Non Target Shunting of Tc-99m Macroaggregates of Albumin and Radiolabeled Yttrium-90 Microspheres into Hepatic Falciform Artery - Less Observed Arterial Variant not to be Overlooked.

Identification of nontarget arteries is crucial prior to Yttrium-90 microspheres radioembolization. We present a case where an uncommon nontarget artery, the hepatic falciform artery was identified during work up for radioembolization and necessary preventive measures were taken to minimize the complications.

Recurrent Stenoses in Arteriovenous Fistula (AVF) for Dialysis Access: cuttIng ballooN angioplaSTy combined wITh paclitaxel drUg-coaTed balloon angioplasty, an observatIONal study (INSTITUTION Study).

PURPOSE: To study the safety and efficacy of cutting balloon angioplasty (CBA) followed by paclitaxel drug-coated balloon (PCB) angioplasty for recurrent venous lesions in arteriovenous fistulas (AVFs). MATERIALS AND METHODS: We conducted a prospective single-arm cohort study of CBA followed by PCB angioplasty for recurrent AVF stenoses between September 2017 and April 2019. In total, 44 participants were recruited. Target lesions were included if they had recurred within 12 months post-angioplasty, were > = 0.5 cm upstream from the arteriovenous anastomosis, and did not involve the central veins. Up to two non-target lesions per circuit/participant with the same definition were allowed. Lesions were considered separate when there was an intervening 2-cm segment of normal vessel. Technical success was defined as complete lesion effacement on angioplasty. End-points of target and circuit patency were evaluated clinically at 3, 6, and 12 months post-procedure. RESULT: Technical success was 96% (42/44): Two participants were excluded from analysis due to the need for high-pressure balloon angioplasty as the target lesions did not efface with CBA. The median follow-up duration was 337.5 days. Mean stenosis pre- and post-angioplasty was 69.0% (51.6-84.8) and 20.8% (0-44.8), respectively. The target lesion primary, primary assisted and circuit patency for the entire study population (n = 42) were 61.6 ± 7.8%, 92.7 ± 4.0%, and 54.7 ± 7.9%, respectively, at 12 months. For participants without non-target lesions (n = 22), the rates were 77.3 ± 8.9%, 90.9 ± 6.1%, and 60.7 ± 11.0%, respectively, at 12 months. CONCLUSION: CBA followed by PCB angioplasty appears safe and feasible for treatment of recurrent venous lesions in dysfunctional AVFs.

MagicTouch PTA Sirolimus Coated Balloon for Femoropopliteal and Below the Knee Disease: Results From XTOSI Pilot Study Up To 12 Months.

INTRODUCTION: Sirolimus coated balloon (SCB) is a promising treatment option to prevent restenosis for peripheral arterial occlusive disease (PAOD). This is a pilot first-in-human study of MagicTouch percutaneous transluminal angioplasty (PTA) SCB for treatment of PAOD for both femoropopliteal and below the knee arteries (BTK). MATERIAL AND METHODS: Xtreme Touch-Neo [MagicTouch PTA] Sirolimus Coated Balloon (XTOSI) pilot study is a prospective, single-arm, open-label, single-center trial evaluating MagicTouch PTA SCB for symptomatic PAOD. Primary endpoint was defined as primary patency at 6 months (duplex ultrasound peak systolic velocity ratio ≤2.4). Secondary endpoints included clinically driven target lesion revascularization (CD-TLR), amputation free survival (AFS), all-cause mortality, and limb salvage success. RESULTS: Fifty patients were recruited. The mean age was 67 (n=31 [62%] males). SCB was applied to femoropopliteal in 20 patients (40%) and BTK in 30 patients (60%). Majority of treatments (94%) were performed for limb salvage indications (Rutherford scores 5 or 6). This was a high risk cohort, in which 90% had diabetes, 36% had coronary artery disease, 20% had end stage renal failure, and American Society of Anaesthesiologists (ASA) score was 3 or more in 80%. Mean lesion length treated was 227±81 mm, of which 36% were total occlusions. Technical and device success were both 100%. At 30 days, mortality was 2% and major limb amputation was also 2%. Six-month primary patency was 80% (88.2% for femoropopliteal; 74% for BTK). At 12 months, freedom from CD-TLR was 89.7% (94.1% for femoropopliteal; 86.3% for BTK), AFS was 81.6% (90.0% for femoropopliteal; 75.9% for BTK), all-cause mortality was 14.3% (10.0% for femoropopliteal; 17.2% for BTK), and limb salvage success was 92.9% (94.4% for femoropopliteal; 91.7% for BTK). There was a statistically significant increase between baseline and 6-month toe pressures for both femoropopliteal (57.3±23.3 mm Hg vs 82.5±37.8 mm Hg; p<.001) and BTK lesions (52.8±19.2 mm Hg vs 70.7±37 mm Hg; p<.037). At 12 months, wound healing rate was 33/39 (84.6%). CONCLUSIONS: MagicTouch PTA SCB in the XTOSI study showed promising 6-month primary patency and encouraging 12-month freedom from CD-TLR, AFS, and limb salvage rates. No early safety concerns were raised. Randomized trials are needed to investigate the safety and efficacy of SCB for treatment of PAOD.

