Characterization and risk factors of inferior vena cava thrombosis in situ detected by computed tomography venography following filter placement: A single-center retrospective cohort study

OBJECTIVE

This study aimed to characterize radiographic characteristics on computed tomography venography and risk factors of inferior vena cava thrombosis (IVCT) in situ after retrievable vena cava filter (VCF) placement.

METHODS

Between September 2018 and June 2023, a single-center retrospective cohort study was conducted in patients with or without IVCT in situ following VCF placement. Patient baseline demographics, presentation of lower extremity deep vein thrombosis (LEDVT), thrombus characteristics, concurrent pulmonary embolism, comorbidities and risk factors for LEDVT, and IVC and VCF-related information were collected and analysed. Univariable analysis followed by multivariable analysis was performed to evaluate the odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

One hundred and seventeen eligible patients were included, regionally isolated filling-defect surrounding the support pillars of VCF and contacting IVC wall on computed tomography venography images were identified, clots were more frequently found on the minor axis or anterior wall of IVC. Univariable analyses suggested that the incidence of IVCT in situ (31.6%, 37/117) was closely associated with age (P = .001), thrombus limb (left (P = .001) and bilateral side (P = .001)), hypertension (P = .008), filter shapes (P < .001), short IVC diameter (P = .009) or magnification percentage (P = .004), and long IVC diameter (P = .006). Multivariable analyses suggested that bilateral side LEDVT (OR, 4.92; 95% CI, 1.56-15.51; P = .007) and increased short IVC magnification percentage (OR, 1.01; 95% CI, 1.00-1.03; P = .013) statistically significant increase the IVCT in situ risk, whereas increased age (OR, 0.96; 95% CI, 0.94-0.99; P = .013) and short IVC diameter (OR, 0.87; 95% CI, 0.77-0.98; P = .026) were associated with decreased odds against IVCT in situ.

CONCLUSIONS

IVCT in situ represents regionally isolated filling-defect at points of filter contact with IVC wall. Bilateral side LEDVT and increased short IVC magnification percentage may be potential risk factors impacting the occurrence of IVCT in situ, while increased age and short IVC diameter may decrease the incidence of IVCT in situ and seem to be protective factor against IVCT in situ emergence.

Percutaneous image-guided management of a misplaced pericardiocentesis catheter into the inferior vena cava

Misplacement of pericardiocentesis catheter in central veins is a rare complication that can be managed with several methods. In this case, we report a percutaneous image-guided plug-assisted management of a misplaced pericardiocentesis catheter into the inferior vena cava through a transhepatic tract successfully occluded. This minimally invasive technique was not previously described in this setting and had a favorable long-term outcome.

Pterygium surgery using inferior rotational conjunctival autograft versus conventional conjunctival autograft with sutures - A comparative study

PURPOSE

To compare the outcomes of pterygium surgery by using an inferior rotational autograft and a conventional superior conjunctival autograft.

METHODS

This was a prospective interventional comparative study of 85 eyes of patients who were divided into two groups of 45 and 40. Standard techniques of both procedures were performed by a single surgeon. Astigmatism, recurrence rates, time taken, and other complications were compared.

RESULTS

All the subjects were in the age group 53 ± 7.56 (40-74) years. Demographic data and type of pterygium were comparable in the two groups. In the rotational group, the preoperative astigmatism was - 2.14 ± 1.36 D, which decreased in 1 week to 1.42 ± 1.11 D, in 1 month to - 1.13 ± 0.99 D, in 3 months to 0.91 ± 0.72 D, and in 6 months to 0.81 ± 0.85 D (P < 0.05 each). Preoperative astigmatism in the conventional group was - 2.63 ± 1.47 D, which decreased to - 1.43 ± 1.04 D in 1 week, -1.18 ± 0.85 D in 1 month, -1.07 ± 0.81 D in 3 months, and - 1.01 ± 0.78 D in 6 months (P < 0.05 each). There was no significant difference between the groups in terms of astigmatism at any follow-up visit (P < 0.05). Complications like dellen, graft edema, and superficial vascularization were seen in both groups. The rotational group had one recurrence (2.86%). No recurrence was noted in the conventional group. None of the complication rates was significantly different between the two groups (P < 0.05).

CONCLUSION

Inferior rotational conjunctival autografting is a good technique for management of pterygium. It has a profile similar to that of conventional conjunctival autograft.

The surgical anatomy of the inferior alveolar nerve: a meta-analysis with clinical implications

BACKGROUND

The main goal of the present meta-analysis was to provide physicians, especially surgeons, with crucial data on the complete anatomy of the inferior alveolar nerve (IAN). It is hoped that our results may help reduce the rates of complications in procedures associated with this anatomical entity.

MATERIALS AND METHODS

Major online medical databases such as PubMed, Embase, Scopus, Web of Science, Google Scholar, and Cochrane Library were searched to gather all studies on IAN anatomy, including topography, morphology, and variations.

RESULTS

IAN mean thickness of the IAN in the mandibular angle area was set to 2.32 mm (LL: 1.82 ; HL: 2.78-). IAN mean thickness of the IAN in the mandibular body region was found to be 2.49 mm (LL: 2.02 ; HL: 2.98). The mean thickness of the IAN in the mental region was established at 1.70 mm (LL: 1.54 ; HL: 1.86). The mean distance from the IAN to the external (buccal) surface of the 1st molar was set to be 4.99 mm (LL: 3.84 ; HL: 6.13).

CONCLUSIONS

In conclusion, this is the most up-to-date and thorough analysis of the complete anatomy of the IAN. We provided morphometric data that present the spatial relationship of the IAN with numerous anatomical landmarks in the mandibular region. These include the ramus of the mandible, the first, second, and third molars, and the body of the mandible, among others. It is hoped that the results of the present meta-analysis may be a helpful tool for physicians, especially surgeons, performing various oral and maxillofacial procedures, such as third molar removal or IAN block anesthesia.

Utility of ultrasonography in preoperative assessment of tumor thrombi in kidney cancer

INTRODUCTION

This study examined the clinical accuracy of ultrasonography compared to magnetic resonance imaging (MRI) and intraoperative findings for evaluation of tumor thrombi level in patients with renal cell carcinoma.

MATERIALS AND METHODS

We retrospectively identified 38 patients at our institution who underwent both ultrasonography and MRI before undergoing open radical nephrectomy with tumor thrombectomy between 2010 and 2019. We compared tumor thrombus level findings of both ultrasonography and MRI, as well as the diagnostic accuracy of each to intraoperative findings. Agreement between ultrasonography, MRI, and surgery was tested with kappa. Logistic regression models identified factors that predict a mismatched thrombus level between an imaging modality and surgical findings.

