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A 79-year-old man was admitted to a municipal hospital with a bilateral sensory level below T3 and gait ataxia since the last month (EDSS 6.5). Magnetic resonance imaging (MRI) revealed spinal cord lesions at vertebra C1-4, at T3/4, and brain microangiopathy. Cerebrospinal fluid (CSF) analysis showed mildly increased albumin, but normal immunoglobulin G (IgG), negative oligoclonal bands (OCB), and a normal cell count. Autoimmune myelitis was suspected, and symptoms improved after intravenous glucocorticoids (EDSS 5.0).\nFour months later, a second attack occurred with severe left-sided optic neuritis and worsening of sensorimotor symptoms (EDSS 9.0). MRI revealed an enlarged myelon lesion (medulla oblongata to vertebra C5, partially gadolinium-enhancing). CSF analysis showed pleocytosis (32/µl). Symptoms improved after intravenous steroids (EDSS 8.0).\nAfter another month, a third attack occurred with dysphagia, a high-cervical transverse spinal cord syndrome with marked tetraparesis, and another severe optic neuritis (blindness in left eye; EDSS 9.0). He was admitted to a university hospital. MRI revealed a lesion extending over the entire myelon and brainstem involvement (Fig. a). CSF analysis showed 43 cells/µl including granulocytes. AQP4-Ab were positive in serum and CSF (ΔMFI 816 and 181, respectively, FACS-based assay), and diagnosis of AQP4-Ab positive NMO [] as part of NMOSD [] was established. Intravenous steroids were given, followed by plasma exchange, without improvement. After further deterioration with respiratory insufficiency because of high cervical myelon involvement (EDSS 9.5) and pneumonia, he required intensive care and died shortly thereafter.

An 80-year-old man was admitted for subacute gait disturbance. His bilateral lower limb impairment had developed over 2 weeks. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting both lower limbs. Deep tendon reflexes were absent in both limbs without pathological reflexes. There was loss of deep sensation below T10. He had bladder and rectal disturbance. His EDSS score was 8.5. Findings from routine serum and CSF studies were normal. Spinal MRI on T2WI revealed high signals extending from Th9 to Th12 in the central part of the cord (Fig. ). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, he received high-dose methylprednisolone (1,000 mg/day for 3 days, 2 courses). His serum was positive for anti-AQP4 antibody on the 15th day of his hospitalization. He was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). The muscle strength of the lower limb slightly improved; however, he was bedridden, and the paraplegia persisted. Repeat MRI showed marked regression of thoracic lesions on the 43rd day of his hospitalization. He was discharged to another hospital for rehabilitation 50 days after his hospitalization with daily prednisolone (10 mg). His EDSS score was 7.5.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

A 79-year-old man was admitted to a municipal hospital with a bilateral sensory level below T3 and gait ataxia since the last month (EDSS 6.5). Magnetic resonance imaging (MRI) revealed spinal cord lesions at vertebra C1-4, at T3/4, and brain microangiopathy. Cerebrospinal fluid (CSF) analysis showed mildly increased albumin, but normal immunoglobulin G (IgG), negative oligoclonal bands (OCB), and a normal cell count. Autoimmune myelitis was suspected, and symptoms improved after intravenous glucocorticoids (EDSS 5.0).\nFour months later, a second attack occurred with severe left-sided optic neuritis and worsening of sensorimotor symptoms (EDSS 9.0). MRI revealed an enlarged myelon lesion (medulla oblongata to vertebra C5, partially gadolinium-enhancing). CSF analysis showed pleocytosis (32/µl). Symptoms improved after intravenous steroids (EDSS 8.0).\nAfter another month, a third attack occurred with dysphagia, a high-cervical transverse spinal cord syndrome with marked tetraparesis, and another severe optic neuritis (blindness in left eye; EDSS 9.0). He was admitted to a university hospital. MRI revealed a lesion extending over the entire myelon and brainstem involvement (Fig. a). CSF analysis showed 43 cells/µl including granulocytes. AQP4-Ab were positive in serum and CSF (ΔMFI 816 and 181, respectively, FACS-based assay), and diagnosis of AQP4-Ab positive NMO [] as part of NMOSD [] was established. Intravenous steroids were given, followed by plasma exchange, without improvement. After further deterioration with respiratory insufficiency because of high cervical myelon involvement (EDSS 9.5) and pneumonia, he required intensive care and died shortly thereafter.

An 88-year-old woman experienced numbness in her legs and moderate paraparesis with impaired gait since 2 days. Spinal MRI demonstrated a myelon lesion from vertebra T6-9 (Fig. b-c), which was initially attributed to compression myelopathy because of concomitant vertebral disc protrusions. Without specific treatment, she recovered partially and was able to walk with a crutch for >100 m (EDSS 6.0). Her previous medical history was negative for prior potential attacks, but included a transient ischemic attack with dysarthria for <24 h 1.5 years before; cerebral MRI had not shown inflammatory lesions.\nEight months later, she was re-admitted with an anew gait impairment and sensorimotor paraparesis (MRC grade 2–3, EDSS 8.5). MRI demonstrated a new T2 hyperintense myelon lesion from vertebra T10–T12 with central gadolinium enhancement (Fig. d–f). Visual evoked potentials had low amplitudes bilaterally and normal latencies. CSF showed mild lymphomonocytic pleocytosis and positive OCB. Serum AQP4-Ab were positive (1:3200, cell-based immunofluorescence assay), as were antibodies against dsDNA and cardiolipin. Diagnosis of AQP4-Ab positive NMOSD was established, and the first myelon lesion was retrospectively attributed also to NMOSD. Treatment included methylprednisolone 5 × 1 g, a second cycle of 5 × 2 g, and then plasma exchange. She recovered partially (EDSS 7.0). Azathioprine was given up to 150 mg/d (2.2 mg/kg); thiopurine S-methyltransferase activity was normal. After 5 months of therapy, regular blood testing revealed pancytopenia. Azathioprine was stopped, but thrombocytopenia persisted and she died of intestinal bleeding. In addition to azathioprine as a likely cause for bone marrow suppression and thrombocytopenia, she had also developed anti-platelet antibodies.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

The patient was a 76-year-old woman who had been suffering from Parkinson disease for 5 years. She had Stage III disease, as assessed using the Hoehn and Yahr (H-Y) Scale, and exhibited a stable condition under the control of l-dopa and dopamine agonists. Two weeks prior to admission, the patient became speechless gradually and spent most of the day in bed. Thus, she was admitted to our hospital for further evaluations. The patient exhibited worsening of bradykinesia and cogwheel rigidity. She required guardian's support for everyday life and was diagnosed with H-Y stage IV. She could walk with minimal assistance. Most strikingly, her consciousness level was impaired and estimated to be Glasgow Coma Scale (GCS) E3V3M5. Involvement of the cranial nerves or cerebellar dysfunction was not obvious. No clinical evidence obtained at that time indicated the involvement of the spinal cord. In addition to the neurological disturbances, a tumor was observed in the right breast, which was later pathologically proven to be invasive ductal carcinoma. Cranial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) examination revealed a high-signal-intensity lesion in the right peri- and intralateral ventricle (Fig. , b). Part of this lesion and the meninges exhibited gadolinium enhancement (Fig. , d). Cerebrospinal fluid (CSF) examination demonstrated the presence of pleocytosis (159 cells/mm3) and an increased protein content (171 mg/dL). A cytological analysis was negative and no significant viral antibody titers were detected. Moreover, no bacterial cultures were obtained. The levels of the myelin basic protein were normal (88 pg/mL; normal <102 pg/mL) and no oligoclonal bands were observed. Anti-AQP-4 antibodies were detected (28.5 U/mL; normal, <3 U/mL) in her serum, whereas various auto-antibodies that indicate paraneoplastic neurological syndromes, such as anti-Yo, anti-Hu, Ro, and others, were negative. Based on these findings, the patient was diagnosed as having late-onset anti-AQP-4 antibody-positive NMOSD with invasive ductal carcinoma and 5-year history of Parkinson disease. Optic neuritis was not observed at that time. The patient received pulsed steroid therapy as the initial treatment, which improved her consciousness level significantly, to GCS E4V4M6. The abnormal signal alterations on MRI also improved (Fig. , f). The results of CSF examination indicating the presence of 32 cells/mm3 and an elevated protein contents of 100 mg/dL were considered to represent partial improvement. After the initial pulsed steroid treatment, the patient received total mastectomy and further rehabilitation therapy for Parkinson disease. Two weeks after the mastectomy, she developed abrupt-onset bilateral leg weakness and walking difficulties; therefore, involvement of the spinal cord was suspected. MRI of the spinal cord revealed the presence of multiple spindle-shaped T2 high-signal-intensity alterations that were indicative of myelitis (Fig. , b). Thus, pulsed steroid therapy was administered again, after which the MRI signal alterations of the spinal cord were reduced (Fig. ) and the patient's leg muscle strength improved. The patient refused further treatment, such as plasma exchange or other immune-modifying medications. Subsequently, the patient was transferred to another hospital for further rehabilitation.

A 79-year-old man was admitted to a municipal hospital with a bilateral sensory level below T3 and gait ataxia since the last month (EDSS 6.5). Magnetic resonance imaging (MRI) revealed spinal cord lesions at vertebra C1-4, at T3/4, and brain microangiopathy. Cerebrospinal fluid (CSF) analysis showed mildly increased albumin, but normal immunoglobulin G (IgG), negative oligoclonal bands (OCB), and a normal cell count. Autoimmune myelitis was suspected, and symptoms improved after intravenous glucocorticoids (EDSS 5.0).\nFour months later, a second attack occurred with severe left-sided optic neuritis and worsening of sensorimotor symptoms (EDSS 9.0). MRI revealed an enlarged myelon lesion (medulla oblongata to vertebra C5, partially gadolinium-enhancing). CSF analysis showed pleocytosis (32/µl). Symptoms improved after intravenous steroids (EDSS 8.0).\nAfter another month, a third attack occurred with dysphagia, a high-cervical transverse spinal cord syndrome with marked tetraparesis, and another severe optic neuritis (blindness in left eye; EDSS 9.0). He was admitted to a university hospital. MRI revealed a lesion extending over the entire myelon and brainstem involvement (Fig. a). CSF analysis showed 43 cells/µl including granulocytes. AQP4-Ab were positive in serum and CSF (ΔMFI 816 and 181, respectively, FACS-based assay), and diagnosis of AQP4-Ab positive NMO [] as part of NMOSD [] was established. Intravenous steroids were given, followed by plasma exchange, without improvement. After further deterioration with respiratory insufficiency because of high cervical myelon involvement (EDSS 9.5) and pneumonia, he required intensive care and died shortly thereafter.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 82-year-old, right-handed Caucasian man was admitted to our neurology service due to rapidly progressive, painless vision loss and sensory loss of the bilateral lower extremities. Prior to the onset of symptoms he was healthy and independent in his activities of daily living. Initially, his vision began to deteriorate in the left eye 2 weeks prior to presentation, and 1 week later he began to have painless vision loss in the right eye. Subsequently, he began to experience abdominal pain in a band around his umbilicus along with numbness that began in the mid-trunk and gradually extended to include his lower extremities, which ultimately led to his presentation to our emergency department.\nHis initial examination showed preserved light perception in the left eye with impaired perception of motion and no light perception in the right eye. He had patchy sensory loss to all modalities below T10. He was hyperreflexic in the left lower extremity with crossed adductors, crossed patellar reflex, and an extensor plantar response on the left. He had no discernable weakness or cranial nerve abnormalities. MRI brain/orbits, C-spine, and T-spine with/without contrast revealed bilateral pre-chiasmatic optic nerve and optic chiasm enhancement, along with patchy but longitudinally extensive hyperintense STIR signal and post-contrast enhancement within the thoracic spinal cord from T3 to T7.\nInitial laboratory testing was unremarkable, including CBC, comprehensive metabolic panel, B12, copper, rapid plasma regain, antinuclear antibodies, erythrocyte sedimentation rate, and C-reactive peptide. His CSF revealed 10 WBCs, 9 RBCs, glucose 52 (roughly 2/3 serum glucose), and protein 59. CSF oligoclonal bands were negative. Serum angiotensin-converting enzyme was low at 3.\nBased on his imaging and CSF findings his working diagnosis was NMO, but neurosarcoidosis was also on our differential given his abnormal age for presentation of NMO. He initially refused steroids, opting for PLEX alone due to the severe reaction he had to oral prednisone 2 months prior (angioedema with airway compromise). He completed 5 rounds of PLEX (every 48 h for 10 days). However, by hospital day 4 his symptoms worsened. His sensory level now extended from T4 and he began to have weakness of the bilateral lower extremities. Ultimately, his serum NMO-IgG returned positive with a titer >1: 100,000, confirming our diagnosis. He reconsidered his position on attempting intravenous steroids given the worsening strength of his upper extremities. Based on the suspicion of lowest probability of cross-reactivity, we initiated dexamethasone, opting for 25 mg every 6 h followed by a taper for 2 days. We moved the patient to an intensive care bed for close monitoring in the event of a severe reaction requiring intubation. His symptoms persisted but did not worsen. However, he suffered from psychosis and hallucinations likely as a consequence of steroid administration on his final 2 days of high-dose dexamethasone. He was ultimately discharged to a rehab facility prior to returning home and arrangements were made to prepare for outpatient rituximab infusions for NMO maintenance therapy.

A 79-year-old man was admitted to a municipal hospital with a bilateral sensory level below T3 and gait ataxia since the last month (EDSS 6.5). Magnetic resonance imaging (MRI) revealed spinal cord lesions at vertebra C1-4, at T3/4, and brain microangiopathy. Cerebrospinal fluid (CSF) analysis showed mildly increased albumin, but normal immunoglobulin G (IgG), negative oligoclonal bands (OCB), and a normal cell count. Autoimmune myelitis was suspected, and symptoms improved after intravenous glucocorticoids (EDSS 5.0).\nFour months later, a second attack occurred with severe left-sided optic neuritis and worsening of sensorimotor symptoms (EDSS 9.0). MRI revealed an enlarged myelon lesion (medulla oblongata to vertebra C5, partially gadolinium-enhancing). CSF analysis showed pleocytosis (32/µl). Symptoms improved after intravenous steroids (EDSS 8.0).\nAfter another month, a third attack occurred with dysphagia, a high-cervical transverse spinal cord syndrome with marked tetraparesis, and another severe optic neuritis (blindness in left eye; EDSS 9.0). He was admitted to a university hospital. MRI revealed a lesion extending over the entire myelon and brainstem involvement (Fig. a). CSF analysis showed 43 cells/µl including granulocytes. AQP4-Ab were positive in serum and CSF (ΔMFI 816 and 181, respectively, FACS-based assay), and diagnosis of AQP4-Ab positive NMO [] as part of NMOSD [] was established. Intravenous steroids were given, followed by plasma exchange, without improvement. After further deterioration with respiratory insufficiency because of high cervical myelon involvement (EDSS 9.5) and pneumonia, he required intensive care and died shortly thereafter.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 82-year-old woman was admitted for acute gait disturbance and hypoesthesia over 3 days. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting the right lower limb and grade 1/5 affecting the left lower limb. Deep tendon reflexes were hyperactive in both limbs. Babinski and Chaddock signs were positive on both sides. There was a loss of position and vibration sense combined with hypesthesia below Th10. She had bladder and rectal disturbance. Her Expanded Disability Status Scale (EDSS) score was 8.0. Findings from routine serum studies were normal. Cerebrospinal fluid (CSF) analysis showed a cell count of 2/mL (100% mononuclear cells), normal glucose level, an increased protein concentration of 48 mg/dL, a myelin basic protein (MBP) level of 862 mg/dL (normal range <102 mg/dL), immunoglobulin G (IgG) and albumin ratios of 1.18 (normal range <0.7), and positive oligoclonal bands. Spinal magnetic resonance imaging (MRI) on a T2-weighted image (T2WI) demonstrated two high signals extending from Th1 to Th2 and Th7 to Th9 in the central part of the cord (Fig. , arrows). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, she received high-dose methylprednisolone (1,000 mg/day for 3 days, 3 courses). Her serum was positive for anti-AQP4 antibody (cell-based assay) 17 days after the onset. She was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). Her condition improved and she was able to walk using a walking instrument. Repeat MRI showed marked regression of thoracic lesions 47 days after the onset. She was discharged to another hospital for rehabilitation 50 days after the onset with daily prednisolone (15 mg). Her EDSS score was 5.5.

An 80-year-old man was admitted for subacute gait disturbance. His bilateral lower limb impairment had developed over 2 weeks. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting both lower limbs. Deep tendon reflexes were absent in both limbs without pathological reflexes. There was loss of deep sensation below T10. He had bladder and rectal disturbance. His EDSS score was 8.5. Findings from routine serum and CSF studies were normal. Spinal MRI on T2WI revealed high signals extending from Th9 to Th12 in the central part of the cord (Fig. ). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, he received high-dose methylprednisolone (1,000 mg/day for 3 days, 2 courses). His serum was positive for anti-AQP4 antibody on the 15th day of his hospitalization. He was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). The muscle strength of the lower limb slightly improved; however, he was bedridden, and the paraplegia persisted. Repeat MRI showed marked regression of thoracic lesions on the 43rd day of his hospitalization. He was discharged to another hospital for rehabilitation 50 days after his hospitalization with daily prednisolone (10 mg). His EDSS score was 7.5.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 82-year-old woman was admitted for acute gait disturbance and hypoesthesia over 3 days. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting the right lower limb and grade 1/5 affecting the left lower limb. Deep tendon reflexes were hyperactive in both limbs. Babinski and Chaddock signs were positive on both sides. There was a loss of position and vibration sense combined with hypesthesia below Th10. She had bladder and rectal disturbance. Her Expanded Disability Status Scale (EDSS) score was 8.0. Findings from routine serum studies were normal. Cerebrospinal fluid (CSF) analysis showed a cell count of 2/mL (100% mononuclear cells), normal glucose level, an increased protein concentration of 48 mg/dL, a myelin basic protein (MBP) level of 862 mg/dL (normal range <102 mg/dL), immunoglobulin G (IgG) and albumin ratios of 1.18 (normal range <0.7), and positive oligoclonal bands. Spinal magnetic resonance imaging (MRI) on a T2-weighted image (T2WI) demonstrated two high signals extending from Th1 to Th2 and Th7 to Th9 in the central part of the cord (Fig. , arrows). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, she received high-dose methylprednisolone (1,000 mg/day for 3 days, 3 courses). Her serum was positive for anti-AQP4 antibody (cell-based assay) 17 days after the onset. She was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). Her condition improved and she was able to walk using a walking instrument. Repeat MRI showed marked regression of thoracic lesions 47 days after the onset. She was discharged to another hospital for rehabilitation 50 days after the onset with daily prednisolone (15 mg). Her EDSS score was 5.5.

An 88-year-old woman experienced numbness in her legs and moderate paraparesis with impaired gait since 2 days. Spinal MRI demonstrated a myelon lesion from vertebra T6-9 (Fig. b-c), which was initially attributed to compression myelopathy because of concomitant vertebral disc protrusions. Without specific treatment, she recovered partially and was able to walk with a crutch for >100 m (EDSS 6.0). Her previous medical history was negative for prior potential attacks, but included a transient ischemic attack with dysarthria for <24 h 1.5 years before; cerebral MRI had not shown inflammatory lesions.\nEight months later, she was re-admitted with an anew gait impairment and sensorimotor paraparesis (MRC grade 2–3, EDSS 8.5). MRI demonstrated a new T2 hyperintense myelon lesion from vertebra T10–T12 with central gadolinium enhancement (Fig. d–f). Visual evoked potentials had low amplitudes bilaterally and normal latencies. CSF showed mild lymphomonocytic pleocytosis and positive OCB. Serum AQP4-Ab were positive (1:3200, cell-based immunofluorescence assay), as were antibodies against dsDNA and cardiolipin. Diagnosis of AQP4-Ab positive NMOSD was established, and the first myelon lesion was retrospectively attributed also to NMOSD. Treatment included methylprednisolone 5 × 1 g, a second cycle of 5 × 2 g, and then plasma exchange. She recovered partially (EDSS 7.0). Azathioprine was given up to 150 mg/d (2.2 mg/kg); thiopurine S-methyltransferase activity was normal. After 5 months of therapy, regular blood testing revealed pancytopenia. Azathioprine was stopped, but thrombocytopenia persisted and she died of intestinal bleeding. In addition to azathioprine as a likely cause for bone marrow suppression and thrombocytopenia, she had also developed anti-platelet antibodies.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 82-year-old woman was admitted for acute gait disturbance and hypoesthesia over 3 days. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting the right lower limb and grade 1/5 affecting the left lower limb. Deep tendon reflexes were hyperactive in both limbs. Babinski and Chaddock signs were positive on both sides. There was a loss of position and vibration sense combined with hypesthesia below Th10. She had bladder and rectal disturbance. Her Expanded Disability Status Scale (EDSS) score was 8.0. Findings from routine serum studies were normal. Cerebrospinal fluid (CSF) analysis showed a cell count of 2/mL (100% mononuclear cells), normal glucose level, an increased protein concentration of 48 mg/dL, a myelin basic protein (MBP) level of 862 mg/dL (normal range <102 mg/dL), immunoglobulin G (IgG) and albumin ratios of 1.18 (normal range <0.7), and positive oligoclonal bands. Spinal magnetic resonance imaging (MRI) on a T2-weighted image (T2WI) demonstrated two high signals extending from Th1 to Th2 and Th7 to Th9 in the central part of the cord (Fig. , arrows). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, she received high-dose methylprednisolone (1,000 mg/day for 3 days, 3 courses). Her serum was positive for anti-AQP4 antibody (cell-based assay) 17 days after the onset. She was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). Her condition improved and she was able to walk using a walking instrument. Repeat MRI showed marked regression of thoracic lesions 47 days after the onset. She was discharged to another hospital for rehabilitation 50 days after the onset with daily prednisolone (15 mg). Her EDSS score was 5.5.

The patient was a 76-year-old woman who had been suffering from Parkinson disease for 5 years. She had Stage III disease, as assessed using the Hoehn and Yahr (H-Y) Scale, and exhibited a stable condition under the control of l-dopa and dopamine agonists. Two weeks prior to admission, the patient became speechless gradually and spent most of the day in bed. Thus, she was admitted to our hospital for further evaluations. The patient exhibited worsening of bradykinesia and cogwheel rigidity. She required guardian's support for everyday life and was diagnosed with H-Y stage IV. She could walk with minimal assistance. Most strikingly, her consciousness level was impaired and estimated to be Glasgow Coma Scale (GCS) E3V3M5. Involvement of the cranial nerves or cerebellar dysfunction was not obvious. No clinical evidence obtained at that time indicated the involvement of the spinal cord. In addition to the neurological disturbances, a tumor was observed in the right breast, which was later pathologically proven to be invasive ductal carcinoma. Cranial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) examination revealed a high-signal-intensity lesion in the right peri- and intralateral ventricle (Fig. , b). Part of this lesion and the meninges exhibited gadolinium enhancement (Fig. , d). Cerebrospinal fluid (CSF) examination demonstrated the presence of pleocytosis (159 cells/mm3) and an increased protein content (171 mg/dL). A cytological analysis was negative and no significant viral antibody titers were detected. Moreover, no bacterial cultures were obtained. The levels of the myelin basic protein were normal (88 pg/mL; normal <102 pg/mL) and no oligoclonal bands were observed. Anti-AQP-4 antibodies were detected (28.5 U/mL; normal, <3 U/mL) in her serum, whereas various auto-antibodies that indicate paraneoplastic neurological syndromes, such as anti-Yo, anti-Hu, Ro, and others, were negative. Based on these findings, the patient was diagnosed as having late-onset anti-AQP-4 antibody-positive NMOSD with invasive ductal carcinoma and 5-year history of Parkinson disease. Optic neuritis was not observed at that time. The patient received pulsed steroid therapy as the initial treatment, which improved her consciousness level significantly, to GCS E4V4M6. The abnormal signal alterations on MRI also improved (Fig. , f). The results of CSF examination indicating the presence of 32 cells/mm3 and an elevated protein contents of 100 mg/dL were considered to represent partial improvement. After the initial pulsed steroid treatment, the patient received total mastectomy and further rehabilitation therapy for Parkinson disease. Two weeks after the mastectomy, she developed abrupt-onset bilateral leg weakness and walking difficulties; therefore, involvement of the spinal cord was suspected. MRI of the spinal cord revealed the presence of multiple spindle-shaped T2 high-signal-intensity alterations that were indicative of myelitis (Fig. , b). Thus, pulsed steroid therapy was administered again, after which the MRI signal alterations of the spinal cord were reduced (Fig. ) and the patient's leg muscle strength improved. The patient refused further treatment, such as plasma exchange or other immune-modifying medications. Subsequently, the patient was transferred to another hospital for further rehabilitation.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 82-year-old woman was admitted for acute gait disturbance and hypoesthesia over 3 days. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting the right lower limb and grade 1/5 affecting the left lower limb. Deep tendon reflexes were hyperactive in both limbs. Babinski and Chaddock signs were positive on both sides. There was a loss of position and vibration sense combined with hypesthesia below Th10. She had bladder and rectal disturbance. Her Expanded Disability Status Scale (EDSS) score was 8.0. Findings from routine serum studies were normal. Cerebrospinal fluid (CSF) analysis showed a cell count of 2/mL (100% mononuclear cells), normal glucose level, an increased protein concentration of 48 mg/dL, a myelin basic protein (MBP) level of 862 mg/dL (normal range <102 mg/dL), immunoglobulin G (IgG) and albumin ratios of 1.18 (normal range <0.7), and positive oligoclonal bands. Spinal magnetic resonance imaging (MRI) on a T2-weighted image (T2WI) demonstrated two high signals extending from Th1 to Th2 and Th7 to Th9 in the central part of the cord (Fig. , arrows). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, she received high-dose methylprednisolone (1,000 mg/day for 3 days, 3 courses). Her serum was positive for anti-AQP4 antibody (cell-based assay) 17 days after the onset. She was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). Her condition improved and she was able to walk using a walking instrument. Repeat MRI showed marked regression of thoracic lesions 47 days after the onset. She was discharged to another hospital for rehabilitation 50 days after the onset with daily prednisolone (15 mg). Her EDSS score was 5.5.

