Kinking Of Artery Research Articles

How Much We Know about Dolicoarteriopathies

Vertebral and carotid artery dolicoarteriopathies, including elongation, kinking, and coiling, are linked to various cerebrovascular dysfunctions. Kinking, categorized by Metz, et al. is graded by angle severity: Grade 1 (90° - 60°), Grade 2 (60° - 30°), and Grade 3 (< 30°). In Grades 2 and 3, reduced blood flow heightens ischemic risk, contributing to hemodynamic instability and cerebrovascular insufficiency. While most symptomatic cases undergo endovascular or surgical correction, some patients with severe kinking remain asymptomatic, questioning current understanding. In 150 cases of carotid or vertebral artery kinking, we observed stenosis in symptomatic patients, differing from the expected arterial enlargement seen in dolicoarteriopathies. This suggests two potential kinking types: stenotic and enlarged. A notable case presented bilateral Grade 3 internal carotid artery kinking, with right-sided stenosis and cerebral hypoperfusion, yet left-sided transient ischemic attacks occurred. This finding challenges existing classifications and suggests further investigation is warranted.

Entrapment of the Subscapular Artery between the Radial Nerve and the Posterior Wall of the Axilla: An Anatomical Variation with Clinical Significance

Objective. The subscapular artery vascularizes a substantial region of the thoracic wall, and the significance of its distribution is well depicted in the diversity of reconstructive procedures that rely on its blood supply. The aim of this study is to present an uncommon anatomical variation of the artery and discuss the clinical implications of its presence.
 Case Report. This case report depicts a rare variant of compression and the kinking of the subscapular artery by the radial nerve on the posterior wall of the axilla that was encountered during dissection of a male cadaver of Greek origin.
 Conclusion. The use of autologous tissues in the reconstruction of defects and treatment of lymphedema is expanding, so the need to establish safer surgical dissections is also becoming more apparent. The case of entrapment of the subscapular artery by the radial nerve is extremely rare, however, utiliz- ing tissues perfused by this artery for reconstructive purposes could potentially be futile and unsuccessful due to the inadequate blood supply or vessel thrombosis. Hence, the surgeon should adapt the treatment plan according to preoperative findings, as the presence of anatomical variants should always be suspected.

NONINVASIVE DIAGNOSTICS OF EXTRACRANIAL ARTERIES TORTUOSITY

Deformations of carotid artery – deviation, tortuosity, coiling, hold the 2nd placeamong other carotid pathologies. They are the cause of 10-17% of cerebrovasculardisorders. It should also be noted that this pathology is common for a relatively youngage. It is considered that in the elderly carotid deformation is an acquired lesion mostcommonly seen in patients suffering from arteriosclerosis and hypertension, while inchildren and younger patients, the kinks and coils are congenital. For diagnostics ofdeformations of magistral arteries, highly efficient non-invasive methods are applied:ultrasound duplex-scanning, MR angiography, and multi-slice CT angiography. We havestudied deformations of magistral carotid and vertebral arteries in cases of isolatedatherosclerosis, isolated arterial hypertension, and a combination of atherosclerosisand hypertension. Out of 205 patients we diagnosed deformations of carotid arteriesin 93 (30%) cases, and deformations of vertebral arteries in 64 (21%) cases. Bilateraldeformation of carotid arteries was diagnosed in 43 (17%) cases. C- or S-shaped deformationsin 55 (81%) cases were located in proximal or medial parts of CCA or ICA. 76%of patients with this pathology had arterial hypertension. In the case of C- or S-typedeformation rate amounted to 30%, in the case of coiling increase of flow it reached50%, and in the case of kinking – exceeded 60%. In the case of C- or S-type elongation,flow volume (Q) is practically within the normal range - 488±38 ml/min. In the case ofspiral shape elongation, it showed the tendency of decrease -402±22 ml/min, which ismore obvious in the case of kinking - 332±22 ml/min. The frequency of elongations ispractically the same in the case of isolated atherosclerosis or hypertension, however,in the case of their combination the frequency increases. In order to study the impactof the deformation of magistral arteries on intracranial hemodynamics, we examined84 patients without any hemodynamically significant atherosclerotic pathology of carotids.We found a total of 91 elongations: In the case of C- or S-shaped deformation,flow parameters remain within the normal range, as in the case of spiral elongation orcoiling. In the case of kinking, there is an obvious tendency for a decrease in flow rate – the average flow rate is 20% below the normal value. Our data correspond to similar data of other authors, who revealed the tendency of a 20-35% decrease of flow rate in the ipsilateral middle cerebral artery, in case of significant tortuosity or kinking of the carotid artery.

