Rapid Arterial Occlusion Evaluation (RACE) Tool in Detecting Large Cerebral Vessel Occlusions; a Systematic Review and Meta-Analysis

Introduction

Large vessel occlusion (LVO) strokes are linked to higher mortality rates and a greater risk of long-term disability. This study aimed to evaluate the diagnostic performance of the Rapid Arterial Occlusion Evaluation (RACE) tool in detecting LVO through a systematic review and meta-analysis.

Methods

A comprehensive search was conducted across online databases including PubMed, Embase, Scopus, and Web of Science, up to June 25th, 2023. Additionally, a manual search on Google and Google Scholar was performed to identify studies that assessed the diagnostic accuracy of the RACE scale in detecting LVO among patients with stroke symptoms.

Results

Data extracted from 43 studies were analyzed. The optimal cut-off points were determined to be 3 and 4, with a sensitivity of 0.86 (95% confidence interval (CI): 0.78, 0.91) and specificity of 0.57 (95% CI: 0.49, 0.67) for cut-off ≥3, and a sensitivity of 0.78 (95% CI: 0.70, 0.84) and specificity of 0.68 (95% CI: 0.59, 0.75) for cut-off ≥4. Subgroup meta-regression analysis revealed significant variations in sensitivity and specificity. RACE scale's sensitivity was significantly higher in LVO detection in suspected stroke cases, in pre-hospital settings, prospective design studies, and when considering both anterior and posterior occlusions for LVO definition. RACE scale's specificity was significantly higher when evaluating confirmed stroke cases, in-hospital settings, and considering only anterior occlusions for LVO definition and retrospective design studies. Notably, RACE exhibited higher sensitivity and specificity when utilized by neurologists and physicians compared to other emergency staff. Despite these variations, our study found comparable diagnostic accuracy across different conditions.

Conclusion

A high level of evidence indicates that the RACE scale lacks promising diagnostic value for detection of LVOs. A sensitivity range of 0.69 to 0.86 is insufficient for a screening tool intended to aid in the diagnosis of strokes, considering the substantial morbidity and mortality associated with this condition.

Early Diagnosis and Intervention Are Needed for a Reasonable Prognosis of Thromboangiitis Obliterans

Background

Thromboangiitis obliterans (TAO) poses a higher risk of amputation than atherosclerosis obliterans. It is characterized by onset at a relatively young age. There are currently no clear treatment guidelines for TAO other than smoking cessation. In this study, we aimed to identify factors that could influence a favorable prognosis of TAO.

Methods

From January 2009 to December 2019, we retrospectively reviewed the initial symptoms, characteristics, treatments, and disease course of 37 patients (45 limbs) with TAO. Logistic regression analysis was performed to investigate factors affecting the course of symptoms that persisted or worsened despite treatment.

Results

Patients' mean age was 37.2±11.4 years, and all patients were men. The mortality rate was 0% during the follow-up period (76.9±51.1 months). All patients were smokers at the time of diagnosis, and 19 patients (51.4%) successfully quit smoking during treatment. When comparing the Rutherford categories before and after treatment, 23 limbs (51.1%) showed improvement, the category was maintained in 11 limbs (24.4%), and 11 limbs (24.4%) worsened. Symptom persistence or exacerbation despite treatment was associated with a higher initial Rutherford category (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.04-2.42; p=0.03) and a higher score of the involved below-knee artery at the time of diagnosis (OR, 2.26; 95% CI, 1.10-4.67; p=0.03).

Conclusion

The degree of disease progression at the time of diagnosis significantly affected patients' prognosis. Therefore, early diagnosis and intervention are important to improve the course of TAO.

Acute ischemia secondary to popliteal artery stent fracture and embolization

Femoropopliteal disease comprises more than one half of lesions in peripheral vascular disease. The treatment modalities for stenosis or occlusion of this anatomic region include femoropopliteal bypass and percutaneous transluminal angioplasty with or without stenting. Our patient developed acute leg ischemia 3 years after stenting, secondary to stent fracture, with distal embolization of stent fragments. Using mechanical thromboembolectomy and superficial femoral artery to below-the-knee popliteal in situ saphenous vein bypass, we were able to restore perfusion to the limb and retrieve fragments of the fractured stent.

Contralateral brachial arterial access for endovascular treatment of recurrent axillofemoral bypass graft stump syndrome: A case report

Axillofemoral bypass graft stump syndrome is an uncommon complication of axillofemoral bypass graft surgery. The traditional treatment is open surgical repair; however, endovascular recanalization can be achieved. Interventional treatment by approaching the brachial artery contralateral to the lesion site has rarely been reported in acute upper extremity ischemia. We report a case of recanalization through the left brachial artery due to embolic occlusion of the right brachial and axillary arteries and suspected axillofemoral bypass graft stump syndrome in a 71-year-old man. Access through the common femoral artery was impossible because the patient underwent reoperation of the left axillofemoral bypass and femorofemoral bypass due to occlusion of the right axillofemoral bypass and femorofemoral bypass surgery. Furthermore, bilateral radial arteries were occluded, allowing access to the left brachial artery. Two self-expandable stents were inserted into the occlusion of the right brachial and axillary arteries, and the stump area was covered. Aspiration thrombectomy was performed for embolism in the ulnar artery. Axillofemoral bypass graft stump syndrome can also be treated with interventional management. If access to the bilateral common femoral and radial arteries is not possible, an upper extremity arterial procedure through the contralateral brachial artery may be considered in cases of steno-occlusion of the upper extremities.

JAK2 allele burden is correlated with a risk of venous but not arterial thrombosis

BACKGROUND

Thrombosis is the main complication in myeloproliferative neoplasms (MPN). A JAK2V617F mutation has been shown to be a risk factor for thrombosis. The implication of other risk factors alongside a mutation allele burden needs to be clarified (Trifa et al., 2018; Borowczyk et al., 2015).

OBJECTIVE

Our aim was to investigate the role of the JAK2 mutation allele burden in the risk of cardiovascular events (CVE) and/or venous thrombosis (VTE) in a cohort of patients with confirmed MPN, as well as in patients without confirmed MPN.

METHODS

We restrospectively included all consecutive patients who were positive for JAK2V617F seen by our unit between December 2008 and September 2016. Inclusion criteria were a positive test for the JAK2V617F mutation, with at least 1% allele burden, with or without confirmed MPN.

