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Vascular complications such as renal artery or renal vein thrombosis and laceration and iliac artery dissection are rarely encountered after renal transplantation. Timely management of these vascular complications is important to prevent ischemic injury of a transplanted kidney. We hereby report a case of a 60-year-old male who had acute renal dysfunction due to iatrogenic left external iliac artery dissection after renal transplantation. An endovascular stenting of the dissected iliac artery resulted in a brisk flow across both iliac and transplanted renal arteries. The management issues related to this rare vascular complication is discussed in the article.
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Dissecção Aórtica/cirurgia , Procedimentos Endovasculares , Doença Iatrogênica , Aneurisma Ilíaco/cirurgia , Transplante de Rim/efeitos adversos , Disfunção Primária do Enxerto/etiologia , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/etiologia , Dissecção Aórtica/fisiopatologia , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/instrumentação , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Aneurisma Ilíaco/etiologia , Aneurisma Ilíaco/fisiopatologia , Masculino , Pessoa de Meia-Idade , Disfunção Primária do Enxerto/diagnóstico , Disfunção Primária do Enxerto/fisiopatologia , Stents , Resultado do Tratamento , Ultrassonografia Doppler em CoresRESUMO
Narcolepsy is a common sleep disorder in Western countries but rarely reported from India. Here, we report a small case series of four narcolepsy patients seen over a four year period in the sleep clinic of a tertiary care hospital in north India. The diagnosis was established by clinical history and two or more sleep-onset rapid eye movements (SOREMs) on multiple sleep latency tests (MSLTs) following overnight polysomnography (PSG). The mean age of patients was 26.2±6.4 yr; one patient had associated cataplexy and another one had all four cardinal symptoms of narcolepsy. All these patients had a history of excessive daytime sleepiness (EDS). The mean body mass index was 24.2±4.7 kg/m[2]. The mean sleep latency during MSLT was 2.7±1.3 min, and the mean REM latency was 5.7±2.9 min. Narcolepsy, although rarely reported from India, should be suspected in young non-obese patients complaining of EDS and confirmed by performing MSLT following overnight PSG.
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Narcolepsia/complicações , Narcolepsia/diagnóstico , Latência do Sono , Adulto , Índice de Massa Corporal , Cataplexia/complicações , Humanos , Índia , Masculino , Narcolepsia/fisiopatologia , Ambulatório Hospitalar , Polissonografia , Centros de Atenção Terciária , Adulto JovemRESUMO
Dyskeratosis Congenita (DC), a 100-year-old known rare hereditary entity, has recently changed its definition as per the pathogenetic model in the last decade. Now it is well known as one of the telomeropathies, pathognomonically characterized by a triad of reticulate pigmentation of the skin, nail dystrophy, and mucosal leukoplakia. It is a progressive systemic disorder which usually presents with involvement of several family members. Malignancies are increasingly reported. Clinical diagnosis is simple once there is a suspicion, but nowadays genetic diagnosis is advocated. Treatment is symptomatic and organ-oriented. We hereby report an adolescent male who presented with the classical mucocutaneous triad of DC with pancytopenia for four months. Bone marrow examination later revealed evolution of acute myeloid leukemia (AML). Liver function tests, imaging, and liver biopsy showed cryptogenic fibrosis with portal hypertension. Chemotherapy was started since hematopoietic stem cell transplantation was not feasible; however, he died very early due to repeated infections before completion of the treatment. AML and liver disease are increasingly reported independently in DC; however, coexistence of both complications in a single patient at first presentation has never been reported earlier. Early age onset of AML is noticeable too.
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Background: The study was aimed to evaluate gender difference and age & gender specific interaction of in-hospital outcomes of patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods: This was a prospective cohort study of 1748 patients with STEMI undergoing primary PCI. The study was dichotomised according to gender to evaluate the difference in the outcome. The study was further stratified based on an age cut-off of 75 years to examine the age-specific gender relationship in survival outcomes. Independent variables for in-hospital mortality were analysed through logistic regression. Results: There were 314 (17.96%) females with an average age of 60.80 years and 1434 (82.03%) males with an average age of 54.87 years. The prevalence of diabetes (24.8% vs. 13.2%) and hypertension (33.1% vs. 12.9%) was significantly higher in female patients compared to male patients, whereas the significantly higher number of male patients were smokers. On multivariate analysis, odds of female gender OR = 3.54 (1.37-9.17), killip class >2 OR = 3.05 (1.97-4.71) and baseline creatinine OR = 2.27 (1.22-4.23) were found as significant predictors of in-hospital mortality. The crude odds ratio of 2.35 (1.49-3.72) and adjusted OR of 2.05 (1.27-3.30) for female mortality was significant among patients aged <75-years. While patients with ≥75-years of age, the mortality difference was insignificant. Conclusion: Although the incidence of STEMI was higher in male compared to female patients, female patients had two-fold higher in-hospital mortality than male. Female gender was an independent predictor for in-hospital mortality in patients <75-years of age.
