Tumor cell metastasis through blood circulation is a complex process and is one of the great challenges in cancer research as metastatic spread is responsible for ∼90% of cancer-related mortality. Tumor cell intravasation into, arrest and adhesion at, and extravasation from the microvessel walls are critical steps in metastatic spread. Understanding these steps may lead to new therapeutic concepts for tumor metastasis. Vascular endothelium forming the microvessel wall and the glycocalyx layer at its surface are the principal barriers to and regulators of the material exchange between circulating blood and body tissues. The cleft between adjacent endothelial cells is the principal pathway for water and solute transport through the microvessel wall in health. This cleft has been found to be the location for tumor cell adhesion and extravasation. The blood flow-induced hydrodynamic factors such as shear rates and stresses, shear rate, and stress gradients, as well as vorticities, especially at the branches and turns of microvasculatures, also play important roles in tumor cell arrest and adhesion. This chapter first reports the current advances from in vivo animal studies and in vitro culture cell studies to demonstrate how the endothelial integrity or microvascular permeability, hydrodynamic factors, microvascular geometry, cell adhesion molecules, and surrounding extracellular matrix affect critical steps of tumor metastasis in the microcirculation. One addition of this updated chapter shows the role of glycocalyx at tumor cells in tumor cell metastasis. Another addition describes a new in vitro 3D-microchannel model for tumor metastasis in the microcirculation.
Detection of large vessel occlusions using a deep learning (DL) algorithm for the anterior circulation has shown promising results. However, the role of DL algorithms in detecting posterior circulation large vessel occlusion (PC-LVO) remains uncertain. We aimed to evaluate the diagnostic performance of a DL algorithm (Methinks PC-LVO) for detecting PC-LVO using noncontrast computed tomography. This is a retrospective, multicenter, observational cohort study that included patients with PC-LVO who underwent both noncontrast computed tomography and computed tomography angiography. The diagnostic performance of the DL algorithm was assessed by analyzing sensitivity, specificity, and area under the curve for PC-LVO detection of consecutive PC-LVO strokes. For comparative analysis, the area under the curve of the DL algorithm was also evaluated against the performance of a neuroradiologist interpreting noncontrast computed tomography. Ground truth labels were established through consensus readings by expert neuroradiologists. Subgroup analyses were performed according to clot location (proximal posterior cerebral artery and basilar artery) and National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score ≥6, NIHSS score ≥8, and NIHSS score ≥10). A total of 196 patients were included, of whom 74 patients had PC-LVO. Among these, 43 had basilar artery occlusions, and 34 had proximal posterior cerebral artery occlusions. The overall sensitivity and specificity of the software were 55.4% and 80.9%, respectively, with an area under the curve of 0.72. The neuroradiologist achieved a sensitivity of 27.4% and specificity of 91.8%. Among patients with proximal posterior cerebral artery occlusion, sensitivity was 55.9%, whereas for basilar artery occlusion, it was 53.5%. When stratified by NIHSS score ≥10, sensitivity in the proximal posterior cerebral artery was 56.2%, and for the basilar artery with NIHSS score ≥10, it increased to 61.5%. Our initial experience with a DL algorithm for the detection of PC-LVO showed promising results. However, further improvements are required before the algorithm can be implemented in clinical practice.
