Renal Embolization Research Articles

Amplatzer vascular plug in renal artery embolization: case report and review of the literature

BackgroundArterial embolization constitutes a safe and effective therapeutic possibility in the treatment of numerous renal pathologies in election and in urgency. Over the years, numerous embolizing materials have been proposed: fibrin (temporary occlusion), glues, coils, and microspheres. The use of St. Jude Amplatzer vascular plug (AVP) constitutes a more recent and less widespread therapeutic choice, and its use in the renal district is not yet widespread although potentially very valid.Case presentationWe present 3 renal arterial embolizations performed with AVP performed between January 2019 and February 2020: two patients had a very bulky renal heteroplastic lesion and were candidates for nephrectomy, and a third patient instead was affected by a high-flow FAV post-biopsy. In our experience, the use of AVP for the treatment of renal arteriovenous fistula and neoplastic masses has given excellent results without any complications during and after the treatment. In all cases, a single plug was used which perfectly adapted to the target artery resulting in complete occlusion of the vessel in a short time.ConclusionRenal artery embolization performed with AVP has growing potential and numerous advantages in terms of the time of the procedure, speed of embolization, and precision of occlusion, but with a relative increase in costs.

Safety of low-dose prolonged infusion of tissue plasminogen activator therapy in patients with thromboembolic events in the intensive care unit.

Objective Thromboembolic events such as acute coronary syndrome related prosthetic heart valve thrombosis, pulmonary artery embolism and renal artery embolism are a rare condition but a major cause of morbidity and mortality. In this study we discussed low-dose thrombolytic therapy, in patients with thromboembolic events in the intensive care unit.Methods The study was performed on 12 consecutive patients [8 female; 50.3±16.0 (35-95) years] with acute thromboembolism including acute coronary syndrome related prosthetic heart valve thrombosis, acute pulmonary embolism and acute renal embolism who were treated with low-dose (25 mg) and slow infusion (6 hours) of t-PA. We evaluated mainly in-hospital safety and also effectiveness.Total treatment episodes was 1.66±0.88 (1-4) times.Results All thromboembolic events have been successfully treated with low-dose (25 mg) and slow infusion (6 hours) of t-PA. The success criteria were clinically improvement and radiologically lysis. None of the patients had ischemic stroke, intracranial hemorrhage, embolism (peripheral and recurrence of coronary artery embolism), bleeding requiring transfusion. The most frequent in-hospital complication was a gum bleeding without need for transfusion (two patients).Conclusions In our case series low-dose (25 mg) and slow infusion (6 hours) of t-PA have been performed successfully for thromboembolic events including acute coronary syndrome related prosthetic heart valve thrombosis, pulmonary embolism and renal embolism in patients with in the intensive care unit. Safety is promising and if efficacy will be proved; this method may be a valuable alternative to standard fibrinolytic regimen.

Thrombectomized Cadavers: An Optimal Endovascular Training Method

Create a model applicable to endovascular arterial and venous interventional skill training. A highly clinically relevant model is optimal for training, both vascular residents and practicing surgeons. While expensive, cadavers remain best to rehearse imaging, navigation, and device use. We conducted one of the largest hands-on training events, purely using a thrombectomized cadavers. We share lessons learned permitting every vascular bed to be used. Ten fresh cadavers (<6 weeks) were used. Procedure sequence was carefully designed not to compromise subsequent device deployment. Cadaver preparation (by trainees) included the following. (1) Bilateral ultrasound-guided arterial and venous femoral access. (2) Wires advanced using standard and wire and catheter techniques into the aorta/carotid/visceral vessels/IVC/Pulmonary arteries, depending on module (3) Thrombus removed from the aorta and iliac arteries using Zelante (Angiojet) catheter. (4) Perform hand injection using 25% contrast (or CO2 or air), select appropriate imaging technique, Angiojet also used for removal of contrast. (5) Warm water flushes used post nitinol device deployment. Lower extremities: (6) Access common femoral artery vie cut down. (7) Place 55-cm 7F sheath into either commons femoral or superficial femoral, loop up over the abdominal wall and cover with drapes, simulating contralateral access. Upper extremities: (8) Cut down on the basilic vein and (9) Access innominate veins retrograde. Procedure sequence (module 1) included transfemoral carotid stents and embolization protection device deployment, and stenting of the supra-aortic trunks. Module 2 comprised thoracic and abdominal aortic stent grafting. Module 3 included lower extremity intervention (set up described elsewhere in this abstract). Module 4 comprised inferior vena cava (IVC) thrombectomy, IVC filter placement, removal of IVC filter, and iliac vein stunting. Module 5 encompassed percutaneous arteriovenous fistula, and stenting of the innominate veins. Fig 1 shows a thrombectomy catheter being used to aspirate contrast after iliac venogram. Fig 2 shows a renal arteriogram in a cadaver model before peripheral renal coil embolization and orificial stenting. All prescribed procedures could be performed in all the cadavers. Although expensive ($1200/cadaver), other than live patients, there is little else that provides a high degree of clinical relevance and challenges. Thrombus removal can be successfully performed using relevant clinical techniques. This then permits the interventional sequence outlined in every vascular bed and makes the use of cadavers a reasonably cost effective in an optimal 2.5-day training paradigm.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Symptomatic Aortic Mural Thrombus Treatment and Outcomes

