Arterial Segments Research Articles

Multidisciplinary Approach to Direct Segmental Artery Revascularization to Prevent Spinal Cord Ischemia Associated With Endovascular Thoracoabdominal Aortic Repair

Purpose: Despite advances in complex endovascular aortic repair techniques, spinal cord ischemia (SCI) remains a devastating complication following endovascular thoracoabdominal aortic repairs. Novel strategies to preserve key intercostal/lumbar arteries have been described. We report our early results of patients who underwent direct intercostal/lumbar artery revascularization using endovascular incorporation of fenestrations/branches or extra-anatomic approaches for fenestrated-branched endovascular aortic repairs (FBEVARs). Materials and Methods: A retrospective review of consecutive patients who underwent FBEVAR with intercostal/lumbar artery revascularization from 2018 to 2022 was performed. Patient characteristics, intraoperative details, and outcomes including SCI and branch occlusions were evaluated. Results: Among 317 patients who underwent FBEVAR during the study period, 12 patients were included. Aortic pathologies consisted of degenerative aneurysms (33%), postdissection aneurysms (33%), extensive penetrating aortic ulcers with intramural hematoma (25%), and visceral patch pseudoaneurysm (8%). Full thoracoabdominal coverage was required in 8 patients and supraceliac coverage >10 cm was required in 4. Nine patients received endovascular incorporation, including directional branches (5/9), unstented fenestrations (2/9), and stented fenestration (2/9). Three patients received extra-anatomic subcutaneous femoral-to-radicular artery bypass using a composite graft of polytetrafluoroethylene (PTFE) and venous conduit. Our institutional SCI prevention protocol, consisting of prophylactic cerebral spinal fluid drain (CSFD) for high-risk patients, hemodynamic augmentation, and oxygen supplementation, was followed. Prophylactic CSFD was placed in 9 patients. One patient had unsuccessful drain placement attempts. The other 2 patients had previous unsuccessful attempts at CSFD placement. Median number of target vessels for FBEVAR was 4 with fluoroscopy time 66±31 minutes, contrast usage 109±51 ml. There were no in-hospital mortalities. Tarlov grade II SCI (ASIA grade D) were seen in 2 patients (1 endovascular and 1 extra-anatomic bypass), which resolved before discharge. At mean follow-up of 472±447 days, 3 patients had thrombosed intercostal/lumbar branches (1 extra-anatomic bypass and 2 endovascular branches) with no new SCI symptoms. Conclusions: In patients at high risk for SCI undergoing FBEVAR, direct revascularization of an intercostal or lumbar artery is feasible using endovascular or extra-anatomic bypass approach. Further studies are planned to identify key contributing segmental arteries and optimization of revascularization strategies. Clinical Impact This study demonstrates the feasibility of Endovascular and extra-anatomic bypass to preserve segmental artery flow, aimed at reducing the risk of spinal cord ischemia during endovascular thoracoabdominal aortic repairs.

Abstract 4115015: Hyperpolarized Carbon-13 Metabolic Imaging Detects Changes in Cardiac Mitochondrial Metabolism in Patients Before and After Coronary Artery Bypass Graft Surgery

Background: Coronary Artery Disease (CAD) is a significant global health issue, necessitating improved diagnostic tools for visualizing cardiac energetics. Traditional imaging methods such as PET and dobutamine stress echocardiography do not directly assess mitochondrial metabolism. Hyperpolarized Carbon-13 metabolic magnetic resonance imaging (HP- 13 C MRI) offers a promising non-invasive method for investigating mitochondrial function in CAD. This study utilizes HP- 13 C MRI to detect changes in mitochondrial metabolism in patients undergoing Coronary Artery Bypass Graft (CABG) surgery (Fig.1). Methods: We conducted HP- 13 C MRI examinations on two patients with advanced CAD before and (~4-6 months after CABG surgery and one healthy subject (Fig. 2 A,B). Participating subjects provided informed consent according to a protocol approved by the Institutional Review Board and Protocol Review Committee. Baseline blood samples were analyzed for pyruvate, triglycerides, free fatty acids, and insulin levels. Post-glucose load, patients received an intravenous injection of an IND-approved metabolic probe, [1- 13 C] pyruvic acid, prepared under Good Manufacturing Practice regulations. The HP solution was administered after polarization in a clinical polarizer (SPINlab™, GE Healthcare). Imaging was performed using a GE MR750 MR system with a Helmholtz loop-pair 13 C coil (PulseTeq Limited, UK). Data were reconstructed and analyzed with MATLAB scripts. Results and Discussion: Baseline blood measurements were normal for the healthy subject, but those with advanced CAD showed variable and abnormal values (Fig. 2C). HP- 13 C MRI safely assessed cardiac metabolism in patients with advanced CAD. Patients with advanced CAD exhibited reduced pyruvate metabolism compared to healthy controls, shown by lower myocardial bicarbonate/(bicarbonate+lactate) ratios (Bic/(Bic+Lac)). Following CABG, only Patient 2 showed improved Bic/(Bic+Lac), while Patient 1 did not (Fig. 3A-B). This variability may be influenced by differences in nutrition, hormonal status, medication regimens, or other factors. Changes in % Bic/(Bic+Lac) across different coronary artery segments were observed post-CABG in CAD patients (Fig. 3C). Conclusion: HP- 13 C MRI non-invasively assesses cardiac metabolism in CAD patients, demonstrating the potential to evaluate post-CABG metabolic changes. Our efforts continue to recruit large cohort to understand individual variability.

