Femoral Artery Stenosis Research Articles

Close clinical monitoring of patients after TAVI implantation using artificial intelligence with a virtual voice assistant

Abstract Introduction The number of procedures and patients candidates for transcatheter aortic valve implantation (TAVI) has increased considerably due to population ageing and the rise in scientific evidence supporting this technique in patients with increasingly lower surgical risk. Early discharge would allow for a more efficient use of available resources, in addition to improving patients’ functionality and quality of life. Objective The use of a virtual voice assistant based on artificial intelligence, could be an effective and safe alternative to closely monitor patients after TAVI implantation in order to facilitate early identification of complications and a more efficient use of the resources available in Cardiology services. Material and methods Observational, prospective, single-center and consecutive study of the implementation of a technology based on artificial intelligence and natural language processing to monitor all patients undergoing transfemoral TAVI implantation, according to usual clinical practice, in the hemodynamics unit of our hospital in the year 2023. The virtual voice assistant, "Lola", carries out a telephonic follow-up during week 1, week 2, month 1, month 3 and 12. In these calls, it asks a series of questions mainly related to vascular access and with the patient's cardiovascular situation. After finishing the call, all the information collected is uploaded to a web platform where we monitor the collected data and thus take the appropriate measures. Results After 12 months, 274 patients have been included to whom 1,039 calls have been made with a total of 385 hours of autonomous conversation. In 44% of the calls, no alerts were detected and, therefore, did not required further review. From the remaining calls, a total of 926 alerts were collected, the predominant ones being: dizziness (24.9%), contact with the emergency services (11.3%) and alteration of general status (10.4%). The number of alerts decreases as the follow-up progresses, reflecting the need for closer monitoring in the initial stages after implantation. These alerts generated at least one intervention in 57% of the calls, the predominant ones being: medical contact (43.0%), nursing contact (26.3%) and medication adjustment (4.0%). These calls resulted in a total of 15 in-person examinations (5.4% of patients), detecting in 2 of them a 3rd degree atrioventricular block, in 3 a femoral pseudoaneurysm and in 1 a critical stenosis of the common femoral artery. According to a patient survey, 88.9% of patients were satisfied or very satisfied (Customer Satisfaction score 4.68/5). Conclusions The application of artificial intelligence permits strict control of the patient after TAVI implantation, thus facilitating early detection of complications. Patient satisfaction regarding this follow-up system was very high.

Evaluation of balloon and self-expandable stents for common femoral artery stenosis

BackgroundEndovascular treatment of the common femoral artery (CFA) and its bifurcation is currently recommended for patients with hostile groin (prior femoral bifurcation open surgery, history of radiotherapy) or severe comorbidities (advanced age, frailty, obesity). Preliminary results have shown favorable outcomes. Among the different endovascular techniques (atherectomy, intravascular lithotripsy, plain balloon angioplasty, drug-coated balloon angioplasty, stenting), stents are mainly used but the best type of stent to use is still debated. The aim of this study was to assess the value of balloon-expandable stents (BES) and self-expandable stents (SES) for stenosis of the femoral bifurcation. MethodsConsecutive patients with stenosis of the CFA and its bifurcation were included from 2016 to 2022. Demographic data, the type of stent used, procedural data, and angiographic variables were collected. Groups were defined according to the type of stent implanted. Primary patency was defined as a binary end point based on a duplex ultrasound peak systolic velocity ratio of ≤2.4 as assessed by duplex ultrasound examination, in the absence of clinically driven target lesion revascularization (TLR) or bypass of the target lesion. Secondary outcomes were clinical sustained improvement, freedom from TLR at 12 months, mean ankle-brachial index improvement, primary-assisted patency, and secondary patency. ResultsA total of 90 procedures conducted in 77 patients were included in this study, 26 in the SES group and 64 in the BES group. The most common symptomatology according to the Rutherford classification was class 2, 3, and 4 (28%, 48%, and 8%, respectively). The type of lesions in the CFA, assessed using the Azema classification, were comparable between both groups (SES/BES group type 2: 31%/27%; type 3: 54%/62%). At 12 months, the primary patency rates for SES and BES were 88% (26/26 patients) and 72% (58/64 patients) (P = .10). At 12 months, freedom from TLR rates for SES and BES were 97% vs 81%, respectively (P = .13). ConclusionsSES for CFA stenosis show a trend toward better patency and freedom from TLR rates at 12 months. However, controlled studies are warranted to further investigate the significance of this trend.

