Lower Extremity Swelling Research Articles

The relationship between lower extremity swelling, quadriceps strength, and functional performance following total knee arthroplasty

BackgroundThe relationships between swelling after total knee arthroplasty (TKA) and quadriceps strength and functional performance are poorly understood.Therefore, the aim of this study was to examine the relationships between lower extremity swelling, measured using bioelectrical impedance assessment (SF-BIA), and quadriceps strength and timed up and go (TUG) times following TKA. Methods53 participants (64 ± 9.5 y/o, 43% male) undergoing primary unilateral TKA were recruited for the longitudinal observational study with repeated measures.Quantities of swelling were examined for contribution to two and six-week outcomes of strength and TUG time using hierarchical regression controlling for age, sex, and the baseline value of the dependent variable. Swelling was assessed using bioelectrical impedance assessment and quantified as the peak level of swelling and cumulative swelling (integral) over the post-TKA time window. Maximum isometric quadriceps strength (MVIC) was measured using a electromechanical dynamometer and participant functional performance measured using the TUG. ResultsNeither peak swelling nor cumulative swelling significantly contributed to the variance of two-week quadriceps strength. At six weeks, peak swelling significantly improved the variance in maximal quadriceps strength by an additional four percent (p = 0.05), while cumulative swelling did not significantly contribute. Peak swelling significantly contributed to the variance in two-week (16%) and six-week (five percent) TUG times (p < 0.05), but the cumulative swelling did not. ConclusionsPeak swelling represents a value of post-TKA swelling that is associated with strength and function. Reducing the peak level of swelling, occurring early after surgery, may improve patient functional recovery. Level of evidenceLevel II — Prospective observational study.

Spine Stabilization Is a Risk Factor for the Development of Pelvic Iliac Vein Lesions

Open lumbar spine stabilization surgery often requires mobilization of the left and right common iliac veins (CIVs) and the placement of plates and screws that can impinge on iliac veins. We reviewed our venography experience during the past 3 years to determine whether there is an association between spine stabilization surgery and the development of iliac vein lesions and symptomatic iliac vein outflow obstruction. A retrospective chart review was performed to identify patients who underwent venography with or without venous stenting and who had a history of previous lumbar spine stabilization. From January 2014 to April 2018, venography were performed in 1713 limbs in 1245 patients at the Center for Vascular Medicine. Of the 1245 patients, 17 patients had a history of lumbar spine stabilization procedures (4 anterior-posterior and 13 posterior). Nine had single-level and eight had two- or three-level fusions. All 17 patients demonstrated pelvic lesions, which included the following: one left CIV aneurysm, five left CIV stenoses, three bilateral CIV stenoses, two left CIV and inferior vena cava occlusions, and two external iliac vein stenoses. The aneurysm patient was treated with anticoagulation. Eight patients underwent stenting, and one patient refused stenting because of relocation to another country. One inferior vena cava-CIV occlusion could not be crossed. Fear of dislodging a thrombus and the proximity to a protruding posteriorly placed screw prevented stenting in two patients. Four patients had a venoplasty alone because of undersizing of a stenosis or missed lesions with intravascular ultrasound after review by a blinded reviewer. Lesions in anterior-posterior patients were extremely stenotic, required predilation, and resulted in a residual stenosis requiring venoplasty at a second setting in one patient. Lumbar spine stabilization surgery may be a risk factor for development of symptomatic venous outflow obstruction lesions. During venography and stenting in patients with anterior-posterior approaches, significant scarring may be encountered, resulting in a residual stenosis after stent placement. Predilation venoplasty, before stent deployment, is recommended to prevent stent migration. Furthermore, a history of spine stabilization surgery in patients presenting with pelvic or lower extremity pain or swelling should prompt consideration of a pelvic venous duplex ultrasound examination to assess for the presence of an iliac venous outflow lesion.

Assessing Lower Extremity Lymphedema Using Upper and Lower Extremity Tissue Dielectric Constant Ratios: Method and Normal Reference Values.

