Vessel Stenosis Research Articles

The correlation between serum MHR and NLR and the severity of coronary lesions in NSTE-ACS patients of different genders

BackgroundTo study the relationship between the monocyte/high-density lipoprotein cholesterol ratio (MHR) and neutrophil-to-lymphocyte ratio (NLR) and coronary artery stenosis in Non-st-elevation acute coronary syndromes (NSTE-ACS) patients of different genders.MethodsA total of 253 control and 800 NSTE-ACS patients were included, and clinic data (29 items) were also collected. NSTE-ACS patients were divided into low-risk (0–23) and high-risk (≥ 23) groups based on the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score. Then, Spearman correlation and multivariate logistic regression analyses were performed to study the associated factors of high-risk SYNTAX score in male and female NSTE-ACS patients, respectively. Finally, the receiver operating characteristic (ROC) curve was used to calculate the diagnostic value of MHR and NLR for predicting high-risk SYNTAX scores in male NSTE-ACS patients.ResultsSixteen distinct factors differed between the high- and low-risk groups in male NSTE-ACS patients, a significantly higher number than female NSTE-ACS patients. Gout/hyperuricemia, smoking, NLR, and MHR are independent risk factors for arterial stenosis. At the same time, high-density lipoprotein and left ventricular ejection fraction (LVEF) are found to be protective factors in male NSTE-ACS patients. Fibrinogen, apolipoprotein B/A, and neutrophils are identified as independent risk factors for arterial stenosis in female NSTE-ACS patients, while LVEF and high-density lipoprotein are protective factors. Finally, combined NLR and MHR [p = 0.000, 95% confidence interval (CI) = 0.726–0.810] had better predictive efficacy on the degree of arterial vessel stenosis than NLR or MHR alone. The sensitivity and specificity of the ROC curve were 0.672 and 0.769, respectively.ConclusionThe combination of MHR and NLR shows potential for predicting and assessing the severity of coronary artery stenosis in male patients with NSTE-ACS.

Spontaneous craniocervical dissection

Spontaneous dissections of the cerebral arteries are among the leading causes of stroke in young adults. They result from hemorrhage into the outer layers of the arterial wall, which can lead to stenosis or even complete vessel occlusion. Clinical presentations vary, ranging from localized pain to cerebral ischemic complications. Early recognition of dissection warning signs and diagnosis through imaging is crucial due to the high risk of recurrent transient ischemic attack (TIA) or stroke within the first two weeks following a dissection, necessitating immediate therapeutic or prophylactic intervention. Magnetic resonance imaging (MRI) is the imaging modality of choice, as it can reliably visualize all characteristic features of dissection. Typically, thin-slice, fat-saturated 3D black-blood sequences are sufficient to detect the pathognomonic intramural hematoma. Acute treatment and secondary prevention depend on the extent of neurological deficits, the location and size of the dissection, any sequelae, concomitant pathologies, and risk factors. In most cases, spontaneous vascular recanalization or regression of vessel stenosis occurs within several months due to resorption of the mural hematoma.

Systematic Review and Meta-analysis on Outcomes of the Advanta V12 or iCAST Bridging Stent Graft Used for Fenestrated and Branched Endovascular Aortic Repair.

Half of re-interventions after fenestrated and branched endovascular aortic repair (FB-EVAR) are target vessel related. Regarding bridging stent choice, existing data are controversial. This meta-analysis aimed to evaluate the performance of Advanta V12/iCAST as bridging stent in FB-EVAR. The English medical literature was searched through MEDLINE, Embase (via Ovid), and Cochrane databases (end date 15 April 2024). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and PICO (Patient; Intervention; Comparison; Outcome) model were followed. A predefined protocol was registered to PROSPERO (CRD42024556603). Randomised controlled trials and observational studies (2010 - 2024) reporting on Advanta V12/iCAST related target vessel outcomes were eligible. Risk of bias was assessed using ROBINS-I, and evidence quality was assessed via Grading of Recommendations Assessment, Development and Evaluations (GRADE). Primary outcomes were freedom from instability, stenosis and or occlusion, endoleak type Ic and IIIc, and re-intervention of target vessels bridged with the Advanta V12/iCAST. Prevalence and regression meta-analysis were performed. From 1 439 articles, ten retrospective studies (7 525 target vessels; 3 890 target vessels bridged with Advanta V12/iCAST) were included. According to ROBINS-I, no study was of high quality. Mean follow up was 24.3 (95% confidence interval [CI] 23.9 - 24.7) months. Freedom from instability, stenosis and or occlusion, and endoleak type Ic and IIIc were 94% (95% CI 91 - 96%; p < .010; I2 = 91%; GRADE certainty, very low), 97% (95% CI 96 - 98%; p = .070, I2 = 44%; GRADE certainty, low), and 97% (95% CI 94 - 98%; p < .010; I2 = 81%; GRADE certainty, very low), respectively. Freedom from target vessel re-intervention was 95% (95% CI 92 - 97%; p < .010; I2 = 85%; GRADE certainty, very low). Four studies provided extractable data on Advanta V12/iCAST in fenestrations and four in branches. No difference was detected in freedom from instability (p = .47), stenosis and or occlusion (p = .36), and endoleak type Ic and IIIc (p = .90). Freedom from re-intervention was 93% (95% CI 87 - 96%; p < .010; I2 = 90%) in fenestrations and 95% (95% CI 91 - 97%; p = .060, I2 = 64%) in branches. Advanta V12/iCAST bridging stent showed high freedom from target vessel instability, stenosis and or occlusion, and endoleak. Freedom from re-intervention was 95%, being similarly high in fenestrations and branches.

