Central venous occlusion in hemodialysis access: Comparison between percutaneous transluminal angioplasty alone and nitinol or stainless-steel stent placement.

PURPOSE: The purpose of this study was to compare the primary and secondary patency rates of percutaneous transluminal angioplasty (PTA) alone with those of metallic stent placement in patients with hemodialysis access and central venous occlusion (CVO) and to compare the respective effects of nitinol and stainless-steel stents on patency. MATERiALS AND METHODS: A total of 150 consecutive patients with hemodialysis access who underwent endovascular treatment for symptomatic CVO with ipsilateral functioning hemodialysis access were evaluated. There were 67 men and 83 women with a mean age of 56.2±15.2 (SD) years (range: 15-86 years). The primary endovascular treatment of CVO was PTA alone. Stent placement either with nitinol or stainless-steel stents was performed as a bailout procedure. The results were analyzed on a per patient basis. RESULTS: Technical success was achieved in 141/150 patients (94%). Of the 141 patients, 109 (77%) underwent PTA alone and 32 (23%) underwent stent placement. The mean number of interventions in the stent group [4.3±2.5 (SD)] was significantly higher than that in the PTA alone group [2.6±2.8 (SD)] (P=0.002). The primary patency rates at 12, 24, and 60 months for the stent group (58.7%, 41.9%, and 27.9%, respectively) were significantly higher than those in the PTA alone group (42.4%, 36.3%, and 20.2%, respectively) (P=0.036). Secondary patency rates at 12, 24, and 60 months for the stent group (87.6%, 80.7%, and 50.3%, respectively) were significantly greater than those in the PTA alone group (68.4%, 56%, and 38.6%, respectively) (P=0.046). Furthermore, the primary patency rates at 6 and 12 months in the nitinol stent group (89% and 80.9%, respectively) were significantly greater than those in the stainless-steel stent group (78.8% and 38.4%, respectively) (P=0.007). The secondary patency rates at 6, 12 and 24 months for the nitinol stent group (92.8%, 87.7% and 65.8%, respectively) were significantly greater than those in the stainless-steel stent group (85.7%, 76.2% and 65.3%, respectively) (P=0.011). CONCLUSiON: Although PTA alone is an effective interventional treatment strategy of CVO in short term, stent placement yields greater primary and secondary patency rates in the long-term. But the mean number of interventions per vein after stenting is significantly higher. Close follow-up and multiple re-interventions are necessary to ensure long-term patency.

Risk factors associated with recanalization of incompetent saphenous veins treated with radiofrequency ablation catheter.

PURPOSE: The purpose of this study was to determine the occlusion rate of incompetent great saphenous veins (GSVs) and small saphenous veins (SSVs) treated with radiofrequency ablation (RFA) and individualize variables associated with recanalization. MATERIALS AND METHODS: A retrospective review of 311 veins (256 GSVs and 55 SSVs) in 211 patients [177 women, 34 men; mean age, 45 years±12 (SD) (range: 18-75 years)] with incompetent GSVs and/or SSVs who were treated using new-generation RFA catheters was performed. The clinical results, occlusion rates, and variables associated with recanalization for the incompetent GSVs and SSVs were analyzed. RESULTS: No major complications were observed in the study population. Ten months after RFA, the occlusion rate was 89% (227/256) for GSVs and 91% (50/55) for SSVs. An increased pre-procedure diameter of the incompetent GSVs was associated with a higher rate of recanalization (OR: 0.825; 95% CI: 0.715-0.952) (P<0.05). No significant differences in age, gender, and side of treated veins were found between patients with recanalization of treated veins and those without recanalization. CONCLUSION: Our results show that pre-procedure diameter of the GSV is the single risk factor for recanalization after RFA.

Successful treatment of aortic rupture with endovascular stent grafting in a patient with mantle cell lymphoma.

