Giant Inferior Mesenteric Vein Aneurysm Secondary to Iatrogenic Inferior Mesenteric Arteriovenous Fistula.

PURPOSE: Visceral venous aneurysms are rare, especially in the inferior mesenteric vein (IMV). We report a giant IMV aneurysm secondary to an iatrogenic arteriovenous fistula (AVF). CASE REPORT: A woman presented with an incidental finding of a 7 cm large IMV aneurysm and an inferior mesenteric arteriovenous shunt. The patient underwent successful endovascular occlusion of the shunt to avoid aneurysm rupture and portal hypertension. CONCLUSION: Embolization is a possible treatment strategy for mesenteric venous aneurysms with an AVF. CLINICAL IMPACT: We describe an unusual mesenteric AV-shunt from a surgical crush injury that caused a giant venous mesenteric aneurysm and offer technical aspects on minimally invasive endovascular treatment.

Embolization of the thoracic duct in patients with iatrogenic chylothorax.

Chylothorax is leakage of lymphatic fluid accumulating in the pleural cavity due to the thoracic duct's (TD) trauma or obstructions. It generally occurs as a traumatic complication after general thoracic surgery procedures (0.4%), especially after esophagectomy (4.7-8.6%). Traditionally, surgical intervention is performed if conservative management fails, but reports of high mortality (2.1%) and morbidity (38%) have led to the development of a minimally invasive percutaneous treatment method; TD embolization (TDE). The records of all patients treated for chylothorax with TDE from April 2015 to June 2019 were reviewed. Only patients with iatrogenic chylothorax were included. The outcomes measures are defined as a technical and a clinical success. A technical success, is defined as the ability to perform the embolization procedure, thereby injecting embolizing material Histoacryl with or without coils. A clinical success is defined as a complete cessation of lymphatic leakage into the pleural cavity without surgical intervention and, therefore, a cured patient. Lymphography was performed in all patients, and visualization of cisterna chyli was achieved in 14/17 patients (82.4%). Of the 17 patients included, 15 patients were successfully embolized and cured of chylothorax (88.2%). Successfully embolized patients had a median discharge time of 7 days. Most patients reported postprocedural pain, which was dealt with using conventional pain medication. TDE seems like a safe percutaneous treatment technique with a high clinical success rate in iatrogenic chylothorax patients which can be readily implemented if the clinical experience is available..

The soluble mannose receptor is released from the liver in cirrhotic patients, but is not associated with bacterial translocation.

BACKGROUND & AIMS: Intestinal bacterial translocation is involved in activation of liver macrophages in cirrhotic patients. Macrophages play a key role in liver inflammation and are involved in the pathogenesis of cirrhosis and complications. Bacterial translocation may be determined by presence of bacterial DNA and macrophage activation, by the soluble mannose receptor. We hypothesize that the soluble mannose receptor is released from hepatic macrophages in cirrhosis and associated with bacterial DNA, portal pressure and complications. METHODS: We investigated 28 cirrhotic patients set for transjugular intrahepatic portosystemic shunt insertion as a result of refractory ascites (n=17), acute (n=3), or recurrent variceal bleeding (n=8). We analysed plasma from the portal and hepatic veins for bacterial DNA and soluble mannose receptor with qPCR and ELISA. RESULTS: The median soluble mannose receptor level was elevated in the hepatic vein compared with the portal vein (0.57(interquartile range 0.31) vs 0.55(0.40) mg/L, P=.005). The soluble mannose receptor levels were similar in bacterial DNA-positive and -negative patients. The soluble mannose receptor level in the portal and hepatic veins correlated with the portal pressure prior to transjugular intrahepatic portosystemic shunt insertion (r=.52, P<.008, both) and the levels correlated with Child-Pugh score (r=.63 and r=.56, P<.004, both). We observed higher soluble mannose receptor levels in patients with acute variceal bleeding compared to other indications (P<.05). CONCLUSION: This study showed hepatic soluble mannose receptor excretion with a higher level in the hepatic than the portal vein, though with no associations to bacterial DNA. We observed associations between soluble mannose receptor levels and portal pressure and higher levels in patients with acute variceal bleeding indicating the soluble mannose receptor as a marker of complications of cirrhosis, but not bacterial translocation.

