Small Thrombi Research Articles

Upside-down positioning of a peri-interventional cava filter during endovascular thrombectomy of a septic superior vena cava thrombosis

A 43-year-old male patient with advanced colon carcinoma presented with disseminated staphylococcus aureus bacteremia and central venous catheter associated septic thrombosis of the superior vena cava. Despite appropriate antimicrobial therapy and surgical debridement of distant foci, bacteremia persisted, so an endovascular thrombectomy was performed. Contrary to the usual application, the Capturex® peri-interventional cava filter was positioned upside down, in the direction of the blood flow, in the superior vena cava to prevent septic embolism during mechanical thrombectomy. The wall-adherent septic thrombus was mechanically detached using a RAT fragmentation basket® followed by Aspirex® rotational thrombectomy. Final phlebography showed complete thrombus removal. Small thrombus fragments could be demonstrated in the filter after retrieval. The adapted technique of a reverse positioning of the Capturex® filter in the superior vena cava seems feasible and effective.

Impact of thrombus burden on long-term clinical outcomes in patients with either anterior or non-anterior ST-segment elevation myocardial infarction

Large thrombus burden (LTB) during ST-segment elevation myocardial infarction (STEMI) could translate into worse clinical outcomes. The impact of a LTB in terms of long-term clinical outcomes on different myocardial infarct territories has not yet been fully evaluated. From April 2002 to December 2004, consecutive patients with STEMI undergoing percutaneous coronary intervention with drug eluting stent were evaluated. The study sample was stratified in two groups: anterior STEMI and non-anterior STEMI. LTB was considered as a thrombus larger than or equal to 2-vessel diameters, and small thrombus burden less than 2-vessel diameters. Major adverse cardiac events (MACE) were evaluated at 10-year and survival data were collected up to 15-year. A total of 812 patients were evaluated, 6 patients were excluded due to inadequate angiographic images, 410 (50.9%) had an anterior STEMI and 396 (49.1%) a non-anterior STEMI. Patients with LTB had higher rates of 10-year mortality (aHR 2.27, 95%CI 1.42–3.63; p = 0.001) and 10-year MACE (aHR 1.46, 95%CI 1.03–2.08; p = 0.033) in anterior STEMI, but not in non-anterior STEMI (aHR 0.78, 95%CI 0.49–1.24; p = 0.298; aHR 0.71, 95%CI 0.50–1.02; p = 0.062). LTB was associated with increased 30-day mortality (aHR 5.60, 95%CI 2.49–12.61; p < 0.001) and 30-day MACE (aHR 2.72, 95%CI 1.45–5.08; p = 0.002) in anterior STEMI, but not in non-anterior STEMI (aHR 0.39, 95%CI 0.15–1.06; p = 0.066; aHR 0.67, 95%CI 0.31–1.46; p = 0.316). Beyond 30-day, LTB had no impact on mortality and MACE in both groups. In anterior STEMI, LTB is associated with worse long-term clinical outcomes, this effect was driven by early events.

Protection of β2GPI Deficient Mice from Thrombosis May Reflect a Platelet Activation Defect