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Tachyarrhythmias have been well-defined in patients with Takotsubo cardiomyopathy (TTCM) and are estimated to occur in almost 13.5% of patients. However, limited data are available on bradyarrhythmias in patients with TTCM. The pathophysiology, clinical implications, and manage-ment are not well defined in this subgroup. We describe a 53-year-old woman presenting with complete heart block with TTCM and a 73-year-old woman presenting with syncope with complete heart block with TTCM. Both had persistent conduction delays despite recovery of ventricular function and eventually required permanent pacemaker implantation. The dependency on pacing was up to 90% in both patients at a 6-month follow-up.
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OBJECTIVE: Cardiogenic shock accounts for the majority of deaths amongst patients with ST-elevation myocardial infarction. Procalcitonin is elevated in acute myocardial infarction, especially when complicated by left heart failure, cardiogenic shock, resuscitated cardiac arrest, and bacterial infections. However, the prognostic utility of procalcitonin in ST-elevation myocardial infarction complicated by cardiogenic shock has not been systematically evaluated. METHODS: We performed a retrospective registry review of 125 patients with ST-elevation myocardial infarction and cardiogenic shock over 2 years at a tertiary referral hospital to examine the prognostic value of serum procalcitonin measurement at 24 hours after the onset of infarction for in-hospital mortality. RESULTS: The mean age of the study population was 57.75 ± 11.1 years, and the median delay from onset to hospital admission was 15 hours. The in-hospital mortality was 28.8%. Receiver operating characteristic analysis revealed a strong relationship between elevated procalcitonin and in-hospital mortality (area under the curve = 0.676; p = 0.002). Although procalcitonin was found to be higher in non-survivors in univariate analysis, it was not an independent predictor of mortality in multivariate regression analysis. Acute kidney injury, left ventricular ejection fraction, and non-revascularization were independently associated with mortality after adjusting for covariates. CONCLUSION: Although procalcitonin was higher in non-survivors, static procalcitonin measurement at 24 hours after the onset of ST-elevation myocardial infarction complicated by cardiogenic shock was not an independent predictor of in-hospital mortality. Additional prospective studies are required to assess the role of serial procalcitonin monitoring in ST-elevation myocardial infarction complicated by cardiogenic shock.
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Pró-Calcitonina , Infarto do Miocárdio com Supradesnível do Segmento ST , Idoso , Mortalidade Hospitalar , Humanos , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Volume Sistólico , Função Ventricular EsquerdaRESUMO
BACKGROUND: Cardiovascular disease is the leading cause of death in India. Our aim is to study the clinical, epidemiological profile and in-hospital outcomes of patients presenting with acute coronary syndrome. METHODS: We did a prospective single center observational study of the 1203 patients presenting with ACS to a tertiary referral center in North India over a period of one year (July 2018-June 2019). RESULTS: The mean age of study population was 58.4 ± 12.5 years. STEMI and NSTE-ACS accounted for 69.9% and 31.1% respectively. 62.1% of our patients were from rural background. The median time to hospital admission was 600 min for STEMI patients, thrombolysis was performed in 52% of cases. Cardiogenic shock at presentation was noted in 18%. Coronary angiography and percutaneous coronary intervention were done in 1062 (88.3%) and 733 (60.9%) patients respectively. The overall in-hospital mortality was 7.6%. STEMI patients had higher mortality than NSTE-ACS (8.9% vs 4.5% p < 0.001). Female gender (OR-3.306 C.I. 1.87-5.845), severe MR (OR-4.65, C.I.-1.187-18.18), acute kidney injury (AKI) at admission (OR-5.15, C.I.-2.5-10.63), higher Killip class (class III/IV) (OR-3.378,C.I.-1.292-8.849), AF (OR-3.25, C.I.-1,18-8.92), complete heart block (CHB) (OR-4.44,C.I.-2.09-9.43) and right bundle branch block (RBBB) (OR-2.86, C.I.-1.2-6.8) were significant predictors of in hospital mortality. CONCLUSIONS: Our study represents the predominance of STEMI as the initial ACS presentation with a considerable delay in first medical contact and higher prevalence of cardiogenic shock (CS). STEMI patients had higher mortality. Female sex, severe MR, AKI, higher Killips class, AF, CHB, RBBB being predictors of high in-hospital mortality in ACS patients.
