Recomendaciones de consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes graves con infección por COVID-19 / SEDAR-SEMICYUC consensus recommendations on the management of haemostasis disorders in severely ill patients with COVID-19 infection

La infección por el coronavirus SARS-CoV-2, causante de la enfermedad denominada COVID-19, provoca alteraciones fundamentalmente en el sistema respiratorio. En los pacientes graves, con frecuencia la enfermedad evoluciona a un síndrome de distrés respiratorio agudo que puede predisponer a los pacientes a un estado de hipercoagulabilidad, con trombosis tanto a nivel venoso como arterial. Esta predisposición presenta una fisiopatología multifactorial, relacionada tanto con la hipoxia como con el grave proceso inflamatorio ligado a esta patología, además de los factores trombóticos adicionales presentes en muchos de los pacientes.Ante la necesidad de optimizar el manejo de la hipercoagulabilidad, los grupos de trabajo de las sociedades científicas de Anestesiología-Reanimación y Terapéutica del Dolor (SEDAR) y de Medicina Intensiva, Crítica y de Unidades Coronarias (SEMICYUC) han desarrollado un consenso para establecer unas pautas de actuación frente a las alteraciones de la hemostasia observadas en los pacientes graves COVID-19. Estas recomendaciones incluyen la profilaxis de la enfermedad tromboembólica venosa en pacientes graves y en el periparto, el manejo de los pacientes en tratamiento crónico con fármacos antiagregantes o anticoagulantes, de las complicaciones hemorrágicas en la evolución de la enfermedad y de la interpretación de las alteraciones generales de la hemostasia

The infection by the coronavirus SARS-CoV-2, which causes the disease called COVID-19, mainly causes alterations in the respiratory system. In severely ill patients, the disease often evolves into an acute respiratory distress syndrome that can predispose patients to a state of hypercoagulability, with thrombosis at both venous and arterial levels. This predisposition presents a multifactorial physiopathology, related to hypoxia as well as to the severe inflammatory process linked to this pathology, including the additional thrombotic factors present in many of the patients. In view of the need to optimise the management of hypercoagulability, the working groups of the Scientific Societies of Anaesthesiology-Resuscitation and Pain Therapy (SEDAR) and of Intensive, Critical Care Medicine and Coronary Units (SEMICYUC) have developed a consensus to establish guidelines for actions to be taken against alterations in haemostasis observed in severely ill patients with COVID-19. These recommendations include prophylaxis of venous thromboembolic disease in these patients, and in the peripartum, management of patients on long-term antiplatelet or anticoagulant treatment, bleeding complications in the course of the disease, and the interpretation of general alterations in haemostasis

SEDAR-SEMICYUC consensus recommendations on the management of haemostasis disorders in severely ill patients with COVID-19 infection. / Recomendaciones de consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes graves con infección por COVID-19.

The infection by the coronavirus SARS-CoV-2, which causes the disease called COVID-19, mainly causes alterations in the respiratory system. In severely ill patients, the disease often evolves into an acute respiratory distress syndrome that can predispose patients to a state of hypercoagulability, with thrombosis at both venous and arterial levels. This predisposition presents a multifactorial physiopathology, related to hypoxia as well as to the severe inflammatory process linked to this pathology, including the additional thrombotic factors present in many of the patients. In view of the need to optimise the management of hypercoagulability, the working groups of the Scientific Societies of Anaesthesiology-Resuscitation and Pain Therapy (SEDAR) and of Intensive, Critical Care Medicine and Coronary Units (SEMICYUC) have developed a consensus to establish guidelines for actions to be taken against alterations in haemostasis observed in severely ill patients with COVID-19. These recommendations include prophylaxis of venous thromboembolic disease in these patients, and in the peripartum, management of patients on long-term antiplatelet or anticoagulant treatment, bleeding complications in the course of the disease, and the interpretation of general alterations in haemostasis.

