Main Artery Research Articles

SHOULD WE BE CONCERNED ABOUT USING INTRAVASCULAR LITHOTRIPSY ON THE LEFT MAIN? INSIGHT FROM ROLLING STONE RETROSPECTIVE REGISTRY

Abstract Background The use of rotational atherectomy is currently prevalent in the treatment of left main coronary artery lesions. However, it often necessitates the use of a large burr to achieve adequate debulking, which, in turn, demands highly experienced operators. Intravascular lithotripsy (IVL) is a promising, user–friendly and increasingly employed technique for calcific plaque modification before percutaneous coronary intervention. Although in many cath labs it is now routinely used to treat lesions of the three main coronary arteries, there are still concerns regarding its use in the left main, primarily due to prolonged inflations required for its optimal efficacy. Methods We conducted a retrospective analysis using data from the multicenter retrospective Rolling Stone registry. The analysis involved data from 474 patients, with a stratification between IVL procedures involving left main coronary artery (46 patients) and those that did not (428 patients). The primary effectiveness endpoint was procedural success (defined as achieving residual stenosis < 20% with TIMI III flow); secondary endpoints included the rate of procedural related adverse events, in hospital adverse events and MACE rate at 30 days and 6 months. Results Between April 2018 and January 2023, a total of 474 underwent IVL procedures. Most patients presented with calcific lesion requiring lithotripsy in non–left main segments, while IVL was performed on the left main artery in 46 patients. No significative differences were found on baseline characteristics between LM and non–LM groups. Treatment of IVL–LM lesion was marked by a high procedural success rate (97.8%) and a low incidence of procedural and peri–procedural complications. However, there was a higher rate of contrast–induced acute kidney injury in patients treated in LM (6.5% vs. 1.6%, p=0.030), although no other differences for in–hospital outcomes were observed. Furthermore, there were no differences in 30–day and 6–month follow–up outcomes between the two groups. Conclusions This study suggests that employing intravascular lithotripsy in the left main coronary artery is not only a safe procedure but also produces excellent results comparable to its application in other coronary branches. This provides a substantial level of confidence in the safety and effectiveness of IVL when used in this specific context.

Review of patients with diagnosis of abdominal aortic aneurysm (AAA) currently on statin prophylaxis in Scartho Lynton Chantry (SLC) Medical Group, Grimsby

Background: An abdominal aortic aneurysm occurs when a lower part ofthe body’s main artery, called the aorta, becomes weakened and bulges.Most aneurysms do not cause any problems, but can pose serious risk ifthey rupture. Hence, one of the prominent ways to reduce the risk ofrupture is by managing cardiovascular risks using statins as per NationalInstitute for Health and Care Excellence (NICE) guidelines.Aims: This review audit was carried out to:To identify the total number of patients with confirmed diagnosis ofAbdominal Aortic Aneurysm (AAA) within the GP Practice who werecurrently taking statins.To confirm how many of these patients have had a previous encounterwith a physician in the practice regarding Statin prophylaxis.To confirm the number of patients who are not currently takingstatins, have no contraindication, and have not had discussion with a clinicianregarding statin prophylaxis.To create awareness for clinicians and patients regarding NICE guidanceon statin prophylaxis.Method: A retrospective review of clinical records was conducted viaSystemone for all the patients with AAA in the SLC practice. Then, inclusionand exclusion criteria were applied to identify those on prophylactic statins.Results: Of the 36 patients with AAA records retrieved, fewer than 2% ofpatients who satisfied the inclusion criteria were not prescribed statins.Conclusion: Lack of awareness of the NICE guideline regarding statinprophylaxis in patients with AAA may contribute significantly to thisoutcome. Therefore, practice clinicians are to be educated on NICEguidelines regarding statin prophylaxis in patients with AAA. Also, anautomated message can be created for patients with AAA, to book anappointment with the clinician and discuss the use of statin.

