Imaging

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.

MONTREAL – Some of the sickest patients treated at U.S. hospitals receive high levels of radiation exposure, based on a review of more than 4,000 medical ICU patients treated recently at one U.S. quaternary-care center.

During 2013, 98 patients admitted to the medical ICU at the Cleveland Clinic – 2% of the 4,155 patients who passed through the medical ICU that year – had cumulative radiation exposure of at least 50 mSv while in the ICU, thereby exceeding the U.S. standard for maximum annual workplace exposure, Dr. Sudhir Krishnan said at the annual meeting of the American College of Chest Physicians. The finding raises questions of whether all these exposures are appropriate and whether they reflect overuse of certain imaging modalities.

Mitchel L. Zoler/Frontline Medical News

Dr. Krishnan and his associates ran a retrospective review of case records for the medical ICU–admitted patients at the Cleveland Clinic during 2013 (Chest. 2015 Oct 25. doi: 10.1378/chest.2278486). During their ICU stay, 3,490 patients (84%) received some amount of radiation exposure. Exposure averaged 7 mSv, with a median of 1.5 mSv. The radiation exposure came primarily from imaging and more specifically from CT examinations, which produced more than half of all radiation-exposure episodes. Other sources included x-rays, nuclear scans, and interventional procedures.

Based on typical radiation dosages received during each type of procedure, the researchers calculated an estimated total radiation dosage received by each patient during their ICU stay. Nearly two-thirds of patients had an exposure of less than 3 mSv, the average annual exposure a person receives from ambient radiation. A quarter of the patients had an exposure of 3-14 mSv, 11% had an exposure of 15-49 mSv, and 2% – 98 patients – had exposure during their ICU stay that ran to 50 mSv or greater, exceeding the U.S. workplace annual maximum . Thirteen patients had an exposure level during their ICU stay that reached 100 mSv or higher; the maximum exposure level was in a patient with cumulative exposure of 176 mSv, said Dr. Krishnan, a critical-care medicine specialist at the Cleveland Clinic.

He and his coworkers did a multivariate analysis to identify factors that linked with a higher likelihood of having high radiation exposure. Patients at greatest risk for high exposure levels were sicker patients with higher APACHE 3 scores, longer stays in the ICU, and the presence of cirrhosis, but those most at risk also tended to be younger. Rates of both ICU deaths and deaths during the entire hospitalization were significantly higher among those with radiation exposure that was 50 mSv or greater.

Dr. Krishnan cautioned that he has not run any analysis that assessed the appropriateness of the imaging that the ICU patients received, nor did he have any data documenting the clinical consequences to the patients who had higher radiation exposure. Despite that uncertainty, he suggested that efforts focus on avoiding unnecessary radiation exposure to patients.

[email protected]

On Twitter @mitchelzoler

MONTREAL – Some of the sickest patients treated at U.S. hospitals receive high levels of radiation exposure, based on a review of more than 4,000 medical ICU patients treated recently at one U.S. quaternary-care center.

During 2013, 98 patients admitted to the medical ICU at the Cleveland Clinic – 2% of the 4,155 patients who passed through the medical ICU that year – had cumulative radiation exposure of at least 50 mSv while in the ICU, thereby exceeding the U.S. standard for maximum annual workplace exposure, Dr. Sudhir Krishnan said at the annual meeting of the American College of Chest Physicians. The finding raises questions of whether all these exposures are appropriate and whether they reflect overuse of certain imaging modalities.

Mitchel L. Zoler/Frontline Medical News

Dr. Krishnan and his associates ran a retrospective review of case records for the medical ICU–admitted patients at the Cleveland Clinic during 2013 (Chest. 2015 Oct 25. doi: 10.1378/chest.2278486). During their ICU stay, 3,490 patients (84%) received some amount of radiation exposure. Exposure averaged 7 mSv, with a median of 1.5 mSv. The radiation exposure came primarily from imaging and more specifically from CT examinations, which produced more than half of all radiation-exposure episodes. Other sources included x-rays, nuclear scans, and interventional procedures.

Based on typical radiation dosages received during each type of procedure, the researchers calculated an estimated total radiation dosage received by each patient during their ICU stay. Nearly two-thirds of patients had an exposure of less than 3 mSv, the average annual exposure a person receives from ambient radiation. A quarter of the patients had an exposure of 3-14 mSv, 11% had an exposure of 15-49 mSv, and 2% – 98 patients – had exposure during their ICU stay that ran to 50 mSv or greater, exceeding the U.S. workplace annual maximum . Thirteen patients had an exposure level during their ICU stay that reached 100 mSv or higher; the maximum exposure level was in a patient with cumulative exposure of 176 mSv, said Dr. Krishnan, a critical-care medicine specialist at the Cleveland Clinic.

He and his coworkers did a multivariate analysis to identify factors that linked with a higher likelihood of having high radiation exposure. Patients at greatest risk for high exposure levels were sicker patients with higher APACHE 3 scores, longer stays in the ICU, and the presence of cirrhosis, but those most at risk also tended to be younger. Rates of both ICU deaths and deaths during the entire hospitalization were significantly higher among those with radiation exposure that was 50 mSv or greater.

Dr. Krishnan cautioned that he has not run any analysis that assessed the appropriateness of the imaging that the ICU patients received, nor did he have any data documenting the clinical consequences to the patients who had higher radiation exposure. Despite that uncertainty, he suggested that efforts focus on avoiding unnecessary radiation exposure to patients.

[email protected]

On Twitter @mitchelzoler

MONTREAL – Some of the sickest patients treated at U.S. hospitals receive high levels of radiation exposure, based on a review of more than 4,000 medical ICU patients treated recently at one U.S. quaternary-care center.

During 2013, 98 patients admitted to the medical ICU at the Cleveland Clinic – 2% of the 4,155 patients who passed through the medical ICU that year – had cumulative radiation exposure of at least 50 mSv while in the ICU, thereby exceeding the U.S. standard for maximum annual workplace exposure, Dr. Sudhir Krishnan said at the annual meeting of the American College of Chest Physicians. The finding raises questions of whether all these exposures are appropriate and whether they reflect overuse of certain imaging modalities.

Mitchel L. Zoler/Frontline Medical News

Dr. Krishnan and his associates ran a retrospective review of case records for the medical ICU–admitted patients at the Cleveland Clinic during 2013 (Chest. 2015 Oct 25. doi: 10.1378/chest.2278486). During their ICU stay, 3,490 patients (84%) received some amount of radiation exposure. Exposure averaged 7 mSv, with a median of 1.5 mSv. The radiation exposure came primarily from imaging and more specifically from CT examinations, which produced more than half of all radiation-exposure episodes. Other sources included x-rays, nuclear scans, and interventional procedures.

Based on typical radiation dosages received during each type of procedure, the researchers calculated an estimated total radiation dosage received by each patient during their ICU stay. Nearly two-thirds of patients had an exposure of less than 3 mSv, the average annual exposure a person receives from ambient radiation. A quarter of the patients had an exposure of 3-14 mSv, 11% had an exposure of 15-49 mSv, and 2% – 98 patients – had exposure during their ICU stay that ran to 50 mSv or greater, exceeding the U.S. workplace annual maximum . Thirteen patients had an exposure level during their ICU stay that reached 100 mSv or higher; the maximum exposure level was in a patient with cumulative exposure of 176 mSv, said Dr. Krishnan, a critical-care medicine specialist at the Cleveland Clinic.

He and his coworkers did a multivariate analysis to identify factors that linked with a higher likelihood of having high radiation exposure. Patients at greatest risk for high exposure levels were sicker patients with higher APACHE 3 scores, longer stays in the ICU, and the presence of cirrhosis, but those most at risk also tended to be younger. Rates of both ICU deaths and deaths during the entire hospitalization were significantly higher among those with radiation exposure that was 50 mSv or greater.

Dr. Krishnan cautioned that he has not run any analysis that assessed the appropriateness of the imaging that the ICU patients received, nor did he have any data documenting the clinical consequences to the patients who had higher radiation exposure. Despite that uncertainty, he suggested that efforts focus on avoiding unnecessary radiation exposure to patients.