Hepatic encephalopathy is secondary to liver failure and is prevalent in 20%-40% of cirrhosis patients. The cause involves ammonia toxicity, gut-brain interactions, and inflammation usually involving the microbiome. The aim was to review succinct management of microbiome disturbances. The purpose includes an argument for further research into the possible selective benefit of lactose and dairy products in managing chronic hepatic encephalopathy in lactose maldigesters. Articles from 1970 to June 2025 were sought on PubMed and Google Scholar, as well as individual articles, regarding using altered microbiome and hepatic encephalopathy management. Non-digestible disaccharides and synthetic polymers, often combined with non-absorbable antibiotic rifaximin, have been found to benefit hepatic encephalopathy. It is of note that after a few reports, lactose was abandoned as a potential treatment in lactase non-persistent cirrhotic patients. After abandonment for unclear reasons, colonic adaptation in lactase non-persistent populations was clearly defined to be associated with microbiome changes similar to other non-absorbable disaccharides. While current treatment is acceptable to most patients, the potential role of lactose and dairy products likely deserves further studies in patients with lactase non-persistence. The process of colonic adaptation may favour improvement in hepatic encephalopathy by altering the bacterial milieu. Use of dairy foods could also improve nutrition in cirrhosis. As such, use of lactose or dairy products could have a wide application since cirrhosis is common in parts of the world where lactose maldigestion is also widespread. Confusion related to advanced liver disease is thought to be related to failure to detoxify urea from protein by the liver. Contributing to ammonia production are bacteria in the lower intestine, and part of the treatment is to change the microenvironment and reduce ammonia production. This article reviews agents that can do this. Standard accepted treatments include certain sugars, such as lactulose. Other ways are to treat with an antibiotic that does not get into the body's circulation and a cleansing powder used to prepare for colonoscopy. A more radical way is to use fecal transplantation from a healthy person. A major focus of this article is to re-establish a rationale for studying the possible benefits of the milk sugar lactose in those who, as adults, do not digest it due to a genetic loss of the intestinal enzyme. It has been observed that consuming regular quantities of lactose (milk and dairy products) leads to expansion of bacteria that do not produce ammonia and mimic effects of lactulose. Prior to these observations, several reports supported the potential benefit of using lactose for patients with advanced liver disease. However, all research on this ended. The reason for this was unclear. The question of why lactose was abandoned was posed to an artificial intelligence chatbot, which answered that the response was erratic and no better than lactulose. This answer did not take into consideration later findings. Since the adult inability to digest lactose affects about two thirds of the world's population, and liver disease is quite common in geographic areas of the world with predominance of this genetic trait, it would be reasonable to carry out further trials with this potential natural milk sugar on such patients with advanced liver diseases.
Mycobacterium kansasii is an exceptionally rare cause of peritoneal dialysis (PD)-related peritonitis and may present with subtle, indolent features that delay recognition. This case illustrates how "silent" atypical peritonitis can be unmasked by pairing contrast-enhanced computed tomography (CT) with CT peritoneography: the former identified nodular biopsy targets, while the latter revealed loculated dialysate flow and failure of free intraperitoneal circulation. A 20-year-old male had received automated PD for 3 years and was being evaluated for combined heart-kidney transplantation because of severe cardiomyopathy. He presented with vague abdominal discomfort, declining ultrafiltration, mild pedal edema, and weight loss. PD effluent (PDE) showed mononuclear-predominant leukocytosis (49-150 cells/µL), but repeated PDE cultures, AFB staining, and molecular testing were negative. Contrast-enhanced CT revealed multiple peritoneal nodules and omental stranding; CT peritoneography exposed a trapped contrast-containing pocket, providing functional evidence of impaired dialysate circulation. Ultrasound-guided biopsy showed necrotizing granulomatous inflammation, and tissue culture subsequently grew M. kansasii with rifampicin resistance. Because the isolate was also resistant to moxifloxacin and ciprofloxacin, fluoroquinolone-based therapy was avoided. Guided by susceptibility testing, we treated him with isoniazid, azithromycin, ethambutol, and amikacin, and the PD catheter was removed for refractory atypical mycobacterial peritonitis with progressive catheter dysfunction, prompting transition to hemodialysis. Symptoms and inflammatory markers resolved within 6 weeks; however, antimycobacterial therapy was curtailed at 165-179 days when the patient sustained an out-of-hospital sudden cardiac arrest of undetermined cause, in the setting of his severe underlying cardiomyopathy. This case adds to the limited literature on M. kansasii PD peritonitis and describes an imaging-guided diagnostic pathway in which contrast-enhanced CT localized peritoneal lesions, CT peritoneography demonstrated impaired dialysate circulation, and targeted biopsy enabled tissue diagnosis. Susceptibility-guided therapy and catheter removal were followed by clinical control of the infection, although definitive cure could not be established because follow-up ended with the patient's death. As a single case, these observations are hypothesis-generating and should not be interpreted as establishing diagnostic criteria or standard management.
