Background:Myocardial infarction with nonobstructive coronary arteries (MINOCA) accounts for a meaningful proportion of acute myocardial infarction presentations and encompasses heterogeneous mechanisms. Coronary microvascular dysfunction (CMD) is a major cause of MINOCA and can be invasively characterized using coronary physiology indices, including the index of microvascular resistance (IMR) and coronary flow reserve (CFR). Systemic sclerosis (SSc) is associated with small-vessel vasculopathy and may predispose individuals to CMD. However, MINOCA attributable to SSc-related CMD confirmed by invasive coronary function testing and cardiac magnetic resonance (CMR) is not widely reported. Case Presentation:A 76-year-old woman with SSc and interstitial pneumonia presented with persistent chest pain. Electrocardiography revealed new T-wave inversions in leads V1-V4, and echocardiography demonstrated mid-anterior left ventricular asynergy. Troponin T was elevated (0.206 ng/mL). Emergency coronary angiography showed no obstructive epicardial stenosis, but left ventriculography confirmed regional wall-motion abnormality. CMR demonstrated base-to-mid anteroseptal dysfunction with increased native T1, T2, and extracellular volume fraction, supporting MINOCA. Transient systemic inflammation was observed (peak C-reactive protein 14.69 mg/dL; white blood cell count 24,600/μL) without evidence of infection and it resolved spontaneously. Six weeks later, acetylcholine provocation testing was negative for epicardial spasm, but invasive physiological assessment identified CMD (IMR 30.5; CFR 1.7). The patient was treated with a calcium-channel blocker and nicorandil. At 3-month follow-up, symptoms, electrocardiographic changes, and CMR abnormalities normalized, which indicated a reverse of the ischemic injury. No recurrence occurred during 1 year of follow-up. Conclusion:SSc-associated MINOCA, possibly driven by CMD, was diagnosed by comprehensive invasive coronary function testing and CMR. Serial CMR may help to document reversibility of microvascular ischemic injury and guide vasodilator therapy and follow-up.
Congenital anomalies of the aortic arch often lead to tracheoesophageal compression during childhood. Occasionally, symptoms may not emerge until adulthood, appearing for the first time at any age due to age-related or pathological dilation of the aortic segments. The oldest patient described with symptoms at the onset was 76 years old. Surgical intervention is complex and poses challenges. This case study describes a patient with a right mirror-image branching aortic arch, Kommerell's diverticulum, and a ligamentum arteriosum originating from the diverticulum. The patient first experienced symptoms of tracheoesophageal compression at 57 years of age. Initial treatment at another hospital, which involved division of the ligamentum and incomplete resection of the diverticulum with its fixation to the chest wall, did not alleviate symptoms. Successful off-pump resurgery was performed through a sternotomy, which included complete resection of Kommerell's diverticulum and direct closure of the aorta without the use of a patch. Additionally, the left brachiocephalic artery was repositioned away from the tracheoesophageal complex. External skin surface cooling to 30°C-31°C in the esophagus facilitated safe clamping of the left brachiocephalic artery during the transfer. This case demonstrates successful exposure of Kommerell's diverticulum through sternotomy and the potential to avoid extracorporeal circulation during clamping of the brachiocephalic trunk by utilizing systemic hypothermia with external cooling.
We report a 36-year-old healthy woman with 2 days of right-sided blurry vision, headache, and pain with eye movement. Exam showed decreased visual acuity, focal retinal pallor, and abnormal cranial nerve II findings. CTA revealed right vertebral artery dissection at C5-C6 with concurrent ophthalmic artery narrowing. She received anticoagulation, intravenous steroids for optic neuritis, and improved with follow-up. This rare presentation underscores the need to consider cervical artery dissection in young patients with painful vision loss and subtle fundoscopic changes, as timely vascular imaging can reveal unexpected concurrent pathology.
