Gonca Eldem

When do we need contrast-enhanced CT in patients with vague urinary system findings on unenhanced CT?

Determination of renal neoplasms, hematoma, infarct, urinoma, cysts, and pyelonephritis may require contrast material administration following unenhanced CT in patients with flank pain. In this pictorial review, we aimed to clarify when contrast material administration is needed following vague urinary system findings on unenhanced CT.

DEFERASIROX USE AFTER HEMATOPOIETIC STEM CELL TRANSPLANTATION IN PEDIATRIC PATIENTS WITH β-THALASSEMIA MAJOR: Preliminary Results

There are limited data on the posttransplantation pharmacological treatment of iron overload in ex-thalassemic patients and the current approach is phlebotomy. The authors chelated 2 ex-thalassemic patients after hematopoietic stem cell transplantation with deferasirox for 6 and 24 months. Although serum ferritin levels decreased, cardiac and hepatic iron load, measured by T2* magnetic resonance imaging (MRI), showed decrease in iron overload in these organs. The drug was tolerated well by both patients and no adverse effect on donor hematopoiesis was observed. This preliminary study demonstrates that deferasirox is well tolerated in these patients and will be a good potential therapy when more data have been obtained from larger studies.

Dual-echo TFE MRI for the assessment of myocardial iron overload in beta-thalassemia major patients.

PURPOSE Cardiac failure due to myocardial iron overload is the most common cause of death in beta-thalassemia patients. Multi/ two echo times-turbo field echo (TE-TFE) magnetic resonance imaging (MRI) is considered the gold standard technique in the evaluation of myocardial iron accumulation. However, multi TE-TFE technique is not available in all scanners. The aim of our study was to show the role of black blood dualecho cardiac triggered TFE in the assessment of myocardial iron overload. MATERIALS AND METHODS Sixteen beta-thalassemia major patients (10 males) with a mean age of 19 years who were receiving parenteral deferoxamine and oral deferiprone treatment were included in this study. Baseline measurement of myocardial T2* values were < 20 ms in all patients. Cardiac MRI was performed after 6 months, 12 months, and 18 months with the same technique. RESULTS The average baseline value of T2* was 8.2 +/- 3.6 ms. After treatment of combined deferoxamine and deferiprone, the average measurements of myocardial T2* at 6, 12, and 18 months were 11.3 +/- 6.0, 13.6 +/- 7.5, and 15.7 +/- 7.4 ms, respectively (P < 0.05). The basal ejection fraction (EF) value was 49 +/- 8.7%. The EFs were 54.4 +/- 11% at 6 months, 54.8 +/- 6.9% at 12 months, and 58.6 +/- 3.6% at 18 months of followup (P > 0.05). CONCLUSION Cardiac MRI with dual TE-TFE technique can be used to determine myocardial iron accumulation and response to the chelation treatment.

HFE gene mutation is a risk factor for tissue iron accumulation in hemodialysis patients

Introduction: HFE gene mutations are responsible from iron overload in general population. Studies in hemodialysis patients investigated the effect of presence of HFE gene mutations on serum ferritin and transferrin saturation (TSAT) with conflicting results. However effect of HFE mutations on iron overload in hemodialysis patients was not previously extensively studied.

Local recurrence of renal cell carcinoma that simulated multiple renal arteriovenous fistulas after laparoscopic partial nephrectomy: Report of a rare case.

Herein we report a patient who was initially thought to have renal arteriovenous fistulas 3 months after laparoscopic partial nephrectomy for a small renal mass. After timely intervention using selective renal artery embolization, computed tomography 9 months post‐surgery showed persistent renal arteriovenous fistulas and nodular lesions in the perirenal fat. The patient then underwent radical nephrectomy, and histopathological examination showed underlying recurrent clear cell renal cell carcinoma invading the intraparenchymal arteries and veins, which was simulating multiple high‐flow renal arteriovenous fistulas.

The Effects of Deferasirox on Renal, Cardiac and Hepatic Iron Load in Patients with β-Thalassemia Major: Preliminary Results

The iron loading related to erythrocyte transfusions is the major cause of morbidities and mortalities in patients with β-thalassemia major (β-TM). Deferasirox, an orally active iron chelator, has been reported to cause serum creatinine increases in addition to acute renal failures in elderly patients with comorbidities. The nefrotoxicities in patients using deferasirox, despite the facts that the drug is minimally excreted from kidneys and its effective chelation of iron from liver and heart, may rise the question of decomparmentalization of iron from these organs to kidneys. Thirteen patients with β-TM were included in the study (mean age 18.5 ± 7.5 years [9–33 years]). The patients received deferasirox in a dose of 34.3 ± 6.5 mg/kg [17–37 mg/kg]. Four patients (31%) exhibited consecutive increases in serum creatinine greater than 33% above baseline twice during the follow-up period. The results indicated that the earliest iron chelation starts in liver in patients receiving deferasirox. Additionally, by the 6th month of deferasirox, the status of cardiac and renal iron in chronically transfused patients with β-TM were preserved. This may indicate that the serum creatinine increases may not be attributed to iron decompartmantalization from other organs to kidneys.

