Systemic Thrombolysis as Initial Treatment of COVID-19 Associated Acute Aortoiliac and Lower Extremity Arterial Thrombosis.

SARS-CoV-2 (COVID-19) patients with associated thromboembolic events have demonstrated poor outcomes despite the use of anticoagulation therapy and surgical intervention. We present a COVID-19 patient with acute limb ischemia, secondary to extensive thrombosis of an aortic aneurysm, iliac arteries, and infrainguinal arteries. Initial treatment with systemic thrombolysis, which restored patency of the aortoiliac occlusion, was followed by open thrombectomies of the infrainguinal occlusions.

Angiotensin converting enzyme inhibitors and angiotensin receptor blockers have no effect on the outcomes of endovascular revascularization in tibial arterial occlusive disease.

The effects of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARBs) on angiogenesis, myocardial remodeling and intermittent claudication have been studied. Clinical studies have shown reduced re-intervention after cardiac stenting with the use of ACEI/ARBs. We hypothesized that the use of ACEI/ARBs decreases re-interventions after endovascular revascularization in tibial artery disease (TAD) patients. This is a retrospective study comparing the effects of ACEI/ARBs on the outcomes after endovascular revascularization for TAD. We divided all patients that underwent endovascular revascularization into Angiotensin converting enzyme inhibitor/Angiotensin receptor blockers (ACEI/ARBs) and No Angiotensin converting enzyme inhibitor/Angiotensin receptor blockers (NoACEI/ARBs) groups. A total of 360 patients underwent endovascular intervention for TAD. One hundred and ninety-six (54%) patients, 124 (57%) males, were on ACEI/ARBs after endovascular intervention for TAD, whereas 164(46%) patients, 87 (53%) males were not. The groups were well matched in the demographic variables except higher incidence of congestive heart failure, coronary artery disease and dialysis in the ACEI/ARBs group (p = .001, 0.02, 0.01 respectively). Reintervention rates were not associated with ACEI/ARBs use (p = .097). Even when corrected for statin use and antiplatelet therapy, no difference was seen in the reintervention rates in the two groups (p = .535, 0.547 respectively). Primary patency, assisted primary patency and secondary patency did not differ with the use of ACEI/ARBs (p = .244 0.096,0.060 respectively). No difference was seen in overall survival between the two groups (p = .690). ACEI/ARBs do not appear to affect the patency and reintervention rates for patients undergoing endovascular revascularization for TAD.

Single Tertiary Care Center Outcomes After Lower Extremity Cadaveric Vein Bypass for Limb Salvage.

OBJECTIVE: Cadaveric saphenous vein (CV) conduits are used in rare instances for limb salvage in patients without autogenous veins although long-term outcome data are scarce. This study was designed to evaluate the outcomes of CV bypass in patients with threatened limbs. METHODS: We retrospectively reviewed the charts from 2010 to 2017 of 25 patients who underwent 30 CV allografts for critical limb ischemia and acute limb ischemia. Patient charts were reviewed for demographics, comorbidities, smoking status, indications for bypass, and outcomes. Primary outcomes included graft patency, major amputation rates, and mortality. Secondary outcomes measured included infection rates, 30-day major adverse cardiac events (MACE) and major adverse limb events (MALE). Statistical analysis was performed using time series and Kaplan-Meier survival curves. RESULTS: A total of 30 limbs received CV lower extremity bypasses (20 males, 10 female), and the average age was 68 ± 4 years. Primary patency rates were 71%, 42%, and 28% at 3, 6, and 12 months, respectively. Assisted primary patency rates were 78%, 56%, and 37% at 3, 6, and 12 months, respectively. Secondary patency rates were 77%, 59%, and 28% at 3, 6, and 12 months, respectively. Minor amputations, defined as amputations below the transmetatarsal level occurred in 5 (20%) patients. Wound infection occurred in 8 (32%) patients which was managed with local wound care and no patients required an extraanatomic bypass for limb salvage. Thirty-day MALE occurred in 7 (23.3%) patients. We had no 30-day mortality or MACE. The average graft length was 64.2 ± 8 cm with an average graft diameter of 3.9 ± 2 mm. Amputation-free survival and overall survival at 12 months were 20 (68%) and 21 (84%), respectively. CONCLUSIONS: Cadaveric saphenous vein allograft may be used as a bypass conduit as a viable surgical option before limb amputation. Despite the poor patency rates, the limb salvage rates of cadaveric vein grafts demonstrate that this alternate conduit may be considered when no autogenous vein is available.

