ABSTRACT
Chronic liver disease has affected a majority of haemophiliacs exposed to factor VIII and factor IX concentrates before effective viral attenuation techniques were introduced. Progressive hepatitis and liver failure have increasingly become causes of morbidity, especially in haemophilia patients also seropositive for HIV. Encouraging reports of recombinant alpha interferon to reverse the histological, laboratory and clinical deterioration of chronic active hepatitis justifies obtaining liver biopsies to assess the severity of liver damage; however, the percutaneous method carries a significant risk of bleeding. Therefore, we employed a transjugular venous approach for liver biopsies in six HCV-, HBSAb- and HIV-seropositive adults with severe haemophilia A (n = 5) or B (n = 1) with persistent liver function abnormalities. Adequacy of the specimens and lack of haemorrhagic complications leads us to conclude that this procedure appears to be safe and effective in individuals with severe haemophilia or other congenital or acquired coagulopathies.
ABSTRACT
PURPOSE: The purpose of this study was to analyze the results of vascular interventions for impotence in men with this complaint. METHODS: Between September 1983 and March 1993, 1094 men with the chief complaint of impotence (average age 54.5 years) were screened by use of penile plethysmography and penile brachial indexes: 635 were considered to have normal flow, and 459 were considered to have abnormal arterial flow, 12.2% of whom were found to have aortoiliac disease. Based on negative neural screening results, absence of erectile responses on increasing doses of intracavernously injected papaverine or prostaglandin E1 (ICI), surgical candidates for microvascular procedures were referred for dynamic infusion cavernosography (DICC) and pudendal arteriography. Operations for men discovered to have aortoiliac disease were based on conventional indications including aneurysm size or limb ischemia. None of the subjects had diabetes. Only those patients without diabetes and those not requiring blood pressure medications were selected for microvascular procedures. We report our experience and surgical outcomes at average follow-ups of 33 to 48 months. Four types of operations were performed on 67 men (age 18 to 79 years). These included 17 aortoiliac reconstructions, 11 dorsal penile artery bypasses, 12 dorsal vein arterializations, and 27 venous interruptions. Follow-up data were obtained by direct examination and noninvasive Doppler examinations; repeat arteriography (4 of 11); repeat DICC after venous ablation procedures (18 of 27) and postoperative ICI response. Mail questionnaires completed postoperative surveillance. RESULTS: Among 17 men undergoing aortoiliac intervention for aneurysms in eight and occlusive disease in nine, 58% functioned spontaneously after operation and 18% used ICI or vacuum constrictor devices at an average follow-up time of 38 months. Among 11 men with dorsal penile artery bypasses, 27% functioned spontaneously and 45% used ICI at an average follow-up time of 34.5 months. Among 12 men with dorsal vein arterialization, 33% functioned spontaneously, and 47% used ICI at an average follow-up time of 48 months. Among 27 with venous interruption, 33% functioned spontaneously and 44% used ICI. In seven of eight aneurysms of 4.5 to 6.0 cm in size, impotence workup led to discovery; probable embolic mechanisms existed in three. Venous interruption efficacy correlated with postoperative DICC results when flow to maintain erection was 40 ml or less. Apart from two cases of glans hyperemia, no surgical complications occurred in the microvascular procedures. There was one episode of bleeding caused by DICC after aortic reconstruction. There were no deaths. CONCLUSIONS: With prospective screening criteria, 6% to 7% of impotent men became candidates for vascular intervention. Including those functioning with ICI or vacuum constriction devices, about 70% of these men were functional after operation. Men undergoing aortoiliac reconstruction has a significantly higher rate (58%) of spontaneous function as compared with those undergoing microvascular procedures.
