A Giant Renal Vein Aneurysm in a Patient with Liver Cirrhosis

We present an unusual case of a 40-year-old female patient with liver cirrhosis and diffuse abdominal pain. The imaging studies revealed a huge renal vein aneurysm. The patient refused any interventional management, despite the risk of possible rupture, and after a week of mild pain therapy, she was discharged. She was followed up closely, and after one year, she remains asymptomatic. Conservative management of such patients has been described before with success. However, open repair or percutaneous thrombosis of the aneurysm remains the indicated therapy, when vein patency is an issue for organ viability

Asymptomatic Pellet Migration to the Heart: Report of a Case and Update on Proper Management

We report a case of a 42-year-old male patient who was transferred to our emergency department suffering from a gunshot wound in his left lateral thigh. The patient was haemodynamically stable, and the physical examination of the abdomen and thorax was unremarkable. There was no obvious exit point and there were no other injuries. The radiologic control of the left thigh showed an intact femur and multiple pellets within the adjacent soft tissues. Routine X-ray evaluation of the thorax revealed a small-sized round object of metal density—possibly a migrated pellet—in the proximity of the right heart atrium. Computed tomography imaging confirmed this finding and showed no other cardiac or mediastinal injury. Ultrasonography of the heart was unremarkable as well. The patient was managed conservatively for the discovered pellet, and remained asymptomatic throughout the entire hospital stay, and 6 months after the discharge. Pellet migration or embolism should be suspected in any gunshot victim without a corresponding exit wound or when the signs and symptoms do not correlate with the suspected course of the missile. Conservative management remains the first choice in asymptomatic patients, although close monitoring at first and regular observation after discharge are indicated

False increase of serum cancer risk markers in a case of benign uterine bleeding

Co-infection by specific Chlamydia species and Human Papilloma Virus has been associated with genital carcinogenesis. Additionally, modern serum biomarkers and risk algorithms for diagnosis and prognosis have proven their efficacy in patients with ovarian cancer although data on endometrial or cervical malignancies are still sparse. We aim to present an unusual case of serum cancer biomarkers increase in a premenopausal female suffering from recurrent uterine bleeding and genital infection by several pathogens. We further discuss proper utilization of these diagnostic tools in such unusual cases

Case Report Absence of Clinical and Hemodynamic Consequences due to Posterior Tibial Artery Congenital Aplasia

The exact knowledge of popliteal artery and its branches' anatomic variations is important for the clinical practice of angiology, vascular surgery, and interventional procedures. Congenital absence of the artery leads, in some cases, to early malformations of the extremity in the childhood; however, it may also remain asymptomatic. We present an unusual case of a 76-year-old male patient complaining of paraesthesia in both limbs and bilateral aplasia of posterior tibial artery (PTA). Physical examination, ankle-brachial indexes, before and after exercise, arterial duplex scan, and magnetic resonance arteriography were performed. Arterial pulses for PTA at the level of the ankle were normal; arterial duplex study showed biphasic arterial flow at the level of the ankle. Color duplex ultrasound as well as magnetic resonance arteriography revealed the absence of the PTA in both limbs. The vascularization of the fibula was bilaterally normal. The patient underwent also neurological examination and electromyography, which were normal. The evaluation of the possible clinical signs and symptoms and the hemodynamic consequences of this condition are further discussed

Case Report Spontaneous Rectus Sheath Hematoma in the Elderly: An Unusual Case and Update on Proper Management

Spontaneous rectus sheath hematoma (SRSH) is an uncommon medical emergency in the elderly. We present a case of SRSH with an atypical clinical presentation and discuss literature regarding diagnosis and proper management. A 75-year-old female patient was transferred to the emergency department due to acute dyspnoea and confusion. Her medical history revealed a viral infection of the upper respiratory tract, and no coughing or use of anticoagulants. The clinical examination showed tenderness of the left lower abdomen, although palpation was misleading due to patient's obesity. Laboratory investigations showed light anaemia. Ultrasonography and computed tomography revealed a large rectus sheath hematoma of the left abdominal wall. Despite further deterioration of the patient, conservative management including bed rest, fluid replacement, blood products transfusion, and proper analgesia was successful. No surgical intervention was needed. Prompt diagnosis and management of SRSH plays significant role in the prognosis, especially in elder patients. Independently of size and severity, conservative management remains the first therapeutic choice. Only by failure of supportive management, progressive and large hematoma or uncontrollable hemodynamic patients, interventional management including surgery or less invasive newer techniques is indicated

