Abstract 17056: Report Of An Adult Living With Undiagnosed Total Anomalous Pulmonary Venous Return

Case Presentation: 25-year-old male presented with cellulitis and abscess of the lower extremity. He was an immigrant from Guatemala. He worked in landscaping and played soccer with limited exertion. His exam was notable for cyanosis and clubbing of all digits. A II/VI systolic ejection murmur at the left upper sternal border and a mildly accentuated P2 was auscultated. ECG was notable for right axis deviation and right ventricle hypertrophy. Chest x-ray showed a widened mediastinum with perihilar vascular prominence. CT chest with contrast demonstrated all pulmonary veins forming a large, coalescing venous structure draining into the left innominate vein. Transthoracic echocardiogram confirmed total pulmonary venous return by way of a large vertical vein draining into a dilated innominate vein and a 2.7 cm ostium secundum ASD. Discussion: Total anomalous pulmonary venous return (TAPVR) is a rare, often deadly condition. Most patients die in infancy. In the rare adult patient with unrepaired TAPVR, exercise intolerance, cyanosis, clubbing of the digits, and growth retardation is often noted. A right ventricular heave with auscultation of a fixed, split second heart sound with a loud pulmonic component is common. On chest x-ray, the classic “snowman” appearance is seen with vertical vein connections as in our patient. Right heart enlargement represents the base, and an enlarged connecting vertical vein and SVC make up the upper portion. Echocardiography can demonstrate the anomalous pulmonary venous conduit coursing behind the left atrium. CT angiography can also reveal TAPVR and the patient’s specific anatomy. Amongst the few surviving adult TAPVR patients, similar characteristics include large ASDs, short anomalous veins, and absence of pulmonary venous obstruction. A large interatrial connection provides adequate systemic flow. The latter two factors reduce pulmonary vascular resistance, hence improving pulmonary flow and systemic oxygen concentrations.

Arteriovenous fistula of the clival diploic vein associated with arteriovenous fistula of the posterior condylar canal

We herein report a rare case of a patient with a clival diploic vein arteriovenous fistula (AVF) associated with a posterior condylar canal AVF and discuss the radiological features of clival diploic vein AVF during decision-making on treatment strategies. A 69-year-old male patient with one-year history of pulsatile tinnitus was evaluated with magnetic resonance angiography, which revealed a dilated venous structure. Digital subtraction angiography revealed AVFs located in the clivus and posterior condylar canal. The clival diploic vein AVF was fed by the right internal maxillary artery and the petrous branch of middle meningeal artery and shed to the posterior condylar canal only through an intraosseous vein in the jugular tubercle. Although a catheter could not be navigated into the venous pouch in the clivus, the AVFs were successfully obliterated by transvenous embolization of the venous pouch in the posterior condylar canal.

Functional ultrasound imaging of the venous valve of the great saphenous vein in the area around the crosse using the novel vector flow technique

PURPOSE: The aim of our pilot study is to consider if the new flow presentation of the vector flow (V-flow) allows an assessment of the valve morphology of the crosses with respect to an insufficiency. MATERIAL AND METHODS: We performed a total of 50 investigations in which we documented a complete valve closure at the so called “crosse” at the valve of the large saphenous vein, a delayed valve closure or an incomplete valve closure with consecutive insufficiency at the crosse. The valve function of the crosse is crucial for the development of varicosis. For our study we recorded age and gender of the patients. One patient in the study was suffering from Covid19. For the examinations we used a 3–9 MHz probe and a high-end ultrasound device. The examination was performed in a lying position and under quiet conditions. Before examination we practiced inhalation and exhalation as well as “pressing” or coughing with the patients, which resulted in a physiological closure of the venous valves. To rule out thrombosis, we carried out compression sonography on the legs. During the examination we documented the B-scan, the Color-Coded Duplex Sonography, the HR-flow and the V-flow for 3 seconds at the estuary of the crosses and incorporated these parameters into our measurements. Via V-flow, vectors can be imaged by representing the flow of erythrocytes and visually indicate a possible insufficiency due to delayed or incomplete valve closure. RESULTS: 31 of 50 patients (age 19–81years) showed a complete valve closure of the crosses, three of them suffered from thrombosis. In eight of the 50 study participants (age 45–79 years) a delayed valve closure could be diagnosed by V-flow within 1–2 seconds. None of them had a thrombosis, but six of them suffered from cancer. In eleven patients we derived an incomplete valve closure with insufficiency (age 51–88 years). With reflux it took >2 seconds to close the valve. The patient with Covid19 also showed an incomplete valve closure with insufficiency. At the same time this patient showed a Covid19-associated deep vein thrombosis. Eight additional patients also had a thrombosis. Six of them suffered from cancer. Overall, the results were best visualized by V-Flow. CONCLUSION: The crosse as a significant venous structure can be well investigated by V-flow with respect to hemodynamic changes and a resulted reflux. Also associated changes close to the valve can be visualized well.

