Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report.

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Retinal structural and microvascular deterioration independent of optic neuritis in aquaporin-4 antibody-positive neuromyelitis optica spectrum disorders: An optical coherence tomography angiography study.

PURPOSE: To assess the retinal structural and microvascular change in aquaporin-4 antibody (AQP4) positive neuromyelitis optica spectrum disorder (NMOSD) patients and the correlation with clinical features. METHODS: A cross-sectional study was performed with optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) to measure retinal structure and microvascular parameters in AQP4 positive NMOSD patients. RESULTS: Sixty-two NMOSD patients (44 eyes with ON, NMOSD+ON; 77 eyes without ON, NMOSD-ON) and 62 healthy controls (HC, 124 eyes) were included. BCVA was worse in NMOSD patients compared to HC (p<0.001). Peripapillary retinal nerve fiber layer (pRNFL, p<0.001) and ganglion cell complex (GCC, p<0.001) was thinner in NMOSD+ON eyes compared to NMOSD-ON eyes and HC. Compared to HC, pRNFL (p = 0.002) and GCC (p = 0.001) was thinner in NMOSD-ON eyes. The vessel density (VD) in superficial capillary plexus (SCP, NMOSD+ON vs HC p<0.001, NMOSD-ON vs HC p = 0.002) and radial peripapillary capillary (RPC, NMOSD+ON vs HC p<0.001, NMOSD-ON vs HC p = 0.001) were also lower in NMOSD patients than HC independent of the history of ON. ON frequency and BCVA were correlated with the thickness of pRNFL and GCC, and VD in SCP and RPC (all p<0.001). EDSS was correlated with thickness of GCC (p = 0.008), and VD in SCP (p = 0.013), DCP (p<0.001) and RPC (p = 0.009). CONCLUSIONS: Subclinical degradation of retinal structure and microvasculature was found in NMOSD patients before the occurrence of ON, and was correlated with clinical disability. Retinal parameter might be a tool to estimate the disease progression and investigate the pathogenesis of NMOSD.

Association between cervical fracture patterns and blunt cerebrovascular injury when screened with computed tomographic angiography.

BACKGROUND CONTEXT: Prior studies have demonstrated a close association between cervical spine fractures and blunt cerebrovascular injuries (BCVI). Undiagnosed BCVI is a feared complication because of the potentially catastrophic outcomes in a missed posterior circulation stroke. Computed tomography angiography (CTA) is commonly used to screen BCVI in the trauma setting. However, determining which cervical fracture patterns mandate screening is still not clearly known. PURPOSE: The aim of this retrospective review is to further elucidate which fracture patterns are associated with BCVI when using CTA and may mandate screening. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: All patients that presented to our trauma and emergency departments with a blunt cervical spine fracture from January 2018 to December 2021. Inclusion criteria included blunt cervical trauma and the use of CTA for BCVI screening. Exclusion criteria included patients under the age of 18, penetrating cervical trauma, and use any imaging modality besides CTA for BCVI screening. OUTCOME MEASURES: Patient demographics (age, gender, Glasgow coma scale, hospital length of stay (LOS), intensive care unit LOS, mechanism of energy of injury, polytrauma status), fracture location, fracture pattern (anterior arch, dens, dislocations/subluxations, facet, hangman, Jefferson, lamina, lateral mass, occipital condyle dissociation, occipital condyle, pedicle, posterior arch, spinous process, transverse process, transverse foramen, and vertebral body), and whether the patient sustained a BCVI or CVA. METHODS: If a patient had multiple fracture levels or fracture patterns, each level and pattern was counted as a separate BCVI. Multilevel fractures were defined as any patient with fractures at two distinct cervical levels. Differences between the patients who had a BCVI and those who did not were analyzed using independent sample t-tests for continuous variables and the chi-square or Fisher exact test for categorical variables. Odds ratios and 95% confidence intervals were calculated to assess likelihood between patient characteristics/fracture characteristics and BCVI. RESULTS: A total of 690 patients were identified as having a blunt cervical spine injury. A total of 453 patients (66%) underwent screening for BCVI with CTA. Among patients who underwent CTA, BCVI was diagnosed in 138 patients (30%), VAI in 119 patients (26%), CAI in 30 patients (7%), and 11 patients were diagnosed with both a VAI and CAI (2%). Overall, among all patients there were 9 strokes, all in patients identified with a BCVI (1%). No individual cervical level was associated with increased risk of BCVI, but when combined, OC-C3 fractures were associated with an increased risk (OR: 1.4, 95% CI: 1.0-1.9, p-value: .006). Multilevel fractures were also associated with an increased risk (OR: 1.7, 95% CI: 1.1-2.3, p-value: .01). The only fracture pattern associated with increased risk of BCVI were fractures associated with a dislocation/subluxation (OR: 3.8, 95% CI: 1.9-7.8, p-value = .0001). CONCLUSIONS: The only fracture pattern associated with an increased risk of BCVI were fractures associated with dislocation/subluxation. The only fracture levels associated with BCVI were combined OC-C3 and multilevel fractures. We recommend that any upper cervical fracture (OC-C3), multilevel fracture, or fracture with dislocation/subluxation undergo screening for BCVI.

