The short-to-midterm results of endovascular stent grafting for acute thoracic aortic diseases in Chinese patients.

OBJECTIVE: To review the results of endovascular treatment of acute thoracic aortic diseases in a group of Chinese patients. DESIGN: Retrospective study. SETTING: A tertiary referral hospital with a cardiothoracic surgery service. PATIENTS: All 15 patients presenting with acute thoracic aortic diseases between September 2001 and October 2005 inclusive, of whom eight had traumatic rupture, four had complicated acute dissections, two had mycotic aneurysms, and one an aneurysm with an aortobronchial fistula. INTERVENTIONS: Thoracic aortic stent grafting. MAIN OUTCOME MEASURES: Immediate success, 6-month and 1-year survival rates. RESULTS: The median follow-up period was 20.6 months (range, 0-50.1 months). Stent grafts were deployed with immediate success in all patients. Two patients had ancillary bypass surgery for the supra-aortic branches. There were two in-hospital deaths. Four sustained access artery injury and needed graft repair. Computed tomography at 1 month showed complete thrombosis of the aneurysmal lumen or the thoracic aortic false lumen in 12 of 13 survivors. Computed tomography at 6 months showed complete thrombosis of the aneurysmal lumen or the false lumen in nine of 10 patients due for follow-up. Both 6-month and 1-year survival rates were 87%. CONCLUSIONS: Thoracic aortic stent grafting for acute thoracic aortic disease is feasible and has a high success rate, with good short-to-midterm results. However, the large size of the stent graft introducer set imposes a high risk of access artery injury, for which further improvements are necessary.

Uterine fibroid embolisation in Chinese women: medium-term results.

OBJECTIVE: To evaluate the medium-term results of uterine fibroid embolisation in Chinese women with symptomatic uterine fibroids. DESIGN: Prospective case series study. SETTING: Gynaecology and Interventional Radiology units in a public hospital, Hong Kong. PATIENTS: Patients with symptomatic fibroids who underwent uterine fibroid embolisation in Queen Elizabeth Hospital from October 1998 to June 2004. RESULTS: Fifty women (mean age, 42.9 years; median follow-up period, 27.5 months) were recruited. Most (82%) had menorrhagia as the chief presenting symptom. Embolisation was successful in 49 (98%) women. Complications occurred in 12 (24%) patients, but were all self-limiting. Significant decrease in the median clinical uterine size (14 weeks vs 10 weeks) and median volume of the largest fibroid on magnetic resonance imaging (157.9 mL vs 45 mL) were observed during the first year. The reduction seemed to be maintained till the last follow-up. Menorrhagia improved in 34 (84%) patients, dysmenorrhoea in 28 (88%), pelvic pain in 18 (82%) and abdominal mass in 15 (83%). Poor response was found for urinary symptoms (29% improvement). Eight (16%) patients underwent hysterectomies after uterine fibroid embolisation. On logistic regression analysis, the only significant predictive factor for symptomatic improvement was fibroid volume reduction at 6 months (P=0.03). CONCLUSION: Uterine fibroid embolisation is an effective uterine-preserving therapy in patients with symptomatic fibroids; overall symptomatic improvement was estimated as 80%. Uterine or fibroid size reduction correlated well with clinical outcome. The impact of uterine fibroid embolisation on young women wishing to conceive is yet to be determined.

Emergency aortic stent grafting for traumatic rupture of the thoracic aorta.