RESULTS

We included 239 patients of median age 71 years [60-81], followed-up for a median of 82.8 months [41.08-146.88]. For JAK2V617F positive patients having an allele burden superior to 50% the cumulative incidence of VTE was significantly higher than for those with an allele burden inferior to 50% (HR 3.11 95% CI [1.10-8.76] p = 0.031). The cumulative incidence of VTE was also higher in patients with obesity (HR 4.58 95% CI [1.33-15.8] p = 0.016). There was no significant association between a JAK2V617F allele burden and arterial thrombosis (manifesting as CVE). Previous VTE was also associated with a higher cumulative incidence of recurrence during follow-up HR 3.22 95% CI [1.17-8.81] p = 0.0231.

CONCLUSION

We show that a JAK2V617F allele burden is associated with risk of VTE but not with CVE.

Staged Hybrid Treatment with Branched Endovascular Aneurysm Repair of a Thoracoabdominal Aortic Aneurysm in the Presence of a Total Infrarenal Aortoiliac Occlusion

Aortoiliac occlusive disease may limit the use of branched endovascular aneurysm repair (BEVAR) of thoracoabdominal aneurysms (TAAAs). Thus, infrarenal aortoiliac occlusion may preclude the use of BEVAR. We present a case involving a 67-year-old patient with a fast-progressing TAAA (diameter: 70 mm) and a concomitant total aortoiliac occlusion. A multi-staged treatment concept included the creation of the access and the distal landing zone for the consecutive endovascular procedures through an aorto-right femoral-left popliteal bypass. At six-week intervals, thoracic endovascular aortic repair for the creation of the proximal landing zone and a 4-vessel BEVAR were accomplished. At 36 months, a type III endoleak occurred due to the fracture of the bridging stent-graft to the celiac trunk and the superior mesenteric artery. It was successfully treated with VBX stent-grafts. This case illustrates the importance of a staged hybrid approach in the management of complex aortic pathologies with poor access and insufficient distal landing zone.

Popliteal artery entrapment syndrome

Popliteal artery entrapment syndrome (PAES) is an uncommon cause of lower extremity exertional claudication due to external compression of vascular structures in the popliteal fossa. A developmental anomaly due to an aberrant relationship of the artery with the surrounding myofascial structures contributes to the vascular compromise. PAES presents in younger, athletic patients without atherosclerotic risk factors. Typical presentation of unilateral or bilateral, intermittent claudication in the feet and calves specifically after exercise and relieved by rest in a young person should prompt further evaluation. Early diagnosis and intervention is essential for preventing thromboembolic complication and in worst cases limb loss. Initial tests with Ankle Brachial indices or Doppler ultrasound with provocative maneuvers will prompt more definitive cross sectional imaging studies. CTA or MRA also with provocative maneuvers has a high sensitivity and specificity and will clinch the diagnosis. There are six subtypes based on the relationship of the vascular structure with surround myofascial structures. CTA and MRA can characterize the subtypes and guide surgical planning. Catheter directed thrombolysis may be attempted adjunctively to reduce surgical thrombectomy or resolve distal emboli; however, myotendinous decompression with or without vascular repair is the definitive treatment. Long term surgical outcomes are satisfactory when the distal circulation is preserved.

A meta-analysis of the diagnostic performance of quiescent-interval-single-shot magnetic resonance angiography in peripheral arterial disease

OBJECTIVES

To evaluate by meta-analysis the diagnostic accuracy of non-contrast quiescent-interval-single-shot (QISS) magnetic resonance angiography (MRA) in patients with peripheral arterial disease (PAD) using digital subtraction angiography (DSA) or contrast-enhanced magnetic resonance angiography (CE-MRA) as reference standard.

METHODS

This study was performed and reported according to the Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. A systematic literature search of MEDLINE, Embase and Scopus was done for studies reporting the diagnostic accuracy of QISS in PAD published up to 31 May 2021. The pooled sensitivity, specificity and diagnostic accuracy of QISS were calculated on a per-segment basis for the entire arterial tree.

RESULTS

Seventeen studies including 459 patients were found eligible for the meta-analysis. There was significant heterogeneity among studies as depicted by chi-square test (p = 0.02) and moderate heterogeneity by I² statistic (I²: 69 [95% CI: 30-100]). The pooled sensitivity and specificity of QISS on a per-segment basis with DSA/CE-MRA as reference standard was 0.88 (95% CI: 0.85-0.91) and 0.94 (95% CI: 0.92-0.96) respectively. The area under hierarchical summary receiver-operating characteristic reflected a high accuracy of 0.96 (95% CI: 0.94-0.98). There was a low likelihood of publication bias as indicated by Deeks' funnel plot.

CONCLUSIONS

The present meta-analysis has consolidated the evidence that QISS has high accuracy for identifying as well as excluding arterial stenosis/occlusions in patients with symptoms of PAD. It can thus be considered the test of choice in patients with renal failure and in "at-risk patients" including pregnant women and patients with contrast allergy.

KEY POINTS

• The pooled sensitivity and specificity of QISS magnetic resonance angiography on a per-segment basis with DSA or contrast-enhanced MRA as reference standard are 88% and 94% respectively. • The diagnostic accuracy of QISS in patients with peripheral arterial disease as reflected by area under hierarchical summary receiver-operating characteristic is high (0.96 (95% CI: 0.94-0.98)). • There is moderate to significant heterogeneity among studies as depicted by I² statistic and chi-square test.

Midterm results of kissing stent reconstruction of the aortoiliac bifurcation

Purpose

One subset of peripheral arterial disease is aortoiliac occlusive diseases (AIOD). AIOD is the term for all arterial lesions between the infrarenal distal aorta and common femoral artery. Implantation of kissing stents (KS) with covered stents (CS), bare-metal stents (BMS) is one of the endovascular treatment (ET) modalities for AIOD involving aortic bifurcation. In this study, we report the outcomes of the KS technique in infrarenal AIOD.

Methods

Between January 2014 and September 2017, 31 patients who underwent ET were treated with KS technique either with balloon-expandable BMS or balloon-expandable CS. Technical details, clinical success, complications, and patency at follow-up were documented.

