Renal Artery Research Articles

Renal artery pseudoaneurysm secondary to an endoscopic combined intrarenal surgery (ecirs): a case report

Renal artery pseudoaneurysm secondary to an endoscopic combined intrarenal surgery (ecirs): a case report

8275 Recurrent Retroperitoneal Paraganglioma

Abstract Disclosure: J. Kang: None. V. Gupta: None. J.S. Subauste: None. Paragangliomas are rare, highly vascular neuroendocrine neoplasms that may originate from sympathetic or parasympathetic paraganglia and may secrete catecholamines. They are closely related to pheochromocytomas which are considered to be their intra-adrenal counterparts. A 65-year-old African American male with type 2 diabetes and tobacco use presented to his primary care physician with night sweats and unintentional weight loss of about 30 pounds in 3 months. Review of systems and laboratory workup was unremarkable. CT Chest/Abdomen/Pelvis with contrast showed a homogenous, well-circumscribed 4.6cm retroperitoneal mass causing mass effect on portal vein, Inferior vena cava, and right renal artery. Interventional radiology performed fine needle aspiration with intra-procedural blood pressure rising to 201/70 mmHg. Pathology showed paraganglioma, staining positive for synaptophysin, chromogranin A, CD 56 and S-100 protein. Plasma metanephrines were elevated at 2818 pg/mL, plasma normetanephrines at 1247 pg/mL with consistent 24-hour urine results. Workup for other adrenal hormones was negative. No family history of pheochromocytoma/paraganglioma or any clinical manifestations of Von-Hippel-Lindau syndrome or Neurofibromatosis were present. He was started on alpha blockade followed by beta blocker and surgical resection was planned. In the interim, escalating requirements of insulin were noted. Intra-operative course was complicated by systolic blood pressure rising to 290s which resolved after mass was removed. Immunohistochemical studies sent to Mayo, Rochester showed retained cytoplasmic SDHB expression in tumor cells. Hence, no further genetic testing was performed. Post excision, plasma-free metanephrines normalized with significant improvement in blood pressure and diabetes. He was followed with yearly plasma-free metanephrines for surveillance. Although asymptomatic, a three-fold rise of plasma metanephrines was noted five years later. CT Abdomen was concerning for recurrence. Dotate/PET scan showed dotate-avid para-aortic soft tissue lesion measuring 2.3 cm between the celiac artery and the superior mesenteric artery which was surgically excised with pathology consistent with paraganglioma (Ki67<1%). Diagnosis of paragangliomas is often in 3rd - 5th decade. About 30% are hereditary and associated with Von-Hippel-Lindau, Neurofibromatosis-1, MEN2A/B among other syndromes. They are mostly benign but SDHB pathogenic variants are likely to be malignant. Genetic testing should be considered in all paraganglioma patients to screen for germline pathogenic variants in SDH and other genes. Diagnosis of secretory paraganglioma is by urinary and/or plasma fractionated metanephrines and catecholamines. Treatment of choice is surgery when amenable to resection with preoperative medical blockade to prevent perioperative complications. Presentation: 6/1/2024