Acinetobacter baumannii poses a severe global health threat due to its extensive multi-drug resistance. This review explores the evolving role of phage therapy as a promising alternative against multi-drug resistant Acinetobacter baumannii infections. We reviewed the latest key mechanisms by which phages exert their therapeutic effects, including direct lysis, biofilm disruption via depolymerases, resensitization of resistant strains to antibiotics through receptor-mediated fitness trade-offs, and the action of phage-derived enzymes such as endolysins. Recent preclinical studies have demonstrated robust efficacy, while clinical case reports and ongoing trials highlight both the potential and challenges of compassionate phage use, including emergence of phage resistance and variable patient responses. Advances in pharmacokinetic optimization, including PEGylation to enhance circulation and immune evasion, are discussed alongside synergistic phage-antibiotic combinations and novel delivery systems such as hydrogel formulations for topical applications. The review further examines emerging strategies in phage engineering and synthetic biology aimed at overcoming host-range limitations and resistance development, including chimeric lysins with enhanced outer membrane penetration and photosensitizer-conjugated phages for biofilm eradication. Finally, we highlight emerging strategies in phage engineering and synthetic biology aimed at overcoming host-range limitations and resistance development, so as the role of artificial intelligence in cocktail design and personalized therapeutics.
A 35-year-old woman taking a low-dose combined oral contraceptive (COC) for uterine fibroids presented by ambulance to a referring hospital with nausea. During the initial evaluation, she suddenly became unresponsive and developed cardiac arrest, prompting immediate cardiopulmonary resuscitation. Electrocardiography (ECG) documented ventricular fibrillation (VF), and external defibrillation restored spontaneous circulation. After return of spontaneous circulation, ECG showed ST-segment elevation in leads II, III, and aVF. She was transferred to our hospital. Emergency coronary angiography demonstrated 90% stenosis of the proximal right coronary artery (RCA) and total occlusion of the mid RCA. During percutaneous coronary intervention, VF storm occurred, necessitating initiation of veno-arterial extracorporeal membrane oxygenation. Intravascular ultrasound (IVUS) revealed a plaque-containing culprit lesion, and drug-coated balloon angioplasty was performed. Subsequent thrombophilia testing disclosed anti-β2-glycoprotein I IgG positivity, establishing antiphospholipid syndrome (APS). Notably, despite the absence of conventional risk factors (e.g. dyslipidemia, diabetes), IVUS demonstrated an atherosclerotic-appearing lesion in the prothrombotic milieu of COC use and APS. In young women, it is important to consider non-atherosclerotic causes such as antiphospholipid syndrome (APS) and combined oral contraceptive use as differential diagnoses for acute coronary syndrome. Although embolic mechanisms are often implicated in such settings, the present case demonstrated an atherosclerotic-appearing lesion on intravascular ultrasound despite the absence of conventional coronary risk factors, suggesting the possibility of APS-related vascular injury contributing to plaque formation.
Fetal echocardiography demonstrated a hyperechogenic lesion (possibly calcification) obstructing the tricuspid inflow along with hypoplasia of the right ventricle (RV) and duct-dependent pulmonary circulation. Postnatal inflow along with hypoplasia of the right ventricle (RV) and duct-dependent pulmonary circulation. Postnatal surgical exploration, only minimal antegrade flow was established. Histopathology confirmed degenerative valvar tissue with dense calcification. Eventually, due to persistent inflow restriction and inadequate RV growth, the infant underwent single-ventricle palliation (bidirectional Glenn shunt) with uneventful follow-up after the procedure. This case highlights the extreme rarity of congenital valvular calcification, its possible developmental and genetic associations, and the hemodynamic significance of inflow obstruction in causing ventricular hypoplasia.
