Spontaneous Right Intrapetrous Internal Carotid Dissection in a Patient With Active COVID-19.

Spontaneous cervical artery dissection, a nontraumatic tear in the wall of an internal carotid or vertebral artery, is a common cause of stroke, particularly in patients younger than 40 years of age; however, petrous internal carotid artery dissection is extremely rare. This case report describes a 50-year-old woman who had a spontaneous intrapetrous internal carotid dissection thought to be secondary to active SARS-CoV-2 infection; the dissection was treated successfully with a flow-diverter stent.

Jetstream® atherectomy for subacutely or chronically occluded femoro-popliteal prosthetic bypass grafts: a report of three cases.

A failed infrainguinal bypass is associated with poor prognosis for the limb in question, particularly if the graft was initially placed for limb salvage. Revascularization of occluded grafts is an important but challenging issue. We present three patients with occluded femoro-popliteal graft in whom the Jetstream(®) system was used successfully to perform thromboatherectomy. The Jetstream(®) system is minimally invasive and avoids use of thrombolytic therapy and its associated costs and complications. The device seems to be highly effective in removing thrombus beyond the acute setting.

COVID-19 and the Heart: Could Transient Takotsubo Cardiomyopathy Be Related to the Pandemic by Incidence and Mechanisms?

Typical emergency hospital care during the COVID-19 pandemic has centered on pulmonary-focused services. Nonetheless, patients with COVID-19 frequently develop complications associated with the dysfunction of other organs, which may greatly affect prognosis. Preliminary evidence suggests that cardiovascular involvement is relatively frequent in COVID-19 and that it correlates with significant worsening of clinical status and mortality in infected patients. In this article, we summarize current knowledge on the cardiovascular effects of COVID-19. In particular, we focus on the association between COVID-19 and transient takotsubo cardiomyopathy (TTC)-two conditions that preliminarily seem epidemiologically associated-and we highlight cardiovascular changes that may help guide future investigations toward full discovery of this new, complex disease entity. We hypothesize that coronary endothelial dysfunction, along with septic state, inflammatory storm, hypercoagulability, endothelial necrosis, and small-vessel clotting, may represent a fundamental hidden link between COVID-19 and TTC. Furthermore, given the likelihood that new genetic mutations of coronaviruses or other organisms will cause similar pandemics and endemics in the future, we must be better prepared so that a substantial complication such as TTC can be more accurately recognized, its pathophysiology better understood, and its treatment made more justifiable, timely, and effective.

EndoAnchors Minimize Endoleaks in Chimney-Graft Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysms.

Juxtarenal abdominal aortic aneurysms (AAAs) are difficult to treat because they often have little or no proximal aortic neck. Patients with this complex anatomy are not usually candidates for an endovascular aneurysm repair (EVAR). Chimney-graft EVAR has been introduced, but type Ia endoleak is a typical risk. We have begun using EndoAnchors to determine whether this risk can be reduced. From July 2013 through July 2014, we used the chimney-graft EVAR technique in 5 patients whose juxtarenal AAAs had a short or no proximal aortic neck. During the procedure, we implanted EndoAnchors as needed. Postprocedurally, at 30 days, and through end of follow-up (duration, 11-18 mo), all patients had patent endografts without type Ia endoleak (our primary endpoint), visceral stent-graft thrombosis, or renal complications. One patient who received 4 chimney grafts had a postprocedural type II endoleak, which was treated with embolization. We found it feasible to use EndoAnchors with the chimney-graft technique to prevent type Ia endoleaks in the treatment of juxtarenal AAAs. Further studies are needed to validate this adjunctive technique and to determine its durability.

Innovative chimney-graft technique for endovascular repair of a pararenal abdominal aortic aneurysm.

