High doses of erythropoietin stimulating agents may be a risk factor for AV-fistula stenosis.

BACKGROUND: A native AV-fistula (AVF) for access in hemodialysis (HD) is preferable. Stenosis, a major hurdle, is associated with older age and diabetes mellitus. PURPOSE: This case-control study aimed to clarify if any medical and/or laboratory factors, that can be altered, could be associated to AVF stenosis. METHODS: 33 patients with a patent AVF without need of intervention during a two year period (Controls) were matched by diagnosis and age with 33 patients (Cases), that had at least one radiological invasive examination/intervention due to suspected AVF malfunction (case-control mode 2:1). RESULTS: Cases had higher weekly doses of Erythropoietin-Stimulating Agent (ESA) than Controls both before intervention (mean 8312±7119 U/w versus 4348±3790, p = 0.005) and after the intervention (7656±6795, versus 4477±3895, p = 0.018). Before intervention serum phosphate was higher in Cases while there was no significant difference in blood hemoglobin, weekly standard Kt/V, parathyroid hormone, calcium, albumin, C-reactive protein, smoking habits, BMI or other medication. CONCLUSION: Higher doses of ESA were administered in patients with AVF stenosis. Since ESA may cause local hypertrophic effects on the vascular endothelium, we should prescribe lower doses of ESA in patients at risk. Further studies should clarify such connection.

Clinical outcomes following corticosteroid administration in patients with delayed diagnosis of spinal arteriovenous fistulas.

BACKGROUND AND PURPOSE: There have been several previously reported cases of acute progression of myelopathic symptoms in patients with spinal arteriovenous fistula (SAVF) treated with intravenous methylprednisolone. This usually occurs during or immediately following steroid administration. We examined a small case series of patients with SAVF treated with epidural, oral, or intravenous steroids to determine the association between steroid administration and clinical outcomes in these patients. METHODS: Following Institutional Review Board approval, we conducted a retrospective review of patients with angiographically-confirmed SAVF who received intravenous, oral, or epidural corticosteroids for treatment of their symptoms. We studied patient-reported motor and sensory function following steroid administration using both the modified Rankin Scale and the Aminoff Motor Disability Scale. RESULTS: Twenty-one patients with SAVF were included in this study. Thirteen patients (61.9%) had intravenous methylprednisolone administered, four patients (19.0%) had epidural steroid injections, and six patients (28.6%) had oral prednisone. Among patients who received intravenous methylprednisolone, seven (53.8%) reported acute worsening of symptoms during or immediately following steroid administration. Among the patients receiving epidural steroids, none reported worsening and one patient reported short-term relief. Among the patients receiving oral steroids, one reported acute worsening of symptoms. Worsened deficits did not consistently resolve after steroid discontinuation. CONCLUSIONS: Our study suggests that intravenous methylprednisolone can cause immediate worsening of motor and sensory symptoms when administered to patients with SAVF. Steroid administration should be avoided in patients with a myelopathy secondary to an untreated SAVF because neurological worsening may not be fully reversible.

Fístula arteriovenosa vertebral. Diagnóstico por auscultación / A vertebral arteriovenous fistula diagnosed by auscultation

Las fístulas arteriovenosas (FAV) vertebrales son lesiones raras. La etiología de las FAV vertebrales puede ser traumática o espontánea. Suelen cursar de forma asintomática o refiriendo «ruidos», o palpándose una vibración en la región cervical. El diagnóstico definitivo serealiza mediante arteriografía, siendo la embolización de la fístula el tratamiento de elección. Comentamos el caso de un varón de 2 años en el que la madre aprecia«como una lavadora en la cabeza». Al explorarle se palpa una vibración y se ausculta un soplo continuo en la región cervical izquierda, siendo el resto normal. Con la sospecha clínica de malformación vascular en la región vertebral se solicita una angio-RNM y una posterior arteriografía que confirma el diagnóstico. Las FAV son raras en la infancia. Es necesario sospecharlas ante la presencia de ruidos, palpación o vibración continua en la región cervical. El diagnóstico precoz puede evitar complicaciones

