Venous Shunt Research Articles

C50 CARDIO–ONCO–HAEMATOLOGY IN CLINICAL PRACTICE. A “CHANGELING” CASE: MORE THAN PARADOXICAL BUBBLES

Abstract 39–year–old female, without cardiovascular risk factors. At the end of pregnancy she complained of progressive dyspnoea and so she was admitted to the emergency room. Blood tests showed elevated D–dimer and LDH values. A chest CT scan was performed showing a mediastinal mass of about 15 cm encompassing the ascending aorta, the left brachiocephalic trunk and the superior vena cava, both of which appeared thrombosed. Therapy with low molecular weight heparin was started. The patient underwent a mediastinal biopsy, which documented a primary mediastinal non–Hodgkin‘s lymphoma. The baseline cardiological evaluation showed a preserved ejection fraction (60%) at echocardiogram (ECHO). The first cycle of chemotherapy with R–CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine) was started. After an episode of hypoesthesia of the left upper limb, that regressed spontaneously within a few hours, she performed MRI that showed multiple areolas compatible with ischemic disease. Following these results the patient was submitted to an ECHO with saline solution injected through the right brachial vein that documented evidence of early opacification of the left atrium and subsequent opacification of the right sections (after 3 cardiac cycles) (Fig. 1–2). This finding suggested a right–to–left shunting, via the bronchial lower district to the left atrium (pulmonary veins). This suspicion was confirmed by CT angiography, which showed occlusion of the superior vena cava with passage of contrast into azygos and early opacification of peribronchial venous circles (Fig. 3). A patency of foramen ovale was ruled out by injection of saline solution through the femoral vein. After the second cycle of chemotherapy, ECHO showed diffuse hypokinesia and reduced EF to 50%. It was then decided to proceed with the third cycle according to the intensified R–DAEPOCH scheme, except for doxorubicin, because of the cardiotoxicity developed by the patient. A cardioprotective therapy was also started with bisoprolol and ramipril with rapid titration. At subsequent radiological controls, a progressive reduction of the mediastinal mass was found and after just one month, the echocardiogram showed a complete recovery of the EF. Contrast injection confirmed presence of a veno–venous shunt. Cardio–oncology is an intriguing and complex discipline that requires the development of local multidisciplinary teams for challenging situations that patients with cancer may ask us to address.

Efficacy of intravenous propranolol for life‐threatening diffuse neonatal hemangiomatosis

Oral propranolol is recommended as the first-line agent for infantile hemangioma requiring systemic treatment. Life-threatening complications such as obstructive infantile hemangioma of the airway or infantile hepatic hemangioma associated with high-output congestive heart failure are major indications for the consideration of early treatment. We present the case of an infant with life-threatening diffuse neonatal hemangiomatosis, including airway obstruction due to subglottic hemangioma, heart failure due to multiple hepatic hemangiomas with portohepatic venous shunts, and severe anemia due to continuous gastrointestinal bleeding, in which treatment with intravenous propranolol proved successful.

Partial splenectomy in children undergoing liver transplantation or venous shunt for severe hypersplenism: A case control comparative study

Background and aimHypersplenism is a consequence of portal hypertension and splenomegaly secondary to cirrhosis or portal cavernoma in children. In order to avoid persistent hypersplenism and splenomegaly after liver transplantation (LT) or venous shunt (VS), partial splenectomy (PS) may represent a relevant therapeutic option. The aim of this retrospective study was to evaluate the results of PS performed in children presenting hypersplenism. MethodsThe following end-points were evaluated: (1) reversion of hypersplenism and its durability over time, (2) postoperative outcome, (3) courses of spleen size and volume and (4) comparison to a control group in which PS was not performed. ResultsBetween 1996 and 2020, 16 children underwent PS associated with LT (8 cases) for cirrhosis or VS (8 cases) for portal cavernoma. From Day 0 to 1 month, mean platelet and white blood cell counts (WBC) dramatically improved from 48 ± 19 at day 0 to 176 ± 70 × 109/L (P < 0.0001) and from 2469 ± 853 to 7198 ± 3982/L (P = 0.001) respectively. PS allowed significant reduction of splenic length and volume from 176 ± 33 to 112 ± 24 cm (P < 0.0001) and from 1228 ± 464 to 450 ± 297 cm3 (P = 0.0003) respectively. After a mean follow-up of 92.6 ± 84.7 months (range: 4.1–210.7), 14 patients are alive with normal platelet and WBC counts and persistent spleen size reduction. Compared to control group, PS was associated with a significant platelet count rise from baseline to one year. ConclusionsPS appears to be effective for treatment of hypersplenism and splenomegaly in combination with LT or VS without compromising outcome.