Computational Study of the Coupled Mechanism of Thermophoretic Transportation and Mixed Convection Flow around the Surface of a Sphere.

The main goal of the current work was to study the coupled mechanism of thermophoretic transportation and mixed convection flow around the surface of the sphere. To analyze the characteristics of heat and fluid flow in the presence of thermophoretic transportation, a mathematical model in terms of non-linear coupled partial differential equations obeying the laws of conservation was formulated. Moreover, the mathematical model of the proposed phenomena was approximated by implementing the finite difference scheme and boundary value problem of fourth order code BVP4C built-in scheme. The novelty point of this paper is that the primitive variable formulation is introduced to transform the system of partial differential equations into a primitive form to make the line of the algorithm smooth. Secondly, the term thermophoretic transportation in the mass equation is introduced in the mass equation and thus the effect of thermophoretic transportation can be calculated at different positions of the sphere. Basically, in this study, some favorite positions around the sphere were located, where the velocity field, temperature distribution, mass concentration, skin friction, and rate of heat transfer can be calculated simultaneously without any separation in flow around the surface of the sphere.

Safety and Feasibility of Performing Fenestrated Endovascular Abdominal Aneurysm Repair Using a Portable C-arm Without Fusion Technology: A Single-Center Experience.

Objective Most centers performing fenestrated endovascular aneurysm repair (F-EVAR) use hybrid rooms with fusion technology for mapping. We present our experience of successfully performing F-EVAR using C-arm without fusion technology. Methods During the period of January 2016 to October 2018, data were collected from a prospectively maintained F-EVAR database at our tertiary care institute. The primary endpoint was technical success, and the secondary outcomes measured were short- and midterm clinical success (both defined by the Society for Vascular Surgery reporting standards), blood loss, radiation dose, operative time, postoperative endoleaks, aneurysm rupture, endograft patency, and complications. Results We performed 11 F-EVARs during the study period in five (45.5%) males and six (54.5%) females, with a mean age of 75+8 years. All procedures were performed under general anesthesia using OEC 9900 Elite Mobile C-arm (GE Healthcare, Chicago, IL, USA) without the use of fusion technology. Three patients had planned preoperative open procedures for access due to prior cutdown or bypass. Technical success was achieved in all 11 (100%) cases. The mean length of stay was 5+2 days, and the mean follow-up was 7.5+6.5 months. The mean procedure time was 301+167 minutes, and the mean blood loss was 361+233 mL. Mean fluoroscopy time was 72+31 minutes, and the mean radiation exposure time was 2,160+930 mGy. No patients required intraoperative transfusion. Thirty-day (short term) clinical success was achieved in 10 (90.0%), cases whereas six-month (midterm) clinical success was achieved in 7 (77.7%) patients. Branch vessel patency was 11 (100%) at 30 days and 9 (81.8%) at six months, and primary endograft patency was 100% (11) at six months. We had no perioperative mortality or major adverse cardiac event at 30 days. Thirty-day postoperative morbidity included readmission for pulmonary edema from cardiac failure in one patient. Two patients had clinically insignificant silent cardiac enzyme elevation. Three patients had re-interventions performed during the mean follow-up period. Two patients developed renal stent thrombosis resulting in renal insufficiency, which is defined as an increase in creatinine concentration ≥0.5 mg/dL, without the need for dialysis. One type II endoleak was identified postoperatively that required trans-lumbar embolization. No type I or III endoleaks were identified during the study period. Asymptomatic common femoral artery thrombosis was seen on follow-up imaging in one patient. Conclusions We conclude that F-EVAR can be safely performed using C-arm without the use of fusion technology. Its utility can be expanded to centers with appropriate skill set but no hybrid technology.

Endovascular Repair of Carotid Artery Pseudoaneurysm using Transcarotid Artery Revascularization Flow Reversal Technique.