RESULTS AND CONCLUSIONS

Tumor thrombus levels determined by ultrasonography matched with MRI in 26 (68.4%) cases. Compared to operative findings, ultrasonography accurately identified the cephalad extent of thrombi in 30 (79.0%) cases, under-staged five (13.2%) cases, and over-staged three (7.9%). Magnetic resonance imaging agreed with operative findings in 30 (79.0%) cases, under-staged five (13.2%) and over-staged three (7.9%) cases. On univariable regression assessment, M1 stage was predictive of a mismatched result between MRI and surgery (OR: 6.0, 95% CI: 1.02-35.3, p = 0.047), but this association did not hold-up in a multivariable model. Ultrasonography and magnetic resonance imaging identified the preoperative tumor thrombus level at a rate of 79%. Ultrasonography is an effective preoperative imaging modality for evaluating tumor thrombi associated with kidney cancer, notably as an adjunct to magnetic resonance imaging.

Clinical outcomes related to glenosphere overhang in reverse shoulder arthroplasty using a lateralized humeral design

BACKGROUND

Previous studies have demonstrated that decreased impingement-free range of motion (ROM) can adversely influence clinical outcomes following reverse shoulder arthroplasty (RSA). Inferior placement of the glenosphere is thought to minimize impingement and its associated sequelae. This study evaluated the relationship between inferior overhang of the glenosphere and clinical outcomes in patients undergoing primary RSA using a lateralized humeral implant design.

METHODS

By use of a prospectively collected shoulder arthroplasty database, all primary RSAs performed at our institution between 2007 and 2015 with a single implant design (lateralized humerus and medialized glenoid) and minimum 2-year follow-up were evaluated. Glenosphere overhang in relation to the inferior rim of the glenoid was measured in millimeters on postoperative Grashey radiographs of the shoulder and categorized into tertiles (low, <7.1 mm; medium, 7.1 to 9.9 mm; and high, >9.9 mm). Clinical outcomes of interest comprised the changes between preoperative and postoperative values in the following ROM and outcome score measures: active forward elevation (aFE), active external rotation, American Shoulder and Elbow Surgeons score, Constant-Murley score, Shoulder Pain and Disability Index score, and Simple Shoulder Test score. Random-effects linear models were used to assess univariate and multivariable associations between overhang tertile and change in patient outcomes. Differences in outcomes were further compared using the minimal clinically important difference (MCID).

RESULTS

The study identified 284 shoulders in 265 patients. The median follow-up period was 36 months (range, 24-108 months). The median glenosphere inferior overhang was 8.4 mm, with an interquartile range of 6.3-10.6 mm. Plots demonstrated nonlinear relationships between overhang and outcome scores and between overhang and ROM. Patients with high overhang experienced a significantly greater improvement in aFE compared with patients with low overhang (P = .019), which exceeded the MCID. No other differences in ROM and outcome scores between overhang groups exceeded the MCID. For other outcome scores and ROM measurements, there was no significant relationship with glenosphere overhang. Increased overhang was associated with a significantly lower incidence of scapular notching (P = .005).

CONCLUSION

Patients undergoing RSA using a lateralized humerus design with greater inferior overhang of the glenosphere demonstrated a significantly greater improvement in aFE and lower rate of notching compared with those with low overhang. No ideal glenosphere overhang range was identified to maximize function in this study.

Preoperative Prediction of Inferior Vena Cava Wall Invasion of Tumor Thrombus in Renal Cell Carcinoma: Radiomics Models Based on Magnetic Resonance Imaging

Objective

To develop radiomics models to predict inferior vena cava (IVC) wall invasion by tumor thrombus (TT) in patients with renal cell carcinoma (RCC).

Methods

Preoperative MR images were retrospectively collected from 91 patients with RCC who underwent radical nephrectomy (RN) and thrombectomy. The images were randomly allocated into a training (n = 64) and validation (n = 27) cohort. The inter-and intra-rater agreements were organized to compare masks delineated by two radiologists. The masks of TT and IVC were manually annotated on axial fat-suppression T2-weighted images (fsT2WI) by one radiologist. The following models were trained to predict the probability of IVC wall invasion: two radiomics models using radiomics features extracted from the two masks (model 1, radiomics model_IVC; model 2, radiomics model_TT), two combined models using radiomics features and radiological features (model 3, combined model_IVC; model 4, combined model_TT), and one radiological model (model 5) using radiological features. Receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA) were applied to validate the discriminatory effect and clinical benefit of the models.

Results

Model 1 to model 5 yielded area under the curves (AUCs) of 0.881, 0.857, 0.883, 0.889, and 0.769, respectively, in the validation cohort. No significant differences were found between these models (p = 0.108-0.951). The dicision curve analysis (DCA) showed that the model 3 had a higher overall net benefit than the model 1, model 2, model 4, and model 5.

Conclusions

The combined model_IVC (model 3) based on axial fsT2WI exhibited excellent predictive performance in predicting IVC wall invasion status.

Primary Spontaneous Inferior Clival Cerebrospinal Fluid Leak

Primary, spontaneous cerebrospinal fluid (CSF) leaks secondary to defects in the clivus are exceedingly rare. Additionally, primary, spontaneous CSF leaks are typically present in obese women with idiopathic intracranial hypertension (IIH). In the present study, we report the first case of a primary, spontaneous CSF leak in the inferior-posterior wall of the clivus in an atypical patient with a BMI of 18.9 kg/m² without IIH. Accurate diagnoses of CSF leaks are imperative in the context of preventing meningitis, and delays in diagnosis and treatment are associated with worse outcomes. Improved characterization of rare, spontaneous CSF leaks may prove beneficial in correctly diagnosing affected patients.

Anterior Inferior Hip Dislocation: Report of Three Cases and Review of Literature

Introduction:

Inferior dislocation of the hip, also called luxatio erecta femoris, is the rarest type of hip dislocation with a poorly understood mechanism of injury. We came across three such cases resulting from high-energy trauma with various other associated injuries.

Case Report:

The first patient, a 25-year-old man, presented with the right hip pain, hip and knee joint in flexion without rotational component, after motor vehicle collision. The second patient, a 42-year-old man, presented with the left hip pain, hip and knee joint in flexion with rotational component, following fall from 20 ft height. The third patient, a 29-year-old lady, presented with the left hip pain, hip and knee joint in flexion with rotational component, after motor vehicle collision. All three patients were diagnosed by radiograph and were managed by closed reduction under short general anesthesia, within 3 h, 9 h, and 6 h, respectively. Thomas splint was used to immobilize the limb in all for 1 month and weight-bearing was started after 2 months from injury. Two of them were followed up to 6 months and one was lost to follow up. No evidence of avascular necrosis of femoral head or other complication related to hip dislocation was noted.

