[The role of bronchial artery embolization in the treatment of hemoptysis]

BACKGROUND

Moderate and severe hemoptysis is a potential life-threatening condition which requires immediate medical examination and intervention.

AIM

Retrospective evaluation of the effectiveness of bronchial artery embolization in the management of hemoptysis (over 50 ml per 24 hours) in the university hospital (from 1998 to 2005).

METHODS

A retrospective case study. Forty seven consecutive patients with hemoptysis over 50 ml per 24 hours were reviewed and data collected from medical documentation (medical history, chest X-ray, bronchoscopy, thorax spiral CT, pulmonary and bronchial angiography).

RESULTS

Forty seven patients, 34 men and 13 women aged between 19-87 years, mean age of 57.1 years, were included in this study. All patients had clinically important hemoptysis (more than 50 ml blood in 24 hours), 23 patients 50-200 ml, 14 patients 200-500 ml, 10 patients over 500 ml. Twenty eight patients had reccurent hemoptysis and nineteen patients had the first stage of hemoptysis. Within the study group we recorded the following clinical causes of hemoptysis: 12 COPD with bronchiectasis, 11 pulmonary malignancy, 11 idiopatic hemoptysis, 5 arterioarterial shunts, 3 pneumonia, 2 aspergillomas, 1 posttuberculous scars, 1 pulmonary trauma, 1 pulmonary arteriovenous malformation. All 47 patients underwent angiography. Thirty seven bronchial artery embolizations (BAE) were performed on the side with greater bronchoscopy and CT abnormality. Polyvinyl-alcohol (sponge particles 45-350 pm) or acrylate glue were used as embolizing agents. We did not observe any complication during this procedures (BAE). Immediate success i.e. cessation of hemoptysis was achieved in 36 patients (97%). Follow-up lasted 4-63 months (33 patients). BAE resulted in long-term success i.e. no recurrent hemoptysis for 28 patients (85%).

CONCLUSION

Transcatheter bronchial artery embolization is an effective and safe procedure for patients suffering from clinically important hemoptysis. Short-term control of hemoptysis can be achieved in 97% and long-term control in 85% of cases. Bronchial artery embolization is a treatment which can reduce the need for acute thoracic surgery.

[Penetrating aortic ulcers--case report on endovascular therapy]

We report our experience with two cases of endovascular treatment of penetrating aortic ulcers (PAU). The first patient was a 71-year-old woman with 30 mm width aortic ulcer accompanied by intramural hematoma of the descending thoracic aorta. The second patient was an 80-year-old obese woman with 50 mm pseudoaneurysma of the abdominal aorta, which was result of PAU. Both patients were successfully treated by means of tubular stentgraft, implanted from surgical cut down of the right femoral artery. Penetrating aortic ulcer represents localized, potentially lethal pathology of the aorta. Together with dissection and intramural hematoma belongs among the acute aortic syndromes. During nature course PAU can progress to the acute classic dissection, pseudoaneurysma or rupture of the aorta. It is principally disease of elderly hypertensive patients. Early diagnosis and appropriate therapy improves prognosis of patients with PAU. Open surgical repair with synthetic graft has been the gold standard of treatment but endovascular therapy is an attractive option in risk elderly patients. It seems to be a safe, effective treatment but stability of results of this method should be proved.

[Role of percutaneous vertebroplasty and kyphoplasty in the treatment of oncology disorders of the spine]

BACKGROUND

The aim of the study is to present results of a prospective uncontrolled clinical study. Percutaneous vertebroplasty or kyphoplasty are minimally invasive methods based on polymethylmethacrylate (PMMA) bone cement application into the damaged vertebra. This leads to decrease of the pain and vertebral body stabilisation. Oncology disorders of the spine are relatively common, having a wide alternative of various methods of treatment. Patients, according to their findings and indication criteria, are treated surgically or conservatively, oncological treatment is usually based on radiotherapy. Authors discuss the role of these invasive procedures in the treating algorithm of patients with spinal metasthases and multiple myeloma.

METHODS AND RESULTS

From September 2003 to December 2005, 21 percutaneous vertebroplasties in 14 patients, mean age 68.7 (47-80) year, were performed in our department. During one treatment session 1-2 vertebrae (total of 21 vertebrae) in level Th9 - L5 were treated. Vertebroplasties and kyphoplasty were performed under fluoroscopy guidance. Transpedicular acces was used. Totally, 3 asymptomatic complications were proved. As first, a bone cement leaked paravertebrally during L5 body treatment, as second, a bone cement leaked into paravertebral veins, and as third, a bone cement leaked into the intervertebral space. Visual analog scale (VAS) was 8.9 points before procedure, 1.9 point 3 months after procedure and 2.6 points 6 months after procedure. We did not prove a symptomatic or total complication.

