Intimal Dissection Research Articles

A new patch technique for valve-sparing aortic root repair in acute type A aortic dissection.

Valve-sparing aortic root replacement is an attractive option for younger patients with acute type A aortic dissection. This study aimed to design a new patch technique for reconstructing the aortic root and preserving the aortic valve following aortic dissection. Between July 2017 and December 2018, 35 patients underwent valve-sparing aortic root repair using this new patch technique. All participants were in the supine position, transesophageal echocardiography and median sternotomy were routinely performed. After thrombi at the aortic root were removed in acute type A dissection, the luminal aortic intimal dissection was removed until the aortic condition was normalized. In each aortic sinus involved in the dissection, a Dacron-graft patch with the shape corresponding to the defect was sutured to the normal remnant vascular wall or aortic annulus in the aortic sinus using 5-0 Prolene suture to reconstruct the aortic root. A total of 2 patients died, and 1 cerebral infarction, and 3 cases of transient brain dysfunction were recorded. The sinus tube junction and sinus diameter were within the normal ranges when they were reexamined 3 months after surgery. This new patch technique circumvents the redesign of the spatial 3D structure of the aortic valve, is simple to operate, and easy to master. It completely removes the diseased dissection tissue, avoids the use of glue, and is an alternative surgical technique, especially for beginners.

Optical coherent tomography for the diagnostic of non-obstructive coronary artery myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. The widespread use of coronary angiography (CAG) in patients with acute coronary syndrome led to the understanding that in some patients myocardial infarction (MI) occurs against angiographically unchanged or slightly modified coronary arteries (CA). In such cases, the so-called "type 2 IM" is diagnosed in some patients, however, to determine the true cause of MI, a modern method of investigation such as optical coherence tomography (OCT) is needed to visualize the intima of the CA and detect a minimal atherosclerotic process. The purpose of the study was to establish the etiology of MI without obstructive coronary artery disease (MINOCA) using OCT. Materials and methods 160 conclusions of the OCT were analyzed. In 9 (6%) cases, the study was conducted in patients who underwent proven MI (mean age 43,1 ± 13,2, 8 males, 1 female) who had no hemodynamically significant CA stenosis according to CAG data. Results in 2 cases (22%) patients had ST-elevation MI, thrombotic occlusion of the CA (in one case, thrombaspiration was performed). In both patients, spontaneous dissection of the intima of the unmodified CA was detected in the OCT. The remaining 7 patients had non-ST-elevation MI, and in 2 cases, a diagnosis of type 2 MI was established: in both patients, the atherosclerotic plaque was visualized, narrowing the lumen of the CA less than 50%, in one case MI developed against a background of the hypertensive crisis, in another - against a background of spasm of CA. In the remaining 5 patients, OCT revealed subintimal atheromatous, with elements of local dissection of the intima. Thus, in 78% of patients atherosclerosis of CA of different severity (from the subintimal deposition of lipids to the development of atherosclerotic plaque, narrowing the clearance of the SC by less than 50%) was diagnosed. In the analysis of risk factors for coronary heart disease (CHD), 57% of patients with atheromatous CA had more than 2 risk factors for CHD: 3 (42%) smoked, 5 (71%) - obesity, 4 (57% ) - had arterial hypertension, 3 (42%) had dyslipidemia, 1 (14%) had type 2 diabetes. In the group of patients with spontaneous intima dissection of the CA, 1 patient (woman) did not have CHD risk factors, the 2-nd suffered from obesity and hypertension. For all patients a lifestyle correction was recommended; statins, antiplatelets were prescribed, patients with spontaneous dissection of CA had the recommendation of examination in the medical-genetic center. Conclusion Based on the results of the study, in most cases, the cause of IMBOC development was an atherosclerotic lesion of the coronary arteries, which is not always visualized with standard coronary angiography. Basically, the patients were young and middle-aged. Most patients had different risk factors for coronary heart disease.

