Comparison of transverse versus longitudinal skin incisions for femoral endarterectomy and patchplasty

Introduction Access to the femoral artery for a femoral endarterectomy and patchplasty (CFE) can be undertaken either through transverse (TI) or longitudinal incision (LI). LIs have been shown in previous studies to have higher groin complications though these were undertaken in multiple types of vascular procedures. We looked at wound complications for patients undergoing elective CFE procedures only with or without angioplasty via TI or LI. Methods All patients who had undergone CFE were retrospectively analysed from a prospective database. Length of stay, wound complications and readmission rates were recorded. Factors for wound complication were looked at using logistic regression with backward elimination. Results 122 CFE procedures were performed (30 TI) over the study period. 92 (76.7%) of patients had a prosthetic patch used, whilst 57 (46.7%) patients underwent an adjunctive endovascular procedure, namely, iliac angioplasty and stenting. Median length of stay was 3 days for both groups. The wound complication rate was 6.7% in the TI group and 22.6% in the LI group. 85.6% of the wound complications were identified after discharge. 6/122 (4.9%) were readmitted for intravenous antibiotics, whilst others were managed in the outpatient setting. TI (aOR = 0.15; 95% 0.03–0.75) and combined open FE with endovascular revascularisation (aOR = 0.33; 95% 0.11–0.95) had protective effects on wound complications. Type of the patch used was not associated with any wound complications ( p = 0.07). Conclusion Compared to traditional LI, TI for CFE and OTA have lower risk of wound complications and reduced readmission rates in our series. We advocate adopting TI as the standard for femoral artery procedures rather than LI.

Abstract 1122‐000127: An Alternative Reduced Dose Regimen of Ticagrelor for Patients Recieving Neuro‐Endovascular Procedures

Introduction : There is a growing use of Ticagrelor in patients undergoing neuroendovascular procedures, especially those who demonstrate Clopidogrel resistance. While multiple dosages are studied in the cardiology literature, the optimal dose for patients with neurological pathology has yet to be established. Here we describe a single center experience involving 39 patients who underwent neuroendovascular procedures that then received an adjusted lower dose of Ticagrelor. Methods : A retrospective chart review was performed between 2013 and 2017 for patients on dual antiplatelet therapy (DAPT) for either cervical or intracranial vascular pathologies, as well as stenting of the neurovasculature, including carotid arteries. Patients were placed on Ticagrelor if their measured PRU responses to Clopidogrel were outside the expected range in our center using the P2Y12 test. All patients were maintained on a dose of 45mg BID except for one patient who received 22.5 mg BID. Responsiveness to Ticagrelor were measured utilizing the P2Y12 test. Results : The mean number of days for follow up post treatment initiation was 532 days. A total of 39 patients were included in the analysis. Of these, 8 patients (21%) received implantation of intracranial stents (5 patients received pipeline embolization devices, 1 patient received stent‐ assisted coiling, and 2 patients received intra‐cranial stents for atherosclerotic disease). Fourteen patients (35%) received carotid angioplasty and stenting. Seventeen patients (44%) did not receive permanent implantation of a stent. All patients on the lower dose Ticagrelor of mg BID achieved responsiveness per the P2Y12 test. Hemorrhagic transformation of ischemic stroke occurred in one patient (2.5%). No other hemorrhagic complications were encountered. No thromboembolic events were recorded aside from one patient (2.5%) with intracranial atherosclerotic disease who had an ischemic event. Conclusions : A lower dose of Ticagrelor (45 mg BID) appears to be a safe and effective in this small cohort of patients who are resistant to Clopidogrel per P2Y12 testing and who have increased risk of ischemic or hemorrhagic strokes due to neurovascular pathologies and implants. Further randomized studies are required to confirm these findings.

