COVID Toes: Concurrent Lower Limb Arterial and Venous Thromboembolism in a Patient with COVID-19 Pneumonitis Presenting with Foot Ischaemia

We present a 74-year-old gentleman, who presented with foot ischaemia requiring bilateral amputation in the absence of radiological signs of occlusive peripheral arterial disease. He was found to have COVID-19 pneumonitis and concurrent arterial and venous thromboemboli despite no initial respiratory symptoms or signs, nor pre-existing risk factors for cardiovascular disease. Patients who present with foot ischaemia with or without respiratory symptoms or signs warrant a high index of suspicion for COVID-19 infection, particularly in those with no predisposing risk factors.

Endograft apposition and infrarenal neck enlargement after endovascular aortic aneurysm repair

BACKGROUND

Sufficient apposition and oversizing of the endograft in the aortic neck are both essential for durable endovascular aneurysm repair (EVAR). These measures are however not regularly stated on post-EVAR computed tomography angiography (CTA) scan reports. In this study endograft apposition and neck enlargement (NE) after EVAR with an Endurant II(s) endograft were analyzed and associated with supra- and infrarenal aortic neck morphology.

METHODS

In 97 consecutive elective patients, the aortic neck morphology was measured on the pre-EVAR CTA scan on a 3mensio vascular workstation. The distance between the lowest renal artery and the proximal edge of the fabric (shortest fabric distance, SFD), and the shortest length of circumferential apposition between endograft and aortic wall (shortest apposition length, SAL) was determined on the early post-EVAR CTA scan. NE, defined as the aortic diameter change between pre- and post-EVAR CTA scan, was determined at eight levels: +40, +30, +20, +15, +10, 0, -5 and -10 mm relative to the lowest renal artery baseline. The aortic neck diameter and preoperative oversizing were correlated to NE with the Pearson correlation coefficient. The effective post-EVAR endograft oversizing is calculated from the nominal endograft diameter and the post-EVAR neck diameter where the endograft is circumferentially apposed.

RESULTS

The median time (interquartile range, IQR) between the EVAR procedure and the pre- and post-EVAR CTA scan was 40 (25, 71) days and 36 (30, 46) days, respectively. The Endurant II(s) endograft was deployed with a median (IQR) SFD of 1.0 (0.0, 3.0) mm. The SAL was <10 mm in 9% of patients and significantly influenced by the pre-EVAR aortic neck length (p=0.001), hostile neck shape (p=0.017), and maximum curvature at the suprarenal aorta (p=0.039). The median (interquartile range) SAL was 21.0 (15.0, 27.0) mm with a median (IQR) pre-EVAR infrarenal neck length of 23.5 (13.0, 34.8) mm. The median (IQR) difference between the SAL and neck length was -5.0 (-12.0, 2.8) mm. Significant (p<.001) NE of 1.7 (0.9, 2.5) mm was observed 5 mm below the renal artery baseline, which resulted in an effective post-EVAR endograft oversizing <10% in 43% of the patients. No correlation was found between NE and aortic neck diameter or preoperative oversizing.

CONCLUSIONS

Circumferential apposition between an endograft and the infrarenal aortic neck, SAL, and NE can be derived from standard postoperative CT scans. These variables provide essential information about the post-procedural endograft and aortic neck morphology regardless of the preoperative measurements. Patients with SAL <10 mm or effective oversizing <10% due to NE may benefit from intensified follow-up, but clinical consequences of SAL and NE should be evaluated in future longitudinal studies with longer term follow-up.

Ruptured Popliteal Artery Aneurysm Complicated with Acute Respiratory Distress Syndrome Secondary to SARS-CoV-2 Infection

We herein report a rare case of the ruptured popliteal artery aneurysm in an 89-year-old man, whose recovery after surgical treatment was complicated with acute respiratory distress syndrome secondary to confirmed infection with SARS-CoV-2. Presenting symptoms, patient's comorbidities, and postoperative course complicated with cardiac and respiratory failure leading to adverse outcome are discussed in this case report.

