Acute Arterial Thrombosis Research Articles

Soluble P-Selectin Levels in Patients with Sickle Cell Disease Reflect Platelets' Activation Rather Than Endothelial Dysfunction

Background: Vascular occlusion is a major cause of the morbidity associated with sickle-cell disease (SCD). The tendency of sickle red blood cells to adhere to the vascular endothelium is believed to be a major contributor and possibly primary cause of the vaso-occlusive process. Therefore mediators of adhesion have become a potential new target for pharmacological therapy to combat the complications of SCD. One of the molecules involved in this process is P-Selectin or CD62P, a cell adherence molecule that is rapidly and chronically expressed on the surface of endothelial cells and platelets when activated. P-Selectin is found in the plasma of normal individuals at ng/mL concentrations. Circulating soluble P-Selectin (sP-Selectin) appears to be slightly smaller than native P-Selectin. An alternatively spliced mRNA encoding a form of human P-Selectin lacking the transmembrane anchoring domain has been reported for both megakaryocytes and endothelial cells, and evidence suggests that the majority of circulating sP-Selectin arises in this manner. We and others have reported elevated sP-Selectin levels in SCD even in steady phase. Recently, a humanized monoclonal antibody that binds to P-Selectin and blocks its interaction with P-selectin glycoprotein ligand 1 (PSGL-1) has been administered to patients with SCD, resulting in an amelioration of painful VOC. In this context we aimed to explore if sP-Selectin levels could be used to choose among the SCD patients those who might benefit from the new therapy. Patients and Methods: Eighty adult Caucasian patients with HbS/βthal at steady phase [40 patients under hydroxyurea (HU+) treatment and 40 patients without hydroxyurea (HU-) treatment] were included in this study, while 20 apparently healthy individuals of similar age and gender served as controls. Along with sP-Selectin levels, measured with the same method as reported previously (Human sP-Selectin/CD62P Immunoassay, R&D Systems, Minneapolis, MN, USA), other parameters of hemolysis, inflammation, endothelial dysfunction, iron accumulation and clinical features of the disease were evaluated. Results are expressed as median values ± SEM. Results: We found that sP-Selectin levels were elevated in 45/80 (56%) patients with HbS/βthal compared to controls (108.2±6.3 vs. 69.3±4.1ng/mL, respectively, p<0.001), independently of patients' βthal genotype and correlated strongly with PLT count (r=0.760, p<0.001). Regarding HU treatment, sP-Selectin levels did not differ between (HU+) and (HU-) patients (112.5±9.8 vs. 100.3±7.4ng/mL, respectively, p>0.07). No significance correlation was found between sP-Selectin levels and markers of: hemolysis (RPI: r=0.191, p>0.100); LDH: r=0.103, p>0.360 and bilirubin: r=0.171, p>0.130); inflammation (hs-CRP: r= 0.002, p>0.842); endothelial dysfunction (vWF:antigen: r=0.141, p>0.210 and ADAMTS-13: r=0.089, p>0.507). Regarding iron accumulation no correlation was found between sP-Selectin and ferritin levels (r=0.090, p>0.438), while a weak negative correlation was found with hepcidin-25 levels (r=-0.283, p=0.018). Furthermore, no correlation was found between sP-Selectin levels and history of clinical complications such as VOC (p>0.795), acute chest syndrome, venous and arterial thrombosis and mean pulmonary artery pressure values, (p>0.402). Conclusion: In this study, we proceeded with an external validation procedure of sP-Selectin determination in patients with HbS/βthal (keeping the same methodology in a different cohort of patients), and we found elevated levels of sP-Selectin with the evidence of PLTs' secretion origin, as no correlation found with other markers of endothelial dysfunction and inflammation. Interestingly, we failed to find a significant link of sP-Selectin levels with other markers of disease severity and/or clinical features of SCD. Thus, we consider that the use sP-Selectin as a biomarker of assessment and treatment of endothelial dysfunction in patients with SCD is of almost negligible importance. Disclosures Voskaridou: Genesis: Consultancy, Research Funding; Protagonist: Research Funding; Celgene Corporation: Consultancy, Research Funding; Acceleron: Consultancy, Research Funding; Addmedica: Membership on an entity's Board of Directors or advisory committees.

