Angiographic evaluation and management of nonvariceal upper gastrointestinal bleeding

Endoscopy is the primary diagnostic and therapeutic tool used in the evaluation and treatment of patients with upper gastrointestinal bleeding. When endoscopy is unsuccessful in identifying or controlling GI hemorrhage, however, arteriography is useful in both the evaluation and treatment of upper GI hemorrhage.

Outcome of 100 patients after transjugular intrahepatic portosystemic shunt for variceal hemorrhage

OBJECTIVES

One hundred consecutive patients with recurrent or refractory acute variceal hemorrhage treated with a transjugular intrahepatic portosystemic shunt (TIPS) from June 1990 to June 1993 at Oregon Health Sciences University or the Portland Veterans Affairs Medical Center were evaluated to assess shunt patency and clinical outcome, including complications of TIPS, rebleeding, and survival.

METHODS

Success of shunt placement, reduction in portal pressure, complications, survival, recurrent hemorrhage, severity of ascites, hepatic encephalopathy before and after TIPS, and shunt patency were assessed in each patient.

RESULTS

The mean follow-up period was 17.7 months (range, 0.1-56.7 months). TIPS was successfully completed in all patients, with a mean reduction in portosystemic gradient from 24 to 11 mm Hg. Major complications occurred in 11 patients, including one death. Survival after TIPS was 85% at 30 days, 71% at 1 yr, and 56% at 2 yr. Variceal bleeding stopped within 24 hours after TIPS in all eight patients with active hemorrhage. Recurrent variceal hemorrhage occurred in 18 patients at a mean of 4.3 months (range, 1-713 days) after TIPS. The cumulative rate of recurrent variceal bleeding was 20% at 1 yr and 25% at 2 yr after TIPS. Recurrent variceal bleeding was associated with shunt stenosis or occlusion in all patients with endoscopically documented variceal hemorrhage, which was successfully managed by reopening obstructed shunts and performing variceal embolization. The prevalence of ascites was significantly reduced among surviving patients evaluated 3 months after TIPS (67 vs 25%, p < 0.005). Three months after TIPS, the incidence of new or worsening hepatic encephalopathy was 20%, but encephalopathy improved in an equal proportion of patients. Seventy-three of 77 (95%) shunts examined for patency were open at the last follow-up examination. However, most shunts required intervention to maintain patency, and only 48% (37 of 77) were primarily patent at a mean of 168 days (range, 2-538 days) of follow-up. Shunt stenosis or occlusion, as determined by venography, became increasingly frequent with longer follow-up (52% at 3-9 months and 70% at 9-15 months).

CONCLUSIONS

TIPS is effective in lowering elevated portal pressures in patients with refractory variceal hemorrhage, has acceptable postprocedure complication and mortality rates, ameliorates ascites, and in, a minority of patients, worsens encephalopathy. Shunt stenosis occurs in the majority of patients but can be effectively treated by interventional techniques to maintain patency. The incidence of recurrent variceal hemorrhage is low and is associated with shunt stenosis or occlusion.

Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy

BACKGROUND

Self-expanding metallic stents (SEMS) are effective in relieving the symptoms of obstructing esophagogastric malignancy. While complications with SEMS have been described, factors influencing such occurrence have not been defined.

METHODS

Self-expanding Gianturco-Rosch Z-stents were placed successfully in 59 patients with obstructing esophagogastric malignancies.

RESULTS

Early procedure-related complications occurred in 6 patients (10%) and were usually minor. Twenty-three late complications occurred in 22 patients (37.5%). Life-threatening complications occurred in 9 patients (15%), including gastrointestinal bleeding (7), perforation (1), and tracheoesophageal fistula (1) and contributed to all five deaths. Eight of 22 patients with prior radiation and/or chemotherapy (36.4%) had life-threatening complications compared to 1 of 37 (2.5%) without prior therapy (p = 0.001). Stent-related mortality occurred in 5 of 22 (23%) patients with prior therapy compared to none of the 37 without prior therapy (p = 0.005). Multivariate analysis confirmed the association between prior radiation and/or chemotherapy and life-threatening complications (p = 0.012; odds ratio, 32.63) and also an association with female gender (p = 0.032; odds ratio, 13.9). There was no association with tumor location or length, histologic type, age, prestent dysphagia grade, or previous surgical resection.

