Search Results (105)

Background: The triglyceride–glucose (TyG) index has emerged as a simple surrogate marker of insulin resistance and metabolic disruption. In the context of ST-elevation myocardial infarction (STEMI), such disturbances have been associated with adverse cardiovascular outcomes, more complex angiographic profiles, and microvascular complications. However, data on the association between TyG and intracoronary thrombus burden (TB) in STEMI remain limited. Methods: In this prospective observational study, we included consecutive STEMI patients treated with primary percutaneous coronary intervention (pPCI). The TyG index was calculated using the following formula: ln [fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. TB was graded according to the modified thrombolysis in myocardial infarction (mTIMI) thrombus classification score after restoration of antegrade flow with a wire or small balloon when the culprit vessel was initially totally occluded. Patients were categorized as low-TB (LTB; mTIMI grades 1–3) and high-TB (HTB; mTIMI grade 4). The primary outcome was HTB; secondary outcomes were distal embolization and no-reflow. Associations between TyG and outcomes were assessed using univariable and multivariable logistic regression, restricted cubic spline analysis, and receiver operating characteristic (ROC) curves to evaluate incremental predictive value. Results: A total of 309 patients were analyzed. The TyG index was significantly higher in the HTB group compared with the LTB group (9.12 ± 0.62 vs. 8.92 ± 0.64, p = 0.004). In a stepwise multivariable model, TyG remained independently associated with HTB (adjusted odds ratio = 1.61; 95% confidence interval: 1.11–2.37; p = 0.014). Adding TyG to a baseline clinical model only numerically improved discrimination for HTB, as reflected by a small increase in ROC area under the curve. Restricted cubic spline analysis demonstrated a monotonic rise in the probability of HTB with higher TyG values. Higher TyG also showed non-significant trends toward increased odds of distal embolization and no-reflow. Conclusions: The TyG index was independently associated with HTB in STEMI patients undergoing pPCI and may serve as an accessible adjunctive marker for incremental risk stratification beyond conventional clinical and angiographic factors. Full article

This study describes five case of prostatic artery embolization (PAE) using n-butyl cyanoacrylate methylsulfone (NBCA; Glubran 2, GEM; Viareggio, Italy) to evaluate its technical advantages, against standard particulate embolization, in managing complex pelvic vascular anatomy while preserving non-target arteries, with particular focus on penile artery protection. NBCA was mixed with iodized oil (Lipiodol Ultra Fluid; Guerbet, Aulnay-sous-Bois, France) at 1:5 dilution and injected in small aliquots (0.1–0.3 mL) under fluoroscopy using a blocked-flow technique, with injection stopped at reflux into the horizontal PA segment. After a few seconds, before the complete polymerization of the glue, the microcatheter is quickly withdrawn, flushed, and reused for the contralateral side. NBCA allowed precise embolic control through distinct mechanisms (direct distal, indirect distal, proximal, reflux and controlateral control), avoiding the need for protective coiling. Glue-based PAE seems a reproducible, safe, and efficient alternative to particulate embolization, offering enhanced embolization control and non-target artery preservation in anatomically complex patients. Full article

Buttock claudication after endovascular aneurysm repair (EVAR) impairs recovery and quality of life, yet individualized preoperative risk tools are scarce. We conducted a retrospective dual-center cohort study of consecutive EVAR patients from Fuxing and Xuanwu Hospitals. The endpoint was new-onset postoperative buttock claudication. Missingness was quantified for each predictor and handled using complete-case analysis or model-based single imputation according to the extent of missingness. Data were split into training and held-out test sets at a 70:30 ratio with outcome stratification. Predictor screening, preprocessing, and hyperparameter tuning were performed within the training/resampling framework to minimize data leakage. Ten algorithms were tuned using stratified 10-fold cross-validation, and test set performance was assessed using discrimination, threshold-based metrics, calibration plots, calibration intercept/slope, Brier score, and decision-curve analysis. SHapley Additive exPlanations (SHAP) provided model-agnostic explanations. A web calculator was deployed. Among 272 patients, 71 (26.1%) developed claudication. Independent risk factors included aneurysm with iliac involvement (adjusted OR 4.04), male sex (3.26), unilateral (3.86) and bilateral internal iliac artery embolization (8.61), and hyperlipidemia (5.66); >2 distal internal iliac branches was protective (0.15). On the test set, the neural network achieved the highest AUROC (test ROC), with the highest sensitivity (0.810) and top F1 (0.557) at balanced specificity (0.617); CatBoost maximized accuracy (0.790) and specificity (0.900). Calibration was acceptable, and DCA showed positive net benefit across clinically plausible thresholds. SHAP confirmed physiologic directions and enabled case-level interpretation. An explainable machine learning framework accurately stratifies risk of buttock claudication after EVAR, highlighting the roles of internal iliac embolization, iliac involvement, and distal branch anatomy. The publicly available Shiny tool supports perfusion-aware planning and shared decision-making. Full article

