Vertebral artery dissection(VAD) is an acute vascular condition characterized by intimal tearing that leads to the formation of intramural hematomas or pseudoaneurysms.^([1,2]) The pathogenesis of VAD involves a multi...Vertebral artery dissection(VAD) is an acute vascular condition characterized by intimal tearing that leads to the formation of intramural hematomas or pseudoaneurysms.^([1,2]) The pathogenesis of VAD involves a multifactorial interplay of genetic susceptibility,structural vessel wall abnormalities,and mechanical stressors.^([3]) We present a case of VAD triggered by cervical mechanical stress,and explore the diagnostic workup and the role of multidisciplinary coordination in therapeutic decision-making.展开更多
Background There is still limited data on predictive value of coronary computed tomography angiography(CCTA)–derived fractional flow reserve(CT-FFR) for long term outcomes. We examined the long-term prognostic value ...Background There is still limited data on predictive value of coronary computed tomography angiography(CCTA)–derived fractional flow reserve(CT-FFR) for long term outcomes. We examined the long-term prognostic value of CT-FFR combined with CCTA–defined atherosclerotic extent in diabetic patients with coronary artery disease(CAD).Methods A retrospective pooled analysis of individual patient data was performed. Deep-learning-based vessel-specific CTFFR was calculated. All patients enrolled were followed-up for at least 5 years. Predictive abilities for major adverse cardiac events(MACE) were compared among three models(model 1), constructed using clinical variables;model 2, model 1+CCTA–derived atherosclerotic extent(Leiden risk score);and model 3, model 2+CT-FFR.Results A total of 480 diabetic patients [median age, 61(55–66) years;52.9% men] were included. During a median follow-up time of 2197(2126–2355) days, 55 patients(11.5%) experienced MACE. In multivariate-adjusted Cox models, Leiden risk score(HR: 1.06;95% CI: 1.01–1.11;P = 0.013) and CT-FFR ≤ 0.80(HR: 6.54;95% CI: 3.18–13.45;P < 0.001) were the independent predictors. The discriminant ability was higher in model 2 than in model 1(C-index, 0.75 vs. 0.63;P < 0.001) and was further promoted by adding CT-FFR to model 3(C-index, 0.81 vs. 0.75;P = 0.002). Net reclassification improvement(NRI) was 0.19(P = 0.009) for model 2 beyond model 1. Of note, adding CT-FFR to model 3 also exhibited significantly improved reclassification compared with model 2(NRI = 0.14;P = 0.011).Conclusion In diabetic patients with CAD, CT-FFR provides robust and incremental prognostic information for predicting longterm outcomes. The combined model exhibits improved prediction abilities, which is beneficial for risk stratification.展开更多
Peripheral artery disease(PAD)remains a significant global health issue,with current treatments primarily focused on relieving symptoms and addressingmacrovascular issues.However,critical immunoinflammatory mechanisms...Peripheral artery disease(PAD)remains a significant global health issue,with current treatments primarily focused on relieving symptoms and addressingmacrovascular issues.However,critical immunoinflammatory mechanisms are often overlooked.Recent evidence suggests that monocyte phenotypic plasticity plays a central role in PAD development,affecting atherogenesis,plaque progression,ischemia-reperfusion injury,and chronic ischemic remodeling.This narrative review aims to summarize the latest advances(2023-2025)in understanding monocyte diversity,functional states,and their changes throughout different stages of PAD.We discuss both established and emerging biomarkers,such as circulating monocyte subset proportions,functional assays,immune checkpoint expression,and multi-omics signatures,highlighting their potential for prognosis and the challenges in translating them to clinical practice.We also present a stage-specific approach to mapping out potential therapies,linking monocyte phenotypes to molecular targets and possible interventions.Additionally,we address regulatory,economic,and implementation considerations for applying these findings in a clinical setting.The goal of this review is to facilitate the development of targeted immunomodulatory strategies to improve limb and cardiovascular outcomes in PAD by combining mechanistic understanding with therapeutic innovation.展开更多
BACKGROUND Hepatocellular carcinoma(HCC)is a major type of liver cancer worldwide.In advanced stages,portal vein tumor thrombosis(PVTT)and jaundice are common,whereas obstructive jaundice(OJ)is relatively rare.Both co...BACKGROUND Hepatocellular carcinoma(HCC)is a major type of liver cancer worldwide.In advanced stages,portal vein tumor thrombosis(PVTT)and jaundice are common,whereas obstructive jaundice(OJ)is relatively rare.Both conditions markedly reduce survival and increase therapeutic complexity.Recently,hepatic artery infusion chemotherapy(HAIC)in combination with targeted immunotherapy has shown promise for advanced HCC.CASE SUMMARY We report a 47-year-old male with advanced HCC complicated by PVTT and OJ,who was admitted with marked jaundice of the skin and sclera.Imaging revealed a large hepatic mass(14.5 cm×11.3 cm)in the right lobe with associated portal vein tumor thrombus.The tertiary bile duct was only mildly dilated,making percutaneous transhepatic cholangiography drainage infeasible.The patient underwent reduced-dose HAIC,which resulted in significant tumor shrinkage and marked reduction in serum bilirubin.This improvement enabled sequential treatment with lenvatinib and camrelizumab.After six cycles,both liver function and alphafetoprotein levels improved.The patient achieved a progression-free survival of 20 months and an overall survival of 29 months.CONCLUSION HAIC can treat high-bilirubin HCC with PVTT and OJ,allowing for subsequent targeted immunotherapy.展开更多
BACKGROUND Middle meningeal artery embolization(MMAE)is emerging as a promising treatment for chronic subdural hematoma(CSDH),serving both as an adjunct to surgery and as a primary therapeutic option depending on pati...BACKGROUND Middle meningeal artery embolization(MMAE)is emerging as a promising treatment for chronic subdural hematoma(CSDH),serving both as an adjunct to surgery and as a primary therapeutic option depending on patient presentation.Due to its low recurrence rate and minimal complications,MMAE has gained increasing acceptance among clinicians in recent years.This report presents a case of diplopia following MMAE due to the presence of a potential anastomotic artery,aiming to enhance awareness of this complication.CASE SUMMARY A 60-year-old male patient presented with a headache following head trauma,and cranial computed tomography revealed a left-sided CSDH.The patient underwent left MMAE;however,polyvinyl alcohol particles inadvertently flowed into the lacrimal artery through an anastomotic artery,resulting in diplopia due to impaired abduction of the left eye.The diplopia resolved by postoperative day 40.The patient’s headache resolved by postoperative day 7,and the hematoma completely resolved by postoperative day 108.CONCLUSION Potential anastomotic arteries in the middle meningeal artery(MMA)can lead to serious complications.Superselective angiography of the MMA or its branches prior to embolization is essential.Performing embolization distal to potential anastomotic sites can reduce risks,and the presence of an anastomosis may warrant coil embolization or termination of the procedure.展开更多