IntroductionAntiphospholipid syndrome (APS) is an autoimmune disorder caused by “antiphospholipid” antibodies (aPL) directed against β2-glycoprotein I (β2GPI). Although β2GPI is proposed to have both anti- and procoagulant properties in vitro, its physiological role in coagulation in vivo is not well understood. Previous studies have shown that β2GPI deficient mice display impaired thrombin generation but failed to demonstrate an anticoagulant role in vivo. Recent findings from our laboratory demonstrated that β2GPI-deficient mice (APOH -/-) developed by CRISPR/Cas9 had shown delayed time to thrombosis as evidenced by prolonged clotting times in carotid artery occlusion models. However, no mechanism was identified for the delayed time to thrombosis phenotype.MethodsVenous thrombosis by complete occlusion of the IVC was performed as described previously (Wrobleski et al., 2011). In brief, an abdominal incision was made on anesthetized mice to visualize IVC. The activated partial thromboplastin time (aPTT); prothrombin time (PT) and Tissue factor-induced thrombin generation time (TGT) were performed as described previously (Stavrou et al., 2014). Protein C activity was performed according to manufacturer's recommendations (Chromogenix Coamatic® Protein C, Diapharma). To assess platelet activation, platelets were isolated under resting conditions using retro-orbital blood and the final washed platelet pellet was resuspended in Tyrodes solution. Platelets were stimulated with 0.25 U/ml thrombin and incubated with 1 µL of CD62P-FITC or Oregon Green conjugated-fibrinogen for 30 minutes. Platelets were fixed with 100 μL 2% formalin, and quantification of platelet surface P-selectin and fibrinogen binding to activated platelet GPIIb/IIIa was performed by flow cytometry (Accuri Flow Cytometer, BD Biosciences). For mouse tail vein bleeding time assays, mice were anesthetized and the tail transected approximately 5 mm from the tip. The tail was then placed in a 50 ml falcon tube containing saline pre-warmed to 37°C. The time to cessation of bleeding was determined visually. All experiments were performed on 8-12 week old mice.ResultsaPTT and PT results for APOH +/+ and APOH -/- mice were 41.82 ± 1.174 and 41.38 ± 2.026 seconds, and 14.55 ± 2.262 and 11.30 ± 0.578 seconds, respectively (NS). After IVC ligation, thrombi in APOH -/- mice had a mean weight of 16.94 ± 1.782 mg compared to 27.69 ± 1.725 mg in APOH +/+ mice littermates (P = 0.0002, Figure A). Thrombin generation induced by either tissue factor or aPPT reagent showed peak thrombin generation at 15 min with no difference between APOH +/+ and APOH -/- mice. Likewise, no significant differences were observed in percent Protein C activity levels between APOH +/+ (8.058 ± 1.433) and APOH -/- (6.453 ± 0.924).Stimulation with 0.25 U/ml thrombin resulted in significantly greater expression of P-selectin) on platelets of APOH +/+ (161.3 ± 30.62 MFI) compared to those from APOH -/- mice (54.47 ± 9.721 MFI) (P= 0.0101;Figure 1B). Likewise, there was significantly greater fibrinogen binding to stimulated platelets from APOH +/+ (129.7 ± 32.21 MFI) compared to APOH-/- mice (35.30 ± 2.144 MFI) with P = 0.0111 (Figure 1C). Finally, consistent with platelet activation studies, tail vein bleeding times were mildly, but significantly prolonged in APOH -/- mice (192.3 ± 45.86 sec) compared to APOH+/+ mice (95.14 ± 9.582 sec) with P = 0..ConclusionThe effects of β2GPI, if any, on coagulation processes is controversial, and has not been thoroughly studied in β2GPI deficient animals. The results presented here suggest that the smaller thrombi that form in mice deficient in β2GPI following IVC occlusion may reflect a mild platelet function defect. This hypothesis is supported by diminished P-selectin expression and fibrinogen binding in response to 0.25 U/ml thrombin by platelets from β2GPI deficient mice compared to wild-type littermates. Moreover, tail vein bleeding times were mildly prolonged in β2GPI deficient mice. Taken together, these studies suggest that β2GPI may actually contribute to hemostasis by supporting platelet responses to low concentrations of thrombin. Additional studies are needed to characterize these effects in detail. [Display omitted] DisclosuresMcCrae: Sanofi, Novartis, Alexion, and Johnson & Johnson: Consultancy, Honoraria; Dova, Novartis, Rigel, and Sanofi Genzyme: Consultancy.

Impact of Large Thrombus Burden on Very Long-Term Clinical Outcomes in Patients Presenting With ST-Segment Elevation Myocardial Infarction.

The impact of large thrombus burden (LTB) on very long-term clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) is unknown. We compared very long-term clinical outcomes in STEMI patients with either LTB or small thrombus burden (STB). Between 2002 and 2004, thrombus burden (TB) was evaluated in consecutive patients with STEMI undergoing percutaneous coronary intervention (PCI). In occluded infarct-related arteries, TB was reclassified after flow restoration. LTB was defined as thrombus ≥2 vessel diameters. Major adverse cardiac event (MACE) rate was evaluated at 10-year follow-up and survival data were collected up to 15 years post PCI. A total of 812 patients were enrolled, and TB assessment was available for 806 patients (99.3%); 580 patients (72.0%) had STB and 226 patients (28.0%) had LTB. Patients with LTB experienced more no reflow (4.0% vs 0.5%; P<.01) and distal embolization (17.3% vs 3.4%; P<.001) than STB patients. Ten-year MACE rate (42.5% vs 42.4%; P=.59), 10-year mortality rate (27.0% vs 26.4%; P=.75), and 15-year mortality rate (31.9% vs 35.9%; P=.29) were similar between STB and LTB groups, respectively. By landmark analysis, MACE rate was higher in the LTB group (15.9% vs 8.8%; P<.01) at 30 days, but not beyond (31.6% vs 36.9%; P=.28). There was no difference in mortality at any time point (at 30 days, 9.7% vs 6.2%; P=.08; beyond 30 days, 17.3% vs 20.5%; P=.48). LTB was an independent predictor of MACE at 30 days post PCI (hazard ratio, 1.60; 95% confidence interval, 1.01-2.51; P=.04). In STEMI patients, LTB might identify a subpopulation at high risk of no-reflow, distal embolization, and early ischemic events, but is not associated with worse clinical outcomes at long-term follow-up.