Conclusion:

Luxatio erecta femoris is a rare type of hip dislocation and with limited publication. The position of limb on presentation should raise the suspicion of same and diagnosis confirmed through radiological investigations. Usually, this type of dislocation can be managed with closed reduction. If closed reduction is unsuccessful, then a fracture femur or bone chip in the joint could be the cause of the difficulty.

Retroperitoneal lymph node dissection for testicular cancer in a patient with a double inferior vena cava

INTRODUCTION

A double inferior vena cava is a rare anomaly with an incidence ranging from 0.3% to 3.0%. In patients with a double inferior vena cava, it is important to understand the precise anatomy and possible irregular lymph node flow when performing surgery for malignancies.

CASE PRESENTATION

A 60-year-old man with a non-seminoma was referred to our hospital after left high orchiectomy. Computed tomography revealed a double inferior vena cava and swollen masses in the para-aortic region. After four cycles of chemotherapy with etoposide and cisplatin, retroperitoneal lymph node dissection was safely performed with a modified template extended to the right side of the paracaval region by referring to three-dimensional images created by SYNAPSE VINCENT® software.

CONCLUSION

Preoperative three-dimensional images were useful to understand this patient's unusual and complicated anatomical positions.

Transcatheter Embolization of the Inferior Epigastric Artery: Technique and Clinical Outcomes

PURPOSE

Symptomatic rectus muscle sheath hematoma may be the result of bleeding originating from the inferior epigastric artery. We report the technique and the results from a series of consecutive patients treated by transcatheter embolization, evaluating both ipsilateral and contralateral retrograde approaches.

METHODS

This was a retrospective study including patients with verified rectus muscle sheath hematoma as a result of active extravasation from the inferior epigastric artery referred for transcatheter embolization. Technical success, clinical success and major complications were calculated. In addition, minor complications, blood transfusions required after a technically successful embolization, length of stay, peri-procedural and 30-day mortality and overall survival at 6 months were obtained. All statistical analysis was performed using SPSS.

RESULTS

Twenty-one patients (mean age = 59.67 ± 19.51 years old) were included. The cause of the bleeding in the vast majority was iatrogenic trauma (n = 12/21, 57.14%). Both contralateral (n = 12/21, 57.14%%) and ipsilateral (n = 9/21, 42.86%) retrograde approaches were used. Embolic materials included micro-coils (n = 13/20, 65%), microspheres (PVA) (n = 1/20, 5%), a combination of PVA and micro-coils (n = 5/20, 25%) and gel-foam (n = 1/20, 5%). Overall technical success was 95.2% (n = 20/21) while clinical success was achieved in all but one of the technically successful cases 95% (n = 19/20). One patient died peri-procedurally due to profound hemodynamic shock. There were no other major complications. Additional transfusion was necessary in 7 patients (n = 7/21, 33.33%). There was a significant increase in the hemoglobin levels after the embolization (7.03 ± 1.78 g/dL pre-procedure Vs 10.91 ± 1.7 g/dL post-procedure, p = 0.048). The median hospital stay was 8 days. The peri-procedure and 30-day mortality was 4.8% (n = 1/21) and 28.6% (n = 6/21) respectively. The 6-month survival was 61.9% (13/21).

CONCLUSION

Percutaneous embolization of the inferior epigastric artery is a minimally invasive method with satisfactory results. Both ipsilateral and contralateral retrograde approaches are feasible.

Voriconazole versus Itraconazole for the Initial and Step-Down Treatment of Histoplasmosis: A Retrospective Cohort

BACKGROUND

Itraconazole is the preferred azole for histoplasmosis in the current Infectious Diseases Society of America guidelines. Voriconazole is increasingly used as treatment for histoplasmosis; it has in-vitro activity against Histoplasma capsulatum and has shown success in case reports and small case series but may have a lower barrier to resistance. No comparative studies have been published.

METHODS

We constructed a single-center retrospective cohort of adult patients diagnosed with histoplasmosis from 2002 to 2017. Individual charts were reviewed to gather clinical information including demographics, clinical features, immune status, treatments, and mortality. Patients were categorized based on initial choice of azole, either as initial treatment or as step-down therapy from amphotericin B. Initial therapies with other azoles were excluded. Mortality was compared using a multivariable Cox proportional hazards with Heaviside function at 42 days.

RESULTS

We identified 261 cases of histoplasmosis from 2002 to 2017. After excluding patients not treated with itraconazole or voriconazole, 194 patients remained. 175 (90%) patients received itraconazole and 19 (10%) received voriconazole. There were no significant demographic differences between patient populations receiving either azole as their initial azole treatment. Death at 180 days occurred in 41 patients (23.4%) in the itraconazole group and 6 patients (31.6%) in the voriconazole group. Patients on voriconazole had a statistically significant increase in mortality during the first 42 days after initiation of treatment when compared to patients receiving itraconazole (HR 4.30 [95% CI 1.3-13.9, p 0.015]) when controlled for other risk factors.

CONCLUSION

Voriconazole in histoplasmosis was associated with increased mortality in the first 42 days compared to itraconazole.

Distance measurements and origin levels of the coeliac trunk, superior mesenteric artery, and inferior mesenteric artery by multiple-detector computed tomography angiography

The aim of this study is to determine vertebral levels of the coeliac trunk, the superior mesenteric artery, and the inferior mesenteric artery originated from the abdominal aorta and to calculate the distance measurements between these arteries and between these arteries and the aortic bifurcation by multidetector computed tomography angiography technique. It was determined that the nine different vertebral levels of the coeliac trunk, the nine different vertebral levels of the superior mesenteric artery, and the eleven different vertebral levels of the inferior mesenteric artery. The distance measurements between the coeliac trunk and the superior mesenteric artery, the inferior mesenteric artery, the aortic bifurcation were found significant between female and male. In this study, it was determined more different levels than the levels described in classical anatomy. The preoperative information of these morphological variations can contribute to the reduction of surgical time and perioperative vascular complications especially for anterior lumbar interbody fusion and defining the location of the primary lymphatic drainage site for gastrointestinal malignancies.

Outcomes in Patients with Renal Cell Carcinoma Undergoing Inferior Vena Cava Ligation without Reconstruction versus Thrombectomy: A Retrospective, Case Controlled Study

PURPOSE

Radical nephrectomy with tumor thrombectomy is considered standard of care in patients with renal cell carcinoma. However, surgical ligation and interruption of the inferior vena cava is sometimes necessary when the tumor thrombus invades the inferior vena cava wall. This study assesses the outcomes in patients with renal cell carcinoma undergoing inferior vena cava ligation compared to inferior vena cava thrombectomy.

