Long-term clinical and functional outcome following treatment for Paget-Schroetter syndrome.

BACKGROUND: Effort-related thrombosis of the axillosubclavian vein (Paget-Schroetter syndrome, PSS) is uncommon. It tends to affect young, active individuals and yet consensus on management is lacking. The aim here was to analyse late outcomes in a series of patients treated for PSS using a standard protocol. METHODS: The medical records of patients treated for PSS over 16 years were analysed. Patients were divided into four groups according to their management. Clinical and functional outcomes were analysed regarding residual venous defects after treatment, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, respectively. RESULTS: Some 117 patients (52 men and 65 women, mean age 32 years) were included. Catheter-directed thrombolysis was successful in 42 of 56 treated patients. Thoracic outlet decompression surgery was performed in 95 patients. DASH scores improved significantly in patients treated surgically (P < 0.001 to P = 0·009); early surgery had a better outcome than delayed surgery (P = 0·040). Patients who were managed conservatively showed no improvement (P = 0·116). Where venoplasty was necessary, it was successful in 18 of 25 patients. A short duration of lysis (less than 24 h) increased the risk of rethrombosis (P = 0·020). The method of postoperative anticoagulation had no influence on the rate of rethrombosis. CONCLUSION: Patients treated surgically for PSS had better functional outcomes than those managed conservatively. Prompt thrombolysis and surgery was superior to delayed management with respect to rethrombosis and functional outcome.

Embolization of renal angiomyolipoma: immediate complications and long-term outcomes.

AIMS: To report the outcomes of elective and emergency embolization of renal angiomyolipoma and describe an angiographic sign that will help localize the symptomatic aneurysm in emergency cases. MATERIALS AND METHODS: A retrospective review of all patients undergoing embolization of renal angiomyolipoma at a two centres between 1998-2007. Indications for treatment and angiographic images were reviewed. Incidence of acute rupture during embolization was noted. RESULTS: Seventeen patients underwent 23 episodes of embolization using polyvinyl alcohol (PVA) particles, bead block, and coils. Thirteen were elective procedures for large or symptomatic angiomyolipoma and 10 were acute procedures for patients presenting with retroperitoneal haemorrhage. Patients presenting acutely with haemorrhage tended to have extensive multifocal renal involvement. Active bleeding on diagnostic angiography was seen in a single patient who presented with retroperitoneal haemorrhage 48h after elective embolization with PVA alone. Seven out of 10 (70%) of the acute cases displayed splaying of adjacent vessels due to peri-aneurysmal haematoma, known locally as the "light bulb sign". This allowed treatment to be focused on the symptomatic aneurysm. The light bulb sign was not present in any patient undergoing elective embolization. Aneurysm rupture with active extravasation occurred following embolization of the distal tumour circulation with PVA in four of 10 (40%) of the patients in the acute group and three of 13 (23%) patients in the elective group. Five patients required a subsequent embolization, three at a different site. Two patients in the elective group required repeat embolization of the target site, one for delayed haemorrhage and the other whose tumour did not shrink following the initial incomplete treatment. CONCLUSIONS: Embolization of renal angiomyolipoma produces durable results. The presence of the light bulb sign is a strong indicator of the site of haemorrhage within the kidney. We advocate using a combination of particulate material and coils, as embolization with PVA alone may predispose to acute haemorrhage occurring during or after embolization.

Complex iliac and bilateral common femoral artery aneurysms: a novel hybrid procedure.

A 74-year-old man presented with a right common iliac artery aneurysm and bilateral common femoral artery aneurysms. These aneurysms were repaired by a hybrid procedure. A one-stage approach was chosen including an endovascular stent-graft and femoro-iliaco-femoral Y-bypass grafting. The authors describe a novel combined open and endovascular approach to repair these complex aneurysms.

Phase II study of anti-gastrin-17 antibodies, raised to G17DT, in advanced pancreatic cancer.

