Postmortem Angiograms Research Articles

Prevalence of left and balanced coronary arterial dominance decreases with increasing age of patients at autopsy. A postmortem coronary angiograms study

In patients presenting with an acute coronary syndrome, left over right coronary dominance appears to be independently associated with increased long-term mortality. This could lead to decreasing numbers of patients with a left dominant coronary artery system in older age groups. We assessed the type of coronary dominance in different age groups in postmortem angiograms that were routinely performed at autopsy between 1993 and 2007. Coronary dominance was determined by identifying the origin of the posterior descending artery and posterolateral branches on postmortem angiography. Age, gender, and cause of death were recorded from the autopsy database. The prevalence of left dominant, right dominant, and codominant systems was determined in three increasing age categories, with cutoffs based on tertiles. A total 1620 coronary angiograms were assessed; 167 were excluded because it was not possible to determine coronary dominance. The median age of all patients was 71 years; 56% were male. Of all deaths, 40% were classified as cardiac. Regarding coronary dominance, 81.2% was right, 9.1% was left, and 9.7% was codominant. Overall, a decrease in prevalence of left and codominant coronary systems was observed with increasing age in the three age cohorts (≤ 63 years, 64-75 years, and ≥ 76 years) (P=.001 for overall comparison). In this large autopsy cohort, the prevalence of a left dominant or codominant coronary system decreased with increasing age. These findings could relate to a slightly higher risk of mortality in case of left versus right coronary artery occlusion.

« S-Z » osteotomy : intérêt d’une corticotomie sagittale pour l’allongement par ostéogenèse en distraction

The radial artery is presently widely used as a bypass graft for coronary artery reconstruction. However, the traditional opinion that the ulnar artery is the larger forearm artery has been questioned.The internal diameters of the radial and ulnar arteries were measured at the wrist in postmortem angiograms of 24 cadavers. Differences in mean values of variables between ulnar and radial arteries were analyzed using the Wilcoxon test.The mean diameter of the radial artery was 28% larger than that of the ulnar artery in the right arm (p < 0.001) and 26% larger in the left arm (p < 0.001). In the right arm the radial artery was dominant in 20 of 24 cadavers (83%), the ulnar artery in 3 of 24 (13%), and the arteries were equal in 1 of 24 (4%). In the left arm the figures were 17 of 24 cadavers (71%), 3 of 24 (13%), and 4 of 24 (17%), respectively.In view of the present investigation the radial artery should be considered the larger forearm artery of the hand in most patients.

Cerebral Arteriogenesis is Enhanced by Pharmacological as Well as Fluid-Shear-Stress Activation of the Trpv4 Calcium Channel

Objectives This study aimed to determine the importance of the shear-stress-sensitive calcium channels Trpc1, Trpm7, Trpp2, Trpv2 (transient receptor potential cation channel, subfamily V, member 2) and Trpv4 for cerebral arteriogenesis. The expression profiles were analysed, comparing the stimulation of collateral growth by target-specific drugs to that achieved by maximum increased fluid shear stress (FSS). Design A prospective, controlled study wherein rats were subjected to bilateral carotid artery ligature (BCL), or BCL + arteriovenous fistula, or BCL + drug application. Methods Messenger RNA (mRNA) abundance and protein expression were determined in FSS-stimulated cerebral collaterals by quantitative real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry. Drugs were applied via osmotic mini pumps and arteriogenesis was evaluated by post-mortem angiograms and Ki67 immunostaining. Results Trpv4 was the only mechanosensitive Trp channel showing significantly increased mRNA abundance and protein expression after FSS stimulation. Activation of Trpv4 by 4α-phorbol-12,13-didecanoate caused significantly enhanced collateral growth (length: 4.43 ± 0.20 mm and diameter: 282.6 ± 8.1 μm) compared with control (length: 3.80 ± 0.06 mm and diameter: 237.3 ± 5.3 μm). Drug application stimulated arteriogenesis to almost the same extent as did maximum FSS stimulation (length: 4.61 ± 0.07 mm and diameter: 327.4 ± 12.6 μm). Conclusions Trpv4 showed significantly increased expression in FSS-stimulated cerebral collaterals. Pharmacological Trpv4 activation enhanced cerebral arteriogenesis, pinpointing Trpv4 as a possible candidate for the development of new therapeutic concepts.