Results

The majority of patients were male (77.4%), and the median age was 62 years (range, 45-78 years). All patients were classified according to the TASC II criteria. Eight patients (25.8%) were classified as TASC B. Fifteen patients (48.4%) were classified as TASC C, and 8 patients (25.8%) were classified as TASC D. These 23 patients were classified as complex AIOD group. BMS was used in 17 patients (54.8%), and CS was used in 14 patients (45.2%). Technical and clinical success was achieved in 100% of treated cases. The median follow-up was 24 months (range, 24-34 months). Primary patency rates at 12, 18, and 24 months after ET were 100%, 96.8%, and 90.3%, respectively.

Conclusion

We found that the KS technique has satisfying 24-month results, even in complex AIOD lesions, with high technical success and acceptable midterm patency. Key Words: Aorta, Arterial occlusive diseases, Endovascular procedures, Iliac artery, Stents.

Heterogeneity between proximal and distal aspects of occlusive thrombi on pretreatment imaging in acute ischemic stroke

BACKGROUND

The potential heterogeneity in occlusive thrombi caused by in situ propagation by secondary thrombosis after embolic occlusion could obscure the characteristics of original thrombi, preventing the clarification of a specific thrombus signature for the etiology of ischemic stroke. We aimed to investigate the heterogeneity of occlusive thrombi by pretreatment imaging.

METHODS

Among consecutive stroke patients with acute embolic anterior circulation large vessel occlusion treated with thrombectomy, we retrospectively reviewed 104 patients with visible occlusive thrombi on pretreatment non-contrast computed tomography admitted from January 2015 to December 2018. A region of interest was set on the whole thrombus on non-contrast computed tomography under the guidance of computed tomography angiography. The region of interest was divided equally into the proximal and distal segments and the difference in Hounsfield unit densities between the two segments was calculated.

RESULTS

Hounsfield unit density in the proximal segment was higher than that in the distal segment (mean difference 4.45; p < 0.001), regardless of stroke subtypes. On multivariate analysis, thrombus length was positively correlated (β = 0.25; p < 0.001) and time from last-known-well to imaging was inversely correlated (β = -0.0041; p = 0.002) with the difference in Hounsfield unit densities between the proximal and distal segments.

CONCLUSIONS

The difference in density between the proximal and distal segments increased as thrombi became longer and decreased as thrombi became older after embolic occlusion. This time/length-dependent thrombus heterogeneity between the two segments is suggestive of secondary thrombosis initially occurring on the proximal side of the occlusion.

Acute lower extremity arterial thrombosis after intraocular foreign body removal under general anesthesia: A case report and review of literature

BACKGROUND

Surgery, which is a major risk factor for venous thrombosis, has rarely been considered a risk factor for arterial thrombosis. Recent studies have suggested that venous and arterial thromboses share common risk factors and have a bidirectional relationship. Accordingly, there is a growing interest in the risk of arterial thrombosis after surgery. We report a case of acute bilateral lower extremity arterial thromboses that developed after a prolonged surgery.

CASE SUMMARY

A 59-year-old man was hospitalized for intraocular foreign body removal surgery. He was a heavy-drinking smoker and had untreated hypertension and varicose veins in both legs. The operation was unexpectedly prolonged, lasting 4 h and 45 min. Immediately after emergence from general anesthesia, the patient complained of extreme pain in both legs. After the surgical drape was removed, cyanosis was evident in both feet of the patient. The pulse was not palpable, and continuous-wave Doppler signals were inaudible in the bilateral dorsalis pedis and posterior tibial arteries. Computed tomography angiography confirmed acute bilateral thrombotic occlusion of the popliteal arteries, proximal anterior tibial arteries, and tibioperoneal trunks. Arterial pulse returned in both lower limbs after 6 h of heparin initiation. The patient was discharged on postoperative day 26 without any sequelae.

CONCLUSION

Acute lower extremity arterial thrombosis can occur after surgery. Anesthesiologists should pay particular attention to patients with risk factors for thrombosis.

Multiple drug-coated balloons can be used effectively for peripheral arterial disease including long femoropopliteal lesions

Purpose

Drug-coated balloons have shown successful results in treating peripheral arterial occlusive disease. However, using multiple balloons for long femoropopliteal lesions (>15 cm) remains challenging; their safety and efficacy need to be explored. Therefore, we aimed to evaluate the outcomes of multiple drug-coated balloons for long femoropopliteal lesions in terms of the primary patency, freedom from clinically-driven target lesion revascularization, and mortality.

Methods

Between April 2015 and September 2018, 96 patients (117 limbs) who underwent balloon angioplasty using at least 2 drug-coated balloons for femoropopliteal lesions were retrospectively reviewed. Lesions were classified as Trans-Atlantic Inter-Society Consensus (TASC) classification C or D. The outcomes were analyzed using Kaplan-Meyer analysis.

Results

The mean age of 96 enrolled patients was 70.8 ± 9.8 years, and 83 patients were males (86.5%). Critical limb-threatening ischemia was found in 29 cases (24.8%). The mean lesion and drug-coated balloon lengths per limb were 292.3 ± 77.8 mm and 325.0 ± 70.2 mm, respectively. The technical success rate was 99.2%. A total of 82.1% were followed-up for more than 6 months. The primary patency rates at 12 and 24 months were 71.4% and 41.7%, respectively; freedom from clinically-driven target lesion revascularization rates were 96.4% and 71.0% at 12 and 24 months, respectively. The Kaplan-Meier estimate of the 2-year overall cumulative mortality rate was 20.8%. All identified mortalities appeared to be less associated with paclitaxel.

Conclusion

Drug-coated balloons can be effectively used without drug-related mortality, even for long lesions, such as TASC classification C or D femoropopliteal lesions.

Relative risk of arterial and venous thromboembolism in persons with cancer vs. persons without cancer-a nationwide analysis

AIMS

An interrelation between cancer and thrombosis is known, but population-based studies on the risk of both arterial thromboembolism (ATE) and venous thromboembolism (VTE) have not been performed.

