Femoral arterial injury following catheterization. Duplex evaluation

Over a 24-month period, 21 patients underwent duplex Doppler evaluation for arterial injury secondary to catheterization. There were seven pseudoaneurysms, one arteriovenous fistula, eight hematomas, and one true aneurysm. Duplex ultrasound was 100% sensitive and specific for detection of pseudoaneurysms and arteriovenous fistulas. The real-time examination alone was unreliable. The only necessary criterion for diagnosis of a femoral pseudoaneurysm was the presence of pulsatile flow in a cystic collection separate from the common femoral artery. This could be determined rapidly. Arterial flow in the femoral vein confirmed the presence of an arteriovenous fistula.     

Umbilical artery aneurysm: prenatal identification in three fetuses with trisomy 18.

Aneurysm of the umbilical artery is an extremely rare anomaly of the umbilical cord, with only two cases being documented in the English language literature. We report three cases diagnosed prenatally by ultrasound in the third trimester, all associated with single umbilical artery and multiple structural fetal anomalies. Prenatal karyotyping revealed trisomy 18 in all three cases. Umbilical cord anomalies, although rare, are associated with significant fetal morbidity and mortality. This report identifies umbilical artery aneurysm as an additional prenatal feature of trisomy 18.     

Successful surgical repair of a giant left main coronary artery aneurysm with arteriovenous fistula draining into a persistent left superior vena cava and coronary sinus: role of intraoperative transesophageal echocardiography

We report the case of a 74-year-old woman with a history of hypertension, hypercholesterolemia, and pacemaker who presented to the hospital with new onset New York Heart Association class IV congestive heart failure. Transthoracic echocardiography revealed a markedly dilated right ventricle with normal right ventricular systolic function. There was moderate pulmonary hypertension with an estimated pulmonary artery systolic pressure of 60 mm Hg. Her echocardiogram 1 year earlier had demonstrated normal right ventricular size and systolic function, and no pulmonary hypertension. Additional transthoracic imaging with saline contrast study through a left peripheral vein demonstrated the presence of a dilated coronary sinus with a persistent left superior vena cava. Color Doppler demonstrated turbulent flow within the coronary sinus with evidence of significant left-to-right shunting. Cardiac catheterization revealed a massively dilated left main coronary artery aneurysm with an arteriovenous fistula into the left superior vena cava and coronary sinus. The calculated Qp/Qs was 2:1. The patient underwent 2 unsuccessful attempts at percutaneous intervention to occlude the arteriovenous fistula. She then underwent successful surgical closure of the coronary arteriovenous fistula. The important role of intraoperative transesophageal echocardiography in guiding this technically challenging surgical case is discussed.     

Prenatal diagnosis of umbilical cord pseudocyst.

The association between umbilical cord anomalies and chromosomal abnormalities has received little attention in the literature. In this report, we present two cases of umbilical cord pseudocyst incidentally detected by ultrasound prior to genetic amniocentesis performed for the indication of advanced maternal age. In the first case it was only the initial abnormal finding in a 21-week fetus ultimately found to have a trisomy 18. In the second case, detected at 26 weeks, the karyotype was normal and a healthy normal neonate was delivered at term. The finding of a umbilical cord cystic mass during prenatal sonographic examination should alert the clinician to the increased risk of aneuploidy.     

Cord vessel compression by an expanding allantoic cyst: case report.

The umbilical cord has been inadequately studied by ultrasound. Umbilical cord masses are rare and often misdiagnosed.A case of a 4.3 x 3.2 cm anechoic floating cystic umbilical mass is reported. Doppler examination of the cord proximal to the cyst revealed a high resistance index of 0.84. Twelve hours later the cyst was larger (5.0 x 4.5 cm) and appeared tense; Doppler velocimetry worsened and absence of end-diastolic flow in the umbilical artery was found. Cardiotocography a few hours later showed a bradycardiac non-reactive trace with late decelerations. A live male weighing 1980 g was delivered by Cesarean section. At birth the cord position was normal. Pathological examination showed the lesion to be consistent with an allantoic cyst.This is the first case in which antenatal evidence of cord compression by an expanding allantoic cyst has been demonstrated.     

