Comparison of clinical outcomes of pharmaco-mechanical thrombectomy in iliac vein thrombosis with and without May-Thurner syndrome.

BACKGROUND: May-Thurner syndrome (MTS) has a different etiology from that of general deep vein thrombosis (DVT). However, few clinical comparisons of MTS-induced and non-MTS-induced DVT have been reported. The aim of this study was to analyze the clinical results of pharmaco-mechanical thrombectomy (PMT) in DVT with and without MTS. METHODS: Forty-seven iliac vein thrombosis patients treated with PMT between January 2008 and December 2013 were enrolled. 25 patients had DVT with MTS and 22 patients had iliac vein DVT without MTS. We retrospectively reviewed medical records and analyzed mid-term patencies and post-thrombotic syndrome (PTS) occurrence by Villalta Score. RESULTS: The median follow-up period was 48.4 (36~92) months. A venous stent was inserted in the iliac vein in all MTS patients. One-/two-/three-year primary patencies in the non-MTS group were 77.3% (N.=17) for all three years in the non-MTS group and were 96.0% (N.=24), 83.1% (N.=22), and 83.1% (N.=22) in the MTS group for years 1/2/3, respectively. One-/two-/three-year secondary patencies were 90.9% (N.=20) for all three years in the non-MTS group and were 96.0% (N.=24), 91.4% (N.=23), and 91.4% (N.=23) in the MTS group, respectively. One-, two-, and three-year Villalta Scores were 4.3, 3.9, and 3.4, respectively, in the non-MTS group, and 3.8, 3.7, and 4.0, respectively, in the MTS group. Primary and secondary patency and Villalta Score were not significantly different between the MTS and non-MTS groups. CONCLUSIONS: Although MTS and DVT have different etiologies, clinical results for both diseases using PMT were not significantly different. Therefore, PMT can be offered as an acceptable initial therapy in DVT patients with and without MTS.

A new endovascular strategy utilizing a hybrid procedure for long segmental occlusion by acute arterial thromboembolism in the lower extremity.

PURPOSE: To evaluate a new endovascular strategy utilizing a hybrid procedure for long segmental arterial thromboembolism in a lower extremity by historical comparison with conventional endovascular strategy. MATERIALS AND METHODS: In a new endovascular strategy, a hybrid procedure was performed for long segmental thromboembolism (longer than 15 cm) and an endovascular procedure for short segmental thromboembolism. The new strategy group (Group A) consisted of 24 procedures (13 hybrid procedures, 11 endovascular procedures) in 19 patients. Data were retrospectively collected from 24 consecutive procedures in 23 patients treated with the conventional strategy (Group B). RESULT: The technical success of Groups A and B was 24/24 and 20/24, respectively (p = 0.11). Major amputation or mortality was not observed in Group A, whereas 3 major amputations and 4 deaths occurred in Group B. Clinical failure in Groups A and B was 0/24 and 7/24, respectively (p < 0.05). Continuous urokinase (UK) infusion was needed in 1/24 in Group A and 14/24 in Group B (p < 0.05). Mean procedure time was 4 h 17 min for Group A and 21 h 30 min for Group B (p < 0.05). CONCLUSION: The hybrid procedure may be faster and more effective than the conventional treatment in long segmental arterial thromboembolisms, while the conventional treatment is still effective for short segmental occlusions.

Thrombosis in Behçet's disease: a Behçet's disease patient with complete thrombotic obstruction of IVC and both iliac veins and decreased protein S activity.

Behçet's disease represents a multisystemic inflammatory disease characterized by recurrent oral ulcers, genital ulcers, and uveitis. Although vascular attack and thrombosis are not major complications in Behçet's disease, they can still pose risks that must not be overlooked. In this paper, we reported that a 25-year-old female Behçet's disease patient with complete thrombotic obstruction of the inferior vena cava that was successfully treated by aspiration thrombectomy and balloon angioplasty. The procedure produced marked symptomatic improvement. Currently, data about the treatment and the prophylaxis of thrombotic events in Behçet's disease are lacking. In this case report, we hope to discuss the future direction of such studies, how we understand the mechanism of Behçet's disease hypercoagulability, and which treatments can improve thrombotic tendencies in Behçet's disease.

