A Case with the Left Common Carotid Artery Involvement as Large Vessel Vasculitis after COVID-19

It is known that there are many other organ involvements in the coronavirus disease of 2019 (COVID-19) apart from respiratory tract involvement, and the disease may occur in different clinical spectrums in different patients. One of the most important structures affected by the virus is the vascular structure. It creates a tendency to thrombosis, especially by causing damage to the vascular endothelium and activating the coagulation system and may lead to important complications. It is known that the virus, which especially affects venous and small-sized arterial vessels, also affects medium-sized vessels. However, large-sized arterial vascular involvement is very rare. In this case report, it was aimed to present the left common carotid artery vasculitis, together with radiological appearence and clinical features, in a patient who presented with the complaint of left anterior neck pain in 4 weeks after COVID-19 infection. © Copyright 2023 by Anatolian Journal of Family Medicine.

CD4+ T cells from preeclamptic patients cause hypertension, autoantibodies and cognitive dysfunction in a pregnant rat model

CD4+ T Cells from Preeclamptic patients with or without a history of COVID-19 during pregnancy cause hypertension, autoantibodies and cognitive dysfunction in a pregnant rat model Objective: Preeclampsia (PE) new onset hypertension (HTN) during pregnancy, is associated with increased autoantibodies, cerebral blood flow (CBF) impaired cognitive function and memory loss. We have shown adoptive transfer of placentalCD4+T cells from PE women into athymic nude pregnant rats causesHTNand autoantibodies associated with PE.COVID-19 (CV) during pregnancy is associated with increased diagnosis of PE. However, we do not know the role of CD4+ T cells stimulated in response to CV in contributing to the PE phenotype seen patients with a Hx of CV during pregnancy. Therefore, we hypothesize that adoptive transfer of placental CD4+ T cells from patients with a CV History (Hx) during pregnancy with PE causes HTN, increased CBF and cognitive dysfunction in pregnant athymic nude recipient rats. Study Design: Placental CD4+ T cells isolated from normotensive (NP), PE, Hx of CV normotensive (CV Hx NT), and Hx of CV with PE (CV Hx+PE) at delivery. One million CD4+ T cells were injected i.p. into nude athymic rats on gestational day (GD) 12. The Barnes maze and the novel object recognition behavioral assays were used to assess cognitive function on GDs 15-19. Blood pressure (MAP) and CBF were measured by carotid catheter and laser Doppler flowmetry on GD19, respectively. A two-way ANOVA was used for statistical analysis. Result(s):MAPincreased inCVHx+PE (111 +/- 4, n = 4) and PE recipient rats (115 +/- 2 mmHg, n = 5) compared to CV Hx NT (100 +/- 4, n = 5) and NP (99 +/- 3 mmHg, n = 4, P < .05). CV Hx+PE and PE exhibited latency with errors navigating in the Barnes maze compared to CV Hx NT and NP groups. Locomotor activity was decreased in CV Hx+PE (P < .05) compared to PE, CV Hx NT, and NP groups. CV Hx+PE and PE spent more time exploring identical objects compared to CV Hx NT and NP groups. PE and CV Hx+ PE had increased CBF compared to CV Hx NT and NP rats. Conclusion(s): Our findings indicate that pregnant recipients of CD4+ T cells from PE with or without a Hx CV during pregnancy cause HTN, increased CBF and cognitive dysfunction compared to recipients of NP or NT Hx COVID-19 CD4+ T cells.

