Spontaneous Recanalization Research Articles

PREVALENCE AND CHARACTERISTICS OF PORTAL VEIN RECANALIZATION IN CIRRHOTIC PATIENTS ADMITTED WITH PORTAL THROMBOSIS IN A THIRD LEVEL CARE CENTER

Portal vein thrombosis (PVT) refers to the formation of blood clots within the trunk of the portal vein (PV) or its main branches, which can spread to the superior mesenteric (SMV) and splenic (VE) veins. The natural history of liver cirrhosis is a complication with a "rebalanced" coagulation system that can promote bleeding or a thrombotic tendency. The prevalence in compensated cirrhotic is 1% in and 8-25% in decompensated patients. To determine the prevalence and characteristics of PV recanalization in cirrhotic patients with PVT. Descriptive, cross-sectional/prevalence. We reviewed medical records of all cirrhotic patients admitted with PVT diagnosis from January 2019 to April 2021. We included patients with a diagnosis of PVT. Qualitative variables were expressed as frequencies and percentages. The numerical variables were expressed as means and standard deviations. We use X2, Fisher's exact, Student's t, and Mann-Whitney U to compare groups as appropriate. Of 553 cirrhotic patients admitted from January 2019 to April 2021, 48(8.67%) patients with PVT diagnoses were included. Of these, 27(56.3%) were women, with a mean age of 59.37±12.67 years, 9(18%) with a diagnosis of cancer, of which 8(16.7%) were hepatocellular carcinoma, 2(33.3%) extended to the two arms, 6(12.5%) received treatment, 100% of the treatment was based on low molecular weight heparin. According to the degree of recanalization: 37(77.08%) recanalized, 27(56.3%) did so partially, of them, 24(88.9%) were spontaneous; 10(20.8%) recanalized utterly, of which 90% were without treatment, with no significant difference between recanalization to free progression vs. treatment ( p =0.179) and 11(22.9%) did not recanalize. Regarding the characteristics of the thrombosis by imaging studies, 26(54.2%) were chronic, 28(58%) partial, only 9(18.8%) with cavernomatous transformation, 30(62.5%) were located in the main trunk, 6(12.5%) extended to the SLM and 11(22.9%) presented flow <15cm/s. In cirrhotics with recent or partial occlusion (> 50% of the lumen) or thrombosis of the main PV or SMV, therapy should be considered. Anticoagulant or interventional therapy has no benefit complete chronic occlusion of the main PV or cavernomatous transformation. Spontaneous recanalization occurs in 40% in 3 months, and with therapy, it is 80%. Several cohort studies reported that near 50% recanalize partially or totally in the next three months, and up to 80% recanalize at 12 months. Clinical trial data are weak regarding the indications for treatment for PVT without ischemic symptoms. Our study showed that 77.08% of cirrhotic patients with PVT recanalized, most partially during follow-up and more than 80% spontaneously, and only a low percentage presented with cavernomatous transformation. In addition, more than 70% of the patients who recanalized have a low risk of re-thrombosis related to flow. The prevalence of PVT in cirrhotic patients was relatively low (10%), complete or partial recanalization was very high, even spontaneously, there was no difference in the degree of recanalization with or without anticoagulation. The authors declares that there is no conflict of interest

