Vascular Conditions Research Articles

The particularities of hemostasis in patients with non-ST elevation myocardial infarction and some comorbidities

The formation of an obstructive thrombus within an artery remains a major cause of mortality and morbidity worldwide. [1] Despite effective inhibition of platelet function by modern antiplatelet therapies, these agents fail to fully eliminate atherothrombotic risk. This may well be related to extensive vascular disease, beyond the protective abilities of the treatment agents used. However, recent evidence suggests that residual vascular risk in those treated with modern antiplatelet therapies is related, at least in part, to impaired fibrin clot lysis. Along these lines, thrombosis is the result of several changes in local homeostasis: endothelial dysfunction, changes in the fibrinolytic system, increased content of some coagulation factors, decreased natural inhibitors, platelet hyperactivity [2] [3]. In this review, we attempt to shed more light on the role of hypofibrinolysis in predisposition to arterial vascular events. We provide a brief overview of the coagulation system followed by addressing the role of impaired coagulation, anticoagulation, and fibrinolysis in acute vascular conditions, including coronary artery disease. We also discuss the prognostic implications of coagulation biomarkers regarding arterial thrombotic events, addressing, in particular, people who are exposed to metabolic risks (hyperlipidemia, hypertension, and diabetes). We conclude that affecting coagulation appears to contribute to residual thrombosis risk in individuals with arterial disease on antiplatelet therapy, and targeting proteins in the fibrinolytic and coagulant system represents a viable strategy to improve outcomes in this population. Future work is required to refine the antithrombotic approach by modulating pathological abnormalities in the fibrinolytic and anticoagulant system and tailoring the therapy according to the need of each individual

Dynamic Imaging is the Ideal Modality for the Diagnosis of Popliteal Artery Entrapment Syndrome

Popliteal Artery Entrapment Syndrome (PAES) is a rare vascular condition with significant equipoise on how to properly diagnose and evaluate relevant imaging. This can lead to misdiagnosis and delay in surgical management. The objective of this study is to describe and compare distinct imaging features of dynamic versus static images to help determine the ideal imaging modality for diagnosis of PAES. This is a retrospective review of patients referred for PAES at a single institution. We reviewed non-invasive imaging studies, diagnostic arteriograms, and cross-sectional images which include computed tomography angiography (CTA) or magnetic resonance angiography (MRA). For each affected and unaffected extremity, the characteristic collaterals for PAES were named and measured on arteriogram using Picture Archiving and Communication Software (PACS). Available cross-sectional images were also analyzed and compared with arteriogram and intraoperative findings during surgical exploration. There were 23 patients referred for PAES who underwent diagnostic evaluation and surgical management between 2013 and 2022. All patients had a duplex ultrasound that revealed a mean popliteal peak-systolic velocity (PSV) of 78 cm/sec at rest. With forced plantar flexion, the PSV increased to a mean 175 cm/sec. A total of 12 extremities had complete loss of flow with provocation during duplex ultrasound. All patients underwent diagnostic angiography of 46 extremities. All limbs with PAES (n=35) exhibited complete popliteal artery occlusion during angiography with forced plantar flexion. Distinct angiographic findings on resting images included a well-developed medial sural artery in 100% of limbs with PAES with a mean diameter of 2.7 mm. In limbs without PAES, only 80% had a visualized medial sural artery on arteriogram with a mean diameter of 2.0 mm (p=0.1). A lateral sural artery was seen in 85% of affected extremities (mean diameter of 1.8 mm) while an anterior tibial recurrent artery was seen in 59% of affected extremities (mean diameter of 1.3 mm). In unaffected limbs, there were no visible lateral sural or anterior tibial recurrent arteries. The mean contrast used with diagnostic arteriograms was 58 milliliters (range 10-100 milliliters). Axial imaging was available for 9 affected extremities. Five had a previous MRA with only 1 being truly positive for arterial compression. Four extremities had previous CTA with 3 being falsely negative despite having type 3 PAES discovered during surgical exploration. Dynamic imaging with angiography provides immediate surgeon feedback by visualizing popliteal artery compression and enlarged sural collaterals during resting arteriography. The medial sural collateral is enlarged in patients with PAES and often the lateral sural and anterior tibial recurrent arteries can be visualized as well. CTA and MRA are associated with high false-negative rates and therefore cause delays in diagnosis and surgical management of PAES. Dynamic imaging should therefore be the gold standard for the diagnosis of PAES.

Your New Year’s “resolution”—check your “screen!”

Your New Year’s “resolution”—check your “screen!”

INKILN is a Novel Long Noncoding RNA Promoting Vascular Smooth Muscle Inflammation via Scaffolding MKL1 and USP10.