Challenging the Controversy Surrounding Percutaneous Brachial Artery Access Related Complications: A Systematic Review and Meta-Analysis.

Endovascular therapy has become increasingly preferred in the diagnosis and treatment of various conditions. The choice of arterial access usually depends on the type of procedure being performed with most via the common femoral artery and increasingly via the radial artery. Percutaneous access via the brachial artery has however been approached with caution due to the perceived increased risk for development of complications. Percutaneous brachial artery access (pBAA) has insufficient evidence when compared to femoral and radial access, with no large-scale studies available. The objective of this study is to review the literature and report the clinical and radiological complications associated with pBAA. EMBASE, EMCARE, CINAHL and Medline were searched for existing data on the complications associated with pBAA. Systematic review and meta-analysis were carried out on the data of 31 studies. The results of this systematic review and meta-analysis indicates that the probability of post procedural haematoma was 4.76%, haemorrhage 1.43%, perforation 1.11% pseudoaneurysm 1.06%, spasm 0.9%, thrombus 0.55%, neuropathy 0.53%, occlusion 0.51%, ischaemia 0.37% and infection 0.24 %. Non-target vessel puncture, stenosis and stroke had a 0% incidence among the assessed population. This study provides evidence to support clinical decision making when it comes to the utility of pBAA in endovascular diagnosis or therapy. The results demonstrate that pBAA is relatively safe with a low incidence of serious complications and thereby provide the clinician with the option of an alternate access point when planning treatment.

MIND diet, Cerebrovascular Health, and Cognition among community‐dwelling Older Adults

AbstractBackgroundWhite matter hyperintensities (WMH) and cerebral arteriosclerosis involving thickening of the vessel wall and stenosis of brain arterioles are common in older adults and associated with poor cognition. The Mediterranean‐DASH Intervention for Neurodegenerative Disease (MIND) diet is associated with better cognition. Little is known about the association of the MIND diet with cerebrovascular outcomes and if this association mediates the link between diet and cognition. This study investigates the association of the MIND diet with WMH volume and arteriolosclerosis, and whether WMH and arteriosclerosis mediate the association between diet and cognition among community‐dwelling older adults.MethodThe study includes 561 participants from an ongoing longitudinal cohort study, the Rush Memory and Aging Project with dietary and neuroimaging data available no more than a year apart. MIND diet scores were obtained using a valid &gt;142‐item food frequency questionnaire. In‐vivo magnetic resonance imaging (MRI) data were collected using a 3T MRI scanner. WMH were segmented using a deep learning model. Arteriolosclerosis was assessed employing a fully automated in‐vivo MRI‐based marker named ARTS (ARTerioloSclerois). An ARTS score was generated for each participant (higher scores indicate a higher likelihood of arteriolosclerosis). Global cognition was assessed using 19‐battery tests. Linear regression models controlled for age, sex, MRI scanner, and education. Mediation analysis was done using structural equation modeling.ResultIn our analytical sample (mean age (81 ± 7.5), 77% female, 16 ± 2.9 years of education a higher MIND diet score was associated with less WMH (β = ‐0.023, SE = 0.009, p = 0.015) and lower ARTS score (β = ‐0.013, SE = 0.004, p = 0.001). The effect estimates were stable when further controlled for BMI and physical activity. The MIND diet was associated with better global cognition (β = 0.0426, SE = 0.012, p = 0.0004), with an indirect association of 10.5% through ARTS score (β = 0.0045, SE = 0.0002, p = 0.038).ConclusionAmong community‐dwelling older adults a higher MIND diet score is associated with less WMH and a lower likelihood of small vessel arteriosclerosis. The association of the MIND diet with cognition is partially mediated by arteriosclerosis. Lifestyle approaches such as adherence to a specific diet may improve cognition by maintaining the cerebrovascular health of older adults.Fundings sources: R01AG054476; R01AG17917; R01AG076143

Electrocardiographic findings for predicting the left anterior descending artery chronic total occlusion in patients with inferior ST-segment elevation myocardial infarction