PURPOSE: To present a case of spontaneous aortic rupture in the course of mantle cell lymphoma and successful management with endovascular repair. CASE REPORT: A 69-year-old woman presented with a cervical mass. The patient was found to have stage IIIA and Mantle Cell Lymphoma International Prognostic Index (MIPI) 4. She was placed in an intermediate-risk group. The patient received an initial cycle of systemic chemotherapy consisting of rituximab, anthracycline, vincristine and methyl prednisolone. During follow-up, she developed abdominal aortic rupture secondary to intramural hematoma which was successfully managed with endovascular exclusion. CONCLUSION: Hemodynamic changes can be seen during the course of lymphoma subsequent to systemic chemotherapy. These changes might be related to the spontaneous rupture of the main vessels. Endovascular repair may be a more appropriate treatment option than open surgery, especially in a patient with multiple comorbidities.

Extending the boundaries of no-touch aorta technique usage for coronary artery bypass grafting in patients with diseased ascending aorta.

AIM: Atherosclerosis of the ascending aorta is a leading cause of cerebrovascular accidents (CVA) in patients who undergo coronary artery bypass grafting (CABG). However, the ascending aorta is considered untouchable only in cases of severe calcification. The aim of this study is to evaluate the effect of the no-touch aorta technique (NAT) on morbidity and mortality with an extension of indication to any degree of atherosclerotic disease is detected on the ascending aorta. METHODS: From March 2001 to March 2006, data were prospectively collected from 101 patients with ascending aorta atherosclerosis who underwent either on- or off-pump CABG with NAT. Demographic data from these 101 patients were compared with those of 1 473 patients who underwent conventional CABG with aortic cross-clamping during the same time period. All preoperative variables were assessed with stepwise logistic regression to determine predictors of ascending aortic disease. RESULTS: Age, hypertension, hyperlipidemia, peripheral vascular disease, EuroSCORE and unstable and redo rates were significantly higher in the NAT group than in the control group (P<0.05). Logistic regression analysis of preoperative variables for all 1 574 cases identified age, peripheral vascular disease, history of smoking, EuroSCORE, and reoperation as independent predictors of atherosclerotic disease of the ascending aorta. No operative or hospital CVA occurred in the study group. Hospital mortality was observed in 2 (1.9%) patients. During the follow-up period of 27.9 +/- 13 months, no patient was re-admitted with angina recurrence or CVA. CONCLUSION: Any degree of atherosclerotic disease on the ascending aorta can potentially cause CVA upon manipulation during CABG. Use of CABG with NAT to eliminate the risk of CVA is associated with low rates of morbidity, stroke and mortality during hospital stay and at mid-term follow-up.

Symptomatic interrupted inferior vena cava: report of a case presenting with haematochezia.

Interrupted inferior vena cava (IVC) is a rare developmental defect. IVC interruption is usually accompanied with azygos and hemiazygos continuation, and is asymptomatic. Here, we report the imaging findings of a patient with an interrupted IVC with diffuse collaterals between the infrarenal IVC and large renal veins, left gonadal, and perirectal haemorrhoidal-portal collateral veins with associated haematochezia. Depending on the haemodynamic changes, interrupted IVC may cause possible different clinical findings as presented here.

Combined off-pump coronary artery bypass grafting and aorto-bicarotid bypass.

A 63-year-old man with severe coronary artery disease and occlusion of aortic arch branches presented with dizziness, syncope and unstable angina. He underwent a combined surgical procedure of aorto-bicarotid bypass and off-pump myocardial revascularization. The operation was successful and he had no complications during 11 months of follow-up.

Double retroaortic left renal veins as a possible cause of pelvic congestion syndrome: imaging findings in two patients.

Pelvic congestion syndrome is characterized by chronic pelvic pain and varicose veins around the uterus and ovaries. We report two cases of double retroaortic left renal vein, associated with left-sided pelvic congestion syndrome, diagnosed by CT and confirmed by clinical findings and colour Doppler ultrasound. Double retroaortic left renal veins may be a contributing factor for the development of left pelvic congestion syndrome. This is the first report of double retroaortic left renal vein and associated pelvic congestion syndrome.

Report of a case with surprising etiology of renovascular hypertension.

