A rare pinch-off case embolized to the pulmonary artery.

The pinch-off syndrome is defined as the embolization of the central catheter inserted via the subclavian approach due to the mechanical compression between the clavicle, the first rib, the subclavius muscle, and the costoclavicular ligament. Embolization to the pulmonary artery is an extremely rare condition. In this article, we present a rare case with ovarian cancer who had multiple metastases both locally and lungs, the port catheter was fractured into three parts, the proximal part was removed, the middle part was left between the subclavian vein and the skin, and the long distal part was embolized to the pulmonary artery.

Results and functional outcomes of en-bloc resection and vascular reconstruction in extremity musculoskeletal tumors.

OBJECTIVES: This paper aims to evaluate the extremity function and vascular outcome after limb-sparing surgery for extremity musculoskeletal tumors invading vascular structure required reconstruction. METHODS: Of the 507 patients with musculoskeletal tumors, who underwent surgery between 2004 and 2007, 17 (3,3%) patients with major vessel involvement were included in the study. The mean age was 37.8 ± 14.5, with a female/male ratio of 8/9. Thirteen (76.4%) patients had Stage IIb disease, and 2 (11,7%) patients had Stage III disease. In 2 (11,7%) patients have locally aggressive tumor that had Stage 3. Fifteen (88.2%) of the cases involved lower extremity, whilst 2 (11.8%) of them involved upper extremity. An arterial reconstruction was carried out in all patients. Wide tumor resection and endoprosthetic reconstruction were performed in 6 (35.2%) patients. Other 11 (65.8%) patients were treated with wide resection and soft tissue reconstruction. Postoperative data included; perioperative morbidities such as bleeding, infection, graft thrombosis, rupture, metastatic local recurrence and mortality. Ankle brachial index (ABI) and color-flow-duplex-scan (CFDS) were done at the final follow-up of the study, in order to prove the efficacy of reconstruction. Functional outcome was evaluated with International Society of Limb Salvage (ISOLS) criteria. RESULTS: The mean follow-up was of 39 months (range 3-120). Perioperative complications were arterial graft thrombosis occurred in 3 (17.6%) patients treated acutely with thrombectomy, uncontrolled deep wound infection occurred in 2 patients whom extremities were amputated. The most frequent complication after surgery was limb edema according to possibly venous and lymphatic obstruction, staged as C1, C2 and C3 disease was established in 6 patients (two patients in each group), and 1 patient was classified as C6 disease. Three (17.6%) patients had local recurrence (1/3 patient died and 2/3 (11.7%) patients underwent transfemoral amputation). At the last follow-up, 9 (52.9%) patients were alive without evidence of disease, 8 (47.1%) patients were died due to primary disease. There were 8 (47.1%) patients alive with an intact limb. Although functional outcome scores were satisfactory, emotional acceptance scores were low. The limb salvage probability was 74.0%. CONCLUSION: Limb-sparing oncological surgery in musculoskeletal tumors with vascular invasion provides a satisfactory limb function, which may lead to an improved life quality. Arterial reconstruction has a high rate of patency in the long term. The surgeon should be aware of early perioperative complication related to vascular reconstruction and infection that effect on the rate of extremity survival. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Favorable survival time provided with radioembolization in hepatocellular carcinoma patients with and without portal vein thrombosis.

PURPOSE: Although some algorithms are defined for the treatment of advanced hepatocellular carcinoma (HCC), the expected survival cannot be prolonged as it is intended. Treatment options for this group of patients are limited. Radioembolization with yttrium-90 (Y-90) microspheres is a new treatment modality, which has also been used in advanced HCC patients. In this study, the authors aimed to assess the efficiency of radioembolization with Y-90 microspheres and evaluate prognostic factors that influence the survival in HCC patients. PATIENTS AND METHODS: The authors retrospectively evaluated data of 29 HCC patients who had radioembolization with Y-90 resin or glass microspheres between May 2009 and January 2014. Patient survival was evaluated by using the Kaplan-Meier method. Subgroup comparisons in terms of age, sex, prior treatment status before radioembolization, tumor burden, time between HCC diagnosis and radioembolization, alpha fetoprotein (AFP) level before radioembolization, presence of portal vein thrombosis (PVT), hepatopulmonary shunt ratio, extrahepatic disease burden, multifocality, bilaterality, Eastern Cooperative Oncology Group (ECOG), Child-Pugh, and Barcelona Clinic Liver Cancer (BCLC) status were performed to evaluate prognostic factors that affected survival. RESULTS: There were 29 HCC patients (mean age: 59.9±12 years) in the patient group. Grade ≤1 and 2 ECOG performance status was present in 19 and 10 patients, respectively. Twenty-six patients were classified as Child A and 3 patients as Child B. According to the BCLC staging system, 18 patients were in stage B and 11 patients were in stage C. PVT was diagnosed in 12 patients. The median follow-up was 15 months. The median overall survival was 17±2.5 months. BCLC disease stage was a significant prognostic variable associated with survival, but other parameters, even the presence of PVT, were found to be not significantly affecting survival. CONCLUSION: Radioembolization provides favorable survival time in advanced HCC patients. Even patients who are not eligible for transarterial chemoembolization due to PVT can have radioembolization without a decrease in the median survival time.