In determining the culprit vessel responsible for inferior ST-segment elevation myocardial infarction (STEMI) as either the right coronary artery (RCA) or left circumflex (LCX), the electrocardiographic value has been validated. However, its ability to predict whether inferior STEMI is complicated by left anterior descending artery (LAD) chronic total occlusion remains uncertain. Based on the involvement of arteries other than the culprit vessels, 189 patients with inferior STEMI from our chest pain center were categorized into four groups: LAD occlusion group (n = 20), LAD stenosis > 50% group (n = 116), normal LAD group (n = 27), and other vessel stenosis > 50% group (n = 26). All groups underwent coronary angiography within 24 h of admission, and electrocardiogram (ECG) and clinical data were retrospectively analyzed. In the LAD occlusion group, hypertension was significantly more prevalent (P = 0.015). Although there was a trend toward higher previous cerebral infarction and lower diabetes prevalence in the Normal LAD group, neither was statistically significant (P = 0.070 and P = 0.088). The LAD occlusion group demonstrated the highest serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and the most reduced LVEF, with a higher susceptibility to cardiogenic shock (P < 0.01). This group also had a higher use of intra-aortic balloon pump (IABP) and a greater occurrence of ventricular fibrillation or tachycardia compared to the other groups (P < 0.05). The QRS duration in lead V4 (QRS V4) was 99.4 ± 19.1 ms in the LAD occlusion group, 87.5 ± 14.9 ms in the LAD stenosis group, 89.6 ± 11.4 ms in the normal LAD group, and 87.7 ± 11.7 ms in the other vessel stenosis group (P = 0.010). The difference between ST-segment depression in V4 and ST-segment elevation in lead III (ST V4↓- ST III↑) in the LAD occlusion group was the largest at -0.06 (-1.19, 1.05) mm (P = 0.029). ROC curve analysis revealed that the sensitivity of QRS V4 > 97.7ms and ST V4↓- ST III↑> 0 mm diagnosing inferior STEMI complicated with LAD occlusion was 54.5% and 50%, with a specificity of 75.1% and 78.0%, respectively. Multivariate logistic regression analysis indicated that QRS V4 (OR = 1.062, P = 0.003), ST V4↓- ST III↑ (OR = 1.641, P = 0.050), and Killip classification (OR = 2.115, P = 0.004) were all independent risk factors for LAD occlusion. In patients with inferior STEMI complicated by LAD occlusion without anterior myocardial infarction, cardiac function is poorer. The ST-segment deviation between the leads V4 and III, and the duration of QRS in the lead V4, can aid in diagnosis.

Outcomes of Adjunct Emergent Stenting Versus Mechanical Thrombectomy Alone: The RESCUE-ICAS Registry.

Underlying intracranial stenosis is the most common cause of failed mechanical thrombectomy in acute ischemic stroke patients with large vessel occlusion. Adjunct emergent stenting is sometimes performed to improve or maintain reperfusion, despite limited data regarding its safety or efficacy. We conducted a prospective multicenter observational international cohort study. Patients were enrolled between January 2022 and December 2023 at 25 thrombectomy capable centers in North America, Europe, and Asia. Consecutive patients treated with mechanical thrombectomy were included if they were identified as having underlying intracranial stenosis, defined as 50-99% residual stenosis of the target vessel or intra-procedural re-occlusion. The primary outcome was functional independence, defined as modified Rankin Scale of 0-2 at 90 days. After applying inverse probability of treatment weighting (IPTW) based on propensity scores, we compared outcomes among patients who underwent adjunct emergent intracranial stenting (stenting) versus those who received mechanical thrombectomy alone. A total of 417 patients were included; 218 patients treated with mechanical thrombectomy alone (168 anterior circulation) and 199 with mechanical thrombectomy plus stenting (144 anterior circulation). Patients in the stenting group were less likely to be non-Hispanic White (51.8% vs 62.4%, p=0.03), and less likely to have diabetes (33.2% vs 43.1%, p=0.037) or hyperlipidemia (43.2% vs 56%, p= 0.009). In addition, there was a lower rate of IV thrombolysis use in the stenting group (18.6% vs 27.5%, p=0.03). There was a higher rate of successful reperfusion (modified Treatment In Cerebral Infarction score ≥ 2B) in the stenting versus mechanical thrombectomy alone group (90.9% vs 77.9%, p<0.001) and a higher rate of a 24-hour infarct volume of <30 mL (n=260, 67.9% vs 50.3%, p=0.005). The overall complication rate was higher in the stenting group (12.6% vs 5%, p=0.006), but there was not a significant difference in the rate of symptomatic hemorrhage (9% vs 5.5%, p=0.162). Functional independence at 90 days was significantly higher in the stenting group (42.2% vs. 28.4%, adjusted odds ratio 2.67; 95% CI, 1.66-4.32). In patients with underlying stenosis who achieved reperfusion with mechanical thrombectomy, adjunct emergent stenting was associated with better functional outcome without a significantly increased risk of symptomatic hemorrhage. https://clinicaltrials.gov/study/NCT05403593.

