Volume 24
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Number 12
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December
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2013
present and the approximate angle of their origin with the main fistula outflow. This angle, if acute, may require additional effort and time to maneuver the catheter and guide wire from one direction to the other. The effort may be similar to the use of an apex puncture in a prosthetic forearm loop graft (4), whereby the sheath must be redirected from the venous to the arterial limb of a forearm loop graft. In conclusion, the use of venous side branches as the access route to AVFs can maximize procedural flexibility when the findings of a preprocedural examination are confusing. The author has used a similar approach to access selected antecubital and upper arm veins when evaluating forearm and upper-arm
Benign Gas in an Abdominal Aortic Aneurysm Sac without Aortoenteric Fistula or Infection From: Abdulmalik A. Aikoye, MRCS Peter Taylor, FRCS Noushad Abu Sufiyan, MRCS Thomas Rix, FRCS Department of Vascular Surgery (A.A.A., N.A.S., T.R.) Kent and Canterbury Hospital Canterbury CT1 3NG, United Kingdom; and Department of Vascular Surgery (P.T.) Guy’s and St. Thomas National Health Service Foundation Trust London, United Kingdom
Editor: We report a case in which intraaneurysmal gas proved an incidental finding unassociated with other pathologic conditions. We have obtained patient consent and local institutional review board approval for preparation of this report. A 67-year-old man was diagnosed with an asymptomatic 6.2-cm abdominal aortic aneurysm (AAA). His medical history included rheumatoid arthritis treated with oral methotrexate 7.5 mg weekly. The AAA was palpable but nontender, and the patient had no signs of systemic infection, gastrointestinal hemorrhage, anemia, tuberculosis, or back pain. A computed tomographic (CT) angiogram with only intravenous contrast medium revealed a bubble of gas within the thrombus lining the aneurysm sac, and effacement of the duodenum (Fig 1). There were no signs of rupture. Echocardiography performed previously had excluded a patent foramen ovale. A radiologic diagnosis of primary aortoenteric fistula was suggested. Gas was also seen within the adjacent intervertebral disc (Fig 1). Other diagnoses
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.06.022
1917
fistulas. Care must be exercised not to jeopardize a potential future surgical option or AV access route.
REFERENCES 1. Falk A. Maintenance and salvage of arteriovenous fistulas. J Vasc Interv Radiol 2006; 17:807–813. 2. Kanterman RY, Vesely TM, Pilgram TK, Guy BW, Windus DW, Picus D. Dialysis access grafts: anatomic location of venous stenoses and results of angioplasty. Radiology 1995; 195:135–139. 3. Rajan DK, Bunston S, Misra S, Pinto R, Lok CE. Dysfunctional autogenous hemodialysis fistulas: outcomes after angioplasty—are there clinical predictors of patency? Radiology 2004; 232:508–515. 4. Hathaway PB, Vesely TM. The apex puncture technique for mechanical thrombolysis of loop hemodialysis grafts. J Vasc Interv Radiol 1999; 10: 775–779.
considered were mycotic aneurysm and lumbar disc collapse. He was excluded from endovascular aneurysm repair because of the short angulated neck of the aneurysm. A radiolabeled indium-111 (111In) white blood cell scan revealed no abnormal accumulation of radiolabeled leukocytes around the aneurysm at 4 hours and 24 hours (Fig 2). A normal white blood cell count of 8.4 109/L and Creactive protein level of 9 mg/L (normal range, 0–10 mg/ L) were measured in venous samples, and the findings of two blood cultures were negative. The patient began a regimen of prophylactic amoxicillin and ciprofloxacin, but these were discontinued after 2 weeks during a flare of rheumatoid arthritis thought to be caused by antibiotic drug interaction with methotrexate. C-reactive protein levels increased to 76 mg/L at this time but decreased to 4 mg/L when his arthritis flare resolved. He did not receive antibiotic therapy for 8 weeks before surgery.
Figure 1. Axial CT scan shows gas in the aneurysm sac (black arrows) and intervertebral disc (white arrow).
1918
’
Letters to the Editor
Figure 2. Whole-body radiolabeled white blood cell 111In scan shows no uptake over the infrarenal AAA after 24 hours.
