Trans-cervical thoracic duct embolization for post-surgical left Chylothorax in a patient with multifocal lymphatic malformations.

BACKGROUND: Mediastinal and abdominal lymphatic malformations may not be diagnosed until adulthood. Radiologic and pathologic diagnosis is often challenging due to the rarity of the lesion. Surgical excision of these lesions may be curative but lymphatic leak is a known complication. Lymphatic duct embolization may then be required to treat the leak. CASE PRESENTATION: We describe a patient with post-surgical chylothorax where thoracic duct lymphangiography and embolization was performed by catheterizing the thoracic duct at the venous angle where it drains into the subclavian vein. CONCLUSION: Lymphatic duct embolization can be challenging in patients with lymphatic malformations. In these patients, if there is adequate visualization on ultrasound or fluoroscopy, terminal aspect of the thoracic duct can be accessed through the subclavian vein to perform the procedure.

Activation of complement factor B contributes to murine and human myocardial ischemia/reperfusion injury.

The pathophysiology of myocardial injury that results from cardiac ischemia and reperfusion (I/R) is incompletely understood. Experimental evidence from murine models indicates that innate immune mechanisms including complement activation via the classical and lectin pathways are crucial. Whether factor B (fB), a component of the alternative complement pathway required for amplification of complement cascade activation, participates in the pathophysiology of myocardial I/R injury has not been addressed. We induced regional myocardial I/R injury by transient coronary ligation in WT C57BL/6 mice, a manipulation that resulted in marked myocardial necrosis associated with activation of fB protein and myocardial deposition of C3 activation products. In contrast, in fB-/- mice, the same procedure resulted in significantly reduced myocardial necrosis (% ventricular tissue necrotic; fB-/- mice, 20 ± 4%; WT mice, 45 ± 3%; P < 0.05) and diminished deposition of C3 activation products in the myocardial tissue (fB-/- mice, 0 ± 0%; WT mice, 31 ± 6%; P<0.05). Reconstitution of fB-/- mice with WT serum followed by cardiac I/R restored the myocardial necrosis and activated C3 deposition in the myocardium. In translational human studies we measured levels of activated fB (Bb) in intracoronary blood samples obtained during cardio-pulmonary bypass surgery before and after aortic cross clamping (AXCL), during which global heart ischemia was induced. Intracoronary Bb increased immediately after AXCL, and the levels were directly correlated with peripheral blood levels of cardiac troponin I, an established biomarker of myocardial necrosis (Spearman coefficient = 0.465, P < 0.01). Taken together, our results support the conclusion that circulating fB is a crucial pathophysiological amplifier of I/R-induced, complement-dependent myocardial necrosis and identify fB as a potential therapeutic target for prevention of human myocardial I/R injury.

Percutaneous Cholecystostomy: Evidence-Based Current Clinical Practice.

The role of percutaneous cholecystostomy (PC) in the management of acute cholecystitis and cholangitis is outlined in the revised 2013 Tokyo Guidelines. These two emergencies constitute the vast majority of PC performed today for therapeutic purposes, and research has repeatedly shown the utility of PC in these conditions. PC is typically employed in the management of critically ill patients who are not surgical candidates. Indications and contraindications to PC are reviewed. Additional innovative applications of PC have been developed since it was first described in 1980. These include biliary drainage, dilation of biliary strictures, and stenting of the biliary tree including the common bile duct. Special consideration must be given to the patient selection criteria when deciding who can benefit from PC. Patient comorbidities can also influence the PC technique employed. Both transhepatic and transperitoneal approaches have distinct advantages and disadvantages. The technical success rate for PC is 95 to 100% and the complication rate is extremely low. Most complications are minor.