Thrombolytic therapy followed by stenting for renal artery dissection secondary to blunt trauma

Clinical Outcomes of Conservative Treatment in Patients with Symptomatic Isolated Spontaneous Renal Artery Dissection and Comparison with Superior Mesenteric Artery Dissection

OBJECTIVES

The aims of this study were to report the clinical outcomes of conservative medical treatment in patients with symptomatic isolated spontaneous renal artery dissection (SRAD) and compare them with those of spontaneous superior mesenteric artery dissection (SSMAD).

METHODS

This was a single centre, observational comparative study between SRAD and SSMAD. Data from a prospective visceral artery dissection registry were analysed retrospectively. Between June 2010 and December 2016, 23 consecutive patients with symptomatic isolated SRAD who initially received conservative medical treatment were included. The primary outcomes were the aggravation of dissection requiring intervention and dissection related mortality. To evaluate the prognosis of symptomatic isolated SRAD, the clinical outcomes of isolated SRAD were compared with those of symptomatic isolated SSMAD (n = 40) during the same study period.

RESULTS

The primary outcome incidence was 39% (9/23) in patients with symptomatic isolated SRAD during the median follow up period of 20 months (range 0-63 months). The dissection related mortality rate was 17% (4/23), and the cause of death in all cases was an abrupt rupture of the dissecting aneurysm with significant true lumen stenosis. None of the patients without aneurysm or with true lumen occlusion had dissection related mortality. During the same study period, compared with the patients with symptomatic isolated SSMAD who initially received conservative medical treatment, the primary outcome incidence (39% vs. 10%, p = .009) and dissection related mortality rate (17% vs. 0%, p = .016) were statistically significantly higher in patients with symptomatic isolated SRAD.

CONCLUSIONS

Although the present analysis involved only a small number of patients, it revealed that symptomatic isolated SRAD with dissection related aneurysm and true lumen stenosis is a potentially life threatening condition and that aggressive surgical or endovascular interventions should be considered in these patients, who are refractory to conservative medical treatment.

Percutaneous renal artery revascularization after prolonged ischemia secondary to blunt trauma: pooled cohort analysis

PURPOSE

We aimed to identify factors related to technical and clinical success of percutaneous revascularization for blunt renal arterial trauma.

METHODS

All cases of percutaneous revascularization for blunt renal arterial trauma were searched in the available literature. We included a case of iatrogenic renal artery occlusion at our institution treated by percutaneous stenting 20 hours after injury. A pooled cohort analysis of percutaneous revascularization for blunt renal artery injury was then performed to analyze factors related to technical and clinical success. Clinical failure was defined as development of new hypertension, serum creatinine rise, or significant asymmetry in split renal function.

RESULTS

A total of 53 cases have been reported, and 54 cases were analyzed including our case. Median follow-up was 6 months. Technical success was 88.9% and clinical success was 75%. Of 12 treatment failures (25%), 66.7% occurred during the first postprocedure month. Time from injury to revascularization was not a predictor of clinical success (OR=1.00, P = 0.681). Renal artery occlusion was significantly associated with clinical failure (OR=7.50, P = 0.017) and postintervention antiplatelet therapy was significantly associated with treatment success (OR=0.16, P = 0.043). At 37-month follow-up, the stented renal artery in our case remained patent and the patient was normotensive with preserved glomerular filtration rate.

CONCLUSION

Percutaneous revascularization for blunt renal arterial injury resulted in relatively high technical and clinical success. Time-to-revascularization was independent of successful outcomes. Clinical success was significantly associated with a patent renal artery at the time of intervention and with postprocedure antiplatelet therapy.

Trends in nonoperative management of traumatic injuries - A synopsis

Nonoperative management of both blunt and penetrating injuries can be challenging. During the past three decades, there has been a major shift from operative to increasingly nonoperative management of traumatic injuries. Greater reliance on nonoperative, or "conservative" management of abdominal solid organ injuries is facilitated by the various sophisticated and highly accurate noninvasive imaging modalities at the trauma surgeon's disposal. This review discusses selected topics in nonoperative management of both blunt and penetrating trauma. Potential complications and pitfalls of nonoperative management are discussed. Adjunctive interventional therapies used in treatment of nonoperative management-related complications are also discussed.

