Unusual Left Superior Vena Cava, Connected to the Left Atrium via the Left Superior Pulmonary Vein

Persistent left superior vena cava (LSVC) that drains into the left atrium (LA) via the left superior pulmonary vein (LSPV) is a rare systemic venous drainage anomaly. It can cause cyanosis and unexplained recurrent strokes. Undiagnosed, it can seriously disrupt the conduct of the cardiopulmonary bypass (CPB), causing sudden air lock and/or flooding of the operative field with venous blood. Its connection with the LSPV outside the pericardium makes its intraoperative diagnosis difficult. We report here the case of a 48-year-old man operated for mitral and aortic valve endocarditis, complicating a Laubry-Pezzi syndrome. The opening of the LA was followed immediately by the entrance of high volume of air bubbles into the superior vena cava cannula which resulted in sudden air lock of the venous outflow line. After multiple lowerings and cessations of pump flow, partial clamping of this cannula resulted in flooding of the LA with venous blood coming from the LSPV. The heart luxation did not allow us to find the LSVC in its usual intrapericardial location, between the LSPV and the left appendage. We had to widely open the left pleura to expose its completely extrapericardial path and its communication with the LSPV. The LSVC was temporally clamped during the remainder of the surgical procedure, then ligated at both ends. The patient underwent mitral valve repair, closure of the infundibular septal defect, aortic valve replacement and tricuspid annuloplasty. He was discharged 10 days later.

[Emergent Operation for Total Anomalous Pulmonary Venous Return]

Total anomalous pulmonary venous return with pulmonary venous obstruction is one of the congenital heart diseases requiring an emergent operation just after birth. The patients with this condition have severe lung congestion and pulmonary hypertension, and cannot survive without relief of pulmonary venous obstruction. During the emergent operation, an appropriate confluence between the common pulmonary venous chamber and left atrium needs to be created under cardiopulmonary bypass. The typical approaches for the anastomosis and the anastomosis techniques are summarized in this article. At the weaning from the cardiopulmonary bypass, the necessary treatments such as nitric oxide or open chest need to be applied. The early surgical outcome for total anomalous pulmonary venous return is referenced from the Japanese National Clinical Database.

Ultrasound findings in neonates with alveolar capillary dysplasia with misalignment of the pulmonary veins: report of two cases

Alveolar capillary dysplasia with misalignment of the pulmonary veins (ACDMPV) is a rare congenital pulmonary disease that affects newborns. Most patients with ACDMPV are born at full term and are healthy. The main clinical manifestations are refractory pulmonary hypertension and pulmonary failure with gastrointestinal, urinary, or cardiac malformations. ACDMPV often progresses rapidly, but no conventional biological or imaging tests other than genetic testing are available for its diagnosis. Lung biopsy is currently the gold standard for diagnosis. We herein report two cases of ACDMPV confirmed by pathological examination and discuss their ultrasonographic findings.

Impact of total anomalous pulmonary venous connection in staged single ventricle palliation

BACKGROUND

Total anomalous pulmonary venous connection (TAPVC) with a functional single ventricle is a risk factor for mortality during staged palliation. This study aimed to assess TAPVC's impact on staged palliation outcomes.

METHODS

In a total of 602 patients with a functional single ventricle who underwent stage 1 palliation (S1P) at our center between 2001 and 2020, 39 (6.5%) patients were associated with TAPVC. Median age at S1P was 12.0 (interquartile range, 7-21) days with a body weight of 3.1 (interquartile range, 2.8-3.6) kg. Outcomes during staged palliation were compared with the remaining 563 patients without TAPVC. Risk factors for mortality were identified using a Cox proportional hazards regression model.

RESULTS

Primary diagnosis in functional single-ventricle patients with TAPVC included hypoplastic left heart syndromes (n = 13), unbalanced atrioventricular septal defects (n = 12) tricuspid atresias (n = 2), double inlet left ventricle (n = 1), and others (n = 11). Types of TAPVC were supracardiac (n = 21), cardiac (n = 10), infracardiac (n = 6), and mixed (n = 2). Pulmonary venous obstruction (PVO) was associated in 19 (49%) patients. S1Ps included Norwood (n = 13), aortopulmonary shunt (n = 21), and pulmonary artery banding (n = 5). Thirty-day mortality after S1P was significantly increased in patients with TAPVC vs without TAPVC (43.6% vs 16.3%; P < .001). After bidirectional cavopulmonary shunt and total cavopulmonary connection procedures, mortality was low in both groups, and no statistically significant differences were found. Correction of TAPVC at the time of S1P was not found to be a significant risk factor in univariable Cox regression analysis. In univariate and multivariate analysis, PVO was identified as an independent risk factor for mortality in patients with TAPVC (P < .001).