Enhanced Vasoconstriction in Sickle Cell Disease is Dependent on ETA Receptor Activation

Sickle Cell Disease (SCD) carries a significant risk for poor vascular health and vascular dysfunction. High levels of vascular reactive oxygen species (ROS) as well as elevated plasma endothelin-1 (ET-1), a potent vasoconstrictor with actions via the ETA receptor, are both common phenotypes in SCD. Alpha-1 adrenergic receptor activation is a major mediator of stress-induced vasoconstriction. However, the mechanism of the SCD enhanced vasoconstrictive response is unknown. We hypothesized that SCD induces enhanced alpha-1 adrenergic mediated vasoconstriction through the ET-1/ETA receptor pathway in arterial tissues. Utilizing humanized SCD (HbSS) and genetic control (HbAA) mice, alpha-1a, but not alpha-1b or alpha-1d, receptor expression was significantly greater in aortic tissue from HbSS mice compared to HbAA mice. Significantly enhanced vasoconstriction in aortic and carotid arterial segments were observed from HbSS mice compared to HbAA mice. Treatment with ambrisentan, a selective ETA receptor antagonist, and a ROS scavenger normalized the aortic vasoconstrictive response in HbSS mice. In a randomized translational study, patients with SCD were treated with placebo or ambrisentan for 3 months, with the treatment group showing an increase in the percent brachial arterial diameter. Taken together, these data suggest that the ETA receptor pathway interaction with the adrenergic receptor pathway contributes to enhanced aortic vasoconstriction in SCD. Findings indicate the potential of ETA antagonism as a therapeutic avenue for improving vascular health in SCD.

Hybrid Thoracic Endovascular Repair of a Large, Saccular Aortic Arch Aneurysm with Coil Embolization of the Left Subclavian Artery in a 31 Year Old Filipino Female with Takayasu Arteritis and Multiple Intracranial Aneurysms: A First in the Philippines

BACKGROUND: Takayasu Arteritis (TA) is a rare, primary large-vessel vasculitis frequently leading to stenosis and less commonly, aneurysm formation. Saccular aneurysms of the aortic arch in patients with TA are fatal, have rarely been reported and represent a significant technical challenge due to the difficult anatomical location and need for protection of the cerebral circulation. Concomitant intracerebral aneurysms in patients with TA are extremely uncommon and have mostly been documented in very few case reports in literature. CASE DISCUSSION: We present a case of a 31 year-old Filipino female with recurrent chest and neck pain radiating to the upper back. Computed tomographic (CT) angiography demonstrated a large saccular aortic arch aneurysm without branch stenosis. CTA of the cerebral circulation likewise demonstrated multiple, saccular, intra-cerebral aneurysms. She underwent hybrid thoracic arch repair with supra-aortic debranching via mini-sternotomy and proximal ligation of the left common carotid artery and staged endovascular aortic arch replacement with coil embolization of the ostial-to-proximal left subclavian artery segment. Post-operative aortogram showed optimal repair with thrombosed aneurysmal sac, optimal graft position, no endoleaks and preservation of cerebral circulation. Patient improved symptomatically post-procedure and remained symptom-free during follow-up after six months. Careful review of local literature suggests that this is the first Philippine TA case with a saccular aortic arch aneurysm successfully managed in this manner. CONCLUSION: Saccular aortic arch aneurysms in patients with Takayasu are unusual and presence of concomitant multiple cerebral saccular aneurysms have rarely been reported in literature. This case highlighted that hybrid endovascular arch repair in patients with TA is feasible, minimally invasive and effective. KEYWORDS: Takayasu arteritis, aortic arch aneurysm, cerebral aneurysm, hybrid endovascular arch repair, aortic de-branching

Acute coronary syndrome as the initial manifestation of infective endocarditis in an apparently normal native valve: a case report

Abstract Background Acute coronary syndrome (ACS) is a rare complication of infectious endocarditis (IE). We present the case of a patient with a bicuspid aortic valve who presented an acute ST elevation myocardial infarction (STEMI) of the inferior wall secondary to vegetation that generated obstruction of the ostium of the right coronary artery (RCA). Case summary A 54-year-old patient with only a history of smoking was admitted for chest pain. An acute ST elevation myocardial infarction (STEMI) in the inferior wall was documented; he underwent an emergent coronary angiography, which showed a mass that obstructed the ostium of the right coronary artery that did not allow its channeling. An angiotomography of the aorta was performed, where dissection was ruled out and the presence of a mass in the right coronary sinus that protruded towards the ostium of the coronary artery was confirmed. In the extension studies, a bicuspid aortic valve, thrombosis in the right brachial artery and in the infrarenal abdominal aorta were documented. Discussion The case was taken to a medical meeting and given the embolic and mechanical compromise; it was decided to perform surgery where a mass that invaded the proximal segment of the right coronary artery was resected. The histopathological study documented findings of vegetation; the cultures were positive for Staphylococcus epidermidis, and he finally received antibiotic and anticoagulation treatment.

