Emergent Angiography Research Articles

The role of coronary collateral circulation in patients presenting with acute left main coronary artery occlusion

Abstract Introduction Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes. Methods In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)]. Results Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p<0.001) and inotropic/vasopressor therapy use (25.0 vs 69.0%, p=0.01) were less frequent in CC Rentrop 2–3 patients. The CC Rentrop 2–3 group had a significantly lower in-hospital (16.7 vs 53.5%, p=0.02) and 30-day mortality (9.1 vs 52.2%, p=0.01). In patients surviving hospitalization there was no significant difference in 1-year (30.0 vs 19.4%, p=0.48) and 5-year mortality (70.0 vs 77.4%, p=0.68). Conclusion A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients. Funding Acknowledgement Type of funding sources: None.

Effect of Respiratory Impairment on the Outcomes of Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction and Coronavirus Disease-2019 (COVID-19).

Coronavirus Disease-2019 (COVID-19) may impair outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The extent of this phenomenon and its mechanisms are unclear.Methods and Results:This study prospectively included 50 consecutive STEMI patients admitted to our center for primary percutaneous coronary intervention (PCI) at the peak of the Italian COVID-19 outbreak. At admission, a COVID-19 test was positive in 24 patients (48%), negative in 26 (52%). The primary endpoint was in-hospital all-cause mortality. Upon admission, COVID-19 subjects had lower PO2/FiO2 (169 [100-425] vs. 390 [302-477], P<0.01), more need for oxygen support (62.5% vs. 26.9%, P=0.02) and a higher rate of myocardial dysfunction (ejection fraction <30% in 45.8% vs. 19.2%, P=0.04). All patients underwent emergency angiography. In 12.5% of COVID-19 patients, no culprit lesions were detected, thus PCI was performed in 87.5% and 100% of COVID-19 positive and negative patients, respectively (P=0.10). Despite a higher rate of obstinate thrombosis in the COVID-19 group (47.6% vs. 11.5%, P<0.01), the PCI result was similar (TIMI 2-3 in 90.5% vs. 100%, P=0.19). In-hospital mortality was 41.7% and 3.8% in COVID-19 positive and negative patients, respectively (P<0.01). Respiratory failure was the leading cause of death (80%) in the COVID-19 group, frequently associated with severe myocardial dysfunction. In-hospital mortality of COVID-19 patients with STEMI remains high despite successful PCI, mainly due to coexisting severe respiratory failure. This may be a critical factor in patient management and treatment selection.

Development of a machine learning-based real-time location system to streamline acute endovascular intervention in acute stroke: a proof-of-concept study

BackgroundDelivery of acute stroke endovascular intervention can be challenging because it requires complex coordination of patient and staff across many different locations. In this proof-of-concept paper we (a) examine whether...

Adolescent With von Willebrand Disease Type 3 Spontaneous Abdominal Hemorrhage

An adolescent female classified as unstable with a spontaneous abdominal hemorrhage was transferred to a level 1 pediatric trauma tertiary emergency department. Pertinent medical history included von Willebrand disease type 3, menorrhagia, and obesity. Preparation before patient arrival included mobilization of multidisciplinary medical team experts in hematology, pharmacy, blood bank, radiology, and nursing who provided lifesaving interventions. The administration of factor products, blood products, interventional radiology, emergent hepatic angiography, and embolization coordination resulted in a successful outcome. After an 18-day intensive hospital course, the patient returned home close to her baseline health status.

Dynamics of Myocardial Remodeling Activity Markers in Patients with Myocardial Infarction with Persistent ST-Segment Elevation on the Background of Multivascular Coronary Artery Disease Depending on Diagnostic and Treatment Tactics

