Epiaortic Vessels Research Articles

ALTERNATIVE STRATEGIES FOR LEFT SUBCLAVIAN ARTERY REVASCULARIZATION DURING ZONE–2 AORTIC ARCH SURGERYEMENT

Abstract Objective Anatomical extension of surgical treatment of thoracic aortic pathologies involving the aortic arch is still controversial. The adoption of distal anastomosis in aortic arch zone–2 (Z2–AAR), in order to facilitate bleeding control, has been widely recommended. In such case the revascularization of left subclavian artery (LSA) may add further concerns. Here we report our different strategy of LSA revascularization in 2 different scenario of Z2–AAR Clinical. Cases Case#1 17 yo male patient affected by Loeys–Dietz Syndrome and a previous David procedure at age of 11yo. He presented complaining chest pain and CT scan revealed a dilatation (5,8 cm) of ascending aorta and an intimal flap with preserved previous distal anastomosis. Surgical strategy #1 (Left subclavian artery in situ): Arch replacement (Zone 2 distal anastomosis) with Siena Graft 24mm and modified Elephant Trunk Tecnique (2cm distal endoluminal graft). Innominate artery and left carotid artery reimplantation. Distal Anastomosis Siena 24 (Z2). Case #2 78 yo male with a previous (6 month before) Biological AVR (Trifecta 25) + ascending aorta replacement (Jotec 30). Presented complaining acute chest pain, CT Scan revealed a residual dilatation of distal ascending aorta, dissection/rupture of distal aortic arch at level of a complicated plaque. Surgical strategy #2 (Left subclavian artery reimplanted): Arch replacement (Zone 2 distal anastomosis) with Siena Graft 30mm and Elephant trunk Teccnique (10cm distal endoluminal graft). Closure of the extended ulcera. Total epiaortic vessels de–branching 10 mm Tube on LSA – Distal Anastomosis Siena 30 (Z2). Conclusion Surgical extension of aortic arch replacement is still matter of discussion. Zone–2 approach for aortic arch replacement seems a safe and effective option. In our mind strategy for left subclavian revascularization should be tailored according patient’s anatomy and potential future scenarios.

A RARE CASE OF TYPE A AORTIC DISSECTION PRESENTING AS ACUTE STROKE: A DIAGNOSTIC CHALLENGE

Abstract A 60–year–old woman presented to the emergency department with acute left hemiplegia, not chest pains. Past medical history was significant for family history of aortic aneurysm, arterial hypertension. At brain–CT was reported hypodensity areas in posterior arm of the right internal capsule and in right tempero–polar lobe, confirmed on brain–MRI, and compatible with acute ischemic injury. Echocolor–dopper of epiaortic vessels documentated ulcerated plaque into the right common carotid artery (CCA). Selective catheterization found focal dissection obstructing the flow, treated with self–expanding stent. On echocardiography evalutation for suspiction of TAAD: dilatation of ascending aorta with flap oscillation, severe arotic regurgitation, pericardial effusion (Fig. 1). CT–Angiography was performed with evidence of type A dissection extending superiorly to the right CCA and inferiorly to the iliac bifurcation. For coma state, the patient was mechanically ventilated, and seriate CTs showed new ischemic lesions and hemorrhagic infarction of previous. Because of contraindication for cardiac surgery due neurological state, the patient was referred at medical therapy as bridge to hybrid aortic arc substitution at resolution of intracranial hemorrhages. In the next days there was progressive improvement neurological status with restoration of sensory and autonomic breathing with hemodynamic stability. Aortic dissection (AD) is defined as a disruption of the medial layer leading to the formation of two lumens separated by an intimomedial flap. AD is a critical diagnosis to make due to life–threatening outcomes and its non–specific presentation as in the case of our patient where the management of AD was delayed due to an unusual initial clinical presentation. Multimodality imaging approach has been fundamental for correct diagnosis and risk stratification. A limited number of studies have reported cases with stroke as the first symptom with concomitant TAAD. Concomitant intracerebral hemorrhage and TAAD is a very rare presentation and the optimal timing of surgery in these patients is unknown. In our opinion, patients who presents acute stroke should be carefully evaluated using multimodal imaging to exclude TAAD before administering reperfusion therapy. In addition, performing CAS before surgery for TAAD is challenging but might be a valid treatment option to maintain good brain perfusion and improve prognosis, but further investigations are needed.