Femoral vessel complications after transfemoral TAVR-A contemporary sonography-based assessment of 480 patients with third-generation transcatheter valves.

Postinterventional sonographic assessment of the femoral artery after transfemoral transcatheter aortic valve replacement (TF-TAVR) has the potential to identify several pathologies. We investigated the incidence and risk factors of femoral vessel complications in a modern TAVR collective using postinterventional sonography. Between September 2017 and March 2022, 480 patients underwent TF-TAVR with postinterventional femoral sonography at a single center. Clinical outcomes and adverse events were analyzed after the Valve Academic Research Consortium 3 (VARC-3) criteria. In this cohort (51.2% male; age 80 ± 7.5 years, median EuroSCORE II 3.7) 74.8% (n = 359) were implanted with a self-expandable and 25.2% (n = 121) with a balloon-expandable valve. The main access (valve-delivery) was located right in 91.4% (n = 438), and the primary closure system was Proglide in 95% (n = 456). Vascular complications (VC) were observed in 29.16% (n = 140) of patients; 23.3% (n = 112) presented with minor- and 5.8% (n = 28) with major VC. Postinterventional femoral artery stenosis on the main access was observed in 9.8% (n = 47). Multivariable logistic regression analysis revealed female sex (p = .03, odds ratio [OR] 2.32, 95% confidence interval [CI] 1.09-4.89) and the number of used endovascular closure devices (p = .014, OR 0.11, 95%CI 0.02-0.64) as predictive factors for femoral artery stenosis. The incidence of postinterventional femoral artery stenosis following TF-TAVR was higher than expected with a number of used closure devices and female sex being independent risk factors. Considering the continuous advance of TAVR in low-risk patients with preserved physical activity, emphasis should be directed at the correct diagnosis and follow-up of these complications.

Abstract 16927: The Mother of All Pseudoaneurysms - A Rare Case

Introduction: Femoral artery pseudoaneurysms (FAP) are typically caused by percutaneous access during coronary and peripheral angiography. It occurs in 0.1 to 0.2% of diagnostic catheterization procedures and in 3.5% to 5.5% of interventional procedures. Cases of “Giant” femoral artery pseudoaneurysms have seldom documented in the past, however, our case is unique for two reasons:- Pseudoaneurysm presented 6 months after femoral arterial access, which is unusual.- This size of pseudo-aneurysm has yet to be documented. Case Description: 74-year-old male with history of diabetes mellitus type II and tobacco abuse presented with chest pain. He underwent cardiac catheterization via radial access, which confirmed severe multi-vessel disease with ejection fraction of 30%. Patient was started on goal-directed medical therapy with planned elective IABP-assisted coronary artery bypass grafting (CABG). On the day of surgery in anticipation of IABP, right femoral artery was accessed, however, intra-operative transesophageal echocardiography showed improvement of ejection fraction to 55%, which led to removal of the femoral sheath and application of a closure device. Six months later, patient presented with a large right groin mass. Computed tomography angiography confirmed a pseudoaneurysm anterior to the right common femoral artery, measuring 9.6 cm x 9.8 cm causing moderate stenosis of the superficial femoral artery. Peripheral arterial duplex ascertained the neck of pseudoaneurysm measuring 1.3 cm. Patient underwent emergent repair of the right femoral pseudoaneurysm, with thrombus removal. No further recurrence of pseudoaneurysm was noted. Discussion: Pseudoaneurysms may arise months after femoral arterial access. Any groin symptoms in patients who underwent percutaneous femoral arterial access warrant additional investigation. Further studies are needed to elucidate the factors that increase the risk of formation and rupture of pseudoaneurysms

The relationship between plasma atherogenic index and long-term outcomes after endovascular intervention in superficial femoral artery lesions.