Inter- and intra-rater agreement in the assessment of the vascularity of spinal metastases using digital subtraction angiography tumor blush.

Background Preoperative embolization is based on the preoperative digital subtraction angiography (DSA) tumor blush, and as such is considered the "gold standard" for determining tumor vascularity. However, to our knowledge reliability studies evaluating vascularity ratings of DSA tumor blush in spinal metastases have not been published previously. Purpose To evaluate inter- and intra-rater agreement in the assessment of the vascularity of spinal metastases using DSA tumor blush. Material and Methods This reliability study included 46 patients with symptomatic metastatic spinal cord compression requiring surgery. DSA data stored in the hospital picture archiving and communication system (PACS) from the participants of a randomized controlled trial were used. Inter- and intra-rater agreement on vascularity assessment using DSA tumor blush according to a three-step ordinal scale was evaluated: no hypervascularity; moderate hypervascularity; and pronounced hypervascularity. The statistical analysis was based on the linear weighted kappa's for multiple raters that extend Cohen's κ. Three raters and κ = 0.2 in the null hypothesis implied that the power of the study was 0.96. Results Inter- and intra-rater agreements were moderate in rating the vascularity of spinal metastases and the agreements were significantly higher than the κ = 0.20 in the null hypothesis ( P = 0.0002 and P = 0.0001). The κ value for inter-rater agreement was 0.57 (95% confidence interval [CI], 0.41-0.72) and for intra-rater agreement 0.55 (95% CI, 0.38-0.71). Conclusion There is moderate inter-rater and intra-rater agreement in classifying the vascularity of spinal metastases on a three-step ordinal scale for DSA tumor blush.

Percutaneous yttrium aluminum garnet-laser lithotripsy of intrahepatic stones and casts after liver transplantation.

Bile duct stones and casts (BDSs) contribute importantly to morbidity after liver transplantation (LT). The purpose of this study was to estimate the clinical efficacy, safety, and long-term results of percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in transplant recipients and to discuss underlying factors affecting the outcome. A retrospective chart review revealed 18 recipients with BDSs treated by PTCSL laser lithotripsy with a holmium-yttrium aluminum garnet laser probe at 365 to 550 µm. They were analyzed in a median follow-up time of 55 months. In all but 1 patient (17/18 or 94%), it was technically feasible to clear all BDSs with a mean of 1.3 sessions. PTCSL was unsuccessful in 1 patient because of multiple stones impacting the bile ducts bilaterally; 17% had early complications (Clavien II). All biliary casts were successfully cleared; 39% had total remission; 61% needed additional interventions in the form of percutaneous transhepatic cholangiography and dilation (17%), re-PTCSL (11%), self-expandable metallic stents (22%), or hepaticojejunostomy (6%); and 22% eventually underwent retransplantation. The overall liver graft survival rate was 78%. Two patients died during follow-up for reasons not related to their BDS. Nonanastomotic strictures (NASs) were significantly associated with treatment failure. We conclude that PTCSL in LT patients is safe and feasible. NASs significantly increased the risk of relapse. Repeated minimally invasive treatments, however, prevented graft failure in 78% of the cases.

Preoperative embolization in surgical treatment of spinal metastases: single-blind, randomized controlled clinical trial of efficacy in decreasing intraoperative blood loss.