To report results achieved in treatment of symptomatic aortic mural thrombus in a single institution. A retrospective analysis of data about 97 patients presenting with acute onset lower limb ischemia (Rutherford stage II-III), upper limb ischemia, and mesenteric ischemia surgically treated between January 2011 and December 2018 in the Vascular and Endovascular Unit of Foch Hospital (Suresnes, France) was conducted. Only patients affected with primary aortic mural thrombus (PAMT) as source of embolism were included. A total of 9 patients (mean age 51years, range 28-69; 55.5%, n 5 men and 44.5% n 4 women) were affected with PAMT. Three (33.3%) patients presented a concomitant renal embolism (22.2% of acute renal failure). Thrombus was located at the level of thoracic aorta (4 patients), visceral aorta (2 patients), or infrarenal aorta (3 patients). PAMT was sessile or pedunculated in 5 (55.5%) and 4 (44.4%) patients, respectively. Treatment consisted of anticoagulation in all patients in association with surgical exclusion of the PAMT, distal thrombectomy alone, or in addition to distal bypass. At a median follow-up of 22months (range 1-57months) no patients died, 4 patients (44.4%) recovered well, and 5 patients (55.5%) experienced recurrence/thrombus persistency and needed secondary interventions. The best results and absence of recurrences were achieved in patients undergoing immediate exclusion of the PAMT. PAMT is an uncommon source of embolism, and no guidelines are at disposal in its management. An aggressive approach with anticoagulation and exclusion of thrombus seems to be efficacious in preventing recurrences limiting complications and optimizing outcomes.

P0460ASSOCIATION BETWEEN CAUSATIVE MICROORGANISMS OF INFECTIVE ENDOCARDITIS AND CLINICAL SPECTRUM OF RENAL LESIONS

Abstract Background and Aims The relation between microorganisms and renal lesions in IE has bilateral nature: urinary tract infections may be source of systemic invasion that will cause IE, IE causative microorganisms may cause inflammatory changes in glomeruli or be disseminated in renal parenchyma gematogenously with the formation of the abscesses in case of fragmentation or migration of the vegetations. IE-associated GN - is an immune-mediated GN caused by bacterial infection. More commonly GN presented in cases of streptococcal and staphylococcal IE. For renal embolism is typical association with staphylococcal infection, and there are documented cases of renal infarctions in IE caused by S. pneumonia, and C. burnetti. The effect of microorganisms on other clinical manifestations of kidney damage in IE has not been studied. Method The study included 209 patients with verified IE. All patients were performed bacteriological and 81(38,8%) parallel one-moment biomolecular (PCR or PCR with follow-up sequenition) tests. In case of death or cardiac surgery, affected valves (n=15) were tested with the same technique. To asses renal function we calculated glomerular filtration rate with CKD-EPI formula. AKI, AKD and CKD were diagnosed in accordance with present guidelines [KDIGO, 2012]. Results Renal ivolvement into the pathological process trended higher in patients with Gr- (p=0,016) and few causative microorganisms (p=0,039). There are significant differences in incidence of different renal syndromes in patients with MRSA, Gr- and few causative microorganisms - these patients more often had acute nephritic syndrome (respectively p=0,036; p=0,005; p=0,003) (tab. 1). Impairment in the renal function was significantly associated with MRSA (p=0,012), Gr- (p=0,01) and few causative microorganisms (p=0,003). In addition long-lasting renal impairment was observed: patients with MRSA had median time of worsening of the renal function 9 days (IQR 4-14), with Gram-negative microorganisms median time was 9 days (IQR 5-12), with polyflora 10 days (IQR 7-14). But there were no significant differences in median time of renal function worsening in patients with other causative microorganisms. Incidence of AKI and AKD depending on causative organism did not significantly differ. Conclusion Kidney lesions in IE significantly associated with Gr- microorganisms, MRSA and with the presence of 2 or more causative microorganisms. Clinical spectrum of renal lesions is diverse: from the changes in the urine sediment to longstanding kidney dysfunction.

Joint Mexican position document on the treatment of atrial fibrillation.