5-years patency results of Zilver PTX on the femoro-popliteal arterial segment: A Northern Sydney experience.

The burden of peripheral arterial disease is increasing. Treatment of femoro-popliteal lesions remains challenging despite novel endovascular devices. Drug-eluting stents suppress post-treatment inflammation and reducing neo-intimal hyperplasia to reduce in-stent restenosis. A multi-centre retrospective 5-years longitudinal study was undertaken to evaluate freedom from clinically driven target limb revascularisation (FF CD-TLR) and patency of Zilver PTX stents in treating symptomatic femoro-popliteal stenotic lesions. Kaplan-Meier survival curves were used to demonstrate FF CD-TLR, primary, primary assisted and secondary patency. There were 148 patients and 183 lesions treated with a mean age of 80.3years and 52% males. The all-cause 5-years mortality was 25%. FF CD-TLR yearly patencies to 5years were 81%, 67%, 62%, 57% and 52%, respectively, with significantly poorer outcomes for in-stent restenosis, longer stent lengths and lesions at the femoro-popliteal junction. Primary patencies were 63%, 47%, 40%, 34% and 24%, assisted primary patencies were 90%, 75%, 68%, 59% and 48% and secondary patencies were 96%, 94%, 94%, 92% and 92%. Major adverse limb events were 5% at 1-year and cumulative at 5-years was 16%. The clinical outcomes in this study population are comparable to recent publications with smaller cohorts. Our study confirms Zilver PTX has very good primary patency over 5years with no discernible effect on all-cause mortality in an elderly cohort with particularly long treated lesions. Our results are similar to those seen in younger patients with shorter lesions. Nonetheless, longer lesions required more reinterventions to maintain patency. Zilver PTX is a safe and durable drug-eluting stent when utilised in the management of femoro-popliteal stenotic lesions with good long-term patency and limited need for re-intervention.

Main versus segmental hepatic artery angioembolization in patients with traumatic liver injuries: A Western Trauma Association multicenter study

IntroductionHepatic angioembolization is highly effective for hemorrhage control in hemodynamically stable patients with traumatic liver injuries and contrast extravasation. However, there is a paucity of data regarding the specific location of angioembolization within the hepatic arterial vasculature and its implications on patient outcomes. MethodsA post-hoc analysis of a multicenter prospective observational study across 23 centers was performed. Adult patients undergoing main hepatic artery angioembolization or segmental hepatic artery angioembolization within 8 hours of arrival were included. The primary outcome was liver-related complications, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. Secondary outcomes were liver-related complication interventions, length of stay, and mortality. ResultsA total of 55 patients underwent hepatic angioembolization, with 23 (41.8%) undergoing main hepatic artery angioembolization and 32 (58.2%) receiving segmental hepatic artery angioembolization. Both groups were comparable in age, vitals, mechanism of injury, liver injury grade distribution, and injury severity score (all P > .05). The main hepatic artery angioembolization group had greater rates of overall liver-related complications (65.2% vs 31.2%, P = .039), specifically perihepatic fluid collection (26.1% vs 6.3%, P = .040) and bile-leak/biloma (34.8% vs 12.5%, P = .048). Main hepatic artery angioembolization had greater rates of 2 or more liver-related complications (47.8% vs 9.4%, P = .001) and readmission within 30 days (30.4% vs 9.4%, P = .046). No significant differences were observed in hospital length of stay and mortality (all P > .05). ConclusionsMain hepatic artery angioembolization is associated with increased rates of liver-related complications, multiple liver-related complications, and readmission within 30 days compared with segmental hepatic artery angioembolization. Thus, main hepatic artery angioembolization should be reserved for use only when segmental hepatic artery angioembolization is not feasible, albeit with significantly increased morbidity.

Is There a Correlation Between the Location of the Clot in the Pulmonary Arterial Tree with the Location of the Mucus Plug in the Pulmonary Bronchial Tree in Patients with chronic obstructive pulmonary disease Experiencing Pulmonary Embolism? Novel Findings.