In patients with myocardial infarction with stable ST-segment elevation, the gold standard is to perform emergency angiography and stenting of the infarct-dependent artery. Meanwhile, the existing recommendations do not contain spe-cific treatment and diagnostic tactics for multivascular coronary pathology. The aim. To analyze the influence of different tactical approaches to the correction of multivascular atherosclerotic lesions of the coronary arteries on the processes of myocardial remodeling. Materials and methods. The study included 102 patients with multivascular coronary artery disease, who were randomly divided into 4 observation groups. The 1st group included 25 (24.5%) patients who had coronary angiography with occlusion of the infarct-dependent vessel and urgent stenting. Later, on day 2-3, the presence of hemodynamically significant stenosis of infarct-independent arteries was proved by determining fractional flow reserve and coherent to-mography with assessment of stability, size, length of atheroma and delayed stenting of these vessels. The 2nd group of observations included 26 (25.5%) patients who underwent stenting of the infarct-dependent artery, and on day 2-3 after the study of fractional flow reserve, but without optical coherence tomography, stenting of the infarct-independent vessel. The 3rd group included 25 (24.5%) patients who underwent simultaneous stenting of infarct-dependent and infarct-independent vessels after coronary angiography without additional angiographic studies (fractional flow reserve and coherent tomography). The 4th group included 26 (25.5%) patients who underwent only standard stenting of the infarct-dependent vessel and who were discharged from the department without further study of the circulation in the infarct-independent arteries and without interventions on them. All the patients received standard two-component an-tiplatelet therapy (acetylsalicylic acid 75-150 mg/day and clopidogrel 75 mg/day) and received atorvastatin 20 mg and ezetimibe 10 mg. The results obtained in patients were compared with similar results in 30 practically healthy people of the same age and sex. Markers of left ventricular myocardial remodeling activity were investigated by determining blood levels of matrix metalloproteinase-1 (MMP-1) and its tissue inhibitor 1 (TIMP-1). Results. Interventions without additional angiographic studies with complete revascularization of infarct-indepen-dent vessels (group 4) contributed to the long-term maintenance of the highest activity of MMP-1 against the background of virtually no activity of TIMP-1. Simultaneous stenting of the infarct-dependent and infarct-independent arteries only by the results of coronary angiography (group 3) contributes only to a slow decrease in the activity of metalloproteinase against the background of a slight increase in the activity of its inhibitor. Stenting of the infarct-dependent artery after coronary angiography with the study of only the fractional flow reserve without coherent tomography contributed to more active inhibition of metalloproteinase activity against the background of increase in concentrations of its inhibitor. The most active in relation to laboratory markers of myocardial remodeling was the tactic using angiographic examina-tion, determination of fractional flow reserve and coherent tomography, followed by a complete set of delayed revascu-larization. The use of delayed treatment of infarct-independent arteries using additional diagnostic techniques (study of fractional flow reserve and coherent tomography) can affect the activity of metalloproteinase 1 and its tissue inhibitor which are markers of activity of postinfarction remodeling.

149 Emergency Clot Retrieval and Stenting for Posterior Circulation Stroke

Abstract The current literature regarding the morphology and presentations of strokes due to basilar artery stenosis/occlusion is limited. This pathology is a rare cause of stroke and its management is not clearly decided in guidelines or published literature. Moreover, posterior circulation strokes are reported to be more devastating than anterior circulation. We present a case of a 68-year-old male who presented in an acute setting with reduced consciousness, myoclonic jerks, weakness and nausea due to a stroke from an occluded mid-segment basilar artery. MRI showed evidence of left cerebellar and right occipital infarcts. Emergent cerebral angiography was performed, and he was immediately treated by thrombectomy and stenting (Stryker Wingspan stent). The patient made a full recovery within one week and remained well at follow-up 3 months post-procedure. Emergency recanalization of basilar artery strokes, by clot retrieval and stenting, should be considered as a treatment option.

Internal carotid artery false aneurysm as a fatal complication of transsphenoidal surgery

False aneurysm of internal carotid artery (ICA) is a rare but serious vascular complication observed after transsphenoidal pituitary surgery. Here, we present a 41-year-old woman with a pseudoaneurysm in the ophthalmic1 segment of the left ICA after exoscopic transsphenoidal pituitary surgery. The initially uneventful procedure was complicated by a subarachnoidal hemorrhage 10 days after the surgery, which was confirmed by cranial computed tomography scan. The emergency angiography revealed a pseudoaneurysm of the ophthalmic1 part of the left ICA. Despite repeated endovascular treatments with a flow diverter and coiling, the patient experienced a re-bleeding with consecutive vasospasms, occlusion hydrocephalus and finally bifrontal intracerebral hemorrhage with fatal outcome. As a conclusion in irregular post-operative courses with for example headache, a post-operative magnetic resonance imaging with vessel presentation using TOF sequence and contrast-enhanced MRA might be recommended in order to detect a possible pseudoaneurysm in an early stage.

