Chronic Limb-Threatening Ischemia in Patients with Type 2 Diabetes: Revascularization Index as a Predictor for Primary Endovascular Intervention Outcome.

Purpose: Chronic limb-threatening ischemia in patients with diabetes is associated with a high risk of adverse outcomes. The associated co-morbidities, the heterogeneity of foot presentation and the distribution of atherosclerotic lesions led to the emergence of multiple revascularization strategies and scoring systems to improve management outcomes. This study aimed to introduce a new index, the revascularization index (RI), and to assess its predictive value for the outcomes of primary endovascular intervention in patients with type 2 diabetes presenting with chronic limb-threatening ischemia. Patients and Methods: A retrospective electronic medical records review was conducted for patients with type 2 diabetes presenting with chronic limb-threatening ischemia managed at King Abdullah University Hospital by primary endovascular interventions between January 2014 and August 2019. The RI was analyzed for its predictive value for the treatment outcomes. Results: A total of 187 patients were included in this study, with a major lower limb amputation rate of 19.3%. The performance of the RI was excellent in predicting secondary revascularization (AUC = 0.80, 95% CI: 0.73-0.86, p-value < 0.001), good to predict major amputation (AUC = 0.76, 95% CI: 0.67-0.85, p-value = 0.047), and poor in predicting death (AUC = 0.46, 95% CI: 0.40-0.55, p-value = 0.398). RI of <1.21 was significantly associated with a higher risk of major lower limb amputation (HR = 5.8, 95% CI: 1.25-26.97, p-value < 0.025), and RI of < 1.3 was associated with a higher risk for secondary revascularization. Conclusion: The RI can be used to predict major adverse lower limb events (MALE). It might be used as a guide for the extent of endovascular interventions for diabetic chronic limb-threatening ischemia with multi-level outflow atherosclerotic disease.

Impact of the COVID-19 pandemic on imaging case volumes in King Abdullah University Hospitals (KAUH).

Objective: COVID-19 has an increased burden on the delivery of services because the measures taken by the governments forced hospitals to cancel most of their elective procedures and led to the shutting down of outpatient clinics. This study aimed to evaluate the impact COVID-19 pandemic on the volume of radiology exams based on patient service locations and imaging modality in the North of Jordan. Methods: The imaging case volumes that were performed at the King Abdullah University Hospital (KAUH), Jordan, from 1 January 2020 to 8 May 2020, were retrospectively collected and compared to those from 1 January 2019 to 28 May 2019, to determine the impact of the pandemic of COVID-19 on the volume of radiological examinations. The 2020 study period was chosen to cover the peak of COVID-19 cases and to record the effects on imaging case volumes. Results: A total of 46,194 imaging case volumes were performed at our tertiary center in 2020 compared to 65,441 imaging cases in 2019. Overall, the imaging case volume in 2020 decreased by 29.4% relative to the same period in 2019. The imaging case volumes decreased for all imaging modalities relative to 2019. The number of nuclear images showed the highest decline (41.0%) in 2020, followed by the number of ultrasounds (33.2%). Interventional radiology was the least affected imaging modality by this decline, with about a 22.9% decline. Conclusion: The number of imaging case volumes decreased significantly during the COVID-19 pandemic and its associated lockdown. The outpatient service location was the most affected by this decline. Effective strategies must be adopted to avoid the aforementioned effect on the healthcare system in future pandemics.

Showering gas bubbles within the inferior vena cava detected sonographically can unmask a hidden infection: a case report of a rare presentation in a patient with emphysematous cystitis.

We present a case of incidentally discovered gas bubbles flowing within the inferior vena cava during a routine abdominal sonographic examination, that subsequently unmasked a previously undiagnosed emphysematous cystitis.

Knee Pain and Limping as Presenting Symptoms of Metastatic Thyroid Cancer.

