Bilateral Hunter's bow syndrome: a rare case diagnosed by dynamic digital subtraction angiography.

A 27-year-old female patient suffered from recurrent episodes of dizziness, visual rotation, and intermittent right-hand numbness over one month. Symptoms persisted and were triggered by rotating the head to the right or left for more than 10 seconds. Neurological examination showed that the symptoms were most pronounced when the head was rotated over 45 degrees to the right. Dynamic digital subtraction angiography (dDSA) was performed to confirm the diagnosis. Leftward head rotation caused occlusion of the right vertebral artery(VA) . However, the symptoms were mild, owing to sufficient compensation by the right posterior communicating artery (PCA) . Rightward head rotation exceeding 45 degrees resulted in occlusion of the left VA. The resultant symptoms were pronounced due to inadequate compensation of the left PCA. CT angiographic reconstruction showed bilateral vertebral arteries with tortuous loops of vessels at the level of the C2 vertebrae . CT images showed no cleavage between the left VA and the anterior surface of the left C2 transverse foramen. Conservative treatment was recommended considering the patient's young age and limited severity of her symptoms. Bow Hunter's syndrome is a rare neurovascular disorder characterized by dynamic occlusion of the VAs during head rotation, leading to inadequate blood flow to the posterior cerebral circulation. Bow hunter syndrome, where bilateral dynamic occlusion occurs without a discernible dominant side of the VA, is uncommon. The medical community must acknowledge cervical vertigo as a distinct disorder. dDSA remains the gold standard for its diagnosis.

Safety, Effectiveness and Pitfalls of Carbon Dioxide Routine Use as a Contrast Agent for Endovascular Abdominal Aortic Repair.

BACKGROUND: Despite the evidence of good performance, carbon dioxide (CO2) routine employment as a contrast agent for endovascular procedures is far from being adopted with its use currently limited to patients with renal impairment and known allergy to iodinated contrast medium (ICM). The purpose of our study is to evaluate the safety and effectiveness of CO2 guided endovascular abdominal aortic aneurysm repair (EVAR) in a standard population and to assess the rationale for a future widespread use. METHODS: We retrospectively collected data of every patient who underwent CO2 guided standard EVAR from September 2020 to May 2021 and compared them with the data of every patient who underwent EVAR using ICM from December 2019 to August 2020 in our unit. The selection of the contrast medium was not based on any preoperative factor as the contrast medium was routinely used in every patient in both periods. The primary end point of the study was the technical success rate. Secondary end points were the early and late complication rates, radiation exposure and renal function impairment. RESULTS: 49 patients underwent ICM guided EVAR and 52 patients underwent CO2 guided EVAR in our unit in the time frames specified above. The technical success rate was 100% in both groups with no accidental coverage of any target vessel. Intraoperative endoleaks were observed in 14% of ICM patients and 25% of CO2 patients. The radiation exposure was higher in the CO2 group if compared to the ICM group (311.48 vs. 159.86 median mGy/cm2 - P < 0.001). The incidence of postoperative acute kidney injury was low and similar in the 2 groups. No significant worsening over time of the renal function has been reported in both groups. CONCLUSIONS: EVAR can be safely performed under CO2 guidance without the integration of any quantity of ICM but with an increase in radiation exposure. The nephroprotective role of CO2 guided EVAR in a standard population is unclear and the same role in renal impaired patients should be validated with further studies on selected populations.

Routine postaccess-closure angiography to detect vascular complications following transfemoral TAVR.

