CT Angiography Of Abdomen Research Articles

Recurrent Leg Deep Vein Thrombosis in a Female with Atypical Right-Sided Variant of May Thurner Syndrome and Factor V Leiden Mutation

I ntroduction: May-Thurner syndrome (MTS) is a condition in which the right common iliac artery presses on the left common iliac vein, causing it to narrow over time. Right-sided MTS is a rare event. We present this unique case of recurrent right leg deep vein thrombosis in a female with atypical right sided variant of MTS and Factor V Leiden mutation. Case Presentation: A 34-year-old lady with with no signficiant past medical history presented to the hospital with right lower leg edema, tingling, and discolouration. She was taking oral contraceptive pills. Vitals were unremarkable. Doppler studies revealed right lower extremity deep vein thrombosis in the right external iliac vein, common iliac vein and common femoral vein. She was started on an intravenous heparin drip and subsequently had a thrombectomy procedure. She was subsequently discharged home on apixaban anticoagulation. We opted to request a hypercoagulable and vasculitis workup in light of the extensive thrombosis, despite the OCP risk factor, and discovered a heterozygous Factor V Leiden mutation. She returned to the hospital 2 days later with worsening right leg pain. Repeat Doppler studies demonstrated acute right femoral and popliteal deep vein thrombosis. CT angiography of abdomen and pelvis revealed significant right femoral vein DVT that extends into the External iliac vein, common iliac vein, and IVC to at least slightly below renal vein level. Invasive Radiology was consulted and she had a venogram and intravascular ultrasound (IVUS) which showed high-grade right common iliac vein and IVC stenosis (>90%) at L4 superior endplate. Iliac stenting and angioplasty improved iliac and inferior IVC diameters. Patient also underwent thrombectomy & IVC filter placement. The diagnostic venography revealed a popliteal-to-proximal femoral vein rethrombosis. This was treated with tissue plasminogen activator (TPA) by 8 French power pulse AngioJet and a mechanical thrombectomy. This resulted in partial clearing of the common femoral vein with persistent narrowing and thrombosis of the popliteal vein. TPA was infused at 1 mg/hour with a 5 French McNamara lysis catheter over the popliteal region.Patient transferred to ICU for overnight intravenous thrombolysis. The patient was then re-initiated on the heparin drip and then bridged to therapeutic warfarin. Discussion: MTS is a phenomenon commonly described as an acquired stenosis of the left common iliac vein secondary to compression by the right common iliac artery 1. It has been associated with genetic clotting factor abnormalities, repeated pregnancies, postpartum, contraceptive pills, prolonged immobilization, scoliosis, anti-phospholipid syndrome, COVID-19, and recurrent DVT 2. In patients with left lower-limb DVT, the incidence of MTS is about 20-50%. Right lower limb DVT in patients with right sided variant of MTS is rare. Right lower limb DVT with right sided variant of MTS with co-existing Factor V Leiden mutation is even rarer. Ultrasound imaging typically cannot detect the high pelvic abnormalities seen in MTS. Contrast venography, MRI, or IVUS are needed to diagnose MTS 4. As was the case in our patient, venography should be done to evaluate stenosis and iliac vein compression hemodynamics after thrombus removal. Treatment of MTS depends on the presentation, severity of symptoms, and whether the patient has developed DVT. Conservative treatment such as compression stockings can be used for patients who are asymptomatic or have mild symptoms. For patients with moderate symptoms or DVT, endovascular treatment with stenting is recommended 5. Conclusion: This is a very atypical presentation of MTS variation affecting the right lower extremity with limited description in the literature. To our knowledge, this is the first case presentation of right sided MTS resulting in a DVT in a patient with factor V Leiden mutation. MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this disease entity is essential for early diagnosis and treatment.

CT angiography of abdomen and pelvis in critically ill COVID-19 patients: imaging findings and correlation with the CT chest score.

PurposeTo assess the spectrum of computed tomography angiogram (CTA) abdominal and pelvic findings in critically ill COVID-19 patients and investigate correlation with CT chest scores.MethodsAn IRB approved retrospective study of CTA of the chest, abdomen and pelvis between dates March 1st to September 15th, 2020 was performed in the hospitalized COVID-19 positive patients. CTA studies of solely the chest were excluded. Medical record review was performed to note patient demographics, CTA scan details and coagulation profile. CTA findings were reviewed to record vascular and non-vascular findings. CT chest was reviewed to calculate CT chest score. Logistic regression analyses were performed to correlate CT chest scores with odds of vascular and other abdomen–pelvis findings. A p < 0.05 was considered statistically significant.ResultsA total of 45 consecutive hospitalized COVID-19 positive patients with 61 years mean age and M:F (2:1) gender ratio were evaluated, out of which majority 68.9% (n = 31) had CTA chest, abdomen and pelvis. The most common vascular findings were hematoma 46.7% (n = 21), active extravasation 24.4% (n = 11) and vascular occlusion 17.8% (n = 8). Higher CT chest scores were significantly associated with hematoma/extravasation (OR 1.19, 95% CI 1.07–1.34, p < 0.01). The most common non-vascular abdomen–pelvis findings were seen in organs gallbladder 20% (n = 9), liver 20% (n = 9) followed by kidney 15.6% (n = 7). Higher CT chest scores were significantly associated with bowel findings (OR 1.28, 95% CI 1.01–1.63, p < 0.05) and cholestasis (OR 13.3, 95% CI 1.28–138.9, p < 0.05).ConclusionPatients with moderate to severe COVID-19 pneumonia have significantly higher rate of vascular complications in the abdomen and pelvis.Graphic Supplementary InformationThe online version contains supplementary material available at 10.1007/s00261-021-03164-y.

