Fahri Tercan

Compression of the left common iliac vein in asymptomatic subjects and patients with left iliofemoral deep vein thrombosis.

PURPOSE To retrospectively evaluate compression of the left common iliac vein as demonstrated at computed tomography (CT) in patients with iliofemoral deep vein thrombosis due to iliac vein compression syndrome (IVCS) and compare compression ratios with those of asymptomatic subjects. MATERIALS AND METHODS Between March 2003 and June 2007, compression of the left common iliac vein by the right common iliac artery, as demonstrated with CT, in 34 patients (25 women and nine men; mean age, 51 years; age range, 21-79 years) with IVCS was retrospectively evaluated. Compression ratios were compared with those of 34 age- and sex-matched asymptomatic subjects. A t test was used to compare the compression ratios. RESULTS The percentages of compression of the left common iliac vein were 45%-100% (mean, 74% +/- 17) for patients with IVCS and 0%-68% (mean, 28% +/- 20) for control subjects (P < .05). Of the 34 patients with IVCS, 11 (32%) had less than 70% compression and 23 (68%) had at least 70% compression. CONCLUSIONS There was considerable overlap between the degree of compression in patients with IVCS and control subjects. Compression of the left common iliac vein was significantly more prominent in patients with lower extremity deep vein thrombosis due to IVCS when compared with control subjects. Compression in excess of 70% as demonstrated at CT can be helpful for identifying possible underlying IVCS in patients with a left lower extremity deep vein thrombosis.

Is Routine Preoperative Ultrasonographic Mapping for Arteriovenous Fistula Creation Necessary in Patients with Favorable Physical Examination Findings? Results of a Randomized Controlled Trial

IntroductionPreoperative ultrasonographic mapping (PUSM) is widely used for arteriovenous fistula creation in end-stage renal disease patients, and some authors even advocate that it be used routinely. To date, however, there are no prospective randomized data to support this suggestion.MethodsThis prospective, randomized, controlled study compared PUSM and physical examination in relation to short-term outcome after AVF creation. Data sets from 70 hemodialysis patients who were deemed eligible for AVF surgery—according to specific physical examination (PE) criteria for vessel anatomy—were analyzed. The patients were randomly divided into two groups. In the PE group, no other investigation was performed, and the patient underwent AVF creation. The other patients (M group) underwent PUSM, and the AVF was created according to the mapping results. Early AVF success was defined as clinical detection of thrill (immediately and on postoperative day 1). Ultrasonographic parameters were recorded on the first postoperative day and at 1 and 6 months postoperatively. The need for intervention and intervention-free AVF survival and cumulative AVF survival were also noted.ResultsThe PE and M groups showed similar rates of early AVF success: immediate thrill, PE 24/35 (68.6%) vs. M 26/33 (78.8%), P = 0.340; postoperative day 1, PE 20/34 (58.8%) vs. M 24/32 (75%), P = 0.164. The groups’ results for ultrasonographic parameters of AVF function were also similar on postoperative day 1 and at 1 month after surgery. The groups had similar intervention-free AVF survival (P = 0.770) and cumulative AVF survival as well (P = 0.916). After an average follow-up of 217.7 ± 239.7 days, the two groups also had similar proportions of patent AVFs: 23/35 (65.7%) vs. 23/35 (65.7%) for PE vs. M, respectively; P = 1.0).ConclusionsThe results indicate that PUSM offers no advantage over PE with regard to AVF function in patients with favorable forearm anatomy. The authors do not advocate routine use of PUSM in patients with favorable PE findings scheduled for forearm AVF creation.

Rupture of the Renal Artery After Cutting Balloon Angioplasty in a Young Woman With Fibromuscular Dysplasia

A 24-year-old woman with uncontrollable high blood pressure for 3 months had significant stenosis of the left renal artery caused by fibromuscular dysplasia (FMD). The lesion was resistant to percutaneous transluminal angioplasty at 18 atm with a semicompliant balloon. Angioplasy with a 6 × 10 mm cutting balloon (CB) caused rupture of the artery. Low-pressure balloon inflation decreased but did not stop the leak. An attempt to place a stent-graft (Jostent; Jomed, Rangendingen, Germany) failed, and a bare, 6-mm balloon-expandable stent (Express SD; Boston Scientific, MN) was deployed to seal the leak, which had decreased considerably after long-duration balloon inflation. The bleeding continued, and the patient underwent emergent surgical revascularization of the renal artery with successful placement of a 6-mm polytetrafluoroethylene bypass graft. CBs should be used very carefully in the treatment of renal artery stenosis, particularly in patients with FMD.

Unusual radiologic manifestations of the echinococcus infection in the thorax.

Unusual location and presentation of hydatid cyst disease in the thorax requires careful consideration with respect to clinical approach and therapy. In this pictorial essay, we present imaging findings and describe treatment of thoracic hydatid cysts in patients with lung, mediastinal, chest wall, cardiac, endobronchial, pulmonary artery, and diaphragmatic involvement. A review of the literature is also included.

