Endovascular Rescue for Renal Artery Pseudoaneurysms following Minimally Invasive Robot-Assisted Partial Nephrectomy—A Case Series

Nephron sparing surgery or partial nephrectomy has been employed ever since in cases of renal tumors with an aim to preserve the function of residual kidney. Lately, there has been increasing adoption in robot-assisted techniques for partial nephrectomy. However, renal surgeries of any kind have always been a hazard for postoperative vascular complications owing to high vascularity of the renal tissues, of which renal artery pseudoaneurysm is one of the most fatal complications. We present a case series where highly super-selective embolization rescues the patient and augments the nephron sparing nature of the precise robot-assisted partial nephrectomy.

Endovascular Embolization of Posttraumatic High-Flow Priapism: Uncommon Arteriovenous Fistula of the Corpus Cavernosum

Background priapism is a persistent penile erection lasting more than four hours without sexual arousal or stimulation. Non-ischemic high-flow priapism is an uncommon finding. Case presentation: we report on a high-flow priapism, an uncommon arteriovenous fistula of the corpus cavernosum after a straddle trauma which was successfully treated by super selective trans-arterial embolization using a temporary embolic agent. At follow up no recurrent episodes of priapism occurred without symptoms of erectile dysfunction or other complications. Conclusion Super selective embolization has a high rate of technical success with preservation of erectile function in this case without complications.

The impact of trans-arterial embolization on the result of chemoradiotherapy in oral cavity cancer

Objectives: Evaluation of the hemostatic effect of trans-arterial embolization on patients with advanced oral cavity cancer who had bleeding complications while undergoing definitive concurrent chemoradiotherapy (CCRT). Additionally, assess the effect of trans-arterial embolization on treatment response following concurrent chemoradiotherapy, as well as overall survival (OS) and progression-free survival (PFS) in the group of patients following the intervention. Method: From September 2018–June 2021, a retrospective descriptive study was conducted on 16 patients with inoperable, locally advanced oral cavity cancer who received definitive concurrent chemoradiotherapy, experienced acute bleeding complications, and received selective intravascular intervention with various embolization materials at Vietnam National Cancer Hospital. Results: After selective embolization, 16/16 patients ceased bleeding; 1 patient re-bled for the second time after 3 weeks. The average duration of chemoradiotherapy interruption due to intervention was 6.7 days. After CCRT, 15/16 (93.75%) patients achieved a response, with 9/16 (56.25%) patients achieving a complete response. The median OS was 14 months (range, 3–26 months), and the median PFS was 10 months (range, 3–20 months). There were no significant complications, particularly neurological side effects. ConclusionsTumor bleeding is a common and serious complication of CCRT treatment in patients with locally advanced oral cavity cancer. Embolization is a safe and effective method of controlling acute bleeding that has no adverse effect on the outcome of definitive concurrent chemoradiotherapy.

Arteriovenous Malformation of the Uterus: A Review and Update.

Arteriovenous malformation of the uterus (AVMU) is a very rare and uncommon condition, because it has been documented that less than 100 cases of AVMU have been reported in the literature. AVMU is potentially a life-threatening condition with regard to the fact that some cases of AVMU could manifest with profuse bleeding from the uterus via the vagina. AVMU could either be congenital AVMU which is less common or acquired AVMU with pregnancy noted to have a role to play in the pathogenesis of AVMUs. The true incidence of AVMU is stated to be difficult to ascertain in view of the fact that some cases of bleeding that have been caused by AVMU do tend to conservative, medical management and many of these AVMUs could remain undiagnosed. The most common manifestations of AVMUs tend to be abnormal uterine bleeding that could be episodic, intermittent, continuous, mild or torrential which could lead to severe anaemia or shock. Some AVMUs could be found incidentally based upon radiology imaging for a different condition. Other symptoms of AVMUs do include: Metrorrhagia; Menorrhagia; Bleeding following a miscarriage; Bleeding following dilatation and curettage; Bleeding subsequently after hysterectomy; Bleeding associated with trophoblastic disease; Bleeding following caesarean section; Post-partum haemorrhage; Intermittent vaginal bleeding; Continuous vaginal bleeding; Post-menopausal bleeding; Acute abdominal pain with hemoperitoneum; Pallor; Dizziness; Weakness; Drowsiness; Being unwell following delivery of a baby; Bleeding following therapeutic abortion; Tachycardia; Supra-pubic pain at times; hypotension. Diagnosis of AVMU tends to be made based upon radiology imaging with utilization of ultrasound scan / Doppler scan of the uterus and pelvis, Contrast Computed Tomography scan, and Contrast Magnetic Resonance Imaging Scan, as well as by selective angiography which tends to be ensued by treatment with embolization of the feeding vessels to the AVMU. The treatment of AVMUs these days has ranged between conservative and medical management that includes hormones for small AVMUs, Hysterectomy, which tends to be a definitive treatment that removes the AVMU but does leave the individual not being able to maintain her future fertility, as well as selective angiography and super-selective embolization of the uterine arterial branches feeding the AVMU, which does tend to maintain the future fertility of the patients and which has the advantage of being undertaken under local anaesthesia. Questions that should be on the minds of clinicians include should doppler ultrasound scan of the uterus be undertaken with regard to all women who develop persistent vaginal bleeding pursuant to or during management of miscarriage, considering that there are very few interventional radiologists in many hospitals. This means that selective angiography plus super-selective embolization cannot be undertaken in district hospitals should all women who have suspected AVMU that have severe bleeding that may require surgical operation be referred to a tertiary hospital so that they could possibly benefit from the undertaking of selective angiography and embolization of their AVMUs instead of hysterectomy to enable them to maintain their future fertility? It is also important for clinicians to be made aware of the existence of AVMUs so that they could appreciate the risk factors as well as the clinical manifestations who should be suspected of possibly having AVMUs. Clinicians also need to learn about various conservative and expectant methods of treating AVMUs including hormonal treatment. Clinicians also need to appreciate the future implications for future fertility of women who have AVMUs. Possible treatment options that have not been utilized for the treatment of AVMUs include: (a) Radiology image-guided cryotherapy of AVMU, (b) Radiology image-guided radiofrequency ablation of AVMU, and (c) Radiology Image-guided Irreversible electroporation of AVMU. There is a global need for the training of more interventional radiologists all over the world including in the developing countries as well as some of the developed countries to that they can undertake embolization of AVMUs as well as they can provide various interventional radiology treatment options for various other conditions.