The study aimed to investigate the impact of mucus plugs on the localization of clots in pulmonary embolisms among chronic obstructive pulmonary disease (COPD) patients. The retrospective study examined 200 participants diagnosed with both COPD and pulmonary embolism. Of these, 100 patients exhibited mucus plugs in the segmental and subsegmental branches of the pulmonary bronchial tree, while the remaining 100 did not, using computed tomography images for diagnosis. Data collection encompassed a comprehensive review of patient records, including medical history and imaging reports, to determine the presence of mucus plugs and the localization of clots in pulmonary embolism cases. Patients with mucus plugs exhibited a notably longer duration of COPD (P = .021) and a higher mean pulmonary arterial occlusion index (23 vs. 12, P = .001). Moreover, the prevalence of clots in major pulmonary arteries was significantly elevated in the mucus plug group compared to the non-mucus plug group (P < .05). Conversely, patients without mucus plugs displayed a higher incidence of clots in segmental and subsegmental arteries (P < .001). Strong positive correlations existed between mucus plugs in segmental branches and clots in major pulmonary arteries, with moderate to strong correlation coefficients (0.51 to 0.62, P < .05). Additionally, strong negative correlations were observed between mucus plugs in segmental branches and clots in segmental and subsegmental arteries, with correlation coefficients (CC) ranging from -0.74 to -0.76 (P < .05). Similarly, a significant negative correlation was noted between mucus plugs in subsegmental branches and clots in subsegmental arteries (CC: -0.68 and -0.71, P < .05). The results suggest that mucus plugs may be associated with increased severity of COPD, higher pulmonary arterial occlusion index, and altered clot distribution within the pulmonary artery tree. These findings emphasize the importance of recognizing mucus plugs as a key consideration in COPD assessment and management, potentially influencing disease severity, vascular remodeling, and thrombotic risk management.

Modified salpingopharyngeus myomucosal flap: a novel technique for skull base reconstruction.

Advancements in endoscopic skull base surgery have enabled complex tumor resections, necessitating a variety of reliable reconstructive techniques to repair resultant defects. Vascularized flaps represent optimal options, but frequently used local pedicled intranasal flaps may be unavailable due to tumor invasion or prior surgery. This study applies a modification to the previously described salpingopharyngeus myomucosal flap (Dicle flap) with potential for its use in extensive endoscopic skull base surgery defect's repair. Cadaveric dissections (n = 5) were performed utilizing endoscopic visualization to access the skull base via endonasal and transoral routes. A superiorly based posterior pharyngeal myomucosal flap along the salpingopharyngeus muscle was elevated off the superior pharyngeal constrictors, preserving their vascular pedicles. This combined flap could be 180 degrees transposed to reconstruct clival defects up to the sella turcica. The modified salpingopharyngeus myomucosal flap (Modified Dicle flap) provided approximately 40 cm2 of robust vascularized tissue based on the ascending pharyngeal artery and random posterior pharyngeal vessels. It was sufficiently mobilized to cover extensive skull base defects in the craniocervical junction, sella turcica, and protecting the exposed internal carotid artery segments. The modified Dicle flap offers a viable reconstructive option for extensive endoscopic endonasal skull base defects when commonly utilized vascularized flaps are unavailable. Further research on clinical cases is warranted to investigate postoperative function and refine techniques to minimize donor site morbidity. Not applicable.

Influence of Forced Field on Blood Flow in an Overlapping Stenosed Arterial Section

This article presents the theoretical analysis of the nonlinear behavior of the blood flow through an angled arterial segment with overlapping stenosis. A mathematically created time-variant stenosis emerges from the formation of arterial narrowing brought on by atheroma. An elastic cylindrical tube with a moving wall is used to represent the artery, and the Casson liquid is used to simulate blood that flows through it. The nonlinear elements that arise in the equations, govern blood flow are taken into account. The impact of the pulsatile pressure gradient that caused by the regular heartbeat on the flow process in the stenosed artery is demonstrated mathematically. By employing the boundary conditions, the present analytical technique can easily compute the velocity profiles, wall shear stress, and flow resistivity. To carry out a systematic quantitative study, the desired quantities are numerically computed. The results are graphically presented in the discussion section. They provide an overview of how the degree of stenosis and the malleability of the artery wall influence blood flow abnormalities. The application of the current model is adequately justified by many significant conclusions.

Efficacy and safety of the needle rendezvous technique for infrainguinal arterial calcified lesions

BackgroundLower extremity artery disease is increasingly prevalent, and complex lesions such as calcified chronic total occlusions pose significant challenges during endovascular therapy. The needle rendezvous technique, which involves puncturing a needle toward the guidewire within the lesion or lumen and advancing the guidewire into the needle lumen to achieve guidewire externalization, offers a potential solution. If device passage remains challenging, the Rendezvous-PIERCE technique can be subsequently employed by advancing the needle over the externalized guidewire to modify the lesion directly. This study aimed to evaluate the procedural outcomes of needle rendezvous in infrainguinal arterial occlusive lesions.MethodsThis single-center, retrospective, single-arm study included patients treated with needle rendezvous between August 2020 and March 2024. The primary outcome was technical success rate, defined as the device passage following guidewire externalization using needle rendezvous. Secondary outcomes included the rates of procedural success, complications, and 30-day clinical-driven target lesion revascularization (CDTLR).ResultsTwenty-five patients (25 limbs) with 52% on hemodialysis and 80% having chronic limb-threatening ischemia in 52% and 80% were enrolled. All cases involved bilateral calcified occlusions, and 72% targeted the infrapopliteal artery segment. The average needle rendezvous time was 3.7 ± 2.0 min. Rendezvous-PIERCE was performed in 28% of cases. All cases achieved 100% technical and procedural success, with no procedure-related complications. The 30-day CDTLR rate was 8%, limited to below-the-knee lesions.ConclusionsNeedle rendezvous is a safe and effective technique for treating complex infrainguinal arterial occlusions, providing a viable alternative when conventional methods fail.