METHODS AND RESULTS

International Classification of Disease 10th Revision (ICD-10) diagnosis codes of all publicly insured persons in Austria (0-90 years) were extracted from the Austrian Association of Social Security Providers dataset covering the years 2006-07 (n = 8 306 244). Patients with a history of cancer or active cancer were defined as having at least one ICD-10 'C' diagnosis code, and patients with ATE and/or VTE as having at least one of I21/I24 (myocardial infarction), I63/I64 (stroke), I74 (arterial embolism), and I26/I80/I82 (venous thromboembolism) diagnosis code. Among 158 675 people with cancer, 8559 (5.4%) had an ATE diagnosis code and 7244 (4.6%) a VTE diagnosis code. In contrast, among 8 147 569 people without cancer, 69 381 (0.9%) had an ATE diagnosis code and 29 307 (0.4%) a VTE diagnosis code. This corresponds to age-stratified random-effects relative risks (RR) of 6.88 [95% confidence interval (CI) 4.81-9.84] for ATE and 14.91 (95% CI 8.90-24.95) for VTE. ATE proportion was highest in patients with urinary tract malignancies (RR: 7.16 [6.74-7.61]) and lowest in patients with endocrine cancer (RR: 2.49 [2.00-3.10]). The corresponding VTE proportion was highest in cancer of the mesothelium/soft tissue (RR: 19.35 [17.44-21.47]) and lowest in oropharyngeal cancer (RR: 6.62 [5.61-7.81]).

CONCLUSION

The RR of both ATE and VTE are significantly higher in persons with cancer. Our population-level meta-data indicate a strong association between cancer, ATE and VTE, and support the concept of shared risk factors and pathobiology between these diseases.Relative risk of ATE and VTE in persons with a cancer diagnosis code versus persons without a cancer diagnosis code.

[Use of the ankle-brachial index in the detection of peripheral arterial disease of the lower extremities in general medicine]

INTRODUCTION

Peripheral arterial disease of the lower extremities (PAD) is a serious condition, frequently under-evaluated. Long asymptomatic, it is easily detected by measuring the ankle-brachial index (ABI), a reference tool that is reliable, reproducible, simple and inexpensive. The objective of this thesis was to determine the rate of achievement of ABI in French Haute Autorité de santé indications, identify the associated factors and prioritize the obstacles to achieving ABI.

METHODS

Descriptive and analytical epidemiological study, with analysis of practices, prospectively addressed by postal questionnaire to a randomized sample of 220 general practitioners practicing in the European Metropolis of Lille between December 15, 2016 and February 15, 2017.

RESULTS

Our sample consisted of 92 GPs (42% participation). Among them, only 6 practiced ABI, notably for: intermittent claudication (n=5: 5%, IC95% [1; 10]), the existence of at least 2 cardiovascular risk factors (n=2: 2%, IC95% [0; 5]), diabetic patients over 40 years of age (n=2: 2%, IC95% [0; 5]), patients with diabetes (n=2: 2%, IC95% [0; 5]), patients with diabetes (n=2: 1%, IC95% [0; 5]), patients with diabetes (n=2: 1%, IC95% [0; 5]), and patients with diabetes (n=2: 1%, IC95% [0; 5]): 2%, CI95% [0; 5]), patients over 50 years of age with a history of diabetes or smoking (n=2: 2%, CI95% [0; 5]), or those with an unhealed lower extremity skin lesion (n=5: 5%, CI95% [1; 10]). The most frequently cited barriers were: the prescription of a routine echo-doppler (61%, 95% CI [51; 71]), lack of control (46%, 95% CI [36; 56]), time considered too long (17%, 95% CI [10; 25]), and equipment purchase or maintenance (19%, 95% CI [10.5; 26.4]).

CONCLUSION

ABI is few used in our sample, mainly due to delegation to angiologists.

Randomized Controlled Comparison of Optimal Medical Therapy with Percutaneous Recanalization of Chronic Total Occlusion (COMET-CTO)

The aim of this randomized prospective study was to evaluate the quality of life (QoL) using the "Seattle Angina Questionnaire" (SAQ) in patients with chronic total occlusion (CTO) in coronary arteries treated with either percutaneous coronary intervention (PCI) or optimal medical therapy (OMT), or only with OMT.The potential benefits of recanalization of CTO by PCI have been controversial because of the scarcity of randomized controlled trials.A total of 100 patients with CTO were randomized (1:1) prospectively into the PCI CTO or the OMT group (50 patients in each group). There were no baseline differences in the SAQ scores between the groups, except for physical limitation scores (P = 0.03). During the mean follow-up (FUP) of 275 ± 88 days, patients in the PCI group reported less physical activity limitations (72.7 ± 21.3 versus 60.5 ± 27, P = 0.014), less frequent angina episodes (89.8 ± 17.6 versus 76.8 ± 27.1, P = 0.006), better QoL (79.9 ± 22.7 versus 62.5 ± 25.5, P = 0.001), greater treatment satisfaction (91.2 ± 13.6 versus 81.4 ± 18.4, P = 0.003), and borderline differences in angina stability (61.2 ± 26.5 versus 51.0 ± 23.7, P = 0.046) compared to patients in the OMT group. There were no significant differences in SAQ scores in the OMT group at baseline and during the FUP. There was a statistically significant increase in all five domains in the PCI group.Symptoms and QoL measured by the SAQ were significantly improved after CTO PCI compared to OMT alone.

Outcomes of Unibody Bifurcated Endograft and Aortobifemoral Bypass for Aortoiliac Occlusive Disease

Purpose

We compared the outcomes between the total endovascular approach using a unibody bifurcated aortoiliac endograft and the gold standard aortobifemoral bypass (ABF) surgery for the management of extensive aortoiliac occlusive disease (AIOD).

Methods

Materials and This retrospective observational study compared the outcomes of endovascular technique with unibody bifurcated endograft (UBE) using the Endologix AFX unibody stent-graft and a standard surgical approach (ABF) in the management of AIOD based on patient records in Western Vascular Institute, Galway University Hospital, National University of Ireland. Procedural details and outcomes were documented to compare both groups.

Results

From January 2002 to December 2018, 67 patients underwent AIOD (20 UBE and 47 ABF). Both the ABF and UBE groups showed 100% immediate clinical and technical successes without 30-day mortality. There were no statistical differences in the overall survival and sustained clinical improvement between the bypass and the UBE groups; however, statistically significant differences were observed in 3-year freedom from re-intervention and amputation-free survival. Furthermore, the mean length of the intensive care unit (ICU) stay was significantly lower in the UBE group than that in the ABF group (0.75 days vs. 3.1 days, P=0.001).

