Transfemoral intraluminal stent graft implanted for thoracic aortic aneurysm

We describe two patients with inoperable descending thoracic aortic aneurysm. The first patient had complained of severe back pain for at least thirteen years. Radiological examination revealed a large posterior mediastinal mass that was misdiagnosed in 1981. Follow-up studies in 1992 revealed this mass to be a large descending thoracic aortic aneurysm, eroding the vertebral bodies of T3 through T6 and entering the spinal canal. Because of the high risk, thoracic aortic surgery was not performed. The second patient had an acute descending thoracic aortic aneurysm. There was contraindication to a second surgical approach due to previous thoracotomy. Both patients underwent an intraluminal bypass of the descending thoracic aorta with a stent graft. Postplacement aortogram and follow-up studies showed that aneurysm was effectively excluded. We believe that this type of therapy should be offered to selected individuals who are considered by cardiovascular surgeons to be a high risk for thoracic aneurysm surgery.

Treatment of malignant esophagorespiratory fistulas with silicone-covered metallic Z stents

PURPOSE

To prospectively evaluate the clinical efficacy of covered metallic Z stents in the treatment of esophagorespiratory fistulas (ERFs).

PATIENTS AND METHODS

Twelve patients with severe aspiration symptoms from malignant ERFs were treated with silicone-covered, metallic, self-expanding Gianturco-Rösch Z (GRZ) stents.

RESULTS

Fluoroscopically guided stent placement was successful and well tolerated in all patients. Immediate postprocedural endoscopy and esophagography showed excellent coverage of the fistulas in all cases. Aspiration symptoms were completely relieved in eight of 12 patients (67%). Four of 12 patients (33%) were improved and able to eat a soft diet. There were no stent-related deaths. Nine patients have died and three patients are alive. Mean follow-up for the entire group was 3.9 months (range, 1 week to 10.5 months). Nonfatal complications occurred in three of 12 patients (25%). Complications included one membrane disruption and one granulomatous reaction with a slight upward stent migration.

CONCLUSION

GRZ stents are an effective and safe means of palliation in patients with malignant esophagorespiratory fistulas.

Combined transjugular intrahepatic portosystemic shunt and segmental Lipiodol hepatic artery embolization for the treatment of esophagogastric varices and hepatocellular carcinoma in patients with cirrhosis: preliminary report

PURPOSE

To evaluate the feasibility of combining placement of a transjugular intrahepatic portosystemic shunt (TIPS) and transcatheter hepatic segmental artery chemoembolization with Lipiodol (Seg-Lp-TAE) in patients with cirrhosis, esophagogastric varices, and hepatocellular carcinoma (HCC).

METHODS

Five patients with bleeding or large, high-flow esophagogastric varices and HCC were treated by TIPS and Seg-Lp-TAE.

RESULTS

The mean portosystemic pressure gradient decreased from 20.8 cm H2O to 7.8 cm H2O after TIPS. The direct portogram and endoscopic examination revealed reduction of varices. At 6 months, one shunt had functionally occluded and could not be reopened; the other TIPS remained functional. Follow-up CT and the changes of alpha fetoprotein indicated effective therapy of Seg-Lp-TAE for HCC. Four patients are in stabile clinical condition at 9, 6, 1, and 1 months after the combined therapy; one died after 14 months due to decompensated liver cirrhosis.

CONCLUSION

The combined therapy of TIPS and Seg-Lp-TAE will become a new interventional approach for patients with HCC and esophagogastric varices.

Experimental nonsurgical female sterilization: transcervical implantation of microspindles in fallopian tubes

PURPOSE

A nonsurgical method of female sterilization was investigated in rabbits.

MATERIALS AND METHODS

A self-expanding microspindle (length 9-18 mm, diameter 1.5-2.0 mm) made from tubular metal mesh was implanted in a single fallopian tube of 12 rabbits via catheterization of a single uterus. The contralateral fallopian tube and uterus served as controls. Each rabbit was scheduled to undergo three cycles of breeding. Before delivery, absence of pregnancy on the side with the microspindle was verified with hysterography.

