Percutaneous cholecystostomy treatment of acute cholecystitis in pregnancy.

BACKGROUND: Medical treatment of acute cholecystitis in pregnancy may lead to prolonged management and recurrent hospitalizations, whereas surgical management predisposes the mother and fetus to the inherent risks of surgery and general anesthesia. Although percutaneous cholecystostomy has been proven to be an efficacious treatment in critically ill and general surgery patients who are at high risk for surgery, this technique has not been used routinely as a treatment for acute cholecystitis in pregnancy. CASES: We report two women (at 30 and 32 weeks' gestation, respectively) who presented with acute calculus cholecystitis. The first patient was a 33-year-old female who failed endoscopic retrograde cholangiopancreatography and papillotomy and had multiple return visits for nausea and vomiting. The second patient was a 23-year-old female with three previous admissions for cholecystitis during the pregnancy. These two patients underwent emergency ultrasound-guided percutaneous transhepatic cholecystostomy. Percutaneous cholecystostomy provided adequate biliary decompression for the remainder of the pregnancy; the patients delivered healthy infants and underwent successful uncomplicated elective laparoscopic cholecystectomy within 3 months of delivery. CONCLUSION: Percutaneous cholecystostomy may provide a safe and effective alternative for the palliation of acute cholecystitis in pregnancy until a postpartum cholecystectomy can be performed.

Anatomy of the junction of the vastus lateralis tendon and the patella.

Forty-one knees from adult cadavera (twenty female and twenty-one male) were dissected to study the relationship between the longitudinal axis of the patella and the angles of insertion into it of the vastus lateralis and vastus lateralis obliquus muscles. The mean and variance in the angles of insertion of the vastus lateralis obliquus tendon were found to be significantly different between men and women (p less than 0.05 and p less than 0.01, respectively). Three distinct anatomical patterns in the insertion of the vastus lateralis obliquus muscle were delineated. The vastus lateralis muscle, particularly the vastus lateralis obliquus, creates an important lateral force-vector on the patella.

Balloon dilation of esophageal strictures in children.

Esophageal strictures in children may develop as a primary constriction, secondary to a surgically repaired esophageal atresia (with or without tracheoesophageal fistula), as a result of chemical injury after caustic ingestion, or following esophageal surgery. Traditional treatment of esophageal strictures has been limited to dilation (using bougie dilators) with esophagoscopy under general anesthesia. Recent reports have shown success with fluoroscopically guided balloon catheter dilation. Eight children (aged 2 months to 14 years) were treated with balloon catheter dilation for focal strictures of the esophagus. In six of the eight cases, complete resolution of the strictures was achieved after an average of 7.5 dilations (range, 1 to 14). Two of the eight patients moved to another part of the country and did not complete treatment. There has been no morbidity or mortality. In selected centers, balloon catheter dilation under fluoroscopic guidance has become a safe treatment of benign esophageal strictures in children. It should be considered the treatment of choice in the initial management of esophageal narrowing and appears to be safer than the more traditional methods of esophageal dilation.

1997 SCVIR Gary J. Becker Young Investigator Award paper. A transluminally created abdominal aortic aneurysm model.

PURPOSE: To develop a stable, transluminally created abdominal aortic aneurysm (AAA) within a live animal model. MATERIALS AND METHODS: Eight mongrel dogs were utilized to evaluate a new, catheter-based technique for the creation of an AAA. With use of a standard angioplasty balloon and a balloon-expandable intravascular metallic stent, the infrarenal abdominal aorta was overdilated to twice its measured diameter into a fusiform shape AAA in eight dogs. At 30 days, aortography was performed, the dogs were killed, and the aorta was resected and evaluated for histopathology. RESULTS: Seven of the eight dogs that underwent transluminal AAA creation survived the initial procedure. A stable, fusiform AAA was successfully created in these seven dogs. At 30 days, repeat angiography and histologic examination confirmed that the seven AAAs were still twice the diameter of the normal aorta (a four-fold increase in luminal area), that the branch arteries remained patent, and that the lumen was endothelialized. One of the eight dogs was killed 9 hours after the procedure because of inability to awaken from anesthesia. Gross and histopathologic results in this one dog also demonstrated an intact aorta containing an AAA. CONCLUSIONS: A stable, infrarenal AAA model can be successfully created in the canine species with use of standard catheter-based techniques and equipment. This model can be used to test emerging endovascular treatments of AAA.

