Preoperative Angiography Research Articles

An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy.

Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

Correlation of the severity of coronary artery disease with patients' metabolic profile- rationale, design and baseline patient characteristics of the CorLipid trial

BackgroundCoronary artery disease (CAD) remains one of the leading causes of mortality and morbidity worldwide. As oxygen and nutrient supply to the myocardium significantly decrease during ischemic periods, important changes occur regarding myocardial intermediary energy metabolism. Metabolomics is an emerging field in systems biology, which quantifies metabolic changes in response to disease progression. This study aims to evaluate the diagnostic utility of plasma metabolomics-based biomarkers for determining the complexity and severity of CAD, as it is assessed via the SYNTAX score.MethodsCorlipid is a prospective, non-interventional cohort trial empowered to enroll 1065 patients with no previous coronary intervention history, who undergo coronary angiography in University Hospital AHEPA, Thessaloniki. Venous blood samples are collected before coronary angiography. State-of the-art analytical methods are performed to calculate the serum levels of novel biomarkers: ceramides, acyl-carnitines, fatty acids, and proteins such as galectin-3, adiponectin, and the ratio of apolipoprotein B/apolipoprotein A1. Furthermore, all patients will be categorized based on the indication for coronary angiography (acute coronary syndrome, chronic coronary syndrome, preoperative coronary angiography) and on the severity of CAD using the SYNTAX score. Follow-up of 12 months after enrollment will be performed to record the occurrence of major adverse cardiovascular events. A risk prediction algorithm will be developed by combining clinical characteristics with established and novel biomarkers to identify patients at high risk for complex CAD based on their metabolite signatures. The first patient was enrolled in July 2019 and completion of enrollment is expected until May 2021.DiscussionCorLipid is an ongoing trial aiming to investigate the correlation between metabolic profile and complexity of coronary artery disease in a cohort of patients undergoing coronary angiography with the potential to suggest a decision-making tool with high discriminative power for patients with CAD. To our knowledge, Corlipid is the first study aspiring to create an integrative metabolomic biomarkers-based algorithm by combining metabolites from multiple classes, involved in a wide range of pathways with well-established biochemical markers.Trial registration CorLipid trial registration: ClinicalTrials.gov number: NCT04580173. Registered 8 October 2020—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04580173.

Coronary computed tomography angiography before on-pump cardiac surgery does not reduce the risk of postoperative acute kidney injury compared to coronary angiography.

Cardiac surgery and contrast media are both related to acute kidney injury. We investigated whether undergoing coronary computed tomography angiography, which uses less contrast medium, before on-pump cardiac surgery could reduce the risk of postoperative acute kidney injury compared to coronary angiography. In this retrospective study, 745 and 171 patients underwent coronary angiography and coronary computed tomography angiography, respectively, within 30days before on-pump cardiac surgery. Postoperative acute kidney injury was defined according to Kidney Disease Improving Global Outcomes Definition and Staging criteria. Age, hypertension, cardiopulmonary bypass time, and performing cardiac surgery within 24h of preoperative angiography (odds ratio: 1.507, 95% confidence interval: 1.111‒2.045, P = 0.008) independently predicted postoperative acute kidney injury on multivariable analysis. After propensity score matching, the acute kidney injury incidence in coronary angiography and computed tomography angiography groups was 43% and 46%, respectively (P = 0.65), and the groups had similar intensive care unit stay (2days vs. 2days, P = 0.209), postoperative hospital stay (11days vs. 12days, P = 0.084), postoperative continuous renal replacement therapy use (0.6% vs 1.9%, P = 0.314), and in-hospital mortality (0 vs. 1.3%, P = 0.156). In-hospital outcomes were similar among patients who underwent preoperative coronary angiography or computed tomography angiography within 24h before cardiac surgery. Although coronary computed tomography angiography uses less contrast medium, it does not reduce the risk of postoperative acute kidney injury or improve in-hospital outcomes compared to coronary angiography.

Revisiting Management Strategies for Popliteal Artery Injuries.

