Occult renal artery pseudoaneurysm causing persistent hematuria after flexible Thulium fibered laser lithotripsy: A case report and literature review of rare but potentially fatal complication.

Renal artery pseudoaneurysm may develop after laser flexible ureteroscopy stone lithotripsy (FURSL). Typical symptoms include flank pain, persistent hematuria, delayed refractory anemia, or hemorrhagic shock in case of pseudoaneurysm rupture. This complication of laser FURSL is very rare with only five cases reported in the literature as of April 2023, of which one involved Thulium laser. We report the case of a 65-year-old man with recurrent renal lithiasis who underwent FURSL using Thulium fibered laser (TFL) for 8 mm stone of left kidney upper pole. Persistent hematuria developed postoperatively, secondary to a pseudoaneurysm from a segmental branch of the left renal artery. It was diagnosed on arteriography performed for sudden hemorrhagic shock 27 days after surgery. Selective embolization with metallic micro-coils resolved hematuria. Although laser FURSL is often uncomplicated and TFL is regarded as safe, this complication should be suspected when refractory hematuria or hemodynamic instability follows the procedure. We report this case to add support to the current literature and outline procedural risk factors and useful precautions during the procedure.

Bioresorbable Magnesium-Based Stent: Real-World Clinical Experience and Feasibility of Follow-Up by Coronary Computed Tomography: A New Window to Look at New Scaffolds.

(1) Background: The diagnostic accuracy of coronary computed tomography angiography (CCTA) for coronary artery disease (CAD) has greatly improved so CCTA represents a transition in the care of patients suffering from CAD. Magnesium-based bioresorbable stents (Mg-BRS) secure acute percutaneous coronary intervention (PCI) results without leaving, in the long term, a metallic caging effect. The purpose of this real-world study was to assess clinical and CCTA medium- and long-term follow-up of all our patients with implanted Mg-BRS. (2) Methods: The patency of 52 Mg-BRS implanted in 44 patients with de novo lesions (24 of which had acute coronary syndrome (ACS)) was evaluated by CCTA and compared to quantitative coronary angiography (QCA) post-implantation. (3) Results: ten events including four deaths occurred during a median follow-up of 48 months. CCTA was interpretable and in-stent measurements were successful at follow-up without being hindered by the stent strut's "blooming effect". Minimal in-stent diameters on CCTA were found to be 1.03 ± 0.60 mm smaller than the expected diameter after post-dilation on implantation (p < 0.05), a difference not found in comparing CCTA and QCA. (4) Conclusions: CCTA follow-up of implanted Mg-BRS is fully interpretable and we confirm the long-term Mg-BRS safety profile.

Vertebral Artery Perforation as a Periprocedural Complication of Coronary Angiography.

Coronary angiography is a routinely performed intervention, with radial catheterization the recommended approach. We report a unique case of perforation of the right vertebral artery following coronary angiography that was successfully treated by endovascular management. (Level of Difficulty: Advanced.).

A case of splenic rupture a week after appendectomy.

A 52-year-old woman developed atraumatic splenic rupture 1 week after appendectomy for perforated appendicitis. The emergency computed tomography (CT) revealed abscessed appendicitis. We performed a laparoscopic appendectomy and meticulous peritoneal lavage of the right lower quadrant peritonitis. Intravenous antibiotics were prolonged after surgery. Six days after appendectomy, she presented acute signs of hypotensive shock associated with abdominal pain and blood in the pelvic drain. Emergency CT scan revealed splenic rupture with major hemoperitoneum and active splenic bleeding. Embolization of the splenic artery was initially successful, but she relapsed into shock a few hours later. We proceeded to splenectomy. Pathological examination only found inflammation. She was discharged 1 month after the initial operation. Spontaneous splenic rupture is a rare but life-threatening complication of appendicitis with major peritonitis. It must be identified and treated immediately. Colic microbiota could be responsible of acute splenitis and congestion after a bacteremia.

A Rare Vascular Cause of Hoarseness.

Teaching point: Hoarseness is a common condition that can be the initial symptom of cardiovascular disorder.

A rare vascular complication of Eagle syndrome highlight by CTA with neck flexion.