Pathological tortuosity of intracranial arteries (pure arterial malformation) - diagnosis and management tactics

Tortuosity of intracranial arteries is rare and usually mistaken for arteriovenous malformations. In the world literature, the term «pure arterial malformations» is used to refer to this disease. To summarize the experience of the Burdenko Neurosurgery Center on diagnosis of intracranial artery tortuosity, management and treatment of these patients, as well as to review appropriate literature data. Tortuosity of intracranial arteries was detected in 11 patients (8 women and 3 men) aged 7-48 years who underwent outpatient or inpatient examination and treatment at the Burdenko Neurosurgery Center between 2009 and 2022. We analyzed angiographic, clinical and follow-up data of these patients, as well as appropriate literature data. According to angiography data, all patients had moderate dilatation, elongation and tortuosity of intracranial arteries without signs of arteriovenous shunting. The most common finding was tortuosity of several segments of internal carotid artery (5 cases). Lesion of PCA, PComA, MCA and ACA was less common. In 7 cases, the walls of the deformed vessels had calcified zones. In two cases, there were saccular aneurysms in the walls of the tortuous vessels. In one case, tortuosity was combined with kinking of the left subclavian artery, in another one - tortuosity of C1 segment of the right ICA. No patient had specific clinical manifestations. The follow-up period was 1-10 years in 7 patients. There were no changes in structure of tortuosity or appearance of new aneurysms. Tortuosity of intracranial arteries is an extremely rare disease with the highest incidence in young women. This abnormality has no specific clinical manifestations and does not require surgical or conservative treatment. Tortuosity of intracranial arteries should be differentiated from arterial dolichoectasia, fusiform aneurysms and AVMs.

Association between internal carotid artery kinking and ischemic stroke: A population-based cross-sectional study

AimEvidence for an association between Internal carotid artery (ICA) kinking and ischemic stroke has been controversial. We aimed to examine the association between ICA tortuosity and risk of ischemic stroke and specific ischemic stroke subtypes (large artery atherosclerosis, LAA; small artery occlusion, SAO). MethodsA total of 419 outpatients were included in this cross-sectional study. ICA kinking was objectively assessed by head and neck computed tomography angiography (CTA). The risk of ischemic stroke for each patient was evaluated according to the Essen Stroke Risk Score (ESRS). Ischemic stroke subtypes (LAA and SAO) were measure with head magnetic resonance imaging (MRI). ResultsThe average age of patients was 59.1 years (SD = 13.25) and 264 (63.0 %) were males. The prevalence of ICA kinking in this sample was 31.5 % (132 out of 419). Individuals with ICA kinking was associated with 0.55-points increase in ESRS score than those without ICA kinking (95 % CI, 0.28–0.81, p < 0.001) among patients over 50 years. In addition, right ICA kinking or left ICA kinking were associated with 0.35-points (95 % CI, 0.08–0.63) and 0.49-points (95 % CI, 0.23–0.76) increase in ESRS score, respectively. For specific ischemic stroke subtypes, individuals with ICA kinking had a 10.34-fold increased risk of SAO compared to those without ICA kinking (95 % CI, 6.22–20.68). Individuals with right ICA kinking had a 4.51-fold risk of SAO than those without kinking (95 % CI, 2.64–7.71), and had an 8.86-fold risk of SAO than those without kinking in the left ICA kinking (95 % CI, 4.97–15.79). ConclusionOur findings support the role of ICA kinking on ischemic stroke. Early screening and proper treatment of carotid artery tortuosity could be a potential intervention strategy for the prevention of ischemic stroke later on.