PFO closure consideration for refractory hypoxia and secondary prevention of recurrent arterial thromboembolism

Acute arterial and deep venous thrombosis presenting simultaneously are uncommon medical emergencies, usually secondary to an underlying cause. We present a 64-year-old woman with concurrent bilateral pulmonary embolisms and acute thrombotic occlusion of the right brachial artery. Her work-up revealed a large patent foramen ovale (PFO), with a right to left intracardiac shunt and bilateral lower extremity deep venous thrombosis. The patient was unable to be weaned off mechanical ventilation due to her refractory hypoxia. However, after closure of the PFO the patient’s oxygenation improved. This case demonstrates the potential beneficial role of PFO closure in a hypoxic patient with a right to left intracardiac shunt. In addition, closure of the PFO may provide secondary prevention of paradoxical systemic thromboembolism.

Clinical efficacy of catheter-directed thrombolysis combined with endovascular interventions for acute lower limb ischemia

Objective: To explore the risk factors and treatment of acute lower limb ischemia with catheter-directed thrombolysis combined with endovascular interventions. Methods: Totally 191 patients (191 lower limbs) with acute lower limb ischemia in department of vascular surgery of the First Affiliated Hospital of Chongqing Medical University from June 2012 to June 2017 who underwent catheter-directed thrombolysis combined with endovascular interventions were collected. According to imaging findings and clinical characteristics, the patients were divided into acute arterial embolism group (n=36) and acute arterial thrombosis group (n=155). The treatment effect, long-term follow-up and the risk factors closely related to primary patency were analyzed. Results: Among the 191 patients, the immediate success rate of surgery was 100%, the amputation rate within 30 days was 8.4% (16/191), and the mortality rate within 30 days was 2.6% (5/191). The mean follow-up was 31.0 (1.0-60.0) months. The 1-year overall survival rate was 92.1% and the 5-year was 79.5%. The primary patency rate was 74.3% within 1 year and 61.5% within 5 years. Primary vascular patency rate within 1 year and 5 years was mainly affected by occlusion segment (OR=3.5, 2.9, P<0.05), outflow tract (OR=3.2, 2.8, P<0.05) and ischemia degree (OR=3.4, 3.6, P<0.05). Conclusion: Catheter-directed thrombolysis combined with endovascular interventions for acute lower limb ischemia is a safe and effective method. Risk factors for primary patency at 1 and 5 years are occlusion segment, outflow tract and ischemia degree.

Natural History of Acute Pediatric Iliofemoral Artery Thrombosis Treated With Antithrombotic Therapy

Natural History of Acute Pediatric Iliofemoral Artery Thrombosis Treated With Antithrombotic Therapy

Recurrent intestinal ischemia following surgery for gastric and duodenal perforations: a case report

BackgroundExtremely low birth weight (ELBW) is a risk factor for various gastrointestinal complications. In the recent decades, advances in medicine have increased the survival of ELBW infants with necrotizing enterocolitis (NEC). To our knowledge, there have been no reports of neonates or infants developing simultaneous gastric and duodenal perforations and later developing NEC. We report a case of an extremely low birth weight infant (ELBWI) who developed both gastric and duodenal perforations at the same time and developed NEC after operation for gastric and duodenal perforations.Case presentationThe patient was a female infant with ELBW who developed both gastric and duodenal perforations at the same time and developed NEC after operation for gastric and duodenal perforations. After birth, endotracheal intubation was performed. However, barotrauma occurred during positive pressure ventilation, resulting in a large area of emphysema in the left lower lung field, leading to collapse of the left lung. This giant bulla may have compressed the pulmonary vein, possibly resulting in pulmonary venous thrombosis (PVT). This episode could have triggered simultaneous gastric and duodenal perforations. In addition, we hypothesized that PVT caused acute arterial ischemia, leading to the development of NEC. The infant was started on heparin for anticoagulation. Later, the infant developed non-immunoglobulin E (IgE)-mediated gastrointestinal food allergies (non-IgE-GI-FAs). The giant bulla associated with barotrauma might have caused PVT, resulting in arterial emboli and multiple simultaneous gastrointestinal perforations.ConclusionsAnticoagulation therapy with heparin for acute arterial thrombosis is effective for preventing the development of short bowel syndrome. Duodenal and intestinal surgery probably acted as risk factors for the subsequent development of non-IgE-GI-FAs. The infant had been stabilized at the time of writing this report.

