High-grade Stenosis Research Articles

Search for Reliable Circulating Biomarkers to Predict Carotid Plaque Vulnerability.

Atherosclerosis is responsible for 20% of ischemic strokes, and the plaques from the internal carotid artery the most frequently involved. Lipoproteins play a key role in carotid atherosclerosis since lipid accumulation contributes to plaque progression and chronic inflammation, both factors leading to plaque vulnerability. Carotid revascularization to prevent future vascular events is reasonable in some patients with high-grade carotid stenosis. However, the degree of stenosis alone is not sufficient to decide upon the best clinical management in some situations. In this context, it is essential to further characterize plaque vulnerability, according to specific characteristics (lipid-rich core, fibrous cap thinning, intraplaque hemorrhage). Although these features can be partly detected by imaging techniques, identifying carotid plaque vulnerability is still challenging. Therefore, the study of circulating biomarkers could provide adjunctive criteria to predict the risk of atherothrombotic stroke. In this regard, several molecules have been found altered, but reliable biomarkers have not been clearly established yet. The current review discusses the concept of vulnerable carotid plaque, and collects existing information about putative circulating biomarkers, being particularly focused on lipid-related and inflammatory molecules.

Combining minimal risk stratification and prediction of obstructive CAD – clinical utility of a dual pre-test probability model

Abstract Background The recently updated pre-test probability (PTP) model for diagnosing chronic coronary syndrome suggested by the European Society of Cardiology (ESC) was designed to predict the presence of obstructive coronary artery disease (CAD). In addition to this model, identification of non-obstructive CAD and utilization of preventive interventions may also lower rates of death and non-fatal myocardial infarction. Opposite to the ESC PTP, the minimal risk tool (MRT) is a new model developed to identify individuals without CAD but symptoms suggestive of CAD. We explored a combined use of the 2 models to predict the absence or presence of obstructive CAD. Methods This was a sub-study of the Danish study of Non-Invasive testing in Coronary Artery Disease (Dan-NICAD) which included patients with low-intermediate PTP of CAD. Minimal risk was defined as having a coronary calcium score of 0, no evidence of coronary atherosclerosis at coronary computed tomography angiography, and no cardiovascular (CV) events defined as myocardial infarction, death or revascularization in the mean observation period of 3.1 [2.7–3.4] years. Obstructive CAD was defined as a fractional flow reserve <0.80 in a major vessel during invasive coronary angiography (ICA) or a high-grade stenosis by visual assessment (>90% lumen reduction). The risk factors included in the MRT were age, sex, smoking history, diabetes mellitus, dyslipidaemia, family history of premature CAD, hypertension, symptoms related to stress, and high-density lipoprotein concentration. Based on a point-system ranging from 0–5, the MRT and the ESC PTP were combined (dual-PTP) (figure 1). A dual-PTP ≤1 indicated very low risk. Using both minimal risk and obstructive CAD as references, the dual PTP was compared to the MRT and the ESC PTP through tests of model discrimination. Results Of the 1544 eligible patients, 710 (46%) had normal coronary arteries and no CV events. Obstructive CAD was diagnosed in 152 (10%). Equivalent to a dual-PTP <1 point, 209 patients with ESC PTP<5% and MRT>50% or ESC PTP 5–15% and MRT >75% were classified as very low risk. Of these patients, 84% were at true minimal risk (red area figure 1). Furthermore, only 6 patients would have been diagnosed with obstructive CAD at ICA, and 0 events would be missed. The dual-PTP was non-inferior to the MRT and the ESC PTP in identifying patients having minimal risk and obstructive CAD, respectively (minimal risk: c-statistics 0.74 (0.72–0.77) vs. 0.76 (0.73–0.78); obstructive CAD: c-statistics 0.66 (0.62–0.70) vs. (0.67 (0.63–0.72)). The dual-PTP was superior to the ESC PTP in discriminating patients at minimal risk (c-statistics 0.74 (0.72–0.77) vs. 0.69 (0.67–0.71). Conclusions Combining the ESC PTP and the MRT, the dual-PTP seems to enable accurate prediction of both patients with minimal risk and patients with obstructive CAD. Based on the dual-PTP, patients can safely be deferred from or referred for diagnostic testing Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Aarhus University, Health Research Fund of Central Denmark Region

T1 Mapping Quantifies Spinal Cord Compression in Patients With Various Degrees of Cervical Spinal Canal Stenosis.