Controlled Delivery of bFGF Remodeled Vascular Network in Muscle Flap and Increased Perfusion Capacity Via Minor Pedicle

The vascular pedicles of superficial skeletal muscles are classified as the dominant pedicle and the minor pedicle. The dominant pedicle can reliably provide adequate circulation to the entire muscle, but the minor pedicle cannot. Therefore, it is impossible to elevate an entire muscle flap based solely on the minor pedicle. We evaluated whether the delivery of basic fibroblast growth factor (bFGF) would remodel the vascular network in the muscle flap and increase the perfusion capacity via the minor pedicle. Using a controlled delivery system with acidic gelatin hydrogel microspheres, bFGF (50 microg, FGF group) or phosphate-buffered saline (PBS group) was delivered to the rabbit gracilis muscle, which contained a single dominant pedicle and a minor pedicle. Seven days later, the gracilis muscle was elevated as a muscle flap on the minor pedicle, and the flap was wrapped with a silicone sheet to avoid vessel in-growth from surrounding tissue. At 7 d after operation, flap viability, microangiograms, and regional blood flow were evaluated. Flap viability in the FGF group (73.6 +/- 20.5%) was significantly higher than that in the PBS group (19.7 +/- 23.5%). Postmortem angiograms of the flap showed obvious communications between the distal vascular networks of the minor and dominant pedicles. Angiographic score and regional blood flow of the flap were significantly higher in the FGF group than in the PBS group. Controlled delivery of bFGF to rabbit gracilis muscle increased the perfusion capacity via the minor pedicle, and the minor pedicle became able to solely provide sufficient circulation to the entire muscle.

Gene transfer of bFGF to recipient bed improves survival of ischemic skin flap

The recipient bed is a promising target of angiogenic therapy to treat ischemic skin flaps. We delivered basic fibroblast growth factor (bFGF) gene to the recipient bed by a plasmid-based method with electroporation, and assessed the effects on flap viability in a rat dorsal skin flap model. A 25 x 90 mm(2) axial skin flap was elevated on the back of male Sprague-Dawley rats. Two days before flap elevation, an expression plasmid vector containing the bFGF gene with the signal sequence was injected into the dorsal muscles beneath the skin flap, and then electroporation was delivered (FGF-E(+) group). As control, rats were injected with a plasmid vector containing LacZ gene (LacZ-E(+) group), instead of bFGF gene. Other groups of animals received plasmid vector containing bFGF (FGF-E(-) group) or LacZ (LacZ-E(-) group) gene without electroporation. Seven days later, the area of necrosis and neovascularisation of the skin flap were evaluated. The bFGF gene was successfully transferred to the dorsal muscles, and bFGF was expressed in muscle tissue. The area of flap necrosis (%) in the FGF-E(+) group (21.7+/-5.3%) was significantly smaller than that in the LacZ-E(+) (28.3+/-4.1%), FGF-E(-) (29.7+/-3.3%), and LacZ-E(-) (28.1+/-2.5%) groups. Postmortem angiograms and histological analyses showed that vascularisation in the distal part of the skin flap was significantly increased in the FGF-E(+) group compared with the other groups. These findings suggested that gene delivery of bFGF to the recipient bed muscles enhanced vascularity and viability of an ischemic skin flap, and that plasmid-based gene delivery with electroporation was a suitable delivery method.

