Showering gas bubbles within the inferior vena cava detected sonographically can unmask a hidden infection: a case report of a rare presentation in a patient with emphysematous cystitis.

We present a case of incidentally discovered gas bubbles flowing within the inferior vena cava during a routine abdominal sonographic examination, that subsequently unmasked a previously undiagnosed emphysematous cystitis.

Redundant Nerve Roots of the Cauda Equina, MRI Findings and Postoperative Clinical Outcome: Emphasizing an Overlooked Entity.

STUDY DESIGN: Retrospective study. OBJECTIVE: To describe the MRI findings of RNRs in patients with low back pain, and observe the imaging findings and the clinical outcome post decompression surgery. METHODS: The lumbar spine MRI of 202 patients (122 females) with proven RNRs were retrospectively reviewed. The morphology and the location of the RNRs in relation to the level of stenosis were described. The level(s), grade and cause of lumbar canal stenosis were recorded. The persistence of symptoms and the imaging findings on follow up post decompression surgery were recorded. The imaging findings were correlated among each other and with patients' demographics. RESULTS: Two distinctive morphological appearance of the RNRs were noted: loop (56.4%), and serpentine-shaped. In the majority of the cases the RNRs were located above the level of stenosis (79.7%). Eighteen patients underwent decompression surgery, only 4 patients remained symptomatic post decompression surgery. The RNRs changed in shape and location after decompression surgery. Age was a strong predictor value in the location of the RNRs. There was no correlation between the shape and location of the RNRs, or with the gender of the patients. CONCLUSION: RNRs is not an uncommon finding on lumbar spine MRI with lumbar canal stenosis. Its importance remains a controversy. A common language between the radiologists and the clinicians is mandatory to aid in the management planning.

Migrated Inferior Vena Cava (IVC) Filter Strut: A Rare Cause of Chronic Distal Pancreatitis with Likely Malignant Transformation.

BACKGROUND Inferior vena cava (IVC) filters are indicated for patients with recurrent venous thrombosis despite proper anticoagulation or whenever anticoagulation is contraindicated. IVC filter deployment is an invasive procedure with various complications. One example is IVC filter limb fracture and migration, which is associated with significant morbidity and/or mortality. Extravascular migration toward pancreas may induce pancreatitis. Patients with chronic pancreatitis are known to have an increased risk of pancreatic malignancy. CASE REPORT We report an extremely rare case of IVC filter fractured limb in 44-year-old woman, which had migrated into the pancreatic tail and manifested as chronic distal pancreatitis. A pancreatic adenocarcinoma was found by biopsy at the pancreas tail. It is likely that a foreign body promoted this metaplasia and neoplastic transformation. CONCLUSIONS Early detection and retrieval of a displaced foreign body in organs, such as the pancreas, seem to be essential to reduce risk of subsequent complications, including chronic inflammation and possibly neoplasia.

Endovascular management of acute mesenteric ischemia in a young patient with thyrotoxicosis and atrial fibrillation: A case report and review of the literature.

INTRODUCTION: Acute mesenteric ischemia caused by an embolism resulting from atrial fibrillation in a thyrotoxic young male patient is a rare event. Endovascular intervention is increasingly being considered as the primary modality of treatment in selected patients. PRESENTATION OF CASE: A 41-years male known to have hyperthyroidism presented with atrial fibrillation, acute mesenteric ischemia, splenic infarction, and left renal infarction. He was successfully managed with endovascular intervention of the superior mesenteric artery. DISCUSSION: Acute mesenteric ischemia has a high mortality rate. CT angiography is the investigation of choice for diagnosis of the mesenteric vessels occlusion and assessment of bowel ischemia. The clinical presentation guides into the treatment and the choice between open surgery and endovascular intervention as the primary modality of treatment. Thyrotoxicosis is a risky comorbid condition for any procedure to be done, so proper perioperative management is essential to decrease morbidity and mortality. CONCLUSION: Prompt diagnosis and management of acute mesenteric ischemia is essential to decrease the morbidity and mortality rates. Endovascular management can be considered as a primary modality of treatment in selected cases.

Successful reversal of isolated delayed spinal cord ischemia following endovascular abdominal aneurysm repair.