Age-related degeneration of the cervical spinal column is the most common cause of spinal cord lesions. T1 mapping has been shown to indicate the grade and site of spinal cord compression in low grade spinal canal stenosis (SCS). Aim of our study was to further investigate the diagnostic potential of a novel T1 mapping method at 0.75 mm resolution and 4 s acquisition time in 31 patients with various grades of degenerative cervical SCS. T1 mapping was performed in axial sections of the stenosis as well as above and below. Included subjects received standard T2-weighted MRI of the cervical spine (including SCS-grading 0-III), electrophysiological, and clinical examination. We found that patients with cervical SCS showed a significant difference in T1 relaxation times within the stenosis (727 ± 66 ms, mean ± standard deviation) in comparison to non-stenotic segments above (854 ± 104 ms, p < 0.001) and below (893 ± 137 ms, p < 0.001). There was no difference in mean T1 in non-stenotic segments in patients (p = 0.232) or between segments in controls (p = 0.272). Mean difference of the T1 relaxation times was significantly higher in grade III stenosis (234 ± 45) vs. in grade II stenosis (176 ± 45, p = 0.037) vs. in grade I stenosis (90 ± 87 ms, p = 0.010). A higher difference in T1 relaxation time was associated with a central efferent conduction deficit. In conclusion, T1 mapping may be useful as a tool for SCS quantification in all grades of SCS, including high-grade stenosis with myelopathy signal in conventional T2-weighted imaging.

Predictors of the pulsatility index in the middle cerebral artery of acute stroke patients

Cervical and transcranial Doppler (TCD) are widely used as non-invasive methods in the evaluation of acute ischemic stroke (AIS) patients. High-grade carotid artery stenosis induces haemodynamic changes such as collateral flow and a so-called post-stenotic flow pattern of the middle cerebral artery (MCA), which appears flattened, with a reduction of the velocity difference between systole and diastole. We studied the influence of carotid artery stenosis and other variables on the flow pattern in the MCA using the pulsatility index (PI), a quantitative TCD parameter reflecting the flow spectrum in a large of cohort AIS patients. We performed ultrasound examinations of 1825 AIS patients at the CHUV from October 2004 to December 2014. We extracted patient characteristics from the ASTRAL registry. Carotid stenosis severity was classified as < 50%, 50–70%, 70–90% and > 90%, or occlusion, according to Doppler velocity criteria. We first determined variables associated with stenosis grade. Then we performed a multivariate analysis after adjusting for baseline differences, using MCA PI as dependent variable. Carotid stenosis > 70% (− 0.07) and carotid stenosis > 90%, or occlusion (− 0.14) and left side (− 0.02) are associated with lower MCA PI values. Age (+0.006 PI units per decade), diabetes (+0.07), acute ischemic changes on initial CT (+0.03) and severe plaque morphology (+0.18) are associated with higher MCA PI values. We found a number of clinical and radiological conditions that significantly influence the PI of the MCA, including high-grade ipsilateral carotid stenosis in AIS patients. We provide for the first time a quantitative evaluation of the effect of these influencing factors from a large cohort of AIS patients.

Low rates of restenosis in primary lateral carotid artery endarterectomy

Carotid artery endarterectomy (CAE) is a treatment of choice for symptomatic and asymptomatic high-grade carotid stenosis, showing great results in reducing stroke morbidity. The optimal technique of the arterial closure is, however, still under discussion, with both patch angioplasty and primary closure having numerous advantages and pitfalls. The definite evidence is still lacking. The aim of this study was to evaluate the results of the modified primary closure technique during CEA. Incidence of restenosis more than 8 months after the surgery was measured. A retrospective observational study to evaluate modified primary internal carotid artery closure was conducted in Republican Vilnius University Hospital from January 1st, 2014 to December 31st, 2018. The patients were enrolled in the trial during their routine follow-up by their surgeon. During the visit, after an informed consent was signed, a qualified investigator performed carotid duplex ultrasound scan, documenting the restenosis rates. Patients also filled in the comorbidity assessment questionnaire, which included their smoking habits, history of hypertension and their adherence to antihypertensive medication as well as cholesterol levels and statin therapy, additional related comorbidities. Out of 342 patients that underwent CAE with primary closure in the Republican Vilnius university hospital from 2014 to 2018, 42 patients were identified as deceased, therefore a follow-up was impossible. Out of planned 150 (50%) consequently selected patients, 125 gave an informed consent to be enrolled into the study. Out of those 6 pre-occlusions were established during the review of the patient medical data and therefore were excluded from the study. In general, we analyzed the data of 119 patients and 125 CAE with a modified primary suture closure. The mean follow-up time was 35.78 months (SE 0.992; SD 11,046). At the time of a follow up, 3 (2,4%) carotid artery occlusions were identified and promptly evaluated. Restenosis rates varied: 5,6% of patients had low grade (&lt;50%), 5,6% had moderate grade (50-69%) and 1,6% had high grade (70-99%) stenosis. The modified lateral CAE with primary closure technique, used in our hospital’s contemporary practice has shown to be a promising alternative to the classical primary suture, due to reduced restenosis rates. More prospective and randomized studies are needed to evaluate this technique in comparison to other CAE closure techniques.