Peripheral arterial disease (PAD) results from the systemic atherosclerotic process. In this study, we aimed to determine the relationship between plasma atherogenic index (AIP), a ratio of molar concentrations of triglycerides to HDL-cholesterol, and long-term outcomes after endovascular therapy (EVT) in patients with superficial femoral artery (SFA) stenosis. We retrospectively evaluated 673 patients who underwent EVT for PAD in our tertiary center between January 2015 and December 2020. In the receiver operating characteristic (ROC) curve analysis, the AIP value with the optimum cutoff value was determined as 0.576 to detect the presence of major adverse limb events (MALEs). Patients were divided into two groups according to low AIP (<0.576 as group 1) and high AIP (>0.576 as group 2). Among the major endpoints, long-term restenosis rates were significantly higher in patients in the high-AIP group than in the low-AIP group (p<.001). The lower extremity amputation rate was not statistically significant between the two groups. All-cause mortality rate (54 (31.6) versus 117 (68.4), p<.001) was significantly higher in patients in the high-AIP group than in the low-AIP group. In addition, the MALE rate (94 (29.2) versus 218 (62.1), p<.001) was significantly higher in patients in the high-AIP group than in those in the low-AIP group. In conclusion, we found that AIP is a significant independent predictor of long-term MALE in patients who underwent EVT for SFA.

Intra-arterial Fractional Flow Reserve Measurements Provide an Objective Assessment of the Functional Significance of Peripheral Arterial Stenoses

Peripheral arterial stenoses (PAS) are commonly investigated with duplex ultrasound (DUS) and angiography, but these are not functional tests. Fractional flow reserve (FFR), a pressure based index, functionally assesses the ischaemic potential of coronary stenoses, but its utility in PAS is unknown. FFR in the peripheral vasculature in patients with limb ischaemia was investigated. Patients scheduled for angioplasty and or stenting of isolated iliac and superficial femoral artery stenoses were recruited. Resting trans-lesional pressure gradient (Pd/Pa) and FFR were measured after adenosine provoked hyperaemia using an intra-arterial 0.014 inch flow and pressure sensing wire (ComboWire XT, Philips). Prior to revascularisation, exercise ABPI (eABPI) and DUS derived peak systolic velocity ratio (PSVR) of the index lesion were determined. Calf muscle oxygenation was measured using blood oxygenation level dependent cardiovascular magnetic resonance prior to and after revascularisation. Forty-one patients (32, 78%, male, mean age 65 ± 11 years) with 61 stenoses (iliac 32; femoral 29) were studied. For lesions < 80% stenosis, resting Pd/Pa was not influenced by the degree of stenosis (p= .074); however, FFR was discriminatory, decreasing as the severity of stenosis increased (p= .019). An FFR of <0.60 was associated with critical limb threatening ischaemia (area under the curve [AUC] 0.87; 95% CI 0.75- 0.95), in this study performing better than angiographic % stenosis (0.79; 0.63 - 0.89), eABPI (0.72;0.57 - 0.83), and PSVR (0.65; 0.51 - 0.78). FFR correlated strongly with calf oxygenation (rho, 0.76; p< .001). A greater increase in FFR signalled resolution of symptoms and signs (ΔFFR 0.25 ± 0.15 vs. 0.13±0.09; p= .009) and a post-angioplasty and stenting FFR of > 0.74 predicted successful revascularisation (combined sensitivity and specificity of 95%; AUC 0.98; 0.91 - 1.00). This pilot study demonstrates that FFR can objectively measure the functional significance of PAS that compares favourably with visual and DUS based assessments. Its role as a quality control adjunct that confirms optimal vessel patency after angioplasty and or stenting also merits further investigation.

Acute Limb Ischemia Rutherford Classification III and COVID-19: A Case Report

Background: COVID-19 is caused by SARS-CoV-2 infections, which are responsible for the recent pandemic. COVID-19 infection increases thromboembolic events, including Acute Limb Ischemia (ALI) by causing elevated cytokine levels, systemic inflammation, hypercoagulation state, and hyperinflammation responses. This complication might cause loss of limbs. Case description: We report a case of a 61-year-old male with COVID-19 who developed an ALI. He presented to the emergency department with acute left leg pain since a day before admission and shortness of breath three days before admission. His left foot was bluish-discolored, cold to the touch, and mottled in appearance. Chest x-ray showed bilateral inhomogeneous consolidation. Left lower limb X-ray revealed a gangrenous appearance. CT-Angiography suggested severe distal stenosis of the left femoral artery with complete occlusion of its distal aspect. COVID-19 was diagnosed based on RT-PCR testing. He received antibiotics and anticoagulation. Unfortunately, he underwent an amputation procedure. Conclusion: A high index of suspicion should be maintained for ALI in COVID-19 patients, which is a vascular emergency. Some patients can achieve revascularization with observation or medical and/or surgical intervention, but other patients succumb to either amputation or death.