The radial artery is larger than the ulnar

Background The radial artery is presently widely used as a bypass graft for coronary artery reconstruction. However, the traditional opinion that the ulnar artery is the larger forearm artery has been questioned. Methods The internal diameters of the radial and ulnar arteries were measured at the wrist in postmortem angiograms of 24 cadavers. Differences in mean values of variables between ulnar and radial arteries were analyzed using the Wilcoxon test. Results The mean diameter of the radial artery was 28% larger than that of the ulnar artery in the right arm ( p < 0.001) and 26% larger in the left arm ( p < 0.001). In the right arm the radial artery was dominant in 20 of 24 cadavers (83%), the ulnar artery in 3 of 24 (13%), and the arteries were equal in 1 of 24 (4%). In the left arm the figures were 17 of 24 cadavers (71%), 3 of 24 (13%), and 4 of 24 (17%), respectively. Conclusions In view of the present investigation the radial artery should be considered the larger forearm artery of the hand in most patients.

GM-CSF: a strong arteriogenic factor acting by amplification of monocyte function

We investigated the role of the colony stimulating factor for monocytes (GM-CSF) to test the hypothesis whether prolongation of the monocyte's life cycle will support arteriogenesis (rapid growth of preexisting collateral arteries). This appeared logical in view of our discovery that circulating monocytes play an important part in the positive remodeling of small preexisting arterioles into arteries to compensate for arterial occlusions (arteriogenesis) and especially following our findings that MCP-1 markedly increases the speed of arteriogenesis. The continuous infusion of GM-CSF for 7 days into the proximal stump of the acutely occluded femoral artery of rabbits by osmotic minipump produced indeed a marked arteriogenic response as demonstrated by an increase (2-fold) in number and size of collateral arteries on postmortem angiograms and by the increase of maximal blood flow during vasodilation measured in vivo by blood pump perfusion of the hindquarter (5-fold). When GM-CSF and MCP-1 were simultaneously infused the effects on arteriogenesis were additive on angiograms as well as on conductance. GM-CSF was also able to widen the time window of MCP-1 activity: MCP-1 treatment alone was ineffective when given after the third week following occlusion. When administered together with GM-CSF about 80% of normal maximal conductance of the artery that was replaced by collaterals were achieved, a result that was not reached before by any other experimental treatment. Experiments with cells isolated from treated animals showed that monocyte apoptosis was markedly reduced. In addition we hypothesize that GM-CSF may aid in releasing pluripotent monocyte (stem-) cells from the bone marrow into the circulation. In contrast to MCP-1, GM-CSF showed no activity on monocyte transmigration through- and also no influence on monocyte adhesion to cultured endothelial cells. In conclusion we have discovered a new function of the hemopoietic stem cell factor GM-CSF, which is also a powerful arteriogenic peptide that acts via prolongation of the life cycle of monocytes/macrophages.

Monocyte chemotactic protein-1 increases collateral and peripheral conductance after femoral artery occlusion.

Monocytes are activated during collateral artery growth in vivo, and monocyte chemotactic protein-1 (MCP-1) has been shown to be upregulated by shear stress in vitro. In order to investigate whether MCP-1 enhances collateral growth after femoral artery occlusion, 12 rabbits were randomly assigned to receive either MCP-1, PBS, or no local infusion via osmotic minipump. Seven days after occlusion, isolated hindlimbs were perfused with autologous blood at different pressures, measuring flows at maximal vasodilation via flow probe and radioactive microspheres, as well as peripheral pressures. This allowed the calculation of collateral (thigh) and peripheral (lower limb) conductances from pressure-flow tracings (slope of the curve). Collateral growth on postmortem angiograms was restricted to the thigh and was markedly enhanced with MCP-1 treatment. Both collateral and peripheral conductances were significantly elevated in animals with MCP-1 treatment compared with the control group, reaching values of nonoccluded hindlimbs after only 1 week of occlusion (collateral conductance, 70.6 +/- 19.23 versus 25.1 +/- 2.59 mL/min per 100 mm Hg; P < .01; peripheral conductance, 119.3 +/- 22.37 versus 45.4 +/- 6.80 mL/min per 100 mm Hg; P < .05). These results suggest that activation of monocytes plays an important role in collateral growth as well as in capillary sprouting.

