Multiple variation of right renal and gonadal vascularization: report of two cases / Variação múltipla da vascularização renal e gonadal direita: relato de dois casos

Abstract We present two cases of multiple anatomical variations of the renal and gonadal vessels. The first case presented duplication of the renal vein and the presence of an accessory renal artery. However, the most interesting fact, in this case, was that the right gonadal vein emptied into the inferior right renal vein instead of ending in the inferior vena cava as would typically be the case. In the second case, we also found an accessory renal artery and the right gonadal vein emptied at the exact junction between the right renal vein and the inferior vena cava. Clinicians and surgeons should be familiar with anatomical variations to provide an accurate diagnosis during preoperative studies and to avoid surprises in abdominal surgical procedures.

Resumo Este estudo apresenta dois casos de variação anatômica múltipla de vasos renais e gonadais. O primeiro caso apresentou uma duplicação da veia renal e a presença de uma artéria renal acessória. Porém, o fato mais interessante nesse caso foi a veia gonadal direita desembocar na veia renal direita inferior em vez de terminar na veia cava inferior, como seria o normal. No segundo caso, além de também encontrarmos uma artéria renal acessória, a veia gonadal direita desembocava no exato ponto de junção entre a veia renal direita e a veia cava inferior. Clínicos e cirurgiões devem estar familiarizados com a presença de possíveis variações dos vasos renais e gonadais, sendo um conhecimento imprescindível para obter um diagnóstico mais preciso e para evitar surpresas em procedimentos cirúrgicos abdominais.

Caracterización de pacientes con tumores renales tratados con embolización transarterial / Characterization of patients with renal tumors treated with transarterial embolization

Introducción: La embolización de la arteria renal es un procedimiento endovascular mínimamente invasivo, de elección para pacientes con tumores renales que no permitan la terapéutica quirúrgica habitual. Objetivo: Caracterizar a los pacientes con tumores renales tratados con embolización transarterial según tipo de intervencionismo. Métodos: Se realizó un estudio observacional, descriptivo, transversal, con datos registrados de forma retrospectiva de 30 pacientes que recibieron procedimientos de embolización transarterial en el Servicio de Imagenología del Hospital Clínico Quirúrgico "Hermanos Ameijeiras" en el período 2019-2022. Se caracterizó la muestra según descripción de las variables de interés. Resultados: Se realizaron 31 procedimientos, pues un paciente (3,3 por ciento) tuvo afectación tumoral en ambos riñones; del resto, 9 (30 por ciento) en riñón derecho y 20 (66,7 por ciento) en el izquierdo. Se aplicaron 22 procedimientos (70,9 por ciento) de embolización transarterial prequirúrgica a igual número de pacientes (73,3 por ciento). La serie tuvo predominio masculino (63,6 por ciento), media de 54,2 años y el 45,4 por ciento de piel blanca. Los procedimientos de embolización paliativa fueron 9 (29 por ciento), en grupos de 8 pacientes (26,7 por ciento). Prevaleció en mujeres (77,8 por ciento), de piel mestiza (50 por ciento) y promedio de 74 años. El 85,7 por ciento tenía actividad metastásica. En ambos grupos hubo sangrado mínimo y tiempo quirúrgico óptimo, y no existieron complicaciones inmediatas. Conclusiones: Los pacientes embolizados, independientemente de la edad, el sexo, el color de la piel y el avance de la enfermedad, así como del tipo de indicación (prequirúrgica o paliativa), presentaron condiciones favorables durante el acto quirúrgico, que evitaron la presencia de complicaciones con éxito en los procedimientos intervencionistas(AU)

Hipertensión como elemento común de trasplante renal con riñón presor y del síndrome de encefalopatía posterior reversible / Hypertension as a common element of renal transplantation with pressor kidney and posterior reversible encephalopathy syndrome

