The Three Most Discussed Questions in Carotid Artery Surgery. Review of Russian and Foreign Studies in the Last Five Years

This literature review analyzes Russian and foreign publications over the past five years on the three most discussed issues related to carotid artery surgery: l.Which is more effective: eversion carotid endarterectomy or conventional carotid endarterectomy with patch closure? 2. Which is better: carotid endarterectomy (CEE) or carotid angioplasty and stenting (CAS)? 3. How soon after the development of ischemic stroke should cerebral revascularization be performed? The authors of the article came to the following conclusions: 1. According to the majority of large studies and meta-analyses, conventional CEE with patch closure is associated with a higher risk of internal carotid artery restenosis compared to eversion carotid endarterectomy. Single-center trials with small samples of patients do not find statistical differences between the outcomes of applying both surgical techniques. 2. Large multicenter randomized trials are required to address the effectiveness of CEA and CAS in symptomatic and asymptomatic patients. To date, there has been no consensus on this matter. 3. CEE and CAS can be equally effective and safe in the most acute and acute periods of ischemic stroke when performed in the presence of a mild neurological deficit and the ischemic brain lesion not exceeding 2.5 cm in diameter. Nevertheless, the choice of treatment strategy should be made strictly personalized by a multidisciplinary council based on the experience of the institution and current recommendations. © 2023 Sklifosovsky Research Institute for Emergency Medicine. All rights reserved.

Acute Pancreatitis Following a Lower Extremity Angioplasty

Introduction: Acute pancreatitis affects a significant population globally. Usual etiologies are gallstones, alcohol, hypertriglyceridemia, medications;less frequent are trauma, hypercalcemia, infections, toxins, ischemia, anatomic anomalies, vasculitis, and idiopathic. Pancreatitis post coronary intervention is an uncommon cause with only 19 published cases in the last two decades. Being cognizant of this etiology is important given the increasing number of patients undergoing angiography. Case Description/Methods: An 81-year-old female with hypertension, diabetes, peripheral arterial disease, prior cholecystectomy underwent left lower extremity angioplasty at an outside center. Within a few hours, she started having severe epigastric pain radiating to her back, nausea, vomiting and loose bloody stool. She presented to the emergency department 24 hours after symptom onset. Epigastric tenderness was present on exam. Labs revealed leukocytosis (24,450/muL), elevated lipase (1410 U/L), elevated creatinine (1.3 mg/dL), lactate (3.1 mmol/L), calcium 9.4 mg/dL and triglycerides 161 mg/dL. Incidentally, found to be positive for COVID-19. Normal common bile duct diameter seen on sonogram. CT angiogram of the abdomen/pelvis showed acute pancreatitis, duodenal and central small bowel enteritis (Figure). She was not on any medications known to cause pancreatitis and denied alcohol use. Patient improved with analgesics and intravenous fluids. She had no recurrence of bloody stools and hemoglobin remained stable. On day 4, she was able to tolerate a regular diet, and leukocyte count and creatinine normalized. Patient did not have any COVID respiratory symptoms, and was discharged. Discussion(s): Given the temporal association to angioplasty and no other identifiable cause, acute pancreatitis was presumed to be due to the contrast used during angioplasty. Other possibilities included cholesterol embolism but no peripheral signs of cholesterol embolism were seen. Patient was an asymptomatic COVID-19 case. Although, there are case series of pancreatitis due to COVID, those were found in very sick symptomatic patients. On review of literature, cholesterol embolism was identified as a definite cause only on autopsy or laparotomy (Table). Other possible mechanisms are: high viscosity of the contrast media leading to ischemia and necrosis, contrast causing NF-kB activation followed by epithelial damage, and vasospasm. Pancreatitis after coronary angiography is rare, nonetheless, an important differential especially if there is a temporal relationship.

RESULTS of ACTIVITIES of the DEPARTMENT of VASCULAR SURGERY AMIDST COVID-19 PANDEMIC.

Aim To conduct comparative analysis of the activities of the department of vascular surgery before and during the spread of new coronavirus infection COVID-19 (SARS-CoV-2). Methods The analysis was performed on the number of outpatient visits of vascular surgeon for types of diagnosis, number and type of surgeries performed at the inpatient facilities of the LLC "Grand Medica" over 2019 (whole year) and 2020 (quarterly). Results Significant decrease was noted in the number of visits of patients with cardiovascular diseases to vascular surgeon in the outpatient facility. The number of surgeries on limb arteries in patients among Kuzbass residents decreased by 26.4 %, among residents of other regions - by 59.5 %;in brachiocephalic arteries - by 12.5 % and 54.5 %, respectively. The number of percutaneous transluminal coronary angioplasty (PTCA) in patients among Kuzbass residents increased by 25.3 %, among residents of other regions remained unchanged. Conclusion Decrease in the volume of provision of care for patients with cardiovascular diseases over 2-4 quarters of 2020 is caused by two groups of factors. The first one is associated directly to the epidemiological situation and countermeasures against the spread of SARS-CoV-2 while the second one is associated indirectly.Copyright © 2021 Russian Academy of Sciences. All right reserved.

