Abdominal Aortogram Research Articles

Treatment of Symptomatic Paravisceral Aortic Thrombus Using Percutaneous Suction Thrombectomy

Paravisceral aortic thrombus in an otherwise normal aorta is rare. A hemodynamically significant thrombus burden in such patients can result in visceral malperfusion and bilateral lower extremity ischemia, both of which, historically, have a high mortality rate. Open thrombectomy via a thoracoabdominal approach is associated with high mortality. Other endovascular alternatives, including Fogerty embolectomy and mechanical thrombectomy, are associated with visceral embolization. The Penumbra CAT-12 lightning device (Penumbra Inc, Alameda, Calif) most commonly used to treat ileofemoral deep vein thrombosis is a 12F suction catheter with the ability to remove large amounts of clot burden with minimal blood loss owing to its sensor mechanism. The ability to suction thrombectomy-focused areas in the aorta reduces the likelihood of embolization. We have presented the cases of two patients with acute symptomatic paravisceral aortic thrombus who were treated with this device and their outcomes. Two patients had presented to the emergency room with acute onset abdominal pain and bilateral lower extremity rest pain and numbness. Patient 1 was a 46-year-old woman with antithrombin III and protein C deficiency (Fig 1). Patient 2 was a 78-year-old woman with recent coronavirus disease 2019 infection, chronic obstructive pulmonary disease, and congestive heart failure (Fig 2). Computed tomography angiography of patients demonstrated aortic thrombus in the paravisceral aorta extending from the supraceliac to the infrarenal aorta. Both patients underwent percutaneous suction thrombectomy of the aorta using the Penumbra CAT-12 lightning device. Patient 2 also underwent bilateral femoral cutdown, thrombectomy, and kissing iliac stents, followed by diagnostic laparoscopy without any further intervention. The intraoperative angiographic images demonstrated the initial aortic thrombus in the paravisceral aorta with resolution of thrombus after suction thrombectomy (Figs 1 and 2). The abdominal pain and bilateral lower extremity rest pain had resolved in both patients postoperatively and did not require any further surgical intervention. Patient 1 was discharged home on postoperative day 3. Patient 2 was discharged to a rehabilitation facility on postoperative day 10. Percutaneous suction thrombectomy devices such as the Penumbra CAT-12 lightning device is effective in removing a large paravisceral aortic clot burden without any embolization to the visceral vessels. This is a newly available alternative to consider for such patients with symptomatic paravisceral aortic thrombus considered to have a high mortality risk with open intervention.Fig 2a, Angiogram demonstrating aortic thrombus at the level of the superior mesenteric artery. b, Coronal view of paravisceral aortic thrombus. c, Abdominal aortogram demonstrating improvement in paravisceral thrombus burden with embolization of thrombus to the aortic bifurcation. d, Lateral aortogram demonstrating patent and disease-free celiac and superior mesenteric artery. e, Aortogram after bilateral femoral embolectomy and bilateral kissing iliac stents showing flow to the lower extremity and pelvis restored with no further thrombus burden. f, Post-op CTA demonstrating aortic lumen patency at the SMA take-off.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Anomalous Celiac Trunk Variation Encountered in Y-90 Radioembolization

Background: 
 Yttrium-90 microsphere embolization is a selective internal radiation therapy (SIRT) used in the treatment of hepatocellular carcinoma and liver metastases. Current literature recommends lobar, or more selective, infusion of SIRT to allow for precise radiation administration and to mitigate risk of non-target embolization. Lobar infusion requires knowledge of anatomical variations of hepatic arterial supply. The trifurcation of the celiac trunk into the left gastric artery, splenic artery, and common hepatic artery is the most common presentation representing 51% to 89% of patient anatomy. A replaced right hepatic artery (RHA) arising from the superior mesenteric artery (SMA) is one of the most common variants of hepatic arterial supply with a prevalence of 10.6% to 15%. Common variations such as these are well described and easily mapped using catheter angiography, but rarer variations are not as well described and more challenging to map. 
 
 Project Methods: 
 Mapping catheter angiogram of the celiac trunk and SMA was obtained. Additional aortogram and CT angiogram were obtained to further elucidate patient’s anatomy. 
 
