Bilateral giant petrocavernous internal carotid artery (ICA) aneurysms are extremely rare, and its natural history, treatment response, and prognosis are unknown. Herein, we present the second case of a bilateral giant petrocavernous aneurysm treated with an external carotid artery-radial artery-M2 segment of the middle cerebral artery (ECA-RA-M2) bypass and ICA ligation. A 12-year-old female diagnosed with bilateral petrocavernous ICA aneurysms presented with headache, vomiting, and ptosis on the left eye. Endovascular treatment was not feasible due to financial limitations; hence, she underwent gradual ICA occlusion with a Poppen clamp followed by Hunterian ligation of the left ICA. Six years later, she returned with progressive blurring of vision on the right eye. CT angiography showed significant enlargement of the right ICA aneurysm (25.8 to 51.6mm) with partial thrombosis. Endovascular treatment was not feasible due to aneurysm length. Hence, a right pterional craniotomy with an ECA-RA-M2 bypass was performed. Intraoperative pressure monitoring confirmed graft patency but inadequate flow. To mitigate ischemic risk, the right ICA was gradually occluded with a Poppen clamp before definitive Hunterian ligation. Postoperative angiography confirmed bypass patency and complete aneurysm exclusion. The patient was discharged without new neurologic deficits; visual status remained stable. Pediatric bilateral petrocavernous ICA aneurysms are exceedingly rare, with limited data to guide therapy. This case illustrates contralateral aneurysm enlargement following unilateral ICA sacrifice, underscoring the hemodynamic burden on the remaining ICA. Long-term surveillance and individualized, multidisciplinary, treatment planning are critical in managing complex aneurysms in this population.

Background: Combined liver-intestine transplantation for complete portal vein thrombosis is an acceptable solution, most groups have not achieved good long term results. Materials and methods: A retrospective analysis of database for adult patients who underwent living donor liver transplantation at our centre between 1st September 2006 and 31st December 2014 was carried out. Patients were divided into three groups: without and with complete portal vein thrombosis and transplant techniques and outcomes after transplant were analyzed. A total of 79 / 1,288 adult patients who underwent living donor liver transplantation. 11 out of 79 patients had complete portal vein thrombosis and the incidence of major complications was similar in both the groups. Results: Portal vein thrombosis often accompanies liver cirrhosis and can affect as many as 25% of the patients. Results of transplantation in presence of portal vein thrombosis is inferior even after successful thrombectomy and it is not clear what is the best surgical option in cases of complete obliteration of portal vein lumen. There is paucity of data on living donor liver transplantation in patients with complete portal vein thrombosis. It is possible that careful surgical technique may allow liver transplant in patients of partial and complete portal vein thrombosis and avoid multi-visceral transplantation. Conclusion: There was no survival difference between those with and without portal vein thrombosis (p = 0.569). Out of the 11 patients, 3 patients died post transplant, one from failure of obtaining adequate portal venous flow and 2 patients from small for size syndrome.

ABSTRACT Chronic suppurative otitis media is an easily managed condition with potential for severe sinus thrombophlebitis complications secondary to cholesteatoma, if not diagnosed and treated promptly. Diagnosis relies on the culture and sensitivity of the drained suppuration, computed tomography (CT), and magnetic resonance imaging (MRI). Treatment entails a combination of all or some surgical, antibiotic, and anticoagulant use with postoperative follow‐up. Our 8‐year‐old female patient presented with chronic left postauricular swelling with foul‐smelling otorrhea and associated otalgia. More recently, she developed fever, headache, and vomiting. Fundoscopy noted papilledema. After ear examination, emergency incision and drainage were conducted with the suppuration sent for culture analysis. Tuberculosis was also ruled out. The patient had no history of dental caries. Contrast CT scan of the brain revealed features suggestive of partial thrombosis of the superior sagittal, left transverse sinus and sigmoid sinus extending up to the jugular vein. MRI and magnetic resonance venography (MRV) also indicated left otomastoiditis. Surgical treatment involved left‐sided tympanomastoidectomy and otomastoidectomy. Anticoagulant Rivaroxaban was used 15 mg twice daily for 21 days. Postoperatively, the dosage was increased to 20 mg once daily for 3 months. Antibiotic vancomycin was administered preoperatively. Postoperative CT showed good prognosis. Postoperatively there was gradual improvement in headache and vision deterioration of right eye; fundoscopy showed improvement in papilledema, patient leukocyte counts also declined significantly, eventually to 13.4/μL. Anticoagulant and antibiotic therapy was continued. Some authors advocate only blood–brain barrier crossing antibiotics, while others employ surgical treatment. The risks involved with using anticoagulants must be carefully weighed before use. Our case presents classic clinical signs and symptoms.