Transplant Hepatic Artery Complications

Hepatic artery complications can be divided into two different categories, non-occlusive and steno-occlusive disease. Steno-occlusive disease is a collective term that encompasses hepatic artery thrombosis, hepatic artery stenosis, and hepatic arterial kinks, while non-occlusive arterial disease encompasses less than 5% of complications and is a collective term used to describe arteriovenous fistulae, pseudoaneurysms, arterial rupture and nonocclusive hepatic artery hypoperfusion syndrome. This article details the angiographic techniques and definitions needed to accurately diagnose arterial transplant complications and describes the technical aspects and results of endoluminal management of these arterial complications. In addition, this article discusses the presentation, etiology and indications for treatment, including surgical management of these various complications.

Criss-cross pulmonary arteries in common arterial trunk – Implications to management and outcome

ObjectivesTo investigate the incidence, types and pathophysiology of criss-cross pattern of the proximal pulmonary arteries in common arterial trunk and its influence on management and outcomes. MethodsRetrospective review of all patients with common arterial trunk who underwent Aswan Truncus Operation with regard to the origin and course of the proximal pulmonary artery branches as defined by 3D segmented models pre, immediately and 1 and 2 years after operation. ResultsBetween January 2019 and September 2022, 39 patients (19 males, aged 1–12 months) underwent the Aswan Truncus Operation. 18 patients (46%) had criss-cross arrangement of the proximal pulmonary artery. The mortality, ICU and hospital stay were not affected by the presence or absence of the criss-cross pattern. However, following operation in the criss-cross group, there was evidence of different degrees of kinking and twisting of the right pulmonary artery. This resulted in severe narrowing which required stenting or reoperation at different stages (1 during ICU stay and another after 1 year). Separate origin of the left pulmonary artery (Criss-cross Type 2) from a long stenotic ductus arteriosus required resection of the stenotic segment followed by anastomosis to the right pulmonary artery recreating a 60° angle of bifurcation. ConclusionCriss-cross pattern of proximal pulmonary arteries is common in patients with common arterial trunk. Pre-operative diagnosis and tailored approaches of repair are required to prevent late complications.

Femoral or Axillary Cannulation for Extracorporeal Circulation during Minimally Invasive Heart Valve Surgery (FAMI): Protocol for a Multi-Center Prospective Randomized Trial.

Minimally invasive heart valve surgery via anterolateral mini-thoracotomy with full endoscopic 3D visualization (MIS) has become the standard treatment of patients with valvular heart disease and low operative risk over the past two decades. It requires extracorporeal circulation and cardioplegic arrest. The most established form of arterial cannulation for MIS is through the femoral artery and is used by most surgeons, but it is suspected to increase the risk of stroke through retrograde blood flow. An alternative route of cannulation is the axillary artery, producing antegrade blood flow during extracorporeal circulation. Femoral or axillary cannulation for extracorporeal circulation during minimally invasive heart valve surgery (FAMI) is a multicenter randomized controlled trial designed to determine whether axillary cannulation is superior to femoral cannulation for the outcome of a manifest stroke within 7 days postoperatively. The target sample size was 848 participants. Patients ≥ 18 years of age, with valvular regurgitation or stenosis scheduled for minimally invasive surgery via anterolateral mini-thoracotomy, were randomized to axillary cannulation (treatment group) or to femoral cannulation (standard care). Patients were followed up for seven days postoperatively. A CT scan was performed pre-operatively to screen patients for vascular calcifications and to assess the safety of femoral cannulation. The standard of care is femoral artery cannulation, but is performed only in patients without significant vascular calcifications or severe kinking of the iliac arteries and in patients with sufficient vessel diameter. The cannulation is performed via Seldinger's technique, and the vessel closed percutaneously using a plug-based vascular closure device. Only patients without significant vascular calcifications are considered for femoral cannulation, as an increased risk of stroke is assumed. In patients with vascular calcifications, axillary cannulation is the standard of care to avoid these risks. Retrospective studies have hinted that, even in patients without vascular calcifications, there may be a lower stroke risk with axillary cannulation compared to femoral cannulation. We present a protocol for a multi-center randomized trial to investigate this hypothesis. To date, evidence on the best access for peripheral artery cannulation during minimally invasive heart valve surgery has been scarce. Patients may benefit from axillary cannulation for extracorporeal circulation in terms of stroke risk and other neurological and vascular complications, though femoral cannulation is the gold standard. The aim of this study is to determine the risks of peri-operative stroke in a prospective randomized comparison of femoral vs. axillary cannulation.