THE EFFICACY AND SAFETY OF USING PHENYLEPHRINE TO OPTIMIZE CEREBRAL PERFUSION IN DELAYED NEURO-INTERVENTION OF ACUTE ISCHEMIC STROKE

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Permissive hypertension (HTN) in the management of acute ischemic stroke (AIS) is not novel but a more recent approach considers the use of vasopressors to optimize cerebral perfusion pressure in the normotensive patient. CASE PRESENTATION: A 67-year-old female, active smoker with no medical history, presented with difficulty speaking for 6 hours. Exam revealed expressive aphasia with no other neurologic deficits. CT angiogram head showed abrupt cut-off of the distal M1 segment extending to the middle cerebral artery (MCA) bifurcation and proximal M2 vessels consistent with thromboembolism. Labs including cardiac enzymes were unremarkable. Cerebral angiogram showed high-grade sub occlusive stenosis of cervical left internal cerebral artery (ICA) and left MCA. She was admitted to the intensive care unit and placed on aspirin and clopidogrel. A systolic blood pressure (SBP) goal of 160-180mmHg was achieved using normal saline and phenylephrine (PE) infusions. 72 hours later she underwent successful percutaneous transluminal carotid artery angioplasty and stenting of the left ICA stenosis with subsequent complete resolution of her symptoms. PE was discontinued with new goal of SBP 100-120mmHg. Three days later she had acute onset chest pain. ST depressions in anterolateral leads on electrocardiogram and elevated cardiac enzymes prompted coronary angiography, which showed triple vessel disease requiring coronary artery bypass grafting. DISCUSSION: A U-shaped relationship exists regarding morbidity and mortality in SBP control in AIS. Elevated SBP increases risk of brain edema and hemorrhagic conversion while low pressures cause decreased central perfusion pressure leading to decreased collateral circulation to ischemic areas. In a 2001 pilot study using PE in patients with AIS, beyond the window of systemic thrombolysis, 54% of patients had improved NIH stroke scale (NIHSS) after achieving target SBP (160 mmHg or increase by 20% of admission SBP without exceeding 200 mmHg); no systemic or neurologic complications were reported.(1) A randomized trial (RT) utilizing PE to target an elevated SBP showed a short-term improvement in the NIHSS, cognitive score, and volume of hypoperfused tissue, when compared to the control group, in individuals with subacute and AIS.(2) In a multicenter RT of patients with noncardioembolic AIS, ineligible for revascularization therapy, PE was used to increase SBP up to 200 mmHg. 88.2% of patients in the intervention group exhibited improvements in NIHSS scores of ≥2 points; safety outcomes did not significantly differ between groups.(3) Our patient had complete resolution of neurologic symptoms after PE use and neuro-intervention, which preceded a cardiac event. CONCLUSIONS: While evidence exists to support the efficacy and safety of PE for SBP augmentation in the setting of AIS, larger studies with emphasis on safety are needed, as currently no guidelines exist. Reference #1: Rordorf G., Koroshetz W.J., Ezzeddine M.A., Segal A.Z., Buonanno F.S. A pilot study of drug-induced hypertension for treatment of acute stroke. Neurology. 2001 May 8;56(9):1210-3. doi:10.1212/wnl.56.9.1210 Reference #2: Hillis A.E., Ulatowski J.A., Barker P.B., et al. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and sub acute stroke. Cerebrovasc Dis. 2003;16(3):236-246. doi: 10.1159/000071122 Reference #3: Bang O.Y., Chung J.W., Kim S.K., et al. Therapeutic-induced hypertension in patients with noncardioembolic acute stroke. Neurology. 2019 Nov 19;93(21):e1955-e1963. Epub 2019 Oct 23. doi: 10.1212/WNL.0000000000008520. DISCLOSURES: No relevant relationships by Kyle Foster, source=Web Response No relevant relationships by Nisha Gandhi, source=Web Response No relevant relationships by Matthew Tavares, source=Web Response

S2957 Chronic Mesenteric Ischemia: A Rarer Cause of Refractory Gastric Ulceration

INTRODUCTION: H. pylori and non-steroidal anti-inflammatory drug (NSAID) use are common causes of peptic ulcer disease (PUD). In cases of refractory PUD after addressing these factors and treatment with a proton pump inhibitor (PPI), mesenteric ischemia should be considered. CASE DESCRIPTION/METHODS: A 74 year-old male experienced a non-ST segment myocardial infarction, underwent drug eluding coronary stenting, and was initiated on clopidogrel and aspirin therapy. That admission, he developed epigastric abdominal pain and “dark stools”. H. pylori serology was positive, and he was treated with high dose pantoprazole and amoxicillin. Despite twice daily PPI and NSAID avoidance, his epigastric pain persisted, so EGD was performed, revealing superficial, non-bleeding ulcerations and erythema in the gastric body; biopsies showed reactive gastropathy and congestion without H. pylori. 2 weeks later he developed overt melena, and small bowel enteroscopy revealed gastric mucosa pallor and an adherent clot overlying a 1 cm oozing peptic ulcer along the greater curvature. The ulcer was successfully treated with epinephrine and hemostatic clips. His pain symptoms and bleeding resolved, though a surveillance EGD 12 weeks later revealed persistent smaller ulcers, flat pigmented spots, and congestion adjacent to site of the larger ulcer. Sucralfate thus was added to his PPI regimen. He remained asymptomatic until his clopidogrel was discontinued, shortly thereafter developing severe epigastric pain. Physical exam was unremarkable and labs were notable for lactate 1.6 mmol/dL, hemoglobin 12.2 g/d, and gastrin 169 pg/ml (on PPI). CT angiogram showed 90% stenosis at the superior mesenteric artery (SMA) origin, high grade stenosis of the celiac and inferior mesenteric arteries, and dilated bowel. Endovascular intervention was attempted, but revascularization failed due to extent of disease, leading to open mesenteric bypass graft from the external iliac artery to proximal SMA. His dyspeptic symptoms completely resolved at 1 month follow up. DISCUSSION: Chronic ischemia rarely causes PUD due to highly-vascularized gastric mucosa. However, in cases such as this with severe stenosis of the major branches of the aorta this rare complication may occur. Mesenteric ischemia is an important diagnosis to consider in patients with refractory gastric ulcers, especially in the setting of known atherosclerotic disease. Mesenteric ischemia and its associated symptoms and mucosal injury can be successfully managed by revascularization.Figure 1.: EGD with superficial, non-bleeding ulcerations and erythema in the gastric body.Figure 2.: CT angiogram with stenosis of the superior mesenteric artery.Figure 3.: CT angiogram with stenosis of the superior mesenteric artery.

