Urethro-venous intravasation during retrograde urethrography in a dog.

A 9-year-old 6-kg male castrated mixed-breed dog was admitted to the hospital as a second opinion for left-sided nephrectomy. Plain radiographs, ultrasound, excretory urography and retrograde urethrography revealed left-sided hydronephrosis and calculi in the bladder and urethra. The urethral calculi were hydropropulsed into the bladder and nephrectomy and cystotomy were performed. Three days after surgery, the patient showed preputial inflammation, pain and pollakiuria. Retrograde urethrography was repeated and extra-urethral leakage of contrast medium into the penile tissue was identified, followed by filling of the draining veins, reaching the caudal vena cava, with subsequent opacification of the right renal pelvis and ureter and opacification of a lymph node. The dog improved during hospitalisation and a retrograde urography performed 6 months after the initial surgery confirmed full recovery.

Lung Transplantation in Pulmonary Hypertension: A Multidisciplinary Unit's Management Experience.

BACKGROUND: Prognosis assessment of pulmonary hypertension (PH) is multifactorial and placement of patients on the lung transplantation (LT) waiting list requires the weighing of a complex set of criteria. The aim of this retrospective cohort study was to analyze a series of patients treated in our unit at the moment of their inclusion on the LT waiting list and long-term survival after LT. MATERIAL AND METHODS: Baseline characteristics, LT outcomes, and survival were evaluated in all patients diagnosed with pulmonary arterial hypertension (PAH) and pulmonary veno-occlusive disease (PVOD) who were included on the LT waiting list in 2011-2016. RESULTS: Thirty-three patients were listed with a diagnosis of PAH or PVOD. Patients had an average age of 43 ± 12 years and 71% were female. The median time between PAH diagnosis and inclusion on the LT waiting list was 62.5 months (interquartile range [IQR], 6-93.3 months). Twenty-eight patients (84%) underwent double LT. The difference between the waiting time in urgent cases (1.5 months; IQR, 0.4-4.2 months) and in elective cases (7.4 months; IQR, 2.7-16.2 months) was significant (P < .049). The 28 patients with PAH/PVOD in our hospital had a 95% short-term survival after LT both at 1 and at 3 months, without variance between urgent and elective LT. Longer-term survival rate was 84% both at 12 and 36 months. CONCLUSIONS: There is great complexity in determining the appropriate time for transplantation referral and inclusion on the waiting list for patients with PAH/PVOD so that LT can be more realistically incorporated into the treatment algorithm for PAH. LT offers a good short- and long-term survival in patients with PAH/PVOD.

Perioperative management of pulmonary hypertension during lung transplantation (a lesson for other anaesthesia settings).

Patients with pulmonary hypertension are some of the most challenging for an anaesthesiologist to manage. Pulmonary hypertension in patients undergoing surgical procedures is associated with high morbidity and mortality due to right ventricular failure, arrhythmias and ischaemia leading to haemodynamic instability. Lung transplantation is the only therapeutic option for end-stage lung disease. Patients undergoing lung transplantation present a variety of challenges for anaesthesia team, but pulmonary hypertension remains the most important. The purpose of this article is to review the anaesthetic management of pulmonary hypertension during lung transplantation, with particular emphasis on the choice of anaesthesia, pulmonary vasodilator therapy, inotropic and vasopressor therapy, and the most recent intraoperative monitoring recommendations to optimize patient care.

Pancreas transplants venous graft thrombosis: endovascular thrombolysis for graft rescue.

PURPOSE: To retrospectively assess the efficacy and safety of percutaneous endovascular treatment in patients with pancreas venous graft thrombosis (PVGT). MATERIALS AND METHODS: Between 2001 and 2009, 206 pancreas transplants were performed at our institution. A retrospective review of pancreas graft recipients who underwent endovascular therapy for PVGT was performed. The study group included 17 patients (10 men, 7 women; mean age 38 years) with PVGT (<60 % [9 patients]; 30-60 % [8 patients]) 6.6 ± 5.7 days after grafting. The angiographic studies, type of endovascular procedure, endovascular procedural and postprocedural effectiveness, and patient and graft outcomes were assessed. RESULTS: In 16 of 17 cases (94 %), significant (87.5 %) or partial (12.5 %) lysis of thrombi was achieved. One patient had external compression of the portal vein due to a hematoma, which hindered mechanical removal of the thrombi. This patient required graft pancreatectomy for extensive areas of parenchymal necrosis 2 days after the endovascular procedure. No complications related to endovascular treatment were observed. Postprocedural bleeding episodes related to anticoagulation were observed in five patients. Patient and pancreas graft survival rates at 12 months were 94 and 76 %, respectively. CONCLUSION: Catheter-directed thrombectomy is an effective treatment for patients with PVGT. Percutaneous thrombectomy, followed by anticoagulation, appears to be an effective therapy to remove the thrombus and is associated with a low complication rate.

