COVID-19 Related Acute Lower Limb Ischemia Treated Via Percutaneous Thrombectomy and Catheter Direct Thrombolisis

Background: The aim of this report is to describe and discuss a unique case of acute lower limb ischemia presented in a recovered COVID-19 patient treated via percutaneous mechanical thrombectomy and catheter directed thrombolysis. Starting from this singular case a wide literature review regarding COVID-19-related thrombo-embolic complications has been accomplished. Methods: A 47-year-old male was admitted to the emergency unit with acute lower limb ischemia three weeks after testing positive for COVID-19. He had been isolated at home because of minor COVID-19-related symptoms. Angio-CT-imaging showed a segmental occlusion of the common iliac artery coupled with retro-articular popliteal artery and leg vessels thrombosis. The patient was first unsuccessfully submitted to trans-femoral iliac thrombo-embolectomy. Results: Instead of peripheral limb vessel re-thromboembolectomy, a percutaneous mechanical thrombectomy coupled with leg vessel catheter direct thrombolysis was performed. The completion angiography showed the recanalization of the popliteal artery and leg vessels as far as the ankle but with a reduced forefoot vascularization. The fibrinolytic treatment was continued for 8 hours post-operatively. A compartment syndrome complicated the early post-operative course. There was a progressive recovery of ischemic symptoms and at 6-month follow-up, peripheral pulses were palpable with an almost complete normalization of foot and toe perfusion and motility. Conclusion: Acute lower limb ischemia following COVID-19-related arterial thrombo-embolic events represents a severe complication of COVID-19 infection and may result in a high rate of revascularization failure. In these cases, Percutaneous Mechanical thrombectomy coupled with catheter directed thrombolysis might represent a less traumatic and more selective approach.

A rare case: Penetrating craneoencefalic trauma by knife

Background: Cranioencephalic penetrating trauma (CPT) is caused by a sharp or short- pointed object that passes through the bone, dura mater, brain and other structures. Its incidence is unknown and few cases are described; penetrating injuries represent 0.4%, therefore there is no protocolized management. Case report: A 24-year-old male patient suffered penetrating trauma at left parietal region with a "knife"; he was sutured and sent home with analgesics. Five days after the trauma, he was admitted for headache, disorientation and decreased visual acuity. X-ray (XR) of Cranium evidencing a foreign body, therefore it is sent to a reference hospital. Evolution: The diagnosis is confirmed by a computerized tomography (CT) scan of the skull with 3-dimensional reconstruction (3D) plus CT angiography (angio CT), which shows "knife" in the left parietal region without vascular compromise. Neurosurgeons perform removal of the foreign body plus a dura mater plasty. Patient stay 12 days hospitalized with a favorable evolution and improvement of neurological symptomatology. Conclusion: CPT due to a knife is an emergency and there is no protocolized management. The removal of the foreign body must be done in a hospital for the risk of lesions of large vessels.

Use of Computed Tomography (CT)-Scan in the Current Coronavirus Pandemic

CT is a medical imaging technique that uses X-rays to provide three-dimensional reconstructed images of the explored anatomical region. Its sensitivity has already been demonstrated in the exploration of pulmonary lesions of traumatic, neoplastic and especially infectious origin. In this chapter we present and highlight the usefulness of CT-scan imaging for diagnosis and management of the thoracic involvement of the COVID-19 pandemic. We also present the use of CT in extra-thoracic involvement, in particular, the angio-CT of the limbs in cases of suspected arterial thrombosis of the limbs during COVID-19. Finally, we evoke the other tools such as artificial intelligence which coupled with the CT-scan allows a greater accuracy and thus are to popularize in order to reinforce the CT as a tool of first plan in the fight against future pandemics with thoracic tropism.

707 Transvenous radiofrequency ablation of epicardial posterior-septal accessory pathways in children with WPW syndrome: can technology and imaging innovations improve the outcome?

