Endovascular Management of Hematomas in Pediatric Transplant Patients

OBJECTIVES

Transcatheter arterial embolization is used to control active hemorrhage at different anatomic locations. Because hematomas can suddenly deteriorate and become life threatening for transplant patients, they require prompt diagnosis and intervention rather than conservative management. Here, we evaluated computed tomography in treatment planning and transcatheter embolization effectiveness for hematoma management in pediatric liver transplant patients.

MATERIALS AND METHODS

Between June 2012 and December 2021, 10 pediatric liver transplant patients were referred to our interventional radiology unit. Computed tomography and angiograms were reviewed for hematoma location and presence of extravasation. We analyzed correlations between computed tomography and angiography findings and technical and clinical success of the endovascular interventions.

RESULTS

Active leak of contrast material during arterial phase was detected on 9/10 CT scans. Although there was no active bleeding on CT in 1 patient, active arterial bleeding was detected on angiography. On the contrary, in 2 patients, although active bleeding was observed on computed tomography, it was not detected on angiography. Source of bleeding was superior mesenteric artery branches in 4, hepatic artery branch in 2, superior epigastric artery in 1, and phrenic artery in 1 patient. Six of 8 patients with active bleeding were treated with endovascular procedures. The remaining 2 patients received surgery: 1 had bleeding from liver cut surface originating from a hepatic artery branch and received open surgery because the bleeding branch was too thin for catheterization, and 1 was hemodynamically unstable and selective catheterization of the internal thoracic artery would take time. Two patients received embolization procedures with N-butyl 2-cyanoacrylate (glue) diluted with iodized oil, and 1 patient had coil and glue with iodized oil. Embolization with coils was performed in 3 patients. Rate of success with transcatheter arterial embolization was 75%. No complications related to patient comorbidities or embolization procedures were shown. No deaths occurred due to progression of the hematoma.

CONCLUSIONS

Transcatheter arterial embolization is effective and safe for treatment of pediatric liver transplant patients with hematomas. Computed tomography has value in identifying the bleeding source and its anatomic relationships and may enhance our intervention abilities to become quicker, more effective, and more secured.

Our Living Donor Protocol for Liver Transplant: A SingleCenter Experience

OBJECTIVES

The shortage of deceased donor organs is a limiting factor in transplant. The growing discrepancy between the wait list demand versus the supply of deceased donor organs has created an incentive for consideration of living donor liver transplant as an alternative. Here, we describe our evaluation process and donor complications.

MATERIALS AND METHODS

Since 1988, we have performed 659 (449 living donor and 210 deceased donor) liver transplants. The most important evaluation criteria is the relationship between donor and recipient, and we require thatthe donor must be related to the recipient. The evaluation protocol has 5 stages. Donor complications were defined as simple, moderate, and severe.

RESULTS

We retrospectively investigated data for 1387 candidates, and 938 (67.7%) were rejected; subsequently, 449 living donor liver transplants were performed. There were no complications in 398 of the donors (88.7%). Total complication rate was 11.3%. Simple complications were seen in 31 patients (6.9%). Moderate complications were seen in 19 patients (4.2%). We had only 1 severe complication, ie, organ failure from unspecified liver necrosis, which resulted in death.

CONCLUSIONS

The relationship between donor and recipient and donor safety should be the primary focus for living donor liver transplant. Donor selection should be made carefully to minimize complications and provide adequately functional grafts.

Transcatheter retrieval of embolized catheter using venovenous loop in a neonate

Varan B, Yakut K, Harman A. Transcatheter retrieval of embolized catheter using venovenous loop in a neonate. Turk J Pediatr 2018; 60: 113-115. Umbilical venous catheters are reliable in providing adequate medical care for premature babies however complications include infections, bleeding, thrombosis, catheter occlusion and migration of a piece of catheter to other parts in the body. Here, we present a case with migration of a piece of umbilical venous catheter which has been trapped between hepatic vein and right upper pulmonary vein causing apnea episodes, recurrent respiratory symptoms, need for mechanical ventilation and increase of acute phase reactants. The embolized catheter was retrieved successfully via percutaneous route.

Unusual Treatment of Unusual Complication: Stenting of Left Ventricular Assist Device Outflow Graft Stenosis

Due to the increase in the number of patients waiting for heart transplantation and shortage of heart donors, both the use of mechanical assist devices and their associated complications increase. Here we present the case of a stenosis occurring in a patient at aortic outflow graft anastomosis for whom we applied a left ventricular assist device, followed by a discussion of the diagnosis, approach, and the treatment we offer in our clinic.

Incidence and Treatment of Bile Stones After Liver Transplant

OBJECTIVES

Although the incidence of bile stones after liver transplant is rare (2%-6%), various complications can occur, including recurrent cholangitis, biliary strictures, graft loss, and patient mortality.

MATERIALS AND METHODS

We retrospectively evaluated bile stone incidence, pathogenesis, and treatment in 352 liver transplant recipients, comparing demographics, transplant indication, blood lipid profile, bile reconstruction technique, postoperative complications, time of diagnosis, and treatment regimens.

RESULTS

Of 352 recipients, 18 had bile stones, with 13 of these patients (72.2%) receiving duct-to-duct bile reconstruction, 17 having biliary complications before bile stone development, 7 (38.9%) having biliary stricture, 6 (33.3%) having biliary leakage, 4 (22.2%) having biliary strictures secondary to biliary leakage, and 7 (38.9%) having hepatic artery complications early posttransplant. Previous biliary complications and recurrent cholangitis significantly increased bile stones. Incidence in patients with triglyceride levels > 250 mg/dL was significantly different from those with levels at < 250 mg/dL. Cold ischemia time was significant in those with and without bile stones (P = .001). Three patients (16%) were treated by endoscopic tools, with others (15/18, 84%) treated via percutaneous procedures.

CONCLUSIONS

Bile stone risk can be greater in those with previous biliary complications, hepatic artery problems, long cold ischemia time, and high cholesterol levels. It can be successfully treated by endoscopic and percutaneous techniques.

Clinical results of carotid artery stenting versus carotid endarterectomy

Objective:

To review our results of carotid artery stenting (CAS) and carotid endarterectomy (CEA).