Pulmonary artery resection and reconstruction in locally advanced lung cancer with moderate hemoptysis

Lobectomy with pulmonary artery (PA) angioplasty in locally advanced lung cancer is an alternative to pneumonectomy. It is feasible, oncologically effective and the procedure of choice in patients with recurrent hemoptysis and limited pulmonary reserves. We present a case of a successful left upper lobectomy with PA resection and reconstruction by an autologous pericardial patch.Copyright © 2022 EDIZIONI MINERVA MEDICA.

Impact of in-hospital medical management for COVID-19 pandemic on door-to-balloon time in patients with ST-elevation myocardial infarction

Background: Delayed door-to-balloon (DTB) time and deterioration of inhospital mortality during the coronavirus disease 2019 (COVID-19) pandemic have been reported. Little is known about the impact of changes in in-hospital medical management before primary percutaneous coronary intervention (PCI) for COVID-19 such as screening test (antigen or polymerase chain reaction (PCR) tests, chest CT for excluding the pneumoniae) and primary PCI under full personal protective equipment (PPE) on DTB time and in-hospital mortality. Purpose(s): The purpose of this study was to evaluate the impact of inhospital medical management for COVID-19 on DTB time and in-hospital mortality during COVID-19 pandemic period. Method(s): We compared DTB time and in-hospital mortality of 502 STelevation myocardial infarction (STEMI) patients during COVID-19 pandemic (February 2020 and January 2021) with 2035 STEMI patients before pandemic (February 2016 and January 2020) using date from Mie ACS registry, a retrospective and multicenter registry. Result(s): The COVID-19 screening tests before primary PCI and/or primary PCI under full PPE was performed on 173/502 (34.5%) patients (antigen or PCR tests;39 (7.8%), chest CT;156 (31.3%), full PPE;11 (2.2%)). These patients had lower rate of achievement of DTB time <=90 min compared with others (Figure 1A). Moreover, In-hospital management of COVID-19 screening tests and/or primary PCI under full PPE was an independent factor of DTB time>90 min with odds ratio of 1.94 (95% confidential interval: 1.37-2.76, p<0.001). In addition, in-hospital mortality of those patients was higher compared with others (Figure 1B). Conclusion(s): In-hospital medical management for COVID-19 screening tests before primary PCI and/or primary PCI under full PPE was the independent factor of DTB time>90 min. This study reinforces the need to focus efforts on shortening DTB time, while controlling the epidemic of infection.

Prediction and Analysis of Heart Diseases Using Heterogeneous Computing Platform

The work in this paper helps study cardiac rhythms and the electrical activity of the heart for two of the most critical cardiac arrhythmias. Various consumer devices exist, but implementation of an appropriate device at a certain position on the body at a certain pressure point containing an enormous number of blood vessels and developing filtering techniques for the most accurate signal extraction from the heart is a challenging task. In this paper, we provide evidence of prediction and analysis of Atrial Fibrillation (AF) and Ventricular Fibrillation (VF). Long-term monitoring of diseases such as AF and VF occurrences is very important, as these will lead to occurrence of ischemic stroke, cardiac arrest and complete heart failure. The AF and VF signal classification accuracy are much higher when processed on a Graphics Processor Unit (GPU) than Central Processing Unit (CPU) or traditional Holter machines. The classifier COMMA-Z filter is applied to the highly-sensitive industry certified Bio PPG sensor placed at the earlobe and computed on GPU.