Evaluation of cardiac damage after carotid endarterectomy or endovascular angioplasty for symptomatic carotid bifurcation stenosis

Aim of the study: Carotid disease is a chronic disease of high incidence and mortality. A great percentage of patients with carotid disease have coronary disease as well. Two interventional methods are used today for therapy of carotid disease, open carotid endarterectomy (CEA) and intravascular angioplasty with stenting (CAS). Aim of our study is to evaluate the perioperative cardiac damage of both methods and to compare the results between different groups of cardiac risk.Methods: 162 patients were scheduled for CEA and 18 patients for CAS. All patients had coronary disease. The SAPPHIRE criteria for stratifying patients considered for carotid endarterectomy in normal and high surgical risk groups, were used prospectively. Patients were also classified preoperatively in groups of perioperative cardiac risk, according (i) to the Vascular Study Group of New England-Risk Cardiac Index (VSG-RCI), (ii) to the findings of stress echocardiography with dobutamine and (iii) to the results of coronary angiography, when indicated. All patients had preoperative full cardiologic evaluation and cTn-I values, as well as on the 1st, 3rd and 7th day postoperatively. Postoperative cTn-I values from 0.05 ng/ml to 0.5 ng/ml were classified as myocardial ischemia and values over 0.5 ng/ml as myocardial infarction.Results: Mortality after CEA was 0.6%, stroke rate was null, cardiac damage rate was 14% and symptomatic myocardial infarction rate was null. Mortality after CAS was null, stroke rate was null and cardiac damage rate was null. All patients with increased cTn-I were asymptomatic. In both series, all patients raised their troponin values postoperatively regardless of cardiac damage. Patients after CEA raised their troponin values more than patients after CAS and showed more cardiac adverse events. There was no statistical difference of the troponin values by patients after CEA, between groups of low and high surgical risk. Patients of low and medium cardiac risk, according to VSG-RCI and stress echocardiography, showed higher cTnI values after CEA and the most adverse cardiac events, as well. There was no statistical difference in troponin values between groups of same cardiac risk but different classification method, in patients without perioperative cardiac damage. Echogenic and Type IV carotid plaques were associated with high cardiac risk according to the results of preoperative coronary angiography and with perioperative cardiac damage. Conclusions: Coronary patients, regardless of their cardiac risk, raise their troponin and are in danger of perioperative cardiac damage, after both CEA and CAS. Patients in high cardiac risk do not result in a higher risk for perioperative cardiac damage. Echogenic and Type IV carotid plaques are associated with the severity of coronary artery disease and with perioperative cardiac damage. A protocol of standardized troponin measurement after CEA or CAS is required to be established for the detection of silent cardiac damage, especially for coronary patients. Larger studies are needed to verify our results.Σκοπός της μελέτης: Η καρωτιδική νόσος αποτελεί χρόνια νόσο, με υψηλό επιπολασμό και θνητότητα. Κλινικά εκδηλώνεται ως χρόνια ισχαιμική εγκεφαλοπάθεια ή ως οξέα εγκεφαλικά αγγειακά επεισόδια. Σε μεγάλο ποσοστό συνυπάρχει και με στεφανιαία νόσο. Σήμερα υπάρχουν δύο παρεμβατικές μέθοδοι για την αντιμετώπισή της, η ανοικτή ενδαρτηρεκτομή καρωτίδας (carotid endarterectomy - CEA) και η ενδαγγειακή αγγειοπλαστική με τοποθέτηση stent (carotid angioplasty with stenting - CAS). Σκοπός της έρευνάς μας είναι η αξιολόγηση της περιεγχειρητικής καρδιακής βλάβης στις δύο αυτές μεθόδους και η σύγκριση των αποτελεσμάτων ανάμεσα σε διαφορετικές ομάδες καρδιακού κινδύνου.