A Case of Successful Thrombolysis on the Verge of a Reperfusion Revolution in Coronary Cardiology and Vascular Neurology

Thrombolytic therapy (TLT), as a method of treatment, began to develop in the second half of the 50s of the last century. At that time, there was an accumulation of data on its effectiveness, side effects and contraindications, as well as the development of fibrinolytic drugs, such as fibrinolysin, streptokinase, urokinase, and the conditions for their administration. Official recognition of TLT in regulatory documents began only in the 80s after the development of more effective and safe tissue plasminogen activators. However, on the threshold of an era of development in this area in the treatment of patients with thrombosis of the coronary, carotid, and other peripheral vascular regions, the researchers obtained conflicting data on the results of the use of thrombolytics. There was no concept of a therapeutic window for the use of TLT, there was no data on possible combinations of thrombolytic drugs with anticoagulants, the high probability of bleeding prevented widespread introduction of the method into clinical practice. At that time, vascular imaging and laboratory diagnostics were not sufficiently developed, there was no consensus of the world's leading experts on the benefits of thrombolysis. The use of TLT in acute arterial thrombosis required not only clinical experience, but also courage and ability to make non-standard decisions. The authors of the article analyze in detail the case of rescuing a patient with progressive thrombotic occlusion of the arteries of the brain stem. Then the pioneer in the field of thrombolytic therapy E. I. Chazov and his colleagues took responsibility for the application in this situation of an insufficiently studied treatment method with uncertain consequences. This decision was not due to the identity of the patient or the threat of an internal investigation. Marshal or soldier - it did not matter for E. I. Chazov and his colleagues. If doctors in this clinical situation relied on recommendations, orders and standards, then such a patient would have to wait thrombolysis for another 30 years.

Iatrogenic Radial Artery Injuries: Variable Injury Patterns, Treatment Times, and Outcomes.

Background: The radial artery is commonly accessed for arterial blood sampling, invasive blood pressure monitoring, and vascular access for cardiac catheterization. Iatrogenic radial artery injury is a rare complication with potentially devastating outcomes. The purpose of our study was to identify the timing of these injuries and define a treatment algorithm. Methods: A retrospective chart review of all patients with iatrogenic radial artery injuries were identified between the years 2008 and 2018. Patient demographics, mechanism of injury, interventions, and outcomes were recorded. Results: A total of 18 patients were identified with iatrogenic radial artery injury over a 10-year period. Fifty percent of these resulted from arterial line cannulation, and 50% occurred after transradial cardiac catheterization. Thirty-three percent resulted in radial artery pseudoaneurysm (RAP), and 66% had acute radial artery thrombosis (RAT). Eleven of the 18 patients underwent operative intervention. Of the 12 patients with RAT, 4 were treated with systemic anticoagulation for 3 months. All patients with RAP who were surgically treated had resolution of symptoms on follow-up evaluation. Of the patients with RAT, 2 had persistent sensorimotor deficits after treatment, and 1 patient had multiple necrotic fingers requiring amputation. Conclusion: Radial artery injuries are an uncommon but potentially devastating complication of common invasive procedures resulting in thrombosis, pseudoaneurysm, or overt hand ischemia. The treatment options vary depending on presenting symptoms.