Conclusion

Total endovascular reconstruction of AIOD is an alternative to invasive bypass procedures, with a shorter ICU stay.

Acute paraplegia as a presentation of acute aortic occlusion

Acute aortic occlusion is a rare life-threatening event. We present a case of a heavy smoking, 54-year-old man who was admitted in the emergency room with sudden paraplegia, associated to severe lower back and lower limbs pain. A neurologic examination showed paralysis of the lower limbs and cold lower extremities. The pedal and femoral pulses were absent. A computed tomography revealed occlusion of the mesenteric superior artery, abdominal aorta, and both iliac arteries. Despite medical treatment, the patient died before evaluation of vascular surgery. Paraplegia is a rare presentation of acute aortic occlusion and clinicians should be alert to make an early intervention.

[Endovascular recanalization of symptomatic non-acute intracranial arterial occlusion: a single center case series]

Objective: To investigate the feasibility and safety of endovascular recanalization for symptomatic non-acute intracranial arterial occlusion (NAICO). Methods: Twenty-five consecutive patients who underwent endovascular recanalization for NAICO between January 2017 and October 2019 at Department of Neurosurgery, Beijing Hospital were retrospectively reviewed.There were 20 males and 5 females, aged (60.5±11.0) years (range: 41 to 73 years).The preoperative modified Rankin score(M(Q(R))) was 2 (2.5)(range: 1 to 5).The occlusion time was 40 (54)days (range: 17 to 570 days).The demographic data were collected. The initial procedural results, including the rate of successful recanalization, periprocedural complications and data pertaining to angiographic and clinical follow-up were recorded. Results: Recanalization was successful in 20 of 27 occlusive lesions of 25 patients. Intraoperative complications occurred in 3 cases, including vascular perforation in 1 case, arterial dissection in 1 case, and perforator occlusion occurred in 1 case. The incidence of permanent complications was 3.7% (1/27). All 25 patients underwent clinical follow-up, with a median period of 8 months (range: 1 to 33 months), and 23 patients with improved or stable modified Rankin scale. One patient developed new ischemic symptoms 2 months after discharge, and 1 patient died of complications of bed rest.The results of the angiography follow-up (median 4 months, range: 2 days to 9 months) showed that reocclusion occurred in 5 of all 20 successfully recanalized patients. Conclusions: Endovascular recanalization for symptomatic NAICO is feasible, relatively safe, and efficacious in highly selected cases. However, further larger scale pilot studies are needed to determine the efficacy and long-term outcome associated with this treatment.

[Exploration on endovascular treatment for symptomatic occlusion of the intracranial vertebral arteries in early non-acute stage]

Objective: To examine the clinical efficacy of endovascular treatment on symptomatic occlusion of intracranial vertebral artery (ICVA) in early non-acute stage. Methods: Nine consecutive patients who presented with aggressive ischemic events in the early non-acute stage of ICVA occlusion from January 2014 to December 2019 and received endovascular treatment at Department of Neurosurgery, Peking University First Hospital were retrospectively reviewed.There were 7 males and 2 females, aged 63.4 years old(range: 52 to 72 years).The average preoperative modified Rankin scale(mRS) was 4.3(range: 4 to 5), the National Institute of Health stroke scale(NIHSS) was 12.3(range: 8 to 18). Among them, 2 patients received a single stage endovascular treatment, and the other 7 patients received staged endovascular treatment.The strategy of staged treatment was as follows: firstly, the occlusion part was passed through by a micro-guidewire and dilated with balloons to maintain the blood flow above Thrombolysis In Cerebral Infarction grade 2b. Then, the intravascular large load thrombus was eliminated by the fibrinolytic system and strengthened antiplatelet drugs. After that, a second stage of angioplasty with stenting was performed on the severe residual stenosis part.The complications and the recanalization rate were collected, and the National NIHSS and mRS after endovascular treatment and in follow-up period were recorded. Results: In the 2 cases received single stage endovascular treatment, although revascularization was achieved lastly, one patient suffered embolus translocation and the other suffered re-occlusion after mechanical thrombectomy during the operation, respectively.Technical success was achieved in 6 of the 7 patients received staged endovascular treatment.On discharge, the average NIHSS scores was 5.7(range: 3 to 4) of the patients. Three months after operation,the average mRS was 1.6(range:0 to 3) and it was 0.9(range: 0 to 2) at the latest follow-up, which were better than preoperative status. Conclusions: Staged endovascular treatment might be a safe, efficient, viable option in carefully selected patients with symptomatic ICVA occlusion in early non-acute stage. It needs to be confirmed by further investigation, preferably in a large controlled setting.

[Surgical treatment of total subclavian artery occlusion: a single center experience of 67 cases]

Objective: To examine the outcomes of surgical repair for patients with total subclavian artery occlusion. Methods: A retrospective analysis was performed on 67 patients with subclavian artery occlusion disease admitted at Ward 1 of Aortic and Vascular Surgery Center, Fuwai Hospital from January 2016 to July 2019. The age was, and There were 51 male patients and 16 females with an age of (61.7±8.2) years (range: 37 to 79 years). The t-test, Mann-Whitney U-test, χ(2) test, and Fisher's exact test were used to analyze the factors related to the technique success. The Kaplan-Meier curve was used to calculate the cumulative patency rate and plot the corresponding survival curves, and the Log-rank test was used for comparison. The length from the subclavian artery ostial to the occlusion area was used as a variable to plot the receiver operating characteristic curve, and the optimal cut-off value was determined by the Youden index. Results: Eighteen patients received open surgery. Forty-nine patients with subclavian artery occlusion accepted endovascular repair, of which 38 patients succeeded (31 cases on left side and 3 cases on right side). Fifteen patients failed with endovascular therapy, of which 10 cases received elective surgery and 5 cases received conservative therapy. The success rate of endovascular repair was 69.4%(34/49). Among them, the success rate of left subclavian artery occlusion was 81.6%(31/38), while the right side was 3/11. Patients with the length from the subclavian artery ostial to the occlusion area ≥6 mm were more likely to get success (23/34 vs. 4/15, χ(2)=5.506, P=0.019). In the endo-group, one patient had hemorrhage in the left chest. In the open-group, one patient had lymphatic leakage. Follow-up period ranged from 3 to 46 months with a median of 22 months. The patency of endovascular repair group and the open surgery group was 92.6% and 90.8% at 12-month, while 82.9% and 84.3% at 24-month, respectively. The cumulative patency rates of smoking patients and non-smoking patients after endovascular treatment were 70.2% vs. 100% (P=0.048) at 24-month. No independent prognosis factors were identified through the Cox proportional risk model which significantly affected postoperative patency rates for patients with subclavian artery occlusion. Conclusions: Part of patients with subclavian artery occlusion can be treated by endovascular therapy. The success rate of left subclavian artery occlusions is higher than right sides. The length from the subclavian artery ostial to the occlusion area affected the success rate of repair.