S1671 Ischemic Colitis Secondary to Cryoglobulinemic Vasculitis: A Rare Entity

INTRODUCTION: Cryoglobulinemic vasculitis is a small-to-medium vessel vasculitis caused by cryoglobulin-containing immune complexes mainly involving the skin, the joints, the peripheral nerve system, and the kidneys. Gastrointestinal involvement can be seen in approximately 5% of the cases, manifested as ischemic bowel disease, gastrointestinal hemorrhage, peritonitis, and acute lesions of the pancreas and gallbladder. We present the case of a 66-year-old female patient who developed ischemic colitis as a consequence of cryoglobulinemic vasculitis. CASE DESCRIPTION/METHODS: The patient is a 66-year-old female with a medical history of hypertension, cerebrovascular accident, congestive heart failure, mitral valve regurgitation, and cryoglobulinemic vasculitis who was taken to the emergency department for confusion. She was initially admitted to the intensive care unit under the impression of acute encephalopathy secondary to hypoglycemia, and heart failure exacerbation. Her course was complicated with hematochezia and hematemesis, for which the gastroenterology team was consulted. On physical exam the patient was afebrile, hemodynamically stable, the abdomen was soft and diffusely tender. She also had ischemia of her digits (Figure 1). The rectal exam revealed blood in stools. Computed tomography angiography (CTA) of the abdomen revealed moderate to high-grade stenosis of the proximal celiac axis with post stenotic dilation. She then underwent a colonoscopy that revealed patchy erythematous mucosa with ulcerations/denudation and pseudomembrane formation in the examined portion of the colon (Figure 2). The endoscopic picture was consistent with underlying ischemic pathology. Biopsies were taken and pathology showed surface epithelial necrosis in the background of acute inflammation and vascular thrombosis, consistent with ischemic colitis (Figure 3). The clinical course was posteriorly complicated with acute respiratory failure secondary to severe mitral regurgitation for which was transferred to another facility for mitral valve repair and was lost to follow up. DISCUSSION: Cryoglobulinemic vasculitis usually runs a slow course, but flares can present with life-threatening manifestations, of which gastrointestinal involvement is one of the most severe. Prompt diagnosis and adequate immunosuppressive therapy, revascularization, or surgical treatment in the appropriate settings are crucial for a successful recovery and prevention of irreversible damage or death.Figure 1.: Physical exam showing ischemic changes of the patients digits.Figure 2.: Colonoscopy revealing patchy erythematous mucosa with ulcerations and pseudomembrane formation.Figure 3.: Surface epithelial necrosis in the background of acute inflammation and vascular thrombosis, consistent with ischemic colitis.

