Variceal Veins Embolization and Left Renal Vein Stenting in a Patient with Combined Nutcracker and May-Thurner Syndrome.

Nutcracker syndrome is defined as a compression of left renal vein leading to symptomatic hematuria and flank pain. There are very few reports about its association with May-Thurner syndrome that is related to compression of left iliac vein causing severe leg edema. We are reporting a rare case of a patient having both conditions successfully treated with sequential percutaneous interventions. This case and treatment options are discussed in detail.

L-carnitine treatment in patients with mild diastolic heart failure is associated with improvement in diastolic function and symptoms.

OBJECTIVES: L-Carnitine is a crucial component of activated fatty acid transport. The aim of this study was to evaluate the effect of L-carnitine on patients with a history of mild heart failure and diastolic dysfunction. METHODS: Twenty-nine patients with a history of NYHA functional class II symptoms and ejection fraction >45% with documented grade 1 diastolic dysfunction on echocardiogram were randomized in blinded fashion to receive 1,500 mg of L-carnitine daily for 3 months in comparison to a no treatment group (31 patients). Baseline echocardiographic and follow-up measurements of diastolic parameters were assessed after 3 months. RESULTS: Important parameters of diastolic function improved in the L-carnitine group only: left atrial size (3.6 +/- 0.4 cm before treatment vs. 3.4 +/- 0.5 cm after treatment, p = 0.01); isovolemic relaxation time (127 +/- 26 ms before vs. 113 +/- 24 ms after treatment, p = 0.007); septal mitral E' velocity (0.064 +/- 0.01 m/s before vs. 0.074 +/- 0.01 m/s after treatment, p = 0.01), and lateral mitral E velocity (0.082 +/- 0.01 m/s before vs. 0.091 +/- 0.02 m/s after treatment, p = 0.006). Dyspnea also significantly improved in L-carnitine-treated patients. CONCLUSION: In patients with a history of diastolic heart failure, important indices of diastolic function and symptoms appear to improve with L-carnitine treatment.

The early presentation of atrial myxoma with acute myocardial infarction.

Atrial myxoma as a rare benign heart tumor can cause acute coronary syndrome via coronary embolization. In this report, we present a 54-year-old woman who presented with acute inferior myocardial infarction. In further evaluation a 2.5 x 3 x 4 cm mass was found in the left atrium. The mass was excised surgically and its pathology was compatible with myxoma. After resection, the patient was discharged with a favorable outcome.

Complete isolation of right subclavian artery supplied by the thoracic aorta and bilateral patent ductus arteriosus.

Disconnection of the subclavian artery from the aortic arch, defined as isolation, is a rare aortic arch anomaly. In this anomaly, loss of continuity between one subclavian artery and the aorta with persistent connection to the homocollateral pulmonary artery through a patent or remnant ductus arteriosus is present. This isolation is almost always seen on the side contralateral to the aortic arch position. Complex cardiac and genetic anomalies are frequently associated with the isolation of a subclavian artery. We report a rare case of right subclavian artery originating from right pulmonary artery with bilateral patent ductus arteriosus in an otherwise normal infant.

A Novel Risk Score in Predicting Failure or Success for Antegrade Approach to Percutaneous Coronary Intervention of Chronic Total Occlusion: Antegrade CTO Score.

Total occlusion of a coronary artery for more than 3 months is defined as chronic total occlusion (CTO). The goal of this study was to develop a risk score in predicting failure or success during attempted percutaneous coronary intervention (PCI) of CTO lesions using antegrade approach. This study was based on retrospective analyses of clinical and angiographic characteristics of CTO lesions that were assessed between February 2012 and February 2014. Success rate was defined as passing through occlusion with successful stent deployment using an antegrade approach. A total of 188 patients were studied. Mean ± SD age was 59 ± 9 years. Failure rate was 33%. In a stepwise multivariate regression analysis, bridging collaterals (OR = 6.7, CI = 1.97-23.17, score = 2), absence of stump (OR = 5.8, CI = 1.95-17.9, score = 2), presence of calcification (OR = 3.21, CI = 1.46-7.07, score = 1), presence of bending (OR = 2.8, CI = 1.28-6.10, score = 1), presence of near side branch (OR = 2.7, CI = 1.08-6.57, score = 1), and absence of retrograde filling (OR = 2.5, CI = 1.03-6.17, score = 1) were independent predictors of PCI failure. A score of 7 or more was associated with 100% failure rate whereas a score of 2 or less was associated with over 80% success rate. Most factors associated with failure of CTO-PCI are related to lesion characteristics. A new risk score (range 0-8) is developed to predict CTO-PCI success or failure rate during antegrade approach as a guide before attempting PCI of CTO lesions.