Methods:

We evaluated the medical records of patients undergoing carotid artery revascularization procedure, between 2001 and 2013 in Baskent University Hospital, Ankara, Turkey. Carotid artery stenting or CEA procedures were performed in patients with asymptomatic carotid stenosis (≥70%) or symptomatic stenosis (≥50%). Demographic data, procedural details, and clinical outcomes were recorded. Primary outcome measures were in 30-day stroke/transient ischemic attacks (TIA)/amaurosis fugax or death. Secondary outcome measures were nerve injury, bleeding complications, length of stay in hospital, stroke, restenosis (ICA patency), and all-cause death during long-term follow-up.

Results:

One hundred ninety-four CEA and 115 CAS procedures were performed for symptomatic and/or asymptomatic carotid artery stenosis. There is no significant differences 30-day mortality and neurologic morbidity between CAS (13%) and CEA procedures (7.7%). Length of stay in hospital were significantly longer in CEA group (p=0.001). In the post-procedural follow up, only in symptomatic patients, restenosis rate was higher in the CEA group (p=.045). The other endpoints did not differ significantly.

Conclusions:

Endovascular stent treatment of carotid artery atherosclerotic disease is an alternative for vascular surgery, especially for patients that are high risk for standard CEA. The increasing experience, development of cerebral protection systems and new treatment protocols increases CAS feasibility.

Evaluation of safety and efficacy of liver biopsy following liver transplant

OBJECTIVES

Liver biopsy is a diagnostic tool for liver pathology after liver transplant. However, biopsy can cause life-threating complications. There is limited knowledge about efficacy and complications of liver biopsy after liver transplant. Our aim was to evaluate the risk and benefit of liver biopsy after liver transplant and quality of biopsy specimens.

MATERIALS AND METHODS

We retrospectively analyzed all liver biopsies performed after liver transplant between January 2000 and October 2014. All patients were monitored for minimum 24 hours after biopsy.

RESULTS

We performed 245 liver biopsies in 159 liver transplant patients. Fifteen biopsies (6%) were nondiagnostic. In the samples, there were 102 cases (41%) of acute rejection, 79 cases (35%) of cholangitis, and 49 cases (20%) of cholestasis observed. Complications after biopsy were seen in 23 patients (9%) and biopsies. There were 7 patients who had severe abdominal pain followed by fever. We diagnosed 4 patients who had intercostal/subcapsular bleeding and 12 patients who had vasovagal reaction. All patients were treated with analgesic agents and monitored for 24 hours. No blood transfusion or surgery was required.

CONCLUSIONS

Liver biopsy after liver transplant is an invasive diagnostic tool for liver pathology. However, it can be used safely in experienced centers.

Sacroiliac pain and CT-guided steroid injection treatment: high-grade arthritis has an adverse effect on outcomes in long-term follow-up

OBJECTIVE

The sacroiliac joint (SIJ) is one of the major sources of low back pain that can lead to severe morbidity. Possible SIJ pain requires a thorough evaluation and treatment option. The purpose of this study was to analyze the possible relationships between computed tomography (CT) grading of SIJ arthritis and the effectiveness of intraarticular steroid injection treatment under CT guidance.

PATIENTS AND METHODS

A total of 61 patients with SIJ pain who were treated with CT guided intraarticular steroid injection were retrospectively reviewed. Visual analog scale (VAS) scores for pain control were recorded for short-term (day after injection, first week, third week) and long-term (sixth months and final control) follow-up times. SIJ arthritis was graded using CT images according to the New York criteria. Patients were assigned into low-grade (0, 1 and 2) and high-grade (3 and 4) groups. The relationship between arthritis grades and VAS scores in short and long-term follow-ups were statistically analyzed.

RESULTS

Mean age and follow-up was 54.8 years (range: 41-68 years) and 27.8 months (range: 24-36 months), respectively. In 40 patients there was low-grade arthritis, while 21 patients were characterized on having high-grade sacroiliac arthritis detected during the radiological evaluation. There was no statistically significant difference between low and high-grade arthritis in regard to short-term VAS scores. On contrary, for long-term VAS scores, there was significant difference between low- and high-grade arthritis.

CONCLUSIONS

Steroid injection treatment for SIJ pain is not effective on a long-term basis for patients with high-grade arthritis, and although they have had decreased VAS scores in the short-term, after 2 years of follow-up, their VAS scores significantly increased leading to symptomatic sacroiliac joint pain.

Transjugular intrahepatic portosystemic shunt: where are we?

BACKGROUND/AIMS

The purpose of this study was to evaluate the technical/hemodynamic success, complications, and biochemical/ hematologic consequences of transjugular intrahepatic portosystemic shunt (TIPS) created with 10-mm bare stents in our patients.

MATERIALS AND METHODS

Data of 27 cirrhotic patients (18 men and 9 women; mean age, 39.7±18.7 years) with a median MELD score 14 (range 7-31) treated with TIPS between January 2000 and August 2010 were evaluated retrospectively.

RESULTS

The indications were refractory bleeding varices in 48.2%, refractory ascites in 22.2%, and Budd-Chiari syndrome in 29.6% of the patients. Technical and hemodynamic success rates were 96.3% and 92.3%, respectively. Mean portosystemic pressure gradient decreased from 21.5±5.3 mm Hg to 9±2.7 mm Hg (p<0.05). The rate of primary stent patency was 76.9% 1 year after the procedure. No statistically significant difference in shunt dysfunction was found between the groups of patients treated for Budd-Chiari syndrome and other indications (p>0.05). One patient (3.7%) had shunt dysfunction due to thrombosis within 24 hours. New and/or worsening hepatic encephalopathy occurred in 34.6% of patients. Increased age (≥40 years) was significantly related to hepatic encephalopathy in both univariate and multivariate analyses (p<0.05). Thirty-day mortality rate and 1-year transplant-free survival rate were 0% and 80.7%, respectively.

CONCLUSION

Transjugular intrahepatic portosystemic shunt procedure is a safe treatment for many patients with cirrhosis, but post-procedure hepatic encephalopathy and shunt dysfunction are still problems. Especially, patient age should be taken into consideration in predicting hepatic encephalopathy risk.

