Selective Angioembolisation of Iatrogenic Renal Artery Pseudoaneurysms Following Minimally Invasive Urological Procedures: A Single Centre Case Series.

INTRODUCTION: The purpose of this study was to report our centre's experience using selective angioembolisation in the treatment of iatrogenic renal artery pseudoaneurysms (RAP) following minimally invasive urological procedures. METHODS: Our retrospective analysis included four consecutive patients treated with angioembolisation for iatrogenic RAP between October 2016 and October 2021. Data on demographics, minimally invasive urological intervention, clinical features, imaging findings, embolization procedure and perioperative details were collected. Rates of technical and clinical success, defined as 1. total occlusion of the extravasation site on completion digital subtraction angiography (DSA), and 2. resolution of symptoms, signs, and serum hemoglobin (Hb) derangements secondary to RAP, were analysed. Renal function, measured by serum creatinine (Cr) and estimated glomerular filtration rate (eGFR), was recorded prior to and post - angioembolisation procedure and compared. RESULTS: Mean time between urological intervention and angioembolisation was 9 days (range, 2-17 days). Rates of technical and clinical success were 100% and 100% respectively. No additional angioembolisation procedures were required, and there were no peri or post-operative complications identified during mean follow-up of 662 days (range, 30-1845 days). Mean serum Cr prior to and post angioembolisation was 83 mmol/L and 79.5 mmol/L. Mean eGFR prior to and post angioembolisation was 73.8 and 77.8 mL/min/1.73 m2. In all patients, no significant difference was observed in serum Cr and eGFR prior to and post angioembolisation. CONCLUSION: Iatrogenic renal artery pseudoaneurysms can occur following a range of minimally invasive urological procedures. This retrospective review highlights the utility of angioembolisation as a safe and effective treatment with high clinical and technical success rates. Further studies involving larger populations are required to validate its broader application.

Concurrent Ilio-Enteric and Ilio-Vesical Fistula From Large Aorto-Iliac Aneurysm.

Iliac artery aneurysms (IAA) are associated frequently with abdominal aortic (AAA) and other degenerative large-vessel aneurysms. Concurrent fistulization of the aortoiliac tree into the gastrointestinal tract (GIT) and bladder is exceptionally rare. We herewith report a unique case of concurrent ilio-enteric and ilio-vesical fistula arising from a large aorto-iliac aneurysm.

Symptomatic sac enlargement and rupture due to seroma after open abdominal aortic aneurysm repair with polytetrafluoroethylene graft: Implications for endovascular repair and endotension.

OBJECTIVE: We report 5 patients in whom a symptomatic perigraft seroma developed within the aortic sac, without vascular endoleak, after open repair of an abdominal aortic aneurysm (AAA) with a polytetrafluoroethylene (PTFE) graft. We also discuss possible relationships of this phenomenon to endovascular repair of AAAs. PATIENTS AND METHODS: Over 18 years, 1156 patients underwent repair of an AAA by one of the authors (B.M.B.). Of these, 1084 underwent open repair, 256 with PTFE grafts. Five patients in the PTFE group (2.3%) returned at a mean of 4.5 years with acute abdominal or back pain and enlargement of the aortic sac. Mean diameter of the aneurysms was 5.9 cm preoperatively and 8.1 cm at readmission. There was no evidence of vascular endoleak on computed tomography scans, but 1 patient had a retroperitoneal hematoma. RESULTS: Laparotomy in 4 patients disclosed a seroma containing firm rubbery gelatinous material under tension, histologically identified as amorphous eosinophilic material containing thrombus and degenerate blood cells in all cases. Rupture of the sac was confirmed in the patient with a retroperitoneal hematoma. The sac contents were evacuated and the integrity of the underlying grafts and anastomoses was confirmed before sac reduction, with imbricating sutures, and closure was performed. One patient died at 8 months of an unrelated cause; the other 3 patients remain well at mean follow-up of 12 months. The fifth patient received conservative treatment and remains asymptomatic 3 years after acute presentation. CONCLUSIONS: These findings of sac enlargement without vascular endoleak after open AAA repair are reminiscent of sac enlargement in the absence of endoleak after endovascular AAA repair. This has been referred to as endotension. The comparatively benign outcome in 5 patients with symptomatic sac enlargement, including 2 patients with rupture, after open AAA repair provides data to support a circumspect approach to endotension, especially in patients with asymptomatic disease, which has been reported as occurring in almost half of patients who received a PTFE Excluder endograft.

Early control of the distal internal carotid artery during endarterectomy: achievability and results.

PURPOSE: The purpose of this study was the report of the results of a consecutive series of carotid endarterectomy (CEA), performed by one surgeon and independently assessed by a neurologist, in which the achievability of selective early control of the distal internal carotid artery (ICA) was prospectively recorded. METHODS: All patients who underwent CEA by the surgical author between November 17, 1999, and November 15, 2001, were entered into a prospective study during which early selective exposure and clamping of the distal ICA were attempted (with initial avoidance of carotid bifurcation exposure and retraction), which allowed the remainder of the procedure (in patients without shunting) to be performed with ICA clamp protection and anticoagulation therapy. All the procedures were performed with local cervical block anesthesia, all the patients underwent a vein patch procedure, and, with one exception, cerebral angiography was not used. Major morbidity (stroke and myocardial infarction), mortality, and consecutiveness were independently verified by a neurologist. RESULTS: 148 consecutive CEAs were performed. In 142 cases (96%), the soft distal ICA could be initially isolated and controlled without dissection of the plaque-bearing bulb bifurcation area (group A), and in the remaining six cases, the carotid bifurcation had to be exposed and retracted to allow ICA clamping (group B). A shunt was needed in 15 cases (14 in group A, one in group B), which left 128 cases (86%) in which the procedure could be performed with the ICA clamped and the brain theoretically protected from particulate plaque embolism. There were no strokes or deaths, one patient had temporary vertebrobasilar ischemia, one patient had a myocardial infarct, one patient had a temporary accessory nerve palsy, one patient returned to the operating room for release of a cervical hematoma, and 94% spent one postoperative night in the hospital. CONCLUSION: Early selective distal ICA control is highly achievable during CEA without apparently compromising clinical results. Its use is relevant when selective methods of shunting that do not need initial control of the common and external carotid arteries (eg, local cervical block anesthesia, electroencephalography/other monitoring) are used. Further evaluation with transcranial Doppler scan monitoring is suggested to substantiate the theoretic potential of this method in the reduction or elimination of particulate plaque embolism.