Objective To develop a non-invasive predictive model for coronary artery stenosis severity based on adaptive multi-modal integration of traditional Chinese and western medicine data.Methods Clinical indicators,echocar...Objective To develop a non-invasive predictive model for coronary artery stenosis severity based on adaptive multi-modal integration of traditional Chinese and western medicine data.Methods Clinical indicators,echocardiographic data,traditional Chinese medicine(TCM)tongue manifestations,and facial features were collected from patients who underwent coro-nary computed tomography angiography(CTA)in the Cardiac Care Unit(CCU)of Shanghai Tenth People's Hospital between May 1,2023 and May 1,2024.An adaptive weighted multi-modal data fusion(AWMDF)model based on deep learning was constructed to predict the severity of coronary artery stenosis.The model was evaluated using metrics including accura-cy,precision,recall,F1 score,and the area under the receiver operating characteristic(ROC)curve(AUC).Further performance assessment was conducted through comparisons with six ensemble machine learning methods,data ablation,model component ablation,and various decision-level fusion strategies.Results A total of 158 patients were included in the study.The AWMDF model achieved ex-cellent predictive performance(AUC=0.973,accuracy=0.937,precision=0.937,recall=0.929,and F1 score=0.933).Compared with model ablation,data ablation experiments,and various traditional machine learning models,the AWMDF model demonstrated superior per-formance.Moreover,the adaptive weighting strategy outperformed alternative approaches,including simple weighting,averaging,voting,and fixed-weight schemes.Conclusion The AWMDF model demonstrates potential clinical value in the non-invasive prediction of coronary artery disease and could serve as a tool for clinical decision support.展开更多
The Kakinuma et al’s case report shows that non-pregnancy-related arterial pseudoaneurysm is a relatively rare,little known by some gynecologists,endo-scopists,surgeons or radiologists,which can cause massive bleedin...The Kakinuma et al’s case report shows that non-pregnancy-related arterial pseudoaneurysm is a relatively rare,little known by some gynecologists,endo-scopists,surgeons or radiologists,which can cause massive bleeding.Arterial pseudoaneurysm is a condition in which the wall of a blood vessel collapses due to some invasive event,and the resulting leaked blood is engulfed by soft tissues,forming a cavity that is in communication with the vessel.It is a potentially life-threatening complication that could occurs after some deliveries and some gynecological invasive procedures.Remarkably,an undetermined percentage of pseudoaneurysms are asymptomatic,and in an asymptomatic patient it is difficult to predict the risk of haemorrhage and the attitude to follow,which depends on several factors,such as,the size and location of the vessel involved,changes in the size of the pseudoaneurysm,or the available therapeutic resources to be offered to patients,among others circumstances.The management of abdominal arterial pseudoaneurysm does not have consistent scientific evidence,but it seems that,regardless of the associated circumstances,the pseudoaneurysm could be treated at least initially,and mainly,through endovascular procedures,as done by Kakinuma et al.展开更多
BACKGROUND Surgical intervention is a critical treatment approach for symptomatic atlantoaxial dislocation.However,vertebral artery injury remains a significant challenge during such procedures.We present a case of su...BACKGROUND Surgical intervention is a critical treatment approach for symptomatic atlantoaxial dislocation.However,vertebral artery injury remains a significant challenge during such procedures.We present a case of successful treatment of atlantoaxial dislocation with concurrent vertebral artery injury using interlaminar screw technology,and review the relevant literature.CASE SUMMARY A 69-year-old female patient,with no history of trauma,was diagnosed with atlantoaxial dislocation based on X-ray,computed tomography(CT),and magnetic resonance imaging.Preoperative CT angiography(CTA)revealed vertebral artery developmental anomalies,and she underwent posterior cervical surgery.Postoperative follow-up showed improvement in the patient’s clinical symptoms such as unstable walking and dizziness,as well as functional scores compared to pre-surgery.Intraoperative vertebral artery injury was successfully managed,and postoperative CTA review revealed no complications related to vascular damage.CONCLUSION Thorough preoperative evaluation,such as CTA imaging,and the surgeon’s expertise in various spinal screw placement techniques are crucial for improving the success rate of atlantoaxial dislocation surgeries.展开更多
The chronic occlusion of intracranial arteries generally has no or mild clinical symptoms,and the clinical symptoms of acute cerebral artery occlusion are mostly manifested as severe cerebral infarction symptoms,which...The chronic occlusion of intracranial arteries generally has no or mild clinical symptoms,and the clinical symptoms of acute cerebral artery occlusion are mostly manifested as severe cerebral infarction symptoms,which often make early diagnosis difficult,thus losing the best treatment opportunity.Once cerebral infarction occurs,the consequences are difficult to recover.This is also an important reason for the high misdiagnosis rate and mortality of this disease.In this paper,the characteristics of the disease were analyzed to provide clinical reference.展开更多
This article provides a detailed account of the diagnosis and treatment of a case involving a uterine artery pseudoaneurysm(UAP),as well as an analysis of UAP etiology.This finding emphasizes that UAP should be consid...This article provides a detailed account of the diagnosis and treatment of a case involving a uterine artery pseudoaneurysm(UAP),as well as an analysis of UAP etiology.This finding emphasizes that UAP should be considered in patients presenting with abnormal genital bleeding after hysteroscopy and offers valuable insights and lessons for gynecologists in hysteroscopic procedures.The patient underwent timely relevant examinations to confirm the diagnosis,allowing for crucial time required for her treatment.In this study,the primary cause of UAP formation in the patient was attributed to a prior hysteroscopic surgical procedure conducted at another medical facility,suggesting that the selection and imple-mentation of dilatation catheters are some of the predisposing factors for UAP.In conclusion,this case study offers a comprehensive analysis of the etiology of UAP and effectively provides timely diagnosis and treatment,offering valuable in-sights for the clinical diagnosis and management of UAP.展开更多
