Antithrombotic Treatment in Lower Extremity Peripheral Arterial Disease

Lower extremity arteries might be affected by atherosclerotic peripheral arterial disease (PAD), or by embolization causing ischaemic symptoms. Patients with PAD often have widespread atherosclerosis, and progression of PAD is associated with increased risk for both other cardiovascular events and cardiovascular mortality. Peripheral arterial disease patients should therefore be offered both non-pharmacological and pharmacological secondary prevention to reduce the risk for future ischemic arterial complications. This review is focussed on the rationale for recommendations on antiplatelet and anticoagulant treatment in PAD. Asymptomatic PAD does not warrant either anticoagulant or antiplatelet treatment, whereas patients with ischaemic lower extremity symptoms such as intermittent claudication or critical limb ischemia caused by atherosclerosis should be offered platelet antiaggregation with either low dose aspirin or clopidogrel. Combined treatment with aspirin and low-dose of the direct oral anticoagulant (DOAC) rivaroxaban should be considered and weighed against bleeding risk in symptomatic PAD patients considered at high risk for recurrent ischaemic events and in patients having undergone endovascular or open surgical intervention for PAD. Patiens with cardiogenic embolization to lower extremity arteries should be recommended anticoagulant treatment with either one of the DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) or warfarin.

Relationship of Arterial Changes in Acute Pancreatitis on CT Angiography with Modified CT Severity Index

Purpose To evaluate the prevalence of arterial changes in patients with acute pancreatitis (AP) on computed tomography angiography (CTA) and determine their association with etiology of AP, presence of necrosis, collections and severity of AP. Materials and Methods A total of 50 patients (20 women, 30 men; mean age: 43.04 ± 13.98; age range: 18–77 years) with AP underwent contrast-enhanced computed tomography (CECT) scan and CTA of abdomen, which was evaluated for necrosis and fluid collection (s). On CTA, splanchnic arterial structures were assessed for vascular complications. Association between vascular changes and presence of necrosis, fluid collections, etiology of AP and severity of AP (as assessed by modified computed tomography severity index CTSI) was determined. Results Arterial complications were seen in 28 percent (14/50). The most frequently involved artery was superior pancreaticoduodenal artery (12 percent), followed by splenic artery (8 percent) and right gastric artery (8 percent; Fig. 1). No significant association was seen between arterial changes and gallstone or alcohol-induced AP. Arterial changes showed a significant association with presence of acute necrotizing pancreatitis (ANP), presence of collections and severe AP (CTSI 8–10) (p < 0.05 for each). Conclusion Arterial changes on CTA are frequently seen in patients of AP having ANP. There is a significant association between arterial changes and presence of necrosis, collections and severe AP.

Emergency interventional endovascular treatment for early disorder of arterial blood flow in the liver graft

Introduction. Liver transplantation is considered the most effective treatment for patients with end-stage liver disease. X-ray endovascular interventions show good results in the treatment of vascular complications after transplantation. The timing, indications and choice of treatment methods require clarification.Objective. To evaluate the safety and efficacy of emergency X-ray endovascular interventions for arterial complications in the early period after liver transplantation.Material and methods. In the period from October 2016 by July 2021, 88 liver transplants were performed. The graft was obtained from a posthumous donor in 75 cases, and from a living donor (right lobe of the liver) in 13 cases. Arterial complications were registered in 10 cases: thrombosis of the hepatic artery in 7 (8.0%), constriction in 3 (3.4%); 4 patients underwent retransplantation due to thrombosis. This analysis included 6 patients aged 27 to 51 years, including 4 men and 2 women. In the early postoperative period (0–14 days), according to laboratory parameters, ultrasound Doppler, and computed tomography with a contrast agent, an impairment of the arterial blood supply of the graft was revealed, for which the patients underwent emergency X-ray image-guided surgical endovascular interventions.Results. Restoration of adequate arterial blood supply to the liver graft was achieved in all six patients. At the time of this writing, the graft function and patency of the hepatic artery were preserved at follow-up periods of 6, 11, 12, 22 (in two patients), and 26 months with a median of 17 months. Four patients developed biliary complications that required surgical correction.Conclusion. X-ray image-guided endovascular interventions can be considered effective and relatively safe in the treatment of patients with arterial complications after liver transplantation. The period of graft arterial ischemia should be minimized as much as possible in order to prevent biliary complications.

Hepatic larva migrans presenting with upper gastrointestinal haemorrhage: A case report

Visceral larva migrans (VLM) occurs because of a host inflammatory response to the migrating larvae of a nematode. Patients usually present with fever, hepatomegaly and abdominal pain; vascular arterial complications are uncommon. A 19-year female presented with fever, jaundice, abdominal discomfort and melena. Computed tomography (CT) revealed multiple discrete, clustered, complex hepatic cystic lesions consistent with VLM, along with an arterial pseudoaneurysm from the right hepatic artery which was managed with endovascular coil embolisation.

