Venous thrombosis causing arterial embolization to the same limb through a patent foramen ovale

We describe a patient who presented with acute ischemia affecting the left lower limb. Because a transthoracic echocardiogram was abnormal, a transesophageal study was arranged. This demonstrated an atrial septal aneurysm and right-to-left shunting of contrast, raising the possibility of paradoxical embolism. The diagnosis was confirmed by contrast venography, which showed extensive thrombosis in the deep veins of the left thigh, and a ventilation-perfusion scan which was consistent with multiple pulmonary emboli. Among the lessons from this case was the finding that in patients with arterial embolism the likely origin of the embolus should be considered and, in the absence of common risk factors (atrial fibrillation, rheumatic heart disease, left ventricular dilatation, widespread atheroma), occult venous thrombosis and a right-to-left shunt should be sought. In this select group of patients, transesophageal echocardiography is significantly more sensitive than transthoracic study and should be the investigation of choice. Second, in the patient described in this report the clinical signs of deep venous thrombosis (DVT) were masked by the more prominent features of acute arterial ischemia. Without the incidental echocardiographic abnormality, it is likely that the important diagnoses of DVT, pulmonary embolism, and paradoxical embolism would not have been made.     

Two cold legs

Bilateral acute lower limb ischaemia is rare. Usually the diagnosis is based on clinical findings. In four patients, three women aged 51, 48, and 72 and a man aged 64 years, bilateral acute ischaemia of the lower limbs was diagnosed, due to different causes: arterial cardiac myxoma embolism, arterial thrombosis probably due to paraneoplastic coagulopathy, aortic dissection, and arterial thrombosis due to cardiac insufficiency, respectively. The management of these conditions includes restoring the circulation as soon as possible. Reperfusion can be achieved by thromboembolectomy or thrombolysis. In patients with underlying atherosclerosis angiography is useful, but time loss must be avoided. The outcome in patients with bilateral ischaemia of the lower limbs depends on the preoperative ischaemia time and the cardiac situation. The mortality varies between 20 and 50%.     

Surgical treatment of coronary artery aneurysm with rupture into the right atrium

Considering the increasing number of patients with chest pain who undergo routine coronary artery arteriography, coronary artery aneurysm may be found more frequently. To know how to manage these aneurysms, we must understand their possible complications. The aneurysms can produce symptoms of angina or acute myocardial infarction by total thrombosis of the aneurysm and vessel, embolism to the distal vessel, or progressive enlargement and encroachment upon the distal vessel until it is occluded. Moreover, the aneurysm may enlarge and rupture into the free pericardium or produce a fistula by eroding into a chamber of the heart. The case described herein may represent the first reported case of a coronary artery aneurysm eroding into a cardiac chamber and causing an arteriovenous fistula. The treatment of choice is resection of the aneurysm, closure of the fistula, and re-establishment of continuity of the distal coronary artery with a saphenous vein bypass graft.     

Catheter-induced thrombus in the superior vena cava diagnosed by transesophageal echocardiography

BACKGROUND: To present the role of transesophageal echocardiography (TEE) in the diagnosis and management of catheter-related superior vena cava thrombosis. CASE HISTORY: A 42-year-old woman with severe Crohn's disease presented with septic shock and pulmonary embolism three weeks after emergency laparotomy and ileocolic resection for small-bowel perforation with peritonitis. Cardiopulmonary evaluation with ECG, pulmonary artery catheter and TEE demonstrated no evidence of acute myocardial ischemia or ventricular dysfunction; hemodynamic indices were consistent with severe sepsis. TEE revealed a large sheathing thrombus surrounding a central venous catheter used for parenteral nutrition. A spiral CT scan of the chest confirmed multiple peripheral pulmonary emboli. Treatment consisted of systemic anticoagulation and antibiotics. To avoid further pulmonary embolism, the central venous catheter was not removed until six days later under TEE monitoring, which revealed that the thrombus was firmly adherent to the superior vena cava. The patient made an uneventful recovery and was discharged from hospital on long-term anticoagulant therapy. CONCLUSION: In a case of catheter-induced superior vena cava thrombosis with septicemia and pulmonary embolism, bedside TEE was very helpful to make the correct diagnosis early, assess thrombus size during anticoagulation, and monitor cardiac performance and thrombus disposition during central venous catheter removal.     

