Stenosis Of Origin Research Articles

Spontaneous Thrombolysis of Multiple Thrombi at Distal Region of Hypoplastic Vertebral Artery After Stent-assisted Angioplasty on Vertebral Artery Origin Stenosis: Angiographic Follow-up

Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment.The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.

Stent Placement to Treat Ruptured Vertebral Dissecting Aneurysms

Conventional endovascular treatment may have limitations for vertebral dissecting aneurysm involving the origin of the posterior inferior cerebellar artery (PICA). We report our experiences of treating vertebral dissecting aneurysm with PICA origin involvement by placing a stent from the distal vertebral artery (VA) to the PICA to save the patency of the PICA. Stenting from the distal VA to the PICA was attempted to treat ruptured VA dissecting aneurysm involving the PICA origin with sufficient contralateral VA in eight patients. The procedure was successfully performed in seven patients with one failure because of PICA origin stenosis, which was treated with two overlapping stents. In the seven patients, PICAs had good patency on postoperative angiography and transient lateral brainstem ischemia represents a procedure-related complication. Follow-up angiographies were performed in seven patients and showed recanalization of the distal VA in three patients without evidence of aneurysmal filling. There was no evidence of aneurysm rupture during the follow-up period, and eight patients had favorable outcomes (mRS, 0 - 1). Placing a stent from the distal VA to the PICA with VA occlusion may present an alternative to conventional endovascular treatment for vertebral dissecting aneurysm with PICA origin involvement with sufficient contralateral VA.

Long-term outcome of vertebral artery origin stenosis in patients with acute ischemic stroke

BackgroundVertebral artery origin (VAO) stenosis is occasionally observed in patients who have acute ischemic stroke. We investigated the long-term outcomes and clinical significance of VAO stenosis in patients with acute ischemic stroke.MethodsWe performed a prospective observational study using a single stroke center registry to investigate the risk of recurrent stroke and vascular outcomes in patients with acute ischemic stroke and VAO stenosis. To relate the clinical significance of VAO stenosis to the vascular territory of the index stroke, patients were classified into an asymptomatic VAO stenosis group and a symptomatic VAO stenosis group.ResultsOf the 774 patients who had acute ischemic stroke, 149 (19.3%) of them had more than 50% stenosis of the VAO. During 309 patient-years of follow-up (mean, 2.3 years), there were 7 ischemic strokes, 6 hemorrhagic strokes, and 2 unknown strokes. The annual event rates were 0.97% for posterior circulation ischemic stroke, 4.86% for all stroke, and 6.80% for the composite cardiovascular outcome. The annual event rate for ischemic stroke in the posterior circulation was significantly higher in patients who had symptomatic VAO stenosis than in patients who had asymptomatic stenosis (1.88% vs. 0%, p = 0.046). In a multivariate analysis, the hazard ratio, per one point increase of the Essen Stroke Risk Score (ESRS) for the composite cardiovascular outcome, was 1.46 (95% CI, 1.02-2.08, p = 0.036).ConclusionsLong-term outcomes of more than 50% stenosis of the VAO in patients with acute ischemic stroke were generally favorable. Additionally, ESRS was a predictor for the composite cardiovascular outcome. Asymptomatic VAO stenosis may not be a specific risk factor for recurrent ischemic stroke in the posterior circulation. However, VAO stenosis may require more clinical attention as a potential source of recurrent stroke when VAO stenosis is observed in patients who have concurrent ischemic stroke in the posterior circulation.

English

Ball valve thrombus which is a spherical free floating clot in left atrium is an often quoted, but uncommonly encountered complication in patients with severe mitral stenosis of rheumatic origin, who are in atrial fibrillation. We describe the case of a 31-year-old lady with rheumatic heart disease, severe mitral stenosis and moderately severe aortic stenosis who had undergone closed mitral valvotomy 13 years ago. The patient presented with an episode of non-exertional syncope and breathlessness on exertion of 6 months duration and was in normal sinus rhythm. Echocardiography facilitated ante-mortem diagnosis and prompt institution of surgery was life saving.