Indications to coronary artery bypass graft angiography in the early postoperative period

Aim. To determine indications to emergency coronary artery bypass angiography.Methods. 7,616 medical records of patients with coronary artery disease who underwent isolated CABG in the period from 2012 to 2019 at the Federal Center for Cardiovascular Surgery were reviewed. Of them, 103 (1.35%) patients underwent emergency coronary artery bypass graft angiography in the early postoperative period to verify signs of myocardial damage. Patients were assigned to two groups based on angiographic findings and selected treatment strategy. Out of 75 patients, 57 patients from Group 1 had no severe angiographic signs of occlusive changes of the grafts and native arteries. But 18 patients reported failed graft and required conservative management. Group 2 (n = 28) included patients who had failed coronary artery bypass grafts according to angiography findings. 20 patients underwent endovascular treatment, and 8 patients underwent repeated surgery. The control group included 30 patients (0.39%) without any signs of ischemic myocardial damage. Intraoperative flow was assessed as well as postoperative electrocardiographic and echocardiographic records. Biochemical markers of myocardial damage were measured.Results. Blood flow velocity was less than 20 ml/min, and the pulsatility index exceeded 3.0 according to the intraoperative flow assessment of coronary artery bypass grafts with impaired blood flow according to angiography findings. There was no relationship found between ischemic changes according to ECG, ECHO-CG, and angiographic findings. Significant differences were found in troponin I levels between Group 1 (patients with coronary artery graft dysfunction) and the control group (Group 3) at all time intervals (1, 6, 12, 24 and 48 hours).Conclusion. The predictors of failed coronary artery bypass grafts in the early postoperative period allowed identifying indications to emergency angiography.

Abstract 3: Early Recanalization of Large Vessel Occlusions by tPA on the Mobile Stroke Unit

Introduction: The benefit of intravenous tPA in acute ischemic stroke patients with large vessel occlusions (LVOs) is limited but time dependent. We evaluated pre-hospital treatment with tPA on the Mobile Stroke Unit (MSU) to explore the recanalization rate in patients with LVOs and its effect on clinical improvement upon ED arrival. Methods: Prospectively derived data were analyzed from patients on the Houston MSU who were treated with tPA and had LVOs identified by hyperdense artery on MSU CT or arterial occlusion on MSU CTA. The primary outcome was early recanalization, categorized as resolution of LVO on repeat vascular imaging in the ED or on emergent angiography versus no recanalization. Secondary outcome was change in baseline NIHSS at 24 hours. Differences in NIHSS were evaluated using Wilcoxon rank sum test with continuity correction. Results: Seventy-one patients received tPA and had proximal LVOs both in the anterior and posterior circulation. Eleven had recanalization on CTA upon ED arrival (15.5%), while 7 had recanalization on emergent angiography (9.9%). The total early recanalization rate with tPA was 25.4%. Forty-seven patients with persistent LVOs on ED arrival (66.2%) underwent endovascular thrombectomy (EVT). Time from symptom onset (last known normal) to tPA bolus did not differ significantly between the early recanalization vs non-early recanalization groups (64.5 minutes [IQR 43.0-78.5] vs 64.0 minutes [52.5-92.0]; p = 0.41). Early recanalization resulted in greater improvement in baseline to ED arrival NIHSS (median NIHSS change 4.0 [0-11.8] vs 0 [0-3.5]; p = 0.01). There were no differences in ED arrival to 24 hour NIHSS between the early recanalization versus non-early recanalization groups irrespective of EVT. Conclusions: Recanalization by ED arrival occurs in 25% of LVO patients with tPA treatment on a MSU and was associated with early clinical improvement. Subsequent EVT did not “make up” for the clinical benefit of early recanalization.

