The Role of Ultrasound in Venous Thoracic Outlet Syndrome: Lesson Based on a Case Report.

Thoracic outlet syndrome is a rare neurovascular disease, usually caused by compression of subclavian vessels and/or brachial plexus by a cervical rib or hypertrophic scalene muscles. When the subclavian artery is compressed, it can cause perfusion deficiency with cyanosis and greater fatigue of the upper limb; if the subclavian vein is compressed, it can cause venous congestion with swelling and pain in the upper limb. When compression affects the brachial plexus, it can cause tingling or paresthesia of the upper limb. It can be mono or bilateral, congenital, or acquired. The diagnosis of vascular alterations is difficult due to the rarity, poor knowledge, and nonspecificity of symptoms. Ultrasound allows to localize and measure the vascular stenosis degree. Failure to diagnose can expose patients to serious health risks. We describe a rare case of venous compression caused by anterior scalene muscle hypertrophy.

Prostate Artery Embolization as Minimally Invasive Treatment for Benign Prostatic Hyperplasia: An Updated Systematic Review.

Background/Objectives: Benign prostatic hyperplasia (BPH) has a significant impact on the quality of life of symptomatic patients. In patients manifesting lower urinary tract symptoms (LUTS), prostatic arterial embolization (PAE) has become a topic of interest in recent years. The purpose of this systematic review is to analyze and review techniques and clinical outcomes of patients who underwent endovascular treatment of BPH, with a special focus on the comparison of surgical and endovascular procedures. Methods: Through the major scientific databases, 1225 articles were selected from the initial research utilizing specific keywords and medical subject headings. Based on the inclusion and exclusion criteria established for selecting relevant studies for our purposes, the systematic analysis of the literature was conducted on a total of seven articles. Results: We collected data on 718 male patients (408 patients underwent PAE and 310 received TURP). The technical success rate varied from 86% to 100% for TAE and was 100% for TURP. During a 12-month follow-up period, both PAE and TURP were comparable on the reduction in IPSS and QoL questionnaire, while TURP showed significant improvements in Qmax and in the reduction in prostate volume. Length and cost of hospitalization were lower for PAE. Complication and adverse events rates were higher in the TURP group rather than in the PAE group (60.6% vs. 35.5%). Conclusions: Prostatic artery embolization represents an emerging minimally invasive procedure for BPH. According to previously released clinical studies, quality-of-life and urological symptom scores of the PAE group were comparable to those of the TURP group. Our research strengthens the evidence supporting the effectiveness and safety of PAE as a therapy for LUTS related to BPH.

Vascular compression syndromes: a pictorial review.

Vascular compression syndromes include a group of rare vascular changes due to extrinsic compression of veins or arteries by surrounding structures. These pathologies are often underestimated due to their rarity, clinicians' poor level of knowledge, and the non-specificity of their symptoms. The best known are Eagle syndrome, thoracic outlet syndrome, nutcracker syndrome, May-Thurner syndrome, Dunbar syndrome, and popliteal entrapment syndrome. This work summarizes the main ultrasonographic characteristics, symptoms, and treatments of choice for these syndromes. Knowledge of these conditions' characteristic signs is essential for the differential diagnosis. Failure to diagnose these rare diseases can expose patients to serious complications and risks to their health.

Wilkie Syndrome and Pseudo-Nutcracker Syndrome a Rare Combination: Description of a Case.

Wilkie's syndrome is a very rare vascular alteration caused by congenital or acquired reduction of space between the superior mesenteric artery (SMA) and aorta. In acquired form, it is caused by perivascular adipose tissue reduction due to rapid weight loss and, if symptomatic, causes postprandial vomiting and weight loss. The left renal vein (LRV) when it has a retro-aortic course can be compressed in aorto-vertebral space (AVS); if the stenosis is severe it can cause venous congestion symptoms with left flank pain, microhematuria, and thrombosis, this vascular alteration is known as a pseudo-nutcracker syndrome. The combination of Wilkie's and pseudo-nutcracker's syndrome (PNCS) is very rare and has not yet been described in the literature. We describe a case of a 62-year-old woman who presented symptoms and alterations typical of two syndromes.

A man with the rare simultaneous combination of three abdominal vascular compression syndromes: median arcuate ligament syndrome, superior mesenteric artery syndrome, and nutcracker syndrome.

Median arcuate ligament syndrome and superior mesenteric artery syndrome are well-known abdominal compression syndromes, the coexistence of which is rarely described in literature. In addition, due to the common pathogenesis, anterior nutcracker syndrome may occur simultaneously to superior mesenteric artery syndrome. To our knowledge, this is the first case reporting combination of these 3 syndromes detected with ultrasound, Computed Tomography and upper gastrointestinal fluoroscopic exam. A 69-year-old man came to our attention for rapid weight loss, postprandial epigastric pain and recurrent vomiting for at least 6 months. Doppler ultrasound showed both celiac artery and left renal vein stenosis with simultaneous left varicocele. Computed tomography showed a reduction of aortomesenteric space causing both left renal vein and duodenal stenosis, this latter confirmed by upper gastrointestinal fluoroscopic exam. The diagnosis of these three vascular compression syndromes (MALS, SMAS, and anterior NCS) has been formulated, based on clinical and imaging findings. We assumed that the postprandial crises caused by median arcuate ligament syndrome may induce a reduction of meals consumption and progressive weight loss which can be a cause of anterior nutcracker syndrome and superior mesenteric artery syndrome onset. Doppler ultrasound, in expert hands, allows to accurately diagnosing these syndromes which are often underestimated. Failure to recognize it and inadequate treatment could have serious consequences for patients' health.