Traumatic vertebral artery injury: Denver grade, bilaterality, and stroke risk. A systematic review and meta-analysis.

OBJECTIVE: Vertebral artery injury (VAI), a complication of blunt trauma, may cause posterior circulation stroke. An association of disease severity, classified in Denver grades, with stroke risk has not been shown. Using a literature-based analysis, the authors estimated the incidence of VAI following blunt trauma with the aim to investigate the impact of Denver grade and bilateral VAI on stroke occurrence. METHODS: A systematic review of the literature on VAI following blunt trauma was conducted, and data on its incidence, the severity per Denver grade, and stroke occurrence were collected. The incidence of VAI and stroke occurrence were analyzed cumulatively and between Denver grades. A meta-analysis with random-effects models was performed. RESULTS: Fifty-six studies including 2563 patients were identified. The overall incidence of VAI was 0.49% among blunt trauma cases and 14.5% among patients screened via any type of angiography. The incidence rates of bilateral VAI and concurrent carotid injury among all VAIs were 12.3% and 19.2%, respectively. VAI severity by Denver grade was as follows: grade I, 23.4%; grade II, 28.2%; grade III, 5.8%; grade IV, 42.1%; and grade V, 0.5%. The overall stroke risk was 5.32%, differing significantly among lesions of different Denver grades (p = 0.02). Grade III and IV lesions had the highest stroke prevalence (9.8% and 10.9% respectively), while strokes occurred significantly less frequently in patients with grade I and II lesions (1.9% and 3.0%, respectively). Denver grade V cases were too rare for meaningful analysis. Bilateral VAI was associated with a 33.2% stroke prevalence. The association between Denver grade and stroke occurrence persisted in a sensitivity subanalysis including only unilateral cases (p = 0.03). CONCLUSIONS: VAI complicates a small yet nontrivial fraction of blunt trauma cases, with Denver grade IV lesions being the most common. This is the first study to document a significantly higher stroke prevalence among grade III and IV VAIs compared with grade I and II VAIs independently from bilaterality. Bilateral VAIs carry a significantly higher stroke rate.

Venous air emboli during esophagoscopy confirmed by computed tomographic pulmonary angiography -a case report.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is vital for the diagnosis and treatment of various gastrointestinal conditions but carries a low risk of venous air embolism (VAE). We report a case of VAE during EGD, confirmed by computed tomographic pulmonary angiography (CTPA). CASE: A 56-year-old male with a history of hypopharyngeal cancer underwent EGD for dysphagia-related esophageal dilation. Signs of VAE were noted, prompting swift interventions, including oxygen therapy, positional changes, and CTPA. CTPA revealed the Mercedes-Benz sign, pneumomediastinum, and a minimal pneumothorax. The patient's oxygen saturation improved within 30 min before undergoing CTPA, and he was discharged on postoperative day 4. CONCLUSIONS: Timely recognition of VAE, resulting in appropriate interventions supported by CTPA, resulted in favorable patient outcomes.

Current status of indocyanine green fluorescent angiography in assessing perfusion of gastric conduit and oesophago-gastric anastomosis.

Anastomotic leak (AL) remains a significant complication after esophagectomy. Indocyanine green fluorescent angiography (ICG-FA) is a promising and safe technique for assessing gastric conduit (GC) perfusion intraoperatively. It provides detailed visualization of tissue perfusion and has demonstrated usefulness in oesophageal surgery. GC perfusion analysis by ICG-FA is crucial in constructing the conduit and selecting the anastomotic site and enables surgeons to make necessary adjustments during surgery to potentially reduce ALs. However, anastomotic integrity involves multiple factors, and ICG-FA must be combined with optimization of patient and procedural factors to decrease AL rates. This review summarizes ICG-FA's current applications in assessing esophago-gastric anastomosis perfusion, including qualitative and quantitative analysis and different imaging systems. It also explores how fluorescent imaging could decrease ALs and aid clinicians in utilizing ICG-FA to improve esophagectomy outcomes.

