D-dimer testing in the diagnosis of transfemoral pseudoaneurysm after percutaneous transluminal procedures.

OBJECTIVE: Pseudoaneurysms are characterized by extravascular circulation and therefore may lead to an activation of the coagulation cascade. We investigated d-dimer levels in patients with and without postcatheterization femoral pseudoaneurysms and hypothesized that d-dimer levels correlate with the presence of pseudoaneurysms at the vascular access site. METHODS: Patients with clinical suspected groin pseudoaneurysms after transluminal procedures were eligible. We compared prospectively-collected laboratory values of quantitative d-dimer testing in patients with and without pseudoaneurysms as assessed by color-coded duplex sonography. Furthermore, we measured the peak systolic velocity at the arterial fistula of each pseudoaneurysm. RESULTS: In 48 (40%) of 120 consecutive patients, a pseudoaneurysm was found. The level of d-dimer values was significantly higher in patients with postcatheterization femoral pseudoaneurysms compared with controls (1.9 microg/mL [interquartile range (IQR), 1.34-2.78 microg/mL] vs 0.8 microg/mL [IQR, 0.53-1.14 microg/mL]; P < .001). Values of d-dimer below 0.67 microg/mL have been calculated with a sensitivity of 94% (87%-100%), a specificity of 38% (27%-50%), a positive predictive value of 50% (40%-60%), a negative predictive value of 90% (82%-99%), and a likelihood ratio of 1.52 (1.25-1.85) with regard to the presence of pseudoaneurysms. We also found a significant correlation of the peak systolic velocity at the arterial fistula and increasing d-dimer levels (r = 0.98, P < .0001). CONCLUSION: We found a significantly higher level of d-dimer values in patients with femoral pseudoaneurysms at the vascular access site. Therefore, d-dimer levels could be a potential serological marker in the diagnosis of pseudoaneurysms. A confirmation is warranted in a larger patient sample.

Coronary artery fistula associated with Kawasaki disease.

BACKGROUND: The aim of this study was to investigate the rate, risks factors, and clinical impact of coronary artery fistula (CAF) in Kawasaki disease (KD). METHODS: From February 1999 to December 2007, a total of 325 pediatric patients fulfilled the diagnostic criteria of KD and admitted for intravenous immunoglobulin treatment were enrolled in this study. Patients with and without CAF were designated as group 1 and group 2, respectively. Patients of group 1 were further subdivided as with and without coronary artery lesions (CALs). The clinical presentations, laboratory data, and outcomes were compared among the groups. RESULTS: The mean age of the 325 patients was 21.1 months. Group 1 had 17 patients, and group 2 had 308 patients. The rate of CAF in KD was 5.3%. There were significant differences between group 1 and group 2 patients regarding age (11.8 +/- 1.8 vs 21.5 +/- 1.2 months, P = .01), the presence of CAL (64.7% vs 25%, P < .01), white blood cell counts (16.4 +/- 1.3 vs 13.5 +/- 0.3 x 10(3)/mm(3), P = .01), and platelet counts (432.1 +/- 39.1 vs 346.4 +/- 8.4 x 10(3)/mm(3), P = .02). Spontaneous closure of CAF was observed in 7 (41%) of the 17 patients during follow-up (mean 45 months). Group 1 patients without CAL had a more benign clinical course (total fever day 5.8 +/- 0.6 vs 8.6 +/- 0.8, P = .03) and higher spontaneous closure rate (5/6 vs 2/11, P = .035) than patients with CAL. CONCLUSIONS: Patients of young age, CAL, high white blood cell counts, and high platelet counts have higher rate of CAF formation. Approximately 5% KD patients may associate with CAF, but most of them have good clinical outcome during follow-up.

Bilhemia: a fatal complication following percutaneous placement of a transhepatic inferior vena cava catheter in a child.

A transhepatic central venous catheter was implanted in a 2-year-old child with a history of multiple venous access procedures and superior and inferior vena cava thrombosis. After 2 weeks, inadvertent dislodgement of the catheter was complicated by a biloma. The biloma was percutaneously drained, but a biliary-venous fistula led to a rapidly progressive and fatal bilhemia. We report this case as an infrequent complication of transhepatic catheterization.