Two ductus venosus: a previously unreported anomaly

In early fetal life, the ductus venosus (DV) connects the umbilical vein, carrying nutrient-rich and oxygenated blood from the placenta to the inferior vena cava (IVC). We present the first ever case of a fetus with two ductus venosus. The fetus presented with a four-vessel cord and a dilated bowel at 31 weeks of gestation. Ultrasonography showed a persistent right umbilical vein. Echocardiographic investigation revealed normal cardiac anatomy with no major malformations. Two DVs with slightly different Doppler patterns were visualized anastomosing with the IVC. The baby was born uneventfully at 39 weeks of gestation with stable hemodynamics. Assuming every supernumerary umbilical vein should be connected to a DV for balanced circulation, a fetus with supernumerary umbilical veins lacking a corresponding number of DV connections is likely to be predisposed to complications such as hydrops fetalis and poor perinatal outcomes. The possibility of one or more umbilical veins lacking a DV connection warrants significant attention and regular monitoring from feto-maternal specialists, given the severity of the associated morbidity and mortality.     

Arteriovenous fistula of the thyroid gland associated with spontaneous bleeding from a flow-induced aneurysm of the inferior thyroid artery.

A case of acute, spontaneous cervical hemorrhage caused by a ruptured aneurysm of the inferior thyroid artery is described. This lesion was accompanied by an arteriovenous fistula within the thyroid gland that caused a flow-induced aneurysm. Diagnosis and treatment were successfully performed by selective angiography with endovascular occlusion and embolization. Both diagnostic and therapeutic management are discussed, and the related literature is reviewed. To our knowledge, this is the first reported case of an aneurysm of a thyroid artery in conjunction with an intraparenchymatous arteriovenous fistula of the thyroid gland.     

三点定位法和传统穿刺法在血液透析动静脉内瘘中的应用效果比较

目的比较三点定位法和传统穿刺法在血液透析患者动静脉内瘘中的应用效果其临床价值。方法将800例血液透析患者随机分为三点定位法穿刺(观察组)和传统穿刺法穿刺(对照组),每组各400例,所有穿刺均由资深护士执行,应用彩色多普勒分别观测穿刺前、穿刺60次后动静脉内瘘血管内膜壁的厚度,对比2组的穿刺失败率、动静脉内瘘动脉瘤发生状况、动静脉内瘘狭窄发生状况及患者满意度。结果 2组患者穿刺前后的动静脉内瘘血管内壁厚经比较差异有统计学意义(P0.05);观察组患者治疗后对动静脉内瘘血管内膜壁的厚度的影响程度显著低于对照组(P0.05);观察组患者穿刺60次的穿刺失败率、动静脉内瘘动脉瘤发生率、动静脉内瘘狭窄发生率显著低于对照组(P0.05);观察组患者满意度显著高于对照组(P0.05)。结论三点定位穿刺法联合氯沙坦的应用在血液透析患者动静脉内瘘中的临床效果较好,可以有效延长穿刺血管的使用寿命,降低血透内瘘血管并发症的发生率。     

Large pseudocyst of the umbilical cord detected in the second trimester

We present a case of a large umbilical cord cyst detected at 21 weeks of gestation. Serial ultrasonographic examination revealed a single umbilical artery and progression of the cystic mass. A 2,842-g male infant was delivered at 37 weeks of gestation, and we confirmed that the umbilical cord cyst was a pseudocyst in our pathological examination. This case demonstrated an uneventful course of pregnancy despite the large umbilical cord pseudocyst.     

Lower extremity venous pathology mimicking deep vein thrombosis: 2 case reports

We report two cases of lower extremity venous pathology mimicking deep vein thrombosis (DVT). The first case was a 20-year-old male with swelling in the left leg. Colour Doppler ultrasound (CDUS) demonstrated a continuous flow pattern, and computed tomography (CT) revealed compression of the dilated left common iliac vein by the right common iliac artery (May-Thurner syndrome). This dilatation of the vein was caused by overload due to the drainage of the gluteal arteriovenous malformations into this vein. The second case was a 55-year-old female with swelling and pain of the left leg persisting for a year following an operation of a herniated lumbar disk. She was diagnosed as DVT and treated accordingly. Control CDUS performed in our department demonstrated a left iliac arteriovenous fistula and a pulsatile flow pattern in the left femoral vein. CT also confirmed this arteriovenous fistula. We suggest that if not all criteria for the diagnosis of DVT are fullfilled by CDUS, another imaging modality such as multidetector CT should be used.     