Mortalidad de las complicaciones postoperatorias (failure to rescue) tras cirugía cardiaca en un hospital universitario / Mortality from postoperative complications (failure to rescue) after cardiac surgery in a university hospital

Objetivo. Este estudio analiza la frecuencia de las complicaciones postoperatorias tras la cirugía cardiaca, la incidencia del fracaso en el rescate (FR) y su relación con la supervivencia. Métodos. Desde enero del 2003 hasta diciembre del 2009, se intervinieron 2.750 pacientes adultos de cirugía cardiaca. Se analizaron 9 complicaciones postoperatorias. Para conocer las variables asociadas con alguna de estas complicaciones, se realizó análisis de regresión logística múltiple. La supervivencia se estimó mediante curvas de Kaplan-Meier y las complicaciones asociadas con la mortalidad se estimaron mediante regresión de Cox. Resultados. La mortalidad hospitalaria fue 1,4% (IC del 95%, 1,01%-1,9%). La frecuencia de complicaciones postoperatorias fue del 38,5% (36,7%-40,4%) y el FR, 3,6% (2,5%-4,9%). La cirugía urgente (OR = 2,03, IC del 95%, 1,52-2,72), la insuficiencia renal crónica (OR = 1,50, IC del 95%, 1,25-1,80) y la edad ≥70 años (OR = 1,42, IC del 95%, 1,20-1,68) fueron las variables que se asociaron con más fuerza con las complicaciones seleccionadas. La supervivencia a los 5 años fue del 93% en los pacientes sin complicaciones y el 83% en los pacientes con alguna de las complicaciones (p < 0,0001). Las complicaciones asociadas con la supervivencia a medio plazo fueron la neumonía (HR 2,6, IC del 95%, 1,275,50), el infarto agudo de miocardio (HR 1,9, IC del 95%, 1,10-2,30) y la insuficiencia renal aguda (HR 1,7, IC del 95%, 1,30-2,26). Conclusiones. La incidencia de complicaciones postoperatorias en cirugía cardiaca oscila alrededor del 40% y aumenta la mortalidad hospitalaria aunque el FR fue muy bajo (3,6%; IC del 95%, 2,5-4,9) (AU)

Objective. This study analyses the rate of post-operative complications after cardiac surgery, the incidence of the failure to rescue (FR), and the relationship between complications and survival. Methods. The study included a total of 2,750 adult patients operated of cardiac surgery between January 2003 and December 2009. An analysis was made of 9 post-operative complications. Multiple logistic regression analysis was used to find independent variables associated with any of the selected complications. Survival was analysed with Kaplan-Meyer survival estimates. A risk-adjusted Cox proportional regression model was used to find out which complications were associated with mid-term survival. Results. Hospital mortality rate was 1.4% (95% CI: 1.0%-1.9%). Postoperative complications rate was 38.5% (36.7%-40.4%), and FR 3.6% (2.5%-4.9%). Urgent surgery (OR = 2.03; 1.52-2.72), chronic renal failure (OR = 1.50, 95%.CI: 1.25-1.80), and age ≥70 years (OR = 1.42; 1.20-1.68) were the variables that showed the highest strength of association with the selected complications. Survival at 5 years in the group of patients without complications was 93%, and in the group of patients with complications it was 83% (P<.0001). Postoperative complications associated with mid-term survival were pneumonia (HR = 2.6, 95% CI; 1.27-5.50), acute myocardial infarction (HR = 1.9; 1.10-2.30), and acute renal failure (HR = 1.7; 1.30-2.26). Conclusions. The incidence of complications after cardiac surgery is around 40%, and was associated with an increase in hospital mortality, although FR was very low (3.6%; 95% CI: 2.5-4.9) (AU)

[Mortality from postoperative complications (failure to rescue) after cardiac surgery in a university hospital]. / Mortalidad de las complicaciones postoperatorias (failure to rescue) tras cirugía cardiaca en un hospital universitario.

OBJECTIVE: This study analyses the rate of post-operative complications after cardiac surgery, the incidence of the failure to rescue (FR), and the relationship between complications and survival. METHODS: The study included a total of 2,750 adult patients operated of cardiac surgery between January 2003 and December 2009. An analysis was made of 9 post-operative complications. Multiple logistic regression analysis was used to find independent variables associated with any of the selected complications. Survival was analysed with Kaplan-Meyer survival estimates. A risk-adjusted Cox proportional regression model was used to find out which complications were associated with mid-term survival. RESULTS: Hospital mortality rate was 1.4% (95% CI: 1.0%-1.9%). Postoperative complications rate was 38.5% (36.7%-40.4%), and FR 3.6% (2.5%-4.9%). Urgent surgery (OR = 2.03; 1.52-2.72), chronic renal failure (OR = 1.50, 95%.CI: 1.25-1.80), and age ≥70 years (OR = 1.42; 1.20-1.68) were the variables that showed the highest strength of association with the selected complications. Survival at 5 years in the group of patients without complications was 93%, and in the group of patients with complications it was 83% (P<.0001). Postoperative complications associated with mid-term survival were pneumonia (HR = 2.6, 95% CI; 1.27-5.50), acute myocardial infarction (HR = 1.9; 1.10-2.30), and acute renal failure (HR = 1.7; 1.30-2.26). CONCLUSIONS: The incidence of complications after cardiac surgery is around 40%, and was associated with an increase in hospital mortality, although FR was very low (3.6%; 95% CI: 2.5-4.9).