Unique vascular complication following extended VV-ECMO support

Objectives: To present an unusual complication related to prolonged ECMO support in a patient with COVID19 induced acute respiratory syndrome (ARDS). Method(s): Clinical chart review of the care process after obtaining the informed consent from the patient. Result(s): A 48-year-old female with COVID-19 infection during second wave of pandemic in August 2021 progressed to severe ARDS. She was put on VV-ECMO support after failing conventional therapy for refractory hypoxemia. Her cannulation configuration included a 25 F venous drainage cannula in the right femoral vein and a 21 F venous return cannula in the right Internal Jugular (IJ) vein. Cannulations were performed using the ;Seldinger technique;under USG guidance, and no difficulties or complications were reported. Her hospital course was notable for delirium, and intermittent bleeding from the cannula sites. After 80 days of support, she showed adequate respiratory improvement which allowed ECMO decannulation. She continued to show improvement, and was eventually discharged after 102 days of total hospital stay. During her 6 weeks follow-up clinic visit a palpable thrill was noted at the jugular ECMO cannula site. A CT angiogram of the neck demonstrated a large venous varix connecting the right IJ and the left common carotid artery with filling from the left common carotid artery. ECMO cannulation site complications such as aneurysm, clots, infections and stenosis are well known. What was unusual in this case is the nature of the aneurysm given that there were no arterial procedures performed on the left side of the neck. She was managed by an ;Amplatzer plug;to the carotid artery at the level of the connection to the varix without any complications. Conclusion(s): Longer duration of ECMO support needs careful follow-up for timely recognition and management of vascular complications. (Figure Presented).

ECMO in acute fulminant myocarditis in pediatrics

Objectives: To describe our experience in ECMO for acute myocarditis Methods: Descriptive, retrospective study (2018-2022) of a cohort of 8 patients < 16 years with acute myocarditis who were assisted on ECMO. Result(s): 8 patients were collected, (6 females), with a mean age 7;8 years [range 0;1-13;8]. In 7/8, the reason for cannulation was hemodynamic instability refractory to medical treatment, with a mean inotropic score of 70 [range 10-122]. Sixty-two percent presented cardiorespiratory arrest prior to cannulation and 2 of them needed ECRP. The mean precannulation troponin level was 1498 ng/ml [range 89-6212]. Primary transport was performed in 4 patients. ECMO was peripheral veno-arterial in 100%, jugulo-carotid in 2/8 and femoro-femoral in 6/8. All patients underwent atrioseptostomy. They received treatment with levosimendan, immunoglobulins, corticoids and carnitine. In 4 acute infectious etiology was confirmed (parvovirus, influenza and SARSCoV2), another one was due to PIMS-TS and in 3 no etiology was found. Six patients underwent myocardial biopsy and 5 of them showed inflammatory infiltrates. The mean time on ECMO was 8 days [range 3-14], 2 of them requiring 2 ECMO courses. The mean length of PICU stay was 21 days [range 10-50]. Two were transferred to a heart transplant center. The main complications were arterial hypertension (88%), bleeding (63%), neurological (50%), arrhythmias (38%), coagulopathy (38%) and infectious (38%). One patient required renal replacement therapy. 1 patient died, 2 had moderate neurological sequels. Conclusion(s): ECMO is a therapeutic option in patients with fulminant myocarditis refractory to medical treatment and may help improve their prognosis.

Clinical and Neuroimaging Characteristics of Ischemic Stroke in Rhino-Orbito-Cerebral Mucormycosis Associated with COVID-19.