Vascular trauma can lead to adverse outcomes if remodeling is uncontrolled. Intimal hyperplasia (IH) is a key process that contributes to luminal narrowing during remodeling and is strongly influenced by mitochondria. Enhanced mitochondrial ATP production and increased production of reactive oxygen species (ROS), along with reduced apoptosis in vascular smooth muscle cells (VSMCs), have been shown to promote IH. In addition, endothelial injury could initiate mitochondrial dysfunction and apoptosis which compromise endothelial integrity and function, leading to the exposure of VSMCs to various circulating factors, thus triggering IH. Therefore, reduction of mitochondrial ATP production, reduction of ROS, and induction of apoptosis in VSMC after vascular injury may present promising strategies in preventing IH. Conversely, promoting re-endothelialization prevents exposure of VSMCs to blood circulation. This review provides comprehensive insights from in vitro and in vivo reports of potential therapeutic strategies attempt to alleviate IH and achieve optimal outcomes.
Respiratory syncytial virus (RSV) and human metapneumovirus (hMPV) are commonly associated with respiratory tract infections (RTIs) in humans. Using national hospital and laboratory data over six seasons (2017-2023), we characterised the epidemiology of RSV and hMPV-associated RTI hospitalisations in Scotland across all age groups. We examined age distribution and estimated annual incidence rate ratios comparing RSV and hMPV hospital incidence in different age groups. Clinical severity was assessed using ICD-10 codes, length of hospital stay, ICU admissions and in-hospital case fatality. Seasonality was evaluated over the study period. This study included 13,807 RSV- and 2491 hMPV-associated RTI admissions. RSV-associated hospitalisations were generally higher than those for hMPV before RSV vaccine introduction, with the greatest differences observed in infants. Severity appeared to increase with age for both viruses and was highest in older adults, with broadly comparable outcomes between the two viruses. Before the coronavirus disease-19 (COVID-19) pandemic, RSV season generally started earlier and lasted shorter than the hMPV season. Both viruses demonstrated marked disruption of seasonal circulation during 2020/21, followed by a partial re-establishment of the winter peak. hMPV and RSV both contributed substantially to RTI-related hospitalisations in Scotland before RSV vaccine introduction. RSV accounted for a greater number of admissions, while hMPV demonstrated comparable disease severity. Children bore the greatest incidence burden, whereas older adults experienced disproportionately severe outcomes. The findings suggest that temporal patterns in RSV and hMPV circulation may have important implications for respiratory virus surveillance and seasonal healthcare preparedness. Enhanced virus-specific testing and targeted immunisation in infants and older adults could improve surveillance and reduce hospital admissions and healthcare pressures.
Long-term outcomes of paclitaxel-coated drug-coated balloons (DCBs) in patients with diabetes mellitus (DM) and infrainguinal peripheral arterial disease (PAD) are incompletely defined. In the current study, we evaluated 5-year outcomes in the diabetic cohort of BIOLUX P-III. BIOLUX P-III was a prospective, international, multicenter, post-market, single-arm study evaluating the Passeo-18 Lux DCB in routine practice. Between October 2014 and January 2017, 877 patients with infrainguinal lesions were treated at 47 centers, of whom 418 (47.7%) had DM. The primary clinical endpoint was 6-month freedom from major adverse events (MAEs), defined as freedom from procedure- or device-related death through 30 days, major target-limb amputation, or clinically driven target-lesion revascularization (CD-TLR). The primary performance endpoint was 12-month freedom from CD-TLR. Time-to-event outcomes were analyzed using Kaplan-Meier methods and the Log rank test. Among 877 treated patients, 418 had DM. Follow-up completion was 81.6%, 86.4%, 82.3%, and 31.3% at 6, 12, 24, and 60 months, respectively. At 5 years, freedom from MAE was lower in patients with DM than in those without DM (71.2% vs 74.7%; P = 0.0359), whereas freedom from CD-TLR was similar between groups (79.8% vs 79.6%; P = 0.535). Patients with DM also had lower overall survival (56.3% vs 73.8%; P < 0.0001), lower freedom from major target-limb amputation (92.4% vs 98.8%; P < 0.0001), and lower amputation-free survival (53.0% vs 73.6%; P < 0.0001). In this real-world registry, the Passeo-18 Lux DCB was associated with durable freedom from reintervention through 5 years, with similar CD-TLR rates in patients with and without DM. Patients with DM had poorer long-term survival and limb outcomes. However, these findings should be interpreted in the context of baseline between-group differences and limited 60-month follow-up (ClinicalTrials.gov number, NCT02276313). Peripheral arterial disease is a condition in which the blood vessels supplying the legs become narrowed or blocked. This can reduce blood flow, cause pain when walking, delay wound healing, and in severe cases increase the risk of amputation. People with diabetes are at especially high risk because they often have more severe artery disease and more other health