Subsequent Dilatation Research Articles

Extenuating the role of Ficus virens Ait and its novel bioactive compound on antioxidant defense system and oxidative damage in cigarette smoke exposed rats

Production of free radicals is associated with cigarette smoke (CS) which in turn generates oxidative stress, could be responsible for alterations in the activities of enzymatic and non-enzymatic antioxidants that links with atherosclerosis. Therefore, the putative preventive effects of F. virens extract and its bioactive compound (F18), n-Octadecanyl-O-α-D-glucopyranosyl(6’→1’’)-O-α-D-glucopyranoside were investigated on overall enzyme and non-enzymatic defense system and in oxidative stress CS-exposed rats. The enzymatic activities of hepatic and lung CAT, SOD, Gred and GST in CS exposed rats were significantly decreased, while Gpx activity in CS exposed rats was increased. Similarly, hepatic and lung GSH content was reduced when compared to value of normal control group. Simultaneous administration of FVBM extract (50 and 100 mg/rat) and F18 bioactive compound (1 mg/rat) significantly increases hepatic and lung CAT, SOD, Gred and GST activity as well GSH concentration coupled with decrease in Gpx level in CS-exposed stress rats. Moreover, our histological observations concludes the pulmonary congestion, thickening of interalveolar septa and foci of collapsed alveoli with subsequent dilation of the adjoining alveolar spaces as well as development of large irregular spaces in rats lung exposed to cigarette smoke. Similarly, the liver also showed morphological alterations with congestion in central vein, portal inflammation and necrosis in CS-exposed rats. These morphological changes reversed significantly after treatment with FVBM extract and F18 compound. Thus biochemical and histopathological studies suggested that, FVBM extract and F18 showed its protective nature against CS-exposed rats.

Postinfarct Left Ventricular Remodelling: A Prevailing Cause of Heart Failure.

Heart failure is a chronic disease with high morbidity and mortality, which represents a growing challenge in medicine. A major risk factor for heart failure with reduced ejection fraction is a history of myocardial infarction. The expansion of a large infarct scar and subsequent regional ventricular dilatation can cause postinfarct remodelling, leading to significant enlargement of the left ventricular chamber. It has a negative prognostic value, because it precedes the clinical manifestations of heart failure. The characteristics of the infarcted myocardium predicting postinfarct remodelling can be studied with cardiac magnetic resonance and experimental imaging modalities such as diffusion tensor imaging can identify the changes in the architecture of myocardial fibers. This review discusses all the aspects related to postinfarct left ventricular remodelling: definition, pathogenesis, diagnosis, consequences, and available therapies, together with experimental interventions that show promising results against postinfarct remodelling and heart failure.

Staged Left Ventricular Recruitment and Biventricular Conversion for Patients With Borderline Left Heart

A borderline left heart may be present in patients with hypoplastic left heart syndrome or an unbalanced atrioventricular canal defect. Traditionally, such patients have been managed either by high-risk biventricular repair in infancy or during the neonatal period, or by definitive single-ventricle palliation. In this article, we present an approach for staged left ventricular recruitment that promotes gradual rehabilitation of left heart structures and allows delay in the commitment to either a single-ventricle pathway or a biventricular pathway. The rationale, techniques, and early results are described.

Submandibular Salivary Sialolith: A Case Report with Review of Literature

Sialolithiasis is a condition characterized by the obstruction of a salivary gland or its excretory duct due to the formation of calcareous concretions, resulting in salivary ectasia and subsequent dilatation of the salivary gland. The majority of sialoliths occurs in the submandibular gland or its duct and is a common cause of acute and chronic infections. Majority of salivary stones are less symptomatic or cause minimal discomfort but the larger stones may interfere with the flow of saliva and cause pain and swelling. Sialoliths are calcified organic matter that is formed within the secretory system of the major salivary glands. Salivary gland calculi account for the most common disease of the salivary glands, and may range from tiny particles to several centimeters in length. This case report describes a patient presenting with submandibular gland sialolith

