Lymphatic visualization during renal transplant rejection.

Intrarenal microlymphatic filling was observed during a microangiographic and histologic study of unmodified canine allograft rejection. The extent of lymphatic visualization was correlated with the pathophysiologic state of the allograft. An example of renal lymphatic visualization following arterial perfusion of a human specimen is also presented. During early rejection, as microvascular and histologic alteration became more severe, there was prominent visualization of lymphatics. However, in late rejection, as cortical necrosis developed, lymphatic filling was less evident. Lymphatic visualization following arterial perfusion during rejection depends on progressive loss of microvascular integrity, contrast extravasation and subsequent filling of lymphatics which are acting as an alternate route of drainage for the excess interstitial edema present due to immune injury.

A fatal eosinophilic process in a Laotian refugee.

A 17-year-old Laotian refugee developed an ultimately fatal disease process characterized by formation of an abdominal eosinophilic mass, peripheral eosinophilia, and elevated serum IgE. No parasitic pathogens that could explain her disease were isolated during life or identified at autopsy. Furthermore, the disease was not consistent with previously described neoplastic, inflammatory, or idiopathic diseases. We believe this process represents a unique, aggressive variation of the hypereosinophilic syndrome, and that immunosuppressive therapy may be warranted.

Drainage of hepatic, intraabdominal, and mediastinal abscesses guided by computerized axial tomography. Successful alternative to open drainage.

Opens surgical drainage of intraabdominal, intrahepatic, and mediastinal abscess is well established. Although this may be the procedure of choice when there are indications for treatment of concurrent intraabdominal and mediastinal surgical disease, with the advent of computerized axial tomography and ultrasonography we have identified a patient population best served by percutaneous catheter drainage. The procedure involves precise localization using ultrasound or CAT scanning, fine needle aspiration for confirmation of diagnosis, and injection of radiopaque contrast medium with fluoroscopic observation to localize the abscess. Catheter placement is usually achieved by a Seldinger technique, although a trochar-cannula method is occasionally required. Our experience with 4 patients, as well as review of the world literature provides a cumulative experience of 252 patients, has led us to believe that this approach is successful 83 percent of the time with a minimal incidence of complications. Percutaneous catheter drainage of intrahepatic, intraabdominal, and mediastinal abscess guided by computerized axial tomography is the treatment of choice in patients who do not have other indications for exploration.

The spleen and its vasculature in pancreatitis: CT findings.

The spleen and its vasculature are susceptible to damage from pancreatic inflammatory exudates. Fourteen patients were identified who demonstrated splenic or splenic vascular involvement from pancreatitis on computed tomography. Findings included intra- and perisplenic inflammatory fluid collections (n = 6), acute splenic hematomas (n = 3), splenic infarction (n = 1), splenic artery pseudoaneurysm (n = 1), and splenic vein thrombosis (n = 6). Eight of the 14 patients went on to urgent interventions including percutaneous catheter drainage (n = 2) and transcatheter embolotherapy (n = 6) based on the CT findings.

Percutaneous translumbar and transhepatic inferior vena caval catheters for prolonged vascular access in children.

Central venous access for children with caval occlusion remains a major challenge to pediatric surgeons. Traditionally, children with superior and inferior vena cava (SVC, IVC) thrombosis have often required a thoracotomy to directly cannulate the azygos system or right atrium (RA). Recently, the possibility of placing tunneled RA catheters (RACs) by a percutaneous translumbar or transhepatic approach has become available. We report our experience of seven children with SVC and IVC obstruction who have received 11 transhepatic and 4 translumbar RACs from 1987 to 1991. All but one child was less than 2.5 years old and all were chronically dependent on parenteral nutrition. All catheters were placed in the angiography suite under general anesthesia using ultrasound guidance and Seldinger technique. This technique was successful in all seven children. Perioperative complications included accidental extubation in one patient and aspiration pneumonia in another. Mechanical complications requiring RAC replacement occurred 5 times in three infants (greater than 2,650 catheter days) and included catheter dislodgement (2) and thrombosis (3). In the patients with catheter thrombosis, the existing tract was successfully wired and the catheter exchanged on three occasions. Thrombolytic therapy was effective in restoring catheter patency on three other occassions. Nine episodes of catheter sepsis occurred in five children. Two late deaths occurred from infection. Of the five remaining children, four are dependent on total parenteral nutrition and have a translumbar or transhepatic catheter in situ and one child has adapted successfully to enteral feedings. Percutaneous translumbar or transhepatic IVC catheters provide excellent alternative routes for prolonged central venous access in those patients whose traditional vascular access sites are no longer available. Complications of the technique itself were minimal and although late catheter complications were not infrequent, they appear to be comparable to the standard approaches reported.