Mesenteric venous thrombosis (MVT) is a rare but life-threatening cause of acute abdominalpain, particularly when associated with congenital protein C deficiency. We present a 65-year-oldVietnamese man with acute epigastric and periumbilical pain and loose stools. Though initiallyhemodynamically stable, he showed signs of peritonitis. Laboratory findings revealedleukocytosis and elevated D-dimer. Contrast-enhanced CT confirmed complete thrombosis of thesuperior mesenteric vein, partial portal vein thrombosis, and bowel wall edema. Protein Cactivity was reduced to 50%. The patient underwent emergency laparotomy with resection of onemeter of necrotic bowel and creation of a double-barrel ileostomy. He received postoperativeanticoagulation with enoxaparin, later switched to apixaban. Discharged in stable condition onpostoperative day 14, he showed resolution of portal vein thrombosis at one-month follow-up.This case underscores the importance of early imaging, recognition of inherited thrombophilia,and timely surgical and anticoagulant therapy in managing MVT.

Aim To study morphological features of lung tissue and pulmonary vessels in patients with pulmonary hypertension (PH) associated with acquired mitral valve (MV) defects, with indications for surgical treatment.Material and methods This cross-sectional study included 105 patients with acquired MV defect of non-infectious origin (median age 60.0 [51.0; 66.0] years, 55.24% men) who underwent corrective surgery under cardiopulmonary bypass between 2024 through March 2025. PH was verified by right heart catheterization before defect correction. In 26 patients with MV defect and PH and 12 patients without PH, intraoperative lung tissue puncture biopsy samples were collected to assess changes in the lung parenchyma and microvasculature.Results In patients with MV defect and PH, the condition of arterioles was characterized by a larger area of intimal hyperplasia and predominantly the presence of thrombosis (34.6%). In patients with MV defect without PH, partial thrombosis of arterioles was more often found (41.66%), and plethoric arterioles were observed in 41.66%. During morphometry of pulmonary vessels, it was noted that the a calculated systolic pressure in the pulmonary artery of >38 mm Hg according to preoperative echocardiography (EchoCG) had a moderate inverse correlation with the area of the vascular wall (Kendall's rank correlation coefficient tau (τ) = -0.34; p=0.01) and a moderate direct association with the greatest thickness at the site of arteriolar intimal hyperplasia (τ = 0.39; p = 0.04). A moderate inverse correlation was found between the systolic excursion of the tricuspid valve annulus (1.7 cm or more) and the greatest thickness at the site of arteriolar intimal hyperplasia (τ= -0.47; p=0.04). MV stenosis was associated with the presence of thrombosed capillaries (odds ratio (OR) 8.75; 95% confidence interval (CI) 1.1-69.5; p=0.029) and focal interstitial fibrosis (OR 10.66; 95% CI 0.89-126.78; p=0.046). The presence of mitral stenosis had a moderate correlation with perivascular fibrosis (τ=0.41; p=0.005). A body mass index of >25 kg/m2 was associated with reduced odds of arteriolar media thickening (OR 0.15; 95% CI 0.02-1.01; p=0.03).Conclusion The severity of PH and right ventricular dysfunction, as determined by EchoCG before MV defect correction, may reflect morphometric changes in the pulmonary vessels. The nature of MV lesion, based on its stenosis type, is associated with a more than 8-fold increase in the odds of thrombosed capillaries and a 10-fold increase in the odds of focal interstitial fibrosis. Being overweight or obese was associated with an 85% reduction in the odds of arteriolar media thickening, as determined by pulmonary vascular morphometry.

