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Spontaneous renal artery dissection (SRAD) is rare. Clinical manifestations vary from minimal symptoms to life-threatening hypertension. We analysed three cases from our institution and conducted a literature review in order to design diagnostic and treatment algorithms for SRAD.

Nedocromil sodium is a nonsteroidal anti-inflammatory drug used to control asthmatic attacks. Our hypothesis is that nedocromil sodium inhibits virus-induced airway inflammation, a common trigger of asthma. We nebulized nedocromil sodium into beagle dogs (n = 10, mean +/- SEM ages: 149 +/- 13 days) before and after inoculation with canine adenovirus type 2 (CAV2). Control dogs (n = 10) received saline aerosols and were either infected with CAV2 (Sal/CAV2, n = 7, mean +/- SEM ages: 140 +/- 11 days) or were not infected (Sal/Sal, n = 3, ages: 143 +/- 0 days). All dogs were anesthetized with choralose (80 mg/kg i.v.), intubated, and mechanically ventilated. Pulmonary function tests and bronchoalveolar lavage (BAL) were performed using standard techniques. Pulmonary function tests revealed no significant change between the nedocromil sodium and non-nedocromil-treated groups. The percentage of infected bronchioles was quantitated as the number of inflamed airways of 40 bronchioles examined times 100 for each dog. Nedocromil-treated dogs had significantly (p < 0.05) less mucosal inflammation (mean +/- SEM, 39% +/- 5%), epithelial denudation (36% +/- 5%), and BAL neutrophilia (11 +/- 3) than did Sal/CAV2 dogs (51% +/- 6%, 57% +/- 4%, and 33% +/- 8%, respectively). We concluded that pretreatment with nedocromil sodium aerosols attenuated CAV2-induced airway inflammation in these beagle puppies.

Key points: (a) Iatrogenic vascular injury is a rare but well recognized complication of spinal surgery; (b) The most serious injuries involve the aorta and its major branches; (c) Vascular injuries following spinal surgery can present early or late; (d) Early presentation usually involves intraoperative hemorrhage and may be associated with hemodynamic instability; (e) Injuries that present late include pseudoaneurysms and arteriovenous fistulae; (f) Arteriography– traditional, CT or MRI angiography– should be used to diagnose the injury and define relevant vascular anatomy; (g) Therapy may require surgery or interventional techniques. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Reilly EF, Weger NS, Stawicki SP. Vascular injury during spinal surgery. OPUS 12 Scientist 2008;2(2):7-10.

Introduction Clopidogrel treatment is associated with a reduction in thrombotic complications in coronary stent placement, improved outcome after acute coronary syndromes, and decreased mortality in patients with coronary artery disease. The purpose of this study was to analyze the effect of preoperative clopidogrel exposure on bleeding complications, blood transfusions requirements, and reoperations in patients undergoing coronary artery bypass grafting (CABG). Patients and methods This study included 320 patients from a single institution that underwent an isolated CABG who were discharged between July 2003 and June 2004. The cohort of 320 patients was classified into 3 groups. The control group consisted of 255 patients that did not receive clopidogrel or stopped clopidogrel 7 days before surgery but were treated with aspirin instead. Clopidogrel I consisted of 25 patients that were taking clopidogrel within 3 days of surgery, and Clopidogrel II consisted of 40 patients that were taking clopidogrel 4 to 7 days before surgery. Patients were compared based on preoperative data (age, gender, use of clopidogrel, preoperative hemoglobin, and ejection fraction), intraoperative data (cross-clamp time), postoperative data (chest tube output, rate of reoperation, units of transfused blood, length of stay in the intensive care unit, and length of intubation). Result There were no significant differences among the 3 groups concerning age, sex, ejection fraction, or preoperative hemoglobin. There were no differences in length of intensive care unit stay and length of intubation among the 3 groups of patients. Patients in the clopidogrel I group had more units of blood transfused than either the control or the Clopidogrel II group (p = 0.027). There is also a trend toward more chest tube output in clopidogrel I group compared with the control group. Fifteen patients (4.6%) of the total group required reoperation secondary to bleeding: 2 (8.0%) in the Clopidogrel I group, 2 (5%) in the clopidogrel II group, and 11 (4.3%) in the control group (p = 0.41). Conclusion This study demonstrated that clopidogrel within 3 days preoperatively increases the requirement for blood transfusion in patients undergoing CABG. Waiting more than 3 days after the last dose of clopidogrel decreases blood transfusion requirements. There is also a trend toward more postoperative bleeding for those patients that took clopidogrel within 3 days before their CABG. The reoperation rate of patients that took clopidogrel within 3 days of their procedure required almost twice as many reoperations as the patients that did not take clopidogrel.

Renal vein thrombosis (RVT) is a rare phenomenon. Bilateral RVT is even less common. RVT has been reported as idiopathic or in association with puerperium, hypercoagulable states, membraneous glomerulonephritis (MGn), renal transplantation, malignancy, and renal vein instrumentation or trauma. Due to its rarity, the literature describing RVT consists mainly of isolated case reports and there are no consistent recommendations regarding diagnosis and treatment of this vascular emergency. We present a case of bilateral RVT associated with MGn. A 45-year-old man complaining of nonspecific abdominal pain of 2 days' duration was found to have bilateral RVT upon computed tomographic evaluation. He was successfully treated with emergent endovascular mechanical thrombectomy in conjunction with chemical thrombolysis and subsequently therapeutically anticoagulated. A renal biopsy demonstrated MGn, and the patient was placed on an appropriate medical regimen. He is well approximately 18 months later, with preserved renal function. Despite a multitude of potential causative mechanisms, all RVT patients should undergo a thorough workup for underlying hypercoagulable disorder and underlying benign or malignant renal causes. Treatment is aimed at prompt relief of venous obstruction and preservation of renal parenchymal function. Interventional radiological procedures, including thrombolysis and thrombectomy, have proven to be valuable in the treatment of RVT. Surgical options include thrombectomy and nephrectomy.

The efficacy of covered stents for treatment of upper extremity pseudoaneurysms (PSA) has not been well documented. We report a case of an 82-year-old woman who presented with a hematoma in the left infraclavicular region as a result of previous permanent pacemaker placement. Subsequent ultrasound and chest computed tomography confirmed an axillary artery PSA. An endovascular approach enabled successful coil embolization and Viabahn stent (W. L. Gore & Associates, Flagstaff, AZ) placement, which excluded the axillary artery PSA. To our knowledge, there is only one other case of this nature reported in the literature.

L’efficacite des stents couverts pour le traitement des faux anevrysmes du membre superieur (PSA) n’a pas ete bien documentee. Nous rapportons le cas d’une femme de 82 ans qui s’est presentee avec un hematome de la region sous-claviculaire gauche lie a la mise en place precedente d’un stimulateur. L’echographie et le scanner thoracique montraient un faux anevrysme de l’artere axillaire. Un abord endovasculaire permis l’embolisation par spires et la mise en place d’un stent Viabahn (W.L. Gore et associes, Flagstaff, AZ, USA), ce qui a exclu le faux anevrysme. A notre connaissance, il y a seulement un autre cas de cette nature rapporte dans la litterature.