Effects of selective angiography of the carotid artery with carbon dioxide on electroencephalogram somatosensory evoked potentials and histopathologic findings. A pilot study in pigs

RATIONALE AND OBJECTIVES

The authors investigate the cerebral effects of selective carotid angiography with carbon dioxide (CO2).

METHODS

In 6 pigs, CO2 was injected into the carotid artery with consecutively increasing doses. Cerebral function was monitored with two-channel electroencephalography and somatosensory evoked potentials (SEPs). After the experiment the brains were investigated histopathologically.

RESULTS

Initial doses led to reversible decreases in electroencephalograph power by 40% to 80%. Further doses result in partly nonreversible electroencephalographic changes. Somatosensory evoked potential latencies (n = 5) were not changed. Amplitudes were not affected in low dose ranges up to 40 mL CO2. Higher CO2 doses led to different changes. There were no SEP amplitude reductions (n = 1), as well as reversible (n = 2) and nonreversible (n = 2) SEP amplitude reductions. Histopathologically, edema (n = 6), edema necrosis (n = 2), and destroyed cells as a sign of ischemia (n = 2) were found.

CONCLUSIONS

Administering CO2 in brain supplying arteries impairs the cerebral function. Consecutive, increasing doses lead to partly nonreversible electroencephalographic and SEP changes and brain tissue damages.

Severe hemoptysis requiring lobectomy in an 11-year-old patient with Kartagener's syndrome

The case of a young girl with severe hemoptysis in a Kartagener's syndrome is described. Because bronchoscopy failed to locate the origin of the bleeding, preoperative angiography was performed. The patient was treated by resection of the middle lobe. The bronchus wall was located as the origin of bleeding.

MR imaging signal-intensity abnormalities after placement of arterial endoprostheses

OBJECTIVE

Our objectives were to describe changes in T2-weighted MR images of patients who had undergone implantation of an endoluminal stent-graft and determine the rate of early reocclusion in patients with abnormal MR findings.

SUBJECTS AND METHODS

Twenty-nine patients with 26 occlusions (average length, 8.7 +/- 5.6 cm) and three dissections of the superficial femoral artery were treated with 45 endoluminal stent-grafts. T2-weighted gradient-echo and T2-weighted turbo spin-echo MR images were obtained for all patients at 48 hr and at 4 weeks after stent-graft placement. We reviewed the MR imaging studies to assess the extent and severity of tissue alteration at the site of stent-graft implantation.

RESULTS

Technical success rate of stent-graft placement was 100%. Three signal-intensity patterns were seen on MR images obtained at 48 hr: normal signal intensity (n = 8), subtle perivascular signal-intensity abnormalities at the site of stent-graft implantation (n = 11), and extensive signal-intensity abnormalities from the adductor canal to the subcutis (n = 10). Twenty of 21 patients with abnormal signal intensity on MR images had fevers and pain at the implantation site. Clinical signs of deep vein thrombosis, a diagnosis excluded on the basis of phlebography, were seen in the 10 patients with extensive signal-intensity abnormalities. In two of these 10 patients, the superficial femoral artery reoccluded within 4 weeks of implantation. MR images obtained at 4 weeks showed no signal-intensity abnormalities in any of the 29 patients.

CONCLUSION

MR findings of perivascular signal-intensity abnormalities after implantation of endoluminal stent-grafts are associated with clinical complications such as local pain and fever. Care should be taken to avoid confusing the clinical signs of the postimplantation syndrome at 48 hr with deep vein thrombosis.

Cardiac-gated two-dimensional phase-contrast MR angiography of lower extremity occlusive disease

OBJECTIVE

The purpose of this study was to evaluate our capability to use coronally acquired, cardiac-gated two-dimensional phase-contrast MR angiography (MRA) to correctly detect and grade arteriosclerotic lesions from the aortic bifurcation to the popliteal artery.

SUBJECTS AND METHODS

One hundred fifteen patients with a total of 253 arteriosclerotic lesions proven by intraarterial digital subtraction angiography were examined prospectively by two-dimensional phase-contrast MRA. MRA was performed from the aortic bifurcation to the popliteal trifurcation. Imaging parameters were TR/TE, 83/9 msec; flip angle, 11 degrees; matrix, 256 x 192; acquisitions, two; slice thickness, 80 mm; and field of view, 320 mm. ECG gating was used routinely and eight to 10 phases were acquired during the cardiac cycle. Velocity encoding was set to 30 cm/sec in the iliac arteries and to 20 cm/sec in the femoral and popliteal arteries. Detected stenoses were graded in the following manner: 1% to less than 50% stenosis, group 1; 50% to less than 75% stenosis, group 2; 75% to less than 100% stenosis, group 3; and total occlusion, group 4.