483 Minoca in a young patient with elevated platelet count

Abstract Aims Ischaemic heart disease is rare in young women, especially in the absence of a positive family history and strong cardiovascular risk factors, such as insulin-dependent diabetes. However, the correct diagnosis of ischaemic heart disease in young population is mandatory, and the specific aetiology should be identified to ensure a proper treatment. Methods and results We present the case of a 35-year-old caucasian woman who underwent ambulatory cardiological evaluation after episodes of chest pain and worsening dyspnoea (NYHA class II). The patient was asymptomatic at rest, BP was normal, heart rate was 80/minute in sinus rhythm, with no clinical signs of acute heart failure. ECG showed sinus rhythm with Q wave (lead DIII) and negative T waves (inferior leads). At echocardiographic evaluation LV was severely dilated (EDVi 105 ml/mq, EDD 66 mm) with akinesia and scar in the infero-posterior wall determining moderate reduction in ejection fraction (LVEF 40%), associated with secondary moderate mitral regurgitation; the right ventricle, the other valves and the aortic root were normal. The young lady was then admitted to Cardiology Unit for further investigations. She underwent cardiac MRI, which confirmed LV dilatation and dysfunction (EDV 198 ml/mq, LVEF 42%), associated with akinesia and infero-postero-lateral wall scar, with transmural myocardial fibrosis in the same segments, and subendocardial fibrosis on the basal segment of the anterior wall. Analysis of blood samples revealed elevated haemoglobin levels (Hb: 17.5 g/dl, n.v. 12–16 g/dl) and extremely elevated platelet count (PLT 945 000/mmc, n.v. 130 000–400 000/mmc). Cardiac troponin I (cTnI) was negative on serial determinations. All findings were suggestive for subacute infero-posterior myocardial infarction. Coronary angiography was performed via radial access: the exam was negative for significant stenosis in any coronary segment, only mild stenosis of proximal dominant left circumflex (LCX) artery was identified; moreover, there were no angiographic signs of coronary dissection. Eventually, SCAD and aortic defects were ruled out by coronary CT scan, which was negative for both coronary and aortic dissection. New blood samples examinations confirmed high values of Hb and PLT. Low levels of EPO (1.4 mU/ml) and JAK-2 mutation V617F positivity suggested the clinical diagnosis of essential thrombocythemia, later confirmed by bone marrow aspiration. Hydroxyurea was prescribed, as well as haematologic follow-up. Conclusions This is an interesting case of ischaemic heart disease, confirmed by ECG, echocardiography, and cardiac MRI, in presence of non-obstructive coronary artery disease. The aetiology of this specific case of MINOCA is potentially to be sought in the haematologic disorder. It is possible to hypothesize that a platelet/RBC clot might have determined acute obstruction of the proximal dominant LCX artery, then followed by spontaneous recanalization. Only mild stenosis on the proximal vessel was identified, and stenting was considered not appropriate for this lesion.

Abstract 1122‐000171: Unusual Multicompartmental Intracranial Hemorrhage After Tenecteplase Administration

Introduction : The 2019 AHA/ASA updated Guidelines for the Early Management of Patients with Acute Ischemic Stroke mention tenecteplase (TNK) as a reasonable therapy in patients without contraindications for IV fibrinolysis who are also eligible to undergo mechanical thrombectomy. We describe a case of acute left MCA ischemic stroke treated with IV TNK (IV bolus of 0.25 mg/kg) followed by mechanical thrombectomy with subsequent multicompartmental intracranial hemorrhages unrelated to area of infraction. Methods : A retrospective review at a single center university hospital was performed for all intravenous TNK administrations outside of a clinical trial setting from October 2020 to July 2021. Results : A 61‐year‐old male with history of HTN and cardiomyopathy (EF&lt;20%). Presented with sudden onset right sided weakness, aphasia and left gaze. Presenting NIHSS was 28. CT head with hyperdense left MCA sign and ASPECTS score of 10. CTA confirmed proximal left MCA M1 segment occlusion. IV TNK was given within 01:23 hours of symptoms onset. Subsequently, patient underwent emergent mechanical thrombectomy for disabling large vessel occlusion stroke. Spontaneous near complete recanalization of left MCA occlusion was noted on initial angiography run with small non flow limiting distal thrombi visualized in the distal MCA territories. Immediate post procedure CT head was negative for any intracranial hemorrhage. Patient’s exam was noted to improve to NIHSS of 2. Approximately 6 hours after the TNK administration, patient became acutely unresponsive with NIHSS of 26. With Glasgow Coma Scale 7 patient required emergent intubation. CT head revealed bilateral cerebellar intraparenchymal hemorrhages, extensive subarachnoid hemorrhage in basal cisterns and within the sulci in bilateral frontotemporal regions, as well as subdural hemorrhages along the falx and tentorial dural folds. Hypertonic saline was administered followed by emergent extraventricular drain placement. Tranexamic acid 1000 mg was given as emergent reversal, fibrinogen level was 155 mg/dL. Despite aggressive medical management and over following 24 hours, exam worsened with loss of pupillary reflexes. Patient was terminally extubated 2 days after initial presentation in accordance with his advance directives. Conclusions : Tenecteplase was a reasonable choice in this case given LVO and disabling stroke. The patient’s neurological exam improved significantly after TNK with evidence of spontaneous recanalization. However, patient’s multicompartmental intracranial hemorrhages unrelated to area of infraction were unusual in the absence of any vascular lesions to predispose hemorrhage based on CT and conventional angiography. Further observational studies are warranted to evaluate similar complications of Tenecteplase administration and their occurrence rates.