Using of optical coherent tomography in the determination of the causes of non-obstructive coronary artery myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. The widespread use of coronary angiography (CAG) in patients with acute coronary syndrome led to the understanding that in some patients myocardial infarction (MI) occurs against angiographically unchanged or slightly modified coronary arteries (CA). In such cases, the so-called "type 2 IM" is diagnosed in some patients, however, to determine the true cause of MI, a modern method of investigation such as optical coherence tomography (OCT) is needed to visualize the intima of the CA and detect a minimal atherosclerotic process. The purpose of the study was to establish the etiology of MI without obstructive coronary artery disease (MINOCA) using OCT. Materials and methods 160 conclusions of the OCT were analyzed. In 9 (6%) cases, the study was conducted in patients who underwent proven MI (mean age 43,1 ± 13,2, 8 males, 1 female) who had no hemodynamically significant CA stenosis according to CAG data. Results in 2 cases (22%) patients had ST elevation MI, thrombotic occlusion of the CA (in one case, thrombaspiration was performed). In both patients, spontaneous dissection of the intima of the unmodified CA was detected in the OCT. The remaining 7 patients had non ST elevation MI, and in 2 cases, a diagnosis of type 2 MI was established: in both patients, atherosclerotic plaque was visualized, narrowing the lumen of the CA less than 50%, in one case MI developed against a background of hypertonic crisis, in another - against a background of spasm of CA. In the remaining 5 patients, OCT revealed subintimal atheromatosis, with elements of local dissection of the intima. Thus, in 78% of patients atherosclerosis of CA of different severity (from the subintimal deposition of lipids to the development of atherosclerotic plaque, narrowing the clearance of the SC by less than 50%) was diagnosed. In the analysis of risk factors for coronary heart disease (CHD), 57% of patients with atheromatous CA had more than 2 risk factors for CHD: 3 (42%) smoked, 5 (71%) - obesity, 4 (57% ) - had arterial hypertension, 3 (42%) had dyslipidemia, 1 (14%) had type 2 diabetes. In the group of patients with spontaneous intima dissection of the CA, 1 patient (woman) did not have CHD risk factors, the 2-nd suffered from obesity and hypertension. For all patients a lifestyle correction was recommended; statins, disaggregants were prescribed, patients with spontaneous dissection of CA had recommendation of examination in the medical-genetic center. Conclusion Based on the results of the study, in most cases, the cause of IMBOC development was atherosclerotic lesion of the coronary arteries, which is not always visualized with standard coronary angiography. Basically, the patients were young and middle-aged. Most patients had different risk factors for coronary heart disease.

Providing Arterial Supply to the Liver Graft with Recipient Splenic Artery in Living Donor Liver Transplantation: Case Report

Hepatic arterial reconstruction is an important step in graft implantation in liver transplant procedure. Hepatic arterial anastomosis always demands meticulous and highly skilled surgical techniques to provide adequate blood supply to the graft. Hepatic arterial intimal dissection in liver transplantation is although a rare but documented complication, with incidence of less than 5%, but having dreadful complications. To overcome this complication of Recipient hepatic artery dissection, various techniques have been described by different authors. Here, in this case report we are describing technique of utilization of transposed recipient splenic artery for graft arterial inflow where native hepatic artery was dissected up to common hepatic artery. Post-operative recovery was uneventful and on follow up, patient was absolutely fine. So, recipient splenic artery is a safe alternative option in such complex situations for providing arterial blood flow to the graft and moreover it avoids the burden of extra anastomosis which is required in conduit technique.

The role of the angiosomaly-oriented endovascular revascularization method in the complex treatment of diabetic foot syndrome

Objective:analyze the effectiveness of the angiosomal oriented endovascular revascularization method in the complex treatment of diabeticfoot syndrome (DFS).Materials and methods.One of the most serious complications of diabetes mellitus is damage to the vessels of the lower extremities. In diabetic macroangiopathy, an extended lesion of medium-sized arteries occurs, which, coupled with an atherosclerotic lesion, often leads to theformation of arterial stenosis and occlusion. The leading method for correcting the patency of the great vessels today is endovascular balloonangioplasty. The study examined the feasibility of selective angiosomal revascularization of the lower extremities. The advantages of angiosomaly-oriented endovascular revascularization are a reduction in the duration of the intervention, a decrease in the volume of the injectedcontrast drug, and targeted restoration of blood flow in the arteries that feed the affected segment of the limb. The study included 49 patientswith a neuroischemic form of DFS with hemodynamically significant stenosis and occlusion of the lower extremities arteries. Patients weredivided into 2 groups. Patients of both groups underwent complex conservative treatment and performed operations on the lower extremities(from surgical debridement to below the knee amputation). Patients of the first group underwent angiosomaly oriented revascularization ofthe lower extremities. Patients from the second group underwent traditional endovascular revascularization.Results.After angiosomaly oriented revascularization, a complete restoration of the initial diameter of the vessel was achieved in 80.0 % ofcases, the absence of residual stenosis – in 82.5 %, the absence of intimal dissection – in 95.0 % of cases. It was possible to achieve laminarblood flow in 90.0 % of cases. A reduction in the revascularization procedure by an average of 30 minutes and a decrease in the consumptionof contrasting pharmaceuticals by an average of 100.0 ml are shown.Conclusion.When evaluating the results of complex treatment of patients after angiosomaly oriented revascularization, a decrease in theaverage hospital stay (11 and 13 days, respectively), a decrease in the average healing time of a wound defect by 1.25 times, a decrease inthe average duration of ulcerative epithelization (9 and 13 days, respectively) and a decrease in the volume of surgical intervention and thenumber of high amputations during the year after angioplasty compared with patients who underwent endovascular revascularization according to the traditional method.