Activation of vascular smooth muscle cell (VSMC) inflammation is vital to initiate vascular disease. The role of human-specific long noncoding RNAs in VSMC inflammation is poorly understood. Bulk RNA sequencing in differentiated human VSMCs revealed a novel human-specific long noncoding RNA called inflammatory MKL1 (megakaryoblastic leukemia 1) interacting long noncoding RNA (INKILN). INKILN expression was assessed in multiple in vitro and ex vivo models of VSMC phenotypic modulation as well as human atherosclerosis and abdominal aortic aneurysm. The transcriptional regulation of INKILN was verified through luciferase reporter and chromatin immunoprecipitation assays. Loss-of-function and gain-of-function studies and multiple RNA-protein and protein-protein interaction assays were used to uncover a mechanistic role of INKILN in the VSMC proinflammatory gene program. Bacterial artificial chromosome transgenic mice were used to study INKILN expression and function in ligation injury-induced neointimal formation. INKILN expression is downregulated in contractile VSMCs and induced in human atherosclerosis and abdominal aortic aneurysm. INKILN is transcriptionally activated by the p65 pathway, partially through a predicted NF-κB (nuclear factor kappa B) site within its proximal promoter. INKILN activates proinflammatory gene expression in cultured human VSMCs and ex vivo cultured vessels. INKILN physically interacts with and stabilizes MKL1, a key activator of VSMC inflammation through the p65/NF-κB pathway. INKILN depletion blocks interleukin-1β-induced nuclear localization of both p65 and MKL1. Knockdown of INKILN abolishes the physical interaction between p65 and MKL1 and the luciferase activity of an NF-κB reporter. Furthermore, INKILN knockdown enhances MKL1 ubiquitination through reduced physical interaction with the deubiquitinating enzyme USP10 (ubiquitin-specific peptidase 10). INKILN is induced in injured carotid arteries and exacerbates ligation injury-induced neointimal formation in bacterial artificial chromosome transgenic mice. These findings elucidate an important pathway of VSMC inflammation involving an INKILN/MKL1/USP10 regulatory axis. Human bacterial artificial chromosome transgenic mice offer a novel and physiologically relevant approach for investigating human-specific long noncoding RNAs under vascular disease conditions.

Preexisting Depression and Ambulatory Status After Stroke: Florida-Puerto Rico Collaboration to Reduce Stroke Disparities.

Stroke is a global public health burden, and therefore it is critical to identify modifiable risk factors to reduce stroke incidence and improve outcomes. Depression is such a risk factor; however, the association between preexisting depression and stroke outcomes, such as independent ambulation, is not well studied, especially among racial-ethnic minority groups. To address this gap in the literature, effects of preexisting depression on ambulatory status at hospital discharge after stroke were evaluated among individuals participating in the racially and ethnically diverse Florida-Puerto Rico Collaboration to Reduce Stroke Disparities project. Data were analyzed from a total of 42,031 ischemic stroke patients, who were independently ambulatory prior to their stroke, after discharge from 84 hospitals between 2014 and 2017. Preexisting depression was confirmed by medical history or antidepressant medication use. Multilevel multivariate logistic regression analyses were used to assess the association of preexisting depression with independent ambulation at hospital discharge. Effects of sex and race-ethnicity on this association were examined. Of 42,031 participants (mean±SD age=70.4±14.2 years; 48% were female; race-ethnicity: 16% Black, 12% Hispanic living in Florida, and 7% Hispanic living in Puerto Rico), 6,379 (15%) had preexisting depression. Compared with participants without depression, those with preexisting depression were older, were more likely to be female and non-Hispanic White, and had a greater burden of vascular risk factors or comorbid conditions. Independent ambulation at hospital discharge was less frequent among women, Black participants, and individuals with vascular risk factors or comorbid conditions. In multivariate models, preexisting depression decreased the likelihood of independent ambulation at discharge (odds ratio=0.88, 95% CI=0.81, 0.97). No interactions were found between preexisting depression and race-ethnicity or sex. Preexisting depression was independently associated with dependent ambulation at hospital discharge after stroke, regardless of sex and race-ethnicity. Treating depression may contribute to primary stroke prevention and could improve ambulatory status at discharge.

Lung biopsy in the diagnosis and management of chILD.

Children's interstitial and diffuse lung disease (chILD) comprises a large number of diverse entities ranging from disorders of lung development, maturation and function unique in infancy to immune-mediated, environmental, vascular and other conditions overlapping with adult disease. Pathologic evaluation of the lung has played a central role in characterizing many of these disorders, resulting in revised nomenclature and classifications to help guide clinical management(1-4). Technological advancements are rapidly uncovering genetic and molecular underpinnings of these conditions, as well as widening the phenotypes which bridge adult disease, often reducing the perceived need for diagnostic lung biopsy. As such the decision to get a lung biopsy in chILD is frequently for rapid ascertainment of disease in a critically ill child or when clinical presentation, imaging and laboratory studies fail to provide a cohesive diagnosis needed for treatment. While there have been modifications in surgical procedures for lung biopsy that minimize postoperative morbidity, it remains a high-risk invasive procedure, especially in a medically complex patient(5). Thus, it is essential that the lung biopsy be handled properly to maximize diagnostic yield, including close communication between the clinician, radiologist, surgeon, and pathologist before biopsy to determine best sampling site(s) and prioritization of tissue utilization. This review provides an overview of optimal handling and evaluation of a surgical lung biopsy for suspected chILD, with emphasis on specific conditions in which pathologic features play a critical role in providing an integrated diagnosis and guiding management.

Timing and Preventability of Cardiovascular-Related Maternal Death.

