Search

Arteriovenous fistula (AVF) is an abnormal direct communication between an artery and the venous drainage without a capillary component. Although renal AVF is rare, detecting the disease is important to assist in management and, thus, help reverse the sequelae of the disease such as hypertension and heart failure. The clinical presentation and radiological features are important parameters that can help in the diagnosis and decision of treatment. We would like to share our successful approach to a 52-year-old female with idiopathic high-flow left renal AVF with concomitant renal artery aneurysm using a single Amplatzer vascular plug in the limit of our setting.

Abstract Background Performing percutaneous renal biopsy procedures in lupus nephritis (LN) and nephrotic syndrome presents a unique challenge to the nephrologist because of the risk of bleeding from the procedure and the hypercoagulable state in hypoalbuminemia. The management of a patient with venous thrombosis with perinephric hematoma post renal biopsy can be difficult if occurred. Case presentation We are presenting a case of perinephric hematoma following percutaneous renal biopsy in a 23-year-old man with lupus nephritis, nephrotic syndrome, and lower limbs deep vein thrombosis (DVT). The patient developed persistent frank haematuria, flank pain and acute urinary retention post-procedure. We have withheld his oral warfarin three days before the procedure, and no anticoagulation was given subsequently. Initial CT Angiography (CTA) renal showing stable hematoma and no visible evidence of vascular injury. Three weeks later, the patient still has persistent frank haematuria and a repeated CTA renal revealed new bilateral renal vein thrombosis. Considering the high risk of worsening symptomatic venous thrombosis, we gave subcutaneous enoxaparin sodium and restart oral warfarin despite ongoing haematuria. The frank haematuria resolved within two days of anticoagulation with no radiological evidence of worsening of the perinephric hematoma. The follow-up ultrasonography a month later showed resolution of the hematoma and renal vein thrombosis with no adverse effect. Conclusion Our experience, in this case, highlighted the importance of case selection for percutaneous renal biopsy among high-risk patients. Additionally, a prolonged frank haematuria in post-renal biopsy with nephrotic syndrome warranted a reassessment, as a clinical presentation of post-procedure perinephric hematoma and renal vein thrombosis can overlap. We also demonstrated that restarting anticoagulation earlier than four weeks in a patient with renal vein thrombosis and post-renal biopsy perinephric hematoma can be safe in the selective case.

Wilms tumor is the most common primary malignant renal tumor of childhood which usually presents between 2 and 6 years of age. Its presentation in the neonatal period is extremely rare and presenting with intestinal obstruction is perhaps unknown. We report a 2-day-old baby girl who manifested features of acute upper gastrointestinal obstruction with frequent post-feeding vomiting and abdominal distension. The initial abdominal radiograph showed abnormally displayed small bowel loops to the right hemiabdomen. Subsequent ultrasound and computed tomography scan of the abdomen detected a massive left renal mass. Left-sided nephrectomy was performed, and histopathology demonstrated left-sided Wilms tumor with favorable histology. Post-treatment yearly follow-up for 5 years recorded a disease-free, normally thriving child.

Extranodal sinonasal natural killer/T-cell lymphoma is known for its locally destructive nature at the midface region. The initial presentations are related to the localized granulomatous-like lesion usually in the nasal cavity that may lead to symptoms of nasal obstruction, discharge, hyposmia and epistaxis. Advanced disease may present with a rapid dissemination of disease to the liver, spleen, skin, lymph nodes, and bone marrow hence poorer prognosis. We report a case of a young lady with rapid progression of extranodal sinonasal NK/T cell lymphoma with torrential tumour bleeding from the oral and nasal cavities compromising the upper airway patency, which warranted an emergency tracheostomy and arterial embolization.

Aortoilliac occlusive disease is occlusive atherosclerosis disease involving the distal aorta and bifurcation of iliac arteries and it is a subtype of peripheral arterial disease. Total occlusion of the abdominal aorta is a rare occurrence with an incidence of 3% -8.5% among the aortoiliac occlusive disease patients. We present a case of a 53 years old patient with a background history of hypertension and ex intravenous drug abuser with negative retroviral screening status, with no previous complaints who was brought to the Emergency Department with sudden onset of altered sensorium and 1 episode of seizure. Computed tomography angiogram of the brain showed a ruptured anterior communicating artery aneurysm. Diagnostic conventional angiogram of the brain was planned; however, difficulty was encountered during bilateral femoral artery cannulation with the abrupt termination of bilateral common iliac arteries. Computed tomography angiogram of the abdomen showed incidental finding of total occlusion of the abdominal aorta. As a conclusion, total occlusion of abdominal aorta secondary to aortoiliac occlusive disease with an associated intracranial aneurysm is never reported in the literature to date. This case highlights the possibility of association in between these two conditions which may benefit from further research.

