Orbital arteriovenous fistula with symptoms contralateral to the arterial supply. A case report.

Carotid-cavernous sinus fistulas presenting signs and symptoms contralateral to the arterial supply of the fistulas are not uncommon. We describe a thoroughly documented case of an orbital arteriovenous fistula with symptoms exclusively contralateral to the arterial source, a rarer entity. A carotid angiography performed on a patient who presented a red chemotic and proptotic left eye showed a shunt between the meningeal branches of the right internal carotid artery and a left orbital vein.

Spontaneous dissection of the abdominal aorta.

Spontaneous abdominal aortic dissection is a rare entity, often with a clinically unspecific presentation. The cause of the dissection is unclear. Angiography used to be the definitive diagnostic study, but today a correct diagnosis can be achieved with CT scanning and magnetic resonance angiography. The optimal form of management for the individual patient is not clearly established. Chronic dissections may best be managed conservatively, with close follow-up achieved with CT scanning and magnetic resonance. Acute and complicated dissections should be treated surgically with aortic and aortic branch replacement if it can be offered with low morbidity and mortality. In selected cases, resection of the ischemic organs may represent an alternative.

Uterine artery pseudo-aneurysm: diagnosis and therapy during pregnancy.

Arterial aneurysms and pseudo-aneurysms are a rare but recognized cause of obstetric hemorrhage. Diagnosis during pregnancy, prior to rupture, is exceptional. We report the first case of diagnosis and treatment of an uterine artery pseudo-aneurysm during pregnancy.

Desmin (a low molecular weight dermatan sulphate) versus heparin in the treatment of patients with deep venous thrombosis.

OBJECTIVE: There is theoretical and experimental evidence which indicates that Desmin, a low molecular weight dermatan sulphate, could be an attractive alternative to heparin in the treatment of deep venous thrombosis (DVT). The present study compares both compounds in patients with established DVT. METHODS: Seventeen consecutive patients admitted with DVT were included in a randomised open study comparing continuous intravenous administration of Desmin and continuous intravenous administration of heparin. Clinical, laboratory and imaging parameters were used to assess the efficacy and safety of both treatments. RESULTS: The results of the coagulation tests confirmed the published data on the antithrombotic profile of Desmin. A trend towards better biochemical tolerance was observed with Desmin. Repeated echo duplex examinations of the deep venous system could not document further thrombus extension in any patient. Pre- and post-treatment phlebographic Marder scores showed a non-significant trend towards superior efficacy of Desmin. Overall, the results regarding efficacy and safety were not significantly different in the two groups. CONCLUSION: Desmin can be safely studied as an alternative to conventional anticoagulation in the treatment of DVT.

Intra-arterial thrombolysis followed by elective surgery for thrombo-embolic popliteal aneurysms.

Two patients with acute limb-threatening lower extremity ischaemia as a result of a thrombosed and embolizing popliteal artery aneurysm are described. Both patients were successfully treated with intra-arterial thrombolysis and subsequent elective vascular reconstruction. Thrombolysis might be an effective method to identify the underlying cause of limb ischaemia and to recanalize the run-off vessels leading to better bypass patency rates. However, this management is only indicated in selected cases of acute limb ischaemia without motor or sensory deficit.

Screening for concomitant diseases in peripheral vascular patients. Results of a systematic approach.

BACKGROUND: Patients considered for arterial surgery, have been shown to have a high incidence of coexistent cardiac, vascular and other diseases, affecting operative risk and survival. We developed a systematic workup strategy for detecting these coexistent diseases in our vascular surgical patients, mainly based on non-invasive diagnostic techniques. METHODS: We evaluated 200 consecutive patients, admitted to the department of vascular surgery in an academic teaching hospital, in order to establish the total incidence of relevant concomitant disorders, the extent to which this screening yielded previously unknown diagnostic information, and the impact on short-term (one year) survival. RESULTS: Coronary artery disease was present in 46% of the patients; 22% had active ischaemia, newly diagnosed in 5.5%. Impaired cardiac function was found in 37%: severely impaired in 12%, newly diagnosed in 27%. Carotid artery disease was present in 32%: critical stenoses were found in 9%; new diagnoses in 29.9%. Aortic aneurysms were present in 7%, newly diagnosed in 5%. Severe renal artery stenosis was present in 5%, newly diagnosed in 3.5%. Sixteen % of the patients had chronic obstructive pulmonary disease, newly diagnosed in 3.5%, and 4.5% had unexpected disorders, which were all new diagnoses. Overall, new diagnoses were reached in 64.5% of the population, affecting therapeutic strategy immediately in 21% of the patients. The presence of coronary artery disease and of cardiac failure were clearly related to one year survival. CONCLUSIONS: We conclude that a systematic screening strategy, mainly based on noninvasive techniques, can detect the presence of concomitant diseases in the vascular surgical patient. Most important seem the newly diagnosed diseases altering surgical management in one out of every five patients; they also have important implications for patient prognosis.