8563 Pheochromocytoma Screening In A Patient With Neurofibromatosis Type I And Medication-Resistant Hypertension

Abstract Disclosure: E. Mora: None. A. Bolduc, MD: None. G. Elshimy: None. Title: Pheochromocytoma Screening in a Patient With Neurofibromatosis Type I and Medication-Resistant Hypertension Background: Patients with neurofibromatosis type I (NF1) have a higher risk of pheochromocytoma and it may be missed if no screening done, thus placing the patient at risk of stroke and/or myocardial infarction. The prevalence of pheochromocytoma in patients with NF1 is 2.9% according to a retrospective cohort study by Gruber et al. We present a case of biochemically silent pheochromocytoma in a patient with NF1 and resistant hypertension Clinical case: A 74-year woman with NF1 presented with episodic headaches and labile systolic blood pressure (BP) in the 170-200s mm Hg on three different antihypertensives consistent with pheochromocytoma. Initial tests for renal artery stenosis and pheochromocytoma showed normal plasma MN (0.43 nmol/L, n< 0.50 nmol/L) and NM (0.86 nmol/L, n< 0.90 nmol/L), and normal flow in both renal hila by color Doppler and no large suprarenal masses identified on retroperitoneal US. Duplex imaging of the bilateral kidneys showed no evidence of renal artery stenosis. CT of abdomen/pelvis with and without IV contrast showed a 1.6 cm nodule on Right (RT) adrenal gland that measured 36 HU on unenhanced phase with an absolute washout of 67%. No discrete nodule in Lt adrenal gland. Dotatate PET/CT revealed a Rt adrenal nodule with elevated asymmetric activity (measured 28.1 standardized uptake values (SUV), n for liver: max 12.3, spleen: max 23.5) relative to the normal physiologic activity of the Leftt adrenal gland, which is concerning for pheochromocytoma. The patient was then referred to our endocrine clinic for further evaluation 6 months after the initial presentation. Labs showed normal aldosterone (5.8 ng/dL, n≤39.2 ng/dL), cortisol (7.66 mcg/dL, n: 3.09-22.40 mcg/dL), ACTH (20 pg/mL, n: 7.2-63 (AM collection), and DHEA-S (28 mcg/dL, n:5.3-124 mcg/dL). Normal repeat plasma MN (0.38 nmol/L, n< 0.50 nmol/L) and NM (0.46 nmol/L, n< 0.90 nmol/L). Repeat CT adrenal washout redemonstrated 1.4 cm Rt adrenal nodule that measured 39 HU on non- contrast image with an absolute washout of 68%. Patient will have a surgical resection of the Rt adrenal biochemically silent pheochromocytoma next week and she has been receiving an alpha-blocker prior to surgery to decrease risk for labile BP. Discussion and Conclusion: This case illustrates how CT and DOtatate scan findings can alert providers to the presence of a pheochromocytoma, even in biochemically negative patients. We recommend pheochromocytoma screening in all patients with NF1 to prevent delayed diagnosis and complications of untreated pheochromocytoma. Presentation: 6/1/2024

6636 Primary Hyperaldosteronism Leading to Aldosterone Deficiency

Abstract Disclosure: N.G. Haverstick: None. J.R. Anthony: None. Primary Hyperaldosteronism is a disease process that is often missed, and under checked due to poor screening tools. The disease presents with a common problem, uncontrolled hypertension. It also presents with hypokalemia, fatigue and headaches. It can easily be masked with blood pressure medications, CKD, and pain medications. After treatment there are some rare reports of patients developing hypoaldosteronism. Some risk factors are age >50, duration of hypertension >10 years, pre-existing renal impairment and adrenal adenoma size >2 cm. The patient will present with the opposite: hyperkalemia and hypotension. This is due to the atrophy of the previously healthy gland. Usually this resolves within a year. However in our patient she has continued to require long standing mineralocorticoid replacement therapy. This case highlights the importance of early recognition of hyperaldosteronism. A 63 year-old-female with a medical history of hypertension and diabetes mellitus is being followed for 30+ years of uncontrolled hypertension. Patient has been on multiple agents and blood pressure remained elevated after trying triamterene/hctz, metoprolol, irbesartan, amlodipine. After changing her PCP, there was further investigation into the cause. Leading differentials were Primary Hyperaldosteronism vs Renal Artery Stenosis vs Primary Hypertension. She also had multiple labs with her Potassium below 3 mEq/l. Additional labs were obtained and her Aldosterone level 209 ng/dl and Renin <0.167 ng/mL/hr. The patient was referred to Endocrinology who performed a fludrocortisone suppression test, which did not suppress the levels. A CT scan of the abdomen was performed that showed a 1.3 cm right adrenal mass typical with adrenal adenoma. The patient had an adrenalectomy surgery in February 2022. The patient recovered well, however now developed hypotension off medication, and had consistent hyperkalemia with K > 5.5 mEq/l. The patient had now developed aldosterone deficiency. This was due to the long standing hyperaldosteronism that had caused her left adrenal gland to atrophy after 30 years. The patient was started on Fludrocortisone 0.1 mg daily and a low potassium diet. She has remained off any blood pressure medications since her right adrenalectomy. She has continued to require the mineralocorticoid replacement to date. The diagnostic work-up for primary aldosteronism involves screening, confirmatory testing, and localization studies to distinguish unilateral pathology which may be amenable to adrenalectomy from bilateral adrenal hyperplasia. Through literature review, one theory is that chronic suppression of renin may cause atrophy of the zona glomerulosa cells and hypoaldosteronism. Throughout the case report we emphasize on the importance of early diagnostic screening of secondary hypertension as well as the complications from adrenalectomy. Presentation: 6/2/2024

Use of Branched EVAR in Treatment of Juxtarenal Aortic Aneurysm and Essential Accessory Renal Artery: Another Tool on the Shelf? A Case Report.

