Safety and efficacy of flow diverter stents in the treatment of middle cerebral artery aneurysms: a single-center experience and follow-up data

PURPOSE: This study aims to evaluate the safety and efficacy of flow diverters (FDs) in the treatment of middle cerebral artery (MCA) aneurysms and share the follow-up (F/U) results. METHODS: The treatment and F/U results of 76 MCA aneurysms treated with the flow re-direction endoluminal device (FRED), FRED Jr., and pipeline embolization device (PED) FD stents were evaluated retrospectively. The aneurysm occlusion rates were compared between FDs, and the integrated and jailed branches were evaluated through follow-ups. The oversizing of the stent was compared between occluded/non-occluded aneurysms and integrated branches. RESULTS: The mean F/U duration was 32 ± 6.3 months, and the mean aneurysm diameter was 4.45 mm. A total of 61 (80.3%) aneurysms were wide-necked; 73 (96.1%) were saccular; 52 (68.4%) were located at the M1 segment; and 36 (45.6%) FREDs, 23 (29.1%) FRED Jr.s, and 19 (24.1%) PEDs were used for treatment. The overall occlusion rates for the 6-, 12-, 24-, 36-, and 60-month digital subtraction angiographies were 43.8%, 63.5%, 73.3%, 85.7%, and 87.5% respectively. The last F/U occlusion rates were 67.6% for FRED, 66.7% for PED, and 60.6% for FRED Jr. (P = 0.863). An integrated branch was covered with an FD during the treatment of 63 (82.8%) aneurysms. A total of six (10%) of the integrated branches were occluded without any symptoms at the last F/U appointment. The median oversizing was 0.45 (0-1.30) for occluded aneurysms, and 0.50 (0-1.40) for non-occluded aneurysms (P = 0.323). The median oversizing was 0.70 (0.45-1.10) in occluded integrated branches and 0.50 (0-1.40) in non-occluded branches (P = 0.131). In-stent stenosis was seen in 22 (30.1%) of the stents at the 6-month F/U and in only 2 (4.7%) at the 24-month F/U. Thus, none of the patients had any neurological deficits because of the in-stent stenosis. Severe in-stent stenosis was seen in two stents. CONCLUSION: MCA aneurysms tend to be complex, with integrated branches and potentially wide necks. FD stents are safe and effective in the treatment of MCA aneurysms, and the patency of the side and jailed branches is preserved in most cases. Higher occlusion and lower in-stent stenosis rates are seen with longer F/U durations.

Review: Roles of human serum albumin in prediction, diagnoses and treatment of COVID-19.

The severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) keeps on destroying normal social integrity worldwide, bringing about extraordinary medical services, cultural and financial interruption. Individuals with diabetes have been demonstrated to be at higher risk of complications and even death when exposed to SARS-CoV-2. Regardless of pandemic scale infection, there is presently limited comprehension on the potential impact of SARS-CoV-2 on individuals with diabetes. Human serum albumin (HSA) is the most abundant circulating plasma protein in human serum and attracted more interest from researchers because most susceptible to non-enzymatic glycation reactions. Albumin down-regulates the expression of ACE2 that is the target receptor of COVID-19. Hypoalbuminemia, coagulopathy, and vascular disease have been connected in COVID-19 and appear to predict outcomes independent of age and morbidity. This review discusses the most recent evidence that the ACE/ACE2 ratio could influence by human serum albumin both the susceptibility of individuals to SARS-CoV-2 infection and the outcome of the COVID-19 disease.

Endothelial Dysfunction, Inflammation, and Oxidative Stress in COVID-19-Mechanisms and Therapeutic Targets.

The outbreak of the COVID-19 pandemic represents an ongoing healthcare emergency responsible for more than 3.4 million deaths worldwide. COVID-19 is the disease caused by SARS-CoV-2, a virus that targets not only the lungs but also the cardiovascular system. COVID-19 can manifest with a wide range of clinical manifestations, from mild symptoms to severe forms of the disease, characterized by respiratory failure due to severe alveolar damage. Several studies investigated the underlying mechanisms of the severe lung damage associated with SARS-CoV-2 infection and revealed that the respiratory failure associated with COVID-19 is the consequence not only of acute respiratory distress syndrome but also of macro- and microvascular involvement. New observations show that COVID-19 is an endothelial disease, and the consequent endotheliopathy is responsible for inflammation, cytokine storm, oxidative stress, and coagulopathy. In this review, we show the central role of endothelial dysfunction, inflammation, and oxidative stress in the COVID-19 pathogenesis and present the therapeutic targets deriving from this endotheliopathy.