[email protected]

On Twitter @mitchelzoler

Case

A 36-year-old woman with a 2-week history of left flank pain presented to the ED via emergency medical services. The patient, who had a history of nephrolithiasis, assumed her pain was due to another kidney stone. She stated that while waiting for the presumed stone to pass, the pain in her left flank worsened and she felt lightheaded and weak.

The patient’s vital signs at presentation were: heart rate, 96 beats/minute; blood pressure, 133/76 mm Hg; respiratory rate, 20 breaths/minute; and temperature, 98.9˚F. Oxygen saturation was 98% on room air. On physical examination, the patient had left lower quadrant pain and left costovertebral angle tenderness. Laboratory studies were remarkable for a negative urine pregnancy test, a hemoglobin level of 6.8 g/dL, and a hematocrit of 21.1%. Based on the patient’s history and symptoms, axial and coronal computed tomography (CT) scans were ordered, revealing a ruptured left renal calyx with hemorrhage from ureterolithiasis (Figures 1a and 1b).

Rupture of renal calyx and extravasation of blood or urine is a potential complication of nephrolithiasis. Stone size, degree of obstruction, and length of symptomatic presentation presumably contribute to complications from nephrolithiasis. Stones that are symptomatic for more than 4 weeks are estimated to have an increased complication rate of up to 20%.¹

Calyx or fornix rupture results from increased intraluminal pressure. Rupture of these structures is thought to be a type of “safety-valve” function to relieve obstructive uropathy.²

Obstructions from small leaks to large urinomas can cause extravasation of urine. In most cases, urinary extravasation is confined to the subcapsular space or perirenal space within the Gerota’s fascia;³ however, as seen in this patient, mixed hematoma/urinomas can form.

Causes

In cases of nontraumatic calyx rupture, the cause of the obstruction is most often a distal obstructing ureteral stone.⁴ Other causes of rupture include extrinsic compression from malignant and benign masses, ureteric junction obstructions, or iatrogenic causes.⁴ Interestingly, in one small study, the median size of the obstructing stone was only 4 mm. The same study also noted that proximal ureteral obstruction occurred when larger stones where present.⁴

Conservative Versus Nonconservative Management

Potential complications of urinomas include abscess formation, sepsis, hydronephrosis, and paralytic ileus.³ Despite possible adverse sequelae, uncomplicated urinomas may be managed conservatively with supportive care. According to a study by Chapman et al,⁵ about 40% of patients managed conservatively recover without complications. In addition, in a retrospective study by Doehn et al⁶ involving 160 cases of fornix rupture treated with endoscopic therapy or nephrostomy tube supplemented with antibiotics, no instances of perinephric abscess or other complications requiring a second procedure were noted.

Management of suspected ureterolithiasis in the ED is focused on analgesia and supportive care. Acute analgesia is often provided parenterally with opioids alone or with an opioid/nonsteroidal anti-inflammatory drug (NSAID) combination.⁷ Frequent reassessment of the patient is required to ensure adequate pain control and to prevent sedation. Other symptoms, such as nausea, vomiting, and dehydration, may be treated with intravenous (IV) fluids and antiemetic medications. Further radiographic evaluation is needed once analgesia is achieved.^7,8

Imaging Studies

Radiological evaluation of patients with suspected ureterolithiasis may involve several imaging modalities. Noncontrast helical CT scan is the standard for rapid and efficient identification of ureteral stones while allowing visualization of other potential pathology (eg, urinoma).^7-9 Other modalities, such as ultrasonography; radiography of the kidneys, ureters, and bladder; and an IV pyelogram with contrasted CT, may be ordered if noncontrast helical CT scan is not available on-site or if there are comorbidities. In addition to imaging studies, basic laboratory studies (eg, serum creatinine and blood urea nitrogen testing) are indicated to assess overall renal function and direct the choice of radiological study.⁷

Disposition

Clinical decision-making is key when recommending inpatient versus outpatient treatment in patients with ureterolithiasis. Patients with uncontrolled pain or vomiting may require inpatient admission for supportive care, while those demonstrating acute renal failure, pyuria with bacteriuria, complete bilateral ureteral obstruction, urinoma, or signs of sepsis demand emergent urology consultation. Specifically, patients with urinoma require ureteroscopy versus nephrostomy^6,10 to allow drainage while carefully monitoring for development of subsequent bleeding and infection.

When discharging patients from the ED, expulsive therapy using tamsulosin⁹ and analgesia with combination of oral opioids and NSAIDs are most commonly effective.¹¹ Outpatient urology referrals are recommended for ureteral stones greater than 5 mm in size or if the stones have been present in the ureter for greater than 4 weeks.¹ Proper evaluation and management of ureterolithiasis in the ED is crucial for positive outcomes and to reduce long-term complications.

Case Conclusion

Computed tomography revealed a ruptured renal calyx on the left side with free fluid in the abdomen. Urology services were consulted and the patient was taken to the operating room for cystoscopy, ureteral stent placement, and laser lithotripsy. Following surgery, she subsequently developed urosepsis for which she was successfully treated with IV antibiotics and discharged on hospital day 15.

Mr Eisenstat is a fourth-year medical student at the University of South Carolina School of Medicine, Greenville. Dr Fabiano is an emergency physician, department of emergency medicine, Greenville Health Systems, Greenville, South Carolina. Dr Collins is family medicine physician, department of emergency medicine, Greenville Health Systems, Greenville, South Carolina.

Case

A 36-year-old woman with a 2-week history of left flank pain presented to the ED via emergency medical services. The patient, who had a history of nephrolithiasis, assumed her pain was due to another kidney stone. She stated that while waiting for the presumed stone to pass, the pain in her left flank worsened and she felt lightheaded and weak.

The patient’s vital signs at presentation were: heart rate, 96 beats/minute; blood pressure, 133/76 mm Hg; respiratory rate, 20 breaths/minute; and temperature, 98.9˚F. Oxygen saturation was 98% on room air. On physical examination, the patient had left lower quadrant pain and left costovertebral angle tenderness. Laboratory studies were remarkable for a negative urine pregnancy test, a hemoglobin level of 6.8 g/dL, and a hematocrit of 21.1%. Based on the patient’s history and symptoms, axial and coronal computed tomography (CT) scans were ordered, revealing a ruptured left renal calyx with hemorrhage from ureterolithiasis (Figures 1a and 1b).

Rupture of renal calyx and extravasation of blood or urine is a potential complication of nephrolithiasis. Stone size, degree of obstruction, and length of symptomatic presentation presumably contribute to complications from nephrolithiasis. Stones that are symptomatic for more than 4 weeks are estimated to have an increased complication rate of up to 20%.¹

Calyx or fornix rupture results from increased intraluminal pressure. Rupture of these structures is thought to be a type of “safety-valve” function to relieve obstructive uropathy.²

Obstructions from small leaks to large urinomas can cause extravasation of urine. In most cases, urinary extravasation is confined to the subcapsular space or perirenal space within the Gerota’s fascia;³ however, as seen in this patient, mixed hematoma/urinomas can form.

Causes

In cases of nontraumatic calyx rupture, the cause of the obstruction is most often a distal obstructing ureteral stone.⁴ Other causes of rupture include extrinsic compression from malignant and benign masses, ureteric junction obstructions, or iatrogenic causes.⁴ Interestingly, in one small study, the median size of the obstructing stone was only 4 mm. The same study also noted that proximal ureteral obstruction occurred when larger stones where present.⁴

Conservative Versus Nonconservative Management

Potential complications of urinomas include abscess formation, sepsis, hydronephrosis, and paralytic ileus.³ Despite possible adverse sequelae, uncomplicated urinomas may be managed conservatively with supportive care. According to a study by Chapman et al,⁵ about 40% of patients managed conservatively recover without complications. In addition, in a retrospective study by Doehn et al⁶ involving 160 cases of fornix rupture treated with endoscopic therapy or nephrostomy tube supplemented with antibiotics, no instances of perinephric abscess or other complications requiring a second procedure were noted.