Asymptomatic hepatic artery dissection early after living-donor liver transplantation with simultaneous splenectomy: two case reports

BackgroundHepatic artery dissection after liver transplantation is an uncommon morbidity. The onset mechanism and management for this disorder remain unclear. The present report describes the cases of two patients with hepatic artery dissection after living-donor liver transplantation (LDLT) with simultaneous splenectomy and provides new insight into the onset mechanism of this disorder.Case presentation: Case 1A 51-year-old man with liver cirrhosis caused by hepatitis B virus underwent LDLT with a right lobe graft and splenectomy simultaneously. The recipient’s right hepatic artery had partial dissection at the anastomosis site; therefore, his left hepatic artery was anastomosed. Contrast-enhanced computed tomography (CT) on postoperative day (POD) 27 showed dissection from his celiac artery to his left hepatic artery with bleeding in the false lumen. There was a risk of rupture of the false lumen; therefore, emergency interventional radiology and coil embolization of the false lumen were performed. The patient was doing well at 6 months after LDLT.Case 2A 58-year-old woman with liver cirrhosis caused by primary biliary cholangitis underwent LDLT with a left lobe graft and splenectomy simultaneously. Her hepatic artery had a dissection that extended from her left hepatic artery to the proper hepatic artery. The gastroduodenal artery was anastomosed. Contrast-enhanced CT on POD 8 revealed dissection from the celiac artery to the common hepatic artery as well as a pseudoaneurysm at the celiac artery. We managed the patient with conservative treatment and performed daily follow-ups with Doppler ultrasonography examination and serial contrast-enhanced CT. At the time of writing this report, the patient was doing well at 34 months after LDLT.ConclusionsPatients who have an intimal dissection at the anastomosis site and/or simultaneous splenectomy are at a higher risk of hepatic artery dissection. Most patients with asymptomatic hepatic artery dissections can be treated conservatively. Blood flow in the intrahepatic artery should be checked frequently using Doppler ultrasonography or contrast-enhanced CT soon after diagnosis.

Managing Recipient Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation.

Recipient hepatic artery intimal dissection (HAD) followed by hepatic artery thrombosis (HAT) is a serious complication of liver transplantation. Once this is recognized intraoperatively, the accepted approach is to use an alternative arterial inflow, which may not be possible in all patients. We describe a new classification and technique for the management of HAD during living donor liver transplantation. On the basis of the longitudinal extent of intimal dissection, HAD was classified into 4 types. Management was based on the type of dissection, availability of an adequate length of hepatic artery (HA), and an alternate source of inflow. The dissected HA itself was used for arterial anastomosis in patients with preserved pulsatile flow in the dissected artery and a lack of an alternative source of arterial inflow. The technique of using the dissected artery was based on close approximation of the tunica intima to the media with the first 2 sutures of the arterial anastomosis. Of 47 (2.4%) patients who developed HAD, 22 (46.8%) had a type 2 dissection for whom the other (right or the left) undissected HA was used for the anastomosis, and 20 (42.6%) had major (type 3 or 4) dissection. The dissected artery was used for the anastomosis in 9 (45%) of these patients. Postoperative HAT developed in only 1 of 9 patients. Pre-existing portal vein thrombosis and prior transarterial embolization were found to be major risk factors for the development of HAD. Using the technique described, the dissected artery can be successfully used for a satisfactory HA anastomosis with low thrombosis rates.

Gunshot wounds of the head in peacetime, with the formation of a delayed carotid-cavernous fistula (case report)

The objective of the article is to present the clinical observation of a gunshot wounds of the head in peacetime, with the formation of a delayed carotid-cavernous fistula.Clinical case. A patient aged 26 years received a penetrating parabasal single gunshot wound to the head. After transfer to the N.V. Sklifosovsky Research Institute of Emergency Medicine from a local hospital, intima dissection and occlusion of the left internal carotid artery (ICA) were diagnosed. Supraclinoid section of the left ICA, left anterior cerebral and middle cerebral arteries were filled from the right ICA through the anterior communicating artery. For prevention of suppurative-septic complications as well as decubitus of the left ICA and development of life-threatening hemorrhages, repeat surgery was performed. Acute subdural hematoma and brain detritus were removed. Using pterional approach, the chiasm and sellar region was accessed. Sequentially the ophthalmic, interpenducular, penducular cisterns, cisterna laminae terminalis and left carotid cistern were dissected. Sequentially the left ophthalmic nerve, left ICA, left choroid arteries were isolated. A metallic foreign object (bullet) located in the medial regions of the larger wing of the sphenoid bone and lateral wall of the cavernous sinus was found and removed. On day 14 after the second surgery, headache became worse, pulsing noise developed in the left part of the head, as well as moderate exophthalmos on the left. Left-hand type A (per the Barrow classification) carotid-cavernous anastomosis with retrograde inflow due to occlusion of the left ICA was diagnosed. Endovascular intervention was performed: separation of the carotid-cavernous anastomosis through retrograde occlusion of the supraclinoid segment of the left ICA with microcoils through contralateral ICA and anterior communicating artery. The patient was discharged at day 30 after hospitalization. Cerebral and meningeal symptoms regressed. Ptosis grade decreased, the left eye started to move.Conclusion. This abovementioned observation is of interest due to the rarity of such pathology and the possibilities of modern multidisciplinary centers for the diagnosis and treatment of such patients as of this date.

