Thrombotic Occlusion Research Articles

Cognitive Impairment Among Patients with Chronic Immune Thrombocytopenia

Introduction: Immune thrombocytopenia (ITP) is an autoimmune disease associated with autoantibody-mediated platelet destruction and impaired platelet production, resulting in thrombocytopenia and high bleeding risk. Fatigue and impairment of both memory and concentration are also common in ITP, theoretically due to acute neural inflammation, microbleeding, and thrombotic occlusions of small blood vessels in the brain. However, little is known about the nature and severity of cognitive impairment in patients with chronic ITP. Tests from the Cogstate Brief Battery (CBB) and composite scores computed from these have a high sensitivity to cognitive dysfunction in clinical and clinical trial contexts. The aim of this analysis was to assess cognitive impairment among difficult-to-treat patients with ITP. Methods: Participants (N=60) in the ongoing, global phase 1/2 study (NCT03395210) assessing the safety and efficacy of the Bruton tyrosine kinase inhibitor rilzabrutinib in ITP, were eligible for cognitive testing at baseline. In the CBB, the Detection test (DET) measured psychomotor function, the Identification test (IDN) measured attention, the One Card Learning test (OCL) measured visual learning, and the One Back test (ONB) measured working memory. For each participant, prior to rilzabrutinib treatment, the score on each test was compared with age-matched normative data to produce a standardized score (Z-score). Z-scores measure the distance between an observed value and a reference mean using standard deviation units and can be positive or negative, indicating that the observed value lies above or below the mean, respectively. Z-scores ≤-1 denoted impairment. Descriptive summary statistics, including mean Z-scores for individual tests and composite cognitive scores (Psychomotor/Attention, Learning/Memory), and level of impairment are presented. Relationships between cognitive impairment and demographics, concomitant medication, and medical history were also explored. Results: At baseline, the 49 patients with CBB assessments had a mean age of 50 years, 57% were females, and 71% had an ITP duration of ≥3 years; 14 patients each had concomitant corticosteroids or thrombopoietin receptor agonists (TPO-RA) and 7 patients had both concomitant therapies. Medical history included hypertension (n=17), depression/anxiety (n=8), diabetes (n=7), and stroke/CNS bleeding (n=1). Mean Z-scores for the psychomotor function, attention, and working memory tests were below age-matched healthy norms (Table 1). The degree of impairment was substantial for the psychomotor function and attention tests and composite scores. Impairment was also large for the working memory test, whereas performance on the visual learning test was close to normal. The level of impairment followed the same pattern, with top rates for the attention (67% of patients), followed by psychomotor function (53% of patients), working memory (39% of patients), and visual learning (16% of patients) tests. Psychomotor/Attention impairment was greater (69% of patients) than Learning/Memory (43% of patients; Table 1) and occurred irrespective of biological/clinical characteristics (Figure 1). More than half of patients aged <65 years, with no concomitant ITP medication, and those with no medical history had a "Clinically Important Cognitive Impairment". Conclusion: This report provides evidence of cognitive impairment in patients with ITP. The cognitive impairment was moderate in magnitude for Psychomotor/Attention, and mild for Learning/Memory. Further, the observed impairment appeared to be irrespective of biological/clinical characteristics and unrelated to concomitant use of corticosteroids or TPO-RA. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Inferior Vena Cava Filter Use at a Large Community Hospital: A Cross-Sectional Analysis

Introduction: Inferior vena cava (IVC) filters are considered among patients who have sustained a recent lower extremity deep vein thrombosis (DVT) and/or pulmonary embolism (PE) with a contraindication to anticoagulation. IVC filter use has risen in recent decades despite a lack of data on the effectiveness of IVC filters in reducing venous thromboembolism (VTE)-related mortality. Moreover, IVC filters may be associated with significant morbidity, including filter migration, IVC thrombosis, and fatal bleeding. Prolonged insertion of an IVC filter risks endothelialization which renders later attempts at removal ineffective, and raises the risk of complications. In this study, we aimed to characterize the pattern of IVC filter use at a large community-based hospital. Specifically, we characterized the indications for IVC filter insertion, rates of IVC filter removal, and filter-associated complications. Methods: A retrospective cohort study of adult patients (>18 years) who received an IVC filter between January 1, 2005 - February 28, 2022 at Windsor Regional Hospital (WRH), which is a large community-based hospital with academic affiliations in Southwestern Ontario, Canada. Data were collected using RedCAP software and analyzed using descriptive methods. Results: To date, we have reviewed 89 patient charts from 2019-2022. Patients with IVC filters inserted through WRH were most often male (58.4%) with a median age of 68 years. The most common indications for IVC filters included recent VTE (DVT and/or PE within 3 months) and active bleeding (43.8%), and recent VTE with a need for anticoagulation interruption for surgery (32.6%). Approximately 21% (19 patients) of IVC filters were inserted for indications outside recommended guidelines, including: need for interruption of anticoagulation in patients with a remote history of VTE (31.6%) or prior to surgery (15.8%), recent VTE & active bleed but anticoagulant therapy not discontinued (21.1%), surgical prophylaxis (10.5%), recent VTE & risk of bleeding with no active bleed (10.5%), failure of anticoagulation (5.3%), and massive PE with residual DVT (5.3%). Only 34.8% of patients had successful removal of their IVC filter with an average of 1.2 attempts at filter removal per patient. At least 4 patients (4.5%) have experienced complications relating to their IVC filter, including IVC thrombotic occlusion (50%) and IVC filter migration (50%). Conclusions: Approximately 21% of IVC filters were inserted for indications that fall outside of current guidelines at a large community-based hospital in Ontario, Canada. Moreover, 65% of IVC filters were not removed which is consistent with rates reported in other studies, and significantly raises the risk of IVC filter complications. Given that the majority of patient care occurs in the community setting, further efforts are needed to understand patterns of IVC filter use at other community hospitals. As well, our findings further support the need for development of concrete guidelines on indications for IVC filter use and monitoring practices. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Comparison of imaging findings on three-dimensional black-blood enhanced MR imaging between intracranial atherosclerotic occlusion and thrombotic occlusion

