Bilateral vs unilateral placement of metal stents for inoperable highgrade hilar biliary strictures: A systemic review and meta-analysis

BACKGROUND Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction.No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting.AIM To assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction.METHODS PubMed,Embase,Scopus,and Cochrane databases,as well as secondary sources(bibliographic review of selected articles and major GI proceedings),were searched through January 2019.The primary outcome was the re-intervention rate.Secondary outcomes were a technical success,early and late complications,and stent malfunction rate.Pooled odds ratio(OR)and 95%confidence interval(CI)were calculated for each outcome.RESULTS A total of 9 studies were included(2 prospective Randomized Controlled Study,5 retrospective studies,and 2 abstracts),involving 782 patients with malignant hilar obstruction.Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage(OR=0.59,95%CI:0.40-0.87,P=0.009).There was no difference in the technical success rate(OR=0.7,CI:0.42-1.17,P=0.17),early complication rate(OR=1.56,CI:0.31-7.75,P=0.59),late complication rate(OR=0.91,CI:0.58-1.41,P=0.56)and stent malfunction(OR=0.69,CI:0.42-1.12,P=0.14)between bilateral and unilateral stenting for malignant hilar biliary strictures.CONCLUSION Bilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures,with no significant difference in technical success,and early or late complication rates.

Magnetic resonance imaging in assessment of stress urinary incontinence in women: Parameters differentiating urethral hypermobility and intrinsic sphincter deficiency

AIM: To define the magnetic resonance imaging(MRI) parameters differentiating urethral hypermobility(UH) and intrinsic sphincter deficiency(ISD) in women with stress urinary incontinence(SUI).METHODS: The static and dynamic MR images of 21 patients with SUI were correlated to urodynamic(UD) findings and compared to those of 10 continent controls. For the assessment of the urethra and integrity of the urethral support structures, we applied the highresolution endocavitary MRI, such as intraurethral MRI, endovaginal or endorectal MRI. For the functional imaging of the urethral support, we performed dynamic MRI with the pelvic phased array coil. We assessed the following MRI parameters in both the patient and thevolunteer groups:(1) urethral angle;(2) bladder neck descent;(3) status of the periurethral ligaments,(4) vaginal shape;(5) urethral sphincter integrity, length and muscle thickness at mid urethra;(6) bladder neck funneling;(7) status of the puborectalis muscle;(8) pubo-vaginal distance. UDs parameters were assessed in the patient study group as follows:(1) urethral mobility angle on Q-tip test;(2) Valsalva leak point pressure(VLPP) measured at 250 cc bladder volume; and(3) maximum urethral closure pressure(MUCP). The UH type of SUI was defined with the Q-tip test angle over 30 degrees, and VLPP pressure over 60 cm H2 O. The ISD incontinence was defined with MUCP pressure below 20 cm H2 O, and VLPP pressure less or equal to 60 cm H2 O. We considered the associations between the MRI and clinical data and UDs using a variety of statistical tools to include linear regression, multivariate logistic regression and receiver operating characteristic(ROC) analysis. All statistical analyses were performed using STATA version 9.0(Stata Corp LP, College Station, TX).RESULTS: In the incontinent group, 52% have history of vaginal delivery trauma as compared to none in control group(P < 0.001). There was no difference between the continent volunteers and incontinent patients in body habitus as assessed by the body mass index. Pubovaginal distance and periurethral ligament disruption are significantly associated with incontinence; periurethral ligament symmetricity reduces the odds of incontinence by 87%. Bladder neck funneling and length of the suprapubic urethral sphincter are significantly associated with the type of incontinence on UDs; funneling reduced the odds of pure UH by almost 95%; increasing suprapubic urethral sphincter length at rest is highly associated with UH. Both MRI variables result in a predictive model for UDs diagnosis(area under the ROC = 0.944). CONCLUSION: MRI may play an important role in assessing the contribution of hypermobility and sphincteric dysfunction to the SUI in women when considering treatment options.

Imaging pitfalls of pancreatic serous cystic neoplasm and its potential mimickers

The aim of this article is to clarify diagnostic pitfalls of pancreatic serous cystic neoplasm(SCN) that may result in erroneous characterization. Usual and unusual imaging findings of SCN as well as potential SCN mimickers are presented. The diagnostic key of SCN is to look for a cluster of microcysts(honeycomb pattern), which may not be always found in the center. Fibrosis in SCN may be mistaken for a mural nodule of intraductal papillary mucinous neoplasm(IPMN). The absence of cyst wall enhancement may be helpful to distinguish SCN from mucinous cystic neoplasm. However, oligocystic SCN and branch duct type IPMN may morphologically overlap. In addition, solid serous adenoma, an extremely rare variant of SCN, is difficult to distinguish from neuroendocrine tumor.