La hipertensión arterial secundaria supone solo un 5-10% de los casos de hipertensión arterial, de ahí la importancia de su sospecha clínica para el diagnóstico. Una de las causas más frecuentes de hipertensión secundaria es la hipertensión renovascular, que se produce por hipoperfusión renal y activación del sistema renina-angiotensina-aldosterona. Además de que la hipertensión arterial supone uno de los factores de riesgo cardiovasculares más prevalente en la población, su mal control puede producir alteraciones neurológicas agudas como el síndrome de leucoencefalopatía posterior reversible (PRES), en el que es característico la aparición de alteraciones visuales. A continuación, exponemos el caso de un paciente trasplantado renal con hipertensión arterial con empeoramiento secundario a estenosis de la arteria renal y desarrollo de PRES. (AU)

Secondary arterial hypertension accounts for only 5-10% of cases of arterial hypertension, hence the importance of its clinical suspicion for diagnosis. One of the most common causes of secondary hypertension is renovascular hypertension, caused by renal hypoperfusion and activation of the renin-angiotensin-aldosterone system. In addition to arterial hypertension being one of the most prevalent cardiovascular risk factors in the population, its poor control can cause acute neurological disorders such as Posterior Reversible Leukoencephalopathy syndrome (PRES), being characteristic the appearance of visuals alterations. Next, we present the case of a kidney transplant patient with well-controlled arterial hypertension with worsening secondary to renal artery stenosis and development of PRES. (AU)

[Hypertension as a common element of renal transplantation with pressor kidney and posterior reversible encephalopathy syndrome]. / Hipertensión como elemento común de trasplante renal con riñón presor y del síndrome de encefalopatía posterior reversible.

Secondary arterial hypertension accounts for only 5-10% of cases of arterial hypertension, hence the importance of its clinical suspicion for diagnosis. One of the most common causes of secondary hypertension is renovascular hypertension, caused by renal hypoperfusion and activation of the renin-angiotensin-aldosterone system. In addition to arterial hypertension being one of the most prevalent cardiovascular risk factors in the population, its poor control can cause acute neurological disorders such as Posterior Reversible Leukoencephalopathy syndrome (PRES), being characteristic the appearance of visuals alterations. Next, we present the case of a kidney transplant patient with well-controlled arterial hypertension with worsening secondary to renal artery stenosis and development of PRES.

Clinically important left superior polar artery giving rise to a left inferior suprarenal artery and an aberrant left inferior polar artery: a case report / Artéria polar superior esquerda de importância clínica dando origem à artéria suprarrenal inferior esquerda e artéria polar inferior esquerda aberrante: relato de caso

Abstract The renal arteries arise from the lateral side of the abdominal aorta at the L2 vertebral level, just below the origin of the superior mesenteric artery. Multiple aberrant renal arteries can pose difficulties in renal transplantation, interventional radiological and urological procedures, renal artery embolization, angioplasty, or vascular reconstruction for congenital and acquired lesions. We present a case of a left kidney supplied by the left renal artery along with superior and inferior polar arteries, arising from the aorta and inferior mesenteric artery respectively. The inferior mesenteric artery was crossed by the left ureter and inferior mesenteric vein. The superior polar artery gave rise to an inferior suprarenal artery making the variation important for clinicians and surgeons.

Resumo As artérias renais originam-se do lado lateral da aorta abdominal, no nível da vértebra L2, logo abaixo da origem da artéria mesentérica superior. A presença de múltiplas artérias renais aberrantes pode representar dificuldades para transplante renal, procedimentos radiológicos e urológicos intervencionistas, embolização da artéria renal, angioplastia e reconstrução vascular para lesões congênitas e adquiridas. Apresentamos um caso de rim esquerdo vascularizado pela artéria renal esquerda e pelas artérias polares superior e inferior, as quais se originavam da aorta e da artéria mesentérica inferior, respectivamente. A artéria mesentérica inferior era cruzada pelo ureter esquerdo e pela veia mesentérica inferior. A artéria polar superior dava origem à artéria suprarrenal inferior, o que torna essa variação importante para clínicos e cirurgiões.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding.

