Critical limb ischemia (CLI) is a syndrome manifested by ischemic rest pain, non-healing ulcers and tissue loss. CLI patients are at very high risk of amputation and experience poor physical function, leading to severe morbidity and mortality. The fundamental goal for CLI treatment is to relieve ischemic rest pain, heal ulcers, prevent limb loss and improve the quality of life, thereby extending the survival of the patient. Surgical or endovascular revascularization aimed at increasing blood flow is currently available for limb salvage in CLI. However, up to 30% of CLI patients are not suitable for such interventions because of high operative risk or unfavorable vascular anatomy. Therefore exploring new and more effective strategies for revascularization of ischemic limbs is imperative for the establishment of a viable therapeutic alternative. With the emergence of new approaches, this review describes up-to-date progress and developments in cell-based therapy as a novel and promising alternative for CLI treatment. Preliminary clinical data have established the safety, feasibility and efficacy of stem cells, and numerous studies are underway to consolidate this evidence further. However, significant hurdles remain to be addressed before this research can be responsibly translated to the bedside. In particular, we need better understanding of the behavior of cells post-transplantation and to learn how to control their survival and migration proliferation/differentiation in the hostile pathologic environment. Future research should focus on methods of isolation, optimal dosage, appropriate cell type, route of administration, role of tissue-derived factors and supportive endogenous stimulation.
Arteriovenous malformation (AVM) are commonly congenital in origin. We hereby describe the case of a 24-year-old male who was diagnosed of left thigh intramuscular AVM at the time of 14 years old. The computerized tomography (CT) scan confirmed a large deep seated intramuscular AVM with the size of 20 x 15 cm, with dilated and distended feeding vessel from profunda femoris artery (PFA) and superficial femoral artery (SFA). He also had another AVM near the left supracondylar region adherent to the sciatic nerve. The main AVM lesion was earlier treated with surgical resection and it remained for asymptomatic for next seven years. Following this, the patient presented again to the clinic with recurring swelling, pain and occasional paraesthesia on the same site. He was then managed with a series of embolization (total of 6 attempts) with histoacryl glue. These attempts of embolization were successful. The interesting case of pulmonary embolism due histoacryl glue following embolization of an AVM is described.
Haemorrhage arising from gastric arteriovenous malformation (AVM) is rare and normally occurs in the elderly. Bleeding gastric AVM presenting in the younger age group is even rarer. We report a case of a 14 year old boy who presented with recurrent episodes of haematemesis. He subsequently underwent a proximal gastrectomy and the histological examination confirmed a gastric AVM. After reviewing the literature we believe this is the youngest ever reported case of bleeding gastric AVM reported in English literature.
Diabetic retinopathy (DR) is a sight threatening complication due to diabetes mellitus that affects the retina. At present, the classification of DR is based on the International Clinical Diabetic Retinopathy Disease Severity. In this paper, FAZ enlargement with DR progression is investigated to enable a new and an effective grading protocol DR severity in an observational clinical study. The performance of a computerised DR monitoring and grading system that digitally analyses colour fundus image to measure the enlargement of FAZ and grade DR is evaluated. The range of FAZ area is optimised to accurately determine DR severity stage and progression stages using a Gaussian Bayes classifier. The system achieves high accuracies of above 96%, sensitivities higher than 88% and specificities higher than 96%, in grading of DR severity. In particular, high sensitivity (100%), specificity (>98%) and accuracy (99%) values are obtained for No DR (normal) and Severe NPDR/PDR stages. The system performance indicates that the DR system is suitable for early detection of DR and for effective treatment of severe cases.
Mediastinal irradiation for various malignancies can cause radiation injury to mediastinal structures, most importantly the cardiovascular system. This article reviews the effect of radiation on cardiovascular structures and the manifestations of various radiation-induced heart diseases.
