Abdominal aorta stenting : before / after (2)

Abdominal aorta endoprothesis (2)

Gore Excluder

Thoracic aorta endoprothesis

cook TX2

Abdominal aorta stenting : before / after (1)

Abdominal aorta endoprothesis (1)

cook Zenith



Pericardial effusion caused by advanced lung cancer

Goiter

The origin of the "3 chimneys" from aortic arch

from right-anterior to left-posterior:
brachiocephalic trunk,
left common carotid artery,
left subclavian artery

Right renal stone

Left distal ureter stone causing hydronephroureter

Swan Ganz to left inferior PA

Aortic annulus abscess s/p pericardial patch + AVR

現在請你禱告

主耶穌啊
我是一個罪人
我需要你
求你進到我的靈裡
除去我的罪
充滿我
叫我得有神的生命
我現在接受你做我的救主和生命
我把自己奉獻給你
奉主的名求
阿們

All by myself -- Celine Dion

When I was young
I never needed anyone
And making love was just for fun
Those days are gone
Livin' alone
I think of all the friends I've known
When I dial the telephone
Nobody's home

All by myself
Don't wanna be
All by myself
Anymore

Hard to be sure
Sometimes I feel so insecure
And loves so distant and obscure
Remains the cure

All by myself
Don't wanna be
All by myself
Anymore
All by myself
Don't wanna live
All by myself
Anymore

When I was young
I never needed anyone
Making love was just for fun
Those days are gone

All by myself
Don't wanna be
All by myself
Anymore
All by myself
Don't wanna live
Oh
Don't wanna live
By myself, by myself
Anymore
By myself
Anymore
Oh
All by myself
Don't wanna live
I never, never, never
Needed anyone

farewell

well
you have your own social circles
I have mine
now you have crossed the line
so this is the end of it


farewell

That's why it's so called snorkel procedure

snorkelling celiac trunk with 8 mm viabahn

snorkel in scuba / diving

zoom in snorkel ( upper most of the figure )

明星臉(5)



明星臉(4)

肺葉切除術後的肋膜積液

肋膜腔積液 ( pleural effusion )
在肺葉切除術後不算少見
大部分再適當的引流就可以了

Over the rail



一個洗腎病患
要放左側的 perm-cath / hickman
不知為何他的 left brachiocephalic vein to SVC 的 angle 一直過不去
我只好用兩條 0.35 wire 作 guide, 一起從 A/V port advance, 增加 support
" over the rail " method
終於成功置入了!

TIMI

TIMI stands for 'Thrombolysis In Myocardial Infarction'

'TIMI Grade Flow' is a widely adopted scoring system from 0-3 referring to levels of coronary blood flow assessed during percutaneous coronary angioplasty:

• TIMI 0 flow (no perfusion) refers to the absence of any antegrade flow beyond a coronary occlusion.
• TIMI 1 flow (penetration without perfusion) is faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed.
• TIMI 2 flow (partial reperfusion) is delayed or sluggish antegrade flow with complete filling of the distal territory.
• TIMI 3 flow (complete perfusion) is normal flow which fills the distal coronary bed completely

Fontaine classification

Stage I – Asymptomatic. Of note: Fontaine stage I does in fact describe patients who are for the most part asymptomatic. Careful history may actually reveal subtle and non-specific symptoms such as paresthesias. Physical examination may reveal cold extremities and other signs of “subclinical” peripheral artery disease. More examples include bruits over blood vessels and lack of normal pulses.

Stage II – Intermittent claudication. This stage takes into account the fact that patients usually have a very constant distance at which they have pain:

• Stage IIa – Intermittent claudication after more than 200 meters of pain free walking.

• Stage IIb – Intermittent claudication after less than 200 meters of walking

Stage III – Rest pain. Rest pain is especially troubling for patients during the night. The reason for this is twofold: First, the legs are usually raised up on to a bed at night, thus diminishing the positive effect gravity may have had during the day when the legs were dependent. Second, during the night the lack of sensory stimuli allow patients to focus on their legs.

Stave IV – Ischemic ulcers or gangrene (which may be dry or humid).

Rutherford classification

Stage 0 – Asymptomatic

Stage 1 – Mild claudication

Stage 2 – Moderate claudication – The distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters.