P167 CARDIAC ARREST IN SUSPECTED LONG QT: APPROACH TO ARRHYTHMIC MITRAL VALVE PROLAPSE

Abstract Mitral valve prolapse is a common condition. It affects 1–3% of the population. Clinical manifestations range from the absence of symptoms to sudden cardiac death. The arrhythmogenic mechanism is related to fibrotic changes in myocardial posterior caused by valve prolapse. ECG abnormalities indicative of high risk are inverted or biphasic T waves, ST depression, QT prolongation or dispersion, and BEV originating from the left outflow tract or papillary muscles. The echocardiogram allows the identification of mitral prolapse and disjunction of the mitral annulus (MAD), while MRI shows fibrosis. ICD implantation should be considered in high–risk patients with documented ventricular arrhythmias. Clinical case A 29–year–old woman with a family history of sudden cardiac death reported a state of absolute well–being until September 2022 when she presented with syncope with referred pulse failure for which she underwent cardiac massage, without defibrillation, by family members. At the arrival of 118 the patient presented bigeminal ventricular extrasystole with superior axis and BBsx type morphology (Fig.1). When she arrived at the hospital, ECG showed long QT (484 ms) associated with hypokalemia (2.8 mmol / l). During hospitalization, the coronary angiography was normal, while the cardiac MRI showed a globular and dilated left ventricle with preserved EF, thickening of the mitral leaflets, prolapse of both leaflets more evident at the level of P2/P3, MAD more evident in P3 with separation maximum end–systolic of 12 mm and absence of edema (Fig. 2). The patient underwent ICD implantation. In the presence of hypertelorism, prognathism, and flat feet, even in the absence of anomalies affecting the aorta and epiaortic vessels, scarring defects or ease to joint sprain, genetic screening was started for channelopathies and collagen diseases. Conclusions The approach to the patient with cardiac arrest and typical facies must be based on a systemic overview of the patient, whose phenotypic characteristics may suggest involvement of connective tissue diseases. In the future, the cardiologist must develop adequate knowledge to fully collect the information that the patient provides not only during instrumental examinations but also during an adequate clinical objective examination and facies, possibly supported by artificial intelligence.

Right cervical aortic arch associated with anomaly of epiaortic vessels and haemodynamically significant obstruction between ascending and descending aorta. Extra-anatomic bypass graft between ascending and descending aorta and long-term follow-up.

Right cervical aortic arch is a rare malformation in which a right-sided aortic arch is unusually long, forms a loop, descends, and crosses behind the oesophagus to continue as a left descending aorta. We present a case of right cervical aortic arch associated with anomaly of epiaortic vessels and aortic obstruction, surgically treated with extra-anatomic bypass graft between ascending and descending aorta.

11 PRINTING 3D MODELS OF THE HEART: CAN IT HELP IN UNDERSTANDING THE COMPLEX ANATOMY?

Abstract The use of 3D printing in the medical field is widespread especially in the dental clinic as a support to orthodontic / implant therapy. In the training of personnel relating to cardiological diagnostic methods, can it be useful to shorten the learning curve of human anatomy? A light-curing liquid resin 3D printer was used to obtain anatomical models that faithfully reproduce the real anatomy of the individual patient. The starting model was obtained from CT with contrast medium performed on patients. Depending on the diagnostic question, CT may contain complete information on both the arterial circulation and the venous circulation of the heart and the epiaortic vessels. From this information a 3D surface reconstruction is obtained which, once reworked, can be used directly for printing. The model size is limited by the print volume of the printer which may vary depending on the printer model. The model to be printed obtained from CT acquisitions the 3D model will be the representation of the lumen of the vessels and cavities of the heart. The models obtained faithfully represent the anatomical reality of the patient who underwent CT with contrast medium. Actual size is affected by the print volume size of the printer model. In my experience in university teaching, the models obtained with 3D printing have been found to be very useful for understanding the complex spatial configuration of the anatomy of the heart and great vessels

564 AN UNUSUAL PRESENTATION OF ICA DISSECTION. A CASE OF TRANSIENT GLOBAL AMNESIA IN A PATIENT WITH PAINLESS SPONTANEOUS INTERNAL CAROTID ARTERY DISSECTION