As Behçet's disease (BD) is a multisystem disorder that affects blood vessels, it predisposes patients to an increased risk of thrombosis. The vessels most commonly involved are those of the lower extremities, although the dural venous system may also be affected. Deep vein thromboses (DVTs) typically occur later in the disease course and are less commonly described as an early manifestation. Herein, we present the case of a young woman who was first diagnosed with unprovoked pulmonary embolism, inferior vena cava thrombosis, and dural venous sinus thrombosis as the initial manifestations of HLA-B51 positive BD.
Visceral artery aneurysms and pseudoaneurysms are defined as aneurysms of the splenic, superior mesenteric, or inferior mesenteric arteries and their respective branches. Mycotic aneurysms, defined as aneurysms of the arterial wall caused by bacterial or fungal embolization, are a rapidly progressive and often fatal form of arterial aneurysms that can form in the visceral arteries. Aneurysms and pseudoaneurysms of the visceral arteries most commonly present as abdominal pain. The ambiguity with which they often present, paired with their high risk of rupture and hemorrhage, creates a highly precarious situation for clinicians. Failure to identify an aneurysm or pseudoaneurysm of the visceral arteries in time can be a fatal mistake. We present a case of mycotic pseudoaneurysms of the superior mesenteric artery and splenic artery secondary to infective endocarditis managed with open surgical resection, coil embolization, and splenectomy in a 36-year-old male with a history of intravenous drug use. The patient presented with a chief complaint of abdominal pain and confusion. He was admitted for sepsis and work-up of suspected bacteremia and endocarditis. MRI revealed multiple cortical infarcts suggestive of an embolic shower, and transesophageal echocardiogram showed mitral valve vegetations. CT imaging showed an aneurysm of the superior mesenteric artery, later determined to be a pseudoaneurysm. The patient underwent emergent open superior mesenteric artery pseudoaneurysm resection as well as splenectomy due to intraparenchymal pseudoaneurysms and associated necrosis and intraparenchymal hemorrhage. Our case highlights the importance of considering visceral artery aneurysms when formulating a list of differential diagnoses for patients presenting with abdominal pain due to their vague presenting symptoms in conjunction with their potential to rapidly progress to aneurysmal rupture and catastrophic hemorrhage.
Popliteal artery aneurysms (PAAs) are largely attributed to arteriosclerotic disease processes, with a rare aetiology of infective and traumatic origin. This disease may be complicated by acute limb ischaemia, which could result in limb loss. Therefore, early management of symptomatic aneurysms, or asymptomatic aneurysms > 2 cm, is suggested. We present a unique case of PAA secondary to a fractured femoropopliteal stent and discuss ongoing challenges toward the management of femoropopliteal disease, along with treatments for PAA.
Intracranial arteriovenous malformations (AVMs) are vascular anomalies that can present with intracranial hemorrhage, seizures, or neurological deficits. In this case, we present a woman with a giant right frontoparietal AVM (Spetzler–Martin Grade V) initially diagnosed after an intracerebral hemorrhage at Age 6. Surgical, endovascular, and radiosurgical treatments were not viable due to the lesion’s size and eloquent location. Over time, the patient developed focal seizures, including catamenial patterns and left‐arm spastic monoparesis. Initial antiseizure medications (ASMs) such as carbamazepine and phenytoin failed to provide adequate control at optimal dosage, with phenytoin exacerbating seizure frequency. Partial seizure control was eventually achieved with a combination of levetiracetam and carbamazepine. Neuroimaging showcases a large AVM, while EEG revealed focal epileptiform activity. This case illustrates the complexity of treating epilepsy secondary to giant AVMs, emphasizing the need for individualized ASM strategies and collaborative, multidisciplinary management.
