Proximal Ramus Research Articles

Diverse changes of ramus coronary artery on computed tomography derived fractional flow reserve due to ramus artery in normal coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background The ramus artery contributes to the development of turbulence, which may influence computed tomography (CT) derived fractional flow reserve (FFRCT) even without coronary artery disease. The relationship between ramus-induced turbulence and FFRCT is unclear. Purpose To investigate the effect of the ramus artery on FFRCT in normal coronary arteries. Methods A total of 120 consecutive patients who underwent both CT angiography including FFRCT and invasive coronary angiography, resulting in < 20% coronary artery stenosis were evaluated. The patients were divided into three groups: absent-ramus (n = 72), small-ramus that could not be analysed by FFRCT (n = 18), and large-ramus that could be analysed by FFRCT (n = 30). FFRCT was measured at the proximal and distal segments of the left anterior descending (LAD), left circumflex (LCX), and ramus artery (in absent-ramus group, FFRCT was measured at just above the bifurcation between LAD and LCX) were measured. The proximal FFRCT segment (proximal LAD, yellow circle; proximal Ramus or just above the bifurcation angle, yellow square; proximal LCX, yellow triangle) was measured at the same level of each vessel and the distal segment (distal LAD, white circle; distal ramus, white square; distal LCX, white triangle) was measured at obtained by the FFRCT analysis (Figure 1). Vessel morphology (vessel length, lumen volume, plaque volume), bifurcation angle, and left ventricular mass were assessed. Results In the absent-ramus group, proximal FFRCT showed no significant difference between three vessels (LAD, 0.96 ± 0.02; MID, 0.97 ± 0.02; LCX, 0.97 ± 0.02). However, in small and large-ramus groups, proximal FFRCT was significantly higher in the ramus artery than LAD and LCX (small-ramus: LAD = 0.95 ± 0.03, Ramus = 0.97 ± 0.02, LCX = 0.95 ± 0.03; large-ramus: LAD = 0.95 ± 0.03, ramus = 0.98 ± 0.01; LCX = 0.96 ± 0.03; p < 0.05) (Figure 2). A large ramus was associated with a higher prevalence of a distal FFRCT ≤0.80 (odds ratio 7.0, 95% CI 1.2–40.1. p = 0.03). A proximal ramus diameter predicted distal FFRCT ≤ 0.80 (cut-off 2.1 mm, AUC 0.76, sensitivity 100%, specificity 52%, 95% CI 0.61–0.90). Conclusions The presence of a large-ramus artery may cause an FFRCT decline in normal coronary arteries.

Impact of ramus coronary artery on computed tomography derived fractional flow reserve (FFRCT ) in no apparent coronary artery disease.

The ramus artery contributes to the development of turbulence, which may influence computed tomography (CT) derived fractional flow reserve (FFRCT ) even without coronary artery disease (CAD). The relationship between ramus-induced turbulence and FFRCT is unclear. A total of 120 patients with<20% coronary stenosis assessed by both FFRCT and invasive coronary angiography were evaluated. The patients were divided into three groups: absent-ramus (n=72), small-ramus that could not be analyzed by FFRCT (n=18), and large-ramus that could be analyzed by FFRCT (n=30). FFRCT measurements were performed at the proximal and distal segments of the left anterior descending (LAD), left circumflex (LCX), and ramus artery. With absent-ramus and small-absent ramus groups, FFRCT was measured at the distal end of the left main trunk at the same level for the proximal segments of the LAD and LCX. In absent-ramus group, proximal FFRCT showed no significant differences between three vessels (LAD=.96±.02; MID=.97±.02; LCX=.97±.02). However, in small and large-ramus groups, proximal FFRCT was significantly higher in the ramus artery than LAD and LCX (small-ramus, LAD=.95±.03, Ramus=.97±.02, LCX=.95±.03; large-ramus: LAD=.95±.03, Ramus=.98±.01; LCX=.96±.03; p<.05). A large ramus was associated with a higher prevalence of a distal FFRCT ≤.80 (odds ratio 7.0, 95% CI 1.2-40.1, p=.03). A proximal ramus diameter predicted distal FFRCT ≤.80 (cut-off 2.1mm, AUC .76, sensitivity 100%, specificity 52%, 95% CI .61-.90). The presence of a large-ramus artery may cause an FFRCT decline in no apparent CAD.

