Indocyanine Green Angiography to Prognosticate Healing of Foot Ulcer in Critical Limb Ischemia: A Novel Technique.

BACKGROUND: To predict wound healing in patients with critical limb ischemia (CLI) is an ongoing issue. Current methods such as ankle-brachial index (ABI), color Doppler and transcutaneous oxygen pressure (TCPO2), and computed tomography angiography are lacking in demonstrating regional perfusion. Indocyanine green angiography (ICGA) has the potential to provide regional perfusion information lacking in other methods. This study was conducted to demonstrate successes of revascularization procedure in CLI patients based on ICGA data. METHODS: A total of 47 patients with grade 2 or grade 3 University of Texas Wound Classification System ischemic foot ulcer undergoing lower limb revascularization procedure were included in this study, from July 2014 to May 2016. ICGA with intravenous 0.1 mg/kg of 0.1% indocyanine green dye was performed before and after revascularization procedure. ICGA data maximum unit, blush time, and blush rate were compared between prerevascularization and postrevascularization data, along with ABI and TCPO2. RESULTS: Out of 47 patients (45 males and 2 females), 43 underwent endovascular revascularization and 4 underwent open procedure. Of all, 76.6% of patients were diabetic and 46.8% were hypertensive. Also, 31.9% had coronary artery disease, 21.2% had history of cerebrovascular disease, 23% had chronic kidney disease, and 74.4% were chronic smokers. A total of 37 patients' ulcer healed completely on follow-up with significant improvement (P < 0.05) in preoperative and postoperative ABI, TCPO2, and ICGA data. Ten patients' ulcer did not heal in the follow-up period. In those 10 patients, preoperative and postoperative ABI and TCPO2 improved, but ICGA data were not improved postoperatively (P > 0.05). CONCLUSIONS: ICGA is an evolving tool to quantify regional perfusion in CLI. ICGA parameters provide qualitative real-time visual images of perfusion in area of interest as well as quantitative information of perfusion.

A Rare Entity: Traumatic Thoracic Aortic Injury in a Patient with Aberrant Right Subclavian Artery.

BACKGROUND: Aberrant right subclavian artery is an uncommon entity incidence ranging from 0.5 to 2.5%. Management of thoracic aortic injury in the presence of such anomalies can be a challenge. We present here a case of traumatic aortic injury, which was incidentally found to have an asymptomatic aberrant right subclavian artery. The patient was managed by an endovascular repair of thoracic aortic injury with an endograft and a right carotid to subclavian artery bypass as a hybrid procedure. METHODS: A 40-year male patient was brought to the emergency in shock with an alleged history of road traffic accident an hour back. After initial resuscitation as per advance trauma life support protocol, imaging revealed thoracic aortic injury with aberrant right subclavian artery with multiple rib and bilateral humerus fracture. After primary stabilization of arm fractures, the patient was shifted to a hybrid operation room. As the aortic injury was within 10 mm of the origin of both subclavian arteries, it was decided to cover the origin of both subclavian arteries and land the endograft distal to the left carotid artery origin. Since there was a right dominant vertebral artery on imaging, right carotid to right subclavian artery bypass was done with expanded polytetrafluoroethylene graft to prevent posterior circulatory stroke along with thoracic endovascular aortic repair to seal the thoracic aortic injury. RESULTS: After endovascular repair of thoracic aortic injury, left subclavian artery perfusion was maintained through left vertebral artery; and hence, revascularization of left subclavian artery was deferred. After management of all fractures, the patient was discharged 3 weeks after the date of admission without any complications. At 6 months follow-up, patient was stable and images showed patent bypass graft and sealed aortic injury. CONCLUSIONS: In a trauma setting with multiple injuries, hybrid procedure with a thoracic endograft is associated with low mortality and morbidity; hence, it is the treatment of choice for thoracic aortic injury over open surgical repair. A hybrid suite can be life and time saving in situations which mandate simultaneous endovascular repair along with surgical revascularization when indicated, especially in cases with aberrant aortic arch anatomy.

Vascular complication after sacrospinous ligament fixation with uterine preservation.

AIM OF THE VIDEO: Sacrospinous ligament fixation (SSLF) is a minimally invasive transvaginal procedure for correcting apical prolapse. Amongst perioperative complications, life-threatening hemorrhage has a reported occurrence rate ranging from 0.2 % to 2 %. We present a case of arterial hemorrhage following SSLF and a multispecialty approach to its successful management. METHODS: The video demonstrates the development of an unexpected progressive postoperative hematoma following left-side sacrospinous hysterocolpopexy via the anterior approach, despite minimal intraoperative bleeding. The mechanism of formation of the hematoma could have been laceration of an aberrant vaginal branch of the inferior vesical artery secondary to pulling the anchor which is tied off at the cervix after closure. To treat these patients effectively, it is essential for the surgeon to make a timely diagnosis, and in our patient, embolization of the inferior vesical artery provided a safe and effective treatment for the pelvic hemorrhage that eliminated the need for an invasive surgical intervention. CONCLUSION: Life-threatening bleeding is a rare complication of transvaginal SSLF. Pelvic vessel embolization can provide an effective, minimally invasive alternative to surgical re-exploration.