The patient underwent an unremarkable open surgical repair of his AAA with the use of polyester graft. At 6-month, follow-up, he remained free from complications. Thrombus from the aneurysm sac was cultured but proved sterile. Infected AAA is uncommon, comprising fewer than 3% of infrarenal AAAs (1), and can be asymptomatic despite the increased risk of rupture and mortality (2). Gas within the sac wall and periaortic inflammatory tissue are features of mycotic aneurysm. In the present case, the immunosuppressive effect of methotrexate
Transarterial Chemoembolization for Palliation of Paraneoplastic Hypoglycemia in a Patient with Advanced Hepatocellular Carcinoma From: Maureen Whitsett, BA, MEd Christina C. Lindenmeyer, MD Colette M. Shaw, MD Jesse M. Civan, MD Jonathan M. Fenkel, MD Jefferson Medical College (M.W.) and Department of Medicine (C.C.L.) and Divisions of Interventional Radiology (C.M.S.) and Gastroenterology and Hepatology (J.M.C., J.M.F.) Thomas Jefferson University Hospital 132 South 10th St. Main Building, Suite 480 Philadelphia, PA 19107
Editor: Hypoglycemia caused by paraneoplastic secretion of insulin-like growth factors (IGFs) is a rare complication
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.07.002
Whitsett et al
’
JVIR
could have increased the risk of mycotic aneurysm, as previously reported (3); however, no organisms were cultured in blood or thrombus. Severe rheumatoid disease can cause aortitis, but no periaortic inflammation was seen in the present case (Fig 1). Spontaneous aortoenteric fistula is less common, and reported only in the presence of infection. When there is communication between the aorta and part of the gastrointestinal tract, ectopic gas adjacent to or within the aorta is the predominant CT finding (4). Degenerative disease of the lumbar intervertebral discs may exhibit gas within the degenerate disc. Perhaps the intervertebral gas diffused into the aneurysm sac; however, we are unaware of any reported cases of spontaneous aneurysm sac gas associated with this condition. In conclusion, the present report suggests that aortic sac gas can be a benign finding, independent of aortic infection or aortoenteric fistula.
REFERENCES 1. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but curable results. J Vasc Surg 2001; 34:900–908. 2. Tang T, Boyle JR, Dixon AK. Inflammatory abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2005; 29:353–362. 3. Kaneko K, Nonomura Y, Watanabe K, et al. Infected abdominal aortic aneurysm caused by non-typhoid Salmonella in an immunocompromised patient with rheumatoid arthritis. J Infect Chemother 2009; 15:312–315. 4. Vu QD, Menias CO, Bhalla S, Peterson C, Wang LL, Balfe DM. Aortoenteric fistulas: CT features and potential mimics. Radiographics 2009; 29: 197–209.
of hepatocellular carcinoma (HCC). This syndrome of refractory hypoglycemia can cause significant morbidity, and there are limited data on treatment options. The present case describes the use of transarterial chemoembolization as a therapy for tumor-induced hypoglycemia in a patient with advanced HCC. The patient was a 68-year-old woman with a history of hepatitis C, diabetes, and hypertension, with a newly diagnosed, biopsy-proven large HCC complicated by profound hypoglycemia requiring continuous 20% dextrose (D20) infusion and high-dose prednisone to maintain euglycemia. She described recent fatigue, jaundice, and shortness of breath. On physical examination, she was volume-overloaded, with a palpable mass in the right upper quadrant and epigastrium, extending approximately five fingerbreadths below the right costal margin. She was hospitalized, and a chest radiograph demonstrated pulmonary edema attributed to her D20 and corticosteroid therapy. Laboratory studies revealed a fasting glucose level of 61 mg/dL, total bilirubin level of 3.7 mg/dL, alkaline phosphatase level of 234 IU/L, aspartate aminotransferase level of 134 IU/L, and alanine aminotransferase level of 28 IU/L. Abdominal ultrasound revealed dilation of the intrahepatic ducts, and endoscopic retrograde cholangiopancreatography demonstrated a malignant-appearing obstruction of the
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Number 12