Coronary Connector Facilitated Total Endoscopic Coronary Artery Bypass: An Ex Vivo Feasibility Study.

Totally endoscopic coronary artery bypass (TECAB) procedures pose significant challenges, motivating the development of Octocon, an automated endoscopic connector designed for coronary anastomoses in off-pump and endoscopic settings. This feasibility study aimed to assess Octocon's functionality and maneuverability in closed-chest conditions during robot-assisted TECAB simulations. The Octocon deployment comprises a 3-step procedure. Initially, delicate self-aligning microstapling technology is used to attach connector halves to individual blood vessels. Subsequently, the connector halves are joined to accomplish the anastomosis process. TECAB conditions were simulated using a dedicated box housing ex vivo porcine hearts. The study, conducted by 3 experienced surgeons, investigated the feasibility and standardization potential of a robot-assisted procedure employing Octocon. It evaluated maneuverability in closed-chest conditions and assessed the effectiveness of grafting internal mammary artery segments to different heart regions using single graft, jump graft, and Y-graft constructions. The robot-assisted procedure, using 4 standard instruments, successfully completed all 3 steps in 18 anastomotic procedures. In 96% of cases, the procedural steps were accomplished on the first attempt. The feasibility of constructing jump graft and Y-graft geometries on both anterior and posterior heart walls was demonstrated. Furthermore, experiences affirmed the device's endoscopic user-friendliness, ease of teachability, reproducibility, and potential to achieve expedient, leak-free anastomoses. This ex vivo study confirmed Octocon's potential suitability and functionality for TECAB. The device can create diverse grafting strategies and achieve wide-open vascular connections on various heart regions, highlighting its potential in advancing minimally invasive, robot-assisted coronary procedures. These promising results justify further exploration for integration into clinical practice.

Myocardial Bridging: a bridge to spasm?

Abstract Introduction Myocardial bridges (MBs) represent a congenital anomaly where a segment of a coronary artery passes through the myocardium, resulting in systolic compression. The role of MBs in causing chest pain has been debated, as coronary blood flow occurs primarily in diastole. MBs are generally considered benign, there is growing evidence implicating them in the pathogenesis of coronary artery spasm (CAS). However, the prevalence of CAS in patients in Europe with MBs, particularly assessed through acetylcholine (ACh) testing, remains poorly defined. Methods We conducted a retrospective analysis of consecutive patients with angina with no obstructive CAD (ANOCA), ischemia with no obstructive CAD (INOCA), or myocardial infarction with no obstructive coronary arteries (MINOCA) undergoing ACh testing between 2021 and 2024 at our centre. Patients with documented MBs on coronary angiography were included. The presence of epicardial CAS, defined as &amp;gt;90% reduction in coronary diameter with symptoms and/or ischemic electrocardiographic changes, was assessed during ACh provocation testing. Clinical characteristics, Fractional flow reserve (FFR), resting full-cycle ratio (RFR), coronary flow reserve (CFR) and the index of microvascular resistance (IMR) were also analyzed. Results From a total of 299 patients who underwent ACh Testing, 21 patients were identified with MBs, (17 Male, 4 Female). The prevalence of focal CAS in the MB among these patients was 90%. None of these patients had abnormal hyperemic (FFR) or non-hyperemic (RFR) measurements. 9 of the 21 patients with MB had increased IMR, and only 1 had a CFR &amp;lt; 2. 1 Patient had both microvascular CAS in addition to focal epicardial CAS. Conclusion This analysis provides valuable insights into the prevalence of CAS in patients with MBs undergoing ACh testing. The findings underscore the importance of considering CAS in the evaluation and management of patients with MBs, particularly during provocative testing. Further prospective studies are warranted to validate these findings and elucidate the clinical implications for risk stratification and treatment strategies in this patient population.

Demographic, clinical characteristics, managements strategies and in-hospital outcomes of patients enrolled in prospective nationwide SCAD registry