RESULTS

Eight rabbits completed three cycles of breeding and pregnancy. Two rabbits had one pregnancy. Two rabbits did not conceive. Spindles were placed correctly in 11 rabbits. Successful contraception was achieved in nine rabbits, who had 25 gestations on the nonspindle side and no gestation on the spindle side. One rabbit, which received the shortest spindle, was bilaterally pregnant, indicating a failure of contraception on the spindle side. No spindles dislocated. Histologic study showed all spindles firmly embedded in the tubal wall without signs of inflammation.

CONCLUSION

Microspindles of a certain minimum length have potential as a transcervically implantable, permanent intratubal contraceptive device.

Silicone-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature

Esophagogastric malignancies often are manifested with progressive dysphagia or esophagorespiratory fistulas. Palliative modalities currently available have significant limitations. A modified Gianturco-Rösch silicone-covered self-expanding metallic Z stent was used in 32 consecutive patients with malignant esophageal obstruction (n = 24) or esophagorespiratory fistulas (n = 8). The stent was placed successfully in all patients. Dysphagia improved by at least two grades in 21 of the 24 patients (87.5%); the mean dysphagia grade fell from 3.21 to 1.08. Six of the 8 patients with fistulas were able to resume a normal diet, and the other 2 were able to eat solids without symptoms of aspiration. Complications occurred in 10/32 patients (31%) and included stent migration (4 patients), food impaction (2 patients), membrane disruption with tumor ingrowth (1 patient), tumor overgrowth (1 patient), early pressure necrosis with hemorrhage (1 patient), and late pressure necrosis with sepsis (1 patient). The latter 2 patients died, giving a mortality rate of 6.3%. Many complications were managed with endoscopic or interventional radiologic techniques. Although randomized prospective clinical trials are needed, the silicone-covered Gianturco-Rösch Z stent offers promise for the effective palliation of malignant esophageal obstruction and esophagorespiratory fistulas.

Self-expandable spindle for transcatheter vascular occlusion: in vivo experiments. Work in progress

A mechanical vascular occluder was studied in eight pigs to test its efficacy in arteries of different diameters, stability over time, and safety in placement. The main component is a self-expandable spindle made of tubular stainless steel mesh. Simple steel spindles, double spindles, and Dacron-core spindles were placed in the common carotid artery, main renal artery, renal artery branches, and infrarenal aorta. Follow-up arteriograms were obtained immediately, 30-60 minutes, and (except for aortic spindles) 7 days after deployment. The left common carotid artery was occluded in all pigs, regardless of spindle type. In the main renal artery and its branches, simple steel spindles did not achieve complete occlusion. Double and Dacron-core spindles produced immediate occlusion without recanalization on the 1-week follow-up arteriogram, except for one spindle with an incomplete Dacron core and two spindles that did not completely fill the arterial lumen. Two Dacron-core spindles achieved immediate complete occlusion of the infrarenal aorta. No migration was seen with any spindle.

Portal decompression after transjugular intrahepatic portosystemic shunt creation with use of a spiral Z stent

PURPOSE

An experimental swine model of acute presinusoidal portal hypertension was used to investigate the feasibility of a spiral Z stent for transjugular intrahepatic portosystemic shunt (TIPS) placement and the correlation between the shunt (stent) size and degree of portal pressure decrease.

MATERIALS AND METHODS

Twelve young swine were used. Acute portal hypertension was induced by means of selective injections of absolute alcohol, ethiodized oil, and polyvinyl alcohol sponge particles into intrahepatic portal branches.

RESULTS

TIPS was successfully created in all swine by using spiral Z stents that were 6, 8, and 10 mm in diameter; each size stent was deployed in four animals. Being sufficiently flexible, spiral Z stents accommodated for curved shunt tracts. An average of 48% portal pressure decrease was achieved with 6-mm-diameter stents, 61% with 8-mm-diameter stents, and 87% with 10-mm-diameter stents.

CONCLUSION

These results are in agreement with our clinical experience with use of Gianturco-Rösch Z stents for TIPS formation.

