Cardiac Angiosarcoma in the Right Atrium Treated by Surgical Resection.

We present the case of a 49-year-old female of Caucasian European descent with chest tightness, fatigue, and palpitations, ultimately diagnosed with primary intracardiac angiosarcoma. Initial echocardiography revealed a significant mass within the right atrium, infiltrating the free wall. Surgical intervention included tumor excision and partial resection of the superior vena cava. Histopathological examination confirmed a high-grade angiosarcoma. Postoperative imaging identified a recurrent mass in the right atrium, suggestive of thrombus, alongside Takotsubo cardiomyopathy. Considering the elevated surgical risks and the presence of cardiomyopathy, management included anticoagulation therapy with Warfarin and adjuvant chemotherapy with Paclitaxel. Follow-up cardiac magnetic resonance imaging demonstrated a recurrent angiosarcoma with superimposed thrombus. This case presents the complex diagnostic and therapeutic landscape of angiosarcoma, highlighting the critical importance of early surgical intervention, advanced imaging techniques, and vigilant postoperative monitoring.

An Unusual Case of Cardiac Mass: A Multimodal Approach in Diagnosis and Treatment.

Diagnosing intracardiac masses poses a complex, multimodal challenge. We present the case of a 72-year-old woman with a history of rheumatic fever leading to mitral stenosis and a previous mitral valve commissurotomy who reported fatigue, weakness, and palpitations over the past three months. Echocardiography revealed a tumor (53 × 40 mm) in the enlarged left atrium, attached by a wide base to the left atrium wall, exhibiting variable densities. Computerized tomography identified a heterodense mass (53 × 46 × 37 mm) with similar attachments. Angiography showed two branches from the circumflex artery intricately associated with the mass. Despite unsuccessful embolization of the mass' blood supply, surgical intervention including mitral valve replacement, tricuspid valve annuloplasty, and tumor removal was pursued. Pathohistological analysis confirmed the mass as a thrombus. During the postoperative follow-up, the patient presented with no complaints. Follow-up echocardiography indicated the normal function of the mechanical mitral valve prosthesis and the absence of intracardiac masses. While it remains unknown whether this neovascularization is specific to patients with severe mitral valve disease, this case highlights the diagnostic challenges of differentiating between thrombi and tumors in the context of mitral valve disease. It illustrates the critical role of multimodal imaging in elucidating the anatomical and functional relationships within the heart, thereby guiding accurate diagnosis and effective treatment.

Idiopathic Dilatation of the Right Atrium: Diagnosis and Management.

Idiopathic dilatation of the right atrium is a rare condition with an unknown etiology. It is characterized by a significant enlargement of the right atrium without the presence of other valvopathies, intracardiac shunts, or pulmonary hypertension. This report presents the case of a 50-year-old woman with a significantly enlarged right atrium that was identified at birth; however, a definitive diagnosis was made later in life. The patient did not have any genetic diseases. Through the help of regular follow-up, anticoagulant therapy, previous radio-frequency ablation, and antiarrhythmic medications, she was able to carry a pregnancy to full term and live a regular life.

Carotid Restenosis Rate After Stenting for Primary Lesions Versus Restenosis After Endarterectomy With Creation of Risk Index.

PURPOSE: Carotid artery stenting (CAS) is an option for carotid restenosis (CR) treatment with favorable outcomes. However, CAS has also emerged as an alternative to carotid endarterectomy (CEA) for the management of patients with primary carotid stenosis. This study aimed to report CR rates after CAS was performed in patients with primary lesions versus restenosis after CEA, to identify predictors of CR, and to report both neurological and overall outcomes. MATERIALS AND METHODS: From January 2000 to September 2018, a total of 782 patients were divided into 2 groups: The CAS (prim) group consisted of 440 patients in whom CAS was performed for primary lesions, and the CAS (res) group consisted of 342 patients with CAS due to restenosis after CEA. Indications for CAS were symptomatic stenosis/restenosis >70% and asymptomatic stenosis/restenosis >85%. A color duplex scan (CDS) of carotid arteries was performed 6 months after CAS, after 1 year, and annually afterward. Follow-up ranged from 12 to 88 months, with a mean follow-up of 34.6±18.0 months. RESULTS: There were no differences in terms of CR rate between the patients in the CAS (prim) and CAS (res) groups (8.7% vs 7.2%, χ2=0.691, p=0.406). The overall CR rate was 7.9%, whereas significant CR (>70%) rate needing re-intervention was 5.6%, but there was no difference between patients in the CAS (prim) and CAS (res) groups (6.4% vs 4.7%, p=0.351). Six independent predictors for CR were smoking, associated previous myocardial infarction and angina pectoris, plaque morphology, spasm after CAS, the use of FilterWire or Spider Fx cerebral protection devices, and time after stenting. A carotid restenosis risk index (CRRI) was created based on these predictors and ranged from -7 (minimal risk) to +10 (maximum risk); patients with a score >-4 were at increased risk for CR. There were no differences in terms of neurological and overall morbidity and mortality between the 2 groups. CONCLUSIONS: There was no difference in CR rate after CAS between the patients with primary stenosis and restenosis after CEA. A CRRI score >-4 is a criterion for identifying high-risk patients for post-CAS CR that should be tested in future randomized trials.