Endovascular Embolization of a Paracavernous Arteriovenous Fistula Through a Cortical Venous Access: 2-Dimensional Operative Video

We present the case of a 62-yr-old female with a right bulging eye and intermittent headaches. A T2 weighted magnetic resonance image revealed a dilated serpiginous vessel in the right orbit and abnormal flow voids lateral to the orbital apex. The right internal carotid contrast injection demonstrated a dural arteriovenous fistula (dAVF) fed by the ophthalmic artery and drainage into the ipsilateral superficial middle cerebral veins (SMCVs) and the basal vein of Rosenthal without opacification of the cavernous sinus. A fistulous pouch was identified anterolateral to the carotid siphon. The venous phase of the left internal carotid injection demonstrated the bilateral cavernous sinuses, suggesting no involvement of the cavernous sinus with the fistula. Concerning the risk of future hemorrhagic events, endovascular treatment was recommended. Considering the robust connection of the cortical draining vein with the superior sagittal sinus (SSS), a transvenous embolization was performed. The lesion was accessed through the SSS and the right SMCV and embolized with platinum coils, resulting in complete fistula obliteration without any complications. The SMCVs can drain into paracavernous venous structure, which independently presents lateral to cavernous sinus.1,2 Because incomplete embolization of this fistula through cavernous sinus can alter the shunt flow toward cerebral veins, we did not get into the fistula site through the cavernous sinus using conventional methods. Transvenous access through a cortical bridging vein is an efficient alternative for endovascular embolization of paracavernous dAVFs. Patient approval and consent was obtained prior to the procedure and for submission of this article.

Nasal swell body: a literature review

The nasal swell body (NSB) is considered to be an enlarged region of the nasal septum, which is located superiorly to the inferior nasal turbinate and anteriorly to the middle nasal turbinate, with a potential effect upon the airflow nasal valve. The histological studies of the NSB demonstrated that it is a glandular formation, not a venous structure, and it is formed by septal cartilage and bone, as well as a thick mucosa. Recent studies emphasized the functional role of the nasal swell body and it is thought to interfere with the nasal airflow and air humidification, due to its proximity to the internal nasal valve and its histological characteristics (venous sinusoids and seromucinous glands). The nasal swell body is strongly related to the presence of rhinosinusal chronic inflammations (allergic rhinitis and chronic rhinosinusitis) and the septal deviation. In case of the presence of the nasal swell body, surgical treatment is not commonly done, due to the absence of a consensus between the ENT practitioners. Most of them consider surgery as being too aggressive because of the presence of seromucinous glands, with slight impact upon the nasal obstruction. Most probably, the lack of consensus is determined by inconsistent anatomical and histological study results.

Restrictive cerebral cortical venopathy: A new clinicopathological entity

We present a case of a novel restrictive cerebral venopathy in a child, consisting of a bilateral network of small to medium cortical veins without evidence of arteriovenous shunting, absence of the deep venous system, venous ischemia, elevated intracranial pressure, and intracranial calcifications. The condition is unlike other diseases characterized by networks of small veins, including cerebral proliferative angiopathy, Sturge-Weber syndrome, or developmental venous anomaly. While this case may be the result of an anatomic variation leading to the congenital absence of or early occlusion of the deep venous system, the insidious nature over many years argues against this. The absence of large cortical veins suggests a congenital abnormality of the venous structure. The child’s presentation with a seizure-like event followed by protracted hemiparesis is consistent with venous ischemia. We propose that this is likely to represent a new clinicopathological entity.

IVC Embryology and Anatomy

As the largest venous structure in the body, the inferior vena cava (IVC) acts as a central conduit in many interventional radiology (IR) procedures. It originates from the regression of three paired embryonic veins in the developing embryo. Given the complex embryology of the IVC, it is not surprising that many anomalies occur. The first portion of this chapter provides an overview of the anatomy and embryology of the IVC to frame subsequent discussions later in the chapter on the anomalies and various pathologies that an interventional radiologist may encounter. An in-depth discussion on IVC filtration is also included.

An Ilio-iliac Arteriovenous Fistula Following Spontaneous Rupture of a Right Common Iliac Artery Aneurysm

The formation of an ilio-iliac arteriovenous fistula is a potentially lethal complication of common iliac artery aneurysm presentations. Whilst trauma predominantly accounts for the majority, spontaneous rupture of a common iliac artery aneurysm into an adjacent venous structure accounts for a small subset of patients. Urgent surgical intervention is warranted with the aim to restore arterial continuity and ideally, closure of the fistula. This case study describes the endovascular management of a spontaneous ilio-iliac arteriovenous fistula following rupture of a common iliac artery aneurysm into an adjacent vein.

Transvenous Coil Embolization for Dural Arteriovenous Fistula of the Anterior Condylar Confluence – a Case Report

Dural arteriovenous fistula (DAVF) of the anterior condylar confluence (ACC) is a rare entity accounting for about 3.6% of all DAVFs. We report on a 63-year-old male patient who presented with pulsatile tinnitus. Angiography revealed a DAVF supplied mainly by neuromeningeal branches of bilateral ascending pharyngeal arteries and draining into the ACC. Transvenous transjugular coil embolization was performed resulting in complete obliteration of the fistula and resolution of the symptoms. Due to the complexity of this venous structure at the skull base, detailed angiographic study is crucial for proper therapeutic planning and management of the patient. We here discuss the clinico-radiological features and various treatment modalities of the ACC DAVF.Nepal Journal of Neuroscience, Volume 15, Number 2, 2018, page: 41-44