Gianturco-Rösch expandable Z-stents in the treatment of superior vena cava syndrome

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.

In vitro comparison of the spiral Z stent and the Gianturco Z stent

A new spiral Z stent is described, and its characteristics are compared in vitro with those of the modified Gianturco Z stent. The spiral Z stent has a more uniform expansile force throughout its effective length; is more compressible, thus allowing for use of a smaller introductory catheter; and is more stable than the modified Z stent. Flexibility of both stent types is similar. Advantages of the spiral Z stent promise to be beneficial for clinical use.

Percutaneous hepaticoneojejunostomy and choledochocholedochal reanastomosis using metallic stents: technical note

A new, nonsurgical approach to biliary duct reconstruction in two high-operative risk patients is presented. The first patient with an obstructed hepaticojejunostomy underwent such reconstruction by placement of Wallstent, which remained patent 9 months until death from recurrent tumor. The second patient with an inadvertently ligated common bile duct underwent a combined percutaneous transhepatic-retrograde endoscopic reconstruction with placement of a Gianturco-Rösch (GR) stent. Because of occlusion by granulation tissue 5 months later, a new GR stent covered with a silicone membrane was placed within the initial stent. Nine months after the second GR stent placement there is no evidence of obstruction.

Silicone-covered expandable metallic stents in the esophagus: an experimental study

Modified silicone-covered Gianturco expandable metallic stents were placed in the normal esophagus of six young pigs. Following endoscopic examination, the stents were placed using endoscopic and fluoroscopic control. The animals were observed for eating behavior and weight gain. Stents appeared to be tolerated well based on these parameters. Three stents remained in position for the full study period, and three stents migrated into the stomach during the study. The pigs were sacrificed at four weeks and postmortem examination performed. Esophageal wall thickening and nodular inflammation were noted at the sites where the wire skirts penetrated the mucosa. Injury was limited to the region of the wire skirts and there was no injury due to the radial force of the stent body. There was no free perforation. This preliminary study suggests that endoscopic and fluoroscopic placement of modified silicone-covered Gianturco stents in the esophagus is feasible and safe. More extensive animal studies, followed by clinical investigation for palliation of malignant strictures, are warranted.

Transjugular liver biopsy

Although transjugular liver biopsy requires the availability of trained personnel, takes more time than percutaneous biopsy and is moderately expensive, it is a safe alternative technique for obtaining adequate liver tissue for diagnosis in special clinical situations. The usual indications for transjugular rather than percutaneous liver biopsy are (a) coagulation disorder (prothrombin time greater than 3 sec over control value and/or platelet count less than 60,000/cm3), (b) massive ascites and (c) desire to perform ancillary procedures, such as measurement of pressures or opacification of the hepatic veins and inferior vena cava. Less common indications for transjugular liver biopsy include failed percutaneous biopsy, massive obesity, small cirrhotic liver (increased risk and lower success rate) and suspected vascular tumor or peliosis hepatis. Results from several centers indicate that adequate or diagnostic liver tissue is obtained in 81% to 97% of cases. The typical length of the biopsy core ranges from 0.3 cm to 2.0 cm. Modification of the classic technique, particularly the adaptation of a Tru-Cut needle, shows promise in yielding longer cores of tissue with less fragmentation. Transjugular liver biopsy is performed with an acceptable complication rate that ranges 0% to 20%. The reported mortality of transjugular liver biopsy was 0 in three major centers and ranged from 0.1% to 0.5% in three other centers. Transjugular liver biopsy may be useful in obtaining diagnostic liver tissue not only in advanced chronic liver disease with coagulopathy, ascites or both, but also in patients with fulminant hepatic failure to better determine prognosis and the need for liver transplantation.