Mid-Term Preliminary Results for Safety and Patency of the Occlutech Atrial Flow Regulator in an Animal Model

Objective:The Atrial Flow Regulator(AFR)is a double disc device made of self-expanding Nitinol wire mesh,structured around a central lumen.Once deployed via the transfemoral route,the device stents the atrial septum leaving a preselected fixed diameter atrial communication.We sought to evaluate the mid-term performance of the AFR by implanting the device in 5 healthy porcine hearts to assess safety and patency of the device fenestration over a period of 150 days.Method:Five AFR devices were implanted in 5 female Yucatan adult minipigs.The animals were survived to 150 days with periodic assessments at days+3,+30,+60,+90,+120,and+150.These assessments consisted of transesophageal echocardiography and fluoroscopic evaluation.The animals were sacrificed at day+150.Histological and pathological assessments were carried out to characterize neointimal tissue growth,inflammation,thrombus formation,endothelial coverage,endothelial maturity,and the presence of any luminal thrombus.Result:There were no unscheduled deaths.Patency was maintained in all 5 animals across the 150-day study.There was no statistically significant difference in the lumen diameter over the study duration.Neointimal growth was mild to moderate in all specimens and occurred mostly on the surfaces of the device in direct contact with the atrial septum.There was no evidence of any significant inflammatory response on routine blood work or by imaging or histological assessment.Scanning electron microscope(SEM)examination showed nearly complete surface coverage with endothelial tissue.The animals were in a healthy condition for the duration of the study with no attributable pathology and no adverse effects noted on distant organs in any of the 5 animals.Conclusion:As a continuation of our earlier work,this 150-day midterm animal study provides important safety and feasibility information.Our preliminary results show that the AFR is both safe and effective in maintaining a sustainable atrial level communication for the duration of the study.

MEASUREMENT OF AMPLITUDE AND DELAY OF STIMULUS FREQUENCY OTOACOUSTIC EMISSIONS

Although stimulus frequency otoacoustic emissions (SFOAEs) have been used as a non-invasive measure of cochlear mechanics, clinical and experimental application of SFOAEs has been limited by difficulties in accurately deriving quantitative information from sound pressure measured in the ear canal. In this study, a novel signal processing method for multicomponent analysis (MCA) was used to measure the amplitude and delay of the SFOAE. This report shows the delay-frequency distribution of the SFOAE measured from the human ear. A low level acoustical suppressor near the probe tone significantly suppressed the SFOAE, strongly indicating that the SFOAE was generated at characteristic frequency locations. Information derived from this method may reveal more details of cochlear mechanics in the human ear.

Spontaneous coronary artery dissection:A review of diagnostic methods and management strategies

Spontaneous coronary artery dissection(SCAD)is a rare non-atherosclerotic cause of acute coronary syndromes defined as non-iatrogenic,non-traumatic separation of the coronary artery wall.The most common profile is a middle-aged woman between 44 and 53 years with few cardiovascular risk factors.SCAD is frequently linked with predisposing factors,such as postpartum,fibromuscular dysplasia or other vasculopathies,connective tissue disease and hormonal therapy,and it is often triggered by intense physical or emotional stress,sympathomimetic drugs,childbirth and activities increasing shear stress of the coronary artery walls.Patients with SCAD usually present at the emergency department with chest discomfort,chest pain,and rapid heartbeat or fluttery.During the last decades,the most common problem of SCAD was the lack of awareness about this condition which has led to significant underdiagnosis and misdiagnosis.However,modern imaging techniques such as optical coherence tomography,intravascular ultrasound,coronary angiography or magnetic resonance imaging have contributed to the early diagnosis of the disease.Treatment of SCAD remains controversial,especially during the last years,where invasive techniques are being used more often and in more emergent cardiac syndromes.Although conservative treatment combining aspirin and betablocker remains the recommended strategy in most cases,revascularization could also be suggested as a method of treatment in specific indications,but with a higher risk of complications.The prognosis of SCAD is usually good and long-term mortality seems to be low in these patients.Follow-up should be performed on a regular basis.

