Device closure of fistula from left lower pulmonary artery to left atrium using a vascular plug:A case report

BACKGROUND Pulmonary artery-to-left atrial fistula is a variant of pulmonary arteriovenous fistula and is a developmental anomaly.Delayed presentation,cyanosis and effort intolerance are some of the important features.The diagnosis is confirmed by computed tomography or pulmonary artery angiography.Catheter-based closure is preferred to surgery.CASE SUMMARY Left pulmonary artery-to-left atrial fistula is rare.A 40-year-old male presented with effort intolerance,central cyanosis,and recurrent seizures.He had a large and highly tortuous left pulmonary artery-to-left atrial fistula associated with a large aneurysmal sac in the course.Catheter-based closure was performed using a vascular plug.CONCLUSION Left pulmonary artery-to-left atrial fistula is relatively uncommon compared to right pulmonary artery-to-left atrial fistula.Percutaneous closure by either a transeptal technique or guide wire insertion into the pulmonary vein through the pulmonary artery is preferred.The need for an arteriovenous loop depends on the tortuosity of the course of the fistula and the size of the device to be implanted because a larger device needs a larger sheath,necessitating firm guide wire support to facilitate negotiation of the stiff combination of the delivery sheath and dilator.

Prevalence and Characteristics of Treatment-Resistant Hypertension among Hypertensive Japanese Outpatients

Aims: To retrospectively investigate the prevalence and characteristics of treatment-resistant hypertension (R-HT) among consecutive hypertensive outpatients, since patients with R-HT are candidates for catheter-based renal sympathetic denervation (RD). Methods: Consecutive hypertensive outpatients (n = 999) were recruited in our hospital. R-HT patients who were candidates for RD had clinic systolic blood pressure > 160 mmHg despite taking three or more antihypertensive drugs including at least one diuretics at higher than standard doses. Results: Our survey indicated that only 26 patients (2.6%) were potential candidates for renal denervation. Candidates for RD showed a significantly higher age (P < 0.005), brain natriuretic peptide level (P = 0.0001), urinary albumin/creatinine excretion ratio in spot urine (P < 0.005), pulse wave velocity (P < 0.01), left ventricular end-diastolic diameter (P < 0.005), and interventricular septal thickness (P < 0.005) than the other 973 patients. Candidates for denervation had a significantly lower hemoglobin (P = 0.0001), serum albumin (P < 0.001), eGFR (P < 0.0005), plasma renin activity (P = 0.0001), and plasma aldosterone level (P < 0.005) than other patients, while their urinary sodium/creatinine ratio was higher, indicating that patients with R-HT appeared to have a high salt intake. Conclusion: Our retrospective clinical survey indicated that only 0.5% of Japanese hypertensive outpatients (5/999 patients) were candidates for RD. Therefore, establishment of hypertension cohort network will be essential to recruit R-HT patients for RD.

Safety and Efficacy of Low Dosage of Urokinase for Catheter-directed Thrombolysis of Deep Venous Thrombosis

Background： Catheter-directed thrombolysis （CDT） has been a mainstay in treating deep venous thrombosis （DVT）. However, the optimal dosage ofa thrombolytic agent is still controversial. The goal of this study was to evaluate the safety and efficacy of low dosage urokinase with CDT for DVT. Methods： A retrospective analysis was perfornaed using data from a total of 427 patients with DVT treated with CDT in our single center between July 2009 and December 2012. Early efficacy of thrombolysis was assessed with a thrombus score based on daily venography. The therapeutic safety was evahmted by adverse events. A venography or duplex ultrasound was performed to assess the outcome at 6 months, 1 year and 2 years postoperatively. Results： The mean total dose of 3.34 （standard deviation [SD] 1.38） million units of urokinase was administered during a mean of 5.18 （SD 2.28） days. Prior to discharge, Grade Ⅲ （complete lysis） was achieved in 154 （36%） patients; Grade II （50-99% lysis） in 222 （52%）： and Grade I （50%~ lysis） in 51 （12%）. The major complications included one intracranial hemorrhage, one henaatochezia, five gross hematuria, and one pulmonary embolism. Moreover, no death occurred in the study. Conclusions： Treatment of low-dose catheter-directed thrombosis is an efficacious and safe therapeutic approach in patients with DVT offering good long-term outcomes and minimal complications.