Sinus Occlusion Research Articles

Depressed Skull Fracture over Cranial Venous Sinuses

Abstract Background Depressed skull fracture overlying venous sinuses deserves a special attention among skull fractures. It puts high demand on every neurosurgeon, as the management of this kind of trauma carry high risk of mortality. It is considered as one of the most dangerous complications of head injuries. Either it is due to fatal venous bleeding, or disturbing the intracranial pressure via thrombosis or stenosis. Therefore, knowledge of appropriate treatment of this kind of head injury is essential. Moreover, it should always be treated with high cautions. Aim of the Work This study aims at reviewing available scientific data based on clinical trials about the proper management approaches for the treatment of depressed skull fractures overlying major cranial venous sinuses. Either through surgery or medical and conservative management. Patients and Methods The study review yielded 22 relevant papers, with a total number of 85 patients. These patients presented to different institutes, at the period between 1996 and 2017. Diagnosed with depressed skull fracture overlying major venous sinuses. The cases divided according to the way of management as follow: 72% of patients treated with surgical approaches. While 28% of patients treated with conservative care. Results In total surgical intervention showed to be successful in 53 patients, out of 85 patients included in the study, without any intraoperative complication of bleeding. While 6 patients passed away during the surgical interventions. On the other hand, 18 patients who treated conservatively did not need any further intervention. While 2 studies reported the need of medication following surgery. Furthermore, 6 studies reported failure of conservative management, and needed urgent surgical elevation of the depressed fragment that compressing the sinus. Based on the results, the mortality rate over all was 7%; death was mainly due to inability to control the profusely bleeding from the injured sinuses. With a success rate over the surgical cases in 87%. While it was 75% over the conservative cases. However, this pooled data need further statistical analysis to obtain guiding evidence for current practice. Conclusions Clinical decision making must be tailored to each patient independently. In the presence of clinical and radiographic evidence of sinus occlusion surgery is preferred. In such instances where there is a clear need for surgery, adequate precautions should be taken, and an expertise in neurotrauma should always be available. Delayed intracranial hypertension is a possible complication and should always be considered in all patients.

SUN-253 FGF21 correlates positively with arteriovenous fistula occlusion in hemodialysis patients

Good vascular pathway is the key to ensure the quality of life in hemodialysis patients. Arteriovenous fistula occlusion lead to insufficient dialysis, increases the probability of hemodialysis complications, even life-threatening. Fibroblast growth factor 21 (FGF21) is increased progressively with a decline of renal function and higher plasma FGF-21 level can be used as a meaningful index to evaluate microinflammation, lipid metabolism and predict dialysis-related complications such as cardiovascular diseases in end stage renal disease patients. This study aimed to investigate the relationship and role of FGF21 in arteriovenous fistula occlusion in our hemodialysis patients cohort. We screened 802 HD patients in Nanjing Zhongda Hospital (n=450) and The First People’s Hospital of Changzhou (n=352) according to a strict inclusion criteria and exclusion criteria. We recorded demographic information, blood data before dialysis and serum FGF21 levels and counted the frequency of arteriovenous fistula occlusion in our hemodialysis cohort. We used bivariate correlation analyses to assess the correlation of the frequency of arteriovenous fistula occlusion with serum FGF21 and other clinical parameters. Stepwise multivariate linear regression analyses were employed to evaluate variables independently associated with the frequency of arteriovenous fistula occlusion. P < 0.05 was considered to be statistically significant. SPSS Software, version 22.0 was used for all statistical analyses. In this cross-sectional study, of 802 hemodialysis patients screened, 76 were eligible. Age of hemodialysis patients was 55.46±15.18 years, and 48 of participants (63.7 %) were male. The median dialysis vintage was 6.4 years (range 0.5 to 23). Serum FGF21 levels were significantly positive associated with the frequency of arteriovenous fistula occlusion (r = 0.321, P = 0.005). In addition, the frequency of arteriovenous fistula occlusion was correlated with the level of hemoglobin(r = -0.277, P = 0.015), the level of albumin (r = -0.269, P = 0.019) and left ventricular mass (r = 0.272, P = 0.018). Variables including FGF 21, hemoglobin, albumin and left ventricular mass and others those well known as promoters of arteriovenous fistula occlusion such as PTH, calcium, phosphorus, glycerin trilaurate and total cholesterol were entered a multivariate linear regression analyses, the result showed that serum FGF21 (β = 0.259, P= 0.022) and left ventricular mass (β = 0.223, P =0.048) were factors independently associated with the frequency of arteriovenous fistula occlusion in hemodialysis patients. We reported for the first time that serum FGF21 and Left ventricular mass were independently associated with arteriovenous fistula occlusion. These findings provide a novel insight about FGF21 on arteriovenous fistula occlusion in hemodialysis patients and may indicate a new therapeutic target for arteriovenous fistula occlusion.