Endovascular Management of Acute Superior Mesenteric Artery Thrombosis in a Delayed Setting

Acute mesenteric ischemia [AMI] is a life-threatening situation, the diagnosis of which is often missed in early stages. Late diagnosis often precludes endovascular management as the primary treatment. The authors here present a case of seven days history of acute mesenteric ischemia in a young female, who not just benefited from endovascular management, but also a major surgical intervention was avoided andwas discharged from the hospital uneventfully. The decision to consider a patient for endovascular management in a late stage, requires a good interdisciplinary communication and successful outcome in such a scenario is rarely achieved.

Factors and mechanisms of arterial hypertension development in patients with atherosclerosis of lower limb arteries

The article contains information about the frequency of development of arterial hypertension (AH), the features and causes of its development in patients with peripheral atherosclerosis. AH in patients with chronic atherosclerotic diseases of lower limb arteries and acute thrombotic occlusion complicates the course of this pathology. In most patients, the opinion that AH associated with atherosclerosis due to affection of renal arteries is generally accepted. Currently, an important practical question remains about the possible negative impact of intensive antihypertensive therapy with a significant reduction in blood pressure and aggravation of necrobiosis processes in the ischemic limb in a patient with acute arterial thrombosis.

Towards the design of mechanically superior tubular structures for microcatheters

Cardiac catheterization (CC) procedures in children and adults, and especially within vasculature of small cross-section comes with the increased risk of complications due to acute occlusive arterial injuries and (or) thrombosis. Micro-catheters play a vital role in enabling CC procedures, however, to extend their functionality beyond large blood vessels and into pediatric wards, necessitates superior mechanical attributes that are fundamental to their structure. There exists a strong correlation between tool footprint and the risk of these injuries, nevertheless, changes in tool-size are impeded by mechanical constraints and manufacturing. In this paper, we propose pattern geometries for tubular structures that can be tuned to obtain desired mechanical characteristics, while retaining a minimum tool cross-section. We perform numerical simulations to systematically investigate the effect of pattern design parameters on the tube’s properties, and present guidelines for obtaining the preferred behavior. The rounded re-entrant honeycomb (RRH) is introduced as the base structure for more responsive catheters, and is contrasted with the dog-bone geometry (DB), and the conventional slot. Notably, the RRH patterned tubes are highly compliant in bending yet strong in torsion while the DB tubes are strong in both torsion and bending. Therefore, our results indicate positively for a wide-range of tunable behavior in patterned tubes, with the RRH poised as a promising alternative for achieving the design goals that are introduced.

Limb Salvage After Percutaneous Mechanical Thrombectomy in Patients with Acute Lower Limb Ischemia: A Retrospective Analysis from Two Institutions

To evaluate the short-term outcomes of percutaneous mechanical thrombectomy (PMT) in patients with acute lower limb ischemia (ALI) and to analyze the effect of ALI of different etiologies on the limb salvage. From January 2015 to December 2017, a retrospective analysis was performed on 112 patients (mean age: 66.5 years; 117 limbs in total; 66 limbs in 61 males) with ALI treated with PMT at 2 vascular institutions. Of the 117 limbs, 44 (41 patients) had acute arterial embolism, 36 (34 patients) had acute arterial thrombosis, and 37 (37 patients) had acute stent (31 limbs in 31 patients) or graft (6 limbs in 6 patients) thrombosis. The primary end point was limb salvage rate, and subgroups were analyzed by etiological factors. The secondary end points included patency rates, major bleeding complications, 30-day mortality, and reintervention rates. The 30-day mortality rate was 3.6%. The incidence of major bleeding complications was 2.7%. During the follow-up, the limb salvage rates at 1year and 2years were 83.8% and 74.7%, respectively. Subgroup analysis showed that the limb salvage rate in patients with acute arterial embolism was 92.9% at 2years after PMT, which was higher than that in patients with acute arterial thrombosis (73.3%, P=0.04, hazard ratio [HR]: 3.6, 95% confidence interval [CI]: 1.1-11.7) and acute stent/graft thrombosis (62.5%, P=0.01, HR: 4.7, 95% CI: 1.5-13.6). PMT in patients with ALI is effective in preventing amputations over the 3-year study period with a reasonable safety profile, especially in patients with acute arterial embolism.

