Tortuous Artery Research Articles

Post-Transcatheter Aortic Valve Replacement (TAVR) Vascular Complications: Femoral Artery Minimal Surgical Access Versus Percutaneous Approach.

Percutaneous transfemoral access approach for the transcatheter aortic valve implantation (TAVI) is still associated with significant vascular complications. Hence, evaluation of best techniques for the reduction of vascular injury via the femoral access remains a key subject of research. We report on a single centre's experience with TAVI performed via the Femoral Artery Minimal Surgical Access (MSA) and percutaneous approach (PC). The primary endpoints were to evaluate the incidents of vascular complications by comparing the MSA versus the PC approach according to the VARC-2 criteria. The secondary endpoint included the impact of vascular complications on the in-hospital 30-day mortality and morbidity. Between June 2010 and September 2020, two hundred and thirty-seven consecutive patients who underwent TAVI for severe symptomatic aortic stenosis in our department were divided into two groups: patients treated using the femoral artery minimal surgical access (n = 173), and patients treated using the percutaneous approach (n = 64). Overall rate of access site complications according the VARC-2 were significantly more frequent in the percutaneous cohort (n = 12/64, 18.8% vs n = 2/173, 1.1%, p = 0.0012). The minor access complications including haematoma, bleeding, aneurysm, dissection, stenosis, seroma and infection were more frequent in the PC group (n = 8/64, 12.5% vs n = 2/173, 1.1%, p < 0.001). There were no major access site complications and hospital deaths in the MSA group, which was statistically significant (p < 0.001). Major access complications (n = 4, 6.3%, p < 0.001) and hospital death (n = 2, 3.1%, p < 0.001) were found in the PC cohort. The minimal surgical access approach provided direct and controlled access and significantly reduced the incidence of access site vascular complications in our TAVI patients. It also significantly reduced the in-hospital vascular-related mortality and morbidity. Though both approaches are complementary to each other, minimal surgical access approach would be a better choice for a calcified or tortuous femoral artery, and for a relatively small femoral artery diameter.

Correlation of a guidewire maximum insertion length with tortuous radial artery and the success rate during transradial coronary angiography

BackgroundPercutaneous coronary intervention (PCI) is a safe and effective therapy for patients with obstructive coronary artery disease (CAD). We aimed to assess the correlation between the success rate of angiography and the maximum insertion length and resistance of a soft-tipped guidewire.MethodsFive hundred twenty-one patients were treated by successful radial artery puncture. According to whether the guidewire resistance, the patients were divided to three groups. 17 patients were maximum insertion length of guidewire ≤ 30 cm when resistance was encountered (group 1). 17 patients were maximum insertion length of guidewire between 30 and 45 cm when resistance was encountered (group 2). 487 patients were no resistance encountered (group 3).ResultsThe coronary angiography success rates of group 1, 2, and 3 were 52.94%, 47.05%, 98.97%, respectively. Typically, angiography can be completed in patients with Ω-shaped, S-shape or Z-shaped tortuosity.ConclusionsThe maximum insertion length of straight guidewire and resistance can be used to determine radial artery status. The radial artery tortuosity or spasm significantly affects the success rate of coronary angiography.

DANCER: Study protocol of a prospective, non-randomized controlled trial for crossed limb versus standard limb configuration in endovascular abdominal aortic aneurysm repair.