An 82-year-old, right-handed Caucasian man was admitted to our neurology service due to rapidly progressive, painless vision loss and sensory loss of the bilateral lower extremities. Prior to the onset of symptoms he was healthy and independent in his activities of daily living. Initially, his vision began to deteriorate in the left eye 2 weeks prior to presentation, and 1 week later he began to have painless vision loss in the right eye. Subsequently, he began to experience abdominal pain in a band around his umbilicus along with numbness that began in the mid-trunk and gradually extended to include his lower extremities, which ultimately led to his presentation to our emergency department.\nHis initial examination showed preserved light perception in the left eye with impaired perception of motion and no light perception in the right eye. He had patchy sensory loss to all modalities below T10. He was hyperreflexic in the left lower extremity with crossed adductors, crossed patellar reflex, and an extensor plantar response on the left. He had no discernable weakness or cranial nerve abnormalities. MRI brain/orbits, C-spine, and T-spine with/without contrast revealed bilateral pre-chiasmatic optic nerve and optic chiasm enhancement, along with patchy but longitudinally extensive hyperintense STIR signal and post-contrast enhancement within the thoracic spinal cord from T3 to T7.\nInitial laboratory testing was unremarkable, including CBC, comprehensive metabolic panel, B12, copper, rapid plasma regain, antinuclear antibodies, erythrocyte sedimentation rate, and C-reactive peptide. His CSF revealed 10 WBCs, 9 RBCs, glucose 52 (roughly 2/3 serum glucose), and protein 59. CSF oligoclonal bands were negative. Serum angiotensin-converting enzyme was low at 3.\nBased on his imaging and CSF findings his working diagnosis was NMO, but neurosarcoidosis was also on our differential given his abnormal age for presentation of NMO. He initially refused steroids, opting for PLEX alone due to the severe reaction he had to oral prednisone 2 months prior (angioedema with airway compromise). He completed 5 rounds of PLEX (every 48 h for 10 days). However, by hospital day 4 his symptoms worsened. His sensory level now extended from T4 and he began to have weakness of the bilateral lower extremities. Ultimately, his serum NMO-IgG returned positive with a titer >1: 100,000, confirming our diagnosis. He reconsidered his position on attempting intravenous steroids given the worsening strength of his upper extremities. Based on the suspicion of lowest probability of cross-reactivity, we initiated dexamethasone, opting for 25 mg every 6 h followed by a taper for 2 days. We moved the patient to an intensive care bed for close monitoring in the event of a severe reaction requiring intubation. His symptoms persisted but did not worsen. However, he suffered from psychosis and hallucinations likely as a consequence of steroid administration on his final 2 days of high-dose dexamethasone. He was ultimately discharged to a rehab facility prior to returning home and arrangements were made to prepare for outpatient rituximab infusions for NMO maintenance therapy.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 80-year-old man was admitted for subacute gait disturbance. His bilateral lower limb impairment had developed over 2 weeks. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting both lower limbs. Deep tendon reflexes were absent in both limbs without pathological reflexes. There was loss of deep sensation below T10. He had bladder and rectal disturbance. His EDSS score was 8.5. Findings from routine serum and CSF studies were normal. Spinal MRI on T2WI revealed high signals extending from Th9 to Th12 in the central part of the cord (Fig. ). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, he received high-dose methylprednisolone (1,000 mg/day for 3 days, 2 courses). His serum was positive for anti-AQP4 antibody on the 15th day of his hospitalization. He was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). The muscle strength of the lower limb slightly improved; however, he was bedridden, and the paraplegia persisted. Repeat MRI showed marked regression of thoracic lesions on the 43rd day of his hospitalization. He was discharged to another hospital for rehabilitation 50 days after his hospitalization with daily prednisolone (10 mg). His EDSS score was 7.5.

An 88-year-old woman experienced numbness in her legs and moderate paraparesis with impaired gait since 2 days. Spinal MRI demonstrated a myelon lesion from vertebra T6-9 (Fig. b-c), which was initially attributed to compression myelopathy because of concomitant vertebral disc protrusions. Without specific treatment, she recovered partially and was able to walk with a crutch for >100 m (EDSS 6.0). Her previous medical history was negative for prior potential attacks, but included a transient ischemic attack with dysarthria for <24 h 1.5 years before; cerebral MRI had not shown inflammatory lesions.\nEight months later, she was re-admitted with an anew gait impairment and sensorimotor paraparesis (MRC grade 2–3, EDSS 8.5). MRI demonstrated a new T2 hyperintense myelon lesion from vertebra T10–T12 with central gadolinium enhancement (Fig. d–f). Visual evoked potentials had low amplitudes bilaterally and normal latencies. CSF showed mild lymphomonocytic pleocytosis and positive OCB. Serum AQP4-Ab were positive (1:3200, cell-based immunofluorescence assay), as were antibodies against dsDNA and cardiolipin. Diagnosis of AQP4-Ab positive NMOSD was established, and the first myelon lesion was retrospectively attributed also to NMOSD. Treatment included methylprednisolone 5 × 1 g, a second cycle of 5 × 2 g, and then plasma exchange. She recovered partially (EDSS 7.0). Azathioprine was given up to 150 mg/d (2.2 mg/kg); thiopurine S-methyltransferase activity was normal. After 5 months of therapy, regular blood testing revealed pancytopenia. Azathioprine was stopped, but thrombocytopenia persisted and she died of intestinal bleeding. In addition to azathioprine as a likely cause for bone marrow suppression and thrombocytopenia, she had also developed anti-platelet antibodies.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 80-year-old man was admitted for subacute gait disturbance. His bilateral lower limb impairment had developed over 2 weeks. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting both lower limbs. Deep tendon reflexes were absent in both limbs without pathological reflexes. There was loss of deep sensation below T10. He had bladder and rectal disturbance. His EDSS score was 8.5. Findings from routine serum and CSF studies were normal. Spinal MRI on T2WI revealed high signals extending from Th9 to Th12 in the central part of the cord (Fig. ). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, he received high-dose methylprednisolone (1,000 mg/day for 3 days, 2 courses). His serum was positive for anti-AQP4 antibody on the 15th day of his hospitalization. He was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). The muscle strength of the lower limb slightly improved; however, he was bedridden, and the paraplegia persisted. Repeat MRI showed marked regression of thoracic lesions on the 43rd day of his hospitalization. He was discharged to another hospital for rehabilitation 50 days after his hospitalization with daily prednisolone (10 mg). His EDSS score was 7.5.

The patient was a 76-year-old woman who had been suffering from Parkinson disease for 5 years. She had Stage III disease, as assessed using the Hoehn and Yahr (H-Y) Scale, and exhibited a stable condition under the control of l-dopa and dopamine agonists. Two weeks prior to admission, the patient became speechless gradually and spent most of the day in bed. Thus, she was admitted to our hospital for further evaluations. The patient exhibited worsening of bradykinesia and cogwheel rigidity. She required guardian's support for everyday life and was diagnosed with H-Y stage IV. She could walk with minimal assistance. Most strikingly, her consciousness level was impaired and estimated to be Glasgow Coma Scale (GCS) E3V3M5. Involvement of the cranial nerves or cerebellar dysfunction was not obvious. No clinical evidence obtained at that time indicated the involvement of the spinal cord. In addition to the neurological disturbances, a tumor was observed in the right breast, which was later pathologically proven to be invasive ductal carcinoma. Cranial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) examination revealed a high-signal-intensity lesion in the right peri- and intralateral ventricle (Fig. , b). Part of this lesion and the meninges exhibited gadolinium enhancement (Fig. , d). Cerebrospinal fluid (CSF) examination demonstrated the presence of pleocytosis (159 cells/mm3) and an increased protein content (171 mg/dL). A cytological analysis was negative and no significant viral antibody titers were detected. Moreover, no bacterial cultures were obtained. The levels of the myelin basic protein were normal (88 pg/mL; normal <102 pg/mL) and no oligoclonal bands were observed. Anti-AQP-4 antibodies were detected (28.5 U/mL; normal, <3 U/mL) in her serum, whereas various auto-antibodies that indicate paraneoplastic neurological syndromes, such as anti-Yo, anti-Hu, Ro, and others, were negative. Based on these findings, the patient was diagnosed as having late-onset anti-AQP-4 antibody-positive NMOSD with invasive ductal carcinoma and 5-year history of Parkinson disease. Optic neuritis was not observed at that time. The patient received pulsed steroid therapy as the initial treatment, which improved her consciousness level significantly, to GCS E4V4M6. The abnormal signal alterations on MRI also improved (Fig. , f). The results of CSF examination indicating the presence of 32 cells/mm3 and an elevated protein contents of 100 mg/dL were considered to represent partial improvement. After the initial pulsed steroid treatment, the patient received total mastectomy and further rehabilitation therapy for Parkinson disease. Two weeks after the mastectomy, she developed abrupt-onset bilateral leg weakness and walking difficulties; therefore, involvement of the spinal cord was suspected. MRI of the spinal cord revealed the presence of multiple spindle-shaped T2 high-signal-intensity alterations that were indicative of myelitis (Fig. , b). Thus, pulsed steroid therapy was administered again, after which the MRI signal alterations of the spinal cord were reduced (Fig. ) and the patient's leg muscle strength improved. The patient refused further treatment, such as plasma exchange or other immune-modifying medications. Subsequently, the patient was transferred to another hospital for further rehabilitation.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 82-year-old, right-handed Caucasian man was admitted to our neurology service due to rapidly progressive, painless vision loss and sensory loss of the bilateral lower extremities. Prior to the onset of symptoms he was healthy and independent in his activities of daily living. Initially, his vision began to deteriorate in the left eye 2 weeks prior to presentation, and 1 week later he began to have painless vision loss in the right eye. Subsequently, he began to experience abdominal pain in a band around his umbilicus along with numbness that began in the mid-trunk and gradually extended to include his lower extremities, which ultimately led to his presentation to our emergency department.\nHis initial examination showed preserved light perception in the left eye with impaired perception of motion and no light perception in the right eye. He had patchy sensory loss to all modalities below T10. He was hyperreflexic in the left lower extremity with crossed adductors, crossed patellar reflex, and an extensor plantar response on the left. He had no discernable weakness or cranial nerve abnormalities. MRI brain/orbits, C-spine, and T-spine with/without contrast revealed bilateral pre-chiasmatic optic nerve and optic chiasm enhancement, along with patchy but longitudinally extensive hyperintense STIR signal and post-contrast enhancement within the thoracic spinal cord from T3 to T7.\nInitial laboratory testing was unremarkable, including CBC, comprehensive metabolic panel, B12, copper, rapid plasma regain, antinuclear antibodies, erythrocyte sedimentation rate, and C-reactive peptide. His CSF revealed 10 WBCs, 9 RBCs, glucose 52 (roughly 2/3 serum glucose), and protein 59. CSF oligoclonal bands were negative. Serum angiotensin-converting enzyme was low at 3.\nBased on his imaging and CSF findings his working diagnosis was NMO, but neurosarcoidosis was also on our differential given his abnormal age for presentation of NMO. He initially refused steroids, opting for PLEX alone due to the severe reaction he had to oral prednisone 2 months prior (angioedema with airway compromise). He completed 5 rounds of PLEX (every 48 h for 10 days). However, by hospital day 4 his symptoms worsened. His sensory level now extended from T4 and he began to have weakness of the bilateral lower extremities. Ultimately, his serum NMO-IgG returned positive with a titer >1: 100,000, confirming our diagnosis. He reconsidered his position on attempting intravenous steroids given the worsening strength of his upper extremities. Based on the suspicion of lowest probability of cross-reactivity, we initiated dexamethasone, opting for 25 mg every 6 h followed by a taper for 2 days. We moved the patient to an intensive care bed for close monitoring in the event of a severe reaction requiring intubation. His symptoms persisted but did not worsen. However, he suffered from psychosis and hallucinations likely as a consequence of steroid administration on his final 2 days of high-dose dexamethasone. He was ultimately discharged to a rehab facility prior to returning home and arrangements were made to prepare for outpatient rituximab infusions for NMO maintenance therapy.

An 80-year-old man was admitted for subacute gait disturbance. His bilateral lower limb impairment had developed over 2 weeks. A general physical examination was normal. Neurological examination revealed muscle weakness of grade 4/5 affecting both lower limbs. Deep tendon reflexes were absent in both limbs without pathological reflexes. There was loss of deep sensation below T10. He had bladder and rectal disturbance. His EDSS score was 8.5. Findings from routine serum and CSF studies were normal. Spinal MRI on T2WI revealed high signals extending from Th9 to Th12 in the central part of the cord (Fig. ). The lesions showed no contrast enhancement. Brain MRI showed no abnormality. As autoimmune myelitis was suspected, he received high-dose methylprednisolone (1,000 mg/day for 3 days, 2 courses). His serum was positive for anti-AQP4 antibody on the 15th day of his hospitalization. He was diagnosed with NMOSD and treated with immunoadsorption plasmapheresis and followed up with daily prednisolone (30 mg). The muscle strength of the lower limb slightly improved; however, he was bedridden, and the paraplegia persisted. Repeat MRI showed marked regression of thoracic lesions on the 43rd day of his hospitalization. He was discharged to another hospital for rehabilitation 50 days after his hospitalization with daily prednisolone (10 mg). His EDSS score was 7.5.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 88-year-old woman experienced numbness in her legs and moderate paraparesis with impaired gait since 2 days. Spinal MRI demonstrated a myelon lesion from vertebra T6-9 (Fig. b-c), which was initially attributed to compression myelopathy because of concomitant vertebral disc protrusions. Without specific treatment, she recovered partially and was able to walk with a crutch for >100 m (EDSS 6.0). Her previous medical history was negative for prior potential attacks, but included a transient ischemic attack with dysarthria for <24 h 1.5 years before; cerebral MRI had not shown inflammatory lesions.\nEight months later, she was re-admitted with an anew gait impairment and sensorimotor paraparesis (MRC grade 2–3, EDSS 8.5). MRI demonstrated a new T2 hyperintense myelon lesion from vertebra T10–T12 with central gadolinium enhancement (Fig. d–f). Visual evoked potentials had low amplitudes bilaterally and normal latencies. CSF showed mild lymphomonocytic pleocytosis and positive OCB. Serum AQP4-Ab were positive (1:3200, cell-based immunofluorescence assay), as were antibodies against dsDNA and cardiolipin. Diagnosis of AQP4-Ab positive NMOSD was established, and the first myelon lesion was retrospectively attributed also to NMOSD. Treatment included methylprednisolone 5 × 1 g, a second cycle of 5 × 2 g, and then plasma exchange. She recovered partially (EDSS 7.0). Azathioprine was given up to 150 mg/d (2.2 mg/kg); thiopurine S-methyltransferase activity was normal. After 5 months of therapy, regular blood testing revealed pancytopenia. Azathioprine was stopped, but thrombocytopenia persisted and she died of intestinal bleeding. In addition to azathioprine as a likely cause for bone marrow suppression and thrombocytopenia, she had also developed anti-platelet antibodies.

The patient was a 76-year-old woman who had been suffering from Parkinson disease for 5 years. She had Stage III disease, as assessed using the Hoehn and Yahr (H-Y) Scale, and exhibited a stable condition under the control of l-dopa and dopamine agonists. Two weeks prior to admission, the patient became speechless gradually and spent most of the day in bed. Thus, she was admitted to our hospital for further evaluations. The patient exhibited worsening of bradykinesia and cogwheel rigidity. She required guardian's support for everyday life and was diagnosed with H-Y stage IV. She could walk with minimal assistance. Most strikingly, her consciousness level was impaired and estimated to be Glasgow Coma Scale (GCS) E3V3M5. Involvement of the cranial nerves or cerebellar dysfunction was not obvious. No clinical evidence obtained at that time indicated the involvement of the spinal cord. In addition to the neurological disturbances, a tumor was observed in the right breast, which was later pathologically proven to be invasive ductal carcinoma. Cranial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) examination revealed a high-signal-intensity lesion in the right peri- and intralateral ventricle (Fig. , b). Part of this lesion and the meninges exhibited gadolinium enhancement (Fig. , d). Cerebrospinal fluid (CSF) examination demonstrated the presence of pleocytosis (159 cells/mm3) and an increased protein content (171 mg/dL). A cytological analysis was negative and no significant viral antibody titers were detected. Moreover, no bacterial cultures were obtained. The levels of the myelin basic protein were normal (88 pg/mL; normal <102 pg/mL) and no oligoclonal bands were observed. Anti-AQP-4 antibodies were detected (28.5 U/mL; normal, <3 U/mL) in her serum, whereas various auto-antibodies that indicate paraneoplastic neurological syndromes, such as anti-Yo, anti-Hu, Ro, and others, were negative. Based on these findings, the patient was diagnosed as having late-onset anti-AQP-4 antibody-positive NMOSD with invasive ductal carcinoma and 5-year history of Parkinson disease. Optic neuritis was not observed at that time. The patient received pulsed steroid therapy as the initial treatment, which improved her consciousness level significantly, to GCS E4V4M6. The abnormal signal alterations on MRI also improved (Fig. , f). The results of CSF examination indicating the presence of 32 cells/mm3 and an elevated protein contents of 100 mg/dL were considered to represent partial improvement. After the initial pulsed steroid treatment, the patient received total mastectomy and further rehabilitation therapy for Parkinson disease. Two weeks after the mastectomy, she developed abrupt-onset bilateral leg weakness and walking difficulties; therefore, involvement of the spinal cord was suspected. MRI of the spinal cord revealed the presence of multiple spindle-shaped T2 high-signal-intensity alterations that were indicative of myelitis (Fig. , b). Thus, pulsed steroid therapy was administered again, after which the MRI signal alterations of the spinal cord were reduced (Fig. ) and the patient's leg muscle strength improved. The patient refused further treatment, such as plasma exchange or other immune-modifying medications. Subsequently, the patient was transferred to another hospital for further rehabilitation.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

An 82-year-old, right-handed Caucasian man was admitted to our neurology service due to rapidly progressive, painless vision loss and sensory loss of the bilateral lower extremities. Prior to the onset of symptoms he was healthy and independent in his activities of daily living. Initially, his vision began to deteriorate in the left eye 2 weeks prior to presentation, and 1 week later he began to have painless vision loss in the right eye. Subsequently, he began to experience abdominal pain in a band around his umbilicus along with numbness that began in the mid-trunk and gradually extended to include his lower extremities, which ultimately led to his presentation to our emergency department.\nHis initial examination showed preserved light perception in the left eye with impaired perception of motion and no light perception in the right eye. He had patchy sensory loss to all modalities below T10. He was hyperreflexic in the left lower extremity with crossed adductors, crossed patellar reflex, and an extensor plantar response on the left. He had no discernable weakness or cranial nerve abnormalities. MRI brain/orbits, C-spine, and T-spine with/without contrast revealed bilateral pre-chiasmatic optic nerve and optic chiasm enhancement, along with patchy but longitudinally extensive hyperintense STIR signal and post-contrast enhancement within the thoracic spinal cord from T3 to T7.\nInitial laboratory testing was unremarkable, including CBC, comprehensive metabolic panel, B12, copper, rapid plasma regain, antinuclear antibodies, erythrocyte sedimentation rate, and C-reactive peptide. His CSF revealed 10 WBCs, 9 RBCs, glucose 52 (roughly 2/3 serum glucose), and protein 59. CSF oligoclonal bands were negative. Serum angiotensin-converting enzyme was low at 3.\nBased on his imaging and CSF findings his working diagnosis was NMO, but neurosarcoidosis was also on our differential given his abnormal age for presentation of NMO. He initially refused steroids, opting for PLEX alone due to the severe reaction he had to oral prednisone 2 months prior (angioedema with airway compromise). He completed 5 rounds of PLEX (every 48 h for 10 days). However, by hospital day 4 his symptoms worsened. His sensory level now extended from T4 and he began to have weakness of the bilateral lower extremities. Ultimately, his serum NMO-IgG returned positive with a titer >1: 100,000, confirming our diagnosis. He reconsidered his position on attempting intravenous steroids given the worsening strength of his upper extremities. Based on the suspicion of lowest probability of cross-reactivity, we initiated dexamethasone, opting for 25 mg every 6 h followed by a taper for 2 days. We moved the patient to an intensive care bed for close monitoring in the event of a severe reaction requiring intubation. His symptoms persisted but did not worsen. However, he suffered from psychosis and hallucinations likely as a consequence of steroid administration on his final 2 days of high-dose dexamethasone. He was ultimately discharged to a rehab facility prior to returning home and arrangements were made to prepare for outpatient rituximab infusions for NMO maintenance therapy.

An 88-year-old woman experienced numbness in her legs and moderate paraparesis with impaired gait since 2 days. Spinal MRI demonstrated a myelon lesion from vertebra T6-9 (Fig. b-c), which was initially attributed to compression myelopathy because of concomitant vertebral disc protrusions. Without specific treatment, she recovered partially and was able to walk with a crutch for >100 m (EDSS 6.0). Her previous medical history was negative for prior potential attacks, but included a transient ischemic attack with dysarthria for <24 h 1.5 years before; cerebral MRI had not shown inflammatory lesions.\nEight months later, she was re-admitted with an anew gait impairment and sensorimotor paraparesis (MRC grade 2–3, EDSS 8.5). MRI demonstrated a new T2 hyperintense myelon lesion from vertebra T10–T12 with central gadolinium enhancement (Fig. d–f). Visual evoked potentials had low amplitudes bilaterally and normal latencies. CSF showed mild lymphomonocytic pleocytosis and positive OCB. Serum AQP4-Ab were positive (1:3200, cell-based immunofluorescence assay), as were antibodies against dsDNA and cardiolipin. Diagnosis of AQP4-Ab positive NMOSD was established, and the first myelon lesion was retrospectively attributed also to NMOSD. Treatment included methylprednisolone 5 × 1 g, a second cycle of 5 × 2 g, and then plasma exchange. She recovered partially (EDSS 7.0). Azathioprine was given up to 150 mg/d (2.2 mg/kg); thiopurine S-methyltransferase activity was normal. After 5 months of therapy, regular blood testing revealed pancytopenia. Azathioprine was stopped, but thrombocytopenia persisted and she died of intestinal bleeding. In addition to azathioprine as a likely cause for bone marrow suppression and thrombocytopenia, she had also developed anti-platelet antibodies.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

The patient was a 76-year-old woman who had been suffering from Parkinson disease for 5 years. She had Stage III disease, as assessed using the Hoehn and Yahr (H-Y) Scale, and exhibited a stable condition under the control of l-dopa and dopamine agonists. Two weeks prior to admission, the patient became speechless gradually and spent most of the day in bed. Thus, she was admitted to our hospital for further evaluations. The patient exhibited worsening of bradykinesia and cogwheel rigidity. She required guardian's support for everyday life and was diagnosed with H-Y stage IV. She could walk with minimal assistance. Most strikingly, her consciousness level was impaired and estimated to be Glasgow Coma Scale (GCS) E3V3M5. Involvement of the cranial nerves or cerebellar dysfunction was not obvious. No clinical evidence obtained at that time indicated the involvement of the spinal cord. In addition to the neurological disturbances, a tumor was observed in the right breast, which was later pathologically proven to be invasive ductal carcinoma. Cranial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) examination revealed a high-signal-intensity lesion in the right peri- and intralateral ventricle (Fig. , b). Part of this lesion and the meninges exhibited gadolinium enhancement (Fig. , d). Cerebrospinal fluid (CSF) examination demonstrated the presence of pleocytosis (159 cells/mm3) and an increased protein content (171 mg/dL). A cytological analysis was negative and no significant viral antibody titers were detected. Moreover, no bacterial cultures were obtained. The levels of the myelin basic protein were normal (88 pg/mL; normal <102 pg/mL) and no oligoclonal bands were observed. Anti-AQP-4 antibodies were detected (28.5 U/mL; normal, <3 U/mL) in her serum, whereas various auto-antibodies that indicate paraneoplastic neurological syndromes, such as anti-Yo, anti-Hu, Ro, and others, were negative. Based on these findings, the patient was diagnosed as having late-onset anti-AQP-4 antibody-positive NMOSD with invasive ductal carcinoma and 5-year history of Parkinson disease. Optic neuritis was not observed at that time. The patient received pulsed steroid therapy as the initial treatment, which improved her consciousness level significantly, to GCS E4V4M6. The abnormal signal alterations on MRI also improved (Fig. , f). The results of CSF examination indicating the presence of 32 cells/mm3 and an elevated protein contents of 100 mg/dL were considered to represent partial improvement. After the initial pulsed steroid treatment, the patient received total mastectomy and further rehabilitation therapy for Parkinson disease. Two weeks after the mastectomy, she developed abrupt-onset bilateral leg weakness and walking difficulties; therefore, involvement of the spinal cord was suspected. MRI of the spinal cord revealed the presence of multiple spindle-shaped T2 high-signal-intensity alterations that were indicative of myelitis (Fig. , b). Thus, pulsed steroid therapy was administered again, after which the MRI signal alterations of the spinal cord were reduced (Fig. ) and the patient's leg muscle strength improved. The patient refused further treatment, such as plasma exchange or other immune-modifying medications. Subsequently, the patient was transferred to another hospital for further rehabilitation.