BACKGROUND: Vascular complications following transfemoral TAVR are associated with increased morbidity and mortality. Measures that may mitigate this risk are important. AIM: To evaluate the utility of routine, access-vessel angiography post sheath-removal in the detection and management of complications in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS: This was a retrospective study of 512 consecutive patients who underwent transfemoral TAVR with routine post access-closure angiography from the radial artery. Rates of mild angiographically evident bleeding, bleeding requiring surgery/interventional-radiology, ischemia, 90-day access-site-related events, and major and minor vascular complications using Valve Academic Research Consortium 3 definitions were recorded. RESULTS: Of 512 patients, digital subtraction angiography (DSA) was undertaken via the radial artery in 467 patients (91%). In the remaining patients (9%) DSA was either not attempted, due to concerns regarding kidney disease and contrast volume, or failed due to anatomical factors (aortic tortuosity/calcification). Significant chronic kidney disease was present at baseline in 72.4% of this cohort (stages III-IV or dialysis). Ninety-four percent of cases underwent TAVR using a balloon-expandable platform. Mild iliofemoral extravasation was observed in 7.7% of the DSA cases. These cases were managed by manual compression with none requiring any vascular intervention subsequently. Valve Academic Research Consortium 3 major and minor access-site-related complications were observed in 0.4% and 12.2%, respectively. Access-site-related bleeding and ischemic events requiring interventional-radiology or vascular-surgery were observed in 0.9% and 1.7% of the DSA cases, respectively. No new renal replacement therapy was needed in any of the DSA cases. Discharge to 90-day access-related complications was 0.8%. CONCLUSIONS: Routine post access-closure angiography is feasible via the radial artery in patients undergoing transfemoral TAVR and appears safe. It facilitates early identification of complications and mitigates risk by enabling prompt action to be taken. Larger studies are needed to confirm these findings.

Computed Tomography Angiography and Three-Dimensional Reconstruction of Renal Arteries in Diagnosing the Bleedings After Mini-Percutaneous Nephrolithotomy: A Single-center Experience of 7 Years.

OBJECTIVE: This study aimed to investigate the role of computed tomography angiography (CTA) and three-dimensional (3D) reconstruction of renal arteries in the evaluation of bleeding after mini- percutaneous nephrolithotomy (PCNL). METHODS: Thirty-one consecutive patients with continuous renal hemorrhage after mini-PCNL were enrolled from January 2015 to January 2022. Demographic and clinical data were retrospectively recorded and analyzed. All patients had received CTA evaluation and subsequently digital subtraction angiography (DSA) embolization to manage renal bleeding. CTA and 3D reconstruction of renal arteries were performed using the 320 multi-detector computed tomography technique and the images were evaluated by experienced radiologists. DSA embolization were performed by an interventional radiologist with more than 10 years of experiences. RESULTS: CTA and 3D construction of renal arteries showed 28 cases of vascular lesions (28/31, 90.3%), including 15 cases of pseudoaneurysm (15/28, 53.6%), 9 cases of arteriovenous fistula (9/28, 32.1%), and 4 cases of suspicious bleeding spot (4/28, 14.3%). While DSA revealed 31 cases of vascular lesions (100%), including 15 cases of pseudoaneurysm (15/31, 48.4%), 10 cases of arteriovenous fistula (10/31, 32.3%), 6 cases of bleeding spot and (6/31, 19.4%). The serum creatinine level was elevated slightly before mini-PCNL and after DSA embolization (73.1±18.1 vs 92.1±33.6, P <.01). 15 patients (15/31, 48.4%) required blood transfusion, with mean blood transfusion volume of 700 ml ±660 ml (range, 400 ml-1800 ml). The bleeding was controlled without any further severe complications. CONCLUSION: CTA and 3D reconstruction of renal arteries were safe and effective in diagnosing renal arterial bleedings after mini-PCNL, with a sensitivity of 90.3% and a specificity of 100%.

Simultaneous Clipping and Superficial Temporal Artery-Middle Cerebral Artery Bypass for Unruptured Middle Cerebral Artery Aneurysm Concomitant with Proximal Stenosis.

