EVF Interactive Cases

A 78-year-old Asian female was referred by her primary care physician for painful blue discoloration and small ulcer at the tip of right big toe since 1 month. She had never seen a doctor in her life up until the prior month. Her only cardiovascular risk factor was recently diagnosed poorly controlled hypertension (HTN); she was taking ACE and calcium channel blockers. She complained of relentless rest pain in the right foot, needing round the clock narcotics. Her serum creatinine was 1.1 mg/dL on the first office visit.

A 50-year-old African-American woman with end stage renal disease secondary to hypertensive and diabetic nephropathy was admitted to the hospital for a cadaveric renal transplant. She had been maintained on hemodialysis via a right upper extremity AV fistula. Following transplantation, she acutely developed right hemifacial swelling. On physical exam, there was a bruit over her right eye. Significantly, she did not complain of altered visual acuity.

A 65-year-old male presented to the Emergency Department with a 10-hour history of left upper quadrant, sudden-onset, dull-aching, intermittent, nonradiating abdominal pain. On examination, the abdomen was distended with diffuse tenderness in the epigastric area. On admission, the vital signs were: BP 98/67 mm Hg, pulse 71, respiration 14, temperature 97.4 degrees F, pain 5, and O2 Sat 100. Routine laboratory tests were unremarkable, with baseline hematocrit of 40.9%, with a range of 42.0-52.0%.

A 75-year-old male patient was referred from the department of nephrology for evaluation of a chronic critical limb ischemia of the right leg. An infection of a chronic ischemic lesion on the great toe was jeopardizing preservation of the lower limb.

One year prior, interventional recanalization of a 12 cm complete occlusion from the distal popliteal artery to the fibular artery (the only remaining calf vessel) was attempted. However, there was no improvement of arterial leg perfusion. Vascular surgery was not considered because of the compromised general condition of the patient, who was suffering from severe renal insufficiency and chronic heart failure (NYHA Class III).

A 79-year-old Caucasian female presented with a 1-month history of severe, relentless rest pain involving both calves and feet as well as acute renal failure. She had a major stroke 3 months prior, from which she had been recuperating in the skilled nursing facility. Renal function normalized with hydration in the first 48 hours.

Clinical examination showed absent femoral pulses with soft bilateral systolic bruits and absent popliteal and pedal pulses. There was pinkish-blue discoloration of toes bilaterally. Her left elbow had flexion contractures from her recent stroke. Duplex examination showed monophasic waveforms with severely diminished peak systolic velocities bilaterally at all levels.

A 68-year-old female with intermittent pain in her great toe over the course of 6 months was referred from podiatry for noninvasive imaging to evaluate wound healing potential preoperatively.

A 72-year-old Caucasian male with a history of diabetes and vascular disease underwent bilateral renal artery stenting in June 2003. Two 5 x 12 Cordis Genesis stents were placed on the right and a 5 x 18 Genesis stent was placed on the left for severe hypertension and renal insufficiency.

He developed recurrent stenosis in November 2004 and was treated with 6 mm angioplasty bilaterally. He then occluded the right stent and had a left-sided restenosis treated with 7 mm angioplasty in February 2007.

Due to rapid restenosis, he underwent 6 mm cutting balloon PTA of the left stent in December 2007.

A 67-year-old male with a history of insulin dependent diabetes mellitus, hypertension, and dyslipidemia had undergone a left femoral-to-popliteal saphenous vein bypass in 2005. In 2006, he developed lifestyle-limiting claudication (LLC) of his left lower extremity (LLE) and was found to have significant left popliteal artery stenosis. He underwent plain old balloon angioplasty (POBA), resulting in resolution of his symptoms. The patient remained asymptomatic until 2009, when he once again developed LLE LLC. His symptoms progressed to inability to walk to his mailbox without having to stop to alleviate the leg pain. He was then referred for vascular evaluation.

The patient is a 73-year-old Japanese male with no history of smoking or prior vascular disease. He complained of rest pain in both legs. The patient underwent PADnet testing in the referring physician’s office. This exam suggested bilateral inflow and outflow disease.

A 61-year-old male patient weighing 85 kg and measuring 179 cm presented to the clinic with symptoms of pain, cyanosis, and edema of the left lower extremity which disturbed the patient for 3 days. There was trauma of the left lower extremity 5 days before he appealed to clinic.

A 51-year-old African-American male with poorly controlled diabetes, hypertension, and a past history of smoking presented to us with right foot rest pain in early November 2009. He underwent a duplex examination, followed by right leg angiogram with SFA angioplasty. Two weeks later, he presented to his podiatrist with a new abscess in the left foot. This was drained and followed by TMA (trans-metatarsal amputation) 4 days later. In the interval, the patient followed up with us in the clinic and had noninvasive physiologic imaging, which is compared to previous imaging from 2008.

A 60-year-old male presented with acute onset of lifestyle limiting claudication of his right lower calf after pain-free walking distance of 50 m (164 feet). The symptoms had started one week ago. He denied earlier symptoms of claudication of rest pain and skin lesions of the lower extremities. Cardiovascular risk factors were absent. Noninvasive arterial workup revealed the presence of moderate ischemia at rest of the right lower limb.

