Therapeutic failure of uterine fibroid embolization caused by underlying leiomyosarcoma.

The authors describe an unusual case in which continued growth of uterine fibroids in a postmenopausal patient after polyvinyl alcohol embolization therapy prompted hysterectomy, which revealed an underlying leiomyosarcoma. The surgery was nearly fatal as a result of venous bleeding, and parasitization of blood from adjacent bowel by the tumor was noted. The difficulty of preoperative diagnosis of leiomyosarcoma and the need for diligent follow-up after uterine fibroid embolization are discussed.

Ultrasound-guided renal biopsy: experience using an automated core biopsy system.

OBJECTIVE: To assess the safety and efficacy of ultrasound-guided percutaneous renal biopsy using an automated core biopsy system, and to determine radiologists' accuracy in predicting sample adequacy. METHODS: Ninety-five biopsies were performed on 25 native kidneys and 70 renal allografts using a 16-gauge automated, spring-loaded core biopsy device under real-time sonographic guidance. Radiologists performing the biopsy estimated the number of core samples needed to obtain an adequate specimen, based on visual inspection of each core. The final determination of the number of samples was made by a pathology technologist who attended each biopsy, based on preliminary microscopic examination of tissue cores. After each biopsy, an ultrasonographic examination was performed to search for biopsy-related hemorrhage, and a questionnaire was given to the patient to determine biopsy-related complications, which were categorized as either minor or major. RESULTS: The main indication for biopsy was acute renal failure (in 43.2% of biopsies). An average of 3 tissue cores per biopsy were obtained. Of the 94 patients in whom a biopsy was conducted to exclude diffuse renal disease, a mean of 12.5 glomeruli were present in each specimen. Overall, adequate tissue for diagnosis was obtained in 98.9% of cases. The radiologists' estimate of the number of core samples needed concurred with the pathology technologists' determination of sample adequacy in 88.4% of cases. A total of 26 complications occurred (in 27.4% of biopsies), consisting of 23 minor (24.2%) and 3 major (3.2%) complications. CONCLUSIONS: Real-time sonographic guidance in conjunction with an automated core biopsy system is a safe and accurate method of performing percutaneous renal biopsy. Routine use of sonographic examinations to search for biopsy-related complications is not indicated. Radiologists are accurate in estimating sample adequacy in most cases; however, the presence of a pathology technologist at the biopsy procedure virtually eliminates the possibility of obtaining insufficient tissue for histologic diagnosis.

Digital subtraction angiography of the abdominal aorta and lower extremities: carbon dioxide versus iodinated contrast material.

PURPOSE: To compare the diagnostic value of carbon dioxide to that of iodinated contrast material for digital subtraction angiography of the abdominal aorta and lower extremities. MATERIALS AND METHODS: Thirty-five patients underwent comparative CO2 and iodinated contrast material arteriography of the abdominal aorta and lower extremities. For each contrast study, three independent observers evaluated the degree of opacification and percentage of stenosis of each vessel, the degree of certainty of their observations, and the overall quality of the study. Data of CO2 and iodinated studies were compared using analysis of variance for repeated measures. Interobserver and intertechnique agreements were estimated with Cohen's kappa and intraclass correlation coefficient. RESULTS: Iodine-based vascular opacification was superior to that with CO2 in the central and distal arteries (P = .02). The degree of certainty and overall quality score were higher for iodine than for CO2-based contrast studies (P = .00001). The interobserver agreement for categorizing stenoses was higher for iodine as compared to CO2-based angiography. No significant difference was observed between the mean stenosis values obtained with CO2 and iodine-based angiography in any segment. Intraclass correlation coefficient demonstrated a high degree of convergence of the two techniques for assessing the percentage of stenosis. CONCLUSION: CO2 can be used as an alternative to iodinated contrast material for obtaining arteriograms of the abdominal aorta and lower extremities for investigating atherosclerotic disease.