CONCLUSIONS

Overall survival is lower in TAPVC single-ventricle patients than in non-TAPVC patients. Most deaths after S1P were associated with TAPVC, but not after S2P. PVO is a mortality risk factor in TAPVC patients.

Echocardiographic evaluation of total anomalous pulmonary venous connection: Comparison of obstructed and unobstructed type

This study aims to compare the differences between obstructed and unobstructed total anomalous pulmonary venous connection (TAPVC) using echocardiography, and to evaluate the clinical and echocardiographic parameters associated with pulmonary venous obstruction (PVO).We conducted a retrospective study of 70 patients with TAPVC between 2014 and 2019. The morphologic and hemodynamic echocardiographic parameters of patients were observed and measured, and the parameters between obstructed and unobstructed TAPVC were compared. The clinical and echocardiographic parameter differences between the two groups were used for ROC curve analysis.Obstructed TAPVC was found in 30 (42.9%) of 70 patients. Between obstructed and unobstructed TAPVC, there were significant differences in atrial septal defect size, pulmonary artery maximum velocity (PA Vmax ), peak E velocity of mitral valve, left ventricular fractional shortening, left ventricular ejection fraction, stroke volume and the incidence of patent ductus arteriosus, but there was no significant difference in birth weight. The first diagnosis age of obstructed TAPVC was earlier than unobstructed type. The ROC curve analysis for the first diagnosis age showed the sensitivity and specificity were 76.7%, 80% respectively. The ROC curve analysis for the PA Vmax showed the sensitivity and specificity were 88.5%, 67.6% respectively.Patients with TAPVC had a high incidence of PVO. The presence of PVO can affect the size of atrial septal defect and the closure of the ductus arteriosus, cause significant changes in PA Vmax, peak E velocity of mitral valve, left ventricular fractional shortening, left ventricular ejection fraction, stroke volume, lead to earlier symptoms and earlier first diagnosis age. The first diagnosis age and PA Vmax were excellent values since they associated with PVO.

Images of the month 1: Ischaemic stroke due to pulmonary arteriovenous fistula

A 38-year-old man was admitted to the hospital due to a "suddenly developed right hemiplegia, unconsciousness and gaze to the right". Pulmonary arteriovenous fistulas (PAVFs) are rare but an important cause of stroke in young people, which is easy to be clinically neglected. Therefore, for young patients with pulmonary diseases and cerebral infarction, the possibility of PAVF should be considered.

Pulmonary arteriovenous malformations: A case of missed diagnosis in a neonate

Pulmonary arteriovenous malformation (PAVM) is a congenital vascular abnormality that can cause persistent cyanosis in children. PAVMs can go undetected till adulthood; however, there have been several neonatal cases reported over the years. This case report describes a classical manifestation of a child with isolated PAVM whose diagnosis was likely missed during the neonatal period. A high level of clinical awareness of this condition is crucial as early diagnosis and appropriate treatment can prevent lifethreatening complications and mortality. Diagnosis was confirmed by computed tomography pulmonary angiography and percutaneous transcatheter embolotherapy resulted in complete resolution of symptoms.

Pulmonary arteriovenous malformations may be the only clinical criterion present in genetically confirmed hereditary haemorrhagic telangiectasia

Pulmonary arteriovenous malformations (PAVMs) result in preventable complications demanding specialty care. Underlying hereditary haemorrhagic telangiectasia (HHT) can be identified by genetic testing, if the diagnosis is considered. Retrospectively reviewing 152 unrelated adults with genetically confirmed HHT due to ACVRL1, ENG or SMAD4, we found that only 104/152 (68%) met a clinical diagnosis of HHT with three Curaçao criteria. The genetic diagnostic rate was similar for patients with three (104/137, 76%) or one to two (48/71, 68%; p=0.25) criteria. Of 83 unrelated probands with PAVM(s) and genetically-confirmed HHT, 20/83 (24%) had few, if any, features of HHT. Enhanced clinical suspicion, as well as HHT genetic testing, is recommended if one or more PAVMs are present.