BACKGROUND Most thyroid nodules are fortunately benign; however, up to 15% of thyroid nodules turn out to be malignant. Follicular thyroid cancer is the second most common type of thyroid malignancy, originating from the follicular cells lined by cuboidal epithelium, with a peak incidence between the ages of 40 and 60 years. The feature that differentiates follicular carcinoma from adenoma is the presence of capsular invasion. While distant metastases occur in 10% to 15% of patients with follicular thyroid cancer, only 2% to 13% of patients with thyroid cancer develop bone metastases. Metastasis to the knee in thyroid cancer is extremely rare. This report describes a rare case of limping and knee pain as presenting symptoms of metastasis of follicular thyroid cancer to the knee joint observed during clinical practice and addresses its implications. CASE REPORT A 60-year-old woman presented with right knee swelling, disabling pain, and difficulty with walking in the last 3 months. Magnetic resonance imaging showed a large mass, and a computed tomography scan-guided biopsy confirmed it to be a distant metastasis of follicular thyroid cancer. The patient underwent total knee replacement and thyroidectomy and was postoperatively treated with radioactive iodine therapy. She was in good condition at her 1-year follow-up, with no recurring pathology. CONCLUSIONS This case reports on the metastasis of follicular thyroid cancer to the knee, which is exceedingly rare. However, it should be considered in the differential diagnoses of lytic bone lesions, as early diagnosis and management yield a more favorable prognosis for patients.

Chest Radiograph Severity Scores, Comorbidity Prevalence, and Outcomes of Patients with Coronavirus Disease Treated at the King Abdullah University Hospital in Jordan: A Retrospective Study.

Introduction: Hospitalized patients with coronavirus disease (COVID-19) often undergo chest x-ray (CXR). Utilizing CXR findings could reduce the cost of COVID-19 treatment and the resultant pressure on the Jordanian healthcare system. Methods: We evaluated the association between the CXR severity score, based on the Radiographic Assessment of Lung Edema (RALE) scoring system, and outcomes of patients with COVID-19. The main objective of this work is to assess the role of the RALE scoring system in predicting in-hospital mortality and clinical outcomes of patients with COVID-19. Adults with a positive severe acute respiratory syndrome COVID-19 two reverse-transcription polymerase chain reaction test results and a baseline CXR image, obtained in November 2020, were included. The RALE severity scores were calculated by expert radiologists and categorized as normal, mild, moderate, and severe. Chi-square tests and multivariable logistic regression were used to assess the association between the severity category and admission location and clinical characteristics. Results: Based on the multivariable regression analysis, it has been found that male sex, hypertension, and the RALE severity score were significantly associated with in-hospital mortality. The baseline RALE severity score was associated with the need for critical care (P<0.001), in-hospital mortality (P<0.001), and the admission location (P=0.002). Discussion: The utilization of RALE severity scores helps to predict clinical outcomes and promote prudent use of resources during the COVID-19 pandemic.

Redundant Nerve Roots of the Cauda Equina, MRI Findings and Postoperative Clinical Outcome: Emphasizing an Overlooked Entity.

STUDY DESIGN: Retrospective study. OBJECTIVE: To describe the MRI findings of RNRs in patients with low back pain, and observe the imaging findings and the clinical outcome post decompression surgery. METHODS: The lumbar spine MRI of 202 patients (122 females) with proven RNRs were retrospectively reviewed. The morphology and the location of the RNRs in relation to the level of stenosis were described. The level(s), grade and cause of lumbar canal stenosis were recorded. The persistence of symptoms and the imaging findings on follow up post decompression surgery were recorded. The imaging findings were correlated among each other and with patients' demographics. RESULTS: Two distinctive morphological appearance of the RNRs were noted: loop (56.4%), and serpentine-shaped. In the majority of the cases the RNRs were located above the level of stenosis (79.7%). Eighteen patients underwent decompression surgery, only 4 patients remained symptomatic post decompression surgery. The RNRs changed in shape and location after decompression surgery. Age was a strong predictor value in the location of the RNRs. There was no correlation between the shape and location of the RNRs, or with the gender of the patients. CONCLUSION: RNRs is not an uncommon finding on lumbar spine MRI with lumbar canal stenosis. Its importance remains a controversy. A common language between the radiologists and the clinicians is mandatory to aid in the management planning.

The radiological characteristics of childhood intussusception including unusual features and rare pathological lead points.