An 82-year-old, right-handed Caucasian man was admitted to our neurology service due to rapidly progressive, painless vision loss and sensory loss of the bilateral lower extremities. Prior to the onset of symptoms he was healthy and independent in his activities of daily living. Initially, his vision began to deteriorate in the left eye 2 weeks prior to presentation, and 1 week later he began to have painless vision loss in the right eye. Subsequently, he began to experience abdominal pain in a band around his umbilicus along with numbness that began in the mid-trunk and gradually extended to include his lower extremities, which ultimately led to his presentation to our emergency department.\nHis initial examination showed preserved light perception in the left eye with impaired perception of motion and no light perception in the right eye. He had patchy sensory loss to all modalities below T10. He was hyperreflexic in the left lower extremity with crossed adductors, crossed patellar reflex, and an extensor plantar response on the left. He had no discernable weakness or cranial nerve abnormalities. MRI brain/orbits, C-spine, and T-spine with/without contrast revealed bilateral pre-chiasmatic optic nerve and optic chiasm enhancement, along with patchy but longitudinally extensive hyperintense STIR signal and post-contrast enhancement within the thoracic spinal cord from T3 to T7.\nInitial laboratory testing was unremarkable, including CBC, comprehensive metabolic panel, B12, copper, rapid plasma regain, antinuclear antibodies, erythrocyte sedimentation rate, and C-reactive peptide. His CSF revealed 10 WBCs, 9 RBCs, glucose 52 (roughly 2/3 serum glucose), and protein 59. CSF oligoclonal bands were negative. Serum angiotensin-converting enzyme was low at 3.\nBased on his imaging and CSF findings his working diagnosis was NMO, but neurosarcoidosis was also on our differential given his abnormal age for presentation of NMO. He initially refused steroids, opting for PLEX alone due to the severe reaction he had to oral prednisone 2 months prior (angioedema with airway compromise). He completed 5 rounds of PLEX (every 48 h for 10 days). However, by hospital day 4 his symptoms worsened. His sensory level now extended from T4 and he began to have weakness of the bilateral lower extremities. Ultimately, his serum NMO-IgG returned positive with a titer >1: 100,000, confirming our diagnosis. He reconsidered his position on attempting intravenous steroids given the worsening strength of his upper extremities. Based on the suspicion of lowest probability of cross-reactivity, we initiated dexamethasone, opting for 25 mg every 6 h followed by a taper for 2 days. We moved the patient to an intensive care bed for close monitoring in the event of a severe reaction requiring intubation. His symptoms persisted but did not worsen. However, he suffered from psychosis and hallucinations likely as a consequence of steroid administration on his final 2 days of high-dose dexamethasone. He was ultimately discharged to a rehab facility prior to returning home and arrangements were made to prepare for outpatient rituximab infusions for NMO maintenance therapy.

Write a detailed clinical case vignette based on the following key phrases: Neuromyelitis Optica Spectrum Disorder (NMOSD), Autoimmune Myelitis, AQP4 Antibodies

A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.

A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.

A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.

A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.

A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.

A36-year-old man was referred to our echocardiography department for follow-up echocardiography. He had undergone the Bentall operation 8 months previously because of an aneurysmal dilation of the ascending aorta (59 mm). His clinical history and physical examinations were unremarkable. Transthoracic echocardiography revealed a round, well-defined mass (35 mm × 32 mm) on the left side of the aortic tube graft in the modified parasternal short-axis view at the level of the aorta [ and ]. The other echocardiographic findings included preserved systolic left ventricular function (ejection fraction = 50%), mild right ventricular dysfunction, up-to-moderate mitral regurgitation, mild tricuspid regurgitation, and a normally functioning bileaflet mechanical aortic valve. Computed tomography (CT) angiography of the aorta showed a well-defined hematoma in the mid-mediastinal space below the pulmonary artery []. The left main coronary site implantation and the distal anastomosis site of the aortic tube graft were intact, and no connection was seen between the aortic tube graft and this hematoma. Because this hematoma produced no compressive symptoms and signs, the heart team decided to follow-up the patient.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.

A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.

A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].

A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].

A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].

A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].

A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].

A36-year-old man was referred to our echocardiography department for follow-up echocardiography. He had undergone the Bentall operation 8 months previously because of an aneurysmal dilation of the ascending aorta (59 mm). His clinical history and physical examinations were unremarkable. Transthoracic echocardiography revealed a round, well-defined mass (35 mm × 32 mm) on the left side of the aortic tube graft in the modified parasternal short-axis view at the level of the aorta [ and ]. The other echocardiographic findings included preserved systolic left ventricular function (ejection fraction = 50%), mild right ventricular dysfunction, up-to-moderate mitral regurgitation, mild tricuspid regurgitation, and a normally functioning bileaflet mechanical aortic valve. Computed tomography (CT) angiography of the aorta showed a well-defined hematoma in the mid-mediastinal space below the pulmonary artery []. The left main coronary site implantation and the distal anastomosis site of the aortic tube graft were intact, and no connection was seen between the aortic tube graft and this hematoma. Because this hematoma produced no compressive symptoms and signs, the heart team decided to follow-up the patient.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].

A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].

A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.

A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.

A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.

A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.

A36-year-old man was referred to our echocardiography department for follow-up echocardiography. He had undergone the Bentall operation 8 months previously because of an aneurysmal dilation of the ascending aorta (59 mm). His clinical history and physical examinations were unremarkable. Transthoracic echocardiography revealed a round, well-defined mass (35 mm × 32 mm) on the left side of the aortic tube graft in the modified parasternal short-axis view at the level of the aorta [ and ]. The other echocardiographic findings included preserved systolic left ventricular function (ejection fraction = 50%), mild right ventricular dysfunction, up-to-moderate mitral regurgitation, mild tricuspid regurgitation, and a normally functioning bileaflet mechanical aortic valve. Computed tomography (CT) angiography of the aorta showed a well-defined hematoma in the mid-mediastinal space below the pulmonary artery []. The left main coronary site implantation and the distal anastomosis site of the aortic tube graft were intact, and no connection was seen between the aortic tube graft and this hematoma. Because this hematoma produced no compressive symptoms and signs, the heart team decided to follow-up the patient.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.

A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.

A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.

A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.

A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.

A36-year-old man was referred to our echocardiography department for follow-up echocardiography. He had undergone the Bentall operation 8 months previously because of an aneurysmal dilation of the ascending aorta (59 mm). His clinical history and physical examinations were unremarkable. Transthoracic echocardiography revealed a round, well-defined mass (35 mm × 32 mm) on the left side of the aortic tube graft in the modified parasternal short-axis view at the level of the aorta [ and ]. The other echocardiographic findings included preserved systolic left ventricular function (ejection fraction = 50%), mild right ventricular dysfunction, up-to-moderate mitral regurgitation, mild tricuspid regurgitation, and a normally functioning bileaflet mechanical aortic valve. Computed tomography (CT) angiography of the aorta showed a well-defined hematoma in the mid-mediastinal space below the pulmonary artery []. The left main coronary site implantation and the distal anastomosis site of the aortic tube graft were intact, and no connection was seen between the aortic tube graft and this hematoma. Because this hematoma produced no compressive symptoms and signs, the heart team decided to follow-up the patient.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.

A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.

A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.

A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A36-year-old man was referred to our echocardiography department for follow-up echocardiography. He had undergone the Bentall operation 8 months previously because of an aneurysmal dilation of the ascending aorta (59 mm). His clinical history and physical examinations were unremarkable. Transthoracic echocardiography revealed a round, well-defined mass (35 mm × 32 mm) on the left side of the aortic tube graft in the modified parasternal short-axis view at the level of the aorta [ and ]. The other echocardiographic findings included preserved systolic left ventricular function (ejection fraction = 50%), mild right ventricular dysfunction, up-to-moderate mitral regurgitation, mild tricuspid regurgitation, and a normally functioning bileaflet mechanical aortic valve. Computed tomography (CT) angiography of the aorta showed a well-defined hematoma in the mid-mediastinal space below the pulmonary artery []. The left main coronary site implantation and the distal anastomosis site of the aortic tube graft were intact, and no connection was seen between the aortic tube graft and this hematoma. Because this hematoma produced no compressive symptoms and signs, the heart team decided to follow-up the patient.

A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.

A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.

A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.

A36-year-old man was referred to our echocardiography department for follow-up echocardiography. He had undergone the Bentall operation 8 months previously because of an aneurysmal dilation of the ascending aorta (59 mm). His clinical history and physical examinations were unremarkable. Transthoracic echocardiography revealed a round, well-defined mass (35 mm × 32 mm) on the left side of the aortic tube graft in the modified parasternal short-axis view at the level of the aorta [ and ]. The other echocardiographic findings included preserved systolic left ventricular function (ejection fraction = 50%), mild right ventricular dysfunction, up-to-moderate mitral regurgitation, mild tricuspid regurgitation, and a normally functioning bileaflet mechanical aortic valve. Computed tomography (CT) angiography of the aorta showed a well-defined hematoma in the mid-mediastinal space below the pulmonary artery []. The left main coronary site implantation and the distal anastomosis site of the aortic tube graft were intact, and no connection was seen between the aortic tube graft and this hematoma. Because this hematoma produced no compressive symptoms and signs, the heart team decided to follow-up the patient.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.

A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.

A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.

A36-year-old man was referred to our echocardiography department for follow-up echocardiography. He had undergone the Bentall operation 8 months previously because of an aneurysmal dilation of the ascending aorta (59 mm). His clinical history and physical examinations were unremarkable. Transthoracic echocardiography revealed a round, well-defined mass (35 mm × 32 mm) on the left side of the aortic tube graft in the modified parasternal short-axis view at the level of the aorta [ and ]. The other echocardiographic findings included preserved systolic left ventricular function (ejection fraction = 50%), mild right ventricular dysfunction, up-to-moderate mitral regurgitation, mild tricuspid regurgitation, and a normally functioning bileaflet mechanical aortic valve. Computed tomography (CT) angiography of the aorta showed a well-defined hematoma in the mid-mediastinal space below the pulmonary artery []. The left main coronary site implantation and the distal anastomosis site of the aortic tube graft were intact, and no connection was seen between the aortic tube graft and this hematoma. Because this hematoma produced no compressive symptoms and signs, the heart team decided to follow-up the patient.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.

A36-year-old man was referred to our echocardiography department for follow-up echocardiography. He had undergone the Bentall operation 8 months previously because of an aneurysmal dilation of the ascending aorta (59 mm). His clinical history and physical examinations were unremarkable. Transthoracic echocardiography revealed a round, well-defined mass (35 mm × 32 mm) on the left side of the aortic tube graft in the modified parasternal short-axis view at the level of the aorta [ and ]. The other echocardiographic findings included preserved systolic left ventricular function (ejection fraction = 50%), mild right ventricular dysfunction, up-to-moderate mitral regurgitation, mild tricuspid regurgitation, and a normally functioning bileaflet mechanical aortic valve. Computed tomography (CT) angiography of the aorta showed a well-defined hematoma in the mid-mediastinal space below the pulmonary artery []. The left main coronary site implantation and the distal anastomosis site of the aortic tube graft were intact, and no connection was seen between the aortic tube graft and this hematoma. Because this hematoma produced no compressive symptoms and signs, the heart team decided to follow-up the patient.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.

A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.

Write a detailed clinical case vignette based on the following key phrases: percutaneous coronary intervention, mediastinal hematoma, vascular perforation

The sixth patient was a 52 year old male who had referred to clinic because of pancytopenia including thrombocytopenia and anemia and leukopenia and demonstrated MDS criteria in BMA. For this patient initiated nutrition drug but no needed to transfusion.\nDuring a 20 month follow up period, no considerable progression in MDS observed and he underwent treatment because of gastric cancer and after the end of treatment, his blood disorders totally resolved.

The first patients was a 27 year old female who has been referred because of Anemia and Leukopenia and during follow up due to Anemia continuity and refractory anemia, she underwent BMA and BMB and had MDS criteria ().\nBesides repeated blood injection along with supportive and therapeutic measures she had been followed up and during a 7 month period, she had a surgery because of Breast mass and she was diagnosed as breast cancer. Patient underwent chemotherapy and Anemia and Cytopenia has been completely resolved after the completion of treatment.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The second patient was a 49 year old man who was referred to clinic because of Macrocytic Anemia and low Retic count and he underwent BMA and BMB because of Anemia continuity and has diagnosed as MDS in BMA (, ).\nDuring follow up period, patient required blood injection once each 15 days, so thalidomide was started for him. He had frequent infections because of leukopenia and had a history of hospitalization. During follow up period and after 1.5 months of thalidomide initiation and 9 months later, he was affected by colon cancer and had no problem in CBC diff. after treatment of colon cancer.

The first patients was a 27 year old female who has been referred because of Anemia and Leukopenia and during follow up due to Anemia continuity and refractory anemia, she underwent BMA and BMB and had MDS criteria ().\nBesides repeated blood injection along with supportive and therapeutic measures she had been followed up and during a 7 month period, she had a surgery because of Breast mass and she was diagnosed as breast cancer. Patient underwent chemotherapy and Anemia and Cytopenia has been completely resolved after the completion of treatment.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The fifth patient was a 39 year old female who was referred because of severe Anemia and Cytopenia and she was diagnosed as MDS in BMA (). During a 4 month follow up period, she had a mass in supraclavicular area and after neck mass resection; she was diagnosed as Hodgkin's lymphoma and patients required blood injection and antibiotics for infection treatment. After the treatment of fourth and fifth patients, blood disorders are totally resolved. In next BMA review, Myelofibrosis or RS (reed-sternberg cell) wasn't seen.

The first patients was a 27 year old female who has been referred because of Anemia and Leukopenia and during follow up due to Anemia continuity and refractory anemia, she underwent BMA and BMB and had MDS criteria ().\nBesides repeated blood injection along with supportive and therapeutic measures she had been followed up and during a 7 month period, she had a surgery because of Breast mass and she was diagnosed as breast cancer. Patient underwent chemotherapy and Anemia and Cytopenia has been completely resolved after the completion of treatment.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The fourth patient was a 28 year old female who has been referred because of Macrocystic Anemia, thrombocytopenia and low Retic counts. During 6 months follow up interval, patient affected by neck mass and she was diagnosed as Hodgkin lymphoma. However she no need to blood transfusion but MDS criteria () disappeared after treatment of oncology disease.

The first patients was a 27 year old female who has been referred because of Anemia and Leukopenia and during follow up due to Anemia continuity and refractory anemia, she underwent BMA and BMB and had MDS criteria ().\nBesides repeated blood injection along with supportive and therapeutic measures she had been followed up and during a 7 month period, she had a surgery because of Breast mass and she was diagnosed as breast cancer. Patient underwent chemotherapy and Anemia and Cytopenia has been completely resolved after the completion of treatment.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The third patient was a 40 year old female due to refractory anemia and leucopenia. She underwent BMA and BMB and had MDS criteria including dyserithropoies and dysgranlopoiesis () who has been diagnosed by colon cancer during a12 months follow up period.

The first patients was a 27 year old female who has been referred because of Anemia and Leukopenia and during follow up due to Anemia continuity and refractory anemia, she underwent BMA and BMB and had MDS criteria ().\nBesides repeated blood injection along with supportive and therapeutic measures she had been followed up and during a 7 month period, she had a surgery because of Breast mass and she was diagnosed as breast cancer. Patient underwent chemotherapy and Anemia and Cytopenia has been completely resolved after the completion of treatment.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The second patient was a 49 year old man who was referred to clinic because of Macrocytic Anemia and low Retic count and he underwent BMA and BMB because of Anemia continuity and has diagnosed as MDS in BMA (, ).\nDuring follow up period, patient required blood injection once each 15 days, so thalidomide was started for him. He had frequent infections because of leukopenia and had a history of hospitalization. During follow up period and after 1.5 months of thalidomide initiation and 9 months later, he was affected by colon cancer and had no problem in CBC diff. after treatment of colon cancer.

The sixth patient was a 52 year old male who had referred to clinic because of pancytopenia including thrombocytopenia and anemia and leukopenia and demonstrated MDS criteria in BMA. For this patient initiated nutrition drug but no needed to transfusion.\nDuring a 20 month follow up period, no considerable progression in MDS observed and he underwent treatment because of gastric cancer and after the end of treatment, his blood disorders totally resolved.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The fifth patient was a 39 year old female who was referred because of severe Anemia and Cytopenia and she was diagnosed as MDS in BMA (). During a 4 month follow up period, she had a mass in supraclavicular area and after neck mass resection; she was diagnosed as Hodgkin's lymphoma and patients required blood injection and antibiotics for infection treatment. After the treatment of fourth and fifth patients, blood disorders are totally resolved. In next BMA review, Myelofibrosis or RS (reed-sternberg cell) wasn't seen.

The sixth patient was a 52 year old male who had referred to clinic because of pancytopenia including thrombocytopenia and anemia and leukopenia and demonstrated MDS criteria in BMA. For this patient initiated nutrition drug but no needed to transfusion.\nDuring a 20 month follow up period, no considerable progression in MDS observed and he underwent treatment because of gastric cancer and after the end of treatment, his blood disorders totally resolved.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The fourth patient was a 28 year old female who has been referred because of Macrocystic Anemia, thrombocytopenia and low Retic counts. During 6 months follow up interval, patient affected by neck mass and she was diagnosed as Hodgkin lymphoma. However she no need to blood transfusion but MDS criteria () disappeared after treatment of oncology disease.

The sixth patient was a 52 year old male who had referred to clinic because of pancytopenia including thrombocytopenia and anemia and leukopenia and demonstrated MDS criteria in BMA. For this patient initiated nutrition drug but no needed to transfusion.\nDuring a 20 month follow up period, no considerable progression in MDS observed and he underwent treatment because of gastric cancer and after the end of treatment, his blood disorders totally resolved.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The sixth patient was a 52 year old male who had referred to clinic because of pancytopenia including thrombocytopenia and anemia and leukopenia and demonstrated MDS criteria in BMA. For this patient initiated nutrition drug but no needed to transfusion.\nDuring a 20 month follow up period, no considerable progression in MDS observed and he underwent treatment because of gastric cancer and after the end of treatment, his blood disorders totally resolved.

The third patient was a 40 year old female due to refractory anemia and leucopenia. She underwent BMA and BMB and had MDS criteria including dyserithropoies and dysgranlopoiesis () who has been diagnosed by colon cancer during a12 months follow up period.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The fifth patient was a 39 year old female who was referred because of severe Anemia and Cytopenia and she was diagnosed as MDS in BMA (). During a 4 month follow up period, she had a mass in supraclavicular area and after neck mass resection; she was diagnosed as Hodgkin's lymphoma and patients required blood injection and antibiotics for infection treatment. After the treatment of fourth and fifth patients, blood disorders are totally resolved. In next BMA review, Myelofibrosis or RS (reed-sternberg cell) wasn't seen.

The second patient was a 49 year old man who was referred to clinic because of Macrocytic Anemia and low Retic count and he underwent BMA and BMB because of Anemia continuity and has diagnosed as MDS in BMA (, ).\nDuring follow up period, patient required blood injection once each 15 days, so thalidomide was started for him. He had frequent infections because of leukopenia and had a history of hospitalization. During follow up period and after 1.5 months of thalidomide initiation and 9 months later, he was affected by colon cancer and had no problem in CBC diff. after treatment of colon cancer.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The fourth patient was a 28 year old female who has been referred because of Macrocystic Anemia, thrombocytopenia and low Retic counts. During 6 months follow up interval, patient affected by neck mass and she was diagnosed as Hodgkin lymphoma. However she no need to blood transfusion but MDS criteria () disappeared after treatment of oncology disease.

The second patient was a 49 year old man who was referred to clinic because of Macrocytic Anemia and low Retic count and he underwent BMA and BMB because of Anemia continuity and has diagnosed as MDS in BMA (, ).\nDuring follow up period, patient required blood injection once each 15 days, so thalidomide was started for him. He had frequent infections because of leukopenia and had a history of hospitalization. During follow up period and after 1.5 months of thalidomide initiation and 9 months later, he was affected by colon cancer and had no problem in CBC diff. after treatment of colon cancer.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The third patient was a 40 year old female due to refractory anemia and leucopenia. She underwent BMA and BMB and had MDS criteria including dyserithropoies and dysgranlopoiesis () who has been diagnosed by colon cancer during a12 months follow up period.

The second patient was a 49 year old man who was referred to clinic because of Macrocytic Anemia and low Retic count and he underwent BMA and BMB because of Anemia continuity and has diagnosed as MDS in BMA (, ).\nDuring follow up period, patient required blood injection once each 15 days, so thalidomide was started for him. He had frequent infections because of leukopenia and had a history of hospitalization. During follow up period and after 1.5 months of thalidomide initiation and 9 months later, he was affected by colon cancer and had no problem in CBC diff. after treatment of colon cancer.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The fourth patient was a 28 year old female who has been referred because of Macrocystic Anemia, thrombocytopenia and low Retic counts. During 6 months follow up interval, patient affected by neck mass and she was diagnosed as Hodgkin lymphoma. However she no need to blood transfusion but MDS criteria () disappeared after treatment of oncology disease.

The fifth patient was a 39 year old female who was referred because of severe Anemia and Cytopenia and she was diagnosed as MDS in BMA (). During a 4 month follow up period, she had a mass in supraclavicular area and after neck mass resection; she was diagnosed as Hodgkin's lymphoma and patients required blood injection and antibiotics for infection treatment. After the treatment of fourth and fifth patients, blood disorders are totally resolved. In next BMA review, Myelofibrosis or RS (reed-sternberg cell) wasn't seen.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The third patient was a 40 year old female due to refractory anemia and leucopenia. She underwent BMA and BMB and had MDS criteria including dyserithropoies and dysgranlopoiesis () who has been diagnosed by colon cancer during a12 months follow up period.

The fifth patient was a 39 year old female who was referred because of severe Anemia and Cytopenia and she was diagnosed as MDS in BMA (). During a 4 month follow up period, she had a mass in supraclavicular area and after neck mass resection; she was diagnosed as Hodgkin's lymphoma and patients required blood injection and antibiotics for infection treatment. After the treatment of fourth and fifth patients, blood disorders are totally resolved. In next BMA review, Myelofibrosis or RS (reed-sternberg cell) wasn't seen.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

The third patient was a 40 year old female due to refractory anemia and leucopenia. She underwent BMA and BMB and had MDS criteria including dyserithropoies and dysgranlopoiesis () who has been diagnosed by colon cancer during a12 months follow up period.

The fourth patient was a 28 year old female who has been referred because of Macrocystic Anemia, thrombocytopenia and low Retic counts. During 6 months follow up interval, patient affected by neck mass and she was diagnosed as Hodgkin lymphoma. However she no need to blood transfusion but MDS criteria () disappeared after treatment of oncology disease.

Write a detailed clinical case vignette based on the following key phrases: Myelodysplastic Syndrome (MDS), Blood Disorders, Cancer Diagnosis and Treatment

A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.

An IVF cycle was planned for a 29-year-old nulligravida patient with unexplained infertility. Prior to this, she had one failed intrauterine insemination (IUI) and three failed IUI cycles with clomiphene citrate. The stimulation was performed with recombinant FSH and hMG using a short protocol with GnRH antagonist. Fourteen oocytes were aspirated during follicular puncture. Seven oocytes were fertilized and cultured. The cultured embryos were of relatively poor quality and the grading of the three embryos selected for transfer on day 3 was 6-cell, grade C; 4-cell, grade B; 4-cell grade C []. About 4 weeks later, three intrauterine gestational sacs were noted by transvaginal ultrasound (). At 7 weeks of gestation, a quintuplet pregnancy with monozygotic (monochorionic, triamniotic) triplets and dizygotic (dichorioinc diamniotic) twins was sonographically confirmed (). All five embryos demonstrated cardiac activity and were concordant. The patient was counseled and referred for selective fetal reduction of the monochorionic triamniotic triplets. This was performed without complications on the 12th week of her pregnancy. Amniocentesis of the triplets during fetal reduction showed normal chromosomes (46, XX) and no structural abnormalities. The pregnancy was subsequently complicated by preterm labor followed by emergency cesarean delivery due to nonreassuring fetal tracing resulting in delivery of healthy female and male babies at 30 weeks of gestation. Both babies were born in 2006 and are currently doing well.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 29-year-old woman with 2 years of primary infertility resulting from male factor infertility (oligoasthenospermia) and abnormal karyotype [45,XY, rob [, ] (q10;q10)] underwent PGD-ICSI treatment at the Center for Reproductive Medicine, Renji Hospital, Shanghai. During her first ART treatment cycle, stimulation was performed with daily administration of 150 units of recombinant follicle stimulating hormone (rFSH) (N.V.Organon, Netherlands) according to a standardised long protocol with Triptorelin 0.05 mg daily downregulation (Ferring, Germany). Following hCG trigger, 17 oocytes were collected, of which eight cleavage stage embryos were biopsied. Following fluorescent in situ hybridization (FISH), two normal euploid embryos were diagnosed, of which one was selected for transfer. The embryo selected had undergone single cell biopsy at the 10 cell stage and was subsequently transferred on day 4.\nThe woman successfully conceived, as confirmed by a hCG level of 2610 IU/L on day 15 post-transfer. Routine two-dimensional (2D) transvaginal ultrasound (US) by a reproductive medicine specialist on day 29 following transfer reported a single gestational sac (37 × 21 × 37 mm) with three yolk sacs and three foetal poles, all with heart beats. The TVU was repeated by the same doctor on day 35 post-transfer reporting a single gestational sac (52 × 19 × 40mm) with three viable foetuses with crown rump lengths (CRL) of 10.5, 8.1 and 10.0 mm. The couple was informed about the increased maternal and foetal risks with this condition and were counselled about the possibility of a foetal reduction procedure.\nAfter consideration, the couple decided to undergo foetal reduction at the prenatal diagnosis centre (PDC) of the First Maternal and Infant Hospital of Shanghai. At 13 + 2 weeks of the pregnancy, an abdominal US was performed by a foetal medicine specialist in fact revealed the presence of a MCQA pregnancy with four equal sized viable foetuses (CRL of 82, 83, 82 and 82 mm), all with nuchal translucency measurements within normal range. The woman subsequently underwent selective foetal reduction via use of radiofrequency ablation on two occasions, at 16 + 3 and 17 + 4 weeks of gestation. In the absence of any definitive evidence, reduction of only one foetus at a time was performed, with the assumption that it may reduce the risk of miscarriage in the remaining foetuses. The procedures were uncomplicated, and two healthy twin girls were delivered by elective Caesarean Section at 35 + 6 weeks of gestation, weighing 2060 and 1985 g. The placental specimen along with the two selectively reduced foetuses confirmed a MCQA pregnancy (Fig. ).