Evaluation of the Relationship Between Radial Artery Intima Media Thickness and Complications at the Intervention Site After Radial Angiography.

The present study investigated the relationship between pre-procedural radial intima-media thickness (rIMT) and radial artery thrombosis (RAO) in patients undergoing angiography using a transradial approach (TRA). Patients (n = 90) who underwent cerebral or peripheral arterial angiography using TRA were included in the study. Ultrasonographic evaluation was performed before and 12 h after the procedure. Preoperative rIMT measurement was performed at the distal radial artery. Presence of radial artery occlusion was evaluated by ultrasonography after radial catheterization and revealed occlusive thrombus in the radial artery in 13 patients. rIMT was found to be statistically significantly higher in patients with thrombus (P < .05). When it was evaluated whether there was a correlation between age and rIMT, a positive significant correlation was found (P < .01). Our study suggests that increase of rIMT may be a risk factor for RAO in the intervention area. Before the procedure, ultrasound (US) assessment of the radial artery may be useful in determining the risk of occlusion. Thus, RAO-related technical risk factors (procedure time, number of punctures, sheath thickness, etc.) can be managed more carefully in patients having radial angiography.

[Perioperative Management of Deep Vein Thrombosis and Treatment of Pulmonary Embolism].

Preoperative evaluation of deep vein thrombosis( DVT), which is a known risk factor for the development of pulmonary embolism( PE), is important prior to performing thoracic surgery. The incidence of DVT after thoracic surgery is estimated to be 4% and the incidence of PE 0.6%. Lung cancer may be responsible for the highest incidence of thrombotic events associated with cancer. Longer operative time, intraoperative bleeding, extended surgical injury, pneumonectomy, and incomplete resection are all correlated to higher chance of acute PE after thoracic surgery. Risk-assessment models for DVT or PE can be utilized in thoracic surgery, and prophylaxis pre and post operation is highly recommended. Estimation of D-dimer levels is a valid preoperative screening strategy to evaluate the risk of DVT, and ultrasonographic examination should be performed in patients whose D-dimer levels are more than 1.0 µg/ ml. Computed tomographic pulmonary angiography is the gold standard in diagnosis of acute PE. Postoperative PE needs to be diagnosed and treated promptly as delay may be fatal. Anticoagulants and thrombolytic therapy have shown a great success in treatment of acute PE. Surgical approach for acute PE has also shown to be a lifesaving in some cases, and percutaneous cardiopulmonary support may be useful for patients with circulatory collapse or cardiopulmonary arrest.

Clinical-radiological-pathological correlation in chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially life-threatening complication of acute pulmonary embolism. It is characterised by persistent fibro-thrombotic pulmonary vascular obstructions and elevated pulmonary artery pressure leading to right heart failure. The diagnosis is based on two steps, as follows: 1) suspicion based on symptoms, echocardiography and ventilation/perfusion scan and 2) confirmation with right heart catheterisation, computed tomography pulmonary angiography and, in most cases, digital subtraction angiography. The management of CTEPH requires a multimodal approach, involving medical therapy, interventional procedures and surgical intervention. This clinical-radiological-pathological correlation paper illustrates the diagnostic and therapeutic management of two patients. The first had chronic thromboembolic pulmonary disease without pulmonary hypertension at rest but with significant physical limitation and was successfully treated with pulmonary endarterectomy. The second patient had CTEPH associated with splenectomy and was considered unsuitable for surgery because of exclusive subsegmental lesions combined with severe pulmonary hypertension. The patient benefited from multimodal treatment involving medical therapy followed by multiple sessions of balloon pulmonary angioplasty. Both patients had normalised functional capacity and pulmonary haemodynamics 3-6 months after the interventional treatment. These two examples show that chronic thromboembolic pulmonary diseases are curable if diagnosed promptly and referred to CTEPH centres for specialist treatment.

Unusual Case of Pulmonary Hypertension due to Acquired Arteriovenous Fistula.