Atrial fibrillation (AF) is a frequent arrhythmia; its prevalence is near 2% in the general population; in Mexico, more than one-half million people are affected. AF needs to be considered as a public health problem. Because AF is an independent risk factor associated with mortality, due to embolic events, heart failure, or sudden death; early diagnosis is of utmost importance. In unstable patients with a recent onset of AF, electrical cardioversion should be practiced. In stable patients, once thromboembolic measures have been taken, it is necessary to assess whether it is reasonable to administer an antiarrhythmic drug to restore sinus rhythm or performed electrical cardioversion. For recidivating cases of paroxysmal and persistent presentation, the most effective strategy is performed pulmonary vein isolation with either radiofrequency or cryoballoon energy. Permanent AF is that in which recovery of sinus rhythm is not possible, the distinguishing feature of this phase is the uncontrollable variability of the ventricular frequency and could be treated pharmacologically with atrioventricular (AV) nodal blockers or with a VVIR pacemaker plus AV nodal ablation. The presence of AF has long been associated with the development of cerebral and systemic (pulmonary, limb, coronary, renal, and visceral) embolism. The prevention of embolisms in "valvular" AF should perform with Vitamin K antagonists (VKA). For patients with AF not associated with mitral stenosis or a mechanical valve prosthesis, a choice can be made between anticoagulant drugs, VKA, or direct oral anticoagulants. Antiplatelet agents have the weakest effect in preventing embolism.

Acute Renal Failure/Acute Kidney Injury (AKI) Associated with Endovascular Procedures.

AKI is one of the most common yet underdiagnosed postoperative complications that can occur after any type of surgery. Contrast-induced nephropathy (CIN) is still poorly defined and due to a wide range of confounding individual variables, its risk is difficult to determine. CIN mainly affects patients with underlying chronic kidney disease, diabetes, sepsis, heart failure, acute coronary syndrome and cardiogenic shock. Further research is necessary to better understand pathophysiology of contrast-induced AKI and consequent implementation of effective prevention and therapeutic strategies. Although many therapies have been tested to avoid CIN, the only potent preventative strategy involves aggressive fluid administration and reduction of contrast volume. Regardless of surgical technique—open or endovascular—perioperative AKI is associated with significant morbidity, mortality and cost. Endovascular procedures always require administration of a contrast media, which may cause acute tubular necrosis or renal vascular embolization leading to renal ischemia and as a consequence, contribute to increased number of post-operative AKIs.

Renal Graft Embolization as a Treatment for Graft Intolerance Syndrome

BackgroundRenal graft intolerance syndrome is an inflammatory process that occurs in up to 40% of patients with graft loss. It is characterized by fever, graft pain, hematuria, and anemia. Traditionally, the treatment has been nephrectomy; however, this procedure is associated with high morbidity and mortality rates. As an alternative, graft embolization is associated with success rates of up to 92%. In this study, we describe the graft embolization experience of 1 center, its clinical outcomes and complications. MethodsAn observational, retrospective study was conducted. It included all patients with graft intolerance syndrome undergoing graft embolization between 2012 and 2018. The success of the procedure was defined by the resolution of the symptoms that motivated the embolization. ResultsWe found 12 cases of patients undergoing embolization. The time of presentation of the graft intolerance syndrome after admission to dialysis was 6 months (range, 0.6-13). The main clinical manifestation was pain in the area of the graft and macroscopic hematuria. Except for 1 patient, all continued with the immunosuppressive treatment regimen after graft loss for 4 months (range, 0.6-9), received antibiotics for 5.5 days (range, 2-14), and 10 patients received steroid treatment for 6.5 days (range, 5-10). The main complication, secondary to the procedure, was hematoma at the puncture site in 3 patients. Only 1 patient had postembolization syndrome, which resolved with steroid administration. Two patients required postembolization nephrectomy due to persistent renal blood flow and symptoms such as pain and hematuria. The average hospital stay was 5.5 days (range, 1-24). ConclusionsRenal graft embolization is an effective technique as a treatment strategy in patients with clinical signs of intolerance syndrome, with a success rate ≥83.3%, low morbidity, and short hospital stay; furthermore, it avoids the potential complications of a surgical nephrectomy. Graft infection should be ruled out before embolization, and the use of prophylactic antibiotics and steroid therapy is recommended to reduce the risk of postembolization syndrome and infectious complications.

Perturbations in myocardial perfusion and oxygen balance in swine with multiple risk factors: a novel model of ischemia and no obstructive coronary artery disease