Detection of Mild Coronary Stenoses Using the Dynamic Spatial Reconstructor

The accuracy of the Dynamic Spatial Reconstructor (DSR) in the detection of moderate coronary artery stenoses was examined in 20 closed-chest dogs. Twenty-eight hollow plastic cylinders were embolized into the left coronary arteries and produced 25% to 56% reductions in arterial lumina diameter. For each dog, one three-dimensional (3-D) image of the heart was reconstructed from each DSR scan recorded during injection of contrast into the aortic root. Analysis involved blinded visual analysis by four independent observers of multiview projection images computed from the single 3-D image. Postmortem coronary angiograms of the isolated heart were considered definitive for location of the stenoses. Overall sensitivity of detection by DSR was 89% and specificity 81%. Sensitivity of detecting stenoses greater than or equal to 50% was 98%. Receiver operating characteristics (ROC) analysis showed that detection of stenoses in the left coronary arteries is of equal sensitivity and specificity.

Atherosclerotic Narrowings of the Mesenteric Circulation

To study the incidence of atherosclerotic involvement of the mesenteric ar teries, autopsies were performed on 47 randomly chosen cadavers that were fifty years old or older. The study encompassed: (1) postmortem angiogram; (2) dissection and macroscopic assessment of the main vessels and any possible col laterals ; and (3) a microscopic grading of the cross-sectional area of the proxi mal 2 cm of the mesenteric arteries. There was a statistically significant preponderance of stenosis among males (83% vs females 67%). The superior mesenteric artery (SMA) had a higher incidence of narrowing (85%) than either the inferior mesenteric artery (IMA) (72%) or the celiac artery (CA) (64%). High-grade stenosis (&gt; 50% of the lumen involved) was most common in the IMA (28%), followed by the SMA (17%) and the CA (11%) . Despite a high incidence of stenosis, a retrospective review of patient charts did not reveal any convincing reports of abdominal complaints. Moreover, only 1 case had dilated collaterals.

Small coronary vessel disease and sudden coronary death.

In an attempt to determine the importance of atherosclerosis in medium-sized coronary arteries, the hearts of 20 patients dying of cardiac disease, within 24 hours of the onset of symptoms, were compared with 19 controls. Post-mortem coronary angiograms were performed and the coronary arteries dissected in detail. Severe stenoses, or complete occlusions, were present in 34 of 80 major coronary arteries in the sudden cardiac death (SCD) group and 5 of 76 in the controls. Medium-sized branch vessels were severely stenosed or occluded in 20.5 per cent (37 of 180 vessels) in the SCD group and 6.4 per cent (11 of 171 vessels) in the controls. Forty of the 48 diseased branch vessels arose from the left anterior descending artery. In the SCD group, 18 patients died from major coronary artery atheroma, one from hypertensive heart disease and only one from disease of a branch vessel. We conclude that, in most cases of SCD, careful macroscopic examination of the major coronary vessels will provide an adequate explanation for death. Detailed dissection of all medium-sized branch vessels is unlikely to be of value as a routine procedure but, at the very least, pathologists should identify and dissect the first septal and diagonal branches of the left anterior descending artery in every post-mortem.

The pathology of clubbing: Vascular changes in the nail bed

In this study post-mortem angiograms were prepared from both normal and clubbed hands and attempts were made to estimate the size of the vascular bed in the terminal parts of each finger. Representative cases were also examined histologically. There were no differences between the groups. The increase in blood flow in clubbing is the result of vasodilatation rather than hyperplasia of vessels in the nail bed.

Occurrence and characteristics of sclerotic lesions in uterine arteries of sterile and multiparous pigs.