Carotid artery aneurysm overall is a rare occurrence with <1% formed after carotid endarterectomy (CEA). Several methods of repair have been described including open and endovascular techniques. Transcarotid artery revascularization (TCAR) with stenting using the reverse flow technique has been used in patients with carotid artery stenosis with neck irradiation, previous neck surgeries, or for those who are at high risk for open surgery. We describe a patient with a post-CEA pseudoaneurysm of the extracranial internal carotid artery that was repaired using the TCAR flow reversal approach with coiling of the external carotid artery.

Contemporary outcomes of infrapopliteal atherectomy with angioplasty versus balloon angioplasty alone for critical limb ischemia.

OBJECTIVE: Limited data exist comparing atherectomy (At) with balloon angioplasty for infrapopliteal peripheral arterial disease. The objective of this study was to compare the outcomes of infrapopliteal At with angioplasty vs angioplasty alone in patients with critical limb ischemia. METHODS: This is a retrospective, single-center, longitudinal study comparing patients undergoing either infrapopliteal At with angioplasty or angioplasty alone for critical limb ischemia, between January 2014 and October 2017. The primary outcome was primary patency rates. Secondary outcomes were reintervention rates, assisted primary patency, secondary patency, major adverse cardiac events, major adverse limb events, amputation-free survival, overall survival, and wound healing rates. Data were analyzed in multivariate generalized linear models with log rank tests to determine survival in Kaplan-Meier curves. RESULTS: There were 342 infrapopliteal interventions, 183 percutaneous balloon angioplasty (PTA; 54%), and 159 atherectomies (At) with PTA (46%) performed on 290 patients, with a mean age of 67 ± 12 years; 61% of the patients were male. The PTA and At/PTA groups had similar demographics, tissue loss (79% vs 84%; P = .26), ischemic rest pain (21% vs 16%; P = .51), mean follow-up (19 ± 9 vs 20 ± 9 months; P = .32), mean number of vessels treated (1.7 ± 0.8 vs 1.9 ± 0.8; P = .08) and the mean lesion length treated (6.55 ± 5.00 cm vs 6.02 ± 4.00 cm; P = .08), respectively. Similar 3-month (96 ± 1% vs 94 ± 1%), 6-month (85 ± 2% vs 86 ± 3%), 12-month (68 ± 3% vs 69 ± 4%), and 18-month (57 ± 4% vs 62 ± 4%) primary patency rates were seen in the two groups (P = .87). At/PTA patients had significantly higher reintervention rates as compared with the PTA patients (28% vs 16%; P = .02). Similar assisted primary patency rates (67 ± 4% vs 69 ± 4%; P = .78) and secondary patency rates (61 ± 4% vs 66 ± 4%; P = .98) were seen in the PTA and At/PTA groups at 18 months. The 30-days major adverse cardiac event rates (3% vs 2%; P = .13) and 30-day major adverse limb event rates (5% vs 4%; P = .2) were similar in both groups. Wound healing rates (72 ± 3% vs 75 ± 2%; P = .12), 1-year amputation-free survival (68 ± 4.1% vs 70 ± 2%; P = .5), and 1-year overall survival (76 ± 4% vs 78 ± 4%; P = .39) rates did not differ in the PTA and At/PTA groups. THE At/PTA group had higher local complication rates (7 [4%] vs 1 [0.5%]; P = .03) CONCLUSIONS: At with angioplasty provides similar patency rates compared with angioplasty alone for infrapopliteal peripheral arterial disease, but associated with higher reintervention and local complication rates. Further appropriately designed studies are required to determine the exact role of At in this subset of patients.

Routine Postoperative Cardiac Testing is Unnecessary after Carotid Endarterectomy.