PURPOSE: To assess whether preoperative transcatheter arterial embolization of spinal metastases reduces blood loss, the need for transfusion with allogeneic red blood cells (RBCs), and surgery time in the surgical treatment of patients with symptomatic metastatic spinal cord compression. MATERIALS AND METHODS: This single-blind, randomized (1:1), controlled, parallel-group, single-center trial was approved by the Danish National Committee on Biomedical Research Ethics and was conducted from May 2011-March 2013. Participants (N = 45) were scheduled for decompression and posterior thoracic/lumbar spinal instrumentation and randomly assigned to either preoperative embolization (n = 23) or a control group (n = 22). The primary outcome was intraoperative blood loss. Secondary outcomes were perioperative blood loss, allogeneic RBC transfusion, and surgery time. Analyses were performed by intention-to-treat. RESULTS: The intention-to-treat analysis included 45 patients. Mean intraoperative blood loss did not differ significantly (P = .270) between the embolization group (618 mL [SD, 282 mL]) and the control group (735 mL [SD, 415 mL]). There was also no significant difference in allogeneic RBC transfusion (P = .243). Surgery time was significantly shorter in the embolization group (P = .031): median 90 minutes (range, 54-252 min) versus 124 minutes (range, 80-183 min). The subanalysis of hypervascular metastases revealed a significant (P = .041) reduction in blood loss in the embolization group: 645 mL (SD, 289 mL) versus 902 mL (SD, 416 mL). CONCLUSIONS: Preoperative embolization in patients with symptomatic spinal metastasis independent of primary tumor diagnosis did not reduce intraoperative blood loss and allogeneic RBC transfusion significantly but did reduce the surgery time. A small reduction of intraoperative blood loss was shown in hypervascular metastases.

Perioperative blood transfusion does not decrease survival after surgical treatment of spinal metastases.

PURPOSE: To assess whether perioperative allogenic blood transfusions in patients undergoing surgical treatment for spinal metastases independently influence patient survival. METHODS: A retrospective study including 170 consecutive patients undergoing surgical treatment for spinal metastases in 2009 and 2010 at a tertiary referral center. Variables related to postoperative survival were all included in the same multivariable logistic regression analysis with either 3- or 12-month survival as the dependent variable. The independent variables were: transfusion of allogenic red blood cells, age at surgery, gender, preoperative hemoglobin, revised Tokuhashi score and no. of instrumented levels. RESULTS: Perioperative allogenic blood transfusion of 1-2 units was associated with increased 12-month survival [p = 0.049, odds ratio 2.619 (confidence interval 1.004-6.831)], but not with 3-month survival. Larger transfusion volumes did not significantly influence survival. CONCLUSION: The results of the present study support that perioperative blood transfusion of <5 units does not decrease survival in patients operated for spinal metastases. Transfusion of 1-2 units seems to be associated with increased 12-month survival. Future studies should assess if a liberal transfusion regime can be applied to this group of patients; thereby, prioritizing early postoperative mobilization.

No difference in portal and hepatic venous bacterial DNA in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt insertion.

BACKGROUND: Bacterial translocation (BT) with immune activation may lead to hemodynamical alterations and poor outcomes in patients with cirrhosis. AIMS: We investigated bacterial DNA (bDNA), a marker of BT, and its relation to portal pressure and markers of inflammation in the portal and hepatic veins in patients with cirrhosis undergoing TIPS insertion. METHODS: We analysed plasma for bDNA and markers of inflammation in 28 patients [median portal pressure gradient 15 (11-19) mmHg] during TIPS treatment for refractory ascites (n = 19) or acute variceal bleeding (n = 9). Advanced cirrhosis was present in the majority [Child-Pugh class (A/B/C): 1/14/13], and most often caused by alcohol (n = 21). RESULTS: bDNA was detectable in one or both samples in 16 of 28 patients (57%). bDNA was present in 39% of the samples from the portal vein vs 43% of the samples in the hepatic vein (P = 0.126). Antibiotics had no effect on bDNA or markers of inflammation. Markers of inflammation did not differ between the hepatic and portal veins with the exceptions of soluble urokinase plasminogen activating receptor (suPAR) and vascular endothelial growth factor (VEGF), both higher in the hepatic vein (P = 0.031 and 0.003 respectively). CONCLUSIONS: No transhepatic gradient of bDNA was evident, suggesting that no major hepatic elimination of bDNA occurs in advanced liver disease. bDNA, in contrast to previous reports was largely unrelated to a panel of markers of inflammation and without relation to portal pressure.