PurposeThe purpose of this study was to compare the imaging findings on three-dimensional (3D) black-blood (BB) contrast-enhanced MR imaging between intracranial atherosclerotic occlusion (IAO) and thrombotic occlusion (TO) of the middle cerebral artery (MCA) territory. Materials and methodsFrom August 2020 to September 2021, we retrospectively reviewed the BB contrast-enhanced MR imaging of patients visiting the emergency room for evaluation of acute ischemic stroke. In total, 77 patients with complete occlusion of the MCA territory on 3D BB contrast-enhanced MR imaging and cerebral angiography were enrolled in this study. We divided the IAO and TO groups according to occlusion causes based on angiography findings. ResultsOf 77 patients, 44 (57.1%) had an IAO in the M1 and M2 and 33 had a TO. Lesion length contrast enhancement (CE) in patients with a TO was significantly longer than that in patients with an IAO (18.95 mm [IQR: 20.91] vs. 7.1 mm [8.92], p <0.001). Overall, 38 (39.4%) patients showed a disconnection of CE on 3D BB contrast-enhanced MR imaging, and 35 showed CE before and after the stenotic or thrombotic lesion. Symptomatic lesions on diffusion-weighted imaging in the TO group were significantly higher than that of the IAO group (97.0% vs, 70.5%, p = 0.003). ConclusionThe long segment CE on 3D BB contrast-enhanced MR imaging was related to TO of MCA. CE before and after a stenotic or thrombotic lesion is a common finding on 3D BB contrast-enhanced MR imaging.

Abstract 9613: Short- and Long-Term Vascular Responses of Stent With Biodegradable Graft for Artery Dissection in Rabbit Iliac Model

Introduction: Arterial dissection or rupture during percutaneous angioplasty is rare but can be lethal. We invented a balloon-expandable stent with a very thin membrane typed biodegradable graft for the treatment of arterial dissection (BioGard). Hypothesis: The efficacy and safety of BioGard were evaluated in the rabbit iliac artery rupture model. The devices would be helpful to seal the emergent blood extravasation due to arterial perforation and reduce unfavorable vascular events in long-term follow-up. Method: Twenty iliac arterial dissections by balloon over-inflation were induced under the guidance of angiography. Twelve rabbits with huge contrast extravasation to retroperitoneal space (Ellis type 3) were treated using BioGards. Serial histologic examinations and micro-computed tomography (CT) were performed at 1, 2, and 8 weeks and 3, 6, 9, and 12 months. Final angiography at 1 year was performed to evaluate any vascular complication. Results: There are no significant adverse cardiovascular events after one year of BioGard implantation. Micro-CT and follow-up angiography at one year revealed no case of significant in-stent restenosis and thrombotic occlusion in vivo. Early-stage histologic examination demonstrated that disrupted vessels were completely sealed up by BioGard with mural hematoma, inflammatory cell infiltration, and red thrombi. Mid- and long-term histologic examination revealed patent stents and neointimal coverage over the stents with biodegraded graft material and mild peri-strut area inflammatory response. Conclusions: Twelve months post-BioGard implantation in rabbit iliac artery dissections demonstrated good efficacy and safety. BioGard at a severely dissected artery would be an option for preventing lethal vascular events. Further clinical evaluation of this novel technology would be warranted.

Abstract 14698: Identifying Sources of Prostacyclin Outside the Vascular Wall and Their Contribution to Cardiovascular Protection