Cervical artery fistulas are rare arteriovenous malformations. The etiology of the vertebral arteriovenous fistulas (AVF) can be traumatic or spontaneous. They tend to be asymptomatic or palpation or continuous vibration in the cervical region. An arteriography is necessary for a definitive diagnosis. The treatment is complete embolization of the fistula. We present the case of a two year-old male, where the mother described it «like a washing machine in his head». On palpation during the physical examination, there was a continuous vibration, and a continuous murmur in left cervical region. A vascular malformation in vertebral region was clinically suspected, and confirmed with angio-MRI and arteriography AVF are rare in childhood. They should be suspected in the presence of noises, palpation or continuous vibration in the cervical region. Early diagnosis can prevent severe complications in asymptomatic children

Fístula arteriovenosa vertebral. Diagnóstico por auscultación / A vertebral arteriovenous fistula diagnosed by auscultation

Las fístulas arteriovenosas (FAV) vertebrales son lesiones raras. La etiología de las FAV vertebrales puede ser traumática o espontánea. Suelen cursar de forma asintomática o refiriendo «ruidos», o palpándose una vibración en la región cervical. El diagnóstico definitivo se realiza mediante arteriografía, siendo la embolización de la fístula el tratamiento de elección. Comentamos el caso de un varón de 2 años en el que la madre aprecia «como una lavadora en la cabeza». Al explorarle se palpa una vibración y se ausculta un soplo continuo en la región cervical izquierda, siendo el resto normal. Con la sospecha clínica de malformación vascular en la región vertebral se solicita una angio-RNM y una posterior arteriografía que confirma el diagnóstico. Las FAV son raras en la infancia. Es necesario sospecharlas ante la presencia de ruidos, palpación o vibración continua en la región cervical. El diagnóstico precoz puede evitar complicaciones

Cervical artery fistulas are rare arteriovenous malformations. The etiology of the vertebral arteriovenous fistulas (AVF) can be traumatic or spontaneous. They tend to be asymptomatic or palpation or continuous vibration in the cervical region. An arteriography is necessary for a definitive diagnosis. The treatment is complete embolization of the fistula. We present the case of a two year-old male, where the mother described it «like a washing machine in his head». On palpation during the physical examination, there was a continuous vibration, and a continuous murmur in left cervical region. A vascular malformation in vertebral region was clinically suspected, and confirmed with angio-MRI and arteriography. AVF are rare in childhood. They should be suspected in the presence of noises, palpation or continuous vibration in the cervical region. Early diagnosis can prevent severe complications in asymptomatic children

Targeted therapy of advanced gallbladder cancer and cholangiocarcinoma with aggressive biology: eliciting early response signals from phase 1 trials.

PURPOSE: Patients with advanced cholangiocarcinoma (CC) and gallbladder carcinoma (GC) have few therapeutic options for relapsed disease. methods: Given the overall poor prognosis in this population and the availability of novel targeted therapies, we systematically analyzed the characteristics and outcomes for GC and CC patients treated on phase I trials with an emphasis on targeted agents and locoregional therapies. RESULTS: Of 40 treated patients (GC=6; CC=34; median age, 60 years), 8 (20%) had stable disease (SD) > 6 months, 3 (8%) partial response (PR), on protocols with hepatic arterial drug infusion and anti-angiogenic, anti-HER-2/neu or novel MAPK/ERK kinase (MEK) inhibitors. Median progression-free survival (PFS) on phase I trials was 2.0 months (95% CI 1.7, 2.8) versus 3.0 months (95% CI 2.4, 5.0), 3.0 months (95% CI 2.3, 4.6), and 3.0 months (95% CI 2.4, 3.9) for their first-, second-, and last-line FDA-approved therapy. In univariate analysis, >3 metastatic sites, elevated alanine aminotransferase (ALT) (>56IU/L), serum creatinine (>1.6mg/dL), and CA19-9 (>35U/mL) were associated with a shorter PFS. Mutational analysis revealed mutation in the KRAS oncogene in 2 of 11 patients (18%). The SD >6 months/PR rate of 28% was seen with hepatic arterial infusion of oxaliplatin, and inhibitors of angiogenesis, HER-2/neu or MEK. CONCLUSIONS: The PFS in phase I trials was similar to that of the first, second, and last-line therapy (P=0.95, 0.98, 0.76, respectively) with FDA-approved agents given in the advanced setting, emphasizing a role for targeted agents in a clinical trials setting as potentially valuable therapeutic options for these patients.