We present the case of a 58-year-old male patient referred to our department from a smaller facility for further evaluation and treatment strategy regarding the choice between open or endovascular surgery. The patient was diagnosed with a 6cm asymptomatic juxtarenal aortic aneurysm and a 5mm diameter accessory renal artery (ARA) supplying the lower half of left kidney. Further diagnostic assessments indicated that the left ARA was perfusing over 40% of the left kidney. Given the patient's significant pre-existing medical conditions and elevated perioperative risk, the decision was made to proceed with minimally invasive endovascular surgery using a custom-made 5-branches stent graft (BEVAR). In the early postoperative period, the patient reported left flank pain. A subsequent CT scan identified a partial infarction in the left kidney due to the occlusion of an early small branch from the upper left renal artery. However, laboratory results showed no significant change in renal function compared to preoperative values. The patient was discharged 6 days post-surgery, with no additional complications observed during the early postoperative period. This case report demonstrates that BEVAR is acceptable technique with satisfactory early postoperative outcomes for treating juxtarenal aortic aneurysms with an accessory renal artery in patients who are high-risk candidates for open repair and anatomically unsuitable for FEVAR or Ch-EVAR procedures.

Percutaneous Endovascular Therapy of Blunt Trauma Related Renal Artery Thrombosis

Percutaneous Endovascular Therapy of Blunt Trauma Related Renal Artery Thrombosis

Physician-modified funnel-shaped covered stent for selective false lumen exclusion in chronic type B aortic dissection.

To describe the technique of off-centering a balloon-expandable covered stent for selective occlusion of a distal entry tear (ET) in a patient, conservatively treated for chronic type B aortic dissection (cTBAD), presenting FL expansion. A 63-year-old male, with conservatively managed cTBAD, presented at follow-up with FL partial thrombosis and expansion (thoracic aorta FL from 21mm to 27mm and abdominal aorta FL from 11mm to 15mm in 6 months). No proximal ET was identifiable. Distal FL perfusion was caused by an ET in the abdominal aorta feeding a 2mm accessory renal artery (ARA). As the aortic diameter was below the threshold for endovascular repair, a selective occlusion of the distal ET and ARA was planned. A balloon-expandable covered stent was modified by off-centering the covered stent proximally and resulting in a funnel-shape occluder after deployment across the ET into the ARA. To prevent type Ic endoleak due to possible FL expansion caused by an intra-operatively detected phrenic artery (PA), coils were deployed into the lumen of the modified stent and the ARA. The pre-discharge computed tomography angiography showed exclusion of both the ARA and ET and a type 2 endoleak from the PA. A balloon-expandable covered stent can be modified by off-centering the covered stent resulting in a funnel shape to adapt to different diameter requirements.

Comparing the Efficacy of Renal Artery Denervation in Uncontrolled Hypertension: A Systematic Review and Network Meta-Analysis

Comparing the Efficacy of Renal Artery Denervation in Uncontrolled Hypertension: A Systematic Review and Network Meta-Analysis

Effects of Catheter-Based Renal Denervation in Hypertension: A Systematic Review and Meta-Analysis.