The ole of Choice-Lck Catheter and Trocar Technique in Percutaneous Ablation of Symptomatic Renal Cysts

Background:

The most common benign lesions of the kidney are simple cysts. They are acquired lesions and mostly affect the elderly population.

Objectives:

To describe the usage of choice-lock catheter and trocar technique in percutaneous renal cyst treatment and determining long-term outcomes.

Patients and Methods:

This retrospective study was carried out between February 2000 and July 2011. Eighty-eight cysts all of which were Bosniak type-1 cysts were selected in 75 patients. The treatment indications were flank pain, hydronephrosis and hypertension. The choice-lock catheter was used for 84 cysts with the trocar technique. Ninety-five percent ethanol was used as the sclerosing agent. Maximum volume of the injected ethanol was 175 ml. The mean follow-up time after the treatment procedure was 23 months. Sixty-four cysts were located in the cortical and 24 cysts were located at the parapelvic region.

Results:

Fifty-seven cysts had complete regression, while 31 cysts regressed partially. After the procedure, pain was relieved in 44 (82%) patients and the pain alleviated in four (8%). Normotension was obtained in five (62.5%) of the eight hypertensive patients and no hydronephrosis was detected in nine patients. There were no relationship between the localization and the regression rate. No major complications occurred.

Conclusions:

Percutaneous ethanol sclerotheraphy in simple cysts is a safe, cost-effective and minimally invasive method. We consider that this technique may be an alternative solution in the percutaneous cyst treatment.

Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis

BACKGROUND

In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy.

METHODS

In 91 patients (American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment (48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average (range 7-29).

RESULT

Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19 (40%) vs 8 (19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16 (33%) vs 4 (9%); P=0.006], a mean postoperative hospital stay (5.3+/-3.3 vs 3.0+/-2.4 days; P=0.001), and a frequency of complications [17 (35%) vs 4 (9%); P=0.003].

CONCLUSION

In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.

Endovascular stent placement of juxtaanastomotic stenosis in native arteriovenous fistula after unsuccessful balloon angioplasty

Background

In hemodialysis patients, the most common problem in arteriovenous fistulas, as the best functional vascular access, is the juxtaanastomotic located lesions. Percutaneous transluminal angioplasty is accepted as the treatment method for juxtanastomotic lesions.

Objectives

To assess juxtaanastomotic stent placement after insufficient balloon angioplasty in the treatment of autogenous radiocephalic or brachiocephalic fistula dysfunction.

Patients and Methods

Between July 2003 and June 2010, 20 hemodialysis patients with autogenous radiocephalic or brachiocephalic fistula dysfunction underwent stent placement for the lesion located at the juxtaanastomotic region. Indications for stent placement were insufficient balloon dilatation, early recurring stenosis, chronic organizing thrombus and vessel rupture. The Kaplan-Meier method was used to calculate the stent patency rates. All patients who had fistula dysfunction (thrombosis of hemodialysis access, difficult access cannulation, extremity pain due to thrombosis or decreased arterial access blood flow) were evaluated by color Doppler ultrasound. The stenoses were initially dilated with standard noncompliant balloons (3 to 10-mm in diameter). Dilatation was followed by high pressure (Blue Max, Boston Scientific) or cutting balloons (Boston Scientific), if the standard balloon failed to dilate the stenotic segment.

Results

Twenty-one stents were applied. The anatomical and clinical success rate was 100%. Seventeen additional interventions were done for 11 (55%) patients due to stent thrombosis or stenosis during follow-up. Our 1- and 2-year secondary patency rates were 76.2% and 65.5%, respectively and were comparable to those after balloon angioplasty and surgical shunt revision.

Conclusion

Metallic stent placement is a safe and effective procedure for salvage of native hemodialysis fistula after unsuccessful balloon angioplasty.

Right common iliac artery stenosis and stent insertion in Behçet's disease

Behçet's disease is a multisystem inflammatory disorder that is classified among the vasculitides and can affect all types and sizes of blood vessels. Vascular manifestations of Behçet's disease are venous and arterial occlusion, and arterial aneurysms. As vasculitis of the vasa vasorum is the main pathological hallmark of Behçet's disease, it is generally seen as superficial thrombo-phlebitis or occlusion of the major veins; however arterial obstruction and aneurysms may also be seen to a lesser extent. Iliac artery stenosis is highly uncommon. Here, a case of common iliac stenosis in a 48-year-old patient with Behçet's disease is reported. As the risk of aneurysm during an operation was high in this patient, he was treated with vascular stent implantation. Due to stent occlusion two months after the operation, percutaneous transluminal angioplasty was performed with an 8-mm balloon. During the three-year follow up, no obstruction was observed.

Diagnosing common parotid tumours with magnetic resonance imaging including diffusion-weighted imaging vs fine-needle aspiration cytology: a comparative study

OBJECTIVES

the purpose of this study was to evaluate the accuracy of MRI combined with diffusion-weighted imaging (DWI) vs fine-needle aspiration cytology (FNAC) in diagnosing common parotid masses.

METHODS

25 consecutive patients (mean age 61 years) with parotid masses were included in this study. Informed consent and ethical approval was obtained. 22 patients underwent both MRI combined with DWI and FNAC. From DWI data, apparent diffusion coefficient maps were generated. The MRI study protocol consisted of T(1) weighted spin echo; T(2) weighted and T(2) weighted fat-suppressed turbo spin echo; DWI; and T(1) weighted fat-suppressed post-contrast images. MRI and FNAC diagnoses were compared with histopathology. Youden's index was used to compare the two methods.

RESULTS

masses comprised eight Warthin tumours, eight adenomas (six pleomorphic adenomas, two basal cell adenomas), five carcinomas, two lipomas, one haemagioma and one benign lymphadenopathy. Technically, MRI was successful in 24 of the 25 patients (96%), FNAC was successful in 20 of the 23 patients (87.0%). The accuracy, sensitivity and specificity of MRI without DWI were 96%, 80% and 100%, respectively. Diagnostic accuracy did not increase by adding DWI to conventional MRI; however, DWI was helpful for diagnosing benign tumour histology. MRI combined with DWI was successful for determining accurate tumour typing in all benign masses except one lymphadenopathy. When FNAC had adequate material the accuracy, sensitivity and specificity were 95%, 75% and 100%, respectively. Youden's index was 0.80 for MRI and 0.75 for FNAC.