CONCLUSION

Patients with prior radiation and/or chemotherapy have an increased risk of severe complications following placement of SEMS.

Effects of hepatic artery embolization with Lipiodol and gelatin sponge particles on normal swine liver

In order to evaluate the effects of hepatic artery embolization (HAE) with Lipiodol (Lp) and gelatin sponge particles (GSP) on swine liver tissue, we embolized the hepatic arteries of 3 pigs with GSP, 9 with Lp, and 9 with Lp + GSP. None of the pigs embolized with GSP died spontaneously during the 4-week experimental period. One pig embolized with 1 ml/kg Lp and three pigs with 2 ml/kg Lp died within 2 h. Two pigs embolized with 0.5 ml/kg Lp + GSP died the following day. The portal vein pressure (PVP) and wedge hepatic vein pressure (WHVP) values before HAE, immediately after, 1 h after, and 4 weeks after HAE showed no remarkable change in the GSP group. Remarkable and temporary elevation was observed in the more than 0.2 ml/kg Lp group. Remarkable and continuous elevation was observed in the 0.2 ml/kg Lp + GSP and 0.5 ml/kg Lp + GSP groups. Gross and histological studies demonstrated no liver damage in the GSP and Lp group. Liver infarction, circular coagulation necrosis with pseudocapsule, and liver atrophy were found in the Lp + GSP group 4 weeks after HAE. The incidence of infarction, circular coagulation necrosis, and liver atrophy in the livers embolized with 0.2 ml/kg Lp + GSP and 0.5 ml/kg Lp + GSP were 67%, 100%, and 75%, respectively. In conclusion, when the hepatic artery is embolized with Lp + GSP, the volume of Lp should be limited to less than 0.1 ml/kg.

Distribution and effect of iodized poppyseed oil in the liver after hepatic artery embolization: experimental study in several animal species

To define the intrahepatic distribution of iodized poppyseed oil and its effect on the liver, hepatic artery embolization (HAE) was performed in five mice, 12 rats, four rabbits, and 21 pigs with the iodized oil alone or in combination with gelatin sponge powder (GSPow) in three rats or gelatin sponge particles (GSPs) in nine pigs. All mice, rats, and rabbits underwent radiography of the upper abdomen and in vivo microscopy of the hepatic periphery during and immediately after injection and 1, 4, and 24 hours later. All pigs underwent angiography before and after HAE as well as measurement of portal venous pressure before HAE and 15, 30, 45, and 60 minutes and 4 weeks after HAE. Follow-up radiographs were obtained in 18 pigs. HAE performed with the iodized oil only was well tolerated by the liver, even when high doses were used, likely because of continuous flushing of the sinusoids by high blood flow from peripheral arterioles. When HAE was performed with the iodized oil and GSPow, this blood flow ceased and necrosis developed. The degree of necrosis after HAE with the iodized oil in combination with GSPs was directly associated with the dose of iodized oil. HAE performed with GSPs only did not cause damage.

Venous stenoses in patients who undergo hemodialysis: treatment with self-expandable endovascular stents

During a 32-month period, 25 modified self-expandable endovascular stents were placed in 20 hemodialysis access sites to treat 21 stenoses and four occlusions in 19 patients. All stenoses were initially dilated with a high-pressure balloon. The initial success rate was 90% (18 of 20 access sites). The stents were patent from 0 to 960 days (mean duration of follow-up, 309 days). At 2 years follow-up, the patency rates were as follows: primary, 25%; secondary, 34%; and tertiary, 42%. The morbidity rate associated with this procedure was 15% (three of 20 sites); the mortality rate, 5% (one of 19 patients). All five complications (graft or native-vein thrombosis [n = 2], nerve deficits [n = 2], and death secondary to sepsis [n = 1]) occurred in three patients early in the study, before the use of prophylactic antibiotics and refinements in technique. The best results occurred in patients in whom the stenosis or occlusion affected a large vein that had no acute angle and was away from venous confluences such as the femoral and iliac regions.