Long-Term Mortality After Pneumonia in Cardiac Surgery Patients: A Propensity-Matched Analysis.

BACKGROUND: The role that intensive care unit (ICU)-acquired pneumonia plays in the long-term outcomes of cardiac surgery patients is not well known. This study examined the association of pneumonia with in-hospital mortality and long-term mortality after adult cardiac surgery. METHODS: A total of 2750 patients admitted to our ICU after cardiac surgery from January 2003 to December 2009 are the basis for this observational study. Patients who developed ICU-acquired pneumonia were matched with patients without it in a 1:2 ratio. The matching criteria were age, urgent or scheduled surgery, surgical procedure, and the propensity score for pneumonia. Multiple regression analysis was used to find predictors of hospital mortality. The relationship between pneumonia and long-term survival was analyzed with Kaplan-Meier survival estimates and a risk-adjusted Cox proportional regression model for patients discharged alive from hospital. RESULTS: Pneumonia was diagnosed in 32 (1.2%) patients and there were 19 cases per 1000 days of mechanical ventilation. Patients with pneumonia had a significantly higher hospital mortality rate (28% vs 6.2%, P = .003) and a higher mortality at the end of follow-up (53% vs 19%, P < .0001) than those without it. Regression analysis showed that pneumonia was a strong predictor of hospital mortality. Five-year survival was as follows: pneumonia, 62%; control, 81%; and cohort patients, 91%. The Cox model showed that, after adjusting for confounding factors, patients with pneumonia (hazard ratio = 3.96, 95% confidence interval [CI]: 1.41-11.14) had poorer long-term survival. CONCLUSION: Pneumonia remains a serious complication in patients operated for cardiac surgery and is associated with increased hospital mortality and reduced long-term survival.

Endoscopic follow-up and management of Barrett's esophagus in relation to its preneoplastic potential.

Barrett's esophagus is an acquired clinical condition in which the squamous epithelium of the distal esophagus is replaced by a columnar epithelium. The diagnosis requires histological confirmation of specialized intestinal metaplasia, in which goblet cells must be present. Barrett's esophagus is a risk factor for the development of esophageal adenocarcinoma, a tumor with an incidence and mortality have increased alarmingly in recent years in the western world. It has been estimated that the annual incidence of cancer in patients with Barrett's esophagus has increased from 0.2-2%. Once diagnosed, Barrett's esophagus is estimated to have an annual neoplastic transformation rate of 0.5% per patient. The highlights of the endoscopic diagnosis and treatment are reviewed here, as well as the screening and monitoring of this process.

Transfusión de hematíes y supervivencia a largo plazo en la cirugía cardíaca no complicada / Red cell transfusion and long-term survival in non-complicated heart surgery

