Negative renal angiography with subsequent denied angioembolization: findings in a series of 180 patients at a tertiary interventional uroradiology unit

Background Renal arterial embolization (RAE) is considered to be a safe and effective method for treating a variety of renal lesions and pathology. It is the optimal method not only to stop bleeding, but to preserve renal parenchyma and renal function. Patients who are scheduled to RAE who showed negative catheter angiography with the procedure subsequently denied have a special concern because they are subjected to unnecessary procedure with its complications and didn’t get its benefits. This circumstance is infrequently reported in the literature, and that compelled us to identify the predictors of negative renal angiography findings that would result in a failure to undertake RAE. Results The study included 180 patients (126 males; 70%) with a mean ± SD age of 44 ± 14 years. Iatrogenic causes were the most common indication for RAE (108 of 180; 60%), while spontaneous unknown reasons constituted (17 of 180 patients; 9%). Angiography showed various lesions in 148 patients: pseudoaneurysm (80 of 148; 54%), tumours (28 of 148; 19%), arteriovenous (AV) fistulas (22 of 148; 15%) and both pseudoaneurysm and AV fistulas (18 of 148; 12%). However, in the remaining 32 of 180 patients (18%) no lesions were identified on renal angiography and RAE procedures were not undertaken. On bivariate analysis, neither gender, side of the lesions, haematuria prior to RAE, or renal artery anatomy were predictors for negative angiography. However, the indication for RAE (spontaneous unknown reasons) of renal haemorrhage was the only predictor for negative angiography (9/17 (53%), P = 0.001). Conclusion Patients scheduled for RAE may show negative findings with no lesions on renal angiography. Among the different indications for RAE, patients with spontaneous (unknown) have the highest probability (53%) of being associated with negative renal angiography findings, however, those with renal tumours and post-traumatic causes have a low probability. In those patients with spontaneous (unknown), conservative management should be the initial treatment of choice in order to avoid unnecessary RAE and its associated complications.

Empiric and Conservative Strategy in The Interventional Management of Late Post-Pancreatoduodenectomy Hemorrhage With Negative Angiographic Result

Background: The aim of the study was to review the outcome of patients who underwent interventional procedures with negative angiographic results for post-PD hemorrhage. Empiric and conservative interventional strategies were compared. Methods: The consecutive patients who underwent interventional procedures for post-PD hemorrhage in our center between Jan 2016 and Jun 2020 were evaluated. 21 cases were enrolled into this study with negative angiographic results. Two different strategies, empiric and conservative, were applied. Clinical data, including age, sex, pathological diagnosis, lab test results, clinical presentation and onset time of bleeding after surgery, technical and clinical outcome was obtained from the medical records and follow up data. Results: All patients in our series presented with delayed post-PD hemorrhage. In the empiric group, embolization was performed at the hepatic artery in 11 cases and at the left gastric artery (LGA) in 1. Two patients died of hemorrhage recurrence despite embolization during the follow up. Two patients required laparotomy and recovered in this group. Recurrence rate was 33.3% (4/12) in this group and mortality rate was 16.7% (2/12). In the conservative group, one patient required re-angiography with bleeding from the hepatic artery revealed 10 days after the first angiography. Hepatic artery embolization and subsequent relaparotomy was required. Another two patients required relaparotomy for hemorrhage recurrence. Recurrence rate was 33.3% (3/9) in this group and all these 3 cases required relaparotomy as definite treatment. Conclusion: Prompt decision making is required when negative result demonstrated during the angiography for post PD hemorrhage, and the surgeons’ judgement is mandatory. Both empiric and conservative treatment may be effective as indicated when negative angiography presented. Great caution is required following the interventional procedure, because recurrence rate after both treatment methods is significant despite negative angiography.

