Simultaneous endovascular repair of an iatrogenic carotid-jugular fistula and a large iliocaval fistula presenting with multiorgan failure: a case report

<p>Abstract</p> <p>Introduction</p> <p>Iliocaval fistulas can complicate an iliac artery aneurysm. The clinical presentation is classically a triad of hypotension, a pulsatile mass and heart failure. In this instance, following presentation with multiorgan failure, management included the immediate use of an endovascular stent graft on discovery of the fistula.</p> <p>Case presentation</p> <p>A 62-year-old Caucasian man presented to our tertiary hospital for management of iatrogenic trauma due to the insertion of a central venous line into his right common carotid artery, causing transient ischemic attack. Our patient presented to a peripheral hospital with fever, nausea, vomiting, acute renal failure, acute hepatic dysfunction and congestive heart failure. A provisional diagnosis of sepsis of unknown origin was made. There was a 6.5 cm×6.5 cm right iliac artery aneurysm present on a non-contrast computed tomography scan. An unexpected intra-operative diagnosis of an iliocaval fistula was made following the successful angiographic removal of the central line to his right common carotid artery. Closure of the iliocaval fistula and repair of the iliac aneurysm using a three-piece endovascular aortic stent graft was then undertaken as part of the same procedure. This was an unexpected presentation of an iliocaval fistula.</p> <p>Conclusion</p> <p>Our case demonstrates that endovascular repair of a large iliac artery aneurysm associated with a caval fistula is safe and effective and can be performed at the time of the diagnostic angiography. The presentation of an iliocaval fistula in this case was unusual which made the diagnosis difficult and unexpected at the time of surgery. The benefit of immediate repair, despite hemodynamic instability during anesthesia, is clear. Our patient had two coronary angiograms through his right femoral artery decades ago. Unusual iatrogenic causes of iliocaval fistulas secondary to previous coronary angiograms with wire and/or catheter manipulation should be considered in patients such as ours.</p

BCG mycotic aneurysm: Case report on a rare entity

Mycotic aortic aneurysms (MAA) are rare, accounting for 0.6–2.0% of all aortic aneuryms. MAA secondary to intravesical BCG instillations are even rarer, with less than a hundred reported cases till date. Given the delayed presentation, non specific presenting symptoms and significant risk of mortality (90% without intervention, 10.3–22.7% with intervention), diagnosing this complication is challenging

Does magnetic resonance imaging–guided biopsy improve prostate cancer detection? A comparison of systematic, cognitive fusion and ultrasound fusion prostate biopsy

Background: The increase in the use of multiparametric magnetic resonance imaging for the detection of prostate cancer has led to the rapid adoption of MRI-guided biopsies (MRGBs). To date, there is limited evidence in the use of MRGB and no direct comparisons between the different types of MRGB. We aimed to assess whether multiparametric MRGBs with MRI-US transperineal fusion biopsy (FB) and cognitive biopsy (CB) improved the management of prostate cancer and to assess if there is any difference in prostate cancer detection with FB compared with CB. Methods: Patients who underwent an MRGB and a systematic biopsy (SB) from June 2014 to August 2016 on the Central Coast, NSW, Australia, were included in the study. The results of SB were compared with MRGB. The primary outcome was prostate cancer detection and if MRGB changed patient management. Results: A total of 121 cases were included with a mean age of 65.5 years and prostate-specific antigen 7.4 ng/mL. Seventy-five cases (62%) had a Prostate Imaging and Reporting Data System 4–5 lesions and 46 (38%) had a Prostate Imaging and Reporting Data System 3 lesions. Fifty-six cases underwent CB and 65 underwent FB.Of the 93 patients with prostate cancer detected, 19 men (20.5%) had their management changed because of the MRGB results. Eight men (9%) had prostate cancer detected on MRGB only and 12 men (13%) underwent radical prostatectomy or radiotherapy based on the MRGB results alone.There was a trend to a higher rate of change in management with FB compared with CB (29% vs. 18%). Conclusions: This is one of the first Australian studies to assess the utility of MRGB and compare FB with CB. MRGB is a useful adjunct to SB, changing management in over 20% of our cases, with a trend toward FB having a greater impact on patient management compared with CB. Keywords: Detection, MRI-guided biopsies, Multiparametric MRI, Prostate cance

Comparison of cost of care for tethered versus non-tethered ureteric stents in the management of uncomplicated upper urinary tract stones

Background: Many surgeons use a stent after ureteroscopic lithotripsy (URSL). For short-term stenting purposes, a surgeon has the choice of either a tethered or a non-tethered stent. Stents may be associated with complications that entail an additional cost to their use. There is a paucity of data on the direct healthcare cost of using stent type after either primary or secondary URSL. Methods: We retrospectively reviewed medical records for patients who underwent URSL for uncomplicated urolithiasis between January 2013 and December 2013 at two tertiary referral hospitals. Costs data was sourced from the costing department with complete data available for 134 patients. The overall medical care cost was estimated by computing the cost of surgery, stent-related emergency department presentations, re-admissions and stent removal. Results: A total of 113 patients had tethered stents and 21 had non-tethered stents, with similar age and gender composition between the two groups and complications rates. The mean cost of URSL and stent placement was A$3071.7 ± A$906.8 versus A$3423.8 ± A$808.4 (P=0.049), mean cost of managing complications was A$309.4 ± A$1744.8 versus A$31.3 ± A$98.9 (P=0.096), mean cost of out-patient clinic stent removal was A$222.5 ± A$60 versus A$1013.6 ± A$75.4 (P<0.001) for endoscopic stent removal, overall mean cost of care was A$3603.6 ± A$1896.7 versus A$4468.1 ± A$820.8 (P=0.042) for tethered and non-tethered stents, respectively. Conclusion: It is cheaper to use a tethered ureteric stent compared with non-tethered stents for short-term stenting after uncomplicated URSL, with a mean cost saving of A$864.5

Growth and renal function dynamics of renal oncocytomas in patients on active surveillance

ObjectivesTo study the natural history of renal oncocytomas and address indications for intervention by determining how growth is associated with renal function over time, the reasons for surgery and ablation, and disease‐specific survival.Patients and MethodsThe study was conducted in a retrospective cohort of consecutive patients with renal oncocytoma on active surveillance reviewed at the Specialist Centre for Kidney Cancer at the Royal Free London NHS Foundation Trust (2012 to 2019). Comparison between groups was performed using Mann–Whitney U‐tests and chi‐squared tests. A mixed‐effects model with a random intercept for patient was used to study the longitudinal association between tumour size and estimated glomerular filtration rate (eGFR).ResultsLongitudinal data from 98 patients with 101 lesions were analysed. Most patients were men (68.3%) and the median (interquartile range [IQR]) age was 69 (13) years. The median (IQR) follow‐up was 29 (26) months. Most lesions were small renal masses, and 24% measured over 4 cm. Over half (64.4%) grew at a median (IQR) rate of 2 (4) mm per year. No association was observed between tumour size and eGFR over time (P = 0.871). Nine lesions (8.9%) were subsequently treated. Two deaths were reported, neither were related to the diagnosis of renal oncocytoma.ConclusionNatural history data from the largest active surveillance cohort of renal oncocytomas to date show that renal function does not seem to be negatively impacted by growing oncocytomas, and confirms clinical outcomes are excellent after a median follow‐up of over 2 years. Active surveillance should be considered the 'gold standard' management of renal oncocytomas up to 7cm