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1/298. Silent occult choroidal vascular abnormalities.

    PURPOSE: To describe clinically occult choroidal vascular abnormalities that can be revealed by indocyanine green (ICG) angiography. methods: Out of approximately 2,700 patients who underwent ICG angiography, a lesion was incidentally observed in eight eyes of eight patients. In five patients, the ICG study included a second examination taken during artificially induced intraocular hypertension. Examinations were repeated in six patients over a follow-up period ranging from 4 months to 3 years. RESULTS: On ICG angiogram, the choroidal vasculopathy appeared as a round-oval hyperfluorescent area 2-4 disk diameters in size that was located at the temporal vascular arcades in six eyes, at the inferomacular region in one eye, and above the optic disk in one eye. The lesions were not identifiable with funduscopic, fluorescein angiographic, or ultrasonographic examination. The lesions filled at the same time as the choroidal arteries and lost fluorescence in mid-late phase of the ICG angiogram. The ICG series taken during induced intraocular hypertension showed the hyperfluorescent areas originated from choroidal arterial abnormalities giving rise to confluent hyperfluorescent patches. Draining vessels connecting the choroidal vasculopathy with a vortex vein were evidenced in three eyes. A sector of apparent choroidal hypoperfusion downstream from the lesion was present in three eyes. During the follow-up period, the lesions remained occult and with an unchanged ICG angiographic pattern in all patients. CONCLUSION: Some silent occult choroidal vascular abnormalities may be incidentally revealed by ICG angiography. These must be distinguished from ICG imaging of concomitant chorioretinal disorders. ( info)

2/298. Limb-threatening lower extremity ischemia successfully treated with intra-arterial infusion--case reports.

    The authors present two patients with acute arterial vasospasm of the lower extremities causing marked ischemia. One patient had a history of Raynaud's disease, the second had been taking Cafergot for migraine headaches. Both patients's were given a test dose of intra-arterial tolazoline (50 mg). The patient with Raynaud's disease demonstrated marked improvement diffusely and was successfully treated with overnight infusion of papaverine. The second patient, taking Cafergot, demonstrated no angiographic response to tolazoline. It was speculated that the arteries of this patient were thrombosed. The patient was successfully treated with urokinase and remained free of pain at the 15-month follow-up. ( info)

3/298. Bilateral ophthalmoplegia and exophthalmos complicating central hemodialysis catheter placement.

    We describe a 58-year-old woman who presented with bilateral ophthalmoplegia, exophthalmos, and headache and was found to have retrograde internal jugular vein flow secondary to a high-grade obstruction of the ipsilateral brachiocephalic vein from a previous hemodialysis catheter placement. The patient had also a high-flow dialysis graft in the ipsilateral arm. The cranial and extracranial venous system congestion resolved, and the signs disappeared soon after a balloon angioplasty and stent placement at the level of the obstruction. ( info)

4/298. Intravascular fasciitis of the forearm vein: a case report with immunohistochemical characterization.

    Intravascular fasciitis is a very unusual variant of nodular fasciitis. A unique case of this lesion occurring in the proximal portion of the superficial vein of the forearm in an otherwise healthy 26-year-old man is reported. The intravascular polypoid lesion grew longitudinally along the vascular lumen, was loosely attached to the intimal layer, and was partly anchored beyond the internal elastic lamina into the medial smooth muscle layer. However, extravascular involvement was absent. The histological features were identical to those observed in ordinary cellular nodular fasciitis. Because of its myofibroblastic phenotype exhibited by highly proliferative spindle cells, certain intimomedial myofibroblasts are thought to be the indigenous source of this unique fibroproliferative lesion. Unless the diagnosis of intravascular fasciitis is considered and appropriate differential markers examined, it may be confused with other intravascular lesions, such as intravascular leiomyoma, intravenous pyogenic granuloma, organized thrombus and, even, fibromuscular dysplasia if it arises in the arteries. A simple excision is considered curable. Even so, two recurrent cases have been documented to date. ( info)

5/298. Vascular reconstruction utilizing artery from an amputated extremity: A case report.

    Although infrainguinal arterial reconstruction is best performed with autologous tissue, reconstruction with vein in an infected field has been associated with vein graft disruption and hemorrhage. H.P., a 61-year-old man with peripheral vascular disease, was initially seen with an infected prosthetic right femoral-tibioperoneal artery bypass graft. Because of the presence of purulent drainage from the proximal and distal anastomotic regions and his comorbidities, a right through-knee guillotine amputation was performed, followed by graft excision and groin debridement. Right hip and thigh perfusion was preserved via arterial reconstruction by using a segment of endarterectomized popliteal artery, harvested from the amputated extremity. Arterial reconstruction with autologous tissue from an amputated extremity allowed us to balance our patient's overall risks with life and tissue preservation. This technique may be applied in the settings of lower extremity ischemia, trauma, or malignancy requiring concomitant arterial or venous reconstruction. ( info)

6/298. Distensible venous malformations of the orbit: clinical and hemodynamic features and a new technique of management.