Υλικά και Μεθοδολογία: 162 ασθενείς υποβλήθηκαν σε CEA και 18 ασθενείς σε CAS. Όλοι οι ασθενείς είχαν στεφανιαία νόσο. Χρησιμοποιήθηκαν προοπτικά τόσο τα κριτήρια της μελέτης SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy trial) για την ταξινόμηση των ασθενών σε ομάδες χαμηλού και υψηλού χειρουργικού κινδύνου, όσο και ο κλινικός δείκτης VSG-RCI (Vascular Surgery Group Cardiac Risk Index), το υπερηχοτομογράφημα κόπωσης με δοβουταμίνη και η στεφανιογραφία, για την ταξινόμηση των ασθενών σε ομάδες καρδιακού κινδύνου. Όλοι οι ασθενείς υποβλήθηκαν σε πλήρη καρδιολογική εκτίμηση προεγχειρητικά. Μέτρηση της καρδιακής τροπονίνης Ι (cTnI) έγινε προεγχειρητικά και την 1η, 3η και 7η ημέρα μετεγχειρητικά. Μετεγχειρητικές τιμές cTnI μεταξύ 0,05 και 0,5 ng/ml ορίστηκαν ως μυοκαρδιακή ισχαιμία και τιμές πάνω από 0,5 ng/ml ως έμφραγμα του μυοκαρδίου.Αποτελέσματα: Στη CEA σημειώθηκε θνητότητα 0,6%, ποσοστό εγκεφαλικών επεισοδίων 0%, ποσοστό ασυμπτωματικών καρδιακών συμβαμάτων 14%, ποσοστό συμπτωματικών εμφραγμάτων μυοκαρδίου 0%. Στη CAS σημειώθηκε θνητότητα 0%, ποσοστό εγκεφαλικών επεισοδίων 0% και ποσοστό καρδιακών συμβαμάτων 0%. Όλοι οι ασθενείς με αυξημένη cTnI ήταν ασυμπτωματικοί. Και στις δύο σειρές, όλοι οι ασθενείς αύξησαν την τροπονίνη μετεγχειρητικά ανεξαρτήτως της εμφάνισης καρδιακής βλάβης. Οι ασθενείς με CEA αύξησαν περισσότερο από τους ασθενείς με CAS την τροπονίνη και εμφάνισαν περισσότερα καρδιακά συμβάματα. Δεν υπήρχε στατιστική διαφορά μεταξύ των τιμών τροπονίνης στους ασθενείς με CEA, ανάμεσα στην ομάδα χαμηλού και υψηλού χειρουργικού κινδύνου. Οι ασθενείς χαμηλού και μέσου καρδιακού κινδύνου με βάση το VSG-RCI και το υπερηχοτομογράφημα κόπωσης παρουσίασαν υψηλότερες αυξήσεις cTnI μετεγχειρητικά και τα περισσότερα καρδιακά συμβάματα. Δεν υπήρχε διαφορά στις τιμές τροπονίνης ανάμεσα στις ομάδες ίδου καρδιακού κινδύνου μεταξύ των πρωτοκόλλων ταξινόμησης σε ασθενείς χωρίς καρδιακή βλάβη.Συμπεράσματα: Οι στεφανιαίοι ασθενείς, ανεξαρτήτως χειρουργικού κινδύνου, αυξάνουν την τροπονίνη και παρουσιάζουν κίνδυνο εμφάνισης καρδιακής βλάβης, τόσο μετά από CEA όσο και μετά από CAS. Οι ασθενείς υψηλού καρδιακού κινδύνου δεν παρουσιάζουν μεγαλύτερο κίνδυνο εμφάνισης περιεγχειρητικής καρδιακής βλάβης. Ένα πρωτόκολλο καθιερωμένης μέτρησης της τροπονίνης είναι αναγκαίο να εφαρμοστεί μετά από CEA και CAS, με σκοπό την ανίχνευση της σιωπηλής καρδιακής βλάβης. Μεγαλύτερες μελέτες χρειάζονται για την επαλήθευση των αποτελεσμάτων της έρευνάς μας

Acute type B aortic dissection: update on proper management

This study aims to collect and present all current literature data on the diagnostic and therapeutic management of acute type B aortic dissection. It includes a comprehensive literature search utilizing the following keywords: ‘acute aortic dissection’, ‘type B aortic dissection’, ‘conservative management’, ‘endovascular repair’, ‘open surgery’ and ‘diagnosis’. Uncomplicated acute type B aortic dissection can be effectively managed using conservative management, although open repair is indicated only for complicated cases. Endovascular repair shows promising results in selected patients with increased perioperative risk and without contraindications. Recent evidence supports endovascular repair even in uncomplicated cases, although more data on long-term outcomes are needed. Early risk stratification and evaluation of the patient is crucial for selection of optimal management