Renal artery occlusion in a young woman - a tale of mysterious thrombosis.

BACKGROUND: Renal artery thrombosis is rare and limited reports exist in the young population. The most common aetiology is thromboembolic disease or abdominal trauma in this population and isolated occurrences are extremely rare. We present the case of an 18-year-old woman with spontaneous unilateral renal artery thrombosis and infarction for whom reperfusion was achieved through endovascular intervention. The aetiology of her thrombosis remains unclear and is under investigation with differential diagnoses being fibromuscular dysplasia, large and medium vessel vasculitis, and thromboembolic causes. OBJECTIVE: To demonstrate the value in attempting salvage of an ischaemic kidney in a young patient with an unexplained spontaneous renal thrombosis. METHOD: JM is an 18-year-old woman who presented to a large regional tertiary hospital with 3 days of right flank pain. She had no infective symptoms and no urinary or bowel changes before admission. She was not pregnant, and her only medication was the oral contraceptive pill commenced 3 months prior. A CT angiogram demonstrated right renal artery thrombosis with renal infarction. The kidney was deemed potentially salvageable, and ultrasound defined adequate vessel calibre to access for thrombectomy in the context of a negative coagulopathy screen. RESULTS: The patient underwent thrombolysis, thrombectomy and balloon angioplasty. Intraoperatively, a thin segment of distal stenosis was identified, and angiogram reperfusion was achieved with subsequent improvement in renal function. CONCLUSION: Renal artery thrombosis in young people is extremely rare and presents a diagnostic and management challenge requiring input from multiple teams including nephrology, rheumatology, paediatrics and vascular surgery. Systemic coagulopathy and vasculitis are differentials against anatomical aetiologies such as fibromuscular dysplasia. Our case adds to the limited literature regarding this in the young population. Renal artery thrombosis with occlusion in young people is very rare and is most often associated with a systemic coagulopathic disorder, such as antiphospholipid syndrome or structural pathology of the renal vasculature such as fibromuscular dysplasia. The work-up of a young female presenting with renal artery thrombosis without any previous medical history screens for a wide range of pathological processes.

Endurant stent graft demonstrates promising outcomes in challenging abdominal aortic aneurysm anatomy.

OBJECTIVE: We aimed to assess the 5-year safety and effectiveness outcomes of patients enrolled in the Endurant Stent Graft Natural Selection Global Post Market Registry (ENGAGE) who were treated outside the approved indications for use (IFU) of the Endurant stent graft. METHODS: Our primary outcome measure was 12-month treatment success, defined as successful endograft delivery and deployment and the absence of type I or III endoleak, stent migration or limb occlusion, late conversion, and abdominal aortic aneurysm diameter increase or rupture. Secondary outcome measures included 30-day all-cause mortality, major adverse events, secondary procedures, technical observations, aneurysm-related mortality, and all-cause mortality within 12 months. RESULTS: Demographic characteristics of ENGAGE patients treated outside (225 [17.8%]) and within (1038 [82.2%]) the IFUs were similar, except that female patients comprised a much higher percentage of the outside IFU group (19.1% vs 8.7%; P < .001). The outside IFU group presented with lower rates of coronary artery disease and cardiac revascularization and a greater number of symptomatic patients compared with the within IFU group (21.3% vs 15.0%; P = .020). Technical success was achieved in more than 99% of all patients. The outside and within IFU groups showed a comparable and low occurrence of uncorrected type I (0.9% vs 1.2%; P = 1.00) and type III endoleak (0.4% vs 0.3%; P = .54) immediately after device implantation. The 5-year freedom from type IA endoleaks was 89.4% vs 96.7% (P < .0001) for those patients outside and within the IFUs, respectively, although both groups had similar type III endoleaks through 5 years (P = .61). Stent graft limb occlusion estimated overall survival, and freedom from aneurysm-related mortality and endovascular interventions were comparable in both patient groups through the 5-year follow-up. The Kaplan-Meier estimates at 5 years showed a trend for low but increased need for type I or III endoleak correction procedures in the outside IFU group compared with the within IFU group (7.2% vs 5.2%; P = .099). CONCLUSIONS: Differences were not observed in all-cause mortality, aneurysm-related mortality, and secondary procedures between within and outside IFU patients through a 5-year follow-up in the ENGAGE registry. Proximal necks with angulation or diameters outside the IFUs were the most common reasons for patients identified as being outside IFU, and the cohort had increased incidence of type IA endoleaks. Despite the challenges presented from the broad range of aortic and abdominal aortic aneurysm morphologies, the Endurant stent graft showed promising 5-year outcomes.

Large spontaneous median sacral artery pseudoaneurysm masquerading as hip pain.

We report the case of an 81-year-old man who presented with severe right hip pain and reduced physical function secondary to a large spontaneous median sacral artery pseudoaneurysm measuring 83.5 × 55.4 mm. The patient had no history of recent trauma, infective or inflammatory disease, or any recent procedures. The patient was taking apixaban for atrial fibrillation. Percutaneous coil embolization was used to occlude the pseudoaneurysm. This case describes a novel disease, spontaneous median sacral artery pseudoaneurysm, presenting with hip pain.

Analysis of Midterm Outcomes of Endovascular Aneurysm Repair in Octogenarians From the ENGAGE Registry.

