Subtotal Obstruction Research Articles

Long-term efficacy of drug-coated balloon-only angioplasty for IgG4-related coronary artery disease: A case report

Abstract Background Although coronary artery involvement in patients with IgG4-related disease (IgG4-RD) is rare, emergency revascularisation is recommended for managing acute coronary syndrome. However, coronary aneurysm formation and stent migration after sirolimus-eluting stent implantation have been reported for this disease. Thus, new treatment modalities are warranted for the management of coronary artery disease in this vasculitis. Case summary A 70-year-old male who experienced progressive chest discomfort for 1 month underwent cardiac examination. Coronary computed tomography angiography (CCTA) revealed right coronary artery hypoplasia, coronary artery aneurysm with severely calcified stenosis in the proximal left anterior descending artery (LAD), and subtotal obstruction in the mid-LAD. The left circumflex artery (LCX) also had stenosis and dilated lesions. Additionally, diffuse perivascular soft tissue thickening was observed in the mid-LCX. Percutaneous coronary intervention was performed for the proximal- and mid-LAD lesions. Rotational atherectomy with low-pressure drug-coated balloon (DCB) dilation was considered for these lesions owing to suspicion of vasculitis. The patient was later diagnosed with Sjögren's syndrome and IgG4-RD overlap syndrome. Oral steroids and immunosuppressive drugs were initiated. In a follow-up at 7 and 26 months, late lumen enlargement was observed in the treated area of the LAD, without enlargement of the adjacent aneurysm. CCTA performed after 26 months revealed resolution of the diffuse perivascular soft tissue thickening in the mid-LCX. Discussion To our knowledge, this is the first case report demonstrating favourable outcomes for treatment of a coronary artery lesion attributed to IgG4-RD with DCB, leaving nothing implanted in the coronary artery tree.

Subtotal Thrombosis of the Left Pulmonary Artery Trunk as a Complication of COVID-19: a Clinical Case

The article describes a clinical case of a 62-year-old patient infected with SARS-CoV-2, in whom, 15 days after the onset of symptoms of COVID-19 with lung damage, chest computed tomography with contrast revealed concurrent subtotal obstruction of the pulmonary artery trunk and defects of its branches filling due to blood clots formed in situ. Against the background of anticoagulant therapy for 13 days, blood clots resolved in both central and peripheral parts of the lung venous bed.

Laparoscopic therapy for Mirizzi syndrome: A case report with review of literature

Mirizzi syndrome (MS) is a rare entity and is due to extrinsic biliary compression. It is a rare complication of cholecystitis and chronic cholelithiasis. The impacted calculi at the infundibulum of the gall bladder or cystic duct lead to compression of the adjacent biliary structures, resulting in total or subtotal obstruction of the common hepatic duct (CHD). This leads to liver dysfunction. We, herein, present one such case of a 50-year-old female patient who was diagnosed to have MS. During surgery, at laparoscopy, she was unexpectedly also found to have a cholecysto-duodenal fistula. Both conditions were successfully treated laparoscopically.

Subtotal obstruction of the left coronary ostium by chronic neo-intimal ingrowth.

Subtotal obstruction of the left coronary ostium by chronic neo-intimal ingrowth.

Lifethreatening tracheal obstruction in a child caused by nodular fasciitis: case presentation

BackgroundNodular fasciitis (NF) is a rare non-neoplastic inflammatory tumor and usually presents as a painless, rapidly growing subcutaneous soft tissue mass. The head and neck are relatively common locations for nodular fasciitis, particularly in children. NF in the trachea is rare and may evolve to a fatal condition, especially due to its rapidly growing nature that can cause life-threatening tracheal obstruction.Case presentationWe report the case of a 5-year-old child with NF in the trachea and subtotal tracheal obstruction. Bronchoscopy and biopsy proved the diagnosis, and bronchoscopic excision of the tumor was performed.ConclusionsNF is a rare airway tumor, occurring mostly in adults, and may presenting with pneumonia-like symptoms. Early detection of the lesion is essential to avoid life-threatening airway obstruction.