Drug-eluting stent for treatment of symptomatic vertebral artery origin stenosis

Drug-eluting stent for treatment of symptomatic vertebral artery origin stenosis

Long term results of surgical management of anomalous origin of the left coronary artery from pulmonary artery (ALCAPA) and mitral incompetence

Establishment of two coronary systems is not the end point of challenge in management of anomalous origin of the left coronary artery from pulmonary artery (ALCAPA). To touch or not touch the mitral valve if there is severe mitral regurgitation is still a point of big challenge, another point is the timing and criteria for mechanical support (ECMO). Forty-seven cases with a median age of 1.29 years (28 days to 8 years) underwent ALCAPA repair from January 1985 to July 2012. Seven cases (14.89%) had associated lesions. Ligation of anomalous left coronary artery was performed in four cases (8.51%), Takeuchi’s repair was done for three cases (6.38%) and 40 cases (85.1%) underwent direct aortic implantation of left coronary artery. Preoperative echo showed moderate to severe left ventricular dysfunction with severe mitral regurgitation in 15 cases (31.91%). Mortality rate was 17.02% (eight cases). Four cases (8.51%) needed ECMO support in operating room and two patients needed ECMO support in intensive care unit. Mitral valve repair was adopted in three cases (6.38) and mitral valve replacement was performed in one case (2.12%). Early postoperative echo showed moderate to severe mitral regurge with severe LV dysfunction in eight cases (17.02%) which improved in the first year of follow up. One case (2.12%) returned back with left coronary artery origin stenosis after Takeuchi’s repair. Early diagnosis and repair of ALCAPA improve outcome of surgery. Aortic implantation of left coronary artery is the best technique of ALCAPA repair and can be done easily. In severe mitral regurgitation, it is better not to touch the mitral valve as repair is very technically demanding especially in small babies without expected good results and consumes a lot of cross clamp time with subsequent bad impact on surgical outcome. Mechanical support should be decided according to the degree of LV dysfunction and severity of mitral valve regurgitation.

Vertebral Artery Origin Stenosis as a Cause of Ischemic Stroke in a Multi-Ethnic Population (P05.240)

Vertebral Artery Origin Stenosis as a Cause of Ischemic Stroke in a Multi-Ethnic Population (P05.240)

Asymptomatic Carotid Stenosis

Case Presentation: A 78-year-old woman, a retired primary school principal, was referred for a second opinion regarding a recommendation that she undergo stenting of a severe carotid stenosis. A bruit in the right carotid had led to a carotid ultrasound study and a diagnosis of 80% stenosis of the right internal carotid artery. This was confirmed by computed tomography angiography, which also showed moderate stenosis of the right vertebral origin. Her only symptoms were vertebrobasilar: She recently had an episode of vertigo accompanied by numbness in the left side of her tongue, which lasted 10 minutes. Her only past history was of a partial hysterectomy at 54 years of age. Her only medications were atorvastatin 10 mg daily and amlodipine 5 mg daily. Her father died at 62 years of age of a myocardial infarction; her mother died at 88 years of age with Alzheimer disease, and a brother was alive and well at 74 years of age. Her height was 5′7″, weight 150 pounds. Her blood pressure was 137/78 mm Hg; her general physical examination was unremarkable except for the right carotid bruit and diagonal ear lobe creases. Her neurological examination was normal except for reduced nasal tickle and reduced corneal sensation on the left; there was no indication of cognitive decline. Her serum lipids (in mg/dL) were total cholesterol 164, triglycerides 125, high-density lipoprotein 1.2, and low-density lipoprotein 2.56. Her cardiologist told her that she was a walking time bomb and offered to stent her right internal carotid artery, but she subsequently read a column by Jane Brody in …

Abstract WMP43: The Natural History of Vertebral Artery Origin Stenosis and Long-term Survival