OBJECTIVE: To investigate the role of aortic stent grafting in emergency treatment of traumatic rupture of the descending thoracic aorta in patients with multiple injuries. DESIGN: Retrospective study. SETTING: Cardiothoracic surgery facility of a tertiary referral hospital, Hong Kong. PATIENTS: Between September 2001 and September 2002, four patients who had sustained a blunt injury to the chest after high-speed deceleration injury were recruited. Three patients were treated with stent grafting because concomitant head injury and multiple other injuries precluded the use of open thoracic surgery. One patient had no head injury and was offered stent grafting as a less invasive treatment. INTERVENTION: The pseudoaneurysm was covered with an aortic stent graft under fluoroscopic and angiographic guidance. MAIN OUTCOME MEASURES: Technical success of treatment, complications, and treatment outcome. RESULTS: Three patients recovered and were discharged from hospital. The computed tomography scan at 3 months to 6 months after surgery showed resolution of the pseudoaneurysm. The final patient was still in the hospital. Follow-up computed tomography 2 weeks later showed exclusion of the pseudoaneurysm. There was one external iliac artery thrombosis on the side of femoral arteriotomy, which was recanalised with thrombectomy. There was another unintentional partial coverage of the left subclavian artery, which was asymptomatic. No other major complication was present and there was no paraplegia after the stent grafting. CONCLUSION: Aortic stent graft is useful for emergency treatment of descending thoracic aortic injury. In the short term, it causes less morbidity and mortality than does open surgery, and can be life-saving when there is no surgical alternative. The long-term effect is still unknown.

Rare pulmonary complications after transarterial chemoembolisation for hepatocellular carcinoma: two case reports.

We report two rare cases of acute pulmonary complication after transarterial chemoembolisation for inoperable hepatocellular carcinoma. Both cases involved a large tumour and hepatic vein invasion. The first patient, a 27-year-old man, died of pulmonary tumour embolism 4 days after transarterial chemoembolisation. Acute dyspnoea developed in the second patient, a 63-year-old man, following the procedure due to pulmonary oil embolisation and chemical pneumonitis. The chest condition of this patient improved, but he subsequently died of liver failure 3 weeks later. Our cases illustrate the point that if locoregional treatment is offered as a palliative treatment, patients with hepatic vein invasion should be warned of the possible complications of massive tumour embolism, pulmonary oil embolisation, and subsequent death.

Percutaneous transhepatic choledochoscopic removal of intrahepatic stones.

BACKGROUND: Treatment of hepatolithiasis is complex and difficult. With the advent of biliary endoscopy and radiological intervention, percutaneous choledochoscopic removal of intrahepatic stones has become a well established procedure. METHODS: Seventy-nine patients with intrahepatic stones that were removed by percutaneous transhepatic choledochoscopy (PTCS) between 1993 and 2001 were studied retrospectively. The results of the procedure and the long-term outcome of these patients were analysed. RESULTS: The success rate of choledochoscopic removal of intrahepatic stones was 76.8 per cent. Complications occurred in 17 patients (21.5 per cent). Removal of stones predominantly on the right side was difficult using this method. Cholangitis occurred in about one third of patients within 3-5 years after PTCS. For patients with a stricture, cholangitis recurred gradually over the years of follow-up. CONCLUSION: Intrahepatic stricture was the major determinant for the recurrence of stones or symptoms. Hepatic resection should be offered to these patients if the disease is localized in one liver segment or lobe. In other cases, percutaneous choledochoscopy and stricture dilatation is a useful solution, and may reduce further damage to the liver.

Prevention of recurrent central venous stenosis using endovascular irradiation following stent placement in hemodialysis patients.

This study was done to evaluate the outcome after brachytherapy (BT) given to prevent restenosis after stent insertion for central venous stenosis in patients with ipsilateral hemodialysis arteriovenous fistulas (AVF). Angioplasty and stenting were performed on 9 primary central venous stenoses in 8 patients with AVF followed by BT, delivering Iridium-192 radiation using an afterloading technique. BT was also administered to three patients with five recurrent stenoses at the stent margins. There was no residual stenosis after angioplasty and stenting. Venographic follow-up (77-644 days, mean 272 days) showed no restenosis in seven primary stenoses. New strictures (45%-100%) developed at the stent margin in six veins (five patients). Angioplasty or stenting was performed for five margin stenoses in three patients, followed by a second BT. Residual stenosis before BT was 0-30%. In our venographic follow-up (140-329 days, mean 215 days), three restenoses occurred (35%-100%). All progressed to complete occlusion on later venographic follow-up irrespective of whether BT was given to the stent margin or not. The mean primary and assisted primary patency of the central veins were 359 days and 639 days, respectively. Endovascular irradiation with a noncentering source does not prolong the patency after angioplasty and stenting of central venous stenosis in hemodialysis patients.

