Imaging

The apparent increase in the prevalence of incidental pancreatic cysts in recent years may be tied to improvements in MRI scanning technology, results of a study suggest.

Researchers conducted a retrospective analysis of data from 500 patients who underwent an MRI for nonpancreatic indications at a single center between 2005 and 2014; 50 were sampled from each year in chronological order.

© parisvas/Thinkstockphotos.com

A total of 208 patients (41.6%) were found to have an incidental cyst, of which less than a quarter were described in the original MRI report, according to a paper published online in Clinical Gastroenterology and Hepatology.

Analysis showed a very strong association between the type of imaging hardware and software, and the presence of cysts; older hardware found pancreatic cysts in 30.3% of patients and the newest hardware found cysts in 56.3% of patients.

However, MRI field strength was not associated with the frequency of lesion discovery (Clin Gastro Hepatol. 2015 Sep 11. doi: 10.1016/j.cgh.2015.08.038).

Most cysts were relatively small, with a median size of 4 mm. Nearly half of the patients with a cyst only had one described.

Nearly two-thirds of these cysts (62%) had an uncertain diagnosis, but 35% of patients were diagnosed with an intraductal papillary mucinous neoplasm, and one patient showed radiologic evidence of subacute pancreatitis.

When compared to the rest of the cohort, individuals with pancreatic cysts were more likely to be older, have diabetes mellitus, or have a personal history of cancer, particularly nonmelanoma skin cancer and hepatocellular carcinoma.

“Our study demonstrates the relationship between the higher trend of incidental pancreatic cysts observed in the recent years and the improvements in the technical features of MRIs,” wrote Dr. Maria Moris and colleagues from the Mayo Clinic, Jacksonville.

The authors said the real prevalence of pancreatic cystic lesions is estimated to range from 0.2% to 44.7%.

Their finding of a prevalence of 41.6% was higher than that found in similar imaging studies, but the authors suggested some of this may be due to the lack of a size cutoff in their study, as opposed to a 5-mm cutoff used in one earlier study that found a prevalence of 10%.

“Moreover, we believe that we may have even underestimated the real prevalence because of the absence of magnetic resonance cholangiopancreatography sequences (only 19% of the examinations), and the lack of 3-T studies (6% of the MRIs),” they wrote.

The median size of the lesions was lower than those found in previous studies.

“This smaller size was unexpected because, as a result of the exclusion criteria applied, the technical features of the MRIs were not the most specific for [pancreatic cystic lesion] PCL visualization,” the authors wrote, suggesting that this may have been due to the radiologist’s experience in this field.

The study was funded by the Joyce E. Baker Foundation for Research at Mayo Clinic in Jacksonville. One author disclosed grants or travel support from Olympus, Boston Scientific, and Cosmo Pharmaceuticals. There were no other conflicts of interest declared.

The apparent increase in the prevalence of incidental pancreatic cysts in recent years may be tied to improvements in MRI scanning technology, results of a study suggest.

Researchers conducted a retrospective analysis of data from 500 patients who underwent an MRI for nonpancreatic indications at a single center between 2005 and 2014; 50 were sampled from each year in chronological order.

© parisvas/Thinkstockphotos.com

A total of 208 patients (41.6%) were found to have an incidental cyst, of which less than a quarter were described in the original MRI report, according to a paper published online in Clinical Gastroenterology and Hepatology.

Analysis showed a very strong association between the type of imaging hardware and software, and the presence of cysts; older hardware found pancreatic cysts in 30.3% of patients and the newest hardware found cysts in 56.3% of patients.

However, MRI field strength was not associated with the frequency of lesion discovery (Clin Gastro Hepatol. 2015 Sep 11. doi: 10.1016/j.cgh.2015.08.038).

Most cysts were relatively small, with a median size of 4 mm. Nearly half of the patients with a cyst only had one described.

Nearly two-thirds of these cysts (62%) had an uncertain diagnosis, but 35% of patients were diagnosed with an intraductal papillary mucinous neoplasm, and one patient showed radiologic evidence of subacute pancreatitis.

When compared to the rest of the cohort, individuals with pancreatic cysts were more likely to be older, have diabetes mellitus, or have a personal history of cancer, particularly nonmelanoma skin cancer and hepatocellular carcinoma.

“Our study demonstrates the relationship between the higher trend of incidental pancreatic cysts observed in the recent years and the improvements in the technical features of MRIs,” wrote Dr. Maria Moris and colleagues from the Mayo Clinic, Jacksonville.

The authors said the real prevalence of pancreatic cystic lesions is estimated to range from 0.2% to 44.7%.

Their finding of a prevalence of 41.6% was higher than that found in similar imaging studies, but the authors suggested some of this may be due to the lack of a size cutoff in their study, as opposed to a 5-mm cutoff used in one earlier study that found a prevalence of 10%.

“Moreover, we believe that we may have even underestimated the real prevalence because of the absence of magnetic resonance cholangiopancreatography sequences (only 19% of the examinations), and the lack of 3-T studies (6% of the MRIs),” they wrote.

The median size of the lesions was lower than those found in previous studies.

“This smaller size was unexpected because, as a result of the exclusion criteria applied, the technical features of the MRIs were not the most specific for [pancreatic cystic lesion] PCL visualization,” the authors wrote, suggesting that this may have been due to the radiologist’s experience in this field.

The study was funded by the Joyce E. Baker Foundation for Research at Mayo Clinic in Jacksonville. One author disclosed grants or travel support from Olympus, Boston Scientific, and Cosmo Pharmaceuticals. There were no other conflicts of interest declared.

The apparent increase in the prevalence of incidental pancreatic cysts in recent years may be tied to improvements in MRI scanning technology, results of a study suggest.

Researchers conducted a retrospective analysis of data from 500 patients who underwent an MRI for nonpancreatic indications at a single center between 2005 and 2014; 50 were sampled from each year in chronological order.

© parisvas/Thinkstockphotos.com

A total of 208 patients (41.6%) were found to have an incidental cyst, of which less than a quarter were described in the original MRI report, according to a paper published online in Clinical Gastroenterology and Hepatology.

Analysis showed a very strong association between the type of imaging hardware and software, and the presence of cysts; older hardware found pancreatic cysts in 30.3% of patients and the newest hardware found cysts in 56.3% of patients.

However, MRI field strength was not associated with the frequency of lesion discovery (Clin Gastro Hepatol. 2015 Sep 11. doi: 10.1016/j.cgh.2015.08.038).

Most cysts were relatively small, with a median size of 4 mm. Nearly half of the patients with a cyst only had one described.

Nearly two-thirds of these cysts (62%) had an uncertain diagnosis, but 35% of patients were diagnosed with an intraductal papillary mucinous neoplasm, and one patient showed radiologic evidence of subacute pancreatitis.

When compared to the rest of the cohort, individuals with pancreatic cysts were more likely to be older, have diabetes mellitus, or have a personal history of cancer, particularly nonmelanoma skin cancer and hepatocellular carcinoma.

“Our study demonstrates the relationship between the higher trend of incidental pancreatic cysts observed in the recent years and the improvements in the technical features of MRIs,” wrote Dr. Maria Moris and colleagues from the Mayo Clinic, Jacksonville.

The authors said the real prevalence of pancreatic cystic lesions is estimated to range from 0.2% to 44.7%.

Their finding of a prevalence of 41.6% was higher than that found in similar imaging studies, but the authors suggested some of this may be due to the lack of a size cutoff in their study, as opposed to a 5-mm cutoff used in one earlier study that found a prevalence of 10%.

“Moreover, we believe that we may have even underestimated the real prevalence because of the absence of magnetic resonance cholangiopancreatography sequences (only 19% of the examinations), and the lack of 3-T studies (6% of the MRIs),” they wrote.

The median size of the lesions was lower than those found in previous studies.

“This smaller size was unexpected because, as a result of the exclusion criteria applied, the technical features of the MRIs were not the most specific for [pancreatic cystic lesion] PCL visualization,” the authors wrote, suggesting that this may have been due to the radiologist’s experience in this field.

The study was funded by the Joyce E. Baker Foundation for Research at Mayo Clinic in Jacksonville. One author disclosed grants or travel support from Olympus, Boston Scientific, and Cosmo Pharmaceuticals. There were no other conflicts of interest declared.