Several sham-controlled trials have investigated the efficacy and safety of catheter-based renal denervation (RDN) with mixed outcomes. We aimed to perform a comprehensive meta-analysis of all randomized, sham-controlled trials investigating RDN with first- and second-generation devices in hypertension. We searched MEDLINE and the Cochrane Library for eligible trials. Outcomes included both efficacy (24-hour and office systolic [SBP] and diastolic blood pressure [DBP]) and safety (all-cause death, vascular complication, renal artery stenosis >70%, hypertensive crisis) of RDN. We performed a study-level, pairwise, random-effects meta-analysis of the summary data. Ten trials comprising 2478 patients with hypertension while being either off or on treatment were included. Compared with sham, RDN reduced 24-hour and office systolic blood pressure by 4.4 mm Hg (95% CI, 2.7 to 6.1; P<0.00001) and 6.6 mm Hg (95% CI, 3.6 to 9.7; P<0.0001), respectively. The 24-hour and office diastolic blood pressure paralleled these findings (-2.6 mm Hg [95% CI, -3.6 to -1.5]; P<0.00001; -3.5 mm Hg [95% CI, -5.4 to -1.6]; P=0.0003). There was no difference in 24-hour and office systolic blood pressure reduction between trials with and without concomitant antihypertensive medication (P for interaction, 0.62 and 0.73, respectively). There was no relevant difference in vascular complications (odds ratio, 1.69 [95% CI, 0.57 to 5.0]; P=0.34), renal artery stenosis (odds ratio, 1.50 [95% CI, 0.06 to 36.97]; P=0.80), hypertensive crisis (odds ratio, 0.65 [95% CI, 0.30 to 1.38]; P=0.26), and all-cause death (odds ratio, 1.76 [95% CI, 0.34 to 9.20]; P=0.50) between RDN and sham groups. Change of renal function based on estimated glomerular filtration rate was comparable between groups (P for interaction, 0.84). There was significant heterogeneity between trials. RDN safely reduces ambulatory and office systolic blood pressure/diastolic blood pressure versus a sham procedure in the presence and absence of antihypertensive medication.

Renal Artery Blood Flow and Surface Parenchymal Perfusion During Renal Artery Endoshunting in a Porcine Model

ObjectiveIschaemia and reperfusion can result in permanent tissue damage. During complex open abdominal aortic surgery, transient clamping of renovisceral arteries may be required to successfully complete the vascular repair. Endovascular shunting (endoshunting) presents an alternative technique for managing such temporary renovisceral ischaemia. This study aimed to investigate the performance of endoshunting to the renal circulation in a porcine model. MethodsThis study of five domestic pigs investigated arterial volume flow rates during endoshunting of a single renal artery and the associated impact on renal perfusion parameters (laser Doppler renal parenchymal perfusion, renal oxygen extraction, and selective urinary output). The study was performed in three steps: baseline registrations (30 minutes), endoshunting (120 minutes), and restitution (60 minutes). The right kidney was used as the experimental side and the left kidney as control. ResultsThe median arterial flow rate in the left control kidney remained constant throughout the experiment. On the right (endoshunted) side, the baseline median arterial flow rate was 267 (range, 160 – 404) mL/min. Following activation of the endoshunt, the median arterial volume flow dropped by 59% to 110 (range, 45 – 150) mL/min (p = .018). During endoshunting, the median kidney surface perfusion decreased to 42% of the baseline value. On the control side, a rise in the median parenchymal perfusion was observed after endoshunt activation, which was again normalised following restitution of native right renal artery flow. During endoshunting, the median regional urine production was 0.32 (range, 0.12 – 0.50) mL/hour but resumed after renal artery flow restitution. ConclusionOn average, the endoshunted kidneys showed a rapid restoration of blood flow, parenchymal perfusion, and urine production after 120 minutes of endoshunting. This suggests that endoshunting to the kidney using an endoshunt system might be a promising strategy to preserve renal function when a temporary interruption of native renal artery blood flow is needed during complex vascular surgical repairs involving the renal arteries.