Sows and gilts of the Great White Polish (GWP) breed were classified into groups of 10 each: gilts 8 mo of age (A), sows over 1 yr old with an average litter size of five (BI) and eleven (BII), 2- to 3-yr-old sows with an average litter size of five (CI) and nine (CII), 4- to 6-yr-old sows with an average litter size of six (DI) and nine (DII). Gilts of group A were necropsied on d 10 of the estrous cycle while sows were necropsied 120 to 360 d postpartum. A blood sample obtained by vena cava puncture immediately before exsanguination was quantitated for total cholesterol, free cholesterol, cholesterol ester, total lipid, triglyceride, high and low density lipoprotein and chylomicrons. Postmortem angiograms of the uterine vasculature were evaluated for occurrence of arteriosclerotic lesions of the arteries and their branches. Sections of blood vessels from areas of restriction were examined histologically and quantitated for lipids and proteolytic and lipolytic enzyme activities. With the exception of high density lipoproteins and chylomicrons, serum concentrations of various lipids increased (P less than .01) with age. Restrictions of the lumen were found in uterine arteries and their branches of most gilts in group A and in sows in groups B, C and D, irrespective of litter size. Histology of uterine artery revealed preatherosclerotic lesions in groups B through D. No relationship between the incidence and degree of sclerotic lesions and litter size was evident. However, the incidence and degree of sclerotic lesions increased with age and parity. Results from histopathology were supported by results from measurement of lipids and enzyme activities of the uterine artery wall. Conception rates of sows in groups C and D were lower than those of group B. Many of these sows (70%) failed to conceive during 1 yr even though they displayed normal estrous cycles.

Femoral venous catheterization during cardiopulmonary resuscitation: A critical appraisal

The placement of femoral venous catheters inserted during unsuccessful resuscitation attempts was studied by postmortem angiograms through the catheters. In 31% of the catheterizations the final position of the catheter was not in the femoral vein. We conclude that femoral venous catheterization by inexperienced operators is an unreliable technique during cardiopulmonary resuscitation.

Transitional blood flow zones between ischemic and nonischemic myocardium in the awake dog. Analysis based on distribution of the intramural vasculature.

The present study evaluates the transitional or border zone of intermediate blood flow reduction between nonischemic and ischemic regions after acute coronary artery occlusion in chronically instrumented dogs, using methods that minimize an admixture of ischemic and nonischemic myocardium in the tissue analyzed. The regions perfused by occluded and nonoccluded vessels were identified by tracing the extra and intramural distribution of the coronary vasculature from postmortem angiograms. Regional blood flow was evaluated in serial 3-mm-wide epicardial and endocardial zones from outside and inside the interface between occluded and nonoccluded vessels. The zone of intermediate reduction in blood flow between nonischemic and ischemic regions occurred in the first 3-mm section immediately inside the region supplied by the occluded vasculature. Mean blood flow in this region was reduced to 58 +/- 6% and 61 +/- 5% (+/- SEM) of nonischemic region blood flow at the lateral and medial epicardial margins, respectively, and 47 +/- 5% and 45 +/- 6% at the lateral and medial endocardial margins, respectively. In the remaining ischemic zone, significant differences in blood flow existed between epicardial and endocardial layers; these differences were highly variable between animals. The data indicate that when the analysis of regional blood flow following acute ischemia is based on the anatomic distribution of the coronary vasculature, the transitional or border zone of intermediate reduction in blood flow is limited to a narrow zone immediately inside the occluded vasculature. Studies performed in acutely anesthetized dogs in which the occluded region was perfused via a two-chamber blood reservoir that allowed maintenance of perfusion and exclusion of microspheres from the circumflex region indicate that intermediate reductions in blood flow at the border of the ischemic zone resulted from an admixture of normal myocardium and, thus, do not represent a border zone of intermediate ischemia.

Arterial segmentation of the human spleen by post-mortem angiograms and corrosion-casts.

In a series of seventy adult human spleens, obtained from embalmed dissecting-room cadavers and post-mortem bodies, the extrasplenic division and intrasplenic architecture of the terminal branches of the splenic artery and of its polar arteries were studied via extrasplenic dissection, angiograms and injection-corrosion casts. The results showed that the splenic artery is divided into two (85.7%), or three (14.3%) primary branches, each of which is subdivided, mostly, into two to four secondary branches. Moreover, a superior polar artery (60.0%) and inferior polar arteries (80.0%) are given from the splenic trunk or from one of its primary branches. The human spleen is divided accordingly into two or three main arterial segments, separated by a definite avascular plane. Also, a rather constant avascular plane separated the polar segments from the remaining of the organ. Each main segment is also subdivided, usually into two to four less constant secondary segments, the architecture of which and the avascular planes between them are very variable. The findings of this study and other relative studies consist the anatomical basis for highly conservative surgical management, as an alternative to splenectomy, in cases of splenic rupture.

