Revascularization Techniques Research Articles

Expression of cardiomyopathy-related genes in mononuclear blood cells predicts all-cause mortality in patients presenting with acute versus chronic coronary syndrome requiring revascularisation

Abstract Objective Despite advances in the revascularisation techniques their net clinical benefit differs substantially between patients presenting with myocardial infarction (ACS) and chronic coronary syndrome (CCS) due to obstructive coronary atherosclerosis. Considering that leukocytes represents a key pathophysiological component of myocardial ischaemia, exploration of mononuclear blood cell (PBMC) gene expression profile in CCS and ACS setting could reveal clinically relevant transcriptomic signals. The aim of the present study was to identify differences in PBMC transcriptome between ACS and CCS patients which are linked to mortality after revascularisation. Methods and Results We analysed PBMC transcriptomes from719 ACS and 486 CCS patients creating discovery cohort. The results of transcriptomic analysis were verified in replication cohort (ACS: N=682 for CCS: N=489) generated based on propensity score matching. Median time from revascularisation to blood collection (IQR) was 15.68 (-4.52, 23.23) hrs. Patients with ACS showed consistent differential expression of 8173 genes (4544 upregulated, 3629 downregulated) when compared with CCS patients. The subsequent pathway analysis also showed significant enrichment of several canonical pathways involved in major cardiovascular pathologies i.e. atherosclerosis (p = 1.22-06, enrichment = 3.39), vascular endothelial growth factor production (p = 1.16-06, enrichment = 16.73), positive regulation of vascular development (p = 2.78-06, enrichment = 5.30) and heterotopic cell adhesion including gene desmocollin 2 (DSC2, p = 3.64-04, enrichment = 6.30). In der multivariate survival analysis with differentially expressed genes, increased expression of DCS2, lamin A/C (LMNA), and UGGT2, and decreased expression of SNRNP70 predicted poor survival over the median follow-up 11.35 yrs. Consistently, controlling the false discovery rate at ≤ 5% these genes enriched pathways involved in cardiomyopathies such as arrhythmogenic right-ventricular cardiomyopathy (p = 4.19x10-4, enrichment = 58.9) and collagen disease (p = 2.29x10-3, enrichment = 23.8). Conclusion We found altered PBMC expression of multiple genes in patients requiring revascularisation for ACS versus CCS. Several differentially expressed genes included in cardiomyopathy pathways predicted long-term all-cause mortality in these patients.

Application of surgical revascularization technique in giant aneurysm of the extracranial internal carotid artery: technical report.

The purpose of this study is to illustrate the diagnostic and therapeutic value and clinical significance of surgical revascularization in giant aneurysms of the extracranial internal carotid artery. The research team screened a group of cases of giant aneurysms of the extracranial internal carotid artery and analyzed the detailed information of the enrolled patients in terms of their basic clinical characteristics, surgical approaches and clinical prognosis. All patients had a good prognosis, except for one patient who was left with only mild facial nerve palsy (grade II facial paralysis). The results demonstrate that surgical revascularization is effective and safe in the treatment of giant aneurysms of the extracranial internal carotid artery. The significant conclusion of this study is to provide an ideal alternative treatment for the treatment of giant aneurysms of the extracranial internal carotid artery. The surgical revascularization technique is a powerful tool for vascular neurosurgeons in the management of complex cerebrovascular diseases when traditional surgical clipping or endovascular interventions encounter bottlenecks.

Analysis of two reperfusion techniques in uterine transplantation in an experimental model.

Uterine transplantation was developed for the treatment of absolute uterine factor infertility. As it is a new modality of transplantation, there is still room for technical improvement. A factor that impacts graft survival in organ transplantation is the warm ischemia time. In uterine transplantation specifically, at least two vascular anastomoses are performed on each side of the uterus, and the graft revascularization takes place when the vascular clamps of the arteries and veins are released on both sides simultaneously. For this reason, the warm ischemia time in uterine transplant is expected to be considerably long. The purpose of this study was to compare the sequential technique of uterine graft revascularization, which aims to reduce the warm ischemia time of the procedure, with the simultaneous revascularization technique. For the procedure, the uterine auto-transplantation technique was performed using 10 non-pregnant adult ewes weighing about 45 kg, divided into two groups: simultaneous revascularization group (5 animals) and sequential revascularization group (5 animals). To evaluate the groups, we analyzed the procedure and warm ischemia times, graft macroscopy, hemodynamic, laboratory, and histological parameters of the uterus. The sequential revascularization technique group had similar surgical procedure times, and the warm ischemia time was significantly shorter with medians of 32 min in the sequential group versus 72 min in the simultaneous group (p < 0.008). The graft macroscopy and hemodynamic, laboratory, and histological parameters evaluated were similar between the groups. The sequential revascularization technique proved to reduce the warm ischemia time in the sheep uterine auto-transplantation model without compromising graft viability.