Safety and Efficacy of a Novel Centrifugal Pump and Driving Devices of the OASSIST ECMO System: A Preclinical Evaluation in the Ovine Model.

Background: Extracorporeal membrane oxygenation (ECMO) provides cardiopulmonary support for critically ill patients. Portable ECMO devices can be applied in both in-hospital and out-of-hospital emergency conditions. We evaluated the safety and biocompatibility of a novel centrifugal pump and ECMO device of the OASSIST ECMO System (Jiangsu STMed Technologies Co., Suzhou, China) in a 168-h ovine ECMO model.Methods: The portable OASSIST ECMO system consists of the control console, the pump drive, and the disposable centrifugal pump. Ten healthy sheep were used to evaluate the OASSIST ECMO system. Five were supported on veno-venous ECMO and five on veno-arterial ECMO, each for 168 h. The systemic anticoagulation was achieved by continuous heparin infusion to maintain the activated clotting time (ACT) between 220 and 250 s. The rotary speed was set at 3,200–3,500 rpm. The ECMO configurations and ACT were recorded every 6 hours (h). The free hemoglobin (fHb), complete blood count, and coagulation action test were monitored, at the 6th h and every 24 h after the initiation of the ECMO. The dissection of the pump head and oxygenator were conducted to explore thrombosis.Results: Ten sheep successfully completed the study duration without device-related accidents. The pumps ran stably, and the ECMO flow ranged from 1.6 ± 0.1 to 2.0 ± 0.11 L/min in the V-V group, and from 1.8 ± 0.1 to 2.4 ± 0.14 L/min in the V-A group. The anticoagulation was well-performed. The ACT was maintained at 239.78 ± 36.31 s, no major bleeding or thrombosis was observed during the ECMO run or in the autopsy. 3/5 in the V-A group and 4/5 in the V-V group developed small thrombus in the bearing pedestal. No obvious thrombus formed in the oxygenator was observed. The hemolytic blood damage was not significant. The average fHb was 0.17 ± 0.12 g/L. Considering hemodilution, the hemoglobin, white blood cell, and platelets didn't reduce during the ECMO runs.Conclusions: The OASSIST ECMO system shows satisfactory safety and biocompatibility for the 168-h preclinical evaluation in the ovine model. The OASSIST ECMO system is promising to be applied in clinical conditions in the future.

Glycated haemoglobin association with severity of thrombus burden in non-diabetic versus diabetic patients with ST-elevation myocardial infarction.

To determine and compare the relationship between glycated haemoglobin level on admission and the angiographic thrombus burden in diabetic and non-diabetic patients with ST-segment elevation myocardial infarction. The cross-sectional study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from June 2018 to July 2019, and comprised patients presenting with ST-elevation myocardial infarction. Demographic details and self-reported duration of diabetes was recorded. The thrombus burden was assessed on angiography classifying 0 = no thrombus, 1 = possible thrombus, 2 = small thrombus, 3 = moderate thrombus, 4 = large thrombus, and 5 = total occlusion. The data was analysed using SPSS 21. Of the 212 patients, 173(81.6%) were men, and 75(35.4%) had body mass index ≥30kg/m2. The overall mean age of the sample was 54.62±11.75 years. Known diabetic cases were 82(38.7%) and 20(24.4%) were insulin-dependent. Mean glycated haemoglobin level was 7.18±2.03% and 96(45.3%) patients had the critical value >6.5%. Pre-procedure thrombus score in 118(55.7%) patients was 3 and 4 and 57(26.9%) had total occlusion. A significant relationship between glycated haemoglobin level and thrombus score was found in the overall sample as well as in diabetic and non-diabetic groups (p<0.001). Increased glycated haemoglobin level was found to have a positive correlation with thrombus score in both diabetic and non-diabetic patients.