BACKGROUND/AIMS: The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy. METHODS: In this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed. RESULTS: Before propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120). CONCLUSIONS: We do not recommend desmopressin administration before kidney biopsy.

Reparación de aneurisma complejo de arteria renal izquierda: nefrectomía laparoscópica, reconstrucción en banco y autotrasplante heterotópico / Repair of complex left renal artery aneurysm: laparoscopic nephrectomy, ex vivo reconstruction and heterotopic autotransplantation

Los aneurismas de la arteria renal son entidades clínicas poco frecuentes. Si bien la mayoría de casos son asintomáticos y se detectan incidentalmente, su rotura se asocia a elevadas tasas de mortalidad y de pérdida del riñón, lo que afecta a los supervivientes. Aunque la mayoría de estos aneurismas pueden tratarse mediante técnicas de reparación endovascular o in situ, esto puede no ser posible en pacientes con aneurismas complejos, como aquellos localizados en la bifurcación arterial. Presentamos el caso de un aneurisma renal complejo tratado satisfactoriamente mediante nefrectomía laparoscópica, reconstrucción vascular en banco y autotrasplante heterotópico.(AU)

renal artery aneurysms are rare clinical entities. While most cases are asymptomatic and detected incidentally, rupture is associated with high mortality rates and loss of the aff ected kidney in survivors. although most of these aneurysms can be treated by endovascular or in situ repair techniques, this may not be possible in patients with complex aneurysms, such as those located at the arterial bifurcation. We present a case of complex renal aneurysm successfully treated by laparoscopic nephrectomy, ex vivo vascular reconstruction, and heterotopic autotransplantation.(AU)

Embolización de la arteria renal: serie de casos y revisión de la literatura / Renal artery embolization: case series and literature review

Resumen Introducción: La embolización de arteria renal (EAR) es un procedimiento percutáneo que ocluye la arteria renal, con la consecuente isquemia del territorio vascular. Sus indicaciones más comunes son la hematuria y el manejo paliativo en cáncer renal metastásico. A pesar del desarrollo técnico y de la experiencia progresiva, los estudios incluyen un número reducido de pacientes y en nuestro país se revisan casos aislados. Objetivo: Describir la experiencia en el Servicio de Salud Valparaíso San Antonio y revisar la literatura existente. Materiales y Método: Realizamos un estudio descriptivo de los pacientes sometidos a EAR por anemia severa secundaria a hematuria, durante los años 2012 a 2020. Posteriormente, realizamos una revisión de la literatura en PubMed, hasta abril de 2020. Resultados: Incluimos 9 pacientes, 6 (66,7%) hombres y 3 (33,3%) mujeres. La mediana de edad fue de 69 años (RIC = 18). La principal causa de la hematuria fue cáncer renal avanzado (7 pacientes). No hubo complicaciones, y se logró éxito clínico en todos los pacientes. Nuestra búsqueda de literatura arrojó 571 referencias y 24 cumplieron con nuestros criterios de elegibilidad. La edad de los pacientes y las causas subyacentes de hematuria fueron variadas. La menor tasa de éxito clínico fue de 65%, sin embargo, 15 estudios (62,5%) reportaron un éxito igual o mayor al 90%. Seis estudios reportaron más de un 10% de pacientes con alguna complicación. Conclusión: Nuestros resultados y la evidencia revisada muestran que la EAR parece ser segura y eficaz en el manejo de anemia severa secundaria a hematuria.