problems that affect the heart, kidneys, and circulation. This study examined the long-term outcomes of a treatment called the Passeo-18 Lux drug-coated balloon in patients with leg artery disease. A drug-coated balloon is used during angioplasty to open narrowed arteries and deliver a medicine called paclitaxel to the artery wall to help reduce re-narrowing. We analyzed 877 patients treated in routine clinical practice, including 418 patients with diabetes, and followed outcomes for up to 5 years. We found that the need for repeat treatment of the same artery was similar in patients with and without diabetes. This suggests that the device performed well at the level of the treated artery over the long term. However, patients with diabetes had worse overall outcomes, including lower survival, higher rates of major amputation, and lower amputation-free survival. These findings suggest that, although the drug-coated balloon may provide durable treatment of the target lesion, long-term outcomes in patients with diabetes are also strongly influenced by the severity of their underlying disease and by other medical conditions. The results highlight the importance of not only restoring blood flow, but also providing ongoing wound care, diabetes management, cardiovascular risk reduction, and close multidisciplinary follow-up. The study has limitations. It was an observational registry rather than a randomized trial, the analyses were not adjusted for all baseline differences between groups, and follow-up was incomplete at 5 years. For these reasons, the findings should be interpreted with caution.
Carotid webs (CWs) are an increasingly recognized cause of ischemic stroke and transient ischemic attacks (TIAs), particularly in patients without an alternative clearly identified etiology, although they likely remain underdiagnosed because of their subtle radiographic appearance and the absence of significant carotid stenosis. The lesion is considered an intimal variant of fibromuscular dysplasia that may promote local blood stasis, thrombus formation, and distal cerebral embolization. We present the case of a 59-year-old woman with recurrent transient neurological deficits and initially negative stroke imaging who was ultimately diagnosed with a bilateral CW. Computed tomography angiography demonstrated bilateral thin linear filling defects at the carotid bulbs, more prominent on the left side, consistent with a CW. Magnetic resonance imaging performed using a stroke protocol showed no evidence of acute ischemic or hemorrhagic stroke. Electroencephalography was normal, and no definitive cardioembolic source was identified. Subsequent digital subtraction angiography confirmed abnormal flow dynamics involving both carotid bulbs. Balloon occlusion testing demonstrated insufficient collateral circulation, supporting the hemodynamic significance of the lesion. Given the recurrent ischemic symptoms and angiographic findings, the patient underwent endovascular carotid reconstruction with angioplasty and placement of a left internal carotid artery stent. Post-procedural angiography demonstrated improved carotid flow dynamics without complications. The patient remained neurologically stable during follow-up without recurrent cerebrovascular events. This case highlights the importance of considering CWs in patients with recurrent cryptogenic TIAs or stroke-like symptoms despite negative initial neuroimaging. Early recognition through dedicated vascular imaging may facilitate timely intervention and potentially reduce recurrent cerebrovascular events.
Early detection of renal allograft complications can prompt immediate treatment to preserve graft function. Radiological evaluation of allograft vascular supply can be achieved with the use of a multimodal approach with Doppler ultrasonography, computed tomography, or magnetic resonance imaging. Although postoperative imaging is common, no consensus exists on the relationship between type of immediate postoperative imaging and short- and long-term graft outcomes. We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. We searched the EMBASE, Medline, and Cochrane databases for studies published from January 1, 1995, to June 19, 2025. Inclusion criteria included any study that reported results of radiological imaging of the renal allograft obtained within 1 week of the renal transplant procedure. Search results showed 36 studies that met the inclusion criteria. An average of 2.76 ±2.39 days was the time between the transplant procedure and the first imaging of the transplanted graft. All included studies described the use of Doppler ultrasonography in the evaluation of the graft function, with magnetic resonance angiography and renal scintigraphy also described. In reports showing radiological measurements within 1 week, 11 studies reported a significant relationship between radiological measurements and renal function, and 12 studies reported a significant relationship between radiological measurements and delayed graft function. At the 1 year posttransplant measurements, 8 studies reported that early abnormalities shown in radiological parameters suggested deterioration in long-term renal function measurements. This systematic review demonstrated the utility of early imaging in the identification of early post-operative allograft complications.