MATERIALS AND METHODS

We conducted a case controlled, retrospective study at a high volume single-center institution. All patients with renal cell carcinoma who underwent ligation without reconstruction were matched with patients undergoing thrombectomy in a 1:2 ratio based on preoperative renal function, renal cell carcinoma stage and intraoperative thrombus level. Endpoints were complications, change in renal function and mortality.

RESULTS

A total of 26 patients with renal cell carcinoma who underwent inferior vena cava ligation between 2005 and 2019 were matched with 52 patients who underwent inferior vena cava thrombectomy in the same time period. When compared to thrombectomy, patients undergoing ligation had higher 90-day readmission rate (19% vs 4%, p=0.025). The ligation group also had a higher postoperative complication rate (73% vs 39%, p=0.004) and higher rates of lymphedema (23% vs 8%, p=0.055). However, by 1-month followup the rate of persistent overall and major complications for both ligation and thrombectomy groups were comparable at 49% vs 31% (p=0.497) ad 8% vs 8% (p=1.000), respectively. Importantly, at 18-month followup, mean estimated glomerular filtration rate declines were similar between ligation group (8.5 ml/min/1.73 m²) and thrombectomy group (9.9 ml/min/1.73 m²; p=0.834). Differences in cancer-specific mortality (p=0.993) and all-cause mortality (p=0.756) were also not statistically significant.

CONCLUSIONS

The outcomes of inferior vena cava ligation compared to inferior vena cava thrombectomy for renal cell carcinoma are similar. Patients with inferior vena cava ligation initially face a more complicated postoperative course but in the longer term have similar renal function recovery, complication rates and survival.

A modified sequential vascular control strategy in robot-assisted level III-IV inferior vena cava thrombectomy: initial series mimicking the open 'milking' technique principle

OBJECTIVE

To introduce a modified sequential vascular control strategy, mimicking the open 'milking' technique principle, for the early release of the first porta hepatis (FPH) and to stop cardiopulmonary bypass (CPB) in level III-IV robot-assisted inferior vena cava (IVC) thrombectomy (RA-IVCTE).

PATIENTS AND METHODS

From November 2014 to June 2019, 27 patients with a level III-IV IVC tumour thrombus (IVCTT) underwent RA-IVCTE in our department. The modified sequential control strategy was used in 12 cases. Previously, we released the FPH after the thrombus was resected and the IVC was closed completely, and CPB was stopped at the end of surgery (15 patients). Presently, using our modified strategy, we place another tourniquet inferior to the second porta hepatis (SPH) once the proximal thrombus is removed from the IVC below the SPH. Then, we suture the right atrium and perform early release of the FPH, and stop CPB. Finally, tumour thrombectomy, vascular reconstruction, and radical nephrectomy are performed.

RESULTS

Compared with the previous strategy, the modified steps resulted in a shorter median FPH clamping (19 vs 47 min, P < 0.001) and CPB times (60 vs 87 min, P < 0.05); a lower rate of Grade II-IV perioperative complications (25% vs 60%, P < 0.05); and better postoperative hepatorenal and coagulation function, including better median serum alanine aminotransferase (172.7 vs 465.4 U/L, P < 0.001), aspartate aminotransferase (282.4 vs 759.8 U/L, P < 0.001), creatinine (113.4 vs 295 μmol/L, P < 0.01), blood urea nitrogen (7.3 vs 16.7 mmol/L, P < 0.01), and D-dimer (5.9 vs 20 mg/L, P < 0.001) levels.

CONCLUSION

With the early release of the FPH and stopping CPB, the modified sequential vascular control strategy in level III-IV RA-IVCTE reduced the perioperative risk for selected patients and improved the feasibility and safety of the surgery. We would recommend this approach to other centres that plan to develop robotic surgery for renal cell carcinoma with level III-IV IVCTT in the future.

Manual aspiration thrombectomy for acute and subacute inferior vena cava thrombosis and lower extremity deep venous thrombosis

Deep vein thrombosis (DVT), which can lead to pulmonary embolism (PE), is a major contributor to the global disease burden and is the third most common cardiovascular pathology after coronary artery disease and stroke. Venous thromboembolic disease, which encompasses the disease entities of DVT and PE, affects up to 10 million cases every year and represents a serious and potentially life-threatening condition. Standard anticoagulation therapy alone is ineffective at promoting deep venous system thrombus removal. Many patients develop postthrombotic syndrome (PTS) despite being on adequate anticoagulation therapy. Aggressive therapy for rapid thrombus removal is important to prevent the development of PTS. Besides impeding the onset of PTS, rapid clearance of the thrombus is also required in the treatment of phlegmasia cerulea dolens, an uncommon but life-threatening complication of acute DVT that can lead to arterial insufficiency, compartment syndrome, venous gangrene, and limb amputation. Manual aspiration thrombectomy (MAT) can provide rapid and effective therapy that could be compared to the open surgical thrombectomy approach with minimal risk of morbidity, mortality, or recurrence after surgery. Though many devices have been developed to date for pharmacomechanical thrombolysis, the cost of the treatment using these devices is very expensive. MAT is simple to perform, easy to learn, inexpensive, and rapid. This review will outline and dissect several studies and case reports, sourced from the PubMed database, on the subject of the use of MAT in treating inferior vena cava thrombosis and lower extremity DVT, including in patients with compression of the iliac vein and phlegmasia cerulea dolens.

Ageing Effects on 3-Dimensional Femoral Neck Cross-Sectional Asymmetry: Implications for Age-Related Bone Fragility in Falling

This paper explores the effects of aging on femoral neck (FN) anatomy in a study of women aged 20-90years in relation to implications for FN fracture propensity in buckling. Five hundred and four participants were scanned by Quantitative Computed Tomography and analyzed using Quantitative Computed Tomography Pro BIT (Mindways). FN cross-section was split through geometric center into superior and inferior sectors. Bone mass, structural measurements, and bone mineral density were analyzed. Buckling ratio was calculated as ratio of buckling radius to cortical thickness. Between 2nd decade and 8th decade, age-related integral bone mass reduction in superior sector was substantially larger than in inferior sector (33% compared to 21%), especially in cortical bone superiorly compared to inferiorly (53% vs 21%; p < 0.001), principally due to reduction in cortical thickness, averaged cortical thickness (56%) with little difference in density. Superior and inferior sector trabecular bone mineral density reduction was similar at 41% and 43% respectively. Differential cortical bone loss in superior sector resulted in a 59% inferior displacement (δ) of center-of-mass from geometric center. Differences in δ and averaged cortical thickness with age accounted for a 151% increase in mean superior buckling ratio from 9 to 23. Analysis confirms significant progressive age-related superior cortical bone loss as the major age effect on FN structure with relative preservation of inferior cortex probably related to maintenance of inferior sector by regular loading as a result of standing and walking. Computation of buckling ratio may allow prediction of fracture propensity in a sideways fall.