Sinus venosus atrial septal defect and partial anomalous pulmonary venous connection in a patient with dextrocardia

An 85-year-old woman presenting with symptomatic pulmonary hypertension (PH) with a history of dextrocardia was referred to our facility for treatment of heart failure. Significant shunting was detected by measuring oxygen saturation during right heart catheterisation (RHC). CT with contrast revealed sinus venosus atrial septal defect (SVASD) and partial anomalous pulmonary venous connection (PAPVC), in which the left upper and middle lobar pulmonary veins returned to the superior vena cava and right atrium. Despite medical treatment, the patient died, and an autopsy was performed. SVASD and PAPVC are rare congenital anomalies. RHC with measurement of oxygen saturation and CT with contrast should be considered in patients with unexplained right atrial and ventricular enlargement or suspected PH.

Venous thrombosis via pulmonary arteriovenous malformation causing acute myocardial infarction in a relatively young female patient

Pulmonary arteriovenous malformation (PAVM) is a probable cause of thromboembolic diseases such as acute myocardial infarction (MI); however, few cases have been reported. A woman in her early 40s developed acute-onset chest pain; an ECG showed ST-elevated MI. Emergency catheter angiography showed that the culprit lesion was a thrombus that was treated successfully with aspiration. She had a history of deep venous thrombosis and CT revealed PAVM. It was likely that the venous thrombus had moved into the coronary artery through the PAVM. Catheter embolisation of the PAVM was performed and she did not experience any other cardiac event until 6 months after embolisation.

Ischemic Stroke and Pulmonary Arteriovenous Malformations: A Review

The potential of covert pulmonary arteriovenous malformations (PAVMs) to cause early onset, preventable ischemic strokes is not well known to neurologists. This is evident by their lack of mention in serial American Heart Association/American Stroke Association (AHA/ASA) Guidelines and the single case report biased literature of recent years. We performed PubMed and Cochrane database searches for major studies on ischemic stroke and PAVMs published from January 1, 1974, through April 3, 2021. This identified 24 major observational studies, 3 societal guidelines, 1 nationwide analysis, 3 systematic reviews, 21 other review/opinion articles, and 18 recent (2017-2021) case reports/series that were synthesized. Key points are that patients with PAVMs have ischemic stroke a decade earlier than routine stroke, losing 9 extra healthy life-years per patient in the recent US nationwide analysis (2005-2014). Large-scale thoracic CT screens of the general population in Japan estimate PAVM prevalence to be 38/100,000 (95% confidence interval 18-76), with ischemic stroke rates exceeding 10% across PAVM series dating back to the 1950s, with most PAVMs remaining undiagnosed until the time of clinical stroke. Notably, the rate of PAVM diagnoses doubled in US ischemic stroke hospitalizations between 2005 and 2014. The burden of silent cerebral infarction approximates to twice that of clinical stroke. More than 80% of patients have underlying hereditary hemorrhagic telangiectasia. The predominant stroke mechanism is paradoxical embolization of platelet-rich emboli, with iron deficiency emerging as a modifiable risk factor. PAVM-related ischemic strokes may be cortical or subcortical, but very rarely cause proximal large vessel occlusions. Single antiplatelet therapy may be effective for secondary stroke prophylaxis, with dual antiplatelet or anticoagulation therapy requiring nuanced risk-benefit analysis given their risk of aggravating iron deficiency. This review summarizes the ischemic stroke burden from PAVMs, the implicative pathophysiology, and relevant diagnostic and treatment overviews to facilitate future incorporation into AHA/ASA guidelines.

Early development of the pulmonary vascular system: An anatomical and histochemical reinvestigation of the pulmonary venous return development in mice

Pulmonary venous return development establishes the fetal circulation and is critical for the formation of pulmonary circulation independent of systemic circulation at birth. Anomalous returns lead to inappropriate drainage of blood flow, sometimes resulting in neonatal cyanosis and cardiac failure. While many classical studies have discussed the anatomical features of the pulmonary venous system development, the cellular dynamics of the endothelia based on the molecular marker expression remain unknown. In the present study, we examined the expression of several endothelial markers during early pulmonary vascular system development of murine embryos. We show that Endomucin and CD31 are expressed early in endothelial cells of the splanchnic plexus, which is the precursor of the pulmonary vascular system. Three-dimensional analyses of the expression patterns revealed the spatiotemporal modification of the venous returns to systemic venous systems or sinoatrial canal during the formation of the pulmonary plexus. We herein report the results of spatiotemporal analyses of the early pulmonary venous system development with histochemistry as well as a delineation of the anatomical features of the tentative drainage pathways.