Background and Purpose: Complete angiographic reperfusion (TICI 3) is considered the optimal procedural endpoint of mechanical thrombectomy (MT) in acute ischemic stroke. However, new diffusion-weighted imaging (DWI) lesions are frequently observed despite apparent angiographic success. We aimed to investigate the incidence, morphological patterns, and clinical relevance of these lesions in a strictly defined TICI 3 cohort. Methods: In this retrospective single-center study, 89 patients with anterior circulation large-vessel occlusion (LVO) who achieved true TICI 3 were analyzed. Baseline and follow-up Magnetic Resonance Imaging (MRI) within 48 h were systematically compared using paired diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps to identify new lesions. Lesions were classified according to morphology and distribution. Stroke etiology was assessed using TOAST criteria. Functional outcomes were evaluated using the 90-day modified Rankin Scale (mRS) with the Rankin Focused Assessment. Results: New DWI lesions were detected in 28 of 89 patients (31.5%). The predominant pattern was millimetric cortical foci (85.7%), most frequently ipsilateral to the recanalized vessel (78.6%), with fewer contralateral (14.3%) and bilateral (7.1%) lesions. Territorial infarcts and isolated basal ganglia infarcts were each identified in 14.3% of patients, with some overlap between categories. No significant differences were observed between patients with and without new lesions regarding baseline characteristics or procedural metrics (all p > 0.05). Importantly, the presence of new DWI lesions was not associated with 90-day functional outcome (p = 0.930) or survival (p = 0.613). Conclusions: New DWI lesions are common even after complete angiographic reperfusion, highlighting a persistent dissociation between macrovascular success and tissue-level integrity. Although predominantly small and clinically silent in the short term, these findings underscore the limitations of angiographic endpoints alone and support the need for strategies targeting microvascular protection and prevention of distal embolization. Full article

Periprocedural myocardial infarction after percutaneous coronary intervention (PCI) remains a debated entity, especially in the era of high-sensitivity cardiac troponin assays, which frequently detect biomarker rises even when clinically meaningful ischemia is absent. This review critically examines the main contemporary frameworks used to define these events, including the Fourth Universal Definition of Myocardial Infarction (UDMI), the Academic Research Consortium (ARC)-2 consensus, and the Society for Cardiovascular Angiography and Interventions (SCAI) definition, comparing biomarker thresholds, requirements for objective evidence of ischemia, and procedural criteria. We discuss how differences among definitions shape reported event rates and contribute to heterogeneity in event adjudication across studies. Key pathophysiologic mechanisms of myocardial injury during PCI are summarized, including side-branch compromise, distal embolization, microvascular dysfunction, and mechanical complications. Particular attention is given to the limitations of current criteria, such as incomplete assay standardization, variability in sampling timing, inconsistent reliability of ancillary criteria, including electrocardiography and imaging, and an uneven relationship between biomarker elevation and subsequent outcomes. Finally, we outline priorities for future updates, including harmonization of biomarker thresholds, greater emphasis on relative biomarker dynamics, and structured adjudication that integrates biomarkers with objective ischemic evidence. These steps may improve diagnostic specificity, reduce misclassification, and strengthen the clinical and trial relevance of periprocedural ischemic endpoints. Full article