Arterial Steal to the Penumbra Area in Patients with Acute MCA Occlusion: A Quantitative Angiographic Analysis

Purpose

In acute middle cerebral artery (MCA) occlusion, collateral vessels provide retrograde supply to the occluded territory. We hypothesized that such collateral flow reduces perfusion of the non-occluded donor region (steal effect).

Materials and Methods

Patients with an MCA occlusion with opacification of both ipsi- and contralateral anterior cerebral arteries (ACA) on angiography prior to endovascular treatment were selected. Arteriovenous transit time (AVTT) for both ACA territories was compared for different grades of collateral supply to the MCA territory. In addition, the influence of diabetes and hypertension was analyzed. After successful revascularization, AVTT was re-assessed to determine reversibility.

Results

Forty-one patients were analyzed. An AVTT of 8.6 seconds (standard deviation [SD] 2.4 seconds) was seen in the ACA territory of the affected hemisphere in comparison to 6.6 seconds (SD 2.1 seconds) for the contralateral side (P<0.001). A more prolonged (but not significant) AVTT was seen in cases with a higher collateral grade. No difference in AVTT was seen in patients with diabetes or hypertension. After successful MCA revascularization, AVTT delay was 7.4 seconds (SD 2.1 seconds).

Conclusion

A cerebral steal effect occurs in patients with an acute MCA occlusion, probably related to augmented flow to the penumbra area.

Tibiopedal and distal femoral retrograde vascular access for challenging chronic total occlusions: predictors for technical success, and complication rates in a large single-center cohort

OBJECTIVE

To evaluate the safety and effectiveness of tibiopedal and distal femoral access for retrograde crossing of chronic total occlusion (CTO) in Rutherford stage III to VI peripheral arterial occlusive disease, and to determine factors that correlate with technical success.

MATERIAL AND METHODS

One hundred seventy-one consecutive patients were included in this retrospective study. Rutherford stages were III, IV, and V/VI in 24%, 8%, and 67% of patients. Inclusion criteria were CTO at the superficial femoral (SFA), popliteal (PA), and/or below-the-knee (BTK) level, and a failed antegrade treatment followed by a distal retrograde approach. The numbers of occluded vascular levels (OVL), lesion length, degree of calcification, technical success rate, complications, and clinical outcome were noted.

RESULTS

OVL were 1 in 72%, 2 in 20%, and 3 in 8% of patients. CTOs were longer than 20 cm in 45.6% of cases and showed severe calcifications in 50.3%. Target vessels for distal access were the distal SFA/PA in 17% and BTK in 83%. The overall technical success rate was 82%. Severe calcification decreased technical success (p = 0.01) despite lesion length and Rutherford stage. Clinical outcome improved in 123/152 patients with a significant increase of the median ABI (N = 158) from 0.53 (interquartile range 0.39 to 0.61) to 0.85 (0.59 to 1.03; p < 0.001). Complications were reported in 7.6% cases with 2.3% related to the distal vascular access.

CONCLUSION

The tibiopedal and distal femoral retrograde access presents a safe and effective treatment option of CTOs at the thigh and/or BTK after a failed antegrade attempt improving clinical outcome. Technical success decreased with lesion's degree of calcification.

KEY POINTS

• Safety and effectiveness of the tibiopedal and distal femoral access for retrograde crossing of chronic total occlusion. • Target lesion's degree of calcification decreases technical success. • Complications related to the distal vascular access were rare.

Evaluation of chronic carotid artery occlusion by non-contrast 3D-MERGE MR vessel wall imaging: comparison with 3D-TOF-MRA, contrast-enhanced MRA, and DSA

OBJECTIVES

To analyze the accuracy of a non-contrast MR vessel wall imaging technique, three-dimensional motion-sensitized driven equilibrium prepared rapid gradient echo (3D-MERGE) for diagnosing chronic carotid artery occlusion (CCAO) characteristics compared with 3D time-of-flight (TOF) MRA, and contrast-enhanced MRA (CE-MRA), using digital subtraction angiography (DSA) as a reference standard.

METHODS

Subjects diagnosed with possible CCAO by ultrasound were retrospectively analyzed. Patients underwent 3.0-T MR imaging with 3D-MERGE, 3D-TOF-MRA, and CE-MRA followed by DSA within 1 week. Diagnostic accuracy of occlusion, occlusion site, and proximal stump condition were assessed independently on 3 MRI sequences and DSA. Agreement of the above indicators was evaluated in reference to DSA.

RESULTS

One hundred twenty-four patients with 129 suspected CCAO (5 with bilateral occlusions) met the inclusion criteria for our study. 3D-MERGE demonstrated a sensitivity, specificity, and accuracy of 97.0%, 86.7%, and 94.6%, respectively, with excellent agreement (Cohen's κ = 0.85; 95% CI, 0.71, 0.94) for diagnosing CCAO in reference to DSA. 3D-MERGE was superior in diagnosing CCAO compared with 3D-TOF-MRA (Cohen's κ = 0.61; 95% CI, 0.42, 0.77) and similar to CE-MRA (Cohen's κ = 0.93; 95% CI, 0.86, 1.00). 3D-MERGE also had excellent agreement compared with DSA for assessing occlusion sites (Cohen's κ = 0.85; 95% CI, 0.71, 0.97) and stump condition (Cohen's κ = 0.83; 95% CI, 0.71, 0.94). Moreover, 3D-MERGE provided additional information regarding the occluded segment, such as distal lumen collapse and vessel wall lesion components.

CONCLUSION

3D-MERGE can reliably assess chronic carotid occlusive characteristics and has the ability to identify other vessel wall features of the occluded segment. This non-contrast MR vessel wall imaging technique is promising for assessment of CCAO.