Carotid Artery Dissection

Carotid artery dissection, firstly described by Pratt-Thomas and Berger in 1947, typically begins in inner layer of artery wall, proceeds to the middle layer, and intramurally extends along length of the artery as a result of the pressure produced by blood stream. This study aims to report a case in which internal carotid artery dissection was diagnosed as secondary to trauma. A 24-year-old male patient was brought to the emergency room by 112 emergency service team after a motorcycle accident. Physical examination of the patient revealed a painful dermabrasion in his right neck region and other system examinations were normal. Carotid-vertebral color Doppler ultrasonography was performed on the patient because he had a right neck pain. Accordingly, an intimal flap appearance compatible with dissection was observed on the right internal carotid artery (ICA) proximal segment. Then, brain+cervical CT angiography was performed on the patient, and an appearance compatible with dissection was observed in the right ICA. Therefore, the patient was referred to neurology and neurosurgery consultation and accordingly admitted to neurosurgery intensive care unit. As a result, carotid artery dissection in addition to other intracranial pathologies should be considered among differential diagnoses for patients with head and/or neck pain complaints regardless of whether or not they have a trauma history.

Sharp recanalization of peripheral arterial chronic total occlusions.

Peripheral arterial chronic total occlusions (CTOs) usually have calcified caps at either ends. When attempting endovascular recanalization, these calcified CTO caps may prevent the interventionist in crossing the lesion with conventional catheter and guidewire techniques. Using specialized CTO devices or re-entry devices can help crossing the CTO, but such devices are usually expensive, not always readily available and require specialist training prior to usage."Sharp recanalization" is an alternative method of crossing the CTOs. If it is not possible to cross the CTO with conventional catheter and guidewire technique, one can take out the floppy end of the guidewire and use the stiff or the "sharp" end of the guidewire to break the hard CTO cap. Once the CTO cap is broken, the stiff end is replaced by the floppy end of the guidewire again to proceed with balloon angioplasty and/or stenting.In order to safely use the sharp recanalization technique while minimizing the risk of perforation, sharp recanalization should only be attempted once conventional methods have failed. The interventionist should plan sharp recanalization with the vascular path in mind and decide in advance how far s/he will proceed. It can be helpful to set a time limit together with the intervention team, past which the sharp recanalization attempt will be abandoned. Using straight catheters can help directing the stiff guidewire tip to the center of the vascular lumen and reduce the risk of sub intimal dissection or arterial wall perforation.

Traumatic Blunt Injuries to the Celiac Artery: A 5-Year Review From a Level I Trauma Center.

Injury to the celiac artery secondary to a blunt mechanism of trauma is an extremely rare injury that accounts for only 1%-2% of all visceral vascular lesions. Although rare, this injury is associated with significant mortality. Despite this high mortality, there are currently only a few published case series of blunt celiac artery injuries in the literature. This study sought to review all cases of blunt celiac artery injuries that presented to our Level I trauma center over a 5-year period. This was a retrospective chart review of all patients who presented with a traumatic blunt celiac artery injury between January 2012 and March 2017. A total of 10 patients met the inclusion criteria for this study. The majority of patients were male (7/10, 70%), the average age was 38.3 ± 16.1 years, and overall mortality was 20% (2/10). On average, patients spent 10.2 ± 6.5 days in the hospital, 4.4 ± 4.5 days in the ICU, and 1.6 ± 2.0 days on the ventilator. The majority of patients presented with either an intimal dissection (3/10, 30%) or an intraluminal thrombus (3/10, 30%). Other injuries included pseudoaneurysms (2/10, 20%), complete avulsion (1/10, 10%), and an intimal dissection with thrombus (1/10, 10%). Of these injuries, 2 (20%) were noted to have retrograde flow on imaging studies including computed tomography angiography and a visceral angiogram. The majority of patients (8/10, 80%) were managed nonoperatively, and 5 (50%) patients were discharged home on aspirin. One patient who was initially managed nonoperatively required an unplanned return to the operating room for ischemic bowel, liver, and stomach. There were no other complications noted. Traumatic blunt injury to the celiac artery is rare. Although there are multiple treatment options, there is currently no consensus in regard to management guidelines. In this case series, the majority of patients were successfully managed nonoperatively suggesting that a selective approach for intervention on patients with a blunt celiac artery injury should be considered.

Intraoperative Challenge for Vascular Reconstruction in Orthotopic Liver Transplantation Because of Extensive Portal Thrombosis and Intimal Dissection of the Hepatic Artery.