Coronary artery involvement in chronic graft‐versus‐host disease presenting as sudden cardiac arrest

Graft-versus-host disease (GVHD) is related to considerable morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Cardiac complications associated with GVHD are uncommon, and coronary artery involvement is even more unusual. We report on a male pediatric patient with chronic GVHD who developed a fatal ventricular arrhythmia caused by coronary artery obstruction after HSCT. At 30months after HSCT, he suddenly collapsed with ventricular fibrillation. After resuscitation, electrocardiography showed abnormal q-wave and ST changes in the inferior leads, suggesting a coronary event. Coronary angiography revealed complete obstruction of the proximal left anterior descending artery, subtotal obstruction of the mid left circumflex artery, and mild narrowing at the right coronary artery. This boy had none of the risk factors for coronary artery disease, and the only possible explanation for the cardiac event is GVHD. Coronary artery disease only rarely occurs as a cardiac event in children. However, coronary artery involvement should be recognized as one of the important manifestations of chronic GVHD in children.

Invasive inflammatory fibroid polyp of the stomach: a case report and literature review

BackgroundInflammatory fibroid polyps (IFPs) are rare mesenchymal lesions that affect the gastrointestinal tract. IFPs are generally considered benign, noninvasive lesions; however, we report a case of an invasive gastric IFP. To the best of our knowledge, this is only the second case report of an invasive gastric IFP.Case presentationA 62-year-old woman presented with complaints of epigastric pain and vomiting. Computed tomography showed a 27-mm, hyper-enhancing tumor in the prepyloric antrum. Upper endoscopy also showed a submucosal tumor causing subtotal obstruction of the gastric outlet. Because a gastrointestinal stromal tumor was suspected, distal gastrectomy was performed. Histopathological examination revealed spindle cell proliferation in the submucosal layer. The spindle cells had invaded the muscularis propria layer and extended to the subserosal layer. The tumor was finally diagnosed as an IFP based on immunohistochemical findings. No mutations were identified in the platelet-derived growth factor receptor alpha (PDGFRA) gene via molecular genetic analysis.Discussion and conclusionsAfter the discovery that IFPs often harbor PDGFRA mutations, these growths have been considered neoplastic lesions rather than reactive lesions. Based on the present case, IFPs might be considered not only neoplastic but also potentially invasive lesions.

Differentiation of chronic total occlusion and subtotal occlusion of the femoropopliteal artery—role of retrograde flow sign and collateral circulation on CT angiography images

Objective:To study the value of a retrograde flow sign and the collateral circulation on CT angiography (CTA) for the differential diagnosis of chronic total occlusion from subtotal occlusion of the femoropopliteal artery (FPA).50 patients with obstruction of the FPA underwent CTA and digital subtraction angiography examinations of the lower limbs. The frequency of a retrograde flow sign and collateral circulation on CTA in chronic total and subtotal occlusion was noted and analyzed, with the results of digital subtraction angiography as a standard to judge total or subtotal occlusion. The decreasing CT value from the distal to proximal direction on CTA suggests the existence of retrograde flow.Results:There were significant differences in the occurrence rates of a retrograde flow sign on CTA in the chronic total and subtotal obstruction groups (X2 = 13.1, p < 0.05), as well as a collateral circulation sign (X2 = 13.5, p < 0.05). Employing both the retrograde flow sign and the collateral circulation sign to diagnose chronic total obstruction of the FPA had a sensitivity of 92.3% and specificity of 89.8%.Conclusion:The retrograde flow sign combined with a collateral circulation sign is of great clinical value for differentiation of chronic total stenosis from severe stenosis (subtotal occlusion) of the FPA.Advances in knowledge:A retrograde flow sign combined with a collateral circulation sign is of great clinical value to differentiate between chronic total stenosis and severe stenosis (subtotal occlusion) of the FPA.

Cardiac transplantation in a neonate-First case in Switzerland and European overview

Twenty-four percent of pediatric heart transplantations (pHTx) are carried out in infants. Neonatal heart transplantation is both rarely performed and challenging. We report on a newborn baby girl suffering from cardiac failure due to a huge tumor (24×52mm) within the free wall of the left ventricle (LV) and subtotal obstruction of the main left bronchus. Following a surgical tumor resection, a Berlin Heart EXCOR left ventricular assist device was implanted as the bridge to the transplantation. In spite of an organ donor/recipient mismatch of >200%, both heart transplantation and the postoperative course were successful. In addition to this case report, the authors also present data from a survey on performed infant and neonatal transplantations in Western Europe. As neonatal heart transplantation is a rare event in Europe, the authors think it is of crucial importance to share this limited experience. We discuss an alternative strategy-namely, palliative surgical correction using the Fontan pathway. The challenges of donor/recipient weight mismatch and the possibilities of overcoming infant donor organ shortage as a postoperative immunosuppressive regimen are discussed as well.

