Idiopathic myointimal hyperplasia of mesenteric veins: radiological evaluation using CT angiography.

A 44-year-old man presented with a chief complaint of constipation. Initial contrast-enhanced CT showed extensive bowel wall thickening, mainly in the left colon, with a thin cord-like inferior mesenteric vein (IMV), in contrast to ectatic mesenteric venous branches, suggesting bowel ischaemia owing to venous stasis. One month later, at the time of symptom exacerbation, CT angiography showed a cord-like IMV and ectatic mesenteric venous branches with early enhancement, suggesting the presence of an arteriovenous fistula (AVF). Owing to the progression of bowel ischaemia and necrosis with peritonitis, emergency surgery was performed. Surgical specimens showed focal myointimal hyperplasia of the proximal mesenteric veins in both ischaemic and non-ischaemic lesions of the resected colon, thus leading to the diagnosis of idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) when combined with the clinical and imaging findings. IMHMV is a bowel ischaemic disease caused by non-thrombotic venous obstruction that requires bowel resection and has been suggested to be associated with AVF. Cord-like IMV and AVF in the mesentery are important CT findings that characterize IMHMV. CT angiography is useful in diagnosing IMHMV.

Treatment of massive hemoptysis after thoracic aortic aneurysm repair.

BACKGROUND: Massive hemoptysis after thoracic aortic aneurysm (TAA) repair is a rare but potentially lethal condition. Endovascular management is a challenging treatment option due to the complexity of culprit vessel access. CASE PRESENTATION: An 81-year-old woman was referred to our hospital with massive hemoptysis. She had a history of graft replacement and thoracic endovascular aortic repair (TEVAR) for dissecting TAA. Computed tomography (CT) showed massive atelectasis with hematoma in the left lower lung lobe adjacent to the descending aortic aneurysm treated with TEVAR. Contrast-enhanced CT revealed a pseudoaneurysm and proliferation of abnormal vessels at the peripheral side of the left pulmonary ligament artery (PLA) in the atelectasis. The PLA continued to the right subscapular artery via a complex collateral pathway. Diagnostic angiography of the right subcapsular artery revealed a pseudoaneurysm and abnormal vessels at the peripheral side of the left PLA with a systemic-pulmonary artery shunt. Transcatheter arterial embolization (TAE) for the left PLA via the collateral pathway with N-butyl cyanoacrylate achieved complete embolization. The patient's hemoptysis was controlled and she was discharged. CONCLUSIONS: Here we presented a case of massive hemoptysis due to PLA disruption that occurred after TAA repair. TAE via a complex collateral pathway is a feasible and effective treatment for hemoptysis, even in patients who have undergone surgical or endovascular TAA repair.

Composite pheochromocytoma-ganglioneuroma: a case with two distinct components radiographically.

Composite pheochromocytoma is an extremely rare tumor that comprises a pheochromocytoma and an embryologically related neurogenic tumor, such as ganglioneuroma, ganglioneuroblastoma, neuroblastoma, or peripheral nerve sheath tumor. A 46-year-old male with hypertension, elevated plasma catecholamine levels, and suspected pheochromocytoma presented to the National Defense Medical College Hospital. CT and MRI showed two adjacent masses in the left adrenal gland; one was a 6 cm cephalic lesion and the other was a 1.5 cm caudal lesion. Only the 1.5 cm caudal mass showed uptake on 123I-metaiodobenzylguanisine single photon emission CT/CT. Pheochromocytoma was suspected and a left adrenalectomy was performed. Pathology confirmed that the 6 cm mass was a ganglioneuroma and the 1.5 cm mass a pheochromocytoma, with cellular intermingling at their border. The two masses were diagnosed as a composite pheochromocytoma-ganglioneuroma. This is the first report in which the two components of a composite pheochromocytoma can be clearly distinguished in the pre-operative images. If a patient with clinically suspected pheochromocytoma has different components from a typical pheochromocytoma, composite pheochromocytoma should be considered.

Destruction of a wandering accessory right hepatic artery in a patient with pancreatic body cancer: a case report.

Aberrant right hepatic arteries are sometimes involved in pancreatic head tumors or accidentally damaged during surgical procedures, which could result in postoperative complications. The risk of such injury has been discussed in patients undergoing pancreatoduodenectomy; however, no reports describe the influence of this anomaly in distal pancreatectomy. We report a patient with pancreatic body cancer with an accessory right hepatic artery following a very unique route. A 77-year-old man was referred to our hospital for the treatment of pancreatic cancer. Computed tomography revealed an anomaly in the hepatic artery, with an accessory right hepatic artery encased in the extensive tumor, which also involved the stomach, left gastric artery, and portal vein. Curative resection was achieved by distal pancreatectomy with wedge resection of the stomach and portal vein reconstruction. Both the accessory right hepatic artery and the left gastric artery were sacrificed after confirming intrahepatic arterial flow by intraoperative Doppler ultrasonography. The route of the accessory right hepatic artery in this patient was unique in that it did not run directly into the hepatic hilum but from behind the pancreatic body, where it was incorporated into the tumor. Accurate preoperative assessment and identification of arterial variations is mandatory in any type of pancreatectomy.