Management of suspected ureterolithiasis in the ED is focused on analgesia and supportive care. Acute analgesia is often provided parenterally with opioids alone or with an opioid/nonsteroidal anti-inflammatory drug (NSAID) combination.⁷ Frequent reassessment of the patient is required to ensure adequate pain control and to prevent sedation. Other symptoms, such as nausea, vomiting, and dehydration, may be treated with intravenous (IV) fluids and antiemetic medications. Further radiographic evaluation is needed once analgesia is achieved.^7,8

Imaging Studies

Radiological evaluation of patients with suspected ureterolithiasis may involve several imaging modalities. Noncontrast helical CT scan is the standard for rapid and efficient identification of ureteral stones while allowing visualization of other potential pathology (eg, urinoma).^7-9 Other modalities, such as ultrasonography; radiography of the kidneys, ureters, and bladder; and an IV pyelogram with contrasted CT, may be ordered if noncontrast helical CT scan is not available on-site or if there are comorbidities. In addition to imaging studies, basic laboratory studies (eg, serum creatinine and blood urea nitrogen testing) are indicated to assess overall renal function and direct the choice of radiological study.⁷

Disposition

Clinical decision-making is key when recommending inpatient versus outpatient treatment in patients with ureterolithiasis. Patients with uncontrolled pain or vomiting may require inpatient admission for supportive care, while those demonstrating acute renal failure, pyuria with bacteriuria, complete bilateral ureteral obstruction, urinoma, or signs of sepsis demand emergent urology consultation. Specifically, patients with urinoma require ureteroscopy versus nephrostomy^6,10 to allow drainage while carefully monitoring for development of subsequent bleeding and infection.

When discharging patients from the ED, expulsive therapy using tamsulosin⁹ and analgesia with combination of oral opioids and NSAIDs are most commonly effective.¹¹ Outpatient urology referrals are recommended for ureteral stones greater than 5 mm in size or if the stones have been present in the ureter for greater than 4 weeks.¹ Proper evaluation and management of ureterolithiasis in the ED is crucial for positive outcomes and to reduce long-term complications.

Case Conclusion

Computed tomography revealed a ruptured renal calyx on the left side with free fluid in the abdomen. Urology services were consulted and the patient was taken to the operating room for cystoscopy, ureteral stent placement, and laser lithotripsy. Following surgery, she subsequently developed urosepsis for which she was successfully treated with IV antibiotics and discharged on hospital day 15.

Mr Eisenstat is a fourth-year medical student at the University of South Carolina School of Medicine, Greenville. Dr Fabiano is an emergency physician, department of emergency medicine, Greenville Health Systems, Greenville, South Carolina. Dr Collins is family medicine physician, department of emergency medicine, Greenville Health Systems, Greenville, South Carolina.

Case

A 36-year-old woman with a 2-week history of left flank pain presented to the ED via emergency medical services. The patient, who had a history of nephrolithiasis, assumed her pain was due to another kidney stone. She stated that while waiting for the presumed stone to pass, the pain in her left flank worsened and she felt lightheaded and weak.

The patient’s vital signs at presentation were: heart rate, 96 beats/minute; blood pressure, 133/76 mm Hg; respiratory rate, 20 breaths/minute; and temperature, 98.9˚F. Oxygen saturation was 98% on room air. On physical examination, the patient had left lower quadrant pain and left costovertebral angle tenderness. Laboratory studies were remarkable for a negative urine pregnancy test, a hemoglobin level of 6.8 g/dL, and a hematocrit of 21.1%. Based on the patient’s history and symptoms, axial and coronal computed tomography (CT) scans were ordered, revealing a ruptured left renal calyx with hemorrhage from ureterolithiasis (Figures 1a and 1b).

Rupture of renal calyx and extravasation of blood or urine is a potential complication of nephrolithiasis. Stone size, degree of obstruction, and length of symptomatic presentation presumably contribute to complications from nephrolithiasis. Stones that are symptomatic for more than 4 weeks are estimated to have an increased complication rate of up to 20%.¹

Calyx or fornix rupture results from increased intraluminal pressure. Rupture of these structures is thought to be a type of “safety-valve” function to relieve obstructive uropathy.²

Obstructions from small leaks to large urinomas can cause extravasation of urine. In most cases, urinary extravasation is confined to the subcapsular space or perirenal space within the Gerota’s fascia;³ however, as seen in this patient, mixed hematoma/urinomas can form.

Causes

In cases of nontraumatic calyx rupture, the cause of the obstruction is most often a distal obstructing ureteral stone.⁴ Other causes of rupture include extrinsic compression from malignant and benign masses, ureteric junction obstructions, or iatrogenic causes.⁴ Interestingly, in one small study, the median size of the obstructing stone was only 4 mm. The same study also noted that proximal ureteral obstruction occurred when larger stones where present.⁴

Conservative Versus Nonconservative Management

Potential complications of urinomas include abscess formation, sepsis, hydronephrosis, and paralytic ileus.³ Despite possible adverse sequelae, uncomplicated urinomas may be managed conservatively with supportive care. According to a study by Chapman et al,⁵ about 40% of patients managed conservatively recover without complications. In addition, in a retrospective study by Doehn et al⁶ involving 160 cases of fornix rupture treated with endoscopic therapy or nephrostomy tube supplemented with antibiotics, no instances of perinephric abscess or other complications requiring a second procedure were noted.

Management of suspected ureterolithiasis in the ED is focused on analgesia and supportive care. Acute analgesia is often provided parenterally with opioids alone or with an opioid/nonsteroidal anti-inflammatory drug (NSAID) combination.⁷ Frequent reassessment of the patient is required to ensure adequate pain control and to prevent sedation. Other symptoms, such as nausea, vomiting, and dehydration, may be treated with intravenous (IV) fluids and antiemetic medications. Further radiographic evaluation is needed once analgesia is achieved.^7,8

Imaging Studies

Radiological evaluation of patients with suspected ureterolithiasis may involve several imaging modalities. Noncontrast helical CT scan is the standard for rapid and efficient identification of ureteral stones while allowing visualization of other potential pathology (eg, urinoma).^7-9 Other modalities, such as ultrasonography; radiography of the kidneys, ureters, and bladder; and an IV pyelogram with contrasted CT, may be ordered if noncontrast helical CT scan is not available on-site or if there are comorbidities. In addition to imaging studies, basic laboratory studies (eg, serum creatinine and blood urea nitrogen testing) are indicated to assess overall renal function and direct the choice of radiological study.⁷

Disposition

Clinical decision-making is key when recommending inpatient versus outpatient treatment in patients with ureterolithiasis. Patients with uncontrolled pain or vomiting may require inpatient admission for supportive care, while those demonstrating acute renal failure, pyuria with bacteriuria, complete bilateral ureteral obstruction, urinoma, or signs of sepsis demand emergent urology consultation. Specifically, patients with urinoma require ureteroscopy versus nephrostomy^6,10 to allow drainage while carefully monitoring for development of subsequent bleeding and infection.

When discharging patients from the ED, expulsive therapy using tamsulosin⁹ and analgesia with combination of oral opioids and NSAIDs are most commonly effective.¹¹ Outpatient urology referrals are recommended for ureteral stones greater than 5 mm in size or if the stones have been present in the ureter for greater than 4 weeks.¹ Proper evaluation and management of ureterolithiasis in the ED is crucial for positive outcomes and to reduce long-term complications.

Case Conclusion

Computed tomography revealed a ruptured renal calyx on the left side with free fluid in the abdomen. Urology services were consulted and the patient was taken to the operating room for cystoscopy, ureteral stent placement, and laser lithotripsy. Following surgery, she subsequently developed urosepsis for which she was successfully treated with IV antibiotics and discharged on hospital day 15.

Mr Eisenstat is a fourth-year medical student at the University of South Carolina School of Medicine, Greenville. Dr Fabiano is an emergency physician, department of emergency medicine, Greenville Health Systems, Greenville, South Carolina. Dr Collins is family medicine physician, department of emergency medicine, Greenville Health Systems, Greenville, South Carolina.

30-year-old woman with a history of alcoholism and anxiety presented to the ED for evaluation of abdominal distension and pain. She reported new social stressors at home and increased alcohol consumption. She also noted gradually increasing abdominal distension over the past several weeks. As patient’s liver function tests were elevated, supine radiographs of the abdomen were acquired for further evaluation; a representative image is presented below (Figure 1a).

What is the suspected diagnosis?
Is any additional imaging required?