Schwannomas provide insight into the role of p75^(NTR) and merlin in Schwann cells following nerve injury and during regeneration

Peripheral nerve injury leads to Wallerian degeneration of severed axons,leaving the Schwann cell（SC）sheath behind.Denervated SCs may then either survive and remyelinate a regenerating axon,or they may undergo cell death.Because SCs provide trophic support and guidance cues to regenerating nerve fibers,SC loss severely hampers nerve regeneration（Hall,1986）.

Modern imaging of the tracheo-bronchial tree

Recent state-of-the-art computed tomography and improved three-dimensional(3-D) postprocessing techniques have revolutionized the capability of visualizing airway pathology,offering physicians an advanced view of pathology and allowing for appropriate management planning.This article is a comprehensive review of trachea and main bronchi imaging,with emphasis on the dynamic airway anatomy,and a discussion of a wide variety of diseases including,but not limited to,congenital large airway abnormalities,tracheobronchial stenoses,benign and malignant neoplasms and tracheobronchomalacia.The importance of multiplanar reconstruction,3-D reconstruction and incorporation of dynamic imaging for non-invasive evaluation of the large airways is stressed.

Relationship between HER-2 overexpression and brain metastasis in esophageal cancer patients

AIM:To study if HER-2 overexpression by locally advanced esophageal cancers increase the chance of brain metastasis following esophagectomy.METHODS:We retrospectively reviewed the medical records of esophageal cancer patients who underwent esophagectomy at University of Iowa Hospitals and Clinics between 2000 and 2010.Data analyzed consisted of demographic and clinical variables.The brain metastasis tissue was assayed for HER-2 overexpression utilizing the FDA approved DAKO Hercept Test.RESULTS:One hundred and forty two patients were reviewed.Median age was 64 years(36-86 years).Eighty eight patients(62%) received neoadjuvant chemoradiotherapy.Pathological complete and partial responses were achieved in 17(19%) and 71(81%) patients.Cancer relapsed in 43/142(30%) patients.The brain was the first site of relapse in 9/43 patients(21%,95% CI:10%-36%).HER-2 immunohistochemistry testing of the brain metastasis tissue showed that 5/9(56%) cases overexpressed HER-2(3+ staining).CONCLUSION:HER-2 overexpression might be associated with increased risk of brain metastasis in esophageal cancer patients following esophagectomy.Further studies will be required to validate this observation.

Mental and physical symptoms associated with lower social support for patients with hepatitis C

AIM: To systematically examine the impact of the hepatitis C virus (HCV) diagnosis on patients' level of social support in a large-scale study. METHODS: Patients evaluated and treated for HCV in a tertiary referral center were enrolled in a cross-sectional study. Demographic data, functional and emotional status as measured by the Hospital Anxiety and Depression Scale (HAD) and the Sickness Impact Profile (SIP), severity of liver disease, mode of acquisition, and physical and psychiatric comorbidities were collected from patients or abstracted from the medical record. All participants completed a semi-structured interview, addressing questions of social support. RESULTS: A total of 342 patients (mean age 45.2 years; 37% women) were enrolled. Ninety-two (27%) patients described lower levels of support by family and friends. Nearly half of the participants (45%) noted the loss of at least one relationship due to the disease. Fears related to transmitting the disease (25%) were common and often associated with ignorance or even discrimination by others (19%). Nearly one fifth of the patients did not share information about their disease with others to avoid being stigmatized. Lower levels of social support were significantly associated with living alone, being unemployed, being excluded from antiviral therapy, having psychiatric comorbidities, contracting HCV through intravenous drug use, having high levels of anxiety and depression as measured by the HAD and negative mood state as measured by the SIP. Patients reporting lower levels of social support also noted more physical symptoms as measured by the SIP. CONCLUSION: Patients with hepatitis C often face significant social problems, ranging from social isolation to familial stress. The most common concerns reflect a limited insight of patients and their relatives and friends about the disease, the risk factors for its spread, and about potential consequences. Our data suggest that educational interventions targeting support persons and the stressors identified in our findings may lessen or alleviate the social strains patients with hepatitis C experience.

