Iatrogenic Renal Artery Injury in 90 Cases: Arteriographic Findings and Outcomes after Embolization for Bleeding

PurposeTo evaluate differences in arteriographic findings and outcomes after embolization among patients with a suspected iatrogenic renal arterial injury (IRAI).Materials and MethodsPatients at the authors’ institution who underwent renal arteriography for suspected IRAIs after partial nephrectomy, biopsy, or percutaneous access over a 20-year period were included. Records, imaging, and outcomes were reviewed. Data analysis was performed using the Fisher exact or Kruskal-Wallis test.ResultsNinety arteriograms were performed on 83 patients after partial nephrectomy (n = 32), biopsy (n = 27), or percutaneous access (n = 24), including for nephrostomy/ureterostomy and stone removal. The median number of days between the index procedure and arteriogram was highest (15 days) after partial nephrectomy and lowest (5 days) after biopsy (P = .0001). Embolization was performed during 76% of arteriograms. If prearteriographic imaging showed positive results for IRAIs, embolization was performed in 67% versus 33% if imaging showed negative results (P = .005). The transfusion rate was higher after biopsy than after partial nephrectomy or percutaneous access (P = .002). Acute kidney injury after arteriogram occurred in 7% of patients; however, all returned to baseline by 1 week.ConclusionsDespite the different mechanism of IRAIs in partial nephrectomy, biopsy, and percutaneous access, arteriographic findings and outcomes were overall similar among groups. Prearteriographic imaging can help identify IRAIs but cannot supersede the clinical judgment regarding indication for embolization. IRAIs can present acutely or after a long interim, although patients who underwent biopsy presented earlier and more frequently required a blood transfusion. IRAIs can be treated with embolization without permanent deleterious effects on renal function.     

Endovascular repair using parallel grafts to treat a suprarenal pancreatitis-related abdominal aortic pseudoaneurysm

Arterial pseudoaneurysms represent an uncommon complication of acute pancreatic inflammation or chronic pancreatitis. We describe a contained rupture of a suprarenal abdominal aortic pseudoaneurysm. An aorto-uni-iliac stent-graft was adopted as the aortic main body and was combined with two chimneys and two periscope stents for celiac/superior mesenteric artery and renal arteries, respectively. The procedure was complicated by the entrapment of the celiac sheath into the barbs of the aortic stent-graft and the attempts to remove the sheath resulted in an upward migration of the stent-grafts. A bail-out endovascular procedure was used to reline the stent-grafts and the pseudoaneurysmal sac was embolized with coils.     

A rare complication of double prosthetic valve endocarditis; reconstructive surgical treatment of mitral-aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula

Mitral aortic intervalvular fibrosa or aorto-mitral curtain is a fibrous avascular skeletal structure located between the anterior leaflet of the mitral valve and the non-coronary and left coronary cusps of the aortic valve. Mitral and aortic valve endocarditis are rarely accompanied by mitral aortic intervalvular fibrosa pseudoaneurysm and left atrial fistula of the aorta. Pseudoaneurysm of mitral aortic intervalvular fibrosa is a fatal complication that can occur after valvular surgery, valvular endocarditis, or blunt trauma. In this article, reconstructive surgical management with the Commando technique of a case who developed mitral-aortic intervalvular fibrosa pseudoaneurysm to left atrial fistula after aortic and mitral prosthetic valve endocarditis is described. The important feature of this article is that it is a first in the literature as it is accompanied by persistent left superior vena cava.     

Trans‐cervical carotid artery stenting associated with open surgical repair of carotid artery pseudoaneurysm

Pseudoaneurysm post carotid artery endarterectomy is uncommon but with employment of a combined technique of trans‐cervical carotid artery stenting with open repair can lead to a successful outcome.     

Novel repair of acute Stanford type B aortic dissection using combined endovascular graft and transfemoral replacement of vascular plug

We present successful treatment of dissected thoracoabdominal aorta using combined thoracic endovascular aortic repair and transfemoral replacement of Amplatzer™ vascular plug in a 38-year-old patient. Computed tomography angiography revealed a false lumen from the left subclavian artery to the left common iliac trunk, with re-entries connecting it to the true lumen of the aorta. We replaced the prosthetic endovascular graft just below the left subclavian artery to the top of the superior mesenteric artery. Amplatzer™ vascular plug was replaced below the diaphragm in a closed transfemoral procedure to prevent re-entry. The patient was discharged in good condition and 2 years postoperation imaging showed complete pseudoaneurysm closure.     

Diagnosis and management of postpancreatectomy hemorrhage: A single-center experience of consecutive 1,096 pancreatoduodenectomies

Background/objectivesThis study aimed to assess the outcomes and characteristics of post-pancreatectomy hemorrhage (PPH) in over 1000 patients who underwent pancreatoduodenectomy (PD) at a high-volume hepatopancreaticobiliary center.MethodsThis retrospective study analyzed consecutive patients who underwent PD from 2010 through 2021. PPH was diagnosed and managed using our algorithm based on timing of onset and location of hemorrhage.ResultsOf 1096 patients who underwent PD, 33 patients (3.0%) had PPH; incidence of in-hospital and 90-day mortality relevant to PPH were one patient (3.0%) and zero patients, respectively. Early (≤24 h after surgery) and late (>24 h) PPH affected 9 patients and 24 patients, respectively; 16 patients experienced late-extraluminal PPH. The incidence of postoperative pancreatic fistula (p < 0.001), abdominal infection (p < 0.001), highest values of drain fluid amylase (DFA) within 3 days, and highest value of C-reactive protein (CRP) within 3 days after surgery (DFA: p < 0.001) (CRP: p = 0.010) were significantly higher in the late-extraluminal-PPH group. The highest values of DFA≥10000U/l (p = 0.022), CRP≥15 mg/dl (p < 0.001), and incidence of abdominal infection (p = 0.004) were identified as independent risk factors for PPH in the multivariate analysis. Although the hospital stay was significantly longer in the late-extraluminal-PPH group (p < 0.001), discharge to patient's home (p = 0.751) and readmission rate within 30-day (p = 0.765) and 90-day (p = 0.062) did not differ between groups.ConclusionsStandardized management of PPH according to the onset and source of hemorrhage minimizes the incidence of serious deterioration and mortality. High-risk patients with PPH can be predicted based on the DFA values, CRP levels, and incidence of abdominal infections.