Endovascular Embolization of Aneurysmal Renal Arteriovenous Malformation.

Renal arteriovenous malformations (AVM) represent an uncommon vascular condition characterized by an abnormal direct communication between an intrarenal artery and vein. Though asymptomatic in many individuals, treatment is often indicated if the AVM causes flank pain, hematuria, or medically refractory hypertension, or if there is an associated renal artery aneurysm. We present a case of a large right renal AVM with associated renal artery aneurysm and large varix which was incidentally found on magnetic resonance imaging of the spine. Endovascular and open surgical options were considered, including ex-vivo renal vascular reconstruction and nephrectomy. The patient was successfully treated with endovascular embolization of the AVM with coil packing of the arterial aneurysm and inflow artery. The patient recovered uneventfully with well-maintained renal function and blood pressure control. We review and discuss the literature on the etiology and treatment options for renal AVM.

Bow Hunter Phenomenon From Advanced Cerebrovascular Disease Treated With Subclavian Artery Stenting and Carotid Endarterectomy.

Bow Hunter syndrome (BHS) is a rare disorder characterized by mechanical occlusion of the vertebral artery (VA) during neck rotation, resulting in symptomatic, transient, and positional vertebrobasilar insufficiency. We describe a case of a 76-year-old female who presented with dizziness and right ear tinnitus triggered by right head rotation. Her symptoms would immediately resolve upon returning her head to the neutral position. CT angiogram showed 80% stenosis of the left subclavian artery origin, 50%-70% stenosis of the proximal right internal carotid artery (ICA), and near occlusive stenoses of the origins of the bilateral VAs. After failing conservative management, the patient was treated with left subclavian artery stenting, followed by a right carotid endarterectomy (CEA) 6 weeks later. Follow-up at 1 month showed resolution of paroxysmal symptoms and no neurological sequelae. To our knowledge, there have not yet been reported cases of patients with concurrent BHS, subclavian artery stenosis, and carotid artery stenosis. We suggest that global revascularization via subclavian artery stenting and CEA may be considered as treatment for patients with BHS complicated by other cerebrovascular disease secondary to stenoses of the ICA and subclavian artery. This approach obviates the need for more complex surgery or endovascular intervention of the VA.

Venous Stasis Ulceration due to Massive Splenomegaly Causing Iliac Vein Compression From Secondary Myelofibrosis.

Venous stasis ulcers are nonhealing lesions due to venous hypertension secondary to valvular dysfunction or deep venous outflow obstruction. We describe a case of a 71-year-old male with a history of polycythemia vera, secondary myelofibrosis, and massive splenomegaly up to 38 cm who presented with chronic, perimalleolar venous stasis ulcers and pain on the left lower extremity. CT showed significant compression of the left common iliac vein due to mass effect from the spleen. He was managed medically while being evaluated for partial splenic artery embolization but expired due to other chronic conditions before any intervention could be performed. Partial splenic artery embolization may be considered as a treatment option for patients with symptomatic iliac vein compression due to massive splenomegaly secondary to myelofibrosis, as long as extramedullary hematopoiesis is not compromised.

Readability of online patient education materials for shoulder instability surgery in English and Spanish.

BACKGROUND: Online patient education materials (OPEMs) exist to inform patient medical decisions, yet the average adult in the United States reads at an eighth-grade level and 50% of Medicaid patients read at or below a fifth-grade level. To appropriately meet US health literacy needs, the American Medical Association and National Institutes of Health recommend that patient education materials not exceed a sixth-grade level. The purpose of this study was to assess and compare the readability of English and Spanish online patient education materials pertaining to shoulder instability surgery. METHODS: Google searches of the terms "shoulder instability surgery" and "cirugía de inestabilidad de hombro'' were conducted to include 25 eligible online patient education materials OPEMs per language. English OPEM readability was calculated using Flesch-Kincaid Grade Level, Flesch Reading Ease, Flesch Reading Ease Grade Level, Gunning-Fog Index, Coleman-Liau Index, and Simple Measure of Gobbledygook. Spanish OPEM readability was assessed using Fernandez-Huerta Index (FHI) (the Spanish equivalent of Flesch Reading Ease), FHI Grade Level, Gutiérrez de Polini's Fórmula de comprensibilidad, and INFLESZ. RESULTS: Readability index analysis revealed that the mean Flesch Reading Ease of English online patient education materials was significantly lower than the mean FHI of Spanish online patient education materials. English materials were also found to be written at a significantly higher grade level than Spanish materials. CONCLUSIONS: Shoulder instability surgery online patient education materials in both English and Spanish are written at higher reading levels than recommended by the American Medical Association and National Institutes of Health, though Spanish online patient education materials were more readable on average.