A Rare Case of Internal Jugular Venous Malformation Treated by Surgical Excision.

This paper reports a case of an internal jugular venous malformation (IJVM) and route of treatment in a patient with limited symptoms. After history and imaging studies, a determination of surgical excision was made to rule out possible malignancy and future problems such as thrombosis. The mass was resected, and part of the IJVM was ligated. The mass had no identifiable malignancy, and the patient recovered fully with no complications. The paper highlights the importance of identifying venous malformations and highlights the reasoning behind the course of action.

The intracranial effects of flow reversal during transcarotid artery revascularization.

Background: This study aimed to assess intraoperative cerebral hemodynamic responses and embolic events during transcarotid artery revascularization via transcranial Doppler, near-infrared spectroscopy, and bispectral index monitoring. Methods: Twelve patients (7 males, 5 females; mean age: 72.8±9.0 years; range, 63 to 91 years) undergoing transcarotid artery revascularization with simultaneous transcranial Doppler, near-infrared spectroscopy, and bispectral index monitoring were analyzed in this retrospective study between September 2017 and December 2019. The mean flow velocity and pulsatility index of the middle cerebral artery, alongside near-infrared spectroscopy and bispectral index values, before flow reversal, during flow reversal, and after flow reversal phases were investigated. The presence and frequency of high-intensity transient signals were recorded to evaluate embolic incidents. Results: Significant reductions in middle cerebral artery mean flow velocity were noted during flow reversal (40.58±10.57 cm/sec to 20.58±14.34 cm/sec, p=0.0004), which subsequently returned to and exceeded baseline values after flow reversal cessation (53.33±17.69 cm/sec, p=0.0005). Near-infrared spectroscopy (71±4.4% to 66±6.2%) and bispectral index (45.71±8.5 to 40.14±8.1) values mirrored these hemodynamic changes, with notable decreases during flow reversal, and recoveries after flow reversal. The highest concentration of high-intensity transient signals was observed during stent deployment, signifying a critical embolic phase. No perioperative neurological complications or other significant adverse events were documented. Conclusion: Transcranial Doppler, near-infrared spectroscopy, and bispectral index effectively monitor cerebral hemodynamics and embolic potential during transcarotid artery revascularization, providing real-time data crucial for optimizing perioperative management. These findings underscore the clinical value of multimodal monitoring in improving patient outcomes in transcarotid artery revascularization procedures.

Pulmonary Embolism and Cardiovascular Care: Revolutionary Advances for the Decade Ahead.

Introductory overview for Methodist DeBakey Cardiovascular Journal Issue 20.3 on Pulmonary Embolism, written by the issues' guest editors.

Image Guidance Techniques and Treatment Approach Optimization in the Management of Type-II Endoleak After Endovascular Aortic Aneurysm Repair.

BACKGROUND: Over the past 3 decades endovascular aortic aneurysm repair emerged as the primary approach for abdominal aortic aneurysm management, however the occurrence of endoleak following endograft implantation imposes a high toll on patients and hospitals alike. The early diagnosis and appropriate treatment of endoleaks is associated with better outcomes, which calls for more advanced imaging and a standardized approach for endoleak diagnosis and management following endovascular aortic aneurysm repair. Although conventional strategy with non-targeted deployment of coils and embolic material in the aneurysm sac is considered to be the standard approach in many hospitals, it may not prove to be a viable option, given that it affects any further follow-up imaging in the event of sub-optimal therapy and consequent recurrence. METHODS: Based on our tertiary aortic referral center experience we summarize and describe strategies for optimal selection of various treatment approaches for Type-II Endoleak management including endovascular, percutaneous and laparoscopic approaches with particular focus on intraoperative image guidance techniques. RESULTS: After failed conventional endovascular embolization attempt we recommend specific complex type II endoleak management approaches based on the location of the endoleak within the aneurysm sac along the x, y and z axis. A transabdominal or laparoscopic approach enable treatment in endoleaks located in the anterior portion of the sac. Endoleaks in the posterior portion of the sac could be treated using the transcaval or the translumbar approach, depending on whether the endoleak is situated on the left or the right side. Alternative strategies should be considered if patient anatomy does not allow for either transcaval or translumbar approach. The transgraft technique is reserved for endoleaks located in the cranial portion of the sac, while the perigraft approach could present a means of treatment for endoleaks situated in the caudal portion of the aneurysm sac. CONCLUSION: We encourage establishing a patient specific treatment plan in accordance with individual anatomy based on cross sectional imaging modality (time resolved dynamic imaging in selected cases) and intraoperative image guidance to provide a safe and accurate endoleak localization and embolization for patients undergoing type II endoleak treatment.