The Low Medial Horizontal Osteotomy in Patients With Atypical Ramus Morphology Undergoing Sagittal Split Osteotomy

Sagittal split osteotomy (SSO) of rami with fused cortices or minimal marrow space above the lingula can increase the risk of an unfavorable osteotomy split of the proximal ramus. To reduce the risk of a proximal segment fracture, a recent modification of the SSO places the medial horizontal osteotomy below the lingula. The purpose of the present study was to evaluate the outcomes of SSOs utilizing a low medial horizontal osteotomy in patients with atypical ramus morphologies. The present study was a prospective series composed of patients with atypical proximal ramus anatomy undergoing SSOs. All patients had undergone bilateral SSO for correction of mandibular deformities. The horizontal ramus osteotomy had been placed at or slightly above the mandibular occlusal plane because of atypical ramus morphology (thin ramus with no appreciable marrow space at or above the lingula and/or narrow retromolar ramus width). The outcome variables were an unfavorable split of the proximal or distal segments, nerve location after SSO (proximal or distal segment), and neurosensory recovery of the inferior alveolar nerve (IAN). The sample included 25 patients who had undergone 50 SSOs using a low medial horizontal osteotomy. Their mean age was 19.6±3.2years; 14 patients were female. Of the 25 patients, 22 had a primary diagnosis of craniofacial anomaly; 23 had undergone bimaxillary surgery and 6 had received concomitant genioplasty. No unfavorable fractures of the proximal segment occurred. No intraoperative IAN injuries occurred. The IAN was contained within the proximal segment in 52% of the cases. All the patients achieved functional sensory recovery of the IAN bilaterally by 1year postoperatively. The mean interval to functional sensory recovery was 116days. The low medial horizontal osteotomy is an effective technique for reliable execution of SSOs in morphologically atypical mandibles.

P714 Contradicting the most basic tenet of black holes: light can, indeed, escape

Abstract A 69-year-old man with history of non-insulin-treated type 2 diabetes mellitus, arterial hypertension and mixed dyslipidemia presented to the emergency department with chest pain lasting for four days. Immediate twelve-lead electrocardiogram unveiled an inferior ST-segment elevation myocardial infarction (STEMI), prompting emergent coronary angiography, which, in turn, revealed two-vessel disease, specifically proximal ramus intermedius 60-70% stenosis and proximal right coronary artery acute occlusion. Culprit lesion was successfully managed with balloon angioplasty and a single drug-eluting stent implantation. Still, clinical course was noticeable for deterioration, under the form of cardiogenic shock, which required invasive ventilation and intravenous vasopressor support with norepinephrine. Despite biventricular systolic function relative preservation, transthoracic echocardiography disclosed inferior akinesis, right ventricle dilation, mild circumferential pericardial effusion and, particularly, a 2.3cm posteroinferior ventricular septal defect (VSD), in the setting of a 4.4cm2 pseudoaneurism, resulting in left-to-right shunting, quantified through maximal/mean trans-VSD pressure gradients of 84/44mmHg. Further imaging with transesophageal echocardiography and cardiac computed tomography angiography allowing the conception of a 3D-printed model was performed. Surgical correction of the defect followed, achieving partial anatomic success, namely with residual shunting, as of a left ventricular systolic pressure of 80mmHg and a right ventricular systolic pressure of 25mmHg. Patient survived, recovered and got discharged three weeks later. At one-year follow-up, he was hospitalized for acute decompensated heart failure (hemodynamic profile C) twice, with medication non-adherence reported as the main precipitating factor. In addition to a significant remaining left-to-right shunt (maximal velocity 3m/s), adverse cardiac remodeling was recognized, featuring left ventricular ejection fraction of 30-35%, severe functional mitral regurgitation, severe postcapillary pulmonary hypertension and de novo left bundle branch block (QRS duration of 197ms). Having been deemed clinically unsuitable for another surgical correction, patient underwent percutaneous VSD closure with both AmplatzerTM septal and muscular VSD occluders, with a suboptimal result. He is now on New York Heart Association class III heart failure and on the waiting list for both MitraClip and cardiac resynchronization therapy implantation. Reflecting numerous breakthroughs in the management of acute myocardial infarction, incidence of mechanical complications is on the decline. Nevertheless, when they occur, morbidity and mortality remain high. Acquired ventricular septal defects are no exception, demanding the best care from a tertiary hospital heart team. Abstract P714 Figure.