Management of unruptured intracranial aneurysms concomitant with proximal stenosis remains challenging. Video 1 demonstrates simultaneous clipping and superficial temporal artery (STA)-middle cerebral artery (MCA) bypass for unruptured MCA aneurysm concomitant with proximal stenosis. A 56-year-old man presented with paroxysmal left limb weakness for 2 years. Magnetic resonance angiography and digital subtraction angiography showed a right MCA bifurcation aneurysm concomitant with severity of proximal M1 stenosis. Arterial spin labeling imaging revealed decreased perfusion in the right frontal and parietal lobe. A frontotemporal craniotomy was performed, and the parietal branch of the STA was dissected as a donor artery.1-3 The MCA (M4) branch with the largest diameter was chosen as the recipient. STA-MCA bypass was performed using end-to-side anastomosis with interrupted 10-0 sutures. Next, the sylvian fissure was opened from distal to proximal dissection. The MCA bifurcation aneurysm with atherosclerosis of the M1 was exposed. A curved clip was used to occlude the aneurysm without temporary occlusion of the parent artery. The patient recovered well without any complications. Six-month follow-up angiography confirmed complete obliteration of the aneurysm and patent STA-MCA anastomosis. For unruptured MCA aneurysms concomitant with proximal stenosis, 1-stage surgical treatment with simultaneous clipping and STA-MCA bypass is a feasible alternative. Further studies are needed to compare the safety and efficacy of 1-stage surgical treatment and endovascular embolization of intracranial aneurysms concomitant with proximal stenosis.

Cerebral Digital Subtraction Angiography in Acute Intracranial Hemorrhage: Considerations in Critically Ill Children.

Cerebrovascular disorders are an important cause of morbidity and mortality in children. Although minimally invasive, cerebral digital subtraction angiography (DSA) has been shown to be safe in children and is a valuable, and perhaps underutilized, technique for the diagnosis and management of pediatric cerebrovascular disorders in the critical care setting. Through a case-based approach, we explore the utility of DSA in critically ill children with acute intracranial hemorrhage (ICH). We discuss the use of DSA in the acute management of aneurysm and arteriovenous malformation rupture as well as cerebral vasospasm. Those caring for critically ill children with acute ICH should consider cerebral DSA as part of a comprehensive approach to the diagnosis and management of these conditions.

Impact of monoplane to biplane angiography upgrade on diagnostic angiography procedures: A retrospective cross-sectional study.

The radiation dose during digital subtraction angiography (DSA) examination is determined on the basis of many factors. The aim of this study was to evaluate the dose-area product, air kerma, and fluoroscopy time on monoplane and biplane DSA of the cerebral arteries. Our results show that biplane angiography offered lower DAP, cumulative air kerma at the reference point and fluoroscopy time despite comparable procedure time.. Further research in this area and personnel training warrant the improvement of the radiosafety of angiographic interventional procedures and further development of angiographic technology.

Computed tomography angiography for quantification of cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

PURPOSE: The purpose of this study was to assess the accuracy of computed tomography angiography (CTA) for quantification of cerebral vasospasm following aneurysmal subarachnoid hemorrhage in proximal and middle segments of intracranial arteries. MATERIALS AND METHODS: Twenty consecutive patients (7 men, 13 women; mean age, 47 ± 7 [SD] years; age range: 27-78 years) with aneurysmal subarachnoid hemorrhage who underwent CTA and digital subtracted angiography (DSA) with a 6-hour window at baseline and during vasospasm period were included. Twelve artery segments were analyzed in each patient. Vasospasm was blindly quantified on CTA and digital subtracted angiography (DSA) by two independent readers with discordance > 10% resolved by open data consensus. Inter-reader and inter-test correlations with DSA as reference, and causes of discordant readings were analyzed. The best sensitivity and specificity of CTA for determination of vasospasm ≥ 50% on DSA was determined using receiver operating curve analysis. RESULTS: Two-hundred-and-ten arterial segments were analyzed after exclusion of 30 segments with missing data or metallic artifacts. An inter-reader discordance >10% was observed in 82 segments (82/210; 39% [95% CI: 32-46]). Inter-test discordances >10% were observed respectively in 115 segments (115/210; 55% [95% CI: 49-62]) with the junior reader and in 73 segments (73/210; 35% [95% CI: 29-42]) with the senior reader. They were related to reader error in 55 (55/210; 26% [95% CI: 20-32]) with the junior reader and 13 (13/210; 6% [95% CI: 3-9]) with the senior reader, as well systematic biases in 8 (8/210; 4% [95% CI: 1-6]), and intrinsic limitation in 52 (52/210; 25% [95% CI: 19-31]). Best sensitivity and specificity of CTA were observed for a threshold value of 30% (sensitivity = 88% [95% CI: 78-97%]; specificity = 84% [95% CI: 77-90%]; area under curve = 0.92 [95% CI: 0.86-0.97]). On a patient basis, sensitivity was 100% (specificity = 60% [95% CI: 38-81%]; area under curve = 0.97 [95% CI: 89-100%] for this same threshold. CONCLUSION: Our study shows a moderate accuracy of CTA for the quantification of cerebral vasospasm, mostly related to challenging interpretation and intrinsic limitations. CTA may rule-out angiographic vasospasm ≥ 50% when no segment has vasospasm over than 30%.