Intrahepatic Portosystemic Shunt In Cardiac Amyloidosis: Turning Off The Faucet Leads To Resolution Of Hepatic Encephalopathy And Improvement In Heart Failure Symptoms

<h3>Introduction</h3> Spontaneous portosystemic shunts (SPSS) are extremely rare and usually extrahepatic due to portal hypertension in the setting of cirrhosis. Current knowledge regarding SPSS in adults in the absence of cirrhosis is limited. The implications of SPSS in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) are unknown. <h3>Case</h3> A 76-year-old man with a history of HTN, CAD and systolic dysfunction (EF 45%) presented to the hospital with symptoms of HF exacerbation and cognitive dysfunction. Initial cardiac labs were notable for a borderline elevated troponin and high natriuretic peptic level. Hepatic labs were notable for mild elevation in transaminases, thrombocytopenia and an elevated ammonia level. Transthoracic echocardiogram (TTE) revealed that the EF was stable at 45%, but there was biatrial enlargement and progression of concentric LVH to 1.8cm and resultant small LV cavity (EDV index 39ml/m²), suspicious for infiltrative cardiomyopathy (Fig A). SPEP/UPEP with immunofixation and serum free light chains were normal and Tc-99m PYP study was consistent with ATTR-CM (Fig B). Abdominal US revealed a large intrahepatic venous shunt from the right portal vein to the right hepatic vein. Right heart catheterization, portal venogram and liver biopsy revealed a right atrial pressure of 14mmHg, cardiac output of 6.2L/min, normal pulmonary vascular resistance, hepatic vein pressure of 14mmHg, portal vein pressure of 15mmHg, confirmation of the large SPSS (Fig C) and no evidence of cirrhosis. The patient underwent embolization of the SPSS with a 22mm vascular plug (Fig D). Following closure, the patient's HF symptoms and HE improved dramatically and his abnormal hepatic labs normalized. He was started on a stabilizer for the treatment of his ATTR-CM. At one year, he has not had recurrent symptoms of HE, nor repeat hospitalization for HF exacerbation. <h3>Discussion</h3> This patient most likely had a SPSS that only manifested clinically in the setting of elevated right atrial and hepatic pressures due to the development of ATTR-CM. Ultimately, the decision was made to close the SPSS for two reasons. The first was to treat HE—in the same way that transjugular intrahepatic portosystemic shunt (TIPS) procedure can cause HE and subsequent TIPS closure can be an effective treatment for refractory HE. The second was to improve HF symptoms. Although this patient's cardiac output was "normal", it was likely actually high in the context of the severe LVH and small LV cavity due to ATTR-CM and the increased venous return was poorly tolerated given the underlying restrictive cardiomyopathy.

Prenatal Diagnosis and Outcome of Umbilical-Portal-Systemic Venous Shunts: Experience of a Tertiary Center and Proposal for a New Complex Type.