MOYAMOYA DISEASE: A STORY OF MULTIPLE STROKES

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Moyamoya disease (MMD) is a specific cerebrovascular disease first described in 1957 by Japanese surgeons, characterized by stenosis or occlusion of the terminal portions of bilateral internal carotid arteries (ICA) with development of fragile small vessel collateral blood vessels. It may cause ischemic attacks or cerebral infarction, more frequent in children than adults. Incidence peaks in two different age groups: children who are approximately 5 years of age and adults in their mid 40's. Initial presentation is that of TIA or cerebral ischemia/hemorrhage. CASE PRESENTATION: 46-year-old female with history of hypertension initially presented with right sided tingling and numbness, CT head was negative, CTA head and neck significant for left ICA stenosis, she received tPA. Underwent full neurology work up including MRI no acute stroke or acute bleeding, MRA head and neck showed >80% narrowing of left ICA, etiology at that time was unknown. Followed by neurology clinic with imaging every 6 months; MRI Brain/MRA two years after initial presentation significant for left ICA supraclinoid occlusion and right supraclinoid moderate stenosis, left hemisphere supply via leptomeningeal collaterals from posterior cerebral artery (PCA) and anterior cerebral artery (ACA) consistent with MoyaMoya Disease. She subsequently had left superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis. Remained asymptomatic for two more years until gradual onset of forgetfulness and memory loss. Repeat imaging at that time demonstrated evolving ischemia of frontal region and high-grade stenosis of bilateral internal carotid arteries, she underwent an additional intracranial bypass. DISCUSSION: Moyamoya disease is a chronic, occlusive cerebrovascular disease involving bilateral stenosis of ICA or occlusion of the terminal portions of MCA and ACA. There are four types of MMD: ischemic, hemorrhagic, seizures, or "other;” hemorrhagic being more common in adults. Initial presentation consists of symptoms of TIA or stroke like symptoms including severe headaches, unilateral weakness, or memory changes. On angiography, characteristic stenosis or occlusion of bilateral terminal portion of ICAs as well as the moyamoya vessels are seen at the base of the brain. Cases with milder symptoms can be medically managed, while more severe symptomatic cases are treated with revascularization such as STA-MCA anastomosis. However, these procedures do not prevent progression of disease and patients may require multiple procedures to prevent ischemic episodes. CONCLUSIONS: Moyamoya disease is a chronic, occlusive cerebrovascular disease involving bilateral ICA, initial symptoms are those of TIA or stroke. Milder cases can be managed medically but more severe cases require surgical intervention, however, this does not slow down progression of disease. Reference #1: Burke, G., Burke, A., Sherma, A., Hurley, M., Batjer, H., Bendok, B (2009). Moyamoya Disease: A Summary. Journal of Neurosurgery. https://doi.org/10.3171/2009.1.FOCUS08310 Reference #2: Fukui M, Kono S, Sueishi K, Ikezaki K. Moyamoya disease. Neuropathology. 2000;20 Suppl:S61-S64. https://doi.org/10.1046/j.1440-1789.2000.00300.x Reference #3: Scott, M., Smith, E. (2009). Moyamoya Disease and Moyamoya Syndrome. The New England Journal of Medicine. 2009; 360: 1226-37. http://moya-moya.org/wp-content/uploads/2011/05/moya-moya.pdf DISCLOSURES: no disclosure on file for Victor Montalvan; No relevant relationships by Brandon Rogers, source=Web Response No relevant relationships by Jasmine Sekhon, source=Web Response

The Incidence of Transverse Sinus Stenosis in Multiple Sclerosis: Further Evidence of Pulse Wave Encephalopathy

BackgroundMultiple sclerosis (MS) is associated with a breakdown in the intracranial pulse wave dampening or windkessel effect. This is manifest by an increase in the arterial stroke volume and a decrease in the dampening afforded by both the CSF displaced into the spinal canal and the blood displaced by the venous sinus pulsation. There is evidence that the reduction in compliance of the sagittal and straight sinuses in MS is caused by an increase in venous pressure despite the jugular bulb pressures being normal. This implies MS patients have a venous outflow stenosis somewhere between the torcular and jugular bulbs. The purpose of the current study is to define the site, significance and cause of these stenoses. Methods50 patients with MS were prospectively recruited from an MS clinic and compared to 50 matched control patients. Using 3DT1 post contrast images, a survey of the venous sinuses was performed looking for the narrowest portion of the sinuses in each of 4 segments from the sagittal sinus to jugular bulbs. The cross sectional areas and wetted circumferences of the venous sinuses were measured at each site to calculate the minimum hydraulic and effective diameters. The BMI, optic nerve sheath diameters and pituitary heights were measured. Statistical analysis was performed using non-parametric methods and was assessed using α≤0.05. ResultsCompared to controls, the MS patients’ sagittal sinuses were 24% larger in cross-section (p=0.0001) with an 18% larger wetted circumference (p=0.0001). The MS patients’ transverse sinuses had an average effective stenosis of 38% by area (p<0.0001) with 8/50 patients having a high grade stenosis of >65% by area and 16/50 a low grade stenosis of between 40-65% by area compared to 1/50 low grade stenoses in this segment in the controls. The commonest cause of the stenosis was a giant arachnoid granulation. The optic nerve sheaths were larger in MS than controls (p=0.0006). Comparing MS patients with transverse sinus stenosis to those without, the pituitary height was 16% smaller and BMI 25% larger (p=0.02 and 0.003 respectively) ConclusionIn patients with MS, the reduction in venous sinus compliance is associated with venous outflow stenoses in the transverse sinuses which increases the upstream venous pressure and dilates the sagittal sinuses. This finding suggests a continuum exists between MS and idiopathic intracranial hypertension.

The effect of carotid revascularization on the ophthalmic artery flow: systematic review and meta-analysis.