An unusual complication following total hip arthroplasty: median circumflex femoral artery pseudoaneurysm.

We report a case of a pseudoaneurysm of the medial circumflex femoral artery that presented 4 months following cementless left total hip arthroplasty (THA). A successful embolization was achieved using super-selective catheterization and coil embolization. Arterial complications associated with THA are remarkably rare. Endovascular techniques have been shown to be effective and are considered a valid alternative to conventional surgery.

Suprafascial pre-expansion of perforator flaps and the effect of pre-expansion on perforator artery diameter.

BACKGROUND: This study addresses the "pre-expanded perforator flap concept" by demonstrating a case series of relevant reconstructive procedures and evaluate the perforator vessel diameter changes that happen during the pre-expansion procedure. METHODS: Fourteen patients were treated with 15 flaps. One patient was treated with two pre-expanded internal mammary artery perforator flaps. In other cases, thoracodorsal, circumflex scapular, lumbar, intercostal, lateral circumflex femoral, and deep inferior epigastric artery perforator flaps were used. Technical details and rate of complications were noted. Evaluations of the flap pedicles were done both by hand held Doppler and by color Doppler ultrasound (CDU). RESULTS: Flaps successfully served to resurface and release thick and rigid broad scar tissues and contractures in 11 of relevant 12 patients (in one patient with 50% flap loss, adequate contracture release could only be obtained with addition of a secondary split thickness skin graft to the residual flap) and provided a good source of tissue for anterior neck reconstruction of one patient and penis reconstruction of another patient. In six patients, perforator artery diameters were measured by CDU both before and after the expansion process and a significant increase secondary to the pre-expansion procedure was detected (Pre-expansion mean: 0.48 ± 0.08 mm; post-expansion mean: 0.65 ± 0.10 mm; P < 0.05). Flaps as large as 30 × 20 cm were harvested. Totally three partial flap necroses were experienced in 15 flap procedures. CONCLUSIONS: Suprafascial pre-expansion of the perforator flaps seems to provide a solution to achieve broader and thinner perforator flaps with larger perforator arteries.

Initial outcome after selective intraarterial radionuclide therapy with yttrium-90 microspheres as salvage therapy for unresectable metastatic liver disease.

PURPOSE: The aim of the study was to retrospectively evaluate the potential benefit on survival outcomes of selective intraarterial radionuclide therapy (SIRT) with Yttrium-90 microspheres as a salvage therapy in liver metastasis of different tumors. MATERIAL AND METHODS: Sixty-one patients who had unresectable liver metastases from colorectal carcinoma (n=23), neuroendocrine tumor (NET; n=12), cholangiocarcinoma (n=9), and others (n=17) received yttrium-90 microspheres. All patients were treated in a salvage setting with an 11-month mean follow-up. Early metabolic treatment response was evaluated by 18F-Fluorodeoxyglucose positron emission tomography (FDG PET-CT) in the sixth week after treatment. RESULTS: Of the 61 patients, 32 were alive at the end of the study; median overall survival (OS) was 17.0 ± 2.5 months (95% confidence interval: 11.9-22.0). A subset analysis of colorectal and noncolorectal groups demonstrated median OS rates of 14.0 ± 5.8 and 17.0 ± 4.8 months, respectively (p=0.543). The mean OS for patients with NET and cholangiocarcinoma was 29.0 ± 3.1 months and 17.7 ± 3.2 months, respectively (p=0.010). According to the early metabolic treatment response, the mean OS of responder and nonresponder groups was 32.0 ± 5.6 months and 11.4 ± 2.1 months, respectively (p=0.054). Eastern Cooperative Oncology Group performance status <1 (p=0.018) and chemotherapy-naive patients (p=0.008) showed significant correlation with survival. CONCLUSION: SIRT is an effective treatment option for patients with metastatic liver disease in a salvage setting with acceptable toxicity.

Local thrombolytic therapy in acute mesenteric ischemia.

BACKGROUND: The aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI). METHODS: From January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator. RESULTS: LTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45-87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining. CONCLUSION: Early intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.

Curative surgery for locally advanced retroperitoneal mature teratoma in an adult. Case report.