Nicolau syndrome, also known as embolia cutis medicamentosa, is a rare iatrogenic reaction that may occur following parenteral drug administration, including inadvertent intra-arterial or periarterial injection. Its pathophysiology remains poorly understood; however, several mechanisms have been proposed, including vasospasm, embolization, cytotoxic inflammation, and secondary tissue necrosis. We report the case of a 22-year-old transgender woman who received intravenous benzathine penicillin in the left arm without a medical prescription following a reactive syphilis screening performed outside a formal healthcare setting. She subsequently developed severe pain, livedoid dermatitis, pallor, distal cyanosis, and blister formation. Radial and brachial pulses remained palpable, and Doppler ultrasonography revealed no evidence of arterial or venous thrombosis. Medical management included daily wound care, anticoagulation, corticosteroids, peripheral vasodilators, antibiotic therapy, and analgesia. The patient was hospitalized for nine days, with partial clinical improvement. However, persistent distal ischemic changes involving the second through fifth fingers raised concern for evolving necrosis and potential amputation. After counseling regarding these risks, the patient requested voluntary discharge. This case underscores the importance of safe medication administration and appropriate injection practices, particularly in low-resource settings. It also highlights the need for improved training of healthcare personnel to ensure early recognition and prompt management of Nicolau syndrome, as well as strengthened patient education to discourage self-medication and promote timely care by qualified healthcare professionals. Full article

Background: We present our experience of carrying out endovascular therapy (EVT) of a pseudo-aneurysm of the posterior tibial artery (PTA) with an associated arteriovenous fistula (AVF). We also present results of a systematic review which was carried out to cast light on endovascular treatment modalities. Methods: A 31-year-old patient with a history of war trauma presented with pain of increasing severity in the lower leg. A CT angiogram confirmed an aneurysm of the PTA with an AVF. With a bidirectional endovascular approach, the aneurysm was occluded with coils and excluded with a Viabahn endoprosthesis. Aspirin and clopidogrel were recommended postoperatively. After 18 months of follow-up, the patient was free of symptoms, with patent endoprosthesis. Multiple databases (Scopus, Pubmed, Medline, OVID) were systematically searched using MeSH terms. The studies were scrutinized, and data on demographics, procedural details, and follow-up were collected and aggregated. Results: A total of 44 studies (56 patients) were eligible and were included. Average age was 50 (15–87 years). The most common etiology was trauma (iatrogenic 29/56 (51.7%); non-iatrogenic 15/56 (26.7%)). EVT strategies included coil embolization (n = 29), stent implantation (n = 25), and a combination of both (n = 2). Median stent diameter was 3 mm (2.5–6). The follow-up period ranged from 1 week to 60 months. Aggregated reported primary patency was 18/27 (66.6%) with no documented complications—an observation that likely reflects reporting and publication bias, rather than a true absence of adverse events. Conclusions: EVT offers a feasible and safe alternative to simple ligation or occlusion of crural aneurysms, to preserve distal flow to the foot. Dedicated stents for crural arteries are not available. Studies with long-term follow-up are lacking. Full article

Background: Peripheral endovascular intervention is the preferred revascularization strategy for patients with chronic lower-limb ischemia. Although generally safe, peri-procedural mechanical complications may occur and are influenced by both lesion complexity and procedural strategy. Data identifying determinants of such complications in routine clinical practice remain limited. Methods: We performed a retrospective single-center analysis of consecutive patients undergoing peripheral endovascular intervention for chronic lower-limb ischemia between 2010 and 2023. The primary endpoint was the occurrence of peri-procedural mechanical complications, defined as mechanical adverse events occurring during or immediately following the index intervention and directly related to catheter manipulation, device deployment, or vascular access. Lesion- and procedure-related predictors were evaluated using multivariable logistic regression analysis. Results: A total of 283 index procedures were included. Peri-procedural mechanical complications occurred in 9 procedures (3.2%), with arterial dissection being the most frequent event (2.1%). No cases of peri-procedural bleeding, distal embolization, or emergent surgical conversion were observed. In multivariable analysis, chronic total occlusion (adjusted odds ratio [aOR] 1.89, 95% confidence interval [CI] 1.14–3.11; p = 0.014), moderate-to-severe arterial calcification (aOR 1.74, 95% CI 1.03–2.93; p = 0.039), introducer sheath size ≥7 French (aOR 2.08, 95% CI 1.21–3.57; p = 0.007), and ≥3 vascular access attempts (aOR 1.67, 95% CI 1.00–2.81; p = 0.048) were associated with increased risk of peri-procedural mechanical complications in adjusted analyses. Conclusions: In this real-world institutional registry, peri-procedural mechanical complications during peripheral endovascular intervention were uncommon. Lesion complexity and procedural factors, rather than access route or device type, were the primary determinants of mechanical risk. These findings highlight the importance of careful lesion assessment and procedural planning to optimize peri-procedural safety in routine practice. Full article