Answer

Centralization of bowel is suggestive of abdominopelvic ascites.¹ Additional radiographic findings that may be seen with ascites include diffusely increased density of the abdomen and bulging of the peritoneal fat stripes/flanks. In the average adult, a minimum of approximately 800 mL of ascitic fluid is required to medially displace bowel loops or abdominal viscera.² While there are many causes of ascites, the radiograph in this case suggests the underlying etiology of cirrhosis. Although the top of the liver is not visualized on the radiograph, the liver contour appears enlarged (red arrow, Figure 1b).

In the ED, ultrasound is the imaging modality of choice to confirm the presence of ascites as it is widely available, quick, relatively inexpensive, and does not require ionizing radiation. Ultrasound is also useful when examining the abdominal viscera since it may detect the underlying cause of ascites.³ The ultrasound image of the abdominal viscera in this case demonstrated a hypoechoic (dark) signal (red arrow, Figure 1c) between the abdominal wall (red asterisk, Figure 1c) and bowel loops (letter ‘B,” Figure 1c). This finding confirmed the presence of ascites because simple fluid does not reflect the ultrasound beam, but instead results in the hypoechoic signal seen in Figure 1c. An additional sonographic image confirmed the presence of an enlarged liver (white asterisk, Figure 1d) and ascites in the right upper quadrant (red arrow, Figure 1d).

The patient was admitted for further workup and treatment of alcoholic cirrhosis. A

Dr Lyons is a resident in the department of radiology at New York Presbyterian Hospital/Weill Cornell Medical College in New York City. Dr Wladyka is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology at Weill Cornell Medical College in New York City. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology at New York-

30-year-old woman with a history of alcoholism and anxiety presented to the ED for evaluation of abdominal distension and pain. She reported new social stressors at home and increased alcohol consumption. She also noted gradually increasing abdominal distension over the past several weeks. As patient’s liver function tests were elevated, supine radiographs of the abdomen were acquired for further evaluation; a representative image is presented below (Figure 1a).

What is the suspected diagnosis?
Is any additional imaging required?

Answer

Centralization of bowel is suggestive of abdominopelvic ascites.¹ Additional radiographic findings that may be seen with ascites include diffusely increased density of the abdomen and bulging of the peritoneal fat stripes/flanks. In the average adult, a minimum of approximately 800 mL of ascitic fluid is required to medially displace bowel loops or abdominal viscera.² While there are many causes of ascites, the radiograph in this case suggests the underlying etiology of cirrhosis. Although the top of the liver is not visualized on the radiograph, the liver contour appears enlarged (red arrow, Figure 1b).

In the ED, ultrasound is the imaging modality of choice to confirm the presence of ascites as it is widely available, quick, relatively inexpensive, and does not require ionizing radiation. Ultrasound is also useful when examining the abdominal viscera since it may detect the underlying cause of ascites.³ The ultrasound image of the abdominal viscera in this case demonstrated a hypoechoic (dark) signal (red arrow, Figure 1c) between the abdominal wall (red asterisk, Figure 1c) and bowel loops (letter ‘B,” Figure 1c). This finding confirmed the presence of ascites because simple fluid does not reflect the ultrasound beam, but instead results in the hypoechoic signal seen in Figure 1c. An additional sonographic image confirmed the presence of an enlarged liver (white asterisk, Figure 1d) and ascites in the right upper quadrant (red arrow, Figure 1d).

The patient was admitted for further workup and treatment of alcoholic cirrhosis. A

Dr Lyons is a resident in the department of radiology at New York Presbyterian Hospital/Weill Cornell Medical College in New York City. Dr Wladyka is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology at Weill Cornell Medical College in New York City. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology at New York-

30-year-old woman with a history of alcoholism and anxiety presented to the ED for evaluation of abdominal distension and pain. She reported new social stressors at home and increased alcohol consumption. She also noted gradually increasing abdominal distension over the past several weeks. As patient’s liver function tests were elevated, supine radiographs of the abdomen were acquired for further evaluation; a representative image is presented below (Figure 1a).

What is the suspected diagnosis?
Is any additional imaging required?

Answer

Centralization of bowel is suggestive of abdominopelvic ascites.¹ Additional radiographic findings that may be seen with ascites include diffusely increased density of the abdomen and bulging of the peritoneal fat stripes/flanks. In the average adult, a minimum of approximately 800 mL of ascitic fluid is required to medially displace bowel loops or abdominal viscera.² While there are many causes of ascites, the radiograph in this case suggests the underlying etiology of cirrhosis. Although the top of the liver is not visualized on the radiograph, the liver contour appears enlarged (red arrow, Figure 1b).

In the ED, ultrasound is the imaging modality of choice to confirm the presence of ascites as it is widely available, quick, relatively inexpensive, and does not require ionizing radiation. Ultrasound is also useful when examining the abdominal viscera since it may detect the underlying cause of ascites.³ The ultrasound image of the abdominal viscera in this case demonstrated a hypoechoic (dark) signal (red arrow, Figure 1c) between the abdominal wall (red asterisk, Figure 1c) and bowel loops (letter ‘B,” Figure 1c). This finding confirmed the presence of ascites because simple fluid does not reflect the ultrasound beam, but instead results in the hypoechoic signal seen in Figure 1c. An additional sonographic image confirmed the presence of an enlarged liver (white asterisk, Figure 1d) and ascites in the right upper quadrant (red arrow, Figure 1d).

The patient was admitted for further workup and treatment of alcoholic cirrhosis. A

Dr Lyons is a resident in the department of radiology at New York Presbyterian Hospital/Weill Cornell Medical College in New York City. Dr Wladyka is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology at Weill Cornell Medical College in New York City. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology at New York-

Reverse total shoulder arthroplasty (RTSA) performed in carefully selected patients often leads to satisfactory outcomes.^1,2 In recent years, its indications and the number performed per year have expanded. Subsequently, there has been a concomitant rise in reported complications,^2,3 with a rate ranging from 19% to 68%.^2,3 Some common complications include scapular notching,^2-4 fracture,^2,3,5-7 dislocation,^2,3,7 and infection.^2,3,7

In this series, we describe 2 cases of coracoid fracture after RTSA. The patients provided written informed consent for print and electronic publication of these case reports.

Case Series

Case 1

An independently functioning 81-year-old right hand–dominant woman (BMI, 22.1 [height, 160 cm; weight, 56.7 kg]) presented with increasing left shoulder pain and dysfunction after a motor vehicle accident 2 months earlier. She had reported vague chronic left shoulder pain in the past, but after the accident her pain was significantly worse. A subacromial corticosteroid injection by her primary care physician provided temporary symptomatic relief, but her symptoms recurred.

On presentation, there was obvious anterior superior escape of the humeral head, which was accentuated by shoulder shrug. Her deltoid motor function was found to be intact, and her active shoulder range of motion was severely limited (pseudoparesis). There was notable crepitation as well as significant weakness and pain with abduction and external rotation strength testing.

Radiographic imaging showed anterior superior escape of the humeral head with some early degenerative changes (Seebauer type IIB⁸ [Figure 1A]). Magnetic resonance imaging confirmed a full-thickness retracted massive rotator cuff tear with complete involvement of the supraspinatus, infraspinatus, and most of the subscapularis muscles. Significant glenohumeral degenerative changes consistent with cuff tear arthropathy were also seen without any evidence of fracture.

After thorough discussion of options, risks, and benefits, the decision was made to proceed with RTSA. The patient underwent the procedure without complications. A DePuy Delta Xtend prosthesis was used with a cemented humeral stem, polyethylene, and glenosphere, sizes of 12, +3, and 38, respectively. The glenosphere component, positioned inferiorly to avoid scapular notching, was secured with 3 screws, and the stem was placed in neutral version. The patient’s shoulder was reduced, ranged, and noted to be stable, allowing for supple passive range of motion without evidence of excessive tightness. She was placed in a sling with the shoulder positioned in neutral alignment. Her postoperative radiograph (Figure 1B) showed satisfactory implantation of the reverse total shoulder prosthesis. Her postoperative course was uneventful, and rehabilitation consisted of 6 weeks of sling protection, with advancing passive and active range of motion. Strengthening exercises were initiated 6 weeks after surgery.