Percutaneous transluminal stenting for superior vena cava syndrome caused by malignant tumors: a single-center retrospective study.

OBJECTIVES: To evaluate the efficacy of percutaneous stent placement in the treatment of superior vena cava syndrome caused by malignant tumors. METHODS: We retrospectively analyzed the clinical data of 32 patients with superior vena cava syndrome who underwent percutaneous endovascular stent treatment in our department from 2015 to 2019 due to malignant tumors and summarized the patient's sex, age, tumor type, endovascular treatment plan, complications and postoperative follow-up. RESULTS: All patients successfully underwent percutaneous intraluminal stent placement with digital subtraction angiography (DSA). Thirty-seven endovascular stents were implanted in 32 patients, including 21 Eluminexx stents, 12 Wallstent stents and 4 covered stents. The technical success rate was 100%, and there were no serious surgery-related complications. The remission rate of clinical symptoms was 53.1% (17/32) at 24 h and 84.4% (27/32) at 48 h. After 48 h, the symptoms of the remaining patients were slowly relieved, and the symptom relief rate was 100% at 7 days. The follow-up period was 1.5-24 months, with an average follow-up period of 6.5 months. During the follow-up, 3 patients had restenosis and 1 patient had secondary thrombosis in the stent. Their symptoms were relieved after the second treatment. CONCLUSION: For superior vena cava syndrome caused by malignant tumors, percutaneous endoluminal stent therapy can quickly and effectively relieve the clinical symptoms of patients, and the incidence of complications is low.

Imaging Diagnosis and Interventional Treatment for Hepatocellular Carcinoma Combined with Arteriovenous Fistula.

In order to explore the imaging diagnosis methods and interventional treatment effects of hepatocellular carcinoma combined with hepatic arteriovenous fistula (HAVF), a total of 120 patients, who were diagnosed as hepatic carcinoma with arteriovenous shunting and underwent medical imaging diagnosis and interventional surgery therapy at a designated hospital by this study from December 2014 to December 2018, were chosen as study subjects. Digital subtraction angiography was performed to analyze the imaging features of hepatocellular carcinoma combined with HAVF in each patient; then, according to these imaging diagnosis results, gelatin sponge or coil was used to block the fistula; mitomycin, carboplatin powder, and lipiodol mixed emulsion was combined or separately utilized for hepatic tumor embolization, in which iodized oil embolization chemotherapy was used for patients with mild paralysis; gelatin sponge granule embolization chemotherapy was used for moderate paralysis patients at their first intervention, and, after about 1 month, if the sputum disappeared, iodized oil embolization was used again; and hepatic arterial infusion chemotherapy was used only for patients with severe paralysis. The results show that the central type of HAVF is characterized by early angiography of portal vein and large branches and tumor staining after portal vein's angiography; the peripheral type of HAVF is characterized by portal vein branching in hepatic tumor and double rail sign accompanied by the arterial branch; 112 cases of patients completed embolization chemotherapy; 8 cases of patients only received chemotherapy perfusion; in 109 cases of patients sputum disappeared or shunt decreased at first treatment; and in 113 cases of patients iodine oil was well deposited or the tumor was stably reduced; most of the symptoms of refractory ascites, diarrhea, and upper gastrointestinal bleeding were controlled or improved, and there were no complications such as pulmonary embolism and hepatic failure. Therefore, HAVF increases the difficulty of interventional therapy, but, as long as the positive and appropriate treatment measures are taken, it can still achieve better curative effect without serious complications, which can effectively alleviate the clinical symptoms of patients and improve the quality of life of patients. The results of this study provide a reference for the further researches on imaging diagnosis and interventional treatment for hepatocellular carcinoma combined with arteriovenous fistula.