True Neurogenic Thoracic Outlet Syndrome Following Hyperabduction during Sleep - A Case Report -.

True neurogenic thoracic outlet syndrome (TOS) is an uncommon disease and is difficult to diagnose at the early stage and then completely cure. We experienced a case of true neurogenic TOS with typical clinical symptoms and electrophysiologic findings as a result of repetitive habitual sleep posture. A 31-year-old woman who had complained of progressive tingling sensation on the 4th and 5th fingers with shoulder pain was diagnosed of brachial plexopathy at the lower trunk level by electrodiagnostic studies. There was no other cause of brachial plexopathy except her habit of hyperabduction of shoulder during sleep. This case demonstrated that the habitual abnormal posture can be the only major cause of neurogenic TOS. It is of importance to consider TOS with the habitual cause because simple correction of the posture could stabilize or even reverse disease progress.

Portosystemic pressure gradient during transjugular intrahepatic portosystemic shunt with Viatorr stent graft: what is the critical low threshold to avoid medically uncontrolled low pressure gradient related complications?

BACKGROUND: Inappropriately decreased portosystemic pressure gradient (PSG) during transjugular intrahepatic portosystemic shunt (TIPS) can cause fatal complications but the critical low threshold of PSG is still not clear. The aim of the present study was to evaluate the critical low threshold of PSG during TIPS. METHODS: Sixty-six patients with cirrhosis who successfully underwent de novo TIPS with Viatorr stent grafts were studied. Medically uncontrolled low pressure gradient (LPR) complication was defined as when a patient died, or when acute transplantation or a TIPS reduction procedure was performed due to refractory encephalopathy or the deterioration of hepatic function within 3 months after the procedure. For the determination of the risk group for medically uncontrolled LPR complications, the Child-Pugh score and the model of end-stage liver disease (MELD) score showing a 100% negative predictive value was decided on as a threshold for each score. The risk group was defined when either of both scores was higher than its threshold. For the determination of a critical low post-TIPS PSG, a value of post-TIPS PSG showing the highest discrimination power on the receiver operating characteristic (ROC) curve in the risk group was decided on as a critical low threshold of PSG. The medically uncontrolled LPR complication rates of the patients with the determined threshold or lower were evaluated for the risk group. RESULTS: Medically uncontrolled LPR complications developed in nine patients (13.6%). Five patients died and four patients had TIPS reduction procedures. Patients with more than 10 on the Child-Pugh score or more than 14 on the MELD score were determined to be the risk group and 34 patients were included. The critical lower threshold of the post-TIPS PSG showing the highest discrimination power on the ROC curve was 5 mmHg (sensitivity 100%, specificity 72%), and the medically uncontrolled LPR complication rates of the patients with 5 mmHg or lower on the post-TIPS PSG were 56.3% (9/16) in the risk group. CONCLUSIONS: The critical threshold of the post-TIPS PSG to avoid the medically uncontrolled LPR complications of TIPS was >5 mmHg. The PSG should not be reduced below this level in the risk group.

Exophytic inflammatory myofibroblastic tumor of the stomach in an adult woman: a rare cause of hemoperitoneum.

Inflammatory myofibroblastic tumor (IMT) of the stomach in adults is extremely rare, with unpredictable prognosis. We present a 55-year-old woman with a gastric IMT. She experienced sudden abdominal pain 4 d previously. Physical examination showed mild abdominal tenderness in the hypogastrium, but no palpable abnormal abdominal mass. Abdominal CT showed a mass of approximately 8 cm in the gastrocolic ligament. On laparoscopic exploration, unexpected hemoperitoneum of approximately 1.5 L of blood was found, and an exophytic gastric mass of approximately 10 cm, appeared from the anterior wall of the gastric body along the greater curvature. Laparoscopy further showed that non-clotting blood in the abdominal cavity seemed to be from the gastric tumor. After conversion to open surgery for more precise evaluation of the cause of hemoperitoneum and the large friable tumor, gastric wedge resection, including the tumor, was conducted. The final diagnosis was consistent with IMT that originated from the gastric wall.