Anatomic Study of Vascular Supply of the External Ear Using CT Angiography in Congenital Microtia

Background: The morphology of the arteries of the external ear on the affected side of congenital microtia differs from normal. The present study aimed to use computed tomography angiography (CTA) to describe the anatomic variations of arteries in microtia and provide theoretical guidance for the first stage of autologous auricular reconstruction by the 2-stage method. Methods: Ten patients with unilateral microtia from May 2021 to August 2021 were included. Computed tomography angiography and 3-dimensional reconstruction were used to analyze the supply and branches of the main arteries of the auricle. The number of the superficial temporal artery (STA) and posterior auricular artery (PAA) branches to the auricle, vessel diameter, and the presence or absence of the STA and PAA branches were documented. The skin flap and incision were designed combined with the anatomic of auricular arteries. Results: The blood supply of the auricle mainly came from the STA and PAA. The STA’s preauricular branch and PAA’s posterior auricular branch were absent to varying degrees, and the middle branch was more prominent. The average diameter of the STA on the healthy auricle was 3.07±0.96 mm, and the average diameter of the PAA was 1.72±0.50 mm. The average diameter of the STA on the microtia auricle was 2.65±0.42 mm, and the average diameter of the PAA was 1.53±0.67 mm. There was a statistically significant difference in the diameter of STA between the healthy auricle and the microtia auricle (P=0.006). However, there was no significant difference in the diameter of the PAA between the healthy auricle and the microtia auricle (P=0.112). The skin flap and incision were designed and combined with the preoperative CTA images, and no flap necrosis was observed in all patients. Conclusion: The vascular distribution of arteries in microtia patients was clearly and accurately assessed by CTA. In our experience, the data and detailed imaging were useful in designing skin flaps and incisions during the first stage of autologous auricular reconstruction by the 2-stage method.

Catheter-Directed Ionic Liquid Embolic Agent for Rapid Portal Vein Embolization, Segmentectomy, and Bile Duct Ablation.

Embolic materials currently in use for portal vein embolization (PVE) do not treat the tumor, which poses a risk for tumor progression during the interval between PVE and surgical resection. Here, is developed an ionic-liquid-based embolic material (LEAD) for portal vein embolization, liver ablation, and drug delivery. LEAD is optimized and characterized for diffusivity, X-ray visibility, and cytotoxicity. In the porcine renal embolization model, LEAD delivered from the main renal artery reached vasculature down to 10 microns with uniform tissue ablation and delivery of small and large therapeutics. In non-survival and survival porcine experiments, successful PVE is achieved in minutes, leading to the expected chemical segmentectomy, and delivery of a large protein drug (i.e., Nivolumab) with LEAD. In cholangiocarcinoma mouse tumor models and in ex vivo human tumors, LEAD consistently achieved an effective ablation and wide drug distribution. Furthermore, various strains of drug-resistant patient-derived bacteria showed significant susceptibility to LEAD, suggesting that LEAD may also prevent infectious complications resulting from tissue ablation. With its capabilities to embolize, ablate, and deliver therapeutics, ease of use, and a high safety profile demonstrated in animal studies, LEAD offers a potential alternative to tumor ablation with or without PVE for FLR growth.

Russian-Persian Economic Relations in Early 20th Century: Road Construction

This article explores the history of the construction of one of the main transportation arteries in modern Iran: the Enzeli-Teheran highway with the Kazvin-Hamadan section. The road was funded by the Russian treasury and aimed to boost Russian-Persian trade by including not only the northern provinces of Persia but also the central part of the country. The intensification of trade was expected to occur through the introduction of automobile traffic on the highway, replacing the archaic caravan routes. The article presents the perspectives of both the Russian government of that period and entrepreneurial circles on the choice of road direction and the justification for transitioning to a new method of cargo delivery. It concludes that there were significant discrepancies in the positions of these parties. While the Russian government saw great geopolitical advantage in connecting the largest Enzeli port with Teheran and constructing the Kazvin-Hamadan branch linking northern Persia with its central part, entrepreneurs viewed it as a threat of European product penetration into northern Persia. Fortunately, the entrepreneurial community was not unanimous in its views, and a group emerged willing to embark on this new venture, promising to be successful and give a fresh impetus to Russian-Persian trade relations.

Long-Term Safety and Efficacy of Transcatheter Microwave and Radiofrequency Denervation in a Chronic Ovine Model.