Takayasu arteritis is a chronic, idiopathic, inflammatory disease that primarily affects large vessels, such as the aorta and its main branches. Epidemiologically, it is found mostly in female patients and is more prevalent in Asian and Latin American countries. Disease may be heterogeneous in presentation. In this report, we present a different clinical expression of Takayasu arteritis in a young man who had hypertension as the sole manifestation of multiple critical arterial involvement with elevated inflammation markers but no other symptoms. A 28-year-old man was admitted with hypertension. There was no evidence for systemic vasculitis by history, serologic studies or other laboratory data. The acute-phase reactants were elevated with an erythrocyte sedimentation rate of 55 mm/h, and a C-reactive protein value of 22 mg/dl. Digital subtraction angiography showed multiple severe stenoses or occlusions of the branches of the abdominal aorta and arcus aortae together with bilateral renal artery involvement. The etiology of renovascular hypertension was found to be Takayasu arteritis with the presence of at least three criteria, as outlined by the American College of Rheumatology in 1990. Patients with Takayasu arteritis may have atypical clinical expression of the disease, and a diagnosis of Takayasu arteritis should be kept in mind in the differential diagnosis of renovascular hypertension in young subjects, even if they do not have associated symptoms of multiple arterial involvement.

Cystic Meckel's diverticulum: A rare cause of cystic pelvic mass presenting with urinary symptoms.

An atypical form of Meckel's diverticulum is presented. A 5-year-old girl was admitted with recurrent urinary tract infections. Ultrasonography showed a cystic mass, which pressed and displaced the urinary bladder on its posterosuperior aspect. Laparotomy results showed a cystic mass originating from the antimesenteric border of the ileum, which was attached tightly to the urinary bladder. It was diagnosed as a cystic Meckel's diverticulum, which had undergone abscess formation with preservation of the ileal mucosa in some areas and had severe inflammatory changes on its wall. The case is unique both in the mode of presentation and type of complication. J Pediatr Surg 36:1855-1858.

Sliding appendiceal inguinal hernia with a congenital fibrovascular band connecting the appendix vermiformis to the right testis.

It is not uncommon to find the appendix vermiformis within a hernia sac; however, sliding appendiceal inguinal hernia is rare. A 9-month-old boy with an incarcerated right scrotal hernia is presented in this case report. Although the hernia was reduced through a conservative approach, appendix vermiformis remained in the hernia sac because of its attachment to the upper pole of the right testis. Exploratory surgery during the inguinal hernia repair revealed a connecting band that extended from the appendix vermiformis into the scrotum and attached to the right testicle. Histologic examination showed that the band was congenital. After reduction of an incarcerated hernia, the persistence of a thickened or a cord-like structure is a warning for the presence of a sliding hernia. We suggest that this uncommon developmental anomaly is likely to cause the processus vaginalis to remain patent, thus facilitating hernia formation.

Tetraventricular hydrocephalus due to ruptured intracranial dermoid cyst.

We present the MR imaging findings in a patient who developed tetraventricular hydrocephalus after massive rupture of dermoid cysts with generalized subarachnoid and ventricular spread of cyst contents. The development of tetraventricular hydrocephalus due to ruptured dermoid is a very unusual complication, and was attributed to cyst contents interfering with passage of cerebrospinal fluid through the arachnoid granulations and fourth ventricular outlet foramina.

Percutaneous treatment of a congenital splenic cyst with alcohol: a new therapeutic approach.

Percutaneous treatment of a huge congenital splenic cyst in a 23-year-old man is presented. The cyst had been catheterized and drained two times within a 3-month period without injecting any sclerosing agent into the cavity. On the third attempt, catheter drainage and injection of alcohol into the cyst cavity were performed because of insufficient response to drainage alone. He was discharged symptom-free after the procedure. The cyst diminished in size considerably 9 months after the treatment with alcohol. The volume of the cyst was reduced from 5200 to 8 ml. Although percutaneous treatment of a congenital splenic cyst with tetracyclin has been reported, to our knowledge this is the first case of a congenital splenic cyst treated with alcohol as a sclerosing agent. Percutaneous treatment of splenic cyst can obviate the need for partial or total splenectomy and may be an alternative to surgical treatment.