Introduction: Renal artery embolization (RAE) is a percutaneous procedure that occludes the renal artery, with consequent ischemia of the vascular territory. The most common indications include hematuria and palliation for metastatic renal cancer. Despite technical development and progressive experience, studies include a small number of patients and few cases have been published in our country. Aim: To share our experience at Valparaíso-San Antonio Health Service and to review the existing literature. Materials and Method: We performed a retrospective descriptive review of medical records of patients with severe anemia due to hematuria managed with RAE, between 2012 and 2020. Subsequently, we conducted a literature search in PubMed, from inception until April 2020. Results: We included 9 patients. There were 6 (66.7%) males and 3 (33.3%) females with a median age of 69 years (IQR = 18). Main cause of hematuria was advanced kidney cancer (7 patients). There were no complications and clinical success was achieved in all patients. Our literature search yielded 571 references, 24 met our eligibility criteria. The age of patients and the underlying causes of hematuria were varied. The lowest clinical success rate was 65%, however, 15 studies (62.5%) reported a success equal to or greater than 90%. Six studies reported more than 10% of patients with complications. Conclusión: Our results and the studies reviewed show that RAE appears to be safe and effective in the management of patients with severe anemia due to hematuria.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding / Ausencia de efecto de la administración de desmopresina antes de una biopsia renal sobre el riesgo de hemorragia mayor tras la biopsia

Background/Aims: The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy.MethodsIn this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed.ResultsBefore propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120).ConclusionsWe do not recommend desmopressin administration before kidney biopsy. (AU)

Antecedentes/objetivos: La complicación más importante de la biopsia renal es la hemorragia y no está claro si la desmopresina es eficaz en su prevención. Por lo tanto, el estudio se realizó para comparar la hemorragia tras una biopsia renal percutánea con o sin prescripción de desmopresina previa a esta.MétodosEn este estudio unicéntrico, retrospectivo y observacional se seleccionaron 3.018 pacientes adultos que se sometieron a una biopsia renal entre el 1 de enero de 2003 y el 31 de marzo de 2019 en nuestro instituto. De ellos, 776 pacientes recibieron desmopresina. Para comparar las diferencias en los acontecimientos de hemorragia mayor entre los pacientes que recibieron desmopresina y los que no, se realizó un emparejamiento por puntuación de propensión.ResultadosAntes del emparejamiento por puntuación de propensión, se observó que los pacientes del grupo con desmopresina tenían una edad significativamente mayor (p<0,001) y presentaban una presión arterial más alta (p<0,001), una creatinina sérica más alta (p<0,001), niveles de hemoglobina más bajos (p<0,001) y recuentos de plaquetas más bajos (p=0,001) que los del grupo sin desmopresina. Además, la incidencia de embolización de la arteria renal no fue significativamente diferente entre los 2 grupos (p=0,077); sin embargo, las transfusiones de sangre se produjeron con una frecuencia significativamente mayor en el grupo con desmopresina (p<0,001). Una comparación de los 2 grupos tras el emparejamiento por puntuación de propensión no reveló diferencias en la incidencia de embolización de la arteria renal (p=0,341), la transfusión de sangre (p=0,579) y los acontecimientos de hemorragia mayor totales (p=0,442). Además, no se observaron diferencias en la incidencia de hematomas perinéfricos en la tomografía computarizada o la ecografía (p=0,120).ConclusionesNo se recomienda la administración de desmopresina antes de una biopsia renal. (AU)

Denervação de artéria renal em paciente com hipertensão arterial refratária / Renal denervation in patient with refrataryarterial hypertension

Caso clínico de uma paciente com quadro de hipertensão arterial refratária, sendo inicialmente atribuída como etiologia a displasia de artéria renal. Os níveis pressóricos mantiveram elevados após a angioplastia de artéria renal, mantendo descontrole pressórico apesar do uso de 10 classes de anti-hipertensivos. Foi indicada a denervação de artéria renal e após tal, foi possível redução das medicações e êxito no controle de seus níveis tensionais. Destaca-se a importância do adequado diagnóstico de hipertensão arterial refratária, a exclusão de hipertensão secundária, somado à otimização terapêutica e indicação de procedimentos quando necessário, tendo como objetivo o melhor controle pressórico e consequente redução de lesões de órgãos-alvo e eventos cardiovasculares graves (AU).