Background

A recent multicenter trial by Smith-Bindman et al¹ showed that ultrasound (point of care [POC] or radiology) should be considered as the first-line imaging test in evaluating patients with suspected renal colic. In addition to its ability to visualize significant renal hydronephrosis, POC ultrasound is also an excellent modality to assess for intrarenal stones.

  

Technique

The study is performed with a curvilinear probe placed in the left and right midaxillary region along the lower costal margin. To obtain a longitudinal view of the kidneys, the probe marker should point toward the head of the bed (Figure 1). The clinician should then slide the probe until the kidney comes into view just caudal to either the liver on the right or the spleen on the left. It is important to remember that the kidneys are retroperitoneal; as such, the probe should be pointed toward the bed to ensure visualization.

The probe should be swept/fanned through the kidney so that the entire organ is visualized from cortex to renal calices. To obtain a transverse view of the kidney, the probe marker should be rotated 90˚ clockwise (Figure 2); the probe should also be swept/fanned through the kidney in this orientation as well. In addition, during evaluation, the bladder should also be scanned in both the longitudinal and transverse planes to assess its volume and the presence of stones.

  

Hydronephrosis

Ureteral or bladder outlet obstruction can lead to unilateral or bilateral renal hydronephrosis, which can present on a spectrum ranging from mild to severe.  As fluid appears black on ultrasound, hydronephrosis will appear black in what is normally an echogenic center of the kidney. The higher the degree of hydronephrosis, the larger the area of black; in cases of severe hydronephrosis, there is thinning of the renal parenchyma and most of the kidney is taken up by dilated calyces (Figure 3). If there is uncertainty during evaluation, color Doppler may be employed to differentiate the vascular renal hilum from hydronephrosis (Figure 4).

  

Ureteral Stones

Ureteral stones are not typically visualized by ultrasound.  However, intrarenal stones can be found. These will appear as hyperechoic structures within the central area of the kidney with acoustic shadowing artifact noted underneath them. Additionally, while scanning the bladder, one can sometimes find a stone lodged in the ureteropelvic junction (UPJ). One can also look for “ureteral jets,” seen as periodic flow of urine within the bladder using color/power Doppler (Figure 5).

  

Pearls/Pitfalls

As abdominal aortic aneurysm (AAA) can mimic renal stones, it is important to scan the aorta in patients presenting with renal colic or flank pain who are at increased risk for AAA or who are older than age 50 years. In addition, during evaluation, the clinician should keep in mind that pregnancy state and aggressive intravenous fluid administration can lead to mild bilateral hydronephrosis. In addition, incidental renal cysts/masses are often encountered during imaging and require close follow-up (Figure 6).

  

  

  

---

Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

Background

A recent multicenter trial by Smith-Bindman et al¹ showed that ultrasound (point of care [POC] or radiology) should be considered as the first-line imaging test in evaluating patients with suspected renal colic. In addition to its ability to visualize significant renal hydronephrosis, POC ultrasound is also an excellent modality to assess for intrarenal stones.

  

Technique

The study is performed with a curvilinear probe placed in the left and right midaxillary region along the lower costal margin. To obtain a longitudinal view of the kidneys, the probe marker should point toward the head of the bed (Figure 1). The clinician should then slide the probe until the kidney comes into view just caudal to either the liver on the right or the spleen on the left. It is important to remember that the kidneys are retroperitoneal; as such, the probe should be pointed toward the bed to ensure visualization.

The probe should be swept/fanned through the kidney so that the entire organ is visualized from cortex to renal calices. To obtain a transverse view of the kidney, the probe marker should be rotated 90˚ clockwise (Figure 2); the probe should also be swept/fanned through the kidney in this orientation as well. In addition, during evaluation, the bladder should also be scanned in both the longitudinal and transverse planes to assess its volume and the presence of stones.

  

Hydronephrosis

Ureteral or bladder outlet obstruction can lead to unilateral or bilateral renal hydronephrosis, which can present on a spectrum ranging from mild to severe.  As fluid appears black on ultrasound, hydronephrosis will appear black in what is normally an echogenic center of the kidney. The higher the degree of hydronephrosis, the larger the area of black; in cases of severe hydronephrosis, there is thinning of the renal parenchyma and most of the kidney is taken up by dilated calyces (Figure 3). If there is uncertainty during evaluation, color Doppler may be employed to differentiate the vascular renal hilum from hydronephrosis (Figure 4).

  

Ureteral Stones

Ureteral stones are not typically visualized by ultrasound.  However, intrarenal stones can be found. These will appear as hyperechoic structures within the central area of the kidney with acoustic shadowing artifact noted underneath them. Additionally, while scanning the bladder, one can sometimes find a stone lodged in the ureteropelvic junction (UPJ). One can also look for “ureteral jets,” seen as periodic flow of urine within the bladder using color/power Doppler (Figure 5).

  

Pearls/Pitfalls

As abdominal aortic aneurysm (AAA) can mimic renal stones, it is important to scan the aorta in patients presenting with renal colic or flank pain who are at increased risk for AAA or who are older than age 50 years. In addition, during evaluation, the clinician should keep in mind that pregnancy state and aggressive intravenous fluid administration can lead to mild bilateral hydronephrosis. In addition, incidental renal cysts/masses are often encountered during imaging and require close follow-up (Figure 6).

  

  

  

---

Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

Background

A recent multicenter trial by Smith-Bindman et al¹ showed that ultrasound (point of care [POC] or radiology) should be considered as the first-line imaging test in evaluating patients with suspected renal colic. In addition to its ability to visualize significant renal hydronephrosis, POC ultrasound is also an excellent modality to assess for intrarenal stones.

  

Technique

The study is performed with a curvilinear probe placed in the left and right midaxillary region along the lower costal margin. To obtain a longitudinal view of the kidneys, the probe marker should point toward the head of the bed (Figure 1). The clinician should then slide the probe until the kidney comes into view just caudal to either the liver on the right or the spleen on the left. It is important to remember that the kidneys are retroperitoneal; as such, the probe should be pointed toward the bed to ensure visualization.

The probe should be swept/fanned through the kidney so that the entire organ is visualized from cortex to renal calices. To obtain a transverse view of the kidney, the probe marker should be rotated 90˚ clockwise (Figure 2); the probe should also be swept/fanned through the kidney in this orientation as well. In addition, during evaluation, the bladder should also be scanned in both the longitudinal and transverse planes to assess its volume and the presence of stones.

  

Hydronephrosis

Ureteral or bladder outlet obstruction can lead to unilateral or bilateral renal hydronephrosis, which can present on a spectrum ranging from mild to severe.  As fluid appears black on ultrasound, hydronephrosis will appear black in what is normally an echogenic center of the kidney. The higher the degree of hydronephrosis, the larger the area of black; in cases of severe hydronephrosis, there is thinning of the renal parenchyma and most of the kidney is taken up by dilated calyces (Figure 3). If there is uncertainty during evaluation, color Doppler may be employed to differentiate the vascular renal hilum from hydronephrosis (Figure 4).

  

Ureteral Stones

Ureteral stones are not typically visualized by ultrasound.  However, intrarenal stones can be found. These will appear as hyperechoic structures within the central area of the kidney with acoustic shadowing artifact noted underneath them. Additionally, while scanning the bladder, one can sometimes find a stone lodged in the ureteropelvic junction (UPJ). One can also look for “ureteral jets,” seen as periodic flow of urine within the bladder using color/power Doppler (Figure 5).

  

Pearls/Pitfalls

As abdominal aortic aneurysm (AAA) can mimic renal stones, it is important to scan the aorta in patients presenting with renal colic or flank pain who are at increased risk for AAA or who are older than age 50 years. In addition, during evaluation, the clinician should keep in mind that pregnancy state and aggressive intravenous fluid administration can lead to mild bilateral hydronephrosis. In addition, incidental renal cysts/masses are often encountered during imaging and require close follow-up (Figure 6).

  

  

  

---

Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

Case

A 32-year-old previously healthy woman presented to the ED with right upper arm pain and swelling of 6 days duration. According to the patient, the swelling began 2 days after she sustained a work-related injury at a coin-manufacturing factory. She stated that her right arm had gotten caught inside of a rolling press while she was cleaning it. The roller had stopped over her upper arm, trapping it between the roller and the platform for several minutes before it was extricated. She was brought to the ED by emergency medical services for evaluation immediately following this incident. At this first visit to the ED, the patient complained of mild pain in her right arm. Physical examination at that time revealed mild diffuse swelling extending from her hand to her distal humerus, with mild pain on passive flexion, and extension without associated numbness or tingling. Plain films of her right upper extremity were ordered, the results of which were relatively unremarkable. She was evaluated by an orthopedist, who ruled out compartment syndrome based on her benign physical examination and soft compartments. She was ultimately discharged and told to follow up with her primary care provider.