Surgical Interventions for Renal Cell Carcinoma with Thrombus Extending into the Inferior Vena Cava: A Multidisciplinary Approach

Objective: To assess surgical strategies and the impact of a multidisciplinary approach on patients undergoing inferior vena caval thrombectomy for renal cell carcinoma and to evaluate perioperative morbidity and mortality associated with these procedures.

Methodology: A retrospective audit for all adults who underwent nephrectomy and inferior vena caval thrombectomy from January 2008 till November 2018 at a University hospital. Patients with incomplete records were excluded from the study.

Results: During the study period, 21 patients underwent inferior vena caval thrombectomy as a completion of radical nephrectomy. Most were males (19 : 2) with a mean age of 54±11.3 years. The most common surgical approach was the 11th rib flank approach (n=8) followed by midline abdominal (n=6) and Mercedes-Benz (n=5). Eight patients had level 1, 10 patients had level 2, and three patients had level 3 tumour thrombus. The cavotomy was closed primarily in 20 patients; one required inferior vena cava (IVC) reconstruction with a pericardial patch. The proximal clamp was applied below the hepatic veins for most patients. Two patients required suprahepatic clamping before thrombectomy. There was no intraoperative mortality. Five patients (24%) developed complications: two required cardiopulmonary resuscitation due to severe hypotension and were revived; one developed acute renal failure; and one patient required a damage control laparotomy for excessive oozing. There was no thirty-day mortality.

Conclusion: The IVC thrombectomy, along with radical nephrectomy for renal cell carcinoma for 1–3 level thrombus, can be performed with acceptable morbidity in a multidisciplinary team approach.

Symptomatic Venous Thromboembolism is Associated with Inferior Survival among Patients Undergoing Nephrectomy with Inferior Vena Cava Tumor Thrombectomy for Renal Cell Carcinoma

PURPOSE

We investigated the incidence and survival impact of symptomatic venous thromboembolism after nephrectomy with inferior vena cava tumor thrombectomy.

MATERIALS AND METHODS

We retrospectively reviewed the records of 183 patients who underwent nephrectomy with inferior vena cava tumor thrombectomy (level I-IV) for renal cell carcinoma between 2000 and 2010. Postoperative venous thromboembolism was defined as symptomatic bland thrombus or embolism confirmed on imaging. The cumulative incidence of venous thromboembolism was estimated by the Kaplan-Meier method. Associations of clinicopathological features with time to thromboembolism after surgery and all cause mortality were evaluated on multivariable analysis with Cox models.

RESULTS

Symptomatic venous thromboembolism developed in 55 patients a median of 23 days (IQR 5-142) postoperatively, including pulmonary thrombosis in 24, deep venous thrombosis in 17, bland inferior vena cava thrombosis in 13 and portal vein thrombosis in 1. The cumulative incidence of thromboembolism 30, 90 and 365 days following surgery was 17%, 22% and 27%, respectively. A history of smoking (HR 2.15, 95% CI 1.09-4.24, p = 0.028), ECOG (Eastern Cooperative Oncology Group) performance status 1 or greater (HR 2.15, 95% CI 1.17-3.93, p = 0.013), hypercoagulability disorder (HR 5.12, 95% CI 1.93-13.59, p = 0.001) and bulky lymphadenopathy at surgery (HR 4.84, 95% CI 1.87-12.51, p = 0.001) was significantly associated with an increased risk of venous thromboembolism on multivariable analysis. Postoperative venous thromboembolism was significantly associated with an increased risk of all cause mortality (HR 1.53, 95% CI 1.04-2.23, p = 0.029).

CONCLUSIONS

Venous thromboembolism after nephrectomy and tumor thrombectomy is common within 90 days of surgery. Symptomatic venous thromboembolism in this population is independently associated with a greater risk of mortality.

Incidental adult polysplenia with situs inversus, interrupted inferior vena cava with azygos continuation, patent ductus arteriosus, and aortic branches variations: a case report

Polysplenia syndrome is a rare condition (about 2.5:100,000 live births) wherein a person has two or more spleens with accompanying various thoracic and abdominal organ abnormalities. Polysplenia is usually associated with situs ambiguous, while polysplenia with situs inversus is very rare. Herein, we report a rare case of incidentally found polysplenia syndrome combined with situs inversus in a 59-year-old female who also had an interrupted inferior vena cava (IVC) with azygos continuation, patent ductus arteriosus (PDA), and variations in the aortic arch branches. An aberrant left subclavian artery with Kommerell's diverticulum and a large aneurysm in the non-aberrant, proximal-right subclavian artery were also noted.

Management of Peripheral and Truncal Venous Injuries

Civilian injuries are increasing according to the World Health Organization, and this is attributed mainly to road traffic accidents and urban interpersonal violence. Vascular injuries are common in these scenarios and are associated with high morbidity and mortality rates. Associated peripheral venous trauma is less likely to lead to death and controversy remains whether ligation or repair should be the primary approach. Conversely, non-compressible truncal venous insult can be lethal due to exsanguination, thus a high index of suspicion is crucial. Operative management is demanding with fair results but recent endovascular adjuncts demonstrate promising results and seem to be the way forward for these serious conditions.

Modified total cavopulmonary shunt as a staged Fontan operation

The left superior vena cava became occluded in an infant with hypoplastic left heart syndrome. After a bidirectional Glenn procedure, he presented with severe oxygen desaturation and right ventricular dysfunction; the left superior vena cava drained into the inferior vena cava through collateral veins. As salvage therapy, we created a modified total cavopulmonary shunt using only autologous tissue in which the right hepatic vein and inferior vena cava drained into the pulmonary artery via a lateral tunnel in the right atrium. Immediately after surgery, his oxygen saturation increased and right ventricular function improved.

Robot-assisted Level II-III Inferior Vena Cava Tumor Thrombectomy: Step-by-Step Technique and 1-Year Outcomes

BACKGROUND

Level II-III inferior vena cava (IVC) tumor thrombectomy for renal cell carcinoma is among the most challenging urologic oncologic surgeries. In 2015, we reported the initial series of robot-assisted level III caval thrombectomy.