PURPOSE: The aim of this study was to compare clinical, neuroimaging, and laboratory features of rhino-orbito-cerebral mucormycosis (ROCM) in COVID-19 patients with and without ischemic stroke complications. METHODS: This observational study was conducted between August and December 2021 and 48 patients who had confirmed ROCM due to COVID-19, according to neuroimaging and histopathology/mycology evidence were included. Brain, orbit and paranasal sinus imaging was performed in all included patients. Data pertaining to clinical, neuroimaging, and laboratory characteristics and risk factors were collected and compared between patients with and without ischemic stroke complications. RESULTS: Of the patients 17 were diagnosed with ischemic stroke. Watershed infarction was the most common pattern (N = 13, 76.4%). Prevalence of conventional risk factors of stroke showed no significant differences between groups (patients with stroke vs. without stroke). Cavernous sinus (p = 0.001, odds ratio, OR = 12.8, 95% confidence interval, CI: 2.3-72) and ICA (p < 0.001, OR = 16.31, 95%CI: 2.91-91.14) involvement was more common in patients with stroke. Internal carotid artery (ICA) size (on the affected side) in patients with ischemic stroke was significantly smaller than in patients without stroke (median = 2.4 mm, interquartile range, IQR: 1.3-4 vs. 3.8 mm, IQR: 3.2-4.3, p = 0.004). Superior ophthalmic vein (SOV) size (on the affected side) in patients with stroke was significantly larger than patients without stroke (2.2 mm, IQR: 1.5-2.5 vs. 1.45 mm IQR: 1.1-1.8, p = 0.019). Involvement of the ethmoid and frontal sinuses were higher in patients with stroke (p = 0.007, OR = 1.85, 95% CI: 1.37-2.49 and p = 0.011, OR = 5, 95% CI: 1.4-18.2, respectively). Patients with stroke had higher D­dimer levels, WBC counts, neutrophil/lymphocyte ratios, and BUN/Cr ratio (all p < 0.05). CONCLUSION: Stroke-related ROCM was not associated with conventional ischemic stroke risk factors. Neuroimaging investigations including qualitative and quantitative parameters of cavernous sinus, ICA and SOV are useful to better understand the mechanism of stroke-related ROCM in COVID-19 patients.

Covid 19 presenting as stroke and MI

Its now a well known fact that covid 19 causes coagulopathy that has been associated with the inflammatory phase of coronavirus disease (COVID-19) and might be involved in this concurrency. Here we present a case of a 55y old female with no underlying comorbidity presented with the chief complaints of mild slurry speech and weakness over the right side of the body from last 8 h. Noncontrast brain computed tomography (CT) scan showed early signs of ischemia in left middle cerebral artery (MCA) territory, and a CT angiogram demonstrated a carotid atheromatous plaque with a superficial thrombus causing 40% stenosis in the left proximal internal carotid artery (ICA), however no intracranial artery occlusion was found. On ecg patient had ST segment depression in and depression in v5 and v6 leads with transthoracic echocardiogram showed lateral wall hypokinesia of the left ventricle, with qualitative troponin-T positive. There were no respiratory or other symptoms compatible with COVID-19 infection or chest pain. Chest CT ruled out inflammatory/infectious signs in the lung parenchyma, and Rapid antigen testing for covid 19 was negative on admission however RTPCR for SARS-CoV-2 was positive. Patient was initially loaded with dual anti platelets and lmw heparin and was subsequently managed with aspirin 150 mg, clopidogrel 75 mg and atorvastatin 40 mg with resolution of the chest pain and slurry speech.

UNet Deep Learning Architecture for Segmentation of Vascular and Non-Vascular Images: A Microscopic Look at UNet Components Buffered With Pruning, Explainable Artificial Intelligence, and Bias

Biomedical image segmentation (BIS) task is challenging due to the variations in organ types, position, shape, size, scale, orientation, and image contrast. Conventional methods lack accurate and automated designs. Artificial intelligence (AI)-based UNet has recently dominated BIS. This is the first review of its kind that microscopically addressed UNet types by complexity, stratification of UNet by its components, addressing UNet in vascular vs. non-vascular framework, the key to segmentation challenge vs. UNet-based architecture, and finally interfacing the three facets of AI, the pruning, the explainable AI (XAI), and the AI-bias. PRISMA was used to select 267 UNet-based studies. Five classes were identified and labeled as conventional UNet, superior UNet, attention-channel UNet, hybrid UNet, and ensemble UNet. We discovered 81 variations of UNet by considering six kinds of components, namely encoder, decoder, skip connection, bridge network, loss function, and their combination. Vascular vs. non-vascular UNet architecture was compared. AP(ai)Bias 2.0-UNet was identified in these UNet classes based on (i) attributes of UNet architecture and its performance, (ii) explainable AI (XAI), and, (iii) pruning (compression). Five bias methods such as (i) ranking, (ii) radial, (iii) regional area, (iv) PROBAST, and (v) ROBINS-I were applied and compared using a Venn diagram. Vascular and non-vascular UNet systems dominated with sUNet classes with attention. Most of the studies suffered from a low interest in XAI and pruning strategies. None of the UNet models qualified to be bias-free. There is a need to move from paper-to-practice paradigms for clinical evaluation and settings.