Over the course of 48 hours from the first ED visit, the patient developed large bullae on the dorsal and volar aspect of her forearm, elbow, and upper arm with associated pain. In addition to dark discolorations of the skin over her affected arm, she noticed that the bullae had become numerous and discolored. These symptoms continued to grow progressively worse, prompting her second presentation to the ED.

With respect to the patient’s history, she denied taking any medications and did not have any significant medical or surgical history. She also denied any new food exposure, infections, or insect bites. Physical examination revealed a young woman who was uncomfortable but cooperative. On inspection, she had multiple hemorrhagic bullae extending circumferentially from the mid-upper arm to her mid-forearm with lightly ecchymotic skin that was more prominent on the medial aspect of her arm (Figure 1). There was notable fluid collection, most prominently in the posterior aspect of her arm underneath the area of greatest skin necrosis. The compartments were flaccid and compressible, and radial, ulnar, and brachial pulses were palpable. The patient complained of diffuse paresthesias and decreased sensation in radial, median, and ulnar nerve distribution. Motor strength of the flexor digitorum superficialis, profundus, extensor policis longus, and extensor carpi radialis remained 5/5.

Laboratory evaluations, which included coagulation studies, were normal with the exception of a minimally elevated creatinine kinase at 239 IU/L (normal, 20-210 IU/L). The patient was evaluated by a trauma surgeon and subsequently underwent ultrasound evaluation (Figure 2) and computed tomography (CT) with intravenous (IV) contrast of the affected arm. Both studies revealed an extensive fluid collection centered in the subcutaneous fat extending from the mid-forearm to the humeral head, consistent with an internal degloving injury.

The patient was taken to the operating room and underwent debridement and resection of the circumferential necrotic skin and subcutaneous tissue in her right arm, and the placement of a skin graft with overlying wound vacuum-assisted closure. During the procedure, a large amount of serosanguinous fluid was drained and cultured, and was found to be sterile. Due to the size of her injury, she underwent two additional episodes of debridement and graft placement over the course of the next 2 weeks.

  

Discussion

First described in the 1850s by the French physician Maurice Morel-Lavallée, Morel-Lavallée lesion is a rare, traumatic, soft-tissue injury.¹ It is an internal degloving injury wherein the skin and subcutaneous tissue have been forcibly separated from the underlying fascia as a result of shear stress. The lymphatic and blood vessels between the layers are also disrupted in this process, resulting in the accumulation of blood and lymphatic fluid as well as subcutaneous debris in the potential space that forms. Excess accumulation over time can compromise blood supply to the overlying skin and cause necrosis.² Morel-Lavallée lesion is missed on initial evaluation in up to one-third of the cases and may have a delay in presentation ranging from hours to months after the inciting injury.³

Morel-Lavallée lesions typically involve the flank, hips, thigh, and prepatellar regions as a result of shear injuries sustained from bicycle falls and motor vehicle accidents.⁴ These lesions are often associated with concomitant acetabular and pelvic fractures.⁵ Involvement of the upper extremities is unusual. Typically, presentation consists of a fluctuant and painful mass underneath the skin which increases over time. The overlying skin may show the mechanism of the original injury, for example, as abrasions after a crush injury. The excessive skin necrosis and hemorrhagic bullae seen in this particular case is a very rare presentation.

 

Differential Diagnosis

The differential diagnosis includes compartment syndrome, coma blisters, a missed fracture, bullous pemphigoid, bullous drug reactions, and linear immunoglobulin A disease. Most of these conditions were easily ruled out in this case as the patient was previously healthy and not on any medications. The lesions in this case could have been confused with coma blisters, which are similar in appearance, self-limiting, and can develop on the extremities. However, coma blisters are classically associated with toxicity from various central nervous system depressants, as well as reduced consciousness from other causes—all of which were readily ruled-out based on the patient’s history. Moreover, the Morel-Lavallée lesion is a degloving injury of the subcutaneous tissue from the fascia underneath, whereas the pathology of coma blisters includes subepidermal bullae formation as well as immunoglobulin and complement deposition.⁶

Diagnostic Imaging

Morel-Lavallée lesion can often be confirmed via several imaging modalities, including  ultrasound, CT, 3D CT, or magnetic resonance imaging (MRI).^3,7 Ultrasound will usually show a well-circumscribed hypoechoic fluid collection with hyperechoic fat globules from the subcutaneous tissue, whereas CT tends to show an encapsulated mass with fluid collection underneath. In MRI, Morel-Lavallée lesion often appears as a hypointense T1-sequence and hyperintense T2-sequence similar to most other fluid collections. There may be variable T1- and T2-intensities with subcutaneous tissues in the fluid collection.²

Management

Despite recognition of this disease entity, controversies still exist regarding management. Case reports have demonstrated a relatively high rate of infected fluid collections depending on the chronicity of the injury.⁸ A recent algorithm to management described by Nickerson et al⁴ proposes that for patients with viable skin, percutaneous aspiration of more than 50 cc of fluid from these lesions should be treated with more extensive operative intervention based on the increased likelihood of recurrence. Patients without viable skin require formal debridement with possible skin grafting.

Other treatment options include conservative management, surgical drainage, sclerodesis, and extensive open surgery.^8-10 Management is always case-based and dependent upon the size of the lesion and associated injuries.

  

Conclusion

This case represents an example of Morel-Lavallée lesions in their most severe and atypical form. It also serves as a reminder that vigilance and knowledge of this disease process is important in helping to diagnose this rare but potentially devastating condition. The key to recognizing this injury lies in keeping this disease process in the differential diagnosis of traumatic injuries with suspicious mechanism involving significant shear forces. Significant physical examination findings may not be present initially and evolve over a time period of hours to days. Once this injury is identified, management hinges on the size of the lesion and affected body part. Despite timely interventions, Morel-Lavallée lesions may result in significant morbidity and functional disability.

  

---

Dr Ye is an emergency medicine resident at the Brown Alpert Medical School in Providence, Rhode Island. Dr Rosenberg is a clinical assistant professor at Brown Alpert Medical School, and an emergency medicine attending physican at Rhode Island Hospital and The Miriam Hospital, Providence, Rhode Island.

Case

A 32-year-old previously healthy woman presented to the ED with right upper arm pain and swelling of 6 days duration. According to the patient, the swelling began 2 days after she sustained a work-related injury at a coin-manufacturing factory. She stated that her right arm had gotten caught inside of a rolling press while she was cleaning it. The roller had stopped over her upper arm, trapping it between the roller and the platform for several minutes before it was extricated. She was brought to the ED by emergency medical services for evaluation immediately following this incident. At this first visit to the ED, the patient complained of mild pain in her right arm. Physical examination at that time revealed mild diffuse swelling extending from her hand to her distal humerus, with mild pain on passive flexion, and extension without associated numbness or tingling. Plain films of her right upper extremity were ordered, the results of which were relatively unremarkable. She was evaluated by an orthopedist, who ruled out compartment syndrome based on her benign physical examination and soft compartments. She was ultimately discharged and told to follow up with her primary care provider.

Over the course of 48 hours from the first ED visit, the patient developed large bullae on the dorsal and volar aspect of her forearm, elbow, and upper arm with associated pain. In addition to dark discolorations of the skin over her affected arm, she noticed that the bullae had become numerous and discolored. These symptoms continued to grow progressively worse, prompting her second presentation to the ED.

With respect to the patient’s history, she denied taking any medications and did not have any significant medical or surgical history. She also denied any new food exposure, infections, or insect bites. Physical examination revealed a young woman who was uncomfortable but cooperative. On inspection, she had multiple hemorrhagic bullae extending circumferentially from the mid-upper arm to her mid-forearm with lightly ecchymotic skin that was more prominent on the medial aspect of her arm (Figure 1). There was notable fluid collection, most prominently in the posterior aspect of her arm underneath the area of greatest skin necrosis. The compartments were flaccid and compressible, and radial, ulnar, and brachial pulses were palpable. The patient complained of diffuse paresthesias and decreased sensation in radial, median, and ulnar nerve distribution. Motor strength of the flexor digitorum superficialis, profundus, extensor policis longus, and extensor carpi radialis remained 5/5.