Background: Lower extremity swelling accompanies many conditions, including gynecological surgery and chronic venous dysfunction. Some clinical and quantitative assessment methods exist, but other ways to rapidly assess early lymphedema and track changes are needed. Our goal was to use lower to upper extremity intraside tissue dielectric constant (TDC) ratios with the specific aim of providing normal reference values potentially useful as a comparison measure against which persons at risk for lower extremity lymphedema might be evaluated. Methods and Results: TDC ratios (calf/forearm, foot/forearm) were measured in 44 young (25.1 ± 2.2 years) and 60 mature (60.1 ± 11.5 years) volunteers equally divided by gender. Foot/forearm and calf/forearm ratios did not differ between genders. For mature, values measured on dominant sides were 1.050 ± 0.151 and 1.013 ± 0.162, respectively. Lymphedema threshold ratios, calculated as the mean ratio plus twice their respective standard deviations, were for calf/forearm and foot/forearm 1.352 and 1.337, respectively. As an initial test of the thresholds, they were compared to TDC ratios determined in six patients with lower extremity edema due to congestive heart failure. Conclusion: Based on these findings, it is proposed that a calf/forearm TDC ratio that exceeds 1.35 is suggestive of lower extremity lymphedema and that the calf/forearm ratio could be used to track temporal changes and therapy-related improvements. The test of these conclusions requires future research in which these intraside TDC ratios and thresholds are evaluated in patients with lower extremity lymphedema and venous-related edema. This work provides the reference values for such comparisons to be systematically done.

Feasibility and Outcomes of Femoral Vein Harvest for Dialysis Access and Arterial Reconstruction

BackgroundWe describe the feasibility and long-term outcomes of using femoral vein (FV) for arteriovenous fistula (AVF) and lower extremity bypass (LEB) creation. MethodsAll patients undergoing AVF or LEB using autogenous FV by a single surgeon (April 2006 to September 2013) were reviewed. Perioperative (30-d) complications and long-term outcomes are described. ResultsForty-four patients underwent vascular reconstruction with FV (AVF = 27 and LEB = 17). Perioperative morbidity was 43.2%, including harvest site infection and or seroma in 15.9%. No patients suffered from compartment syndrome or venous thromboembolic event. At median follow-up of 50.0 mon, overall patency was 70.4% for AVF (primary = 37.0% and secondary = 70.3%) and 76.5% for LEB (primary = 70.6% and secondary = 76.5%). Long-term lower extremity swelling occurred in 18.2% of patients. ConclusionsPerioperative morbidity following FV harvest is high, but long-term patency rates are excellent. FV harvest is feasible and should be considered as a valid conduit in patients without useable great saphenous vein or other more commonly used sources of autogenous vein.

Development of a reference chart to monitor postoperative swelling following total knee arthroplasty

Title: Development of a reference chart to monitor postoperative swelling following total knee arthroplasty.Purpose: Lower extremity swelling is a feature of total knee arthroplasty. Until recently, clinicians lacked tools to accurately measure swelling in clinical settings, but bioelectrical impedance assessment has shown promise in this regard. The purpose of this study was to develop a reference chart of lower extremity swelling following total knee arthroplasty.Method: Fifty-six participants (54% male, mean age = 64 years) were followed for the first 7 weeks following total knee arthroplasty, during which frequent lower extremity bioelectrical impedance assessments were performed. Using Generalized Additive Models for Location Scale and Shape, a reference chart for swelling was developed with bioelectrical impedance assessment data from the first 40 patients enrolled in the study (223 observations) and preliminarily tested for performance in the remaining 16 patients’ data (96 observations).Results: The reference chart illustrates approximately 10% per day increase for the first 3 days following surgery. Peak swelling occurs 6–8 days following surgery; the 10th percentile demonstrates a peak of 25%, whereas the 90th percentile peaks at 47%. In the test data, this reference chart demonstrated accurate coverage at each estimated centile.Conclusion: The reference chart provides a novel framework for monitoring swelling following total knee arthroplasty and may augment clinical decisions to improve postoperative swelling management.Implications for rehabilitationThe use of bioelectrical impedance assessment provides an accurate and easily implemented approach for rehabilitation professionals to measure swelling.The reference chart provided allows for monitoring of patient recovery of swelling following total knee arthroplasty.Precise depictions of where a patient’s swelling is in reference to others will improve clinical decision making at the individual level.

