Search Results (485)

Abdominal arteriovenous fistula [AVF] is a rare but serious complication of penetrating trauma, often associated with high morbidity and mortality. This report presents the case of a 24-year-old male who sustained multiple gunshot wounds, leading to the formation of an ilio-iliac AVF and a pseudoaneurysm. The patient arrived at the emergency department hemodynamically unstable, with bullet wounds to the forearm, thigh, and lumbosacral region. Initial non-arterial phase CT revealed a pseudoaneurysm anterior to the right external iliac vessels and a surrounding hematoma, raising suspicion for AVF. A second biphasic CTA confirmed an AVF connection between the right external iliac artery and external iliac vein, as well as the arterialization of the vein. Additionally, fat stranding and bowel wall thickening suggested potential hollow viscus injury. Due to the patient’s unstable condition and possible intra-abdominal injuries, an open laparotomy was performed. A stent was placed in the right external iliac artery, the vein was primarily repaired, and serosal injuries to the duodenum and cecum were surgically addressed. The patient recovered gradually, although a persistent serous discharge was noted and managed in follow-up. This case highlights the importance of considering AVF in penetrating abdominal trauma and the critical role of biphasic CTA in diagnosis and surgical planning. Full article

Valvular hemangiomas are uncommon vascular anomalies that appear on the surface of heart valves. They can cause an array of non-specific symptoms and are consequently rarely diagnosed, with only 31 such cases (including the present one) reported to date in the literature; the present case is the first report of an arteriovenous hemangioma with a tricuspid localization. During the preoperative echocardiographic examination for a ventricular septal defect, a mass was incidentally discovered on the tricuspid valve of a 9-month-old infant. The involved leaflet was surgically removed and sent to the pathology department for analysis and subsequently diagnosed as an arteriovenous hemangioma. The patient recovered well, with no local tumor recurrence or other complications. The microscopic examination showed multiple blood vessels which stained positive for the endothelial markers CD31 and CD34 and which did not express D2-40, normally found in lymphatic endothelia. Surprisingly, endothelial cells lining the vessels also showed positivity for SMA, a mesenchymal cell marker, indicating a possible involvement of endothelial-to-mesenchymal transition and its opposite process, mesenchymal-to-endothelial transition, in the pathogenesis of these vascular anomalies. Full article

Intimal hyperplasia (IH) compromises the patency of arteriovenous fistula (AVF) vascular access in patients with end-stage kidney disease. Uncontrolled cell proliferation and migration, driven by inflammation, shear stress and surgery, are well-known triggers in IH. Recently, microRNAs (miRNAs) have emerged as regulators of core mechanisms in cardiovascular diseases and as potential markers of IH. This study was aimed at identifying a specific miRNA panel in failed AVFs and clarifying the miRNA involvement in IH. miRNA profiling performed in tissues from patients with IH (AVFs) and normal veins (NVs) highlighted a subset of four miRNAs significantly deregulated (hsa-miR-155-5p, hsa-miR-449a-5p, hsa-miR-29c-3p, hsa-miR-194-5p) between the two groups. These miRNAs were analyzed in tissue-derived cells (NVCs and AVFCs), human aortic smooth muscle cells (HAOSMCs) and human umbilical vein endothelial cells (HUVECs). The panel of hsa-miR-449a-5p, hsa-miR-155-5p, hsa-miR-29c-3p and hsa-miR-194-5p was up-regulated in AVFCs, HAOSMCs and HUVEC under inflammatory stimuli. Notably, overexpression of hsa-miR-449a-5p exacerbated the proliferative, migratory and inflammatory features of AVFCs. In vitro pharmacological modulation of these miRNAs with pioglitazone, particularly the down-regulation of hsa-miR-155-5p and hsa-miR-29c-3p, suggested their involvement in IH pathogenesis and a potential translational application. Overall, these findings provide new insights into the pathogenesis of AVF failure, reinforcing the miRNA contribution to IH detection and prevention. Full article