 Results: 
 Initial mapping angiogram was only partially successful because the RHA could not be selected. Abdominal aortogram and CT angiogram of the abdomen and pelvis revealed a replaced RHA arising directly from the distal celiac trunk. Additionally, the patient had a replaced cystic artery arising from the left hepatic artery and an arc of Buhler connecting the proximal SMA to the proximal aspect of the right hepatic artery. 
 
 Conclusion: 
 Radiologists need to be aware of rare variations in hepatic arterial supply for the safe and effective treatment of hepatic neoplasms, whether primary or metastatic. Description of arterial variation and informed selection of arterial branches will remain a critical aspect of improving efficiency and reducing risks of hepatic embolization procedures.

An Uncommon Cause for Colonic Ischemia

We present a case of Polyarteritis Nodosa (PAN) in a hepatitis B negative patient presenting as ischemic colitis with delay in diagnosis leading to renal failure. There have been less than 10 cases reported in literature.A 49 year old male with a history of hypertension with resultant chronic kidney disease Stage 2 and rheumatoid arthritis (on Prednisone) presented to our hospital with generalized malaise, intermittent nausea and vomiting along with loose stools for the past 1 month. He noted a 30lb weight loss over the previous few months. Labs were notable for normocytic anemia, leukocytosis and acute kidney injury ( Creatinine of 3.4 from a baseline of 1.5). Urinalysis showed trace protein, no WBC or RBC with negative urine eosinophils. His renal function improved with hydration, however his gastrointestinal symptoms persisted. Work up revealed no infections and he underwent a colonoscopy which revealed ulcerated mass like lesions in the hepatic, transverse and sigmoid colon. Biopsies revealed ischemic colitis. He underwent an abdominal aortogram with carbon dioxide which showed no evidence of mesenteric stenosis. His renal function underwent progressive rapid decline necessitating a kidney biopsy revealing necrotizing arteritis consistent with a diagnosis of polyarteritis nodosa (PAN). He was started on hemodialysis and immunosuppresion with steroids and cyclosporine. His gastrointestinal symptoms resolved. A repeat follow up colonoscopy revealed normal colonic mucosa. PAN usually presents as ischemic disease in the small bowel and much more rarely in the colon. Colonic presentation can be mistaken for IBD in younger patients and atherosclerotic ischemic colitis in older patients as in this patient. Unlike some other vasculitides such as Wegener granulomatosis, remission can be obtained with PAN if diagnosed early. This patient was started on an immunosuppression regimen, which suppressed recurrence of GI symptoms, however was too late to salvage kidney function. In patients who present with a constellation of laboratory findings in the setting of ischemic colitis a broad differential should be obtained and repeat deep biopsies should be taken to confirm diagnosis of a vasculitis. A delay in diagnosis can lead to life changing consequences and even death.

Spontaneous renal artery dissection in a cannabis user

A 32-year-old previously healthy male presented to the emergency department with acute onset of right-sided abdominal and back pain. Review of his social history was positive for heavy daily cannabis use. Unenhanced abdominal computed tomography (CT) showed possible pyelonephritis that prompted treatment with oral antibiotics. After 7 days of persistent hypertension and pain, a followup contrast-enhanced abdominal CT revealed areas of infarction in the right kidney (Panel A). Duplex ultrasound confirmed decreased parenchymal flow with a monophasic pattern in the upper pole of the right kidney (Panel B). An abdominal aortogram demonstrated a perfusion defect in the same region (Panel C, dashed outline). Selective angiography of the right superior hilar artery confirmed the presence of a complex dissection extending into the distal segment (Panel D). Endovascular intervention was attempted, but the guidewire could not advance beyond the zone of dissection (asterisk). Intravascular ultrasound (IVUS) (Volcano Corporation; inset) with color imaging (ChromaFlo ® ) demonstrated a dissection flap with flow in both true (T) and false (F) lumens (entire IVUS recording available as a supplemental video). Extensive serological testing found no evidence of known coagulopathies or vasculitides. Intracranial and

An Analysis of the Factors Influencing Radiation Dose and Fluoroscopic Time During Renal Artery Stent Placement