A Swollen Leg

Abstract We report a patient with a rheumatic overlap syndrome on hydroxychloroquine and prednisone who developed tuberculous pyomyositis shortly after receiving 9 months of treatment of miliary tuberculosis. Her only presenting symptom was swelling of the left lower extremity without any systemic manifestation, despite extensive radiographic evidence of disseminated abscess formation. Acid-fast bacilli stains and cultures of the purulent material were negative for Mycobacterium tuberculosis (MTB), but polymerase chain reaction confirmed the diagnosis. To our knowledge, this is the first case report of tuberculous pyomyositis that developed shortly after the patient completed a full course of antituberculous therapy. We believe that the concurrent therapy of her rheumatic overlap syndrome with hydroxychloroquine likely led to her treatment failure for MTB and will discuss the possible pathogenesis. Our case also illustrates that MTB can cause significant soft tissue disease without systemic manifestations and that polymerase chain reaction is a valuable diagnostic study.

Femoral Fracture During Cesarean Section: A Case of Professional Liability? Case Presentation and Review of the Literature

Breech foetuses are commonly delivered via caesarean section to prevent trauma and decrease the risk of head entrapment, though extraction by abdominal route can very rarely lead to traumatic femur fracture. Typical site of fracture is femoral diaphysis. Although femur fracture is a relatively rare complication, it represents one of the most common fractures of the lower extremity presenting in newborns. A 3900 g female child born at 39 weeks of gestation by caesarean section, presented swelling and tenderness of the left lower extremity in the second day of life. There was no apparent bone disorder predisposing to femur fracture. Fracture of left diaphysis was successfully treated by immobilization with Pavlik harness, healing in a good position for 23 days. Three months after birth, radiogram revealed regular bone consolidation and fracture fully welded. One year after birth, both lower limbs showed a proper mobility with no dysmetria. Caesarean delivery reduces increasingly traumatic complications, especially in breech delivery compared with vaginal delivery, but does not eliminate possible accidental injuries of the newborn. Predisposing factors are many, especially breech presentation and foetuses with malpresentation. Clinicians must be aware that abdominal delivery does not preclude the occurrence of femur fractures.

May‐Thurner syndrome and thrombosis: A systematic review of antithrombotic use after endovascular stent placement

BackgroundMay‐Thurner Syndrome (MTS) is caused by compression of the left common iliac vein between the right common iliac artery and the pelvis. It likely predisposes an individual to lower extremity deep vein thrombosis (DVT) as well as symptoms of unilateral lower extremity swelling and discomfort in the absence of a known history of thrombosis. In the case of MTS‐associated acute thrombosis, there is low‐quality evidence to suggest that endovascular intervention including thrombolysis and endovascular stent placement reduces the risk of recurrent thrombosis. However, the optimal type and duration of antithrombotic therapy after stent placement for left iliofemoral vein stenosis is not known. MethodsA systematic literature search including studies that evaluated the outcome of endovascular stent occlusion and systemic anticoagulant use in patients with MTS associated DVT was performed. The primary outcome of interest was 12‐month risk of endovascular stent occlusion or recurrent DVT. ResultsA total of five studies encompassing 61 patients were included in our study. All studies were retrospective without a comparator group. A variety of anticoagulants and durations were prescribed. Of the 55 patients evaluable, the 12‐month rate of endovascular stent occlusion or recurrent DVT ranged from 0% to 40%. The 12‐month stent patency rate ranged from 60% to 100%. ConclusionsThe published evidence regarding antithrombotic treatment for patients with MTS who have undergone stent placement for a DVT is limited. Further high‐quality, prospective studies are needed in this setting to inform clinical decision making.

Iatrogenic Bilateral Lower Extremity Subcutaneous Emphysema after Robotic-Assisted Laparoscopic Hysterectomy with Bilateral Salpingo-Oophorectomy and Sacrocolpopexy

As minimally invasive surgery becomes more prevalent, it is important to keep in mind the unique complications that can be associated with the use of carbon dioxide insufflation. Postoperative patients presenting with lower extremity pain and swelling should have the diagnosis of iatrogenic subcutaneous emphysema on the differential, alongside deep venous thrombosis and necrotizing fasciitis.