OBJETIVO: Averiguar si existe asociación entre la transfusión perioperatoria de 1-2 unidades de hematíes y la morbilidad hospitalaria, la mortalidad a 30 días y la supervivencia a largo plazo en los pacientes operados en cirugía cardíaca. DISEÑO: Estudio de cohorte prospectivo. Ámbito: UCI de un hospital universitario. PACIENTES: Se valoró a todos los pacientes mayores de 17 años operados de cirugía cardíaca e ingresados en la UCI desde noviembre del 2002 hasta diciembre del 2009. Se analizó a los pacientes que no recibieron transfusión de hematíes (n = 703) y a los que recibieron transfusión perioperatoria de 1-2 unidades de hematíes (n = 959). Variables de interés: Se analizó el efecto de la transfusión sobre la morbilidad hospitalaria y la mortalidad a 30 días. El seguimiento de los enfermos dados de alta vivos del hospital finalizó el 31 de diciembre del 2011. La asociación de la transfusión con la supervivencia a largo plazo se evaluó con el método de Kaplan-Meier. La evaluación de los posibles factores predictivos de mortalidad a largo plazo se realizó mediante la construcción de modelos de regresión de Cox. RESULTADOS: La frecuencia de complicaciones postoperatorias cardíacas y no cardíacas fue mayor en los pacientes que recibieron transfusión. La mortalidad a 30 días de estos últimos fue mayor que en los pacientes no transfundidos (1% vs. 0,1%, p = 0,02). La presencia de anemia preoperatoria se asoció a un mayor uso de transfusión. La transfusión de hematíes no fue un factor de riesgo de mortalidad a largo plazo (Hazard ratio = 1,4; intervalo de confianza del 95%, 0,9-2,1). CONCLUSIONES: La transfusión perioperatoria de 1-2 unidades de hematíes en los pacientes operados de cirugía cardíaca se asocia a un incremento de la morbilidad hospitalaria y la mortalidad a 30 días, y no tiene efecto en la mortalidad a largo plazo

OBJECTIVE: A study was made to explore the possible association between the perioperative transfusion of 1 - 2 red blood cell units and in-hospital morbidity, 30-day mortality, and long-term survival in patients undergoing heart surgery. DESIGN: A prospective observational study was carried out. SETTING: The ICU of a university hospital. PATIENTS: All patients over 17 years of age that underwent heart surgery and were admitted to the ICU between November 2002 and December 2009 were included. Those patients who did not (n = 703) and those who did (n = 959) receive the perioperative transfusion of 1 - 2 red blood cell units were assessed. Study endpoints: The endpoints were the effect of transfusion on both hospital morbidity and on 30-day mortality. In addition, all patients discharged alive from hospital until 31 December 2011 were subjected to follow-up. The association between transfusion and survival was assessed by means of the Kaplan-Meier method. Cox proportional hazards models were used to assess factors associated with long-term survival. RESULTS: The frequency of both cardiac and non-cardiac perioperative complications was higher in patients receiving transfusion. The 30-day mortality rate was higher in those who received transfusion (1% vs 0.1%, P = .02). Preoperative anemia was associated with a more intensive use of transfusion. Red blood cell transfusion was not found to be a risk factor for long-term mortality (hazar ratio = 1.4, 95% CI 0.9-2.1). CONCLUSIONS: The perioperative transfusion of 1 - 2 red blood cell units in patients undergoing heart surgery increases both hospital morbidity and the 30-day mortality rate, but does not increase long-term mortality

[Red cell transfusion and long-term survival in non-complicated heart surgery]. / Transfusión de hematíes y supervivencia a largo plazo en la cirugía cardíaca no complicada.

OBJECTIVE: A study was made to explore the possible association between the perioperative transfusion of 1 - 2 red blood cell units and in-hospital morbidity, 30-day mortality, and long-term survival in patients undergoing heart surgery. DESIGN: A prospective observational study was carried out. SETTING: The ICU of a university hospital. PATIENTS: All patients over 17 years of age that underwent heart surgery and were admitted to the ICU between November 2002 and December 2009 were included. Those patients who did not (n=703) and those who did (n=959) receive the perioperative transfusion of 1 - 2 red blood cell units were assessed. STUDY ENDPOINTS: The endpoints were the effect of transfusion on both hospital morbidity and on 30-day mortality. In addition, all patients discharged alive from hospital until 31 December 2011 were subjected to follow-up. The association between transfusion and survival was assessed by means of the Kaplan-Meier method. Cox proportional hazards models were used to assess factors associated with long-term survival. RESULTS: The frequency of both cardiac and non-cardiac perioperative complications was higher in patients receiving transfusion. The 30-day mortality rate was higher in those who received transfusion (1% vs 0.1%, P=.02). Preoperative anemia was associated with a more intensive use of transfusion. Red blood cell transfusion was not found to be a risk factor for long-term mortality (hazar ratio=1.4, 95%CI 0.9-2.1). CONCLUSIONS: The perioperative transfusion of 1 - 2 red blood cell units in patients undergoing heart surgery increases both hospital morbidity and the 30-day mortality rate, but does not increase long-term mortality.