Popliteal artery injuries (PAIs) were reported to own the highest rates of limb loss in vascular injuries of extremities. The complex nature of PAIs makes the treatment more difficult. We aimed to present our cases using our proposed algorithm and revisit the strategies for management. A retrospective study of 45 cases with PAIs managed at the Kaohsiung Chang Gung Memorial Hospital over a 10-year period was conducted. The proposed algorithm for decision making was applied, which contains variables including the interval before surgery, the revascularization being delayed or not, the presence of fasciotomy, the acquisition of preoperative angiography, and the existence of collateral circulation. Whether the injured limbs were salvaged successfully avoiding amputation was recorded. Of all the included 45 patients, the rate of a successful salvage of the injured limb from amputation was 71.1%. Six patients did not receive revascularization because of their poor conditions of the injured limbs. In terms of limb salvage in PAIs, the interval before surgery, the revascularization being delayed or not, the presence of fasciotomy, or the acquisition of preoperative angiography did not make a significant difference (P > 0.05). Instead, an existence of collateral circulation at the distal injured limb was correlated to a significant higher rate of salvage, regardless of having revascularization or not (P = 0.001 and < 0.001, respectively). Seven patients had the injured vessels repaired directly and all were prevented from amputation. In other patients who underwent vascular repair using a graft, vein graft (n = 20) showed a higher successful rate in salvage significantly than Gore-Tex graft (n = 9, P < 0.001). Collateral circulation determines much of the fate of limb salvage in PAIs. As a result, a delayed revascularization could be accepted as long as there is existence of collateral circulation at the distal injured limb. An autologous vein graft is favored when a direct repair is not able to be performed for revascularization. Although fasciotomy was not found to be associated with a successful salvage in this study, its importance could not be neglected and it should be performed when there is an observed or impending compartment syndrome.

Surgical resection for pelvic retroperitoneal Castleman's disease: A case report and review literature.

Castleman's disease (CD) is a rare atypical lymphoproliferation disorder first reported in 1954. Clinically, CD is classified as unicentric or multicentric CD based on anatomical distribution. Unicentric CD primarily affects the mediastinum, and rarely affects the retroperitoneal location. The standard treatment for unicentric CD is complete surgical resection; however, this can be complicated by a high degree of attachment with other organs or hypervascularity. Preoperative angiography and embolization of the arteries that feed the problematic mass can reduce intraoperative bleeding in cases of CD with hypervascularity. In the present case report, a 44-year-old man who was found to have a pelvic retroperitoneal mass with calcification based on abdominal imaging results is discussed. Due to the hypervascularity of the mass, preoperative embolization was performed. The mass was completely resected without any complications. Additionally, a review of the literature on pelvic CD and preoperative embolization of CD was performed to provide an up-to-date reference on the management and outcomes of patients with CD.

Status of coronary disease and results from early endovascular aneurysm repair after preventive percutaneous coronary revascularization.

The incidence of coronary artery disease (CAD) is high in patients with an aortic aneurysm but preoperative routine coronary angiography and preventive coronary revascularization are not recommended to reduce cardiac events in patients with severe CAD. This study evaluated the safeness and efficacy of preventive percutaneous coronary intervention (PCI) in patients with severe CAD scheduled for endovascular aneurysm repair (EVAR). All patients with descending thoracic aneurysm (DTA) or abdominal aortic aneurysm (AAA) scheduled for EVAR underwent preliminary coronary angiography. Based on coronary angiography results, 917 patients (40.7%) had significant CAD and were treated by percutaneous coronary intervention (PCI; CAD group) and 1337 patients (59.3%) were without or with mild/moderate CAD and were considered as controls (no-CAD group). To evaluate the safeness and efficacy of preventive PCI in patients with severe CAD undergoing EVAR, groups were compared for hospital and 12-monthcardiac adverse events. CAD was present in 1210 patients (53.6%): significant in 917 patients (38%) and mild to moderate in 293 patients (5.3%). Hospital and 12-monthcardiac events occurred in 15 (1.6%) and 13 (1.4%) CAD group patients and in 9 (0.7%) and 8 (0.4%) no-CAD group patients (p = .05 and p = .08), respectively. Hospital and 12-monthcardiac deaths occurred in 3 (0.3%) and 2 (0.2%) CAD group patients and in 3 (0.2%) and 2 (0.2%) no-CAD group patients (p = .9 and p = .9), respectively. The strategy to treat severe CAD preoperatively by PCI and early subsequent EVAR brings a similar outcome to that in patients without or with mild/moderate CAD.