RESULTS

All arteriosclerotic lesions were revealed by MRA. Two hundred seventeen of 253 lesions were also graded correctly. Sensitivity was 95%, specificity was 90%, positive predictive value was 90%, and negative predictive value was 96%. The weighted kappa index was (.92). Sensitivity and specificity for occlusions were both 100%; for high-grade stenoses, 94% and 91%, respectively; for moderate stenoses, 84% and 94%, respectively; and for mild stenoses, 79% and 100%, respectively.

CONCLUSION

Two-dimensional phase-contrast MRA can provide MR angiograms with high sensitivity and specificity for high-grade stenoses in a reasonable amount of time in patients with peripheral artery occlusive disease.

Contrast-enhanced, K-space-centered, breath-hold MR angiography of the renal arteries and the abdominal aorta

The purpose of this study was to evaluate the capability of contrast-enhanced breath-hold fast imaging with steady-state precession (FISP) three-dimensional MR angiography (MRA) to detect stenotic lesions of the abdominal aorta, the renal arteries, and the iliac arteries by using a K-space-centered 20-ml gadolinium-diethylene pentaacetic acid (Gd-DTPA) bolus. Fifty patients were studied before conventional x-ray angiography. Contrast-enhanced breath-hold FISP three-dimensional MRA was applied in the coronal view, centered at the renal arteries. Twenty ml of Gd-DTPA was used in all subjects. A test bolus was applied to determine the injection time for the K-space-centered bolus injection. Of 300 segments, 284 segments were classified correctly, 11 were overestimated, and five were underestimated. Sensitivity was 98%, specificity was 96%, positive predictive value was 96%, negative predictive value was 98%, and accuracy was 97%. Of the 50 patients studied, 43 were staged correctly. No venous overlay was seen in 31 patients; partial overlay was seen in 16 patients, and venous structure overlay obscuring arterial anatomy was found in two patients. Six of nine accessory renal arteries could be identified by MRA. Intraobserver variability was .94. This study has shown the ability of contrast-enhanced breath-hold FISP three-dimensional MRA to detect and grade vascular lesions in the abdominal aorta and the renal arteries. The method may serve as a screening tool in the future.

[MR angiography of pelvic arteries]

During the last years, magnetic resonance angiography (MRA) has become a widely used modality for intracerebral and carotid artery imaging. Due to technical limitations, the clinical impact of MRA in the iliofemoral arteries has been rather poor. New developments in MRA like ECG-triggered sequences and the occurrence of contrast-enhanced MRA has overcome most of these limitations. Therefore, a major advance in clinical use of these diagnostic tools can be predicted. This paper discussed the advantages of ECG-gated 2D-Phase contrast, ECG-gated 2D-Time-of-Flight and contrast enhanced FLASH 3D angiography sequences from a clinical point of view. 2D-PC-MRA is a robust technique, which provides an overview of the iliofemoral artery system in less than 5 minutes. Limitations are the true 2D impression of the sequence and the partial venous overlay. 2D-TOF-MRA on the other hand is time consuming, however it enables 3D reconstruction and effective venous suppression can be applied. Contrast enhanced MRA as the third sequence discussed provides high resolution images in less than 30 sec. However contrast bolus timing might be a problem. In conclusion the authors suggest a combination of 2D-PC-MRA and additional 2D-TOF sequences at questionable vascular areas as the modality of choice, due to the fact, that MRA of the iliofemoral arteries ist mostly only one step of a complete lower limb examination. Contrast MRA might become the method of choice in the future however problems with multiple contrast injections and upper limits of contrast dose have to be solved.

Common carotid artery bifurcation: preliminary results of CT angiography and color-coded duplex sonography compared with digital subtraction angiography

OBJECTIVE

The purpose of this study was to compare the abilities of color-coded duplex sonography, CT angiography, and selective digital subtraction angiography to reveal disease requiring surgery in patients with occlusive disease of the carotid bifurcation.