Types of the prostate blood supply during super-selective embolization of prostatic arteries

Introduction. Pelvic arteries have various anatomy and anastomoses with other branches of the internal iliac artery (IIA). This explains the technical complexity of identification and catheterization of prostatic arteries (PA), as well as the possibility of complications associated with non-target embolization of prostatic artery anastomoses.Purpose of the study. To analyze the most common variants of prostate blood supply and evaluate the effectiveness of methods for identifying prostatic arteries.Materials and methods. The study included 168 patients treated from 2013 to 2021. For catheterization of the prostatic arteries, 4 – 5 Fr microconductors and 2 – 2.8 Fr microcatheters were used. For embolization, hydrogel microspheres with a diameter of 100 – 300 µm and 300 – 500 µm were used, as well as PVA microparticles with a diameter of 100 – 500 µm. Preoperatively multi-sliced computed tomography (MSCT) angiography of the pelvic organs was performed to determine the type of prostatic angioarchitectonics.Results. The use of preoperative MSCT angiography in combination with intraoperative digital subtraction angiography made it possible to determine the variations of prostatic artery divergence and identify their anastomoses in 100% of patients (336 pelvic sides). One prostatic artery was detected in 91.4% (307) of the pelvic sides. two independent pAs in 8.6% (29) of cases. Symmetrical anatomy of the prostatic arteries on both sides was revealed in 14.3% (24) patients, the remaining 85.7% (144) patients showed asymmetry on both sides. The absence of prostatic arteries anastomoses was detected in 75.5% (254) of the pelvic sides, and in 24.4% (82) of the pelvic sides, anastomoses were detected. Interlobar intraprostatic anastomoses were found in 10.1% (34) of the pelvic sides, communication with a. dorsalis penis was detected in 8% (27) of cases, with rectal arteries in 5.3% (18) of the pelvic sides and with urinary bladder arteries in 3.6% (12) of cases. Based on the analysis of the small pelvis angioarchitectonics in 168 patients, an anatomical classification of the prostatic arteries anatomy was proposed.Conclusion. Super-selective embolization of the prostatic arteries is a contemporary minimally invasive method of prostatic hyperplasia treatment with a high safety profile. The pelvic arteries have extremely various anatomy, as well as anastomoses with other branches of the internal iliac artery, which complicates the implementation of super-selective embolization of prostatic arteries. The combination of preoperative MSCT and intraoperative digital subtraction angiography makes it possible to identify the prostatic artery and its anastomoses in most cases.

284 Wunderlich Syndrome - Case Report of a Surgical Emergency Due to Spontaneous Non-Traumatic Retroperitoneal Haemorrhage

A 42-year-old female with no other significant co-morbidities presented with complaints of sudden onset abdominal pain, she was in state of shock- her haemoglobin dropped drastically to 6.8g/dl from 11.8g/dl. She was resuscitated and was given blood transfusion. CT Scan was suggestive of retroperitoneal haemorrhage due to rupture of Renal angiomyolipoma (RAML). Patient underwent selective embolization of renal artery the next day and was discharged after 3 days of post-operative stay. Wunderlich Syndrome-is a rare condition in which spontaneous nontraumatic renal haemorrhage occurs into the subcapsular and perirenal spaces is most commonly caused due to spontaneous rupture of RAML.It is characterized by Lenk’s triad – Acute flank pain, flank mass, hypovolemic shock. Size of AML (>4 cm), prothrombotic states such as pregnancy are main causes of AML rupture. Patients are managed conservatively or with help of selective arterial embolization. Nephrectomy is last resort in a hemodynamically unstable patient or in cases of embolization failure. When dealing with acute abdomen with haemodynamic instability in non-traumatic cases it is essential to consider possibility of Wunderlich Syndrome. Early diagnosis, availability of Interventional radiology is key to successful management and potentially avoiding a Nephrectomy.

