A case of hepatocellular carcinoma with pseudoaneurysm formation upon lenvatinib administration.

A 79-year-old man received treatment for multiple intrahepatic hepatocellular carcinoma with atezolizumab + bevacizumab. However, he developed lower back pain attributed to spinal metastases upon tumor enlargement; thus, he was admitted to our hospital for a change from atezolizumab + bevacizumab to lenvatinib and radiation therapy for the spinal metastases. On the 11th day after starting lenvatinib treatment, a pulsatile aneurysm appeared in the tumor, detected using abdominal ultrasonography Micro B-flow imaging, which visualized blood flow at a high frame rate; this was diagnosed as a pseudoaneurysm. The patient refused treatment for the pseudoaneurysm; therefore, he was carefully followed up. Fortunately, the pseudoaneurysm disappeared on the 17th day. One month later, the tumor had become completely necrotic. Lenvatinib demonstrated effectiveness in inhibiting angiogenesis in the tumor, as evidenced by a decrease in tumor blood flow. This case report suggests that pseudoaneurysm formation within the tumor occurs early after the administration of lenvatinib; thus, clinicians must be aware of the potential risk of pseudoaneurysm rupture.

Painful shoulder in a patient receiving anticoagulation therapy with rivaroxaban. / Hombro doloroso en paciente anticoagulado con rivaroxabán.

We report the case of an 83-year-old man on rivaroxaban treatment, with pain in right shoulder, back of the upper arm, forearm and wrist, and inability to extend the wrist and fingers, as the result of an injury. The radiographs were normal, but thoracic CT showed an axillary artery pseudoaneurysm and a secondary hematoma that compressed the brachial plexus. This should be borne in mind in patients with painful shoulder, treated with anticoagulant therapy and without associated radiographic changes.

Anticoagulation-induced unilateral adrenal haemorrhage and pseudoaneurysm.

Spontaneous unilateral adrenal haemorrhage (AH) is extremely rare. Its presentation is usually non-specific and requires a high degree of suspicion as it is associated with high morbidity and mortality if diagnosis is delayed. Hereby, we present a case of 67-year-old man with significant cardiac history presented with right-sided chest pain and non-specific abdominal pain. He was previously treated for non-ST elevation myocardial infarction 5 days ago prior to the current presentation. CT scan of abdomen and pelvis demonstrated a right-sided active AH. The patient subsequently underwent digital subtraction angiography. Angio-embolisation was attempted for the pseudoaneurysm but failed due to spasm of the vessel. He was managed conservatively and discharged after clinical improvement. Clinic review 6 months later showed significant size reduction of the pseudoaneurysm.

Complications of Bioglue postsurgery for aortic dissections and aortic valve replacement.

AIMS: Bioglue is an adhesive used during cardiovascular surgery to improve hemostasis perioperatively and to strengthen and reinforce vascular anastomoses. It has also been used to 'seal' the false lumen in patients presenting with acute aortic dissections. Herein, we examine the complications of Bioglue, which may lead to redo sternotomy in selected patients. METHODS: A review of pathology records at our institution from 2002 to 2010 found 4 cases of excised aortic tissue and/or aortic valves with previous Bioglue use at initial operation. Excised tissues and valves were examined, looking for the presence of Bioglue, inflammatory cells (acute, chronic, macrophage and giant cells) and micro-organisms. Patient demographics were also reviewed and recorded. RESULTS: We identified four cases of Bioglue use found at redo surgery, after the formation of pseudoaneurysm (n=3) and aortic stenosis (n=1). Mean interval to redo surgery was 2.28 + 0.32 years (range 2-2.6 years). Pseudoaneurysm formation was thought to be caused by an inflammatory reaction to the Bioglue itself in two cases, while one case found no such reaction. One patient with previous aortic valve replacement had large annular abscesses filled with necrotic debris surrounding the prosthesis and pannus found on the sewing cuff, comprised of Bioglue itself. CONCLUSIONS: The mechanisms leading to these complications include mechanical strain, inflammation and tissue necrosis. The judicious use of Bioglue when clinically indicated, and close follow-up of these patients with serial imaging, remain an integral part of avoiding future complications.

Intracranial bilateral vertebral artery dissection during anticoagulation after cerebral venous and sinus thrombosis (CSVT).