Aims: To share our experience in the prenatal diagnosis of umbilical–portal–systemic venous shunts (UPSVS) and to study the prognostic factors for proper prenatal and perinatal management. Material and Methods: A five-year prospective study regarding the detection of UPSVS was conducted in two referral centers, Medgin Ginecho Clinic and the Prenatal Diagnostic Unit of the tertiary center, University Emergency County Hospital Craiova, Romania. We included in the analysis a series of agenesis of ductus venosus (ADV) cases previously reported by our center. We analyzed the incidence of the UPSVS types, their associations, and outcome predictors. Results: UPSVS were diagnosed in all 16 cases that were presented to our center at the time of first trimester anomaly scan, except one (94.12%). We diagnosed: 19 type I (61.2%), 4 type II (12.9%) and 5 type IIIa (16.1%) UPSVS. In three cases (9.6%) we noted multiple shunts, which we referred to as type IV (a new UPSVS type). Type IIIa-associated fetal growth restriction (FGR) was found in 60% of cases. Major anomalies worsened the outcome. Of the UPVSS cases, 57.1% were associated with PVS anomalies. Genetic anomalies were present in 40% of the tested cases. Conclusions: The incidence of UPSVS in our study was 0.2%. Early detection is feasible. The postnatal outcome mainly depends on the presence of structural, genetic and PVS anomalies. FGR may be associated. The new category presented a poor outcome secondary to poor hemodynamic and major associated anomalies.

Ultrasonographic characteristics and outcome of Type III umbilical-portal-systemic venous shunt.

According to a novel in-utero classification termed "umbilical-portal-systemic venous shunt (UPSVS)" recentlyproposed for an abnormal umbilical, portal and ductal venous system, the portal-systemic shunt belongs to type III UPSVS.This study was designed to examine the ultrasonographic characteristics and outcome of type III UPSVS.Material andmethods: All cases of Type III UPSVS diagnosed at our department from April 2016 to December 2020 were retrospectivelystudied. Seventeen patients with type III UPSVS including 12 type IIIa and 5 IIIb cases were identified. Sonographyshowed a shunt between the inferior left portal vein and the left hepatic vein in all type IIIa cases. Three cases of type IIIb hada combination of another shunt (2 with type I and one with type IIIa). Integrate intrahepatic portal vein system was not seenin those 2 cases of type IIIb combined with type I UPSVS, leading to termination of pregnancy (TOP). TOP occurred in 4patients with type IIIa as requested by the parents. Two cases (type IIIa and type IIIb each) underwent surgical procedure forthe closure of the shunt. Spontaneous complete closure in 4 type IIIa cases and partial closure in one type IIIb case occurredduring a period of 3-16 months. The majority of patients had type IIIa UPSVS presenting a good outcome. Thelack of integrate intrahepatic portal vein system was the main reason for TOP in patients with type IIIb UPSVS. These datasuggest the UPSVS classification is a useful tool for a prognosis prediction of type III UPSVS.

Intrahepatic aneurysmal portosystemic venous shunt diagnosed on EUS

Video 1EUS demonstration of aneurysmal intrahepatic portosystemic venous shunt.

Congenital Portosystemic Shunts in Children: A Case Series From Single Centre

Background: Congenital portosystemic venous shunts (CPSS) are uncommon foetal vascular developmental anomalies where splanchnic venous flow bypasses liver. Four cases of CPSS are reported at our centre.

Type II Abernethy malformation in an adult male patient\u2014a rare and reversible cause of pulmonary hypertension: a case report with review of literature

BackgroundCo-occurrence of Type II Abernethy malformation (AM) with Type 1 pulmonary hypertension (PH) is extremely rare. In these patients, management of AM leads to reversal of PH.Case presentationWe report a case of 24-year-old male that presented with fever and dyspnea of insidious-onset. Initial X-ray chest revealed pulmonary edema, prominent pulmonary knuckle, and dilated right descending pulmonary artery. Two-dimensional echocardiography suggested raised pulmonary artery systolic pressure (145 mmHg) and pulmonary angiogram revealed findings suggestive of Type 1 PH. Treatment with Tab. Tadalafil-Bosentan (20/5 mg, thrice daily) was initiated, but no major relief was obtained. On day 10, dyspnea worsened. Routine ultrasound revealed splenomegaly. Further evaluation with Doppler of the portal vein was suggestive of portal hypertension, and arterial ammonia was found to be raised. Contrast-enhanced computed tomography of abdomen and pelvis demonstrated a single dilated (1.3 cm) and torturous venous shunt between right internal iliac vein and superior mesenteric vein. Thus, a definitive diagnosis of Type II AM was reached. The patient was stabilized and subjected to the shunt closure with ASD Cocoon stent graft and recovered well.ConclusionOur case demonstrates a rare but reversible cause of PH. Type II AM should be included in the differential diagnosis of a patient presenting with dyspnea and provisionally diagnosed as a case of PH.