Early electrocardiographic signs in acute massive pulmonary embolism.

As a result of the increasing accuracy in diagnosing acute pulmonary embolism by isotopic ventilation-perfusion scintigraphy and pulmonary arterial angiography, the electrocardiographic changes associated with acute cor pulmonale are being abandoned as a diagnostic tool for this life-threatening disease. Nevertheless, certain electrocardiographic findings can raise the suspicion of pulmonary embolism. In our view the electrocardiogram does have some merits in the emergency work-up of a patient with a high suspicion of pulmonary embolism. In this case report we emphasize the importance of the electrocardiographic findings which forwarded the diagnosis of pulmonary embolism. Hence the necessary invasive diagnostic and therapeutic measures, i.e. pulmonary arterial angiography and thrombolytic therapy, can be taken immediately after admission to the emergency department.

[Superselective cerebral embolization of an arteriovenous malformation in the temporal lobe following partial neurosurgical resection]. / Superselectieve cerebrale embolisatie van een arterioveneuze malformatie in de temporale lob na partiële neurochirurgische resectie.

We report a case of cerebral embolization of an arteriovenous malformation in the temporal lobe after partial neurosurgical resection. The lesion consisted of two compartments of which only the lateral part with combined large hematoma was resected. The medial compartment was treated by superselective embolization using a microcatheter and polyvinyl alcohol particles. Because of his psychiatric condition, general anaesthesia was used in this young male.

Transbrachial approach for aortic and selective supraaortic vessel catheterization using a safe and easy technique to reform the Simmons II catheter tip.

A total of 286 patients (158 outpatients) were examined by intra-arterial DSA in the evaluation of cerebrovascular disease using a transbrachial approach. In all cases a 5F introducer sheath, a 5F pigtail catheter for aortic arch injection and a 5F Simmons II catheter for selective catheterization were used. Excellent demonstration of aortic arch and supraaortic arteries (including intracranial circulation) was obtained (92.2-100%). The complication rate was favorable, with only one major complication (thrombosis of an axillary artery). The use of an introducer sheath minimizes local complications and vessel wall damage during catheter exchange. Aortic arch injection must always be performed prior to selective catheterization. The results of selective catheterization prove the suitability of the Simmons II catheter, whose typical shape was easily and safely obtained using the configuration of the pigtail catheter and a 180 cm long guide wire for catheter exchange. Using the technique as described, the transbrachial approach is a safe and easy way for optimal vascular evaluation in cerebrovascular disease, especially useful in outpatients.

CT-assisted chemonucleolysis.

The safety and success rate of chemonucleolysis are largely dependent on correct needle insertion. The neurological complications of chemonucleolysis are related to inadvertent puncture of the dura, nerve root and/or spinal nerve. To avoid this complication, a puncture angle of 50 degrees to 60 degrees above the sagittal plane is widely recommended (1). Our CT study of the location of the spinal nerve L4-L5 and L5-S1 demonstrates a great variability of this location and also explains some of the possible hazards of 50 degrees to 60 degrees puncture (2). The CT-evaluation of the relationship between the nerve root, spinal nerve and apophyseal joint with respect to the puncture angle is suitable. In our experience, this method is helpful for fast, safe and easy insertion of the needle.

Diagnosis of herniated nucleus pulposus by digital spinal phlebography with false negative CT and/or radiculosaccography.

Saccoradiculography, spinal phlebography or NMR can be performed in cases of discrepancy between CT and clinical symptoms. We believe that the introduction of DSA must generate a renewed interest in spinal phlebography for cases with radicular syndrome and normal CT.