A unique presentation of a spinal dural arteriovenous fistula exacerbated by steroids.

Spinal dural arteriovenous fistula (DAVF) is an acquired vascular malformation of the spinal cord that presents as a congestive myelopathy resulting from venous hypertension, edema, and ischemia within the cord. Acute clinical exacerbations have been demonstrated in a variety of clinical settings. We report a unique presentation of a 45-year-old male with progressive paraplegia that acutely worsened following three independent treatments with oral and intravenous steroid administration. Spinal angiogram revealed a spinal DAVF at L3 and the patient underwent successful surgical repair. This report highlights the clinical presentation of spinal DAVF and emphasizes the unique and important potential relationship between steroid administration and clinical deterioration.

Creation of large elastase-induced aneurysms: presurgical arterial remodeling using arteriovenous fistulas.

BACKGROUND AND PURPOSE: The size of elastase-induced aneurysms created in the usual way is relatively small. Our aim was to determine whether creation of a carotid-jugular AVF to induce remodeling of the RCCA results in larger elastase-induced aneurysms in rabbits. MATERIALS AND METHODS: RCCA right-jugular AVFs were created in 6 New Zealand white rabbits (group 1), followed by elastase-induced aneurysm creation 4 weeks later. Follow-up DSA was performed to assess AVF patency and aneurysm sizes. Six other elastase-induced aneurysms created in the usual way were used as controls (group 2). The diameters of the RCCA and LCCA in group 1 and aneurysm sizes in both groups were measured from DSA images and compared by using the Student t test. RESULTS: The patency of AVFs in group 1 was confirmed in all 6 (100%) cases. The mean RCCA diameter in group 1 was larger than that in the contralateral LCCA (3.6 ± 0.7 mm versus 2.0 ± 0.1 mm, range, 1.8-2.2 mm, P < .01). The mean aneurysm neck diameter, width, and height for group 1 was larger than those of group 2 (4.6 ± 0.9 mm versus 3.5 ± 0.7 mm, P < .05; 4.7 ± 1.1 mm versus 3.4 ± 0.5 mm, P < .05; 13.8 ± 3.2 mm versus 8.1 ± 1.3 mm, P < .05, respectively). Aneurysm volume for group 1 was significantly larger than that of group 2 (273 ± 172 mm³ versus 77 ± 32 mm³, P < .05). CONCLUSIONS: Carotid-jugular AVFs result in RCCA remodeling that yields relatively larger elastase-induced aneurysms.

Sodium nitroprusside compared with isoflurane-induced hypotension: the effects on brain oxygenation and arteriovenous shunting.