After abdominal aortic aneurysm repair, progressive degeneration of the aneurysm can be challenging to treat. Multiple comorbidities and previous operations place such patients at high risk for repeat surgery. Endovascular repair is a possible alternative; however, challenging anatomy can push the limits of available technology. We describe the case of a 71-year-old man who presented with a 5.3-cm pararenal aneurysm 4 years after undergoing open abdominal aortic aneurysm repair. To avoid reoperation, we excluded the aneurysm by endovascular means, using visceral-artery stenting, a chimney-graft technique. Low-profile balloons on a monorail system enabled the rapid exchange of coronary wires via a buddy-wire technique. This novel approach facilitated stenting and simultaneous angioplasty of multiple visceral vessels and the abdominal aorta.

Median arcuate ligament syndrome confirmed with the use of intravascular ultrasound.

Median arcuate ligament syndrome, a rarely reported condition, is characterized by postprandial abdominal pain, nausea, vomiting, and weight loss. Its cause is unclear. We present the case of a 45-year-old woman who had intermittent chronic positional abdominal pain without weight loss. Magnetic resonance angiograms and computed tomograms revealed stenosis of the celiac artery. Ostial compression was confirmed on catheter angiographic and intravascular ultrasonographic images. Intravascular ultrasound revealed far greater stenosis than did the initial imaging methods and confirmed a diagnosis of median arcuate ligament syndrome. In lieu of surgery, the patient underwent a celiac ganglion block procedure that substantially relieved her symptoms. To our knowledge, this is the first report of the use of intravascular ultrasound in the diagnosis of median arcuate ligament syndrome. We recommend using this imaging method preoperatively in other suspected cases of the syndrome, to better identify patients who might benefit from corrective surgery.

Apical hypertrophic cardiomyopathy: preliminary attempt at palliation with use of subselective alcohol ablation.

We report a case of severe apical hypertrophic cardiomyopathy in order to discuss the nature of this unusual condition and the possibility of using selective alcohol ablation to effectively treat symptomatic hypertrophic cardiomyopathy that presents with apical aneurysm. A 73-year-old woman with severe, progressive dyspnea and intermittent chest pain was found to have localized left ventricular apical dyskinesia distal to an obstructive mid-distal muscular ring. The ring caused total systolic obliteration of the apical left ventricular cavity. Apical cavity pressure was extremely high, up to 330 mmHg-200 mmHg above that in the main left ventricular cavity. Because of the danger of apical rupture and clot formation, we attempted the experimental use of alcohol ablation for effective palliation. We present our pilot experience, offer a novel interpretation of the nature of this obscure entity, and possibly justify a new catheter treatment. In addition, we discuss the developmental, pathophysiologic, and clinical implications of this unusual form of hypertrophic cardiomyopathy. To our knowledge, ours is the first reported use of subselective, modified-protocol alcohol septal ablation to treat an obstructive mid-apical muscular ring in a patient with apical hypertrophic cardiomyopathy.

Cryoplasty for peripheral artery disease in an unselected patient population in a tertiary center.

Endovascular treatment of peripheral artery occlusive disease has suboptimal long-term patency rates. The addition of cryoplasty to balloon angioplasty, which involves the application of cold thermal energy to atherosclerotic plaque, might improve outcomes and decrease the need for reintervention. At a single tertiary center, we retrospectively analyzed data from the angiograms and medical records of unselected patients who underwent cryoplasty for peripheral artery disease from January 2004 through November 2006. We calculated rates of freedom from amputation, freedom from intervention, and freedom from death and examined the data using the Kaplan-Meier method. Paired t tests were used to compare the ankle-brachial indices before and after cryoplasty. The study population comprised 99 patients who received treatment for 132 atherosclerotic lesions, including 62 lesions in the superficial femoral artery, 28 in the popliteal artery, and 25 in arteries below the knee; 71 patients completed follow-up (64 ± 57 wk). Short-term periprocedural success was achieved in 98.5% of the interventions. Dissections occurred in 12.2% of patients treated successfully without bail-out stenting or additional balloon inflations. At 6 months, more than 88% of the patients were alive and had not had an amputation. However, reintervention was required for 42% of patients. Mean ankle-brachial indices improved significantly after treatment (P < 0.0001). Our results show that cryoplasty for treatment of peripheral artery disease is safe and has a high rate of periprocedural success. However, long-term efficacy is compromised because of the frequent need for reintervention.