When the platelet count falls below 20¥ 109/L, the risk of spontaneous life threatening hemorrhage is concerning for both physician and patient. When medical management fails, splenectomy is often used to manage the severe thrombocytopenia before spontaneous, life-threatening gastrointestinal or intracranial bleeding occurs. We present the non surgical management of such a patient with refractory sever thrombocytopenia who refused surgical intervention. She underwent partial splenic embolic therapy with 500-700 μ particles. Her platelet count spontaneous recovered from less than 20¥109/L to normal range. Her counts remained in normal range after discharge home. Further study is needed to determine the most appropriate role for embolization in patients who are refractory to medical management and those with chronically low platelet counts requiring frequent plate transfusions for invasive procedures.
Fortunately, acute renal artery injuries occur infrequently in blunt trauma patients. Renal salvage in the multi-trauma patient is a daunting task. If after judicious consideration, intervention is warranted, then expeditious repair should follow. Rapid control of exanguinating injuries should be accomplished and the patient stabilized for further intervention - surgical or endovascular. We present the case of a patent who presented with left pneumothorax, multiple bilateral rib, scapula, long bone fractures, hypotension, hemoperitoneum, non perfusion of the left kidney, and a shattered spleen. She underwent emergent splenectomy and stabilization of her pressure. The left renal artery was evaluated and repaired with a covered stent. This approach might be beneficial in highly selected patients with favorable physiologic and anatomical presentations.
Enteral feeding is still the preferred method of nutritional support even in patients with excessive body mass index. Often, this mass poses a hindrance in performing routine procedures. We present a case describing the technique used to safely place a fluoroscopically guided G-tube in a patient with a significant nutritional deficit after repair of a ruptured thoracic aneurysm. Her admission weight was in excess of 180 Kg. However, protracted respiratory insufficiency and mechanical ventilation prolonged her hospital course. The G-tube was successfully placed using a fluoroscopically guided technique. The advantages of such an approach are discussed.
Symptomatic iliac fossa and suprapubic varicosities are uncommon presentations in adults. Such presentations often point to acquired obstructive process to pelvic outflow or to the progression of venous insufficiency and reflux in the pelvic and gonadal veins. Less frequently, venous anomalies of the renal veins or IVC might be implicated. Furthermore, late presentations of congenital or acquired developmental abnormalities might become manifest. As this case illustrates, a thorough understanding of the underlying pathologic process and the anatomical derangement must be sought before any treatment is instituted. Unnecessary extirpation of these varicosities would simply have removed vital physiologic cross-pelvic collateral circulation from the lower extremity in the face of chronic iliac vein occlusion.