Synergistic effect of adrenal steroids and angiotensin II on plasminogen activator inhibitor-1 production.

Recent data suggest an interaction between the renin-angiotensin-aldosterone system and fibrinolysis. Although previous work has focused on the effect of angiotensin II (Ang II) on plasminogen activator inhibitor (PAI-1) expression, the present study tests the hypothesis that aldosterone contributes to the regulation of PAI-1 expression. To test this hypothesis in vitro, luciferase reporter constructs containing the human PAI-1 promoter were transfected into rat aortic smooth muscle cells. Exposure of the cells to 100 nmol/L Ang II resulted in a 3-fold increase in luciferase activity. Neither 1 micromol/L dexamethasone nor 1 micromol/L aldosterone alone increased PAI-1 expression. However, both dexamethasone and aldosterone enhanced the effect of Ang II in a dose-dependent manner. This effect was abolished by mutation in the region of a putative glucocorticoid-responsive element. A similar interactive effect of Ang II and aldosterone was observed in cultured human umbilical vein endothelial cells. The time course of the effect of aldosterone on Ang II-induced PAI-1 expression was consistent with a classical mineralocorticoid receptor mechanism, and the effect of aldosterone on PAI-1 synthesis was attenuated by spironolactone. To determine whether aldosterone affected PAI-1 expression in vivo, we measured local venous PAI-1 antigen concentrations in six patients with primary hyperaldosteronism undergoing selective adrenal vein sampling. PAI-1 antigen, but not tissue plasminogen activator antigen, concentrations were significantly higher in adrenal venous blood than in peripheral venous blood. Taken together, these data support the hypothesis that aldosterone modulates the effect of Ang II on PAI-1 expression in vitro and in vivo in humans.

Percutaneous transluminal angioplasty. The procedure of choice in the hypertensive renal allograft recipient with renal artery stenosis.

A retrospective review of 547 renal transplants performed over a six-year period revealed allograft renovascular hypertension secondary to RTAS in 39 (7.1%) patients. Percutaneous transluminal angioplasty (PTA) resulted in immediate cure or improvement in 76% of the patients, increasing to 83% in patients with functioning kidneys at a mean follow-up period of 30 months (1-72 months). The renal artery stenosis (RTAS) was equally distributed between living-related and cadaver kidney recipients and did not appear to be more prevalent in end-to-end or end-to-side anastomoses. The blood pressures fell from pre-PTA levels of 167 +/- 22 mmHg systolic to 141 +/- 23.7 post-PTA and 102 +/- 11 mmHg diastolic pre-PTA to 88 +/- 12 mmHg post-PTA (P less than 0.01). Of 25 cured or improved patients, 24 are on significantly less hypertensive medication. Two patients died of causes unrelated to the PTA and only one patient lost a kidney because of the procedure. Compared with operation, PTA is a safer and more effective procedure for the initial treatment of RTAS.

Embolization techniques in the urinary tract.

Transcatheter embolization of genitourinary pathology has enjoyed widespread acceptance over the past several years. In many centers, preoperative embolization of hypervascular renal-cell carcinomas has become a routine practice and, in patients deemed unresectable, may be used as a primary form of therapy. The authors present the indications for embolization and discuss relevant technical points.

Conversion of choledochojejunostomy stents to jejunal feeding tubes for postoperative enteral alimentation.

The problem of protein calorie malnutrition following major gastrointestinal surgery can be treated with central venous or enteric alimentation, with the latter being preferred. The authors describe a simple technique for the conversion of biliary stents placed after pancreaticoduodenal surgery into jejunal feeding tubes when the stenting function is no longer needed. Three illustrative cases are presented. In each case, the procedure took less than 30 min and had no associated morbidity. This technique allows early conversion from central venous to enteric alimentation without the need to create a second surgical enterostomy.

Spontaneous retraction of indwelling catheters: previously unreported complications.

The development of totally implantable reservoir central venous access systems has been an important advance in patients requiring long-term central venous access. With lower rates of infection and thrombosis than those with external catheters, they have potential for greater longevity and patient acceptance. Complications such as subcutaneous prosthetic infection, infusate extravasation, and difficulty in locating and puncturing the port have been reported. We present two cases of catheter migration and withdrawal from the subclavian vein. This presumably occurred from the action of the underlying pectoralis muscle on the reservoir, as well as a "jetting effect" during flushing. We make suggestions for prevention of similar problems in the future.

Disseminated histoplasmosis diagnosed by percutaneous needle biopsy of a retroperitoneal lymph node. A case report.