Aims The aim of the study was to analyse our recent single-centre experience about epicardial posterior-septal accessory pathways transcatheter ablation in children and young patients using radiofrequency through the coronary sinus, in order to understand which mapping and ablation strategy is associated with higher success rate and safety. Methods and results We reviewed all the cases of ablation of overt accessory pathways (in Wolff–Parkinson–White syndrome) with epicardial posterior-septal localization performed in children or young patients at our institution in the last 5 years. Twenty-two paediatric patients (mean age: 13 ± 3 years) with epicardial posterior-septal accessory pathways (15 in coronary sinus and 7 in the Middle Cardiac Vein) underwent radiofrequency transcatheter ablation with CARTO 3TM. Acute success rate was 77%. No patient was lost to follow-up (mean time 14.4 ± 9 months). The recurrence rate was 18%. Two patients underwent a successful redo-procedure; the overall long-term success rate was 68%. NAVISTAR® catheter presented the highest acute success rate in the coronary sinus. NAVISTAR SMARTTOUCH® was the only catheter that did not present recurrences after the acute success and it was successfully used in two patients previously unsuccessfully treated with a NAVISTAR THERMOCOOL®. Integration with angio-CT of coronary sinus branches obtained with CARTOMERGE was associated with higher success rate in patients with a previous failed ablation attempt. Conclusions Epicardial posterior-septal accessory pathways can be successfully treated with transvenous radiofrequency ablation in more than half of the cases in children/young patients. Acute success rate does not seem to depend on catheters used but contact-force catheter seems to be useful in cases with recurrences. Image integration with cardiac-CT reconstruction of coronary sinus branches anatomy can be useful to better guide ablation in case of previously failed attempts.

A foreign body lodged in the sub-mental space through to the retro-pharyngeal area: a review of anatomical risks and surgical approaches

Background Foreign body inclusions are rare in head and neck. They are challenging in regard to anatomical risks and surgical approaches. This is the case of a particular foreign body with a curious trajectory, associated with a brief review of anatomical risks and surgical approaches. Case presentation This is the case of a 25-year-old male who has been attacked with a sharp object, which caused an inclusion of a part of the foreign body in the sub-mental and pharyngeal areas. The clinical exam showed a painful bulging in the sub-mental area, with moderately hemorrhagic sputum and difficulty while swallowing. The intra-oral exam showed a foreign body that was located at the right side of the base of the tongue, and which goes backwards and outwards to penetrate retro-pharyngeal mucosa. The patients underwent an angio-CT scan, which showed a curious fine and sharp metallic object, without direct signs of lesions to the jugular vein or carotid artery or any collateral branches. The patient underwent extraction through cervical approach, with satisfying bleeding control. Intra-oral exploration showed a retro-pharyngeal lesion of 2 cm, without particular bleeding. The cervical lesion and retro-pharyngeal lesions were closed. The lesion at the base of the tongue was of 1 cm, palpable but not accessible to sutures, and a naso-pharyngeal tube was inserted. The patient presented very satisfying post-operative outcome, without any complications. Conclusion When dealing with foreign bodies of head and neck, physicians must be precocious and prepared for the risk of bleeding after extraction. Thorough radiological exploration is necessary as long as the patient is stable. Direct and indirect radiological signs allow the clinician to understand the nature and the trajectory of the object, as well as the damage to collateral structures.

Dual-Energy Heart CT: Beyond Better Angiography—Review

Heart CT has undergone substantial development from the use of calcium scores performed on electron beam CT to modern 256+-row CT scanners. The latest big step in its evolution was the invention of dual-energy scanners with much greater capabilities than just performing better ECG-gated angio-CT. In this review, we present the unique features of dual-energy CT in heart diagnostics.

The incidence and localization of arterial Fenestrations of the human brain and their Association to brain aneurysms

The aim of the study was to determine the frequency of occurrence and the most common locations of the fenestration of the cerebral arteries, i.e. developmental anomalies consisting of segmental vessel splitting and also the correlation between their presence and the formation of intracranial aneurysms. 6,545 patients in Independent Public Teaching Hospital No. 4 in Lublin in years 2009-2019 who have undergone the angio-CT examination of the head were retrospectively analyzed. The incidence of vascular fenestration was 0.75%, of which 75% were women and 25% men. Reported vascular anomalies most often occurred in the anterior parts of the circle of Willis – ACA (30.61%), AComA (22.45%) and also in BA (30.61%). It has been shown that the occurrence of different types of fenestrations was similar in the group of men and women. There have been diagnosed 11 cases of intracranial aneurysms among patients with observed fenestration (22.45%). For comparison, the incidence of cerebral aneurysms in Western Europe and the US ranges from 2% to 6%. It leads to the conclusion that among patients with fenestration, this type of vascular anomaly occurs much more often, hence they require more frequent control.