Background: Partial anomalous pulmonary venous connections are embryologic defects in which the normal connection between the pulmonary veins and left atrium is disrupted. These rare anomalies are often asymptomatic and identified incidentally. The most common variant is a connection between the left upper pulmonary veins and the left innominate vein. Although typically asymptomatic, these variants are important to be aware of, particularly when performing procedures involving the venous anatomy. Case Presentation: We present the case of a 52-year-old female with a previous history of colon cancer who underwent right hemicolectomy and presented to the hospital due to severe dehydration secondary to profuse nausea, vomiting, and diarrhea. She developed an acute kidney injury with electrolyte derangement and metabolic acidosis requiring initiation of hemodialysis. Due to her preexisting right internal jugular port access, the decision was made to proceed with left internal jugular dialysis catheter access. Central venous access was performed in standard fashion. There was venous-appearing blood return at the time of needle access and subsequent dilations. However, at the time of catheter advancement, there was noted return of bright red blood and resistance to advancement, concerning for possible arterial cannulation. Concerning arterial placement, an arterial blood gas (ABG) test and chest x-ray were performed; however, the transducer waveforms were not consistent with this. Computed tomography angiography obtained revealed left internal jugular venous access with catheter extension into an anomalous pulmonary vein within the left upper lobe. The patient was taken to the angiography suite and under fluoroscopy guidance had new left internal jugular catheter access with the catheter terminating successfully in the superior vena cava. She underwent successful dialysis and was subsequently discharged on postprocedure Day 8. Conclusions: Central line placement is a commonly performed procedure in hospitals. There are steps that have been developed to limit complications for this procedure, including ultrasound guidance, visualization of venous blood, and confirmatory imaging prior to use. This is a case in which arterial-appearing blood, paO2, and chest x-ray were concerning for incorrect placement, but additional imaging revealed accurate access with anomalous anatomy. Overall, the case of central line placement in anomalous pulmonary venous connections is rare but needs consideration when the clinical scenario is appropriate.
A 78-year-old man was diagnosed with an abdominal aortic aneurysm with a meandering mesenteric artery. We performed abdominal aortic replacement and inferior mesenteric artery reconstruction using intraoperative inferior mesenteric artery perfusion during surgery. A 4-Fr arterial sheath was inserted into the left brachial artery, and a 10-Fr balloon catheter was inserted into the inferior mesenteric artery for perfusion. The intraoperative intestinal blood flow was satisfactory, and the patient’s postoperative course was favorable. This method was an easy and effective option for abdominal aortic surgery in patients with a meandering mesenteric artery.
An infection and aortic arch pseudoaneurysm can be fatal if not emergently and adequately treated. Optimal surgical procedures and optimal graft materials remain controversial. We describe a 61-year-old patient who underwent in situ repair of the infected pseudoaneurysm of the aortic arch. A porcine pericardium patch (BioIntegral Surgical Inc., Mississauga, ON, Canada) was used to reconstruct the aortic wall, followed by the reconstruction of the brachiocephalic trunk using a surgeon-made tube. The patient made a full recovery. Self-made tube grafts for in situ reconstruction offer many advantages and may be a valuable option.
May-Thurner syndrome (MTS) is characterized by the formation of an intravenous scar or venous "spur" resulting from chronic pulsatile compression of the left common iliac vein (LCIV) by the right common iliac artery (RCIA) against the fourth or fifth lumbar vertebral body. This pulsatile compression creates a flow-limiting stenosis of the LCIV, leading to increased intravenous pressure in the veins draining the left lower extremity (LLE). Consequently, this elevated venous pressure manifests as a spectrum of chronic symptoms including unilateral LLE edema, pain, tenderness, warmth, skin inflammation, and discoloration, along with pelvic symptoms such as sensation of fullness and dyspareunia. Furthermore, MTS significantly elevates the risk of venous thromboembolism characterized by LCIV deep vein thrombosis (DVT) and potentially fatal pulmonary embolism (PE). Treatment options for MTS range from anticoagulant therapy to, in severe cases, operative intervention. Herein, we present a case of a 79-year-old male with MTS who experienced a near-fatal DVT that led to PE, compounded by a chronically distended urinary bladder, necessitating immediate operative removal of the PE.