Treatment of malignant esophageal obstruction with silicone-coated metallic self-expanding stents

Six patients with high-grade malignant esophageal obstruction were treated with silicone-coated metallic self-expanding esophageal stents (Z stents). Endoscopic placement of stents was well tolerated. All patients achieved excellent palliation, defined by a decrease of at least two dysphagia grades, which was sustained. Complications occurred during follow-up in four patients and included stent migration, silicone disruption with tumor ingrowth, food impaction, and perforation (discovered at autopsy) at the distal stent site. Three of the four complications were promptly treated by endoscopic or radiologic intervention. Recent modification in stent design and placement technique will hopefully reduce complications. The self-expanding stent has several theoretical advantages over the rigid plastic stent and Nd:YAG laser for palliation of obstructing esophageal malignancy.

Radiographic fallopian tube recanalization: absorbed ovarian radiation dose

Absorbed radiation dose to the ovaries during radiographic fallopian tube recanalization was estimated in 29 patients with use of thermoluminescent dosimeters placed in the vaginal fornix. With an average fluoroscopic time of 8.5 minutes +/- 5.5 and an average of 14 +/- 5 105-mm spot radiographs obtained, the average absorbed dose to the ovaries was 8.5 mGy +/- 5.6 (0.85 rad +/- 0.56). Technical guidelines for keeping patient radiation exposure to a minimum during this new interventional procedure are suggested.

Expandable venous stents for treatment of the Budd-Chiari syndrome

The goals of treatment of the Budd-Chiari syndrome are relief of portal hypertension, relief of inferior vena cava syndrome, if present, and preservation of hepatic function. This study presents a patient with clinical resolution of the Budd-Chiari syndrome after placement of expandable metallic stents in the inferior vena cava and hepatic veins. A 26-year-old man with severe ascites and lower extremity edema but with relatively preserved hepatic function had a small gradient across a suprahepatic caval web, large gradients across an intrahepatic caval stenosis and the left hepatic vein, and an occluded right hepatic vein. Under angiographic control, web and caval stenosis were balloon-dilated, and modified Gianturco expandable metallic stents were placed in the intrahepatic vena cava. The left hepatic vein was dilated twice and a stent was placed. All gradients were completely eliminated. There were no complications and after 1 year, the stents have fully expanded without migration, edema and ascites have resolved, hepatic function has normalized, and the patient has returned to work. This new technique provides a simple, safe, effective, relatively inexpensive, and potentially long-lasting treatment for selected patients with the Budd-Chiari syndrome.

Phosphorylation and thiophosphorylation by myosin light chain kinase: different effects on mechanical properties of chemically skinned ventricular fibers from the pig

The influence of myosin light chain phosphorylation (treatment with myosin light chain kinase = MLCK, calmodulin and ATP) and thiophosphorylation (incubation with MLCK, calmodulin and ATP gamma S) on the maximal shortening velocity (Vmax) and Ca2+ sensitivity of chemically-skinned ventricular fibers from the pig has been studied. Vmax was determined by the slack-test method and by extrapolation of the force-velocity relation by the isotonic quick release method. Vmax was 1.53 muscle length/s (L/s) and 1.94 L/s using the force-velocity relation and the slack-test, respectively. Phosphorylation increased the Ca2+ sensitivity for isometric force development of skinned fibers but had no influence on Vmax. Thiophosphorylation decreased Vmax but had no influence on Ca2+ sensitivity. Phosphorylation pattern of the myosin light chains of the skinned fibers was studied using [gamma-32P]ATP or [gamma-P35S]ATP (250 muCi each) and autoradiography. Incubation of skinned fibers with labeled ATP led to a phosphate incorporation into the 18-kDa myosin light chain (MPLC or regulatory light chain) while incubation with labeled ATP gamma S led to an incorporation of thiophosphate into the 28-kDa myosin light chain (alkali light chain) and tropomyosin. We suggest that the difference in mechanical behavior between phosphorylated and thiophosphorylated skinned fibers are due to differences in the phosphorylation profiles of myofibrillar regulatory proteins.

Interventional treatment of hepatic arterial and venous pathology: a commentary

Hepatic aneurysms, pseudoaneurysms and fistulas (arterial biliary and arterial portal) causing bleeding or portal hypertension, and arteriovenous malformations causing high output cardiac failure in adults can be successfully managed by embolization techniques. Results of embolization in infantile hemangioendotheliomas are less uniform and tumors with massive arteriovenous shunting are difficult to manage. Transjugular intrahepatic portal systemic shunts using expendable stents have been successfully created in patients and have effectively controlled portal hypertension and variceal bleeding.