Background: Headache is the most common clinical presentation of cerebral venous thrombosis (CVT). The most frequent symptoms reflect an intracranial hypertension syndrome, including headache, papilledema, and visual disturbances. Among diagnostic tools, orbital ultrasonography is emerging as a safe, accessible, and non-invasive method to detect elevated ICP. The optic nerve sheath diameter (ONSD), measurable via ultrasound due to the nerve's distinct anatomy, has shown good correlation with papilledema and elevated ICP in several studies, supporting its use as a bedside screening tool. Methods: A 42-year-old male smoker presented in May 2024 with right-sided headache, periorbital pain, ipsilateral tearing, and rhinorrhoea. Imaging (CT, CT venography, and MRI) revealed cerebral venous thrombosis involving the superior sagittal, right transverse, and sigmoid sinuses, along with partial thrombosis of cortical veins in the bilateral fronto-parietal region. The patient was discharged on Rivaroxaban 20 mg daily. Follow-up imaging showed initial recanalization. From August 2024, he developed worsening headaches and bilateral visual disturbances. Repeat MRI revealed recurrent thrombosis, prompting readmission in October 2024. A CSF depletion test confirmed elevated intracranial pressure (21–22 mmHg) with partial clinical benefit. During treatment with corticosteroids and acetazolamide, we monitored the intracranial hypertension through the ultrasound valuation of ONSD and papilledema using a linear probe (10 MHz) positioned at the transpalpebral level. The ONSD was measured starting at 30 mm from the optic disc. Results: We evaluated the optic nerve sheath diameter and the size of the optic disc using ultrasound before cerebrospinal fluid depletion and at 1 hour, 1 day, 3 days, and 15 days after the depletion. The measured values improved progressively, correlating with the patient’s clinical condition. ONSD before CSF depletion (0.57 cm OO) and after 15 days (0.47 cm OO). Papillae before CSF depletion (0.12 cm OO) and after 15 days (0.07 OD, 0.06 OS). Conclusion: Cerebral venous thrombosis is a rare condition that primarily affects young adults. Patients sometimes present symptoms of intracranial hypertension such as headache, papilledema, and decreased visual acuity. Ultrasound measurement of the ONSD should be considered as a reliable and non-invasive tool to estimate and monitoring the increased intracranial pressure.

BACKGROUND: Obstructive sleep apnea (OSA) is a prevalent comorbidity strongly associated with cardiovascular diseases, particularly in patients with aortic dissection (AD). However, the long-term impact of severe OSA on survival and distal aortic remodeling after total arch replacement for acute type A aortic dissection (ATAAD) remains unclear. OBJECTIVES: This study aimed to elucidate the specific long-term prognostic impact of severe OSA in patients undergoing ATAAD repair. METHODS: A total of 86 prospectively collected patients who underwent acute type A aortic dissection repair at Beijing Anzhen Hospital between January 2018 and December 2018 were enrolled in the study. All these patients underwent total aortic arch replacement. All patients underwent sleep monitoring within 90 days postoperatively. The association between severe OSA and major adverse events (MAEs) was analyzed using a multivariable Cox proportional hazards model. Kaplan-Meier survival analysis was performed to assess long-term survival. RESULTS: Of these 86 patients, 22 (25.6%) exhibiting severe OSA and 64 (74.4%) not. Individuals with severe OSA had a notably higher rate of major adverse events (MAEs) compared to those without severe OSA (27.3% vs. 7.8%, P =0.047) and a significantly lower long-term survival rate (81.8% vs. 97.4%, P =0.003). After adjusting for potential confounding variables, severe OSA remained an independent predictor of MAEs (HR=3.7, 95% CI: 1.1–12.4, P =0.032). Imaging follow-ups indicated that patients with severe OSA experienced significantly higher stent-graft distal aortic expansion rates (1.8 mm/year vs. 0.4 mm/year, P =0.030), abdominal aortic expansion rates (2.2 mm/year vs. 0.7 mm/year, P <0.001), and false lumen expansion rates in the descending aorta (2.5 mm/year vs. 0.8 mm/year, P =0.003). Moreover, partial thrombosis of the false lumen was more frequently observed in patients with severe OSA (40.9% vs. 14.1%, P =0.028). Conversely, complete false lumen thrombosis (64.1% vs. 45.5%, P =0.028) and false lumen patency (21.9% vs. 13.6%, P =0.028) were more commonly observed in patients without severe OSA. CONCLUSIONS: Severe OSA is associated with an elevated risk of MAEs and is implicated in abnormal distal aortic expansion and false lumen thrombosis among patients undergoing ATAAD repair. These results highlight the importance role of identifying and managing severe OSA in the long-term postoperative care of patients with ATAAD.