KEY POINTS

• Excellent agreement was found between 3D-MERGE and DSA for assessing chronic carotid artery occlusion, occlusion site, and proximal stump condition. • 3D-MERGE was shown to be a more accurate and efficient tool than 3D-TOF-MRA to detect the characteristics of the occluded segment. • 3D-MERGE provides not only luminal images for characterizing the proximal characteristics of occlusion but also vessel wall images for assessing the distal lumen and morphology of occlusion segment, which might help clinicians to optimize the treatment strategy for patients with chronic carotid artery occlusion.

[Study of practices: What do general practitioners first propose when faced with asymptomatic lower extremity peripheral artery disease?]

INTRODUCTION

Peripheral artery disease of lower limbs (PAD) can be discovered at an asymptomatic stage by the realization of systolic pressure indices. The 2006 recommendations of the French National Authority for Health on AOMI encourage the systematic prescription of antiplatelet agents; the 2012 recommendations on the proper use of antiplatelet agents no longer encourage it in the case of asymptomatic PAD. These two recommendations still coexist. Our objective was to determine the management of an asymptomatic PAD by general practitioners.

METHODS

Descriptive and analytical epidemiological study, with analysis of practices, prospectively addressed by postal questionnaire to a randomized sample of 220 GPs practicing in the European Metropolis of Lille between December 15, 2016 and February 15, 2017. The question was: "if an asymptomatic PAD is discovered in a 50-year-old patient who is otherwise in good general condition, what do you generally do?"

RESULTS

Our sample was 92 general practitioners (42% participation). Of these, only 6 were practicing HPIs. Before an asymptomatic PAD, management included an opinion from an angiologist (84%) and/or a cardiologist (75%) before the drug was prescribed (antiplatelet agent for 57%, statin for 33% and ACE inhibitor for 14%).

CONCLUSION

The extension assessment was carried out in more than 8 out of 10 cases. The use of antiplatelet antiaggregants was significant, which can be explained by the coexistence of divergent recommendations. The rapid clarification of recommendations is essential with the evolution of scientific data.

Resting-state Functional Magnetic Resonance Imaging Identifies Cerebrovascular Reactivity Impairment in Patients With Arterial Occlusive Diseases: A Pilot Study

BACKGROUND

The development of noninvasive approaches for identifying hypoperfused brain tissue at risk is of major interest. Recently, the temporal-shift (TS) maps estimated from resting-state blood oxygenation level-dependent (BOLD) signals have been proposed for determining hemodynamic state.

OBJECTIVE

To examine the equivalency of the TS map and the cerebrovascular reactivity (CVR) map derived from acetazolamide-challenged single-photon emission computed tomography (SPECT) in identifying hemodynamic impairment in patients with arterial occlusive diseases.

METHODS

Twenty-three patients with arterial occlusive diseases who underwent SPECT were studied. With a recursive TS analysis of low-frequency fluctuation of the BOLD signal, a TS map relative to the global signal was created for each patient. The voxel-by-voxel correlation coefficient was calculated to examine the image similarity between TS and SPECT-based cerebral blood flow (CBF) or CVR maps in each patient. Furthermore, simple linear regression analyses were performed to examine the quantitative relationship between the TS of BOLD signals and CVR in each cerebrovascular territory.

RESULTS

The within-patient, voxel-by-voxel comparison revealed that the TS map was more closely correlated with SPECT-CVR map ([Z(r)] = 0.42 ± 0.18) than SPECT-CBF map ([Z(r)] = 0.058 ± 0.11; P < .001, paired t-test). The regression analysis showed a significant linear association between the TS of BOLD signals and CVR in the anterior circulation where the reduction of CVR was evident in the patient group.

CONCLUSION

BOLD TS analysis has potential as a noninvasive alternative to current methods based on CVR for identification of tissue at risk of ischemic stroke.

Long-term outcomes of axillary to carotid bypass for symptomatic patients with chronic common carotid artery occlusion

OBJECTIVE

Relatively little is known about the natural history of atherosclerotic common carotid artery occlusion and optimal treatment of these patients is still unclear. The aim of this retrospective study was to evaluate the immediate- and long-term outcomes of axillary to carotid bypass with polytetrafluoroethylene graft for symptomatic patients with chronic common carotid artery occlusion.

METHODS

From March 2001 to December 2017, 58 symptomatic patients (41 men; mean age 64.7 years) with chronic common carotid artery occlusion underwent axillary to carotid bypass at one academic hospital. The clinical data of this patient cohort were retrospectively analyzed. The cumulative graft patency, overall survival, freedom from symptoms, and freedom from ipsilateral stroke were calculated with Kaplan-Meier method.

RESULTS

Thirty-three patients presented with transient ischemic attack and 25 patients presented with minor stroke. At 30 days after bypass, the overall perioperative complication rate was 3.4% (2/58). Mild injuries of brachial plexus occurred in one (1.7%) patient and myocardial infarction occurred in one (1.7%) patient. No perioperative stroke or death occurred. The median follow-up was 51 months (range, 12-203) for this series. The cumulative graft patency rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 83%, respectively. The cumulative freedom from symptoms rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 75%, respectively. The cumulative freedom from ipsilateral stroke rates at 1, 3, 5, and 10 years were 100%, 100%, 94%, and 82%, respectively. The overall survival rates at 1, 3, 5, and 10 years were 98%, 89%, 81%, and 67%, respectively.

CONCLUSIONS

Axillary to carotid bypass with polytetrafluoroethylene graft is safe and durable for symptomatic patients with chronic common carotid artery occlusion. The results of this study should be confirmed with a larger, randomized controlled trial in future.