Effect of Individualized Bladder Rehabilitation Program in Patients with Neurogenic Lower Urinary Tract Dysfunction, a Pilot Study

Objectives: Neurogenic lower urinary tract dysfunction (NLUTD) is one of the major sequelae after spinal cord injury (SCI) and a cause of increased morbidity and mortality in SCI patients. Current treatment strategies for NLUTD include medication, non-invasive conservative management, minimally invasive therapy, and surgical intervention. However, there are no studies regarding non-invasive conservative management that combines pelvic floor muscle (PFM) exercises and electrical stimulation (ES). This study was designed to evaluate the efficacy of individualized bladder rehabilitation programs, which included education on voiding behavior, PFM exercise training combined with electromyography (EMG) biofeedback, and ES (for bladder inhibition or PFM strengthening), in SCI patients with NLUTD. Methods: Individualized bladder rehabilitation programs were provided for 2 months for patients with incomplete SCI at the suprasacral level or cauda equina syndrome. The patients were evaluated using post-voiding residual urine (PVR) amounts and the questionnaires of the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), Urogenital Distress Inventory-6 (UDI-6), and Incontinence Impact Questionnaire-7 (IIQ-7). Results: After the individualized bladder rehabilitation programs, the post-voiding residual urine amounts; OABSS, UDI-6, and IIQ-7 scores; and subtotal incontinence score and quality of life (QOL) scores of the IPSS all decreased significantly. These results indicate an improved quality of life and fewer symptoms. However, the changes in the subtotal obstruction score and the total symptom score of the IPSS were not significant. Conclusion: Selected SCI patients with NLUTD could benefit from individualized bladder rehabilitation programs, which include education on voiding behavior, PFM exercises combined with EMG biofeedback, and ES for bladder inhibition or PFM strengthening. Patients who received bladder rehabilitation programs obtained beneficial effects on reducing PVR amounts and QOL scores related to incontinence.

0343: Obstructive cardiac tumor in Hodgkin’s lymphoma: course of cardiac involvement under emergency chemotherapy

Cardiac involvement in Hodgkin’s disease (HD) is one of the least investigated subjects in cardiac oncology. Emergency chemotherapy is a rare necessity in Hodgkin’s disease, but life-threatening cardiac involvement is possible, compromising hemodynamic stability. We report a case of Hodgkin’s lymphoma which presented with acute obstructive left heart failure. It is about a 37 years old patient treated in 2000 for HD, type3, stage IVB medullar by chemotherapy (4MOPP+ABVD) followed by radiotherapy, and judged in complete remission. Few months ago, the patient presents a cardiac relapse, echocardiography revealed an enormous left atrial mass inducing a subtotal mitral obstruction confirmed by the tomodensitomety. After a multidisciplinary concertation we used the CEOP protocol (cyclophosphamide 650 mg/m 2 , etoposid100 mg/m 2 , oncovin 1,4 mg/m 2 , prednisone, 40 mg/m 2 ) associated to the conventional heart failure treatement. Under chemotherapy the evolution was favourable with amelioration of symptoms strengthen by regression of cardiac mass gradually in the weekly echocardiography checking after 4 cures. HD is not a steroid-sensitive disease, no single drug is rapidly efficient, and no recommendation is available in the literature regarding urgent cytoreduction. Therefore, if a decision for emergency chemotherapy is made, an aggressive combination may be recommended. In addition, newer agents resulting in improved cancer therapy outcomes might alter the prevalence and location of metastatic deposits to include more unusual disease sites, including intracardiac locations. Lymphomatous involvement of the heart, previously a rarity, is now being reported with greater frequency. The increased incidence might be partly a result of increased clinical awareness, improved imaging techniques. Adaptative chemotherapy can successfully improve the long term outcome of these patients.