PURPOSE: To describe the radiological characteristics for childhood intussusceptions including unusual radiological features and rare pathological lead points (PLP). MATERIAL AND METHODS: The medical records of all childhood intussusceptions between 1/1/2010 -1/10/2020 were retrospectively reviewed. 95 cases were identified in 82 patients. The demographic data, presenting symptoms, diagnostic and treatment methods, radiological features, and PLPs among the different types of intussusception were analyzed. RESULTS: Ileocolic intussusception (ICI) represented 53.7% (51/95). The average age for ICI was 1.87 years. Males constituted 72.1% (31/43). 29.4% (15/51) were treated primarily surgically due to peritonitis. Small bowel intussusception (SBI) represented 40% (38/95) in which females constituted 51.5% (17/33). Ileo-ileal represented 63.2% (24/38). 81.8% (27/33) were transient. On ultrasound; There was a statistically significant difference in the size of the outer diameter of ICI compared to SBI (P-value 0.00012). Ileo-ileocolic and colo-colic intussusceptions constituted 3.2% (3/95); each and were more common in females. Vomiting was the most common symptom for intussusception and ultrasound was diagnostic in the majority of cases. PLPs were seen in 36.6% (30/82) of the patients of which the average age was 7 years. PLPs/risk factors were benign in 80% (24/30). A case of colo-colic intussusception was seen in a 16-year-old female due to clear cell sarcoma which was not reported before. 12.2% patients (10/82) had recurrent intussusception. CONCLUSION: Our study showed that ICI is the most commonly encountered type. SBIs are mostly transient. It is important to radiologically determine the type of intussusception and to identify PLPs or unusual radiological features to avoid unnecessary intervention and significant patient morbidity.

The relation of anatomical distribution of symptomatic peripheral arterial disease (PAD) with HbA1c level in patients with type 2 diabetes mellitus.

AIMS: Increased level of glycated hemoglobin (HbA1c) is associated with an increased prevalence of peripheral arterial disease (PAD). This study aimed to assess the relationship between the anatomical distribution of symptomatic PAD lesions in patients with type 2 diabetes and HbA1c levels at the time of PAD diagnosis. PATIENTS AND METHODS: A retrospective study was conducted at King Abdullah University Hospital during the period August 2011 to December 2015. Consecutive patients with type 2 diabetes presented with symptomatic PAD confirmed by computed tomography-angiography (CTA) were included in this study. CTA images were reviewed. Relevant information including demographic data, PAD symptoms, comorbidities, HbA1c level, lipid profile, C-reactive protein and the mean platelets volume were retrieved from medical records. RESULTS: A total of 332 patients with type 2 diabetes (255 males and 77 females) were included in this study. The mean HbA1c at the time of PAD diagnosis was 8.68% (±2.06%). The prevalence of hemodynamic relevant atherosclerotic lesions of the superficial femoral artery, popliteal artery, leg vessels, femoro-popliteal, and crural segments was significantly higher in patients with HbA1c >7.5% compared with patients with HbA1c ⩽7.5%. CONCLUSION: The anatomical distribution of symptomatic PAD in patients with type 2 diabetes mellitus differed significantly according to HbA1c level at the time of PAD diagnosis.

Migrated Inferior Vena Cava (IVC) Filter Strut: A Rare Cause of Chronic Distal Pancreatitis with Likely Malignant Transformation.

BACKGROUND Inferior vena cava (IVC) filters are indicated for patients with recurrent venous thrombosis despite proper anticoagulation or whenever anticoagulation is contraindicated. IVC filter deployment is an invasive procedure with various complications. One example is IVC filter limb fracture and migration, which is associated with significant morbidity and/or mortality. Extravascular migration toward pancreas may induce pancreatitis. Patients with chronic pancreatitis are known to have an increased risk of pancreatic malignancy. CASE REPORT We report an extremely rare case of IVC filter fractured limb in 44-year-old woman, which had migrated into the pancreatic tail and manifested as chronic distal pancreatitis. A pancreatic adenocarcinoma was found by biopsy at the pancreas tail. It is likely that a foreign body promoted this metaplasia and neoplastic transformation. CONCLUSIONS Early detection and retrieval of a displaced foreign body in organs, such as the pancreas, seem to be essential to reduce risk of subsequent complications, including chronic inflammation and possibly neoplasia.