MATERIALS AND METHODS

Fifty-six carotid arteries in 28 patients who had 48 carotid stenoses and symptomatic cerebrovascular disease were prospectively studied by selective digital subtraction angiography, color-coded duplex sonography, and CT angiography. CT data were displayed in maximum intensity projection. The degree of stenoses revealed were graded as mild, moderate, severe, and occluded according to North American Symptomatic Carotid Endarterectomy Trial criteria. The results of CT angiography and color-coded duplex sonography were correlated with the gold standard of digital subtraction angiography.

RESULTS

Grading of stenoses on CT angiography agreed with grading of stenoses on digital subtraction angiography in 89% of cases. All high-grade stenoses and occlusions revealed on CT angiography were correctly interpreted by all observers. For stenoses revealed by color-coded duplex sonography and digital subtraction angiography, observers' agreement was 75%. Two severe stenoses were incorrectly graded as occluded by the interpreter of the color-coded duplex sonograms. Also, one occluded carotid artery was misdiagnosed as moderate stenosis.

CONCLUSION

Our results indicate that CT angiography is superior to color-coded duplex sonography for evaluating carotid disease and determining disease requiring surgery. CT angiography warrants further investigation in a larger group of patients.

The total entropy for evaluating 31P-magnetic resonance spectra of the liver in healthy volunteers and patients with metastases

RATIONALE AND OBJECTIVES

The authors describe the clinical status of liver tissue with only a single numerical quantity (total entropy) derived from spectroscopic data of 31P-magnetic resonance (MR) spectra.

METHODS

Twenty-four patients with liver metastases and 20 volunteers were investigated with image-guided volume selective 31P-MR spectroscopy on a 1.5-T whole body scanner. From each in vivo 31P-MR spectrum, the ratios of phosphomonoester (PME)/beta-adenosine triphosphate (ATP), inorganic phosphate (Pi)/beta-ATP and phosphodiester (PDE)/ beta-ATP and the total entropy (H*) were calculated. Mean values and standard deviations were determined and significance of the differences were tested with Student's t test.

RESULTS

For patients, the H* = 4.7 +/- 4.3, PME/beta-ATP 0.72 +/- 0.28, Pi/beta-ATP = 1.00 +/- 0.39, PDE/beta-ATP = 1.68 +/- 0.59. For the volunteers, H* = 7.6 +/- 2.5, PME/beta-ATP = 0.39 +/- 0.15, Pi/beta-ATP = 0.90 +/- 0.19, PDE/beta-ATP = 1.25 +/- 0.28. The total entropy of patients' spectra showed significantly lower values compared with those of volunteers. PME/beta-ATP and PDE/beta-ATP of the patients increased and differed significantly from volunteer data.

CONCLUSIONS

It was demonstrated that the results of in vivo 31P-MR spectroscopy may be described with a single criterion by means of the total entropy.

[3D-CT angiography and duplex sonography compared to arteriography in carotid stenoses]

PURPOSE

To determine the value of 3D-CT angiography, duplex sonography in comparison to selective digital subtraction angiography for evaluation of carotid artery stenoses.

METHODS

30 patients with 51 stenoses of carotid artery underwent 3D-CT angiography, duplex sonography and angiography. Quantification of stenosis was determined according to the NASCET study and categorized into mild (0-29%), moderate (30-69%), severe (70-99%) and occluded (100%).

RESULTS

The agreement of 3D-CT angiography with intraarterial digital subtraction angiography (DSA) was 62% (r = 0.89; p < 0.0001) and of duplex sonography with DSA was 77% (r = 0.94; p < 0.0001). Both modalities underestimated one occlusion as stenosed. In the evaluation of moderate and severe stenoses 3D-CT angiography showed an agreement with DSA in 50% (duplex: 88%) and 55% (duplex: 89%) respectively and was inferior to duplex sonography.

CONCLUSION

3D-CT angiography is inferior to duplex sonography in the evaluation of carotid stenosis and not useful as a screening or reference examination.

