Embolization Research Articles

Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management.

Jejunal Dieulafoy’s lesion is an exceedingly rare but important cause of gastrointestinal bleeding. It frequently presents as a diagnostic and therapeutic conundrum due to the rare occurrence, intermittent bleeding symptoms often requiring prompt clinical action, variability in the detection and treatment methods, and the risk of rebleeding. We performed a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding jejunal Dieulafoy’s lesio from inception till June 2020. A total of 136 cases were retrieved from 76 articles. The mean age was 55 ± 24 years, with 55% of cases reported in males. Patients commonly presented with melena (33%), obscure-overt gastrointestinal bleeding (29%), and hemodynamic compromise (20%). Hypertension (26%), prior gastrointestinal surgery (14%), and valvular heart disease (13%) were the major underlying disorders. Conventional endoscopy often failed but single- and double-balloon enteroscopy identified the lesion in 96% and 98% of patients, respectively. There was no consensus on the treatment. Endoscopic therapy was instituted in 64% of patients. Combination therapy (34%) with two or more endoscopic modalities, was the preferred approach. With regard to endoscopic monotherapy, hemoclipping (19%) and argon plasma coagulation (4%) were frequently employed procedures. Furthermore, direct surgical intervention in 32% and angiographic embolization was performed in 4% of patients. The rebleeding rate was 13.4%, with a mean follow-up duration of 17.6 ± 21.98 months. The overall mortality rate was 4.4%. Jejunal Dieulafoy’s lesion is still difficult to diagnose and manage. Although the standard diagnostic and therapeutic modalities remain to be determined, device-assisted enteroscopy might yield promising outcomes.

Life-threatening hematomas in COVID-19 patients.

The COVID-19 pandemic has caused over 1.75 million deaths in the world to date. Although the leading cause of mortality is respiratory disorders and thromboembolic pathologies, other rare pathologies may also increase mortality and morbidity. In our study, we aimed to examine life-threatening hematomas, risk factors, and management during COVID-19. Institutional center (a third level pandemic center) database was searched for patients hospitalized for COVID-19 during 10 months period between March 11, 2020, and December 17, 2020, retrospectively. Patients with bleeding symptoms/signs were de-tected. Patients with gastrointestinal system bleeding were excluded from the study. Patients with hematomas were included in the study. Eleven of a total 5484 patients had hematomas (0.2%). Median age was 76 (min-max: 56-90). Seven (63.6%) patients were male and 4 (36.4%) were female. All patients had at least one comorbidities, been under treatment dose of low-molecular-weight hep-arin (LMWH) and severe or critical COVID-19 disease. Seven retroperitoneal hematomas, two rectus sheath hematomas, one breast hematoma, and in one patient both retroperitoneal and breast hematomas were diagnosed. Angiographic arterial embolization was applied to 5 (45.5%) patients. Overall mortality rate in patients with bleeding complications was 54.5% (n=6), and the male-to-female ratio was 66.7% (n=4) versus 33.3% (n=2). Hematomas are rare, but mortality increasing phenomena in COVID-19 patients. Age, male gender, severe or critical COVID-19 disease, comorbidities, and treatment dose of LMWH may be risk factors. New onset of abdominal/back pain and ecchymotic skin lesions may be signs of bleeding in this patient group. Mortality can be reduced by early diagnosis of hematoma and interventional methods.

Aerococcus urinae : A Rare Cause of Endocarditis Presenting With Acute Stroke

Aerococcus urinae is a rare organism infrequently isolated from cultures. Mostly known to cause urinary tract infection, it can cause bacteremia leading to severe urosepsis and infective endocarditis. Embolization is frequently reported with Aerococcus urinae endocarditis (AUE); hence, the presentation is highly variable. Sequelae such as various central nervous system manifestations, sepsis, valvular regurgitation with heart failure and even coronary artery involvement have been reported. We report a case of a 58-year-old man with AUE of the aortic valve, severe aortic regurgitation and embolic stroke as a result of embolization from AUE and ultimately required aortic valve replacement. Our case highlights this rare cause of endocarditis and offers insight into the variability of patient presentation and risk factors to consider. J Med Cases. 2021;12(2):65-70 doi: https://doi.org/10.14740/jmc3612

