Renal Infarction Research Articles

HERE A CLOT, THERE A CLOT, EVERYWHERE A CLOT: A CASE OF VENOUS AND ARTERIAL THROMBI IN A PATIENT WITH COVID-19

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Venous and arterial thrombi are both common complications seen in patients with COVID-19. This phenomenon may be due to the hyper-inflammatory state seen in COVID-19 infection. While venous thrombosis has been reported in 21% of patients with COVID-19, arterial thrombosis is more infrequent, reported in 2% of patients [1]. We present a patient with COVID-19 infection found to have pulmonary embolism (PE), left ventricular (LV) thrombus, and renal infarcts. CASE PRESENTATION: A 54-year-old male with a history of hypertension, diabetes mellitus, coronary artery disease, and heart failure with EF of 40% presented with worsening shortness of breath 10 days after having tested positive for SARS-COVID-19. The patient was placed on 100% FiO2 via high flow nasal cannula for acute hypoxic respiratory failure and started on dexamethasone, remdesivir, and enoxaparin for VTE prophylaxis.On day 6 of admission, the patient had acute onset pleuritic chest pain. ECG was unchanged from baseline and troponin level remained undetectable, however the d-dimer level increased from 338 ng/mL on admission to >10,000 ng/mL. CT chest with IV contrast revealed right upper lobe pulmonary emboli (Figure 1) and suspicion of left ventricular thrombus. The patient was started on therapeutic heparin infusion.TTE showed an akinetic left ventricular apex with echo density in apex suggestive of apical thrombus (Figure 2) and a 30% EF not seen previously. The patient was initiated on a heparin-warfarin bridge. On day 12 of admission, the patient experienced acute severe right lower quadrant pain. CT with IV contrast revealed multifocal large right renal infarcts with patent renal vessels (Figure 3). Because his renal function remained stable, no further intervention was taken. The patient's respiratory status began to improve and the patient was discharged home on warfarin. DISCUSSION: LV thrombus is a serious complication most often seen after acute myocardial infarction, but it can be found in 6% of patients with low ejection fraction and ischemic heart disease [2]. There have been reports of it in patients with COVID-19, particularly those with pre-existing cardiomyopathy such as our patient. LV thrombus would be unlikely to cause the PE seen in this patient, indicating the patient had unrelated venous and arterial thrombi due to COVID-19. However, the renal infarcts found after the patient had acute abdominal pain suggest that they are embolic from the LV thrombus. Early diagnosis and treatment of LV thrombus with warfarin as gold standard is important due to the high risk of stroke or systemic embolism [3]. CONCLUSIONS: There is an increased risk of both venous and arterial thrombi in COVID-19 despite prophylaxis. Patients with existing ischemic cardiomyopathy may be at risk for LV thrombus. Prompt recognition and management is critical to preventing additional venous and arterial embolic events and improving mortality. REFERENCE #1: Malas MB, Naazie IN, Elsayed N, Mathlouthi A, Marmor R, Clary B. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis. EClinicalMedicine. 2020 Dec;29:100639. doi: 10.1016/j.eclinm.2020.100639. Epub 2020 Nov 20. REFERENCE #2: Aljaber NN, Mattash ZA, Alshoabi SA, Alhazmi FH. The prevalence of left ventricular thrombus among patients with low ejection fraction by trans-thoracic echocardiography. Pak J Med Sci. 2020 May-Jun;36(4):673-677. doi: 10.12669/pjms.36.4.1972. REFERENCE #3: Robinson AA, Trankle CR, Eubanks G, Schumann C, Thompson P, Wallace RL, Gottiparthi S, Ruth B, Kramer CM, Salerno M, Bilchick KC, Deen C, Kontos MC, Dent J. Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi. JAMA Cardiol. 2020 Jun 1;5(6):685-692. doi: 10.1001/jamacardio.2020.0652. DISCLOSURES: No relevant relationships by Tony Li-Geng, source=Web Response no disclosure on file for Carrie Mahowald;