BACKGROUND Alagille syndrome is a multisystem disease that results in various vascular anomalies,commonly involving the cardiac and pulmonary systems.To the best of our knowledge,there is no literature regarding the c...BACKGROUND Alagille syndrome is a multisystem disease that results in various vascular anomalies,commonly involving the cardiac and pulmonary systems.To the best of our knowledge,there is no literature regarding the cardiovascular outcomes of these patients in association with coronavirus disease 2019(COVID-19).CASE SUMMARY A 34-year-old woman with a history of Alagille syndrome who underwent successful atrial septal defect with partial anomalous pulmonary veins and patent ductus arteriosus repair,as well as left pulmonary artery catheterization and stenting in childhood due to pulmonary stenosis.The patient was without any respiratory symptoms and was a dancer prior to contracting COVID-19.Several weeks after her COVID-19 infection,she developed left pulmonary artery stent thrombosis and subsequent symptomatic pulmonary hypertension.A treatment strategy of anticoagulation alongside pharmacological agents for pulmonary hypertension for 3 months followed by balloon pulmonary artery angioplasty to reopen the stenosis was unsuccessful.CONCLUSION In the era of COVID-19,patients with pulmonary vascular malformations and endovascular stents are at an increased risk for chronic thromboembolic disease.Patients may benefit from prophylactic antiplatelet or anticoagulation therapy.Stent thrombosis is a devastating phenomenon and should be treated urgently and aggressively with balloon pulmonary angioplasty,and/or a thrombolytic agent.展开更多
BACKGROUND The root of mesentery dissection is one of the critical maneuvers,especially in borderline resectable pancreatic head cancer.Intra-abdominal chyle leak(CL)including chylous ascites may ensue in up to 10%of ...BACKGROUND The root of mesentery dissection is one of the critical maneuvers,especially in borderline resectable pancreatic head cancer.Intra-abdominal chyle leak(CL)including chylous ascites may ensue in up to 10%of patients after pancreatic resections.Globally recognized superior mesenteric artery(SMA)first approaches are invariably performed.The mesenteric dissection through the inferior infracolic approach has been discussed in this study emphasizing its post-operative impact on CL which is the cornerstone of this study.AIM To assess incidence,risk factors,clinical impact of CL following root of mesentery dissection,and the different treatment modalities.METHODS This is a retrospective study incorporating the patients who underwent dissection of the root of mesentery with inferior infracolic SMA first approach pancreat-oduodenectomy for the ventral body and uncinate mass of pancreas in the Department of Gastrointestinal and General Surgery of Kathmandu Medical College and Teaching Hospital from January 1,2021 to February 28,2024.Intraop-erative findings and postoperative outcomes were analyzed.RESULTS In three years,ten patients underwent root of mesentery dissection with inferior infracolic SMA first approach pancreatoduodenectomy.The mean age was 67.6 years with a male-to-female ratio of 4:5.CL was seen in four patients.With virtue of CL,Clavien-Dindo grade Ⅱ or higher morbidity was observed in four patients.Two patients had a hospital stay of more than 20 days with the former having a delayed gastric emptying and the latter with long-term total parenteral nutrition requirement.The mean operative time was 330 minutes.Curative resection was achieved in 100%of the patients.The mean duration of the intensive care unit and hospital stay were 2.55±1.45 days and 15.7±5.32 days,respectively.CONCLUSION Root of mesentery dissection with lymphadenectomy and vascular resection correlated with occurrence of CL.After complete curative resection,these were managed with total parenteral nutrition without adversely impacting outcome.展开更多
BACKGROUND 2D-echocardiography(2DE)has been the primary imaging modality in children with Kawasaki disease(KD)to assess coronary arteries.AIM To report the presence and implications of incidental congenital coronary a...BACKGROUND 2D-echocardiography(2DE)has been the primary imaging modality in children with Kawasaki disease(KD)to assess coronary arteries.AIM To report the presence and implications of incidental congenital coronary artery anomalies that had been misinterpreted as coronary artery abnormalities(CAAs)on 2DE.METHODS Records of children diagnosed with KD,who underwent computed tomography coronary angiography(CTCA)at our center between 2013-2023 were reviewed.We identified 3 children with congenital coronary artery anomalies in this cohort on CTCA.Findings of CTCA and 2DE were compared in these 3 children.RESULTS Of the 241 patients with KD who underwent CTCA,3(1.24%)had congenital coronary artery anomalies on CTCA detected incidentally.In all 3 patients,baseline 2DE had identified CAAs.CTCA was then performed for detailed evaluation as per our unit protocol.One(11-year-boy)amongst the 3 patients had complete KD,while the other two(3.3-year-boy;4-month-girl)had incomplete KD.CTCA revealed separate origins of left anterior descending artery and left circumflex from left sinus[misinterpreted as dilated left main coronary artery(LCA)on 2DE],single coronary artery(interpreted as dilated LCA on 2DE)and dilated right coronary artery on 2DE in case of anomalous origin of LCA from the main pulmonary artery.The latter one was subsequently operated upon.CONCLUSION CTCA is essential for detailed assessment of coronary arteries in children with KD especially in cases where there is suspicion of congenital coronary artery anomalies.Relying solely on 2DE may not be sufficient in such cases,and findings from CTCA can significantly impact therapeutic decision-making.展开更多
BACKGROUND Central retinal artery occlusion(CRAO)is a potentially blinding disease,and hyperbaric oxygen therapy(HBOT)is becoming increasingly popular with the support of scientific evidence.Despite the presence of va...BACKGROUND Central retinal artery occlusion(CRAO)is a potentially blinding disease,and hyperbaric oxygen therapy(HBOT)is becoming increasingly popular with the support of scientific evidence.Despite the presence of various acute management measures,there is no clear evidence on the gold standard treatment for CRAO.AIM To identify factors and imaging parameters associated with good visual outcome,which guide ophthalmologists in the triage of CRAO patients for HBOT.METHODS Patients who suffered from CRAO and had a symptom onset≤6 h were recruited for a course of HBOT in a tertiary hospital after failing bedside treatment.Patient demographics,onset time,CRAO eye parameters,and past medical history were prospectively collected.Visual outcomes after HBOT were also analyzed.RESULTS A total of 26 patients were included;the female-to-male ratio was 1:1.6,and the mean age was 67.5 years±13.3 years(range 44–89 years).The mean duration of follow-up and mean visual acuity(VA)improvement were 10.0 mo±5.3 mo and 0.48 logarithm of minimal angle of resolution(logMAR)±0.57 logMAR(approx-imately 9 letters in ETDRS)(P=0.0001,Z=-3.67),respectively.The 1 mm zone of central macular thickness(CMT)on optical coherence tomography was not associated with VA changes(P=0.119);however,the 1-to-3 mm circular rim of CMT was fairly associated(P=0.02,Spearman's coefficient=0.45).Complete retinal perfusion time during fundus fluorescein angiography(FFA)was mode-rately associated(P=0.01,Spearman's coefficient=0.58)with visual outcome.展开更多
