Search

We present the case of a 39-year-old pregnant woman who had intrauterine fetal death and imminent uterine rupture and underwent cesarean section. She also underwent catheter embolization for hemorrhagic shock due to bleeding from the uterine artery, and heparin-containing saline was used. On day 7 of hospitalization, she felt severe pain in her right lower leg, and computed tomography (CT) revealed focal nonocclusive thrombus formations in the right common and external iliac artery. After intravenous heparin administration, she suddenly developed dyspnea, her blood pressure dropped, and her platelet count decreased. We diagnosed her with heparin-induced thrombocytopenia (HIT). Although we discontinued heparin and switched to argatroban, CT after 5 days revealed subtotal occlusion of the right iliac artery by a massive thrombus. We performed surgical thrombectomy using a Fogarty catheter, but blood flow was not restored. Therefore, we administered urokinase continuously with catheter-directed thrombolysis (CDT). The thrombus in the iliac artery gradually cleared and was successfully eliminated. However, the patient developed gangrene in her right lower leg, and we decided to perform an above-knee amputation of the right leg. She was discharged with a prosthetic leg and prescribed 15 mg of rivaroxaban per day. LEARNING OBJECTIVE: HIT is a known serious side effect of heparin administration, and it can sometimes be fatal. HIT treatment using aggressive thrombectomy procedures may be ineffective since such procedures may accelerate thrombus formation when the coagulation cascade is highly activated. In this case, CDT may have to be considered as the first-line treatment before Fogarty thrombectomy when argatroban therapy fails.

Although the importance of the retrieval of an optional inferior vena cava filter (o-IVCF) has gained attention because of the awareness of a high complication rate with long indwelling time, the o-IVCF retrieval rate remains low. The advanced retrieval technique of o-IVCF may increase the retrieval rate, which in turn diminishes future adverse events. Through two cases, we describe how to perform the novel approach "bidirectional sling technique with biopsy forceps." This technique will improve the retrieval rate in patients following the failure by conventional retrieval technique.

Central venous occlusion (CVO) remains an unresolved issue in hemodialysis patients. We herein present an interesting case of a 42-year-old hemodialysis female patient with complete vision loss in the left eye, who was at high risk of losing vision in her right eye because of neovascular glaucoma (NVG). Computed tomography (CT) showed occlusion of the right internal jugular vein (IJV) just above the junction with the right innominate vein. From the configuration and location of the lesion, it was concluded the occlusion had been caused by venous valvular degeneration. Her NVG with progressive intraocular pressure (IOP) elevation was presumably attributed to the right IJV occlusion. The extra-rigid occlusive lesion was successfully penetrated by means of a Brockenbrough needle and subsequently implanted with a balloon-expandable stent. Intravascular ultrasound (IVUS) guidance allowed us to manipulate the Brockenbrough needle safely. After stent implantation, the right IOP declined dramatically, resulting in the preservation of her eyesight.

Background It is recommended to remove retrievable inferior vena cava filters (r-IVCFs) when they are no longer needed because their presence may give rise to serious complications related to prolonged placement of the filter. An advanced filter retrieval technique may help improve the retrieval rate.Methods and Results:107 consecutive patients (mean age; 61±18 years, male 53%) in whom r-IVCF retrieval was attempted were prospectively enrolled between April 2012 and December 2018. The frequently used advanced techniques were sling technique and biopsy forceps dissection technique. Retrieval success was 75% with standard retrieval technique alone; however, the overall retrieval success rate improved to 98% with advanced techniques. We observed few serious complications related to the retrieval procedure. Logistic multivariate analysis identified prolonged indwelling time (P=0.0011) and embedded hook in the caval wall (P=0.0114) as independent predictors, and the cutoff value for the indwelling time for requirement of advanced technique was 80 days. Conclusions Advanced retrieval techniques helped improve the retrieval rate without serious complications. We may need to consider the referral of patients to centers with expertise in advanced retrieval techniques when the indwelling time is >80 days, and pre-retrieval CT image shows a hook embedded in the vessel wall.