Is management of complex abdominal aortic aneurysms consistent? A questionnaire-based survey

BACKGROUND

Complex abdominal aortic aneurysm (AAA) is a relatively common presentation to the vascular specialist. Despite this there is little consensus on how to manage the often comorbid group of patients. Recent advances in endovascular technology have led to the availability of multiple devices, many of which could be used to treat the same aneurysm. The aim of this study was to quantify this potential variability across vascular specialists from multiple countries.

METHODS

An online survey was emailed to members of the Vascular Society for Great Britain and Ireland (VSGBI), the Canadian Society for Vascular Surgery (CSVS) and the Australian and New Zealand Society for Vascular Surgery (ANZSVS). The survey presented a vignette of a 63-year-old woman with significant respiratory comorbidity and a 54 mm juxtarenal AAA (7 mm neck). There were no other adverse morphological features for endovascular repair. The survey included images and questions related to management of the aneurysm.

RESULTS

The survey received 238 responses; 61 from ANZSVS, 65 from CSVS and 112 from VSGBI. VSGBI specialists were significantly more likely to continue surveillance than both ANZSVS (odds ratio [OR] 3.41, 95% confidence interval [CI] 1.61-7.65; P<0.001) and CSVS counterparts (OR 2.61, 95% CI: 1.29-5.47; P<0.01). ANZSVS specialists were significantly more likely to perform an endovascular repair than those from CSVS (OR 3.28, 95% CI: 1.50-7.40; P<0.01) and VSGBI (OR 3.65, 95% CI: 1.81-7.59; P<0.001). CSVS specialists were significantly more likely to manage the aneurysm with open surgery than colleagues from the VSGBI (OR 6.57, 95% CI: 2.58-18.46; P<0.001) and ANZSVS (OR 7.18, 95% CI: 2.22-30.79; P<0.001).

CONCLUSIONS

Significant variation in the management of a juxtarenal AAA between countries was observed. The same patient would be more likely to have an endovascular repair in Australia and New Zealand, open surgery in Canada and continuing surveillance in the UK and Ireland. This variation reflects the lack of long-term evidence and international consensus on the optimal management of complex AAA.

Is the management of complex abdominal aortic aneurysms consistent across the UK? A questionnaire-based survey

BACKGROUND

Our objective was to quantify variability across the UK in the management of a complex abdominal aortic aneurysm (AAA).

METHODS

An online survey was emailed to all members of the Vascular Society for Great Britain and Ireland. The survey presented a vignette of a 63-year-old woman with significant respiratory co-morbidity whose computed tomographic (CT) angiogram demonstrated a 54 mm AAA with a short (7 mm) proximal neck but no other adverse morphological features for a standard or complex endovascular aneurysm repair (EVAR). The survey included images and questions related to AAA management as well as surgeon access to operating facilities. 111 responses were received.

RESULTS

47% of participants indicated a preference for continuing surveillance, 29% for fenestrated EVAR and 7% each for no operative intervention and open surgical repair. The remainder indicated various preferences including standard EVAR (3%), standard EVAR with endoanchors (3%), chimney EVAR (2%), EVAS (endovascular aneurysm sealing) (1%) and chimney EVAS (1%). Of the 47% who wanted to continue surveillance, once their threshold was reached, 73% would manage with a fenestrated EVAR, 17% with open repair and the remainder with standard EVAR with endoanchors (2%), EVAS (2%) or chimney EVAS (2%). 49% of participants carried out endovascular procedures in hybrid theatres, 36% in radiology angiosuites and 15% in standard operating theatres. The location had no significant effect on the consultant choice of treatment method.

CONCLUSIONS

The study results support anecdotal variation in practice among vascular specialists. This reflects the lack of solid evidence on the optimal management of complex AAA.

Body temperature and cardiac changes induced by peripherally administered oxytocin, vasopressin and the non-peptide oxytocin receptor agonist WAY 267,464: a biotelemetry study in rats

BACKGROUND AND PURPOSE

There is current interest in oxytocin (OT) as a possible therapeutic in psychiatric disorders. However, the usefulness of OT may be constrained by peripheral autonomic effects, which may involve an action at both OT and vasopressin V1A receptors. Here, we characterized the cardiovascular and thermoregulatory effects of OT, vasopressin (AVP) and the non-peptide OT receptor agonist WAY 267,464 in rats, and assessed the relative involvement of the OT and V1A receptors in these effects.