Application of spectral CT in the diagnosis of contrast encephalopathy following carotid artery stenting: a case report.

BACKGROUND: Contrast encephalopathy is a rare complication of carotid artery stenting (CAS). Contrast encephalopathy is a diagnosis of exclusion that often needs to be distinguished from high perfusion syndrome, cerebral haemorrhage, subarachnoid haemorrhage (SAH), cerebral infarction and so on. CASE PRESENTATION: In this study, we report on a 70-year-old man who was admitted to the hospital with transient ischaemic attacks presenting paroxysmal weakness of limbs in the previous 2 years. He had severe stenosis of the left internal carotid artery diagnosed by digital subtraction angiography (DSA) and underwent CAS. Two hours after the operation, the patient developed paralysis of the right upper limb, unclear speech, fever and restlessness. Emergency skull computed tomography (CT) showed swelling and a linear high-density area in the left cerebral hemisphere. To clarify the components of this high-density area in the traditional CT, the patient had spectral CT, which made the diagnosis of the leakage of contrast clear. After 1 week of supportive treatment, the patient improved. CONCLUSIONS: Spectral CT can easily distinguish the components of high-density areas on traditional CT, which is haemorrhage, calcification or iodine contrast leakage. Therefore, spectral CT is worth consideration for the differential diagnosis of complications of vascular intervention.

Emergent Premedication for Contrast Allergy Prior to Endovascular Treatment of Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Management of contrast media allergies may lead to treatment delays in patients with acute ischemic stroke undergoing endovascular therapy. The optimal premedication strategy remains unclear. The aim of this report was to analyze our experience with emergent administration of premedication regimens before endovascular therapy. MATERIALS AND METHODS: We retrospectively reviewed prospective data for all patients undergoing endovascular therapy from 2012 to 2019 at an academic comprehensive stroke center. Records of patients with documented contrast allergy were reviewed and analyzed. Data collected included stroke risk factors and characteristics, historical contrast reaction details, premedication regimens administered, and signs or symptoms of allergic reaction developing post-endovascular therapy. Hospital arrival time to endovascular therapy was compared with that in those who did not have a history of contrast allergy. RESULTS: We analyzed 1521 patients undergoing endovascular therapy; 60 (4%) had documented contrast allergies and constituted the study cohort. The median age was 73 years (interquartile range, 66-81 years), and 65% were women. The median time from premedication to contrast was 24 minutes (interquartile range, 0-36 minutes). Forty-three patients (72%) proceeded directly to endovascular therapy; in 17 patients, the first contrast exposure was CTA. Time from hospital arrival to endovascular therapy was not slower for patients with documented allergies (96 versus 134 minutes, P = .32). No patients experienced a contrast media reaction. CONCLUSIONS: In a single-institution cohort study of 60 consecutive patients with documented contrast allergies undergoing endovascular therapy with emergent premedication en route to (or in) the neuroangiography suite, no patients experienced allergic symptoms. This pragmatic approach may be safe for patients who have documented contrast media allergies.

Ultrasound-Guided Fibrin Glue Injection for Treatment of Iatrogenic Femoral Pseudoaneurysms.

INTRODUCTION: Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI). MATERIALS AND METHODS: Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed. RESULTS: A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI. CONCLUSION: Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged.

Dose reduction using digital fluoroscopy versus digital subtraction angiography in endovascular aneurysm repair: A prospective randomized trial.

OBJECTIVE: Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) vs the standard technique using digital subtraction angiography (DSA). METHODS: Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard treatment DSA cohort or a DF cohort in which two or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose-area product (DAP) and cumulative air kerma. Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization). RESULTS: For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Of the 26 DF patients, 5 (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than in the DSA cohort (132 vs 174 Gy·cm2; P = .04). When patients were separated by number of DSA acquisitions (two or fewer vs three or more), mean DAP decreased 41% (109 vs 185 Gy·cm2; P = .005) and cumulative air kerma decreased 40% (578 vs 964 mGy; P = .004). CONCLUSIONS: In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.