Recovery of function in a solitary kidney after intra-arterial thrombolytic therapy

Renal artery thromboembolism is a rare event that most often occurs in patients with cardiac dysrhythmias. Surgical thromboembolectomy is risky and medical therapy with intra-arterial thrombolytic agents has become increasingly popular. Although successful clot dissolution has been well documented, renal function often is not recovered. We describe a patient with anuria from thromboembolism to a solitary kidney, treated with low dose intra-arterial streptokinase infusion. There were no adverse effects from therapy and renal function returned to a point where dialysis was no longer required. A review of the literature is included with special attention to various protocols for infusion. Early diagnosis and prompt initiation of therapy may result in clinically significant recovery of renal function.

Small vessel leg angiography for distal vessel bypass grafts

To improve visualization of the small vessels for distal bypass grafting, arteriograms of the lower extremity were obtained in 187 patients by use of active warming of the extremities, selective distal positioning of the catheter for contrast agent injections, and intraarterial administration of tolazoline. With these techniques, satisfactory visualization was obtained for planning of operation, and in only one patient was an intraoperative arteriogram necessary before bypass grafts were placed.

Diagnosis of cornual obstruction by transcervical fallopian tube cannulation

Interstitial fallopian tube obstruction (IFTO) occurs in 15% of hysterosalpingograms (HSG) performed for infertility. Conventional HSG or laparoscopy may not differentiate cornual spasm or other temporary cause from true obstruction. We used transcervical cannulation of the proximal oviduct with a 3-F Teflon catheter and flexible guidewire 0.018 inch (0.043 cm) in diameter under hysteroscopic or fluoroscopic guidance to evaluate IFTO in 28 patients. Fluoroscopic catheterization techniques with selective salpingography demonstrated patency in 84% of obstructed tubes. Hysteroscopic cannulation with direct visualization by laparoscopy or laparotomy was successful in 92%. In one patient, perforation of the isthmus occurred without sequelae. Transcervical coaxial cannulation of the proximal oviduct is an effective method for evaluating cornual obstruction.

Urokinase in gastrointestinal tract bleeding

Selective urokinase infusion into the superior mesenteric artery allowed the accurate determination of the site of small bowel bleeding in a patient with recurrent lower gastrointestinal bleeding who bled despite resective surgery and who had negative findings on four angiograms. Fibrinolytic agents are useful in rare cases in which the need for successful and accurate diagnosis outweighs the risks of reactivating the bleeding.

Nonbronchial systemic collateral arteries: significance in percutaneous embolotherapy for hemoptysis

Twenty patients with massive or recurrent hemoptysis underwent percutaneous transcatheter embolotherapy between 1979 and 1986 for the following diseases: cavitary aspergillosis (n = 4); cystic fibrosis (n = 4); tuberculosis (n = 3); bronchogenic carcinoma (n = 3); bronchiectasis (n = 3); small cell lung carcinoma 6 years after irradiation (n = 1); congenital heart disease, after Glenn and Blalock anastomoses (n = 1); and unknown interstitial disease (n = 1). Bronchial arteries were embolized in all but one patient. In nine patients (45%) nonbronchial systemic collateral arteries contributed significantly to areas of pathologic pulmonary tissue and frequently were the major arterial supply. These nonbronchial systemic collaterals included branches of the subclavian and axillary arteries (n = 7), intercostal arteries (n = 5), and phrenic arteries (n = 3) and accounted for 59.5% of the total number of arteries embolized. Recognition and occlusion of nonbronchial systemic collaterals providing blood to hypervascular pulmonary lesions is essential for successful percutaneous embolotherapy of hemoptysis.