Amyloid Cardiomyopathy in the Emergency Department

BackgroundCardiac amyloidosis is an underdiagnosed cause of restrictive cardiomyopathy resulting from the infiltration of the myocardium by amyloid proteins. Case ReportWe report the case of an 83-year-old woman who presented with increasing dyspnea and lower-extremity swelling. She reported a medical history of unspecified heart failure. Evaluation in the Emergency Department (ED) revealed evidence of heart failure on physical examination, low-voltage electrocardiogram, chest x-ray study with mild pulmonary edema, and laboratory evaluation with elevated brain natriuretic peptide and troponin. Bedside cardiac ultrasound illustrated severe concentric ventricular hypertrophy and interventricular septal wall thickening with “sparkling” hyperechoic appearance of the myocardium, mildly reduced left ventricular ejection fraction, and small pericardial effusion. Inpatient comprehensive echocardiogram and follow-up nuclear medicine cardiac amyloid pyrophosphate study were suggestive of cardiac amyloidosis. Why Should an Emergency Physician Be Aware of This?Emergency physicians commonly treat acute on chronic systolic heart failure with diuresis and reductions in preload and afterload with nitrates. Identifying amyloid cardiomyopathy in the ED is of clinical significance because treatment should include loop diuretics but should avoid β-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, and digoxin. Atrioventricular nodal blocking agents may have detrimental effects in cardiac amyloidosis because the cardiac output in this patient population is dependent on heart rate due to a significantly reduced stroke volume from the concentric hypertrophy minimizing diastolic filling. Also, caution should be taken when initiating nitrates in amyloid cardiomyopathy because further reducing preload in an already preload-depleted state can result in hypotension.

Case series of seven women with uterine fibroids associated with venous thromboembolism and chronic thromboembolic disease

Uterine fibroids have been described as an associate to acute venous thromboembolism (VTE), with case reports showing an association between large uterine fibroids, acute deep venous thrombosis (DVT), and acute pulmonary embolism (PE). However, there is little known about the association or causation between uterine fibroids, chronic thromboembolic disease (CTED), and chronic thromboembolic pulmonary hypertension (CTEPH). We report on six women with uterine fibroids and CTEPH, as well as one woman with CTED, all of whom presented with exertional dyspnea, lower extremity swelling, and in the cases of CTEPH, clinical, echocardiographic, and hemodynamic evidence of pulmonary hypertension and right heart failure. Compression of the pelvic veins by fibroids was directly observed with invasive venography or contrast-enhanced computed tomography in five cases. All seven women underwent pulmonary thromboendarterectomy (PTE) followed by marked improvement in functional, clinical, and hemodynamic status.

Rare case of a kidney and inferior vena cava abnormalities with extensive lower extremity deep vein thrombosis in a young healthy male.

Kidney and inferior vena cava (IVC) abnormalities with extensive deep vein thrombosis (DVT) is a very rare cause of DVT and has a diverse clinical presentation. Computed tomography (CT) angiography is the gold standard for diagnosis and treatment including thrombectomy, thrombolysis and systemic anticoagulation. We present a rare case of active young healthy male admitted with acute onset of right lower extremity pain and swelling who was found to have extensive DVT on doppler ultrasound. CT abdomen showed extensive clot burden involving right common femoral vein extending into internal and external iliac veins associated with IVC hypoplasia and hypoplastic left kidney. Patient underwent urgent thrombectomy, catheter directed thrombolysis and was discharged home in stable condition on oral anticoagulation.