To describe the clinical profile, management, and potential preventability of maternal cardiovascular deaths. We conducted a retrospective, descriptive study of all maternal deaths resulting from a cardiovascular disease during pregnancy or up to 1 year after the end of pregnancy in France from 2007 to 2015. Deaths were identified through the nationwide permanent enhanced maternal mortality surveillance system (ENCMM [Enquête Nationale Confidentielle sur les Morts Maternelles]). Women were classified into four groups based on the assessment of the national experts committee: those who died of a cardiac condition and those who died of a vascular condition and, within these two groups, whether the condition was known before the acute event. Maternal characteristics, clinical features and components of suboptimal care, and preventability factors, which were assessed with a standard evaluation form, were described among those four groups. During the 9-year period, 103 women died of cardiac or vascular disease, which corresponds to a maternal mortality ratio from these conditions of 1.4 per 100,000 live births (95% CI 1.1-1.7). Analyses were conducted on 93 maternal deaths resulting from cardiac (n=70) and vascular (n=23) disease with available data from confidential inquiry. More than two thirds of these deaths occurred in women with no known pre-existing cardiac or vascular condition. Among the 70 deaths resulting from a cardiac condition, 60.7% were preventable, and the main preventability factor was a lack of multidisciplinary prepregnancy and prenatal care for women with a known cardiac disease. For those with no known pre-existing cardiac condition, preventability factors were related mostly to inadequate prehospital care of the acute event, in particular an underestimation of the severity and inadequate investigation of the dyspnea. Among the 23 women who died of a vascular disease, three had previously known conditions. For women with no previously known vascular condition, 47.4% of deaths were preventable, and preventability factors were related mostly to wrong or delayed diagnosis and management of acute intense chest or abdominal pain in a pregnant woman. Most maternal deaths attributable to cardiac or vascular diseases were potentially preventable. The preventability factors varied according to the cardiac or vascular site and whether the condition was known before pregnancy. A more granular understanding of the cause and related risk factors for maternal mortality is crucial to identify relevant opportunities for improving care and training health care professionals.

Abstract 157: Inkiln is a Novel Long Noncoding RNA Promoting Vascular Smooth Muscle Inflammation Via Scaffolding Mkl1 and Usp10

Activation of vascular smooth muscle cells (VSMCs) inflammation is critical in initiation and progression of vascular disease. However, the role of human-specific long noncoding RNAs (lncRNAs) in VSMC inflammation is largely unknown. We performed Bulk RNA-seq in differentiated human VSMCs and revealed a novel human-specific lncRNA called IN flammatory M K L1 I nteracting L ong N oncoding RNA ( INKILN ). INKILN is barely expressed in contractile VSMCs or healthy vessels and induced in human atherosclerosis and abdominal aortic aneurysm. INKILN is transcriptionally activated through p65/NF-κB pathway. INKILN activates proinflammatory gene expression in cultured human VSMCs and in ex vivo cultured vessels. Mechanistically, INKILN physically binds to and stabilizes MKL1 protein, a key activator of VSMC inflammation through the p65/NF-κB pathway. In the IL1β-activated VSMCs, depletion of INKILN blocks the nuclear localization of both p65 and MKL1, and abolishes the physical interaction between these two proteins, resulting in the reduced transactvity of p65/NF-κB. Further, INKILN knockdown enhances MKL1 ubiquitination, likely through the reduced physical interaction with the deubiquitinating enzyme USP10. The in vivo study of INKILN has utilized a Bacterial Artificial Chromosome (BAC) INKILN -Transgenic (Tg) mouse line, due to the lack of non-conserved INKILN gene in the mouse genome. In the ligation-injured carotid arteries of BAC INKILN -Tg mice, human lncRNA INKILN is induced and has exacerbated neointimal formation. In conclusion, these findings elucidate an important pathway of VSMC inflammation involving an INKILN /MKL1/USP10 regulatory axis. Human BAC Tg mice offer a novel and physiologically relevant approach for investigating human-specific lncRNAs under vascular disease conditions.

Inhibition of p90RSK Ameliorates PDGF-BB-Mediated Phenotypic Change of Vascular Smooth Muscle Cell and Subsequent Hyperplasia of Neointima.

Platelet-derived growth factor type BB (PDGF-BB) regulates vascular smooth muscle cell (VSMC) migration and proliferation, which play critical roles in the development of vascular conditions. p90 ribosomal S6 kinase (p90RSK) can regulate various cellular processes through many different target substrates in several cell types, but the regulatory function of p90RSK on PDGF-BB-mediated cell migration and proliferation and subsequent vascular neointima formation has not yet been extensively examined. In this study, we investigated whether p90RSK inhibition protects VSMCs against PDGF-BB-induced cellular phenotypic changes and the molecular mechanisms underlying the effect of p90RSK inhibition on neointimal hyperplasia in vivo. Pretreatment of cultured primary rat VSMCs with FMK or BI-D1870, which are specific inhibitors of p90RSK, suppressed PDGF-BB-induced phenotypic changes, including migration, proliferation, and extracellular matrix accumulation, in VSMCs. Additionally, FMK and BI-D1870 repressed the PDGF-BB-induced upregulation of cyclin D1 and cyclin-dependent kinase-4 expression. Furthermore, p90RSK inhibition hindered the inhibitory effect of PDGF-BB on Cdk inhibitor p27 expression, indicating that p90RSK may induce VSMC proliferation by regulating the G0/G1 phase. Notably, treatment with FMK resulted in attenuation of neointima development in ligated carotid arteries in mice. The findings imply that p90RSK inhibition mitigates the phenotypic switch and neointimal hyperplasia induced by PDGF-BB.

