Stenotic Segment Research Articles

CCTA-based CABG SYNTAX Score: a tool to evaluate completeness of coronary segment revascularization after bypass surgery

To describe the updated coronary computed tomographic angiography (CCTA)-based coronary artery bypass graft (CABG) anatomic SYNTAX Score (aSS) and assess its utility and reproducibility for assessing the completeness of revascularization after CABG. The CCTA-CABG aSS is a visual assessment using CCTA post-CABG which quantifies the failure in effectively grafting stenotic coronary segments, and therefore assesses the completeness of surgical revascularization. It is calculated by subtracting the aSS of successfully anastomosed coronary segments from the aSS of the native coronary tree. The inter-observer reproducibility of the CCTA-CABG aSS was evaluated in 45 consecutive patients with three-vessel disease with or without left main disease who underwent a CCTA 30 days (± 7 days) after CABG. The CCTA-CABG aSS was evaluated in 45 consecutive patients with 117 bypass grafts and 152 anastomoses. The median native coronary aSS was 35.0 [interquartile range (IQR) 27.0–41.0], whilst the median CCTA-CABG aSS was 13.0 (IQR 9.0–20.5). The inter-observer level of agreement for the native coronary aSS and the CCTA-CABG aSS were both substantial with respective Kappas of 0.67 and 0.61. The CCTA-CABG aSS was feasible in all patients who underwent CABG for complex coronary artery disease with substantial inter-observer reproducibility, and therefore can be used to quantify the completeness of revascularization after CABG.

Abstract 191: Simulating Intracranial Stenosis: A Methodological Approach In An In‐Vitro Neurovascular Model

Introduction Intracranial atherosclerotic disease (ICAD) induces the luminal narrowing of an intracranial vessel and represents one of the major causes of ischemic strokes [1, 2, 3, 4]. In vitro 3D printed models have gained popularity in the stroke research field as they are morphologically accurate and offer the possibility to simulate clinical scenarios for training purposes or device testing. Despite being a challenge for interventionalists, to date, clinically accurate ICAD in vitro models have not been developed. We aimed to develop a 3D printed ICAD model including realistic features to provide an optimal simulation phantom for research and training purposes. Methods Stereolithography 3D printing technique was used to create a resin neurovascular model based on vascular anatomies extracted from anonymized CTA images. The phantom includes the aortic arch, all supraoptic cervical arteries and a complete circle of Willis up to the M2‐MCA, A2‐ACA and P2‐PCA segments. 3% sodium alginate solution was cast into a stenosis mold and crosslinked in a 40% calcium chloride. The deformable gel constituted an 8mm long replaceable stenotic segment at the level of M1‐MCA simulating an atherosclerotic plaque with a 0.5mm internal diameter. A flow sensor (ME‐8PXL, Transonic) was used to measure the lesion flow rate before and after endovascular treatment was performed under fluoroscopy. Results The baseline angiographic run showed an irregular 80% stenosis at the level of M1‐MCA that generated a substantial delay of contrast arrival to the distal branches. After angioplasty (Gateway PTA Balloon Catheter 3.5x20mm, Boston Scientific) and stenting (Wingspan 2.5mmx15mm, Stryker) were performed the residual stenosis was <10% (Figure 1). An initial stenosis flow rate was registered with a value of 8.5 ± 5.33 mL/min. Following the completion of the endovascular procedure, the flow sensor detected a post‐procedural stenosis flow rate of 160 ± 3.45 mL/min. Conclusion The developed ICAD model is anatomically accurate and offers realistic physiological and procedural features. The phantom represents an ideal tool for training purposes and a platform to test different devices for the endovascular treatment of ICAD. The methodology and materials could be applied to simulate stenotic lesions at different levels in the cervical and intracranial arteries.