ANATOMIC PATTERNS OF DISTRIBUTION OF THE RENAL ARTERIES' ORIGIN FROM THE AORTA

To characterize the variation of the renal arteries' origin from the aorta, through examination of computed-tomography angiographies (CTA) in a cohort of patients, and to evaluate any gender-related difference. CTA of the thoraco-abdominal district in patients with a non-dilated aorta (group A), patients with aortic aneurysm involving the origin of splanchnic and/or renal vessels (group B), and patients with abdominal aortic aneurysm (group C), were retrospectively analyzed. The diameter and angles of emergence (axial and cranio-caudals) of the renal arteries were measured, as well as their mutual distance, and the distance between the renal vessels and the superior mesenteric artery/the aortic bifurcation. Shapiro-Wilk, one-way ANOVA and bivariate Pearson's Correlation tests were performed as appropriate. A p-value <0.05 was considered statistically significant. Six-hundred CTA of patients (452 males) were examined, being 286 in group A, 119 in group B, and 195 in group C. When examining the whole population and also the subgroup of female patients, the clock position of the right renal artery (RRA) was the only parameter that followed a Gaussian distribution, and its ostium raised from the aorta with a mean axial angle of -61.5°+16.6°. There was a negative correlation between left renal artery (LRA) and RRA's coronal angle and aortic diameter at the same level, as well as between the LRA's clock position and the aortic diameter at the same level. The longitudinal distances between established landmarks and both renal arteries positively correlated to the aortic diameter. The LRA showed a high anatomic variability, both in males and in females. With the increase of the aortic diameters in the juxtarenal/infrarenal portion of the aorta, the renal vessels tended to have a more horizontal course in the coronal view, a more acute "clock-position" and longer longitudinal distances between their ostia and the aortic bifurcation.

A three-year experience with the balloon expandable GORE® VIABAHN® VBX in the treatment of thoraco-abdominal aortic aneurysms within the EXPAND Trial

The EXPAND registry is a post-market, multicenter registry that aims at evaluating the safety and performance of the GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis (VBX stent) implanted in peripheral vessels. This subgroup analysis assesses the three-year outcomes of the VBX stent as a bridging stent-graft (BSG) for visceral vessels during branched endovascular aortic repair (BEVAR). This prospective, multicenter, observational registry includes 16 European sites. Patients were enrolled from November 2018 to March 2022. Endpoints included three-year primary patency (PP), secondary patency (SP), and stent graft-related death and serious adverse events (SAE). Seventy-three patients of whom 57 (78.1%) were male with a mean age of 73 years (± 8.1) were included. At three years, 42 (57.5%) patients returned for follow-up. Overall, 223 target vessels (TV) were treated. The estimated freedom from loss of TV primary patency was 93.6%. Per target vessel primary patency rates were 97.0% for the celiac trunk, 93.9% for the superior mesenteric artery (SMA), 91.2% for the left renal artery, and 92.5% for the right renal artery. The overall estimated freedom from loss of secondary patency was 96.8%, and freedom from target vessel instability was 94.5%. The VBX stent demonstrated excellent sustained results at three years with almost 94% primary patency, 97% secondary patency, and 94.5% freedom from target vessel instability. Patency in the renal arteries was lower than in the celiac trunk and SMA. The VBX stent appears to be a reliable bridging stent for target vessels in BEVAR.

LASER FENESTRATION FOR COMPLEX AORTIC REPAIR: VERSATILE OPTION IN DIFFICULT ANATOMY, EMERGENCIES AND BAILOUTS

BackgroundBranched and fenestrated endovascular aortic repair (b/fEVAR) for thoracoabdominal aortic disease as well as thoracic disease (b/fTEVAR) has been well described. Its utilization has also grown over time with the need for solutions having outpaced technologies available in the United States. As more practitioners utilize these and other complex aortic repairs there is a growing utilization of adjunctive modalities expanding the capabilities of current devices. In-situ fenestration (ISF) has arisen as one of those modalities for both vessel fenestration and endoleak repair. ISF has been described for its role in bailout of thoracic endovascular aortic repair (TEVAR) particularly in fenestration for the left subclavian artery, but has not been well described in b/fEVAR in respect to the visceral vessels with most data limited to case series. We sought to review our single institution experience with this technique. MethodsSingle institution retrospective review of ISF during initial b/fEVAR, TEVAR from 2020 to 2022. Laser fenestrations post original b/fEVAR or TEVAR for endoleak repair were also included. Perioperative outcomes were obtained as well as angiographic results and short -term results found on follow up CT scans per SVS guidelines. Detailed operative techniques are discussed. ResultsA total of 13 patients were identified with 17 laser fenestrations. 11 ISF were planned preoperatively and 2 were intra-op decisions. The indications for surgery were type B aortic dissection with malperfusion (3), thoracoabdominal aortic aneurysm (TAAA): Non-ruptured (7), Ruptured (1), Type III endoleak post b/EVAR (1) and Type IA endoleak s/p fEVAR (1). Laser fenestration was used in conjunction of 3 TEVAR and 10 (b/fEVAR). The distribution of vessels fenestrated was: 5 left renal artery (LRA), 5 right renal artery (RRA), 4 left subclavian artery (LSCA), 1 superior mesenteric artery (SMA), 1 Celiac. Technical success was achieved in all 17 fenestrations with no 30-day mortalities, no post op dissection or spinal cord ischemia. There were 3 cases of endoleak at the completion of the operation, 1 type II and 1 type IIIc. ConclusionISF of aortic stent grafts in b/fEVAR and TEVAR is useful as a bailout in complex aortic repair with high likelihood of technical success and low morbidity.