Successful percutaneous occlusion of a large left circumflex coronary artery fistula draining into the coronary sinus using a ventricular septal defect occluder: a case report

BackgroundCoronary artery fistula (CAF) is a congenital anomaly of the coronaries that can lead to significant intracardiac shunting and myocardial ischaemia.Case summaryWe describe the case of a 15-year-old male with an incidentally documented precordial cardiac murmur. An evidently dilated coronary sinus (CS) on transthoracic echocardiography prompted further investigation. A computed tomography (CT) revealed the presence of a large CAF from the left circumflex coronary artery to the CS. No other structural heart defects were detected. A haemodynamically significant intracardiac shunt was confirmed during cardiac catheterization, and it was decided to close the fistula. This was successfully performed using a ventricular septal defect (VSD) occluder (Konar 10-8, Lifetech Scientific) that was deployed through a 6 Fr right coronary guiding catheter. A partial thrombotic occlusion of the CS behind the closure device was noted during follow-up which led to anticoagulation in a higher target INR range and concomitant start of low dose carbasalate calcium to reduce further retrograde thrombus extension. Patient is doing well at over 1 year of follow-up, and no further thrombotic extension into the CS was seen on a recent CT.DiscussionThis report illustrates the diagnostic workup and a percutaneous treatment strategy of a CAF using a VSD occluder. We also describe a not previously reported complication, thrombotic CS occlusion. Improving transcatheter techniques and marketing of novel devices with a broad spectrum of applications can offer new opportunities for treating CAF and avoiding surgical correction often involving cardiopulmonary bypass, reserving this option for patients with complex anatomy or failed transcatheter closure.

Transsternal occlusion of main bronchi fistulae after pneumonectomy

To summarize our experience in transsternal occlusion of main bronchus fistula. We have performed 146 transsternal occlusions of the main bronchi for the period from 1979 to 2018. There were 123 (84.2%) men and 23 (15.7%) women. Mean age of patients was 63 years. Lung tuberculosis was diagnosed in 36 (24.7%) patients, lung cancer - 91 (62.3%) patients, non-specific suppurative lung diseases - 14 (9.6%) patients, trauma - 5 (3.4%) patients. All patients underwent transsternal occlusion of the main bronchi fistulae with or without pericardial cavity dissection. Wedge-shaped bronchial resection or tracheal bifurcation resection were carried out for a short stump fistula. Perioperative complications occurred in 28 (19.2%) out of 146 patients. Intraoperative complications developed in 4 (2.6%) patients. Postoperative complications were observed in 25 (17.1%) patients. Intraoperative mortality rate was 1.4% (n=2), postoperative mortality - 6.2% (n=9). Thus, overall mortality rate was 7.6% (n=11 It should be noted that intraoperative complications were absent if dissection of the pericardium and pulmonary artery stump ligation were not performed. Transsternal occlusion of the main bronchi fistulae was successful in 80.8% of patients. In these cases, healing of fistulae was not associated with any complications. Thus, we believe that transsternal occlusion of the main bronchial stump fistula should be considered as preferable surgical strategy.