It will be explained the patient clinical case of with refractory hypertension, which was initially attributed to renal artery dysplasia, but after the renal artery angioplasty, remained with high blood pressure levels despite adequate anti-hypertensive drugs administration. Renal denervation was indicated and after medications was reduced, with adequate blood pressure level control. It emphasizes the importance of secondary hypertension diagnosis, therapeutic optimization and specific therapies, if necessary, with the aim to take blood pressure control and the consequent reduction of target-organ damage and severe vascular events (AU).

[Renal allograft transplant vascular complications. Diagnostic and treatment.] / Complicaciones vasculares del trasplante renal. Diagnóstico y tratamiento.

Vascular complications remain common after renal transplantation, occurring in 3% to 15% of patients. These complications can compromise graft function,with graft loss rates ranging from 12.6 to 66.7%.Vascular abnormalities of the graft, specifically the presence of multiple vessels, represent the most frequently studied risk factor for the development of vascular complications. Other risk factors identified for the development of vascular complications are linked to the characteristics of the recipient, or thromboembolic diseasesharing atherosclerosis and/or hypercoagulant state aspathogenic features.Although the most frequent vascular complication is renal artery stenosis, we will also address the complications according to their early or late on set in order to highlightthe potentially more severe complications that may affectgraft survival during the follow-up period.Early vascular complications include mainly arterial and venous thrombosis and lacerations or disruptions of artery and/or vein, as well as arterio-venous fistulas or intrarenal pseudoaneurysms. In contrast, late-onset complications include stenosis or kinking of the renal artery-and less commonly of the renal vein-, as well as extrinsic compression as a consequence of the presence of perigraft fluid collections. Finally, extrarenal pseudoaneurysm is a potentially severe complication in the late post-transplant period.Finally, this article explores special transplant situations such as complications derived from the paediatric donor in adult recipients, transplantation in the paediatric recipient and emerging techniques like robotic renal transplantation.

Las complicaciones vasculares siguen siendo frecuentes después del trasplante renal, ocurriendo entre el 3% y el 15% de los pacientes. Estas complicaciones pueden comprometer la función del injerto,con unas tasas de pérdida del injerto que varían entreel 12,6 ­ 66,7%.Las anomalías vasculares del injerto, y concretamente la presencia de múltiples vasos, representan el factor de riesgo más frecuente y estudiado para el desarrollo de complicaciones vasculares. Otros factores de riesgo de complicaciones vasculares se han relacionado con las características del receptor, o la enfermedad tromboembólica, compartiendo como características patogénicas la aterosclerosis y/o el estado hipercoagulante. Aunque la complicación vascular más frecuente está constituida por la estenosis de la arteria renal, expondremos las complicaciones en función de su presentación clínica temprana o tardía en un intento de destacar para el lector las complicaciones potencialmente más severas y que en cada momento del tiempo pueden condicionar la supervivencia del injerto.Las complicaciones de presentación preferentemente perioperatoria incluyen fundamentalmente la trombosis arterial y venosa y las laceraciones o disrupciones de arteria y/o vena, así como las fístulas arterio-venosas opseudoaneurismas intrarrenales. Por el contrario, otras complicaciones tienen comúnmente una presentación clínica más tardía. En este grupo incluimos la estenosiso acodamiento de la arteria renal y excepcionalmente de la vena renal, así como la compresión extrínseca de los vasos del injerto como consecuencia de la presencia de colecciones peri-injerto. Finalmente, una complicación severa que puede manifestarse de forma tardía enla evolución del receptor, es el pseudoaneurisma extrarrenal. Finalmente, haremos brevemente referencia a situaciones especiales del trasplante como las complicaciones derivadas del donante pediátrico en receptores adultos,del trasplante en el receptor pediátrico y de técnicas emergentes como el trasplante renal robótico.

