rupture, emergency angiography was performed, which confirmed rupture of the left ITAA without extravasation. The ITAA was successfully treated with multiple microcoils at the proximal and distal ends. The patient had an uneventful recovery and was discharged on the fourth postoperative day.ConclusionsThis case highlights the importance of considering vascular lesions in NF-1 patients who present with pleural effusion. It also emphasizes the challenges in diagnosing ITAA and the effectiveness of thin-slice contrast-enhanced computed tomography scans and endovascular treatment.

Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report

BackgroundIntercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage.Case presentationA 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful.ConclusionWe report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

Follow-up computed tomography and unexpected hemostasis in non-operative management of pediatric blunt liver and spleen injury.

While follow-up CT and prophylactic embolization with angiography are often conducted during non-operative management (NOM) for BLSI, particularly in a high-grade injury, the utility of early repeated CT for preventing unexpected hemorrhage remains unclear. This study aimed to elucidate whether early follow-up computerized tomography (CT) within 7 days after admission would decrease unexpected hemostatic procedures on pediatric blunt liver and spleen injury (BLSI). A post-hoc analysis of a multicenter observational cohort study on pediatric patients with BLSI (2008-2019) was conducted on those who underwent NOM, in whom the timing of follow-up CT were decided by treating physicians. The incidence of unexpected hemostatic procedure (laparotomy and/or emergency angiography for ruptured pseudoaneurysm) and complications related to BLSI were compared between patients with and without early follow-up CT within 7 days. Inverse probability weighting with propensity scores adjusted patient demographics, comorbidities, mechanism and severity of injury, initial resuscitation, and institutional characteristics. Among 1320 included patients, 552 underwent early follow-up CT. Approximately 25% of patients underwent angiography on the day of admission. The incidence of unexpected hemostasis was similar between patients with and without early repeat CT (8 [1.4%] vs. 6 [0.8%]; adjusted OR, 1.44 [0.62-3.34]; p = 0.40). Patients with repeat CT scans more frequently underwent multiple angiographies (OR, 2.79 [1.32-5.88]) and had more complications related to BLSI, particularly bile leak (OR, 1.73 [1.04-2.87]). Follow-up CT scans within 7 days was not associated with reduced unexpected hemostasis in NOM for pediatric BLSI.

Association Between Coronary Assessment in Heart Failure and Clinical Outcomes Within a Safety-Net Setting Using a Target Trial Emulation Observational Design.

Ischemic cardiomyopathy is the leading cause of heart failure (HF). Most patients do not undergo coronary assessment after HF diagnosis. There are no randomized clinical trials of coronary assessment after HF diagnosis. Using an electronic health record cohort of all individuals with HF within the San Francisco Health Network from 2001 to 2019, we identified factors associated with coronary assessment. Then, we studied the association of coronary assessment within 30 days of HF diagnosis with all-cause mortality and a composite of mortality and emergent angiography using a target trial emulation observational comparative-effectiveness approach. Target trial emulation is an approach to causal inference based on creating a hypothetical randomized clinical trial protocol and using observational data to emulate the protocol. We used propensity scores for covariate adjustment. We used national death records to improve the ascertainment of mortality and included falsification end points for the cause of death. Among 14 829 individuals with HF (median, 62 years old; 5855 [40%] women), 3987 (26.9%) ever completed coronary assessment, with 2467/13 301 (18.5%) with unknown coronary artery disease status at HF diagnosis assessed. Women, older individuals, and people without stable housing were less likely to complete coronary assessment. Among 5972 eligible persons of whom 627 underwent early elective coronary assessment, coronary assessment was associated with lower mortality (hazard ratio, 0.84 [95% CI, 0.72-0.97]; P=0.025), reduced risk of the composite outcome (hazard ratio, 0.86 [95% CI, 0.73-1.00]), higher rates of revascularization (odds ratio, 7.6 [95% CI, 5.4-10.6]), and higher use of medical therapy (odds ratio, 2.5 [95% CI, 1.7-3.6]), but not the falsification end points. In a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by coronary artery disease risk factors. Early coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and guideline-directed medical therapy but with low certainty that this finding is not attributable to unmeasured confounding.

