Arterial embolization during percutaneous vertebroplasty resulting in bilateral renal infarcts and ischemic colitis.

This case report documents an arterial embolic event that occurred during vertebroplasty for a pathological compression fracture of T12 in a 54-year-old female with known metastatic breast carcinoma. A CT angiogram performed after the procedure demonstrated cement migration into the aorta, both kidneys, and the inferior mesenteric artery and its branches, with ischemic colitis involving the descending colon and sigmoid colon. A CT scan 4 months post-procedure demonstrated resolution of the colitis. Neovascularity and cortical destruction in malignant bone lesions are thought to contribute to arterial cement leak.

Impact of intentional accessory renal artery coverage on renal outcomes after fenestrated-branched endovascular aortic repair.

OBJECTIVE: The objective of this study was to evaluate the impact of intentional coverage of accessory renal arteries (ARAs) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms. METHODS: We analyzed the clinical data of 296 patients enrolled in a prospective nonrandomized study to evaluate outcomes of FB-EVAR between 2013 and 2018. Patients with solitary kidneys, intraoperative loss of main renal arteries, or pre-existing stage V chronic kidney disease were excluded. Two groups were analyzed: patients with intentional ARA coverage; and controls, who had complete preservation. End points included 30-day mortality; major adverse events; acute kidney injury (AKI), defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease); renal function deterioration (RFD), defined by >30% decline in baseline estimated glomerular filtration rate; and presence of renal infarcts. RESULTS: There were 254 patients (184 male; mean age, 75 ± 8 years) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of whom 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs preservation (2.7 ± 0.9 mm vs 3.4 ± 0.2 mm; P < .001). There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. All ARAs intended to be incorporated were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs 25%; P < .001). There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (32% vs 19%; P = .04) because of higher incidence of AKI (21% vs 9%; P = .02). None of the 16 patients who had ARA preservation developed AKI. At 3 years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55% ± 9% vs 76% ± 5%; log-rank, P = .02). By multivariate analysis, predictors of AKI were ARA coverage (odds ratio, 2.8; 95% confidence interval [CI], 1.2-6.2; P = .01) and estimated blood loss >1 L (odds ratio, 3.8; 95% CI, 1.2-12.3; P = .03). Postoperative AKI (hazard ratio [HR], 4.4; 95% CI, 2.4-8.1; P < .001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; P = .002), aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.06; P < .001), and ARA coverage (HR, 2.0; 95% CI, 2.4-8.1; P = .02) were predictors of RFD. CONCLUSIONS: Intentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included postoperative AKI, renal reinterventions for stenosis, and ARA coverage. Incorporation of ARAs during FB-EVAR, when it is technically feasible, helps decrease risk of AKI and RFD.

Segmental Arterial Mediolysis in Pigs Presenting With Renal Infarcts.

Segmental arterial mediolysis, a rare arteriopathy first reported in humans, is described in the kidneys of 36 pigs slaughtered in an abattoir in Jutland, Denmark. The kidney changes presented themselves macroscopically as one or more cortical wedge-shaped hemorrhagic or pale lesions. The arterial lesions involved the interlobar and arcuate arteries and exhibited injurious and reparative phases of development. Two types of injurious lesions occurred: (1) a tearing separation of the outer media from the adventitia with fibrin, erythrocytes, and edema fluid filling the formed space, causing collapse of the arterial wall, and (2) outer and mid-medial foci showing irregularly bordered cytoplasmic vacuolar change containing membranous and organelle debris or smooth muscle shrinkage with nuclear loss. In the reparative phase, granulation tissue filled and expanded tear sites and zones of arterial medial muscle loss and extended into the adventitia and through the intima into the arterial lumen. Sequelae, including dissecting hematomas and arterial occlusions causing renal infarcts, were found. Although repartitioning agents widely used in animal husbandry in many countries may potentially cause segmental arterial mediolysis, no such link could be identified. The causation of segmental arterial mediolysis in these pigs is currently unknown but is being further investigated.

Establishing Background Pathologic Changes of Valve Replacement Surgery in Sheep.

PURPOSE: Sheep are the standard preclinical model for assessing safety of novel replacement heart valves, yet the anatomic and pathologic effects of invasive surgery, including those involving cardiopulmonary bypass (CPB), are unknown. Thus, we aimed to determine the gross, hematologic and biochemical effects of sham mitral and aortic replacement valve procedures in sheep to establish a useful control for evaluation of novel replacement valves. METHODS: Six control sheep were examined without any surgical intervention. Six sham mitral valve replacements (MVR) and six sham aortic valve replacements (AVR) were performed on 12 sheep. Complete blood counts and serum biochemistry were performed throughout the study. Sheep were sacrificed with a necropsy performed at 90 days. RESULTS: Renal infarcts (RIs) were the most frequently observed lesion, averaging 4.7 in control sheep, 2.5 with MVR and 5.8 with AVR. The number of infarcts strongly correlated with total estimated area of infarcted kidney (r = .84, p < .01). Additional cardiac interventions were significantly correlated with increased numbers of RIs (r = .85, p < .01). There was no correlation between number of RIs and time on CPB, or between AVR and MVR procedures. CONCLUSION: The sheep model for AVR and MVR requires invasive surgery and CPB, which are associated with background anatomic and pathologic changes, especially in cases with additional surgical cardiac interventions. These findings serve as a critical control for future evaluation and development of novel replacement valves in order to distinguish device-related safety issues from expected outcomes of the surgical procedure and normal background changes in sheep.

