Acute Pancreatitis-Induced Thrombosis of Celiac Artery: An Unusual Complication of Acute Pancreatitis.

Acute pancreatitis can lead to both local and systemic complications, including pseudocysts, biliary obstruction, duodenal obstruction, sepsis, necrosis, vascular complications, and multiorgan failure. Vascular complications following acute pancreatitis are associated with a high risk of morbidity and mortality due to their thrombotic and hemorrhagic effects. When thrombosis is present, it usually involves the splanchnic venous system, but it is rarely seen in the arterial system. Celiac artery thrombosis is rare with only a few cases reported in the literature. In this case, we present a 65-year-old Hispanic female who presented to the emergency department with abdominal pain and nausea, with computed tomography angiography (CTA) of the abdomen revealing acute pancreatitis with thrombosis of the celiac artery, which was managed with anticoagulation.

Trombosis arterial aguda de miembros inferiores en pacientes infectadospor la COVID-19: experiencia en un hospital nacional de Perú / Acute lower limb arterial thrombosis in COVID-19 infected patients: experience in a national hospital in Peru

Introducción y objetivo: la pandemia por la COVID-19 se ha asociado a una serie de condiciones clínicas vasculares de tipo trombosis arterial aguda de miembros inferiores (TAAmI), que se han relacionado con un elevada morbimortalidad y pérdida de la extremidad afectada. El objetivo del estudio fue describir las carácterísticas clínico-quirúrgicas de los pacientes infectados por la COVID-19 y con TAAmI en un hospital nacional de Perú. Métodos: estudio observacional, descriptivo y retrospectivo realizado en el Hospital Nacional Edgardo Rebagliati martins desde marzo del 2020 a febrero del 2022. Las principales variables consideradas fueron el estadio clínico de la COVID-19, exámenes de laboratorio, grado, tiempo y ubicación del TAAmI, tratamiento, tipo de amputación, mortalidad y supervivencia a 30 días. Resultados: se analizaron 96 pacientes (edad media: 62,9 años), principalmente varones (61,45 %), y la principal comorbilidad fue la diabetes (54,16 %). El tiempo medio de TAAmI fue de 11,5 horas y el 25 % del total de pacientes presentó la infección severa de la COVID-19. El principal marcador Rutherford fue IIB (32,29 %) y las principales arterias afectadas pertenecieron al segmento femoropoplíteo (femoral superfi cial: 41,81 %) e infrapoplíteo (tibial anterior: 39,67 %). La tromboembolectomía (60,41 %) fue el principal tratamiento quirúrgico y el 55,17 % de los pacientes terminaron en amputación. La supervivencia y la mortalidad a 30 días fue del 46,8 % y del 53,2 %, respectivamente. Las principales causas de mortalidad fueron la difi cultad respiratoria severa (69,41 %) y el shock séptico (22,94 %). Conclusiones: el diagnóstico precoz y el manejo oportuno de la TAAmI determinan un factor importante para el pronóstico del paciente; sin embargo, las comorbilidades asociadas, la gravedad de la infección por la COVID-19, tiempos prolongados de isquemia, infección sobreagregada y los estados hiperinfl amatorios relacionados terminan dirigiendo...(AU)