BACKGROUND Our understanding of the correlation between postdischarge cancer and mortality in patients with coronary artery disease(CAD)remains incomplete.The aim of this study was to investigate the relationships bet...BACKGROUND Our understanding of the correlation between postdischarge cancer and mortality in patients with coronary artery disease(CAD)remains incomplete.The aim of this study was to investigate the relationships between postdischarge cancers and all-cause mortality and cardiovascular mortality in CAD patients.METHODS In this retrospective cohort study,25%of CAD patients without prior cancer history who underwent coronary artery angiography between January 1,2011 and December 31,2015,were randomly enrolled using SPSS 26.0.Patients were monitored for the incidence of postdischarge cancer,which was defined as cancer diagnosed after the index hospitalization,survival status and cause of death.Cox regression analysis was used to explore the association between postdischarge cancer and all-cause mortality and cardiovascular mortality in CAD patients.RESULTS A total of 4085 patients were included in the final analysis.During a median follow-up period of 8 years,174 patients(4.3%)developed postdischarge cancer,and 343 patients(8.4%)died.A total of 173 patients died from cardiovascular diseases.Postdischarge cancer was associated with increased all-cause mortality risk(HR=2.653,95%CI:1.727–4.076,P<0.001)and cardiovascular mortality risk(HR=2.756,95%CI:1.470–5.167,P=0.002).Postdischarge lung cancer(HR=5.497,95%CI:2.922–10.343,P<0.001)and gastrointestinal cancer(HR=1.984,95%CI:1.049–3.750,P=0.035)were associated with all-cause mortality in CAD patients.Postdischarge lung cancer was significantly associated with cardiovascular death in CAD patients(HR=4.979,95%CI:2.114–11.728,P<0.001),and cardiovascular death was not significantly correlated with gastrointestinal cancer or other types of cancer.CONCLUSIONS Postdischarge cancer was associated with all-cause mortality and cardiovascular mortality in CAD patients.Compared with other cancers,postdischarge lung cancer had a more significant effect on all-cause mortality and cardiovascular mortality in CAD patients.展开更多
BACKGROUND The persistent burden of cardiovascular(CV)disease in the United States requires innovative and cost-effective prognostic markers that can be relied upon.AIM To provide insights into how adiponectin can pre...BACKGROUND The persistent burden of cardiovascular(CV)disease in the United States requires innovative and cost-effective prognostic markers that can be relied upon.AIM To provide insights into how adiponectin can predict all-cause mortality and major adverse CV events(MACE)in patients with coronary artery disease(CAD)and to determine the prognostic value of adiponectin in predicting all-cause mortality and MACE in patients with stable CAD.METHODS We conducted a systematic search on PubMed,Scopus,and Google Scholar to find relevant studies published through June 2023 evaluating the long-term prognostic role of adiponectin in patients with stable CAD.Using a random effects model with 95%CI,we estimated the odds ratio(OR)while assessing heterogeneity through I^(2)statistics.To ensure robustness,we performed a sensitivity analysis using the leave-one-out approach.RESULTS After screening,we included five prospective studies involving 3225 patients who were followed up for a median duration of 3.8 years.Within the study population,prevalent risk factors included hypertension,diabetes,hyperlipidemia,and smoking.The commonly prescribed medications were angiotensin-converting enzyme inhibitors,beta blockers,and statins.The combined adjusted OR for all-cause mortality was found to be 2.51(95%CI:1.36–4.62),showing heterogeneity(I^(2)=65.51%,P=0.03).On the other hand,the combined adjusted OR for MACE was determined to be 1.04(95%CI:1.02–1.06)with no significant heterogeneity observed(I^(2)=0%,P=0.68).Through a sensitivity analysis,it was discovered that none of the studies significantly impacted the overall results of the meta-analysis,thus indicating their robustness.CONCLUSION Higher levels of adiponectin were found to be associated with an increased risk of long-term mortality and MACE in patients with CAD,which highlights its potential as a cost-effective marker for risk assessment and guiding treatment strategies.Further research on the role of adiponectin could greatly influence decision-making and resource allocation in CV care.展开更多
Unilateral pulmonary artery agenesis(UPAA)is a rare congenital cardiovascular anomaly defined by the complete absence of one pulmonary artery,most often affecting the right side.[1]Although typically identified in chi...Unilateral pulmonary artery agenesis(UPAA)is a rare congenital cardiovascular anomaly defined by the complete absence of one pulmonary artery,most often affecting the right side.[1]Although typically identified in childhood due to symptomatic presentation,certain cases may remain undiagnosed until adulthood,particularly in asymptomatic patients or those with subtle clinical signs.展开更多
Transradial access (TRA) has emerged as the preferred vascular access route forcoronary angiography and percutaneous coronary interventions due to itssuperior safety profile compared to transfemoral access. However, i...Transradial access (TRA) has emerged as the preferred vascular access route forcoronary angiography and percutaneous coronary interventions due to itssuperior safety profile compared to transfemoral access. However, its widespreadadoption raises concerns regarding structural alterations in the radial artery,which may impact long-term vascular health and future procedural feasibility.TRA is associated with histopathologic changes in the arterial wall, such asintimal injury and hyperplasia, medial remodeling and adventitial inflammation,collectively contributing to radial artery remodeling. Moreover, TRA can inducechanges in radial artery lumen diameter driven by an inflammatory response dueto arterial puncture and mechanical friction during the procedure. Nonetheless, amore clinically significant consequence is radial artery occlusion, which is influencedby various procedural and patient-related factors. Strategies to minimizeremodeling include meticulous pre-procedural ultrasound assessment to ensureappropriate sheath-to-artery size matching, periprocedural pharmacologicalinterventions and implementation of patent hemostasis techniques. This reviewsynthesizes current knowledge regarding the mechanisms, clinical implications,and preventive strategies related to radial artery remodeling following TRA. Further research is needed toelucidate the long-term consequences of radial artery remodeling and to refine preventive strategies for preservingradial artery patency and its suitability for future interventions.展开更多
