Greater Curvature, Centerline or Straightened Centerline Length - Which length is Most Accurate for Preprocedural Planning in Thoracic Endovascular Aortic Repair?

BACKGROUND: Automated centerline (CL) measurements have been conventionally used for stent-graft length estimation during thoracic endovascular aortic repair (TEVAR). The purpose of this study was to assess the accuracy of greater curvature length (GL), semiautomated CL and straightened centerline length (SCL) for preprocedural planning in TEVAR. METHODS: Immediate postprocedural CT Angiographies of 30 patients (22 males, age-49.2 ± 10.1years) who underwent TEVAR between 2015 and 2017 were retrospectively analyzed. CL, GL, SCL and the straightline length(SL) were measured between proximal and distal ends of the stent-graft and results were compared with the true length of the stent-graft (TL). Tortuosity index (TI = CL/SL) was calculated. RESULTS: GL (17.92 ± 4.78 cm) was the closest in predicting the TL (17.75 ± 4.29 cm) (P = 0.414) overall, as well as in both dissection and aneurysm subgroups (P= 0.9). There was a significant difference between CL (16.67 ± 4.07 cm) and TL (P< 0.0001) as well as between SCL (16.86 ± 4.16 cm) and TL (P= 0.001). These differences were greater in dissection subgroup than in the aneurysm group (P< 0.0001 and P= 0.03 for TL-CL and TL-SCL, respectively). The extent of mismatch between GL or CL and TL did not correlate with tortuosity, but the difference between TL and SCL had a significant positive correlation with tortuosity (r = 0.375, P= 0.04). TL-GL had a negative linear correlation with the stent-graft length (TL) in the dissection group (r = 0.50, P= 0.03). CONCLUSIONS: The greater curvature length predicts the actual total length of the deployed stent-graft more accurately than centerline or straightened centerline lengths. Hence, it should be used in planning for the length of stent-graft required for TEVAR.

Use of intra-arterial gadolinium as contrast medium for thoracic endovascular aortic repair in a patient with iodine hypersensitivity: an uncharted territory.

We hereby present a case in which we used gadolinium as contrast medium for thoracic endovascular aortic repair in a patient with iodine hypersensitivity.

IgG4-related cardiovascular disease: imaging features on cardiac computed tomography and magnetic resonance imaging.

We present a case of diffuse involvement of cardiovascular structures in a patient with immunoglobulin4 (IgG4) vasculitis. We also highlight the important role of computed tomography (CT) angiography in diagnosing the same.

Single-blind, randomized study comparing clinical equivalence of trulene and prolene polypropylene sutures in elective primary coronary artery bypass graft surgery.

BACKGROUND: Coronary artery bypass graft surgery (CABG) is one of the principle therapies for coronary artery disease, as it improves survival rate and quality of life (QoL). Polypropylene suture is commonly used in vascular and cardiac surgeries for anastomosis due to its long-term tensile strength and minimal tissue trauma. This study compared the clinical equivalence of Trulene® (Healthium Medtech Limited) and Prolene® (Ethicon-Johnson & Johnson) polypropylene sutures regarding incidence of myocardial infarction, stroke, renal failure and cardiac death (MACCE) occurring up to 26 weeks' period post-CABG surgery. METHODS: This multicenter, prospective, two-arm, parallel-group, randomized (1:1), single-blind study (n = 89) was conducted between August 2020 and September 2021. The primary endpoint, post-surgery cumulative incidence of MACCE was evaluated. In addition, anastomotic revision, surgical site infection (SSI), operative time, length of post-operative hospital stay, repeat revascularization, intraoperative suture handling characteristics, time taken to return to work and resume normal day to day activities, subject satisfaction score and QoL, and other adverse events were also recorded. RESULTS: A total of 80 (89.89%) males and 9 (10.11%) females participated in the study. No incidence of MACCE was recorded in any of the study participants. Non-significant difference was observed in anastomotic revision, SSI, operative time, post-operative hospital stay, revascularization, return to work and normal day-to-day activities, subject satisfaction score and QoL, and intraoperative handling parameters (except ease of passage) between the treatment groups, Trulene® and Prolene®. Compared to screening visit, proportion of subjects with 'no problems' for each QoL dimension and the mean visual analogue scale increased with each subsequent follow-up visit. CONCLUSION: Trulene® polypropylene suture is clinically equivalent to Prolene® polypropylene suture and is safe and effective for anastomosis construction in CABG surgery during a routine clinical procedure. Trial registration CTRI Registration No.: CTRI/2020/05/025157 (Registered on: 13/05/2020).