Hostile anatomy, especially severely angulated neck and tortuous iliac arteries, has always been a conundrum in endovascular aneurysm repair (EVAR). Crossed limb (CL) graft, also called the "ballerina technique," has been utilized to address this problem by facilitating gate cannulation. In terms of short and long-term outcomes, correlated studies have made inconsistent conclusions and this issue remains controversial. Based on a previous cohort study conducted in our center, we aim to prospectively compare the safety and efficacy between CL and standard limb (SL) configuration in patients receiving EVAR. This is a prospective, single-center, non-randomized controlled trial. A total of 275 patients who meet the inclusion criteria will be enrolled and allocated with a 4:11 ratio of CL to SL, which is based on results of our previous study. All patients will receive same perioperative management and postoperative medications. All EVAR procedures will be performed under standard protocol, utilizing Endurant II or IIs Stent Graft. The configuration of the graft stent will be decided by surgeons and confirmed by final angiography. The primary outcome is 3-year freedom from major adverse limb-graft events (MALEs). Endpoints will be assessed at the following time points: 1, 6, 12, 24, and 36 months. To our best knowledge, this crosseD vs. stANdard Configuration in Endovascular Repair (DANCER) trial is the first non-randomized controlled trial to compare these two graft configurations in EVAR. The main aim is to compare the MALEs between two groups at 3 years postoperatively. This trial will hopefully provide high-level evidence for employing CL in EVAR. [www.chictr.org.cn], identifier [ChiCTR2100053055].

Carotid tortuosity is associated with extracranial carotid artery aneurysms.

Tortuous arteries may be associated with carotid dissection. The intima disruption caused by a carotid dissection is a possible cause of extracranial carotid artery aneurysms (ECAAs). The aim was to investigate if carotid tortuosity is also associated with ECAA in patients without presence or history of a carotid artery dissection. A retrospective case-control study was performed including 35 unilateral ECAA patients (cases) and 105 age- and sex-matched controls. Tortuosity was expressed as tortuosity-index (TI), curvature, and torsion measured on computed tomography angiography (CTA) data in 3Mensio Vascular and MATLAB by two independent investigators. Primary comparison was tortuosity in ipsi- versus contralateral carotid artery within the cohort of ECAA patients. Secondary comparison was tortuosity with ipsilateral carotid arteries in control patients. All observations were assessed on inter- and intra-operator reproducibility. Carotid tortuosity was comparable within the cohort of ECAA patients (Spearman correlation 0.76, P<0.001), yet distinctively higher in comparison with unilateral controls. After adjustment for patient characteristics, presence of ECAA was associated with TI (β 0.146, 95% CI: 0.100-0.192). All tortuosity observations showed excellent inter- and intra-operator reproducibility. Carotid tortuosity seems to be a risk factor for development of ECAA. Surveillance of individuals with increased carotid tortuosity therefore potentially ensures prompt diagnosis and treatment of ECAA. However, future research should investigate if persons with an increased tortuosity do indeed develop ECAA.

Preliminary Experience of the Surpass Streamline Flow Diverter for Large and Giant Unruptured Internal Carotid Artery Aneurysms.

As of January 2021, the Surpass Streamline (SS) is the most recently approved flow diverter in Japan. A total of 28 Japanese patients, including 9 clinical trial patients, with 28 large or giant unruptured internal carotid artery (ICA) aneurysms, underwent SS embolization at Juntendo University Hospital. Procedural failure occurred in two patients due to the difficulty to navigate the device in the tortuous parent artery. Therefore, 26 patients with 26 aneurysms were available for clinical and anatomical assessments. Patients' mean age was 62.6 years (range 46-86), and 24 patients (92.3%) were female. Mean aneurysm size and neck width were 15.4 mm and 7.7 mm, respectively, with 20 saccular and 6 fusiform aneurysms. Seven aneurysms were symptomatic due to the aneurysmal mass effect. Twenty patients underwent a 6-month follow-up angiography to evaluate the degree of occlusion. Anatomical outcomes were 12 (60%) complete occlusion (CO), 4 (20%) residual neck (RN), and 4 (20%) residual aneurysm. Favorable aneurysm occlusion consisted of CO, and RN was achieved in 16 (80.0%). There were no significant device stenoses. Aneurysmal mass effect improved in one and was unchanged in eight patients. There were three device-related complications, namely, delayed aneurysm rupture, minor ischemic stroke, and device occlusion (11.5%). One patient with minor ischemic stroke fully recovered before 30 days, and our series showed 7.7% risk of major ipsilateral stroke and neurological death at 30 days. The SS embolization for large and giant unruptured ICA aneurysms offers satisfactory anatomical and clinical outcomes with a low risk of device-related complications.

