Bartosz Żabicki

CT-assisted transfemoral intrahepatic portosystemic shunt in a long duration follow-up: A case report

Summary Background Transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension may be considered as a rescue therapy in case of recurrent variceal bleeding or failure of endoscopic management. Case Reports We present a case of a patient with massive gastroesophageal variceal bleeding refractory to numerous endoscopic treatments in which TIPS was considered in an attempt to decrease the risk of potentially fatal rebleeding. Standard TIPS procedure was not feasible due to altered anatomy of the liver resulting from right hemidiaphragmatic paresis. Computed Tomography (CT) fluoroscopic guidance was utilized for direct percutaneous puncture of the left hepatic and left portal vein with subsequent guidewire snaring to perform portosystemic shunting via femoral access. Since the procedure, no recurrent variceal bleeding was reported and the shunt remained patent at a 3-year follow-up. Although stent fracture with fragment migration was observed. Conclusions Significant variation in liver anatomy does not preclude the creation of nonsurgical portosystemic shunt. In these cases, combined percutaneous and endovascular technique may be utilized.

CT-Guided Thrombin Injection to Control Rapid Expansion of Ascending Aortic False Aneurysm 15 Months After Bentall–Bono Operation

We report a case of 57-year-old man treated emergently with CT-guided local thrombin injection as the first, life-saving step for control rapid expansion of the aortic pseudoaneurysm. Fifteen months earlier, he was operated on for ascending aortic true aneurysm and coronary artery disease. Upon admission, he had an anterior thoracic wall pulsatile tumor. Due to critical status, definite surgery was postponed and thrombin was injected close to the origin of pseudoaneurysm. It controlled successfully, bleeding from the ascending aorta and enabled the patient to survive the acute phase.

Endovascular Treatment of Arteriovenous Malformation

Vascular anomalies are common congenital or neonatal abnormalities. According to the approved classification of vascular lesions by Glowacki and Mulliken, hemangiomas and vascular malformations are distinguishable. Hemangiomas usually appear during the first days or weeks after birth and grow faster than the whole body of the infant. They are proliferating benign tumors that often involute. The opposite of hemangiomas, vascular malformations are present at birth, grow commensurately with the patient, demonstrate normal endothelial turnover, and never involute. The case of a young woman with an arteriovenous malformation (AVM) located on the left side of her face beneath the lower lip is described. The patient did not have any specific complaints except the cosmetic effect, which was a reddish and bluish discoloration of the skin over the lesion. The AVM was embolized with polyvinyl alcohol, and no subsequent surgery was performed. Follow-up ultrasound examination after a 12-month period showed no flow within the lesion area.

Eyelid arteriovenous malformation treated with pre-surgical embolization: A case report:

Background Arteriovenous malformations are potentially serious vascular anomalies that are rarely encountered in the eyelid and require a multidisciplinary approach. Objectives We would like to describe the technical and clinical aspects related to the treatment of palpebral arteriovenous malformation with selective embolization, followed by surgical resection. Methods A 40-year-old patient presented with an isolated high-flow palpebral arteriovenous malformation. Transarterial embolization, using a liquid embolic agent (PHIL™), was performed in this patient. Results Angiographic and clinical follow-up revealed good results with clinical regression of the mass. Conclusion Although endovascular treatment of palpebral arteriovenous malformations is technically challenging, good functional and cosmetic result was achieved. Arteriovenous malformation embolization using PHIL™ seems to be very effective and makes subsequent surgical procedure safe and feasible. Level IV Evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

An asymptomatic giant thoracoabdominal aortic aneurysm

Giant ascending and descending aorta aneurysm with coexistent abdominal aorta aneurysm in a non-Marfan patient is a very rare condition; however, huge ascending aorta aneurysms, alone or with concomitant aortic arch enlargement, are frequently reported in literature. The occurrence of chest pain is one of the most common symptoms accompanying thoracic aorta aneurysm, so the complete absence of the patient’s symptoms in such a large aortic pathology is interesting for physicians involved in the management of elderly patients with aortic aneurysms. A 52-year-old man was admitted to our hospital due to casual disclosure of a giant aneurysm of ascending, descending, and abdominal aorta for further evaluation. Thoracic aortic aneurysm was suspected at the chest X-ray, performed due to scheduled orthopaedic surgery. Imaging revealed suggestive enlargement of the mediastinum (Fig. 1A). Besides a diagnosis of epilepsy since childhood the patient was generally asymptomatic. He had no family history of connective tissue diseases and no signs of Marfan syndrome. Blood inflammatory parameters, antinuclear and antineutrophil cytoplasmic antibodies, as well as syphilis tests (VDRL) were negative. The trans-thoracic echocardiography showed enlargement of left ventricle (67 mm), hypertrophy of posterior wall (13 mm) and interventricular septum (12 mm), and an ascending aortic aneurysm with severe aortic regurgitation with backflow in the descending aorta and preserved ejection fraction of 55%. Computed tomography angiography (CTA) confirmed an aneurysm of ascending aorta maximally 82 mm in diameter (Fig. 1B, C). The thoracic aorta reduced stepwise in size and reached 30 mm in the aortic arch. The descending aorta was also enlarged to 74 mm in diameter with an eccentric thrombus in its lumen (Fig. 1D). Additionally performed magnetic resonance angiography showed the spread of the aneurysm into the suprarenal part of the abdominal aorta (Fig. 1E). Moreover, in CTA of coronary arteries aneurysmal enlargement of proximal part of left anterior descending artery was found at the level of the first diagonal branch (10 × 6 mm). The patient did not consent to invasive treatment. Although ascending aortic aneurysm is a frequent entity, the size and range of aortic pathology in our patient make such a case rare. Furthermore, the natural history of untreated aortic aneurysm indicates very high incidence of death because of rupture or dissection, and the size of the aneurysm is the most important predictor. However, the benefit-risk ratio of surgical treatment requires thorough evaluation.