Direct Thrombin Inhibitors as the Primary Treatment Modality for Cerebral Venous Sinus Thrombosis (CVST)

Background: Cerebral venous sinus thrombosis (CVST) is an uncommon entity with improved clinical outcome over time due to utilization of advanced diagnostic tools and effective treatment modalities. Previous treatment regimen pertained to primarily medical therapies, with use of anticoagulants like Coumadin and Heparin. However the advent of Direct Thrombin Inhibitors (DTI) which do not need regular monitoring of blood coagulation panel and has better safety profile than Coumadin, has been suggested as a treatment modality for CVST in recent literature. Case Description: It is a case series of 3 adult patients presenting with intracerebral hemorrhage secondary to CVST from occlusion of dural venous sinuses. Dabigatran, a DTI was used as the primary treatment modality for a period of 6 months for 2 patients who had identifiable underlying cause and lifelong for 1 patient who had no identifiable underlying cause for dural sinus thrombosis. Patients has been followed for a total period of six months while on DTI treatment, with Magnetic Resonance Venography (MRV) of the brain performed at 6 months follow up visit to assess recanalization of the obstructed dural sinuses. All the 3 patients had improved clinical outcome at 6 months follow up visit with no added morbidity upon using DTI. Two patients had complete recanalization of obstructed venous sinuses, while 1 patient had partial recanalization at 6 months follow-up visit. No patient had increased hematoma volume while on treatment with DTI. Conclusion: This case series suggests DTI are probably effective primary treatment modality for patients with CVST with good safety profile.

Complex Arteriovenous Malformation in a Kidney with Multiple Renal Arteries: A Case Report

The abnormal communications between arteries and veins outside the capillary level are called Arteriovenous Malformation (AVM). A 25-year-old known hypertensive on irregular medications, presented with acute stroke (Computed Tomography (CT) brain revealed left putamen haemorrhage). On evaluation, all routine investigations were normal except for microscopic haematuria. Ultrasound (USG) KUB showed right AVM and on further evaluation with 320 slice Contrast Enhanced Computed Tomography (CECT) abdomen with angiogram and 3D reconstruction revealed right kidney supplied by three renal arteries. The second renal artery was dilated (1.1 cm diameter) and communicates directly with aneurysmally dilated right renal vein (2.9 cm diameter). Digital Subtraction Angiography (DSA) with angioembolisation was done four days’ postadmission. Large second renal artery with a direct Arteriovenous Fistula (AVF) draining into the renal vein with aneurysmal venous sacs was occluded with 16 mm, 12 mm and 10 mm coils. Complete obliteration of fistula was confirmed. Then the inferior most third renal artery was accessed and angiogram revealed RAVM with multiple feeders shunting into the venous sacs and it was occluded with 40% glue. Postoperative day one USG showed thrombosed venous aneurysmal sacs and occlusion of the arterial fistulae. He was discharged at four weeks with antihypertensive and antiseizure medications. During the follow-up there was no loss in the function of the kidney and micro or macroscopic haematuria was not detected.

Safety and Efficacy of the Percutaneous Manual Aspiration Thrombectomy Technique to Treat Thrombotic Occlusion of Native Arteriovenous Fistulas for Hemodialysis

목적혈액투석용 자가혈관 동정맥루의 혈전을 동반한 폐색에서 경피적 수동 흡인 혈전제거술의 안전성과 유용성에 대해 평가하고자 한다.대상과 방법2012년 3월부터 2017년 12월까지 자가혈관 동정맥루의 혈전을 동반한 폐색으로 내원하여 경피적 혈관 내 시술을 시행 받은 20명의 환자를 후향적으로 분석하였다. 기술적 및 임상적 시술 성공률, 1차 및 2차 개통률, 그리고 시술에 따른 합병증을 분석하였다.결과총 20명의 환자에서 20회의 경피적 혈관 내 시술을 시행하였다. 모든 환자에서 혈전을 제거하기 위해 경피적 수동 흡인 혈전제거술을 시행하였고, 협착이 동반된 경우 풍선카테터를 이용한 혈관성형술을 함께 시행하였다. 17명의 환자는 혈전이 제거되어 혈류가 정상적으로 회복되었고(기술적 성공률 85%), 17명 환자 모두 시술 직후 혈액투석이 정상적으로 시행되었다(임상적 성공률 85%). 동정맥루 위치는 좌측 요골두정맥루가 13명, 좌측 상완두정맥루가 4명, 우측 요골두정맥루가 3명이었다. 동반된 협착 부위는 문합부 주위 정맥이 16예, 원위부 배출정맥이 12예, 중심정맥이 4예였다. 1차 및 2차 개통률은 1, 3, 6, 12개월에서 각각 100%, 70.6%, 70.6%, 56.5% 및 100%, 94.1%, 94.1%, 86.9%였다. 시술과 관련된 합병증은 없었다.결론혈액투석용 자가혈관 동정맥루에서 혈전을 동반한 폐색의 치료로서 경피적 수동 흡인 혈전제거술은 안전하고 유용한 시술이다.