PURPOSE: The prognosis for advanced pancreatic cancer remains poor. Gastrin acts as a growth factor for pancreatic cancer. We describe the first study of the antigastrin immunogen G17DT in pancreatic cancer. Our aims were to determine the antibody response, safety, tolerability, and preliminary evidence of efficacy of G17DT in advanced pancreatic cancer. PATIENTS AND METHODS: Thirty patients with advanced pancreatic cancer were immunized with three doses of either 100 micro g or 250 micro g of G17DT. RESULTS: In the whole group, 20 (67%) of 30 patients produced an antibody response. The 250- micro g dose resulted in a significantly greater response rate of 82% compared with 46% for the 100- micro g group (P =.018). The most significant side effects, seen in three patients, were local abscess and/or fever. The median survival for the whole group from the date of the first immunization was 187 days; median survival was 217 days for the antibody responders and 121 days for the antibody nonresponders. The difference in survival between the antibody responders and nonresponders was significant (P =.0023). CONCLUSION: Patients with advanced pancreatic cancer are able to mount an adequate antibody response to G17DT. The 250- micro g dose is superior to the 100- micro g dose, and it appears to be generally well tolerated. Antibody responders demonstrate significantly greater survival than antibody nonresponders. Phase III studies are currently underway in order to determine efficacy.

Surgical management of choledochal cysts.

Choledochal cysts are an unusual cause of biliary obstruction with up to 85% of reported cases being of the type I variety, that is, fusiform dilations of the common bile duct. Recommended management of this type I cyst is complete surgical excision; however, difficulties arise in type IVa cysts when the cystic dilation extends up into the intrahepatic biliary tree. The purpose of this study is to review the management of choledochal cysts with particular reference to the type IVa variety. Statistical analysis of outcome differences was undertaken using Fisher's exact test. A total of 23 consecutive patients with choledochal cysts seen at our institution in a 5-year period were reviewed: 8 patients had type I cysts, 1 patient had a type III cyst, and 14 patients had type IVa cysts. All type I cysts underwent complete cyst excision with hepaticojejunostomy and modified Houston loop formation. Of 14 patients with type IVa cysts, 13 underwent complete excision of the extrahepatic portion of the cyst with hepatico- and cystojejunostomy and modified Hutson loop formation. One patient required hepatic lobectomy. With a mean follow-up of 33 months, 4 patients with type IVa choledochal cyst have had episodes of recurrent cholangitis, with access to the library tree being achieved via the Hutson loop in 3 of the 4 patients. Three of these cases represented anastomotic strictures that were treated nonoperatively. We concluded that recurrent cholangitis and anastomotic stricture after resection of type IVa choledochal cysts is frequent and recommend Hutson loop formation at the time of primary resection.

Superior vena cava obstruction: a modern management strategy.

Superior vena cava obstruction (SVCO) is a distressing syndrome. The condition may present to specialists in many branches of medicine, but patients have traditionally been referred on to clinical oncologists for management, as malignancy is the main aetiological factor. Treatment without a histological diagnosis is no longer justified, because management needs to be tailored to the underlying disease. This article reviews the causes, symptoms, methods of diagnosis and therapy options. The role of stenting in SVCO is discussed and a management algorithm is proposed.

Magnetic resonance imaging of meniscal and cruciate injuries of the knee.

We investigated 133 knees with suspected meniscal or cruciate injuries by magnetic resonance imaging, and compared the findings with those at arthroscopy. MRI was found to be highly sensitive, specific and accurate in the evaluation of the menisci and the anterior cruciate ligament.

Palliative tracheal stenting in invasive papillary thyroid carcinoma.

Malignant tracheal stenosis presents a considerable challenge to the head and neck surgeon. The use of intraluminal stents has been previously described, but current literature notes a paucity of supportive physiological data. We describe the use of a self-expanding metallic Wallstent in the palliation of a case of papillary thyroid carcinoma. This is accompanied by significant improvement in quantitative pulmonary function.

Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management.

