Objective Isolated renal artery aneurysms are rare and controversy remains about indications for surgical repair. Little is known about the impact of endovascular therapy on patient selection and outcomes of renal artery aneurysms. Methods We identified all patients undergoing open or endovascular repair of isolated renal artery aneurysms in the Nationwide Inpatient Sample (NIS) from 1988 to 2011 for epidemiologic analysis. Elective cases were selected from the period of 2000 to 2011, to create comparable cohorts for outcome comparison. We identified all patients with a primary diagnosis of renal artery aneurysms undergoing open surgery (reconstruction or nephrectomy) or endovascular repair (coil or stent). Patients with a concomitant aortic aneurysms or dissections were excluded. We evaluated patient characteristics, management, and in-hospital outcomes for open and endovascular repair, and we examined changes in management and outcomes over time. Results We identified 6,234 renal artery aneurysm repairs between 1988 and 2011. Total repairs increased after the introduction of endovascular repair (8.4 in 1988 to 13.8 in 2011 per 10million(M) US population, P=0.03). Endovascular repair increased from 0 in 1988 to 6.4 in 2011 per 10M US population (P<.0001). However, there was no concomitant decrease in open surgery (5.5 in 1988 to 7.4 in 2011 per 10M US population, P=0.28). From 2000–2011 there were 1,627 open and 1,082 endovascular elective repairs. Patients undergoing endovascular repair were more likely to have a history of coronary artery disease (18% vs. 11%, P<0.001), prior myocardial infarction (5.2% vs. 1.8%, P<0.001) and renal failure (7.7% vs. 3.3%, P<0.001). In-hospital mortality was 1.8% for endovascular and 0.9% for open reconstruction (P=0.037), and 5.4% for nephrectomy (P<.001 compared to all revascularization). Complication rates were 12.4% for open repair vs 10.5% for endovascular repair (P=0.134), including more cardiac (2.2% vs. 0.6%, P=0.001) and peripheral vascular complications (0.6% vs. 0.0%, P=0.014) with open repair. Open repair had a longer length of stay (6.0 vs. 4.6 days, P<0.001). After adjustment for other predictors of mortality, age (OR 1.05 per decade, 95% CI 1.0–1.1, P=0.001), heart failure (OR 7.0, 95% CI 3.1–16.0, P<.001) and dysrhythmia (OR 5.9, 95% CI 2.0–16.8, P=0.005), Endovascular repair was still not protective (OR 1.6, 95% CI 0.8–3.2, P=0.145). Conclusion More renal artery aneurysms are being treated with the advent of endovascular techniques, without a reduction in operative mortality or a reduction in open surgery. Indications for repair of renal artery aneurysms should be re-evaluated.
IntroductionThe use of recombinant factor VII (rFVIIa) as a last resort for the management of coagulopathy when there is severe metabolic acidosis during large bleedings in trauma might be deemed inappropriate. The objective of this study was to identify critical degrees of acidosis and associated factors at which rFVIIa might be considered of no utility.MethodsAll massively transfused (≥ 8 units of red blood cells within 12 hours) trauma patients from Jan 2000 to Nov 2006. Demographic, baseline physiologic and rFVIIa dosage data were collected. Rate of red blood cell transfusion in the first 6 hours of hospitalization (RBC/hr) was calculated and used as a surrogate for bleeding. Last resort use of rFVIIa was defined by a pH≤ 7.02 based on ROC analysis for survival. In-hospital mortality was analyzed in last resort and non-last resort groups. Univariate analysis was performed to assess for differences between groups and identify factors associates with no utility of rFVIIa.Results71 patients who received rFVIIa were analyzed. The pH> 7.02 had 100% sensitivity for the identification of potential survivors. All 11 coagulopathic, severely acidotic (pH ≤ 7.02) patients with high rates of bleeding (4RBC/hr) died despite administration of rFVIIa. The financial cost of administering rFVIIa as a last resort to these 11 severely acidotic and coagulophatic cases was $75,162 (CA).ConclusionsOur study found no utility of rFVIIa in treating severely acidotic, coagulopathic trauma patients with high rates of bleeding; and thus restrictions should be set on its usage in these circumstances.
A solitary fibrous tumor of the pleura (SFTP) presenting with an aberrant arterial supply from the abdominal aorta is extremely rare, and it may be difficult to distinguish from intralobar sequestration (ILS). We report the case of a 38-year-old woman who presented with acute chest pain and was subsequently found to have a 17.5-cm intrathoracic mass. After preoperative arterial embolization of its feeding vessel, this presumed ILS was resected. However, the intraoperative findings revealed a benign SFTP. Here we discuss a unique presentation of a large SFTP radiographically mimicking an ILS, and we propose a safe management strategy for this entity.
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