High-grade internal carotid stenosis results in impaired flow dynamics in the ocular circulation that may lead to a rare clinical entity; ophthalmic ischemic syndrome (OIS). The aim of this study was to investigate hemodynamic changes in the ophthalmic circulation after carotid revascularization, assessed with duplex ultrasonography (DUS), and their potential impact on ocular function in patients suffering from OIS. A systematic review of the literature was performed according to the PRISMA guidelines. Medline, Embase and Central databases were searched. The analysis included fourteen cohort studies (589 patients) reporting on the hemodynamic effect of carotid revascularization on the ophthalmic circulation using DUS. Eighty-five per cent of patients were treated for symptomatic carotid stenosis. The pre- and postoperative ophthalmological evaluation was recorded in four studies (227 out of 358 patients [63%] diagnosed with OIS). Reversed ophthalmic artery (OA) flow prior to carotid revascularization was present in 86 cases (24%). Following carotid revascularization, a significant increase in peak systolic velocity (PSV) (mean difference [MD] 14.712 cm/s, 95% confidence interval [CI] 10.566-18.858, P<0.001, I2=96%) and a significant anterograde restoration of flow in the OA (OR: 2.047, 95% CI: 1.72-2.42, P<0.001, Ι2=0%) were recorded. Carotid revascularization resulted in regression of ischemic symptoms in 93.1% of patients (95% CI: 56.4-99.3%), P=0.001, I2=82%). Carotid revascularization may be associated with a significant flow restoration and PSV increase in the OA; as well as clinical improvement in ischemic ophthalmic symptoms in patients with OIS.

The Dilator-Dotter Technique: A Modified Method of Rapid Internal Carotid Artery Revascularization in Acute Ischemic Stroke.

Acute ischemic stroke due to tandem occlusive lesions involves high-grade ICA stenosis or occlusion with a distal intracranial occlusion. Several approaches and devices exist in the treatment of tandem occlusions; however, a consensus on the optimal technique does not exist. The Dotter technique is a method of catheter-based angioplasty to recanalize cervical ICA occlusions. We present a modified dilator-Dotter technique, which involves a polyethylene, tapered inner dilator to initially cross the occlusion, followed by guide catheterization and subsequent intracranial thrombectomy. The purpose of this study was to examine the safety and efficacy of this dilator-Dotter technique. We performed a retrospective review of patients with acute stroke due to tandem ICA intracranial occlusions, treated with our dilator-Dotter technique and thrombectomy between June 2018 and December 2019. We examined clinical, radiographic, and procedural data, as well as complications and outcomes. Thirty-two patients were included. In 100% of cases, the dilator-Dotter technique resulted in ICA recanalization allowing successful thrombectomy. TICI 2b-3 revascularization was obtained in 31 patients (96%), within an average time of 25 minutes. The average preprocedural ICA stenosis was 98%, including 23 patients (72%) with complete occlusion. Following the dilator-Dotter technique, average ICA stenosis improved to 59%. There were no instances of death, iatrogenic dissection, emboli to new territory, or symptomatic intracranial hemorrhage. The dilator-Dotter technique may be a safe and effective modification of the traditional Dotter technique in allowing rapid ICA recanalization in cases of acute ischemic stroke due to tandem occlusions.

Balloon Dilation for Endosonographic Staging in Esophageal Cancer: A Phase 1 Clinical Trial

Dilation in patients with malignant esophageal strictures precluding the passage of the endoscopic ultrasonography (EUS) scope allows complete evaluation; however, it may be associated with complications. This study evaluates the safety and clinical value of balloon dilation to complete EUS in patients with stenotic esophageal cancers. This study consists of a phase I clinical trial. One-hundred-and fifty patients were recruited. Endoscopic balloon dilation was performed before EUS in patients with high-grade stenosis. The analysis was focused on the ability to complete an endosonographic examination after dilation, 30-day morbidity, and change in the final stage or definitive management based on the completed endosonographic examination. Dilation was required in 55 patients (36.7%), with a complication rate of 10.9% (n= 6). Dilation allowed completion of EUS in 53 patients (96.4%), leading to a modification of the clinical stage for 18 patients (34%) and a deviation in the treatment plan in 7 patients (13.2%). No differences were found in these variables when compared with the group that did not require dilation (26.3% and 14.7%, P= .33 and P= .79, respectively). Dilation was associated with more advanced disease on final pathology among patients who underwent surgical resection (P= .006). High-grade malignant esophageal strictures that preclude the passage of the ultrasound probe are associated with advanced stage disease. Owing to the high risk of perforation and the limited benefit in staging, balloon dilation to complete the EUS staging should be avoided. (Clinicaltrials.gov identifier: NCT01950442.).

Coronary atherosclerosis profile in patients with end-stage liver disease prior to liver transplantation due to alcoholic fatty liver: a coronary CTA study