Intractable Biliary Candidiasis in Patients with Obstructive Jaundice and Regional Malignancy: A Retrospective Case Series.

BACKGROUND: Candida species are infrequently grown in bile cultures. An association between biliary candidiasis and regional malignancy may exist. The role of fungus membranes in frequent biliary stent occlusion is also presented in this case series. METHODS: We retrospectively identified patients who underwent percutaneous trans-hepatic cholangiogram (PTC) for obstructive jaundice between January 2014 and January 2019. The results of bile cultures - obtained by PTC - for all patients were analyzed, and patients with fungus growth were determined; their medical records were reviewed. RESULTS: A total of 71 patients with obstructive jaundice underwent PTC between January 2015 and January 2019. Five patients (all male; mean age 55.8 years) had candida species growth in bile cultures. Two patients were diagnosed with cholangiocarcinoma, one with adenocarcinoma of the head of the pancreas, one with gallbladder cancer, and one with locally advanced gastric adenocarcinoma. Formation of fungal balls predisposed to frequent PTC drain clogging. Eradication of Candida was achieved in 4 patients after 10 days to 3 weeks of antifungal therapy. CONCLUSION: We present a case series of biliary candidiasis in patients with obstructive jaundice and regional malignancy. We suggest that patients with obstructive jaundice and regional malignancy should be screened for biliary candidiasis. Persistent cholestasis may be caused by the recurrent formation of fungal membranes (balls).

Impact of the COVID-19 pandemic on the management of chronic limb-threatening ischemia in Northern Jordan: Case series and literature review.

INTRODUCTION: The novel COVID-19 pandemic has imposed unprecedented restrictions on healthcare services worldwide. In developing nations such as Jordan, appreciable impacts on healthcare delivery ensued owing to limited resources. As a result, managing chronic limb-threatening ischemia (CLTI) has been modified to accommodate altercations in the system. This study assessed the impact of the COVID-19 pandemic on managing patients with critical limb-threatening ischemia (CLTI) during the lockdown. METHODS: Objectives were accomplished by retrieving records of clinical data and perioperative results for patients diagnosed with CLTI at King Abdullah University Hospital between March 17 and June 1, 2020. Patients' demographics, Rutherford classification, type of intervention, and intervention variables during the outbreak were retrospectively analyzed (pandemic Group A) and compared with patients from the same period last year (control Group B). RESULTS: A total of 96 patients with CLTI were included in the study; Groups A and B consisted of 28 and 68 patients, respectively. The mean ages for Groups A and B were 62.8 and 60.2 years, respectively. Conservative management was applied to 53.6% (P < 0.01) of Group A patients, whereas endovascular revascularization was the primary approach in Group B (39.7%, P < 0.01). After the intervention, the majority of patients in Group A were classified as category six on the Rutherford classification system (46.4%, P < 0.01), whereas the majority in group B were classified as category five (55.9%, P < 0.01). CONCLUSIONS: The more unsatisfactory outcome of CLTI during the pandemic entails substantial measures to ensure conscientious virtual encounters and ambulatory community-based services during current and future pandemics. The endovascular-first policy should be endorsed in future pandemics as it is better at reducing aerosol transmission than standard surgical intervention. Moreover, endovascular procedures are minimally invasive and associated with favorable outcomes when medical optimization and hospital beds are limited.

Endovascular management of acute mesenteric ischemia in a young patient with thyrotoxicosis and atrial fibrillation: A case report and review of the literature.

INTRODUCTION: Acute mesenteric ischemia caused by an embolism resulting from atrial fibrillation in a thyrotoxic young male patient is a rare event. Endovascular intervention is increasingly being considered as the primary modality of treatment in selected patients. PRESENTATION OF CASE: A 41-years male known to have hyperthyroidism presented with atrial fibrillation, acute mesenteric ischemia, splenic infarction, and left renal infarction. He was successfully managed with endovascular intervention of the superior mesenteric artery. DISCUSSION: Acute mesenteric ischemia has a high mortality rate. CT angiography is the investigation of choice for diagnosis of the mesenteric vessels occlusion and assessment of bowel ischemia. The clinical presentation guides into the treatment and the choice between open surgery and endovascular intervention as the primary modality of treatment. Thyrotoxicosis is a risky comorbid condition for any procedure to be done, so proper perioperative management is essential to decrease morbidity and mortality. CONCLUSION: Prompt diagnosis and management of acute mesenteric ischemia is essential to decrease the morbidity and mortality rates. Endovascular management can be considered as a primary modality of treatment in selected cases.