Building A Risk Prediction Model for Postoperative Pulmonary Vein Obstruction via Quantitative Analysis of CTA Images

Total anomalous pulmonary venous connection (TAPVC) is a rare but mortal congenital heart disease in children and can be repaired by surgical operations. However, some patients may suffer from pulmonary venous obstruction (PVO) after surgery with insufcient blood supply, necessitating special follow-up strategy and treatment. Therefore, it is a clinically important yet challenging problem to predict such patients before surgery. In this paper, we address this issue and propose a computational framework to determine the risk factors for postoperative PVO (PPVO) from computed tomography angiography (CTA) images and build the PPVO risk prediction model. From clinical experiences, such risk factors are likely from the left atrium (LA) and pulmonary vein (PV) of the patient. Thus, 3D models of LA and PV are rst reconstructed from low-dose CTA images. Then, a feature pool is built by computing different morphological features from 3D models of LA and PV, and the coupling spatial features of LA and PV. Finally, four risk factors are identied from the feature pool using the machine learning techniques, followed by a risk prediction model. As a result, not only PPVO patients can be effectively predicted but also qualitative risk factors reported in the literature can now be quantied. Finally, the risk prediction model is evaluated on two independent clinical datasets from two hospitals. The model can achieve the AUC values of 0.88 and 0.87 respectively, demonstrating its effectiveness in risk prediction.

The anomalous drainage of the inferior vena cava into the left atrium

BACKGROUND

Anomalies in systemic venous return most commonly involve a persistent left supe-rior vena cava draining into the left atrium. Anomalous drainage of the inferior vena cava (IVC) into the left atrium is a rare congenital vascular disorder. The diagnosis was confirmed as anoma-lous drainage of the right superior pulmonary vein and large atrial septal defect following echo-cardiography. Anomalous drainage of the inferior vena cave was confirmed with computed tomog-raphy (CT). We report a rare combination of drainage of the inferior vena cava associated with atrial septal defect (ASD) and partial anomalous pulmonary venous return.

CASE

A 14-year-old girl was referred to our hospital for the evaluation of palpitations, hypoxia, exertional dyspnea, and cyanosis. Transthoracic echocardiography (TTE) revealed a large sinus venosus ASD and anomalous right superior pulmonary venous return. A cardiac CT demonstrated IVC drainage to the left atrium and an anomalous right superior pulmonary vein draining into the right atrium.

CONCLUSIONS

In older patients with cyanosis, further imaging methods together with TTE will be useful in detecting additional cardiac anomalies. Patients with inferior vena cava opening to the left atrium are different from caval type ASD`s and should be surgically repaired using a patch. Corrective surgery involves repositioning of the interatrial septum via a patch.

Congenital pulmonary varix: Two case reports

RATIONALE

Patients with congenital pulmonary varix are asymptomatic and require no treatment, but the radiological characteristics of a pulmonary varix are similar to those of a pulmonary arteriovenous malformation, which requires treatment. Pulmonary angiography is useful for obtaining information about the dynamics of pulmonary blood flow to differentiate a pulmonary varix from a pulmonary arteriovenous malformation for the purpose of treatment planning. Two cases of congenital pulmonary varices that were differentiated from pulmonary arteriovenous malformations based on pulmonary angiography findings are presented.

PATIENT CONCERNS AND DIAGNOSIS

The first patient was an asymptomatic 39-year-old man. Non-contrast-enhanced computed tomography performed as part of the treatment course for pneumonia showed pulmonary arteriovenous malformation in the right lung. Pulmonary angiography was performed and showed that it was a pulmonary varix. The second patient was an asymptomatic 23-year-old woman. As part of her regular health check-up, she underwent plain chest X-ray examination, which showed an abnormal shadow. Non-contrast-enhanced computed tomography was performed, and pulmonary arteriovenous malformation was suspected. However, contrast-enhanced computed tomography findings suggested that the patient had a congenital pulmonary varix rather than a pulmonary arteriovenous malformation. Pulmonary angiography was subsequently performed for diagnosis, and a pulmonary varix was confirmed.