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Síndrome Coronariana Aguda , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/terapia , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Índia/epidemiologia , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Centros de Atenção TerciáriaRESUMO
Certain factors like ostial disease, chronic total occlusion, and long, multiple stents are the main causes of multiple stent fractures, as were present in this case. Such stent fractures are usually associated with significant in-stent restenosis; however, this patient had a patent lumen despite multiple fractures.
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Angioplastia , Artéria Femoral/diagnóstico por imagem , Oclusão de Enxerto Vascular/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Falha de Prótese/efeitos adversos , Stents/efeitos adversos , Angioplastia/instrumentação , Angioplastia/métodos , Índice Tornozelo-Braço , Procedimentos Endovasculares , Artéria Femoral/patologia , Artéria Femoral/fisiopatologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Grau de Desobstrução VascularRESUMO
Pulmonary haemorrhage is a rare but a life-threatening complication of thrombolytic therapy in patients with acute ST-elevation myocardial infarction (MI). It usually presents with anaemia, massive haemoptysis, acute-onset respiratory distress and diffuse bilateral lung infiltrates on imaging. We hereby describe two patients, who had pulmonary haemorrhage following streptokinase therapy for acute MI. The first patient improved with conservative treatment, while the second patient died due to respiratory failure. Streptokinase, a fibrin non-specific agent, is a widely used thrombolytic in low-income and middle-income countries. Pulmonary haemorrhage should be suspected in patients who develop sudden respiratory compromise after receiving thrombolytics, especially streptokinase. The management issues related to this uncommon life-threatening complication have been discussed in this article.
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Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Pneumopatias/induzido quimicamente , Infarto do Miocárdio/complicações , Estreptoquinase/efeitos adversos , Terapia Trombolítica/efeitos adversos , Idoso , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Estreptoquinase/uso terapêuticoRESUMO
The Absorb bioresorbable vascular scaffold (Abbott Vascular) does not have an artifact on computed tomography coronary angiography (CTCA); the extent/location of the stent in situ can only be assessed by localizing its radiopaque platinum markers in a non-contrast CTCA. The characteristic appearance of BVS on CTCA should be interpreted as the footprint of a resorbed BVS, instead of a calcified plaque.
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Implantes Absorvíveis , Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Fármacos Cardiovasculares , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , Stents Farmacológicos , Seguimentos , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Desenho de Prótese , Sirolimo , Resultado do TratamentoRESUMO
High-grade and complete heart block commonly occurs in adult patients with restrictive cardiomyopathy, and requires aggressive monitoring and prophylactic pacemaker/defibrillator. There are limited data on the procedural details of pacemaker implantation in this group of patients, and as reported, special maneuvers may be required for ventricular lead placement.
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Bloqueio Atrioventricular , Cardiomiopatia Restritiva , Marca-Passo Artificial , Adulto , Bloqueio Atrioventricular/diagnóstico , Bloqueio Atrioventricular/etiologia , Bloqueio Atrioventricular/terapia , Cardiomiopatia Restritiva/diagnóstico , Cardiomiopatia Restritiva/terapia , Ventrículos do Coração , HumanosRESUMO
The common cause of renal artery stenosis in young is fibromuscular dysplasia or Takayasu arteritis. Recanalized thrombus, on the other hand, is a rare cause for renal artery stenosis in young patients. OCT imaging confirmed the diagnosis and optimized the renal stenting results.