An IVF cycle was planned for a 29-year-old nulligravida patient with unexplained infertility. Prior to this, she had one failed intrauterine insemination (IUI) and three failed IUI cycles with clomiphene citrate. The stimulation was performed with recombinant FSH and hMG using a short protocol with GnRH antagonist. Fourteen oocytes were aspirated during follicular puncture. Seven oocytes were fertilized and cultured. The cultured embryos were of relatively poor quality and the grading of the three embryos selected for transfer on day 3 was 6-cell, grade C; 4-cell, grade B; 4-cell grade C []. About 4 weeks later, three intrauterine gestational sacs were noted by transvaginal ultrasound (). At 7 weeks of gestation, a quintuplet pregnancy with monozygotic (monochorionic, triamniotic) triplets and dizygotic (dichorioinc diamniotic) twins was sonographically confirmed (). All five embryos demonstrated cardiac activity and were concordant. The patient was counseled and referred for selective fetal reduction of the monochorionic triamniotic triplets. This was performed without complications on the 12th week of her pregnancy. Amniocentesis of the triplets during fetal reduction showed normal chromosomes (46, XX) and no structural abnormalities. The pregnancy was subsequently complicated by preterm labor followed by emergency cesarean delivery due to nonreassuring fetal tracing resulting in delivery of healthy female and male babies at 30 weeks of gestation. Both babies were born in 2006 and are currently doing well.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

An IVF cycle was planned for a 29-year-old nulligravida patient with unexplained infertility. Prior to this, she had one failed intrauterine insemination (IUI) and three failed IUI cycles with clomiphene citrate. The stimulation was performed with recombinant FSH and hMG using a short protocol with GnRH antagonist. Fourteen oocytes were aspirated during follicular puncture. Seven oocytes were fertilized and cultured. The cultured embryos were of relatively poor quality and the grading of the three embryos selected for transfer on day 3 was 6-cell, grade C; 4-cell, grade B; 4-cell grade C []. About 4 weeks later, three intrauterine gestational sacs were noted by transvaginal ultrasound (). At 7 weeks of gestation, a quintuplet pregnancy with monozygotic (monochorionic, triamniotic) triplets and dizygotic (dichorioinc diamniotic) twins was sonographically confirmed (). All five embryos demonstrated cardiac activity and were concordant. The patient was counseled and referred for selective fetal reduction of the monochorionic triamniotic triplets. This was performed without complications on the 12th week of her pregnancy. Amniocentesis of the triplets during fetal reduction showed normal chromosomes (46, XX) and no structural abnormalities. The pregnancy was subsequently complicated by preterm labor followed by emergency cesarean delivery due to nonreassuring fetal tracing resulting in delivery of healthy female and male babies at 30 weeks of gestation. Both babies were born in 2006 and are currently doing well.

A 34-year-old woman with 4 years of primary infertility (resulting from male-factor infertility) underwent IVF treatment at our clinic after several failed intrauterine inseminations. A mild stimulation protocol was performed using clomiphene and human menopausal gonadotropin (HMG; 150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Oocyte maturation was triggered using 1000 IU of human chorionic gonadotropin (hCG) (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Nine mature oocytes were collected, of which 7 were fertilized via intracytoplasmic sperm injection (ICSI) and cultured for 3 days. Embryo transfer was performed during the next cycle due to the endometrial thickness. Three day-3 embryos were cryopreserved. During the next cycle, a frozen-thawed embryo transfer was performed and she became pregnant. She delivered a healthy baby at 40 weeks of gestation.\nWanting another child, she requested a frozen embryo transfer when she was 39 years old. The endometrium was prepared with hormone replacement therapy (HRT). The two remaining embryos were of poor grade (Veeck’s classification: 9 cells grade 4 and 8 cells grade 4, respectively) and were transferred using assisted hatching under transabdominal ultrasound (US). Luteal progesterone support was administered for 2 weeks. The woman successfully conceived, as confirmed by an hCG level of 450 IU/L on day 11 post-transfer (4 weeks 0 days). HRT was continued and a transvaginal US was performed on day 18 post-transfer (5 weeks 0 days). There were two gestational sacs (GSs) with dizygotic twins suspected. On day 32 post-transfer (7 weeks 0 days), an US showed two GSs with three fetuses, and a dizygotic trichorionic triamniotic triplet pregnancy was suspected (Fig. ). On day 48 post-transfer (9 weeks 2 days), the heartbeat of one of the monozygotic twin fetuses had stopped, resulting in a dichorionic diamniotic twin pregnancy. The subsequent pregnancy course went well, and a healthy boy and girl were delivered by elective caesarean section at 36 weeks 5 days of gestation.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 34-year-old lady with 7 years of secondary infertility due to tubal factor underwent conventional IVF treatment at the University ART unit, Prince of Wales Hospital, Hong Kong. She had a previous first trimester miscarriage in 2007 and a right ectopic pregnancy in 2008, at which time she had a salpingectomy. Subsequent investigations including a laparoscopy confirmed blockage of the contralateral tube and evidence of endometriosis. During her first ART cycle, stimulation was performed with daily administration of 225 units of human menopausal gonadotrophin (hMG) (Serono, Aubonne/Switzerland) according to a standardised antagonist protocol with Ganirelix 0.25 mg downregulation (Merck Serono, Germany). Following hCG trigger, 14 mature oocytes were collected, of which 12 were fertilised, yielding 6 viable blastocysts (i.e. Gardner grading of BB grading or above) on day 5. No assisted hatching was performed, and a single expanding blastocyst (i.e. increasing blastocoel cavity with thinning of the zona pellucida and differentiation of the inner cell mass) was transferred to the patient on day 5. The remaining blastocysts were all cryopreserved following appropriate consent.\nThe woman successfully conceived, as confirmed by an hCG level of 154 IU/L on day 9 post-transfer. Routine 2D transvaginal US 23 days following transfer was suspicious of monochorionic twin or triplet pregnancy; therefore, a 3D US was performed on the same day demonstrating clearly a single gestational sac with three yolk sacs and three foetal poles (CRL of 4.5, 3.1 and 3.0 mm) (Fig. ). On day 36 following transfer, 3D US confirmed a MCTA pregnancy (Fig. ). The couple was informed appropriately regarding the increased maternal and foetal risks of higher order monozygotic gestations and was counselled regarding the possibility of a foetal reduction procedure.\nAfter being reviewed by the foetal medicine team of the Prince of Wales Hospital, an US at 11 + 5 weeks showed all three CRLs of the triplets to be within normal range, although the nuchal translucency was increased in one of the triplets (3.6 mm versus 2.3 and 1.2 for the other two). The couple subsequently decided to proceed with selective foetal reduction via use of radiofrequency ablation, which was successfully performed for the triplet with the thickest nuchal translucency at 14 + 1 weeks of gestation. The procedure was uncomplicated, and the remaining twins are well at the time of writing this article.

An IVF cycle was planned for a 29-year-old nulligravida patient with unexplained infertility. Prior to this, she had one failed intrauterine insemination (IUI) and three failed IUI cycles with clomiphene citrate. The stimulation was performed with recombinant FSH and hMG using a short protocol with GnRH antagonist. Fourteen oocytes were aspirated during follicular puncture. Seven oocytes were fertilized and cultured. The cultured embryos were of relatively poor quality and the grading of the three embryos selected for transfer on day 3 was 6-cell, grade C; 4-cell, grade B; 4-cell grade C []. About 4 weeks later, three intrauterine gestational sacs were noted by transvaginal ultrasound (). At 7 weeks of gestation, a quintuplet pregnancy with monozygotic (monochorionic, triamniotic) triplets and dizygotic (dichorioinc diamniotic) twins was sonographically confirmed (). All five embryos demonstrated cardiac activity and were concordant. The patient was counseled and referred for selective fetal reduction of the monochorionic triamniotic triplets. This was performed without complications on the 12th week of her pregnancy. Amniocentesis of the triplets during fetal reduction showed normal chromosomes (46, XX) and no structural abnormalities. The pregnancy was subsequently complicated by preterm labor followed by emergency cesarean delivery due to nonreassuring fetal tracing resulting in delivery of healthy female and male babies at 30 weeks of gestation. Both babies were born in 2006 and are currently doing well.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old nulligravida Asian female visited the Sendai Art Clinic with primary infertility, including anovulation for the past 2 years. She was diagnosed with PCOS according to the Rotterdam ESHRE/ASRM consensus criteria []. Hysterosalpingography showed bilateral tubal patency and no defects of uterine cavity. Her husband’s semen analysis showed normozoospermia, based on the 2010 World Health Organization criteria. After she had failed to achieve pregnancy following several courses of ovulation induction with clomiphene citrate or gonadotrophin injections, she opted for IVM treatment to retrieve germinal vesicle (GV) oocytes for in vitro culture. Informed consent was provided.\nShe was initiated on an IVM-in vitro fertilization (IVF) protocol on day 6 of a spontaneous menstrual cycle and given 4 days of 75 IU recombinant FSH (Gonal-F, Serono Japan, Tokyo, Japan). She was repetitively evaluated on days 6 and 8 of the menstrual cycle by transvaginal ultrasound scans. When the leading follicle size was less than 12 mm, 5000 IU of urinary human chorionic gonadotropin (hCG) (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan) was administered and oocyte retrieval was carried out 34 h after hCG triggering. The collection and culture of immature oocytes were performed as previously described [].\nFifteen GV stage immature oocytes were retrieved and incubated for 26 h in IVM culture medium (MediCult IVM medium, ORIGIO Japan, Yokohama, Japan) supplemented with recombinant FSH 75 mIU/ml (Gonal-F, Serono Japan, Tokyo, Japan), hCG 100 mIU/ml (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan), and 10% patient’s inactivated serum. The oocytes were then denuded from the cumulus cells. Eleven mature oocytes were obtained and subjected to ICSI with fresh sperm (Fig. ). Zygotes were cultured in culture medium (Universal IVF, ORIGIO Japan, Yokohama, Japan), and fertilization was judged 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Nine (81.8%) oocytes were fertilized. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA) and all embryos developed to blastocysts on day 5 (one middle expanding blastocyst and early blastocysts) and were cryopreserved by vitrification.\nFor the preparation of the endometrium, transcutaneous estradiol (Estrana TAPE 0.72 mg, Hisamitsu Pharmaceutical, Tokyo, Japan; four sheets every 2 days) was administered on day of the hormone replacement therapy (HRT). The endometrial lining was evaluated on days 12–14 of the HRT cycle and the endometrial thickness needed to be a minimum of 8 mm. A vaginal progesterone suppository (Luteum, Aska pharmacy, Tokyo, Japan; 2 tablets everyday) was administered when the endometrial thickness achieved was greater than 8 mm. The transcutaneous estradiol and vaginal progesterone suppository were continued until 9 weeks of gestation. A single frozen-thawed blastocyst (Gardner’s classification:4 BC) (Fig. ) was transferred under transvaginal ultrasound guidance on day 5 after vaginal progesterone suppository was administered. Two weeks after blastocyst transfer, the patient’s serum hCG concentration was 2194 IU/L and pregnancy was confirmed. Transvaginal ultrasound performed at 5 weeks and 0 days of gestation showed 2 gestational sacs inside the uterus. At 8 weeks 2 days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy was observed by ultrasound (Fig. ). The subsequent pregnancy course went well until 28 weeks 5 days when she was admitted to the maternal fetus intensive care unit for fetal growth restriction. She received prenatal steroids for fetal lung maturation and intravenous magnesium sulfate for tocolysis until the delivery. At 33 weeks 4 days, three baby girls were delivered by an elective Caesarean section. Their weight and APGAR scores at 1 min and 5 min were 1852 g, 8–8, 1817 g, 7–8, and 1495 g, 8–9, respectively. Histological examination of the placenta confirmed monochorionicity. The babies remained in the neonatology unit without morbidity and were discharged 4 weeks after birth.

An IVF cycle was planned for a 29-year-old nulligravida patient with unexplained infertility. Prior to this, she had one failed intrauterine insemination (IUI) and three failed IUI cycles with clomiphene citrate. The stimulation was performed with recombinant FSH and hMG using a short protocol with GnRH antagonist. Fourteen oocytes were aspirated during follicular puncture. Seven oocytes were fertilized and cultured. The cultured embryos were of relatively poor quality and the grading of the three embryos selected for transfer on day 3 was 6-cell, grade C; 4-cell, grade B; 4-cell grade C []. About 4 weeks later, three intrauterine gestational sacs were noted by transvaginal ultrasound (). At 7 weeks of gestation, a quintuplet pregnancy with monozygotic (monochorionic, triamniotic) triplets and dizygotic (dichorioinc diamniotic) twins was sonographically confirmed (). All five embryos demonstrated cardiac activity and were concordant. The patient was counseled and referred for selective fetal reduction of the monochorionic triamniotic triplets. This was performed without complications on the 12th week of her pregnancy. Amniocentesis of the triplets during fetal reduction showed normal chromosomes (46, XX) and no structural abnormalities. The pregnancy was subsequently complicated by preterm labor followed by emergency cesarean delivery due to nonreassuring fetal tracing resulting in delivery of healthy female and male babies at 30 weeks of gestation. Both babies were born in 2006 and are currently doing well.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

An IVF cycle was planned for a 29-year-old nulligravida patient with unexplained infertility. Prior to this, she had one failed intrauterine insemination (IUI) and three failed IUI cycles with clomiphene citrate. The stimulation was performed with recombinant FSH and hMG using a short protocol with GnRH antagonist. Fourteen oocytes were aspirated during follicular puncture. Seven oocytes were fertilized and cultured. The cultured embryos were of relatively poor quality and the grading of the three embryos selected for transfer on day 3 was 6-cell, grade C; 4-cell, grade B; 4-cell grade C []. About 4 weeks later, three intrauterine gestational sacs were noted by transvaginal ultrasound (). At 7 weeks of gestation, a quintuplet pregnancy with monozygotic (monochorionic, triamniotic) triplets and dizygotic (dichorioinc diamniotic) twins was sonographically confirmed (). All five embryos demonstrated cardiac activity and were concordant. The patient was counseled and referred for selective fetal reduction of the monochorionic triamniotic triplets. This was performed without complications on the 12th week of her pregnancy. Amniocentesis of the triplets during fetal reduction showed normal chromosomes (46, XX) and no structural abnormalities. The pregnancy was subsequently complicated by preterm labor followed by emergency cesarean delivery due to nonreassuring fetal tracing resulting in delivery of healthy female and male babies at 30 weeks of gestation. Both babies were born in 2006 and are currently doing well.

A 29-year-old woman presented with secondary infertility of 3-year duration. The couple was married for 6 years with regular menstrual cycles and normal husband's semen analysis. Her reproductive history included an ectopic pregnancy for which she had undergone the right salpingectomy and a missed miscarriage at 8 weeks pregnancy in the past. She had 4 failed intrauterine insemination cycles and was then planned for IVF in view of tubal factor.\nShe was started on the standard antagonist protocol and stimulated with 150 iu of recombinant follicle-stimulating hormone (rFSH; Gonal-F, Merck Serono, Geneva, Switzerland) and 75 iu of HMG-HP (Menopur, Ferring Pharmaceuticals, Sweden) daily. GnRH antagonist was started on day 6 of stimulation and administered daily till the day of human chorionic gonadotropin (hCG). Egg retrieval was performed 35 h after administration of 250 ug of recombinant hCG (rhCG; Ovitrelle, Merck Serono) and 16 oocytes were retrieved. The 15 metaphase II oocytes were subjected to conventional IVF since semen parameters were normal. 14 oocytes fertilized and after 5 days of in vitro culture (Vitrolife G1.3, Göteborg, Sweden), 6 blastocysts were obtained. Two top quality blastocysts (4AA, 2AA) were transferred, and 4 were cryopreserved. She received standard luteal support with vaginal progesterone gel (Crinone gel 8%, Merck Serono). A positive beta hCG was obtained 14 days after embryo transfer. Ultrasound performed at 5 weeks of pregnancy showed a single gestational sac. At 7 weeks of gestation, ultrasound revealed MCTA triplets with three yolk sacs and three fetal poles with cardiac activity in each [Figures and ]. In view of monochorionic gestation, she was offered fetal reduction by selective cord ligation at 16 weeks. Despite counseling about increased chances of antenatal complications with triplets, the couple chose to continue pregnancy without fetal reduction. She had an uneventful pregnancy till 17 weeks gestation after which she developed preterm premature rupture of membranes and cord prolapse. Her pregnancy was terminated using medical management.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

An IVF cycle was planned for a 29-year-old nulligravida patient with unexplained infertility. Prior to this, she had one failed intrauterine insemination (IUI) and three failed IUI cycles with clomiphene citrate. The stimulation was performed with recombinant FSH and hMG using a short protocol with GnRH antagonist. Fourteen oocytes were aspirated during follicular puncture. Seven oocytes were fertilized and cultured. The cultured embryos were of relatively poor quality and the grading of the three embryos selected for transfer on day 3 was 6-cell, grade C; 4-cell, grade B; 4-cell grade C []. About 4 weeks later, three intrauterine gestational sacs were noted by transvaginal ultrasound (). At 7 weeks of gestation, a quintuplet pregnancy with monozygotic (monochorionic, triamniotic) triplets and dizygotic (dichorioinc diamniotic) twins was sonographically confirmed (). All five embryos demonstrated cardiac activity and were concordant. The patient was counseled and referred for selective fetal reduction of the monochorionic triamniotic triplets. This was performed without complications on the 12th week of her pregnancy. Amniocentesis of the triplets during fetal reduction showed normal chromosomes (46, XX) and no structural abnormalities. The pregnancy was subsequently complicated by preterm labor followed by emergency cesarean delivery due to nonreassuring fetal tracing resulting in delivery of healthy female and male babies at 30 weeks of gestation. Both babies were born in 2006 and are currently doing well.

The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.

A 29-year-old woman with 2 years of primary infertility resulting from male factor infertility (oligoasthenospermia) and abnormal karyotype [45,XY, rob [, ] (q10;q10)] underwent PGD-ICSI treatment at the Center for Reproductive Medicine, Renji Hospital, Shanghai. During her first ART treatment cycle, stimulation was performed with daily administration of 150 units of recombinant follicle stimulating hormone (rFSH) (N.V.Organon, Netherlands) according to a standardised long protocol with Triptorelin 0.05 mg daily downregulation (Ferring, Germany). Following hCG trigger, 17 oocytes were collected, of which eight cleavage stage embryos were biopsied. Following fluorescent in situ hybridization (FISH), two normal euploid embryos were diagnosed, of which one was selected for transfer. The embryo selected had undergone single cell biopsy at the 10 cell stage and was subsequently transferred on day 4.\nThe woman successfully conceived, as confirmed by a hCG level of 2610 IU/L on day 15 post-transfer. Routine two-dimensional (2D) transvaginal ultrasound (US) by a reproductive medicine specialist on day 29 following transfer reported a single gestational sac (37 × 21 × 37 mm) with three yolk sacs and three foetal poles, all with heart beats. The TVU was repeated by the same doctor on day 35 post-transfer reporting a single gestational sac (52 × 19 × 40mm) with three viable foetuses with crown rump lengths (CRL) of 10.5, 8.1 and 10.0 mm. The couple was informed about the increased maternal and foetal risks with this condition and were counselled about the possibility of a foetal reduction procedure.\nAfter consideration, the couple decided to undergo foetal reduction at the prenatal diagnosis centre (PDC) of the First Maternal and Infant Hospital of Shanghai. At 13 + 2 weeks of the pregnancy, an abdominal US was performed by a foetal medicine specialist in fact revealed the presence of a MCQA pregnancy with four equal sized viable foetuses (CRL of 82, 83, 82 and 82 mm), all with nuchal translucency measurements within normal range. The woman subsequently underwent selective foetal reduction via use of radiofrequency ablation on two occasions, at 16 + 3 and 17 + 4 weeks of gestation. In the absence of any definitive evidence, reduction of only one foetus at a time was performed, with the assumption that it may reduce the risk of miscarriage in the remaining foetuses. The procedures were uncomplicated, and two healthy twin girls were delivered by elective Caesarean Section at 35 + 6 weeks of gestation, weighing 2060 and 1985 g. The placental specimen along with the two selectively reduced foetuses confirmed a MCQA pregnancy (Fig. ).

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.

A 34-year-old woman with 4 years of primary infertility (resulting from male-factor infertility) underwent IVF treatment at our clinic after several failed intrauterine inseminations. A mild stimulation protocol was performed using clomiphene and human menopausal gonadotropin (HMG; 150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Oocyte maturation was triggered using 1000 IU of human chorionic gonadotropin (hCG) (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Nine mature oocytes were collected, of which 7 were fertilized via intracytoplasmic sperm injection (ICSI) and cultured for 3 days. Embryo transfer was performed during the next cycle due to the endometrial thickness. Three day-3 embryos were cryopreserved. During the next cycle, a frozen-thawed embryo transfer was performed and she became pregnant. She delivered a healthy baby at 40 weeks of gestation.\nWanting another child, she requested a frozen embryo transfer when she was 39 years old. The endometrium was prepared with hormone replacement therapy (HRT). The two remaining embryos were of poor grade (Veeck’s classification: 9 cells grade 4 and 8 cells grade 4, respectively) and were transferred using assisted hatching under transabdominal ultrasound (US). Luteal progesterone support was administered for 2 weeks. The woman successfully conceived, as confirmed by an hCG level of 450 IU/L on day 11 post-transfer (4 weeks 0 days). HRT was continued and a transvaginal US was performed on day 18 post-transfer (5 weeks 0 days). There were two gestational sacs (GSs) with dizygotic twins suspected. On day 32 post-transfer (7 weeks 0 days), an US showed two GSs with three fetuses, and a dizygotic trichorionic triamniotic triplet pregnancy was suspected (Fig. ). On day 48 post-transfer (9 weeks 2 days), the heartbeat of one of the monozygotic twin fetuses had stopped, resulting in a dichorionic diamniotic twin pregnancy. The subsequent pregnancy course went well, and a healthy boy and girl were delivered by elective caesarean section at 36 weeks 5 days of gestation.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.

A 34-year-old lady with 7 years of secondary infertility due to tubal factor underwent conventional IVF treatment at the University ART unit, Prince of Wales Hospital, Hong Kong. She had a previous first trimester miscarriage in 2007 and a right ectopic pregnancy in 2008, at which time she had a salpingectomy. Subsequent investigations including a laparoscopy confirmed blockage of the contralateral tube and evidence of endometriosis. During her first ART cycle, stimulation was performed with daily administration of 225 units of human menopausal gonadotrophin (hMG) (Serono, Aubonne/Switzerland) according to a standardised antagonist protocol with Ganirelix 0.25 mg downregulation (Merck Serono, Germany). Following hCG trigger, 14 mature oocytes were collected, of which 12 were fertilised, yielding 6 viable blastocysts (i.e. Gardner grading of BB grading or above) on day 5. No assisted hatching was performed, and a single expanding blastocyst (i.e. increasing blastocoel cavity with thinning of the zona pellucida and differentiation of the inner cell mass) was transferred to the patient on day 5. The remaining blastocysts were all cryopreserved following appropriate consent.\nThe woman successfully conceived, as confirmed by an hCG level of 154 IU/L on day 9 post-transfer. Routine 2D transvaginal US 23 days following transfer was suspicious of monochorionic twin or triplet pregnancy; therefore, a 3D US was performed on the same day demonstrating clearly a single gestational sac with three yolk sacs and three foetal poles (CRL of 4.5, 3.1 and 3.0 mm) (Fig. ). On day 36 following transfer, 3D US confirmed a MCTA pregnancy (Fig. ). The couple was informed appropriately regarding the increased maternal and foetal risks of higher order monozygotic gestations and was counselled regarding the possibility of a foetal reduction procedure.\nAfter being reviewed by the foetal medicine team of the Prince of Wales Hospital, an US at 11 + 5 weeks showed all three CRLs of the triplets to be within normal range, although the nuchal translucency was increased in one of the triplets (3.6 mm versus 2.3 and 1.2 for the other two). The couple subsequently decided to proceed with selective foetal reduction via use of radiofrequency ablation, which was successfully performed for the triplet with the thickest nuchal translucency at 14 + 1 weeks of gestation. The procedure was uncomplicated, and the remaining twins are well at the time of writing this article.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.