Time-of-flight magnetic resonance angiography (TOF-MRA) of the normal equine head.

REASONS FOR PERFORMING STUDY: Noncontrast magnetic resonance angiography (MRA) is widely used in human and small animal medicine. However, this technique has not yet been described in the horse, and compared to other angiographic techniques MRA could be more cost efficient and potentially safer. OBJECTIVES: The aim of this study was to provide a comprehensive anatomical reference of the normal equine head vasculature using a noncontrast MRA technique, on both low- and high-field MRI. METHODS: Five healthy adult horses were examined, 4 with a low-field magnet (0.23T) and the remaining one with a high-field magnet (1.5T). The magnetic resonance angiography sequence used was TOF (time-of-flight) 2D-MRA and CT images of a vascular corrosion cast were subsequently used as anatomical references. RESULTS: The MRA imaging protocol provided good visualisation of all major intra- and extracranial vessels down to a size of approximately 2 mm in diameter on both low- and high-field systems. This resulted in identification of vessels to the order of 3rd-4th branches of ramification. The visibility of the arteries was higher than of the veins, which showed lower signal intensity. Overall, MRA obtained with the high-field protocol provided better visualisation of the arteries, showing all the small arterial branches with a superior resolution. CONCLUSIONS: The use of a specific vascular sequence such as TOF 2D-MRA allows good visualisation of the equine head vasculature and eliminates the need for contrast media for MRA. POTENTIAL RELEVANCE: Magnetic resonance angiography allows for visualisation of the vasculature of the equine head. Vessel morphology, symmetry and size can be evaluated and this may possibly play a role in preoperative planning or characterisation of diseases of the head, such as neoplasia or guttural pouch mycosis.

Tratamiento percutáneo e intraarterial del carcinoma hepatocelular / Percutaneous and intra-arterial treatment of hepatocellular carcinoma

La mayoría de pacientes con un carcinoma hepatocelular (CHC) no son candidatos a resección quirúrgica o trasplante hepático debido al estadio en el momento diagnóstico. Para este grupo de pacientes existen una serie de tratamientos locorregionales que consiguen una alta tasa de respuestas objetivas. La ablación percutánea está considerada la mejor opción terapéutica para el CHC (estadio 0/A-BCLC) no tributario de tratamiento quirúrgico. En el carcinoma hepatocelular multifocal sin invasión vascular ni extensión extrahepática (estadio B- BCLC) la única opción terapéutica que ha demostrado mejorar la supervivencia en estudios controlados y aleatorizados es la quimioembolización. La valoración de la efectividad de estos tratamientos se basa en la reducción del tumor viable y se realiza mediante TC, RM o US con contraste. En este trabajo se revisan las indicaciones, la técnica y la eficacia terapéutica de los distintos tratamientos locorregionales en el CHC (AU)

Most patients with hepatocellular carcinoma (CHC) are not candidates for surgical resection or liver transplantation because of their stage at the time of diagnosis. There are a series of locoregional treatments that achieve a high objective response rate in this group of patients. Percutaneous ablation is considered the best treatment option for CHC (BCLC stage 0/A) not amenable to surgical treatment. In multifocal hepatocellular carcinoma without vascular invasion or extrahepatic extension (BCLC stage B), the only treatment option that has been shown to improve survival in randomized controlled trials is chemoembolization. The evaluation of the effectiveness of these treatments is based on the reduction of viable tumor observed at CT, MRI, or contrast-enhanced US. In this article, we review the indications, technique, and therapeutic efficacy of the different locoregional treatments for CHC (AU)

[Percutaneous and intra-arterial treatment of hepatocellular carcinoma]. / Tratamiento percutáneo e intraarterial del carcinoma hepatocelular.

