Provocative mesenteric angiography for localizing ambiguous gastrointestinal hemorrhage

Objectives: Five percent of patients with recurrent gastrointestinal (GI) hemorrhage have indeterminate origin by radiological and endoscopic examinations. To improve diagnostic accuracy and therapeutic embolization, the technique of provocative mesenteric angiography (PMA) has been developed. It involves the addition of pharmacologic agents to standard angiographic protocols to induce bleeding. Material and Methods: This is an institutional review board-approved, retrospective study of 20 patients who underwent PMA between 2014 and 2019. All patients had clinical evidence of GI hemorrhage without a definite source. PMA consisted of anticoagulation with 5000 units of heparin and selective transcatheter injection of up to 600 μg of nitroglycerine, followed by slow infusion of up to 24 mg of tissue plasminogen activator into the arterial distribution of the highest suspicion mesenteric artery. Results: Among the 20 patients who underwent PMA, 11/20 (55%) resulted in angiographically visible extravasation. Of these 11 patients, nine patients underwent successful embolization with coil or glue and were discharged upon achieving hemodynamic stability. Two patients spontaneously stopped bleeding. In our series, PMA resulted in the successful treatment of 9/20 (45%) patients with recurrent hemorrhage. No procedure-associated complications were reported with these 20 patients during the procedure and their course of hospitalization. Conclusion: In our experience, PMA is an effective and safe approach in localizing and treating the source of GI bleeding in about half of patients with an otherwise unidentifiable source.

Differences of liver CT perfusion of blunt trauma treated with therapeutic embolization and observation management

Massive hepatic necrosis after therapeutic embolization has been reported. We employed a 320-detector CT scanner to compare liver perfusion differences between blunt liver trauma patients treated with embolization and observation. This prospective study with informed consent was approved by institution review board. From January 2013 to December 2016, we enrolled 16 major liver trauma patients (6 women, 10 men; mean age 34.9 ± 12.8 years) who fulfilled inclusion criteria. Liver CT perfusion parameters were calculated by a two-input maximum slope model. Of 16 patients, 9 received embolization and 7 received observation. Among 9 patients of embolization group, their arterial perfusion (78.1 ± 69.3 versus 163.1 ± 134.3 mL/min/100 mL, p = 0.011) and portal venous perfusion (74.4 ± 53.0 versus 160.9 ± 140.8 mL/min/100 mL, p = 0.008) were significantly lower at traumatic parenchyma than at non-traumatic parenchyma. Among 7 patients of observation group, only portal venous perfusion was significantly lower at traumatic parenchyma than non-traumatic parenchyma (132.1 ± 127.1 vs. 231.1 ± 174.4 mL/min/100 mL, p = 0.018). The perfusion index between groups did not differ. None had massive hepatic necrosis. They were not different in age, injury severity score and injury grades. Therefore, reduction of both arterial and portal venous perfusion can occur when therapeutic embolization was performed in preexisting major liver trauma, but hepatic perfusion index may not be compromised.

Haemobilia of a 17 Years Girl Following Road Traffic Accident

Haemobilia is a rare cause of gastrointestinal bleeding, which develops as a result of communication between blood vessel and biliary tract. It should be considered in patients presenting with upper gastrointestinal bleeding with prior history of blunt trauma abdomen. We present a case of 17 years girl who sustained blunt trauma abdomen due to road traffic accident. She developed hematemesis & melena with bleeding from the wound after laparotomy for liver injury. Endoscopy of upper gastrointestinal tract revealed blood coming from ampulla of vater. CT angiography of abdomen showed pseudoaneurysm in a branch of right hepatic artery. Patient recovered completely after therapeutic embolization. Journal of Surgical Sciences (2019) Vol. 23 (1) : 40-42

Maxillary Artery Pseudoaneurysm as a Complication of Maxillofacial Injuries: Report of three cases and literature review

Traumatic maxillary artery pseudoaneurysm is an uncommonly reported complication in the field of oral and maxillofacial surgery. It is usually discovered incidentally, either early after trauma or weeks-to-months later. Quick recognition and prompt management are essential to avoid devastating consequences. In this paper, we report three uncommon cases of maxillary artery pseudoaneurysm recognised during the surgical management of maxillofacial injuries in Muscat, Oman. All cases presented as sudden brisk bleeding during the intraoperative surgical repair and were subsequently diagnosed and successfully managed by endovascular embolisation with platinum coils. This case report highlights the clinical presentation, diagnosis and management of maxillary artery pseudoaneurysm, in addition to a brief review of the literature.Keywords: Maxillofacial Injuries; Maxillary Artery; Pseudoaneurysm; Mandibular Condyle; Angiography; Therapeutic Embolization; Case Report; Oman.

