Adem Ucar

Improvement of Endothelial Dysfunction with Simvastatin in Patients with Autosomal Dominant Polycystic Kidney Disease

Cardiovascular problems are a major cause of morbidity and mortality in patients with autosomal dominant polycystic kidney disease (ADPKD). Endothelial dysfunction (ED), which is an early manifestation of vascular injury, has been shown in patients with ADPKD. Statins have a beneficial effect in the reversal of ED. The aim of this study was to investigate the effects of a statin, simvastatin, on ED in patients with ADPKD. Sixteen patients with ADPKD having well-preserved renal function were included in the study. Endothelial function of the brachial artery was evaluated by using high-resolution vascular ultrasound. Endothelial-dependent dilatation (EDD) was expressed as the percentage change in the brachial artery diameter from baseline to reactive hyperemia. After the baseline evaluations of EDDs, patients were started treatment with simvastatin at a dose of 40 mg/day and were treated for six months. EDDs were recalculated after one and six months of therapy. Interleukin-6 (IL-6) and high-sensitivity C-reactive protein were also measured as markers of inflammation. Baseline EDD was 11.3 ± 6.9% in patients with ADPKD. After one month of simvastatin treatment, EDD increased significantly to 14.6 ± 4.6 % (P = 0.016 versus baseline). Endothelial-dependent dilatation further increased significantly to 18.9 ± 7.5 % (P = 0.011 versus baseline, P = 0.048 versus first month) after six months of therapy. There was also a significant decrease in the level of IL-6 from 21.6 ± 21.7 pg/mL to 9.1 ± 3.5 pg/mL (P= 0.002). Six months of simvastatin therapy resulted in a significant improvement of ED in patients with ADPKD. This finding may be in part related to the pleiotropic effects of simvastatin.

Cesarean scar pregnancy: A rare cause of uterine arteriovenous malformation

A 38‐year‐old gravida 4, para 2 woman with a history of two Cesarean sections and one curettage was referred to our hospital, because of painless vaginal bleeding and 6 weeks + 2 days of amenorrhea. The first diagnosis was Cesarean scar pregnancy, managed with methotrexate. Subsequently, an arteriovenous malformation developed, which was diagnosed with color Doppler imaging. The diagnosis was confirmed with angiography. Successful bilateral uterine artery embolization was performed with ethylene vinyl alcohol copolymer (Onyx), n‐butyl‐2‐cyanoacrylate (Histoacryl), and gelfoam.

Sialoblastoma: MRI findings.

Sialoblastoma is a rare, aggressive and potentially malignant salivary gland tumour diagnosed in the neonatal period. A total of 28 cases have been reported in the literature, but reports of the imaging findings are limited. We describe a neonate with a right parotid sialoblastoma. MRI showed a large facial mass, which was mostly hypointense to the brain on T1-weighted images and mildly hyperintense on T2-weighted images. There were foci of haemorrhage and necrosis. Heterogeneous and weak contrast enhancement was detected on contrast-enhanced images. The tumour invaded the maxilla and adjacent muscles.

Our early experience with iliofemoral vein stenting in patients with post-thrombotic syndrome.

Introduction: Venous balloon dilation and stent therapy have been proposed as effective treatments for chronic iliofemoral thrombosis. In this study, we report our experience and describe the one-year outcome and efficacy of balloon angioplasty and stenting for the treatment of post-thrombotic syndrome (PTS) in iliofemoral vein segments. Methods: From June 2011 to June 2012, 52 consecutive patients with chronic PTS (59 limbs; 75% women; median age 58 years; range: 23–76 years) referred to our unit for interventional assessment were included in the study. Treatment effects were assessed using Villalta scale, Venous Clinical Severity Score (VCSS) and Chronic Venous Insufficiency Questionnaire (CIVIQ)-20 for PTS, CEAP (clinical, aetiological, anatomical and pathological elements) grading and measurement of leg circumference, before and after intervention. Results: Stenting was successfully accomplished in all patients. Coagulation abnormality was identified in 21 subjects (40.3%). CEAP grades were as follows: C3 in 19 patients, C4 in 24 patients, C5 in one patient and C6 in eight patients. According to Villalta scores, three patients were mild, seven patients were moderate and 42 patients were severe PTS. VCSS, Villalta scale and CIVTQ-20 showed a significant decrease in the severity of PTS signs and symptoms (P < 0.001). The calf and middle thigh circumferences decreased significantly on both sides (P < 0.001). Conclusion: Treatment of iliac venous obstruction with balloon angioplasty and stenting appears to be a minimally invasive and safe therapeutic approach in patients with PTS offering quick symptomatic relief, good patency and minimal morbidity.