Utilidad de la embolización vascular prequirúrgica de tumores renales con trombo tumoral en la vena renal izquierda / Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

Introducción y objetivos: La embolización prequirúrgica de la arteria renal (EPAR) puede emplearse en grandes masas renales antes de la nefrectomía para simplificar el procedimiento y disminuir el sangrado intraoperatorio. Nuestro objetivo es determinar el papel de la EPAR sobre el sangrado intraoperatorio y las complicaciones postoperatorias en los tumores renales izquierdos con trombo tumoral limitado a la vena renal izquierda (nivel-0).Material y métodosAnálisis retrospectivo de 46 pacientes intervenidos de nefrectomía radical izquierda y trombectomía como tratamiento de un carcinoma de células renales asociado a trombo tumoral de nivel 0 durante el periodo 1990-2020. La EPAR se limitó a aquellos casos en los que el acceso quirúrgico a la arteria renal principal se encontraba a priori dificultado en el estudio de imagen prequirúrgico (n=9; 19,6%). El sangrado intraoperatorio se estimó en base a la tasa de transfusión perioperatoria, y las complicaciones postoperatorias se categorizaron según la clasificación de Clavien-Dindo. Para el contraste de variables se utilizó el test Chi-cuadrado. Se realizó un análisis multivariable para identificar los predictores de transfusión y complicaciones.ResultadosNo existieron diferencias significativas en la tasa de complicaciones global (11,1 vs. 32,4%; p=0,19), complicaciones graves (0 vs. 8,1%; p=0,51), o tasa de transfusión (11,1 vs. 19%; p=0,49) entre ambos grupos (EPAR vs. no-EPAR). En el análisis multivariable la EPAR no se comportó como un predictor de complicaciones (OR: 0,11; IC95% 0,01-2,86; p=0,18) ni de transfusión (OR: 0.46; IC95% 0,02-7,38; p=0,58). (AU)

Introduction and objectives: Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).Material and methodsRetrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n=9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.ResultsThere were no significant differences in the overall complication rate (11.1% vs. 32.4%, P=.19), major complication rate (0% vs.8.1%, P=.51), or transfusion rate (11.1% vs. 19%, P=.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR:0.11, 95%CI 0.01-2.86; P=.18) nor transfusion (OR:0.46, 95%CI 0.02-7.38;P=.58). (AU)

Síndrome de Pickering: insuficiencia cardiaca aguda con un actor inesperado / Pickering syndrome: acute heart failure with an unexpected actor

El síndrome de Pickering es una entidad clínica descrita en 1988 que consiste en la presentación de edemas agudos de pulmón «flash» recurrentes y de predominio nocturno e hipertensión arterial secundarios a estenosis bilateral de las arterias renales o unilateral en pacientes monorrenos. Describimos el caso de un varón de 74 años que tras el tratamiento percutáneo de exclusión de un aneurisma aórtico infrarrenal presentó síndrome de Pickering debido a obstrucción hemodinámica de la arteria renal izquierda por la endoprótesis aórtica; con evolución clínica satisfactoria después de la revascularización. (AU)

Pickering's syndrome is a clinical entity described in 1988 that consists of the presentation of recurrent and predominantly nocturnal acute flash pulmonary oedema and arterial hypertension secondary to bilateral renal artery stenosis or unilateral in single-kidney patients. We describe the case of a 74-year-old man who, after percutaneous exclusion treatment of an aortic infrarenal aneurysm, developed Pickering syndrome due to haemodynamic obstruction of the left renal artery because of the aortic endoprosthesis; with satisfactory clinical evolution after revascularization. (AU)

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus.

INTRODUCTION AND OBJECTIVES: Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0). MATERIAL AND METHODS: Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n = 9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications. RESULTS: There were no significant differences in the overall complication rate (11.1% vs. 32.4%, p = 0.19), major complication rate (0% vs. 8.1%, p = 0.51), or transfusion rate (11.1% vs. 19%, p = 0.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR: 0.11, 95%CI 0.01-2.86; p = 0.18) nor transfusion (OR: 0.46, 95%CI 0.02-7.38; p = 0.58). CONCLUSIONS: In our study on left RCC with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Implicaciones clínicas de la variante accesoria de arteria renal. Revisión sistemática de la literatura / Clinical implications of the accessory renal artery. A systematic literature review