Introduction Endovascular coil embolization has been effective for cerebral aneurysms since its inception; however, compared with surgical clipping, recanalization remains a concern after coiling. Significant recanalization often necessitates retreatment by re‐coiling or clipping. Established predictors include large/giant size, wide neck, ruptured status, and partial thrombosis. Migration or compaction of coils into intraluminal thrombus can further promote delayed recanalization. Purpose To present a case of recanalization of a partially thrombosed giant ACOM aneurysm after coiling. Methods Patient was encountered during routine clinical practice. Results A 64‐year‐old right‐handed man, heavy smoker and alcohol user with hypertension, presented with new‐onset generalized tonic‐clonic seizure. Brain MRI/MRA demonstrated a giant (3.5 × 2.4 × 3.0 cm) Anterior communicating (ACOM) artery aneurysm with substantial neck filling (17 × 8 × 6 mm) and partial thrombosis. The patient underwent stent‐assisted coil embolization of the aneurysm. At 6‐month follow‐up, diagnostic angiography revealed neck recanalization attributed to flow‐related coil migration into the partially thrombosed sac. He subsequently underwent additional embolization with a Pipeline Flex flow‐diverting stent. Conclusion Patients should be followed by a neurointerventional specialist after coiling to enable early detection of complications. Recanalization should be anticipated in giant, wide‐necked, ruptured, or partially thrombosed aneurysms. Complex intra‐aneurysmal flow and coil migration into mural thrombus can drive recurrence; in such settings, definitive flow diversion may be required at recurrence or considered in initial planning. image

Introduction/Purpose Posterior circulation aneurysms account for 10‐15% of unruptured intracranial aneurysms and are more prone to rupture than those of anterior circulation. Giant basilar artery aneurysms pose significant risk as 80% of symptomatic patients become severely disabled or die within 5 years at a 50% five‐year rupture rate. Complications, including cranial neuropathies, hydrocephalus, quadriparesis, and respiratory failure, are related to local mass effect. Neurointerventional device limitations and their unique anatomy restrict conventional flow diversion, open surgical access, or parent vessel reconstruction. In this report, we highlight the novel management of a giant basilar artery aneurysm with deconstructive vertebral artery (VA) sacrifice and VA‐to‐VA pipeline embolization. Materials/Methods Case report. Results/Case Description An elderly male with hypertension and tobacco use presented with vomiting and dizziness. CTA revealed a 22mm basilar artery aneurysm. Angiogram revealed a giant, nearly‐completely thrombosed, complex neck semisaccular basilar aneurysm between the vertebrobasilar junction and AICAs. It exceeded flow diverter diameters and was not treated. He developed quadriplegia, dysphagia, and respiratory failure. MRI revealed aneurysmal enlargement with partial thrombosis, brainstem and fourth ventricular compression, and hydrocephalus. He required VPS, tracheostomy, and gastrostomy. Repeat angiogram demonstrated near‐complete aneurysmal thrombosis and bilaterally patent PICAs. He underwent right distal VA coil embolization as a pre‐operative adjunct to aneurysm clipping. Deemed a high‐risk neurosurgical candidate, he was instead discharged and re‐admitted 1‐month post‐embolization to evaluate treatment efficacy with a repeat angiogram. Despite coiling, the aneurysm had grown with partial recanalization and associated progressive brainstem edema. VA‐to‐VA pipeline embolization was performed by placing 3 pipeline embolization devices from the right V4 to the left V4 across the vertebrobasilar junction with collateral flow to the distal posterior circulation via the right PICA. Post‐operative course included cerebellar and occipital infarcts. Conclusion This report is, to our knowledge, the first VA‐to‐VA pipeline embolization for the management of a giant basilar artery aneurysm. Growth despite aneurysmal thrombosis and hydrocephalus requiring VPS remain under‐appreciated complications of these aneurysms. image

