Portion Of Artery Research Articles

PHACTR1 is associated with disease progression in Chinese Moyamoya disease.

Moyamoya disease (MMD) is a progressive stenosis at the terminal portion of internal carotid artery and frequently occurs in East Asian countries. The etiology of MMD is still largely unknown. We performed a case-control design with whole-exome sequencing analysis on 31 sporadic MMD patients and 10 normal controls with matched age and gender. Patients clinically diagnosed with MMD was determined by digital subtraction angiography (DSA). Twelve predisposing mutations on seven genes associated with the sporadic MMD patients of Chinese ancestry (CCER2, HLA-DRB1, NSD-1, PDGFRB, PHACTR1, POGLUT1, and RNF213) were identified, of which eight single nucleotide variants (SNVs) were deleterious with CADD PHRED scaled score > 15. Sanger sequencing of nine cases with disease progression and 22 stable MMD cases validated that SNV (c.13185159G>T, p.V265L) on PHACTR1 was highly associated with the disease progression of MMD. Finally, we knocked down the expression of PHACTR1 by transfection with siRNA and measured the cell survival of human coronary artery endothelial cell (HCAEC) cells. PHACTR1 silence reduced the cell survival of HCAEC cells under serum starvation cultural condition. Together, these data identify novel predisposing mutations associated with MMD and reveal a requirement for PHACTR1 in mediating cell survival of endothelial cells.

Abstract TMP112: Increased Large Vessel Diameter is Associated With Increased Cerebral Metabolic Stress in Children With Sickle Cell Anemia

Background: Children with sickle cell anemia (SCA) invoke compensatory mechanisms to meet cerebral oxygen demand in the setting of low oxygen carrying capacity. Whereas cerebral blood flow (CBF) is largely regulated by cerebral arterioles as one compensatory mechanism, we sought to determine if the cross-sectional area of the large in-flow arteries was also increased. Methods: Children and young adults with SCA underwent 3 Tesla magnetic resonance angiography (MRA) and imaging (MRI) with pseudocontinuous arterial spin labeling (pCASL) and asymmetric spin echo sequence to measure CBF and oxygen extraction fraction (OEF) respectively. Using the double oblique method, we measured artery diameters and calculated the area (A) of the vessel as A=πr 2 . The total inflow area (A T-inflow ) was the summation of the areas of distal portions of both internal carotid arteries and basilar artery. CBF, OEF, arterial oxygen content [(CaO 2 ) = 1.36*Hemoglobin*%saturation on pulse oximetry] and A T-inflow were compared between groups with nonparametric statistics. Spearman’s correlation determined relationship of A T-inflow with other variables. Results: Data was available for 29 subjects with SCA (median age 15 years (range 9-26), 45% male) and 17 age-matched controls (15y (range 9-18), 47% male) underwent scanning. Children with SCA had larger A T-inflow (36 [29, 40] mm 2 ) compared to age-matched controls (29 [26, 31] mm 2 , p=0.01). CBF and OEF were higher (p=0.001, p=0.002), and CaO 2 was lower (p<0.001) in SCA compared to controls. A T-inflow positively correlated with CBF (p=0.002) and OEF (p<0.001), and negatively correlated with CaO 2 (p=0.02; Figure ). Conclusion: Increased cross sectional area of large cerebral arteries may provide an additional compensatory mechanism in SCA to augment CBF and aid in meeting cerebral oxygen demand. Further work is needed to determine if MRA measurements provide a non-invasive precursor to increased cerebral metabolic stress and stroke risk.

Abstract TP194: Relation Between Lipoprotein (a) and Cerebral Arteriosclerosis

Background: Lipoprotein(a) is known to be associated with increased atherosclerotic burden and vascular event. We investigated the relationship between lipoprotein(a) level and cerebral arteriosclerosis burden, including both atherosclerosis and small vessel disease. Methods: Consecutive patients with acute cerebral infarction or transient ischemic attack who had been through both brain imaging and serum lipoprotein a level analysis were included in the study. For cerebral atherosclerosis, intracranial arterial calcification status at cavernous portion of internal carotid artery and cerebral atherosclerosis score as the sum of major cerebral arterial stenosis were measured from brain CT angiography. Assessed cerebral small vessel disease phenotype included white matter hyperintensities, old lacune, cerebral microbleeds and extensive perivascular space. The patients were categorized into four groups according to the predefined cut-off values of lipoprotein(a) (15, 30, 50mg/dL). Results: A total of 990 patients were included with 457 female patients (mean age = 68.2 ± 12.8 years). Overall cerebral atherosclerosis score or total small vessel disease burden was not increased according to increased lipoprotein(a) group, although the proportion of the patients with severe calcification showed increasing tendency. Multivariable logistic regression analysis revealed that increased lipoprotein(a) was independently associated with severe calcification (group 4, odds ratio = 1.68, confidence interval = 1.01 – 2.80). Increased lipoprotein(a) was associated with the presence of white matter hyperintensities and extensive perivascular space, but not associated with old lacune or cerebral microbleed. Conclusion: Lipoprotein(a) is independently associated with severe calcification of intracranial artery. The impact of elevated lipoprotein(a) toward small vessel disease burden seems to be different according to its phenotype.