HEART FAILURE AND PREGNANCY: TO DELIVER OR TO CARRY ON

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Management of acute decompensated heart failure and life-threatening arrhythmias during pregnancy is challenging. Increasing physiological demands of pregnancy and limited pharmacological treatment options often push physicians to pursue early delivery. We report a rare case of cardiomyopathy manifesting as incessant ventricular tachycardia during second trimester of pregnancy. CASE PRESENTATION: A 30 year-old Caucasian female with no past medical history presented to the hospital with shortness of breath, palpitations, and lower extremity swelling during the 26th week of her first pregnancy. Electrocardiogram and telemetry revealed a high burden of non-sustained polymorphic ventricular tachycardia (VT) (figure 1). Patient was transferred to intensive care unit (ICU) and transthoracic echocardiogram (TTE) showed biventricular failure with left ventricular ejection fraction (LVEF) of 20%, severe left atrial dilation and mitral regurgitation (figure 2). Patient was started on esmolol and lidocaine infusions. A pulmonary artery catheter was placed for hemodynamic monitoring (figure 3). Diuresis was also initiated. Given the persistent VT and evidence of lidocaine toxicity, mexiletine was initiated and lidocaine discontinued. After 7 days, the frequency of ventricular ectopic beats significantly decreased. Considering the likelihood of peripartum cardiomyopathy, bromocriptine was administered, but patient could not tolerate it due to worsening hypotension and nausea. With increasing cardiovascular demands of pregnancy and persistent severe cardiomyopathy, a decision was made to pursue caesarian section at 28 weeks. Given the stress of surgery and mortality associated with it, an Impella CP left ventricular assist device was placed immediately prior to caesarian section. Patient tolerated both procedures well and was subsequently weaned off Impella CP device in the surgical ICU. Baby was also viable. Patient was eventually discharged on metoprolol and mexilitine along with standard therapy as well as a LifeVest. Follow up TTE at 4 months showed slight improvement in LEVF at 25%. Cardiac magnetic resonance imaging revealed extensive patchy and transmural late gadolinium enhancement (figure 3). DISCUSSION: Management of incessant ventricular tachycardia in pregnancy can be difficult as amiodarone is associated with fetal growth retardation. Lidocaine, procainamide and mexiletine are the recommend anti-arrhythmic agents for stable cases. In patients with severely depressed LVEF, caesarean section carries a high mortality rate. Preemptive use of circulatory left ventricular assist device such as Impella CP is potentially life saving. CONCLUSIONS: Cardiomyopathy in pregnancy can present as incessant ventricular tachycardia and should alert physician for further work up. Reference #1: Arany Z, and Elkayam U. Peripartum Cardiomyopathy. Circulation. 2016;133(14):1397-409. DISCLOSURES: No relevant relationships by Anthony Lubinsky, source=Web Response No relevant relationships by Assad Oskuei, source=Web Response

A Rare Case of Undifferentiated High-Grade Sarcoma Masquerading as Thrombus Resulting in Acute Budd-Chiari Syndrome

We present a rare case of Budd-Chiari Syndrome (BCS) from a high-grade undifferentiated sarcoma that invaded and obstructed the inferior vena cava (IVC), hepatic veins and right atrium. There are just 6 cases of venous undifferentiated intimal sarcomas reported in the literature. A 56-year-old Caucasian female with hypertension presented to her primary doctor with 2 weeks of abdominal bloating, abdominal pain, 10-pound weight gain and lower extremity swelling. On exam she had mild ascites, tender hepatomegaly and lower extremity edema. Liver tests were unremarkable, but abdominal ultrasound revealed both mild ascites and both IVC and hepatic vein thrombosis. She was referred to the hospital and a CT revealed extensive thrombus within the entire IVC extending into the right atrium showing a separate 5.0 cm right atrial mass, as well as thrombus extending into the right gonadal vein and the renal veins bilaterally. Imaging showed moderate ascites as well as heterogeneous liver appearance presumably related to passive congestion. A 2-D echocardiogram revealed an ejection fraction of 50-55% with IVC thrombus extending into the right atrium creating a functional tricuspid stenosis from inflow obstruction. The patient was started on a heparin drip to prevent further clot burden and transferred to a tertiary care facility for further intervention. During open heart surgery the right atrial portion of the 5.0cm mass was excised and freed from the tricuspid valve. The portion of the mass coming from the IVC was adherent to the wall of the vessel and right atrium and unresectable. Frozen section immunostains of the tumor cells revealed negative epithelial differentiation (pancytokeratin), endothelial cell markers (CD34, CD117), nerve sheath differentiation (S100), and smooth muscle actin (SMA). Additional stains were negative for actin (HHF), desmin, CD99, EMA and CAM 5.2. The histology showed that there was cell neoplasm with pleomorphism - bizarre, enlarged nuclei, high nuclear-cytoplasmic ratio and abundant mitoses indicative of undifferentiated high-grade sarcoma. The patient was referred to an oncology center for chemotherapy and the patient is doing well. Without surgical intervention this could have been misdiagnosed and treated with long term anticoagulation. This unique BCS case stresses the importance of using different image modalities such as ultrasound and CT imaging to promptly diagnosis and assess the surgical approach.2429_A Figure 1. High-grade undifferentiated sarcoma extension into the inferior vena cava (IVC) and the right atrium showing a separate 5.0 cm right atrial mass, which caused a functional tricuspid stenosis from inflow obstruction.2429_B Figure 2. CT imaging shows a massive high-grade sarcoma tumor continuously present within the dilated inferior vena cava and tumor occupation extending into the right atrium. Thrombus extends into the right gonadal vein and the renal veins bilaterally. Moderate ascites and subcutaneous edema with small bilateral pleural effusions and heterogeneous appearance to the liver presumably related to passive congestion.2429_C Figure 3. Frozen section immunostains of the tumor cells revealed negative epithelial differentiation (pancytokeratin), endothelial cell markers (CD34, CD117), nerve sheath differentiation (S100), and smooth muscle actin (SMA). Additional stains were negative for actin (HHF), desmin, CD99, EMA and CAM 5.2. The histology showed that there was cell neoplasm with pleomorphism - bizarre, enlarged nuclei, high nuclear-cytoplasmic ratio and abundant mitoses indicative of undifferentiated high-grade sarcoma.