Comorbidities of ischemic heart disease, including diabetes mellitus (DM), hypercholesterolemia (HC) and chronic kidney disease (CKD), are associated with coronary microvascular dysfunction (CMD). Increasing evidence suggests that CMD may contribute to myocardial ‘Ischemia and No Obstructive Coronary Artery disease’ (INOCA). In the present study, we tested the hypothesis that CMD results in perturbations in myocardial perfusion and oxygen delivery using a novel swine model with multiple comorbidities. DM (streptozotocin), HC (high-fat diet) and CKD (renal embolization) were induced in 10 female swine (DM + HC + CKD), while 12 healthy female swine on a normal diet served as controls (Normal). After 5 months, at a time when coronary atherosclerosis was still negligible, myocardial perfusion, metabolism, and function were studied at rest and during treadmill exercise. DM + HC + CKD animals showed hyperglycemia, hypercholesterolemia, and impaired kidney function. During exercise, DM + HC + CKD swine demonstrated perturbations in myocardial blood flow and oxygen delivery, necessitating a higher myocardial oxygen extraction—achieved despite reduced capillary density—resulting in lower coronary venous oxygen levels. Moreover, myocardial efficiency was lower, requiring higher oxygen consumption for a given level of myocardial work. These perturbations in myocardial oxygen balance were associated with lower myocardial lactate consumption, stroke volume, and LVdP/dtmax, suggestive of myocardial ischemia and dysfunction. Further analyses showed a reduction in adenosine-recruitable coronary flow reserve, but this was exclusively the result of an increase in basal coronary blood flow, while maximal coronary flow per gram of myocardium was maintained; the latter was consistent with the unchanged arteriolar wall/lumen ratio, arteriolar density and peri-arteriolar collagen content. However, isolated small arteries displayed selective blunting of endothelium-dependent vasodilation in response to bradykinin in DM + HC + CKD swine, suggesting that changes in coronary microvascular function rather than in structure contributed to the perturbations in myocardial oxygen delivery. In conclusion, common comorbidities in swine result in CMD, in the absence of appreciable atherosclerosis, which is severe enough to produce perturbations in myocardial oxygen balance, particularly during exercise, resembling key features of INOCA.

Superselective renal artery embolization for treatment of urological hemorrhage after partial nephrectomy in a solitary kidney.

Embolization is a well-known and accepted form of treatment for bleeding caused by a multitude of renal procedures. We present a case of a 66-year-old woman who had a history of left nephrectomy for clear cell carcinoma seven years previously and now presented with a 6 cm tumor involving the solitary kidney. She underwent partial laparoscopic nephrectomy with removal of the tumor on the right kidney. In the immediate postoperative period she had important and persistent hematuria associated with tachycardia, hypotension, and lumbar pain. After showing signs of hemodynamic instability, she was taken to the catheter laboratory where selective angiography of the right kidney was performed. Superselective embolization with controlled release of fibrous microcoils was performed. The superselective renal embolization technique performed on an emergency basis to control hemorrhage after a urological procedure is effective and achieves lasting resolution of symptoms.

Renal Infarction and Pulmonary Embolism in Patient with Myelodysplastic/Myeloproliferative Neoplasm Unclassifiable

The myelodysplastic syndrome-myeloproliferative neoplasms (MDS/MPNs) are defined by a group of heterogeneous hematological malignancies resulting from stem cell−driven clonal growth of pathological hematopoietic progenitors and ineffective hematopoiesis, they are characterized concomitant myelodysplastic and myeloproliferative signs. Myelodysplastic/myeloproliferative disorders have been considered to have a higher risk of thrombus formation.We report a rare case about a 64 years old Moroccan woman, experienced renal infarction (RI) associated with pulmonary embolism as a complication of a myelodysplastic/myeloproliferative disorder.The patient complained of acute-onset severe left flank pain, a contrast-enhanced computed tomography (CT) of the chest and abdomen revealed RI by a large wedge-shaped defect in the right kidney with pulmonary embolism.Biological exam showed deep anemia, the bone marrow aspiration found myelodysplasia.the bone biopsy showed signs of myeloproliferatif disease. The karyotype was normal, BCR-ABL, JAK2, CALR mutations were absents, and MPL mutation was positive. The International Prognostic Scoring System (IPSS-R) was 0, and the patient was included to the low risk group.Anticoagulation therapy was initiated with heparin to treat RI and pulmonary embolism. Three months later, pulmonary embolism had resolved without the appearance of additional peripheral infarction.This case emphasizes the need to consider myelodysplastic/myeloproliferative disorders as a cause of infraction renal and pulmonary embolism.

Initial experience of flexible ureteroscopy combined with thulium laser for the treatment of upper urinary tract urothelial carcinoma