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Angiografia/métodos , Angioplastia com Balão , Hipertensão Renovascular , Obstrução da Artéria Renal , Artéria Renal , Arterite de Takayasu/diagnóstico , Trombose , Tomografia de Coerência Óptica/métodos , Angioplastia com Balão/instrumentação , Angioplastia com Balão/métodos , Diagnóstico Diferencial , Stents Farmacológicos , Humanos , Hipertensão Renovascular/diagnóstico , Hipertensão Renovascular/terapia , Masculino , Artéria Renal/diagnóstico por imagem , Artéria Renal/patologia , Artéria Renal/cirurgia , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/etiologia , Obstrução da Artéria Renal/fisiopatologia , Obstrução da Artéria Renal/cirurgia , Trombose/diagnóstico , Trombose/fisiopatologia , Trombose/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
A 42-year-old female with end-stage chronic kidney disease, who was on maintenance hemodialysis for the last 3 years, presented with facial and upper-limb swelling of 2-month duration. A computed tomography (CT) scan confirmed significant stenosis of the superior vena cava (SVC). Following discussion in a multidisciplinary meeting, it was proposed to perform a repeat endovascular intervention to relieve the SVC obstruction and manage the migrated stent.
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Procedimentos Endovasculares , Átrios do Coração , Síndrome da Veia Cava Superior , Adulto , Feminino , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Humanos , Stents , Síndrome da Veia Cava Superior/diagnóstico , Síndrome da Veia Cava Superior/etiologia , Síndrome da Veia Cava Superior/cirurgia , Veia Cava Superior/diagnóstico por imagem , Veia Cava Superior/cirurgiaRESUMO
We report a case series of 14 cases (mean age 54.14 ± 14.75 years) of successful percutaneous coronary intervention of anomalous left circumflex artery. While the intermediate-term follow-up (mean 36.0 ± 20.58 months) was uneventful in 12 patients, one died of a non-cardiac cause, while other lost to follow-up.
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Anomalias dos Vasos Coronários/cirurgia , Vasos Coronários/cirurgia , Intervenção Coronária Percutânea/métodos , Angiografia Coronária , Anomalias dos Vasos Coronários/diagnóstico , Anomalias dos Vasos Coronários/mortalidade , Vasos Coronários/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida/tendênciasRESUMO
In this difficult case, StentBoost (Philips Medical Systems) demonstrated abluminal passage of the guidewire through the proximal stent struts.
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Angiografia Coronária , Stents , Adulto , Humanos , Masculino , Resultado do TratamentoRESUMO
Although measurements of natriuretic peptides have a role in chronic heart failure and acute coronary syndrome, their role has not been studied in ST-elevation myocardial infarction complicated by cardiogenic shock (CS-STEMI). Sixty-four patients with CS-STEMI were prospectively recruited to assess the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement after 24 h of the onset of angina or anginal equivalent. Patients who died within 24 h were excluded. The mean age was 56.9 ± 10.6 years and the median time to presentation was 22 h (Interquartile range 7-48 h). Thrombolysis was done in 51% and PCI in 31% of cases. The in-hospital mortality was 26.5%. The ROC analysis showed a strong relationship between elevated NT-proBNP and in-hospital mortality (AUC = 0.748; p = 0.003). An NT-proBNP value > 8582 pg/mL showed 76.5% sensitivity, 68% specificity, 46.4% positive predictive value, and 89% negative predictive value for in-hospital mortality. Acute kidney injury [Odds ratio (OR) 7.30; 95% confidence interval (CI) 1.42-37.37] and NT-proBNP (OR 1.12 per 1000 pg/mL; CI 1.012-1.25) were independent predictors of mortality in multivariate regression analysis. Although we found plasma NT-proBNP at 24 h to be an independent predictor of in-hospital mortality in CS-STEMI, additional studies with a larger sample are required to ascertain these findings and validate the appropriate cut-off values.
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Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Medição de Risco/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Choque Cardiogênico/sangue , Biomarcadores/sangue , Eletrocardiografia , Feminino , Seguimentos , Humanos , Incidência , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Precursores de Proteínas , Curva ROC , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/etiologia , Taxa de Sobrevida/tendênciasRESUMO
BACKGROUND: Aorto-oesophageal fistula (AOF) is a rare, catastrophic disease with an extremely poor prognosis. A ruptured thoracic aortic aneurysm is a common aetiology for AOF. The clinical presentation is usually massive haematemesis and collapse. Timely diagnosis and appropriate treatment are crucial in managing AOF. CASE SUMMARY: We hereby report two cases of AOF, who underwent successful emergency thoracic endovascular aortic repair (TEVAR) to control active bleed and exsanguination. Case 1, an elderly lady with atherosclerotic aneurysm had TEVAR followed by open surgery for oesophageal rent and necrosed left main bronchus. Case 2 had mycotic tubercular aneurysm who later had infected graft-stent following TEVAR. DISCUSSION: Open surgery is the conventional treatment for AOF; however, TEVAR can be an alternative and less invasive approach in selected high-risk patients. Various management issues related to TEVAR with AOF have been discussed in the article.