An 8-Mm Polyp Is Worth a 1,000 Words: Metastatic Lung Cancer Within a Tubular Adenoma

Introduction: Lung cancer is the leading cause of cancer deaths in the United States, and cases are often metastatic at the time of diagnosis. We report a case of metastatic lung cancer initially diagnosed incidentally when a metastatic lesion was found within a tubular adenoma. Case Description: A 64-year-old male with thirty pack-year smoking history presented to the hospital with left lower extremity swelling and found to have an extensive unprovoked deep vein thrombosis. He was placed on rivaroxaban. The patient returned to hospital two weeks later with painless hematochezia. Colonoscopy was performed but did not identify a source of bleeding. However, an 8 mm polyp in the sigmoid colon were resected. Pathology results revealed a tubular adenoma containing poorly differentiated adenocarcinoma invading the lamina propria, consistent with pulmonary origin (TTF1 and CK7 positive; CK20, CDX2, GATA3 and S100 negative). Subsequent CT chest/abdomen/pelvis demonstrated multiple spiculated pulmonary nodules and enlarged supraclavicular, cervical, mediastinal and hilar nodes consistent with metastatic lung cancer. Based on the mutation pattern (PD-L1 positive; EGFR/Alk/Ros unmutated), the patient received pembrolizumab as palliative treatment.1538_A Figure 1. Chromogenic photomicrograph of colonic tubular adenoma showing metastatic poorly differentiated adenocarcinoma with negative CDX2 (specific for intestinal epithelium) staining. (x10 magnification)Discussion: Lung cancer is one of the most common primary malignancies with nearly 50% distal metastasis at the time of diagnosis. However, intestinal metastases are considered quite rare. The prevalence of metastasis to GI tract varies by report from 0.5-14%. The most common histologic types are SCC and large cell. Of the potential GI tract metastasis, the most sites are the esophagus, small intestine, and stomach. When colonic metastasis are present, two-thirds of patients are symptomatic at the time of the diagnosis and most commonly describe symptoms of abdominal pain, nausea, vomiting, and weight loss. Metastases to the GI tract are most often encountered during evaluation of symptomatic cases. In the asymptomatic patient they are often found incidentally on imaging or autopsy. Distant metastasis in lung cancer confers poor prognosis. Diagnostic modalities such as colonoscopy likely do not provide mortality benefit but less is known regarding morbidity and prevention of GI complications. In conclusion, lung cancer metastasis to the colon is exceedingly rare, and this is the first reported case of a metastatic lung cancer within a colon polyp.1538_B Figure 2. Chromogenic photomicrograph of poorly differentiated carcinoma showing positive staining for TTF1 (specific for primary lung adenocarcinomas). (x20 magnification)1538_C Figure 3. Spiculated nodular opacity in the left upper lobe anteriorly in an area of focal emphysema measuring 1 cm.

