Evidence Of Stenosis Research Articles

Guidewire advancement is interrupted by an internal jugular vein valve with a restricted opening: an ultrasound image

To the Editor, Anesthesiologists have generally paid relatively little attention to the internal jugular vein valve (IJVV) during central venous catheter insertion. Interruption of guidewire insertion by the IJVV is known to occur; however, very few related images appear in the published literature. Recently, a 73-yr-old male with a bicuspid aortic valve and a history of hypertension presented to our hospital for aortic valve replacement. Following induction of anesthesia, we attempted an ultrasound-guided placement of the Sheath Introducer (Multi-lumen access catheter, ARROW ) into the patient’s right internal jugular vein (IJV). We rotated the patient’s head to the left while slightly extending his neck, and we then confirmed that the IJV was lying parallel to the right carotid artery which had no evidence of stenosis. Ultrasound imaging was used to confirm the location of the needle tip within the vessel and backflow of blood. Next, we attempted to introduce a guidewire into the right IJV; however, we were unable to advance the guidewire more than 8 cm due to resistance. During ultrasound-guided indwelling of the guidewire, a large membranous structure was detected protruding from the posterior wall of the IJV. Although we attempted to advance the guidewire with the assistance of ultrasound imaging, the wire could only push the bottom of membranous structure (Figure, Panel A). The guidewire was caught by the membranous structure, and we could not advance the wire further. After several failed attempts, we placed the Sheathe Introducer into the left IJV instead. Internal jugular vein valves are the only barrier between the brain and the heart that prevent retrograde venous blood flow when the intrathoracic pressure increases. Malfunction of the IJVV may include restriction of the opening and valve incompetence. As was the case here, a restricted opening may impede insertion of the catheter or guidewire during central venous catheterization, while valve incompetence may be a complication of catheterization. A guidewire is introduced along the posterior wall of the IJV. In this case, the patient’s IJVV was a bicuspid valve which consisted of a large posterior leaflet and a small anterior leaflet. Advancement of the guidewire was obstructed by the bottom of the posterior leaflet with a restricted opening. Based on our experience, we suggest assessing any malfunctioning opening movement of the IJVV with a preprocedural ultrasound scan. Macchi et al. reported that IJVV incompetence may be considered a normal finding; however, a pressure gradient develops in this valve during coughing. Catheterization of the IJV involves a risk of injury to the IJVV. Wu et al. reported that IJVV incompetence is more commonly caused by cannulation and catheterization at the proximal site of the IJV than at the distal site. Internal jugular vein valve incompetence causes an increase in retrograde

OC-055 A Novel Technique for full Thickness Laparoendoscopic Excision of Colonic Lesions: an Experimental Pilot Study

<h3>Introduction</h3> Introduction of a National Bowel Cancer Screening Program in England has resulted in an increasing number of patients diagnosed with endoscopically irresectable colonic polyps. A significant proportion of these patients is referred for hemicolectomy and is subject to a significant risk of morbidity and mortality. Therefore, a less invasive treatment option is required and to address this, we modified a previously reported full thickness laparo-endoscopic excision (FLEX) technique. <h3>Methods</h3> Surgery was performed in five 70-kg pigs. A simulated colonic polyp was created by endoscopic injection of Spot® and the clearance margin delineated by circumferential placement of mucosal argon plasma coagulator (APC) marks. Full thickness eversion of the colonic wall, including the lesion, was achieved by endoscopic placement of prototype BraceBars (BBs). The everted section was excised using a linear laparoscopic stapler placed below the BBs. The first pig was terminated immediately and others were sacrificed 8 days after surgery. <h3>Results</h3> The median procedure duration, defined from placement of mucosal APC marks to specimen excision, was 26 min (range 20–31 min). All excised specimens contained three pairs of BBs, included the APC marks and had a median diameter of 5.1 cm (range 4.5–6.3 cm). Postoperative recovery in survival animals was uneventful. Post-mortem evaluation demonstrated well-healed resection sites with no evidence of intra-abdominal infection or inadvertent organ damage. Endoscopic evaluation of anastomoses at post-mortem demonstrated a widely patent lumen without evidence of stenosis at excision sites. Histological examination of the anastomoses showed primary closure by mucosal abbutal and regeneration, with repair and restoration of submucosal continuity. <h3>Conclusion</h3> This proof-of-concept study has demonstrated the feasibility and safety of a novel full thickness colonic excision technique that is now ready for translation as an alternative to hemicolectomy. The excision size will accommodate most colonic polyps that currently come to surgery. Accurate placement of endoscopic BBs ensures complete excision, reducing the risk of residual disease and recurrence, while laparoscopic overview avoids collateral damage. The ability to preserve mesenteric vasculature and colonic length is likely to result in less morbidity and mortality, better functional outcomes and the approach should reduce treatment costs. <h3>Disclosure of Interest</h3> None Declared