Arteriography and interventional therapy for diseases of the hand.

Because the vessels of the hand are small and very responsive to stimuli, arteriography of the hand requires painstaking technique, temperature control, and sometimes vasodilator administration to produce sufficient radiographic detail. Twenty-five patients underwent arteriography of the hand, which was performed from a transfemoral approach to evaluate pathologic changes and the possibility of interventional treatment. Production of high-quality images by means of attention to technical factors particular to the hand permitted recognition of radiographic detail essential to diagnosis. Twelve patients had a history of trauma, and five patients had congenital lesions. In eight patients, atherosclerotic, vasospastic, or embolic arterio-occlusive disease was diagnosed. Interventional radiologic procedures such as thrombolysis, therapeutic embolization, and percutaneous transluminal angioplasty are important adjuvant or primary management options. Angiography of vascular hand lesions can yield high-quality diagnostic images when technical factors and physiologic variables are maximized. Differentiation between traumatic, congenital, and occlusive lesions is then possible.

Transcatheter embolization for acute lower gastrointestinal hemorrhage.

PURPOSE: The authors review their experience using transcatheter embolization in the treatment of acute lower gastrointestinal hemorrhage. MATERIALS AND METHODS: A retrospective review was conducted on 17 patients who underwent superselective transcatheter embolization for an acute lower gastrointestinal hemorrhage. All 17 patients were followed clinically 4 days to 60 months (mean, 18.5 months) after embolization for the presence of ischemia or for recurrent bleeding. In addition, 12 of 17 patients were examined 1 day to 12 months (mean, 38.8 months) after embolization by means of colonoscopy or by pathologic review. RESULTS: Transcatheter embolization achieved immediate hemostasis in 15 of 17 patients (88%) and was the definitive treatment in 76%. The other two patients underwent successful surgical resections after incomplete hemostasis of cecal lesions. Two patients of the 15, with initially successful embolizations, had recurrent hemorrhage within 30 days; both underwent further embolization with one failure. No intestinal infarction or stricture developed in the 15 patients who underwent successful embolization. CONCLUSIONS: The authors' experience supports the role of transcatheter embolization as a primary means of therapy for patients with an acute lower gastrointestinal hemorrhage. Their data further supports growing evidence that superselective embolization may be most efficacious in reducing complication rates.

Direct percutaneous jejunostomy.

PURPOSE: Enteral feeding via gastrostomy or gastrojejunostomy tubes has an established role in patients unable to maintain adequate oral intake. However, creation and maintenance of a site for long-term nutritional support can be significant problems in patients who have undergone previous surgery or in patients with chronic aspiration, abnormal stomach position, or recurrent inadvertent tube dislodgment. Direct percutaneous jejunostomy (DPJ) tube placement performed with fluoroscopic guidance was evaluated in these patients. PATIENTS AND METHODS: Fourteen DPJ tube placements for enteral feeding were attempted in 13 patients with use of local anesthesia, fluoroscopic guidance, the Seldinger technique, and jejunopexy. There were nine male and four female patients with a mean age of 75.2 years (range, 45-95 years). RESULTS: DPJ was successful in 11 of 13 patients. A mean follow-up of 58.9 days (range, 3-291 days) was obtained in all 11 patients. CONCLUSIONS: DPJ is a safe and viable alternative for the creation and maintenance of long-term enteral tube feeding, particularly in patients with underlying esophagogastric malignancy, recurrent inadvertent tube dislodgement, or previous gastric surgery.

Arteriographic embolization of visceral artery pseudoaneurysms.