Paget Schroetter syndrome, or effort thrombosis of the axillosubclavian venous system, is distinct from other forms of upper limb deep vein thrombosis. It occurs in younger patients and often is secondary to competitive sport, music, or strenuous occupation. If untreated, there is a higher incidence of disabling venous hypertension than was previously appreciated. Anticoagulation alone or in combination with thrombolysis leads to a high rate of rethrombosis. We have established a multidisciplinary protocol over 15 years, based on careful patient selection and a combination of lysis, decompressive surgery, and postoperative percutaneous venoplasty. During the past 10 years, a total of 232 decompression procedures have been performed. This article reviews the literature and presents the Exeter Protocol along with practical recommendations for management.

A novel "cheese wire" technique for stent positioning following difficult iliac artery subintimal dissection and aortic re-entry.

Subintimal wire dissection is a well-established method for traversing difficult vascular occlusions. This technique relies on re-entry of the true lumen distal to the occlusion, which may be difficult in diseased vessels with significant calcification. This case report describes a novel "cheese wire" technique to allow stent positioning without the use of proprietary re-entry devices.

Glue ablation of a late-presentation urinary fistula after partial nephrectomy.

Urinary fistula is an acknowledged complication of partial nephrectomy. We describe a case of a urinary fistula that failed to respond to conventional treatment and the subsequent use of percutaneous Hystoacryl glue to achieve its resolution.

Technical report: the use of the reformed sidewinder loop in the dilated ureter.

A case is presented of a patient requiring percutaneous stenting of a ureteroenteric stricture. A hairpin bend between the strictured ureter and the ileal conduit was easily negotiated by reforming a Sidewinder loop within the contralateral ureter and withdrawing it until the tip entered the conduit. This technique does not appear to have been described before.

Complications of direct brachial artery puncture for arteriography: a comparison of techniques.

Direct brachial artery puncture is used increasingly for day-case arteriography and patients with severe aorto-iliac disease. In expert hands low complication rates are reported, but the risks of brachial artery puncture may be higher when it is performed by less experienced operators. Over a 2 year period 49 direct brachial artery punctures were performed for arteriography. In 27 cases catheters were inserted directly over a guide-wire via a variable puncture site. In 22 cases catheters were inserted through an introducer sheath via a high brachial puncture. Significant complications requiring active treatment or surgical intervention occurred in three (11%) cases where direct catheter insertion was used. There were no complications when an introducer sheath was used. Percutaneous high brachial aortography using an introducer sheath is a safer technique when brachial artery puncture is performed infrequently.

Expandable Wallstent for the treatment of obstruction of the superior vena cava.

BACKGROUND: Palliative treatments for obstruction of the superior vena cava all have disadvantages. The use of a fine braided wire self expanding stent (Wallstent, Schneider (Europe) AG) in patients with malignant and benign causes of superior vena cava obstruction is reported. METHODS: Five patients with obstruction of the superior vena cava were treated with balloon angioplasty of the stricture and the percutaneous insertion of an expandable Wallstent endoprosthesis across the site of the stricture. Four patients had advanced mediastinal malignancy previously treated by radiotherapy and one patient had fibrosing mediastinitis. RESULTS: All patients experienced rapid symptomatic relief and, in three cases, complete palliation was achieved during survival times of seven weeks, nine weeks, and 24 weeks, respectively. Two surviving patients (with a recurrent thymoma and fibrosing mediastinitis) were free of symptoms when followed up at eight and nine months respectively. CONCLUSIONS: Initial experience with the Wallstent endoprosthesis suggests that it is a valuable treatment alternative once conventional therapy has failed and gives rapid relief of symptoms to patients with obstruction of the superior vena cava.

A case series of inferior vena cava stenting for lower limb oedema in palliative care.

Inferior vena caval obstruction (IVCO) is an occasional cause of lower limb oedema in palliative care patients with metastatic malignancy. We present five cases who underwent IVC stenting for symptomatic relief. Four of the five cases had significant reduction in their oedema but three of these four patients died within two weeks of the procedure. The procedure itself is described and the appropriateness of this intervention in patients with end-stage disease is discussed.