S2586 Don’t Get 2 Comfortable: A Rare Case of Meckel’s Diverticulum Causing Hemorrhagic Shock in an Adult

Introduction: Meckel’s diverticulum (MD) is a true diverticulum that results from incomplete obliteration from the vitelline duct during embryonic development. It is a one of the most common congenital disorders of the gastrointestinal (GI) tract. Often characterized using “The Rule of 2’s”: MD occurs in approximately 2% of the population, is 2 inches long, is within 2 feet from the ileocecal valve, is twice as common in males than females, can contain 2 types of tissue (gastric or pancreatic), 2% become symptomatic, and most present before the age of 2. The majority of symptomatic MD occur as painless hematochezia in children and therefore is often lower on the differential of an adult with a GI bleed. Even when MD is suspected as an etiology for GI bleeding in an adult, the evaluation can be challenging. Case Description/Methods: A 25-year-old male with no significant past medical history was admitted to the hospital for GI bleeding and then developed hemorrhagic shock requiring resuscitation with transfusion of large volumes of blood products. The etiology of his GI bleed remained elusive for several days despite evaluation with upper endoscopy, three colonoscopies, three CT angiograms of the abdomen and pelvis, and a video capsule endoscopy. Subsequently, he underwent two separate fluoroscopic angiograms with interventional radiology. While the first angiogram was unrevealing, the second angiogram demonstrated a tortuous ileal artery branch with active extravasation that was treated with embolization. Given IR findings, a Meckel’s scan was performed which was negative. A multi-disciplinary review of the case prompted further review of the patient’s abdominal CT angiogram and a potential finding of MD was seen at the distal ileum. Ultimately, the surgery team decided to take the patient to the operating room where they found and resected a segment of small bowel with tissue examination revealing the MD (Figure 1). Discussion: A Meckel’s scan is often considered the modality of choice for diagnosing MD in children, however, its diagnostic accuracy is considered to be much lower in adults. The typical approach to GI bleeding via upper endoscopy, colonoscopy, capsule endoscopy, CT and procedural angiography may be negative, as seen in our case. Balloon assisted enteroscopy, where available, may also be a potentially useful tool for diagnosing MD. This case highlights the importance of maintaining a broad differential diagnosis for GI bleeding and the challenges with current diagnostic modalities.Figure 1.: Meckel's diverticulum at the level of distal small bowel, approximately 60 cm from the ileocecal valve.

Study of course and termination of brachial artery by dissection and computed tomography angiography methods with clinical importance.

The Brachial artery is a continuation of the axillary artery, from the inferior border of the tendon of teres major to the neck of the radius, terminating into radial and ulnar arteries just a cm distal to the elbow joint. Unlike veins, variations in the arteries are comparatively less common. Anatomical variations of the brachial artery occur in almost 20% of the cases and are commonly found during routine dissection or clinical practice. To observe the variations in the course and termination of brachial artery by dissection and computed tomography (CT) angiography methods. The present study was conducted on 40 upper limbs each in the department of Anatomy & Radiology of JSS Medical College and Hospital, Mysuru. The brachial artery was traced from origin to termination and variations were noted and photographed. Patients who were undergoing CT angiography of the upper limbs in JSS Hospital were included in the study. Variations noted and compared with the dissection method. In the present study, normal patterns of the brachial arterial course and termination were observed in 31 specimens. The remaining 9 specimens showed variant course and termination in the brachial artery like an unusually tortuous superficial brachial artery, superficial brachio-ulnar artery and brachio-radial artery. CT angiography showed 6 variations and a tortuous brachial artery. A detailed description of the vascular pattern of upper limbs especially variations in their origin and termination is of extreme importance in clinical practice. The knowledge of these variations is important for catheterization, graft harvesting, arteriovenous fistula creation, shunt application and astrup examination.