Double Barrel In Situ Recanalization of Thrombosed Nonretrievable IVC filter.

We report a case of endovascular recanalization of complete thrombotic occlusion of the inferior vena cava (IVC) and bilateral iliac veins using the architectural knowledge of the in situ permanent IVC filter in a 23-year-old male. The infrarenal permanent IVC filter was TRAPEASE permanent vena cava filter (Cordis) placed at an outstation hospital for pulmonary embolism. Being permanent variant of filter, percutaneous removal was not possible. The patient had severe venous claudication and an attempt to recanalize the blocked filter was considered, in view of the age no justifiable indication for a long-term filter. After pharmacomechanical catheter-directed thrombolysis, there was residual focal flow-limiting thrombus within the filter. The design of the Trapease Cordis filter was instrumental in our decision to attempt to recanalize the filter in situ using 2 parallel stents with the filter struts as anchoring pillars in a double-barrel alignment. In similar cases of persistent Trapease filter-related thrombotic occlusion of the IVC, this double barrel in situ recanalization shall be a viable alternative to the well-described technique of crushing the filter and recanalizing it with a single stent.

Renal Doppler indices in sickle cell disease: early radiologic predictors of renovascular changes.

OBJECTIVE: The purpose of our study was to detect changes in renovascular resistance through renal Doppler indexes in young sickle cell disease patients with normal routine urine laboratory tests. CONCLUSION: Renal Doppler sonography resistive index and pulsatility index values can serve as early radiologic predictors of renovascular changes in sickle cell disease. Thereby, these findings can guide clinicians in the use of more intensive monitoring of laboratory values and initiating adequate treatment at an early stage.

Intrapericardial teratoma diagnosed on CT.

Intrapericardial teratomas are rare tumors which usually present in infancy. These tumors may be life-threatening because of the associated large pericardial effusion and cardiac compression. Here we present a case of intrapericardial teratoma which presented with cardiac tamponade in a neonate and was diagnosed using multidetector spiral computed tomography. The imaging features, clinical presentation, and differential diagnosis of this seldom-encountered entity are discussed.

CT urography: a comparison of strategies for upper urinary tract opacification.

A consensus is yet to be reached regarding the best strategy for ensuring maximum ureteric delineation during CT urography (CTU). In this study we have compared various CTU protocols to try to establish the best method for ureteric delineation. Saline infusion in the supine position, saline infusion in the prone position, furosemide administration (10 mg, iv) and buscopan administration (20 mg iv) with saline infusion in the prone position were tried in four groups, each having 15 patients who were undergoing CTU. The pelvicalyceal system and ureter were divided into six segments, to each of which an opacification score was assigned (0, unopacified segment; 1, less than 50% opacified segment; 2, 50-99% of the segment opacified; or 3, completely opacified segment) and the results compared. Furosemide administration resulted in complete opacification of 93% of the ureters (28 of 30). In the distal (below the sciatic notch) ureter, the mean score with furosemide was 2.9, while that with saline, supine and prone positioning was 1.87 and 1.83, respectively, and this difference was highly significant (P = 0.0002 and P = 0.0001). It was also significantly higher than the buscopan group (score 2.3, P = 0.002). Also in the lower (the iliac crest to the sciatic notch) and upper (above the iliac crest) ureter, furosemide had significantly higher scores than saline infusion in either position. Saline infusion in the supine and prone positions had very similar scores in all segments that were less than the buscopan group, but this difference was not statistically significant. During CT urography, furosemide administration in low doses is the most effective and convenient technique for ureteric opacification.

Unusual presentations of midgut volvulus with the whirlpool sign.

OBJECTIVE: The purpose of this series was to emphasize the varied presentations of midgut volvulus from neonatal life to well into adulthood and to evaluate the role of the whirlpool sign on sonography in diagnosing this condition. METHODS: A retrospective search of all midgut volvulus cases diagnosed in the radiology department of a 1500-bed general hospital between February 2002 and July 2005 was done. Eight patients with surgically confirmed midgut volvulus were found, all of whom had undergone sonography as the initial screening investigation. RESULTS: Eight patients, with ages ranging from 9 days to 32 years (mean age, 11.8 years), had undergone sonography for varied conditions, including bilious and nonbilious vomiting, vague abdominal pain, epigastric lumps, weight loss, features mimicking appendicitis, and pancreatitis. In all patients, the diagnosis of midgut volvulus was made on the basis of the clockwise whirlpool sign on sonography. Subsequently, 4 patients underwent upper gastrointestinal series, and contrast-enhanced computed tomography was done in 6 cases. Surgical confirmation of the diagnosis was obtained in all cases. Two patients were taken for surgery on the basis of only sonographic findings. CONCLUSIONS: Midgut volvulus can also appear much beyond the neonatal age group with a variety of clinical presentations, making the clinical diagnosis in such patients very difficult, if not impossible. Identification of the clockwise whirlpool sign on sonography is an accurate way of diagnosing this condition, which can preclude the need for further investigations and can allow prompt surgical intervention.