Central retinal artery occlusion(CRAO)is an acute ophthalmic emergency,characterized by sudden vision loss due to retinal ischemia in areas corresponding to arterial occlusion sites.Diagnosis primarily relies on fundu...Central retinal artery occlusion(CRAO)is an acute ophthalmic emergency,characterized by sudden vision loss due to retinal ischemia in areas corresponding to arterial occlusion sites.Diagnosis primarily relies on fundus fluorescein angiography(FFA)and optical coherence tomography(OCT),which show delayed retinal artery filling time hours to days after occlusion and increased hyperreflectivity of the inner retina.展开更多
Dear Editor,We aimed to describe the management of the intraoperative injury of the right external iliac artery that occurred during robot-assisted right nephroureterectomy with bladder cuff excision.Surgery was sched...Dear Editor,We aimed to describe the management of the intraoperative injury of the right external iliac artery that occurred during robot-assisted right nephroureterectomy with bladder cuff excision.Surgery was scheduled for suspected urothelial carcinoma of the distal ureter in a 60-year-old woman.The patient involved in the present research signed a dedicated form to consent to the publication of images and/or information about her.Past medical history included Brugada syndrome diagnosed in 2015,and hypercholesterolemia.Past surgical history included one cesarean section only.Family history included ovarian cancer(sister),colorectal cancer(mother),and kidney cancer(father).展开更多
文摘Vertebral artery dissection(VAD) is an acute vascular condition characterized by intimal tearing that leads to the formation of intramural hematomas or pseudoaneurysms.^([1,2]) The pathogenesis of VAD involves a multifactorial interplay of genetic susceptibility,structural vessel wall abnormalities,and mechanical stressors.^([3]) We present a case of VAD triggered by cervical mechanical stress,and explore the diagnostic workup and the role of multidisciplinary coordination in therapeutic decision-making.
文摘Background There is still limited data on predictive value of coronary computed tomography angiography(CCTA)–derived fractional flow reserve(CT-FFR) for long term outcomes. We examined the long-term prognostic value of CT-FFR combined with CCTA–defined atherosclerotic extent in diabetic patients with coronary artery disease(CAD).Methods A retrospective pooled analysis of individual patient data was performed. Deep-learning-based vessel-specific CTFFR was calculated. All patients enrolled were followed-up for at least 5 years. Predictive abilities for major adverse cardiac events(MACE) were compared among three models(model 1), constructed using clinical variables;model 2, model 1+CCTA–derived atherosclerotic extent(Leiden risk score);and model 3, model 2+CT-FFR.Results A total of 480 diabetic patients [median age, 61(55–66) years;52.9% men] were included. During a median follow-up time of 2197(2126–2355) days, 55 patients(11.5%) experienced MACE. In multivariate-adjusted Cox models, Leiden risk score(HR: 1.06;95% CI: 1.01–1.11;P = 0.013) and CT-FFR ≤ 0.80(HR: 6.54;95% CI: 3.18–13.45;P < 0.001) were the independent predictors. The discriminant ability was higher in model 2 than in model 1(C-index, 0.75 vs. 0.63;P < 0.001) and was further promoted by adding CT-FFR to model 3(C-index, 0.81 vs. 0.75;P = 0.002). Net reclassification improvement(NRI) was 0.19(P = 0.009) for model 2 beyond model 1. Of note, adding CT-FFR to model 3 also exhibited significantly improved reclassification compared with model 2(NRI = 0.14;P = 0.011).Conclusion In diabetic patients with CAD, CT-FFR provides robust and incremental prognostic information for predicting longterm outcomes. The combined model exhibits improved prediction abilities, which is beneficial for risk stratification.
文摘Peripheral artery disease(PAD)remains a significant global health issue,with current treatments primarily focused on relieving symptoms and addressingmacrovascular issues.However,critical immunoinflammatory mechanisms are often overlooked.Recent evidence suggests that monocyte phenotypic plasticity plays a central role in PAD development,affecting atherogenesis,plaque progression,ischemia-reperfusion injury,and chronic ischemic remodeling.This narrative review aims to summarize the latest advances(2023-2025)in understanding monocyte diversity,functional states,and their changes throughout different stages of PAD.We discuss both established and emerging biomarkers,such as circulating monocyte subset proportions,functional assays,immune checkpoint expression,and multi-omics signatures,highlighting their potential for prognosis and the challenges in translating them to clinical practice.We also present a stage-specific approach to mapping out potential therapies,linking monocyte phenotypes to molecular targets and possible interventions.Additionally,we address regulatory,economic,and implementation considerations for applying these findings in a clinical setting.The goal of this review is to facilitate the development of targeted immunomodulatory strategies to improve limb and cardiovascular outcomes in PAD by combining mechanistic understanding with therapeutic innovation.
文摘BACKGROUND Hepatocellular carcinoma(HCC)is a major type of liver cancer worldwide.In advanced stages,portal vein tumor thrombosis(PVTT)and jaundice are common,whereas obstructive jaundice(OJ)is relatively rare.Both conditions markedly reduce survival and increase therapeutic complexity.Recently,hepatic artery infusion chemotherapy(HAIC)in combination with targeted immunotherapy has shown promise for advanced HCC.CASE SUMMARY We report a 47-year-old male with advanced HCC complicated by PVTT and OJ,who was admitted with marked jaundice of the skin and sclera.Imaging revealed a large hepatic mass(14.5 cm×11.3 cm)in the right lobe with associated portal vein tumor thrombus.The tertiary bile duct was only mildly dilated,making percutaneous transhepatic cholangiography drainage infeasible.The patient underwent reduced-dose HAIC,which resulted in significant tumor shrinkage and marked reduction in serum bilirubin.This improvement enabled sequential treatment with lenvatinib and camrelizumab.After six cycles,both liver function and alphafetoprotein levels improved.The patient achieved a progression-free survival of 20 months and an overall survival of 29 months.CONCLUSION HAIC can treat high-bilirubin HCC with PVTT and OJ,allowing for subsequent targeted immunotherapy.