A rare case of CSU+CIndU resistant to systemic treatment with GCS and methotrexate initiated to Takayasu's disease

Case report Background: It is well known that chronic spontaneous urticaria (CSU) has an autoimmune etiology in 40% of cases. It is often comorbid with other autoimmune diseases and a wide spectrum of autoantibodies involved in the pathogenesis of CSU is discussed. Objective(s): We share a clinical case of a rare underline autoimmune disease with later onset of CSU and chronic induced urticaria (CIU). Case: A 38-year- old woman was admitted to the hospital with SARS-CoV- 2 infection. At the age of 22, she was diagnosed with Takayasu's disease involving the aorta, the common and external carotid artery, and the left subclavian artery. Surgical interventions were performed twice -angioplasty of the involved vessels, but in both cases restenosis of the affected arteries was observed. Regarding the underlying disease, the patient received 10 mg of methotrexate once a week and 20 mg of prednisone daily. Due to detailed history collection, the patient noted that for the last 4 months she has rashes, bright red in color, rising above the surface of the skin and accompanied by a strong burning and itching dominantly on the upper and lower extremities, trunk. Appearing every day spontaneously, they have a rounded shape (diameter of up to 40-50 mm). While liner scratching the rash has similar contour. Rash elements disappear within a few hours, do not leave traces. During the current hospitalization, a wheal element up to 40 mm in diameter was observed at the wrist area, stayed for a few hours. UAS-7 -42. According to examination: eosinophils 1000 cells/mcl (patient noticed that eosinophilia of the blood has happened before, an examination was conducted, helminthiasis and parasitosis were excluded), total IgE -more than 2000 IU/ml, antibodies to b2-glycoprotein were revealed. Freak test -negative, but the linear wheals were confirmed by retrospective photos. Result(s): In this clinical case, CSU occurs in combination with induced dermographic urticaria. This patient has extremely aggressive urticaria according to its frequency of occurrence despite therapy with systemic GCS and methotrexate. After recovery from coronavirus infection, further examination and consideration of the appointment of biologicals(anti-IgE) is planned.

Periinterventional management of edoxaban in major procedures: Results from the DRESDEN NOAC REGISTRY

Introduction Edoxaban is a non-vitamin K dependent oral anticoagulant (NOAC) licensed for venous thromboembolism (VTE) treatment or stroke prevention in atrial fibrillation (SPAF). Major surgical procedures are not uncommon in anticoagulated patients but data on perioperative edoxaban management are scarce. Method Using data from the prospective DRESDEN NOAC REGISTRY we extracted data on major surgical procedures in patients who took edoxaban within the preceding 7 days. Periinterventional edoxaban management patterns and rates of outcome events were evaluated until day 30 after procedure. Results Between 2011 and 2021, 3448 procedures were identified in edoxaban patients, including 287 (8.3 %) major procedures. Overall, patient characteristics were comparable for major and non-major procedures, but significant differences existed with regard to gender, concomitant antiplatelet therapies and the proportion of patients with a CHA2DS2-VASc score >= 2 (Table 1). Major procedures consisted of orthopaedic/trauma surgery (44.3 %);open pelvic, abdominal or thoracic surgery (30.4 %), central nervous system surgery and procedures (13.9 %), vascular surgery (9.1 %) and extensive wound revision surgery (2.4 %). A scheduled interruption of edoxaban was observed in 284/287 major procedures (99 %) with a total median edoxaban interruption time of 11.0 days (25- 75th percentile 5.0-18.0 days). Heparin bridging was documented in 183 procedures (46 prophylactic dosages, 111 intermediate and 26 therapeutic dosages). Overall, 7 (2.4 %;95 %-CI 1.2 %-4.9 %) major cardiovascular events (5 VTE, 2 arterial thromboembolic events) occurred and 63 bleeding events were observed in 287 major procedures (22.0 %;95 %-CI 17.6 %-2.71 %), comprising of 38 ISTH major bleeding events (13.2 %;95 %-CI 9.8 %-17.7 %) and 25 ISTH CRNM bleedings (8.7 %;95 %-CI 6.0 %-12.5 %). Rates of major cardiovascular events with or without heparin bridging were comparable (6/183;3.3 %;95 %-CI 1.5 %-7.0 % vs. 1/36;2.8 %;95 %-CI 0.5 %-14.2 %;p = 0.7173). ISTH major bleeding occurred numerically more frequent in patients receiving heparin bridging (30/183;16.4 %;95 %-CI 11.7 %-22.4 %) versus procedures without heparin bridging (2/36;5.6 %;95 %-CI 1.5 %-18.1 %;p = 0.1542) (Fig. 1). Within 30 days of follow up, 6 patients died (2.1 %;95 %-CI 1.0 %-4.5 %) with causes of death being a ruptured truncus coeliacus following palliative angioplasty for an infiltrating pancreas cancer (ruled as fatal bleeding), septic organ failure, pneumocystis jirovecii pneumonia, COVID-19-pneumonia, septic complications following clipping of a ruptured cerebrovascular aneurism or terminal malignant disease. No fatal cardiovascular event occurred. Conclusion Within the limitations of our study design, periprocedural edoxaban management seems effective and safe in routine care. Use of heparin bridging seems to have limited effects on reducing vascular events but may increase bleeding risk. (Table Presented).