Numerical study of irreversibility analysis on pulsatile flow of blood through a ω-shaped stenotic artery

The mathematical modeling of blood flow in a stenotic blood vessel is very important for understanding the effects of various geometric and rheological parameters on the normal flow of blood. The present study is concerned with the heat and mass transfer in the blood flow of a non-Newtonian fluid through a ω-shaped stenotic arterial segment. The non-Newtonian behavior of blood is described mathematically by employing the constitutive equation of the Herschel-Bulkley fluid. The wall of the artery is considered to be rigid having ω-shaped constriction in its lumen. The mild stenosis assumption is used to simplify the fully coupled momentum, energy, and concentration equations as well as the constitutive equation of the Herschel-Bulkley fluid. Numerical solutions for fluid velocity, temperature, mass concentration, and entropy generation are evaluated by using the explicit finite difference scheme. The effects of various emerging parameters on the velocity, wall shear stress, flow rate, temperature, concentration, and entropy distributions have been analyzed in detail. A comparison between different fluid models has also been presented. It is found that the temperature in the Herschel-Bulkley fluid is marginally lower than that of the Newtonian, Power law, and Bingham fluids whereas an opposite trend is noticed in the case of mass concentration.

Safety and efficacy of the Low-Profile Visualized Intraluminal Support stent in treating intracranial atherosclerotic stenosis

PurposeThe performance of the Low-Profile Visualized Intraluminal Support (LVIS) stent deployed following balloon angioplasty is unknown in treating intracranial atherosclerotic stenosis, and this study was to investigate the safety and efficacy of the LVIS stent in treating intracranial atherosclerotic stenosis in the middle cerebral artery M1 segment. MethodsThirty-five patients were enrolled with 35 atherosclerotic stenoses at the M1 segment. The stenosis was about 75% in 16 patients, 80% in 15, and 90% in the rest four. The LVIS stent was used to treat these patients. ResultsThe success rate of stenting was 97.1%. The stenting procedure was failed in one patient because of intraprocedural dissection of the stenotic (75%) segment, resulting in a 30-day periprocedural complication rate of 2.9% (1/35). Before stenting, the stenosis rate ranged 75%–90% (mean 78.9%±4.7%), and after stenting, the diameter of the stented segment was significantly (P<0.0001) increased to 1.5–3.4mm (mean 2.1±0.32mm) ranging 68.2%–100% (mean 94.0%±5.8%) of the normal arterial diameter, with the residual stenosis ranging 0–31.8% (median 4.8%, IQR 2.4%–7.3%). Follow-up was performed at 6–20 months (mean 8.5) after stenting. One patient (2.9%) had occlusion of the stented M1 segment with no symptoms, and two patients (5.7%) had slight asymptomatic instent stenosis (40%) at the M1 segment, with the instent restenosis and occlusion rate of 8.6% (3/35). ConclusionThe braided LVIS stent can be safely applied for treatment of intracranial atherosclerotic stenosis in the middle cerebral artery with good safety and efficacy immediately after stenting and at follow-up.

Association and Repair of Right Aortic Arch With Aberrant Left Subclavian Artery With Subclavian Stenosis.

Surgical repair of right aortic arch and aberrant left subclavian artery has traditionally involved ligamentum division. Such patients can have stenosis at the origin of the aberrant subclavian artery either at the time of presentation or later. The more recently popularized repair involving resection of Kommerell diverticulum with transfer of the subclavian artery to the left carotid artery allows resection of the stenotic segment and serves as an effective treatment for subclavian stenosis as well. We present three cases of early repair of this arch anomaly with associated subclavian stenosis repaired successfully in that manner.

Criss-cross pulmonary arteries in common arterial trunk – Implications to management and outcome

ObjectivesTo investigate the incidence, types and pathophysiology of criss-cross pattern of the proximal pulmonary arteries in common arterial trunk and its influence on management and outcomes. MethodsRetrospective review of all patients with common arterial trunk who underwent Aswan Truncus Operation with regard to the origin and course of the proximal pulmonary artery branches as defined by 3D segmented models pre, immediately and 1 and 2 years after operation. ResultsBetween January 2019 and September 2022, 39 patients (19 males, aged 1–12 months) underwent the Aswan Truncus Operation. 18 patients (46%) had criss-cross arrangement of the proximal pulmonary artery. The mortality, ICU and hospital stay were not affected by the presence or absence of the criss-cross pattern. However, following operation in the criss-cross group, there was evidence of different degrees of kinking and twisting of the right pulmonary artery. This resulted in severe narrowing which required stenting or reoperation at different stages (1 during ICU stay and another after 1 year). Separate origin of the left pulmonary artery (Criss-cross Type 2) from a long stenotic ductus arteriosus required resection of the stenotic segment followed by anastomosis to the right pulmonary artery recreating a 60° angle of bifurcation. ConclusionCriss-cross pattern of proximal pulmonary arteries is common in patients with common arterial trunk. Pre-operative diagnosis and tailored approaches of repair are required to prevent late complications.

