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Vascular urologic emergencies: image-guided interventions
JVIR
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Posters and Exhibits
S159
Background: Solid organ injuries are seen in accidental trauma, blunt and penetrating. Early identification and management of these injuries is key to survival. Injury to door times in the ER have reduced at most major urban trauma centers, resulting in a better chance of survival. While surgical evaluation of several of these injuries is usually first step, referral to catheter based therapies has now become standard of care in several major organs and injuries. Catheter based techniques allow rapid identification and management options using either a “plug it” embolic approach or “exclude it” stent approach. Clinical Findings/Procedure Details: Cases demonstrated include1) Pulmonary artery pseudoanerysm secondary to knife wound treated with coils 2) Renal artery dissection and occlusion treated with stenting 3) Renal aneurysm treated with coils 4) Hepatic arterial aneurysm treated with coils 5) Splenic rupture and aneurysm treated with coils 6) Arterio-ureteral fistula treated with stent graft 7) Delayed arterio-enteric fistula treated with stent graft 8) Carotid laceration treated with stent graft 9) Giant gluteal pseudoaneurysm treated with percutaneous thrombin injection 10) Aortic rupture treated with stent graft Conclusion and/or Teaching Points: Interventionalists play an increasingly important role in the management of traumatic solid visceral injury. A basic knowledge of the presentation and treatment of these injuries is of core educational value to the modern practicing interventionalist.
Educational Exhibit
Abstract No. 356
Vascular urologic emergencies: imageguided interventions A.W. Maxwell, G. Kumar; University of Missouri School of Medicine, Columbia, MO
Abstract No. 357 Making the best out of the lab values; correlation of fibrinogen level with rate of thrombus resolution during tissue plasminogen (TPA) therapy S. Laroia, S. Alexander, S.A. Morales, N.G. Miller, A. laroia; University of Iowa, Iowa City, IA Purpose: Continuous infusion of TPA is commonly used for treating arterial and venous thrombosis. Fibrinogen levels are typically serially monitored over the infusion period and used as surrogate marker for impending bleeding. We correlated the fibrinogen level fluctuations with the rate of thrombus resolution, with the aim to use this as a prognostic factor indicating adequate thrombus resolution. We hypothesized that fibrinogen level falling more than 30% from baseline indicated better response to thrombolytic therapy. To our knowledge, this correlation has not been studied in human subjects so far. Materials and Methods: 32 patients undergoing systemic tPA therapy were studied in a retrospective manner and serial fibrinogen levels were tabulated. Based on the the level of fibrinogen, patients were divided into three categories. Group 1: fibrinogen level falling less than 10% of the baseline in first 12 hours, Group 2: fibrinogen level falling 10-30%, Group 3: fibrinogen level falling more than 30%. The level of clot resolution in these patients (based upon review of the thrombolysis procedure reports) was used to further separate the data into three additional categories: minimal clot resolution, o¼ 50% decrease in clot burden, and 4 50% decrease in clot burden. The data were reviewed qualitatively and a chi-squared test was used to determine the statistically significant relationship between the two methods of grouping. Results: 9 (28%) patients showed fibrinogen level falling more than 30% from the baseline. All these patients showed more than 80% resolution of the thrombus load in first 12 hours. 6 (18%) patients showed less than 10% fluctuation in the fibrinogen level in the initial 12 hours, all these patients showed poor resolution of the thrombus in the first 12 hours. Chisquared analysis showed there was a significant relationship between the level of fibrinogen change and the level of clot burden resolution.
Posters and Exhibits
Learning Objectives: Modern imaging studies such as computerized topography (CT) and ultrasound (US) provide an advantage for the detection of vascular urological injuries because of their speed, while digital subtraction angiography (DSA) allows for the precision needed for effective intervention. Minimally invasive techniques offer potentially lower complication rates and faster recovery times than traditional methods. This study demonstrates the role of image-guided percutaneous angiography (PCA) in such emergencies through five cases that cover the scope of neoplastic, iatrogenic, postoperative, and traumatic hemorrhages as well as priapism. Background: PCA has revolutionized vascular interventions. DSA provides both a detailed diagnosis and an avenue for precise interventions. Embolization of pathologic vessels or hemorrhage sites can be achieved using embospheres, microcoils or gel foam. These techniques are easily extrapolated in the context of vascular urologic emergencies. Clinical Findings/Procedure Details: One such case was a 57 year-old woman with an acute hemorrhage following surgical resectioning for renal cellular carcinoma (RCC). The postoperative period was complicated by a difficult extubation followed by acute hemorrhagic shock. The patient’s hemoglobin
dropped to 6.5 as her surgical drain emptied serosanguineous fluid. After requiring 6 units of PRBC, 4 units FFP and 1 unit of platelets, IR was consulted and emergent renal DSA was performed of the left main renal artery. Subselective left inferior renal segmental branch angiography showed two small pseudoaneurysms peripheral to the site of resectioning. Microcoil embolization of the left inferior segmental branch was performed, successfully occluding perfusion to the pseudoaneurysms. The patient’s hemodynamic status soon stabilized and she was transferred out of the ICU in the following days. Conclusion and/or Teaching Points: The case above demonstrates the application of interventional radiologic techniques in just one urologic vascular emergency. Furthermore, the methods used in the above case are not dissimilar to those used in the following case reviews, which illustrate the unique treatment options image-guided interventions can offer in the urologic setting.