Dilated cardiomyopathy-related stroke mimicking large-artery atherosclerosis-related stroke: report of two cases

The clinical characteristics and treatment of stroke caused by dilated cardiomyopathy (DCM) are not clear, especially in patients with large-artery atherosclerosis (LAA)-related stenosis, which commonly causes acute ischemic stroke (AIS); therefore, the diagnosis and treatment of such patients are challenging. Herein, we summarize the clinical characteristics and suggest clues to guide the diagnosis and treatment of two cases. Case 1: A 67-year-old woman with a history of DCM presented with sudden-onset slurred speech and left limb weakness (&gt;2 hours duration), which worsened after intravenous thrombolysis. Repeated brain computed tomography showed no hemorrhage; thus, cerebral artery occlusion or embolism was suspected. Emergency magnetic resonance imaging (MRI) and angiography (MRA) revealed acute multiple bilateral cerebral infarctions and severe left middle cerebral artery stenosis, respectively. We considered a DCM-related stroke and administered anticoagulation therapy. Subsequently, the patient’s symptoms improved significantly, and she was discharged on day 9, after showing no abnormal neurological signs. Case 2: A 49-year-old man with a history of DCM presented with acute headache and blurred vision for 4 days. MRI and MRA revealed multiple acute cerebral infarctions and left vertebral artery stenosis, respectively. We considered an LAA-related stroke and administered antiplatelet and cholesterol-lowering drugs. Eventually, the patient was discharged on day 13, after his right-sided hemianopia improved significantly. Both patients had LAA, which can be easily misdiagnosed as a stroke. LAA-related and DCM-related stroke need to be differentiated. DCM-related AIS lesions are often distributed in the areas supplied by the different cerebral arteries. It is necessary to carefully analyze the shape, location, and scope of the lesions, and identify the main causes of stroke. Anticoagulant therapy is preferred for DCM-related AIS.

How Do We Perform Imaging Tests before Treating Cerebral Aneurysms?

Acquiring appropriate preoperative images is an important step in the treatment of cerebral aneurysms. Despite recent advances in contrast-enhanced CT and MRI, catheter angiography remains the standard of care in preoperative imaging tests for both ruptured and unruptured intracranial aneurysms. Three-dimensional rotational angiography can provide a clear view of vascular structure around the aneurysm in an intuitive manner, including the small perforators. For ruptured aneurysms, the treatment modality(i.e., surgical clipping or endovascular embolization)is usually based on emergent contrast CT and catheter angiography findings. For unruptured aneurysms, integrated assessment involving CT, MRI, and angiography is often useful in multimodal treatment decision making.

Contrast nephropathy incidence after coronary angiography among patients with acute renal dysfunction

Aim: Contrast-induced acute kidney injury (AKI) may be seen after contrast agent exposure which is known as nephrotoxic. It is fact that, patients with AKI have an increased risk after contrast exposure compared to patients with normal renal function values. However, the incidence of contrast nephropathy after contrast exposure with AKI is not clear. In this study, we planned to investigate the incidence of contrast nephropathy in patients undergoing coronary angiography with AKI and whether there is an increased risk compared to the control group. Materials and Methods: The study was planned as a retrospective study and we investigated the clinical outcome of patients who underwent isoosmolar contrast angiography in the arterial phase with acute kidney injury between January 2014 and December 2017. Results: The number of AKI patients included in the study was 280 and the control group consisted of 478 participants. There was no statistically significant difference between two groups. (3.2% (n: 9) of patients with AKI contrast nephropathy vs 6.5% (n: 31) of patients with normal kidney function and contrast nephropathy) (p> 0.05). On the other hand, there was statistically significant difference between two groups according to diabetes mellitus (patients with contrast nephropathy 26 (65%) had diabetes vs 14 (35%) participants had no diabetes). This difference was statistically significant (p <0.05). Conclusion: In this study, in patients who underwent emergency angiography with a preliminary diagnosis of acute coronary syndrome in the emergency department, we did not find an increased risk of acute renal injury and contrast-enhanced nephropathy compared to the patient population with normal kidney function.

Definitive Repair of Injuries to the Liver During Initial Trauma Laparotomy.