Iliac Artery Tortuosity, Calcification and Abnormal Shape Augment Aortic Aneurysm Anatomy in Predicting Complications After Endovascular Aneurysm Repair

Post-surgical complications following endovascular aneurysm repair (EVAR) remain a risk, arising from technical difficulties imposed by highly calcified or tortuous iliac arteries. Automated methods enable segmentation of the iliac artery to potentially better define perioperative risk prediction. This study uses imaging software to characterise segmental iliac artery anatomy and aims to establish if iliac artery abnormalities can predict adverse outcomes following EVAR. Pre-operative clinical information and CT angiograms were obtained from 189 patients who underwent elective EVAR. Patients were followed for up to 3 years to detect stent-related complications and mortality. Aneurysm morphology was manually measured on CT scans. Automated measurements of vessel shape, curvature and calcification were taken for multiple subdivisions of the common and external iliac arteries. Logistic regression models were trained to assess the influence of iliac artery and aneurysm morphology on outcomes. Combining iliac and aortic features improved predictions of both stent-related complications and morbidity over using either alone. Models predicting death and both early and late stent complications had respective areas under the curve (AUCs) of 0.761, 0.935 and 0.833. Iliac artery calcification and curvature were significant predictors of poor outcomes. Automated morphological assessment of the common and external iliac artery improves the prediction of complications following EVAR. The improved power of iliac morphology to predict late complications and death implies that regional abnormalities of the iliac arteries are important when assessing surgical risk. This allows further rationalisation of the selection of individuals for treatment and may improve patient outcomes.

Management of Calcium in Coronaries: Not Always as Expected

Percutaneous revascularization of calcified coronary lesions is being performed with increasing frequency. Particularly, in elderly patients at high bleeding risk (HBR), these procedures are rife with technical challenges, which need to be balanced against the need to adhere to the KISS (keep it simple and swift) principle, minimizing procedural complexity and duration. We report the case of a 75-year-old male with HBR, presenting with angina, in whom intravascular imaging-guided multivessel percutaneous revascularization was performed in vessels with coronary artery calcium (CAC). Rotational atherectomy was done for concentric calcification in the left anterior descending artery. CAC in a tortuous right coronary artery was tackled with a balloon-based strategy, with the help of a guide extension catheter (GEC), which itself led to long stent damage during manipulation, necessitating bailout. This case demonstrates the judicious use of available armamentarium in resource-limited settings for tackling different presentations of CAC and the appropriate selection of calcium-modifying strategy guided by intravascular imaging. We also emphasize the importance of exercising caution when using equipment such as GEC and the need for swift and appropriate bailout mechanisms of these complications.

Utility of Balloon-Expandable Covered Stents as Iliac limbs in Endovascular Aortic Aneurysm Repair

Tortuous, calcified, and diseased iliac arteries pose a substantial challenge to the delivery and deployment of iliac limbs during endovascular repair of aortic aneurysms (EVAR). The purpose of this study is to review our experience using balloon-expandable covered stents instead of commercially available self-expanding iliac limbs during complex EVAR in patients with unfavorable iliac artery anatomy.

The medial wall and medial compartment of the cavernous sinus: an anatomic study using plastinated histological sections

The medial wall of the cavernous sinus (CS) has a significant role in evaluation and treatment of pituitary adenomas. This study was conducted to clarify the fine architecture of the medial wall and medial compartment of the CS at both macro- and micro-levels in twenty-one human cadaveric heads by using the epoxy sheet plastination technique. The sellar part medial wall is an intact dural layer that separates the CS from the pituitary gland. This dural wall adhered to the diaphragma sellae and the periosteum of the sella turcica to form fibrous triangles. Eight micro-protrusions of the pituitary gland were found at both sides of that wall. The thickness of the sellar part medial wall at its central portion was significantly thinner than that at the other surrounding portions. From the superior view, tortuous intracavernous carotid arteries can be divided into outward bending type and inward bending type. The inward bending intracavernous carotid was apt to bent towards the central part of the sellar part medial wall, where there were usually wide and short fibrous bands with more densely stained connective tissues between them. The micro-protrusion of the pituitary gland in the medial wall of the CS could provide an anatomical basis for the occult tumor invasion and the recurrence of residual tumor. Different bending facing states of tortuous intracavernous carotid arteries in the lateral direction may be a factor of the determination of the direction of growth of pituitary tumors.