BACKGROUND: Routine laboratory testing to rule out myocardial infarction (MI) after carotid endarterectomy (CEA) is common in many centers. Its use in this patient population has not been thoroughly investigated. We hypothesize that routine testing for MI in post-CEA patients is of low yield and not cost-effective. METHODS: A retrospective review of 291 consecutive CEAs from February 2011 to July 2015 was performed. Two patients were excluded: one for postoperative noncardiac death and one for preoperative MI. Patient demographics, medications, medical history, type of anesthesia, and postoperative laboratory results were reviewed. All patients had troponin-I and creatine kinase-MB levels taken postoperatively. A patient was judged to have an MI if troponin-I was greater than or equal to 0.6 ng/mL or CK-MB is >6.3 ng/mL. The incidence of postoperative MI was recorded, and a cost analysis was performed. RESULTS: The mean age was 70.2 years (range: 42-92). Of all, 59.5% were male, and 92.4% had a history of hypertension. Preoperatively, 57.4% were on beta-blocker therapy, 86.5% on aspirin, and 52.2% on both. Most (80.6%) were on preoperative statin therapy, 26.9% had a prior history of MI (37.2% within 5 years of surgery), and 56.4% of patients had a prior coronary intervention (27.6% percutaneous, 28.7% coronary artery bypass grafting, and 11% both). All patients received general anesthesia. The mean procedure time was 121.5 min (range: 62-258). The mean postoperative length of stay was 2.6 days. Eight patients (2.7%) were judged to have acute MI, one of which was symptomatic. Three of the 8 (38%) had a prior history of MI. In asymptomatic patients, the peak level of troponin-I ranges from 0.52 to 3.64 ng/mL and that of CK-MB from 11.8 to 24 ng/mL. The symptomatic patient had chest pain and bradycardia. The patient had a peak troponin-I level of 1.59 ng/mL, with a CK-MB level of 11.5 ng/mL. All patients were treated medically. The cost per troponin-I and CK-MB is $27.78 and $31.44, respectively, in our institution. We estimate that eliminating routine postoperative troponin-I and CK-MB testing in patients who underwent CEA would have saved an estimated $51,343 over the course of treatment of the studied population. CONCLUSIONS: Routine postoperative cardiac laboratory testing in asymptomatic patients after CEA increases the hospital cost. The low overall rate of postoperative MI suggests that cardiac testing is best reserved for symptomatic patients or those with clinical suspicion for MI.

Safety and Feasibility of Transradial Access for Noncoronary and Peripheral Vascular Interventions.

BACKGROUND: Transradial access (TRad) is becoming the preferred access for cardiac catheterization. The use and safety of TRad in noncoronary and peripheral vascular interventions remains ill-defined and serves as the basis for this study. METHODS: Patients undergoing noncoronary and peripheral endovascular procedures via TRad from August 2010 to February 2013 at our institution were reviewed retrospectively. Demographic data, indications, interventions performed, sheath size, procedural outcomes, and access-site complications were evaluated. Postprocedural radial artery patency and hand ischemic symptoms were evaluated clinically and by duplex ultrasound. RESULTS: Nineteen patients underwent 24 procedures via TRad for both diagnostic (11/24) and therapeutic (13/24) purposes. Twelve (63%) were women, and 75% (18/24) were from left radial artery. Indications included absent femoral pulses in 12 (50%), morbid obesity in 6 (25%), previous bypass originating or terminating in the groin in 4 (17%), and groin wound infection in 2 (8%) cases. A 5F sheath was used in 13 (54%) cases, 6F in 10 (42%) cases, and 7F in 1 (4%) case. Thirteen therapeutic interventions included 7 (29%) iliac angioplasties and/or stent, 3 (13%) femoral anastomosis angioplasties, 2 (8%) superficial femoral artery angioplasties, and 1 (4%) mesenteric angioplasty. No access-site hematoma or procedure-related deaths were reported. Postprocedural radial artery occlusion was observed in 6 (31%) patients. All occlusions were asymptomatic, except for 1 (4%) patient with self-limiting forearm pain lasting for 1 day. Sheath size strongly correlated with radial artery occlusion. CONCLUSIONS: TRad appears to be a safe and feasible alternative option for patients undergoing noncoronary and peripheral interventions. Radial artery occlusion, mostly asymptomatic, can occur and is directly related to the sheath size. Smaller sheath sizes, longer platform devices, better radial access kits, and better closure devices could potentially eliminate some of the challenges associated with TRad.

A kinetic flux vector splitting scheme for shallow water equations incorporating variable bottom topography and horizontal temperature gradients.

This paper is concerned with the derivation of a well-balanced kinetic scheme to approximate a shallow flow model incorporating non-flat bottom topography and horizontal temperature gradients. The considered model equations, also called as Ripa system, are the non-homogeneous shallow water equations considering temperature gradients and non-uniform bottom topography. Due to the presence of temperature gradient terms, the steady state at rest is of primary interest from the physical point of view. However, capturing of this steady state is a challenging task for the applied numerical methods. The proposed well-balanced kinetic flux vector splitting (KFVS) scheme is non-oscillatory and second order accurate. The second order accuracy of the scheme is obtained by considering a MUSCL-type initial reconstruction and Runge-Kutta time stepping method. The scheme is applied to solve the model equations in one and two space dimensions. Several numerical case studies are carried out to validate the proposed numerical algorithm. The numerical results obtained are compared with those of staggered central NT scheme. The results obtained are also in good agreement with the recently published results in the literature, verifying the potential, efficiency, accuracy and robustness of the suggested numerical scheme.