Background Right heart structural abnormalities occur in both tricuspid regurgitation (TR) and pulmonary hypertension (PH). They may occur independently or together, but their joint effects on cardiac structure are incompletely described. This study examined the interactions of TR severity and PH on right heart structural changes. Methods The study evaluated 455 patients undergoing both echocardiography and CT angiography (CTA). Cases were divided into 3 groups by TR severity: trace (n=217), mild (n=174), and significant (moderate or severe, n=64). Each TR level was subdivided into two groups by PH absent or present. Cardiac structural measurements included tricuspid annulus area (TAA), right atrial (RA) and right ventricular volume (RV) indexed to body surface area. Results Analysis by TR and PH showed that indexed RA Volume and TAA were very sensitive to TR severity. RA volume was most affected by pulmonary hypertension when TR was trace or mild, while PH had less effect on TAA. In significant TR, neither RA volume nor TAA were changed by PH. Indexed RV volume was insensitive to trace and mild TR, and PH similarly had little effect. Conclusions RA volume and tricuspid annulus area enlarge in proportion to TR severity, trace through significant. PH impacts RA volume but only in trace and mild TR. RA volume best reflects TR impact on right heart structure, both with and without PH. Right atrial volume and tricuspid annulus area are the cardinal indices of TR-induced right heart structural disease et al.l severities. Ultramini abstract Right heart structural effects of TR and PH were examined in this study. Patients were evaluated by echo and CTA, and grouped by TR severity as trace, mild, and significant, and were subdivided by PH absence/presence. Analysis by TR severity and PH showed that Indexed RA volume is the parameter most sensitive to TR severity, and PH causes incremental RA volume increases in trace/mild TR. Indexed tricuspid annulus area (TAA) similarly increases with TR severity, but was unaffected by PH at any TR severity. RV volume is insensitive to TR severity and PH. Indexed right atrial volume and tricuspid annulus area are cardinal indices for TR-induced right heart structural disease and increase proportionally to TR severity. RA volume is more sensitive to PH than is tricuspid annular area. TR severity may be more accurately assessed by increased RA volume and annulus area. Perspective statement The right atrium (RA) and tricuspid annulus (TA) are the cardinal cardiac structures affected by tricuspid regurgitation (TR). They each enlarge with TR severity. The right ventricle exhibits minimal change across TR severity. Pulmonary hypertension (PH) enhances TR-mediated RA and TA dilation, but only in trace and mild TR. PH has no effect on RA, TA, or RV size in significant TR. Central message Right atrial volume and tricuspid annulus area are the most sensitive to TR severity, and are also sensitive to pulmonary hypertension.

We report a case of a dialysis patient with severe aortic stenosis(AS) along with bilateral pheochromocytomas. A 52-year-old man presented with syncope and was diagnosed with severe AS. Although aortic valve replacement(AVR) was scheduled, bilateral pheochromocytomas were found during preoperative examination. There was a high possibility of developing hemodynamical crisis during AVR, and we planned to perform adrenalectomy prior to AVR. To avoid circulatory collapse just after adrenalectomy, balloon aortic valvuloplasty (BAV) was performed beforehand. Two weeks after the adrenalectomy, AVR was performed in a stable condition.

A 65-year-old woman with type Ⅱ diabetes and unstable angina presented with chest pain due to in-stent restenosis. Her regular medication comprised an sodium-glucose co-transporter( SGLT) 2 inhibitor. Because of unstable hemodynamic status, semi-emergency coronary artery bypass grafting (CABG) was performed. Postoperatively, the cardiac and hemodynamic status stabilized, but there was progression of metabolic acidosis. Based on the presence of massive urinary ketone bodies without hyper glycosuria, the patient was diagnosed with euglycemic diabetic ketoacidosis( DKA) caused by an SGLT2 inhibitor. Ketoacidosis without elevated blood glucose( i.e., euglycemic DKA) has been reported to be associated with intake of an SGLT2 inhibitor, which promoted glucose excretion in the urine. Our patient developed euglycemic DKA due to the progression of myocardial ischemia and surgical stress. Guidelines in other countries have stipulated that SGLT2 inhibitor should be stopped 24 hours preoperatively. In our case, euglycemic DKA occurred even when the SGLT2 inhibitor was stopped for more than 24 hours preoperatively. Further studies on the withdrawal of an SGLT2 inhibitor in the appropriate perioperative period are required.

