Jugular foramen and venous collaterals may help to discriminate congenital from post-thrombotic jugular stenosis

Purpose Unilateral jugular stenosis is easily mistaken as jugular hypoplasia for their similar jugular appearances. This study aimed to propose a scheme to differentiate acquired internal jugular vein stenosis (IJVS) from congenital jugular variation through two case examples. Methods We presented a dynamic evolution process of the IJVS formation, through a case of a 17-year-old female with paroxysmal nocturnal hemoglobinuria (PNH)-associated right internal jugular venous thrombosis (IJVT), which resulted in post-thrombotic IJVS in the rare context of rapid recanalization. Meanwhile, we compared her images with images of a 39-year-old healthy male with hypoplastic IJV to determine the differences between the acquired IJVS and congenital dysplasia. Results Based on the first case, we noticed the whole formative process of acquired IJVS from nothing to something. Meantime, we found that acquired IJVS was surrounded by abnormal corkscrew collaterals as imaged on contrast-enhanced magnetic resonance venography (CE-MRV), and the ipsilateral jugular foramen (JF) was normal-sized as displayed on computer tomography (CT). Conversely, jugular hypoplasia was with ipsilateral stenotic JF and without serpentine collaterals. Conclusion JF morphology and venous collaterals may be deemed as surrogate identifiers to distinguish acquired unilateral IJVS from jugular hypoplasia.

Non diagnosed PAPVC induce large reverse venovenous shunt after modified Fontan surgery: A case report of a rare anomaly and embolization therapy

Fontan operation is a reliable palliative surgery for patients with single ventricle physiology. Still, the development of complication is common; one of these complications that need to interventional approach is veno-venous collaterals between systemic and pulmonary veins. A 16-yearoldgirl with a history of modified Fontan operation at 9 years ago was referred with progressive cyanosis and dyspnea on exertion. In contrast trans-thoracic echocardiography (TTE), no fenestration was seen in Fontan circulation. Cardiac magnetic resonance revealed partial anomalous pulmonary vein connection (PAPVC) from left upper pulmonary vein to vertical vein and then into the in nominate vein and SVC with the reverse flow from superior vena cava (SVC) to left upper pulmonary vein(LUPV). This anomalous vein became severe engorged and tortuous. Possibly, LUPV and the verticalvein was dilated gradually as a result of increased pressure in the Fontan circuit. Finally, she underwent successful coil embolization in the midpart of the vertical vein. The oxygen saturation increased from80% to 93%.

Intracranial collateral circulation and its role in neurovascular pathology

Background Collateral circulation is a vascular network which maintains the blood flow after the partial blockage of primary vascular pathways. This acts as potential vascular supplementary system and plays important role in the cerebral ischemia. Main body Collateral circulation has implications in the management especially related to cerebral endovascular treatment and thrombolytic therapy. It is considered as subsidiary network of vascular channels, which is highly variable. Insufficient arterial supply is due to the hemodynamic compromise because of thromboembolism. Apart from the collaterals, there is additional existence of a group of vessels known as venous collaterals. Their function is variable and they contribute to the augmentation of venous drainage in venous ischemias. Various pharmacological interventions are used to modulate the collaterals, these can prove to be a complementary alternative to the invasive intracerebral interventions. Conclusions The aim of this review article is to highlight the importance of cerebral collateral circulation and to discuss the various available pharmacological alternatives available and their current relevance in the management of various neurovascular pathologies.

Impact of transjugular intrahepatic portosystemic shunt creation on the central lymphatic system in liver cirrhosis

The puropse of this study was to evaluate associations of cisterna chyli (CCh) diameter with portal hemodynamics and the influence of TIPS-creation in cirrhotic patients. 93 cirrhotic patients (57 male, mean age 59 years) received CT prior to TIPS-creation. 38/93 additionally underwent post-interventional CT. CCh-diameter was measured. After categorization into patients with and without large venous collaterals (i.e. > 6 mm), data were analyzed regarding associations between CCh-diameter, clinical and portal-hemodynamic parameters and diameter-changes after TIPS-creation. Patient survival post-TIPS was analyzed. Median portosystemic pressure-gradient decreased from 20 to 9 mmHg after TIPS-creation. Large venous collaterals were observed in 59 patients. In 69/93 patients (74.2%) the CCh was detectable. Mean pre-interventional diameter was 9.4 ± 2.7 mm (large collaterals: 8.7 ± 2.0 mm, no large collaterals: 10.7 ± 3.2 mm, p = 0.003). CCh-diameter correlated strongly with pre-TIPS portal-pressure (Rs = 0.685, p = 0.0001), moderately with portosystemic-gradient (Rs = 0.524, p = 0.006), liver shear-wave-elastography (Rs = 0.597, p = 0.004) and spleen size (Rs = 0.501, p = 0.01) in patients without large collaterals, but not in patients with large collaterals. Post-TIPS CCh-diameter decreased significantly from 10.2 ± 2.8 mm to 8.3 ± 3.0 mm (p < 0.001). Patients without a detectable CCh on CT survived significantly shorter. The diameter of the CCh is associated with portal-pressure and decreases after TIPS-creation in cirrhotic patients, reflecting a portal decompression mechanism via the lymphatic system. Lack of larger central lymphatics detectable on CT may be associated with shorter survival.