Laboratory evaluations, which included coagulation studies, were normal with the exception of a minimally elevated creatinine kinase at 239 IU/L (normal, 20-210 IU/L). The patient was evaluated by a trauma surgeon and subsequently underwent ultrasound evaluation (Figure 2) and computed tomography (CT) with intravenous (IV) contrast of the affected arm. Both studies revealed an extensive fluid collection centered in the subcutaneous fat extending from the mid-forearm to the humeral head, consistent with an internal degloving injury.

The patient was taken to the operating room and underwent debridement and resection of the circumferential necrotic skin and subcutaneous tissue in her right arm, and the placement of a skin graft with overlying wound vacuum-assisted closure. During the procedure, a large amount of serosanguinous fluid was drained and cultured, and was found to be sterile. Due to the size of her injury, she underwent two additional episodes of debridement and graft placement over the course of the next 2 weeks.

  

Discussion

First described in the 1850s by the French physician Maurice Morel-Lavallée, Morel-Lavallée lesion is a rare, traumatic, soft-tissue injury.¹ It is an internal degloving injury wherein the skin and subcutaneous tissue have been forcibly separated from the underlying fascia as a result of shear stress. The lymphatic and blood vessels between the layers are also disrupted in this process, resulting in the accumulation of blood and lymphatic fluid as well as subcutaneous debris in the potential space that forms. Excess accumulation over time can compromise blood supply to the overlying skin and cause necrosis.² Morel-Lavallée lesion is missed on initial evaluation in up to one-third of the cases and may have a delay in presentation ranging from hours to months after the inciting injury.³

Morel-Lavallée lesions typically involve the flank, hips, thigh, and prepatellar regions as a result of shear injuries sustained from bicycle falls and motor vehicle accidents.⁴ These lesions are often associated with concomitant acetabular and pelvic fractures.⁵ Involvement of the upper extremities is unusual. Typically, presentation consists of a fluctuant and painful mass underneath the skin which increases over time. The overlying skin may show the mechanism of the original injury, for example, as abrasions after a crush injury. The excessive skin necrosis and hemorrhagic bullae seen in this particular case is a very rare presentation.

 

Differential Diagnosis

The differential diagnosis includes compartment syndrome, coma blisters, a missed fracture, bullous pemphigoid, bullous drug reactions, and linear immunoglobulin A disease. Most of these conditions were easily ruled out in this case as the patient was previously healthy and not on any medications. The lesions in this case could have been confused with coma blisters, which are similar in appearance, self-limiting, and can develop on the extremities. However, coma blisters are classically associated with toxicity from various central nervous system depressants, as well as reduced consciousness from other causes—all of which were readily ruled-out based on the patient’s history. Moreover, the Morel-Lavallée lesion is a degloving injury of the subcutaneous tissue from the fascia underneath, whereas the pathology of coma blisters includes subepidermal bullae formation as well as immunoglobulin and complement deposition.⁶

Diagnostic Imaging

Morel-Lavallée lesion can often be confirmed via several imaging modalities, including  ultrasound, CT, 3D CT, or magnetic resonance imaging (MRI).^3,7 Ultrasound will usually show a well-circumscribed hypoechoic fluid collection with hyperechoic fat globules from the subcutaneous tissue, whereas CT tends to show an encapsulated mass with fluid collection underneath. In MRI, Morel-Lavallée lesion often appears as a hypointense T1-sequence and hyperintense T2-sequence similar to most other fluid collections. There may be variable T1- and T2-intensities with subcutaneous tissues in the fluid collection.²

Management

Despite recognition of this disease entity, controversies still exist regarding management. Case reports have demonstrated a relatively high rate of infected fluid collections depending on the chronicity of the injury.⁸ A recent algorithm to management described by Nickerson et al⁴ proposes that for patients with viable skin, percutaneous aspiration of more than 50 cc of fluid from these lesions should be treated with more extensive operative intervention based on the increased likelihood of recurrence. Patients without viable skin require formal debridement with possible skin grafting.

Other treatment options include conservative management, surgical drainage, sclerodesis, and extensive open surgery.^8-10 Management is always case-based and dependent upon the size of the lesion and associated injuries.

  

Conclusion

This case represents an example of Morel-Lavallée lesions in their most severe and atypical form. It also serves as a reminder that vigilance and knowledge of this disease process is important in helping to diagnose this rare but potentially devastating condition. The key to recognizing this injury lies in keeping this disease process in the differential diagnosis of traumatic injuries with suspicious mechanism involving significant shear forces. Significant physical examination findings may not be present initially and evolve over a time period of hours to days. Once this injury is identified, management hinges on the size of the lesion and affected body part. Despite timely interventions, Morel-Lavallée lesions may result in significant morbidity and functional disability.

  

---

Dr Ye is an emergency medicine resident at the Brown Alpert Medical School in Providence, Rhode Island. Dr Rosenberg is a clinical assistant professor at Brown Alpert Medical School, and an emergency medicine attending physican at Rhode Island Hospital and The Miriam Hospital, Providence, Rhode Island.

Case

A 32-year-old previously healthy woman presented to the ED with right upper arm pain and swelling of 6 days duration. According to the patient, the swelling began 2 days after she sustained a work-related injury at a coin-manufacturing factory. She stated that her right arm had gotten caught inside of a rolling press while she was cleaning it. The roller had stopped over her upper arm, trapping it between the roller and the platform for several minutes before it was extricated. She was brought to the ED by emergency medical services for evaluation immediately following this incident. At this first visit to the ED, the patient complained of mild pain in her right arm. Physical examination at that time revealed mild diffuse swelling extending from her hand to her distal humerus, with mild pain on passive flexion, and extension without associated numbness or tingling. Plain films of her right upper extremity were ordered, the results of which were relatively unremarkable. She was evaluated by an orthopedist, who ruled out compartment syndrome based on her benign physical examination and soft compartments. She was ultimately discharged and told to follow up with her primary care provider.

Over the course of 48 hours from the first ED visit, the patient developed large bullae on the dorsal and volar aspect of her forearm, elbow, and upper arm with associated pain. In addition to dark discolorations of the skin over her affected arm, she noticed that the bullae had become numerous and discolored. These symptoms continued to grow progressively worse, prompting her second presentation to the ED.

With respect to the patient’s history, she denied taking any medications and did not have any significant medical or surgical history. She also denied any new food exposure, infections, or insect bites. Physical examination revealed a young woman who was uncomfortable but cooperative. On inspection, she had multiple hemorrhagic bullae extending circumferentially from the mid-upper arm to her mid-forearm with lightly ecchymotic skin that was more prominent on the medial aspect of her arm (Figure 1). There was notable fluid collection, most prominently in the posterior aspect of her arm underneath the area of greatest skin necrosis. The compartments were flaccid and compressible, and radial, ulnar, and brachial pulses were palpable. The patient complained of diffuse paresthesias and decreased sensation in radial, median, and ulnar nerve distribution. Motor strength of the flexor digitorum superficialis, profundus, extensor policis longus, and extensor carpi radialis remained 5/5.

Laboratory evaluations, which included coagulation studies, were normal with the exception of a minimally elevated creatinine kinase at 239 IU/L (normal, 20-210 IU/L). The patient was evaluated by a trauma surgeon and subsequently underwent ultrasound evaluation (Figure 2) and computed tomography (CT) with intravenous (IV) contrast of the affected arm. Both studies revealed an extensive fluid collection centered in the subcutaneous fat extending from the mid-forearm to the humeral head, consistent with an internal degloving injury.

The patient was taken to the operating room and underwent debridement and resection of the circumferential necrotic skin and subcutaneous tissue in her right arm, and the placement of a skin graft with overlying wound vacuum-assisted closure. During the procedure, a large amount of serosanguinous fluid was drained and cultured, and was found to be sterile. Due to the size of her injury, she underwent two additional episodes of debridement and graft placement over the course of the next 2 weeks.

