In situ management of late thrombosis of a renal graft vein in a patient with Cockett syndrome / Prise en charge in situ d'une thrombose tardive de la veine d'un greffon rénal chez une patiente avec un syndrome de Cockett

Late thrombosis of the renal graft vein is a rare complication that results in graft loss in the majority of cases. We describe the case of a 57-year-old female patient who had a kidney transplant 32 years ago and developed a late thrombosis of the graft vein, accompanied by extensive thrombosis in the common femoral and iliac veins. Risk factors included severe malnutrition, chronic inflammation due to an anal fistula, and Cockett syndrome. The treatment consisted of mechanical thrombectomy of the iliac vein, placement of a stent in the common iliac vein, partial thromboaspiration of the renal vein thrombus with local thrombolysis, followed by systemic anticoagulation. With this approach, renal function fully recovered without major complications.

La thrombose tardive de la veine du greffon rénal est une complication rare qui conduit à la perte du greffon dans la majorité des cas. Nous présentons le cas d'une femme de 57 ans, transplantée depuis 32 ans, qui a développé une thrombose de la veine du greffon, se manifestant par une insuffisance rénale aiguë anurique. Cette thrombose compliquait une thrombose extensive débutant dans la veine fémorale superficielle et s'étendant dans les veines fémorale commune et iliaque. La patiente présentait plusieurs facteurs de risque de thrombose veineuse, tels qu'un état de malnutrition sévère, une inflammation chronique due à une fistule anale chronique et un syndrome de Cockett. La patiente a été traitée en plusieurs étapes successives : une thrombectomie mécanique de toute la veine iliaque a d'abord été réalisée, suivie de la mise en place d'un stent dans la veine iliaque commune gauche en raison du syndrome de Cockett, puis d'une thrombo-aspiration partielle du thrombus de la veine rénale combinée à une thrombolyse locale (par urokinase) de la veine rénale via un cathéter, et enfin d'une anticoagulation systémique. Cette approche a permis une récupération complète de la fonction rénale sans complication notable. Nous rapportons cette prise en charge in situ d'une thrombose tardive de la veine d'un greffon rénal chez une patiente avec un syndrome de Cockett, ayant permis une issue favorable.

Aortic Coarctation Stenting in Adolescents and Adults: A Single-Center Experience.

PURPOSE/BACKGROUND: The aim of this study was to evaluate the short and midterm results of aortic coarctation (AoCo) stenting in an adolescent and adult population. METHODS: All patients with a AoCo older than 14 years treated by stent placement between December 2000 and November 2016 were included in this study. Twenty-eight patients with an invasive peak systolic pressure gradient >20 mmHg were identified. Number of redilations, non-invasive systolic blood pressure, peak systolic pressure gradient, antihypertensive medication intake, claudication status and complications were evaluated. RESULTS: Twenty-two covered and 6 uncovered stents were successfully placed. Peak systolic pressure gradient decreased immediately after stenting from a mean of 32 mmHg to 0 mmHg (± 7 mmHg). Mean AoCo diameter increased from 8 tot 16 mm (± 4 mm). Peripheral arterial injury was seen in 2 patients (7.1%). The mean follow-up time was 60 ± 49 months. Redilation of the stent was required in 4 patients, 2 to accommodate for growth and 2 for restenosis. Six (35%) patients could stop all antihypertensive medication. All claudicants (6/28) became and remained asymptomatic after surgery and during their follow-up. No aneurysms, stent fractures or dissections were noticed. There were 2 stent migrations during the first procedure with only 1 needing additional stent placement. CONCLUSION: Aortic coarctation stenting is a safe and effective treatment that significantly reduces the peak systolic pressure gradient. Antihypertensive medication can be reduced, and increase of walking distance in claudicants can be obtained. Younger patients may need more frequent reinterventions to accommodate for growth.

Comparison of different inflation times on the angiographic image after balloon angioplasty in the femoropopliteal segment: a prospective randomized clinical trial.

BACKGROUND: Endovascular balloon angioplasty is a common practice to treat femoropopliteal arterial lesions. The precise balloon inflation duration to obtain the best lesion dilatation is unclear. The aim of this study was to assess angiographic images after 3- and 5-minute balloon inflation in femoropopliteal de-novo atherosclerotic lesions. METHODS: We randomly assigned 61 femoropopliteal arterial lesions to undergo balloon angioplasty for 3 and 5 minutes. The primary endpoint was the rate of favorable angiographic images after balloon angioplasty. The correlation between angiographic image and degree of calcification was studied. The secondary endpoint was the need of additional ballooning or stenting of the dilated lesion. RESULTS: Thirty-two (52%) lesions were randomized to a 3-minute inflation time and 29 (48%) lesions to a 5-minute inflation time. Median lesion length was 83±32mm in the 3-minute group and 89±31mm in the 5-minute inflation group (P=0.47). After deflation, vessel recoil was significantly higher in the 3-minute group compared to the 5-minute group (P=0.04), in mild to moderate calcified lesions, 18 (56%) and 9 (31%) cases, respectively. The angiographic result after balloon angioplasty was significantly more favorable (P=0.007) in the 5-minute group with 20 (69%) cases compared to 10 (31%) cases in the 3-minute group. An increase of vessel recoil of 62% has been seen in severe calcified lesions in the 5-minute group. Additional intervention rate was significantly higher (P=0.007) in the 3-minute group compared to the 5-minute group. CONCLUSIONS: A prolonged inflation time of 5 minutes has an overall better angiographic image in the femoropopliteal segment and especially in non- or mildly calcified lesions.

Ventriculoperitoneal Shunt Alone Does Not Guarantee Spinal Cord Protection After Complex Aortic Aneurysm Repair.

INTRODUCTION: Spinal cord ischaemia (SCI) is a devastating complication of the treatment of thoraco-abdominal aneurysms. Peri-operative cerebrospinal fluid (CSF) drainage, typically using a spinal catheter, is a possible preventive measure. There are no reports or guidelines on peri-operative CSF drainage for this indication in patients with a ventriculoperitoneal (VP) shunt. REPORT: A single case of a patient suffering SCI after fenestrated endovascular aortic repair for the treatment of a pararenal aneurysm after previous open repair of an infrarenal aortic aneurysm is presented. Despite the presence of a patent VP shunt, elevated CSF pressures were observed after placement of a CSF drain. DISCUSSION: A VP shunt with a gravitational component may drain insufficiently in bedridden patients who often lie with their head tilted on a cushion. In this position, both the differential pressure component and the gravitational component become active, thereby increasing the overall resistance to CSF outflow, hence increasing intracranial and intraspinal pressure. VP shunts with gravitational components should be managed with caution in the setting of prophylactic or therapeutic drainage of CSF to prevent SCI in extensive aortic repair. For reliable CSF pressure monitoring or active drainage in case of symptoms, the insertion of a spinal drain is indicated.