Abstract Spontaneous coronary artery dissection (SCAD) is an uncommon yet increasingly recognized cause of acute coronary syndrome (ACS), particularly in young to middle-aged women. This multicentric, prospective nation-wide registry aimed to elucidate the demographic characteristics, clinical presentation, management strategies, and outcomes of patients with SCAD. A total of 95 patients with SCAD were enrolled in 10 centers, with females constituting 81% of the cohort, and with an average age of 49.7±11.9 years. Among the traditional risk factors, prior hypertension was observed in 49%, followed by hyperlipidemia in 43%, diabetes mellitus in 9% and prior or current smoking in 47% of patients. The presentation of SCAD as ST-elevation myocardial infarction (STEMI) was predominant, occurring in 61% of cases, with the left anterior descending artery (LAD) being the most involved vessel (68%). Regarding the classification of SCAD, type 2 SCAD was the most frequent (53%), followed by type 1 (24%) and type 4 (16%). Notably, involvement of the distal segment of the culprit artery was observed in 68% of cases, while baseline TIMI 3 flow was noted in 52% of patients. Percutaneous coronary intervention (PCI) was performed in 52% of cases, with pre-interventional TIMI 0-2 flow (62% Vs. 28%; p&amp;lt;0.05) and proximal artery involvement (41% Vs. 13%; p&amp;lt;0.05) being more prevalent compared to conservatively managed patients. Final stent implantation was performed in 67% of PCI cases, with TIMI 3 flow restoration in 76% of patients undergoing PCI. The average left ventricular ejection fraction prior to discharge was 51±9.9%. In-hospital mortality was reported in three female patients, undergoing attempted PCI with left main and LAD involvement. The use of antiplatelet therapy was widespread, with aspirin administered to 98% and P2Y12 inhibitors to 75% of patients at discharge. Data from this prospective nationwide multicentric SCAD registry show that SCAD occurs predominantly in relatively young female patients, with moderately prevalent traditional cardiovascular risk factors, usually presents as STEMI, with good overall survival rates despite half of the patients managed conservatively. PCI was often attempted in SCAD lesion with compromised arterial flow and located proximally, with lower rates of stent implantation and procedure success compared to traditionally observed rates in primary PCI. This underscores the importance of heightened awareness and tailored management approaches for this unique subset of ACS patients in order to refine risk stratification, optimize treatment strategies, and improve outcomes in this population.

Emergency microsurgical trapping, decompression, and revascularization of a middle cerebral artery dissecting aneurysm using a minipterional approach in a pediatric patient: illustrative case.

Pediatric intracranial aneurysms present unique diagnostic and therapeutic challenges due to their rarity and their distinct anatomical and physiological considerations compared with those of adult intracranial aneurysms. The authors present the case of a symptomatic pediatric patient who required emergency microsurgical treatment after a thrombosed dissecting aneurysm was identified in the right M1 segment of the middle cerebral artery. The lesion completely occluded its parent vessel, although distal blood flow was reconstituted through leptomeningeal collaterals. However, aneurysm wall contrast enhancement and signs of early perfusion changes were noticed, which prompted emergency treatment consisting of microsurgical aneurysm trapping, decompression, and extracranial/intracranial revascularization to be successfully performed through a minipterional craniotomy. After 1 year, the bypass occluded, although the patient remained asymptomatic. A slight enlargement of the ipsilateral anterior cerebral artery suggested the possibility of a benign hemodynamic rearrangement. Emergency treatment may be necessary when signs of lesion instability or hemodynamic compromise are present; however, a comprehensive multidisciplinary evaluation is required. Treatment of complex vascular lesions using a minipterional approach is feasible even in pediatric patients, and delayed bypass occlusion may be a benign phenomenon reflecting gradual blood flow reorganization. https://thejns.org/doi/10.3171/CASE24484.

Comparison between coronary calcium score and segment involvement score when used in clinical routine

Abstract Data from a nationwide registry on coronary computer tomography angiography. Background The Coronary Artery Calcium Score (CACS) and segment involvement score (SIS) are crucial factors in assessing the severity of coronary artery disease (CAD) and determining the likelihood of future cardiovascular events. However, there are few large multicenter studies comparing the predictive value of CACS and SIS when used in the clinical routine. Objectives To compare CACS and SIS ability to predict cardiovascular outcomes when used in the clinical routine. Methods This retrospective cohort study included patients who underwent Coronary Computed Tomography Angiography (CCTA) for CAD evaluation between 2006-2022 in 29 different centers in Sweden. CACS was calculated using the Agatston method, and SIS was determined based on the number of coronary segments exhibiting plaque. For SIS, patients were categorized into SIS=0, SIS=1, SIS=2, SIS=3, SIS³4, for CACS patients were categorized into CACS=0, CACS=1-9, CACS=10-99, CACS=100-299, CACS³300. Patients were followed regarding the primary outcome of death or myocardial infarction. Multivariable Cox proportional hazards models were used for adjusting for potential confounders. Results A total of 23034 patients underwent CCTA and were followed for up to ten years. Median age (IQR) was 58 (49–67) years, 50% were women, 9% had diabetes mellitus, 42% had hypertension, 25% had hyperlipidemia, 5% had previously known CAD. There were 955 patients (4.1%) with myocardial infarction (MI) and 409 patients (2.2%) died during follow up. There was an increase in cardiovascular events with increasing SIS. When comparing SIS and presence of obstructive stenosis, SIS was a better predictor of outcome (Figure 1). There was also an increase cardiovascular events with increasing CACS (Figure 2). When adjusted for age, sex, risk factors, previous cardiovascular disease and intervention, both SIS and CACS were independently associated with outcome. When SIS and CACS were compared in a receiver operating characteristic curve, CACS had significantly larger AUC than SIS, (0.70[0.67-0.73] vs 0.62[0.60-0.63]). Conclusion Our findings show that both CACS and SIS are important and independent predictors of cardiovascular outcomes thereby offering a valuable tool for personalized risk stratification and management in clinical settings. When used in the clinical routine, CACS appears to be more strongly associated with outcome than SIS.Figure1 Survival SISFigure 2 Survival CACS