Analysis of the results of endovascular and open surgical treatment of acute limb ischemia

ObjectiveThe objective of this study was to evaluate the long-term estimates of limb salvage and survival in patients with acute limb ischemia (ALI) receiving open surgery or endovascular revascularization. MethodsThis was a retrospective consecutive cohort study of patients with ALI who underwent open surgery or endovascular treatment at the Vascular and Endovascular Surgery Unit, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2010 and July 2016. The overall mortality, limb salvage, and survival rates at 720 days were analyzed in both the open surgery (group 1) and endovascular treatment (group 2) groups. ResultsA total of 69 patients were admitted for a limb salvage procedure. The mean follow-up period was 822 ± 480.5 days. All of the analyses were performed at 720 days. Of the 69 patients, 46 (66.6%) were in group 1 and 23 (33.4%) in group 2. The clinical characteristics were similar between the groups, except for higher rates of chronic kidney disease (P = .04) and arrhythmia (P = .01) in group 1. Group 1 had a higher postoperative ankle-brachial index (P = .03). Concerning the Rutherford classification, group 1 had a higher prevalence of Rutherford IIB ALI (P = .003). The preoperative creatine kinase level was higher in group 1 than in group 2 (780 [range, 198-6546] mg/dL and 245 [65-78] mg/dL, respectively). A creatine kinase level >200 mg/dL was seen in 65.2% and 47.8% of patients in group 1 and group 2, respectively (P = .028). The limb salvage and overall survival estimates at 720 days were similar between group 1 and group 2 (79.2% vs 90.6% [P = .27] and 53% vs 60.8% [P = .45], respectively). The overall mortality rate was 10.1% (seven patients) within the first 30 days, and it was higher in group 1 (six patients [13.0%]; P = .03). ConclusionsBoth open surgery and endovascular procedures are safe treatments of patients with ALI, with acceptable limb salvage and survival rates. No previous study has suggested the preferred treatment of ALI. However, based on this study and the overall literature, endovascular treatment may be the preferred treatment of patients with Rutherford I and IIA ALI; open surgery may be the best option for ALI due to arterial embolism and for Rutherford IIB acute arterial thrombosis because of a greater urgency to restore blood flow.

A phase 1, first-in-human study of 18F-GP1 positron emission tomography for imaging acute arterial thrombosis

Background18F-GP1 is a novel positron emission tomography (PET) tracer that targets glycoprotein IIb/IIIa receptors on activated platelets. The study objective was to explore the feasibility of directly imaging acute arterial thrombosis (AAT) with 18F-GP1 PET/computed tomography (PET/CT) and to quantitatively assess 18F-GP1 uptake. Safety, biodistribution, pharmacokinetics and metabolism were also evaluated.MethodsAdult patients who had signs or symptoms of AAT or had recently undergone arterial intervention or surgery within 14 days prior to 18F-GP1 PET/CT were eligible for inclusion. The AAT focus was demonstrated by conventional imaging within the 5 days prior to 18F-GP1 administration. Whole-body dynamic 18F-GP1 PET/CT images were acquired for up to 140 min after injection of 250 MBq of 18F-GP1. Venous plasma samples were analysed to determine 18F-GP1 clearance and metabolite formation.ResultsAmong the ten eligible patients assessed, underlying diseases were abdominal aortic aneurysm with endovascular repair (n = 6), bypass surgery and stent placement (n = 1), endarterectomy (n = 1), arterial dissection (n = 1) and acute cerebral infarction (n = 1). 18F-GP1 administration and PET/CT procedures were well tolerated, with no drug-related adverse events. All patients showed high initial 18F-GP1 uptake in the spleen, kidney and blood pool, followed by rapid clearance. Unmetabolised plasma 18F-GP1 levels peaked at 4 min post-injection and decreased over time until 120 min. The overall image quality was sufficient for diagnosis in all patients and AAT foci were detected in all participants. The 18F-GP1 uptake in AAT foci remained constant from 7 min after injection and began to separate from the blood pool after 20 min. The median standardised uptake value of AAT was 5.0 (range 2.4–7.9) at 120 min post-injection. The median ratio of standardised uptake value of AAT foci to the mean blood pool activity was 3.4 (range 2.0–6.3) at 120 min.Conclusions18F-GP1 is a safe and promising novel PET tracer for imaging AAT with a favourable biodistribution and pharmacokinetic profile.Trial registrationClinicalTrials.gov identifier: NCT02864810, Registered August 3, 2016.