Outcomes of partial splenic embolization in patients with massive splenomegaly due to idiopathic portal hypertension

AIM To determine the outcomes of partial splenic embolization (PSE) for massive splenomegaly due to idiopathic portal hypertension (IPH). METHODS In this prospective study, we evaluated the characteristics and prognosis of consecutive patients with IPH who underwent PSE for all indications at a single medical center between June 2009 and January 2015. The inclusion criteria were: presence of hypersplenism, massive splenomegaly, and resultant pancytopenia. The exclusion criteria were: presence of other diseases causing portal hypertension. During the post-PSE period, the patients were hospitalized. All patients underwent abdominal computed tomography imaging 4 wk post-PSE to determine total splenic and non-infarcted splenic volumes. RESULTS A total of 11 patients, with median age of 33.27 ± 4.8 years, were included in the study. Mean spleen size was 22.9 cm (21-28 cm), and severe hypersplenism was diagnosed in all patients before PSE. Post-PSE, leukocyte and platelet counts increased significantly, reaching peak levels in the second week with gradual decreases thereafter. Liver function tests did not exhibit significant changes during post-intervention follow-up. All patients developed post-embolization syndrome, and one patient experienced serious complications; all complications were successfully treated with conservative therapy and no death occurred. CONCLUSION Our findings showed that PSE has a lower complication rate than previously-reported surgical complication rates, which supports this intervention as a viable alternative for high-risk operable patients with severe hypersplenism.

Endovascular treatment of true renal artery aneurysms: a single center experience

PURPOSE We aimed to report a single centers experience on endovascular treatment of true renal artery aneurysms (TRAAs), including treatment techniques and outcomes. METHODS This retrospective study was designed to evaluate the treatment and follow-up of TRAAs treated by a variety of endovascular interventional techniques over a period of 6 years. Six patients with nine TRAAs were identified; seven of the TRAAs were treated using different combinations of coil embolization and flow diverter stents. The clinical findings, aneurysm characteristics, endovascular methods and treatment outcomes were reported. RESULTS Seven TRAAs of six patients were treated, with a median aneurysm size of 20 mm. Three TRAAs were treated with primary sac occlusion (one with primary coil embolization, one with balloon and stent assisted coil and glue embolization, and one with amplatzer vascular occlusion device and coil embolization). The remaining four TRAAs of three patients were treated with flow diverter stents (Cardiatis, Silk, Pipeline, and Surpass). Immediate clinical success was achieved in patients treated with primary sac embolization (95% CI, 29.2%-100%). Among patients treated with flow diverter stents, one patient required an additional flow diverter at 6-month follow-up. The occlusion time in flow diverters ranged from 1 month to 12 months (median, 3.5 months) taking the repeat procedure into account. In patients treated with flow diverters, the clinical success rate was 100% (95% CI, 29.2%-100%) at one-year follow-up. Long-term follow-up ranged from 3 to 52 months. One intraprocedural complication was encountered with a flow diverter during deployment, which required additional stenting and tirofiban infusion. No other major complication was seen. CONCLUSION Endovascular treatment is an effective and safe method offering high success rates and low morbidity in the treatment of TRAAs and may supplant surgery as the primary therapy. Current experience in the use of flow diverter stents in TRAAs is limited to individual case reports with one brand of flow diverter device. Our small numbered series of four TRAAs shows our experience regarding endovascular treatment with different flow diverter brands.

Iliac arteriovenous fistulas after lumbar spinal surgery

Iatrogenic arteriovenous fistula (AVF) is an unusual and potentially fatal complication of lumbar spinal surgery. The presentation of these injuries is usually late, with symptoms such as leg swelling or cardiac failure. It is crucial to suspect AVF in the patient which presents to emergency with lumbar spinal surgery history. The diagnosis is often based on imaging studies such as computed tomography (CT) or magnetic resonance (MR) angiography. Surgery was the first choice of treatment, but with recent advances in stent technology endovascular approach has become widely popular. We present two cases of AVF secondary to lumbar spinal surgery, one of them presenting with overt heart failure and the other one with leg swelling.

An unusual cause of massive gastrointestinal bleeding

Fig. 2. A 38-year-old man, with a past medical history of recurrent pper gastrointestinal bleeding, was referred to our clinic because f a new episode of acute bleeding presenting with syncope nd acute anaemia, requiring 6 units of packed red blood cell ransfusion. Physical examination, laboratory tests and abdomial ultrasonography were unremarkable. Upper gastrointestinal ndoscopy revealed isolated fundal vascular dilatation without aemorrhage. Computerized tomography scan showed complete cclusion of celiac trunk and splenic artery (Figs. 1 and 2). ngiography also demonstrated complete occlusion. Furthermore, umerous collateral vessels were seen originating from infeior phrenic artery and mimicking fundal varices (Supplementary igure S1). Transcatheter embolization of the fundal collateral rtery was performed via microcatheter using micro-coils. After months, follow-up endoscopy demonstrated decompression of rterial lesion. He was well at 6-month follow-up.