Unexpected presentation and surgical salvage of transplant renal artery dissection caused by vascular clamping: a case report

BackgroundTransplant renal artery dissection is a rare and serious event that can cause allograft dysfunction and activation of the renin–mediated renovascular hypertension. Most cases are induced by percutaneous transluminal angioplasty, arteriosclerotic disease, or fibromuscular dysplasia. We observed a case of transplant renal artery dissection induced by unusual causes during kidney transplantation.Case presentationA 35-year-old woman, whose mother donated a kidney to her, underwent ABO-incompatible living kidney transplantation. The allograft had one renal artery and vein that were anastomosed to the internal iliac artery and external iliac vein, respectively. Although careful handling was performed in all procedures including vascular clamping, Doppler ultrasonography (US) immediately after reperfusion showed an increase in the systolic blood velocity and urine output was not observed. Arterial anastomotic stenosis was suspected, but upon exploration, a renal artery dissection was detected in the middle portion of the donor artery. The part of the transplant renal artery was resected, and cold reflux was started again. At the resected part of transplant renal artery, dissection was identified. After re-anastomosis, Doppler US revealed that the blood flow of the renal artery was adequate without an increase in the systolic blood velocity, and sufficient blood flow was observed throughout the allograft. Urine output was also observed as soon as blood flow returned, and serum creatinine level decreased to 0.95 mg/dL after surgery. The cause of injury might have been vascular clamping in order to drain the air and check bleeding at the anastomosis.ConclusionsOur case reaffirmed that careful handling is needed in all procedures, including donor nephrectomy, cannulation for transplant perfusion, vascular clamping, and anastomosis, even without any evidence of arteriosclerosis. Kidney transplant recipients commonly have atherosclerosis and hypertension, which are risk factors for arterial dissection. Early diagnosis and intervention can lead to the prevention of allograft dysfunction. Therefore, close monitoring of allograft blood flow by Doppler US during surgery should be considered.

Preauricular retromandibular trans tympanic plate and styloid process keyhole approach to parapharyngeal lesions: a laboratory study.

The surgical removal of the infratemporal parapharyngeal lesions (IPL) is challenging due to its anatomical complexity. Previous surgical approaches have often been too invasive and necessitated sacrifice of normal function and anatomical structures, particularly in the retromandibular nerve region. Therefore, we sought to identify an approach corridor to this area that requires less sacrifice and report an innovative approach through a retromandibular fossa route to the IPL. Five cadaveric specimens were dissected bilaterally with a trans-tympanic plate and styloid process approach. These specimens were investigated microanatomically and morphometrically to examine the extent of the approach in the parapharyngeal space. The clinical application of this approach was compared to previous approaches to the IPL used in our clinical series of 20 cases. Using this novel approach, the inferior alveolar nerve was identified in all specimens, while the chorda tympani and lingual nerve were identified in 6 (60%) and 4 (40%) dissections, respectively. In all specimens, the petrous portion of the internal carotid artery and the exit of the lower cranial nerve were identified. The average length of the exposed lower cranial nerves was 16.6 ± 3.8mm (range: 11-25mm). The described approach is feasible for accessing the IPL at the retromandibular nerve and is less invasive than conventionally used approaches.

Balloon-Occluded Trans-Arterial Chemo-Embolization Technique with Repeated Alternate Infusion of Cisplatin Solution and Sparse Gelatin Slurry (RAIB-TACE) for Large Hepatocellular Carcinoma Nodules More than 7 cm in Diameter.

