Vascular Events Research Articles

Therapeutic Strategies for Retinal Artery Occlusion—A Literature Review

Retinal artery occlusion (RAO) is an emergency condition causing acute retinal ischemia and is considered an equivalent of ischemic stroke. The occurrence of an episode of RAO is associated with significant impairment of visual functions and correlates with an increased risk of future vascular events. Although RAO requires immediate diagnosis and treatment, there are currently no clear guidelines specifying optimal management. This review discusses current and future therapeutic strategies following an episode of RAO, including secondary prevention.

Abstract 4145821: Serial Vascular Responses of Balloon-expandable Stent with Biodegradable Film-type Graft in a Rabbit Iliac Artery Dissection Model (BioGard Study)

Introduction and Background: Arterial dissection during endovascular therapy rarely occurs but can be lethal. A significant blood volume extravasation during coronary artery interventions is related to the very high mortality (20-30%). In this hyperacute emergent clinical situation, covered stents have been considered as a primary measure to prevent further serious arterial events. A fabric-based covered graft stents yield poor clinical outcomes. To overcome these challenges, the balloon-expandable stent with biodegradable film-type graft for treating arterial dissection was invented. Research Questions and Objectives: A novel balloon-expandable stent with biodegradable film graft for overcoming these issues would be valid for efficacy and safety in a rabbit iliac artery dissection model. Method and Approach: Eighteen iliac artery dissections were induced by balloon over-inflation on angiography (Ellis type 2 or 3) and treated using the test device (3.0 x 24 mm). Subsequently, twelve animals underwent histologic examinations and micro-computed tomography (CT) at 0, 2, 4, and 8 weeks and 3, 6, 9, and 12 months and angiography at one-year. Results and Data: There were no adverse cardiovascular events during the one-year. Early-stage histologic examination revealed complete sealing of disrupted vessels by the device, exhibiting mural hematoma, peri-stent red thrombi, and dense infiltration of inflammatory cells. Mid- and long-term histologic examination showed patent stents with neointimal hyperplasia over the stents (% area stenosis: 11.8 at 2weeks, 26.1 at 1month, 29.7 at 3months, 49.2 at 9months, and 51.0 at 1year), along with mild peri-strut inflammatory response (Grade: 1-2 at mid-term and 0-1 at long-term). The graft film became scarcely visible after six months. Both CT and angiography revealed no instances of thrombotic occlusion or in-stent restenosis (% diameter stenosis: 5.7 at 2weeks, 12.3 at 1month, 14.2 at 3months, 25.1 at 9months, and 26.6 at 1 year). Conclusion: The novel balloon-expandable stent with a biodegradable film graft demonstrates feasibility in managing severe artery dissection and preventing lethal vascular events in animal model. Future human studies are warranted to validate these findings and elucidate the clinical outcomes of the study.

Abstract 4136916: Indobufen: A Viable Alternative to Aspirin for Antiplatelet Therapy in patients with Aspirin Intolerance

Introduction: Antiplatelet therapy with aspirin has been recommended for patients with stroke and myocardial infarction (MI). Clinicians face challenges when they come across aspirin hypersensitivity in their clinical practice. Therefore, potential alternative drugs can help avoid the omission of anti-thrombotic therapy. Indobufen is a cyclooxygenase-1 inhibitor studied as an alternative to aspirin. Hypothesis: Compared to aspirin, indobufen will be equally effective in preventing cardiovascular events in patients needing antiplatelet therapy but will cause fewer bleeding complications. Methods: We systematically searched PubMed, Scopus, and Cochrane Central databases for studies comparing antiplatelet therapy with indobufen vs. aspirin. The efficacy outcomes of interest were composite vascular events, MI, and ischemic stroke. The safety outcomes of interest were major bleeding and any bleeding. Heterogeneity was assessed using I 2 statistics. Analysis followed the PRISMA guideline and was registered in the PROSPERO database (CRD42024540911). Results: The systematic review identified 4 studies, including 11,495 patients (indobufen n=5,728, 49.83%), with two studies in patients post-MI and two post-stroke patients. Composite vascular events at 90 days (RR 1.03; 95%CI 0.58-1.86; p=0.911; I 2 =46%) and 1 year (RR 1.10; 95%CI 0.96-1.27; p=0.184; I 2 =0%) did not show any difference between the groups. MI (RR 0.67; 95%CI 0.36-1.23; p=0.197; I 2 =0%) and ischemic stroke (RR 1.17; 95%CI 0.99-1.38; p=0.064; I 2 =0%) at 1 year did not show any significant difference between the groups. Major (RR 0.68; 95%CI 0.36-1.27; p=0.225; I 2 =74%) and any bleeding (RR 0.62; 95%CI 0.36-1.06; p=0.079; I 2 =91%) at 1 year were also comparable between the groups. Conclusion: Antiplatelet therapy with indobufen was comparable with aspirin in efficacy and safety. Indobufen can be considered an alternative to aspirin in patients with intolerance or hypersensitivity. However, more trials with a larger population are needed to confirm the clinical applicability.