Valor pronóstico de las micrometástasis linfoganglionares en pacientes con cáncer colorrectal en estadios A y B de Dukes (T1-T4, N0, M0) / Prognostic value of lymph node micrometastases in patients with colorectal cancer in Dukes stages A and B (T1-T4, N0, M0)

Introducción: un 30% de los pacientes con cáncer colorrectal(CCR) en estadios A y B de Dukes (T1-T4, N0, M0) presentan recidivatumoral y/o fallecen a los 5 años. Esta inesperada malaevolución, en casos presumiblemente curados podría deberse, entreotras causas, a la presencia de micrometástasis linfoganglionaresno detectadas en el estudio de rutina: hematoxilina-eosina(H&E).Objetivo: determinar si la presencia de micrometástasis linfoganglionaresdetectadas mediante inmunohistoquímica con anticuerposanticitoqueratina AE1/AE3, influyen en la evolución delCCR.Pacientes y métodos: se han estudiado los ganglios linfáticoslocorregionales de 85 pacientes con CCR en estadios A y Bde Dukes (T1-T4, N0, M0), mediante técnicas de inmunohistoquímicacon anticuerpos anticitoqueratinas AE1/AE3, para poner demanifiesto la presencia de micrometástasis. Se ha realizado un estudiodescriptivo, inferencial bivariante y de supervivencia, segúndistintos factores de riesgo, centrado en la presencia o no de micrometástasis.Resultados: hemos observado que el estadio de Dukes y laangioinvasión neoplásica son factores que influyen en el pronósticode estos pacientes. Sin embargo, no se ha demostrado que lapresencia de micrometástasis linfoganglionares se asocie a unapeor evolución en el CCR.Conclusiones: las micrometástasis linfoganglionares locorregionalesdetectadas mediante anticuerpos anticitoqueratinaAE1/AE3, en pacientes con CCR en estadios A y B de Dukes, nose asocian a una menor supervivencia(au9

Background: 30% of patients with colorectal cancer (CRC) inDukes stages A and B (T1-T4, N0, M0) present tumor recurrenceand die after 5 years follow up. This unexpectedly poor evolutionmight be attributable to the presence of lymph node micrometastasisundetected in routine examination with haematoxilin-eosine(H&E).Objective: to assess the presence of undetected micrometastasis.Patients and methods: we conducted a retrospective studyof the locoregional lymph nodes in 85 patients operated for CRCin Dukes stages A and B (T1-T4, N0, M0), using immunohistochemistrywith anticytokeratin antibodies AE1/AE3. In this descriptive,inferential bivariant and survival study, we analyzed differentrisk factors, including local infiltration T1/T4, Dukes A/B,number of dissected lymph nodes, vascular invasion, micrometastasis,tumor recurrence and death in the context of the presenceor absence of micrometastases.Results: Dukes stage and neoplastic angioinvasion are influentialin patient prognosis; however, lymph node micrometastaseswere not associated with a poorer outcome of CRC.Conclusions: locorregional lymph node micrometastases detectedwith anticytokeratine antibodies AE1/AE3 in Dukes A andB CRC patients are not associated with reduced survival(AU)

[Diagnosis and management of choledochal cysts. A review of 10 new cases]. / Diagnóstico y tratamiento de los quistes de colédoco. Presentación de 10 nuevos casos.

AIM: the aim of this study was to analyze the diagnostic and therapeutic options for the various types of this rare disease. PATIENTS AND METHODS: 10 patients with choledochal cysts (CC) were diagnosed in our hospital since 1991. Type of cyst was established according to the Alonso-Lej classification. RESULTS: we report 7 type-I, 1 type-III, 1 type-IVa, and 1 type-V CC cases. Clinical manifestations were abdominal pain in all cases with biliary or pancreatic features. The diagnosis was established using abdominal ultrasonography, computed tomography, and endoscopic retrograde cholangiopancreatography (ERCP). All 7 patients with type-I CC underwent total cyst excision with Roux-en-Y hepatojejunostomy. For type-III CC an endoscopic sphincterotomy (ES) was performed, and in type-IVa CC a transductal sphincterotomy and cholecistectomy was made. The patient with Caroli s disease (type V) underwent liver transplantation. We have followed up all patients for several years without significant complications. CONCLUSIONS: CC is more frequent in childhood, but is not exceptional in the adult. Imaging techniques and ERCP play an important role in the diagnosis, and also in the treatment of type-III cysts. Therapeutic options depend on cyst type, but due to the potential malignancy of this disease total cyst excision is recommended for types I, II and IV. In type-III CC endoscopic sphyncterothomy is recommended, while liver transplantation is sometimes necessary for type V. Long-term follow-up is crucial to prevent malignant transformation except for type-III CC where this complication is very unusual.