Serum Uric Acid and Its Association with Coronary Artery Disease

Background: Few studies have assessed the relation of uric acid level with the severity of coronary artery disease (CAD). This study investigated the association between high uric acid levels with the presence and severity of CAD.Materials and Methods: This study was designed as an observational cohort study. The study was composed of 180 patients admitted at our institution due to symptoms related to CAD. Patients having angiographic evidence of stenosis in coronary artery were as case group and without stenosis control group. Patients with high uric acid (hyperuricemia) were defined as serum uric acid concentration ?7.0mg/dl or ?420 ?mol/L in men and ?6mg/dl or ?360 ? mol/L in women. The presence of CAD has been defined as the Gensini score being ?1. Results: There was a statistically significant difference between the mean uric acid levels of patients with and without CAD (358.23±71.11 ?mol/l vs251.32±54.92 ?mol/l respectively, p&lt;0.001). There was a statistically significant difference between ejection fraction of patients with and without CAD (54.50±9.25 vs. 63.16±6.56 respectively, p?0.001). Spearman correlation analysis demonstrated a positive correlation between the serum uric acid level and the severity of CAD (p=?0.001, r=0.39). When patients were classified into four groups according to their Gensini score, mean serum uric acid level was found to be significantly increased across the tertiles, and a statistically significant difference was detected between the tertiles (p= ?0.001). Conclusion: In conclusion, a significant association has been found between serum uric acid level and the presence and severity of CAD. In addition to the evaluation of conventional risk factors in daily clinical practice, the measurement of uric acid level might provide significant prognostic benefits in terms of global cardiovascular risk and management of the patients. DOI: http://dx.doi.org/10.3329/cardio.v5i1.12206 Cardiovasc. j. 2012; 5(1): 12-17

Picture Quiz: An Acute, Blue, Swollen, Painful Leg (Answer)

Urgent Duplex ultrasound demonstrated ilio-femoral deep vein thrombosis (DVT) with involvement of the long saphenous and short saphenous superficial veins. Arterial Doppler waveforms were normal distally with no evidence of stenosis. The diagnosis was therefore Phlegmasia cerulea dolens (PCD), resulting from an extensive, proximal DVT with total or near total venous outflow occlusion.

CO2 ULTRASONOGRAPHIC ASSESSMENT OF COLONIC WALL IN PEDIATRIC ULCERATIVE COLITIS: COMPARATIVE STUDY WITH ILEO-COLONOSCOPY

Background and Aim: Stricturing is the most common complicated phenotype in children with Crohn’s disease (CD), but only few studies have described its course and there are no data on the efficacy of medical treatment. The purpose of this study was to retrospectively describe in pediatric stricturing CD the course and assess clinical and radiological response to medical therapy. Patients and Methods: 36 patients (pts) with stricturing CD (64% males, age range: 7.3–20.2 years, median 14.7), were identified by our department database. Records were reviewed for disease duration before detecting stenosis, location of strictures, type of medical treatment received, number of disease recurrences and hospitalizations. Pediatric Crohn’s disease Activity Index (PCDAI), need to change medical treatment or surgery, magnetic resonance imaging or small intestine contrast ultrasonography were used as outcomes and evaluated at 6, 12, 18 and 24 months after diagnosis of stenosis. Results: Strictures were ileal in 61% of pts, ileocolonic in 28% and colonic in 11%; 6 pts (17%) also had proximal jejunal stenosis. Thirteen pts (36%) had a stricturing disease at the time of CD diagnosis, while 64% developed it at the follow-up (2.48±4.12 years after CD diagnosis). Cumulative risk for developing stenosis was 22%, 27% and 28% at 12, 18 and 24 months, respectively. At baseline, 89% of pts underwent medical treatment, while 11% had surgical resection: in a multivariate analysis, only ileal stenosis and severe abdominal pain significantly differed between the two groups (p: 0.05 and p: 0.006, respectively). At 6, 12, 18, and 24 months, 53%, 50%, 42%, and 35% had a complete response to medical treatment, respectively; whereas 34%, 43%, 40%, and 34% had a partial response, defined as a radiological evidence of stenosis requiring a change of their medical therapy. Overall, 44% were unresponsive to medical therapy and required surgery during 24 months followup; responders and non-responders did not statistically differ for clinical variables such as duration of disease, location of stenosis, mean PCDAI at the beginning of the therapy and type of medical treatment. Conclusions: A stricturing phenotype is not uncommon at the diagnosis of CD in children. Medical therapy seems to be poorly effective in avoiding intestinal resection and common clinical variables are not of value in discriminating between responder and non responders to medical therapy. Prospective studies are needed to define the optimal management strategy of stricturing CD and to identify predictive factors of medical treatment failure.