EXTRA-CARDIAC SHUNT: AN UNUSUAL CAUSE OF STROKE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Embolic phenomenon, while not contributing as much as a cause as atherosclerotic disease for ischemic stroke, remains an important cause for ischemic stroke. While atrial fibrillation represents the majority of the patients in this subset, there are other less conspicuous causes. Here, we present a case of an ischemic stroke, found to be due to an isolated extra-cardiac shunt without a patent foramen ovale. CASE PRESENTATION: A 56-year-old right-handed female with no significant past medical history presented with left-sided weakness concerning for acute stroke. On admission, her National Institute of Health Stroke Scale (NIHSS) was 20. MRI showed an occlusion of the right middle cerebral artery at M1 and right carotid terminus. Dual anti-platelet therapy (DAPT) and statin were started. Revascularization was achieved with thrombectomy. Deep vein thrombosis was ruled out and trans-thoracic echocardiogram was unremarkable. Telemetry revealed persistent first-degree AV block. Suspecting a cardioembolic etiology, a loop recorder was placed and DAPT was changed to apixaban. Trans-esophageal echocardiogram ruled out valvular abnormalities or clots, but identified an extra-cardiac shunt, suspected to be from pulmonary arteriovenous malformation (PAVM). Despite the findings, the patient declined further workup in the hospital and was discharged with medical management. DISCUSSION: PAVM, often associated with Osler-Weber-Rendu disease (OWRD) or migraines is a rare cause for stroke.[1] The absence of a capillary bed allows small thrombi or bacteria to reach the systemic circulation. The resulting manifestations can be severe, including cerebrovascular accidents and brain or intra-medullary abscesses.[2] In a study involving over 700 patients with stroke, only 4 with isolated PAVM were identified, suggesting this is a very rare presentation.[3] In our patient, however, there was no history of migraines or clinical features of OWRD other than PAVM (1 out of 4 per Curacao diagnostic criteria). Therefore, we believe the stroke was likely secondary to an isolated PAVM. Studies reported varied approaches on management of isolated PAVM, with majority opted for embolization. There was also varied recommendations on anti-platelet therapy or anti-coagulation. Our patient was managed with anti-coagulation therapy. CONCLUSIONS: Cryptogenic strokes in low-risk patients warrant evaluating for less common causes, such as AVM, as the implications could be devastating. Although there are treatments that lower the risk of recurrent strokes, little is known on the best practice for patients with isolated PAVM. REFERENCE #1: Peery WH. Clinical Spectrum of Hereditary Hemorrhagic Telangiectasi (Osler-Weber-Rendu Disease). Am J Med. 1987;82:9. REFERENCE #2: Kawano H, Hirano T, Ikeno K, Fuwa I, Uchino M. Brain Abscess Caused by Pulmonary Arteriovenous Fistulas without Rendu-Osler-Weber Disease. Intern Med. 2009;48(6):485-487. REFERENCE #3: Kimura K, Minematsu K, Nakajima M. Isolated pulmonary arteriovenous fistula without Rendu-Osler-Weber disease as a cause of cryptogenic stroke. J Neurol Neurosurg Psychiatry. 2004;75(2):311-313. DISCLOSURES: No relevant relationships by Vernon Chan, source=Web Response No relevant relationships by Dana Daoud, source=Web Response No relevant relationships by Jayaram Thimmapuram, source=Web Response

Removal of Shield Needles from Graphene Oxide Thrombus and Preparation

Atherosclerosis is a chronic inflammatory disease commonly seen in clinical practice. It can lead to thickening of vascular intima, occlusion of lumen stenosis and thrombosis, leading to angina pectoris, hypertension, myocardial infarction and other diseases, posing a serious threat to human life and health. This study provides a method for removing shield needles from graphene oxide thrombus and its preparation. The graphene oxide shield needle mainly includes flexible rotating shaft, radial flexible rod, rotating needle, adsorption main pipe and dosing main pipe, laser measuring device, high definition camera and other structures, which has the following advantages:firstly, it achieves multi-angle rotation grinding thrombosis, precise rotation grinding, avoids vascular damage and infection; secondly, thrombolytic drugs can be applied in the process of rotary grinding and small thrombus can be adsorbed to effectively avoid secondary embolization of blood vessels; thirdly, it a coating of graphene oxide on a rotating needle, which protects against bacteria and infection. This study has practical reference value for the development of thrombotherapy and the application of graphene in the medical field.

The association of anticoagulation therapy characteristics with left atrial thrombus lysis in patients with nonvalvular persistent atrial fibrillation

Purpose. The aim of this study was to reveal the effect of the duration and characteristics of anticoagulant therapy on the clot dissolution in the left atrial appendage (LAA) in patients with persistent atrial fibrillation (AF).Material and methods. The repeat transesophageal echocardiography was performed in 68 patients with persistent AF, because the thrombus was detected in the LAA during the first examination. Of these, 37 (54.4%) patients started or continued to receive warfarin and 31 (45.6%) patients continued to receive the direct oral anticoagulants. Transesophageal echocardiography was repeated after 3-5 weeks. One follow-up examination was for 53 patients, two follow-up examination was for 11 patients and three follow-up examination was for 4 patients. Cox regression analysis was performed to identify factors affecting the likelihood of clot dissolution and Kaplan-Meier survival analyses with log-rank tests were used to compare the clot dissolution time.Results. The chance of the LAA thrombus lysis is 50% after 35.0 ± 3.7 days of receiving anticoagulants. This time is reduced to 30.0 ± 1.4 days for small thrombus (no more than 18 mm), and it increases to 45.0 ± 7.4 days (p = 0.038) for large thrombus. The dissolution time of small thrombus depends on the characteristics of the treatment: the median of the dissolution curve is 24.0 ± 3.7 days when the patients received the direct oral anticoagulants, and the median of the dissolution curve is 40.0 ± 7.2 days (p = 0.009), if the patients received warfarin. The dependence of the dissolution time of large thrombus on the characteristics of treatment did not found.Conclusion. The LAA thrombus dissolution time in patients with atrial fibrillation depends on their size, and the dissolution time of small thrombi depends on the characteristics of anticoagulant therapy.