Functional Outcome and Rate of Recovery in Endovascular Treatment of Brain Arteriovenous Malformations: analysis of a single-center cohort of 66 cases

We report our experience with endovascular approach to brain arteriovenous malformations. Objective: Weemphasize the good safety profile of this approach and its potential for anatomical cure. Materials and Methods: This cohortstudy includes all patients diagnosed with a brain arteriovenous malformation who underwent therapeutic embolization inthe 4-year period, from January 2015 to December 2018 at the Endovascular Neurologic Center (CEN) of Médica Uruguaya,Montevideo Uruguay. Data were collected from clinical records and computerized databases, as well as from clinical examinationsto define current neurological and functional status according to the modified Rankin scale results. Results: 66 patients werereviewed, ranging from ages 1 to 73, 28 patients had previous bleeding, 18 had seizures, 9 were incidentally diagnosed and theremaining had minor headaches and neurological deficits. Only 3 patients underwent other therapies (2 had neurosurgeryand 1 radiosurgery). Clinical results can be considered as very good, an overall 27% of anatomic cures; the treatment-relatedmorbidity was very low, mRS 0-2 97% and mRS 3 in 3%. There were no patients with mRS 4-6. Clinical improvement wasnoted in 77.6% of patients. Conclusion: In our experience, endovascular therapy as a treatment of arteriovenous malformationsis safe, can achieve control of the disease with no changes in quality of life and can be potentially curative in certain cases.

EVOLUÇÃO CLÍNICA DE PACIENTES COM ANEURISMA CEREBRAL INTERNADOS EM UM HOSPITAL PÚBLICO

Este estudo tem como objetivo analisar a evolução clínica de pacientes com aneurisma cerebral internados aguardando neurocirurgia de embolização; acompanhar e registrar a evolução clínica e complicações desses pacientes durante a internação hospitalar; identificar a média de tempo de permanência de internação hospitalar na enfermaria neurológica e caracterizar os motivos relacionados com a permanência hospitalar desses pacientes. Trata-se de uma pesquisa longitudinal, descritiva e prospectiva realizada na Clínica Neurológica de um Hospital Público, de julho a outubro de 2017 com pacientes diagnosticados com aneurisma cerebral e aguardando microcirurgia de embolização. Amostra composta por 51 pacientes, sendo 74,51% do sexo feminino, com idade da amostra variando entre 24 a 77 anos, com idade média de 53,45 anos, ± 11,78. A Hemiplegia foi o déficit motor mais presente na admissão e alta. O desfecho óbito esteve presente em 11,76 %. A média de permanência hospitalar foi de 20,1 dias. A embolização demostrou ser uma cirurgia favorável ao desfecho clínico do paciente, já que os óbitos estiveram mais relacionados com piora clínica antes do procedimento. O tempo de permanência hospitalar foi maior que o da literatura encontrada e carência de vaga de UTI foi o motivo mais frequente para permanência no leito aguardando agendamento e para suspensão de cirurgias já agendadas interferindo diretamente no tempo de permanência hospitalar.Palavras-chave: Aneurisma Intracraniano. Embolização Terapêutica. Tempo de Permanência. Evolução Clínica. CLINICAL EVOLUTION OF PATIENTS WITH CEREBRAL ANEURYSM HOSPITALIZED IN A PUBLIC HOSPITAL ABSTRACT: This study aims to analyze the clinical evolution of patients with cerebral aneurysms hospitalized waiting for neurosurgery of embolization; monitor and record the clinical course and complications of these patients during hospitalization; to identify the average length of hospital stay in the neurological ward and to characterize the reasons related to the hospital stay of these patients. This is a longitudinal, descriptive and prospective study conducted at the Neurological Clinic of a Public Hospital from July to October 2017 with patients diagnosed with cerebral aneurysm and awaiting embolization microsurgery. The sample consisted of 51 patients, 74.51% female, with a sample age ranging from 24 to 77 years, mean age of 53.45 years, ± 11.78. Hemiplegia was the most present motor deficit at admission and discharge. The death outcome was present in 11.76%. The mean hospital stay was 20.1 days. Embolization proved to be favorable surgery for the clinical outcome of the patient, since the deaths were more related to clinical worsening before the procedure. The length of hospital stay was higher than that of the literature found and lack of ICU vacancy was the most frequent reason for stay in bed waiting for scheduling and for suspension of surgeries already scheduled interfering directly in the length of hospital stay.Keywords: Intracranial Aneurysm. Therapeutic Embolization. Lenght of stay. Clinical Evolution.