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December
’
2013
present and the approximate angle of their origin with the main fistula outflow. This angle, if acute, may require additional effort and time to maneuver the catheter and guide wire from one direction to the other. The effort may be similar to the use of an apex puncture in a prosthetic forearm loop graft (4), whereby the sheath must be redirected from the venous to the arterial limb of a forearm loop graft. In conclusion, the use of venous side branches as the access route to AVFs can maximize procedural flexibility when the findings of a preprocedural examination are confusing. The author has used a similar approach to access selected antecubital and upper arm veins when evaluating forearm and upper-arm
Benign Gas in an Abdominal Aortic Aneurysm Sac without Aortoenteric Fistula or Infection From: Abdulmalik A. Aikoye, MRCS Peter Taylor, FRCS Noushad Abu Sufiyan, MRCS Thomas Rix, FRCS Department of Vascular Surgery (A.A.A., N.A.S., T.R.) Kent and Canterbury Hospital Canterbury CT1 3NG, United Kingdom; and Department of Vascular Surgery (P.T.) Guy’s and St. Thomas National Health Service Foundation Trust London, United Kingdom
Editor: We report a case in which intraaneurysmal gas proved an incidental finding unassociated with other pathologic conditions. We have obtained patient consent and local institutional review board approval for preparation of this report. A 67-year-old man was diagnosed with an asymptomatic 6.2-cm abdominal aortic aneurysm (AAA). His medical history included rheumatoid arthritis treated with oral methotrexate 7.5 mg weekly. The AAA was palpable but nontender, and the patient had no signs of systemic infection, gastrointestinal hemorrhage, anemia, tuberculosis, or back pain. A computed tomographic (CT) angiogram with only intravenous contrast medium revealed a bubble of gas within the thrombus lining the aneurysm sac, and effacement of the duodenum (Fig 1). There were no signs of rupture. Echocardiography performed previously had excluded a patent foramen ovale. A radiologic diagnosis of primary aortoenteric fistula was suggested. Gas was also seen within the adjacent intervertebral disc (Fig 1). Other diagnoses
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.06.022
1917
fistulas. Care must be exercised not to jeopardize a potential future surgical option or AV access route.
REFERENCES 1. Falk A. Maintenance and salvage of arteriovenous fistulas. J Vasc Interv Radiol 2006; 17:807–813. 2. Kanterman RY, Vesely TM, Pilgram TK, Guy BW, Windus DW, Picus D. Dialysis access grafts: anatomic location of venous stenoses and results of angioplasty. Radiology 1995; 195:135–139. 3. Rajan DK, Bunston S, Misra S, Pinto R, Lok CE. Dysfunctional autogenous hemodialysis fistulas: outcomes after angioplasty—are there clinical predictors of patency? Radiology 2004; 232:508–515. 4. Hathaway PB, Vesely TM. The apex puncture technique for mechanical thrombolysis of loop hemodialysis grafts. J Vasc Interv Radiol 1999; 10: 775–779.
considered were mycotic aneurysm and lumbar disc collapse. He was excluded from endovascular aneurysm repair because of the short angulated neck of the aneurysm. A radiolabeled indium-111 (111In) white blood cell scan revealed no abnormal accumulation of radiolabeled leukocytes around the aneurysm at 4 hours and 24 hours (Fig 2). A normal white blood cell count of 8.4 109/L and Creactive protein level of 9 mg/L (normal range, 0–10 mg/ L) were measured in venous samples, and the findings of two blood cultures were negative. The patient began a regimen of prophylactic amoxicillin and ciprofloxacin, but these were discontinued after 2 weeks during a flare of rheumatoid arthritis thought to be caused by antibiotic drug interaction with methotrexate. C-reactive protein levels increased to 76 mg/L at this time but decreased to 4 mg/L when his arthritis flare resolved. He did not receive antibiotic therapy for 8 weeks before surgery.
Figure 1. Axial CT scan shows gas in the aneurysm sac (black arrows) and intervertebral disc (white arrow).
1918
’
Letters to the Editor
Figure 2. Whole-body radiolabeled white blood cell 111In scan shows no uptake over the infrarenal AAA after 24 hours.