Changes in endothelial function before and after renal transplantation

Endothelial dysfunction is an early key event in the development of atherosclerotic cardiovascular disease observed in chronic renal failure patients. The role of renal transplantation (RTx) on endothelial dysfunction is still unclear. The aim of this study was to evaluate the endothelial function of chronic renal failure patients before RTx (while they were on hemodialysis, HD), and after RTx (at the 6th and 12th months) by a noninvasive method, brachial arterial ultrasound. A total of 22 (17 male, mean age: 33.9 ± 11.6 years) RTx recipients were enrolled in the study. Endothelium‐dependent vasodilation (EDD) was assessed by establishing reactive hyperemia. EDD prior to transplantation was significantly lower when compared with EDD measured at the 6th and 12th months after RTx (EDD pretransplantation: 6 ± 3.7%, EDD at the 6th month of RTx: 8.3 ± 2.3% and EDD at the 12th month of RTx: 12.1 ± 3.6%, P < 0.001). When the EDD values measured at the 6th and 12th months of RTx were compared, measurements of the 12th month were found significantly higher than those of the 6th month (P < 0.001). Our results also showed that RTx has provided improvement in endothelial function by eliminating the uremic environment although not in the early post‐RTx period.

Hepatic pseudolesion around the falciform ligament: prevalence, aberrant venous supply, and fatty infiltration evaluated by multidetector computed tomography and magnetic resonance imaging.

Purpose: The aim of this study was to determine the prevalence and aberrant venous supply (inferior veins of Sappey) of hypoattenuating hepatic pseudolesions seen around the falciform ligament on portal-dominant phase multidetector computed tomography (MDCT) and the frequency of fatty infiltration of these pseudolesions on chemical-shift magnetic resonance imaging. Materials and Methods: Portal-dominant phase abdominal MDCT examinations of 728 patients were evaluated for the presence of a pseudolesion around the falciform ligament, and those with a presumed pseudolesion underwent chemical-shift magnetic resonance imaging to detect the fatty infiltration. Reconstructed MDCT images were investigated for the presence of an inferior vein of Sappey, and 30 patients without a pseudolesion were evaluated as a control group. Results: A total of 160 pseudolesions were detected around the falciform ligament in 146 (20%) patients. The longest diameter of the pseudolesions was in the craniocaudal direction in most patients (61%). An inferior vein of Sappey supplying these pseudolesions was depicted in 40 (27%) patients, and it was highly significant (P = 0.001) compared with the controls for the presence of a pseudolesion around the falciform ligament. Fatty infiltration was found in 47 (29%) patients. Conclusions: Hepatic pseudolesions around the falciform ligament are frequently encountered on portal-dominant phase MDCT images. Detection of craniocaudal extension, inferior veins of Sappey, and fatty infiltration of these pseudolesions, which were firstly described in this article, with the largest subject group based on cross-sectional imaging, might be valuable in excluding true tumors.

Final destination of an ingested needle: the liver.

Foreign body ingestion is a common problem in children, but it is also seen among adults. Most foreign bodies pass through the gastrointestinal tract without causing complications. Perforation of the gut by a foreign body, followed by migration of the foreign body to the liver is quite rare. Herein we report a case of inadvertent ingestion of a sewing needle that perforated the duodenum and migrated to the liver. The patient was monitored weekly with abdominal radiographs, but displacement of the needle could not be observed. At follow-up, right upper quadrant pain was noted. Two weeks later, computed tomography revealed that the needle was completely buried into the right lobe of the liver. Ultrasonographic examination successfully showed the extracapsular displacement of the needle. Eventually, laparoscopic removal of the needle was easily performed.

Local thrombolytic therapy in acute mesenteric ischemia.