At the patient’s 6-week postoperative visit, she demonstrated pain-free passive elevation to 80° and active forward elevation to 70°. At her 3-month postoperative visit, she reported a 1-week onset of anterior shoulder pain accompanied by a strange noise at the anterior aspect of the operative shoulder. She denied any recent trauma. She continued to have minimal shoulder pain with passive forward flexion of 80°; however, her active forward elevation was very limited because of pain in the anterior aspect of her shoulder. Active external rotation was noted to be 20° and internal rotation was to her buttock. She had pain to palpation of the coracoid process. Radiographs were unchanged from immediate postoperative radiographs. Computed tomography (CT), which was ordered to ensure that the implant was stable with no loosening, showed satisfactory alignment of the prosthesis and no loosening. However, CT was notable for a nondisplaced fracture through the base of the coracoid (Figures 2A-2D). The patient stopped formal physical therapy, and sling immobilization was initiated. After 3 weeks, the sling was discontinued and physical therapy was begun again. She responded satisfactorily to this treatment approach, and, at her 6-month postoperative follow-up, she was without pain, instability, or crepitation. Her range of motion had improved with pain-free active forward flexion, external rotation, and abduction of 100°, 15°, and 90°, respectively. At 28-month postoperative follow-up, her visual analog scale, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score were 3, 73, and 67, respectively. 

Case 2

A 68-year-old, right-handed woman (BMI, 22.5 [height, 160 cm; weight, 57.6 kg]) presented with right shoulder pain and dysfunction of 3 years’ duration. She had undergone an open rotator cuff repair at an outside facility 4 years ago that was unsuccessful. At the time of her presentation to our institution, she had already undergone a failed course of physical therapy. A trial of corticosteroid subacromial injections did not adequately manage her symptoms.

On presentation, her active forward flexion, abduction, and external rotation were 40°, 30°, and 10°, respectively. She had full passive range of motion and pain with active and passive shoulder motion. Radiographic imaging showed superior migration of the humeral head with evidence of glenohumeral arthropathy suggestive of rotator cuff arthropathy (Seebauer type IIA⁸). After thorough discussion of options, risks, and benefits, the decision was made to proceed with RTSA. She underwent the procedure without complications. A DePuy Delta Xtend prosthesis was used with a cemented humeral stem, polyethylene, and glenosphere, sizes of 8, +3, and 38, respectively. The glenosphere component, positioned inferiorly to avoid scapular notching, was secured with 4 screws, and the stem was placed in neutral version. Her shoulder was reduced, ranged, and noted to be stable, allowing for supple passive range of motion without evidence of excessive tightness. She was placed in a sling with the shoulder positioned in neutral alignment. Her postoperative radiographs revealed satisfactory implantation of the reverse total shoulder prosthesis. Her postoperative course was uneventful. She was taken out of her shoulder immobilizer 4 weeks after surgery and began home-based physical therapy.

At 1 year after surgery, the patient had minimal shoulder pain with active forward flexion, external rotation, and abduction of 135°, 20°, and 85°, respectively. She presented to our clinic 15 months after RTSA with acute onset of pain about her anterior shoulder. She denied any recent trauma or infectious exposures. On examination, her motion was unchanged from prior examinations. However, she was tender on palpation of the coracoid. Radiographs at that time were unchanged (Figures 3A, 3B). Laboratory tests (erythrocyte sedimentation rate, C-reactive protein, and complete blood count with differential) that were subsequently ordered to rule out an occult infection were within normal limits. Computed tomography, which was ordered for further assessment and to ensure that the implant was stable with no loosening, showed satisfactory alignment of the prosthesis without loosening. However, a lucency was noted in the midportion of the coracoid that was suggestive of a fracture (Figures 4A, 4B). A conservative plan of treatment was advised with sling immobilization for 3 weeks and follow-up visits. The patient responded satisfactorily to this treatment approach, and, at her latest follow-up, 8 months after presenting with a coracoid fracture, she was pain-free. At the 5-year postoperative follow-up, her visual analog scale, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score were 1-2, 78, and 75, respectively. 

Discussion

The reverse prosthesis, a semi-constrained ball-and-socket device, provides satisfactory functional outcomes when used in carefully selected patients with rotator cuff arthropathy and pseudoparalysis, failed shoulder arthroplasty, and fracture sequelae.^1,9-11 By the traditional Grammont principles of medializing the center of rotation and lowering the humerus, shear forces about the glenoid are reduced and the deltoid muscle is tensioned, allowing for adequate torque generation, required to facilitate shoulder motion.^12,13 While long-term outcomes  concerning durability and survivorship are pending, some studies have attempted to improve our understanding of implant and functional longevity. Guery and colleagues¹⁴ noted an implant survival of 91% at 120 months. However, increased pain and decreased function were seen at the 6-year mark.¹⁴ A more recent study by Cuff and colleagues¹⁵ revealed 94% implant survivorship and sustained improvement in range of motion and pain at 5 years. 

Despite considerable success, RTSA can be associated with a myriad of complications. The most common complications of RTSA include scapular notching (44%-96%), glenoid side failure (5%-40%), instability (2.4%-31%), and infection (1%-15.3%).^2,3 In the setting of inflammatory arthropathy, there is an increased risk for intraoperative and postoperative fractures.^16,17 To date, there are only 2 reported cases of coracoid process fractures after RTSA.^18,19 In the case by Nolan and colleagues,¹⁸ conservative management with a sling for 6 weeks led to successful resolution of symptoms. Although little information is provided on the management of these rare fractures, literature on the slightly more common scapular (0.9%-7.2%) and acromial (0.9%-4.9%) fractures suggest that periscapular fractures are on the rise, may increase the risk for revision surgery, and can lead to inferior outcomes when compared with patients without fractures.^5,20,21

Acromial fractures after RTSA have been reported to occur at a rate of 0.9% to 4.9%.^5,21 This is a concern because of RTSA reliance on a functional deltoid.^5,6 The cause of these fractures remains to be fully elucidated. Wahlquist and colleagues⁶ in 2011 reported the cases of 5 patients that sustained acromial base fractures after RTSA. All 5 patients were noted to have unsatisfactory functional results despite achieving union (3 were treated with open reduction and internal fixation, and 2 were treated nonoperatively). Acromial fractures tend to present with pain within 6 months of surgery, which may indicate excessive constraint about the scapula, eventually leading to fracture. Furthermore, disruption of this bony structure can lead to devastating results because the acromial base serves as a fulcrum for the deltoid.

Despite a well-placed reverse prosthesis, there is increased reliance on surrounding glenohumeral musculature, resulting from poor rotator cuff function and biomechanical differences compared with a native shoulder. Both our patients were found to have relatively small body habitus. It is possible that, by nature of their smaller statures, they were more susceptible to consequences of excessive joint and soft-tissue tension after RTSA. One explanation for acromial fractures after RTSA is that, by excessively lengthening and/or lateralizing the deltoid, the tension on the acromion in these elderly patients may be sufficient to cause a fracture. A similar mechanism may explain their coracoid fractures. As the arm is lengthened and the prosthesis is tightened, the conjoint tendon is significantly tensioned. We routinely check the tension of these muscles as an extra confirmation of joint stability. However, excessive tension for a significant duration may provide too much stress for bone turnover to match with the inherent repair process, potentially causing a fracture. Recent evidence has also found that bone mineral density of the coracoid diminishes with age, suggesting some predisposition to fracture with lower-energy mechanisms.²²

Another possible cause for coracoid fractures may be the orientation of the implants. While we did not have mechanistic evidence, it is possible that, with adduction and internal rotation, prosthetic impingement against the coracoid is feasible, particularly in patients of small stature. Although a glenoid implant placed high can increase the chance for coracoid–implant impingement, the fact that the patients improved without revision makes chronic mechanical impingement less likely. Drill holes, especially multiple ones, placed throughout the base of the coracoid may also predispose to coracoid fractures.