A 71-year-old white male presented to the hospital with a 3 week history of increasing jaundice and 1-2 day history of fever and chills. He had a significant past medical history of intractable idiopathic ascites since 1999, idiopathic thrombocytopenic purpura (ITP) that was refractory to steroids and splenectomy but responsive to Danazol. A previous liver biopsy showed fatty liver and early fibrotic changes. There was no history of abdominal pain. He had lost approximately 10 pounds of weight with severe anorexia during this time.

A 56-year-old woman with a history of obesity, fibromyalgia, COPD, DM, and a right-sided port presented to an outside hospital with 7-10 days of worsening SOB, facial flushing, and edema of the face, neck, and upper extremities bilaterally. A CT venogram at that institution showed an extensive clot in the proximal SVC extending to the brachiocephalic and internal jugular veins. A heparin drip was started and the patient was transferred to Boston Medical Center (BMC) for further care. On admission, an MR venogram was performed which showed an extensive clot involving the upper SVC, left and right brachiocephalic, left and right subclavian, and proximal right internal jugular veins.

A 16-year-old male patient presented complaining of uncontrolled hypertension of 170/110 mmHg despite taking beta blockers and diuretics. On examination, his BP was still high, upper limb pulsations were equal on both sides, lower limb pulsations were good on both sides, and cardiac examination was normal. ECG, echo, and duplex study were normal.

A 69-year-old male African-American with a history of CAD, two CABG procedures, PAD with multiple foot ulcers in the past, carotid stenosis, carotid endarterectomy, type 2 diabetes, and hypertension was admitted to the cardiovascular center for right big toe gangrene and right leg rest pain. A few weeks ago, he had injured his right leg, which resulted in the gangrenous right big toe. The patient had no previous lower limb vascular procedures. He declined surgical intervention. His baseline serum creatinine was 1.6 mg/dL and the rest of his labs were unremarkable.

A 55-year-old woman with long-standing hypertension and diabetes developed congestive heart failure. She underwent placement of a biventricular pacemaker/internal cardiac defibrillator (ICD) via the left subclavian vein 5 years ago, which led to improvement in her heart failure control. Over time she developed chronic renal insufficiency, and 2.5 months before her first visit to our service, she had surgical creation of a left upper arm arteriovenous graft (AVG) so she could start hemodialysis.

A 72-year-old male presented to our hospital after the dialysis nurse had difficulty cannulating his brachio-cephalic fistula and was "pulling clots" out of it. His past medical history was significant for end stage renal disease secondary to polycystic kidney disease and hypertension. He received a left brachio-cephalic fistula 2/09 but noticed symptoms of steal while using it. In October of 2009 he underwent a distal revascularization interval ligation (DRIL) procedure that completely resolved his symptoms. He had been dialyzing without difficulty up to 2/2010. On physical exam he had a somewhat diminished pulse and weak thrill in the fistula. There were no signs of ecchymosis or swelling. We decided to perform an ultrasound to map out our approach before accessing the fistula.

The patient is a 50-year-old African-American male who presented at the Los Angeles Vascular Center with an occluded left upper arm AV fistula. On physical evaluation, the fistula was very prominent. The fistula, a cephalic vein to brachial artery conduit, was placed surgically 4 years prior to presentation. The fistula had been occluded for 3 weeks prior to presentation. The patient had been receiving dialysis on his regular schedule through a right internal jugular tunneled dialysis catheter during the time of fistula occlusion. On presentation the patient was in no sign of physical distress.

A 73-year-old female presented with lifestyle-limiting claudication of the right lower limb with a pain-free walking capacity of 50 meters (164 feet) and arterial hypertension refractory to medical therapy (arterial blood pressure upon admission 220/90 mmHg). Cardiovascular risk factors were severe arterial hypertension and cigarette smoking (75 pack years). Her patient history also included renal insufficiency (creatinine clearance: 27 ml/min at baseline).

A 41-year-old male with a history of hepatitis B, alcohol abuse, and cirrhosis presented with one day of bright red hematemesis. On arrival, the patient was hemodynamically stable. Pantoprazole and octeotride were started, and the patient was admitted to the ICU for further investigation of his GI bleed. Gastroenterology performed an EGD which showed gastric varices without active bleeding.

A 45-year-old vasculopath was evaluated for recent-onset ischemic nocturnal rest pain in both feet.

These symptoms were present for the past several weeks. There was no tissue loss reported. The patient had been suffering from longstanding intermittent claudication of both legs. This manifested primarily as calf claudication but continued walking also precipitated bilateral buttock pain. Upon questioning, he reported bilateral calf claudication symptoms as a young child. These were previously not worked up.

A 56-year-old female patient with a positive coronary catheterization from an outside hospital was transferred to our institution because of persistent unstable angina and hypotension. Emergency percutaneous coronary intervention was performed and the distal LAD was stented. Final angiography showed excellent angiographic results. After stenting, the patient remained hypotensive. Angiography of the right common femoral artery was performed in preparation to remove the sheath and complete the procedure.

A 41-year-old female with a past medical history of obstructive airway disease was transferred to Boston Medical Center for further evaluation and management of acute respiratory distress that was later confirmed to be H1N1 infection. During her infection work-up, the patient was found to have an acute deep vein thrombosis (DVT) in the proximal right peroneal vein.