  

Discussion

First described in the 1850s by the French physician Maurice Morel-Lavallée, Morel-Lavallée lesion is a rare, traumatic, soft-tissue injury.¹ It is an internal degloving injury wherein the skin and subcutaneous tissue have been forcibly separated from the underlying fascia as a result of shear stress. The lymphatic and blood vessels between the layers are also disrupted in this process, resulting in the accumulation of blood and lymphatic fluid as well as subcutaneous debris in the potential space that forms. Excess accumulation over time can compromise blood supply to the overlying skin and cause necrosis.² Morel-Lavallée lesion is missed on initial evaluation in up to one-third of the cases and may have a delay in presentation ranging from hours to months after the inciting injury.³

Morel-Lavallée lesions typically involve the flank, hips, thigh, and prepatellar regions as a result of shear injuries sustained from bicycle falls and motor vehicle accidents.⁴ These lesions are often associated with concomitant acetabular and pelvic fractures.⁵ Involvement of the upper extremities is unusual. Typically, presentation consists of a fluctuant and painful mass underneath the skin which increases over time. The overlying skin may show the mechanism of the original injury, for example, as abrasions after a crush injury. The excessive skin necrosis and hemorrhagic bullae seen in this particular case is a very rare presentation.

 

Differential Diagnosis

The differential diagnosis includes compartment syndrome, coma blisters, a missed fracture, bullous pemphigoid, bullous drug reactions, and linear immunoglobulin A disease. Most of these conditions were easily ruled out in this case as the patient was previously healthy and not on any medications. The lesions in this case could have been confused with coma blisters, which are similar in appearance, self-limiting, and can develop on the extremities. However, coma blisters are classically associated with toxicity from various central nervous system depressants, as well as reduced consciousness from other causes—all of which were readily ruled-out based on the patient’s history. Moreover, the Morel-Lavallée lesion is a degloving injury of the subcutaneous tissue from the fascia underneath, whereas the pathology of coma blisters includes subepidermal bullae formation as well as immunoglobulin and complement deposition.⁶

Diagnostic Imaging

Morel-Lavallée lesion can often be confirmed via several imaging modalities, including  ultrasound, CT, 3D CT, or magnetic resonance imaging (MRI).^3,7 Ultrasound will usually show a well-circumscribed hypoechoic fluid collection with hyperechoic fat globules from the subcutaneous tissue, whereas CT tends to show an encapsulated mass with fluid collection underneath. In MRI, Morel-Lavallée lesion often appears as a hypointense T1-sequence and hyperintense T2-sequence similar to most other fluid collections. There may be variable T1- and T2-intensities with subcutaneous tissues in the fluid collection.²

Management

Despite recognition of this disease entity, controversies still exist regarding management. Case reports have demonstrated a relatively high rate of infected fluid collections depending on the chronicity of the injury.⁸ A recent algorithm to management described by Nickerson et al⁴ proposes that for patients with viable skin, percutaneous aspiration of more than 50 cc of fluid from these lesions should be treated with more extensive operative intervention based on the increased likelihood of recurrence. Patients without viable skin require formal debridement with possible skin grafting.

Other treatment options include conservative management, surgical drainage, sclerodesis, and extensive open surgery.^8-10 Management is always case-based and dependent upon the size of the lesion and associated injuries.

  

Conclusion

This case represents an example of Morel-Lavallée lesions in their most severe and atypical form. It also serves as a reminder that vigilance and knowledge of this disease process is important in helping to diagnose this rare but potentially devastating condition. The key to recognizing this injury lies in keeping this disease process in the differential diagnosis of traumatic injuries with suspicious mechanism involving significant shear forces. Significant physical examination findings may not be present initially and evolve over a time period of hours to days. Once this injury is identified, management hinges on the size of the lesion and affected body part. Despite timely interventions, Morel-Lavallée lesions may result in significant morbidity and functional disability.

  

---

Dr Ye is an emergency medicine resident at the Brown Alpert Medical School in Providence, Rhode Island. Dr Rosenberg is a clinical assistant professor at Brown Alpert Medical School, and an emergency medicine attending physican at Rhode Island Hospital and The Miriam Hospital, Providence, Rhode Island.

ORLANDO – Combining the coronary artery calcium score with the ACC/AHA cardiovascular risk calculator tool enables physicians to refine their decision making about who to recommend for statin therapy, Dr. Salman Waheed reported at the American Heart Association scientific sessions.

He presented an analysis of 1,225 asymptomatic adults followed for a median of 3.9 years in the observational arm of the St. Francis Health Study, an early landmark prospective study of the relationship between electron beam CT coronary artery calcium (CAC) score and cardiovascular event risk.

Bruce Jancin/Frontline Medical News

The 217 subjects who today would not be recommended for statin therapy on the basis of a 10-year atherosclerotic cardiovascular disease risk of 5%-7.4% as determined by the risk calculator included in the 2013 ACC/AHA cholesterol management guidelines (Circulation. 2014 Jun 24;129[25 Suppl 2]:S1-45) would be reclassified as warranting statin therapy if they had a CAC greater than 0, as was the case for 169 of the 217 (78%). Indeed, the presence of a CAC of 1 or more boosted their estimated 10-year risk to 10.8%.

On the other hand, there were 510 patients who would be classified as high risk by the ACC/AHA clinical risk calculator, with a 10-year risk of 7.5%-20%. Taking their CAC score into account would result in 73 being reclassified as low risk and becoming no longer statin candidates because their CAC of 0 was associated with a 10-year event risk of less than 1%. In contrast, for the 447 remaining subjects with a CAC greater than 0, the 10-year risk climbed to 21.9%, according to Dr. Waheed of the University of Kansas, Kansas City.

The composite outcome utilized in this analysis from the St. Francis Heart Study was comprised of nonfatal MI, coronary death, stroke, peripheral arterial revascularization, or coronary revascularization. Of note, heart failure wasn’t included.

Among the 545 subjects deemed at low cardiovascular risk because they weren’t eligible for statin therapy according to the 2013 ACC/AHA guidelines, 209 would be recategorized as high risk on the basis of a CAC score at or above the 80th percentile adjusted for age and gender. The adjusted risk of a cardiovascular event in the high CAC/low clinical risk group was 24.9-fold greater than in the low CAC/low clinical risk group.

“Among those eligible for statin therapy based upon current guidelines, high CAC portends a sixfold higher outcome risk than low CAC,” Dr. Waheed added.

The magnitude of CAC progression over the course of 4 years was similar across the baseline risk categories; however, the absolute CAC progression was greater among those with a high CAC at baseline.

Audience member Dr. Daniel S. Berman observed that the results of Dr. Waheed’s study are highly concordant with an earlier report from the Multi-Ethnic Study of Atherosclerosis in which a CAC of 0 was quite common in patients for whom statins would be recommended under the current ACC/AHA guidelines.

“Your data support the idea that stratification based upon CAC could more personalize the statin recommendations,” said Dr. Berman, chief of cardiac imaging and nuclear cardiology at Cedars-Sinai Medical Center and professor of medicine at the University of California, Los Angeles.

Another audience member, Dr. Donald M. Lloyd-Jones, one of the architects of the current guidelines, commented that the analyses from the St. Francis Heart Study and the Multi-Ethnic Study of Atherosclerosis suggest CAC screening coupled with the ACC/AHA risk score provides added value in a select group of patients.

“Your analysis continues to reinforce the point that we probably shouldn’t be doing universal CAC screening because in the people with a 10-year risk of less than 5% the yield is low and the CAC didn’t change anything, while in the people with a 10-year risk of 20% or higher the yield is incredibly high and the CAC didn’t change anything,” observed Dr. Lloyd-Jones, professor and chair of the department of preventive medicine at Northwestern University, Chicago.

“So CAC really is for those intermediate-risk folks where we’re on the bubble, where we might consider withholding therapy. And I’d love to see a trial to show that’s safe, by the way, but maybe that day will come. But we certainly would be comfortable up-classifying somebody if more CAC is present than there should be,” he added.

Dr. Waheed reported having no financial conflicts regarding his study.

[email protected]

ORLANDO – Combining the coronary artery calcium score with the ACC/AHA cardiovascular risk calculator tool enables physicians to refine their decision making about who to recommend for statin therapy, Dr. Salman Waheed reported at the American Heart Association scientific sessions.

He presented an analysis of 1,225 asymptomatic adults followed for a median of 3.9 years in the observational arm of the St. Francis Health Study, an early landmark prospective study of the relationship between electron beam CT coronary artery calcium (CAC) score and cardiovascular event risk.