Laparoscopic abdominal perineal rectal resection for rectal cancer with a horseshoe kidney using preoperative 3D-CT angiography: a case report

BackgroundA horseshoe kidney is a congenital malformation involving the fusion of the bilateral kidneys and is often accompanied by anomalies of the ureteropelvic and vascular systems. When performing resection of colorectal cancer in a patient with horseshoe kidney, damage to the ureter or excessive renal arteries should be avoided. To achieve this purpose, comprehensive preoperative anatomical assessments and surgical planning are important. Here, we report a case of a laparoscopic abdominal perineal rectal resection for lower rectal cancer with a horseshoe kidney.Case presentationA 79-year-old woman presented with bloody stool and was diagnosed with advanced lower rectal cancer, immediately above the rectal dentate line, without metastasis. A preoperative computed tomography (CT) scan revealed a horseshoe kidney, while a three-dimensional CT (3D-CT) angiography revealed aberrant excess renal artery from the aorta to the renal isthmus. The left ureter ran in front of the isthmus of the horseshoe kidney and presented calculus formation. Laparoscopic abdominal perineal rectal resection was performed with D3 lymph node dissection. During the operation, we mobilized the sigmoid colon mesentery via a medial approach and preserved the left ureter, the left gonadal vessels, and the hypogastric nerve plexus in the retroperitoneum in front of the horseshoe kidney.ConclusionsWe report a rare case of rectal cancer surgery in a patient with a horseshoe kidney. We discuss the anatomical peculiarities of a horseshoe kidney, such as excess renal arteries, inferior vena cava, ureter, gonadal vessels, and nerves, that should be preserved according to the literature. We suggest that preoperative 3D-CT angiography is both useful for revealing the relationship between the vascular system and a horseshoe kidney and helpful when performing laparoscopic surgery for a left-sided colon and rectal cancer to avoid intraoperative injury.

Endovascular Treatment for Lateral Wall Paraclinoid Aneurysms and the Influence of Internal Carotid Artery Angle.

Lateral wall paraclinoid aneurysms (LPA) are a rare type of aneurysm located on the lesser curve side of the internal carotid artery (ICA) bend, at the level of the anterior clinoid process. The objective of this study was to assess the influence of flexion of the ICA on the morphology of aneurysms and outcome of endovascular treatment. Between 2003 and 2018, we treated 643 cases of unruptured paraclinoid aneurysms with endovascular therapy in our institution. Of those cases, aneurysms projecting laterally on preoperative angiography were defined as LPA. The degree of bending of the ICA (ICA angle) was measured and statistically analyzed in relation to the aneurysm characteristics and the occlusion status after treatment. In all, 43 aneurysms were identified. ICA angle was positively correlated with the maximum dome size of the aneurysm (P <0.01) and the aspect ratio (P <0.01), and negatively correlated with the volume coil embolization ratio (P <0.01). Complete occlusion (CO) was achieved in 23 cases (53.5%) immediately after treatment, and in 35 cases (81.4%) at follow-up. The mean ICA angle in the incomplete occlusion group was significantly larger than in the CO group (P = 0.01). Larger ICA angle resulted in recurrence, whereas smaller ICA angle was more likely to obtain progressive thrombosis (P = 0.02). Endovascular treatment for LPA was safe and effective. The degree of flexion of the ICA may contribute to the level of hemodynamic stress on the aneurysm, its morphology, and the embolization effect.