Telemedicine Justification

Funding: None. Synopsis: Because of COVID-19, re-imbursement restrictions for medical services have been relaxed, both to continue provision of healthcare services and afford physicians a stream of revenue. While telemedicine may have relevance in medical and psychiatric practices, its benefits appear less tangible for vascular surgical patients. Those patients, most of whom have multiple co-morbidities, have a high acuity of illness and assessment absent physical examination has the potential for providing a lower standard of care. Many articles laud telemedicine without determining if telemedicine is non-inferior to customary hand-on care. To determine if telemedicine is equivalent, a retrospective review was performed to ascertain if telemedicine provides equivalent care Methods: A retrospective, single observer, the charts of 100 consecutive patients were reviewed to determine if their condition could have been adequately treated via telemedicine. Data were collected from patient records and each chart was reviewed to determine if physical patient contact was essential to the assessment and treatment strategy. Result(s): Of the 100 patient encounters, 78 patients were determined to require an in-depth interview and physical examination. 40 were new patients and 60 were established patients, seen either for post-surgical follow-up or manifestation of a new problem. There were 55 males and 45 females. Average age was 56.2 years with 59 patients older than 65. Diagnoses and clinical severity were recorded and the determination was made if a face-to-face encounter could have been conducted via telemedicine. Those conditions requiring direct contact included chronic kidney disease, differentiation between vascular and neurogenic symptoms, aneurysm, carotid stenosis, wound complications, and musculoskeletal disorders. (TABLE 1) Conditions that could have been safely managed with telemedicine included venous insufficiency, carotid ultrasound results, lymphedema, and pre-operative patients. Of the 100 patients, only 7 seven patients were candidates for telemedicine. (TABLE 2) Not included in this study were 57 additional patients who underwent ultrasounds/non-invasive studies and whose results were transmitted to the patients by a mid-level. Conclusion(s): A small minority of vascular patients are adequately treated via telemedicine. While Medicare payments for the telephone evaluation and management visits are equivalent to established office/outpatient visits, care must be taken to assure that equivalency exists between telemedicine and face-to-face encounters. Controlled outcome studies with larger populations should be performed to determine if telemedicine and in-person visits provide equal patient benefit. [Formula presented] [Formula presented] Institution: Memorial Healthcare System, Davie, FLCopyright © 2022

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.

Recurrent floating common carotid artery thrombus related to COVID-19: A case report.

The occurrence of arterial and venous thrombosis during coronavirus infection has been widely reported since the beginning of the epidemic. Floating carotid thrombus (FCT) in the common carotid artery is exceptional and its main known cause is atherosclerosis. We describe the case of a 54-year-old man who developed, one week after the onset symptomatology of related to COVID-19 infection, an ischemic stroke, complicating a large intraluminal floating thrombus in the left common carotid artery. Despite surgery and anticoagulation, a local recurrence with other thrombotic complications occurred and the patient died.

Neuroanesthesia practice during COVID-19: A single-center experience

The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.Copyright © 2020 Wolters Kluwer Medknow Publications. All rights reserved.