Thrombosis of Aberrant Right Subclavian Artery Presenting As Myocardial Infarction

Aberrant right subclavian artery (ARSA) is a rare anomaly, in which the right subclavian artery arises directly from the aortic arch instead of originating from the brachiocephalic artery. This anomaly should be taken into consideration during surgical procedures around the esophagus, such as esophagectomy. Any unintentional injury of this artery during surgical procedures could be extremely life-threatening. The patient was an 88-year-old male, known case of hypertension, CAD, COPD, presented with the chief complaint of chest pain for 2 days associated with the history of right-hand weakness and numbness for 1 week. ECG has done suggestive of Sinus Rhythm with LBBB Trop I – 6.1 ng/ml Coronary Angiography LMCA- Normal LAD- Mid LAD 80% stenosis LCX- Proximal 99-100% occluded RCA- normal CT ANGIO right upper limb done findings revealed anomalous retro esophageal course of right subclavian artery with narrowing at its origin and a small thrombus in juxta osteal segment. Thrombus of 6.7 cm long segment of the distal third of right brachial artery with the reformation of brachial artery at the level of elbow joint along with thrombosis of right ulnar artery at a short distance from its origin. Keywords: Aberrant right subclavian artery; Thrombosis; Myocardial infarction.

ASAIO 2021 Annual Meeting Abstracts.

Study: Deep venous thrombosis (DVT) is said to be the most preventable cause of death in hospitals today (Centers for Disease Control, February 2020). This silent killer most frequently starts in the lower extremities as a small thrombus that initially forms in a valve pocket located behind a venous valve leaflet. Failure to initiate preventative measures to reduce the risk of DVT can result in the development of life-threatening pulmonary emboli (PE) and chronic venous insufficiency (CVI). These risks are currently exacerbated by the current SARS-CoV-2 pandemic that has increased the frequency of DVT formation and PE in patients through mechanisms that are not fully understood. The current study is using artificial intelligence (AI) and machine learning (ML) to evaluate changes in blood rheology, venous blood flow, and venous valve configuration that can lead to increased risk of DVT, PE, and CVI. Methods: In our model, AI/ML is used to evaluate previously recorded images of normal and abnormal cadaver veins and venous valves. Using these data, we can predict that previous DVT formation produced the observed leaflet damage and will increase the risk of CVI and future DVT formation. The contribution that changes in blood rheology could make to venous blood flow abnormality will also be assessed. We leverage the latest advances in image processing to quantify the valve leaflet geometry with respect to the susceptibility to recurrent DVT. Results: Based on this data, AI/ML will predict, on a patient-by-patient basis, the probability of deep venous thrombosis formation. This will allow healthcare professionals to determine when preventative measures are most appropriate. It will also allow physicians to assess whether a patient has an increased risk of developing a future DVT and/or CVI insufficiency. With this information patient care can be improved and the debilitating and life-threatening complications of DVT can be substantially reduced.

Reverse redistribution-like change on dipyridamole-stress 99mTc-tetrofosmin imaging in a patient with angiographically mild coronary artery stenosis

A 50-year-old man with a 1-month history of chest pain presented to our hospital. Transthoracic echocardiography showed normal left ventricular wall motion. Coronary computed tomography angiography revealed a mild stenosis with low-density non-calcified plaque in the proximal left anterior descending coronary artery (LAD) (Figure 1A, yellow arrows); therefore, the patient underwent a 1-day protocol of dipyridamole stress and rest 99mTc-tetrofosmin myocardial perfusion imaging (MPI). Baseline electrocardiography was normal; however, he developed angina 8 minutes after the start of .56 mg·kg−1 (.14 mg·kg−1·min−1 for 4 minutes) of intravenous dipyridamole infusion and his electrocardiogram showed ST-segment elevation in the precordial leads (Figure 2). After intravenous aminophylline with sublingual nitroglycerin was given, the ST-segment elevation was gradually resolved. Stress MPI showed no perfusion defect (Figure 1B) with abnormal wall motion in the anterior and septal walls on gated MPI (Supplementary Material). He had recurrent angina after the stress MPI. Rest MPI at 2 hours after the stress test showed reverse redistribution-like reduced uptake in the LAD territory (Figure 1B) with normal left ventricular wall motion on gated MPI (Supplementary Material). As with the coronary computed tomography, invasive coronary angiography via the right radial artery demonstrated the mild stenosis in the proximal LAD (Figure 3, yellow arrow). Intravascular ultrasound and optical coherence tomography images showed coronary plaque with neovascularization (Figure 3, red arrows) and small thrombi (Figure 3, white arrows) at the minimum lumen area site, indicating the increased vulnerability of the coronary plaque.1 Percutaneous coronary intervention (PCI) with a drug-eluting stent (4.0 × 33 mm) was successfully performed (Figure 3, red arrows). On the day following the PCI, he underwent cardiopulmonary exercise testing and did not present with chest pain at peak exercise (VO2 at peak was 22.5 mL·kg−1·min−1 [6.4 METs]). Open in a separate window Figure 1 (A) Coronary computed tomography angiography revealed a mild stenosis (yellow arrows) with low-density non-calcified plaque in the proximal left anterior descending coronary artery (LAD). (B) Dipyridamole stress and rest 99mTc-tetrofosmin myocardial perfusion imaging (MPI). Stress MPI (300 MBq of 99mTc-tetrofosmin) showed no perfusion defect, whereas rest MPI (900 MBq of 99mTc-tetrofosmin) 2 hours after the stress test showed reduced uptake (reverse redistribution) in the LAD territory