A case of chronic limb threatening ischemia with kinking of the external iliac artery due to downward deviation of abdominal aortic stent graft.

A case of chronic limb threatening ischemia with kinking of the external iliac artery due to downward deviation of abdominal aortic stent graft.

Transaxillary implantation of a temporary microaxial left ventricular assist device in a patient with a rectangular kinked subclavian artery.

Transaxillary implantation of a temporary microaxial left ventricular assist device in patients suffering from cardiogenic shock is an established technique. We present a 77-year-old female patient with severe mitral regurgitation. She underwent minimally invasive surgical mitral valve replacement. After an uneventful postoperative course, the patient developed acute heart failure on the 11th postoperative day. Transthoracic echocardiography revealed new onset of takotsubo cardiomyopathy with a severely decreased left ventricular ejection fraction. Implantation of a microaxial flow pump for left ventricular decompression was scheduled. Preoperative computed tomography revealed a rectangular course of the right subclavian artery. To advance the Impella we employed an introducer fitted over the guidewire behind the Impella device as a 'cue stick' to move the rigid part of the pump forward to overcome the kinking using a 'shuffleboard technique'. The haemodynamic situation stabilized immediately after implantation. The Impella 5.5 was successfully weaned after six days of support. In the event of (rectangular) kinking of the subclavian artery, the 'shuffleboard technique' can be used for successful positioning of the pump.

Diagnostic and therapeutic strategies for vascular complications after renal transplantation: a single-center experience in 2,304 renal transplantations.

Vascular complications after renal transplantation are one of the serious surgical complications, which can affect the transplantation outcome and even endanger life if not treated properly. We performed a retrospective analysis of the 2,304 renal transplantations procedures completed between the period of Jan., 2015 and Jan., 2022, which consisted of 1,658 male patients and 646 female patients. Among the above cases, there were 54 cases of vascular complications after renal transplantation, the incidence of vascular complications in our study was 2.34% (54/2,304), the most common vascular complication was transplanted renal artery stenosis (TRAS, n = 36), followed by external iliac artery dissection (n = 5), renal artery rupture (n = 4), renal vein thrombosis (n = 3), renal artery thrombosis (n = 2), renal artery dissection (n = 1), renal artery pseudoaneurysm (n = 1), and internal iliac artery pseudoaneurysm (n = 1), and renal artery kinking (n = 1). 40 patients were treated by percutaneous transluminal angioplasty (PTA), including 3 balloon catheter dilatation and 37 endovascular stentings, and 14 underwent open surgery. Eventually, 9 patients had graft nephrectomy, resulting in an overall treatment rate of 81.5%. Most vascular complications can be treated satisfactorily with PTA. However, the overall treatment of renal artery rupture, thrombosis, renal artery kinking, and other complications is poor, and the rate of transplanted renal loss is high.

A Study of the Association Between Carotid Artery Curvature and Intracranial Aneurysms.

Carotid artery curvature is considered a sign of a weak vessel wall, and we hypothesize that a weak vascular wall under the effect of hemodynamics may cause intracranial aneurysms. The general data of 534 patients with aneurysms and 473 control patients were retrospectively analyzed in a case-control study. Carotid artery curvature was characterized as none, tortuosity, kinking, and coiling by computed tomography angiography images. Univariate analysis was performed to determine the degree of carotid artery tortuosity and to analyze the general data between the aneurysm group and the control group, and then, multivariate statistical logistic regression analysis was used to analyze the statistical significance of the univariate analysis. Finally, the correlation between aneurysm-related features and carotid artery curvature was analyzed. Univariate analysis showed that kinking was significantly related to the occurrence of intracranial aneurysms (P=0.009). The results of multivariate regression analysis showed that kinking was an independent risk factor for the occurrence of aneurysms (odds ratio: 1.942; 95% confidence interval: 1.387-2.720 for model 1; odds ratio: 1.995; 95% confidence interval: 1.419-2.805 for model 2). In the analysis of the correlation between the characteristics of intracranial aneurysms and the curvature of the internal carotid artery, there was no correlation between the curvature of the internal carotid artery and the size, location or number of aneurysms, or whether the intracranial aneurysm was ruptured. Intracranial aneurysms are associated with carotid artery curvature. Kinking of the internal carotid artery may indicate a higher risk for aneurysm formation.

