Marginal Artery Research Articles

Stent Balloon Entrapment At Left Main Stem; A Low Resource Setting Approach

A 60 year old, male patient underwent an elective percutaneous coronary angioplasty and stenting of mid circumflex coronary artery lesion at the origin of second obtuse marginal artery. The bare metal stent deployed in a partially inflated state due to a tight calcific area with subsequent stent balloon entrapment inside the stent by the calcified plaque. It was entrapped entering the left main stem in the partially withdrawn state. With impending surgical retrieval progressive supra burst pressure dilatation attempted to dilate the entrapped segment, final supra burst pressure with successful retrieval. This case highlight the steps to attempt in a low resource setting and final supra burst dilatation of a same stent balloon to overcome an entrapped vessel segment before surgical retrieval options. DOI: http://dx.doi.org/10.3126/njh.v12i1.12342 Nepalese Heart Journal Vol.12(1) 2015: 31-36

A rare marginal tentorial artery to ophthalmic artery anastomosis

We report a patient with a marginal tentorial artery to ophthalmic artery anastomosis. A middle-aged man presented with subarachnoid hemorrhage and underwent angiography, where selective microcatheter injection of the meningohypophyseal trunk and marginal tentorial artery revealed a collateral to the distal ophthalmic artery. The radiological findings, embryology behind ophthalmic artery anastomoses and the neurosurgical and neurovascular relevance are discussed.

Evaluation of the intestinal blood flow near the rectosigmoid junction using the indocyanine green fluorescence method in a colorectal cancer surgery.

It has been reported that some patients do not have an anastomosis of a marginal artery near the rectosigmoid junction, but the frequency of this condition and its clinical significance so far remain unclear. The aim of this study was to evaluate the blood flow at the marginal artery near the rectosigmoid junction. From January 2013 to January 2014, we enrolled consecutive patients with a preoperative diagnosis of left-sided colon cancer or rectal cancer who underwent surgery with lymph node dissection. During the operation, the blood flow through the point of origin of the last sigmoid arterial branch, originating from the inferior mesenteric artery, was interrupted, and the rectosigmoid junction was supplied by only the marginal artery. We injected indocyanine green intravenously and observed the blood flow using a near-infrared camera system. A total of 119 consecutive patients were enrolled in this study. Sixty-eight patients (57.1 %) had a good anastomosis of the marginal artery near the rectosigmoid junction (type A). In 27 patients (22.7 %), a fluorescence border was recognized, but the fluorescence border diminished within 60 s (Type B). In 18 patients (15.1 %), delayed fluorescence was recognized over 60 s (type C), and 6 patients (5.0 %) had no fluorescence at all (type D). A mean length of 14.8 cm was found from the peritoneal reflection to fluorescence border of blood flow. This study proves that cases without the anastomosis of the marginal artery of the rectosigmoid junction truly exist, using studies in living humans (UMIN000011186).

How to Treat a Case of Post Coronary Artery Bypass Grafting Presenting with Myocardial Infarction?

A 78 year old diabetic male who was a case of chronic stable angina had undergone coronary arterial angiogram 4 months back. He was diagnosed as a case of triple vessel disease and had undergone CABG about 3 months back. 1 arterial [Left internal mammary artery (LIMA) to left anterior descending (LAD)] and 3 venous grafts [to diagonal, obtuse marginal (OM) and right coronary artery (RCA)] were used for CABG.

Concomitant grafting of both postbifurcation internal thoracic artery branches.

We aimed to assess the clinical outcome and graft patency after concomitant grafting of both postbifurcation internal thoracic artery (ITA) branches. Between 2007 and 2013, 17 patients (14 men; mean [SD] age, 60 [9.3] years) underwent skeletonized bifurcated ITA grafting. Respective targets were restricted to non-left anterior descending (LAD) area. In all patients, a complementary standard ITA was used to graft the LAD artery. Graft patency was assessed by standard coronary angiography or serial multidetector computed tomography. Of the bifurcated conduits, 94% were right ITA. Respective right ITA target sets were first and second obtuse marginal arteries (M1-M2) (n = 12), ramus-M1 (n = 2), and distal right coronary artery-posterior descending artery (n = 2). Right ITAs were mobilized retroaortic (via the transverse sinus) in 14 patients (82%) (to circumflex artery targets). Circumflex artery targets comprised 88.2% of all anastomoses (30/34). There were no early mortalities, myocardial infarctions, or hypoperfusion syndromes. During median follow-up of 44 months (range, 3-63), there was no late mortality. Overall reintervention rate was 11.7%, and bifurcated ITA-related reintervention rate was 5.8%. At 5 years, freedom from major adverse cardiac or cerebrovascular event related to bifurcated ITA respective territory was 87% (Kaplan-Meier). Coronary imaging was achieved in 76% of the patients (elective multidetector computed tomography, n = 9; symptoms-directed coronary catheterization, n = 4). Bifurcation branch patency rate was 88.4% (23/26) at a median of 3.5 years. Grafting both postbifurcation ITA branches is technically feasible and may be selectively considered. Current observations are valid for skeletonized conduits and limited to non-LAD targets. These preliminary findings should be corroborated by larger data sets.

