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Background: Arteriovenous malformations (AVMs) within the mediastinum are rare vascular anomalies. With the increasing number of coronary angiographies being performed, the number of incidentally found cases is rising. This presents challenges in terms of determining the appropriate treatment strategy. Case summary: We present the case of a 79-year-old man with aortic stenosis, experiencing functional dyspnoea and fatigue. Echocardiography showed a bicuspid aortic valve, and while left heart catheterization confirmed no significant coronary stenosis, it revealed a tortuous vessel originating from the circumflex artery (Cx), assumed to be heading toward the pulmonary circulation. The patient was scheduled for a surgical replacement of the aortic valve (SAVR). During the SAVR, the tortuous vessel was revealed to be a large, complex AVM located in the mediastinum. This increased both the duration of the surgery and the use of cardioplegia. Further, bleeding occurred per-operatively. Post-operatively, the patient developed tachy-brady syndrome and was treated with a pacemaker before discharge. Discussion: Due to the rarity of incidental AVMs in the middle/posterior mediastinum, no standard treatment protocol is available. This leaves clinicians and surgeons to manage the disease on a case-by-case basis, often with limited experience to guide their decisions. This patient case underscores the challenge of determining whether patients should be offered transcatheter aortic valve implantation (TAVI) or surgery. Furthermore, it highlights the intricate challenges that can arise when dealing with thoracic AVMs during cardiac procedures, emphasizing the importance of pre-operative awareness and tailored surgical approaches based on multidisciplinary discussions.
RESUMO
A 44-year-old otherwise healthy male with a history of trauma and surgical interventions in his right knee presented to the emergency department with repeated hemarthrosis of the right knee. The patient underwent blood tests, X-rays, and magnetic resonance imaging of the knee. A computed tomography angiography revealed blushing of the synovium of the knee. The patient underwent successful embolization of the genicular artery branches. Hemarthrosis did not recur. The use of genicular artery embolization, in our case, not only successfully addressed recurrent hemarthrosis but also underscores its emerging role in comprehensive patient management. This minimally invasive approach, precisely targeting the vascular supply to the affected synovium, offers an effective alternative where conventional therapies may fall short. Beyond symptom relief, it holds promise for preventing hemarthrosis recurrence, a valuable addition to clinicians' interventions for challenging knee joint bleeding cases. Further investigation in larger cohorts and comparative studies may reveal its broader applicability and long-term efficacy, shaping treatment options for recurrent hemarthrosis.
RESUMO
BACKGROUND: Chronic mesenteric ischaemia (CMI) is a vastly underdiagnosed condition that typically leads to postprandial abdominal pain and weight loss. The aim of the study was to explore the involvement of various mesenteric vessels in total splanchnic blood flow (SBF) and hepatic vein oxygenation. METHODS: Single-blinded comparative trial of 476 patients clinically suspected of CMI. Routine investigation included measurement of hepatic vein oxygen saturation, indirect measurement of the total splanchnic blood flow (SBF), using Fick's principle and the tracer [99m Tc]Mebrofenin, before and after a meal, and digital subtraction angiography. RESULTS: A total of 176 of the 476 patients (36%) had at least one angiographically significant stenosis (lumen reduction ≥70%). In patients with a significant one-vessel disease, the percentage having CMI according to SBF was 10% for a celiac trunk stenosis (n = 60), 50% for a superior mesenteric stenosis (n = 24) and 6% for an inferior mesenteric artery stenosis (n = 34). In patients with a significant two-vessel disease, the percentage with CMI according to SBF response was 92%, 18% and 79%, for no significant stenosis of the celiac trunk (n = 13), superior mesenteric artery (n = 17) and inferior mesenteric artery (n = 19), respectively. CONCLUSION: Patients with significant one- or two-vessel stenosis involving the superior mesenteric artery have a higher likelihood of CMI according to flow criteria and a greater postprandial decrease in hepatic vein saturation on average than patients with no involvement of the superior mesenteric artery.