THE NOVEL USE OF NEBULIZED TRANEXAMIC ACID FOR MASSIVE HEMOPTYSIS IN THE SETTING OF ACUTE STENT PLACEMENT AND DUAL ANTIPLATELET THERAPY POST CARDIAC ARREST

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Traumatic lung injury is a common complication following CPR. We present a case with massive hemoptysis following CPR, using the LUCAS chest compression system, in whom nebulized tranexamic acid was used to control the bleeding after acute coronary stent placement and being placed on DAPT CASE PRESENTATION: A 57-year-old male with no known PMHx presented to the ER after a witnessed cardiac arrest. CPR was started by the wife. On EMS arrival, the patient was in VF arrest and CPR continued on a LUCAS chest compression system for about 40 minutes before ROSC was achieved in the ER where the patient was intubated. The patient was found to have an acute STEMI and was taken emergently to the cath lab and underwent percutaneous coronary intervention with a drug-eluting stent to the proximal ramus and was started on DAPT (Aspirin and Ticagrelor) The patient was started on a hypothermia protocol and cooled to 32°C for 24 hours before rewarming was initiated After rewarming, on day 4 of hospitalization, the patient was noted to have worsening respiratory distress with increasing PEEP and FiO2 requirements. The patient also had progressively worsening bloody secretions from the ET tube over the previous 24 hours (approximately 300mL). A bronchoscopy was done and showed intra-alveolar hemorrhage with additional 100-150mL suctioned during bronchoscopy. The patient received one dose of nebulized tranexamic acid 500 mg in an attempt to stop the bleeding. The patient was then placed in the prone position, paralyzed with Cisatracurium, and ventilated per our ARDS protocol using 6 ml/kg PBW tidal volume goal. After 24 hours, he had significant improvement in his breathing status with cessation of the bloody secretions from the ETT. The patient was extubated 4 days later. The patient showed gradual improvement in his mental and functional status and was eventually transferred to a long-term care facility in stable condition DISCUSSION: Massive hemoptysis secondary to lung trauma is a complication of CPR. In this case, the patient developed massive hemoptysis following cardiac arrest with prolonged CPR using a LUCAS chest compression system and aggravated by starting him on DAPT after stent placement. Following one dose of inhaled tranexamic acid 500 mg followed by ventilating the patient with our ARDS protocol, there was a rapid improvement in his respiratory status with cessation of the bleeding. Tranexamic acid is a fibrinolysis inhibitor that works by displacing plasminogen from fibrin. Inhaled tranexamic acid has been used to treat hemoptysis. Its use in this case of massive hemoptysis following CPR while the patient is on DAPT after a new stent placement demonstrates a potential for its use in similar cases if more studies are conducted CONCLUSIONS: Inhaled tranexamic acid was effective in controlling massive hemoptysis following prolonged CPR in a patient on DAPT after a new stent placement Reference #1: Inhaled tranexamic acid as an alternative for hemoptysis treatment Calvo G.S., De Granda-Orive I., Padilla D.L. (2016) Chest, 149 (2), pp. 604 DISCLOSURES: No relevant relationships by Abdullah Al-abcha, source=Web Response No relevant relationships by Sherif Elkinany, source=Web Response No relevant relationships by Asfar Ghauri, source=Web Response No relevant relationships by Angela Smolarz, source=Web Response

The outcome of skeletofacial reconstruction with mandibular rotation for management of asymmetric skeletal class III deformity: A three-dimensional computer-assisted investigation