The role of renal sympathetic nerves in the pathogenesis of ischemic acute renal failure (ARF) and the immediate changes in the renal excretory functions following renal ischemia were investigated. Two groups of male Sprague Dawley (SD) rats were anesthetized (pentobarbitone sodium, 60 mg kg(-1) i.p.) and subjected to unilateral renal ischemia by clamping the left renal artery for 30 min followed by reperfusion. In group 1, the renal nerves were electrically stimulated and the responses in the renal blood flow (RBF) and renal vascular resistance (RVR) were recorded, while group 2 was used to study the early changes in the renal functions following renal ischemia. In post-ischemic animals, basal RBF and the renal vasoconstrictor reperfusion to renal nerve stimulation (RNS) were significantly lower (all p < 0.05 vs. control). Mean arterial pressure (MAP), basal RVR, urine flow rate (UFR), absolute and fractional excretions of sodium (U(Na)V and FE(Na)), and potassium (U(K)V and FE(K)) were higher in ARF rats (all p < 0.05 vs. control). Post-ischemic animals showed markedly lower glomerular filtration rate (GFR) (p < 0.05 vs. control). No appreciable differences were observed in urinary sodium to potassium ratio (U(Na)/U(K)) during the early reperfusion phase of renal ischemia (p > 0.05 vs. control). The data suggest an immediate involvement of renal sympathetic nerve action in the pathogenesis of ischemic ARF primarily through altered renal hemodynamics. Diuresis, natriuresis, and kaliuresis due to impaired renal tubular functions are typical responses to renal ischemia and of comparable magnitudes.
The management of epistaxis remains to be a challenging problem for most ENT surgeon especially posterior epistaxis. Most cases are managed by placement of posterior nasal packs or balloons and failure leads to more invasive techniques, involving ligation of the internal maxillary artery. The above management is associated with significant patient complication and morbidity. Endoscopic ligation or cauterization of the sphenopalatine artery has emerged as a viable and minimally invasive alternative. We have performed endoscopic cauterization of nine sphenopalatine arteries in eight patients with no further episodes of epistaxis and complications, with an average follow-up of 25 months. The mean age of the patients was 52.75 years. Fifty percent of the patients had a history of hypertension.
The obturator artery (OA) originates from the internal iliac artery. Variation in the origin of the OA may be asymptomatic in individuals and occasionally be detected during routine cadaveric dissections or autopsies. In the present study, we observed the origin and the branching pattern of the OA on 34 lower limbs (17 right sides and 17 left sides) irrespective of sex. The bifurcation of the common iliac artery into internal and external iliac from the sacral ala varied between 4.3-5.3 cm. The distance of the origin of the anterior division of internal iliac artery from the bifurcation of common iliac artery varied between 1-6 cm. The distance of the origin of the posterior division of the internal iliac artery from the point of bifurcation of the common iliac artery varied between 0-6 cm. Out of 34 lower limbs studied, two specimens (5.8%) showed anomalous origin of the OA originating from the posterior division of the internal iliac artery. Of these two, one limb belonged to the right side while the other was from the left side. The anomalous OA gave off an inferior vesical branch to the prostate in both the specimens. No other associated anomalies regarding the origin or branching pattern of the OA were observed. Prior knowledge of the anatomical variations may be beneficial for vascular surgeons ligating the internal iliac artery or its branches and the radiologists interpreting angiograms of the pelvic region.
Chronic venous disorders are conditions of increasing prevalence in the developing world, and venous ulceration is the terminal sequel. Currently there are only limited data on all aspects of this from Southeast Asia. The aim of the present study was to assess differences in the demography and outcome between varicose vein surgery (VVS) and the relatively new endovenous laser therapy (EVT) in patients from Penang, Malaysia.
Variations in the arterial pattern of the upper limb have been observed frequently, either in the routine dissections or in clinical practice. The aim of the present study was to describe the anatomical, surgical and embryological importance of major arteries of upper limbs of human beings. The present article is the report of low division and trifurcation of brachial artery and abnormal course of radial artery (passing deep to the pronator teres muscle) found in a 45-year-old embalmed male cadaver. Knowledge of the arterial variations in the upper limb is of considerable importance during invasive and non-invasive investigative procedures or orthopedic, reconstructive, or surgical procedures.
An abnormal communication between an artery and a vein is known as arteriovenous malformation (AVM) or arteriovenous fistula (AVF). The AVM or the AVF might be congenital in origin or even acquired. The arteriovenous communications are usually surgically made in patients undergoing repeated hemodialysis, while suffering from any chronic renal disease. The abnormal arteriovenous communications may be asymptomatic in nature. The arteriovenous communications might be an incidental finding during any anatomical dissections or medico-legal autopsies. The present study reports the presence of BBC on both sides of a 54-year-old male cadaver who died of road traffic accident. There was a communication between the brachial artery and the brachial vein, 11.5 cm above the medial epicondyle. The oblique communicating channel measured 1.5 cm in length and connected the brachial artery to the brachial vein. A detailed histological study of the communication showed the presence of thick tunica media. Knowledge of arteriovenous communications may be beneficial for any academic studies and equally important for vascular surgeons and radiologists performing angiographic studies.