Vertebro-Vertebral Fistula Occlusion Using a Woven EndoBridgeTM-Device.

Vertebro-vertebral fistulas (VVFs) are vascular lesions that may develop after trauma or spontaneously in association with connective tissue disorders. We present a rare case of a post-traumatic VVF in a young patient presenting with a painless swelling and a bruit in her left upper neck. Digital subtraction angiography showed an arteriovenous fistula between the left vertebral artery (VA) and the vertebral venous plexus with significant steal phenomenon. Endovascular therapy was performed using a Woven EndoBridgeTM (WEB)-device combined with coils that allowed preservation of the VA. The patient fully recovered from her symptoms and follow-up imaging showed stable occlusion. In conclusion, VVFs can be effectively treated using intrasaccular flow diverters such as the WEB-device, allowing for complete and stable occlusion while preserving the parent artery.

[Uterine arterial embolisation in cases with bleeding non-tubal ectopic pregnancy as a new acute treatment].

Ectopic pregnancy is a potential lifethreatening condition and can be treated conservatively, with methotrexat or acute surgery depending upon the patient's condition. A 38-year-old woman was brought to the gynaecological acute ward with an ectopic pregnancy. However, the woman had a previous history of major abdominal surgery and many adhesions. In a multidisciplinary effort it was decided to perform an embolisation of the uterine artery with a good result. This case study depicts that an embolisation can be a valid treatment of an ectopic pregnancy.

Early diagnosis enabling precision medicine treatment in a young boy with PIK3R1-related overgrowth.

Mosaic PIK3R1 variants have recently been demonstrated in patients with complex vascular malformations and overgrowth in a syndrome resembling PIK3CA-related overgrowth syndrome (PROS). The PIK3CA-inhibitor, alpelisib, seems to be a promising treatment option for PROS patients. We describe a young boy with overgrowth and a pathogenic mosaic variant in PIK3R1; c.1699A > G, p.(Lys567Glu). He was prenatally suspected of a syndrome on the presence of unusual transient fluctuating subcutaneous edemas and lymphedema of his left shoulder. The pathogenic variant, later found to be causative, was below detection threshold in whole-genome sequencing (WGS) analysis of amniotic fluid. Upon delivery a mosaic pathogenic PIK3R1 variant, was identified by whole-exome sequencing (WES) of a skin biopsy. With no proven treatment options available, and based on the theoretical disease mechanism, alpelisib therapy was initiated at nine months of age. In the first year of treatment growth normalized and the affected vascular and lymphatic tissue regressed. No side effects have been observed. This report underlines the importance of early variant detection in children suspected of having severe mosaic overgrowth, and proves that prenatal diagnosis is possible, enabling prompt treatment. Furthermore, it demonstrates the promising effects of alpelisib in this patient group.

Rituximab Treatment in a Patient with Kimura Disease and Membranous Nephropathy: Case Report.

Kimura disease (KD) is a chronic, inflammatory disorder with slowly developing subcutaneous tumor-like swellings, often occurring in the head and neck region. KD is diagnosed based on histology, elevated levels of immunoglobulin type E, and increased peripheral eosinophil granulocytes. KD may coexist with glomerular renal diseases, and this case report is based on a patient with KD-associated membranous nephropathy. Patients with membranous nephropathy without KD have demonstrated responsiveness to treatment with monoclonal anti-CD20 antibodies. This case report is the first to investigate the effect of rituximab treatment in a patient with KD-associated membranous nephropathy. A 30-year-old Italian man living in Denmark was diagnosed with Kimura's disease based on subcutaneous nodules with eosinophil angiolymphoid hyperplasia. The patient was admitted to the hospital due to nephrotic syndrome. Serology showed eosinophil granulocytosis and negative PLA2-receptor antibody. Renal biopsy showed membranous nephropathy, and the patient was treated with systemic methylprednisolone followed by cyclosporin and then cyclophosphamide with only partial remission. Ultimately, treatment with intravenous rituximab was initiated, which resulted in overall remission and no nephrotic relapses at 30 months of follow-up. Thus, intravenous rituximab effectively decreased proteinuria and prevented nephrotic relapses in a patient with treatment-refractory membranous nephropathy due to KD.