Percutaneous inferior vena cava placement of tunneled silastic catheters for prolonged vascular access in infants.

In infants and children requiring prolonged and multiple central venous catheterizations, conventional cannulation sites may become thrombosed or stenotic, making inability to gain vascular access a life-threatening problem. The technique we use for the percutaneous placement of inferior vena caval tunneled silastic catheters via the translumbar and transhepatic approaches is described. Three translumbar placements and one transhepatic placement in three children without immediate complications have been performed. We conclude that percutaneous inferior vena caval cannulation via the translumbar or transhepatic routes offers a viable alternative in these patients with difficult vascular access.

Chronic posttraumatic aortic pseudoaneurysm. Recognition before rupture.

Few patients survive transection of the aorta caused by blunt trauma. However, among those who do are a small number who go on to live with an unrecognized pseudoaneurysm that may rupture at any time. Because these aneurysms may be mistaken for more common disease processes, such as hilar adenopathy, atherosclerotic aneurysm, or neoplasia, the authors describe radiographic findings that suggest the correct diagnosis.

Barium duodenography as an adjunct to percutaneous transhepatic cholangiography.

Performance of barium duodenography at the end of transhepatic cholangiography improves visualization of the anatomy of the porta hepatis and lower common bile duct. The relationships of C loop, common the bile duct, and ampulla are clearly demonstrated. Without the barium study, the variability of the relationship between the biliary tree and the duodenum may not be appreciated. The technique is described and illustrated by four cases.

Paradoxical embolism in morbidly obese persons.

Three cases of paradoxical embolism are reported in patients with morbid obesity. Early consideration of the possibility of paradoxical embolism allows the appropriate therapy to be instituted without delay. It appears that these patients are at increased risk for both pulmonary emboli and paradoxical emboli. The necessity of early diagnosis in the pathophysiology of paradoxical embolism is discussed.

Modified trocar-cannula system for percutaneous pancreatic abscess drainage.

A trocar-catheter system using a 7.1-F pigtail catheter and a translumbar needle was used successfully in the percutaneous drainage of a pancreatic abscess via an anterior approach. This system provides a) adequate drainage size, b) adequate length for deep-seated abscesses, and c) pigtail-catheter configuration.

Anal verge and low rectal bleeding. A diagnostic problem.

We describe five patients with lower gastrointestinal bleeding with negative endoscopy who subsequently proved to have sources of bleeding in the rectum close to the anal verge. The failure to identify such sources of bleeding via the endoscope was due to endoscopic geometry within the rectum, limited colonic preparation possible in the massively bleeding bowel, endoscopic inexperience, and a low clinical suspicion for very distal lesions. We discuss appropriate application of the available diagnostic techniques and methods to avoid endoscopic diagnostic failures in low rectal hemorrhage.

New technique for left adrenal vein catheterization.

A technique for left adrenal vein catheterization utilizing a Mikaelsson catheter is described. This technique allows a stable catheter position within the left adrenal vein and permits bilateral adrenal vein catheterization using a single catheter.

Radiologic placement of long-term central venous catheters: a review.

The need for long-term placement of catheters within the central venous system is continually expanding and follows the increasing use of hemodialysis, total parenteral nutrition, and long-term chemotherapy for neoplastic and infectious diseases. Whereas these catheters have traditionally been placed by surgeons in an operating room, it is now clear that they can be effectively placed by interventional radiologists using percutaneous techniques within an interventional/angiographic suite. This review is based on the radiologic percutaneous placement of nearly 1,500 central venous catheters including approximately 500 tunneled Hickman/Leonard catheters, 350 double-lumen cuffed dialysis catheters, and 150 chest wall subcutaneous ports.