Potential association between coronary artery disease and the inflammatory biomarker YKL-40 in asymptomatic patients with type 2 diabetes mellitus

BackgroundInflammation plays an important role in coronary artery disease from the initiation of endothelial dysfunction to plaque formation to final rupture of the plaque. In this study, we investigated the potential pathophysiological and clinical relevance of novel cytokines secreted from various cells including adipocytes, endothelial cells, and inflammatory cells, in predicting coronary artery disease (CAD) in asymptomatic subjects with type 2 diabetes mellitus.MethodsWe enrolled a total of 70 asymptomatic type 2 diabetic patients without a documented history of cardiovascular disease, and determined serum levels of chemerin, omentin-1, YKL-40, and sCD26. We performed coronary computed tomographic angiography (cCTA) in all subjects, and defined coronary artery stenosis ≥ 50 % as significant CAD in this study.ResultsSubjects were classified into two groups: patients with suspected coronary artery stenosis on cCTA (group I, n = 41) and patients without any evidence of stenosis on cCTA (group II, n = 29). Group I showed significantly higher YLK-40 levels and lower HDL-C levels than group II (p = 0.038, 0.036, respectively). Levels of chemerin, omentin-1, and sCD26 were not significantly different between the two groups. Serum YKL-40 levels were positively correlated with systolic/diastolic BP, fasting/postprandial triglyceride levels, and Framingham risk score. Furthermore, YKL-40 levels showed moderate correlation with the degree of coronary artery stenosis and the coronary artery calcium score determined from cCTA. In multivariate logistic analysis, after adjusting for age, gender, smoking history, hypertension, and LDL-cholesterol, YLK-40 levels showed only borderline significance.ConclusionsYKL-40, which is secreted primarily from inflammatory cells, was associated with several CVD risk factors and was elevated in type 2 diabetic patients with suspected coronary artery stensosis on cCTA. These results suggest the possibility that the inflammatory biomarker YKL-40 might be associated with coronary artery disease in asymptomatic patients with type 2 diabetes mellitus.

Mo1724 Disease Course and Outcome of Medical Therapy in Pediatric Stricturing Crohn's Disease

Background and Aim: Stricturing is the most common complicated phenotype in children with Crohn’s disease (CD), but only few studies have described its course and there are no data on the efficacy of medical treatment. The purpose of this study was to retrospectively describe in pediatric stricturing CD the course and assess clinical and radiological response to medical therapy. Patients and Methods: 36 patients (pts) with stricturing CD (64% males, age range: 7.3–20.2 years, median 14.7), were identified by our department database. Records were reviewed for disease duration before detecting stenosis, location of strictures, type of medical treatment received, number of disease recurrences and hospitalizations. Pediatric Crohn’s disease Activity Index (PCDAI), need to change medical treatment or surgery, magnetic resonance imaging or small intestine contrast ultrasonography were used as outcomes and evaluated at 6, 12, 18 and 24 months after diagnosis of stenosis. Results: Strictures were ileal in 61% of pts, ileocolonic in 28% and colonic in 11%; 6 pts (17%) also had proximal jejunal stenosis. Thirteen pts (36%) had a stricturing disease at the time of CD diagnosis, while 64% developed it at the follow-up (2.48±4.12 years after CD diagnosis). Cumulative risk for developing stenosis was 22%, 27% and 28% at 12, 18 and 24 months, respectively. At baseline, 89% of pts underwent medical treatment, while 11% had surgical resection: in a multivariate analysis, only ileal stenosis and severe abdominal pain significantly differed between the two groups (p: 0.05 and p: 0.006, respectively). At 6, 12, 18, and 24 months, 53%, 50%, 42%, and 35% had a complete response to medical treatment, respectively; whereas 34%, 43%, 40%, and 34% had a partial response, defined as a radiological evidence of stenosis requiring a change of their medical therapy. Overall, 44% were unresponsive to medical therapy and required surgery during 24 months followup; responders and non-responders did not statistically differ for clinical variables such as duration of disease, location of stenosis, mean PCDAI at the beginning of the therapy and type of medical treatment. Conclusions: A stricturing phenotype is not uncommon at the diagnosis of CD in children. Medical therapy seems to be poorly effective in avoiding intestinal resection and common clinical variables are not of value in discriminating between responder and non responders to medical therapy. Prospective studies are needed to define the optimal management strategy of stricturing CD and to identify predictive factors of medical treatment failure.