UNLABELLED: We compared sodium nitroprusside (SNP)-induced hypotension with 3% isoflurane-induced hypotension with regard to brain tissue oxygen pressure (PtO(2)), middle cerebral artery (MCA) blood flow, and cerebral arteriovenous shunting. Eight dogs were anesthetized with 1.5% isoflurane. After a craniotomy, a probe was inserted into the left frontoparietal brain cortex to mea-sure tissue gases and pH. Blood flow was measured in a secondary branch of the MCA by a flowprobe. Measurements were made during baseline 1.5% isoflurane, during 1.5% isoflurane and SNP-induced hypotension or 3% isoflurane-induced hypotension to a mean pressure of 60-65 mm Hg, and during continued treatment with SNP or 3% isoflurane with blood pressure support to baseline levels with phenylephrine. Shunting was calculated from arterial, sagittal sinus, and tissue (indicating capillary) oxygen content. During hypotension with SNP, PtO(2) decreased 50%, and shunting increased 50%. During hypotension with 3% isoflurane, PtO(2) and shunting did not change. Blood pressure support increased PtO(2) and MCA flow during both SNP and 3% isoflurane treatment. These results show that SNP is a cerebrovasodilator but that hypotension will decrease PtO(2), probably because of an increase in arteriovenous shunting and a decrease in capillary perfusion. IMPLICATIONS: We measured brain arteriovenous shunting and tissue oxygen pressure(PtO(2))during a 40% decrease in blood pressure induced by sodium nitroprusside (SNP)or 3% isoflurane. Large-dose isoflurane maintainedPtO(2) with no change in shunting. SNP infusion decreasedPtO(2) 50%and increased shunting 50%. This suggests that SNP-induced hypotension decreases PtO(2) because of a decrease in capillary perfusion.

Arteriovenous fistula induced by a peribulbar nerve block.

Arteriovenous fistula (AVF) of the head and neck region is an uncommon clinical condition that can be of congenital or acquired etiology. We report a case of AVF of the left supraorbital vessels that developed after a peribulbar nerve block was given for cataract surgery.

Hepatic vascular side effects of styrene maleic acid neocarzinostatin in the treatment of hepatocellular carcinoma.

Styrene-maleic acid neocarzinostatin (SMANCS) sometimes causes hepatic vascular side effects, including arterial stricture, obstruction, and arterio-portal shunt. A total of 128 intra-arterial SMANCS injection treatments, performed for 89 patients with hepatocellular carcinoma, were analyzed to determine the relationship between angiographic findings and subsequent hepatic vascular injuries. After SMANCS therapy, hepatic arterial stricture or obstruction occurred in 5 patients (5/128; 3.9%), arterio-portal shunting in 12 (12/128; 9.4%), liver shrinkage in 4 (4/128; 3.1%), and cholangitis or biloma in 2 (2/128; 1.6%). Among 23 patients whose plain abdominal X-ray films just after SMANCS injection showed Lipiodol retention in the hepatic artery, 5 patients developed arterial obstruction, 10 developed arterio-portal shunt, and 2, cholangitis or biloma. Among 26 patients with Lipiodol retention in the portal vein, 4 developed hepatic lobe atrophy with aggravation of liver function. Among 3 patients with Lipiodol retention in both the hepatic artery and the portal vein, 1 developed arterio-portal shunt. In 76 treatments without excessive Lipiodol retention, only 1 of the patients developed arterio-portal shunt. Excessive retention of Lipiodol in hepatic vascular beds just after SMANCS therapy was significantly associated with future vascular side effects (22/52 vs 1/76; P < 0.0001). Lipiodol retention in arteries just after SMANCS injection was closely associated with subsequent arterial obstruction or arterio-portal shunt, and Lipiodol retention in the portal vein was related to subsequent hepatic lobe atrophy.

Dynamic MR follow-up of small hepatocellular carcinoma after percutaneous ethanol injection therapy.

For patients with small hepatocellular carcinomas (HCCs) treated by percutaneous ethanol injection (PEI) therapy, dynamic MRI has been performed to evaluate the therapeutic efficacy at our institute. In this pictorial essay, we illustrate the various dynamic MR findings of HCCs after PEI therapy, including complete necrosis, partial necrosis, local recurrence, and pathologic conditions such as arterioportal shunt and contractive changes of hepatic parenchyma. We also present the limitation of dynamic MRI in the evaluation of therapeutic effectiveness of PEI therapy.

Dural arteriovenous fistula caused by jugular vein stenosis--case report.

A 32-year-old female presented with a dural arteriovenous fistula in the transverse-sigmoid sinus caused by stenosis of the left internal jugular vein. The feeding arteries were embolized, resulting in nearly complete disappearance of the fistula. This case supports the idea that dural arteriovenous fistula is an acquired lesion caused by intravenous hypertension.