De Novo Atherosclerotic Renal Artery Stenosis Covered Stent Treatment for Resistant Hypertension (ARTISAN) Results

BackgroundAtherosclerotic renal artery stenosis (ARAS) may provoke hypertension and/or impaired kidney function. Some patients develop uncontrolled hypertension and deteriorating kidney function despite optimal medical therapy. In these patients, endovascular treatment is an important therapeutic option. ARTISAN was a prospective, open-label, single-arm, multicenter clinical trial to evaluate the safety and effectiveness of the iCast RX covered stent both functionally for reestablishing renal artery flow, and clinically for controlling resistant hypertension. MethodsPatients considered for enrollment had average systolic blood pressure (SBP) ≥155 mm Hg despite taking 3 antihypertensive medications. Prior to enrollment and covered stent placement, angiographic confirmation of ARAS ≥80% with physiologic significance was required. Clinical assessments were performed at 30 days, 9 months, and annually through 36 months. Covered stent safety and efficacy were based on 9-month coprimary end points, including primary vessel patency and SBP improvement at 9 months. Secondary outcomes included target lesion revascularization, major adverse events, and secondary patency. ResultsSixty-eight of the planned 138 subjects were enrolled. Primary patency was seen in 94.3% of subject lesions; the mean SBP reduction was 15.7 mm Hg. The functional and clinical end points met prespecified performance goals of 70% primary patency (P < .0001) and ≥10 mm Hg SBP decrease (P = .0192), respectively, at 9 months. Six subjects (8.8%) experienced 7 major adverse events within 36 months. The clinically driven target lesion revascularization rate was 7.3% at 36 months. ConclusionsThe high primary patency and improvement in SBP, persisting through 36 months, suggest that the iCast RX covered stent is safe and effective for the treatment of appropriately selected patients with ARAS.

Midterm single center results with the use of custom-made endografts with inner branches, a call for attention.

ObjectiveTo evaluate the patency of bridging covered stents (BCS) bridged to inner branches in custom-made thoracoabdominal endografts. MethodsSingle-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f/b EVAR) in whom the reno-visceral target vessels (TV) were bridged with a BCS to an inner branch of a custom made (CMD) endograft.. Technical success and perioperative complications were noted. Follow-up BCS patency were evaluated and in patients with follow-up, two groups based on BCS were created, a group with BCS occlusion and a group with BCS patent. Uni und multivariable analysis were performed to analyze factors related to visceral and renal bridging stent occlusion. ResultsFrom 2019-2022, 69 patients undergoing complex aortic repair had at least one TV bridged to an inner branch built into a CMD endograft. 86% of the grafts had only inner branches, whereas 14% had a mix of fenestrations for the visceral TV and inner branches for the renal arteries. Twenty-five percent of patients presented as urgency and received an endograft originally designed for another patient and available on our shelf at the time. 245 TVs were connected to inner branches: celiac trunk (CT): 54, superior mesenteric artery (SMA): 59, renal artery (RA): 132. Technical success was 99%. There was a 23% complication and 9% perioperative mortality rate. At follow-up, we identified 6% of visceral and 14% of renal BCS occlusions. The primary patency for RA BCS was 83% at 12 months and 58% at 24 months. For the CT-SMA BCS, Kaplan-Maier (KM) showed a patency of 99% and 96% at 12 and 24 months. In the univariate analysis a misaligned TV ostium (p 0.001), the postoperative BCS diameter on postoperative CTA (p 0.02) and the preoperative infrarenal aortic angle >60º (0.007) were correlated with RA BCS occlusion. In the multivariate analysis only the misaligned TV ostium (p 0.002) and infrarenal angle > 60° (p 0.01) were significantly correlated. ConclusionsIn our series of complex aortic repair, the incorporation of inner branches to bridge TVs is associated with a high renal BCS occlusion rate. Improper alignment of the branches with the TV ostium and acute aortic angles might play a significant role. Further research on this technology is needed.

A Dedicated Algorithm for Endovascular Approach as a First-Line Treatment Option for Visceral Artery Aneurysms

Few data are reported in literature about visceral artery aneurysms (VAAs) management. The aim of the present study was to analyze VAAs management in a single institution, with a dedicated algorithm for endovascular approach as the first line treatment. A single-center retrospective cohort study was performed. Patients with a VAA submitted to either endovascular repair or open surgery from 2016 to 2023 were included. A dedicated algorithm was used to evaluate the endovascular approach feasibility assessing on the preoperative computed tomography angiography the following parameters: (a) the tortuosity of the involved artery (<150°), (b) the healthy arterial diameter (>4mm), (c) the VAA proximity to the hilum and/or the presence of a bifurcation of the aneurysmatic artery, and (d) the circumferential calcium presence. An endovascular approach was chosen if (a) and (b) criteria were satisfied without (c) and (d) ones. Otherwise, it was deemed a challenging anatomy, and an open surgical treatment was considered. In the absence of (a) and/or (b) criteria open surgery was the preferred option. Thirty-one asymptomatic aneurysms (28 patients) were treated electively. The most frequent VAA location was the splenic artery (18 cases; 58%), followed by the renal arteries (6 cases; 19%), the common hepatic artery (5 cases; 16%), the gastroepiploic artery (1 case, 3.2%) and the pancreatoduodenal artery (1 case; 3%). Twenty-two aneurysms (71%) were initially treated by an endovascular approach (stent-graft deployment and/or transcatheter embolization) with 3 (13%) of them needing a surgical conversion. Nine aneurysms (29%) were submitted directly to a surgical treatment (aneurysm resection with or without interposition bypass) with no peri-operative and long-term complications. Technical success was 90.3%. Endovascular management as a first line approach is safe and effective in most cases. A preoperative dedicated algorithm is useful to identify suitable cases. Open surgery can be considered an alternative option in specific challenging anatomical situations or in case of endovascular failure.

Characteristics, treatment, and outcomes of spontaneous renal artery dissection: a 10-year retrospective single-center experience.

Spontaneous renal artery dissection (SRAD) is a rare cause of renal failure and renovascular hypertension, with the diagnosis often being delayed and treatment varying across different centers. The objective of this retrospective cohort study was to scrutinize the characteristics, treatment modalities, and outcomes of patients with SRAD at our center over the past ten years. Furthermore, the study sought to identify the most suitable treatment options for different categories of patients with SRAD. Data from 21 consecutive patients who presented with symptoms of SRAD from December 2013 to December 2023 were collected. Lesion characteristics, treatment options, blood pressure (BP) control, serum creatinine and estimated glomerular filtration rate (eGFR) were analyzed. A paired t-test was used for comparisons of BP, serum creatinine, and eGFR. An independent samples t-test was used to analyze baseline BP and BP change in different treatment groups. The mean age, weight, and height of patients with SRAD was 49.2±13.0 (range, 18-69) years, 69.0±9.7 (range, 50-80) kg, and 1.7±0.1 (range 1.6-1.8) m, respectively. New-onset hypertension was found in 8 (38.1%) patients. Renal artery dissecting aneurysm and renal artery stenosis were found in 1 (4.8%) and 4 (19.0%) patients, respectively. Supportive medical treatment alone, endovascular intervention, and nephrectomy were required in 15, 4 and 2 cases, respectively. Stable renal function and satisfactory hypertension control were obtained in all treatment groups, with a median follow-up of 18.1 (range, 12-32) months. Medical management is a reasonable choice in most patients with SRAD. Interventional management is an efficacious strategy for the management of renovascular hypertension and the preservation of renal function.