Benign inoperable tracheal stenosis in COVID versus non-COVID patients at the pandemic epicenter: a case series.

The COVID-19 pandemic has exponentially expanded the number of patients requiring treatment for chronic respiratory failure. One consequence is an increase in the number of patients requiring intubation and mechanical ventilation. Benign inoperable tracheal stenosis presents a challenge, especially in COVID-19 patients. We describe a case series of 15 patients with Benign inoperable tracheal stenosis treated with interventional bronchoscopy over a 15-month period. These patients were divided into two groups, COVID and non-COVID. We used an electrocautery snare as an electrocautery knife to cut the stenotic segment followed by four injections of 1mg submucosal Decadron via a Wang needle. Patients were subsequently followed by the pulmonary clinic. Institutional review board approval was not required as per our institutional policy for a retrospective case series. There was a high degree of success with this intervention, with a low rate of recurrence. We also noticed the following differences between the two subgroups. COVID tracheal stenosis was longer in length, had a higher percentage of cartilage involvement, and was located more distal to cords than the non-COVID group. The median age was younger in the COVID group. COVID pandemic an enormous number of intubations and tracheotomies have been performed. As a result, there will be an increased prevalence of tracheal stenosis. Most of these cases can be effectively treated with surgery. Dealing with complex inoperable cases remains a dilemma. Our case series/research article is an attempt to provide an easy technique with a high cure rate.

Case report: a case report and literature analysis on intestinal tuberculosis intestinal perforation complicated by umbilical intestinal fistula and bladder ileal fistula

BackgroundIntestinal tuberculosis is a chronic and specific infection caused by Mycobacterium tuberculosis invading the intestine. Due to the nonspecific clinical presentation, it is stressed that intestinal perforation complicates umbilical intestinal fistula and bladder ileal fistula is very rare and extremely difficult to be diagnosed. It is significant to identify the disease and take urgent intervene in the early stage.Case presentationAn 18-month-old boy patient presented with abdominal pain. Abdominal CT suggested abscess formation in the right lower abdomen and pelvis. The patient underwent resection of necrotic and stenotic intestinal segments with the creation of an ileostomy, cystostomy and vesicoureteral fistula repair for the presence of intestinal perforation complicated by vesicoureteral fistula and umbilical enterocutaneous fistula. Histopathology confirmed the intestinal tuberculosis. The patient was discharged successfully after 11 days post anti-tuberculosis treatment.ConclusionOur case report here is a rare case of umbilical intestinal fistula with bladder ileal fistula secondary to intestinal perforation from intestinal tuberculosis. The purpose of this report is to make the surgical community aware of atypical presentations of intestinal tuberculosis. If our peers encounter the similar situation, they can be prepared for corresponding diagnosis and treatment.

Role of MRI Diffusion Tensor Imaging in Early Diagnosis of Cervical Spondylotic Myelopathy (CSM)

