Emergent Computed Tomography Angiography Research Articles

Acute Nonvariceal Gastrointestinal Bleeding: A Comprehensive Review and Approach for an Interventional Radiologist

AbstractGastrointestinal bleeding (GIB) is one of the most common leading life-threatening conditions requiring prompt diagnosis and rapid endoscopic and interventional radiology (IR) management. Endoscopy is the first line of management for upper GIB, while it has a limited role in lower GIB, especially in acute clinical settings, due to poor bowel preparation. Patients with failed and refractory endoscopic management necessitate emergent computed tomography angiography (CTA) evaluation. CTA is crucial in assessing underlying causes and planning transarterial embolization (TAE). It has been almost three decades since IR gained popularity by virtue of increased technical experience, availability of sophisticated hardware, and evolving techniques. Newer embolization agents and catheters, as well as the established role of CTA, have expanded and enhanced the role of IR in the management of GIB. TAE has been proven to be a safe, rapid, effective, and minimally invasive procedure alternative to surgery when endoscopic management fails to control GIB. We present a comprehensive approach for managing nonvariceal GIB, including CTA protocol, anatomical variants, visceral to visceral collateral pathways, and specific embolization techniques. This article will help readers get an insight into TAE that will help better management of patients with GIB.

Letter to the Editor Regarding: “Endoscopic Contralateral Interhemispheric Transfalcine Keyhole Approach for Large Falcine Meningiomas”

A 39-year-old male presented to our institution after sustaining a gunshot wound to the face. He was initially unresponsive with bleeding from the nares bilaterally and was intubated for airway protection. A computed tomography angiogram of the head and neck demonstrated multiple foci of active extravasation in the left maxillary sinus. The patient was taken for emergent neuroendovascular intervention, during which a large, 6.1 mm × 6.4 mm pseudoaneurysm of the left pterygoid artery was discovered and embolized with Onyx liquid embolic agent, with subsequent complete obliteration of the pseudoaneurysm. Embolization immediately halted the bleeding. The patient was neurologically intact at his most recent follow-up appointment. This case demonstrates the importance of obtaining an emergent computed tomography angiography for patients with ballistic facial trauma and early involvement of endovascular neurosurgery for treatment of intractable sinonasal bleeding.

Analysis of Advanced Imaging Utilization in Low National Institutes of Health Stroke Scale Score and Rate of Large Vessel Occlusion Detection in Large Telestroke Database (S24.009)

<h3>Objective:</h3> Analyze the rate of large vessel occlusion (LVO) detection in low National Institutes of Health Stroke Scale (NIHSS) score patients in a large multicenter database. <h3>Background:</h3> The benefits of mechanical thrombectomy in low NIHSS score (&lt;6) is unclear and undergoing investigation. Currently, great variation exists in practice patterns of computed tomography angiography (CTA) for patients with low NIHSS. Current guidelines do not address low NIHSS largely owing to a paucity of data. Better understanding of the rate of LVO associated with low NIHSS could help guide clinical practice and pave the way for expanding guideline recommendations. <h3>Design/Methods:</h3> Acute stroke consultations seen in the emergency department in 227 facilities (27 states) from July 1, 2021 to December 31, 2021 were extracted from the TeleCare™ database. The encounters seen within 24 hours of last known normal were reviewed for CTA performed, LVO detected, and NIHSS score. Multivariate analysis was performed to determine the odds ratio (OR) for CTA performed, and LVO found at each NIHSS score of 0–5 with reference of ≥6. <h3>Results:</h3> 23,166 acute stroke encounters were included and 10,507 had CTA performed. There were lesser odds for CTA being performed among patients with an NIHSS of: 0 (OR=0.14, [0.13,0.15]); 1 (OR=0.16, [0.15,0.18]); 2 (OR=0.27, [0.24,0.3]); 3 (OR=0.33, [0.3,0.37]); 4 (OR=0.49, [0.43,0.55]); and 5 (OR=0.71, [0.61,0.82]). In addition, there were lesser odds of an LVO detected among patients with an NIHSS of: 0 (OR=0.1, [0.07,0.13]); 1 (OR=0.09, [0.06,0.12]); 2 (OR=0.16, [0.12,0.22]); 3 (OR=0.14, [0.1,0.2]); 4 (OR=0.24, [0.18,0.32]), and 5 (OR=0.27, [0.2,0.37]). <h3>Conclusions:</h3> Analysis of our large telemedicine database demonstrated a significant number of LVOs detected with NIHSS &lt;6, supporting lowering the minimum NIHSS score for emergent CTA. The cutoff of ≥4 may be optimal threshold for LVO capture. We suggest a rational approach to CTA performance to include patients with NIHSS ≥4 or cortical symptoms. <b>Disclosure:</b> Dr. Sevilis has stock in Moderna. Dr. Fowler has nothing to disclose. Dr. Avila has nothing to disclose. Ms. Boyd has nothing to disclose. Mr. Collins has nothing to disclose. Dr. Gao has nothing to disclose. Dr. Heath has received personal compensation in the range of $0-$499 for serving as a Epidemiologic analysis consultant with Neuroscience Innovation Foundation . Dr. Devlin has received personal compensation for serving as an employee of Neuroscience Innovation Foundation. Dr. Devlin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Nova Signal. Dr. Devlin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Viz.ai. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Medtronic. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Medtronic. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Viz,ai. Dr. Devlin has received personal compensation in the range of $5,000-$9,999 for serving as an officer or member of the Board of Directors for Neuroscience Innovation Foundation. Dr. Devlin has stock in Nova Signal. Dr. Devlin has stock in Viz.ai. The institution of Dr. Devlin has received research support from Viz.ai. Dr. Devlin has received research support from Nova Signal. Dr. Devlin has received intellectual property interests from a discovery or technology relating to health care.