Longitudinal Magnetic Resonance Imaging-Based Superficial Femoral Artery Velocity Measurements in Diabetic and Nondiabetic Patients With Peripheral Artery Disease.

BACKGROUND: Longitudinal associations of noninvasive 2-dimensional phase-contrast magnetic resonance imaging (2D-PC-MRI) velocity markers of the superficial femoral artery (SFA) were analyzed along with the characteristics of peripheral artery disease (PAD). We hypothesized that the 2-year differences in MRI-based measures of SFA velocity were associated with longitudinal changes in markers of PAD. METHODS: A total of 33 (11 diabetic, 22 nondiabetic) patients with PAD with baseline and 2-year follow-up MRI scans were included in this secondary analysis of the Effect of Lipid Modification on Peripheral Artery Disease after Endovascular Intervention Trial (ELIMIT). Electrocardiographically gated 2D-PC-MRI was performed at a proximal and a distal location of the distal SFA territory. SFA lumen, wall, and total vessel volumes and the normalized wall index (NWI) were analyzed. RESULTS: Baseline characteristics did not differ between diabetic and nondiabetic PAD patients. Maximum proximal and distal SFA velocity measures did not differ between baseline and 2 years (41.98 interquartile range (IQR) (23.58-72.6) cm/s vs. 40.31 IQR (26.69-61.29) cm/s; P = 0.30). Pooled analysis (N = 33) showed that the 24-month change in the NWI was inversely associated with the 24-month change in the proximal maximal SFA velocity (beta = -168.36, R2 = 0.150, P value = 0.03). The 24-month change of the maximum velocity differences between the proximal and distal SFA locations was inversely associated with the 24-month changes in peak walking distance (beta = -0.003, R2 = 0.360, P value = 0.011). CONCLUSION: The 2-year change of SFA plaque burden is inversely associated with the 2-year change of proximal peak SFA blood flow velocity. 2D-PC-MRI measured SFA velocity may be of interest in assessing PAD longitudinally.

Endovascular retrieval of a fractured Optease inferior vena cava filter using endobronchial forceps and intraoperative cone-beam computed tomography guidance.

Endovascular retrieval of fractured inferior vena cava (IVC) filters after the manufacturer recommended indwelling time can be challenging and require advanced retrieval techniques. We describe an endovascular retrieval technique of a fractured Optease IVC filter in a 57-year-old woman using endobronchial forceps and intraoperative cone-beam computed tomography guidance. Following incomplete filter retrieval, the location and orientation of fractured strut was confirmed by cone-beam computed tomography venography. The embedded filter fragment was then successfully removed using endobronchial forceps via a transjugular venous approach. In the present report, we highlight the additional value of intraoperative cross-sectional imaging, in conjunction with advanced endovascular techniques, for retrieval of challenging IVC filters.

Emerging Applications for Computer Vision and Artificial Intelligence in Management of the Cardiovascular Patient.

Artificial intelligence and telemedicine promise to reshape patient care to an unprecedented extent, leading to a safer and more sustainable work environment and improved patient care. In this article, we summarize how these emerging technologies can be used in the care of cardiovascular patients in such ways as fall detection and prevention, virtual nursing, remote case support, automation of instrument counts in the operating room, and efficiency optimization in the cardiovascular suite.

Scoping review of atherectomy and intravascular lithotripsy with or without balloon angioplasty in below-the-knee lesions.