More Than an Accessory: Renal Artery Stenosis in a Second Renal Artery Driving Uncontrolled Hypertension

More Than an Accessory: Renal Artery Stenosis in a Second Renal Artery Driving Uncontrolled Hypertension

Using Doppler duplex ultrasound to determine hemodynamic alterations in renal vasculature: Crucial pathophysiological event preceding renal dysfunction in decompensated cirrhosis

BackgroundRenal dysfunction is a watershed event in cirrhosis, often preceded by renal vasoconstriction. However, our reliability on elevated serum creatinine often delays interventions. Measurement of Renal Resistive Index (RI) and Renal Venous Stasis Index (RVSI) by Doppler ultrasound offers insight into renal vasoconstriction. MethodsFifty participants with decompensated cirrhosis with ascites and normal serum creatinine underwent renal Doppler ultrasound for the measurement of RI and RVSI. All patients were compliant with a salt-restricted diet. Individuals aged <18 years, hepatocellular carcinoma, non-cirrhosis-related ascites, pre-existing renal disease, obstructive uropathy, or history of nephrotoxic medication use were excluded. Statistical analyses, including Pearson correlation, regression analysis, and Chi-square/Fisher’s exact tests, were performed to assess the statistical significance between RI, RVSI, and renal parameters. Additionally, the association of RI with the model for end-stage liver disease sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) scores was also assessed. ResultsMajority were males (88%), average CTP score was 11.7, mean MELD-Na score was 20.92, and mean serum creatinine was 1.05 mg/dL. Renal parameters had varying RI values among renal arteries, with the main right and left arteries at 0.615 [standard deviation (SD): 0.089] and 0.638 (SD: 0.083), respectively. RI and RVSI are significantly correlated with serum creatinine. Further, significant correlation between, RI, RVSI values noted with MELD-Na score even when serum creatinine values are normal. ConclusionStrong correlations between serum creatinine, RI, and MELD-Na scores hints at predictive clinical potential. Future research with larger cohorts and extended follow-up is required to gauge clinical utility and its impact on outcomes.

Pegloticase-Induced Rapid Uric Acid Lowering and Kidney and Cardiac Health Markers in Youth-Onset Type 2 Diabetes: A Pilot Clinical Trial

Rationale & ObjectiveElevated serum uric acid (SUA) is a risk factor for incident hypertension and diabetic kidney disease in young persons with type 2 diabetes (T2D), particularly men. The acute benefit of aggressively lowering SUA on kidney and cardiovascular function in this population remains underexplored. This study was conducted to investigate the impact of a single pegloticase infusion on kidney and cardiovascular function. Study DesignAn open-label pilot trial. Setting & ParticipantsThe study involved 10 young adult males with youth-onset T2D and SUA levels ≥5 mg/dL. Intervention(s)Participants received a single infusion of pegloticase (8 mg). Evaluations were conducted using iohexol-based measured glomerular filtration rate (mGFR) and cardiac/kidney MRI before and one week after infusion. OutcomesThe primary outcomes were changes in SUA and mGFR one week after pegloticase infusion. ResultsNine participants (mean [±SD] age 22±5 years, HbA1c 8.6±3.3%, BMI 40.1±11.0 kg/m2, SUA 6.7±1.1 mg/dL) completed the pegloticase infusion and were included in the analysis. One week after the infusion, median [p25,p75] SUA concentrations dropped from 6.4 [5.6,7.6] to 0.5 [0.5,4.6] mg/dL (p=0.01). Mean mGFR increased from 113±20 to 122±19 ml/min per 1.73 m2 (p=0.004). Among responders (SUA reduction ≥3 mg/dL), an increase in mGFR correlated with an increase in renal artery blood flow (r:0.60, p=0.24) and decrease in SUA (r:-0.79, p=0.05). Mean MRI peak longitudinal cardiac strain additionally decreased from 15.4±2.2 to 13.1±2.2 % (p=0.03) in these responders. LimitationsThe pilot nature of the study and the small sample size limit the generalizability of the findings. ConclusionsIn young adult males with T2D, a single pegloticase infusion decreased SUA levels, which increased mGFR and was strongly associated with increased renal blood flow and impaired cardiac global longitudinal strain. Further research is required to assess the long-term efficacy and safety of pegloticase in patients with T2D.