Abdominal aortic mural thrombus in association with active ulcerative colitis.

Aortic mural thrombus (AMT) in the absence of aneurysm or atherosclerosis is a rare clinical finding and an uncommon cause of peripheral arterial embolization. AMT in a normal artery is usually attributed to systemic hypercoagulability. We describe a case of subacute lower limb ischemia due to AMT associated with active ulcerative colitis (UC). A 46-year-old man with active UC was referred to our hospital for the evaluation and treatment of left leg pain. Ultrasound and contrast computed tomography showed occlusion of the left popliteal artery, and an AMT in the abdominal aorta between the inferior mesenteric artery and the aortic bifurcation. We started anticoagulant therapy, intravenous infliximab, and cytapheresis. Four weeks after initiating anticoagulation therapy, we were able to successfully treat the AMT with anticoagulation therapy without surgical thrombectomy. The inflammatory status of ulcerative colitis was also under control, and AMT had not recurred at 1 year after treatment. Invasive therapies are often selected to treat AMT. However, if a patient's hypercoagulable state is controlled, AMT can safely be treated with anticoagulation therapy alone without recurrence. Learning objective: Aortic mural thrombus (AMT) in the absence of aneurysm or atherosclerosis is a rare clinical finding and an uncommon cause of peripheral arterial embolization. AMT in a normal artery is usually attributed to systemic hypercoagulability. We describe a case of subacute lower limb ischemia due to AMT associated with active ulcerative colitis. We controlled the ulcerative colitis condition and successfully treated the AMT with anticoagulation therapy alone.

Percutaneous transluminal renal artery stenting using digital subtraction angiography with diluted contrast medium in a patient with severe chronic kidney disease.

Atherosclerotic renal artery stenosis (ARAS) is associated with ischemic nephropathy, kidney failure, and secondary hypertension. Percutaneous transluminal renal artery stenting (PTRAS) is required for patients with hemodynamically significant ARAS. However, PTRAS can be problematic in patients with chronic kidney disease (CKD) because the use of a large amount of iodinated contrast medium is associated with an increased risk of contrast-induced nephropathy. We describe a case of PTRAS with successful revascularization by using digital subtraction angiography (DSA) with diluted contrast medium (1:10 dilution). An 89-year-old man with resistant hypertension and CKD was hospitalized in our institution for acute coronary syndrome. During hospitalization, the patient's blood pressure was extremely high (180-200/70-90 mmHg), despite the use of four antihypertensive agents. We examined the cause of hypertension and detected significant right renal artery stenosis and left kidney atrophy with renal artery obstruction. We performed PTRAS on the right renal artery by using DSA with a diluted contrast medium. Revascularization was successful using only 3 mL of the contrast medium. PTRAS using DSA with diluted contrast medium can be an effective technique for treating ARAS in patients with CKD to preserve renal function. Learning objectives: Atherosclerotic renal artery stenosis (ARAS) is associated with ischemic nephropathy, kidney failure, and secondary hypertension. Percutaneous transluminal renal artery stenting (PTRAS) is required for patients with hemodynamically significant ARAS. However, PTRAS can be problematic in patients with chronic kidney disease because of the increased risk of contrast-induced nephropathy. We describe a technique of PTRAS using digital subtraction angiography with a diluted contrast medium to achieve a successful revascularization.

Efficacy of endoscopic combined intrarenal surgery in the prone split-leg position for staghorn calculi.

UNLABELLED: Abstract Purpose: To evaluate the efficacy of endoscopic combined intrarenal surgery (ECIRS) using retrograde flexible ureteroscopy and miniature percutaneous nephrolithotomy (PNL) for the treatment of patients with staghorn calculi in the prone split-leg position. PATIENTS AND METHODS: We retrospectively reviewed the records of 42 patients with staghorn calculi (45.8±3.2 mm) who underwent ECIRS using retrograde flexible ureteroscopy and miniature PNL in the prone split-leg position for the treatment of staghorn calculi in our center between December 2010 and August 2013. A flexible ureteroscope with a laser fiber was inserted through a ureteral access sheath, and lithoclast lithotripsy was performed through a mini-percutaneous tract. Both procedures were performed simultaneously by two urologists. Surgical parameters, including surgical time, stone-free (SF) rates, modified Clavien complication grades, and risk factors for residual stones, were analyzed. RESULTS: Fifteen patients (35.7%) had complete staghorn calculi. Among the 42 staghorn calculi treated, 23 had 0 to 5 stone branches, 14 had 6 to 10 stone branches, and 5 had ≥11 stone branches. All procedures were performed successfully using a single lithotripsy tract with the patient in the prone split-leg position. The mean surgical time was 143.2±9.2 minutes. The initial SF rate was 71.4%, and the final SF rate was 83.3% after further treatment. One patient required a blood transfusion (2.4%), but no patient experienced a ≥3 Clavien grade complication. Risk factors for residual stones were stone size, stone surface area, complete staghorn calculi, and the number of stone branches. CONCLUSIONS: ECIRS for staghorn calculi in the prone split-leg position is a safe, efficient, and versatile method for the effective management of staghorn calculi without the creation of multiple percutaneous tracts.

Combined endoscopic surgery in the prone-split leg position for successful single-session removal of an encrusted ureteral stent: a case report.

INTRODUCTION: Although encrusted stents may lead to some unwanted complications including urinary tract obstruction, urinary sepsis, and potential loss of kidney function, there is currently no consensus on the most efficient method for managing stents that are intentionally left in situ. This is the first report describing the management of an encrusted stent using combined endoscopic surgery in the prone split-leg position in a single session. CASE PRESENTATION: A 47-year-old Asian man presented with left flank pain and macrohematuria. The patient had undergone left ureteral stenting three years previously for the treatment of left ureteral stones and hydronephrosis; however, he was lost to follow-up before the treatment for the ureter stones was completed. Therefore, the ureteral stent and stones were not removed. An abdominal radiograph and a noncontrast computed tomography scan showed encrustation along the retained stent with stone burdens in the kidney and ureter. The ureteral stent could not be removed by cystoscopy after shock wave lithotripsy of the left ureteral stones. Therefore, endoscopic lithotripsy combined with flexible ureteroscopy and miniature nephroscopy was performed with the patient in the prone split-leg position. All the stones and the encrusted ureteral stent were successfully removed in a single session. CONCLUSIONS: In this case, percutaneous nephrolithomy in addition to flexible ureteroscopy was preferred because severe encrustation of the proximal stent and ureteral stones complicated the therapeutic strategy. Combined endoscopic techniques in the prone split-leg position can achieve successful and safe management of encrusted stents.