Superior Mesenteric Artery Occlusion: A case report and mini Review.

Introduction: Acute mesenteric ischemia/occlusion is a life-threatening vascular emergency that requires early diagnosis and intervention to restore mesenteric blood flow and to prevent loss of life. Despite progress in our understanding about the mesenteric ischemia, diagnostic modalities, and treatment options, the mesenteric ischemia remains a diagnostic challenge. This leads to delayed implementation of treatment and thus contributes to high mortality and morbidity. Methods: Here, we have presented a case report of superior mesenteric artery thrombosis. It discusses the various aspects of superior mesenteric artery occlusion, the etiology, the difficulty with diagnosis, and the best possible course of action. Results: The Superior Mesenteric Artery (SMA) supplies the whole of the small intestine except the superior part of the duodenum. It also supplies the caecum, ascending colon and most of the transverse colon. Acute mesenteric ischemia (AMI) is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischemia and eventual gangrene of the bowel wall. Conclusion: The acute mesenteric ischemia (AMI) comprises four different primary clinical entities, Non-occlusive mesenteric ischemia (NOMI), and occlusive mesenteric artery ischemia (OMAI).This OMAI is further subdivided into acute mesenteric arterial embolism (AMRE) and acute mesenteric arterial thrombosis (AMRT). The AMI as the venous disease takes the form of Mesenteric venous thrombosis. (MVT). The overall prevalence of AMI is 0.1% of all hospital admissions; venous thrombosis is found in approximately 0.001% of patients who undergo exploratory laparotomy. The risk factor for AMI includes arrhythmia, heart diseases, mitral stenosis, endocarditis, recent MI, and intra-abdominal malignancies.

Beyond HELLP: Peripartum Catastrophic Thromboembolism due to Hereditary Diffuse Gastric Cancer

Peripartum thrombocytopenia and thrombotic events are usually attributable to diseases like Hemolysis Elevated Liver Enzymes Low Platelets (HELLP) and thrombotic thrombocytopenic purpura (TTP). Malignancy is a rare cause and gastric cancer even more unusual. We report the case of a 28-year-old female with undiagnosed hereditary diffuse gastric cancer (HDGC) in the peripartum period initially presenting with nausea and blurry vision at 35 weeks’ gestation. Following cesarean section 1 week later, she developed thrombocytopenia and elevated blood pressure; HELLP was diagnosed. Development of acute kidney injury, decreasing platelet count and anemia lead to consideration of TTP. Despite plasmapheresis she had no improvement, developed respiratory failure and had acute large vessel arterial and venous thrombosis with multiple cerebral, renal, splenic and lower extremity arterial infarctions. Deep venous thrombosis of lower limbs was also seen. She was placed on corticosteroids and anticoagulation. Following extensive workup, vegetations on mitral valve were seen on echocardiography and she was started on antibiotics for endocarditis. She deteriorated into refractory shock, multiple organ failure and died on postpartum day 8. Autopsy done revealed diffuse submucosal gastric adenocarcinoma (linitus plastica). Metastases were present on small bowel, fallopian tubes, ovary and the placenta. Mitral valve had marantic vegetations. Tumor cells showed CDH1 gene mutation. Such a diagnosis in pregnancy is very challenging due to overlapping symptoms leading to misdiagnosis. Here, thromboembolism was malignancy-related and rapid spread probably hormone-associated. The purpose of this report is to highlight the need to warrant investigation for cancer, among workup for other common conditions, for atypical thromboembolism in pregnancy. J Clin Gynecol Obstet. 2018;7(3-4):81-83 doi: https://doi.org/10.14740/jcgo512w

