Endovascular Therapy for Distal Superior Mesenteric Artery Mycotic Aneurysms due to Infective Endocarditis.

Purpose: To report 3 patients with infective endocarditis who underwent transcatheter arterial embolization for mycotic aneurysm of the distal superior mesenteric artery (SMA). Case Report: Three men (60, 64, and 65 years old) were diagnosed with infective endocarditis. Antibiotics were initiated immediately after admission and continued for several weeks to months. Distal SMA mycotic aneurysm was identified on computed tomography in the vicinity of the ileocolic artery at 33, 26, and 30 days after admission. In case 1, the ileal artery was occluded distal to the aneurysm, with collateral flow to the ileum. In case 2, the mycotic aneurysm was located below the ileocolic artery, which was stenosed distal to the lesion. In case 3, the aneurysm was located on a branch of the ileal artery. Transarterial embolization using microcoils was successfully performed in all patients. No complications associated with embolotherapy or relapse of infection were observed in these 3 patients at 60, 30, and 15 months, respectively. Conclusion: Transcatheter arterial embolization for distal SMA mycotic aneurysm could provide an alternative to open surgery. Anatomical assessment of collateral flow and preprocedure long-term antibiotic therapy could play important roles in preventing bowel ischemia and minimizing the risk of infection relapse.

Chest Compression-Associated Internal Thoracic Artery Injury During Cardiopulmonary Resuscitation: Incidence, Injury Patterns and Efficacy of Transcatheter Arterial Embolization.

PURPOSE: To investigate the incidence and patterns of chest compression-associated internal thoracic artery injury (CAI) during cardiopulmonary resuscitation and identify the embolization techniques used to treat hemorrhage. MATERIALS AND METHODS: A retrospective study was conducted in the patients who underwent transcatheter arterial embolization (TAE) for life-threatening hemorrhage caused by CAI at two tertiary care centers between May 2013 and December 2019. Data on background characteristics, imaging findings, embolization and outcomes were collected from the medical records. RESULTS: Among 385 patients in whom circulation returned after resuscitation, there were 9 patients (2.3%) who required TAE for CAI. Eight of 9 patients had acute myocardial infarction, and all had been started on extracorporeal membrane oxygenation before TAE. Seven patients had unilateral, and two had bilateral internal thoracic artery injuries. Main trunk injury of internal thoracic artery was seen in 27%, while branch injury in 73%. Six patients (67%) had multiple injuries in the internal thoracic artery territory, and five (56%) had injuries to other vessels. In all cases, we embolized the main trunk of the internal thoracic artery using n-butyl 2-cyanoacrylate and coils (n = 8), a gelatin sponge only (n = 2), or coils and a gelatin sponge (n = 1). TAE was technically successful in all, without any complication. The 30-day mortality rate was 44%. CONCLUSIONS: CAI needing hemostatic intervention occurred in 2.3% of patients after successful cardiopulmonary resuscitation. Branch injury was more common than main trunk injury, and multiple vessel injuries were common. TAE appears to be safe and effective for controlling life-threatening hemorrhage.

A Case of Transient Unilateral Right Leg Edema Caused by a Markedly Distended Bladder.

External compression of a vein is a relatively rare but important cause of unilateral leg edema. Here, we present a case of unilateral right leg edema caused by external compression of the right iliac vein due to a markedly distended urinary bladder, secondary to a neurogenic bladder. The patient initially had bilateral leg edema associated with chronic heart failure. However, the right-leg edema worsened and remained painful for several days. Lower extremity ultrasonography and computed tomography revealed an enlarged bladder. Based on these findings, venous angiography and intravascular ultrasound were performed. External compression is a significant cause of leg edema. It is important to consider the possibility of intra-abdominal/pelvic processes that may lead to external compression of the venous system in patients with unilateral and even bilateral lower extremity swelling.

Survey on chest CT findings in COVID-19 patients in Okinawa, Japan: differences between the delta and omicron variants.