The Co-Existence of Hypovitaminosis D and Diabetes Mellitus Triples the Incidence of Severe Coronary Artery Disease in Women.

Background and Aims: Hypovitaminosis D is involved in the development and progression of atherosclerosis, and it is more prevalent in women. The differential impact of hypovitaminosis D on the severity of coronary artery disease (CAD) between genders remains poorly understood. This study aims to address this literature gap. Methods: A total of 1484 consecutive patients with acute myocardial infarction (AMI) were enrolled in the study. Hypovitaminosis D was defined as vitamin D ≤ 20 ng/mL. CAD was defined as the presence of at least one coronary vessel stenosis > 50%, while severe CAD was defined as left main disease and/or three-vessel disease > 50%. Results: The mean age of the cohort was 66.3 (11.5) years, with a predominance of the male gender (71.8%). Vitamin D values were significantly lower in women than in men (15.7 [8.4-25.4] ng/mL vs. 17.9 [11-24.3] ng/mL, p = 0.01). A higher prevalence of severe CAD was observed in female patients with hypovitaminosis D compared to those without (33% vs. 19%, p < 0.01). This finding was not observed in men. Among women, hypovitaminosis D significantly increased the risk of severe CAD (OR: 1.85, p = 0.01), together with diabetes mellitus (DM) and older age, adjusted for GFR < 60 mL/min/1.73 m2, cholesterol and body mass index. Furthermore, women with both hypovitaminosis D and DM had more than three times the risk of severe CAD compared with women who lacked both (OR: 3.56, p = 0.02). Conclusions: In women, hypovitaminosis D increases the risk of severe CAD, and the co-existence of hypovitaminosis D and DM triples the incidence of severe CAD.

In-depth hemodynamic assessment in acute mild stroke patients with large vessel occlusion or stenosis

ObjectiveAcute treatment in mild stroke patients with acute anterior circulation large vessel occlusion/stenosis (AACLVO/S) had limited evidence. Hemodynamic play an important role in neurological deterioration. We aimed to investigate predictor value of hemodynamic assessment for clinical outcome predicting and guiding individual therapeutic decisions in those patients.MethodsWe retrospectively analyze the stroke database in our stroke center. We recruited patients with mild stroke, defined by National Institutes of Health Stroke Scale (NIHSS) score ≤ 5, caused by AACLVO/S treated with just medical management (MT). They all received cerebral autoregulation (CA) assessments within 72 h after stroke onset. The primary end point was clinical outcome at 90-day after stroke.ResultsLogistic regression analysis showed that bilateral higher baseline phase difference (PD) were independent variables related to favorable 90-day outcome, (OR 0.963, 95% CI 0.936–0.991, p = 0.040; OR 0.943, 95% CI 0.970–0.997; p = 0.008, respectively). The optimal cutoff value of bilateral PD was > 34.97º and > 14.29º respectively.ConclusionCA evaluation can provide hemodynamic status in mild stroke patients with AACLVO/S.

Abstract 250: Early Revascularization in Cervical Artery Dissection: Case Studies of Improved Neurological Outcomes

Introduction Cervical artery dissection (CAD) involves a tear in the inner lining of the carotid or vertebral artery, contributing to up to 25% of ischemic strokes in individuals under 50 years of age. This condition can lead to the formation of a false lumen within the vessel wall, potentially causing intraluminal thrombus, vessel stenosis, or pseudoaneurysm, ultimately leading to cerebral ischemia. Endovascular therapy is an option for recurrent cerebrovascular events, dissecting aneurysms, and severe stenosis, as well as in cases where anticoagulation is not tolerated. Here, we describe two cases of left internal carotid artery dissections that required revascularization due to recurrent episodes of reduced blood supply or distal embolism. Methods Electronical medical records review. Results Case 1: A 39‐year‐old man with a history of hypertension, hyperlipidemia, and migraine presented with traumatic bilateral carotid stenosis due to dissection after a fall. Initially discharged on antiplatelet agents and returned with TIA symptoms of left hemispheric hypoperfusion followed by a small left MCA stroke. Catheter angiography revealed cervical ICA dissection with a false and true lumen, along with a 99% distal cervical carotid stenosis and trace distal flow. Revascularization was performed by crossing the stenosis with an Aristotle 14 wire for good distal access. Subsequently, the Spider device was deployed in the petrous internal carotid, and Xact stents (8times6x40mm and 9times7x40mm) were placed across the distal and proximal portion of the stenosis. Post‐intervention, the patient was started on Eptifibatide infusion for 4 hours, followed by DAPT and Apixaban upon discharge. At the 30‐day follow‐up, the patient had a modified Rankin Scale (mRS) score of 0 and repeated carotid Doppler ultrasonography (CDUS) showed a patent stent. Case 2 A 36‐year‐old female with a history of hyperlipidemia, depression, and hypertension presented as a level 1 code stroke for aphasia and right hemiplegia. On arrival, her NIHSS was 9. CTA head and neck revealed a left ICA occlusion caused by dissection with reconstitution and occlusion of the left MCA inferior division. Catheter angiography revealed a left ICA occlusion due to dissection with a true and false lumen and distal reconstitution of the vessel. The diagnostic catheter and base catheter were advanced past the dissection, and a thrombectomy was performed using an Aristotle 14 wire catheter with aspiration and a stent retriever with TICI 2b reperfusion. Following this, the catheter was retracted to the cervical carotid, and the Walrus balloon was inflated, followed by the deployment of Xact stents (8times6x40mm and 9times7x40mm). Post‐intervention, the patient was started on Aspirin and Ticagrelor. Subsequent MRI of the brain and MRA showed a left MCA stroke with occlusion of the stent, which CDUS confirmed. Despite this, on discharge, the patient had mixed aphasia and RSW (3/5 strength). At 30 days, the patient had mild expressive aphasia with a mRS of 2, which improved to a mRS of 1 at 90 days. Conclusion These cases illustrate examples of select situations where early revascularization intervention can improve neurological outcomes under specific conditions. Additional studies are required.

