Traumatic Pseudoaneurysm and Arteriovenous Fistula Detected by Bedside Ultrasound

Background

The case of late presentation of a pseudoaneurysm and an arteriovenous fistula (AVF) of the common femoral artery and vein secondary to penetrating trauma is reported. Traumatic AVF and pseudoaneurysm may be present within a variety of clinical conditions, which sometimes makes it difficult to detect them clinically. Undiagnosed AVF can lead to clinical manifestations mostly secondary to increased output generated by the fistula.

Case Report

A 31-year-old man presented to the Emergency Department (ED) for wound care follow-up. A week before, he had suffered a stab wound to the medial thigh and the primary suture was performed in our ED. During his first visit to our ED, the vascular examination revealed palpable dorsalis pedis and tibialis posterior pulses. The formal Doppler ultrasound was negative. During his second presentation, however, the physical examination was remarkable for a palpable thrill and continuous bruit in the left mid-thigh region. Also, an ultrasound with a 7.5-MHz linear probe demonstrated a pseudoaneurysm and an AVF between the femoral artery and vein.

Conclusion

The mechanism of the injury, wound location and tract, and physical findings after a penetrating thigh trauma can help to predict femoral artery injury. Also, occult injuries to the medial thigh after penetrating trauma may be easily overlooked on the physical examination. Furthermore, bedside ultrasound performed by an emergency physician may be helpful in diagnosing occult vascular injuries.     

The validation of left atrial strain imaging for the assessment of diastolic functions in patients with ST-segment elevation myocardial infarction

Assessment of left ventricular filling pressure (LVFP) is crucial in patients with ST-segment elevation myocardial infarction (STEMI). Since current guideline recommended echocardiographic parameters have limited value, more comprehensive assessment methods are required in this patient subset.In this study, we aimed to investigate the clinical utility of left atrial reservoir strain (LARS) imaging in patients treated with primary percutaneous coronary intervention (pPCI). Patients who underwent successful pPCI were included. Left ventricular end-diastolic pressure (LVEDP) was measured invasively following pPCI. Left atrial strain imaging was performed following pPCI within 24 h of pPCI. Normal LARS value was accepted as above 23%. We prospectively enrolled 69 patients; there were 18 patients with LARS below 23% who were included into group 1 and rest of the study population included into group 2. There was no significant difference between groups in terms of comorbidities.Troponin and pro-BNP levels were significantly higher in group 1 (p: 0.036 and 0.047 respectively). Left atrial volume and tricuspid regurgitation velocity were similar between groups (p: 0.416 and p: 0.351 respectively). Septal tissue velocity was higher (p: 0.001) and Septal E/e’ ratio was lower (p: 0.004) in group 2. Left ventricular (LV) global longitudinal strain value was higher in group 1 which is consistent with observed lower ejection (LVEF) fraction in group 1 (p: 0.001 for LV strain and p: 0.001 for LVEF). Estimated mean LVFP was also higher in group 1 (p: 0.003).Correlation analyses revealed moderate correlation between LARS and LVEDP (r: ? 0.300). Our results indicate that left atrial strain imaging is a promising tool for the assessment of left atrial pressure in patients with STEMI.

     

Clinical utility of insulin and insulin analogs

Diabetes is a pandemic disease characterized by autoimmune, genetic and metabolic abnormalities. While insulin deficiency manifested as hyperglycemia is a common sequel of both Type-1 and Type-2 diabetes (T1DM and T2DM), it does not result from a single genetic defect—rather insulin deficiency results from the functional loss of pancreatic β cells due to multifactorial mechanisms. Since pancreatic β cells of patients with T1DM are destroyed by autoimmune reaction, these patients require daily insulin injections. Insulin resistance followed by β cell dysfunction and β cell loss is the characteristics of T2DM. Therefore, most patients with T2DM will require insulin treatment due to eventual loss of insulin secretion. Despite the evidence of early insulin treatment lowering macrovascular (coronary artery disease, peripheral arterial disease and stroke) and microvascular (diabetic nephropathy, neuropathy and retinopathy) complications of T2DM, controversy exists among physicians on how to initiate and intensify insulin therapy. The slow acting nature of regular human insulin makes its use ineffective in counteracting postprandial hyperglycemia. Instead, recombinant insulin analogs have been generated with a variable degree of specificity and action. Due to the metabolic variability among individuals, optimum blood glucose management is a formidable task to accomplish despite the presence of novel insulin analogs. In this article, we present a recent update on insulin analog structure and function with an overview of the evidence on the various insulin regimens clinically used to treat diabetes.     