Clinical Applications of Optical Coherence Tomography Angiography in Inherited Retinal Diseases: An Up-to-Date Review of the Literature.

Optical coherence tomography angiography (OCT-A) is a valuable imaging technique, allowing non-invasive, depth-resolved, motion-contrast, high-resolution images of both retinal and choroidal vascular networks. The imaging capabilities of OCT-A have enhanced our understanding of the retinal and choroidal alterations that occur in inherited retinal diseases (IRDs), a group of clinically and genetically heterogeneous disorders that may be complicated by several vascular conditions requiring a prompt diagnosis. In this review, we aimed to comprehensively summarize all clinical applications of OCT-A in the diagnosis and management of IRDs, highlighting significant vascular findings on retinitis pigmentosa, Stargardt disease, choroideremia, Best disease and other less common forms of retinal dystrophies. All advantages and limitations of this novel imaging modality will be also discussed.

P111 Exploratory Analysis of Filgotinib Safety Data in Patients With Moderately to Severely Active Rheumatoid arthritis and an Increased Risk of Cardiovascular Events: Data From Phase 2 and 3 Clinical Trials

Abstract Background/Aims The safety profile of filgotinib (FIL), a second-generation oral Janus kinase (JAK) 1 preferential inhibitor approved in Europe, Japan, and the UK for treatment of rheumatoid arthritis (RA) has been reported. In patients (pts) with active RA aged ≥50y with ≥1 cardiovascular (CV) risk factor, treated with the pan-JAK inhibitor tofacitinib, data from an interventional post-marketing study (NCT02092467) suggested a higher risk of major adverse cardiovascular events (MACE) and malignancies compared with TNF inhibitors. No data are available from a similar prospective study with FIL. This post hoc exploratory analysis aimed to describe the incidence of MACE and malignancies in a subgroup of pts with RA from the FINCH and DARWIN clinical trials, receiving FIL 200 mg (FIL200) and FIL 100 mg (FIL100). Methods Exploratory analysis of adverse events of special interest are reported using integrated FIL RA data from phase 2 (NCT01668641, NCT01894516), phase 3 (NCT02889796, NCT02873936, NCT02886728), and the long-term extension (LTE) studies DARWIN 3 (NCT02065700) and FINCH 4 (NCT03025308), in a pt population at higher risk of CV events similar to ORAL-SURVEILLANCE,1 namely, aged ≥50y with ≥1 CV risk factor (history of dyslipidemia, diabetes or CV disease; hypertension, ischemic vascular conditions, peripheral vascular disease, extra-articular manifestations of RA; or current smokers). All pts met ACR criteria for functional class I-III. Censored exposure-adjusted incidence rates (EAIRs)/100 pt-years of exposure for MACE, venous thromboembolism (VTE), malignancies excluding nonmelanoma skin cancer (NMSC), NMSC, (serious) infections, and deaths were determined. Data were as of Jan 11, 2022 (DARWIN 3) and Jan 31, 2022 (FINCH 4). Analyses were performed on an ad hoc interim analysis data set without additional cleaning. Results The higher-risk population included 1484 pts: mean age 62.1y (536 [36.1%] aged ≥65y), 291 (22.5%) current smokers, and 904 (60.9%) received background MTX; baseline (BL) MTX use was higher in the FIL100 vs FIL200 group (66.6% vs 54.6%); other BL demographics were balanced. Numerically higher EAIRs for malignancies (excluding NMSC), NMSC, serious infections, and deaths were observed for pts receiving FIL200 vs FIL100; 95% confidence intervals overlapped. For MACE and VTE, incidence is considered similar for both doses. The risk of experiencing MACE, malignancies excluding NMSC, and NMSC over time with FIL100 or FIL200 will be described. Conclusion In this RA population at higher risk of CV events, the incidence of MACE and VTE was similar for both doses. A numerically higher incidence of malignancies (excluding NMSC), NMSC, serious infections, and deaths was observed in the high- vs low-dose group. Limitations included population selection bias, low event numbers, and the post hoc nature of the analysis. The ongoing LTE and real-world studies in RA will continue to investigate the safety of FIL in these populations. Disclosure M.H. Buch: Honoraria; MHB has recieved funding (Paid to her host institution) fromAbbVie, Galapagos, Gilead, Pfizer, Eli Lilly, Merck-Serono, Roche, UCB. G.R. Burmester: Honoraria; AbbVie, Galapagos, Lilly, MSD, Pfizer, Roche, UCB, Janssen, Gilead Sciences, Inc. X. Mariette: Honoraria; AstraZeneca, Bristol Myers Squibb, Galapagos, GSK, Novartis, Pfizer. C. Charles-Schoeman: Honoraria; AbbVie, Bristol Myers Squibb (BMS), Pfizer, Regeneron-Sanofi, Gilead. V. Rajendran: Other; Employee of Galapagos NV. P. Stiers: Other; Employee of Galapagos NV. A. Cerani: Other; Employee of Galapagos NV. P. Van Hoek: Other; Employee of Galapagos NV. K. Van Beneden: Other; Employee of Galapagos NV. Y. Tanaka: Honoraria; Lilly, AbbVie, Bristol Myers Squibb, Chugai, Daiichi Sankyo, Eisai, Pfizer, Mitsubishi Tanabe, GlaxoSmithKline, Asahi Kasei, Takeda, Astellas, Janssen, Novartis, Sanofi, UCB, YL Biologics, MSD, Ono, T. H. Schulze-Koops: Honoraria; AbbVie, Galapagos, Lilly, Pfizer. R. Westhovens: Honoraria; Celltrion, Galapagos, Gilead. E. Favalli: Honoraria; AbbVie, BMS, Celltrion, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, UCB.