To determine the factors that affect mean absorbed dose and fluoroscopic times during renal artery stent placement. After institutional review board approval, the HI-IQ database was queried for patients undergoing renal artery stent placement only from January 2007 to June 2010. Procedures that were performed as part of other procedures such as iliac artery stents were excluded. The HI-IQ data included fluoroscopy time (f) and radiation dose (mGy). Demographic, medical history, procedural details, and advanced preprocedural renal artery stent imaging were obtained. Variables (number of stents, average body mass index , number of stents placed per year and number of years' service of an interventional physician, pre-procedural imaging, and use of embolic protection device) were analyzed using a t test after log transformation and testing for variance with an F test. A total of 134 patients (75 males, 70.6 ± 10.5 years old) underwent the placement of 177 renal artery stents (unilateral [n = 95], average stent per patient = 1.3). Mean fluoroscopy time was 15.6 minutes and mean absorbed dose to the patient was 1729 mGy. The average fluoroscopic time and absorbed dose was significantly higher with bilateral stent placement compared to unilateral placement (13.8 vs 19.7 minutes, P = .002; 1803 vs 2380 mGy, P = .03). The average fluoroscopic time was significantly higher in patients undergoing abdominal aortogram prior to renal artery selection and stent placement. The placement of more than 1 stent with an abdominal angiogram prior to renal artery stent placement results in increased fluoroscopic time and mean absorbed dose.

Direct sonographic-guided superior gluteal artery access for treatment of a previously treated expanding internal iliac artery aneurysm

Isolated internal iliac artery aneurysms are relatively uncommon compared with all aortoiliac aneurysms. Transcatheter treatment with coil embolization is an attractive noninvasive alternative to surgical resection. However, if the aneurysm is insufficiently treated with only proximal coil embolization without concurrent embolization of distal runoff vessels, there is a risk of aneurysm expansion from retrograde collateral flow. We present a case of previously treated internal iliac aneurysm that underwent late rapid expansion. Due to occlusion of the internal iliac artery, direct sonographic-guided puncture of the superior gluteal artery was made in order to access the aneurysm. We believe this is the first reported case of such treatment.

A teenager with uncontrolled hypertension: a case report

BackgroundTakayasu Arteritis is a vasculitis occurring mostly in young females which may present in diverse ways. Here we report a teenager with Takayasu Arteritis who presented with uncontrolled hypertension. This case depicts an atypical presentation of this disease where the girl visited many physicians for controlling the level of hypertension and put a diagnostic dilemma about the underlying etiology of young hypertension.Case presentationA 13 year old girl presented with epistaxis, persistent headache and uncontrolled hypertension. Her clinical examination revealed normal radial, very feeble femoral and absent other lower limb pulses. There was a blood pressure discrepancy of 50/40 mm of Hg between two arms. There were bruits over multiple areas including the abdominal aorta. She had features of left ventricular hypertrophy. Her Arch aortogram showed hugely dilated arch of aorta which became abruptly normal just after origin of left subclavian artery. There was ostio-proximal stenosis of right bracheocephalic artery, left common carotid and left subclavian artery with post stenotic dilatation of all the vessels. Abdominal aortogram revealed critical stenosis of abdominal aorta above the origin of renal arteries with a pressure gradient of 80/11 mm of Hg.ConclusionTakayasu’s Arteritis should also be kept in mind while searching for the cause of uncontrolled hypertension in the young age group.

Percutaneous Ventricular Assist Device in Hypertrophic Obstructive Cardiomyopathy With Cardiogenic Shock: Bridge to Myectomy

We present the case of a 69-year-old woman with end-stage hypertrophic obstructive cardiomyopathy who developed cardiogenic shock. She underwent emergent placement of a percutaneous left ventricular assist device (TandemHeart) in the catheterization lab as a bridge support device until a septal myectomy could be performed as definitive treatment. This case suggests a novel and promising use of the TandemHeart as a bridge to myectomy.

Coil Embolization of a Ruptured Basilar Tip Aneurysm Associated with Bilateral Cervical Internal Carotid Artery Occlusion: A Case Report and Literature Review

We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.