CONCLUSIONS

According to our experience, percutaneous vertebroplasty is an effective alternative treatment of painful oncologic spine disease.

[The endovascular treatment of the aortic trauma]

BACKGROUND

Traumatic injuries of the thoracic aorta are very frequent during motor vehicle accidents with sudden deceleration. Spiral CT has become the modality of choice for evaluating significant blunt trauma and grading system for aortic injury has been developed. Immediate diagnosis, introduction of antihypertensive therapy and endovascular treatment by means of stentgraft give a better chance for patients with blunt aortic injury.

AIM

Prospective evaluation of results of endovascularly treated patients with blunt aortic injury.

MATERIALS AND METHODS

We prospectively followed patients after endovascular treatment of acute aortic injury. Diagnosis was based on chest x-ray and CT examination. Stentgrafts were placed under fluoroscopic guidance and patients were routinely followed by CT and clinical visit.

RESULTS

Between December 1999 and September 2004 we endovascularly treated seven patients (6 men, 1 woman, mean age 41.7 years) for blunt aortic injury of the thoracic aorta. Stentgraft was implanted between 5 hours and 6 days (mean 3.2 days) after injury. Seven stentgrafts were implanted in 7 patients in total. One patient died due to failure of endovascular technique for collapsed stentgraft. A new onset of lower legs paraparesis was detected in one patient. Other five patients are regularly followed (3-55 months, mean 30.7 months) without any complications.

CONCLUSION

Endoluminal technique can be used successfully in the immediate repair of aortic trauma. At present time in our center, treatment by means of the stentgraft placement is the first line therapy in injured patients. It allows rapid stabilization of aortic trauma and further treatment of other injuries.

Fatal Intraventricular Hemorrhage After the Extracranial Carotid Artery Angioplasty and Stent Placement

We report on a 72-year-old female with an unusual intracranial bleeding complication after an extracranial carotid artery stenting procedure performed for a tight left ICA stenosis associated with contralateral carotid occlusion. Two hours after the procedure, the initial signs of intracranial bleeding appeared that led to the patient's demise 5 days later. A brain CT showed and autopsy proved massive intraventricular bleeding. To our knowledge, our case is only the second report of isolated reperfusion intraventricular hemorrhage post-CAS.

[Percutaneous vertebroplasty]

Percutaneous vertebroplasty is a therapeutic, interventional radiologic procedure originally developed in France by Galibert, Deramond et al. (1987). The technique consists of the percutaneous puncture of the affected vertebral body, followed by injection of bone cement into a vertebral body for the relief of pain, and the strengthening of the bone. The procedure was used initially to treat aggressive hemangiomas, but it then was extended to the treatment of osteolytic metastases, multiple myeloma and osteoporotic compression fractures refractory to medical therapy. In this article we review the current techniques, indications for this procedure, preoperative and postoperative evaluations.

[Diagnosis of spontaneous arteriovenous fistula complicating aortoiliac aneurysm using spiral CT. Report of 3 cases]

Acute spontaneous arterio-venous fistula complicating atherosclerotic abdominal aortic aneurysm (AAA) is rare. This life-threatening setting is observed in 1-2% of all AAAs and 2-4% of ruptured of AAAs. The triad of abdominal or lower back pain, pulsatile abdominal mass, and continual abdominal machinery-like bruit is seen only in half of cases. Currently, CT angiography is a noninvasive technique which enables a rapid and exact preoperative diagnosis. The authors describe three cases of aortoiliac aneurysm complicated by an acute arteriovenous fistula which were diagnosed using spiral CT.

[Cooperation between a surgeon and an interventional radiologist in cases of internal bleeding]

INTRODUCTION

Internal bleeding still remains a serious condition, which must be urgently diagnosed and treated. In the Faculty Hospital in Hradec Králové the diagnosis of the internal bleeding source and its consequent treatment is managed under cooperation between a surgeon and an interventional radiologist. A CASE-REVIEW: In the case-review section of this report, a total number of five patients with serious cases of internal bleeding, the source of which was diagnosed and treated under cooperation between the above mentioned specialists is presented. The patients concerned suffered from the following: a trauma to the liver parenchyma, posttraumatic arterioportal shunts, an intraheparic aneurysm, a relaps of the uterine carcinoma with hemorrhaging into the colon and the vagina, bleeding into retroperitoneum. In all the cases the lesion was successfully treated and the hemorrhage was managed.