Exposures of lateral and inferior cardiac surface for coronary anastomosis during minimally invasive coronary artery bypass grafting.

Exposure of the lateral and inferior surface of the heart during off-pump coronary artery bypass grafting is associated with some degree of cardiac instability during recovery with completion of grafting. Exposure of lateral and posterior surfaces by currently available equipment is difficult in minimally invasive coronary artery bypass grafting (MICABG) owing to limited exposure. We describe an effective variation of often-used technique of pericardial stitch in exposure of cardiac surfaces during MICABG. This technique was used in 24 patients undergoing multivessel MICABG. Deep pericardial sutures were used to manipulate the exposure of cardiac surfaces. Left anterior descending artery was grafted in all 24 cases. Obtuse marginal artery was grafted in 20 cases and posterior descending artery in 12 cases. Average grafts were 2.3 per patient. There was no conversion to median sternotomy. Use of deep pericardial suture is simple technique for exposure of lateral and inferior surface during multivessel MICABG. This offers adequate exposure and operating space for easy maneuverability.

Regional differences of testicular artery blood flow in post pubertal and pre-pubertal dogs.

BackgroundMeasurement of testicular artery blood flow is used in several species to evaluate reproductive function and testicular and scrotal pathology. In dogs there are inconsistent reports about normal flow in post-pubertal dogs and no information concerning pre-pubertal dogs. The aim of this study was to describe regional differences in testicular artery blood flow in clinically normal post-pubertal and pre-pubertal dogs with no history of reproductive tract disease.ResultsThe post-pubertal dogs produced normal ejaculates throughout the study. In all dogs the three different regions of the artery were imaged and monophasic flow with an obvious systolic peak and flow throughout diastole was observed on every occasion. The highest peak systolic velocity (PSV) and end diastolic velocity (EDV) were measured within the distal supra-testicular artery and marginal artery whilst the lowest PSV and EDV were measured within the intra-testicular arteries. Flow measurements were not different between left and right testes and were consistent between dogs on different examination days. Calculated resistance index (RI) and pulsatility index (PI) were lowest in the intra-testicular arteries.The pre-pubertal dogs had significantly smaller testes than the post-pubertal dogs (p < 0.05) and were unable to ejaculate during the study. The three different artery regions were imaged at every examination time point, and flow profiles had a similar appearance to those of the post-pubertal dogs. PSV, EDV, RI and PI showed a similar trend to the post-pubertal dogs in that values were lowest in the intra-testicular arteries. Notably, values of PSV, EDV, RI and PI were significantly lower (p < 0.05) in pre-pubertal dogs compared with post-pubertal dogs.ConclusionsThis study demonstrated important regional and pubertal differences in testicular artery blood flow of dogs, and form the basis for establishing baseline reference values that may be employed for the purposes of clinical diagnosis.

An Observational Comparative Study of Cardiac Index Estimated By FloTrac and Intermittent Thermo Dilution in Off-Pump Coronary Artery Bypass Grafting

Objective: The purpose of this study was to determine the correlation between cardiac index (CI) measurements made using intermittent thermodilution (ITD) technique by pulmonary artery catheter (PAC) and arterial pulse-contour analysis by FloTrac. Design: Prospective observational study. Setting: Cardiac surgery unit in a 350 bedded tertiary care hospital in India. Participants: 31 adult patients undergoing elective off-pump coronary artery bypass grafting (OPCABG) Interventions: CI measurements performed by the two different methods at six time points during the surgery (before skin incision, during grafting of left anterior descending artery, obtuse marginal artery and right coronary/ posterior descending artery, after protamine administration and after shifting the patient to recovery room). Measurements and results: The techniques a weak correlation at all six time points during the OPCABG. The mean bias of 0.85 L/min/m2 and precision of 0.55 was found in the study population. The percentage error calculated using Critchley s criteria was found to be 46%. Conclusion: CI measurements obtained using FloTrac showed a limited correlation with those acquired by ITD technique at different stages of OPCABG. Further studies are required in other patient populations and clinical situations.