Predictors of heart failure symptoms in hereditary hemorrhagic telangiectasia patients with hepatic arteriovenous malformations

BackgroundHepatic arteriovenous malformations (AVMs) in hereditary hemorrhagic telangiectasia (HHT) patients are most commonly hepatic artery to hepatic venous shunts which can result in high-output heart failure. This condition can be debilitating and is a leading cause of liver transplantation in HHT patients. However, it is not known what characteristics can discriminate between asymptomatic patients and those who will develop heart failure symptoms.Results176 patients with HHT were evaluated with computed tomography angiography (CTA) between April 2004 and February 2019 at our HHT Center of Excellence. 63/176 (35.8%) patients were found to have hepatic AVMs on CTA. 18 of these patients were excluded because of the presence of another condition which could confound evaluation of heart failure symptoms. In the remaining 45 patients included in our cohort, 25/45 (55.6%) patients were classified as asymptomatic and 20/45 (44.4%) were classified as symptomatic, and these groups were compared.In symptomatic patients, mean common hepatic artery (CHA) diameter was significantly higher (11.1 versus 8.4 mm) and mean hemoglobin levels were significantly lower (10.7 vs 12.6 g/dL). A stepwise multiple logistic regression analysis demonstrated that both CHA diameter and hemoglobin level were independent predictors of heart failure symptoms with ORs of 2.554 (95% CI 1.372–4.754) and 0.489 (95% CI 0.299–0.799), respectively. The receiver operator characteristic (ROC) curve of our analysis demonstrated an AUC of 0.906 (95% CI 0.816–0.996), sensitivity 80.0% (95% CI 55.7–93.4%), and specificity 75.0% (95% CI 52.9–89.4%).ConclusionsCTA is an effective and easily reproducible method to evaluate hepatic involvement of HHT. Utilizing CTA, clinical, and laboratory data we determined CHA diameter and hemoglobin level were independent predictors of heart failure symptoms.

The relationship between umbilical–portal–systemic venous shunt and outcome in 11 fetuses

Objective: To investigate the relationship between congenital umbilical–portal–systemic venous shunt (UPSVs) and fetal outcome. Methods: The ultrasonographic and genetic characteristics of 11 cases of UPSVS were retrospectively analyzed and followed up to postnatal. Results: Four cases of ductus venosus -- systemic shunt (DVSS), one case of extrahepatic portal -- systemic shunt (EHPSS), and one case of umbilical systemic shunt (USS) combined with intrahepatic portal-systemic shunt (IHPSS), six cases of intrahepatic portal-systemic shunt (IHPSS) were observed. chromosomal abnormalities were observed in 9.1% (1/11), other ultrasonic abnormalities in 54.5% (6/11), cardiothoracic ratio increase in 45.5% (5/11), fetal growth restriction in 36.4% (4/11), edema was in 9.1% (1/11) and live birth was in 72.7% (8/11). Conclusion: The incidence of IHPSS is the highest and the outcome is the best. Shunt of DVSS and IHPSS can be closed spontaneously after birth. When the prenatal diagnosis is congenital UPSVs, chromosomal abnormalities and other ultrasonic abnormalities should be required further examination, and the growth and development of the fetus should be closely monitored.