IVC filters - Indications for placement and retrieval trends- experience from a tertiary referral centre in India type of submission- full paper.

OBJECTIVES: There is wide variation in the practice of IVC filter placement and retrievals. We conducted a retrospective study to identify the trends in placement and retrievals of IVC filters in a tertiary referral centre in India. METHODS: The data of patients obtained from our hospital records, in whom IVC filter was placed between 2010 and 2018, were analysed for demographics, indications for placement of IVC filter, underlying comorbidities, characteristics of the filters as well as the retrieval rates. RESULTS: IVC filters were placed in 50 patients, and data was retrieved for 31 patients (mean - 51.24 years, 67.74% males). According to ACCP/AHA guidelines, 24 (77.42%) had an absolute indication for IVC filter. All 31 IVC filters were temporary, 23 (74.19%) of which were placed via femoral access. 29(93.55%) patients had infrarenal IVC filter placement. The average tilt at deployment was 3.71°, whereas it was 5.3° at retrieval. There were no periprocedural complications or filter migrations during placement or retrieval. Retrieval was attempted in 11 (35.48%) patients and was successful in 10. The mean indwelling time in this group was 158.55 days (range 55-366 days). CONCLUSION: Our study reveals low IVC filter implantation rates which are predominantly for absolute rather than relative indications. Though in sync with the worldwide trend, the poor retrieval rates reflect the urgent need for better patient and physician awareness. Periodic follow up is imperative to improve the IVC filter retrieval rate and to prevent complication rates.

Intra-atrial right coronary artery on dual-source CT: prevalence and characteristics.

PURPOSE: We aimed to determine the prevalence rate and radiological characteristics of intra-atrial right coronary artery (IARCA) in an adult population undergoing computed tomography coronary angiography (CTCA) on a dual-source CT scanner. METHODS: Overall, 7114 consecutive CTCAs acquired using a dual-source CT scanner in a high-volume, specialized cardiac care facility were retrospectively analyzed for the presence of IARCA. We scrutinized the CTCA datasets to determine the prevalence rate of IARCA and also to characterize its various imaging features including its length, depth from right atrial wall, segment involved, and presence and absence of atherosclerosis within the involved segment and in the rest of the right coronary artery (RCA). RESULTS: The prevalence of IARCA was 0.29% (21/7114) in our study population. The mean length and depth of the intra-atrial segment was 14.85 mm and 2.57 mm, respectively. The mid-RCA was the most common segment to be involved, and no significant atherosclerosis was noted either in the intra-atrial segment or the rest of the RCA. CONCLUSION: The prevalence rate of the incidental IARCA in the adult subjects undergoing CTCA is higher than previously reported for anatomical series, as seen in our study using a dual-source scanner. This under-reported anomaly must be explicitly assessed in patients undergoing ablative and other electrophysiological procedures, where it can have important implications.

Prevalence Rates of Congenital Coronary Anomalies and Coronary Variations in Adult Indian Population Using Dual-Source Computed Tomography Coronary Angiography: Analysis of Regional Distribution of Coronary Anomalies and the Need for Standardized Reporting Formats.

Background Congenital coronary artery anomalies (CCAA) are predominantly discovered as incidental findings on computed tomography coronary angiography (CTCA) of adults. They are rare but significant, considering their importance during endovascular or surgical interventions. This study describes the prevalence of CCAA and coronary variants (CV) in adults as identified by CTCA. Methods It is a retrospective evaluation of 7,694 CTCAs of adults performed in a tertiary care facility in North India. Results CCAA and CV were observed in a total of 9.6% of patients. The most common CV was myocardial bridging, observed in 7.1%. Anomalies of origin and course were detected in 2.3% of the patients. The frequency of these anomalies in the right coronary artery, left main, left circumflex artery, and the left anterior descending artery arteries were 1.06, 0.41, 0.03, and 0.38%, respectively. The single coronary pattern was seen in 0.05% and coronary artery fistulas in 0.03%. Scrutiny of data on Indian regional distribution revealed differing definitions and inclusion and exclusion criteria, making comparisons difficult, highlighting the need for uniform definitions as well as the need to adopt a standardized reporting template and format. Conclusion The prevalence of CCAA and CV is 9.6% in adult Indian patients undergoing CTCA. Prior knowledge of these anatomical finding can prevent a catastrophe during surgery or endovascular interventions. Hence, it is important that clinicians, as well as radiologists, are aware of these entities.