A 74-year-old patient presented with isolated fecal incontinence 6 weeks following endovascular aneurysm repair. The delayed presentation of spinal cord ischemia was precipitated by commencement of alpha-blockers for benign prostatic hyperplasia. This case stresses that vulnerability to spinal cord perfusion is not limited to the perioperative period. In addition, systemic arterial pressure should be closely monitored in cases of marginal vascular insufficiency of the spinal cord.

Endovascular Management of May-Thurner Syndrome in a Patient with Left-Sided Superior Vena Cava: A Case Report.

BACKGROUND May-Thurner syndrome (MTS) is a condition characterized by compression of the left common iliac vein (LCFV) between the right common iliac artery (RCIA) and the lumbar vertebrae. This anatomical entrapment typically affects young women and is mostly asymptomatic. High index of suspicion is required in cases of recurrent left-sided deep vein thrombosis (DVT) and severe leg pain. We describe a case of MTS in a young male patient with a left-sided superior vena cava (LSSVC) that was successfully managed by an endovascular approach. To the best of our knowledge, the coexistence of MTS and LSSVC anomaly has not been reported previously. CASE REPORT A 31-year-old man presented with a history of left-sided iliofemoral deep vein thrombosis and disabling venous claudication of 2 years' duration. Duplex ultrasound and computed tomography venogram (CTV) revealed evidence of MTS with chronic subtotal occlusion of the left common iliac vein (LCIV) with extensive venous collaterals. Venogram via the left femoral vein puncture confirmed the aforementioned findings. Retrograde recanalization of the occluded segment was attempted without success. Therefore, an antegrade approach via the right internal jugular vein was performed to facilitate recanalization. Surprisingly, venography revealed an LSSVC. The occluded CIV was successfully stented and the patient had complete resolution of his symptoms at 22-month follow-up. CONCLUSIONS MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this coincidence is essential to prevent unwarranted mishaps during endovascular management when the jugular approach is used.

Portomesenteric Venous Thrombosis Post-Laparoscopic Sleeve Gastrectomy: Do Energy Systems Pose as Instigating Factor to This Infrequent Complication?

BACKGROUND: Portomesenteric venous thrombosis (PMVT), a rare complication after laparoscopic sleeve gastrectomy (LSG). Severe consequences are owed to a high risk of bowel ischemia. Our aim is to present a series of patients who developed PMVT after LSG, highlighting the potential role of the vessel sealer and divider as a risk factor. METHODS: Medical records of seven patients who underwent LSG and developed PMVT from April 2010 to January 2019, at King Abdullah University Hospital and Jordan University Hospital, Jordan were reviewed. Our findings were studied, audited, and compared with published data. RESULTS: A sum of 4900 patients underwent LSG, 7 (0.14%) developed PMVT. The mean age and body mass index (BMI) were 36.8 years and 45 kg/m2, respectively. Four were women. Epigastric pain radiating to the back was the presenting symptom at a median time of 9 days after surgery. Computed tomography (CT) of the abdomen confirmed the diagnosis. Five patients presented with a total portal vein thrombosis (PVT), one with splenic vein thrombosis and one with dual portal and mesenteric vein thrombosis. CONCLUSION: Portomesenteric venous thrombosis is a relatively uncommon complication following LSG. Early recognition is required to avoid catastrophic outcomes. The role of energy systems in the development of PMVT remains unknown and requires further elaboration.

Risk factors attributed to failure of ultrasound-guided compression for post-cardiac catheterization femoral artery pseudoaneurysms.