CONCLUSIONS

MRI combined with DWI seems to have similar diagnostic potential as FNAC in differentiation of benign vs malignant parotid masses.

A walking model to assess the onset of analgesia in osteoarthritis knee pain

OBJECTIVE

To assess a walking model utilizing a set of standardized treadmill walks to measure acute analgesic response in osteoarthritis (OA) of the knee.

DESIGN

Randomized, double-blind, placebo-controlled, multiple dose, three-period crossover study. Patients > or =45 years of age (N=22) with symptomatic knee OA were randomized to naproxen 500 mg bid, tramadol/acetaminophen 37.5 mg/325 mg in forced titration, or placebo in each of three periods. Patients performed multiple 20-minute treadmill walks on Day 1 and Day 3 at a consistent self-selected pace predetermined at screening. Pain intensity (PI) during the walks was assessed on an 11-point numerical rating scale at 0, 3, 6, 9, 12, 15, 18, and 20 min. The primary endpoint was the time-weighted average (TWA) change from baseline PI on Day 3 for the two self-paced walks for the active treatments vs placebo. Time to moderate pain (TTMP) was a key secondary endpoint.

RESULTS

Compared with placebo, the TWA change from baseline PI on Day 3 was significantly better with tramadol/acetaminophen (P=0.043) but not with naproxen (P=0.089). TWA change from baseline on Day 1 was also significantly better with both tramadol/acetaminophen (P=0.001) and naproxen (P=0.048) compared with placebo. TTMP was significantly better for tramadol/acetaminophen and naproxen than placebo (P<0.001 to P=0.015) for walks on Day 1 after a single dose and on Day 3.

CONCLUSIONS

This novel OA pain model was able to discriminate both tramadol/acetaminophen and naproxen from placebo after single and multiple doses. ClinicalTrials.gov identifier: NCT00772967.

Appendiceal endometriosis presenting as perforated appendicitis: report of a case and review of the literature

While endometriosis is a common disorder in women of reproductive age, appendiceal endometriosis accounts for less than 1% of all pelvic endometriotic lesions. Involvement at this site may present as acute appendicitis and be diagnosed only upon postoperative histopathologic examination. We report such an occurrence of appendiceal endometriosis in a 40-year-old woman who presented with acute perforated appendicitis.

Treatment approaches for spontaneous retroperitoneal bleeding

In this study, we investigated critical issues in the diagnosis and treatment of spontaneous retroperitoneal bleeding. The medical records of 16 patients who were admitted to the emergency department and were diagnosed as having spontaneous retroperitoneal bleeding were reviewed retrospectively. Retroperitoneal bleeding was diagnosed by intravenous contrast-enhanced computed tomography in 8 men and 8 women (median age, 70.5 years; mean hemoglobin level, 7.4 +/- 1.3 mg/dl). Thirteen patients (81%) received conservative treatment. Bleeding was controlled by therapeutic angiographic intervention in two patients (12%) and by surgery in one patient (6%). Two patients (12%) died. Clinicians should suspect retroperitoneal bleeding in anemic patients who are admitted to an emergency department. If active bleeding is detected, interventional radiologic methods should be used as the initial treatment, and surgery can be performed if conservative and interventional radiologic methods fail.

Correction of displaced peritoneal dialysis catheters with an angular stiff rod

BACKGROUND

Fluoroscopically guided guidewire manipulations are readily available and inexpensive methods of correcting malfunctioning peritoneal dialysis catheters, with reported success rates ranging from 25% to 67%.

PURPOSE

To improve the success rates of guidewire manipulations with a modified technique.

MATERIAL AND METHODS

Using a stiff rod and a stiff wire under fluoroscopy guidance, catheters that had migrated were drawn back into the rectovesical pouch. An angular rod was used to lever the catheter downward, and the guidewire was used to push the catheter down.

RESULTS

No complications developed, and immediate success was achieved in 13 of 14 interventions. With this technique, catheter patency in chronic ambulatory peritoneal dialysis (CAPD) patients (11/12) was higher than that of previously reported methods. Durable success was maintained in nine of 12 patients after a single intervention. All re-manipulations (2/2) were successful.

CONCLUSION

Although used in only 14 interventions in 12 patients, the outcome was promising. This method is a safe and favorable alternative to other guidewire manipulations, based on absence of complications and high success.

Multidetector CT findings of splenic artery aneurysm in children with chronic liver disease

BACKGROUND

Splenic artery aneurysm (SAA) is a well-known complication of chronic liver disease and portal hypertension in adults. The incidence of SAA in children undergoing selective hepatic angiography prior to liver transplantation is reported as 4%, but there are few systematic studies.

OBJECTIVE

To investigate the SAAs detected by multidetector CT angiography (MDCTA) among children with chronic liver disease.

MATERIALS AND METHODS

A total of 124 children (71 girls, 53 boys; mean age 118 months; age range 5 days to 204 months) with chronic liver disease underwent MDCTA to display the vascular anatomy and any vascular complications during the pretransplantation period. Of these children, 23 also underwent coeliac angiography. The digital subtraction angiography (DSA) and MDCTA findings were compared.

RESULTS

SAAs were detected in 13 children (10.4%); none was detectable by US. All patients had more than one aneurysm; ten patients had more than three. In all except one patient, the SAAs were located only in the intraparenchymal branches of the splenic artery; in one patient they were located in the intraparenchymal segment and in the distal third of the splenic artery. The mean size of the aneurysms was 6.5 mm (range 2.5-18 mm). All patients with aneurysms had splenomegaly and vascular collaterals. Nine of the children with SAAs had portal vein pathologies (two occlusions, two stenoses, five dilatations). A statistically significant difference existed with regard to the size of spleen (P < 0.05) and patient age (P < 0.05) between children with SAAs and children without SAAs. There was an increased risk of SAAs in patients with portal vein pathologies. In 19 patients without SAAs on MDCTA, no SAAs were seen on DSA.

CONCLUSIONS

It is likely that the incidence of SAA in children with chronic liver disease will increase with improved survival of children with long-standing portal hypertension and chronic liver disease. MDCTA with multiplanar reconstruction is a noninvasive and effective means of imaging paediatric patients with SAAs, especially during the peritransplantation period, which is considered to be a time of significant risk for SAA rupture in this patient population.