Assessing the Effect of Personalized Nursing on Thrombolytic Hemodialysis Patients After Arteriovenous Fistula Occlusion

Objective: To assess the effect of personalized nursing on thrombolytic hemodialysis patients after arteriovenous fistula occlusion. Methods: 92 patients who undergoing arteriovenous fistula in the hospital were invited to join our study. The time of they receive the treatment is from May 2015 to July 2020. In study beginning, the patients were randomly assigned to the control group (n = 46) and an intervention group (n = 46). The two groups receive different nursing intervention. The control group receive common nursing intervention. On the other hand, the intervention group patients receive personalized nursing intervention in treatment process. Result: In basic patient information, the patient basic status are similar [20 (47.6%) vs 23 (54.8%), 38.14±9.12 vs 37.88±10.07, 1.41±0.75 vs 1.37±0.69], that the gender, age and number of thrombolysis are not statistical significance (p > 0.05). In thrombolysis success rate research, the intervention group has higher thrombolysis success rate than that of control group [38 (90.5%) vs 32 (76.2%), p = 0.016]. In patient satisfaction research result, more intervention group patients make very well assessment than that of control group patients [19 (45.2%) vs 10 (23.8%), p < 0.005]. Conclusion: the personalized nursing intervention not only increase thrombolysis success rate but also improve the patient satisfaction in arteriovenous fistula occlusion.

Bilateral Cavernous Sinus Dural Arteriovenous Fistulae : The Strategies for Endovascular Treatment.

Most cavernous sinus dural arteriovenous fistulas (CSDAVF) are unilateral; however, simultaneous bilateral CSDAVFs occasionally may be found. This article reports on 141 patients and compares the angioarchitecture and outcomes of embolization of bilateral CSDAVFs with those of unilateral CSDAVFs, with reference to limited demographics (sex and age) of the patients. From January 2010 to February 2018 a total of 141 consecutive patients with CSDAVFs were referred for transvenous embolization. Bilateral CSDAVFs were found in 20patients (14.2%, with amean age of 62.2 years). The angioarchitecture of the 141 patients with CSDAVFs were evaluated by conventional cerebral angiography. We compared the angioarchitecture and treatment outcomes of 20bilateral and 121 unilateral CSDAVFs, and in relation to the patients' sex and age. Female patients significantly dominated the bilateral CSDAVFs (90%, p = 0.043). Bilateral eye symptoms were significantly more common in bilateral CSDAVFs (p = 0.011), with dominant orbital and cavernous symptoms, and showed statistical significance (p = 0.049 and 0.011, respectively). Occlusion of one CSDAVF may significantly decrease the fistula flow of the other untreated side (n = 13, 65%), leading to less coil utilization for embolization in bilateral CSDAVFs (p < 0.001). There was no statistical significance in the occurrence of occlusion of the inferior petrous sinus(s), in pial vein reflux, and treatment outcomes in the unilateral and bilateral CSDAVFs. Bilateral CSDAVFs were more dominant in female patients and frequently presented with orbital and cavernous symptoms. Fewer coils were used per lesion in the bilateral CSDAVFs. There was no statistical significance in bilateral and unilateral CSDAVFs in terms of impact of venous drainage, pial vein reflux and treatment outcomes.