Clinical Case Reports 1976 - 79

In this paper five case reports were presented and include growth of hypoplastic right ventricle following pulmonary valvotomy, intracavitary electrocardiography in the diagnosis of Ebstein’s anomaly of the left atrioventricular valve in congenital corrected transposition of the great arteries, growth phenomenon as a cause of kinking of the right pulmonary artery in Waterston anastomosis, the usefulness of pulmonary vein wedge angiography in the visualization of an obstructed pulmonary artery, false aneurysm of the right pulmonary artery as a new complication of the Waterston anastomosis. For each case report, clinical, chest x-ray, electrocardiogram, angiogram, and other pertinent findings were presented. This was followed by discussion of etiology, diagnosis, and treatment options, as appropriate.

Kinked Innominate Artery – A Rare Cause for Upper Limb Ischemia

Abstract Interventions of the aortic arch can lead to unexpected complication of atheroembolization from the plaques with many cases of CVA following TEVAR being reported in the literature. It is especially seen in old diabetic patients. Embolizations is a known entity in cases of loop Common carotid vessels. The abnormal curvature causes stasis of blood leading onto development of thrombus. Diseases related to Innominate artery are very rare. Kinking of Innominate artery is even rarer abnormality and very few cases only have been reported in the literature. The various clinical scenarios of kinked innominate artery reported are presence of pulsatile mass in the neck, In CXR the kinked artery masquerading as right upper lobe lung mass. Herein we report a case of Right upper limb little finger gangrene following coronary angiogram. On CT Angio evaluation it was found that there was thrombus in distal innominate and subclavian vessels with kinking of Innominate, Left Common carotid and Left Subclavian also. The passage of hardwares across the kinked innominate artery had caused the thrombus formation and subsequent embolization. This is the 1st case in literature to report the kinked innominate artery has caused a procedural complication. We report this case to inform that extreme caution should be undertaken during interventional procedures in cases of abnormal curvatures of great vessels to avoid complication.

PS-R07-6: RENOVASCULAR HYPERTENSION SECONDARY TO MASSIVE ILIOPSOAS HEMATOMA

An 81-year-old female with stage G3 chronic kidney disease and post left nephrectomy for upper tract urothelial carcinoma 20 years ago, was admitted to our hospital for heart failure. She acutely developed right thigh pain, and contrast-enhanced computed tomography (CT) revealed an idiopathic iliopsoas hematoma for which transcatheter arterial embolization (TAE) was performed. Subsequently, her hypertension worsened despite multiple antihypertensive medications (Nifedipine, Carvedilol, Doxazosin, Spironolactone), remained uncontrolled over one month. At this point, plasma renin activity and plasma aldosterone concentration were both elevated on taking carvedilol and spironolactone. An angiotensin II receptor blocker (ARB, Olmesartan) was additionally started for refractory hypertension. Oliguric acute kidney injury (AKI) developed on the day following ARB administration, and her serum creatinine increased from 0.98 to 2.0 mg/dL. After stopping the ARB, the kidney function immediately recovered to the previous level. On review of the previously performed contrast CT, the remnant (right) kidney was ventrally displaced, and the right renal artery was kinked by the massive iliopsoas hematoma (Figure 1a and 1b). Three months after TAE, the hematoma completely disappeared, and the right kidney and renal artery returned to their original positions. Renal Doppler ultrasonography before the appearance, and after the disappearance of hematoma, demonstrated no abnormalities indicative of renal artery stenosis. Furthermore, hypertension also improved over the three months after TAE. Renal artery stenosis is primarily caused by atherosclerosis, fibromuscular dysplasia, and rarely external compression. We report a rare case of renovascular hypertension which would be induced by renal artery kinking due to massive iliopsoas hematoma. JOURNAL/jhype/04.03/00004872-202301001-01329/figure1/v/2023-10-24T163949Z/r/image-jpeg

Comprehensive outcomes after primary arterial switch operation.