CASE REPORT The presence of the portal vein (PV) thrombosis in cirrhotic patients is not considered an absolute contraindication for liver transplantation, despite being technically challenging and associated with longer operative time and poor outcomes.1 We aim to present a patient with an extensive portal thrombosis who underwent a deceased donor liver transplantation. A 41-year-old man presented with a diagnosis of alcoholic cirrhosis (Model for End-Stage Liver Disease score = 28) and a history of multiple upper gastrointestinal bleeding and refractory ascites. Computed tomography revealed revascularized PV cavernous transformation with signs of left segmental portal hypertension in the splenic, gastric, and esophagic territories, without low-pressure signs in the superior mesenteric vein system (Figure 1). The patient underwent a successful nonanatomical liver transplantation with an implantation of the donor PV into the recipient's left gastric vein (LGV) in an end-to-side fashion. To increase the flow in the liver graft, a distal ligation of LGV was performed to avoid vascular steal phenomenon toward the esophagus or gastric territories (Figure 2). Intraoperatively, a complete intimal dissection of the recipient common hepatic artery was confirmed and thus, the donor hepatic artery flow was reconstructed using an iliac artery interposition graft from the infrarenal aorta (Figure 3). The postoperative outcome was uneventful, and the patient was discharged under anticoagulation therapy on the seventh postoperative day (Video 1; watch the video at https://links.lww.com/ACGCR/A20).Figure 1.: Computed tomography showing signs of segmental portal hypertension in the splenic, gastric, and esophagic areas due to portal vein cavernous transformation.Figure 2.: Nonanatomical reconstruction of the graft portal flow with an implantation of the donor PV into the recipient left gastric vein (distal ligation to increase PV flow). PV, portal vein.Figure 3.: The final aspect of the liver graft vascular reconstruction. The arterial anastomosis of the donor common hepatic artery and iliac artery interposition graft from the infrarenal aorta. PV reconstruction of the donor PV and the recipient left gastric vein. PV, portal vein.The presence of PV thrombosis is a complex scenario in patients on a waiting list for liver transplantation, and it is observed in 10% of preoperative imaging in cirrhotic patients.2 The cause of the occurrence of PV thrombosis is multifactorial, and it is probably related to the presence of extensive fibrosis of the hepatic parenchyma, a procoagulant state, and periportal lymphangitis. Other risk factors have been described including male sex, alcoholic liver disease, previous splenectomy, and the coexistence of a hepatocellular carcinoma. Unfortunately, the presence of PV thrombosis has been associated with poor patient survival after a liver transplantation.3,4 Despite being a challenging situation, it does not represent a contraindication for liver transplantation.1 There are several options to manage portal reconstruction including anatomical reconstruction with portal-portal anastomosis after portal thrombectomy or nonanatomical reconstruction including the implantation of the donor PV in the recipient superior mesenteric vein, LGV, vena cava with or without the use of interposition iliac vein grafts.5 From the surgical point of view, PV flow reconstruction in this setting represents a technical challenge and usually increases operative time, bleeding risk, graft failure rate, and finally, the risk of postoperative PV rethrombosis.6 In our case, it was performed for a nonanatomic PV reconstruction using the recipient LGV with an end-to-lateral anastomosis and distal ligation of the LGV to redirect the portal flow to the liver graft. DISCLOSURES Author contributions: F. Laxague wrote the manuscript and is the article guarantor. V. Agustin provided the video. R. Dario and Q. Emilio edited the manuscript. C. M. Agustina provided the video and images. L. McCormack wrote and revised the manuscript for intellectual content. Financial disclosure: None to report. Informed consent was obtained for this case report.

Greater Saphenous Vein Graft Revascularization of the Left Hepatic Artery after Resection of Intrahepatic Cholangiocarcinoma with Common Hepatic Artery Resection

Resection of biliary tract malignancies may require resection of the hepatic vasculature. While immediate revascularization of the liver is necessary, reconstruction is difficult when the original vessels are unavailable. We document a case in which a segment of the common hepatic artery was excised during tumor resection and the remaining proximal vessel displayed intima dissection. A greater saphenous vein was placed as a bridge between the remaining left hepatic artery and gastroduodenal artery for successful revascularization.