Tomographic 3D ultrasound for grading stenosis of superficial femoral artery.

Treatment decision of lower extremity peripheral arterial disease (PAD) is governed by the severity of stenosis. Tomographic 3D ultrasound (t3DUS) is a reliable imaging technique for measuring vessel stenosis. In this study we attempted to provide a precise measurement of superficial femoral artery (SFA) stenosis using t3DUS in patients with PAD. t3DUS was used to measure maximum stenosis percentage in SFA from 50 patients with lower extremity PAD. The maximum stenosed segment in SFA was defined using Duplex 2DUS aliasing was noted. The peak systolic velocity (PSV) was measured at the maximum stenotic site and proximal to aliasing for calculating the velocity ratio. The association between blood flow velocity ratio and the degree of stenosis measured using Duplex 2DUS and t3DUS, respectively, was assessed using Spearman rank correlation. There was a strong positive correlation between velocity ratio and degree of stenosis in SFA measured using t3DUS (correlation value (r) = 0.99, p < 0.001). The correlation between Stenosis percentage and velocity ratio in SFA are as followed: <50:<2; 50-54:2-2.4; 55-59:2.5-2.9; 60-64:3-3.4; 65-69:3.5-3.9; 70-74:4-4.4; 75-79:4.5-4.9; >80:>5.

Phasicity and resistance of the arterial spectral Doppler waveform in a canine femoral focal artery stenosis model.

This study aims to evaluate changes in the arterial spectral Doppler waveform in a canine artery stenosis model. Canine femoral artery stenosis models were established in 12 beagle dogs. Doppler waveforms were recorded in the femoral artery preoperatively and postoperatively in the femoral artery and at the ankle after formation of a 50%, 70%, and 90% stenosis or occlusion. Major descriptors for arterial Doppler waveform were used to analyse waveforms. The proportion of multiphasic waveforms proximal to a moderate stenosis decreased compared to normal baseline, although the difference was not statistically significant, whereas the decreases at the stenosis, distal to the stenosis, and at the ankle were significant (p < 0.05). The decreases in arteries with a more severe stenosis or occlusion were significant at all locations (p < 0.05). The proportion of high resistive waveforms decreased significantly at the ankle in the arteries with a moderate stenosis (50%) (p = 0.002), but the decreases proximal to, at, and distal to the stenosis were not significant. The decreases were significant at all locations in the arteries with a more severe stenosis (p < 0.05). The decrease was significant at the ankle in the arteries with an occlusion (p < 0.001) but not significant pre, at, and post an occlusion. Phasicity and resistance of Doppler waveforms alter in canine femoral arteries with a stenosis. Phasicity change seems more sensitive in response to an arterial stenosis than resistance change. Additional information on arterial resistance could be obtained using end-diastolic ratios, resistive indices, and potentially end-systolic notch velocity measurements.