A 70-year-old male presented with interdigital ulceration of the right foot that had occurred 6 weeks prior. Cardiovascular risk factors were diabetes mellitus and arterial hypertension and the patient was on hemodialysis. The referring nephrologist reported episodes of hypotension during dialysis as well as presence of congenital aortic isthmus stenosis. Noninvasive arterial workup revealed the presence of critical limb ischemia.

A 40-year-old Hispanic male with a history of ulcerative colitis presented to our ER with a cool and painful right foot x 2 days. Approximately two weeks prior to presentation, he had noticed significant discomfort in the right calf after walking 30-50 feet. Two days prior to hospital evaluation, he had noticed nocturnal right foot discomfort that would wake him up from sleep. On the day of presentation, he noticed diminished sensation and numbness in this foot along with inability to bear weight on it. He denied any chest, back, or abdominal discomfort. There was no history of urinary or fecal incontinence. No hematuria, oligura, or anuria was present. There was no recent history of hematochezia or melena.

A 61-year-old Latino female patient with end stage renal disease (ESRD) referred for right upper arm AV graft that had thrombosed 3 days prior. The patient denied any fever, chills, or perspiration. The right brachiobasilic AV graft had been placed 6 months prior. In the last 3 months, she had had 2 thrombosis events which were endovascularly treated, including a stent graft placement in the venous limb.

A 48-year-old female presented to her primary care doctor in January 2009 with unexplained fevers, lasting 10-15 minutes daily. She was otherwise asymptomatic. Laboratory tests revealed leukocytosis, with WBC of 14,000. Urine analysis was consistent with a urinary tract infection (UTI) and she was treated with a course of antibiotics. The patient developed symptoms of flank pain, for which a CT scan was ordered to rule out pyonephrosis/abscess, and she was found to have a splenic lesion consistent with a small infarction.

A 79-year-old white male presented to an affiliated hospital with a chief complaint of dizziness. His past medical history was significant for well-managed hypertension and a 9-cm AAA repaired endovascularly with a Gore AneuRx device 2 years ago at an outside hospital. On further work-up, emergent chest and abdominal CT scans were performed which showed the following (see Images 1-4).

A 43-year-old woman who recently immigrated from Haiti presented with a long-standing history of hypertension that she stated was first diagnosed approximately 20 years ago. She had been on pharmacotherapy for approximately 2 years, and was referred for refractory hypertension despite concurrent use of four antihypertensive medications. Laboratory tests showed hyperaldosteronism with an elevated aldosterone-to-renin ratio. In addition, medical records indicated a remote history of hypokalemia which improved with spironolactone therapy.

A 57-year-old male Caucasian patient referred to Vascular Medicine for severe and disabling bilateral thigh claudication. He had had bilateral aortoiliac angioplasty and covered stenting 15 months earlier, with short-term symptomatic resolution. CTA showed lower aortic and bilateral common and right external iliac stent occlusion with reconstitution of right common femoral and left external iliac arteries. The right hypogastric artery was also chronically occluded (see Videos 1 and 2).

A 48-year-old female presented to the Emergency Department with an acute right middle cerebral artery territory stroke. Her past medical history was significant for hypertension. Work up included MRA of the neck, which revealed an aneurysm of the high cervical segment of the right internal carotid artery.

A 42-year-old G5P2 woman was referred by her gynecologist to the interventional radiology clinic for a uterine artery embolization (UAE) consultation. The patient had a chief complaint of worsening dysmenorrhea, dyspareunia, menorrhagia, and pelvic pain for the past three years. The patient’s pain had become unbearable over the past three months.

The patient, a 51-year-old male with a 30 pack/year tobacco history and hyperlipidemia, presented to our vascular clinic with a 6-8 month history of progressive bilateral hip and thigh claudication. At presentation he stated that he was able to ambulate approximately 25 feet before he had severe cramping pain in his hips and thighs which required him to stop and rest for several minutes before he could resume his previous activities. This was severely limiting his work and activities. He denied any history of rest pain, embolic events, or acute ischemia in his extremities. On physical examination, the common femoral pulses were diminished bilaterally, and the pulses at the feet were detected with Doppler, but nonpalpable. No other physical exam abnormalities were present. In-office ABI examination demonstrated a right ABI of 0.75 and a left of 0.71 at rest

A 55-year-old male with a history of coronary artery bypass grafting, hypercholesterolemia, and hypertension presented with chest pain. The patient had negative cardiac enzymes and underwent a stress test (see Image 1), which demonstrated anterior wall reversible ischemia.

An 84-year-old Caucasian male came to the Emergency Room with a 4-week history of painful blue-colored skin over the left 5th toe that had not improved with over-the-counter topical antifungal cream. He had a long history of on-and-off back pain. Past medical and surgical history was significant for TIA, hypertension, CAD, aortic valve replacement with a bioprosthetic device, and CABG.

A 76-year-old male presented to the Emergency Department with a one-week history of oliguria and red-tinged urine. A Foley catheter was placed in the ER with minimal return of urine. The patient had a history of atrial fibrillation but was not anticoagulated due to recurrent epistaxis and a recent episode of gastrointestinal bleeding. His history was remarkable for coronary artery disease with a distal LAD stent placed 4 years earlier, prior ventricular pacemaker placement, prior CVA with no residual deficit, hypertension, a solitary functional kidney, renal artery stenosis (treated medically), peripheral vascular disease, and hyperlipidemia.