Endovascular Management of Acute Total Occlusion of the Aorta

Acute total occlusion of the aorta is a rare and clinically critical condition requiring aggressive immediate diagnosis and treatment. A 73-year-old male was seen at our hospital complaining of pain sensation in both legs. Under the likely impression of an acute total occlusion of the aorta, emergency abdominal aortogram was done, which revealed total occlusion of the distal aorta and both iliac arteries. Intra-arterial thrombolysis with urokinase was attempted for 48 hours as intervention during the acute stage is highly related to distal thromboembolic events. Follow-up angiography showed improved arterial flow but residual stenosis at both the common iliac arteries. Self-expandable nitinol stents were inserted at both the iliac arteries by the v-kissing technique resulting in a satisfying outcome as seen on angiography without complications. The patient was discharged without additional medical problems. From our experience, we conclude that the use of intra-arterial thrombolysis with percutaneous transluminal angioplasty is an alternative to the conventional surgical approach in treating acute total occlusion of the aorta.

Outpatient Vascular and Interventional Radiology Practice from 2001–2008

To describe experience with an outpatient vascular interventional radiology (IR) practice with respect to number of patients seen, number of procedures performed, and number of imaging studies ordered in follow-up. The outpatient vascular IR practice at the authors' institution was established in 2001 with two physicians spending one half-day per week; a third physician joined in 2004. A retrospective review was done of all patients seen by an interventional radiologist from 2001 to July 2008. The following data were collected for each physician per year: the number of new and established patients seen, the number and type of procedures performed, and the number and type of imaging studies ordered. Data are presented as mean ± standard deviation per physician per year and total number. In 2001, the average number of new patients seen was 61 ± 11 (total number = 122), which peaked in 2006 at 127 ± 28 (total number = 380). A similar trend occurred with the established patients. In 2001, the procedure performed with the greatest frequency was abdominal aortogram with stent placement, which started at 18 ± 2 (total number = 35) and peaked by 2006 at 37 ± 23 (total number = 122). The number of ancillary imaging studies ordered by each physician increased each year and by 2006 was nearly 93 ± 77 (total number = 278). A robust outpatient IR practice in vascular disease can be developed in 3-5 years with downstream imaging studies being ordered for the radiology department.

Abstract No. 352: The outpatient vascular and interventional radiology practice from 2001-2008

To describe our experience with our outpatient vascular interventional radiology (IR) practice with respect to number of patients seen, number of procedures performed, and number of imaging studies ordered in follow-up. Our outpatient vascular IR practice was established in 2001 with two physicians spending 0.1 FTE per year with a third physician joined in 2004. We retrospectively reviewed from all patients seen by an interventional radiologist 2001 to July 2008. The following data were collected for each IR physician per year: the number of new and established patients seen, the number and type of procedures performed, and the number and type of imaging studies ordered. Data are presented as mean ± standard deviation/IR physician/year. In 2001, the average number of new patients seen was 61 ± 11 which peaked by 2006 at 127 ± 28. A similar trend occurred with the established patients. In 2001, the procedure performed with the greatest frequency was abdominal aortogram with stent placement, which started at 18 ± 2 and peaked by 2006 at 37 ± 23. In addition, the number of ancillary imaging ordered by each physician grew each year and by 2006–2007 it was nearly 93 ± 77. A robust outpatient IR practice in vascular disease can be developed in 3–5 years. The interventional radiologist can successfully consult on vascular patients and gradually grow a practice in procedural volume along with downstream imaging studies being ordered for the diagnostic radiology department.

Role of multidetector-row CT in assessing the source of arterial haemorrhage in patients with pelvic vascular trauma. Comparison with angiography