Dual Antiplatelet Versus Alteplase for Early Neurologic Deterioration in Minor Stroke With Versus Without Large Vessel Occlusion: Prespecified Post Hoc Analysis of the ARAMIS Trial.

Dual antiplatelet therapy (DAPT) was noninferior to alteplase in minor nondisabling strokes in the ARAMIS trial (Antiplatelet Versus R-tPA for Acute Mild Ischemic Stroke); however, early neurological deterioration (END) associated with vessel stenosis may benefit from DAPT. We investigated whether the efficacy of DAPT was greater than alteplase in minor strokes with no large vessel occlusion (LVO). This study was a prespecified post hoc analysis of the ARAMIS trial and included patients with responsible vessel examination in the as-treated analysis set of the ARAMIS trial who were divided into LVO group and non-LVO group. In each group, patients were further classified into DAPT and intravenous alteplase treatments. Primary outcome was END at 24 hours defined as more than or equal to 4-point National Institutes of Health Stroke Scale score increase compared with baseline, and safety outcomes were symptomatic intracerebral hemorrhage and bleeding events during study. The primary analysis was estimated with a risk difference calculated by a generalized linear model including adjusted different baseline characteristics between treatments. Of 723 patients from the ARAMIS trial, 480 patients were included: 36 were categorized into LVO group and 444 into non-LVO group, of whom 20 patients had END. Compared with intravenous alteplase, a lower proportion of END was found after DAPT treatment in the non-LVO group (adjusted risk difference, -4.8% [95% CI, -6.9% to -2.6%]; P<0.001), but not in the LVO group (adjusted risk difference, 2.3% [95% CI, -17.6% to 22.3%]; P=0.82). The interaction was marginally significant between groups (P=0.06). In the non-LVO group, a lower proportion of bleeding events was found after DAPT treatment than intravenous alteplase (adjusted risk difference, -6.4% [95% CI, -8.9% to -3.9%]; P<0.001). Other safety outcomes were similar between the 2 treatments. Among minor nondisabling acute ischemic stroke without LVO, DAPT may be superior to intravenous alteplase regarding preventing END with a better safety profile. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03661411.

Abstract 384: Rapid accumulation of spontaneous intracranial dissection cases within two years

Introduction Spontaneous intracranial dissection is very uncommon and there are few cases reported so far. Interestingly most cases reported are from Asia. Genetic perspective would be one of the speculative causes. Making a definite diagnosis is also one of the pitfalls and distinguishing from other more common diseases, intracranial atherosclerosis which is also much more prevalent in Asia is sometimes difficult. With such a limited case, clinical progression and appropriate treatment would possibly be hard to define. Method We present a series of 11 cases directed or transferred to our hospital referral center from 2022‐2024. All patient information retrospectively collected in demographic, clinical presentation, and radiologic workups including relevant investigation, treatment, and clinical outcomes were described. Outcome All patients are between 29 and 82 years old with the six decades being the most prevalent composed of 8 cases of middle cerebral artery dissection, M1 segment and one case of M2 segment of middle cerebral artery dissection, one case of anterior cerebral artery dissection, and one case of posterior cerebral artery dissection, P2 segment. These cases have intracranial dissection spontaneously, there are no connective tissue disorders related to physical examination and there is no history of head injury before the event. Most of them present with acute ischemic stroke or transient ischemic attack and a few of them with headaches from subarachnoid hemorrhage. Interestingly there is another case that has transient ischemic attack and hyperkinetic movement disorders. Magnetic resonance imaging or cerebral angiogram reveals an intimal flap, double lumen, or string sign in all cases. These findings could distinguish from intracranial atherosclerosis if looked at carefully. The case of M2 segment middle cerebral artery dissection shows rapid progressive change in the dissecting aneurysm. Most of them had no anterograde flow impairment therefore these cases received antiplatelet treatment but four cases (36%) present with acute large vessel occlusion or severe stenosis received endovascular treatment and two of them ended up with rescue permanent stenting. One of two cases who has subarachnoid hemorrhage receives surgical clipping and bypass. All cases presenting with ischemic stroke have good clinical outcomes at three months follow up including cases with subarachnoid hemorrhage. Conclusion Spontaneous intracranial dissection is uncommon and underdiagnosed. Differentiating from intracranial atherosclerosis is important, and recognizing intracranial dissection features is useful. Clinical features or progression may not be benign since some of them may present with acute large vessel occlusion or stenosis. Providing treatment in this type is very challenging otherwise complications from endovascular treatment may be devastating.

