I Want My Bullet Back: Percutaneous Endovascular Removal of a Right Atrial Foreign Body.

The incidence and prevalence of firearm-related homicide in the United States make headlines daily. As a result, an epidemic of penetrating injuries is on the rise. Specifically, foreign bodies such as bullets and shrapnel are usually left inside the human body due to penetrating injuries, unless they are in close proximity to vital structures. We present a case of a bullet within the right atrial chamber of the heart, which was successfully removed by a minimally invasive endovascular approach.

A Route Less Traveled: Anomalous Venous Drainage of the Right Heart.

Congenital anomalies of the coronary sinus and veins have been well documented, but only one instance of an anomalous small cardiac vein draining into the superior vena cava (SVC) has been reported. The majority of patients with anomalies of the coronary venous system are asymptomatic, but these variants are important to document as they may have clinically significant implications in the management and possible interventions patients may receive. This report describes an anomalous connection from the coronary venous system to the superior vena cava discovered incidentally in a patient with SVC syndrome and end-stage renal disease (ESRD). This may reflect a congenital variant which accommodated collateral flow to bypass the fully occluded SVC. Alternatively, it may be the result of repeated venoplasty of the stenotic SVC which opened an iatrogenic tract that was maintained and vascularized over time.

Embolization-induced Renal Tumor Shrinkage Followed by Definitive Cryoablation.

Significant incidental findings reported on computed tomography (CT) scans are common. This article describes a 72-year-old man evaluated for possible bowel obstruction in whom was found a 3.1-cm x 2.6-cm centrally located enhancing mass in the left kidney highly suspicious for renal cell carcinoma. Due to substantial medical comorbidities, the patient was deemed a poor surgical candidate for either partial or complete nephrectomy. Interventional radiology was consulted for a minimally invasive ablation procedure. The large size and central location of the tumor involving the renal collecting system initially precluded definitive percutaneous cryoablation. Intra-arterial embolization was used as neoadjuvant therapy to decrease tumor burden. Fluoroscopy-guided bland embolization was performed targeting the arterial supply of the mass until stagnation of flow was achieved. A subsequent two-month post-embolization follow-up CT scan showed a 30% reduction in tumor size. Shrinkage of the mass from a central to a more peripheral location allowed for a cryoablation approach that would avoid damage to the vulnerable collecting system. Cryoablation was performed, and intraoperative CT demonstrated complete coverage of the tumor by the ice ball with no damage to the renal collecting system. A follow-up CT scan four years later showed no residual malignancy at the ablation site.

To nearly come full circle: Nonoperative management of high-grade IV-V blunt splenic trauma is safe using a protocol with routine angioembolization.

INTRODUCTION: Nonoperative management (NOM) of hemodynamically stable high-grade (IV-V) blunt splenic trauma remains controversial given the high failure rates (19%) that persist despite angioembolization (AE) protocols. The NOM protocol was modified in 2011 to include mandatory AE of all grade (IV-V) injuries without contrast blush (CB) along with selective AE of grade (I-V) with CB. The purpose of this study was to determine if this new AE (NAE) protocol significantly lowered the failure rates for grade (IV-V) injuries allowing for safe observation without surgery and if the exclusion of grade III injuries allowed for the prevention of unnecessary angiograms without affecting the overall failure rates. METHODS: The records of patients with blunt splenic trauma from January 2000 to October 2014 at a Level I trauma center were retrospectively reviewed. Patients were divided into two groups and failure of NOM (FNOM) rates compared: NAE protocol (2011-2014) with mandatory AE for all grade (IV-V) injuries without CB and selective AE for grade (I-V) with CB versus old AE (OAE) protocol (2000-2010) with selective AE for grade (I-V) with CB. RESULTS: Seven hundred twelve patients underwent NOM with 522 (73%) in the OAE group and 190 (27%) in the NAE group. Evolving from the OAE to the NAE strategy resulted in a significantly lower FNOM rate for the overall group (grade I-V) (OAE vs. NAE, 4% to 1%, p = 0.04) and the grade (IV-V) group (OAE vs. NAE, 19% vs. 3%, p = 0.01). Angiograms were avoided in 113 grade (I-III) injuries with no CB; these patients had NOM with observation alone and none failed. CONCLUSIONS: A protocol using mandatory AE of all high-grade (IV-V) injuries without CB and selective AE of grade (I-V) with CB may provide for optimum salvage with safe NOM of the high-grade injuries (IV-V) and limited unnecessary angiograms. LEVEL OF EVIDENCE: Therapeutic study, level IV.

At first blush: absence of computed tomography contrast extravasation in Grade IV or V adult blunt splenic trauma should not preclude angioembolization.

BACKGROUND: To clarify the role, indications, and outcomes for angioembolization (AE) of nonoperatively managed (NOM) splenic trauma, the implications of absent contrast blush (CB) on computed tomography of high-grade (IV-V) blunt splenic trauma (BST) in adults were analyzed. METHODS: All BST patients presenting at a single institution from July 2000 to December 2011 were retrospectively reviewed. Grade of injury (American Association for the Surgery of Trauma scale), CB on initial computed tomography, numbers of NOM and undergoing AE, and failures of NOM were analyzed. Statistical analysis was performed using χ(2). RESULTS: Of the 1,056 total BST patients, 556 (64%) were hemodynamically stable and eligible for NOM; 95 NOM patients (17%) had CB. AE was performed in 88 of these, with angiographic extravasation found in 86 (97.7%), and 3 of these 88 (3.4%) failed NOM. The remaining 7 CBs were observed without AE, of which 5 (71.4%) failed NOM (p = 0.0004). Of all 556 NOM patients, 51 (9.5%) had high-grade injuries without CB; 20 of these (39%) underwent AE, 17 (85.0%) underwent angiographic extravasation, and there were no NOM failures in this group. The other 31 high-grade injuries without CB or AE had 8 failures of NOM (26%) (p = 0.03). CONCLUSION: The strong correlation of CB with active bleeding on angiogram mandates AE for CB in all BST undergoing NOM. However, the absence of CB in high-grade (IV-V) BST does not reliably exclude active bleeding. This may be the reason for the high reported failure rates of NOM in high-grade (IV-V) BST because AE is not typically performed in the absence of CB. These data suggest that all hemodynamically stable high-grade (IV-V) BST in adults should undergo AE regardless of CB to optimize the success and safety of NOM. LEVEL OF EVIDENCE: Therapeutic study, level III.

Nutcracker syndrome: symptoms of syncope and hypotension improved following endovascular stenting.

'Nutcracker syndrome' encompasses classical symptoms of hematuria and flank pain resulting from the compression of the left renal vein between the aorta and the superior mesenteric artery. In patients with unexplained left-sided hematuria, flank pain or non-specific abdominal pain, careful interrogation of diagnostic abdominal imaging should be performed to exclude the possibility of external compression on the left renal vein. The patient discussed in this case report is a 19-year-old woman with unilateral hematuria. Her symptoms started 13 months prior with nausea, lower abdominal pain and weight loss. Six months after the nausea began, she started having syncope, sometimes multiple episodes in one day. Syncope is one of the more rarely reported symptoms associated with nutcracker syndrome. As more cases are reported, endovascular repair is becoming an alternative treatment for nutcracker syndrome. The patient was treated with stenting of her left renal vein. At the three-week follow-up, she reported near resolution of nausea and abdominal pain. She had gained four pounds, no longer had gross hematuria and had had no episodes of syncope and her blood pressure had normalized. Endovascular specialists should be aware of the variety of symptoms that can occur with nutcracker syndrome, including syncope. The severity of these symptoms should guide the recommendation for intervention.