Most patients with hepatocellular carcinoma (CHC) are not candidates for surgical resection or liver transplantation because of their stage at the time of diagnosis. There are a series of locoregional treatments that achieve a high objective response rate in this group of patients. Percutaneous ablation is considered the best treatment option for CHC (BCLC stage 0/A) not amenable to surgical treatment. In multifocal hepatocellular carcinoma without vascular invasion or extrahepatic extension (BCLC stage B), the only treatment option that has been shown to improve survival in randomized controlled trials is chemoembolization. The evaluation of the effectiveness of these treatments is based on the reduction of viable tumor observed at CT, MRI, or contrast-enhanced US. In this article, we review the indications, technique, and therapeutic efficacy of the different locoregional treatments for CHC.

Anesthetic management of a combined heart and liver transplantation in an amyloidotic patient: a case report.

Few cases of combined heart and liver transplantation (CHLT) have been reported for familial amyloidosis. Our first CHLT was performed on a female patient with familial amyloidosis due to a genetic defect in transthyretin, characterized by deposition of amyloid in various organs and tissues. This disease produced autonomic heart dysfunction that preceded the development of clinical manifestations and may be an important factor in determining the optimal timing for liver transplantation. CHLT can be performed successfully, even in patients with advanced disease. However, the most compromised patients are more exposed to intraoperative risks, postoperative complications, and worsening of extracardiac and extrahepatic symptoms. Our patient presented severe cardiac dysfunction requiring CHLT. The operative technique is far from being consolidated, despite this, both organs were transplanted in the same day with 2 hours in the intensive care unit (ICU) between surgeries. The outcome of both organs has been favorable. The amyloidotic liver was transplanted to another patient, a sequential (domino) transplantation.

Successful treatment by selective arterial embolization of severe retroperitoneal hemorrhage secondary to bone marrow biopsy in post-polycythemic myelofibrosis.

Severe retroperitoneal hemorrhage represents an infrequent and serious complication of bone marrow biopsy. A 53-year-old man, diagnosed with polycythemia vera 12 years earlier, was submitted to a bone marrow biopsy due to the appearance of anemia with clinical and hematological features suggesting myelofibrotic transformation, a diagnosis that was confirmed by the marrow study. At 2 h of a right anterior iliac bone marrow trephine biopsy, the patient suddenly developed severe pain in the area of the biopsy, with antialgic flexion of the right leg. Computed tomographic (CT) scan of the abdomen showed a 5 x 9.5 cm hematoma in the right iliac and psoas muscles. The patient was initially managed with analgesics and transfusional support, but the pain persisted and a continuous fall in the hematocrit was observed in the following days. Angiographic examination of the right external iliac artery showed contrast extravasation arising from the circumflex iliac branch, which was embolized using polivinyl alcohol particles and one coil. Following such procedure, the patient recovered uneventfully and was discharged in good condition a few days later. This case illustrates the effectiveness of an endovascular approach in providing a fast and minimally invasive treatment for this life-threatening complication of bone marrow trephine biopsy.

Treatment and outcome of pancreatic venous graft thrombosis after kidney--pancreas transplantation.

BACKGROUND: Pancreas venous graft thrombosis after transplantation is the main non-immunological cause of graft failure and usually results in pancreatectomy. Duplex Doppler ultrasonography is the primary imaging technique for monitoring vascular patency after pancreas transplantation. This study reports the results of rescue treatments for pancreas graft thrombosis after simultaneous pancreas--kidney transplantation. METHODS: One hundred and ninety-six patients with insulin-dependent diabetes mellitus received a simultaneous pancreas--kidney transplantation. Venous graft thrombosis was diagnosed in 25 of these patients based on Doppler ultrasonographic findings. RESULTS: Total venous graft thrombosis was diagnosed in 20 symptomatic patients, of whom 14 required graft pancreatectomy. Surgical thrombectomy was attempted in six patients with preserved arterial supply and was successful in four. Partial venous graft thrombosis was diagnosed in five asymptomatic patients; one also had partial splenic artery thrombosis. Rescue graft procedures included systemic anticoagulation (one patient), arterial thrombolysis (one) and venous thrombolysis and/or mechanical venous thrombectomy (four episodes in three patients). Graft rescue was achieved in three patients treated by venous thrombolysis/thrombectomy. CONCLUSION: Doppler ultrasonography allows the appropriate selection of rescue treatment based on the findings of total or partial thrombosis.