Objective To summarize the initial experience of flexible ureteroscopy combined with thulium laser for the treatment of high-risk upper urinary tract urothelial carcinoma (UTUC) in patients with solitary kidney or renal insufficiency. Methods A retrospective analysis was performed in 5 cases of UTUC with solitary kidney or renal insufficiency treated via flexible ureteroscopy combined with thulium laser from May 2016 to November 2018. Patients consisted of 4 cases of left side tumor, 1 case of right side tumor, with median age of 73 years old(ranging 53-87 years old). Among the 5 cases, 3 were solitary kidney with renal pelvis tumors, 2 cases were renal insufficiency accompanied with proximal ureter or renal pelvis tumor. All the patients had tumors large than 2 cm in diameter. The creatine in 3 cases with solitary kidney was 102, 128, 143μmol/L, respectively. The creatine in 2 cases with renal insufficiency was 281, 179μmol/L, respectively. Variable hydronephrosis was noticed in all paients. The cytological examination could reveal tumor cells in all cases. During the operation, part of tumor tissues were resected for pathological examination and the remaining visible tumor tissue was all ablated and vaporized. As there was no obvious residual tumor tissue, double J stent was retained. Patients were regularly reexamined after surgery. Results Of the 5 cases, 4 patients were successfully performed, while intraoperative bleeding occurred in 1 case. The operation was suspended after indwelling double J stent. Then, the renal artery interventional embolism was performed after ineffective conservative treatment, and the bleeding was well controlled. One month later, the patient was treated with thulium laser tumor ablation and vaporizaiton under flexible ureteroscopy again. The pathology of all cases was high-grade invasive urinary epithelial carcinoma. Patients were followed up with regular imaging and endoscopic examination. The median follow-up period was 19 (4-26) months, during which 4 cases had local recurrence, one patient died of non-tumor factors. No recurrence of urothelial carcinoma occurred in the bladder during follow-up, the overall recurrence rate was 80%, and the median recurrence time was 6 (1-24) months. Patients with recurrence was treated with thulium laser tumor ablation and vaporizaiton under flexible ureteroscopy again. Conclusions Flexible ureteroscopy combined with thulium laser is an alternative treatment for high-risk upper urinary tract urothelial carcinoma in patients with solitary kidney or renal insufficiency, while with high tumor recurrence rate. Therefore, a stringent imaging and endoscopic follow-up should carry out postoperatively. Key words: Ureteroscopy; Flexible ureteroscope; Thulium laser; Upper urinary tract urothelial carcinoma

Embolisation artérielle des reins polykystiques en alternative à la néphrectomie ergonomique en pré greffe rénale. Étude monocentrique rétrospective sur 15 cas

This study aims at providing a retrospective assessment of the decrease in renal volume after renal artery embolization (RAE) among a group of patients with autosomal dominant polycystic renal disease and for whom transplantation, for ergonomic reasons was temporarily advised against. Between November 2014 and March 2017, as part of pre-transplantory procedure 15 patients, including 11 men and 4 women benfited from renal embolization (RAE) in a context of preparation for transplant in Lille University Hospital. All of the patients were suffering from autosomal dominant polycystic renal disease (ADPKD) at a severe or terminal stage of renal disease. The original mean total kidney volume (TKV) was 2550.6 cm3±1771 (1102 cm3; 7310 cm3), the average TKV at 3 months was 1684 cm3±1539 (648 cm3; 6930 cm3) with an average decrease of 33% in the volume (5.2%; 83.9%) (95% confidence interval [0.229-0.436]) (P<0.01) and 1632±1743 (599 cm3; 6758 cm3) at 6 months with an average decrease of 40.7% (7.6%; 64.1%) (IC95% 0.306-0.508) (P<0.01). Among the 15 patients, 13 had their contraindication removed and to date 7 have had successful transplants. One failure due to a very high initial volume (7310cm3) required a secondary nephrectomy. No post-embolization syndrome has been noticed, 2 minor complications occurred (13%) involving a difficult resumption of transit and there was one case of hematuria. ERA procedures must have a place in the ergonomic transplant strategy of patients with ADPKD with a low complication rate and a high efficiency. Nephrectomy indications before transplantation must therefore be reconsidered due to a major postoperative risk. Our results are in line with larger scale studies. Nevertheless, these results need to be confirmed by a large-scale randomized prospective study. 4.

Characterization of Calibrated Gelatin Sponge Particles in a Rabbit Renal Embolization Model.

To evaluate the level of artery occlusion, degradation periods, tissue response and vessel recanalization of calibrated gelatin sponge particles after segmental renal artery embolization. Superselective embolization of 14 adult rabbits was performed with calibrated gelatin sponge particles (150-350μm). Two rabbits were killed immediately after the procedure (day 0). One pair of rabbits was killed on each of the following days: 1, 3, 7, 14, 28 and 56. One rabbit from each pair underwent CT angiography before embolization and killing. The pathologic changes of the embolized renal parenchyma and embolic characteristics of calibrated gelatin sponge particles were evaluated histologically and angiographically. Calibrated gelatin sponge particles were distally located in interlobular artery with a dense packing on day 0. The level of occlusion paralleled the size of the particles. Partial degradation of the particles was observed on day 3, and complete degradation was observed on day 14. Vessel recanalization was observed through both CTA and histological analysis starting on day 3. Vascular inflammation responding to gelatin sponge particles was mild and subsided with the degradation of the particles. On day 28 and day 56, attenuation of embolized vessels occurred due to marked intimal proliferation, and vascular occlusion developed. Gelatin sponge particles of 150-350μm produced dense and distal embolization, and were resorbed before day 14 with a mild tissue reaction. Vessel recanalization occurred secondary to the resorption of gelatin sponge particles, but permanent vascular occlusion developed due to marked intimal hyperplasia after day 28.