To report the long-term outcomes of the arterial switch operation for transposition of the great arteries. The data of 35 patients who underwent an arterial switch operation between April 2006 and May 2021 were retrospectively examined; five had double-outlet right ventricles, three had side-by-side transposition, and 27 had d-transposition. The punch-out technique was the basic method for coronary transplantation; however, if coronary artery kinking after additional peeling was a concern, the trap-door technique was used. In aortic reconstruction, the caliber difference between the neoascending aorta and the native pulmonary artery was fixed using the pulmonary artery flap. In pulmonary reconstruction, the pulmonary artery was bilaterally exposed over the second branch. The median age at operation and follow-up duration were 10.0 (8.0-12.5) days and 72.9 (40.7-139.5) months, respectively. Thirty-four patients survived, and one was lost to follow-up ([coronary transplantation]: right coronary artery, punch-out = 31, trap-door = 2; left coronary artery, punch-out = 28, trap-door = 7; [aortic regurgitation]: no-slight = 27, mild = 6, moderate = 1; [pulmonary regurgitation]: no-slight = 22, mild = 11, moderate = 1). Slight coronary bending occurred in two patients; ischemia was not observed. Catheter stent placement was performed in one of three patients with stenosis at the pulmonary artery bifurcation. Catheter balloon dilation was performed in one patient with supravalvular pulmonary stenosis. There were no cases of coronary, aortic, or pulmonary artery reoperations. The 15-year cumulative reintervention avoidance rate was 91.0%. There were no deaths or reoperations during the long-term follow-up period, and arterial switch operation outcomes at our hospital were satisfactory.

Role of Interventional Radiology in the Management of Early Vascular Complications After Liver Transplant.

A hepatic vascular complication after liver transplant is a critical situation, often resulting in graft failure and potentially leading to patient death. Early diagnosis and treatment of vascular complications can provide prolonged graft survival and prohibit further complications. This study presents our experiences with endovascular treatment during the first week after liver transplant. Between January 2012 and February 2021, 240 liver transplants were performed, with 43 patients having early endovascular treatment (37 men; mean age 27 ± 2.9 years) at a single center. Early endovascular interventions were carried out 1 to 7 days (mean ± SD of 2.7 ± 0.24 days) after transplant. Patients with vascular complications were grouped by arterial, venous, and portal complications. In addition, arterial complications were subgrouped by occlusive (hepatic artery thrombosis) and nonocclusive (hepatic artery stenosis/splenic artery steal syndrome) complications. Patients had median follow-up of 47 ± 4 months. In the first week after liver transplant, vascular complications included splenic artery steal syndrome in 27 patients (62.7%), hepatic complications in 10 patients (23.2%) (7 with hepatic artery thrombosis, 3 with hepatic artery stenosis), hepatic venous outflow complications in 4 patients (9.3%), and portal vein complications in 2 patients (4.6%). Only 1 patient required revision surgery because of excessive arterial kinking; the remaining patients with arterial complications were successfully managed with multiple endovascular treatment attempts. Patients with splenic artery steal syndrome were treated by selective arterial embolization with coil devices. Resistivity index, peak systolic velocity of hepatic arteries, and portal vein maximal velocity significantly improved (P < .001). Patients with hepatic venous outflow and portal vein complications who had endovascular treatments and vascular structures maintained good results over follow-up. Early endovascular intervention is feasible and safe for hepatic vascular complications following liver transplant, with high success treatment rates with advances in interventional radiology.

Use of absorbable hemostat bolster for prevention of donor renal artery kinking in kidney transplant.