Appraising SARS-CoV-2 infections after full mRNA COVID-19 vaccination in patients with systemic lupus erythematosus (SLE)

The 2019 Coronavirus disease (COVID-19) vaccine is a major weapon in the fight against the severe acute respiratory syndrome brought about by coronavirus 2 (SARS-CoV-2). The vaccine significantly reduces the risk and severity of infection by SARS-CoV-2. Patients with systemic lupus erythematosus (SLE) need protection from vaccine-preventable diseases including COVID-19. SLE patients have higher rates of severe infections due to immunosuppressive therapies and multiple immunologic defects - both of which are capable of blunting the immune responses after vaccination. In the management of COVID-19, recommendations have been developed to guide adjustments and/or continuation of immunosuppressive therapies for an effective immune response following vaccination with mRNA-based or viral vector-delivered vaccines. Monoclonal antibodies have also become available since December 2021. Here we present three cases of SLE patients who contracted COVID-19 after vaccination. One was managed in ambulatory settings and two required inpatient hospital admission.Copyright © 2022

Bilateral Axillo-Brachial Artery Stenosis Following Messenger Ribonucleic Acid (mRNA) Vaccination Against Severe Acute Respiratory Coronavirus 2 (COVID-19).

The following case report is an overview of an unusual presentation of bilateral axillo-brachial artery occlusion following messenger ribonucleic acid (mRNA) vaccination against severe acute respiratory coronavirus 2 (COVID-19). A 64-year-old female presented with symptoms initially consistent with polymyalgia rheumatica five weeks following the first booster of the Pfizer-BioNTech COVID-19 vaccine. She was successfully treated with prednisone therapy; however, despite the normalization of inflammatory markers, she later presented with bilaterally occluded axillo-brachial arteries. She successfully underwent endovascular management for the treatment of her symptoms. To our knowledge, this is the first case report of chronically occluded bilateral axillo-brachial artery disease following mRNA vaccination for COVID-19 successfully treated with endovascular therapy. The unusual pathogenesis of upper extremity arterial disease is reviewed and a review of endovascular treatment options is presented. A literature review of the types of vasculitis seen following mRNA COVID-19 vaccination is also presented.

Percutaneous Coronary Intervention Associated with a Higher Risk of Hypoxemia and COVID-19 Severity.

Objective The primary goal of the present study was to measure the implications of hypoxemia in COVID-19 patients with a history of coronary artery disease (CAD). Methods A systematic search of the literature published from November 1, 2019 to May 1, 2021, was conducted on PubMed/MEDLINE, Embase, and Web of Science databases. Afterwards, an observational study was designed based on the electronic health records of COVID-19 patients hospitalized in a tertiary referral hospital during the same period. A total of 179 COVID-19 cases were divided into two groups: cases with a history of CAD and percutaneous coronary intervention (CAD/PCI+, n = 89) and controls (n = 90). Clinical data were extracted from the electronic database of the hospital and statistically analyzed. Results After the application of inclusion/exclusion criteria, only three studies were deemed eligible, one of which was concerned with the impact of CAD on the all-cause mortality of COVID-19. Results from our observational study indicated that the cases were older (median age: 74 vs. 45) and more likely to develop hypoxemia (25.8% vs. 8.8%) than the controls. CAD/PCI+ was correlated with a more severe COVID-19 (11% vs. 1%). Age was a moderately significant independent predictor of increased COVID-19 severity, while hypoxemia was not. Conclusion Considering the negative impact of hypoxemia on the prognosis of COVID-19 and its higher prevalence among COVID-19 patients with underlying CAD, further research is warranted to unravel the negative effects of COVID-19 on the mechanisms of gas exchange and delivery in patients with pre-existing CAD.