STROKE: A COMPREHENSIVE OVERVIEW OF TRENDS, PREVENTION, AND TREATMENT (LITERATURE REVIEW)

A stroke is an emergency medical condition, commonly referred to as a cerebrovascular accident, occurs when the blood supply to the brain is interrupted, depriving brain tissue of oxygen and essential nutrients. This interruption can lead to rapid neurological impairment and, if not treated promptly, permanent brain damage or even death. Stroke is primarily categorized into two types: ischemic, resulting from arterial blockage, and hemorrhagic, caused by a ruptured blood vessel. Conditions such as acute cerebral circulatory disorder, atherosclerosis, and carotid artery stenosis are strongly associated with an increased stroke risk. Understanding these underlying factors is crucial for effective prevention, early detection, and management of stroke. Globally, stroke ranks as the second lead in cause of disability and mortality, disproportion at early affecting low-and-middle - income countries. Efforts in stroke prevention emphasizes the significance of early detection, management, promoting healthy lifestyles, and implementing legislative measures. The healthcare costs associated with stroke are substantial and projected to grow significantly. Socioeconomic factors and adverse working conditions also influence stroke incidence. Advancements in surgical revascularization techniques, such as carotid endarterectomy and stenting, have demonstrated efficacy in reducing stroke risk. Continuous research and development of optimal treatment strategies and monitoring protocols are essential for improving stroke outcomes and mitigating its global burden.

Steroid-resistant immunoglobulin G4-related coronary arteritis: A case report

Abstract Background Immunoglobulin G4 (IgG4)-related diseases are systemic fibroinflammatory disease characterized by extensive infiltration of IgG4-positive plasma cells in the affected tissue(s), with high plasma levels of IgG4. However, coronary involvement is rare. Case Summary A 70-year-old man was diagnosed with IgG4-related coronary arteritis, pancreatitis, and cholangitis during full-body contrast computed tomography (CT) examination prior to surgery for an iliac artery aneurysm. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/CT showed increased uptake of 18F-FDG in the pancreas, extrahepatic bile ducts, and proximal right coronary artery (RCA). Despite the patient being asymptomatic, the RCA showed severe stenosis. The patient was administered a conservative treatment with prednisolone, 30 mg/day, gradually tapered to 5 mg/day, for 6 months. Two years later, contrast CT showed improvement of the pancreatic and bile duct lesions; however, the steroid therapy had not improved the coronary artery lesions, and gradual progression of the lesions was observed. Percutaneous coronary intervention was performed with a cutting balloon in the RCA, and good patency was maintained for 1 year after the procedure. Discussion Steroid therapy is the first-line treatment for IgG4-related diseases; however, there may be some refractory cases. The stenotic and aneurysmal type IgG4-related coronary arteritis are life-threatening; therefore, we performed revascularization using balloon angioplasty. Determining the optimal revascularization technique for drug-refractory cases requires further investigation.

Role of Multistate Models to Predict Patency, Limb Salvage, and Survival: New Concepts to Analyse Data in Peripheral Arterial Disease

In peripheral arterial disease, patency, limb salvage, and survival rates are mostly reported using Kaplan-Meier analyses. When comparing different revascularisation techniques, these methods have limitations in analysing complex patient flows over time. This study aimed to present, illustrate, and discuss new concepts based on multistate models of analysing outcome parameters in peripheral arterial disease. Previously published data from a single centre, randomised controlled trial (RCT) with 218 cases that underwent either vein bypass surgery (bypass group, n = 109) or nitinol stent angioplasty (stent group, n = 109) of long femoropopliteal lesions were re-analysed using non-homogeneous Markov models. A step by step description of the concepts of states, state space, definitions, and illustration of transition probability curves as well as the benefits of multistate models is given. The RCT was registered at ISRCTN.com (ISRCTN18315574). Transition probability curves over time showed similar patterns in the bypass and stent groups. Significant differences in the transition probabilities were found for transitions from primary patency as well as secondary patency to end of patency. The transition probability for patients with preserved primary patency at 24 months who moved to end of patency at 48 months was 19.9% in the stent group vs. 6.4% in the bypass group (p < .001). The proposed method can answer important questions, such as: Did patients after femoropopliteal stenting with preserved primary patency at two years lose their patency more quickly within the following years compared with bypass surgery? and Did stent patients after a re-intervention to maintain patency at one year lose their patency more quickly compared with bypass surgery within the following years? Completely new research questions can now be raised and answered to optimise treatment and follow up strategies; this might lead to better identification of subgroups at higher risk of clinical deterioration following revascularisation procedures.