The patient underwent an unremarkable open surgical repair of his AAA with the use of polyester graft. At 6-month, follow-up, he remained free from complications. Thrombus from the aneurysm sac was cultured but proved sterile. Infected AAA is uncommon, comprising fewer than 3% of infrarenal AAAs (1), and can be asymptomatic despite the increased risk of rupture and mortality (2). Gas within the sac wall and periaortic inflammatory tissue are features of mycotic aneurysm. In the present case, the immunosuppressive effect of methotrexate
Transarterial Chemoembolization for Palliation of Paraneoplastic Hypoglycemia in a Patient with Advanced Hepatocellular Carcinoma From: Maureen Whitsett, BA, MEd Christina C. Lindenmeyer, MD Colette M. Shaw, MD Jesse M. Civan, MD Jonathan M. Fenkel, MD Jefferson Medical College (M.W.) and Department of Medicine (C.C.L.) and Divisions of Interventional Radiology (C.M.S.) and Gastroenterology and Hepatology (J.M.C., J.M.F.) Thomas Jefferson University Hospital 132 South 10th St. Main Building, Suite 480 Philadelphia, PA 19107
Editor: Hypoglycemia caused by paraneoplastic secretion of insulin-like growth factors (IGFs) is a rare complication
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.07.002
Whitsett et al
’
JVIR
could have increased the risk of mycotic aneurysm, as previously reported (3); however, no organisms were cultured in blood or thrombus. Severe rheumatoid disease can cause aortitis, but no periaortic inflammation was seen in the present case (Fig 1). Spontaneous aortoenteric fistula is less common, and reported only in the presence of infection. When there is communication between the aorta and part of the gastrointestinal tract, ectopic gas adjacent to or within the aorta is the predominant CT finding (4). Degenerative disease of the lumbar intervertebral discs may exhibit gas within the degenerate disc. Perhaps the intervertebral gas diffused into the aneurysm sac; however, we are unaware of any reported cases of spontaneous aneurysm sac gas associated with this condition. In conclusion, the present report suggests that aortic sac gas can be a benign finding, independent of aortic infection or aortoenteric fistula.
REFERENCES 1. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but curable results. J Vasc Surg 2001; 34:900–908. 2. Tang T, Boyle JR, Dixon AK. Inflammatory abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2005; 29:353–362. 3. Kaneko K, Nonomura Y, Watanabe K, et al. Infected abdominal aortic aneurysm caused by non-typhoid Salmonella in an immunocompromised patient with rheumatoid arthritis. J Infect Chemother 2009; 15:312–315. 4. Vu QD, Menias CO, Bhalla S, Peterson C, Wang LL, Balfe DM. Aortoenteric fistulas: CT features and potential mimics. Radiographics 2009; 29: 197–209.
of hepatocellular carcinoma (HCC). This syndrome of refractory hypoglycemia can cause significant morbidity, and there are limited data on treatment options. The present case describes the use of transarterial chemoembolization as a therapy for tumor-induced hypoglycemia in a patient with advanced HCC. The patient was a 68-year-old woman with a history of hepatitis C, diabetes, and hypertension, with a newly diagnosed, biopsy-proven large HCC complicated by profound hypoglycemia requiring continuous 20% dextrose (D20) infusion and high-dose prednisone to maintain euglycemia. She described recent fatigue, jaundice, and shortness of breath. On physical examination, she was volume-overloaded, with a palpable mass in the right upper quadrant and epigastrium, extending approximately five fingerbreadths below the right costal margin. She was hospitalized, and a chest radiograph demonstrated pulmonary edema attributed to her D20 and corticosteroid therapy. Laboratory studies revealed a fasting glucose level of 61 mg/dL, total bilirubin level of 3.7 mg/dL, alkaline phosphatase level of 234 IU/L, aspartate aminotransferase level of 134 IU/L, and alanine aminotransferase level of 28 IU/L. Abdominal ultrasound revealed dilation of the intrahepatic ducts, and endoscopic retrograde cholangiopancreatography demonstrated a malignant-appearing obstruction of the