BackgroundThe aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI).MethodsFrom January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator.ResultsLTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45–87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining.ConclusionEarly intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.

Combination of unicuspid aortic valve, aortic coarctation, and aberrant right subclavian artery in a child: MR imaging and CTA findings.

Unicuspid aortic valve is a rare, but well-described congenital valve anomaly in the pediatric population. However, series of congenital unicuspid aortic valves in adults are limited. The estimated incidence of congenital unicuspid aortic valve in an adult echocardiographic population was reported to be about 0.02% [1]. It is often discovered during surgery or autopsy and can easily be mistaken for a bicuspid aortic valve, which, in contrast, is a common congenital cardiac anomaly occurring in up to 2% of live births [2, 3]. Multiplanar and biplanar transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) are widely used diagnostic imaging tools for aortic valve abnormalities. Multiplanar TEE is found to be much more sensitive and specific in determining the anomalies [3]. A few cases of unicuspid aortic valve with coexisting anomalies detected by echocardiography have been reported [1, 4]. However, to the best of our knowledge, the combination of unicuspid aortic valve with aortic coarctation and aberrant right subclavian artery has not been reported previously. Furthermore, we assume that this is the first case report depicting magnetic resonance (MR) imaging and computed tomography angiography (CTA) findings of unicuspid aortic valve with coexisting anomalies.

Spontaneous thrombosis of uterine artery pseudoaneurysm: Follow‐up with doppler ultrasonography and interventional management

Iatrogenic uterine arterial injury is one of the possible causes of pseudoaneurysm formation occurring during pelvic or obstetrical surgery. Cesarean delivery is the commonest cause. Repeat vaginal bleeding is the most frequent symptom, but fever and lower abdominal pain have also been reported. Doppler sonography (US) has been used to detect a pelvic pseudoaneurysm. Transcatheter arterial embolization of the uterine artery is a highly effective, relatively minimally invasive method for treating such condition. A 21-year-old primigravida was admitted to our hospital with a history of repeated vaginal bleeding following a Cesarean section that she underwent 2 months earlier. Transvaginal color Doppler US (TV-CDUS) examination showed a 14 mm 12 mm pseudoaneurysm arising from the left uterine artery at the isthmic level. The pseudoaneurysm was located in the myometrium and had a thin, peripheral rim-like thrombosis (Figure 1). Catheter angiography performed 2 days later did not reveal filling of the pseudoaneurysm, and there was no extravasation of contrast. TV-CDUS immediately after angiography revealed a spontaneous total thrombosis of the pseudoaneurysm (Figure 2). The patient was clinically stable and vaginal bleeding had ceased for 36 hours. Because most of the pseudoaneurysm had thrombosed spontaneously and there was no angiographic finding, conservative management was recommended. On follow-up TV-CDUS 2 days later, a complete thrombosis of the pseudoaneurysm was observed but, 1 day later, the patient was readmitted with vaginal bleeding. Taking into account a possible hemorrhage from the other probably injured uterine artery (which could be occult on angiography and could also be due to rebleeding of the thrombosed pseudoaneurysm), transarterial embolization of both uterine arteries with gelfoam was undertaken. The patient has not suffered from any vaginal bleeding after the embolization. A pseudoaneurysm of the uterine artery is a rare complication of pelvic surgery but may result in life-threatening complications such as massive vaginal hemorrhage. In general, pseudoaneurysms are thrombosed in a centripetal manner (from the periphery to the center) like in our case. CDUS can elegantly demonstrate the sequence of steps leading to the complete thrombosis of the pseudoaneurysm. In some circumstances, a pseudoaneurysm cannot be demonstrated on angiography. Transarterial embolization of the uterine arteries is a safe and effective means of controlling secondary postpartum hemorrhage. In our case, according to TV-CDUS findings, the pseudoaneurysm completely thrombosed in a short period of time, and angiography was negative. We could not exclude hemorrhage from the contralateral uterine artery (which may have been injured during previous surgery), so bilateral uterine arteries were embolized. In conclusion, a spontaneous thrombosis of a uterine artery pseudoaneurysm can occur. TVCDUS provides sufficient information to detect and follow-up the progress of the thrombosis.