Transcatheter renal denervation (RDN) has had inconsistent efficacy and concerns for durability of denervation. We aimed to investigate long-term safety and efficacy of transcatheter microwave RDN invivo in normotensive sheep in comparison to conventional radiofrequency ablation. Sheep underwent bilateral RDN, receiving 1 to 2 microwave ablations (maximum power of 80-120 W for 240 s-480 s) and 12 to 16 radiofrequency ablations (180 s-240 s) in the main renal artery in a paired fashion, alternating the side of treatment, euthanized at 2 weeks (acute N=15) or 5.5 months (chronic N=15), and compared with undenervated controls (N=4). Microwave RDN produced substantial circumferential perivascular injury compared with radiofrequency at both 2 weeks [area 239.8 (interquartile range [IQR] 152.0-343.4) mm2 versus 50.1 (IQR, 32.0-74.6) mm2, P <0.001; depth 16.4 (IQR, 13.9-18.9) mm versus 7.5 (IQR, 6.0-8.9) mm P <0.001] and 5.5 months [area 20.0 (IQR, 3.4-31.8) mm2 versus 5.0 (IQR, 1.4-7.3) mm2, P=0.025; depth 5.9 (IQR, 1.9-8.8) mm versus 3.1 (IQR, 1.2-4.1) mm, P=0.005] using mixed models. Renal denervation resulted in significant long-term reductions in viability of renal sympathetic nerves [58.9% reduction with microwave (P=0.01) and 45% reduction with radiofrequency (P=0.017)] and median cortical norepinephrine levels [71% reduction with microwave (P <0.001) and 72.9% reduction with radiofrequency (P <0.001)] at 5.5 months compared with undenervated controls. Transcatheter microwave RDN produces deep circumferential perivascular ablations without significant arterial injury to provide effective and durable RDN at 5.5 months compared with radiofrequency RDN.

Bypass-Assisted Microsurgical Clipping for an Endovascular Treatment-Resistant Ruptured Internal Carotid-Posterior Communicating Artery Aneurysm, Recurring Two Decades Postinitial Clipping: 2-Dimensional Operative Video.

Salvage treatment of postclipping recurrent aneurysms remains challenging.1,2 The salvage microsurgical clipping is a possible intervention but sometimes difficult because of tissue adhesions around the aneurysm and previously installed clips; therefore, salvage coil embolization may have certain advantages.1-5 However, when coil embolization is not applicable,6 microsurgical clipping is a stand-alone curative treatment, requiring proficient and reliable microsurgical techniques. This article describes a unique case of a 70-year-old female patient complaining of a severe headache with subarachnoid hemorrhage due to a recurrent ruptured left internal carotid-posterior communicating artery aneurysm after microsurgical clipping 23 years ago. An initial attempt at coil embolization proved unsuccessful because of the aneurysm shape. Consequently, the salvage microsurgical clipping was planned. Given the additional time for trapping the internal carotid artery for the old clip removal, a superficial temporal artery-middle cerebral artery bypass was also planned. The operation entailed a superficial temporal artery-middle cerebral artery bypass, a Sylvian fissure dissection, the old clip removal, and aneurysm clipping. Intraoperatively, the complete aneurysm neck clipping was successfully performed without any complication, and patient postoperative course was uneventful. A wide surgical field should be obtained to be able to manipulate the aneurysm and old clip safely under a microscope. It is also important to temporarily trap the main artery to ensure removal of old clips and to prepare for intraprocedural ischemia using bypass after a precise assessment of hemodynamics before surgery. The patient provided informed consent for the procedure and the publication of the case along with its pertinent imaging, and this report was approved by the institutional review board at our hospital.

Clinical and cardiac CT characteristics of congenital coronary abnormalities occasionally detected in a middle-aged population: A long-term follow-up study