Artificial Intelligence and Oct Angiography in Full Thickness Macular Hole. &lt;i&gt;New Developments for Personalized Medicine&lt;/i&gt;

Background: To evaluate the predictive performance for 1-year visual acuity of an artificial intelligence (AI) based model applied to optical coherence tomography angiography (OCT-A) vascular layers scans from eyes with full thickness macular hole (FTMH). Methods: In this observational, cross-sectional study, 35 eyes of 35 patients with FTMH were analyzed by OCT-A before surgery. Superficial vascular plexus (SVP) and deep vascular plexus (DVP) high quality images were collected for the analysis. An AI approach based on convolutional neural networks (CNN) was used to generate a continuous predictive variable based on both SVP and DPV. Different pre-trained CNN networks were used for feature extraction and compared for predictive accuracy. Findings: 35 patients affected by FTMH were analyzed with a mean 1-year BCVA score distribution of 56.63 (±19.6 SD). Among the different tested models, the Inception V3 network applied on the combination of deep and superficial OCT-A images, showed the most significant differences between the two obtained image clusters: BCVA C1= 49.10 (±18.60 SD) and BCVA C2= 66.67 (±16.00 SD) (p=0.005). Interpretation: The AI based analysis of preoperative optical coherence tomography angiography (OCT-A) images of eyes affected by FTMH may be useful support systems in setting up predictive of visual acuity recovery. The combination of preoperative SVP and DVP images showed a significant morphological predictive performance for visual acuity recovery. Funding: Universita Cattolica del Sacro Cuore contributed to the funding of this research project and its publication. Declaration of Interest: The authors have no conflict of interest to disclose. Ethical Approval: This prospective, observational, cross-sectional study evaluated 35 eyes of 35 patients affected by FTMH and evaluated with preoperative OCTA. This study adheres to the tenets of the Declaration of Helsinki (52nd WMA General Assembly, Edinburgh, Scotland, October 2000), and written informed consent was obtained from all patients prior to participation in the study. Institutional Ethics Committee approval was obtained from the Fondazione Policlinico Universitario “A. Gemelli” IRCCS of Rome, Italy(ID number: 3680).

When Is Diagnostic Subtraction Angiography Indicated Before Clipping of Unruptured and Ruptured Intracranial Aneurysms? An International Survey of Current Practice.

The goal of this survey is to investigate the indications for preoperative digital subtraction angiography (DSA) before clipping of ruptured and unruptured intracranial aneurysms in an international panel of neurovascular specialists. An anonymous survey of 23 multiple-choice questions relating to indications for DSA before clipping of an intracranial aneurysm was distributed to the international panel of attendees of the European-Japanese Cerebrovascular Congress (EJCVC), which took place in Milan, Italy on 7-9 June 2018. The survey was collected during the same conference. Descriptive statistics were used to analyze the data. A total of 93 surveys were distributed, and 67 (72%) completed surveys were returned by responders from 13 different countries. Eighty-five percent of all responders were neurosurgeons. For unruptured and ruptured middle cerebral artery (MCA) aneurysms without life-threatening hematoma, approximately 60% of responders perform surgery without preoperative DSA. For aneurysms in other locations than MCA, microsurgery is done without preoperative DSA in 68% of unruptured and in 73% of ruptured cases. In cases of ruptured MCA or ruptured non-MCA aneurysms with life-threatening hematoma, surgery is performed without DSA in 97% and 96% of patients, respectively. Factors which lead to preoperative DSA being performed were: aneurysmal shape (fusiform, dissecting), etiology (infectious), size (>25mm), possible presence of perforators or efferent vessels arising from the aneurysm, intra-aneurysmal thrombus, previous treatment, location (posterior circulation and paraclinoid aneurysm) and flow-replacement bypass contemplated for final aneurysm treatment. These are all factors that qualify an aneurysm as a complex aneurysm. There is still a high variability in the surgeons' preoperative workup regarding the indication for DSA before clipping of ruptured and unruptured intracranial aneurysms, except for ruptured aneurysms with life-threatening hematoma. There is a general consensus among cerebrovascular specialists that any angioanatomical feature indicating a complex aneurysm should lead to a more detailed workup including preoperative DSA.