Introduction and objective: the COVID-19 pandemic has been associated with a series of clinical vascular conditions of the Acute Arterial Thrombosis of the Lower Limbs (AATLL) type and which have been associated with highmorbidity and mortality and loss of the affected limb. The objective of the study was to describe the clinical-surgicalcharacteristics of patients infected with COVID-19 and TAAmI in a national hospital in Peru. Methods: observational, descriptive; and retrospective study carried out at the Edgardo Rebagliati martins NationalHospital from march 2020-February 2022. The main variables considered were the clinical stage of COVID-19, lab-oratory tests, grade, time and location of the TAAmI, treatment, type of amputation, mortality; and 30-day survival. Results: 96 patients (mean age, 62.9 years) mainly male (61.45 %) were analyzed; and the main comorbidity was diabetes (54.16 %). The mean TAAmI time was 11.5 hours, and 25 % of all patients presented severe COVID-19 infection.The main Rutherford Score was IIB (32.29 %) and the main affected arteries belonged to the femoro-popliteal segment(superficial femoral, 41.81 %) and infra-popliteal (anterior tibial, 39.67 %). Thromboembolectomy (60.41 %) was the mainsurgical treatment and 55.17 % of the patients ended in amputation. Survival and mortality at 30 days were 46.8 % and53.2 %, respectively. The main causes of mortality were severe respiratory distress (69.41 %) and septic shock (22.94 %).Conclusions: early diagnosis and timely management of TAAmI determines an important factor for the patient'sprognosis; however, the associated comorbidities, severity of the COVID-19 infection, prolonged times of ischemia,superimposed infection and related hyperinflammatory states, end up directing the patient's destiny towards aseries of complications that include amputation, functional limitation and associated mortality.(AU)

Acute Thrombosis of Left Anterior Descending Coronary Artery During Anaphylactic Reaction to Contrast Dye.

Anaphylaxis is a systemic inflammatory response to an antigen and can result in hemodynamic compromise. While uncommon, it remains an important differential diagnosis in the setting of intraprocedural hypotension. Acute thrombosis has been associated with anaphylaxis and should be suspected based on clinical symptoms. We describe a clinical case of intraprocedural anaphylaxis secondary to intravenous contrast dye leading to hypotension and acute thrombosis of the left anterior descending coronary artery.

[Acute arterial thrombosis in hemophilia with inhibitory antibodies]. / Ostryi arterial'nyi tromboz pri ingibitornoi forme gemofilii.

The authors demonstrate an importance of personalized approach to perioperative hemostatic therapy in a 48-year-old patient with hemophilia A and inhibitory antibodies. Laparoscopic hernia repair and extraction of 15 decayed teeth were performed. Hemostatic therapy included AICC and rFVIIa. Postoperative period was complicated by acute thrombosis of splenic artery and partial spleen infarction. An essential factor in splenic artery thrombosis was increase in blood coagulation potential under rFVIIa administration and depletion of fibrinolytic system (prolongation of XIIa-dependent fibrinolysis from 25 to 75 min) and antithrombin III decrease up to 81%. Cancellation of hemostatic therapy under TEG control ensured fast regression of arterial thrombosis and preservation of spleen. Individual characteristics of patients (compensatory mechanisms of coagulation, comorbidities, clinical changes) should be considered when prescribing hemostatic therapy in hemophilia patients. Perioperative control of all possible coagulation tests (routine and integral) is required for individual selection of hemostatic therapy and decrease of the risk of hemorrhagic and thrombotic complications.

COVID-19-Associated Acute Limb Ischemia in a Patient on Therapeutic Anticoagulation.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been found to cause multiple complications across several organ systems in patterns not typically observed in previous iterations of the virus. Hemostatic mechanisms have been noted to be significantly altered in particular, resulting in a disseminated intravascular coagulation (DIC)-like picture with elements of coagulopathy as well as hypercoagulability. A 65-year-old man with hypertension, hyperlipidemia, prior tobacco use, chronic kidney disease, and diabetes presented from a correctional facility with hypoxia. The diagnosis of COVID-19 was confirmed. With his elevated D-dimer of >7,955 ng/mL (reference: 90-500 ng/mL) in the setting of COVID-19 and hypoxia, he was empirically started on therapeutic anticoagulation with enoxaparin. His oxygen requirements increased, mental status deteriorated, and platelets began falling, raising concern for heparin-induced thrombocytopenia versus DIC. Heparin products were discontinued in favor of a direct oral anticoagulant. He later became obtunded and unable to tolerate oral medications. Fondaparinux was initiated. Two days later, he was found to have acute limb ischemia of the right lower extremity. He underwent surgical thrombectomy but required an above-the-knee amputation the following day. Shortly after he died secondary to hypoxic respiratory failure. This case highlights the derangement of hemostatic mechanisms seen prominently in COVID-19 infection and raises questions as to appropriate anticoagulant choices to adequately prevent thrombosis. Thorough physical exams should be performed on all patients with COVID-19, taking into account this documented hypercoagulability. Further investigation is warranted into the use of heparin products as the anticoagulant of choice in these patients given observed deficiencies of antithrombin III (ATIII).