Pseudoaneurysm of the Pterygoid Artery After a Gunshot to the Face

A 39-year-old male presented to our institution after sustaining a gunshot wound to the face. He was initially unresponsive with bleeding from the nares bilaterally and was intubated for airway protection. A computed tomography angiogram of the head and neck demonstrated multiple foci of active extravasation in the left maxillary sinus. The patient was taken for emergent neuroendovascular intervention, during which a large, 6.1 mm× 6.4 mm pseudoaneurysm of the left pterygoid artery was discovered and embolized with Onyx liquid embolic agent, with subsequent complete obliteration of the pseudoaneurysm. Embolization immediately halted the bleeding. The patient was neurologically intact at his most recent follow-up appointment. This case demonstrates the importance of obtaining an emergent computed tomography angiography for patients with ballistic facial trauma and early involvement of endovascular neurosurgery for treatment of intractable sinonasal bleeding.

Left atrial appendage thrombus in acute stroke: diagnostic accuracy of CT angiography compared to transesophageal echocardiography

ObjectivesTo evaluate the value of an extended emergency computed tomography angiography (CTA) including cardiac imaging in patients with acute ischemic stroke for the detection of left atrial appendage (LAA) thrombus compared to transesophageal echocardiography (TEE) as a reference standard. Materials and MethodsWe conducted a retrospective case-control study of patients with presumed acute ischemic stroke who had undergone non-ECG-gated CTA for the craniocervical vessels with an extended coverage including the heart in the context of emergency stroke evaluation and for whom TEE was available as part of the routine stroke diagnostic. We selected cases with evidence of LAA thrombus in TEE and controls without LAA thrombus in TEE in a 1:3 ratio. Two independent observers analyzed CTA images for presence of LAA thrombus and were blinded to the presence of thrombus in TEE. ResultsTwenty-two patients with LAA thrombus in TEE, and 66 patients without LAA thrombus in TEE were included. The detection of LAA thrombus using CTA showed a sensitivity of 63.6%, a specificity of 81.8%, a positive predictive value of 53.9% and a negative predicted value of 87.1%. Interobserver agreement was only moderate (Cohen´s κ = 0.43). ConclusionsAn extended emergency CTA including cardiac imaging can be helpful in early risk stratification in patients with stroke of cardioembolic origin. However, our data show that a standard CTA of craniocervical vessels with extended coverage of the heart is of limited value when compared to TEE, the standard method of detecting LAA thrombi.

