Pseudoaneurismas arteriales secundarios a fractura de fémur: opciones terapéuticas / Arterial pseudoaneurysms secondary to femur fracture: treatment options

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A propósito de un caso de pseudoaneurisma de la arteria cística: causa infrecuente de hemorragia digestiva alta en un cuadro de colecistitis xantogranulomatosa / Pseudoaneurysm of the cystic artery: An uncommon cause of upper gastrointestinal bleeding in a case of xanthogranulomatous cholecystitis

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Endovascular management of iatrogenic renal arterial lesions and clinical outcomes.

PURPOSE: We aimed to evaluate iatrogenic renal arterial lesions, including pseudoaneurysm, arteriovenous fistula, and arteriocaliceal fistula, their management by endovascular embolization, and the clinical results. METHODS: Fifty-five patients (forty males, fifteen females) with a median age of 40 years (range, 8-85 years), who underwent endovascular embolization of iatrogenic renal arterial lesions between March 2003 and December 2013 were included in this retrospective study. Types of iatrogenic lesions and details of embolization procedures were reported. Estimated glomerular filtration rate (eGFR), renal function tests, hemoglobin, and hematocrit levels before and after embolization were recorded and compared. RESULTS: Median follow-up was 24 months. We identified 53 pseudoaneurysms, 30 arteriovenous fistulas, and 11 arteriocaliceal fistulas in 55 patients, after percutaneous nephrolithotomy (n=26), renal biopsy (n=21), nephrostomy (n=3), renal surgery (n=3), and extracorporeal shock wave lithotripsy (n=2). Median number of pseudoaneurysms was 1 (range, 1-4) with a median size of 7 mm (range, 1.5-35 mm). Fifty-one patients underwent coil embolization. Median number of coils was 5 (range, 2-21) and median renal parenchymal loss was 5% (range, 1%-50%). There were no significant differences between pre- and postoperative eGFR and serum parameters. CONCLUSION: Iatrogenic renal arterial lesion can be a life threatening condition. Superselective coil embolization is a safe, minimally invasive treatment option with minimal renal parenchymal loss and without significant change in renal function.

Preparation and characterization of injectable fibrillar type I collagen and evaluation for pseudoaneurysm treatment in a pig model.

OBJECTIVE: Despite the efficacy of collagen in femoral artery pseudoaneurysm treatment, as reported in one patient study, its use has not yet gained wide acceptance in clinical practice. In this particular study, the collagen was not described in detail. To further investigate the potential of collagen preparations, we prepared and characterized highly purified injectable fibrillar type I collagen and evaluated its use for femoral artery pseudoaneurysm (PSA) treatment in vivo using a pig model. METHODS: Purified fibrillar type I collagen was characterized using electron microscopy. The effect of three different sterilization procedures, ie, hydrogen peroxide gas plasma (H2O2), ethylene oxide gas (EtO), and gamma irradiation, was studied on both SDS-PAGE and platelet aggregation. Different collagen injectables were prepared (3%, 4%, and 5%) and tested using an injection force test applying a 21-gauge needle. To evaluate the network characteristics of the injectable collagen, the collagen was suspended in phosphate buffered saline (PBS) at 37°C and studied both macroscopically and electron microscopically. To determine whether the collagen induced hemostasis in vivo, a pig PSA model was used applying a 4% EtO sterilized collagen injectable, and evaluation by angiography and routine histology. RESULTS: Electron microscopy of the purified type I collagen revealed intact fibrils with a distinct striated pattern and a length<300 µm. Both SDS-PAGE and platelet aggregation analysis of the sterilized collagen indicated no major differences between EtO and H2O2 sterilization, although gamma-irradiated collagen showed degradation products. Both 3% and 4% (w/v) collagen suspensions were acceptable with respect to the force used (<50 N). The 4% suspension was selected as the preferred injectable collagen, which formed a dense network under physiologic conditions. Testing the collagen in vivo (n=5), the angiograms revealed that the PSA partly or completely coagulated. Histology confirmed the network formation, which was surrounded by thrombus. CONCLUSIONS: Collagen injectables were prepared and EtO sterilized without major loss of structural integrity and platelet activity. In vivo, the injectable collagen formed a dense network and triggered (partial) local hemostasis. Although optimization is needed, an injectable collagen may be used as a therapeutic agent for femoral PSA treatment.

D-dimer testing in the diagnosis of transfemoral pseudoaneurysm after percutaneous transluminal procedures.