女性尿直肠隔畸形序列征产前超声表现

目的总结分析胎儿尿直肠隔畸形序列征产前超声声像图及引产胎儿尸检特征。方法对2003年1月至2012年12月在南方医科大学附属深圳市妇幼保健院产前超声诊断的11例尿直肠隔畸形序列征胎儿超声图像表现和产后尸检特点进行总结分析。结果 11例尿直肠隔畸形序列征胎儿产前超声均显示腹腔内巨大囊性包块（双房或单房囊性结构2例,三房囊性结构9例,囊内透声清亮3例,囊内透声浑浊8例）和肛门闭锁,其中7例肾脏异常,6例伴腹腔积液;3例可见肠石症;伴发其他系统畸形包括脊髓栓系2例、单脐动脉2例、脐带囊肿2例、骶尾部发育不良1例、心肌致密化不全1例。染色体检查发现21-三体1例。引产胎儿标本尸检证实11例均为女性,有单个会阴开口,外生殖器性别不清楚,阴蒂肥大及阴唇融合;内生殖器异常包括双阴道或阴道纵隔9例,双子宫或双角子宫10例,阴道发育不良1例。结论尿直肠隔畸形序列征是一种包括泌尿系统、生殖系统、胃肠道异常的复杂先天畸形,腹腔内囊性包块是女性尿直肠隔畸形序列征的特征改变,具有重要诊断价值,产前超声发现肾脏异常及外生殖器性别不清楚有助于诊断尿直肠隔畸形序列征。     

人脐血间充质干细胞尾静脉移植治疗扩张型心肌病

背景：体外研究表明人脐血间充质干细胞可分化为自律性跳动的心肌细胞,而经静脉移植人脐血间充质干细胞治疗扩张型心肌病心力衰竭的报道较少。目的：探讨经尾静脉移植人脐血间充质干细胞对扩张型心肌病大鼠心肌结构、心功能的影响。方法：Wistar大鼠通过腹腔注射阿霉素诱导扩张型心肌病模型,扩张型心肌病实验组于造模后8周经尾静脉移植人脐血间充质干细胞,扩张型心肌病对照组注射等量DMEM培养基。健康对照组不造模,于相同时间点注射等体积的生理盐水。结果与结论：与健康对照组相比,扩张型心肌病组心功能明显受损,且扩张型心肌病实验组受损较扩张型心肌病对照组轻;移植的细胞有肌钙蛋白T的表达。结果提示人脐血间充质干细胞移植能促进扩张型心肌病大鼠心功能恢复,使心肌组织病变减轻。     

Pitfall: a pseudo tumor within the left liver lobe presenting with abdominal pain, jaundice and severe weight loss

A 51 year old male patient with a history of chronic alcohol consumption and recurrent pancreatitis was referred to our hospital with jaundice, epigastric pain, severe diarrhoea and weight loss of 28 kg within the last 12 months. A CT scan of the abdomen 4 months before admission had shown a pancreatitis with free fluid around the corpus and tail of the pancreas as well as dilated intrahepatic bile ducts and a cavernous transformation of the portal vein. Moreover, a tumor (3.5 x 3.0 x 3.6 cm) with irregular contrast enhancement was seen within the left liver lobe. The patient was referred to us for further evaluation and treatment. The initial B-Mode sonogram revealed a bull's eye like well defined lesion (8.1 x 7.5 x 7.0 cm) within the left liver lobe, consistent with a tumour or abscess. Prior to a diagnostic needle biopsy a PTCD was performed in this case presenting with dilated intrahepatic bile ducts and having a history of Billroth II operation. An additional colour coded Duplex Doppler ultrasonography demonstrated a visceral artery aneurysm and prevented us from performing the diagnostic puncture. The aneurysm was assumed to originate from a variant or a branch of the left hepatic artery. Angiography revealed a pseudoaneurysm of the pancreaticoduodenal artery and coil embolization was performed because of the increasing size and the risk of a bleeding complication. Postinterventional colour duplex ultrasound measurement showed no blood flow within the aneurysm. Retrospectively, the pseudoaneurysm must have led to a compression of the common bile duct, since the patient did not develop cholestasis after embolization and removal of the PTCD. Thus, a pseudoaneurysm of the pancreaticoduodenal artery must be included in the differential diagnosis of liver tumours in patients with chronic pancreatitis, despite its unusual localization near the liver. Therefore, we suggest that colour coded ultrasonography should be applied to any unclear, bull's eye like lesion, even though this method alone cannot exactly determine the origin of the pseudoaneurysm. Interventional angiography remains the gold standard for the diagnosis and therapy of visceral artery aneurysm.     