Objective: With the increasing prevalence of mechanical thrombectomy (MT) for large vessel occlusion strokes, encountering unruptured cerebral aneurysms (uANs) in MT target vessels has become more common, necessitating case accumulation to establish safety guidelines for MT in such cases. In this study, we aimed to review and present cases of uAN associated with MT target vessels at our hospital. Methods: Among 320 patients who underwent MT for large vessel occlusion strokes at our hospital between January 2018 and December 2021, we selected patients with uAN in the MT target vessel and analyzed various parameters including the occluded vessel, uAN location, timing of uAN discovery, thrombus retrieval procedures, materials, recanalization outcomes, and uAN rupture incidence. Results: Of the 320 patients, 7 had aneurysms in the target vessel (2.2%). The uANs were identified before the device crossed the occluded lesion (lesion crossing (LC)) in four cases, while in three cases, identification occurred after LC or recanalization. In 1 of the 3 cases, a uAN was suspected on preoperative computed tomography at the retrospective review. The thrombectomy procedures included a direct aspiration first pass technique (ADAPT) alone in one patient, stent retrieval (SR) alone in two patients, combination therapy in three patients, and SR combined with local infusion of urokinase in one patient. The effective recanalization rate, defined as TICI 2b or 3, was 57.1% (4/7). The average puncture-to-recanalization time was 77.4 min, and there were no instances of uAN rupture associated with MT. Conclusions: We presented seven cases of uAN in the MT target vessel. No uAN rupture was associated with MT, although the same strategies and techniques of routine MT at our hospital were employed, prioritizing recanalization. Preoperative image assessment considering the possibility of a uAN being present in the MT target vessel is more essential, as well as careful selection of MT procedures according to the situation of each patient.
Acute limb ischemia (ALI) in neonates is a rare but critical condition often resulting from iatrogenic causes, such as arterial catheterization. This case highlights the unique challenges in diagnosing and managing ALI in this population, where evidence-based guidelines are scarce and treatment decisions rely heavily on expert consensus and extrapolation from adult data. We report the case of a premature neonate, born at 30 weeks’ gestation, who developed ALI secondary to femoral artery thrombosis following arterial line insertion. The patient presented with bluish discoloration, diminished capillary refill, and absent distal pulses in the affected limb. Duplex ultrasonography confirmed occlusion of the right common femoral artery. Conservative management with anticoagulation and close observation was adopted by multidisciplinary consensus involving neonatology and vascular surgery. Despite signs of worsening ischemia and skin necrosis during therapeutic anticoagulation, the team opted to continue conservative management due to the high surgical risk posed by the patient’s prematurity and multiple comorbidities. Over the next week, gradual clinical and imaging improvements were noted, including recanalization of the occluded artery and restoration of arterial flow, ultimately leading to successful limb salvage. This case underscores the importance of individualized, multidisciplinary decision-making in managing neonatal ALI. Conservative management with therapeutic anticoagulation can achieve favorable outcomes, even in cases with worsening ischemia, provided that close monitoring and optimal supportive care are ensured. It also highlights the need for further research to develop standardized pediatric guidelines for this rare but potentially devastating condition.
Introduction: Postthrombotic syndrome (PTS) describes a condition arising after an acute deep venous thrombosis (DVT) that is characterised by leg heaviness, discomfort, and recurrent venous ulceration. Venous disease is associated with significant morbidity and impairment of mobility due to pain, infection, and oedema. Report: We present a patient in his 40s attending with left lower limb ulceration, swelling, and refractory pain despite previous best medical management and superficial radiofrequency ablation. A venous duplex ultrasound revealed a trifid femoral vein with a competent and incompetent component. Venography showed patent deep veins but failed to offer the same level of detail as duplex. The patient underwent a femoral vein ligation after multidisciplinary discussion. The role of intraoperative duplex ultrasound was essential. The patient clinically improved and is now free of his venous ulcerations. Conclusion: Duplex provided vital information for surgical planning, which venogram was unable to offer. This is an imaging pitfall that is important to be aware of in patients presenting with recurrent venous disease. Our case highlights the importance of thorough clinical assessment and the value of the Doppler ultrasonography assessment in confirming venous incompetence.