Subject(s)
Impotence, Vasculogenic/surgery , Adolescent , Adult , Aged , Alprostadil , Aneurysm/complications , Aneurysm/surgery , Aortic Aneurysm/complications , Aortic Aneurysm/surgery , Aortic Diseases/complications , Aortic Diseases/surgery , Arterial Occlusive Diseases/complications , Arterial Occlusive Diseases/surgery , Brachial Artery/diagnostic imaging , Brachial Artery/physiopathology , Follow-Up Studies , Humans , Iliac Artery , Impotence, Vasculogenic/diagnostic imaging , Impotence, Vasculogenic/etiology , Impotence, Vasculogenic/physiopathology , Male , Microsurgery , Middle Aged , Papaverine , Penile Erection/physiology , Penis/blood supply , Penis/diagnostic imaging , Plethysmography , Prospective Studies , Radiography , Regional Blood Flow/physiology , Treatment OutcomeABSTRACT
RATIONALE AND OBJECTIVES: The use of nonionic contrast media for peripheral angiography has been well established in various reports. These agents provide the clinical benefit of decreased pain and heat sensations thought to be a function of osmolality, viscosity, and vasodilation. Iopromide is a new nonionic contrast medium that has been extensively studied for both intravenous (i.v.) and intraarterial indications. This study compares iopromide with similar concentrations of two other nonionic agents to evaluate their efficacy, tolerance, and adverse effects in peripheral angiography. METHODS: Two prospective, double-blind, randomized comparative clinical trials compared the safety profile, tolerance, and diagnostic quality of iopromide with two control drugs, iopamidol and iohexol. Eighty-one patients received iopromide, 19 received iohexol, and 40 received iopamidol. The trials evaluated potential changes in routine hematologic, biochemical, and renal function studies up to 72 hours after completion of the studies. Efficacy evaluation was performed by a physician who was blinded to the contrast used. Tolerance and adverse effects were determined by questionnaire, direct observation, and chart review. RESULTS: Demographic parameters were comparable among the three study sites. There was no difference in vessel visualization or diagnostic quality of the examination among the three agents. Minor adverse events occurred in all groups. Serious adverse events were, in almost all instances, thought to be secondary to factors other than the contrast media administered. CONCLUSIONS: This study confirms the safety and efficacy of iopromide (300 mg I/mL) for peripheral arteriography. Its safety and efficacy profiles are comparable with those of iopamidol and iohexol at similar concentrations and dosage.
Subject(s)
Angiography , Contrast Media , Iohexol/analogs & derivatives , Contrast Media/adverse effects , Double-Blind Method , Drug Tolerance , Female , Humans , Iohexol/adverse effects , Iopamidol/adverse effects , Male , Prospective Studies , SafetyABSTRACT
RATIONALE AND OBJECTIVES: Nonionic contrast media have been shown to be more effective, better tolerated, and safer than standard high-osmolality contrast media when given intravascularly. The aim of this study was to assess the diagnostic efficacy, tolerance, and safety of a new nonionic contrast agent, iopromide (370 mg I/mL), in comparison with two available similar agents, iopamidol (370 mg I/mL) and iohexol (350 mg I/mL), in two randomized, double-blind clinical studies of patients undergoing abdominal aortography and visceral angiography. METHODS: The iopromide group included 80 patients, and the comparator group consisted of 36 iopamidol and 45 iohexol patients. The quality and diagnostic efficacy of all three contrast agents was rated equally as either good or excellent. RESULTS: On a scale of 0 (none) to 3 (severe) for heat and pain, respectively, the mean scores were 1.08 and 0.43 for iopromide in comparison with 1.15 and 0.35 for the comparator media. Minor adverse clinical experiences were noted in 23% of the iopromide group versus 20% of the comparator group. Nausea and vomiting were more common in the comparator group (7% versus 3%), and headache was noted only in the iopromide group (4%). There were no clinically significant changes in laboratory values in any group. Three severe adverse experiences occurred, but all were deemed unrelated to the contrast agents. CONCLUSION: Based on the results of this study, iopromide appears to be efficacious, safe, well tolerated, and comparable with iohexol and iopamidol for use in abdominal aortography and visceral angiography.