Hemodinamika femoro-poplitealne by-pass hirurgije metodom analize konačnih elemenata

Objective. Femoropopliteal bypass is indicated in the advanced stage of peripheral arterial occlusive disease. The indications for surgical treatment are determined on the basis of a clinical exam, "ankle-brachial index" and angiographic findings. Using the finite element analysis method, three-dimensional models can be made based on angiography, and these models can be used to measure different physical quantities and calculate the value of the "ankle-brachial index". The aim of this paper is to show the hemodynamics of arteries by using the finite element analysis method based on preoperative and postoperative angiography, as well as physical quantities that can be measured in this way. Methods. This case shows the hemodynamics of femoropopliteal bypass in the preoperative and postoperative models. The models obtained by finite element analysis show: pressure, shear stress, velocities, and streamlines. The pressure, i.e. the "ankle-brachial index", was compared with the values measured on the patient, while the other three values were compared preoperatively and postoperatively. Results. Postoperatively, higher values of pressure and "ankle-brachial index" were measured on the patient and on the models. Wall shear stress and velocity values were reduced in postoperative models. The streamlines showed a dominant anterior tibial artery. Conclusion. The values of physical quantities measured on patient and on the models obtained by the finite element analysis method correlate significantly. Some physical quantities could indicate the "weak points" of a particular model.

Effect of Automatic Extraction Accuracy by Different Image Reconstruction Methods Using a Three-dimensional Image Analysis System for Pulmonary Segmentectomy Preoperative CT Angiography

This study aimed to determine the optimal image reconstruction method for preoperative computed tomography (CT) angiography for pulmonary segmentectomy. This study enrolled 20 patients who underwent contrast-enhanced CT examination for pulmonary segmentectomy. The optimal image reconstruction algorithm among four different reconstruction algorithms (filtered back projection, hybrid iterative reconstruction, model- based iterative reconstruction, and deep learning reconstruction [DLR]) was investigated by assessing the CT numbers, vessel extraction ratios, and misclassification ratios. The vessel extraction ratios for main and subsegment branches reconstructed using DLR were significantly higher than those using other reconstruction algorithms (96.7% and 90.8% for pulmonary artery and vein, respectively). The misclassification ratios at the right upper lobe pulmonary vessels (V1 and V2) were especially high because they were close to the superior vena cava, and their CT numbers were similar in all four reconstructions. In conclusion, the DLR allows a high extraction rate of pulmonary blood vessels and a low misclassification rate of automatic extraction.

The Clinical Application Value of Selective Unifocalization in the Treatment of Severe Pulmonary Artery Atresia with Ventricular Septal Defect

Background: This study aims to explore the efficacy of selective unifocalization (UF) for major aortopulmonary collateral arteries (MAPCAs) unifocalization in children with pulmonary atresia with ventricular septal defect (PA/VSD). Methods: A retrospective analysis of 13 patients with PA/VSD/MAPCAs who underwent surgery from June 2017 to December 2019. Sex, age, preoperative cardiovascular angiography test results and McGoon ratio were collected. The properties of the collateral arteries were evaluated by angiography, and selective UF for the “dendritic” MAPCAs and ligation of MAPCAs demonstrating distortion and resistance. Results: A total of 13 severe patients underwent one-stage repair, of which 1 case underwent ventricular septal fenestration and died after 2 weeks of ECMO support. The median age was 37 months, and a median weight was 14.0 kg. A right ventricular to aortic systolic pressure ratio (pRV/pAo) of no more than 0.5 was achieved in 12 living patients. Conclusion: Selective unifocalization based on MAPCAs morphology can achieved a good outcome at the early stage. This surgical concept might be provided a novel insight into treatment for some of the subgroups presenting with this complex form of PA/VSD/MAPCAs.

Surgical Strategy for Sacral Tumor Resection.