A randomized clinical trial comparing autologous blood clot and gelfoam in transarterial chemoembolization for inoperable hepatocellular carcinoma.

BACKGROUND/AIM: Inoperable hepatocellular carcinoma is common in Asia and is usually treated with repeated transarterial chemoembolization. Gunji et al. showed better survival and fewer complications with autologous blood clot as compared with gelfoam used for embolization. Our aim was to compare the effect of blood clot versus gelfoam. METHODS: We conducted a prospective randomized trial in 100 patients with inoperable hepatocellular carcinoma, and compared the side effects and cumulative survival in the two groups. Cox's proportional hazard model was used to study the prognostic factors. RESULTS: The diameter of the main tumor was 7.9+/-4.6 cm. Our study did not show additional beneficial effects of blood clot. The proportion of side effects was similar and the common ones included fever, pain and vomiting. Though the hepatic artery remained patent for a longer period with blood clot (p=0.061), there was no difference in survival (p=0.129 for Okuda I disease and p=0.388 for Okuda II disease). Subgroup analysis showed longer survival in patients with vascular occlusion (p=0.034 for Okuda I and p=0.029 for Okuda II disease). The independent factors of survival were sex, Child's class, Okuda stage, tumor type and presence of metastases. CONCLUSION: This study showed no additional benefits of blood clot in patients with inoperable hepatocellular carcinoma, in Okuda I and II disease. The longer survival in patients with vascular occlusion suggested that the damage to normal liver tissue by planned periodic transarterial chemoembolization may outweigh its benefit in later sessions of repeated TACE in certain patients.

Percutaneous ethanol injection as a possible curative treatment for malignant portal vein thrombosis in hepatocellular carcinoma.

Postoperative residual hepatocellular carcinoma (HCC) with malignant portal vein thrombosis in a 48-year-old man was cured with transarterial chemoembolization (TACE) for the parenchymal portion and percutaneous ethanol injection (PEI) for the malignant portal vein thrombosis. No evidence of tumor recurrence was noted after 18 months of follow-up. The only severe complication in our patient was biliary stricture which was treated with an internal stent via endoscopic retrograde pancreatico-cholangiography (ERCP).

A radiological approach to the through and through technique for percutaneous passage of ureteric strictures.

Some ureteric strictures are so tight that they are difficult to traverse with balloon catheters or internal stents. We present five such cases, which were traversed using a modified through and through technique with a hydrophilic coated guide-wire. The reasons for the difficulty are discussed, and the merits of the modified technique compared with conventional techniques are described.

Adolescent pregnancy in Tasmania.

The obstetric performance of 1719 pregnancies in mothers aged less than 18 years was compared to that of the rest of the obstetric population. There was a significantly poorer outcome in the adolescents in the mean birthweight, the prevalence of birthweight below 2500 g and of gestation period below 28 weeks, Apgar score, perinatal mortality and the occurrence of hypertension in pregnancy. When the primiparous adolescent group (1607) was compared with primiparas aged 18-34 years (16 220), these differences were less marked. The two groups (adolescent and adult primiparas) were matched by marital status and socioeconomic class, and no significant differences were found in these parameters. It is concluded that biological age per se does not confer an increased risk in pregnancy. The high proportion of primiparas in the adolescent group (93%), and the associated increased prevalence of high-risk factors in this group (single marital status, low socioeconomic class, and smoking) would explain the poorer obstetric outcome in comparison with that of the total adult group.