Risk Factors for Carotid Restenosis in Patients After Eversion Endarterectomy vs Stenting: A Single-Center Experience.

The primary aim of the presented study is to analyze and compare the rate of carotid restenosis in patients after eversion carotid endarterectomy (eCEA), primary carotid angioplasty and stenting (CASp), and stenting for carotid artery restenosis after previous eCEA (CASr). The secondary aim is to compare clinical outcomes in patients with carotid restenosis. The total number of patients with evident carotid restenosis was 223 (24.8%). In patients with eCEA, significant carotid restenosis rate was 12.7%, in the CASp group 18.7%, and CASr 6.7%. Patients with carotid restenosis were asymptomatic in 95.1% of cases. Patients in the CASp group experienced transient ischemic attack more than patients with eCEA (P = .007), while no difference was observed regarding cerebrovascular insult (CVI). The incidence of carotid restenosis was higher in CASp patients, and increased during the follow-up. The majority of patients are asymptomatic post-procedural and the degree of carotid restenosis does not correlate with the occurrence of postoperative symptoms. High low-density lipoprotein cholesterol (LDL-C) levels, low high-density lipoprotein cholesterol (HDL-C) levels, smoking, and a history of vascular surgery correlate with higher degrees of carotid restenosis. The most important factor in the prevention of carotid restenosis is risk factor control as well as adequate pharmacological therapy.

Endovascular treatment of different types of iliac occlusions-Results from an observational study.

OBJECTIVE: The aim of this study was to evaluate the results of endovascular therapy on the treatment of different types of iliac occlusions. MATERIALS AND METHODS: A bi-center prospective, non-randomized study was conducted on 100 patients (mean age 59.14 ± 8.53; 64 men) who underwent endovascular treatment of iliac occlusive disease between January 2013 and November 2017. We evaluated baseline data, procedure, and follow-up results for the entire group, and according to Trans-Atlantic Inter-Society Consensus (TASC II) classification. The majority of patients (60%) were treated for severe claudication; 56 (56%) patients had TASC B occlusions, 28 patients TASC C, and 16 patients TASC D. RESULTS: The mean length of the occluded segments was 61.41 ± 35.15 mm. Procedural complications developed in 6 patients (6%). Mean ankle-brachial pressure index increased from 0.40 ± 0.12 preoperatively to 0.82 ± 0.16 postoperatively. The mean follow-up was 33.18 ± 15.03 months. After 1 and 5 years, the primary patency rates were 98% and 75.1%, and the secondary patency rate was 97% respectively. Regarding occlusion complexity there were no statistical significant differences in primary patency rates (TASC B vs. C vs. D: p = 0.19). There were no statistically significant differences in primary patency rates between patients in different clinical stages, as well as between the type of stents, and location of the occlusion. CONCLUSION: In our study, endovascular treatment for iliac artery occlusions proved to be a safe and efficient approach with excellent primary and secondary patency rates regardless of the complexity of occlusions defined by TASC II classification. This study is aligned with the notion that in well selected patients, endovascular therapy can be the treatment of choice even in complex iliac lesions if performed by experienced endovascular interventionists in high volume centers.

A Novel Antegrade Approach for Simultaneous Carotid Endarterectomy and Angioplasty of Proximal Lesions in Patients with Tandem Stenosis of Supraaortic Arch Vessels.