Spontaneous craniocervical dissection

Spontaneous craniocervical dissection is one of the main causes of stroke in juvenile and middle-aged patients. It is caused by intramural hematoma which may result in stenosis or even occlusion of the artery. Clinical manifestation varies from local pain to ischemic complications. The imaging modality of choice is magnetic resonance imaging (MRI) which is able to detect all characteristic signs of dissection. Intramural hematoma is detected with thin slice fat-saturated 3D black-blood images. However, with the use of special imaging techniques, questionable findings can be clarified and especially the more difficult to detect intradural dissection can be accurately diagnosed. Acute treatment depends on the severity of neurological symptoms and their duration. Factors like the location of the dissection, cerebral infarction or hemorrhage influence the choice of medication for primary and secondary prophylaxis. Resorption of the intramural hematoma often leads to spontaneous recanalization within afew months.

Aortic remodeling and competitive flow after surgical treatment of aortic dissection

Aortic remodeling after dissection is poorly understood and remains a focus of current research. In the present report, we have described the cases of two patients with acute lower extremity ischemia related to malperfusion from aortic dissection treated with extra-anatomic axillobifemoral bypass. During long-term follow-up, aortic remodeling led to reinstitution of flow through the native aorta. This resulted in competitive flow, leading to complete thrombosis of the extra-anatomic conduits. These cases highlight the occurrence of spontaneous aortic recanalization and subsequent competitive flow, two vascular phenomena that are not well understood but can significantly affect patient outcomes.

Early Hepatic Artery Thrombosis After Living Donor Liver Transplant: A 13-Year Single-Center Experience in Jordan.

Early hepatic artery thrombosis is a serious complication that may follow living donor liver transplant. Acute graft loss and patient morbidity and mortality are possible consequences. The therapeutic algorithm includes surgical or interventional revascularization, conservative approaches, or retransplantation. Among 155 patients who underwent living donor liver transplant at our transplant center from 2004 to 2020, there were 5 who developed hepatic artery thrombosis. From our 13- year experience, we herein present their demographic and clinical characteristics, radiological imaging findings, perioperative courses, and the postoperative follow-up. All patients displayed advanced liver disease with a Child-Pugh score of C and a mean Model for End-Stage Liver Disease score of 32. Underlying causes for end-stage liver disease included hepatitis B and C infection and cryptogenic liver cirrhosis. The mean patient age was 49 years; 2 patients were female. Living donor liver transplant was performed with donor tissue from immediate kin, according to Jordanian allocation rules. The diagnosis of hepatic artery thrombosis was made by Doppler ultrasonography and confirmed via computed tomography. After surgical revision of the anastomosis, our first patient experienced thrombotic recurrence. All patients received interventional catheterization with local thrombolysis and subsequently developed rethrombosis. Despite prevalent thrombosis, 4 patients achieved long-term survival without further deterioration of liver function. Cumulative 1-year, 5-year, and 10-year survival rates were 80%, 80%, and 60%, respectively. Spontaneous recanalization of the hepatic artery was observed in 1 patient. Favorable long-term outcomes are achievable in patients with persistent hepatic artery thrombosis. When retransplant is not feasible and interventional approaches fail, conservative treatment with careful observation of liver function should be implemented. Attentive observation of collateral circulation toward the liver, distal of the thrombosis, may be beneficial to both graft and patient survival.

Abstract No. 67 Spontaneous and assisted recanalization of hemodialysis access after prior failed thrombectomy and abandonment: the Lazarus phenomenon

