Iliocaval fistula presenting with paradoxical pulmonary embolism combined with high-output heart failure successfully treated by endovascular stent-graft repair: case report.

A 51-yr-old man presented exertional dyspnea as a consequence of iliocaval fistula combined with paradoxical pulmonary embolism and high-output heart failure. Endovascular stent-graft repair was performed to cover iliocaval fistula and restore the heart function. After the procedure, dyspnea was improved and procedure related complication was not seen. A 6-month follow-up computed tomography showed regression of pulmonary thromboembolism and well-positioned stent-graft without graft migration, aortacaval communication or endoleak. Stent graft implantation should be considered an alternative of open repair surgery for treament of abdominal arteriovenous fisula, especially in patient with high risk for surgery.

Impact of arterial microcalcification of the vascular access on cardiovascular mortality in hemodialysis patients.

Gross vascular calcification seen on imaging studies is common in hemodialysis (HD) patients, and is a significant predictor for cardiovascular mortality in HD patients. We have reported that arterial microcalcification (AMiC) of the vascular access is associated with increased aortic stiffness. This study investigated the impact of vascular access AMiC on cardiovascular mortality in HD patients. The study included 149 HD patients (mean age: 59.1 ± 13.9 years, 86 men and 63 women, 65.8% diabetic) who underwent vascular access surgery. Radial or brachial artery specimens were obtained intraoperatively, and pathologic examination was performed using von Kossa stain to identify AMiC. We compared all-cause and cardiovascular mortality between patients with and without AMiC. The mean follow-up was 37.8 ± 34.5 months, and AMiC was present in 38.8% (n = 57) of patients. The presence of diabetes (odds ratio: 16.49, 95% confidence interval: 1.81-150.36, P = 0.013) was the only independent risk factor for vascular access AMiC. During the observational period, there were 27 cardiovascular deaths. Kaplan-Meier analysis showed an increased cardiovascular mortality risk (log rank = 4.83, P = 0.028) in AMiC patients, and Cox regression analysis confirmed that AMiC was an independent predictor for cardiovascular mortality (hazard ratio: 2.35, 95% confidence interval: 1.09-5.09, P = 0.030). In conclusion, vascular access AMiC is a strong risk factor for cardiovascular mortality in HD patients.

Abdominal compartment syndrome due to spontaneous retroperitoneal hemorrhage in a patient undergoing anticoagulation.

Spontaneous retroperitoneal hemorrhage is one of the most serious and often lethal complications of anticoagulation therapy. The clinical symptoms vary from femoral neuropathy to abdominal compartment syndrome or fatal hypovolemic shock. Of these symptoms, abdominal compartment syndrome is the most serious of all, because it leads to anuria, worsening of renal failure, a decrease in cardiac output, respiratory failure, and intestinal ischemia. We report a case of a spontaneous retroperitoneal hemorrhage in a 48-year-old female who had been receiving warfarin and aspirin for her artificial aortic valve. She presented with a sudden onset of lower abdominal pain, dizziness and a palpable abdominal mass after prolonged straining to defecate. Computed tomography demonstrated a huge retroperitoneal hematoma and active bleeding from the right internal iliac artery. After achieving successful bleeding control with transcatheter arterial embolization, surgical decompression of the hematoma was performed for management of the femoral neuropathy and the abdominal compartment syndrome. She recovered without any complications. We suggest that initial hemostasis by transcatheter arterial embolization followed by surgical decompression of hematoma is a safe, effective treatment method for a spontaneous retroperitoneal hemorrhage complicated with intractable pain, femoral neuropathy, or abdominal compartment syndrome.