Diagnóstico y tratamiento de los quistes de colédoco. Presentación de 10 nuevos casos / No disponible

Objetivo: analizar las técnicas diagnósticas y las distintas posibilidadesterapéuticas de esta rara patología.Pacientes y métodos: presentamos un estudio retrospectivode todos los casos de quistes de colédoco diagnosticados en nuestrohospital desde 1991. Incluye 10 nuevos casos y distintos tiposde quistes de colédoco (QC).Resultados: de los 10 pacientes diagnosticados de QC sietetenían menos de 10 años. En cuanto a los diferentes tipos de QC:7 eran de tipo I, 1 de tipo III, 1 de tipo IVa y otro de tipo V. Lasmanifestaciones clínicas habitualmente tenían un perfil biliar opancreático. El diagnóstico se ha realizado mediante técnicas deimagen no invasivas (ECO, TAC) y CPRE. El tratamiento ha venidocondicionado por el tipo de quiste: quistectomía con hepaticoyeyunostomíaen “Y de Roux” en los de tipo I, CPRE con esfinterotomíaendoscópica en los de tipo III y trasplante hepático en laenfermedad de Caroli. En el único QC tipo IVa se realizó una papilotomíatransductal y una colecistectomía. Todos han sido controladosperiódicamente, sin que hayamos registrado complicacionesrelevantes durante el seguimiento.Conclusión: los QC son más frecuentes en niños pero no sonexcepcionales en adultos. Las técnicas de imagen y la CPRE sonesenciales en el diagnóstico de esta patología. El tratamiento dependerádel tipo de quiste de colédoco. Es aconsejable el seguimientoperiódico y prolongado de estos pacientes para detectarprecozmente complicaciones como la transformación maligna

Aim: the aim of this study was to analyze the diagnostic and therapeuticoptions for the various types of this rare disease.Patients and methods: 10 patients with choledochal cysts(CC) were diagnosed in our hospital since 1991. Type of cyst wasestablished according to the Alonso-Lej classification.Results: we report 7 type-I, 1 type-III, 1 type-IVa, and 1 type-VCC cases. Clinical manifestations were abdominal pain in all caseswith biliary or pancreatic features. The diagnosis was established usingabdominal ultrasonography, computed tomography, and endoscopicretrograde cholangiopancreatography (ERCP). All 7 patientswith type-I CC underwent total cyst excision with Roux-en-Y hepatojejunostomy.For type-III CC an endoscopic sphincterotomy (ES) wasperformed, and in type-IVa CC a transductal sphincterotomy andcholecistectomy was made. The patient with Caroli’s disease (type V)underwent liver transplantation. We have followed up all patients forseveral years without significant complications.Conclusions: CC is more frequent in childhood, but is not exceptionalin the adult. Imaging techniques and ERCP play an importantrole in the diagnosis, and also in the treatment of type-III cysts.Therapeutic options depend on cyst type, but due to the potentialmalignancy of this disease total cyst excision is recommended fortypes I, II and IV. In type-III CC endoscopic sphyncterothomy is recommended,while liver transplantation is sometimes necessary fortype V. Long-term follow-up is crucial to prevent malignant transformationexcept for type-III CC where this complication is very unusual

[Spontaneous aneurysmal portohepatic fistula: imaging diagnosis]. / Fístula aneurismática portohepática venosa espontánea: diagnóstico por imagen.

Intrahepatic portosystemic venous shunts not related to trauma or biopsy are infrequent and their etiology is controversial. A congenital or acquired origin due to cirrhosis and portal hypertension has been proposed. Hepatic encephalopathy is present when there is associated cirrhosis. We describe a case of aneurysmal portohepatic venous fistula that was incidentally diagnosed with conventional ultrasonography and was subsequently confirmed by Doppler ultrasonography and computed tomography scan. Because there were no symptoms of encephalopathy, no surgical or vascular percutaneous treatment was provided.