Protocolo diagnóstico y terapéutico de la hemoptisis

Hemoptysis is the expectoration of blood from the tracheobronchial tree. The most common causes are bronchial infections, bronchiectasis, and bronchogenic carcinoma. To diagnose it, it is necessary to take a good medical history and conduct a good physical examination as well as quantify the volume of hemoptysis in a graduated container to identify if it is life-threatening hemoptysis. In non-life-threatening hemoptysis, a blood test, a chest x-ray, and, if it is pathological, a computed tomography (CT) scan of the chest should be performed. In addition, treatment should be started with general and antitussive measures and empirical antibiotic treatment. When faced with life-threatening hemoptysis, it is necessary to notify the ICU and, later, conduct an emergency CT angiography of the bronchial arteries in order to evaluate whether to embolize those that are aberrant. If the patient presents with hemodynamic instability, it will be necessary to perform an emergency bronchoscopy prior to intubation of the patient. Surgery will be reserved for select cases in which it is not possible to control bleeding.

Extravascular incidental findings in computed tomography angiography are associated with lower amputation-free survival in patients with acute lower limb ischaemia.

Emergency computed tomography angiography (CTA) is the most important imaging modality to visualize arterial occlusions in patients with acute lower limb ischaemia (ALI). Extravascular incidental findings (EVIFs) have received less attention. The aims of this study were to evaluate the incidence of EVIFs of immediate clinical relevance in patients with ALI undergoing CTA and evaluate the association between EVIFs and emergency revascularization and amputation-free survival at 1 year. Retrospective cohort study. Emergency CTA in patients with ALI between 2015 and 2018 were independently scrutinized by two senior radiologists. EVIFs were classified into immediate (category I), potential (category II) or no clinical relevance (category III). Multi-variable binary logistic regression analysis was expressed in Odds ratios (OR) with 95% confidence intervals (CI). The intra-class correlation (ICC) coefficient for EVIF category I between the raters was 0.94 (95% CI 0.92-0.96). Among 118 patients with ALI, 78 patients underwent emergency revascularization. Forty-six EVIFs (34 patients) were category I, of which 63% were found in the chest, including pleural effusion (n = 12), pneumonia (n = 8) and cardiac thrombus (n = 4). Ascites (n = 4) and cancer disease (n = 4) were other category I findings. Category I EVIFs were associated with reduced rate of emergency revascularization (OR 0.26, 95% CI 0.10-0.66) and increased rate of combined major amputation/mortality at 1year (OR 2.9, 95% CI 1.1-8.2) in adjusted analysis. It is important to evaluate EVIFs in emergency CTA in patients with ALI since these findings are both common and associated with reduced emergency revascularization and amputation-free survival at 1year.

Rapid Identification of Patients Eligible for Direct Emergent Computed Tomography Angiography during Acute Ischemic Stroke: The DARE-PACE Assessment.

Background: We investigated the clinical signs to establish a method for rapid identification of patients with the National Institute of Health Stroke Scale (NIHSS) score ≥ 8 eligible for direct brain CTA study; Methods: We retrospectively enrolled 2895 in patients with acute ischemic stroke (AIS). Four items in the NIHSS were selected as the main clinical signs of stroke; Results: A total of 922 (31.8%) patients had an initial NIHSS score of ≥8. The average door-to-CT time and door-to-CTA time were 13.4 ± 1.8 and 75.5 ± 44.5 min, respectively. Among 658 patients who had the priority signs, namely dense hemiplegia (D), aphasia with right arm drop (AR), and eyeball forced deviation (E), 634 patients (96.4%) with an NIHSS score ≥ 8 were identified. By using a classification and regression tree analysis, 153 patients with an NIHSS ≥ 8 were identified among 175 patients (87.4%) who had the secondary signs, namely hemiparesis with limb falls (P), aphasia (A), drowsy or worse consciousness (C), and eyeball limitation (E). The sensitivity, specificity, and accuracy were 85.4%, 97.7%, and 95.3%, respectively. Conclusions: The DARE-PACE assessment involving a checkbox list provides excellent accuracy for rapid identification of AIS patients with an NIHSS score ≥ 8 for direct CTA study to reduce the time delay for endovascular thrombectomy.