Objective It is sometimes difficult to obtain complete/partial response of large hepatocellular carcinoma (HCC) nodules by trans-arterial chemoembolization/embolization (TACE/TAE). The aim is retrospective investigation of tumor response of large HCC nodules (>7 cm) treated by the new TACE technique, repeated alternate infusion of cisplatin solution, and sparse gelatin slurry under balloon occlusion (RAIB-TACE). Materials and Methods. A microballoon catheter was placed at a proximal portion of the hepatic artery (subsegmental to the lobar level hepatic artery), and alternate infusion of cisplatin solution and sparse gelatin slurry were repeated under balloon occlusion until stasis of gelatin slurry beyond the catheter was seen. RAIB-TACE of multiple proximal hepatic and extrahepatic collateral arteries were performed to treat hemi-lobe or more of the liver while avoiding infusion into gastric and cystic arteries for 19 large nodules (>7 cm) in 19 patients without portal venous invasion. All patients underwent dynamic CT/MRI 1–3 months after RAIB-TACE, and tumor response of each large nodule was evaluated based on modified RECIST criteria. Results CR, PR, SD, and PD were achieved in 11, 8, 0, and 0 nodules, respectively. CR and PR were considered as success, and the ratio of success was 100%. Major complications were abscess formation in the necrotic nodule (n = 1) which was treated by drainage tube placement, and subsegmental level liver infarction (n = 1) which was treated by drainage tube placement, and subsegmental level liver infarction (Conclusion New TACE technique, RAIB-TACE, was useful to achieve successful response of large HCC nodules.

Ultrasound for the Clinical Management of Vascular Access Cannulation and Needle Position in Hemodialysis Patients

A native arteriovenous fistula (AVF) is the vascular access of choice for hemodialysis (HD) treatment. Compared with other types of vascular access such as grafts and central venous catheters, it functions longer and is associated with a lower risk of complications. The aim of the study described here was to assess, in an HD population, the position of the fistula needles during an HD session and evaluate the role of ultrasound in the management of AVF puncture. Forty-five consecutive chronic HD patients with an AVF or an arteriovenous vascular graft were included in the study for ultrasound evaluation. Each patient underwent an ultrasound evaluation during HD treatment to assess the position of the needles inside the vascular access. The ultrasound evaluation revealed that 81.8% of the traditional needles were incorrectly adjacent to the vessel walls, in the absence of clinical symptoms or hemodynamic alterations detectable on the dialysis monitor. A greater frequency of malpositioning has been observed for needles in the arterial portion of the vascular access, closer to the anastomosis. The absence of clinically detectable signs of venipuncture-related complications does not ensure correct positioning of the needles within the AVF. Ultrasound evaluation may not only resolve suboptimal cannulation problems of new or complicated vascular accesses but may also be useful in the prevention of acute and chronic damage to the AVF.

A pilot study of blood supply of the coracoid process and the coracoid bone graft after Latarjet osteotomy.

Latarjet osteotomy is still one of the most reliable and commonly used surgeries in treating recurrent anterior shoulder dislocation. The coracoid process (CP) is the main structure of this surgery. However, the blood supply of CP is not fully understood, and the extent of destruction of blood supply of coracoid bone graft after Latarjet osteotomy procedure is still controversial. Five embalmed cadaveric upper limbs specimens were employed for macro observation of the blood supply of CP. The conjoint tendon (CT) and CP interface were dissected for histology. Sixteen fresh frozen shoulder specimens were used for perfusion and micro CT scanning. Eight specimens were used to present the whole vessel structure of CP. The other eight underwent Latarjet osteotomy procedure. The coracoid bone grafts in both groups were scanned to clarify the remnant blood supply. It was found that the CP was nourished by supra-scapular artery (SSA), thoracic-acromial artery and branch from second portion of the axillary artery (AA). After Latarjet osteotomy procedure, no artery from CT was detected to penetrate the CP at its attachment. Only in one specimen the blood vessel that originated from the CT penetrated the bone graft at the inferior side. Therefore, most of the blood supply was destroyed although there is a subtle possibility that the vessels derived from the CT nourished the inferior side of the CP. In a nutshell, CP is a structure with rich blood supply. The traditional Latarjet osteotomy procedure would inevitably cut off the blood supply of the coracoid bone graft.

