Acute limb ischemia due to severe heparin-included thrombocytopenia with thrombosis during puerperium.

We present the case of a 39-year-old pregnant woman who had intrauterine fetal death and imminent uterine rupture and underwent cesarean section. She also underwent catheter embolization for hemorrhagic shock due to bleeding from the uterine artery, and heparin-containing saline was used. On day 7 of hospitalization, she felt severe pain in her right lower leg, and computed tomography (CT) revealed focal nonocclusive thrombus formations in the right common and external iliac artery. After intravenous heparin administration, she suddenly developed dyspnea, her blood pressure dropped, and her platelet count decreased. We diagnosed her with heparin-induced thrombocytopenia (HIT). Although we discontinued heparin and switched to argatroban, CT after 5 days revealed subtotal occlusion of the right iliac artery by a massive thrombus. We performed surgical thrombectomy using a Fogarty catheter, but blood flow was not restored. Therefore, we administered urokinase continuously with catheter-directed thrombolysis (CDT). The thrombus in the iliac artery gradually cleared and was successfully eliminated. However, the patient developed gangrene in her right lower leg, and we decided to perform an above-knee amputation of the right leg. She was discharged with a prosthetic leg and prescribed 15 mg of rivaroxaban per day. Learning objective: HIT is a known serious side effect of heparin administration, and it can sometimes be fatal. HIT treatment using aggressive thrombectomy procedures may be ineffective since such procedures may accelerate thrombus formation when the coagulation cascade is highly activated. In this case, CDT may have to be considered as the first-line treatment before Fogarty thrombectomy when argatroban therapy fails.

Bidirectional Sling Technique with Biopsy Forceps for Inferior Vena Cava Filter Retrieval.

Although the importance of the retrieval of an optional inferior vena cava filter (o-IVCF) has gained attention because of the awareness of a high complication rate with long indwelling time, the o-IVCF retrieval rate remains low. The advanced retrieval technique of o-IVCF may increase the retrieval rate, which in turn diminishes future adverse events. Through two cases, we describe how to perform the novel approach "bidirectional sling technique with biopsy forceps." This technique will improve the retrieval rate in patients following the failure by conventional retrieval technique.

Impact of Advanced Technique on Improvement in the Retrievable Inferior Vena Cava Filter Retrieval Rate.

BACKGROUND: It is recommended to remove retrievable inferior vena cava filters (r-IVCFs) when they are no longer needed because their presence may give rise to serious complications related to prolonged placement of the filter. An advanced filter retrieval technique may help improve the retrieval rate.Methods and Results:107 consecutive patients (mean age; 61±18 years, male 53%) in whom r-IVCF retrieval was attempted were prospectively enrolled between April 2012 and December 2018. The frequently used advanced techniques were sling technique and biopsy forceps dissection technique. Retrieval success was 75% with standard retrieval technique alone; however, the overall retrieval success rate improved to 98% with advanced techniques. We observed few serious complications related to the retrieval procedure. Logistic multivariate analysis identified prolonged indwelling time (P=0.0011) and embedded hook in the caval wall (P=0.0114) as independent predictors, and the cutoff value for the indwelling time for requirement of advanced technique was 80 days. CONCLUSIONS: Advanced retrieval techniques helped improve the retrieval rate without serious complications. We may need to consider the referral of patients to centers with expertise in advanced retrieval techniques when the indwelling time is >80 days, and pre-retrieval CT image shows a hook embedded in the vessel wall.

Successful stent implantation in the internal jugular vein occlusion using Brockenbrough needle under intravascular ultrasound guidance leading to prevention of vision loss in a hemodialysis patient with neovascular glaucoma.

Central venous occlusion (CVO) remains an unresolved issue in hemodialysis patients. We herein present an interesting case of a 42-year-old hemodialysis female patient with complete vision loss in the left eye, who was at high risk of losing vision in her right eye because of neovascular glaucoma (NVG). Computed tomography (CT) showed occlusion of the right internal jugular vein (IJV) just above the junction with the right innominate vein. From the configuration and location of the lesion, it was concluded the occlusion had been caused by venous valvular degeneration. Her NVG with progressive intraocular pressure (IOP) elevation was presumably attributed to the right IJV occlusion. The extra-rigid occlusive lesion was successfully penetrated by means of a Brockenbrough needle and subsequently implanted with a balloon-expandable stent. Intravascular ultrasound (IVUS) guidance allowed us to manipulate the Brockenbrough needle safely. After stent implantation, the right IOP declined dramatically, resulting in the preservation of her eyesight. .

[Surgical Treatment of Aortic Stenosis Combined with Bilateral Pheochromocytomas in a Dialysis Patient].

We report a case of a dialysis patient with severe aortic stenosis(AS) along with bilateral pheochromocytomas. A 52-year-old man presented with syncope and was diagnosed with severe AS. Although aortic valve replacement(AVR) was scheduled, bilateral pheochromocytomas were found during preoperative examination. There was a high possibility of developing hemodynamical crisis during AVR, and we planned to perform adrenalectomy prior to AVR. To avoid circulatory collapse just after adrenalectomy, balloon aortic valvuloplasty (BAV) was performed beforehand. Two weeks after the adrenalectomy, AVR was performed in a stable condition.

The distribution and function of aquaporins in the kidney: resolved and unresolved questions.

The membrane water channel aquaporin (AQP) family is composed of 13 isoforms in mammals, eight of which are reportedly expressed in the kidney: AQP1, 2, 3, 4, 6, 7, 8, and 11. These isoforms are differentially expressed along the renal tubules and collecting ducts. AQP1 and 7 are distributed in the proximal tubules, whereas AQP2, 3, and 4 occur in the collecting duct system. They play important roles in the reabsorption of water and some solutes across the plasma membrane. In contrast to other aquaporins found in the kidney, AQP6, 8, and 11 are localized to the cytoplasm rather than to the apical or basolateral membranes. It is therefore doubtful that these isoforms are directly involved in water or solute reabsorption. AQP6 is localized in acid-secreting type A intercalated cells of the collecting duct. AQP8 has been found in the proximal tubule but its cellular location has not yet been defined by immunohistochemistry. AQP11 seems to be localized in the endoplasmic reticulum (ER) of proximal tubule cells. Interestingly, polycystic kidneys develop in AQP11-null mice. Many vacuole-like structures are seen in proximal tubule cells in kidneys of newborn AQP11-null mice. Subsequently, cysts are generated, and most of the mice die within a month due to severe renal failure. Although ER stress and impairment of polycystin-1, the product of the gene mutated in autosomal-dominant polycystic kidney disease, are possible causes of cystogenesis in AQP11-null mice, the exact mechanism of pathogenesis and the physiological function of AQP11 are yet to be resolved.