Endovascular therapy for thoracic and abdominal aortic emergencies

BACKGROUND

Emergent situations of both the thoracic and abdominal aortae are serious life-threatening situations. Endovascular stent graft repair offers an alternative to conventional operation for management of aortic diseases. Our aim was to report our experience with endovascular stent graft repair of thoracic and abdominal aortic emergencies.

METHODS

Between April 2004 and March 2007, endovascular stent graft repair was performed in 16 patients (13 males, 3 females; mean age 61.4+/-16.3; range 38 to 86 years). The emergent lesions were in the thoracic aorta in 8 patients and abdominal aorta in the remainder. The deployed stent graft systems were Talent-Medtronic (n=8) and Excluder-Gore (n=8).

RESULTS

Successful deployment of the stent grafts in the appropriate position was achieved in all patients. Hospital mortality occurred in 3 patients. There was no conversion to open surgery. The total number of endoleaks was 3 (18.75%).

CONCLUSION

Endovascular stent graft placement is a feasible and effective approach in the emergency treatment of patients with complicated emergent pathologies of both thoracic and abdominal aortae.

Endovascular stent placement in patients with hepatic artery stenoses or thromboses after liver transplant

Hepatic artery stenosis or thrombosis following liver transplant is a potentially life-threatening complication. Successful liver transplant depends on uncompromised hepatic arterial inflow. Early diagnosis and treatment of complications prolong graft survival. Interventional radiologic techniques are frequently used to treat hepatic artery complications. Twenty patients with hepatic artery stenoses (n = 11) or thromboses (n = 9) were included in this study. Eighteen of the 20 patients were successfully treated by stent placement. In 9 patients, early endovascular interventions were performed 1 to 7 days after surgery. Two patients were operated owing to the effects of dissection and bleeding from the hepatic artery. Repeat endovascular interventions were performed 10 times in 6 patients. Follow-up ranged from 5 months to 4.5 years. Nine patients with patent hepatic arteries died during follow-up owing to reasons unrelated to the hepatic artery interventions. In 3 patients, the stents became occluded at 3, 5, and 9 months after surgery but no clinical symptoms were present.

CT-guided cutting needle lung biopsy using modified coaxial technique: factors effecting risk of complications

PURPOSE

We present our 7-year experience with coaxial computed tomography (CT)-guided cutting needle lung biopsy and evaluate the factors affecting risk of complications.

MATERIAL AND METHOD

Between June 2000 and March 2007, we performed 225 CT-guided coaxial lung biopsies in 213 consecutive patients (161 men, 52 women). Lesion size, lesion depth, lesion location, needle-pleural angle, presence of pleural effusion, patient's position, and complications secondary to biopsy procedure (pneumothorax and bleeding) were noted. Pneumothorax was graded as mild, moderate, and severe. Bleeding complications were graded as mild, moderate, and severe.

RESULTS

Two hundred twenty-five biopsy procedures were performed in 213 patients. The mean diameter of the lung lesion was 41.3+/-20.1mm. The mean distance from the peripheral margin of the lesion to the pleura was 17.3+/-19.2mm. After 225 procedures, there were 42 mild (18.6%), 13 moderate (5.7%), and 4 severe (1.7%) pneumothoraxes. Small hemoptysis occurred in 27 patients (12%), and mild parenchymal hemorrhage occurred in 2 patients (0.8%). The overall complication rate was 39.1%. Although, a statistically significant correlation was found between female sex, presence of emphysema, lesion depth, and pneumothorax, none of these factors had a predictive value for pneumothorax. Although, statistically significant correlations were found between female sex, lesion size, and bleeding, only lesion size had a predictive value for bleeding.

CONCLUSION

The most frequent and important complications of this procedure are pneumothorax and bleeding. But any factor is the predictor of pneumothorax and lesion depth is a poor predictor of bleeding complication.

Perforated ileal diverticulitis: CT findings

Diverticulosis of the ileum is very uncommon. The differential diagnosis for any inflammatory process in the right lower quadrant of the abdomen includes appendicitis, Crohn's disease, and other infectious and inflammatory conditions of the terminal ileum and cecum. Diagnosis of small bowel diverticulitis is based on radiological findings, and computed tomography is the method of choice to demonstrate mural changes and the mesenteric extent of the inflammation. Preoperative knowledge of this condition may influence surgical and medical management.

Percutaneous management of anastomotic bile leaks following liver transplantation

PURPOSE

To review our experience with percutaneous internal-external biliary drainage in treating biliary anastomotic leaks following orthotopic liver transplantation.

MATERIALS AND METHODS

Between September 1997 and June 2006, 157 liver transplantations were performed in our hospital. Percutaneous transhepatic biliary drainage was performed in 10 patients (9 males, 1 female; mean age, 32.9 years; age range, 2-62 years) with patent hepatic arterial systems to treat clinically significant anastomotic bile leaks.

RESULTS

Bile leaks were resolved and anastomotic patency was restored in all patients. Massive hemobilia occurred in 1 patient due to arterial pseudoaneurysm and was treated with embolization. No major complications were seen in the other patients. During a mean follow-up of 19.5 months, anastomotic stricture occurred in 2 patients (1 in combination with a recurrent leak). Both patients were successfully treated with percutaneous methods. The remaining 8 patients had no biliary problems.

CONCLUSION

When treating anastomotic bile leaks in liver transplant patients, percutaneous procedures may be performed with high technical success and low complication rates.

Endovascular treatment of active bleeding after liver transplant

OBJECTIVES

To evaluate the incidence of active bleeding complications following transplant and the efficacy of interventional radiologic management.

MATERIALS AND METHODS

Between June 2000 and February 2007, 14 liver transplant patients with active bleeding were treated via endovascular techniques (coils, glue, or graft-covered stents). Active bleeding was spontaneous in 6 patients through the inferior epigastric artery (n=1), the inferior phrenic artery (n=1), the superior mesenteric artery (n=2), the internal mammary artery (n=1), and the hepatic artery (n=1). In 8 patients, active bleeding was due to transhepatic biliary or endovascular interventions. Hemobilia (n=2) due to pseudoaneurysm formation after transhepatic biliary interventions was embolized with coils. Hepatic artery rupture was observed in 6 patients during endovascular interventions performed on hepatic artery stenosis or thrombosis that had been treated with graft-covered stents. Technical success, clinical improvement, and complications were documented.