Bruce Jancin/Frontline Medical News

The 217 subjects who today would not be recommended for statin therapy on the basis of a 10-year atherosclerotic cardiovascular disease risk of 5%-7.4% as determined by the risk calculator included in the 2013 ACC/AHA cholesterol management guidelines (Circulation. 2014 Jun 24;129[25 Suppl 2]:S1-45) would be reclassified as warranting statin therapy if they had a CAC greater than 0, as was the case for 169 of the 217 (78%). Indeed, the presence of a CAC of 1 or more boosted their estimated 10-year risk to 10.8%.

On the other hand, there were 510 patients who would be classified as high risk by the ACC/AHA clinical risk calculator, with a 10-year risk of 7.5%-20%. Taking their CAC score into account would result in 73 being reclassified as low risk and becoming no longer statin candidates because their CAC of 0 was associated with a 10-year event risk of less than 1%. In contrast, for the 447 remaining subjects with a CAC greater than 0, the 10-year risk climbed to 21.9%, according to Dr. Waheed of the University of Kansas, Kansas City.

The composite outcome utilized in this analysis from the St. Francis Heart Study was comprised of nonfatal MI, coronary death, stroke, peripheral arterial revascularization, or coronary revascularization. Of note, heart failure wasn’t included.

Among the 545 subjects deemed at low cardiovascular risk because they weren’t eligible for statin therapy according to the 2013 ACC/AHA guidelines, 209 would be recategorized as high risk on the basis of a CAC score at or above the 80th percentile adjusted for age and gender. The adjusted risk of a cardiovascular event in the high CAC/low clinical risk group was 24.9-fold greater than in the low CAC/low clinical risk group.

“Among those eligible for statin therapy based upon current guidelines, high CAC portends a sixfold higher outcome risk than low CAC,” Dr. Waheed added.

The magnitude of CAC progression over the course of 4 years was similar across the baseline risk categories; however, the absolute CAC progression was greater among those with a high CAC at baseline.

Audience member Dr. Daniel S. Berman observed that the results of Dr. Waheed’s study are highly concordant with an earlier report from the Multi-Ethnic Study of Atherosclerosis in which a CAC of 0 was quite common in patients for whom statins would be recommended under the current ACC/AHA guidelines.

“Your data support the idea that stratification based upon CAC could more personalize the statin recommendations,” said Dr. Berman, chief of cardiac imaging and nuclear cardiology at Cedars-Sinai Medical Center and professor of medicine at the University of California, Los Angeles.

Another audience member, Dr. Donald M. Lloyd-Jones, one of the architects of the current guidelines, commented that the analyses from the St. Francis Heart Study and the Multi-Ethnic Study of Atherosclerosis suggest CAC screening coupled with the ACC/AHA risk score provides added value in a select group of patients.

“Your analysis continues to reinforce the point that we probably shouldn’t be doing universal CAC screening because in the people with a 10-year risk of less than 5% the yield is low and the CAC didn’t change anything, while in the people with a 10-year risk of 20% or higher the yield is incredibly high and the CAC didn’t change anything,” observed Dr. Lloyd-Jones, professor and chair of the department of preventive medicine at Northwestern University, Chicago.

“So CAC really is for those intermediate-risk folks where we’re on the bubble, where we might consider withholding therapy. And I’d love to see a trial to show that’s safe, by the way, but maybe that day will come. But we certainly would be comfortable up-classifying somebody if more CAC is present than there should be,” he added.

Dr. Waheed reported having no financial conflicts regarding his study.

[email protected]

ORLANDO – Combining the coronary artery calcium score with the ACC/AHA cardiovascular risk calculator tool enables physicians to refine their decision making about who to recommend for statin therapy, Dr. Salman Waheed reported at the American Heart Association scientific sessions.

He presented an analysis of 1,225 asymptomatic adults followed for a median of 3.9 years in the observational arm of the St. Francis Health Study, an early landmark prospective study of the relationship between electron beam CT coronary artery calcium (CAC) score and cardiovascular event risk.

Bruce Jancin/Frontline Medical News

The 217 subjects who today would not be recommended for statin therapy on the basis of a 10-year atherosclerotic cardiovascular disease risk of 5%-7.4% as determined by the risk calculator included in the 2013 ACC/AHA cholesterol management guidelines (Circulation. 2014 Jun 24;129[25 Suppl 2]:S1-45) would be reclassified as warranting statin therapy if they had a CAC greater than 0, as was the case for 169 of the 217 (78%). Indeed, the presence of a CAC of 1 or more boosted their estimated 10-year risk to 10.8%.

On the other hand, there were 510 patients who would be classified as high risk by the ACC/AHA clinical risk calculator, with a 10-year risk of 7.5%-20%. Taking their CAC score into account would result in 73 being reclassified as low risk and becoming no longer statin candidates because their CAC of 0 was associated with a 10-year event risk of less than 1%. In contrast, for the 447 remaining subjects with a CAC greater than 0, the 10-year risk climbed to 21.9%, according to Dr. Waheed of the University of Kansas, Kansas City.

The composite outcome utilized in this analysis from the St. Francis Heart Study was comprised of nonfatal MI, coronary death, stroke, peripheral arterial revascularization, or coronary revascularization. Of note, heart failure wasn’t included.

Among the 545 subjects deemed at low cardiovascular risk because they weren’t eligible for statin therapy according to the 2013 ACC/AHA guidelines, 209 would be recategorized as high risk on the basis of a CAC score at or above the 80th percentile adjusted for age and gender. The adjusted risk of a cardiovascular event in the high CAC/low clinical risk group was 24.9-fold greater than in the low CAC/low clinical risk group.

“Among those eligible for statin therapy based upon current guidelines, high CAC portends a sixfold higher outcome risk than low CAC,” Dr. Waheed added.

The magnitude of CAC progression over the course of 4 years was similar across the baseline risk categories; however, the absolute CAC progression was greater among those with a high CAC at baseline.

Audience member Dr. Daniel S. Berman observed that the results of Dr. Waheed’s study are highly concordant with an earlier report from the Multi-Ethnic Study of Atherosclerosis in which a CAC of 0 was quite common in patients for whom statins would be recommended under the current ACC/AHA guidelines.

“Your data support the idea that stratification based upon CAC could more personalize the statin recommendations,” said Dr. Berman, chief of cardiac imaging and nuclear cardiology at Cedars-Sinai Medical Center and professor of medicine at the University of California, Los Angeles.

Another audience member, Dr. Donald M. Lloyd-Jones, one of the architects of the current guidelines, commented that the analyses from the St. Francis Heart Study and the Multi-Ethnic Study of Atherosclerosis suggest CAC screening coupled with the ACC/AHA risk score provides added value in a select group of patients.

“Your analysis continues to reinforce the point that we probably shouldn’t be doing universal CAC screening because in the people with a 10-year risk of less than 5% the yield is low and the CAC didn’t change anything, while in the people with a 10-year risk of 20% or higher the yield is incredibly high and the CAC didn’t change anything,” observed Dr. Lloyd-Jones, professor and chair of the department of preventive medicine at Northwestern University, Chicago.

“So CAC really is for those intermediate-risk folks where we’re on the bubble, where we might consider withholding therapy. And I’d love to see a trial to show that’s safe, by the way, but maybe that day will come. But we certainly would be comfortable up-classifying somebody if more CAC is present than there should be,” he added.

Dr. Waheed reported having no financial conflicts regarding his study.

[email protected]

ORLANDO – Cases of contrast-induced nephropathy increased dramatically among Medicare patients undergoing percutaneous coronary intervention (PCI) during a recent 5-year period, despite the increased attention that has been drawn to the problem.

“These findings suggest that despite a longstanding focus on preventing CIN [contrast-induced nephropathy], the complication is increasing steadily and new efforts to reduce PCI-related CIN are warranted,” Dr. Phillip P. Brown said at the American Heart Association scientific sessions.

A fresh approach is a priority for Medicare, in part because new-onset renal failure requiring hemodialysis as a result of CIN increases health care costs substantially for the remainder of the patient’s life, noted Dr. Brown of Cardiac Data Solutions in Atlanta.

He presented a retrospective analysis of Medicare data files for 2009-2013. Among 1,552,960 Medicare beneficiaries who underwent PCI without valve surgery or coronary artery bypass graft surgery, 275,471 were admitted for nonelective PCI.