    OBJECTIVE: To investigate distensible venous malformations of the orbit (DVMO) as part of a spectrum of orbital vascular malformations, including some that involved periorbital skin, extraorbital sites (central nervous system or nasal sinuses), or combinations of these. The authors also investigated the effectiveness of a new technique of management for selected cases. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Thirty patients had distensible venous anomalies, of which four were combined distensible venous-lymphatic vascular malformations. Distensible lesions were defined as those showing clinical or radiographic expansion with valsalva maneuver or when the head was placed in a dependent position. These lesions were then classified as superficial (anterior to the equator of the globe), deep (posterior to the globe's equator), combined (deep and superficial), or complex (with intracranial or major extraorbital involvement). INTERVENTION: Surgery was performed on 15 patients (50%), mainly for pain or for cosmetic indications. Six patients underwent this new technique, which involved intraoperative direct venography with control of outflow via pressure at the superior or inferior orbital fissure. The venous malformation was then embolized (by use of cyanoacrylate glue) and excised. RESULTS: The mean age at presentation was 28.2 years (range, 8 months to 75 years). Sixty-six percent of cases involved the left orbit. Superior and medial orbital involvement was most common. Three cases (10%) were classified as superficial, and 13 (43%) as deep. Six patients (20%) had combined superficial and deep components. Eight (27%) had major extraorbital involvement (4 intracranial, 2 facial, and 2 paranasal sinus). Direct venography demonstrated complex multichannel anomalies draining to various sites, including the face and pterygopalatine fossa, without necessarily having a direct connection to the major orbital venous circulation. CONCLUSIONS: Distensible venous malformations of the orbit are part of a spectrum of developmental venous malformations that may be localized to the orbit or involve it as part of a more extensive lesion. The authors describe their clinical and radiologic features and report a new technique of management for selected cases. This method of vascular isolation and embolization of lesions may greatly facilitate excision. ( info)

7/298. Awake use of a new laryngeal mask prototype in a non-fasted patient requiring urgent peripheral vascular surgery.

    This case illustrates that a new prototype laryngeal mask with high seal pressures can be placed in the awake patient with minimal cardiorespiratory changes and that it facilitates passage of a nasogastric tube. ( info)

8/298. Fibroblast growth factor as therapy for critical limb ischemia: a case report.

    In an attempt to avert impending, primary amputation, an 85-year-old woman with chronic critical leg ischemia was enrolled in an experimental protocol to induce therapeutic angiogenesis. Treatment consisted of six consecutive, weekly intravenous infusions of recombinant basic fibroblast growth factor (bFGF). Angiographic evaluation was performed before and after therapy. The patient's clinical response was monitored through serial measurements of the ankle/brachial index and by repetitive assessment of limb flow by mercury strain-gauge plethysmography. A beneficial clinical response was detectable by week 4 of therapy, which was characterized by an improved walking distance, relief of ischemic pain, a marked reduction in analgesic consumption, and healing of persistent, unresponsive, painful inflammation of the hallux. The clinical improvement was sustained throughout the remaining weeks of therapy and follow-up evaluation. plethysmography documented improved blood flow; specifically, the augmentation of digital flow was sustained and correlated with the marked improvement in the patient's clinical status. ( info)

9/298. Popliteal vascular malformation simulating a soft tissue sarcoma.

    Differentiation of vascular abnormalities from soft tissue sarcomas may be difficult on clinical grounds, but is usually possible on imaging criteria. We report the MRI and digital subtraction angiography (DSA) findings in a patient presenting with a mass behind the knee. We discuss differentiating features and review the literature of similar cases. ( info)

10/298. Redo cardiac surgery in a patient with severe peripheral vascular disease and pericardial adhesions using subclavian arterial cannulation and port-access technology.

    patients viewed as conventionally inoperative candidates are now given alternative surgical choices. The ability to provide new technology such as the port-access minimally invasive approach, kinetic venous assist, and specialized cannulae have made this possible. This case report discusses the ability to apply and modify this new technology to provide a successful surgical outcome in a patient with severe peripheral vascular disease and dense mediastinal adhesions. ( info)
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