A 32-year-old nulligravida Asian female visited the Sendai Art Clinic with primary infertility, including anovulation for the past 2 years. She was diagnosed with PCOS according to the Rotterdam ESHRE/ASRM consensus criteria []. Hysterosalpingography showed bilateral tubal patency and no defects of uterine cavity. Her husband’s semen analysis showed normozoospermia, based on the 2010 World Health Organization criteria. After she had failed to achieve pregnancy following several courses of ovulation induction with clomiphene citrate or gonadotrophin injections, she opted for IVM treatment to retrieve germinal vesicle (GV) oocytes for in vitro culture. Informed consent was provided.\nShe was initiated on an IVM-in vitro fertilization (IVF) protocol on day 6 of a spontaneous menstrual cycle and given 4 days of 75 IU recombinant FSH (Gonal-F, Serono Japan, Tokyo, Japan). She was repetitively evaluated on days 6 and 8 of the menstrual cycle by transvaginal ultrasound scans. When the leading follicle size was less than 12 mm, 5000 IU of urinary human chorionic gonadotropin (hCG) (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan) was administered and oocyte retrieval was carried out 34 h after hCG triggering. The collection and culture of immature oocytes were performed as previously described [].\nFifteen GV stage immature oocytes were retrieved and incubated for 26 h in IVM culture medium (MediCult IVM medium, ORIGIO Japan, Yokohama, Japan) supplemented with recombinant FSH 75 mIU/ml (Gonal-F, Serono Japan, Tokyo, Japan), hCG 100 mIU/ml (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan), and 10% patient’s inactivated serum. The oocytes were then denuded from the cumulus cells. Eleven mature oocytes were obtained and subjected to ICSI with fresh sperm (Fig. ). Zygotes were cultured in culture medium (Universal IVF, ORIGIO Japan, Yokohama, Japan), and fertilization was judged 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Nine (81.8%) oocytes were fertilized. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA) and all embryos developed to blastocysts on day 5 (one middle expanding blastocyst and early blastocysts) and were cryopreserved by vitrification.\nFor the preparation of the endometrium, transcutaneous estradiol (Estrana TAPE 0.72 mg, Hisamitsu Pharmaceutical, Tokyo, Japan; four sheets every 2 days) was administered on day of the hormone replacement therapy (HRT). The endometrial lining was evaluated on days 12–14 of the HRT cycle and the endometrial thickness needed to be a minimum of 8 mm. A vaginal progesterone suppository (Luteum, Aska pharmacy, Tokyo, Japan; 2 tablets everyday) was administered when the endometrial thickness achieved was greater than 8 mm. The transcutaneous estradiol and vaginal progesterone suppository were continued until 9 weeks of gestation. A single frozen-thawed blastocyst (Gardner’s classification:4 BC) (Fig. ) was transferred under transvaginal ultrasound guidance on day 5 after vaginal progesterone suppository was administered. Two weeks after blastocyst transfer, the patient’s serum hCG concentration was 2194 IU/L and pregnancy was confirmed. Transvaginal ultrasound performed at 5 weeks and 0 days of gestation showed 2 gestational sacs inside the uterus. At 8 weeks 2 days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy was observed by ultrasound (Fig. ). The subsequent pregnancy course went well until 28 weeks 5 days when she was admitted to the maternal fetus intensive care unit for fetal growth restriction. She received prenatal steroids for fetal lung maturation and intravenous magnesium sulfate for tocolysis until the delivery. At 33 weeks 4 days, three baby girls were delivered by an elective Caesarean section. Their weight and APGAR scores at 1 min and 5 min were 1852 g, 8–8, 1817 g, 7–8, and 1495 g, 8–9, respectively. Histological examination of the placenta confirmed monochorionicity. The babies remained in the neonatology unit without morbidity and were discharged 4 weeks after birth.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.

A 29-year-old woman presented with secondary infertility of 3-year duration. The couple was married for 6 years with regular menstrual cycles and normal husband's semen analysis. Her reproductive history included an ectopic pregnancy for which she had undergone the right salpingectomy and a missed miscarriage at 8 weeks pregnancy in the past. She had 4 failed intrauterine insemination cycles and was then planned for IVF in view of tubal factor.\nShe was started on the standard antagonist protocol and stimulated with 150 iu of recombinant follicle-stimulating hormone (rFSH; Gonal-F, Merck Serono, Geneva, Switzerland) and 75 iu of HMG-HP (Menopur, Ferring Pharmaceuticals, Sweden) daily. GnRH antagonist was started on day 6 of stimulation and administered daily till the day of human chorionic gonadotropin (hCG). Egg retrieval was performed 35 h after administration of 250 ug of recombinant hCG (rhCG; Ovitrelle, Merck Serono) and 16 oocytes were retrieved. The 15 metaphase II oocytes were subjected to conventional IVF since semen parameters were normal. 14 oocytes fertilized and after 5 days of in vitro culture (Vitrolife G1.3, Göteborg, Sweden), 6 blastocysts were obtained. Two top quality blastocysts (4AA, 2AA) were transferred, and 4 were cryopreserved. She received standard luteal support with vaginal progesterone gel (Crinone gel 8%, Merck Serono). A positive beta hCG was obtained 14 days after embryo transfer. Ultrasound performed at 5 weeks of pregnancy showed a single gestational sac. At 7 weeks of gestation, ultrasound revealed MCTA triplets with three yolk sacs and three fetal poles with cardiac activity in each [Figures and ]. In view of monochorionic gestation, she was offered fetal reduction by selective cord ligation at 16 weeks. Despite counseling about increased chances of antenatal complications with triplets, the couple chose to continue pregnancy without fetal reduction. She had an uneventful pregnancy till 17 weeks gestation after which she developed preterm premature rupture of membranes and cord prolapse. Her pregnancy was terminated using medical management.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.

The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 29-year-old woman with 2 years of primary infertility resulting from male factor infertility (oligoasthenospermia) and abnormal karyotype [45,XY, rob [, ] (q10;q10)] underwent PGD-ICSI treatment at the Center for Reproductive Medicine, Renji Hospital, Shanghai. During her first ART treatment cycle, stimulation was performed with daily administration of 150 units of recombinant follicle stimulating hormone (rFSH) (N.V.Organon, Netherlands) according to a standardised long protocol with Triptorelin 0.05 mg daily downregulation (Ferring, Germany). Following hCG trigger, 17 oocytes were collected, of which eight cleavage stage embryos were biopsied. Following fluorescent in situ hybridization (FISH), two normal euploid embryos were diagnosed, of which one was selected for transfer. The embryo selected had undergone single cell biopsy at the 10 cell stage and was subsequently transferred on day 4.\nThe woman successfully conceived, as confirmed by a hCG level of 2610 IU/L on day 15 post-transfer. Routine two-dimensional (2D) transvaginal ultrasound (US) by a reproductive medicine specialist on day 29 following transfer reported a single gestational sac (37 × 21 × 37 mm) with three yolk sacs and three foetal poles, all with heart beats. The TVU was repeated by the same doctor on day 35 post-transfer reporting a single gestational sac (52 × 19 × 40mm) with three viable foetuses with crown rump lengths (CRL) of 10.5, 8.1 and 10.0 mm. The couple was informed about the increased maternal and foetal risks with this condition and were counselled about the possibility of a foetal reduction procedure.\nAfter consideration, the couple decided to undergo foetal reduction at the prenatal diagnosis centre (PDC) of the First Maternal and Infant Hospital of Shanghai. At 13 + 2 weeks of the pregnancy, an abdominal US was performed by a foetal medicine specialist in fact revealed the presence of a MCQA pregnancy with four equal sized viable foetuses (CRL of 82, 83, 82 and 82 mm), all with nuchal translucency measurements within normal range. The woman subsequently underwent selective foetal reduction via use of radiofrequency ablation on two occasions, at 16 + 3 and 17 + 4 weeks of gestation. In the absence of any definitive evidence, reduction of only one foetus at a time was performed, with the assumption that it may reduce the risk of miscarriage in the remaining foetuses. The procedures were uncomplicated, and two healthy twin girls were delivered by elective Caesarean Section at 35 + 6 weeks of gestation, weighing 2060 and 1985 g. The placental specimen along with the two selectively reduced foetuses confirmed a MCQA pregnancy (Fig. ).

A 34-year-old woman with 4 years of primary infertility (resulting from male-factor infertility) underwent IVF treatment at our clinic after several failed intrauterine inseminations. A mild stimulation protocol was performed using clomiphene and human menopausal gonadotropin (HMG; 150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Oocyte maturation was triggered using 1000 IU of human chorionic gonadotropin (hCG) (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Nine mature oocytes were collected, of which 7 were fertilized via intracytoplasmic sperm injection (ICSI) and cultured for 3 days. Embryo transfer was performed during the next cycle due to the endometrial thickness. Three day-3 embryos were cryopreserved. During the next cycle, a frozen-thawed embryo transfer was performed and she became pregnant. She delivered a healthy baby at 40 weeks of gestation.\nWanting another child, she requested a frozen embryo transfer when she was 39 years old. The endometrium was prepared with hormone replacement therapy (HRT). The two remaining embryos were of poor grade (Veeck’s classification: 9 cells grade 4 and 8 cells grade 4, respectively) and were transferred using assisted hatching under transabdominal ultrasound (US). Luteal progesterone support was administered for 2 weeks. The woman successfully conceived, as confirmed by an hCG level of 450 IU/L on day 11 post-transfer (4 weeks 0 days). HRT was continued and a transvaginal US was performed on day 18 post-transfer (5 weeks 0 days). There were two gestational sacs (GSs) with dizygotic twins suspected. On day 32 post-transfer (7 weeks 0 days), an US showed two GSs with three fetuses, and a dizygotic trichorionic triamniotic triplet pregnancy was suspected (Fig. ). On day 48 post-transfer (9 weeks 2 days), the heartbeat of one of the monozygotic twin fetuses had stopped, resulting in a dichorionic diamniotic twin pregnancy. The subsequent pregnancy course went well, and a healthy boy and girl were delivered by elective caesarean section at 36 weeks 5 days of gestation.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 29-year-old woman with 2 years of primary infertility resulting from male factor infertility (oligoasthenospermia) and abnormal karyotype [45,XY, rob [, ] (q10;q10)] underwent PGD-ICSI treatment at the Center for Reproductive Medicine, Renji Hospital, Shanghai. During her first ART treatment cycle, stimulation was performed with daily administration of 150 units of recombinant follicle stimulating hormone (rFSH) (N.V.Organon, Netherlands) according to a standardised long protocol with Triptorelin 0.05 mg daily downregulation (Ferring, Germany). Following hCG trigger, 17 oocytes were collected, of which eight cleavage stage embryos were biopsied. Following fluorescent in situ hybridization (FISH), two normal euploid embryos were diagnosed, of which one was selected for transfer. The embryo selected had undergone single cell biopsy at the 10 cell stage and was subsequently transferred on day 4.\nThe woman successfully conceived, as confirmed by a hCG level of 2610 IU/L on day 15 post-transfer. Routine two-dimensional (2D) transvaginal ultrasound (US) by a reproductive medicine specialist on day 29 following transfer reported a single gestational sac (37 × 21 × 37 mm) with three yolk sacs and three foetal poles, all with heart beats. The TVU was repeated by the same doctor on day 35 post-transfer reporting a single gestational sac (52 × 19 × 40mm) with three viable foetuses with crown rump lengths (CRL) of 10.5, 8.1 and 10.0 mm. The couple was informed about the increased maternal and foetal risks with this condition and were counselled about the possibility of a foetal reduction procedure.\nAfter consideration, the couple decided to undergo foetal reduction at the prenatal diagnosis centre (PDC) of the First Maternal and Infant Hospital of Shanghai. At 13 + 2 weeks of the pregnancy, an abdominal US was performed by a foetal medicine specialist in fact revealed the presence of a MCQA pregnancy with four equal sized viable foetuses (CRL of 82, 83, 82 and 82 mm), all with nuchal translucency measurements within normal range. The woman subsequently underwent selective foetal reduction via use of radiofrequency ablation on two occasions, at 16 + 3 and 17 + 4 weeks of gestation. In the absence of any definitive evidence, reduction of only one foetus at a time was performed, with the assumption that it may reduce the risk of miscarriage in the remaining foetuses. The procedures were uncomplicated, and two healthy twin girls were delivered by elective Caesarean Section at 35 + 6 weeks of gestation, weighing 2060 and 1985 g. The placental specimen along with the two selectively reduced foetuses confirmed a MCQA pregnancy (Fig. ).

A 34-year-old lady with 7 years of secondary infertility due to tubal factor underwent conventional IVF treatment at the University ART unit, Prince of Wales Hospital, Hong Kong. She had a previous first trimester miscarriage in 2007 and a right ectopic pregnancy in 2008, at which time she had a salpingectomy. Subsequent investigations including a laparoscopy confirmed blockage of the contralateral tube and evidence of endometriosis. During her first ART cycle, stimulation was performed with daily administration of 225 units of human menopausal gonadotrophin (hMG) (Serono, Aubonne/Switzerland) according to a standardised antagonist protocol with Ganirelix 0.25 mg downregulation (Merck Serono, Germany). Following hCG trigger, 14 mature oocytes were collected, of which 12 were fertilised, yielding 6 viable blastocysts (i.e. Gardner grading of BB grading or above) on day 5. No assisted hatching was performed, and a single expanding blastocyst (i.e. increasing blastocoel cavity with thinning of the zona pellucida and differentiation of the inner cell mass) was transferred to the patient on day 5. The remaining blastocysts were all cryopreserved following appropriate consent.\nThe woman successfully conceived, as confirmed by an hCG level of 154 IU/L on day 9 post-transfer. Routine 2D transvaginal US 23 days following transfer was suspicious of monochorionic twin or triplet pregnancy; therefore, a 3D US was performed on the same day demonstrating clearly a single gestational sac with three yolk sacs and three foetal poles (CRL of 4.5, 3.1 and 3.0 mm) (Fig. ). On day 36 following transfer, 3D US confirmed a MCTA pregnancy (Fig. ). The couple was informed appropriately regarding the increased maternal and foetal risks of higher order monozygotic gestations and was counselled regarding the possibility of a foetal reduction procedure.\nAfter being reviewed by the foetal medicine team of the Prince of Wales Hospital, an US at 11 + 5 weeks showed all three CRLs of the triplets to be within normal range, although the nuchal translucency was increased in one of the triplets (3.6 mm versus 2.3 and 1.2 for the other two). The couple subsequently decided to proceed with selective foetal reduction via use of radiofrequency ablation, which was successfully performed for the triplet with the thickest nuchal translucency at 14 + 1 weeks of gestation. The procedure was uncomplicated, and the remaining twins are well at the time of writing this article.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 29-year-old woman with 2 years of primary infertility resulting from male factor infertility (oligoasthenospermia) and abnormal karyotype [45,XY, rob [, ] (q10;q10)] underwent PGD-ICSI treatment at the Center for Reproductive Medicine, Renji Hospital, Shanghai. During her first ART treatment cycle, stimulation was performed with daily administration of 150 units of recombinant follicle stimulating hormone (rFSH) (N.V.Organon, Netherlands) according to a standardised long protocol with Triptorelin 0.05 mg daily downregulation (Ferring, Germany). Following hCG trigger, 17 oocytes were collected, of which eight cleavage stage embryos were biopsied. Following fluorescent in situ hybridization (FISH), two normal euploid embryos were diagnosed, of which one was selected for transfer. The embryo selected had undergone single cell biopsy at the 10 cell stage and was subsequently transferred on day 4.\nThe woman successfully conceived, as confirmed by a hCG level of 2610 IU/L on day 15 post-transfer. Routine two-dimensional (2D) transvaginal ultrasound (US) by a reproductive medicine specialist on day 29 following transfer reported a single gestational sac (37 × 21 × 37 mm) with three yolk sacs and three foetal poles, all with heart beats. The TVU was repeated by the same doctor on day 35 post-transfer reporting a single gestational sac (52 × 19 × 40mm) with three viable foetuses with crown rump lengths (CRL) of 10.5, 8.1 and 10.0 mm. The couple was informed about the increased maternal and foetal risks with this condition and were counselled about the possibility of a foetal reduction procedure.\nAfter consideration, the couple decided to undergo foetal reduction at the prenatal diagnosis centre (PDC) of the First Maternal and Infant Hospital of Shanghai. At 13 + 2 weeks of the pregnancy, an abdominal US was performed by a foetal medicine specialist in fact revealed the presence of a MCQA pregnancy with four equal sized viable foetuses (CRL of 82, 83, 82 and 82 mm), all with nuchal translucency measurements within normal range. The woman subsequently underwent selective foetal reduction via use of radiofrequency ablation on two occasions, at 16 + 3 and 17 + 4 weeks of gestation. In the absence of any definitive evidence, reduction of only one foetus at a time was performed, with the assumption that it may reduce the risk of miscarriage in the remaining foetuses. The procedures were uncomplicated, and two healthy twin girls were delivered by elective Caesarean Section at 35 + 6 weeks of gestation, weighing 2060 and 1985 g. The placental specimen along with the two selectively reduced foetuses confirmed a MCQA pregnancy (Fig. ).

A 32-year-old nulligravida Asian female visited the Sendai Art Clinic with primary infertility, including anovulation for the past 2 years. She was diagnosed with PCOS according to the Rotterdam ESHRE/ASRM consensus criteria []. Hysterosalpingography showed bilateral tubal patency and no defects of uterine cavity. Her husband’s semen analysis showed normozoospermia, based on the 2010 World Health Organization criteria. After she had failed to achieve pregnancy following several courses of ovulation induction with clomiphene citrate or gonadotrophin injections, she opted for IVM treatment to retrieve germinal vesicle (GV) oocytes for in vitro culture. Informed consent was provided.\nShe was initiated on an IVM-in vitro fertilization (IVF) protocol on day 6 of a spontaneous menstrual cycle and given 4 days of 75 IU recombinant FSH (Gonal-F, Serono Japan, Tokyo, Japan). She was repetitively evaluated on days 6 and 8 of the menstrual cycle by transvaginal ultrasound scans. When the leading follicle size was less than 12 mm, 5000 IU of urinary human chorionic gonadotropin (hCG) (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan) was administered and oocyte retrieval was carried out 34 h after hCG triggering. The collection and culture of immature oocytes were performed as previously described [].\nFifteen GV stage immature oocytes were retrieved and incubated for 26 h in IVM culture medium (MediCult IVM medium, ORIGIO Japan, Yokohama, Japan) supplemented with recombinant FSH 75 mIU/ml (Gonal-F, Serono Japan, Tokyo, Japan), hCG 100 mIU/ml (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan), and 10% patient’s inactivated serum. The oocytes were then denuded from the cumulus cells. Eleven mature oocytes were obtained and subjected to ICSI with fresh sperm (Fig. ). Zygotes were cultured in culture medium (Universal IVF, ORIGIO Japan, Yokohama, Japan), and fertilization was judged 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Nine (81.8%) oocytes were fertilized. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA) and all embryos developed to blastocysts on day 5 (one middle expanding blastocyst and early blastocysts) and were cryopreserved by vitrification.\nFor the preparation of the endometrium, transcutaneous estradiol (Estrana TAPE 0.72 mg, Hisamitsu Pharmaceutical, Tokyo, Japan; four sheets every 2 days) was administered on day of the hormone replacement therapy (HRT). The endometrial lining was evaluated on days 12–14 of the HRT cycle and the endometrial thickness needed to be a minimum of 8 mm. A vaginal progesterone suppository (Luteum, Aska pharmacy, Tokyo, Japan; 2 tablets everyday) was administered when the endometrial thickness achieved was greater than 8 mm. The transcutaneous estradiol and vaginal progesterone suppository were continued until 9 weeks of gestation. A single frozen-thawed blastocyst (Gardner’s classification:4 BC) (Fig. ) was transferred under transvaginal ultrasound guidance on day 5 after vaginal progesterone suppository was administered. Two weeks after blastocyst transfer, the patient’s serum hCG concentration was 2194 IU/L and pregnancy was confirmed. Transvaginal ultrasound performed at 5 weeks and 0 days of gestation showed 2 gestational sacs inside the uterus. At 8 weeks 2 days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy was observed by ultrasound (Fig. ). The subsequent pregnancy course went well until 28 weeks 5 days when she was admitted to the maternal fetus intensive care unit for fetal growth restriction. She received prenatal steroids for fetal lung maturation and intravenous magnesium sulfate for tocolysis until the delivery. At 33 weeks 4 days, three baby girls were delivered by an elective Caesarean section. Their weight and APGAR scores at 1 min and 5 min were 1852 g, 8–8, 1817 g, 7–8, and 1495 g, 8–9, respectively. Histological examination of the placenta confirmed monochorionicity. The babies remained in the neonatology unit without morbidity and were discharged 4 weeks after birth.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 29-year-old woman with 2 years of primary infertility resulting from male factor infertility (oligoasthenospermia) and abnormal karyotype [45,XY, rob [, ] (q10;q10)] underwent PGD-ICSI treatment at the Center for Reproductive Medicine, Renji Hospital, Shanghai. During her first ART treatment cycle, stimulation was performed with daily administration of 150 units of recombinant follicle stimulating hormone (rFSH) (N.V.Organon, Netherlands) according to a standardised long protocol with Triptorelin 0.05 mg daily downregulation (Ferring, Germany). Following hCG trigger, 17 oocytes were collected, of which eight cleavage stage embryos were biopsied. Following fluorescent in situ hybridization (FISH), two normal euploid embryos were diagnosed, of which one was selected for transfer. The embryo selected had undergone single cell biopsy at the 10 cell stage and was subsequently transferred on day 4.\nThe woman successfully conceived, as confirmed by a hCG level of 2610 IU/L on day 15 post-transfer. Routine two-dimensional (2D) transvaginal ultrasound (US) by a reproductive medicine specialist on day 29 following transfer reported a single gestational sac (37 × 21 × 37 mm) with three yolk sacs and three foetal poles, all with heart beats. The TVU was repeated by the same doctor on day 35 post-transfer reporting a single gestational sac (52 × 19 × 40mm) with three viable foetuses with crown rump lengths (CRL) of 10.5, 8.1 and 10.0 mm. The couple was informed about the increased maternal and foetal risks with this condition and were counselled about the possibility of a foetal reduction procedure.\nAfter consideration, the couple decided to undergo foetal reduction at the prenatal diagnosis centre (PDC) of the First Maternal and Infant Hospital of Shanghai. At 13 + 2 weeks of the pregnancy, an abdominal US was performed by a foetal medicine specialist in fact revealed the presence of a MCQA pregnancy with four equal sized viable foetuses (CRL of 82, 83, 82 and 82 mm), all with nuchal translucency measurements within normal range. The woman subsequently underwent selective foetal reduction via use of radiofrequency ablation on two occasions, at 16 + 3 and 17 + 4 weeks of gestation. In the absence of any definitive evidence, reduction of only one foetus at a time was performed, with the assumption that it may reduce the risk of miscarriage in the remaining foetuses. The procedures were uncomplicated, and two healthy twin girls were delivered by elective Caesarean Section at 35 + 6 weeks of gestation, weighing 2060 and 1985 g. The placental specimen along with the two selectively reduced foetuses confirmed a MCQA pregnancy (Fig. ).

A 29-year-old woman presented with secondary infertility of 3-year duration. The couple was married for 6 years with regular menstrual cycles and normal husband's semen analysis. Her reproductive history included an ectopic pregnancy for which she had undergone the right salpingectomy and a missed miscarriage at 8 weeks pregnancy in the past. She had 4 failed intrauterine insemination cycles and was then planned for IVF in view of tubal factor.\nShe was started on the standard antagonist protocol and stimulated with 150 iu of recombinant follicle-stimulating hormone (rFSH; Gonal-F, Merck Serono, Geneva, Switzerland) and 75 iu of HMG-HP (Menopur, Ferring Pharmaceuticals, Sweden) daily. GnRH antagonist was started on day 6 of stimulation and administered daily till the day of human chorionic gonadotropin (hCG). Egg retrieval was performed 35 h after administration of 250 ug of recombinant hCG (rhCG; Ovitrelle, Merck Serono) and 16 oocytes were retrieved. The 15 metaphase II oocytes were subjected to conventional IVF since semen parameters were normal. 14 oocytes fertilized and after 5 days of in vitro culture (Vitrolife G1.3, Göteborg, Sweden), 6 blastocysts were obtained. Two top quality blastocysts (4AA, 2AA) were transferred, and 4 were cryopreserved. She received standard luteal support with vaginal progesterone gel (Crinone gel 8%, Merck Serono). A positive beta hCG was obtained 14 days after embryo transfer. Ultrasound performed at 5 weeks of pregnancy showed a single gestational sac. At 7 weeks of gestation, ultrasound revealed MCTA triplets with three yolk sacs and three fetal poles with cardiac activity in each [Figures and ]. In view of monochorionic gestation, she was offered fetal reduction by selective cord ligation at 16 weeks. Despite counseling about increased chances of antenatal complications with triplets, the couple chose to continue pregnancy without fetal reduction. She had an uneventful pregnancy till 17 weeks gestation after which she developed preterm premature rupture of membranes and cord prolapse. Her pregnancy was terminated using medical management.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 29-year-old woman with 2 years of primary infertility resulting from male factor infertility (oligoasthenospermia) and abnormal karyotype [45,XY, rob [, ] (q10;q10)] underwent PGD-ICSI treatment at the Center for Reproductive Medicine, Renji Hospital, Shanghai. During her first ART treatment cycle, stimulation was performed with daily administration of 150 units of recombinant follicle stimulating hormone (rFSH) (N.V.Organon, Netherlands) according to a standardised long protocol with Triptorelin 0.05 mg daily downregulation (Ferring, Germany). Following hCG trigger, 17 oocytes were collected, of which eight cleavage stage embryos were biopsied. Following fluorescent in situ hybridization (FISH), two normal euploid embryos were diagnosed, of which one was selected for transfer. The embryo selected had undergone single cell biopsy at the 10 cell stage and was subsequently transferred on day 4.\nThe woman successfully conceived, as confirmed by a hCG level of 2610 IU/L on day 15 post-transfer. Routine two-dimensional (2D) transvaginal ultrasound (US) by a reproductive medicine specialist on day 29 following transfer reported a single gestational sac (37 × 21 × 37 mm) with three yolk sacs and three foetal poles, all with heart beats. The TVU was repeated by the same doctor on day 35 post-transfer reporting a single gestational sac (52 × 19 × 40mm) with three viable foetuses with crown rump lengths (CRL) of 10.5, 8.1 and 10.0 mm. The couple was informed about the increased maternal and foetal risks with this condition and were counselled about the possibility of a foetal reduction procedure.\nAfter consideration, the couple decided to undergo foetal reduction at the prenatal diagnosis centre (PDC) of the First Maternal and Infant Hospital of Shanghai. At 13 + 2 weeks of the pregnancy, an abdominal US was performed by a foetal medicine specialist in fact revealed the presence of a MCQA pregnancy with four equal sized viable foetuses (CRL of 82, 83, 82 and 82 mm), all with nuchal translucency measurements within normal range. The woman subsequently underwent selective foetal reduction via use of radiofrequency ablation on two occasions, at 16 + 3 and 17 + 4 weeks of gestation. In the absence of any definitive evidence, reduction of only one foetus at a time was performed, with the assumption that it may reduce the risk of miscarriage in the remaining foetuses. The procedures were uncomplicated, and two healthy twin girls were delivered by elective Caesarean Section at 35 + 6 weeks of gestation, weighing 2060 and 1985 g. The placental specimen along with the two selectively reduced foetuses confirmed a MCQA pregnancy (Fig. ).