The mandibular proximal ramus segments should be moved and rotated during orthognathic surgery-based skeletofacial reconstruction for the correction of challenging patients with facial asymmetry and malocclusion, but quantitative data regarding this rotation were not sufficient to date. This 3D computer-assisted study measured the proximal ramus segment rotation after 3D simulation-guided two-jaw surgery in patients with facial asymmetric deformity and class III malocclusion (n = 31). Using 3D mandible models and a reliable proximal ramus segment-related plane, angular changes in pitch, roll and yaw directions were measured before and one month after surgery. Significant rotational changes (p < 0.01) were observed in the left and right sides and overall proximal ramus segments after surgery, with absolute differences of 4.1 ± 3.0 (range −7.8 to 6.9), 2.8 ± 2.3 (−8.8 to 5.0), and 2.7 ± 2.4 (−6.6 to 9.9) degrees in pitch, roll, and yaw rotations, respectively. Numbness and mouth opening limiting occurred within the first 6 months after surgery but the patients had an unremarkable long-term postoperative course, with no revisionary surgery required. This study contributes to the multidisciplinary-related literature by revealing that proximal ramus segment rotation and rigid fixation with no postoperative intermaxillary immobilization was practicable in skeletofacial surgery for the successful treatment of asymmetric deformity and class III malocclusion.

Koronarintervention bei einer Patientin mit akuter myeloischer Leukämie

A 63-year-old woman was referred to our hospital for evaluation of leukocytopenia and blast cells in the peripheral blood smear. The general condition was reduced, a maculo-papulous exanthema of the face and upper body as well as a general lymphadenopathy were found. Bone marrow examination revealed the diagnosis of acute myeloid leukemia (AML) FAB M1 and a normal karyotype. Extramedullary manifestations of AML were demonstrated in skin and lymphnode biopsies. ECG showed no signs of ischemia, echocardiography a normal left-ventricular function. The patient received induction treatment using sequential high-dose cytosinarabinosid and mitoxantrone, which rapidly resolved the extramedullary skin- and lymphnode-manifestations of the AML. During the chemotherapy-associated bone marrow aplasia a non-ST-elevation infarction (NSTEMI) developed combined with severe ischemic cardiomyopathy, high-grade mitral valve deficiency and serious congestive heart failure with respiratory failure. Coronary artery angiography showed a complete occlusion of the proximal ramus circumflexus. Percutanous coronary intervention (PCI) with implantation of a bare-metal stent was performed, which resulted in prompt improvement of the condition. Despite the transfusion-dependent thrombocytopenia a dual antiplatelet therapy with acetylsalicylic acid and clopidogrel was given. After each unit of platelets transfused a loading dose of 600 mg clopidogrel was given to prevent stent thrombosis. The patient did not experience major bleeding and was discharged in complete remission of AML and completely cardially recompensated. Coronary angiography and stenting can generally be safely performed in patients with transfusion-dependent thrombocytopenia. Despite a higher risk of bleeding an oral dual antiplatelet therapy with aspirin and e. g. clopidogrel according to the guidelines should be performed, but its duration should be adapted to the individual patient circumstances.

Brachytherapy with gamma radiation of a coronary artery for in-stent restenosis may induce the regression of in-stent restenosis of an adjacent coronary artery without angioplasty. First case report and review of the literature

Here, we present a case of a 63-year-old male who presented with in-stent restenosis of two coronary arteries simultaneously (mid circumflex and proximal ramus). After the brachytherapy of the circumflex artery for in-stent restenosis, the patient refused the staged procedure for the ramus in-stent restenosis. After approximately 2 years, the patient underwent coronary angiography for recurrent chest pain. Surprisingly, the proximal ramus stent showed marked regression of in-stent restenosis. We hypothesized that the gamma brachytherapy of the circumflex artery could have induced the regression of in-stent restenosis of the adjacent ramus artery due to the deep tissue penetration of gamma radiation. Based on our observation, we believe that in the treatment of in-stent restenosis of a coronary artery, the initial balloon angioplasty may not be as important as the radiation itself. This observation warrants further study to evaluate the effect of external or internal radiation on in-stent restenosis without balloon angioplasty. If our hypothesis is confirmed, the treatment of in-stent restenosis with external radiation could substantially simplify the treatment of this disease. This case report follows a brief review of the literature.

A new model for testing therapeutic interventions during myocardial ischemia.

An open-chest dog heart model is presented which shows highly reproducible hemodynamic, electrophysiologic, and metabolic changes during and after short-term coronary occlusions. We repeatedly performed 3-min coronary ligations of the proximal ramus interventricularis anterior followed by reperfusion periods of 45 min. Thus, hemodynamic, metabolic, and electrophysiologic parameters of myocardial damage were fully reversible. The experimental model presented seems well suited to evaluate interventions which aim at influencing the extent and damage of myocardial ischemia without needing a large number of separate experiments.