Methods: We retrospectively reviewed clinical data on patients admitted at a single institution for possible stroke between 2004 and 2007, and selected subjects who underwent angiography of the neck. We classified subjects as having vertebral artery origin stenosis (VAOS) by ‘moderate’ to ‘severe’ (≥50%) occlusion. Age, sex, and race-matched control subjects were selected from our study population as having no evidence of VAOS on angiography. Long-term follow-up data was collected and death certificates were searched for comparison among cases and controls. A Kaplan-Meier curve was plotted based on time to event (stroke or death). Results: The proportion of subjects that were found to have VAOS was 58 per 358 cases, or 16.2%. Four subjects were excluded because of stenting, so a total of 54 cases and 54 matched controls were included for long-term follow-up analysis. In our study population, we calculated the relative risk of having a stroke or dying in patients with VAOS to be 6.0 times that of patients without VAOS ( p <0.02). The observed 5-year survival for patients with VAOS was 67% (36/54) compared to 89% (48/54) in control subjects ( p <0.01). Conclusions: Patients with vertebral artery origin stenosis are at a significantly higher risk of having a stroke or dying. Subsequent prospective, multicenter studies are needed to validate our results.

The Natural History of Vertebral Artery Origin Stenosis

We sought to determine the long-term survival and natural history of vertebral artery origin stenosis (VAOS) as it relates to stroke. We retrospectively reviewed clinical data on patients admitted at a single institution for possible stroke between 2004 and 2007 and selected subjects who underwent angiography of the neck. We classified VAOS subjects as having "moderate" to "severe" (≥50%) occlusion. Age-, sex-, and race-matched control subjects with no evidence of VAOS on angiography were selected from our study population. Long-term follow-up data were collected and death certificates were searched for comparison among cases and controls. A Kaplan-Meier curve was plotted based on time to event (stroke or death). Fifty-eight of the 358 subjects were found to have VAOS (16.2%). Four subjects were excluded because of stenting; therefore, 54 cases and 54 matched controls were included for long-term follow-up analysis. In our study population, we calculated that the relative risk of having a stroke or dying in patients with VAOS was 6 times that of patients without VAOS (P < .02). The observed 5-year survival rate for patients with VAOS was 67% (36/54) compared to 89% (48/54) in control subjects (P < .01). Patients with VAOS are at a significantly higher risk of having a stroke or dying. Subsequent prospective, multicenter studies are needed to validate our results.

Usefulness of Acceleration Time for Internal Carotid Artery Origin Stenosis

Calcification of the internal carotid artery (ICA) hinders accurate evaluation of the stenosis by conventional ultrasonography due to acoustic shadow. We examined the relationship between acceleration time (AcT) and ICA origin stenosis. One hundred thrity seven samples (266 vessels) that enforced duplex ultrasonography in our hospital were targeted. The results have shown that there is a significant relationship between AcT and stenosis. AcT of more than 110 msec suggests that the stenosis is more than 60% by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method. AcT is thought to be useful for the diagnosis of ICA stenosis with calcification. (English Translation of J Jpn Coll Angiol 2011; 51: 365-371).

Anaesthetic Management of a Patient with Pulmonary Stenosis for Laparoscopic Cholecystectomy

A 32 year old female patient posted for laparoscopic cholecystectomy was diagnosed to have moderate pulmonary stenosis of rheumatic origin. We report, successful management of this case under combined epidural and general anaesthesia.

Techniques for the diagnosis of vertebral artery origin stenosis and considerations for determining treatment and timing

Vertebral artery origin stenosis (VAOS) is a treatable cause of posterior circulation stroke in 9–20% of cases. VAOS can cause stroke due to artery–artery thromboembolism or flow-related posterior circulation hypoperfusion. It is recommended to maximize medical treatment of asymptomatic VAOS. Endovascular treatment of symptomatic VAOS is technically safe and effective, and may be used in secondary stroke prevention in light of the low complication rate of the procedure. The major concern with endovascular treatment appears to be long-term durability owing to significant restenosis rates.

