Acute non-high-risk pulmonary thromboembolism (PTE) is generally relieved within months of anticoagulation treatment initiation. However, some patients experience complications. This study aimed to assess the efficacy of urokinase thrombolysis in intermediate-risk PTE using a modified pulmonary artery obstruction index (PAOI). We retrospectively assessed the data of 85 patients with acute PTE and venous thromboembolism of the lower extremities treated between January 2018 and January 2023. All patients underwent inferior vena cava filter implantation and thrombolysis via the dorsal foot vein. We evaluated thrombolysis efficacy using computed tomography pulmonary angiography, Doppler echocardiography, D-dimer (D-D) levels, and PAOI. The effects of age, preoperative D-D level, urokinase dosage, and thrombolysis time on efficacy and safety were analyzed. Complete thrombus dissolution in pulmonary arteries occurred in 67.1% of patients (thrombolysis efficacy, 100%). The modified PAOI/40, artery diameter, and artery-to-aorta diameter ratio showed significant improvements post-thrombolysis. The average daily usage of urokinase ranged from 36.36 × 104 to 100 × 104 units. Spearman rank correlation test revealed a relationship between PAOI change rate and pre-intervention D-D level (r = 0.291; P = .007) and average daily urokinase dosage (r = -0.341; P = .001). In multinomial logistic regression, total urokinase dosage (odds ratio = 1.052, P = .032) and thrombolysis time (odds ratio = 0.012, P = .032) were identified as significant factors. During follow-up, thromboembolism recurred in 2 cases; clinical manifestations of right heart insufficiency were not observed in other patients. Higher preoperative D-D levels may suggest a better thrombolytic effect in intermediate-risk acute PTE. An appropriate daily dosage of urokinase may yield good therapeutic effects. Managing urokinase dosage and duration helps prevent serious bleeding complications.

Acute mesenteric ischemia remains one of the most lethal abdominal emergencies, particularly when bowel necrosis has already occurred at the time of diagnosis. Embolic occlusion of the superior mesenteric artery is most commonly associated with atrial fibrillation. Although hyperthyroidism is a recognized trigger for atrial fibrillation, widespread systemic arterial embolization in this setting is rarely reported. We describe a 77-year-old woman with biochemical thyrotoxicosis and new-onset atrial fibrillation who developed simultaneous superior mesenteric and peripheral arterial occlusions, resulting in near-total small bowel necrosis that was not surgically survivable. Her rapid clinical deterioration underscores the aggressive nature of embolic mesenteric ischemia and the narrow window available for intervention.

Comparative data on vessel preparation using intravascular Shockwave lithotripsy (Johnson and Johnson, New Brunswick, NJ) or the 355-nm Auryon laser (Angiodynamics, Latham, NY) in calcified femoropopliteal arterial disease is limited. This is a retrospective, single-center study evaluating the 30-day safety and effectiveness of the 355-nm laser system versus Shockwave lithotripsy in treating calcified femoropopliteal arterial disease. Angiographic images were reviewed by core laboratory. The primary endpoint of safety is freedom from major adverse limb event (MALE) at 1 month. The primary effectiveness endpoint is acute procedural success, defined as achieving less or equal 30% mean residual narrowing postfinal treatment with no bailout stenting. A total of 29 consecutive patients were included (355-nm laser 15 patients [15 vessels] and Shockwave lithoplasty 14 patients [15 vessels]). At baseline, there were no differences between the two cohorts in demographics or clinical presentation. Also, there were no difference in total occlusions (33.3 vs. 33.3%), lesion length (median: 12.0 vs. 12.1 cm), presence of moderate to severe calcium (86.7 vs. 100%). At 30-day, there were no MALEs in both groups. There were no perforations, type D dissections, or distal embolization seen in both cohorts. Bailout stent was driven by a higher residual stenosis and was 35.7 vs. 13.3% in Shockwave versus laser, respectively (p = 0.215). At 30-day ankle-brachial indices were similar between the two groups (median: 0.9 vs. 1.09). Both Shockwave and 355-nm laser are effective and safe in calcified femoropopliteal lesions. A numerically higher rate of bailout stenting was seen with Shockwave lithoplasty.

Severe rheumatic mitral stenosis with atrial fibrillation creates a highly thrombogenic left atrial substrate, particularly when anticoagulation is inadequate. Coronary embolism may present as ST-elevation myocardial infarction (STEMI) and can mask simultaneous systemic arterial embolization.