Randomized Controlled Trial Comparing Drug-coated Balloon Angioplasty versus Conventional Balloon Angioplasty for Treating Below-the-Knee Arteries in Critical Limb Ischemia: The SINGA-PACLI Trial.

Background There is a paucity of randomized trials demonstrating superior efficacy of drug-coated balloon angioplasty (DCBA) compared with conventional percutaneous transluminal angioplasty (PTA) for below-the-knee arterial disease in patients with -critical limb ischemia. Purpose To compare DCBA versus PTA for below-the-knee lesions in participants with critical limb ischemia through 12 months. Materials and Methods In this prospective, randomized, two-center, double-blind superiority study, participants with critical limb ischemia with rest pain or tissue loss with atherosclerotic disease in the native below-the-knee arteries were randomly assigned (in a one-to-one ratio) to DCBA or PTA after stratification for diabetes and renal failure between November 2013 and October 2017. The primary efficacy end point was angiographic primary patency at 6 months analyzed on an intention-to-treat basis. Secondary end points through 12 months were composed of major adverse events including death and major amputations, wound healing, limb salvage, clinically driven target-lesion revascularization, and amputation-free survival. Primary and binary secondary end points, analyzed by using generalized-linear model and time-to-event analyses, were estimated with Kaplan-Meier survival curves and hazard ratios (Cox regression). Results Seventy participants (mean age, 61 years ± 10 [standard deviation]; 43 men) in the DCBA group and 68 (mean age, 64 years ± 10; 50 men) in the PTA group were evaluated. The percentage of patients with angiographic primary patency at 6 months was 43% (30 of 70) in the DCBA group and 38% (26 of 68) in the PTA group (P = .48). Through 12 months, the percentage of deaths was similar: 21% in the DCBA group and 16% in the PTA group (P = .43). Amputation-free survival rate assessed with Kaplan-Meier curves differed through 12 months: 59% (41 of 70) in the DCBA group compared with 78% (53 of 68) in the PTA group (P = .01). Conclusion In participants with critical limb ischemia, the drug-coated balloon angioplasty group and the conventional percutaneous transluminal angioplasty group had similar primary patency rates at 6 months after treatment of below-the-knee arteries. Amputation-free survival rates through 12 months were higher in the percutaneous transluminal angioplasty group. © RSNA, 2021 Online supplemental material is available for this article.

Combined utility of one lung ventilation and artificial pneumothorax in thermal ablation of hepatic dome tumor: a technical note.

Radiofrequency ablation and microwave ablation are established treatment modalities for smaller (<3 cm) or isolated hepatic tumors. Transthoracic ablation of hepatic dome lesions is a well described technique. We report the use of one lung ventilation to facilitate the successful percutaneous transthoracic microwave ablation of a segment 8 hepatic dome lesion after induction of artificial pneumothorax. This involved the use of general anesthesia and insertion of a double lumen endotracheal tube to allow isolated ventilation of one lung, followed by creation of an artificial pneumothorax under computed tomography (CT) guidance. Complete ablation of the lesion was confirmed on CT liver at 1 and 7 months with no local recurrence. The combined techniques of one lung ventilation and artificial pneumothorax enabled a safe and accurate transthoracic targeting of the hepatic dome lesion.