Congenital sub-total IVC obstruction and rheumatic severe mitral stenosis-treated percutaneously in a single stage procedure using the same hardware

We report a rare case of a 25-year old female with rheumatic mitral stenosis (MS) with incidentally picked up asymptomatic near complete congenital inferior vena cava (IVC) obstruction. The IVC obstruction made the performance of percutaneous transvenous mitral commissurotomy (PTMC) from the femoral vein approach difficult.The patient subsequently underwent successful PTMC by Inoue technique from the femoral vein access followed by balloon dilatation of membranous obstruction of IVC simultaneously using same hardware. The outcome of the procedure was successful and the patient was discharged in stable condition which has been maintained during the course of follow up.This case is unique in the performance of PTMC and IVC dilatation in the same setting using the same hardware from the femoral vein approach irrespective of the hindrance caused by the IVC obstruction in the performance of PTMC through this approach. There have been case reports of successful IVC stenting for venous web but the combination of these two illnesses is relatively rare occurrence and the performance of both the procedures simultaneously using an Inoue balloon is unique and this report imparts confidence to interventionists for performance of successful PTMC even in cases with critical stenosis of the inferior vena cava and that the two procedures can be completed simultaneously in the same sitting in a cost effective way.

Enteral stents: from esophagus to colon

Because of significant advances in endoscopic techniques and the development of high-quality stents, endoscopic enteral stent placement is increasingly being performed for the management of malignant GI obstruction. Palliative stenting is now routinely performed for malignant esophageal, gastric, duodenal, and colon obstruction. In addition to palliative indications, preoperative stenting in the colon may be performed as a bridge to surgery to achieve immediate decompression and convert an emergent surgery into an elective, 1-stage procedure.The realm of enteral stenting has recently expanded to include management of benign conditions such as leaks, fistulas, and benign strictures in the GI tract. Further research is required to study the use of enteral stents in benign conditions and to adequately compare endoscopic stent placement with surgical intervention. Promising new technologies such as biodegradable stents and drug-eluting stents also require further investigation. With continued innovation in endoscopic techniques and stenting devices, the field of enteral stenting is likely to expand further, with an increase in indications and improvement in outcomes.

Coronary vasomotor response to intracoronary acetylcholine injection, clinical features, and long-term prognosis in 873 consecutive patients with coronary spasm: analysis of a single-center study over 20 years.

BackgroundThe aim of this study was to elucidate the correlation between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection, clinical features, and long‐term prognosis in patients with vasospastic angina (VSA).Methods and ResultsThis is a retrospective, observational, single‐center study of 1877 consecutive patients who underwent ACh‐provocation test between January 1991 and December 2010. ACh‐provoked coronary spasm was observed in 873 of 1637 patients included in the present analysis. ACh‐positive patients were more likely to be older male smokers with dyslipidemia, to have a family history of ischemic heart disease, and to have a comorbidity of coronary epicardial stenosis than were ACh‐negative patients. ACh‐positive patients were divided into 2 groups: those with focal (total or subtotal obstruction, n=511) and those with diffuse (severe diffuse vasoconstriction, n=362) spasm patterns. Multivariable logistic regression analysis identified female sex and low comorbidity of coronary epicardial stenosis to correlate with the ACh‐provoked diffuse spasm pattern in patients with VSA. Kaplan–Meier survival curve indicated better 5‐year survival rates free from major adverse cardiovascular events in patients with diffuse spasm pattern compared with those with focal spasm pattern (P=0.019). Multivariable Cox hazard regression analysis identified diffuse spasm pattern as a negative predictor of major adverse cardiovascular events in patients with VSA.ConclusionsACh‐induced diffuse coronary spasm was frequently observed in female VSA patients free of severe coronary epicardial stenosis and was associated with better prognosis than focal spasm. These results suggest the need to identify the ACh‐provoked coronary spasm subtypes in patients with VSA.