Immediate Angiography and Decreased In-Hospital Mortality of Adult Trauma Patients: A Nationwide Study.

This study aimed to elucidate whether immediate angiography within 30min is associated with lower in-hospital mortality compared with non-immediate angiography. We conducted a retrospective cohort study using a nationwide trauma databank (2019-2020). Adult trauma patients who underwent emergency angiography within 12h after hospital arrival were included. Patients who underwent surgery before angiography were excluded. Immediate angiography was defined as one performed within 30min after arrival (door-to-angio time ≤ 30min). In-hospital mortality and non-operative management (NOM) failure were compared between patients with immediate and non-immediate angiography. Inverse probability weighting with propensity scores was conducted to adjust patient demographics, injury mechanism and severity, vital signs on hospital arrival, and resuscitative procedures. A restricted cubic spline curve was drawn to reveal survival benefits by door-to-angio time. Among 1,455 patients eligible for this study, 92 underwent immediate angiography. Angiography ≤ 30min was associated with decreased in-hospital mortality (5.0% vs 11.1%; adjusted odds ratio [OR], 0.42 [95% CI, 0.31-0.56]; p < 0.001), as well as lower frequency of NOM failure: thoracotomy and laparotomy after angiography (0.8% vs. 1.8%; OR, 0.44 [0.22-0.89] and 2.6% vs. 6.5%; OR, 0.38 [0.26-0.56], respectively). The spline curve showed a linear association between increasing mortality and prolonged door-to-angio time in the initial 100min after arrival. In trauma patients, immediate angiography ≤ 30min was associated with lower in-hospital mortality and fewer NOM failures. Level 3b, non randomized controlled cohort/follow up study.

Prospective study examining the impact of cerebral angiography on quantitative pupillometer values in the interventional radiology suite

ObjectivesThe purpose of this pilot study was to obtain baseline quantitative pupillometry (QP) measurements before and after catheter-directed cerebral angiography (DCA) to explore the hypothesis that cerebral angiography is an...

Angioembolization performed by trauma surgeons for trauma patients: is it feasible in Korea? A retrospective study.

Recent advancements in interventional radiology have made angioembolization an invaluable modality in trauma care. Angioembolization is typically performed by interventional radiologists. In this study, we aimed to investigate the safety and efficacy of emergency angioembolization performed by trauma surgeons. We identified trauma patients who underwent emergency angiography due to significant trauma-related hemorrhage between January 2020 and June 2023 at Jeju Regional Trauma Center. Until May 2022, two dedicated interventional radiologists performed emergency angiography at our center. However, since June 2022, a trauma surgeon with a background and experience in vascular surgery has performed emergency angiography for trauma-related bleeding. The indications for trauma surgeon-performed angiography included significant hemorrhage from liver injury, pelvic injury, splenic injury, or kidney injury. We assessed the angiography results according to the operator of the initial angiographic procedure. The term "failure of the first angioembolization" was defined as rebleeding from any cause, encompassing patients who underwent either re-embolization due to rebleeding or surgery due to rebleeding. No significant differences were found between the interventional radiologists and the trauma surgeon in terms of re-embolization due to rebleeding, surgery due to rebleeding, or the overall failure rate of the first angioembolization. Mortality and morbidity rates were also similar between the two groups. In a multivariable logistic regression analysis evaluating failure after the first angioembolization, pelvic embolization emerged as the sole significant risk factor (adjusted odds ratio, 3.29; 95% confidence interval, 1.05-10.33; P=0.041). Trauma surgeon-performed angioembolization was not deemed a significant risk factor in the multivariable logistic regression model. Trauma surgeons, when equipped with the necessary endovascular skills and experience, can safely perform angioembolization. To further improve quality control, an enhanced training curriculum for trauma surgeons is warranted.