Lesion Type Analysis of Hemodialysis Patients Who Underwent Endovascular Management for Symptomatic Central Venous Disease.

PURPOSE: Central venous lesions (CVLs) can adversely affect hemodialysis access maturation and maintenance, which in turn worsen patient morbidity and access circuit patency. In this study, we assessed several clinical variables, patient characteristics, and clinical consequences of symptomatic central vein stenosis and obstruction in patients who underwent renal replacement therapy in the form of hemodialysis. PATIENTS AND METHODS: The medical records of all hemodialysis patients with clinically symptomatic CVLs who underwent digital subtraction angiography treatment at King Abdullah University Hospital between January 2017 and December 2019 were retrieved. Patient characteristics and the clinical and anatomical features of CVLs were analyzed retrospectively. Pearson's chi-square tests of association were used to identify and assess relationships between patient characteristics and CVLs. RESULTS: The study cohort comprised 66 patients with end-stage renal disease who developed symptomatic central vein stenosis. Of the 66 patients, 56.1% were men, and their mean age was approximately 52 years. Most (62.1%) of the patients were determined to have a history of central catheter insertion into the jugular vein. Hypertension was the most common comorbidity (78.8%, p<0.001), followed by type 2 diabetes mellitus (47.0 %, p<0.01). The incidence of stenosis was found to be significantly higher in the brachiocephalic vein than in other central veins (43.9%, p<0.001). A repeated central catheter insertion in a patient was predictive of central venous occlusion (p<0.05). Stenotic lesions were found to be associated with a significantly higher success rate than occlusive lesions (91.2%, p<0.01). CONCLUSION: Multiple central venous catheters (CVCs) are found to be associated with occlusive CVLs and unfavorable recanalization outcomes. Multiple CVC should be avoided by creating a permanent vascular access in a timely fashion for patients with chronic kidney disease and by avoiding the ipsilateral insertion of CVC and AVF.

Pitfalls and value of organ specific approach in evaluating indeterminate lesions detected on CT in colorectal cancer by [F18] FDG PET/CT.

OBJECTIVE: The objective of this study is to evaluate the value of FDG PET/CT for different involved organs showing Indeterminate/ equivocal / suspicious lesions detected on IV contrasted CT during surveillance follow up for colorectal cancer. MATERIALS AND METHODS: A total of 67 patients with colorectal cancer how are on regular surveillance follow up by IV contrasted CT scans revealing indeterminate lesions were studied. Subsequent FDG PET/CT evaluation was performed as a problem solving modality. PET/CT results were statistically characterized when compared to biopsy results or to follow/up results. Also Statistical parameters were calculated for each organ involved. The evaluation of all CT indeterminate lesions by FDG PET/CT showed overall sensitivity of 93%, Specificity of 81%, Negative predictive value of 94%, Positive predictive value 80% and accuracy of 87%. However in an organ specific approach the highest accuracy was for lymph nodes with results showing a 100% accuracy and the lowest accuracy was for local disease at a value of 80%. Probable explanations for the falsely characterized lesions resulting in the pitfalls seen and in the imperfect accuracy were provided. CONCLUSION: Study shows that FDG PET/CT is an excellent tool in characterizing CT indeterminate lesions during surveillance of colorectal cancer, However different organs showed variable accuracy results with the highest accuracy for our study was for lymph node status (100%) and the lowest accuracy being for local disease at the original site of primary tumor (80%).

Ankylosing Spondylitis With Bilateral Symmetrical Uptake in the Greater Trochanters on Bone Scan.

