A novel approach to deep venous arterialization using WavelinQ EndoAVF technology.

Deep venous arterialization is increasingly being considered for the management of patients with "no option chronic limb threatening ischemia" (CLTI) who would otherwise require a major limb amputation. WavelinQ (Becton Dickinson) is a new technology increasing in popularity for its role in the formation of endovascular arteriovenous fistulas but might well have applications in other areas of vascular surgery. We present a novel approach to deep venous arterialization using WavelinQ arteriovenous fistula technology for a patient with nonreconstructable chronic limb threatening ischemia experiencing both rest pain and forefoot gangrene. The patient's early tissue loss healed and he remained symptom free at 6 months after the intervention.

Early toxic epidermal necrolysis syndrome post-intra-cranial tumor resection.

INTRODUCTION: SJS and TEN are two rare self-limited but serious cutaneous drug reactions with significant morbidity and mortality. There are many drugs associated with the condition. We report a case of early TEN syndrome post Carbamazepine use, review the current literature and discuss the management challenges. CASE REPORT: A 51-year-old female was admitted to hospital for investigation and management of complex partial seizures secondary to a meningioma. She was commenced on 100mg BD of Carbamazepine for seizure control and discharged home. Surgical resection of the meningioma was performed electively 2 weeks later. A localized erythematous macular rash mainly in the left shoulder was noted on postoperative day 3. Two days later, the patient had sloughing of the mucosa of the lips in addition to progression of the rash. Early Toxic Epidermal Necrolysis (TEN) syndrome was diagnosed by the Burns and Dermatology teams and the culprit drug was discontinued. Skin biopsy confirmed the diagnosis. The patient was commenced on intravenous immunoglobulins with excellent improvement in skin integrity and resolution of excoriations noted on discharge. DISCUSSION: Stevens - Johnson syndrome (SJS) and TEN are two rare self-limited but serious cutaneous drug reactions with significant morbidity and mortality. The current treatment of TENS/SJS is divided into early management and symptom control. The immediate cessation of the culprit drug is quintessential. There is vast documented evidence of carbamazepine- induced SJS/TEN in patients of Asian ethnicity due to the presence of the HLA allele B*1502. HLA-B*1502 screening should be performed when using aromatic anticonvulsants such as carbamazepine in high-risk patients.

Metastatic Angiosarcoma Presenting as Ischemic Anterior Circulation Stroke.

BACKGROUND: Angiosarcoma is a rare malignant neoplasm that can arise from vascular endothelium. We report a case of angiosarcoma that presented as thromboembolic stroke, review the current literature, and discuss the management challenges. CASE REPORT: A 77-year-old man presented with a right anterior circulation stroke with a history of multiple, recent transient ischemic attacks. The diagnosis was confirmed on computed tomography and subsequent investigation revealed thrombus within the distal common carotid artery, with an atherosclerotic plaque causing a significant stenosis of the origin of the internal carotid artery above this. In the context of the presentation with recurrent events, carotid endarterectomy was recommended and subsequently performed. At the time of surgery, the common, internal, and external carotid arteries had macroscopic evidence of atherosclerotic disease but appeared otherwise normal. Intraoperatively friable thrombus adherent to the common carotid endothelium was retrieved and sent for histologic assessment. Subsequent immunohistochemistry evaluation revealed changes pathognomic with angiosarcoma. RESULTS: It is unclear in this case whether the pathology originated in the carotid artery or was the result of embolization from a proximal source. There was no extraluminal carotid pathology identified at the time of surgery, and no abnormalities identified on cross-sectional imaging. Similarly, there was no evidence of a proximal source that may have resulted in tumor embolization. As such, it has proved impossible to define an optimal therapeutic pathway for this patient.