Saphenous Vein Graft Wrapping by Nitinol Mesh: A Word of Caution.

Saphenous vein conduits are still used in a large proportion of coronary artery bypass graft (CABG) operations. A recently commercialized nitinol mesh seems to improve venous graft patency. The aim of this study was to control nitinol mesh vein graft patency in a series of isolated CABG patients by computed tomographic (CT) scan. In 25 patients (mean age: 61.0 ± 9.65 years), operated for isolated CABG, the eSVS nitinol mesh (Kips Bay Medical Inc., Minneapolis, Minnesota, United States) was used to wrap one vein graft in each patient. Nitinol mesh vein graft was used to revascularize the right coronary (4 patients; 16%), the posterior descending (18 patients; 72%), and the obtuse marginal (3 patients; 12%) arteries. CT scans were performed at 1, 6, and 12 months postoperatively. The procedure was uneventful in all patients. CT controls showed an overall patency rate of 86.9, 42.7, and 34.1% at 1, 6, and 12 months, respectively. The 4 mm mesh had a significantly higher patency rate at 12 months (83.33%) than the 3.5 mm one which showed quite unsatisfactory results (20%) (p = 0.02). Patients with graft occlusion underwent stress testing which was mildly positive in two cases. One of them underwent a percutaneous revascularization. Despite promising early results, use of nitinol mesh for saphenous veins was disappointing in our experience. Further refinements are probably needed.

Sequential Monte Carlo tracking of the marginal artery by multiple cue fusion and random forest regression.

Given the potential importance of marginal artery localization in automated registration in computed tomography colonography (CTC), we have devised a semi-automated method of marginal vessel detection employing sequential Monte Carlo tracking (also known as particle filtering tracking) by multiple cue fusion based on intensity, vesselness, organ detection, and minimum spanning tree information for poorly enhanced vessel segments. We then employed a random forest algorithm for intelligent cue fusion and decision making which achieved high sensitivity and robustness. After applying a vessel pruning procedure to the tracking results, we achieved statistically significantly improved precision compared to a baseline Hessian detection method (2.7% versus 75.2%, p<0.001). This method also showed statistically significantly improved recall rate compared to a 2-cue baseline method using fewer vessel cues (30.7% versus 67.7%, p<0.001). These results demonstrate that marginal artery localization on CTC is feasible by combining a discriminative classifier (i.e., random forest) with a sequential Monte Carlo tracking mechanism. In so doing, we present the effective application of an anatomical probability map to vessel pruning as well as a supplementary spatial coordinate system for colonic segmentation and registration when this task has been confounded by colon lumen collapse.

Multi-embolic ST-elevation Myocardial Infarction Secondary to Aortic Valve Endocarditis

We present the case of a 42 year-old woman admitted to hospital with ST-elevation myocardial infarction involving two separate coronary territories. Angiography revealed multi-embolic occlusions of her left anterior descending (LAD) and first obtuse marginal (OM1) coronary arteries. Transoesophageal echocardiogram (TOE) showed a lesion attached to the left cusp of the aortic valve and she was treated for infective endocarditis. We discuss the management issues raised from this unique patient, including reperfusion strategies in endocarditis-associated myocardial infarction.

Intraoperative Coronary Angiography: A Novel Method

A 70-year-old man underwent elective off-pump coronary artery bypass surgery in a hybrid theater, with grafting of right internal mammary artery (IMA) to left anterior descending artery, left IMA to obtuse marginal artery (OM), and radial T-graft off left IMA to posterior descending artery (PDA) as a side-to-side anastomosis. A flexible catheter was fashioned from a silicone elastomer vascular loop (1.1 × 1.7 mm × 30.5 cm long) connected to an 18-gauge catheter and inserted into the end of the radial artery graft distal to the PDA anastomosis and secured with a silk suture.