Introduction/Purpose Cerebral venous sinus thrombosis (CVST) is the presence of thrombosis in the dural venous sinuses or the cerebral veins. CVST most commonly involves the superior sagittal sinuses, followed by the transverse sinuses, and the straight sinus. Here, we present a rare case of extensive CVST affecting nearly all intra‐cranial dural venous sinuses, including the deep and superficial venous sinuses, in a patient with concurrent COVID‐19 infection and mastoiditis, who re‐thrombosed post‐thrombectomy but improved with anticoagulation. Materials/Methods N/A Results A 58‐year‐old female with hypertension and hyperlipidemia presented with acute onset vertigo, nausea, vomiting, and headache. She tested positive for COVID‐19, and a brain magnetic resonance imaging (MRI) showed left‐sided mastoiditis. During hospitalization, the patient developed acute encephalopathy, somnolence, expressive aphasia, and right‐sided weakness. Magnetic resonance venography (MRV) revealed extensive intracranial venous thrombosis involving the superior sagittal sinus, vein of Galen, straight sinus, bilateral transverse sinuses, and left sigmoid sinus, with partial thrombosis of the right transverse sinus, extending into the proximal left internal jugular vein. She was started on therapeutic heparin anticoagulation, but developed subdural and subarachnoid hemorrhage, suggesting compromised venous outflow and congestion. She underwent endovascular venous thrombectomy, achieving near‐complete recanalization. Anticoagulation was eventually transitioned to Eliquis. A computed tomography venogram (CTV) of the brain the following day showed complete re‐thrombosis of all dural venous sinuses. Patient was started on Warfarin and remained stable with improvement in headache. Conclusion This case underscores the complexity and severity of extensive CVST involving nearly all dural venous sinuses in the context of COVID‐19 and mastoiditis. Despite aggressive therapeutic anticoagulation and endovascular thrombectomy, re‐thrombosis occurred, underscoring management challenges. This emphasizes the need for ongoing research into more effective treatments for CVST in patients with concurrent COVID‐19 and mastoiditis. image image Figures 1 and 2 : CTV sagittal and coronal views showing extensive venous sinus thrombosis.

Cerebral venous thrombosis (CVT) is an uncommon but serious cause of pediatric stroke. In infants, it is most often related to dehydration, infection, or perinatal complications, while inherited thrombophilia is a rare underlying factor. Protein S deficiency, a congenital prothrombotic disorder, predisposes to severe thrombotic events from early life, though its presentation with intracardiac thrombosis is exceptional. We report the case of a six-month-old infant admitted with status epilepticus, in whom brain magnetic resonance imaging (MRI) demonstrated extensive CVT involving the superior sagittal, lateral, and straight sinuses. Echocardiography further revealed right atrial thrombi causing functional tricuspid stenosis, an atrial septal defect, and partial thrombosis of the superior vena cava. Etiological work-up confirmed congenital protein S deficiency. The association of CVT with right atrial thrombi in the absence of central venous catheters or structural heart disease is extremely rare. Functional obstruction of the tricuspid valve and the presence of an interatrial communication raised the possibility of paradoxical embolism as a contributing mechanism. The patient was successfully stabilized with anticoagulation alone. This case highlights the severity and unusual presentations of congenital protein S deficiency and underscores the importance of considering inherited thrombophilia in infants with extensive or multifocal thrombosis.