Woman with Epigastric Pain

A 67-year-old woman presented to the emergency department with several hours of epigastric pain. She had a history of pancreatitis complicated by a pseudocyst 5 years before. On physical examination, she was afebrile, with a blood pressure of 205/110 mm Hg and pulse rate of 83 beats/min. She had marked tenderness without muscle guarding over the epigastric area. Laboratory investigations revealed a normal hemoglobin level and an elevated lipase level (111 IU/L). Although pancreatitis was suspected, the emergency physician performed point-of-care ultrasonography (Figure 1) and confirmed the diagnosis with a computed tomographic (CT) scan (Figure 2).Figure 2CT image of the abdomen showing a cystic mass (arrowhead) in the pancreatic tail with a hemorrhagic component and contrast extravasation (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Pancreatic pseudocyst with intracystic hemorrhage. Emergency transarterial embolization of the posterior pancreatic artery was performed, and she was discharged uneventfully from the hospital. Pancreatic pseudocyst is a common complication of pancreatitis, but intracystic hemorrhage is a rare and potentially life-threatening condition with a mortality rate ranging from 15% to 50%.1Chiang K.C. Chen T.H. Hsu J.T. Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm.World J Gastroenterol. 2014; 20: 16132-16137Crossref PubMed Scopus (28) Google Scholar Clinical manifestations include abdominal pain, anemia, and melena.2Chiu H.H. Chen C.M. Wang K.C. et al.Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage.Am J Surg. 2006; 192: 87-88Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Delayed diagnosis may lead to complications such as rupture of the hemorrhagic pseudocyst, which can cause hemoperitoneum and shock. Angiographic embolization of the culprit artery is the mainstay of management,3Gambiez L.P. Ernst O.J. Merlier O.A. et al.Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis.Arch Surg. 1997; 132: 1016-1021Crossref PubMed Scopus (115) Google Scholar with surgical intervention reserved for refractory cases.

Relationship between angiography timing and angiographic visualization of extravasation in patients with acute non-variceal gastrointestinal bleeding

BackgroundAngiographic embolization is now considered the first-line therapy for acute gastrointestinal (GI) bleeding refractory to endoscopic therapy. The success of angiographic embolization depends on the detection of the bleeding site. This study aimed to identify the clinical and procedural predictors for the angiographic visualization of extravasation, including angiography timing, as well as analyze the outcomes of angiographic embolization according to the angiographic visualization of extravasation.MethodsThe clinical and procedural data of 138 consecutive patients (mean age, 66.5 years; 65.9% men) who underwent angiography with or without embolization for acute non-variceal GI bleeding between February 2008 and July 2018 were retrospectively analyzed.ResultsOf the 138 patients, 58 (42%) had active extravasation on initial angiography and 113 (81.9%) underwent embolization. The angiographic visualization of extravasation was significantly higher in patients with diabetes (p = 0.036), a low platelet count (p = 0.048), high maximum heart rate (p = 0.002) and AIMS65 score (p = 0.026), upper GI bleeding (p = 0.025), and short time-to-angiography (p = 0.031). The angiographic embolization was successful in all angiograms, with angiographic visualization of extravasation (100%). The clinical success of patients without angiographic visualization of extravasation (83.9%) was significantly higher than that of patients with angiographic visualization of extravasation (65.5%) (p = 0.004). In multivariate analysis, the time-to-angiography (odds ratio 0.373 [95% CI 0.154–0.903], p = 0.029) was the only significant predictor associated with the angiographic visualization of extravasation. The cutoff value of time-to-angiography was 5.0 h, with a sensitivity and specificity of 79.3% and 47.5%, respectively (p = 0.012).ConclusionsAngiography timing is an important factor that is associated with the angiographic visualization of extravasation in patients with acute GI bleeding. Angiography should be performed early in the course of bleeding in critically ill patients.

