Akitoshi Sasamoto

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: Report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.

Upper extremity ischemia in athletes : Embolism from the injured posterior circumflex humeral artery

Upper extremity ischemia in athletes is caused by embolism from the proximal arterial compromise at the thoracic outlet or under the pectoralis minor. The posterior circumflex humeral artery (PCHA), a branch of the third part of the axillary artery, can also be injured by repetitive overhead activity including the tennis or volleyball game, resulting in aneurysm formation or thrombotic occlusion, and this lesion could be a source of distal embolism. We report two patients with complaints of hand and forearm ischemia due to distal embolism from the aneurysm in one patient and thrombotic occlusion of the PCHA in the other. The former was a 20-year-old amateur tennis player. Angiography revealed an aneurysm of the PCHA and multiple distal embolism. He was treated by resection of the aneurysm and thromboendarterectomy with vein patchplasty of the occluded ulnar artery. Five years after surgery now, he can enjoy playing tennis without new embolic events, although he still has mild ischemic symptoms during playing tennis. The latter was a 17-year-old volleyball player. Angiography showed thrombotic occlusion of the PCHA and embolic occlusion of the digital arteries. Surgical intervention was not required because he decided not to play volleyball. Two years later now, he has had no new episodes of embolism, although he has ischemic symptoms only when cold.