INTRODUCTION: Primary teratomas of retroperitoneum are not usual in the adult population. These tumors most commonly seen at the gonadal and sacrococcygeal regions. Herein we describe a case of an 18-year-old female who had a benign cystic teratoma at the retroperitoneum. PRESENTATION OF CASE: The patient underwent an operation at another hospital following a misdiagnosis of hydatid cyst. The patient was referred to our hospital because of the detection of an unresectable tumor during her operation. A computerized tomography (CT)-angiography revealed a cystic mass, with a diameter of 14cm which was invaded into the retrohepatic suprarenal inferior vena cava and also extended to the posterior aspect of the liver. Additionally the mass invaded the posterior wall of the inferior vena cava and the right renal vein. The tumor was completely resected with a vascular resection. The inferior vena cava was reconstructed with a 12cm Dacron(®) graft and the renal vein was implanted. The patient's postoperative period was uneventful. DISCUSSION: Germ cell tumors of retroperitoneum are usually seen in children, but there are also some reports of adult cases in the literature. Adult cases are especially seen in females. Imaging studies are paramount for diagnosis, preoperative strategy and safe surgical excision. CT scans and MRIs can identify various components of these tumors. CONCLUSION: Even though primary retroperitoneal teratomas are quite rare in adults. Preoperative radiology imaging and strategy is critical for performing a safe surgery. The gold standard treatment strategy for this neoplasm is the surgical resection.

Major donor area complication after a mandibular reconstruction with an osseous fibular free flap: pseudo-compartment syndrome.

The popularity of the fibular free flap in mandibular reconstructions is persisting, and major donor area complications rarely occur after fibular free flap operations. Still, we have observed a pseudo-compartment syndrome in a 52-year-old patient on the 12th postoperative day after a mandibular reconstruction with a fibular free flap. When an obstruction in the deep venous system (deep vein thrombosis) was observed in the Doppler ultrasound-guided imaging, the patient has been taken to the operating room for an emergency surgery and the donor area has been completely reopened (in the manner of a fasciotomy). After this procedure, the circulation in the foot appeared to return to normal. The exposed muscles of the patient, who was started on a low-molecular-weight heparin treatment for the deep vein thrombosis, have been closed with skin grafts on the 10th day. No functional loss was observed during the 2-month follow-up period.

Ultrasonographically determined pedicled breast reduction in severe gigantomastia.

BACKGROUND: The free nipple breast reduction method has certain disadvantages, such as nipple hyposensitivity, loss of lactation, and loss of projection. To eliminate these risks, the authors describe a patient-based breast reduction technique in which the major supplier vessels of the nipple-areola complex were determined by color Doppler ultrasonography. Pedicles containing these vessels were designed for reductions. METHODS: Sixteen severe gigantomastia patients with a mean age of 41 years (range, 23 to 60 years) were included in the study. Major nipple-areola complex perforators were determined with 13- to 5-MHz linear probe Doppler ultrasonography before surgery. Pedicles were designed according to the vessel locations, and reductions were performed with superomedial-, superolateral-, or mediolateral-based designs. RESULTS: Different combinations of internal mammary and lateral thoracic artery perforator-based reductions were achieved. None of the patients had areola necrosis. Mean reduction weight was 1795 g (range, 1320 to 2280) per breast. CONCLUSIONS: Instead of using standard markings for severe gigantomastia patients, custom-made and sonographically determined pedicles were used. This technique can be considered as a "guide" for the surgeon during very large breast reductions.

Cesarean scar pregnancy: a rare cause of uterine arteriovenous malformation.

A 38-year-old gravida 4, para 2 woman with a history of two Cesarean sections and one curettage was referred to our hospital, because of painless vaginal bleeding and 6 weeks + 2 days of amenorrhea. The first diagnosis was Cesarean scar pregnancy, managed with methotrexate. Subsequently, an arteriovenous malformation developed, which was diagnosed with color Doppler imaging. The diagnosis was confirmed with angiography. Successful bilateral uterine artery embolization was performed with ethylene vinyl alcohol copolymer (Onyx), n-butyl-2-cyanoacrylate (Histoacryl), and gelfoam.

Focal nodular hyperplasia vs. hemangioma: computed tomography and magnetic resonance imaging findings.

Focal nodular hyperplasia (FNH) and hemangioma are benign and generally asymptomatic hepatic tumors. With distinctive imaging findings on dynamic computed tomography (CT) and magnetic resonance imaging (MRI), differentiation of these benign hepatic tumors from metastases can be made. We described imaging findings of these hepatic lesions in a 57-year-old man who presented with rectal adenocarcinoma for staging.

Cutting-balloon angioplasty in transplant renal artery stenosis as first-line treatment in the early postoperative period.

Percutaneous transluminal angioplasty has been successfully used for the treatment of transplant renal artery stenosis (RAS). Cutting-balloon angioplasty (CBA) is being used as a second option in pressure-resistant stenosis. It is thought that CBA is less traumatic and therefore restenosis occurs less frequently than in conventional angioplasty. This case report describes the unusual use of a cutting balloon in transplant RAS as a first option in the early postoperative period. Long-term follow-up data are also presented.