Long-term results of super-selective trans-catheter embolization of the vesical arteries for the treatment of intractable bladder haematuria

PurposeTo evaluate the feasibility, safety and long-term efficacy of super-selective trans-catheter arterial embolization for the management of intractable bladder bleeding.Materials and methodsThe records of 20 patients with intractable haematuria referred urgently for selective arterial embolization after failed conventional therapy, between 2013 and 2018, were retrospectively analyzed. Primary outcomes were technical (cessation of extravasation and/or stasis of flow within the target vessel) and clinical (bleeding control) success. Secondary outcomes included complication and re-intervention rates.ResultsTechnical success was 90% (18/20 cases), as in 2 cases, embolization was not feasible. Super-selective embolization of the vesical arteries was feasible in 15/18 cases (83.3%). Selective proximal occlusion of the anterior division of the internal iliac artery was performed in two cases (11%) and embolization of the anterior division after coil blockage of the posterior division was performed in one case (5%). Bilateral and unilateral embolization was performed in 10 and 8 cases, respectively. Peri-procedural mortality rate was 5% (1/18 patients). One possible procedure-related death occurred due to myocardial infarction ten days following non-target embolization of the buttocks and the anterior abdominal wall. Mean time follow up was 35 ± 15 months. Bleeding reoccurred in three patients (16.6%), all successfully managed (one conservatively and two with further embolization). Clinical success was 85% (17/20 cases). During follow up 11 more patients died, due to underlying conditions not related to bleeding or the procedure.ConclusionsSuper-selective angiographic embolization is feasible, safe and effective to control refractory, life threatening bladder bleeding and should be considered as a first line treatment, as to obviate the need for emergency surgery.

Tratamiento angiográfico percutáneo de lesión vascular colónica en paciente anticoagulada

Tratamiento angiográfico percutáneo de lesión vascular colónica en paciente anticoagulada

Unruptured Intracranial Aneurysms in Elderly Patients: Results of Surgical and Endovascular Treatment

Background: Management of unruptured intracranial aneurysms (UIA) in elderly patients is controversial, taking into consideration their limited life-expectancy and existing comorbidities. With advances in endovascular techniques, we decided to evaluate treatment results in this population and to assess results in surgically and endovascularly treated cases. Methods: Thirty six elderly patients, aged ≥ 70, with the total of 39 aneurysms, were treated. The possibility of endovascular treatment was considered as the first option and surgical treatment as the second method of intervention. Results: No patient died and no patient became bedridden after the procedures. In surgical group (14 UIA), deterioration was observed in five cases at the time of discharge, but persisted in only two cases at follow-up. In endovascular group (25 UIA), deterioration was observed in one case at the time of discharge and persisted at follow-up. Endovascular techniques included coils placement alone in nine (36%) procedures, coiling with stent placement in five (20%) procedures and stent placement alone in eleven (44%) procedures. Follow-up DSA revealed no treatment effect in three patients after stent placement alone (12% of endovascularly treated aneurysms). Of these, two patients were successfully retreated with second flow-diverting stent placement and one patient refused retreatment. Conclusion: Treatment of elderly patients with UIA is relatively safe and effective. Worse short-term and long-term outcomes were observed among the operated compared to embolized patients. In patients treated with stent placement alone, treatment failure and the need for the next stage of embolization in some cases should be taken into account.

Hemoptysis after Lung Transplantation Caused by Bronchial Arterial Neovascularization: Angiographic Analysis and Successful Embolization

This report discusses 3 bilateral lung transplant recipients (2 female, 1 male) who presented with late hemoptysis (10 y, 18 y, and 19 y after transplantation). All patients had a history of pulmonary infections, bronchiectasis, and/or Aspergillus infection. Arteriography, through catherization of the common femoral artery, demonstrated spontaneous bronchial and systemic neovascularization arising from the thyrocervical trunk, internal thoracic artery, intercostal arteries, and dorsal scapular artery. Embolization was performed with microspheres, polyvinyl alcohol microparticles, and/or glue and effectively terminated hemoptysis. One patient died 10 d later as a result of fungal infection, and the 2 others remained in stable condition (18- and 26-mo postembolization follow-up available).