INTERVENTIONS AND OUTCOMES

No treatment was administered to either patient. The first patient was followed up for four years, and the second patient for two years. Both patients had no symptoms or complications during the follow-up period.

LESSONS

Two cases of congenital pulmonary varices were reported. Information about the dynamics of pulmonary blood flow obtained by performing pulmonary angiography was effective in distinguishing between pulmonary arteriovenous malformation and congenital pulmonary varix.

Sutureless Repair with Extended Atriotomy for Post-repair Pulmonary Venous Obstruction

Post-repair pulmonary venous obstruction (PR-PVO) is a common cause of reoperation following total anomalous pulmonary venous return repair. Herein, we report three cases of specific type of PR-PVO with eccentric stenosis of pulmonary vein ostium due to retained composite neo-septum and the technique used for subsequent repair. Post-repair pulmonary venous obstruction (PR-PVO) after total anomalous pulmonary venous return (TAPVR) repair is a common complication and represents a significant surgical challenge with a high recurrence rate. One pattern of PR-PVO includes eccentric stenosis of pulmonary vein ostium with a stenotic residual leftward-displaced anastomotic orifice and prominent retained partition between the pulmonary veins and the left atrium composed of pulmonary vein and overlying left atrium and atrial septum - hereby termed "retained composite neo-septum". We describe three patients with this pattern and describe a surgical technique applicable for this subset.

Clinical Significance of Partial Anomalous Pulmonary Venous Connections (Isolated and Atrial Septal Defect Associated) Determined by Cardiovascular Magnetic Resonance

BACKGROUND

Partial anomalous venous connections (PAPVC) are associated with left to right shunting and right heart dilatation. Identification of PAPVC has increased with widespread use of cross-sectional imaging modalities. However, management strategies are mostly based on expert opinion given the scarcity of data from large series. We aimed to define types and significance of isolated and atrial septal defect (ASD) associated PAPVC detected by cardiovascular magnetic resonance.

METHODS

We retrospectively reviewed our cardiovascular magnetic resonance database from 2002 to 2018 to identify isolated or ASD-associated PAPVC cases.

RESULTS

A total of 215 patients (median age 46 years; range, 6-83) with isolated or ASD-associated PAPVC were identified among 102 135 clinical cardiovascular magnetic resonance studies. Of these, 104 were isolated and 111 were associated with an ASD. Anomalous connection of right upper pulmonary vein was the most common single venous anomaly (99/215), but in the isolated PAPVC group there were more anomalous left than right upper pulmonary veins (39 versus 34). The Qp/Qs was significantly higher for isolated anomalous single right upper pulmonary vein than left upper pulmonary vein (1.6 versus 1.4 respectively; P=0.01) as were right ventricular end-diastolic volumes (113.7±30.9 versus 90 [57-157] mL/m2, P=0.004). In the PAPVC with an ASD group, sinus venosus ASDs (82%) were associated with right-sided PAPVCs while both right and left-sided venous anomalies were seen in secundum ASDs (18%). In a substantial number of patients (30 out of 91) with sinus venosus ASDs, PAPVCs were more complex and involved more than a single anomalous right upper pulmonary vein; and in 5 patients with ASD, PAPVC was identified only after the ASD closure.

CONCLUSIONS

This large series provides descriptive and hemodynamic features for isolated and ASD-associated PAPVCs. Anomalous isolated right upper pulmonary vein may cause a significant shunt (Qp/Qs >1.5). PAPVC associated with sinus venosus and secundum ASDs might be more complex than a single anomalous pulmonary vein and missed before ASD correction.

A modified suprasternal approach in transthoracic echocardiography for isolated left upper partial anomalous pulmonary venous connection: Hard to diagnose, easy to miss

BACKGROUND

Isolated left upper partial anomalous pulmonary venous connection (PAPVC) via the innominate vein to the right atrium is a rare congenital anomaly. This study was undertaken to determine the efficacy of a modified suprasternal view in transthoracic echocardiography (TTE) for the detection of left upper PAPVC.