Prediction of degree of carotid stenosis with the transluminal attenuation difference ratio.

PURPOSE: We aimed to assess the diagnostic performance of transluminal attenuation difference (TAD) in predicting the severity of internal carotid artery (ICA) stenosis. METHODS: The study cohort consisted of 48 patients with <50% stenosis, 50%-69% stenosis, 70%-99% stenosis, and 51 controls without plaque development in ICA. A total of 143 measurements were performed through right and left internal and common carotid arteries. The TAD ratio was calculated as the difference between the mean attenuation values of the common carotid artery (CCA) and ICA, divided by the MAV of the CCA, multiplied by 100. RESULTS: TAD ratio was significantly higher in severe (>70%) stenosis compared with control arteries and low-moderate stenosis. A TAD ratio cutoff of 4.5 predicted 70%-99% stenosis with a sensitivity of 100% and specificity of 93%. The inter- and intraobserver agreements in TAD measurements were almost perfect (ICC, 0.89-0.86). CONCLUSION: Assessment of TAD ratio predicts the degree of stenosis in concordance with NASCET system.

Anaphylactic Shock After Indocyanine Green Video Angiography During Cerebrovascular Surgery.

BACKGROUND: Indocyanine green (ICG) video angiography has been widely used in cerebrovascular surgery. ICG injection is generally safe, with a low incidence of complications. ICG-related anaphylactic reactions during neurosurgery have been rarely reported. We report the cases of 2 patients who had experienced anaphylactic shock in response to intravenous ICG injection (DID Indocyanine Green [Dongindang, Inc., Gyeonggi-do, Republic of Korea]) during intracranial aneurysm (IA) surgery. CASE DESCRIPTION: The first patient, a 69-year-old woman with an unruptured IA, had been undergoing clipping surgery under general anesthesia. Immediately after ICG injection, her blood pressure suddenly decreased from 140/80 mm Hg to 50/30 mm Hg and she developed a skin rash on her abdomen and all extremities. Chest compression was initiated, and her vital signs gradually recovered to their pre-ICG levels within 10 minutes. The second patient was a 58-year-old woman with an unruptured IA who had been undergoing clipping surgery. After ICG injection, her blood pressure had decreased from 130/80 mm Hg to 60/40 mm Hg, and a rash-like skin lesion was observed on her abdomen. After intravenous injection of norepinephrine and dexamethasone, her blood pressure recovered to its pre-ICG level within 30 minutes and remained stable thereafter. The postoperative ICG skin provocation test findings were positive for both patients; however, only 1 patient showed markedly increased serum tryptase levels. CONCLUSION: Despite the rarity of ICG-related anaphylaxis, clinicians should be aware of this unexpected, but potentially life-threatening, drug reaction in patients undergoing cerebrovascular surgery.

Utilization of Carbon Dioxide Angiography and Percutaneous Balloon Angioplasty for Treatment of Transplant Renal Artery Stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) may lead to graft dysfunction and failure. Progressive deterioration of renal allograft function may be exacerbated by contrast-induced nephrotoxicity during iodine contrast administration for renovascular imaging of allografts. We present our institutional experience of endovascular management for TRAS using CO2 digital subtraction angiography (CO2-DSA) and balloon angioplasty to manage failing renal transplants. METHODS: Four patients with renal allografts from March 2017-May 2018 were referred for graft dysfunction and pending renal transplant failure. Indications for referral included refractory hypertension, decreasing renal functioning, and elevated renovascular systolic velocities. RESULTS: Median age of the four patients was 41.5 years (22-60 years). There were two male and female patients. Chronic hypertension and type 2 diabetes mellitus were the most common comorbidities. An average total of 75 mL of CO2 was used, supplemented with 17.4 mL of iodinated contrast. All patients had improvements in renal function following intervention with a mean decrease in systolic and diastolic blood pressure of 25.8% and 21.4%, respectively. We also observed a mean decrease of BUN by 13.6% and creatinine by 37.4%. Additionally, eGFR increased by 37.7%. All allografts survived after surgery, and only one patient required repeat angioplasty for recurrence. CONCLUSIONS: CO2-DSA with balloon angioplasty can be successfully utilized to salvage deteriorating kidney allograft function in patients with TRAS.