The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 34-year-old lady with 7 years of secondary infertility due to tubal factor underwent conventional IVF treatment at the University ART unit, Prince of Wales Hospital, Hong Kong. She had a previous first trimester miscarriage in 2007 and a right ectopic pregnancy in 2008, at which time she had a salpingectomy. Subsequent investigations including a laparoscopy confirmed blockage of the contralateral tube and evidence of endometriosis. During her first ART cycle, stimulation was performed with daily administration of 225 units of human menopausal gonadotrophin (hMG) (Serono, Aubonne/Switzerland) according to a standardised antagonist protocol with Ganirelix 0.25 mg downregulation (Merck Serono, Germany). Following hCG trigger, 14 mature oocytes were collected, of which 12 were fertilised, yielding 6 viable blastocysts (i.e. Gardner grading of BB grading or above) on day 5. No assisted hatching was performed, and a single expanding blastocyst (i.e. increasing blastocoel cavity with thinning of the zona pellucida and differentiation of the inner cell mass) was transferred to the patient on day 5. The remaining blastocysts were all cryopreserved following appropriate consent.\nThe woman successfully conceived, as confirmed by an hCG level of 154 IU/L on day 9 post-transfer. Routine 2D transvaginal US 23 days following transfer was suspicious of monochorionic twin or triplet pregnancy; therefore, a 3D US was performed on the same day demonstrating clearly a single gestational sac with three yolk sacs and three foetal poles (CRL of 4.5, 3.1 and 3.0 mm) (Fig. ). On day 36 following transfer, 3D US confirmed a MCTA pregnancy (Fig. ). The couple was informed appropriately regarding the increased maternal and foetal risks of higher order monozygotic gestations and was counselled regarding the possibility of a foetal reduction procedure.\nAfter being reviewed by the foetal medicine team of the Prince of Wales Hospital, an US at 11 + 5 weeks showed all three CRLs of the triplets to be within normal range, although the nuchal translucency was increased in one of the triplets (3.6 mm versus 2.3 and 1.2 for the other two). The couple subsequently decided to proceed with selective foetal reduction via use of radiofrequency ablation, which was successfully performed for the triplet with the thickest nuchal translucency at 14 + 1 weeks of gestation. The procedure was uncomplicated, and the remaining twins are well at the time of writing this article.

A 34-year-old woman with 4 years of primary infertility (resulting from male-factor infertility) underwent IVF treatment at our clinic after several failed intrauterine inseminations. A mild stimulation protocol was performed using clomiphene and human menopausal gonadotropin (HMG; 150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Oocyte maturation was triggered using 1000 IU of human chorionic gonadotropin (hCG) (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Nine mature oocytes were collected, of which 7 were fertilized via intracytoplasmic sperm injection (ICSI) and cultured for 3 days. Embryo transfer was performed during the next cycle due to the endometrial thickness. Three day-3 embryos were cryopreserved. During the next cycle, a frozen-thawed embryo transfer was performed and she became pregnant. She delivered a healthy baby at 40 weeks of gestation.\nWanting another child, she requested a frozen embryo transfer when she was 39 years old. The endometrium was prepared with hormone replacement therapy (HRT). The two remaining embryos were of poor grade (Veeck’s classification: 9 cells grade 4 and 8 cells grade 4, respectively) and were transferred using assisted hatching under transabdominal ultrasound (US). Luteal progesterone support was administered for 2 weeks. The woman successfully conceived, as confirmed by an hCG level of 450 IU/L on day 11 post-transfer (4 weeks 0 days). HRT was continued and a transvaginal US was performed on day 18 post-transfer (5 weeks 0 days). There were two gestational sacs (GSs) with dizygotic twins suspected. On day 32 post-transfer (7 weeks 0 days), an US showed two GSs with three fetuses, and a dizygotic trichorionic triamniotic triplet pregnancy was suspected (Fig. ). On day 48 post-transfer (9 weeks 2 days), the heartbeat of one of the monozygotic twin fetuses had stopped, resulting in a dichorionic diamniotic twin pregnancy. The subsequent pregnancy course went well, and a healthy boy and girl were delivered by elective caesarean section at 36 weeks 5 days of gestation.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 34-year-old woman with 4 years of primary infertility (resulting from male-factor infertility) underwent IVF treatment at our clinic after several failed intrauterine inseminations. A mild stimulation protocol was performed using clomiphene and human menopausal gonadotropin (HMG; 150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Oocyte maturation was triggered using 1000 IU of human chorionic gonadotropin (hCG) (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Nine mature oocytes were collected, of which 7 were fertilized via intracytoplasmic sperm injection (ICSI) and cultured for 3 days. Embryo transfer was performed during the next cycle due to the endometrial thickness. Three day-3 embryos were cryopreserved. During the next cycle, a frozen-thawed embryo transfer was performed and she became pregnant. She delivered a healthy baby at 40 weeks of gestation.\nWanting another child, she requested a frozen embryo transfer when she was 39 years old. The endometrium was prepared with hormone replacement therapy (HRT). The two remaining embryos were of poor grade (Veeck’s classification: 9 cells grade 4 and 8 cells grade 4, respectively) and were transferred using assisted hatching under transabdominal ultrasound (US). Luteal progesterone support was administered for 2 weeks. The woman successfully conceived, as confirmed by an hCG level of 450 IU/L on day 11 post-transfer (4 weeks 0 days). HRT was continued and a transvaginal US was performed on day 18 post-transfer (5 weeks 0 days). There were two gestational sacs (GSs) with dizygotic twins suspected. On day 32 post-transfer (7 weeks 0 days), an US showed two GSs with three fetuses, and a dizygotic trichorionic triamniotic triplet pregnancy was suspected (Fig. ). On day 48 post-transfer (9 weeks 2 days), the heartbeat of one of the monozygotic twin fetuses had stopped, resulting in a dichorionic diamniotic twin pregnancy. The subsequent pregnancy course went well, and a healthy boy and girl were delivered by elective caesarean section at 36 weeks 5 days of gestation.

A 32-year-old nulligravida Asian female visited the Sendai Art Clinic with primary infertility, including anovulation for the past 2 years. She was diagnosed with PCOS according to the Rotterdam ESHRE/ASRM consensus criteria []. Hysterosalpingography showed bilateral tubal patency and no defects of uterine cavity. Her husband’s semen analysis showed normozoospermia, based on the 2010 World Health Organization criteria. After she had failed to achieve pregnancy following several courses of ovulation induction with clomiphene citrate or gonadotrophin injections, she opted for IVM treatment to retrieve germinal vesicle (GV) oocytes for in vitro culture. Informed consent was provided.\nShe was initiated on an IVM-in vitro fertilization (IVF) protocol on day 6 of a spontaneous menstrual cycle and given 4 days of 75 IU recombinant FSH (Gonal-F, Serono Japan, Tokyo, Japan). She was repetitively evaluated on days 6 and 8 of the menstrual cycle by transvaginal ultrasound scans. When the leading follicle size was less than 12 mm, 5000 IU of urinary human chorionic gonadotropin (hCG) (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan) was administered and oocyte retrieval was carried out 34 h after hCG triggering. The collection and culture of immature oocytes were performed as previously described [].\nFifteen GV stage immature oocytes were retrieved and incubated for 26 h in IVM culture medium (MediCult IVM medium, ORIGIO Japan, Yokohama, Japan) supplemented with recombinant FSH 75 mIU/ml (Gonal-F, Serono Japan, Tokyo, Japan), hCG 100 mIU/ml (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan), and 10% patient’s inactivated serum. The oocytes were then denuded from the cumulus cells. Eleven mature oocytes were obtained and subjected to ICSI with fresh sperm (Fig. ). Zygotes were cultured in culture medium (Universal IVF, ORIGIO Japan, Yokohama, Japan), and fertilization was judged 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Nine (81.8%) oocytes were fertilized. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA) and all embryos developed to blastocysts on day 5 (one middle expanding blastocyst and early blastocysts) and were cryopreserved by vitrification.\nFor the preparation of the endometrium, transcutaneous estradiol (Estrana TAPE 0.72 mg, Hisamitsu Pharmaceutical, Tokyo, Japan; four sheets every 2 days) was administered on day of the hormone replacement therapy (HRT). The endometrial lining was evaluated on days 12–14 of the HRT cycle and the endometrial thickness needed to be a minimum of 8 mm. A vaginal progesterone suppository (Luteum, Aska pharmacy, Tokyo, Japan; 2 tablets everyday) was administered when the endometrial thickness achieved was greater than 8 mm. The transcutaneous estradiol and vaginal progesterone suppository were continued until 9 weeks of gestation. A single frozen-thawed blastocyst (Gardner’s classification:4 BC) (Fig. ) was transferred under transvaginal ultrasound guidance on day 5 after vaginal progesterone suppository was administered. Two weeks after blastocyst transfer, the patient’s serum hCG concentration was 2194 IU/L and pregnancy was confirmed. Transvaginal ultrasound performed at 5 weeks and 0 days of gestation showed 2 gestational sacs inside the uterus. At 8 weeks 2 days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy was observed by ultrasound (Fig. ). The subsequent pregnancy course went well until 28 weeks 5 days when she was admitted to the maternal fetus intensive care unit for fetal growth restriction. She received prenatal steroids for fetal lung maturation and intravenous magnesium sulfate for tocolysis until the delivery. At 33 weeks 4 days, three baby girls were delivered by an elective Caesarean section. Their weight and APGAR scores at 1 min and 5 min were 1852 g, 8–8, 1817 g, 7–8, and 1495 g, 8–9, respectively. Histological examination of the placenta confirmed monochorionicity. The babies remained in the neonatology unit without morbidity and were discharged 4 weeks after birth.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 34-year-old woman with 4 years of primary infertility (resulting from male-factor infertility) underwent IVF treatment at our clinic after several failed intrauterine inseminations. A mild stimulation protocol was performed using clomiphene and human menopausal gonadotropin (HMG; 150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Oocyte maturation was triggered using 1000 IU of human chorionic gonadotropin (hCG) (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Nine mature oocytes were collected, of which 7 were fertilized via intracytoplasmic sperm injection (ICSI) and cultured for 3 days. Embryo transfer was performed during the next cycle due to the endometrial thickness. Three day-3 embryos were cryopreserved. During the next cycle, a frozen-thawed embryo transfer was performed and she became pregnant. She delivered a healthy baby at 40 weeks of gestation.\nWanting another child, she requested a frozen embryo transfer when she was 39 years old. The endometrium was prepared with hormone replacement therapy (HRT). The two remaining embryos were of poor grade (Veeck’s classification: 9 cells grade 4 and 8 cells grade 4, respectively) and were transferred using assisted hatching under transabdominal ultrasound (US). Luteal progesterone support was administered for 2 weeks. The woman successfully conceived, as confirmed by an hCG level of 450 IU/L on day 11 post-transfer (4 weeks 0 days). HRT was continued and a transvaginal US was performed on day 18 post-transfer (5 weeks 0 days). There were two gestational sacs (GSs) with dizygotic twins suspected. On day 32 post-transfer (7 weeks 0 days), an US showed two GSs with three fetuses, and a dizygotic trichorionic triamniotic triplet pregnancy was suspected (Fig. ). On day 48 post-transfer (9 weeks 2 days), the heartbeat of one of the monozygotic twin fetuses had stopped, resulting in a dichorionic diamniotic twin pregnancy. The subsequent pregnancy course went well, and a healthy boy and girl were delivered by elective caesarean section at 36 weeks 5 days of gestation.

A 29-year-old woman presented with secondary infertility of 3-year duration. The couple was married for 6 years with regular menstrual cycles and normal husband's semen analysis. Her reproductive history included an ectopic pregnancy for which she had undergone the right salpingectomy and a missed miscarriage at 8 weeks pregnancy in the past. She had 4 failed intrauterine insemination cycles and was then planned for IVF in view of tubal factor.\nShe was started on the standard antagonist protocol and stimulated with 150 iu of recombinant follicle-stimulating hormone (rFSH; Gonal-F, Merck Serono, Geneva, Switzerland) and 75 iu of HMG-HP (Menopur, Ferring Pharmaceuticals, Sweden) daily. GnRH antagonist was started on day 6 of stimulation and administered daily till the day of human chorionic gonadotropin (hCG). Egg retrieval was performed 35 h after administration of 250 ug of recombinant hCG (rhCG; Ovitrelle, Merck Serono) and 16 oocytes were retrieved. The 15 metaphase II oocytes were subjected to conventional IVF since semen parameters were normal. 14 oocytes fertilized and after 5 days of in vitro culture (Vitrolife G1.3, Göteborg, Sweden), 6 blastocysts were obtained. Two top quality blastocysts (4AA, 2AA) were transferred, and 4 were cryopreserved. She received standard luteal support with vaginal progesterone gel (Crinone gel 8%, Merck Serono). A positive beta hCG was obtained 14 days after embryo transfer. Ultrasound performed at 5 weeks of pregnancy showed a single gestational sac. At 7 weeks of gestation, ultrasound revealed MCTA triplets with three yolk sacs and three fetal poles with cardiac activity in each [Figures and ]. In view of monochorionic gestation, she was offered fetal reduction by selective cord ligation at 16 weeks. Despite counseling about increased chances of antenatal complications with triplets, the couple chose to continue pregnancy without fetal reduction. She had an uneventful pregnancy till 17 weeks gestation after which she developed preterm premature rupture of membranes and cord prolapse. Her pregnancy was terminated using medical management.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 34-year-old woman with 4 years of primary infertility (resulting from male-factor infertility) underwent IVF treatment at our clinic after several failed intrauterine inseminations. A mild stimulation protocol was performed using clomiphene and human menopausal gonadotropin (HMG; 150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Oocyte maturation was triggered using 1000 IU of human chorionic gonadotropin (hCG) (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Nine mature oocytes were collected, of which 7 were fertilized via intracytoplasmic sperm injection (ICSI) and cultured for 3 days. Embryo transfer was performed during the next cycle due to the endometrial thickness. Three day-3 embryos were cryopreserved. During the next cycle, a frozen-thawed embryo transfer was performed and she became pregnant. She delivered a healthy baby at 40 weeks of gestation.\nWanting another child, she requested a frozen embryo transfer when she was 39 years old. The endometrium was prepared with hormone replacement therapy (HRT). The two remaining embryos were of poor grade (Veeck’s classification: 9 cells grade 4 and 8 cells grade 4, respectively) and were transferred using assisted hatching under transabdominal ultrasound (US). Luteal progesterone support was administered for 2 weeks. The woman successfully conceived, as confirmed by an hCG level of 450 IU/L on day 11 post-transfer (4 weeks 0 days). HRT was continued and a transvaginal US was performed on day 18 post-transfer (5 weeks 0 days). There were two gestational sacs (GSs) with dizygotic twins suspected. On day 32 post-transfer (7 weeks 0 days), an US showed two GSs with three fetuses, and a dizygotic trichorionic triamniotic triplet pregnancy was suspected (Fig. ). On day 48 post-transfer (9 weeks 2 days), the heartbeat of one of the monozygotic twin fetuses had stopped, resulting in a dichorionic diamniotic twin pregnancy. The subsequent pregnancy course went well, and a healthy boy and girl were delivered by elective caesarean section at 36 weeks 5 days of gestation.

The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 34-year-old lady with 7 years of secondary infertility due to tubal factor underwent conventional IVF treatment at the University ART unit, Prince of Wales Hospital, Hong Kong. She had a previous first trimester miscarriage in 2007 and a right ectopic pregnancy in 2008, at which time she had a salpingectomy. Subsequent investigations including a laparoscopy confirmed blockage of the contralateral tube and evidence of endometriosis. During her first ART cycle, stimulation was performed with daily administration of 225 units of human menopausal gonadotrophin (hMG) (Serono, Aubonne/Switzerland) according to a standardised antagonist protocol with Ganirelix 0.25 mg downregulation (Merck Serono, Germany). Following hCG trigger, 14 mature oocytes were collected, of which 12 were fertilised, yielding 6 viable blastocysts (i.e. Gardner grading of BB grading or above) on day 5. No assisted hatching was performed, and a single expanding blastocyst (i.e. increasing blastocoel cavity with thinning of the zona pellucida and differentiation of the inner cell mass) was transferred to the patient on day 5. The remaining blastocysts were all cryopreserved following appropriate consent.\nThe woman successfully conceived, as confirmed by an hCG level of 154 IU/L on day 9 post-transfer. Routine 2D transvaginal US 23 days following transfer was suspicious of monochorionic twin or triplet pregnancy; therefore, a 3D US was performed on the same day demonstrating clearly a single gestational sac with three yolk sacs and three foetal poles (CRL of 4.5, 3.1 and 3.0 mm) (Fig. ). On day 36 following transfer, 3D US confirmed a MCTA pregnancy (Fig. ). The couple was informed appropriately regarding the increased maternal and foetal risks of higher order monozygotic gestations and was counselled regarding the possibility of a foetal reduction procedure.\nAfter being reviewed by the foetal medicine team of the Prince of Wales Hospital, an US at 11 + 5 weeks showed all three CRLs of the triplets to be within normal range, although the nuchal translucency was increased in one of the triplets (3.6 mm versus 2.3 and 1.2 for the other two). The couple subsequently decided to proceed with selective foetal reduction via use of radiofrequency ablation, which was successfully performed for the triplet with the thickest nuchal translucency at 14 + 1 weeks of gestation. The procedure was uncomplicated, and the remaining twins are well at the time of writing this article.

A 32-year-old nulligravida Asian female visited the Sendai Art Clinic with primary infertility, including anovulation for the past 2 years. She was diagnosed with PCOS according to the Rotterdam ESHRE/ASRM consensus criteria []. Hysterosalpingography showed bilateral tubal patency and no defects of uterine cavity. Her husband’s semen analysis showed normozoospermia, based on the 2010 World Health Organization criteria. After she had failed to achieve pregnancy following several courses of ovulation induction with clomiphene citrate or gonadotrophin injections, she opted for IVM treatment to retrieve germinal vesicle (GV) oocytes for in vitro culture. Informed consent was provided.\nShe was initiated on an IVM-in vitro fertilization (IVF) protocol on day 6 of a spontaneous menstrual cycle and given 4 days of 75 IU recombinant FSH (Gonal-F, Serono Japan, Tokyo, Japan). She was repetitively evaluated on days 6 and 8 of the menstrual cycle by transvaginal ultrasound scans. When the leading follicle size was less than 12 mm, 5000 IU of urinary human chorionic gonadotropin (hCG) (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan) was administered and oocyte retrieval was carried out 34 h after hCG triggering. The collection and culture of immature oocytes were performed as previously described [].\nFifteen GV stage immature oocytes were retrieved and incubated for 26 h in IVM culture medium (MediCult IVM medium, ORIGIO Japan, Yokohama, Japan) supplemented with recombinant FSH 75 mIU/ml (Gonal-F, Serono Japan, Tokyo, Japan), hCG 100 mIU/ml (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan), and 10% patient’s inactivated serum. The oocytes were then denuded from the cumulus cells. Eleven mature oocytes were obtained and subjected to ICSI with fresh sperm (Fig. ). Zygotes were cultured in culture medium (Universal IVF, ORIGIO Japan, Yokohama, Japan), and fertilization was judged 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Nine (81.8%) oocytes were fertilized. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA) and all embryos developed to blastocysts on day 5 (one middle expanding blastocyst and early blastocysts) and were cryopreserved by vitrification.\nFor the preparation of the endometrium, transcutaneous estradiol (Estrana TAPE 0.72 mg, Hisamitsu Pharmaceutical, Tokyo, Japan; four sheets every 2 days) was administered on day of the hormone replacement therapy (HRT). The endometrial lining was evaluated on days 12–14 of the HRT cycle and the endometrial thickness needed to be a minimum of 8 mm. A vaginal progesterone suppository (Luteum, Aska pharmacy, Tokyo, Japan; 2 tablets everyday) was administered when the endometrial thickness achieved was greater than 8 mm. The transcutaneous estradiol and vaginal progesterone suppository were continued until 9 weeks of gestation. A single frozen-thawed blastocyst (Gardner’s classification:4 BC) (Fig. ) was transferred under transvaginal ultrasound guidance on day 5 after vaginal progesterone suppository was administered. Two weeks after blastocyst transfer, the patient’s serum hCG concentration was 2194 IU/L and pregnancy was confirmed. Transvaginal ultrasound performed at 5 weeks and 0 days of gestation showed 2 gestational sacs inside the uterus. At 8 weeks 2 days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy was observed by ultrasound (Fig. ). The subsequent pregnancy course went well until 28 weeks 5 days when she was admitted to the maternal fetus intensive care unit for fetal growth restriction. She received prenatal steroids for fetal lung maturation and intravenous magnesium sulfate for tocolysis until the delivery. At 33 weeks 4 days, three baby girls were delivered by an elective Caesarean section. Their weight and APGAR scores at 1 min and 5 min were 1852 g, 8–8, 1817 g, 7–8, and 1495 g, 8–9, respectively. Histological examination of the placenta confirmed monochorionicity. The babies remained in the neonatology unit without morbidity and were discharged 4 weeks after birth.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 34-year-old lady with 7 years of secondary infertility due to tubal factor underwent conventional IVF treatment at the University ART unit, Prince of Wales Hospital, Hong Kong. She had a previous first trimester miscarriage in 2007 and a right ectopic pregnancy in 2008, at which time she had a salpingectomy. Subsequent investigations including a laparoscopy confirmed blockage of the contralateral tube and evidence of endometriosis. During her first ART cycle, stimulation was performed with daily administration of 225 units of human menopausal gonadotrophin (hMG) (Serono, Aubonne/Switzerland) according to a standardised antagonist protocol with Ganirelix 0.25 mg downregulation (Merck Serono, Germany). Following hCG trigger, 14 mature oocytes were collected, of which 12 were fertilised, yielding 6 viable blastocysts (i.e. Gardner grading of BB grading or above) on day 5. No assisted hatching was performed, and a single expanding blastocyst (i.e. increasing blastocoel cavity with thinning of the zona pellucida and differentiation of the inner cell mass) was transferred to the patient on day 5. The remaining blastocysts were all cryopreserved following appropriate consent.\nThe woman successfully conceived, as confirmed by an hCG level of 154 IU/L on day 9 post-transfer. Routine 2D transvaginal US 23 days following transfer was suspicious of monochorionic twin or triplet pregnancy; therefore, a 3D US was performed on the same day demonstrating clearly a single gestational sac with three yolk sacs and three foetal poles (CRL of 4.5, 3.1 and 3.0 mm) (Fig. ). On day 36 following transfer, 3D US confirmed a MCTA pregnancy (Fig. ). The couple was informed appropriately regarding the increased maternal and foetal risks of higher order monozygotic gestations and was counselled regarding the possibility of a foetal reduction procedure.\nAfter being reviewed by the foetal medicine team of the Prince of Wales Hospital, an US at 11 + 5 weeks showed all three CRLs of the triplets to be within normal range, although the nuchal translucency was increased in one of the triplets (3.6 mm versus 2.3 and 1.2 for the other two). The couple subsequently decided to proceed with selective foetal reduction via use of radiofrequency ablation, which was successfully performed for the triplet with the thickest nuchal translucency at 14 + 1 weeks of gestation. The procedure was uncomplicated, and the remaining twins are well at the time of writing this article.

A 29-year-old woman presented with secondary infertility of 3-year duration. The couple was married for 6 years with regular menstrual cycles and normal husband's semen analysis. Her reproductive history included an ectopic pregnancy for which she had undergone the right salpingectomy and a missed miscarriage at 8 weeks pregnancy in the past. She had 4 failed intrauterine insemination cycles and was then planned for IVF in view of tubal factor.\nShe was started on the standard antagonist protocol and stimulated with 150 iu of recombinant follicle-stimulating hormone (rFSH; Gonal-F, Merck Serono, Geneva, Switzerland) and 75 iu of HMG-HP (Menopur, Ferring Pharmaceuticals, Sweden) daily. GnRH antagonist was started on day 6 of stimulation and administered daily till the day of human chorionic gonadotropin (hCG). Egg retrieval was performed 35 h after administration of 250 ug of recombinant hCG (rhCG; Ovitrelle, Merck Serono) and 16 oocytes were retrieved. The 15 metaphase II oocytes were subjected to conventional IVF since semen parameters were normal. 14 oocytes fertilized and after 5 days of in vitro culture (Vitrolife G1.3, Göteborg, Sweden), 6 blastocysts were obtained. Two top quality blastocysts (4AA, 2AA) were transferred, and 4 were cryopreserved. She received standard luteal support with vaginal progesterone gel (Crinone gel 8%, Merck Serono). A positive beta hCG was obtained 14 days after embryo transfer. Ultrasound performed at 5 weeks of pregnancy showed a single gestational sac. At 7 weeks of gestation, ultrasound revealed MCTA triplets with three yolk sacs and three fetal poles with cardiac activity in each [Figures and ]. In view of monochorionic gestation, she was offered fetal reduction by selective cord ligation at 16 weeks. Despite counseling about increased chances of antenatal complications with triplets, the couple chose to continue pregnancy without fetal reduction. She had an uneventful pregnancy till 17 weeks gestation after which she developed preterm premature rupture of membranes and cord prolapse. Her pregnancy was terminated using medical management.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 34-year-old lady with 7 years of secondary infertility due to tubal factor underwent conventional IVF treatment at the University ART unit, Prince of Wales Hospital, Hong Kong. She had a previous first trimester miscarriage in 2007 and a right ectopic pregnancy in 2008, at which time she had a salpingectomy. Subsequent investigations including a laparoscopy confirmed blockage of the contralateral tube and evidence of endometriosis. During her first ART cycle, stimulation was performed with daily administration of 225 units of human menopausal gonadotrophin (hMG) (Serono, Aubonne/Switzerland) according to a standardised antagonist protocol with Ganirelix 0.25 mg downregulation (Merck Serono, Germany). Following hCG trigger, 14 mature oocytes were collected, of which 12 were fertilised, yielding 6 viable blastocysts (i.e. Gardner grading of BB grading or above) on day 5. No assisted hatching was performed, and a single expanding blastocyst (i.e. increasing blastocoel cavity with thinning of the zona pellucida and differentiation of the inner cell mass) was transferred to the patient on day 5. The remaining blastocysts were all cryopreserved following appropriate consent.\nThe woman successfully conceived, as confirmed by an hCG level of 154 IU/L on day 9 post-transfer. Routine 2D transvaginal US 23 days following transfer was suspicious of monochorionic twin or triplet pregnancy; therefore, a 3D US was performed on the same day demonstrating clearly a single gestational sac with three yolk sacs and three foetal poles (CRL of 4.5, 3.1 and 3.0 mm) (Fig. ). On day 36 following transfer, 3D US confirmed a MCTA pregnancy (Fig. ). The couple was informed appropriately regarding the increased maternal and foetal risks of higher order monozygotic gestations and was counselled regarding the possibility of a foetal reduction procedure.\nAfter being reviewed by the foetal medicine team of the Prince of Wales Hospital, an US at 11 + 5 weeks showed all three CRLs of the triplets to be within normal range, although the nuchal translucency was increased in one of the triplets (3.6 mm versus 2.3 and 1.2 for the other two). The couple subsequently decided to proceed with selective foetal reduction via use of radiofrequency ablation, which was successfully performed for the triplet with the thickest nuchal translucency at 14 + 1 weeks of gestation. The procedure was uncomplicated, and the remaining twins are well at the time of writing this article.