Male Paraurethral Duct Infection and Subsequent Paraurethral Duct Dilation

To the Editor: Only a small amount of studies were reported about paraurethral duct infection in males.[123] To investigate the pathogens causing paraurethral duct infection and the secondary paraurethral duct dilation in males, and to understand the clinical characteristics and treatment options in paraurethral duct dilation, we retrospectively analyzed the data of male patients with paraurethral duct infection and subsequent paraurethral duct dilation who were treated at the Department of Dermatology of Changshu First People's Hospital from January 2000 to October 2013. Twenty-three patients (age range, 17–65 years; mean age, 31.5 years) with paraurethral duct infection and subsequent paraurethral duct dilation were enrolled in this study. All were presented with erythematous swelling of the external urethral orifice with a pinhead-like ostium at the center of the swollen area, through which pus could be expressed with pressure. The mean duration of paraurethral duct infection symptoms was 17 days (range: 9–39 days). All lesions were solitary. All the patients experienced tenderness, and 17 felt spontaneous pain. Among the purulent excretion specimens from the patients’ paraurethral ducts, 10 had detectable gonococci, 6 had Staphylococcus aureus, 5 had Chlamydia trachomatis, and 2 had Escherichia coli. Rapid plasma reagin test, Treponema pallidum hemagglutination assay, and human immunodeficiency virus antibody test results were also negative in all the patients. Patients with gonococcal infection were given intramuscular ceftriaxone sodium (1 g once daily for 5 days). Patients with S. aureus infection were treated with levofloxacin (0.5 g once daily for 8 days). Patients with C. trachomatis infection were treated with azithromycin (0.5 g once daily for 5 days). Patients with E. coli infection were treated with nitrofurantoin (0.1 g 3 times a day for 10 days). Re-evaluation was performed after 6 weeks and results showed that erythematous swelling of the external urethral orifice and the purulent excretion from the ostium were eliminated. However, the ostium did not close and transparent liquid could be expressed with pressure [Figure 1a and b]. None of the patients felt pain or had tenderness.Figure 1: (a) A pinhead-like ostium was present at the 8 o’clock position on the right side of the external urethral orifice. (b) The ostium did not close, and an overflow of transparent liquid was still visible after squeezing the lesion.The discharge from paraurethral duct was re-collected for Gram-staining. The discharge results were negative for trichomonads and Gram-negative diplococci were not visible within phagocytes, direct microscopic fungi tests were negative, and cultures for general bacteria, gonococci, Ureaplasma urealyticum, and fungi showed negative results. Fluorescence quantitative polymerase chain reaction for the DNA of gonococci, C. trachomatis, U. urealyticum, and herpes simplex virus types 1 and 2 also yielded negative results. All lesions were examined using an ultrasound system (ACUSON X300®, Siemens, Erlangen, Germany) with a probe frequency of 7.5–10.0 MHz. All patients’ examinations showed a tubular hypoechoic area with well-defined borders and smooth margins. One end was blind and the other was open to the environment. The mean lumen diameter was 1.1 ± 0.1 mm (range: 0.96–1.4 mm), and the mean length was 8.2 ± 0.8 mm (range: 7.1–11.7 mm). Thirteen patients were elected to undergo surgical treatment. Wedge excision was performed to remove the lesion. Postoperative histopathological examination revealed a tubular structure in the dermis connected to the epidermis and lined with stratified squamous epithelium. The peripheral stroma was fibrous and infiltrated by inflammatory cells. In all the 13 patients, the ostium had disappeared at 6-month follow-up and the glans penis showed no defects. Ten patients did not undergo excision; their lesions did not resolve over 6 months, and there continued to be a discharge of transparent liquid from the ostium with pressure. The male paraurethral duct is lined with columnar epithelium.[4] However, postoperative pathological examination in the current study showed that paraurethral ducts were all lined with squamous epithelium, and it is possible that the columnar epithelium had been destroyed by pathogens and replaced by squamous epithelium.[4] The present study showed that in addition to gonococci, S. aureus, C. trachomatis, and E. coli also infected the paraurethral duct and caused secondary paraurethral duct dilation. In the present study, two patients infected with E. coli had a history of anal intercourse before symptom onset. E. coli that had colonized the intestinal tract might have been transferred to the paraurethral ducts by anal intercourse and caused paraurethral duct infection. We consider local excision[1] to be a reasonable treatment strategy if the patient finds the symptoms distressing or if the dilated paraurethral duct is persistently infected. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Abstract 17543: The Chicken or the Eggs? Examining the Causal Relationship Between the Development of Atrioventricular Valve Regurgitation and Ventricular Dysfunction in Patients With Functionally Single-Ventricle Physiology

