Vishal Kumar

CT-detected traumatic small artery extremity injuries: surgery, embolize, or watch? A 10-year experience

Advances in computed tomography (CT) angiography have increased the sensitivity and specificity of detecting small branch arterial injuries in the extremities of trauma patients. However, it is unclear whether these patients should undergo surgery, angioembolization, or conservative watchful waiting. We hypothesized that uncomplicated small arterial branch injuries can be managed successfully with watchful waiting. A 10-year retrospective review of extremity CT angiograms with search findings of arterial “active extravasation” or “pseudoaneurysm” was performed at a level 1 county trauma center. Subgroup analysis was performed on those with isolated extremity injury and those with concurrent injuries. A total of 31 patients had CT-detected active extravasation (84xa0%) or pseudoaneurysm (16xa0%), 71xa0% of which were isolated vascular injuries. Of the patients evaluated, 71xa0% (nu2009=u200922) were managed with watchful waiting, 19xa0% (nu2009=u20096) with angioembolization, and 10xa0% (nu2009=u20093) with surgery. Watchful waiting complications included progression to alternative treatment (nu2009=u20091) and blood transfusions (nu2009=u20092). Complications of surgery included the inability to find active bleeding (nu2009=u20091) and postoperative psychosis (nu2009=u20091). Complications of angioembolization were limited to a postprocedure blood transfusion (nu2009=u20091). Patients with isolated vascular injuries had an average length of stay of 2.9xa0days, with management averages of the following: 2.7xa0days with watchful waiting (nu2009=u200916), 3.3xa0days with angioembolization (nu2009=u20093), and 3.7xa0days with surgery (nu2009=u20093). CT angiography has greatly increased the reported incidence of traumatic arterial injury in the extremity. We propose that small branch arterial injuries in the extremities can be managed successfully with watchful waiting and do not often require immediate embolization.

Endovascular Biopsy and Endothelial Cell Gene Expression Analysis of Dialysis Arteriovenous Fistulas: A Feasibility Study

PURPOSEnTo demonstrate feasibility of endothelial cell (EC) biopsy from dialysis arteriovenous fistulas (AVFs) with the use of guidewires and to characterize gene expression differences between ECs from stenotic and nonstenotic outflow vein segments.nnnMATERIALS AND METHODSnNine consecutive patients undergoing fistulography for AVF dysfunction from June to August 2016 were enrolled. ECs were biopsied with the use of guidewires from venous outflow stenoses and control outflow veins central to the stenoses. ECs were sorted with the use of flow cytometry, and the Fluidigm Biomark HD system was used for single-cell quantitative polymerase chain reaction (qPCR) analysis of gene expression. Forty-eight genes were assessed and were selected based on different cellular functions and previous literature. Linear mixed models (LMMs) were used to identify differential gene expression between the groups, and self-organizing maps (SOMs) were used to identify cell clusters based on gene coexpression profiles.nnnRESULTSnA total of 219 and 213 ECs were sampled from venous outflow stenoses and control vein segments, respectively. There were no immediate biopsy-related complications. Forty-eight cells per patient were sorted for qPCR analysis. LMM identified 7 genes with different levels of expression at stenotic segments (P < .05), including AGTR-2, HMOX-2, MTHFR, SERPINC-1, SERPINE-1, SMAD-4, and VWF. SOM analysis identified 4 cell clusters with unique gene expression profiles, each containing stenotic and control ECs.nnnCONCLUSIONSnEC biopsy from dialysis AVFs with the use of guidewires is feasible. Gene expression data suggest that genes involved in multiple cellular functions are dysregulated in stenotic areas. SOMs identified 4 unique clusters of cells, indicating EC phenotypic heterogeneity in outflow veins.

Operator Dose Reduction during Transjugular Liver Biopsy Using a Radiation-Attenuating Drape: A Prospective, Randomized Study

PURPOSEnTo assess the effectiveness of disposable radiation-absorbing surgical drapes on operator radiation dose during transjugular liver biopsy (TJLB).nnnMATERIALS AND METHODSnThis dual-arm prospective, randomized study was conducted between May 2017 and January 2018 at a single institution. TJLB procedures (Nxa0= 62; patient age range, 19-80 y) were assigned at a 1:1 ratio to the use of radiation-absorbing surgical drapes or standard surgical draping. The primary outcome was cumulative radiation equivalent dose incident on the operator, as determined by an electronic personal dosimeter worn at the chest during each procedure. Cumulative kerma-area product (KAP), total fluoroscopy time, and total number of exposures used during each liver biopsy procedure were also determined.nnnRESULTSnMean radiation dose incident on the operator decreased by 56% with the use of radiation-absorbing drapes (37 μSv ± 35; range, 4-183 μSv) compared with standard draping (84 μSv ± 58; range, 11-220 μSv). Radiation incident on the patient was similar between groups, with no significant differences in mean KAP, total fluoroscopy time, and number of exposures acquired during the procedures.nnnCONCLUSIONSnUse of disposable radiation-absorbing drapes reduces scatter radiation to interventionalists performing TJLB.

Percutaneous embolization of post traumatic splenic pseudoaneurysm

Management of splenic pseudoaneurysms in hemodynamically stable patients has shifted toward nonoperative management, including watchful waiting and endovascular embolization. Standard of treatment does not include percutaneous embolization for splenic pseudoaneurysm repair. In this case report, we document a successful percutaneous embolization of a post traumatic splenic pseudoaneurysm with thrombin. Percutaneous embolization of splenic pseudoaneurysms can be considered a viable technique in patients who fail endovascular embolization or have lesions inaccessible to endovascular repair.

Solitary fibrous tumor in the abdomen and pelvis: A case series with radiological findings and treatment recommendations☆

This study presents the radiological findings of seven cases of solitary fibrous tumor (SFT) in the abdomen and pelvis. A retrospective search of the pathology database at our institution was performed to identify cases of SFT in the abdomen and pelvis. After identifying seven cases, cross-sectional imaging was reviewed and characterized. We conclude that SFTs in the abdomen and pelvis should be considered with well-defined, circular, hypervascular masses. Pelvic SFTs should be considered with homogenous, avidly enhancing masses. Embolization of feeding arteries can allow safe surgical resection or biopsy, but embolization appears to not offer a definitive therapy.

Herpes-associated erythema multiforme worsened by a Siddha drug, Alpinia galanga, in an 18-year-old man

An 18-year-old man with fever and headache for 1u2005week was prescribed with capsules containing Alpinia galanga by a Siddha physician.Three days later, the patient developed extensive crustations on the lower lip. A provisional diagnosis of erythema multiforme was made with this drug history and, after further investigation, herpes-associated erythema multiforme (HAEM) was made. The patient was managed with a 1-week course of tablet acyclovir and prednisolone. This case details the role of A. galanga in exasperating HAEM and also describes its management approach.nnA. galanga belongs to Zingiberaceae (the ginger family). Its rhizome (rootstock) is commonly used in herbal medicine and as a spice in food. Its pharmacological actions are anti-inflammation, antioxidation, antiallergy, gastroprotection, hypoglycaemic effect and marked immunostimulation. An erythema multiforme-like reaction caused by A. galanga is due to the haptens present in it. The haptens in A. galanga are also strong allergens to T cells and provoke a T-cell-mediated immune response. Mechanisms of tissue damage include direct cytotoxicity against keratinocytes, mostly mediated by CD8+ T cells, and the T -cell release of cytokines that amplify the inflammatory response by targeting resident skin cells.1nnErythema multiforme is an acute and self-limiting mucocutaneous hypersensitivity reaction triggered by certain …