Ineffectiveness of methylprednisolone to reduce infarct size in experimental coronary occlusion.

Two medium-sized branches of the left coronary artery were prepared in each of 10 anesthetized open chest dogs for later occlusion. The first artery was occluded during 90 minutes and reperfused thereafter. This occlusion produced the control infarct. Methylprednisolone (50 mg/kg i.v.) was injected and the second artery was occluded also for 90 minutes and reperfused thereafter. Both infarcts were made visible by staining left ventricular rings with p-nitrobluetetrazolium. Infarct size was compared with the size of the perfusion area, which we obtained from the postmortem angiogram. Both infarcts were equal in size and comprised 50% of the area of perfusion of the occluded artery. Methylprednisolone in a single high dose given prophylactically did not influence infarct size nor any of the measured parameters.

Experimental myocardial infarction in a closed-chest canine model. Observations of temporal and spatial evolution over 24 hours.

Myocardial infarction was induced in 7 mongrel dogs by transfemoral intraluminal occlusion of the left anterior descending coronary artery. Perfusion area at risk was determined by post-mortem coronarography and infarct size by macrohistological staining with para-nitrophenoltetrazolium. Regional flow was determined by injection of radioactive microspheres 0.2 hours, 12 hours, and 24 hours post occlusion. Infarct size as determined by planimetry of post-mortem angiograms and macrohistological stains at identical magnification revealed 74.5 +/- 12.1% infarcted tissue of the perfusion area at risk. The flow of the necrotic tissue was below 13 Ml/100 g min without exception, indicating a threshold perfusion for maintenance of myocardial viability. Accordingly, a flow of less than or equal to 10 ml/100 g min identified 93% of the entire infarcted myocardium, resulting in 71 +/0 20% as compared to the perfusion area at risk. Based on the good agreement of macrohistological and flow data, the evolution of myocardial injury was determined by flow measurements. The results indicated a different progression of the borders of critical flow in the subendocardial and subepicardial layers, whereas in the subendocardium 85% of the tissue at risk was identified by the critical flow at 0.2 hours and 97% at 12 hours, the subepicardial flow changed at a different pace: only 53% showed subcritical perfusion at 0.2 hours, 61% at 12 hours with a final increase of 39% from 12 to 24 hours.

Technique of Comparative Angiographic andMorphologic Examination of the Heart and Pulmonary Circulation

Morphological changes of the cardiovascular system, e.g., due to congenital or acquired valvular diseases, cannot be analysed, evaluated or documented sufficiently by traditional gross pathological examination alone. The investigation of gross specimens of the heart and lungs is limited mainly to the inspection of the natural and cut surface, whereas postmortem angiograms allow three-dimensional examination of the vasculature even stereoscopically. Small vessels, e.g., bronchial arteries and anastomoses can easily be demonstrated by routine methods. The specimens can be formalin-fixed and contrasted by special techniques. Formalin-fixed and contrasted specimens of the heart and lungs are especially useful in the search for occult bleeding sources, emboli in chronic recurrent pulmonary embolism, and the investigation of the vascular system in pneumoconioses, primary and secondary tumors as well as in the analysis of the pulmonary vasculature in cases of defect of the ventricular septum and cor pulmonale. The basic morphology of computerized transaxial tomography can be studied from these sliced heart-lung specimens.

Systemic-pulmonary arterial supply in pulmonary atresia with ventricular septal defect: Postmortem angiograms and histologic survey: L. Daliento, P. Stritoni, R. Chioin, et al. Chest 74:685–687, (December), 1978

Systemic-pulmonary arterial supply in pulmonary atresia with ventricular septal defect: Postmortem angiograms and histologic survey: L. Daliento, P. Stritoni, R. Chioin, et al. Chest 74:685–687, (December), 1978