Contrast-Enhanced Endoscopic Ultrasound for Evaluation of Common Bile Duct in Presence of Portal Cavernoma

Endoscopic ultrasound (EUS) is an excellent imaging modality for the evaluation of common bile duct (CBD) because of its close proximity to the transducer placed in duodenum. However, in the presence of portal cavernoma, identification and proper evaluation of CBD become difficult because of presence of numerous venous collaterals. In these circumstances, the evaluation of CBD is more difficult if it is nondilated. In these difficult situations, contrast-enhanced EUS can provide better and clear images of CBD and therefore seems to be an excellent modality to evaluate nondilated CBD in the presence of portal cavernoma.

The Effect of Vertebral Venous Collaterals on Intracranial Hypertension and Related Symptoms in Patients with Bilateral Transverse Sinus Stenosis

Background: Vertebral venous collaterals (VVC) were often found in patients with bilateral transverse sinus stenosis (BTSS). The purpose of this study was to investigate the physiological role of VVC in BTSS patients.Methods: The index of TSS was used in the assessment of BTSS severity. Subjects underwent a standard lumbar puncture to measure the intracranial pressure (ICP). Papilledema and tinnitus were evaluated by using Frisén's grade and questionnaires for tinnitus handicap inventory (THI), respectively. The intensity and impact of headache was assessed by using 10-point Numeric Pain Rating Scale (NPRS) and six-item Headache Impact Test (HIT-6).Results: BTSS group had more patients with severe intracranial hypertension (IH) and less patients with normal ICP. BTSS patients had higher ICP than normal controls. Further analysis on VVC showed that VVC decreased the elevated ICP in BTSS patients and exerted no impact on ICP in normal controls. A similar incidence of VVC in BTSS patients and normal controls were found. BTSS patients with normal ICP and mild IH exhibited a higher incidence of VVC compared with those with severe IH. VVC, rather than the severity of BTSS, regulated the ICP. Furthermore, VVC alleviated IH-related clinical manifestations including papilledema and tinnitus in BTSS patients.Conclusions: The present study demonstrated BTSS is correlated with IH. The presence of VVC, which is postulated to be congenitally formed, normalizes the elevated ICP and alleviated IH-related symptoms in BTSS patients. VVC may be used as an indicator of relatively low ICP in BTSS patients.Trial registration: This study was registered retrospectively on 07/28/2020 (NCT04492332).

Balloon angioplasty of bidirectional Glenn anastomosis

Objective:We aim to assess the safety and efficacy of the transcatheter balloon dilation of superior cavopulmonary anastomosis (SCPA).Background:SCPA stenosis can lead to impaired pulmonary blood flow, hypoxemia and development of veno-venous collaterals with right-to-left shunt. Balloon dilation of SCPA has been rarely reported and follow-up information is lacking.Methods:We performed a retrospective review of patients who underwent cardiac catheterisation and angioplasty of SCPA and reviewed patient’s demographics, diagnosis, SCPA surgery and post-operative course, catheterisation haemodynamics, procedural technique, angiography, and the findings of follow-up catheterisation.Results:Between 2008 and 2017, seven patients showed significant narrowing of SCPA and underwent balloon angioplasty, all of whom had undergone bidirectional Glenn (BDG). Indications for cardiac catheterisation included persistent pleural effusion, hypoxemia, and echocardiographic evidence of BDG stenosis or routine pre-Fontan assessment. Five patients had bilateral SCPA. The procedure was successful in all cases with increase in the stenosis diameter from a median of 3.3 mm (range 1.2–4.7 mm) to a median of 4.7 mm (range 2.6–7.8 mm). All patients had at least one follow-up cardiac catheterisation. Only one patient required repeat angioplasty at the 2.3-month follow-up with no further recurrence. Sustained results and interval growth were noted in all other cases during up to 29 months of follow-up. No adverse events were encountered.Conclusion:Based on our small series, balloon angioplasty of BDG stenosis is feasible and safe and appears to provide sustained improvement with interval growth and only the rare recurrence of stenosis.

The Myth of May Thurner

Less invasive contemporary endovenous techniques with improved stents have made treatment of the May Thurner Syndrome(MTS) more accessible and safer. However, clear criteria for the accurate diagnosis remain obscure. All imaging modalities are performed with patients in a supine position were compression of the left Common Iliac Vein is seen in both asymptomatic and symptomatic patients. There is no clear threshold value. There are no validated hemodynamic criteria. This leads to the necessity of additional information such as measurements performed in an upright position as well as greater scrutiny in detecting fibrous wall thickening and spurs as well as identifying the presence of venous collaterals. Moreover, those contemplating treating MTS should not only identify specific symptoms, but also should consider that patient complaints may be related to a more complex presentation of pelvic congestion.