A 63-year-old male patient weighing 79 kg and measuring 183 cm presented to the clinic in August 2009. The year before, the patient was treated for iliofemoral deep vein thrombosis of the left lower extremity. There was trauma of the left lower extremity in anamnesis. During duplex ultrasound a floating thrombus of the left vena iliaca communis was diagnosed.

The patient is a 51-year-old male with a past medical history significant for HIV, prior PE, end-stage renal disease, hepatitis C, and remote polio affecting the right leg diagnosed in childhood. He was admitted to the hospital for an infected dialysis graft in his arm and on physical examination the admitting intern discovered a focal area of left leg swelling. Admission orders included a left lower extremity ultrasound to evaluate for DVT as the etiology for swelling. The ultrasound was negative for DVT. However, a large pseudoaneurysm measuring 5.4 x 4.3 x 2.7 cm was identified on the medial aspect of the lower leg just above the ankle.

A 75-year-old male patient was referred in June 2008 with a 3-month history of sore right leg. He had been treated for hypertension and dyslipidemia. He smoked 20 cigarettes a day for 50 years before quitting 6 years before. Surgically he had bilateral ligation and stripping of varicose veins in the 1970s and a right femoropopliteal synthetic bypass at another hospital 5 years before. Over the last 3 months his symptoms progressed from half-block intermittent claudication to a feeling of sore leg all the time. His physical exam was within normal limits except for the scarred legs from his surgeries, absent right pedal pulses, and cyanotic right toes. His arterial Doppler showed that his resting right Ankle Brachial Index was 0.48; it was 0.92 on the left.

A 57-year-old female without any prior history of coronary artery disease presented to us with a history of worsening exertional angina over the past 1 month. Her known risk factors are diabetes, hypertension, hypercholesterolemia, and smoking. She was initially evaluated with a Bruce protocol treadmill ECG stress test on an outpatient basis. She completed 6 minutes and 30 seconds before termination due to chest pain and 2 mm ST segment depressions in leads II, III, and AVF and 1 mm in leads V4 through V6. Her chest pain resolved shortly after termination of exercise but the ST segment changes persisted 10 minutes into recovery.

A 74-year old Caucasian man referred to Vascular Medicine for evaluation and management of bilateral common iliac and left hypogastric arterial aneurysms and history of open repair of a ruptured AAA 10 years ago. He denied abdominal or back pain and had no episodes of blue toe syndrome, claudication, or rest pain. The CT angiogram of abdomen and pelvis showed bilateral common iliac aneurysms (2.7 cm on the right side and 2.8 cm on the left side). Aneurysms extended from the aortoiliac bifurcation to the bilateral hypogastric ostia. The left hypogastric aneurysm measured 2.0 cm and extended from its ostium to the proximal 2-cm segment.

A 17-year-old male presented to us with a history of recurrent left varicocele after varicocelectomy. The patient was not having any pain at rest, but he had mild to moderate scrotal pain and swelling after his routine exercise and games. His family was also concerned regarding his future fertility. Physical examination showed a grade III varicocele and a low-placed incision on left side. Given his history of previous surgery and location of the incision, it was decided that the best treatment option for this young patient with a concern of fertility would be to undergo percutaneous embolization in interventional radiology.

A 72-year-old female with a history of diabetes and hypertension presented for an outpatient CT scan to evaluate for ongoing epigastric pain that had been present for the past several months. She denied any history of pancreatitis, hypersplenism, portal hypertension, or trauma. The patient had had one uncomplicated pregnancy approximately 30 years prior to her presentation. Her hemodynamics were stable at evaluation. CT scan revealed a 5.1 cm saccular splenic artery aneurysm originating from the midportion of the distal splenic artery. The splenic artery was also noted to be originating from the superior mesenteric artery.

The patient was an asymptomatic 16-year–old female discovered to be hypertensive during a routine general exam (BP 160/100 mmHg, with weak bilateral femoral pulsations). Cardiac exam revealed a short systolic murmur over the left sternal border. ECG was normal and chest x-ray showed rib notching. Echo Doppler study showed normal chamber dimensions and good left ventricular function. A localized aneurysmal dilatation was noted protruding from the descending thoracic aorta just distal to the left subclavian artery, with a pressure gradient of 70 mmHg across a narrow segment of the descending thoracic aorta immediately distal to the aneurysm.

A 69-year-old male Asian retired farmer presented with a history of bilateral dependent ankle edema, intense pain, and tenderness over the left lateral ankle bone for several months. Pain mostly involved the left ankle and foot, which severely interfered with sleep when he lay down, as the pain was aggravated by pressure on the lower calf. He also had darkened skin around both ankles for the last 6 months. He denied local trauma, recent or remote fractures, or deep venous thrombosis (DVT); ankle x-ray was unremarkable. Past medical history was contributory for hypertension and diabetes mellitus.

A 71-year-old female with a history of diabetes mellitus, hypertension, coronary artery disease, and congestive heart failure presented to the Emergency Department approximately two hours after the abrupt onset of left-sided weakness, which was noted by her daughters. There was no observed seizure activity. History was limited, as this was obtained from the daughters; however, there was no apparent history of atrial fibrillation or carotid artery intervention, and the patient was not taking Coumadin.