Robot-Assisted Minimally Invasive Coronary Artery Bypass Grafting: Total Arterial Revascularization Using the Double-Docking Technique.

The right internal mammary artery is considered to be the second choice for arterial conduits for coronary artery bypass grafting (CABG). However, the widespread use of bilateral internal mammary artery (BIMA) grafting is limited owing to increased technical demands, lengthy procedure, and high incidence of sternal wound complications. We compared the early clinical outcomes of a novel robot-assisted double-docking technique (DDT) with an open sternotomy technique for total arterial revascularization using BIMA. Between June 2019 and June 2023, 445 patients with multivessel coronary artery disease underwent open sternotomy CABG using BIMA grafting and 145 patients underwent robot-assisted BIMA grafting using DDT. Comparative analysis of 104 pairs of matched patients obtained using propensity score matching was performed. Procedural characteristics, postoperative 30-day mortality, and composite outcome (major adverse cardiac and cerebrovascular events) at a median follow-up of 1.5 years were evaluated. Preprocedural characteristics were well balanced between the groups after propensity matching. The number of distal anastomoses performed in the conventional group was statistically higher than that performed using DDT (P < 0.001). The durations of postsurgical ventilation, intensive care unit stay, and in-hospital stay were significantly lower with the DDT than with conventional CABG (P < 0.001). There was no significant difference in all-cause mortality or major adverse cardiac events between the DDT and conventional CABG groups at a median follow-up of 1.5 years. The DDT is feasible and efficacious for revascularization of multiple coronary targets in select individuals. It is equivalent to open sternotomy in terms of early clinical outcomes and superior to open sternotomy with regard to rates of sternal infection and intensive care unit and in-hospital stay.

Experience of an interdisciplinary management for pediatric Moyamoya disease: application of a novel Hemispheric Surgical Score.

The primary purpose of this study was to develop and implement a novel Hemispheric Surgical Score to guide the treatment of pediatric patients with Moyamoya disease (MMD). Additionally, we aimed to describe a comprehensive flowchart for the evaluation, treatment, and follow-up of these patients and to share our experience with the interdisciplinary management of a large pediatric cohort at a referral pediatric hospital. We conducted a retrospective observational study using medical records of patients diagnosed with MMD at the Pediatric Hospital "Prof. Dr. Juan P. Garrahan" in Buenos Aires, Argentina, from July 2013 to July 2023. From July 2016 onward, data were analyzed prospectively following the implementation of the Hemispheric Surgical Score and the flowchart. Evaluations included clinical, MRI, and angiographic criteria, and patients were managed by an interdisciplinary team. Demographic, clinical, and neuroimaging data were collected and analyzed. Eighty hemispheres from 40 patients were analyzed, with cerebral revascularization performed on 72 hemispheres from 37 patients. The Hemispheric Surgical Score and flowchart standardized treatment decisions, and reduced the need for invasive studies like angiographies for follow-up. The majority of patients (79.1%) had favorable outcomes, with complete disease progression arrest and no worsening of imaging nor clinical scores during a median follow-up of 35.8months. The Hemispheric Surgical Score and the comprehensive flowchart have improved the management of MMD in pediatric patients by standardizing treatment and reducing unnecessary invasive procedures. This interdisciplinary approach has led to better patient outcomes, highlighting the need for further validation in larger studies and comparisons of different revascularization techniques through randomized clinical trials.

