Combination of mural thrombus and age improves the identification of all-cause mortality following branched endovascular repair.

BACKGROUND: In-hospital and 30-day mortality rates of endovascular repair of thoracoabdominal aortic aneurysms shows a significant improvement over open surgery, although we are not seeing a significant difference at 1 year. We assess the hypothesis that a greater mural thrombus ratio within the aorta could function as an indicator of postoperative mortality. METHODS: The mural thrombus ratio and preoperative comorbidities of 100 consecutive patients from a single center undergoing endo-debranching between 2012 and 2019 were evaluated. Logistic regression, survival analysis, and decision tree methods were used to examine each variable's association with death at 1 year. RESULTS: At the time of analysis, 73 subjects had 1-year outcomes and adequate imaging to assess the parameters. At 1 year, the overall survival for all subjects was 71.2% (21 died, 52 survived). For patients with a favorable mural thrombus ratio (n = 36), the overall 1-year survival was 86.1% (5 died, 31 survived). The subjects with an unfavorable mural thrombus ratio (n = 37), had an overall 1 year survival of 56.8% (16 died, and 21 survived). The only preoperative mortality factor that was statistically significant between the subjects with an unfavorable mural thrombus ratio was age of the patient. The survival for subjects 75 years and older with an unfavorable mural thrombus ratio was 90% (one died, nine survived) vs only 44.4% survival for subjects less than 75 years with an unfavorable mural thrombus ratio (15 died, 12 survived). CONCLUSIONS: This study examined whether a patient's mural thrombus ratio may be an indicator of 1-year survival. These findings suggest that the combination of a patient's aortic mural thrombus ratio and age can function as a preoperative indicator of their underlying cardiac reserve. Identifying patients with low cardiac reserve and fitness to handle the increased cardiac demands owing to the physiologic response to extensive aortic stent grafting before undergoing aortic repair may allow for modification of preoperative patient counseling and postoperative care guidelines to better treat this patient population.

Retained Coronary Balloon Requiring Emergent Open Surgical Retrieval: An Uncommon Complication Requiring Individualized Management Strategies.

The entrapment of coronary intervention devices within the coronary vasculature is a rare but potentially devastating procedural complication. We report a case of an entrapped balloon and broken shaft that had to be retrieved by an open surgical approach. When device extraction is indicated and the use of snaring equipment is unsuccessful or inappropriate, a number of alternative percutaneous maneuvers can be attempted. These include (1) simple advancement and withdrawal of a trapped balloon, (2) use of a "buddy" wire to straighten the vessel and free the trapped device, (3) inflation of a buddy balloon adjacent to a trapped primary balloon to free the device, (4) partial inflation of a buddy balloon distal to a trapped device followed by gentle withdrawal, (5) use of an in-guide secondary balloon to trap the lost device, (6) advancement and twisting of guidewires to entwine the lost device, (7) saline dilution of trapped balloons, and (8) anchoring balloon and reverse-wire puncture of an undeflated and entrapped primary balloon. Careful consideration of various device retrieval strategies is indicated before resorting to open surgical retrieval in the rare instance of intracoronary device entrapment.

Extranodal Rosai-Dorfman Disease Presenting as a Pericardial Mass and Constrictive Pericarditis.

Rosai-Dorfman disease is a rare, idiopathic disorder of histiocyte proliferation. We describe a case of a 59-year-old woman who presented with heart failure symptoms from a large pericardial mass causing constrictive pericarditis. Pathologic findings including immunohistochemistry suggested the diagnosis. She was treated with corticosteroids and improved clinically. (Level of Difficulty: Advanced.).

Single Coronary Artery Arising from the Right Sinus of Valsalva and the Role of Coronary Computed Tomography Angiography.