Fatal liver mass rupture in a common-variable-immunodeficiency patient with probable nodular regenerating hyperplasia

BackgroundNodular regenerating hyperplasia (NRH) is the most common liver involvement in common variable immunodeficiency (CVID). Most patients are asymptomatic with gradually increasing alkaline phosphatase (ALP) and mildly elevated transaminase enzymes over the years. We report the first case of fatal liver mass rupture in a CVID patient with probable NRH.Case presentationA 24-year-old man was diagnosed with CVID at the age of 1.25 years. Genetic testing revealed a transmembrane activator and calcium-modulator and cyclophilin-ligand interactor (TACI) mutation. He had been receiving intravenous immunoglobulin (IVIg) replacement therapy ever since then. The trough level of serum IgG ranged between 750–1200 mg/dL. However, he still had occasional episodes of lower respiratory tract infection until bronchiectasis developed. At 22 years old, computed tomography (CT) chest and abdomen as an investigation for lung infection revealed incidental findings of numerous nodular arterial-enhancing lesions in the liver and mild splenomegaly suggestive of NRH with portal hypertension. Seven months later, he developed sudden hypotension and tense bloody ascites. Emergency CT angiography of the abdomen showed NRH with intrahepatic hemorrhage and hemoperitoneum. Despite successful gel foam embolization, the patient died from prolonged shock and multiple organ failure.ConclusionsAlthough CVID patients with NRH are generally asymptomatic, late complications including portal hypertension, hepatic failure, and hepatic rupture could occur. Therefore, an evaluation of liver function should be included in the regular follow-up of CVID patients.

Acute retrograde type A intramural hematoma during severe acute respiratory syndrome coronavirus 2 pandemic

Acute intramural hematomas (IMHs) occur in ∼6% of patients with acute dissections (ADs) and mostly affect the descending aorta.1Harris K.M. Braverman A.C. Eagle K.A. Woznicki E.M. Reed E.P. Myrmel T. et al.Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection.Circulation. 2012; 126: S91-S96Crossref PubMed Scopus (147) Google Scholar Type A IMHs involve the ascending aorta and type B IMHs do not involve the ascending aorta. Retrograde type A IMHs (retro-TAIMHs) originate in the descending aorta and extend into the arch or ascending aorta. TAIMHs with distal AD carry an in-hospital mortality risk of 12% to 26%.1Harris K.M. Braverman A.C. Eagle K.A. Woznicki E.M. Reed E.P. Myrmel T. et al.Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection.Circulation. 2012; 126: S91-S96Crossref PubMed Scopus (147) Google Scholar,2Tolenaar J.L. Harris K.M. Upchurch Jr., G.R. Evangelista A. Moll F.L. Di Eusnio M. et al.The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection.J Vasc Surg. 2013; 58: 1498-1504Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar We report the case of an 85-year-old woman with acute retro-TAIMH and distal AD. The patient provided consent for the report of her case. She was admitted to the emergency room with acute onset dyspnea and chest pain but no evidence of malperfusion. Emergency computed tomography angiography identified a retro-TAIMH with AD and a proximal entry tear above the celiac axis (A/Cover). The patient was hemodynamically stable. She was treated with hypotensive and analgesic therapy and hospitalized for intensive monitoring. Follow-up computed tomography angiography was performed at 24 hours (B) and 7 days (C) showing progressive to complete thrombosis of the entry tear, with a reduction in the aortic diameter, the most important predictor of IMH regression and positive outcomes.3Evangelista A. Dominguez R. Sebastia C. Salas A. Permanyer-Miralda G. Avegliano G. et al.Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma: therapeutic implications.Eur Heart J. 2004; 25: 81-87Crossref PubMed Scopus (100) Google Scholar Complete symptom regression occurred. The event was observed during the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in Lombardy, Italy. The patient had tested positive for SARS-CoV-2 at 5 days after symptom onset, with progressive dyspnea and worsening findings on a chest radiograph (D). She died of pulmonary complications at 19 days postoperatively. Hybrid treatment with ascending aortic replacement and distal thoracic aortic endovascular repair (TEVAR) or using the frozen elephant trunk procedure is the most appropriate treatment for acute retro-TAIMH. TEVAR is a valid alternative only for patients with prohibitive surgical risk, although the landing zones could be unsuitable and the risk of neurologic and cardiac complications can be high.4Nauta F. De Beaufort H. Mussa F.F. De Vincentiis C. Omura A. Matsuda H. et al.Management of retrograde type A IMH with acute arch tear/type B dissection.Ann Cardiothorac Surg. 2019; 8: 531-539Crossref PubMed Scopus (7) Google Scholar Medical treatment appears to be appropriate for asymptomatic patients, those with noncomplicated retro-TAIMHs, and patients with high open surgical and TEVAR risks.4Nauta F. De Beaufort H. Mussa F.F. De Vincentiis C. Omura A. Matsuda H. et al.Management of retrograde type A IMH with acute arch tear/type B dissection.Ann Cardiothorac Surg. 2019; 8: 531-539Crossref PubMed Scopus (7) Google Scholar Considering both the absence of end-organ malperfusion and the advanced age of our patient, we chose medical treatment, which can reduce mortality by 67% to 95%.5Ince H. Nienaber C.A. Diagnosis and management of patients with aortic dissection.Heart. 2007; 93: 266-270Crossref PubMed Scopus (60) Google Scholar This choice proved effective with symptom recovery and clinical stability of the present patient, until the deadly overlap of SARS-CoV-2. Toward a unified pathophysiology in COVID-19 acute aortopathiesJournal of Vascular SurgeryVol. 74Issue 5PreviewThe interesting article by Katsarou et al1 about aortic intramural hematoma complicating a severe acute respiratory disease coronavirus 2 (SARS-CoV-2) infection is compelling, and its pathophysiology needs to be elucidated further. Full-Text PDF