Introduction: Prostacyclin is a key anti-thrombotic hormone synthesised through cyclooxygenase (COX) enzymes. Historically, its production has been almost universally associated with the endothelium however the role of non-vascular sources has not been systematically evaluated due to a lack of suitable tools. This has resulted in an underappreciation of its cardiovascular biology and role in other contexts. Hypothesis: We hypothesised that cells outside the vascular wall contribute to generation of prostacyclin which can enter the circulation to provide anti-thrombotic protection. Methods: Global, endothelial and fibroblast COX1 or COX2 knockout mice were studied alongside freshly isolated healthy human lung tissue and primary cell cultures. Prostacyclin levels in plasma and released from cells/tissue ex vivo were measured by ELISA. Individual cell populations were isolated by FACS. Thrombosis in vivo was measured using a FeCl 3 -carotid artery injury model. Results: Vascular endothelial COX1 deletion strongly reduced prostacyclin release from mouse aorta and heart, but not from isolated lung, colon, kidney or spleen (Fig A). This non-vascular prostacyclin required COX1 as it was abolished by global COX1 and not COX2 deletion. Freshly isolated lung fibroblasts exhibited greater prostacyclin synthesis than endothelial or other cell types (Fig B) and this was confirmed in primary human lung cell cultures. Deletion of COX1 from fibroblasts in mice reduced lung prostacyclin release (Fig C) and plasma prostacyclin levels (Fig D) and this was associated with accelerated thrombotic occlusion after carotid artery injury (Fig E). Conclusions: These findings define a new paradigm in prostacyclin biology in which fibroblast/non-vascular-derived prostacyclin works in parallel with endothelium-derived prostanoids to control thrombosis. This may have particular relevance to understanding how local diseases of the lung result in cardiovascular risk.

Abstract 10907: Woven Coronary Artery: A River With Many Currents

Introduction: Congenital coronary artery anomalies can increase the risk of cardiovascular events and sudden death. A woven coronary artery is a rare abnormality with multiple lumens in a single vessel, giving the appearance of complex coronary plaque or a dissection flap on coronary angiography. Clinical Case: A 57-year-old man with group IV pulmonary hypertension and chronic right-sided heart failure presented for consideration of pulmonary endarterectomy. He underwent preoperative coronary angiography which demonstrated nonobstructive disease within the left anterior descending and circumflex arteries and a complex lesion in the right coronary artery (RCA- Figure 1). The lesion was further evaluated using intravascular ultrasound (IVUS) which demonstrated numerous, complex, communicating lumens and fenestrations within a single external elastic lamina suggestive of a woven coronary artery anomaly (Figure 2). This was recognized as a benign abnormality for which the patient was managed medically, and he underwent a successful pulmonary endarterectomy several days later. Discussion: Woven coronary arteries are rare and complex lesions made up of numerous lumens often found in the proximal to mid-RCA. These lesions typically permit normal blood flow and are found incidentally in asymptomatic patients. Woven coronary arteries can be mistaken for complex lesions, dissection, or recanalized thrombus, leading to unnecessary and potentially dangerous percutaneous coronary intervention. Woven arteries should not be treated with angioplasty in the absence of thrombotic occlusion as this can lead to arterial vessel damage. Intracoronary imaging, including IVUS, is vital to differentiate woven coronary arteries from other coronary pathologies. Conclusion: Woven coronary arteries may mimic dissection or recanalized thrombus, but can be promptly recognized as a benign congenital anomaly with intracoronary imaging modalities such as IVUS.

Abstract 11958: Incidence of Acute Thrombotic Occlusion and Its Predictors After Contemporary Femoropopliteal Endovascular Therapy in Patients With Peripheral Artery Disease

Introduction: Although there is robust evidence for the superiority of contemporary femoropopliteal (FP)-specific devices to traditional therapy using non-coated balloon or bare metal stent, cohesive reports on the incidence of acute thrombotic occlusion (ATO) after endovascular therapy (EVT) with contemporary FP devices are scarce. This study investigated the incidence of ATO and its predictors after contemporary FP-EVT for peripheral artery disease. Methods: We retrospectively examined 763 limbs (chronic limb-threatening ischemia [CLTI]: 44%, involving popliteal arterial lesion: 44%) in 644 patients (mean age: 75±9 years, male: 71%, hemodialysis: 34%) who successfully underwent EVT with contemporary FP devices (drug-coated balloon [DCB]: n=235, scaffold: n=528 [drug-coated stent: n=220, stent graft: n=158, drug-eluting stent: n=150]) from June 2012 to July 2020. The outcome measure was ATO defined as acute onset of claudication and/or signs of CLTI in combination with angiographic evidence of occlusive thrombus formation within the treated segment. Cox proportional hazards regression models were used to identify baseline characteristics associated with the incidence of ATO after contemporary FP-EVT. Results: The 24-month incidence of ATO in the overall population was 4.3±0.8% (DCB: 1.0±0.7% versus scaffold: 5.8±1.1%, P&lt;.01). Due to the remarkably lower incidence of ATO after EVT with DCB, risk factors for ATO in patients treated with scaffold was identified. Hemodialysis (hazard ratio [HR]: 2.63, P=.02) and involving popliteal lesion (HR: 8.22, P&lt;.01) were independently associated with an increased risk of ATO. The 24-month incidence of ATO in patients with those risk factors was 21.0±3.3%, while that in patients without those factors was 0.5±0.2%. Conclusions: We found a substantial incidence of ATO after contemporary FP-EVT, particularly with scaffold. Hemodialysis and involving popliteal lesion were significantly associated with ATO risk in patients treated with scaffold. The scaffold was safely used in patients without those risk factors of ATO, but a non-scaffolding strategy, including surgical bypass therapy, should be considered for patients with those risk factors.