A 46-year-old male presented with symptoms of claudication in the left lower limb that had a sudden onset about 3 months earlier. His pain-free walking capacity was limited to 50 meters. His patient history contained balloon angioplasty of the left superficial femoral artery 10 years ago in an outside hospital. Cardiovascular risk factors were hyperlipidemia, arterial hypertension, and smoking.

The patient, an 85-year-old Caucasian male with hypertension, hyperlipidemia, and coronary artery disease, presented with severe and disabling right lower limb claudication that had progressively worsened for 2 years. Currently, he had right calf pains upon walking fewer than 50 feet, which essentially confined him to a chair during most of his day.

The patient is an 84-year-old female with a cold left leg that has worsened over the past few days. Her past medical history is significant for hypertension, coronary artery disease, peripheral vascular disease, atrial fibrillation, hypercholesterolemia, diabetes, and right breast cancer. She had a right mastectomy in the 1980s, CABG in the 1980s, aorto-bifemoral bypass graft in the 1990s, left femoro-popliteal bypass graft in 2000, and numerous stenting procedures at an outside hospital.

A 65-year-old male presented with severe, lifestyle-limiting claudication of the left lower limb with a pain-free walking distance of 100 meters. Thirty-one years ago, he had undergone irradiation therapy for urine bladder carcinoma, and 26 years ago a continent urostomy procedure was performed. The patient’s risk factor background contained type II diabetes mellitus, cigarette smoking (30 packyears), hyperlipidemia, and arterial hypertension.

The patient is a 51-year-old Caucasian female with history of dilated cardiomyopathy which was diagnosed 10 years ago, with an ejection fraction of 55 to 60%, and a history of pulmonary hypertension. She also has a history of chronic atrial fibrillation, chronic venous stasis bilaterally in the lower extremities, obstructive sleep apnea, anxiety, and temporal arteritis by exam only, which was diagnosed one year ago.

An 82-year-old male patient was referred from his general practitioner for left-sided backside and thigh claudication. He reports increasing pain in his backside and thigh after walking a hundred yards. Uphill walking and fast walking increase the pain. A short break of two minutes relieves these symptoms.

A 66-year-old Caucasian woman presented with left lower extremity dependent edema and claudication pains upon walking for the last 6 months. Symptoms were severely disturbing her quality of life and her work as a hair dresser. She had left femoropopliteal venous spontaneous deep vein thrombosis (DVT) 9 months ago, for which an IVC filter was implanted prophylactically and being anticoagulated. She had not been using compression therapy since the DVT episode. She was on postmenopausal estrogen replacement therapy up until the DVT episode, but stopped after the event.

The patient is a 65-year-old white male who presented with a five-day history of abdominal and left flank pain. Past medical history was remarkable for hypertension, a left pneumonectomy for squamous cell carcinoma, and a recent (four months) myocardial infarction (MRI). In the emergency department (ED), his vital signs were normal and he was in no acute distress. On physical exam, abdominal tenderness was elicited in the epigastrium over a pulsatile mass. An abdominal ultrasound in the ED revealed an abdominal aortic aneurysm (AAA) without any overt sign of rupture. His labs were all within normal limits. EKG showed a previous anterior MI and aspecific ST changes. A vascular surgery consultation was requested.

A 52-year-old male presents to Boston Medical Center with severe abdominal pain. His medical history is significant for alcohol abuse, grade III esophageal varices verified by upper endoscopy, and recurrent upper gastrointestinal bleeding despite medical and endoscopic management.

A 55-year-old Caucasian woman presented to the Emergency Department with a 1-week history of intermittent melena and 3 episodes of hematemesis a few hours prior to admission. She reported progressively worsening severe right upper quadrant pain requiring higher doses of Indocin and morphine over the past week to control pain. Patient denied fever, chills, chest pain, shortness of breath, syncope, hematochezia, and dyspepsia. She also denied previous episodes of gastrointestinal bleeding prior to this admission.

A 26-year-old woman with a long-standing history of Crohn’s disease and multiple bowel resections presented with abdominal pain. She was diagnosed with a Crohn’s flare and admitted for IV steroids and bowel rest. Anticipating the need for prolonged bowel rest, a right upper extremity PICC line was placed for TPN. Two days after PICC placement, she developed mild right upper extremity swelling. The next day the arm was more swollen and was very painful. On exam, she had massive swelling with 2+ pitting edema from her hand to her axilla on the right arm. She had a normal neurologic and pulse exam but very limited range of motion secondary to pain.

The patient is a 46-year-old male who presented with a left parotid/neck mass in December 2008. CT imaging of the neck was performed. Biopsy demonstrated a parotid squamous cell carcinoma with mucinous features. The patient failed neoadjuvant chemotherapy and developed renal insufficiency secondary to chemotoxicity. He then underwent 3 weeks of radiation therapy to which he showed a response. He did develop a large skin ulcer over the tumor site, with deep extension to the cervical vasculature. He suffered from intermittent mild bleeding at the ulcer site. The patient was referred for plastic surgery evaluation for wound flap repair, but was noncompliant with follow-up.

A 60-year-old male patient was referred from his general practitioner for evaluation of clinically evident pubic venous collaterals. The patient had recently undergone left-sided varicose vein surgery with crossectomy and stripping of the left greater saphenous vein. Following this varicose vein ablation he kept complaining about leg swelling and leg pain after 15 minutes of walking. His background contained a history of testicular cancer, which was removed successfully by hemiorchiectomy 30 years ago.