Abstract 1122‐000095: Revisiting the Role of Angioplasty and Stenting for Symptomatic Intracranial Stenosis ‐ A Case Series

Introduction : Early and long‐term results of the SAMMPRIS trial showed superiority of aggressive medical management over stenting in patients with symptomatic intracranial stenosis, in part due to the high risk of periprocedural complications. However, even with maximal medical management, the risk of recurrent TIA or stroke in patients with high‐grade stenosis often remains elevated. Methods : A review of our stroke database was conducted, identifying three relevant cases. Results : CASE 1: A 69 year‐old man with multiple vascular risk factors and atrial fibrillation on apixaban presented with several months of multiple stereotyped episodes of limb‐shaking TIAs affecting the left leg, often leading to falls. CT angiogram revealed 70–80% stenosis of A2 segment of right ACA. Symptoms completely resolved after stenting with Neuroform Atlas stent. Repeat angiogram at 6 months showed excellent vessel caliber. CASE 2: A 78 year‐old man with hypertension, DM, CAD, and known left ICA occlusion presented with recurrent episodes of aphasia and right arm weakness while on maximal medical therapy. CT angiogram showed severe right supraclinoid ICA stenosis which was corrected with Resolute Onyx DES stent with improvement of symptoms. CASE 3: A 77 year‐old with hypertension, DM, CAD and aortic dissection on dual antiplatelet therapy and high‐intensity statin was admitted with stereotyped, blood pressure‐dependent episodes of aphasia and right face/arm weakness secondary to high‐grade stenosis of both M2 divisions of the left MCA. Successful angioplasty and Y‐stenting with Neuroform EZ and Wingspan stents led to complete resolution of symptoms. Conclusions : At high‐volume centers and with newer interventional devices and techniques, intracranial angioplasty and stenting should be considered as a valuable therapeutic option in patients with symptomatic intracranial stenosis refractory to maximal medical therapy.

Percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease: The experience of a single stroke centre

Background Percutaneous transluminal angioplasty and stenting in acute stroke due to severe basilar artery stenosis or basilar artery occlusion remain a matter of debate. The higher risk of stroke recurrence in patients with vertebrobasilar stenosis compared to anterior circulation atherosclerotic disease creates high expectations concerning endovascular approaches. This study aims to review our experience with percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease. Methods Our prospective database from June 2014 until December 2020 was screened and patients with acutely symptomatic severe (>80%) basilar artery stenosis or acute basilar artery occlusion who underwent percutaneous transluminal angioplasty and stenting were analysed. Results Twenty-five patients included: 72% men (mean age 68.6 years), all with prior modified Rankin Scale <2. Twelve presented with acute basilar artery occlusion and were submitted to mechanical thrombectomy before percutaneous transluminal angioplasty and stenting, while the remaining had severe basilar artery stenosis. Successful stent placement was achieved in 22 (88%). Procedure-related complications included new small ischemic lesions (16%), basilar artery dissection (8%), vertebral artery dissection (12%) and death (12%). At 3 months post-percutaneous transluminal angioplasty and stenting, 10 out of 23 patients (43.5%) were independent (mRS ≤ 2) and six died. Fourteen patients underwent transcranial Doppler ultrasound 3 months post-percutaneous transluminal angioplasty and stenting: 12 showed residual stenosis, one significant stent restenosis and one presented stent occlusion. Conclusions Percutaneous transluminal angioplasty and stenting showed to be a technically feasible and reasonably safe procedure in selected patients. However, good clinical outcomes may be difficult to achieve as only 43.5% of the patients remained independent at 3 months. Randomized studies are needed to confirm the efficacy and safety outcomes of percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease.

EP.WE.635The Pied-Piper, How Gastroenteritis Led Us Astray. Fibromuscular Dysplasia: A Surgical Perspective of a Rare Vascular Disorder