Abstract Background and Purpose Cervical spondylotic myelopathy (CSM) is a common degenerative disorder of the cervical spine and is considered as the most common cause of spinal cord dysfunction in older individuals worldwide. Assessing the severity of the disease objectively remains a challenge and there is still remaining controversy in terms of the optimal timing and indications for surgical intervention. The conventional MRI is the gold standard for radiographic evaluation of the spinal cord; however, it cannot assess the underlying microstructural deficits of the spinal cord and it has a limited application in determining prognosis and recovery of the disease [1]. We sought to assess the utility of MR diffusion tensor imaging as an imaging technique in clinically suggested CSM patients by obtaining the microstructural parameters (Fractional anisotropy; FA and apparent diffusion coefficient; ADC) in the cervical spinal cord segments. Patient &amp; methods our study was a prospective cross-sectional study including 40 patients with clinical manifestations of cervical spondylotic myelopathy. The patients were sorted according to the European myelopathy score into three categories as follows: grade 1 (with mild symptoms), grade 2 (with moderate symptoms) and grade 3 (with severe symptoms). All the patients were investigated with a 1.5 T MRI unit acquiring conventional MRI and DTI sequences. FA and ADC values at each spinal segment from C2/C3 to C6/C7 were generated and measured using manual drawing of multiple ROIs within the cervical cord in the sagittal and axial combined anatomical and color-coded images. For each of these cases, the patient’s age, gender, DTI parameters at each spinal segment level, maximum compression level, conventional T2WI characteristics and EMS score were recorded, analyzed and compared. Results The study included 23 females (57.5%) and 17 males (42.5%). Their age ranged from 30 to 72 years with a mean age of 47.3 ± 9.79 years. The study revealed a significant difference in the mean FA and ADC values between stenotic and non-stenotic segments of the cervical spinal cord. There was a significant correlation between the European myelopathy score and DTI parameters (FA and ADC). FA and ADC values performed better in recognizing myelopathic changes in patients who were classified as grade 1 according to EMS compared to conventional MRI T2WI which performed very poorly in recognizing myelopathy changes in the same patients, therefore DTI indices were more sensitive in the detection of CSM patients compared to conventional MRI especially in early myelopathic stages. T2 weighted images were highly significant in recognizing myelopathy changes in patients who were classified as grade 3 according to EMS. The CSM patients had significant FA decrease and ADC increase at the most compressed part of the cervical spinal cord and there was a significant correlation between the number of patients who had myelopathic changes by DTI parameters and the severity of disease. The FA sensitivity and specificity in recognition of myelopathic changes were 73.5% and 83.3% respectively and the ADC sensitivity and specificity were 100% and 70.6% respectively. Conclusion In conclusion, diffusion tensor imaging enhances the efficacy and accuracy of MRI in the diagnosis of cervical spondylotic myelopathy. Therefore, it can be used as a non-invasive modality for detection of the spondylotic myelopathy changes in the early stages helping to decide the appropriate timing of decompression surgery before attaining the irreversible chronic changes. Abbreviations ADC: Apparent diffusion coefficient; CSM: Cervical spondylotic myelopathy; DTI: Diffusion tensor imaging; FA: Fractional Anisotropy; EMS: European myelopathy score

Impact of preoperative docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy on degree of malignant esophageal stenosis

BackgroundMalignant esophageal stenosis is a common and severe complication of advanced esophageal cancer that can be a serious problem in the continuation of chemotherapy and other anticancer treatments. The impact of chemotherapy regimens on the degree of improvement in esophageal stenosis is unknown. In this study, we focused on the impacts of chemotherapy on the direct anticancer effects, and in the improvement of malignant stenosis.MethodsPatients who underwent radical esophagectomy after chemotherapy, either adjuvant 5-fluorouracil and cisplatin (FP) or docetaxel, cisplatin, and 5-fluorouracil (DCF) regimen, were included. We assessed the length of the cancerous stenosis, the width of the narrowest segment, and the size of the intraluminal area in the stenotic segment by fluoroscopy, and compared the differences before and after chemotherapy. In addition, we evaluated the dysphagia score (Mellow-Pinkas scoring system) as the evaluation of patients’ symptoms. The antitumor effects of chemotherapy were also investigated.ResultsA total of 81 patients were enrolled: 50 were treated with FP, and 31 were treated with DCF. The expansion rate in the length of the narrowest part was significantly increased in the DCF group compared with the FP group. Furthermore, the stenosis index (intraluminal stenotic area/stenotic length) was significantly increased in the DCF group compared with the FP group (112% vs 96%, P = 0.038). Dysphagia score after chemotherapy significantly improved in the DCF group compared to the FP group (P = 0.007). The response rates were 60% in the FP group and 67.7% in the DCF group. Effective histopathological response (improvement to grade 2 or 3) was 24% in the FP group and 38.8% in the DCF group.ConclusionDCF therapy is more effective than FP treatment in the improvement of malignant esophageal stenosis.

High plasma concentrations of vanin-1 in patients with coronary artery disease.