Abstract 4119300: Prevalence and Outcomes of Atrial Fibrillation during Pregnancy and Puerperium

Background: Atrial fibrillation (AF) during pregnancy and puerperium is devastating for the mother and her family, yet data regarding incidence and outcomes are very limited. Objective: We aimed to investigate the incidence and outcomes of AF during pregnancy and puerperium in a large database. The value of the CHA 2 DS 2 -VASc score in predicting adverse outcomes during pregnancy was also assessed. Study Design: The National Inpatient Sample (NIS) database was queried to identify pregnancy-related hospitalizations from 2008 to 2017. Temporal trends in the incidence and outcomes of AF were extracted. The CHA 2 DS 2 -VASc score was calculated for all patients, and the score was classified into three groups: low-risk group (1 point), moderate-risk group (2-3 points), and high-risk group (≥4 points). Results: Among 40,996,860 pregnancy-related hospitalizations, 15,162 (0.037%) were diagnosed with AF. The incidence increased from 2.18 per 10,000 hospitalizations in 2008 to 4.87 per 10,000 in 2017 ( P trend < .0001). The proportion of patients with AF increased with advanced maternal age ( P trend < .0001). Subgroup analysis showed that the incidence of AF was higher in black women, lowest-income households, and elderly parturients ( P trend < .0001). The following factors were significantly associated with AF during pregnancy: age ≥45 years, lipid metabolism disorders, hypertension, obstructive sleep apnea, hyperthyroidism, and valvular disease ( P < .0001). The in-hospital mortality rate of pregnant women with AF was significantly higher than those without AF (OR = 2.26, 95%CI = 1.75-2.93, P < .0001). The mortality rate of AF during pregnancy was positively associated with an increasing CHA 2 DS 2 -VASc score ( P trend < .0001), which was 0.35% (95% CI: 0.24%-0.47%) in the low-risk group, 1.30% (95% CI: 0.98%-1.62%) in the moderate-risk group, and 2.18% (95% CI: 0.86%-3.51%) in the high-risk group. The incidence of stroke, acute myocardial infarction, acute heart failure, and cardiac shock during pregnancy was also significantly correlated with the increasing CHA 2 DS 2 -VASc score in AF patients ( P trend < .0001), with the highest prevalence in the high-risk group. Conclusion: The incidence of AF during pregnancy and puerperium increased consistently, associated with high maternal mortality. The CHA 2 DS 2 -VASc score can be an essential risk stratification tool to predict severe cardio-cerebral vascular events and even death in AF patients during pregnancy and puerperium.

Is retinal vein occlusion highly associated with an increased risk of myocardial infarction? A systematic review and meta-analysis.

Retinal vein occlusion (RVO) and acute myocardial infarction (MI) are significant vascular events that impact patient health and mortality. Both conditions share common risk factors, such as hypertension, diabetes, and atherosclerosis. This study investigated the potential connection between RVO and MI, particularly among younger individuals, to improve preventive measures and management protocols. A systematic review and meta-analysis were conducted, adhering to the PRISMA and MOOSE guidelines. Multiple databases, including PubMed, Scopus, MEDLINE, ScienceDirect, and ClinicalTrials.gov, were exhaustively searched until August 24, 2024. Studies were selected based on their reports of the association between RVO and MI risk. Quality assessment was performed using the Newcastle-Ottawa Quality Assessment Scale, and data were pooled using a random-effects model with hazard ratios and 95% confidence intervals. Twelve studies comprising 371,817 participants were included. Meta-analysis revealed a pooled hazard ratio of 1.324 (95% CI, 1.238-1.415), indicating a significant association between RVO and increased MI risk (p = 0.0001). Subgroup analysis for central retinal vein occlusion (CRVO) showed a hazard ratio of 1.691 (95% confidence interval [CI] 1.142, 2.502, p = 0.009) with moderate heterogeneity (I2 = 36%), whereas branch retinal vein occlusion (BRVO) yielded a non-significant hazard ratio of 1.167 (95% CI 0.843, 2.106, p = 0.444; I2 = 33%). Publication bias was identified (Egger's test, p = 0.036) and addressed through trim-and-fill adjustment, maintaining statistical significance. Our meta-analysis shows a strong association between CRVO and a 69.1% increased risk of MI, while BRVO shows no significant correlation. Overall, RVO is linked to a 32.4% elevated risk of MI. Despite slight publication bias, adjusted analyses confirm reliability, indicating that improved cardiovascular monitoring for RVO patients, especially those with CRVO, is essential to mitigate MI risk. Not applicable.