CMV enteritis as unusual source of bleeding to GIT

Introduction: Cytomegalovirus disease affecting the gastrointestinal tract is a rare but severe disease presenting particularly in people under immunosuppression, solid organ transplant recipients and AIDS patients with CD4 count under 100/mm3. When colon or small intestine are affected, the disease may be complicated by severe bleeding. CMV therapy includes antivirals and, in case of bleeding, methods of therapeutic endoscopy or interventional radiology. Case description: We present a case of a 74-year-old woman 3 years after kidney transplantation owing to vascular nephrosclerosis, treated with belatacept, mycophenolate mophetile and prednisone. She was admitted to hospital for acute dyspnoea. During hospitalisation, she presented with intestinal bleeding, but the endoscopic intervention at the first colonoscopy was not successful. She was referred to the Department of Hepatogastroenterology of the Institute of Clinical and Experimental Medicine and subsequent colonoscopy revealed a 15 cm long part of ileum with ulcerations as the source of bleeding. The histological assessment described a severe CMV enteritis. The CMV DNA blood level established by PCR was higher than 10 000 000 U/ml. The patient was treated with intravenous ganciclovir and she underwent selective embolization of the inferior mesenteric artery with an excellent clinical effect. Conclusions: CMV enteritis may be associated with a high mortality. The approach to therapy is multidisciplinary and needs collaboration of gastroenterologist, endoscopist and interventional radiologist. Key words: CMV – GIT bleeding – immunosuppression – transplantation

Endovascular interventions in management of renal artery aneurysm

Renal artery aneurysm is a rare disease. With modern non-invasive imaging modalities, the disease is being increasingly diagnosed. It is a slow-growing aneurysm with high mortality in the event of rupture; especially in pregnant females and patients with multiple comorbidities. Traditionally, aneurysms located in the main renal artery had been successfully treated with endoprosthesis but technical limitations existed in more distal locations where patients were treated surgically. With advances in endovascular therapy, numerous techniques have been employed to manage complex RAA in artery bifurcation, branch and segmental arteries with excellent technical and clinical success. The various recent techniques include the use of flow diverter stents, remodelling with stent-assisted coil embolization[SACE], balloon-assisted coil embolization[BACE], selective embolization with coils-sac packing, inflow occlusion and coil trapping and selective embolization with liquid embolic agents-Hystroacril and Onyx. A combination of stent-graft with liquid embolization and liquid with microcoil embolization have been advocated with success. The most common complication encountered is renal infarction. This is mostly without impairment of renal function and secondary to embolization. Endovascular therapy has shorter operative time, less blood loss, shorter intensive care stay, done under conscious sedation and is associated with lesser postoperative morbidity compared to surgery. Reduction in hypertension, improvement of renal function and symptoms has been seen in most studies. Endovascular management of RAA has become the management of choice even with complex anatomy and technically challenging lesions.

Spontaneous perirenal hemorrhage in systemic lupus erythematosus: a rare case report and literature review

Background Spontaneous perirenal hemorrhage is relatively uncommon but may be life-threatening. There are some challenges in early diagnosis due to the lack of specific presentations. Case presentation We report a case of spontaneous perirenal hemorrhage in a newly diagnosed systemic lupus erythematosus patient who initially presented with non-specific flank pain. Weakness and unstable vital signs were noted on admission. Abdominal ultrasonography and computed tomography revealed a sizable perirenal hematoma over the left retroperitoneal cavity. Renal arteriography identified active extravasation of contrast media from a distant branch of the left renal artery, and selective embolization effectively obliterated the bleeding spot. After cessation of bleeding, the patient received intensive immunosuppressive therapy for acute kidney injury and encephalopathy due to lupus. Her mental status recovered successfully, and she was withdrawn from short-term hemodialysis. Conclusions Spontaneous perirenal hemorrhage in the condition of systemic lupus erythematosus was a rare clinical entity with life-threatening potential. Early accurate diagnosis of spontaneous renal hemorrhage requires both detailed clinical examination and radiologic studies. Interventional embolization is essential and effective for both diagnosis and treatment. A high index of suspicion is necessary to avoid missing this potentially fatal syndrome, especially in patients with an increased risk of bleeding.