Follow-up after insertion of Bird's Nest inferior vena caval filters.

OBJECTIVE: To determine the long-term clinical and radiographic outcome of patients who undergo insertion of a Gianturco-Roehm Bird's Nest vena caval filter (Cook Inc., Bloomington, Ind.). PATIENTS AND METHOD: The medical records of 40 patients who, over a 34-month period, underwent insertion of a Bird's Nest filter were reviewed and the reasons for filter insertion determined. The causes of any subsequent deaths were noted, and the autopsy findings, when available, were reviewed. Surviving patients were contacted, and 12 were willing to return for follow-up imaging, which consisted of plain radiography, real-time ultrasonography, colour Doppler imaging and contrast-enhanced computed tomography. Changes in filter position, the presence of thrombus and perforation of the vessel wall by the filter struts were documented. RESULTS: All 10 patients who underwent filter insertion while in an intensive care unit (ICU) died, an average of 22 days after the procedure. Eleven other patients also died. Recurrent pulmonary embolism was not suspected in any of these patients, and five autopsies revealed no caval thrombosis. Imaging studies in 12 of the surviving patients revealed no occlusion of the inferior vena cava and no filter migration; however, the vena caval wall was perforated in all of these patients. Nonocclusive intrafilter thrombus was detected by colour Doppler imaging in three patients. CONCLUSIONS: In this small group of patients the Bird's Nest filter was effective in preventing recurrent pulmonary embolism and caused less caval thrombosis than has previously been suspected, although intrafilter clot was found in 25% of the patients who underwent follow-up imaging. Colour Doppler imaging is the method of choice for detecting nonocclusive thrombus with this type of filter. Perforation of the caval wall was universal but not clinically symptomatic. Finally, guidelines should be established to ensure the cost-effective use of inferior vena caval filters in ICU patients.

Osteogenic sarcoma metastatic to the kidney: spontaneous subcapsular hemorrhage with renal artery thrombosis.

The authors describe an occult metastatic deposit in the kidney of a 22-year-old woman; such lesions are not usually detected until autopsy. They postulate that after the development of acute subcapsular hematoma, a "renal compartmental syndrome" occurred, leading to renal artery thrombosis. Primary vascular involvement by the metastatic osteosarcoma, which was remote from the renal hilus, was not identified pathologically.

Primary renal artery dissection.

A typical case of primary renal artery dissection, an unusual entity causing renal infarction, is described. This abnormality, masquerading as renal colic, affects otherwise-healthy middle-aged men. Angiography, which will confirm the diagnosis, should precede nephrectomy, because vascular repair may be feasible.

Aggressive clinical pattern of angina at restenosis following coronary angioplasty in unstable angina.

The frequency, clinical pattern, and timing of recurrent angina following successful single-lesion percutaneous transluminal coronary angioplasty (PTCA) was assessed in a consecutive group of 104 patients with stable angina and in 85 with unstable angina. In addition, the relationship between lesion morphology and angiographic features and the pattern of recurrent angina was determined. Restenosis, defined as recurrence of symptoms with > 50% stenosis at the site of PTCA, occurred in 25 (24%) of the stable group and in 23 (27%) of the unstable group (p = NS). The pattern of angina at repeat presentation was aggressive in nature in 8% of the stable group and in 48% of the unstable group (p = 0.002). The time interval between the recurrence of symptoms and repeat coronary angiogram or PTCA was longer in the nonaggressive group than in the aggressive group, 16 +/- 12.1 and 5 +/- 6.8 weeks, respectively (p < 0.003). The key factors predicting the recurrent angina pattern identified by multiple logistic regression analysis were the angina status pre-PTCA (p = 0.001) and the presence of double-vessel disease (p = 0.01). An aggressive pattern of angina at the time of restenosis is frequent in patients with unstable angina at the time of PTCA, and close post-PTCA surveillance is necessary in these patients.