There are few data that directly compared the efficacy of direct oral anti coagulants (DOACs) for acute pulmonary embolism (PE). The aim of this study is to compare the efficacy and safety of standard-dose and double-dose DOACs by thrombus quantitative analysis using computed tomography (CT). This

A vascular closure device (VCD) can be useful, but an infected pseudoaneurysm caused by a VCD can be serious and fatal. A 79-year-old man underwent EVT for right iliac artery using a VCD. An abscess formed in the right inguinal region 1 week later and CT revealed a right femoral artery

A 29-year-old man presented with complaints of fever and pain and itching of his left neck with atopic dermatitis and abrasion. These symptoms had persisted for two days and dullness and fever developed, but the patient did not consult a physician. On the following day, he had a fever of 40°C and redness and swelling of the left neck. He visited a local clinic and was hospitalized with suspected cellulitis. A thrombus was detected in the internal jugular vein on MRI, and he was referred to our hospital. Neck ultrasonography showed the presence of an immovable thrombus in the area from the left internal jugular vein to the left brachiocephalic peripheral vein. Blood analysis indicated a major inflammatory response and juvenile idiopathic thrombophlebitis was suspected. A filter was carefully inserted into the superior vena cava, and anticoagulant therapy and medication with antibiotics led to remission. We present this case as a rare example of a condition mimicking Lemierre syndrome that was caused by dermal infection, and we include a review of the literature.

Background: While preprocedural statin treatment for acute coronary syndrome (ACS) is widely regarded as beneficial, there has been no prospective randomized multicenter trial of patients with non-ST elevation ACS in the Japanese population to examine the efficacy of preprocedural aggressive statin use. The aim of this study was to confirm this effect by prospective randomized multicenter design. Methods: Fifty patients who presented with non-ST elevation ACS were enrolled, and randomly assigned to aggressive statin administration before percutaneous coronary intervention (PCI). Troponin-T (TnT), creatine phosphokinase (CK), CK-myocardial band (CK-MB), high-sense C-reactive protein (hs-CRP), and brain natriuretic peptide (BNP) were measured at baseline and/ or after procedure. Results: Three days after PCI, the statin group had significantly less CK elevation compared with the nonstatin group (84±17 IU/l versus 180±68 IU/l, respectively, p = 0.02). CK-MB elevation also tended to be lower in the statin group than in the nonstatin group (3.2±1.9 versus. 7.0±3.0, respectively, p = 0.07), as was BNP level (3.2±1.9 versus 7.0±3.0 pg/ml, respectively, p = 0.07). The change of serum LDL cholesterol was significantly correlated with CK ( p = 0.01) and TnT ( p = 0.02) at 1 day after PCI. Conclusions: Aggressive statin usage before PCI to Japanese patients with non-ST elevation ACS appears to reduce myocardial damage after procedure. The degree of serum lipid level reduction may reflect the vulnerability of atheromatous plaques that could cause cardiac damage after PCI.

Tricuspid Regurgitation (TR) in the setting of left sided valve disease (LVD) is aggressively treated since TR is an independent and potent mortality risk in this population. Although transcatheter aortic valve therapy is becoming common in elderly populations, percutaneous devices for TR are not

Background: While some therapies implemented for newly diagnosed Diabetes Mellitus (DM) or impaired Glucose Tolerance (IGT) are effective in preventing cardiovascular events, investigations of coronary plaque in patients with newly diagnosed DM or IGT are lacking. Methods: We evaluated 96 patients with acute coronary syndrome. The External Elastic Membrane (EEM), Lumen Cross-Sectional Area (CSA), plaque CSA, and plaque burden in the Left Anterior Descending (LAD) artery proximal to the lesion, diagnosed as normal by Coronary Angiography (CAG), were measured using Intravascular Ultrasound (IVUS). Patients were divided according to DM status (DM=35, non-DM=61). Non-DM patients underwent a 75g Oral Glucose Tolerance Test (OGTT) and were further divided into abnormal glucose tolerance (AGT; n=29) and Normal Glucose Tolerance (NGT) groups (n=32). Results: Quantitative Coronary Angiography (QCA) showed no significant differences in EEM or vessel diameter between groups. However, the lumen CSA was significantly smaller in the DM group than in the NGT group. The plaque CSA and plaque burden were significantly greater in the DM and AGT groups than in the NGT group. Total insulin and glucose values and insulin and glucose values at 120 min after the OGTT correlated with plaque CSA; insulin values at 120 min after the OGTT showed the strongest correlation (R=0.505, P

Paravalvular leak (PVL) is recognized in 9-22% of patients undergoing transcatheter aortic valve replacement (TAVR). It is an independent risk factor for mortality at short-and mid-term follow-up. Recognized causes include inadequate valve stent dilation and eccentric aortic valve calcification.