Numerous surgical approaches and hemostatic techniques are used and have been described when operating on the traumatized liver. Despite a substantial decline in operative liver trauma, there still remains a debate on the optimal surgical approach, and goals, during the initial trauma laparotomy. Hepatic resection during the first operation, including the damage control settings, is advocated and practiced in only a select few institutions and remains highly controversial. Here, we describe our success with hepatic resection, repair, and/or hepatic vascular repair, during the trauma laparotomy with our emphasis on the collaboration between the trauma and hepatobiliary surgical teams. From 207 patients with liver injuries during the study period, 7 patients had definitive liver resection or repair during the initial trauma laparotomy. One had hepatic tissue repair, 1 had hepatic vein repair, and 5 had liver resections. All the operations involved a hepatobiliary surgeon together with the trauma team. There were no fatalities in the liver operation group, no sepsis, or need for emergent angiography because of hemorrhage. Four patients needed endoscopic retrograde cholangiopancreatography (ERCP) and stenting because of biliary leak. Three patients were discharged home and 4 to rehabilitation. Hepatic resection, and/or definitive hepatic repair, may be safe and beneficial to the patients during the initial operation even in a damage control setting when the patients' overall condition allows. We emphasize the benefit of collaboration with experienced and trained liver surgery, especially in lower volume trauma centers. ERCP is commonly needed for postoperative biliary leak and should be readily utilized.

Unstable Angina and Non-ST Segment Elevation Acute Coronary Syndrome

Unstable angina and non-ST-segment acute coronary syndrome represent a frequent and serious presentation to the emergency department. While most patients present with chest discomfort, atypical presentations warrant that clinicians maintain a high index of suspicion. This review summarizes the present nomenclature, definitions, and pathophysiology for this high morbidity disease process. The rapid acquisition of an electrocardiogram and serial cardiac troponins are mainstays of diagnosis. Also outlined is an approach for initial assessment, high-risk ECG findings, risk stratification, biomarker strategies, and subsequent stabilization. Once diagnosed, treatment options for these patients aim to halt continued ischemia and resultant necrosis. These therapies may include agents such as supplemental oxygen, nitrates, anti-platelet agents, beta blockers, anti-coagulation, anti-thrombin and statin therapies in appropriate settings. Caution should be exercised when dosing high-risk patients for bleeding such as those who are elderly or who weigh less than 60kg. Emergent angiography is reserved for patients who develop hemodynamic instability, cardiogenic shock, pulmonary edema, persistent angina refractory to medical therapy, and sustained arrhythmia. This review contains 2 figures, 12 tables, and 64 references. Keywords: acute coronary syndrome, unstable angina, myocardial infarction, troponin, electrocardiogram

Role of Intraoperative Neurophysiologic Monitoring in Internal Carotid Artery Injury During Endoscopic Endonasal Skull Base Surgery

In the present study, we investigated the role of intraoperative neuromonitoring (IONM) in internal carotid artery (ICA) injury during endoscopic endonasal skull base surgery (EESBS). The study group included all 13 patients who had experienced an ICA injury during EESBS with IONM from 2004 to 2017. The medical records were reviewed for the perioperative data. The IONM reports were reviewed to evaluate the baseline somatosensory evoked potentials (SSEP), electroencephalography (EEG), and brainstem auditory evoked potentials (BAEP) and their significant changes related to ICA injury and/or the subsequent surgical/endovascular interventions. All 13 patients had undergone SSEP and 7 patients had BAEP monitoring during surgery. EEG was added during emergent angiography following the surgery for 5 patients. Two patients showed significant SSEP changes, and one showed significant SSEP and EEG changes, indicating cerebral hypoperfusion. Of these 3 patients, patient 1 had experienced irreversible SSEP loss with postoperative stroke. Patients 2 and 3 had SSEP and/or EEG changes that had recovered to baseline after interventions without postoperative deficits. Despite ICA injury, 10 patients showed no significant SSEP and/or EEG changes, and all 7 patients with BAEP monitoring showed no significant BAEP changes, indicating adequate cerebral and brainstem perfusion, respectively. The injured ICA was sacrificed in 4 patients, of whom 3 showed stable SSEP and 1 had experienced irreversible SSEP loss. IONM correlated with the postoperative neurologic examination findings in all cases, adequately predicting the neurologic outcomes after ICA injury. SSEP and EEG monitoring can accurately detect cerebral hypoperfusion and provide real-time feedback during surgery. SSEP and EEG changes predicted forneurologic outcomes and guide surgical decisions regarding the preservation or sacrifice of the ICA. Comprehensive multimodality monitoring according to the surgical risks can serve to detect and guide the management of ICA injury in EESBS.