Chronobiological perspectives and meteorological associations in symptomatic popliteal artery aneurysms

ABSTRACT The potential influence of circadian rhythm, seasonal variations, and alterations in meteorological parameters has been studied across various vascular events. However, there is a lack of evidence on the potential chronobiological impacts on thromboembolic events related to the most common peripheral aneurysm, the popliteal artery aneurysm (PAA). Data was obtained from a German PAA registry and the German Meteorological Service (Deutscher Wetterdienst). In this observational cohort study seasonality and chronobiology as well as associations with meteorological parameters of symptomatic PAA were investigated. In a multivariate logistic regression analysis, it was further analyzed whether meteorological parameters could distinguish asymptomatic from symptomatic patients in the registry. Of 1200 registered PAA, n = 142 PAA presented with acute limb ischemia between February 2011 and September 2022. More symptomatic patients (57.0%) presented to the hospital between January and June than in the second half of the year with a nadir in the fall season. Symptom onset was predominantly in the morning hours (39.5%). Atmospheric pressure and humidity values from the index dates diverged from a normal distribution showing a bimodal (“double-peak”) configuration. Most patients developed symptoms after a reduction in temperatures compared to 1 or 2 d prior to the index date. However, we found evidence for an interaction between age and temperature difference, where the effects of a decreasing temperature fade with increasing age. Facing the complexity of individual-environment interactions, further investigations are needed to determine whether meteorological parameters are true risk modifiers or surrogates for seasonal differences and altered behaviors.

Case report: Acute macular neuroretinopathy post-COVID-19 infection.

Acute macular neuroretinopathy (AMN) is a rare disease that causes transient or permanent visual disturbance. The exact etiology remains unknown, but vascular compromise of the deep retinal capillary plexus was postulated as the main mechanism. Retinal vascular event post-coronavirus disease 2019 (COVID-19) infection is recently highlighted during the pandemic, which includes AMN. To report a case of AMN post-COVID-19 infection. A 24-year-old Indian woman presented with acute-onset painless bilateral central scotoma for a day. The symptom was preceded by a history of COVID-19 infection 3 weeks prior. Ocular examination revealed a near-normal visual acuity for both eyes. Fundus examination showed bilateral dull foveal reflex with mild scattered cotton wool spot and vascular tortuosity. Optical coherence tomography macula revealed a distinct short hyperreflective band involving the outer plexiform and outer nuclear layers nasal to the fovea. The Bjerrum perimetry test revealed central scotoma temporal to the fixation. Optical coherence tomography lesions and scotomas are identical and congruous in both eyes. Serial fundus photographs are captured showing the evolving changes of near-normal macula to pigmented wedge-shaped petaloid lesions around the fovea. The patient was diagnosed as bilateral AMN and treated with oral prednisolone. On subsequent follow-up, the central scotoma improved. This case illustrates a clear temporal and possible causal relationship of COVID-19 infection with AMN. Further studies and data are required to justify its association, but the rising cases of AMN shall be anticipated as COVID-19 infections have become endemic worldwide.

A study of the comparative effectiveness of dual antiplatelet therapy and a combination of acetylsalicylic acid with colchicine in patients in the acute period of “minor” ischemic atherothrombotic stroke during hospitalization. Interim analysis of data from the «COLCHIDA» study

Influence on inflammation is currently becoming a priority target for the prevention of recurrent atherothrombotic events, including stroke. In 2022, we planned the KOLCHIDA study, a two-center, prospective, randomized, open-label, controlled clinical trial with endpoint assessment (ClinicalTrials.gov identifier: NCT06102720). The purpose of this study is to conduct a comparative assessment of the clinical effectiveness of dual antiplatelet therapy with acetylsalicylic acid (ASA) and clopidogrel and the combination of ASA with colchicine in patients in the acute period of “minor” ischemic atherothrombotic stroke. The purpose of this publication is to present the basic concept of the protocol, its design and the first intermediate results. Material and methods. The intervention consisted of colchicine 0.5 mg/day in addition to ASA versus dual antiplatelet therapy (DAPT) in patients with non-severe ischemic stroke. 31 patients were included in the colchicine and ASA group, and 34 patients were included in the DAPT group. Results. In the comparison group, 7 (20.6%) recurrent non-fatal strokes were recorded, in contrast to the colchicine group, where acute vascular events were recorded in only two patients (6.5%) [RRR 2.2, NNT = 7, χ2 = 2, 9, p = 0.09]. There were no clinically significant bleeding or other adverse events in both groups. Conclusion. Interim results of the study indicate possible confirmation of the hypothesis that anti-inflammatory therapy with low doses of colchicine in combination with standard therapy is not inferior to the combination of ASA and clopidogrel, and perhaps more effectively reduces the number of early neurological deteriorations and recurrent ischemic strokes in patients in the acute period of mild atherothrombotic stroke with equal security profile.

Echocardiographic Assessment in Patients with Vascular Ehlers-Danlos Syndrome: Insights from an Unexplored Field.