The purpose of this study was to determine the safety and efficacy of transcatheter embolization in the management of bleeding visceral artery pseudoaneurysms. Eight patients (four women and four men) whose mean age was 61.0 years (range 44 to 77 years) underwent emergency transcatheter embolization for acute hemorrhage from a visceral artery pseudoaneurysm. Arteriographic technique was used to localize and selectively embolize these seven visceral artery pseudoaneurysms (three inferior pancreaticoduodenal, one gastroduodenal, two hepatic, and one splenic) by means of intravascular steel coils. Arteriography demonstrated visceral artery pseudoaneurysms in all eight patients. Acute hemorrhage was documented by endoscopy, falling hematocrit levels, CT scans, and arteriography. Successful embolization of these visceral artery pseudoaneurysms was achieved in seven (88%) of eight patients. In one patient embolization was not attempted because of a worsening clinical status, and this patient subsequently underwent emergency surgical resection. There was no significant morbidity associated with the procedures and seven patients remain asymptomatic with no further bleeding at a mean follow-up of 21.1 months (range 11 to 46 months). Arteriographic embolization of visceral artery pseudoaneurysms is a safe and highly successful technique for the effective identification and treatment of hemorrhage even in critically ill patients.

Percutaneous transluminal stent placement in the abdominal aorta.

PURPOSE: To retrospectively review and to report the results of stent placement for focal mid-abdominal aortic stenoses. MATERIALS AND METHODS: During a 4-year period, 10 focal mid-abdominal aortic stenoses were treated with stent placement in nine patients (six women and three men; mean age, 61 years; range, 49-73 years). All of the stenoses were atherosclerotic in nature except for one at the proximal anastomosis of an aortobi-femoral graft, which may have been from fibrointimal hyperplasia. Seven of the 10 stenoses were treated with primary stent placement, whereas three were treated with stent placement after suboptimal angioplasty. RESULTS: The technical success rate was 100%. Clinical success, defined as complete elimination or improvement of symptoms present before stent placement, was achieved in eight of the nine patients with a mean duration of follow-up of 1.6 years (range, 0.2-3.0 years). CONCLUSION: In view of the excellent technical and clinical success, the authors believe that stent placement should be considered as an adjective therapy to angioplasty or as a primary method of treatment in properly selected patients with focal mid-abdominal aortic stenoses.

Current status and extended applications of intravascular stents.

The introduction of several novel techniques and mechanical devices to interventional radiology has expanded the range of therapies for a variety of medical disorders. Intravascular metallic stents have received widespread acclaim and may possess the most potential of all the newest devices available to the interventionist. The addition of metallic stents to the percutaneous therapeutic arsenal provides the interventionist with a device that can resist the elastic recoil of a stenotic vessel or support a newly created vascular tract. Peripheral artery metallic stent placement holds great promise for the treatment of selected patients; other applications of stents, including transjugular intrahepatic portosystemic stent shunts are likely to have a great impact in patient management. We review the techniques, appropriate indications, and recent clinical results of vascular stents for percutaneous intervention and therapy.

Local thrombolytic therapy as part of a multidisciplinary approach to acute axillosubclavian vein thrombosis (Paget-Schroetter syndrome).

PURPOSE: To evaluate the efficacy of thrombolytic therapy in the treatment of acute axillosubclavian vein thrombosis in patients with Paget-Schroetter syndrome. MATERIALS AND METHODS: A 4.5-year, retrospective study of all patients with "effort" thrombosis of the axillosubclavian vein was performed. RESULTS: Six men and eight women (age range, 18-56 years; mean, 34 years) presented with acute axillosubclavian vein thrombosis. Twenty thrombotic events occurred in the 14 patients and were treated with urokinase only (14 of 20) or urokinase combined with percutaneous transluminal angioplasty (PTA) (six of 20), Nine of the 14 treatments with urokinase only (64%) resulted in complete lysis of thrombus, whereas four treatments (29%) resulted in restoration of flow with some residual stenosis, yielding an immediate patency rate of 93%. Eight of the 14 patients remained asymptomatic after thrombolytic therapy (urokinase or urokinase and PTA) alone (n = 4), or in combination with a first rib resection (n = 4) at a mean follow-up of 24 months (range, 1-36 months). CONCLUSIONS: Thrombolytic therapy appears to be a safe and efficacious method of establishing immediate patency of the axillosubclavian vein and may be helpful in establishing a symptom-free result in patients with Paget-Schroetter syndrome. Rib resection and repeated thrombolytic therapy are frequently necessary to complete treatment.