Inferior ST-elevation myocardial infarction managed with a pharmacoinvasive strategy and conservative management of delayed atrioventricular block: classical case report.

BackgroundThe 2017 ESC guideline on patients with ST-segment elevation myocardial infarction (STEMI) provides guidance regarding the optimal management of these patients. Transient atrioventricular (AV) block is a relatively common complication of inferior STEMI and its management is also addressed in the guidelines.Case summaryA 64-year-old gentleman with multiple cardiovascular risk factors presented to the emergency department with a history of ischaemic type chest pain and evidence of inferior ST-segment elevation on his electrocardiogram (ECG). First-degree AV block was noted on his initial ECG. He was given thrombolytic therapy as part of a pharmacoinvasive strategy of reperfusion. He, however, failed fibrinolytic therapy, and emergency angiography revealed critical disease of the right coronary artery which was successfully stented. Subsequent to reperfusion, he developed complete AV block without evidence of re-infarction, which was managed conservatively with successful resolution of the block after 7 days of expectant management with temporary transvenous pacing.DiscussionWe highlight some of the important management principles from the ESC guideline of STEMI including timing and the management of AV block in these patients. In addition, we highlight the role of a pharmacoinvasive strategy for reperfusion where timeous primary percutaneous coronary intervention cannot be performed. The usefulness of such a strategy within the COVID-19 era is also emphasized.

The de Winter's pattern revisited: a case series.

BackgroundThe de Winter’s electrocardiogram (ECG) pattern signifying proximal left anterior descending (LAD) artery occlusion was first described in 2008. The ECG changes were thought to be static and mechanisms for this were suggested. In addition, the optimal management of these patients was reported to be via a primary percutaneous coronary intervention (PCI) strategy.Case summary Case 1: A 48-year-old gentleman presented with a 2-h history of ischaemic chest pain with initial de Winter’s pattern on ECG. This progressed to anterior ST-elevation myocardial infarction (STEMI) complicated by ventricular fibrillation. Emergency angiography revealed a mid-vessel LAD occlusion which was successfully reperfused. Case 2: A 34-year-old female presented with a 2-h history of ischaemic chest pain with initial ECG showing a de Winter’s pattern. Due to concerns of performing PCI timeously, a pharmacoinvasive strategy of reperfusion was adopted with resolution of the de Winter’s pattern. Urgent angiography revealed a proximal LAD lesion which was successfully stented.DiscussionThe two cases highlight that the de Winter’s pattern may in fact not be static, but rather lie along the continuum of ischaemia and may evolve into STEMI. In addition, we provide further evidence that if primary PCI cannot be offered in a timeous manner, thrombolytic therapy may be considered in such patients. The de Winter’s pattern remains a high-risk ECG pattern that requires early recognition and intervention.

The “Real” Incidence of Popliteal Artery Injury After Knee Dislocations and Fractures

Popliteal arterial injury (PAI) after knee trauma is associated with an increased risk of limb loss and higher mortality rates; however, its specific incidence and mechanism risk association remains unknown.1,2 Although the concomitance of PAI with knee dislocations (KDs) has been well established, with mandatory emergency angiography being included in the standard of care of KD diagnosis until the early 2000s, previously reported incidence rates of PAI in KD are highly heterogeneous, ranging between 5% and 60%.