ObjectivesTo assess the coronary atherosclerosis profile by coronary computed tomography angiography (CTA) in patients with end-stage liver disease (ESLD) due to alcohol-related liver disease (ARLD) evaluated for liver transplantation (LT), in a retrospective matched case-controlled cohort study.MethodsOne hundred forty patients (age 60.6 years ± 9.8, 20.7% females) who underwent coronary CTA were included. Seventy patients with ESLD due to ARLD (ESLD-alc) were propensity score (1:1) matched for age, gender, and the major 5 cardiovascular risk factors with healthy controls. CTA analysis included the following: stenosis severity according to CAD-RADS as (0) = no, (1) minimal < 25%, (2) mild 25–50%, (3) moderate 50–70%, and (4) severe > 70% stenosis, total mixed plaque burden weighted for non-calcified component (G-score) and high-risk plaque criteria (Napkin-Ring, low attenuation plaque, spotty calcification, positive remodeling).ResultsPrevalence of coronary artery disease (CAD) was high (84.4%) in the ESLD-alc group but similar to controls. Stenosis severity was similar (CAD-RADS, 1.9 vs. 2.2, p = 0.289). High-grade stenosis (> 70%) was observed in 12.5% of ESLD-alc patients. High-risk plaques were less frequent in the ESLD-alc cohort as compared to controls (4.5% vs. 37.5%, p < 0.001), and total mixed plaque burden was lower (G-score, 4.9 versus 7.4, p = 0.001). Plaque density was lower in controls (56.6HU ± 3.2 vs. 91.3HU ± 4.5, p = 0.007) indicating more lipid-rich in controls, but higher mixed fibro-calcific plaque component in those with alcohol-related ESLD.ConclusionPatients with alcohol-related ESLD exhibit more mixed fibro-calcified plaques but less plaque with high-risk features and less fibro-fatty plaque burden, while total CAD prevalence is high.Key Points• Patients with ESLD prior to LT have a high total prevalence of CAD and stenosis severity, which is similar to those of healthy controls with an identical cardiovascular risk profile.• Patients with ESLD prior to LT due to alcohol abuse have more calcific but less fibro-fatty plaque and less high-risk plaque.• CTA seems to be a useful imaging technique for risk stratification prior to LT.

Drug-Coated Balloon Treatment in Symptomatic Intracranial High Grade Stenosis : A Retrospective Study of 33Patients.

Endovascular therapy (EVT) represents an alternative treatment modality for symptomatic intracranial high-grade atherosclerotic stenosis (sICAS); however, periprocedural complication rates as well as midterm restenosis rates represent relevant limitations of EVT. Drug-coated balloon percutaneous transluminal angioplasty (DCB-PTA) may overcome some of these shortcomings. The aim of this study was to assess feasibility and safety as well as the stroke recurrence rate in 33patients. Aretrospective, monocentric cohort study of sICAS patients treated with DCB-PTA. Outcome measures were the periprocedural intracranial complication rate, the recurrent stroke rate and mortality during follow-up. This cohort study included 33patients with 35sICAS treated with DCB-PTA. The median age was 72years (interquartile range, IQR 66-77 years); median clinical and mean radiological follow-up time was 9months (IQR 3-22 months). Median preprocedural degree of stenosis (WASID) was 80% (IQR 73-80%) and median postprocedural residual stenosis degree (WASID) was 50% (IQR 33-60%). Intracranial periprocedural complications occurred in 2 (6%) patients. The overall restenosis rate was 15% (n = 5). In four patients asymptomatic ischemic re-event occurred within 7months after the initial treatment. None of the patients died. This DCB-PTA cohort study showed arelatively low intracranial complication rate of 6% with asymptomatic recurrence rate of 12%. Larger trials are needed to validate these promising observations.

Basics of Tunneled Dialysis Catheter Placement for Haemodialysis – Single Centre Experience

/non tunneled dialysis catheters or through arteriovenous fistulas/grafts. The tunneled dialysis catheters act as bridge dialysis devices during maturation period of arteriovenous fistulas/grafts and also serve as the last option for end stage renal disease patients who have exhausted all the other dialysis accesses. The aim and objective is to review the basic key concepts of internal Jugular, External Jugular and Subclavian tunneled venous catheter placement, techniques utilized, complications encountered, issues of suboptimal functioning and their management. Subjects and Methods: This was a prospective observational study done in department of Radio diagnosis, Narayana medical college, Nellore. About 54 cases were performed in our institution from December 2018 to Mar 2020 (including three pediatric patients). The age range of these patients is 10 to 75 years. Results: Out of 54 cases, one case had failed, as the guide wire didn’t pass across the brachiocephalic vein. Venogram revealed high grade stenosis of right brachiocephalic vein. There were major complications in two cases, minor complications in five cases with delayed complications in two cases. Conclusion: Tunneled catheters play a key role in serving as bridging devices during maturation of AVF/AVG or as the last option in chronic kidney disease patients in whom all other options have exhausted. Intervention radiologist should have good experience and an overall knowledge of the issues involved in placement of tunneled dialysis catheters, knowledge about the complications, technical issues of suboptimal functioning, for optimal catheter placement and also for improving catheter function.

Retinal arterial occlusion with multiple retinal emboli and carotid artery occlusion disease. Haemodynamic changes and pathways of embolism

ObjectiveTo introduce a special subgroup, retinal artery occlusion (RAO) with multiple emboli, which is highly associated with ipsilateral carotid artery occlusion disease (CAOD).Methods and analysisThis is a cohort study. Cases...