PurposeThis study aimed to present our experiences with a precise surgical strategy for sacrectomy.Materials and MethodsThis study comprised a retrospective review of 16 patients (6 males and 10 females) who underwent sacrectomy from 2011 to 2019. The average age was 42.4 years old, and the mean follow-up period was 40.8 months. Clinical data, including age, sex, history, pathology, radiographs, surgical approaches, onset of recurrence, and prognosis, were analyzed.ResultsThe main preoperative symptom was non-specific local pain. Nine patients (56%) complained of bladder and bowel symptoms. All patients required spinopelvic reconstruction after sacrectomy. Three patients, one high, one middle, and one hemi-sacrectomy, underwent spinopelvic reconstruction. The pathology findings of tumors varied (chordoma, n=7; nerve sheath tumor, n=4; giant cell tumor, n=3, etc.). Adjuvant radiotherapy was performed for 5 patients, chemotherapy for three, and combined chemoradiotherapy for another three. Six patients (38%) reported postoperative motor weakness, and newly postoperative bladder and bowel symptoms occurred in 5 patients. Three patients (12%) experienced recurrence and expired.ConclusionIn surgical resection of sacral tumors, the surgical approach depends on the size, location, extension, and pathology of the tumors. The recommended treatment option for sacral tumors is to remove as much of the tumor as possible. The level of root sacrifice is a predicting factor for postoperative neurologic functional impairment and the potential for morbidity. Pre-operative angiography and embolization are recommended to prevent excessive bleeding during surgery. Spinopelvic reconstruction must be considered following a total or high sacrectomy or sacroiliac joint removal.

Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease

The aim of this study was to analyze duplex ultrasound (DUS) and intraoperative angiography concordance for diagnosis of lower limb peripheral artery disease and its value for surgical planning. This was a prospective, observational study, including patients who underwent revascularization of the lower limbs during 2018, diagnosed by DUS only or combined with preoperative computed tomography (CT) angiography. The concordance between preoperative DUS or CT angiography and the intraoperative angiography was studied using the Cohen kappa coefficient (k). The degree of agreement between the DUS-based surgical plan and the final surgical technique was also evaluated. Fifty-one patients were included, with mean age of 71.8±11.96years (46-94); 23 had chronic kidney disease (45%). In 17 patients (34%), preoperative CT angiography was also performed. DUS showed a sensitivity of 100% (95% confidence interval (CI) [83.3-100%]), 80% (95% CI [50.21-100%,]), and 100% (95% CI [96.43-100%]) at the iliac, femoral, and popliteal sector, respectively, and a specificity of 93.55% (95% CI [83.29-100%]), 95.45% (95% CI [84.48-100%]), and 90.48% (95% CI [75.54-100%]) at the iliac, femoral, and popliteal sector, respectively. The positive predictive value for DUS was 60% (95% CI [7.06-100%]), 88.9% (95% CI [62.8-100%]), and 87.5% (95% CI [68.17-100%]) for the iliac, femoral, and popliteal sectors, respectively, whereas the negative predictive value was 100% (95% CI [98.28-100%]), 91.3% (95% CI [77.61-100%]), and 100% (95% CI, [97.37-100%]). The concordance between DUS and intraoperative angiography showed a k index of 0.587 (P=0.000) in the iliac sector, 0.799 in the femoral sector (P=0.000), and 0.699 in the popliteal sector (P=0.000). The concordance between CT angiography/intraoperative angiography had a k index of 0.71 in the iliac sector (P=0.0093), 0.566 in the femoral sector (P=0.006), and 0.5 in the popliteal sector (P=0.028). DUS-based surgical plan was accurate in 86% of cases (n=44). Our experience suggests that DUS arterial mapping of the femoral and popliteal areas is better than CT angiography and can be considered as a unique preoperative imaging test during the surgical planning in patients undergoing a lower limb revascularization procedure.

The incidence and related factors of coronary events among 40-49 years old patients undergoing cardiac thoracotomy without preoperative CAG