Compression of the Distal Common Bile Duct by Enlarged Inferior Pancreaticoduodenal Artery Branches in a Patient with Celiac Trunk Stenosis: A Case Report

AbstractVarious benign and malignant pathologies/conditions can cause compression of the extrahepatic biliary system. Anatomical and/or topographic variations of the hepatic artery have long been recognized as a possible cause of the EBS compression. However, anatomical and/or topographic variations, other than the hepatic artery's, should also be considered during the evaluation of the EBS compression. We, herein, report a unique case of the distal common bile duct compression by tortuous and enlarged inferior pancreaticoduodenal artery branches due to severe stenosis of the celiac trunk orifice.

Transcatheter aortic valve replacement through the carotid artery in a 60-year-old man with aortic stenosis and chronic dialysis: a case report

Transcatheter aortic valve replacement (TAVR) through the carotid artery in middle-aged patients with severe aortic stenosis and chronic hemodialysis has been a challenge in clinical practice because of the complex technique. A 60-year-old man was admitted to our hospital because of his symptomatic severe aortic stenosis. With the high risk of open surgery due to chronic hemodialysis, TAVR was selected after an in-depth discussion between the heart team and the patient. The transfemoral access route was not appropriate due to severe calcifications and tortuous iliofemoral arteries, therefore, the left carotid route was chosen. A 29-mm CoreValve Evolut R system was successfully implanted without any complications. His symptoms significantly improved at 12-month follow-up, without any major cardiovascular adverse events. TAVR via the carotid artery thus demonstrates the feasibility, safety, and effectiveness in such complex conditions.

Subarachnoid Hemorrhage from Ruptured Internal Carotid Artery Aneurysm: Association with Arterial Tortuosity

Many researchers have found a correlation between tortuous arteries and development of aneurysms in cerebral arteries. We decided to determine whether tortuosity of the internal carotid artery can be related to its aneurysm rupture. We retrospectively analyzed the internal carotid artery anatomy of 149 patients with internal carotid artery aneurysms. For each patient, we calculated relative length (RL), sum of angle metrics (SOAM), triangular index (TI), product of angle distance (PAD), and inflection count metrics (ICM). A total of 33 patients (22.15%) had subarachnoid hemorrhage. These patients had significantly lower SOAM (0.31 ± 0.17 vs. 0.42 ± 0.21; P < 0.01), TI (0.27 ± 0.09 vs. 0.31 ± 0.11; P= 0.03) and ICM (0.25 ± 0.11 vs. 0.31 ± 0.17; P= 0.04). In multivariate logistic regression analysis, higher SOAM (odds ratio, 0.780; 95% confidence interval, 0.619-0.961; P= 0.025) remained independently associated with lower risk of internal carotid artery aneurysm rupture. In addition, we found significant positive correlation of aneurysm dome size with SOAM (R= 0.224; P=0.013) and PAD (0.269; P < 0.01). Our study also showed that age (R= 0.252; P= 0.036), Glasgow Coma Scale score (R= -0.706; P < 0.01), and TI (R= -0.249; P= 0.042) were independently correlated with modified Rankin Scale score on discharge. Lower tortuosity might be a protective factor against internal carotid artery aneurysm rupture and poor outcome after subarachnoid hemorrhage. Higher tortuosity is correlated with internal carotid artery aneurysm growth.

A Sri Lankan child with hypersplenism secondary to pre-hepatic portal hypertension, successfully managed with partial splenic artery embolization: a case report and review of the literature