Preprocedural chronic kidney disease and contrast-induced acute kidney injury are predictors of in-hospital death and long-term mortality. However, neither the time course of kidney function after percutaneous coronary intervention (PCI) nor the relation between the time course of kidney function and prognosis has been adequately studied. We studied 531 patients who underwent PCI for acute coronary syndrome. The continuous deterioration of kidney function (CDKF) was defined as a >25% increase in serum creatinine level or serum creatinine >0.5 mg/dl above baseline at 6 to 8 months after PCI. CDKF was observed in 87 patients (16.4%). Independent risk factors for CDKF were contrast-induced acute kidney injury, preprocedural hemoglobin level, and proteinuria. Patients with CDKF exhibited significant higher 5-year mortality rate than patients without CDKF (25% vs 9.4%, log-rank p = 0.0006). Independent risk factors for 5-year mortality were age >75 year, anemia, New York Heart Association class III or IV, low ejection fraction, and CDKF. CDKF is associated with an increased risk of all-cause mortality of 5 years in patients with acute coronary syndrome undergoing PCI.

One of the most compelling scenarios of embolic transport is for cardiogenic particles. These emboli are a major cause of death and disability, resulting in an estimated 20%–30% of ischemic brain strokes. Whether cardiogenic emboli continue distally in the descending aorta, or travel into the aortic branch arteries has critical consequences for stroke. Previous studies found that embolic particles tend to favor larger diameter arteries at bifurcations, which suggests that cardiogenic emboli should be preferentially transported to the descending aorta, even beyond expectations due to flow rate. However, extrapolating previous findings to this scenario is questionable because previous models do not represent the unique fluid dynamics and morphology of the ascending aorta. We utilized medical imaging and computational modeling to better understand the transport of cardiac emboli to the cerebral arteries. Results indicate that particle transport to aortic branch arteries, and subsequently the arteries to the head, has a strong size-destination predilection that varies markedly from volumetric blood flow distribution.Copyright © 2013 by ASME

While it is intuitively clear that aortic anatomy and embolus size could be important determinants for cardiogenic embolic stroke risk and stroke location, few data exist confirming or characterizing this hypothesis. The objective of this study is to use medical imaging and computational modeling to better understand if aortic anatomy and embolus size influence predilections for cardiogenic embolic transport and right vs. left hemisphere propensity. Anatomically accurate models of the human aorta and branch arteries to the head were reconstructed from computed tomography (CT) angiography of 10 patients. Blood flow was modeled by the Navier-Stokes equations using a well-validated flow solver with physiologic inflow and boundary conditions. Embolic particulate was released from the aortic root and tracked through the common carotid and vertebral arteries for a range of particle sizes. Cardiogenic emboli reaching the carotid and vertebral arteries appeared to have a strong size-destination relationship that varied markedly from expectations based on blood distribution. Observed trends were robust to modeling parameters. A patient's aortic anatomy appeared to significantly influence the probability a cardiogenic particle becomes embolic to the head. Right hemisphere propensity appeared dominant for cardiogenic emboli, which has been confirmed clinically. The predilections discovered through this modeling could represent an important mechanism underlying cardiogenic embolic stroke etiology.

Obesity is an important public health problem, especially among patients with cardiovascular disease. However, little is known about the impact of obesity on the long-term prognoses of patients with acute myocardial infarction (AMI). Major adverse cardiac and cerebrovascular events (MACCE) consist of all causes of death, stroke, target lesion revascularization, target vessel revascularization, non-fatal myocardial infarction, and hospitalization. From January 2001 to March 2005, we analyzed 121 patients who survived30 days after suffering their first AMI of the left anterior descending artery for MACCE. The mean follow-up period for this study was 59 ± 26 months. Seventy-five patients presented with normal weight (BMI 25 kg/m(2)) and 46 were obese (BMI 25 kg/m(2)). During the follow-up period, 56 patients presented MACCE, including 18 deaths, 11 strokes, and seven non-fatal myocardial infarctions. Normal weight was significantly associated with the occurrence of MACCE (p = 0.012). Grouping of the patients by BMI and homeostasis model assessment ratio (HOMA-R) indicated that the combination of a higher BMI (25) and lower insulin resistance (HOMA-R 2.0) provided the best prognosis (p = 0.0006). Kaplan-Meier curves stratified to the four groups, sorted by diabetes mellitus and BMI at admission, showed that the normal weight patients with diabetes mellitus presented the highest risk of MACCE (p 0.0001). Patients with higher BMI and no insulin resistance or diabetes mellitus present better long-term outcomes following anterior AMI.