Asking informed consent may lead to significant participation bias and suboptimal cardiovascular risk management in learning healthcare systems

BackgroundThe Utrecht Cardiovascular Cohort – CardioVascular Risk Management (UCC-CVRM) was set up as a learning healthcare system (LHS), aiming at guideline based cardiovascular risk factor measurement in all patients in routine clinical care. However, not all patients provided informed consent, which may lead to participation bias. We aimed to study participation bias in a LHS by assessing differences in and completeness of cardiovascular risk management (CVRM) indicators in electronic health records (EHRs) of consenting, non-consenting, and non-responding patients, using the UCC-CVRM as an example.MethodsAll patients visiting the University Medical Center Utrecht for first time evaluation of a(n) (a)symptomatic vascular disease or condition were invited to participate. Routine care data was collected in the EHR and an informed consent was asked. Differences in patient characteristics were compared between consent groups. We performed multivariable logistic regression to identify determinants of non-consent. We used multinomial regression for an exploratory analysis for the determinants of non-response. Presence of CVRM indicators were compared between consent groups. A waiver (19/641) was obtained from our ethics committee.ResultsOut of 5730 patients invited, 2378 were consenting, 1907 non-consenting, and 1445 non-responding. Non-consent was related to young and old age, lower education level, lower BMI, physical activity and haemoglobin levels, higher heartrate, cardiovascular disease history and absence of proteinuria. Non-response increased with young and old age, higher education level, physical activity, HbA1c and decreased with lower levels of haemoglobin, BMI, and systolic blood pressure. Presence of CVRM indicators was 5–30% lower in non-consenting patients and even lower in non-responding patients, compared to consenting patients. Non-consent and non-response varied across specialisms.ConclusionsA traditional informed consent procedure in a LHS may lead to participation bias and potentially to suboptimal CVRM, which is detrimental for feedback on findings in a LHS. This underlines the importance of reassessing the informed consent procedure in a LHS.

Spinal Hematoma Visualized with Dual-energy CT-derived Electron Density Overlay Maps.

HomeRadiologyRecently Published PreviousNext Reviews and CommentaryFree AccessImages in RadiologySpinal Hematoma Visualized with Dual-energy CT-derived Electron Density Overlay MapsChristian Nelles, Simon Lennartz Christian Nelles, Simon Lennartz Author AffiliationsInstitute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.Address correspondence to S.L. (email: [email protected]).Christian NellesSimon Lennartz Published Online:Apr 11 2023https://doi.org/10.1148/radiol.222680MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 67-year-old man was admitted to the hospital with spontaneous, sudden-onset, severe thoracic back pain, radiating to the neck and lower back, accompanied by an episode of transient paraplegia of unknown severity, which lasted for 30–45 minutes. Three years prior, he had undergone mechanical aortic valve replacement with resection of an ascending aortic aneurysm associated with a bicuspid aortic valve. Consecutively, he had been treated with phenprocoumon for anticoagulation, with an international normalized ratio value of 4.5 at the time of admission (therapeutic range: 2.0–3.0). As the symptoms raised suspicion for aortic dissection, CT angiography of the chest and abdomen was performed with dual-layer dual-energy CT (dlDECT). dlDECT is a detector-based dual-energy CT technique in which a stacked scintillator registers lower energetic photons in the upper layer, whereas higher energetic photons are detected within the subjacent layer (1). The examination did not show signs of aortic dissection or other acute vascular pathologic conditions. Apart from persistent back pain, the patient’s symptoms receded. He was kept under surveillance for 3 days, after which worsening of the pain and the development of new high-grade paraplegia occurred, prompting an emergency MRI examination of the spine. The MRI scan showed extensive spinal hematoma, ranging from T1 to L1, with the maximum diameter and spinal cord compression at the level of T4-6 but without abnormal signal intensity of the spinal cord (Figure, A). The hematoma could not unequivocally be assigned to either the epi- or subdural space. Additionally, subarachnoid hemorrhage was noted along the cauda equina. The patient underwent successful emergency surgical evacuation of the hematoma, which during surgery showed extension to both the epi- and subdural as well as the subarachnoid space. Because digital subtraction angiography scans showed no vascular cause of the hematoma, spontaneous hemorrhage due to over-anticoagulation was determined as the most likely cause. After surgery, the pain and neurologic symptoms resolved rapidly, and the patient was discharged for subsequent rehabilitation. At retrospective review, different spectral data were reconstructed to determine if any of them might have facilitated earlier diagnosis of spinal hematoma with CT. Besides conventional images, virtual noncontrast and iodine images were also unremarkable. However, electron density overlay maps (Figure, B) clearly depicted the hematoma. The increased content of hemoglobin within the hematoma results in a higher material density at this location with a lesser effect on the average atomic number. There is only one study that showed that electron density maps may improve detection of prevertebral hematoma (2), which is in line with the finding in the case presented here. However, the application for detecting intraspinal hematoma has not been described yet. This might be a promising topic for systematic scientific evaluation, as electron density maps could improve CT-based detection of spinal hematoma in the emergency setting, potentially decreasing morbidity by enabling earlier treatment.(A) MRI scans of the spine in a 67-year-old man. Sagittal T2-weighted (top left) and T1-weighted (top right) images and axial contrast-enhanced, fat-saturated, T1-weighted image (bottom) show extensive spinal hematoma (arrows). The maximum diameter is located at the level of thoracic vertebrae T4-6 with effacement of the perimedullary cerebrospinal fluid and spinal cord compression. (B) Dual-layer dual-energy CT reconstructions show the corresponding CT angiography scans of the chest. Electron density overlay images (left) clearly depict the hematoma (green; arrows) that is protruding in the spinal canal. Conventional images (right) in the sagittal and axial plane. The hematoma is almost entirely imperceivable (arrows).Download as PowerPointOpen in Image Viewer Disclosures of conflicts of interest: C.N. No relevant relationships. S.L. Senior deputy editor for Radiology In Training; member of the Radiology editorial board.