Stroke in patients with COVID associated Mucormycosis: A Report of Two Cases

Mucormycosis is a rare and invasive fungal disease with potentially fatal outcome. It most commonly affects patients with compromised immunity, especiallly those with poorly controlled diabetes. The incidence of mucormycosis has increased after the COVID-19 pandemic and both COVID-19 and mucormycosis are associated with an increased incidence of stroke. We present a report of two cases of COVID associated mucormycosis who had stroke. A 50-year-old patient with uncontrolled diabetes developed swelling of left eye and face ultimately leading to complete ophthalmoplegia of left eye. Imaging studies of brain revealed infarcts. MRI/MRA brain showed left internal carotid artery thrombosis, cavernous sinus thrombosis and a brain abscess in left temporal lobe. A second patient was a 65-year-old diabetic and hypertensive male who had COVID and then developed right MCA territory infarct and right sided cavernous sinus thrombosis. Diagnostic nasal endoscopy and biopsy was suggestive of mucormycosis in both the cases. Both these cases were managed with combination of tight glycemic control, antifungal therapy, and surgery. Clinicians should be aware of the association of stroke with COVID and COVID associated mucormycosis (CAM). Copyright © 2022 International Medical Sciences Academy. All rights reserved.

Vascular Function, Systemic Inflammation, and Coagulation Activation 18 Months after COVID-19 Infection: An Observational Cohort Study.

INTRODUCTION: Among its effect on virtually all other organs, COVID-19 affects the cardiovascular system, potentially jeopardizing the cardiovascular health of millions. Previous research has shown no indication of macrovascular dysfunction as reflected by carotid artery reactivity, but has shown sustained microvascular dysfunction, systemic inflammation, and coagulation activation at 3 months after acute COVID-19. The long-term effects of COVID-19 on vascular function remain unknown. MATERIALS AND METHODS: This cohort study involved 167 patients who participated in the COVAS trial. At 3 months and 18 months after acute COVID-19, macrovascular dysfunction was evaluated by measuring the carotid artery diameter in response to cold pressor testing. Additionally, plasma endothelin-1, von Willebrand factor, Interleukin(IL)-1ra, IL-6, IL-18, and coagulation factor complexes were measured using ELISA techniques. RESULTS: The prevalence of macrovascular dysfunction did not differ between 3 months (14.5%) and 18 months (11.7%) after COVID-19 infection (p = 0.585). However, there was a significant decrease in absolute carotid artery diameter change, 3.5% ± 4.7 vs. 2.7% ± 2.5, p-0.001, respectively. Additionally, levels of vWF:Ag were persistently high in 80% of COVID-19 survivors, reflecting endothelial cell damage and possibly attenuated endothelial function. Furthermore, while levels of the inflammatory cytokines interleukin(IL)-1RA and IL-18 were normalized and evidence of contact pathway activation was no longer present, the concentrations of IL-6 and thrombin:antithrombin complexes were further increased at 18 months versus 3 months (2.5 pg/mL ± 2.6 vs. 4.0 pg/mL ± 4.6, p = 0.006 and 4.9 µg/L ± 4.4 vs. 18.2 µg/L ± 11.4, p < 0.001, respectively). DISCUSSION: This study shows that 18 months after COVID-19 infection, the incidence of macrovascular dysfunction as defined by a constrictive response during carotid artery reactivity testing is not increased. Nonetheless, plasma biomarkers indicate sustained endothelial cell activation (vWF), systemic inflammation (IL-6), and extrinsic/common pathway coagulation activation (FVII:AT, TAT) 18 months after COVID-19 infection.

The relationship between arterial stiffness and disease severity in patients with COVID-19