Transplant renal artery stenosis due to mechanical kinking is a rare but significant complication in kidney transplantation that can lead to graft dysfunction due to graft hypoperfusion, delayed graft function, or even global kidney infarction. When detected during surgery, re-anastomosis is usually performed after re-clamping, which inevitably prolongs the warm ischemia time, and increases the possibility of primary graft non-function. In this report, we describe a novel, noninvasive surgical technique whereby the donor renal artery is padded with absorbable hemostatic material (i.e., Surgicel) bolster, placed below the middle third of the renal artery in recipients who were found to have mechanical kinking during the implantation procedure. The bolster technique was used in 12 kidney transplant recipients who were found to have kinking of the donor artery during the primary surgery. After pillowing the renal artery with absorbable hemostatic bolster, no residual kinking was observed intra-operatively, and good allograft perfusion was confirmed with no Doppler ultrasound evidence of renal artery stenosis confirmed at 1 week, 1 month, and 1 year after transplantation.

Accidental coronary artery kinking by leadless pacemaker fixation tine.

We present a case of a 59-year-old woman who presented with a coronary syndrome soon after an uneventful leadless pacemaker (MicraVR™, Medtronic) implantation. A routine postoperative electrocardiogram (ECG) revealed alteration of the baseline ECG (Panel A, left) with appearance of a complete right bundle branch block (RBBB) and ST-segment elevation in V3 (Panel A, middle). She reported intermittent moderate chest pain which worsened in left lateral position. An emergency transthoracic echocardiogram showed minimal pericardial effusion (<0.5 mm) with a normal systolic left ventricular function. A coronary computed tomography angiogram suggested that the septal anchor of the pacemaker partially occluded the distal segment of the left anterior descending (LAD) artery (Panel B). This was associated with enhancement defects on septo-apical and apical segments, consistent with ischaemia. The coronary angiography confirmed the partial LAD kinking in relation to the device anchor which was considered extravascular (Panel C). After patient consent, pacemaker retrieval was successfully performed using a 26Fr Gore DrySeal™ introducer sheath, a 12Fr Cook Performer™ guiding sheath holding an EV3 Amplatz gooseneck Snare of 15 mm. Once the pacemaker was trapped and before applying traction, a 0.14 Asahi FielderXT™ coronary wire was inserted through the lesion, to protect the vessel in case of injury. The coronary integrity was confirmed after device removal (Panel D). The RBBB disappeared 48 h later, leaving a Q wave in lead V3 (Panel A, right). Systematic postoperative ECG is warranted after leadless pacemaker implantation.

Association between kinking of the cervical carotid or vertebral artery and ischemic stroke/TIA.

IntroductionKinking of the cervical carotid or vertebral artery is a common structural abnormality in patients with cerebrovascular disease. However, there is no consensus about the relationship between kinking and ischemic stroke/TIA. We aim to determine the effect of arterial kinking on ischemic stroke/TIA.MethodsA retrospective study was performed on patients who underwent cerebral angiography with DSA between January 2014 and December 2018. Demographic information and comorbidities were recorded. Each anatomical circulation system was defined as an observation unit. Kinking and stenosis of each circulation unit were recorded. Ischemia stroke or TIA within 6 months and its location were assessed as an outcome. Logistic regression with a generalized estimating equation approach was used for the analysis.ResultsA total of 1,062 patients (mean age 57.9 ± 14.5 years, 740 males and 322 females) were included in the study. Of the patients, 369 (35%) had kinking and 771 (73%) had ischemic stroke/TIA. There were 110 left anterior, 90 right anterior, and 308 posterior circulation units, among which 343 had mild, 160 had moderate, and 243 had severe kinking. Multivariate regression analysis showed that ischemic stroke/TIA was associated with severe kinking (OR 1.39, 95% CI 1.03–1.88, P = 0.03). Posterior circulation was more vulnerable to acute ischemia than left anterior and right anterior circulation (OR 3.58, 95% CI 2.81–4.56, P < 0.0001).ConclusionSevere kinking of the cervical carotid or vertebral artery may be associated with a higher risk of ischemic stroke/TIA, especially when the kinking is located in the posterior circulation.