New possibilities for testing direct arterial liver perfusion after liver transplantation

The aim of the study was to show new promising possibilities of direct perfusion test for the transplanted liver.Materials and methods. We have performed 246 liver transplantations (1998–2020). Since 2015 arterial complications were detected in 24 (23%) patients after 105 transplantations complicated by liver hypoperfusion: splenic artery steal syndrome (n = 8), hepatic artery thrombosis (n = 7), combination of hepatic artery stenosis and steal syndrome (n = 6), hepatic artery stenosis (n = 3). Endovascular interventions were performed in these cases for revascularization. Direct perfusion test was performed in 8 patients.Results. The liver perfusion index increased from 0.27 (0.13–0.45) to 0.62 (0.33–0.89) after endovascular procedures. Sufficient perfusion was ≥0.65.Conclusion. Direct liver perfusion test makes possible to identify and objectify graft blood supply, timely and adequate correction, and reduces the risk of developing biliary ischemic complications.

Articulating Cervical Rib - A Culprit Often Overlooked on Imaging! : Review Article

Background: Cervical rib, though it is seen incidentally in the radiographic examination of chest and cervical spine, a particular subset of it can present with thoracic outlet syndrome. This article mainly focuses on the symptom causation of articulating cervical rib, as compared to non-articulating cervical rib which is often asymptomatic. There are many articles describing a cervical rib, but those highlighting this particular relation between the types of cervical rib and symptom causation are not present in present database. The review of serial radiographs upon correlating clinically, lead us to conclude that articulating variant of cervical rib is majorly symptomatic and caused grave arterial complications. The article consists brief discussions on the types of cervical ribs, thoracic outlet syndrome and role of imaging in diagnosing a cervical rib. Main Body: We have illustrated five such cases from our tertiary care hospital and highlighted the relationship between the magnitude of symptoms and variations of cervical rib. In compliance with PRISMA guidelines, we screened 33 articles dealing with cervical rib and 13 with thoracic outlet syndrome. Overall, 46 articles were filtered on studying the abstract. Further, 15 more had to be excluded as they were case reports and case series, and finally 31 articles were included in our study. We studied and discussed these articles and research papers in relation to variant anatomy of cervical rib, its types and symptom causation. In our study, also routine sequential chest radiographs were reviewed during the period of January 2020 to January 2021 and those with cervical rib and/or elongated C7 transverse process were included. Conclusion: Thus, to conclude we can state that articulating cervical ribs pose a greater threat and cause arterial occlusion. Key words: Cervical rib, thoracic outlet syndrome, subclavian artery.

Management of Arterial Complications in Patients with Inadvertent Arterial Injection

Aim: The aim of this study is to assess complications in inadvertent arterial injection and their management. Methods: From June 2018 to May 2020 in Tanta University Hospitals vascular and endovascular surgery department, this study was conducted on 30 patients with inadvertent intra-arterial drug injection complications, including femoral artery pseudoaneurysm, acute ischemia, and compartment syndrome. In 20 patients with femoral artery pseudoaneurysm, proximal control to external iliac artery and assessment of the vascularity was done intra-operatively for distal arterial Doppler flow. If the distal arterial flow was present, ligation of the common femoral artery was done, While if it was absent, iliofemoral bypass was done. Brachio-ulnar bypass was done for brachial artery pseudoaneurysm. Fasciotomy was done for compartment syndrome. Results: The mean age of patients was 27.4 years ranged from 1 year to 64 years. The femoral artery was affected in 20 cases. The brachial artery was involved in 6 cases, radial artery in 2 cases, and ulnar artery in 2 cases. In 20 patients, ligations of the common femoral artery CFA with debridement of necrotic were done for all cases. Twelve patients had good Doppler flow, eight patients had no Doppler flow, and iliofemoral bypass was done. In the upper limb cases, one case presented by severe edema in hand necessitating fasciotomy. Four cases presented with fixed color changes and gangrene in fingers after one brachial, one radial, and two ulnar arteries injections and required minor amputation. Two cases were presented with neglected ischemia and extensive infection, and above the elbow, amputation was done. In three cases with brachial pseudoaneurysm, we ligated the brachial artery, and no bypass was done with the preserved distal flow in one case; in the other two cases of brachial artery pseudoaneurysm, we did brachio-ulnar bypass. Conclusion: Inadvertent IA injection of medications has no appropriate therapeutic guidelines. The actual incidence rates, natural history, and pathophysiologic factors surrounding these complications are unclear. For prevention, the best tools are the assessment of the risk factors and consequences. The treatment options are immediate recognition of the situation, disease progress, pain control, anticoagulation, specific therapy.

Peak Systolic Velocity at Arterial Doppler Ultrasound in Pediatric Liver Transplantation: as Predictor of Acute Severe Complications.

The objective of this study is to determine whether hepatic artery Doppler ultrasound parameters can predict arterial complications in the immediate period after a liver transplantation in children.A retrospective review of the pediatric liver database at our tertiary-care pediatric hospital was performed. The study included 57 pediatric patients who underwent liver transplantation from 2016 to 2020. Clinical, laboratory and Doppler findings were recorded daily the first 5 days after transplantation. Especial attention was focused on extrahepatic post-anastomotic Peak Systolic Velocity (PSV) and intrahepatic Resistive Index (RI). Forty-nine liver transplant recipients were analyzed. Patients with acute hepatic artery complications, including acute thrombosis and stenosis, had lower PSV values at 3 and 4 days after surgery compared to the group with non-complications, with a statistical significance (p=.015). Receiver operating characteristic (ROC) curve analysis determined an optimal cut-off value of PSV less than 30 cm/s to discriminate children with and without acute hepatic arterial complications, which is lower than that proposed in adults. It correlates with acute arterial stenosis and thrombosis in children even before RI, clinical symptoms or laboratory anomalies appear.