BACKGROUND: To date, all published studies analyzing simultaneous treatment of carotid and proximal atherosclerotic lesions are describing retrograde approach and several technical variations. In the presented study, for the first time, antegrade approach is described for simultaneous carotid endarterectomy (CEA) and associated brachiocephalic trunk (BCT) or common carotid artery (CCA) angioplasty in the hybrid operating room. METHODS: From January 2012 till January 2016, antegrade hybrid procedures were performed in 18 patients. All patients were admitted to our institute for elective supraaortic arch multidetector computed tomography angiography when significant simultaneous proximal and distal supraaortic arch lesions were revealed. After surgical exposure of carotid arteries, proximal lesions were crossed by antegrade approach. Prior to stent placement, internal carotid artery (ICA) is clamped at its origin with the guidewire placed in the external carotid artery (ECA). After primary stenting and control arteriography, CCA and ECA are clamped and the ICA clamp moved more distally. An arteriotomy is performed in the CCA, with flushing of possible debris and thrombus before performance of the eversion CEA, once again flushing before completion of the anastomosis. Follow-up ranged from 6 to 36 months with average follow-up of 22.15 ± 11.31 months. RESULTS: All procedures went uneventfully. Out of 18 patients, 11 were males and 7 females, mean age 66.6 ± 3.82 years. In 10 patients (55.5%), simultaneous CEA and CCA angioplasty was performed, in 7 patients (38.9%) CEA and BCT angioplasty, and in 1 patient (5.5%) tubular graft interposition between the CCA and the ICA and CCA angioplasty. In 6 patients (33.3%), CCA/BCT balloon angioplasty alone was performed simultaneously with CEA. None of the patient had postoperative transient ischemic attack, stroke, hematoma, dissection, myocardial infarction, or ischemia in the early postoperative period and during the follow-up. There were no lethal outcomes, neither in the early postoperative course nor during the follow-up. CONCLUSIONS: Antegrade approach for simultaneous treatment of proximal CCA/BCT and distal carotid lesions with temporary ICA clamping is safe and feasible procedure that should be thought of in the future in addition to already described retrograde approach.

An (In)Significant Ventricular Septal Defect and/or Double-Chambered Right Ventricle: Are There Any Differences in Diagnosis and Prognosis in Adult Patients.

A double-chambered right ventricle (DCRV) is an uncommon congenital anomaly: the right ventricle (RV) is divided into two chambers due to the presence of an abnormally located muscular band or anomalous muscle hypertrophy in the subinfundibular part of RV outflow tract, with a variable degree of obstruction. Generally, DCRV is well recognized in childhood and misdiagnosed in adult patients. Transthoracic and/or transesophageal echocardiography are the mx0435;thods of choice for the diagnosis of DCRV. Due to limitations of echocardiography in adult patients, this entity may be missed, particularly if it presents concomitant with other congenital defects, and therefore additional imaging methods such as MRI or cardiac catheterization are required for a definitive diagnosis.

Mid-term patency of the inverted left internal thoracic artery conduit.

In order to expand the revascularization of the left anterior descending coronary artery, we have applied the inverted left internal thoracic artery (left internal thoracic artery [LITA] transected near its origin, thus supplied by retrograde flow from superior epigastric and musculophrenic arteries) in carefully selected cases (four patients). The 64-slice multidetector row computed tomographic scans performed postoperatively (range, 6 to 40 days), as well as the scans performed in the follow-up period (range, 18 to 35 months) showed preserved inverted LITA conduits with thrombolysis in myocardial infarction (TIMI) 3 flow in all patients.

Carotid angioplasty and stenting is safe and effective for treatment of recurrent stenosis after eversion endarterectomy.

OBJECTIVE: This study was conducted to determine the efficiency and long-term durability of percutaneous transluminal angioplasty and carotid artery stenting in carotid restenosis (CR) treatment after eversion endarterectomy, with emphasis on variables that could influence the outcome. METHODS: We analyzed 319 patients (220 asymptomatic and 99 symptomatic) who underwent carotid angioplasty from 2002 until 2012 for CR that occurred after eversion endarterectomy. During this period, 7993 eversion endarterectomies were done for significant carotid artery stenosis. Significant CR was detected by ultrasound examination and confirmed by digital subtraction angiography or multidetector computed tomography angiography. After angioplasty (with or without stenting), color duplex ultrasound imaging was done after 1 month, 6 months, 1 year, and annually thereafter. End points encompassed myocardial infarction, stroke, and cardiovascular death (fatal myocardial infarction, fatal cardiac failure, fatal stroke), and also puncture site hematoma and recurrent restenosis. Primary end points were analyzed as early results (≤30 days after the procedure), and secondary end points were long-term results (>30 days). Variables and risk factors influencing the early-term and long-term results were also analyzed. Median follow-up was 49.8 ± 22.8 months (range, 17-121 months). RESULTS: All but one procedure ended with a technical success (99.7%). In the early postoperative period, transient ischemic attack occurred in 2.8% of the patients and stroke in 1.6%, followed by one lethal outcome (0.3%). Stent thrombosis occurred in one patient (0.3%) several hours after the angioplasty, followed by urgent surgery and graft interposition. In the long-term follow-up, there were no transient ischemic attacks or strokes, non-neurologic mortality was 3.13%, and the recurrent restenosis rate was 4.4%. The rate of non-neurologic outcomes during the follow-up was significantly higher in asymptomatic patients than in symptomatic patients (4.54% vs 0%; P = .034). The statically highest rate of transient ischemic attack was verified in patients in whom Precise (Cordis Corporation, New Brunswick, NJ) stents was used (12.2%) and a Spider Fx (Covidien, Dublin, Ireland) cerebral protection device (12.5%) was used. Female gender, coronary artery disease, plaque calcifications, and smoking history were associated with an adverse outcome after angioplasty. CONCLUSIONS: Carotid artery stenting is safe and reliable procedure for CR after eversion endarterectomy treatment, with low rate of postprocedural complications. Type of stent and cerebral embolic protection device may influence the rate of postprocedural neurologic ischemic events.