Abstract 9683: Acetylcholine-Provoked Diffuse Coronary Spasm is Frequently Observed in Female Patients with Coronary Vasospastic Angina Without Severe Coronary Organic Stenosis

Coronary Vasospastic angina (VSA) plays an important role in the pathogenesis of ischemic heart disease. However, the relation between angiographic variation of acetylcholine (ACh)-induced coronary spasm and clinical features in VSA patients is not well understood. We analyzed retrospectively angiographic appearance of coronary vasomotor response induced by ACh injection into left coronary artery (LACh) in 1760 consecutive patients who had rest angina-like chest pain between January 1991 and December 2010. Coronary spasm induced by LACh test was defined as a total or subtotal obstruction (focal spasm), or severe diffuse constriction (diffuse spasm) of left epicardial coronary artery associated with transient myocardial ischemia as evidenced by ischemic ST-segment changes on ECG. Of total 1760 patients, 754 (43%) patients were positive for LACh test on the basis of positive criteria (329 diffuse and 425 focal spasm). Patient characteristics were compared between LACh-positive and -negative groups. Rate of smoking, dyslipidemia, family history of ischemic heart disease (IHD), comorbidity of coronary organic stenosis, and myocardial lactate production were significantly higher in LACh-positive than negative groups (49.7% vs. 42.7%, p=0.005, 48.0% vs. 38.1%, p&lt;0.001, 16.2% vs. 9.6%, p&lt;0.001, 26.9% vs. 14.1%, p&lt;0.001, and 60.9% vs. 13.9%, p&lt;0.001, respectively). Next, we analyzed relation between angiographic variation of LACh-provoked coronary spasm and clinical features in VSA patients. Multiple logistic regression analysis revealed that female gender and low comorbidity rate of coronary organic stenosis were significantly associated with diffuse spasm subtype (OR 2.97; 95%CI: 1.90 to 4.66; p&lt;0.001, and OR 0.60; 95%CI: 0.40 to 0.89; p=0.012, respectively). In conclusions, ACh-provoked diffuse coronary spasm was frequently observed in female VSA patients without severe coronary organic stenosis. These results suggested that angiographic subtypes of ACh-provoked coronary spasm might have different clinical features in VSA patients, indicating the necessity of medical treatment suitable for each subtype of the ACh-provoked coronary spasm.

Diagnosis of Abnormal Subclavian Venous Flow by Radionuclide Venography in Patients with Permanent Pacemaker

In this study, we investigated the role of radionuclide venography in the diagnosis of abnormal subclavian venous flow due to the lead in patients (pts) with permanent pacemakers. The study was conducted with 53 frames in 52 asymptomatic pts (26 females, mean age 64.5 +/- 15; range 25-89 years). The mean time after implant was 67.6 +/- 47.5 months. Technetium 99m pertecnetate (250 MBq) was given to both antecubital veins simultaneously. The images were acquired in 0.25-second frames for 20 seconds. The pts were evaluated visually in terms of the activity flow through the subclavian veins bilaterally. The retrograde flow in the jugular vein, decrease in flow rate, and subtotal and total obstruction of the subclavian veins were accepted as abnormal venous flow patterns. In 17 pts with abnormal findings, 10 (58.8%) had retrograde flow in the jugular vein, 4 had (23.5%) decreased flow rate, 1 (5.8%) had subtotal and 2 (11.7%) total obstruction in the subclavian vein. The mean of the body diameter of the leads was significantly greater and the percentage of the silicone-insulated leads was higher (76% vs 52%) in the group with abnormal flow. No complication due to the procedure was seen. In conclusion, radionuclide venography, a noninvasive method, may be used easily and safely to show the venous flow abnormalities due to the lead in pts with permanent pacemakers. The abnormal subclavian venous flow was especially seen in pts who had larger leads.

Delayed subtotal coronary obstruction after transapical aortic valve implantation

We report on an obstruction of the left main coronary artery which occurred after completion of an uneventful transapical aortic valve implantation (TAVI) procedure. This delayed subtotal coronary obstruction was detected by routine final transesophageal echocardiographic examination. Emergency implantation of a coronary stent eliminated myocardial ischemia. This case demonstrated that coronary artery obstruction can occur not only during the TAVI procedure but also some time later. This finding reinforces the idea that these patients must also be carefully evaluated in the early post-procedure period.