S2105 Isolated Cecal Varices: A Rare Cause of Hematochezia

INTRODUCTION: Ectopic varices (outside gastro-esophageal region) are uncommon in patients with portal hypertension (PH) and account for 5 % of all variceal bleeding cases. Isolated cecal varices (ICV) without pancolonic varices are extremely rare with only handful of cases reported so far. Here we present a case of bleeding from ICV in patient with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 55-year-old male with history of alcoholic cirrhosis (last alcohol use 1 y ago), CKD3 was admitted with 1 day history of hematochezia and dizziness. Hemoglobin on admission was 5.8 gm/dL, platelet 126 b/L and INR 1.4. After initial resuscitation, he underwent EGD which revealed non-bleeding grade 2 esophageal varices which were banded. He continued to have hematochezia. He subsequently underwent colonoscopy which revealed a 4 cm area of granularity in cecum. This area was biopsied following which sudden spurting of blood was seen. He was sent for emergent abdominal CT angiography, which came back negative for active arterial bleeding. Retrospectively, the area of granularity in cecum was thought to represent an ICV. There was spontaneous cessation of bleeding and the patient was discharged in next few days. Two months later, he presented to our hospital for similar episodes of lower GI bleeding. EGD showed non-bleeding grade 1 esophageal varices. Due to suspected bleed from ICV, patient was taken for emergent TIPS. Mesenteric angiogram showed contrast extravasation from a large cecal varix. TIPS and coil embolization of cecal varix was performed resulting in hemostasis. DISCUSSION: Ectopic varices occur in the small intestine, biliary system, colon, rectum, and surgical ostomy sites and can develop in the setting of PH, prior abdominal surgery, vascular thrombosis, or anomalies of the venous outflow vessels. ICV without pancolonic involvement are extremely rare as less than 20 cases have been reported so far in English literature. Almost all the reported cases have presented with massive lower GI bleeding. Usually EGD is performed to rule out more common upper GI bleeding from esophageal varices. CT angiography may be obtained but extravasation may only be seen in the venous phase. No- bleeding ICV can be missed on colonoscopy as over-insufflation can cause the collapse of such varices. Exsanguinating ICV are usually treated by performing emergent TIPS with or without adjunctive variceal embolization.Figure 1.: Colonoscopy showing area of granularity in cecum representing cecal varix (left). Active bleeding seen when this area was mistakenly biopsied (right).Figure 2.: Abdominal angiogram showing large isolated cecal varix with extravasation of contrast.Figure 3.: Fluoroscopic image showing coil embolization of the cecal varix.

S1513 Liver Biopsy Leading to Hemobilia Complicated by Cholangitis, Biliary Pancreatitis, and Massive Gastrointestinal Hemorrhage

INTRODUCTION: Percutaneous liver biopsies (PLB) are performed routinely to investigate liver masses, unexplained hepatomegaly or abnormal liver chemistries and are relatively safe in the absence of coagulopathy. Here, we present a rare complication of PLB: arterio-biliary fistula presenting with delayed onset of hemobilia, massive gastrointestinal hemorrhage, acute cholangitis and acute biliary pancreatitis requiring emergent embolization and antimicrobial therapy. CASE DESCRIPTION/METHODS: A 62-year-old female recently diagnosed primary biliary cholangitis presented with hematemesis, hematochezia and jaundice 1 week after percutaneous liver biopsy. On admission, she was febrile, hypotensive and tachycardic. Physical exam was notable for scleral icterus, jaundice and right upper quadrant abdominal tenderness with voluntary guarding. Rectal exam revealed a large amount of bright red blood. Laboratory data was significant for hemoglobin of 7.7 g/dL from 11.1 g/dL prior to liver biopsy, total bilirubin 7.5 mg/dL (1.0 unconjugated/4.5 conjugated), ALP 587 U/L, GGT 504 U/L, AST 98 U/L, ALT 83 U/L, lipase 3017 U/L. CT angiography of the abdomen showed contrast throughout the proximal hepatic and common bile ducts concerning for active bleeding from an arterio-biliary fistula resulting in hemobilia, moderate biliary dilation, and bowel contents concerning for intraluminal bleeding from the biliary system. She was treated with broad-spectrum antibiotics and successfully resuscitated with IV crystalloids and blood products. She underwent emergent mesenteric angiography with left hepatic artery and arterioportal fistula coil embolization which resulted in hemostasis and rapid normalization of liver chemistries. DISCUSSION: Major gastrointestinal bleeding complications due to iatrogenic arterio-biliary fistula formation after PLB are exceedingly rare, occurring less than 1% of the time due to needle intersection with the portal triad, resulting in epithelialized shunt formation between the hepatic artery and bile duct. This case represents a later presentation of hemobilia, which typically occurs within 24 hours of PLB. The accumulation of blood clots in the biliary tree can lead to life threatening cholangitis and biliary pancreatitis. Early recognition of this complication is essential as urgent embolization and aggressive antimicrobial therapy can lead to a significant reduction in mortality.Figure 1.: CT angiogram abdomen/pelvis: contrast visible in the common hepatic duct.Figure 2.: Pre-embolization: segment 3 branch of hepatic artery.Figure 3.: Post-embolization: segment 3 branch of hepatic artery.