Abstract Image focus A 42-year-old woman was carried to emergency room lamenting sudden memory loss. Her husband witnessed the onset of the episode. No recent head trauma was reported, blood pressure was under control. Anterograde and retrograde memory loss was present and confirmed by a neurologist. No other neurological signs were elicitable. Blood exams and toxicological analysis were negative. ECG, chest radiography, and cerebral TC showed no abnormalities. At physical examination a carotid bruit could be appreciated. We performed an eco-color-Doppler of carotid artery that showed a left common and internal carotid artery dissection (figure 1). The diagnosis of ICA dissection was confirmed with a contrast CT. The coexistence of an aortic dissection was excluded with the same imaging technique. The anterograde amnesia resolved 15 h after the admission. A neurologist confirmed that the patient experimented an episode of transient global amnesia (TGA). After a vascular surgery consultation, a conservative treatment was deemed appropriate. After a 6 month follow up the patient didn't complain of any other neurological symptom or sign. Transient global amnesia (TGA) is characterized by reversible anterograde and retrograde amnesia of sudden onset. This amnesic syndrome resolves spontaneously within 24 h. Annual incidence rate for all ages of spontaneous ICA dissection is approximately of 2.6 per 100 000 inhabitants, however data are extremely variable among different studies. TGA has never been associated with a spontaneous ICA dissection. In order to not miss a spontaneous ICA dissection as a rare ethology of TGA, we suggest performing an eco-color-Doppler of the epi-aortic vessels in patient affected by such amnesic syndrome.

Chimney Stenting Versus Surgical Debranching for the Treatment of Aortic Arch Pathologies—A Propensity-Matched Analysis

Endovascular repair of aortic arch lesions requires revascularization of epiaortic vessels in case of coverage. The objective of this study was to compare the outcomes of surgical bypass versus endovascular reconstruction with a chimney graft. A retrospective analysis of a multicenter register between January 2005 and December 2019 was performed. A total of 127 patients were included and divided into 2 groups: thoracic endovascular aortic repair+surgical debranching (n=72) and thoracic endovascular aortic repair+chimney stenting (n=55). The main end points were major neurologic sequelae and type IA endoleak. Propensity score matching was performed to analyse baseline variables related to these outcomes. The mean follow-up was 35.6months for the debranching group and 34.1 for the chimney group (P=0.65). The incidence of stroke was higher in the chimney group although not statistically significant (7.3% vs. 4.1%; P=0.46); for both groups, a wide angle between the ostium of the target vessel and the aorta and landing in Ishimaru Zone 0 was found to be the main predictors for major neurologic sequelae (P=0.002 and P=0.003, respectively). During follow-up, 9 (12.5%) type IA endoleaks occurred in the debranching group and 12 (21.8%) in the chimney group (P=0.14). Aortic diameter larger than 66mm and arch angle >46° had a strong association with proximal endoleak incidence (P=0.001 and P=0.011, respectively) CONCLUSIONS: Surgical debranching showed better results than chimney stenting in terms of major neurologic events incidence and type IA endoleak, although the difference between the groups was not statistically significant. Further research with larger cohorts is needed to establish the indications for these procedures.

The need for custom made frozen elephant trunk: when and where.

The frozen elephant trunk (FET) technique is an increasingly common procedure to treat complex extensive aortic disease both in elective and emergency setting. In a contemporary era, several prostheses are available to be used by surgeons performing such procedures, merging the advantages of endovascular and conventional surgery and preparing a more useful landing zone for second-stage downstream endovascular or open repair. Thoraflex hybrid (Terumo Aortic, Scotland) is a largely used hybrid vascular device merging a conventional surgical vascular graft made of gelatin-sealed woven polyester graft with a nitinol self-expanding stent graft. Since its release in 2012, this prosthesis has gained a large consensus, mainly for the plexus version, which allows for single reimplantation of the epiaortic vessels. In the last few years, new devices have come out to offer new specific weapons to be used by the surgical team in different clinical scenarios. In this context, the need of making the supra-aortic vessel debranching easier and more functional to our surgical technique has pushed our demand for a customization of a conventional Thoraflex hybrid. Here we report a modification to its standard design, the concept beyond the “Custom device” and its potential advantages with regards to our peculiar implantation technique and intraoperative cerebral perfusion during circulatory arrest time.

