Renal biopsy in high-risk patients with medical diseases of the kidney.

The number of high-risk patients undergoing renal biopsy is likely to increase in the near future because of the increased use of anticoagulants for such conditions as atrial fibrillation, combined liver and kidney disease caused by hepatitis C, and the aging of the population. Nephrologists need to become increasingly familiar with evaluating such patients through both specialized management of percutaneous kidney biopsy and alternate methods of renal biopsy, which primarily consist of open (surgical) biopsy, transjugular (transvenous) biopsy, and laparoscopic biopsy. The indications, complications, and general approach to such patients are discussed. This is a US government work. There are no restrictions on its use.

Multidisciplinary airway stent team: a comprehensive approach and protocol for tracheobronchial stent treatment.

Tracheobronchial stents are being used with increasing frequency to treat major airway obstruction from both malignant and benign processes. Traditionally, stents have been placed via rigid bronchoscopy, flexible bronchoscopy, or fluoroscopy by members of various individual disciplines. We describe a novel multidisciplinary airway stent team (MAST) protocol for tracheobronchial stent placement and endoscopic management of major airway obstruction. A patient with symptoms of airway obstruction is generally first evaluated with a computed tomography scan and a videotaped flexible bronchoscopy. These studies are reviewed by the team otolaryngologist, pulmonologist, and interventional radiologist. A treatment plan, including the type and location of stents and the need for adjuvant therapies, is formulated. Stent placement is performed in the operating room under general anesthesia. Rigid bronchoscopy, with flexible bronchoscopy and fluoroscopy as needed, allows precise stent placement and the best use of various therapeutic methods. The MAST protocol combines the skills, knowledge, and unique therapeutic options of specialists from otolaryngology, pulmonology, and interventional radiology. This approach allows optimal stent placement and the use of other endobronchial therapies, including laser ablation, balloon dilation, photodynamic therapy, cryotherapy, and brachytherapy. A protocol with representative case reports is presented, along with a review and comparison of several of our most commonly used stents. Otolaryngologists who practice bronchoesophagoscopy, by virtue of their operative skill and knowledge of airway management, are well equipped to become leaders of MASTs and are encouraged to initiate MASTs at their institutions.

Mediastinal bronchogenic cyst: demonstration of a fluid-fluid level at MR imaging.

The appearance of mediastinal bronchogenic cysts at cross-sectional imaging is variable. Intracystic hemorrhage, proteinaceous fluid, or suspended calcium may belie the true cystic nature of the lesion at computed tomography or magnetic resonance (MR) imaging. The authors report a case of a fluid-fluid level seen on MR images of a bronchogenic cyst. This appearance, likely due to dependent layering of proteinaceous material, helped preoperatively confirm the true cystic nature of the lesion.

Long-term follow-up of upper extremity implanted venous access devices in oncology patients.

PURPOSE: To evaluate function and assess incidence of complications relating to upper extremity implanted venous access devices placed in oncology patients primarily for chemotherapy. MATERIALS AND METHODS: The authors retrospectively evaluated the clinical course of 205 upper extremity implanted venous access devices placed with fluoroscopic and sonographic guidance in 204 patients during a 2-year period. All patients had a diagnosis of malignancy for which chemotherapy was planned. Follow-up data were collected by patient examination, direct evaluation of device function, as well as chart review and review of relevant imaging procedures. A modified technique for device placement is described. RESULTS: The devices were placed successfully on the initial attempt in all cases. Clinical follow-up was obtained for 195 devices (95.1%) for a total device service period of 33,619 days (mean service interval = 169 days). Seventy-eight devices (40%) had service intervals greater than 180 days. Thirty-seven devices (19% of total devices) led to 39 complications (0.116 event/100 days). No immediate procedural complications were incurred. Eight complications occurred after 180 days of port service. Nineteen devices (9.7% of total devices followed) required removal as a result of complication. Common complications included port malfunction requiring urokinase to clear (n = 10; 0.030 event/100 days), ipsilateral upper extremity deep venous thrombosis (n = 9; 0.027), and local infection (n = 7, 0.021). A comparison of these results relative to other published series of similar devices placed for mixed indications is presented. CONCLUSIONS: Implanted venous access devices are an effective means of long-term venous access in oncology patients. Complication rates in this large series compared favorably to other published radiologic and surgical series. Analysis of complications in a subgroup of extended use implanted venous access devices (greater than 180 days follow-up) showed no statistically significant (P < .05) difference from the larger group of devices.

Supra-aortic arterial stenoses: management with Palmaz balloon-expandable intraluminal stents.

PURPOSE: The authors report on the use of Palmaz balloon-expandable intraluminal metallic stents to supplement conventional balloon angioplasty and to primarily treat a variety of supra-aortic arterial atherosclerotic lesions manifested by claudication or embolic phenomena. PATIENTS AND METHODS: Results from a series of seven patients are reported. Five patients received stents following percutaneous balloon angioplasty (PTA): four patients received five stents for suboptimal initial result of PTA and one patient received one stent for early restenosis following successful PTA. Two patients received three stents primarily: one patient had one stent placed for a highly eccentric innominate lesion and the other patient had two stents placed for an ulcerated nonocclusive subclavian lesion causing blue digits. RESULTS: Treatment produced immediate angiographic or hemodynamic improvement in all seven patients. Clinical follow-up was obtained on all patients (mean, 10 months; range, 3-18 months). One patient had an episode of vertigo after PTA of a right subclavian lesion that resolved after thrombolytic therapy and stent placement. CONCLUSION: The placement of metallic stents in supra-aortic arteries represented an effective adjunct to PTA of atherosclerotic stenoses in these vessels. Primary stent placement may be an effective treatment for selected lesions.