Background: Pulmonary infarction (PI) is the result of the occlusion of distal pulmonary arteries resulting in damage to downstream lung areas that become ischemic, hemorrhagic, or necrotic, and it is often a complication of an underlying condition such as pulmonary embolism (PE). Since in most of cases it is located peripherally, lung ultrasound (LUS) can be a good evaluation tool. The typical radiological features of PI are well-known; however, there are limited data on its sonographic characteristics and its evolution. Methods: The aim of this study is to evaluate, using LUS, a convenience sample of patients with acute PE with computed tomography (CT) consolidation findings consistent with PI. Patients’ clinical characteristics were collected and LUS findings at baseline and their short-term progression was assessed. LUS was performed within 72 h of PE diagnosis (T0) and repeated after one (T1) and four weeks (T2). Each procedure started with a focused examination of the areas of lesions based on CT findings, followed by an exploration of the other posterior and lateral lung fields. The convex probe was used for initial evaluation integrating LUS evaluation with the linear one was employed for smaller and more superficial lesions and when appropriate. Color Doppler mode was added to study vascularization. Results: From June to October 2023, 14 consecutive patients were enrolled at the Respiratory Unit of the University Hospital of Pisa. The main population characteristics included the absence of respiratory failure and prognostic high-risk PE (100%), the absence of significant comorbidities (79%), and the presence of typical symptoms, such as chest pain (57%) and dyspnea (50%). The average number of consolidations per patient was 1.4 ± 0.6. Follow-up LUS showed the disappearance of some consolidations and some morphological changes in the remaining lesions: the presence of hypoechoic consolidation with a central hyperechoic area (“bubbly consolidation”) was more typical at T1 while the presence of a small pleural effusion often persisted both at T1 and T2. A decrease in wedge/triangular-shaped consolidations was observed (82% at T0, 67% at T1, 24% at T2), as was an increase in elongated shapes, representing a residual pleural thickening over time (9% at T0, 13% at T1, 44% at T2). A reduction in size was also observed by comparing the mean diameter, long axis, and short axis measurements of each consolidation at the three different studied time points: the average of the short axes and the median of the mean diameters showed a statistically significant reduction after four weeks. Additionally, a correlation between lesion size and pleuritic pain was described, although it did not achieve statistical significance. Conclusions: Patients’ clinical characteristics and ultrasound features are consistent with previous studies studying PI at PE diagnosis. Most consolidations detected by LUS change over time regarding size and form, but a minority of them do not differ. LUS is a safe and non-invasive exam that could help to improve patients’ clinical approach in emergency rooms as well as medical and pulmonology settings, clinically contextualized for cases of chest pain and dyspnea. Future studies could expand the morphological study of PI. Full article