[Endoscopic diagnosis and treatment of non-traumatic bilhemia. A case report]. / Diagnóstico endoscópico y tratamiento de bilhemia de origen no traumática. Reporte de un caso.

Biliovascular fistulas are abnormal communications with two types of clinical manifestations depending on type of flow in fistulous tract: 1) hemorrhage into biliary tract known as hemobilia, or 2) bile into bloodstream, known as bilhemia. Historically, this complication has been treated with surgery; however, technological progress at present allows treatment with intervention techniques without surgery being mandatory. In 1975, Clemens and Wittrin introduced the term bilhemia, a rare complication of hepatic damage producing excessively high levels of serum bilirubin and moderate rise of hepatic enzymes secondary to post-traumatic intrahepatic biliovenous fistula. Although this pathology is rare, it is considered dangerous; of 50 patients reported in the literature, 25 died due to this problem. The main purpose of treatment is to release tract obstruction by endoscopic sphincterotomy of Vater's papilla or, if the process is localized in proximal areas of biliary tract, through percutaneous biliary drainage or preferably nasobiliary drainage with continuous suction. This procedure can at least produce temporary relief and occasionally fistula closure. A longer effect can be achieved with biliary stent placement. We describe what is, to our knowledge, the first case of diagnosis and successful treatment of non-traumatic bilhemia with endoscopic sphincterotomy and nasobiliary catheter placement.

Myxedema accompanied by huge portal-systemic shunt without portal hypertension.

A 43-year-old woman with a huge portal-systemic shunt accompanied by myxedema showed slow speech and behavior. Several imaging studies revealed a bold portal-systemic shunt from the splenic vein to the left renal vein. In addition, hypothyroidism caused by chronic thyroiditis was diagnosed, and synthesized thyroxine replacement was effective for the symptoms. However, the serum ammonia and indocyanin green retention remained in the abnormal range, nevertheless the portal vein pressure was normal and findings of liver cirrohsis were not recognized histologically. Surgical shunt closure was performed, resulting in normalized serum ammonia levels and serum branched chain amino acids /aromatic amino acids ratio, and improvement of the ammonia tolerance test.

Mass screening of Irish wolfhound puppies for portosystemic shunts by the dynamic bile acid test.

Five hundred and sixty-six Irish wolfhound puppies aged six to 15 weeks were tested for congenital portosystemic shunts by the dynamic bile acid method. Plasma ammonia concentration was also measured in 165 of the puppies both fasting and postprandially. Nineteen puppies (3.4 per cent), nine males and 10 females, had portosystemic shunts. Smaller litters appeared to be more likely to contain affected puppies. The postprandial bile acid concentration was a reliable predictor of the presence of a shunt, with the highest concentration in a normal puppy being 38 mumol/litre and the lowest in an affected puppy being 43 mumol/litre. In contrast, fasting bile acid concentrations were normal in the majority of the affected puppies. There was considerable overlap in fasting plasma ammonia concentrations between normal and affected puppies (26 puppies, 15.8 per cent of those tested). Postprandial ammonia concentration appeared to give better separation between the two groups, apart from two individuals which produced bizarre results. It was concluded that the postprandial or dynamic bile acid test is an appropriate test for the mass screening of Irish wolfhound puppies for portosystemic shunts, and guidelines are proposed for the interpretation and follow-up of the test.

Jugular venous oxygen monitoring: a helpful technique in the early diagnosis of a traumatic carotid-cavernous sinus fistula.

This report describes the early diagnosis of a right traumatic carotid-cavernous sinus fistula (CCSF) in a patient with head injury manifested as an acute increase in right jugular venous oxygen saturation and with no ophthalmic clinical signs. High values of jugular venous oxygen saturation must be cautiously interpreted with the clinical examination and computed tomographic findings to establish an accurate diagnosis of hyperemia with or without a CCSF.