Vanin-1 is a pantetheinase that hydrolyzes pantetheine to pantothenic acid and cysteamine. Vanin-1 has become recognized to be associated with oxidative stress and inflammation. In animal models, vanin-1 was reported to accelerate atherosclerosis. However, no study has reported blood vanin-1 concentrations in patients with coronary artery disease (CAD). We investigated plasma vanin-1 concentrations in 388 patients undergoing elective coronary angiography for suspected CAD. Patients with acute coronary syndrome were excluded. Of the 388 study patients, CAD was found in 207 patients [1-vessel (1-VD), n = 88; 2-vessel (2-VD), n = 66; and 3-vessel disease (3-VD), n = 53]. Plasma vanin-1 concentrations were higher in patients with CAD than in those without CAD (median 0.59 vs. 0.46 ng/mL, P < 0.005). Vanin-1 concentrations in patients without CAD and those with 1-VD, 2-VD, and 3-VD were 0.46, 0.58, 0.57, and 0.61 ng/mL, respectively, and were highest in 3-VD (P < 0.05). A high vainin-1 concentration (> 0.48 ng/mL) was found in 46% of patients without CAD, 61% of 1-VD, 65% of 2-VD, and 66% of 3-VD (P < 0.01). Vanin-1 concentrations significantly correlated with the number of stenotic coronary segments (r = 0.14, P < 0.02). In the multivariate analysis, vanin-1 concentration was a significant factor associated with CAD independent of atherosclerotic risk factors. The odds ratio for CAD was 1.63 (95%CI = 1.04-2.55) for the high vanin-1 concentration of > 0.48 ng/mL. Thus, plasma vanin-1 concentrations in patients with CAD were found to be high and to be associated with the presence and severity of CAD.

Use of an autologous dermal flap and rib cartilage graft in the repair of a large tracheoesophageal fistula with tracheal stenosis.

Management of large tracheoesophageal fistulas complicated by tracheal stenosis remains challenging as it requires an ideal replacement for the membranous defect as well as a permanent buttress to reconstruct the stenotic segment. We present the successful use of an autologous free dermal flap reinforced with a pedicled pectoralis major muscle to repair the tracheal membranous wall and a rib cartilage graft to enlarge the tracheal lumen.

Contrast Venography Versus Intravenous Ultrasound in Hemodialysis Arteriovenous Access Dysfunction

Contrast Venography Versus Intravenous Ultrasound in Hemodialysis Arteriovenous Access Dysfunction

Intraluminal arterial transit artifact as a predictor of intracranial large artery stenosis on 3D time of flight MR angiography: Expanding the application of arterial spin labeling MRI in ischemic stroke.

The objective of this study was to evaluate the diagnostic value of "intraluminal arterial transit artifact" in the prediction of intracranial large artery stenosis and to determine if this finding is predictive of ischemic stroke in the territory of the involved artery. The presence of arterial transit artifact (ATA) within the lumen of an intracranial large vessel was noted on three-dimensional time of flight (3D-TOF) magnetic resonance angiography (MRA) (ATA group). The patients with stenosis but with no ATA (no-ATA group), patients with total occlusion (total occlusion group), and patients with no stenosis/occlusion (normal group) were included in the analysis. There were four groups of patients included in the final analysis, the ATA group (n = 22), the no-ATA group (n = 23), the normal group (n = 25), and the total occlusion group (n = 9). Among patients with any demonstrable stenosis (n = 45), the presence of ATA within the stenotic segment was predictive of stenosis of ≥56% (Sensitivity of 100% [85.2-100, 95% CI], specificity of 100% [86.4-100, 95% CI]), with area under curve of 1.0 (0.92-.0, 95% CI). The presence of intra-arterial ATA signal was significantly associated with ischemic stroke as compared with the no-ATA group (86.36% vs. 26.08%, P = 0.0003). Intraluminal ATA was found to be an independent predictor of infarction in the territory of the involved artery. Intraluminal ATA is predictive of stenosis of at least 56% in the involved artery on 3D-TOF MRA. Intraluminal ATA sign may be an independent predictor of infarction in the territory of the involved artery.

Excision and primary anastomotic urethroplasty

Objective: To retrospectively review patients with strictures (&lt;3 cm) of the bulbous urethra who had Undergone urethroplasty with excision of the stenotic segment and end-to-end anastomosis. Patients and Methods: One hundred patients were analyzed, all males with ages ranging from 18 to 60 who were treated for strictures between 5 and 30 mm in length between 2007 and 2021. Endoscopic internal urethrotomy was used in the treatment of 65 patients (%), and three patients (20()) had internal urethrotomy performed on them twice. The removal &amp; primary anastomotic urethroplasty were performed on all patients. With the patient in a lithotomy posture, the stenotic segment was removed and the stumps spatulated for end-to-end anastomosis through a perineal incision. The average (range) time of an operation was 119 (75-150) minutes. Although one patient underwent revision surgery for a perineal urine fistula, the surgery itself and the time spent in the position of lithotomy were both uneventful. Results: After a median of 12 months of observation, 95% of patients were deemed cured since the stricture had not returned. Perineal urinary fistula and recurring stricture occurred in one case. No other adverse events occurred as a result of the treatment.