Background: Awake craniotomy (AC) surgeries are less common in the pediatric population in comparison to their adult counterparts. Nonetheless, they can be considered for selected cases whereby speech preservation is paramount during maximal safe resection of intracranial lesions. We describe a case of AC for the excision of a brain arteriovenous malformation (bAVM) with language mapping in a pediatric patient. Methods: A previously well 16-year-old male presented with a spontaneous left frontal intracranial hemorrhage. Neuroimaging confirmed the cause to be a left antero-temporal bAVM centered in the insula. A decision was made for AC bAVM excision with language mapping for speech preservation. Results: As part of the pre-operative preparation, the patient and his caregivers were reviewed by a multidisciplinary team. For the conduct of the AC, the asleep–awake–asleep technique was used with processed EEG to guide anesthesia management. Additional modifications to make the patient comfortable included the avoidance of rigid cranial skull pins, urinary catheterization and central line insertion at the start of the surgery. Conclusions: Our experience concurs with the evidence that AC in children is a feasible option for select individuals. To our knowledge, this is the first detailed case description of a pediatric patient undergoing AC with language mapping for a bAVM. Emphases include a strong rapport between the patient and the managing multidisciplinary team, flexibility to adjust conventional workflows and limitations of neuroimaging adjuncts. Full article

Arteriovenous malformations (AVMs) are congenital vascular anomalies defined by abnormal direct connections between arteries and veins due to their complex structure or endovascular approaches. Pharmacological strategies targeting the underlying molecular mechanisms are thus gaining increasing attention in an effort to determine the mechanism involved in AVM regulation. In this study, we examined 30 human tissue samples, comprising 10 vascular samples, 10 human fibroblasts derived from AVM tissue, and 10 vascular samples derived from healthy individuals. The pharmacological agents thalidomide, U0126, and rapamycin were applied to the isolated endothelial cells (ECs). The pharmacological treatments reduced the proliferation of AVM ECs and downregulated miR-135b-5p, a biomarker associated with AVMs. The expression levels of angiogenesis-related genes, including VEGF, ANG2, FSTL1, and MARCKS, decreased; in comparison, CSPG4, a gene related to capillary networks, was upregulated. Following analysis of these findings, skin samples from 10 AVM patients were reprogrammed into induced pluripotent stem cells (iPSCs) to generate AVM blood vessel organoids. Treatment of these AVM blood vessel organoids with thalidomide, U0126, and rapamycin resulted in a reduction in the expression of the EC markers CD31 and α-SMA. The establishment of AVM blood vessel organoids offers a physiologically relevant in vitro model for disease characterization and drug screening. The authors of future studies should aim to refine this model using advanced techniques, such as microfluidic systems, to more efficiently replicate AVMs’ pathology and support the development of personalized therapies. Full article

Background: Arteriovenous malformations (AVMs) are rare vascular anomalies that can cause intracerebral hemorrhage, particularly in pediatric patients. Low-flow AVMs may not be visualized on initial non-invasive imaging modalities such as MR angiography. Methods: We report a 6-year-old boy who presented with intracerebral hemorrhage and initially had no detectable vascular anomaly on MR angiography and MR venography. Two years later, he was re-admitted with a recurrent hemorrhage. Repeating MR angiography again failed to reveal any vascular pathology. Results: Digital subtraction angiography (DSA) performed later identified a grade 3 low-flow AVM in the left posterior temporal region. The patient underwent successful endovascular treatment with no subsequent neurological deficits. Conclusions: This case underscores the limitations of MR angiography in detecting low-flow AVMs and highlights the essential role of DSA in the definitive diagnosis and management of unexplained intracerebral hemorrhages in pediatric patients. Full article

Arterial aneurysms are vascular conditions associated with life-threatening consequences in patients, such as dissection and rupture. Understanding their genetic basis is an evolving field, driven by the robust reporting of genetic variants associated with aneurysms in patients. In this study, we present clinical and genetic data from nine unrelated subjects with arterial aneurysms who were identified to harbor rare variants in the TNXB gene, mainly affecting fibronectin type III (FNIII) domains. The cohort included three female and six male subjects with a mean age of 53.5 years (SD = 14.4). The most frequently affected vascular territory was the thoracic ascending aorta (n = 7). A range of pathogenic impacts was predicted via multiple in silico tools that analyze evolutionary conservation and biochemical properties. Computational protein structure modeling with AlphaFold 3 predicted domain-specific alterations across multiple FNIII regions for four unique missense variants and one in-frame deletion, and premature protein truncation resulting from two frameshift variants. To our knowledge, this study is one of the first and largest to associate TNXB variants with arterial aneurysmal disease. Our findings demonstrate the potential of computational genomics and structural modeling to advance the understanding of extracellular matrix gene alterations in aneurysm pathogenesis. Full article