Tube tamponade: potential pitfall in angiography of arterial hemorrhage associated with percutaneous drainage catheters

Diagnostic angiography performed to search for a source of hemorrhage in three patients with percutaneous transhepatic biliary catheters and one patient with a percutaneous nephrostomy catheter was initially unrewarding when performed with the drainage catheter in place. In each patient, removal of the drainage catheter resulted in severe pulsatile hemorrhage from the parenchymal tract and allowed angiographic localization of the bleeding site. Temporary control of the hemorrhage was then obtained by inflating an angioplasty balloon within the tract. Transcatheter embolotherapy provided definitive control of bleeding in three patients. When initial angiographic evaluation for bleeding in patients with percutaneous biliary and nephrostomy catheters fails to depict a source, the study should be repeated immediately after removal of the drainage catheter. Because hemorrhage can be severe once tamponade is relieved, the drainage catheter should be withdrawn over a guide wire so that a tamponading catheter can be rapidly reinserted to control hemorrhage until more definitive therapy is undertaken.

Fallopian tubes: improved technique for catheterization

Successful fallopian tube catheterization for diagnosis or treatment of infertility combines hysterosalpingographic and angiographic techniques. An improvement in the catheterization strategy was developed so that angled, tortuous, or more distally obstructed fallopian tubes could be catheterized. In 22 patients, 38 fallopian tubes were catheterized by using this strategy. In nine tubes (24%), forceful ostial injection alone of contrast material was able to open and/or depict the fallopian tube. In 13 tubes (34%), a discrete obstruction was recanalized by using the standard fallopian tube catheterization set. In 12 tubes (32%), successful recanalization required the use of a softer, tapered guide wire and catheter. In four tubes (10%), recanalization was unsuccessful.

Nonsurgical fallopian tube recanalization for treatment of infertility

Fluoroscopic transcervical fallopian tube recanalization was performed in 100 consecutive patients with infertility and proximal tubal obstruction documented with hysterosalpingography. In 86 patients, the procedure enabled at least one tube to be opened. Twenty-six intrauterine pregnancies resulted from the successful recanalization. A well-defined subset of 20 patients were evaluated to better define the treatment effect of fallopian tube recanalization. All 20 had bilateral proximal tubal obstruction without other tubal disease, and all had been recommended for tubal microsurgery or in vitro fertilization. Recanalization of one or both tubes was successful in 19 of these women (95%). Nine patients conceived (47%) without receiving any other therapy, and the average time from procedure to conception was 4 months. All pregnancies were intrauterine. Eight of the 10 patients who did not conceive underwent follow-up hysterosalpingography an average of 6 months following the procedure; four (50%) demonstrated reocclusion of both tubes. The authors conclude that nonsurgical fallopian tube recanalization is an effective treatment for infertility caused by proximal tubal obstruction.

Device for hysterosalpingography and fallopian tube catheterization

A device was developed for hysterosalpingography and fallopian tube recanalization. It differs from the previously used vacuum-cup device in that the central shaft slides and has an acorn-shaped tip. Optimal results were obtained in all 14 women (100%) who underwent catheterization with the new device; optimal results were achieved in only five of eight women (62%) who underwent catheterization with the fixed-shaft device during the same time period.

Transvaginal fallopian tube catheterization in an animal model

A rabbit model for testing the safety and effectiveness of diagnostic and interventional techniques of fallopian tube catheterization is presented. Hysterography with injection into the terminal portion of the uterine horn visualized the fallopian tube in only 6% of cases; however, this increased from 33% to 50% by pretreatment with progesterone, administration of glucagon or phentolamine, or increased pressure of injection with balloon obstruction of the uterine horn. Salpingography with a catheter introduced in the tubal ostium or directly inside the tube was most effective and resulted in a consistent (100%) visualization of the fallopian tube. The technique also allowed coaxial introduction of small diameter guidewires and catheters deep into the fallopian tube.