PCR-ribotyping and pyrolysis mass spectrometry fingerprinting of environmental and hospital isolates of Clostridium difficile

Pancreatic ischemia is a very rare etiology of clinical acute pancreatitis, complicating cardiac surgery, hemorrhagic shock, and transplantation of the pancreas. In this article, we present two patients with acute ischemic necrotizing pancreatitis, complicating a generalized atheromatous disease with extensive lesions in the splanchnic circulation (patient 1) and repair of a descending thoracic aortic aneurysm (patient 2). Diagnostic approach and management of ischemic necrotizing pancreatitis are discussed.     

Substance P and related peptides in porcine cortex: whole tissue and nuclear localization

We experienced a case of a 60 year-old man with cardiac sympathetic denervation after aortic graft replacement of ascending aorta for a dissecting aneurysm (Debakey type II). Fourteen years after pheochromocytomectomy (paraganglioma), the patient developed a severe chest pain, and admitted to the hospital for the diagnosis of dissecting aneurysm. CT scan with contrast enhancement revealed thrombosed dissecting aneurysm in the region of ascending aorta to aortic arch. Graft replacement was undergone on the same day. 123I-MIBG imaging 20 days after the operation showed severely attenuated myocardial uptake (heart to mediastinum ratio 1.19), although the MIBG imaging before the operation showed normal myocardial uptake (heart to mediastinum ratio 1.55). Heart rate variability analysis in Holter ECG showed that the power of the low frequency (LF), that of the high frequency (HF) and L/H ratio were severely decreased. MIBG and heart rate variability analysis indicated that cardiac sympathetic and parasympathetic nerve were denervated. This is the first report of cardiac sympathetic denervation after aortic vascular surgery. Clinical significance of cardiac sympathetic denervation after aortic vascular surgery is uncertain, and further investigation will be required.     

Rupture of an abdominal aortic aneurysm following acute descending thoracic aortic dissection. Case report

The coexistence of an abdominal aortic aneurysm and an acute aortic dissection seems to be rare and only a few reports are to be found in the literature. We report a case of a patient with acute aortic dissection of the descending thoracic aorta that caused rupture of a pre-existing abdominal aortic aneurysm. The literature is also thoroughly reviewed.     

A case of Stanford type A acute aortic dissection associated with a distal aortic arch atherosclerotic aneurysm

We report a rare case of Stanford type A acute aortic dissection associated with a distal aortic arch atherosclerotic aneurysm. A 71-year-old female was referred to us with the diagnosis of thrombosed Stanford type A acute aortic dissection, however on the next day transesophageal echocardiography revealed the false lumen has been recanalized. In the operation, there was a distal aortic arch atherosclerotic aneurysm which was unidentified at the preoperation. It is very rare that the dissection originated from atherosclerotic aneurysm and proceeded to proximal and distal portion of the aorta.     

EEG recordings during episodes of palinacousis and palinopsia]

Stent-graft placement was performed in 2 patients with saccular aortic aneurysm. A Dacron-covered nitinol stent-graft was deployed in the thracoabdominal and infrarenal abdominal aorta. These procedures were successfully performed. The aneurysm disappeared on intraoperative angiogram immediately after deployment. Follow-up CT showed thrombosis or disappearance of aortic aneurysm. Distal embolization occurred in one patient, who required resection of the small bowel on the following day and renal dialysis due to renal infarction. Both patients were still alive one and a half years and one year after the procedure, respectively. Stent-graft placement is a feasible alternative to surgery for aortic aneurysm in selected patients.     

Diagnosis and treatment of abdominal aortic aneurysms

Abdominal aortic aneurysms occur in 5 to 7 percent of people over age 60 in the United States. An aneurysm is defined as a permanent localized dilatation of an artery, with an increase in diameter of greater than 1.5 times its normal diameter. Abdominal aortic aneurysms may be manifested by catastrophic rupture, signs of pressure on other viscera or an embolism originating in the aneurysmal wall, but most cases are asymptomatic. The diagnosis is often made by physical examination of the abdomen, which reveals a pulsatile mass left of the midline, between the xyphoid process and the umbilicus. The diagnosis may be confirmed by B-mode ultrasound. Ultrasound screening should be considered for individuals at risk for abdominal aortic aneurysms. This group includes individuals over age 60 who smoke, have hypertension or have vascular disease. Elective surgical intervention is indicated for most patients with abdominal aortic aneurysms greater than 5 cm in diameter to prevent rupture and death. Smaller abdominal aortic aneurysms should be monitored by regular ultrasound measurements. Screening and identification of abdominal aortic aneurysms by primary care physicians can have a significant impact on patient survival.     