Renal artery thrombosis as a long-term complication of COVID-19

Coronavirus disease 2019 (COVID-19) has been extensively associated with microvascular and macrovascular thrombosis. Several reports have demonstrated a link between COVID-19 and pulmonary embolism, deep vein thrombosis, myocardial infarction, stroke, and aortic thrombosis. Renal artery thrombosis is of special interest because of its life-threatening consequences, such as acute kidney injury and renal infarction. We present a case of left renal artery thrombosis as a long-term complication of COVID-19. Moreover, we demonstrate the effectiveness of interventional radiology to regain vascularization of the affected kidney. © 2022

Lung Perfusion SPECT/CT in Suspected Chronic Thromboembolic Pulmonary Hypertension: Impact on Classification of Pulmonary Hypertension and Therapeutic Decision

Aim/Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH) is a difficult entity to diagnose due to its association with other etiologies causing pulmonary hypertension (PHT), mainly cardiological disease. Our aim is to analyse the value of pulmonary perfusion SPECT/CT in the presence of suspected CTEPH and to evaluate its impact on the diagnosis and subsequent therapeutic approach. Material(s) and Method(s): Retrospective series of 108 patients with suspected CTEPH who were performed a lung perfusion SPECT/CT in the presence of perfusion defects on planar images between March 2020-April 2022. Variables such as age, sex, scintigraphic result, other radiological findings, correlation with catheterisation and CT angiography, type of PHT (according to Dana Point Consensus Classification of Pulmonary Hypertension, California 2008) and therapy of choice after scintigraphy were analysed. Result(s): Mean age: 69 +/- 12 years (25-90). 54% women. In 55 patients(51%) CTEPH was ruled out by SPECT/CT(-), although other radiological findings were observed (13% chronic parenchymal pathology/post-COVID-19 infection, 7% cardiomegaly, 5% pleural effusion, 4% infiltrates consistent with COVID-19 infection,2% pulmonary nodule suspicious of malignancy). 6 of the 18 patients with catheterisation(33%) had a pulmonary capillary pressure(PCP) suspicious for CTEPH(<=15mmHg), which was ruled out after negative scintigraphy. In the 53(49%) confirmed CTEPH by SPECT/ CT(+), 28 with other radiological findings(36% chronic pulmonary pathology/post-COVID-19,11% pulmonary nodule suspicious of malignancy,11% infiltrates consistent with COVID-19 infection). 10 of 15 patients(67%) with CT angiography(-). 55% of the patients with catheterisation(11/20) presented with a PCP not suspicious of CTEPH(>=15mmHg), and were finally diagnosed with CTEPH after positive SPECT. In patients without CTEPH after SPECT(-), PHT was classified into the following types:37 with PHT type-II/left heart disease(6 candidates for valve replacement),9 type-III/pulmonary disease and/or hypoxaemia, 5 mixed type-II+III, 2 type-I (1 portal hypertension in cirrhotic patient and 1 scleroderma), 2 type-V (1 obstruction of tumour origin and 1 chronic renal failure). of the patients who were confirmed to have CTEPH, 19(36%) had purely embolic PHT(type-IV), with 5 being candidates for endacterectomy/ angioplasty, and the remaining 34(64%) had mixed PHT(24 type-II+IV, 5 type-III+IV, 5 type-II+III+IV), with 35% being candidates for surgery. Conclusion(s): Lung perfusion SPECT/CT imaging is a very useful test for the classification of pulmonary hypertension leading to better therapeutic management of these patients. The greatest efficiency is seen with a negative result as the embolic origin is excluded with excellent reliability, thus avoiding more aggressive and/or difficult-to-manage therapies. In addition, low-dose CT provides additional information of great clinical relevance.

Interventional challenges in vasculitis

Background: This case highlights how coronary pathology presents in vasculitis. Case presentation: A 49-year-old male, never-smoker presented to our hospital for a series of Acute Coronary Syndromes (ACS). The first in October 2019;angiogram revealed diffuse aneurysms and clot in the right coronary artery (RCA) and stenosis in the posterolateral branch (PLB). Post aspiration thrombectomy, and drug eluting stent (DES) to the PLB, patient was discharged on standard ACS meds. Coagulopathy workup was unremarkable. Follow up in November 2020, the patient was recommended reducing ticagrelor to 60mg twice daily (bid). The second ACS, one year later, revealed severe in-stent restenosis of the PLB stent. Patient had 2 DES placed in the PLB and was discharged on escalated therapy of rivaroxaban 2.5mg bid, and ticagrelor 90mg bid. Two months later the patient had COVID-19;during that admission he had two ACS events. The first showing mid-RCA stenosis and thrombosis of the same PLB;this was treated with only angioplasty. The next day, he had repeat ACS showing thrombosis of the RCA, but despite multiple attempts RCA recanalization was unsuccessful and discharged on medical therapy only. During clinic follow up, May 2022, the patient revealed that he had Kawasaki's disease as a kid. Conclusion(s): Coronary aneurysms are high risk because of slow flow and endothelial dysfunction that makes balloon dilation, stent sizing, and post interventional medical therapy difficult. Currently no standard guidelines exist to help providers treat this population. It may be beneficial to regularly follow up, monitor inflammatory markers (ESR, CRP correlated well with interleukin 6 and 8), and use CT or PET to follow active vasculitis and changes in aneurysms. Kawasaki's disease is a vasculitis of small and medium-sized vessels and often presents in childhood. Prospective studies show that patients with coronary aneurysms tend to have systemic artery aneurysms, so it is important to screen other arterial beds. Valvular disease has also been found to co-exist in patients with vasculitis, and pre-existing disease should be followed with echocardiography.