A computational fluid dynamics study pre- and post-fistula closure in a coronary artery fistula

This study numerically investigated the hemodynamics of a patient-specific coronary artery fistula (CAF) before and after the fistula closure. The results indicated that the dilated fistula result in inadequate perfusion to other healthy aortas. Disturbed blood flow, aberrant WSSs, local negative pressure gradients and sharp pressure changes are shown in both untreated and occluded fistula. Furthermore, extreme high WSS appeared at the fistula bending after the terminal closure. It was concluded that the fistula closure may effectively improve the phenomenon of stealing blood but worsen the unfavorable hemodyanmics predisposing the thrombosis formation due to its geometrical torturosity.

The Comparison of Medical Expenses and Patency Between Surgical Reconstruction and Percutaneous Transluminal Angioplasty to Treat Arteriovenous Fistula Stenosis or Occlusion – A Regional Teaching Hospital’s Experience in Taiwan

The Comparison of Medical Expenses and Patency Between Surgical Reconstruction and Percutaneous Transluminal Angioplasty to Treat Arteriovenous Fistula Stenosis or Occlusion – A Regional Teaching Hospital’s Experience in Taiwan

Factors Predicting De Novo Formation of Fistulas After Dural Fistula Embolization Using Venous Sinus Balloon Protection

Endovascular embolization with transvenous sinus preservation using balloon is at present the preferred modality for dural arteriovenous fistulas involving venous sinuses (sagittal, transverse, and sigmoid) with potential drainage function. The aim of the study was to evaluate the necessity and medium-term efficacy of this technique. Patients with dural arteriovenous fistulas involving large sinuses who underwent vascular embolization with transvenous balloon protection technique at our center from December 2012 to July 2017 were retrospectively reviewed. The clinical symptoms, postoperative and mid-term follow-up imaging results, perioperative complications, and follow-up clinical outcomes were analyzed. Eighteen patients (8 women and 10 men) with mean age 49 years were included in this study. Complete (16 of 18) or near-complete (1 of 18) occlusion of original fistula was achieved in 17 patients (94.4%). Recurrence of original fistula (1 of 18) or de novo fistula (3 of 18) occurred in 4 patients (22.2%). The patency rate of balloon-protected sinus was 72.2% (13 of 18) during the follow-up, and the involved sinuses were eventually occluded in 5 patients (27.8%). The frequency of de novo fistulas was higher in patients with sinus occlusion (P < 0.05). Stenosis of the involved sinus was more likely related to balloon-protected sinus occlusion (P < 0.05). After a mean follow-up of 17.6 months, 17 patients (94.4%) achieved remission of the original symptoms. Transvenous balloon protection technique maintains sinus patency in most cases, and preoperative stenosis increases the probability of sinus occlusion. De novo fistula is related to sinus occlusion during the follow-up.

Hydrocephalus Following Giant Transosseous Vertex Meningioma Resection

Introduction Meningiomas are among the most common primary intracranial tumors. While well-described, there is limited information on the outcomes and consequences following treatment of giant-sized vertex-based meningiomas. These meningiomas have specific risks and potential complications due to their size, location, and involvement with extracalvarial soft tissue and dural sinuses. Herein, we present four giant-sized vertex transosseous meningioma cases with involvement and occlusion of the sagittal sinus, that postoperatively developed external hydrocephalus and ultimately required shunting. Methods A retrospective chart review identified patients with large vertex meningiomas that were: (1) large (>6 cm) with hemispheric (no skull base) location, (2) involvement of the superior sagittal sinus resulting in complete sinus occlusion, (3) involvement of dura resulting in a large duraplasty area, (4) transosseous involvement requiring a 5 cm or larger craniectomy for resection of invaded calvarial bone. Results Tumors were resected in all four cases, with all patients subsequently developing external hydrocephalus which required shunting within 2 weeks to 6 months postsurgery. Conclusion We believe this may be the first report of the development of hydrocephalus following surgical resection of these large lesions. Based on our observations, we propose that a combination of superior sagittal sinus occlusion and changes in brain elasticity and compliance affect the brain's CSF absorptive capacity, which ultimately lead to hydrocephalus development. We suggest that neurosurgeons be aware that postoperative hydrocephalus can quickly develop following treatment of giant-sized vertex-based meningiomas, and that correction of hydrocephalus with shunting can readily be achieved.