There are many variations of coronary anatomy encountered during coronary angiogram. Anatomy demonstrating a single coronary artery is a rare congenital coronary artery anomaly. The entire heart is supplied solely by a coronary artery with single coronary ostium. We present a rare case of single coronary artery arising from the right sinus of Valsalva. The patient had presented with atypical chest pain and a stress test was performed, which was abnormal. We proceeded with coronary angiography which showed a common ostium of the right and left coronary artery coming from the right coronary cusp. The coronary computed tomography angiography revealed the left main had a pre-pulmonic course, crossing the base of the heart and passing anterior to the pulmonary artery and then branching into the left anterior descending artery and left circumflex artery. Patients with single coronary artery usually has benign prognosis; however, a specific coronary anomaly may result in myocardial ischemia and sudden cardiac death if the anomalous coronary artery takes an intra-arterial course, running between the aorta and the pulmonary artery. Coronary computed tomography angiography is a useful imaging modality to identify anatomical course of coronary anomaly.

A Rare Case of Coronary Artery Embolism in a Patient with d-Transposition of the Great Arteries with Prior Mustard Repair.

The dextro-transposition of great arteries (d-TGA) is a rare, congenital, cyanotic heart disease and there is a paucity of data regarding long-term cardiovascular outcomes. We present a rare case of non-ST-elevation myocardial infarction (NSTEMI) in a patient with surgically repaired d-TGA. A 43-year-old male who had previously undergone a Mustard atrial switch palliative procedure presented with chest pain and diaphoresis and was diagnosed with NSTEMI. A coronary angiogram revealed a small, underdeveloped, left anterior descending and a large, left circumflex coronary artery with an acute embolic lesion. The embolic lesion was secondary to atrial fibrillation and was successfully treated with aspiration thrombectomy. This case highlights the variations in coronary anatomy in surgically repaired d-TGA and the importance of recognizing the potential for long-term complications in these cases.

Spontaneous Coronary Artery Dissection: A Rare Manifestation of Alport Syndrome.

Alport syndrome (AS) is a genetic disorder due to inheritance of genetic mutations which lead to production of abnormal type IV collagen. AS has been associated with renal, auditory, and ocular diseases due to the presence of abnormal alpha chains of type IV collagen in the glomerulus, cochlea, cornea, lens, and retina. The resulting disorder includes hereditary nephritis, corneal opacities, anterior lenticonus, fleck retinopathy, temporal retinal thinning, and sensorineural deafness. Aortic and aortic valve pathologies have been described as extrarenal manifestations of AS in multiple case reports. One case report described intramural hematoma of the coronary artery. We report the first case of true spontaneous coronary artery dissection (SCAD) with an intimal flap as a very rare manifestation of AS. The patient is a 36-year-old female with history of AS with chronic kidney disease, hypertension, and obesity who presented to the emergency room with acute onset of substernal chest pain radiating to her neck and arms. Troponin was elevated, and ECG showed transient 1 mm ST-segment elevation in the inferior leads. Subsequent coronary angiography revealed localized dissection of the left circumflex artery. Percutaneous coronary angioplasty was performed and her symptoms improved. This case illustrates that SCAD may be a manifestation of AS patients with chest pain.

A rare large right atrial myxoma with rapid growth rate.

Atrial myxomas are the most common benign intracavitary cardiac neoplasms. They most frequently occur in the left atrium. Right atrial tumors are rare, comprising 20 percent of myxomas achieving an incidence of 0.02 percent. Due to their rarity, right atrial tumor development and associated clinical symptoms has not been well described. The classical clinical triad for the presentation of left atrial myxomas--heart failure, embolic events, and constitutional symptoms--may not be applicable to right sided tumors. Also, natural development of myxoma is not well described, as surgical resection is the common practice. Previously ascribed growth rates of myxomas refer mostly to left atrial ones, as right atrial tumors are rare. We present a case of right atrial myxoma with growth rates exceeding those previously described.

A multispecialty consensus-based approach to carotid artery revascularization is feasible in routine clinical practice and results in excellent clinical outcomes.