Particular Misdiagnosed Acs-Nstemi in a Young Adult with History of Hodgkin's Lymphoma in the Era of Frequent Sars-Cov2 Related Myocarditis: Nothing Should Ever Be Left to Chance

Background: Radiotherapy plays a key role in the multimodality treatment of thoracic tumors. Radiotherapy-induced heart disease (RIHD) has become an increasingly recognized adverse reaction contributing to major radiation-associated toxicities, including nonmalignant death. Especially patients with diseases with excellent prognosis, such as breast cancer or Hodgkin's lymphoma, may suffer from delayed side effects 2-6 including RIHD in a dose-dependent manner. The pathological spectrum of RIHD includes conduction abnormalities, valvular disease, coronary artery disease, pericarditis and pericardial constriction or effusion, cardiomyopathy, and myocardial fibrosis. Here we describe the case of a young man cured of Hodgkin's lymphoma who presented to our laboratory with the diagnosis of suspected myocarditis in the Sars-COV 2 era, but the presenting clinical picture confused the clinicians and complex coronary artery disease was behind it. Method-Clinical Case: A young 33-years-old man presented to the emergency room with typical exertional chest pain. Clinical history: smoker patient who denied familiarity for cardiovascular diseases, dyslipidemic, 10 years previously underwent chemotherapy and radiotherapy for Hodgkin's Lymphoma in complete remission. A nasopharyngeal molecular swab for Sars-COV 2 was performed, which was negative. The presentation electrocardiogram (EKG) documented nonspecific repolarization abnormalities;the myocardionecrosis enzyme curve performed at three times was frankly positive with elevated PCR values (102 pg/ml). Color Doppler echocardiography documented a left ventricular ejection fraction at the lower limits of normal, hypokinesia of the midbasal segments of the infer-posterolateral wall with moderate mitral valve regurgitation. On suspicion of acute myocarditis, the patient was transferred to the Coronary Care Unit and, during admission, underwent MRI, which showed a slightly enlarged left ventricle (DTD 58 mm, EDV 147 ml), slightly depressed systolic function (LVEF 46%), akinesia of the proximal lateral and mid-proximal wall. In delayed enhancement sequences late persistence of gadolinium in the endomesocardium (60%), proximal lateral and mid-proximal wall with involvement of areas adjacent to the base of implantation of both papillary muscles. In light of the instrumental picture, the patient underwent coronarography, which showed an unexpected nightmare picture, given his young age. Circumflex branch (lcx-lesion culprit) suboccluded to the middle segment with TIMI I downstream flow at the bifurcation with a prominent obtuse marginal branch (OM) with a delayed reperfusion (Medina 1,1,1);diffusely atheromatous left anterior descending artery (LAD), showing 70% complex critical disease in the proximal segment at the bifurcation with a first diagonal branch of good caliber and good distribution area (Medina 1,1,1). Clinical resolution/Results: Therefore, in a patient with misdiagnosed ACS-NSTEMI, two complex coronary bifurcation angioplasties according to TAP technique (Fig 3-4) were performed through left radial access with Slender 7 in 6 introducer at one time. The following drugs were administered in the cathlab: Cangrelor bolus/kg followed by continuous infusion for 2 hours and Prasugrel 60 mg, initially UFH 5000 IU and anticoagulation control according to ACT during the procedure. The procedure ended with complete revascularization and asymptomatic patient. During the following days of hospitalization, no late electrical or mechanical complications occurred. Conclusion(s): The one just described represents a complex and unexpected scenario for a young adult. The literature available has analyzed the pathophysiology of myocardial damage resulting from exposure to high amounts of radiation in patients undergoing curative radiotherapy for Hodgkin's lymphoma. It is now generally accepted that the most common clinical syndromes after irradiation are pericarditis in acute and chronic forms,. However, coronary vessel lesions have been considered exceptionally rare, so the true pathophysi logical triggering mechanism is still poorly understood. The most widely accepted hypothesis on the onset of RICHD is a dual pathway of vascular damage ("two-hit combined hypothesis"). The most important preventive measure regarding RICHD is doseminimization. Few data are available in the literature on outcomes according to the revascularization strategy adopted in patients with RICHD (PCI vs. CABG). Morbidity andmortality from post-radiotherapy cardiovascular complications in patients with Hodgkin's lymphoma must be reduced through close cardiological surveillance in primary prevention and a close collaboration between oncologists and cardiologists in order to minimize any deleterious complications, especially in the young. Further research is needed to elucidate profibrotic mechanisms, identify promising therapies that can be implemented early during the course of treatment and to compare revascularization strategies with longer-term mortality in such patients, in order to guide the physicians in the decision-making.