Thoracic Aortic Erosion into the Esophagus With Aortoesophageal Fistula

A 76-year-old woman with a past medical history of a known 6-cm thoracic aortic aneurysm was transferred to our facility for 1 day of hematemesis and hematochezia to undergo upper endoscopy. On arrival the patient had an emergent esophagogastroduodenoscopy, which revealed a visible thoracic aorta eroding into the esophagus through a large transmural defect (Figure A) and a nonbleeding aortoesophageal fistula (Figure B) directly superior to the erosion in the middle third of the esophagus. The patient underwent emergent computed tomography angiography of the aorta and a thoracic endovascular aorta repair with fluoroscopic images demonstrating extravasation at aortoesophageal fistula (Figure C, red arrow) and successful graft deployment and fistula closure (Figure D).

Femoral vascular complications after catheter ablation in the current era: The utility of computed tomography imaging.

Few studies have examined the characteristics of catheter ablation vascular complications, and recently physicians increasingly use computed tomography angiography (CTA) for diagnosing. We sought to investigate the incidence of femoral vascular complications in catheter ablation and factors associated with complications in the current era. This single-center observational study consisted of 311 consecutive (atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia, and ventricular arrhythmias in 222 [71.4%], 7 [2.3%], 43 [13.8%], and 39 [12.5%]) patients who underwent catheter ablation. The detailed patient data and clinical outcomes were obtained from the medical records. Emergent CTA was performed in a total of 8 (2.6%) patients at a median of 4.5 (2.0-12.5) days postprocedure, and the precise diagnosis was obtained in all. Among them, pseudoaneurysms, arteriovenous fistulae (AVF), and actively bleeding hematomas were identified in two, one, and one patient, respectively, and all required readmissions after discharge. AVF was diagnosed by a Doppler ultrasound examination in another patient. In total, 5 (1.6%) patients exhibited major femoral vascular complications including two pseudoaneurysms, two AVFs, and one active bleeding hematoma. The pseudoaneurysms and AVFs were successfully eliminated by direct compression, and extravasation from the femoral circumflex artery required coil embolization. Antiplatelet therapy and the use of larger arterial sheaths (≥7-Fr) increased the major femoral arterial complications, but atrial fibrillation ablation under uninterrupted anticoagulation therapy or the use of larger venous sheaths did not. Vascular complications are still not negligible procedure-related complications during catheter ablation in the current era. CTA provides a rapid and precise diagnosis for optimal treatment strategies.

Benefits and Risks of CT Angiography Immediately after Emergency Arrival for Patients with Intracerebral Hematoma.