Acute aortoiliac and infrainguinal arterial thrombotic events in four patients diagnosed with the novel coronavirus 2019.

The novel coronavirus disease 2019 (COVID-19) pandemic is seriously challenging the healthcare system globally. Endothelial damage and increased coagulation activity have been reported in some patients with COVID-19, resulting in a variety of thrombotic events. We report the cases of four patients with various severities of COVID-19 who had presented with acute arterial thrombosis. Although these are rare events, they carry high morbidity and mortality and require prompt diagnosis and treatment. These cases highlight the major life- and limb-threatening clinical sequelae of COVID-19 that frontline medical providers must be aware can occur even in the absence of previous cardiovascular disease.

Acute Promyelocytic Leukemia Presenting as Bilateral Acute Limb Ischemia and ST Elevation Myocardial Infarction: A Case Report.

Acute myelogenous leukemia (AML) is one of the most common hematologic malignancies. Among them, acute promyelocytic leukemia (APL) is well known for its coagulopathies. Bleeding secondary to disseminated intravascular coagulation, is a common initial presentation and carries a high risk for mortality if left untreated. Thrombotic complications are uncommon and can be related to treatment with chemotherapeutic agents. Large artery thrombosis is very rare, and standardized management remains elusive given the classic revascularization techniques carry a significant risk of re-thrombosis, as well as high risk for mortality given the multiple surgical and percutaneous interventions that are attempted. A multidisciplinary approach is necessary in these cases to carefully weigh the risk and benefits as the classical approach to revascularization and acute arterial thrombosis could potentially cause harm.

Experiencia de trabajo en cirugía vascular en Ecuador / Experiences working in vascular surgeries in Ecuador

Introducción: Las enfermedades vasculares periféricas comprenden un variado número de entidades nosológicas que afectan a los sistema arterial (excluidos los vasos del corazón, e intracraneales) y venolinfáticos del organismo. Objetivo: Describir las características de los pacientes que necesitaron ser atendidos por un cirujano vascular por presentar algún tipo de enfermedad vascular periférica. Métodos: Estudio descriptivo realizado en el total de pacientes atendidos por consulta externa y hospitalizados en el Servicio de Cirugía Vascular del Instituto Ecuatoriano de Seguridad Social; Hospital Manuel Ignacio Montero Valdivieso. El período de estudio fue de dos años (septiembre de 2014 a octubre de 2016). Se tuvieron en cuenta las siguientes enfermedades vasculares periféricas: enfermedades vasculares periféricas, insuficiencia venosa crónica, pie diabético, trombosis venosa profunda y trombosis arterial aguda Los resultados se expresaron en trabajo con las frecuencias absolutas y relativas. Resultados: La insuficiencia venosa crónica fue la causa más frecuente de hospitalización y consulta externa. Se encontró un predominio del sexo femenino. La úlcera del pie diabético se ubicó en orden decreciente de frecuencia entre las enfermedades consideradas. El desbridamiento quirúrgico o limpieza quirúrgica fue el procedimiento más empleado. La amputación mayor se realizó en todos los pacientes que tuvieron una trombosis arterial aguda de extremidades inferiores. Conclusiones: Se describen las características de los pacientes atendidos por el cirujano vascular en Ecuador, así como las enfermedades vasculares periféricas más frecuentes atendidas que son motivo de consulta externa y de hospitalización(AU)