Implantable subcutaneous chemoports are routinely employed for delivering chemotherapy in oncology. Spontaneous catheter dislodgement and embolization of the catheters are rare complications of the procedure. Herein, we report our experience with a patient presenting with spontaneous dislodgement and migration of the catheter to the pulmonary artery. The patient having familial adenomatous polyposis with adenocarcinoma of the right colon underwent total proctocolectomy and had placement of the chemoport through the internal jugular vein for adjuvant FOLFOX chemotherapy. The entrapped catheter was successfully managed by percutaneous retrieval by an interventional cardiologist.
Jugular venous compression syndrome (JVCS) is caused by internal jugular vein compression, leading to headaches, neck discomfort, tinnitus, vertigo, confusion, and blurred vision. These impairments can diminish functional outcomes and compromise quality of life for patients. Literature-based treatments focus on surgical approaches and do not include chemodenervation. However, chemodenervation may be an additional treatment modality to consider. We present the first published case of chemodenervation utilized to successfully treat debilitating neck pain, headaches, and vertigo symptoms for JVCS, resulting in improved functionality and quality of life. This chemical denervation to the anterior neck musculature was trialed in hopes of avoiding surgical intervention. After three treatments, significant symptomatic relief with improved ability to work, improved performance of activities of daily living, and enhanced quality of life were noted. Educating physicians about JVCS and the various treatment modalities available is essential, as less invasive treatment options may not only become available to assist with the functional component of the condition but could also serve as potential alternatives to surgical and endovascular management in carefully selected patients, with the goal of optimizing function and improving quality of life among patients.
Peripheral arterial disease (PAD) affects more than 230 million adults worldwide. Revascularization via angioplasty is a common method to manage stenosis in the superficial femoral artery (SFA). In-stent restenosis, however, is a common complication in endovascular interventions, especially in the SFA. Here, we present a case that involves recanalization of the SFA in a patient with a previously occluded stent and failed surgical revascularization. This patient initially presented with an occluded SFA which was stented. Four years later, the stent was reoccluded and surgical endarterectomy of the artery was performed with partial removal of the stent. Ten years later, the SFA is again occluded. Recanalization of the SFA using laser atherectomy and restenting of the occluded stent with GORE VIABAHN endoprosthesis was performed successfully. The combination of such methods is a suitable way to manage chronic lesions and minimize restenosis in patients with PAD.
This case report describes an instance of vulvar lymphangioma occurring in the setting of May–Thurner syndrome (MTS), an association between two vascular conditions that we do not believe has been previously reported. Lymphangioma, also known as lymphatic malformation, is a benign lesion typified by dilatation of endothelial-lined lymphatic channels involving the skin and subcutis, which can occur either as a congenital abnormality or as a result of acquired damage to lymphatic channels. Lymphangioma is a rare lesion in the vulva. MTS, also known as iliac vein compression syndrome or Cockett’s syndrome, is a condition of left iliac vein obstruction due to overriding the right common iliac artery which can lead to iliofemoral deep vein thrombosis. In this report, we describe the case of a 29-year-old woman with MTS diagnosed at 7 years of age with poor lymphatic drainage and pelvic pain requiring left iliac vein stenting. She presented with left vulvar discomfort and chronic lower extremity edema and was found to have warty vulvar masses, with histopathological examination showing lymphangioma of the vulva. We believe that this is the first report of vulvar lymphangioma recognized in the setting of MTS, and we will discuss the clinical features, etiology, and possible pathophysiologic association between these two entities.