Computed tomography venography versus intravascular ultrasound in the diagnosis of iliofemoral vein stenosis.

Background: Iliofemoral vein stenosis can cause debilitating chronic venous disease. Diagnostic tools include both computed tomography venography (CTV) and intravascular ultrasonography (IVUS). We aim to compare the diagnostic performance of CTV and IVUS. Patients and methods: We performed a retrospective study of patients with chronic venous disease presenting with iliac vein compression or post-thrombotic limb symptoms, excluding those with acute deep vein thrombosis, high anaesthesia risk, or who had contrast allergy. All patients received CTV before IVUS, as part of the diagnostic work-up and intervention. The cross-sectional area (CSA) of iliofemoral vein segments obtained from both studies were compared against reference CSAs to derive percentage stenosis. A 50% reduction in CSA was considered significant. Results: We studied 50 patients between May 2018 and April 2019. 58% of patients had severe disease CEAP C5-6. 48% of patients had at least one vein segment with significant stenosis. The left proximal common iliac vein was the most commonly stenosed vein segment (n = 12, 24% on IVUS). CSA measurements from CTV were greater than those of IVUS, with a correlation coefficient of 0.57 (p < 0.005). Conversely, percentage stenosis measured on CTV was lower than on IVUS, with approximately one-third of significant stenosis missed on CTV (58 veins from CTV vs. 78 from IVUS, p < 0.005). With IVUS as the gold standard, CTV has low sensitivity (37.2%, 95% CI 26.5-48.9) and high specificity (92.5%, 95% CI 89.3-94.9) in detecting significant stenosis. Conclusions: CTV has limited diagnostic performance in identifying iliofemoral vein stenosis. Patients with normal CTV findings should proceed with IVUS imaging if the clinical features are supportive of iliofemoral vein stenosis.

Management of arterial dissections in 12 patients during transarterial chemoembolization and yttrium-90 selective internal radiotherapy for primary and secondary liver tumours.

OBJECTIVE: To describe rates and management strategies of arterial dissections in transarterial chemoembolization (TACE) and Yttrium-90 selective internal radiotherapy (90Y SIRT) for primary and secondary liver tumours. MATERIALS AND METHODS: This retrospective review included 1377 hepatic angiographies between May 2010 and June 2015 in a single centre for TACE and 90Y SIRT of liver tumours. The angiogram results, management, treatment outcomes and follow-up angiography/imaging findings were recorded. RESULTS AND DISCUSSION: Twelve cases of arterial dissections (12/1377, 0.87%) were documented. Three dissections (3/633, 0.47%) occurred during TACE, seven (7/449, 1.56%) during pre-treatment planning angiographies (PTPA) for 90Y SIRT, and two (2/249, 0.80%) during the treatment procedure of 90Y SIRT. The preferred management strategy was to manoeuvre past the dissection and complete the procedure, which was achieved in six patients (50%). Angioplasty with stenting was performed in one patient. In three patients, the procedure was held off for up to 3 months to allow the dissection to heal before repeating the procedure. A dissection that occurred during PTPA was detected only when the patient returned for 90Y SIRT. PTPA was immediately repeated for this patient. The last patient opted for sorafenib. Residual 50% stenosis was seen in one patient on follow-up hepatic angiography, but he was otherwise asymptomatic. In the remaining patients, no residual dissection or clinical sequelae was observed on follow-up. CONCLUSION: Arterial dissection is a rare but important complication of transarterial locoregional therapy. Where possible, attempts should be made at completing the therapy. Deferring treatment can be considered as dissections usually heal within 3 months. LEVEL OF EVIDENCE: Level 4, case series.

Use of the VENOVO™ and Sinus Obliquus™ venous stents in the treatment of non-thrombotic or post-thrombotic iliac vein lesions - Short-term results from a multi-centre Asian cohort.