Use of angioplasty in the prevention and treatment of coronary--subclavian steal syndrome.

PURPOSE: The coronary-subclavian artery steal (CSS) syndrome is caused by critical stenosis in the subclavian artery proximal to a bypass graft from the internal mammary artery (IMA) to the coronary artery. The stenosis results in retrograde flow in the IMA and steal from the coronary artery. PATIENTS AND METHODS: Percutaneous transluminal angioplasty (PTA) was performed in eight patients (five men, three women). In four patients (group 1), coronary ischemia had developed 0.5-70 months (mean, 31 months) after IMA-to-coronary artery bypass surgery. These four patients (mean age, 58 years; range, 44-68 years) underwent PTA of a single area of focal subclavian stenosis to treat CSS. In four other patients (group 2), atherosclerotic subclavian stenosis had developed proximal to a donor IMA before planned bypass surgery. These patients (mean age, 53 years; range, 50-57 years) underwent PTA of a single focal subclavian stenosis to prevent CSS. RESULTS: Group 1 patients were free of myocardial ischemia at follow-up (mean follow-up, 39.0 months; range, 14-101 months). Three of four patients in group 2 underwent coronary artery bypass grafting with the ipsilateral IMA following PTA of the subclavian stenosis; they were free of angina at follow-up (mean follow-up, 14 months; range, 10-18 months). CONCLUSION: PTA is a safe and efficacious short-term method for prevention and treatment of CSS syndrome.

Stent placement for treatment of mesenteric artery stenoses or occlusions.

PURPOSE: To evaluate stent placement in the treatment of mesenteric ischemia. PATIENTS AND METHODS: Twelve patients (eight women, four men; mean age, 63 years) with chronic mesenteric ischemia underwent stent placement for stenoses or occlusions during a 5.5-year period. Nine patients with 10 stenoses (three celiac arteries, seven superior mesenteric arteries) and three patients with three chronic occlusions (two superior mesenteric arteries, one aortosuperior mesenteric artery bypass graft) were treated. RESULTS: Initial technical success was achieved in 11 of the 12 patients (92%), including all three patients with chronic occlusions. There were no technical complications. There was one postprocedural death (<30 days) due to bowel ischemia and infarction, despite a technically successful procedure. Clinical follow-up was available in all 12 patients, with a mean follow-up of 15.7 months (range, 0-38.5 months). Primary and primary-assisted patency up to 18 months was 74% (standard error [SE], 13%) and 83% (SE, 11%), respectively. Secondary patency was 83% (SE, 11%) at 3 years. All three patients (100%) with chronic occlusions had relief of clinical signs and symptoms at a mean follow-up of 22 months (range, 13-38.5 months). CONCLUSIONS: Stent placement is safe and clinically effective as an adjunctive therapy to angioplasty or as a primary method of treatment for chronic mesenteric ischemia in patients with focal visceral artery stenoses or occlusions.

Angioplasty for the treatment of visceral ischemia.

PURPOSE: To evaluate percutaneous transluminal angioplasty (PTA) in the treatment of visceral ischemia. PATIENTS AND METHODS: Over a 14-year period, 25 focal visceral artery stenoses were treated with PTA in 16 patients with acute or chronic visceral ischemia. Thirteen patients were women and three were men, with a mean age of 64.7 years (range, 54-79 years). PTA was performed in seven celiac arteries, 17 superior mesenteric arteries, and one inferior mesenteric artery. RESULTS: PTA was technically successful in 14 of 16 patients (88%). Two patients were lost to follow-up. Nine of 12 patients (75%) demonstrated primary patency with relief of clinical symptoms at a mean follow-up of 2.3 years (range, 0.3-5 years). The remaining three patients underwent successful repeat PTA for recurrent symptoms. There was one postprocedural death, and one patient subsequently underwent successful surgical bypass for recurrent visceral ischemia. CONCLUSIONS: Angioplasty of the visceral arteries may provide relief for select patients with intestinal ischemia, but redilation may be required in some patients.

Hypogastric artery embolization in endovascular abdominal aortic aneurysm repair.