We investigated the role of multidetector-row computed tomography (MDCT) in identifying active bleeding and its source in polytrauma patients with pelvic vascular injuries with or without associated fractures of the pelvis. From January 2003 to December 2007, 28 patients (19 men and nine women, age range 16-80 years) with acute symptoms from blunt pelvic trauma and a drop in haematocrit underwent MDCT and angiography. Conventional radiography of the pelvis was performed in all patients at the time of admission to the emergency department. MDCT was performed with a four-row unit in 15 patients and a 16-row unit in the remaining 13 patients. The study included whole-body CT to identify craniocerebral, vertebral, thoracic, abdominal and pelvic injuries. CT was performed before and after rapid infusion (4-5 ml/s) of intravenous contrast material (120 ml) using a power injector. A triphasic contrast-enhanced study was performed in all patients. MDCT images were transferred to a workstation to assess pelvic fracture, site of haematoma and active extravasation of contrast material, visibility of possible vascular injuries and associated traumatic lesions. At angiography, an abdominal and pelvic aortogram was obtained in all cases before selective catheterisation of the internal iliac arteries and superselective catheterisation of their branches for embolisation purposes. Results related to identifying the source of bleeding at MDCT were compared with sites of bleeding or vascular injury identified by selective pelvic angiography. The sensitivity and positive predictive value (PPV) of MDCT were determined. MDCT allowed us to identify pelvic bleeding in 21/28 patients (75%), with most cases being detected in the delayed contrast-enhanced phase (13/21 cases, 61.9%). Injured arteries were identified on MDCT in 12/21 cases (57%): the obturator artery (n=9), internal iliac artery (n=6), internal pudendal artery (n=6) and superior gluteal artery (n=5) were most frequently injured. In 8/21 patients (28.6%), more than one artery was injured. Among the 12 patients in whom MDCT showed the presence of pelvic haemorrhage, there was agreement between MDCT and angiography in ten cases. Angiography confirmed the site of bleeding detected on MDCT and identified a second arterial haemorrhage in one patient. There was no agreement between MDCT and angiography in the last patient. MDCT showed a sensitivity of 42.85% and a PPV of 100% in identifying the injured arteries. Arterial haemorrhage is one of the most serious problems associated with pelvic fracture, and it remains the leading cause of death attributable to such fractures. MDCT provides diagnostic information regarding the presence of small pelvic fractures and, thanks to the contrast-enhanced angiographic technique, it is capable of identifying pelvic bleeding, with the demonstration in some cases of it source. The presence of contrast material extravasation is an indicator of injury to a specific artery passing through the region of the pelvis where the extravasation is noted on MDCT. Urgent angiography and subsequent transcatheter embolisation are the most effective methods for controlling ongoing arterial bleeding in pelvic injuries.

Livedo reticularis due to catastrophic cholesterol embolization

A 55-year-old man was admitted for severe bilateral lower extremity claudication with diminished peripheral pulses. An abdominal aortogram revealed severe atherosclerosis, primarily involving the right-sided external iliac, femoral and popliteal arteries. The condition was treated with endovascular stenting. Twelve hours after the procedure, the patient developed severe bilateral buttock, thigh and calf pain with profound mottling and purple skin discolouration (livedo reticularis) of the thigh (Figure 1). He also developed severe rhabdomyolysis, followed by a compartment syndrome that necessitated fasciotomy followed by bilateral, below-the-knee amputation. Biopsy of the gangrenous portions revealed intra-arterial cholesterol crystals (black arrow) and clefts (white arrow) (Figure 2), which resulted from cholesterol washout during histological processing. This finding confirmed cholesterol crystal embolization induced by the endovascular intervention. Atheromatous embolization is a multisystem disease complicating advanced atherosclerosis. It occurs most often as a complication of angiography, an endovascular procedure or cardiovascular surgery (1). Figure 1 Figure 2

Lumbar Artery Laceration with Retroperitoneal Hematoma After Placement of a G-2 Inferior Vena Cava Filter