Distinct central anticholinergic syndrome following general anaesthesia

The purpose of this prospective study was to identify the incidence of a distinct central anticholinergic syndrome following routine anaesthesia. For 2 months, all inpatients aged more than 15 years scheduled for elective procedures and cared for in the recovery room were investigated for symptoms of the syndrome. Patients with neuropsychiatric disease or other disorders that could alter consciousness were excluded. Prolonged action of anaesthetics or relaxants, respiratory depression and metabolic disorder were ruled out before making the diagnosis. Out of 962 patients (366 men, 596 women), 18 (4 men, 14 women) developed the syndrome. The difference between men and women was not statistically significant. Six out of 60 women developed the syndrome after a hysterectomy with or without adnectomy/oophorectomy, and this high incidence was significantly different from that observed after all other procedures in women (P = 0.003) or all other gynaecological procedures (P = 0.013). The reason for this is unknown. In six of the 18 cases, untreated prolonged somnolence lasted for more than 2 h. All patients woke up after an injection of physostigmine, but six of them relapsed into somnolence and needed a second, and in one case a third, injection. The findings of the study emphasize that, when there is delayed recovery from anaesthesia, the diagnosis of central anticholinergic syndrome should be considered if other accessible causes for that condition have been excluded.

[MR angiography of the carotid arteries using 3D TOF technique with sagittal double-volume acquisition using a new head-neck coil]

PURPOSE

The aim of the study was to assess the value of MR angiography (MRA) in sagittal technique compared to DSA in the evaluation of carotid artery stenosis.

METHODS

80 carotid arteries in 40 symptomatic patients were prospectively studied with DSA and MRA. MRA was carried out by means of 3 D time-of-flight technique with a FISP sequence (TE6 ms/TR80 ms, flip angle 25 degrees, FOV 240 x 210 mm, matrix 157 x 256 mm, in-plane resolution 1.34 x 0.94 mm, partition thickness 1.32 mm, slab thickness 45 mm, acquisition time 7 min) using a new head-neck coll. Data acquisition was performed in sagittal orientation with the "double-slab" technique. Imaging quality of the extracranial carotid arteries and correctness of quantification of stenosis was performed.

RESULTS

Imaging quality was good at the origin of the carotid arteries in 65%, at the bifurcation region in 98% and near the skull base in 81%. The agreement of DSA and MRA was 96% of the normal arteries (24/25), 90% of the severe stenoses (28/31) and 100% of the occluded arteries (9/9).

CONCLUSION

MRA in sagittal "double-slab" technique is a noninvasive technique allowing to detect normal arteries and candidates for surgery with a high degree of certainty.

[Modified manual rt-PA pulse-spray lysis in occlusions of leg arteries and femoro-popliteal bypasses]

PURPOSE

The evaluation of local rt-PA pulse-spray-lysis (PSL) by the Katzen infusion wire for treatment of thrombosed leg arteries and bypass grafts.

MATERIAL AND METHOD

21 patients (mean age 64.4 years) with either occluded leg arteries (n = 19) or femorocrural bypass grafts (n = 2) were treated with PSL. Mean length of occlusion was 13.2 +/- 11.6 cm. Time of occlusion ranged from less than one week to 6 months.

RESULTS

In 71.43% (15/21) the occlusions could be successfully recanalized with PSL. The mean rt-PA dose was 10.7 +/- 4.9 mg. Remaining stenoses were handled with PTA (n = 9) and additional stent implantation (n = 3). Additional long-time-lysis with 17.5 mg rt-PA was necessary in two cases, the success rate increased to 81% (17/21). The anlde-brachial-index increased from 0.38 +/- 0.29 to 0.83 +/- 0.32 within 24 hours after intervention. In 4 cases bleeding complications occurred. 5 patients showed reocclusions during 6 months follow-up.

CONCLUSIONS

Local fibrinolysis with rt-PA in PSL technique using the Katzen infusion wire is a feasible and promising treatment of thrombosed leg arteries and grafts. Even careful and dosage-minimized rt-PA application cannot prevent bleeding complications.

[Therapy of venous stenosis using wall stents]

OBJECTIVE

To evaluate the patency of Wallstents implanted for the treatment of venous stenoses in patients with benign or malignant disease.

PATIENTS AND METHODS

22 Wallstents (20 central venous; two peripheral) were implanted during a period of two years in 12 patients (nine men, three women; mean age 57.8 [26-76] years) with malignant venous stenoses (n = 9) or stenosed dialysis shunts (n = 3). Stent diameter ranged from 8-16 mm, length from 32-91 mm. Introduction of the stents were by percutaneous transfemoral catheterisation, in six patients with simultaneous wire placement from a cubital to the femoral vein. The superior vena cava was the involved vessel in six patients (in two each also the subclavian or brachiocephalic veins), in three only the subclavian vein, twice only the inferior vena cava and once the cephalic vein.