Vascular Ehlers-Danlos syndrome (vEDS) is an inherited connective tissue disorder characterized by arterial fragility. Celiprolol is a β1-adrenoceptor antagonist with partial β2 agonist activity that has been shown to reduce rates of vascular events in this setting, though the underlying mechanisms are not yet fully understood. Moreover, very few echocardiographic data are available in patients with vEDS. To perform a comprehensive echocardiographic assessment of a cohort of patients with vEDS with or without celiprolol therapy compared with healthy subjects. Twenty patients with genetically confirmed diagnosis of vEDS followed at our Institution (University Hospital of Brescia, Italy) were divided into two groups according to whether or not they were on celiprolol therapy at the maximum recommended dose (400mg daily) for at least 12 months. Both groups were compared to 10 healthy individuals matched for sex, age, body mass index (BMI), and office blood pressure (BP) values. Each participant underwent transthoracic echocardiography with tissue Doppler analysis (TDI) for a comprehensive evaluation of cardiac structure and function. Mean age was 35 years and mean BMI was 21.6 kg/m2. Female sex was prevalent (60%). Left ventricular (LV) internal diameter values tended to be lower in patients with untreated vEDS than in healthy controls (4.33 vs 4.74cm, respectively), though this difference was not statistically significant. Similar data were observed for LV mass index (56.9 vs 68.6 g/m2), stroke volume (56.6 vs 71.6 mL), and E/A ratio (1.26 vs 1.66), whereas an opposite trend was observed for e' lateral (13.2 vs 12.2cm/s). No statistically significant difference was found between groups in terms of other parameters of LV mass, systolic and diastolic function. A normal LV geometry was found in all the cases. Indices of mechano-energetic efficiency and ventricular-arterial coupling were also similar between groups. No patient presented with aortic root dilation, mitral valve prolapse, valve insufficiency of more than mild degree, or valve stenosis of any degree. Our study suggests that patients with vEDS have normal cardiac mass and geometry, as well as normal systolic and diastolic function. Celiprolol therapy does not seem to significantly influence such aspects. Compared with vascular imaging, less stringent follow-up with echocardiography seems reasonable in this setting. Future studies with prospective design should confirm these aspects.

OA27 A Thrombus Tale

Abstract Introduction Non catheter related arterial thrombosis is very rare in children. Our patient had a peripheral arterial thrombus with no risk factors apart from a background of recurrent Henoch-Schönlein Purpura (HSP). He had no history of trauma. Thrombosis as a complication of HSP is extremely rare with onlyeight case reports so far in children and among those eight, there is only one resembling our case with an arterial thrombus. We considered other causes of thrombosis and screened our patient for thrombophilia, infection and malignancy. Case description Our patient, a 12-year-old boy with a background of recurrent HSP for the last two years, presented with a rash on the left 2nd toe followed by blackish discolouration of the distal part of the same toe, a few days later. His initial presentation with purpuric rash, arthralgia, and abdominal pain was diagnosed as HSP and he required no intervention required for this. He continued to have regular flares of his HSP every six weeks, and these were self-limiting. His last flare was in February 2024. In April 2024, his feet appeared dusky and mottled. He presented to his local hospital with a rash on the tip of his left 2nd toe which turned gangrenous. He was otherwise systemically well. He was initially treated with antibiotics and acyclovir as a swab from the lesions grew staphylococcus aureus and the rash was bullous initially. He was referred to our tertiary rheumatology and haematology teams at Nottingham due to worsening ischemia and an absent left dorsalis pedis pulse. His examination revealed normal blood pressure, mottled, dusky lower legs, warm left foot with a faint petechial rash near left malleolus, absent left Dorsalis pedis pulse and an ischemic tip of left 2nd toe. Bilateral femoral and upper limb pulses were well felt. His respiratory, cardiovascular, abdomen & musculoskeletal examination were normal apart from an antalgic gait. His clotting and thrombophilia screen including antiphospholipid screen was normal. His D dimer was raised at 1894ug/l. A duplex scan of his left leg showed occlusions in the distal anterior and posterior tibial artery as well as in the dorsalis pedis artery with no emboli. His inflammatory markers and autoantibodies were normal. Infection screen including mycoplasma, CMV, EBV and ASOT titres were all negative. Echo was normal. A skin biopsy from the toe revealed IgA vasculitis. Discussion We had a multidisciplinary team (MDT) discussion with haematology, vascular surgery and dermatology. As per the MDT discussion, he was given a pulse of intravenous methylprednisolone after careful consideration weighing the risk versus benefit of steroids adding to the pro thrombotic state versus active vasculitis causing narrowing of the arteries. He was also commenced on Aspirin at 1 mg/kg/day. There was marked improvement in his symptoms with improvement in the discolouration and pain, his d-dimer reduced, and he was able to mobilise comfortably. We felt that active vasculitis could be causing the vascular event. As immunology screen was negative and the skin biopsy was confirmatory of HSP. There was no thrombus specifically mentioned in the duplex but with D-dimer being raised it was a reasonable assumption was that there was a thrombus occluding the peripheral arteries. As his HSP was recurring quite frequently and was bothersome, as well as the thought that the recurrences might contribute to further vascular events and complications, we started our patient on Azathioprine. We have also sent genetic tests and awaiting a catheter angiogram to complete the investigation process. Key learning points • Consider vasculitis as one of the differentials in a child with unexplained venous or arterial thrombosis. • In a child with recurrent HSP, keep an open mind for rare complications that may occur. • Recurrent HSP in an older child may need immunosuppression. • Treatment considerations in a case with vasculitis with a thrombus has to be in close connection with haematology to decide on anticoagulation and its implications on the young person and their lifestyle. • Should there be any other investigations done or alternative diagnosis though of at this point?