Portal and hepatic vein embolization before major liver resection

Portal and hepatic vein embolization before major liver resection

RARE HEPATOPULMONARY FISTULA DUE TO LIVER ABSCESS RUPTURE

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hepatopulmonary fistulas are quite rare, a complication which can be due to primary etiologies such as hydatid or pyogenic cysts (1) These insults cause transdiaphragmatic infiltration leading to rupture at the lower lung leading to the formation of a fistula Secondary causes are congenital abnormalities, surgical or penetrating trauma Our patient developed an extremely rare complication of fistulization with the right lung pleura due to a suppurative hepatic collection leading to a complicated clinical presentation There are known septic embolic or constitutional symptoms associated with the diagnosis which were not present in our case, rather acute hypoxic respiratory failure and septic shock due to rupture of the hepatic abscess CASE PRESENTATION: A 59-year-old female with a recent history of a benign liver tumor presented for shortness of breath and dry cough for two days On physical exam, she was tachypneic and increased work of breathing Vital signs were significant for oxygen desaturation to 86% on room air, required mechanical ventilation She was admitted to the intensive care unit for acute respiratory failure due to possible multifocal pneumonia and rule out COVID-19 Upon admission evaluation, laboratory results significant for transaminitis (Alk Phos 353, AST 197 and ALT 60) Chest X-ray (Figure 1) raised right hemidiaphragm, right lower lobe atelectasis and bilateral alveolar infiltrates CT AP with IV contrast revealed a large right sub diaphragmatic abscess with a right-sided empyema (Figure 2) Upon review of daily CXR, day 6 of the admission, new loculated pneumothoraces in the upper and middle right lung Chest tube was placed for the pnuemothoraces The pleural fluid was exudative and neutrophil predominant Followed by an IR drainage of the liver abscess yielding 60 cc of brown purulent fluid The spontaneous pneumothorax was likely in the setting of a cystopleural fistula resulting from ruptured hepatic abscess given similar microbiology with anaerobic gram positive rod growth from the IR guided liver abscess drainage and the chest tube drainage DISCUSSION: Hepatopulmonary fistulas may have benign courses but there is a significant mortality rate due to septic shock and florid infection A pyogenic abscess causes obstruction of the biliary tree allowing for bacterial overgrowth complicated by rupture leading to peritonitis or sepsis CONCLUSIONS: Our case is a rare presentation showing the severe progression of a pyogenic liver abscess allowing for this communication between the lung and liver This case emphasizes the importance of early recognition of infectious liver abscesses and early intervention Reference #1: Gulamhussein, Patrini, Pararajasingham, Adams, Shukla, Velissaris, Lawrence, Panagiotopoulous “Hepatopulmonary Fistula: a life threatening complication of hydatid cyst” J Cardiothorac Surg 2015 Reference #2: Abbas M, Khan F, Muhsin S, Al-Dehwe “Epidemiology, Clinical features and outcome of Liver Abcsess: A single Reference Center Experience in Qatar” Oman Med J 2014 DISCLOSURES: No relevant relationships by Kinjal Patel, source=Web Response No relevant relationships by Jean Singh, source=Web Response No relevant relationships by Ivan Wong, source=Web Response

Endovascular management of unilateral common iliac artery ostial occlusive disease; bilateral kissing stents, unilateral stent with contralateral supporting balloon or unilateral stent with contralateral safety wire; comparative study