To evaluate the occurrence of spontaneous and assisted recanalization of hemodialysis accesses following failed percutaneous mechanical thrombectomy and abandonment of the access A retrospective review was performed of a prospectively managed quality assurance database of all hemodialysis (HD) access interventions performed between March 2001 and September 2020. Of 11,266 hemodialysis access interventions, 3,137 thrombectomy procedures were performed. Successful thrombectomy procedures were performed in 2,891 cases for an overall success rate of 92.2%. A total of 246 failed thrombectomy procedures were identified. An access was considered abandoned if no further attempts at thrombectomy were planned. Cases in which thrombectomy was recorded as failure due to other issues such as procedure complication but not considered abandoned, with planned subsequent return for repeat attempt, were excluded from analysis. Retrospective review of all failed thrombectomy procedures was performed to evaluate for a subset of accesses deemed abandoned that demonstrated spontaneous or assisted recanalization. Of the 246 failed mechanical thrombectomy procedures, access types included 99 native fistulas, 120 grafts, 9 hybrid access, and 18 without documented access details. There were 14 accesses (5.7% of failures) that demonstrated recanalization enabling subsequent salvage of the access after failed thrombectomy and access abandonment; all accesses exhibited trace flow beyond the (arterial) anastomosis at the time of failed thrombectomy. Of these salvaged accesses, 9 occurred in fistulas, 4 in grafts, and 1 in a hybrid access. Secondary procedures were performed in 7 patients including repeat thrombectomy with angioplasty (n = 3), thrombectomy with stent (n = 1), angioplasty (n = 1) and stent (n = 1) to maintain access function. Seven of the cases demonstrated spontaneous recanalization with no required additional intervention. All 14 salvaged accesses were successfully used for hemodialysis within 30 days post spontaneous or assisted recanalization. Spontaneous recanalization of clotted hemodialysis accesses considered abandoned after failed mechanical thrombectomy can occur. Further characterization of this phenomenon is needed to determine whether an observation period of catheter HD is warranted in the subset of patients with trace flow beyond the anastomosis following failed thrombectomy.

Temporary application of lower body positive pressure improves intracranial velocities in symptomatic acute carotid occlusion or tight stenosis: A pilot study

Patients with isolated cervical carotid artery occlusion not eligible to recanalization therapies but with compromised intracranial hemodynamics may be at risk of further clinical events. Apart from lying flat until spontaneous recanalization or adjustment of the collateral circulation hopefully occurs, no specific treatment is currently implemented. Improving collateral flow is an attractive option in this setting. Lower body positive pressure (LBPP) is known to result in rapid venous blood shift from the lower to the upper body part, in turn improving cardiac preload and output, and is routinely used in acute hemorrhagic shock. We report here cerebral blood flow velocities measured during LBPP in this patient population. This is a retrospective analysis of the clinical, physiological, and transcranial Doppler monitoring data collected during and 15 min after LBPP in 21 consecutive patients (10 females, median age: 54 years) with recently symptomatic isolated carotid occlusion/tight stenosis (unilateral in 18) mostly due to atherosclerosis or dissection. LBPP was applied for 90 min at a median 5 days after symptom onset. At baseline, middle-cerebral artery velocities were markedly lower on the symptomatic, as compared to asymptomatic, side. LBPP significantly improved blood flow velocities in both the symptomatic and asymptomatic middle-cerebral artery as well as the basilar artery, which persisted 15 min after discontinuing the procedure. LBPP also resulted in mild but significant increases in mean arterial blood pressure. LBPP improved intracranial hemodynamics downstream recently symptomatic carotid occlusion/tight stenosis as well as in the contralateral and posterior circulations, which persisted after LBPP deflation. Randomized trials should determine if this easy-to-use, noninvasive, nonpharmacologic approach has long-lasting benefits on the intracranial circulation and improves functional outcome.

Hemorrhagic transformation of ischemic stroke

The article reviews the problem of hemorrhagic transformation (HT) of ischemic stroke. The frequency and relevance of this complication in clinical practice is high considering the widespread implementation of cerebral recanalization methods: intravenous thrombolytic therapy and intravascular thromboembolectomy. The etiology and pathogenesis, as well as alternative mechanisms underlying the development of HT are also discussed. The probability of HT increases in case of extensive cerebral ischemia commonly associated with cardiac embolism. The role of spontaneous and medication-induced arterial recanalization of cerebral arteries in the genesis HT is discussed. In particular, it is noted that arterial recanalization is not an essential factor for the occurrence of HT in cerebral infarction. The severity of HT is determined by the duration and degree of cerebral ischemia. There is a need for a targeted search for HT predictors. The classification of types and criteria of HT are presented. The risk factors and scales used to predict HT are studied. Risk factors for HT are combined into several groups: clinical, laboratory, genetic, neuroimaging. Their comparative analysis is carried out and practical significance is estimated.