An Autopsy Case of Paradoxical Pulmonary Thromboembolism by Arteriovenous Fistula from Right Common Iliac Artery to Common Iliac Vein: A Rare Cause of Pulmonary Embolism

Patient: Male, 74Final Diagnosis: Paradoxical pulmonary thromboembolismSymptoms: DyspneaMedication: —Clinical Procedure: AutopsySpecialty: PulmonologyObjective:Rare co-existance of disease or pathologyBackground:Pulmonary thromboembolism (PTE) sometimes leads to a shock state and sudden death due to acute massive pulmonary arterial thrombosis. The origins of pulmonary arterial thrombi are varied, but most arise from deep vein thrombosis. We herein presented a very rare cause of PTE due to paradoxical embolism caused by arteriovenous fistula from common iliac artery to common iliac vein.Case Report:A 74-year-old man was admitted because of increasing dyspnea on exertion. The diagnosis of idiopathic pulmonary fibrosis was made and corticosteroid therapy was started. On the 5th hospital day, the patient suddenly developed cardiopulmonary arrest and died despite cardiopulmonary resuscitation. An autopsy revealed that the left main pulmonary artery was occluded by a massive but organized thrombus that was similar to an arterial thrombus in the right common iliac artery. On histopathological examination, the emboli in the pulmonary artery demonstrated characteristics similar to thrombus in the common iliac artery. This suggested that the emboli had passed through the arteriovenous fistula from the right common iliac artery to the common iliac vein.Conclusions:This is a very rare cause of fatal paradoxical pulmonary thromboembolism. Paradoxical emboli passing through arteriovenous fistula from the right common iliac artery to the common iliac vein are a rare cause of PTE.

T-ALL Presenting With Acute Mesenteric Ischemia

T-cell acute lymphoblastic leukemia is a rare and aggressive type of leukemia. We discuss the case of a 43 year old male who presented to the hospital with acute abdominal pain for one day. The patient reported waking up in the middle of the night with sudden onset nausea, vomiting and diffuse abdominal pain. The pain was constant, 10/10 and non radiating. The pain did not improve with narcotic medications. Physical exam revealed soft, non distended and mildly tender abdomen. The patient pain was “out of proportion” to the physical exam. Labs revealed pancytopenia and CT abdomen demonstrated acute superior mesenteric artery thrombosis. Exploratory laparotomy revealed necrotic bowel. The patient underwent multiple surgeries for revascularization and small bowel resection. Flow cytometry and bone marrow biopsy confirmed T-ALL. To our knowledge, this is the first case report of T-ALL presenting with acute mesenteric ischemia.2506 Figure 1. SMA thrombosis

Acute Subclavian Artery Thrombosis Secondary to Oral Contraceptive Agent Consumption: A Case Report

Subclavian artery thrombosis is an uncommon cause of limb ischemia in females without a history of vasculopathy. This condition usually occurs secondary to atherosclerotic changes and hypercoagulable states, which are generally asymptomatic. However, it can manifest with such symptoms as coldness, pain, and pulselessness in the upper extremity. Herein, we presented a 40-year-old female admitted to our hospital with three days history of right-side hemiparesis and complaints of imbalance and vertigo. The patient had a history of 2-month consumption of high-dose oral contraceptive (OCP) agents for birth control purposes. Cervical magnetic resonance angiography showed a significant occlusion in the proximal part of the left subclavian artery, leading to the diagnosis of subclavian artery thrombosis secondary to the use of long-term high-dose OCP. Our diagnosis was confirmed with the Doppler color sonography. This case demonstrated the importance of a full assessment regardless of the patient’s chief complaints. This kind of assessment allows for a faster and more effective management, thereby reducing the associated costs. Therefore, any suggestive signs or symptoms of arterial thrombosis should be followed up even in low-risk patients. Accordingly, in case the achievement of confirmatory findings regarding the diagnosis of arterial thrombosis, the patient should be immediately subjected to proper medical and surgical interventions.