Inferior vena cava (IVC) filters have been shown to be effective in reducing pulmonary embolism in certain highrisk individuals with deep venous thrombosis (DVT) [1]. While anticoagulation therapy remains the standard of care, vena caval filter placement is an alternative management in selected patients [1]. Although penetration of the wall of the IVC following insertion of an IVC filter is a well-recognized event, serious symptoms are rare. A 75-year-old female with recurrent pulmonary embolism from lower extremity DVT despite adequate anticoagulation (prothrombin time [PT], 31 s; International Normalized Ratio [INR], –3.0) underwent IVC filter placement. Her medical history included hypertension, diabetes mellitus type 2, hyperlipidemia, and DVT. She was discharged from the hospital 4 days later on warfarin, 3 mg p.o daily, with PT/ INR in the therapeutic range. She reported to the emergency room 10 days after discharge from the hospital, complaining of colicky abdominal pain associated with nausea and vomiting without radiation. A contrast-enhanced CT examination of the abdomen showed a large acute retroperitoneal hematoma on the right, compressing and displacing the IVC anteriorly. Two contrast-filled areas within the hematoma were suggestive of pseudoaneuryms (Figs. 1A and B). The patient was admitted on the floor; anticoagulant was discontinued and she was monitored with serial hemoglobin level and telemetry. On day 1 of admission her blood pressure and pulse rate were 155/80 mm Hg and 75/min, respectively. On the second day of admission her hemoglobin dropped rapidly from 10.0 to 6.9 g/dl. Blood pressure and pulse rate measured 100/45 mm Hg and 90/min, respectively. Coagulation profile and platelet counts were normal. Blood transfusion was offered to her several times but was refused. In view of evidence of continued blood loss, deterioration in clinical condition, and CT findings of pseudoaneuryms adjacent to a lumbar artery, a consult was sent to interventional radiology for possible embolization. A frontal abdominal aortogram was done and confirmed the two pseudoaneuryms from the fourth right lumbar artery about 3 cm from its origin. Close observation showed two hooks of the filter contiguous to the pseudoaneurysms (Figs. 2A and B). Selective catheterization of this artery was done using a 5-Fr Sos Omni angiographic catheter (Angiodynamics Inc., Queensbury, NY, USA). A Renegade microcatheter (Boston Scientific Inc., Natick, MA, USA) was coaxially placed distal to the lacerated areas of the artery. Embolization of the artery was performed using 3-mm fibered stainless-steel coils (Cook Medical Inc., Bloomington, IN, USA) across the lacerations. Follow-up angiogram showed successful embolization, with nonvisualization of the pseudoaneurysms (Fig. 3). Over the next 3 days the vital signs and hemoglobin remained stable (7.2 g/dl). Follow-up contrast-enhanced CT examination of the abdomen 4 days after embolization showed no active bleeding, with a decrease in the size of the hematoma. The patient was discharged to a nursing home 6 days following endovascular embolization. Anticoagulant therapy was stopped considering her risk of bleeding. Use of percutaneous insertion of a vena cava filter has grown at a steady rate over the last 3 decades due to its reduced cost, availability, and ease of placement. IVC filter placement is an endovascular procedure commonly performed to reduce the incidence of pulmonary embolism, but with its share of complications. The major complications A. O. Amole M. K. Kathuria (&) O. S. Ozkan A. S. Gill E. O. Ozkan Section of Vascular and Interventional Radiology, Department of Radiology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA e-mail: mkkathur@utmb.edu

The meandering mesenteric artery or central anastomotic artery

A 50-year-old woman who was a heavy smoker presented with intermittent claudication of both lower extremities. An abdominal aortogram with bilateral lower extremity runoff demonstrated marked arteriosclerotic occlusive disease of the superficial femoral arteries. It also demonstrated a huge meandering mesenteric artery as an important collateral system (A). Note that the inferior mesenteric artery (IMA) is dilated and may be seen in continuity with an enlarged left colic (LCA) and marginal artery (MA). Despite the excellent filling of the abdominal aortic branches, the superior mesenteric artery was not visualized. The lateral projection of the same abdominal aortogram (B) shows severe stenosis of the celiac artery (CA) at its origin (arrow) and of the superior mesenteric artery (SMA) just downstream from its origin (arrow). The origin of the inferior mesenteric artery is not stenotic but rather markedly enlarged as the beginning of the central anastomotic mesenteric artery or, as it is sometimes called, the meandering mesenteric artery. No symptoms referable to the abdomen were present. The recognition of a meandering mesenteric artery of the colon is sufficient evidence by itself to conclude that major abdominal arterial stenosis or occlusion is present. Such arterial disease is either severe stenosis or occlusion of the celiac and superior mesenteric arteries as seen only by a lateral aortic projection or a Leriche aortic occlusion just below the renal arteries. Its presence with mesenteric occlusive disease means that blood flow in the enlarged central anastomotic artery is upward from the open inferior mesenteric artery to supply the branches of the stenotic celiac and superior mesenteric arteries. When the disease is an occluded aorta, the collateral flow is from above downward to supply the lower extremities. Stenosis or occlusion of the celiac and superior mesenteric arteries is commonly associated with abdominal angina or loss of viability of the intestine. However, it need not cause symptoms as demonstrated in this patient. The central anastomosing mesenteric artery can enlarge enough to furnish adequate blood flow between the superior and inferior mesenteric circulations when the two major trunks are severely stenotic or even occluded.1Moskowitz M. Zimmerman H. Felson B. The meandering mesenteric artery of the colon.AJR. 1964; 92: 1088-1099Google Scholar, 2Connolly J.E. Abrams H.L. Kieraldo J.H. Observations on the diagnosis and treatment of obliterative disease of the visceral branches of the abdominal aorta.Arch Surgery. 1965; 90: 596-606Crossref PubMed Scopus (8) Google Scholar If this central anastomotic artery is interfered with during nonvascular abdominal surgery by thrombosis or division, acute ischemia and gangrene of the intestinal system will result. Likewise, division of an enlarged anastomotic artery without its reimplantation into the abdominal aorta or aortic graft may result in infarction of the bowel that it supplies. Its recognition on abdominal aortography or at laparotomy (C, Cover) is of great importance. This anastomotic pathway explains why surgical division of the inferior mesenteric artery has, on occasion, even resulted in gangrene of the legs when distal aortic or iliac artery obstruction was present. Our patient underwent bilateral femoral-popliteal bipasses for claudification and a subsequent nonvascular abdominal operation. At which time we obtain photo C, Cover. We also continued to monitor her for any symptoms of mesenteric ischemia. More commonly, the ability of the central anastomotic artery to enlarge may be limited, and in such patients, its presence is especially valuable in signaling impending bowel ischemia even before intestinal angina may appear. In such cases, we recommend prophylactic concomitant revascularization of the compromised mesenteric vessels during aortic reconstructive procedures.3Connolly J.E. Kwaan J.H. Prophylactic revascularization of the gut.Ann Surg. 1979; 190: 514-522Crossref PubMed Scopus (31) Google Scholar