Age stratified differences in coronary artery plaque phenotype in women and men with non-obstructive coronary artery disease

Abstract Background Development of coronary artery disease (CAD) and risk of acute cardiac events differ between women and men during the life span. The aim of this study was therefore to characterize sex differences in coronary artery plaque phenotype among patients with symptomatic non-obstructive CAD in different age groups. Methods Advanced coronary artery plaque phenotyping by coronary computed tomography angiography was performed in 606 patients (31% women) with symptomatic non-obstructive CAD from the Norwegian Registry of Invasive Cardiology. A 1:1 sex-matched study design ensured equal distribution of the sexes in the different age groups. We assessed total plaque burden adjusted for vessel volume and plaque composition consisting of dense calcium, fibrous, fibro-fatty, and necrotic core. Patients were further stratified into age groups of ≤50, 51-64, and ≥65 years to explore the relationship between age and sex on coronary artery plaque phenotype. Results In the study population, patients ≥65 years had a higher prevalence of hypertension, higher calcium score, coronary artery segment involvement score and total plaque burden, whereas the prevalence of obesity was lower compared to patients aged 51-64 and ≤50 years (all p&amp;lt;0.05). The prevalence of smoking, diabetes and statin treatment was similar between groups. A two-way analysis of variance demonstrated an interaction between sex and age group on total plaque burden (F [2, 600] =3.431, p=0.33), where women aged 51-64 and ≥65 years had a higher total plaque burden compared to men (p=0.002 and p&amp;lt;0.001, respectively, Figure 1). Plaque composition in women ≥65 years was characterized by an increased proportion of stable dense calcified plaques compared to men and younger women (all p&amp;lt;0.05), whereas men ≥65 years had a higher proportion of vulnerable necrotic core plaque phenotype (p&amp;lt;0.001). Women showed consistently lower proportions of more vulnerable fibro-fatty plaques compared to men across all age groups (all p&amp;lt;0.05, Figure 2). Conclusions In non-obstructive CAD, higher total plaque burden was associated with older age and female sex. Women had a lower proportion of vulnerable fibro-fatty plaques across all age groups and a higher proportion of stable dense calcified plaques at an older age compared to men. Future longitudinal studies on coronary artery plaque phenotype during the life span will increase the understanding of sex differences in CAD development and may contribute to customise risk stratification in women and men.Figure 1.Total plaque burdenFigure 2.Compositional plaque burden

Non-contrast-enhanced MR-angiography of the abdominal arteries: intraindividual comparison between relaxation-enhanced angiography without contrast and triggering (REACT) and 4D contrast-enhanced MR-angiography.

To evaluate Relaxation-Enhanced Angiography without Contrast and Triggering (REACT), a novel 3D isotropic flow-independent non-contrast-enhanced magnetic resonance angiography (non-CE-MRA) for imaging of the abdominal arteries, by comparing image quality and assessment of vessel stenosis intraindidually with 4D CE-MRA. Thirty patients (mean age 35.7 ± 16.8years; 20 females) referred for the assessment of the arterial abdominal vasculature at 3T were included in this retrospective, single-centre study. The protocol comprised both 4D CE-MRA and REACT (navigator-triggering, Compressed SENSE factor 10, nominal scan time 02:54min, and reconstructed voxel size 0.78 × 0.78 × 0.85 mm3). Two radiologists independently evaluated 14 abdominal artery segments for stenoses, anatomical variants, and vascular findings (aortic dissection, abdominal aorta aneurysms and its branches). Subjective image quality was assessed using a 4-point Likert scale (1 = non-diagnostic, 4 = excellent). REACT had a total acquisition time of 5:36 ± 00:40min, while 4D CE-MRA showed a total acquisition time (including the native scan and bolus tracking sequence) of 3:45 ± 00:59min (p = 0.001). Considering 4D CE-MRA as the reference standard, REACT achieved a sensitivity of 87.5% and specificity of 100.0% for relevant (≥ 50%) stenosis while detecting 89.5% of all vascular findings other than stenosis. For all vessels combined, subjective vessel quality was slightly higher in 4D CE-MRA (3.0 [IQR: 2.0; 4.0.]; P = 0.040), although comparable to REACT (3.0 [IQR: 2.0; 3.5]). In a short scan time of about 5min, REACT provides good diagnostic performance for detection of relevant stenoses, variants, and vascular findings of the abdominal arteries, while yielding to 4D CE-MRA comparable image quality.