Subject(s)
Angiography , Aortography , Contrast Media , Iohexol/analogs & derivatives , Contrast Media/adverse effects , Double-Blind Method , Drug Tolerance , Humans , Iohexol/adverse effects , Iopamidol/adverse effects , Middle Aged , Safety , Viscera/blood supplyABSTRACT
The authors encountered a patient with an indwelling central venous catheter who presented with pulmonary edema after the catheter hub was disconnected. Pulmonary arteriography demonstrated diffuse peripheral vasoconstriction, decreased arterial-to-venous transit time, and arterial occlusions. The former two findings allowed the authors to prospectively suggest the diagnosis of pulmonary air embolism.
Subject(s)
Catheterization, Central Venous/adverse effects , Embolism, Air/diagnostic imaging , Pulmonary Embolism/diagnostic imaging , Adult , Catheters, Indwelling/adverse effects , Embolism, Air/etiology , Humans , Male , Prospective Studies , Pulmonary Embolism/etiology , RadiographyABSTRACT
To delineate neural, arterial, and venous components contributing to impotence, we used a previously described noninvasive screening sequence combined with stimulation of artificial erection with papaverine injection, selective pudendal arteriography (SPA), and dynamic cavernosography (DC). Among 572 men with impotence, age range 17 to 78 years (average age 54.8 years), 26 men with potential cavernosal leaks in absence of other factors were identified; 16 underwent DC; among these five had normal cavernous venous drainage. Eight men with abnormal cavernosal venous drainage required cavernous infusion flow rates higher than 120 ml/min to obtain erection and higher than 40 ml/min to maintain erection. Radiographic studies showed cavernosal leakage in all eight patients. Eight men, ages 39 to 61 years, underwent surgical ablation of abnormal cavernosal venous drainage. Among these, five men have had excellent results for up to 3 years. One failure was related to unrecognized penile arterial disease later shown by SPA. In two men small doses of papaverine now induce erection. We now recommend SPA before DC to rule out an arterial abnormality. Accurate identification of factors contributing to erectile failure is critical for successful treatment; in this experience candidates for correction of cavernosal leak syndrome were uncommon.
Subject(s)
Erectile Dysfunction/etiology , Penis/blood supply , Adolescent , Adult , Aged , Contrast Media , Erectile Dysfunction/diagnosis , Erectile Dysfunction/diagnostic imaging , Erectile Dysfunction/surgery , Humans , Male , Middle Aged , Papaverine/administration & dosage , Penile Erection , Penis/innervation , Perfusion , Phlebography , Pressure , Vascular Diseases/complications , VeinsABSTRACT
A 36-year-old man was thought (for 20 years) to have an arteriovenous malformation that could not be excised. Repeated ligations of proximal arterial supply to the vascular lesion were only transiently beneficial and may have caused a delay in correct diagnosis because of impaired angioaccess. Once it was discovered that he had an arteriovenous fistula--probably caused by a tonsillectomy at age 6--it was possible to occlude the fistula with detachable balloons. The mass and his headaches subsequently resolved. AV fistulas are caused by trauma. Growth of AVMs is often stimulated by trauma. Both lesions have pulsatile masses associated with overlying bruits. The differential diagnosis can usually be made by arteriography, since AV fistulas are acquired lesions with a single communication between an artery and a vein, whereas AVMs are congenital lesions with multiple, large arterial feeding vessels and numerous arteriovenous communications. Proper diagnosis is important, since AVMs are aggressive lesions that tend to regrow if not completely excised. AV fistulas will be cured if the single arteriovenous communication can be obliterated. Proper treatment for AV fistula is obliteration of the single arteriovenous communication, operatively or with occlusive balloons; treatment of AVMs--when possible--is excision of the entire mass, combined (on occasion) with preoperative embolization of the tumor mass. This case report emphasizes the importance of accuracy in the differential diagnosis between arteriovenous malformations and arteriovenous fistulas; moreover, it demonstrates both the ineffectiveness and deleterious consequences of proximal arterial ligation, since collateral development is enhanced and angiographic access is compromised.