Aim To evaluate the safety, early, and short-term efficacy of kissing stents, unilateral common iliac artery (CIA) stent with contralateral supporting balloon, and unilateral CIA stent with contralateral safety wire in patients with symptomatic unilateral CIA ostial occlusive disease. Patients and methods This prospective study was carried out from April 2016 to November 2019 at 6 October Insurance Hospital, Cairo, and Sohag University Hospitals on 79 patients complaining of de novo unilateral CIA ostial occlusive disease, Rutherford category 3, 4, and 5, who were divided randomly into three groups to be treated endovascularly by bilateral kissing stent technique (group A), unilateral CIA stent in affected side associated with supporting balloon in the contralateral CIA (group B), or unilateral CIA stent in affected side associated with a safety wire in the contralateral CIA (group C). Patients were scheduled to be evaluated and followed up for 1 year. Results Technical success rate was 100, 87, and 67.9 in groups A, B, and C, respectively (P=0.006). One-year primary patency rate was 91.7, 90.9, and 87.5% in groups A, B, and C, respectively (P=0.998). A total of seven (9.3%) patients developed significant stenosis. Of the seven patients, and three continued medically, as they were claudicant; three cases were treated by drug-coated balloon angioplasty, and one patient by aortofemoral bypass. Plaque shift incidence was 4.3 and 14.3% in groups B and C, respectively (P=0.095). Distal embolization occurred in the contralateral side in 8.7 and 17.9% in groups B and C, respectively (P=0.083). Conclusion Kissing stent technique for treatment of unilateral ostial CIA occlusive disease achieves excellent technical success with minimal early and short-term procedure-related complications compared with unilateral stent with contralateral supporting balloon or unilateral stent with contralateral safety wire.

DILEMMA OF SYSTEMIC ANTICOAGULATION: A COVID-19 PATIENT WITH SPONTANEOUS CHEST WALL HEMATOMA

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Systemic anticoagulation use remains a crucial therapeutic strategy in the treatment of COVID-19 disease (respiratory tract infection caused by SARS-CoV-2 RNA) affected patient population By presenting a sporadic case of chest wall hematoma we bring to light factors surrounding this decision CASE PRESENTATION: A 77-year-old Hispanic female with a history of Hypertension, Diabetes, and Obesity presented with myalgias, cough, and dyspnea at rest After being diagnosed with COVID-19 Pneumonia, she was started on Hydroxychloroquine As the patient’s oxygen requirement increased despite receiving Tocilizumab and Remdesivir, systemic anticoagulation with Enoxaparin was initiated Upon receiving therapeutic Enoxaparin subcutaneous for five days, the patient started to complain of left upper chest wall pain, which was noted to have loculated swelling with diffuse ecchymosis Upon development of sudden hypotension, lightheadedness, acute anemia, she underwent CT Angiography of Chest diagnosing arterial hematoma and attributed to systemic anticoagulation The patient received several blood products and evacuation of 600 ml chocolate-colored fluid from loculated hematoma with the placement of an in-dwelling drain She did not require any embolization or surgical intervention, as there was no active arterial diathesis Before discharge, her symptoms resolved, and she was weaned to a nasal cannula She continued to improve, and the catheter was subsequently discontinued The patient was eventually discharged with no further adverse events DISCUSSION: The incidence of spontaneous muscle hematomas in patients using anticoagulant therapy is infrequent The proposed risk factors of pathophysiology in these cases include microangiopathy, diabetes, elderly age, vascular lesions, collagen, or hemostatic disorders1 Current literature suggests COVID 19 to be prothrombotic, with varying degrees of abnormalities noted in coagulation test parameters2,3 Reports suggest better outcomes, lower severity of illness with the use of therapeutic anticoagulation4 Pathology reports show COVID 19 infection to cause proinflammatory changes and microthrombi in arterioles5 However, this patient had a bleeding event contrary to published reports so far, including lower extremity and bowel ischemia6,7 This raises the question of appropriate timing, dosage, and use of anticoagulation in these patients CONCLUSIONS: We aim to throw light into the conundrum surrounding the use of systemic anticoagulation in the COVID19 patient population by highlighting one of the very rare adverse events in the setting of anticoagulation use Reference #1: Dohan A, Darnige L, Sapoval M, Pellerin O Spontaneous soft tissue hematomas Diagn Interv Imaging 2015;96(7-8):789-96 Reference #2: Panigada M, Bottino N, Tagliabue P, et al Hypercoagulability of COVID-19 patients in the Intensive Care Unit A Report of Thromboelastography Findings and other Parameters of Hemostasis J Thromb Haemost 2020 Reference #3: Ranucci M, Ballotta A, Di dedda U, et al The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome J Thromb Haemost 2020;DISCLOSURES: No relevant relationships by Medhat Ismail, source=Web Response No relevant relationships by Ashesha Mechineni, source=Web Response No relevant relationships by Sushant Nanavati, source=Web Response No relevant relationships by Roberto A Solis, source=Web Response

Racial Disparities at Mixed-Race and Minority Hospitals : Treatment of African American Males With High-Grade Splenic Injuries.