Endovascular treatment of thoracic aortic diseases.

BACKGROUND/AIM: Endovascular treatment of thoracic aortic diseases is an adequate alternative to open surgery. This method was firstly performed in Serbia in 2004, while routine usage started in 2007. Aim of this study was to analyse initial experience in endovacular treatment of thoracic aortic diseses of three main vascular hospitals in Belgrade - Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia, Clinic for Vascular Surgery of the Military Medical Academy, and Clinic for Vascular Surgery of the Institute for Cardiovascular Diseases "Dedinje". METHODS: Between March 2004. and November 2010. 41 patients were treated in these three hospitals due to different diseases of the thoracic aorta. A total of 21 patients had degenerative atherosclerotic aneurysm, 6 patients had penetrating aortic ulcer, 6 had posttraumatic aneurysm, 4 patients had ruptured thoracic aortic aneurysm, 1 had false anastomotic aneurysm after open repair, and 3 patients had dissected thoracic aneurysm of the thoracoabdominal aorta. In 15 cases the endovascular procedure was performed as a part of the hybrid procedure, after carotid-subclavian bypass in 4 patients and subclavian artery transposition in 1 patient due to the short aneurysmatic neck; in 2 patients iliac conduit was used due to hypoplastic or stenotic iliac artery; in 5 patients previous reconstruction of abdominal aorta was performed; in 1 patient complete debranching of the aortic arch, and in 2 patients visceral abdominal debranching were performed. RESULTS: The intrahospital mortality rate (30 days) was 7.26% (3 patients with ruptured thoracic aneurysms died). Endoleak type II in the first control exam was revealed in 3 patients (7.26%). The patients were followed up in a period of 1-72 months, on average 29 months. The most devastating complication during a followup period was aortoesofageal fistula in 1 patient a year after the treatment of posttraumatic aneurysm. Conversion was performed with explantation of stent-graft and open aortic in situ recontruction, followed by esophagectomy and the creation of cervical and gastrical stoma. CONCLUSION: Having in mind initial results of the 3 main vascular clinics in Belgrade, Serbia, economical situation in our country, as well as the published international results, endovascular treatment of thoracic aortic diseases is indicated in hemodinamicaly unstable patients with acute traumatic aneurysm, or in stabile patients older than 65, as well as in case of chronic diseases of the thoracic aorta in patients with significant comorbid conditions or in patients older than 65 years. Endovascular procedures on the thoracic aorta could be performed, hower, only in high-volume centers with experience in routine open surgery of thoracic aorta.

How to use the left internal thoracic artery which has been damaged during harvesting?

The established superiority of the internal thoracic artery as a coronary arterial conduit has led to its mandatory use in coronary artery bypass grafting surgery. Therefore, the damage of the internal thoracic artery during harvesting is an abysmal complication, after which the conduit is usually discarded. An alternative approach is presented here, which has allowed us to use the distal two thirds of the proximally damaged left internal thoracic artery as an in situ (with retrograde blood supply from superior epigastric and musculophrenic arteries), reversed arterial conduit to revascularize the left anterior descending coronary artery.

Long-term follow-up of endovascular treatment for trans-Atlantic inter-society consensus II type B Iliac lesions in patients aged <50 years.