Hepatic hemangioendothelioma: prenatal sonographic findings and evolution of the lesion

We describe a case of hepatic hemangioendothelioma that was first suspected based on prenatal sonographic findings at 19 weeks' menstrual age. At 16 weeks, the patient presented with a markedly elevated maternal serum alpha-fetoprotein level. Serial sonographic examinations revealed that the fetus had cardiomegaly, hepatomegaly with a hepatic mass and dilated intrahepatic vessels, a single umbilical artery, and a placental chorioangioma. Arteriovenous shunting within the hepatic mass was seen using color Doppler and pulsed Doppler sonography. An enlarged artery arising from the abdominal aorta supplying the mass was demonstrated. Postnatal physical examination and radiologic studies supported the diagnosis of hepatic hemangioendothelioma. The evolution in the sonographic appearance of this hepatic lesion in utero over a 17-week period is described.     

Intrarenal arteriovenous fistula causing a "pseudonutcracker effect"

We report a case in which an intrarenal arteriovenous fistula caused the nutcracker effect. Color Doppler sonography of the left renal artery showed a peak systolic velocity of 150 cm/second and renoaortic ratio of 2.1. The left renal vein was significantly dilated, and the adjacent renal artery was kinked. A stenosis in the left renal vein at the aorto-mesenteric bifurcation was demonstrated, with a maximum velocity of 201 cm/second. Renal Doppler evaluation showed an area of high-velocity, low-resistance arterial flow consistent with an arteriovenous fistula in the inferior half of the left kidney. Angiography confirmed the fistula. The fistula was successfully occluded by coil embolization. Follow-up sonography showed almost complete obliteration of the fistula, regression of the renal vein dilatation, and a reduction in renal venous and arterial flow velocities. Given the reversibility of the fistula's effects, we suggest the term "pseudonutcracker effect" to describe this case.     

Reversed end-diastolic flow in the umbilical artery at 10-14 weeks of gestation is associated with absent pulmonary valve syndrome.

OBJECTIVE: To determine the incidence of reversed end-diastolic flow (REDF) in the umbilical artery in high-risk first-trimester pregnancies and evaluate associated conditions. METHODS: This was a prospective evaluation of the umbilical artery Doppler waveforms of 614 consecutive high-risk pregnancies between 10 and 14 weeks of gestation, to determine those with REDF. The associated anomalies and characteristics of these fetuses were then investigated. RESULTS: In 278/614 (45.3%) fetuses, there was positive end-diastolic flow in the umbilical artery; in 331/614 (53.9%) end-diastolic flow was absent and in 5/614 (0.8%) there was REDF. Three of the five fetuses with REDF had tetralogy of Fallot (TOF) with absent pulmonary valve syndrome (APVS) and a patent ductus arteriosus, and all three showed signs of cardiac failure, with reversed blood flow in the ductus venosus during atrial systole and generalized skin edema. Another fetus had a large ventricular septal defect and the remaining fetus had agenesis of the ductus venosus. Three fetuses had trisomy 18 and one had trisomy 13. CONCLUSIONS: REDF in the umbilical artery is very rare in early pregnancy and mostly occurs in association with major fetal vascular anomalies and cardiac defects, particularly TOF with APVS and patent arterial duct. We propose that the patency of the arterial duct in TOF with APVS leads to heart failure with subsequent demise early in pregnancy. Therefore, the frequent absence of the arterial duct observed in APVS in later pregnancy is more likely to be a result of early selection than a prerequisite for the development of this lesion as has been proposed previously.     