Introduction: Development of atrioventricular valve regurgitation (AVVR) with or without ventricular dysfunction (VD) often occurs during the first 6 months of life and has a significant impact on outcomes for single-ventricle patients. Yet, it is not well known whether AVVR causes VD or vice versa. Thus, we sought to identify the timing and causal relationship between AVVR and VD. Methods: Among 156 consecutive single-ventricle patients who had staged palliation (2005- 2012), 28 who had AVV repair at the time of stage II (n=24, 86%) or inter-stage (n=4, 14%) were reviewed. Diagnosis included HLHS in 17 (61%) patients, tricuspid atresia in 2 (7%), and others in 9 (32%). Ventricular morphology was left-dominant in 6 (21%) patients and right-dominant in 22 (79%). AVV morphology included mitral in 6 (21%) patients, tricuspid in 18 (64%), and common in 4 (14%). Serial echocardiograms were reviewed to identify the timing of development of AVVR and/or VD. Results: After stage I palliation, ventricular end-diastolic dimension (VEDD) z-score significantly increased from 4.01 to 5.69 (p<0.01) AVVR (Figure). By the time of stage II palliation, VEDD further increased and subsequent AVV annular dilation occurred, resulting in 23 patients with significant AVVR. None of the patients, however, had significant VD before stage II palliation/AVV repair, but 9 patients developed significant VD after AVV repair. Conclusions: Ventricular dilation occurred immediately after stage I palliation and continued until stage II palliation. Secondary annular dilation occurred inter-stage and this further triggered the development of AVVR. Tangible ventricular dysfunction was not seen before AVV repair, however, important ventricular dysfunction was unmasked after volume unloading surgery. Heart failure management and early intervention to significant AVVR may reduce the incidence of ventricular dysfunction following AVV repair.

Therapeutic effects of uterine artery embolisation (UAE) and methotrexate (MTX) conservative therapy used in treatment of cesarean scar pregnancy.

Cesarean scar pregnancy (CSP) is a rare and severe complication after cesarean section. The incidence of CSP has been increased significantly in recent years. In this retrospective case study of 131 CSP patients, the therapeutic effects and prognosis were compared between the two treatment groups: uterine artery embolization and systemic methotrexate injection conservative therapy. In addition, the necessary of subsequent dilation and curettage as a further treatment was also evaluated. The 131 CSP patients were assigned into two groups receiving uterine artery embolization (UAE) or MTX conservative therapy. Based on patients' myometrial thickness and reducing degree of β-hCG level, each of the two treatment group was further divided into two subgroups according to whether the patient received subsequent dilation and curettage as further treatment. The therapeutic effect of two treatment groups was compared. The results indicated that both UAE and MTX conservative treatment achieved the expected therapeutic effect, and the recovery time in dilation and curettage subgroup was significantly shorter than that of the non-curettage subgroup. One hundred and thirty patients resumed normal menstrual cycles within 3-10 months after the treatment. The individualized therapeutic regimen is an important factor to achieve the desired therapeutic effect based on the specific indications. Dilation and curettage could shorten the recovery time significantly.

Bypass and embolization for a vertebral artery aneurysm in a patient with Marfan syndrome.

Extracranial vertebral artery aneurysms represent an uncommon presentation of collagen vascular disease. We performed staged proximal embolization of large left vertebral artery aneurysm after distal common carotid-to-vertebral bypass at C2 in a young adult patient with Marfan syndrome and a hypoplastic contralateral vertebral artery. Dilation of the autogenous saphenous vein graft occurred at 1 year with proximal graft stenosis requiring operative revision. Subsequent dilation of the basilar artery led to symptoms of pontine compression at 18 months that have resolved at 31 months of follow-up.