Introduction: The vascular architecture of the vocal folds plays a critical role in sustaining the dynamic demands of phonation. Disruptions in this microvascular system are linked to various pathological conditions, including Reinke’s edema, hemorrhage, and laryngeal carcinoma. This review explores the structural and functional components of vocal fold microvascularization, with emphasis on pericytes, endothelial interactions, and neurovascular regulation. Materials and Methods: A systematic review of the literature was conducted using databases such as PubMed, Scopus, Web of Science, and Embase. Keywords included “pericytes”, “Reinke’s edema”, and “vocal fold microvascularization”. Selected studies were peer-reviewed and met criteria for methodological quality and relevance to laryngeal microvascular physiology and pathology. Results: The vocal fold vasculature is organized in a parallel, tree-like pattern with distinct arterioles, capillaries, and venules. Capillaries dominate the superficial lamina propria, while transitional vessels connect to deeper arterioles surrounded by smooth muscle. Pericytes, present from birth, form tight associations with endothelial cells and contribute to capillary stability, vessel remodeling, and mechanical protection during vibration. Their thick cytoplasmic processes suggest a unique adaptation to the biomechanical stress of phonation. Arteriovenous anastomoses regulate perfusion by shunting blood according to functional demand. Furthermore, neurovascular control is mediated by noradrenergic fibers and neuropeptides such as VIP and CGRP, modulating vascular tone and glandular secretion. The limited lymphatic presence in the vocal fold mucosa contributes to edema accumulation while also restricting carcinoma spread, offering both therapeutic challenges and advantages. Conclusions: A deeper understanding of vocal fold microvascularization enhances clinical approaches to voice disorders and laryngeal disease, offering new perspectives for targeted therapies and regenerative strategies. Full article

This review synthesizes current evidence on clinical nursing practices in the management of arteriovenous fistulas (AVFs) among patients undergoing hemodialysis (HD). It investigates the identification of risk factors and elements contributing to AVF dysfunction, emphasizing the crucial role of nursing professionals in maintaining, monitoring, and enhancing the long-term functionality of vascular access. The findings indicate that implementing upper limb exercise protocols can significantly support AVF maturation, enhance hemodynamic parameters, and improve vascular access outcomes. Notably, the review highlights the necessity of continuous education for nurses in AVF management, emphasizing their critical role in the successful preservation and optimization of vascular access, including the promotion of exercise interventions. These insights underscore the importance of equipping nursing staff with current knowledge and skills to improve patient outcomes in HD care. Full article

Background/Objectives: According to the guidelines established by the European Society of Vascular Surgery (ESVS), a minimum 2 mm diameter is advised for both the radial artery (RA) and cephalic vein (CV) to perform a radio-cephalic arteriovenous fistula (RC-AVF). However, studies have suggested that larger vein diameters, over 2.5 or 3 mm, or even smaller vessel diameters, above 1.6 mm, can yield satisfactory outcomes in both the medium and long term. This study aims to analyze how preoperative vascular mapping influences the long-term RC-AVF failure, considering adherence to guidelines. Methods: This retrospective, monocentric, and observational study enrolled 110 patients with ESKD who were admitted, between 2018 and 2024, to the Vascular Surgery Department at the Emergency County Hospital of Târgu Mureș for the creation of an RC-AVF. Demographic characteristics, comorbidities, preoperative vascular mapping data, and laboratory data were meticulously collected from the hospital’s electronic databases. Patients enrolled in the current study were categorized into two groups based on their adherence to guideline recommendations. Results: Patients whose RC-AVF was created outside guideline recommendations demonstrated smaller arterial (p < 0.001) and venous (p < 0.001) diameters. Additionally, a higher percentage of these patients were on hemodialysis via CVC at the time of RC-AVF creation (p = 0.041), as well as a higher incidence of 6-week AVF maturation failure (p = 0.012) and long-term AVF failure (p = 0.016). In ROC Curve analysis, a threshold of 2.75 mm was established for the RA (AUC: 0.647, p = 0.005) and 2.52 mm for the CV (AUC: 0.677, p = 0.001). Additionally, patients whose RC-AVF procedures adhered to guideline recommendations had a significantly lower risk of long-term RC-AVF failure (HR: 0.44, p = 0.012). This association lost significance after adjusting for cardiovascular risk factors and the presence of CVC at admission (HR: 0.69, p = 0.328). After full adjustment, only the CV remained an independent predictor of long-term successful RC-AVF (HR: 0.68, p = 0.026). In contrast, RA lost significance after adjusting for cardiovascular risk factors and the presence of CVC at admission (HR: 0.71, p = 0.086). Conclusions: In conclusion, this study reveals that only the diameter of the CV is correlated with the long-term failure of RC-AVF, independent of age, gender, diabetes, hypertension, active smoking, and the presence of a CVC at the time of AVF creation. Therefore, while adhering to the threshold diameters of the AR and CV, as recommended by the ESVS guidelines, facilitates the creation of a functional RC-AVF, we assert that additional cofactors, such as demographic data, usual cardiovascular risk factors, or CVC presence, must also be considered to achieve optimal long-term AVF. Full article