Smooth Muscle Cell – Extracellular Matrix Alterations in Genetic Vasculopathies

Pathogenic variants in 11 genes predispose individuals to aneurysms and dissections of the thoracic aorta and in some cases, vascular complications throughout the arterial tree, termed heritable thoracic aortic disease (HTAD) (Renard M et al. JACC, 2018;72:605–615). These genes are involved in vascular smooth muscle cell (SMC) contraction and metabolism, extracellular matrix (ECM) integrity and transforming growth factor β (TGF β) signaling. A unifying hypothesis is that the mutated gene products contribute to altered mechano‐transduction leading to vasculopathy (Humphrey JD et al. Circ Res 2015;116:1448–1461; Pinard A, Jones GT, Milewicz DM. Circ Res 2019;124:588–606). The objective of this study was to employ light (LM) and electron (EM) microscopy to evaluate the thoracic aortic and other arterial tissue from individuals harboring pathogenic variants in the 11 established predisposition genes who underwent surgical aneurysm or dissection repair. These individuals (n) harbored pathogenic variants in the following genes: FBN1 (13), ACTA2 (6), TGFBR1 (7), TGFBR2 (3), TGFβ2 (3), SMAD3 (3), LOX (1), MYLK (1), PRKG1 (1), and COL3A1 (4); total 42. Arterial specimens were evaluated using LM consensus criteria (Halushka MK et al. Cardiovasc Pathol 2016;25:247–257). EM was performed on selected cases (Davis EC. Lab Invest 1993;68:89–99). By LM, specimens were graded (0 – 3+) for mucoid extracellular matrix accumulation (MEMA), elastic fiber fragmentation and/or loss (EFFL), SMC nuclear loss/laminar medial collapse (SMCNL/LMC), and overall medial degeneration (A 1–2, B 3–4, C 5–6, D 7–9); intimal lesions (0–3+) and medial dissection (+/−) also were noted. The 42 specimens included 17 with medial dissection and 25 non‐dissected aneurysms. By LM, cases showed a spectrum of extent and severity of medial degenerative changes: A mild 8 cases, B moderate 18 cases, C moderately severe 14 cases, and D severe 2 cases. By EM, COL3A1 specimens showed reduction of collagen fibrils and shape variations of residual collagen fibrils; elastin fiber connections to SMCs were intact. In contrast, specimens with mutations in the TGF β pathway exhibited multiple foci with deficiency of elastic fibers and loss of elastic fiber connections to SMC but had normal collagen ultrastructure. These results support the hypothesis that the pathogenesis of genetic vasculopathies involves structural defects in the interaction of ECM components and SMCs, including impairment of the elastin‐contractile unit directly or through loss of structural support provided by collagen.Support or Funding InformationLocal funds

Endovascular management of femoral access-site and access-related vascular complications following percutaneous coronary interventions (PCI).

BackgroundMajor vascular complications (VCs) of ilio–femoral arterial access after percutaneous coronary interventions are infrequent, but are associated with increased mortality and morbidity. Routine endovascular repair of VCs is becoming the treatment of choice, especially for patients who cannot tolerate vascular surgery due to advanced cardiovascular disease or are in a bailout situation. Here, we review the different types of vascular access site complications associated with percutaneous coronary interventions (PCIs) and assess the safety and efficacy of endovascular treatment.MethodsData were retrospectively analysed from patients who experienced VCs after transfemoral PCIs, from December 2014 to May 2018. During this period, out of 2833 patients who underwent femoral coronary interventions, 53 (1.9%) experienced major VCs.ResultsIn total, 40/53 (75.5%) cases with major VCs led to unplanned endovascular repair and 13/53 (24.5%) cases required surgical repair. VCs included 17 (32.1%) retroperitoneal bleeding events (BARC-2, 3a,b), 20 (37.7%) intimal dissections, and 16 (30.2%) femoral pseudoaneurysms. Overall, 32 (60.4%) patients received a covered stent, two (3.8%) received a nitinol stent, five (9.4%) patients with dissections were treated with prolonged balloon angioplasty alone, and one patient with femoral pseudoaneurysm underwent thrombin injection with simultaneous balloon occlusion. The mean hospital stay for patients after endovascular treatment was 11.06 ± 5.2 days, while for patients after surgical repair it was 17 ± 8.2 days. Endovascularly treated patients were transfused with red blood cells (13/40 32.5% vs. 2/13 15.4%) significantly more often than patients treated surgically, although surgically treated patients received more red blood cell concentrates per unit than endovascularly treated patients (1 ± 0.47 vs. 2 ± 0.93). During the one-year follow-up, no intermittent claudication was reported, and no patient required secondary endovascular or surgical repair.ConclusionsFor patients who cannot tolerate vascular surgery due to advanced cardiovascular disease or are in a bailout situation, endovascular management of VCs following PCIs seems to be a feasible and safe treatment option, and represents an alternative to surgical repair in life-threatening situations. Endovascular treatment was associated with significantly fewer red blood cell concentrates per patient and fewer days in hospital than surgical treatment.

Optical coherence tomography imaging after endovascular thrombectomy: a novel method for evaluating vascular injury in a swine model.