Pulmonary hypertension is a disease process affecting pulmonary circulation and is defined by an increase in pulmonary artery pressure subsequently causing right ventricular failure. Vascular complications, including arteriovenous (AV) fistula, are recognized, but are uncommon complications of spinal surgery. AV fistula increases venous return to the right heart and can promote a volume overload related high-output cardiac state, pulmonary hypertension, and right heart failure. Hereby, we describe a rare pulmonary hypertension case with severe right heart failure, lower leg edema, and progressive dyspnea caused by an AV fistula between the left common iliac artery and vein as a complication of a lumbar spinal/disk surgery. Pulmonary hypertension was confirmed by hemodynamic assessments and the etiology was established by both abdominal computed tomography and conventional peripheric angiography. After closure of the AV-fistula by stent-graft implantation, the right heart failure resolved completely.

Diagnostic Yield, Radiation Exposure, and the Role of Clinical Decision Rules to Limit Computed Tomographic Pulmonary Angiography-Associated Complications.

OBJECTIVES: Computed tomographic pulmonary angiography (CT-PA) is associated with significant cost, contrast, and radiation exposure. Clinical decision rules (CDRs) reduce the need for diagnostic imaging; however, their utility in the medical intensive care unit (MICU) remains unknown. We explored the diagnostic yield and complications associated with CT-PA (radiation exposure and contrast-induced acute kidney injury [AKI]) while investigating the efficacy of CDRs to reduce unnecessary testing. METHODS: All CT-PAs performed in an academic MICU for 4 years were retrospectively reviewed. The Wells and revised Geneva scores (CDRs) and radiation dose per CT-PA were calculated, and the incidence of post-CT-PA AKI was recorded. RESULTS: A total of 439 studies were analyzed; the diagnostic yield was 11% (48 PEs). Positive CT-PAs were associated with a higher Wells score (5.8 versus 3.2, P < 0.001), but similar revised Geneva scores (6.4 versus 6.0, P = 0.32). A Wells score of ≥4 had a positive likelihood ratio of 2.1 with a negative predictive value of 98.2. More than half (88.9%) of patients with a Wells score of ≤4 developed an AKI, with 55.6% of those having recovery of renal function. CONCLUSIONS: There is overutilization of CT-PA in the MICU. The Wells score retains its negative predictive value in critically ill adult patients and may aid to limit radiation exposure and contrast-induced AKI in MICU.

The Nightmare of Aneurysm Surgery: Intraoperative Rupture.

Intraoperative rupture is the most important complication of aneurysm surgery1-5 and occurs in 3 different stages: premature (before dissection), dissection, and clipping.5 We present a video of premature rupture and its management (Video 1). A 45-year-old patient presented with subarachnoid hemorrhage originating from a dorsal internal carotid artery (ICA) aneurysm of the communicating segment. Due to our sufficient experience, we preferred direct clipping in this case. The Sylvian fissure could only be partially opened due to excessive adhesions. During retraction of the frontal lobe, severe bleeding occurred. This was a premature rupture since neither the aneurysm nor the ICA had yet been seen. While aspirating the bleeding just over the rupture site with the left hand, the ICA was explored with the right hand and a temporary clip was placed. The bleeding continued, though it decreased. The aneurysm dome was rapidly explored with 1 hand, and a pilot clip was placed on the dome to stop the bleeding. Immediately afterwards, the aneurysm neck was dissected and clipped parallel to the ICA with a sideward clip. The temporary clip and pilot clip were removed. The temporary occlusion time was 7 minutes and 40 seconds. Postoperative angiogram confirmed complete aneurysm occlusion. The patient discharged with normal neurologic examination. In the literature review including 10,540 cases,1 the mean incidence of IOR is 16.6%. Therefore every neurosurgeon should be prepared for this important complication and know its management well. This case reminds us once again the golden rule of aneurysm surgery: proximal control first.

[Endovascular embolization hemoptysis in a patient with coronary artery as non-bronchial systemic artery: a case report].

The coronary artery as a responsible vessel for hemoptysis is very rare. This patient was admitted to the hospital with bronchiectasis and hemoptysis, and the right coronary artery was found to be one of the non-bronchial systemic arteries by computed tomography angiography, and the hemoptysis stopped immediately after successful embolization of all bronchial arteries and non-bronchial systemic arteries by bronchial artery embolization. However, the patient had a recurrence of a small amount of hemoptysis 1 month and 3 months after surgery. The patient underwent lobectomy of the lesion after multidisciplinary discussion and did not have any hemoptysis after surgery.

Effect of computed tomography angiography prior to bronchial embolization on radiation dose and recurrent hemoptysis.