To investigate the frequency of pneumonia and chest computed tomography (CT) findings in patients with coronavirus disease 2019 (COVID-19) during the fifth Delta variant-predominant and sixth Omicron variant-predominant waves of the COVID-19 pandemic in Okinawa, Japan. A survey on chest CT examinations for patients with COVID-19 was conducted byhospitals with board-certified radiologists who provided treatment for COVID-19 pneumonia in Okinawa Prefecture. Data from 11 facilities were investigated. Indications for chest CT; number of COVID-19 patients undergoing chest CT; number of patients with late-onset pneumonia, tracheal intubation, and number of deaths; and COVID-19 Reporting and Data System classifications of initial chest CT scans were compared by the chi-squared test between the two pandemic waves (Delta vs. Omicron variants). A total of 1944 CT scans were performed during the fifth wave, and 1178 were performed during the sixth wave. CT implementation rates, which were the number of patients with COVID-19 undergoing CT examinations divided by the total number of COVID-19 cases in Okinawa Prefecture during the waves, were 7.1% for the fifth wave and 2.1% for the sixth wave. The rates of tracheal intubation and mortality were higher in the fifth wave. Differences between the distributions of the CO-RADS classifications were statistically significant for the fifth and sixth waves (p < 0.0001). In the fifth wave, CO-RADS 5 (typical of COVID-19) was most common (65%); in the sixth wave, CO-RADS 1 (no findings of pneumonia) was most common (50%). The finding of "typical for other infection but not COVID-19" was more frequent in the sixth than in the fifth wave (13.6% vs. 1.9%, respectively). The frequencies of pneumonia and typical CT findings were higher in the fifth Delta variant-predominant wave, and nontypical CT findings were more frequent in the sixth Omicron variant-predominant wave of the COVID-19 pandemic in Okinawa, Japan.

Endovascular treatment for a spontaneous rupture of the posterior tibial artery in a patient with Ehlers-Danlos syndrome Type IV: report of a case.

This report presents the case of a 27-year-old woman with a history of Ehlers-Danlos syndrome Type IV (EDS-IV) who suffered from acute compartment syndrome caused by the spontaneous rupture of the posterior tibial artery. Bleeding control was achieved by endovascular embolization. A fasciotomy was successfully performed without any trouble with hemorrhaging. Endovascular treatment could therefore represent the ideal option for treating infrapopliteal lesions, particularly for EDS-IV patients.

Aorto-right pulmonary venous fistula after mitral valve replacement for prosthetic mitral valve infective endocarditis: a case report.

BACKGROUND: Aorto-cavitary fistula is a rare condition, and the most common underlying aetiology is infective endocarditis (IE) of the native or the prosthetic aortic valve. We report a case of aorto-right inferior pulmonary venous fistula following redo mitral valve replacement (MVR) for prosthetic mitral valve IE. CASE SUMMARY: A 74-year-old woman underwent urgent redo MVR for prosthetic mitral valve IE. The post-operative course was complicated with heart failure and mediastinal haematoma compressing the left atrium. The haematoma was surgically removed and laceration of the left atrial wall was suture ligated; this was attributed to the surgical trauma dissection of the adhesive tissues. One-week post-operatively, a continuous murmur emerged, which prompted an evaluation of the left to right shunt. Transthoracic echocardiography revealed an echolucent area posterior to the aorta, with continuous flow on colour Doppler. Three-dimensional computed tomography showed a fistula between the aorta and the right inferior pulmonary vein. There was a high risk involved in surgical management; therefore, she was managed medically. Fortunately, the continuous murmur and echolucent space disappeared after 6 months. The fistula was considered to be obstructed by spontaneous thrombus formation in the narrowed segment of the fistula tract. DISCUSSION: The cause of fistula was attributed to possible surgical trauma in the presence of infection. The present case was unique, as it showed spontaneous healing of an aorto-cavitary fistula, which is very rare. The patient was alive with good health status, 6 years after the MVR.

Factors Associated with Secondary Functional Patency After Percutaneous Transluminal Angioplasty of the Early Failing or Immature Hemodialysis Arteriovenous Fistula.

PURPOSE: To evaluate the efficacy of percutaneous transluminal angioplasty for early failing hemodialysis arteriovenous fistulas (AVFs) and predictors of secondary functional patency (FP). METHODS: A review of our endovascular registry database showed that 61 patients with early failure after a surgically created AVF underwent endovascular intervention between 2011 and 2016. Median time from AVF creation to first intervention was 5.6 weeks. Median duration of follow-up was 14 months. Items related to the technical success rate and primary and secondary FP, and factors associated with secondary FP were analyzed. RESULTS: Technical success was achieved in 55 (90%) of 61 patients. The primary and secondary FP rates were 42% and 65% at 12 months, respectively. Multivariate analysis showed that lesion length (HR; 1.15, P = 0.001) and lesions including juxta-AVF (the portion of fistula vein within 2 cm of the arteriovenous anastomosis, HR; 6.23, P = 0.008) were factors associated with reduced secondary FP. ROC curve analysis indicated lesion length with cutoff value ≥ 9 cm as a risk factor for reduced secondary FP. Secondary FP at 12 months for patients with no risk factors, with 1, and with 2 was 86%, 65%, and 0%, respectively. There was a significant difference in secondary FP rates among these groups (P = 0.001). CONCLUSIONS: A lesion length and juxta-AVF lesion are the risk factors for reduced secondary FP. The secondary FP rate at 12 months is acceptable in patients without risk factors.