Subject(s)
Arteriovenous Fistula/diagnosis , Arteriovenous Malformations/diagnosis , Catheterization/methods , Adolescent , Arteriovenous Fistula/therapy , Arteriovenous Malformations/therapy , Carotid Arteries/diagnostic imaging , Diagnosis, Differential , Humans , Male , RadiographyABSTRACT
We report the cases of four patients who complained of post-exertional shoulder and/or arm discomfort, and who were diagnosed with acute or possible impending axillary-subclavian vein thrombosis. One regained full patency of a stenotic and obstructed vein after local streptokinase infusion, first rib surgical resection, and transvenous angioplasty. A second with a patent but narrowed and tented vein was treated with heat and elevation, and was referred for possible surgical correction of thoracic outlet syndrome. The third patient, who presented two weeks after the thrombotic event, experienced a poor clinical outcome characterized by recurrent thrombosis despite aggressive therapy. The fourth, whose thrombosis was the presenting sign of mediastinal lymphoma, was treated with heat and elevation with resolution of pain and swelling.
Subject(s)
Axillary Vein , Subclavian Vein , Thrombosis/diagnosis , Acute Disease , Adult , Angioplasty, Balloon , Athletic Injuries/diagnosis , Combined Modality Therapy , Female , Hot Temperature/therapeutic use , Humans , Male , Physical Exertion , Recurrence , Streptokinase/therapeutic use , Tennis , Thrombosis/therapy , Weight LiftingABSTRACT
Delineation of neural, arterial, and venous components contributing to penile erectile failure is critical to proper patient selection for surgical interventions, particularly for a subset of men with impotence as the sole manifestation of pelvic arterial disease. In addition to obtaining a history and physical examination specific for disordered erectile function and vascular risk factors, we developed a sequence of testing to include noninvasive estimates of penile perfusion, pulse volume recording (PVR), and penile/brachial blood pressure indices (PBPI); somatosensory evoked potentials from dorsal penile (PEP) and posterior tibial nerve stimulation (SEP) and bulbocavernosus reflex time (BCR); stimulation of artificial erection with injection of papaverine (AE); and selective hypogastric-pudendal arteriography with patients under epidural anesthesia, and corpus cavernosography with AE. Three hundred fifty-three men complaining of impotence were screened by PVR and PBPI; among these 42 impotent men and 20 additional concurrent potent control subjects had evoked potentials and BCR measurements, and 55 men received one or more AE injections. On the basis of these results, angiographic investigation was recommended. Age and risk factors were similar in the two groups. Abnormal penile blood perfusion was associated significantly only with cigarette smoking (p less than 0.0001) or overt large vessel disease. Impotent men with (138) or without perfusion abnormalities (215) averaged 54 and 56 years of age, respectively; impotent men with normal flow patterns most commonly had treated hypertension or diabetes (79 of 215 men). Covert neurologic abnormalities were detected in 28 of 42 impotent men. Abnormal penile perfusion plus failure of AE predicted isolated ischiopudendal trunk or pudendal artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)
Subject(s)
Erectile Dysfunction/diagnosis , Penis/blood supply , Adult , Age Factors , Aged , Algorithms , Angiography , Arteries , Blood Pressure , Electric Stimulation , Erectile Dysfunction/etiology , Erectile Dysfunction/physiopathology , Evoked Potentials, Somatosensory , Humans , Male , Middle Aged , Papaverine , Penis/diagnostic imaging , Penis/innervation , Pulse , Reflex , Risk , Smoking , Tibial Nerve/physiology , Vascular Diseases/complicationsABSTRACT
We have reported the case of a 26-year-old man who had had intermittent but severe gastrointestinal bleeding over a 30-month period from a Meckel's diverticulum. Meckel's diverticulum should be searched for angiographically, even in the face of normal isotopic scans, in cases of chronic or intermittent gastrointestinal hemorrhage, particularly in younger patients.