The rate of new hemodialysis as a complication of nonelective PCI increased by 24.8% annually during the study period, climbing to an incidence of 1.15% in 2013. Among patients admitted for elective PCI, the rate of new-onset renal failure requiring hemodialysis essentially doubled from 1% to 2% during the 5-year period.

The rate of new-onset acute renal failure as a complication of nonelective PCI increased by an average of 6.9% annually, reaching 7.67% in 2013. The increase in acute renal failure as a complication of elective PCI was even steeper: an average of 10.6% per year.

In addition to the rising rates of acute renal failure and need for dialysis as a complication of PCI, the proportion of patients who presented with prior dialysis or acute renal failure at admission for the procedure also rose year by year. In 2013, acute renal failure was present at admission in 6.12% of patients undergoing elective and 7.02% having nonelective PCI. Prior dialysis at admission was present in 2.61% and 0.94%, respectively.

Dr. Brown reported having no financial conflicts regarding this descriptive study.

[email protected]

ORLANDO – Cases of contrast-induced nephropathy increased dramatically among Medicare patients undergoing percutaneous coronary intervention (PCI) during a recent 5-year period, despite the increased attention that has been drawn to the problem.

“These findings suggest that despite a longstanding focus on preventing CIN [contrast-induced nephropathy], the complication is increasing steadily and new efforts to reduce PCI-related CIN are warranted,” Dr. Phillip P. Brown said at the American Heart Association scientific sessions.

A fresh approach is a priority for Medicare, in part because new-onset renal failure requiring hemodialysis as a result of CIN increases health care costs substantially for the remainder of the patient’s life, noted Dr. Brown of Cardiac Data Solutions in Atlanta.

He presented a retrospective analysis of Medicare data files for 2009-2013. Among 1,552,960 Medicare beneficiaries who underwent PCI without valve surgery or coronary artery bypass graft surgery, 275,471 were admitted for nonelective PCI.

The rate of new hemodialysis as a complication of nonelective PCI increased by 24.8% annually during the study period, climbing to an incidence of 1.15% in 2013. Among patients admitted for elective PCI, the rate of new-onset renal failure requiring hemodialysis essentially doubled from 1% to 2% during the 5-year period.

The rate of new-onset acute renal failure as a complication of nonelective PCI increased by an average of 6.9% annually, reaching 7.67% in 2013. The increase in acute renal failure as a complication of elective PCI was even steeper: an average of 10.6% per year.

In addition to the rising rates of acute renal failure and need for dialysis as a complication of PCI, the proportion of patients who presented with prior dialysis or acute renal failure at admission for the procedure also rose year by year. In 2013, acute renal failure was present at admission in 6.12% of patients undergoing elective and 7.02% having nonelective PCI. Prior dialysis at admission was present in 2.61% and 0.94%, respectively.

Dr. Brown reported having no financial conflicts regarding this descriptive study.

[email protected]

ORLANDO – Cases of contrast-induced nephropathy increased dramatically among Medicare patients undergoing percutaneous coronary intervention (PCI) during a recent 5-year period, despite the increased attention that has been drawn to the problem.

“These findings suggest that despite a longstanding focus on preventing CIN [contrast-induced nephropathy], the complication is increasing steadily and new efforts to reduce PCI-related CIN are warranted,” Dr. Phillip P. Brown said at the American Heart Association scientific sessions.

A fresh approach is a priority for Medicare, in part because new-onset renal failure requiring hemodialysis as a result of CIN increases health care costs substantially for the remainder of the patient’s life, noted Dr. Brown of Cardiac Data Solutions in Atlanta.

He presented a retrospective analysis of Medicare data files for 2009-2013. Among 1,552,960 Medicare beneficiaries who underwent PCI without valve surgery or coronary artery bypass graft surgery, 275,471 were admitted for nonelective PCI.

The rate of new hemodialysis as a complication of nonelective PCI increased by 24.8% annually during the study period, climbing to an incidence of 1.15% in 2013. Among patients admitted for elective PCI, the rate of new-onset renal failure requiring hemodialysis essentially doubled from 1% to 2% during the 5-year period.

The rate of new-onset acute renal failure as a complication of nonelective PCI increased by an average of 6.9% annually, reaching 7.67% in 2013. The increase in acute renal failure as a complication of elective PCI was even steeper: an average of 10.6% per year.

In addition to the rising rates of acute renal failure and need for dialysis as a complication of PCI, the proportion of patients who presented with prior dialysis or acute renal failure at admission for the procedure also rose year by year. In 2013, acute renal failure was present at admission in 6.12% of patients undergoing elective and 7.02% having nonelective PCI. Prior dialysis at admission was present in 2.61% and 0.94%, respectively.

Dr. Brown reported having no financial conflicts regarding this descriptive study.

[email protected]

SAN DIEGO – Contrast agents administered through the coronary vessels for invasive angiography led to significantly more kidney damage than contrast agents administered intravenously for coronary computed tomography angiography, according to a randomized study.

In the Coronary Artery Disease-Management (CAD-Man) study, contrast-induced kidney injury was two to three times more likely after intracoronary than after intravenous contrast administration, explained study investigators Dr. Eva Schönenberger and Dr. Marc Dewey of Charité Medical University, Berlin.

Contrast agents used to detect and treat blockages in coronary arteries are known to damage the kidneys in 2%-20% of patients. In the United States, about 4 million doses of contrast are administered directly into the coronary vessels during invasive catheterization, and 40 million into superficial veins, said Dr. Dewey, Heisenberg Professor of Radiology at the German Research Foundation and vice chair of the department of radiology at Charité.

That makes contrast administration a significant clinical decision for physicians, he added, not just because of potential for harm, but also the potential for added costs.

CAD-Man included 326 patients with suspected coronary disease. Researchers randomized 161 patients to intracoronary contrast agent (ICA) for invasive coronary angiography and 165 patients to IV contrast agent for coronary computed tomography angiography (CTA). All patients received the same contrast agent.

Blood samples were taken at baseline before the procedure, and at two time points after: between 18 and 24 hours, and between 46 and 50 hours. Baseline creatinine levels were similar in the two groups. The researchers defined contrast-associated nephrotoxicity as an increase in creatinine of at least 0.5 mg/dL, or 25%.

At follow-up, 21 of 158 ICA patients (13%) and 9 of 160 CTA patients (6%) had contrast-associated nephropathy, a significant difference (P less than .05). In patients without coronary disease, 13% of ICA patients and 4% of CTA patients developed contrast-associated nephropathy, also a significant difference (P less than .05).

Catheter administration concentrates more contrast in the heart and above the kidneys than intravenous administration, Dr. Schönenberger explained at the meeting sponsored by the American Society of Nephrology. Thus, the increased kidney damage in invasive-angiography patients may be due to higher dosages of contrast in their kidneys.

Physicians “have to keep in mind that putting contrast agents directly into the coronaries might produce more of an increase of creatinine, and more acute kidney injury, than just giving it through an IV,” explained Dr. Schönenberger, a nephrologist in the department of anesthesiology and operative intensive care medicine at Charité.

Physicians should take this information into consideration when deciding how to administer contrast for patients suspected of having coronary artery disease, Dr. Dewey noted. “In addition to being noninvasive, cardiac CT may thus also have the advantage of reducing kidney risk.”

Cost should be a big concern as well. Dr. Dewey referred to published literature indicating that contrast-induced kidney injury can lead to “longer hospital and intensive care unit stays, [increased] dialysis, cost of adverse events, and higher mortality rates. The in-hospital cost was $10,000 per contrast-induced acute kidney injury, and the 1-year cost of treatment was more than $11,000.”

Because CAD-Man’s last patient was enrolled in mid-September, the data are still being analyzed, Dr. Schönenberger noted. Therefore, some confounders may be discovered that influenced the results.

For example, cardiologists may select their sicker patients for invasive procedures in order to be ready to insert stents, so there may not be as much flexibility in which approach to use.

Also unclear is the amount of contrast used for each patient in each arm of this study. Some physicians may have used more contrast for patients suspected of having disease that was harder to detect, although that part of the analysis remains under review, Dr. Dewey and Dr. Schönenberger said.

It remains unclear whether the nephrotoxicity found in the invasive angiography group was all due to the contrast, Dr. Schönenberger noted, or whether some of it might have been caused by small particles of hardened cholesterol spreading to blood vessels in the kidneys – a process known as atheroembolic renal disease. That, too, is under review.