Efficacy of Dual Antiplatelet therapy after Ischemic Stroke According to hsCRP Levels and CYP2C19 Genotype

BackgroundBoth high-sensitive C-reactive protein (hsCRP) and CYP2C19 genotypes are independent predictors of clinical outcomes after ischemic stroke. We aim to evaluate the association of CYP2C19 loss-of-function alleles (LoFA) carrying status with the effects of dual/single antiplatelet therapy at different hsCRP levels using the CHANCE trial. MethodsSubjects with both of CYP2C19 major alleles information (*2, *3, and *17) and hsCRP measurements were enrolled from the prespecified subgroup. CYP2C19 LoFA carriers were defined as patients with either*2 or *3 allele. Cox proportional hazards models were used to assess the interaction of CYP2C19 LoFA carrying status with the effects of dual/single antiplatelet therapy at different hsCRP levels. The primary outcome was recurrent stroke within 90 days. ResultsAmong 2801 patients, 1646 (58.8%) were LoFA carriers, and 922 (32.9%) had elevated hsCRP. In patients with non-elevated hsCRP, there was a significant interaction effect between CYP2C19 LoFA carrying status and dual/single antiplatelet regimens for prevention of recurrent stroke and combined vascular events (p =0.048, 0.048, respectively), but, not in patients with elevated hsCRP (p =0.502, 0.472, respectively). Only among patients with non-elevated hsCRP and non-carrier of CYP2C19 LoFA, dual antiplatelets significantly reduced the risk of recurrent stroke compared with aspirin alone (hazard ratio= 0.44 [0.26-0.74], p=0.003). No significant differences in bleeding were found. ConclusionsNon-elevated hsCRP and non-carrier of CYP2C19 LoFA may predict a better response to dual antiplatelet therapy in reducing stroke recurrence and composite vascular events for patients with minor stroke and high-risk TIA. TRIAL REGISTRATIONclinicaltrials.gov Identifier: NCT00979589

Association of testosterone replacement therapy with atrial fibrillation and acute kidney injury.

Secondary analyses of the Testosterone Replacement Therapy for Assessment of Long-Term Vascular Events and Efficacy Response in Hypogonadal Men (TRAVERSE) trial revealed significantly higher rates of new-onset atrial fibrillation (AF) and acute kidney injury (AKI) in the testosterone replacement therapy (TRT) cohort. To validate the secondary findings of the TRAVERSE trial. We utilized the TriNetX Research Network to identify a cohort of men ages 45-80years old who met similar inclusion criteria to the TRAVERSE trial. We compared hypogonadal men (testosterone 100-300ng/dL) who had a prescription for topical testosterone therapy and men who did not. Propensity score matching was used to match patient populations. Kaplan Meier survival analysis was used to determine the relative risk of new-onset AF and AKI within 3years. New-onset AF and AKI within 3years. There were 2134 men included in each cohort after propensity score matching. Men on TRT had significantly lower testosterone (T) at the time of diagnosis compared to men not prescribed TRT (207 ± 66ng/dL vs 246 ± 140ng/dL, P< 0.001). Kaplan-Meier survival analysis showed a significantly increased risk of AKI among men on TRT (RR 1.53, 95% CI 1.07-2.18). However, TRT was not associated with a significantly increased risk of new-onset AF (RR 1.48, 95% CI 0.93-2.37). Hypogonadal men with underlying cardiovascular risk factors or pre-existing cardiovascular disease who receive TRT may be at increased risk of AKI after starting therapy. We evaluated a large global research database and utilized similar inclusion and exclusion to the TRAVERSE trial. However, our results are limited by the retrospective study design and reliance on documented claims data. Similar to the TRAVERSE trial, our study demonstrated an increased risk of AKI among men on TRT, but did not find increased risk of AF. However, further studies are required to validate these results.