Abstract 14522: Infective Mitral Valve Endocarditis in an Immunocompetent Patient Caused by Lactobacillus Species Transmitted by Intranasal Cocaine Use

A 59-year-old male with controlled DM2, HTN, tobacco abuse, and remote MSSA bacteremia secondary to longstanding intranasal cocaine use (never IV drug user) presented to the ER with acute onset of left leg pain. He was in extreme distress and examination showed a cold left leg with absent extremity pulses. Cardiac assessment was notable for an apical systolic murmur. Magnetic resonance angiography (MRA) of the leg revealed a thrombotic occlusion of the left common femoral artery extending into the popliteal artery prompting emergent successful femoral artery thrombectomy and compartment fasciotomy. An intraoperative TEE revealed mobile echodensities on the anterior and posterior MV leaflets with severe eccentric mitral regurgitation (MR) [Figure1]. Blood and thrombectomy debris cultures yielded Lactobacillus acidophilus vs. gasseri species. Further workup showed multiple small embolic infarcts on MRA head and chronic sinusitis on CT sinuses, while CT chest, abdomen and pelvis were unremarkable. He received IV ampicillin for 1 week with bacterial clearance, followed by bioprosthetic mitral valve replacement. Gram stain of the mitral valve revealed gram positive rods, cultures grew Lactobacillus species, and histopathology confirmed the presence of infective endocarditis. The patient completed 7 weeks of penicillin G intravenously with clinical recovery. Lactobacillus acidophilus and gasseri are normal flora of the human oral cavity, gastrointestinal and genitourinary tracts. Lactobacillus endocarditis is rare and has been identified in only 0.05-0.4% of endocarditis cases. Infections primarily affect the immunocompromised, but to the best of our knowledge this is the first case of Lactobacillus mitral valve endocarditis presenting with concomitant acute limb ischemia with infected thromboembolic debris in an immunocompetent individual with the suspected inciting event being intranasal cocaine use causing trauma to the nasal vasculature.

Abstract 10542: The Utility of Repeat Coronary Angiography in Patients With Non Ischemic Cardiomyopathy

Introduction: Up to 20% of angiograms reveal no coronary artery disease (CAD). Repeat studies are often done for chest pain, dyspnea, or reduction in ejection fraction (EF), but little is known about the diagnostic yield of this practice. Methods: Retrospective cohort of patients with no or minimal CAD on their first angiography (&lt;30% stenosis) and a repeat angiography in the last 5 years were included in the study. Results: There were 17 patients with no CAD and 26 patients with mild CAD on initial angiography, with 58 incidences of repeat angiography over an average follow-up of 5.4 years. The average time between procedures was 3.07 ± 1.83 years. Of these, 13 (30.2%) patients had demonstratable progression of CAD, and 8 (18.6%) patients ultimately required PCI. Findings on initial angiogram were associated with CAD progression (p=0.01) but not with intervention requirement (p=0.18), with the odds of new CAD in those with normal coronaries on first angiogram 0.07 (95% C.I. 0.008-0.634, p=0.005). Neither a low EF (&lt;50%) (n=21) nor a drop in EF by &gt;10% (n=17) was associated with CAD progression or PCI. The 8 patients that required PCI presented with STEMI (n=3), NSTEMI (n=3), and unstable angina (n=2). Only one patient with normal coronaries on initial angiography required PCI, after presenting with a STEMI 4 years later and found to have distal LAD thrombotic occlusion with otherwise no coronary atherosclerosis. Conclusions: Repeat angiography had a low yield in our patient population. A drop in EF by &gt;10% was not associated with new findings on repeat angiography or revascularization. Larger studies are needed to investigate if a drop in EF requires invasive testing.

Abstract 15140: Post-Myocardial Infarction Ventricular Septal Defect in a Patient With Mixed Connective Tissue Disorder

Mixed connective tissue disorder (MCTD) is associated with a broad range of cardiovascular abnormalities, including coronary artery disease (CAD). It has been proposed that chronic systemic inflammation plays a key role in the development of atherosclerotic disease. A 66-year-old female with a history of MCTD and hypertension presented with mild dyspnea and pleuritic chest pain after one week of persistent flu-like symptoms. Her blood pressure was 108/77 mmHg, pulse 92 bpm, saturating 98% on room air. She was comfortable and denied other risk factors such as diabetes, hyperlipidemia, or prior smoking history. On exam she was found to have a soft holosystolic murmur across her precordium. EKG showed sinus rhythm with small Q waves and ST elevation in V1-V6. She was taken for cardiac catheterization which revealed a thrombotic occlusion in the proximal left anterior descending artery (LAD) and a severe lesion in the left circumflex artery. She underwent angioplasty with one drug eluted stent placed to LAD. Left ventriculography revealed a VSD near the apex, and transthoracic echocardiogram showed a 7.6 mm muscular VSD with left to right shunt, ejection fraction of 35% and hypokinesis of the anterior wall. She became hypotensive and required vasopressors prior to coronary artery bypass grafting and primary closure of her apical VSD. Intraoperatively, a 2 cm VSD with 5 cm of necrotic surrounding tissue was noted. Post-operative complications included asystolic cardiac arrest, marked cardiogenic shock and multiorgan failure to which she ultimately succumbed. Post-myocardial infarction VSD is a rare complication of MI occurring in approximately 0.2% of cases. However, patients with MCTD can develop atypical symptoms, resulting in delayed presentation and therefore higher risk of mechanical complications. We highlight the importance of a thorough physical exam and high suspicion for mechanical complications in these patients even when hemodynamically stable.

