warfarin and Flank-Pain

Renal artery embolism was first described in 1940, but it is only recently becoming recognized as a clinically significant entity. Although relatively uncommon, it is clearly responsible for considerable morbidity in patients who experience it. The pathogenesis is typically related to cardiac thrombus formation with subsequent embolization, although other etiologies have been described. The authors present a case report followed by a review of the literature to highlight the clinical characteristics of this phenomena. Presentation, diagnostics, and treatment options will be reviewed with the aim of increasing awareness of renal artery embolism. As clinicians become more familiar with this condition, they will be more likely to consider it as a possible diagnosis in patients with a typical presentation. This will hopefully lead to improved care through prompt diagnosis and treatment, particularly as one treatment option may be time sensitive.

Topics: Aged; Aged, 80 and over; Anticoagulants; Biomarkers; Embolism; Female; Flank Pain; Heparin; Humans; Kidney Function Tests; Magnetic Resonance Imaging; Male; Radiography; Renal Artery Obstruction; Ultrasonics; Warfarin

We describe an extremely rare case of idiopathic spontaneous extensive venous thrombosis in a young man involving the inferior vena cava, the iliac veins and both renal veins associated with right haemorrhagic renal infarction with non-functioning right kidney.

Topics: Administration, Intravenous; Adult; Computed Tomography Angiography; Drug Substitution; Fibrinolytic Agents; Flank Pain; Heparin; Humans; Iliac Vein; Infarction; Kidney; Kidney Function Tests; Male; Renal Veins; Treatment Outcome; Vena Cava, Inferior; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Antiphospholipid Syndrome; Antirheumatic Agents; Flank Pain; Humans; Hydroxychloroquine; Infarction; Kidney; Male; Middle Aged; Tomography, X-Ray Computed; Ultrasonography; Warfarin

Topics: Aged; Angiography; Anticoagulants; Embolization, Therapeutic; Female; Flank Pain; Hematoma; Humans; Kidney Diseases; Renal Artery; Tomography, X-Ray Computed; Ultrasonography; Warfarin

Topics: Abdominal Pain; Aged; Anticoagulants; Atrial Fibrillation; Back Pain; Diagnosis, Differential; Embolization, Therapeutic; Emergency Service, Hospital; Female; Flank Pain; Humans; Infarction; Kidney; Risk Factors; Tachycardia; Thrombosis; Tomography, X-Ray Computed; Warfarin

A 57-year-old woman with known moderate-to-severe mitral stenosis and atrial fibrillation (AF) presented to the emergency department with acute onset right loin pain after having a coronary angiogram and left and right heart catheterisation through the right femoral route about 28 h ago. The cardiac catheterisation was done after she presented with one episode of troponin-negative chest pain and progressive shortness of breath. She had anterior wall myocardial infarction (MI) 25 years ago, which was thought to be due to coronary artery embolism. Her mitral stenosis was diagnosed at that stage.Her warfarin was stopped for 5 days before cardiac catheterisation and international normalised ratio (INR) on the day of the procedure was 1.1. No bridging heparin/low molecular weight heparin (LMWH) was used and warfarin was restarted on the evening of the procedure at the usual dose. Clinical examination revealed some guarding in the right iliac fossa and some tenderness in the right loin. She was not feverish and there was no dysuria or frequency. There was no lump at the puncture site.On presentation to the emergency department, a contrast-enhanced CT scan of the abdomen was performed (figures 1 and 2).. Which of the following is the aetiology of the pain? Abdominal aortic dissectionRenal artery embolismRetroperitoneal haematomaUreteric stone.

Topics: Administration, Intravenous; Anticoagulants; Atrial Fibrillation; Cardiac Catheterization; Coronary Angiography; Drug Administration Schedule; Embolism; Female; Flank Pain; Heparin; Humans; International Normalized Ratio; Middle Aged; Mitral Valve Stenosis; Renal Artery Obstruction; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

The emergency department (ED) serves as the primary gateway for acute care and the source of health care of last resort. Emergency physicians are commonly expected to rapidly assess and treat patients with a variety of life-threatening conditions. However, patients do refuse recommended therapy, even when the consequences are significant morbidity and even mortality. This raises the ethical dilemma of how emergency physicians and ED staff can rapidly determine whether patient refusal of treatment recommendations is based on intact decision-making capacity and how to respond in an appropriate manner when the declining of necessary care by the patient is lacking a basis in informed judgment. This article presents a case that illustrates the ethical tensions raised by the refusal of life-sustaining care in the ED and how such situations can be approached in an ethically appropriate manner.