Using Arterial Pulse and Laser Doppler Analyses to Discriminate between the Cardiovascular Effects of Different Running Levels.

Running can induce advantageous cardiovascular effects such as improved arterial stiffness and blood-supply perfusion. However, the differences between the vascular and blood-flow perfusion conditions under different levels of endurance-running performance remains unclear. The present study aimed to assess the vascular and blood-flow perfusion conditions among 3 groups (44 male volunteers) according to the time taken to run 3 km: Level 1, Level 2, and Level 3. The radial blood pressure waveform (BPW), finger photoplethygraphy (PPG), and skin-surface laser-Doppler flowmetry (LDF) signals of the subjects were measured. Frequency-domain analysis was applied to BPW and PPG signals; time- and frequency-domain analyses were applied to LDF signals. Pulse waveform and LDF indices differed significantly among the three groups. These could be used to evaluate the advantageous cardiovascular effects provided by long-term endurance-running training, such as vessel relaxation (pulse waveform indices), improvement in blood supply perfusion (LDF indices), and changes in cardiovascular regulation activities (pulse and LDF variability indices). Using the relative changes in pulse-effect indices, we achieved almost perfect discrimination between Level 3 and Level 2 (AUC = 0.878). Furthermore, the present pulse waveform analysis could also be used to discriminate between the Level-1 and Level-2 groups. The present findings contribute to the development of a noninvasive, easy-to-use, and objective evaluation technique for the cardiovascular benefits of prolonged endurance-running training.

Analysis of factors influencing the values of parameters of intraoperative flowmetry of coronary bypass grafts: retrospective single-center cross-sectional study

Оbjective. This study determines the factors that can affect the value of the parameters of intraoperative flowmetry of coronary bypass grafts.
 Material and methods. TTFM is a routine procedure accompanying coronary artery bypass grafting at the Federal State Budgetary Institution FTSSSh (Penza). This retrospective study included 995 consecutive patients who underwent isolated coronary artery bypass grafting of the left coronary artery. The exclusion criteria were damage to the right coronary artery bed, the emergency nature of the operation, and the combined pathology of the valvular apparatus. Patients who underwent anastomosis revision due to flowmetry parameters changes were also excluded from the study. Intraoperative assessment of coronary artery bypass grafts was performed using VeryQ and MiraQ MediStim flowmeters (Norway).
 Results. A total of 1733 arterial and 479 venous grafts were evaluated. The following factors influenced the average volumetric blood flow velocity value: composite shunting of the border stenosis increases the chance of reducing the volumetric blood flow below the threshold value by 1.841 times (OR=1.841; p=0.018), the combination of occlusion and borderline stenosis with composite shunting increases the chance of reducing the volumetric blood flow velocity by 3.91 times (OR=3.91; p=0.041), an increase in the diameter of the bypassed artery by 1.0 mm reduces the chance of a decrease in blood flow volume velocity by 53.7% (OR=0.423; p=0.05).
 Conclusion. The following factors influence the peripheral resistance index: coronary artery diameter (OR=0.21; p=0.001), degree of artery proximal stenosis (OR=0.987; p=0.034), the vascular wall condition (OR=2.25; p=0.05), type of conduit used (OR=0.298; p=0.002), and shunting method (OR=1.699; p=0.017). The following factors influence the mean volumetric blood flow velocity value: bypass method (OR=1.841; p=0.018), a combination of occlusion and borderline stenosis in composite bypass grafting (OR=3.91; p=0.041), and the bypassed artery diameter (OR=0.423; p=0.423; p=0.05).