Abnormal foreshortening of a Flow Re-Direction Endoluminal Device caused by in-stent thrombosis immediately after deployment.

Thromboembolic complications are a concern in the treatment of cerebral aneurysms using a flow diverter. In this study, we report a case of abnormal foreshortening of a Flow Re-Direction Endoluminal Device (FRED) caused by in-stent thrombosis immediately after its deployment. A 72-year-old woman had a large cavernous carotid aneurysm, which caused ptosis and diplopia. FRED deployment was planned, and dual antiplatelet therapy was initiated 2 weeks before the procedure. Under systemic heparinization, FRED was deployed with local compaction over the aneurysm orifice. Cone-beam computed tomography subsequently revealed slightly poor wall apposition at the proximal side. While the balloon catheter was prepared for angioplasty, the stent became abnormally foreshortened, the proximal side slipped into the aneurysm, and the internal carotid artery became occluded. FRED was removed using a snare wire, and recanalization was obtained. The lumen of the removed FRED was filled with thrombus. The antiplatelet therapy was changed to triple regimen, and a Pipeline Flex embolization device was placed 1 month later. At that time, no thromboembolic complications were noted. It was considered that thrombotic occlusion was followed by foreshortening of FRED on the distal side because of antegrade blood flow. Multiple factors, such as increased mesh density by locally compacted stent deployment, slightly poor wall apposition, clopidogrel resistance, and the dual-layer structure of FRED, may have been involved in thrombus formation.

Outcome of endovascular treatment of internal iliac artery aneurysms: a single center retrospective review

PurposeTo evaluate the technical feasibility and clinical outcomes of endovascular treatment for internal iliac artery (IIA) aneurysms.Material and methodsThis was a retrospective analysis of 25 patients with 32 IIA aneurysms (mean diameter: 39.1 ± 12.6 mm) who underwent endovascular treatment over a 10-year period, and were available for follow-up. Univariate analysis was used to determine the association between variables (including aortoiliac involvement and technique) and outcome.ResultsThe IIA inflow was covered with an iliac stent graft (N = 29) or embolized with a plug (N = 3). The IIA outflow was embolized in all but one case in which there was thrombotic occlusion of outflow branches. Outflow embolization using plugs or coils was performed in the distal IIA or anterior/posterior trunks in 9 cases and distal IIA branches in 22 cases. During a mean follow-up period of 39.9 months, 31.2% of aneurysms demonstrated endoleak and 12.5% demonstrated enlargement. Univariate analysis revealed that endoleak was associated with technical failure (p = 0.01) and that endoleak rate was higher in patients who underwent distal IIA branch embolization (p = 0.03). No variable was associated with sac expansion. Major complication occurred in one patient who died from aneurysm rupture. Minor complications were reported in six patients who developed femoral pseudoaneurysm (N = 2, 8%), buttock claudication (N = 3, 12%), and limb graft occlusion (N = 1, 4%).ConclusionEndovascular treatment of IIA aneurysms effectively prevents sac expansion. Endoleak was more frequently observed in cases of technical failure and those in which distal IIA branches were embolized.Level of EvidenceLevel 3b, retrospective cohort study.

Bioabsorbable, elastomer-coated magnesium alloy coils for treating saccular cerebrovascular aneurysms

Cerebral aneurysm embolization is a therapeutic approach to prevent rupture and resultant clinical sequelae. Current, non-biodegradable metallic coils (platinum or tungsten) are the first-line choice to secure cerebral aneurysms. However, clinical studies report that up to 17% of aneurysms recur within 1 year after coiling, leading to retreatment and additional surgery. It would be ideal for the aneurysm coiling material to induce acute thrombotic occlusion, contribute to a tissue development process to fortify the degenerated vessel wall, and ultimately resorb to avoid leaving a permanent foreign body. With these properties in mind, a new fatty amide-based polyurethane urea (PHEUU) elastomer was synthesized and coated on biodegradable metallic (Mg alloy) coils to prepare a bioabsorbable cerebral saccular aneurysm embolization device. The chemical structure of PHEUU was confirmed using two-dimensional nuclear magnetic resonance spectroscopy. PHEUU showed comparable physical properties to elastomeric biodegradable polyurethanes lacking fatty amide immobilization, modest enzymatic degradation profiles in the first 8 wks, inherent antioxidant activity (>70% at 48 h), no cytotoxicity, and better protection for the underlying Mg alloy than poly(lactic-co-glycolic acid) (PLGA) against surface corrosion and cracking. Rat aortic smooth muscle cell attachment and platelet deposition were higher with the PHEUUs compared to bare or PLGA coated Mg alloy in vitro. PHEUU-coated Mg alloy coils showed the potential to design a fully bioabsorbable embolization coil amenable to clinical placement conditions based on computational mechanics modeling and blood-contacting test using an in vitro aneurysm model. In vivo studies using a mouse aneurysm model elicited comparable inflammatory cytokine expression to a commercially available platinum coil.