Long-term safety and efficacy of stenting on correcting internal jugular vein and cerebral venous sinus stenosis.

To compare the long-term safety and efficacy of stenting in correcting cerebral venous sinus stenosis (CVSS) and internal jugular venous stenosis (IJVS). Patients confirmed with CVSS or IJVS by imaging were enrolled in this real-world study from 2014 through 2021. Clinical characteristics and long-term outcomes of these two diseases entities post-stenting were followed up and compared. Three hundred and nineteen patients were enrolled in this study, with a mean age of 48.83 years and a BMI of 25.08 on average. In which, 144 patients underwent stenting, the stenotic segments were corrected and the venous blood flow was restored immediately post-stenting. At 6.15 ± 1.67 days follow-up, significant improvement was observed in headache, tinnitus, insomnia, ICP, and mean pressure gradient in both groups (all p < 0.05). At 30.53 ± 4.41 months follow-up post-stenting, the headache, tinnitus, visual loss, papilledema, and insomnia were attenuated remarkably or even completely disappeared. The Frisen papilledema grade scores declined from 2 (0-4) to 1 (0-3) in IJVS group and from 4 (1-5) to 1 (0-4) in CVSS group compared to the baseline. One hundred and twenty-seven out of the 144 patients (95.5%) maintained sufficient blood flow verified by followed up computed tomographic venography or contrast-enhanced magnetic resonance angiography. Adverse events related to stenting included three cases of intraluminal restenosis and three cases of in-stent thrombosis, no intracranial hemorrhage, venous thromboembolisms, stent-adjacent stenosis, and stent displacement occurred. Using stents to correct IH and related neurological issues has shown to be a safe and effective approach for both IJVS and CVSS.

Subglottic Tracheal Stenosis, Resection, And Reconstruction: A Case Report

Abstract Post-intubation stenosis are the most frequent indications for tracheal resection and reconstructions. They are mostly caused postintubation inflated cuff and after distal tracheostomy. 16- year-old female was admitted to thoracic surgery department, General hospital Vienna with the diagnosis of an impossible weaning with a tracheostomy in place. The pre-operative bronchoscopy and MSCT of the neck evaluation revealed a total occlusion of the trachea below the cricoid arch and reaching distally to the level of the tracheostomy (total length approx. 3cm) by means of an acquired tracheostomy-associated tracheal stenosis (Myer-Cotton IV°). The distal trachea was unaffected. Thus, the indication for a surgical repair was set. Tracheal resection through a cervical incision was performed. The pre-existing tracheostomy as well as the stenotic segment was resected (resection length approx. 3.5cm) and a cricotracheal end-to-end anastomosis was performed. Subglottic resection of the trachea is rare, if conducted a good selection of patients performed precise surgical procedures with the support of anesthesia is considered by some to be the procedure of choice for the treatment severe (&gt;70% luminal obstruction).

A surgical conundrum: Managing primary tracheal adenoid cystic carcinoma with preservation of larynx

Title: A surgical conundrum: managing primary tracheal adenoid cystic carcinoma with preservation of larynx. Introduction: Tracheal tumors are extremely uncommon. The incidence of tracheal tumors is 0.09–0.2% out of which 10% are Adenoid cystic carcinoma. The origin of adenoid cystic carcinoma is from the submucosal glands of the tracheal tree. It is typically regarded as a low-grade malignancy with a favorable prognosis. Case Presentation: A 35 years old male patient came to Out Patient Department with chief complaints of change in voice since 6 months and stridor since 1 week. On Indirect laryngoscopy there was left sided vocal cord palsy with submucosal swelling in subglottic area compromising the airway. Contrast Enhanced Computed Tomography revealed a hyperintense lesion of about 5.5 cm craniocaudally in the posterolateral aspect of the subglottic trachea and inferior border of the cricoid pushing left thyroid lobe anterolaterally along with significant obstruction of the airway at the level of cricoid. An emergency tracheostomy was done at lower level to secure the airway. Flexible bronchoscopy showed a 1.5-2cm stenotic segment obstructing 50 to 75% of the airway in a subglottic region with left vocal cord palsy. A biopsy of the lesion took externally which came as an Adenoid Cystic Carcinoma. On Magnetic Resonance Imaging there was no involvement of the nerve or metastasis. Wide local excision of the lesion involving tracheal resection with cricotracheal anastomosis and Montgomery Tube insertion was done followed by chemoradiation. Montgomery tube was successfully removed and the patient satisfactorily decannulated. Conclusion: Adenoid cystic carcinoma should be considered as a differential diagnosis in patients with changes in voice and stridor. As adenoid cystic carcinoma is very slow-growing tumor so instead of being so radical a combined approach that gives a functional larynx and better quality of life should opt.