Racial and socioeconomic disparities in health access and outcomes for many conditions is well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American ([AA] vs White) males with high-grade splenic injuries. Data from the National Trauma Data Bank were utilized from 2007 to 2015; 24 855 AA or White males with high-grade splenic injuries were included. Multilevel mixed-effects regression analysis was used to evaluate disparities in outcomes and resource allocation. Mortality was significantly higher for AA males at mixed-race (OR 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI, 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2, P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08). While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs.

Missile Fragment Embolism of the Coronary Artery in a Patient with Coronary Artery Disease

A 51-year-old war veteran referred to us with typical chest pain and dyspnea on exertion. He had a history of hypertension from several years before, for which he had been prescribed anti-hypertensive medications. He also gave a history of missile fragment injury to his chest from the Iran-Iraq war, for which he had been hospitalized, but had received conservative medical treatment only. After admission and initial workup, echocardiography revealed mild left ventricular dysfunction with an ejection fraction of 45% and a metallic fragment at the diaphragmatic surface of the right ventricle. Coronary angiography showed significant stenosis at the LAD – Diagonal bifurcation, as well as a metallic fragment occluding the PDA branch of the right coronary artery. Coronary artery bypass surgery was performed successfully and the patient was discharged uneventfully. To the best of our knowledge, this is the first report of an embolized missile fragment to the coronary artery found incidentally in a patient undergoing surgery for coronary artery disease.

Rare complication of lateral abdominal wall hematoma after coronary angioplasty

Abdominal wall hematoma is a rare but potentially serious complication that may develop after percutaneous coronary interventional procedures. In particular, an oblique muscle hematoma caused by injury to the superficial circumflex iliac branch of the femoral artery is very rare. Most of these cases can be managed by conservative measures including hydration and blood component transfusion. However, when active bleeding continues, angiographic embolization or surgery might be needed. Here, we report an uncommon case of lateral abdominal wall hematoma following left femoral artery puncture during the performance of percutaneous coronary intervention by the retrograde approach in a totally occluded right coronary artery.

A Fistula Where? Left Anterior Descending to Pulmonary Artery Fistula

Fistulas are abnormal passageways between two organs or vessels that usually do not connect. Coronary artery fistulas occur when one of the coronary arteries is connected to either a heart chamber or another blood vessel. This case presents a coronary artery fistula which may or may not be impacting the patient’s heart function. A 69-year-old male with multiple comorbidities presents with a chief complaint of shortness of breath. Catheterization reveals an anomalous left anterior descending to pulmonary artery fistula without a step up in oxygen saturation at the level of the pulmonary artery. Surgical management was deferred as this fistula was not deemed to contribute to the patient’s declining cardiac function. Operative management versus embolization would be a feasible alternative for patients who are symptomatic secondary to the coronary artery fistula and remains to be controversial in patients who are asymptomatic. Given the possibility of these fistulae eventually causing symptoms it would be practical to close them early on before symptoms arise or before size of the fistulae becomes an issue. Further research should be conducted to understand the management strategies for patients who present with coronary artery fistulas. J Med Cases. 2020;11(10):306-308 doi: https://doi.org/10.14740/jmc3527

Prevalence of paroxysmal atrial fibrillation in patients presenting with embolic stroke of undetermined source