Objective: We evaluated how contemporary data on infrapopliteal vessel preparation have been reported to identify knowledge gaps and opportunities for future research. Methods: A literature search was performed on Web of Science, PubMed, and Google Scholar to identify clinical research studies reporting on the outcomes of vessel preparation in below-the-knee lesions between 2006 and 2021. Studies were excluded if they were case reports or case series with a sample size of <10. Results: A total of 15 studies comprising 5450 patients were included in this review, with vessel preparation performed in 2179 cases (40%). Of the 15 studies, 2 were randomized controlled trials, 6 were prospective cohort studies, and 7 were retrospective studies. Only 2 of the 15 studies evaluated intravascular lithotripsy devices, and 6 were noncomparative studies. The mean diameter stenosis treated was 86.7% ± 12.6%, and the lesion length was 71.7 ± 55.3 mm. Large heterogeneity was found in the choice and definitions of end points and lesion characterization. Procedural success ranged between 84% and 90%, and bailout stenting was performed in 0.8% to 15% of cases. Of the five studies comparing procedural success of atherectomy with or without balloon angioplasty to balloon angioplasty alone, only one was in favor of the former (99% vs 90%; P < .001). The remaining studies did not show any statistically significant differences. Similarly, atherectomy had a significantly superior limb salvage rate in only one of seven studies (91% vs 73%; P = .036). In contrast, the seven studies evaluating target lesion revascularization reported conflicting outcomes, with two in favor of atherectomy, two against atherectomy, and three reporting similar outcomes between atherectomy and balloon angioplasty alone. None of the studies evaluating intravascular lithotripsy was comparative. Conclusions: The current body of evidence on vessel preparation in tibial arteries is largely based on observational studies with a large amount of heterogeneity and a number of inconsistencies. Further clinical and experimental studies with more robust study designs are warranted to investigate the comparative efficacy and safety of vessel preparation in calcified tibial arteries.

Cardiovascular collapse during mechanical thrombectomy for acute pulmonary embolism and the role of extracorporeal membrane oxygenation in patient rescue.

BACKGROUND: Driven by the ability to avoid thrombolytics and provide a one stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for the treatment of intermediate-to-high risk pulmonary embolism (PE). This study investigated the incidence and outcomes of cardiovascular collapse during MT procedures and demonstrates the role of extracorporeal membrane oxygenation (ECMO) in salvaging patients. METHODS: This single-center retrospective review included patients with PE undergoing MT with the FlowTriever device between 2017 and 2022. Patients presenting periprocedural cardiac arrest were identified and their perioperative characteristics and postoperative outcomes were evaluated. RESULTS: A total of 151 patients with a mean age of 64 ± 14 years who presented with intermediate-to-high risk PE received LBAT procedures during the study period. The simplified PE severity score was ≥1 in 83% of cases and the average RV/LV ratio was 1.6 ± 0.5, with and elevated troponin in 84%. Technical success was achieved in 98.7% and a significant decrease in pulmonary artery systolic pressure (PASP) was observed (37 mm Hg vs 56 mm Hg; P < .0001). Intraoperative cardiac arrest occurred in nine patients (6%). These patients were more likely to present PASP of ≥70 mm Hg (84% vs 14%; P < .001), were more hypotensive upon admission (systolic of 94 ± 14 mm Hg vs 119 ± 23 mm Hg; P = .004), presented lower oxygen saturation levels (87 ± 6% vs 92 ± 6%; P = .023) and were more likely to present with a history of recent surgery (67% vs 18%; P = .004). Four patients were rescued successfully with ECMO and their residual PE was subsequently removed before discharge by surgical embolectomy in two of the four cases and repeat MT in the other two. All five patients (3%) who did not receive ECMO support expired intraoperatively. The overall 30-day mortality was 8% with no death occurring in patients who were salvaged with ECMO. CONCLUSIONS: Large-bore aspiration thrombectomy for acute PE is associated with favorable technical outcomes, but the concern for acute cardiac decompensation is non-negligible in patients presenting with high-risk features and a PASP of ≥70 mm Hg. ECMO can help to salvage some of these patients and should be considered in the treatment algorithms of patients deemed at high risk.

Dynamic Imaging of Aortic Pathologies: Review of Clinical Applications and Imaging Protocols.

The past decade has seen significant advances in dynamic imaging of the aorta. Today's vascular surgeons have the opportunity to choose from a wide array of imaging modalities to evaluate different aortic pathologies. While vascular ultrasound and aortography are considered to be the bread and butter imaging modalities, newer dynamic imaging techniques provide time-resolved information in various aortic pathologies. However, despite growing evidence of their advantages in the literature, they have not been routinely adopted. In order to understand the role of these emerging modalities, one must understand their principles, advantages, and limitations in the context of various clinical scenarios. In this review, we provide an overview of dynamic imaging techniques for aortic pathologies and describe various dynamic computed tomography and magnetic resonance imaging protocols, clinical applications, and potential future directions.