Magnetocardiographic imaging of Tpeak-Tend magnetic field dynamics discriminates between ventricular repolarization disorders due to mitral valve prolapse and to ischemic heart disease

Abstract Background Several etiopathogenetic mechanisms, including ischemia of the papillary muscles, abnormal catecholamine regulation, baroreflex modulation, and activation of atrial natriuretic peptide induced by abnormal stretch of the prolapsing mitral leaflets, have been suggested as possible causes of ventricular repolarization abnormalities (VRab) in patients (pts) with mitral valve prolapse (MVP) [1-3], especially in those with chest pain (CP). Purpose Since magnetocardiography (MCG) is a sensitive alternative to improve the detection of VRab, this study aimed to evaluate its discrimination accuracy to differentiate VRab due to MVP from those due to ischemic heart disease (IHD). Methods MCG recordings of 32 female patients (age 40.3±13.3 years) with MVP (at echocardiography), 20 of them with CP and/or palpitations, were retrospectively compared with those of 35 pts with IHD (at least one vessel stenosis &amp;gt;70%) (age 66.2±10.6 years), and with those of 32 age-matched (age 40.8±11.5 years) healthy females (HF) without MVP. The cardiac magnetic field (MF) component perpendicular to the anterior chest wall (Bz) was recorded with a 36-channel DC-SQUID MCG system (sensitivity ~30 fT/VHz). Thirteen MCG parameters, five derived from the analysis of the T-wave MF extrema dynamics, and eight from the effective magnetic vector (EMV) dynamics, were automatically calculated with proprietary software during the Tpeak-Tend interval (T3-T4 in Figure 1). Discriminant analysis (DA) was applied to separate groups. Results At univariate analysis, 11 MCG parameters were significantly different (p&amp;lt; 0.05) between MVP and IHD pts (Table 1). After multivariate analysis, 9 parameters (AzimuthMeanA, TrajectoryLengthRangeD, AngleDerivativeRangeD, AzimuthdiffAD, Q2AnalysisScore, AngleMinimum, AngleDynamics, DistanceDynamics, RatioDynamics) differentiated MVP and IHD pts’ VRab with 80% accuracy (cross-correlated), at DA. Moreover, in IHD pts abnormality of EMV dynamics extended also along the whole T-wave [4]. Three EMV parameters of the Tpeak-Tend interval (TrajectoryLengthRangeD, AzimuthdiffAD, Q2AnalysisScore), and three T-wave MF extrema parameters (AngleMinimum, Distance Dynamics, and Ratio Dynamics) were abnormal in 11 MVP pts, 10 of them with CP but normal ECG, and only one asymptomatic. Discussion: MCG EMV and MF dynamics calculated from rest-MCG data are reliable to identify VRab in pts with MVP and with IHD, differentiating them with a good discrimination accuracy. MCG VRa abnormality was mostly confined in the Tpeak-Tend interval in pts with MVP (in agreement with previous ECG findings [5]), while extended to the whole ST interval in IHD pts. Rest MCG is more sensitive than ECG in detecting VRab in pts with MVP and CP. Due to the limited number of investigated cases, the potential arrhythmogenicity of MVP-related VRab detected with MCG was not evaluated.Figure 1.MCG imaging of Tpeak-Tend MFTable 1

Dysregulation of sympathoadrenal system activity in patients with microvascular angina