The contrast agent used in the study, low-osmolar nonionic Xenetix 350, is used in 96 countries but is not approved by the U.S. Food and Drug Administration, Dr. Schönenberger said. However, it is very similar to those agents that are in use in the United States, she added.

The study was funded by the German Research Foundation through the Heisenberg Professorship Program. The researchers reported no financial disclosures.

SAN DIEGO – Contrast agents administered through the coronary vessels for invasive angiography led to significantly more kidney damage than contrast agents administered intravenously for coronary computed tomography angiography, according to a randomized study.

In the Coronary Artery Disease-Management (CAD-Man) study, contrast-induced kidney injury was two to three times more likely after intracoronary than after intravenous contrast administration, explained study investigators Dr. Eva Schönenberger and Dr. Marc Dewey of Charité Medical University, Berlin.

Contrast agents used to detect and treat blockages in coronary arteries are known to damage the kidneys in 2%-20% of patients. In the United States, about 4 million doses of contrast are administered directly into the coronary vessels during invasive catheterization, and 40 million into superficial veins, said Dr. Dewey, Heisenberg Professor of Radiology at the German Research Foundation and vice chair of the department of radiology at Charité.

That makes contrast administration a significant clinical decision for physicians, he added, not just because of potential for harm, but also the potential for added costs.

CAD-Man included 326 patients with suspected coronary disease. Researchers randomized 161 patients to intracoronary contrast agent (ICA) for invasive coronary angiography and 165 patients to IV contrast agent for coronary computed tomography angiography (CTA). All patients received the same contrast agent.

Blood samples were taken at baseline before the procedure, and at two time points after: between 18 and 24 hours, and between 46 and 50 hours. Baseline creatinine levels were similar in the two groups. The researchers defined contrast-associated nephrotoxicity as an increase in creatinine of at least 0.5 mg/dL, or 25%.

At follow-up, 21 of 158 ICA patients (13%) and 9 of 160 CTA patients (6%) had contrast-associated nephropathy, a significant difference (P less than .05). In patients without coronary disease, 13% of ICA patients and 4% of CTA patients developed contrast-associated nephropathy, also a significant difference (P less than .05).

Catheter administration concentrates more contrast in the heart and above the kidneys than intravenous administration, Dr. Schönenberger explained at the meeting sponsored by the American Society of Nephrology. Thus, the increased kidney damage in invasive-angiography patients may be due to higher dosages of contrast in their kidneys.

Physicians “have to keep in mind that putting contrast agents directly into the coronaries might produce more of an increase of creatinine, and more acute kidney injury, than just giving it through an IV,” explained Dr. Schönenberger, a nephrologist in the department of anesthesiology and operative intensive care medicine at Charité.

Physicians should take this information into consideration when deciding how to administer contrast for patients suspected of having coronary artery disease, Dr. Dewey noted. “In addition to being noninvasive, cardiac CT may thus also have the advantage of reducing kidney risk.”

Cost should be a big concern as well. Dr. Dewey referred to published literature indicating that contrast-induced kidney injury can lead to “longer hospital and intensive care unit stays, [increased] dialysis, cost of adverse events, and higher mortality rates. The in-hospital cost was $10,000 per contrast-induced acute kidney injury, and the 1-year cost of treatment was more than $11,000.”

Because CAD-Man’s last patient was enrolled in mid-September, the data are still being analyzed, Dr. Schönenberger noted. Therefore, some confounders may be discovered that influenced the results.

For example, cardiologists may select their sicker patients for invasive procedures in order to be ready to insert stents, so there may not be as much flexibility in which approach to use.

Also unclear is the amount of contrast used for each patient in each arm of this study. Some physicians may have used more contrast for patients suspected of having disease that was harder to detect, although that part of the analysis remains under review, Dr. Dewey and Dr. Schönenberger said.

It remains unclear whether the nephrotoxicity found in the invasive angiography group was all due to the contrast, Dr. Schönenberger noted, or whether some of it might have been caused by small particles of hardened cholesterol spreading to blood vessels in the kidneys – a process known as atheroembolic renal disease. That, too, is under review.

The contrast agent used in the study, low-osmolar nonionic Xenetix 350, is used in 96 countries but is not approved by the U.S. Food and Drug Administration, Dr. Schönenberger said. However, it is very similar to those agents that are in use in the United States, she added.

The study was funded by the German Research Foundation through the Heisenberg Professorship Program. The researchers reported no financial disclosures.

SAN DIEGO – Contrast agents administered through the coronary vessels for invasive angiography led to significantly more kidney damage than contrast agents administered intravenously for coronary computed tomography angiography, according to a randomized study.

In the Coronary Artery Disease-Management (CAD-Man) study, contrast-induced kidney injury was two to three times more likely after intracoronary than after intravenous contrast administration, explained study investigators Dr. Eva Schönenberger and Dr. Marc Dewey of Charité Medical University, Berlin.

Contrast agents used to detect and treat blockages in coronary arteries are known to damage the kidneys in 2%-20% of patients. In the United States, about 4 million doses of contrast are administered directly into the coronary vessels during invasive catheterization, and 40 million into superficial veins, said Dr. Dewey, Heisenberg Professor of Radiology at the German Research Foundation and vice chair of the department of radiology at Charité.

That makes contrast administration a significant clinical decision for physicians, he added, not just because of potential for harm, but also the potential for added costs.

CAD-Man included 326 patients with suspected coronary disease. Researchers randomized 161 patients to intracoronary contrast agent (ICA) for invasive coronary angiography and 165 patients to IV contrast agent for coronary computed tomography angiography (CTA). All patients received the same contrast agent.

Blood samples were taken at baseline before the procedure, and at two time points after: between 18 and 24 hours, and between 46 and 50 hours. Baseline creatinine levels were similar in the two groups. The researchers defined contrast-associated nephrotoxicity as an increase in creatinine of at least 0.5 mg/dL, or 25%.

At follow-up, 21 of 158 ICA patients (13%) and 9 of 160 CTA patients (6%) had contrast-associated nephropathy, a significant difference (P less than .05). In patients without coronary disease, 13% of ICA patients and 4% of CTA patients developed contrast-associated nephropathy, also a significant difference (P less than .05).

Catheter administration concentrates more contrast in the heart and above the kidneys than intravenous administration, Dr. Schönenberger explained at the meeting sponsored by the American Society of Nephrology. Thus, the increased kidney damage in invasive-angiography patients may be due to higher dosages of contrast in their kidneys.

Physicians “have to keep in mind that putting contrast agents directly into the coronaries might produce more of an increase of creatinine, and more acute kidney injury, than just giving it through an IV,” explained Dr. Schönenberger, a nephrologist in the department of anesthesiology and operative intensive care medicine at Charité.

Physicians should take this information into consideration when deciding how to administer contrast for patients suspected of having coronary artery disease, Dr. Dewey noted. “In addition to being noninvasive, cardiac CT may thus also have the advantage of reducing kidney risk.”

Cost should be a big concern as well. Dr. Dewey referred to published literature indicating that contrast-induced kidney injury can lead to “longer hospital and intensive care unit stays, [increased] dialysis, cost of adverse events, and higher mortality rates. The in-hospital cost was $10,000 per contrast-induced acute kidney injury, and the 1-year cost of treatment was more than $11,000.”

Because CAD-Man’s last patient was enrolled in mid-September, the data are still being analyzed, Dr. Schönenberger noted. Therefore, some confounders may be discovered that influenced the results.

For example, cardiologists may select their sicker patients for invasive procedures in order to be ready to insert stents, so there may not be as much flexibility in which approach to use.

Also unclear is the amount of contrast used for each patient in each arm of this study. Some physicians may have used more contrast for patients suspected of having disease that was harder to detect, although that part of the analysis remains under review, Dr. Dewey and Dr. Schönenberger said.

It remains unclear whether the nephrotoxicity found in the invasive angiography group was all due to the contrast, Dr. Schönenberger noted, or whether some of it might have been caused by small particles of hardened cholesterol spreading to blood vessels in the kidneys – a process known as atheroembolic renal disease. That, too, is under review.

The contrast agent used in the study, low-osmolar nonionic Xenetix 350, is used in 96 countries but is not approved by the U.S. Food and Drug Administration, Dr. Schönenberger said. However, it is very similar to those agents that are in use in the United States, she added.

The study was funded by the German Research Foundation through the Heisenberg Professorship Program. The researchers reported no financial disclosures.