Background and Aim: It is known that COVID-19 infection causes cardiovascular complications. It is thought that this may be related to endothelial dysfunction. The aim of this study is to reveal the relationship between arterial stiffness, which may be an indicator of endothelial dysfunction, and disease severity. Method(s): Patients with COVID-19 infection and age, sex and cardiac risk factors matched control group were included in the study. Arterial stiffness was measured in the early period (within the first month) of COVID-19 infection. Echocardiographic measurements were also performed at the same time. The patients were divided into two groups according to the severity of covid, as mild and severe. In order to determine the severity of the disease, oxygen or intensive care need, biochemical parameters such as C-reactive protein (CRP), hs-troponin, complete blood count (CBC) were used in line with the recommendations. Arterial stiffness measurements were made by the gold standard applanation tonometry method, from the radial, carotid and femoral arteries. Result(s): A total of 84 patients were included in the study, 27 of which were in the control, 32 in the mild disease and 25 in the severe disease groups. The mean age of the population was 48.6+/-12.9 years, and 69% (n=58) were male. The whole group had 30% hypertension (HT), 10% Diabetes Mellitus (DM), 11% coronary artery disease (CAD), 11% were smoking and 2% with hyperlipidemia (HL). There was no significant difference between the groups in terms of these risk factors. The mean pulse wave velocity (PWV) value obtained in arterial stiffness measurements was 8.02, 8.07 and 8.75 in the control group, mild disease group and severe disease group, respectively. These values were found to be statistically significant when the control group and mild disease groups were compared with the severe disease group. (p=0.007, p=0.008, respectively). Conclusion(s): The results of this study revealed that the deterioration in arterial stiffnes, which is a good indicator of endothelial dysfunction, is more significant in patients with severe COVID-19 infection. These patients should be followed more closely for subsequent cardiovascular complications.

Bilateral Cerebral Strokes and Adrenal Hemorrhage Associated with Mis-A

INTRODUCTION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is an underrecognized post-infectious manifestation of COVID-19.We report a case of a 21-year-old male with MIS-A who presented with adrenal hemorrhages, acute kidney injury (AKI) and cerebral strokes leading to multiorgan system failure and death. DESCRIPTION: A 21-year-old, morbidly obese male presented at an outside hospital with COVID-19 and abdominal pain. His abdominal CT demonstrated bilateral adrenal hemorrhages, he was discharged home on hydrocortisone. A month later was readmitted with fever, diarrhea, thrombocytopenia and AKI. Laboratory work revealed creatinine 5.49mg/dL, ferritin 701ng/ml, BNP 3020 pg/ml and D-Dimer 17,650 ng/ml. He received hydrocortisone, intravenous immunoglobulin and enoxaparin. Fever subsided and renal function normalized. On day 7 he developed acute altered mental status and recurrent AKI. Head CTA showed multiple short stenotic segments in the anterior circulation, diminutive appearance of several intracranial arteries and basal ganglia hypodensities. Brain MRA demonstrated extensive bilateral acute/subacute strokes, no evidence of sinus thrombosis and markedly decreased caliber of internal carotid, left middle and anterior cerebral arteries without evidence of thrombus. He received aggressive neurocritical care management including decompressive craniectomy and pulse steroids for suspected vasculitis. Due to the severity of his neurological injury and poor neurologic prognosis family elected to withdraw support. His autopsy demonstrated hepatomegaly, acute tubular necrosis, bilateral adrenal hemorrhages and hypercellular bone marrow with myeloid predominance. Neuropathology showed severe segmental stenosis of the carotid arteries and bilateral vertebral arteries. DISCUSSION: Stroke is a potentially life-threatening complication of COVID-19 including large vessel occlusion and less frequently vasculitis-like phenotype with vessel wall enhancement. Despite initial improvement, our patient developed an acute extensive ischemic stroke leading to a devastating neurologic injury. The neuropathology findings suggest SARS-CoV-2 associated vasculitis. Stroke in the context of COVID-19 may have different pathogenetic mechanisms, clinical characteristics and complications that warrant further investigation.