OBJECTIVES: Deep venous stenting with intravascular ultrasound (IVUS) guidance is gaining favour as the treatment modality of choice for symptomatic ilio-femoral venous occlusive disease. The aim was to determine the short-term patency and symptomatic relief gained using the Bard Venovo™ and Optimed Sinus Obliquus™ stents in the endovascular treatment of non-thrombotic iliac vein lesions (NIVL) and post-thrombotic venous obstruction (PTO) from two Asian tertiary vascular centres. METHODS: Sixty patients (males = 21/60 (35.0%); median age 67 years (interquartile range 54-77)) who underwent IVUS interrogation and ilio-femoral stenting (June 2018-May 2019) in two Asian centres were prospectively followed. Clinical improvement was determined by the revised Venous Clinical Severity Score (rVCSS), pain using the Visual Analogue Scale (VAS) and ulcer healing rate. Patency rates were evaluated using Duplex ultrasound and computer tomography venogram. RESULTS: Seventy-one legs were interrogated and stented; 11/60 (18.3%) patients had a bilateral procedure. Indications for surgery were PTO (n = 11/71 (15.5%)) and NIVL (n = 60/71 (84.5%)). Twenty-seven of 71 (38.0%) patients had CEAP 6 disease. The median follow-up was 283 (interquartile range 211-370) days. Technical and procedural success was both 100%. Twenty-one of 71 (29.6%) legs had a combination of Venovo™ and Sinus Obliquus™ stents inserted for concurrent ilio-caval and iliac lesions. There were no major post-operative complications. Six-month primary, assisted primary and secondary patency rates were 94.1, 97.1 and 100%, respectively. There were no stent fractures. Mean rVCSS and VAS improved from 12.26 (±3.31) to 4.33 (±2.78) and 6.97 (±1.38) to 2.03 (±1.65), respectively, at three months (p < 0.01). Complete ulcer healing was seen in 27/27 (100%) patients at three months. CONCLUSION: Use of Venovo™ and Sinus Obliquus™ stents for symptomatic ilio-femoral venous disease showed excellent six-month primary patency rate with no stent fractures. There were significant clinical improvement and low-device-related complications. Longer follow-up is awaited to see how these dedicated venous stents perform.

Endovascular Deep Vein Stenting of Symptomatic Post-Thrombotic and Non-Thrombotic Iliac Vein Stenotic Lesions: A Multicentre Cohort Experience from Singapore.

INTRODUCTION: This paper presents our experience with deep venous stenting in a multi-ethnic Asian cohort of patients with symptomatic Non-Thrombotic Iliac Vein Lesions (NIVL) and Post-Thrombotic Syndrome (PTS). MATERIALS AND METHODS: This was a multicentre retrospective cohort study of patients who had symptomatic deep venous disease. Stent patency rate was evaluated using Duplex ultrasonography immediately post-intervention and at 3, 6 and 12 months. Clinical outcomes were evaluated using the revised Venous Clinical Severity Score (rVCSS) and Visual Analogue Scale (VAS) pain score at baseline and 3 months post-procedure. RESULTS: 87 patients (males = 47/87 (54.0%)); median age = 62 years (IQR 55 - 70)) and 115 limbs were analysed (left = 76/115 (66.1%)). Median follow-up time was 175 (IQR 57 - 257) days. 97/115 (84.3%) had NIVLs and 55/115 (47.8%) had May-Thurner-Syndrome. 43/115 (37.4%) had Clinical, Etiology, Anatomy and Pathophysiology (CEAP) 6 disease. Primary stent patency rates were 98.2% (112/114), 97.9% (93/95), 95.7% (89/93) and 92.8% (64/69) immediately post-intervention, 3, 6 and 12 months, respectively. The 6-month secondary patency rate was 99.1% (114/115). Mean rVCSS and VAS improved from 11.52 (±3.54) to 5.77 (±2.36) (P < 0.01) and 6.62 (±1.93) to 2.92 (±1.50) (P < 0.01) respectively, at 3 months. 41/43 (95.3%) venous ulcers healed over a median time of 169 days (IQR 120 - 253). CONCLUSIONS: Short term primary patency rates following deep venous stenting are excellent, with few re-interventions. Patients presented with NIVLs rather than PTS. There was excellent clinical improvement at 3 months, with a high and expedient venous ulcer healing rate.