Antimicrobial activity, toxicity and anti-inflammatory potential of methanolic extracts of four ethnomedicinal plant species from Punjab, Pakistan.

BACKGROUND: The plant species Aristolochia indica (AI), Melilotus indicus (MI), Tribulus terrestris (TT) and Cuscuta pedicellata (CP) are widely used in folk medicine in the villages around Chowk Azam, South Punjab, Pakistan. The aim of this study was to evaluate the antioxidant activity, phytochemical composition, and the antibacterial, antifungal, cytotoxic and anti-inflammatory potential of the four medicinal plants listed above. For CP stem, this study represents (to the best of our knowledge) the first time phytochemicals have been identified and the antioxidant and anti-inflammatory potential determined. METHODS: Phytochemicals were analyzed through chemical tests, thin layer chromatography (TLC) and spectrophotometric methods. Antioxidant activities (DPPH and H2O2) were also determined through spectrophotometric methods. Extracts were evaluated for antibacterial potential via the agar well diffusion method against Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumonia and Acinetobacter baumannii. The minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) were determined by the microdilution method. Antifungal activities were tested using the agar tube dilution method against three species: Aspergillus fumigatus, Aspergillus flavus and Rhizopus oryzae. The cytotoxic potential of the plant extracts was checked using the brine shrimp assay. In vitro anti-inflammatory activity of the selected plant extracts was evaluated using albumin denaturation, membrane stabilization and proteinase inhibitory assays. RESULTS: Of all the methanolic extracts tested, those from CP (stem) and TTF (T. terrestris fruit) had the highest phenolic, flavonoid and flavonol contents (497±4 mg GAE/g, 385±8 mg QE/g and 139±4 mg QE/g; 426±5 mg GAE/g, 371±8 mg QE/g and 138±6 mg QE/g, respectively) and also exhibited strong antioxidant potential in scavenging DPPH and hydrogen peroxide (IC50 values; 20±1 and 18±0.7 µg/mL; 92±2 and 26±2 µg/mL, respectively). CP, TTF and TTL (T. terrestris leaf) extracts substantially inhibited the growth of the bacteria A. baumannii, S. aureus, and K. pneumonia and also exhibited the highest antifungal potential. The ranking of the plant extracts for cytotoxicity was TTF > TTL > AI > CP > MI, while the ranking for in vitro anti-inflammatory potential at a concentration of 200 µg/mL of the selected plant extracts was CP > TTL, TTF > AI > MI. The lowest IC50 (28 µg/mL) observed in the albumin denaturation assay was for CP. Positive correlations were observed between total phenolics, antioxidants, antibacterial, antifungal and anti-inflammatory potential of the selected plant extracts, indicating a significant contribution of phenolic compounds in the plant extracts to these activities. CONCLUSIONS: This study revealed the strong antimicrobial, antioxidant, cytotoxic and anti-inflammatory potential of the plant species CP and TT used in folk medicine.

Catheter-Directed Therapy is Safe and Effective for the Management of Acute Inferior Vena Cava Thrombosis.