Leaflet length and left main coronary artery occlusion following transcatheter aortic valve replacement

Coronary artery occlusion during transcatheter aortic valve replacement is a rare complication. However, it is a very severe and life‐threatening event. Although there are some possible causes of this phenomenon, definite etiologies and predictors are unknown because of the small number. We describe one case of left main coronary artery occlusion immediately after deployment of a prosthetic valve. The patient became hypotensive and developed cardiopulmonary arrest. However, the coronary artery was successfully stented with a help of cardiopulmonary bypass and he recovered well. In this case, pre‐procedural computed tomography (CT) showed the adequately high coronary height and no other significant conventional predictor for coronary occlusion. The examinations were retrospectively reviewed and the CT showed a long leaflet compared to the coronary sinus complex. The fluoroscopy appeared to show the long leaflet covering the left main coronary artery ostium immediately after the valve deployment. The height of the coronary artery ostium from the aortic annulus appeared sufficiently high in this case and did not explain the coronary compromise; leaflet length in relation to the coronary sinus dimension seemed more relevant. The ratio between leaflet length and curved coronary sinus height (L/C) may be one novel predictor for coronary artery occlusion. © 2013 Wiley Periodicals, Inc.     

Aortic and coronary calcifications in Takayasu arteritis

Objectives

Atherosclerosis is well recognized in Takayasu arteritis (TAK) and the associated plaques tend to be more common in areas of arteritis. We now report arterial wall calcification in a large group of TAK patients and controls. We hypothesized that the degree of coronary artery calcification would point to a systemic effect of inflammation while that in the thoracic aorta more of local inflammation.

Methods

A total of 47 patients with TAK, 43 patients with SLE and 70 healthy controls (HC) were studied. The presence of coronary artery and thoracic aorta calcifications (ToAC) was investigated by multi-detector computed tomography (MDCT). Atherosclerotic plaques in the carotid arteries were screened using B mode ultrasound.

Results

The frequency of coronary artery calcification was significantly increased among patients with SLE as compared to the healthy controls while the increase in TAK did not reach statistical significance. There were more TAK patients with ToAC among the TAK as compared to the SLE patients [21/47 (45%) vs 10/43 (23%), P = 0.033]. In addition, a circumferential type of calcification, vs a punctuate or linear type, was the more common type in 67% of patients with TAK whereas only the linear or punctuate type was seen in SLE patients and HC. SLE and TAK patients were found to have increased risk for carotid artery plaques. Among TAK patients, coronary artery calcification, ToAC and carotid artery plaques tend to be at sites of primary vasculitic involvement.

Conclusions

There is increased atherosclerosis in TAK and SLE. Vessel wall inflammation seems to be also important in the atherosclerosis associated with TAK.     

Erectile dysfunction and sex hormone changes in chronic obstructive pulmonary disease patients

Background

The prevalence of sexual dysfunction in patients with COPD is high and its significance has not been sufficiently stressed. The aim of this study is to investigate the incidence of erectile dysfunction (ED) and the factors affecting its frequency in COPD patients.

Methods

Seventy patients with COPD and 68 healthy volunteers were included in the study. The International Index of Erectile Function questionnaire was used to evaluate ED, and the Beck Depression Inventory was used to evaluate depression.

Results

The smoking rate was higher and oxygen saturation (SaO₂) and body mass index (BMI) were lower in the COPD group. Blood tests revealed higher levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol. Testosterone level was lower but it was not statistically significant. Various degrees of ED were detected in 78.6% of COPD patients and 55.8% of the controls. Depression was more common in the COPD group. There was a negative correlation between forced expiratory volume in 1 sec (FEV1) level and ED and between SaO₂ and ED in the COPD group. A positive correlation was noted between age and ED in both groups. No significant correlation was found among hormonal status and FEV₁, ED, depression, SaO₂, or BMI.

Conclusions

The present study provides further confirmation that COPD is a risk factor for erectile dysfunction. When establishing a treatment plan for improving the pulmonary function of COPD patients, sexual dysfunction and depression, which are usually neglected but diminish quality of life, should also be addressed.