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Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.

Transfusion of autologous late‐outgrowth endothelial cells (OECs) is a promising treatment for restenosis after revascularization. Preparing cells by in vitro amplification is a key step to implement the therapy. This study aimed to demonstrate that bilobalide, a terpenoid, enhances the OEC amplification. Human‐, rabbit‐ and rat OECs and a mouse femoral artery injury model were used. Expanding OECs used endothelial growth medium‐2 as the standard culture medium while exploring the mechanisms used endothelial basal medium‐2. Proliferation assay used MTT method and BrdU method. Migration assay used the modified Boyden chamber. Intracellular nitric oxide, superoxide anion, hydroxyl radical/peroxynitrite and H2O2 were quantified with DAF‐FM DA, dihydroethidium, hydroxyphenyl fluorescein and a H2O2 assay kit, respectively. Activated ERK1/2 and eNOS were tested with the Western blot. Bilobalide concentration‐dependently enhanced OEC number increase in vitro. Transfusion of bilobalide‐based human OECs into femoral injured athymia nude mouse reduced the intimal hyperplasia. Bilobalide promoted OEC proliferation and migration and increased the intracellular nitric oxide level. L‐NAME, a NOS inhibitor, inhibits but not abolishes OEC proliferation, migration and ERK1/2 activation. Bilobalide concentration‐dependently enhanced the eNOS Ser‐1177 phosphorylation and Thr‐495 dephosphorylation in activated OECs. Bilobalide alleviates the increase in hydroxyl radical/peroxynitrite, superoxide anion and H2O2 in proliferating OECs. In conclusion, nitric oxide plays a partial role in OEC proliferation and migration; bilobalide increases OEC nitric oxide production and decreases nitric oxide depletion, promoting the OEC number increase; Bilobalide‐based OECs are active in vivo. The findings may simplify the preparation of OECs, facilitating the implementation of the autologous‐OECs‐transfusion therapy.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) may benefit patients with severe subdiaphragmatic traumatic hemorrhage. This study compares outcomes in patients with penetrating abdominal vascular injury treated with REBOA versus those managed without REBOA. Using the Trauma Quality Improvement Program (TQIP) database, we identified adult patients with penetrating abdominal vascular injury from 2017 to 2022. Propensity scores matched REBOA patients 1:3 with non-REBOA patients. The primary outcome was in-hospital mortality, with secondary outcomes including 24-h mortality, transfusion needs, and complications such as acute kidney injury (AKI), deep vein thrombosis (DVT), pulmonary embolism (PE), lower extremity compartment syndrome, fasciotomy, amputation, and femoral artery repair. Two hundred ninety-three REBOA patients were matched with 879 non-REBOA patients. REBOA patients had higher in-hospital mortality (46.8 ​% vs 36.3 ​%, p ​= ​0.002), packed-red blood cell (PRBC) transfusion requirements within 4 ​h (median 15.3 vs 8.2, p ​< ​0.001), AKI (8.5 ​% vs 4.7 ​%, p ​= ​0.013), fasciotomy (6.5 ​% vs 3.6 ​%, p ​= ​0.039), amputation (3.4 ​% vs 1.4 ​%, p ​= ​0.025), and femoral artery repair (3.4 ​% vs 0.6 ​%, p ​< ​0.001). In a subgroup analysis of patients without severe extra-abdominal injuries, REBOA was associated with higher in-hospital mortality (49.7 ​% vs. 38.2 ​%, p ​= ​0.013) and increased packed red blood cell (PRBC) transfusion requirements (median 14.1 vs. 8.3 units, p ​< ​0.001). In penetrating abdominal vascular injuries, REBOA was associated with worse outcomes. [Display omitted] •REBOA increases in-hospital mortality after penetrating abdominal vascular injuries.•REBOA is associated with higher complications, including amputation and need for fasciotomy.•Focused research needed to identify trauma populations that benefit from REBOA.