Angiographic profile of coronary arteries in Keralite population

Abstract Background and aims: The incidence of Coronary Artery Disease (CAD) has reached alanning proportions in India. The pathological hall mark of CAD is myocardial ischemia resulting from the atherosclerotic narrowing of coronary arteries. In this era of advanced interventions and cardiac surgery, a thorough knowledge of normal and variant anatomy of coronary arteries is of prime significance and of great use both to the clinicians and anatomists. Materials and methods: One hundred coronary angiograms of patients free of disease were studied in detail in different profiles. The data obtained was quantified according to their frequencies. The relation between the length of left main coronary artery and coronary artery dominance was statistically analyzed using the 'Chi Square test for Trend'. Results: This study highlighted some interesting findings such as the origin of Sino- atrial nodal artery from the second segment of right coronary artery in 3% of cases, double right marginal artery in 4% cases. Other variations such as Mouchet's posterior recurrent interventricular artery, origin of circumflex artery from the right coronary artery and abnormal communication between the terminal parts of right coronary artery and circumflex artery were each noticed in 1 % of cases. Conclusions: Coronary arteries and their branches are prone to variations in their course and morphology. Prior knowledge about this is important for the interpretation of coronary angiograms and surgical myocardial revascularization. The present work on normal and variant pattern of coronary arteries will help in gathering momentum to the already advancing research work in this field.

Clinical and Computed Tomographic Evaluation of Safety and Efficacy of Facet Screw Fixation in the Subaxial Cervical Spine

A retrospective study comparing screw positioning and associated complications between 2 different facet screw placement methods. To review the anatomic location, clinical safety, efficacy, and limitations of 2 facet screw placement techniques. Facet screw fixation in the subaxial cervical spine penetrates 4 cortical layers and affords better stability than lateral mass screws. Takayasu and colleagues recommended placing screws in the sagittal plane. We modified the trajectory to direct the screws laterally from the sagittal plane to place the root at less risk and improve fixation by increasing the excursion of the screws into bone. No clinical reports exist describing the quadricortical facet screw placed in a lateral direction. A total of 95 screws were used in 18 consecutive patients who underwent posterior cervical stabilization for various spinal disorders: 34 screws used sagittal plane screw placement and 61 used our technique. Screw-related complications were reviewed. Screw trajectories and screw tip positions related to the ventral cortical margin and vertebral artery were evaluated using postoperative 3-dimensional computed tomograms taken within 6 months after surgery. Instrumentation failures were evaluated from postoperative 3-dimensional computed tomograms taken 2 years after surgery. There was 1 complication, nerve root irritation due to screw malposition. Postoperative computed tomographic images revealed that drilling was 30 degrees lateral from the sagittal plane in our method. Fourth cortex penetration failed in 29% of the screws placed in the sagittal plane and in 5% by our method. Screw loosening was significantly increased using screws placed in the sagittal plane (24% vs. 2%). Quadricortical facet screw placement aimed at the juncture between the transverse process and the facet is practicable. Screw loosening was significantly reduced using this lateral screw direction. One of the disadvantages of this technique is that extensive cranial exposure is required to align the instruments in the proper sagittal trajectory.

Acute vessel closure salvaged by use of the retrograde approach

Acute vessel closure is a percutaneous coronary artery complication with potential catastrophic consequences. In this article we report a case where the retrograde approach was used to salvage an acute vessel occlusion during a first obtuse marginal percutaneous coronary artery.

Doppler velocimetric parameters of the testicular artery in healthy dogs

This study aimed to examine the Doppler velocimetric pattern of the testicular artery of small dogs in two different locations. Testes of 21 dogs were evaluated by two-dimensional ultrasonography to measure testicular volume and by Doppler ultrasonography to record the velocimetric patterns of the testicular artery in the spermatic cord and marginal location. The volume of left testes (4.70 ± 1.22 cm3) was significantly higher than the volume of the right testes (4.45 ± 1.17 cm3). Peak systolic velocity (PSV) of the left spermatic cord was significantly higher than the right side. End-diastolic velocity was significantly higher in the marginal artery than the spermatic cord on both sides; however, resistance and pulsatility indexes were significantly lower in the marginal artery. Results demonstrate the viability of Doppler ultrasonography for characterization of the testicular artery in small dogs and Doppler velocimetric values vary according to the location of measurement along the artery.

