Median arcuate ligament syndrome with post stenotic pancreaticoduodenal aneurysm: case report

Background: Median arcuate ligament syndrome (celiac artery compression syndrome, Dunbar syndrome) is an infrequent form of chronic mesenterial ischemia. The culprit for a sub optimal celiac blood flow is a lowpositioned median arcuate ligament which is an arch of fibrous tissue connecting the diaphragmatic crura. Symptomatic patients complain of postprandial pain situated in the epigastrium. Still, most of the individuals proven to have some form of celiac artery compressions report no complaints at all. The gold standard for diagnosis is a CT angiography and treatment is surgical. The median arcuate ligament is transacted with or without additional endovascular treatment. Case study: We present the case of a 50-year-old male patient with a radiologically confirmed diagnosis of median arcuate ligament syndrome treated surgically at our institution. An open approach was used since the patient had a previous median laparotomy scar. Due to a post stenotic pancreaticoduodenal aneurysm coil embolization was additionally performed. On follow up the patient had no further complaints. Conclusion: Patients with chronic postprandial pain require a systematic approach. In the differential diagnosis of abdominal angina, although uncommon, median arcuate ligament syndrome is to be remembered. The diagnosis is rather straightforward once clinical suspicion is established and treatment-wise minimally invasive surgery is performed whenever possible

A conservative approach to a thoracic duct injury caused by left subclavian vein catheterization

Thoracic duct injury is a rare complication of left subclavian vein catheterization. A significant injury could lead to chylothorax, a condition with high mortality rate if not treated. It is diagnosed with lymphography or by laboratory tests of pleural fluid aspirate. A 51 year old Caucasian male with a history of unregulated hypertension presented to our Emergency department (ED) with anginous symptoms and increased serum creatinine level. After the placement of a temporary central venous catheter for hemodialysis in left subclavian vein, he developed lymph leakage on puncture site beside the catheter, at drainage rate of 75 ml/h. In the absence of more serious clinical symptoms, conservative treatment with close patient monitoring and diet changes was chosen, rather than more invasive treatment options

Venous spread of renal cell carcinoma: MDCT

BACKGROUND: The purpose of our study was to present multidetector computed tomography (MDCT) findings in venous spread of renal cell carcinoma (RCC), to determine the superior extent of tumor thrombus and to compare MDCT findings with surgical report. ----- METHODS: The prospective MDCT study was performed on 31 patients diagnosed with RCC with venous spread (19 males and 12 females; age range 39-80 years; mean age 62.6 years). CT scans were obtained by MDCT scanner, in triphasic scanning protocol. All postprocessing techniques were performed by two independent radiologists, and the findings were reported in their consensus. MDCT diagnosis was compared with surgical and pathohistological findings. ----- RESULTS: Tumor thrombus extension into renal vein only (T3b stage) was found in 13/31 (42%) patients. Involvement of infradiaphragmatic level of inferior vena cava (IVC) (T3c stage) was found in 14/31 (45%) patients and supradiaphragmatic level of IVC (T4b stage) in 4/31 (13%) patients. In 27/31 (87%) patients surgery was performed, while 4/31 (13%) could not undergo surgery. In comparison with surgical report, in 25/27 (93%) operated patients the upper extent of the tumor thrombus was correctly diagnosed by MDCT, and 2/27 (7%) patients were falsely diagnosed. ----- CONCLUSION: MDCT represents a fast, relatively inexpensive, and reliable diagnostic method for evaluating the venous spread of RCC as well as the level of its upper extent. Triphasic MDCT is often the only diagnostic method necessary for planning the surgical procedure. Surgery should be performed as soon as possible for MDCT findings to be valid

The "Woundosome" Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia

This editorial assembles endovascular specialists from diverse clinical backgrounds and nationalities with a global call to address key challenges to enhance revascularization in chronic limb-threatening ischemia (CLTI) patients.- Dedicated below-the-ankle (BTA) angiography and revascularization is underutilized in ischemic foot treatment. Existing guidelines do not address comprehensive BTA vessel analysis. CLTI trials also often lack data on in-line arterial flow to the ischemic lesion and BTA vessel evaluation, hindering outcome assessment.- Dedicated multi-planar angiographic evaluation of the distal microcirculation is key: Direct arterial flow or good-quality collaterals are crucial in influencing wound healing and need to be assessed diligently to the level of the distal ischemic wound territory, termed “woundosome.”- An important primary emphasis of future trials should be on validating technologies and strategies for assessing tissue perfusion before, during, and after revascularization undertaken to heal tissue loss in CLTI patients. This will allow determination of a potentially significant delta in tissue perfusion prior to and following intervention at the “woundosome” level. Once changes in arterial perfusion have been identified as positively correlated to wound healing, these could serve as a much-needed novel primary technical outcome measure for patients with tissue loss undergoing surgical, hybrid, or endovascular revascularization