Retinal vascular events and relationship to CANCER development

BackgroundCentral retinal vein occlusion (CRVO) is a frequent and clinically relevant vascular pathology. The main risk factors are the same as systemic cardiovascular risk factors, but recently other significant risk factors have been studied. The aim of this study is to analyse the risk factors for retinal venous thrombosis and their relationship with the development of cancer. Methods710 patients with retinal vascular pathology were included, of whom 527 had suffered retinal venous thrombosis. Patients were followed up in internal medicine outpatient clinics between September 24, 1999, and April 30, 2022. The incidence of cancer during that time was collected. ResultsOf 527 patients evaluated, 448 (86.7 %) presented cardiovascular risk factors, and 89 (17.2 %) developed some neoplasm, being the most frequent: prostate (19.1 %), colon (16.9 %), skin (12.4 %), breast (9.0 %). Retinal venous thrombosis was related to the development of neoplasms during follow-up time (Log Rank = 5.28, p = 0.022; Breslow = 4.84, p = 0.028). Other significant factors were age above the median, smoking, HbA1c levels, and homocysteine levels higher than the median, and cholesterol and LDL-Cholesterol lower than the median. Age above the median (p < 0.001), smoking (p = 0.003) and levels of cholesterol below the median (p = 0.026) were independently related to the development of neoplasms. ConclusionsRetinal venous thrombosis is associated with the development of cancer. Other factors related to its development have been identified. If this is confirmed, the implications for the diagnosis, control, and treatment of these patients should be evaluated.

An Umbrella Literature Review on Aortopathy and Fluoroquinolone Use

Background: Aortic dissection and aortic rupture are critical vascular events often predisposed by aneurysmal dilation of the aorta. The use of fluoroquinolone has been associated with aortic dissection and aortic rupture, necessitating a careful clinical review before use. Despite black box warnings, fluoroquinolones continue to be one of the commonly prescribed antibiotics. Critical care providers, specifically those who work in close association with high-volume aortic centers, can play an active role in antibiotic stewardship in the use of fluoroquinolones in patients with a known or predisposition to aortopathy. Aim: This paper provides a brief review of the potential effects of fluoroquinolones on the development of aortic aneurysm, dissection, and or rupture and the cautions to be exercised when using fluoroquinolones, especially in people who are predisposed to developing aortopathies. Methods: A rapid umbrella review was conducted on the effects of fluoroquinolones on aortopathy and the potential for acute aortic events associated with their use. The PICO (Population, Intervention, Comparator, Outcome) strategy coined the research question. It is as follows: In patients with known aortopathy or a known risk of aortopathy, what are the risks of an acute aortic event from taking fluoroquinolones compared to other antibiotics? A meta-analysis was done with selected studies utilizing a random effects model (utilizing Statsdirect software), which showed a pooled effect that favored the association of fluoroquinolones with aortopathy. Findings: Meta-analysis results showed a pooled effect that favored the association of fluoroquinolones with aortopathy. Discussion: Fluoroquinolone use potentiates the risk of developing aortic aneurysm and aortic dissection. Despite published evidence and warnings from manufacturers and regulatory bodies, fluoroquinolone use continues to be a covert contributor to the development of aortopathy. Conclusion: The literature reports multiple instances of fluoroquinolone-induced aortopathy. As such, fluoroquinolones should be reserved for use in situations where their benefits clearly outweigh the risks.

Perivascular Neutrophil Extracellular Traps Exacerbate Microvasospasm After Experimental Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) can lead to acute or delayed cerebral ischemia. Recent findings have revealed that spasm of microvessels, called microvasospasm, may contribute to SAH-related cerebral ischemia, and perivascular inflammation is considered important in the development of microvasospasms. However, owing to the difficulty in investigating the dynamics of vascular and perivascular events, little is known about the mechanisms underlying microvasospasms. We established an experimental system aiming to investigate the vascular and perivascular pathology of SAH by combining a SAH mouse model with intravital 2-photon imaging. SAH was induced by intracisternal blood injection, and the distribution of erythrocytes, neutrophil behavior, and morphological changes in the pial arterioles were analyzed over time by 2-photon microscopy imaging. To further explore the role of neutrophils and neutrophil extracellular traps (NETs) in microvasospasm, we performed neutrophil depletion by intraperitoneal administration of neutrophil-specific antibody or NETs removal by intracisternal administration of DNase. Erythrocytes were immediately distributed in the perivascular space of the arterioles after SAH induction; neutrophils intensively infiltrated the perivascular space within 2 days and subsequently showed NETosis; and pial arterioles in the same region developed pearl-string-like microvasospasms in the subacute phase. Neutrophil depletion significantly reduced the number of microvasospasms. Furthermore, the removal of perivascular NETs drastically reduced microvasospasms. By establishing a unique experimental system, we demonstrated that perivascular NETs could be a new therapeutic target for microvasospasms.