Spontaneous right coronary artery dissection in a patient with COVID-19 infection: A case report and review of the literature.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the global coronavirus disease 2019 (COVID-19) pandemic. Although the virus predominantly causes respiratory system infection, recent reports have shown that it is also associated with many cardiovascular complications. It has been reported that COVID-19 may cause myocarditis, type 1 and 2 acute myocardial infarction, and thrombotic complications.[1] Spontaneous coronary artery dissection (SCAD) is a rare form of coronary artery disease that has recently been associated with COVID-19 in a few case reports. The case reported here is of COVID-19 associated SCAD in a patient with no history of cardiovascular disease.

Managing Vascular Surgery Emergencies and Referrals During the COVID-19 Pandemic at a Tertiary Centre in Oman.

OBJECTIVES: This study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome. METHODS: This study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas. RESULTS: Only one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail. CONCLUSIONS: With the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively.

Differences in hub and spoke vascular units practice during the novel Coronavirus-19 (COVID-19) outbreak in Lombardy, Italy.

BACKGROUND: To highlight differences in clinical practice among referral (hub, HH) or satellite (spoke, SH) hospital vascular surgery units (VSUs) in Lombardy, during the COVID-19 pandemic "phase 1" period (March 8 - May 3, 2020). METHODS: The Vascular Surgery Group of Regione Lombardia Register, a real-word, multicenter, retrospective register was interrogated. All patients admitted with vascular disease were included. Patients' data on demographics, COVID-19 positivity, comorbidities and outcomes were extrapolated. Two cohorts were obtained: patients admitted to HH or SH. Primary endpoint was 30-day mortality rate. Secondary outcomes were 30-day complications and amputation (in case of peripheral artery disease [PAD]) rates. Univariate and multivariate analysis were used to compare HH and SH groups and predictors of poor outcomes. RESULTS: During the study period, 659 vascular patients in 4 HH and 27 SH were analyzed. Among these, 321 (48.7%) were admitted to a HH. No difference in COVID-19 positive patients was described (21.7% in HH vs. 15.9% in SH; P=0.058). After 30 days from intervention, HH and SH experienced similar mortality and no-intervention-related complication rate (12.1% vs. 10.0%; P=0.427 and 10.3% vs. 8.3%; P=0.377, respectively). Conversely, in HH postoperative complications were higher (23.4% vs. 16.9%, P=0.038) and amputations in patients treated for PAD were lower (10.8% vs. 26.8%; P<0.001) than in SH. Multivariate analysis demonstrated in both cohorts COVID-19-related pneumonia as independent predictor of death and postoperative complications, while age only for death. CONCLUSIONS: HH and SH ensured stackable results in patients with vascular disease during COVID-19 "phase 1." Despite this, poor outcomes were observed in both HH and SH cohorts, due to COVID-19 infection and its related pneumonia.

COVID-19 - A vascular disease.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) leads to multi-system dysfunction with emerging evidence suggesting that SARS-CoV-2-mediated endothelial injury is an important effector of the virus. Potential therapies that address vascular system dysfunction and its sequelae may have an important role in treating SARS-CoV-2 infection and its long-lasting effects.

Understanding wound care from a venous and lymphatic perspective.

The uncertainty due to COVID-19 surrounding live events has remained present and persistent. Therefore, this year, the American Vein & Lymphatic Society (AVLS) Annual Congress will be a virtual-only event that will take place on 15 October 2020. It will include a live-streamed session will complement the fundamental knowledge of providing wound care for patients. On-demand content will allow attendees to participate at their own pace, watching as much or as little as they want each day, potentially earning AMA PRA Category 1 CreditsTM.

Triage of patients with venous and lymphatic diseases during the COVID-19 pandemic - The Venous and Lymphatic Triage and Acuity Scale (VELTAS) : A consensus document of the International Union of Phlebology (UIP), Australasian College of Phlebology (ACP), American Vein and Lymphatic Society (AVLS), American Venous Forum (AVF), European College of Phlebology (ECoP), European Venous Forum (EVF), Interventional Radiology Society of Australasia (IRSA), Latin American Venous Forum, Pan-American Society of Phlebology and Lymphology and the Venous Association of India (VAI) This consensus document has been co-published in Phlebology [DOI: 10.1177/0268355520930884] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.05.002]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/).