Incidence and predictors of severe acute esophagitis and subsequent esophageal stricture in patients treated with accelerated hyperfractionated chemoradiation for limited-stage small cell lung cancer

PurposeClinical and dosimetric predictors of severe (grade 3 or greater) acute esophageal toxicity and subsequent esophageal dilation were explored in patients with limited-stage small cell lung cancer treated with accelerated hyperfractionated chemoradiation. Methods and materialsA total of 130 patients were identified who were treated to 45 Gy in 1.5-Gy twice-daily fractions with concurrent platinum-based chemotherapy between 2000 and 2009. Data on clinical, disease-related, and treatment-related variables were collected. Patients with percutaneous endoscopic gastrostomy tube insertion or intravenous hydration because of poor oral intake were designated as having acute grade 3 esophagitis. Univariate and multivariate analyses that associated treatment characteristics with esophagitis were assessed via logistic regression, and optimal cut points were identified with recursive partitioning analysis. ResultsTwenty-five patients developed severe acute esophagitis, at a rate of 26% (18/69) in patients treated with earlier 3-dimensional conformal radiation therapy techniques and 11.5% (7/61) in patients treated with intensity modulated radiation therapy techniques and omission of elective nodal irradiation. The incidence of esophageal stricture was 6% overall (8 of 128 eligible) but 26% (6/23) among those who experienced prior grade 3 acute esophagitis and 2% (2/105) among those with acute esophagitis less than or equal to grade 2. Significant multivariate predictors of acute esophagitis were mean dose and volume of esophagus receiving at least 5% to 35% of the prescribed dose (V5 to V40). Patients with V5 ≥ 74% had a 44.4% risk of severe acute esophagitis (12/27) versus 12.6% (13/103) among those with V5 < 74%. V45 was the only dosimetric predictor for esophageal stricture, with 13.7% of patients in whom V45 was ≥37.5% requiring subsequent dilation. ConclusionsModern radiation techniques are associated with a lower frequency of severe acute esophagitis than previous paradigms. The proportion of esophagus receiving low- to moderate-range doses (mean, V5 through V40) predicts acute esophagitis, whereas the proportion of esophagus that receives high doses (V45) predicts the development of esophageal stricture that requires dilation. Patients who develop grade 3 acute esophagitis are at significant risk for subsequent esophageal stricture, whereas those with acute esophagitis of grade 2 or less display minimal risk.

A Novel Approach to Overcoming Cervical Stenosis and False Passages

Cervical stenosis, and inadvertant creation of a cervical wall defect, is a difficult complication to overcome. This video demonstrates an intraoperative technique to overcome cervical stenosis and creation of a false passage, using hysteroscopic hydrodilation, and vessel dilator over a guide wire. Cervical stenosis, and creation of a cervical stromal tract, during cervical dilation is an infrequent but difficult intraoperative complication to overcome. Preoperative techniques to decrease the risk of this complication have been described, and has proven benefits. Once a false passage has been created, attempts to overcome this complication often results in worsening of the stromal defect, and places the patient at greater risk for perforation at the level of the cervix. This video demonstrates an intraoperative technique to overcome cervical stenosis, and creation of a false passage, using hysteroscopic hydrodilation and a vessel dilator over a guide wire. Hysteroscopic hydrodilation provides adequate distention of both the false passage and endocervical canal, allowing adequate differentiation between the two. This technique also allows proper placement of a guide wire under direct visualization, and subsequent dilation of the obliterated endocervical canal with the vessel dilator. The case presented shows how cervical stenosis and a false passage can be overcome, using a guide wire and vessel dilator, when placed under hysterscopic guidance. These tools are readily available in any operating room.

Management of an 11-week cesarean scar pregnancy

Introduction: cesarean scar pregnancy is a lifethreatening condition, especially in the advanced gestational age. Optimal management has not yet been established because this is a rare condition. case report: A 30-year-old female, with a previous cesarean, diagnosed with a viable cesarean scar pregnancy with 11 weeks of gestation. successful termination of cesarean scar pregnancy was achieved with systemic and local (ultrasoundguided) methotrexate administration with subsequent dilatation and evacuation, under ultrasound guidance, in a two- stage procedure: rupture of the amniotic sac with partial removal of the fetus and one week later total evacuation of uterine content, with satisfactory hemostasis. conclusion: cesarean scar pregnancy is associated with a high morbidity and adverse consequences for future fertility. there is no optimal management established, because of the rarity of the condition. We present a case of successful termination of an advanced first trimester cesarean scar pregnancy.