Iliofemoral Artery Endofibrosis Associated with Microembolization

ObjectivesEndoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease.MethodsCase report.ResultsA 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution.ConclusionsFig 2Intraoperative appearance of iliofemoral fibrosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT) ObjectivesEndoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease. Endoluminal fibrosis is a rarely described cause of exertional claudication in athletes. It typically is located to the external iliac artery,but has been described in the femoral segment as well. Rare reports have described arterial changes as a nidus for microembolic disease. MethodsCase report. Case report. ResultsA 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution. A 20-year-old male presented to the emergency department with 3 months of worsening right calf claudication. He reported a history of lupus anticoagulant, not currently being treated. He was a semi-professional soccer player and very physically active until symptom onset. The patient intermittently vaped. On physical exam, he had non-palpable pulses throughout the right leg with strongly palpable pulses throughout the left. Focal fixed petechiae were noted on the right toes. Duplex ultrasound showed focal high-grade stenosis of the right common femoral artery, and a subsequent CT angiogram demonstrated near-occlusion of a segment of the common femoral and a very small diameter (3 mm) right external iliac artery (Fig 1). All other lower extremity arteries were patent. Due to concern for a thromboembolic source, we performed a right iliofemoral endarterectomy with patch angioplasty. Intraoperatively, a dense, nearly occlusive rubbery mass at the external iliac-common femoral junction was identified (Fig 2). Pathology showed benign myxoid myofibroblastic proliferation, without signs of atherosclerosis. The intraoperative findings at this point suggested an endoluminal fibrosis with distal embolization. Palpable pedal pulses were restored. CTA was repeated 2 months postoperatively which demonstrated patency of the endarterectomy and normalization of the right external iliac diameter. The patient had been placed on warfarin and hydroxychloroquine with symptom resolution. Conclusions

Simultaneous Onset of Pediatric Systemic Lupus Erythematosus in Twin Brothers: Case Report

There are hundreds of twin adult patients with systemic lupus erythematosus (SLE), but male children with SLE are rarely affected. Two monozygotic twin brothers developed SLE at the age of 11 years during 1 month. The index brother manifested with Henoch-Shonlein purpura, accompanied by ANA positivity, and later developed critical left femoral arterial stenosis with high levels of anti-dsDNA, antiphospholipid antibodies, hypocomplementemia, and Coombs-positive hemolytic anemia. At that time his twin brother had only identical autoimmune findings and developed clinical manifestation (myositis and fasciitis) a month later. Both twins had increased IFN-score and shared a heterozygous variant in the RNASEL gene. Index patients developed scalp rash and nephritis 6 months after their parents refused the treatment which has been lasted for 1 year after disease diagnostics.ConclusionThe simultaneous onset of the pediatric SLE in the male twin is a very rare situation suspected monogenic origin of the disease. Further functional studies are required to confirm the causative role of the mutation.

Maximizing Angioplasty Results in Peripheral Interventions

The field of Interventional Radiology is said to have begun in 1964, when Dotter successfully restored circulation to an 82-year-old woman's leg with critical limb ischemia and gangrene by percutaneously dilating a localized stenosis of the superficial femoral artery using a Teflon catheter. The dilation catheter was revolutionary in the inception of angioplasty, and progress evolved with the development of angioplasty balloons. As angioplasty became more widely utilized, the focus turned to improving its results. Several factors are important to consider with regards to maximizing angioplasty results in peripheral interventions. These factors include vessel size, lesion length, lesion location, and the anatomic vascular bed. Operators must make thoughtful decisions regarding balloon choice, diameter, length, inflation pressures, inflation time, and employ these devices with excellent technique to optimize outcomes. Complications from angioplasty include elastic recoil, vessel dissection, vessel rupture, distal embolization, and neointimal hyperplasia. The most widely recognized limitation of angioplasty is the longevity of treatment effect. In order to improve long-term outcomes, different specialty balloons have been developed to address lesions resistant to plain balloon angioplasty and combat neointimal hyperplasia to improve outcomes. Ultimately the goal is to maximize vessel patency for the longest duration possible, and many exciting new technologies are on the horizon.

MO230: De Novo Double Glomerulopathy (Membranous Nephropathy, Mn and Collapsing Focal Segmental Glomerulosclerosis, CFSGS) Associated to Positive Myeloperoxidase-O (MPO) Antibody Following Pfizer-Biontech MRNA Vaccination Covid 19

