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Vulvar Lymphangioma Arising in the Setting of May-Thurner Syndrome.

This case report describes an instance of vulvar lymphangioma occurring in the setting of May-Thurner syndrome (MTS), an association between two vascular conditions that we do not believe has been previously reported. Lymphangioma, also known as lymphatic malformation, is a benign lesion typified by dilatation of endothelial-lined lymphatic channels involving the skin and subcutis, which can occur either as a congenital abnormality or as a result of acquired damage to lymphatic channels. Lymphangioma is a rare lesion in the vulva. MTS, also known as iliac vein compression syndrome or Cockett's syndrome, is a condition of left iliac vein obstruction due to overriding the right common iliac artery which can lead to iliofemoral deep vein thrombosis. In this report, we describe the case of a 29-year-old woman with MTS diagnosed at 7 years of age with poor lymphatic drainage and pelvic pain requiring left iliac vein stenting. She presented with left vulvar discomfort and chronic lower extremity edema and was found to have warty vulvar masses, with histopathological examination showing lymphangioma of the vulva. We believe that this is the first report of vulvar lymphangioma recognized in the setting of MTS, and we will discuss the clinical features, etiology, and possible pathophysiologic association between these two entities.

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Angiographic and Clinical Impact of Novel Revascularization for Occluded Femoropopliteal Prosthetic Bypass Graft: A Combination of Surgical Thrombectomy and Drug-Coated Balloon Angioplasty.

Previous reports have revealed various endovascular intervention techniques for prosthetic femoropopliteal bypass occlusion (PFPBO); however, treatment for PFPBO remains challenging for most interventionalists and vascular surgeons because the procedure is complicated. Most of the reported techniques involve device implantation. In the present study, we performed a combination of surgical graft thrombectomy and drug-coated balloon angioplasty for PFPBO without implanting any additional devices. Furthermore, we determined the favorable long-term results of this treatment using follow-up angiography. Case Presentation. A 77-year-old man with a history of chronic kidney disease and coronary artery disease presented to our clinic with rest pain on his left leg. Seven years prior to the current consult, he underwent femoropopliteal bypass (FPB) surgery using a prosthetic graft due to in-stent occlusion of the left superficial femoral artery (SFA). Four years after surgery, a duplex ultrasound scan revealed stenosis of the proximal anastomosis site; hence, medical therapy was continued. On the current consult, diagnostic angiography revealed occlusion of the FPB and infrapopliteal vessels. In the first attempt at recanalization, the guidewire was unable to pass through the occluded SFA. Therefore, another technique was performed to revascularize the FPBO and infrapopliteal vessels. We obtained an angiography of the left leg after inserting the guiding sheath via the right common femoral artery (CFA). First, surgical thrombectomy using a Fogarty catheter via the exposed left CFA was performed. Following endovascular therapy via the right CFA, we performed drug-coated balloon angioplasty for anastomotic stenosis and recanalized occlusive infrapopliteal vessels. Restenosis was not observed on follow-up angiograms. On further follow-up angiography, there was notable regression of the residual stenosis at the proximal anastomosis of the prosthetic graft. This novel revascularization strategy may be a viable treatment option for PFPBO.

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Peripheral Arteriovenous Malformation Embolization Using Squid.

Between January 2018 and December 2020, twenty patients (7 men and 13 women) with peripheral high-flow arteriovenous malformations who were treated primarily with arterial embolization using squid were retrospectively included. Anatomical sites being treated included the head and neck (16), extremities (2), uterus (1), and pelvis (1). Squid was used as the sole embolic agent in 15 patients, and transarterial embolization was employed in all cases except one where direct puncture embolization was used. Treatments were delivered over one or two sessions, with or without surgery. A total of 27 sessions were carried out with an interval time ranging from 6 to 36 months between sessions. Technical success was achieved in all cases. In those patients treated with squid alone, 13 exhibited total devascularization following embolization, and a further 4 required surgical excision to achieve complete obliteration of the arteriovenous malformation. There were no major complications, cases of microcatheter entrapment, or dimethyl sulfoxide-related pain recorded. On follow-up, one patient reported persistent pain, and another patient developed a garlicky taste. All other patients reported complete resolution of symptoms following treatment. This study demonstrates the successful use of squid in managing peripheral arteriovenous malformations with low complication rates and long-term stable results, therefore validating its efficacy when used alone or in combination with other embolic agents. Squid may be the preferred embolic agent in any interventional radiologist's armamentarium as it offers formulations with varying viscosities (squid-18 and squid-12). We conclude that squid should be considered as a first-line embolic agent in the management of peripheral arteriovenous malformations.

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