Pulmonary ligament rupture due to a bronchial artery aneurysm-induced hematoma: a case report

BackgroundBronchial artery aneurysm (BAA) is a rare vascular anomaly with the potential for serious complications, such as rupture leading to hemothorax or hemoptysis. Although bronchial artery embolization (BAE) is recognized as an effective intervention for ruptured BAA, video-assisted thoracoscopic surgery (VATS) is a minimally invasive approach for the treatment of associated hemothorax.Case presentationA 73-year-old woman presented with a mediastinal hematoma from a ruptured BAA, causing bilateral hemothorax. Emergency angiography revealed a saccular BAA that was successfully embolized using a microcatheter and coil. Subsequent computed tomography revealed an expanding hemothorax managed by VATS, with 1400 mL of blood drained. During VATS, thoracoscopy revealed pulmonary ligament rupture, which was attributed to increased intramediastinal pressure. The patient was discharged eight days postoperatively with no complications. This case highlights the use of BAE and VATS in the management of mediastinal BAA rupture and massive hemothorax.ConclusionsBAE proved to be an effective strategy for the management of ruptured mediastinal BAAs. VATS is a valuable standby procedure for hematoma removal, but the indication should be carefully determined because of the risk of BAA re-rupture.

Characteristics and outcomes of cardiac arrest patients with prolonged resuscitation

Background: There is lack of uniformity and consensus amongst the emergency physicians about an appropriate duration of cardiopulmonary resuscitation (CPR) and resuscitative efforts before deciding about termination of resuscitation (TOR) in patients with either out-of-hospital or in the emergency department (ED) non-traumatic cardiac arrests. An ideal duration of resuscitation for those with persistent cardiac arrest has not been determined yet. This study aims to evaluate the resuscitative interventions, patient factors and outcomes associated with prolonged duration of resuscitation in these patients. Methods: A retrospective study conducted in the Emergency Department (ED) of Changi General Hospital, Singapore and included 15 non-consecutive and randomly selected adult patients who either had an out-hospital cardiac arrest (OHCA) or suffered a witnessed cardiac arrest soon after arrival in the ED and were resuscitated further. Results: The median age was 58 years (IQR 51.5–70.5 years), and the median total CPR and resuscitation duration was 46 min (IQR 40–62.5 min). 12 patients sustained ROSC and one had transient ROSC. Ten (10) patients survived to hospital admission from ED and 5 of them underwent emergency angiography from ED. Three patients were discharged from hospital eventually with mRS scores of 0–1. Conclusion: Patients with sustained ROSC were older, had more prevalence of co-morbidities and lesser prevalence of shockable rhythms, received bystander CPR and pre-hospital adrenaline more frequently, had longer total duration of CPR and a larger proportion were administered intravenous calcium gluconate during ED resuscitation.