Abstract BACKGROUND AND AIMS In the COVID 19 pandemic era, anti SARS-CoV-2 vaccination showed high efficacy at preventing the infection and its most severe complications. The aim of this report is to describe an unusual double glomerulopathy related to anti SARS-CoV-2 vaccination and the good results obtained with the immunosoppressive treatment. METHOD An 80-year-old caucasian woman developed a nephrotic syndrome, progressive renal insufficiency and microhematuria. The patient presented a medical history of thrombocytopenic purpura treated and resolved by steroids in 2013, hypothyroidism, hypertension, ischaemic heart disease treated with surgical bypass in 2019 and pacemaker in 2020 for atrial ventricular block. Due to pandemic COVID 19 status, she received two doses of the Pfizer BioNTech mRNA COVID-19 vaccine in March 2021. Two weeks after the second dose her weight increased of 23 kg. The family physician added furosemide to her therapy for generalized edema with no diuretic effect. In April, creatinine was 1.38 mg/dL (versus 0.8 mg/dL 1 year before); urinalysis showed proteinuria (300 mg/dL) and microscopic hematuria; serum total cholesterol level was 218 mg/dL and triglycerides 178 mg/dL; then it was suggested to increase the doses of furosemide. In May 2021, creatinine resulted 2 mg/dL, serum albumin 2 g/dL, and urinalysis confirmed proteinuria and microscopic hematuria; proteinuria was 10 g/day. Abdomen ultrasound showed normal liver, kidneys and spleen, not ascites. Lower limb eco-Doppler showed right superficial femoral artery stenosis of 60% and absence of venous thrombosis. The physical examination evidenced anasarca. The patients were admitted to the nephrology unit; hepatitis B surface antigen, hepatitis C antibody and human immunodeficiency virus antigen and antibody were negative. Both complement C3 and C4 levels resulted within the normal range. Cryoglobulins were absent. Urinary Bence Jones, antinuclear antibody (ANA), anti-extractable nuclear antigen (ENA), anti-double stranded DNA (nDNA) antibodies were negative. Antineutrophil cytoplasm antibodies (ANCA) were 1:2560 with Perinuclear pattern and anti-MPO positivity (716 UA/mL); anti-proteinase-3 antibodies (PR3) were negative. Anti-phosholipase A2 receptor antibody (PLA2R Ab) was positive with high titre. A kidney biopsy was performed showing a double nephropathy: a focal segmental glomerulosclerosis (FSGS) with some collapsing features, superimposed on membranous glomerulonephritis (Fig. 1). RESULTS We started the Ponticelli regimen (alternate months steroids and cyclophosphamide). After the first month of therapy, blood tests revealed creatinine 1.7 mg/dL, haemoglobin 11.7 g/dL; serum albumin 2.7 g/dL and urinalysis without microscopic haematuria. At the third month of therapy, the patient developed atrial fibrillation and started anticoagulation; blood tests were as follows: creatinine 1.1 mg/dL, serum albumin 3.0 g/dL, Ab anti-MPO 7 UA/mL and PLA2R Ab was absent. A left ocular, frontal and parietal herpes zoster induced a short discontinuation of therapy and responded well to Acyclovir; then we concluded the fourth month of therapy. At the fifth month, a SARS CoV 2 RT PCR unexpectedly resulted positive; the patient remained asymptomatic, but we stopped definitively the therapy. One month later, blood tests showed: creatinine 1 mg/dL, serum albumin 4 g/dL, proteinuria 0.7 g/die, MPO 2 UA/mL and PLA2R Ab absent. CONCLUSION To our knowledge, this is the first case of nephrotic sindrome secondary to a de novo MN and FSGS, associated with positive MPO antibody, following Pfizer–BioNTech mRNA vaccination COVID 19; the patient responded well to immunosoppression going in remission and regaining renal function.

Transbrachial Secondary Vascular Access in Transcatheter Aortic Valve Replacement Procedures: A Single-Centre Retrospective Analysis

Transfemoral transcatheter aortic valve replacement (TAVR) procedures require secondary vascular access for inserting accessory catheters and performing percutaneous repair of femoral artery injury. Use of the transbrachial approach for secondary vascular access in TAVR procedures has not been reported. This study identified 48 patients at the current institution who had undergone transfemoral TAVR utilising transbrachial secondary vascular access. Efficacy and safety of this strategy for achieving a successful totally percutaneous procedure were examined. Study endpoints were occurrence of vascular complications and bleeding related to transbrachial access, as well as periprocedural and 1-year mortality. Mean patient age was 80±7 years and Society of Thoracic Surgeons Predicted Risk of Mortality score was 10.6±3.1. Sizes of sheaths inserted into the brachial artery were 6 Fr (85%), 8 Fr (2%), and 9 Fr (13%). Transbrachial access was used for delivering stent grafts to the femoral artery in 13% of the patients, inflation of an occlusive balloon within the iliac artery in 10%, and treatment of iatrogenic femoral artery stenosis in 2%. Successful valve replacement was achieved in all cases. Brachial sheaths were removed by manual compression following administration of protamine sulfate. There were no major access site complications or VARC-3 type ≥2 bleeding related to the brachial vascular access. Brachial artery occlusion occurred in two patients (4%) who underwent surgical vascular repair. Two (2) additional patients developed mild arm ischaemia, which was treated conservatively. Periprocedural mortality was 0% and early mortality was 8%. Transbrachial secondary access in TAVR procedures was feasible and enabled percutaneous vascular repair in cases of femoral artery injury.