Utility of endoscopic ultrasound in pancreatitis:A review

The close proximity of the endoscopic ultrasound probe to the pancreas results in superior spatial resolution compared to CT scan and MRI. In addition, endoscopic ultrasound (EUS) is a minimally invasive procedure that does not share the relatively high complication rate of ERCP. Due to these advantages, EUS has evolved into an important technique to assess pancreatobiliary disease. This review will discuss the role of EUS in patients with pancreatitis. The indications can be divided into acute pancreatitis and chronic pancreatitis. In acute pancreatitis, EUS is used to determine the etiology; in suspected chronic pancreatitis it is helpful to establish the diagnosis. Lastly, this review will discuss biliary pancreatitis with suspicion for persistent choledocholithiasis.

Giant idiopathic renal arteriovenous fistula managed by coils and amplatzer device:Case report and literature review

An idiopathic renal arteriovenous(AV) fistula is a rare malformation of the kidney that may present insidiously with heart failure or hematuria.The treatment may be challenging due to large fistula size that may limit endovascular management.The authors report a case of an 85-year-old Caucasian woman who presented with acute heart failure and was found to have a right renal AV fistula.Since she had no prior history of renal intervention or trauma,a diagnosis of idiopathic renal AV fistula was made.She was managed by endoluminal occlusion using multiple stainless steel coils and Amplatzer vascular plug II device.The follow-up computed tomography showed complete occlusion of the fistula.This report highlights the late presentation of this rare disease and presents the utility of the combination of coils and Amplatzer device for management of a large fistula.It also reiterates that even if large,these fistulas can be managed by endovascular occlusion.

Trends in the rates of hospitalizations for acute stroke among patients over 90 years of age with atrial fibrillation in the United States： from 2005 to 2014

Background Acute stroke （AS） rates in patients over 90 years of age （very elderly） with atrial fibrillation （AF） in the United States（US） are not known. We assessed trends in hospitalizations for AS among very elderly with AF in the US from 2005 to 2014. Methods Weused the nationwide inpatient sample （NIS） from the USA; 2005-2014. AF and AS diagnoses were abstracted using international classifica-tion of diseases, 9th Revision, clinical modification （ICD-9-CM） codes. Results From 2005 to 2014, 3,606,073 hospitalizations of veryelderly with AF were reported. Of these, 188,948 hospitalizations （141,822 hospitalizations in women and 47,126 hospitalizations in men）had AS as the primary diagnosis. Age adjusted AS hospitalizations increased in the total cohort （3217/million in 2005 to 3871/million in2014）, in women （3540/million in 2005 to 4487/million in 2014） and in men （2490/million in 2005 to 3173/million in 2014） （P 〈 0.001）.Anticoagnlation rates increased in women （8% in 2005 to 19.9% in 2014） and in men （8.9% in 2005 to 21.6% in 2014）. AS rates, thoughnumerically lower than the total cohort, showed an increasing trend in anticoagnlated patients as well （all anticoagulated patients： 212/millionin 2005 to 513/million in 2014; anticoagulated women： 224/million in 2005 to 529/million in 2014, anticoagnlated men： 184/million in 2005to 518/million in 2014）. Conclusions There is an increasing trend in AS hospitalizations among nonagenarians with AF in the US despiteimproving utilization of anticoagulants in this patient population. The etiologies driving this alarming trend are unclear and require fur-ther study.

A Study of Quasi-Monochromatic X-Ray Sources for Breast Cancer Early Detection

Objectives: Early detection and treatment provide the opportunity to decrease the mortality rate from breast cancer. Quasi-monochromatic technique can enhance low contrast lesion detection by eliminating beam-hardening artifacts. We hypothesized that this technique would be feasible and can be used to assist in breast cancer early detection. Methods: The performance of stationary Digital Breast Tomosynthesis with quasi-monochromatic X-ray sources was evaluated using both simulated and physical phantoms. Normalized spectra in the fraction of total photons vs. photon energy were generated. Results: As expected, the peaked energies from sources, from smallest to largest, are Mo/Mo, W/Ag-1000, and W/Ce-10, W/Ce-100. For contrast vs. noise standard deviation on the simulated CIRS phantom, W/Ce-100 and W/Ce-10 have similar performance on both low and high contrast objects. For low contrast object, W/Ce-100 is barely noticeably better than W/Ce-10, and they are better than both W/Ag-1000 and Mo/Mo. For high contrast objects W/Ce-10 is slightly better than W/Ce-100. The spectra of the implemented W/Ce-10 X-ray source were measured, which matched the simulation well. The contrast noise ratios of reconstructed objects in American College of Radiology mammographic phantom with and without using W/Ce-10 combination are 7.1 and 5.4, respectively. Conclusions: The combination of stationary digital breast tomosynthesis and quasi-monochromatic technique can compensate the loss of X-ray flux due to heavy K-edge filtering. This technique can enable the stationary DBT scanners to operate at acceptable scanning times with better low contrast lesion detectability. Advances in Knowledge: The stationary digital breast tomosynthesis can provide high quality images within short scanning time by using X-ray source array, which makes quasi-monochromatic technique feasible.