Biopsy proven eradication of an aneurysmal bone cyst treated by superselective embolization: a case report

A large aneurysmal bone cyst of the upper tibia in a 17-year-old patient was treated by superselective embolization with excellent clinical and radiological results. Extensive curettage and detailed pathologic analysis performed 2 years following embolization revealed only healing bone. The presented case and reviewed cases in the literature indicate that embolization is a promising method for definitive therapy of the aneurysmal bone cyst.

Fluoroscopic transcervical fallopian tube catheterization for diagnosis and treatment of female infertility caused by tubal obstruction

The described technique simplifies the diagnosis of fallopian tube disease and has promising potential for nonsurgical treatment of female infertility caused by fallopian tube obstruction.

Selective transcervical fallopian tube catheterization: technique update

A technique of transcervical fallopian tube catheterization involving use of a new vacuum hysterograph and coaxial catheter set is described. In 25 women, selective catheterization of the uterine cornua was accomplished with a 94% success rate. Ostial salpingography permitted visualization of 26% of the 46 tubes found to be obstructed or poorly visualized with conventional hysterosalpingography. Recanalization was successful in 96% of 28 proximal tubal obstructions and in 33% of six midisthmic obstructions unrelated to surgery. Recanalization attempts resulted in tubal perforations without apparent clinical effects in four tubes, one with proximal and three with midisthmic postsurgical obstructions. The new hysterograph with coaxial catheter set is more suitable for recanalization of the obstructed fallopian tubes than is the previously used balloon catheter set.

Curved guide wire for percutaneous pulmonary angiography

A curved, tapered, solid-core, movable J guide wire was developed for use in percutaneous transfemoral pulmonary angiography. The guide wire was used in 30 patients and, compared with other techniques, greatly reduced the time required to pass the catheter through the right side of the heart. No complications occurred, and only occasional premature ventricular contractions were detected.

Superior vena cava syndrome associated with massive thrombosis: treatment with expandable wire stents

Two patients with superior vena cava syndrome (SVCS) associated with massive thrombosis were treated by means of local thrombolytic therapy and placement of modified Gianturco expandable wire stents. Treatment resulted in complete resolution of the SVCS symptoms. The combination of local thrombolytic therapy and stent placement allows a more aggressive approach to treatment of SVCS and provides longer-term palliation of symptoms even for patients with later stages of the disease.

Roentgenologic diagnosis of pancreatic disease. By Josef Rösch, 1967

On the basis of his own experience and of literary sources, the author reports the present situation of the roentgenologic diagnosis of the pancreas. He evaluates the various examination methods and gives a general description of the typical characteristics of the diseases of the pancreas. In conclusion, he suggests ways for further improvements.

Terbutaline in diagnosis of interstitial fallopian tube obstruction

Effectiveness of terbutaline, a potent uterine muscle relaxant, for differentiation of temporary and anatomic interstitial fallopian tube obstruction (IFTO) at hysterosalpingography (HSG) was explored. In 43 IFTO evaluated, HSG after terbutaline showed patency in only one of 16 tubes in which IFTO was caused by spasm or other temporary cause. We conclude that terbutaline is not helpful in differentiating temporary from anatomic tubal obstruction during HSG.

Gianturco expandable wire stents in the treatment of superior vena cava syndrome recurring after maximum-tolerance radiation

Two patients with superior vena cava syndrome (SVCS) recurring after maximum-tolerance radiation were treated by placing a Gianturco expandable wire stent (GEWS) into the obstructed superior vena cava. The SVCS symptoms rapidly disappeared and good short-term (6 months) palliation was achieved. GEWS placement is a promising therapeutic alternative for palliation of SVCS symptoms when other therapeutic modes cannot be used or are not effective.

"Atraumatic" transjugular needle for portal vein puncture in swine

A new coaxial needle-catheter system was designed for transjugular portal vein puncture in young domestic swine. It was tested in 32 animals and successfully entered the portal circulation via a hepatic vein or intrahepatic portion of the inferior vena cava. No complications were encountered.