Wisconsin Spine Outcome Study–Pilot: preliminary data

Given the pragmatic difficulties in developing randomized controlled trials in patients with disorders of the spine, the Wisconsin Spine Outcome Group has adopted the use of a prospective registry design to perform comparative effectiveness research on treatments for degenerative lumbar disorders. The goal of the Wisconsin Spine Outcome Study-Pilot (WISPOS-P) was to establish a Web-based, Health Insurance Portability and Accountability Act-compliant registry and to implement a patient registration paradigm that demonstrates at least 80% compliance in collecting pre- and posttreatment data in patients with lumbar disorders, regardless of the treatment they receive. The primary outcome measures were the percentage of patients with lumbar spine disorders who completed a Web-based survey preappointment, and at 1 and 3 months postappointment; the percentage of patients receiving a physician-assigned diagnosis in the registry; and the success of electronic data transition from the Web-based interface to a locally controlled registry. The WISPOS-P uses a prospective, diagnosis-based registry design. A universally accessible and secure Internet-based data management platform was created that accrues self-entered patient data on validated disability indices, including the visual analog pain scale, Oswestry Disability Index (ODI), and the 36-Item Short Form Health Survey questionnaire. Data were obtained on patients, preappointment and at 1 and 3 months postappointment, regardless of the treatment rendered. A physician-entered diagnosis was assigned to each patient for data stratification. One hundred patients were invited into the WISPOS-P; 90 patients participated, and 10 withdrew for various reasons. Eighty-eight of 90 patients were assigned a diagnosis by the evaluating physician. Preliminary and qualitative assessment of the data shows that the major difference between patients who withdrew from the study and those who participated was the number of days between study invitation and clinic appointment (median 11 vs 20.5 days, respectively). In evaluating patients by mode of survey completion, the 2 largest groups were those who completed their intake forms electronically before their clinic appointment and those who used the paper format. The median age of patients electronically completing this survey was 14.34 years younger than those using the paper format. A significantly higher proportion of patients who completed their forms electronically had listed an email address. The 3 major diagnoses were disc disease (32 patients), stenosis (24 patients), and nonsurgical pain of spinal origin (14 patients). Patients with stenosis were older than those in the other 2 groups. Patients with nonsurgical pain of spinal origin had lower ODI scores compared with the other 2 groups. A diagnosis-based registry design is effective in collecting pretreatment data for patients with lumbar disorders. When stratified by diagnosis, comparative effectiveness analyses can be performed to identify optimum treatments for lumbar disorders given individual patient characteristics. The WISPOS-P has established a mechanism and proof of principle for the participation of patients in an outcomes registry.

Angina without significant coronary stenosis of non vasospastic origin. Clinical profile and long-term follow-up of patients with vs patients without stress induced ST segment depression

The syndrome of chest pain without significant coronary stenosis, coronary spasm or myocardial infarction (MI) has long been recognized [1–6] and is mainly identified as syndrome X (SX) [4,7] and angina with normal coronary angiogram (ANCA) [1–3,5,6,8]. SX refers to ST depression during stress test [4,7], occurs in a minority of patients [2,3,5,8] and includes typical angina and atypical chest pain whereas ANCA series very often pool patients with a positive or negative stress test, and with or without typical angina [1–3,5,6].

Concurrent Stenoocclusive Disease of Intracranial and Extracranial Arteries in a Patient with Polycythemia Vera

Moyamoya disease is a stenoocclusive disease involving the intracranial carotid and proximal middle cerebral arteries. There are rarely any additional extracranial stenoses occurring concurrently with moyamoya. The pathophysiology of moyamoya remains obscure, but hematologic disorders, notably sickle-cell anemia, have been associated in some cases. We describe the novel case of polycythemia vera associated with severe steno-occlusive disease of both intracranial and extracranial large arteries. A 47-year-old woman with polycythemia vera had multiple transient ischemic attacks, and noninvasive vessel imaging revealed steno-occlusive disease of bilateral supraclinoid internal carotid arteries with moyamoya-type collaterals, proximal left subclavian artery, right vertebral artery origin, bilateral renal arteries, superior mesenteric artery, and right common iliac artery. Laboratory workup for systemic vasculitis was negative. She required bilateral direct external carotid to internal carotid bypass procedures and percutaneous balloon angioplasty of her right VA origin stenosis. This case suggests that hematologic disorders can lead to vessel stenoses and occlusion. The pathophysiology may be due to a prothrombotic state leading to repeated endothelial injury, resultant intimal hyperplasia, and progressive steno-occlusion.