Patients with periscapular fractures (acromion, scapular spine, or coracoid) after RTSA often present with pain and occasional deficits in function. Both patients in this series noted pain out of proportion to examination. The onset of this pain differed, with 1 patient noting pain within the first 3 months and 1 noting discomfort later. Neither patient had any trauma. In the presence of significant symptoms, negative radiographs, and a poor response to conservative treatment, we recommend advanced imaging to rule out fracture. However, prior to obtaining advanced imaging, proper radiographic techniques should be utilized. Eyres and colleagues,²³ in a series of 12 fractures of the coracoid process, relied primarily on coracoid views directed 45° in a cephalic direction and thin-slice CT. An isotope bone scan identified 1 case not initially found on radiographs.²³

Conservative management with use of a sling until resolution of symptoms was successful in our series. If symptoms persist, a bone stimulator can be used prior to implementing a surgical solution; however, current evidence does not expound on timing and utility of such modalities. Perhaps as important as treatment is education of the patient and the rehabilitation team about the importance of identifying increasing pain as a potential sign of impending fracture in this population. Subsequent activity modification until the pain resolves can help avoid the setback in postoperative recovery that this complication may cause.

Conclusion

We present 2 patients with coracoid fractures encountered at 3 months and 15 months after RTSA. Nonoperative management proved adequate in treating both cases. We suggest a high level of suspicion for possible fracture in the patient who comes in with new-onset pain in a localized region with or without functional deficits.

Reverse total shoulder arthroplasty (RTSA) performed in carefully selected patients often leads to satisfactory outcomes.^1,2 In recent years, its indications and the number performed per year have expanded. Subsequently, there has been a concomitant rise in reported complications,^2,3 with a rate ranging from 19% to 68%.^2,3 Some common complications include scapular notching,^2-4 fracture,^2,3,5-7 dislocation,^2,3,7 and infection.^2,3,7

In this series, we describe 2 cases of coracoid fracture after RTSA. The patients provided written informed consent for print and electronic publication of these case reports.

Case Series

Case 1

An independently functioning 81-year-old right hand–dominant woman (BMI, 22.1 [height, 160 cm; weight, 56.7 kg]) presented with increasing left shoulder pain and dysfunction after a motor vehicle accident 2 months earlier. She had reported vague chronic left shoulder pain in the past, but after the accident her pain was significantly worse. A subacromial corticosteroid injection by her primary care physician provided temporary symptomatic relief, but her symptoms recurred.

On presentation, there was obvious anterior superior escape of the humeral head, which was accentuated by shoulder shrug. Her deltoid motor function was found to be intact, and her active shoulder range of motion was severely limited (pseudoparesis). There was notable crepitation as well as significant weakness and pain with abduction and external rotation strength testing.

Radiographic imaging showed anterior superior escape of the humeral head with some early degenerative changes (Seebauer type IIB⁸ [Figure 1A]). Magnetic resonance imaging confirmed a full-thickness retracted massive rotator cuff tear with complete involvement of the supraspinatus, infraspinatus, and most of the subscapularis muscles. Significant glenohumeral degenerative changes consistent with cuff tear arthropathy were also seen without any evidence of fracture.

After thorough discussion of options, risks, and benefits, the decision was made to proceed with RTSA. The patient underwent the procedure without complications. A DePuy Delta Xtend prosthesis was used with a cemented humeral stem, polyethylene, and glenosphere, sizes of 12, +3, and 38, respectively. The glenosphere component, positioned inferiorly to avoid scapular notching, was secured with 3 screws, and the stem was placed in neutral version. The patient’s shoulder was reduced, ranged, and noted to be stable, allowing for supple passive range of motion without evidence of excessive tightness. She was placed in a sling with the shoulder positioned in neutral alignment. Her postoperative radiograph (Figure 1B) showed satisfactory implantation of the reverse total shoulder prosthesis. Her postoperative course was uneventful, and rehabilitation consisted of 6 weeks of sling protection, with advancing passive and active range of motion. Strengthening exercises were initiated 6 weeks after surgery.

At the patient’s 6-week postoperative visit, she demonstrated pain-free passive elevation to 80° and active forward elevation to 70°. At her 3-month postoperative visit, she reported a 1-week onset of anterior shoulder pain accompanied by a strange noise at the anterior aspect of the operative shoulder. She denied any recent trauma. She continued to have minimal shoulder pain with passive forward flexion of 80°; however, her active forward elevation was very limited because of pain in the anterior aspect of her shoulder. Active external rotation was noted to be 20° and internal rotation was to her buttock. She had pain to palpation of the coracoid process. Radiographs were unchanged from immediate postoperative radiographs. Computed tomography (CT), which was ordered to ensure that the implant was stable with no loosening, showed satisfactory alignment of the prosthesis and no loosening. However, CT was notable for a nondisplaced fracture through the base of the coracoid (Figures 2A-2D). The patient stopped formal physical therapy, and sling immobilization was initiated. After 3 weeks, the sling was discontinued and physical therapy was begun again. She responded satisfactorily to this treatment approach, and, at her 6-month postoperative follow-up, she was without pain, instability, or crepitation. Her range of motion had improved with pain-free active forward flexion, external rotation, and abduction of 100°, 15°, and 90°, respectively. At 28-month postoperative follow-up, her visual analog scale, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score were 3, 73, and 67, respectively. 

Case 2

A 68-year-old, right-handed woman (BMI, 22.5 [height, 160 cm; weight, 57.6 kg]) presented with right shoulder pain and dysfunction of 3 years’ duration. She had undergone an open rotator cuff repair at an outside facility 4 years ago that was unsuccessful. At the time of her presentation to our institution, she had already undergone a failed course of physical therapy. A trial of corticosteroid subacromial injections did not adequately manage her symptoms.

On presentation, her active forward flexion, abduction, and external rotation were 40°, 30°, and 10°, respectively. She had full passive range of motion and pain with active and passive shoulder motion. Radiographic imaging showed superior migration of the humeral head with evidence of glenohumeral arthropathy suggestive of rotator cuff arthropathy (Seebauer type IIA⁸). After thorough discussion of options, risks, and benefits, the decision was made to proceed with RTSA. She underwent the procedure without complications. A DePuy Delta Xtend prosthesis was used with a cemented humeral stem, polyethylene, and glenosphere, sizes of 8, +3, and 38, respectively. The glenosphere component, positioned inferiorly to avoid scapular notching, was secured with 4 screws, and the stem was placed in neutral version. Her shoulder was reduced, ranged, and noted to be stable, allowing for supple passive range of motion without evidence of excessive tightness. She was placed in a sling with the shoulder positioned in neutral alignment. Her postoperative radiographs revealed satisfactory implantation of the reverse total shoulder prosthesis. Her postoperative course was uneventful. She was taken out of her shoulder immobilizer 4 weeks after surgery and began home-based physical therapy.

At 1 year after surgery, the patient had minimal shoulder pain with active forward flexion, external rotation, and abduction of 135°, 20°, and 85°, respectively. She presented to our clinic 15 months after RTSA with acute onset of pain about her anterior shoulder. She denied any recent trauma or infectious exposures. On examination, her motion was unchanged from prior examinations. However, she was tender on palpation of the coracoid. Radiographs at that time were unchanged (Figures 3A, 3B). Laboratory tests (erythrocyte sedimentation rate, C-reactive protein, and complete blood count with differential) that were subsequently ordered to rule out an occult infection were within normal limits. Computed tomography, which was ordered for further assessment and to ensure that the implant was stable with no loosening, showed satisfactory alignment of the prosthesis without loosening. However, a lucency was noted in the midportion of the coracoid that was suggestive of a fracture (Figures 4A, 4B). A conservative plan of treatment was advised with sling immobilization for 3 weeks and follow-up visits. The patient responded satisfactorily to this treatment approach, and, at her latest follow-up, 8 months after presenting with a coracoid fracture, she was pain-free. At the 5-year postoperative follow-up, her visual analog scale, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score were 1-2, 78, and 75, respectively. 

Discussion

The reverse prosthesis, a semi-constrained ball-and-socket device, provides satisfactory functional outcomes when used in carefully selected patients with rotator cuff arthropathy and pseudoparalysis, failed shoulder arthroplasty, and fracture sequelae.^1,9-11 By the traditional Grammont principles of medializing the center of rotation and lowering the humerus, shear forces about the glenoid are reduced and the deltoid muscle is tensioned, allowing for adequate torque generation, required to facilitate shoulder motion.^12,13 While long-term outcomes  concerning durability and survivorship are pending, some studies have attempted to improve our understanding of implant and functional longevity. Guery and colleagues¹⁴ noted an implant survival of 91% at 120 months. However, increased pain and decreased function were seen at the 6-year mark.¹⁴ A more recent study by Cuff and colleagues¹⁵ revealed 94% implant survivorship and sustained improvement in range of motion and pain at 5 years. 