Background Accumulation of lipids within coronary plaques is an important process in disease progression. However, gray-scale intravascular ultrasound images cannot detect plaque lipids effectively. Radiofrequency signal analysis could provide more accurate information on preclinical coronary plaques. Methods We analyzed 29 zones of mild atheroma in human coronary arteries acquired at autopsy. Two histologic groups, i.e., plaques with a lipid core (group L) and plaques without a lipid core (group N), were analyzed by automatic calculation of integrated backscatter. One hundred regions of interest were set on the target zone. Radiofrequency signals from a 50 MHz transducer were digitized at 240 MHz with 12-bit resolution. The intensity of integrated backscatter and its distribution within each plaque were compared between the two groups. Results Although the mean backscatter was similar between the groups, intraplaque variation of backscatter and backscatter in the axial direction were larger in group L than in group N (p = 0.02). Conventional intravascular ultrasound showed extremely low sensitivity for lipid detection, despite a high specificity. In contrast, a cut-off value>32 for the total variance of integrated backscatter identified lipid-containing plaque with a high sensitivity (85%) and specificity (75%). Conclusion Compared with conventional imaging, assessment of the intraplaque distribution of integrated backscatter is more effective for detecting lipid. As coronary atheroma progresses, its composition becomes heterogeneous and multi-layered. This radiofrequency technique can portray complex plaque histology and can detect the early stage of plaque progression.

The benefits of treating patients with acute coronary syndrome (ACS) with statins are well established. This study investigated the effects of statins on patients who presented with low levels of low-density lipoprotein (LDL) cholesterol, were diagnosed with non-ST elevation ACS, and subsequently underwent percutaneous coronary interventions (PCI).From 2000 to 2003, 87 patients(mean age 68 +/- 10 years, 69 males, 18 females) underwent PCI because of non-ST elevation ACS, and had low LDL cholesterol on presentation. These patients were divided into two groups: those who had been taking statins (S-group, n = 46), and those not taking statins, or controls (C-group, n = 41). Only patients whose LDL cholesterol was100 mg/dl at admission (average: 82 +/- 12 mg/dl) were included in the study. Troponin-T (TnT), creatine kinase (CK), CK-MB, and high-sense C reactive protein (hs-CRP) were measured before and 6 hr after PCI. The two groups were evaluated at 6 months clinical follow-up.There was no difference in these markers before PCI in both groups. TnT and CK-MB in the S-group at 6 hr post-PCI were significantly decreased compared to those of the C-group (0.45 +/- 1.34 vs 1.40 +/- 2.37 ng/ml, respectively, for TnT, p = 0.04; 17.2 +/- 45.5 vs 81.3 +/- 157.2 IU/l, respectively, for CK-MB, p = 0.02). Major adverse cardiac events (MACE) defined as death, myocardial infarction, congestive heart failure and target lesion revascularization were evaluated after 6 months. There was no difference in MACE between the two groups.Statin treatment before PCI in patients with non-ST elevation ACS demonstrated beneficial effects such as less myocardial damage, even though both groups presented with low LDL cholesterol levels. However, no significant effect on MACE was seen at 6 months after PCI.

Summary Spontaneous renal artery dissection is a rare condition that precedes renal infarction. We describe a 48-year-old, normotensive healthy woman presenting with left flank pain of sudden onset. Enhanced abdominal computed tomography demonstrated a dissecting intimal flap of the left renal artery complicating renal infarction. Doppler ultrasonography, selective angiography, and intravascular ultrasound revealed a dissecting intimal flap, with a large false lumen and narrow true lumen, of the renal artery bilaterally. Conservative management was undertaken with anticoagulant and analgesic therapy, and the patient was discharged after an uneventful clinical course.

Renal denervation is a prominent, emerging therapy for resistant hypertension. However, it is associated with a non-response rate of 10-40%. Recent data suggest that accessory renal arteries may play a causative role in non-response, though mechanisms are uncertain. A highly relevant question