Fistula occlusion and ligation for a giant right coronary artery aneurysm concurrent with right atrial fistula: a case report

BackgroundCoronary artery aneurysms in most cases require surgical treatment once diagnosed. Lifelong anticoagulation is often needed after surgery. We herein describe a 55-year-old man who was asymptomatic and diagnosed with right giant coronary artery aneurysm combined with right atrial fistula.Case presentationThis is a case of asymptomatic giant right coronary artery aneurysm concurrent with coronary artery fistula. Because the aneurysm was in the distal right posterior descending coronary artery, right coronary artery ligation and fistula occlusion through the right atrium were performed in the absence of cardiopulmonary bypass. The aneurysm was excluded without impacting the myocardial blood supply, and the patient was exempted from lifelong anticoagulation regimen. The follow-up revealed favorable outcomes and the patient’s life expectancy was improved.ConclusionDecompression and exclusion without cardiopulmonary bypass can be adopted for distal coronary artery aneurysms that do not involve or only have a limited impact on distal blood supply. This procedure can exempt the patient from the lifelong anticoagulation regimen. In addition, the risk for myocardial ischemia caused by the thrombus in the aneurysm can also be avoided. The whole procedure is comparatively easy to perform.

Endoscopic closure of a bronchopleural fistula after pneumonectomy with the Amplatzer occluder: a step forward?

A bronchopleural fistula after pneumonectomy is a relatively rare but very serious complication. The development of endoscopic methods of treatment opens a new page in treating this condition. The goal of this paper was to confirm that the atrial septal defect Amplatzer device can be used for bronchopleural fistula closure in properly selected patients. A retrospective study of 13 patients with bronchopleural fistula after pneumonectomy was performed. There were 11 men and 2 women aged 26-70 years. Right-sided fistulas occurred in 10 patients and left-sided fistulas occurred in 3. The underlying disease was lung cancer in 7 patients and pulmonary tuberculosis in 6. Video-assisted thoracoscopic surgery (N = 7) and open-window thoracostomy (N = 6) were used to treat the empyema. To treat occlusion of the bronchial fistulas, we used Amplatzer atrial septal defect occluders originally intended for closure of ventricular and interatrial septal defects. The occluder was inserted from the bronchus by flexible bronchoscopy with the patient under local anaesthesia, with the help of video-assisted thoracoscopy or through a window thoracostomy from the pleural cavity. We noted 3 complications after the procedure. In 2 patients, displacement of the occluders required re-installation in 1 patient and latissimus dorsi muscle coverage in the other. In the third patient, the occluder became dislodged during severe exacerbation of tuberculosis that occurred after the patient violated the treatment regimen. She died of tuberculosis 6 months after the occluder was inserted. The course in the remaining 10 patients was uneventful. Our experience suggests that the use of an atrial septal defect occluder for the treatment of a bronchial fistula after pneumonectomy is a reliable option.

Transcatheter occlusion of giant congenital coronary cameral fistulae: a case series

BackgroundA coronary cameral fistula is a rare connection between a coronary artery and a cardiac chamber or vein bypassing the cardiac capillary bed system. Most of these fistulae are congenital and solitary, although they can be acquired and multiple.Cases presentationCase 1: A 10-year-old black South African boy presented with a long-standing history of fatigue; he had a heart murmur, and a bounding pulse and wide pulse pressure. An echocardiogram demonstrated a large coronary cameral fistula involving his left coronary artery and his left ventricle. This was also confirmed on ascending aortogram. Surgical ligation was done and his symptoms improved afterward, but a small residual fistula remained. Case 2: A 7-year-old black South African boy had decreased effort tolerance and a heart murmur on the mid-sternal border. He had cardiomegaly on chest roentgenogram and a dilated left coronary artery origin on echocardiogram. An ascending aortogram confirmed a large left coronary cameral fistula draining to the left ventricle. Case 3: A 28-year-old black South African woman with decreased effort tolerance and chest pain on exertion had a continuous murmur over the lower sternal border. Echocardiography demonstrated a dilated right coronary artery with a fistulous connection to her right ventricle. An ascending aortogram demonstrated a tortuous coronary cameral fistula arising from her right coronary artery to her right ventricle. All three patients were successfully treated percutaneously using the Amplatzer vascular plug type II device.ConclusionThe availability of numerous vascular closure devices has made transcatheter occlusion the treatment of choice for the majority of coronary cameral fistulae, rather than the traditional surgical ligation.