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30-90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6-12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.

Telemedicine platforms and their use in the coronavirus disease-19 era to deliver comprehensive vascular care.

Implementation of telemedicine for patient encounters optimizes personal safety and allows for continuity of patient care. Embracing telehealth reduces the use of personal protective equipment and other resources consumed during in-person visits. The use of telehealth has increased to historic levels in response to the coronavirus disease 2019 (COVID-19) pandemic. Telehealth may be a key modality to fight against COVID-19, allowing us to take care of patients, conserve personal protective equipment, and protect health care workers all while minimizing the risk of viral spread. We must not neglect vascular health issues while the coronavirus pandemic continues to flood many hospitals and keep people confined to their homes. Patients are not immune to diseases and illnesses such as stroke, critical limb ischemia, and deep vein thrombosis while being confined to their homes and afraid to visit hospitals. Emerging from the COVID-19 crisis, incorporating telemedicine into routine medical care is transformative. By leveraging digital technology, the authors discuss their experience with the implementation, workflow, coding, and reimbursement issues of telehealth during the COVID-19 era.

Pilot Study Using Telemedicine Video Consultation for Vascular Patients' Care During the COVID-19 Period.

BACKGROUND: The aim of this pilot study was to evaluate the effectiveness and patients satisfaction of using telemedicine virtual communications to provide remote health care to vascular patients during the coronavirus disease 2019 (COVID-19) period in China. METHODS: Video calls using WeChat software (Tencent, Shenzhen, China) between patients and vascular surgeons were conducted in a period when there were restrictions and limitations for people' travels in China. At the end of each video call, a short questionnaire was used to evaluate the patient satisfaction level. RESULTS: During the COVID-19 period from 19 February to March 16, 2020, a sample of 114 from 165 (69%) patients was reached after one phone call attempt. One hundred forty-two telemedicine remote communications were made between the two vascular surgeons and 114 patients. The mean age of this cohort of patients were 60 ± 15.2 (range 25 to 90) years old, and 74 (65%) were men. Twenty-five patients (22%) were outside of our province when they received the video call. The mean duration of the video call was 11.0 ± 8.9 minutes. All of the patients thought telemedicine was a good substitute for coming to hospital, and 95% (108/114) of them preferred to have remote telemedicine rather than postpone the appointment. All the patients agreed with the advantages of telemedicine including no infection risks, no need to travel, and no need to wait for long time. All the patients were "satisfied" or "highly satisfied" with the video call and they would like to use telemedicine for follow-up in the future. CONCLUSIONS: Telemedicine virtual communications was effective to provide remote health care with a high patient satisfaction during the COVID-19 period. Telemedicine offers support to vulnerable vascular patients without the need for travel and face-to-face hospital consultation, and so avoided transmission and infection.

Spontaneous coronary artery dissection of the left anterior descending artery in a patient with COVID-19 infection.

A 48-year-old woman with a past medical history of migraines and hyperlipidemia presented due to severe retrosternal chest pain with no other associated signs or symptoms. The patient was hemodynamically stable and was found to have an elevated troponin with electrocardiogram showing no ischemic changes. Computed tomography of the coronary arteries showed a left dominant system with dissection extending from the mid-to-distal left anterior descending (LAD) artery. The patient was subsequently discharged on medical therapy but returned 3 days later due to worsening chest pain. Electrocardiogram revealed inferior and anteroseptal ST segment changes with peak troponin of 14.9 ng/ml (reference range <0.80 ng/ml). Coronavirus disease 2019 (COVID-19) nasopharyngeal swab was performed prior to urgent coronary angiogram. Coronary angiogram was performed with full personal protective equipment for respiratory and droplet precautions due to pending COVID-19 testing results. Angiogram revealed spontaneous coronary artery dissection (SCAD) extending from the ostium of the LAD to the distal vessel. COVID-19 testing returned positive while in intensive care unit. The patient was not a percutaneous coronary intervention candidate due to the extent of the dissection and was not a surgical candidate due to a lack of graftable target and medical management was continued. To our knowledge, this case is the first in which SCAD has been reported in the LAD in a patient with COVID-19 with no other symptoms of respiratory illness or symptoms classically associated with the novel coronavirus. SCAD should be considered on the differential as one of the various cardiac manifestations of COVID-19 infection.