IntroductionCongenital coronary artery anomalies (CCAA) represent one of the most challenging conditions as their clinical presentation may range from sudden cardiac death to a complete subclinical form. The aim of the present study was to evaluate the diagnostic and prognostic role of cardiac CT (CCT) evaluation in patients with CCAA, focusing on anomalies of origin. Material and methodsThe present is a retrospective analysis of a prospective clinical registry including a consecutive cohort of patients who underwent clinically indicated CCT from January 2007 to October 2015 for suspected but unknown coronary artery disease (CAD) and were diagnosed for having a congenital coronary abnormality compared to a control group matched for age, sex and segment stenosis score (SSS). Dedicated analysis of all CCT was performed for the present study and only coronary anomalies of origin were considered and included in the study. Two different composite end-points were identified for the present analysis: major cardiovascular events (MACE) and all-cause of death. ResultsAmong the 81 patients with CCAAs enrolled the most frequent anomaly was left main artery absence, which was identified in 41 individuals (50.6%). Forty-five subjects (55.5%) have an anomalous origin of the coronary artery from a different sinus of Valsalva and 45 subjects had also an anomalous course with the retro-aortic being the most common (32%). Eleven participants (13.6%) displayed also an intramural segment, while 10 (10.3%) had a slit-like ostial morphology. At multivariate analysis CT identification of ARCA, anomalous inter-arterial course and abnormal ostial morphology were significantly associated with MACE even when adjusted for age and SSS, without any differences in all-cause mortality between the two groups (6.2% vs 2.4% p ​= ​0.2478). ConclusionThe result of the present study is that CCT can be successfully used to define the anatomy and features of CAA. It suggested that in middle-aged patients, the identification of high risk characteristics at CT may have a prognostic value in term of cardiovascular events occurrence at follow-up even if the rate of events strictly linked to CCAA is low.

Prevalence and Impact of Concomitant Atrial Fibrillation in Patients Undergoing Percutaneous Coronary Intervention for Acute Myocardial Infarction.

Background: Concomitant atrial fibrillation (AF) is associated with an adverse prognosis in patients with acute myocardial infarction (MI). However, it remains unclear whether this is due to a causal effect of AF or whether AF acts as a surrogate marker for comorbidities in this population. Furthermore, there are limited data on whether coronary artery disease distribution impacts the risk of developing AF. Methods: Consecutive patients admitted with acute MI and treated using percutaneous coronary intervention (PCI) at a single centre were retrospectively identified. Associations between AF and major adverse cardiac and cerebrovascular events (MACCEs) over a median of five years of follow-up were assessed using Cox regression, with adjustment for confounding factors performed using both multivariable modelling and a propensity-score-matched analysis. Results: AF was identified in N = 65/1000 (6.5%) of cases; these patients were significantly older (mean: 73 vs. 65 years, p < 0.001), with lower creatinine clearance (p < 0.001), and were more likely to have a history of cerebrovascular disease (p = 0.011) than those without AF. In addition, patients with AF had a greater propensity for left main stem (p = 0.001) or left circumflex artery (p = 0.004) involvement. Long-term MACCE rates were significantly higher in the AF group than in the non-AF group (50.8% vs. 34.2% at five years), yielding an unadjusted hazard ratio (HR) of 1.86 (95% CI: 1.32-2.64, p < 0.001). However, after adjustment for confounding factors, AF was no longer independently associated with MACCEs, either on multivariable (adjusted HR: 1.25, 95% CI: 0.81-1.92, p = 0.319) or propensity-score-matched (HR: 1.04, 95% CI: 0.59-1.82, p = 0.886) analyses. Conclusions: AF is observed in 6.5% of patients admitted with acute MI, and those with AF are more likely to have significant diseases involving left main or circumflex arteries. Although unadjusted MACCE rates were significantly higher in patients with AF, this effect was not found to remain significant after adjustment for comorbidities. As such, this study provided no evidence to suggest that AF is independently associated with MACCEs.

Distal Bypass Surgery for Critical Ischemia Using a Related Donor Vein

The article presents a case of using the trunk of the great saphenous vein from a living related donor in elective surgery for the main arteries of the lower leg. The possibility of using a vein from a relative in special clinical situations is shown. High risks of repeated interventions aimed at relieving early and late complications of vascular reconstructions remain an urgent problem in angiosurgery. Very often, operations are performed in the presence of extensive necrosis and trophic ulcers (stage IV according to the Fontaine-Pokrovsky classification). The gold standard for choosing a shunt during reconstructive operations on the infrainguinal arteries was and remains an autovenous conduit from the great saphenous vein (C, D type of arterial bed lesion according to TASC II). During repeated reconstructions in the absence of a suitable autovein and with the distal position of the peripheral anastomosis, it is not always possible to use a synthetic prosthesis as a reliable alternative. Unsatisfactory Results of using such materials dictate the need to choose a suitable graft. The problem of using allografts requires further in-depth study. In this regard, the case of using a donor vein as a material for reconstruction is given. It was concluded that it is possible to effectively use allovein from a related donor in a patient after previously performed reconstructive interventions and in the absence of autologous material for bypass surgery.