Successful transcatheter arterial embolization of a ruptured right gastroepiploic artery aneurysm: A case report.

BACKGROUND: Gastroepiploic artery aneurysms (GEAAs) are extremely rare. Ruptured GEAAs are related to high mortality and often treated by open surgery. We describe a case of a ruptured right GEAA that was successfully treated by transcatheter arterial embolization (TAE). PRESENTATION OF CASE: An 80-year-old woman presented to the emergency department with sudden abdominal pain. We diagnosed her as having a ruptured right GEAA based on the contrast-enhanced computed tomography finding. We performed TAE for the GEAA after resuscitation. The patient had an uneventful recovery and was discharged 10 days after TAE. DISCUSSION: A ruptured GEAA causes high mortality; thus, immediate and adequate treatment is mandatory. Previously, many cases of successful surgical resections of ruptured GEAAs have been reported. In our case, we decided that the patient was not suitable for surgery because of her advanced age and bronchiectasis; therefore, we performed TAE and had a good outcome. CONCLUSION: In patients at high risk for surgery, TAE can be an effective treatment for a ruptured GEAA.

Indications of airway stenting for severe central airway obstruction due to advanced cancer.

BACKGROUND: Management of severe central airway obstruction due to advanced cancer is a medical and technical challenge. The impact of airway stenting on the clinical outcome of such patients is unclear. METHOD: This single-center, retrospective study evaluated 21 patients who underwent airway stenting for advanced cancer. We examined predictors of the post-stenting mortality, including age, serum albumin, tracheal diameter, smoking, opioid use, respiratory failure, and performance status (PS). We also compared survival according to the PS. RESULTS: The mean survival period after stenting was 85.2 days. On univariate analysis, age, albumin, PS before airway stenting, respiratory failure, admission route, and PS grade were the candidates as possible predictors of prognosis after the procedure. On multivariate analysis, PS before airway stenting was identified as possible predictor of prognosis after stenting (HR 1.6180, 95% CI 0.969 to 2.7015, p = 0.066). The mean survival period after stenting was significantly longer in the good PS group, compared to the poor PS group (147.8 days vs. 38.2 days,p = 0.0346). CONCLUSION: Airway stenting for advanced cancer may be more effective for patients in good general condition than in those with poor performance status.

Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review.

BACKGROUND AND METHOD: The aim of this study was to assess retrospectively the clinical presentation, management and outcome of three patients with isolated SMA dissection encountered at Okinawa Prefectural Chubu Hospital, Japan from 2005 to 2006, along with a review of the literature. We follow up the patient's clinical symptoms and the image by using enhanced dynamic CT at 1 week, 1 or 2 months, 6 months, and yearly after onset. CASE PRESENTATION: We present three patients with acute abdominal pain due to spontaneous dissection of the superior mesenteric artery (SMA), who were treated by surgical revascularization or conservative management. Two patients underwent surgery because of signs or symptoms of intestinal ischemia and one patient elected conservative management. The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA. All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years. CONCLUSION: Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.

True aneurysm of the pancreaticoduodenal arteries: a single institution experience.

BACKGROUND: True pancreaticoduodenal artery (PDA) aneurysm is a rare but potentially fatal disease. The aim of this study was to make recommendations for management of true PDA aneurysm. METHODS: True aneurysms of the PDA were diagnosed at our institution between 1996 and 2007 and analyzed retrospectively, for clinical presentation, management, and outcome. RESULTS: Eight patients were admitted to our institution for true aneurysms of the PDA. Five patients had aneurysmal rupture, and three were asymptomatic. In the rupture group, computed tomography (CT) showed the retroperitoneal hematoma around the pancreas and aneurysm, ranging from 5 to 25 mm (median, 12 mm). In the non-rupture group, CT revealed saccular aneurysm, ranging from 10 to 20 mm (median, 16 mm). The celiac axis was occluded in two patients, stenotic in four, and normal in two. Two patients underwent laparotomy, and we finally performed transcatheter arterial embolization in seven. All patients are alive, and there is no evidence of recurrence after median follow-up of 6 years. CONCLUSIONS: We recommend treatment of all true PDA aneurysms at the time of diagnosis. True PDA aneurysm with celiac artery stenosis or occlusion requires precise techniques for embolization to preserve blood flow in the celiac artery territory.