Comparison of a new polytetrafluoroethylene-covered metallic stent to a noncovered stent in canine ureters.

The aim of this study was to determine the feasibility of using a newly designed polytetrafluoroethylene (PTFE)-covered metallic stent in the ureter by comparing its effectiveness with that of the noncovered stent in a canine model. We placed 14 stents in the ureters of seven mongrel dogs that weighed 30-40 kg each. The covered and noncovered stents were deployed in the right and left ureters, respectively, of six dogs. In the seventh dog, a covered stent and a double-J catheter were inserted in the right ureter, and a covered stent only was inserted in the left ureter. The first six dogs were sacrificed at 5, 10, and 15 weeks after deployment of the stents (two for each follow-up period), and the seventh dog was sacrificed at 30 weeks. There was no migration or poor expansion of any of the stents observed on plain radiography. On intravenous pyelogram and retrograde pyelogram, all of the covered stents at each follow-up period had patent lumens at the stented segments without hydronephrosis, and the passage of contrast material through it was well preserved. The noncovered stents in the dogs sacrificed at 5 and 10 weeks and one of the two dogs sacrificed at 15 weeks showed near-complete occlusion of the stent lumen due to ingrowth of the soft tissue, and severe hydronephrosis was also noted. The noncovered stent in the other dog sacrificed at 15 weeks showed the passage of contrast material without hydronephrosis, but the lumen of the stent was still nearly occluded by the soft tissue. There was no evidence of hydronephrosis or passage disturbance of the contrast material in both ureters of the dog sacrificed at 30 weeks. We conclude that the newly designed PTFE-covered stent effectively prevented the luminal occlusion caused by urothelial hyperplasia compared to the near-total occlusion of the noncovered stents, and no migration of the covered stents was noted.

Treatment of high-flow priapism with superselective transcatheter embolization in 27 patients: a multicenter study.

PURPOSE: To evaluate the effectiveness and safety of treatment of high-flow priapism (HFP) with superselective transcatheter embolization at nine university hospitals. MATERIALS AND METHODS: Between May 1994 and October 2006, 27 patients underwent superselective embolization of the cavernous artery for HFP. Trauma was apparent in 22 patients, there was self-administered intracavernosal injection for erectile dysfunction in two, and the remaining three did not recall any penile or perineal trauma. The embolic agents used were autologous blood clot (n = 12), gelatin sponge (n = 12), microcoils combined with gelatin sponge (n = 1), polyvinyl alcohol (n = 1), and N-butyl cyanoacrylate (n = 1). Recurrence of priapism and change in erectile function were evaluated during a mean follow-up of 13 months. Differences in results between patients treated with autologous blood clot versus gelatin sponge were statistically analyzed with use of the chi(2) test. RESULTS: In 24 of 27 patients (89%), a single embolization was sufficient for complete resolution of priapism. Repeat embolization was required in two patients (7%), and in the remaining patient (4%), shunt surgery was performed after embolization as a result of HFP coexisting with corporeal venoocclusive dysfunction. Eighteen of 23 patients (78%) who had premorbid normal erectile function showed maintained potency during the follow-up period. There was no significant difference affecting required repeat embolization (P = .537) and change in quality of erection (P = .615) during the follow-up period between the autologous blood clot and gelatin sponge treatment groups. CONCLUSIONS: Superselective transcatheter embolization in the treatment of HFP is effective and ensures a high level of preservation of premorbid erectile function.

Computed tomographic differences of pyogenic liver abscesses caused by Klebsiella pneumoniae and non-Klebsiella pneumoniae.