Traumatic iatrogenic chylothorax after external electrical cardioversion.

Chylothorax, an uncommon cause of pleural effusion, results from the accumulation of lymph in the pleural space due to damage or obstruction of the thoracic duct. Chylothorax can be due to several aetiologies, many of which are rare, and it is often a diagnostic challenge to identify the cause. This case report refers to a patient with rapid recurrent episodes of bilateral pleural chylothorax due to damage of the thoracic duct after external electrical cardioversion treatment. The diagnosis took place by the method of exclusion, when all known causes of chylothorax, both non-traumatic and traumatic, were ruled out. A review of the literature on chylothorax was performed using PubMed to assess the different aetiologies, investigations, and treatments usually performed. Chylothorax is usually secondary to malignancy, trauma, congenital diseases, and infections. However, even non-invasive thoracic procedures, such as the one described in our case report, can be the cause.

Efficacy of dexamethasone in reducing the postembolisation syndrome in men undergoing prostatic artery embolisation for benign prostatic hyperplasia: protocol for a single-centre, randomised, double-blind, placebo-controlled trial-the 'DEXAPAE' study.

INTRODUCTION: Postembolisation syndrome (PES) is the most common side effect of vascular embolisation of solid organs. Although prophylactic corticosteroids are known to reduce the incidence and severity of PES, no trials investigating their efficacy have been conducted in men undergoing prostatic artery embolisation (PAE). We postulate that steroids can have a similar effect in reducing PES after PAE. This paper describes the rationale and detailed protocol for a randomised controlled trial evaluating the efficacy of dexamethasone (DEXA) in reducing PES after PAE. METHODS AND ANALYSIS: In this single-centre, randomised, double-blind, placebo-controlled trial, we will enrol 60 individuals undergoing PAE for benign prostatic hyperplasia. Participants will be randomised to receive IV DEXA (24 mg) or placebo (saline). The primary outcomes will be postprocedural fever, pain and quality of life. The secondary outcomes will include postprocedural nausea, postprocedural medicine usage, laboratory parameters (C reactive protein, prostate-specific antigen) and early PAE results. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Danish Committee on Health Research Ethics in the Capital Region (H-20025910). The results from this trial will be disseminated through publication in peer-reviewed journals and national and international presentations. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov identifier: NCT04588857; EudraCT number: 2020-000915-53.

[Diagnosis and treatment of a multisystemic disorder in children called congenital portosystemic shunts].

Congenital portosystemic shunts (CPSS) are rare malformations, which connect the portal venous system and the systemic circulation. The disorder is discovered at prenatal screening, neonatal cholestasis as an incidental finding or by systemic complications such as pulmonary hypertension, encephalopathies or liver nodules. CPSS are associated to cardiac malformations and several syndromes. Intervention radiology plays a key role in treatment by closure of the shunt, which is indicated, if the patient has complications, the shunt is extrahepatic, or it is still persistent at two years of age, using a two-step approach, as summarised and discussed in this review.

Prostate Artery Embolization for Lower Urinary Tract Symptoms in Men Unfit for Surgery.