Spontaneous Expulsion of a Dacron Patch After Carotid Endarterectomy

Patch angioplasty during carotid endarterectomy (CEA) has been shown to reduce the risks of peri-operative and late stroke as well as recurrent stenosis. Two frequently used synthetic materials for patch angioplasty are polytetrafluoroethylene (PTFE) and knitted polyester (Dacron). Although complications from synthetic carotid patches are rare, infection and pseudoaneurysm formation have been reported. We report a case of a spontaneous Dacron patch expulsion without any stenosis or pseudoaneurysm formation. This is a late complication that has not been previously reported in the literature. A 68 year old woman with a history of diabetes mellitus, coronary artery disease, and peripheral arterial disease underwent a left CEA with Dacron patch angioplasty for asymptomatic high grade stenosis in March of 2006. The procedure was technically unremarkable. The patient was discharged home on post operative day one with no complications. She was making a satisfactory recovery during her postoperative clinic visit at 1 month. She remained asymptomatic until January 2010. She visited her primary care physician for a ‘boil' in the mid aspect of her incision. This was diagnosed as a stitch abscess and treated with warm compress. Over the next two months the patient had some flare ups of her incision site with minimal bloody discharge. In March of 2010, the patient removed some patch material which was extruding from the incision (Fig 1). The remainder of the patch exteriorized over the next two days. The patient visited her cardiologist who referred her for further evaluation. On follow up visit, a small sinus was present in the mid aspect of the left neck incision without any erythema or drainage. Examination of the exteriorized material confirmed expulsion of the entire Dacron patch. A selective left carotid angiogram was performed (Fig 2). The study demonstrated intact left common, internal and external carotid arteries without any evidence of stenosis or pseudoaneurysm formation. The patient was managed conservatively. The left neck sinus has subsequently healed. Patch angioplasty is commonly performed after CEA. Studies have demonstrated a decrease in stroke and recurrent stenosis. Synthetic material, such as Dacron or PTFE, are readily available and easy to use. The incidence of complications such as infection and pseudoaneurysm formation is extremely low. Although expulsion of a PTFE patch after CEA has been reported in two patients, based on our review of the literature, this is the first report of a Dacron patch rejection. The most likely explanation of this patient's clinical course is a chronic patch infection with gradual sinus formation and foreign body rejection. Although no stenosis or pseudoaneurysm was visualized on this patient's angiogram, an intact arterial wall cannot be proven without histological evaluation. Our plan is to follow this patient with serial ultrasound.

Brain magnetic resonance angiography in splenectomized adults with β-thalassemia intermedia

Hypercoagulability and venous thromboembolism are common in patients with β-thalassemia intermedia (TI), especially in the splenectomized adult. Although arterial involvement is not commonly reported, we have recently observed a high prevalence (60%) of silent brain infarction on brain MRI in 30 splenectomized adults with TI. The pathophysiology of these white matter lesions remains unknown. In this prospective work, we evaluated magnetic resonance angiography (MRA) scans of the same cohort of 30 patients. Data collected were the presence or absence of vascular lesions, their locations, and severity. Correlations between MRA abnormality and patients/disease characteristics were evaluated. Comparisons between MRA and previous MRI findings were made. Of 29 evaluable patients, 8 (27.6%) had evidence of arterial stenosis on MRA. The majority of lesions had mild narrowing and mostly involved the internal carotid artery. Five patients (17.2%) had evidence of aneurysms. Low total hemoglobin and high non-transferrin-bound iron levels independently characterized patients with evidence of stenosis on MRA. Among the 18 patients with silent brain infarction on MRI, three had evidence of stenosis on MRA with only one patient having lesions that could explain the silent infarcts. Cerebral vasculopathy is common in splenectomized adults with TI. However, large-vessel disease does not explain the occurrence of silent brain infarction. The combined use of MRA and MRI better identifies splenectomized TI adults with neuroimaging abnormalities.