Resumen Objetivo: Establecer las posibles implicaciones clínicas y quirúrgicas asociadas a la presencia de arterias renales accesorias y su relación con desenlaces relevantes para la salud como la hipertensión arterial sistémica resistente y el rechazo agudo de trasplantes renales. Material y métodos: Revisión sistemática de la literatura registrada en International Prospective Register of Systematic Reviews. Cuatro autores cegados realizaron su búsqueda de 2008 a 2018, según criterios de inclusión, términos y combinaciones prestablecidos, en cinco bases de datos y gestor de referencias bibliográficas Zotero, evaluación de calidad con la herramienta Study Quality Assessment Tools, del National Heart, Lung, and Blood Institute y cálculo de índice Kappa. Resultados: 32 estudios seleccionados, superaron el mínimo de puntuación en la evaluación de la calidad metodológica, revelando bajo riesgo de sesgo. El grado de acuerdo entre los revisores, fue de 0.81-1.0, interpretado como concordancia, casi perfecta. Las características de los estudios, según el año de publicación fue considerable para los años 2013 y 2009. La mayoría de los estudios fueron realizados en Estados Unidos, seguido de otros países. Como desenlaces se encontraron seis estudios para Hipertensión arterial sistémica y 26 para Trasplante renal. Conclusiones: La presencia de arterias renales accesorias es una de las posibles causas a valorar en pacientes hipertensos con refractariedad al tratamiento convencional. Por su parte, la incidencia de rechazo y pérdida de viabilidad post trasplante renal se aproxima al 20% en pacientes con arterias renales accesorias y se asocia con complicaciones urológicas o sistémicas.

Abstract Objective: To establish some of the possible surgical and clinical implications related to the presence of accessory renal arteries and their relationship with relevant health outcomes like resistant systemic hypertension and acute rejection of renal transplantation. Methods: Systematic review of the literature registered in the International prospective register of systematic reviews. Four blinded authors carried out their search from 2008 to 2018, according to the inclusion criteria, pre-established terms, and combinations, in five databases and the Zotero bibliographic reference manager, quality assessment with the Study Quality Assessment Tools, from the National Heart, Lung, and Blood Institute, and calculation of Kappa indices. Results: 32 selected studies exceeded the minimum score in the assessment of methodological quality, revealing a low risk of bias. The degree of agreement between the reviewers was 0.81-1.0, interpreted as almost perfect concordance. The characteristics of the studies, according to the year of publication, were considerable for the years 2013 and 2009. Most of the studies were carried out in the United States, followed by other countries. Based on the outcomes, the following studies were found, six for systemic arterial hypertension and 26 for kidney transplantation. Conclusions: The presence of accessory renal arteries is one of the possible causes when assessing hypertension patients with refractoriness to conventional treatment. For its part, incidence of acute rejection and post-transplantation loss of viability are near 20% in patients treated with accessory renal arteries; it is associated with urological and systemic complications.

[Pickering syndrome: acute heart failure with an unexpected actor]. / Síndrome de Pickering: insuficiencia cardiaca aguda con un actor inesperado.

Pickering's syndrome is a clinical entity described in 1988 that consists of the presentation of recurrent and predominantly nocturnal acute flash pulmonary oedema and arterial hypertension secondary to bilateral renal artery stenosis or unilateral in single-kidney patients. We describe the case of a 74-year-old man who, after percutaneous exclusion treatment of an aortic infrarenal aneurysm, developed Pickering syndrome due to haemodynamic obstruction of the left renal artery because of the aortic endoprosthesis; with satisfactory clinical evolution after revascularization.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus. / Utilidad de la embolización vascular prequirúrgica de tumores renales con trombo tumoral en la vena renal izquierda.

INTRODUCTION AND OBJECTIVES: Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0). MATERIAL AND METHODS: Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n=9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications. RESULTS: There were no significant differences in the overall complication rate (11.1% vs. 32.4%, P=.19), major complication rate (0% vs.8.1%, P=.51), or transfusion rate (11.1% vs. 19%, P=.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR:0.11, 95%CI 0.01-2.86; P=.18) nor transfusion (OR:0.46, 95%CI 0.02-7.38;P=.58). CONCLUSIONS: In our study on left renal cell carcinomas with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding.