Alterations in Myocardial Oxygen Balance, Anaerobic Metabolism and Diastolic Dysfunction in Exercising Swine with Multiple Comorbidities

IntroductionMultiple comorbidities, including diabetes mellitus (DM), hypercholesterolemia and chronic kidney disease (CKD) are associated with diastolic dysfunction. These risk factors also cause coronary microvascular dysfunction leading to impaired myocardial perfusion and ischemia with non‐obstructive coronary artery disease (INOCA). Recently a link has been proposed between INOCA and HFpEF. We investigated the detrimental effects of DM, CKD and high fat diet (HFD) on myocardial function and perfusion.HypothesisProlonged exposure to multiple comorbidities in swine leads to diastolic dysfunction, associated with impaired myocardial perfusion and anaerobic metabolism.MethodsDM (streptozotocin 3×50mg/kg i.v.) and CKD (renal embolization) were induced in 7 female swine fed a high fat diet (DM+HFD+CKD), while 10 female healthy swine on normal diet served as controls (CON). After 6 months, myocardial perfusion and oxygen balance were studied at rest and during treadmill exercise. At sacrifice PV‐loop measurements and histology were performed.ResultsDM+HFD+CKD animals showed hyperglycemia (glucose: 19.2±1.5 vs 7.5±0.6 mmol/L), renal dysfunction (glomerular filtration rate: 132±14 vs 197±10 ml/min) and hypercholesterolemia (total cholesterol: 8.28±0.86 vs 1.65±0.06 mmol/l, all P&lt;0.05). DM+HFD+CKD had an increased EDPVR (0.14±0.02 vs 0.09±0.01 mmHg/mL) with preserved ejection fraction, a lower cardiac index compared to CON at similar levels of exercise (fig A). Left ventricular myocardial capillary density was decreased (1229±59 vs 1502±86 #/mm2) and collagen content was increased (9.6±1.9 vs 5.0±0.6 %). Their myocardium required more oxygen for similar levels of cardiac work, suggesting cardiac inefficiency (fig B). Furthermore, they showed a lower myocardial oxygen delivery (fig C), forcing the myocardium to increase its oxygen extraction (fig D) leading to lower coronary venous oxygen saturation (fig E) both at rest and during exercise. This was accompanied by a decrease in myocardial lactate consumption at the same lactate supply as in CON (fig F), suggestive of anaerobic metabolism. Importantly, DM+HFD+CKD showed no coronary atherosclerosis.ConclusionMultiple co‐morbidities in swine result in severe perturbations in myocardial oxygen balance and anaerobic metabolism in the absence of significant atherosclerosis, indicating severe coronary microvascular dysfunction co‐occurring with diastolic dysfunction.Support or Funding InformationThis study was supported by grants from the European Commission FP7‐Health‐2010 grant MEDIA‐261409, the Netherlands CardioVascular Research Initiative: an initiative with support of the Dutch Heart Foundation [CVON2012‐08 (PHAEDRA), CVON2014‐11 (RECONNECT)]. Cardiac index (CI) of DM+HFD+CKD was lower than in CON swine (A). Myocardium of DM+HFD+CKD swine shows increased oxygen consumption (MVO2) for the same level of cardiac work (B), has a lower myocardial oxygen delivery (MDO2, C) and a higher oxygen extraction (MEO2, D), which results in lower coronary venous oxygen saturation (cv SaO2, E). Lower myocardial lactate consumption (MVlactate) at a given level of myocardial lactate delivery (MDlactate, F). *p&lt;0.05 DM+HFD+CKD versus CONimageCardiac index (CI) of DM+HFD+CKD was lower than in CON swine (A). Myocardium of DM+HFD+CKD swine shows increased oxygen consumption (MVO2) for the same level of cardiac work (B), has a lower myocardial oxygen delivery (MDO2, C) and a higher oxygen extraction (MEO2, D), which results in lower coronary venous oxygen saturation (cv SaO2, E). Lower myocardial lactate consumption (MVlactate) at a given level of myocardial lactate delivery (MDlactate, F). *p&lt;0.05 DM+HFD+CKD versus CONThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Pulmonary vascular disease in swine with multiple comorbidities