Fallopian tube obstruction: selective salpingography and recanalization. Work in progress

Seven infertile women, in whom interstitial fallopian tube obstruction (IFTO) was suspected at hysterosalpingography and who were recommended for surgical evaluation and treatment, were treated with catheterization techniques. Selective salpingography with ostial injection demonstrated tubal patency in two patients; direct intratubal salpingography demonstrated patency in another patient. Four patients with a true IFTO underwent fallopian tube recanalization: in the first two, a small soft-tipped guide wire was used, and in the other two, a guide wire and 3-F catheter were used. The suggested catheterization techniques have the potential to make evaluation and treatment of IFTO more efficient, safer, and less expensive than presently used methods.

Aggressive angiographic diagnosis in acute lower gastrointestinal hemorrhage

To assess the value of recently developed aggressive pharmacologic angiographic techniques for the diagnosis of acute lower gastrointestinal hemorrhage, we reviewed our experience with 63 consecutive patients referred for angiography. Hemorrhage was severe as indicated by a mean blood transfusion requirement of 9.4 units. Extravasation of contrast (46%), or an obvious vascular abnormality suggestive of a bleeding site (32%), was identified in 78% of patients. Extravasation was seen more frequently in patients with greater than or equal to 3 units of transfusion (66%) than in those with less than 3 units of transfusion (17%, P less than 0.001). After the introduction of pharmacologic techniques using heparin, tolazoline, streptokinase, and indwelling arterial catheters, the percentage of studies with extravasation of contrast increased from 32 to 65% (P less than 0.01). Application of aggressive angiographic techniques increases the diagnostic yield of angiography in acute severe lower gastrointestinal hemorrhage while exposing the patient to modest increased procedure-related risks which can be accepted in selected patients.

Experimental intrahepatic portacaval anastomosis: use of expandable Gianturco stents

Original Gianturco expandable stents and their modifications were used to create an experimental intrahepatic portacaval anastomosis (EIPCA) in 30 young domestic swine without portal hypertension. The study focused on the design of a suitable stent, the technique of its application, and the evaluation of short-term patency of the EIPCA. A stent with a 2.5-cm-long body and wire skirts on both ends was most suitable for EIPCA creation. Well-positioned stents shunted most of the portal blood in the inferior vena cava circulation and remained patent for 4-6 weeks. Ingrowth of liver parenchyma and abundant proliferation of the intima and connective tissue inside the stent lumen in these rapidly growing animals gradually decreased EIPCA patency, and thrombus formation with diminished blood flow closed them completely.

Interventional angiography in the diagnosis of acute lower gastrointestinal bleeding

Interventional angiography with the use of indwelling arterial catheters, anticoagulants, vasodilators and fibrinolytic agents, complements conventional angiography in the diagnosis of acute lower gastrointestinal bleeding. These interventional techniques prolong, augment or reactive bleeding and, by enabling better timing of examinations, they increase the diagnostic efficacy of angiography. In the reported series of 63 patients with acute lower gastrointestinal hemorrhage, interventions increased the diagnostic yield of angiography for demonstration of extravasation from 32% to 65% and decreased the percentage of negative angiograms from 27% to 16%. Indications, techniques and risks of interventional angiography in the diagnosis of acute lower gastrointestinal bleeding are discussed.

Antegrade internal ureteral stenting: a technical refinement

A pliable, easy to place, double pigtail, internal ureteral stent made of elastomeric polyurethane is described. The tapered distal pigtail end minimizes bladder irritation and the combination of a pusher and absorbable suture enables optimal placement of the proximal pigtail end in the renal pelvis. Ten stents used in eight patients remained functional without bladder irritation for a mean period of 8 months (range, 2-14 months).