Although studies have shown that some degree of iatrogenic endothelial injury occurs during endovascular thrombectomy (EVT), the clinical significance of such injury is uncertain. Furthermore, it is likely that iatrogenic effects such as endothelial denudation, intimal dissection, and tunica media edema will have varying clinical implications. The purpose of this study was to assess the feasibility of endovascular optical coherence tomography (OCT) in quantifying vessel injury in real time after EVT, correlate vessel injury with histological findings, and perform imaging at varying time intervals after EVT to assess the impact of prolonged direct exposure of the vessel to the thrombus. Yorkshire swine weighing 35-40 kg were selected for use as the animal model, with a total of 9 vessels from 3 swine examined. Thrombectomy was performed using a second-generation stent retriever 1, 3, and 6 hours after thrombus deposition. The presence and degree of denudation of the endothelium, detachment and separation of the layers of the tunic media, hemorrhage within the media, dissection of the vessels, and thrombus within the lumina were assessed using OCT images acquired immediately after EVT. Bland-Altman analysis indicated that these OCT findings were correlated with postmortem histological findings. OCT image acquisition was technically successful in all cases. Endothelial denudation was present in 65% ± 16%, 87% ± 8%, and 93% ± 7% of the vessel surface 1, 3, and 6 hours, respectively, after thrombus deposition and subsequent EVT. Residual intraluminal thrombus was present in vessels at all time intervals despite complete angiographic revascularization. Bland-Altman plots showed good agreement between OCT and histological analysis with respect to the degree of endothelial denudation and elevation, separation of the tunica media, and hemorrhage within the media. OCT appears to be more specific than histological analysis in detecting endothelial elevation. OCT is a feasible method that can be used to assess vascular injury after EVT with histological accuracy. Varying degrees of vessel injury occur after EVT, and residual luminal thrombus can be present despite complete angiographic revascularization.

Excimer Laser Coronary Angioplasty (ELCA): Fundamentals, Mechanism of Action, and Clinical Applications.

Laser coronary angioplasty was developed to modify atherosclerotic plaque and help with the acute and longer-term limitations of balloon angioplasty, namely, intimal dissection and restenosis, respectively. Excimer laser debulks and modifies the tissue with its photochemical, photothermal, and photokinetic properties without causing significant injury. With important refinements and advancements, laser has gained a renewed place in treating complex and resistant coronary lesions after a disappointing start. When used in line with the instructions, laser is an important tool that allows the completion of difficult and complicated cases. It is a useful tool in the catheterization laboratory to treat lesions that are uncrossable or undilatable. Laser is also helpful in cases where a stent was deployed but remains under-expanded, with accumulating evidence of its efficacy in such cases. In addition, laser is increasingly used for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) to facilitate modification of the proximal CTO cap to allow penetration with a wire and completion of the procedure. Laser has been used in certain circumstances by experienced operators with simultaneous contrast rather than saline injection, to increase its effect and allow the successful completion of complex PCIs. This article outlines the scientific background, experimental data, practical procedural techniques, and clinical applications of excimer laser coronary angioplasty in the treatment of coronary artery disease.

P723 A dissecting thoracic aortic aneurysm presenting with mild symptoms in a young woman

Abstract Introduction Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. Case presentation We present the case of a 29 years old young woman, brought to the emergency department with mild chest and back pain, shortness of breath on exertion with an onset of 12 days prior to admission. The patient has a history of 3 pregnancies delivered by natural birth and C-section (last one 2 years ago), but no personal cardiovascular disease history. She relates a family history of sudden cardiac death at a young age (mother, grandmother, great-grandmother) and a sister with diagnosed aortic aneurysm associated with a genetic mutation. Physical examination revealed a marfanoid habitus, diastolic heart murmur, low diastolic blood pressure (BP of 90/25 mmHg). Transthoracic echocardiography performed in the ED, discovered an anuloaortic aneurysm with a maximum diameter of 8.7 cm at the aortic root and a dissecting intimal flap of the ascending aorta up to the aortic arch. We also detected a dilated left ventricle with a low ejection fraction (30%) and a severe aortic regurgitation. The findings were confirmed by contrast-enhanced CT Angiography, showing the aneurysm of 8.4/8.7 cm and the intimal dissection flap with patency of both true- and false lumens. At this point we diagnosed an anuloaortic aneurysm with Stanford type A acute aortic dissection and a Marfan syndrome (according to the Ghent Nosology criteria). She immediately underwent surgery, the Bentall procedure was performed, consisting of a composite graft replacement of the entire ascending aorta and aortic valve, followed by direct implantation of the coronary arteries. Histopathological examination of the excised aortic wall reinforced the diagnoses of a connective tissue disorder. The early postoperative evolution was marked by the development of a left-sided hemiparesis and seizures, caused by an acute ischemic stroke. The patient was discharged after the complete resolution of the neurological symptoms under appropriate medication. Recommendations were made for periodic follow-up, genetic testing and the screening of her children after the age of 10 years old. Conclusion Discussions evolve around the interesting fact that she managed to survive 3 pregnancies, natural births and a C-section, without developing an aortic dissection or even a possible fatal rupture up until this presentation. It is imperative to mention that the lack of a follow-up from a general practitioner, who could have notice the signs of a possible connective tissue disorder, have possibly led to the development of such aortic sizes. The current guidelines sustain the importance of surgical approach in all types of ascending aortic dissection, the only treatment proven to increase the short- and long term mortality. Abstract P723 Figure. Imaging studies