Myocardial microvascular function during acute coronary artery stenosis: effect of hypertension and hypercholesterolaemia

Coronary collateral arteries (CCA) reduce cardiovascular events. We tested the hypothesis that new microvessels that proliferate in early atherosclerosis may be associated with myocardial protection during acute subtotal coronary artery obstruction (CAO). Acute left anterior descending CAO was induced by a balloon catheter in pigs after 12 weeks of high-cholesterol (HC) diet, renovascular hypertension (HTN), or normal control. Cardiac structure, myocardial perfusion, and functional response to iv adenosine and CAO were studied in vivo using electron beam computed tomography (CT). The intra-myocardial microvessels were subsequently evaluated ex vivo using micro-CT, and myocardial expression of growth factors using immunoblotting. Basal myocardial perfusion and microvascular permeability were similar among the groups, whereas their responses to adenosine were attenuated in HC and HTN. A significant decline in myocardial perfusion in normal pigs during acute CAO was attenuated in HC and abolished in HTN. CAO also elicited an increase in normal anterior wall microvascular permeability (+202 +/- 59%, P < 0.05), which was attenuated in HC and HTN (+55 +/- 9 and +31 +/- 8%, respectively, P < 0.05 vs. normal). Microvascular (<200 microm) spatial density was significantly elevated in HC and HTN, accompanied by increased myocardial growth factor expression. This study demonstrates that early exposure to the cardiovascular risk factors HC and HTN protects the heart from decreases in myocardial perfusion during acute subtotal CAO. This protective effect is associated with and potentially mediated by pre-emptive development of intra-myocardial microvessels that might serve as recruitable CCA.

Respiratory difficulties encountered during posterior fossa exploration

This report describes an unusual case of obstruction of a reinforced endotracheal tube during posterior Fossa exploration to excise glioma tumor. An 11-year-old male child, scheduled for excision of a glioma in the prone position. The trachea was intubated using a 5.0-mm nylon reinforced latex endotracheal tube (TT). The anesthesiologist ventilated his lungs with a mixture of isoflurane 1.0 MAC in oxygen (35%) and medical air. It was observed that his peak airway pressure was 21 cm H2O at the beginning of anaesthesia, increased to 26 cm H2O over three hours. After that and over 30 min, the peak reached 35 cm H2O, while the end-tidal CO2 pressure was 45 mmHg then gradually increased to 100 mmHg. The anesthesiologists suspected partial obstruction of the tracheal tube (TT). However, the anesthesiologists could not pass a suction catheter through the TT. The anesthesiologist could not advance a suction catheter beyond 8 cm. Re-intubation of the trachea with a 5.5 mm PVC TT relieved the airway obstruction. The termination of surgery allowed to take a chest x­ray which revealed unimpressive marginal pneumothorax which was drained but did not relieved the difficulties. The recording of tissue oxygen saturation and end tidal CO2 were consistent with gradual subtotal obstruction which allowed oxygenation, and delivering inhalational agent but retention of carbon dioxide. In this report we described an unusual incidence of tracheal tube obstruction complicated by presence of small pneumothorax which was successfully treated.

Infected urocolpos and generalized peritonitis secondary to labia minora adhesions

Introduction Labia minora adhesions (LMA) are a common finding in young girls. Usually, this condition is asymptomatic and spontaneously disappears during adolescence. We report on a case revealed by infected urocolpos and peritonitis and whose treatment finally required surgical reduction labioplasty. Case report A 9-year-old girl presented with a 2-day history of abdominal pain and fever. Urinary continence had never been obtained, with diurnal leaks. Physical examination showed signs of peritoneal irritation and a subtotal vulvar obstruction due to LMA. At surgery, after LMA lysis, a large amount of cloudy urine-like fluid emptied under pressure from the vagina. Laparoscopy showed generalized peritonitis without any intraabdominal cause. The same Escherichia coli was identified in the infected urocolpos and the abdominal fluid. Postoperative course was uneventful. Because of recurrent LMA, the patient underwent several courses of local estrogen therapy. Labia minora hypertrophy with LMA developed 2 years after peritonitis, requiring surgical reduction labioplasty. We used a new technique with interposition of skin flaps. The girl is now well, without LMA or infection, 4 years after labioplasty. Conclusion Although rare, subtotal vulvar obstruction because of LMA may lead to infected hydrocolpos and peritonitis. Recurrent LMA may necessitate surgical labioplasty.