Abstract Pseudoaneurysms of the ulnar artery are rare vascular complications, typically following penetrating trauma. Chronic, neglected pseudoaneurysms presenting after several years are extremely uncommon and can lead to diagnostic delay and operative complexity. A 35-year-old male presented with a gradually enlarging, pulsatile swelling over the medial aspect of the right proximal forearm. He had sustained penetrating trauma in the same region 10 years prior. Imaging confirmed a large pseudoaneurysm arising from the ulnar artery with partial thrombosis and reduced distal flow. Surgical exploration confirmed a pseudoaneurysm measuring approximately 7 cm × 6 cm, embedded within the intermuscular plane. The lesion was adherent to the surrounding tissues, with the ulnar nerve located along its inferior aspect and carefully dissected free. Due to the absence of distal flow, the ulnar artery was not reconstructed. Collateral perfusion via the radial artery and deep palmar arch was intact. This case highlights the importance of considering vascular lesions in chronic posttraumatic swellings and demonstrates the feasibility of excision without reconstruction in the presence of adequate collateral circulation.

One of the complications of autogenous arteriovenous fistula (AVF) used for hemodialysis is the development of a true arteriovenous vein (VA) aneurysm. The consequences of aneurysm formation – including infection – skin changes at the aneurysm site, bleeding, rupture, thrombosis, and impaired blood flow – can result in inadequate hemodialysis. Among these complications, the most critical indication requiring urgent intervention is life-threatening bleeding. The standard treatment for a massive AVF aneurysm often involves ligation or resection with prosthetic interposition. Whenever possible, the first surgical intervention should aim to preserve natural access ideally without prosthetic grafting, creation of new vascular anastomoses or fistula ligation. Partial aneurysmectomy with or without reductive venoplasty, has been proposed as a method of managing this complication while maintaining fully autogenic access. The article describes a simple surgical technique for correcting a double aneurysmally altered AVF in a patient 7 years after the creation of an AVF mid-forearm. The procedure did not require postoperative central catheter implantation. Given the risk of partial fistula thrombosis, suppuration, and potentially fatal hemorrhage due to rupture, reconstructive surgery was performed. The operation consisted of partial excision of of the diseased venous segments (aneurysmorrhaphy), while preserving AVF function. The advantages of aneurysmorraphy include technical simplicity, safety under local anesthesia, effective removal of diseased tissues; and preservation of AVF function. This approach maintains inherent benefits of an autogenous AVF, while conserving vascular access site for future use. Aneurysmorraphy – also referred as reductive aneurysmoplasty, partial aneurysmectomy, or restoration/recalibration – represents a valuable surgical option, particularly for megaphystules. It emphasized preservation of native access while allowing flexibility in surgical technique tailoring individual case.

Background Central venous stenosis is a common problem encountered in hemodialysis (HD) patients, especially those with a history of repeated central venous catheter insertions. Central venous stenosis decreases the efficiency of dialysis by the arteriovenous fistula owing to the high recirculation rates. Moreover, it reduces the potential of the creation of new vascular access. The study aimed to determine the role of noncontrast magnetic resonance venography (MRV) in the detection of stenosed or occluded intrathoracic central veins in HD patients with failed vascular access. Patients and methods The study was conducted on 16 end-stage kidney disease patients on maintenance HD. All candidates were subjected to detailed history taking, focusing on vascular access and full physical examination. Noncontrast MRV for central veins in the neck and chest was done using 1.5 T closed MRI. Results Findings detected by the noncontrast MRV included occlusion of the right internal jugular vein in 37.5% of patients, as well as occlusion of the left internal jugular vein in 37.5% of patients. An occluded left brachiocephalic vein was detected in 25% of the patients. Partial thrombosis of the superior vena cava was detected in 12.5% of patients. Four (25%) of the studied patients had occlusion or stenosis in five different veins simultaneously. Conclusions Implementation of noncontrast MRV as a screening method to guide the choice of sites of catheterization or arteriovenous fistula limb, can improve longevity and function of vascular access in HD patients.