Evolution of Medical and Surgical Management of Carotid Disease from Carotid Endarterectomy to Transfemoral Carotid Stenting to TCAR

Patients with carotid stenosis can be broadly classified into two categories: symptomatic and asymptomatic. While there is little disagreement about surgical management of symptomatic carotid stenosis, the optimal management strategy for the patients with asymptomatic carotid disease has undergone significant evolution over past five decades. With increasing focus on role of plaque morphology on the etiology of symptoms, there has been an increased focus on optimizing the medical management targeted at plaque stabilization, especially for the patients with asymptomatic carotid disease, while reserving the most aggressive surgical treatment options for the patients with symptomatic carotid stenosis. This review summarizes the scientific evidence based on multiple large clinical studies showing how the modern-day management of carotid stenosis has evolved. Multiple, large randomized clinical trials have established carotid endarterectomy (CEA) as the treatment of choice for symptomatic patients with symptomatic, >50% stenosis of carotid artery or those who have asymptomatic high grade carotid stenosis. With the advancements in endovascular techniques, the technique of Trans Femoral Carotid Artery Stenting (TF-CAS) was popularized, but after multiple, large randomized controlled trials demonstrated superiority of CEA, the indications for TF-CAS as the initial operation of choice for carotid disease for all patients have been reduced. In the past five years, the introduction of the newer technique of Trans Carotid Artery Revascularization (TCAR) has shown promising results with significant reduction in the incidence of perioperative complications as compared to CEA and TF-CAS, however, there have been no randomized controlled trials comparing TCAR to either CEA or TF-CAS. Moreover, with the developments in the medical field with introduction of several new medications which have been demonstrated to successfully change the plaque morphology, there has been a renewed interest in exploring if the indications for surgical management for the asymptomatic carotid disease should be revisited.

Comparative Retrospective Cohort Study of Carotid-Subclavian Bypass versus In Situ Fenestration for Left Subclavian Artery Revascularization during Zone 2 Thoracic Endovascular Aortic Repair: A Single-Center Experience.

Background: Thoracic endovascular aortic repair (TEVAR) has become the first-line therapy for descending aortic disease. Recent studies have demonstrated that preventive revascularization of the left subclavian artery (LSA) in zone 2 TEVAR cases reduces the risk of neurological complications. However, there is no uniform consensus on the choice of revascularization techniques. Although carotid-subclavian bypass is considered the gold standard method, in situ fenestration techniques have also shown encouraging results. This study aims to compare the carotid-LSA bypass with in situ fenestration (ISF) for LSA revascularization and to discuss our treatment approach. Methods: We conducted a retrospective review of all patients undergoing zone 2 TEVAR with in situ fenestration (ISF) or carotid-subclavian artery bypasses for LSA revascularization at our institution between February 2011 and February 2024. Preoperative patient characteristics and primary outcomes, such as operative mortality, transient ischemic attack, stroke, and spinal cord ischemia, were analyzed between the groups. Results: During the 13-year study period, 185 patients underwent TEVAR procedures. Of these, 51 patients had LSA revascularization with zone 2 TEVAR; 32 patients underwent carotid-subclavian artery bypasses, and 19 underwent in situ fenestration. The technical success rate was 100%. Statistically, there was no significant difference between the groups in terms of primary outcomes such as stroke, transient ischemic attack, spinal cord ischemia, and death (p > 0.05). Conclusions: In situ fenestration (ISF) may be an effective and feasible method for LSA revascularization. With precise patient selection and in experienced hands, ISF appears to be associated with similar perioperative outcomes and mortality rates to the carotid-subclavian bypass.

The uric acid/albumin ratio might be a better indicator for predicting repeat revascularization in young patients with acute coronary syndrome: Beyond inflammatory biomarkers.

Despite advancements in percutaneous and surgical revascularization techniques, nearly 20% of patients who undergo myocardial revascularization need repeat revascularization. Recently, identified as a prognostication factor for adverse cardiovascular events, the uric acid/albumin ratio (UAR) serves as a new marker for assessing inflammation and oxidative stress. Our objective was to investigate the association between UAR levels and repeat revascularization in young patients with acute coronary syndrome (ACS). We enrolled 371 patients with ACS who were under the age of 55 years and who had previously undergone primary percutaneous coronary intervention. Due to their recurrent symptoms, these patients underwent subsequent coronary angiographic examination. The study cohort was splitted into two groups based on whether repeat revascularization was needed. The study and control groups consisted of 99 and 272 patients, respectively. The mean age of the patients in the study cohort was 41.99±4.99 years. Patients who needed repeat revascularization, in comparison to those who did not, exhibited significantly greater levels of the UAR and uric acid, along with lower levels of neutrophils, stent diameter and high density lipoprotein-cholesterol. Additionally, they had more complex disease, as described by the SYNTAX score. To identify the influential factors associated with repeat revascularization, multivariate logistic regression was performed. SYNTAX score, stent diameter, uric acid levels and the UAR were predictive of the need for repeat revascularization. UAR was found to be an inexpensive, easily accessible marker for identifying young patients with ACS requiring repeat revascularization.