Revision using distal inflow for high flow hemodialysis access alters arterial flow characteristics in the dialysis arm

ObjectiveRevision using distal inflow (RUDI) is currently proposed in patients on hemodialysis having a high flow access (HFA; >2 L/min) or hemodialysis access-induced distal ischemia (HAIDI). However, a recurrence of high flow or hand ischemia is not unusual in the years after RUDI. The aim of the present study was to describe changes in flow characteristics and arterial diameters in the dialysis arm after RUDI for HFA. MethodsVolume flow, diameter, peak systolic velocity and end diastolic velocity of the brachial artery (BA) were studied 2 and 12 months after RUDI using duplex imaging. In a portion of patients, these characteristics were also assessed at proximal and distal portions of radial and ulnar arteries (proximal forearm radial artery, distal radial artery, ulnar artery, and distal ulnar artery), and in the greater saphenous venous interponate. HFA patients were grouped according to presence of concomitant hand ischemia (HFA-HAIDI) or absence (HFA). ResultsFifteen patients (54 ± 16 year old; 10 males; HFA-HAIDI, n = 6; HFA, n = 9) with a BA HFA (flow volume, 2740 ± 322 mL/min) undergoing RUDI were studied between March 2011 and October 2016 in two Dutch hospitals. After 2 months, flow volume had decreased (1180 ± 189 mL/min), but again increased at 12 months (1520 ± 217 mL/min; P < .001). BA diameters did not change (7.4 ± 0.5 mm), but proximal forearm radial diameters doubled (overall 2.6 ± 0.2 mm to 5.4 ±1.0 mm; P < .001), albeit less prominent in HFA-HAIDI (+80%) than in HFA (+130%; P = .019). During follow-up, the distal ulnar artery peak systolic velocity in HFA-HAIDI (83 ± 10 cm/s) was higher compared with the HFA group (54 ± 5 cm/s; P < .01). Dilatation was not present in the greater saphenous venous interponate. ConclusionsRUDI for HFA reduction does not reverse BA dilatation, suggesting irreversible structural arterial wall damage possibly contributing to recurrent high flow. Radial artery remodeling is attenuated in HFA patients previously reporting concurrent hand ischemia diminishing the likelihood of high flow recurrence in this subgroup.

Spinal Arterial Blood Supply Does Not Arisefrom the Bronchial Arteries: A Detailed Analysis of Angiographic Studies Performed for Hemoptysis.

To determine the angiographic prevalence of spinal arteries originating directly from the bronchial arteries in the setting of embolization for hemoptysis. Over a 14-year interval, 205 patients underwent angiography for hemoptysis. Twenty-five patients were excluded because their bronchial arteries were not visualized. The remaining 180 patients underwent a total of 254 angiographic procedures (range, 1-8 per patient). Images were reviewed jointly by 2 interventional radiologists with formal fellowship training in both peripheral and neurological interventional radiology. All catheterized arteries were evaluated for arterial contribution to the spinal cord. For patients with multiple studies, each unique artery was reported only once. Embolization was performed during at least 1 procedure in 158 patients (88%). Electronic record review was used to assess neurological sequelae after the procedure. One or 2 bronchial arteries originating from the aorta were identified in 57 patients (32%) on the right and in 75 patients (42%) on the left. Conjoined bronchial arteries were found in 76 patients (42%). Spinal arterial supply was absent in all. A total of 102 patients (57%) had at least 1 right and 11 patients (6%) at least 1 left intercostobronchial artery. Spinal arterial supply from the intercostal portion of an intercostobronchial artery was found in 6 patients (5 right, 1 left). Medical record review revealed no postprocedure symptoms referable to spinal cord injury in any patient. Spinal arterial supply does not originate directly from the bronchial artery but can originate from the intercostal portion of an intercostobronchial artery.

