Sonography before and after carpal tunnel release: video article.

Carpal tunnel release for compression of the median nerve at the wrist is a common procedure, often resulting in good clinical outcomes. There are, however, many anatomical variations in and around the carpal tunnel and it is important to be aware of these during carpal tunnel release. After surgery, recurrent carpal tunnel syndrome is uncommon, but difficult to diagnose and treat. Ultrasonography is often necessary for the evaluation of the anatomical variations before carpal tunnel release and to evaluate the most common complications after carpal tunnel release.

Effect of iodinated contrast medium on thyroid function: a study in children undergoing cardiac computed tomography.

BACKGROUND: Few studies, and with conflicting results, have evaluated the potential effects of iodinated contrast media on children's thyroid function. OBJECTIVE: To investigate the effects of iodinated contrast medium on thyroid function in neonates, infants and young children with congenital heart disease undergoing cardiac computed tomography (CT). MATERIALS AND METHODS: We retrospectively evaluated 10 neonates (group 1) and 23 infants and young children (group 2) without thyroid or renal disease for serum levels of thyroid-stimulating hormone, free triiodothyronine and free thyroxine before contrast-enhanced cardiac CT, 48 h after CT and at discharge from the hospital. Cardiac CT was performed with intravenous administration of 1.14±0.17 mL/kg of body weight of iopromide (containing 370 mg of iodine/mL). RESULTS: Group 1 had a reduction of thyroid-stimulating hormone from baseline to 48 h post injection (P=0.002). Group 2 had a reduction of thyroid-stimulating hormone median levels from baseline to 48 h post injection and an increase from 48 h to discharge (P=0.0005 and P=0.0001, respectively). CONCLUSION: Intravenous iodinated contrast medium in children with congenital heart disease caused transient thyroid-stimulating hormone decrease 48 h after CT, with thyroid-stimulating hormone returning to normal range at discharge.

Stent Grafts Provided Superior Primary Patency for Central Venous Stenosis Treatment in Comparison with Angioplasty and Bare Metal Stent: A Retrospective Single Center Study on 70 Hemodialysis Patients.

PURPOSE: To compare patency in dialysis patients following different endovascular treatment of symptomatic central venous stenosis. MATERIALS AND METHODS: A 10-year retrospective evaluation in 70 patients (32 men) dialyzing through vascular access (33, 47%) and tunneled catheters (37, 53%) was made. Three cohorts were compared: angioplasty alone (22), bare metal stent (28), and stent graft (20). Patencies were described with Kaplan-Meier method, and Cox uni- and multivariate models were analyzed to find factors associated. RESULTS: All patients had a favorable anatomical and clinical outcome. Restenosis occurred in 22 (31%) of 70 patients requiring 41 additional interventions; 34 of 70 patients died (median follow-up 19.4 months). Primary patency at 3, 6, 12, and 24 months was 100%, 100%, 100%, and 84% for stent graft versus 90%, 79%, 58%, and 43% for angioplasty (P = .014) versus 84%, 80%, 75%, and 46% for bare-metal stent (P = .062). The overall comparison was more favorable for stent graft (P = .020) when the sites of lesions were matched. Patencies for angioplasty and bare-metal stents were equivalent (P = .141). A lower risk of restenosis (hazard rate [HR] 0.20, confidence interval [CI] 0.06-0.7) and fewer reinterventions (P < .01) were associated with stent graft, whereas age (HR 1.04, CI 1.001-1.08) and cardiovascular disease (HR 2.26, CI 1.06-4.84) influenced the overall survival. No difference in assisted primary patency was found. CONCLUSION: Stent graft seems to improve primary patency for central venous stenosis and requires fewer reinterventions in a dialysis population with a high prevalence of long-term catheters.

Dealing with stuck hemodialysis catheter: state of the art and tips for the nephrologist.

The term stuck catheter refers to the condition in which a catheter is not removable from a central vein using standard techniques. Although it is a rare complication, in the last few years it has been reported ever more frequently in hemodialysis due to the widespread use of tunneled catheters. Poor knowledge of the correct procedures and limited experience and training of the specialist in facing this problem are the main reasons for catheter internalization. Stuck catheter is often diagnosed by the nephrologist, who should be competent enough to manage this clinical complication. Among the many options for removing a stuck catheter from the fibrin sleeve, an interventional radiology approach, mainly with endoluminal balloon dilatation, probably provides the best solution. Vascular surgery should be reserved to selected cases in which percutaneous techniques have failed. Nephrologists must play a central role in organizing the treatment of this complication with other specialists in order to avoid making mistakes that may preclude future positive results.

A refinement of Hong's technique for the removal of stuck dialysis catheters: an easy solution to a complex problem.

AIM: A long-term tunneled hemodialysis catheter can be difficult or impossible to pull out if a fibrin sleeve has attached it to the venous wall. We report the outcome of a refinement of Hong's technique for removing incarcerated catheters aimed at improving its feasibility and safety. METHODS: We applied a modification of Hong's technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from adhesions. In our technical refinement, we cut the catheter close to its venous entry point in order to facilitate pullout and inserted a valved introducer as access for guide wires as well as for inflations of the catheter balloon. A stiff guide wire was placed in the inferior vena cava to avoid potential damage to heart cavities. Dilation was monitored under fluoroscopy with constrictions showing points where the catheter was incarcerated. If adhesions persisted through the same introducer, endoluminal dilations were repeated with a larger diameter balloon until the catheter was released. New catheters can be positioned using the stiff guide wire already in place. All removals were carried out under local anesthesia in an angiographic room by interventional radiologists. RESULTS: All catheters were successfully removed without complications. Average fluoroscopy time for removal was 12 minutes. In the case of a Tesio catheter removed after 12 years because of infection, a computed tomography scan 2 months later revealed persistence of a calcified fibrin sleeve in the vessel. CONCLUSIONS: Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus' egg in this previously risky field.