Excimer Laser Coronary Atherectomy (ELCA) has re-emerged as a valuable adjunctive modality in percutaneous coronary intervention (PCI), particularly in the context of increasingly complex coronary anatomy and rising procedural expectations. By delivering pulsed ultraviolet energy at 308 nm through flexible fiber-optic catheters, ELCA enables precise photochemical, photothermal, and photomechanical ablation of atherosclerotic, fibrotic, calcified, and thrombotic tissue while minimizing thermal injury to surrounding structures. Recent technical refinements, simplified catheter designs, and improved safety profiles have enhanced its feasibility and utility across a range of challenging lesion subsets. This review summarizes the fundamental principles underlying excimer laser–tissue interaction, discusses available equipment and key procedural considerations, and examines the expanding clinical evidence supporting ELCA in contemporary practice. Data from observational studies and multicenter registries suggest that ELCA may enhance device crossability, restore coronary flow, and reduce distal embolization in thrombus-rich lesions, particularly during primary PCI. In device-uncrossable lesions, ELCA facilitates plaque modification and improves procedural success, including in chronic total occlusions. Furthermore, ELCA—especially when performed with simultaneous contrast injection—has demonstrated efficacy in treating stent underexpansion refractory to high-pressure balloon dilation, improving minimal stent area and enabling optimal post-dilatation. As lesion complexity continues to increase, ELCA is gaining recognition as an important tool within the interventional armamentarium. While generally safe in experienced hands, ELCA carries a risk of procedural complications that must be carefully considered. Ongoing investigations are expected to further define its optimal use and reinforce its relevance in modern interventional cardiology. Full article

Background/Objectives: Complex aneurysms of the posterior inferior cerebellar artery (PICA) remain challenging because of their deep location, variable morphology, and proximity to critical neurovascular structures. Although endovascular therapy is preferred, its feasibility is limited in wide-necked, fusiform, or dissecting lesions. We describe our tertiary referral hospital single-center experience with tailored microsurgical and endovascular strategies—emphasizing occipital artery–PICA (OA-PICA) bypass, transcondylar fossa craniotomy, and cerebellomedullary fissure opening—and analyze perioperative factors that influence outcome. Methods: All consecutive patients treated for PICA origin or distal-PICA aneurysms between January 2021 and April 2025 were retrospectively reviewed. Demographics, aneurysm characteristics, procedure type, antithrombotic regimen, complications, diffusion-weighted MRI findings, and 3-month modified Rankin Scale scores were collected. Results: Twelve aneurysms (mean age 61.4 ± 15.2 years; 8 women) were treated: trapping + OA-PICA bypass in 5, direct clipping in 2, flow diverter in 1, endovascular parent artery occlusion in 2, coil embolization in 1, and a hybrid bypass-plus-coil strategy in 1. Two cases were ruptured aneurysms. Perioperative aspirin was used in 2/5 bypass cases; heparin was added in one hybrid case. Asymptomatic PICA-territory infarcts occurred in the three bypasses performed without antiplatelet therapy (one with intra-anastomotic thrombus). No leaks or subcutaneous collections of cerebrospinal fluid were encountered, and no graft occlusions were observed. At 3 months, 9/12 patients achieved a good outcome (mRS 0–2); among them, only one patient with subarachnoid hemorrhage (SAH) experienced postoperative worsening of the mRS. Two cranial nerve palsies (one permanent, one transient) and one wound site hematoma (heparin-associated) resolved without sequelae. Conclusions: Meticulous operative planning allows safe treatment of complex PICA aneurysms. Perioperative aspirin appears beneficial for OA-PICA bypass, whereas perioperative heparin increases bleeding risk. Individualized selection of endovascular, microsurgical, or combined strategies yields favorable early neurological outcomes in this demanding subset of cerebrovascular disease. Full article

The coronary no-reflow phenomenon remains a daunting and unresolved barrier during percutaneous coronary procedures, especially for acute coronary syndrome. Despite successful epicardial artery patency restoration, decreased microvascular perfusion leads to unfavorable outcomes such as ventricular remodeling, progression of heart failure, and increased mortality. This review provides a new, integrative informative perspective by combining multifactorial pathophysiology, which includes systemic inflammation, thrombogenicity, ischemia–reperfusion injury, and distal embolization, with advances in diagnostic imaging, such as cardiac magnetic resonance and computed tomography. Therapeutic options, including antithrombotic regimes, vasodilators, and mechanical adjuncts, are evaluated in the context of developing debates and unmet clinical needs. Importantly, we provide feasible future directions for artificial intelligence-based predictive modeling and targeted microvascular treatments. This comprehensive review fills a significant gap, aiming to inform personalized approaches and improve both short- and long-term outcomes in this high-risk patient population. Full article