INFECTIVE ENDOCARDITIS WITH SPINAL CORD INFARCTION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis can present with disseminated septic emboli phenomenon. Neurological complications of disseminated infective endocarditis include spinal epidural abscess. Spinal cord infarction is a very rare complication of infective endocarditis with only two cases previously reported. We present a case with fulminant infective endocarditis with widespread septic emboli and spinal cord infarction. CASE PRESENTATION: 34-year-old male, intravenous drug abuser with recent incarceration presented with five-day history of progressive lower extremity weakness and pain associated with inability to walk, lower back pain, loss of bowel and bladder control, and pleuritic chest pain. Past medical history was significant for recurrent infective endocarditis of tricuspid valve and prosthetic tricuspid valve with recent tricuspid valve repair 6 months ago. Laboratory analysis was remarkable for leukocytosis, microcytic anemia, severe thrombocytopenia, lactic acidosis, and oliguric acute kidney injury requiring emergent hemodialysis. The patient was subsequently intubated for acute respiratory failure with worsening septic shock requiring pressor support. Transthoracic echocardiogram revealed a normal left ventricular ejection fraction. A large 4.1 x 1.6 cm mobile vegetation was noted involving the bioprosthetic tricuspid valve extending into the right ventricle associated with moderate stenosis. Blood cultures were positive for Serratia marcescens. CT chest was significant for bilateral ground-glass opacities, multiple nodular infiltrates, and cystic cavitary lesions representing septic emboli. CT abdomen was significant for splenomegaly with multiple splenic infarcts and bilateral multiple renal cortical infarcts. CT scan of spine ruled out epidural abscess. MRI could not be performed due to presence of epicardial leads. Based on above findings, patient was diagnosed with infective endocarditis with systemic shower of septic emboli to lungs, spleen, and kidneys with high suspicion of spinal cord infarction. Patient was started on empiric antibiotics on admission later adjusted to culture sensitivities. He continued to deteriorate clinically and underwent cardiac arrest within 72 hours of admission and expired. DISCUSSION: Infective endocarditis with septic emboli phenomenon can present with a myriad of clinical features. In the presence of neurological deficits, spinal cord infarction should be high in the differential and managed emergently due to its time-sensitive salvage. However, the probability of complete recovery after spinal infarction is very low; overall mortality in the first month is 25%, with long-term disability in 40-50% requiring wheelchair or chronic bladder catheterization. CONCLUSIONS: Spinal cord infarction is a rare complication of infective endocarditis with disseminated septic emboli phenomenon that requires emergent time-sensitive management with overall high mortality. REFERENCE #1: Kfoury B, Sharma D, Mansour W, Suen P, Abou Yassine A, Chalhoub M. Endocarditis to the Spine: A Rare Cause of Spinal Cord Infarction. Chest. 2017 Oct 1;152(4):A366. REFERENCE #2: Robertson, C.E., et al., Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology, 2012. 78(2): p. 114-21 DISCLOSURES: No relevant relationships by Huda Asif, source=Web Response No relevant relationships by Adam Friedlander, source=Web Response No relevant relationships by Katherine Hodgin, source=Web Response No relevant relationships by Stanislav Ivanov, source=Web Response No relevant relationships by Arsalan Wappi, source=Web Response No relevant relationships by Christopher Wood, source=Web Response

COVID-19 COAGULOPATHY SECONDARY TO ACTIVATING PLATELET ANTIBODIES

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coagulopathies have been extensively reported in COVID-19 patients (1). CASE PRESENTATION: A 58-year old female presented to the emergency department (ED) with 2-weeks history of shortness of breath. A nasopharyngeal swab was positive for SARS-CoV-2. She was treated and discharged on room air. D-dimer (DD) and platelet (plt) count at the time of discharge were within normal. Six days after discharge she presented to the ED with severe abdominal and right leg pain. Lower extremity pulses were present by doppler but hard to palpate. Laboratory tests showed elevated DD (27,820 ng/ml) and elevated plt (530 x109/L), table-1. Computed tomography scan (fig-1) of the abdomen and pelvis showed multiple wedge-shape infarcts in the liver, spleen, and right kidney and acute thrombosis of the right common iliac artery. Acute deep vein thrombosis in the lower and upper extremities were excluded by US. Duplex US of the right lower extremity showed ankle brachial index of 0.2. The patient was admitted and started on heparin therapy. On day 2, plt count dropped to 127 x 109/L. The 4T score was 5, heparin was stopped and argatroban was started. Serotonin release assay was sent and showed no inhibition with high dose heparin. However, non-heparin dependent anti-platelet activating antibodies (class I HLA antibodies) were detected. Anti-platelet factor-4 was negative and patient was restarted back on heparin. Thrombophilia and autoimmune work up were negative. Patient was discharged on low-molecular weight heparin. Plt count was 179 x109/L before discharge. DISCUSSION: Recent study published by Bilaloglu showed that 533 (16.0%) COVID-19 patients had at least one thrombotic evet during hospitalization. Of all 3334 patients, only 32 (1.0%) had acute limb ischemia, upper extremity arterial thrombosis, renal, and splenic infarcts, and portal vein thrombosis (2). In another case series, 4 of the reported 7 cases developed progressive irreversible lower limb ischemia. Two patients presented with lower limb ischemia and the other two developed severe thrombosis after 4 and 15 days respectively. Of the reported lab values, two patients had D-dimer levels more than 20,000 ng/ml and the same two were thrombocytopenic (1). Interestingly, our patient had reversible limb ischemia as shown by the repeated duplex US done after discharge. Nicolai and colleagues reported that plts hyperactivation and possible immuno-thrombosis may play a role in the pathogenesis of coagulopathy among severe COVID-19 patients (3). In our case, patient had hypercoagulability secondary to activating anti-platelets antibodies, a novel finding that can help understanding the pathogenesis of COVID-19 induced hypercoagulability. CONCLUSIONS: COVID-19 associated coagulopathy can be un-predictable. Activating anti-plt antibodies may play a role in the pathogenesis of COVID-19 coagulopathy. REFERENCE #1: Kashi M, Jacquin A, Dakhil B, et al. Severe arterial thrombosis associated with Covid-19 infection. Thromb Res 2020;192:75-7. REFERENCE #2: Bilaloglu S, Aphinyanaphongs Y, Jones S, Iturrate E, Hochman J, Berger JS. Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System. JAMA 2020. REFERENCE #3: Nicolai L, Leunig A, Brambs S, et al. Immunothrombotic Dysregulation in COVID-19 Pneumonia is Associated with Respiratory Failure and Coagulopathy. Circulation 2020. DISCLOSURES: No relevant relationships by Bahaa Abdelghaffar, source=Web Response No relevant relationships by hamed daw, source=Web Response No relevant relationships by Tariq Kewan, source=Web Response No relevant relationships by Talha Saleem, source=Web Response

A TICKING TIMEBOMB: FLOATING AORTIC ARCH THROMBUS IN A PATIENT WITH METASTATIC SQUAMOUS CELL CARCINOMA OF THE LUNG

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Thoracic aortic mural thrombi are a rare clinical entity and most patients are asymptomatic before significant embolic events occur(1). There are only a few reported cases and are mostly in patients who presented with complications of peripheral thromboembolism. We report the case of a patient who presented with symptoms of congestive heart failure and was found to have a large floating thoracic aortic thrombus. CASE PRESENTATION: The patient is a 61-year-old female with no prior medical history who presented with shortness of breath on exertion and dry cough of three weeks duration. The patient has an extensive 40 pack-year smoking history. On evaluation, the patient was tachypneic, hypertensive, and was saturating well on room air. Crackles could be heard at the bases of the lungs and there was pitting edema of bilateral lower extremities. Laboratory studies showed a b-type natriuretic peptide level of 1741 pg/mL. A chest X-ray revealed pulmonary edema and bilateral pleural effusions. With a diagnosis of heart failure, gentle diuresis with intravenous furosemide was initiated. An echocardiogram showed global hypokinesis of the left ventricle with a reduced ejection fraction of 25-30%. CT scan of the chest revealed a large 6 x 7 cm necrotic mass in the left lower lung field with mediastinal adenopathy. There was a pulmonary embolus in the posterior basal segment of the left pulmonary artery, originating from the location of the mass. The CT was also significant for an intraluminal polypoid filling defect in the aortic arch with multiple small splenic and left renal infarcts, suggestive of a peripherally embolizing aortic thrombus. The patient was started on anticoagulation with low molecular weight heparin and was recommended to have an aortic arch stent placed to prevent further embolization of the thrombus. However, the patient decided against the procedure. Further biopsy and staging workup of the left lung mass revealed metastatic squamous cell carcinoma. The patient decided against palliative chemotherapy and opted for hospice care. DISCUSSION: Thoracic aortic mural thrombus is the result of disturbances in the Virchow's triad, ie, stasis, hypercoagulability, and endothelial dysfunction. The patient's smoking history, extensive atherosclerosis, malignancy, and left ventricular dysfunction were likely contributing factors. Aortic thrombi are prone to peripheral embolization to sites such as the spleen, kidneys, small bowel, and lower extremities(2). Early diagnosis and prompt management with anticoagulation are key. Endovascular repair with endograft stents is a novel modality of treatment with higher safety, patient acceptability, and a lower rate of peripheral embolization(3). CONCLUSIONS: Thoracic aortic thrombi are an initially silent rare disease condition with potentially fatal complications. Prompt management with anticoagulation and possible endovascular treatment is warranted. REFERENCE #1: Yang P, Li Y, Huang Y, Lu C, Liang W, Hu J. A giant floating thrombus in the ascending aorta: a case report. BMC Surg. 2020 Dec 9;20(1):321 REFERENCE #2: Bukharovich IF, Wever-Pinzon O, Shah A, Todd G, Chaudhry FA, Sherrid MV. Arterial Embolism Caused by Large Mobile Aortic Thrombus in the Absence of Atherosclerosis, Associated with Iron Deficiency Anemia. Echocardiogr Mt Kisco N. 2012 Mar;29(3):369–72. REFERENCE #3: Jamjoom R, Zagzoog MM, Sait S. Outcome of Endovascular Approach for Management of Thoracic Aortic Thrombus. Ann Vasc Surg. 2019 Aug 1;59:307.e7-307.e12. DISCLOSURES: No relevant relationships by Amjad Basheer, source=Web Response No relevant relationships by Rana Prathap Padappayil, source=Web Response No relevant relationships by DISHANT SHAH, source=Web Response No relevant relationships by vinit singh, source=Web Response No relevant relationships by Raghu Tiperneni, source=Web Response

The management of a patient with multiple infarcts with different etiologies

72 yo male, presents for abdominal pain and motor deficiency of the left upper limb. Clinical examination reveal severe general condition, left brachial hemiparesis, right arm blood pressure (BP) 240/120 mmHg, left arm BP 210/100 mmHg, heart rate (HR) 110 bpm, arrhythmic, abdominal pain at superficial palpation, without other abnormalities. Biological: negative hs troponin I, positive D-dimers, positive CRP, GFR 38 ml/min/m2, potassium 2.97 mmol/l. ECG: Atrial fibrillation. Abdominal ultrasound: abdominal dilated aorta, dissection flap. Abdominal and pelvic CT scan: right renal infarction, multiple splenic infarction, abdominal aortic aneurysm with dissection. Underwent interventional treatment of the abdominal aortic dissection (EVAR). Particularity of the case: concomitant diagnosis of multiple infarction with different etiologies, for which therapeutic decision was challenging.

Insights from intravascular pressure measurement of renal artery revascularization in patients with fibromuscular dysplasia: The DYSART study

ObjectiveThe indication of percutaneous renal transluminal angioplasty (PTRA) in fibromuscular dysplasia (FMD) is mainly based on renal artery stenosis (RAS) due to atherosclerosis criteria, which are not specific to FMD. Consequently, the selection of patients who could benefit from this treatment and its effectiveness remain uncertain. The aims of this study were to: (1) report the effects of PTRA guided by trans-stenotic pressure measurements on hypertension 7 months after treatment; (2) assess the impact of pressure measurement to guide treatment efficacy in comparison to visual angiographic parameters; and (3) evaluate the reproducibility and accuracy of the stenosis measurement using a 4F catheter in comparison to a pressure guidewire. MethodsThis prospective multi-centric study analyzed 24 patients with hypertension with RAS due to FMD that required PTRA. Clinical, duplex ultrasound, and angiographic indices were collected, and patients were followed up for 7 months (±1 month). Angiographic indices were measured twice both by a pressure guidewire and a 4F catheter. Assessment of procedural and clinical success of angioplasty was performed for all patients. ResultsTwenty-three patients (96%) had procedural success (considered as a post-PTRA translesional systolic gradient ≤10 mmHg or reduced by at least 80%) with a significant decrease in the systolic gradient after angioplasty (26.50 mmHg; [interquartile range, 16.75-38.75] vs 0.00 [interquartile range, 0.00-2.00]; P < .01). Three patients (12%) had complications, including two renal artery dissections and one partial renal infarction. Twenty-one patients (88%) were clinical responders to angioplasty at follow-up. Visual stenosis assessment showed a poor correlation with systolic gradient measurement before and after PTRA (R from −0.05 to 0.41; P = 0.06-0.82). High correlations were found between pressure measurements made by a 4F catheter and guidewire (R from 0.64 to 0.89; P ≤ .003). ConclusionsIn patients selected by clinical indicators and duplex ultrasound, reaching a translesional systolic gradient ≤10 mmHg or reduced by at least 80% after angioplasty, promotes a high success rate for PTRA in hypertension due to FMD RAS.

Percutaneous Intervention in Acute Renal Attack

A young patient with renal infarction presented with right lower abdominal pain due to renal artery thrombosis is a rare clinical condition that warrants epidemiologic, clinical, angiographic, and prognostic importance. The patient’s condition was acute and was featured with abdominal pain, leukocytosis, and minimal renal impairment. The case presented here enabled us to widened our vision with patients presented with abdominal pain should warrant clinical suspicion about renal infarction although this is a rare clinical entity.

Role of Digital Subtraction Angiography in Diagnosis of Fibromusculardysplasia

Fibromuscular dysplasia (FMD) is a vascular disease characterized by abnormal arterial wall architecture, usually visualized angiographically as the classic “string of beads” sign. We present the diagnostic dilemma of a 51-year-old woman admitted for a spontaneous renal infarct, with initial examination and investigations equivocal. She was consequently assessed for thromboembolic and vasculitic disease, before proceeding to digital subtraction angiography (DSA). This invasive method elucidated an area of focal FMD, previously not seen on computed tomography angiography (CTA). This is unusual due to CTA's high sensitivity and specificity but could be attributed to the less common subtype of FMD which requires combined imaging modalities to arrive at a diagnosis. Hence, there may be a role for the dual use of CTA and DSA in young patients presenting with a spontaneous renal infarct in the absence of other diagnoses.

Asymptomatic renal infarction after left upper lobectomy: Case report

BackgroundRenal infarction after pulmonary resection is relatively rare; however, it is associated with severe morbidity.Case presentationAn 80-year-old woman without any severe comorbidity or smoking history underwent left upper lobectomy (LUL) concomitant with mediastinal lymph node dissection for lung adenocarcinoma. She did not show fever, flank pain, and/or nausea; however, laboratory data revealed an elevated white blood cell count (WBC) (13,460 cells/mm3) and elevated serum lactate dehydrogenase (LDH) (670 IU/L) and C-reactive protein (CRP) (23.6 mg/dL) levels on the fifth postoperative day. Contrast-enhanced computed tomography from the thorax to the pelvic cavity revealed a partial defect of the right kidney without any indication of infection and no pulmonary vein stump thrombosis. We diagnosed the patient with partial right renal infarction, and heparin (10,000 IU/day) was initiated. Laboratory data showed gradual reduction in the WBC (7700 cells/mm3), as well as in the serum LDH (355 IU/L) and CRP (0.76 mg/dL) levels, 7 days after heparin initiation. Anticoagulation therapy including heparin administration was discontinued because renal function remained, and we observed no pulmonary vein stump thrombosis. Laboratory data remained within normal limits, and the patient was discharged on postoperative day 15.ConclusionsLUL is considered a risk factor for this condition, and elevated WBC, as well as serum LDH and CRP levels are useful diagnostic indicators.

Laboratory parameters can be used to differentiate renal infarction and urolithiasis in patients who are admitted to the emergency department with flank pain

Abstract&#x0D; Aim&#x0D; We aimed to determine the predictive value of laboratory parameters for the distinction between urolithiasis (UL) and renal infarction (RI) in patients presenting to the emergency department with flank pain complaint.&#x0D; Methods&#x0D; In our retrospective study, the files of 73 patients who presented to the emergency department (ED) with flank pain and whose costovertebral angle tenderness was positive were reviewed. Routine blood tests and the results of contrast-enhanced abdominal computed tomography were obtained. The patients were divided into two groups as RI and UL according to the results of computed tomography. Accordingly, 8 patients were found to have RI, and 65 had UL.&#x0D; Results&#x0D; LDH and PLR values were significantly higher in the RI group compared to the UL group (p

Post-traumatic renal artery thrombosis secondary to blunt abdominal trauma: a rare case report

Background: Blunt abdominal trauma is one of the leading causes of morbidity and mortality among populations worldwide. However, renal artery injury due to blunt abdominal trauma is a rare occurrence. In this case, a patient who suffered multiple trauma was found in the emergency department, including blunt abdominal trauma, after a motor vehicle accident.Case report: A 13-year-old boy with multiple trauma was referred to our emergency department, with the primary consideration being to lose consciousness 3 hours before admission due to a traffic accident. After receiving examination, there was no evidence of abdominal bruising, whereas the results of the head CT scan show epidural hemorrhage. After four days of treatment, the urea and creatinine serum levels increased, abdominal CT scan shows right renal infarction suggestive of right renal arterial rupture. The patient was diagnosed with a moderate head injury and right renal trauma AAST grade IV. The patient was referred to the interventional radiology unit. The endovascular revascularization techniques were performed with renal artery stent placement and vasodilator (nitroglycerin) flush into the renal artery before stent placement. Renal artery stenting placement performed on main right renal artery demonstrates the absence of intraluminal defects and substantially blood flow was established, abdomen CT Scan shows an enhancement on right renal parenchyma which mean right kidney vascularization appears to be improved with the return of glomerular filtration rate to normal value at the time the patient was discharged.Conclusion: Traumatic renal artery thrombosis is a rare occurrence with devastating consequences if any imaging is missed. Endovascular therapy plays a significant role in the treatment of renal artery thrombosis with a better prognosis.

Renal Infarction and Decreased Splenic Perfusion Secondary to a Left Ventricular Thrombus: A Case Report

We report a case of a 67-year-old man who presented to urgent care with a one-week history of left-sided abdominal pain and oliguria. Over the past month, he reported feeling fatigued as well as noticed decreased urine output. The patient does have a significant cardiac medical history that includes coronary artery disease with a previous myocardial infarction, reduced ejection fraction, and hypertension. Imaging studies were conducted which revealed the likely etiology of his current symptoms. A transthoracic echocardiogram (TTE) revealed the presence of a large non-mobile apical thrombus occupying most of the apex of the left ventricle. Computed Tomography (CT) confirmed an apical left ventricular thrombus and showed decreased perfusion to the spleen and ischemia/infarction of the left kidney. The patient was initially treated with heparin but subsequently given enoxaparin with bridging to warfarin. He began to feel better with less left flank pain. Although this presentation of an LV thrombus is a rare occurrence, it is important for physicians to consider abdominal pain as a presenting complaint.

Renal Infarction

Renal infarction is a rare vascular disease describing the obstruction of the renal artery or its branches from blood clots formed in the vascular system of the patient. The correct diagnosis may prove to be a challenging procedure considering that the disease may mimic the symptomatology of urinary lithiasis or other urologic emergencies. A discussion of the diagnostic dilemmas, imaging modalities, treatment options, and prognosis of the disease, based on the more recent findings, is presented in this review.

Who shot first? Three possible causes of a kidney infarction

Renal infarction is a rare disease whose incidence is less than 1%. The symptoms can be abdominal or flank pain, nausea, vomiting, fever or hypertension. The diagnosis is complex, and it is based on symptoms, blood analysis with an elevated level of lactate dehydrogenase and computed tomography angiography. The two major causes of renal infarction are thromboembolism and in situ thrombosis. The treatment depends on an adequate etiological diagnosis.

Endovascular interventions in management of renal artery aneurysm.

Renal artery aneurysm (RAA) is a rare disease. With modern non-invasive imaging modalities, the disease is being increasingly diagnosed. It is a slow-growing aneurysm with high mortality in the event of rupture; especially in pregnant females for in which case patients were treated surgically. With advances in endovascular therapy, numerous techniques have been employed to manage complex RAA in artery bifurcation, branch and segmental arteries with excellent technical and clinical success. The various recent techniques include the use of flow diverter stents, remodelling with stent-assisted coil embolization (SACE), balloon-assisted coil embolization (BACE), selective embolization with coils-sac packing, inflow occlusion and coil trapping and selective embolization with liquid embolic agents-hystroacril and onyx. A combination of stent-graft with liquid embolization and liquid with microcoil embolization has been advocated with success. The most common complication encountered is renal infarction. This is mostly without impairment of renal function and secondary to embolization. Endovascular therapy has shorter operative time, less blood loss, shorter intensive care stay, done under conscious sedation and is associated with lesser postoperative morbidity compared to surgery. Reduction in hypertension, improvement of renal function and symptoms has been seen in most studies. Endovascular management of RAA has become the management of choice even with complex anatomy and technically challenging lesions.

Building a Web-Augmented Reality application for demonstration of kidney pathology for veterinary education.

Three-dimensional (3D) models created with computers and educational applications designed using such models are used in the medical field every day. However, there is a lack of macroscopic demonstration applications built with digital 3D models in the field of veterinary pathology. The aim is to build a fully interactive 3D educational web-based augmented reality application, to demonstrate macroscopic lesions in kidneys for educational purposes. We used open source and free software for all 3D modelling, Augmented Reality and website building. Sixteen 3D kidney pathology models were created. Kidney models modelled in 3D and published as WebAR are as follows: normal kidney, unilateral neurogenic shutdown with atrophy, hydronephrosis, hypercalcemia of malignancy tubular nephrosis, interstitial corticomedullary nephritis, renal infarct, multifocal petechial hemorrhages, polycystic kidneys, renal masses, multifocal nephritis, pigmentary nephrosis, papillary necrosis, glucose-related rapid autolysis (pulpy kidney), pyelonephritis, renomegaly and kidney stones. With the workflow shown here, it has been presented as a feasible model application for human pathology and presented to educators, researchers and developers who have 3D models and AR in their field of interest. To the best of the authors' knowledge, this is the first study on Web-Augmented Reality application for veterinary pathology education.

Left ventricular noncompaction\u2014a rare cause of triad: heart failure, ventricular arrhythmias, and systemic embolic events: a\xa0case report\xa0

BackgroundLeft ventricular noncompaction is a rare cardiomyopathy characterized by a thin, compacted epicardial layer and a noncompacted endocardial layer, with trabeculations and recesses that communicate with the left ventricular cavity. In the advanced stage of the disease, the classical triad of heart failure, ventricular arrhythmia, and systemic embolization is common. Segments involved are the apex and mid inferior and lateral walls. The right ventricular apex may be affected as well.Case presentationA 29-year-old Caucasian male was hospitalized with dyspnea and fatigue at minimal exertion during the last months before admission. He also described a history of edema of the legs and abdominal pain in the last weeks. Physical examination revealed dyspnea, pulmonary rales, cardiomegaly, hepatomegaly, and splenomegaly. Electrocardiography showed sinus rhythm with nonspecific repolarization changes. Twenty-four-hour Holter monitoring identified ventricular tachycardia episodes with right bundle branch block morphology. Transthoracic echocardiography at admission revealed dilated left ventricle with trabeculations located predominantly at the apex but also in the apical and mid portion of lateral and inferior wall; end-systolic ratio of noncompacted to compacted layers > 2; moderate mitral regurgitation; and reduced left ventricular ejection fraction. Between apical trabeculations, multiple thrombi were found. The right ventricle had normal morphology and function. Speckle-tracking echocardiography also revealed systolic left ventricle dysfunction and solid body rotation. Abdominal echocardiography showed hepatomegaly and splenomegaly. Abdominal computed tomography was suggestive for hepatic and renal infarctions. Laboratory tests revealed high levels of N-terminal pro-brain natriuretic peptide and liver enzymes. Cardiac magnetic resonance evaluation at 1 month after discharge confirmed the diagnosis. The patient received anticoagulants, antiarrhythmics, and heart failure treatment. After 2 months, before device implantation, he presented clinical improvement, and echocardiographic evaluation did not detect thrombi in the left ventricle. Coronary angiography was within normal range. A cardioverter defibrillator was implanted for prevention of sudden cardiac death.ConclusionsLeft ventricular noncompaction is rare cardiomyopathy, but it should always be considered as a possible diagnosis in a patient hospitalized with heart failure, ventricular arrhythmias, and systemic embolic events. Echocardiography and cardiac magnetic resonance are essential imaging tools for diagnosis and follow-up.

Successful Conservative Treatment of a Complicated Aortic Thrombus in a Woman with Factor V Leiden Mutation.

Thrombus in the aortic trunk is a rare complication. We report the case of a 63-year-old patient with a factor V Leiden mutation in whom an aortic arch thrombus was discovered accidentally. Conservative treatment was initiated with therapeutic anticoagulation with low-molecular-weight heparin leading to complete thrombus lysis after 3 months but associated shortly after anticoagulation initiation with a large splenic and limited renal infarctions.LEARNING POINTSIntra-aortic thrombus is rarely diagnosed on routine CT examination.Even a complicated aortic arch thrombus can be successfully treated with conservative anticoagulation.Vascular systemic embolisms are possible after therapeutic anticoagulation is started.

¿Quién disparó primero? Infarto renal de tres posibles causas

Renal infarction is a rare disease whose incidence is less than 1%. The symptoms can be abdominal or flank pain, nausea, vomiting, fever or hypertension. The diagnosis is complex, and it is based on symptoms, blood analysis with an elevated level of lactate dehydrogenase and computed tomography angiography. The two major causes of renal infarction are thromboembolism and in situ thrombosis. The treatment depends on an adequate etiological diagnosis.

MO226A NEW DIAGNOSTIC TOOL FOR CKD PATIENTS: CONTRAST-ENHANCED ULTRASONOGRAPHY. A SINGLE CENTER EXPERIENCE

Abstract Background and Aims Contrast-enhanced ultrasonography (CEUS) is a minimally invasive diagnostic tool available for diagnosing microvascular disturbances in tumors and many vascular pathologies. Unlike other radiological contrast agents, it is completely harmless for CKD patients and therefore it is used for the safe diagnosis of many diffuse or focal pathologies. Method We used CEUS examination in 50 CKD patients for the following pathologies: 10 atypical cysts, 15 liver focal lesions, 2 splenic focal lesions, 3 renal infarcts, 12 kidney focal lesions and 8 other organ involvements. Examination was made using a VOLUSON E8 machine (GE Medical System Kreztechnik GmbH Tiefenbach 15, Austria) with a 3.5 MHz convex array abdominal transducer. 2.4 ml of microbubble contrast-agent was administered intravenously and recording of the results were made for 3-5 minutes after injection. Results Depending on the organ vascular characteristics, contrast enhancement and/or wash-out were suggestive for the final diagnosis. In liver lesions there are three phases and in kidneys, spleen, gallbladder, adenopathies there are two vascular phases. We obtained a very good positive predictive value and sensitivity in detecting malignant lesions. Conclusion According to The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound they are used both for hepatic and Non-Hepatic Applications. Being non-invasive and non-irradiating it could be the main diagnostic examination in CKD population in the future.