Ankylosing spondylitis is a chronic inflammatory bone disease that commonly affects the spine and the sacroiliac joints. Ankylosing spondylitis can also cause enthesitis, or enthesopathy, which is an inflammation at the tendinous or ligamentous insertion sites on the bones. In this study, we present the case of a 37-year-old man with ankylosing spondylitis with a unique Tc-HDP bone scan finding of symmetrical increased uptake bilaterally in the greater trochanters.

Endovascular Management of Superficial Femoral Artery Occlusion Secondary to Embolization of Celt ACD® Vascular Closure Device.

BACKGROUND This report describes the endovascular management of a Celt ACD® vascular closure device (VCD) lodged in the superficial femoral artery (SFA), 1 year after its deployment. There is a paucity of evidence in the existing literature regarding the management of complications related to embolized VCD discovered months or years after its deployment. CASE REPORT A 70-year-old male patient, who was a heavy smoker, presented with right lower-limb intermittent claudication of 2 months' duration. He underwent a successful left retrograde iliac artery and left SFA angioplasty 1 year ago. The right femoral pulse was normal, whereas the right popliteal pulse was absent. The right ankle-brachial index was 0.64. Doppler ultrasound showed evidence of mid-right SFA occlusion. Angiogram showed an embolized Celt ACD VCD in the right SFA causing segmental occlusion. An endovascular attempt to retrieve the embolized VCD via a snare failed, as the VCD got deeply embedded in the vessel wall. After successful balloon angioplasty, a stent was placed into the SFA with excellent angiographic and clinical outcomes. CONCLUSIONS This case demonstrates the risk of dislodgement of the VCD and its distal embolization with a risk of late ischemia. Endovascular retrieval may be unsuccessful for chronically embolized VCD. Therefore, stent angioplasty is an acceptable option.

Splenic artery tortuosity index on abdominal CT Scan: correlation with age, sex, BMI and abdominal cavity diameters / Índice de tortuosidad de la arteria esplénica en TC abdominal: correlación con la edad, el sexo, el IMC y los diámetros de la cavidad abdominal

Thorough knowledge of splenic artery course and morphology may help clinician to provide better practice. This Study aims at finding out if there was a relationship between splenic artery tortuosity index and age, sex, Body Mass Index (BMI) and abdominal cavity diameters. Routine abdominal Computerized Tomography (CT) scan images were retrospectively analyzed for 219 patients. Splenic artery tortuosity index was calculated. Abdominal cavity diameters were measured. Age, sex, and BMI were recorded. Splenic artery straight length (x) mean was 9.41 cm (SD 1.33). Splenic artery tortuous length mean was 15.15 cm (SD 3.31). Splenic artery tortuosity index mean was 1.63 (SD 0.36). Pearson correlation coefficient for Splenic artery tortuosity index vs. age was: 0.02 (P value 0.80). Splenic artery tortuosity index for females vs. males were 1.70 vs. 1.57 (P value 0.01). Pearson correlation coefficient for Splenic artery tortuosity index vs. BMI was 0.02 (P value 0.75). Pearson correlation coefficient for Splenic artery tortuosity index vs. abdominal cavity diameters were: Anterior-Posterior (AP) diameter -0.01 (P value 0.88) and transverse diameter 0.00 (P value 0.98). There may be a relationship between splenic artery tortuosity and female sex, but not with age, BMI and abdominal cavity diameters (AP and Transverse).

El conocimiento del curso y la morfología de la arteria esplénica puede ayudar al médico a proporcionar un diagnóstico y tratamiento oportuno al paciente. Este estudio tuvo como objetivo determinar si existe una relación entre el índice de tortuosidad de la arteria esplénica y la edad, el sexo, el índice de masa corporal (IMC) y los diámetros de la cavidad abdominal. Se tomaron imágenes retrospectivas, de rutina, de 219 pacientes de tomografía computarizada (TC) abdominal. Se calculó el índice de tortuosidad de la arteria esplénica. Se midieron los diámetros de la cavidad abdominal y se registró la edad, sexo y el IMC. La media de la longitud recta de la arteria esplénica (x) fue de 9,41 cm (DE 1,33). La longitud tortuosa de la arteria esplénica fue de 15,15 cm (DE 3,31). La media del índice de tortuosidad de la arteria esplénica fue de 1,63 (DE 0,36). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica vs. edad fue: 0,02 (valor de P 0,80). El índice de tortuosidad de la arteria esplénica para las mujeres frente a los hombres fue de 1,70 frente a 1,57 (valor de P 0,01). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica versus el IMC fue de 0,02 (valor de P 0,75). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica frente a los diámetros de la cavidad abdominal fue: diámetro anterior-posterior (AP) -0,01 (valor P 0,88) y diámetro transversal 0,00 (valor P 0,98). Puede existir una relación entre la tortuosidad de la arteria esplénica y el sexo femenino, sin embargo no se encontró relación con la edad, el IMC y los diámetros de la cavidad abdominal (AP y transversal).

Successful reversal of isolated delayed spinal cord ischemia following endovascular abdominal aneurysm repair.

A 74-year-old patient presented with isolated fecal incontinence 6 weeks following endovascular aneurysm repair. The delayed presentation of spinal cord ischemia was precipitated by commencement of alpha-blockers for benign prostatic hyperplasia. This case stresses that vulnerability to spinal cord perfusion is not limited to the perioperative period. In addition, systemic arterial pressure should be closely monitored in cases of marginal vascular insufficiency of the spinal cord.

Endovascular Management of May-Thurner Syndrome in a Patient with Left-Sided Superior Vena Cava: A Case Report.

BACKGROUND May-Thurner syndrome (MTS) is a condition characterized by compression of the left common iliac vein (LCFV) between the right common iliac artery (RCIA) and the lumbar vertebrae. This anatomical entrapment typically affects young women and is mostly asymptomatic. High index of suspicion is required in cases of recurrent left-sided deep vein thrombosis (DVT) and severe leg pain. We describe a case of MTS in a young male patient with a left-sided superior vena cava (LSSVC) that was successfully managed by an endovascular approach. To the best of our knowledge, the coexistence of MTS and LSSVC anomaly has not been reported previously. CASE REPORT A 31-year-old man presented with a history of left-sided iliofemoral deep vein thrombosis and disabling venous claudication of 2 years' duration. Duplex ultrasound and computed tomography venogram (CTV) revealed evidence of MTS with chronic subtotal occlusion of the left common iliac vein (LCIV) with extensive venous collaterals. Venogram via the left femoral vein puncture confirmed the aforementioned findings. Retrograde recanalization of the occluded segment was attempted without success. Therefore, an antegrade approach via the right internal jugular vein was performed to facilitate recanalization. Surprisingly, venography revealed an LSSVC. The occluded CIV was successfully stented and the patient had complete resolution of his symptoms at 22-month follow-up. CONCLUSIONS MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this coincidence is essential to prevent unwarranted mishaps during endovascular management when the jugular approach is used.

Portomesenteric Venous Thrombosis Post-Laparoscopic Sleeve Gastrectomy: Do Energy Systems Pose as Instigating Factor to This Infrequent Complication?

BACKGROUND: Portomesenteric venous thrombosis (PMVT), a rare complication after laparoscopic sleeve gastrectomy (LSG). Severe consequences are owed to a high risk of bowel ischemia. Our aim is to present a series of patients who developed PMVT after LSG, highlighting the potential role of the vessel sealer and divider as a risk factor. METHODS: Medical records of seven patients who underwent LSG and developed PMVT from April 2010 to January 2019, at King Abdullah University Hospital and Jordan University Hospital, Jordan were reviewed. Our findings were studied, audited, and compared with published data. RESULTS: A sum of 4900 patients underwent LSG, 7 (0.14%) developed PMVT. The mean age and body mass index (BMI) were 36.8 years and 45 kg/m2, respectively. Four were women. Epigastric pain radiating to the back was the presenting symptom at a median time of 9 days after surgery. Computed tomography (CT) of the abdomen confirmed the diagnosis. Five patients presented with a total portal vein thrombosis (PVT), one with splenic vein thrombosis and one with dual portal and mesenteric vein thrombosis. CONCLUSION: Portomesenteric venous thrombosis is a relatively uncommon complication following LSG. Early recognition is required to avoid catastrophic outcomes. The role of energy systems in the development of PMVT remains unknown and requires further elaboration.