Introduction: Peripheral vascular diseases include a varied number of nosologic entities that affect the arterial (excluding heart and intracranial vessels) and venolymphatic systems of the organism. Objective: To characterize patients who needed to be treated by a vascular surgeon after presenting some type of peripheral vascular disease. Method: A descriptive and prospective study was carried out in all the patients treated by external consultation and to the patients hospitalized in the service of Vascular surgery of the Ecuadorian Institute of Social Security and Manuel Ignacio Montero Valdivieso Hospital. The study lasted two years ( from September 2014 to October 2016). The following peripheral vascular diseases were taken into account: peripheral vascular diseases, chronic venous insufficiency, diabetic foot, deep-vein thrombosis and acute arterial thrombosis. The results were expressed in this paper with absolute and relative frequencies. Results: Chronic venous failure was the most frequent cause of hospitalization and outpatient consultation. A prevalence of female sex was found. The diabetic foot ulcer was observed in a decreasing order of frequency. Surgical debridement and/or surgical cleaning were the most used procedures. Major amputations were performed in all patients who had an acute arterial thrombosis of the lower limbs. Conclusions: It was possible to characterize the patients treated by the vascular surgeon in Ecuador, as well as the most frequent peripheral vascular diseases attended that needed outpatient consultation and hospitalization(AU)

Mesenteric Ischemia: A Deadly Miss.

Mesenteric ischemia has 4 etiologies: arterial embolus, arterial thrombosis, venous thrombosis, and nonocclusive. No history or physical examination finding can definitively diagnose the condition. A wide variety of presentations occur. Pain out of proportion and gut emptying may occur early, with minimal tenderness. Once transmural infarction occurs, peritoneal findings and tenderness to palpation may occur. Physicians must be suspicious of pain out of proportion and scrutinize risk factors. Computed tomography angiography is the best imaging modality. Treatment requires surgery and interventional radiology consultation, intravenous antibiotics and fluids, and anticoagulation. The physician at the bedside is the best diagnostic tool.

Elevated Factor VIII Levels Associated with Acute Graft Occlusion and Arterial and Venous Thrombosis After Off Pump CABG.

Factor VIII is a common acute phase reactant and elevated levels confer an increased risk of thrombosis. Such thrombotic events have been documented in the literature, though to a limited extent. We present the case of a 54-year-old man presenting with a non-Q-wave myocardial infarction who was found to have triple vessel disease and subsequently underwent a 4-vessel coronary artery bypass grafting (CABG). Postoperatively, he was found to have multiple occluded vessels, deep vein thromboses, and a cerebrovascular accident (CVA). A hypercoagulability work-up revealed significantly elevated levels of factor VIII at 377% normal, which likely contributed to these thrombotic events. Further exploration is warranted to elucidate causal mechanisms of these thrombotic events, particularly of multiple graft occlusions, and to guide clinical decision making with regards to anticoagulation and stent management.

Significantly reduced function of T cells in patients with acute arterial thrombosis.

OBJECTIVES: To explore the intrinsic factors related to the pathogenesis of acute arterial thrombosis (AAT) and to elucidate the pathogenesis of AAT on the basis of differentially expressed genes. METHODS: Patients with acute myocardial infarction (AMI), stable angina (SA) and healthy controls (n = 20 per group) were recruited, and the whole human genome microarray analysis was performed to detect the differentially expressed genes among these subjects. RESULTS: Patients with AMI had disease-specific gene expression pattern. Biological functional analysis showed the function of T cells was significantly reduced, the mitochondrial metabolism significantly decreased, the ion metabolism was abnormal, the cell apoptosis and inflammatory reaction increased, the phagocytosis elevated, the neutrophil-mediated immunity increased and the post-traumatic repair of cells and tissues increased in AMI patients. The biological function in SA group and healthy controls remained stable and was comparable. CONCLUSIONS: The reduced function of T cell gene models in AAT showed the dysfunction of the immune system. The pathogenesis of AAT may be related to the inflammatory reaction after arterial intima infection caused by potential pathogenic microorganisms.