Protein Phosphatase 2A Regulates Phenotypic and Metabolic Alteration of Microglia Cells in HFD-Associated Vascular Dementia Mice via TNF-α/Arg-1 Axis.

Protein phosphatase 2A (PP2A), the activity of which is dictated by the composition of its regulatory subunit, is strongly related to the progression of neurodegenerative disease. The potential role of PP2A on the phenotypic transition of microglial cells under obese conditions is poorly explored. An understanding of the role of PP2A and identification of regulatory subunits contributing to microglial phenotypic transitions in obese condition may serve as a therapeutic target for obesity-associated neurodegeneration. C57BL/6 mice were exposed to obese-associated vascular dementia conditions by performing unilateral common carotid artery occlusion on obese mice of microglial polarization and PP2A activity using flow cytometry, real-time PCR, western blotting, and immunoprecipitation enzymatic assay, followed identifications of PP2A regulatory subunits using LCMS and RT-PCR. Chronic HFD feeding significantly increased the populations of infiltrated macrophages, showing a high percentage of CD86+ in VaD mice, and the expression of pro-inflammatory cytokines, and we observed that PP2A modulates metabolic reprogramming of microglia by regulating OXPHOS/ECAR activity. Using Co-IP and LCMS, we identified the six specific regulatory subunits, namely PPP2R2A, PPP2R2D, PPP2R5B, PPP2R5C, PPP2R5D, and PPP2R5E, that are associated with microglial-activation during obesity-associated-VaD. Interestingly, pharmacological up-regulation of PP2A more significantly suppressed the expression of TNF-alpha than other pro-inflammatory-cytokines and increased the expression of Arginase-1, suggesting that PP2A modulates microglial-phenotypic transitions through TNF-α/Arg-1 axis.Our present findings demonstrate microglial polarization in HFD associated with VaD, and point towards atherapeutic target by providing specific PP2A regulatory-subunits implicated in microglial activation during obesity-related-vascular-dementia.

Importance of Combination of Intravitreal Bevacizumab and Panretinal Photocoagulation in Proliferative Diabetic Retinopathy

Introduction: Diabetic retinopathy is a vascular condition of the retina that develops due to diabetes mellitus (DM). This study aimed to compare intravitreal bevacizumab, pan-retinal photocoagulation or a combination of both in proliferative diabetic retinopathy.
 Method: In this prospective, randomized interventional study, 180 patients with PDR were enrolled and divided into three equal groups, i.e., Group A patients treated with laser alone and group B- patients treated with anti-VEGF alone and Group C- patients treated with anti-VEGF and laser. The patient’s detailed history and clinical and demographical data were recorded and compared. The examination was done, including visual acuity assessment with Snellen’s chart, slit-lamp biomicroscopic examination, Intraocular pressure and pupillary assessment for optic nerve dysfunction.
 Results: The mean age of group-A, B and C were 57.13 ± 6.88, 55.62 ± 5.97 and 54.86 ± 4.98 were comparable. At the same
 
 time, most of the patients were between the age group of 58–66 years [25(41.67%)]. Majority of the patients were male in all three groups. A significant difference was observed in mean FBS and duration of diabetes. In group A and C, most patients affected eye was left [35(58.33%)] and [34(56.67)], respectively, while in group B right eye was affected [33(55.00%)]. The mean VA Log MAR was found to be significant among the three groups. Mean SNELLENS and IOP were insignificant among the groups. At first, follow up the mean VA LOG MAR, SNELLENS, FFA and OCT were found to significant among the groups. At second follow-up, the mean VA LOG MAR was significant. Intragroup analysis between the treatment of the eye was found insignificant, while the rest of the parameters and characteristics were found significant. Conclusion: The present study suggests that the anti-VEGF + PRP were the best treatment regime, followed by anti-VEGF, and PRP was the least effective.

ROLE OF DUPLEX ULTRASONOGRAPHY IN DIAGNOSIS OF PERIPHERAL VASCULAR DISEASE IN WESTERN INDIAN POPULATION: A CROSS-SECTIONAL STUDY OF 100 PATIENTS

Peripheral arterial disease (PAD) is a common vascular condition that affects the lower extremities, and its prevalence is increasing worldwide. We studied 100 patients over a period of 9 months to understand the role of duplex ultrasound in peripheral arterial disease and assess the spectrum of vascular disease in western Gujarat population. Duplex ultrasound is a non-invasive imaging modality that plays a crucial role in the diagnosis, evaluation, and management of PAD. This technique combines two types of ultrasound, B-mode and Doppler, to visualize the arterial anatomy and assess blood ow velocities. Duplex ultrasound provides accurate information about the presence and severity of stenosis or occlusion, as well as the hemodynamic signicance of the disease. It can classify PAD based on various parameters, including the ankle-brachial index (ABI) and pulse wave velocity (PWV). Duplex ultrasound is also useful in monitoring disease progression and treatment response. The technique has several advantages over other imaging modalities, including its non-invasive nature, lower cost, portability, and ability to provide real-time imaging during interventions. However, interpreting duplex ultrasound results requires expertise in vascular anatomy and hemodynamics. Overall, duplex ultrasound is a versatile and valuable tool in the diagnosis and management of PAD