REPUBLISHED WITH PERMISSION FROM

Stawicki SPA. Trends in nonoperative management of traumatic injuries - A synopsis. OPUS 12 Scientist 2007;1(1):19-35.

Evaluation of characteristics, associations and clinical course of isolated spontaneous renal artery dissection

BACKGROUND

Spontaneous renal artery dissection (SRAD) is a rare entity of unknown etiology. We aimed to study the clinical course and outcomes and compare the characteristics of patients with SRAD with those of the general population.

METHODS

All cases of isolated renal artery dissection diagnosed at the University of Michigan Hospitals between January 2000 and July 2012 were identified by the ICD-9 code. Cases were matched by age, gender and race with individuals from the 2009-2010 National Health and Nutrition Examination Survey (NHANES). Characteristics and awareness of comorbid conditions were compared. Information about the clinical course after diagnosis was retrieved from the case group to ascertain their outcomes.

RESULTS

Overall, 17 patients with SRAD with a mean age of 38.6 years (SD = 8.3) were identified. Eleven patients were male and 14 were white. The most common presenting symptom was excruciating sudden-onset flank pain ipsilateral to the site of dissection. Fibromuscular dysplasia, Ehlers-Danlos and polyarteritis nodosa were present in 4, 4 and 1 patients, respectively. After adjusting in a multivariable model, the case group was more likely to report history of hypertension, cancer and connective tissue disorders (P < 0.001), and less likely to have obesity (BMI ≥30 kg/m(2)) compared with the general population. Supportive medical treatment, endovascular intervention and surgery were required in 8, 5 and 4 cases, respectively. After discharge from the hospital, hypertension was adequately controlled in all the patients but one.

CONCLUSION

SRAD may be part of a syndrome having multi-organ involvement. With appropriate medical or surgical management, long-term clinical outcome appears favorable.

The role of interventional radiology in urologic tract trauma

The kidney is the third most common abdominal organ to be injured in trauma, following the spleen and liver, respectively. Several classification systems convey the severity of injury to kidneys, ureter, bladder, and urethra. The most commonly used classification scheme is the American Association for the Surgery of Trauma (AAST) classification of blunt renal injuries, which grades renal injury according the size of laceration and its proximity to the renal hilum. Ureteral injury is graded according to its extent relative to the circumference of the ureter and the extent of associated devascularization. Bladder injury is graded according to its location relative to the peritoneum. Urethral injury is graded according to the extent of damage to surrounding anatomic structures. Although these classification schema may not be always used in common parlance, they do help delineate most important features of urologic tract injury that impact patient management and interventions.

A 10-year review of blunt renal artery injuries at an urban level I trauma centre

INTRODUCTION

Little consensus exists over the management of high-grade renal injuries, with continued debate over observation versus invasive surgery. Blunt renal artery injury (BRAI) is a high-grade injury that may result in renal dysfunction, hypertension, or failure.

MATERIALS AND METHODS

Management of BRAI at a level I trauma centre during a decade was retrospectively reviewed to determine incidence, assess management strategy, and evaluate hospital outcomes. Data collected included demographics, injury details, standardised scoring, renal injury grade, haemodynamic stability, diagnostic modalities, medical interventions, mortality, and hospitalisation length.

RESULTS

Thirty-eight BRAI patients (21 Grade IV and 17 Grade V injuries) were admitted, representing 0.16% of trauma admissions, and consisting primarily of young males. Ultrasonography and CT was performed in 92.1% and 76.3% of patients, respectively. Primary management included exploratory laparotomy in 42.9%, angiography and embolisation in 34.3%, and observation in 22.9%. Six nephrectomies and one revascularisation were performed. The incidence of BRAI and use of angiography are higher than those reported in previous studies.

CONCLUSION

Over the past decade, increased use of CT as a diagnostic tool for confirming renal injury in haemodynamically stable patients at our institution may have contributed to the increase in BRAI detection. Higher utilisation of angiography has enabled a more conservative approach. In this series, angiography had a success rate of 94.4%. Angiography and embolisation or observation with careful monitoring are viable management options in haemodynamically stable patients with isolated BRAI.