Analysis of patients listed for liver transplantation in Shiraz, Iran.

AIM: To analyze records of patients listed for liver transplantation (LT) at our hospital, the first and the largest LT center in Iran. METHODS: We analyzed medical records of patients aged 14 years or older, who were listed for LT for chronic liver disease between 1994 and 2004. Outcome was determined from records or follow-up data. RESULTS: Among the 480 patients (mean age 39 [SD 13] years; 327 [68.1%] men) listed for LT, common causes of cirrhosis were cryptogenic (143; 29.9%) and hepatitis B (127; 26.5%). Child-Turcott-Pugh (CTP) class distribution of these patients was: A - 37 (7.7%), B - 258 (53.7%) and C - 185 (38.6%). Mean (SD) follow-up duration was 11.4 (11.8) months (range 1-108). One hundred and four (21.7%) patients received LT and 173 (36%) died while awaiting LT. CTP class influenced 1-year (90%, 73% and 55% in class A, B and C, respectively) and 2-year (84%, 48% and 25%, respectively) survival rates. MELD score also influenced survival. Survival was better in patients who underwent LT than in those who continued on the waiting list (p< 0.01). CONCLUSION: Only about one-fifth of patients listed for LT in Iran received LT and a large proportion died without LT.

Arteriovenous fistula thrombosis in patients on regular hemodialysis: a report of 171 patients.

BACKGROUND: Fistula thrombosis in patients on maintenance hemodialysis is an important morbidity factor. Arterial or venous thrombotic events have been described as complications in patients on regular hemodialysis. This study was designed to evaluate the risk factors for arteriovenous fistula thrombosis. METHODS: One hundred and seventy-one patients with arteriovenous fistula on maintenance hemodialysis were studied prospectively during a period of 14 months for any episode of arteriovenous fistula thrombosis, after anticardiolipin antibodies were assayed by ELISA. Other risk factors for thrombosis such as the presence of diabetes or hypertension, the use of erythropoietin (rhEPO), fistula site, gender, age, ultrafiltration, hypotension during dialysis, and the number of dialysis visits in a week were assessed. RESULTS: Fifty-six percent of patients had IgG-anticardiolipin antibodies > or = 10GPL, which was significantly correlated with dialysis duration (23.18 +/- 24.56 months in patients with anticardiolipin antibodies < or = 10GPL vs. 37.73 +/- 36.35 months in patients with 20 < or = IgG-anticardiolipin antibodies < 40GPL). Within the 14 months of follow-up, 36 episodes of arteriovenous fistula thrombosis occurred in 31 patients (18.1%). Considering anticardiolipin antibodies and other risk factors in a Cox proportional hazard model, only fistula site (P = 0.021, RR = 2.48, Cl = 1.14 - 5.37) and erythropoietin (Eprex) use (P = 0.021, RR = 10.92, Cl = 1.43 - 83.02) seemed to have an influence on fistula patency. According to fistula site, the survival of brachiocephalic fistulas were significantly (P = 0.007) better than radiocephalic ones (1- and 3-year survival were 95% and 87% for upper, and 88% and 72% for lower ones, respectively). CONCLUSION: Although the incidence of the anticardiolipin antibody was high in our patients, in the presence of other risk factors for thrombosis, we found no correlation between IgG-anticardiolipin antibodies and arteriovenous fistula thrombosis. Instead, erythropoietin (Eprex) use and fistula site seem to have an important role in the correlation between IgG-anticardiolipin antibodies and arteriovenous fistula thrombosis.

The long-term immunity among health care workers vaccinated against hepatitis B virus in a large referral hospital in southern Iran.