Visual Impairment Secondary to Right Sigmoid and Transverse Sinus Thrombosis in Setting of COVID- 19 Viral Infection: A Case Report

Case Diagnosis: 23-year-old female with past medical history significant for morbid obesity and prior oral contraceptive use diagnosed with right sigmoid and transverse sinus thrombosis resulting in visual impairment nineteen days after testing positive for COVID-19 infection. Case Description or Program Description: Patient initially presented to the emergency department for evaluation of worsening dyspnea and chest tightness eight days after diagnosis of COVID-19 infection. At that time a diagnosis of right lower lobe pulmonary embolism was established. She was discharged home with warfarin for anticoagulation. Prior to discharge, the patient did not have visual disturbance or focal neurological deficits. Five days after discharge and nineteen days after COVID-19 diagnosis patient returned to the emergency department for evaluation of new onset blurry vision and tinnitus. Setting(s): Tertiary care hospital Assessment/Results: Physical examination revealed bilateral mydriasis, abducens palsy, and papilledema. Patient with a therapeutic INR at time of admission. Full neurological workup was performed including MRI/MRV of brain which revealed extensive venous sinus thrombosis involving the right transverse and sigmoid sinuses and significant bilateral optic nerve head edema. Patient underwent left optic nerve sheath fenestration followed by thrombectomy of right sigmoid sinus with angioplasty. Serial lumbar punctures were performed for cerebrospinal fluid pressure reduction. Despite treatment the patient was left with permanent vision loss and was admitted to an inpatient rehabilitation facility (IRF) for three weeks prior to discharge home. Discussion (relevance): The inflammatory response related to COVID-19 infection places patients in a hypercoagulable state and those who have pre-existing risk factors for venous thrombosis should be monitored closely for complications related to acute thrombosis. Conclusion(s): This case brings awareness to possible neurological deficits seen following the acute phase of a COVID-19 infection. It is important for physiatrists to be mindful of these complications as they may present following acute phase of infection within an IRF to assist with early detection and improved outcomes.