"Angioplasty-First" Approach for Limb Salvage in Asian Patients with Critical Limb Ischemia: Outcomes from 3,303 Angioplasties on 2,402 Limbs in a Single Tertiary Hospital.

PURPOSE: To review outcomes of patients with critical limb ischemia (CLI) who underwent conventional percutaneous transluminal angioplasty (PTA) as first-line treatment for revascularization. MATERIALS AND METHODS: Retrospective review of 3,303 angioplasty procedures on 2,402 limbs in 1,968 patients with CLI was conducted. Mean patient age was 68 years ± 11, and 1,057 patients (54%) were male. Diabetes mellitus (DM) was present in 1,736 patients (88%), and end-stage renal disease (ESRD) in 579 (29%). A majority of patients (90%) had tissue loss. Limb salvage rates were generated by Kaplan-Meier plot. Univariate and multivariate Cox regression analysis was conducted to investigate associations between clinical predictors and time-to-event outcome. RESULTS: Limb salvage rates at 1, 3, 5, and 10 years were 75%, 73%, 72%, and 62%, respectively, and overall survival rates were 79%, 64%, 56%, and 34%, respectively. In multivariable Cox regression analysis with the outcome of major amputation, significant predictors included age < 69 years (P = .032), Malay race (P = .029), DM (P < .001), history of cerebral vascular disease (P = .003), ESRD (P < .001), Rutherford classification (P = .042), repeat intervention (P = .034), and number of straight-line flows (P < .001) and plantar arch integrity (P < .001) on completion angiography. Significant associations with mortality were age < 69 years (P < .001), male sex (P = .030), Malay race (P = .027), history of ischemic heart disease (P < .001), ESRD (P < .001), and repeat intervention (P < .001). CONCLUSIONS: PTA as first-line revascularization for patients with CLI is safe and effective. Further studies are suggested to validate the outcome predictive model.

Subcentimetre thyroid nodules: Sonographic features associated with malignancy.

INTRODUCTION: The aim of this study was to identify the ultrasound features which are associated with malignancy in subcentimetre thyroid nodules. METHODS: This retrospective study included 454 thyroid nodules <10 mm in size in 413 patients from 2012 to 2016, which were subjected to fine needle aspiration cytology. Each nodule was classified according to the ultrasound patterns of the 2015 American Thyroid Association guidelines and the high suspicion ultrasound features (solid, hypo-echogenicity, irregular margins, microcalcifications, taller-than-wide, interrupted rim calcifications, and extrathyroidal extension) were identified for evaluation of their diagnostic performance. RESULTS: Of the American Thyroid Association high suspicion ultrasound features, univariate analysis showed that hypo-echogenicity (sensitivity 81.6% (95% CI 65.7-92.3%), specificity 50.0% (95% CI 43.4-56.6%)), irregular margins (sensitivity 34.2% (95% CI 19.6-51.4%), specificity 92.2% (95% CI 88.0-95.3%)), microcalcifications (sensitivity 23.7% (95% CI 11.4-40.2%), specificity 91.0% (95% CI 86.5-94.3%)), and taller-than-wide (sensitivity 23.7% (95% CI 11.4-40.2%), specificity 92.2% (95% CI 88.0-95.3%)) were significantly associated with a malignant diagnosis. Amongst the above features, subsequent multivariate analysis identified a combination of hypo-echogenicity and irregular margins as significantly associated with malignancy. Our malignancy rates based on American Thyroid Association ultrasound patterns from benign to high suspicion were 0.0, 8.3, 3.9, 15.7, and 40.4%, respectively. The American Thyroid Association high suspicion ultrasound pattern had a sensitivity of 50.0% (95% CI 33.4-66.7%) and specificity of 84.5% (95% CI 79.2-88.9%). CONCLUSION: The presence of both hypo-echogenicity and irregular margins was significantly associated with malignancy in subcentimetre thyroid nodules in our study. Hence, subcentimetre nodules which are hypoechoic with irregular margins may warrant further follow-up.