Percutaneous repair of an iatrogenic laceration of the left bile duct with a covered stent.

The presence of biliary leaks after liver resections is not an unusual problem, especially after extended hepatectomies. The usual treatment of choice for biliary duct injuries is to decompress the biliary system with draining catheters. Persistent biliary fistulas are nevertheless a challenging problem when endoscopic or percutaneous approaches fail to achieve occlusion of the bile leakage. The authors report a bile duct injury after a right lobe hepatectomy treated percutaneously with placement of a covered stent. After 6 months, the patient was tube-free and without any episode of cholangitis or bile duct dilation. Longer follow-up will clarify the future role of this kind of device in biliary system lacerations.

[Selective embolization of post-traumatic renal pseudoaneurysm in monorenal patient]. / Embolización selectiva de pseudoaneurisma renal post-traumático en paciente monorreno.

Presentation of one case of a patient who presented two non-penetrating abdominal traumatism along a year period. In the first incident it was necessary to practice a left nefrectomy and in the second one the therapeutic opcion was a superselective embolization of a pseudoameurism communicated with urinary tract.

Embolización selectiva de pseudoaneurisma renal post-traumático en paciente monorreno / Superselective embolization of post-traumatic pseudoaneurysm renal un a monorrenal pacient

Presentamos el caso de un paciente que en el intervalo de un año había sufrido dos traumatismos abdominales no penetrantes. En el primer episodio fue necesario practicar nefrectomía izquierda y en el segundo la opción terapéutica llevada a cabo fue la embolización selectiva de un pseudoaneurisma comunicado a la vía urinaria (AU)

Liver transplantation for small hepatocellular carcinoma: the tumor-node-metastasis classification does not have prognostic power.

Tumoral recurrence rate and survival of patients with hepatocellular carcinoma (HCC) treated by orthotopic liver transplantation (OLT) depend on tumor stage. Thereby, from the beginning of our program, we selected only patients with solitary tumors < or = 5 cm without vascular invasion, thus avoiding the use of the tumor-node-metastasis (TNM) staging system as a selection tool. The present study reports the results obtained in 58 consecutive patients (52 +/- 8 years, 47 males) with HCC (7 incidentals) transplanted between 1989 and 1995. Transplantation was indicated because of tumor diagnosis in 40 cases and advanced liver failure in 18. Mean tumor size at staging was 28.2 +/- 12.1 mm. No adjuvant treatment was applied during the waiting period (58.9 +/- 45.1 days). The pathological tumor-node-metastasis (pTNM) classification allocated 15 patients to stage I, 19 to stage II, 11 to stage IIIA, and 13 to stage IVA showing preoperative understaging in 43% of the cases with known tumor. After a median follow up of 31 months, only two patients have shown tumor recurrence and fifteen have died, the 1-, 3-, and 5-year survival being 84%, 74%, and 74%. All HCV+ patients remain infected and 94% showed significant liver disease (6 cirrhosis). Six patients have had a second transplant. In conclusion, the application of restrictive criteria not following the TNM staging system prompts excellent results for liver transplantation in patients with HCC, both in terms of survival and disease recurrence, even without applying adjuvant treatment; however, the survival data should be tempered by the appearance of complications that may worsen the long-term prognosis.

Occlusion of the superior mesenteric artery in a patient with polycythemia vera: resolution with percutaneous transluminal angioplasty.

The case is reported of a 46-year-old male patient with polycythemia vera (PV) treated with phlebotomy who developed an occlusive thrombosis of the superior mesenteric artery 2 years after the diagnosis. He was successfully managed with percutaneous transluminal angioplasty. The patient did not develop any other thrombotic phenomena. To our knowledge, there are no previous reports on the use of percutaneous transluminal angioplasty in the management of arterial thrombotic complications in PV patients.