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Complications of endovascular management of aortoiliac occlusive disease
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
Karem C. Harth, Saideep Bose, Vikram S. Kashyap
If sheaths are pulled in the recovery area and hypotension occurs, a prompt return to the intervention suite or operating room should be made to evaluate for bleeding with re-intervention as needed. If the bleeding cannot be stopped endovascularly with a covered stent, then balloon occlusion can be used to control inflow while surgical control is obtained. Repair of perforations closer to the common femoral artery are associated with high procedural success and low morbidity/mortality,26 whereas perforations closer to the aorta are more treacherous affairs. Oftentimes a patient will experience some pain after intervention or after sheath removal without any corresponding hemodynamic changes. After access site complications are ruled out, development of a retroperitoneal hematoma can be evaluated with a non-contrasted CT scan. Stable physical exam, serial hemoglobins, and repeat imaging generally indicate a patient can be discharged safely without further intervention after an overnight observation.
Introduction
Published in Shayne C. Gad, Toxicology of the Gastrointestinal Tract, 2018
The peritoneum is the largest serous membrane of the body; it consists of a layer of simple squamous epithelium (mesothelium) with an underlying supporting layer of connective tissue. The peritoneum is divided into the parietal peritoneum, which lines the wall of the abdominopelvic cavity, and the visceral peritoneum, which covers some of the organs in the cavity and is their serosa. The slim space between the parietal and visceral portions of the peritoneum is called the peritoneal cavity, which contains serous fluid. In certain diseases, the peritoneal cavity may become distended by the accumulation of several liters of fluid, a condition called ascites. As we will see, some organs lie on the posterior abdominal wall and are covered by peritoneum only on their anterior surfaces. Such organs, including the kidneys and pancreas, are said to be retroperitoneal.
Truncal vascular trauma
Published in Sachinder Singh Hans, Alexander D Shepard, Mitchell R Weaver, Paul G Bove, Graham W Long, Endovascular and Open Vascular Reconstruction, 2017
Blunt abdominal vascular trauma is produced by local tissue compression or acceleration/deceleration resulting in significant shear forces that can disrupt the normal integrity of the layers of the blood vessel wall (intima, media, and adventitia). Intra-abdominal hemorrhage from a vascular injury is often associated with a retroperitoneal hematoma. Such hematomas are categorized according to their location: zone 1 is the midline retroperitoneum (aorta, IVC); zone 2 the upper lateral retroperitoneum (the renal vessels); and zone 3 the pelvic retroperitoneum (the iliac vessels and pelvic bone fracture) (Figure 51.4). In general, retroperitoneal hematomas following penetrating injury are routinely explored, while only zone 1 injuries from blunt trauma are explored (Figure 51.5). Recently, however, this practice has been questioned in light of successful observation of stable, nonexpanding zone 2 hematomas away from the renal hila, and in cases of stable retrohepatic hematomas that once opened can easily lead to exsanguination. While early adoption of REBOA may be useful in select cases to initially control hemorrhage, the operative approach to these life-threatening injuries is to rapidly control and stop bleeding through a midline laparotomy. The approach and appropriate techniques for managing such challenging injuries depend on the location of the injury.
IgG4 related disease and aortitis: an up-to-date review
Published in Scandinavian Journal of Rheumatology, 2023
N Jayachamarajapura Onkaramurthy, SC Suresh, P Theetha Kariyanna, A Jayarangaiah, G Prakash, B Raju
Active and symptomatic patients with IgG4-RD need treatment to decrease inflammation, maintain remission, and preserve organ function (67). Asymptomatic aortitis or periaortitis with or without retroperitoneal fibrosis needs treatment. In the case of retroperitoneal fibrosis causing urinary tract obstruction, hydronephrosis, and post-renal acute kidney injury, relieving the obstruction should be the priority, followed by immunosuppression. Most patients (> 90%) respond to a moderate dose (0.5 mg/kg) of steroids (17). It is crucial to be cautious with steroids in large aneurysms as they are prone to rupture. Ozawa et al documented that 20% of the patients showed aortic luminal dilatation post-steroid therapy, although they responded well to steroids (68). Hence, it would be wise to weigh the benefits versus risks when considering steroid therapy in patients with aneurysmal dilatation. But there are no clear guidelines or data on dose or on the size of aortic aneurysms that are at increased risk of rupture post-steroid therapy. There is anecdotal evidence of aneurysmal rupture post-steroid therapy (69). A small proportion of patients (n = 2) with aortic luminal dilatation showed an increase in luminal dilatation after treatment with glucocorticoids (70). The recent large prospective study of IgG4-related aortic disease did not report the incidence of rupture or significant increase in aneurysmal size following moderate-dose steroids in patients with IgG4-related aortic disease (17).
Successful treatment of sclerosing mesenteritis with tamoxifen monotherapy
Published in Baylor University Medical Center Proceedings, 2023
Lauren Zammerilla Westcott, Dallas Wolford, Taylor G. Maloney, Ronald C. Jones
Given the lack of therapeutic trials, treatment recommendations are based on case reports, small case series, and trials in other fibrosing diseases such as idiopathic retroperitoneal fibrosis.2 Tamoxifen has been described as a treatment option for retroperitoneal fibrosis, specifically for patients who cannot tolerate high-dose glucocorticoids.7 The mechanism by which tamoxifen exerts its effect is unknown but is thought to be hormonal independent. It has been suggested that tamoxifen affects growth factors that inhibit fibroblast proliferation, which may explain its role in the treatment of both retroperitoneal fibrosis and sclerosing mesenteritis. Its antiangiogenic and antiestrogen properties may also contribute to its efficacy, perhaps suppressing inflammation and immune-mediated responses.7
Cefazolin-induced hypoprothrombinemia
Published in Baylor University Medical Center Proceedings, 2022
Mallory Smith, James Doyle, Cameron Crane, Charles Bussell
A 57-year-old white man with chronic back pain presented with worsening back pain and weakness and numbness in both legs. Ten weeks earlier, he underwent decompressive surgery with removal of the C7 spinous process. He now had Staphylococcus aureus bacteremia, as well as a T5–8 epidural and paraspinous phlegmon and abscess. He underwent surgical debridement with T6–7 costotransversectomy and T6–8 and T10–11 thoracic laminectomies. After starting oxacillin, his serum creatinine rose from his baseline of 1.2 mg/dL to 2.4 mg/dL. He was switched to cefazolin monotherapy at a dose of 2 g every 8 hours, and his serum creatinine returned to baseline. On day 6 of cefazolin therapy, laboratory tests revealed a hemoglobin of 6.2 g/dL. His blood pressure was 84/60 mm Hg and a large bruise was noted over his left flank. Platelets were 365 × 103/µL; international normalized ratio, 10.71; prothrombin time, 83.5 seconds; and partial thromboplastin time, >150 seconds. Abdominopelvic computed tomography showed a large left retroperitoneal hematoma with no evidence of active extravasation (Figure 2).