Pseudomembranous Gastritis of Unknown Etiology

Pseudomembranes are formed by the eruption of neutrophils, nuclear debris, and inflammatory agents from the lamina propria to the epithelial lining. They are seen most frequently in the small and large bowel of hospitalized patients. Pseudomembranous gastritis, however, is a rare clinical finding with only four cases that have been reported. We present a case of pseudomembranous gastritis of an unknown etiology. A 64 year-old morbidly obese male with a history of hypertension, congestive heart failure (CHF), atrial fibrillation on rivaroxaban, and obstructive sleep apnea presented with a complaint of shortness of breath and bilateral lower extremity swelling. He was admitted for an acute CHF exacerbation and started on intravenous diuresis. Soon after, he had an episode of non-bloody emesis followed by two episodes of coffee ground hematemesis. His hemoglobin dropped from 14.2 gm/dL to 12.4 gm/dL. His last dose of rivaroxaban was two days prior to presentation. He denied abdominal pain, history of liver disease, gastrointestinal bleeds, varices, melena, hematochezia, prior hematemesis, heartburn, cancer, or prior endoscopies. He then underwent an esophagogastroduodenoscopy which did not reveal a cause of the hematemesis. However, a flat, round, 3 cm prepyloric lesion was observed. The lesion was focal and covered with adherent, white exudates not easily scraped with forceps. Biopsy of the lesion showed a surface layer of fibrin, mucus, and neutrophils overlying distended gastric glands with a volcano-like appearance. The lamina propria was distended by a mixed inflammatory cell infiltrate. The tissue sample was negative for fungi, bacteria, and atypical cells. His condition stabilized and he was discharged with an outpatient follow up. This case highlights a potentially incidental finding during esophagogastroduodenoscopy which may be concerning. Clinicians must be aware that such lesions can be seen without an obvious cause. Also, it is possible that isolated, smaller lesions are of a more benign nature as compared to diffuse pathological findings. Our case is further unique due to the fact that the patient had a confined region of the lesion, as opposed to previous reports which had a diffuse pseudomembranes spread all across the gastric mucosa.1459_A Figure 1. Pseudomembrane on endoscopy.1459_B Figure 2. Pseudomembrane on endoscopy.1459_C Figure 3. Pseudomembrane on endoscopy.

Management of Nonthrombotic May-Thurner Syndrome

Venous outflow pathology of the lower extremity may be categorized into thrombotic or nonthrombotic etiology. This chapter focuses on the nonthrombotic etiology that results from the compression of the left iliac vein or May-Thurner syndrome (MTS). MTS is an anatomic variant condition associated with venous outflow stenosis due to extrinsic compression of the iliocaval venous segment. The most common cause of the partial obstruction is left iliac vein compression by the overlying right common iliac artery, although other anatomic varieties of MTS do exist. Partial or complete impedance to the venous outflow in the iliocaval venous segment may lead to extensive deep vein thrombosis of the ipsilateral extremity. Clinical presentations may include, but are not limited to, pain, extensive lower-extremity swelling, venous stasis ulcers, and skin discolorations. Treatment is based entirely on the clinical presentation; normally for nonthrombotic MTS, angioplasty and stenting of the diseased iliac vein segment are usually sufficient after defining the location and extent of stenosis. In this review, we (1) describe and define MTS, (2) highlight variable presentations of MTS, and (3) outline the possible management strategies within the current Society for Vascular Surgery updated consensus guidelines. This review contains 3 Figures, 2 Videos, 3 Tables and 66 references Key Words: angioplasty, artery compression, deep venous thrombosis, iliac vein, iliofemoral stenosis, May-Thurner syndrome, spur, stent, venogram, venous hypertension

Management of Nonthrombotic May-Thurner Syndrome

Venous outflow pathology of the lower extremity may be categorized into thrombotic or nonthrombotic etiology. This chapter focuses on the nonthrombotic etiology that results from the compression of the left iliac vein or May-Thurner syndrome (MTS). MTS is an anatomic variant condition associated with venous outflow stenosis due to extrinsic compression of the iliocaval venous segment. The most common cause of the partial obstruction is left iliac vein compression by the overlying right common iliac artery, although other anatomic varieties of MTS do exist. Partial or complete impedance to the venous outflow in the iliocaval venous segment may lead to extensive deep vein thrombosis of the ipsilateral extremity. Clinical presentations may include, but are not limited to, pain, extensive lower-extremity swelling, venous stasis ulcers, and skin discolorations. Treatment is based entirely on the clinical presentation; normally for nonthrombotic MTS, angioplasty and stenting of the diseased iliac vein segment are usually sufficient after defining the location and extent of stenosis. In this review, we (1) describe and define MTS, (2) highlight variable presentations of MTS, and (3) outline the possible management strategies within the current Society for Vascular Surgery updated consensus guidelines. This review contains 3 Figures, 2 Videos, 3 Tables and 66 references Key Words: angioplasty, artery compression, deep venous thrombosis, iliac vein, iliofemoral stenosis, May-Thurner syndrome, spur, stent, venogram, venous hypertension