Ultrasonographic Assessment of Atherosclerotic Renal Artery Stenosis in Elderly Patients with Chronic Kidney Disease: An Italian Cohort Study.

Although atherosclerotic renal artery stenosis (ARAS) is strictly associated with high cardiovascular risk and mortality, it often may remain unrecognized being clinically silent and frequently masked by co-morbidities especially in elderly patients with coexisting chronic kidney disease (CKD). The present observational study was conducted in elderly CKD-patients with atherosclerosis on other arterial beds. The aims were assessment of (1) ARAS prevalence; (2) best predictor(s) of ARAS, using duplex ultrasound; and (3) cardiovascular and renal outcomes at one-year follow-up. The cohort was represented by 607 consecutive in-patients. Inclusion criteria were age ≥65 years; CKD stages 2–5 not on dialysis; single or multiple atherosclerotic plaque on epiaortic vessels, abdominal aorta, aortic arch, coronary arteries, peripheral arteries that had been previously ascertained by one or more procedures. Duplex ultrasound was used to detect ARAS. Multiple regression analysis and ROS curve were performed to identify the predictors of ARAS. ARAS was found in 53 (44%) out of 120 patients who met the inclusion criteria. In univariate analysis, GFR (b = −0.021; p = 0.02); hemoglobin (b = −0.233; p = 0.02); BMI (b = 0.134; p = 0.036) and atherosclerosis of abdominal aorta and/or peripheral vessels (b = 1.025; p < 0.001) were associated with ARAS. In multivariable analysis, abdominal aorta and/or peripheral atherosclerosis was a significant (p = 0.002) predictor of ARAS. The area under the ROC curve was 0.655 (C.I. = 0.532–0.777; p = 0.019). ARAS is common in older CKD patients with extra-renal atherosclerosis, with the highest prevalence in those with aortic and peripheral atherosclerosis. ARAS may pass by unnoticed in everyday clinical practice.

P124 ECOCARDIOGRAPHIC DIAGNOSIS OF TYPE A AORTIC DISSECTION

Abstract Clinical case In August 2021, an 89–year–old woman with no previous cardiovascular history, suffering from systemic arterial hypertension under pharmacological treatment, dyslipidemia and M. di Parkinson came to our observation for syncopal episode. The clinical presentation was characterized by a syncopal episode in the absence of prodromes and reported chest pain upon awakening. At the time of arrival in PS the patient was alert, attentive, and oriented, asymptomatic, hemodynamically stable with PAS 90 mmHg, with normo–iso–sphygmic peripheral pulses. A cardiological evaluation was requested and the transthoracic echocardiography revealed dissection of the proximal ascending aorta with evidence of intimal flap starting from the aortic root and extending to the proximal tract of the aortic arch, moderate aortic valve insufficiency and moderate circumferential pericardial effusion (2 cm), with the presence of blood clots, in the absence of signs of hemodynamic compromise. CT angiography confirmed Stanford type A aortic dissection with intimal flap originating in the supravalvular site (maximum diameter 6 cm), longitudinally extended for about 6 cm at the level of the ascending aorta until the emergence of the epiaortic vessels which were not involved. Consequently, cardiac surgery teleconsultation was required which, based on the patient‘s advanced age, did not allow surgical treatment due to a prohibitive operative risk, considered comparable to the natural course of the disease. The patient was then admitted to intensive care where remained asymptomatic and in cardio–circulatory compensation until death occurred on the third day due to cardio–circulatory arrest from PEA. Conclusions Aortic dissection is a high–mortality condition that requires an immediate diagnostic–therapeutic approach. In the diagnostic process, transthoracic echocardiography represents the most promptly performed examination and not infrequently allows the diagnosis before radiological confirmation by angioTC.