Traumatic liver injury can be classified by grading using American Association with Surgery Trauma (AAST). We presented a case of a 22-year-old female who had a motor vehicle accident and sustained a stable Grade 4 liver injury. An angioembolization was performed by the interventional radiologist team, which successfully occluded all the extravasation of the bleed. If the patient is hemodynamically stable in high grade or bleeding liver injury, a non-invasive technique such as angioembolization could be practiced at the bleeding site to minimize or stop the bleeding.

PURPOSEWe sought to present our preliminary experience on the effectiveness and safety of magnetic resonance imaging (MRI)-guided, high-intensity focused ultrasound (HIFU) therapy using a volumetric ablation technique in the treatment of Association of Asian Nations (ASEAN) patients with symptomatic uterine leiomyomas.METHODSThis study included 33 women who underwent HIFU treatment. Tissue characteristics of leiomyomas were assessed based on T2- and T1-weighted MRI. The immediate nonperfused volume (NPV) ratio and the treatment effectiveness of MRI-guided HIFU on the basis of the degrees of volume reduction and improvement in transformed symptom severity score (SSS) were assessed.RESULTSThe median immediate NPV ratio was 89.8%. Additionally, the median acoustic sonication power and HIFU treatment durations were 150 W and 125 min, respectively. At six-month follow-up, the median leiomyoma volume had decreased from 139 mL at baseline to 84 mL and the median transformed SSS had decreased from 56.2 at baseline to 18.8. No major adverse events were observed.CONCLUSIONThe preliminary results demonstrated that volumetric MRI-guided HIFU therapy for the treatment of symptomatic leiomyomas in ASEAN patients appears to be clinically acceptable with regard to treatment effectiveness and safety.

Pulmonary underdevelopment is a rare congenital disease which manifests as persistent hemithorax opacification at chest radiography. We present three patients with different types of pulmonary underdevelopment, their imaging features and associated anomalies. Case 1 is a premature neonate with persistent respiratory distress. Further imaging confirmed right pulmonary hypoplasia, associated with a patent foramen ovale, patent ductus arteriosus and vertebral anomalies. Case 2 is a 6-year-old child with corrected anorectal malformation, and recurrent pneumonia. Further imaging confirmed left pulmonary aplasia, associated with an aberrant right subclavian artery and vertebral anomaly. Case 3 is a full term neonate who developed excessive drooling of saliva and respiratory distress. Further imaging confirmed right pulmonary agenesis, associated with an atrial septal defect, patent ductus arteriosus and tracheo-oesophageal fistula. Pulmonary underdevelopment is classified into three types: hypoplasia, aplasia and agenesis. The majority of them have associated anomalies. This condition should be considered a differential diagnosis in paediatric patients with an opaque hemithorax on chest radiography.

Objective: To evaluate the outcome of pregnant women with abnormal placentation who underwent transient hypogastric artery balloon occlusion with cesarean hysterectomy. Material and Methods: Descriptive retrospective study of patients with abnormal adherent placenta who underwent transient hypogastric artery balloon occlusion with cesarean hysterectomy between January 2014 and December 2016. Data were recorded and analyzed. Results: Fourteen pregnant women with abnormal placentation were included in our series. Most patients underwent cesarean hysterectomy at less than 37 weeks of gestational age. The sonograms of 7 cases overestimated the severity of placenta adherence compared with the pathological diagnosis. The median estimated blood loss was 4,350 milliliters (mL). The median estimated blood loss in placenta accrete, increta and percreta were 3,000 mL, 5,337 mL and 5,150 mL, respectively. One case had a procedure-related complication: perforation of the small branch of the anterior division of the right hypogastric artery from the guidewire. Conclusion: Intraoperative transient balloon occlusion of the hypogastric arteries was an effective method and safe treatment for controlling the massive intraoperative bleeding of cesarean hysterectomy. This technique can be an alternative option in combination with surgery in cases of abnormal placental adherence.