2209 Abdominal Arterial Aneurysms in a Patient With Budd-Chiari Syndrome

INTRODUCTION: Budd-Chiari syndrome (BCS) is defined as hepatic venous outflow tract obstruction. Chronic BCS eventually leads to post-sinusoidal hypertension resulting in the symptoms of the disease. There have been case reports of BCS leading to intra-abdominal bleeding from ectopic varices, however, these are cases of venous bleeding. Here, we report a unique case of a Chinese woman with BCS presenting with bleeding from arterial aneurysms. CASE DESCRIPTION/METHODS: A 61-year-old woman with BCS requiring multiple prior porto-systemic shunting procedures was brought by EMS for coffee ground emesis. At the ED, she was stuporous and developed bloody emesis and hypotension. She was intubated and transferred to the ICU. Exam was remarkable for abdominal distention (AD) with a fluid wave. Labs showed leukocytosis; prolonged coags, elevated troponins, lactate, LDH and decreased fibrinogen and haptoglobin. FAST showed intra-abdominal free fluid. EGD showed grade II varices in the esophagus that were banded. However, the patient continued to deteriorate with increasing AD. CT-AP revealed a cirrhotic liver with occluded left and middle hepatic veins and extravasation of contrast near the greater curvature of the stomach into a LUQ hematoma (Figure 1). IR embolized the left gastric artery and identified aneurysms along a branch of the SMA (Figure 2) in addition to an aneurysm at the celiac artery origin (Figure 3). On the 2nd post-op day, the patient again developed hypotension with AD. Attempted embolization of the SMA branch was unsuccessful. On the 5th post-op day, the family agreed to withdrawal of life support and the patient was extubated and vasopressors were stopped. The patient passed away in a few hours. DISCUSSION: Chronic BCS presents with complications of cirrhosis; i.e., ascites and rupture of esophageal varices, like in our patient. On CTA, both the hepatic veins and part of the IVC were occluded. In fact, 31% of BCS patients have outflow occlusion at both these locations. However, in our patient, CTA revealed aneurysms in the celiac artery and distal portions of an SMA branch along with left gastric artery bleeding. Multiple arterial aneurysms have been associated with disorders such as PAN, Behcet's, Ehler-Danlos etc. By comparison, there have not been many reports of multiple idiopathic arterial aneurysms in adults. Several of these possible causes were unable to be worked up for due to the acute presentation, although our patient’s history was not typical for these diseases.

Takayasu arteritis: a rare case scenario

Takayasu’s arteritis (TA), commonly known as “Pulseless disease”, is rare granulomatous arteritis, which affects large and medium-sized arteries, especially the aorta and its branches. Other arteries that can be affected are proximal portions of pulmonary, coronary, and renal arteries. Initially, mononuclear cell infiltrates in the adventitia leading to granuloma formation, followed by disruption of the elastic layer and subsequent massive medial and intimal fibrosis. These lesions result in segmental stenosis, occlusion, dilatation, and aneurysmal formation in the affected vessels. Diminished or absent pulses are present in 84-96% of patients, associated with limb claudication and blood pressure discrepancies between the two arms. The symptoms are secondary to the involved artery, and it may evolve into a life-threatening condition. The involvement of the carotid artery leads to ophthalmic artery hypoperfusion and causes the ocular ischemic syndrome. It usually affects young females during the second and the third decades of life but rare cases have been reported in children as young as 24 months of age. Although females are more likely to be affected in TA, males are also affected. In adults approximately 80% of patients with TA are women, although the female-to-male ratio varied from 9:1 in reports from Japan, 6.9:1 in Mexico to 1.2:1 in Israel. Aim of our report is to describe the case of a young female of 14 years of age. She presented with arterial hypertension and respiratory distress. CT Angiography showed Type IIb Takayasu Arteritis. ECHO revealed dilated cardiomyopathy with grade III diastolic dysfunction with decreased ejection fraction up to 20-25%. She was treated with steroids, anti-hypertensive drugs, and diuretics.

Atherosclerotic plaque in HIV-positive patients presenting with acute coronary syndromes.

This study aimed to characterise the atherosclerotic plaque and plaque burden in HIV-positive patients presenting with acute coronary syndromes (ACS), using intravascular ultrasound (IVUS) and virtual histology (VH). This was a prospective study of 20 HIV-positive patients who presented with ACS. IVUS and VH were used to assess plaque burden and plaque characteristics in the culprit and non-culprit coronary arteries. HIV-positive patients with ACS had a mean age of 51.1 ± 8.1 years. There were 13 (65%) male patients. ST-segment elevation myocardial infarction was the most common presentation of ACS (75%) with the left anterior descending artery being the most common culprit artery (60%). In 60% of patients, the total plaque burden was of moderate degree (40-70% stenosis) while it was of mild degree (< 40% stenosis) in 35%, and in 5% of patients it was severe (> 70% stenosis). A severe degree of total plaque burden was more commonly found in the culprit vessel (30%) than in the non-culprit vessels (5%). Furthermore, the plaque burden was found to be located predominantly in the proximal portion of the coronary arteries. The predominant plaque morphology consisted of fibrous plaque (55.4%) and fibro-fatty plaque (26.6%), while necrotic core was present in 13.3%. Dense calcium was present in only 4.7% of the cohort. IVUS and VH demonstrated a high burden of atherosclerosis in the left anterior descending artery and proximal vasculature of HIV-positive patients. The atherosclerotic plaque predominantly comprised non-calcified fibrous and fibro-fatty plaque.