S2896 A Rare Case of Proximal Intestinal Obstruction from Superior Mesenteric Artery Syndrome

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a rare disorder that is characterized by compression of the third portion of the duodenum due to narrowing of the angle between the SMA and the aorta. Patients typically present with intermittent postprandial epigastric pain, nausea, and bilious vomiting. We report a case of a 25-year-old female who presents with symptoms of intestinal obstruction, diagnostic evaluation revealing SMA syndrome, and successful duodeno-jejunostomy procedure. CASE DESCRIPTION/METHODS: A 25-year-old female history of cholecystectomy presented with worsening symptoms of nausea, intractable vomiting, postprandial epigastric pain, and twenty pound weight loss for 2 years. She had multiple hospitalizations and extensive gastrointestinal work-up in the past without any identifiable cause of her symptoms. Physical exam, labs, CT abdomen and pelvis, EGD, colonoscopy, and PillCam endoscopy were benign. CT angiography of abdomen and pelvis demonstrated a decreased aorta-superior mesenteric artery angle of 9.1 degrees (normal 38 degrees to 65 degrees) with aorta- superior mesenteric distance of 5.1 mm (normal 10 to 28 mm), and compression of the third part of duodenum, confirming the diagnoses of SMA syndrome. She was initially managed conservatively with duodenal and gastric decompression via NG tube, fluid and electrolyte correction, body positioning, proton pump inhibitors, and nutritional support. Unfortunately, the patient had no improvement in her symptoms and subsequently required duodeno-jejunostomy. Upon completion of the procedure, the patient had complete resolution of her presenting symptoms. DISCUSSION: The diagnosis of SMA syndrome requires a high clinical suspicion in order to obtain abdominal angiography in patients with persistent symptoms despite negative endoscopic and conventional radiographic findings. Diagnosis requires an aorto-mesenteric angle between 6-22 degrees and an aorto-mesenteric distance between 2-8 mm on CT angiography. Patients should initially be managed with conservative therapy. However, if symptoms fail to improve or increase in severity, surgery is the definitive treatment. Surgical options include duodeno-jejunostomy, gastro-jejunostomy, and Strong’s procedure. Duodeno-jejunostomy is the procedure of choice, as it carries a 90% success rate.

36. All headaches are not GCA

IntroductionVasculitis is a heterogeneous group of autoimmune disorders having multisystem involvement. In many cases, the neurological disorders have an atypical clinical course or even an early onset, and the healthcare professionals should be aware of them.Case descriptionWe report a case of 57-year-old Asian male without any significant past medical history admitted under the urology department. He had presented with abdominal pain and fever and was being treated for presumptive pyelonephritis (on antibiotics). He was referred to rheumatology when he developed severe unilateral headache on right side with significant scalp tenderness. Headache involved temporal and fronto-parietal-occipital area with no jaw claudication or any significant visual disturbance. There was no limb claudication or polymyalgia symptoms. On examination he had new onset hypertension (BP:174/94mmHg), rest of the systemic examination was normal with no bruit. Musculoskeletal and skin examination was normal.Investigations included CRP of 204, hemoglobin 133, white cell count 15.2 (neutrophils: 12.06), creatinine 118 (eGFR 59). Liver function: normal. Urine dip: Normal and blood/urine culture: negative. Immunological profile and viral screen was negative. Urgent CT head was done for severe headache which was normal. Patient was referred to rheumatology with provisional diagnosis of giant cell arteritis due to headache and raised inflammatory markers. On reviewing his CT abdomen, the renal parenchyma showed symmetrical well demarcated bilateral involvement which was more in favor of renal infarct rather than pyelonephritis. CT angiography of abdomen was requested which showed multiple vessel involvement including mesenteric artery and bilateral renal arteries with beaded appearance and stenosis. MR angiogram showed 6mm aneurysm of PICA with stenosis of P1 segment of PCA. Currently he is being screened for ADA2 deficiency. During his stay his renal function deteriorated, not responding previously to antibiotics. He was started on methylprednisolone pulse and antibiotics stopped in view of worsening liver function. On day 3 of methylprednisolone pulse he had significant improvement of his headache with stabilization of renal and liver function. Our plan is to start him on steroid sparing therapy based on the ADA2 levels.DiscussionThe classification of vasculitis is still unsatisfactory as the patho-genetic mechanisms have not been fully understood. Existing criteria classify based on predominant vessel involvement but there is still some overlap between them. The prevalence of CNS involvement in medium vessel vasculitis ranges as widely as 2-10% and does not usually occur until late in the course of the disease. The most commonly reported CNS manifestation is diffuse encephalopathy, followed in frequency by focal deficits and seizures. Intracranial aneurysms are rare with around 15 reported cases usually multiple and located in supra- as well as infra-tentorial compartments. Most of the cases presented with subarachnoid or parenchymal hemorrhage. Treatment guidelines are still not clear and most are treated conservatively by medical management. Repeat hemorrhages or re-bleed in spite of medical treatment have also been reported Deficiency of ADA2 (DADA2) has been recently recognized first molecularly described monogenic vasculitis having biallelic hypomorphic mutation in ADA2 gene. CNS involvement is one of the main features of DADA2 which presents with a wide spectrum of clinical manifestations ranging from systemic inflammation to cutaneous or visceral PAN like vasculopathy and early onset stroke.Our patient had presented with primary CNS and renal involvement with impending rupture aneurysm. Timely control of inflammation is pertinent in such cases with remission induction and maintenance to prevent stroke. Although cyclophosphamide is still used in such cases DADA2 usually require anti-TNF therapy. Our patient had good response to primary steroid therapy.Key learning pointsAcute GCA-like neurological presentation of medium vessel vasculitis with cerebral involvement is rare. If not recognised in a timely fashion, it can lead to sub-arachnoid haemorrhage which is the most common presentation of such cases. DADA2 is a recently recognised entity that presents with stroke and vasculitis/vasculopathy and responds to anti-TNF therapy.Conflicts of interestThe authors have declared no conflicts of interest.