Endovascular Management of Nonvariceal Upper Gastrointestinal Bleeding

Nonvariceal upper gastrointestinal bleeding (UGIB) is associated with significant morbidity and mortality among hospitalized patients and thus presents a treatment challenge for the interventional radiologist. Common causes of nonvariceal UGIB include peptic ulcer disease, Mallory–Weiss tear, erosive inflammatory changes, ulcer disease, malignancy, and vascular malformations. Noninvasive imaging workup for this condition may include computed tomography angiography and tagged red blood cell scan. Invasive angiography allows for both the diagnosis and endovascular treatment of nonvariceal UGIB. Transcatheter embolization can be performed using a variety of embolic agents, such as coils, vascular plugs, and Gelfoam. For patients with negative angiography results despite the presence of clinically and endoscopically significant UGIB from a known source such as gastric ulcer or duodenal ulcer, the left gastric or gastroduodenal artery can be empirically embolized. In high-risk patients with multiple comorbidities who have failed endoscopic therapy, endovascular embolization is associated with lower complication rates compared with open surgery. In this review, we discuss current management strategy and endovascular techniques for the management of the nonvariceal upper GI hemorrhage.

Safety of Early Pharmacological Thromboprophylaxis after Subarachnoid Hemorrhage

ObjectiveThe recent guidelines on management of aneurysmal subarachnoid hemorrhage (aSAH) advise pharmacological thromboprophylaxis (PTP) after aneurysm obliteration. However, no study has addressed the safety of PTP in the aSAH population. Therefore, the aim of this study was to assess the safety of early PTP after aSAH.MethodsRetrospective cohort of aSAH patients admitted between January 2012 and June 2013 in a single high-volume aSAH center. Traumatic SAH and perimesencephalic hemorrhage patients were excluded. Patients were grouped according to PTP timing: early PTP group (PTP within 24 hours of aneurysm treatment), and delayed PTP group (PTP started > 24 hours).ResultsA total of 174 SAH patients (mean age 56.3±12.5 years) were admitted during the study period. Thirty-nine patients (22%) did not receive PTP, whereas 135 patients (78%) received PTP after aneurysm treatment or negative angiography. Among the patients who received PTP, 65 (48%) had an external ventricular drain. Twenty-eight patients (21%) received early PTP, and 107 (79%) received delayed PTP. No patient in the early treatment group and three patients in the delayed PTP group developed an intracerebral hemorrhagic complication. Two required neurosurgical intervention and one died. These three patients were on concomitant PTP and dual antiplatelet therapy.ConclusionsThe initiation of PTP within 24 hours may be safe after the treatment of a ruptured aneurysm or in angiogram-negative SAH patients with diffuse aneurysmal hemorrhage pattern. We suggest caution with concomitant use of PTP and dual antiplatelet agents, because it possibly increases the risk for intracerebral hemorrhage.

Is this Subarachnoid Hemorrhage Significant? A National Survey of Neurosurgeons

Background:Previously all subarachnoid hemorrhage (SAH) patients were admitted, whereas now patients with angiography may be discharged.Objective:To survey neurosurgeons to determine current practice and what constitutes a clinically significant subarachnoid hemorrhage.Methods:We surveyed all neurosurgeons listed in the Canadian Medical Directory. We used a modified Dillman technique with up to five mailed surveys plus a pre-notification letter. Neurosurgeons rated the significance of 13 scenarios of subarachnoid hemorrhage. Scenarios varied from aneurysmal subarachnoid hemorrhage to patients with isolated xanthochromia in cerebrospinal fluid. Each scenario was rated for clinical significance using a 5-point scale [1(always) to 5(never)].Results:Of the 224 surveyed, 115 neurosurgeons responded. Scenarios with aneurysms requiring intervention, arteriovenous malformations, death or any surgical intervention all had median responses of 1 (IQR 1, 1). Scenarios having xanthochromia and few red blood cells in cerebrospinal fluid with negative computerized tomogram (CT) and angiography had median responses of 3 (IQR 1, 4). Scenarios with perimesencephalic pattern on CT with negative angiography had median of 3 (IQR 2, 4). Scenarios where patient is discharged from the emergency department had median of 4 (IQR 3, 5).Conclusion:Subarachnoid hemorrhages due to aneurysms or arteriovenous malformations causing death or requiring surgical intervention are always clinically significant. Other types of nonaneurysmal subarachnoid hemorrhages had inconsistent ratings for clinical significance. These survey results highlight the need for further discussions to standardize the diagnosis of what constitutes a clinically significant subarachnoid hemorrhage and what care should be afforded to these patients.