COVID-19 Induced Bilateral Lower Limb Ischemia and Visceral Infarcts.

Emerging cases of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) have been associated with a variety of disorders including respiratory failure, immune reactive syndrome, multiorgan failure, and hypercoagulable states. COVID-19 induces a severe global inflammatory response which can result in endothelial damage leading to hypercoagulability. Most COVID-19 cases of hypercoagulable states reported venous thrombosis. We report here a case of a 65-year-old Hispanic male diagnosed with bilateral acute lower limb ischemia and renal infarcts secondary to a severe COVID-19 infection.

Serratia marcescens Endocarditis.

Infective endocarditis (IE) secondary to Staphylococcus aureus and streptococcus species comprises the majority of cases in literature with Gram negative bacterial insults occurring infrequently. Serratia marcescens is a Gram negative bacillus which is classified as motile, non-lactose fermenting, and a facultative anerobe. The presumed risk factor for the development of S. marcescens IE is intravenous drug use (IVDU). We report two cases of IE causes by S. marcescens: first case describes IE of tricuspid and aortic valve requiring surgical intervention further complicated by epidural abscess. The second case was associated with renal and splenic infarct. These cases highlight the severity and complicated nature of S. marcescens IE. Given S. marcescens IE has been infrequently described in the literature, we believe that our cases are worth reporting to contribute to the present incidence and management of S. marcescens IE.

Case Report: Segmental Arterial Mediolysis, a Rare Cause of Hypertension.

RATIONALE: The differential diagnosis for hypertension with elevated plasma renin is broad. This case illustrates one of the rarer, and therefore underrecognized, causes of high renin hypertension. PRESENTING CONCERNS OF THE PATIENT: A 41-year-old man with a medical history significant for multiple ischemic strokes and dyslipidemia presented for assessment of decreased renal function and resistant hypertension. His initial workup for secondary causes of hypertension was remarkable for an elevated plasma renin and normal aldosterone. Further investigation with computed tomography (CT) angiography was performed, which demonstrated multiple bilateral renal aneurysms and infarcts. DIAGNOSES: After ruling out other potential causes of bilateral renal aneurysms and infarcts, a diagnosis of segmental arterial mediolysis (SAM) was made. INTERVENTIONS: Optimization of antihypertensive regimen, counseling regarding regular home blood pressure monitoring, and smoking cessation. OUTCOMES: The patient achieved excellent blood pressure control, stable renal function, and had no further strokes or other vascular events. TEACHING POINTS: Our case demonstrates the importance of considering SAM in the diagnosis of hypertension with elevated plasma renin and as a vasculitis mimic. It also highlights the importance of considering renal vascular imaging in the workup of resistant hypertension.

JUSTIFICATION: Le diagnostic différentiel de l'hypertension avec élévation des concentrations plasmatiques de rénine est vaste. Le cas présenté illustre une des causes les plus rares et les moins connues de cette forme d'hypertension. PRÉSENTATION DU CAS: Un patient de 41 ans dont les antécédents médicaux montraient des dyslipidémies et des accidents ischémiques cérébraux multiples s'est présenté pour une réduction de la fonction rénale et une hypertension résistante. Le premier bilan des causes secondaires de l'hypertension se distinguait par une concentration plasmatique élevée de rénine et une aldostérone normale. L'angiographie par tomodensitométrie a révélé de multiples anévrismes et infarctus rénaux bilatéraux. DIAGNOSTIC: Après avoir écarté les autres causes potentielles d'anévrismes et d'infarctus rénaux bilatéraux, un diagnostic de médiolyse artérielle segmentaire a été posé. INTERVENTIONS: Optimisation du traitement antihypertenseur, encadrement quant à la surveillance régulière de la pression artérielle à domicile et abandon du tabac. RÉSULTATS: Le patient a réussi à contrôler sa pression artérielle, sa fonction rénale s'est stabilisée et aucun autre événement vasculaire n'est survenu. LEÇONS TIRÉES: Ce cas souligne l'importance d'envisager la médiolyse artérielle segmentaire comme affection analogue de la vascularite, et d'en tenir compte dans le diagnostic de l'hypertension avec élévation de la concentration plasmatique de rénine. Ce cas insiste également sur l'importance de considérer l'imagerie vasculaire rénale dans l'étude de l'hypertension résistante.

Spontaneous isolated superior mesenteric artery dissection - Report of two cases.

Two cases of isolated superior mesenteric artery dissection diagnosed by contrast enhanced 64 slice CT are reported. In both, the dissection was seen extending along the entire length of the artery with one of them showing partially thrombosed false lumen. One case was associated with dissection of left renal artery with consequent renal infarcts. Although superior mesenteric artery dissection is a rare phenomenon, it should be considered in the differential diagnosis of abdominal angina.