EXPERIMENTAL APPROACH

Biotelemetry in freely moving male Wistar rats was used to examine body temperature and heart rate after OT (0.01 - 1 mg kg(-1); i.p.), AVP (0.001 - 0.1 mg kg(-1); i.p.) or WAY 267,464 (10 and 100 mg kg(-1); i.p.). The actions of the OT receptor antagonist Compound 25 (C25, 5 and 10 mg kg(-1)) and V1A receptor antagonist SR49059 (1 and 10 mg kg(-1)) were studied, as well as possible V1A receptor antagonist effects of WAY 267,464.

KEY RESULTS

OT and AVP dose-dependently reduced body temperature and heart rate. WAY 267,464 had similar, but more modest, effects. SR49059, but not C25, prevented the hypothermia and bradycardia induced by OT and AVP. WAY 267,464 (100 mg·kg(-1)) prevented the effects of OT, and to some extent AVP.

CONCLUSIONS AND IMPLICATIONS

Peripherally administered OT and AVP have profound cardiovascular and thermoregulatory effects that appear to principally involve the V1A receptor rather than the OT receptor. Additionally, WAY 267,464 is not a simple OT receptor agonist, as it has functionally relevant V1A antagonist actions.

Kavalactone pharmacophores for major cellular drug targets

A number of studies have identified differential kavalactone activity against a variety of molecular targets, including P-glycoprotein (Pgp), platelet monoamine oxidase (MAO-B), transcription factor binding domains, pregnane X (PXR) and GABA receptors, and cytochrome P450 and cyclo-oxygenase (COX) enzymes. The molecular structure of the kavalactones possesses a pharmacophore for several of these targets. In most cases, conformational stability is more significant than the substituents present. The analysis of these pharmacophores provides important insights for future medicinal chemistry-based approaches to kavalactone-type drugs.

Giant oesophageal liposarcoma: case report

We describe imaging findings of a oesophageal liposarcoma in a 66 year old man. The computed tomography scan was performed after a chest radiograph showed a large posterior mediastinal mass. Oesophageal liposarcomas are rare tumours. They can achieve large size before they become symptomatic. Our patient was successfully managed with complete surgical removal.

Kyphosis, a rare cause of dysphagia

Degenerative kyphosis is mostly asymptomatic. When symptomatic, pain and humping of the back are the commonest features. Dysphagia associated with kyphosis is a rare presentation, though it is otherwise common in older people due to various reasons. We report the case of an 81-year-old kyphotic woman who presented with dysphagia. On barium swallow examination, she was found to have an acute bend in the mid-oesophagus leading to narrowing, secondary to the kyphosis.

Cerebral abscess caused by Cladosporium bantianum infection--case report

A 26-year-old woman currently treated for systemic lupus erythematosus with steroid therapy presented with sudden onset of right hemiplegia. Computed tomography of the brain showed a large frontoparietal ring-enhanced lesion with perifocal edema. Stereotactic aspiration of the lesion revealed Cladosporium bantianum. The size of the abscess did not reduce in spite of optimum antifungal treatment. The abscess was subsequently excised through a frontoparietal craniotomy. At follow up after 24 months, there was no recurrence of the abscess. Cerebral Cladosporium bantianum infection is usually refractory to antifungal agents and the prognosis is very poor. This patient had the longest survival period in a case of Cladosporium brain abscess so far reported.

Fetus in fetu. Rare cause of a lump in an adult's abdomen

Fetus in fetu is a rare entity. The patient usually presents in childhood. A case in which the patient presented in adulthood, with a lump in the abdomen, is reported. Computed tomography findings were diagnostic of this condition and a prospective diagnosis could be made. Computed tomography also helped to differentiate it from mature teratoma.

Unusual "floating balls" appearance of an ovarian cystic teratoma: sonographic and CT findings

Ovarian cystic teratomas are cystic fatty tumors that can be easily diagnosed by sonography and CT. We present a case of ovarian cystic teratoma with an unusual sonographic appearance of mobile, hyperechoic, intracystic fat balls; this finding correlated well with the appearance on CT.