A woman in her 60s presented to the emergency department with a 1-day history of abdominal pain. She reported acute onset of pain that woke her up from sleep, was crampy in nature, and was localized to the right upper quadrant. She denied any nausea or vomiting and there was no association with eating. She reported similar pain over the previous month but not to the current severity. There was no history of fevers/chills, diarrhea, melena, or hematochezia. She had never had a colonoscopy. Her medical history included hypertension and gastroesophageal reflux. She had no smoking or alcohol history. Her only operations in the past were nononcologic, nongastrointestinal procedures.On examination, her heart and lungs were normal. Her abdomen was soft but tender in the right upper quadrant. Laboratory evaluation revealed a normal compete blood cell count, including a white blood cell count of 8900/μL (to convert to ×10 9 per liter, multiply by 0.001). Results from a complete metabolic panel, including lipase, and from carcinoembryonic antigen and carbohydrate antigen 19-9 testing were normal. Ultrasonography revealed asymmetric thickening of the gallbladder wall without pericholecystic fluid. Computed tomographic scans of the abdomen with oral and intravenous contrast were obtained (Figure 1).Quiz at jamasurgery.com
We present the case of a 71-year-old man with critical stenosis of the innominate artery after previously undergoing bilateral carotid artery endarterectomies. We used an open retrograde approach of the right carotid artery to stent the innominate artery lesion employing the new ENROUTE Transcarotid Stent System with flow reversal.
Arterial thoracic outlet syndrome (TOS) is the least common form of TOS in adults. It is an entity that is associated with bony anomalies resulting in chronic subclavian artery compression. Most patients with arterial TOS are young adults presenting either with limb-threatening upper extremity ischemia or chronic symptoms suggestive of arterial insufficiency involving the extremity. Initial diagnostic evaluation involves chest radiography, which may reveal cervical or anomalous first rib. Catheter-based arteriography has a diagnostic as well as therapeutic role. Magnetic resonance angiography and computed tomographic angiography, which are readily available, can be used in surgical planning. Treatment involves revascularization of the extremity, subsequent first rib resection, and possible reconstruction of the subclavian artery.
This review contains 4 figures, 1 table and 45 references
Key Words: arterial complication, brachial thromboembolectomy, cervical rib, costoclavicular space, first rib resection, pectoralis minor space, scalene triangle, subclavian artery stenosis, thoracic outlet syndrome
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