A Single-Surgeon Experience Transitioning to Total Arterial Revascularization.

Background: Coronary artery bypass grafting remains the standard of care for advanced and multifocal coronary artery disease; however, for patients that are surgical candidates, total arterial revascularization (TAR) remains underutilized due to concerns such as sternal wound infections and the learning curve. We present the results of a large cohort of mid-career surgeons transitioning to TAR, focusing on short-term outcomes and the learning curve. Methods: The surgeons transitioned to using TAR as the preferred revascularization technique in August of 2017. The Society of Thoracic Surgeons database was reviewed to identify all patients who underwent isolated non-emergent CABG performed by a single surgeon from January 2014 through January 2022. Patients were divided into two groups-those who had TAR and those who had traditional CABG using one internal mammary artery and vein grafts (IMA-SVG). Results: Eight hundred ninety-eight patients meet inclusion criteria (458 IMA-SVG and 440 TAR). The TAR group had slightly longer cardiopulmonary bypass time, cross clamp times, and operative times (all p < 0.05); however, ICU stay was shorter and 30-day readmission rate was lower for TAR compared to IMA-SVG (all p < 0.05). The TAR group also required fewer postoperative transfusions (p = 0.005). There was no difference in prolonged intubation, stroke, length of stay, mortality, or sternal wound complications between groups (all p > 0.05). The average TAR was 30 min longer; however, learning curves, stratified by number of grafts placed, showed no significant learning curve associated with TAR. Conclusions: An experienced surgeon transitioning from IMA-SVG to TAR slightly increases operative time, but decreases ICU stay, readmissions, and postoperative transfusions with no significant difference in rates of immediate post-operative complications or 30-day mortality, with a minimal learning curve.

Microaxial flow pump (Impella CP®) in patients with ST-elevation myocardial infarction complicated by cardiogenic shock.

Cardiogenic shock due to ST-elevation myocardial infarction remains a critical condition with a high mortality rate, even with current revascularization techniques. The use of mechanical circulatory support, such as the microaxial flow pump device (Impella CP®), presents a promising approach to enhance cardiac output and systemic perfusion. The DanGer Shock trial explored the efficacy of Impella CP® in addition to standard care compared to standard care alone in improving survival outcomes for these patients. Despite the potential for increased adverse events, the Impella CP® device significantly reduces mortality in patients with ST-elevation myocardial infarction complicated by cardiogenic shock. Future research should focus on refining patient selection criteria and minimizing device-related complications to maximize the therapeutic benefits of mechanical circulatory support in this critical population.

Below-the-Ankle Antegrade Teleferic Technique: New Approach for Below-the-Ankle Revascularization in Challenging Cases of Chronic Limb-Threatening Ischemia.

To describe a novel bailout technique to approach below-the-ankle (BTA) chronic total occlusions or plantar-arch severe disease where the balloon/catheter is unable to follow the crossing guidewire and no other described recanalization approach is feasible. When facing a complex BTA revascularization, if the guidewire crosses but the balloon cannot progress due to a lack of pushability, an antegrade puncture of the infrapopliteal vessel where the tip of the guidewire lays is performed. The guidewire is then carefully navigated through this distal BTA vessel into the needle to achieve its rendezvous and externalization. A low-profile balloon is inserted through the femoral access and advanced till the non-crossable point of the BTA vessels. A torque device is then attached to the proximal hub of the balloon, and the through-and-through guidewire is subsequently pulled from the new distal access, allowing the balloon to be dragged across the lesion together with the wire. The below-the-ankle antegrade teleferic (BAT) technique may be considered for highly complex BTA revascularization procedures where the wire crosses the lesion, but no other device can be tracked over it. The clinical impact of this article lies in the description of a bailout technique for BTA revascularization where the guidewire crosses, but no device can be advanced. This technique can be helpful in scenarios where failure to achieve success could result in limb loss. The BAT technique provides a solution in extremely challenging cases, enhancing technical success, improving outcomes and potentially preserving the limbs of patients who would otherwise face amputation, if not revascularized.The video shows the BAT technique performed with a support catheter under fluoroscopy: antegrate puncture of the DP, advancement of the support catheter over the wire, rendezvous of the guidewire in the catheter and subsequent externalization of the wire.