RESULTS

Active bleeding was stopped by endovascular intervention in 13 of 14 patients. Embolizations with coils or glue were successful. In 1 patient with hepatic artery bleeding, the graft-covered stent failed to seal the rupture site, and this patient underwent reoperation.

CONCLUSION

Arterial bleeding complications after liver transplant during the early and late postoperative period, due either to spontaneous active bleeding or to percutaneous or endovascular interventions, can be successfully managed with interventional radiologic techniques.

Percutaneous therapy of ureteral obstructions and leak after renal transplantation: long-term results

The purpose of this study was to evaluate the long-term outcome of percutaneous therapy of ureteral complications after renal transplantation. Between January 2000 and June 2006 we percutaneously treated 26 renal transplant patients with ureteral obstruction (n=19) and leak (n=7). Obstructions were classified as early (<2 months after transplantation) or late (>2 months). Patients with leak were treated with nephro-ureteral catheter placement and subsequent double-J stenting. Balloon dilatation, stent placement, and basket extraction were used to treat ureteral obstructions. Patients were followed with ultrasonography. No major procedure-related complication occurred. The mean follow-up time was 34.3 months (range: 6 to 74 months). Initial clinical success was achieved in all 19 patients with obstruction and 6 of 7 patients with leak. Four of 9 early obstructions and 4 of 10 late obstructions recurred during the follow-up. All recurrences were initially managed again with percutaneous methods, including cutting balloon technique and metallic stent placement. Although there was no recurrence in patients with successfully treated leak, stricture was seen at the previous leak site in two patients. These strictures were also successfully managed percutaneously. We conclude that in the treatment of ureteral obstruction and leak following renal transplantation, percutaneous therapy is an effective alternative to surgery. However, further interventions are usually needed to maintain long-term patency.

Multidetector Computed Tomographic Angiography Findings of Splenic Artery Steal Syndrome in Liver Transplantation

AIMS

Splenic artery steal syndrome, a common complication in liver transplantation, is diagnosed by conventional angiography showing an enlarged splenic artery and by dynamic findings. The aim of this study was to determine multidetector computed tomographic angiography (MDCTA) findings of splenic artery steal syndrome to develop diagnostic criteria.

MATERIALS AND METHODS

Ten patients were diagnosed as displaying splenic artery steal syndrome among 198 liver transplant patients. The diagnosis was confirmed by celiac angiography. In eight of them, MDCTA was performed. Axial and coronal maximum-intensity projection images were obtained in arterial and portal phases. We measured the diameter of the celiac trunk and of the splenic, left gastric, common hepatic, superior mesenteric artery, and transplant hepatic arteries. We also measured the diameter of the proximal and the distal segments of the abdominal aorta, along with the size of the spleen, the ratio of the splenic artery to the common hepatic artery, the ratio of splenic artery to transplant hepatic artery, the diameter of portal vein and superior mesenteric vein. The control group consisted of liver transplant patients with normal liver enzyme levels. We performed Student t test for statistical examination.

RESULTS

The diameter of the splenic artery (P<.05), the size of the spleen (P<.01), and the ratio of the splenic to the transplant hepatic arteries (P<.05) was significant between the two groups. The diameter of the splenic artery was larger than 4 mm in all patients in the study group.

CONCLUSIONS

Conventional angiography was mandatory for the diagnosis of splenic artery steal syndrome. MDCTA is a noninvasive method. Some computed tomography criteria are important for early diagnosis and treatment.

Transjugular Intrahepatic Portosystemic Shunt Creation in Budd-Chiari Syndrome: Percutaneous Ultrasound-Guided Direct Simultaneous Puncture of the Portal Vein and Vena Cava

Budd-Chiari syndrome (BCS) is an uncommon disorder that can be life-threatening, depending on the degree of hepatic venous outflow obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) provides decompression of the congested liver but the hepatic vein obstruction makes the procedure more difficult. We describe a modified method that involved a single percutaneous puncture of the portal vein and inferior vena cava simultaneously for TIPS creation in a patient with BCS.

Use of the rendezvous technique in the treatment of biliary anastomotic disruption in a liver transplant recipient

In liver transplant recipients, the treatment of a biliary leak resulting from anastomotic disruption usually requires surgical intervention. However, reoperation results in significant morbidity in such patients, whose clinical status may preclude a second surgery. Restoring the integrity of a disrupted biliary anastomosis can be difficult, and in some patients with that complication, neither the percutaneous technique nor the endoscopic approach effectively stents the biliary anastomosis. In those individuals, bile drainage can be achieved by means of a combined percutaneous transhepatic and endoscopic transpapillary approach (the rendezvous technique). In conclusion, we present the case report of a liver transplant recipient with an anastomotic bile leak that was successfully treated with the rendezvous technique.

Nonvascular complications in pediatric liver recipients: multidetector computed tomography evaluation

In pediatric liver transplantation postoperative diagnosis of complications is crucial for graft salvage. Multidetector computed tomography (MDCT) is a technique to evaluate complications. In this study we present nonvascular abdominal complications encountered in pediatric recipients after liver transplantation. We retrospectively examined 113 MDCT examinations in 43 pediatric patients who underwent liver transplantation between 1997 and 2005. Computed tomography (CT) examinations were made by a 16-detector multislice CT scanner. The pathological findings on CT images were: intraperitoneal free fluid, intrahepatic bile duct dilatation, graft liver infarction, perihepatic and intraperitoneal fluid collections (six biloma), colonic and/or intestinal dilatation, splenic infarction, perihepatic hematoma, right adrenal hemorrhage, perihepatic abscess, incisional hernia, intrahepatic biloma and periportal collar. In one patient intestinal hemorrhage was suspected. Intestinal perforation was suspected in three patients. Among these three patients, one patient died before any surgical intervention. In two patients the diagnosis was confirmed at surgery. In pediatric patients, the short examination time, brief sedation duration, and high-resolution images make MDCT an effective radiological method to evaluate nonvascular transplant complications.