Adrenal Infarct as a Presenting Finding in Polycythemia Vera (PV)

Adrenal infarct as a presenting finding in Polycythemia Vera (PV)Marie Guruli, Vitaly KantorovichBackground: While hemorrhagic adrenal infarcts, usually bilateral, have been described in hematologic malignancies, usually PV, no hemorrhagic variant are exceedingly rare. Here we describe a single case of unilateral nonhemorrhagic adrenal infarct.Case Presentation: 30-year- old male with past medical history of type 1 diabetes on insulin, presented with one day history of right upper quadrant (RUQ) abdominal pain. Initially pain was mild but slowly progressed to 10/10 intensity within the next several hours, felt like a sharp and stabbing pain with radiation up to the chest. Patient also reported to have difficulty breathing due to pain, along with nausea and vomiting. Laboratory results showed leukocytosis 11.2, H&H of 19.1/56.8, platelet count of 637, glucose of 283, alkaline phosphatase of 147. Abdominal ultrasonography reported nonspecific mild hepatomegaly and strongly suspected small thrombus within the IVC. Further work up included CTA study was negative for PE (pulmonary embolus), but MRI showed a filling defect in the suprarenal IVC along with right adrenal infarction. Patient was thermodynamically stable. Fortunately, cortisol was 21.3 and DHEA levels were 419, indicating no apparent effect on adrenal function. Patient underwent a bone marrow biopsy and was eventually diagnosed with PV. He was discharged in the stable condition with a close follow up with his endocrinologist for monitoring and repeat MRI for right adrenal infarct within the next few months.Conclusion: This case illustrates the importance to screen patients with PV who presented with similar clinical presentation for possible adrenal insufficiency. It also highlights the importance of undertaking imaging for careful consideration, close follow up to prevent life threatening complications and even death.

Abstract No. 76 ▪ FEATURED ABSTRACT Intravascular ultrasound-guided transvenous biopsy of retroperitoneal targets inaccessible by percutaneous iopsy: technique and initial clinical experience

Retroperitoneal lymph nodes and masses adjacent to the inferior vena cava (IVC) or iliac veins can be inaccessible by a conventional percutaneous needle biopsy (PNB) approach due to surrounding vascular and osseous structures. The purpose of this study was to report initial clinical experience with the use of intravascular ultrasound-guided transvenous biopsy (IVUS-TVB) of difficult to access extravascular lymph nodes and masses. From October 2018 to August 2020, 41 IVUS-TVB procedures were performed under fluoroscopy in 38 patients (n = 19 males, mean age = 63) using side viewing intracardiac echocardiography IVUS catheters (ViewFlex Xtra, St. Jude Medical) and 18-gauge transjugular liver biopsy kits (Argon) through separate 10 French sheaths. All cases were initially reviewed for feasibility by PNB but were deemed unacceptably high risk. Patient demographics, target locations and sizes, success rates, and 30-day complications were recorded. Forty biopsies were performed, and 1 lesion was determined to be a vascular malformation by IVUS. Lymph nodes were interaortocaval (n = 11), porta hepatis (n = 5), right paracaval (n = 3), retrocaval (n = 3), iliac chain (n = 3), and retrocrural (n = 2), and masses were in liver (caudate n = 2, dome n = 2, segment 6 n = 2), right adrenal (n = 3), pancreas (n = 2), aortic wall (n = 1) and IVC (n = 1). The average short axis size was 2.6 cm (range 1.0-6.8). IVUS access was jugular (n = 27) or femoral (n = 13), and biopsy access was jugular (n = 28), femoral (n = 11), or portal (n = 1) with passes made from the IVC (n = 37), iliac (n = 2), or portal vein (n = 1). In 32 procedures (80%) IVUS visualization was good. Final pathology was diagnostic of malignancy in 29 procedures (73%), correctly excluded malignancy in 4 (10%), and was non-diagnostic in 7 (18%) with subsequent diagnosis made via repeat IVUS-TVB (n = 3) or surgical biopsy (n = 2) or remaining unknown (n = 2). There were 3 minor complications requiring no treatment (hyperbilirubinemia attributed to hemobilia; contrast induced acute kidney injury; small non-occlusive IVC thrombus at the biopsy site). There was 1 major complication directly related to the biopsy (bleeding at the femoral vein access site requiring transfusion) and 1 other major complication (aortic pseudoaneurysm in a patient with preexisting salmonella aortitis). IVUS-TVB achieves high diagnostic yields similar to accepted thresholds for PNB. Complications rates may be higher but should be weighed relative to the risks of difficult PNB, surgical biopsy, or clinical management without biopsy.