OBJECTIVE: To investigate the distinctive computed tomographic(CT) features of pyogenic liver abscess (PLA) caused by Klebsiella pneumoniae (KLA). METHODS: 114 PLA patients (62 men, 52 women, age range 25-89 years, mean age 60.9 years) with positive yield of blood or pus cultures were divided into 2 groups; KLA group (n = 58) and non-KLA group (n = 56). We retrospectively reviewed the CT images. The independent-sample t-test, X2 test, or Fisher's exact test were used with SPSS for windows version 11.0. RESULTS: Gas formation showed no significant difference between two groups (P = 0.284), but air-fluid pattern was found only in KLA group (P = 0.027). The rim on dynamic CT was showed less frequently in KLA group than non-KLA group (P < 0.001), and smooth and regular rim was more common in non-KLA group (P < 0.001). The septation and septal breakage were more common in KLA group (P < 0.001). The turquoise sign was found significantly more in KLA group (P < 0.001). The hairball sign was detected only in KLA group (P < 0.001). The cluster sign was less frequent in KLA group (P < 0.001). CONCLUSION: KLA had a series of characteristic intra-abscess features; septal breakage, turquoise-like structure, hairball-like content, air-fluid level, and no enhanced rim. When turquoise/hairball sign or air-fluid level is present in abscess, KLA would be a probable diagnosis in the clinical field.

Traumatic axillary artery dissection with radial artery embolism.

This report describes a case of pathologically proven traumatic arterial dissection, presenting as complete occlusion of the axillary artery with radial artery embolism. Occlusion of the axillary artery by traumatic dissection mimicked transection and radial artery embolism mimicked congenital absence of the radial artery on the initial angiogram, but these were correctly diagnosed with the following sonogram.

Fluid infusion technique for ultrasound-guided percutaneous nephrostomy.

We describe a simple but useful technique for improving the visualization of the needle during ultrasound-guided percutaneous nephrostomy, especially suitable for obese patients.

Endovascular management of chronic mesenteric ischemia.

Chronic mesenteric ischemia is a rare condition caused by occlusive disease of the mesenteric vessels. While the traditional therapy in symptomatic patients has been surgery, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Mesenteric angioplasty and stenting has a technical success rate of 80 to 100% with a clinical efficacy of 80 to 95%. Published studies indicate a primary patency of 75 to 85%. This article presents a review of the literature and the technical aspects of the procedure.

Imaging findings of mantle cell lymphoma involving gastrointestinal tract.

Clinical manifestations and imaging findings of mantle cell lymphoma involving gastrointestinal tract were evaluated. The subjects were 7 cases of mantle cell lymphoma involving the gastrointestinal tract. All cases were pathologically confirmed in our hospital during the period from April 1994 to July 2000. Five patients were male and 2 were female, and their age ranged from 49 to 63 years (average 57.4). The objectives were: 1) characteristics and distribution of multiple polyposis, 2) presence, location and enhancement pattern of bowel wall thickening or mass formation, 3) presence of splenomegaly, 4) presence and location of abdominal lymph node enlargement, 5) involved extra-abdominal organs, 6) combined cancer and location, and 7) other findings. All mantle cell lymphomas occurred in elderly persons, over 40 years, and most showed multiple polyposis (6/7), bowel wall thickening or mass formation (6/7), lymph node enlargements (6/7) and extra- abdominal involvement (5/7). All cases of polyposis involved the small bowel and colon, and the size of the polyps ranged from 0.1-4.0cm. Four of 6 patients showed combined sessile and polypoid polyps, while the other 2 showed only sessile polyps. Most of or some of the polyps in 3 patients showed small central ulcerations. Most of the patients (5/6) showed an uncountable number of polyps. Polyposis was predominant in the rectum, ascending colon, rather than other sections in the colon, and the ileum were almost always involved by polyposis. Bowel wall thickening or mass formation developed exclusively in the ascending colon, rectum or ileum. Extra- abdominal involvement developed either simultaneously or nonconcurrently with gastrointestinal involvement. Some of patients showed splenomegaly (3/7), appendiceal enlargement (2/7), and intussusception (1/7), and some had associated adenocarcinomas (3/7).