Undermining and Ballooning the Proximal Part of the Left Main Coronary Artery Stent Resulting in an Iatrogenic Stent Deformation

We present a case of a 52-year-old woman with iatrogenic stent deformation occurred after deployment of the left main (LM) stent due to the unintentional undermining of the proximal part of the LM stent with subsequent balloon dilatation. We tried to crush the deformed part of the LM stent against the left coronary cusp by pushing it with a guiding catheter.

Fusion Fore Dilation by Snare Proteins

Hormones and neurotransmitters are released through exocytotic fusion pores (FPs) that can flicker open and shut multiple times, fluctuate in conductance, and either dilate or reseal irreversibly. FP properties determine the size and the amount of cargo released, and the time course of release, which modulate downstream effects. Fusion is driven by formation of a four-helix complex between the neuronal/exocytotic vesicle-associated v-SNARE VAMP2/synaptobrevin-2 (VAMP2) and its cognate plasma-membrane t-SNARE partner composed of syntaxin-1 and SNAP25. Pore nucleation requires zippering between the v- and t-SNAREs, but what molecular factors govern the subsequent pore dilation is not understood. Here, using conductance measurements across voltage-clamped single FPs we show that multiple SNARE proteins cooperate to dilate metastable FPs. We isolated flickering fusion pores in a biochemically defined assay where v-SNARE-reconstituted bilayer nanodiscs (vNDs) fuse with cells ectopically expressing cognate, “flipped” t-SNAREs. Using newly developed, large NDs that are 21-27 nm in diameter, we varied v-SNARE copy numbers from zero to up to 11 per ND face. Pore nucleation required a minimum of 2, and reached a maximum above ∼4 copies per face, but the probability of pore dilation was far from saturating at 11 copies, the maximum that the NDs could hold per face. Our results indicate that copy numbers of available SNAREs may be pivotal in determining whether neurotransmitters or hormones are released through a transient (kiss & run) or an irreversibly dilating pore (full fusion) and provide a rationale as to why synaptic vesicles carrying 70 copies of v-SNAREs dock onto sites where as many t-SNAREs are clustered while only a few SNARE complexes are apparently enough to achieve fusion.

Marfan syndrome with a giant noncoronary sinus of Valsalva aneurysm.

Once presented in 2011 by Dayi SU et al. our case is a 30-year-old woman with Marfan syndrome who had undergone aortic valve replacement due to severe aortic regurgitation secondary to dilatation of the aortic root in 2000 and supracoronary aortic replacement due to Stanford type A dissection in 2002 with subsequent dilatation of sinus of Valsalva. When described by Dayi SU et al. the size of the aneurysm was noted to be 6x6.5x6.5 cm in dimensions and it was formed from noncoronary sinus of Valsalva. At this time conservative followup was found to be the appropriate therapy because high risk of redo surgery. Three years later the same patient was observed in echocardiography laboratory with a rapid progression of the same aneurysm of sinus of Valsalva to 8.3x9.3x8.2 cm in size (Figure 1A). Moderate mitral and tricuspid regurgitation with prolapse of valves and normal function of mechanical aortic valve were observed. Computed tomography angiography also confirmed enlargement of the aneurysm to 91.9x91.8 in size (Figures 1B, C, and D). Herein, we would like to draw attention to the clinical presentation and progression of Marfan syndrome.

Antegrade ureteroscopic assistance during percutaneous nephrolithotomy for complete renal staghorn stone: Technique and outcomes