Radiologic management of fluid collections in children.

Percutaneous catheter drainage procedures have become widely accepted in the management of intraabdominal fluid collections in adults. We report our experience in 12 children with 15 fluid collections who underwent 22 procedures and emphasize the usefulness of this procedure in the pediatric population. Thirteen fluid collections were cured by the procedure. One collection improved with the procedure but needed definitive surgical correction to effect a cure. One other patient with an intestinal fistula did not respond. The complicated nature of many of our cases coupled with the high cure rate (87%) and low complication rate (4.5%) makes percutaneous drainage an excellent alternative to surgical drainage under general anesthesia.

Percutaneous abscess drainage in Crohn's disease.

The effect of 18 percutaneous abscess drainage procedures on the clinical management of 10 patients with Crohn's disease was evaluated. Two abscesses occurred immediately after surgery (two patients), five were in the liver (three patients), and 11 were the result of direct spread of disease from adjacent transmural bowel involvement (seven patients). Both postoperative and all five hepatic abscesses were treated successfully with percutaneous drainage. In two of the seven patients with abscesses secondary to transmural bowel disease, percutaneous drainage resulted in resolution of the abscess without the need for any further surgical intervention. The remaining five patients had subsequent elective intestinal surgery in which a single-stage surgical resection and primary reanastomosis were performed successfully. Two of these patients had abscesses recur at the same location, prompting a repeat percutaneous drainage before surgery. No enterocutaneous fistulas secondary to percutaneous drainage developed in any of the 10 patients. These results indicate that percutaneous abscess drainage can be a valuable technique for treating abscesses that result as a complication of Crohn's disease.

Cervical vessel injury after blunt trauma.

Blunt trauma accounts for 3% to 10% of cervical vessel injuries. Death and severe neurologic impairment have been reported in more than 80% of blunt carotid injuries. In our recent experience, 10 patients sustained 18 blunt cervical arterial injuries: two internal carotid artery (ICA) dissections, three ICA transections with pseudoaneurysm, five ICA thromboses, two vertebral artery dissections, one vertebral artery transection with pseudoaneurysm, one vertebral artery thrombosis, one minimal vertebral artery injury, and three caroticocavernous fistulas. A delay of more than 12 hours in making the diagnosis occurred in seven of the 10 patients. The mental status was initially normal in seven patients. The subsequent development of focal neurologic findings incongruent with CT scanning of the head prompted four-vessel angiography. Treatment was individualized and included supportive management, intravenous heparin, ligation, extracranial-intracranial bypass, and radiologic embolization. We have developed an angiographic classification that may aid management. Early angiography in patients with neurologic findings incongruent with head CT scan or in whom a normal sensorium and hemiparesis are present may permit improved outcomes. We advocate direct operative repair for accessible lesions of recent onset. For surgically inaccessible lesions, those with delayed presentation or in some cases with a fixed neurologic deficit, intravenous heparin can be started and follow-up angiography, head CT scanning, and the patient's clinical status determine further therapy.

The failed transhepatic cholangiogram.

A study of percutaneous transhepatic cholangiograms in 94 consecutive patients revealed that success is largely determined by the number of passes attempted. Two of 43 patients with dilated intrahepatic ducts had unsuccessful cholangiograms, but in these patients only two and three passes were attempted. In the remaining 41 patients fewer than seven passes were required. In patients with nondilated ducts, the success rate bears an almost linear relationship to the number of attempted passes beyond the fourth pass. Since patient tolerance often limits the number of passes, careful technique is important; one such technique is described. In the cholangiogram failures with nondilated ducts, subsequent liver biopsy had a high diagnostic yield.

US guidance for vascular access. Technical note.

Real-time ultrasonography (US) is frequently used to access the biliary tree, urinary system, and pleural cavity, as well as abscesses and other fluid collections, but is rarely used to access blood vessels. This article describes the clinically indicated circumstances and technical aspects of US-guided access to veins and arteries. The authors' experience suggests that appropriate use of this modality significantly simplifies vascular access difficulties, reduces procedure time and morbidity, and is cost-effective.