Ultrasound-guided percutaneous cholecystostomy for acute cholecystitis in critically ill patients: one center's experience

BACKGROUND/AIMS

The standard treatment for acute cholecystitis is cholecystectomy; however, cholecystectomy is not an option in some patients who are too high-risk for emergency surgery. Ultrasound-guided percutaneous cholecystostomy is an alternative for such patients. This study presents one center's five-year clinical experience with ultrasound-guided percutaneous cholecystostomy for treatment of acute cholecystitis.

METHODS

In this study the records of all patients (18 total; mean age, 68.2+/-15.4 years; range, 42-91 years) who underwent ultrasound-guided percutaneous cholecystostomy for acute cholecystitis between June 1998 and October 2003 were reviewed. Duration of hospitalization, duration of tube placement, mortality and morbidity after tube placement, complication rates, culture results for aspirated bile, and clinical outcomes were analyzed.

RESULTS

Fourteen patients were diagnosed with acute calculous cholecystitis and four were diagnosed with acalculous cholecystitis. The average hospital stay was 19+/-12.6 days (range, 5-52 days), and the average duration of catheter drainage was 20.5+/-19.1 days (range, 1-75 days). Six patients underwent open cholecystectomy between days 16 and 26 of catheter drainage, and none had postoperative complications.

CONCLUSIONS

Ultrasound-guided percutaneous cholecystostomy is a relatively safe and easy method for treating acute cholecystitis in critically ill patients. The risk of complications is low and the likelihood of success is high.

The retinal ganglion cell layer and visual acuity of the camel

We examined the retinal ganglion cell layer of the dromedary camel, Camelus dromedarius. We have estimated that there are 8 million neurons in the ganglion cell layer of this large retina (mean area of 2,300 mm(-2)). However, only approximately 1 million are considered to be ganglion cells. The ganglion cells are arranged as two areas of high cell density, one in the temporal and one in the nasal retina. Densities of ganglion cells between these two high density regions is much lower, often less than 100 per mm(-2). In between these two high density regions, on the nasal side of the optic nerve head, is a unique and dense vertical streak of mostly non-ganglion cells; the function of this specialization is unknown. On the basis of ganglion cell density we estimate that the peak acuity in the dromedary camel is about 10 and 9.5 cycles per degree in the temporal and nasal high density regions respectively and falls to 2-3 cycles per degree in the central retina. Behavioral acuity was estimated for one bactrian camel and was found to be approximately 10 cyc deg(-1). The camel has a retina with a mean thickness of 104 microm, less than the 143 microm thickness that has previously been thought to be necessary for a retinal vasculature. Nevertheless, there is an extensive vitreal vasculature that does not appear to spare any retinal region.

Myctolaimellus robiniae n. sp. (Diplogasterida: Cylindrocorporidae) from Larval Cavities of the Locust Borer, Megacyllene robiniae Forster

A new nematode species of the family Cylindrocorporidae and the genus Myctolaimellus from subcortical cavities made by the locust borer (Megacyllene robiniae Forster) in black locust (Robinia pseudoacacia L.) is described. Males of the new species have a length of 700 to 1,050 microm; a bursate tail, peloderan with nine pairs of rays; and knobbed, curved spicules with tips bending gently into a hook. The distinctive gubernaculum is half the length of the spicules, deeply grooved longitudinally along both its dorsal and ventral surfaces, and has a spoon-shaped end. Females have a length of 830 to 1,340 microm, an amphidelphic reproductive tract with long ovaries crossing each other to extend beyond the equatorial vulva, and a gradually tapering tail.

Neuronal density in the human retinal ganglion cell layer from 16-77 years

Literature assessing whether or not neurons (retinal ganglion cells and displaced amacrine cells) are lost from the retinal ganglion cell layer in mammals with age is still controversial, some studies finding a decrease in cell density and others not. To date there have been no studies estimating the total number of neurons in the retinal ganglion cell layer of humans throughout life. Recent studies have concentrated on the macular region and examined cell densities, which are reported to decrease during aging. In a study of the human retinal pigment epithelium (RPE), we showed that, while RPE cell number does not change, cell density increases significantly in central temporal retina (macular region) as the retina ages. We speculated that the increase in density represents a "drawing together" of the retinal sheet to maintain high cell densities, in this region of the neural retina, in the face of presumed cell loss from the ganglion cell layer due to aging. Here, therefore, we have sampled the entire ganglion cell layer of the human retina and estimated total neuron numbers in 12 retinae aged from 16 to 77 years. Human retinae, fixed in formalin, were obtained from the Queensland Eye Bank and whole-mounted, ganglion cell layer uppermost. The total number of neurons was lower in the older than younger retinae and neuronal density was lower in most retinal regions in older retinae. Retinal area increased with age and neuronal density fell throughout the retina with a mean reduction of 0.53% per year. However, the percentage reduction in density was much lower for the macular region, with a value of 0.29% per year. It is possible that this lesser reduction in cell density in the macula is a result of the drawing together of the retinal sheet in this region as we speculated from RPE data.

First evidence of diversity in eutherian chiasmatic architecture: tree shrews, like marsupials, have spatially segregated crossed and uncrossed chiasmatic pathways

In the optic chiasm of mammals, axons either cross the midline to the opposite side of the brain or remain uncrossed. In the eutherian species studied to date, uncrossed axons in the caudal nerve are found in all regions. In the chiasm, they are dispersed through the hemichiasm, with many axons approaching the midline and then turning back to enter the same side of the brain as the originating eye. In marsupials, by contrast, uncrossed axons never approach the midline; instead, they remain grouped in the lateral nerve and chiasm. The impression gained from these data is that there is a major difference in chiasmatic architecture between eutherian and marsupial mammals. Therefore, the mechanisms by which axons choose their route through the chiasm was also thought to differ between the two major groups of mammals. However, the present study shows that the chiasm of a highly visual eutherian mammal, the tree shrew, is similar to that found in marsupials, with uncrossed axons confined to lateral regions and not approaching the midline. However, unlike marsupials, in the tree shrew, optic fascicles in the chiasm are often separated by thick collagen bundles. It is probable that the chiasmatic structure described to date for eutherian mammals is not ubiquitous, as was previously thought, and theories explaining the mechanisms by which axons chose their route through the chiasm during development will have to be expanded.