Explant of the Aortic Endograft: Today's Solutions, Tomorrow's Problems.

Type 2 endoleaks remain the Achilles heel of abdominal aortic endografting. They drive imaging costs and repeat intervention. We believe that after two endovascular interventions, patients should be considered for either graft explantation or graft salvage through an open abdominal exploration. Graft explantation has been associated with increased morbidity and mortality but remains necessary in the face of non-correctible type 1a endoleaks, graft failure, or graft infection. In the majority of cases AAA expansion due to persistent type 2 endoleak is the culprit. In this situation, open repair, with oversewing of the lumbar or inferior mesenteric arteries, can be accomplished providing the seal zones and component overall zones are adequate. This approach does not require aortic clamping. We provide detailed descriptions and videos to facilitate the surgeon in performing these complex procedures.

To Cross or Not to Cross: Using MRI-Histology to Characterize Dense Collagenous Plaque in Critical Limb Ischemia.

Peripheral artery disease (PAD) is caused by atherosclerotic buildup in the lower extremities, leading to obstruction and inadequate perfusion to the peripheral vasculature. Impenetrable plaques initially treated with percutaneous vascular intervention (PVI) have led to worse secondary bypass outcomes and amputation in patients. In this case report, we discuss the importance of using magnetic resonance imaging (MRI) histology in PVI planning in a patient with critical limb ischemia. PVI attempts to recanalize the limb failed because of an impenetrable occlusion in the popliteal artery that was not identified on routine preoperative imaging. Subsequent bypass occluded multiple times eventually requiring an above-knee amputation. An MRI-histology protocol-using ultrashort echo time (UTE) and T2-weighted (T2W) sequences-that was performed prior to the index PVI identified the occlusion as a dense collagen plaque. Histology analysis of the amputated specimen confirmed the MRI finding. This imaging modality offers a novel approach to characterize plaque composition and morphology, thereby identifying lesions at greatest risk of PVI failure and potentially playing an important role in selecting the right candidates for an endovascular-first approach.

Dynamic Computed Tomography Angiography is More Accurate in Diagnosing Endoleaks than Standard Triphasic Computed Tomography Angiography and Enables Targeted Embolization.

BACKGROUND: The primary objective was to compare the accuracy of dynamic computed tomography (CT) angiography (d-CTA) with standardized triphasic contrast enhanced CT angiography (t-CTA) in diagnosing endoleak type after endovascular aortic repair (EVAR) using digital subtraction angiography (DSA) as reference standard. The secondary objective was to study the impact of d-CTA on image fusion-guided endoleak embolization. METHODS: A retrospective review of patients who underwent d-CTA imaging after EVAR between March 2019 and July 2021 was performed. Deidentified images were independently reviewed by two-two blinded readers to document endoleak type and target vessels. An impact of d-CTA-guided embolization was evaluated by a number of planning angiograms, radiation exposure, and accuracy of target vessel overlay. RESULTS: During the study period, 52 patients underwent d-CTA and 19 had all 3 modalities available for analysis. DSA imaging confirmed 4 (21.0%) type-I, 14 (73.7%) type-II, and 1 (5.3%) type-III endoleak. Findings from d-CTA matched with DSA in 19/19 cases (100%), whereas t-CTA matched in 14/19 cases (73.7%). In type-II endoleaks, the number of target vessels identified by d-CTA, t-CTA, and DSA were 23, 17, and 16, respectively. Mean dose-length product from d-CTA and t-CTA was 1,445 ± 551 and 1,612 ± 530 mGy × cm (P = 0.26). Nine patients underwent d-CTA-guided type-II endoleak embolization, using a median of 1 (range: 1-4) planning angiogram before embolization using 21.6 (± 8.7)% of total procedural radiation dose. Target vessel overlay was accurate in 9/9 (100%) cases. CONCLUSIONS: Dynamic, time-resolved CTA is more accurate compared to standardized triphasic contrast enhanced CTA in diagnosing endoleak type after EVAR. In type-II endoleak, d-CTA better identified target vessels and enabled safe, targeted embolization.