Background and Objectives: Pediatric cerebral arteriovenous malformations (AVMs) are associated with significant morbidity and mortality. The aim of this study was to assess the long-term outcomes of surgical excision and stereotactic radiosurgery (SRS) of cerebral AVMs in pediatric patients. Materials and Methods: A single-center retrospective analysis was conducted using data obtained from a single medical center between January 2012 and July 2022. The Modified Rankin Scale (mRS) at admission and discharge and the Spetzler–Martin (SM) scores were analyzed. Results: Among 45 patients (mean age 11.8 years), 19 patients (42.2%) received surgical resection, with good outcomes (mRS 0–2) in 16 patients and complete obliteration in all patients. In total, 26 patients (57.8%) were managed with SRS. After 36.3 months on average, complete obliteration in 19 of 26 patients (69.2%) was confirmed. Among the 7 SRS patients without complete obliteration, 6 had residual cerebral AVMs at the last follow-up, and 1 had recurrence. All patients receiving SRS had favorable outcomes (mRS 0–1) and no apparent radiosurgery-related complications. Conclusions: In our study, the surgical resection or SRS was selected based on individual patient conditions, and the overall outcomes were satisfactory. Both surgical resection and SRS proved to be effective treatment options. Microsurgical resection demonstrated a high rate of obliteration and remains a favorable therapeutic choice with acceptable risks for pediatric AVMs. Full article

Background: Vascular access (VA) is one of the most critical procedures during dialysis for patients with end-stage renal disease (ESRD), as it influences morbidity, mortality, and quality of life. Methods: This cross-sectional study analyzed the vascular access epidemiology of patients undergoing chronic HD in 15 nephrology centers across Greece from 2013 to 2019. Data on VA type, demographic characteristics, fatigue severity, and quality of life were gathered from a sample of 373 patients. Results: The prevailing result of this study is that arteriovenous fistula (AVF) was the commonly practiced VA, and its associated survival outcomes were better when compared to arteriovenous grafts (AVGs) and central venous catheters (CVCs). Patients with AVFs had significantly longer survival times (median 165 months) compared to non-fistula access. Furthermore, the degree of fatigue and quality of life were also dependent on the type of VA used, with patients on AVF having lower fatigue levels and better quality of life. Age, gender, and an early nephrologist referral were noted to affect the selection and the rate of maturation of VA. Despite AVF being the preferred VA, late referrals and high initial reliance on CVCs remain challenges. Conclusions: This study underscores the need for early nephrological intervention, surveillance programs, and patient education to optimize vascular access outcomes. Future research should focus on national strategies to reduce CVC-related complications and improve long-term HD care in Greece. Full article