Long Distance Triathlete With Iliac Endofibrosis

A 48 year old long distance triathlete complained of exercise induced thigh pain on the left side for several years. Physical examination in the presence of strongly palpable foot pulses was uneventful at rest, but there was a drop in ankle brachial index (ABI) to 0.4 after exercise. Magnetic resonance angiography (MRA) revealed a mild stenosis of the external iliac artery (EIA) on the left side (A). Through extraperitoneal access, a high grade stenosis became apparent (B). After vein patch plasty and an uneventful post-operative recovery, the athlete was able to increase training intensity free of pain.Image 1

Outcomes of Arterial Conduits in Vascular Reconstruction After Oncologic Resection of Locally Advanced Pancreatic Malignancies

To determine early and midterm outcomes of various conduit types for visceral artery reconstruction after resection of locally advanced pancreatic malignancies. Retrospective review of all patients who underwent resection for pancreatic malignancy with visceral reconstruction using superficial femoral artery (SFA), great saphenous vein (GSV), splenic artery (SA), cryopreserved allograft, or prosthetic graft (PG) between 2000 and 2019. The SFA donor limbs were revascularized with expanded polytetrafluoroethylene interposition grafts. End points for visceral and donor limb arterial reconstructions are primary and secondary patency, vascular complications, and mortality. Visceral reconstruction for oncologic resection was performed in 57 patients. Reconstructed arteries included proper hepatic (n = 24), common hepatic (n = 17), superior mesenteric (n = 22), right hepatic (n = 5), and left hepatic (n = 2) with multivessel reconstructions performed in 13 patients. Of 57 visceral reconstructions, 30 were performed with autogenous SFA; 27 had no preoperative evidence of peripheral arterial disease. Median follow-up for all patients was 9 months. The 30-day visceral reconstruction complications included pseudoaneurysms in one SFA conduit (requiring gastroduodenal artery coiling and covered stent placement) and one GSV conduit (requiring covered stent placement), thrombosis in one PG conduit and one GSV conduit (both requiring open thrombectomy), and anastomotic bleed from one SA conduit (requiring operative repair). The 30-day SFA harvest donor limb complications included one hematoma, one lymphocele, and one symptomatic edema. Early mortality occurred in three patients including one SA conduit with multiorgan failure, one GSV conduit pseudoaneurysm rupture secondary to pancreatic leak and one SFA conduit of unknown cause. Midterm visceral reconstruction complications included pseudoaneurysm in 6 patients (3 SFA conduits with 2 treated, 3 GSV conduits with all treated), and graft occlusion in 10 patients (3 SFA, 4 GSV, 1 cryopreserved allograft and 2 PG). One patient underwent percutaneous angioplasty for high-grade stenosis of a SA graft. This gave a primary and secondary patency for all visceral arterial reconstructions of 81% and 84%, respectively. Midterm SFA donor limb patency was 100% with median follow-up of 8 months. Late mortality occurred in 19 patients (33%) with 11 cancer-related deaths and 5 of unknown cause or unrelated to the primary cancer. Three late mortalities occurred secondary to mycotic graft pseudoaneurysm ruptures in the setting of bile and pancreatic leaks (1 GSV, 1 PG secondary reconstruction in SFA conduit patient and 1 SFA conduit). This preliminary study suggests that superficial femoral artery can be considered feasible conduit in oncologic reconstructions with low morbidity of the donor limb. Long-term follow-up is needed to identify oncologic and patency-related outcomes.TablePrimary end points by conduit choiceConduitNo. of patientsPrimary patencySecondary patencyMajor early visceral graft complicationsAll-cause mortality, % (vascular-related, %)Median follow-up, months (range)Superficial femoral artery3090%90%n = 1 pseudoaneurysm30 (7)8 (2-39)Cryopreserved allograft988%88%n = 00 (0)4 (1-23)Great saphenous vein838%38%n = 2 (1 pseudoaneurysm, 1 thrombosis)75 (25)11 (0-25)Prosthetic graft667%83%n = 1 thrombosis67 (0)12 (1-107)Splenic artery450%50%n = 1 anastomotic bleed50 (0)26 (1-52) Open table in a new tab

A lateral lead variant of the de Winter pattern due to left main stenosis and left anterior descending artery occlusion

Early recognition of ST-segment elevation myocardial infarction equivalent electrocardiogram patterns is of paramount importance. Successful identification of these ischemic patterns helps ensure proper triage of patients needing urgent restoration of coronary perfusion. The so-called de Winter sign has become increasingly recognized as a ST-segment elevation myocardial infarction equivalent pattern due to proximal left anterior descending artery occlusion. Yet, despite the de Winter pattern's well-defined electrocardiographic-angiographic relationship, the electrophysiologic explanation for its characteristic electrocardiographic manifestations remains unclear. Herein, we report a case in which an ischemic lateral lead variant of the de Winter pattern emerged from a patient inflicted by an abrupt thrombotic occlusion of the ostial left anterior descending artery, which developed in series with a high-grade stenosis of the distal left main coronary artery. We examine the patient's presenting electrocardiographic findings and clinical course to (i) establish causal inferences that align with the distribution of myocardial ischemia supported by coronary angiography and (ii) provide an accompanying analysis of the relevant scientific literature.