文摘BACKGROUND Middle meningeal artery embolization(MMAE)is emerging as a promising treatment for chronic subdural hematoma(CSDH),serving both as an adjunct to surgery and as a primary therapeutic option depending on patient presentation.Due to its low recurrence rate and minimal complications,MMAE has gained increasing acceptance among clinicians in recent years.This report presents a case of diplopia following MMAE due to the presence of a potential anastomotic artery,aiming to enhance awareness of this complication.CASE SUMMARY A 60-year-old male patient presented with a headache following head trauma,and cranial computed tomography revealed a left-sided CSDH.The patient underwent left MMAE;however,polyvinyl alcohol particles inadvertently flowed into the lacrimal artery through an anastomotic artery,resulting in diplopia due to impaired abduction of the left eye.The diplopia resolved by postoperative day 40.The patient’s headache resolved by postoperative day 7,and the hematoma completely resolved by postoperative day 108.CONCLUSION Potential anastomotic arteries in the middle meningeal artery(MMA)can lead to serious complications.Superselective angiography of the MMA or its branches prior to embolization is essential.Performing embolization distal to potential anastomotic sites can reduce risks,and the presence of an anastomosis may warrant coil embolization or termination of the procedure.
基金Construction Program of the Key Discipline of State Administration of Traditional Chinese Medicine of China(ZYYZDXK-2023069)Research Project of Shanghai Municipal Health Commission (2024QN018)Shanghai University of Traditional Chinese Medicine Science and Technology Development Program (23KFL005)。
文摘Objective To develop a non-invasive predictive model for coronary artery stenosis severity based on adaptive multi-modal integration of traditional Chinese and western medicine data.Methods Clinical indicators,echocardiographic data,traditional Chinese medicine(TCM)tongue manifestations,and facial features were collected from patients who underwent coro-nary computed tomography angiography(CTA)in the Cardiac Care Unit(CCU)of Shanghai Tenth People's Hospital between May 1,2023 and May 1,2024.An adaptive weighted multi-modal data fusion(AWMDF)model based on deep learning was constructed to predict the severity of coronary artery stenosis.The model was evaluated using metrics including accura-cy,precision,recall,F1 score,and the area under the receiver operating characteristic(ROC)curve(AUC).Further performance assessment was conducted through comparisons with six ensemble machine learning methods,data ablation,model component ablation,and various decision-level fusion strategies.Results A total of 158 patients were included in the study.The AWMDF model achieved ex-cellent predictive performance(AUC=0.973,accuracy=0.937,precision=0.937,recall=0.929,and F1 score=0.933).Compared with model ablation,data ablation experiments,and various traditional machine learning models,the AWMDF model demonstrated superior per-formance.Moreover,the adaptive weighting strategy outperformed alternative approaches,including simple weighting,averaging,voting,and fixed-weight schemes.Conclusion The AWMDF model demonstrates potential clinical value in the non-invasive prediction of coronary artery disease and could serve as a tool for clinical decision support.
文摘The Kakinuma et al’s case report shows that non-pregnancy-related arterial pseudoaneurysm is a relatively rare,little known by some gynecologists,endo-scopists,surgeons or radiologists,which can cause massive bleeding.Arterial pseudoaneurysm is a condition in which the wall of a blood vessel collapses due to some invasive event,and the resulting leaked blood is engulfed by soft tissues,forming a cavity that is in communication with the vessel.It is a potentially life-threatening complication that could occurs after some deliveries and some gynecological invasive procedures.Remarkably,an undetermined percentage of pseudoaneurysms are asymptomatic,and in an asymptomatic patient it is difficult to predict the risk of haemorrhage and the attitude to follow,which depends on several factors,such as,the size and location of the vessel involved,changes in the size of the pseudoaneurysm,or the available therapeutic resources to be offered to patients,among others circumstances.The management of abdominal arterial pseudoaneurysm does not have consistent scientific evidence,but it seems that,regardless of the associated circumstances,the pseudoaneurysm could be treated at least initially,and mainly,through endovascular procedures,as done by Kakinuma et al.
基金Supported by Applied Basic Research Programs of Science and Technology Commission Foundation of Yunnan Province of China,No.202401AY070001-158.
文摘BACKGROUND Surgical intervention is a critical treatment approach for symptomatic atlantoaxial dislocation.However,vertebral artery injury remains a significant challenge during such procedures.We present a case of successful treatment of atlantoaxial dislocation with concurrent vertebral artery injury using interlaminar screw technology,and review the relevant literature.CASE SUMMARY A 69-year-old female patient,with no history of trauma,was diagnosed with atlantoaxial dislocation based on X-ray,computed tomography(CT),and magnetic resonance imaging.Preoperative CT angiography(CTA)revealed vertebral artery developmental anomalies,and she underwent posterior cervical surgery.Postoperative follow-up showed improvement in the patient’s clinical symptoms such as unstable walking and dizziness,as well as functional scores compared to pre-surgery.Intraoperative vertebral artery injury was successfully managed,and postoperative CTA review revealed no complications related to vascular damage.CONCLUSION Thorough preoperative evaluation,such as CTA imaging,and the surgeon’s expertise in various spinal screw placement techniques are crucial for improving the success rate of atlantoaxial dislocation surgeries.
基金Supported by the Science and Technology Program of Nantong Health Committee,No.MA2019003 and No.MA2021017Kangda College of Nanjing Medical University,No.KD2021JYYJYB025,No.KD2022KYJJZD019,and No.KD2022KYJJZD022+1 种基金Research Project of Nantong Health and Health Commission,No.MS2023041the Science and Technology Program of Nantong City,No.Key003 and No.JCZ2022040.
文摘The chronic occlusion of intracranial arteries generally has no or mild clinical symptoms,and the clinical symptoms of acute cerebral artery occlusion are mostly manifested as severe cerebral infarction symptoms,which often make early diagnosis difficult,thus losing the best treatment opportunity.Once cerebral infarction occurs,the consequences are difficult to recover.This is also an important reason for the high misdiagnosis rate and mortality of this disease.In this paper,the characteristics of the disease were analyzed to provide clinical reference.
文摘This article provides a detailed account of the diagnosis and treatment of a case involving a uterine artery pseudoaneurysm(UAP),as well as an analysis of UAP etiology.This finding emphasizes that UAP should be considered in patients presenting with abnormal genital bleeding after hysteroscopy and offers valuable insights and lessons for gynecologists in hysteroscopic procedures.The patient underwent timely relevant examinations to confirm the diagnosis,allowing for crucial time required for her treatment.In this study,the primary cause of UAP formation in the patient was attributed to a prior hysteroscopic surgical procedure conducted at another medical facility,suggesting that the selection and imple-mentation of dilatation catheters are some of the predisposing factors for UAP.In conclusion,this case study offers a comprehensive analysis of the etiology of UAP and effectively provides timely diagnosis and treatment,offering valuable in-sights for the clinical diagnosis and management of UAP.