Iliac-Femoral Venous Stenting for Lower Extremity Venous Stasis Symptoms

Venous outflow obstruction may play a role in patients with chronic venous stasis symptoms who fail to improve despite conventional modalities of treatment that focus on the reflux component of the disease with little attention to the possibility of an obstructive component. The introduction of minimally invasive venous stenting using venography and intravenous ultrasonography (IVUS) provides the ability to treat the "obstructive" component of the disease. We undertook a retrospective review of 56 limbs in 53 patients with chronic venous stasis symptoms. Initial transcutaneous Doppler ultrasonographic evaluation of the inferior vena cava, iliac, femoral, greater saphenous, and perforator veins was performed looking for any evidence of deep venous thrombosis, superficial venous thrombosis, perforator veins, and reflux (location and degree). Afterword, the patients were managed in the conventional fashion (leg elevation, compression, and great saphenous vein (GSV) and perforator ablation, if present) for a period of 3 months. If ulcer healing was not noted, iliac-femoral venography and IVUS were undertaken. A significant stenosis was defined as a 50% reduction in vein cross-sectional area as measured by IVUS.(1,2,3) Stenotic lesions were managed with stenting followed by balloon angioplasty. Patients were followed up for ulcer healing or improvement of stasis symptoms. Of the 56 limbs, 10 (17.8%) had postthrombotic changes, 7 (12.5%) had incompetent perforators, and 27 (48.2%) had an incompetent superficial venous system. In the stented group (n = 29), 3 limbs had perforator ablation alone, 13 limbs had GSV ablation alone, and 1 limb had both perforator and GSV ablation. In the unstented group (n = 27), 10 limbs had GSV ablation alone, and 3 limbs had both perforator and GSV ablation. The overall incidence of deep reflux was 51.8%; 17 of 29 limbs (58.6%) in the stented group had evidence of deep reflux, and 12 of 27 limbs (44.4%) in the unstented group had deep reflux. All venograms except one (98.2%) were performed under local anesthesia with sedation. The procedure was performed in an ambulatory setting in 69.6% (39 of 56) of the limbs. CEAP clinical severity class distribution was as follows: C2, 4%; C3, 16%; C4, 18%; C5, 5%; C6, 57%. Over half of the limbs (29 of 56) were found to have stenotic lesions and required stenting. Eight patients (11 limbs) did not return for ulcer healing assessment. The majority (19 of 29) of limbs in the stented group had a CEAP of 6. Among the patients with CEAP 6 who returned for follow-up (n = 26), 7 had no evidence of stenosis and required no stenting. Only one of those (14.3%) healed his ulcers after 3 months (average follow-up of 4.8 months). The remainder 19 limbs were found to have stenotic lesions and underwent stenting. The ulcers healed in 11 of those (58%) over a period of 1 week to 8 months (average of 5 months), with average follow-up of 3.6 months (p = 0.08). The cumulative primary and secondary patency rates were 93.1% (27 of 29) and 100% (29 of 29), respectively. Two stent thromboses occurred within 4 weeks of the initial procedure. Both occurred in patients with postthrombotic obstruction. One patient developed a superficial femoral artery pseudoaneurysm. Over half of our patients with open ulcers had stenotic lesions. The ulcers healed in 58% of the stented limbs. That indicates that outflow obstruction may play a significant role in patients with chronic venous stasis symptoms, especially those with open ulcers who failed to respond to other treatment modalities. The procedure itself is relatively safe and simple and can be performed on an ambulatory basis.

Inferior Mesenteric Artery Duplex in the Management of Chronic Mesenteric Ischemia

Introduction Duplex interrogation of the mesenteric arteries is a frequent practice during the workup of chronic mesenteric ischemia (CMI). We report a case in which duplex ultrasound identified a stenosis of the inferior mesenteric artery (IMA) that was not initially detected on either angiogram or computed tomography angiography (CTA). Case Report A 72-year-old Hispanic man with a history of CMI presented with a 1-week history of vague postprandial abdominal pain that became severe and constant during the last 3 days. The patient was admitted and an aortic angiogram was performed, demonstrating a normal celiac axis and IMA, and short segment superior mesenteric artery (SMA) occlusion with reconstitution via a large meandering branch of the IMA. Aortic duplex was also performed that confirmed the occlusion of the SMA and demonstrated significant velocity elevation (&gt;450 mm/sec) with color flow disturbances suggestive of high-grade stenosis at the origin of the IMA. This duplex ultrasound finding prompted further investigation with CTA of the abdomen and pelvis, which demonstrated a high-grade stenosis of the celiac axis, occlusion of the SMA, and an atherosclerotic plaque in the infrarenal aorta near the origin of the IMA without evidence of stenosis. Because of the patient's persistent abdominal symptoms and disparate imaging results, a repeat angiogram with multiple views was able to identify both the celiac and IMA stenoses, each of which was successfully treated with stents. The patient's abdominal symptoms resolved within 4 days. Three months after stenting, the patient remains symptom free, and a follow-up duplex examination showed patency of both the celiac artery and IMA stents. Conclusion Multiple imaging modalities are often essential in the work up for patients with CMI. This case demonstrates the sensitivity of duplex ultrasound in the identification of an IMA stenosis in a patient with a known occlusion of the SMA, and not initially identified on the angiogram or CTA.