Oncocytoma managed by active surveillance in a transplant allograft kidney: a case report

BackgroundThe ethical implications of the utilization of kidneys with solid renal masses (SRMs) in transplantation are the subject of lively debate in the transplantation community and beyond. One of such implications is that as the life expectancy of renal transplant patients improve, the prevalence of SRMs in donors is likely to increase. We report a case of an oncocytoma in a renal allograft complicating a deceased-donor kidney transplant.Case presentationA 60-year-old woman received and underwent deceased-donor renal transplantation for end-stage renal disease after a waiting-list period of 11 years. Kidney Doppler ultrasound (DUS) of the deceased donor was negative for any nodular lesion. The finding of the DUS, done on postoperative day 1, to assess the patency of the graft, was suspicious for an acute arterial thrombosis but did not reveal any focal irregularities. An ensuing computed tomography (CT) scan did not show any arterial complications but serendipitously revealed a 2.4-cm lesion on the upper pole of the renal allograft, which was not detected during the back-table or ultrasonography monitoring. Histology of the biopsied lesion was consistent with oncocytoma. However, because the eosinophilic variant of chromophobe renal cell carcinoma may morphologically resemble renal oncocytoma, immunohistochemical staining was performed. The results were negative, ruling out chromophobe RCC. After discussing the therapeutic options and potential related outcomes with the patient, we found no reason for resection of the lesion or an allograft nephrectomy, given the low risk of malignant transformation in an oncocytoma. Active surveillance of the benign tumor was done with ultrasonography, every 2 months, for the first year and, then, with magnetic resonance imaging, every year. The patient received mycophenolate-mofetil, tacrolimus, and prednisone throughout the 5-year follow-up period, and the regimen for immunosuppression was not changed despite the presence of the renal mass. After 60 months, we report that none of the radiological findings have shown any morphological changes of the lesion, and the patient is well.ConclusionTo the best of our knowledge, we report the first case of an oncocytoma in a renal allograft complicating a deceased-donor kidney transplant, which was successfully managed by active surveillance.

Risk Factors for Thirty-Day Readmissions After Lower Extremity Amputation in Patients With Vascular Disease

BackgroundUnderstanding risk factors associated with readmission after lower extremity amputation may indicate targets for reducing readmission. ObjectiveTo evaluate factors associated with all-cause 30-day readmission after lower extremity amputation procedures. DesignRetrospective cohort study. SettingInpatient. PatientsA total of 2480 patients who had lower extremity amputations between 2008 and 2014 were selected from national electronic medical record database, Cerner Health Facts. MethodsUnivariate analysis of demographics, diagnoses, postoperative medications, and laboratory results were examined. Multivariate logistic regression models were used to identify characteristics independently associated with readmission overall and by amputation location—above the knee (AKA) or below the knee (BKA). Main Outcome MeasurementReadmission within 30 days of discharge. ResultsMore than one half of patients (1403, 57%) underwent BKA and 1077 (43%) underwent AKA. Readmission within 30 days was 22% (24.1% BKA versus 19.4% AKA, P = .005). In multivariable logistic regression, factors associated with 30-day readmission after any amputation included BKA (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.15-1.74, P = .001), hypertension (OR 1.70, 95% CI 1.33-2.16), surgical-site infections (OR 1.44, 95% CI 1.02-2.04), heart failure (OR 1.39, 95% CI 1.10-1.75), discharge to a skilled nursing facility (OR 1.88, 95% CI 1.41-2.51), and emergency/urgent procedures (OR 1.32, 95% CI 1.04-1.67). At readmission, 13.3% of patients with a BKA required an AKA revision, and 21.3% had a diagnosis of surgical-site infection. ConclusionsRisk factors for readmission after any amputation included cardiac comorbidities, associated postoperative medications, and discharge to a skilled nursing facility. The finding that acute arterial embolism or thrombosis and a BKA during the index admission was highly associated with readmission, combined with the high rates of 30-day conversion to an AKA when readmitted, suggests these patients more often develop stump complications or may be undertreated during the initial hospitalization. Level of EvidenceIII