恶性胶质瘤的治疗：综合方案的进展

第一部分 中枢神经系统肿瘤（central nerous system tumors） 一、流行病学特征（epidemiological features） 中枢神经系统原发肿瘤，从高度恶性胶质瘤和原始神经外胚层肿瘤到良性脑膜瘤、神经瘤及垂体腺瘤，可表现出不同的生物学行为。根据来自美国脑肿瘤注册中心（Central Brain Tumor Registry of the United States，CBTRUS）的最新报告，每年新诊断的原发脑恶性肿瘤的人数为7．30／10万人。美国脑肿瘤注册中心2005年报告新诊断的中枢神经系统原发肿瘤患者为21690例，死亡12760例。胶质瘤占神经系统原发肿瘤的42％，占恶性肿瘤的77％。胶质瘤起源于不同的组织类型，包括少突胶质细胞瘤、星形细胞瘤、混合型少突星形细胞瘤，表现为不同的恶性程度，而且均具有向高度恶性转化的趋势，其中多形性胶质母细胞瘤（glioblasto mamultiforme，GBM）为成人中最常见的并具有浸润性的原发脑肿瘤。

Hepatocellular carcinoma: From diagnosis to treatment

Hepatocellular carcinoma(HCC) is the sixth most prevalent malignancy worldwide and is a rising cause of cancer related mortality. Risk factors for HCC are well documented and effective surveillance and early diagnosis allow for curative therapies. The majority of HCC appears to be caused by cirrhosis from chronic hepatitis B and hepatitis C virus. Preventive strategies include vaccination programs and anti-viral treatments.Surveillance with ultrasonography detects early stage disease and improves survival rates. Many treatment options exist for individuals with HCC and are determined by stage of presentation. Liver transplantation is offered to patients who are within the Milan criteria and are not candidates for hepatic resection. In patients with advanced stage disease, sorafenib shows some survival benefit.

Chronic hepatitis E: A brief review

Hepatitis E viral infection has traditionally been considered an acute, self-limited, water borne disease similar to hepatitis A, endemic to developing countries. However, over the past decade, zoonotic transmission and progression to chronicity in human patients has been identified, resulting in persistently elevated transaminase levels, progressive liver injury and cirrhosis. In addition to liver injury, neurological, renal and rheumatological manifestations have also been reported. Chronic hepatitis E occurs mainly in immunosuppressed individuals such as transplant recipients, human immunodeficiency virus patients with low CD4 counts and in patients with hematological malignancies receiving chemotherapy. Diagnosis is established by persistent elevation of hepatitis E virus RNA in the stool or serum. This population often requires treatment with antiviral agents, particularly ribavirin, as spontaneous clearance with reduction in immunosuppression occurs only in about a third of the patients. The purpose of this review, is to further discuss the clinical presentation, and recent advances in diagnosis, treatment and prophylaxis of chronic hepatitis E.

Safety of tirofiban and dual antiplatelet therapy in treating intracranial aneurysms

Background Endovascular treatment of intracranial aneurysms usually involves stent-assisted coiling(SAC)and flow diverters.Glycoprotein IIb/IIIa inhibitors such as tirofiban and dual antiplatelet therapy(DAPT)are required to prevent thromboembolic complications afterwards.We sought to determine the safety of tirofiban and DAPT in these cases.Methods We conducted a retrospective analysis of our database for patients with intracranial aneurysms who underwent SAC or flow diversion.The tirofiban-DAPT protocol used is described.Data regarding duration of infusion,placement of external ventricular devices(EVDs),complications,haemoglobin levels and platelet count before and 24 hours after antiplatelet therapy were collected and analysed.results One-hundred and forty-one patients with 148 aneurysms/procedures were included.110 aneurysms were treated acutely and 38 electively.Minor and major haemorrhagic events were recognised in 20%(30/148)aneurysms.Only 5(3.4%)intracerebral haemorrhages were symptomatic:3 cortical/SAH and 2 EVD-related.The average blood volume in symptomatic haemorrhages was 24.8 cc versus 5.42 cc in asymptomatic haemorrhages(p=0.002).The rate of EVD-related haemorrhages was 15.7%(19/121)and only 2(1.7%)were symptomatic.Most haemorrhagic events occurred in ruptured aneurysms(90.1%,p=0.01).No significant change in platelet count or haemoglobin levels before and 24 hours after administration of tirofiban and DAPT was documented.Concomitant administration of heparin did not increase haemorrhagic events.Conclusion The use of the GP IIb/IIIa inhibitors tirofiban and DAPT in this series was safe.Tirofiban and DAPT did not affect platelet count or haemoglobin levels and did not increase rate of symptomatic haemorrhages or thromboembolic complications.