Microvascular obstruction (MVO) accounts for up to 50% of patients diagnosed with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). The pathogenesis is multifactorial and includes myocardial ischemia, distal embolization, and ischemia–reperfusion injury, in a context of individual susceptibility. Its occurrence has been related to adverse outcomes. Despite an extensive body of research, no single pharmacological or interventional strategy has proven effectiveness. The inconclusive nature of the evidence can be attributed to lack of standardization among studies in terms of drugs used and their dosage, the variability in study designs, and the fact that available studies performed a decade ago feature reperfusion strategies and drugs used that differ significantly from the current standard of care. In this context, our review aims to discuss the pharmacological and interventional approaches to MVO. Full article

Background/Objectives: Downstream occlusion (DOC) is a commonly observed, yet frequently overlooked, angiographic event during mechanical thrombectomy (MT) for acute large vessel occlusion (LVO). This phenomenon has the potential to complicate procedures and influence outcomes. However, its prevalence, predictors, and endovascular trajectories remain poorly understood. Methods: A retrospective analysis of 703 patients who underwent MT for acute intracranial LVO between 2010 and 2021 at a tertiary stroke center was conducted. DOC was angiographically identified as a newly developed occlusion in a downstream artery following recanalization of the primary occlusion. Multivariate logistic regression was employed to analyze the clinical and procedural predictors of DOC. Endovascular and clinical outcomes were compared between patients with and without DOC. The DOC trajectory, including immediate reperfusion status, subsequent recanalization attempts, and final outcomes, was analyzed based on the occlusion location. Results: DOC was identified in 254 patients (36.1%). Atrial fibrillation and proximal occlusion were independently associated with DOC. Despite DOC adversely affecting endovascular procedural details, patients with DOC demonstrated comparable rates of final successful recanalization (92.5% vs. 91.3%; p = 0.577) and 90-day functional independence (40.2% vs. 46.3%; p = 0.114). Notably, about half of the patients exhibited an immediate modified Thrombolysis In Cerebral Infarction (mTICI) grade 2b at the time of DOC. Further recanalization attempts were undertaken in 67.7% of DOC cases, resulting in enhanced mTICI grades in 76.7% of cases and achieving final successful recanalization in 94.2% of cases. The functional advantages of additional recanalization attempts varied depending on DOC location but were generally limited. Conclusions: Despite its procedural complexity, DOC did not significantly compromise final recanalization or functional outcomes. Many cases were effectively managed with additional endovascular treatment, highlighting the importance of achieving sufficient final recanalization. Full article

Background: Patients with atrial fibrillation (AF) who have a high bleeding risk or contraindications to anticoagulation may be candidates for left atrial appendage closure (LAAC). However, the presence of a thrombus in the left atrial appendage (LAA) is generally considered a contraindication to the procedure. While the feasibility and short-term safety of LAAC in patients with pre-existing LAA thrombus has been reported, data on long-term outcomes remain limited. Objective: To assess the long-term clinical outcomes of AF patients undergoing LAAC in the presence of an LAA thrombus. Methods: This retrospective, single-center registry included all AF patients who underwent LAAC between June 2010 and April 2024. Patients were stratified based on the presence or absence of LAA thrombus at the time of the procedure. The primary endpoint was a 5-year composite of stroke, systemic embolism, or all-cause mortality. Results: A total of 403 patients underwent LAAC, of whom 24 (6%) had an LAA thrombus at the time of the procedure. During a median follow-up of 3.9 years, the primary endpoint occurred in 116 patients: 110 events (41%) in the no-thrombus group and 6 events (38%) in the thrombus group. There was no statistically significant difference in major adverse cardiovascular events (MACE) between groups (log-rank p = 0.862). Conclusions: LAAC may be performed safely in selected patients with distal LAA thrombus, with long-term outcomes comparable to those without thrombus. Full article