PURPOSE: To assess periprocedural results and secondary endovascular procedure outcomes over 5 years in patients aged ≥80 vs <80 years undergoing endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Data from the Endurant Stent Graft Natural Selection Global post-market registry (ENGAGE) were used for the analyses. A total of 1263 consecutive patients were enrolled in the prospective, observational, single-arm registry and divided into 2 groups according to age: ≥80 years (290, 22.9%) and <80 years (973, 77.1%). Baseline patient characteristics, risk scores according to the Society for Vascular Surgery (SVS) reporting standards, American Society of Anesthesiologists (ASA) classification, quality of life assessments [EuroQol 5 (EQ5D) index], and treatment outcomes, including all-cause mortality, aneurysm-related mortality, major adverse events, secondary endovascular procedures, and endoleaks were compared between groups. RESULTS: Octogenarians were classified into the highest category of the SVS risk stratification system; however, this did not result in a significant difference in the 30-day mortality [1.4% (4/290) vs 1.2% (12/973) for controls; p=0.85] or major adverse event rates [5.2% (15/290) vs 3.6% (35/973), p=0.23]. Multivariable analysis confirmed that age ≥80 years, pulmonary disease, large aneurysm diameter, and renal insufficiency were significantly associated with all-cause mortality, whereas diameter was the only parameter associated with increased aneurysm-related mortality. The differences in freedom from secondary endovascular procedures over 5 years between octogenarians and controls did not reach statistical significance (88.5% vs 83.2%, p=0.07). CONCLUSION: EVAR can be performed in individuals aged ≥80 years with no statistically significant difference in midterm aneurysm-related deaths compared with younger patients. The findings in this elderly patient cohort show that EVAR can be safely performed with acceptable morbidity rates in octogenarians.

Multicentre Covariate Adjustment Analysis of Short-Term and 5-Year Outcomes after Endovascular Repair according to Sex.

BACKGROUND: Several studies have reported worse outcomes in women compared to men after endovascular aneurysm repair (EVAR). This study aimed to evaluate sex-specific short-term and 5-year outcomes after EVAR. METHODS: A total of 409 consecutive patients underwent elective EVAR from 2004 to 2017 at two tertiary hospitals in Western Australia. Baseline, intraoperative, and postoperative variables were examined retrospectively according to sex. The primary outcome was 30-day mortality (death within 30 days after EVAR). Secondary outcomes were 30-day composite endpoint, length of stay after EVAR, 5-year survival, freedom from reintervention, residual aneurysm size after EVAR, and major adverse event rate at 5-year follow-up. RESULTS: A cohort of 409 patients, comprising 57 women (14%) and 352 men (86%), was analysed. Female patients were older (median age, 76.8 versus 73.5 years, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%. CONCLUSION: This study found no significant differences in 30-day and 5-year outcomes between female and male patients treated with EVAR, implying that EVAR remains a safe treatment choice for female patients.

Covered Stenting as Bail-Out Technique for Central Venous Catheter Malposition Within the Brachiocephalic Trunk.

Central venous catheter (CVC) insertion with ultrasound guidance is routine clinical practice in the critically ill patient. Arterial malposition is serious and may lead to severe complications such as hemorrhage, stroke, or death. We describe a bail-out technique for removal of right-sided CVC that was mispositioned into the brachiocephalic trunk (BCT) at the origin of the right common carotid artery (CCA). Covered stenting of the BCT extending into the CCA in combination with plug embolization of the right subclavian artery was utilized.

An Off-Label Use of a Unibody Aortic Stent-Graft System for the Treatment of Infrarenal Abdominal Aortic Dissections.

Infrarenal abdominal aortic dissections (IAAD) are exceedingly rare, accounting for 1-4% of all aortic dissections. The evidence is scarce on how to best manage IAAD when they become symptomatic. Two main interventional approaches exist, open surgery and the endovascular approach. Conventional stent-graft systems make it difficult to treat nonaneurysmal aortic disease due to limb competition in a narrow distal aorta. Thus, we present a novel use of the Endologix Anatomical Fixation 2 (AFX2) Abdominal Aortic Aneurysm (AAA) endograft system for the treatment of four patients with IAAD. We also highlight an individual case study that was treated with an alternative endovascular approach and the complications that followed. This was to highlight and compare our successful experience with Endologix AFX2 AAA endograft system. There were multiple benefits for choosing this stent-graft; however the main advantage is its suitability in the narrow distal aorta. Our aim was to highlight an alternative endovascular approach for the successful treatment of a rare, challenging, and potentially fatal pathology.

Filiarial chyluria with nephrotic-range proteinuria and associated hypoalbuminaemia and hypogammaglobulinaemia secondary to bilateral lymphorenal fistulae.

A 55-year-old man of Indian descent, presented to the emergency department with a 2-year history of passing 'milky' white urine, associated with dysuria, urinary retention, bilateral flank pain and 15 kg weight loss. He had migrated to Australia from India at the age of 16, with no overseas travel since, and denied having any fevers, rigours or chills. He was found to have chyluria and nephrotic-range proteinuria with marked hypoalbuminaemia and hypogammaglobulinaemia. Due to his ethnic origin and by diagnostic exclusion, a presumptive diagnosis of filariasis was made. With bilateral lymphorenal disconnection, as definitive management, the patient's chyluria and proteinuria resolved with restoration of normal plasma protein and immunoglobulin levels.