A Calcified Artery of Drummond, Could It Be a Sentinel Sign of Further Complications?

Objective: To understand the role of the artery of Drummond in the elderly population. The artery plays a crucial role in the anastamosis between the inferior mesenteric artery and superior mesenteric artery. Its maintenance is particularly important for the survivability of the bowel in events of stenosis of either one of the native arteries; SMA or IMA. Method: A 94 year old lady presents with post-prandial abdominal pain and significant emaciation. The patient undergoes clinical and radiological investigations to find out the cause of her ailments. Results: Abdominal X-ray revealed a serpentine structure that was later defined as the artery of Drummond, CT scan revealed a calcified and enlarged artery of Drummond in addition to an occluded origin of SMA and celiac artery as well as a severe stenosis origin of IMA. Conclusion: The artery of Drummond was immensely hypertrophied and was supplying the entire bowel through the native IMA; subsequent occlusion of the IMA was the main cause that caused the demise of the patient.

Multicenter Study of Safety in Stenting for Symptomatic Vertebral Artery Origin Stenosis: Results from the Society of Vascular and Interventional Neurology Research Consortium

To assess the safety and efficacy of vertebral artery origin angioplasty and stenting for stroke prevention in a multicenter clinical experience. Patients with symptomatic vertebral artery origin stenosis (VAOS) were gathered from the Society of Vascular and Interventional Neurology Research Consortium. Demographic, clinical, and procedural data were collected. The main outcome measure was procedural and peri-procedural risks of stroke, transient ischemic attack (TIA), or death at 1 and 3 months. Logistic regression analysis was used to assess covariates associated with future restenosis. A total of 148 patients were included with mean age of 66.2 ± 11.5; 74% men and 77% Caucasian. One patient (.8%) had a stroke at 1 month and 5 of 96 (5.2%) patients had TIA at 3 months. There were no immediate procedural events or deaths. The mean angiographic pre-treatment stenosis was 80.5 ± 12.7%, which was reduced to 5.3 ± 9.1% after stent deployment. Follow-up angiography showed 15.5% of patients had significant restenosis (≥50%). Predictors of restenosis included age (OR 3.08; 95% CI 1.01, 9.41) and smoking (OR 3.10; 95% CI 1.12, 8.64). Endovascular intervention of VAOS is associated with low peri-procedural complication rates. Restenosis remains a concern; age and smoking predicted future restenosis.

How should I treat a patient with left main disease and a totally occluded left anterior descending artery with a diseased saphenous venous graft?

A 60-year-old man with history of coronary bypass surgery in 2000 with three saphenous venous grafts (SVG) to left anterior descending artery (LAD), diagonal and obtuse marginal branches, presented by worsening chest tightness of one month duration. He had a clinical history of hypertension, dyslipidaemia and chronic renal impairment. Physical examination, electrocardiography, laboratory tests, echocardiography and coronary angiography. Significant aorto-ostial stenosis of the SVG to LAD, left main stenosis, chronic total occlusion of LAD from its origin and significant stenosis of the mid portion of left circumflex artery. Percutaneous intervention re-do bypass surgery, dual anti-platelet therapy.

Late Tricuspid Regurgitation as a Result of Rheumatic Tricuspid Disease in a Patient With Prosthetic Mitral Valve. Combined Two-Dimensional and Real- Time Three-Dimensional Transthoracic Echocardiographic Assessment

We herein present the case of a 65-year-old lady with late tricuspid regurgitation 15 years after successful mitral valve replacement due to severe mitral stenosis of rheumatic origin. She presented to our department complaining of fatigue which worsened over the last 6 months. Transthoracic echocardiographic examination including both 2D and real time 3D modalities revealed severe tricuspid regurgitation and the patient was scheduled for tricuspid annuloplasty. A propos with this case, a brief review of the literature is provided highlighting the key points of this topic.