BACKGROUND: Femoral pseudoaneurysm is the most important access site complication following cardiac catheterization. Ultrasound-guided compression repair is a safe and effective therapeutic modality with variable failure rates and risk factors. The aim of this study was to investigate which factors were associated with a higher incidence of ultrasound-guided compression repair failure for post-cardiac catheterization femoral pseudoaneurysm. METHODS: Data were retrospectively collected from medical records at King Abdullah University Hospital during the period from January 2011 to December 2016. A total of 42 patients with post-cardiac catheterization femoral pseudoaneurysm had attempted ultrasound-guided compression repair. Data regarding patients, procedure and aneurysm-related factors were evaluated by univariate analysis and multivariate logistic regression. RESULTS: Ultrasound-guided compression repair failed in 31% of the patients. Patients with body mass index of ⩾28 kg/m2, platelet count of ⩽180,000/L, time lag (age of aneurysm) of >48 h following puncture time, aneurysmal neck diameter of ⩾4 mm and communicating tract length of <8 mm were associated with higher rate of ultrasound-guided compression repair failure in the univariate analysis. In the multivariate analysis, time lag (age of aneurysm) > 48 h (odds ratio = 5.7), body mass index ⩾ 28 kg/m2 (odds ratio = 7.8), neck diameter > 4 mm (odds ratio = 14.4) and tract length < 8 mm (odds ratio = 18.6) were significantly associated with ultrasound-guided compression repair failure. CONCLUSION: Ultrasound-guided compression repair for patients with post-cardiac catheterization femoral pseudoaneurysm was successful in 69% of the patients. Risk factors for failed ultrasound-guided compression repair were as follows: delayed ultrasound-guided compression repair of >48 h, body mass index ⩾ 28 kg/m2, wide neck diameter > 4 mm and short aneurysmal communication tract < 8 mm.

Mesenteric panniculitis: comparison of computed tomography findings in patients with and without malignancy.

PURPOSE: The aim was to compare computed tomography (CT) findings between patients with mesenteric panniculitis (MP) with and without known malignancy. PATIENTS AND METHODS: We retrospectively analyzed 116 consecutive patients who were diagnosed with MP on the basis of CT findings and categorized them according to the absence (Group 1: 73 patients) or presence (Group 2: 43 patients) of malignancy. Patient age and sex, diameter, size, mass effect, location, and fat density of the MP mass, presence of a pseudocapsule and/or halo sign, and lymph node status were compared between the two groups. RESULTS: MP tends to be more common in males, and this trend shows statistical significance when combining the findings for both groups (P=0.041). Patients in Group 1 were significantly younger than those in Group 2 (54.29 vs 64.77 years, P=0.001). A well-defined fatty mass at the small bowel root was observed in all patients. The halo sign was present in most cases in both groups. A pseudocapsule was observed in 36 patients (49%) in Group 1 and 29 (67%) in Group 2 (P=0.045). The average craniocaudal diameter of the MP masses on the sagittal view was 11.14 and 12.5 cm in Groups 1 and 2, respectively (P=0.005). The MP fat density was less negative in patients with malignancy (-66 vs -76 HU, P=0.001). Lymph node status was similar in both groups. CONCLUSION: Detailed CT features should be evaluated in patients with MP, as some of these features may indicate an associated malignancy, necessitating further investigation and close follow-up.

Factors Affecting Pregnancy Rate Following Fallopian Tube Recanalization in Women with Proximal Fallopian Tube Obstruction.

Fallopian tube obstruction is a major cause of female infertility. We aimed to evaluate the factors potentially affecting pregnancy rate following fallopian tube recanalization (FTR) in infertile women with proximal fallopian tube obstruction. Data was retrospectively collected for 61 women (25, primary infertility; 36, secondary infertility) who underwent FTR at our institution. Bivariable and multivariable analyses of clinical pregnancy rates in relation to the following factors were performed: primary vs. secondary infertility, duration of infertility, age at the time of FTR, unilateral vs. bilateral obstruction, and previous pelvic interventions. All women who underwent fluoroscopically guided transcervical FTR of one or both proximally obstructed tubes were successfully recanalized (technical success rate, 100%). Within a year after FTR, 41% of women had conceived. None of the studied variables was significantly associated with pregnancy rate on bivariable analysis. Nevertheless, on multivariable analysis, the type and duration of infertility were significantly associated with pregnancy among women aged <35 years at the time of FTR. Our findings regarding pregnancy rates following FTR reflect the diversity of the patient population and suggest the presence of multiple contributing factors. Younger women with secondary infertility for <5 years are highly likely to achieve conception following FTR.

Cystic avascular necrosis of the triquetrum.

Carpal bones are rarely affected by avascular necrosis (AVN) in the absence of fractures. The lunate is the most frequently affected carpal bone, followed by the scaphoid and the capitate. The triquetrum is rarely affected by AVN. We report a case of multiple cystic changes in the triquetrum in a patient with a history of trauma. He was treated by below elbow Colles plaster cast for 3 months, with no improvement. Cystic changes resulted from irreversible AVN of the triquetrum. This is the first case to be reported in the literature with cystic AVN changes in the triquetrum.