Effect of pituitary adenylate cyclase-activating polypeptide-27 on cerebral hemodynamics in healthy volunteers: A 3T MRI study

Pituitary adenylate cyclase-activating polypeptide (PACAP) has emerged as an important signaling peptide in migraine pathogenesis. Recently, we have shown that the less-abundant PACAP isoform, PACAP27, induced migraine and headache in patients equipotently to PACAP38. The present study examined the effect of PACAP27 on cerebral hemodynamics in healthy volunteers using high resolution magnetic resonance angiography (MRA). Eighteen healthy volunteers received infusion of PACAP27 (10 pmol/kg/min) or placebo over 20 min and were scanned repeatedly in fixed intervals for 5 h in a double-blind, randomized, placebo-controlled study. The circumference of extra-intracerebral arteries was measured and compared with PACAP38 data. We found significant dilation of middle meningeal artery (MMA) (p = 0.019), superficial temporal artery (p = 0.001) and external carotid artery (p = 0.039) after PACAP27 infusion compared to placebo. Whereas the middle cerebral artery (MCA) (p = 0.011) and internal carotid artery (ICA) (pICAcervical = 0.015, pICAcerebral = 0.019) were constricted. No effects on basilar artery (p = 0.708) and cavernous portion of ICA were found. Post hoc analyses revealed significant larger area under the curve for MMA after PACAP38 compared to PACAP27 (p = 0.033). We also found that PACAP27 induced headache in nine out of twelve (75%) volunteers and one (17%) after placebo. In conclusion, PACAP27 induced headache and dilated extracerebral arteries (>5 h) and slightly constricted MCA in healthy volunteers. Post hoc analysis of PACAP38 data compared with PACAP27 showed that PACAP isoforms dilates MMA with significantly different magnitude.

Renal and segmental artery hemodynamics during whole body passive heating and cooling recovery.

High environmental temperatures are associated with increased risk of acute kidney injury, which may be related to reductions in renal blood flow. The susceptibility of the kidneys may be increased because of heat stress-induced changes in renal vascular resistance (RVR) to sympathetic activation. We tested the hypotheses that, compared with normothermia, increases in RVR during the cold pressor test (CPT, a sympathoexcitatory maneuver) are attenuated during passive heating and exacerbated after cooling recovery. Twenty-four healthy adults (22 ± 2 yr; 12 women, 12 men) completed CPTs at normothermic baseline, after passive heating to a rise in core temperature of ~1.2°C, and after cooling recovery when core temperature returned to ~0.2°C above normothermic baseline. Blood velocity was measured by Doppler ultrasound in the distal segment of the right renal artery (Renal, n = 24 during thermal stress, n = 12 during CPTs) or the middle portion of a segmental artery (Segmental, n = 12). RVR was calculated as mean arterial pressure divided by renal or segmental blood velocity. RVR increased at the end of CPT during normothermic baseline in both arteries (Renal: by 1.0 ± 1.0 mmHg·cm-1·s, Segmental: by 2.2 ± 1.2 mmHg·cm-1·s, P ≤ 0.03), and these increases were abolished with passive heating (P ≥ 0.76). At the end of cooling recovery, RVR in both arteries to the CPT was restored to that of normothermic baseline (P ≤ 0.17). These data show that increases in RVR to sympathetic activation during passive heating are attenuated and return to that of normothermic baseline after cooling recovery.NEW & NOTEWORTHY Our data indicate that increases in renal vascular resistance to the cold pressor test (i.e., sympathetic activation) are attenuated during passive heating, but at the end of cooling recovery this response returns to that of normothermic baseline. Importantly, hemodynamic responses were assessed in arteries going to (renal artery) and within (segmental artery) the kidney, which has not been previously examined in the same study during thermal and/or sympathetic stressors.