Extracranial venous hemodynamics in multiple sclerosis

A chronic state of impaired cerebral and cervical venous drainage, termed chronic cerebrospinal venous insufficiency (CCSVI), has recently been implicated in the pathogenesis of multiple sclerosis (MS). We performed a color-coded Doppler sonography case-control study to externally validate the CCSVI criteria. We prospectively evaluated consecutive patients with clinically definite MS and healthy volunteers using extracranial and transcranial color-coded Doppler sonography. The recently developed neurosonology criteria for CCSVI detection were used for interpretation of ultrasound assessments. The presence of venous reflux in cervical veins was assessed both in the sitting and upright position during a short period of apnea and after Valsalva maneuver. We recruited 42 patients with MS (mean age 39 ± 11 years, 17 men) and 43 control individuals (mean age 38 ± 12 years, 16 men). Very good/excellent intrarater and interrater agreement (κ values 0.82-1.00) was documented in 3 out of 5 CCSVI criteria. There was no evidence of stenosis or nondetectable Doppler flow in cervical veins in patients and controls. Reflux in internal jugular vein (IJV) was documented in 1 patient (2%) and 1 control subject (2%), both in sitting and supine posture during apnea. After performing Valsalva maneuver, we documented the presence of IJV valve incompetence in 3 patients with MS (7%) and 4 healthy volunteers (9%; p > 0.999). With established reproducibility of venous ultrasound testing, our data argue against CCSVI as the underlying mechanism of MS. Without further independent validation of CCSVI, potentially dangerous endovascular procedures, proposed as novel therapy for MS, should not be performed outside controlled clinical trials.

Contrast-Enhanced Ultrasound of Carotid Artery Wall in Takayasu Disease

A 35-year-old woman with chronic anterior cervicalgia was referred to our institution for an ultrasound of the neck. The B-mode ultrasound (Siemens S 2000, linear phased array probe 9 to 13 MHz) revealed a 1.6-mm hyperechoic circumferential wall thickening of the right common carotid artery, involving the whole artery, without evidence of stenosis (Figure 1). The other supraaortic arteries appeared normal. Positron-emission tomography and computed tomography scans demonstrated further localizations of arterial wall thickening in the right brachiocephalic artery, the aortic arch, and the abdominal aorta. The patient’s long medical history of hypertension, carotidynia, radial pulse asymmetry, and biological inflammatory syndrome along with the imaging results led to the diagnosis of Takayasu disease.1 Figure 1. Mode-B ultrasound: right common carotid artery circumferential wall thickening suggesting inflammatory arteritis. Contrast-enhanced ultrasound of carotid arteries was then performed (T0) before the patient started steroid treatment. We used …

Transcranial doppler ultrasonography in acute ischemic stroke predicts stroke subtype and clinical outcome: a study in Omani population