Background: A vascular access blood flow (Qa) to cardiac output (CO) ratio greater than 0.3 increases the risk of high-output heart failure (HOHF). This study analyzed the characteristics and risk factors associated with a high Qa/CO ratio and effective CO (COef) in these patients over one year. Methods: This prospective study enrolled 142 hemodialysis (HD) patients, divided by the Qa/CO ratio. Baseline and one-year hemodynamics were measured: volume by bioimpedance, CO by echocardiography, Qa and brachial flow by transonic and ultrasound. Risk factors for HOHF were analyzed using receiver operating characteristic (ROC) curves and multivariable regression. Results: The study population was 66% male, mean age of 65, with 71% using arteriovenous fistulae (AVF) for vascular access. In the high Qa/CO group, cases of younger ages (62 vs. 67 years, p = 0.040) with upper arm access (73.1% vs. 32.8%, p < 0.001) were more prevalent, and diastolic blood pressure (DBP) was higher (76.8 ± 15.1 vs. 66.7 ± 14.4 mmHg, p = 0.002). Independent risk factors for high Qa/CO were elevated DBP (odds ratio [OR]: 1.080; 95% confidence interval [CI]: 1.028–1.134), upper arm access (OR: 8.113; 95% CI: 1.842–35.741), low resistive index (RI) (OR: 0.000; 95% CI: 0.000–0.417), and COef (OR: 0.164; 95% CI: 0.065–0.416). After one year, the high Qa/CO group showed significant increases in CO and COef (4.82 ± 1.25 L/min vs. 6.16 ± 2.05 L/min, p = 0.007, and 2.84 ± 0.95 L/min to 4.40 ± 1.89 L/min, p = 0.001, respectively). A baseline Qa cutoff value of 1.4 L/min demonstrated high diagnostic efficacy in identifying the high Qa/CO group. Conclusions: High Qa/CO ratios increase overt HOHF risk due to cardiac strain. This study reveals AV access-driven cardiac adaptations in patients with high Qa/CO and low COef, emphasizing the necessity for ongoing clinical and hemodynamic monitoring. Full article

Background: Extracranial arteriovenous malformations (AVMs) are rare congenital vascular anomalies that often require endovascular treatment due to symptoms such as pain, bleeding, or functional impairment. Endovascular strategies include arterial, venous, or combined embolization approaches; however, recurrence remains a major challenge. We retrospectively evaluate the technical success, safety, and clinical outcomes of arterial-only versus combined arterial and venous embolization for the treatment of extracranial AVMs. Materials and Methods: This single-center retrospective study included 14 patients (mean age 31.8 ± 21.7 years; 64% female) with symptomatic extracranial AVMs (Schobinger stage II) treated between 2017 and 2023. AVMs were classified angiographically (Yakes classification) and treated with embolization via arterial or combined access routes. The primary endpoint was technical success (defined as angiographic nidus occlusion), while secondary endpoints included clinical recurrence and procedure-related complications. Follow-up included clinical and Doppler ultrasound assessments. Results: Nine patients (64%) underwent arterial embolization alone; five (36%) received combined arterial and venous embolization, including Lauromacrogol injection via direct puncture. Technical success was achieved in all cases (100%). Clinical recurrence occurred in two patients (14%), both from the arterial-only group. One major complication (tongue ischemia) occurred in a single patient (7%). No complications or recurrences were observed in the combined treatment group. Statistical analysis showed no significant difference in recurrence or complication rates between groups. Full article

Pulsatile tinnitus (PT) is a subtype of tinnitus characterized by a perception of heartbeat-synchronous sound. It represents approximately 5–10% of all tinnitus cases and may have either a vascular or non-vascular etiology. Accurate diagnosis is crucial due to the potentially serious implications this condition can entail. Assessment through anamnesis and physical examination may often suggest a diagnosis of PT, but it is rarely definitive. Therefore, a comprehensive and specific imaging diagnostic protocol is essential when evaluating PT. A lack of consensus has been identified regarding the use of a standardized protocol for both pulsatile and non-pulsatile tinnitus, whether unilateral or bilateral. Consequently, neuroradiologists, otologists, and otoneurologists from a tertiary hospital have developed a new imaging diagnostic protocol for PT. The aim of this article is to present an updated approach to the diagnostic and therapeutic management of PT, aiming to establish a protocol that serves as a guide for clinicians assessing this symptom. In patients with bilateral PT, systemic conditions leading to increased cardiac output should generally be ruled out; in unilateral cases, focused imaging studies should be performed to exclude organic etiologies at the cervical and cranial levels. Full article