Catheter-Based Therapy for Atherosclerotic Renal Artery Stenosis

Atherosclerotic renal artery stenosis (RAS) is more common than has been previously appreciated1,2 and is an independent predictor of death regardless of the presence, severity, or method of revascularization of coronary artery disease.3–5 Among 1235 patients undergoing diagnostic coronary angiography, multivariate analysis demonstrated that RAS (>50%) was a stronger independent predictor of all-cause mortality (relative risk [RR], 2.9; 95% confidence interval [CI], 1.7 to 7.0) than congestive heart failure (RR, 2.3; 95% CI, 1.3 to 4.1), elevated left ventricular ejection fraction (RR, 1.7; 95% CI, 1.2 to 2.2), or decreased renal function (serum creatinine) (RR, 1.3; 95% CI, 1.1 to 1.5).3 A subsequent expansion of that study group, extended to 3987 patients undergoing abdominal aortography at the time of diagnostic cardiac catheterization, identified an incremental effect of the severity of RAS on the 4-year mortality rates. They found that a mild-to-moderate (50%) RAS was associated with a 30% 4-year mortality rate, which almost doubled (52%) with severe (>95%) RAS.4 The cause-and-effect relation between RAS and death is uncertain. It is possible that the presence of RAS is simply a marker for more diffuse or extensive atherosclerosis, which would result in more vascular-related deaths. However, there is one study5 that raises the possibility that the treatment of RAS with a renal stent in patients with renal insufficiency can improve mortality rates. In this trial, patients who improved their renal function after renal stent placement had significantly better survival rates compared with those whose renal function did not improve. A dedicated educational effort aimed at improving the diagnosis and treatment of peripheral arterial disease, including RAS, has been supported over the past 10 years by several professional societies.6–8 There is now objective evidence from the Medicare database that this effort to increase the number of patients …