A Novel Mouse Model for Cerebral Venous Sinus Thrombosis.

Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke resulting in parenchymal injuries associated with heterogeneous clinical symptoms and prognosis. Therefore, an experimental animal model is required to further study underlying mechanisms involved in CVST. This study is aimed at developing a novel murine model suitable and relevant for evaluating injury patterns during CVST and studying its clinical aspects. CVST was achieved in C57BL/6J mice by autologous clot injection into the superior sagittal sinus (SSS) combined with bilateral ligation of external jugular veins. Clot was prepared ex vivo using thrombin before injection. On days 1 and 7 after CVST, SSS occlusion and associated-parenchymal lesions were monitored using different modalities: in vivo real-time intravital microscopy, magnetic resonance imaging (MRI), and immuno-histology. In addition, mice were subjected to a neurological sensory-motor evaluation. Thrombin-induced clot provided fibrin- and erythrocyte-rich thrombi that lead to reproducible SSS occlusion at day 1 after CVST induction. On day 7 post-CVST, venous occlusion monitoring (MRI, intravital microscopy) showed that initial injected-thrombus size did not significantly change demonstrating no early spontaneous recanalization. Microscopic histological analysis revealed that SSS occlusion resulted in brain edema, extensive fibrin-rich venular thrombotic occlusion, and ischemic and hemorrhagic lesions. Mice with CVST showed a significant lower neurological score on post-operative days 1 and 7, compared to the sham-operated group. We established a novel clinically CVST-relevant model with a persistent and reproducible SSS occlusion responsible for symptomatic ischemic and hemorrhagic lesions. This method provides a reliable model to study CVST physiopathology and evaluation of therapeutic new regimens.

Subepicardial aneurysm with free wall rupture and its successful surgical intervention: a case report

BackgroundSubepicardial aneurysm (SEA) is an uncommon but potentially fatal complication of acute myocardial infarction (MI) associated with an increased risk of free wall rupture (FWR) leading to sudden death. We describe a rare case of a silent myocardial infarction complicated by SEA and subsequent FWR, resulting in cardiac tamponade.Case summaryA 68-year-old man with no previous chest symptoms presented with syncope. Cardiac computed tomography incidentally revealed a small aneurysmal cavity at the inferolateral wall of the left ventricle, which was overlooked on initial transthoracic echocardiography. Coronary angiography demonstrated a narrowed first obtuse marginal branch with coronary slow flow, suggesting that spontaneous recanalization of the occluded obtuse marginal branch induced SEA and subsequent FWR. The patient underwent an emergency left ventricular aneurysm repair. The post-operative course was uneventful, and the patient was discharged from the hospital on post-operative day 20.DiscussionThis case emphasizes the importance of prompt detection and surgical intervention for SEA. Subepicardial aneurysm should be suspected in patients with pericardial effusion and suspected MI. Cardiac computed tomography is not only useful in the detection of such cases but also facilitates the development of a successful surgical strategy.

Chronic total occlusion and spontaneous recanalization of the internal carotid artery: Natural history and management strategy.

Spontaneous recanalization of a chronic total occlusion of the extra-cranial internal carotid artery is an under-reported clinical entity. This paper reviews the different etiologies of internal carotid artery occlusion, its natural course, as well as the significance and our recommendations for the management of spontaneous internal carotid artery recanalization. A review of literature on etiology, diagnosis, and treatment of internal carotid artery occlusion and recanalization was conducted. PubMed database was searched using the terms "internal carotid occlusion" and "recanalization". Articles were reviewed and studies involving the management of internal carotid artery occlusion and spontaneous recanalization were included. We subsequently developed a management algorithm for chronic total occlusion of the internal carotid artery and spontaneous recanalization of such lesions based on the available evidence. Common etiologies of chronic total occlusion of the internal carotid artery include carotid atherosclerotic disease, cardioembolic, and carotid dissection. Progression of an asymptomatic to symptomatic occlusion is estimated at 2-8% annually. Well-compensated patients can be asymptomatic. In others, clinical symptoms range from ipsilateral or global hypoperfusion to embolic stroke in some cases of spontaneous recanalization. Spontaneous recanalization occurs in 2.3-10.3% of patients but rarely results in a cerebrovascular event. Progression of an asymptomatic chronic total occlusion of the internal carotid artery to symptomatic is infrequent. The management algorithm of chronic total occlusion of the internal carotid artery and spontaneous recanalization of the internal carotid artery must be tailored to the patient based on symptoms, etiology of the lesion, imaging findings, surgical risk, and reliability for follow-up.