DISCUSSION

Exact location of the bleeding artery during an arteriogragraphic examination is a prerequisite of a successful treatment of the condition. Both, the absorbable materials which allow gradual recanalization of the embolized vessel, and the non-absorbable materials may be used to conduct embolization of the affected vessel. It is necessary to haemodynamically stabilize the patient prior to the procedure.

CONCLUSION

In many cases, the cooperation between a surgeon and an interventional radiologist allows for the source of the internal bleeding to be located and managed. It is indicated in certain cases of benign and malignant disorders and in some cases of the parenchymatose organs trauma.

[Intravascular brachytherapy in the prevention of vascular restenosis]

Vascular restenoses currently represent a major problem in the treatment of vascular stenoses. One of new approaches in the prevention of restenoses is intravascular brachytherapy. Intravascular brachytherapy uses local irradiation of the stenotic vessel segment by ionizing radiation with the aim of prevention of restenosis. This is a new rapidly developing multidisciplinary approach based on collaboration of specialties of intervention radiology, intervention cardiology, angiology, nephrology and radiation oncology. This review examines current options of intravascular brachytherapy as well as results of clinical trials evaluating the efficacy of intravascular brachytherapy in the different anatomical regions. Intravascular brachytherapy may substantially reduce the rate of restenoses. However, intravascular brachytherapy should be currently used only in the setting of clinical trials. Optimal method of irradiation of the stenotic segment of the vessel is still to be defined.

[Endovascular treatment of atherosclerotic stenoses of the subrenal aorta]

The authors present results of endovascular treatment of subrenal aortic atherosclerotic stenoses. Between 1996 and 2001 they treated 9 patients (5 men, 4 women, mean age 57.4 years). Aortic stenoses were caused by an atherosclerotic process in all cases. In addition, in three patients iliac arteries were affected by sclerotic lesions. The endovascular procedure consists of predilatation performed by a small calibre angioplasty balloon catheter and implantation of a stent. Three times a balloon expandable stainless steel stent was implanted and self-expandible nitinol stents were used in the six cases. The primary technical success rate was 100%, no major complications were observed. One distal embolization was successfully resolved by intraarterial thrombolysis. Only one stent restenosis occurred after 36 months. It was successfully treated by implantation of a longer stent. That means that the primary patency of stented subrenal aorta during a mean follow-up period of 19 months was 87.5%. The claudication interval improved in six patients and three patients were symptom free. Endovascular therapy can be recommended for short sclerotic stenoses of the infrarenal aorta. This miniinvasive technique has a high technical and clinical success rate, favourable long-term patency and low complication rate.

Wedged hepatic venography for targeting the portal vein during TIPS: comparison of carbon dioxide and iodinated contrast agents

PURPOSE

Carbon dioxide (CO2) can traverse the hepatic sinusoids better than iodinated contrast medium and has been used by many interventionalists for wedged hepatic venography during transjugular intrahepatic portosystemic shunt (TIPS) procedures. Our study was designed to compare the extent of the portal vein opacification using either CO2 or iodinated contrast medium.

METHODS

Wedged hepatic venography for portal vein opacification during TIPS was performed using hand injection through a 6.5 Fr diagnostic catheter. Portograms of 36 patients performed with 10 ml of iodinated contrast medium were retrospectively compared with portograms of 45 patients performed with 30-40 ml of CO2. Opacification of the right portal vein branch including the portal vein bifurcation was defined as a successful study.

RESULTS

Using CO2 the right portal vein branch and the portal vein bifurcation were opacified in 87% of patients (39 of 45); only a part of the right portal vein branch was opacified in 6% of patients and no opacification of any portal vein branch was seen in 7% of patients. Using iodinated contrast medium, there was opacification of the portal vein bifurcation in 25% of patients (9 of 36), of a part of the portal vein branch in 36% and no opacification of any branch in 39%. There was one case of hepatic laceration from CO2 wedged venography which was treated with microcoil embolization.

CONCLUSIONS

Using CO2 as a contrast medium, opacification of the portal vein bifurcation by wedged hepatic venography was seen in 87% of patients, in comparison with only 25% when iodinated contrast medium was used (p < 0.001). CO2 is superior to iodinated contrast medium for wedged hepatic venography during TIPS.