Computed tomography angiography (CTA) immediately after diagnosis of intracerebral hematoma (ICH) on noncontrast CT in the emergency room has benefits, which consist of early diagnosis of secondary ICH and prediction of hematoma growth using the spot sign in primary ICH, but CTA also involves possible risks of acute kidney injury (AKI) and adverse reactions. The purpose of this study was to evaluate the benefits and risks of CTA. A total of 1423 consecutive adult patients diagnosed with ICH who were admitted within 3 days of onset between 2010 and 2017 were retrospectively analyzed. Of 1082 patients undergoing CTA, 162 patients (15.0%) showed secondary ICH, and the sensitivity of CTA for secondary ICH was 95.7%. Of 920 patients with primary ICH, a logistic regression model using the spot sign and four other previously reported risk factors (antiplatelet agents, anticoagulants, interval from onset to arrival, hematoma volume) with an area under the curve (AUC) of 0.787 significantly improved model performance to predict hematoma growth compared with a model using the same four factors without the spot sign (AUC: 0.697) (DeLong’s test: P = 0.0002). Rates of AKI occurrence were 9.0% and 9.8% in patients with and without CTA, respectively. The odds ratio of AKI in patients with CTA adjusted by reported risk factors was 1.16 (95% confidence interval: 0.72–1.95, P = 0.5548). Emergency CTA following noncontrast CT in patients with ICH could be useful for early diagnosis of secondary ICH and prediction of hematoma growth using the spot sign in primary ICH with little risk.

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients

IntroductionBlunt thoracic aortic injury (BTAI) is rare in elderly patients. As the population ages and life expectancy increases, the frequency of this injury will increase, while the treatment and outcomes remain unclear. MethodsWe retrospectively analyzed the collected data of patients >60 years old with BTAI to investigate the mechanism of trauma; time interval from injury to diagnosis; type and timing of surgical intervention; aortic arch pattern; choice of left subclavian artery reconstruction; endograft to treat BTAI; length of the endovascular procedure; endoleaks; complications including stroke, paraplegia, and renal failure; length of hospital stay (LOS) and intensive care unit stay (L.ICUS); and 30-day mortality. ResultsFive elderly trauma patients were found to have BTAI. Four (80%) were males, the cohort mean age was 68 years, the major mechanism of trauma was fall injury, and the associated injury was thoracic trauma. All patients were transferred to our hospital, and emergency computed tomography angiography showed BTAI in each patient. The average time interval from injury to diagnosis was 2.7 days. Two patients suddenly showed signs of instability in their vital signs and underwent immediate endovascular repair, while 3 patients underwent delayed endovascular repair. The injury site was located in the aortic isthmus just distal to the origin of the left subclavian artery; the aortic arch pattern was II (80.0%) in 4 cases and III in 1 case (20.0%). The choice of left subclavian artery reconstruction included chimney, double chimney, prefenestration, and chimney combined with in situ fenestration. Endografts to treat BTAI included the Ankura (Lifetech Scientific, Shenzhen, China) and the C-TAG (W.L. Gore & Associates, Flagstaff, AZ USA).The length of the endovascular procedure was 75.4 min; there were no endoleaks and no complications including stroke, paraplegia, or renal failure. The average LOS was 25 days, and the average L.ICUS of 2 patients was 15 days, with no 30-day mortality. ConclusionElderly patients with fall injury should promptly exclude BTAI. Thoracic endovascular aortic repair (TEVAR) with a left subclavian artery reconstruction technique provided good results without procedure-related or neurological complications. Because of the low incidence of this type of injury, we are unable to provide any evidence to guide the treatment option for this life-threatening condition.

A large idiopathic pseudoaneurysm of the popliteal artery: A case report

Introduction. Pseudoaneurysm, also known as a false aneurysm, is a collection of blood which passes through individual layers of the blood vessel or through all layers, but it is retained in the surrounding soft tissues. Case Report. We report presents a 41-yearold patient with a large idiopathic pseudaneurysm of the second segment of the popliteal artery, referred by an orthopedist with a magnetic resonance image of the left leg. The patient?s medical history showed that the pain started three weeks ago, the swelling in the left popliteal fossa about 6 months ago, and a large, painful, non-pulsatile tumefaction was found during the examination, resulting in a 90 degrees flexion contracture of the left knee. The magnetic resonance showed a pseudoaneurysm of the left popliteal artery, and an emergency computed tomography angiography was performed; it confirmed a pseudoaneurysm of the left leg second segment of the left popliteal artery without signs of obliterative diseases. The posterior approach and exposition of the popliteal artery was applied; autovenous graft interposition with a great saphenous vein of the right leg was done. Conclusion. Early diagnosis plays an important role in avoiding temporary and permanent complications. Arterial reconstruction with autovein grafting is a gold standard and a method of choice in the surgery of the pseudaneurysm of the popliteal artery. The temporary setting of occlusive Fogarty catheters reduces damage to the surrounding tissue, accelerates bleeding control, which together shortens the time of surgery.