BackgroundHypersplenism, one of the major complications of portal hypertension, is traditionally treated by splenectomy. However, partial splenic artery embolization is an evolving minimally invasive intervention to treat these patients effectively.Case presentationA 13-year-old girl was referred for further evaluation of isolated splenomegaly with pancytopenia. She did not have bleeding manifestations or features of anemia. She never had hematemesis or melena. On examination, she was pale. Abdominal examination revealed massive splenomegaly of 10 cm below the costal margin without hepatomegaly. Rest of the examination was unremarkable. Her investigations revealed a white cell count of 1700/mm3 (neutrophils 9.8% and lymphocytes 88.7%), hemoglobin 9.5 g/dL and platelet count 42,000/mm3. Blood picture showed pancytopenia without abnormal cells. Her reticulocyte count was 1.9%. Complete liver profile was normal. Abdominal ultrasonography revealed massive splenomegaly with the oblique length of 17 cm and normal echogenic liver with normal size. Cavernous transformation of portal vein with portal hypertension was evident. Mesenteric angiogram showed portal vein thrombosis and markedly tortuous splenic artery. Anti-nuclear antibodies and double-stranded DNA were negative. Ham test and urine for hemosiderin were negative. Clauss fibrinogen assay was normal. Hemoglobin high performance liquid chromatography for hemoglobin subtypes was normal. Anti-phospholipid antibodies were negative. JAK2 V617F mutation was not identified. Diagnosis of pre hepatic portal hypertension was made. Her upper gastrointestinal endoscopy was normal. Partial splenic artery coil embolization was done by interventional radiology team. Vaccines against capsulated organisms were given. Post-procedure contrast abdominal computed tomography revealed infarction of approximately 70% of the spleen and blood counts were improved. Index case is in the follow up for 3 years. She is on penicillin prophylaxis with regular blood count and annual upper gastrointestinal endoscopy monitoring.ConclusionsMinimally invasive interventions such as partial splenic artery embolization should be considered in managing the patients with hypersplenism secondary to portal hypertension.

Effectiveness of Anchoring with Balloon Guide Catheter and Stent Retriever in Difficult Mechanical Thrombectomy for Large Vessel Occlusion.

ObjectiveA distal navigation of a large bore aspiration catheter during mechanical thrombectomy (MT) is important. However, delivering a large bore aspiration catheter is difficult to a tortuous or atherosclerotic artery. We report the experience of anchoring with balloon guide catheter (BGC) and stent retriever to facilitate the passage of an aspiration catheter in MT. MethodsWhen navigating an aspiration catheter failed with a conventional co-axial microcatheter delivery, an anchoring technique was used. Two types of anchoring technique were applied to facilitate distal navigation of a large bore aspiration catheter during MT. First, a passage of aspiration catheter was attempted with a proximal BGC anchoring technique. If this technique also failed, another anchoring technique with distal stent retriever was tried. Consecutive patients who underwent MT with an anchoring technique were identified. Details of procedure, radiologic outcomes, and safety variables were evaluated. ResultsA total of 67 patients underwent MT with an anchoring technique. Initial trial of aspiration catheter passage with proximal BGC anchoring technique was successful for 35 patients (52.2%) and the second trial with distal stent retriever anchoring was successful for 32 patients (47.8%). Overall, navigation of a large bore aspiration catheter was successful for all patients (100%) without any procedure related complications. ConclusionOur study showed the usefulness of anchoring technique with proximal BGC and distal stent retriever during MT, especially in those with an unfavorable anatomical structure. This technique could be an alternative option for delivering an of aspiration catheter to a distal location.

Endovascular management of hemoptysis in a known case of tetralogy of fallot and tuberculosis complicated with aspergilloma: a case report

BackgroundHemoptysis is a life-threatening complication due to bleeding either from hypertrophied bronchial arteries or enlarged non-bronchial systemic collaterals, having multiple etiologies. Bronchial artery embolization (BAE) is a minimally invasive modality of management that can effectively manage moderate-to-severe hemoptysis.Case presentationWe report the case of a 25-year-old female with moderate-to-severe hemoptysis. There was prior history of tuberculosis and treatment with anti-tubercular therapy 6 months back. There was also a background of tetralogy of Fallot(TOF) with symptoms of chronic breathlessness and palpitations. Imaging evaluation with X-ray and HRCT thorax revealed a cavity in the left upper lobe with dependent soft tissue, implying a diagnosis of aspergilloma in an old tubercular cavity. TOF and right-sided aortic arch were noted. CT bronchial angiography showed dilated and tortuous left bronchial artery, as well as non-bronchial systemic collaterals from the ipsilateral internal mammary artery. Endovascular management was achieved by super-selective catheterization and embolization of the involved branch of the left bronchial artery and selective embolization of non-bronchial systemic collaterals from the ipsilateral internal mammary artery.ConclusionsBAE has a high clinical success rate and is recommended as first-line therapy in the management of massive hemoptysis. The CT pulmonary angiography, as well as the pre-embolization angiogram, is very important to detect the source of hemoptysis from the non-bronchial systemic circulation, increasing the success rate and decreasing the incidence of recurrence. BAE is effective even in presence of underlying vascular anomalies such as Fallot of Tetralogy.