BACKGROUND: The management of acute thrombosis of inferior vena cava (AT-IVC) has evolved to catheter-based therapies, the results of which remain uncertain. We report our institution's experience treating AT-IVC using endovascular methods. METHODS: A 10-year retrospective review of patients presenting with symptomatic IVC thrombosis between the years 2005 and 2014 was performed. Demographic data, treatment modalities, and outcomes were reviewed. RESULTS: Twenty-five patients (44% men) underwent treatment for acute (<2 weeks) symptomatic IVC thrombosis. Presenting symptoms included pain and limb swelling in 23 (92%), motor dysfunction in 16 (64%), sensory loss in 14 (56%), and pulmonary embolism (PE) in 2 (8%) patients. Phlegmasia cerulea dolens was present in 5 patients, a history of malignancy was identified in 7 patients, and 21 patients had an IVC filter at presentation (Trapease 12, G2X 3, Option 2, Eclipse 2, Meridian 2). Four patients had a documented hypercoagulable state, 21 patients underwent venous angioplasty, and 7 (28%) patients underwent venous stenting of the IVC or iliofemoral veins. Significant (>50% luminal gain) angiographic resolution of venous thrombus was achieved in all 25 patients. Twenty-one (84%) patients reported moderate-to-complete symptomatic improvement immediately after completion of the procedures. Two patients had a clinically symptomatic PE and 1 patient underwent an above-knee amputation secondary to venous gangrene. Other complications included 6 minor bleeding complications (2 local hematoma, 4 hematuria) all of which resolved spontaneously. There were 2 major bleeding complications (1 disseminated intravascular coagulation, 1 retroperitoneal hematoma). CONCLUSIONS: Endovascular treatment of AT-IVC, regardless of etiology, is safe and effective with excellent short-term clinical results. An aggressive endovascular approach to treatment of AT-IVC is warranted even in the presence of a thrombosed vena cava filter.

Central upwind scheme for a compressible two-phase flow model.

In this article, a compressible two-phase reduced five-equation flow model is numerically investigated. The model is non-conservative and the governing equations consist of two equations describing the conservation of mass, one for overall momentum and one for total energy. The fifth equation is the energy equation for one of the two phases and it includes source term on the right-hand side which represents the energy exchange between two fluids in the form of mechanical and thermodynamical work. For the numerical approximation of the model a high resolution central upwind scheme is implemented. This is a non-oscillatory upwind biased finite volume scheme which does not require a Riemann solver at each time step. Few numerical case studies of two-phase flows are presented. For validation and comparison, the same model is also solved by using kinetic flux-vector splitting (KFVS) and staggered central schemes. It was found that central upwind scheme produces comparable results to the KFVS scheme.

A novel technique to remove inferior vena cava filters using a homemade snare device.

The need to retrieve inferior vena cava filters is quite evident due to the long-term complications. We present a novel technique to remove inferior vena cava filters using a homemade snare created using a looped a 0.014-inch semistiff wire. Employing this technique, 18 consecutive retrievable filters were removed. All filters were easily snared on the very first attempt, and no complications occurred. Our novel technique to retrieve filters is efficient, safe, and cost-effective.

Sestamibi imaging for primary hyperparathyroidism: the impact of surgeon interpretation and radiologist volume.

BACKGROUND: Preoperative localization is the first step towards minimally invasive targeted parathyroidectomy. While there are data emphasizing that surgeon experience optimizes operative outcomes, the role of the radiologist's experience in successful preoperative imaging is unclear. We hypothesized that the accuracy of sestamibi scanning for primary hyperparathyroidism is dependent upon surgeon interpretation and radiologist volume. METHODS: Between January 2000 to August 2009, 1,255 patients underwent parathyroidectomy for hyperparathyroidism at our institution. Of these, 763 had sestamibi scans for primary hyperparathyroidism. All scans were reviewed by surgeons and radiologists blinded, and were correlated with the operative findings and pathological reports. Radiologists were grouped into high volume (>50 cases/year, HV-RAD) or low volume (<50 cases/year, LV-RAD) based upon a database of >6,000 parathyroid cases reported by 89 regional hospitals. RESULTS: Of the 763 patients, 77 % were female and the mean age was 60 years. Mean baseline calcium and parathyroid hormone levels were 11.2 ± 0.03 mg/dl and 133 ± 3.27 pg/ml, respectively. The sensitivity of the surgeon (93 %) was higher than both HV (83 %) and LV (72 %) radiologists. Importantly, the positive predictive values were similar: 96 % for surgeon, 93 % for HV-RAD, and 98 % for LV-RAD. As a result, out of 99 scans which were correctly read by the surgeon but not by radiologist, 84 were read as negative by radiologist, 11 on the wrong side of the neck, and 4 on the same side but the wrong gland. CONCLUSIONS: Surgeon interpretation and radiologist volume increase the likelihood of successful preoperative sestamibi parathyroid localization for primary hyperparathyroidism. We recommend that imaging be reviewed by experienced parathyroid surgeons rather than relying on radiological interpretation alone.