A 37-year-old woman presented with cerebral venous and sinus thrombosis (CVST). During the period of anticoagulation she developed asymptomatic dissection of the intracranial segments of both vertebral arteries with an enlarging false aneurysm on the right side. Endovascular occlusion of the pathological segment of the right vertebral artery including the dissecting aneurysm and conservative management of the other side resulted in complete recovery without neurological complications.

Two significant complications following percutaneous needle fasciotomy in a patient on anticoagulants.

Percutaneous needle fasciotomy treatment of Dupuytren's disease has been used on the continent for over two decades but has only recently gained popularity in the UK. The National Institute for Clinical Excellence published guidance in February 2004 stating that the procedure is safe and effective. We report a case of two complications in the same patient following the use of the technique, on only one occasion, in a patient who was anticoagulated. We believe that it is the first time that a false aneurysm has been reported following the procedure and that this was probably related to the inhibited coagulation cascade. The patient also sustained an injury to flexor digitorum profundus but had an intact superficialis tendon and we find it difficult to explain this occurrence. We report the above complication as we feel this technique may be chosen specifically in patients with co-existing medical problems such as anticoagulation.

Eptifibatide in peripheral vascular interventions: results of the Integrilin Reduces Inflammation in Peripheral Vascular Interventions (INFLAME) trial.

An acute inflammatory response occurs following percutaneous coronary and peripheral vascular interventions (PVI), partly mediated by platelet activation. Glycoprotein (GP) IIb-IIIa inhibitors might partially attenuate this inflammation rise in the coronary patient, but data in patients undergoing PVI are lacking. In the Integrilin Reduces Inflammation in Peripheral Vascular Interventions trial (INFLAME), we hypothesized that eptifibatide reduces the acute inflammatory responses following PVI. This is a single-center, randomized, open-label study of intravenous eptifibatide (180 micro/kg bolus x 2, 10 minutes apart, then 2 micro/kg/min infusion over 18 hours) and low-dose unfractionated heparin (60 Units per kg, target activated clotting time (ACT) 200-250 sec) [LDH+I group; n = 21] versus high-dose unfractionated heparin alone (100 Units per kg, target ACT 300-400 sec) [HDH group; n = 21] in patients undergoing iliac and infrainguinal interventions. The primary endpoints of the study were markers of inflammation (soluble CD-40L [sCD-40L], high-sensitivity C-reactive protein [hs-CRP] and interleukin-6 [IL-6]), thrombin generation (Fragment 1.2 [F1.2]), and fibrinogen measured at baseline and postrandomization. Markers were assayed at baseline, postdilatation at 30 minutes, 2 hours, 18 hours, 48 hours and 7 days. Mean platelet inhibition with eptifibatide was 98% (range 92-100%) using the Accumetrics Rapid Platelet Function Assay at 10 minutes after final bolus. After adjusting for baseline values, the mean +/- SE difference in sCD-40L (loge scale), hs-CRP and F1.2 between the LDH+I group and the HDH was not significant. Fibrinogen had significantly higher mean levels at 7 days for the LDH+I group (541.19 mg/dL versus 472.26 mg/dL; p-value = 0.024). IL-6 was more detectable in the LDH+I group compared to the HDH following intervention. We conclude that LDH+I combination did not reduce acute inflammatory responses as compared to HDH in patients undergoing peripheral vascular interventions.

[Acute femoral artery thrombosis after thrombin injection of a pseudoaneurysm]. / Akute Femoralarterienthrombose nach Thrombininjektionsbehandlung eines Aneurysma spurium. Erfolgreiche Katheterintervention und intraarterielle Fibrinolyse mit r-tPA.

HISTORY: A 64-year old woman was admitted because of unstable angina pectoris. The coronary angiogram revealed two-vessel coronary disease with predominantly subtotal stenosis of the right coronary artery, which was treated by primary coronary stenting. The post-interventional clinical course after closure of the right femoral artery was complicated by the development of a complex pseudoaneurysm: its ultrasound-guided compression was unsuccessful. INVESTIGATIONS: The clinical findings included a marked superficial hematoma in the right groin without any evidence of an abscess, confirmed by color duplex ultrasonography. TREATMENT AND COURSE: 24 hours later a successful percutaneous ultrasound-guided thrombin injection of the pseudoaneurysm was performed without any problems regarding the injection into the aneurysm. A small area within the aneurysm remained perfused and was treated by additional ultrasound-guided compression. A few minutes after the compression complete thrombosis of the right superficial femoral artery occurred with acute critical ischemia of the right leg, probably due to leakage of thrombin into the femoral artery at the sheath puncture. The immediate therapy, including interventional recanalization of the right femoral superficial artery and subsequent fibrinolysis, produced a complete reperfusion of the right femoral superficial and popliteal artery. The fibrinolytic therapy resolved the thrombosis of the pseudoaneurysm. The remainder of the perfused pseudoaneurysm was treated surgically after one week without problems. CONCLUSION: This case demonstrates a so far rarely published complication of the displacement of thrombin from an intervention ally treated pseudoaneurysm into the right superficial femoral artery through a broad compound channel after ultrasound-guided compression.