LEFT INFERIOR VENA CAVA IN A LIVING KIDNEY DONOR

A healthy 32-year-old male was cleared as per our institution’s protocol for a living related laparoscopic donor nephrectomy. Preoperative evaluation included intravenous contrast enhanced computerized tomography (CT), which generated 5 mm sections of the abdomen and pelvis. The CT scan revealed 2 left renal arteries (fig. 1) and a left inferior vena cava (IVC) (fig. 2). The IVC crossed anterior to the aorta at the level of the renal vasculature, returning to its normal right position on its course to the heart. Because the right kidney was larger and had 3 renal arteries, we elected to proceed with a left nephrectomy. The patient underwent an uneventful laparoscopic left donor nephrectomy and the CT findings were confirmed. The left renal vein was stapled and transected at its junction with the left IVC. Neither donor nor recipient experienced any untoward events during the procedure or hospital stay, and the transplant had an excellent immediate result. During 5 to 7 weeks of gestation the cardinal veins form the main drainage system of the embryo. Bilateral supracardinal and subcardinal veins join to form common cardinal veins before exiting the fetus. The right subcardinal vein forms the suprarenal IVC, while the right supracardinal vein forms the infrarenal IVC. Normally, the left subcardinal and supracardinal veins recede. A left inferior IVC is likely the result of a persistent left supracardinal vein,1 which is often associated with a circumcaval ureter, situs inversus or vena caval duplication.2 However, in our case, the left IVC was an isolated finding, without any other associated abnormalities. A review of the literature revealed a single case report of a left IVC identified incidentally during an open donor nephrectomy in 1987.3 Preoperative imaging, including an excretory urogram and an abdominal aortogram, did not reveal the abnormality. Despite this finding, no adverse effects were reported. This case differed from ours in that we used preoperative CT imaging which demonstrated the anomalous vasculature and we removed the donor kidney laparoscopically. In cases of donor nephrectomy, preoperative imaging studies should be carefully reviewed, and the operation should proceed with attention to the surgeon’s comfort level and to donor safety. In our brief experience a left IVC is not an impediment to a left laparoscopic donor nephrectomy.

Renal Artery Stenosis is Not Associated with the Development of Acute Renal Failure Following Coronary Artery Bypass Grafting

Background: Acute renal failure (ARF) is a frequent complication of coronary artery bypass grafting (CABG) surgery and is strongly associated with perioperative morbidity and mortality. We hypothesized that renal artery stenosis (RAS), causing occult renal ischemia, may be an important factor contributing to development of ARF after CABG surgery. Methods: Preoperative and intraoperative data on 798 consecutive adult patients undergoing CABG surgery with cardiopulmonary bypass from February 1, 1995 to February 1, 1997 (who had also undergone an abdominal aortogram for the evaluation of RAS) were recorded and entered into a computerized database. The development of ARF was defined as a rise in serum creatinine of 1 mg/dL (88.4 µmol/L) above baseline postoperatively. The association between the presence of renal artery stenosis together with preoperative and intraoperative variables and the development of ARF was assessed by multivariate logistic regression. Results: A total of 798 patients underwent isolated coronary bypass grafting, of which 18.7% demonstrated 50% or more RAS. ARF developed in 82 patients (10.2%), of which three (0.3%) required dialysis support. The mortality for patients who developed ARF was 14% (OR 15, P = 0.0001) compared to 0.2% among those who did not develop ARF. The presence of renal artery stenosis of any severity ranging from unilateral 50% RAS to bilateral 95% RAS was not associated with the subsequent development of ARF. Conclusions: The development of ARF following CABG surgery is associated with high mortality. The presence of RAS does not appear to increase the risk for developing ARF.

Poster 61: Focal dystonia of the hamstring after total knee replacement: a case report

Setting: Outpatient musculoskeletal clinic. Patient: A 75-year-old man with dystonia of the left hamstring, after bilateral total knee replacements (TKRs). Case Description: The patient had bilateral, severe degenerative joint disease of his knees. After bilateral TKR, he developed focal dystonia of the left hamstring muscles. Assessment/Results: Abdominal aortogram and left lower-extremity arteriogram, for a left knee hemarthrosis, were significant only for moderate right renal artery stenosis. The patient underwent an evacuation of a left knee hematoma and synovetomy. After multiple attempts at aggressive therapy and extension splinting, no significant improvement was noted. The patient continued to have symptoms, which were increased nocturnally. Magnetic resonance imaging of the lumbosacral spine for radicular etiology revealed degenerative joint disease of L3-S1 with mild disk bulge throughout. Epidural steroid injections yielded no measurable improvement. The patient continued to have marked restriction in range of the left knee, with palpable spasm of the left hamstring muscles and gait difficulty. Range of motion (ROM) was 30° to 95°. Oral medications, cyclobenzaprine (Flexeril) and baclofen, did not improve his range. 100U of botulinum toxin were injected into 5 areas of the left hamstring muscles with excellent results. The patient gradually regained a functional range of 3° to 130°, which was maintained at a 9-month follow-up after the injection. Discussion: To our knowledge, focal dystonia has not been described in the literature as a complication of TKR. In this case, botulinum toxin was used to treat hamstring dystonia after physical therapy, splinting, and oral medications failed. ROM and functional gait were restored. Conclusion: Use of botulinum toxin to restore functional ROM in a patient with focal dystonia after TKR should be studied further.