RESULTS

The patency of the stents was checked after 4.7 +/- 3.6 (1-14) months, in seven patients clinically, by digital subtraction phlebography in three, by computed tomography in two. In nine patients there was no evidence of obstruction to flow or flow was normal. Stent occlusion had occurred in three patients, 4, 9 and 14 months after placement. There were no complications. Five patients died after a mean period of 4.8 +/- 3.6 (1-6.5) months from the underlying disease, without symptoms of obstruction to flow.

CONCLUSION

Stent placement should be considered early, as it is a well-tolerated and effective palliative procedure for central venous stenoses associated with malignant disease or stenosis of dialysis shunts.

[MR diagnosis after a Ross operation]

PURPOSE

To determine the ability of MRI to diagnose morphological and functional changes in patients after Ross procedure.

MATERIAL AND METHODS

During one year, 5 patients after Ross procedure were studied by MRI. T1-weighted spin-echo sequences in different orientations as well as cine sequences and a VENC sequence were used.

RESULTS

In all patients the morphology including the postoperative changes could be visualised by MRI. The cine sequences provided functional information on valvular and ventricular function. VENC-MR yielded an exact quantification of the regurgitant fraction.

CONCLUSION

MRI is capable of providing all important diagnostic information in patients after Ross procedure such as valvular and ventricular function and valvular and outflow tract morphology in a single examination.

[Mechanical thrombolysis with the Amplatz thrombectomy catheter]

PURPOSE

To determine the efficiency of the Amplatz thrombectomy device (ATD) in thromboembolic occlusions of lower limb arteries and haemodialysis shunts.

PATIENTS AND METHODS

9 patients (mean age 61 years) with either occluded native leg arteries (n = 7) or haemodialysis graft access (n = 2) were treated with the ATD. Mean length of occlusion was 10 +/- 4.47 cm.

RESULTS

The occlusions were primarily successfully recanalized by ATD within 44 +/- 17 seconds. Remaining stenoses were treated with percutaneous transluminal angioplasty (PTA, n = 6) and an additional implantation of a vascular stent (n = 3). The ankle-brachial-index (ABI) increased from 0.46 +/- 0.37 to 0.81 +/- 0.2 within 24 hours after intervention. In the first month ABI measured 0.9 +/- 0.15 and decreased from 0.7 +/- 0.23 after three months to 0.72 +/- 0.26 within 6 months. After 5 months, a shunt occlusion and a native leq artery occlusion appeared.

CONCLUSIONS

Thrombolysis by ATD is a safe, feasible and simple procedure. There are no contraindications. No complications were seen.

Determination of binding constants of diabodies directed against prostate-specific antigen using electrochemiluminescence-based immunoassays

Two diabody molecules directed against the prostate-specific antigen (PSA) were generated from a combinatorial phage display library. The C-termini of diabodies incorporated the FLAG peptide epitope (P008D diabody) or the myc epitope (P001D). Both diabodies have the same antigen-binding site. Equilibrium-binding constants of these molecules were determined in two immunoassays using the ORIGEN detection system based on electrochemiluminescence. The binding of diabodies to biotinylated PSA was detected with either polyclonal antimouse Fab F(ab')2 or a monoclonal antibody directed against the FLAG epitope. Both detecting antibody preparations were covalently labeled with a ruthenium (II) tris (bipyridyl) moiety, Ru(bpy)3(2+), which allows quantification via an electrochemically triggered light reaction in an ORIGEN analyzer. The binding constants obtained by Scatchard analysis of non-linear curve fitting calculations from electrochemiluminescence immunoassays were compared with data derived from kinetic-binding studies using the BIAcore technology based on surface plasmon resonance. Depending on the detecting antibody, the dissociation constants KD determined at equilibrium with the ORIGEN technology are between 0.1 and 0.4 nM for both diabodies. From the kinetic constants kon and koff measured with the BIAcore instrument KD was calculated to be 0.2 nM for P001D and 0.6 nM for P008D. It is concluded that these two very different methods generate comparable affinity data for the diabodies.

Perivascular inflammatory reaction after percutaneous placement of covered stents

A 52-year-old woman with an extensive superficial femoral artery occlusion was treated with percutaneous transluminal angioplasty. Because of extensive dissections, two covered stents were placed percutaneously. The intervention was successful with respect to vessel patency, but local pain and fever developed 5 hr after the intervention. Swelling of the thigh occurred, but deep venous thrombosis was excluded. MRI revealed pronounced soft-tissue edema in the adductor canal that persisted for 4 weeks. The fever responded to antiinflammatory medication, but the pain remained for 4 weeks. The vessel was patent at the last follow-up, 8 weeks after graft placement. Soft-tissue edema after percutaneous placement of covered stents has been reported previously. The cause of the inflammatory reaction is unclear.