[Recurrent hemoptysis secondary to an aortobronchial fistula]. / Hemoptisis recurrente secundaria a una fístula aortobronquial.

Aortobronchial fistula is a rare but serious cause of hemoptysis. It can develop from an aneurysm of the descending thoracic aorta in the context of infections or it may appear as a sequel of surgical repair of congenital heart defects. Presenting symptoms include mild bronchial hemorrhages and recurrent chest pain, culminating in a normally fatal massive hemorrhage. Diagnosis by imaging is not always conclusive and clinical suspicion based on medical history is essential. Surgical placement of an endovascular stent graft is the treatment of choice. Post-surgical prognosis is good although there is a risk of recurrence in the case of superinfection.

Psuedoaneurysm of the superficial femoral artery resulting from stingray envenomation.

Stingray envenomations usually result in minor injuries with localized symptoms. In some cases the injury incurred is more serious, resulting in significant morbidity if not adequately treated. We report a case of pseudoaneurysm of the superficial femoral artery resulting from a stingray envenomation in a young female. Stingray venom is known to have necrosing properties in human tissues and in this case this led to graft failure requiring surgical repair. This case emphasizes the insidious nature of stingray venom and the necessity of extensive surgical debridement for more significant envenomations.

Oral anticoagulant therapy during and after coronary angioplasty the intensity and duration of anticoagulation are essential to reduce thrombotic complications.

BACKGROUND: In the randomized Balloon Angioplasty and Anticoagulation Study (BAAS), the addition of oral anticoagulants to aspirin significantly reduced early and late events after coronary angioplasty. However, bleeding episodes were increased. The present report studied the intensity and the duration of anticoagulation as predictors of thrombotic and bleeding events. METHODS AND RESULTS: A total of 530 patients, 34% of whom received a stent, were treated with aspirin plus coumarins. Half of the patients were randomized to angiographic follow-up. The target international normalized ratio (INR) was 2.1 to 4.8 during angioplasty and 6-month follow-up. Thrombotic events were death, myocardial infarction, target lesion revascularization, and thrombotic stroke. Bleeding complications were hemorrhagic stroke, major extracranial bleeding, and false aneurysm. "Optimal" anticoagulation was defined as an INR in the target range for at least 70% of the follow-up time. There were 17 early thrombotic events (3.2%), 7 early bleeding episodes (1.3%), and 10 false aneurysms (1.9%). The incidence rate for both early thrombotic and bleeding events was lowest in patients in the target range. A total of 61 late thrombotic events occurred (11.6%). Optimal anticoagulation was an independent predictor of late thrombotic events (relative risk, 0.33; 95% CI, 0.19 to 0.57) and was associated with a 0.21 mm (95% CI, 0.17 to 0.42) larger vessel lumen at 6 months. Late bleeding episodes (1.4%) were lowest in patients in the target range. CONCLUSIONS: Coumarins started before coronary angioplasty with a target INR of 2.1 to 4.8 led to the lowest procedural event rate, without an increase in bleeding episodes. During follow-up, optimal anticoagulation was associated with a decrease in the incidence of late events by 67% and a significant improvement in 6-month angiographic outcome.

Recurrence of dialysis shunt pseudoaneurysm following percutaneous thrombin embolization.

We report an unusual case of a 58-year-old woman on maintenance hemodialysis who presented with an iatrogenic radial artery pseudoaneurysm proximal to a Cimino-Brescia fistula. The pseudoaneurysm was not amenable to ultrasonographic compression due to the vascular anatomy. The pseudoaneurysm recurred despite initial successful response to two direct injections of thrombin on separate occasions. We highlight the role of ultrasound and thrombin injection in the treatment of pseudoaneurysm and emphasize the need for follow-up ultrasound examination to monitor recurrence.