Stroke mechanisms and outcomes of isolated symptomatic basilar artery stenosis

background While diffuse atherosclerotic disease affecting the posterior circulation has been described extensively,the prevalence,natural history and angiographic characteristics of isolated symptomatic basilar artery stenosis(ISBAS)remain unknown.Methods We reviewed our prospective institutional database to identify patients with≥50% symptomatic basilar artery(BA)stenosis without significant atherosclerotic burden in the vertebral or posterior cerebral arteries.Stroke mechanism,collateral circulation,and degree and length of stenosis were analysed.The primary outcome was time from index event to new transient ischaemic attack(TIA),acute ischaemic stroke(AIS)or death.Other outcome variables included modified Rankin Scale(mRS)score on discharge and last follow-up.results Of 6369 patients with AIS/TIA,91(1.43%)had ISBAS.Seventy-three(80.2%)patients presented with AIS and 18(19.8%)with TIA.Twenty-nine(31.9%)were women and the median age was 66.8±13.6 years.The mean follow-up time was 2.7 years.The most common stroke mechanism was artery-to artery thromboembolism(45.2%),followed by perforator occlusion(28.7%)and flow-dependent/hypoperfusion(15.1%).The percentage of stenosis was lower in patients who had favourable outcome compared with those with mRS 3-6 on discharge(78.3±14.3 vs 86.9±14.5,p=0.007).Kaplan-Meier curves showed higher recurrence/death rates in patients with≥80% stenosis,mid-basilar location and poor collateral circulation.Approximately 13% of patients with ISBAS presented with complete BA occlusion.Conclusion ISBAS is an uncommon(1.43%)cause of TIA and AIS.Men in their 60s are mostly affected,and artery-to artery embolism is the most common stroke mechanism.Mid-basilar location,≥80% stenosis and poor collateral circulation are important factors associated with worse prognosis.

Giant saphenous vein graft pseudoaneurysm to right posterior descending artery presenting with superior vena cava syndrome

Saphenous vein grafts(SVG) pseudoaneurysms,especially giant ones,are rare and occur as a late complication of coronary artery bypass grafting. This condition affects both genders and typically occurs within the sixth decade of life. The clinical presentation ranges from an asymptomatic incidental finding on imaging studies to new onset angina,dyspnea,myocardial infarction or symptoms related to compression of neighboring structures. An 82-year-old woman presented with acute onset back pain,dyspnea and was noted to have significantly engorged neck veins. In the emergency department,a chest computed tomographic angiogram with intravenous contrast revealed a ruptured giant bilobed SVG pseudoaneurysm to the right posterior descending artery(RPDA). This imaging modality also demonstrated compression of the superior vena cava(SVC) by the SVG pseudoaneurysm. Coronary angiogram with bypass study was performed to establish the patency of this graft. Endovascular coiling and embolization of the SVG to RPDA was initially considered but disfavored after the coronary angiogram revealed preserved flow from the graft to this arterial branch. After reviewing the angiogram films,a surgical strategy was favored over a percutaneous intervention with a Nitinol self-expanding stent since the latter would have not addressed the superior vena cava compression caused by the giant pseudoaneurysm. Intraoperative transesophageal echocardiogram demonstrated SVCcompression by the giant pseudoaneurysm cranial lobe. Our patient underwent surgical ligation and excision of the giant pseudoaneurysm and the RPDA was regrafted successfully. In summary,saphenous vein grafts pseudoaneurysms can be life-threatening and its therapy should be guided based on the presence of mechanical complications,the patency of the affected vein graft and the involved myocardial territory viability.