Hepatogenic pulmonary angiodysplasia treated with coil-spring embolization

Coil-spring embolization is a procedure for treatment of pulmonary arteriovenous malformations. Herein is described a patient with hepatogenic pulmonary angiodysplasia ("pulmonary spiders") managed with this technique.

Selective therapeutic embolization of renal cell carcinoma in solitary kidneys

We report 3 cases of renal cell carcinoma in a solitary kidney treated by selective tumor embolization. Embolization resulted in occlusion of the majority of the vascular supply of the tumor, with preservation of normal renal parenchyma and sufficient renal function. Selective tumor embolization is a good therapeutic alternative in patients in whom partial nephrectomy cannot be performed. Owing to the limited availability of bucrylate, absolute ethanol is recommended as the preferred embolic agent.

Percutaneous renal ablation in patients with end-stage renal disease: alternative to surgical nephrectomy

Percutaneous transcatheter ablation was performed on 18 kidneys in ten patients with end-stage renal disease (ESRD), who were either on hemodialysis or had undergone renal transplantation, for the following indications: nephrotic syndrome with massive protein loss (seven patients, 13 kidneys), poorly controlled posttransplantation hypertension in the absence of transplant renal artery stenosis (two patients, three kidneys), and diabetic nephropathy with persistent urine leak from ureterocutaneous fistulas following pelvic irradiation (one patient, two kidneys). Desired clinical results were achieved in all cases. Percutaneous renal ablation is an effective alternative to surgery in patients with ESRD who require nephrectomy.

Arterial embolization for massive upper gastrointestinal tract bleeding in poor surgical candidates

Therapeutic vascular occlusion was used in 32 patients to control massive upper gastrointestinal tract bleeding. All patients were poor surgical candidates and received an average of 12 U of red cells before embolization. Control of bleeding (for greater than 24 h) was attained in 23 of 32 patients (72%). Six of these 23 patients (26%) subsequently died within a 6-mo follow-up period, 5 due to underlying diseases, and only 1 due to rebleeding. Nine patients were not controlled initially with embolization, although 6 had marked reduction in bleeding. Eight of these 9 patients died (89%), 6 from hemorrhage or emergent gastric surgery, and 2 from underlying diseases. All patients with Mallory-Weiss tears (5) and with hemobilia (3) were successfully treated with embolization. Serious complications included gastric infarction in 2 patients with prior compromise of gastric arterial supply. Embolization offers an efficacious alternative to emergent surgery for control of massive upper gastrointestinal arterial hemorrhage in the poor risk surgical candidate.

Natural history of asymptomatic coronary arteriographic lesions in diabetic patients with end-stage renal disease

Arteriosclerotic heart disease is a major cause of death in insulin-requiring juvenile diabetic patients treated for end-stage renal disease. Eleven consecutive diabetic patients without clinical evidence of coronary artery disease underwent complete cardiac evaluations, including coronary arteriography, as part of transplant recipient work-ups. Seven were women and four were men; their mean age was 32 (21 to 50 years). Angiographically, every patient had multifocal atherosclerotic coronary disease. Four of seven patients tested had positive-stress electrocardiograms. In this group of patients followed for a mean of 19.8 months, eight died. Of these deaths, six were due to coronary heart disease and another due to a stroke. In two patients who became clinically symptomatic, serial angiograms revealed progressive disease of the coronary circulation; in one case, despite normal renal allograft function and serum lipid levels. The mode of end-stage renal disease treatment, serum lipids or blood pressure control could not be linked to mortality. It is concluded that arteriosclerotic heart disease is common in diabetic patients with end-stage renal disease even when angina is absent. The natural history in this high risk population is an important consideration in the selection of patients for end-stage renal disease treatment.