Type 2 Endoleaks: Common and Hard to Eradicate yet Benign?

PURPOSE: The exact significance of type 2 endoleaks (T2ELs) and the indication and efficacy of treatment are widely debated. We report our experience with managing T2ELs in a tertiary Asian centre. MATERIALS AND METHODS: This was a retrospective study of patients who underwent endovascular abdominal aortic aneurysm repair (EVAR) between February 2006 and December 2016. Patients with T2ELs were identified, and their data were analysed. RESULTS: A total of 156 patients underwent EVAR, of which 67 (42.9%) developed T2ELs. Seven were lost to follow-up. The remaining 60 patients had a mean follow-up period of 50.3 ± 33.9 months-34 (56.7%) experienced T2ELs early and the rest (43.3%) had late T2ELs. Forty-one patients had isolated T2EL, whilst 19 had concomitant T1EL and/or T3EL. Spontaneous resolution occurred in 25 patients (41.7%). All T2ELs with stable sac size were on continued surveillance. Amongst those with persistent T2ELs associated with sac growth (n = 17), 14 underwent intervention, of which 7 (50%) received > 1 embolisation procedure. A total of 16 transarterial embolisation and 8 translumbar embolisation procedures were performed. Technical success rate was 75%. In the intervention group, 5 (35.7%) had complete and sustained resolution, 7 had persistent/recurrent T2ELs but stable sac size, and 2 had progressive sac expansion. Overall mortality due to sac rupture occurred in 2 patients with concomitant T2EL and T1EL/T3EL. CONCLUSION: T2ELs are common, albeit mostly benign if occurring in isolation and not in association with sac growth. Achieving complete T2EL resolution with embolisation is difficult even with reinterventions. LEVEL OF EVIDENCE: Level 2B, retrospective study.

Preparing IR for COVID-19: The Singapore Experience.

This paper describes country-wide special measures undertaken for interventional radiology staff during the current coronavirus disease 2019 (COVID-19) pandemic. Although each interventional radiology service around the world faces unique challenges, the principles outlined in this article will be useful when designing or strengthening individual practices and integrating them within wider hospital and national measures. Moving beyond the current outbreak, these measures will be useful for any future infectious diseases which are likely to arise.

Review of imaging and endovascular intervention of iliocaval venous compression syndrome.

Iliocaval venous compression syndrome (ICS) is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra. Chronic compression can lead to venous stenosis and stasis, which manifests as chronic venous disease and treatment resistance. Therefore, early recognition of ICS and prompt treatment are essential. Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies. The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass, which is followed by computed tomography (CT) or magnetic resonance (MR) venography. CT and MRI can identify the anatomical causes for venous compression. In patients with high clinical suspicion for ICS, negative findings on CT and MR venography would still warrant further investigations. Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality. In this review paper, we will discuss the evidence, utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.

Catheter-Directed Computed Tomography Hepatic Angiography for Yttrium-90 Selective Internal Radiotherapy of Hepatocellular Carcinoma Reduces Prophylactic Embolization of Extrahepatic Vessels.

OBJECTIVES: To determine the rate of prophylactic embolization of extrahepatic vessels in patients undergoing yttrium-90 selective internal radiotherapy (90Y SIRT) for hepatocellular carcinoma (HCC) with the use of catheter-directed computed tomography hepatic angiography (CD-CTHA). MATERIALS AND METHODS: This retrospective study included 186 HCC patients who received 90Y SIRT from May 2010 to June 2015 in a single institution. All procedures were performed in a hybrid angiography-CT suite equipped with digital subtraction angiography (DSA) and CD-CTHA capabilities. CD-CTHA was performed during pre-treatment hepatic angiography. 90Y SIRT was administered approximately 2 weeks later. Selective prophylactic embolization of extrahepatic vessels was performed if extrahepatic enhancement was seen on CD-CTHA or if an extrahepatic vessel opacified on DSA/CD-CTHA despite the final microcatheter position for 90Y microsphere delivery being beyond the origin of this vessel. RESULTS: Thirty-five patients (18.8%) required selective embolization of extrahepatic vessels. Technical success of 90Y SIRT was 99.5%. Two patients (1.1%) developed radiation-induced gastrointestinal ulceration, and one (0.54%) developed radiation-induced pneumonitis. Extrahepatic uptake of 90Y microspheres was seen in the gallbladder of one patient without significant complications. CONCLUSION: The use of CD-CTHA in 90Y SIRT of HCC was associated with a low rate of prophylactic embolization of extrahepatic vessels while maintaining a high technical success rate of treatment and low rate of complications. LEVEL OF EVIDENCE: Level 4, case series.

