Superior vena cava syndrome-induced hemoptysis.

Superior vena cava (SVC) syndrome resulting from obstruction of the blood flow to the superior vena cava is rarely reported to present with life-threatening hemoptysis. The pathogenesis and the underlying mechanism are still not well described in the literature. We report a unique case of a 27-year-old man known to have end-stage kidney disease (ESKD) on hemodialysis that presented with shortness of breath and life-threatening hemoptysis that developed during the dialysis session. Computerized tomography with contrast (CTPA) confirmed the presence of a large, calcified thrombus within the SVC along with the formation of multiple collaterals which was diagnostic for SVC syndrome. Attempts for revascularization and stenting failed, and the patient had a prolonged and stormy course while admitted, including difficult alternative dialysis access that unfortunately resulted in death eventually. Here we are highlighting the importance of recognition of hemoptysis as a presentation of SVC syndrome by explaining the underlying pathogenesis and possible management options.

Rupture of Renal Angiomyolipoma Post Fibrinolysis: A rare complication of fibrinolytic therapy.

Angiomyolipoma is a common benign solid tumour that accounts for up to 3% of all renal tumours; most of the cases are sporadic. However, it can be part of other diseases. Angiomyolipomas are usually found incidentally through unrelated clinically indicated images but also, they can be diagnosed after complications have occurred. We report the case of retroperitoneal haemorrhage following the rupture of renal angiomyolipoma post-fibrinolysis, we are highlighting such a rare condition, the management options and the follow-up plan. The management of angiomyolipomas ranges from conservative treatment to surgical intervention depending on the patient's condition and the tumour's radiological features. Following-up on patients with angiomyolipomas depends on the symptoms and the tumour size. Till date, there is no reported cases of renal angiomyolipoma rupture post-fibrinolysis therapy as a treatment for myocardial infarction in non-percutaneous intervention capable facility.

Emphysematous Pyelonephritis Disparities observed in the use of percutaneous drainage techniques.

Objectives: The recent drop in the mortality rates of emphysematous pyelonephritis, a serious medical condition, is attributable to renal percutaneous drainage (PCD) techniques that have also reduced the necessity for surgery. Since the difference in the objectives of the two specific techniques, i.e. PCD and percutaneous nephrostomy (PCN), is often overlooked, this study aimed to highlight the inconsistencies in the use of these two techniques. Methods: A retrospective study of 17 patients was conducted over a 10-year period from January 2008 to December 2017 at The Royal Hospital, Muscat, Oman. All patients had undergone abdominal computerised tomography. The obtained images were reviewed and categorised based on Huang and Tseng's classification. Results: From the sample, 13 patients (76%) were categorised as class I and II, three (17%) as class IIIA and one (6%) as class IIIB. Five patients from the class I and II categories underwent drainage of the pelvicalyceal system, four by PCN and one by a double-J stent insertion. PCN was performed on all the class IIIA and IIIB patients. One class IIIB patient required PCD for localised gas and fluid collection but later underwent emergency nephrectomy. There were no mortalities. Conclusion: The favourable outcome of this study was in keeping with those of the more recent studies. However, despite the present classifications and guidelines, wide variations were reported in the use of percutaneous drains with PCD, ranging from 2.5-91%. The lack of precise guidelines may be a cause of these disparities in clinical management.

May-Thurner Syndrome: A Case Report and a Concise Review.

We report a case of a 31-year-oldman who presented to the hospital with extensive deep vein thrombosis (DVT) complicated by pulmonary embolism (PE) after a recent trauma and prolonged immobilization. He underwent contrast venography that revealed features of May-Thurner syndrome (MTS). He was managed with therapeutic anticoagulation, inferior vena cava filter placement, mechanical clot aspiration, catheter-directed thrombolytic therapy, and left common iliac vein stenting. MTS is a vascular condition caused by the compression of the left common iliac vein by an overlying right common iliac artery against a vertebral body. This results in indolent endothelial changes secondary to the pulsating nearby artery as well as the compression increasing the susceptibility to venous thrombosis. Females are thought to be more prone to the condition due to the nature of their pelvic anatomy. Most patients are asymptomatic or present with unspecific symptoms, rendering the condition underdiagnosed. The gold standard diagnostic modality is contrast venography that reveals collaterals and a pressure gradient greater than 2 mmHg at rest across the stenotic region. Treatment is revolved around the removal of the thrombus along with the correction of the anatomical defect through interventional or surgical treatment to prevent a recurrence. Untreated MTS complicated with DVT carries a risk of potentially life-threatening complications, such as PE, iliac vein rupture, retroperitoneal hematoma, or refractory DVT that is difficult to treat. Due to the chronicity of this syndrome, its management plan differs from that of other causes of DVT. Proper identification of MTS carries a positive outcome in treating DVT secondary to MTS. Here we are going to discuss a case diagnosed with MTS complicated by saddle PE outlying the possible pathophysiology, clinical manifestation, diagnostic tools, and management of complicated MTS.

Ultrasound Measurement and Kidney Development: a Mini-Review for Nephrologists.

Ultrasound (US) is a noninvasive, simple and safe imaging investigation that can be done as many times as needed. Therefore, it is the primary imaging modality for evaluating kidneys. We carried out a literature review of information about ultrasonography for clinicians, especially nephrologists. US utilization from prenatal time till adult life with various measurements including, length, width, depth, and volume was searched during 2019. US identifies 90% of fetal kidneys by 20 weeks of gestational age. Kidney weight and volume at birth are approximately only 10% of the mature kidney. Kidney growth is most rapid during the first few weeks of life, with the kidney length increasing by as much as 15-20% in full-term neonates. There is a good correlation between relative function shown by scintigraphy and relative volume estimated from sonography. The most accurate measurement of kidney size is provided by kidney volume, which is correlated with subject's height, weight, and total body area. Kidney length is the most easily reproduced. Kidney volume is a better approximation of size than length because of the shape of the kidney varies considerably, but it is technically more demanding and needs four measurements in two different planes. It has been shown that in normal adult kidneys, the sonography measurements of kidney length differ by values of between about 1 cm and 1.85 cm in 95% of the cases, irrespective of whether the measurements are performed by the same or by different sonographers. Measuring the renal parenchyma with US is a novel method to assess fetal kidney development and predict future renal function.

Inferior Vena Cava Filter Placement in a Duplicated Inferior Vena Cava: A Case Report.

Inferior vena cava (IVC) duplication is a well-known anatomic variation that is important when relevant procedures are being planned. Duplication of IVC is a relatively rare to detect especially vascular anomaly with a prevalence of 1.5% (range 0.2-3.0%). Knowing this anatomical variation is very important in cases of IVC filter placement. Filter placement in duplicated IVC cases has many options like placing it in both vena cavae, suprarenal filter placement, or coil embolization of the intervenous segment plus placing a filter in the right IVC. We report a case of a patient with newly diagnosed bladder cancer who had a high risk of thrombosis and a recent massive pulmonary embolism. The patient was planned for transurethral resection of the bladder tumor. As a prophylactic measure, an IVC filter placement was requested to prevent further pulmonary emboli that might occur during or after surgery. Cavography showed a duplicated IVC, and the filter placement was performed in the suprarenal portion and was proved to be an adequate and safe procedure. No procedure-related complications were reported. There are few worldwide reported cases of filter placement in a duplicated vena cava, and to our best knowledge, this is the first case reported in Oman.