Final destination of an ingested needle: the liver.

Foreign body ingestion is a common problem in children, but it is also seen among adults. Most foreign bodies pass through the gastrointestinal tract without causing complications. Perforation of the gut by a foreign body, followed by migration of the foreign body to the liver is quite rare. Herein we report a case of inadvertent ingestion of a sewing needle that perforated the duodenum and migrated to the liver. The patient was monitored weekly with abdominal radiographs, but displacement of the needle could not be observed. At follow-up, right upper quadrant pain was noted. Two weeks later, computed tomography revealed that the needle was completely buried into the right lobe of the liver. Ultrasonographic examination successfully showed the extracapsular displacement of the needle. Eventually, laparoscopic removal of the needle was easily performed.

Unusual cause of right ventricular outflow tract compression: mediastinal lipomatosis.

Mediastinal lipomatosis (ML) is a benign condition characterized by the accumulation of mature adipose tissue within the mediastinum. ML is usually associated with Cushing syndrome and obesity. Most patients are asymptomatic, but some have thoracic pain, dyspnea, cough, dysphonia, dysphagia, and supraventricular tachycardia. We report a case of ML compressing the right ventricular outflow tract in a patient with Behçet disease.

Case report: acute pancreatitis caused by postcholecystectomic hemobilia.

BACKGROUND: Hemobilia is a rare cause of upper GI bleeding and the reasons for the majority of the cases are iatrogenic. It is also one of the rarest vascular complication following laparoscopic cholecystectomy but acute pancreatitis due to postcholecystectomic hemobilia as a late complication of cholecystectomy is not yet described. CASE PRESENTATION: We presented the case of a 32-year-old female, admitted to our emergency surgery clinic with hematemesis, jaundice and abdominal pain who had a history of laparoscopic cholecystectomy 4 months ago. Patient was diagnosed as acute pancreatitis and obstructive jaundice caused by postcholecystectomic hemobilia. Afterwards she is successfully treated by ERCP, angiographic identification and embolization of right hepatic artery pseudoaneurysm. CONCLUSIONS: We presented that postcholecystectomic hemobilia may cause acute pancreatitis and acute pancreatitis caused by postcholecystectomic hemobilia should also be included to the rare complications which may occur following cholecystectomy.

Severe spasm of the renal artery after blunt abdominal trauma simulating end-organ infarction.

Traumatic occlusion of the renal artery is a serious injury. Management differs according to the grade of injury. In most circumstances, emergency surgical revascularization or endovascular intervention is required. We describe the case of a child with multiorgan injuries and spasm of the main renal artery after blunt trauma simulating arterial occlusion or end-organ infarction.

Pushable springcoil embolization of pseudoaneurysms caused by gluteal stab injuries.

PURPOSE: To retrospectively review the outcomes of 21 patients with stab wounds to the gluteal region who underwent embolization for pseudoaneurysms causing active bleeding. MATERIALS AND METHODS: Between 1997 and 2007, 3 superior gluteal artery, 2 inferior gluteal artery and 16 deep femoral artery muscular branch pseudoaneurysms detected by digital subtraction angiography were selectively catheterized with diagnostic catheters with hydrophilic coating and embolized with pushable springcoils. 17 of the 21 pseudoaneurysms were located in a distal end of an artery where outflow vessels could not be depicted. The other 4 lesions were side wall injuries which required the placement of coils distal and proximal to the injury site. RESULTS: Embolization was successful in controlling the bleeding in all of the patients. 16 patients required 1 or 2 coils, 4 patients required 3 coils and 1 patient required 5 coils. 2 patients had femoral puncture site hematomas which resolved spontaneously. 2 patients required surgical evacuation of large gluteal hematomas following the embolization because of symptoms second to mass effect. There were no procedure related major complications or mortality. CONCLUSIONS: Our experience demonstrates that pushable coil embolization is a relatively simple, effective and economic method for the embolization of pseudoaneurysms caused by penetrating gluteal injuries. Experimenting with other embolization materials does not seem to be justified.

Acute effects of smoking on coronary flow velocity reserve and ventricular diastolic functions.

Although it is well known that chronic effect of smoking on cardiovascular system, relation between coronary vascular reactivity and ventricular functions after acute smoking has not been well understood. The purpose of this study was to assess the relation between coronary flow velocity reserve and ventricular diastolic functions measured by tissue Doppler imaging after acute smoking. We found that coronary flow velocity and diastolic functions of right ventricle were decreased. Also, there was a correlation between coronary flow velocity reserve and diastolic ratio of the ventricle. Acute smoking may affect diastolic functions of the ventricles, especially right ventricle via changes of coronary flow.