BACKGROUND/AIMS: The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy. METHODS: In this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed. RESULTS: Before propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120). CONCLUSIONS: We do not recommend desmopressin administration before kidney biopsy.

Simultaneous endovascular revascularization of external iliac artery dissection and transplant renal artery stenosis in a recent renal allograft recipient / Revascularização endovascular simultânea de dissecção da artéria ilíaca externa e de estenose da artéria renal transplantada em receptor recente de aloenxerto renal

Abstract Various vascular complications following renal transplantation include renal artery and vein thrombosis, renal artery stenosis, pseudoaneurysm, and iliac artery dissection. Transplant renal artery stenosis (TRAS) is the most common, while iliac artery dissection is the rarest of these various vascular complications. We describe an elderly male, who had both external iliac artery dissection and TRAS at 2 months following renal transplantation. He underwent successful percutaneous endovascular intervention of both complications. The post-intervention course was uneventful, with improvement in graft renal functions and left lower limb perfusion.

Resumo As diversas complicações vasculares possíveis após um transplante renal incluem trombose da veia e artéria renais, estenose da artéria renal, pseudoaneurisma e dissecção da artéria ilíaca. Entre essas diversas complicações, a estenose da artéria renal transplantada é a mais comum, enquanto a dissecção da artéria ilíaca é a mais rara. Relatamos o caso de um homem idoso que desenvolveu tanto dissecção da artéria ilíaca quanto estenose da artéria renal transplantada 2 meses após transplante renal. As intervenções endovasculares percutâneas foram bem-sucedidas em ambas as complicações. O período pós-intervenção cursou sem complicações, com melhora na função renal do enxerto e na perfusão do membro inferior esquerdo.

Endovascular stenting with a drug-eluting stent of transplanted renal artery stenosis in a dual kidney transplanted patient / Tratamento endovascular com stent farmacológico em estenose de artéria renal transplantada de paciente com transplante renal duplo

Abstract Renal transplant remains the preferred therapy for end-stage renal disease (ESRD). Given the shortage of suitable donor kidneys, use of an expanded criteria donor (ECD) allows marginal kidneys to be transplanted; albeit at risk of increased graft failure due to lower nephron mass. To reduce the risk of graft failure, double kidney transplant (DKT) is advocated, with favorable outcomes. Transplant renal artery stenosis (TRAS) is one of the most common vascular complications following renal transplant. Unlike single kidney transplants, where TRAS usually presents with fluid overload, uncontrolled hypertension, and worsening kidney functions; it may be clinically silent in DKT patients since they have two functional transplanted kidneys. We hereby report a case of TRAS in a DKT patient who had 2 years of favorable clinical outcomes following successful endovascular stenting. He however recently died of COVID-19 associated pneumonitis.

Resumo O transplante renal continua sendo a terapia preferida para doenças renais em fase terminal. Dada a escassez de rins de doadores adequados, o doador com critérios expandidos permite que rins marginais sejam transplantados, embora haja um maior risco de falha do enxerto devido à diminuição da massa nefrótica. Para diminuir o risco de falha do enxerto, recomenda-se o transplante renal duplo (TRD), com resultados favoráveis. A estenose de artéria renal transplantada (EART) é uma das complicações vasculares mais comuns após o transplante renal. Ao contrário dos transplantes de rim simples, nos quais a EART geralmente se manifesta como sobrecarga de fluido, hipertensão descontrolada e piora das funções renais, ela pode ser clinicamente silenciosa em pacientes com TRD, pois eles têm dois rins funcionais transplantados. Relatamos aqui um caso de EART em um paciente com TRD que teve resultados clínicos favoráveis por dois anos após o sucesso do implante de stent endovascular. No entanto, ele morreu recentemente de pneumonite associada à covid-19.