Direct tumour extension into the internal jugular veins (IJV) and right atrium in thyroid cancer is extremely uncommon. We report three cases of advanced thyroid cancer invading into the IJV and right atrium. All three patients had well-differentiated thyroid cancer and presented with typical clinical picture of the superior cava syndrome coupled with significant compressive symptoms. Two patients had obvious tumour thrombus extending to the superior vena cava (SVC) and right atrium, whilst in one patient, the thrombus extended to the SVC close to the edge of the right atrium. In all three patients, the intraluminal tumour thrombus was clinically palpable. Involvement of the IJV, SVC and right atrium was confirmed with computed tomography (CT) scan and echocardiography. The decision to extract the thrombus transcervically was made on the basis of the positive "ring sign", which is a thin rim of contrast surrounding the tumour thrombus documented on CT. All three patients underwent total thyroidectomy with segmental resection and ligation of the IJV. The tumour thrombus was successfully extracted transcervically. The histopathology report confirmed follicular carcinoma in all three patients. Two patients had radioiodine ablation therapy postoperatively, and were well 18 months after operation. One patient who had lung metastases documented on chest CT succumbed to the disease due to massive haemoptysis 3 weeks after operation.
A pyolaryngocele is an uncommon complication of a laryngocele that has become infected. We present a case of a pyolaryngocele that was probably due to repeated injections in the neck veins. The pathogenesis, clinical features and management are discussed in detail.
Meckel's diverticulum is a relatively common gastrointestinal entity which occasionally causes complications. Meckel's diverticulum is classically described to mimic acute appendicitis when inflamed as well as being a cause of unexplained luminal gastrointestinal bleeding. An unusual cause of spontaneous non traumatic haemoperitoneum found during surgery performed for a suspected acute appendicitis in a 22-year old female is described. The patient was found to have a significant haemoperitoneum due to a bleeding serosal vessel of a Meckel's diverticulum. The diverticulum was routinely excised. It was macroscopically and histologically devoid of inflammation. The bleeding vessel was not found to be abnormal or part of an arteriovenous malformation.
The availability of multiple investigating modalities should be utilized to arrive at the correct diagnosis of the spinal arteriovenous malformation (AVM). We hereby report the case of a 21-year-old, obese female, who presented with paraplegia and impaired bowel control two years after an episode of the fall. The Magnetic Resonance Imaging (MRI) of her spine not only revealed disc prolapse at T11-T12, but also tortuous dilated spinal veins and cord oedema. A diagnosis of a spinal arterio-venous fistula was confirmed after a spinal angiogram. The dilemma of treating the right pathology for the clinical signs and symptoms are being discussed.
CT and MRI scans are widely used in medical diagnosis procedures, but they only produce 2-D images. However, the human anatomical structure, the abnormalities, tumors, tissues and organs are in 3-D. 2-D images from these devices are difficult to interpret because they only show cross-sectional views of the human structure. Consequently, such circumstances require doctors to use their expert experiences in the interpretation of the possible location, size or shape of the abnormalities, even for large datasets of enormous amount of slices. Previously, the concept of reconstructing 2-D images to 3-D was introduced. However, such reconstruction model requires high performance computation, may either be time-consuming or costly. Furthermore, detecting the internal features of human anatomical structure, such as the imaging of the blood vessels, is still an open topic in the computer-aided diagnosis of disorders and pathologies. This paper proposes a volume visualization framework using Compute Unified Device Architecture (CUDA), augmenting the widely proven ray casting technique in terms of superior qualities of images but with slow speed. Considering the rapid development of technology in the medical community, our framework is implemented on Microsoft.NET environment for easy interoperability with other emerging revolutionary tools. The framework was evaluated with brain datasets from the department of Surgery, University of North Carolina, United States, containing around 109 MRA datasets. Uniquely, at a reasonably cheaper cost, our framework achieves immediate reconstruction and obvious mappings of the internal features of human brain, reliable enough for instantaneous locations of possible blockages in the brain blood vessels.