Transcranial Doppler ultrasonography (TCD) is being increasingly used for its ability to provide cerebral hemodynamic information in stroke. Few studies have explored its association with cerebral arteriographic changes and stroke subtype. This study explored the relation of TCD changes in acute stroke with stroke subtypes, MR cerebral arteriography and clinical outcome in Omani population. Adult patients presenting with acute ischemic stroke within 4days of stroke onset were subjected to TCD through the temporal and suboccipital windows using a 2MHz probe; flow velocities, pulsatility and direction of flow were recorded from arteries at the skull base. MR arteriographic (MRA) changes on corresponding arteries were graded on a scale of 1-4. ANOVA, student's t test and ROC analysis were used to evaluate TCD in relation to stroke type, outcome and stenosis on MRA. Of 60 patients recruited, 52 (M:F::36:16; mean age: 60+13years) had adequate bone window for TCD study. Large artery stroke occurred in 30 (58%) patients; lacunar stroke-11 (21%); cardioembolic and mixed groups 9 (17%), other specificed causes-2 (4%). 86.5% had evidence of intracranial disease. 10/52 patients (19%) died while 33 (63%) had good outcome (modified Rankin Score 0-3). Of the 186 arteries studied by the two methods, 52 had TCD evidence of stenosis while 42 were abnormal on MRA, giving a sensitivity of 60%, specificity: 81.25%; positive likelihood ratio: 3.18 and negative likelihood ratio: 0.5. 29/52 (56%) of patients had TCD changes in the arteries corresponding to stroke location. Abnormal TCD was associated with large artery strokes (p=0.007), poor outcome (p=0.038) and mortality (p=0.01). This study of TCD in acute stroke in Omani population demonstrates a relatively higher burden of intracranial arterial disease. TCD changes are associated with type of stroke and outcome in this population. TCD is a simple and fairly useful method of evaluation in patients with acute stroke. Adopting TCD in evaluation of stroke patients may provide useful information regarding the pathophysiology which could enhance patient management.

PP-036: IMPLANTABLE CARDIOVERTER DEFIBRILLATOR SHOCK DESPITE TERMINATION OF VENTRICULAR TACHYCARDIA BY ANTITACHYCARDIA PACING DURING CHARGING

normal left atrium and normal valves with no evidence of stenosis or regurgitation. The patient was discharged on the second day with oral 150mg propafenone twice a day for one week then after oral propafenone treatment was stopped. One week later, he brought to us a similar insect that stung him and this insect was European hornet (Vespa Crabro). Conclusions: Hornet stings have been associated with a wide variety of local and systemic reactions including atrial fibrillation episodes. Clinical condition is usually self-limiting; electrical cardioversion and/or propafenone are successful therapeutic options.

PP-035: CARDIAC MAGNETIC RESONANCE IMAGING FOR DETERMINATION OF VENTRICULER TACHYCARDIA FOCUS

normal left atrium and normal valves with no evidence of stenosis or regurgitation. The patient was discharged on the second day with oral 150mg propafenone twice a day for one week then after oral propafenone treatment was stopped. One week later, he brought to us a similar insect that stung him and this insect was European hornet (Vespa Crabro). Conclusions: Hornet stings have been associated with a wide variety of local and systemic reactions including atrial fibrillation episodes. Clinical condition is usually self-limiting; electrical cardioversion and/or propafenone are successful therapeutic options.

Clinical Outcome at Ten Years after Laparoscopic Fundoplication: Nissen versus Toupet

Laparoscopic surgery has become the elective approach for the surgical treatment of gastroesophageal reflux disease in the last decade. Outcome data beyond 10 years are available for open fundoplication, with good-to-excellent results, but few studies report long-term follow-up after laparoscopic fundoplication. We performed a retrospective study of all the patients that underwent laparoscopic Nissen and Toupet fundoplications as antireflux surgery between 1995 and 1998 in our institution. To evaluate the long-term results, a face-to-face interview was performed in 2009. One hundred and six patients were included in the study. Surgical techniques performed were Nissen fundoplication (NF) in 56 patients and Toupet (TF) in 50. Complication rate was 4 per cent in both groups (nonsignificant [NS]). Two patients (4%) of NF required reoperation because of dysphagia. After 10 years, 10 per cent of the patients remain symptomatic in both groups. Fifteen per cent of NF take daily inhibitors of the proton pump versus 14 per cent of TF (NS). Twenty per cent of NF refer dysphagia, all of them without evidence of stenosis at endoscopy or contrasted studies. The satisfaction rate of the patients was 96 per cent in NF and 98 per cent in TF. Laparoscopic Toupet fundoplication seems to be as safe and long-term effective as Nissen, but with a lower incidence of postoperative dysphagia. In our experience Toupet fundoplication should be the elective approach for the surgical treatment of gastroesophageal reflux disease.

Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery

Many patients with severe aortic stenosis and coexisting conditions are not candidates for surgical replacement of the aortic valve. Recently, transcatheter aortic-valve implantation (TAVI) has been suggested as a less invasive treatment for high-risk patients with aortic stenosis. We randomly assigned patients with severe aortic stenosis, whom surgeons considered not to be suitable candidates for surgery, to standard therapy (including balloon aortic valvuloplasty) or transfemoral transcatheter implantation of a balloon-expandable bovine pericardial valve. The primary end point was the rate of death from any cause. A total of 358 patients with aortic stenosis who were not considered to be suitable candidates for surgery underwent randomization at 21 centers (17 in the United States). At 1 year, the rate of death from any cause (Kaplan–Meier analysis) was 30.7% with TAVI, as compared with 50.7% with standard therapy (hazard ratio with TAVI, 0.55; 95% confidence interval [CI], 0.40 to 0.74; P<0.001). The rate of the composite end point of death from any cause or repeat hospitalization was 42.5% with TAVI as compared with 71.6% with standard therapy (hazard ratio, 0.46; 95% CI, 0.35 to 0.59; P<0.001). Among survivors at 1 year, the rate of cardiac symptoms (New York Heart Association class III or IV) was lower among patients who had undergone TAVI than among those who had received standard therapy (25.2% vs. 58.0%, P<0.001). At 30 days, TAVI, as compared with standard therapy, was associated with a higher incidence of major strokes (5.0% vs. 1.1%, P=0.06) and major vascular complications (16.2% vs. 1.1%, P<0.001). In the year after TAVI, there was no deterioration in the functioning of the bioprosthetic valve, as assessed by evidence of stenosis or regurgitation on an echocardiogram. In patients with severe aortic stenosis who were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.).

A Branched, Balloon-Deployable, Aortomonoiliac Stent-Graft for Treatment of AAA in a Patient With a Solitary Intrapelvic Kidney

To report the use of a branched, balloon-deployable stent-graft to treat abdominal aortic aneurysm (AAA) in the setting of a solitary kidney. A 72-year-old man with a solitary intrapelvic kidney and multiple comorbid conditions was diagnosed with an asymptomatic 5.3-cm abdominal aortic aneurysm (AAA); the renal artery emerged from the aneurysm sac. A customized branched, balloon-deployable, aortomonoiliac stent-graft was utilized to exclude the AAA and preserve perfusion to the single renal artery. A synthetic bypass was then implanted to restore perfusion to the contralateral limb. The diameter of the aneurysm decreased from 5.3 to 2.7 cm at 18 months. The renal artery was patent without evidence of stenosis; renal function was normal. The deployment of a novel branched stent-graft represents an interesting alternative approach to the treatment of a juxtarenal aneurysm.

Giant Coronary and Systemic Aneurysms of Kawasaki Disease in an Infant

Kawasaki disease (KD) was diagnosed in a 4-month-old male infant after 4 days of fever, rash, and bulbar conjunctivitis. He received two doses of intravenous immunoglobulin (IVIG), high-dose oral acetylsalicylic acid, and three doses of methylprednisolone within in the first week of illness for persistent fever. During the third week of his illness, echocardiogram showed giant aneurysms at the origin of the right coronary artery (17 mm) and at the bifurcation of the left coronary artery (9 mm). Anticoagulant therapy was started. At 9-month follow-up, the child was clinically well, and there were no ST-T wave changes on electrocardiogram. Aortography showed a giant aneurysm (19 9 19 mm) at the origin of the right coronary artery and another aneurysm (9 9 17 mm) distally (Figs. 1 and 2). The left coronary artery showed a large aneurysm (10 9 6 mm) at the bifurcation (Fig. 1). There was no evidence of stenosis in the right or left coronary artery. Subclavian artery injections showed large aneurysms in both the right (8 9 12 mm) and left (12 9 24 mm) brachial arteries (Fig. 3). Abdominal and carotid angiography were normal. At present, the infant is being maintained on low-dose aspirin and anticoagulant therapy. The international normalized ratio (INR) has been maintained between 2 and 2.5 (Fig. 4). KD is an acute multisystem vasculitis of unknown etiology that predominantly affects smalland medium-sized arteries. Fifteen percent of KD occurs in patients from 6 months to 4 years of age and often presents as the incomplete form [1]. Giant aneurysms (diameter [ 5 mm) are considered a high risk factor for the long-term development of stenotic coronary lesions [2]. Administration of IVIG within 10 days of illness decreases the incidence of giant aneurysms [3]. The risk of coronary artery aneurysms is higher for patients who do not respond to the first dose of IVIG, as happened in our case [3]. Systemic artery aneurysms have been reported to occur in 2% of patients with KD, and they are often associated with coronary aneurysms [4]. Fig. 1 Aortography showing a large aneurysm at the origin of the right coronary artery (white arrow) and a large aneurysm at the bifurcation of the left main coronary artery (red arrow). (Color figure online)