Abstract Introduction Recent studies have highlighted that a significant proportion of patients (up to 47%) undergoing coronary angiography due to clinical indications do not exhibit significant stenosis in epicardial vessels. Among these patients, up to 50% may suffer from microvascular angina (MVA). Despite the absence of intramural coronary artery lesions typically associated with atherosclerosis, the occurrence of transient myocardial ischemia and cardiac pain syndrome raises interest due to the incomplete understanding of their underlying mechanisms. Objective This study aims to comprehensively investigate sympathoadrenal system activity in patients with microvascular angina. Materials and Methods A total of 40 patients diagnosed with MVA, aged 35-76 years, including 11 (27.5%) men and 29 (72.5%) women, were enrolled, along with 20 healthy individuals. Assessment of sympathoadrenal system (SAS) activity involved determining daily urinary excretion levels of free and conjugated catecholamine fractions (CA) using solid-phase enzyme immunoassay: adrenaline (A), noradrenaline (NA), dopamine (DA), and DOFA. Additionally, catecholamine deamination enzyme activity—monoamine oxidase (MAO)—was determined using solid-phase EIA. Results Patients with MVA exhibited a significant increase in the excretion of all CA fractions. Specifically, adrenaline (A) excretion increased by 56.7%, surpassing the control by 1.7 times (p&amp;lt;0.001). Noradrenaline (NA) levels were elevated by 59.5% in MVA patients, which was 1.6 times higher than the control group (p&amp;lt;0.001). Dopamine (DA) levels in MVA patients increased by 31.0%, surpassing control values by 1.36 times (p&amp;lt;0.001). Moderate elevation in DOFA levels by 19.7% was observed, which was 1.23 times higher than the control (p&amp;lt;0.01). Ratios of CA sulfocatecholamine formation processes indicated pronounced deviations from normal. Gender differences revealed marked changes in sympathoadrenal activity, particularly in women (p&amp;lt;0.001). Studies of MAO activity on the first day identified a moderate decrease in its activity in MVA patients—0.03±0.002 units/ext. (p&amp;lt;0.01), while healthy individuals exhibited an activity level of 0.07±0.001 units/ext. Conclusion The findings underscore the crucial pathogenetic role of SAS in the development of MVA. The study demonstrates that the severity of ischemia correlates with disruptions in SAS components. Notably, these disruptions are pronounced in MVA, indicating an overload of the sympathoadrenal system—a critical component of organismal homeostasis. Under conditions of SAS overload, the pivotal enzyme in biogenic amine oxidation, MAO, undergoes significant transformation, leading to reduced activity towards monoamines. These findings were consistent with our clinical investigation.

Long-term clinical and imaging outcomes of patients undergoing percutaneous femoral intervention following TAVI-related vascular access complications

Abstract Introdcution: Vascular access complications (VAC) are the most common in-hospital adverse event following transcatheter aortic valve implantation (TAVI). Often, ileo-femoral VAC requires bail-out percutaneous interventions with either prolonged balloon inflation and/or stent implantation. The long-term outcomes of these procedures have not been characterized. We aim to assess the clinical and imaging outcomes of patients who underwent bailout percutaneous vascular interventions due to VAC following TAVI. Methods Single-centre prospective study including all consecutive patients with a VAC following trans-femoral TAVI, between 2015-July 2023. VAC was defined as uncontrolled bleeding, acute occlusion or flow limiting stenosis of the femoral vessel leading to percutaneous treatment. Clinical and imaging follow-up was performed with bilateral arterial ultrasound (US) Doppler to assess patency and peak systolic velocity of common femoral arteries. Results A total of 1518 patients underwent TF-TAVI, of which 107 (7%) underwent concomitant ileo-femoral percutaneous angioplasty (PTA) intervention in the same day as TAVI. In patients submitted to PTA, 7 were treated to gain access for TAVI, and 100 (7%) were performed to treat vascular access complications. At a mean follow-up time of 23±3 months, 37 patients died (37%), 6 (16%) from in-hospital complications and 31 (84%) from non-vascular causes after discharge. From the surviving 63 patients (study group) – mean age 83±6 years-old, 29% male, 46% with previous peripheral arterial disease –, 24 underwent bilateral US. Unable to perform imaging on 39 patients due to geographical or mobility issues. At a mean follow-up time of 30±23 months, only 6 patients (10%) reported intermittent claudication, of which 4 (67%) had pre-TAVI symptoms. No patient had at rest symptoms or amputation history. All but one had patent vessel on US. The mean peak systolic velocity of the treated vessel and the contralateral vessel were 71.1±22.9cm/s and 73.1±23.8cm/s, respectively, with no statistically significant difference between them in each patient (mean difference 1.9±25.4, p=0.709). We found no statistically significant differences between peak systolic velocities between both vessels in each patient, accordingly with the treated vessel (Table 2). Conclusion This prospective study shows that patients submitted to percutaneous bailout iliofemoral interventions have a very low rate of lower limb adverse events with very good patency rates at mean follow up of 2.5 years.