Non-variceal gastrointestinal bleeding is the significant emergency problem to manage in the hospital. Transcatheter arterial embolization is minimally invasive treatment, which becomes an essential role in controlling bleeding, leading to lifesaving. To reach the goal, the interventional radiologist should have fundamental of vascular anatomy and choice of embolic material, which is the key to success.

Objective: To evaluate the eicacy of uterine artery embolization (UAE) in the treatment of postpartum hemorrhage (PPH). Methods: All women who underwent UAE for the treatment of PPH between August 2008 and February 2016 were included. he patients were divided into early and late PPH deined by the onset of bleeding. All UAE procedures were performed by experienced interventional radiologists. Electronic medical records and radiological images were reviewed for data collection. Statistically signiicant associations between angiographic indings and the onset of PPH were evaluated. Results: Total twenty-one women were enrolled in the study. he mean age of the patients was 30.1 years (range 16- 42 years).Total 23 UAE procedures were performed in 21 women. Major clinical presentation was vaginal bleeding in 19 patients (90.5%) and hypovolemic shock was found in 10 patients (47.6%). Eight patients (38.1%) were in early PPH group and thirteen patients (61.9%) were in late PPH group. Five women underwent hysterectomy before UAE. Active contrast extravasation was a common inding associated with early PPH (50%) while pseudoaneurysms were commonly found in late PPH (53.8%) (p=0.016). he overall technical and clinical success rate were 100%. However, two women required repeated UAE ater gelatin sponge embolization for active extravasation due to re-bleeding. No immediate complication of UAE was found in our study. Conclusion: UAE is a safe and efective treatment for both early and late PPH. Various embolic materials can be used but permanent embolic material is preferable in patient with extravasation.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Introduction: Bronchoscopy is a commonly used procedure in the context of aspiration in the Intensive Care Unit setting. Despite its ability to remove mucus plug and undigested gastric contents, aspiration of gastric content into the trachea is one of the most feared complications among anesthesiologist. Discussion: The scenario is made worst if the aspiration causes acute hypoxemic respiratory failure immediately post intubation. However, in the event of desaturation, the quick decision to proceed with bronchoscopy is a challenging task to the anesthesiologist without knowing the causes. Case presentation: We present a case of a 12-year-old boy who had a difficult-to-ventilate scenario post transferring and immediately connected to ventilator in operation theatre (OT) from portable ventilator from the emergency department. She was successfully managed by bronchoscopy. Conclusion: Special attention should be given to the difficult-to-ventilate scenario post intubation of traumatic brain injury patient prior to operation. Prompt diagnosis and bronchoscope-assisted removal of foreign body was found to be a successful to reduce morbidity and mortality. Keywords: Foreign body, Aspiration, Chicken meat, Difficult ventilation

In Malaysia, melioidosis is commonly encountered as this infection is known as part of the endemic area for the disease. Managing cases of positive Burkholderia pseudomallei infection can involve multidisciplinary unit mainly, microbiologist, infectious disease team and intensive care as it may be quite difficult to distinguish melioidosis from a number of other diseases on the clinical setting alone. Laboratory diagnosis plays a vital role in determining the direction of management. Investigations such as culture, polymerase chain reaction (PCR) and serology should be evaluated once the disease is suspected. In this particular case, the patient is a young adult involved in a road traffic accident. Unlike any other cases with melioidosis, he had no potential risk factors which may have contributed to the severity of the disease and it is likely that the site of the accident was the source of acquisition of this gram negative bacterium.

Introduction: Non-invasive ventilation (NIV) is not proven to be effective in treating respiratory failure in severe pneumonia. However, some clinicians nevertheless attempt NIV to indirectly deliver adequate oxygenation and avoid unnecessary endotracheal intubation. Case presentation: In this article, we report the case of a 24-year-old woman at 32 weeks' gestation who presented with hypoxemic respiratory failure requiring mechanical ventilation. She was successfully managed by NIV. Discussion: However, NIV must be managed by providers who are trained in mechanical ventilation. This is of the utmost importance in avoiding any delay should the patient's condition worsen and require endotracheal intubation. Moreover, in pregnant women, the severity of illness may progress quickly due to the immunosuppression inherent in these patients. Conclusion: Special attention should be given to the choices of invasive ventilation and NIV to manage community acquired pneumonia patients in third trimester.