A diagnosis of vascular ehlers-danlos syndrome in childhood: clinical and molecular features of 63 individuals

Abstract Background Vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited connective tissue disorder characterised by generalised severe tissue friability and predominantly caused by pathogenic COL3A1 variants. Diagnosis of vEDS in childhood primarily occurs due to a positive family history and/or the occurrence of an early arterial or intestinal event. However, little has been reported on additional clinical characteristics and management in this population. Purpose This study aims to identify critical drivers of a childhood vEDS diagnosis in individuals diagnosed through a national EDS service. Methods 63 individuals (24 index, 31 females) with a clinical and genetic diagnosis of vEDS in childhood (&amp;lt; 18 years) were identified through a national EDS service, and childhood cardiovascular surveillance was conducted through joint inherited cardiovascular disease clinics. Results Diagnosis of vEDS in childhood occurred at a median age of 7 years (IQR 3-12) and was predominantly driven by positive family history of vEDS (55.5%). Clinical investigations were directly initiated by occurrence of a major clinical event in n=13 (20.6%), and a total of 17 major clinical events in childhood were recorded in 13 individuals. First events occurred at a median age of 11 years (IQR 0-13) and vascular events, though infrequent, occurred as early as the first year of life. In individuals who did not have a positive family history or major event, easy and/or excessive bruising was the most frequent cause for referral (60%). Conclusions This cohort provides further details of the clinical and genetic characteristics of children with vEDS and contributes new insight into drivers of vEDS diagnosis in childhood and the importance of long-term management, including paediatric cardiovascular surveillance.

Safety and efficacy of brachial approach for coronary angiography and percutaneous coronary intervention

Abstract Background There are many feasible ways to reach the coronary arteries through a percutaneous technique. Till now, the most commonly used approach is the radial artery approach because it has the lowest risk of known vascular adverse events. However, it could not be an option in some situations as congenital radial artery hypoplasia and radial artery spasm. In these cases, the second most common access is the femoral artery access. The current literature over the brachial artery access is controversial. Our study's objective is to verify the brachial artery approach's effectiveness and safety. Methods We studied 300 patients who underwent elective coronary angiography and percutaneous angioplasty in our institution with failed radial access between August 2022 and February 2023. They were classified into two groups; 150 patients in a group with brachial access and 150 in a group with femoral access. Baseline clinical and demographic traits of all enrolled patients were obtained from hospital records and the cardiovascular risk factors were identified. Venous blood samples, resting 12-lead electrocardiogram and transthoracic echocardiography were done before the coronary angiography. Access, procedural and fluoroscopy times were recorded. Doppler evaluations of both brachial and femoral arteries were done the day after the procedure. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Results Our data showed that no statistically significant difference between the studied groups regarding the cardiovascular risk factors, demographic, clinical and laboratory characteristics. Left brachial access was used more frequently than left femoral access (32.7% vs. 22.7%, p= 0.05), but no significant difference regarding right sided or bilateral access. Procedure time, fluoroscopy time, and contrast volume did not differ significantly (p=0.19, 0.06 and 0.1 respectively). However, brachial group had shorter access time (2.6 ±1.1 vs. 3.4 ± 0.7 minutes, p=0.05) and shorter hospital stay (3.5 ± 1.1 vs. 5.9 ± 1.3 days, p&amp;lt;0.001). Regarding complications, both major and minor complications were significantly lower in the brachial arm (p=0.04 and 0.05, respectively). Conclusion Brachial artery access is a safe, efficient alternative and non-inferior to the femoral route for coronary intervention whenever radial access is not an option.

Intracardiac vs transesophageal echocardiography for percutaneous LAA occlusion: a meta-analysis

Abstract Background Percutaneous left atrial appendage occlusion (LAAO) is typically performed under the guidance of transesophageal echocardiography (TEE) and fluoroscopy. Intracardiac echocardiography (ICE) appears to be a potential alternative to guide implantation. Purpose We sought to perform a meta-analysis comparing ICE and TEE for endocardial LAAO. Methods A comprehensive literature search was performed in PubMed and Google Scholar regarding published abstracts and manuscripts on July 1, 2023. Studies reporting clinical outcomes comparing ICE vs TEE for endocardial LAAO were included. Results A total of 16 studies with 123,444 patients (ICE-5,122 patients and TEE-122,667 patients) (mean age 75±4 years, 59%male) fulfilled the criteria. Five included Watchman, four included the Amplatzer Cardiac Plug/ Amulet device, and seven included both devices. There was no significant difference in CHA2DS2VASC or HAS-BLED scores between both groups. Outcomes assessed including procedural success between ICE vs TEE (risk ratio [RR], 1.01; 95% CI, 1.00-1.01), fluoroscopy time (mean difference [MD], 1.25 minutes; 95% CI, -1.63- 4.14) and total procedure time (MD, −3.74 minutes; 95% CI, − 13.42-5.94) were found to be similar between both groups. There was also no significant difference in complications including vascular complications, bleeding events, device embolization, and stroke between both groups. Of note, patients undergoing LAA closure under ICE guidance had higher risk for pericardial effusion and/or cardiac tamponade compared to those in the TEE group (RR 1.72; 95% CI, 1.32-2.23). Conclusions Although TEE is the gold standard for perioperative guidance of LAAO, imaging with ICE is a feasible alternative associated with similar efficacy outcomes in LAAO procedures. However, further studies needed to clarify safety of ICE as an alternative perioperative imaging technique.