The pattern of renal artery Doppler indices in patients with sickle cell disease

Aim: To evaluate the pattern of renal artery Doppler indices in patients with sickle cell disease who do not have laboratory evidence of renal impairment. Material and methods: A case-control study was carried out after enrolling 50 patients with sickle cell disease (HbSS phenotype) (sickle cell disease group) and 50 con- trol subjects (control group). All the participants underwent ultrasound and color Doppler examination, and the pulsatility index and resistive index values of the main renal artery, segmental artery, and interlobar artery in both kidneys were recorded and compared. Results: The Doppler measurements of the main renal artery, segmental artery, and interlobar artery were compared between the control and sickle cell disease groups. It was found that both pulsatility index and resistive index were significantly higher in the sickle cell disease group, as compared to the control group, for the main renal artery, segmental artery, and interlobar artery (p &lt;0.0001, p &lt;0.0001, and p &lt;0.0001, respectively). The optimal cut-off points for mean pulsatility index and resistive index, as measured by the Youden index, were found to be &gt;1.08 (72% sensitivity and 88% specificity) and &gt;0.635 (66% sensitivity and 98% specificity), respectively. Conclusions: Resistive index and pulsatility index values in renal Doppler sonography can serve as early radiologic predictors of renal vascular changes in sickle cell disease patients who do not have laboratory evidence of renal impairment.

More potential uses of specific perforator flaps in the calf – A cadaveric study on the subdermal vascular structure of the lower leg

BackgroundThe perforator flap has garnered significant interest since its inception due to its advantage of not needing a vascular network at the deep fascial level. Perforator flaps are commonly utilized in different flap transplant surgeries, and the thigh flap is presently the most widely used perforator flap. Is it possible for the calf to replace the thigh as a more suitable site for harvesting materials? Currently, there is a lack of relevant anatomical research. This study aims to address this question from an anatomical and imaging perspective. MethodsThis study used cadavers to observe the branches and courses of perforators on the calf and the distribution of skin branches using microdissection techniques, digital X-ray photography, and micro-computed tomography techniques. ResultsThe perforators had three main branches: the vertical cutaneous branch, the oblique cutaneous branch, and the superficial fascial branch. The superficial fascial branch traveled in the superficial fascia and connected with the nearby perforators. The vertical and oblique cutaneous branches entered the subdermal layer and connected with each other to create the subdermal vascular network. ConclusionsWe observed an intact calf cutaneous branch chain between the cutaneous nerve and the perforator of the infrapopliteal main artery at the superficial vein site. Utilizing this anatomical structure, the calfskin branch has the potential to serve as a substitute for thigh skin flap transplantation and may be applied to perforator flap transplantation in more locations.

Arterial highways of the foot of the American raccoon (Procyon lotor)

The vascular system is one of the integrating systems of the human and animal body. The course and branching of the vessels of various areas of the body follows general patterns. However, the variability of the vascular bed is quite high even within a single species of animal. The lack of data on both the topography and the peculiarities of arterial branching makes it difficult to carry out diagnostic and therapeutic manipulations. In addition, the data obtained during the study significantly enrich the available information on the comparative anatomy of the vascular bed. The purpose of the study is to study the main arterial arteries of the American raccoon foot area, to give them a morphometric characteristic. The research was carried out on 4 corpses of an American raccoon, delivered to the Department of Animal Anatomy of the St. Petersburg State University of Veterinary Medicine from veterinary clinics. Classical methods were chosen as research methods: fine anatomical dissection, morphometry, photographing and vasorentgenography. During the study, it was found that two arterial highways are distinguished on the foot of the American raccoon. The dorsal trunk is represented by the dorsal artery of the foot, the plantar trunk is represented by the middle plantar artery. The dorsal artery of the foot passes into the arc artery – the first anastomosis that unites the vessels of the two highways. The middle plantar artery gives rise to the second and third plantar metatarsal arteries and participates in the formation of a deep plantar arch, which is the second major anastomosis of the foot area. Axial and non-axial finger arteries also form collateral blood flow. Analyzing the obtained morphometric data of arterial highways, it follows to conclude that the plantar surface highways have the largest diameter. Thus, the diameter of the middle plantar artery is 1.72 times higher than the same parameter of the dorsal artery of the foot. The largest total diameter is characteristic of the arteries located in the metatarsal region, the smallest in the area of the metatarsal.

A novel, proof-of-concept radiofrequency renal denervation strategy to improve procedural efficiency: 12-month results from the SPYRAL DYSTAL pilot study

BackgroundCatheter-based renal sympathetic denervation (RDN) reduced blood pressure (BP) in multiple randomized sham-controlled trials of patients with uncontrolled hypertension (HTN). We tested proof-of-concept for a more selective treatment strategy, exclusively targeting these areas to improve the efficiency of the procedure. MethodsThe SPYRAL DYSTAL Pilot study was designed to mirror the SPYRAL HTN-OFF MED Pivotal study, enabling comparison with a propensity score adjusted active-control group. Patients were antihypertensive medication-free for one month before undergoing BP assessment. Those with office BP of 150–180/>90 mmHg and with an ambulatory systolic BP of 140–170 mmHg were selected to undergo open label treatment, delivering energy only to the distal main renal arteries and first order branches. Patients from DYSTAL were compared with patients who underwent maximized RF RDN treatment in the prior randomized OFF MED trial at 3 months. After 3 months, patients resumed antihypertensive medications as indicated. Safety and efficacy outcomes were assessed post hoc through 12 months. ResultsThe SPYRAL DYSTAL Pilot study treated 56 HTN patients. Baseline office systolic BP (OSBP) and 24-h ambulatory systolic BP (ASBP) were similar between DYSTAL and OFF MED patient groups. The number of ablations (32.3 ± 8.0 vs 46.6 ± 15.3, p < 0.001), procedure time (67 ± 21 min vs 99 ± 36 min; p < 0.001), and contrast volume (173 ± 77 cc vs 208 ± 96 cc; p = 0.014) were significantly lower with the simplified treatment strategy. OSBP and ASBP changes compared with baseline were −9.0 and −1.4 mmHg at 3 months, −20.3 and −13.9 mmHg at 6 months, and −20.3 and −16.6 mmHg at 12 months, respectively. During the medication up-titration phase, BP reductions among DYSTAL patients were similar to reductions observed in OFF MED through 12 months, with comparable number of drugs (1.4 and 1.5 medications, respectively (P=NS)). Two adverse events related to guidewire placement were reported. ConclusionIn this pilot study, focusing ablation treatment on the distal main and proximal branch renal arteries was performed, resulting in fewer RF lesions, and reduced contrast volume and procedure time. Whether BP reductions are similar between a selective vs. maximized RDN approach requires further prospective study.

Renal Artery Coil Embolization as an Endovascular Approach for Establishing a Rabbit Model of Chronic Kidney Disease

PurposeTo investigate the safety and feasibility of renal artery coil embolization for establishing chronic kidney disease (CKD) in rabbits. Materials and MethodsTen male adult New Zealand rabbits underwent renal artery coil embolization. Initially, the main renal artery on 1 side was completely embolized, followed by embolization of approximately two-thirds of the primary branches of the contralateral renal artery 1 week later. Four rabbits were randomly chosen for killing at 4 weeks after embolization, whereas the remaining 6 were killed at 8 weeks after embolization. The assessment encompassed the animals’ general condition, angiography, biochemical parameters, inflammatory markers, and histopathological examination of the kidneys and hearts. ResultsFour weeks after embolization, serum creatinine level showed a substantial increase (2.4 mg/dL [SD ± 0.6]; P = .009 vs baseline), with a subsequent 4.12-fold elevation at 8 weeks after embolization (4.9 mg/dL [SD ± 1.4]; P < .001 vs baseline). Additionally, considerable increases in serum blood urea nitrogen, calcium, and potassium ions were observed at 8 weeks after embolization (58.3 mg/dL [SD ± 19.0]; P < .001 vs baseline; 23.1 mg/dL [SD ± 4.4]; P < .001 vs baseline; and 6.3 mEq/L [SD ± 0.7]; P < .001 vs baseline, respectively). The completely embolized kidney exhibited notable atrophy, severe fibrosis, and cortical calcification, whereas the contralateral partially embolized kidney displayed compensatory hypertrophy, along with glomerulosclerosis, tubular dilation, tubular casts, and interstitial fibrosis. ConclusionsRenal artery coil embolization proved to be effective and safe for establishing a CKD model in rabbits.

Сapabilities of Dynamic Infrared Thermography for Planning and Monitoring of Perforating Flaps

Background. Free perforating flaps are the most optimal for reconstruction of both upper and lower extremities. However, along with the obvious advantages of these flaps, there are also a number of difficulties associated with their more complex vascular anatomy and, as a consequence, more time-consuming dissection. This determines the need for a more thorough preoperative planning, including the mapping of perforating vessels and development of flap design. At the same time, the problems with intraoperative assessment of perfusion of perforating flaps and their monitoring in the postoperative period have not been solved. For these purposes, several instrumental methods of examination such as MRI and CT angiography, Doppler sonography, ICG and dynamic infrared thermography are used.&#x0D; Aim of the study — to evaluate the capabilities of dynamic infrared thermography (DIT) for mapping of perforating vessels when planning the design of perforating flaps, as well as for assessing their intra- and postoperative perfusion.&#x0D; Methods. We have analyzed the results of using DIT along with CT-angiography and Doppler sonography for preliminary mapping of perforating vessels in the design of 18 perforating flaps (ALT flap — 10, SCIP flap — 8) transplanted in 15 patients from 01.01.2022 to 30.07.2022. DIT was also used in all cases for intraoperative instrumental confirmation of flap perfusion and for its monitoring in the postoperative period.&#x0D; Results. A total of 39 perforating vessels were detected by CT angiography at the point of origin from the main arteries. DIT was used to detect the distal portions of 37 perforating vessels in 15 patients at the marking of 18 flaps. On average, 2.5 per ALT flap and 1.4 per SCIP flap. Thermographic examination time was approximately 10 minutes. Localization of all perforating vessels detected by DIT were first confirmed by Doppler sonography and then visualized intraoperatively during flap dissection. Intraoperatively, perfusion of all transplanted flaps was clearly confirmed by DIT. In the postoperative period, perfusion problems were clinically detected in 3 (16%) flaps and confirmed by DIT: venous stasis — 2 cases, arterial insufficiency — 1 case. In two patients (13%) with a body mass index of more than 35 (corresponding to class 2–3 obesity), the location of perforating vessels could not be determined by thermography and Doppler sonography. Also, in these patients DIT was ineffective for confirmation of flap perfusion intraoperatively and in the postoperative period.&#x0D; Conclusion. This study confirms that CT angiography, Doppler sonography and infrared thermography are complementary methods that allow to detect and visualize perforating arteries from their origin from a main artery to the site of their passage through the deep fascia (CT-angiography), as well as to determine their more accurate projection on the skin surface (DIT and Doppler sonography). DIT is also an auxiliary method for flap monitoring in the intraoperative and postoperative periods, which allows to engage nursing staff in postoperative monitoring.

AUTOTRANSPLANTATION WITH EXTRACORPORAL RECONSTRUCTION OF RENAL VESSELS: A CLINICAL CASE OF “THE NUTCRACKER SYNDROME” AND LEFT RENAL ARTERIES HYPOPLASIA COMBINATION