Nearly one in three men develop lower urinary tract symptoms (LUTS) and 10% clinically progress despite medication. Transurethral resection of the prostate (TURP) is the reference standard for symptoms refractory to medical treatment. However, some patients cannot tolerate TURP for medical (e.g., comorbidity) or technical (e.g., large prostate) reasons. This study estimated the safety and effect of prostate artery embolization (PAE) in men unfit for surgery. A prospective, single-centre trial including men with LUTS or urinary retention secondary to benign prostatic hyperplasia (BPH) who were unfit for surgery. The primary objective was to treat urinary retention and LUTS. Outcome measures included International Prostate Symptom Score (IPSS), quality of life (IPSS-QoL), International Index of Erectile Function (IIEF-5), prostate volume (PV), prostate-specific antigen (PSA), peak void flow (Qmax), post-void residual (PVR), and complications. A p-value < 0.05 was considered statistically significant. Eleven consecutive patients with a mean age of 75.2 (SD ± 8.2) underwent PAE. Catheter removal was successful in 60%. IPSS-QoL improved 4.5 points (95% CI: -5.6; -3.4), and PV was reduced by 26.2 cm3 (95% CI: -50.9; -2.3). None of the remaining outcomes changed. No major complications occurred. PAE was effective and safe for LUTS and urinary retention associated with BPH in men unfit for surgery.

[Prostate artery embolisation is a new treatment for prostate disease].

Prostate artery embolisation (PAE) is a new minimally in-vasive treatment for prostate disease. Recent studies have shown, that PAE may be an alternative to transurethral resection of the prostate (TURP), and it reduces the prostate volume by 40%. The reduction in symptom score is com-parable to that of TURP, and only few major complications have been reported. The purpose of this narrative review is to provide a brief overview of the current literature on PAE.

[Correct diagnostic of traumatic renal trauma is important for the treatment].

Renal trauma is injury to the kidney because of either blunt or penetrating trauma. The condition must be diagnosed quickly and correctly in order to preserve kidney function. This article describes classification, diagnostics, treatment and follow-up. It is important to do a CT-urography to classify the injury properly. The majority of the patients with renal injury can be managed conservatively. Surgical exploration is primarily for the control of haemorrhage. Complications may require additional imaging or inter-ventions. Follow-up is focused on renal function and blood pressure.

Lipomatous tumours of the face in infants: diagnosis and treatment.

PURPOSE: The aim of this review is to present the different lipomatous tumours of the face typically found in infants. Lipomatous tumours induce a diagnostic challenge due to the low frequency, and the fact that the different lipomatous tumours mimic each other. METHOD: This study developed a flowchart for use in the evaluation of these tumours, including congenital infiltrating lipomatosis of the face, lipoblastomas, and liposarcomas. RESULTS AND CONCLUSIONS: The clinical presentation, histological features, imaging characteristics and treatment options are covered. It is suggested that a careful clinical examination is followed by magnetic resonance imaging. A histological analysis is often necessary to establish a definitive diagnosis, and a core needle biopsy is preferred in regards to sampling. Surgery is the treatment of choice, and should be performed by multidisciplinary teams in highly experienced centres. Individual surgical planning is mandatory.

Concurrent biliary drainage and portal vein embolization in preparation for extended hepatectomy in patients with biliary cancer.

BACKGROUND: Patients with perihilar cholangiocarcinoma and gallbladder cancer extending into the hilum often present with jaundice and a small future liver remnant (FLR). If resectable, preoperative biliary drainage and portal vein embolization (PVE) are indicated. Classically, these measures have been performed sequentially, separated by 4-6 weeks. PURPOSE: To report on a new regime where percutaneous transhepatic biliary drainage (PTBD) and PVE are performed simultaneously, shortening the preoperative process. MATERIAL AND METHODS: Six patients were treated with concurrent PTBD and PVE under general anesthesia. RESULTS: Surgical exploration followed the combined procedure after 35 days (range, 28-51 days). The FLR ratio increased from 22% to 32%. Three patients developed cholangitis after the procedure. CONCLUSION: The combined approach of PTBD and PVE seems feasible, but more studies on morbidity are warranted.