BACKGROUND: Carotid artery stenting (CAS) and endarterectomy (CEA) are considered competing rather than complementary carotid artery revascularization (CAR) strategies. However, patient characteristics that increase procedural risk are quite different for CAS or CEA. We hypothesized that selecting a CAR strategy based on individual patient characteristics using a multispecialty consensus based (MSCB) approach will result in superior outcomes in the overall CAR group. We evaluated the feasibility of an MSCB approach to CAR in routine clinical practice. METHODS: We performed a retrospective review of patients undergoing CEA or CAS at the Kansas City Veterans hospital over a 2-year period. As routine clinical practice, each case was discussed in a weekly "vascular conference" by vascular surgery, radiology, and interventional cardiology physicians and a revascularization strategy was chosen. Thirty-day and 1-year incidences of stroke, transient ischemic attack, myocardial infarction, and death were recorded. RESULTS: Eighty CAR procedures were performed (45 CEAs and 35 CASs). The CAS group had an average of 1.9 surgical high-risk features, while the CEA group had 0.5 (P<.05). The CAS group had significantly more common carotid stenosis, stenoses considered too high or low for CEA, and more long internal carotid artery lesions. For the overall CAR group, 30-day incidence of stroke/transient ischemic attack, myocardial infarction, and death was 2.5% and 1-year incidence of stroke and death was 5%. CONCLUSION: An MSCB approach allows the choice of an optimal CAR strategy with excellent clinical outcomes. Reporting outcomes for the overall CAR may be a better way of assessing and comparing outcomes of CAR across healthcare systems rather than CEA or CAS outcomes separately.

Medical therapy for peripheral arterial disease.

PURPOSE OF REVIEW: Peripheral arterial disease (PAD) is underdiagnosed, undertreated, and increasing in prevalence. Continued advances in understanding atherosclerosis, pathophysiology of vascular disease and risk factor modification emphasize the importance of a complete medical regimen. With the recently changed guidelines for PAD suggesting screening patients at an earlier age and the known benefits of using preventive therapies for PAD, this is the perfect time to review recent information and research on medical therapy for PAD, both for symptomatic patients and for secondary prevention. RECENT FINDINGS: PAD is a manifestation of systemic atherosclerosis. With the recent update of the ACC/AHA guidelines for the management of PAD, risk factor modification continues to be a major focus. Smoking is one of the most important modifiable risk factors in patients with PAD. New recommendations and therapeutic options exist for assisting patients in smoking cessation. Additionally, new evidence continues to support controlling hypertension, controlling lipids and use of antiplatelet agents. Evidence continues to evolve about the evidence of exercise therapy in symptomatic and asymptomatic PAD. SUMMARY: PAD is associated with increased risk of cardiovascular morbidity and mortality. Medical therapy is targeted toward systemic atherosclerosis and risk factor modification. Exercise therapy is the most studied and validated therapy for symptomatic peripheral arterial disease.

Role of hybrid endovascular suite in improving outcomes of surgical ligation of coronary artery fistula.

Coronary artery fistulae are rare congenital or acquired coronary artery anomalies that can lead to significant cardiovascular morbidity and mortality. Surgical ligation has long been utilized in the treatment of these abnormalities. However, there is a high rate of recurrence due to incomplete closure of the fistulae, especially when multiple channels are present. Transcatheter techniques have become an acceptable alternative with good outcomes. Nevertheless, not all fistulae are amenable to the transcatheter approach and surgical repair is the treatment of choice. Intraoperative coronary angiography can improve the outcomes of surgery but has only sparingly been used due to the technical difficulties in a standard operating suite. Hybrid suites are becoming quite common these days with the emergence of procedures such as endovascular stent grafting and percutaneous valves. These suites have a complete imaging set up like a traditional catheterization laboratory and are also full operating suites. This case report discusses the use and potential benefits of performing intraoperative coronary angiography in a dedicated hybrid suite to help guide and ensure complete surgical closure of all fistulous connections.

Peripheral arterial disease in women.

Women with peripheral arterial disease (PAD) are not well identified in cardiology practice, are undertreated, and have different relative risks for development of PAD than men. Recognizing that PAD is considered a coronary artery disease risk equivalent emphasizes that primary care physicians and cardiologists need to be aggressive for screening and treatment of this disorder. This article reviews the prevalence and risk factors for PAD in women, sex-based differences in development of PAD, and current screening and treatment recommendations.