Spontaneous Disappearance and Recanalization of Ruptured Pericallosal Artery Aneurysm

Spontaneous Disappearance and Recanalization of Ruptured Pericallosal Artery Aneurysm

Spontaneous recanalization of occluded transplant renal artery: a rare case report

BackgroundTransplant renal artery stenosis (TRAS) is a serious vascular complication that occurs after renal transplantation and can result in hypertension, renal functional impairment, and graft loss. Endovascular treatment has become the first-line treatment for TRAS because of its low invasiveness and high success rate.Case presentationA 23-year-old female with end-stage renal disease of unknown cause received a living-donor kidney transplantation 10 months ago. Seven months after the transplantation, her blood pressure gradually deteriorated. Magnetic resonance angiography revealed bending and stenosis of the transplant renal artery, and the patient received endovascular treatment. A digital subtraction angiography revealed significant stenosis of 95% in the proximal transplant renal artery. The guidewire could not pass through the stenotic segment of the transplant renal artery even with repeated attempts by the surgeons; as a result, the transplant renal artery became occluded, and vasodilators were ineffective. After the operation, renal function gradually worsened, so she began to receive regular dialysis. Twenty-five days later, the patient’s urine volume was significantly higher than that before, and ultrasound showed that the proximal transplant renal artery was not completely occluded. A re-intervention was performed, and the stent was placed successfully in the stenotic segment. After the operation, renal function gradually recovered, and dialysis was no longer needed.ConclusionPatients with iatrogenic transplant renal artery occlusion may have the possibility of spontaneous recanalization, which can help prevent the need for re-transplantation.

Extracorporeal cardiopulmonary resuscitation with low pump flow for blocked modified Blalock-Taussig shunt followed by spontaneous recanalization.

A 2-week-old male newborn with a double inlet left ventricle developed a cardiac arrest following modified Blalock-Taussig anastomosis in pediatric intensive care unit. Probable causes of the arrest were hemodynamic instability and thrombosed shunt, which was later recanalized on extracorporeal membrane oxygenation therapy, which was successfully used with a pump flow lower than recommended in these patients-without the shunt clip, but without any complications.

Last Electrically Well: Intraoperative Neurophysiological Monitoring for Identification and Triage of Large Vessel Occlusions

IntroductionIntra-operative stroke (IOS) is associated with poor clinical outcome as detection is often delayed and time of symptom onset or patient's last known well (LKW) is uncertain. Intra-operative neurophysiological monitoring (IONM) is uniquely capable of detecting onset of neurological dysfunction in anesthetized patients, thereby precisely defining time last electrically well (LEW). This novel parameter may aid in the detection of large vessel occlusion (LVO) and prompt treatment with endovascular thrombectomy (EVT). MethodsWe performed a retrospective analysis of a prospectively maintained AIS and LVO database from May 2018-August 2019. Inclusion criteria required any surgical procedure under general anesthesia (GA) utilizing EEG (electroencephalography) and/or SSEP (somatosensory evoked potentials) monitoring with development of intraoperative focal persistent changes using predefined alarm criteria and who were considered for EVT. ResultFive cases were identified. LKW to closure time ranged from 66 to 321 minutes, while LEW to closure time ranged from 43 to 174 min. All LVOs were in the anterior circulation. Angiography was not pursued in two cases due to large established infarct (both patients expired in the hospital). EVT was pursued in two cases with successful recanalization and spontaneous recanalization was noted in one patient (mRS 0–3 at 90 days was achieved in all 3 cases). ConclusionsThis study demonstrates that significant IONM changes can accurately identify patients with an acute LVO in the operative setting. Given the challenges of recognizing peri-operative stroke, LEW may be an appropriate surrogate to quickly identify and treat IOS.