IntroductionDiabetes mellitus (DM), chronic kidney disease (CKD) and hypercholesterolemia are common co‐morbidities associated with low‐grade inflammation and endothelial dysfunction leading to increased systemic vascular resistance, diastolic dysfunction and exercise intolerance. Diastolic dysfunction is a risk factor for development of post‐capillary pulmonary hypertension (PH), which, in a subgroup of patients, deteriorates into combined pre‐and post‐capillary PH. This process is characterized by an increase in pulmonary vascular resistance (PVR) due to pulmonary vascular dysfunction and remodeling. It is incompletely understood which factors predispose to the development of combined pre‐and post‐capillary PH. We hypothesize that comorbidities cause pulmonary endothelial dysfunction, which in turn initiates pulmonary vascular remodeling, increases PVR and further reduces exercise tolerance.ObjectiveTo investigate the contribution of endothelial dysfunction, characterized by perturbances in the nitric oxide (NO)‐cGMP‐phosphodiesterase 5 (PDE5) pathway, to changes in PVR at rest and during exercise in a swine model with multiple co‐morbidities.MethodsDM (streptozotocin 3×50mg/kg iv) and CKD (renal embolization) were induced in 6 female swine fed a high fat diet (DM+HFD+CKD), while 8 female healthy swine on normal diet served as controls (CON). Six months later, swine were chronically instrumented and hemodynamics were studied at rest and during exercise, in the absence and presence of eNOS‐inhibition (LNNA, 20 mg/kg iv) and PDE5‐inhibition (sildenafil, 100 mg iv).ResultsDM+HFD+CKD swine exhibited hyperglycemia (18.7±1.9 vs 7.5±0.6mmol/L), hypercholesterolemia (7.3±0.7 vs 1.7±0.1mmol/l), renal dysfunction (glomerular filtration rate: 123±12 vs 202±8 ml/min), and inflammation (TNF‐α 51.6±5.1 vs 24.6±5.5pg/ml, all P&lt;0.05).DM+HFD+CKD swine had similar pulmonary arterial pressures at rest and during exercise compared to CON swine, while cardiac index was significantly reduced, reflecting the higher PVR in DM+HFD+CKD. DM+HFD+CKD swine showed a similar increase in PVR in response to eNOS‐inhibition compared to CON swine at rest and during exercise. However, PDE5 inhibition resulted in a significant reduction in PVR, reflecting pulmonary vasodilation in CON, but not in DM+HFD+CKD swine. Altogether, these data suggest that impaired PDE5‐activity acts to preserve the vasodilator effect of endogenous NO in DM+HFD+CKD.ConclusionsExposure to multiple co‐morbidities in a swine model causes an increase in inflammatory factors, which is accompanied by a reduced activity in the NO‐pathway, that is counterbalanced by reduction in PDE5‐activity in swine with DM+HFD+CKD. Hence, exposure to co‐morbidities causes pulmonary endothelial dysfunction and an increase in PVR, even in the absence of overt PH. Thus, pulmonary vascular disease might be an underestimated contributing factor in the disease progress in patients with multiple co‐morbidities and diastolic dysfunction.Support or Funding InformationFunding: CVON‐RECONNECTThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

04:12 PM Abstract No. 343 Combined transarterial renal embolization and percutaneous image-guided renal ablation for treatment of T1B and central renal cell carcinomas in patients with high surgical risk

04:12 PM Abstract No. 343 Combined transarterial renal embolization and percutaneous image-guided renal ablation for treatment of T1B and central renal cell carcinomas in patients with high surgical risk

Ultrasound-guided percutaneous nephrolithotomy for upper urinary tract calculi in patients with spinal deformity: a decade's experience.

To evaluate the efficacy and safety of ultrasound (US)-guided percutaneous nephrolithotomy (PCNL) in managing upper urinary tract calculi in patients with spinal deformity based on our experience over the last decade. A retrospective study was conducted on patients with spinal deformity who were admitted to Beijing Tsinghua Changgung Hospital and collaborative hospitals from August 2004 to August 2017. Patients diagnosed with urolithiasis and who underwent US-guided PCNL, performed by the same surgeon, were included. Patients' data were collected and the following variables were analysed: age; sex; plain abdominal radiograph of the kidneys, ureters and bladder (KUB); computed tomography (CT); stone burden; evaluation of spinal anatomy; respiratory function; operative time; and postoperative findings. The severity of surgical complications was determined according to the modified Clavien classification system (MCCS). A total of 72 patients (41 males and 31 females) were included, with a mean (range) age of 35(21-69)years. The mean (range) stone diameter was 38(19-68)mm. Seven patients had bilateral PCNL, completed in staged surgery with a 1-week interval. Five kidneys received staged PCNL because of either large residual stones or the potential risk of a long operation time. In all, 19 patients underwent the surgery in a prone position, 29 lateral, nine oblique supine, and the other 27 in unconventional positions (lateral prone, lateral supine, and lateral jackknife position). All procedures were successfully completed with no major complications during the operation. The mean (SD) tract building time was 8.5(1.7)min. The mean (SD) stone disintegration time was 39.3(14.6)min. The mean (range) temperature and postoperative haemoglobin (Hb) drop on the first postoperative day were 37.6(36.7-39.2)°C and 1.5(0.2-4.3)g/dL, respectively. Four patients needed blood transfusions and none of the patients had septic shock or severe renal bleeding requiring angiographic renal embolisation or nephrectomy. A stone-free status was achieved in 71 kidneys (89.87%). Eight patients with residual fragments ≥4mm were either observed without treatment during follow-up or re-treated with shockwave lithotripsy (SWL) according to clinical significance. PCNL in patients with spinal deformities is challenging but safe and effective. US-guided puncture and access establishment has its unique advantages when such patients are placed in unconventional positions.

