Valerija Mosenko

Background and Objectives: Contralateral A1 and AComA aplasia/hypoplasia are critically important in distal ICA T occlusion as the protective collateral blood supply from the circle of Willis via the anterior communicating artery is compromised. Although the terms aplasia/hypoplasia are used broadly in the literature, the need for concrete measurements and data on their clinical significance is apparent. Features of the individual anatomy of the circle of Willis may determine patient outcomes. We aim to determine the cut-off values of contralateral A1 and AComA segments that determine worse outcomes for patients with acute ischemic stroke with T occlusion of the terminal internal carotid artery. Material and Methods: Retrospective patient data from 2015 to 2020 and prospective data from 2021 to 2022 of 482 patients with diagnosed acute ischemic stroke that underwent mechanical thrombectomy at the Republican Vilnius University Hospital (Vilnius, Lithuania) were obtained. Of these patients, 70 were selected with occlusion of internal carotid artery bifurcation and extension to M1 or A1 segments. For statistically significant interactions, patient data were analyzed using two statistical methods (logistic regression and Multivariate Adaptive Regression Splines (MARS)). Results: The narrowest segment of contralateral A1 and/or AComA was statistically significant for 7-day NIHSS, and the optimal cut-off points for this variable were 1.1 mm (MARS model) and 1.2 mm (logistic regression, p = 0.0079, sensitivity 66.7%, specificity 67.9%). The other considered variables (age, gender, time from last seen well to groin puncture, intravenous recombinant tissue plasminogen activator, admission NIHSS, and ASPECT score) and their interactions were not statistically significant. Conclusions: A negative correlation was found between the narrowest segment and seven days of NIHSS. A larger diameter of contralateral A1 and AComA appears to be essential for better patient outcomes at 7-day evaluation post mechanical thrombectomy.

Background and Objectives: The published literature highlights the fact that the integrity of the Circle of Willis has a direct impact on stroke outcome, especially in cases of distal internal carotid T occlusion. The aim of this study was to review the available data on the Circle of Willis configuration and thrombus location impact on patient outcome in cases of ischemic stroke. Materials and Methods: A systematic search according to PRISMA guidelines was performed in PubMed, Cochrane, and EMBASE databases to identify studies investigating the influence of Circle of Willis variants on ischemic stroke outcomes published up to March 2023. The manuscripts were reviewed by three researchers separately and scored on the quality of the research using the MINORS criteria. Results: After screening 157 manuscripts, 11 studies (n = 4643) were included. Circle of Willis integrity plays a vital role in stroke outcome, especially when T-form occlusions are present. Despite this, in the event of M1 occlusion Circle of Willis configuration does not play an important role. In cases of distal internal carotid artery occlusion, the presence of a fully developed contralateral A1 segment and anterior communicating artery is essential for a favorable stroke outcome. Conclusions: The preserved integrity of the Circle of Willis has great significance for collateral flow in the event of ischemic stroke and helps patients to achieve more favorable outcomes, as it determines the affected brain territory. The clinical outcome of the ischemic stroke appears to be significantly better if only one artery territory is affected, compared to two or more.

Recently, AAA volume measurement has been proposed as a potentially valuable surveillance method in situations when diameter measurement might fail. Objective: The aim of this systematic review was to analyze the results of previous studies comparing AAA diameter and volume measurements. Methods: A systematic search in PubMed, Cochrane, and EMBASE databases was performed to identify studies investigating the use of diameter and volume measurements in AAA diagnosis and prognosis in English, German, and Russian, published until December 2022. The manuscripts were reviewed by three researchers and scored on the quality of the research using MINORS criteria. Results: After screening 752 manuscripts, 19 studies (n = 1690) were included. The majority (n = 17) of the manuscripts appeared to favor volume. It is, however, important to highlight the heterogeneity of methodologies and lack of standardized protocol for measuring both volume and diameter in the included studies, which hindered the interpretation of the results. Conclusions: The clinical relevance of abdominal aortic aneurysm volume measurement is still unclear, although studies show favorable and promising results for volumetric changes in AAA, especially in follow-up after EVAR.

Enterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and the skin; by some estimates, it represents 88.2% of all fistulae. It can either develop spontaneously due to underlying malignancy, inflammatory bowel disease, radiation exposure, or, more commonly, as a complication of gastrointestinal surgery. A 75-year-old woman was treated for a small bowel enterocutaneous fistula that developed after laparoscopic cholecystectomy using a HANAROSTENT self-expanding metal stent (SEMS) to cover the fistula. Seven months later, the patient was discharged. For the following 2 years, the patient refused the reconstructive surgery until stent obstruction occurred. After optimizing the patient’s nutritional status, laparotomy and small bowel resection were performed successfully. The use of SEMS in fistulas of the lower gastrointestinal tract is a heavily debated and fairly under-researched topic, especially in the context of enterocutaneous fistulas. No international guidelines officially recommend using SEMS in the small bowel ECF.

Peripheral arterial disease is a stenosis or occlusion of peripheral arteries that results in compromised blood flow and muscle ischemia. The available diagnostic methods are mostly used to measure and visualize blood flow and are not useful in the evaluation of perfusion, especially in diabetic patients, which is now considered to be a research priority by most of the vascular societies around the world as this is still a relatively poorly studied phenomenon. The aim of this review is to explore the clinical significance of muscle tissue oxygenation monitoring in lower-extremity peripheral artery disease diagnosis using the near-infrared spectroscopy method. A systematic search in PubMed, CINAHL, and Cochrane databases was performed to identify clinical near-infrared spectroscopy (NIRS) studies in English and Russian, published until September 2019, involving muscle tissue oxygenation in peripheral arterial disease (PAD). The manuscripts were reviewed by two researchers independently and scored on the quality of the research using MINORS criteria. After screening 443 manuscripts, 23 studies (n = 1580) were included. NIRS-evaluated recovery time seems to be more accurate than ankle-brachial index in diabetic patients to differentiate between moderate and severe claudication. Consistent findings across all the included studies showed that both the oxygenation and deoxygenation rates as well as the recovery times varied from patient to patient and therefore were not suitable for standardization. The clinical relevance of routine use of NIRS to diagnose PAD is unproven; therefore, its use is not currently part of standard-of-care for patients with PAD since the absolute values seem to vary significantly, depending on the outside conditions. More data need to be provided on the possible use of NIRS monitoring intraoperatively where the conditions can be more controlled.

Low rates of restenosis in primary lateral carotid artery endarterectomy

Introduction: Uretero-arterial fistula (UAF) poses major challenges in management and diagnosis due to the rarity of this condition and associated high morbidity/mortality rates. Methods: We describe a case of a UAF associated with previous aorto-biiliac grafting, ureteric stenting and right nephrectomy because of chronic pielonephritis and complicated by surgical site infection. This case illustrates a very complex pathology, with a challenging diagnosis and multiple treatment options. Results: A 72 year-old woman was referred to Vilnius Vascular Unit for open UAF repair. The patient had a history of open abdominal aortic aneurysm repair using a bifurcated graft 25 years ago. The right ureter was injured during the operation and a rigid indwelling ureteric stent was inserted. Six months prior to referral, she underwent a right nephrectomy due to a chronic pyelonephritis, complicated by surgical site infection, which was still present at the time of admission. Initial CTA demonstrated bilateral iliac aneurysms, but no signs of UAF. A further CTA revealed a UAF between the right ureteral stump and the right common iliac artery (CIA) para-anastomotic aneurysm. After unsuccessful attempts to embolize the UAF using both coils and glue, the patient was referred to Vilnius Vascular Unit for open repair. Left axillo-bifemoral bypass reconstruction was performed followed by UAF repair and bifurcated graft explantation. Follow-up after 2 years showed no recurrence of haematuria, good function of the remaining kidney and patent axillo-bifemoral bypass with no signs of infection around the prosthetic aortic stump. Conclusions: Uretero-arterial fistula is a uncommon condition in everyday clinical practice. The rarity of this condition may lead to delayed or missed diagnosis which can result in life-threating consequences. A multidisciplinary approach involving urologists, vascular surgeon and radiologist are crucial to both the diagnosis and managment of this rare entity.