Cardiovascular disease risk in liver transplant recipients transplanted due to chronic viral hepatitis.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality after liver transplantation, mostly in patients transplanted for nonalcoholic steatohepatitis, obesity and diabetes. Few data exist on cardiovascular diseases among patients transplanted for viral hepatitis. Our aim is to clarify the cardiovascular risk and subclinical vascular damage among liver transplant recipients for chronic viral hepatitis (i.e. hepatits C virus, hepatis B virus and hepatitis D virus infection). Adult patients (age ≥ 18 years) with orthotopic liver transplants (OLT) due to viral hepatitis who signed informed consent, and were admitted for a routine follow-up between June 2019 and September 2020 at the Infectious Disease outpatient clinic of the University of Campania Luigi Vanvitelli, Naples, Italy, were prospectively enrolled. An estimation of cardiovascular risk was assessed using three main risk charts, echocolor-Doppler of epiaortic vessels was performed to assess subclinical Intima-Media changes. A total of 161 patients were evaluated; of these 15 were excluded because not affected by viral hepatitis. 146 patients were considered. 83 patients (56.8%) were considered at high cardiovascular risk according to Framingham, 54 patients (36.9%) to American Heart Association Arteriosclerotic Cardiovascular Disease (ASCVD) score and 19 (13.0%) to Heart Score. Only 8 patients (5.4%) showed a normal carotid ultrasound, while 52 patients (35.6%) had a carotid artery Intima-Media Thickness (IMT) and 86 (58.9%) an atherosclerotic plaque. Liver transplant recipients for virus-related associated liver disease are, in light of the high percentage of carotid lesions, at high risk of CVD. Risk charts compared to subclinical carotid lesions which represent damage already established and a real localization of the disease, seem to underestimate the cardiovascular risk. A chronic inflammatory status, could play a key role. It's important to raise the awareness of cardiovascular risk in liver transplant patients to prevent cardiovascular diseases and improve the timing of early diagnosis of premature vascular lesions.

Prevalence of Atherosclerosis in Psoriatic Patients Detected with Epiaortic Color Doppler Ultrasound and Computed Tomography Angiography.

IntroductionPsoriasis (PsO), a chronic inflammatory, multisystemic, and multifactorial disease can cause endothelial dysfunction, artery calcification, and atherosclerotic disease. A higher incidence of vascular occlusive events has been observed in psoriatic patients compared to healthy controls, and multiple studies confirm the association between moderate-severe PsO and atherosclerosis, coronary artery calcification, and higher cardiovascular risk.ObjectiveWe sought to analyze atherosclerotic disease prevalence in epiaortic vessels of psoriatic and non-psoriatic patients to understand if PsO could represent an independent risk factor predisposing to atherosclerotic disease.MethodsWe evaluated 47 psoriatic patients without cardiovascular risk factors with color Doppler ultrasound (CDUS). If atheromatous plaques were detected, a computed tomography angiography (CTA) was performed. We evaluated 47 non-psoriatic patients without cardiovascular risk factors with CDUS. Atherosclerosis prevalence in both groups were statistically analyzed. CDUS performance was compared to CTA.ResultsIn the psoriatic group (mean age 50.9 years), 6 had atheromatous plaques and 12 had an intima-media thickness (IMT) > 1 mm (overall prevalence of atherosclerotic disease: 38.2%). All plaques detected with CDUS were confirmed at CTA. In the control group (mean age 51.3 years), CDUS revealed atheromatous plaques in 4 patients and IMT > 1 mm in 4 ones (overall prevalence of 17%). The difference of atherosclerotic disease prevalence between the groups was statistically significant (P < 0.05).ConclusionOur results highlight that PsO could be considered a predisposing factor for atherosclerotic disease development in epiaortic vessels, as it causes an increased IMT, that is also considered an independent cardiovascular risk factor.

Association between carotid artery dissection and vascular tortuosity: a case-control study.

We aimed to verify if vascular tortuosity (VT) may represent a risk factor for spontaneous epiaortic vessel dissection (sEVD) in young adult patients. We identified 304 patients aged under 55years consecutively admitted for acute cerebrovascular events to our Stroke Unit. After checking the possibility to perform a 3D reconstruction of epiaortic vessels on CT-angiography images, we selected and compared fifty patients with sEVD (cases) with fifty-one patients without dissection (controls). VT of carotid and vertebral arteries was measured on reconstructions evaluating the vascular tortuosity index (VTI), calculated according to a specific algorithm, and the presence of kinking and coiling. Differences between groups were analyzed by Student-t test for numeric variables and chi-square test for categoric ones. A ROC curve analysis was used to look for a VTI threshold value beyond which the risk of dissection was significantly increased. VTI was significantly higher in cases than in controls only considering carotid arteries (p = 0.029); cases did not have a significantly higher rate of kinking and coiling than controls (p = 0.059 and 0.077, respectively). We have found a significant VTI threshold value of 27.9% (under curve area = 61.6%, p = 0.04) only for carotid artery dissection. VT appears to be associated with an increased risk of dissection for the carotid district but not for the vertebral one. The different structure, embryogenesis, and pathophysiology of dissection between the two districts could explain this finding. VTI threshold as carotid artery dissection predictor deserves confirmation in larger studies.