THE CHALLENGE OF KIDNEY DAMAGE DURING INTERVENTIONAL CARDIOLOGY PROCEDURES

Introduction: Contrast nephropat(CN) is a frequent cause of acute renal failure (ARF). The diagnosis is based on an elevation of serum creatinine of 0.5 mg/dl (= 44.2 µmol/l) and/or ? 25% of baseline creatinine. In 90% of patients developing AKI on PC, it classically occurs between 24 and 72 hours after the examination. Diuresis is generally preserved, proteinuria is minimal, and urine sediment shows only granular cylinders and few cells. The differential diagnosis is that of ARF caused by cholesterol emboli from invasive procedures in the suprarenal aorta. In the short term, AKI following coronary angiography is associated with procedural complications, a longer hospital stay (8.1 days versus 4.7 days p &lt; 0.001), and higher one-year mortality (12.1% versus 3.7%). Patients at risk of developing PC-related nephropathy, particularly those with chronic renal failure or concomitant hypovolemia, have the need for extrarenal purification in some cases, in addition to the risk of cardiovascular mortality. This makes contrast media nephropathy a serious event for which clinicians must be prepared. Objective:the aim of this work was to determine the incidence of NIPC in patients undergoing primary angioplasty and/or coronary angiography procedures and generate hypotheses about risk factors. Materials and methods In collaboration with the cardiology department, we conducted a longitudinal descriptive study between January 2019 and January 2021. It included a cohort of 180 patients undergoing emergency or cold angiocoronary angiography for diagnostic or therapeutic purposes. Clinical and biological follow-up was 3 months for all patients. Patients with a blood test including creatininelevels before the examination and creatinine levels at 3 days, 15 days, 1 month, and 3 months after the procedure were included. Those who had undergone PCI for anexamination other than coronary Results Characteristics of the overall population All patients hadnormal creatinine levels and were predominantly male (70.0%) with an average age of 60.8 years. Of these patients, 20.6% had diabetes, 18.2% hypertension and 6.4% heart failure (HF). The rate of IR was 20.8%. Descriptive study Comparison of patient characteristics with and without NCI: The multivariate logistic regression study demonstrated that diabetes mellitus (Odds Ratio (OR)=2.26 95% confidence interval (CI95%): 1.29-3.98, p=0.005), a left ventricular ejection fraction (LVEF) &lt; 45% (OR=2. 03 IC95% :1.22-3.39, p=0.007) and a quantity of iodinated contrast medium (ICP) &gt; 90ml (1.72 IC95%:.of iodinated contrast medium (ICP) &gt; 90ml (1.72 IC95%: 0.99-2.99, p=0.05) were predictive of the occurrence of NCI. It should be noted that age was linked to creatinine clearance, and it was through a reduction in renal function that advanced age was responsible for a higher incidence of CIN. Furthermore, the search for correlations between these five independent factors 2 by 2 showed a significant relationship between diabetes and reduced renal function in the co-presence of these two factors, their effects are reciprocally potentiated and are responsible for an increased risk. Preventive measures showed? their efficacý only in the diabetic group, where prior hydration with saline significantly reduced the incidence of CIN: 16% versus 50% in diabetics who did not receive saline infusion Conclusion: Despite current management, this pathology affects the cardiovascular prognosis of patients, even though normalization of renal function is usually achieved within a month of exploration. In addition to identifying factors predictive of NIPC with a view to implementing appropriate preventive measures in patients at risk, we stress the importance of ensuring a good hemodynamic state intra-procedurally27.

Point-of-care biomarkers of thrombotic status predict spontaneous reperfusion in ST-segment elevation MI and clinical outcomes

Abstract Background Spontaneous reperfusion, seen in ∼20% of patients with ST-segment elevation myocardial infarction (STEMI), manifests as normal epicardial flow in the infarct-related artery (IRA), with or without ST-segment resolution, before percutaneous coronary intervention (PCI). The drivers mediating this are unknown. Purpose We aimed to assess whether the thrombotic profile of patients with and without spontaneous reperfusion differed significantly, and whether such patients had better outcomes. Methods We performed a prospective, observational study in consecutive patients presenting with STEMI. Blood samples were taken from a 6 Fr arterial sheath immediately before emergency angiography, before PPCI, after dual antiplatelet therapy loading, but before the administration of heparin or other anticoagulant. Blood samples were tested using a point-of-care global test of thrombotic status, measuring occlusion (OT) and endogenous fibrinolysis (LT) times. Spontaneous reperfusion was defined as IRA TIMI III flow pre-PCI. Patients were followed for major cardiovascular events (MACE; death, myocardial infarction, stroke). Results Spontaneous reperfusion was associated with longer OT (435s vs. 366s, p&amp;lt;0.001) and shorter LT (1257s vs. 1616s, p&amp;lt;0.001), lower troponin and better LV function. LT was superior to OT for predicting spontaneous reperfusion (AUC for LT: 0.707, 95% CI 0.661-0.753; AUC for OT: 0.629, 95% CI 0.581-0.677). Amongst patients with spontaneous reperfusion, those with complete, versus partial ST-segment resolution, had longer OT (p=0.002) and shorter LT (p&amp;lt;0.001). Spontaneous reperfusion was unrelated to clinical characteristics or pain-to-angiography times. Over 4-years, patients with spontaneous reperfusion experienced fewer MACE than those without (4.1% vs. 10.6%, p=0.013), especially in those with both spontaneous reperfusion and complete ST-segment resolution (1.5% vs. 10.1%, p=0.029). Conclusions We demonstrate a novel haematological signature in STEMI patients with spontaneous reperfusion, namely reduced platelet reactivity and faster endogenous fibrinolysis, relating to smaller infarcts and improved survival. This indicates a role for modulating thrombotic status early following STEMI-onset, to facilitate spontaneous reperfusion and improve outcomes.Visual abstractThrombotic profile predicts outcome

Abstract 018: External carotid artery Pseudo aneurysm induced Internal Carotid Artery compression causing acute ischemic stroke