In-hospital outcomes of ventricular tachycardia catheter ablation in the presence of intra-cardiac thrombus

Abstract Background Ventricular tachycardia (VT) catheter ablation in the presence of intracardiac thrombi was evaluated in very few studies. Objectives To investigate in-hospital outcomes of VT ablation in the presence of an intracardiac thrombus, in a large inpatient US registry. Methods Using the National Inpatient Sample (NIS) database, patients who underwent non-elective VT catheter ablations in the US between 2016 and 2019 were identified using ICD-10 codes. Sociodemographic, clinical data, in-hospital procedures and outcomes as well as in-hospital mortality were collected. In-hospital outcomes were compared using propensity score (PS) matching analysis with a 1:3 ratio between patients with and without intracardiac thrombus. Results A weighted total of 15,725 admissions for non-elective VT ablation were included in the study, of which 190 (1.2%) had a discharge diagnosis of intracardiac thrombus. Patients with intracardiac thrombus had a higher comorbidity burden and were more likely to have ischemic cardiomyopathy and a diagnosis of cardiac aneurysm. In PS analysis, the presence of intracardiac thrombus was significantly associated with higher rates of any in-hospital complications (42.1% vs 19.3%, P&amp;lt;0.009), driven by higher periprocedural cerebrovascular accident and vascular injury events. In-hospital mortality rates were not significantly different between the groups. Conclusions In patients undergoing non-elective VT ablation, intracardiac thrombus was associated with higher rates of in-hospital complications, but not higher in-hospital mortality. These findings suggest that intracardiac thrombus should not contraindicate VT ablation when deemed necessary, while efforts should be made to decrease potential complications.

Systemic inflammation in patients with atherosclerotic cardiovascular and chronic kidney disease in Spain: a population-based study using electronic medical records from a primary care database

Abstract Background Systemic inflammation (SI) is recognized as a critical driver of atherosclerotic cardiovascular disease (ASCVD), and it is frequently observed in ASCVD patients with comorbid chronic kidney disease (CKD). Elevated C-reactive protein (CRP) levels, a common biomarker for SI, have been associated with poor prognosis in ASCVD and CKD patients, increased risk of major adverse cardiovascular events and renal disease progression, as well as greater mortality. Purpose To estimate the prevalence of SI in patients with ASCVD in Spain overall and by CKD status, and to describe patients’ clinical characteristics. Methods In this population-based observational study, data from THIN Spain, a database of electronic medical records from a large network of general practitioners, were used to identify adult patients with a diagnosis code of ASCVD (atherosclerotic coronary or cerebrovascular event, peripheral arterial disease, or other atherosclerotic vascular event) and ≥1 eligible CRP measurement between January 1st 2014 to July 31st 2023 (latest data available at time of data extraction).[Figure] SI was defined as CRP ≥ 2mg/L. Point prevalence of SI at the end of the study (among patients alive with ≥1 CRP in the prior 18 months) and the proportion of patients with evidence of SI during the study period (2014-2023) were estimated overall and by CKD status (defined as CKD stage 3+, or eGFR &amp;lt;60 mL/min/1.73m², or urinary albumin-to-creatinine ratio ≥30 mg/g). Patients’ comorbidities (defined using primary care diagnoses), and laboratory values were reported by SI status at first CRP measurement during the study period. Results Among 76,423 patients with ASCVD diagnosis, 15,798 patients (20.7%) were included in the study (mean age: 71.1 years; 43% females), of whom 5,111 (34%) had CKD at first eligible CRP (n=975 with unknown CKD status). Mean CRP in ASCVD patients with CKD was 24% higher than in those without CKD (4.36 vs 3.53 mg/L, p&amp;lt;0.001). The proportion of ASCVD patients with SI at first CRP measurement was 58% overall (65% among CKD patients; 55% among patients without CKD; p&amp;lt;0.001). The point prevalence of SI at the end of the study was 56% among ASCVD patients overall (62% among CKD patients; 52% among patients without CKD; p&amp;lt;0.001), while 64% of ASCVD patients had evidence of SI at any time during the study period (72% among CKD patients; 59% among patients without CKD; p&amp;lt;0.001). Compared to ASCVD patients without SI, higher proportion of SI patients were smokers and with comorbidities. Also, ASCVD patients with SI had lower baseline eGFR levels and higher levels of LDL-C and triglycerides than ASCVD patients without SI.[Table] Conclusions SI prevalence is high among patients with ASCVD in Spain, especially among patients with comorbid CKD. Strategies to target SI may have beneficial effects in prevention of cardiovascular events and mortality in ASCVD patients.