Integrated Care Systems and the Aortovascular Hub.

Aortovascular medicine and surgery in relation to vascular health of the population requires input from a broad range of specialists and institutions throughout a patient life as well as integration with allied health care providers. This paper presents the essence of the novel clinical concept of the 'Aortovascular Hub' .

Reply: Will the new tool used for cerebral perfusion be able to "keep it simple" or not?

We appreciate the comments provided by the authors about the new AV Flow cannula (MedEurope Srl, Bologna, Italy), used for antegrade selective cerebral perfusion in arch surgery. They better clarify the positive features of this interesting device, including the possibility of guidewire introduction and suture of epiaortic vessels in the graft without having the bulk of the cannula.1 Nevertheless, a very important concept to observe in surgery is to standardize and simplify the procedure to reduce complications and achieve durable outcomes, especially in complex scenarios.

Aortic Arch Replacement in 2051: Endovascular Skills Would Be Routinely Part of the Procedure

In the last decades we observed an increased use of endovascular techniques to facilitate complex arch reconstruction. The most relevant contribution to open surgery was the deployment of a bare metal stent in the descending thoracic aorta in the frozen elephant trunk procedure.1 The possibility of stenting the distal arch encouraged simplification of the procedure, moving proximally the distal anastomosis and reducing the number of sutures required to replace the arch.2,3 However, that often necessitated endovascular skills to handle catheters and grafts for epiaortic vessels rerouting.

First-in-Man Study Evaluating the Emblok Embolic Protection System During Transcatheter Aortic Valve Replacement

ObjectivesThis study sought to evaluate the feasibility of complete cerebral protection during transcatheter aortic valve replacement (TAVR) with a novel embolic protection device. BackgroundEvidences and data about new cerebral embolic protection devices are lacking and scarce. MethodsA prospective, nonrandomized, multicenter, first-in-man pilot study designed to evaluate the efficacy and safety of cerebral embolic protection utilizing the Emblok embolic protection system (Innovative Cardiovascular Solutions, Grand Rapids, Michigan) during TAVR. The Emblok is a transfemoral aortic filter that provide full coverage of the epiaortic vessels. Brain diffusion-weighted magnetic resonance imaging (DW-MRI) was performed at baseline and 2 to 5 days after TAVR. Primary endpoints were technical success and immediate cerebral embolic burden after TAVR, defined as number and volume of new brain lesions detected with DW-MRI at days 2 to 5 post-TAVR compared with baseline. ResultsA total of 20 subjects were enrolled. The Emblok system was successfully positioned in all the cases. At 30-day follow-up, no major adverse cardiovascular and cerebrovascular events occurred. Nineteen (95%) patients had new ischemic defects at post-procedural DW-MRI. The median number of new lesions per patient was 10.00 (interquartile range [IQR]: 4.75 to 15.25). The total new lesion volume was 199.9 mm3 (IQR: 83.9 to 447.5 mm3) and the mean lesion volume per lesion was 42.5 mm3 (IQR: 21.5 to 75.6 mm3). Histopathologic analysis showed evidence of significant debris in 18 (90%) filters. ConclusionsThe Emblok embolic protection system appears to be feasible and safe during TAVR. The device was successfully placed and retrieved in all cases and no neurological events were observed. Cerebral total new lesion volume was similar to other trials on cerebral protection during TAVR, thus warranting a larger study. (European Study Evaluating the Emblok Embolic Protection System During TAVR; NCT03130491)

Archi-Prevaleat Project. A National Register of Color-Doppler Ultrasonography of the Epi-Aortic Vessels in Patients Living with HIV.