Intravascular ultrasound for valve frame expansion and orifice area measurement as well as paravalvular leak assessment during transcatheter aortic valve replacement

Introduction Valve frame expansion (measured outer valve frame area/nominal valve dimension), but not oversizing (nominal valve dimension/annulus area, %) determines pattern of restored blood flow after transcatheter aortic valve replacement (TAVR). There is no online measure of frame expansion, and error in current echocardiographic assessment of effective orifice area (EOA) and paravalvular leak (PVL) are common. Purpose To evaluate large imaging field intravascular ultrasound (IVUS) during TAVR for measuring valve geometry [frame expansion, minimal geometric orifice area (min GOA), and mechanism of PVL] with transthoracic echo and angio-CT serving for comparative measures, along with the nominal EOA as established by Hahn et al. Methods After successful TAVR either a 10MHz Vision PV 0.035" (60mm imaging field) or 20MHz Vision PV 0.018" (24mm imaging field plus Chr omaFlo) IVUS catheter (Philips) was slowly pulled from the left ventricle outflow (LVOT) to the aorta with continuous imaging of the aortic root. Results There were 16 pts (80.8±7.1 yrs, 8 female) treated for de novo aortic stenosis (n=15) or failed bioprosthesis (n=1), 7 of whom were treated with balloon-expandable TAVR. PV 0.35" catheters were used in 8 pts (including valve-in-valve) and allowed complete geometry assessment of 26.6±2.7mm nominal prosthesis Ø (Figure 1A) whereas PV 0.018" allowed complete geometry assessment in only 4 of 8 pts with nominal prosthesis Ø of 26.1±2.8mm (Figure 1B). Actual % valve inflow expansion (IVUS outer frame/valve nominal dimension) was significantly smaller than % valve oversizing (80%±19% vs 125±19%, p=0.005). Min GOA was substantially bigger than corresponding nominal EOA and EOA calculated using the post-procedural LVOT diameter (272±84mm2 vs 174±25mm2 vs 181±59mm2, p=0.001 correspondingly). However, min GOA was similar to EOA calculated using baseline LVOT area (272±84mm2 vs 230±90mm2; r=0.713, p=0.009). IVUS and angio-CT measurements of outer prosthesis frame area were similar for inflow, coaptation site, and outflow (460±143mm2 vs 454±134mm2 and 455±134mm2 vs 447±114mm2 and 722±174mm2 vs 725±180; p≤0.001 for all paired correlations). Inflow expansion (IVUS outer frame/baseline CT annulus area) tended to be smaller among valves with ≥mild vs no PVL (95±14% vs 107±11%, p=0.156), with clear ChromaFlo signal seen in the space between the aortic annulus wall and outer-valve frame surface (Figure 1C). Conclusions Large imaging field IVUS during TAVR allows for peri-procedural assessment of actual valve geometry that differs substantially from nominal. IVUS offers online tomographic perspective and highest accuracy in anatomy evaluation corresponding with valve function. FUNDunding Acknowledgement Type of funding sources: None. Figure 1

Giant dissected aortic aneurysm presenting as a superior vena cava syndrome

A 47-year-old man, with a history of aortic valve replacement 28 years earlier, was admitted to the emergency department with a right cervical mass and a superior vena cava syndrome. Thoracic angio-CT revealed a giant ascending aorta aneurysm, with an intramural thrombus and dissection flap, compressing the superior vena cava. Emergency surgery was performed, confirming those findings. The dissection had ruptured but was contained by surrounding structures, creating a false-aneurysm that compressed the superior vena cava. The aneurysm was excluded and the aorta was replaced by a Dacron conduit, thereby decompressing the upper mediastinum. The patient made an uneventful recovery.