Despite considerable success, RTSA can be associated with a myriad of complications. The most common complications of RTSA include scapular notching (44%-96%), glenoid side failure (5%-40%), instability (2.4%-31%), and infection (1%-15.3%).^2,3 In the setting of inflammatory arthropathy, there is an increased risk for intraoperative and postoperative fractures.^16,17 To date, there are only 2 reported cases of coracoid process fractures after RTSA.^18,19 In the case by Nolan and colleagues,¹⁸ conservative management with a sling for 6 weeks led to successful resolution of symptoms. Although little information is provided on the management of these rare fractures, literature on the slightly more common scapular (0.9%-7.2%) and acromial (0.9%-4.9%) fractures suggest that periscapular fractures are on the rise, may increase the risk for revision surgery, and can lead to inferior outcomes when compared with patients without fractures.^5,20,21

Acromial fractures after RTSA have been reported to occur at a rate of 0.9% to 4.9%.^5,21 This is a concern because of RTSA reliance on a functional deltoid.^5,6 The cause of these fractures remains to be fully elucidated. Wahlquist and colleagues⁶ in 2011 reported the cases of 5 patients that sustained acromial base fractures after RTSA. All 5 patients were noted to have unsatisfactory functional results despite achieving union (3 were treated with open reduction and internal fixation, and 2 were treated nonoperatively). Acromial fractures tend to present with pain within 6 months of surgery, which may indicate excessive constraint about the scapula, eventually leading to fracture. Furthermore, disruption of this bony structure can lead to devastating results because the acromial base serves as a fulcrum for the deltoid.

Despite a well-placed reverse prosthesis, there is increased reliance on surrounding glenohumeral musculature, resulting from poor rotator cuff function and biomechanical differences compared with a native shoulder. Both our patients were found to have relatively small body habitus. It is possible that, by nature of their smaller statures, they were more susceptible to consequences of excessive joint and soft-tissue tension after RTSA. One explanation for acromial fractures after RTSA is that, by excessively lengthening and/or lateralizing the deltoid, the tension on the acromion in these elderly patients may be sufficient to cause a fracture. A similar mechanism may explain their coracoid fractures. As the arm is lengthened and the prosthesis is tightened, the conjoint tendon is significantly tensioned. We routinely check the tension of these muscles as an extra confirmation of joint stability. However, excessive tension for a significant duration may provide too much stress for bone turnover to match with the inherent repair process, potentially causing a fracture. Recent evidence has also found that bone mineral density of the coracoid diminishes with age, suggesting some predisposition to fracture with lower-energy mechanisms.²²

Another possible cause for coracoid fractures may be the orientation of the implants. While we did not have mechanistic evidence, it is possible that, with adduction and internal rotation, prosthetic impingement against the coracoid is feasible, particularly in patients of small stature. Although a glenoid implant placed high can increase the chance for coracoid–implant impingement, the fact that the patients improved without revision makes chronic mechanical impingement less likely. Drill holes, especially multiple ones, placed throughout the base of the coracoid may also predispose to coracoid fractures.

Patients with periscapular fractures (acromion, scapular spine, or coracoid) after RTSA often present with pain and occasional deficits in function. Both patients in this series noted pain out of proportion to examination. The onset of this pain differed, with 1 patient noting pain within the first 3 months and 1 noting discomfort later. Neither patient had any trauma. In the presence of significant symptoms, negative radiographs, and a poor response to conservative treatment, we recommend advanced imaging to rule out fracture. However, prior to obtaining advanced imaging, proper radiographic techniques should be utilized. Eyres and colleagues,²³ in a series of 12 fractures of the coracoid process, relied primarily on coracoid views directed 45° in a cephalic direction and thin-slice CT. An isotope bone scan identified 1 case not initially found on radiographs.²³

Conservative management with use of a sling until resolution of symptoms was successful in our series. If symptoms persist, a bone stimulator can be used prior to implementing a surgical solution; however, current evidence does not expound on timing and utility of such modalities. Perhaps as important as treatment is education of the patient and the rehabilitation team about the importance of identifying increasing pain as a potential sign of impending fracture in this population. Subsequent activity modification until the pain resolves can help avoid the setback in postoperative recovery that this complication may cause.

Conclusion

We present 2 patients with coracoid fractures encountered at 3 months and 15 months after RTSA. Nonoperative management proved adequate in treating both cases. We suggest a high level of suspicion for possible fracture in the patient who comes in with new-onset pain in a localized region with or without functional deficits.

Reverse total shoulder arthroplasty (RTSA) performed in carefully selected patients often leads to satisfactory outcomes.^1,2 In recent years, its indications and the number performed per year have expanded. Subsequently, there has been a concomitant rise in reported complications,^2,3 with a rate ranging from 19% to 68%.^2,3 Some common complications include scapular notching,^2-4 fracture,^2,3,5-7 dislocation,^2,3,7 and infection.^2,3,7

In this series, we describe 2 cases of coracoid fracture after RTSA. The patients provided written informed consent for print and electronic publication of these case reports.

Case Series

Case 1

An independently functioning 81-year-old right hand–dominant woman (BMI, 22.1 [height, 160 cm; weight, 56.7 kg]) presented with increasing left shoulder pain and dysfunction after a motor vehicle accident 2 months earlier. She had reported vague chronic left shoulder pain in the past, but after the accident her pain was significantly worse. A subacromial corticosteroid injection by her primary care physician provided temporary symptomatic relief, but her symptoms recurred.

On presentation, there was obvious anterior superior escape of the humeral head, which was accentuated by shoulder shrug. Her deltoid motor function was found to be intact, and her active shoulder range of motion was severely limited (pseudoparesis). There was notable crepitation as well as significant weakness and pain with abduction and external rotation strength testing.

Radiographic imaging showed anterior superior escape of the humeral head with some early degenerative changes (Seebauer type IIB⁸ [Figure 1A]). Magnetic resonance imaging confirmed a full-thickness retracted massive rotator cuff tear with complete involvement of the supraspinatus, infraspinatus, and most of the subscapularis muscles. Significant glenohumeral degenerative changes consistent with cuff tear arthropathy were also seen without any evidence of fracture.

After thorough discussion of options, risks, and benefits, the decision was made to proceed with RTSA. The patient underwent the procedure without complications. A DePuy Delta Xtend prosthesis was used with a cemented humeral stem, polyethylene, and glenosphere, sizes of 12, +3, and 38, respectively. The glenosphere component, positioned inferiorly to avoid scapular notching, was secured with 3 screws, and the stem was placed in neutral version. The patient’s shoulder was reduced, ranged, and noted to be stable, allowing for supple passive range of motion without evidence of excessive tightness. She was placed in a sling with the shoulder positioned in neutral alignment. Her postoperative radiograph (Figure 1B) showed satisfactory implantation of the reverse total shoulder prosthesis. Her postoperative course was uneventful, and rehabilitation consisted of 6 weeks of sling protection, with advancing passive and active range of motion. Strengthening exercises were initiated 6 weeks after surgery.

At the patient’s 6-week postoperative visit, she demonstrated pain-free passive elevation to 80° and active forward elevation to 70°. At her 3-month postoperative visit, she reported a 1-week onset of anterior shoulder pain accompanied by a strange noise at the anterior aspect of the operative shoulder. She denied any recent trauma. She continued to have minimal shoulder pain with passive forward flexion of 80°; however, her active forward elevation was very limited because of pain in the anterior aspect of her shoulder. Active external rotation was noted to be 20° and internal rotation was to her buttock. She had pain to palpation of the coracoid process. Radiographs were unchanged from immediate postoperative radiographs. Computed tomography (CT), which was ordered to ensure that the implant was stable with no loosening, showed satisfactory alignment of the prosthesis and no loosening. However, CT was notable for a nondisplaced fracture through the base of the coracoid (Figures 2A-2D). The patient stopped formal physical therapy, and sling immobilization was initiated. After 3 weeks, the sling was discontinued and physical therapy was begun again. She responded satisfactorily to this treatment approach, and, at her 6-month postoperative follow-up, she was without pain, instability, or crepitation. Her range of motion had improved with pain-free active forward flexion, external rotation, and abduction of 100°, 15°, and 90°, respectively. At 28-month postoperative follow-up, her visual analog scale, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score were 3, 73, and 67, respectively. 