OBJECTIVE

To describe our University of Southern California technique in a step-by-step fashion for robot-assisted IVC level II-III tumor thrombectomy.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-five selected patients with renal neoplasm and level II-III IVC tumor thrombus underwent robot-assisted surgery with a minimum 1-yr follow-up (July 2011 to March 2015).

SURGICAL PROCEDURE

Our standardized anatomic-based "IVC-first, kidney-last" technique for robot-assisted IVC thrombectomy focuses on minimizing the chances of an intraoperative tumor thromboembolism and major hemorrhage.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline demographics, pathology data, 90-d and 1-yr complications, and oncologic outcomes at last follow-up were assessed.

RESULTS AND LIMITATIONS

Robot-assisted IVC thrombectomy was successful in 24 patients (96%) (level III: n=11; level II: n=13); one patient was electively converted to open surgery for failure to progress. Median data included operative time of 4.5h, estimated blood loss was 240ml, hospital stay 4 d; five patients (21%) received intraoperative blood transfusion. All surgical margins were negative. Complications occurred in four patients (17%): two were Clavien 2, one was Clavien 3a, and one was Clavien 3b. All patients were alive at a 16-mo median follow-up (range: 12-39 mo).

CONCLUSIONS

Robotic IVC tumor thrombectomy is feasible for level II-III thrombi. To maximize intraoperative safety and chances of success, a thorough understanding of applied anatomy and altered vascular collateral flow channels, careful patient selection, meticulous cross-sectional imaging, and a highly experienced robotic team are essential.

PATIENT SUMMARY

We present the detailed operative steps of a new minimally invasive robot-assisted surgical approach to treat patients with advanced kidney cancer. This type of surgery can be performed safely with low blood loss and excellent outcomes. Even patients with advanced kidney cancer could now benefit from robotic surgery with a quicker recovery.

Correlation between Central Venous Pressure and Inferior Vena Cava Sonographic Diameter; Determining the Best Anatomic Location

INTRODUCTION

The correlation of central venous pressure (CVP) with inferior vena cava (IVC) sonographic diameter has been reported in several studies. However, few studies have attempted to find the best anatomic location of measurement. Therefore, the purpose of this study was determining the best anatomic location to find precise correlation between CVP and IVC diameter using transesophageal echocardiography (TEE).

METHODS

In the present diagnostic accuracy study, patients in need of central venous catheterization and TEE were enrolled. Maximum diameter of IVC were measured during expiratory phase of respiratory cycle at the level of diaphragm, 2cm above the diaphragm and at the point of entry into the right atrium using SonoSite TEE device. CVP was measured using an electronic transducer connected to the central venous line. The best location for sonography was determined via calculating and comparing area under the receiver operating characteristics (ROC) curve (AUC).

RESULTS

39 patients were enrolled (53.8% female). Mean CVP was 6.8 ± 1.4 mmHg and 25 (64.1%) patients had normal CVP, while 14 (35.9%) showed elevated CVP (> 6 mmHg). Evaluating AUC showed that IVC diameter (p = 0.01), aorta diameter (p = 0.01) and IVC / aorta ratio (p = 0.004) had acceptable correlation with CVP. Point of entry of IVC into the right atrium with AUC of 0.98 (95% CI: 0.95 - 1.00) was the location of highest correlation with CVP.

CONCLUSION

Based on the present findings, the IVC sonographic diameter and IVC / aorta ratio had acceptable correlation with CVP at the level of IVC entry into the right atrium.

Left-Sided Inferior Vena Cava Encountered During Organ Retrieval Surgery: Report of Two Cases

Left-sided inferior vena cava (IVC) is the second most common anatomical anomaly of the IVC after duplication. Herein, we present two cases of left-sided IVC, diagnosed during organ retrieval procedure. In a young brain-dead man, a single left-sided IVC was observed; it originated from iliac confluence in the left side of the aorta and extended throughout the abdomen. There was no retrohepatic IVC in the patient; hepatic veins drained directly into the right atrium. The second case was a brain-dead young woman with a left-sided IVC originated from iliac confluence to the kidney level; then, the IVC crossed anterior to the abdominal aorta to join a normally positioned retrohepatic IVC. In cases of retroperitoneal surgeries, IVC anomalies should be considered during preoperative imaging studies, because they may be misdiagnosed as para-aortic lymphadenopathy, tumor or dilated gonadal vein that may result in iatrogenic damage during surgery.

Multi-Institutional Experience with Robotic Nephrectomy with Inferior Vena Cava Tumor Thrombectomy

PURPOSE

Since the first report of robotic management of renal tumors with inferior vena cava tumor thrombi, few additional cases have been reported in the literature. We report our combined experience with this procedure, to our knowledge the first multi-institutional and largest series reported to date.

MATERIALS AND METHODS

A retrospective, multi-institutional review of robotic nephrectomy with inferior vena cava tumor thrombectomy was performed with institutional review board approval.

RESULTS

A total of 32 cases were performed among 9 surgeons at 9 institutions since the first known procedure in 2008. Of these cases 30 were level II and 2 were level III thrombi with no level I thrombi (renal vein only) included in the analysis. Each surgeon performed between 1 and 10 procedures. Mean patient age was 63 years (range 43 to 81) with a mean body mass index of 30 kg/m(2) (range 17 to 43) and mean maximal tumor diameter of 9.6 cm (range 5.4 to 20). The length of inferior vena cava tumor thrombi ranged from 1 to 11 cm (median 4.2) on preoperative imaging. The inferior vena cava required cross-clamping in 24 cases. One patient had 2 renal veins with 2 caval thrombi and 1 patient required synthetic patch cavoplasty. Mean operative time was 292 minutes (range 180 to 411) with a mean blood loss of 399 cc (range 25 to 2,000). There were no conversions to open surgery or aborted procedures and there were 3 transfusions of 1 to 3 units. All but 2 patients ambulated by postoperative day 1 and mean hospital stay was 3.2 days (range 1 to 7). Lymphadenectomy in 24 patients yielded a mean of 11 nodes and 8 patients had node positive disease. There were 7 patients who experienced distant recurrence at a mean followup of 15.4 months, including 4 who had node positive disease on postoperative pathological examination.

CONCLUSIONS

Robotic nephrectomy in the setting of inferior vena cava tumor thrombus is feasible and was performed safely in selected patients. Despite the complex and critical nature of these procedures, our series demonstrates favorable outcomes and reproducibility with adequate robotic experience.

Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series

PURPOSE

Level III inferior vena cava tumor thrombectomy for renal cancer is one of the most challenging open urologic oncology surgeries. We present the initial series of completely intracorporeal robotic level III inferior vena cava tumor thrombectomy.