Case Report: An Unusual Presentation of Bilateral Subclavian Stenosis in a Patient with Asymptomatic Hypotension.

BACKGROUND Subclavian stenosis is an uncommon clinical condition associated with severe cardiovascular complications, usually presenting with claudication and subclavian steal syndrome. Here we describe the rare case of bilateral subclavian artery stenosis in an asymptomatic patient. CASE REPORT Our patient was a 63-year-old chronic smoker with no prior medical history whose chief complaint was dyspnea from an exacerbation of his chronic obstructive pulmonary disease (COPD). He was hypotensive with blood pressure 74/56 mmHg at admission, which raised suspicion for sepsis, adrenal insufficiency but the workup (renal panel, full blood count and synacthen tests) were normal. He quickly recovered after we treated his COPD exacerbation, but his hypotension persisted despite repeated fluid challenges. To evaluate for structural causes of his hypotension, we performed a full cardiovascular examination with 4 limb blood pressure measurements and found upper limb hypotension and lower limb hypertension. Subsequent imaging with ultrasound and computed tomography confirmed the presence of bilateral subclavian artery stenosis. Our diagnosis was thus bilateral subclavian artery stenosis secondary to atherosclerosis from chronic smoking. The patient was subsequently referred to vascular surgery for consideration of surgical revascularization. CONCLUSIONS Bilateral subclavian stenosis is extremely rare and requires a high index of clinical suspicion. Early diagnosis is important in the primary prevention of associated cardiovascular diseases.

Should we perform fine needle aspiration cytology of subcentimetre thyroid nodules? A retrospective review of local practice.

In light of the rising rate of incidentally detected subcentimetre thyroid nodules due to improved surveillance and diagnostic imaging, the decision of whether to perform fine needle aspiration cytology is increasingly pertinent. We aim to assess (1) the sampling adequacy of fine needle aspiration cytology, (2) malignancy rate, (3) thyroidectomy rate and (4) diagnostic accuracy of fine needle aspiration cytology. A total of 245 subcentimetre nodules in 220 patients underwent fine needle aspiration cytology between 2011 and 2014. Medical records were reviewed for cytology results, subsequent management and histopathological results in the event the patient underwent thyroidectomy. Sampling adequacy was calculated as the percentage of diagnostic results (Bethesda II-VI). Malignancy rate was defined as the percentage of Bethesda IV-VI diagnoses. Amongst patients with Bethesda IV-VI diagnoses who underwent thyroidectomy, their cytology reports were correlated with post-operative histopathological findings. The sampling adequacy of fine needle aspiration cytology was 77.1%. Malignancy rate (Bethesda IV-VI) was 9.7%. The respective malignancy rates in the < 5 mm nodule group and ≥ 5 mm nodule group were 6.67 and 10.0%. In total, 79.2% (19/24) of the malignant nodules underwent surgical excision. The rest declined surgery and/or were lost to follow-up. Amongst the malignant nodules which were surgically resected, 84.2% (16/19) had definitive malignant histology. Five of these demonstrated multifocal carcinoma and/or extrathyroidal extension of carcinoma on histology. Initial fine needle aspiration cytology and subsequent histopathological diagnoses matched in all cases except for three that had false-positive fine needle aspiration cytology results. Majority of our patients with suspicious cytology results subsequently underwent thyroidectomy, notwithstanding the relatively lower diagnostic accuracy of fine needle aspiration cytology in subcentimetre thyroid nodules.