Our purpose was to assess the prevalence of liver injuries as well as concomitant injuries to the liver and spleen in patients with blunt or penetrating abdominal trauma, and to determine the prevalence, management and outcome of active bleeding and contained vascular injuries (CVI; pseudoaneurysm/AV-fistula) seen on admission CT. A retrospective, single-center, longitudinal cohort study with nine-year data (2013–2021) of all ≥ 15-year-old patients with severe blunt or penetrating abdominal trauma and an ICD code for liver and/or splenic trauma. CT examinations were identified. Radiology, medical reports and images were reviewed and only patients with an adequate admission CT were included in the final study group. Of 2805 patients with abdominal trauma (71% males), 409 patients (14.6%) had a liver injury, and 329 had a CT on admission (329/409; 80.4%). 313 patients (11.2%) had a splenic injury and 262 had a CT (262/313; 83.7%). Of these, 65 patients or 2.3% (65/2805) had injury to both organs, with 49 patients with CT (49/65; 75.4%), combined group (CG) (79% males). The median (range) ISS was 21 (4–75) for single organ injury patients and 34 (9–75) for patients with both organs injured ( p  < 0.0001). Active liver or splenic bleeding was seen in 5.8% and 17.9%, respectively. In CG, 11 (11/49; 22.4%) patients had active bleeding. Of these, two patients had active bleeing in both organs (4.1%). Liver patients with active bleeding had significantly higher ISS ( p  = 0.025) than those without. In CG, ISS did not differ significantly between patients with and without active bleeding ( p  = 0.073), however, it tended to be higher in those with active bleeding. Most liver injuries with active bleeding were treated non-operatively (12/19; 63.2%). An active bleeding was more common in spleen than in liver patients; odds ratio (OR) (95% CI) 3.57 (2.04–6.25), p  < 0.0001. A CVI was more common in splenic compared with liver injuries, OR 6.71 (95% CI; 2.27–19.9, p  < 0.0001). Active bleeding was more common in CG than in single organ injury patients; OR 3.67 (1.73–7.79), p  < 0.0016. 30-day survival rate did not differ between patients with or without active bleeding, but was slightly lower in CG compared with only liver injury (89.8% vs. 93.7%, p  = 0.36). In conclusion the prevalence of liver injury in abdominal trauma seen on admission CT was 11.7% of all patients with blunt or penetrating abdominal trauma, and concomitant splenic and liver injury was seen in 1.7%. Non-operative management was applied in almost two thirds of patients with liver injuries. Active bleeding was seen in 5.8% of liver, 17.9% of splenic and 22.4% of CG patients. ISS was doubled in CG compared with single organ injury patients. Active bleeding was more common in CG, and CG had slightly increased mortality rate compared with single organ injury patients.

Background Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is effective. This study aims to audit the technique and outcomes of FCBT. Methods Adult patients with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were prospectively captured on an approved electronic registry. Retrospective analysis included demographics, major injuries, investigations, management and outcomes. Results During the study period, 628 patients with PNI were treated at GSH. In 95 patients (15.2%), FCBT was utilised. The majority were men (98%) with an average age of 27.9 years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH. Computerised tomographic angiography (CTA) was done in 92.6% of patients, while eight patients (8.4%) required catheter-directed angiography. Six were performed for interventional endovascular management. Thirty-four arterial injuries were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate for haemorrhage control. Thirteen (13.7%) patients required neck exploration. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48–72 h. Two of these bled on catheter removal. A total of 36 complications were documented in 28 patients (29.5%). There was one death due to uncontrolled haemorrhage from the neck wound. Conclusion This large series highlights the ease of use of FCBT with high rates of success at haemorrhage control (97%). Venous injuries and minor arterial injuries are definitively managed with this technique.

One of the feared complications of war-related peripheral vascular injury is the development of delayed hemorrhage. This study describes our experience with an innovative protocol of surveillance diagnostic angiography to detect occult late vascular complications in an effort to prevent delayed hemorrhage. This retrospective cohort study was conducted at a single level one trauma center, reviewing patients with war-related peripheral vascular injuries caused by penetrating trauma from October 7th, 2023, to January 21st, 2024. Data collected included patient demographics, primary injury characteristics, associated complications, incidence of late vascular injuries (either symptomatic or occult), means of diagnosis, treatment strategies and outcomes. The cohort included 41 patients with war-related peripheral vascular injuries affecting 51 limbs. All patients were male (100%) with a median age of 25 years, the majority being soldiers (85%). 24 occurrences of late vascular injuries were observed in 22 (43%) out of 51 limbs (100%). Half were symptomatic, with delayed hemorrhage occurring in 5 limbs in total (10%), and half were asymptomatic. A total of 17 surveillance diagnostic angiographies were performed with the sole indication of identifying occult late vascular injuries in asymptomatic patients, of which 4 (24%) were positive for findings. Five additional diagnostic angiographies were performed to assess late injuries discovered incidentally on imaging studies that were performed for other indications, and all were positive for late vascular injuries. Of all late vascular injuries, a total of 83% required subsequent treatment. Late vascular injuries are a potentially lethal complication of war-related peripheral vascular injury. Aggressive surveillance with diagnostic angiography prior to discharge from a high intensity care unit can detect asymptomatic late vascular injuries, the treatment of which may prevent life-threatening hemorrhage.