Case 2

A 68-year-old, right-handed woman (BMI, 22.5 [height, 160 cm; weight, 57.6 kg]) presented with right shoulder pain and dysfunction of 3 years’ duration. She had undergone an open rotator cuff repair at an outside facility 4 years ago that was unsuccessful. At the time of her presentation to our institution, she had already undergone a failed course of physical therapy. A trial of corticosteroid subacromial injections did not adequately manage her symptoms.

On presentation, her active forward flexion, abduction, and external rotation were 40°, 30°, and 10°, respectively. She had full passive range of motion and pain with active and passive shoulder motion. Radiographic imaging showed superior migration of the humeral head with evidence of glenohumeral arthropathy suggestive of rotator cuff arthropathy (Seebauer type IIA⁸). After thorough discussion of options, risks, and benefits, the decision was made to proceed with RTSA. She underwent the procedure without complications. A DePuy Delta Xtend prosthesis was used with a cemented humeral stem, polyethylene, and glenosphere, sizes of 8, +3, and 38, respectively. The glenosphere component, positioned inferiorly to avoid scapular notching, was secured with 4 screws, and the stem was placed in neutral version. Her shoulder was reduced, ranged, and noted to be stable, allowing for supple passive range of motion without evidence of excessive tightness. She was placed in a sling with the shoulder positioned in neutral alignment. Her postoperative radiographs revealed satisfactory implantation of the reverse total shoulder prosthesis. Her postoperative course was uneventful. She was taken out of her shoulder immobilizer 4 weeks after surgery and began home-based physical therapy.

At 1 year after surgery, the patient had minimal shoulder pain with active forward flexion, external rotation, and abduction of 135°, 20°, and 85°, respectively. She presented to our clinic 15 months after RTSA with acute onset of pain about her anterior shoulder. She denied any recent trauma or infectious exposures. On examination, her motion was unchanged from prior examinations. However, she was tender on palpation of the coracoid. Radiographs at that time were unchanged (Figures 3A, 3B). Laboratory tests (erythrocyte sedimentation rate, C-reactive protein, and complete blood count with differential) that were subsequently ordered to rule out an occult infection were within normal limits. Computed tomography, which was ordered for further assessment and to ensure that the implant was stable with no loosening, showed satisfactory alignment of the prosthesis without loosening. However, a lucency was noted in the midportion of the coracoid that was suggestive of a fracture (Figures 4A, 4B). A conservative plan of treatment was advised with sling immobilization for 3 weeks and follow-up visits. The patient responded satisfactorily to this treatment approach, and, at her latest follow-up, 8 months after presenting with a coracoid fracture, she was pain-free. At the 5-year postoperative follow-up, her visual analog scale, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score were 1-2, 78, and 75, respectively. 

Discussion

The reverse prosthesis, a semi-constrained ball-and-socket device, provides satisfactory functional outcomes when used in carefully selected patients with rotator cuff arthropathy and pseudoparalysis, failed shoulder arthroplasty, and fracture sequelae.^1,9-11 By the traditional Grammont principles of medializing the center of rotation and lowering the humerus, shear forces about the glenoid are reduced and the deltoid muscle is tensioned, allowing for adequate torque generation, required to facilitate shoulder motion.^12,13 While long-term outcomes  concerning durability and survivorship are pending, some studies have attempted to improve our understanding of implant and functional longevity. Guery and colleagues¹⁴ noted an implant survival of 91% at 120 months. However, increased pain and decreased function were seen at the 6-year mark.¹⁴ A more recent study by Cuff and colleagues¹⁵ revealed 94% implant survivorship and sustained improvement in range of motion and pain at 5 years. 

Despite considerable success, RTSA can be associated with a myriad of complications. The most common complications of RTSA include scapular notching (44%-96%), glenoid side failure (5%-40%), instability (2.4%-31%), and infection (1%-15.3%).^2,3 In the setting of inflammatory arthropathy, there is an increased risk for intraoperative and postoperative fractures.^16,17 To date, there are only 2 reported cases of coracoid process fractures after RTSA.^18,19 In the case by Nolan and colleagues,¹⁸ conservative management with a sling for 6 weeks led to successful resolution of symptoms. Although little information is provided on the management of these rare fractures, literature on the slightly more common scapular (0.9%-7.2%) and acromial (0.9%-4.9%) fractures suggest that periscapular fractures are on the rise, may increase the risk for revision surgery, and can lead to inferior outcomes when compared with patients without fractures.^5,20,21

Acromial fractures after RTSA have been reported to occur at a rate of 0.9% to 4.9%.^5,21 This is a concern because of RTSA reliance on a functional deltoid.^5,6 The cause of these fractures remains to be fully elucidated. Wahlquist and colleagues⁶ in 2011 reported the cases of 5 patients that sustained acromial base fractures after RTSA. All 5 patients were noted to have unsatisfactory functional results despite achieving union (3 were treated with open reduction and internal fixation, and 2 were treated nonoperatively). Acromial fractures tend to present with pain within 6 months of surgery, which may indicate excessive constraint about the scapula, eventually leading to fracture. Furthermore, disruption of this bony structure can lead to devastating results because the acromial base serves as a fulcrum for the deltoid.

Despite a well-placed reverse prosthesis, there is increased reliance on surrounding glenohumeral musculature, resulting from poor rotator cuff function and biomechanical differences compared with a native shoulder. Both our patients were found to have relatively small body habitus. It is possible that, by nature of their smaller statures, they were more susceptible to consequences of excessive joint and soft-tissue tension after RTSA. One explanation for acromial fractures after RTSA is that, by excessively lengthening and/or lateralizing the deltoid, the tension on the acromion in these elderly patients may be sufficient to cause a fracture. A similar mechanism may explain their coracoid fractures. As the arm is lengthened and the prosthesis is tightened, the conjoint tendon is significantly tensioned. We routinely check the tension of these muscles as an extra confirmation of joint stability. However, excessive tension for a significant duration may provide too much stress for bone turnover to match with the inherent repair process, potentially causing a fracture. Recent evidence has also found that bone mineral density of the coracoid diminishes with age, suggesting some predisposition to fracture with lower-energy mechanisms.²²

Another possible cause for coracoid fractures may be the orientation of the implants. While we did not have mechanistic evidence, it is possible that, with adduction and internal rotation, prosthetic impingement against the coracoid is feasible, particularly in patients of small stature. Although a glenoid implant placed high can increase the chance for coracoid–implant impingement, the fact that the patients improved without revision makes chronic mechanical impingement less likely. Drill holes, especially multiple ones, placed throughout the base of the coracoid may also predispose to coracoid fractures.

Patients with periscapular fractures (acromion, scapular spine, or coracoid) after RTSA often present with pain and occasional deficits in function. Both patients in this series noted pain out of proportion to examination. The onset of this pain differed, with 1 patient noting pain within the first 3 months and 1 noting discomfort later. Neither patient had any trauma. In the presence of significant symptoms, negative radiographs, and a poor response to conservative treatment, we recommend advanced imaging to rule out fracture. However, prior to obtaining advanced imaging, proper radiographic techniques should be utilized. Eyres and colleagues,²³ in a series of 12 fractures of the coracoid process, relied primarily on coracoid views directed 45° in a cephalic direction and thin-slice CT. An isotope bone scan identified 1 case not initially found on radiographs.²³

Conservative management with use of a sling until resolution of symptoms was successful in our series. If symptoms persist, a bone stimulator can be used prior to implementing a surgical solution; however, current evidence does not expound on timing and utility of such modalities. Perhaps as important as treatment is education of the patient and the rehabilitation team about the importance of identifying increasing pain as a potential sign of impending fracture in this population. Subsequent activity modification until the pain resolves can help avoid the setback in postoperative recovery that this complication may cause.

Conclusion

We present 2 patients with coracoid fractures encountered at 3 months and 15 months after RTSA. Nonoperative management proved adequate in treating both cases. We suggest a high level of suspicion for possible fracture in the patient who comes in with new-onset pain in a localized region with or without functional deficits.