Severe digital ischemia disclosing Basedow's disease: 2 cases

We report two observations of young women with concomitant diagnosis of acute arterial occlusion of the upper limb and Graves' disease. The occlusion was probably related to arterial embolism on paroxysmal atrial fibrillation, without underlying cardiopathy. Dosage of thyroid hormones should be performed in case of arterial occlusion in young subjects without cardiovascular risk factors.     

Spontaneous thrombosis of an intracranial aneurysm during treatment with epsilon aminocaproic acid

The authors report spontaneous thrombosis of a middle cerebral artery aneurysm in a patient receiving the anti-fibrinolytic agent, epsilon aminocaproic acid. Intense vasospasm and profound neurologic deficit accompanied the initial hemorrhage. Follow-up angiography two, four and ten weeks following the initial hemorrhage demonstrated occlusion of the aneurysm and progressive thrombosis of a middle cerebral artery branch despite the disappearance of vasospasm. The patient had a persistent hemiparesis.     

Evaluation of acute mental status change in the nonhead injured trauma patient

Acute mental status change in the first 24 hours after trauma is uncommon in nonhead injured patients who initially present with a normal sensorium. Although arterial hypoxemia is the classic etiology for such a mental status change, three less common etiologies should always be considered: cerebral fat embolism, blunt carotid artery injury, and vertebrobasilar artery thrombosis. Prompt diagnosis and appropriate treatment can significantly improve patient morbidity and mortality. Three nonhead injured trauma patients are described illustrating cerebral fat embolism, blunt carotid artery injury, and vertebrobasilar artery thrombosis as causes of acute mental status change. Each patient initially presented with a clear sensorium, but subsequently developed neurological deficits within 24 hours after admission. All had a normal admission CT scan of the head. MRI or conventional arteriography was diagnostic in each case. Any patient who is initially lucid and subsequently develops a neurological deficit, or a patient whose neurological status does not correlate with brain CT findings should undergo immediate evaluation for possible cerebral fat embolism or cervical vessel injury. An algorithm for management of nonhead injured trauma patients with acute mental status deterioration is presented.     

Congenital malformations in infants of 517 pregestational diabetic mothers

PURPOSE: To explore a method of combined endovascular/conventional treatment of abdominal aortic aneurysm (AAA), in which the iliac arteries are reconstructed by conventional surgical techniques to provide the anatomic substrate for subsequent endovascular repair of the aortic aneurysm. METHOD: A 77-year-old patient with severe cardiac disease was found to have a 6.5-cm AAA, bilateral common iliac artery (CIA) aneurysms, and diffusely narrowed, tortuous external iliac arteries. The left internal iliac artery was occluded. At operation, the right CIA was exposed through a transverse retroperitoneal incision under epidural anesthesia. An iliobifemoral bypass was constructed using a preformed bifurcated graft. A stent-graft was delivered through the right limb of the bifurcated iliobifemoral graft. The proximal end of the stent-graft was implanted in the neck of the aneurysm, and the distal end was deployed in the common trunk of the iliobifemoral graft, thereby excluding the AAA and both native iliac arteries from prograde arterial flow. RESULTS: Completion angiography and follow-up contrast computed tomography showed the aneurysm to be excluded from the circulation. The patient was not intubated, was never hemodynamically unstable, and had aortic blood flow interrupted for no more than 20 seconds. In addition, he was able to resume his usual diet on the first postoperative day. He continues to be well and without evidence of endoleak at 6-month follow-up. CONCLUSIONS: This case demonstrates that iliac artery stenosis, tortuosity, and aneurysmal dilatation are not impediments to endovascular AAA exclusion. Any necessary surgical modifications of pelvic arterial anatomy can be performed before stent-graft insertion to minimize aortic occlusion time.     

Arterial aneurysms in geriatric age

After reviewing the literature on the subject, the authors examine all the cases of aortic aneurysm referred to their attention. From the tests performed, they note that males are most often affected and the age group with the highest incidence is the seventh decade of life, in particular between 60-66 years old. After having observed a pulsing abdominal mass leading to a suspected diagnosis, the radiological methods recommended by the authors include echotomography or CT, or if required, magnetic resonance. Arteriography is less convincing than the previous tests for diagnostic purposes because, as well as providing a false image of the vessel lumen (owing to the overlay of stratified thrombi it can show a virtually normal lumen), it may cause a risk of embolism. The surgeon therefore prefers an intraoperative finding in the case of subrenal aneurysm. In conclusion, faced with a diagnosis of aneurysm of the abdominal aorta, in the majority of cases, having prepared the patient, it is necessary to perform aorto-bisiliac or bifemoral graft surgery depending on aneurysm size as soon as possible in order to avoid the fissuration or even the rupture of the aneurysm.     