Percutaneous transhepatic obliteration of gastroesophageal varices: some technical aspects

Two cases of bleeding from gastroesophageal varices treated by variceal obliteration illustrate multiple routes of variceal supply, and alert embolizing angiographers to the presence of spontaneous portosystemic shunts which should be kept open. In one case, variceal obliteration required embolization of the left gastric vein and a transhepatic collateral originating from the left hepatic portal branch and contributing substantially to variceal filling. A second patient with a relatively large spontaneous splenorenal shunt had recurrent variceal bleeding two months after a successful embolization of the coronary vein and a short gastric vein. A repeat study revealed the recurrent varices were supplied by enlarged right gastric and gastroepiploic veins. Superior mesenteric venography was necessary for their visualization.

The role of arteriography in abdominal aortic aneurysm

The results of arteriography in the management of 100 consecutive patients with abdominal aortic aneurysms are presented. Arteriographic information had substantial influence upon management decisions and performance of surgery in 75 per cent of cases. We found the preoperative knowledge of the precise vascular pathology or anatomic variants not only permitted a more rational recommendation for or against surgery but aided in the selection of the most suitable surgical procedure.

Cromolyn sodium nasal solution in the prophylactic treatment of pollen-induced seasonal allergic rhinitis

A large-scale multicenter investigation was undertaken in 3 cities with comparable pollen seasons and atmospheric pollen concentrations in order to obtain more definite information about the safety and efficacy of cromolyn sodium in the treatment of pollen-induced seasonal rhinitis. The 9-wk double-blind study was conducted in 104 patiets in Pittsburgh, Pa., Cleveland, Ohio, and Louisville, Ky., during the 1975 ragweed season. It indicated that a nebulized 4% aqueous solution of cromolyn sodium is effective in reducing sneezing, rhinorrhea, nasal congestion, and ocular irritation in ragweed hay fever patients. The efficacy of the drug was notable despite the fact that patients used an average of 52 mg instead of the recommended 62.4 mg daily. Cromolyn sodium did not appear to have a significant effect on transseasonal antiragweed IgE (IgEAR) levels. Patients acceptance of the cromolyn nasal solution was good, and there were no significant adverse reactions. The side effects, which were distributed equally between the drug and placebo groups, were mild and of limited duration.

Acute coronary insufficiency with normal coronary arteriograms

Two patients presenting with apparent symptomatic and electrocardiographic evidence of acute coronary insufficiency and found to have normal coronary arteriograms are documented. The patients remain symptom free at follow-up 9 and 14 months later although one requires 160 mg propranolol daily. The electrocardiographic, myocardial metabolic and haemodynamic data in 413 patients with angina and normal coronary arteriograms are reviewed and the suggested aetiologies documented. Follow-up of patients in these series indicates a good prognosis for symptom-free survival.

Angiography in the diagnosis and therapy of frostbite

Five patients with frostbite injury were studied by selective angiography and treated by selective intra-arterial application of reserpine with follow-up angiography two days later. Control angiograms showed various degrees of vascular spasm as well as organic stenosis and occlusion. Intra-arterial reserpine produced dramatic subsiding of vasospasm, as evidenced by angiography and relief of clinical symptoms. Complete healing without tissue loss occurred in 4 patients. Amputation was necessary in one case, due at least in part to pre-existing peripheral atherosclerotic disease. Selective angiography was found to contribute significantly to both the diagnosis and therapy of frostbite injury.

Retrograde pancreatic venography. An experimental study

To explore the feasibility of retrograde pancreatic venography, transhepatic portal catherization via jugular and hepatic veins was performed in 10 dogs. Coaxially introduced catheters were then used to enter individual pancreatic veins for retrograde venography. Appropriate injection technique led to detailed visualization of the pancreatic venous system without anatomically evident injury to the pancreas. The (readily avoidable) injection of contrast agent through catheters wedged into pancreatic veins caused parenchymal extravasation and hemorrhagic pancreatitis. The detection of pancreatic cancer in patients not approachable by arteriography and the intensified search for small islet cell tumors are possible indications for pancreatic venography when the safety of this method is further demonstrated.