Background: Cerebrovascular stroke is a major cause of morbidity and disability. Many etiologies may contribute to its presence. Some patients have none of the identifiable risk factors yet face the consequences of stroke or transit ischemic attack. This type of stroke is known as embolic stroke of undetermined source (ESUS). It has a high rate of recurrence due to the presence of an unknown uncorrected etiology. Paroxysmal atrial fibrillation remains a hidden bottom of an iceberg, representing a major hidden etiology of ESUS. We aimed to determine the prevalence of paroxysmal atrial fibrillation in patients with ESUS using 72-h Holter monitoring. Methods: Patients diagnosed with ESUS underwent 72-h Holter monitoring within the 1st week of the incident stroke. Holter monitors determined whether atrial fibrillation (more than 3 s) is present or not. Results: This study included 200 patients with stroke of an undetermined source who underwent 72-h Holter monitoring within 1 week of the incident stroke. The patients' ages ranged between 22 and 77 years (mean age 48.46 ± 12.74 years); 136 were males and body mass index (BMI) ranged from 21 to 35 kg/m2, with a mean BMI of 24.78 ± 2.99 kg/m2. Their left atrial anteroposterior diameter in the parasternal long-axis view ranged from 26 mm to 47 mm, with a mean diameter of 36.08 ± 5.23 mm. Thirty-two out of the 200 patients were diagnosed with paroxysmal atrial fibrillation, representing 16%. There was a statistically significant association between the presence of paroxysmal atrial fibrillation and both age (P = 0.009) and left atrial diameter (P = 0.001). There was an associated finding that needs further investigation regarding the significant association between supraventricular ectopic beats and the presence of atrial fibrillation or stroke. Conclusion: Paroxysmal atrial fibrillation is an important hidden etiology of embolic stroke of undetermined etiology that can be detected early using 72-h Holter monitoring within 1 week of the incident stroke.

Rotura de seudoaneurisma de la arteria uterina posterior a cesárea

La hemorragia posparto es una causa importante de mortalidad materna. La rotura del pseudoaneurisma de la arteria uterina es una lesión vascular con prevalencia desconocida que produce hemorragia posparto secundaria sin causa evidente. Puede ser potencialmente mortal, si no es diagnosticada y tratada adecuadamente. La etiología incluye traumatismo vascular durante la cesárea, parto vaginal, legrado o histerotomía. Su presentación clínica tiene variedad de síntomas que a menudo se asocian con otras patologías ginecológicas / obstétricas más frecuentes, con y sin sangrado vaginal, y puede abarcar desde ausencia de síntomas hasta hemorragia posparto severa con choque hipovolémico. Para evitar la hemorragia mortal, se debe hacer un diagnóstico rápido y preciso que muestre la naturaleza vascular de esta lesión. El diagnóstico está basado en estudios de imágenes no invasivos. En casos seleccionados adecuadamente, la embolización angiográfica es un método seguro y eficaz para controlar la hemorragia en pacientes hemodinámicamente estables y debe ser una opción antes de recurrir a la cirugía. Se describe un caso de rotura de pseudoaneurisma de arteria uterina posterior a cesárea.

Value of Dyna CT in guiding embolization during transarterial uterine artery embolization of fibroids.

The present study aimed to assess the usefulness of Dyna CT during transarterial uterine artery embolization (UAE) of fibroids. A total of 65 patients with symptomatic submucosal and intramural fibroids scheduled for transarterial UAE at the First People's Hospital of Changhou between May 2016 and September 2018 were included. Dyna CT and routine digital subtraction angiography (DSA) were performed in all patients during angiographic embolization of the bilateral internal iliac arteries. The visualization qualities of uterine artery origin and fibroids, as imaged by Dyna CT, were compared with DSA anterior-posterior images. Dyna CT provided excellent 3-dimensional visualization of vascular structures of the bilateral internal iliac arteries and uterine artery origin. Dyna CT was primarily useful in patients with overlapped uterine arteries or complex vascular anatomies on DSA anterior-posterior images (Dyna CT 100% vs. DSA anterior-posterior 69.2%, P=0.03). However, stained fibroids were identified in 57/65 cases (87.7%) by Dyna CT, and in all of the cases (100%) by DSA anterior-posterior imaging (P=0.03). Dyna CT is not suitable for procedural evaluation when used alone for transarterial UAE of fibroids. However, Dyna CT is an excellent supplement to DSA anterior-posterior imaging, as it provides additional information to aid in treatment planning.