UNIQUE CASE OF ENDOBRONCHIAL VALVE IN TB BRONCHOPLEURAL FISTULA

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: A bronchopleural fistula (BPF) is a pathological connection between bronchial tree and the pleural space. BPF is a well-known complication of pulmonary tuberculosis (PTB). Endobronchial valve (EbV) are conventionally used to treat persistent air leaks (PAL) in the setting of non-surgical bronchopleural fistula. EbV are not routinely used in BPF secondary to active PTB. We describe a unique case where EbV was used to treat BPF secondary to active cavitatory pulmonary tuberculosis CASE PRESENTATION: A 30-year-old Spanish-speaking female, emigrated from Honduras 5 years ago presented to the emergency department with worsening productive cough and anorexia for two months. On admission patient was noted to be in respiratory distress and saturating 88% on room air. She once cachectic had poor inspiratory effort and bilateral rhonchorous breath sounds. Chest imaging was significant for bilateral upper lobe thick walled cavitatory lesions. Mycobacterium tuberculosis without rifampin resistance was detected, and patient was started on antituberculous therapy. On day 7 patient developed acute respiratory distress secondary to large right-side pneumothorax requiring chest tube placement. Patient required mechanical ventilation for hypercarbic respiratory failure, felt secondary to significant air leak. Bronchoscopy with balloon occlusion was performed, BPF with air leak was identified in right upper lobe with complete disappearance of air leak on occlusion of all three segments of right upper lobe (RUL). On day14 patient underwent endobronchial valve placement with complete occlusion of RUL. The hypercapnia, hypoxia improved, and patient stabilized clinically. Unfortunately, patient had complicated ICU course with failure to thrive and venous thromboembolism. On day 35 family requested terminal extubation and comfort care. DISCUSSION: There is very limited literature on utility and safety of EbV in patients with BPF and PAL secondary to active cavitatory PTB. Since their first description in 2005 by Snell (1), EbV have been in use for more than a decade now. The main indication of EbV is non-surgical management of BPF and PAL. PAL have been associated with significant morbidity, mortality and prolonged hospital stay(2). There is recent literature in multidrug resistant tuberculosis where EbV was used safely to treat cavernous tuberculosis with improved cavity closure and bacteriological conversion (3). In our patient the main reason for EbV placement was to improve minute ventilation and hypercapnia secondary to PAL. Endobronchial valve placement stabilized the clinical status in our patient without any associated adverse events. CONCLUSIONS: We need more literature and randomized controlled trials to evaluate safety and long-term complications of EbV in pulmonary tuberculosis associated BPF. Our case highlights that EbV could be a safe option for BPF in patients with active pulmonary tuberculosis. Reference #1: Snell, G., Holsworth, L., Fowler, S., Eriksson, L., Reed, A., Daniels, F.. (2005) Occlusion of a broncho-cutaneous fistula with endobronchial one-way valves. Ann Thorac Surg 80: 1930–1932. Reference #2: Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128:3955–65. Reference #3: Denis Krasnov, Yana Petrova, Sergei Skluev, Irina Felker, Vladimir Krasnov, Nikolay Grischenko. Endobronchial valve in complex treatment of patients with destructive pulmonary TB/HIV co-infection.European Respiratory Journal 2016 48: PA775; https://doi.org/10.1183/13993003.congress-2016.PA775 DISCLOSURES: No relevant relationships by Sean Dikdan, source=Web Response No relevant relationships by Boyd Hehn, source=Web Response No relevant relationships by MRINALINI VENKATA SUBRAMANI, source=Web Response

Thrombophilic risk factors in hemodialysis: Association with early vascular access occlusion and patient survival in long-term follow-up.