Late stent thrombosis and acute ST-elevation myocardial infarction in a case affected with COVID-19: A rare manifestation

A 65-year-old male was introduced with a history of percutaneous coronary intervention 2 years ago who received Aspirin and Plavix. He was referred for coronary angiography after receiving thrombolytic therapy for ST-elevation myocardial infarction in precordial leads. On admission, he had dyspnea with low oxygen saturation, leukocytosis, lymphopenia, elevated C-reactive protein, and cardiac troponin levels. Transthoracic echocardiography demonstrated left ventricular ejection fraction (LVEF) of 25% and pulmonary artery pressure of 45 mmHg. A small thrombus at the site of the previously deployed stent was noticeable at coronary angiography. The chest computed tomography depicted significant involvement of the lungs manifested by peripheral ground-glass opacifications. A positive polymerase chain reaction confirmed coronavirus infection. He was oxygen dependent for 1 week. Gradually, his respiratory distress improved and his LVEF reached to 30% after discharge.

Abstract 14887: Look Beyond the Coronaries: A Rare Cause of Acute Papillary Muscle Rupture

A 63-year-old male with numerous cardiac risk factors presented with two hours of rapidly progressing chest pain and shortness of breath. Exam was notable for respiratory distress requiring non-invasive mechanical ventilation and a holosystolic apical murmur radiating to the axilla. He had an elevated troponin and an electrocardiogram with anteroseptal ST depressions. He was diagnosed with a non-ST segment elevation acute coronary syndrome and taken for cardiac catheterization. Surprisingly, no occlusive epicardial disease was discovered. Left ventriculogram revealed engorgement of the left atrium and pulmonary arteries suggestive of severe mitral regurgitation. The mechanism of mitral regurgitation was unclear until transesophageal echocardiography showed a ruptured posteromedial papillary muscle with flail mitral valve, a picture classically caused by myocardial infarction. Cardiac MRI demonstrated preserved LV function with minor inferior apical hypokinesis, nonspecific endocardial late gadolinium enhancement in the inferior segments, and a small LV thrombus. An embolic myocardial infarction targeting a small territory involving posteromedial papillary muscle was thought most probable. The patient then underwent an uneventful mitral valve replacement and recovery. However, he returned two months later with severe biventricular dysfunction and cardiogenic shock with peripheral eosinophilia. Myocardial biopsy confirmed the diagnosis of eosinophilic myocarditis. An exhaustive workup for the etiology of his eosinophilia proved unrevealing; he was consequently diagnosed with the idiopathic subtype. The case highlights a rare but important clinical entity that has a varied phenotype. Our patient presented atypically with an acute papillary muscle rupture that mimicked an acute myocardial infarction, ultimately delaying diagnosis. As evidenced by our case, clinical suspicion of myocarditis should be high in all patients presenting with typical anginal symptoms with mechanical or circulatory compromise in the absence of acute coronary occlusion.

Association of stress hyperglycemia ratio with intracoronary thrombus burden in diabetic patients with ST-segment elevation myocardial infarction.