Implantation of a bioabsorbable vascular scaffold into a coronary vein graft: a two-week angiography follow-up

An 83-year-old patient with a history of coronary artery bypass grafting (CABG) performed 13 years ago was admitted due to unstable angina for diagnostic catheterisation. His medical history consisted of CABG with left internal mammary artery to left anterior descending artery and vein grafts to obtuse margin artery (OM), diagonal artery (D1) and right coronary artery (RCA). Following that, the patient had multiple percutaneous coronary interventions (PCI) in vein grafts: bare metal stent implantation into the Ao-OM (three years ago), two POBA of Ao-OM (one and two years ago), two drug eluting stents (DES) into Ao-OM (six and 12 months ago), and DES into Ao-D1 (two years ago). Coronary angio graphy revealed significant stenosis in distal segment of Ao-RCA and in stent restenosis in DES implanted to Ao-OM. The lesion in Ao-RCA (% diameter stenosis = 82%, minimal diameter = 0.43 mm, lesion length = 5 mm) was treated with an everolimus-eluting bioabsorbable vascular scaffold (BVS) (Absorb, 2.5 × 15 mm) achieving good post procedural angiographic results (% diameter stenosis = 13%, minimal diameter = 2.5 mm) (Fig. 1). Two weeks after the procedure, the patient was hospitalised again for an elective PCI of Ao-OM in stent restenosis. The bypass angiography revealed patent Ao-RCA with sustained good angiographic results at the site of BVS implantation. Drug eluting BVS implantation may be a new option for the treatment of stenotic coronary vein grafts. However, a prospective study is needed to validate the safety of such a BVS application.

Excesso de fator VIII em doente com síndroma coronária aguda

Factor VIII is a clotting factor that plays a crucial role in the coagulation cascade. Above‐normal levels are found in 11% of the general adult population. Various studies have established a causal association between elevated factor VIII and venous thrombosis; some studies also suggest a relation with arterial thrombosis, particularly myocardial infarction and stroke.We report the case of a 36‐year‐old man with obesity, smoking and dyslipidemia as cardiovascular risk factors and a history of acute myocardial infarction at age 26. He was admitted to the coronary care unit with a diagnosis of ST‐elevation myocardial infarction. Coronary angiography showed a thrombus in the distal segment of the first obtuse marginal artery, which was causing the obstruction. The thrombus was aspirated but there was no reflow. A coagulation study revealed elevated factor VIII; other parameters were normal.Even though this patient presented several cardiovascular risk factors, we highlight the need for more studies on the effect of elevated factor VIII on thrombus formation leading to acute coronary syndrome. Another important question is the use of oral anticoagulation in these patients as an integral part of the management of acute coronary syndrome.

An Unusual Case of Cardiogenic Shock: Common Cause From Uncommon Etiology

Mechanical complications of an acute coronary syndrome can lead to hemodynamic instability out of proportion to the degree of left ventricular dysfunction. We present the case of a patient with cardiogenic shock secondary to severe mitral regurgitation in the setting of an acutely occluded obtuse marginal artery. Echocardiography and pathologic findings revealed an uncommon cause of anterolateral papillary muscle rupture. Using the unique features of this case, we present a clinical self-assessment exercise highlighting the challenges involved in the management of this type of patient.

Direct Injury to Right Coronary Artery in Patients Undergoing Tricuspid Annuloplasty

Direct injury to the right coronary artery as a result of reparative operation on the tricuspid valve is a rare, probably underdiagnosed, but serious complication, which often involves dramatic clinical consequences. So far, only five cases have been described in the literature. We describe our single-center experience of this complication, and review and analyze relevant clinical and anatomic considerations related to this entity. Cases previously reported in the literature were also reviewed. We describe four cases of direct injury to the right coronary artery in patients undergoing tricuspid annuloplasty (DeVega annuloplasty, 3; ring annuloplasty, 1) in our institution since 2005. All patients had right ventricular dilatation and severely dilated tricuspid annulus. Right coronary artery occlusion always occurred between the right marginal artery and the crux of the heart. Patients presented with hemodynamic or electrical instability. Coronary flow could be restored in 2 patients (percutaneously 1; surgically 1), both of whom finally survived, while it was not technically possible in the other 2 (1 died). Occlusion of the right coronary artery in patients undergoing tricuspid annuloplasty is a rare complication that may occur if great annulus dilatation is present, thus altering both normal annular geometry and the relationship between the right coronary artery and the tricuspid annulus, particularly when DeVega annuloplasty is performed. Such an entity should be considered in the immediate postoperative period in an unstable patient, especially when complementary tests support this diagnosis. Prompt recognition and treatment can positively affect the patient's outcome, most often by means of an emergency revascularization strategy.