The patient is a 29-year-old otherwise healthy male who presented with a one-month history of a dry cough, progressive fatigue, and right-sided chest pain. He was seen in the emergency room, where a chest x-ray and CT scan demonstrated an anterior mediastinal mass enveloping the aortic arch and arch vessels. An initial needle biopsy was performed via CT scan guidance but was inconclusive. A subsequent mediastinoscopy and biopsy were performed, complicated by brisk arterial bleeding. This was temporized by a partial sternotomy with placement of pledgeted sutures at the site of bleeding with control of surface bleeding. A subsequent CT scan of the chest demonstrated a 3-cm pseudoaneurysm arising for the innominate artery. (Figure 1, 2) It was felt that the lymphoma had facilitated the tamponade on this pseudoaneurysm and that the institution of chemotherapy may increase the risk of rupture.

A 63-year-old male presented with bilateral buttock claudication after a pain-free walking distance of about 200 meters. Sixteen years prior to admission the patient had undergone aorto-bilateral bypass grafting for chronic distal aortic occlusion (Lériche`s syndrome). Upon admission, no details on the postoperative vascular anatomy (level of distal graft anastomosis) were available. The patient was a former smoker and had arterial hypertension and hyperlipidemia.

An otherwise healthy 74 year old male with osteoarthritis had undergone total knee arthroplasty in 2000. At the time of surgery, there were no untoward complications and the patient continued to recover within an expected post operative period. The patient reported a significant decrease in post operative pain and increase in function, maintaining a high level of activity.

A 40-year-old male patient was referred to the interventional radiology suite approximately two weeks after being struck in the perineum with a manhole cover. His injury was associated with significant ecchymosis of the perineum and penis. He complained of a painless persistent semi-rigid erection.

A 47-year-old AA female presented to our tertiary care cardiovascular center with a one-year history of progressively worsening swelling of lower limbs extending on to the abdominal wall associated with itching and abdominal discomfort. Her edema was predominantly dependent, which lately extended onto her face with dependency, for which she was placed on Lasix. Her past medical history was remarkable only for essential hypertension and hysterectomy for benign cause. Her mother and brothers were diabetics, but there was no family history suggestive of thrombophilia or DVT. She is non-alcoholic, nonsmoker and denies substance abuse. She is not on birth control or other hormonal medications. Her renal and liver function tests were unremarkable.

Physical examination was remarkable only for pitting type edema involving lower limb and abdominal wall.

A 73 year-old-male presented with rest pain of the right foot starting one week ago. Prior to this admission, he had undergone endovascular aspiration thrombectomy of the right deep femoral artery due to embolic occlusion (see Fig. 1).

Further patient history contained atrial fibrillation causing embolic stroke 18 years ago. Cardiovascular risk factors were hyperlipidemia, arterial hypertension and smoking.

Since his initial presentation, the patient had long-segment occlusion of the superficial femoral artery (see Fig. 1). One and two years prior to admission, he had undergone endovascular aspiration thrombectomy for embolic occlusion of the deep femoral artery (see Fig. 1).

Clinically, the pulses in the popliteal fossa as well as at the ankle were not palpable and the temperature of the right foot was decreased. Hemodynamic workup revealed low arterial ankle and toe pressures of the right lower extremity reflecting critical limb ischemia (see Fig. 2).

Duplex ultrasound showed a triphasic signal in the right common femoral artery indicating patency of the iliac segment but a high-grade obstruction of the mid-distal deep femoral artery (see Fig. 3).

A 26-year-old female with past medical history significant for only episodic tension type headaches, presented to the emergency room with a severe headache. Initial laboratory tests (including CBC, BMP and urine Hcg) and a non-contrast CT scan of the head (see Fig. 1) were unremarkable. The patient denies smoking, drugs or alcohol abuse and does not take any medications, including birth control pills. Patient has never been hospitalized, had major surgery or any significant childhood illness. Social history is significant for employment with the Democratic Presidential Campaign, for which she works approximately 16-18 hours daily over the past 6 weeks. Family history was noncontributory. She was initially discharged from the ER with diagnosis of migraine headaches.

A 74 year-old-man with a PMH significant for HTN, CAD s/p MI and a ruptured AAA repair in 2003 via a left retroperitoneal approach presented with pain in the right groin. The patient was driving when he experienced sudden onset of pain in the right groin. In the ED, his vital signs were normal and he was in no acute distress. A pulsatile mass was felt in his right groin and he was transferred to our institution for further evaluation. He denied any history of fever, chills, sweats, or weight loss. His labs were all within normal limits.

A male patient, aged 67 years , is known to be a heavy cigarette smoker. He presented with grade II hypertension and mentioned that he had difficulty walking 50 meters where he had to stop as he complained of severe intolerable pain in both legs. In addition to this, the patient had chest discomfort which necessitated admission to CCU. His BP was 200/110 mmHG, HR 76/ minute, regular, with absent Pulsation in right CFA and weak pulsation of the left popliteal A and posterior tibial A. ECG showed inferior ST segment depression . Echocardiography revealed hypokinesia of the inferior wall , Posterior IVS, with estimated LVEF nearly 48%.