Auto-venous femoral-popliteal bypass in patients with critical lower extremity ischemia and coronary heart disease associated with diabetes melitus

Аim — to improve the results of treatment of patients with atherosclerotic lesions of the arteries of femoral-popliteal segment, who underwent auto­venous femoral-popliteal bypassgrafting.Materials and methods. During the period of years 2018 to 2021, 34 patients with critical ischemia of the lower extremities underwent autovenous shunting with a reversed great saphenous vein with treatment of the inner surface of the vein with a solution of cytostatics (paclitaxel). Besides, the treatment was analysed in two control groups, who underwent autovenous reverse vein shunting (30 patients) and autovenous in-situ shunting (33 patients). The follow-up periods lasted for 24 months. The evaluation criteria included the cases of shunt thrombosis, shunt stenosis, mortality, serious ischemic events — acute lower extremity ischemia, myocardial infarction, ischemic stroke, cases of high amputations of the lower extremities.Results. In the postoperative period, no deaths were observed; absence of complicationswas registered in 96 (98 %) patients. In the main group, the frequency of shunt thrombosis was 5 (14.7 %), hemodynamically significant restenosis was diagnosed in 6 patients (17.6 %), acute myocardial infarction in 1 patient (2.9 %). In the comparison group, 11 cases of autovenous shunt thrombosis were defined.Conclusions. Our clinical experience showed promising short- and medium-term results. The chosen surgical approach and topical application of cytostatic drugs enabled to achieve long-term patency of venous shunt, which is of particular importance for patients with diabetes mellitus.

Outcome Following Hemorrhage From Cranial Dural Arteriovenous Fistulae: Analysis of the Multicenter International CONDOR Registry.

Dural arteriovenous fistulae can present with hemorrhage, but there remains a paucity of data regarding subsequent outcomes. We sought to use the CONDOR (Consortium for Dural Arteriovenous Fistula Outcomes Research), a multi-institutional registry, to characterize the morbidity and mortality of dural arteriovenous fistula–related hemorrhage. A retrospective review of patients in CONDOR who presented with dural arteriovenous fistula–related hemorrhage was performed. Patient characteristics, clinical follow-up, and radiographic details were analyzed for associations with poor outcome (defined as modified Rankin Scale score ≥3). The CONDOR dataset yielded 262 patients with incident hemorrhage, with median follow-up of 1.4 years. Poor outcome was observed in 17.0% (95% CI, 12.3%–21.7%) at follow-up, including a 3.6% (95% CI, 1.3%–6.0%) mortality. Age and anticoagulant use were associated with poor outcome on multivariable analysis (odds ratio, 1.04, odds ratio, 5.1 respectively). Subtype of hemorrhage and venous shunting pattern of the lesion did not affect outcome significantly. Within the CONDOR registry, dural arteriovenous fistula–related hemorrhage was associated with a relatively lower morbidity and mortality than published outcomes from other arterialized cerebrovascular lesions but still at clinically consequential rates.

Оценка эффективности интенсивной терапии гепатоспланхнической ишемии при политравме под контролем значений pH интрамукозного