Pencil Beam Presaturation Magnetic Resonance Imaging Helps to Identify Patients at Risk for Intolerance to Temporary Internal Carotid Artery Occlusion During Carotid Endarterectomy and Carotid Artery Stenting

There has been no effective method to predict ischemic intolerance to temporary internal carotid artery (ICA) occlusion during carotid artery reconstruction. Pencil beam presaturation (BeamSAT) pulse suppresses the flow signal of the target vessel in magnetic resonance angiography (MRA). Applying this method, we constructed ICA-selective MRA images. The aim of this study was to identify patients at risk for ischemic intolerance by ICA-selective MRA. By evaluating flow of anterior communicating artery (Acom) and A1 portion of anterior cerebral artery with ICA-selective MRA and posterior communicating artery (Pcom) with conventional MRA, we investigated associations of these collateral flow patterns with ischemic intolerance and decrease of regional cerebral oxygen saturation. The study included 58 patients who underwent carotid endarterectomy or carotid artery stenting. Six of 7 patients without Acom flow and Pcom flow demonstrated ischemic intolerance, whereas all patients (n= 51) with Acom and/or Pcom flow demonstrated tolerance. The accuracy of this prediction model according to Acom and Pcom flow patterns for ischemic intolerance was 0.98 (P=0.01, binomial test). Regional cerebral oxygen saturation decrease after ICA occlusion was significantly larger in patients without Acom flow and Pcom flow (12.0%± 6.0%) than in patients with Acom flow and Pcom flow (3.0% ± 3.1%, P < 0.01) and in patients with Acom flow but no Pcom flow (2.4% ± 5.2%, P < 0.01). These findings support the importance of Acom flow as a collateral route. ICA-selective MRA enables prediction of ischemic intolerance to temporary ICA occlusion during carotid endarterectomy or carotid artery stenting. This method provides valuable information regarding probability of an ischemic complication.

RAPID PROGRESSION FROM UNILATERAL TO BILATERAL RENAL ARTERY STENOSIS (RAS) IN A PATIENT WITH FLASH PULMONARY OEDEMA, HYPERTENSIVE ENCEPHALOPATHY AND RENAL SHUT-DOWN

Objective: Atherosclerotic renal artery stenosis (RAS) affects the most proximal portion of the renal artery and approximately 20% of patients have bilateral RAS. We describe an elderly patient with unilateral RAS, post renal artery angioplasty presenting with resistant hypertension, hypertensive encephalopathy, flash pulmonary oedema and renal shutdown after progressing to bilateral RAS kidneys. Design and method: We present a case of 71 year old Indian women with known history of hypertension secondary to right renal artery stenosis underwent right renal artery stenting in March 2016, who was admitted in April 2018 with hypertensive urgency. Results: Ultrasound Doppler of renal artery showed more than 50% stenosis with stent hyperplasia throughout length of the stented right renal artery. There was no evidence of RAS on the left side on ultrasound Doppler. Right renal artery angioplasty was done in view of poorly controlled hypertension with systolic blood pressure ranging between 190 to 230mmHg. During right renal angioplasty, there was incidental finding 50–60% stenosis of the left renal artery. Day 2 post stenting, patient's systolic blood pressure rose to 220 mmHg and started complaining of bi-frontal headache and vomiting. Computed tomography of the brain revealed subtle vasogenic oedema in bilateral frontal lobes likely posterior reversible encephalopathy syndrome (PRES). The patient clinically deteriorated with worsening renal function (creatinine value: 440mmol/L from a baseline of 64mmol/L), metabolic acidosis, oliguria, acute pulmonary oedema and high blood pressure requiring eight (including diuretics) anti-hypertensive. Hemodialysis was initiated and urgent CT angiogram was done to evaluate left renal artery which showed 90% left renal artery stenosis and stented subsequently. Post left renal artery stenosis, patient's blood pressure stabilised and the number of anti- hypertensive were reduced to 5 types. The patient's renal function normalised (creatinine value: 72mmol/L) and recovered from acute pulmonary oedema. Conclusions: In a patient with unilateral RAS post stenting presenting with resistant hypertension, it is important to rule out stent thrombosis versus progression to bilateral RAS and rapid reversal with revascularization is crucial in order to prevent cardiovascular and renal complications, reduce the mortality and morbidity and restore the renal function.

Application of side-hole catheter technique for transradial arterial chemoembolization in patients with hepatocellular carcinoma.