Unexpected renal hemorrhage after endovascular repair of complicated type B aortic dissection: two cases report

BackgroundThoracic endovascular aortic repair (TEVAR) is the therapeutic choice for type B aortic dissection. One of the most unfavored complications of this procedure is hemorrhage, which has a low incidence but high mortality. Renal hemorrhage (RH) after endovascular aortic repair has been rarely reported. We presented two cases of unexpected RH after TEVAR for complicated type B aortic dissection, and the potential causes, diagnosis and therapeutic management were discussed.Case presentationA 67-year-old female developed hypotension and progressively decrease of hemoglobin within 5 h after TEVAR for acute complicated type B dissection. Bedside ultrasonography and abdominal computed tomography angiography revealed a massive right perinephric hematoma. The right renal angiography detected multiple tortuous vascular branches with diffuse perinephric bleeding. The main trunk of right renal artery was embolized. The patient recovered uneventfully and presented with normal renal function 6 months later. Another patient was a 69-year-old male who was admitted for endovascular repair of a chronic complicated type B aortic dissection. The patient presented with hemodynamic instability early after TEVAR. Bedside ultrasonography showed a giant left retroperitoneal hematoma. The abdominal angiography revealed two active bleeding sits located in the distal branches of left renal artery. A super-selective embolization of the two arteries was performed, however the patient developed abdominal compartment syndrome and died of multiple organ failure.ConclusionsUnexpected RH after endovascular repair of aortic dissection might be associated with iatrogenic and idiopathic factors. Close surveillance and clinician’s awareness of this rare complication is crucial for accurate and prompt diagnosis. Renal angiography and subsequent selective embolization of bleeding vessels are effective interventions for treating this fatal condition.

Multicenter experience with endovascular treatment of aortic coarctation in adults

ObjectiveThe objective of this study was to evaluate outcomes of endovascular treatment of aortic coarctation in adults. MethodsClinical data and imaging studies of 93 consecutive patients treated at nine institutions from 1999 to 2015 were reviewed. We included newly diagnosed aortic coarctation (NCO), recurrent coarctation, and aneurysmal/pseudoaneurysmal degeneration (ANE) after prior open surgical repair (OSR) of coarctation. Primary end points were morbidity and mortality. Secondary end points were stent patency and freedom from reintervention. ResultsThere were 54 (58%) male and 39 (42%) female patients with a mean age of 44 ± 17 years. Thirty-two patients had NCO (mean age, 48 ± 16 years) and 61 had endovascular reinterventions after prior OSR during childhood (mean, 30 ± 17 years after initial repair), including 50 patients (54%) with recurrent coarctation and 11 (12%) with ANE. Clinical presentation included asymptomatic in 31 patients (33%), difficult to control hypertension in 42 (45%), and lower extremity claudication in 20 (22%). Endovascular treatment was performed using balloon-expandable covered stents in 47 (51%) patients, stent grafts in 36 (39%) patients, balloon-expandable uncovered stents in 9 (10%) patients, and primary angioplasty in 1 (1%) patient. Mean lesion length and diameter were 64.5 ± 50.6 mm and 19.5 ± 6.7 mm, respectively. Mean systolic pressure gradient decreased from 24.0 ± 17.5 mm Hg to 4.4 ± 7.4 mm Hg after treatment (P < .001). Complications occurred in nine (10%) patients, including aortic dissections in three (3%) patients and intraoperative ruptures in two patients; type IA endoleak, renal embolus, spinal headache, and access site hemorrhage occurred in one patient each. The aortic dissections and ruptures were treated successfully by deploying an additional covered stent proximal to the site of dissection or rupture. Two patients died within 30 days of the index procedure. After a mean follow-up of 3.2 ± 3.1 years, nearly all patients (98%) were clinically improved and all stents were patent. Reintervention was needed in 10 (11%) patients. Freedom from reintervention at 5 years was 85%. Two additional patients died during follow-up of coarctation-related causes, including rupture of an infected graft and visceral ischemia. Patient survival at 5 years was 89%. ConclusionsEndovascular repair is effective with an acceptable safety profile in the treatment of NCO and postsurgical complications of coarctation after initial OSR. Aortic rupture is an infrequent (2%) but devastating complication with high mortality. Balloon-expandable covered stents are preferred for NCO, whereas stent grafts are used for ANE. The rate of reinterventions is acceptable, with high procedural and long-term clinical success.