Abstract TMP66: Safety of Urgent Computed Tomographic Angiography in the Evaluation of Patients with Acute Stroke

Objective: Computed Tomography Angiography ( CTA) is the standard of care test for ischemic stroke patients with suspected large vessel occlusion. When establishing emergency room stroke pathways, concerns for contrast induced nephropathy (CIN), which occurs in 11% of the general population could influence the time efficiency for CTA. Our aim is to report the incidence of CIN in our suspected severe stroke population. Method: With Institutional Review board approval, we maintained a prospective database on patients who were identified to have a high pre-hospital Rapid Arterial occlusion Evaluation ( RACE) between July 2015 and June of 2016. Per protocol, RACE alert patients go directly to the CT scanner to obtain a CT head and a CTA unless the test is cancelled by the stroke team. Labs are typically not available when CTA is performed. Our data included patient demographics, pre-morbid risk factors, baseline serum Creatinine level (Cr), peak Cr level during admission and at discharge. Incidence of renal consults and need for Hemodialysis was also monitored. Results: A total of 150 RACE alert patients were included in the analysis. Median age of patients was 73 and 12 patients had pre-morbid chronic renal failure. CTA was not performed in 21 of patients, due to low probabability of stroke determined by stroke team onsite.. Transient CIN occurred in 9(6%) of patients, renal consult was obtained in 4(3%) patients and 2(1) patients had a diagnosis of acute kidney injury on discharge. Conclusion: Emergent CTA resulted in a low number of transient CIN in our RACE alert patients. No cases of chronic renal Failure or need for HD were reported in our prospective cohort. A larger prospective registry may be needed to confirm the safety of this approach.

Double thrombolysis in early pregnancy can be safe

W niniejszej pracy przedstawiono przypadek kobiety w ciąży ze zdiagnozowaną masywną zatorowością płucną, która przeszła pomyślnie podwójną trombolizę. Pacjentka w wieku 23 lat w 7. tygodniu trzeciej ciąży została przyjęta na Oddział Intensywnej Opieki Kardiologicznej 2 h po nagłym pojawieniu się bólu w klatce piersiowej i duszności. W wykonanym w trybie pilnym badaniu elektrokardiograficznym stwierdzono tachykardię zatokową z typowym zespołem S1Q3T3 i rsr’ w odprowadzeniu V1. W przezklatkowym badanie echokardiograficznym przeprowadzonym przy przyjęciu wykazano przeciążenie prawej komory. W tomografii komputerowej klatki piersiowej z opcją naczyniową (angio-TK) wykonanej w trybie nagłym uwidoczniono rozległą skrzeplinę w obu tętnicach płucnych, ograniczającą przepływ krwi. Początkowo stosowano heparynę niefrakcjonowaną we wlewie, pod kontrolą czasu częściowej tromboplastyny po aktywacji. Mimo leczenia stan pacjentki pogarszał się, dlatego też zdecydowano o podaniu pełnej dawki alteplazy (10 mg bolus, następnie 90 mg przez kolejne 2 h). Uzyskano istotną poprawę stanu klinicznego chorej. Badanie ultrasonograficzne naczyń miednicy i kończyn dolnych wykazało wrzecionowatego kształtu skrzeplinę w rozwidleniu prawej żyły biodrowej wspólnej i zewnętrznej żyły biodrowej. W 10. dniu hospitalizacji, podczas uruchamiania, wystąpiły u pacjentki objawy wstrząsu. Chora wymagała intubacji dotchawiczej, wentylacji mechanicznej i stosowania wlewu amin katecholowych. Drugi raz zastosowano pełną dawkę alteplazy. Nie zaobserwowano dalszych komplikacji podczas ciąży. Pacjentka urodziła w 38. tygodniu siłami natury zdrowego syna ważącego 3580 g (10 punktów w skali Apgar). Po porodzie zamieniono heparynę drobnocząsteczkową na warfarynę (pod kontrolą INR). Wykazano, że podwójna tromboliza u kobiety we wczesnym okresie ciąży może być bezpieczna zarówno dla matki, jak i dziecka, ale konieczne jest przeprowadzenie badań obejmującym większą grupę chorych.

