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  • ISSN: 2378-9344
    Volume 4, Issue 3
    Case Report
    Patanè Domenico, Failla Giovanni, Coniglio Giovanni, Morale Walter, Seminara Giuseppe, Calcara Giacomo, Bisceglie Paola, and Malfa Pierantonio
    Central venous stenosis is a frequent complication associated with central venous catheter placement. Patients often present as asymptomatic or with "big arm" syndrome displaying evidence of superficial collateral circles associated with high venous resistance. In our case report we describe two unusual pathological conditions that contribute to the development of this set of symptoms.
    In the first case, an 85-year-old man undergoing hemodialysis treatment through distal radio-cephalic AVF in the left forearm, developed progressive upper limb edema with worsened in January 2015. A Color Doppler ultrasound (CDUS) and Computed Tomography Angiography (CTA) were performed, and which revealed focal stenosis of the venous brachiocefalic left trunk. Digital Subtraction Angiography (DSA) revealed the stenosis, and a subsequent (PTA) displayed stenting for a non-responsive recoil.
    Three months later, the patient's condition had continued to worsen and another CTA demonstrated the previously placed stent had been crushed between the anonymous arterial trunk and a bone protrusion of left sternoclavicular articulation, which had resulted from a previous fracture. Surgical treatment of the left emimanubrectomia of the sternum, and resection of the clavicle head were performed. A left upper PTA was performed with another stent positioning. In September of 2015, five months after the latest procedure, the patient developed new onset ipsilateral upper limb edema in the forearm, with patency of central venous vessels and multiple superficial collateral circles into the forearm. Further evaluation revealed exhaustion of venous superficial circulation and a steal syndrome secondary to a excessively broad shunt. It was decided to close the AVF positioning and endoprosthesis, which resulted in the complete resolution of symptoms.
    This revealed that "typical" symptoms of "big arm" syndrome may present with atypical symptoms that must be correctly identified and interpreted during diagnostic procedures before performing any surgical or endovascular treatments.
    Review Article
    Rajamma Mathew*
    The major causes of pulmonary hypertension (PH) in children are congenital heart defect (CHD) and PH associated with prematurity, respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD). Idiopathic pulmonary arterial hypertension (PAH) and PAH associated with genetic mutations are also known to manifest in the pediatric age group. This review will mainly discuss the problems encountered in the management of PAH associated with CHD, especially left to right shunts, and in PH associated with premature birth and BPD.
    Elevated homocysteine (Hcy) levels can induce several cardiovascular diseases. H-Hcy may act by indirect mechanisms, like DNA hypomethylation, or direct effect of Hcy, such as N-homocysteinylation, endothelial dysfunction, oxidative stress, inflammation, increased platelets’ aggregation or toxic action. In the first evenience, Hcy is a simple marker; in the second case, it is atrue risk factor of cardiovascular disease. Dependent on these two different mechanisms, B-vitamins supplementations able to reduce increased Hcy concentration alone, or both elevated Hcy levels and cardiovascular risk. It must be also added that, vitamins B supplementation have obtained conflicting results about the reduction of cardiovascular risk, respectively in prospective and retrospective studies. Finally, although Hcy prevalently induces arterial diseases, it has also a role in venous thrombosis. All these contrasting effects are responsible of some uncertainties regarding the pathogenesis of cardiovascular impairments, the employment of B-6-9-12 vitamins’ supplementation, and the type of antithrombotic (anti-platelets or anticoagulants) therapy to be adopted in these patients.
    Case Report
    Helbert de O. Manduca Palmiero, Ricardo Chmelnitsky Wainberg, Ricardo Lourenço Caramanti, Yair Ugalde Hernández, and Feres Eduardo Aparecido Chaddad*
    Infratentorial arteriovenous malformations are less common than supratentorial AVMs. However, there is major reported bleeding and greater morbidity and mortality in the latter. Cases of AVM during the pregnancy are uncommon.
    Case presentation: This is a case about a pregnant woman, in the third trimester, which presented seizure and decreased consciousness level. The team verified posterior fossa bleeding with obstructive hydrocephalus. We implanted external ventricular drainage, after we performed the childbirth by caesarean and then indicated microsurgery for exeresis the cerebellar AVM.
    Discussion: The relation between pregnancy and AVMs bleeding is known but uncommon. In the case presented, we treated the hydrocephalus, performed the delivery and then performed the exeresis of AVM. Microsurgery is the most indicated treatment for infratentorial AVMs. The patient presented good clinical evolution.
    Illan A*, Aires J, Ayala P, Gorospe I, Munoz J, Quintana L, Collado R, Rodriguez MA, Borrega P, Lopez de Ceballos MH, Gonzalez S, Alonso S, and Garcia-Escobar I
    Paraneoplastic hypercoagulable status is a cancer entity that affects one of every two hundred patients with cancer. We have reviewed scientific literature about this paraneoplastic syndrome. Also, there are described many cytostatic drugs that promotes thrombotic phenomena.
    We presented an oncologic patient with massive pulmonary thromboembolism in the context of tumor hypercoagulable status and cetuximab treatment.
    The presence of cancer cells in the systemic circulation generates and activates procoagulant and antifibrinolytic state, with production of pro-inflammatory cytokines (IL-1, TNF, VEGF) and interaction of cancer cells with other vascular cells (endothelial cells, platelets and monocytes).
    The relative risk of thrombosis in cancer patients is between 2 and 6. The diagnosis must be established with clinical suspicion, imaging tests and predictive scales such as Wells, Geneva and Khorana in the case of venous thromboembolic disease. On the other hand, among Cetuximab toxicities, even it’s rare; it has been described pulmonary embolism.
    In the treatment of thrombosis in cancer patients the use of LMWH is recommended in order to present less drug interactions with cytostatic and other drugs, and be easier to handle, than oral anticoagulants.
    The duration of the anticoagulation treatment if there is any potential reversible cause (curable cancer) is at least 6 months (range between 6 and 9 months is acceptable); in case of advanced malignancies or patients receiving palliative chemotherapy, maintenance anticoagulation should be indefinite.
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