The Association Between Angiographically Derived Radial Wall Strain and the Risk of Acute Myocardial Infarction

BackgroundThe radial wall strain (RWS) is a novel angiography-based method to assess the biomechanical property of the coronary artery and whether it can predict future acute myocardial infarction (AMI) events remains to be elucidated. ObjectivesThis study aimed to investigate the association between angiography-derived RWS and future AMI events in mild to intermediate lesions. MethodsWe performed a matched case-control analysis nested in a retrospective cohort of patients who had received prior angiography (the index procedure) at least 1 month before and were hospitalized again for repeat angiography. Patients with at least 1 de novo mild to intermediate lesion identified at the index procedure and eligible for RWS analysis were enrolled. The study identified cases with target lesion–related AMI diagnosed at the repeat angiography, matching each case to 3 control subjects without AMI. ResultsAltogether 44 patients with lesion-related AMI and 132 matched controls were enrolled. The median diameter stenosis of the overall interrogated lesions was 34.0%. The baseline maximum RWS (RWSmax), which was defined as the highest RWS in the stenotic segment, was significantly higher in lesions responsible for AMI than those that remained quiescent (median 13% vs 10%; P < 0.001). RWSmax was predictive of lesion-related AMI, with an area under the curve of 0.83 (95% CI: 0.76-0.90; P < 0.001) and an optimal cutoff >12%. RWSmax >12% was found to be independently associated with subsequent AMI events with a risk ratio of 7.25 (95% CI: 3.94-13.37; P < 0.001). ConclusionsAmong angiographically mild to intermediate lesions, a high-strain pattern identified by angiography-derived RWS was associated with an increased risk of AMI events.

679 Epidural Hypertension Theory in Patients With Lumbar Spinal Stenosis

INTRODUCTION: Laminectomy is the standard of treatment in Lumbar Spinal Stenosis(LSS). Multiple studies (Mariconda;Boden;Schonstrom;Matsumoto;Herno;Webber.) have not found relationship between spinal canal widening and symptoms improvement in LSS. Neurogenic compression and rootlets hypoxia theories try to explain pathophysiology of LSS. We propose Epidural Hypertension (EH) as a new paradigm that explains dynamic stress of neural structures involved in LSS. METHODS: Group A: single-segment LSS diagnosed by magnetic resonance (n = 4). Group B: Patients without LSS requiring surgery for another diagnosis (spinal cord stimulation, foraminotomy) (n = 3). Laminectomy was performed, previously, flavum ligament was meticulously dissected and a pressure microsensor was inserted in epidural space in stenotic segment. EP was measured in 0 and 50° extension in order to extrapolate EP in standing position. RESULTS: EP in LSS patients was 18,5 mmHg at 0° (IQR 16.5-37.5 mmHg) and 26 mmHg at 50° (IQR 20-34.5 mmHg). In patients without LSS, EP was 8mmHg at 0° (IQR 1-8 mmHg) and 3 mmHg at 50° (IQR 1-12 mmHg). We found differences using Wilcoxon's test. EP was greater in patients with LSS at 0° (p = 0.031) y 50° (p = 0.034). CONCLUSIONS: EH may play a foundamental role in pathophysiology of LSS. In Patients without LSS we found a drop in EP at 50° possibly secondary to caudal CSF displacement. In LSS patients we found a raise in EP at 50° possibly secondary to spinal canal narrowing impeding normal CSF flow increasing hydrostatic pressure in the stenotic segment. This results might be the first step to consider EH as a treatment target in LSS and determine its relationship with LSS symptoms.