We report a case of a 53-year-old woman admitted to the emergency department with left hemiplegia, tinnitus and palpitations. A cerebral and cervical computed tomography angiography revealed an acute large ischemic stroke on the right Sylvian territory, which was related to a dissection of the right internal carotid. Moreover, a left internal carotid pseudo-aneurysm was observed. These two injuries were presumably imputable to a bilateral Eagle Syndrome. Indeed, the temporal styloid processes were measured at 31mm on both sides. To support our hypothesis of a stylocarotid impingement, a cervical CTA with hyperflexion (45°) of the neck was performed. It clearly revealed the bilateral impingement between the styloid processes and internal carotids. It seems important to know that Eagle syndrome may lead to disabling diseases or even death as well as an ischemic stroke. The vascular impingement with bilateral vascular injuries was never described. To our knowledge, our "neck flexion cervical CTA" to reveal the stylocarotid impingement has never been described before. This approach could lead to a new investigation technique, to better identify this underestimated pathology in the medical doctors community.

Uncontrolled bleeding of the gastrointestinal tract.

PURPOSE OF REVIEW: Acute gastrointestinal bleeding is a frequent emergency situation, whose incidence will likely rise as a result of the increasing use of direct anticoagulants and of the medical progresses resulting in longer life expectancy with underlying comorbidities. Updated guidelines and improvements in the diagnostic and therapeutic tools are now available and will likely improve the management of massive gastrointestinal bleeding in the near future. RECENT FINDINGS: The assessment of severity has been improved by validated scores useable upon admission. Massive blood transfusion protocols and specific care in case of bleeding of patients treated with direct anticoagulants, including concentrates of coagulation factors and monoclonal antibodies are now available. The endoscopic management has been facilitated by the use of hemostatic powders and by the use of self-expanding metal stents in case of variceal hemorrhage. New diagnostic tools include emergency video-capsule endoscopy, multiphasic computed tomography angiography and enterography. SUMMARY: The implementation of multidisciplinary diagnostic and therapeutic algorithms for the management of massive bleeding requires a close collaboration between emergency physicians, intensivists, endoscopists, radiologists and surgeons. A sequential strategy involving each of these specialists is desirable for a successful management of acute and massive gastrointestinal bleeding.

All-arthroscopic Weaver-Dunn-Chuinard procedure with double-button fixation for chronic acromioclavicular joint dislocation.

PURPOSE: We described a novel all-arthroscopic technique of coracoclavicular ligament reconstruction and reported the early clinical and radiologic results of this procedure. METHODS: We performed all-arthroscopic coracoclavicular ligament reconstruction in 10 consecutive patients (8 men and 2 women; mean age, 41 years) with a symptomatic chronic and complete acromioclavicular (AC) joint dislocation (Rockwood type III or IV). Four patients had undergone surgery previously: two had initial pinning of the acute AC joint separation, and two had a subsequent Mumford procedure. The surgical technique, performed entirely by arthroscopy, consisted of (1) rerouting the coracoacromial ligament with a bone block harvested from the tip of the acromion in a socket created in the distal clavicle (Chuinard's modification of the Weaver-Dunn procedure) and (2) augmenting the reconstruction with 2 titanium buttons connected by a heavy suture in a 4-strand configuration (Double-Button fixation; Smith & Nephew Endoscopy, Andover, MA). Patients were prospectively followed up for a mean of 12.8 months (range, 6 to 20 months). RESULTS: One patient had a superficial infection of the superior (clavicular) portal, which resolved with oral antibiotics. At the most recent review, all patients were satisfied or very satisfied with the cosmesis, and 9 of 10 returned to previous sports, including contact and overhead sports. All symptoms resolved (pain, shoulder weakness, paresthesia). The mean postoperative University of California, Los Angeles modified AC rating score was 16.5 points (range, 13 to 18 points) out of 20 points. The mean Subjective Shoulder Value improved from 36% (range, 0% to 70%) preoperatively to 82.5% (range, 70% to 100%) postoperatively (P = .005). The bone block was totally healed in the medullary canal in 8 cases and partially healed in 2. No loss of reduction was observed in any of the patients. CONCLUSIONS: Our study shows that severe chronic symptomatic AC joint separations, defined as Rockwood types III through V, can be repaired entirely by arthroscopy safely and effectively by transferring the coracoacromial ligament with a bone block in the distal clavicle. The bone block transfer (Weaver-Dunn-Chuinard procedure) has the advantage of making the repair easier and stronger, and it provides bone-to-bone healing by use of free, autologous vascularized tissue. Double-Button fixation has the advantage of maintaining the reduction during the biological healing process. Although the durability of the reconstruction remains unproven, in our short-term follow-up we observed no loss of reduction and the functional and cosmetic results were uniformly good. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Glenoid loosening after total shoulder arthroplasty: an in vitro CT-scan study.