[Factors influencing poor prognosis of mechanical thrombectomy in time window of acute ischemic stroke]

Objective: Investigate the causes of poor prognosis of mechanical thrombectomy in the time window of acute ischemic stroke (AIS) with anterior circulation. Methods: A retrospective analysis was made on the data of 78 patients with anterior circulation AIS who underwent mechanical thrombectomy in the time window from January 2017 to December 2017 in the Department of Vascular Neurosurgery of Liaocheng Brain Hospital. The modified Rankin scale (mRS) was used to evaluate the prognosis of the patients 3 months after operation. According to the prognosis,the patients were divided into the group with good prognosis (42 cases, mRS<2 points) and the group with poor prognosis (36 cases, mRS<3 points). Univariate and multivariate Logistic regression analysis was used to analyze the related factors of poor prognosis. Results: (1) Univariate analysis showed that the prognosis of patients with good combination and primary stenosis of diabetes mellitus and atherosclerosis was lower than that of patients with poor prognosis (P<0.05). The collateral circulation compensation rate and vascular recanalization rate of patients with good prognosis were higher than those of patients with poor prognosis (P<0.05). Learning significance (P<0.05). (2) Multivariate analysis showed that diabetes mellitus (P=0.035), collateral circulation compensation (P=0.011) and primary atherosclerotic stenosis (P=0.042) were independent risk factors for poor prognosis. Conclusion: Perfect preoperative evaluation and strict screening of patients, good collateral circulation compensation,individualized treatment for patients with primary atherosclerotic stenosis,and strict control of postoperative hyperglycemia can improve the clinical prognosis of endovascular therapy.

[Chronic leg ulcers in older patients]

Chronic ulcers of the lower extremities are one of the most common medical problems encountered in western societies. The prevalence of leg ulcers is estimated to be 0.5-1.0% of the German population and is clearly associated with age. Therefore, in an aging society chronic leg ulcers are an important health issue with respect to increased morbidity and healthcare costs. The most frequent causes of leg ulcers are chronic venous insufficiency, peripheral arterial occlusive disease and diabetes mellitus. Efficient treatment necessitates an exact diagnosis and a close interdisciplinary collaboration. Affected patients often require instructions regarding self-help and support for competent nursing and prophylaxis. Therapeutic strategies, especially in the geriatric setting, aim to maintain the quality of life through preservation of patient mobility and autonomy.

Hybrid Surgery to Treat Multiple Visceral Aneurysms Secondary to Polyarteritis Nodosa

A 57-year-old woman presented to vascular surgery clinic with visceral artery aneurysms that were incidentally detected during regular check-up. Imaging studies revealed occlusion of the celiac axis and severe stenosis of the superior mesenteric artery and 3 aneurysms along the posterior and inferior pancreaticoduodenal arteries, as well as the right gastroepiploic artery. Endovascular embolization of all aneurysms was rejected because of the risk of hepatic ischemia. These complicated lesion caused by polyarteritis nodosa were successfully treated using a hybrid operation with coil embolization, aneurysm resection, and antegrade aorto-celiac-superior mesentery artery bypass.

[Surgical treatment of aortic dissection with lower extremity ischemia]

Objective: To explore the clinical outcome of the surgical treatment for aortic dissection with lower extremity ischemia. Methods: Between March 2009 and April 2013, 14 patients with type A aortic dissection and lower extremity ischemia underwent Sun's procedure in Beijing Anzhen Hospital. Ascending aorta-iliac artery bypass, ascending aorta-femoral artery bypass, femoral-femoral artery bypass and axillary -femoral artery bypass were performed on some severe patients at the same time. Results: Two death occurred, and the others were improved or recovered from symptoms. Follow-up was complete with an average time of 24 months and no aortic relevant complications occurred. Conclusion: As for patients with type A aortic dissection and lower extremity ischemia, simultaneous radical femoral artery bypass procedure is effective in improving their survival rate and quality of life.

Successful surgical treatment for thoracoabdominal aortic aneurysm with leriche syndrome

Thoracoabdominal aortic aneurysm accompanied by Leriche syndrome is an extremely rare combination of aortic diseases, the surgical management of which has not been described to date. We report the successful treatment of one such case through open surgical repair of the thoracoabdominal aorta.

[Peripheral artery disease and acute coronary syndrome]

Peripheral arterial disease is a common manifestation of systemic atherosclerosis that is associated with increased cardiovascular risk. When presented in the context of an acute coronary syndrome a differential diagnosis with aorta dissection should be made, because peripheral arterial disease may be asymptomatic despite the absence or asymmetry of femoral pulses.

Finger necrosis after accidental radial artery puncture

Radial artery puncture, an invasive procedure, is frequently used for critical patients. Although considered safe, severe complications such as finger necrosis can occur. Herein, we review the clinical course of finger necrosis after accidental radial artery puncture. A 63-year-old woman visited the emergency department (ED) with left second and third finger pain after undergoing intravenous (IV) access in her wrist for procedural sedation. During the IV access, she experienced wrist pain, which increased during the 12 hours prior to her ED presentation. Emergency angiography revealed a pseudoaneurysm in her left radial artery and absence of blood flow to the proper palmar digital artery. Subsequent angiointervention and urokinase thrombolysis failed. The second finger was eventually amputated owing to gangrene. Radial artery puncture can occur accidentally during IV wrist access, resulting in severe morbidity. Providers should carefully examine the puncture site and collateral flow, followed by multiple examinations to ensure distal circulation.

Carotid endarterectomy versus carotid artery stenting: findings in regard to neuroclinical outcomes and diffusion-weighted imaging

The purpose of our study was to evaluate prospectively the frequency and significance of brain lesions after elective carotid endarterectomy (CAE) and carotid artery stenting (CAS) by using diffusion-weighted magnetic resonance imaging (DW MRI) and then to correlate imaging findings with neuroclinical outcomes. From February 2003 through March 2005, 95 consecutive patients underwent surgical endarterectomy or CAS (with a cerebral protection device) at our institution. A total of 59 CAE procedures were performed in 46 consecutive patients (mean age, 65.8 +/- 9 yr), and 56 CAS procedures were performed in 49 consecutive patients (mean age, 66.3 +/- 9 yr). Diffusion-weighted magnetic resonance imaging of the brain was performed in all patients within 24 hours of the procedure, both before and after. The post-procedural stroke rate was slightly higher in the CAS group, but this difference was not significant (5.4% vs 0). One early and 1 late death occurred in the stent group. Although the incidence of ischemic lesions was similar in both groups (surgery group, 12.5%; stent group, 13.5%), new DW MRI lesions were higher in the endarterectomy group (27.1% vs 12.5%, P=0.041). This difference was due chiefly to nonischemic lesions such as hemorrhage and watershed ischemia. In the analysis of patients with embolic ischemia, incidences of symptomatic stroke (P=0.046) and large infarct (P=0.013) were higher in the stent group. When we used protective devices during CAS, the incidence of embolic complications was similar to that of surgical enarterectomy. On the other hand, the clinical results of CAS need improvement.