MATERIALS AND METHODS

Nine patients underwent robotic level III inferior vena cava thrombectomy and 7 patients underwent level II thrombectomy. The entire operation (high intrahepatic inferior vena cava control, caval exclusion, tumor thrombectomy, inferior vena cava repair, radical nephrectomy, retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize the chances of intraoperative inferior vena cava thrombus embolization, an "inferior vena cava-first, kidney-last" robotic technique was developed. Data were accrued prospectively.

RESULTS

All 16 robotic procedures were successful, without open conversion or mortality. For level III cases (9), median primary kidney (right 6, left 3) cancer size was 8.5 cm (range 5.3 to 10.8) and inferior vena cava thrombus length was 5.7 cm (range 4 to 7). Median operative time was 4.9 hours (range 4.5 to 6.3), estimated blood loss was 375 cc (range 200 to 7,000) and hospital stay was 4.5 days. All surgical margins were negative. There were no intraoperative complications and 1 postoperative complication (Clavien 3b). At a median 7 months of followup (range 1 to 18) all patients are alive. Compared to level II thrombi the level III cohort trended toward greater inferior vena cava thrombus length (3.3 vs 5.7 cm), operative time (4.5 vs 4.9 hours) and blood loss (290 vs 375 cc).

CONCLUSIONS

With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level III inferior vena cava thrombectomy is feasible and can be performed efficiently. Larger experience, longer followup and comparison with open surgery are needed to confirm these initial outcomes.

Cardiopulmonary Bypass has No Significant Impact on Survival in Patients Undergoing Nephrectomy and Level III-IV Inferior Vena Cava Thrombectomy: Multi-Institutional Analysis

PURPOSE

The impact of cardiopulmonary bypass in level III-IV tumor thrombectomy on surgical and oncologic outcomes is unknown. We determine the impact of cardiopulmonary bypass on overall and cancer specific survival, as well as surgical complication rates and immediate outcomes in patients undergoing nephrectomy and level III-IV tumor thrombectomy with or without cardiopulmonary bypass.

MATERIALS AND METHODS

We retrospectively analyzed 362 patients with renal cell cancer and with level III or IV tumor thrombus from 1992 to 2012 at 22 U.S. and European centers. Cox proportional hazards models were used to compare overall and cancer specific survival between patients with and without cardiopulmonary bypass. Perioperative mortality and complication rates were assessed using logistic regression analyses.

RESULTS

Median overall survival was 24.6 months in noncardiopulmonary bypass cases and 26.6 months in cardiopulmonary bypass cases. Overall survival and cancer specific survival did not differ significantly in both groups on univariate analysis or when adjusting for known risk factors. On multivariate analysis no significant differences were seen in hospital length of stay, Clavien 1-4 complication rate, intraoperative or 30-day mortality and cancer specific survival. Limitations include the retrospective nature of the study.

CONCLUSIONS

In our multi-institutional analysis the use of cardiopulmonary bypass did not significantly impact cancer specific survival or overall survival in patients undergoing nephrectomy and level III or IV tumor thrombectomy. Neither approach was independently associated with increased mortality on multivariate analysis. Greater surgical complications were not independently associated with the use of cardiopulmonary bypass.

Living related donor liver transplantation with atrio-caval anastomosis of inferior vena cava graft stored in deep-freeze for budd-Chiari syndrome

We have previously reported our experience in inferior vena cava resection and reconstruction techniques during liver transplantation for Budd-Chiari syndrome. Herein, we present on a case that demonstrates the importance of experience in complex vascular reconstruction techniques for living donor liver transplantation. A 15-year-old boy was scheduled for living donor liver transplantation for Budd-Chiari syndrome. Venous occlusion was extended up to the right atrial orifice of the supra-hepatic vena cava. Retro- and supra-hepatic segments of the vena cava was resected. Inferior vena cava graft stored in deep-freeze was available. Venous reconstruction was performed with end-to-end atrio-caval anastomosis. Surgical treatment was completed with the implantation of the right liver lobe donated by the patient's mother. Post-surgical course was uneventful.

Extracardiac Fontan in apicocaval juxtaposition

Extracardiac total cavopulmonary connection between the inferior vena cava and right pulmonary artery has become the most popular Fontan modification nowadays, yielding good results. However, certain situs anomalies along with systemic venous drainage variations give rise to an issue about the best way for extracardiac conduit routing. Three cases of apicocaval juxtaposition are described. The situs was inversus with the apex and inferior vena cava on the same side (left), whereas the superior vena cava (Glenn) was located on the right in all cases. The literature is revisited and technical options are discussed. Surgery was carried out with excellent short- and midterm results.

Leiomyosarcoma of the inferior vena cava

Inferior vena cava leiomyosarcoma is a rare tumor with a variety of symptoms. A 41-year-old woman was admitted with nonspecific epigastric pain. Computed tomography revealed a dense mass between the inferior vena cava and the liver. The patient underwent successful resection of the mass. The pathologic study confirmed leiomyosarcoma. Adjuvant radiation therapy was completed, and after 12 months of follow-up, the patient had no problems.

Subacromial, supracoracoid dislocation of the acromioclavicular joint with ipsilateral clavicle fracture: a case report with review of the literature and classification

A type VI acromioclavicular joint injury with a supracoracoid location of the distal end of the clavicle (VIa) may be associated with low energy injuries and, in association with a clavicle fracture, can successfully be treated with reduction of the dislocation, fixation of the clavicle, and may not require reconstruction of the acromioclavicular ligaments. An infracoracoid location (VIb) is highly suggestive of a higher energy injury.

A surgical challenge

We describe the case of a 37-year-old woman who presented with an unusually large (26 × 20 × 16 cm) extraluminal leiomyosarcoma arising from segment I (below the renal vessels) of the inferior vena cava. She was successfully managed with radical surgical excision and reconstruction of the inferior vena cava with synthetic graft.

Oncologic outcomes following surgical resection of renal cell carcinoma with inferior vena caval thrombus extending above the hepatic veins: a contemporary multicenter cohort

PURPOSE

Suprahepatic inferior vena caval tumor thrombus in renal cell carcinoma cases has historically portended a poor prognosis. With advances in perioperative treatment of patients with high level thrombus contemporary outcomes are hypothesized to be improved. We evaluated long-term oncologic outcomes of contemporary surgical treatment of patients with renal cell carcinoma in whom level III-IV inferior vena caval thrombus was managed at high volume centers.