Human Cadaveric Model for Vessel Preparation Device Testing in Calcified Tibial Arteries.

To describe an ex vivo model for vessel preparation device testing in tibial arteries. We performed orbital atherectomy (OA), intravascular lithotripsy (IVL), and plain balloon angioplasty (POBA) on human amputated limbs with evidence of concentric tibial artery calcification. The arterial segments were then harvested for ex vivo processing which included imaging with microCT, decalcification, and histology. The model was tested out in 15 limbs and was successful in 14 but had to be aborted in 1/15 case due to inability to achieve wire access. A total of 22 lesions were treated with OA on 3/22 lesions, IVL on 8/22, and POBA without vessel preparation on the remaining 11/22. Luminal gain was assessed with intravascular ultrasound and histology was able to demonstrate plaque disruption, dissections, and cracks within the calcified lesions. A human cadaveric model using amputated limbs is a feasible, high-fidelity option for evaluating the performance of vessel preparation devices in calcified tibial arteries.

Dynamic, Time-Resolved CT Angiography After EVAR: A Quantitative Approach to Accurately Characterize Aortic Endoleak Type and Identify Inflow Vessels.

PURPOSE: Our purpose was to study the accuracy of dynamic computed tomography angiography (d-CTA) in characterizing endoleak type, inflow vessels as compared with digital subtraction angiography (DSA) using qualitative and quantitative analysis. METHODS: Between March 2019 and January 2021, all patients who underwent d-CTA imaging after EVAR were retrospectively reviewed. Two blinded independent reviewers qualitatively reviewed d-CTA and DSA images. Quantitative region of interest (ROI) analysis was performed by measuring time-resolved contrast enhancement within the aorta and endoleak lesion(s) in the aneurysm sac. Differences between time-to-peak enhancement (Δ TTP) across different ROIs were quantified. RESULTS: A total of 48 patients underwent d-CTA during the study period, of whom 24 patients had abdominal EVAR and DSA imaging for comparison. Qualitative review of DSA imaging showed type I (n=4), type II (n=16), and type III (n=2) and no endoleak (n=2). In 23 of 24 patients (95.8%), d-CTA findings correlated with DSA findings for endoleak type. One patient had a type III endoleak that was demonstrated only in d-CTA (arising from defect in polymer sealing ring of Ovation stent graft) imaging. In type II endoleak cases, d-CTA identified more inflow vessels than DSA imaging (33 vs 21 vessels, p=0.010). Quantitative analysis showed mean (±SD) Δ TTP values for type I endoleak as 1.8 (±1.8) seconds, type II as 9.6 (±3.5) seconds, and for type III endoleak as 5.6 (±1.3) seconds. CONCLUSION: Dynamic CTA can accurately characterize aortic endoleak type, inflow vessels as compared with DSA imaging. Quantitative parameters such as Δ TTP enhancement can help better differentiate endoleak types and provide an objective approach to endoleak diagnosis.

From bench to bedside: A narrative review and institutional experience with experimental models for vascular device design and translation.

The past 2 decades have seen a rise in vascular innovations and a rapid evolution in endovascular device technology, with the emergence of atherectomy, intravascular lithotripsy, drug elution technology, thrombectomy devices, and many more. Like all other medical devices, vascular devices undergo a life cycle composed of a concept phase, a planning and design phase, a regulatory process, a launch phase, and a post-market stage. Experimental and preclinical models are required at various stages of the life cycle to aid in the designing, refining, and feasibility testing of novel devices before they are transferred to clinical practice. The experimental testing of these devices relies heavily on the ability to simulate human anatomy and physiology, and to mimic or induce specific disease processes. Computational and benchtop models play very important roles at the early stages of the manufacturing process, and animal and cadaveric models are indispensable for testing the mechanistic performance, safety, and efficacy of novel devices before they are used in clinical trials and regulatory approval is obtained for public use.

Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Model Using Motion-Based Performance Metrics.

PURPOSE: Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model. MATERIALS AND METHODS: Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities. RESULTS: Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (-5.78±3.14 and -8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually. CONCLUSIONS: Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system. CLINICAL IMPACT: Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS.