450
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Letters to the Editor
caliber of vessels feeding the pseudoaneurysm and the presence of at least two vessels. Coil migration and ureteric obstruction, although rare, is a known complication after renal artery embolization with a few cases reported in the literature (2). To our knowledge, only one case of glue migration has been described (1) with an unsuccessful treatment. The pathogenetic hypothesis for glue migration is unclear. It is known that the glue injected into the tissues enhances migration and activation of fibroblasts (3); this may have caused fragmentation and migration of the glue cast into the collecting system through a fissure caused by local ischemia secondary to embolization. Another possibility is that embolization of the entire sac was performed, and this may have caused increased pressure within it causing the fragment to slip out. The decision to perform embolization of the entire sac was based on the presence of a complex anatomy, with at least two feeding vessels and the high possibility of reperfusion through collateral circles, but a selective and more accurate embolization of the two vessels alone probably would have prevented the migration. In the only case described in the literature (1), all treatment attempts were unsuccessful. Ureteroscopy failed because of severe angulation of the middle ureter, percutaneous nephroscopy failed because the glue particle could not be found within the renal pelvis, and open ureterotomy failed to locate the glue material because of severe adhesion of the ureter and the right internal iliac artery aneurysm. The glue particle was spontaneously expelled. In the present case, urgent ureteroscopy was performed because of acute ureteric obstruction with flank pain and high fever after complete glue removal. Laser lithotripsy was revealed to be a helpful tool in fragmenting the solid foreign body, which was susceptible to laser pulse shock waves. In conclusion, the presence of flank pain in a patient who previously had undergone renal artery embolization with N-butyl cyanoacrylate should raise the suspicion of glue migration, and a CT scan is indicated. If ureteral obstruction caused by glue migration is confirmed, ureteroscopy with foreign body removal should be performed.
REFERENCES 1. Chen WJ, Wang SC, Chen SL, Kao YL. Foreign body in the ureter: a particle of glue after transarterial embolization of a renal pseudoaneurysm during percutaneous nephrostomy. J Chin Med Assoc 2012; 75: 183–186. 2. Rajesparan K, Partridge W, Taha N, Samman R, Aldin Z. Early migration and ureteric obstruction of an embolisation coil used to treat massive haemorrhage following percutaneous nephrolithotomy. Cardiovasc Intervent Radiol 2011; 34:868–872. 3. Redl H, Schlag G. Properties of different tissue sealants with emphasis on fibrin-based preparations. In: Schlag G, Redl H, editors. Fibrin Sealant in Operative Medicine. Berlin: Springer; 1986. p. 27–38.
Logan et al
’
JVIR
Acute Renal Failure after Renal Denervation From: Alexander G. Logan, MD, FRCP(C) Vlad Diaconita, HBSc Douglas J. Ing, MD George D. Oreopoulos, MD, FRCS(C) John S. Floras, MD, DPhil, FRCP(C) Dheeraj K. Rajan, MD, FSIR Departments of Medicine (A.G.L., V.D., D.J.I., J.S.F.), Medical Imaging (D.K.R.), and Surgery (G.D.O.) University Health Network and Mount Sinai Hospital Peter Munk Cardiac Centre (D.J.I., G.D.O., J.S.F., D.K.R.) University Health Network University of Toronto 585 University Avenue, NCSB 1C-553 Toronto, Ontario, Canada, M5G 2N2
Editor: Catheter-based renal sympathetic denervation potentially decreases the blood pressure (BP) of patients with treatment-resistant hypertension (1). No serious adverse consequences have been reported, including renal failure, after this procedure (2,3). Institutional review board approval was obtained for this report. A 58-year-old white woman with resistant primary hypertension as determined in the clinic and on ambulatory 24-hour BP monitoring despite receiving seven antihypertensive medications including furosemide and spironolactone and normal serum creatinine was referred for this procedure. Her past medical history included an episode of malignant hypertension, early stage 3 chronic renal disease, and Parkinson disease. She had been hospitalized 7 years before referral for denervation for the management of acute prerenal failure thought to be caused by diarrhea. Before denervation, her BP as obtained by an automatic BP monitor (BpTRU; BpTRU Medical Devices, Coquitlam, British Columbia, Canada) was 135/98 mm Hg, and medications included amlodipine 10 mg twice a day, spironolactone 100 mg twice a day, clonidine 0.2 mg twice a day, furosemide 80 mg twice a day, lisinopril 20 mg twice a day, terazosin 2 mg every day, and atenolol 50 mg every day. Serum creatinine was 120 μmol/L, estimated glomerular filtration rate was 43 mL/min, and body mass index was 32.6. Renal denervation proceeded uneventfully. Renal angiography performed immediately after the procedure revealed no renovascular abnormality. A total of 45 mL of nonionic contrast material was used. Immediately after the procedure, the patientʼs systolic BP decreased to 110/70 mm Hg, requiring 750 mL of normal saline as a bolus to maintain her BP 4 100 mm None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.11.017
Volume 26
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Number 3
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March
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2015
Hg systolic within a 4-hour period. She was discharged the following morning, and all hypertensive medications were discontinued immediately after the procedure with the exception of clonidine and atenolol, which were tapered off over 2 weeks. A serum creatinine value was not obtained after the procedure because this is not routine practice at our institution. The patient was seen in the clinic 5 days after the procedure; at this time, her office BP was 82/50 mm Hg, and her doses of clonidine and atenolol were reduced. No blood work was obtained at that time. She was seen by her family physician 19 days after the procedure when her BP was observed to be normal, serum creatinine was 639 μmol/ L, and serum potassium was 8.9 mmol/L. The patient was transferred to the hospital immediately, where her BP was 82/54 mm Hg. Urinalysis was unremarkable. Random urinary sodium was 85 mmol/L and urinary potassium was 10 mmol/L, a pattern consistent with renal tubular dysfunction. Plasma renin mass was 623 ng/L (normal range, 6–20 ng/L), plasma aldosterone was 417 pmol/L, and serum cortisol was 424 nmol/L. Urine output and creatinine improved rapidly after resuscitation from hypovolemic shock with normal saline. Sphingomonas paucimobilis, a rare cause of nosocomial infection, grew in one of four blood cultures drawn in the emergency department. Although S. paucimobilis was considered a contaminant by the infectious diseases service, she received a 7-day course of oral ciprofloxacin as an outpatient. At no time, with the exception of decreased BP, did the patient exhibit clinical signs and laboratory findings of sepsis. Because BP remained low and serum potassium was high, she was started empirically on fludrocortisone. This medication was stopped after 3 weeks, when she developed fluid retention and hypertension, which was managed with furosemide and spironolactone. At 3-month follow-up assessment, office BP was 132/96 mm Hg, serum creatinine was 101 μmol/L, plasma renin mass was 18.3 ng/L, and plasma aldosterone was 378 pmol/L. Repeat renal imaging with computed tomography angiography was unremarkable. The clinical course of this patient suggests that catheter-based renal sympathetic denervation can impair renal sodium handling, which could lead to severe hypovolemia and acute renal failure. Renal sympathetic denervation decreases neurally mediated salt and water retention by the kidneys, reducing extracellular fluid volume (4). Patients with Parkinson disease, which has associated increased sympathetic activity, or other conditions associated with autonomic dysfunction may be particularly vulnerable (5). Clinicians performing this procedure should consider this potential complication. As a result of this experience, we now assess the renal function and volume status of all our patients who undergo renal denervation 72–96 hours after the procedure.
451
REFERENCES 1. Symplicity HTN-2 Investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomized controlled trial. Lancet 2010; 376:1903–1909. 2. Schmieder RE, Redon J, Grassi G, et al. ESH position paper: renal denervation—an interventional therapy of resistant hypertension. J Hypertens 2012; 30:837–841. 3. Bhatt DL, Kandzari DE, OʼNeill WW, et al. SYMPLICITY HTN-3 Investigators. A controlled trial of renal denervation for resistant hypertension. N Engl J Med 2014; 370:1393–1401. 4. Esler M. The sympathetic nervous system through the ages: from Thomas Willis to resistant hypertension. Exp Physiol 2011; 96:611–622. 5. Biaggioni I. Parkinson’s disease. Autonomic neuronopathy with impaired cardiovascular regulation. Hypertension 2007; 49:21–22.
Stent-Assisted Coil Embolization for a Traumatic Pseudoaneurysm of the Visceral Aortic Segment From: Chang Shu, MD, PhD Tun Wang, MD, PhD Quan-ming Li, MD, PhD Ming Li, MD, PhD Jason T. Lee, MD Department of Vascular Surgery (C.S., T.W., Q.-m.L., M.L.) The 2nd Xiang-ya Hospital of Central-South University Changsha, Hunan China Department of Vascular Surgery (J.T.L.) Stanford Hospital and Clinics and Lucile Packard Children’s Hospital Palo Alto, California
Editor: Pseudoaneurysm of the visceral aortic segment is rare and lethal. Open surgery with a retroperitoneal thoracoabdominal incision to reconstruct the lesion site is challenging, and surrounding vital visceral arteries present challenges for endovascular treatment. We describe a novel endovascular technique used to seal an aortic pseudoaneurysm and preserve all involved visceral arteries. Institutional review board approval was obtained for this study. A 41-year-old man sustained a gunshot wound to the left upper abdomen and underwent emergent laparotomy with vena cava, pancreas, and stomach repair. The patient presented 14 days later with complaints of sudden epigastric distention and pain. Computed tomography (CT) angiography demonstrated the presence of a 10 cm 6 cm pancreatic pseudocyst and a 1.5 cm 1.3 cm pseudoaneurysm in the visceral aortic segment, presumably traumatic in nature. The absence of fever, leukocytosis, and periaortic
None of the authors have identified a conflict of interest. C.S. and T.W. equally contributed to this manuscript. http://dx.doi.org/10.1016/j.jvir.2014.11.024
’
Letters to the Editor
caliber of vessels feeding the pseudoaneurysm and the presence of at least two vessels. Coil migration and ureteric obstruction, although rare, is a known complication after renal artery embolization with a few cases reported in the literature (2). To our knowledge, only one case of glue migration has been described (1) with an unsuccessful treatment. The pathogenetic hypothesis for glue migration is unclear. It is known that the glue injected into the tissues enhances migration and activation of fibroblasts (3); this may have caused fragmentation and migration of the glue cast into the collecting system through a fissure caused by local ischemia secondary to embolization. Another possibility is that embolization of the entire sac was performed, and this may have caused increased pressure within it causing the fragment to slip out. The decision to perform embolization of the entire sac was based on the presence of a complex anatomy, with at least two feeding vessels and the high possibility of reperfusion through collateral circles, but a selective and more accurate embolization of the two vessels alone probably would have prevented the migration. In the only case described in the literature (1), all treatment attempts were unsuccessful. Ureteroscopy failed because of severe angulation of the middle ureter, percutaneous nephroscopy failed because the glue particle could not be found within the renal pelvis, and open ureterotomy failed to locate the glue material because of severe adhesion of the ureter and the right internal iliac artery aneurysm. The glue particle was spontaneously expelled. In the present case, urgent ureteroscopy was performed because of acute ureteric obstruction with flank pain and high fever after complete glue removal. Laser lithotripsy was revealed to be a helpful tool in fragmenting the solid foreign body, which was susceptible to laser pulse shock waves. In conclusion, the presence of flank pain in a patient who previously had undergone renal artery embolization with N-butyl cyanoacrylate should raise the suspicion of glue migration, and a CT scan is indicated. If ureteral obstruction caused by glue migration is confirmed, ureteroscopy with foreign body removal should be performed.
REFERENCES 1. Chen WJ, Wang SC, Chen SL, Kao YL. Foreign body in the ureter: a particle of glue after transarterial embolization of a renal pseudoaneurysm during percutaneous nephrostomy. J Chin Med Assoc 2012; 75: 183–186. 2. Rajesparan K, Partridge W, Taha N, Samman R, Aldin Z. Early migration and ureteric obstruction of an embolisation coil used to treat massive haemorrhage following percutaneous nephrolithotomy. Cardiovasc Intervent Radiol 2011; 34:868–872. 3. Redl H, Schlag G. Properties of different tissue sealants with emphasis on fibrin-based preparations. In: Schlag G, Redl H, editors. Fibrin Sealant in Operative Medicine. Berlin: Springer; 1986. p. 27–38.
Logan et al
’
JVIR
Acute Renal Failure after Renal Denervation From: Alexander G. Logan, MD, FRCP(C) Vlad Diaconita, HBSc Douglas J. Ing, MD George D. Oreopoulos, MD, FRCS(C) John S. Floras, MD, DPhil, FRCP(C) Dheeraj K. Rajan, MD, FSIR Departments of Medicine (A.G.L., V.D., D.J.I., J.S.F.), Medical Imaging (D.K.R.), and Surgery (G.D.O.) University Health Network and Mount Sinai Hospital Peter Munk Cardiac Centre (D.J.I., G.D.O., J.S.F., D.K.R.) University Health Network University of Toronto 585 University Avenue, NCSB 1C-553 Toronto, Ontario, Canada, M5G 2N2
Editor: Catheter-based renal sympathetic denervation potentially decreases the blood pressure (BP) of patients with treatment-resistant hypertension (1). No serious adverse consequences have been reported, including renal failure, after this procedure (2,3). Institutional review board approval was obtained for this report. A 58-year-old white woman with resistant primary hypertension as determined in the clinic and on ambulatory 24-hour BP monitoring despite receiving seven antihypertensive medications including furosemide and spironolactone and normal serum creatinine was referred for this procedure. Her past medical history included an episode of malignant hypertension, early stage 3 chronic renal disease, and Parkinson disease. She had been hospitalized 7 years before referral for denervation for the management of acute prerenal failure thought to be caused by diarrhea. Before denervation, her BP as obtained by an automatic BP monitor (BpTRU; BpTRU Medical Devices, Coquitlam, British Columbia, Canada) was 135/98 mm Hg, and medications included amlodipine 10 mg twice a day, spironolactone 100 mg twice a day, clonidine 0.2 mg twice a day, furosemide 80 mg twice a day, lisinopril 20 mg twice a day, terazosin 2 mg every day, and atenolol 50 mg every day. Serum creatinine was 120 μmol/L, estimated glomerular filtration rate was 43 mL/min, and body mass index was 32.6. Renal denervation proceeded uneventfully. Renal angiography performed immediately after the procedure revealed no renovascular abnormality. A total of 45 mL of nonionic contrast material was used. Immediately after the procedure, the patientʼs systolic BP decreased to 110/70 mm Hg, requiring 750 mL of normal saline as a bolus to maintain her BP 4 100 mm None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.11.017
Volume 26
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Number 3
’
March
’
2015
Hg systolic within a 4-hour period. She was discharged the following morning, and all hypertensive medications were discontinued immediately after the procedure with the exception of clonidine and atenolol, which were tapered off over 2 weeks. A serum creatinine value was not obtained after the procedure because this is not routine practice at our institution. The patient was seen in the clinic 5 days after the procedure; at this time, her office BP was 82/50 mm Hg, and her doses of clonidine and atenolol were reduced. No blood work was obtained at that time. She was seen by her family physician 19 days after the procedure when her BP was observed to be normal, serum creatinine was 639 μmol/ L, and serum potassium was 8.9 mmol/L. The patient was transferred to the hospital immediately, where her BP was 82/54 mm Hg. Urinalysis was unremarkable. Random urinary sodium was 85 mmol/L and urinary potassium was 10 mmol/L, a pattern consistent with renal tubular dysfunction. Plasma renin mass was 623 ng/L (normal range, 6–20 ng/L), plasma