MATERIALS AND METHODS

We examined clinical and pathological data on patients with renal cell carcinoma and level III-IV thrombus treated with surgery from January 2000 to June 2013 at 4 tertiary referral centers. Survival outcomes and associated prognostic variables were assessed by Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

We identified 166 patients, including 69 with level III and 97 with level IV thrombus. Median postoperative followup was 27.8 months. Patients with no evidence of nodal or distant metastasis (pN0/X, M0) had 5-year 49.0% cancer specific survival and 42.2% overall survival. There was no difference in survival based on tumor thrombus level or pathological tumor stage. Variables associated with an increased risk of death from kidney cancer on multivariate analysis were regional nodal metastases (HR 3.94, p <0.0001), systemic metastases (HR 2.39, p = 0.01), tumor grade 4 (HR 2.25, p = 0.02), histological tissue necrosis (HR 3.11, p = 0.004) and increased preoperative serum alkaline phosphatase (HR 2.30, p = 0.006).

CONCLUSIONS

Contemporary surgical management achieves almost 50% 5-year survival in patients without metastasis who have renal cell carcinoma thrombus above the hepatic veins. Factors associated with increased mortality included nodal/distant metastases, advanced grade, histological necrosis and increased preoperative serum alkaline phosphatase. These findings support an aggressive surgical approach to the treatment of patients with renal cell carcinoma who have advanced tumor thrombus.

Changing coupling pattern of The ON-OFF direction-selective ganglion cells in early postnatal mouse retina

In the adult rabbit and mouse retina, about 30% of the ON-OFF direction selective ganglion cells (DSGCs) are coupled via gap junctions. In early postnatal rabbit retinas, a greater proportion of morphological ON-OFF DSGCs shows coupling with a larger number of nearby somas. It is not clear whether the coupled ON-OFF DSGCs belong to the same subtype, or how coupling patterns change during development. In this study, we showed that in adult mouse retinas, all coupled ON-OFF DSGCs exhibited preferred directions (PDs) to superior, and this pattern emerged at postnatal day 15 (P15). At P13, the ON-OFF DSGCs with PDs to posterior were also coupled. Every ON-OFF DSGC in every subtype injected at P12 exhibited coupling. Therefore, a rapid decoupling process takes place in DSGCs around eye opening. Light deprivation delayed but did not halt the decoupling process. By using a transgenic mouse line in which green fluorescent protein (GFP) is selectively expressed in DSGCs with PDs to posterior and by performing in situ hybridization of cadherin-6, a marker for the DSGCs with PDs to superior and inferior, we showed that heterologous coupling existed between DSGCs with PDs to anterior and posterior till P12, but this heterologous coupling never spread to DSGCs positive for cadherin-6.

Inhibition shapes selectivity to vocalizations in the inferior colliculus of awake mice

The inferior colliculus (IC) is a major center for integration of auditory information as it receives ascending projections from a variety of brainstem nuclei as well as descending projections from the thalamus and auditory cortex. The ascending projections are both excitatory and inhibitory and their convergence at the IC results in a microcircuitry that is important for shaping responses to simple, binaural, and modulated sounds in the IC. Here, we examined the role inhibition plays in shaping selectivity to vocalizations in the IC of awake, normal-hearing adult mice (CBA/CaJ strain). Neurons in the IC of mice show selectivity in their responses to vocalizations, and we hypothesized that this selectivity is created by inhibitory microcircuitry in the IC. We compared single unit responses in the IC to pure tones and a variety of ultrasonic mouse vocalizations before and after iontophoretic application of GABA(A) receptor (GABA(A)R) and glycine receptor (GlyR) antagonists. The most pronounced effects of blocking GABA(A)R and GlyR on IC neurons were to increase spike rates and broaden excitatory frequency tuning curves in response to pure tone stimuli, and to decrease selectivity to vocalizations. Thus, inhibition plays an important role in creating selectivity to vocalizations in the IC.

Inferior conjunctival autografting for pterygium surgery: an alternative way of preserving the glaucoma filtration site in far western Nepal

BACKGROUND

The purpose of this study was to evaluate the outcome of pterygium excision with inferior conjunctival autografting for primary pterygium.

METHODS

This was a prospective noncomparative interventional case series study enrolling 50 eyes of 50 patients with primary pterygium between November 1, 2010 and October 30, 2011. All patients underwent the standard surgical technique for pterygium excision with inferior conjunctival autografting. The sampling method was purposive. The study variables were complications of surgery and recurrence rates during a follow-up period of 6 months.

RESULTS

The mean age of the patients was 43 ± 7.97 (range 26-64) years. Grade 1 pterygium comprised 64% while grade 2 pterygium comprised 36% of cases. The mean size of pterygium was 3.2 ± 0.60 mm. Minor complications did occur, but only 4% required resuturing. Recurrence occurred in two eyes (4%) which we detected 3 months after surgery in both cases. We observed conjunctival scarring at the donor site in four eyes (8%); however, there was no symblepharon formation or restriction of upgaze.

CONCLUSION

Inferior conjunctival autografting is an effective technique with a low recurrence rate. This is a useful technique when it is not possible or desirable to use the superior conjunctiva as a donor source. It is an especially good option for preserving the glaucoma filtration site for the future.

Ovarian vein and caval thrombosis

We present an illustrative case of postpartum ovarian vein thrombosis and describe its clinical presentation, differential diagnosis, and management. This pathologic process may produce clinical complications or a catastrophic outcome. These adverse events may be avoided if an expeditious diagnosis is made and appropriate treatment is instituted. This mandates a high index of suspicion, the ability to rule out the presence of other processes that may produce similar symptoms in the postpartum patient, and the appropriate triage of specific patients to either medical or surgical management.

Rapidly progressing Budd-Chiari syndrome complicated by hepatocellular carcinoma

Budd-Chiari syndrome (BCS) is a disorder caused by occlusion of the hepatic vein or inferior vena cava. The clinical presentation include abdominal pain, hepatomegaly, ascites, leg edema, collateral venous dilatation of the body trunk, and portal hypertension. In addition, BCS can cause hepatocellular carcinoma (HCC) in some patients, although its pathogenesis is not yet completely understood. The average reported time lag from diagnosis of BCS to full-blown HCC ranges from several years to several decades. Hepatic carcinogenesis in patients with BCS perhaps reflects a prolonged and persistent liver injury in that it occurs in the primary inferior vena cava obstruction rather than the primary hepatic vein thrombosis. Among patients with BCS, membranous obstruction of the vena cava (MOVC) usually presents an insidious and chronic illness, whereas primary hepatic vein thrombosis presents an acute or subacute illness. We experienced a case of a patient with BCS, which progressed rapidly that HCC developed only nine months after the diagnosis of BCS. The factors causing this rapid progression are still unclear and remain to be investigated.