’
Posters and Exhibits
S159
Background: Solid organ injuries are seen in accidental trauma, blunt and penetrating. Early identification and management of these injuries is key to survival. Injury to door times in the ER have reduced at most major urban trauma centers, resulting in a better chance of survival. While surgical evaluation of several of these injuries is usually first step, referral to catheter based therapies has now become standard of care in several major organs and injuries. Catheter based techniques allow rapid identification and management options using either a “plug it” embolic approach or “exclude it” stent approach. Clinical Findings/Procedure Details: Cases demonstrated include1) Pulmonary artery pseudoanerysm secondary to knife wound treated with coils 2) Renal artery dissection and occlusion treated with stenting 3) Renal aneurysm treated with coils 4) Hepatic arterial aneurysm treated with coils 5) Splenic rupture and aneurysm treated with coils 6) Arterio-ureteral fistula treated with stent graft 7) Delayed arterio-enteric fistula treated with stent graft 8) Carotid laceration treated with stent graft 9) Giant gluteal pseudoaneurysm treated with percutaneous thrombin injection 10) Aortic rupture treated with stent graft Conclusion and/or Teaching Points: Interventionalists play an increasingly important role in the management of traumatic solid visceral injury. A basic knowledge of the presentation and treatment of these injuries is of core educational value to the modern practicing interventionalist.
Educational Exhibit
Abstract No. 356
Vascular urologic emergencies: imageguided interventions A.W. Maxwell, G. Kumar; University of Missouri School of Medicine, Columbia, MO
Abstract No. 357 Making the best out of the lab values; correlation of fibrinogen level with rate of thrombus resolution during tissue plasminogen (TPA) therapy S. Laroia, S. Alexander, S.A. Morales, N.G. Miller, A. laroia; University of Iowa, Iowa City, IA Purpose: Continuous infusion of TPA is commonly used for treating arterial and venous thrombosis. Fibrinogen levels are typically serially monitored over the infusion period and used as surrogate marker for impending bleeding. We correlated the fibrinogen level fluctuations with the rate of thrombus resolution, with the aim to use this as a prognostic factor indicating adequate thrombus resolution. We hypothesized that fibrinogen level falling more than 30% from baseline indicated better response to thrombolytic therapy. To our knowledge, this correlation has not been studied in human subjects so far. Materials and Methods: 32 patients undergoing systemic tPA therapy were studied in a retrospective manner and serial fibrinogen levels were tabulated. Based on the the level of fibrinogen, patients were divided into three categories. Group 1: fibrinogen level falling less than 10% of the baseline in first 12 hours, Group 2: fibrinogen level falling 10-30%, Group 3: fibrinogen level falling more than 30%. The level of clot resolution in these patients (based upon review of the thrombolysis procedure reports) was used to further separate the data into three additional categories: minimal clot resolution, o¼ 50% decrease in clot burden, and 4 50% decrease in clot burden. The data were reviewed qualitatively and a chi-squared test was used to determine the statistically significant relationship between the two methods of grouping. Results: 9 (28%) patients showed fibrinogen level falling more than 30% from the baseline. All these patients showed more than 80% resolution of the thrombus load in first 12 hours. 6 (18%) patients showed less than 10% fluctuation in the fibrinogen level in the initial 12 hours, all these patients showed poor resolution of the thrombus in the first 12 hours. Chisquared analysis showed there was a significant relationship between the level of fibrinogen change and the level of clot burden resolution.
Posters and Exhibits
Learning Objectives: Modern imaging studies such as computerized topography (CT) and ultrasound (US) provide an advantage for the detection of vascular urological injuries because of their speed, while digital subtraction angiography (DSA) allows for the precision needed for effective intervention. Minimally invasive techniques offer potentially lower complication rates and faster recovery times than traditional methods. This study demonstrates the role of image-guided percutaneous angiography (PCA) in such emergencies through five cases that cover the scope of neoplastic, iatrogenic, postoperative, and traumatic hemorrhages as well as priapism. Background: PCA has revolutionized vascular interventions. DSA provides both a detailed diagnosis and an avenue for precise interventions. Embolization of pathologic vessels or hemorrhage sites can be achieved using embospheres, microcoils or gel foam. These techniques are easily extrapolated in the context of vascular urologic emergencies. Clinical Findings/Procedure Details: One such case was a 57 year-old woman with an acute hemorrhage following surgical resectioning for renal cellular carcinoma (RCC). The postoperative period was complicated by a difficult extubation followed by acute hemorrhagic shock. The patient’s hemoglobin
dropped to 6.5 as her surgical drain emptied serosanguineous fluid. After requiring 6 units of PRBC, 4 units FFP and 1 unit of platelets, IR was consulted and emergent renal DSA was performed of the left main renal artery. Subselective left inferior renal segmental branch angiography showed two small pseudoaneurysms peripheral to the site of resectioning. Microcoil embolization of the left inferior segmental branch was performed, successfully occluding perfusion to the pseudoaneurysms. The patient’s hemodynamic status soon stabilized and she was transferred out of the ICU in the following days. Conclusion and/or Teaching Points: The case above demonstrates the application of interventional radiologic techniques in just one urologic vascular emergency. Furthermore, the methods used in the above case are not dissimilar to those used in the following case reviews, which illustrate the unique treatment options image-guided interventions can offer in the urologic setting.