An unusual presentation of simultaneous bilateral popliteal artery embolism--a case report

We present what we believe is the first case in the literature of carcinoma of the lung presenting de novo as an intracardiac mass with bilateral, simultaneous popliteal artery embolization. Arterial thromboembolism of cardiac origin and in situ thrombosis of a preexisting atherosclerotic lesion or aneurysm account for the majority of cases of acute lower extremity ischemia. Less common causes include trauma, aortic dissection, venous ischemia, and foreign body or tissue embolization. Although the history, physical examination, and electrocardiographic findings may provide a likely explanation in many cases, noninvasive studies such as echocardiography may help further elucidate the embolic source.     

Surgical treatment of pediatric laryngeal stenosis in the area of the ring cartilage

Nineteen patients of Thoraco-abdominal aortic aneurysm were operated during a nine year period. All were larger than 10 cm. in size. Four were operated in emergency. Seven underwent patch aortoplasty while eleven required tube inlay aortoplasty with visceral vessel reimplantation. One patient continued to be paraplegic postoperatively. Two (10.52%) had acute renal failure and there were two (10.52%) deaths. A sincere effort to keep the aortic and renal occlusion times to minimum and successful reimplantation of lower intercoastals and visceral branches appear to offer significant help in accomplishing successful repair with justifiable expectancy.     

Cardiovascular involvement in relapsing polychondritis

Relapsing polychondritis is an inflammatory disease that characteristically involves cartilagenous tissues. Cardiovascular involvement is a fairly common complication and the second most frequent cause of mortality in this disease. The case of a man with a progressive cardiac involvement, aortic incompetence, mitral regurgitation, and finally complete atrioventricular block offered the opportunity of reviewing the cardiovascular complications in relapsing polychondritis. The most frequent abnormalities are aortic regurgitation and aortic aneurysm. Furthermore, several cases of atrioventricular block, mitral regurgitation, and acute pericarditis have been reported. For early diagnosis and treatment of these severe complications, periodic cardiovascular examination is mandatory in these patients.     

Popliteal venous aneurysm: report of two cases and review of the world literature

Two new cases of popliteal venous aneurysm are reported and added to the 22 other cases of popliteal venous aneurysm available for review. Both patients were first seen with acute pulmonary embolism and were treated with thrombolytic therapy followed by anticoagulation. Each had recurrent venous thromboembolism before discovery of the popliteal venous aneurysm. One popliteal venous aneurysm was diagnosed with phlebography and the second with venous duplex imaging, confirmed with phlebography. Both were surgically corrected with tangential aneurysmectomy and lateral venorrhaphy. Twenty-four cases of popliteal venous aneurysm are now available for review. Seventy-one percent (17 of 24) presented with pulmonary embolism, 88% (21 of 24) were saccular, and 96% (23 of 24) were located in the proximal popliteal vein. All but two were diagnosed by ascending phlebography. Three patients received no treatment: in two of these the outcome was not documented and the third had occasional pain. Two patients received anticoagulation without subsequent operative repair and both died of recurrent pulmonary emboli. Operative correction resulted in a 75% patency rate with 21% complications, most of which were related to postoperative anticoagulation. No patient who was operated on had subsequent pulmonary embolism, and there were no operative deaths. We suggest that all patients who have pulmonary embolism have lower-extremity venous duplex imaging. All popliteal venous aneurysms should be surgically repaired, inasmuch as nonoperative therapy results in recurrent thromboembolism and an unacceptably high mortality rate. Tangential aneurysmectomy with lateral venorrhaphy is the recommended procedure.     

Left ventricular aneurysm and peripheral embolism as cause of atypical foot pain

Sudden occlusion of a peripheral artery by embolization or acute thrombosis results in acute ischemia. This is most commonly associated with sudden onset of severe pain, numbness and pallor. Chronic ischemia from peripheral vascular disease results in intermittent claudication. We present a case of peripheral embolization from a left ventricular aneurysm in a previously asymptomatic male who presented to the emergency department complaining of two weeks of pain in his left great toe. Included in the discussion are important diagnostic tests for peripheral thromboembolism and ventricular aneurysm as well as suggestions for emergency department management.