Stage 3 – Severe claudication

Stage 4 – Rest pain

Stage 5 – Ischemic ulceration not exceeding ulcer of the digits of the foot

Stage 6 – Severe ischemic ulcers or frank gangrene

怎樣

怎樣的人生   才算完整?

現在的我

非常寂寞

City Slogan

I am Amsterdam

Soul ( Seoul ) of Asia
其實我覺得 Explore Your Soul / Seoul  比較好 ...

抱抱

Slazenger

Jaguar

Puma

Chiling @ 重慶

AVF/AVG duplex study format

1)  Access  type:
      native  /  graft  / hybrid
 
2)  Site:
     left / right   forearm / upper arm 
3)  Clinical  problem:
     newly created / decreased VF / increased VP / occlusion

4)  Age  of  vascular  access: 
      ____   years   ____ months

5)  Result:
     lumen  narrowing :
     lesion location :  
     flow  turbulence : yes / no
     VF from  feeding  brachial  artery  : adeqaute / inadeqaute 
     VF= _____  ml/min 

6)  Suggestion: 

      __  clinical  follow  up 
      __  may try  shunt  puncture 
      __  keep warm  packing
      __  keep handgripping  exercise
      __  need recent PTA

esophageal diverticula

2 categories : pulsion and traction
2 types of pulsion diverticula : Zenker's diverticulum and epiphrenic diverticulum


pulsion is due to intraluminal pressure
traction is due to adjacent tissue inflammation and fibrosis



pulsion is pseudo diverticulum  ( mucosa layer only )
traction is true diverticulum       ( whole layers )


Zenker's is the most common diverticulum of the esophagus

橫隔膜疝氣 diaphragmatic hernia

橫膈膜疝氣指的是腹腔內的臟器
因腹壓升高或是橫膈膜通道的鬆弛
而造成應該在腹腔內的臟器跑道了胸腔

最常偷跑到胸腔的器官就是 "胃" 了

治療橫隔膜疝氣需要手術
要嘛從腹腔把它拉回來 ( pull back )
要嘛從胸腔把它推回去 ( push in )
端看橫膈疝氣的解剖位置和外科醫師的技術
當然
已經鬆弛的橫膈通道要加強它的緊度 ( re-inforcement )
以減少日後復發

食道憩室 esophageal diverticulum

食道憩室就是食道壁的一個向外膨出
以位置來分可分為上,中,下段的食道憩室
這位病患的憩室在橫隔膜上方
屬於下段的食道憩室
hence so called : epiphrenic ( 橫隔膜上方的 ) diverticulum ( 憩室 )

上圖中畫面右上方的一球鋇劑顯影即是放射科醫師作食道攝影所發現的食道憩室



由另一角度(由後往前看)之同一個食道憩室

其實從胸部 X 光片就可以看出一些端倪
在心臟的位置可以看到不正常的 air-fluid level

食道憩室一經診斷
治療方法為手術切除
依其大小
可做開胸切除 ( thoracotomy ) 或是胸腔鏡 ( VATS ) 切除

主動脈腸道廔管 (AEF)

AEF, Aortic-Enteric Fistula
主動脈腸道廔管, 是死亡率很高的疾病
根據統計,被診斷有主動脈腸道廔管的病人,存活率是50%
兩個病人就有一個會死掉
因為主動脈是人體最大條的血管
一旦它和腸道形成一個原本不該有的通道(即所謂廔管)
可想而知患者不是大量吐血就是大量血便
出血量會很大,往往造成患者休克
緊急手術時患者就回天乏術( die on table ),也是有可能的

幸好這不是一個很常見的疾病
它好發在腹主動脈瘤手術後的病人
事實上,百分之95以上主動脈腸道廔管的病患
都有腹主動脈瘤手術的病史

治療方式:
可先以主動脈支架將廔管洞口擋住
若仍無法完封,只好以傳統開刀修補
遺憾的是,目前兩種治療的長期存活率都並不高

B型主動脈剝離

主動脈剝離, 臨床上分為A型和B型
這個病人是B型
因為他的剝離點是在"三根煙囪"之後

豬尾巴

右側豬尾巴
使用前

使用後