BACKGROUND: Health care workers are at increased risk of occupational exposure to hepatitis B virus (HBV) infection. Reassessment for revaccination of such high-risk persons after 10 years may be appropriate if anti-HBs antibody titers declined below 10 mlU/mL. This study was conducted to evaluate the long-term efficacy of HBV vaccine in health care workers and the need for their reassessment for revaccination. METHODS: We interviewed 600 health care workers in a referral hospital in Shiraz, southern Iran. They were asked to complete a confidential questionnaire including information on their age, gender, vaccination date, number of doses of vaccine, their job description in hospital, previous history of needlestick injury, and educational level. Anti-HBs antibodies were determined by the ELISA method and titers of >10 mlU/mL were considered protective. Those with a positive HBsAg or anti-HBcAb were excluded from the study. RESULTS: Among 600 health care workers interviewed, 339 subjects who accepted to participate in the study, were vaccinated with three doses of HBV vaccine. Anti-HBsAb titers were >100 mlU/mL in 211 subjects (62.2%), 10 - 100 mlU/mL in 85 (25.1%), and <10 mlU/mL in 43 (12.7%) persons. Among 339 subjects who received three doses of vaccine, 273 were vaccinated less than 5 years, 47 cases between 5 - 10 years, and 19 cases were vaccinated more than 10 years before the study. The majority of them had an antibody concentration above the protective level (88.1%, 88.9%, and 60.9%, respectively, P = 0.001). CONCLUSION: Reassessment for revaccination in health care workers should be considered according to their anti-HBsAb levels 10 years after vaccination. In our health care workers, we think that due to the existence of low immunity against HBV, reassessment for revaccination after 10 years is mandatory.

The Safety of Using Large Amount (30 cc) of Onyx (Ethylene-vinyl Alcohol Copolymer) for the Treatment of Large Type II Endoleak after Endovascular Repair of Abdominal Aortic Aneurysm.

Endovascular aneurysm repair (EVAR) is associated with late complications including the development of endoleaks as major complications. Type II endoleak is the consequence of collateral retrograde flow from the aortic branches; generally from the lumbar arteries, inferior mesenteric artery, or middle sacral artery. The method and the ideal timing for the treatment of endoleaks remain controversial. We are presenting a case of successful treatment of a large type II endoleak using embolization with large amount of Onyx copolymer via a percutaneous transfemoral route without any adverse outcome. A significant advantage of Onyx as opposed to glue is that it may be injected for a long period of time (20-60 minutes) with a lower risk for microcatheter entrapment. This case report suggests that much higher amount of Onyx can safely be used if needed to seal large endoleaks without adverse event.

Resistant hypertension due to unilateral renal artery occlusion as the first presentation of antiphospholipid syndrome.

Resistant hypertension in the setting of renal artery occlusion should prompt further investigation for secondary causes in a young patient. We present renal artery occlusion in the setting of antiphospholipid syndrome as the initial presentation successfully treated with percutaneous intervention. This case is followed by review of the literature.

Incidence of hip fracture in Shiraz, Iran.

Hip fracture, the most serious complication of osteoporosis, puts the burden of a lot of costs for treatment on any health system. Previous reports on rates of hip fracture in Asian countries differ a lot. The aim of this study was to estimate the incidence rate of hip fracture in Shiraz, Iran. In Shiraz, Iran, all operating-room logs with diagnosis of hip fracture were reviewed for hip fractures caused by a simple fall in patients over 50 years, during March 21, 2000, to March 21, 2003. According to patients' medical records, age, sex, type of fracture (intertrochanteric, neck, subtrochanteric) and patients' regions according to Shiraz municipality divisions were obtained. The age-adjusted incidence rates of hip fracture standardized to the 1985 US white population (325.74/100,000 for men and 519.05/100,000 for women) and to the 1989 US white population (384.61/100,000 for men and 548.17/100,000 for women) were the highest in Asia. The intertrochanteric fractures were significantly higher among females ( p =0.003). The incidence of intertrochanteric and neck fractures were increased with age. In all age groups, females had higher incidence rates, except for ages over 80 years, in which males had higher incidence rates than females. In wealthier regions of the city, the incidence rates were higher than in other regions. High incidence of hip fracture in our population, especially in males over 80 years, shows that preventive strategies for hip fracture and osteoporosis should be considered in males as well as females. Further studies are needed to find incidence rates in other cities, especially in the very urbanized city of Tehran.