Introduction Here, we describe a patient in whom ischemic stroke was caused by compression of the Internal Carotid Artery (ICA) by a Pseudoaneurysm (PSA) of the External Carotid Artery (ECA) after Gun Shot injury. Eventually, the PSA of the Internal maxillary artery (IMAX) was embolized, resulting in resolution of the patient's symptoms. Methods Case Report Results A 75‐year‐old male with a history of atrial fibrillation on Eliquis presented to the emergency department after sustaining a gunshot wound to the left face. He had extensive injuries through the left masticator and submandibular space with an inferior orbital wall fracture. A Computed Tomography Angiography (CTA) neck showed injuries to the left proximal IMAX with a small PSA. As the PSA was asymptomatic it was managed with observation. On HOD day 13, CTA was done for a brief period of unresponsiveness, which showed high‐grade narrowing of left cervical ICA due to extrinsic compression from PSA which was supplied by a branch of the left ECA with distal re‐constitution (image A). The next day, patient developed right sided plegia and aphasia with NIHSS of 17. A CT head showed no acute intracranial abnormality. The patient underwent emergent Digital Subtraction Angiography (DSA), which demonstrated occlusion of the left cervical ICA from compression from a left IMAX PSA which was treated with n‐butyl‐cyanoacrylate TRUFILL embolization with resolution of flow limitation in the left cervical ICA (Image B1,B2). After embolization, the patient was oriented and able to lift right arm and leg anti‐gravity. Magnetic Resonance Imaging (MRI) was contraindicated due to retained bullet fragments. Repeat CT head did not show stroke. Conclusion A Pseudo aneurysm is characterized by a rupture of the arterial wall and the formation of an aneurysmal sac by the adjacent structures while the sustaining artery remains intact. The most prevalent causes are penetrating or acute blunt neck trauma, hyperextension injury, and injury to the base of the skull (1). Predisposing factors for PSA include carotid endarterectomy or a late complication of carotid artery dissection, infection, radiotherapy, and malignancy (1‐2). Cox et al. reported 124 patients with significant neck and head penetrating injuries. Eleven patients were found to have thirteen head and neck PSA: two in the ICA, one in the vertebral artery, and ten involving branches of the ECA. Two of seven symptomatic PSAs manifested with episodes of massive hemorrhage (3). There have been case reports describing the consequences of an elongated styloid process causing an ischemic stroke due to subsequent dissection and PSA formation (4). According to our knowledge, this case report is one of the first to describe acute ischemic symptoms resulting from ECA PSA‐induced ICA compression, with resolution of symptoms following PSA embolization. The educational value of our case lies not only in the rarity of the condition but also in the uniqueness of its presentation. This case is a fundamental addition to the existing literature on rare neuro‐vascular anomalies leading to potential catastrophic outcomes.

Vasculitis and Ischemic Stroke in Lyme Neuroborreliosis-Interventional Management Approach and Literature Review.

In rare cases, Lyme neuroborreliosis (LNB) can induce cerebral vasculitis leading to severe stenosis of the cerebral vasculature and consecutive ischemia. Therapy is based on anti-biotic treatment of the tick-borne disease, whereas interventional therapeutic options have not been assessed yet. We report on a patient with LNB and concomitant stenoses and progressive and fatal vasculitis of the cerebral vessels despite all therapeutic efforts by the departments of neurology and interventional neuroradiology. In this context, we also conducted a literature review on endovascular treatment of LNB-associated cerebral ischemia. A 52-year-old female presented with transient neglect and psychomotor slowdown (initial NIHSS = 0). MRI and serology led to the diagnosis of basal meningitis due to LNB with vasculitis of cerebral arteries. Despite immediate treatment with antibiotics and steroids, neurologic deterioration (NIHSS 8) led to an emergency angiography on day 2 after admission. Hemodynamically relevant stenoses of the MCA were treated via spasmolysis and PTA, leading to almost complete neurological recovery. Despite intensified medical treatment, the vasculitis progressed and could only be transiently ameliorated via repetitive spasmolysis. On day 19, she again presented with significant neurologic deterioration (NIHSS 9), and PTA and stenting of the nearly occluded MCA were performed with a patent vessel, initially without hemorrhagic complications. Despite all therapeutic efforts and preserved stent perfusion, vasculitis worsened and the concurrent occurrence of subdural hemorrhage led to the death of the patient. Neuroradiological interventions, i.e., spasmolysis, PTA, and, if necessary, stenting, can and should be considered in cases of LNB-induced vasculitis and stroke that are refractory to best medical treatment alone. Neuroradiological interventions can be considered in patients with vascular complications of Lyme neuroborreliosis as an additional extension of the primary drug therapy.