Percutaneous management of iatrogenic arterial venous fistulas by coil spring occlusion

Six patients with iatrogenic arterial venous fistulas (AVFs) underwent successful transcatheter occlusion with coil springs. Three patients had AVFs as complications of surgery and in two other patients the AVFs were due to insertion of the central venous catheters. One iatrogenic AVF occurred following transhepatic obliteration of gastroesophageal varices. Management of iatrogenic AVFs by transcatheter occlusion avoids additional surgery and reduces morbidity and hospital costs. Coil springs are highly suitable for occluding iatrogenic arterial venous fistulas. They need no special preparation, are readily available, inexpensive, and easy to use.

Iopamidol arteriography: discomfort and pain

A double-blind, randomized study was performed to compare discomfort and pain associated with the use of iopamidol and Hypaque (diatrizoate sodium and diatrizoate meglumine) during iliofemoral runoff arteriography in 33 patients. Iopamidol caused substantially less discomfort and pain. The evaluation was helped by audiotaping the study and comparing patients' vocal responses to injections of these materials.

Treatment of hemobilia by transcatheter vascular occlusion

Four cases of hemobilia treated by transcatheter arterial occlusion are presented and reviewed with 30 similar cases reported in the literature. Transcatheter vascular occlusion successfully controlled hemorrhage in all 34 patients. No obvious liver parenchymal damage appeared in 26 patients; transient elevation of liver enzymes occurred in 6 patients (18%) including one in our series; two of the patients reviewed died of acute hepatic insufficiency following nonselective hepatic artery embolization. Hemobilia should be considered when gastrointestinal hemorrhage occurs after abdominal trauma, liver biopsy or other manipulative liver procedures. Hepatic angiography establishes the diagnosis and selective vascular occlusion is the treatment of choice for control of intractable or recurrent hemorrhage. Techniques and precautions for the diagnosis and transcatheter therapy of hemobilia are discussed.

Pulmonary arteriovenous fistulas occluded by percutaneous introduction of coil springs

Between July 1980 and July 1983, we occluded 30 pulmonary arteriovenous fistulas (PAVFs) in four patients by percutaneous placement of coil springs. All patients had significant right-to-left shunts and hypoxemia. One presented with recurrent cerebral abscesses following bilateral thoracotomy and lobectomy. The technique requires advancement of the catheter superselectively into the feeding artery just proximal to the fistula. Occlusion at this site preserves the maximum amount of functioning pulmonary parenchyma. Frequently more than one coil spring is required for occlusion. In our experience, the coil spring is a safe, effective, economical vaso-occlusive device for management of PAVFs.

Percutaneous removal of ureteral stents

A new device for the removal of ureteral stents by the percutaneous nephrostomy route is presented. We used this device successfully in a 4-month-old male child. Its advantages in the removal of unwanted intracorporeal wanderers such as lost catheters are discussed.

Gelfoam powder embolization of the left gastric artery in treatment of massive small-vessel gastric bleeding

Gelfoam (gelatin foam) powder was used for embolization therapy of massive gastric bleeding from small vessels in 14 patients with severe underlying medical problems. Bleeding was controlled in 10 patients with lesions localized in areas supplied by the embolized left gastric artery. In four patients with concurrent lesions in other portions of the stomach, bleeding decreased only (3 patients) or did not respond to embolization (1 patient). Complications developed in 2 patients with compromised vascular supply of the stomach: superficial ischemic ulcers that healed, and a large ulcer that perforated and required surgery. Microscopic studies demonstrated Gelfoam powder penetration mostly into vessels 100 to 200 microns in diameter and only occasionally into smaller vessels 50 to 60 microns, with occlusion of approximately 10 to 15% of the vasculature. It is concluded that Gelfoam fragments are the primary embolic material to be used for occlusion of the left gastric artery. Use of Gelfoam powder should be limited to occasional patients who have only little chance of responding to Gelfoam fragment embolization. Potential candidates for Gelfoam powder embolization include patients with major coagulopathies and/or uremia who massively hemorrhage from small-vessel lesions localized in upper portions of the stomach, exhibit significant mucosal hypervascularity, and do not respond to selective vasopressin treatment. An uncompromised vascular supply of the stomach is a precondition of a safe left gastric artery embolization.