Ventilatory inefficiency predicts abnormal hemodynamic response to exercise in chronic thromboembolic disease

Abstract Background Chronic thromboembolic disease (CTED) refers to the presence of chronic thrombotic pulmonary vascular occlusion in the absence of pulmonary hypertension (PH) at rest. Nevertheless, their exercise tolerance may be decreased. We hypothesized that exercise intolerance may be explained by an abnormal haemodynamic response to exercise and that this may correlate to the functional and ventilatory parameters exhibited at the cardiopulmonary exercise test (CPET). Objective To evaluate the values reached in the CPET according to the hemodynamic response to exercise at the exercise right heart catheterization (RHC) in patients with CTED. Methods We selected symptomatic patients with confirmed perfusion defects in lung scintigraphy despite optimal anticoagulant therapy for a minimum of 6 months after a pulmonary embolism with normal lung function tests. Thrombotic burden was assessed with computed tomography (CT). Left heart disease (LHD) and PH were ruled out with RHC (inclusion criteria implied mean pulmonary arterial pressure (mPAP)&amp;lt;25 mmHg and pulmonary vascular resistance (PVR)&amp;lt;3 uW and pulmonary arterial wedge pressure (PAWP)&amp;lt;15 mmHg). All patients underwent a cardiopulmonary exercise test (CPET). Exercise RHC was performed within 24 hours after CPET. The exercise protocol was the same for both tests. Pulmonary pressures and cardiac output (CO) were collected at each exercise level. Abnormal hemodynamic exercise response was considered following the proposal of the 2020 CTED consensus (mPAP/CO slope &amp;gt;3 mmHg/L/min). Results 22 patients (median age 54.5±14.8 years, 32% females) were included, of whom 13 (59%) showed an abnormal hemodynamic response (mPAP/CO slope 4.5 vs 2.3 mmHg/L/min, Figure 1A). Baseline characteristics and time from the embolic event were similar in both groups (3.4 vs 2.5 years, p=0.815) (Table 1). Patients with abnormal exercise response showed worse ventilatory efficiency at the CPET: 1) a flattened end-tidal carbon dioxide pressure pattern (PetCO2) (Figure 1B), 2) a steeper VE/CO2 slope, and 3) a higher ventilatory equivalent for CO2 at the anaerobic threshold (EQCO2_AT); compared to the group with normal hemodynamic behavior. Oxygen consumption at the anaerobic threshold (VO2_AT) and peak oxygen consumption (VO2) were slightly decreased without statistically significant differences between groups. VE/CO2 slope, EqCO2_AT and PETCO2_AT showed a moderate mPAP/CO slope correlation (r=0.66, p&amp;lt;0.001; r=0.63, p=0.003; r=−0.51, p=0.017 respectively). PetCO2_AT and EqCO2_AT accurately discriminated between both groups with an area under the receiver operating characteristic curve of 0.752 and 0.710 respectively. Conclusion In patients with CTED and normal/near normal pulmonary pressures at rest, ventilatory inefficiency parameters in CPET correlate with an abnormal hemodynamic exercise response. PETCO2 pattern and EqCO2_AT accurately discriminated the subgroup with abnormal hemodynamic behaviour. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Sociedad Española de Cardiologia

ST Segment myocardial infarction due to totally occluded unprotected left main coronary artery (TOULM): an insight from nationwide database

Abstract Objective This study sought to describe the clinical profile, management and short-term outcomes of patients with ST elevation myocardial infraction (STEMI) due to totally occluded unprotected left main coronary artery (TOULM). Methods This is a retrospective analysis of nationwide STEMI database of patients who underwent primary percutaneous intervention (PPCI). Patients with TOULM are defined as having 100% acute thrombotic occlusion of the left main artery or subtotal occlusion with no more than TIMI 1 flow. Results Between January 2011 and February 2022, 7107 patients underwent Primary Percutaneous Intervention for STEMI. 35 cases (0.5%) of all STEMI were due to TOULM. The average age of patients with TOULM was 51±14 years, predominantly male (94%) and had no prior cardiac history (94%). 11 patients (31%) suffered cardiac arrest and 16 (45%) were on mechanical ventilation prior to arrival to cardiac catheterization laboratory. The right coronary artery was the dominant vessel in 29 (89%) patients. Right to left collaterals were present in 15 (42%), absent in 8 (23%) and unknown (the right coronary artery was injected after TOULM intervention or not injected) in 12 (34%) patients. Mechanical circulatory support was used in 37% of the cases (IABP 8, ECMO 3 and ECMO plus IABP 2). Revascularization was achieved with PCI and stenting in 30 patients (86%). Five patients underwent urgent CABG after balloon angioplasty. Survival to hospital discharge was 55%. Conclusions STEMI due to TOULM is a rare occurrence and involved mainly male with no prior cardiac history. Despite all the patients in our series undergoing revascularization, the in-hospital mortality is almost 50%. One major limitations of our study is we had no post-mortem data of any patient who died prior to coronary angiography, which potentially will lead to higher recorded cases of TOULM related mortality. Funding Acknowledgement Type of funding sources: None.

Sono-assisted-thrombolysis by three-dimensional diagnostic ultrasound improves epicardial recanalization and microvascular perfusion in acute myocardial infarction.

BackgroundThis study aimed to evaluate the multiple interactions between therapeutic ultrasound (TUS), microbubbles (MB), and recombinant tissue plasminogen activator (r-tPA) by using three-dimensional (3D) ultrasound to examine the impact of thrombolysis with r-tPA on epicardial recanalization and microcirculation in patients with acute ST-segment-elevation myocardial infarction (STEMI).MethodsAcute thrombotic occlusion of the left anterior descending (LAD) artery was induced in 32 Bama pigs, who were fed a high-cholesterol diet and randomized into four groups: (I) a 3D-sono-assisted-thrombolysis (3D/TUS + MB + r-tPA) group; (II) a 3D/TUS + MB group; (III) a full-dose r-tPA group; and (IV) a 3D/TUS alone group. Epicardial angiographic recanalization rate, microcirculation in the at-risk myocardium, ST-segment elevation on electrocardiogram, and changes in the at-risk myocardium and the myocardial infarct area were compared between the groups.ResultsAfter treatment, distal LAD recanalization was observed in 87.5% (7/8) of pigs in the 3D/TUS + MB + r-tPA group, which was significantly higher than the rates observed in the 3D/TUS + MB (37.5%) and the full-dose r-tPA (50.0%) groups (all P<0.05). The average acoustic intensity in the 3D/TUS + MB + r-tPA group (193.78±10.15 dB) was also significantly higher than that in the 3D/TUS + MB (154.29±31.94 dB) and the r-tPA (141.42±28.31 dB) groups (all P<0.05). The decrease in ST-segment elevation in the 3D/TUS + MB + r-tPA group (1.31±1.22 mm) was significantly higher than that in the 3D/TUS + MB (5.38±1.77 mm) and the r-tPA (4.30±2.08 mm) groups (all P<0.05). Furthermore, the ratio of the infarcted myocardial area divided by the at-risk myocardial area was markedly lower in the 3D/TUS + MB + r-tPA group (0.51±0.14) than in the 3D/TUS + MB (0.69±0.28) and r-tPA (0.75±0.23) groups (all P<0.05).ConclusionsThree-dimensional sono-assisted-thrombolysis directly improves infarct-related recanalization rates, enhances microcirculation, reduces r-tPA dosage, and ameliorates the thrombolytic effect of r-tPA in acute STEMI.

ACUTE ANTERIOR WALL MYOCARDIAL INFARCTION BY AN ANOMALOUS MID LEFT ANTERIOR DESCENDING ARTERY ORIGINATING FROM THE PROXIMAL RIGHT CORONARY ARTERY

SESSION TITLE: Etiologies of Cardiovascular Disease Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: The estimated incidence of coronary artery anomalies is up to 1%.CASE PRESENTATION: A 50-year-old man with peripheral artery disease and drug abuse was brought to the emergency department unresponsive post cardiac arrest.Before arrival, he had ventricular fibrillation which progressed to asystole.He received two defibrillations, cardiopulmonary resuscitation, epinephrine, and amiodarone before return of spontaneous circulation. On arrival, he was intubated.EKG showed ST-segment anterior ST-elevations.The patient emergently transported to the cardiac catheterization laboratory.Diagnostic coronary angiography showed a 100% thrombotic stenosis of the second diagonal branch and an anomalous mid and distal LAD originating from the proximal RCA.The D2 was repaired successfully with a 2.5 x 34 mm Resolute Onyx drug-eluting stent.Following decision was made to pursue a dual injection to evaluate for a mid and distal LAD arising as a branch from the conus. Following a 6F JR5 catheter was used to engage the RCA.Dual injections were performed in multiple projections, and a mid and distal LAD arising from the conus was confirmed.At the end of the procedure, the EKG showed resolution of the ST elevations. The patient was transferred to the intensive care unit.DISCUSSION: These anomalies are generally asymptomatic, but rarely may lead to myocardial ischemia/infarction and/or sudden death.In particular, STEMI is a rare clinical presentation and identification of the culprit lesion with subsequent emergent PCI can be challenging in this setting.CONCLUSIONS: We report a rare case of cardiac arrest due to 100% thrombotic occlusion of culprit anomalous LAD originating from RCA leading to acute anterior wall myocardial infarction.Reference #1: Kheirkhah J, Sadeghipour P, Kouchaki A. An anomalous origin of left anterior descending coronary artery from right coronary artery in a patient with acute coronary syndrome. J Tehran Heart Cent. 2011 Nov;6(4):217-9. Epub 2011 Nov 30. PMID: 23074373; PMCID: PMC3467955.DISCLOSURES: No relevant relationships by Samiullah ArshadNo relevant relationships by Huzefa BhopalwalaNo relevant relationships by Nakeya Dewaswalano disclosure on file for Hussam Fawzi Ahmad Hawamdeh;no disclosure submitted for Andrew Leventhal;no disclosure submitted for Adrian Messerli;No relevant relationships by Vinayak Mishra SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The estimated incidence of coronary artery anomalies is up to 1%. CASE PRESENTATION: A 50-year-old man with peripheral artery disease and drug abuse was brought to the emergency department unresponsive post cardiac arrest. Before arrival, he had ventricular fibrillation which progressed to asystole. He received two defibrillations, cardiopulmonary resuscitation, epinephrine, and amiodarone before return of spontaneous circulation. On arrival, he was intubated. EKG showed ST-segment anterior ST-elevations. The patient emergently transported to the cardiac catheterization laboratory. Diagnostic coronary angiography showed a 100% thrombotic stenosis of the second diagonal branch and an anomalous mid and distal LAD originating from the proximal RCA. The D2 was repaired successfully with a 2.5 x 34 mm Resolute Onyx drug-eluting stent. Following decision was made to pursue a dual injection to evaluate for a mid and distal LAD arising as a branch from the conus. Following a 6F JR5 catheter was used to engage the RCA. Dual injections were performed in multiple projections, and a mid and distal LAD arising from the conus was confirmed. At the end of the procedure, the EKG showed resolution of the ST elevations. The patient was transferred to the intensive care unit. DISCUSSION: These anomalies are generally asymptomatic, but rarely may lead to myocardial ischemia/infarction and/or sudden death. In particular, STEMI is a rare clinical presentation and identification of the culprit lesion with subsequent emergent PCI can be challenging in this setting. CONCLUSIONS: We report a rare case of cardiac arrest due to 100% thrombotic occlusion of culprit anomalous LAD originating from RCA leading to acute anterior wall myocardial infarction. Reference #1: Kheirkhah J, Sadeghipour P, Kouchaki A. An anomalous origin of left anterior descending coronary artery from right coronary artery in a patient with acute coronary syndrome. J Tehran Heart Cent. 2011 Nov;6(4):217-9. Epub 2011 Nov 30. PMID: 23074373; PMCID: PMC3467955. DISCLOSURES: No relevant relationships by Samiullah Arshad No relevant relationships by Huzefa Bhopalwala No relevant relationships by Nakeya Dewaswala no disclosure on file for Hussam Fawzi Ahmad Hawamdeh; no disclosure submitted for Andrew Leventhal; no disclosure submitted for Adrian Messerli; No relevant relationships by Vinayak Mishra

Thrombophilia in Budd-Chiari syndrome patient

A 27-years old female patient presented with a severe general condition of generalized edema and hypotension. Two months earlier computed tomography imaged thrombosis of the inferior vena cava and the three hepatic veins, or Budd-Chiari syndrome (BCS). Additional findings were thrombosis of the right common iliac vein and thrombosis of the renal veins bilaterally. Genetic testing proved congenital thrombophilia. Anticoagulation therapy did not affect thrombotic occlusions. In another cardiovascular center, an unsuccessful attempt for interventional treatment of the inferior vena cava with a jugular approach was made. The patient was admitted to our hospital for further evaluation and decision on treatment strategy. Laboratory and non-invasive imaging at admission rejected hepatic cirrhosis. An abdominal ultrasound scan demonstrated complete occlusion of the three hepatic veins and post hepatic portal hypertension. When thrombosis of all hepatic veins was detected transjugular intrahepatic portosystemic shunt (TIPS) was an option. An endovascular strategy for inferior vena cava was undertaken and complete revascularization was achieved with the right femoral approach as a bridge to TIPS shunt procedure, since the patient didn&amp;rsquo;t meet the criteria for liver transplantation. In diagnosing disease, the main contributors were the gastroenterologist, diagnostic imaging specialist, and hematologist, while the multidisciplinary team included also cardiologist, interventional cardiologist, and angiologist. In this case the multidisciplinary decisions played a major role in diagnosing and building an appropriate therapeutic strategy for systemic illnesses and conditions for which medical guidance does not yet have clear guidelines.

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

Myocardial infarction in combination with anaphylactic shock (Kounis syndrome): a case report

Introduction. Allergic reactions and side effects are a common consequence of drug use and account for ~5% of all hospital admissions. The co-occurrence of ana phylactic shock and acute myocardial infarction (AMI) is called Kounis synd rome (KS).Brief description. The article analyzes the case of ceftriaxone-induced KS in a 56-year-old female patient with a history of anaphylactic shock after ampicillin therapy. The patient was treated on an outpatient basis due to an acute upper respiratory infection. The patient was diagnosed with acute bronchitis, in connection with which antibiotic therapy with azithromycin was started. Due to inefficiency the drug was canceled and ceftriaxone 1 g in 3,5 ml of 1% lidocaine solution 2 times a day was prescribed. After the first intramuscular injection, the patient developed anaphylactic shock, which was stopped by intravenous administration of prednisolone 120 mg, dexamethasone 8 mg and adrenaline hydrochloride 1,0 ml. Almost immediately, the ST segment elevation was recorded, in connection with which thrombolytic therapy with fortelyzin 15 mg was performed. Coronary angiography revealed thrombotic occlusion of the left anterior descending artery in the upper segment. Further examination verified AMI in the patient.Discussion. This case of AMI is pathogenetically associated with anaphylactic shock. However, the available data on the state of patient coronary system and no data on the morphologic characteristics of thrombus do not make it possibelr to define a type of KS.Conclusion. This clinical case indicates the need for a thorough allergic anamnesis collection by physicians of any specialty and prescribing medications taking it into account.