Sixteen-year outcomes of patients undergoing minimally invasive direct coronary artery bypass surgery: a single-center experience

BackgroundMinimally invasive direct coronary artery bypass (MIDCAB) grafting is a safe technique for revascularization of the left anterior descending artery. The objective of this study was to evaluate the long-term outcomes of patients who underwent MIDCAB surgery in our institution. This was a retrospective, observational outcome study of retrospectively collected data. Data was collected using community, electronic, and paper medical records as well as telephone follow-up conversations with patients who underwent MIDCAB between December 1996 and June 2021. The primary outcome measure was mortality. Secondary outcomes included revascularization, myocardial infarction, and wound infection. Survival analysis was performed using the Kaplan–Meier method.ResultsA total of 215 patients were identified in the study period undergoing MIDCAB at our center. The median age was 77 years, and the cohort consisted of 180 (83.3%) of male patients. The median follow-up period was 16 years (12.1–17.7). At follow-up, freedom from repeat left anterior descending revascularization and from other vessels, revascularization was 96.7% and 89.1% respectively. Survival rates were 99.5%, 81.0%, and 45.2% survival at 1 year, 10 years, and 25 years respectively. Univariate analysis showed age (p < 0.01, Hazard ratio 1.08 confidence interval 1.05–1.11) and left ventricular function (p < 0.01, hazard ratio 2.40, confidence interval 1.66–3.45) as factors associated with mortality.ConclusionsOur single-center experience of MIDCAB demonstrated excellent long-term freedom from revascularization and other complications. Although limited by the retrospective nature, the study shows MIDCAB to be a safe procedure for definitive revascularization of the left anterior descending coronary artery.

Safety and Effectiveness of Coronary Sinus Reducer in the Therapy of Refractory Angina Pectoris-Mid-Term Results of the Real-Life Cohort.

Background: Despite continuous improvements in revascularization techniques, refractory angina without potential revascularization options remains a relevant clinical issue with significant impact on the patient's quality of life. Recently, a novel device, the Coronary Sinus Reducer (CSR), has been introduced into clinical practice as a therapeutic option for patients with disabling angina pectoris. In this single-center, observational study, we evaluated the mid-term (3-month) safety and efficacy of the CSR in a real-world cohort. Methods: The study population consisted of 55 patients with refractory angina without potential revascularization options, who were predominantly men (87.3%) with a high cardiovascular risk factor burden and advanced angina (baseline CCS angina class 3.15 ± 0.6). In terms of procedure safety, all patients underwent successful device deployment with only one periprocedural complication. Results: At the 3-month follow-up, we observed a statistically significant improvement in angina control measured CCS class and SAQ-7 total questionnaire along with increased abolition of physical limitation-6-MWT (233.3 ± 107.1 vs. 305.2 ± 126.8; p < 0.0001). Additionally, we observed significant improvement in terms of quality of life measurements SF-36, the EQ-5D-5L questionnaire, and the EQ-VAS. Conclusions: Our real-world data suggest that CSR implantation is a relatively safe procedure and appears to be particularly effective in relieving angina symptoms and improving quality of life in subjects with refractory angina.

Management of Acute Coronary Syndromes in Older People: Comprehensive Review and Multidisciplinary Practice-Based Recommendations.

Managing health care for older adults aged 75 years and older can pose unique challenges stemming from age-related physiological differences and comorbidities, along with elevated risk of delirium, frailty, disability, and polypharmacy. This review is aimed at providing a comprehensive analysis of the management of acute coronary syndromes (ACS) in older patients, a demographic substantially underrepresented in major clinical trials. Because older patients often exhibit atypical ACS symptoms, a nuanced diagnostic and risk stratification approach is necessary. We aim to address diagnostic challenges for older populations and highlight the diminished sensitivity of traditional symptoms with age, and the importance of biomarkers and imaging techniques tailored for older patients. Additionally, we review the efficacy and safety of pharmacological agents for ACS management in older people, emphasizing the need for a personalized and shared decision-making approach to treatment. This review also explores revascularization strategies, considering the implications of invasive procedures in older people, and weighing the potential benefits against the heightened procedural risks, particularly with surgical revascularization techniques. We explore the perioperative management of older patients experiencing myocardial infarction in the setting of noncardiac surgeries, including preoperative risk stratification and postoperative care considerations. Furthermore, we highlight the critical role of a multidisciplinary approach involving cardiologists, geriatricians, general and internal medicine physicians, primary care physicians, and allied health, to ensure a holistic care pathway in this patient cohort.