Quantitative Evaluation of Post-stenotic Blood Flow Disturbance in Canine Femoral Artery Stenosis Model: An Early Experience With Vector Flow Imaging.

ObjectiveTo investigate the value of Vector Flow Imaging (V Flow) in the assessment of post-stenotic turbulence in the canine arterial stenosis model.Materials and MethodsCanine femoral artery stenosis models were established using ameroid constrictors in 12 beagle dogs. 50% and then 70% femoral artery stenoses were confirmed by selective femoral artery angiography. V Flow was used to measure femoral artery flow turbulence index (Tur) preoperatively as a baseline. After establishing of a 50% and then 70% stenoses, the Tur indices were recorded in the femoral artery at 1, 3, 5, 7, 9, 11, 13, 15, 17, and 19 mm distal to the stenosis.ResultsBaseline Tur indices of normal canine femoral arteries were <1% in 11 of 12 cases (91.7%). Distal to a 50% stenosis, the Tur index (>1%) was recorded in 83.3–100% cases between 1 and 9 mm, 41.7–58.3% between 11 and 17 mm, and 16.7% at 19 mm. For a 70% stenosis, the Tur index (>1%) occurred in 81.8–100% cases between 1 and 17 mm distal to the stenosis, and 63.6% at 19 mm. The Tur index peaked around 7 mm or 2.3 times of the initial vessel diameter (3 mm) downstream for a 50% stenosis and 11 mm or 3.7 times of vessel diameter downstream for a 70% stenosis.ConclusionV Flow with Tur index measurement adds quantitative information of post-stenotic turbulence when assessing an arterial stenosis with ultrasound. Tur index of 1% seems a useful threshold for assessment of flow turbulence in this small sample study. Further studies with larger sample size are needed to evaluate the value of V Flow in clinical applications.

Effect of Revascularization on Intramuscular Vascular Endothelial Growth Factor Levels in Peripheral Arterial Disease.

Vascular endothelial growth factor (VEGF) is a potent driver of angiogenesis, which may help to relieve ischemia in peripheral arterial disease (PAD). We aimed to investigate the role of intramuscular VEGF in ischemic and non-ischemic skeletal muscle in PAD patients before and after surgical or endovascular revascularization and different stages of PAD. Biopsies of the gastrocnemius and vastus muscles from twenty PAD patients with stenosis or occlusion of the superficial femoral artery were obtained both during revascularization and 8 weeks postoperatively. The gastrocnemius muscle was considered ischemic, while vastus muscle biopsies served as intraindividual controls. The levels of vascular endothelial growth factor in muscle lysates were then determined by ELISA. Preoperative VEGF levels were significantly higher in ischemic muscles compared to the controls (98.07 ± 61.96 pg/mL vs. 55.50 ± 27.33 pg/mL, p = 0.004). Postoperative values decreased significantly (p = 0.010) to 54.83 ± 49.60 pg/mL in gastrocnemius biopsies. No significant change was observed in vastus muscle biopsies, with mean postoperative VEGF values found at 54.16 ± 40.66 pg/mL. Since all patients still had indications for revascularization, impairment of angiogenesis mechanisms can be assumed. More research about angiogenesis in PAD is needed with the ultimate goal to improve conservative treatment.