Ex vivo kidney autotransplantation with renal artery reconstruction is an effective method of surgical correction of vascular abnormalities (fibromuscular dysplasia, hypoplasia, and renal artery aneurysms) showing good long-term results. The combination of renal artery abnormalities with aorto-mesenteric compression syndrome (“the nutcracker” syndrome) is extremely rare and complicates the diagnosis making greatly. Renal artery hypoplasia is an abnormality that is rarely diagnosed and may not manifest clinically in the absence of contralateral kidney pathology as well as its vascular structures. Renal hypoplasia may be caused by mutations in the kidney development genes (HNF1B, PAX2, PBX1) and/or several environmental factors such as intrauterine growth retardation, maternal diseases (diabetes, hypertension), medication taken by the mother (renin-angiotensin system inhibitors or nonsteroidal anti-inflammatory drugs) and intoxication (smoking and alcohol). Premature delivery (before the 36th week) is also a risk factor due to incomplete nephrogenesis. Renal arteries hypoplasia is associated with fibromuscular dysplasia in most cases. The disease is characterized by non-inflammatory non-uniform focal hyperplasia of the renal artery wall with damage to small and medium arteries. Simultaneous damage to two or more vascular segments is detected in 25% of patients.&#x0D; A clinical case of successful treatment of “the nutcracker” syndrome (annular renal vein) combined with hypoplasia of the left main and accessory renal arteries associated with fibromuscular dysplasia is described. A 27-year-old female was admitted to the Department of Vascular Surgery of Municipal Noncommercial Enterprise of the Lviv Regional Council “Lviv Regional Clinical Hospital” on October 4, 2021, with complaints of pain in the left lumbar region and the left half of the abdomen, hematuria, proteinuria, a persistent increase in blood pressure. Ultrasound of the renal veins: the left renal vein in the aorto-mesenteric segment was not visualized, the posterior portion of the left renal vein was determined. Peak systolic velocity was up to 230 cm/s at the point of confluence with the inferior vena cava and 28 cm/s more distally. The vein was up to 12.0 mm in the renal hilum and up to 11.0 mm in the middle third. MSCT of the abdominal cavity, retroperitoneal space and pelvic organs: CT signs of pyelonephritis of the left kidney. Hypoplasia of the left kidney. Reactive para-aortic lymphadenopathy on the left. Hypoplastic left renal artery (3,8 mm) and presense of accessory ones, annular left renal vein. Angiomyolipoma of the right kidney (2,6 cm). Varicose veins of the small pelvis on the left. The patient underwent surgical treatment, namely ex vivo autovenous prosthetic repair of the left renal artery with autotransplantation of the left kidney. The course of the postoperative period was without complications, the reconstruction was functioning. Ultrasound of the renal vessels (1 week after the surgery): the blood flow was located in the renal hilum in the course of Doppler sonography of intrarenal branches. Venous outflow was unobstructed. Corticomedullary differentiation was marked satisfactorily.&#x0D; The study presented by us demonstrates the effectiveness of kidney autotransplantation for the correction of renal vascular abnormalities.&#x0D; Though of a solitary nature, the combination of renal vessels abnormalities complicates significantly the course of the disease and the possibilities of this pathology diagnostics.

Ultrasound Duplex Scanning of Vessels in the Diagnosis of Limb Length Discrepancy in Pediatric Patients with Congenital Vascular Malformations

Ultrasound Duplex Scanning of Vessels in the Diagnosis of Limb Length Discrepancy in Pediatric Patients with Congenital Vascular Malformations

Paclitaxel-induced acute myocardial infarction: a case report and literature review

BackgroundPaclitaxel is a chemotherapeutic agent commonly used for ovarian, lung, breast carcinoma, and Kaposi’s sarcoma. Its common side effects include hypersensitivity reaction, bone marrow suppression, and peripheral neuropathy. However, a rare and life-threatening side effect is paclitaxel-induced myocardial infarction.Case presentationA 71-year-old man with type 2 diabetes mellitus, hypertension, heavy smoking history, previous coronary artery disease with percutaneous coronary intervention (PCI) in left anterior descending artery (LAD), and non-small lung cancer presented with non-ST elevation myocardial infarction during infusion of paclitaxel infusion. Coronary angiogram showed de novo three vessel disease with 70% stenosis in ostial to distal left main artery (LM) and 80% in-stent re-stenosis in proximal to mid left anterior descending artery.ConclusionsPhysicians should be keeping this in mind when dealing with patients on paclitaxel, especially if they have previous risk factors for coronary artery disease.

Two stents’ dislodgement in the left main coronary artery: a case report

BackgroundStent dislodgement is a life-threatening complication that can result in coronary artery embolization, stent thrombosis, acute myocardial infarction, and even death. Severely angulated, heavily calcified, and previously stented coronary arteries are associated risk factors. With the development of different lesion preparation techniques and the drug eluting stent era, the reported incidence of stent dislodgement has decreased to < 1% in the last few years.Case presentationWe report a case of a 64-year-old Moroccan man complicated during percutaneous intervention in the left main artery by the loss of two stents. This complication was successfully managed by passing the stent’s balloon into the stent and then fully expanding it. In our case, the device’s characteristics were involved and could play a role in such complications, but it is still not well understood.ConclusionsThe main treatment option is stent retrieval with different available techniques. If retrieval of the stent is impossible, crushing it against the blood vessel wall could be considered.