A Unique and Effective Bypass Technique to Treat Partially Thrombosed Giant Distal Anterior Cerebral Artery Aneurysms in Extremely Narrow Surgical Corridors

Surgical treatment of large or giant thrombosed anterior cerebral artery (ACA) aneurysms often involves revascularization. Herein, we describe a unique and effective bypass technique to treat partially thrombosed giant distal ACA aneurysms in extremely narrow surgical corridors. A 68-year-old man underwent aneurysm trapping and ACA revascularization for a partially thrombosed giant ACA aneurysm in a surgical corridor that was narrow due to anatomic factors. By combining a side-to-side anastomosis and an end-to-side anastomosis at a single anastomotic site, we successfully redirected blood flow from the left pericallosal artery to the right pericallosal and callosomarginal arteries. Postoperatively, cerebral angiography showed that the blood flow in the aneurysm had disappeared, and the bypass remained open. The patient's functional disability gradually improved, and he reported consistently positive outcomes at the 6-month postoperative follow-up examination. This revascularization technique may represent an effective novel treatment option, particularly when multiple revascularization procedures are required within a narrow surgical field.

Evaluation of Success and Complications Scores for Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the Latin American Registry

Chronic total occlusion (CTO) percutaneous coronary intervention is a complex procedure and is associated with considerable risk of complications. Several success and complication scores have been developed; however, data regarding their external validation in other populations such as Latin America are scarce. This study aimed to evaluate the accuracy of the main predictors of success and complications in a broad cohort of procedures in the Latin American (LATAM) CTO registry. From April 2008 to December 2023, 3,706 consecutive procedures listed in the LATAM CTO registry were screened. Of these, 2,835 procedures had sufficient information to analyze the Multicenter CTO Registry in Japan (J-CTO); Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS); Ostial location, Rentrop grade, and Age (ORA); Clinical and Lesion-related Score (CL-score); and EuroCTO Score (CASTLE) success scores. The complication scores were PROGRESS (MACE, mortality, and pericardiocentesis) and Outcomes, Patient health status, and Efficiency iN Chronic Total Occlusion hybrid procedures (OPEN-CTO),OPEN-CLEAN. The J-CTO and CASTLE scores demonstrated the highest areas under the curve (AUC) of 0.718 and 0.703, respectively. The AUC value for the CL-score was 0.685, whereas the PROGRESS score had an AUC of 0.598 and the ORA AUC was 0.545. The level of agreement between scores was low; only 4% of the procedures were classified as difficult or very difficult by all scores and <1% were classified as easy by all 5 scores. Of the complication scores, PROGRESS mortality (AUC 0.651) and PROGRESS MACE (AUC 0.588) showed the best performance, identifying groups with >10% event rate. These results may improve the selection of revascularization techniques, especially for patient demographics that are historically underrepresented in CTO research.

Performing median arcuate ligament release surgery in celiac artery compression syndrome: Insights from a tertiary care hospital.

Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery (CA) compression syndrome, is a rare condition characterized by persistent post-meal or post-exercise abdominal discomfort, often more pronounced during expiration. Additional symptoms include nausea, vomiting, and weight loss. To document the clinical presentation, diagnostic process, and treatment outcomes of seven patients diagnosed with MALS and to evaluate the effectiveness of surgical release of the median arcuate ligament (MAL) over a follow-up period of at least six months. The study included seven patients diagnosed with MALS from 2019 to 2021. Diagnosis was based on the presence of chronic abdominal pain and associated symptoms, absence of alternative diagnoses after various clinical assessments, and angiographic evidence of CA compression. The primary treatment involved surgical decompression of the CA by releasing the MAL through either open or laparoscopic techniques. All seven patients underwent successful surgical release of the MAL. The patients were followed up for at least six months post-surgery. The study evaluated the persistence of symptoms and the need for additional interventions such as revascularization techniques. Surgical release of the MAL is the primary treatment for MALS, providing relief for many patients. However, long-term follow-up is essential as some patients may continue to experience symptoms post-surgery, necessitating further interventions.