Fused umbilical arteries: prenatal sonographic diagnosis and clinical significance.

This report describes a series of 5 fetuses with fused umbilical arteries that had the prenatal feature of a single umbilical artery near the placental insertion and the normal 2 umbilical arteries at the fetal end of the cord. In 1 case this vascular anomaly was associated with unilateral renal agenesis in a fetus with a subsequent diagnosis of Hallermann-Streiff syndrome. No perinatal complications were identified in the remaining 4 fetuses. Postpartum examination of the cord revealed that the 2 umbilical arteries fused to form 1 artery for a long segment of the distal portion of the cord. Our findings suggest that the prenatal evaluation of the umbilical cord to document the number of vessels should include multiple views of the cord and demonstration of the 2 intra-abdominal umbilical arteries with color Doppler imaging for a confident diagnosis. Our observation also suggests that, at least in some cases, single umbilical artery may result from incomplete splitting of the single artery normally present in early human embryos.     

Fetal umbilical vein varix: sonographic appearance and postnatal outcome.

We describe five cases of dilation or varix of the umbilical portion of the left portal vein appearing as a fetal intra-abdominal cyst. Doppler or color flow examination, or both, indicated umbilical venous flow within the cystic area in each case. Only one fetus exhibited transient cardiomegaly, which resolved before birth. This fetus was the only one discovered to have the varix as early as the second trimester. All five infants were delivered at term without sequelae.     

彩色多普勒超声对眼上静脉扩张的诊断价值

目的探讨彩色多普勒超声检查对眼上静脉扩张及其病因的诊断价值。方法对1996～2005年经彩色多普勒超声检查明确眼上静脉扩张的94例眼眶病患者进行回顾性分析。结果眼上静脉扩张的病因包括颈动脉海绵窦瘘81例，眼眶静脉曲张7例，眼眶动静脉畸形6例。颈动脉海绵窦瘘显示为反向动脉化血流的眼上静脉扩张。眼眶静脉曲张呈正向血流的眼上静脉扩张。眼眶动静脉畸形则呈双向混杂血流的眼上静脉扩张，并常合并眶前部畸形血管团。结论彩色多普勒超声可以显示眼上静脉扩张及其血流动力学状态，对眼上静脉扩张的病因具有鉴别诊断价值。     

Fetal aneuploidy and umbilical cord thickness measured between 14 and 23 weeks' gestational age.

OBJECTIVE: To evaluate and compare umbilical cord thickness of aneuploid fetuses with umbilical cord diameter nomograms generated from euploid fetuses between 14 and 23 weeks' gestational age. METHODS: A retrospective study was conducted in which 56 fetuses and neonates had diagnoses of abnormal karyotypes, of which 46 fetuses had numerical chromosomal abnormalities. Among these cases, 26 subjects with adequate umbilical cord sonographic images were included in the study. The umbilical cord thickness was measured and plotted against the umbilical cord diameter nomogram that was generated from previously published data. RESULTS: From 26 evaluated fetuses and neonates, in 14 subjects (53.8%), the umbilical cord thickness was greater than the 95th percentile for gestational age. A thick umbilical cord was observed in 57.8% of fetuses with trisomy 21 and 50% of subjects with trisomy 18 and monosomy 45,XO. One fetus with trisomy 2 had umbilical cord thickness within the normal range. The largest number of aneuploid fetuses with thick umbilical cords (87.5%) was observed between 16 and 17 gestational weeks. CONCLUSION: Aneuploid fetuses have thicker umbilical cords than euploid fetuses. The umbilical cord thickness can be related to an increased amount of Wharton jelly. Because of the smaller number of thick umbilical cords in aneuploid subjects at later gestational ages, we speculate that abnormal cord thickness has a natural tendency toward its own resolution with the advancement of gestational age.