AngioPy: an open-source, deep learning-driven tool for coronary artery segmentation

Abstract Background Quantitative coronary angiography (QCA) permits the objective assessment of coronary artery disease. However, traditional edge detection algorithms often struggle with accurate vessel segmentation due to the complexity and variable quality of angiographic images. As a result, manual correction is frequently needed, which is a major limitation of current QCA systems. Purpose We developed angioPy, a deep learning-driven tool for vessel segmentation that employs user-defined ground truth points to minimise manual correction. We compared its performance without correction with an established QCA system. Methods angioPy was developed using 2455 images from the Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2 (FAME 2) study. Deep learning models were constructed using the U-Net architecture with one of three popular backbones for image classification: ResNet101, DenseNet121, and InceptionResNet-v2. Critically, the model was constructed to integrate the user’s clinical expertise through the selection of a 5-10 ground-truth points along the length of the vessel of interest including the desired start and end point of vessel segmentation. These ground truth points were added to a separate channel of the input image. Five-fold cross validation was performed using proportions of 3:1:1 for training, validation, and test sets, respectively. External validation was performed on a separate dataset of 580 images not used for model development. For both datasets, ground truth segmentation masks were provided by interventional cardiologists using specialised in-house software. A separate analysis was performed in a cohort of 74 patients with mild/moderate stenoses that underwent vessel segmentation using both angioPy and an established commercial QCA package (Medis QFR®). Vessel dimensions at stenoses (proximal and distal reference, minimal luminal diameter) were extracted from both segmentation approaches and compared (609 diameters in total). Results The best performing model performed segmentation with an average F1 score of 0.927 (pixel accuracy 0.998, precision 0.925, sensitivity 0.930, specificity 0.999) with 99.2% of masks exhibiting an F1 score &amp;gt; 0.8 (Figure 1). Simliar results were achieved in the external validation set (F1 score 0.924, pixel accuracy 0.997, precision 0.921, sensitivity 0.929, specificity 0.999). Stenosis dimensions measured with angioPy (mean diameter 3.54 ±1.15 mm) exhibited excellent agreement with QCA (r=0.95 [95% CI 0.95-0.96], p&amp;lt;0.001; mean difference -0.18 mm [limits of agreement: -0.84 to 0.49]) (Figure 2). Minimal luminal diameter (mean 2.93 ±0.91 mm) also exhibited strong agreement (r=0.93 [95% CI 0.91-0.95], p&amp;lt;0.001; mean difference -0.06 mm [limits of agreement: -0.70 to 0.59]. Conclusion angioPy performs rapid and accurate coronary segmentation without the need for manual correction. Available as an open-source tool, angioPy has the potential to increase the efficiency and reliability of QCA.Figure 1.angioPy segmentationFigure 2.angioPy vs QCA (Medis)

Evaluation of non-target lesions in femoropopliteal disease using near-infrared spectroscopy intravascular ultrasound imaging

Abstract Aim This study aims to assess the plaque morphology of non-target lesions, especially lipid-core-containing plaque (LCP), and compare it to target lesions using near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) in patients with femoropopliteal disease. Methods We conducted a single-center prospective observational study on 14 patients who underwent endovascular therapy for femoropopliteal disease between July 2022 and November 2023. NIRS-IVUS assessment was performed on the whole femoropopliteal arterial segment. Forty-one LCP lesions &amp;gt; maximum lipid-core burden index in any 4-mm region (max LCBI4mm) 100 were detected by NIRS-IVUS. We evaluated patient and lesion characteristics. In addition, the LCP lesions were divided into two groups, the target lesion group (n=18) and the non-target lesion group (n=23), and compared. Results Patient characteristics were notable for advanced age (76.8±6.6 years), high incidence of male (78.7%), hypertension (100%), dyslipidemia (78.6%), diabetes (64.3%), statin use (71.4%). Lipid profiles were as follows: LDL-cholesterol 85.9±26.7 mg/dl, HDL-cholesterol 48.9±12.7 mg/dl, triglyceride 138.9±80.3 mg/dl, lipoprotein(a) 19.6±16.3 mg/dl. Ten participants had LCPs in the non-target lesion (71.4%). For IVUS findings, the target lesion group had significantly longer lesion length (34.6±11.9 mm vs. 22.6±8.7 mm, p=0.001), smaller minimum lumen area (7.0±2.8 mm2 vs. 14.8±5.4 mm2, p&amp;lt;0.001), and larger plaque burden (78.0±5.0 % vs. 53.0±12.0 %, p&amp;lt;0.001) than those in the non-target lesion group. No significant differences were observed in the prevalence of calcification (target lesion group vs. non-target lesion group: 83.3 % vs. 91.3 %, p=0.64) and the extent of calcification (p=0.76). For NIRS findings, the target lesion group contained a significantly smaller proportion of LCP in the lesion length (25.9±15.7 % vs. 50.6±29.2 %, p=0.002) than the non-target lesion group. On the other hand, there were no significant differences in the value of max LCBI4mm (284.4±153.4 vs. 289.5±113.1, p=0.90) and the length of LCP lesion (9.8±9.7 mm vs. 10.7±6.9 mm, p=0.74) and distribution of LCP (p=0.08) between both groups. In addition, the number of LCPs in the target femoropopliteal artery was positively correlated with max LCBI4mm in the target femoropopliteal artery (r=0.671, p=0.008) Conclusion NIRS-IVUS findings in this study demonstrated that the non-target lesions contained LCPs to the same degree as the target lesions.