Complement Factor H (CFH) is a key regulator of the alternative complement pathway, and mutations in its gene are commonly associated with atypical hemolytic uremic syndrome (aHUS). Typically linked to renal thrombotic microangiopathy (TMA), CFH also interacts with coagulation factors, suggesting its role in thrombosis. We describe a 22-year-old male with AKI, nephrotic-range proteinuria, and anuria. Renal biopsy revealed chronic TMA. A CT revealed partial thrombosis of the right internal jugular vein (IJV). Thrombophilia workup was unremarkable. Genetic testing identified a pathogenic heterozygous CFH mutation (c.3572C>T; p.Ser1191Leu). This case illustrates an unusual CFH deficiency with venous thrombosis in the absence of traditional risk factors. Structural similarities between CFH and β2-glycoprotein I may underlie its anticoagulant function. Complement dysregulation should be considered in the differential diagnosis of unexplained thrombosis, particularly when associated with renal dysfunction.

Background. Klippel-Trenaunay syndrome (KTS) is a rare congenital vascular disorder characterized by the triad of capillary malformations, venous anomalies, and limb hypertrophy. It most commonly affects the lower limbs and presents with varied clinical severity, often necessitating multimodal imaging and multidisciplinary care. This case series aims to highlight the imaging features and clinical complexity of KTS through three distinct patient presentations. Case presentation. Three patients with confirmed KTS were evaluated. The first, a 16-year-old male, presented with progressive swelling and heaviness in the left lower limb since birth. CT and MR venography revealed soft tissue hypertrophy, deep venous hypoplasia, and anomalous venous drainage into the contralateral femoral vein. The second case involved a 32-year-old female with a chronic foot ulcer, right limb hypertrophy, and arteriovenous shunting demonstrated on imaging. CT angiography showed abnormal communications between the internal iliac artery and superficial femoral vein, with multiple varicosities and a limb length discrepancy. The third patient, a 31-year-old male, presented with long-standing swelling in the right leg. Imaging demonstrated extensive tortuous, multilobulated venous malformations with partial thrombosis, subcutaneous and intermuscular involvement, and localized gigantism. All patients were managed conserva­tively with compression therapy and wound care, and were evaluated for interventional planning as needed. Conclusion. KTS presents with diverse clinical and radiologic features, making diagnosis and management challenging. This case series emphasizes the vital role of multimodal imaging in diagnosis and preoperative planning. Conservative management remains the cornerstone of care, though targeted therapies and image-guided interventions are emerging as promising advances. Early recognition, individualized treatment, and longitudinal follow-up are key to improving quality of life and reducing complications in patients with Klippel-Trenaunay syndrome.

Flow diversion induces progressive aneurysm occlusion by reducing blood flow across the aneurysm neck over time. Various factors, including comorbid conditions, aneurysm characteristics, and stent design, have been shown to affect occlusion rates after flow diversion. Our study analyzed predictors of angiographic occlusion after flow diversion of intracranial aneurysms using the Flow Redirection Endoluminal Device with X-technology (FRED-X). This was a multicenter study of ruptured and unruptured aneurysms treated at 6 participating institutions across the United States. Data were collected on patient-specific factors and aneurysm characteristics. Angiographic occlusion was assessed using the Raymond Roy Occlusion Classification. Multivariate logistic regression was used to analyze predictors of complete angiographic occlusion at either the 6- or 12-month follow-up. One hundred forty-four patients with 152 aneurysms met criteria for inclusion. A total of 69.4% of patients (n = 100) achieved complete occlusion. The average age of the cohort that achieved complete occlusion was 56.2 years, and 84% (n = 84) was female. On univariate analysis, aneurysm laterality, partial thrombosis of the aneurysm sac, proximal and distal diameters of the parent artery, and procedure time were significantly associated with complete angiographic occlusion. On multivariate analysis, parent artery diameter distal to the aneurysm was associated with 0.46-fold decreased odds of complete occlusion (95% CI: 0.26-0.78, P < .002). One patient in the incompletely occluded cohort underwent retreatment using the Pipeline Shield at 7 months after the initial flow diversion procedure using the FRED-X. Our study identified that parent artery diameter distal to the aneurysm was associated with decreased odds of aneurysm occlusion after flow diversion using the FRED-X. This adds to the literature on the importance of device sizing during flow diversion. Further prospective studies could help validate these findings.