Atherosclerotic Risk Factors and Segmental Distribution in Symptomatic Peripheral Artery Disease

PURPOSE To determine the distribution of atherosclerotic peripheral artery disease (PAD) and associated risk factors in patients who have undergone pelvic and lower-limb angiography. MATERIALS AND METHODS Records of 626 consecutive patients (88 women, 538 men; mean age, 62 years; age range, 31-85 y) with PAD were retrospectively reviewed. Severity of limb ischemia was staged according to Rutherford classification of PAD. The arterial system was divided into three segments including aortoiliac, femoropopliteal, and crural segments. PAD was defined as a greater than 50% stenosis or occlusion of any segment. Univariate and multivariate analyses were used to determine associations between segmental arterial disease and patient demographics, medical history, and angiographic findings. RESULTS Of the 626 patients, 400 (64%) had multisegmental disease, the most common form of which was combined femoropopliteal and crural disease (25%). A significant association was found between severity of limb ischemia and distribution of PAD. Intermittent claudication was significantly associated with aortoiliac disease (odds ratio, 2.15; P < .001), whereas critical limb ischemia was associated with crural disease (odds ratio, 2.5; P = .001) on multivariate analysis. Significant associations were found between smoking and aortoiliac, femoropopliteal, and multisegment disease; between diabetes mellitus and crural disease; and between age and femoropopliteal and multisegment disease. CONCLUSIONS PAD was multisegmental in most of the patients in this study group. Different clinical risk factors predict the involvement of different arterial segments. Severity of limb ischemia was significantly associated with the distribution of PAD.

Primary hepatic carcinoid tumor: dynamic CT findings

Most carcinoid tumors involve the gastrointestinal tract or respiratory system. Primary hepatic carcinoid tumor is a rare entity. A 46-year-old woman presented with abdominal pain, vomiting, and diarrhea. She was diagnosed with primary hepatic carcinoid tumor based on radiologic and laboratory findings, namely a mass in the fifth segment of the liver and markedly elevated levels of 5-hydroxyindole acetic acid in the urine. Histologic and immunohistochemical findings of the resected liver segment showed a malignant carcinoid tumor of the liver. This case is of interest because of the rarity of this neoplasm. This report describes the case and reviews the clinical features, radiologic findings, and treatment in previously reported cases.

Manual aspiration thrombectomy with stent placement: rapid and effective treatment for phlegmasia cerulea dolens with impending venous gangrene.

Phlegmasia cerulea dolens is an uncommon but potentially life-threatening complication of acute deep vein thrombosis. It is an emergency and delay in treatment may cause death or loss of the patient’s limb. Surgical thrombectomy is the recommended treatment in venous gangrene. Catheter-directed intrathrombus thrombolysis has been reported as successful, but it may require a lengthy infusion. Manual aspiration thrombectomy may clear the entire thrombus with no need for thrombolytic administration and provide rapid and effective treatment for patients with phlegmasia cerulea dolens with impending venous gangrene.

Successful Endovascular Treatment of Iliac Vein Compression (May-Thurner) Syndrome in a Pediatric Patient

A 10-year-old boy presented to our clinic with left lower extremity swelling present for 1 year with deterioration of symptoms during the prior month. Laboratory investigation for deep vein thrombosis was negative. Venography and computed tomography scan of the pelvis showed compression of the left common iliac vein by the right common iliac artery. A diagnosis of iliac vein compression syndrome was made. After venography, endovascular treatment was planned. The stenosis did not respond to balloon dilatation and a 12 mm Wallstent was placed with successful outcome. The patient’s symptoms improved but did not resolve completely, probably due to a chronically occluded left superficial femoral vein that did not respond to endovascular recanalization. To the best of our knowledge, this is the first case of successful endovascular treatment of iliac vein compression syndrome with stent placement in a pediatric patient.

Catheter-Directed Thrombolysis of Acute Deep Vein Thrombosis in the Lower Extremity of a Child with Interrupted Inferior Vena Cava

We present the case of a 14-year-old girl who developed acute deep vein thrombosis (DVT) in her right lower extremity. Laboratory testing revealed protein S deficiency, and the patient’s father also had this abnormality with a history of lower extremity DVT. Manual thromboaspiration followed by catheter-directed thrombolysis resulted in total clearance of all thrombi. Computed tomography and later venography revealed an interrupted inferior vena cava. Catheter-directed thrombolysis is an established treatment for adults with acute DVT. To the best of our knowledge, this report is the first to describe catheter-directed thrombolysis in a pediatric patient with lower extremity DVT. Our results suggest that catheter-directed thrombolysis is safe and effective for use in selected older children and adolescents with acute DVT in the lower extremity.

Percutaneous treatment of portal vein thrombosis in a child who has undergone splenectomy

Thrombosis of the portal venous system is a well-recognized and potentially lethal complication after open or laparoscopic splenectomy. A 7-year-old girl with idiopathic thrombocytopenic purpura developed a portal vein thrombosis after open splenectomy. The portal vein thrombosis was diagnosed by color Doppler sonography. A percutaneous transhepatic thromboaspiration of the acute thrombus was done on the third postoperative day. Anticoagulation was continued for 6 months. The presented patient is the youngest patient to undergo percutaneous thromboaspiration of an acute thrombus via the transhepatic route. Percutaneous thromboaspiration via the transhepatic route is an effective means of treating a portal vein thrombosis.