P724 The mysteries of sinus of Valsalva

Abstract Sinus of Valsalva aneurysms are a rare pathology that can be clinically silent during years and/or become suddenly symptomatic. We described 3 cases with different clinical presentation, complications and surgical treatment. A 26-year-old male, competitive cyclist was admitted with a 1.5 month history of fatigue, palpitations, and nocturnal cough and sweating. At physical examination he was apyretic, blood pressure 157/49mmHg and radial pulse 96 bpm; jugular vein engorgement and continuous heart murmur, were noticed. Blood samples only revealed a mild raised BNP. EKG showed sinus tachycardia and right intraventricular conduction delay and the transthoracic echocardiography (TTE) revealed high velocity systolic-diastolic shunt (image) between a non-dilated right coronary sinus (RCS) and the right atrium (RA); moderate left ventricle dilation, severe right atrium and mild right ventricle enlargement with mild pulmonary hypertension and normal biventricular systolic function. He was referred to angioCT that showed a large communication between a non-dilated RCS and RA with signs of right ventricular overload. He was submitted to surgery, where ruptured aneurysm sac was found. Fistula closure, aneurysm sac suture and tricuspid annuloplasty were performed. A 45-year-old male asymptomatic, with no relevant medical background went to a Cardiology consultation after detection of a holossistolic murmur in the physical exam. EKG showed sinus rhythm arrhythmia with a nonspecific intraventricular conduction delay and the TTE revealed a communication between a dilated noncoronary sinus (NCS) and RA; the biventricular systolic function was normal. He was referred to angioCT which confirmed the diagnosis. He was submitted to surgery where an exeresis and closure of the fistula was performed. A 38-year-old male with no relevant medical background was admitted to emergence room for an intermittent anterior thoracic pain radiating to the neck (2 days of evolution). The EKG showed sinus tachycardia, incomplete right bundle branch block and the high-sensitivity troponin assays were negative. The TTE revealed severe sinus of Valsalva aneurysm, particularly of the NCS with mild aortic regurgitation. The patient performed transesophageal echocardiography and angioCT which excluded an acute aortic syndrome. He was oriented to surgery where a contained rupture of the RCS and a non-visualization of the ostium right coronary artery were detected, suggesting an intimal dissection. The patient was submitted to Bentall procedure and a bypass with internal mammary artery to right coronary artery. In spite of the unclear etiology, all the cases had a good clinical and echocardiographic evolution at follow-up. The difficulty in making a timely diagnosis is related to the variability of clinical presentation and the need of high clinical suspicion. Echocardiography and angioTC have demonstrated its value, in providing a prompt diagnosis and appropriate management guidance. Abstract P724 Figure. Ruptured aneurysm sac and fistula

IVUS Directed Stent Placement Decision in a Hybrid Procedure for Lower Limb Revascularization. is Angiography Enough?

Introduction: The decision of wether to implant a stent or not after endovascuar angioplasty of the Superficia femoral artery (SFA) is clasically based on arteriographic control. Neverthless, the angiographical signs in which stent implatation indication is based are subjective and unccurate. Intravascular ultrasound (IVUS) is an intraopertive, readily availabel tool that can help to decide when angiography is unconclusive. We present a case report in which IVUS confirmed a postangioplasty dissection with critical residual stenosis inadvertent in angiography. Methods: A 56 year old male patient with Rutherford 5 lower limb ischemia underwent hybrid revascularization consisting in surgical endarterectomy of the common femoral artery and endoavascular treatment of the SFA and anterior tibial artery. A very calcified short lesion at the SFA was initially dilated with plain balloon angioplasty, without evident residual stenosis and good outflow in angiographic control, but with turbulent flow at the treated segment. IVUS confirmed critical residual stenosis secondary to intimal dissection, indicating stent implantation. Stent dimensions were decided based on measurements obtained with IVUS, which helped to identify the length and diameter of the dissected arterial segment. Complete expansion of the stent was also assesed by IVUS control. Results: The patient recovered pedal pulse immediatelly after the procedure. 3 Months after revascularization all whounds at the foot had healed, without rest pain and complete patency of all the arterial treated segments assesed by dupplex ultrasound. Conclusion: Angiographic control after angioplasty of complex lessions at the SFA is sometimes misleading, avoiding detection of local complicactions at the treated segment and jeopardizing short term patency results of endovascular procedures. IVUS provides crucial additional information when deciding whether or not to implant a stent, and could become an essential tool for these procedures in the future, even displacing arteriography as a the gold-standard for post-angioplasty control image.