BackgroundLarge intracoronary thrombus burden is not rare during primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). Stress hyperglycemia is independently associated with poor prognosis. However, the underlying relationship between stress hyperglycemia and thrombus burden remains unknown. This study aims to investigate the association of stress hyperglycemia, evaluated by the combination of acute and chronic glycemic levels, with intracoronary thrombus burden in diabetic patients with STEMI.MethodsWe enrolled 227 consecutive diabetic patients with STEMI undergoing primary PCI within 12 hours after symptom onset. Stress hyperglycemia was estimated using the stress hyperglycemia ratio (SHR), which was calculated as admission glycemia divided by estimated average glucose derived from glycosylated hemoglobin. Based on reclassified angiographic thrombolysis in myocardial infarction (TIMI) thrombus grades, patients were divided into small thrombus burden (STB) group (TIMI thrombus grades <4) and large thrombus burden (LTB) group (TIMI thrombus grades 4 or 5).ResultsOf the entire study population, 77 (33.9%) patients were categorized as LTB group, whereas 150 (66.1%) patients presented with STB. The mean age was 64.1 years, and 80.6% of the patients were male. The SHR levels were significantly higher in patients with LTB than in those with STB [1.31; interquartile range (IQR): 1.13–1.48 versus 1.11; IQR: 0.96–1.32; P<0.001]. The predictive performance of SHR for LTB was moderate (area under the curve: 0.669; 95% confidence interval: 0.604–0.730; P<0.001), with the best cut-off value 1.19 (sensitivity 71.4%, specificity 64.7%). The incidence of LTB with SHR ≥1.19 was significantly higher compared with SHR <1.19 (50.9% versus 18.5%; P<0.001). Based on the multivariable logistic regression analysis, the high SHR (≥1.19) was found to be an independent predictor of LTB following adjustment for baseline clinical confounders.ConclusionsA high SHR value was independently associated with large thrombus burden and has a better predictive value than glycemia at admission in diabetic patients with STEMI undergoing primary PCI. Stress hyperglycemia may play an important role on the intracoronary thrombus formation.

Clinical impact of angiographically insignificant suboptimal poststent findings detected by optical coherence tomography after drug-eluting stent implantation.

Although optical coherence tomography (OCT)-detected suboptimal findings (SF-OCT) such as malapposition, edge dissection, tissue protrusion, thrombus and small minimal stent area (MSA) are frequently observed after the implantation of drug-eluting stents (DES), their clinical implications are controversial. Clinical outcomes may differ between patients with SF-OCTs and without SF-OCTs after DES implantation. A total of 576 patients undergoing OCT analysis after DES implantation were divided into SF-OCT group (n = 379, 379 lesions) and No SF-OCT group (n = 197, 197 lesions). The study population had no significant abnormal finding in final angiography. Quantification was performed for each SF-OCT. The incidences of major adverse cardiovascular events (MACE: all-cause death, non-fatal myocardial infarction, target vessel revascularization, and stent thrombosis) were compared between the two groups. A median follow-up duration was 21.5 months. Among 379 patients with SF-OCT, 32.4% had multiple SF-OCTs. Malapposition (32.1%, IQR of maximal depth 315-580 μm) was the most frequent, followed by small MSA (31.6%), edge dissection (12.5%, IQR of maximal flap of opening 0.27-0.52 mm), thrombus (7.6%, IQR of diameter 1.31-1.97mm) and tissue protrusion (6.8%, IQR of diameter 1.05-1.67 mm). The SF-OCT group showed smaller stent diameter and longer stent length, and lower in-stent lumen expansion rate. The incidence of MACE did not differ between the two groups (3.0% for No SF-OCT vs. 5.0% for SF-OCT; HR 1.601; 95% CI 0.639 to 4.011; P = 0.310). The presence of angiographically insignificant SF-OCTs were not associated with clinical outcomes in this study.

Docked severe acute respiratory syndrome coronavirus 2 proteins within the cutaneous and subcutaneous microvasculature and their role in the pathogenesis of severe coronavirus disease 2019

The purpose of this study was to examine the deltoid skin biopsy in twenty-three patients with coronavirus disease 2019 (COVID-19), most severely ill, for vascular complement deposition and correlate this with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral RNA and protein localization and ACE2 expression. Deltoid skin microvascular complement screening has been applied to patients with various systemic complement-mediated microvascular syndromes, best exemplified by atypical hemolytic uremic syndrome. In 21 of 23 cases, substantial microvascular deposition of complement components was identified. The two patients without significant complement deposition included one patient with moderate disease and a severely ill patient who although on a ventilator for a day was discharged after 3 days. The dominant microvascular complement immunoreactant identified was the terminal membranolytic attack complex C5b-9. Microvascular complement deposition strongly colocalized in situ with the SARS-CoV-2 viral proteins including spike glycoproteins in the endothelial cells as well as the viral receptor ACE2 in lesional and nonlesional skin; viral RNA was not evident. Microvascular SARS-CoV-2 viral protein, complement, and ACE2 expression was most conspicuous in the subcutaneous fat. Although the samples from severely ill patients with COVID-19 were from grossly normal skin, light microscopically focal microvascular abnormalities were evident that included endothelial cell denudement, basement membrane zone reduplication, and small thrombi. It is concluded that complement activation is common in grossly normal skin, especially in the subcutaneous fat which may provide a link between severe disease and obesity, in people with severe COVID-19, and the strong colocalization with the ACE2 receptor and viral capsid proteins without viral RNA suggests that circulating viral proteins (ie, pseudovirions) may dock onto the endothelial of these microvessels and induce complement activation.

Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management.

Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ©RSNA, 2020.