METHODS

After the incidental diagnosis of left upper PAPVC in our first patient in 2008, we added a modified suprasternal view to all TTEs performed in our pediatric cardiology clinic. This was obtained by tilting the tail of the probe 30-45⁰ towards the right shoulder of the patient during suprasternal long axis view for a better visualization of the innominate vein.

RESULTS

Among 7200 patients who underwent TTEs between 2008 and 2020, we identified 13 patients with left upper PAPVC into the innominate vein. All were asymptomatic children with normal cardiac chambers and no accompanying congenital disorders. In 10 cases, diagnoses were confirmed by multi-slice computerized tomography, whereas one patient underwent catheterization for confirmation.

CONCLUSION

Isolated left upper PAPVC to the innominate vein is a rare congenital disorder that can be present in asymptomatic children with normal cardiac chambers. TTE, with a modified approach in suprasternal long axis view, has a high diagnostic value in the detection of this condition.

De Novo mutation of FOXF1 causes alveolar capillary dysplasia with misalignment of pulmonary veins: A case report

RATIONALE

Alveolar capillary dysplasia with misalignment of the pulmonary veins (ACD/MPV) is a rare congenital malformation in neonates that results in severe respiratory distress and pulmonary hypertension. ACD/MPV is caused by mutations in the FOXF1 gene. Herein, a new case of a girl with ACD/MPV carrying a novel pathogenic variant of FOXF1 was reported.

PATIENT CONCERNS

A 3-month-old Chinese girl was admitted to the hospital presenting a complaint of cyanosis for 10 days and respiratory distress for 2 days. The history of foreign body inhalation was denied.

DIAGNOSES

Blood routine, liver and kidney function, electrolytes, type B natriuretic peptide, electrocardiogram, cardiac computed tomography (CT), and echocardiography were done after admission. Dysplasia of the alveolar and the left upper pulmonary vein was displayed through cardiac CT. Echocardiography showed atrial septal defect, tricuspid valve malformation, and pulmonary hypertension. Sequence analysis of FOXF1 from genomic deoxyribonucleic acid (DNA) revealed that the patient was heterozygous for a novel missense variant (c.418 C>T, p.Pro140Gly). Furthermore, genetic analysis of both parents confirmed the de novo occurrence of the variant. Conservation analysis showed that the locus was highly conserved across species. Then, ACD/MPV was a clinical diagnosis.

INTERVENTIONS

After admission, nasal catheter oxygen inhalation, cefazoxime sodium, furosemide diuretic, milrinone lactate, and Bosentan were given to the patient.

OUTCOMES

After 6 days of hospitalization, the patient's condition did not improved, the parents gave up treatment and discharged. The patient died half a month after discharge.

LESSONS

ACD/MPV is a rare congenital malformation with a poor prognosis. A new de novo mutation of FOXF1 was found in our case. Non-invasive methods such as DNA sequencing and FOXF1 analysis are helpful in the clinical diagnosis of ACD/MPV especially in early infants with respiratory distress and pulmonary hypertension.

Thalamic abscess in a patient with hereditary hemorrhagic telangiectasia successfully treated with an empiric antibiotic regime: case report and review of the literature

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease associated with neurological complications, including cerebral abscesses (CA). They tend to be unique, supratentorial and lobar. While the surgical intervention is a rule of thumb when treating and diagnosing the etiology of these lesions, this is not always possible due to dangerous or inaccessible locations. We report the case of a patient solely treated with empiric antibiotics without stereotaxic intervention and satisfactory results.

CASE PRESENTATION

We present the case of a 21-year-old patient with a right thalamic abscess due to HHT and pulmonary arteriovenous malformations, previously embolized, treated solely with antibiotics. At first, we contemplated the possibility of a stereotaxic biopsy, but the high-risk location and the fact that our patient received a previous full course of antibiotic treatment (in another center), made us discard this intervention because of the low diagnostic yield. We started an empiric antibiotic regime. We followed up very closely the clinical and radiological evaluation the next weeks, adjusting our antibiotic treatment when necessary. The results were favorable from both the radiological and clinical aspects and 6 months after the diagnosis the images show its almost complete disappearance.

CONCLUSION

Carefully tailored antibiotic-only regime and vigilance of its adverse effects and close radiological following is a good treatment approach when surgery is not an option.