Glenoid fixation failure has only been grossly characterized. This lack of information hinders attempts to improve fixation because of a lack of methodologies for detecting and monitoring fixation failure. Our goal was twofold: to collect detailed data of glenoid fixation fracture, and to investigate computed tomography (CT)-scanning as a tool for investigations of fixation failure. Six cadaver scapulas and six bone-substitute specimens were cyclically loaded and CT-scanned at clinical settings after 0, 1,000, 5,000, 10,000, 30,000, 50,000 and 70,000 load cycles. The fixation status was evaluated by inspection of the scans. After 70,000 cycles, the specimens were sectioned, and the fixation inspected by microscopy. The results of the microscopy analysis were compared to the CT-scan analysis. Fracture of the glenoid fixation initiated at the edge of the glenoid rim and propagated towards and around the keel of the implant. The entire process from initiation to complete fracture took place at the polyethylene implant-cement interface, while the cement, the adjacent bone, and the cement-bone interface remained intact. Thus, strengthening the polyethylene-cement interface should improve glenoid fixation. Microscopy results validated the CT methodology, suggesting that the CT technique is reliable.

Evaluation of the hip center in total hip arthroplasty for old developmental dysplasia.

We describe the problems with positioning the hip center according to the severity of dislocation in 97 cementless total hip arthroplasty for developmental dysplasia of the hip. The mean location of the hip center from the interteardrop was 30.4 +/- 8.7 mm horizontally and 23.4 +/- 5.4 mm vertically. The presence of a limp correlated with a superior placement of the cup. Four cups were revised, 2 of which with a significant high hip center. The survival rate of the acetabular component was 95% at 12 years. Craniopodal repositioning was easy in class 1. In class 2, the cup was the largest. In class 3, the greatest variations of the hip center were found. In class 4, the smallest implants were necessary for positioning in the true acetabulum.

Loss of rotator cuff tendon-to-bone interface pressure after reattachment using a suture anchor.

The purpose of this study was to examine the tendon-to-bone interface pressure, contact area, and force after reattaching a tendon to bone by use of a suture and suture anchor. Repairs were made in 8 ovine shoulders in vitro, by use of 3 suture types in each: Ethibond, polydioxanone, or Orthocord. A Tekscan pressure sensor was placed between the tendon and bone and monitored for 1 hour after the repair. The principal finding was a significant loss of approximately 60% of the contact parameters immediately after the suture was tied, followed by further significant loss over the next hour to a mean of only 14% of the initial readings. We concluded that pressure measurement systems that only record the initial maximum pressure would yield overly optimistic results for the actual repair pressure after the repair is completed. The Tekscan system, however, allowed us to monitor pressure reductions that occurred both during and after the repair.

Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?

BACKGROUND: Good functional results have been reported for arthroscopic repair of rotator cuff tears, but the rate of tendon-to-bone healing is still unknown. Our hypothesis was that arthroscopic repair of full-thickness supraspinatus tears achieves a rate of complete tendon healing equivalent to those reported in the literature with open or mini-open techniques. METHODS: Sixty-five consecutive shoulders with a chronic full-thickness supraspinatus tear were repaired arthroscopically in sixty-five patients with use of a tension-band suture technique. Patients ranged in age from twenty-nine to seventy-nine years. The average duration of follow-up was twenty-nine months. Fifty-one patients (fifty-one shoulders) had a computed tomographic arthrogram, and fourteen had a magnetic resonance imaging scan, performed between six months and three years after surgery. All patients were assessed with regard to function and the strength of the shoulder elevation. RESULTS: The rotator cuff was completely healed and watertight in forty-six (71%) of the sixty-five patients and was partially healed in three. Although the supraspinatus tendon did not heal to the tuberosity in sixteen shoulders, the size of the persistent defect was smaller than the initial tear in fifteen. Sixty-two of the sixty-five patients were satisfied with the result. The Constant score improved from an average (and standard deviation) of 51.6 +/- 10.6 points preoperatively to 83.8 +/- 10.3 points at the time of the last follow-up evaluation (p < 0.001), and the average University of California at Los Angeles score improved from 11.5 +/- 1.1 to 32.3 +/- 1.3 (p < 0.001). The average strength of the shoulder elevation was significantly better (p = 0.001) when the tendon had healed (7.3 +/- 2.9 kg) than when it had not (4.7 +/- 1.9 kg). Factors that were negatively associated with tendon healing were increasing age and associated delamination of the subscapularis or infraspinatus tendon. Only ten (43%) of twenty-three patients over the age of sixty-five years had completely healed tendons (p < 0.001). CONCLUSIONS: Arthroscopic repair of an isolated supraspinatus detachment commonly leads to complete tendon healing. The absence of healing of the repaired rotator cuff is associated with inferior strength. Patients over the age of sixty-five years (p = 0.001) and patients with associated delamination of the subscapularis and/or the infraspinatus (p = 0.02) have significantly lower rates of healing.