OBJECTIVE: Pseudoaneurysms are characterized by extravascular circulation and therefore may lead to an activation of the coagulation cascade. We investigated d-dimer levels in patients with and without postcatheterization femoral pseudoaneurysms and hypothesized that d-dimer levels correlate with the presence of pseudoaneurysms at the vascular access site. METHODS: Patients with clinical suspected groin pseudoaneurysms after transluminal procedures were eligible. We compared prospectively-collected laboratory values of quantitative d-dimer testing in patients with and without pseudoaneurysms as assessed by color-coded duplex sonography. Furthermore, we measured the peak systolic velocity at the arterial fistula of each pseudoaneurysm. RESULTS: In 48 (40%) of 120 consecutive patients, a pseudoaneurysm was found. The level of d-dimer values was significantly higher in patients with postcatheterization femoral pseudoaneurysms compared with controls (1.9 microg/mL [interquartile range (IQR), 1.34-2.78 microg/mL] vs 0.8 microg/mL [IQR, 0.53-1.14 microg/mL]; P < .001). Values of d-dimer below 0.67 microg/mL have been calculated with a sensitivity of 94% (87%-100%), a specificity of 38% (27%-50%), a positive predictive value of 50% (40%-60%), a negative predictive value of 90% (82%-99%), and a likelihood ratio of 1.52 (1.25-1.85) with regard to the presence of pseudoaneurysms. We also found a significant correlation of the peak systolic velocity at the arterial fistula and increasing d-dimer levels (r = 0.98, P < .0001). CONCLUSION: We found a significantly higher level of d-dimer values in patients with femoral pseudoaneurysms at the vascular access site. Therefore, d-dimer levels could be a potential serological marker in the diagnosis of pseudoaneurysms. A confirmation is warranted in a larger patient sample.

Sangramento espontâneo de artéria lombar em paciente com doença de Von Recklinghausen: tratamento endovascular / Spontaneous lumbar artery bleeding in patient with Von Recklinghausen’s disease: endovascular treatment

Os sangramentos no retroperitônio são, em sua grande maioria, secundários a eventos traumáticos envolvendo grande energia cinética, com poucos relatos na literatura caracterizados como espontâneos. No presente relato, descrevemos paciente gestante, portadora de doença de Von Recklinghausen e com volumoso hematoma retroperitoneal diagnosticado durante o parto cesariano, secundário a ruptura espontânea de artéria lombar. A doença de Von Recklinghausen apresenta manifestações vasculares bem descritas, caracterizando-se principalmente por estenoses que são secundárias a tumores intramurais (proliferação das células de Schwann) e raramente dilatações aneurismáticas, assintomáticas em sua maioria. No presente caso, foi realizada a aortografia com cateterização seletiva e embolização da artéria sangrante com sucesso.

Retroperitoneal bleeding is mainly due to traumatic events with a high amount of kinetic energy, with few reported cases of spontaneous events in the literature. We report on a case of a pregnant woman with Von Recklinghausen"s disease and bulky retroperitoneal hematoma diagnosed during cesarean delivery secondary to spontaneous lumbar artery rupture. Von Recklinghausen"s disease has well-described vascular manifestations, mainly characterized by stenoses related to intramural tumors (Schwann cell proliferation) and rarely asymptomatic aneurysmal dilatations. In this case, aortography was performed with successful selective catheterization and embolization of the bleeding artery.

Late massive uterine hemorrhage caused by ruptured uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy.

Diagnosis and management of ruptured uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy is described.

Effects of superselective embolization for renal vascular injuries on renal parenchyma and function.

AIM: Our objective was to evaluate the outcome of superselective embolization used for treatment of renal vascular injuries on renal parenchyma and renal function. MATERIALS AND METHODS: Between January 1999 and December 2001, 6 consecutive patients (five males, one female, mean age 45 years) underwent embolization to treat bleeding from renal vascular injuries, resulting from iatrogenic interventions (4) and blunt abdominal trauma (2). Five patients had increased serum creatinine. Angiography depicted a pseudoaneurysm (PA) in three, PA with arteriovenous fistula (AVF) in one, and active extravasation in two patients. Superselective catheterization was achieved using a 5-F catheter in three, and coaxial microcatheter in the remaining three cases. All lesions were successfully embolized with 0.035" or 0.018" coils. RESULTS: Bleeding was ceased in all patients and did not recur. Mean post-embolization parenchymal ischemic area was 11.7% (range: 0-30%). Imaging follow-up (mean: 12 months, range: 5-23) showed that mean parenchymal infarcted area was 6% (range: 0-15%). Serum creatinine level was normal in all patients one week after the procedure and at the latest follow-up. CONCLUSION: Superselective embolization resulted in permanent cessation of bleeding. Serious parenchymal infarction was prevented and serum creatinine level returned to the pre-bleeding values. Embolization should be considered as the treatment of choice in this patient population.

Vascular complications of transsphenoidal surgery.

Vascular complication of transsphenoidal surgery can lead to mortality and serious morbidity. In a series of 3,061 transsphenoidal operations for pituitary disease, 24 such complications were encountered, seven of which were fatal. The anatomic substrate for such complications is discussed, along with technical aspects of surgery and other methods for the avoidance of vascular complications.