A case of disseminated histoplasmosis diagnosed by percutaneous needle biopsy cytology is reported. The patient presented with fever and pancytopenia. Computed tomography (CT) revealed retroperitoneal lymphadenopathy. Cytology smears prepared from a CT-guided screw needle biopsy of one of the lymph nodes showed numerous histiocytes with intracytoplasmic yeast forms consistent with Histoplasma capsulatum. Fungal cultures prepared from additional needle biopsy material confirmed the diagnosis. This case illustrates the utility of needle biopsy in the evaluation of radiographically detected retroperitoneal lymphadenopathy and in the rapid diagnosis of infectious disease in certain clinical settings.

Early removal of retained biliary stone without T-tube removal: case report.

Techniques for removal of retained common bile duct stones through mature tracts are safe and well established. When symptomatic, the stones may require removal prior to the 4-6 week period required for tract maturation. We report a case in which substituting a Teflon sheath for the standard polyethylene basket sheath allowed manipulation through the T-tube lumen and basketing of an impacted distal common bile duct stone, which had caused pancreatitis. This technique is simple and avoids the problem of loss of access to the biliary tree in the early postoperative period.

Enteric alimentation: a radiologic approach.

A new guide wire-directed enteric feeding tube is described. Clinical trials have shown the tube can be rapidly placed in the small bowel in patients with altered gastric anatomy or decreased peristalsis. Fluoroscopically guided feeding tube placement has proved to be a valuable adjunct in the therapy of patients requiring long-term enteric alimentation.

Percutaneous extraction of gallstones in 20 patients.

Percutaneous cholecystolithotomy (PCL) was accomplished successfully without general anesthesia in 17 of 20 consecutive symptomatic patients from an outpatient gallstone center who were at risk for or had refused cholecystectomy. The other three patients underwent cholecystectomy because of a gallbladder collapse before admission, a tight stone-bearing phrygian cap, and a cannula slippage, respectively. A subhepatic approach was preferentially used after the fundus of the gallbladder was stabilized with a percutaneous anchor to prevent invagination and bile leakage. Retrograde slippage of the anchor into the tract in the first six patients was remedied by elongating the anchor from 2 to 3 cm. Calculi were removed in one session (11 patients) or two consecutive sessions (six patients). Morbidity included rehospitalization for stitch infection (n = 1) and dehydration (n = 1), cannula slippage (n = 1), broken guide wire (n = 1), vasovagal reaction (n = 1), and unextractable anchors (n = 3). Gallbladder endoscopy enabled identification of stones not visible at cholecystography. Hospitalization lasted 3-5 days; outpatient gallbladder drains were removed in 2-3 weeks in 10 patients and 4-6 weeks in seven (older) patients. No retained stones were seen at 6 months. The authors recommend PCL for patients at risk for surgery.

Percutaneous drainage of abscesses in patients with Crohn's disease.

The hospital courses of 9 patients with intraabdominal abscesses and Crohn's disease who underwent abscess drainage utilizing percutaneous techniques were reviewed. Percutaneous methods brought about resolution of fever, leukocytosis, and the abscess cavity in 8 patients. In 5 of these, definitive cure was achieved with percutaneous drainage. In 3, single-stage bowel surgery and fistulectomy were performed following resolution of the abscess cavities and improvement of clinical signs and symptoms. All patients had uncomplicated postoperative courses. Percutaneous drainage should be the initial drainage procedure in treating postoperative abscesses, and, when performed preoperatively, can diminish surgical morbidity.

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.

Positron emission tomography with F-18-fluorodeoxyglucose to evaluate the results of hepatic chemoembolization.

BACKGROUND: Positron emission tomography (PET) using F-18-flurodeoxyglucose (18FDG) is an imaging modality allowing direct evaluation of cellular glucose metabolism. The purpose of this study was to examine the role of 18FDG-PET in monitoring chemoembolization therapy of patients with liver metastases from adenocarcinoma. METHODS: Thirty-four hepatic lesions in 4 patients were evaluated with 18FDG-PET before and 2-3 months after interventional therapy. All patients underwent transcatheter arterial chemoembolization. A total of nine PET studies were performed. Semiquantitative measurement of the metabolic activity of the lesions was performed using the standard uptake value (SUV) of 18FDG. Comparison was performed between sequential PET scans using Student's t test for paired data analysis. The PET findings were also compared with tumor marker levels measured at the time of the PET scans. RESULTS: Twenty-five of 34 lesions had decreased 18FDG uptake (SUV = 8 +/- 2 vs. 3 +/- 1; P < 0.00001), as expected in successful tumor chemoembolization. These findings were associated with a significant decrease in serum tumor marker levels (86 +/- 4%; P < 0.05) after treatment. However, there were 3 new lesions, and 6 of the 34 lesions demonstrated persistent or increased 18FDG uptake after treatment (SUV = 8 +/- 2 vs. 13 +/- 3; P < 0.05), consistent with the presence of residual viable tumor. These findings led to further interventional therapy in all patients. CONCLUSIONS: 18FDG-PET allows monitoring of response to treatment with hepatic chemoembolization in patients with liver metastases from adenocarcinoma. PET is a useful diagnostic tool and has the potential to be used to guide further interventional therapy.