The purpose of this study was to retrospectively evaluate the efficacy and safety of side-hole catheter technique for transarterial chemoembolization (TACE) via transradial artery access (TRA) in patients with hepatocellular carcinoma. From November 2015 to August 2017, a total of 1040 TACE procedures were performed via TRA for hepatocellular carcinoma. In 10 (1%) of these 1040 TACE procedures via TRA, conventional microcatheter technique (CMT) failed and side-hole catheter technique was attempted. Ten procedures of selective catheterizations by CMT failed due to the poor stability of the angiographic catheters or the target artery arising from the very proximal portion of the parent artery. These arteries included the right inferior phrenic artery in eight patients, one left gastric artery, and one right renal capsular artery. Cobra or MPA catheter with the microcatheter through the side-hole yielded a technical success rate of 100%. No procedure-related complications were observed. The mean time required to catheterize the target artery with the side-hole catheter was 9.5min (5-15min). Side-hole catheter technique may enable the completion of chemoembolization in cases that a potential tumor-feeding vessel cannot be catheterized by means of CMT for TACE via TRA.

Endovascular treatment for acute carotid T and carotid non-T occlusion: A retrospective multicentre study of 81 patients.

The functional prognosis of patients with carotid T occlusion is poor, but few comprehensive studies have investigated carotid non-T occlusion, in which the terminal internal carotid artery portion is unobstructed. We aimed to elucidate the clinical features of carotid non-T occlusion by comparing patients with acute carotid T occlusion and carotid non-T occlusion. Among 362 patients who underwent thrombectomy between January 2015 and June 2018, 20 and 61 were diagnosed with carotid non-T occlusion and carotid T occlusion, respectively. We compared preoperative clinical findings, treatment strategies, treatment complications and functional outcomes between the two groups. Age, sex, preoperative National Institutes of Health stroke scale, cerebral infarction subtypes and medical history did not significantly differ. In contrast, preoperative diffusion-weighted imaging-Alberta Stroke Program early computed tomography scores were 9 (1-11) and 6.5 (0-11) for the carotid non-T occlusion and carotid T occlusion groups, respectively (P = 0.015). The duration of treatment or the median number of passes (2.5 vs. 2.0), the numbers of patients with thrombolysis in cerebral infarction 2b/3, bleeding complications and modified Rankin scale scores of 0-2 on postoperative day 90 did not significantly differ between the two groups. Manual aspiration before, internal carotid artery arrest while crossing a lesion and injection into the contralateral side were significantly more frequent in patients with carotid non-T occlusion. Intracranial internal carotid artery stenosis was significantly more frequent in patients with carotid non-T occlusion (n = 4, 20%) than carotid T occlusion (n = 0), and 10% of patients with carotid non-T occlusion had arterial dissection. Patients with carotid non-T occlusion more frequently had a background of intracranial internal carotid artery stenosis or arterial dissection than patients with carotid T occlusion. Specific treatment strategies should be developed to improve the clinical outcomes of patients with carotid non-T occlusion.

Clinical efficacy of collateral circulation in the evaluation of endovascular treatment for acute internal carotid artery occlusion

ObjectivesDespite successful recanalization, there remain many patients suffering bad outcome after endovascular treatment, especially for occlusion at the distal portion of internal carotid artery. The goal of the current study was to investigate the value of collateral circulation in predicting malignant events after endovascular treatment in acute ischemic stroke-terminal internal carotid artery (AIS-TICA) patients. MethodsThe records of forty-one patients with AIS-TICA as confirmed by digital subtraction angiography and subjected to mechanical thrombectomy were reviewed. On the basis of the collateral circulation grading system (ACG) from the American Society of Interventional and Therapeutic Neuroradiology/American Society of Interventional Radiology (ASITN/SIR), class of leptomeningeal compensation were evaluated as grade 0 to 4. Factors for malignant events were evaluated by retrospectively univariate analysis. Moreover, analysis of correlation was performed between collateral circulation and malignant events. Malignant events were defined as a malignant middle cerebral artery infarction or parenchymal hemorrhage 2. ResultsOf the 41 subjects, 13 (31.71%) had postoperative malignant events. Though 36 (87.80%) of the patients had a complete recanalization, only 17 patients (41.46%) showed good outcomes with modified Rankin score≤2 at 3 months. 9 (21.95%) deaths occurred in the hospital. Besides, patients in the malignant group had significantly higher scores on the National Institute of Health stroke scale (P = 0.032) and lower anterior circulation compensation (P = 0.000). Furthermore, correlation analysis showed that probability of malignant events was negatively correlated with anterior circulation compensation (rs = -0.534, P = 0.000). ConclusionsThe leptomeningeal compensation of anterior circulation can be predicted whether a malignant event will occur after endovascular treatment in AIS-TICA patients. The probability of malignant events is significantly increased if the anterior circulation collateral compensation score is 0–1.