Rendezvous technique to recanalize a stapled esophagus after esophageal exclusion for salvaging concomitant esophageal and bronchial rupture due to Sengstaken Blakemore tube misplacement: A novel application of an old technique

AbstractThis is the first reported case on concomitant bronchial and esophageal rupture due to Sengstaken Blakemore tube misplacement. Patient was managed with emergency laparotomy and thoracotomy. Esophageal exclusion and esophagostomy diversion were performed. Spontaneous recanalization of the cervical esophagus was evident 1 month after operation. However, it did not occur at the distal esophagus. A combined antegrade–retrograde rendezvous technique was employed, with two endoscopes approaching from two sides of the oesophagogastric junction, under fluoroscopic guidance, the digestive tract was successfully restored without further operation. Such rendezvous technique to recanalize a stapled esophagus has never been reported. Safety issues of Sengstaken tube insertion were reviewed.

Return of the Left Internal Mammary Artery

Competitive flow from a non-critical native vessel leading to longitudinal narrowing/atresia of the left internal mammary artery (LIMA) is described as “the string phenomenon.” We describe spontaneous recanalization of an atretic LIMA following coronary artery bypass grafting for multivessel coronary artery disease.

Appropriateness, safety, and effectiveness of “drip and ship” teleconsultation model in Southeastern Tuscany: a feasibility study

Teleconsultation is a consultation between two or more physicians about the diagnostic work-up and therapeutic strategy in the treatment of an individual case by means of modern telematics. 'Drip-and-ship' teleconsultation model consists of the transfer of patients, through telematics stroke networks, with large arteries occlusions from primary to comprehensive stroke centers equipped for endovascular therapy. We retrospectively investigated appropriateness, safety, and effectiveness of 'drip-and-ship' teleconsultation model in a rural area of Tuscany. Outcome measures were: door-to-ship time (including door-to-needle time), ratio of number treated/total sent patients, adverse events/mortality during transfer, and mortality and modified Rankin scale at 90 days. Analysis of non-treated patients was also done. Seventy-eight patients were included; 16/78 patients were sent for endovascular therapy alone, and 62/78 for "drip-and-ship"; 12 patients were not treated. Door-to-ship, and door-to-needle times (mean ± SD) were 105 ± 29.8 and 62.5 ± 37.5min, respectively. The ratio number of treated/total sent patients was 0.85. At 90days, the global mortality rate was 21%, and 40% of patients showed favorable outcome. The main cause of non-treatment was spontaneous recanalization. The high value for treated/total sent patients' ratio underlines that "drip-and-ship" teleconsultation model is appropriate and effective, with a few untreated patients. The model is safe, without adverse events during transfer. Taken together, our outcomes are in line with the previous reports. "Drip-and-ship" teleconsultation model is safe and effective in rural areas, allowing good selections and rapid treatments for stroke patients, based on the transfer from the primary to the comprehensive stroke center.

The p48 Flow Modulation Device with Hydrophilic Polymer Coating (HPC) for the Treatment of Acutely Ruptured Aneurysms: Early Clinical Experience Using Single Antiplatelet Therapy

BackgroundFlow diversion (FD) remains a potential treatment option following aneurysmal subarachnoid hemorrhage (aSAH) when standard options may not be feasible. However, it should not be considered a first-line treatment due to the need for dual antiplatelet therapy (DAPT). The hydrophilic polymer coating on the p48MW flow diverter (HPC, phenox) is a surface modification that inhibits platelet adhesion. This study aims to report on our early single-center experience using the p48MW HPC (phenox) flow diverter with single antiplatelet therapy (SAPT) following an aSAH.Materials and MethodsWe retrospectively identified all patients who had been treated with the p48MW HPC for aSAH under SAPT. All patients treated within 30 days following an aSAH were included. Any occurrence of thromboembolic and hemorrhagic complications was recorded alongside angiographic and clinical follow-up details.ResultsEight patients were identified. The mean interval between aSAH and FD was 6 days. Of the eight ruptured aneurysms, one was blister-like, one saccular, one mycotic, and the remaining five were dissecting aneurysms. Intraprocedural transient thrombus formation was observed in four patients (50%). Stent thrombosis was observed in one patient (12.5%) on day 3 with spontaneous recanalization after being switched onto DAPT. None of the aneurysms rebled after treatment. Two patients died due to cerebral vasospasm. Complete aneurysm occlusion had been achieved in all but one patient at angiographic follow-up (average 6 months).ConclusionsThis small series highlights the possibility and limitations of using the p48MW HPC with SAPT in ruptured aneurysms. Randomized trials with longer follow-up in larger cohorts are underway.