PURPOSE: To investigate whether pre-procedure Computed Tomography Angiography (CTA) improves radiation exposure, procedure complexity, and symptom recurrence after bronchial embolization for massive hemoptysis. MATERIAL AND METHODS: A single-center retrospective review of bronchial artery embolization (BAE) for massive hemoptysis was performed for procedures between 2008 and 2019. Multi-variate analysis was performed to determine the significance of pre-procedure CTA and etiology of hemoptysis on patient radiation exposure (reference point air kerma, RPAK) and rate of recurrent hemoptysis. RESULTS: There were 61 patients (mean age 52.5 years; SD = 19.2 years, and 57.3% male) and CTA was obtained for 42.6% (26/61). Number of vessels selected was a mean of 7.2 (SD = 3.4) in those without CTA and 7.4 (SD = 3.4) in those with CTA (p = 0.923). Mean procedure duration was 1.8 h (SD = 1.6 h) in those without CTA and 1.3 h (SD = 1.0 h) in those with CTA (p = 0.466). Mean fluoroscopy time and RPAK per procedure were 34.9 min (SD = 21.5 min) and 1091.7 mGy (SD = 1316.6 mGy) for those without a CTA and 30.7 min (SD = 30.7 min) and 771.5 mGy (SD = 590.0 mGy) for those with a CTA (p = 0.523, and p = 0.879, respectively). Mean total iodine given was 49.2 g (SD = 31.9 g) for those without a CTA and 70.6 g (SD = 24.9 g) for those with a CTA (p = 0.001). Ongoing hemoptysis at last clinical follow up was 13/35 (37.1%) in those without CTA and 9/26 (34.6%) in those with CTA (p = 0.794). CONCLUSIONS: Pre-procedure CTA did not improve radiation effective dose and symptom recurrence after BAE and is associated with significant increases in total iodine dose.

"Missing-piece" sign with dural arteriovenous fistula at craniocervical junction: A case report.

OBJECTIVES: Spinal dural arteriovenous fistula (sDAVF) is a rare and often underdiagnosed spinal disease. Early diagnosis is required because the deficits are reversible and delays in treatment cause permanent morbidity. Although the abnormal vascular flow void is a critical radiographic feature of sDAVF, they are not always present. A characteristic enhancement pattern of sDAVF has been recently reported as the "missing-piece" sign which can lead to the early and correct diagnosis. METHODS: We presented imaging findings, treatment decisions, and the outcome of a rare case of sDAVF, in which the "missing-piece" sign appeared atypical. RESULTS: A 60-year-old woman developed numbness and weakness in her extremities. Spinal MRI revealed longitudinal hyperintensity in the T2-weighted image, extending from the thoracic level to medulla oblongata. At first, myelopathy with inflammation or tumor was suspected because of the lack of flow voids and vascular abnormalities in CT-angiography and MR-DSA. However, we administered intravenous methylprednisolone and her symptom got worse with the appearance of the "missing-piece" sign. Then, we successfully diagnosed sDAVF by angiography. The "missing-piece" sign was considered to derive from inconsistency of the intrinsic venous system of spinal cord, with the abrupt segments without enhancement. The same etiology was considered in our case. CONCLUSIONS: Detecting the "missing-piece" sign can lead to the correct diagnosis of sDAVF, even if the sign appeared atypical.

A Multimodal Approach to Control of Massive Hemorrhage Secondary to Rectal Cancer.

The management of patients with symptomatic rectal masses can be challenging and is further complicated in cases of advanced age, comorbidities, prior surgeries, and acute hemorrhage. In this report, we describe a patient who presented with massive hemorrhage from a 7 cm low rectal tumor with subsequent cardiac arrest. After return of spontaneous circulation, emergent pelvic angiography identified extensive tumor enhancement and blush off the anterior division of the right internal iliac artery from multiple parasitized vessels. The right internal iliac artery was embolized with multiple microcoils to decrease the tumor blood supply and slow the rate of bleeding. The patient was then taken directly from the angiography suite to radiation oncology for planning CT, and within several hours, underwent his first session of radiation. In conjunction with angioembolization, short-course radiation therapy can be an effective treatment modality for advanced bleeding rectal tumors not amenable to surgical resection.

Typology, Severity, and Outcomes of Adverse Events Related to Angiographic Equipment-A Ten-Year Analysis of the FDA MAUDE Database.