IntroductionDespite broader acceptance of transradial approach (TRA) for neurointerventional procedures, there is a paucity of data describing the technique and safety of using a short 8-Fr sheath with large bore 8-French guide catheters in the radial artery. The purpose of this study is to describe the technique and evaluate the safety and feasibility of a short 8-Fr sheath in the radial artery for neurointerventional procedures.MethodsConsecutive patients who had neurointerventional procedures with TRA using a short 8-Fr sheath between January 2019 and March 2024 were identified retrospectively utilizing our prospectively maintained institutional database. Procedures were evaluated for technical success, radial artery avulsion or extravasation, and the rate of radial artery patency among patients who had a follow-up procedure.ResultsTRA with a short 8-Fr sheath was attempted in 94 consecutive patients (52.1% women; median age 68 years) for a total of 111 procedures. TRA procedures were successfully completed in 82.0% (n = 100) of the cases. 20 procedures (18.0%) required crossover to TFA. In 28 patients who underwent radial artery ultrasound at follow-up angiography (median follow-up time 8.1 months), 23 patients (82.1%) had a patent radial artery, while 17.9% (n = 5) had partial thrombosis of the radial artery, which was recanalized by the access wire.ConclusionUsing a short 8-Fr sheath during TRA for neurointerventional procedures with large bore 8-Fr guide catheters is safe and feasible, with a high procedural success and favorable safety profile.

Giant aneurysm of the left internal carotid artery with partial thrombosis

Objective: Our primary endpoint was to determine the prevalence of superior mesenteric artery aneurysms (SMAAs) in infectious endocarditis (IE) patients. Methods: Retrospective study of 474 IE-patients (2005–2020) with abdominal computed tomography-angiography (CTA): the data of 10 SMAA-IE-patients (2.1%) are analyzed. Results: The median age of the 10 patients was 50.4 years (6 men). Microorganisms were Streptococcus spp. (n=6), Gemella spp. (n=2), Staphylococcus aureus (n=1), Enterococcus faecalis (n=1). Aneurysms were saccular (n=9), fusiform (n=1). Five SMAAs were partially thrombosed. Three patients presented acute abdominal pain, associated with partial thrombosis. Three became symptomatic: SMAA growth (n=2) and delayed aneurysm, enlargement, rupture, and bowel ischemia (n=1). Four were small (&lt;25 mm), 6 were large (25–70 mm), mostly distally located (6/10). Five (3 small, 2 large) regressed under antibiotic therapy alone, 2 (25 and 40 mm) underwent coil embolization. Three underwent surgery (30, 50, and 60 mm), because of large aneurysm at SMA origin, rapid enlargement and rupture, and bowel ischemia. The outcome was favorable (mean follow-up: 43.5 months; range: 9–72). Conclusion: Abdominal pain, vomiting, diarrhea, occurring in a patient with a current or recent history of IE should be carefully evaluated by CTA. Symptomatic, growing aneurysms and fusiform aneurysms mainly underwent an operative repair. Five silent aneurysms (&lt;20 mm, n=2; &gt;20 mm, n=3) were safely monitored under antibiotic therapy, enhancing the need to further have cross-sectional imaging of the visceral circulation in all cases of left-sided IE to detect asymptomatic aneurysms. SMAAs can regress, thus conservative management of small asymptomatic ones is possible. Clinical Impact In our series of superior mesenteric artery infectious aneurysms (SMAA) in infective endocarditis (IE) patients (incidence: 2.1%), symptomatic, growing aneurysms and fusiform aneurysms mainly underwent an operative repair. Five silent aneurysms (&lt;20mm, n=2; &gt;20mm, n=3) were safely monitored under antibiotic therapy. Our study showed first, the need to have cross-sectional imaging of the visceral circulation in all cases of left sided infective endocarditis. Obviously, abdominal CT-angiography monitoring is also a cornerstone of the efficacy of the antibiotic regimen. Second, SMAAs in IE patients can regress: thus conservative management of small asymptomatic ones is possible.