Objective: To investigate the long-term incidence of coronary events and related factors in patients undergoing cardiac thoracotomy without preoperative coronary angiography (CAG). Methods: This was a retrospective study. The clinical data of patients, aged between 40 and 49 years old, who underwent cardiothoracic surgery, including heart valve surgery, congenital heart disease surgery, cardio great vessels surgery and other non-coronary artery disease (CAD) surgery, in Nanjing Drum Tower Hospital from December 2009 to May 2017, were enrolled. Patients with suspected CAD, or patients with coronary CTA defined calcified coronary arteries received CAG examination prior operation, and the rest patients did not receive routine CAG examinations. The patients who did not receive routine CAG examinations were followed up by telephone. The primary endpoints include death related to coronary arteries, coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI). The secondary endpoints include the new onset angina, clinically diagnosed CAD or receiving the first and second prevention for CAD. The other outcome events included cardiac death and all-cause mortality. The primary and secondary endpoints were all regarded as coronary events. The patients without preoperative CAG were divided into two groups: the positive group and the negative group, according to the incidence of coronary events during follow-up. Clinical data were compared between the two groups. Results: A total of 952 patients were included. The age was (45.2±2.7) years old, 406(42.65%) patients were male. Preoperative CAG was performed in 73 patients, among whom 9 (12.32%) patients underwent simultaneous CABG. Among the 879 cases who did not undergo coronary angiography before the operation, 18(2.05%) died during perioperative period (hospitalization and within 30 days after discharge). The patients were followed up for (61.6±25.8) months, and 28(3.25%) patients were lost to follow up. During long-term follow up, there were no fatal cases due to severe coronary events and no cases of CABG or PCI. Only 4.41% (38/861) patients had the secondary endpoints, namely the occasional onset of atypical angina. The incidence rate of the long-term coronary events, all-cause mortality and cardiac death were 4.41% (38/861), 1.16% (10/861), 0.46% (4/861) during long-term follow-up. The prevalence of hypertension was significantly higher in positive group than negative group (34.21% (13/38) vs. 20.89% (164/785), P=0.045). Conclusions: It is feasible not to perform preoperative CAG examination for non-CAD patients aged 40-49 years who will undergo cardiac thoracotomy. However, we need to be aware the risk of coronary events in the patients complicating with risk factors of CAD, such as hypertension.

Microsurgical Findings of Pial Arterial Feeders in Intracranial Dural Arteriovenous Fistulae: A Case Series.

Pial arterial feeders in an intracranial dural arteriovenous fistula (dAVF) are risk factors for both ischemic and hemorrhagic complications during endovascular embolization. Microsurgery in dAVF with pial arterial feeders has rarely been reported. To assess our original experience with microsurgery for dAVF with pial arterial feeders by investigating surgical findings and outcomes. In 40 patients with intracranial dAVF who underwent microsurgery, we found 8 patients who had pial arterial feeders. A retrospective review was conducted. The locations of the dAVFs were as follows: tentorium, 2 patients; Galenic system, 1; straight sinus, 1; torcula, 1; transverse sinus, 1; ethmoid, 1; and convexity, 1. Preoperative angiography revealed that the pial arterial feeders originated from the middle cerebral artery in 2 patients, the anterior cerebral artery in 1, the posterior cerebral artery in 2, and the posterior medial choroidal artery in 1. Of note, in 2 patients (6.7%), feeders from the superior cerebellar artery were determined to be angiographically occult during preoperative examination and were detected through careful intraoperative observation and arachnoid dissection. In 5 cases, the additional obliteration of the pial arterial feeders and/or more distal cortical venous drainers after the simple disconnection of proximal cortical drainers was necessary to cure the dAVF. Finally, all shunts were cured with only 1 minor complication. Although microsurgical results were acceptable, the surgeon should be aware of the presence of pial arterial feeders even after the simple disconnection of cortical venous drainage. Angiographically occult feeders may also exist.

Long-Term Patency and Final Structure After Superficial Temporal Artery–Middle Cerebral Artery Bypass Surgery: A Retrospective Study