BACKGROUND: To study the initial and long-term results of endovascular treatment in patients aged <50 years with trans-Atlantic inter-society consensus-II type B unilateral iliac lesions and chronic limb ischemia. METHODS: From January 2000 to February 2010, 60 consecutive endovascular interventions were performed on 23 women and 37 men aged ≤50 years. After successful treatment, all patients were followed up at 1, 3, 6, and 12 months after the procedure and every 6 months thereafter. RESULTS: Successful percutaneous revascularization of the iliac artery was achieved in 56 patients (93.3%). The early vascular-related complication rate was 6.7%. The primary patency rates at 1, 3, and 5 years were 88%, 59%, and 49%, respectively. Cox univariate analysis revealed that an age range of 45 to 50 years (hazard ratio [HR]: 0.290; 95% confidence interval [CI]: 0.152-0.553; P = 0.0001), lower preprocedural ankle-brachial index (HR: 2.438; 95% CI: 1.04-5.715; P = 0.047), lesion length >5 cm (HR: 0.838; 95% CI: 0.746-0.943; P = 0.003), and diabetes (HR: 2.005; 95% CI: 1.010-3.980; P = 0.047) had significant influence on decreasing primary patency. CONCLUSIONS: Endovascular treatment of TASC-II type B iliac lesions in patients aged <50 years is a safe procedure with low procedural risk. Primary patency rates at 1, 3, and 5 years were 88%, 59%, and 49%, respectively.

A case of extrinsic chronic cerebrospinal venous insufficiency in a patient with multiple sclerosis.

We aim to present a very rare case of chronic cerebrospinal venous insufficiency due to both brachiocephalic vein obstruction by aberrant right subclavian artery and internal jugular vein distal compression by first cervical vertebra transverse process, demonstrated by multislice computerized tomography in a patient with multiple sclerosis.

Initial and long-term results of endovascular therapy for chronic total occlusion of the subclavian artery.

PURPOSE: To study the initial and long-term results of angioplasty and primary stenting for the treatment of chronic total occlusion (CTO) of the subclavian artery (SA). MATERIALS AND METHODS: From January 1999 to February 2010, 56 patients (25 men with a mean age of 58 ± 8 years) underwent endovascular treatment for CTO of the SA. Duplex scans and arteriograms confirmed occlusion in all cases. Indications for recanalization were subclavian steal syndrome in 33 patients (58.1%), arm claudication in 13 patients (23.2%), and coronary ischemia in 7 patients (12.5%) who had a history of previous coronary artery bypass grafting that included left internal thoracic artery graft. Three patients (5.4%) were treated before the scheduled coronary artery bypass surgery, which included left internal thoracic artery graft. After successful recanalization, all arteries were stented, and all of the patients were followed-up at 1, 3, 6, and 12 months after surgery and annually thereafter. RESULTS: Successful recanalization of the SA was achieved in 46 patients (82.1%), and the complication rate was 7.1%. During follow-up (mean 40 ± 26 months; range 2 to 125), the primary patency rates after 1 and 3 years were 97.9% and 82.7%, respectively. At the end of follow-up, 76% of the arteries showed no evidence of restenosis. Univariate analysis failed to identify any variable predictive of long-term patency of successfully recanalized SA. CONCLUSION: Percutaneous transluminal angioplasty with stenting of the complete total occlusion of the SA is a safe and effective procedure associated with low risks and good long-term results.

Simultaneous stenting of the left main coronary stem and internal carotid artery in a hemodynamically unstable patient.

INTRODUCTION: Combined endovascular interventions on carotid and coronary arteries are rare. Stenting of the unprotected coronary left main stem is a high risk procedure. We presented hemodynamically unstable patient with combined carotid artery and left main stem coronary artery stenting. CASE REPORT: A 78-year-old female patient was admitted to our institution for right carotid endaterectomy. The patient had 80% stenosis of the right carotid artery and occlusion of the left carotid artery. Coronary angiography revealed 70% ostial left main stenosis, occlusion of the right coronary artery and the left circumflex artery, and 80% stenosis of the left anterior descending artery. Simultaneous carotid artery endaterectomy and coronary artery by-pass grafting were considered. Due to high perioperative risk, surgery was rejected, and the patient was treated endovascularly with stenting of arteries occluded. The procedure was completed without complications and the patient was hemodynamically stabilised. CONCLUSION: This report illustrates simultaneous coronary and carotid stenting as a successfull lifesaving procedure.

Multimodality imaging in the assessment of cardiac lymphoma presented as new-onset atrial fibrillation.

Cardiac involvement by non-Hodgkin's lymphoma is not uncommon, however rarely diagnosed during life due to nonspecific clinical presentation. We report a case of secondary cardiac lymphoma in patient who presented with new-onset atrial fibrillation. Cardiac lymphoma was in a form of bulky right atrial mass, infiltrating the atrial septum and cavo-atrial junction with concomitant mild pericardial effusion. In the present case, we illustrate complementary role of transthoracic, transesophageal echocardiography and multislice CT scan with three-dimensional reconstruction, in detection and evaluation of secondary cardiac tumor. Usefulness of echocardiography to follow up the effects of chemotherapy is also shown.