Changes of creatine phosphokinase MB levels in the context of myocardial reperfusion injury

In patients with initially elevated levels of creatine phosphokinase MB (CPK-MB), its increase after percutaneous coronary intervention (PCI) may be due not only to additional injury, but also to natural release during myocardial infarction. Therefore, CPK-MB should be evaluated relative to the initial values.Aim. To compare the CPK-MB dynamics after myocardial reperfusion relative to baseline values and the upper limit of normal (ULN) for the optimal approach to determining myocardial reperfusion injury in patients with acute coronary syndrome.Material and methods. A single center observational study was conducted with the participation of 90 patients hospitalized with a diagnosis of acute coronary syndrome. Patients underwent a biochemical blood test for CPK-MB twice and its dynamics was determined relative to the initial value and ULN.Results. Between the ischemia time and CPK-MB dynamics relative to the initial values, there is a moderate negative correlation. At the same time, the ratio of CPKMB after surgery to ULN is not associated with ischemia time. Analysis of covariance showed that the CPK-MB dynamics, determined relative to the initial values, is 20% dependent on the ischemia time. Individual features of coronary system anatomy, localization of the infarct-associated artery and the subsequent reperfusion procedure together explain the CPK-MB dynamics after surgery by 27%. When the ratio of CPK-MB to ULN is included in the analysis of covariance, all the above factors lose statistical significance.Conclusion. Thus, for a more accurate assessment of myocardial reperfusion injury after PCI, not the upper limit of normal should be analyzed, but the initial values of CPK-MB. In patients with the left heart dominant, as well as in the infarction localization in the system of right or left anterior descending artery, there is a slight change in the marker. On the contrary, more pronounced dynamics is observed in patients with tortuous coronary arteries and with implantation of 2 or more stents. At the same time, the assessment of CPK-MB in relation to ULN is not associated with the ischemia time and does not depend on the clinical and angiographic characteristics and tactics of the operation.

I saw the sign: the “corkscrew sign” of the hepatic arteries

•The corkscrew sign describes the hepatic arteries' tortuous appearance in the radiologic imaging of cirrhosis patients. •The corkscrew sign is accepted as a typical imaging finding of cirrhosis, as are surface nodularity and capsular retraction. •Tortuous hepatic arteries complicate selective catheterization during interventional procedures.

Hemifacial spasm caused by tortuous vertebrobasilar artery: a case report

BackgroundHemifacial spasm is a rare movement disorder. Prevalence estimates worldwide was 14.5 per 100,000 women and 7.4 per 100,000 men. Hemifacial spasm generally caused by compression of blood vessels at the root entry zone of the facial nerve in the brainstem, tortuous anteroinferior cerebellar artery (AICA) and posteroinferior cerebellar artery (PICA). Direct compression by vertebrobasilar dolichoectasia (VBD) with coincidence cavernoma is extremely rare.Case reportA 50-year-old woman with right hemifacial spasm for 1 year, with a history of hypertension for 10 years, did not take medication regularly. MRI MRA was performed showing suspicious dolichoectasia in the vertebrobasilar artery and cavernoma in the left basal ganglia. Then digital subtraction angiography was performed, it was found that the tortuous vertebrobasilar junction artery with a curve to the right caused right hemifacial spasm.ConclusionVascular imaging examination is important to do to find the cause of hemifacial spasm suspected to be due to vascular causes. The finding of two types of intracranial vascular malformations should be explored further. Therefore, the selection of therapy and management becomes more appropriate.