Relief of right ventricular to pulmonary artery conduit stenosis using a self-expanding stent.

Intravascular stents have recently been used to treat vascular stenoses in congenital heart disease. Size limitations, however, may preclude their use in certain situations. We describe the successful relief of right ventricular to pulmonary artery conduit stenosis in an adult patient late after repair of truncus arteriosus using a larger, self-expanding wall stent.

Steel occlusion coils: pretreatment with thrombin.

Stainless steel vascular occlusion coils provide a convenient and effective means for occluding large vessels. Occasionally, coagulopathies or extremely high-flow states delay or preclude the formation of an effective thrombus around this device. A technique is described for pretreating these coils with a thrombin solution. This pretreatment assures a prompt and effective occlusion of the target vessel.

Transesophageal drainage of mediastinal abscesses.

Esophageal perforation with subsequent formation of a mediastinal abscess is a well-recognized clinical entity. Causes include perforation due to rigid and fiberoptic endoscopy, bouginage, breakdown of surgical anastomoses, and protracted vomiting. This disorder is associated with a high morbidity and, without intervention, a high mortality. In the past, surgery has been the treatment of choice. Although percutaneous drainage techniques have been used in some cases, they are frequently less attractive due to the location of the esophagus and its proximity to thoracic organs and vascular structures. In this study, eight abscesses caused by esophageal perforations were drained through a transesophageal route with minimal patient morbidity. These cases are presented with a discussion of the techniques and patient follow-up.

Fibrolamellar hepatocellular carcinoma: pitfalls in nonoperative diagnosis.

Results from ultrasonography, computed tomography (CT), scintigraphy, hepatic angiography, and magnetic resonance (MR) imaging were analyzed for five patients with surgically proved fibrolamellar hepatocellular carcinoma (FL-HCC)--a variant of hepatocellular carcinoma (HCC) that usually occurs in younger patients and has an improved prognosis and chance for curative resection. The radiologic findings were generally inconclusive for a differential diagnosis because the appearance of the lesions on the various imaging studies closely simulated that of either focal nodular hyperplasia, HCC, or metastases. CT and technetium-99m sulfur colloid scintigraphy were the most effective techniques for the workup of these lesions, but because they do not allow a definitive diagnosis, open biopsy is recommended for most lesions simulating focal nodular hyperplasia and HCC in younger patients. Although the current specificity of MR imaging in diagnosing liver lesions is low, further experience may permit more specific characterization of these lesions.

Embolization of a subclavian artery aneurysm with steel coils and thrombin.

Subclavian artery aneurysms are rare lesions usually treated by surgical excision or ligation. Steel coils were used successfully to treat a rapidly enlarging subclavian aneurysm in a patient deemed unsuitable for surgery. Because of a profound, uncorrectable coagulopathy, thrombin was required to obtain effective thrombosis.

Transient hypertension after percutaneous transluminal renal artery angioplasty.

A retrospective analysis of 128 technically successful percutaneous transluminal renal angioplasty (PTRA) procedures was performed. After the procedures, transient systemic hypertension (TSH) developed in 39 patients. The phenomenon usually occurred within 30 minutes of balloon dilation and always within 2 hours of PTRA. TSH lasted less than 5 hours in 35 patients and never persisted for more than 24 hours. TSH is a self-limiting process and should not be confused with the more sustained hypertension that arises from a complication of balloon angioplasty.

Infantile hemangioendothelioma: angiographic features and factors determining efficacy of hepatic artery embolization.

The angiographic features of infantile hepatic hemangioendothelioma are discussed as well as the role of hepatic artery embolization in its management when more conservative measures have failed. A unique case with portal vein supply of the tumor is presented, and the impact of this angiographic feature is discussed.