Subject(s)
Gastrointestinal Hemorrhage/diagnostic imaging , Meckel Diverticulum/diagnostic imaging , Adult , Gastrointestinal Hemorrhage/etiology , Humans , Male , Meckel Diverticulum/complications , Meckel Diverticulum/surgery , Mesenteric Arteries/diagnostic imaging , Radiography , Radionuclide Imaging , RecurrenceABSTRACT
The importance of individualized treatment of patients with primary and secondary axillary-subclavian vein thrombosis is described with special emphasis on the use of thrombolytic therapy. Nine patients were treated with streptokinase or urokinase. Balloon dilation of the axillary or subclavian vein and first rib resection were also selectively used. Of the five patients with primary axillary-subclavian thrombosis, three did not have symptoms after the thrombus was lysed. Two had successful lysis of the thrombus but later suffered a rethrombosis, one of which most likely resulted from an untreated stenosis. All four of the patients with secondary thrombosis had successful thrombolysis. Patients with primary axillary-subclavian thrombosis are usually young and as many as 40% continue to have intermittent upper extremity edema or pain. For this reason we believe aggressive attempts to reestablish normal venous return through the axillary and subclavian veins are warranted. Patients with secondary axillary-subclavian thrombosis usually require prolonged venous catheterization for chemotherapy or total parenteral nutrition. Since patency of major upper extremity veins is extremely important in these patients with secondary thrombosis, we believe that vigorous attempts to restore these venous access routes are indicated and appropriate.
Subject(s)
Axillary Vein , Fibrinolytic Agents/therapeutic use , Subclavian Vein , Thrombosis/drug therapy , Adult , Axillary Vein/diagnostic imaging , Dilatation , Humans , Middle Aged , Physical Exertion , Radiography , Ribs/surgery , Streptokinase/therapeutic use , Subclavian Vein/diagnostic imaging , Thrombosis/diagnostic imaging , Thrombosis/etiology , Urokinase-Type Plasminogen Activator/therapeutic useABSTRACT
Vicarious excretion of urographic contrast media by the liver has been detected by conventional radiographic methods in patients with renal impairment or unilateral obstruction. It occurs in patients with normal renal function, however, and can be detected by delayed postcontrast computed tomography scans. A case is presented in which an intrahepatic cholangiocarcinoma was best depicted on scans delayed for 2 hours. After 2 hours, the contrast medium remained within hepatic parenchyma but was virtually cleared from the vascular and interstitial spaces.
Subject(s)
Adenoma, Bile Duct/diagnostic imaging , Liver Neoplasms/diagnostic imaging , Tomography, X-Ray Computed/methods , Adult , Contrast Media , Female , Humans , Liver/physiology , Time FactorsABSTRACT
Xanthogranulomatous pyelonephritis is an uncommon form of chronic renal infection which can be confused clinically, radiographically, and pathologically with renal carcinoma. Occasionally, xanthogranulomatous changes are more prominent in perinephric tissue than in the renal parenchyma itself. We present a case of locally invasive xanthogranulomatous perinephritis associated with thrombosis of the renal vein and inferior vena cava. With this constellation of findings, infections as well as malignant etiologies should be considered in the differential diagnosis.
Subject(s)
Granuloma/complications , Perinephritis/complications , Renal Veins/diagnostic imaging , Thrombosis/etiology , Vena Cava, Inferior/diagnostic imaging , Xanthomatosis/complications , Female , Humans , Middle Aged , Thrombosis/diagnostic imaging , Tomography, X-Ray ComputedABSTRACT
A technique for the percutaneous decompression of the obstructed right and left hepatic ducts using a single percutaneous tract was performed successfully on eight patients with bilateral ductal obstruction of various etiologies. Eliminating a second percutaneous drainage procedure when bilobar biliary decompression is indicated results in decreased morbidity, increased patient acceptance, and effective palliation of centrally obstructing lesions of the biliary tract.
Subject(s)
Cholestasis, Intrahepatic/therapy , Drainage/methods , Aged , Cholangiography , Drainage/adverse effects , Humans , MaleABSTRACT
Five patients with postoperative ureteral fistulae subsequent to surgically created ureteral anastomoses were treated successfully by temporary percutaneous nephroureteral drainage and stenting. Low, constant suction applied to the drainage tubes achieved total urinary diversion, while concomitant ureteral stenting seemed to prevent subsequent stricture formation. The techniques have reduced considerably the morbidity of this particular postoperative complication.