ObjectiveTo describe the technique and outcomes of antegrade ureteroscopic assistance during the initial nephrostomy access for the management of renal staghorn stone. Materials and methodsFrom 2000 to 2009, a total of 153 patients with complete staghorn stones were treated with percutaneous nephrolithotomy (PCNL) at our hospital. Antegrade ureteroscopic assistance was applied, starting in the 50th patient, during the initial nephrostomy access so as to prevent the creation of a false tract and to create more intracalyceal space for subsequent tract dilation. We report the characteristics of the patients, stones, treatment outcomes, and complications in the groups with and without antegrade ureteroscopic assistance. ResultsIntergroup differences in the groups with (n = 104) and without (n = 49) antegrade ureteroscopic assistance with regard to the patients' characteristics and stone surface areas were not significant (24.0 ± 18.1 cm2 versus 21.8 ± 11.8 cm2). Patients who underwent PCNL with antegrade ureteroscopic assistance required a significantly shorter operation time and hospital stay than those who underwent PCNL without antegrade ureteroscopic assistance (143 ± 78 minutes versus 105 ± 35 minutes, p < 0.0001; 5.4 ± 2.9 days versus 4.3 ± 2.2 days, p = 0.009, unpaired t test). Furthermore, intergroup differences with regard to the stone-free rate, transfusion rate, and incidence of postoperative urosepsis were not statistically significant (p = 0.67, p = 0.18, and p = 0.75, respectively). ConclusionSuch an ancillary procedure might be suitable for the management of complete staghorn stones or other complex renal stones in patients in whom adequate intracalyceal space was not available for the creation of nephrostomy access.

Foreign Body Ingestion Masquerading as Crohn’s Disease

Introduction: A 48-year-old woman presents to clinic with chronic lower abdominal pain for 2 years. The pain described as severe and cramping, aggravated by eating food, stress and activity. There was also some associated loose stool. She further revealed having frequent epigastric burning, which she attributed to GERD. She never had a colonoscopy. Her history included ingestion of a quarter when she was 6 years old. It was assumed this had passed. She eventually underwent laparoscopy for these chronic GI symptoms 42 years later. The surgeon noted the presence of creeping fat mesentery in terminal ileum and she was labeled with a diagnosis of “Crohn’s disease.” A quarter was removed from her terminal ileum at that time. She was referred to GI clinic in order to further consider a diagnosis of Crohn’s. Her colonoscopy revealed stenosis in the terminal ileum with no inflammation in this area. Upper GI endoscopy showed mild gastritis. Biopsies from the stenotic region revealed normal findings. There was no evidence of IBD. Subsequent dilatation of the stricture was performed endoscopically after which her symptoms greatly improved. We report a case of foreign body ingestion, which after many years presented with abdominal pain and loose stool, with laparoscopic findings of creeping fat mesentery in the terminal ileum. There are few other reported cases in which foreign body ingestion chronically resulted in findings that mimic Crohn’s disease. To our knowledge, this is the first case in which foreign body ingestion has led to creeping fat mesentery in the terminal ileum. Moreover, this is a chronic case of foreign body ingestion with presentation after several decades. Crohn’s disease is an idiopathic, chronic inflammatory process of the GI tract that can affect any part of the GI system - from the mouth to the anus; however, the terminal ileum is involved in 70% of cases. The phenomenon of creeping fat in Crohn’s disease characterized by hypertrophy of mesenteric fat surrounding inflamed intestinal segments, and was first described by Burrill Crohn himself. Non-caseating granulomas are also a hallmark of Crohn’s disease, yet the absence of granulomas does not disqualify a diagnosis of Crohn’s disease. Upper and lower GI endoscopies are indispensable in diagnosing Crohn’s disease and differentiating it from foreign body ingestion. Endoscopies provide a direct visualization of the alimentary tract and help us take biopsies for histopathological confirmation. Other tests such as plain film and US are usually performed, but are of limited significance in differentiating Crohn’s from foreign body ingestion. Prognosis is good after removal of foreign body.

Technique of Percutaneous Direct Needle Puncture of Calcified Plaque in the Superficial Femoral Artery or Tibial Artery to Facilitate Balloon Catheter Passage and Balloon Dilation of Calcified Lesions

Heavy calcified arterial lesions are challenging to endovascular treatment. Even if a guide wire passes the lesion, calcified plaque can inhibit passage or dilation of the balloon catheter. We developed a novel technique of percutaneous direct needle puncture of calcified plaque (PIERCE) to allow subsequent passage and dilation of the balloon. PIERCE was performed in three patients with superficial femoral artery (SFA) lesions and one patient with a tibial artery lesion. In all four cases, balloon passage and lesion dilatation were achieved. Minor hemorrhage from the punctured site occurred in two patients with SFA lesions, which resolved with stent placement.