Persons Living with HIV (PLWH) are at higher risk of cardiovascular disease (CVD) than the general population. Carotid ultrasound is a non-invasive diagnostic tool, aimed at the assessment of vascular anatomy and function. Our present aim is to generate a National Register of color-Doppler ultrasonography (Archi-Prevaleat) to better evaluate the characteristics of vascular lesions in PLWH on a large number of data.

Computational fluid dynamics of a novel perfusion strategy during hybrid thoracic aortic repair.

To mitigate the risk of perioperative neurological complications during frozen elephant trunk procedures, we aimed to computationally evaluate the effects of direct cerebral perfusion strategy through a left carotid-subclavian bypass on hemodynamics in a patient-specific thoracic aorta model. Between July 2016 and March 2019, 11 consecutive patients underwent frozen elephant trunk operation using the left carotid-subclavian bypass with a side graft anastomosis and right-axillary cannulation for systemic and brain perfusion. A multiscale model realized coupling three-dimensional computational fluid dynamics was developed and validated with in vivo data. Model comparison with direct antegrade cannulation of all epiaortic vessels was performed. Wall shear stress, wall shear stress spatial gradient, and localized normalized helicity were selected as hemodynamic indicators. Four cerebral perfusion flows were tested (6 to 15 mL/kg/min). Direct cerebral perfusion of the left subclavian bypass resulted in higher flow rates with augmented speeds in all epiaortic vessels in comparison with traditional perfusion model. At the level of the left vertebral artery (LVA), a speed of 22.5 vs 21 mL/min and mean velocity of 3.07 vs 2.93 cm/s were registered, respectively. With a cerebral perfusion flow of 15 mL/kg, lower LVA wall shear stress (1.596 vs 2.030 N/m2 ), and wall shear stress gradient (1445 vs 5882 N/m3 ) were observed. A less disturbed flow considering the localized normalized helicity was documented. No patients experienced neurological/spinal cord damages. Direct perfusion of a left carotid bypass proved to be cerebroprotective, resulting in a more physiological and stable anterior and posterior cerebral perfusion.

P1495 Suddenly haunted by a turbulent heart beat in the right ear. Post-traumatic monolateral pulsatile tinnitus caused by cervical arteriovenous malformation: colour-Doppler ultrasound and angio-CT find

Abstract Funding Acknowledgements No financial disclosure to be added INTRODUCTION Tinnitus, the perceived sensation of sound in absence of corresponding external acoustic stimulus, has a prevalence of 15% among adults [1]; it may impair quality of life in about 1-2% of cases. When pulsatile, objective and synchronous with heart beat, it may be secondary to vascular abnormalities [2]; in some patients a post-traumatic pathogenesis ( head and neck) has been reported, with a prevalence up to 10% . CASE REPORT We report the case of a 28 year old male patient with a history of a right side pulsatile tinnitus occurred three days after head trauma. Described as "hearing heart beat in the right ear as a turbulent sound", it corresponded with an audible bruit and palpable fremitus in latero-cervical region. History was negative for medical or surgical comorbidities as laboratory investigation; color Doppler ultrasound revealed an external carotid artery collateral- internal jugular vein fistula, resulting in a pulsatile turbulent flow, synchronic with heart beat. Angio-CT scan of epiaortic vessels confirmed findings in the context of occipital articulation, near jugular foramen. Patient postponed further investigations for personal reasons. DISCUSSION Vascular post-traumatic lesions may cause post-traumatic pulsatile tinnitus. Symptom onset may be delayed from several days up to twelve weeks after trauma and it can be a sign of life-threatening disorders such as carotid cavernous fistulas, arteriovenous malformations, and carotid dissections [3 ] . Clinical management includes basic diagnostic steps ( history, assessment of tinnitus severity, clinical ear examination, audiological and a neurovascular examination [2] . CT and MR with angiography, following colour-Doppler ultrasound , are used to determine the anatomical cause of vascular pulsatile tinnitus and to study surrounding structures. Angiography may be helpful for diagnosis and treatment planning [4]. CONCLUSIONS Pulsatile tinnitus may occur after head and neck trauma, may affect quality of life and can be caused by live-threatening lesions. Arteriovenous fistulae between carotid artery branches and jugular vein may be treatable anatomical cause of symptoms, and have to be considered in differential diagnosis . Abstract P1495 Figure. Pulsatile tinnitus:Imaging and Pathology