The value of computed tomography for head trauma in patients presenting with out-of-hospital cardiac arrest before emergency percutaneous coronary intervention.

Out-of-hospital cardiac arrest (OHCA) caused by an ST-elevation myocardial infarction (STEMI) is often accompanied by asudden loss of consciousness that may cause the patient to collapse with resulting head trauma, leading to asuspicion of possible intracranial haemorrhage. To rule out intracranial haemorrhage before emergency percutaneous coronary intervention (PCI), emergency computed tomography (CT) of the head might be useful but also causes adelay in percutaneous STEMI treatment. The medical records of all adult patients that presented with OHCA to the emergency department (ED) of the University Medical Centre Utrecht (UMCU), the Netherlands between 16February 2020 and 16February 2022 were reviewed. Atotal of 263 patients presented to the ED with an OHCA; 50presented with aSTEMI requiring emergency PCI. Thirty-nine (78%) patients with aSTEMI were immediately referred to the catheterisation laboratory and 11(22%) STEMI patients underwent aCT scan prior to emergency angiography; in no case was PCI deferred on the basis of the CT findings. The dominant indication for CT of the head was collapse, reported by 10patients and resulting in avisible traumatic head injury in 7patients. In none of the patients was intracranial haemorrhage detected. However, there was adelay between presentation to the ED and arrival at the catheterisation laboratory in patients who underwent CT of the head (mean 63 ± 25 min) before emergency PCI compared to patients without aCT scan (mean 37 ± 21 min). CT of the head did not result in adiagnosis of intracranial haemorrhage or deferral of PCI but did delay PCI treatment for STEMI in patients presenting with OHCA.

Spontaneous middle meningeal arteriovenous fistula without cortical venous reflux presenting with acute subdural hematoma: illustrative case.

Dural arteriovenous fistula (AVF) without cortical venous reflux (CVR) has a relatively benign course. Here, the authors describe a patient presenting with subdural hematoma due to a middle meningeal AVF without CVR. A 17-year-old male was admitted to the emergency department with acute headache without an episode of head trauma. Computed tomography demonstrated a left acute subdural hematoma (SDH). Because the nontraumatic SDH raised the suspicion of vascular pathology, emergent angiography was performed, which demonstrated an AVF fed by the middle meningeal artery and draining to the diploic vein via the serpentine meningeal vein without CVR. T2-weighted magnetic resonance imaging (MRI) revealed no signs of venous congestion. Given the proximity of the AVF to the SDH and the MRI findings, we suspected that the serpentine meningeal vein was responsible for the SDH. The patient was successfully treated with transarterial Onyx embolization. During the injection, Onyx migrated to the extravascular space following its penetration into the serpentine meningeal vein, suggesting the meningeal vein was a bleeding source of the subdural hematoma. Despite the absence of cortical venous reflux, serpentine meningeal venous drainage of middle meningeal AVF can be a source of subdural hemorrhage.

SPONTANEOUS RUPTURED OF RIGHT DEEP BRACHIAL ARTERY PSEUDOANEURYSM WITH UNDERLYING NEUROFIBROMATOSIS TYPE 1

Neurofibromatosis type 1 (NF-1) is known to develop vascular lesions, yet they are uncommon. If missed or ignored, it can be limb-threatening. When a ruptured pseudoaneurysm is clinically identified, rapid surgical intervention is required. We discuss a case of NF-1 that involved a spontaneous rupture of the right deep brachial artery. A 41-year-old woman reported sudden right arm swelling and intensifying pain. She was hemodynamically stable; however, her right arm was enlarged and tense on examination. A radiological test revealed a deep brachial artery haemorrhage. The patient was promptly referred to a vascular surgeon and had endovascular intervention performed. Early detection, emergency angiography, and endovascular treatment for vascular lesions should be initiated immediately.