To investigate long-term bypass patency and final structure for patients who underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass. This study retrospectively evaluated 20 patients who underwent STA-MCA bypass and had 2-year follow-up with cerebral angiography. Patients were divided into internal carotid artery occlusion (n= 11) and MCA occlusion or stenosis (n= 9) groups, and diagnosis was either arteriosclerotic (n= 14) or nonarteriosclerotic (n= 6) disease. Final bypass formation was examined with cerebral angiography at 2 years postoperatively. Diameters of the STA, middle meningeal artery (MMA), and deep temporal artery (DTA) were measured at preoperative angiography and at 2-year follow-up. No significant differences in STA, MMA, and DTA diameters were reported between the internal carotid artery versus MCA group. For patients with arteriosclerotic disease, thicker STA diameters were noted on preoperative angiography. For patients with nonarteriosclerotic disease, MMA and DTA dilatation was noted on 2-year follow-up imaging. For patients with arteriosclerotic disease, all direct bypasses were patent at 2 years. For patients with nonarteriosclerotic disease, remarkable angiogenesis was demonstrated. Long-term patency of a direct bypass may be correlated with arteriosclerotic or nonarteriosclerotic etiology. An indirect bypass route may develop in patients with nonarteriosclerotic disease; therefore, it is important to create a foundation for an indirect bypass with MMA and DTA preservation during craniotomy. In 2 patients with nonarteriosclerotic disease, STA remained the primary bypass foundation; however, the technique resembled novel angiogenesis after encephaloduroarteriosynangiosis and not direct STA-MCA bypass. Therefore, final bypass structure might be affected by disease etiology.

Risk factors for medullary infarction after endovascular trapping of vertebral artery dissecting aneurysms

Internal trapping (IT) is a treatment option for intracranial vertebral artery dissecting aneurysms (VADAs). Medullary infarction (MI) is a complication linked to this treatment. This study aims to clarify the outcomes of IT for VADAs and the risk factors for MIs. We retrospectively reviewed the databases from 2010 to 2017 to identify patients with VADAs treated by IT at seven collaborating institutions. Radiological findings, clinical courses, and outcomes were analyzed. Perforating arteries were classified into terminal or longitudinal types using preoperative angiography. IT was completed in 90 patients (74 ruptured and 16 unruptured VADA). Postoperative rebleeding did not occur in any ruptured VADA patients. Postoperative MRI detected MIs in 26 patients (28.9%). The incidence of MIs in the ruptured VADA (32%) was higher compared with that in the unruptured VADA (13%), though it was not significant. In the MI group, the occlusion or blind alley of the terminal-type and longitudinal-type perforator was confirmed in 23 patients (88%) and 11 patients (42%), respectively. The occlusion or blind alley of the terminal-type perforator was an independent risk factor for MIs in the logistic regression analysis (OR 5.81; 95% CI 1.34-25.11; p = 0.018). In ruptured VADA, postoperative MI (OR 12.2; 95% CI 3.19-64.55; p = 0.0001) and high-grade SAH (OR 8.02; 95% CI 2.32-37.70; p = 0.0006) were independent risk factors of an unfavorable clinical outcome. In conclusion,MIs were an independent risk factor for unfavorable outcomes after IT, especially for a ruptured VADA. The occlusion or blind alley of the terminal-type perforator caused by the IT was associated with postoperative MIs.

Diagnostic reliability of the Berlin classification for complex MCA aneurysms\u2014usability in a series of only giant aneurysms

Background and objectiveThe main challenge of bypass surgery of complex MCA aneurysms is not the selection of the bypass type but the initial decision-making of how to exclude the affected vessel segment from circulation. To this end, we have previously proposed a classification for complex MCA aneurysms based on the preoperative angiography. The current study aimed to validate this new classification and assess its diagnostic reliability using the giant aneurysm registry as an independent data set.MethodsWe reviewed the pretreatment neuroimaging of 51 patients with giant (> 2.5 cm) MCA aneurysms from 18 centers, prospectively entered into the international giant aneurysm registry. We classified the aneurysms according to our previously proposed Berlin classification for complex MCA aneurysms. To test for interrater diagnostic reliability, the data set was reviewed by four independent observers.ResultsWe were able to classify all 51 aneurysms according to the Berlin classification for complex MCA aneurysms. Eight percent of the aneurysm were classified as type 1a, 14% as type 1b, 14% as type 2a, 24% as type 2b, 33% as type 2c, and 8% as type 3. The interrater reliability was moderate with Fleiss’s Kappa of 0.419.ConclusionThe recently published Berlin classification for complex MCA aneurysms showed diagnostic reliability, independent of the observer when applied to the MCA aneurysms of the international giant aneurysm registry.