PURPOSE: Iliac artery anatomy is a central factor in endoluminal abdominal aortic aneurysm therapy. It serves as the conduit for graft deployment and as the region of distal graft seal. Thirty-eight percent of iliac vessels in our patients require special treatment because of aneurysms, tortuosity, or small size. Bilateral hypogastric artery exclusion has been avoided because of concerns of colorectal ischemia, hip/buttock claudication, and impotence. We suggest that elective, staged, bilateral hypogastric embolization can be performed safely with reasonably low morbidity and can expand the anatomic boundaries for stent-graft abdominal aortic aneurysm repair. METHODS: This study was performed as a retrospective chart review of patients requiring hypogastric artery embolization for endovascular repair of abdominal aortic aneurysms between June 1998 and June 2000. Patients with otherwise appropriate anatomy and common iliac artery aneurysms were informed of the option for stent-graft repair with internal iliac artery embolization with its risks of impotence, hip/buttock claudication, and bowel ischemia. Patients underwent unilateral or staged bilateral coil embolizations of their proximal hypogastric arteries with an approximate 1-week interval between procedures. Hospital and office records were reviewed; phone interviews were performed. Follow-up ranged from 1 to 12 months. RESULTS: During a 24-month period, 65 patients underwent endovascular abdominal aortic aneurysm repair; 18 patients (28%) required hypogastric artery embolization. Seven (39%) of these patients underwent bilateral embolization. There were no episodes of clinically evident bowel ischemia. Lactate levels were normal in all measured patients. Postoperative fevers (> 101.0 degrees F) were documented in 10 (56%) of 18 patients. The average white blood cell count was 12.8 x 10(9)/L (range, 8.5-22.9). There were no positive blood culture results. The return to the full preoperative diet occurred in 1 to 3 days. Hip/buttock claudication occurred in approximately 50% of patients with persistent but improved symptoms at 6 months. Eighty-seven percent of patients had preoperative erectile dysfunction. Only two patients noted worsening of erectile function postoperatively. CONCLUSIONS: Preliminary results indicate that bilateral hypogastric artery embolization can be performed, when necessary, with reasonable morbidity in patients undergoing stent-graft abdominal aortic aneurysm repair.

Percutaneous transluminal angioplasty of the abdominal aorta.

PURPOSE: To determine the long-term results of percutaneous transluminal angioplasty (PTA) of focal infrarenal abdominal aortic stenoses. PATIENTS AND METHODS: Over a 10-year period, 15 focal infrarenal abdominal aortic stenoses were treated with PTA in 14 patients (13 women and one man; mean age, 53.2 years; range, 43-78 years). RESULTS: The initial technical success rate was 100%. Clinical patency, as defined by continued absence or improvement in symptoms after PTA, was achieved in 14 of the 15 angioplasty procedures (93%) with a mean duration of clinical follow-up of 4.3 years (range, 0.6-9.8 years) in the 14 patients. Long-term noninvasive follow-up demonstrated continued patency of the angioplasty site in 11 of 11 patients available for study. The mean ankle-arm index in these 11 patients was 0.95 (range, 0.9-1.0) at a mean follow-up of 4.8 years (range, 0.6-9.8 years). There was no significant morbidity or mortality associated with the angioplasty procedures. CONCLUSION: In view of the high degree of technical success and the excellent long-term patency, we believe that PTA should be considered a primary method of treatment in properly selected patients with focal abdominal aortic stenoses.

Importance of daily rounds by the radiologist after interventional procedures of the abdomen and chest.

A prospective study was performed to evaluate the clinical utility of daily rounds by the radiologist for patients with indwelling catheters in the chest and abdomen, placed during interventional radiologic procedures. The 7-week evaluation included documentation of the number of patients seen, time spent with each per day, number of problems identified, management of these problems, and consultations for new cases generated by interaction with other staff. During the 268 visits to 37 patients, 59 catheter-related problems were identified; 17 (29%) required further intervention in the radiology department, and 42 (71%) were managed at the patient's bedside. Of the patients who were followed up, 22 (59%) had some catheter-related problem identified during their hospital stay. Daily rounds by the radiologist are an essential component of patient care after catheter-related interventional procedures and should be made by those who perform and understand the procedures.