The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old nulligravida Asian female visited the Sendai Art Clinic with primary infertility, including anovulation for the past 2 years. She was diagnosed with PCOS according to the Rotterdam ESHRE/ASRM consensus criteria []. Hysterosalpingography showed bilateral tubal patency and no defects of uterine cavity. Her husband’s semen analysis showed normozoospermia, based on the 2010 World Health Organization criteria. After she had failed to achieve pregnancy following several courses of ovulation induction with clomiphene citrate or gonadotrophin injections, she opted for IVM treatment to retrieve germinal vesicle (GV) oocytes for in vitro culture. Informed consent was provided.\nShe was initiated on an IVM-in vitro fertilization (IVF) protocol on day 6 of a spontaneous menstrual cycle and given 4 days of 75 IU recombinant FSH (Gonal-F, Serono Japan, Tokyo, Japan). She was repetitively evaluated on days 6 and 8 of the menstrual cycle by transvaginal ultrasound scans. When the leading follicle size was less than 12 mm, 5000 IU of urinary human chorionic gonadotropin (hCG) (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan) was administered and oocyte retrieval was carried out 34 h after hCG triggering. The collection and culture of immature oocytes were performed as previously described [].\nFifteen GV stage immature oocytes were retrieved and incubated for 26 h in IVM culture medium (MediCult IVM medium, ORIGIO Japan, Yokohama, Japan) supplemented with recombinant FSH 75 mIU/ml (Gonal-F, Serono Japan, Tokyo, Japan), hCG 100 mIU/ml (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan), and 10% patient’s inactivated serum. The oocytes were then denuded from the cumulus cells. Eleven mature oocytes were obtained and subjected to ICSI with fresh sperm (Fig. ). Zygotes were cultured in culture medium (Universal IVF, ORIGIO Japan, Yokohama, Japan), and fertilization was judged 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Nine (81.8%) oocytes were fertilized. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA) and all embryos developed to blastocysts on day 5 (one middle expanding blastocyst and early blastocysts) and were cryopreserved by vitrification.\nFor the preparation of the endometrium, transcutaneous estradiol (Estrana TAPE 0.72 mg, Hisamitsu Pharmaceutical, Tokyo, Japan; four sheets every 2 days) was administered on day of the hormone replacement therapy (HRT). The endometrial lining was evaluated on days 12–14 of the HRT cycle and the endometrial thickness needed to be a minimum of 8 mm. A vaginal progesterone suppository (Luteum, Aska pharmacy, Tokyo, Japan; 2 tablets everyday) was administered when the endometrial thickness achieved was greater than 8 mm. The transcutaneous estradiol and vaginal progesterone suppository were continued until 9 weeks of gestation. A single frozen-thawed blastocyst (Gardner’s classification:4 BC) (Fig. ) was transferred under transvaginal ultrasound guidance on day 5 after vaginal progesterone suppository was administered. Two weeks after blastocyst transfer, the patient’s serum hCG concentration was 2194 IU/L and pregnancy was confirmed. Transvaginal ultrasound performed at 5 weeks and 0 days of gestation showed 2 gestational sacs inside the uterus. At 8 weeks 2 days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy was observed by ultrasound (Fig. ). The subsequent pregnancy course went well until 28 weeks 5 days when she was admitted to the maternal fetus intensive care unit for fetal growth restriction. She received prenatal steroids for fetal lung maturation and intravenous magnesium sulfate for tocolysis until the delivery. At 33 weeks 4 days, three baby girls were delivered by an elective Caesarean section. Their weight and APGAR scores at 1 min and 5 min were 1852 g, 8–8, 1817 g, 7–8, and 1495 g, 8–9, respectively. Histological examination of the placenta confirmed monochorionicity. The babies remained in the neonatology unit without morbidity and were discharged 4 weeks after birth.

A 29-year-old woman presented with secondary infertility of 3-year duration. The couple was married for 6 years with regular menstrual cycles and normal husband's semen analysis. Her reproductive history included an ectopic pregnancy for which she had undergone the right salpingectomy and a missed miscarriage at 8 weeks pregnancy in the past. She had 4 failed intrauterine insemination cycles and was then planned for IVF in view of tubal factor.\nShe was started on the standard antagonist protocol and stimulated with 150 iu of recombinant follicle-stimulating hormone (rFSH; Gonal-F, Merck Serono, Geneva, Switzerland) and 75 iu of HMG-HP (Menopur, Ferring Pharmaceuticals, Sweden) daily. GnRH antagonist was started on day 6 of stimulation and administered daily till the day of human chorionic gonadotropin (hCG). Egg retrieval was performed 35 h after administration of 250 ug of recombinant hCG (rhCG; Ovitrelle, Merck Serono) and 16 oocytes were retrieved. The 15 metaphase II oocytes were subjected to conventional IVF since semen parameters were normal. 14 oocytes fertilized and after 5 days of in vitro culture (Vitrolife G1.3, Göteborg, Sweden), 6 blastocysts were obtained. Two top quality blastocysts (4AA, 2AA) were transferred, and 4 were cryopreserved. She received standard luteal support with vaginal progesterone gel (Crinone gel 8%, Merck Serono). A positive beta hCG was obtained 14 days after embryo transfer. Ultrasound performed at 5 weeks of pregnancy showed a single gestational sac. At 7 weeks of gestation, ultrasound revealed MCTA triplets with three yolk sacs and three fetal poles with cardiac activity in each [Figures and ]. In view of monochorionic gestation, she was offered fetal reduction by selective cord ligation at 16 weeks. Despite counseling about increased chances of antenatal complications with triplets, the couple chose to continue pregnancy without fetal reduction. She had an uneventful pregnancy till 17 weeks gestation after which she developed preterm premature rupture of membranes and cord prolapse. Her pregnancy was terminated using medical management.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 32-year-old nulligravida Asian female visited the Sendai Art Clinic with primary infertility, including anovulation for the past 2 years. She was diagnosed with PCOS according to the Rotterdam ESHRE/ASRM consensus criteria []. Hysterosalpingography showed bilateral tubal patency and no defects of uterine cavity. Her husband’s semen analysis showed normozoospermia, based on the 2010 World Health Organization criteria. After she had failed to achieve pregnancy following several courses of ovulation induction with clomiphene citrate or gonadotrophin injections, she opted for IVM treatment to retrieve germinal vesicle (GV) oocytes for in vitro culture. Informed consent was provided.\nShe was initiated on an IVM-in vitro fertilization (IVF) protocol on day 6 of a spontaneous menstrual cycle and given 4 days of 75 IU recombinant FSH (Gonal-F, Serono Japan, Tokyo, Japan). She was repetitively evaluated on days 6 and 8 of the menstrual cycle by transvaginal ultrasound scans. When the leading follicle size was less than 12 mm, 5000 IU of urinary human chorionic gonadotropin (hCG) (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan) was administered and oocyte retrieval was carried out 34 h after hCG triggering. The collection and culture of immature oocytes were performed as previously described [].\nFifteen GV stage immature oocytes were retrieved and incubated for 26 h in IVM culture medium (MediCult IVM medium, ORIGIO Japan, Yokohama, Japan) supplemented with recombinant FSH 75 mIU/ml (Gonal-F, Serono Japan, Tokyo, Japan), hCG 100 mIU/ml (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan), and 10% patient’s inactivated serum. The oocytes were then denuded from the cumulus cells. Eleven mature oocytes were obtained and subjected to ICSI with fresh sperm (Fig. ). Zygotes were cultured in culture medium (Universal IVF, ORIGIO Japan, Yokohama, Japan), and fertilization was judged 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Nine (81.8%) oocytes were fertilized. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA) and all embryos developed to blastocysts on day 5 (one middle expanding blastocyst and early blastocysts) and were cryopreserved by vitrification.\nFor the preparation of the endometrium, transcutaneous estradiol (Estrana TAPE 0.72 mg, Hisamitsu Pharmaceutical, Tokyo, Japan; four sheets every 2 days) was administered on day of the hormone replacement therapy (HRT). The endometrial lining was evaluated on days 12–14 of the HRT cycle and the endometrial thickness needed to be a minimum of 8 mm. A vaginal progesterone suppository (Luteum, Aska pharmacy, Tokyo, Japan; 2 tablets everyday) was administered when the endometrial thickness achieved was greater than 8 mm. The transcutaneous estradiol and vaginal progesterone suppository were continued until 9 weeks of gestation. A single frozen-thawed blastocyst (Gardner’s classification:4 BC) (Fig. ) was transferred under transvaginal ultrasound guidance on day 5 after vaginal progesterone suppository was administered. Two weeks after blastocyst transfer, the patient’s serum hCG concentration was 2194 IU/L and pregnancy was confirmed. Transvaginal ultrasound performed at 5 weeks and 0 days of gestation showed 2 gestational sacs inside the uterus. At 8 weeks 2 days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy was observed by ultrasound (Fig. ). The subsequent pregnancy course went well until 28 weeks 5 days when she was admitted to the maternal fetus intensive care unit for fetal growth restriction. She received prenatal steroids for fetal lung maturation and intravenous magnesium sulfate for tocolysis until the delivery. At 33 weeks 4 days, three baby girls were delivered by an elective Caesarean section. Their weight and APGAR scores at 1 min and 5 min were 1852 g, 8–8, 1817 g, 7–8, and 1495 g, 8–9, respectively. Histological examination of the placenta confirmed monochorionicity. The babies remained in the neonatology unit without morbidity and were discharged 4 weeks after birth.

The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

A 29-year-old woman presented with secondary infertility of 3-year duration. The couple was married for 6 years with regular menstrual cycles and normal husband's semen analysis. Her reproductive history included an ectopic pregnancy for which she had undergone the right salpingectomy and a missed miscarriage at 8 weeks pregnancy in the past. She had 4 failed intrauterine insemination cycles and was then planned for IVF in view of tubal factor.\nShe was started on the standard antagonist protocol and stimulated with 150 iu of recombinant follicle-stimulating hormone (rFSH; Gonal-F, Merck Serono, Geneva, Switzerland) and 75 iu of HMG-HP (Menopur, Ferring Pharmaceuticals, Sweden) daily. GnRH antagonist was started on day 6 of stimulation and administered daily till the day of human chorionic gonadotropin (hCG). Egg retrieval was performed 35 h after administration of 250 ug of recombinant hCG (rhCG; Ovitrelle, Merck Serono) and 16 oocytes were retrieved. The 15 metaphase II oocytes were subjected to conventional IVF since semen parameters were normal. 14 oocytes fertilized and after 5 days of in vitro culture (Vitrolife G1.3, Göteborg, Sweden), 6 blastocysts were obtained. Two top quality blastocysts (4AA, 2AA) were transferred, and 4 were cryopreserved. She received standard luteal support with vaginal progesterone gel (Crinone gel 8%, Merck Serono). A positive beta hCG was obtained 14 days after embryo transfer. Ultrasound performed at 5 weeks of pregnancy showed a single gestational sac. At 7 weeks of gestation, ultrasound revealed MCTA triplets with three yolk sacs and three fetal poles with cardiac activity in each [Figures and ]. In view of monochorionic gestation, she was offered fetal reduction by selective cord ligation at 16 weeks. Despite counseling about increased chances of antenatal complications with triplets, the couple chose to continue pregnancy without fetal reduction. She had an uneventful pregnancy till 17 weeks gestation after which she developed preterm premature rupture of membranes and cord prolapse. Her pregnancy was terminated using medical management.

The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.

Write a detailed clinical case vignette based on the following key phrases: Assisted Reproductive Technology (ART), Multiple Pregnancy, Fetal Reduction

An 82-year-old man presented to the emergency department with chief complaint of nonproductive cough, chest congestion, subjective fevers, hoarseness, and shortness of breath on ambulation for 2 days. He had chronic mild neck pain, which had been treated conservatively for the past 10 years. The patient had a history of 35 pack-years of smoking, which was discontinued 30 years prior to presentation. His medical history included hypertension, type II diabetes mellitus, and peripheral vascular disease with claudication, benign prostatic hypertrophy, colonic polyps, and multifocal osteoarthritis.\nOn examination, the patient had a grade 3/6 systolic murmur and decreased breath sounds at the bases bilaterally. Additionally the patient noted a 6-month history of unstable gait and loss of hand dexterity as well as bilateral upper extremity numbness and pain. Spine examination revealed decreased cervical range of motion. Neurologic examination revealed diffuse upper extremity weakness and hyperreflexia in the upper and lower extremities. He had negative Hoffman and Babinski signs. He then underwent an extensive metabolic workup, which revealed an elevated white blood cell count, elevated troponins, hyponatremia, and elevated blood glucose. Auxiliary tests included an abnormal electrocardiogram as well as elevated right hemidiaphragm with full inspiration on chest radiograph.\nThe patient was admitted to the hospital with persistent dyspnea. On hospital day 3, he underwent cardiac catheterization, which revealed extensive stenosis of the major coronary arteries, which was believed to be the main cause of his dyspnea. On hospital day 5, he underwent triple coronary artery bypass grafting. Despite the cardiac surgery, the patient's dyspnea did not improve. In addition, he developed new complaints of generalized weakness. He continued to complain of chest discomfort as well.\nMagnetic resonance imaging (MRI) and radiographic imaging of the cervical spine revealed extensive multilevel degenerative spondylosis with moderate to severe central canal narrowing from C2 to C7 and myelomalacia (\n). The patient underwent C2–C6 laminectomy and instrumented fusion with local autograft (\n). Lateral mass screws were utilized in the subaxial spine and pedicle screws were utilized at C2. Dome laminectomy was performed at C2. After surgery, the patient had gradual relief of dyspnea as well as improvement of strength. At 12-month follow-up, the patient was ambulating well and had improved neck pain. The dyspnea was completely resolved. His neck disability index had improved from 38% preoperatively to 30% at 1-year follow-up. The patient's chest X-rays showed that the right hemidiaphragm returned to its normal position.

A sixty-year-old female presented with intermittent shortness of breath happened in the morning of the day. She was a patient with chronic rheumatoid arthritis (RA) and was regularly followed in the rheumatologic clinic. During the past two weeks, she also complained of progressive numbness over bilateral hands and feet. Since the symptoms were not resolved by her daily medications and became more severe in the evening, she was brought to the ED for further evaluation.\nAt the ED, the patient was ambulatory, cooperative, and in mild distress, complaining of shortness of breath. Her vital signs were temperature 36.8°C, pulse rate 110 beats/min, respiratory rate 24 breaths/min, blood pressure of 168/81, and pulse oximetry 97%. Breathing sounds were normal without crackles or wheeze while auscultation. Other physical examination was unremarkable. Arterial blood gas was obtained and the data were within normal range. Because of the elevated D-dimer level, computed tomography of the chest was arranged to rule out the pulmonary embolism, but there was no significant finding.\nThe patient felt better after the use of oxygen during observation. However, reviewing of the medical records indicated the X-ray of the cervical spine was taken one week ago for the evaluation of limb numbness, and the increased distance at atlantoaxial space was noted (). Magnetic resonance imaging of the cervical spine was arranged and atlantoaxial subluxation with acute cervical spinal cord compression over C1-C2 level was found. The neurosurgeon was consulted and surgical intervention was suggested. However, the patient refused operation and conservative treatments with neck immobilization, and steroids were initiated during hospitalization. The patient was discharged 5 days thereafter with preserved neurologic function.

Write a detailed clinical case vignette based on the following key phrases: Cervical Spine, Respiratory Distress, Neurological Symptoms

An 87-year-old Caucasian man was transferred from another hospital after an episode of altered mental status secondary to hypercapnea requiring intubation. His past medical history included type 2 diabetes, stage 3 chronic kidney disease, and heart failure with preserved ejection fraction. He was a lifelong non-cigarette smoker. Per the family he was complaining of shortness of breath, weight gain and worsening leg swelling for 3 weeks, and was progressively more somnolent over the last week. On admission to the outside hospital the results of his laboratory tests were significant for a normal blood glucose of 176mg/dL, normal white blood cell count at 7000 cells/mm3, creatinine of 1.6mg/dL (at his baseline), elevated brain natriuretic peptide at 778pg/mL and negative toxicology screen. He had no history of opioid or benzodiazepine usage. His ABG showed acute on chronic hypercapnea with a pH of 7.22, partial pressure of carbon dioxide (pCO2) of 83mmHg and bicarbonate (HCO3) of 36mmol/L requiring intubation explaining his altered mental status. He was noted to be in congestive cardiac failure and was given diuretics and eventually he was extubated. He was transferred to our institution on nightly bilevel positive airway pressure (bipap) for his unexplained hypercapnic failure. His only complaint on transfer was his chronic two-pillow orthopnea.\nOn arrival he was in no acute distress with a heart rate of 74, respiratory rate of 20, blood pressure of 107/65mmHg, and oxygen saturation of 98% on 2L nasal cannula. A cardiovascular and respiratory system examination was unrevealing with normal jugular venous pressure and normal cardiac examination. There was paradoxical abdominal motion with the abdominal wall moving inwards on inspiration. A neurologic examination revealed 3/5 strength in his left deltoid and decreased biceps reflexes bilaterally. Power, tone and reflexes were normal in both his lower limbs. He also had severe osteoarthrosis of distal and proximal interphalangeal joints bilaterally with Heberden’s nodes.\nHis ABG on room air showed a partial pressure of oxygen of 64mmHg, pCO2 of 53mmHg, HCO3 of 28mmol/L and a pH of 7.33 with a normal A-a gradient of 18. This was consistent with chronic respiratory acidosis secondary to hypoventilation, given the normal A-a gradient. A chest X-ray showed elevated hemidiaphragms bilaterally (Figure ). Pulmonary function testing showed a restrictive pattern with a normal ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of 0.79 (114% predicted), with FEV1 and FVC 49 and 42% of predicted respectively. There were also significantly decreased maximum inspiratory and maximum expiratory pressures of 27.2 and 31.4% predicted; and a decrease in FVC of 22% from the sitting to supine position suggestive of neuromuscular weakness (>20%). The diffusing capacity was normal suggesting a chest wall or neuromuscular cause of restrictive lung mechanics.\nGiven his abnormal neurologic examination with left deltoid weakness and decreased biceps reflexes, our differential included respiratory neuromuscular weakness from cervical spondylosis and phrenic nerve root compression (given the C5 neurological deficits); or possible cervical myelopathy at C5/C6. The absent biceps reflex (C5 and C6) raised suspicion for myelopathy at the C5 to C6 level although this is typically associated with a brisk triceps reflex (C7). The lack of neurological findings in his lower extremities also argued against myelopathy, but given the potential variable manifestations of cervical myelopathy, an electromyogram (EMG) and nerve conduction study (NCS) were performed. The EMG and NCS revealed decreased amplitude in the phrenic nerves bilaterally and radiculopathy in his upper limbs, suggestive of nerve root compression at the cervical foraminal level. There was no evidence of amyotrophic lateral sclerosis or myopathy on EMG/NCS and serum creatine phosphokinase was normal. A cervical MRI was performed and showed severe bilateral foraminal narrowing at C3, C4 and C5 with no evidence of myelopathy, confirming the diagnosis of phrenic nerve root compression from cervical spondylosis as the cause of hypoventilation. When he developed pulmonary edema, the resultant decreased lung compliance placed an increased respiratory load on his weakened neuromuscular apparatus leading to worsening hypercapnea and resultant metabolic encephalopathy with altered mental status. Carbon dioxide, being readily diffusible across the blood–brain barrier is a well-known cause of encephalopathy in the setting of hypercapnea.\nHe was offered surgical decompression of cervical motor roots or possible diaphragmatic pacing. Given his age, he opted for conservative management with nightly bipap to rest his respiratory muscles at night. He showed significant improvement with night-time bipap and felt less fatigued during the day, probably from the rest provided to his respiratory neuromuscular apparatus. Following discharge he remained stable but gradually became less compliant with bipap. He had four admissions in 2 years with hypercapnic respiratory failure in the setting of pulmonary edema from heart failure. Pulmonary edema and the resultant decreased lung compliance placed an increased respiratory load on his weakened neuromuscular apparatus. As expected he fatigued more easily with his weakened neuromusculature leading to hypoventilation and worsening hypercapnea. He required continuous bipap while hospitalized until diuresis improved chest wall compliance and respiratory mechanics. He continued to refuse invasive therapies and was managed conservatively with nightly bipap. He developed evidence of right ventricular failure and pulmonary hypertension on echo from a combination of pulmonary venous hypertension from heart failure and chronic hypoxia from hypoventilation secondary to his neuromuscular weakness. Given his recurrent episodes of respiratory failure and worsening heart failure he was eventually transitioned to hospice care.

A sixty-year-old female presented with intermittent shortness of breath happened in the morning of the day. She was a patient with chronic rheumatoid arthritis (RA) and was regularly followed in the rheumatologic clinic. During the past two weeks, she also complained of progressive numbness over bilateral hands and feet. Since the symptoms were not resolved by her daily medications and became more severe in the evening, she was brought to the ED for further evaluation.\nAt the ED, the patient was ambulatory, cooperative, and in mild distress, complaining of shortness of breath. Her vital signs were temperature 36.8°C, pulse rate 110 beats/min, respiratory rate 24 breaths/min, blood pressure of 168/81, and pulse oximetry 97%. Breathing sounds were normal without crackles or wheeze while auscultation. Other physical examination was unremarkable. Arterial blood gas was obtained and the data were within normal range. Because of the elevated D-dimer level, computed tomography of the chest was arranged to rule out the pulmonary embolism, but there was no significant finding.\nThe patient felt better after the use of oxygen during observation. However, reviewing of the medical records indicated the X-ray of the cervical spine was taken one week ago for the evaluation of limb numbness, and the increased distance at atlantoaxial space was noted (). Magnetic resonance imaging of the cervical spine was arranged and atlantoaxial subluxation with acute cervical spinal cord compression over C1-C2 level was found. The neurosurgeon was consulted and surgical intervention was suggested. However, the patient refused operation and conservative treatments with neck immobilization, and steroids were initiated during hospitalization. The patient was discharged 5 days thereafter with preserved neurologic function.

Write a detailed clinical case vignette based on the following key phrases: Cervical Spine, Respiratory Distress, Neurological Symptoms

A 64-year-old man was referred to the orthopaedic service with right hemidiaphragm paralysis. He had initially presented to his general practitioner reporting subjective shortness of breath after stand-up paddleboarding. His past medical history was significant for asbestos exposure and polio. Chest radiograph revealed an elevated right hemidiaphragm (Figures and ). A previous chest radiograph taken five years before showed normal diaphragmatic contours. He was subsequently referred to the respiratory physicians where workup included a chest CT scan (which revealed no intrathoracic abnormality) and dynamic fluoroscopic sniffing test (which confirmed complete right hemidiaphragm paralysis). He reported innocuous injuries to his neck in the past and intermittent neck pain for which he had previously consulted both a chiropractor and an osteopath. An MRI scan was undertaken which showed right-sided cervical foraminal stenosis (with uncovertebral and facet joint osteophytic changes at C3/4 and C4/5) (). He was therefore referred to the orthopaedic service. On examination, he had no focal cervical spine tenderness with a well-preserved range of motion. He did have some generalized right shoulder girdle and upper limb wasting and weakness compared to the left (presumed to be secondary to his postpolio syndrome). His upper limb reflexes were intact and symmetrical with the contralateral side.\nThe underlying cause for his hemidiaphragm paralysis, whether it was related to his cervical foraminal stenosis or postpolio syndrome, was indeterminant ().\nAfter obtaining multiple subspecialist opinions, a decision was made to proceed with posterior right C3/4 and C4/5 foraminotomies accepting that this may not have any effect on his shortness of breath. Surgery proceeded uneventfully as did postoperative recovery. By three months postoperatively, his hemidiaphragm paralysis had completely resolved on chest radiograph, and his shortness of breath had also improved (). Comparison of preoperative and postoperative spirometry lung function showed significant improvements in all parameters tested: increases in FVC from 3.88L to 4.86L, FEV1 from 2.44L to 3.13L, TLC from 5.11L to 7.65L, FRCpl from 2.61 to 3.63, and RV from 1.23L to 2.58L. A graphic representation of these findings is shown in . A satisfactory outcome was thus achieved.