Vascular access and closure remain a challenge in transcatheter aortic valve replacement (TAVR). This single-center study aimed to report the incidence, predictive factors, and clinical outcomes of access-related vascular injury and subsequent vascular intervention. During a 30-month period, 365 patients underwent TAVR and 333 patients (94%) were treated by true percutaneous transfemoral approach. Of this latter group, 83 patients (25%) had an access-related vascular injury that was managed by the use of a covered self-expanding stent (n = 49), balloon angioplasty (n = 33), or by surgical intervention (n = 1). In 16 patients (5%), the vascular injury was classified as a major vascular complication. Absence of a preprocedural computed tomography angiography (CTA) of the iliofemoral arteries (OR 2.04, p = 0.007) and female gender (OR 2.18, p = 0.004) were independent predictors of the need for access-related vascular intervention. In addition, a high sheath/common femoral artery ratio as measured on preoperative CTA was associated with a higher rate of post-TAVR vascular intervention. The radiation dose, iodine contrast volume, transfusion need, length of hospitalization, and 30-day mortality were not significantly different between patients with versus without access-related vascular intervention. In conclusion, access-related vascular intervention in patients who underwent transfemoral-TAVR is not uncommon. Female gender and a high sheath/common femoral artery ratio are risk factors for access-related vascular injury, whereas preprocedural planning with CTA of the access vessels may reduce the risk of vascular injury. Importantly, most access-related vascular injuries may be treated by percutaneous techniques with similar clinical outcomes to patients without vascular injuries.

Intercellular communication between mesenchymal stem cells (MSCs) and their target cells in the perivascular environment is modulated by exosomes derived from MSCs. However, the potential role of exosome‐mediated microRNA transfer in neointimal hyperplasia remains to be investigated. To evaluate the effects of MSC‐derived exosomes (MSC‐Exo) on neointimal hyperplasia, their effects upon vascular smooth muscle cell (VSMC) growth in vitro and neointimal hyperplasia in vivo were assessed in a model of balloon‐induced vascular injury. Our results showed that MSC‐Exo were internalised by VSMCs and inhibited proliferation and migration in vitro. Further analysis revealed that miR‐125b was enriched in MSC‐Exo, and repressed the expression of myosin 1E (Myo1e) by targeting its 3ʹ untranslated region. Additionally, MSC‐Exo and exosomally transferred miR‐125b repressed Myo1e expression and suppressed VSMC proliferation and migration and neointimal hyperplasia in vivo. In summary, our findings revealed that MSC‐Exo can transfer miR‐125b to VSMCs and inhibit VSMC proliferation and migration in vitro and neointimal hyperplasia in vivo by repressing Myo1e, indicating that miR‐125b may be a therapeutic target in the treatment of vascular diseases.

Background Iatrogenic coronary artery dissection is a potential complication during percutaneous coronary bioresorbable vascular scaffolds placement. We report that significant dissection occurred during post-expansion of the left circumflex branch bioresorbable vascular scaffolds to attach it to the wall. Additional resorbable stents successfully covered the dissection without blood flow restriction. Casereport The patient was a 49-year-old male with refusing intracoronary metal stents and was diagnosed with stable angina pectoris and type 2 diabetes. Coronary angiography showed serious lesions in three vessels. A Noevas stent was had placed in the proximal segment of the anterior descending branch. Unfortunately a type-D dissection occurred during post-dilatation after the second scaffold was placed in the proximal of the circumflex branch. A third scaffold was inserted to cover the dissection and optical coherence tomography reexamination showed good apposition. After 6 months of coronary angiography, optical coherence tomography examination showed no deterioration of the circumflex branch dissection, and the proximal intimal hyperplasia in the proximal scaffold was 95%. Scoring balloon and drug balloon dilatation were successfully performed, and right coronary artery dilatation with drug coated balloon was performed. The patient had no symptoms of chest pain after 2 years of follow-up. Conclusion Additional bioresorbable vascular scaffold coverage of coronary type-D dissection with the help of imaging tools may be a practical strategy when patients selcet for coronary metal-less implantation. Furthermore, imaging review is recommended especially for diabetics.

Background Ascending aortic perforation is a rare complication of the transseptal puncture procedure that often requires emergency management. Case presentation We report the case of a 53-year-old woman with severe mitral stenosis (MS) who underwent percutaneous balloon mitral valvuloplasty (PBMV). After the transseptal puncture procedure, a right atrium-iatrogenic ascending aortic perforation was observed. An 8-mm muscular ventricular septal defect (VSD) occluder was then successfully used for emergency closure. Conclusion Percutaneous closure of ascending aortic perforations via a muscular VSD occluder is a feasible treatment approach.