Significantly reduced function of T cells in patients with acute arterial thrombosis / 老年心脏病学杂志（英文版）

Objectives To explore the intrinsic factors related to the pathogenesis of acute arterial thrombosis (AAT) and to elucidate the patho-genesis of AAT on the basis of differentially expressed genes. Methods Patients with acute myocardial infarction (AMI), stable angina (SA) and healthy controls (n=20 per group) were recruited, and the whole human genome microarray analysis was performed to detect the dif-ferentially expressed genes among these subjects. Results Patients with AMI had disease-specific gene expression pattern. Biological func-tional analysis showed the function of T cells was significantly reduced, the mitochondrial metabolism significantly decreased, the ion me-tabolism was abnormal, the cell apoptosis and inflammatory reaction increased, the phagocytosis elevated, the neutrophil-mediated immunity increased and the post-traumatic repair of cells and tissues increased in AMI patients. The biological function in SA group and healthy con-trols remained stable and was comparable. Conclusions The reduced function of T cell gene models in AAT showed the dysfunction of the immune system. The pathogenesis of AAT may be related to the inflammatory reaction after arterial intima infection caused by potential pathogenic microorganisms.

A Case of Repeated Acute Limb Ischemia with Malignant Tumor / 日本心臓血管外科学会雑誌

A 72-year-old man had undergone aorto-bifemoral bypass for Leriche syndrome at age 67, but acute limb ischemia developed three times after the first operation, in January 2008, April 2008, and April 2009. There were no abnormal heart rhythms or thrombotic factors, and he had received anticoagulant therapy with warfarin (target prothrombin time-international normalized ratio : 1.7 to 3.0) since January 2008. Nevertheless, he came to our hospital because of sudden onset of severe pain in the right lower limb in April 2010. Since CT showed occlusions in the right leg involving the aortobifemoral bypass and femoropopliteal bypass graft, emergency thrombectomy and femoropopliteal bypass (below knee), was performed. CT on admission showed enlargement of lymph nodes around the stomach, and gastric cancer was diagnosed by esophagogastroduodenoscopy. Since we considered the hypercoagulability in this patient with cancer to have resulted in repeated acute arterial thrombosis, these episodes were broadly diagnosed as Trousseau's syndrome.

A case of acute arterial thrombosis caused by nephrotic syndrome.

Venous thromboembolic complications are frequently caused by nephrotic syndrome, while arterial thrombosis has rarely been reported. We report the successful treatment of a 53-year-old man who suffered from sudden severe pain of the left lower limb and facial edema. Abdominal computed tomography showed that the left common iliac artery was occluded from its origin. Although he had left peroneal nerve paralysis, thrombectomy and fasciotomy were performed for limb salvage. Renal biopsy revealed minimal change nephrotic syndrome after the operation. No recurrence has been observed. Nephrotic syndrome might be considered as a cause of acute arterial thrombosis.

Acute Arterial Thrombosis in Leg Associated with Hyperhomocysteinemia

Herein, two cases of acute arterial thrombosis associated with hyperhomocysteinemia are reported. A 34-year old male patient without heart disease, was brought to hospital with an acute ischemic limb due to thromboses of both superficial femoral arteries, where no atherosclerotic lesions were found. Subsequent investigation revealed that the patient had hyperhomocysteinemia, with a low folic acid level. Catheter directed thrombolysis was attempted, but failed, so bypass surgery was performed. After revascularization, anticoagulation therapy and folate supplementation were initiated. His plasma homocysteine level returned to normal, and there has been no recurrence during the 48 month follow up periods. The other case was a 51-year man with an acute left ilio-femoro-popliteal artery occlusion, who had also shown hyperhomocysteinemia, with a low folic acid level. There was nothing abnormal from his medical records, and showed normal findings in his transesophageal echocardiogram. In a serologic hypercoagulability test, everything was normal, with the exception of an increased homocysteine level. After a successful thrombectomy with a Fogarty catheter, folate supplementation was administered until his homocysteine level returned to normal. In both patients, the heterozygous mutation of 5, 10-methylenetetrahydrofolate reductase (MTHFR), C677T (alanine to valine substitution), was detected.