Цель исследования: обоснование и внедрение в интенсивную терапию гепатоспланхнической ишемии при политравме эмпирической реоксигенации общего и локального действия. В исследование включены 85 пострадавших с политравмой, в структуру которой входила черепно-мозговая травма: по современной клинической классификации — ушиб головного мозга легкой и средней степени тяжести. Условия для включения в исследование: наличие более 32 баллов по шкале тяжести повреждений — Inyuri Severity Score (ISS), тяжесть состояния по шкале Acute Physiology and Chronic Health Evaluation (APACHE ІІ) — 25 и более баллов. Клинико-биохимические исследования проводили на следующих этапах: при поступлении (1-й этап), через 12–24 часа после начала интенсивной терапии (2-й этап), 3-и, 5-е, 7-е сутки (3, 5, 7-й этапы соответственно). Клиническое наблюдение осуществляли до 32 суток от момента травмы. При поступлении в стационар наблюдались определенные отличия в зависимости от исхода заболевания. У пострадавших с последующим летальным исходом были выше кровопотеря (на 27,65 %, р &lt; 0,05), дефицит объема циркулирующей крови (на 33,42 %, р &lt; 0,05), более выраженные гипотония, тахикардия; возрастали артериальная гипоксемия; показатель венозного шунтирования крови в легких значительно превышал значения в группе выживших и физиологическое шунтирование. При сигмоидальной газовой тонометрии у выживших пострадавших рН интрамукозный находился в пределах 6,88–7,0 ед.; рСО2 от 85,6 до 118,38 мм рт.ст. У умерших рН интрамукозный колебался от 6,79 до 6,9 ед.; рСО2 — от 95,61 до 121,71 мм рт.ст. В 85 % случаев фиброгастродуоденоскопической визуализацией определялись эрозивно-язвенные изменения слизистой оболочки антрального отдела желудка. Гастроинтестинальная недостаточность у пострадавших с последующим летальным исходом клинически соответствовала II–III стадии; по проявлениям гистологических изменений в слизистой оболочке антрального отдела желудка — III–IV стадии. В основе описанных особенностей лежит преобладание у умерших пострадавших значений шкал ISS на 11,77 %, APACHE II на 20,78 % и SOFA на 74,52 %, определяющих тяжесть повреждения, состояние пострадавших, степень выраженности органных повреждений. Начиная с 1-х суток интенсивной терапии различия между изучаемыми показателями у выживших и умерших пострадавших продолжали усугубляться. У выживших пациентов с 1-х суток восстанавливалась оксигенация артериальной крови до физиологических значений, что обусловлено устранением венозного шунтирования крови в легких, переходом к нормодинамическому типу кровообращения. Уже на 3-и сутки рН интрамукозный составил 99,59 % от нормы. У умерших восстановление индекса оксигенации на 1-е сутки сочеталось со снижением тканевой экстракции кислорода, гиповолемическим шоком, рефрактерным к вазопрессорной терапии с 3-х суток исследования. Значения рН превышали 7,35 ед. лишь к 5-м суткам, при этом клинически функция пищеварения не восстановилась и на 7-е сутки исследования. Данные клинической оценки гастроэнтеральной недостаточности нашли свое подтверждение в фиброгастроскопической картине, данных гистологического и гистохимического исследования слизистой оболочки антрального отдела желудка. Установлена высокая, положительная, достоверная корреляционная зависимость между рН интрамукозным и исходом заболевания. Фактическая летальность по промежуточным точкам составила 20 %: на 3-и сутки умерли 3 пострадавших, на 5-е сутки — 2 пострадавших. До 28-х суток клинического наблюдения фактическая летальность составила 44 %: с 7-х по 28-е сутки умерли еще 6 пострадавших. С 28-х по 32-е сутки летальность не зарегистрирована. То есть фактическая летальность по конечным точкам исследования составила 44 %, что ниже предполагаемой летальности приблизительно на 7 %.

Selection of optimal endarterectomy technique in the left anterior descending artery for diffuse coronary atherosclerosis

Aim. To determine the optimal method for performing coronary artery endarterectomy (СE) based on immediate and long-term outcomes of coronary artery bypass grafting (CABG) in combination with open or closed CE in the left anterior descending artery (LAD).Material and methods. This retrospective study included 103 patients who underwent CABG in combination with closed CE and 204 after open CE in the LAD during the period from 2003 to 2016. In both groups, the patient age was comparable (65 years [56; 69] vs 67 years [58; 72] (p=0,263)). There were more men (88,3% vs 81,4% (p=0,421). The mean follow-up period was 94 months [38; 180]. Long-term outcomes were assessed in 86,4% (n=89) and 83,8% (n=171) of patients from the closed and open CE groups, respectively (p=0,141). Angiographic data were studied in 75,3% and 67,3% of patients, respectively (p=0,441).Results. In the closed and open CE groups, in-hospital mortality was 4,8% and 1,5% (p=0,0012), incidence of perioperative myocardial infarction — 11,6% vs 2,5%, (p&lt;0,001), survival rate after 7,8 years — 81,3±5,1% and 84,4±3,2% (p=0,342), respectively. The patency of arterial shunts was significantly higher in the open CE group — 93,1% vs 80,6% (p=0,004). At the same time, the patency of venous shunts in the long-term period between the groups was comparable — 70,1% vs 73,7% (p=0,314).Conclusion. Open CE in combination with CABG provides better immediate outcomes compared to closed CE. Long-term survival and freedom from angina between the groups were comparable. In the long-term period, the patency of internal thoracic artery after open CE is better than after the closed technique. Open CE is a safe and effective method to achieve complete myocardial revascularization in patients with severe diffuse LAD atherosclerosis.