May-Thurner Syndrome with Double Compression of the Iliac Vein: Lessons Based on a Case Report.

BACKGROUND May-Thurner syndrome, also known as Cockett's syndrome, is characterized by vascular alterations due to stenosis of the left iliac vein, usually caused by compression against the vertebral column by the right iliac artery. Doppler ultrasound represents the first level of examination for the study of this vascular pathology, and allows a very accurate study of the lower-limb vessels. We describe an unusual presentation with double stenosis of the left common iliac vein. CASE REPORT A 73-year-old woman came to the clinic for acute onset of worsening dyspnea, with lymphedema of the left lower limb, and was examined using ultrasound and multidetector computed tomography. The Doppler ultrasound exam showed 2 compressions of the common iliac vein by the right and left iliac artery due to a combination of osteophytosis of the vertebral column and reduced distance between the left iliac vein and the spine. CONCLUSIONS May-Thurner syndrome should be suspected in patients with symptoms of venous stasis of the left lower limb. Doppler ultrasound identified stenosis of the common iliac vein and the consequent flow changes. Failure to diagnose and treat May-Thurner syndrome could expose patients to very serious risks to their health.

Superior mesenteric artery syndrome (Wilkie Syndrome) with unusual clinical onset: Description of a rare case.

Wilkie's Syndrome is a very rare disease caused by reduction of aorto-mesenteric space with consequent duodenum compression. It can combine with left renal vein stenosis which, when symptomatic, is known as "Nutcracker Syndrome". We describe a clinical onset case with epigastric pain without vomiting in a normal weight patient. 28-year-old woman who came to our observation for intense epigastric pain after a weight loss of 14 kg in 4 months. Multidetector Computed Tomography and Ultrasound revealed gastric and duodenal overdistension with hydro-air levels, severe duodenum stenosis, and left renal vein compression. Wilkie's Syndrome is common in anorexic individuals suffering from recurrent postprandial vomiting, onset with severe epigastric pain, without vomiting, is quite unusual. High-calorie diet must be first therapeutic approach, in case of failure treatment of first choice should be endovascular stenting and, only in selected cases, surgical treatment should be used because it is very invasive and burdened with numerous complications. Failure to diagnose this disease can expose patients to serious health risks.

Stylo-Jugular Venous Compression Syndrome: Lessons Based on a Case Report.

BACKGROUND Eagle syndrome is a vascular compression syndrome that is caused by a very elongated styloid process and/or calcification of the stylohyoid ligament compressing the vascular or nerve structures of the neck, resulting in vascular congestion, thrombosis, or neurological symptoms (eg, dysphagia, neck pain, ear pain). Stylo-jugular venous compression syndrome is a subtype of Eagle syndrome and is caused by compression of the internal jugular vein. Treatment varies according to the symptoms and the severity of the compression, and it can be pharmacological or surgical, with vascular stenting and/or removal of the styloid process. We describe a rare case of left cerebral venous sinus thrombosis and ipsilateral internal jugular vein stenosis sustained by excessive length of the left styloid process. CASE REPORT A 36-year-old woman presented with recurrent episodes of drug-resistant headache and recent memory disturbances. She underwent cerebral and neck multidetector computed tomography-angiography and Doppler ultrasound of the epiaortic vessels that respectively revealed thrombosis of the left cerebral venous sinus and left internal jugular vein stenosis due to a very long styloid process. The patient was treated with anticoagulant drugs and experienced a gradual remission of symptoms. CONCLUSIONS Compression of the jugular vein by the styloid process is a rare entity, and it often goes undiagnosed when it is asymptomatic. Doppler ultrasound is a sensitive method for identifying jugular vein stenosis and can provide an estimated degree of stenosis, which is useful for treatment planning. Doppler ultrasound should be combined with multidetector computed tomography-angiography to rule out compression of other vascular structures and other causes of compression. Failure to treat these patients could have serious health consequences for them.

Non traumatic intrathoracic liver herniation mimicking a pulmonary metastasis in patient with breast cancer: A case report.

Non-traumatic hepatic hernia is defined as hepatic protrusion through acquired or congenital defects on diaphragm without prior trauma. This event is rare among adults and infrequently reported in literature. 52-year-old Caucasian woman with surgically treated breast cancer with suspected lung metastasis detected during a routine Multidetector Computed Tomography lung exam. Ultrasound and subsequently Magnetic Resonance Imaging (MRI) was performed which revealed an overdiaphragmatic mass in contiguity with liver parenchyma compatible with overdiaphragmatic hepatic hernia. Differential diagnosis should be made with diaphragmatic or pulmonary nodule. Correct diagnosis can avoid further diagnostic investigations or invasive procedures such as biopsy. Magnetic Resonance Imaging is a non-risky method and can clarify interpretative doubts. Currently there are still controversies about traumatic or idiopathic nature of this hernia.