Duplex scan showed bilateral subtotal femoral artery obstruction. Coronary angiography and aortography was done transradial approach.

An 81-year-old Caucasian woman was referred to our tertiary care vascular center for 7-years history of right arm progressive swelling, since she had right auxiliary lymphnodal dissection and radiation therapy. Since 3-years she also complains of right finger bluish skin discoloration and pain of 7/10 intensity aggravated with movements or on cold exposure. The pain interfered her sleep as well as right arm use and was dependent on round-the-clock narcotics for relief. She was also intolerant to lymphedema compression therapy. She had non-healing skin ulcer over the right axilla (see Fig.1a & 1b).

The past medical history consists of right mastectomy and radiation therapy 36 years ago for malignancy and bilateral GSV ablations for varocose veins.

The patient is a 39 year old female with a past medical history significant for systemic lupus erythematosis and end stage renal disease secondary to lupus nephritis. She has had multiple bilateral upper extremity dialysis access procedures. She was found to have a short segment right brachiocephalic vein occlusion in 2007 that could not be traversed with conventional wire and catheter techniques or with the use of the back end of a glide wire. The patient was asymptomatic outside of the anatomic occlusion at that time. The right side was completely abandoned for dialysis access and a left upper arm graft was placed in mid-2008. She had a previous dialysis catheter on the left side. She progressively developed worsening facial and neck swelling with significant lifestyle compromise. Although the graft could have been ligated with patient improvement, this patient was a renal transplant candidate and did not wish to risk her lower extremity veins for hemodialysis access.

A 47-year-old Caucasian woman presented to our tertiary care vascular center with 1-year history of progressively worsening bilateral thigh and buttock pain within 200- yards of walking. She had been using cilostazol without relief. Her past medical history is contributory for hyperlipidemia and long-standing heavy smoking. Family history is remarkable for CAD, PAD, and DVT.

An 88-year-old male patient was referred from dermatology with lifestyle-limiting claudication of the right lower limb and a slow-healing ulcer due to chronic venous insufficiency. His risk factor background contained arterial hypertension and hyperlipidemia.


Duplex sonography revealed a long-segment occlusion of the right superficial femoral artery (arising one centimetre distal to the femoral bifurcation) as well as incompetent valves of the deep lower limb veins.

This patient is a 55-year-old female who presented with a three day history of severe lower abdominal and back pain. She was seen at an outside hospital the day prior to presentation at our facility. There she underwent a non-contrasted CT scan of her abdomen and pelvis which was non-revealing. Upon presentation to our emergency department she had a systolic blood pressure in the 200’s and immediately had a CT scan which revealed an infrarenal abdominal aortic dissection (see Fig. 1). Bilateral lower extremity pulses were normal as well as a renal function panel (cq1). After adequate blood pressure control and a preoperative arteriogram, the patient was taken for endovascular repair.

The patient is a 67-year-old female with a past medical history significant for diabetes mellitus with chronic renal failure. She is 23 months status-post left upper extremity autogenous hemodialysis brachiocephalic arteriovenous fistula (AVF) construction and has been receiving regular hemodialysis. She now presents with significant left arm swelling, most dramatic over the previous 2-3 weeks. Her AVF continues to function normally for hemodialysis.

The patient is a 42-year-old Caucasian woman who was admitted at an outside hospital for sudden onset of pulmonary embolism (PE) and right ventricular (RV) thrombus, where she was heparinized and transferred to our institution. A surgical RV thrombectomy was performed. She tested positive for Heparin-induced thrombocytopenia (HIT); all Heparin products were replaced with IV Argatroban. She also had history of cervical cancer, which was treated with radical hysterectomy and which, she was told, was in “remission.”

The patient is a 76-year-old man that was transferred from a nearby ER on March 26, 2007. He presented with abdominal and left flank pain that was found to be secondary to a ruptured abdominal aortic aneurysm (AAA) measuring 7.3 cm in maximum diameter. The patient had a history of hypertension, hyperlipidemia, coronary artery disease, and atrial fibrillation. The patient was also taking a combination of Coumadin, Toprol XL, ASA, Allopurinol, Lasix, Prednisone, Clonazepam. The patient presented to the ER with improved but persistent flank pain and was hemodynamically stable. The AAA was ruptured with a favorable anatomy for EVAR.

The patient is a 49-year-old woman with history of chronic renal failure secondary to membranous glomerulonephritis. On exam, her brachiocephalic AVF is pulsatile; she has failed to reach sufficient blood flow volume for the past two hemodialysis sessions. Ultrasound shows insufficient flow volume (less than 350 mL). She has been referred for fistulography that reveals significant cephalic arch stenosis (central cephalic vein as it curves to meet the junction of the axillo-subclavian vein segment).

A 55-year old Caucasian male presented to the vascular center with a 2-week history of rest-pain and cold sensation involving the right leg and foot. He also has history of right calf intermittent claudication for several months prior to the onset of current symptom. He is markedly obese, hypertensive, chronic heavy smoker and non-compliant to medical treatment for hypertension. Physical examination revealed cold and pale right leg with absent pedal pulses, pedal skin hypoasthesia; but intact motor function.