[Infectious aneurysm of the abdominal aorta caused by Salmonella: diagnosis, endovascular therapy]

The authors present a case of an infected abdominal aortic aneurysms by means of a minimally invasive endovascular method using a stent graft. This patient had already been treated by TIPS (transjugular intrahepatic portosystemic shunt) for repeated varicose bleeding due to liver cirrhosis. Standard surgical therapy of infected abdominal aneurysms and about advantages and possibilities of endovascular treatment with stent grafts are discussed. Regular follow-up of the patient and long-term antibiotics therapy are important for accurate assessment of an implanted stent graft into the infected abdominal aorta. Endovascular stent graft combined with antibiotic therapy may be an alternative to conventional open surgery in managing infected infrarenal abdominal aneurysms.

Endovascular brachytherapy potentiated by hyperthermia in the prevention of vascular restenosis. A case report

BACKGROUND

The combination of hyperthermia and radiotherapy has additive or synergistic effects. This combination has been studied extensively in radiation oncology, but not in the prevention of vascular restenosis.

CASE REPORT

A patient with restenosis of cephalic vein underwent percutaneous transluminal angioplasty (PTA) followed by endovascular irradiation with 192Iridium (12 Gy) using a high dose rate afterloading technique. After endovascular irradiation, one fraction of external ultrasound hyperthermia was administered to the irradiated segment. There was no restenosis in the treated vessel segment according to duplex sonography performed 192 days after treatment. No radiation or hyperthermia associated side effects were observed.

CONCLUSIONS

Present observations suggest that endovascular brachytherapy of restenosis potentiated by hyperthermia is a technically feasible and well-tolerated treatment. The additive and synergistic effects of hyperthermia, in conjunction with radiation, could be of benefit in the prevention of vascular restenosis.

Endovascular brachytherapy in the prevention of vascular restenosis

PURPOSE

To evaluate the technical feasibility and efficacy of endovascular brachytherapy for prophylaxis of restenosis after femoropopliteal percutaneous transluminal angioplasty (PTA).

MATERIALS AND METHODS

Ten patients with recurrence of stenosis in the femoropopliteal region underwent PTA followed by endovascular irradiation with Iridium-192 a high-dose rate after-loading technique. We used a single fraction of dose 12 Gy given in 3 mm from the source axis in the stenotic vessel segment.

RESULTS

During follow-up of 59-580 days restenosis occurred in four patients 111, 460, 472 and 580 days after irradiation. All other patients are without restenosis. No radiation-associated side effects were observed.

CONCLUSIONS

Endovascular brachytherapy of restenosis in the femoropopliteal region is technically feasible, and may be done as a part of the PTA. These encouraging results open the possibility of reduction of restenosis by the present method.

Advancing health promotion in Australian general practice

Health promotion activities, while having the potential to prevent disease and decrease the burden of ill health, often play a minor role in the health care offered by general practitioners. There are several identified barriers to the involvement of Australian general practitioners in health promotion. These include structural barriers and barriers within the practice setting, individual practitioner and patient factors, and difficulties in evaluating the outcomes of health promotion activities. This article explores the barriers to the engagement of Australian general practice with health promotion and reviews several recent initiatives that have the potential to increase the health promotion activities of general practitioners. These initiatives act at the level of the individual practitioner, the practice, and in the community. Despite the lack of a coordinated national approach, these strategies form an important development in general practice.

[Preservation of venous grafts]

The objective of the work was to find an optimal preservation medium for short-term preservation of venous grafts which could be subsequently used to line metal stents. The external jugular vein of dogs (n = 15) was removed surgically, divided into portions and immersed into preservation media. For hypothermic preservation (+4 degrees C) solutions of Optisol (Chiron, USA), University of Wisconsin (Baxter, USA), Eurocollins (Fresenius, GFR) and saline (Bieffe Medital, Italy) were used. For normothermic preservation (+37 degrees C) in an atmosphere with 5% CO2 Dulbecc's medium for tissue cultures (Sigma, USA) was used. During hypothermic preservation the specimens were kept for 24 hours, 3 and 7 days, during normothermic preservation in Dulbecc s medium also for 24 hours, 3 and 7 days. The specimens were evaluated by light microscopy and raster electron microscopy. The results revealed that minimal changes on the endothelia of venous grafts occurred during normothermic preservation in Dulbecc's medium where after 7 days the endothelium did not become detached and the vitality of cells did not change. During hypothermic preservation the solution of Wisconsin University proved most suitable. By addition of 5% human albumin to this solution it proved possible moreover to reduce pyknosis of the endothelial cell nuclei. The specimens kept in saline displayed deformities of the nuclei, oedema and loss of endothelia incl. incipient oedema of the cellular wall already after 24 hours of hypothermic preservation. The authors consider the use of this solution unsuitable for preservation.

