Selective Angioembolisation of Iatrogenic Renal Artery Pseudoaneurysms Following Minimally Invasive Urological Procedures: A Single Centre Case Series.

INTRODUCTION: The purpose of this study was to report our centre's experience using selective angioembolisation in the treatment of iatrogenic renal artery pseudoaneurysms (RAP) following minimally invasive urological procedures. METHODS: Our retrospective analysis included four consecutive patients treated with angioembolisation for iatrogenic RAP between October 2016 and October 2021. Data on demographics, minimally invasive urological intervention, clinical features, imaging findings, embolization procedure and perioperative details were collected. Rates of technical and clinical success, defined as 1. total occlusion of the extravasation site on completion digital subtraction angiography (DSA), and 2. resolution of symptoms, signs, and serum hemoglobin (Hb) derangements secondary to RAP, were analysed. Renal function, measured by serum creatinine (Cr) and estimated glomerular filtration rate (eGFR), was recorded prior to and post - angioembolisation procedure and compared. RESULTS: Mean time between urological intervention and angioembolisation was 9 days (range, 2-17 days). Rates of technical and clinical success were 100% and 100% respectively. No additional angioembolisation procedures were required, and there were no peri or post-operative complications identified during mean follow-up of 662 days (range, 30-1845 days). Mean serum Cr prior to and post angioembolisation was 83 mmol/L and 79.5 mmol/L. Mean eGFR prior to and post angioembolisation was 73.8 and 77.8 mL/min/1.73 m2. In all patients, no significant difference was observed in serum Cr and eGFR prior to and post angioembolisation. CONCLUSION: Iatrogenic renal artery pseudoaneurysms can occur following a range of minimally invasive urological procedures. This retrospective review highlights the utility of angioembolisation as a safe and effective treatment with high clinical and technical success rates. Further studies involving larger populations are required to validate its broader application.

Utility of Adjunctive Digital Subtraction Venography for the Treatment of Saphenous Vein Insufficiency.

PURPOSE: To report the use of adjunctive venography for the treatment of superficial venous reflux. METHODS: Two hundred consecutive patients (mean age 60.9 years, range 33-86; 128 women) with chronic venous disease underwent saphenous or perforator vein ablation in 268 limbs (305 venous trunks) guided by adjunctive venography and fluoroscopy in addition to ultrasound between October 2010 and May 2016. Intraprocedural venograms were independently evaluated by 2 vascular specialists to identify the presence of venous anomalies and the need for fluoroscopy-guided maneuvers to successfully complete venous ablation. Intraprocedural venography results were compared with preoperative venous duplex scan reports to ascertain if the duplex study could be of value in identifying preoperatively any anatomical variants that may pose a technical challenge to the operator. RESULTS: In this cohort, 542 venograms (2.0/limb) were performed with a mean duration of 4.9±9.1 minutes (range 1-48). Two thirds of patients (132, 66%) had anomalies or abnormalities within the target vein; more than a third (88, 44%) required an endovascular maneuver to successfully complete the ablation and 17% (34) of cases were impossible to complete without adjunctive fluoroscopic guidance. Per-patient comparison of intraprocedural venography with preoperative venous duplex reports identified 21 (11%) patients with abnormalities detected on ultrasound (23 anomalies) compared with 123 (64%) on venography (193 anomalies). This gave ultrasound a 17.1% sensitivity, 100% specificity and positive predictive value, and 40.7% negative predictive value. CONCLUSION: Venography is a valuable addition to ultrasound to facilitate complete ablation of insufficient saphenous veins in selected patients with complex anatomy.

Sonographic diagnosis of mid-aortic syndrome in a 2-year-old patient with hypertension.

Mid-aortic syndrome is a rare cause of hypertension in the paediatric population. We present here the sonographic findings of a 2 year old who presented with hypertension. Mid-aortic syndrome was diagnosed upon finding renal artery and infrarenal aortic stenoses on ultrasound. The clinical entity and interrogation of the paediatric renal and aortic vessels are discussed.