Ruptured abdominal aortic aneurysm with aortocaval fistula and embolic IVC thrombus-a rare clinical scenario detected on CT angiography.

Rupture with fistulization of an abdominal aortic aneurysm with the vena cava is a rare complication and typically presents with congestive cardiac failure. Embolization of a thrombus from the aneurysm into the vena cava can however present in the absence of failure symptoms which can make it difficult to diagnose clinically without cross sectional imaging.

Aortic root surgery in Marfan syndrome.

Marfan syndrome (MFS) is an autosomal dominant connective disease etiologically related with FBN-1 gene mutation. The altered microfibril protein structure result in characteristic cardiovascular abnormalities including aortic root dilatation, aortic root aneurysms, and aortic dissections. Aortic root aneurysms and subsequent dissection are the major causes of reduced life expectancy in MFS patients. Prophylactic aortic root replacement has improved the survival of patients with MFS. Elective root replacement carries very low mortality and morbidity. Emergency root replacement for dissection is accompanied with higher early mortality and late deaths/interventions. Both the techniques of aortic root replacement, total root replacement (TRR) with a prosthetic valved conduit, and valve-sparing root replacement (VSRR) yield excellent early and late results. Considering the low risk of prosthetic valve-related events, the improved long-term survival, and event-free survival, TRR continues to be a very effective surgical option. VSSR also seems to be a good option for the first 10 to 15 years following surgery in MFS patients. The choice of procedure depends upon available expertise, patients' choice, feasibility of anticoagulation, possibility of pregnancy, and lifestyle of the patient. Aortic root morphology and state of valve cusps also affect the decision making. In recent times, personalized external aortic root support (PEARS) with a macroporous mesh sleeve has also emerged as a promising alternative to aortic root replacement. All these patients need close monitoring for whole life after surgical intervention.

Pigtail saves a twisted redo: successful management of chylopericardium after midline valve surgery.

Pericardial effusion after midline cardiac surgery may be transudative or exudative. The exudative infective or haemorrhagic variety requires early surgical intervention. However there are rare cases of collections like chylomediastinum which should be ruled out. Their low incidence prompts to establish protocol for evaluating postoperative pericardial collections, which includes echocardiography and biochemical analysis of aspirate. The same is important from the perspective of management as chylopericardium may be successfully managed without surgical intervention by aspiration, pig tail insertion, dietary and medical management, which we demonstrate through our rare case which occurred after midline double valve replacement.

Jejunal adenocarcinoma with concomitant enterolith presenting as acute intestinal obstruction.

An enterolith is an infrequent clinical entity. It is generally diagnosed on imaging or at surgery. It is usually associated with underlying benign lesions like intestinal tuberculosis or Crohn's disease. Here, we report an unusual case of an elderly lady presenting with an acute small-bowel obstruction. On admission, her abdominal X-ray revealed a radio-opacity obstructing the jejunum. Her subsequent abdominal contrast-enhanced computed tomography revealed a big enterolith entrapped in a stricturous jejunal lesion. However, there was no pneumobilia. Consequently, she underwent an exploratory laparotomy followed by an "en-block" jejunal resection for suspiciously malignant impassable jejunal stricture. The cutopen specimen revealed 5 x 4 cm enterolith embedded in a tight ulcero-proliferative stricture. Histopathology confirmed jejunal adenocarcinoma. It is always prudent to suspect an underlying small-bowel malignancy while managing a seemingly straightforward case of small-bowel obstruction. The policy of prophylactic radical oncologic clearance may avoid inadvertent R1/R2 resections.