Autologous vein stent-graft: feasibility study

PURPOSE

To evaluate expandable stents healed into vein wall as autologous vein stent-grafts for endoluminal grafting.

MATERIALS AND METHODS

Balloon expandable stents were placed into external jugular veins of eight dogs. Stent and vein patency was followed by ultrasonography. Five weeks after stent placement, jugular veins with endothelialized stent were harvested. The autologous vein stent-grafts were divided into two groups. In group A, autologous vein stent-grafts (n = 3) were placed immediately into Baker solution for microscopic examination. In group B, autologous vein stent-grafts (n = 3) underwent mechanical manipulation; they were compressed, mounted on angioplasty balloon, pushed through a 9-F sheath and dilated. The autologous vein stent-graft endothelialization and changes after mechanical manipulation were evaluated by light and electron microscopy.

RESULTS

Stent placement was successful in seven dogs. One stent migrated into the pulmonary artery. One well placed stent was damaged by compression dressing and thrombosed. At 5 weeks, gross and microscopic examinations revealed the autologous vein stent-grafts were fully covered by a 0.115- +/- 0.036-mm-thick neointimal layer. Small wall thrombus was observed in one autologous vein stent-graft. Repeated manipulations did not result in any intimal damage or stent loosening in the autologous vein stent-grafts.

CONCLUSION

Expandable stents healed into a vein have potential to be used as autologous vein stent-grafts for endoluminal grafting without risk of disruption during percutaneous transcatheter introduction.

Endovascular brachytherapy of transjugular intrahepatic portosystemic shunt

PURPOSE

To evaluate the technical feasibility and efficacy of endovascular brachytherapy with Iridium-192 in the prevention of restenosis caused by neointimal hyperplasia of transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

The endovascular brachytherapy with high dose rate automatic afterloading system was performed in six patients with recurrent of stenosis of TIPS. We used a single dose fraction of 12 Gy delivered at 3 millimeter (mm) from the source axis to the stenotic vessel segment in five patients with spiral Z-stent, and 15 Gy at 5 mm in one patient with Wallstent.

RESULTS

Follow-up time ranged from 148 to 639 days. In one patient, restenosis occurred in the treated vessel segment, diagnosed 71 days after endovascular brachytherapy by doppler ultrasound. All other patients were, during the follow-up time, without restenosis in the irradiated vessel segment. Radiation-associated side effects were not observed.

CONCLUSIONS

Endovascular brachytherapy of TIPS is technically feasible and may be done as a part of the percutaneous revision of the shunt. This pilot study may be the largest experience of treating TIPS restenosis in humans to date. For definitive conclusions, a lot of studies are needed.

[Percutaneous therapy of obliterative disease of the femoropopliteal arteries using stents--2 years' experience]

PURPOSE

To evaluate the clinical results and short and mid-term stent patency in patients with femoropopliteal stent placement.

MATERIAL AND METHODS

Forty-one patients (42 limbs) underwent stent placement--27x into superficial femoral artery, 15x into popliteal artery. There were inserted 44 self-expandable stents. In 3 cases PTA of stents and in 2 cases local endovascular brachytherapy were performed because of restenosis. The mean follow-up is 12.9 months (1-24 months).

RESULTS

Stents were successfully inserted in all cases. Clinical improvement at the time of latest follow-up occurred in 77% of patients, no improvement in 13% and clinical worsement in 10% of patients. Primary patency rates at 6 months, 12 an 24 months were 83.8%, 67.7% and 67.7%, respectively. Primary assisted patency were 90.3% at 6 months, 77.4% at 12 months and 77.4% at 24 months.

CONCLUSION

Stents implantation in femoropopliteal arteries is a method of choice after suboptimal angioplasty results in patients with critical limb ischemia for whom no reasonable surgical alternative exists.

[Complications of endovascular therapy of abdominal aortic aneurysms. Analysis and possible treatment]

The required result of correctly implemented endovascular treatment is bridging and elimination of the aneurysmatic sac from the blood flow in the aorta. Perfusion of the sac after release of the endovascular prosthesis is one of the most frequent complications of endovascular treatment. The majority of these perfusions is caused by a leak of the endovascular prosthesis at the site of the stented anastomosis, or more rarely by a collateral flow into the aneurysmatic sac or rupture of the endoprosthesis. Perfusion of the sac "endoleak" complicates endovascular treatment in cca 30%. During the postoperative period about half the perfusions recede spontaneously and about half require further treatment. Based on their own experience the author submits suggestions for the classification of leakage of endovascular prostheses with regard to the method of their treatment.