Application of cyberknife in treatment of retroperitoneal lymph node metastatic tumors in 81 cases

Objective To evaluate the clinical efficacy and side effects of cyberknife therapy in the treatment of retroperitoneal lymph node metastatic tumor. Methods Among the 81 patients presenting with postoperative retroperitoneal lymph node metastases, 33 cases suffered from abdominal pain or low back pain, 7 had unilateral hydronephrosis and ureteral dilatation, and 8 developed unilateral or bilateral lower limb swelling. Using stereotactic radiotherapy with a cyberknife, DT was delivered at 33-45 Gy/3-6 F. The improvement of symptoms, objective tumor response rate, and irradiation-induced side effects were observed. Results At 4 weeks after treatment, pain and swelling of the lower extremities were completely mitigated, and hydronephrosis was fully healed in all patients. Enhanced CT or MRI was performed every 2 to 3 months. After 6-month follow-up, the complete response (CR) rate was calculated as 77%(62/81), 21%(17/81) for the partial response (PR) rate, 3%(2/81) for the stable disease (SD) rate and the effective rate (CR+ PR) was 98%.No case progressed. The main side effect was intestinal injury, including grade 1 in 16%(13/81), grade 2 in 9%(7/81). Multivariate analysis demonstrated the CR rate was not correlated with the type of the primary tumor or the size of the tumor (P>0.05), but was significantly associated with the distance of>0.5 cm between the tumor and intestine and the BED (α/β=10)>70 Gy of the tumor irradiation (P 5 cm and the distance of<0.5 cm between the tumor and intestine (P<0.01). Conclusion Cyberknife is an efficacious and safe approach in the treatment of retroperitoneal lymph node metastatic tumors. Key words: Retroperitoneal lymph node metastatic neoplasms/stereotactic radiotherapy; Radiotherapy, cyber knife

Reversal of Cardiac Allograft Dysfunction with Medical Therapy

Background Acute cellular rejection (ACR) among heart transplant recipients is common with up to 20% to 40% of patients developing an episode in the first year. Yet, stability is the norm after the first year. Late graft dysfunction is less common and can result in the need for re-transplantation. We present a case in which medical therapy was used in lieu and resulted in resolution of graft dysfunction. Case report A 48 year old man who underwent orthotopic heart transplant in July 2014 had an uncomplicated early transplant course with negative endomyocardial biopsy (EMBx) for allograft rejection through 21 months. At that time he presented with dyspnea, lower extremity swelling and excess sinus tachycardia (140 bpm). Given new heart failure symptoms, rejection evaluation was completed, including EMBx. Pathology revealed International Society for Heart and Lunt Transplantation (ISHLT) grade 2R ACR. Staining for antibody mediated rejection was negative. An echocardiogram (TTE) revealed a decline in allograft function from 70% to 40% with restrictive filling pattern. Treatment with anti-thymocyte globulin, high dose prednisone taper, plasmapheresis and bortezomib was given. Despite treatment the patient returned for heart failure hospitalization 3 months later. Right heart catheterization (RHC) showed pulmonary capillary wedge pressure of 24 mmHg, mean right atrial pressure of 12 mmHg and cardiac index of 1.9 L/min/m^2. Due to reluctance on the part of the patient to immediately consider re-transplantation, intravenous milrinone and titration of guideline-directed medical therapy was completed. Fortunately, the graft ejection fraction normalized on subsequent TTE and he was successfully weaned off milrinone over 5 months. Repeat RHC showed normal filling pressures and normal cardiac index. Conclusions Patients who develop graft dysfunction with cellular rejection may continue to experience residual graft dysfunction after treatment. Continued medical therapy with standard heart failure regimen and inotropes helped support this patient during decompensation. This case suggests the possibility of late allograft recovery with medical support and avoidance of re-transplantation. Further research is needed regarding effective medical management of graft dysfunction.