Pulmonary embolism (PE) is a thromboembolic disorder characterized by obstruction of the pulmonary arterial circulation, most commonly due to embolization of thrombi originating from the deep venous system of the lower extremities. Massive PE is a critical condition marked by hemodynamic instability not caused by a new arrhythmia, cardiogenic shock, or circulatory collapse. The patient is a 28-year-old male with no significant medical history who arrived at the Emergency Department with a self-inflicted neck wound. He received initial treatment, including securement of the airway, antibiotics, analgesia, and suturing. After neck exploration and tracheal repair, he was diagnosed with MRSA and ESBL + Klebsiella pneumoniae and treated with IV antibiotics. After 17 days of admission, the patient was discharged home but returned the same day with hypotension, shortness of breath, chest pain, and shock, with hypoxia. Point-of-care ultrasound (POCUS) revealed right ventricular dilatation suggestive of PE, which was finally confirmed with further testing. Echocardiogram confirmed substantial right ventricular and right atrial dilation with an estimated pulmonary artery pressure of 53 mm Hg and a positive McConnell's sign. In conclusion, cardiac POCUS is a non-invasive, quick, and cost-effective imaging technique used in emergency settings to diagnose PE by identifying PE markers. This case report underscores the importance of POCUS in promptly diagnosing PE, emphasizing its role in preventing fatal outcomes due to delayed diagnosis.
A 58-year-old man presented with out-of-hospital cardiac arrest. The initial rhythm was pulseless electrical activity, which deteriorated into ventricular fibrillation during resuscitation. After return of spontaneous circulation, electrocardiography demonstrated diffuse ST-segment depression with ST-segment elevation in lead aVR, strongly suggesting acute coronary syndrome. Emergent coronary angiography revealed simultaneous angiographic occlusion with TIMI 0 flow in the ostial left anterior descending artery and distal right coronary artery. During preparation for percutaneous coronary intervention, coronary flow spontaneously recovered to TIMI 3 without balloon dilation, stenting, or intracoronary vasodilator administration. Intravascular ultrasound demonstrated no plaque rupture or thrombus. Persistent coma prompted neuroimaging, which revealed diffuse subarachnoid hemorrhage with hydrocephalus. Although cardiac arrest associated with subarachnoid hemorrhage usually presents with non-shockable rhythms, this case demonstrated recurrent ventricular fibrillation and transient multivessel coronary occlusion closely mimicking acute myocardial infarction.
Trauma-induced arteriovenous fistulas of the plantar artery are exceedingly rare. Although they may initially remain asymptomatic, progressive shunt flow can, over time, result in venous hyperperfusion and congestion. Definitive treatment requires closure of the fistula to restore physiological venous circulation. Endovascular embolization is the primary, minimally invasive treatment and is effective in achieving thrombosis and symptom control in many cases. In the present case, endovascular coil embolization was insufficient, and surgical closure of a chronic arteriovenous fistula of the lateral plantar artery proved to be a reliable and promising treatment alternative.
Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac anomaly. Most affected infants develop significant symptoms shortly after birth and require early intervention to improve survival. However, a small subset of patients develops extensive collateral circulation, which may mask myocardial ischemia and, in very rare cases, allow them to reach adulthood without obvious cardiac symptoms. We report such a case in which a patient presented with mild chest discomfort during a routine examination at our hospital. Multimodality imaging, including echocardiography and contrast-enhanced computed tomography (CT), three-dimensional CT reconstruction, confirmed the diagnosis of ALCAPA syndrome. The patient subsequently underwent Takeuchi repair, preventing future adverse cardiovascular events or chronic left ventricular dysfunction.