文摘BACKGROUND Alagille syndrome is a multisystem disease that results in various vascular anomalies,commonly involving the cardiac and pulmonary systems.To the best of our knowledge,there is no literature regarding the cardiovascular outcomes of these patients in association with coronavirus disease 2019(COVID-19).CASE SUMMARY A 34-year-old woman with a history of Alagille syndrome who underwent successful atrial septal defect with partial anomalous pulmonary veins and patent ductus arteriosus repair,as well as left pulmonary artery catheterization and stenting in childhood due to pulmonary stenosis.The patient was without any respiratory symptoms and was a dancer prior to contracting COVID-19.Several weeks after her COVID-19 infection,she developed left pulmonary artery stent thrombosis and subsequent symptomatic pulmonary hypertension.A treatment strategy of anticoagulation alongside pharmacological agents for pulmonary hypertension for 3 months followed by balloon pulmonary artery angioplasty to reopen the stenosis was unsuccessful.CONCLUSION In the era of COVID-19,patients with pulmonary vascular malformations and endovascular stents are at an increased risk for chronic thromboembolic disease.Patients may benefit from prophylactic antiplatelet or anticoagulation therapy.Stent thrombosis is a devastating phenomenon and should be treated urgently and aggressively with balloon pulmonary angioplasty,and/or a thrombolytic agent.
文摘BACKGROUND The root of mesentery dissection is one of the critical maneuvers,especially in borderline resectable pancreatic head cancer.Intra-abdominal chyle leak(CL)including chylous ascites may ensue in up to 10%of patients after pancreatic resections.Globally recognized superior mesenteric artery(SMA)first approaches are invariably performed.The mesenteric dissection through the inferior infracolic approach has been discussed in this study emphasizing its post-operative impact on CL which is the cornerstone of this study.AIM To assess incidence,risk factors,clinical impact of CL following root of mesentery dissection,and the different treatment modalities.METHODS This is a retrospective study incorporating the patients who underwent dissection of the root of mesentery with inferior infracolic SMA first approach pancreat-oduodenectomy for the ventral body and uncinate mass of pancreas in the Department of Gastrointestinal and General Surgery of Kathmandu Medical College and Teaching Hospital from January 1,2021 to February 28,2024.Intraop-erative findings and postoperative outcomes were analyzed.RESULTS In three years,ten patients underwent root of mesentery dissection with inferior infracolic SMA first approach pancreatoduodenectomy.The mean age was 67.6 years with a male-to-female ratio of 4:5.CL was seen in four patients.With virtue of CL,Clavien-Dindo grade Ⅱ or higher morbidity was observed in four patients.Two patients had a hospital stay of more than 20 days with the former having a delayed gastric emptying and the latter with long-term total parenteral nutrition requirement.The mean operative time was 330 minutes.Curative resection was achieved in 100%of the patients.The mean duration of the intensive care unit and hospital stay were 2.55±1.45 days and 15.7±5.32 days,respectively.CONCLUSION Root of mesentery dissection with lymphadenectomy and vascular resection correlated with occurrence of CL.After complete curative resection,these were managed with total parenteral nutrition without adversely impacting outcome.
文摘BACKGROUND 2D-echocardiography(2DE)has been the primary imaging modality in children with Kawasaki disease(KD)to assess coronary arteries.AIM To report the presence and implications of incidental congenital coronary artery anomalies that had been misinterpreted as coronary artery abnormalities(CAAs)on 2DE.METHODS Records of children diagnosed with KD,who underwent computed tomography coronary angiography(CTCA)at our center between 2013-2023 were reviewed.We identified 3 children with congenital coronary artery anomalies in this cohort on CTCA.Findings of CTCA and 2DE were compared in these 3 children.RESULTS Of the 241 patients with KD who underwent CTCA,3(1.24%)had congenital coronary artery anomalies on CTCA detected incidentally.In all 3 patients,baseline 2DE had identified CAAs.CTCA was then performed for detailed evaluation as per our unit protocol.One(11-year-boy)amongst the 3 patients had complete KD,while the other two(3.3-year-boy;4-month-girl)had incomplete KD.CTCA revealed separate origins of left anterior descending artery and left circumflex from left sinus[misinterpreted as dilated left main coronary artery(LCA)on 2DE],single coronary artery(interpreted as dilated LCA on 2DE)and dilated right coronary artery on 2DE in case of anomalous origin of LCA from the main pulmonary artery.The latter one was subsequently operated upon.CONCLUSION CTCA is essential for detailed assessment of coronary arteries in children with KD especially in cases where there is suspicion of congenital coronary artery anomalies.Relying solely on 2DE may not be sufficient in such cases,and findings from CTCA can significantly impact therapeutic decision-making.
文摘BACKGROUND Central retinal artery occlusion(CRAO)is a potentially blinding disease,and hyperbaric oxygen therapy(HBOT)is becoming increasingly popular with the support of scientific evidence.Despite the presence of various acute management measures,there is no clear evidence on the gold standard treatment for CRAO.AIM To identify factors and imaging parameters associated with good visual outcome,which guide ophthalmologists in the triage of CRAO patients for HBOT.METHODS Patients who suffered from CRAO and had a symptom onset≤6 h were recruited for a course of HBOT in a tertiary hospital after failing bedside treatment.Patient demographics,onset time,CRAO eye parameters,and past medical history were prospectively collected.Visual outcomes after HBOT were also analyzed.RESULTS A total of 26 patients were included;the female-to-male ratio was 1:1.6,and the mean age was 67.5 years±13.3 years(range 44–89 years).The mean duration of follow-up and mean visual acuity(VA)improvement were 10.0 mo±5.3 mo and 0.48 logarithm of minimal angle of resolution(logMAR)±0.57 logMAR(approx-imately 9 letters in ETDRS)(P=0.0001,Z=-3.67),respectively.The 1 mm zone of central macular thickness(CMT)on optical coherence tomography was not associated with VA changes(P=0.119);however,the 1-to-3 mm circular rim of CMT was fairly associated(P=0.02,Spearman's coefficient=0.45).Complete retinal perfusion time during fundus fluorescein angiography(FFA)was mode-rately associated(P=0.01,Spearman's coefficient=0.58)with visual outcome.