Case A 73-year-old female was admitted for abdominal pain after eating an out-of-date pie. She was treated for gastroenteritis for 48 hours, after which she became unexpectedly haemodynamically unstable. Computerised Tomography (CT) suggested mesocolic arterial bleed with a large mesenteric haematoma. CT angiography confirmed false aneurysms of the middle colic artery and multiple beading of coeliac branches, small mesenteric vessels and the inferior mesenteric artery. Opinion was sought from multiple specialties, pseudoaneurysm embolisation was undertaken and steroids commenced for presumed vasculitis. Vasculitis screen was negative, and PET CT scan showed no metabolically active vasculitis. It was felt a diagnosis of fibromuscular dysplasia (FMD) was likely. Steroids were weaned and the patient is under active observation. Background FMD is a rare idiopathic condition of abnormal cellular growth in medium/large arterial vessel walls. It has a frequency of approximately 0.02%, predominantly affecting middle-aged Caucasian women. It manifests mostly in renal and cerebrovascular arteries and can present as hypertension or stroke. Complications include aneurysms, stenosis and dissections. Characteristic angiographical finding is a “beads on a string” appearance. There is no current cure, but surgical or interventional involvement by angioplasty and stenting may play a role treatment. Discussion And Conclusion This case elegantly highlights the ambiguity in diagnosis of abdominal pain in a general surgical setting; with a wide variety of differentials spanning multiple specialties, it emphasises the importance to consider rare presentations of equally rare pathologies. It is a celebration of the merits of a multi-disciplinary approach to solve complex clinical questions.

Hypercholesterolemia as a factor in the risk stratification of patients with hypertension depending on the ITGA2 gene polymorphism

Mutation C807 in the ITGA2 gene is associated with the risk of early myocardial infarction, ischemic stroke, embolism, thrombosis after angioplasty and stenting of coronary arteries. Aim To study the relationship between ITGA2 gene polymorphism and increased risk of CAD in patients with hypertension and hypercholesterolemia Materials and methods 72 patients were included. Study involved patients with ACS, which developed on the background of hypertension, 32 patients also had coronary angiography and stenting. We used analysis of spontaneous and induced platelet aggregation, polymorphism of C807T of the ITGA2 gene was determined by polymerase chain reaction. Results At 82.5% of patients with ACS genotype ITGA 2 C/T was prevalent – 40.3%, T/T – 31.9%. Aggregation capability research in the studied groups has shown that patients of all groups had their degree of spontaneous aggregation significantly exceeding limits of control. Wherein, the highest indices were recorded in the T/T genotype group, which exceeded reference values by 3,02 times. AA-induced aggregation in the group of patients with T/T genotype exceeded indexes of the C/C group by 17.3%, while C/T group's rates-by 16.5% (p&lt;0.05 in both cases). Studying the degree of collagen-induced aggregation, it was noted that the highest rates were recorded in T/T genotype group – 1.68 times higher than control group. Conclusion It is found that T allele of ITGA2 carrier is typical for 72.1% of patients with acute coronary syndrome and combined with spontaneous acceleration of platelet aggregation and increases sensitivity of platelets to ADP and collagen. Results allow us to consider the carrier of the T-allele as a marker of predisposition to thrombophilia. FUNDunding Acknowledgement Type of funding sources: None.

Treatment of patients with occlusive-stenotic diseases of the arteries by endovascular method

Annotation. The case of successful treatment of a patient with critical lower extremity ischemia illuminates the possibilities of different approaches of the endovascular surgical method. The results of treatment of patients with occlusive-stenotic diseases of the lower extremities arteries as a result of obliterating atherosclerosis were analyzed. 243 patients underwent endovascular surgery. 14 (5.76%) patients were previously operated on. The multi-storey lesions were found in 35 (14.4%) cases. Most patients were ranged in age from 46 to 86 years. There were 175 men (72.0%) and 68 women (28.0%). The right lower extremity was affected more often – 148 (60.9%) patients than the left ones – 95 (39.1%). The thrombosis was diagnosed in 21 (10.6%) individuals as the most common complications in the early postoperative period. Limb amputation was performed in 12 patients. Mortality rate in the early postoperative period was 2.56% (4 patients died). It is established that the methods of choice in the reconstruction of stenotic-occlusive lesions of the arteries are: balloon angioplasty (and stenting), rotor-mechanical thromboaspiration, regional thrombolytic therapy. These methods are performed mainly under local anesthesia, they are minimally invasive and can be used in patients with severe comorbidities.