A Multimodal Approach to Control of Massive Hemorrhage Secondary to Rectal Cancer.

The management of patients with symptomatic rectal masses can be challenging and is further complicated in cases of advanced age, comorbidities, prior surgeries, and acute hemorrhage. In this report, we describe a patient who presented with massive hemorrhage from a 7cm low rectal tumor with subsequent cardiac arrest. After return of spontaneous circulation, emergent pelvic angiography identified extensive tumor enhancement and blush off the anterior division of the right internal iliac artery from multiple parasitized vessels. The right internal iliac artery was embolized with multiple microcoils to decrease the tumor blood supply and slow the rate of bleeding. The patient was then taken directly from the angiography suite to radiation oncology for planning CT, and within several hours, underwent his first session of radiation. In conjunction with angioembolization, short-course radiation therapy can be an effective treatment modality for advanced bleeding rectal tumors not amenable to surgical resection.

A Case of Subacute Stent Thrombosis

A 67-year-old male presenting with an anterior ST-segment elevation myocardial infarction (STEMI) underwent stent placement in the left anterior descending coronary. The patient was discharged on an appropriate medical regimen containing dual antiplatelet therapy (DAPT). Four days later, the patient presented with repeat acute coronary syndrome symptomatology. Electrocardiogram demonstrated ongoing STEMI in the previously treated artery distribution. Emergency angiography revealed restenosis and total thrombotic occlusion. Post-intervention stenosis was 0% after aspiration thrombectomy and balloon angioplasty. Stent thrombosis is a high-mortality and therapeutically challenging condition requiring prepared clinicians who recognize predisposing risk factors and initiate early management.

Электрокардиографические изменения в раннем периоде после плановой реваскуляризации миокарда

INTRODUCTION: To date, highly effective methods of myocardial protection have been developed, which are widely used in cardiac surgery. At the same time, the problem of perioperative myocardial infarction still exists and is one of the causes of adverse cardiovascular events and mortality, both at the hospital stage of treatment and in the long-term period. A factor leading to such a complication may be acute dysfunction of the coronary bypass graft, the timely detection and elimination of which will reduce the negative consequences of myocardial damage. The relevance of the study results from investigation of the relationship between the angiographic data and the character of ischemic changes on the electrocardiogram of patients with and without proven acute dysfunction of coronary bypass graft. AIM: Identification of the most pathognomonic electrocardiographic signs of dysfunction of coronary bypass grafts in the early postoperative period after planned myocardial revascularization. MATERIALS AND METHODS: The study included 196 (1.86%) of 10,550 patients operated for coronary artery disease in Chelyabinsk Center of Cardiovascular Surgery from 2011 to 2020, who underwent emergency angiography after planned coronary artery bypass graft surgery due to the appearance of signs of myocardial damage in the early postoperative period. Depending on the type of angiographic findings and the chosen treatment tactics, patients were divided to 3 groups. Group I (n = 86) included patients in whom angiography revealed defects in the area of large bypassed coronary arteries, of them 60 patients underwent endovascular treatment, and 26 patients underwent repeated open surgery. Group II (n = 33) consisted of patients in whom bypass graft dysfunction was noted, but, however, due to the small diameter or pronounced diffuse lesion of the bypassed coronary arteries, all the patients underwent conservative therapy. Group III included 77 patients in whom hemodynamically significant defects in grafts and native arteries were not identified. RESULTS: When studying postoperative electrocardiographic data, it was found that significant differences between the groups were obtained only in the occurrence of ventricular arrhythmias (P1–2 = 0.027; P2–3 = 0.01). As for other pathological electrocardiographic signs and their combinations, no statistical differences were found. CONCLUSIONS: An isolated electrocardiographic study in the early postoperative period does not permit to identify patients with dysfunction of coronary bypass grafts. It is necessary to develop a diagnostic algorithm, including instrumental and laboratory methods, for accurate diagnosis of myocardial ischemia caused by impaired graft function or pathological deformation of the coronary bed due to surgical procedures.