Topics: Adult; Anticoagulants; Cerebral Veins; Chest Pain; Chronic Pain; Emergency Service, Hospital; Fatal Outcome; Female; Flank Pain; Headache Disorders; Humans; Narcotics; Pulmonary Artery; Treatment Refusal; Venous Thrombosis; Vision Disorders; Warfarin

The aim of this study was to evaluate the correlation of clinical characteristics with serial imaging findings of symptomatic spontaneous celiac artery dissection treated by conservative management.. Eight consecutive, hemodynamically stable patients with symptomatic spontaneous celiac artery dissection without associated aortic dissection that received non-operative treatments were included in this study. Their clinical characteristics, treatment methods, serial imaging findings and outcomes were analyzed retrospectively.. Acute left flank pain related to splenic infarction was the most common clinical manifestation. Initial contrast-enhanced dynamic computed tomography scan showed celiac artery dissection with partial thrombosis in all eight patients and involvement of branch vessels in 7. Full anticoagulation was carried out immediately after the diagnosis in seven patients. All patients, except one with endovascular stent placement, were asymptomatic after successful conservative management and follow-up computed tomography scan showed preservation of distal perfusion with ongoing regression of false lumen in five patients. After a mean follow-up of 16 months, there was no mortality or morbidity related to the dissection.. Serial imaging findings showed that conservative management of celiac artery dissection can be performed successfully in selective patients with stable hemodynamics.

Topics: Adult; Anticoagulants; Aortic Dissection; Celiac Artery; Celiac Disease; Contrast Media; Flank Pain; Follow-Up Studies; Heparin; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Radiographic Image Enhancement; Retrospective Studies; Thrombosis; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Abscess; Adult; Anti-Bacterial Agents; Diagnosis, Differential; Drug Therapy, Combination; Dysuria; Female; Fever of Unknown Origin; Fibrinolytic Agents; Flank Pain; Humans; Kidney Diseases; Renal Veins; Thrombosis; Tomography, X-Ray Computed; Warfarin

Isolated spontaneous renal artery dissection is a rare condition that can result in renal parenchymal loss and severe hypertension. Although several risk factors have been identified in association with renal artery dissection, the natural history is not well defined. The rarity and nonspecific presentation of the disease often lead to diagnostic delay. That, coupled with the anatomic limitations imposed by dissection into small branch arteries, frequently precludes successful revascularization. Over a 12-month period, four cases of spontaneous renal artery dissection (SRAD) were treated at a single institution. The patients (ages 44-58 years) presented with acute onset of abdominal/flank pain, fever, and hematuria. Diagnostic work-up included an abdominal CT scan revealing segmental renal infarction. Angiographic evaluation was diagnostic for renal artery dissection in all cases. In one case there was evidence of fibromuscular dysplasia (FMD), and in a second there was acute dissection superimposed upon atherosclerotic disease. Diagnosis was made within 12-72 hr of the onset of symptoms. All patients were managed expectantly with anticoagulation. Two patients were known to have a history of hypertension prior to admission. All four patients have required antihypertensive treatment following dissection, but the condition has been easily controlled. Renal function has remained stable in all cases. None of the four cases required exploration. Two of the four patients underwent repeat angiographic evaluation for recurrent symptoms of pain. In the case of the patient with FMD, a new dissection was seen in the contralateral renal artery, and in the second, repeat angiogram revealed proximal remodeling of the dissected artery. Management strategies for SRAD include surgical revascularization, endovascular intervention, and observation with or without anticoagulation. The available literature does not demonstrate a clear benefit of treatment with any of these modalities. In the short term, the combination of anticoagulation and expectant management appears to produce satisfactory outcomes for this difficult problem.

Topics: Adult; Anticoagulants; Antihypertensive Agents; Aortic Dissection; Female; Flank Pain; Heparin; Humans; Hypertension; Male; Middle Aged; Renal Artery; Tomography, X-Ray Computed; Warfarin