Occurrence, Risk Factors and Predictors for Early Reintervention After Coronary Artery Bypass Grafting- Regression and ML analysis

Background: Coronary re-interventions after CABG are generally preferably percutaneous, and may be related to progression of atherosclerosis due to pre-existing risk factors and may be influenced by operator experience, type of surgery-(off pump or on-pump), and conduits used. We analysed the demographics, patient and operative characteristics, clinical features of patients undergoing early re-interventions - arbitrarily defined as within 2 years of index "primary" CABG for this study (i.e. no prior percutaneous coronary interventions) to determine predictors of the same. Method(s): We collected data on 1367 patients who underwent primary CABG over a decade from Jan 1,2010 to Jan 1 2020( pre-COVID).Demographic and clinical risk factors for CAD, angiographic characteristics, pattern of CAD, electrocardiographic (ECG) changes, and prevalent LV function were evaluated at baseline, immediate post-op and on follow ups till the need of the next intervention. Patients who underwent re-intervention in the said period were compared with an age- and gender- matched population who did not undergo re interventions to determine predictors for re-intervention by both Logistic regression and Machine learning analysis using SVM, KNN and Naive Bayes Classifier Results: 160 patients ( 11.7%) patients underwent re-intervention within 2 years of the primary CABG. Multivariate backward logistic regression analysis and Machine learning analysis with three models revealed that re-intervention was performed significantly more frequent in patients with : Index admission with uncontrolled diabetes mellitus (strongest risk factor), patient age < 50 years, emergency CABG -Both as primary CABG or bail-out for PCI complications, Use of saphenous vein graft v/s total arterial revascularisation ( except RIMA usage), those undergoing off- pump CABG, failure of DAPT to continue beyond three months, CABG following recent acute coronary syndrome, CABG in Multivessel disease with Syntax score> 27 need of mechanical support following CABG ( IABP), higher ventilation requirement with delayed sternal course, patients with post-op renal insufficiency with /without undergoing assisted renal replacement, statin intolerance/ lower doses, and CABG with more than 4 grafts(all p < 0.001). Patients with carotid disease and peripheral disease were also higher in number in the re-intervened arm. Re-interventions were more common in patients with LVEF > 50% at time of need of re-intervention, but this may be attributed to selection bias due to preference for conservative management if the LVEF was too low on follow up. Conclusion(s): Predictors for early re-intervention after CABG are a pointer towards more aggressive "malignant" form of atherosclerosis. There is actually higher graft loss in younger age especially in emergency CABG, patients with uncontrolled DM, renal insufficiency and high SS, and inadequate statin usage- all of which may contribute to( or indicate towards) an inflammatory process of atherosclerosis. Knowledge of these risk factors may guide the surgeon in counselling the patient for possible graft loss as well as suitably plan the surgical course in reducing re-intervention. Copyright © 2022

Society for Vascular Medicine Vascular Scientific Sessions

The proceedings contain 83 papers. The topics discussed include: Aortobronchial fistula in a 75-year-old male presenting with hemoptysis- a case report;a rare case of COVID-19 associated aortitis;complications of vascular Ehlers-Danlos Syndrome;good things don't always come in small packages: Idiopathic small-vessel vasculitis;kissing carotids: A case of incidental found bilateral retropharyngeal carotid arteries;downhill esophageal varices: Rare cause of esophageal varices;acute upper limb ischemia and a large cardioembolic infarct in an elderly female presenting with multiple intracardiac thrombi;acute upper limb ischemia as initial presentation of COVID-19 infection in a 49-year-old male: A case report;a missed ruptured abdominal aortic aneurysm in a paraplegic patient;rare adverse event following cyanoacrylate closure of greater saphenous vein;and vascular Ehlers-Danlos Syndrome: A case of leaking intracranial and intraabdominal aneurysms.

Bilateral Carotid Artery Dissections and Ischemic Stroke in a Patient With COVID-19: A Case Report.

An unresponsive patient with COVID-19 infection should prompt immediate evaluation with consideration of a vast differential diagnosis entailing a multitude of diagnostic and therapeutic interventions in the emergency department. We report a case of an unresponsive 41-year-old female with COVID-19 infection and a history of rheumatoid arthritis who presented to the emergency department with bilateral carotid artery dissections and left internal carotid artery thrombus that extended into the middle cerebral artery. This case calls into question if COVID-19 is coincidentally or causally associated with acute vascular and thromboembolic disease.