Peripherally inserted central catheters (PICCs) are commonly used for prolonged intravenous therapies, particularly in oncology patients requiring chemotherapy. Although generally safe, PICC-related complications such as catheter fracture and embolization are rare but potentially life-threatening conditions requiring urgent intervention. We report a rare case of PICC line fracture with embolization into the bilateral pulmonary arteries in a 57-year-old female undergoing chemotherapy for esophageal carcinoma at a private hospital in Dar es Salaam, Tanzania. The patient was asymptomatic, and chest computed tomography demonstrated a fractured PICC line looped within the right and left pulmonary arteries. Endovascular retrieval was initially attempted through a femoral venous approach using balloon-assisted mobilization and snare techniques; however, both strategies failed because the catheter lacked an accessible free end. Following A stepwise dual-access approach was subsequently performed using pigtail catheter-assisted repositioning of the fragment into the inferior vena cava followed by successful snare retrieval through the right internal jugular vein. The catheter was retrieved intact without procedural or cardiopulmonary complications. The patient was monitored for 24 hours postprocedure and subsequently discharged, with continued oncology admission for advanced metastatic disease unrelated to the PICC complication. This case demonstrates the feasibility of stepwise dual-access endovascular techniques for retrieval of complex embolized PICC fragments from the pulmonary circulation, particularly in resource-constrained settings.
Chorioangiomas are associated with a significant risk of fetal demise due to high-output cardiac failure. Standard invasive treatment, including fetoscopic laser photocoagulation and intratumoral embolization, shows limited success and has high fetal mortality rates. The biological parallels between chorioangiomas and infantile hemangiomas suggest that these tumors may share common therapeutic targets. Propranolol is a proven therapy for infantile hemangiomas, therefore this established efficacy provides a strong rationale for its consideration in the management of symptomatic or rapidly growing placental chorioangiomas. We hypothesized that maternal oral propranolol administration could selectively target placental chorioangiomas while preserving overall placental function, thereby offering a potential off-label therapeutic use of the drug. We report a case series of four fetuses that presented to Leiden University Medical Center, Leiden, The Netherlands, between December 2023 and May 2025 with a large chorioangioma and signs of fetal decompensation, varying from hyperdynamic circulation to evolving hydrops, and were treated with maternal propranolol. In all four cases, the fetal condition improved significantly upon propranolol treatment, with normalization of cardiac function and resolution of hydrops, paralleled by tumor regression and thrombosis confirmed histologically. These findings support a shift in the clinical management of chorioangiomas to improve fetal outcomes while minimizing procedural risks. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Pulmonary arteriovenous malformations (PAVMs) are rare vascular anomalies that create a right-to-left intrapulmonary shunt, allowing embolic material to bypass the pulmonary capillary filter and enter the systemic circulation. This predisposes affected individuals to paradoxical embolic events, including transient ischaemic attack and ischaemic stroke. Although uncommon, PAVMs represent an important and potentially treatable cause of cryptogenic stroke in young adults.We report a young woman in her early 20s with a 4-year history of intermittent central cyanosis, digital clubbing and exertional dyspnoea who presented with transient perioral paraesthesia, dysarthria and aphasia. Brain MRI demonstrated subacute infarcts in the right paraventricular region and a lacunar infarct in the left caudate nucleus. In the context of chronic hypoxaemia and clinical features of right-to-left shunt physiology, a paradoxical embolic mechanism was suspected.CT pulmonary angiography revealed multiple PAVMs, which were successfully treated with transcatheter embolisation, resulting in normalisation of oxygen saturation.
Transcatheter Fontan is an alternative palliation in severely hypoxic univentricular hearts at high-risk for Fontan surgery. While sternotomy, prolonged intubation, and positive-pressure ventilation impede passive systemic venous return, transcatheter Fontan allows early extubation and mobilization to promote inspiratory venous return, additionally aided by the skeletal muscle pump. Following puncture of the pulmonary artery (PA) and atrium through the transverse pericardial sinus, a long-covered stent bridges the inferior vena cava to the PA. Concurrent interventions create wide inter-atrial communication, interrupt competitive aortopulmonary or antegrade flows, and relieve PA stenosis. This case series details such interventions to facilitate optimal hemodynamics after establishing neo-Fontan circulation.