Mixed-braided stent: An effective way to improve comprehensive mechanical properties of poly (L-lactic acid) self-expandable braided stent

For its unique flexibility, self-expandable braided stent has been wildly used in the treatment of peripheral vascular diseases, such as the superficial femoral artery stenosis. With the application of bioabsorbable polymer materials, stent braided by polymer filaments is explored, and expected to minimize the complications caused by long-term retention of commercial metallic stents in the human body. Poly (L-lactic acid) (PLLA) is the representative of degradable polymer materials, and has been broadly applied in stent for its good mechanical properties and biocompatibility. This study aimed to propose a new preparation method for PLLA self-expandable braided stent by mixed-braided technology, and evaluate its mechanical properties especially in radial supporting performance and flexibility. For this purpose, a series of stent samples were prepared by mixed braiding PLLA monofilament with different diameters. In addition, the pitch angle and monofilament diameter are also considered as two critical design parameters affecting stent mechanical performance. Then, the radial strength and flexibility of different samples were evaluated respectively. The results show that the mixed-braided stent keep the excellent flexibility of thin monofilament braided stent, meanwhile it possesses the good radial supporting performance of the thick monofilament braided stent. This paper provides an idea to improve the comprehensive mechanical properties of PLLA self-expandable braided stent.

Early result of minimally invasive left atrial myxoma resection at Cardiovascular Center - E hospital

Objectives: The study aimed to evaluate clinical and paraclinical characteristics of left atrial myxoma and the early result of minimally invasive left atrial myxoma resection at E hospital.&#x0D; Patients and methods: This is retrospective, descriptive study of consecutive patients, who underwent minimally invasive left atrial myxoma rejection, using total or video-assisted endoscopic technique from October 2016 to March 2021 at E hospital. There were 31 patients, consisting of 27 females and 04 males. The mean age was 53 ± 13 years old (range [17-74]).&#x0D; Results: Preoperative clinical manifestations were diverse. Asymptomatic form was in 3 patients (9.7%), hemodynamic symptoms were in 26 patients (83.9%), embolism were presented in 4 patients (12.9%), systemic symptoms were in 8 patients (25.8%). Anemia and elevated erythrocyte sedimentation rates were observed in 45.2% and 74.2%, respectively. Echocardiography results: the average tumor size was 4.2 ± 1.7 cm (range [1.7-8]), the site of attachment was mainly in the atrial septum (77.4%). Cardiopulmonary bypass time was 158 ± 43 minutes (range [100-252]), cross-clamp time was 84 ± 34.2 minutes (range [42-153]), ventilation time was 10,8 ± 7,0 hours (range [3-30]), intensive care unit stay was 1,5 ± 1,0 days (range [0.5-4]), and in-hospital stay was 9.5 ± 5.0 days (range [3-30]). There was no hospital mortality. Cerebrovascular accident was presented in one (3.2%), femoral artery stenosis was in one (3.2%), atrial fibrillation after surgery was in one(3.2%).There was no bleeding, that require reoperation, and no other serious complications.&#x0D; Conclusions: Initial results of left atrial myxoma resection, using minimally invasive total or video-assisted technique wassafe and effectivewith low complications, could be recommended toapply routinely in cardiac surgery centers.

Early results of endovascular treatment of peripheral artery diseases at Dong Nai General Hospital

Introduction: Peripheral artery disease is a chronic disease with long-term progression and risk of disability. Treatment includes surgery and endovascular interventions, the latter is becoming more and more developed. This approach has good early and medium-term outcomes&#x0D; Subjects: We report 07 cases of patients diagnosed with peripheral arterial disease who received endovascular intervention at Dong Nai General Hospital.&#x0D; Results: 7 patients with peripheral vascular disease was treated with endovascular approach at Dong Nai General Hospital. Stenosis or chronic occlusion of the superficial femoral artery accounts for 50% of cases, the rest are stenosis of common iliac arteries, external iliac arteries and below-the-knee lesions. The primary intervention results were good, there were no serious complications, the rate of early vascular patency was 100%, the wound healing rate was 100%, there were 3 cases with stenting after balloon angioplasty and 3 cases of minor amputation. No reintervention was needed in these patients.&#x0D; Conclusion: The initial results of endovascular intervention for peripheral vascular disease at Dong Nai General Hospital are encouraging, helping to expand the indications for intervention, including hybrid surgery and creating first steps in multispecialty treatment of cardiovascular disease, a new trend in the future.

Predictors of Peripheral Artery Disease Progression. Is there Any Role for Vascular Age?

Predictors of Peripheral Artery Disease Progression. Is there Any Role for Vascular Age?