Thoracic outlet syndrome (TOS) encompasses a spectrum of disorders caused by compression of neurovascular structures at the thoracic outlet. Arterial thoracic outlet syndrome (aTOS) is rare, accounting for less than 1% of cases, yet carries significant morbidity due to arterial injury, thrombosis, and distal embolization. We present a 34-year-old woman with progressive pain, paresthesia, and bluish discoloration of the left upper limb. Doppler ultrasound demonstrated reduced ulnar artery calibre with a tardus-parvus waveform, indicating distal arterial compromise. CT angiography revealed a fused cervical rib causing focal compression of the left subclavian artery with associated poststenotic dilatation. The patient underwent surgical decompression with cervical rib excision, thrombus evacuation, and arterial reconstruction, resulting in restoration of distal perfusion. Postoperatively, MRI of the shoulder-performed for persistent pain-demonstrated edema of the infraspinatus and teres minor muscles without fatty infiltration, suggestive of acute denervation edema. This case illustrates the full imaging continuum of aTOS, from structural vascular compression and distal ischemia to postoperative neural involvement, underscoring the critical role of multimodality imaging in both diagnosis and follow-up.

Dural arteriovenous fistulas are acquired intracranial vascular malformations characterized by abnormal shunting between dural arterial feeders and venous structures. Anterior cranial fossa and ethmoidal dural arteriovenous fistulas are uncommon but clinically important lesions because they frequently drain directly into cortical veins and may be associated with venous ectasia or aneurysmal venous dilatation. When venous variceal dilatation is present, these lesions may mimic intracranial aneurysms on noninvasive vascular imaging, making digital subtraction angiography essential for definitive diagnosis and treatment planning. We report the case of an 84-year-old man who presented with slurred speech and left-sided limb weakness. Magnetic resonance imaging demonstrated bilateral chronic ischemic white matter changes and lacunar infarct-related signal abnormalities; therefore, the acute presentation was initially attributed to ischemic cerebrovascular disease. However, computed tomography angiography more clearly demonstrated abnormal vessels with localized aneurysm-like dilatation in the right frontal/anterior cranial fossa region, prompting further angiographic evaluation. Digital subtraction angiography revealed an anterior cranial fossa dural arteriovenous fistula supplied by bilateral ophthalmic arteries, predominantly from the right side, with direct cortical venous drainage and aneurysmal venous dilatation in the right frontal region. These findings classified the lesion as a high-grade dural arteriovenous fistula corresponding to Borden type III and Cognard type IV. The patient underwent endovascular treatment under general anesthesia. The dominant right ophthalmic/anterior ethmoidal arterial feeder was selectively catheterized using an Echelon microcatheter over a Synchro microguidewire. Axium Prime detachable coils were deployed in the mid-to-distal arterial segment distal to the origin of the central retinal artery, followed by a controlled injection of Onyx-18. Final angiography demonstrated no residual arteriovenous shunting, complete disconnection of the aneurysmally dilated venous pouch from the arterial feeder, and no early venous filling during the arterial phase. The postoperative course was uneventful, with no clinically evident new neurological or visual complications. This case highlights the diagnostic importance of digital subtraction angiography in aneurysm-mimicking anterior cranial fossa vascular lesions and demonstrates that coil-assisted Onyx embolization may be feasible in carefully selected ophthalmic/anterior ethmoidal artery-supplied dural arteriovenous fistulas when safe distal catheterization and controlled embolic delivery can be achieved.

Cerebral arterial gas embolism (CAGE) is a recognised complication of diving-related barotrauma and of medical procedures whereby gas enters the vascular system. CAGE is a principal indication for hyperbaric oxygen treatment (HBOT). In contrast, CAGE resulting from HBOT itself is exceedingly rare. We describe the case of a 73-year-old man undergoing his first session of HBOT for a chronic lower limb wound, who developed acute focal neurological deficits during decompression. He had no known respiratory disease or smoking history. Immediate assessment demonstrated stable physiology. Initial computed tomography (CT) scan of the brain and neck vessels and perfusion imaging did not show any evidence of thrombus or intravascular gas, and partial neurological recovery occurred over several hours. Subsequent magnetic resonance imaging of the brain demonstrated acute infarction involving the left precentral and postcentral gyri. High-resolution CT chest revealed multiple bilateral thin-walled pulmonary cysts, including a left upper lobe cyst with an air-fluid level consistent with recent barotrauma. A transient broncho-venous fistula allowing arterial oxygen embolisation during decompression was considered the most plausible mechanism. The patient improved with supportive management and was discharged with minimal residuae. This case highlights an exceptionally rare but serious complication of HBOT and underscores the importance of vigilance during decompression and careful consideration of occult pulmonary pathology.