Spermiogenesis and spermiation in a marsupial, the tammar wallaby (Macropus eugenii)

Fourteen steps of spermatid development in the tammar wallaby (Macropus eugenii), from the newly formed spermatid to the release of the spermatozoon into the lumen of the seminiferous tubules, were recognised at the ultrastructural level using transmission and scanning electron microscopy. This study confirmed that although the main events are generally similar, the process of the differentiation of the spermatid in marsupials is notably different and relatively more complex than that in most studied eutherian mammals and birds. For example, the sperm head rotated twice in the late stage of spermiogenesis: the shape of the spermatid changed from a T-shape at step 10 into a streamlined shape in step 14, and then back to T-shape in the testicular spermatozoa. Some unique figures occurring during the spermiogenesis in other marsupial species, such as the presence of Sertoli cell spurs, the nuclear ring and the subacrosomal space, were also found in the tammar wallaby. However, an important new finding of this study was the development of the postacrosome complex (PAC), a special structure that was first evident as a line of electron dense material on the nuclear membrane of the step 7 spermatid. Subsequently it became a discontinuous line of electron particles, and migrated from the ventral side of the nucleus to the area just behind the posterior end of the acrosome, which was closely located to the sperm-egg fusion site proposed for Monodelphis domestica (Taggart et al. 1993). The PAC and its possible role in both American and Australian marsupials requires detailed examination. Distinct immature features were discovered in the wallaby testicular spermatozoa. A scoop shape of the acrosome was found on the testicular spermatozoa of the tammar wallaby, which was completely different to the compact button shape of acrosome in ejaculated spermatozoa. The fibre network found beneath the cytoplasm membrane of the midpiece of the ejaculated sperm also did not occur in the testicular spermatozoa, although the structure of the principle piece was fully formed and had no obvious morphological difference from that of the epididymal and ejaculated spermatozoa. The time frame of the formation of morphologically mature spermatozoa in the epididymis of the tammar wallaby needs to be determined by further studies.

Tropospheric ozone: respiratory effects and Australian air quality goals

OBJECTIVE

To review the health effects of tropospheric ozone and discuss the implications for public health policy.

DESIGN

Literature review and consultation with scientists in Australia and overseas. Papers in English or with English language abstracts were identified by Medline search from the international peer reviewed published reports. Those from the period 1980-93 were read systematically but selected earlier papers were also considered. Reports on ozone exposures were obtained from environmental agencies in the region.

RESULTS

Exposure to ozone at concentrations below the current Australian air quality goal (0.12 ppm averaged over one hour) may cause impaired respiratory function. Inflammatory changes in the small airways and respiratory symptoms result from moderate to heavy exercise in the presence of ozone at levels of 0.08-0.12 ppm. The changes in respiratory function due to ozone are short lived, vary with the duration of exposure, may be modified by levels of other pollutants (such as sulphur dioxide and particulates), and differ appreciably between individuals. Bronchial lavage studies indicate that inflammation and other pathological changes may occur in the airways before reductions in air flow are detectable, and persist after respiratory function has returned to normal. It is not known whether exposures to ozone at low levels (0.08-0.12 ppm) cause lasting damage to the lung or, if such damage does occur, whether it is functionally significant. At present, it is not possible to identify confidently population subgroups with heightened susceptibility to ozone. People with asthma may be more susceptible to the effects of ozone than the general population but the evidence is not consistent. Recent reports suggest that ozone increases airway reactivity on subsequent challenge with allergens and other irritants. Animal studies are consistent with the findings in human populations.

CONCLUSION

A new one hour air quality ozone goal of 0.08 ppm for Australia, and the introduction of a four hour goal of 0.06 ppm are recommended on health grounds.

Interactions of cimetidine and ranitidine with aluminum-containing antacids and a clay-containing gastric-protective drug in an "artificial stomach-duodenum" model

Interactions of cimetidine and ranitidine with aluminum-containing antacids and clay-containing gastric-protective drugs were analyzed in vitro by using an artificial stomach-duodenum model. The model reproduced near-physiologic conditions, taking into account gastric and duodenal flux variations and interactions between gastric mucosa and drugs added to the gastric content. Clay bound cimetidine in acid medium, but the drug was released when the pH increased, resulting in cimetidine amounts in the duodenal site close to those in controls. In contrast, clay bound ranitidine in acid medium and did not release it in the duodenal site. Aluminum-containing antacids did not significantly modify the amount of cimetidine or ranitidine available for absorption. Several factors play a role in the interactions of cimetidine and ranitidine with aluminum-containing antacids and clay-containing gastric-protective drugs: the structure of the antisecretory drugs, gastroduodenal pH, interactions of the antacid and clay with the gastric mucosa, and release of aluminum that could adsorb the drugs or prevent their adsorption by the mucosa. These phenomena are intricate and difficult to analyze without using a physicochemical approach.

Horizontal cells in the retina of the brush-tailed possum

Most species of eutherian (placental) mammals examined have two types of horizontal cell, one is axonless and the other has a short axon. We have recently shown that a marsupial, the quokka wallaby, also has two types of horizontal cell and that the axonless cell in this species has unusual stubby processes that pass through the inner nuclear layer to reach the inner plexiform layer. In order to discover whether these descending processes are a feature of marsupials in general, I examined the morphology of retinal horizontal cells in the brush-tailed possum, using horseradish peroxidase labelling. There are two types of horizontal cell in the possum. One type is axonless and has long, fine dendrites somewhat similar to that in the quokka; however, there are several marked differences between the axonless cells seen in the two species. The axonless cell in the possum has on average ten secondary dendrites, twice as many as seen in the quokka. These dendrites are arranged in a radial distribution, unlike those in the quokka, which are polarised in a direction often orthogonal to the overlying ganglion cell axons. Axonless horizontal cells in the possum do not have descending processes that reach the inner plexiform layer as has been seen in the quokka. The second horizontal cell type, the short-axon cell, has an axon and an axonal arbor and is similar to the short-axon cell seen in the retina of the quokka. Therefore, the morphology of the axonless horizontal cell appears to be variable, while that of the short-axon cell is conserved in marsupials as in eutherians.