Patient is an 80-year-old left-handed female who presents with complaints of intermittent left hand numbness for the last month. Patient denies any seizure history or activity. Patient's medical history is significant for hypertension, lung cancer (in remission), and hyperlipidemia.

A 70-year-old female presented with severe lifestyle-limiting claudication of the right lower limb with a pain-free walking distance of 30 meters when walking uphill.

A 73-year-old female hypertensive, diabetic patient with a 5-year history of end stage renal disease requiring hemodialysis was referred for evaluation of high venous pressures during dialysis.

A 74-year-old white female with a history of hypertension and endometrial cancer was referred to us for evaluation of a possible pseudoaneurysm. The patient had previously undergone a hysterectomy and bilateral salpingo-oopherectomy one-year prior.

The patient is a 58-year-old female with a medical history significant for diabetes mellitus with diabetic nephropathy. Four months prior, a left upper extremity autogenous hemodialysis brachiocephalic arteriovenous fistula (AVF) was constructed. A physical exam suggests failure of AVF maturation, rendering it non-functional for hemodialysis.

A 48-year-old Caucasian woman presented with an 8-year history of left thigh swelling and discomfort, aggravated by prolonged sitting, standing, and ambulation. Her primary MD diagnosed this as "lymphedema." She denied history of DVT or family history of DVT, lymphedema. She had no previous varicose veins or venous procedures. Her symptoms were severe enough to interfere with her personal and professional life.

A 71-year-old male was admitted for limb-threatening ischemia of the left forefoot. He complained about ulceration of the left great toe. His risk factor background contained type II diabetes mellitus, arterial hypertension, hyperlipidemia, and mild renal insufficiency. The patient had undergone coronary artery bypass grafting and percutaneous transluminal angioplasty (PTA) of the left renal artery 10 years prior, and was currently asymptomatic with regard to cardiac symptoms.

The patient is a 32-year-old female with a past medical history significant for systemic lupus erythematosus with lupus anticoagulant and two previous mediports. After her most recent mediport became non-functional it was removed.

A 24-year-old Caucasian male presented to our tertiary cardiopulmonary care center with a 3-month history of recurrent hemoptysis. He denied chest pain, syncopal episodes, exertional dyspnea/orthopnea, or any other cardiopulmonary symptoms. He had no prior cardiopulmonary surgeries, medical/surgical co-morbidities, congenital cardiac anomalies that could contribute to his symptoms. He was a non-smoker and denied illicit substance usage. His family, occupational and personal histories were unremarkable. Physical examination, baseline laboratory data, and chest x-rays were normal.

A 62-year-old male was referred to our practice for evaluation of an Abdominal Aortic Aneurysm (AAA) discovered on a CT scan of the abdomen and pelvis done without contrast in July, 2003 during a workup for hematuria. The initial CT showed a 7.2 cm aneurysm. The patient's risk factors include a long history of smoking and an extensive cardiac history including coronary artery disease and multiple myocardial infarctions. In 1999 he underwent three vessel coronary artery bypass grafting and had an internal cardiac defibrillator placed. During this time the patient was ventilator dependent via a tracheostomy. In 2001 he underwent mitral valve replacement and tricuspid annuloplasty.

A 76-year-old man presented following two episodes of transient left-sided hemiplegia. Three hours after the onset of the second episode, he was admitted to our emergency room. The patient's medical history included hypertension and ischemic heart disease (including previous coronary artery stenting). He was taking 100 mg aspirin daily.

A 75-year-old female patient presents to her primary care physician with a history of increasing left foot rest pain during the previous month. Her medical history includes smoking, hypertension, and diabetes mellitus type 2. She also underwent a Femoropopliteal (p3) infrapatelar bypass in 2001.

A 68-year-old Caucasian woman presented to the primary care physician's office with a recent onset of intense pain and bluish discoloration of her left great toe. Her symptoms began when she was traveling "cross country" by car. She was diagnosed by her primary physician with "Raynaud's syndrome" and was given oral Nifedepine with no clinical improvement. She is a non-smoker and denies have any cardiovascular risk factors or symptoms of coronary, peripheral arterial disease (PAD), and cardiac arrhythmias.

A 74-year-old female with a long history of diabetes mellitus presents with recent painful ischemic left foot ulcers and rest pain, which keeps her awake at night. She is on insulin and Metformin 500 mg twice daily for her diabetes. She gives a history of intermittent claudication at less than 50 meters, particularly on the left, which is being managed conservatively including an exercise program. Previous bilateral common iliac angioplasties have been performed for moderate iliac stenoses. Other relevant medical history includes hypertension, hypercholesterolemia, ischemic heart disease (including a previous coronary artery bypass graft), and osteoarthritis.

A 57-year-old white male, who works as an elevator operator, presented with a history of a right lower extremity ulcer for five months and left lower extremity ulcer for nine months. His primary physician treated the patient with wet-to-dry dressings and ace wraps.

The patient is a 50-year old male with a history of sclerotherapy for varicosities of the medial knee and calf. The previous sclerotherapy was performed by a dermatologist. The varicosities measured 7 mm to 8 mm when standing. The patient also reports heaviness, throbbing, and itching in the distribution of the varicosities. Initially, his varicosities responded to sclerotherapy; the varicosities recurred approximately 9 months later.

A 55-year-old male with longstanding history of Type I diabetes melliltus presents with crescendo transient ischemic attacks.