Involvement of Neutrophil Extracellular Traps in Cerebral Arteriovenous Malformations

Cerebral arteriovenous malformations (cAVMs) represent tangles of abnormal vasculature without intervening capillaries. High-pressure vascular channels due to abnormal arterial and venous shunts can lead to rupture. Multiple pathways are involved in the pathobiology of cAVMs including inflammation and genetic factors such as KRAS mutations. Neutrophil release of nuclear chromatin, known as neutrophil extracellular traps (NETs), plays a multifunctional role in infection, inflammation, thrombosis, intracranial aneurysms, and tumor progression. However, the relationship between NETs and the pathobiology of cAVMs remains unknown. We tested whether NETs play a role in the pathobiology of cAVMs. We analyzed samples from patients who had undergone surgery for cAVM and immunohistochemically investigated expression of citrullinated histone H3 (CitH3) as a marker of NETs. CitH3 expression was compared among samples from cAVM patients, epilepsy patients, and normal human brain tissue. Expressions of thrombotic and inflammatory markers were also examined immunohistochemically in samples from cAVM patients. Expression of CitH3 derived from neutrophils was observed intravascularly in all cAVM samples but not other samples. Nidi of AVMs showed migration of many Iba-I-positive cells adjacent to the endothelium and endothelial COX2 expression, accompanied by expression of IL-6 and IL-8 in the endothelium and intravascular neutrophils. Unexpectedly, expression of CitH3 was not necessarily localized to the vascular wall and thrombus. Our results offer the first evidence of intravascular expression of NETs, which might be associated with vascular inflammation in cAVMs.

Stress Echocardiography with Adenosinethreephosphate and Atrial Pacing in Diagnosis of Late Coronary Shunts Stenosis

The aim of the study was to evaluate diagnostic accuracy of stress echocardiography (stress echoCG) with combination of high doze АТР and atrial pacing in diagnosis of late coronary shunts stenosis.48 men aged from 45 to 64 (48,4 ± 1,6 years), 36 patients undergone mammarocoronary shunting, 12 patients undergone auto venous shunting. Stress echoCG with combination of high doze ATP and atrial pacing suggested shunts lesions in 44 patients, in 8 cases previously intact coronary arteries, approved with coronary angiography. Coronary angiographies reviled no coronary lesions in 24 patients &gt; 70 % shunts restenosis, in 22 coronary stenosis from 50 up to 70 %. Accuracy, sensitivity and specificity of stress- EchoCG with combination of stress-agents in coronary shunts restenosis, as well as stenosis of previously intact coronary arteries were 100 %.

Focal Hepatic Hot Spot Sign

The focal hepatic hot spot sign appears as an area of increased radiopharmaceutical uptake of the quadrate lobe of the liver in the arteial an veinous phase. This sign seen on CT is due to obstruction of the superior vena cava and portosystemic venous shunt between the superior vena cava and the left portal vein via the thoracic and internal para-umbilical veins.

Management of Ostomy-Related Varices.

Management of Ostomy-Related Varices.

Hepatic encephalopathy. Clinical case

Hepatic encephalopathy is a neuropsychiatric syndrome associated with abnormal liver function and portosystemic venous shunting. According to the West-Haven classification, depending on the degree of neurological disorders, there are minimal, I - IV stages of HE, which are characterized by a gradual progression of the disease. To date, the pathogenesis of HE is controversial.