Dislocation of a bare metal stent from the left main coronary artery to the right internal carotid artery.

Dislocation of a coronary stent to the peripheral arterial systems is a rare complication after percutaneous transluminal coronary angioplasty (PTCA), with an estimated incidence ranging from 0.9% to 8.4%. It may remain asymptomatic or cause acute ischaemia. We present a case of an asymptomatic migration of a bare metal stent (BMS) from the left main coronary artery (LMCA) to the right internal carotid artery (RICA), treated with carotid arteriotomy. A 67-year-old male was admitted to our department due to the presence of a foreign body in the RICA. Previously he underwent PTCA with implantation of BMS (Liberte 5.0 × 16 mm) into dissected LMCA. After four months he was scheduled for another PTCA, which revealed dislocation of the stent into RICA (Fig. 1). As a cardiologist failed to remove the stent during PTCA, the patient was referred to the tertiary cardiology ward in our hospital for further treatment. Endovascular removal of BMS was attempted in the next few days by a radiologist without success. A decision for surgical intervention was made and the patient was transferred once again to a new department. Four days later he underwent standard carotid arteriotomy. The BMS firmly attached to the RICA internal wall and protruding into the common carotid was fully exposed and totally excised (Fig. 2). The thrombotic material in the stent was scarce, probably due to the pharmacological therapy with two antiplatelet drugs. Postoperative course was uneventful and the patient was discharged home after three days. In the follow-up he remains well and in good condition. To the best of our knowledge the dislocation of BMS to RICA was not previously described in medical literature. The casuistic papers comment mainly on migration of drug-eluting stents to certain arteries such as external iliac, femoral, deep femoral, peroneal, and tibial artery. If symptoms of acute ischaemia occurred, the patients underwent endovascular or surgical procedure. Asymptomatic patients were observed. There were two described cases of dislocation to carotid arteries. The first one was asymptomatic, mimicking only carotid stenosis. Another one presented as acute thrombotic occlusion and cerebral infarction. Both patients underwent standard carotid thrombectomy. We believe that prompt extraction of migrated stents is mandatory in cases manifesting with acute ischaemia as well as in asymptomatic dislocations at the level of vessel bifurcations like femoral, brachial, and, above all, carotid. With great certainty, it prevents intimal injury, adherence to the internal wall, and thrombotic occlusion of the arteries.

Altered course of non-affected left coronary artery as a reason for symptoms of coronary artery disease

Anomalies of coronary arteries are rare (about 0.3–1.3% of patients undergoing a coronary angiography procedure), and left coronary artery (LCA) going from the right sinus of Valsalva (RSV) is described in 0.09–0.15% of cases. We present the case of a 61-year-old female who complained of typical angina symptoms for two years. A cardiac stress test was performed with positive result. The patient was admitted to hospital for coronary catheterisation. Electrocardiogram (ECG) revealed: sinus rhythm 66/min, with T-wave inversion in leads III and aVF and ST depression in leads V4–V6. Echocardiography showed: no segmental wall motion abnormalities and ejection fraction 65%. A coronary angiography was performed. Anomalous origin of LCA from the RSV was observed. Apart from that, the coronary arteries were not affected. Because coronary angiography reveals only two-dimensional views, coronary computed tomography angiography was performed to evaluate the detailed anatomy and course of the coronary arteries. A study was performed with ECG gating at 56–61 bpm using a retrospective acquisition technique. Anatomy and patency of coronary arteries was evaluated using dedicated coronary software. Coronary arteries and their braches were free of plaques, which might have caused significant stenoses and related symptoms. RSV was a source of short common trunk, which bifurcated into the right coronary artery (RCA) and LCA (Fig. 1). The RCA followed its typical anatomical course, and the LCA ran to the left, initially between the right ventricular outflow tract and ascending aorta, and subsequently within the basal anterior segment of the intraventricular septum (Fig. 2A, B). Intramuscular segment supplied the branch corresponding with the diagonal (D1) branch of left anterior descending artery (LAD) and a tiny branch that seemed to supply the intraventricular septum. Further segments of the LCA anatomically corresponding to the LAD ran in epicardial fat tissue giving an origin to the left circumflex artery and its obtuse marginal branches. The type of anomalous course of LCA described in our patient (inter-arterial) has the worst prognosis and is associated with sudden cardiac death (> 50%), especially connected with exercise. For that reason the case of our patient is also unusual. As a young woman she practiced athletics for several years. Her professional work was connected with great physical effort. And finally she gave birth to three children (forces of nature). None of these situations provoked any symptoms. At the time of writing, the state of the patient is stable, so she has been offered optimal medical treatment.