Multiple pipeline twists encountered during treatment of a symptomatic fusiform ICA aneurysm.

Pipeline embolisation device (PED) 'twisting' is an intra-operative complication that manifests with the appearance of a 'figure-8' in perpendicular planes on digital subtraction angiography. A twisted PED causes narrowing and/or complete occlusion of the vessel lumen and poses significant risks for thrombus formation and downstream ischaemia. Here, we present a case in which three unique PED implants become twisted during pipeline embolisation of a large fusiform internal carotid artery aneurysm. The twists were remediated by balloon angioplasty and a combination of techniques that allowed the PED to rotate and restore its original axis. Six-month and twelve-month follow-up angiography demonstrated complete aneurysm occlusion with preservation of the parent vessel, proving that proper remediation of PED twisting can still result in successful long-term outcomes.

Oclusión de la arteria central de la retina iatrogénica tras angiografía de sustracción digital cerebral / Iatrogenic retinal central artery occlusion after a cerebral digital subtraction angiography

La angiografía de sustracción digital (ASD), es una técnica empleada en el diagnóstico de alteraciones vasculares cerebrales. La oclusión de arteria central de la retina (OACR) es una complicación descrita tras la realización de técnicas endovasculares que implican la movilización de placas arterioscleróticas produciendo émbolos. Presentamos el caso de un varón que inicia una pérdida de agudeza visual durante la ASD. En la funduscopia presenta palidez y mancha rojo cereza, y la angiografía es compatible con la presencia de un trombo en la salida de la arteria central de la retina. Se diagnostica una OACR que se trata sin éxito mediante masaje ocular, hipotensores tópicos, acetazolamida vía oral y paracentesis de cámara anterior, obteniendo una agudeza visual final inferior a 0,05. La OACR, pese a ser una complicación rara, se debe por su mal pronóstico considerar en la realización de procedimientos neuro-radiológicos como la ASD

Digital subtraction angiography (DSA) is a technique used in interventional radiology for the diagnosis of vascular cerebral conditions. Central retinal artery occlusion (CRAO) is a complication of endovascular procedures that involve atherosclerotic plaque removal with subsequent embolisation. The case is presented on a patient who noticed a sudden vision loss during a DSA. Funduscopy showed retinal pallor and a cherry red spot. The angiography showed a structure suggesting the presence of an embolus in the central retinal artery. The patient was diagnosed with a CRAO, and unsuccessfully treated with ocular massage, topical hypotensive drugs, oral acetazolamide, and anterior chamber paracentesis, with a final visual acuity of 0.05. Central retinal artery occlusion is a rare complication, but due to its poor prognosis, it must be considered when performing neuroradiological procedures such as DSA

Iatrogenic retinal central artery occlusion after a cerebral digital subtraction angiography. / Oclusión de la arteria central de la retina iatrogénica tras angiografía de sustracción digital cerebral.

Digital subtraction angiography (DSA) is a technique used in interventional radiology for the diagnosis of vascular cerebral conditions. Central retinal artery occlusion (CRAO) is a complication of endovascular procedures that involve atherosclerotic plaque removal with subsequent embolisation. The case is presented on a patient who noticed a sudden vision loss during a DSA. Funduscopy showed retinal pallor and a cherry red spot. The angiography showed a structure suggesting the presence of an embolus in the central retinal artery. The patient was diagnosed with a CRAO, and unsuccessfully treated with ocular massage, topical hypotensive drugs, oral acetazolamide, and anterior chamber paracentesis, with a final visual acuity of 0.05. Central retinal artery occlusion is a rare complication, but due to its poor prognosis, it must be considered when performing neuroradiological procedures such as DSA.