Medullary nephrocalcinosis associated with vesicoureteral reflux.

A case of medullary nephrocalcinosis developing in the course of vesicoureteral reflux is described. It is suggested that the probable mechanism of nephrocalcinosis was the stagnation of urine in collecting tubules favouring precipitation of calcium salts.

Congenital tracheoesophageal fistula without atresia: an incidental finding.

A four-year-old boy who had a long history of upper respiratory tract infections and growth retardation was admitted because of recurrent abdominal pain. During upper gastrointestinal series to search for a gastric or duodenal ulcer, the examiner noticed a minute amount of contrast medium within the trachea. Repeat esophagography on an angiographic table led to the correct diagnosis of a congenital H-type fistula. The patient did not have the classical symptoms of a history of choking and cyanosis after feeding during infancy or recurrent lower respiratory tract infections. The only finding consistent with a fistula was growth retardation, and the diagnosis was established incidentally during a work-up for abdominal pain.

Inferior suprarenal artery aneurysm in polyarteritis nodosa.

A 16-year-old boy with the complaints of fever, abdominal pain, arthralgia and hypertension was found to have polyarteritis nodosa. Selective renal angiography disclosed a 5-mm microaneurysm of the right inferior suprarenal artery, which has not been previously reported in polyarteritis nodosa. Aside from the diagnostic view-point, some of the perirenal and retroperitoneal hemorrhages of unknown origin seen in polyarteritis nodosa might be due to the rupture of suprarenal artery aneurysms.

Primary non-Hodgkin's lymphoma of the esophagus.

The esophagus is the least commonly involved gastrointestinal organ, accounting for fewer than 1% of patients with lymphoma. Such involvement is mostly secondary, from mediastinal lymph nodes or gastric lymphoma. The primary form arises from the esophageal wall itself and occurs much less frequently. Primary esophageal lymphoma is mostly seen in male patients with Hodgkin's disease. A primary non-Hodgkin's lymphoma of the esophagus with concomitant involvement of the bone marrow is presented, and imaging features of esophageal lymphoma are reviewed.

Embolization of a high-output postnephrectomy aortocaval fistula with Gianturco coils and cyanoacrylate.

The authors describe the endovascular treatment of a high-output, large-caliber, postnephrectomy aortocaval fistula using a mixture of cyanoacrylate and lipiodol combined with Gianturco coil embolization. Thirty-nine coils were used to decrease the flow through the fistula so that a fast-polymerizing glue mixture could be injected into the fistula. During rapid polymerization, the N-butyl-2-cyanoacrylate (NBCA) mixture was trapped within the coils, providing an easily controllable glue cast in the fistula, thereby preventing inadvertent embolization into the lungs. This approach can be of considerable benefit for the endovascular treatment of central high-output fistulas.

Traumatic aneurysm and arteriovenous fistula of the splenic artery.

Aneurysmal arteriovenous fistulas are rare and mostly seen in adults. A 13-year-old girl developed a subcapsular hematoma of the spleen following blunt abdominal trauma. Follow-up ultrasonography 4 months after the trauma revealed an aneurysm at the splenic hilum. Selective splenic angiography demonstrated the lesion to be an aneurysmal arteriovenous fistula. Repeat ultrasonography enabled us to be certain of the traumatic origin of the aneurysm and arteriovenous fistula which are very unusual in the pediatric age group.

Ultrasonographic diagnosis of intestinal ascariasis.

Ascaris lumbricoides is the most common roundworm in warm and temperate areas. Although radiological features of Ascaris lumbricoides are well defined, there are only a few reports on the ultrasonographic findings of intestinal ascariasis. In our two patients with no acute abdominal symptoms, intestinal ascariasis was initially diagnosed by abdominal ultrasonography. In both patients, tubular structures in the segments of the small intestine were demonstrated by ultrasonography.