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OBJECTIVE: Transcatheter closure is the first-choice strategy for the management of appropriate patients with patent ductus arteriosus (PDA). The management of large PDAs is challenging due to the limited available sizes of approved devices and the inherent risks of surgical ligation, especially in adults with calcified PDAs. This study aimed to assess the outcomes of the off-label use of large occluders at a tertiary center. METHODS: This retrospective review included patients who underwent transcatheter PDA closure with large occluders (≥16 mm) over 16 years. The baseline patient data, procedural details, angiograms, and immediate outcomes were recorded and patients were followed up at 3, 6, 12 months after the intervention and annually thereafter. RESULTS: Of the 685 patients who underwent transcatheter PDA closure, 36 patients (mean age 16.6 ± 12.5 years) needed occluders ≥ 16 mm in size. Cocoon duct occluder, Cera duct occluder, Amplatzer atrial septal occluder (ASO), and Cera muscular ventricular septal defect occluders were used for PDA closure. There was no device embolization, one patient in whom ASO was used had residual shunt with intravascular hemolysis requiring surgery, and one patient had mild left pulmonary artery narrowing after the intervention, which was managed conservatively. No patient had residual shunt and one patient had persistent pulmonary hypertension at an intermediate duration of follow-up. CONCLUSION: Transcatheter PDA closure with the use of large devices, which are available in Asia and Europe, is an effective and safe method, especially in adolescents and adults. However, a close follow-up of these patients is mandatory.
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Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/instrumentação , Permeabilidade do Canal Arterial/terapia , Dispositivo para Oclusão Septal , Adolescente , Permeabilidade do Canal Arterial/diagnóstico , Permeabilidade do Canal Arterial/cirurgia , Desenho de Equipamento , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Vascular spasm is well known to occur in the arterial system. Central venous spasm during pacemaker implantation is uncommon with only a few cases reported from time to time. Sometimes, the venous spasms may not respond to nitroglycerine injections which requires a change of access site and undue discomfort for the patient. CASE PRESENTATION: A 72-year-old female patient with no prior comorbidities presented to us with recurrent dizziness on exertion and at rest. The electrocardiogram showed complete heart block, likely to be of sclerodegenerative etiology as the patient did not have any ischemic symptoms, also the electrocardiogram and echocardiogram did not show any evidence of ischemia. As part of the hospital protocol, a venogram was performed by giving intravenous diluted contrast (iohexol) through the left brachial vein, which showed good-sized axillary and subclavian veins. We attempted to cannulate the left axillary vein with a 16G needle using Seldinger technique, but the axillary vein could not be cannulated despite multiple attempts. We gave incremental boluses of intravenous nitroglycerine, despite that the left axillary vein could not be cannulated. Repeat intravenous contrast injection showed severe spasm of axillary and subclavian veins. Finally, the axillary vein was cannulated from the right side using anatomical landmarks and a pacemaker was implanted. CONCLUSIONS: Venous spasm during device implantation although uncommon, it should be anticipated in patients with difficult cannulation to prevent inadvertent complications like pneumothorax and arterial injuries. Mild venous spasm may relieve with time but severe venous spasm may require a change of access site.
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Coral reef aorta (CRA) is a rare condition, characterised by rock-hard calcification of the juxta-renal and supra-renal aorta with luminal encroachment causing significant stenosis of the aorta and its branches. It usually presents as resistant hypertension, renal dysfunction, mesenteric ischaemia, limb claudication or embolic manifestations. Although surgical thrombo-endarterectomy along with bypass graft to the affected visceral arteries remains the cornerstone of treatment, it is associated with considerable mortality and morbidity, especially in patients with pre-existing comorbidities. Here we report an elderly female of resistant hypertension, who had successful endovascular aortic stenting using a non-graft self-expanding stent. Her blood pressure dramatically improved following endovascular management. In comparison to the conventional surgical approach, endovascular stenting can be an alternative, less invasive approach in selected CRA patients.