ObjectiveThrombophilic risk factors (TRFs) occur rather frequently in hemodialysis (HD) patients. However, little is known about their significance in HD patients, besides their potential impact on arteriovenous (AV) access failure, with varying results. We examined the effects of a wide variety of TRFs on both early AV fistula occlusion and survival among HD patients in long-term follow-up.MethodsIn this single-center, observational study, 70 consecutive HD patients from our dialysis center were examined with respect to shunt occlusion within the first 2 years after fistula creation and patient survival in a long-term follow-up (at least 16 years). We examined the presence of factor V, prothrombin, and MTHFR mutations using real-time fluorescence polymerase chain reaction. Furthermore, antithrombin (AT), protein C, protein S, and antiphospholipid antibodies (APL-Abs) were assessed.ResultsAmong the 70 patients, 32 had MTHFR mutations, 10 had heterozygous factor V Leiden mutations, 4 had prothrombin mutations, 4 had protein S deficiency, 2 had protein C deficiency, 9 had AT deficiency, and 14 had APL-Abs. 40 patients had shunt occlusion. TRFs were associated with a significantly increased risk for shunt thrombosis (P<0.02). Kaplan–Meier analysis with a log-rank test revealed significantly shorter survival in HD patients with TRFs (P<0.02). Cox regression analysis showed that the presence of TRFs (P<0.05; hazard ratio, 1.94; 95% CI: 1.07–3.56), but not early shunt occlusion, was associated with short patient survival.ConclusionsTRFs in hemodialysis patients have a strong impact on patient survival and early AV fistula failure; however, patient survival is not significantly affected by early shunt occlusion.

Pseudotumor hemofílico de fosa posterior como forma de presentación de hemofilia en paciente pediátrico. Reporte de caso y revisión

Paciente masculino de 10 meses es ingresado por parálisis hemifacial y hemiparesia derecha de un mes de evolución. En su exámen neurológico se observa con dismetría y lateropulsión derecha. El estudio de resonancia magnética se observa con una lesión intradural extraxial con efecto de masa y erosión de la escama occipital, con oclusión del seno transverso. Por tiempo de tromboplastina prolongado se protocoliza con diagnóstico de Hemofilia A leve (activida de factor VIII 12,8%). Se realiza reposición de factor VIII con posterior resección de la lesión. El estudio histopatológico revela hematoma subdural crónico. El paciente evoluciona favorablemente por lo que se egresa posteriormente. El pseudotumor hemofílico debe considerarse parte de los diagnósticos diferenciales de las lesiones intracraneales en paciente hemofílicos.

Falcine Sinus and Parafalcine Collateral Veins in Meningiomas Invading the Superior Sagittal Sinus

Venous collaterals form because of occlusion of the superior sagittal sinus (SSS), thus preserving venous drainage. Previous studies have focused on the evaluation and protection of sinuses and cortical veins and have neglected the collaterals between the SSS and deep venous system, which are important for surgical planning. We aimed to study the venous compensatory patterns inside and on both sides of the cerebral falx(parafalx) in patients with meningioma invading theSSS. Conventional magnetic resonance imaging, magnetic resonance venography, and a three-dimensional reconstructed venous model of 45 patients were analyzed. The venous collateral pattern of the parafalx was divided into 4 types: A), with cerebral medial cortical vein displacement or hyperplasia; B), collaterals connect the 2 ends of the occluded segment of the SSS; C), collaterals connect the occluded segment of the SSS with the deep cerebral venous system; and D), recanalization or secondary formation of a falcine sinus. The incidence of each type in different occlusion grades and positions of the SSS was analyzed. The 4 types of venous collaterals were ranked according to their prevalence: A, 46.7%; C, 15.6%; D, 8.9%; and B, 4.4%. The collaterals of types B, C, and D were found only in patients with severe SSS occlusion, and both types C and D were found only in middle and posterior occlusions of the SSS. In meningiomas invading the SSS, especially with complete posterior SSS occlusion, the parafalcine collateral veins and falcine sinus should be evaluated preoperatively to avoid iatrogenic injury.