[Results of percutaneous implantation of coated vascular prostheses in long-distance femoropopliteal occlusions]

PURPOSE

Evaluation of primary patency rate, complications and midterm follow-up after implantation of endoprostheses in femoropopliteal occlusions.

MATERIAL AND METHODS

25 patients suffering from femoropopliteal occlusion (average length 7 cm) underwent percutaneous femoropopliteal endoprosthesis treatment. A total of 34 endoprostheses were implanted. Clinical and Doppler follow-up was performed after 1, 3, 6 and 9 months. Mean follow-up is 6 months.

RESULTS

Percutaneous placement of endoprostheses was successful primarily in 24/25 patients. In one patient an early occlusion of the endoprosthesis occurred, caused by an embolic complication. Primary patency was 64% after 6 months and secondary patency rate was 71%. Severe local pain at the application site and fever was observed in 40% of the patients.

CONCLUSION

The occlusion rate of 36% after 6 months is high. Long-term follow-up must be awaited before a general recommendation can be made. The cause of the local pain and fever in the early postinterventional period remains unclear.

[CT and PRI angiographic findings in dissection of the neck arteries]

PURPOSE

To determine the usefulness of CT angiography (CTA) and MR angiography (MRA) for evaluation of dissection in cervical vessels.

MATERIAL AND METHODS

Dissection of cervical vessels was revealed by conventional angiography in 4 patients (two female, two male) of 30-62 years of age. Dissection was located in the carotid artery (n = 3) and in the vertebral artery (n = 1). In two patients CTA and in two patients MRA was performed.

RESULTS

Diagnosis of dissection was possible by CTA (internal carotid artery: n = 2) and by MRA (internal carotid artery and vertebral artery). Imaging of the dissection membrane of the vessel wall was possible in one case with MRA.

CONCLUSION

CT and MR angiography was successful for detection of typical morphology of dissection in all cases. If results in a greater number can be obtained it seems to be conceivable that both methods can be used in primary diagnosis.

Dacron-covered stent-grafts for the percutaneous treatment of carotid aneurysms: effectiveness and biocompatibility--experimental study in swine

PURPOSE

To evaluate the short-term effectiveness and biocompatibility of Dacron-covered stent-grafts for percutaneous treatment of carotid aneurysms.

MATERIALS AND METHODS

In eight swine, nine aneurysms were created surgically in the common carotid artery. Percutaneous treatment was performed with Dacron-covered stent-grafts. Seven of eight swine underwent follow-up angiography at 2, 3, 4, and 5 weeks after stent implantation. Histologic examinations of tissue from the site of stent implantation were performed at the same intervals.

RESULTS

Initial closing off of the aneurysm was possible in all swine. Angiographic follow-up revealed patency of only one Dacron-covered stent-graft after 2 weeks. In six of seven swine, the stent was occluded on the follow-up angiogram. One of the swine died of unclear cause after 1 week. The stent-graft of this swine was not occluded. In all Dacron-covered stent-grafts, inflammatory reaction with granulocyte infiltration was found next to the Dacron material.

CONCLUSION

Primary treatment of carotid aneurysms with Dacron-covered stent-grafts is effective. However, the short-term patency rate is poor, which probably can be attributed to the limited biocompatibility of the Dacron cover. An acute inflammatory reaction against Dacron seems responsible for the poor patency rate.

Rheolytic thrombectomy of an acutely thrombosed transjugular intrahepatic portosystemic stent shunt

As an alternative to chemical thrombolysis, an acutely occluded transjugular intrahepatic portosystemic stent shunt in a 72-year-old woman was successfully recanalized using a 5 Fr rheolytic catheter system. No adjunctive thrombectomy treatment was necessary. The underlying stenotic leason was treated with percutaneous transluminal angioplasty and a Palmaz stent. Immediately after the intervention optimal shunt flow was achieved. Ascites vanished within a few days and no further bleeding complications appeared.

Iatrogenic vertebrojugular arteriovenous fistula

Arteriovenous fistulae originating from the vertebral artery are rare. We report a patient in whom a vertebral artery-jugular venous fistula developed following insertion of a central venous catheter via the internal jugular vein. The fistula was successfully occluded surgically.