Treatment of Unresectable Unicentric Castleman Disease with Therapeutic Embolization

Introduction: Unicentric Castleman disease (UCD) is a rare non-clonal lymphoproliferative disorder affecting one lymph node station. UCD can be an incidental finding on radiologic studies, whilst other patients have symptomatology due to compression of vital structures. Surgical extirpation is the preferred therapy and is usually curative, but unresectable UCD can represent a therapeutic challenge. Castleman lymph nodes are often highly vascularized, which offers the opportunity for therapeutic embolization. We report a series of 6 patients with unresectable UCD who were treated with embolization either as sole therapy or supplemented by cryoablation and surgery. Methods: CT rotational angiography was performed to localize the arterial supply of UCD masses. Feeding vessels were selectively embolized using a 50:50 mixture of lipiodol and alcohol or 300-500 micron embospheres. A second arteriography was performed 2 to 3 months later to identify and embolize any new arterial channels. Results: Data is summarized in Table 1. Of a cohort of 47 patients with UCD, 6 (13%) were found to have symptomatic, unresectable disease. All patients were HIV and human herpesvirus-8 negative. The median patient age was 34 years (range: 28-34); five patients were male and one was female. Disease was localized to the pelvis (n=3), mediastinum (n=2), and axilla (n=1). In all but one case, the histology was of the hyaline vascular variety. Four patients had failed R-CHOP, rituximab/steroids, or both. In 2 patients, embolization was done as primary therapy, while 3 underwent additional surgery. In 5 patients, embolization was performed twice to ablate secondary arterial channels that had appeared after the first procedure. Adjunctive cryoablation at the time of embolization was applied in 2 patients. All treated patients had major reduction in their lymph node mass. The median reduction in tumor bulk was from 274cc (range:13-969) to 21cc (range: 3-394). One patient with an axillary mass involving the brachial plexus failed therapy and received radiation. A second patient had regrowth of the UCD and responded to combination lenalidomide and obinituzumab. Responses were sustained for at least 2 years in the remaining patients. Conclusion: A small number of case reports have been described UCD patients treated with arterial embolization as an immediate preoperative adjunct to surgery to limit intraoperative bleeding. In the present series, we utilized embolic devascularization to achieve cytoreduction rather than merely prevent surgical hemorrhage. Embolization was complemented by cryoablation and rendered surgery feasible. This case series highlights that effective disease control can be obtained of unresectable UCD using a multimodality approach in which vascular embolization plays a crucial role. Disclosures No relevant conflicts of interest to declare.

Pediatric Renal Trauma

This review addresses the new staging criteria applied to classify renal trauma accurately. We discuss the unique differences in the etiology and management of renal trauma between adults and children. The commentary defines the differences in managing low-, medium-, and high-velocity traumatic injuries compared with blunt renal trauma, and the criteria and methods used to screen for these injuries in children are provided. Absolute and relative indications for surgical exploration of traumatic renal injuries are examined. Management of the complications of acute and delayed renal hemorrhage, asymptomatic and symptomatic urinomas, chronic pain, and hypertension is discussed. Recommendations for physical activity following the traumatic loss of a kidney are reviewed. This review contains 10 figures, 7 tables and 49 references Key words: false aneurysm, hematuria, kidney, nonpenetrating wounds, penetrating wounds, renal hypertension, renal trauma, therapeutic embolization, traumatic shock, urinoma

Late recurrent hemarthrosis following elective total knee arthroplasty

In certain scenarios following total knee arthroplasty (TKA), vascular complications can present as recurrent hemarthrosis, resulting in continued pain and restricted range of motion post-operatively. We present a 77 year old female who underwent a right TKA. She had an uncomplicated recovery for 1 year following the TKA, but then developed episodic knee pain, with pain and swelling, which resulted in limitations to ambulation. Work-up was negative for infection or hardware related complications. At presentation to our office 2 years following the right TKA, aspiration showed thick hemarthrosis from the right knee. Right lower extremity angiogram demonstrated a non-tumoral blush indicative of chronic synovial hyperemia. Patient underwent successful transarterial coil and selective embolization of the responsible geniculate arteries, resulting in complete resolution of symptoms at 2 years follow-up. Physicians and surgeons should be aware of vascular complications following TKA that can occur at mid or long term follow-up which may require therapeutic embolization for resolution of symptoms. Keywords: Hemarthrosis, Total knee arthroplasty, Embolization, Geniculate arteries.