A Real-World Experience With the Supera Interwoven Nitinol Stent in Femoropopliteal Arteries: Midterm Patency Results and Failure Analysis.

PURPOSE: To evaluate the safety and midterm patency of the Supera interwoven nitinol stent in a real-world population and determine deployment and patient-related factors that may predispose to loss of patency. METHODS: A retrospective analysis was conducted of 111 consecutive limbs from 97 patients (mean age 75.3 years; 68 men) with severe atherosclerotic disease of the superficial femoral and popliteal arteries that were treated with Supera stents between June 2012 and October 2014. Half the patients had claudication (56%); the remainder had rest pain (19%) and tissue loss (26%). Forty-eight (43%) lesions were chronic total occlusions, and more than half were classified as TransAtlantic Inter-Society Consensus C (22%) or D (30%). RESULTS: All 146 Supera stents (1.32 stents per limb) were deployed successfully, extending over a mean length of 175.5±130.5 mm to treat lesions averaging 151.5±127.1 mm long. At 30 days, Kaplan-Meier estimated freedom from death, target lesion revascularization, and amputation was 97.3%. Primary patency and freedom from clinically driven target lesion revascularization rates were 87.1% and 95.0% at 6 months, respectively, and 78.9% and 87.6% at 12 months, respectively. Four distinct mechanisms for failure were identified in the 13 limbs in which patency was lost; stent intussusception (n=4), compromised inflow or outflow (n=2), gross oversizing (n=1), and neoplastic thrombophilia (n=1); the cause of 5 occlusions could not be identified. CONCLUSION: In this heterogeneous group that included long and complex atheromatous femoropopliteal lesions, the Supera stent achieved excellent clinical and patency results at 1 year. Further improvement may be achieved through careful patient selection and the avoidance of deployment pitfalls.

Hard to diagnose and potentially fatal: slow aortic erosion post spinal fusion.

BACKGROUND: Delayed aortic injuries are a rare, but well-recognized complication of spinal surgery. They are a result of slow erosion of osteosynthesis material into the aorta. Although this is a life-threatening complication, patients might present years later with nonspecific symptoms. OBJECTIVE: A complex case of slow aortic injury after thoracic spinal surgery is presented, which highlights the challenges involved in diagnosis and treatment. CASE REPORT: A 62-year-old man had a T6 vertebrectomy and T5-7 anterior spinal fusion for multiple myeloma 5 years earlier. Two years postoperatively, the patient developed intermittent hemoptysis that triggered several presentations to the emergency department and consecutive hospital admissions during a 3-year period. All investigations, including endoscopy, bronchoscopy, and repeated chest computed tomography (CT) scans, were unremarkable. Eventually, the patient presented with frank hemoptysis associated with severe left-sided chest pain. Urgent CT angiography revealed a pseudoaneurysm measuring 34 × 20 mm at the level of the vertebrectomy. The patient underwent emergency surgery and an endoluminal stent graft was successfully placed. The patient remains well after 6 months. CONCLUSIONS: The close proximity of the aorta and spine entertains the risk of aortic injury associated with vertebral osteosynthesis. Long-term complications of slow aortic erosion are extremely difficult to diagnose. The presented patient suffered from an undetected bronchio-aortic fistula with consecutive pseudoaneurysm formation and rupture. Awareness of slow aortic erosion is important for correct diagnostic pathways and subsequent early diagnosis to ensure a positive outcome for the patient.

Medical students, medical schools and international health.

Over the past decade, student participation in international health has moved beyond individual elective terms in developing countries to collective responses led by student international health organisations. There are now at least 10 such organisations, with more than 500 medical students participating at a local or national level each year. Student international health organisations can deliver short- and long-term benefits to developing countries, while equipping students with skills such as leadership, teamwork and cultural sensitivity. Activities include delivery of medical equipment, fundraising, educating university communities, and acting as advocates for social justice. We believe Australian medical schools must formally incorporate international health into their curricula, drawing upon the experiences of schools in Europe and North America.