Isolated celiac artery aneurysm: A case report

Celiac artery aneurysms (CAAs) account for 4% of all visceral arteries aneurysms. They are rare, vascular lesions, usually asymptomatic and recognized coincidentally while searching for causes of abdominal pain or other intra abdominal problems. Their significance is in their potential to rupture, which can lead to death. CAAs have no gender predilection, with most manifesting during the fifth decade of life. The diagnosis of these rare aneurysms is being established more frequently as our use of cross-sectional imaging increases. We present the case of isolated celiac artery aneurysm diagnosed incidentally by routine ultrasonography (USG) of abdomen for lower abdominal pain, followed by three dimensional CT angiography of abdomen in a 65-year-old female.

Liver Space Occupying Lesion in a Patient with Secondary Immunodeficiency

A 46-year-old female presented with significant weight loss and low grade fever of 2 months duration. She had cholecystectomy one year back. Ultrasonography abdomen revealed large mass in right lobe of liver. Complete blood count was and peripheral smear were normal. Her hepatitis B virus antigen (HBsAg) and antibody to hepatitis C virus (anti-HCV) were non-reactive. Human immunodeficiency virus (HIV) serology was positive. Subsequently, CT angiography of abdomen was done which revealed a large heterogenous mass of 7 cm × 5.8 cm in segment 4 and 5 of liver infiltrating gall-bladder fossa (Figure 1A & B). CA 19.9 and AFP were normal. Her CD 4 + counts was 43/μl and HIV RNA was 1,90,000/μl. Figure 1 A: Arterial phase of triphasic CT showing infiltrating lesion in segment 4 & 5. There is no enhancement in arterial phase. B: Venous phase of Triphasic CT showing infiltrating lesion in segment 4 & 5. There is no contrast uptake in venous ... Ultrasound guided biopsy from liver mass revealed non-Hodgkin’s Lymphoma (NHL), diffuse large B cell (Figure 2) and positive CD 20 staining (Figure 3). CT chest and bone marrow aspirate was done; both were normal. She was started on highly activated anti-retroviral therapy (HAART) i.e. tenofovir, emtricitabine and efavirenz along with R–CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). Figure 2 Liver biopsy showing infiltration by atypical lymphoid cells (arrow). Figure 3 Strong immunopositivity of atypical lymphoid cells for B cell marker CD 20. (IHC × 400). NHL in acquired immunodeficiency syndrome (AIDS) is a late manifestation of disease, most often associated with CD4+ < 100, though can occur at any CD4+ count.1 Whereas secondary involvement of the liver by NHL is relatively common, involving liver in as many as 21% of advanced NHL cases, primary hepatic lymphoma is extremely rare. NHL associated with AIDS involves primarily extranodal sites, especially the digestive tract and the central nervous system. Primary hepatic lymphoma is an uncommon neoplasm among these patients.2 Lei et al proposed diagnostic criteria for PHL3 (i) the symptoms are mainly caused by liver involvement at presentation, (ii) distant lymphadenopathy is neither palpable clinically at presentation or detected during radiological staging studies and (iii) no leukemic blood picture is observed on the peripheral blood film. Diffuse large B cell lymphoma is the commonest histological type of PHL as was seen in this patient. Incidence of all AIDS-related lymphomas has declined since the use of HAART. Still with better control of opportunistic infections, PHL is a common AIDS-defining illness. There are many histologic types of primary hepatic lymphoma however diffuse large B cell lymphoma is most common type. Chemotherapy with RCHOP regimen is treatment of choice.4 PHL is an aggressive disease with poor response to therapy and survival.