True Lumen Stenting for a Spontaneously Dissected Superior Mesenteric Artery May Compromise Major Intestinal Branches and Aggravate Bowel Ischemia

Optimal endovascular therapy for isolated superior mesenteric artery (SMA) dissection remains undetermined. Here, we report a 56-year-old male with ischemic bowel syndrome caused by such a serious vascular disease. He was treated with endovascular true lumen stenting yet got aggravated in bowel ischemia from unexpected jail of major intestinal branches perfused by the false lumen, requiring subsequent complex rewiring and dilatation procedures to resolve at the cost of excessive fluoroscopic and contrast medium exposure. Thus, when treating patients with isolated SMA dissection with a functioning false lumen, true lumen stenting may inadvertently compromise crucial intestinal branches and should not be indiscriminately considered as the prime therapeutic option.

A Rare Cause of Mirizziʼs Syndrome: Cholangiocarcinoma

Introduction: Elevated liver function tests are the most common reason for consultation to a hepatology service, the etiologies of which are varied but most commonly are due to viral hepatitis, toxic, and ischemic injuries. Obstruction due to biliary stones are also a common etiology as well, but we present a more rare case of biliary obstruction that resulted in elevated liver function tests and has a higher incidence of carcinoma. Case Report: A 48-year-old female with no past medical history presents with 1-month history of gradual yellowing of her eyes and skin. Also noted decreased appetite, increasing pruritis, and some subjective weight loss. She denied any abdominal pain, nausea, vomiting, signs of gastrointestinal bleeding, fevers, or chills. She has never experienced this prior. On exam, her vital signs were normal but she had overt jaundice as well as scleral icterus. She had mild tenderness to palpation in the right upper quadrant but negative Murphy's sign. Admission labs revealed a total bilirubin of 14.1 with a direct bilirubin of 10.3. Her AST and ALT were elevated to 112 and 78, respectively, as well as an alkaline phosphatase elevation to 308. Her amylase and lipase were mildly elevated to 146 and 168, respectively. Workup included negative hepatitis serologies and autoimmune panel among other tests. An MRCP was performed which showed a large obstructing cystic duct stone compressing against the common bile duct (CBD) with subsequent biliary tree dilation. An ERCP was performed which confirmed these findings and a CBD stent was placed with effective biliary drainage. She subsequently went for a cholecystectomy. However, 1 month later she presented again with weight loss and jaundice, and was subsequently diagnosed with cholangiocarcinoma after ERCP and further surgical evaluation. Discussion: Mirizzi's syndrome is a rare disorder for which the indication for cholecystectomy is <1%. It is characterized by two different classifications (Csendes or McSherry) based on the presence of and the extent of a cholecystocholedochal fistula. The diagnosis can be made preoperatively with MRCP or ERCP, but often they are diagnosed intraoperatively. The ultimate treatment is surgical cholecystectomy but an ERCP with stent placement can be a temporizing measure. One lesser known association of Mirizzi's syndrome is that there is a higher incidence of gallbladder carcinoma; in one study up to 27%. Thus it is imperative to send the specimen for pathology to evaluate for malignancy and to also expedite any cases of Mirizzi's syndrome for surgical resection. To date, we report the only case of Mirizzi's syndrome associated with cholangiocarcinoma.

Role of the femorofemoral crossover graft in acute lower limb ischemia due to acute type B aortic dissection

Acute limb ischemia due to type B aortic dissection is rare and continues to be a management challenge. A case series is presented here with the aim of assessing the outcomes of treatment with a femorofemoral crossover graft with or without thoracic stent graft insertion. This is a combined retrospective and prospective review of nine cases of acute lower limb ischemia secondary to acute type B aortic dissection. The presenting features, radiological findings, treatment and outcomes were reviewed. Five patients had a femorofemoral crossover graft (FFXO) alone, two an FFXO with a thoracic stent graft and the eighth a thoracic and iliac stent. The other case was initially treated conservatively but subsequently required an FFXO. The mean follow-up was 16 (3-51) months. A further two thoracic stents were placed during the follow-up period. Thus five out of nine patients (56%) required aortic stenting. This series suggests that an FFXO is a reliable treatment for acute limb ischemia due to type B aortic dissection. However, these patients are often complex with ischemia in other vascular beds and are at risk of subsequent aneurysmal dilation.