A sixty-year-old female presented with intermittent shortness of breath happened in the morning of the day. She was a patient with chronic rheumatoid arthritis (RA) and was regularly followed in the rheumatologic clinic. During the past two weeks, she also complained of progressive numbness over bilateral hands and feet. Since the symptoms were not resolved by her daily medications and became more severe in the evening, she was brought to the ED for further evaluation.\nAt the ED, the patient was ambulatory, cooperative, and in mild distress, complaining of shortness of breath. Her vital signs were temperature 36.8°C, pulse rate 110 beats/min, respiratory rate 24 breaths/min, blood pressure of 168/81, and pulse oximetry 97%. Breathing sounds were normal without crackles or wheeze while auscultation. Other physical examination was unremarkable. Arterial blood gas was obtained and the data were within normal range. Because of the elevated D-dimer level, computed tomography of the chest was arranged to rule out the pulmonary embolism, but there was no significant finding.\nThe patient felt better after the use of oxygen during observation. However, reviewing of the medical records indicated the X-ray of the cervical spine was taken one week ago for the evaluation of limb numbness, and the increased distance at atlantoaxial space was noted (). Magnetic resonance imaging of the cervical spine was arranged and atlantoaxial subluxation with acute cervical spinal cord compression over C1-C2 level was found. The neurosurgeon was consulted and surgical intervention was suggested. However, the patient refused operation and conservative treatments with neck immobilization, and steroids were initiated during hospitalization. The patient was discharged 5 days thereafter with preserved neurologic function.

Write a detailed clinical case vignette based on the following key phrases: Cervical Spine, Respiratory Distress, Neurological Symptoms

A 59-year-old man presented with exertional dyspnea that started 1 month earlier. He had undergone wide excision for tongue cancer 6 years ago and no evidence of recurrence was observed.\nA chest radiograph revealed a marked elevation of the right diaphragm compared with the left diaphragm (Fig. A). Chest computed tomography (CT) showed no abnormalities of the mediastinal and chest thorax. In pulmonary function tests using a spirometer, his vital capacity was 3.02 L (68% of predicted), forced vital capacity was 3.17 L (71% of predicted), and forced expiratory volume-1 second was 2.17 L (61% of predicted).\nThe differential diagnosis of unilateral phrenic nerve palsy included thoracic evaluation for lung and mediastinal tumors or infections. Neurologic evaluation for neurodegenerative diseases and imaging studies for recurrent tongue cancer failed to identify the underlying cause. After excluding all possible causes, he was referred for cervical spondylosis evaluation for diaphragmatic paralysis. He did not complain of radiating pain. Motor weakness, sensory changes, and hyperactive deep tendon reflexes were also not observed on neurological examination.\nCervical CT revealed C3–4 and C4–5 foraminal space narrowing due to osteophyte formation (Fig. A) and magnetic resonance imaging (MRI) showed that the C4 root was compressed by a bony spur at the right C3–4 foraminal space (Fig. B). However, spinal cord compression was not prominent on CT and MRI.\nDespite conservative treatment for 1 month, the patient was admitted to the hospital for recurrent fever and dyspnea. Under the diagnosis of hemidiaphragmatic paralysis due to cervical foraminal stenosis, the patient underwent foraminotomies at C3–4 and C4–5 on the right side and the operative findings revealed right C4 root severe compression caused by a bony spur. Foraminal decompression was done until the root passed without resistance.\nThe chest radiograph demonstrated no interval change at 1 postoperative month (Fig. B). At 3 months postoperatively, the chest radiograph revealed a remarkable descent of the right diaphragm compared with the initial radiograph (Fig. A and B). The postoperative CT showed a widening of the foraminal canal compared with the preoperative CT (Fig. ). No dyspnea or pneumonia was observed at the surgical follow-up. The patient has provided informed consent for the publication of this case report and accompanying images.

A sixty-year-old female presented with intermittent shortness of breath happened in the morning of the day. She was a patient with chronic rheumatoid arthritis (RA) and was regularly followed in the rheumatologic clinic. During the past two weeks, she also complained of progressive numbness over bilateral hands and feet. Since the symptoms were not resolved by her daily medications and became more severe in the evening, she was brought to the ED for further evaluation.\nAt the ED, the patient was ambulatory, cooperative, and in mild distress, complaining of shortness of breath. Her vital signs were temperature 36.8°C, pulse rate 110 beats/min, respiratory rate 24 breaths/min, blood pressure of 168/81, and pulse oximetry 97%. Breathing sounds were normal without crackles or wheeze while auscultation. Other physical examination was unremarkable. Arterial blood gas was obtained and the data were within normal range. Because of the elevated D-dimer level, computed tomography of the chest was arranged to rule out the pulmonary embolism, but there was no significant finding.\nThe patient felt better after the use of oxygen during observation. However, reviewing of the medical records indicated the X-ray of the cervical spine was taken one week ago for the evaluation of limb numbness, and the increased distance at atlantoaxial space was noted (). Magnetic resonance imaging of the cervical spine was arranged and atlantoaxial subluxation with acute cervical spinal cord compression over C1-C2 level was found. The neurosurgeon was consulted and surgical intervention was suggested. However, the patient refused operation and conservative treatments with neck immobilization, and steroids were initiated during hospitalization. The patient was discharged 5 days thereafter with preserved neurologic function.

Write a detailed clinical case vignette based on the following key phrases: Cervical Spine, Respiratory Distress, Neurological Symptoms

Our in-patient rheumatology service evaluated a 17-year-old Hispanic woman for pain in the neck, low back, bilateral hip, and knee as well as for headaches and morning stiffness lasting two months. At her initial hospitalization two weeks into the disease course, and at six weeks prior to rheumatology evaluation, the hospital service noted that she had decreased range of motion in her neck secondary to pain. Plain radiographic films of the cervical spine (Figure ) revealed no abnormalities, and she was discharged with a course of naproxen. Non-steroidal anti-inflammatory drugs (NSAIDs) offered only minimal relief of symptoms, which prompted an out-patient orthopedics community evaluation and resulted in diagnosis of 'gluteal strain' and bursitis. She was placed on propoxyphene/acetaminophen and cyclobenzaprine, but they did not improve her symptoms.\nDue to the unremitting nature of our patient's symptoms two months into her illness, her pediatrician obtained laboratory studies and a bone scan which revealed abnormal uptake in the right seventh rib (possibly due to prior fracture), increased uptake in the left distal femur and anterior superior left tibial spine, and focal uptake at the facets of several thoracic vertebrae. Her erythrocyte sedimentation rate (ESR) was 49 mm/hour and high-sensitivity C reactive protein was 44.7 mg/L. Concerned about infection or malignancy, our patient's physician readmitted her to our institution. She did not have, then or previously, a history of fever, lymphadenopathy, bleeding or easy bruisability, weight loss, gastrointestinal symptoms, cardiac murmur, or rashes. Stool guaiac results were negative, and an abdominal ultrasound showed no abnormalities. A complete blood count was without cytopenias except for mild normocytic anemia.\nA rheumatological evaluation revealed an obese (body mass index (BMI) 42, greater than 97%) adolescent with findings of point tenderness in her bilateral inferior patella, lower sacrum, and anterior hips. She had a reduced range of motion with muscle spasms in her neck, but no psoriatic lesions or nail pitting. Her spinal symptoms were most severe in the morning and improved with movement and NSAID use. Her family history was positive for idiopathic iritis (father) and inflammatory bowel disease with spondyloarthritis (paternal aunt). A rheumatoid factor was non-reactive, and anti-nuclear antibody was not detected. Creatine kinase and aldolase levels were within normal limits. A HLA-B27 marker was present in our patient. Imaging studies were consistent with an inflammatory process: a hip ultrasound revealed bilateral hip effusions, and a lower extremity MRI revealed T2 abnormal signals in patellar tendon insertions and subcutaneous tissue anterior to the inferior aspect of the left patellar tendon. Prior to her rheumatology evaluation, our patient was given celecoxib (as prescribed by her family physician), which provided significant pain relief in her back and reduction of morning stiffness. Our pediatric rheumatologist diagnosed our patient with undifferentiated spondyloarthritis using the European Spondyloarthropathy Study Group (ESSG) classification criteria (inflammatory spinal pain, hip synovitis, positive family history of HLA-B27-associated diseases, and enthesopathy/enthesitis). The family and our pediatric rheumatologists opted to keep our patient on celecoxib and have close out-patient follow-up because her musculoskeletal pain decreased and her inflammatory markers improved, Although her hip, back, and knee pain improved, our patient continued to have persistent neck pain with symptoms of occipital neuralgia after three months of scheduled NSAID therapy. New plain radiographic imaging of the cervical spine revealed a reversal of the normal lordotic curvature, and a 10 mm distance between the odontoid and anterior arches of C1 had markedly increased since prior films (Figure ). A computed tomography (CT) scan of the cervical spine showed evidence of bony erosion at the tip of the odontoid as well as mild rightward rotatory subluxation of C1, with moderate cervical stenosis at C1 and minimal flattening of the spinal cord (Figure ). This was confirmed on MRI (Figure ), which also demonstrated inflammation around the apical and transverse ligaments and adjacent pannus formation. There was no signal abnormality within the cord itself.\nAt this point, doctors were concerned about our patient's joint instability and referred her to the neurosurgery department. She had no recent history of travel, fever, pharyngitis, torticolis, or trauma. Results of a general examination showed our patient was obese but otherwise normal. She was awake and alert, with full strength throughout. Her left upper extremity was hyper-reflexive compared to her right upper extremity, and her right lower extremity was hyper-reflexive compared to her left lower extremity. Proprioception was intact. She had up-going toes bilaterally but no clonus or Hoffman sign. She had a steady gait with no sway on Romberg testing. Because clinical and radiographic evaluations showed evidence of atlantoaxial instability in the setting of undifferentiated spondyloarthritis, our neurosurgeons recommended a C1-2 fusion to our patient and her family. The doctors postulated that inflammation-mediated ligamentous laxity was causing joint instability but that ongoing infection did not cause the cervical spine disease (Grisel's syndrome). Her anti-inflammatory medication was stopped about one week prior to surgery.\nAfter our patient was fiber-optically intubated with in-line stabilization, we placed needle electrodes for intra-operative neurophysiological monitoring. Then, we measured and recorded baseline somatosensory-evoked potentials, motor-evoked potentials, and free-run electromyography (EMG) readings from the upper and lower extremities. Our patient was then positioned prone using the Mayfield three-point fixation system and a Jackson table; there was no change in her electrophysiology monitoring after positioning. Using fluoroscopy, we checked alignment of the cervical spine, finding a decrease in the atlantodental interval from pre-operative studies. Then, we made a midline incision over the spinous processes and dissected, in standard sub-periosteal fashion, the paraspinous muscle from the spinous processes and laminae. Subsequently, we isolated and bilaterally divided the C2 nerve roots and clearly identified bilaterally the C1 lateral masses, C2 pars, and C1-2 facet complexes. Under fluoroscopic guidance, we placed C1 lateral mass screws: a 4.0 × 34 mm screw on the right and 4.0 × 32 mm screw on the left (Vertex; Medtronic Sofamor Danek, Memphis, TN USA). Then, we placed bilateral, crossing, 3.5 × 24 mm translaminar C2 screws. We performed a C1 laminectomy to ensure that the cervical cord was well decompressed; decorticated the bone; and placed the C1 laminectomy autograft over the denuded surfaces using bone morphogenetic protein (Infuse; Medtronic Sofamor Danek, Memphis, TN USA) and bone matrix (Mastergraft; Medtronic Sofamor Danek) to supplement the graft. We then placed the rods, performed the final tightening, and closed the wound in a layered fashion. Intra-operative-evoked potentials revealed no changes during the case. There was no spontaneous EMG activity. In the immediate post-operative period after waking from general anesthesia, our patient was at her baseline examination levels.\nAt two weeks after surgery, our patient was restarted on celecoxib. Poor wound healing and drainage required antibiotic coverage and delayed initiation of immunomodulation. At four weeks after surgery, our patient received a methylprednisolone infusion (1 g) and was started on adalimumab (40 mg subcutaneously every other week (actual text of hospital formulary)) eight weeks after her operation. She has had relief from neck pain and remains neurologically intact except for soft signs of myelopathy, which were found pre-operatively. There was no evidence of abnormal motion between the C1 and C2 vertebrae or evidence of instrumentation failure on dynamic cervical spine X-rays (Figure ). While maintained on adalimumab, our patient has had intermittent complaints of hip and knee pain exacerbated by weather changes. Inflammatory markers have remained within normal limits since our patient started adalimumab (even during mild clinical flares). She has not developed psoriasis and there has been no evidence of sacroiliitis or irritable bowel disease (IBD) on MRI scans during a two-year follow up period.

A sixty-year-old female presented with intermittent shortness of breath happened in the morning of the day. She was a patient with chronic rheumatoid arthritis (RA) and was regularly followed in the rheumatologic clinic. During the past two weeks, she also complained of progressive numbness over bilateral hands and feet. Since the symptoms were not resolved by her daily medications and became more severe in the evening, she was brought to the ED for further evaluation.\nAt the ED, the patient was ambulatory, cooperative, and in mild distress, complaining of shortness of breath. Her vital signs were temperature 36.8°C, pulse rate 110 beats/min, respiratory rate 24 breaths/min, blood pressure of 168/81, and pulse oximetry 97%. Breathing sounds were normal without crackles or wheeze while auscultation. Other physical examination was unremarkable. Arterial blood gas was obtained and the data were within normal range. Because of the elevated D-dimer level, computed tomography of the chest was arranged to rule out the pulmonary embolism, but there was no significant finding.\nThe patient felt better after the use of oxygen during observation. However, reviewing of the medical records indicated the X-ray of the cervical spine was taken one week ago for the evaluation of limb numbness, and the increased distance at atlantoaxial space was noted (). Magnetic resonance imaging of the cervical spine was arranged and atlantoaxial subluxation with acute cervical spinal cord compression over C1-C2 level was found. The neurosurgeon was consulted and surgical intervention was suggested. However, the patient refused operation and conservative treatments with neck immobilization, and steroids were initiated during hospitalization. The patient was discharged 5 days thereafter with preserved neurologic function.

Write a detailed clinical case vignette based on the following key phrases: Cervical Spine, Respiratory Distress, Neurological Symptoms

An 82-year-old man presented to the emergency department with chief complaint of nonproductive cough, chest congestion, subjective fevers, hoarseness, and shortness of breath on ambulation for 2 days. He had chronic mild neck pain, which had been treated conservatively for the past 10 years. The patient had a history of 35 pack-years of smoking, which was discontinued 30 years prior to presentation. His medical history included hypertension, type II diabetes mellitus, and peripheral vascular disease with claudication, benign prostatic hypertrophy, colonic polyps, and multifocal osteoarthritis.\nOn examination, the patient had a grade 3/6 systolic murmur and decreased breath sounds at the bases bilaterally. Additionally the patient noted a 6-month history of unstable gait and loss of hand dexterity as well as bilateral upper extremity numbness and pain. Spine examination revealed decreased cervical range of motion. Neurologic examination revealed diffuse upper extremity weakness and hyperreflexia in the upper and lower extremities. He had negative Hoffman and Babinski signs. He then underwent an extensive metabolic workup, which revealed an elevated white blood cell count, elevated troponins, hyponatremia, and elevated blood glucose. Auxiliary tests included an abnormal electrocardiogram as well as elevated right hemidiaphragm with full inspiration on chest radiograph.\nThe patient was admitted to the hospital with persistent dyspnea. On hospital day 3, he underwent cardiac catheterization, which revealed extensive stenosis of the major coronary arteries, which was believed to be the main cause of his dyspnea. On hospital day 5, he underwent triple coronary artery bypass grafting. Despite the cardiac surgery, the patient's dyspnea did not improve. In addition, he developed new complaints of generalized weakness. He continued to complain of chest discomfort as well.\nMagnetic resonance imaging (MRI) and radiographic imaging of the cervical spine revealed extensive multilevel degenerative spondylosis with moderate to severe central canal narrowing from C2 to C7 and myelomalacia (\n). The patient underwent C2–C6 laminectomy and instrumented fusion with local autograft (\n). Lateral mass screws were utilized in the subaxial spine and pedicle screws were utilized at C2. Dome laminectomy was performed at C2. After surgery, the patient had gradual relief of dyspnea as well as improvement of strength. At 12-month follow-up, the patient was ambulating well and had improved neck pain. The dyspnea was completely resolved. His neck disability index had improved from 38% preoperatively to 30% at 1-year follow-up. The patient's chest X-rays showed that the right hemidiaphragm returned to its normal position.

An 87-year-old Caucasian man was transferred from another hospital after an episode of altered mental status secondary to hypercapnea requiring intubation. His past medical history included type 2 diabetes, stage 3 chronic kidney disease, and heart failure with preserved ejection fraction. He was a lifelong non-cigarette smoker. Per the family he was complaining of shortness of breath, weight gain and worsening leg swelling for 3 weeks, and was progressively more somnolent over the last week. On admission to the outside hospital the results of his laboratory tests were significant for a normal blood glucose of 176mg/dL, normal white blood cell count at 7000 cells/mm3, creatinine of 1.6mg/dL (at his baseline), elevated brain natriuretic peptide at 778pg/mL and negative toxicology screen. He had no history of opioid or benzodiazepine usage. His ABG showed acute on chronic hypercapnea with a pH of 7.22, partial pressure of carbon dioxide (pCO2) of 83mmHg and bicarbonate (HCO3) of 36mmol/L requiring intubation explaining his altered mental status. He was noted to be in congestive cardiac failure and was given diuretics and eventually he was extubated. He was transferred to our institution on nightly bilevel positive airway pressure (bipap) for his unexplained hypercapnic failure. His only complaint on transfer was his chronic two-pillow orthopnea.\nOn arrival he was in no acute distress with a heart rate of 74, respiratory rate of 20, blood pressure of 107/65mmHg, and oxygen saturation of 98% on 2L nasal cannula. A cardiovascular and respiratory system examination was unrevealing with normal jugular venous pressure and normal cardiac examination. There was paradoxical abdominal motion with the abdominal wall moving inwards on inspiration. A neurologic examination revealed 3/5 strength in his left deltoid and decreased biceps reflexes bilaterally. Power, tone and reflexes were normal in both his lower limbs. He also had severe osteoarthrosis of distal and proximal interphalangeal joints bilaterally with Heberden’s nodes.\nHis ABG on room air showed a partial pressure of oxygen of 64mmHg, pCO2 of 53mmHg, HCO3 of 28mmol/L and a pH of 7.33 with a normal A-a gradient of 18. This was consistent with chronic respiratory acidosis secondary to hypoventilation, given the normal A-a gradient. A chest X-ray showed elevated hemidiaphragms bilaterally (Figure ). Pulmonary function testing showed a restrictive pattern with a normal ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of 0.79 (114% predicted), with FEV1 and FVC 49 and 42% of predicted respectively. There were also significantly decreased maximum inspiratory and maximum expiratory pressures of 27.2 and 31.4% predicted; and a decrease in FVC of 22% from the sitting to supine position suggestive of neuromuscular weakness (>20%). The diffusing capacity was normal suggesting a chest wall or neuromuscular cause of restrictive lung mechanics.\nGiven his abnormal neurologic examination with left deltoid weakness and decreased biceps reflexes, our differential included respiratory neuromuscular weakness from cervical spondylosis and phrenic nerve root compression (given the C5 neurological deficits); or possible cervical myelopathy at C5/C6. The absent biceps reflex (C5 and C6) raised suspicion for myelopathy at the C5 to C6 level although this is typically associated with a brisk triceps reflex (C7). The lack of neurological findings in his lower extremities also argued against myelopathy, but given the potential variable manifestations of cervical myelopathy, an electromyogram (EMG) and nerve conduction study (NCS) were performed. The EMG and NCS revealed decreased amplitude in the phrenic nerves bilaterally and radiculopathy in his upper limbs, suggestive of nerve root compression at the cervical foraminal level. There was no evidence of amyotrophic lateral sclerosis or myopathy on EMG/NCS and serum creatine phosphokinase was normal. A cervical MRI was performed and showed severe bilateral foraminal narrowing at C3, C4 and C5 with no evidence of myelopathy, confirming the diagnosis of phrenic nerve root compression from cervical spondylosis as the cause of hypoventilation. When he developed pulmonary edema, the resultant decreased lung compliance placed an increased respiratory load on his weakened neuromuscular apparatus leading to worsening hypercapnea and resultant metabolic encephalopathy with altered mental status. Carbon dioxide, being readily diffusible across the blood–brain barrier is a well-known cause of encephalopathy in the setting of hypercapnea.\nHe was offered surgical decompression of cervical motor roots or possible diaphragmatic pacing. Given his age, he opted for conservative management with nightly bipap to rest his respiratory muscles at night. He showed significant improvement with night-time bipap and felt less fatigued during the day, probably from the rest provided to his respiratory neuromuscular apparatus. Following discharge he remained stable but gradually became less compliant with bipap. He had four admissions in 2 years with hypercapnic respiratory failure in the setting of pulmonary edema from heart failure. Pulmonary edema and the resultant decreased lung compliance placed an increased respiratory load on his weakened neuromuscular apparatus. As expected he fatigued more easily with his weakened neuromusculature leading to hypoventilation and worsening hypercapnea. He required continuous bipap while hospitalized until diuresis improved chest wall compliance and respiratory mechanics. He continued to refuse invasive therapies and was managed conservatively with nightly bipap. He developed evidence of right ventricular failure and pulmonary hypertension on echo from a combination of pulmonary venous hypertension from heart failure and chronic hypoxia from hypoventilation secondary to his neuromuscular weakness. Given his recurrent episodes of respiratory failure and worsening heart failure he was eventually transitioned to hospice care.

Write a detailed clinical case vignette based on the following key phrases: Cervical Spine, Respiratory Distress, Neurological Symptoms

An 82-year-old man presented to the emergency department with chief complaint of nonproductive cough, chest congestion, subjective fevers, hoarseness, and shortness of breath on ambulation for 2 days. He had chronic mild neck pain, which had been treated conservatively for the past 10 years. The patient had a history of 35 pack-years of smoking, which was discontinued 30 years prior to presentation. His medical history included hypertension, type II diabetes mellitus, and peripheral vascular disease with claudication, benign prostatic hypertrophy, colonic polyps, and multifocal osteoarthritis.\nOn examination, the patient had a grade 3/6 systolic murmur and decreased breath sounds at the bases bilaterally. Additionally the patient noted a 6-month history of unstable gait and loss of hand dexterity as well as bilateral upper extremity numbness and pain. Spine examination revealed decreased cervical range of motion. Neurologic examination revealed diffuse upper extremity weakness and hyperreflexia in the upper and lower extremities. He had negative Hoffman and Babinski signs. He then underwent an extensive metabolic workup, which revealed an elevated white blood cell count, elevated troponins, hyponatremia, and elevated blood glucose. Auxiliary tests included an abnormal electrocardiogram as well as elevated right hemidiaphragm with full inspiration on chest radiograph.\nThe patient was admitted to the hospital with persistent dyspnea. On hospital day 3, he underwent cardiac catheterization, which revealed extensive stenosis of the major coronary arteries, which was believed to be the main cause of his dyspnea. On hospital day 5, he underwent triple coronary artery bypass grafting. Despite the cardiac surgery, the patient's dyspnea did not improve. In addition, he developed new complaints of generalized weakness. He continued to complain of chest discomfort as well.\nMagnetic resonance imaging (MRI) and radiographic imaging of the cervical spine revealed extensive multilevel degenerative spondylosis with moderate to severe central canal narrowing from C2 to C7 and myelomalacia (\n). The patient underwent C2–C6 laminectomy and instrumented fusion with local autograft (\n). Lateral mass screws were utilized in the subaxial spine and pedicle screws were utilized at C2. Dome laminectomy was performed at C2. After surgery, the patient had gradual relief of dyspnea as well as improvement of strength. At 12-month follow-up, the patient was ambulating well and had improved neck pain. The dyspnea was completely resolved. His neck disability index had improved from 38% preoperatively to 30% at 1-year follow-up. The patient's chest X-rays showed that the right hemidiaphragm returned to its normal position.

A 64-year-old man was referred to the orthopaedic service with right hemidiaphragm paralysis. He had initially presented to his general practitioner reporting subjective shortness of breath after stand-up paddleboarding. His past medical history was significant for asbestos exposure and polio. Chest radiograph revealed an elevated right hemidiaphragm (Figures and ). A previous chest radiograph taken five years before showed normal diaphragmatic contours. He was subsequently referred to the respiratory physicians where workup included a chest CT scan (which revealed no intrathoracic abnormality) and dynamic fluoroscopic sniffing test (which confirmed complete right hemidiaphragm paralysis). He reported innocuous injuries to his neck in the past and intermittent neck pain for which he had previously consulted both a chiropractor and an osteopath. An MRI scan was undertaken which showed right-sided cervical foraminal stenosis (with uncovertebral and facet joint osteophytic changes at C3/4 and C4/5) (). He was therefore referred to the orthopaedic service. On examination, he had no focal cervical spine tenderness with a well-preserved range of motion. He did have some generalized right shoulder girdle and upper limb wasting and weakness compared to the left (presumed to be secondary to his postpolio syndrome). His upper limb reflexes were intact and symmetrical with the contralateral side.\nThe underlying cause for his hemidiaphragm paralysis, whether it was related to his cervical foraminal stenosis or postpolio syndrome, was indeterminant ().\nAfter obtaining multiple subspecialist opinions, a decision was made to proceed with posterior right C3/4 and C4/5 foraminotomies accepting that this may not have any effect on his shortness of breath. Surgery proceeded uneventfully as did postoperative recovery. By three months postoperatively, his hemidiaphragm paralysis had completely resolved on chest radiograph, and his shortness of breath had also improved (). Comparison of preoperative and postoperative spirometry lung function showed significant improvements in all parameters tested: increases in FVC from 3.88L to 4.86L, FEV1 from 2.44L to 3.13L, TLC from 5.11L to 7.65L, FRCpl from 2.61 to 3.63, and RV from 1.23L to 2.58L. A graphic representation of these findings is shown in . A satisfactory outcome was thus achieved.

Write a detailed clinical case vignette based on the following key phrases: Cervical Spine, Respiratory Distress, Neurological Symptoms