A RARE CASE OF ASYMPTOMATIC COVID-19 INFECTION MASQUERADING AS PHLEGMASIA CERULEA DOLENS

SESSION TITLE: Look again: Infections and Mimics SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Phlegmasia Cerulea Dolens (PCD) is a rare and critical condition caused by venous thrombosis requiring emergent treatment to prevent limb ischemia. COVID 19 has been widely reported to cause venous thromboembolism and compromise of tissue perfusion. We report a case of PCD in a patient with asymptomatic COVID-19 infection. CASE PRESENTATION: A 60 year-old female with no known medical history, unvaccinated for COVID-19 presented with sudden onset left lower extremity pain and swelling associated with numbness. Physical examination was remarkable for left lower extremity swelling with bluish discoloration, poikilothermia, and paraesthesia. Computed tomography angiogram (CTA) chest, abdomen and pelvis revealed left lower extremity deep vein thrombosis with compromised blood flow with focal thrombosis of the IVC extending inferiorly to the great saphenous and popliteal vein, along with small bilateral segmental and subsegmental pulmonary emboli. Diffuse Ground glass opacities suspicious for COVID-19 pneumonia. COVID-19 PCR was positive. Anticoagulation with heparin drip was initiated, and the patient underwent successful left iliocaval to popliteal vein thrombectomy and venoplasty by interventional radiology with successful restoration of circulation to the affected extremity. She was eventually transitioned to apixaban. She experienced marked improvement in her symptoms post procedure. DISCUSSION: Patients with COVID 19 develop venous thromboembolisms at an alarming rate despite thromboprophylaxis. The mechanism is likely explained by the virchow's triad (venous stasis, hypercoagulable state, vessel wall injury) in the setting of increased pro-inflammatory markers. We report the first case at our institution of PCD in the setting of COVID-19.We noted that our patient had a similar presentation as those reported in literature, which include acute leg swelling associated with pain and cyanosis. Complications include venous outflow obstruction, which can result in compartment syndrome with arterial ischemia, eventually progressing to gangrene of the affected limb. PCD is a very rare but life-threatening complication caused by extensive clot burden associated with acute limb ischemia and increased mortality rates. This condition requires emergent initiation of intravenous anticoagulation and thrombectomy with or without tissue plasminogen activator (tPA). If this condition is not treated in a timely fashion, it can result in acute limb ischemia and gangrene requiring amputation. CONCLUSIONS: Physicians should recognize PCD in patients who have been exposed to COVID-19 as it is a life-threatening condition which requires emergent initiation of anticoagulation and treatment. Diagnosis is usually made with clinical examination and ultrasonography or CT imaging. Management options include open thrombectomy with leg fasciotomy or catheter directed thrombolysis or percutaneous transluminal angioplasty. Reference #1: Chun TT, Jimenez JC, Pantoja JL, Moriarty JM, Freeman S. Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation. J Vasc Surg Cases Innov Tech. 2020;6(4):653-656. doi:10.1016/j.jvscit.2020.10.002 Reference #2: Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg. 2022 Feb;79:122-126. doi: 10.1016/j.avsg.2021.07.034. Epub 2021 Oct 10. PMID: 34644637;PMCID: PMC8502248 Reference #3: : Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020;38(9):1978.e1-1978.e3. doi:10.1016/j.ajem.2020.05.022 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller N relevant relationships by jasparit minhas No relevant relationships by houman mirtorabi No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by Kiran Zaman

Critical leg ischemia related to COVID 19 in doubly vaccinated patients

Background: COVID and venous thromboembolism in unvaccinated population is now a well-established entity but this case is unique as the 1) patient had both COVID vaccines and then tested positive for COVID and 2) presented with vague symptoms and had minimum oxygen requirement 3) developed arterial thromboembolism and acute leg ischemia after 4 days of admission leading to limb amputation ultimately. Data on COVID and COVID vaccine's association with Arterial thromboembolismstill needs to be explored. In our case it was challenging to establish whether the thromboembolism was a complication of vaccine, COVID or was that the result of synergistic interaction of both. Case Presentation: 61 Years old gentleman presented to Emergency Department with vague history of lethargy ongoing for 3-4 weeks and no significant prior co-morbid except sickle cell trait. He had received both doses of COVID vaccine 2 months before presentation and denied any shortness of breath, cough, fever or pain. On presentation he was de-saturating to 77% on Room air and had bilateral crepitations in his chest with PO2 of 7.4 kPa on ABG and raised inflammatory markers on bloods. His CXR showed changes consistent with COVID and he was started on Dexamethasone. His COVID test came back as positive. Throughout his staymaximumamount of oxygen required by him was 36% day1 which improved to 28-32% later, he had not been tachypneic or tachycardiac. His d-dimer was raised at 3000 which was thought to be COVID related, and the decision was taken to perform CTPA to rule out Pulmonary embolism if oxygen requirement worsens. His oxygen requirement continued to remain static with a little improvement or worsening. His inflammatory markers also got better. On Day 4 Patient complained of Right Leg pain. On further enquiry he revealed pain has been ongoing for last 2-3 weeks. His legs were bilaterally ice cold to touch and had hair loss in bilateral legs, pulses in both legs down the femoral artery were not palpable bilaterally. His blood gas Lactate was 2.6 with worsening inflammatory markers but no fever spikes or worsening in oxygen requirement or any other symptoms apart from leg pain. He was immediately seen by vascular Surgery team and was started on therapeutic anticoagulation suspecting acute leg ischemia. CT Angio report showed: Occlusion of Right iliac system, common femoral artery part of the SFA and all the popliteal artery and tibial vessels and unstable thrombus in the left common iliac artery causing severe stenosis and occluded left TP trunk. He was continued on therapeutic anticoagulation and then underwent Right iliofemoral embolectomy, on table angiogram, left common iliac angioplasty via left groin approach and right above knee amputation. Postoperatively he remained well and was tested COVID negative later. He was then discharged to Rehab from hospital for further care. Discussion and conclusion: We suggest that COVID patients with significantly raised d-dimers should be investigated for hidden thromboembolic focus in same way in non COVID patients and not just in lungs but in other organ systems as well. There should be some guidelines regarding increased dose prophylaxis or a flowchart to investigate for these thromboembolic association in COVID.