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

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

CT imaging using variable helical pitch scanning for lower extremity arterial disease: Reduced contrast medium dose, improved image quality and diagnostic accuracy

ObjectivesThis study aimed to explore the feasibility of reducing contrast medium (CM) volume, improving image quality and diagnostic accuracy using variable helical pitch (VHP) scanning for patients with lower extremity arterial disease (LEAD). Materials and methodsEighty patients who underwent lower extremity CT angiography (CTA) were prospectively enrolled and randomly assigned to either the VHP group (n = 40) or the conventional group (n = 40). Quantitative parameters and qualitative scores were compared between the two groups. Additionally, out of these patients, 72 arteries from 18 patients had DSA as the reference standard, and the diagnostic accuracy for the degree of vessel stenosis was assessed and compared. ResultsIn the VHP group, the contrast volume was significantly lower than in the conventional group (79.55 ± 11.87 mL vs. 89.63 ± 10.03 mL, p < 0.001), showing a reduction of 12.7 %. For all image quality characteristics, scores in VHP group were significantly superior to those in the conventional groups (all p < 0.05). Quantitative analysis revealed that images from the VHP group exhibited superior CT enhancement, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) in the anterior tibial arteries (ATA) and dorsali pedis arteries (DPA) compared to the conventional group (all p < 0.001). Moreover, segment-based analysis showed the VHP group had significantly higher positive predictive value (PPV) and accuracy than the conventional group (PPV: 100 % vs. 76.19 %, p = 0.01; accuracy: 100 % vs. 84.38 %, p = 0.01, respectively). ConclusionsThe implementation of the VHP protocol led to a 12.7 % decrease in contrast medium dosage compared to the conventional lower extremity CTA scanning protocol. Furthermore, it improved image quality and diagnostic accuracy, particularly for arteries below the knee.

The Neck-Crossing Technique Using the Low-Profile Distal Access Catheter in Flow Diverter Placement for Dissecting Posterior Cerebral Artery Aneurysm: A Case Report

AbstractWe report a case in which a novel distal access catheter proved successful in the placement of a flow diverter for a challenging distal cerebral artery lesion. We discuss the advantages and pitfalls of this technique and considerations for its use. A 74-year-old female presented with intermittent headaches, and was diagnosed with a dissecting aneurysm at the proximal right posterior cerebral artery with a sharp bleb, measuring 9.8 mm in diameter. Given the complex vascular anatomy, stent-assisted coil embolization was initially considered but deemed high risk for dual catheter for jailing technique with 6-Fr size guiding catheter due to the tortuosity and stenosis of the parent vessel. Therefore, we opted for flow diverter treatment, which presented its challenges during delivery. By employing a low-profile distal access catheter, Phenom Plus (outer diameter: 4.2-Fr. inner diameter: 1.13 mm; Medtronic, Minneapolis, Minnesota, United States), with a minimal ledge between it and the delivery catheter, Phenom 27 (outer diameter: 2.8-Fr, 0.91 mm; Medtronic), we successfully crossed the neck of the aneurysm with Phenom Plus and placed the flow diverter. While acknowledging potential risks, this case demonstrates the value of the neck-crossing technique using a low-profile distal access catheter as an alternative option for treating challenging peripheral artery aneurysms with flow diverters. This technique offers promise in specific situations where conventional methods pose challenges.

Braids and beyond: a comprehensive study on pipeline device braid stability from PREMIER data

BackgroundThe pipeline embolization device (PED) has been increasingly used to treat brain aneurysms; however, concerns have been raised about braid stability with newer drawn filled tubing technology devices.ObjectiveTo evaluate braid...

Effectiveness of Resting Transthoracic Echocardiography at Detecting Significant Coronary Artery Disease in Adults

Abstract Background: Detection of the regional wall motion abnormalities (RWMA) on the transthoracic echocardiography (TTE) is commonly used to correlate with coronary artery disease (CAD) and often prompts a further workup, including cardiac computed tomography or cardiac catheterization. However, the RWMA do not consistently predict obstructive CAD. This study investigates the accuracy and reliability of the presence of the RWMA on the TTE at detecting significant CAD (≥70% vessel stenosis). Materials and Methods: A retrospective chart review was conducted on the adults seen by the Baylor Scott and White Temple Echocardiography Laboratory who received a resting TTE followed by a cardiac catheterization within 30 days over 4 years. The exclusion criteria included catheterization without coronary angiography and a prior history of CAD, percutaneous coronary intervention, or coronary artery bypass graft. We analyzed the RWMA on the TTE and atherosclerotic CAD on the cardiac catheterization to assess correlation. Results: Four hundred and thirty-five patients were included in the study, and 198 patients received ultrasound-enhancing agent (UEA). The sensitivity and specificity of the RWMA on the TTE for detecting CAD in the adults were 49.5% and 78.8%, respectively. The positive and negative likelihood ratios were 2.33 and 0.641, respectively. The use of UEA made no significant difference in the sensitivity or specificity. Discussion: Our results show that the presence of the RWMA on the TTE has a high ability to rule in CAD, but the absence of the RWMA displays a much lower ability to rule out CAD than previously reported. Our results also show UEA did not enhance or detract from the sensitivity or specificity of TTE on CAD. The clinicians should be aware that the presence of the RWMA on the resting TTE has a high association with obstructive CAD, but the absence of the RWMA does not sufficiently exclude CAD.