aldosterone was 417 pmol/L, and serum cortisol was 424 nmol/L. Urine output and creatinine improved rapidly after resuscitation from hypovolemic shock with normal saline. Sphingomonas paucimobilis, a rare cause of nosocomial infection, grew in one of four blood cultures drawn in the emergency department. Although S. paucimobilis was considered a contaminant by the infectious diseases service, she received a 7-day course of oral ciprofloxacin as an outpatient. At no time, with the exception of decreased BP, did the patient exhibit clinical signs and laboratory findings of sepsis. Because BP remained low and serum potassium was high, she was started empirically on fludrocortisone. This medication was stopped after 3 weeks, when she developed fluid retention and hypertension, which was managed with furosemide and spironolactone. At 3-month follow-up assessment, office BP was 132/96 mm Hg, serum creatinine was 101 μmol/L, plasma renin mass was 18.3 ng/L, and plasma aldosterone was 378 pmol/L. Repeat renal imaging with computed tomography angiography was unremarkable. The clinical course of this patient suggests that catheter-based renal sympathetic denervation can impair renal sodium handling, which could lead to severe hypovolemia and acute renal failure. Renal sympathetic denervation decreases neurally mediated salt and water retention by the kidneys, reducing extracellular fluid volume (4). Patients with Parkinson disease, which has associated increased sympathetic activity, or other conditions associated with autonomic dysfunction may be particularly vulnerable (5). Clinicians performing this procedure should consider this potential complication. As a result of this experience, we now assess the renal function and volume status of all our patients who undergo renal denervation 72–96 hours after the procedure.
451
REFERENCES 1. Symplicity HTN-2 Investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomized controlled trial. Lancet 2010; 376:1903–1909. 2. Schmieder RE, Redon J, Grassi G, et al. ESH position paper: renal denervation—an interventional therapy of resistant hypertension. J Hypertens 2012; 30:837–841. 3. Bhatt DL, Kandzari DE, OʼNeill WW, et al. SYMPLICITY HTN-3 Investigators. A controlled trial of renal denervation for resistant hypertension. N Engl J Med 2014; 370:1393–1401. 4. Esler M. The sympathetic nervous system through the ages: from Thomas Willis to resistant hypertension. Exp Physiol 2011; 96:611–622. 5. Biaggioni I. Parkinson’s disease. Autonomic neuronopathy with impaired cardiovascular regulation. Hypertension 2007; 49:21–22.
Stent-Assisted Coil Embolization for a Traumatic Pseudoaneurysm of the Visceral Aortic Segment From: Chang Shu, MD, PhD Tun Wang, MD, PhD Quan-ming Li, MD, PhD Ming Li, MD, PhD Jason T. Lee, MD Department of Vascular Surgery (C.S., T.W., Q.-m.L., M.L.) The 2nd Xiang-ya Hospital of Central-South University Changsha, Hunan China Department of Vascular Surgery (J.T.L.) Stanford Hospital and Clinics and Lucile Packard Children’s Hospital Palo Alto, California
Editor: Pseudoaneurysm of the visceral aortic segment is rare and lethal. Open surgery with a retroperitoneal thoracoabdominal incision to reconstruct the lesion site is challenging, and surrounding vital visceral arteries present challenges for endovascular treatment. We describe a novel endovascular technique used to seal an aortic pseudoaneurysm and preserve all involved visceral arteries. Institutional review board approval was obtained for this study. A 41-year-old man sustained a gunshot wound to the left upper abdomen and underwent emergent laparotomy with vena cava, pancreas, and stomach repair. The patient presented 14 days later with complaints of sudden epigastric distention and pain. Computed tomography (CT) angiography demonstrated the presence of a 10 cm 6 cm pancreatic pseudocyst and a 1.5 cm 1.3 cm pseudoaneurysm in the visceral aortic segment, presumably traumatic in nature. The absence of fever, leukocytosis, and periaortic
None of the authors have identified a conflict of interest. C.S. and T.W. equally contributed to this manuscript. http://dx.doi.org/10.1016/j.jvir.2014.11.024
