Treatment of hemodialysis graft pseudoaneurysms with stent grafts: institutional experience and review of the literature.

Hemodialysis access grafts are an important component of the treatment of patients with renal failure. Because access sites are limited, maximizing graft lifespan is of major importance to dialysis patients. Pseudoaneurysm formation is a rare, but important complication potentially limiting the longevity of dialysis grafts. With rapidly advancing technology, placement of stent grafts in patients with end-stage renal disease is an important step in prolonging the life of the graft. We conducted a review of the literature regarding stent-graft use for hemodialysis access. In addition, we looked at our experience utilizing the Viabahn(®) (W. L. Gore & Associates, Newark, DE) stent graft in pseudoaneurysm repair. Our patients achieved primary patency of their grafts for 1, 5, and 9 months, respectively. No complications related to stent-graft implementation have been encountered in six stent-graft implants over the course of 29 months.

Four hundred fifty-three consecutive pancreaticoduodenectomies with pancreaticogastrostomy.

BACKGROUND: Patients who undergo pancreaticoduodenectomy (PD) have the pancreatic remnant (PR) anastomosed to the jejunum. In this study, all patients had the PR anastomosed to the stomach. Our aims are to evaluate postoperative outcomes of patients undergoing PD with pancreaticogastrostomy (PG). METHODS: There was 453 patients who underwent PD with PG. Preoperative characteristics, intraoperative data, and postoperative outcomes were analyzed using univariate and multivariate models. RESULTS: The patient cohort had a median age of 67 years and underwent resection for pancreatic (40.8%), ampullary (15.9%), duodenal (6.6%), distal bile duct (6.4%) cancers. Multivariate analysis revealed poor prognosis was related to age, tumor diameter, lymph node ratio, perineural invasion, and tumor differentiation in patients with periampullary adenocarcinoma. CONCLUSIONS: This series of patients undergoing PD with PG shows that the operation can be performed safely with excellent outcomes for a variety of malignant and benign conditions.

Post-transplant IVC occlusion and thrombosis treated with tPA, heparin, and sharp recanalization.

Complete inferior vena cava (IVC) thrombosis can be a lethal complication in a liver transplant recipient. The case of a 52-year-old liver transplant recipient, who developed complete IVC as well as left iliofemoral thrombosis, is reported. After treatment with combined tissue plasminogen activator (tPA) and heparin, the IVC was successfully recanalized with sharp dissection, balloon dilatation, and stent placement.

Chronic mesenteric ischemia resulting from isolated lesions of the superior mesenteric artery--a case report.

Atherosclerosis is a common cause of chronic mesenteric ischemia, generally affecting 2 or more arterial branches supplying the gut. The authors present a case in which symptomatic mesenteric ischemia was the result of 2 tandem atherosclerotic lesions in the superior mesenteric artery. Both the celiac axis and inferior mesenteric arteries were fully patent. The patient experienced complete relief of symptoms after percutaneous deployment of an intravascular stent across the proximal arterial narrowing. The case also documents the existence of an atheroma in a distal mesenteric artery.

Simultaneous transjugular renal biopsy and hemodialysis catheter placement in patients with ARF.

BACKGROUND: Previous studies have evaluated transjugular renal biopsy in patients with contraindications to percutaneous renal biopsy or those undergoing simultaneous renal and hepatic biopsies. We sought to evaluate transjugular renal biopsy in patients with acute renal failure (ARF) or ARF in the presence of chronic renal insufficiency (CRI) who required venous catheter placement for hemodialysis (HD). METHODS: Ten consecutive patients (6 patients, ARF; 4 patients, ARF on CRI) at a single tertiary-care medical center, while undergoing placement of HD access through the internal jugular route, also underwent transjugular renal biopsy using the Quick-Core (Cook, Bloomington, IN) system to delineate the cause of ARF. Transjugular renal biopsy was performed because it was the opinion of the attending nephrologist that a histological diagnosis might alter management. RESULTS: Renal biopsy findings were diabetic nephropathy (3 patients), acute tubular necrosis (ATN; 2 patients), nephrosclerosis (2 patients), immunoglobulin A nephropathy (1 patient), lupus nephritis with focal crescents and ATN (1 patient), and pauci-immune necrotizing glomerulonephritis (1 patient). There were no major complications from the procedures. Among the 6 patients with ARF, management was directly affected in 3 patients (either initiation of appropriate immunosuppressive therapy or withholding of such therapy). In the remaining 3 patients with ARF and in patients with ARF on CRI, performing transjugular renal biopsy at the time of HD access placement obviated additional testing and/or unnecessary therapy. Four patients recovered renal function and HD therapy was discontinued, 2 patients died, and 1 patient was lost to follow-up. CONCLUSION: Simultaneous transjugular renal biopsy/HD catheter placement should be considered in patients with ARF requiring HD therapy for whom knowledge of the renal histological diagnosis may alter patient management.

Embolization of a traumatic uterine arteriovenous malformation.

Uterine arteriovenous malformation (AVM) is a rare but potentially life-threatening source of bleeding. A high index of suspicion and accurate diagnosis of the condition in a timely manor are essential because instrumentation that is often used for other sources of uterine bleeding can lead to massive hemorrhage. Although angiography remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the modalities of choice for the evaluation of a suspected AVM. US and MRI cannot only accurately define a uterine AVM, but they also have the ability to assess the extent of pelvic involvement noninvasively. The definitive treatment of uterine AVM is hysterectomy. However, most women diagnosed with the condition are of childbearing age. Transcatheter uterine artery embolization offers a safe and effective alternative to surgery, with the major advantage of retaining childbearing capacity.

Saline Mobilization of the Colon during Percutaneous Renal Cryoablation.

A 62-year-old woman with a history of multiple abdominal surgeries underwent computed tomography-guided percutaneous renal cryoablation for a 1.5-cm enhancing left renal mass. We describe the technique of salinoma formation to displace the colon away from the tumor to avoid colonic injury during cryoablation.

Pulmonary artery pseudoaneurysm: etiology, presentation, diagnosis, and treatment.

Pulmonary artery pseudoaneurysms (PAPs) are uncommon but associated with high mortality. Left untreated, lesions can enlarge, rupture, and lead to exsanguination and death. Presentations range from life-threatening hemorrhage to silent lesions that enlarge for days, months, or years. Because abnormalities on imaging studies can lead to early diagnosis and treatment and embolization is the treatment of choice, the radiologist can contribute to both timely diagnosis and treatment of PAPs. Pseudoaneurysms due to penetrating trauma, blunt trauma, bacterial endocarditis, and complications related to pulmonary artery catheters and right heart catheterization are presented. Three were treated by embolization.

Pelvic lymphocele following motor vehicle collision.

The development of lymphocele has been described in the mediastinum following thoracic duct injury from blunt trauma or surgery, in lower extremity surgery or trauma, and in the pelvis following renal transplant or staging lymphadenectomy. We describe a case of pelvic lymphocele following blunt trauma from a motor vehicle collision in which the patient did not sustain any fractures. The patient subsequently experienced right lower extremity pain and swelling thought to result from a deep venous thrombosis. Venogram demonstrated external compression of the right iliac vein, and computed tomography revealed a pelvic fluid collection. The patient underwent successful pigtail catheter placement under ultrasound guidance, and his symptoms resolved completely following 4 weeks of external drainage. A brief review of the diagnosis and management of lymphocele follows.