Relevance of the Viborg Population Based Screening Programme (VISP) for Cardiovascular Conditions Among 67 Year Olds: Attendance Rate, Prevalence, and Proportion of Initiated Cardiovascular Medicines Stratified By Sex

To report sex-specific overall attendance rate, prevalence of screening detected cardiovascular conditions, proportion of unknown conditions before screening, and proportion initiating prophylactic medicine among 67-year-olds in Denmark. Cross-sectional cohort study. Since 2014, all 67-year-olds in Viborg, Denmark, have been invited to screen for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), hypertension, cardiac disease, and type 2 diabetes. Individuals with AAA, PAD, and/or CP are recommended cardiovascular prophylaxis. Combining data with registries has facilitated estimation of unknown screening detected conditions. Until August 2019, 5 505 had been invited; registry data were available for the first 4 826 who were invited. Attendance rate was 83.7%, without sex difference. Screening detected prevalence was significantly lower among women than men: AAA, 5 (0.3%) vs. 38 (1.9%) (p < .001); PAD, 90 (4.5%) vs. 134 (6.6%) (p = .011); CP, 641 (31.8%) vs. 907 (44.8%) (p < .001); arrhythmia, 26 (1.4%) vs. 77 (4.2%) (p < .001); blood pressure ≥ 160/100 mmHg, 277 (13.8%) vs. 346 (17.1%) (p = .004); and hbA1c ≥ 48 mM/M, 155 (7.7%) vs. 198 (9.8%) (p = .019), respectively. Pre-screening proportions of unknown conditions were particularly high for AAA (95.4%) and PAD (87.5%). Abdominal aortic aneurysm, PAD, and/or CP were found in 1 623 (40.2%), of whom 470 (29.0%) received pre-screening antiplatelets and 743 (45.8%) lipid-lowering therapy. Furthermore, 413 (25.5%) started antiplatelet therapy and 347 (21.4%) started lipid-lowering therapy. Only smoking was significantly associated with all vascular conditions in multivariate analysis: odds ratios (ORs) for current smoking were AAA 8.11 (95% CI 2.27 - 28.97), PAD 5.60 (95% CI 3.61 - 8.67) and CP 3.64 (95% CI 2.95 - 4.47). The attendance rate signals public acceptability for attending cardiovascular screening. Men had more screening detected conditions than women, but prophylactic medicine was started equally frequently in both sexes. Sex-specific (cost-) effectiveness follow up is warranted.

A130 ENDOSCOPIC ULTRASOUND GUIDED THROMBIN INJECTION: A NOVEL TECHNIQUE IN THE MANAGEMENT OF RECURRENT UPPER GASTROINTESTINAL BLEEDING CAUSED BY GASTRODUODENAL ARTERY PSEUDOANEURYSMS

Abstract Background Gastroduodenal artery (GDA) aneurysm is a rare vascular condition that is potentially life-threatening. It is associated with significant morbidity and mortality and most often encountered in patients with chronic pancreatitis. Other etiologies including atherosclerosis, peptic ulcer disease, alcohol abuse, cholecystectomy and absence of celiac axis, have been reported. False and true GDA aneurysms account for about 1.5% of all visceral artery aneurysms however are associated with a risk of rupturing and hemorrhage up to 75%. Mainstay of GDA aneurysm management involves aneurysm repair with open surgery with vessel ligation or endovascular repair with coil embolization or stent placement, depending on the patient’s comorbidities and overall hemodynamic stability. The use of percutaneous thrombin injection via computed tomography (CT) and ultrasound has also been described in the literature and is being increasingly used to promote clot formation and pseudoaneurysm occlusion as a less invasive option. Purpose To present a case of endoscopic ultrasound guided thrombin injection as an effective and safe management strategy for GDA pseudoaneurysms. Method At this time, there are limited data in the literature on endoscopic ultrasound guided thrombin injection for pseudoaneurysms. To our knowledge, this is the first case report describing a patient with recurrent gastrointestinal bleeding from a duodenal ulcer, who had undergone multiple endoscopic and angiographic procedures, with subsequent development of a gastroduodenal pseudoaneurysm unrelated to pancreatitis which was successfully managed by occluding the pseudoaneurysm with thrombin injection under endoscopic ultrasound guidance. EUS guided thrombin injection is a viable alternative to traditional interventional radiology guided thrombin injection for management of pseudoaneurysms. Result(s) In clinic follow-up three weeks after thrombin injection, our patient continued to do clinically well, without abdominal pain or symptoms. Repeat CT angiogram demonstrated the GDA pseudoaneurysm had remained thrombosed, indicating successful endoscopic obliteration. He had no further signs of gastrointestinal bleeding. Conclusion(s) EUS guided thrombin injection is a novel approach that has been presented as an option in the management of bleeding gastroduodenal pseudoaneurysms, especially when radiology guided or surgical options are higher risk or have previously failed. The paucity of available data highlights the need for ongoing clinical studies comparing the different therapeutic strategies that can effectively and safely manage these rare but life-threatening vascular entities. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared