Dialysis access-associated steal syndrome with percutaneous endovascular arteriovenous fistula creation.

BACKGROUND: Dialysis access-associated steal syndrome (DASS) is an infrequent complication after hemodialysis access creation. Clinical symptoms depend on the degree of steal. Percutaneous arteriovenous fistula creation offers a minimally invasive alternative to surgical creation, though complications have been reported. The following presents the first described case of DASS after percutaneous endovascular arteriovenous fistula creation, and discusses risk factors and management. CASE PRESENTATION: Our case is that of a 27-year-old male with end stage renal disease due to congenital renal dysplasia, who underwent left percutaneous arteriovenous fistula creation for initiation of dialysis. Two months after the procedure the patient complained of coldness, pain, tingling, and numbness in the left arm during dialysis, concerning for steal syndrome. The patient subsequently underwent brachial artery angiogram, which showed minimal antegrade flow through the ulnar and interosseous arteries towards the hand, and a focal, severe stenosis in the distal ulnar artery. Angioplasty of the stenosis was performed, though steal symptoms continued. CONCLUSIONS: DASS, though rare, can be seen with percutaneous arteriovenous fistula creation. Identification of the risk factors prior to creation can help avoid this complication. Management is largely guided by clinical presentation. As long as there is adequate collateral supply to the extremity, single vessel occlusion is not a contraindication to percutaneous arteriovenous fistula creation with the use of WavelinQ technology. Careful patient selection with pre-creation angiogram may reduce the risk of symptomatic steal.

Paratesticular Dermoid Cyst Mimicking a Torsed Supernumerary Testis: A Case Report.

BACKGROUND Paratesticular tumors are rare causes of scrotal masses; most are benign and arise from the spermatic cord. We present the case of a dermoid cyst, a rare benign paratesticular tumor mimicking a torsed supernumerary testis. CASE REPORT An 8-year-old male presented to the Emergency Department with intense pain and swelling in the left hemiscrotum. He reported severe stabbing pain in his left hemiscrotum, quantified as 10/10, and demonstrating no improvement with change in position. Ultrasonography of the scrotum showed an oval-shaped heterogeneous, predominantly hypoechoic structure observed immediately inferior and lateral to the left testicle, showing no internal vascularity. The right hemiscrotum showed no testicular structure. Based on the sonographic observations, the possibility of 2 adjacent testicles in the left hemiscrotum was raised; the one without vascularity and with hypoechoic texture suggested the presence of ischemic changes due to torsion. The differential diagnosis of a paratesticular mass includes a paratesticular tumor, mimicking of paratesticular neoplasms (i.e. polyorchidism and splenogonadal fusion) and metastases. Surgical exploration of the left hemiscrotum revealed a normal untorsed left testis with an adherent paratesticular mass. An intraoperative frozen biopsy of the mass offered the preliminary diagnosis of an epidermoid cyst. CONCLUSIONS Paratesticular tumors can clinically present variably as a mass, which can be painful. Dermoid cysts can present as a painful mass and the sonographic appearance varies from anechoic to hyperechoic according to the cyst contents. A dermoid cyst as the differential diagnosis of a painful paratesticular mass in boys is important along with the possibility of a torsed supernumerary testicle.

Iatrogenic Cerebral Air Embolism During Esophago-Gastroduodenoscopy.

BACKGROUND Cerebral air embolism is a rare iatrogenic complication of endoscopic procedures that can result in irreversible neurological damage. The symptoms of cerebral air embolism are nonspecific and may be attributed to sedation-related complications and central nervous system insults. Having awareness of this rare iatrogenic event and deciding on immediate imaging when it is suspected are essential for prompt diagnosis and treatment. CASE REPORT A 72-year-old man with a past medical history of alcoholic liver cirrhosis with associated portal hypertension underwent an outpatient esophago-gastroduodenoscopy for surveillance of esophageal varices. During the procedure, the patient retched several times and developed a mucosal tear, which was repaired using endoscopic clips. After the procedure, the patient remained sedated for a prolonged time and was subsequently unresponsive. Nonenhanced CT of the head showed several foci of gas throughout the subarachnoid spaces. Follow-up nonenhanced brain magnetic resonance imaging demonstrated ischemic changes, which were more prominent along the right cerebral hemisphere. CONCLUSIONS Cerebral air embolism is an iatrogenic complication of endoscopic procedures that can result in irreversible neurological damage. It must be included in the differential diagnosis of a patient presenting with altered mental status and neurological deficits after an endoscopic procedure. Diagnostic imaging can be useful in identifying key features of this iatrogenic event. Timely diagnosis and treatment can improve patient outcomes.

Non-Surgical Management of Colo-Colonic Intussusception in Patients with Hereditary Angioedema.

BACKGROUND Hereditary angioedema (HAE) is an autosomal disease caused either by deficiency or presence of a non-functioning C1 inhibitor. The lack or non-functionality of said inhibitors leads to activation of an inflammatory cascade, which result in cutaneous and mucosal edema. Most patients with HAE present with either cutaneous, laryngeal/pharyngeal, or gastrointestinal exacerbations. An uncommon gastrointestinal manifestation of HAE is an intussusception, which in most cases require invasive/surgical management. CASE REPORT A 17-year-old Hispanic female patient with past medical history of HAE, presented with a 4-day history of episodic abdominal pain, worsening during the last 2 days with associated nausea, vomiting, and bright red blood per rectum. The abdominal ultrasound performed at our institution showed an elongated region of hypoechoic and hyperechoic concentric rings, raising suspicion of an intussusception. The patient was treated conservatively, with 30 mg of ecallantide and a unit of fresh frozen plasma (FFP). Follow-up abdominopelvic computed tomography scan was performed approximately 20 hours after the administration of fresh frozen plasma revealing complete interval resolution of the colo-colonic intussusception. Subsequently, the patient was kept under hospital care for the next 4 days with adequate progression of diet and without recurrence of intussusception. CONCLUSIONS To the best of our knowledge, most cases of patient with HAE presenting with intussusception have been treated with invasive/surgical procedures. In our case, conservative management has proven successful to reduce edema with subsequent non-surgical reduction of the intussusception. By directly targeting the pathophysiologic aspects of HAE, an unnecessary invasive procedure, as well as its potential complications, were avoided.