Purpose: Angiographic equipment is a key component of healthcare infrastructure, used for endovascular procedures throughout the body. The literature on adverse events related to this technology is limited. The purpose of this study was to analyze adverse events related to angiographic devices from the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database. Methods: MAUDE data on angiographic imaging equipment from July 2011 to July 2021 were extracted. Qualitative content analysis was performed, a typology of adverse events was derived, and this was used to classify the data. Outcomes were assessed using the Healthcare Performance Improvement (HPI) and Society of Interventional Radiology (SIR) adverse event classifications. Results: There were 651 adverse events reported. Most were near misses (67%), followed by precursor safety events (20.5%), serious safety events (11.2%), and unclassifiable (1.2%). Events impacted patients (42.1%), staff (3.2%), both (1.2%), or neither (53.5%). The most common events associated with patient harm were intra-procedure system shut down, foot pedal malfunction, table movement malfunction, image quality deterioration, patient falls, and fluid damage to system. Overall, 34 (5.2%) events were associated with patient death; 18 during the procedure and 5 during patient transport to another angiographic suite/hospital due to critical failure of equipment. Conclusion: Adverse events related to angiographic equipment are rare; however, serious adverse events and deaths have been reported. This study has defined a typology of the most common adverse events associated with patient and staff harm. Increased understanding of these failures may lead to improved product design, user training, and departmental contingency planning.

Left Distal Transradial Approach for the Treatment of a Sacral Extradural Arteriovenous Fistula: A Technical Note and Literature Review.

BACKGROUND: Sacral extradural arteriovenous fistula (SEAVF) is relatively rare, and its etiology is unknown. They are mostly fed by the lateral sacral artery (LSA). For endovascular treatment, both the stability of the guiding catheter and accessibility of the microcatheter to the fistula, distal to the LSA are required for sufficient embolization of the fistulous point. Cannulation of these vessels requires either crossover at the aortic bifurcation or retrograde cannulation using the transfemoral approach. However, atherosclerotic femoral and tortuous aortoiliac vessels can make the procedure technically difficult. Although the right transradial approach (TRA) can reduce this difficulty by straightening the access route, a potential risk remains for cerebral embolism because it passes the aortic arch. Herein, we present a case of successful embolization of a SEAVF using a left distal TRA. METHODS: We report a case of a 47-year-old man with SEAVF treated with embolization using a left distal TRA. Lumbar spinal angiography showed a SEAVF with an intradural vein through the epidural venous plexus fed by the left LSA. A 6-French guiding sheath was cannulated into the internal iliac artery via the descending aorta using the left distal TRA. A microcatheter could be advanced into the extradural venous plexus over the fistula point from the intermediate catheter placed at the LSA. Embolization with coils and n-butyl cyanoacrylate was successfully performed. RESULTS: The SEAVF completely disappeared on neuroimaging, and the patient gradually recovered. CONCLUSIONS: Left distal TRA could be a useful, safe, and less invasive option for the embolization of SEAVF, especially for patients with high-risk factors for aortogenic embolism or puncture site complications.

Healthcare-Associated nontuberculous mycobacterial endocarditis following coronary artery angiography.

Infective endocarditis in a patient with structural heart disease following coronary artery angiography is a rare complication. We report a rare case of Mycobacterium chelonae infective endocarditis following coronary artery angiography in a young male with congenital heart disease. This case illustrates the diagnostic as well as therapeutic challenges we faced when managing this rare infectious entity.

Impact of Dynamic Change of Meandering of Parallel Artery to the Idiopathic Tarsal Tunnel Syndrome.

In idiopathic tarsal tunnel syndrome (TTS), walking seems to make symptoms worse. The findings imply that an ankle movement dynamic component may have an impact on the etiology of idiopathic TTS. We describe how the ankle movement affects the nerve compression caused by the surround tissue, particularly the posterior tibial artery. We enrolled 8 cases (15 sides) that had TTS surgery after tarsal tunnel (TT) MRI preoperatively. Dorsiflexion and plantar flexion were the two separate ankle positions used for the T2* fat suppression 3D and MR Angiography of TT. Based on these findings, we looked at how the two different ankle positions affected the posterior tibial artery's ability to compress the nerve. Additionally, we assessed the posterior tibial artery's distorted angle. We divided the region around the TT into four sections: proximal and distal to the TT and proximal half and distal half to the TT. Major compression cause was posterior tibial artery. Most severe compression point was proximal half in the TT in all cases without one case. In each scenario, the nerve compression worsens by the plantar flexion. The angle of the twisted angle of the posterior tibial artery was significantly worsened by the plantar flexion. In idiopathic TTS, deformation of posterior tibial artery was the primary compression component. Nerve compression was exacerbated by the plantar flexion, and it was attributable with the change of the distorted angle of the posterior tibial artery. This could be a contributing factor of the deteriorating etiology by walking in idiopathic TTS.