基金supported by the National Natural Science Foundation of China(No.82173450&No.81770237).
文摘BACKGROUND Our understanding of the correlation between postdischarge cancer and mortality in patients with coronary artery disease(CAD)remains incomplete.The aim of this study was to investigate the relationships between postdischarge cancers and all-cause mortality and cardiovascular mortality in CAD patients.METHODS In this retrospective cohort study,25%of CAD patients without prior cancer history who underwent coronary artery angiography between January 1,2011 and December 31,2015,were randomly enrolled using SPSS 26.0.Patients were monitored for the incidence of postdischarge cancer,which was defined as cancer diagnosed after the index hospitalization,survival status and cause of death.Cox regression analysis was used to explore the association between postdischarge cancer and all-cause mortality and cardiovascular mortality in CAD patients.RESULTS A total of 4085 patients were included in the final analysis.During a median follow-up period of 8 years,174 patients(4.3%)developed postdischarge cancer,and 343 patients(8.4%)died.A total of 173 patients died from cardiovascular diseases.Postdischarge cancer was associated with increased all-cause mortality risk(HR=2.653,95%CI:1.727–4.076,P<0.001)and cardiovascular mortality risk(HR=2.756,95%CI:1.470–5.167,P=0.002).Postdischarge lung cancer(HR=5.497,95%CI:2.922–10.343,P<0.001)and gastrointestinal cancer(HR=1.984,95%CI:1.049–3.750,P=0.035)were associated with all-cause mortality in CAD patients.Postdischarge lung cancer was significantly associated with cardiovascular death in CAD patients(HR=4.979,95%CI:2.114–11.728,P<0.001),and cardiovascular death was not significantly correlated with gastrointestinal cancer or other types of cancer.CONCLUSIONS Postdischarge cancer was associated with all-cause mortality and cardiovascular mortality in CAD patients.Compared with other cancers,postdischarge lung cancer had a more significant effect on all-cause mortality and cardiovascular mortality in CAD patients.
文摘BACKGROUND The persistent burden of cardiovascular(CV)disease in the United States requires innovative and cost-effective prognostic markers that can be relied upon.AIM To provide insights into how adiponectin can predict all-cause mortality and major adverse CV events(MACE)in patients with coronary artery disease(CAD)and to determine the prognostic value of adiponectin in predicting all-cause mortality and MACE in patients with stable CAD.METHODS We conducted a systematic search on PubMed,Scopus,and Google Scholar to find relevant studies published through June 2023 evaluating the long-term prognostic role of adiponectin in patients with stable CAD.Using a random effects model with 95%CI,we estimated the odds ratio(OR)while assessing heterogeneity through I^(2)statistics.To ensure robustness,we performed a sensitivity analysis using the leave-one-out approach.RESULTS After screening,we included five prospective studies involving 3225 patients who were followed up for a median duration of 3.8 years.Within the study population,prevalent risk factors included hypertension,diabetes,hyperlipidemia,and smoking.The commonly prescribed medications were angiotensin-converting enzyme inhibitors,beta blockers,and statins.The combined adjusted OR for all-cause mortality was found to be 2.51(95%CI:1.36–4.62),showing heterogeneity(I^(2)=65.51%,P=0.03).On the other hand,the combined adjusted OR for MACE was determined to be 1.04(95%CI:1.02–1.06)with no significant heterogeneity observed(I^(2)=0%,P=0.68).Through a sensitivity analysis,it was discovered that none of the studies significantly impacted the overall results of the meta-analysis,thus indicating their robustness.CONCLUSION Higher levels of adiponectin were found to be associated with an increased risk of long-term mortality and MACE in patients with CAD,which highlights its potential as a cost-effective marker for risk assessment and guiding treatment strategies.Further research on the role of adiponectin could greatly influence decision-making and resource allocation in CV care.
文摘Unilateral pulmonary artery agenesis(UPAA)is a rare congenital cardiovascular anomaly defined by the complete absence of one pulmonary artery,most often affecting the right side.[1]Although typically identified in childhood due to symptomatic presentation,certain cases may remain undiagnosed until adulthood,particularly in asymptomatic patients or those with subtle clinical signs.
文摘Transradial access (TRA) has emerged as the preferred vascular access route forcoronary angiography and percutaneous coronary interventions due to itssuperior safety profile compared to transfemoral access. However, its widespreadadoption raises concerns regarding structural alterations in the radial artery,which may impact long-term vascular health and future procedural feasibility.TRA is associated with histopathologic changes in the arterial wall, such asintimal injury and hyperplasia, medial remodeling and adventitial inflammation,collectively contributing to radial artery remodeling. Moreover, TRA can inducechanges in radial artery lumen diameter driven by an inflammatory response dueto arterial puncture and mechanical friction during the procedure. Nonetheless, amore clinically significant consequence is radial artery occlusion, which is influencedby various procedural and patient-related factors. Strategies to minimizeremodeling include meticulous pre-procedural ultrasound assessment to ensureappropriate sheath-to-artery size matching, periprocedural pharmacologicalinterventions and implementation of patent hemostasis techniques. This reviewsynthesizes current knowledge regarding the mechanisms, clinical implications,and preventive strategies related to radial artery remodeling following TRA. Further research is needed toelucidate the long-term consequences of radial artery remodeling and to refine preventive strategies for preservingradial artery patency and its suitability for future interventions.
基金Supported by National Natural Science Foundation of China(No.82070991).
文摘Central retinal artery occlusion(CRAO)is an acute ophthalmic emergency,characterized by sudden vision loss due to retinal ischemia in areas corresponding to arterial occlusion sites.Diagnosis primarily relies on fundus fluorescein angiography(FFA)and optical coherence tomography(OCT),which show delayed retinal artery filling time hours to days after occlusion and increased hyperreflectivity of the inner retina.
文摘Dear Editor,We aimed to describe the management of the intraoperative injury of the right external iliac artery that occurred during robot-assisted right nephroureterectomy with bladder cuff excision.Surgery was scheduled for suspected urothelial carcinoma of the distal ureter in a 60-year-old woman.The patient involved in the present research signed a dedicated form to consent to the publication of images and/or information about her.Past medical history included Brugada syndrome diagnosed in 2015,and hypercholesterolemia.Past surgical history included one cesarean section only.Family history included ovarian cancer(sister),colorectal cancer(mother),and kidney cancer(father).