Transarterial embolization for pelvic hematoma following laparoscopic radical prostatectomy: A case report and review of the literature.

The present study reports a case of hemorrhage from branches of the right obturator artery following laparoscopic radical prostatectomy. On post-operative day 9, the patient complained of lower abdominal pain, and the hemoglobin and hematocrit levels had decreased. Emergency computed tomography angiography showed a large pelvic hematoma suggesting active bleeding. Transarterial embolization (TAE) was performed using microcoils. There were no post-procedure complications. At 3 months post-surgery, using computed tomography, the pelvic hematoma was shown to have been absorbed. To the best of our knowledge, TAE for a hemorrhage from the obturator artery following laparoscopic prostatectomy has not previously been described. TAE is a safe and minimally invasive treatment compared with surgical intervention, and should be considered as a treatment for post-operative arterial hemorrhage.

Computed tomography angiography based emergency microsurgery for massive intracranial hematoma arising from arteriovenous malformations

Digital subtraction angiography (DSA) and magnetic resonance angiography are the imaging modalities for the detection of intracranial arteriovenous malformations. However, these modalities are time consuming and cannot be used in emergency conditions. Computed tomography angiography (CTA) has also been shown to reliably detect vascular disorders such as cerebral arteriovenous malformations (AVMs). The purpose of this study was to evaluate the usefulness CTA in the surgical treatment of AVMs and the hematoma evacuation. Case records of 18 patients with massive intracranial hematoma secondary to AVMs were retrospectively reviewed. All patients had emergent brain CT and CTA. Follow-up DSA was performed two to three weeks after surgery. The outcome was assessed using Glasgow Outcome Scale (GOS). Results : Emergent CTA demonstrated AVMs and defined the feeding arteries, abnormal vascular nest, and draining veins in all the patients. Fourteen patients underwent hematoma evacuation and total resection of the AVMs, and four patients had hematoma evacuation and a partial resection. Follow-up DSA demonstrated complete resection of AVM in 14/18 patients and partial resection in 4 patients. There were no deaths and none of the patients had rebleeding in the follow up. A GOS scores during follow-up were: GOS 3 in 12 patients, GOS 4 in 4 patients and GOS 2 in 2 patients. CTA can be a reliable and rapid diagnostic tool for detecting underlying AVM in patients presenting with intracranial hematoma and for the pretreatment planning of emergency craniotomy.

Application of a new pulmonary artery obstruction score in the prognostic evaluation of acute pulmonary embolism: comparison with clinical and haemodynamic parameters

Evaluation of computed tomography (CT) pulmonary angiography parameters revealing pulmonary embolism (PE) severity with particular attention to pulmonary obstruction indexes. Comparison with clinical and hemodynamic data and determination of predictive role in the development of chronic pulmonary heart disease. This retrospective study analyzes 45 not consecutive patients from November 2007 to December 2008 with CT angiography diagnosis of acute PE. Included in the study are patients at the first documented episode of acute PE, with 6 month follow-up. Patients with severe pre-existent cardiopulmonary pathology or neoplastic diseases were excluded from the study. CT angiography evaluated right ventricular (RV)/left ventricular (LV) ratio, obstruction index according to Qanadli and Total Clot Burden (Ghanima score). PE indexes were compared with Troponin I measurement and echocardiography result; at last hospitalization and intensive care time were reported. A significant association was found between Ghanima and Qanadli score: the two indexes are equivalent in quantification of pulmonary arterial obstruction (p<0.001). Among others CT parameters, the new Ghanima score evidenced the best accuracy to detect patients evolving to chronic pulmonary heart disease (76%). This value is higher than that of echocardiography (71%). Troponins showed highest accuracy (82%). Ghanima score can be used in emergency CT angiography diagnosis as prognostic marker for a quickly risk stratification of pulmonary heart disease or death in patients with acute PE. This approach allows to obtain, with just one test, both the diagnosis and a rather accurate acute PE risk stratification.