A case of pseudo-xanthoma elasticum presenting with ischaemic claudication.

A 37-year-old man presented with symptoms of intermittent claudication. Investigations revealed atypical calf vessel disease but no obvious aetiology. Ten years later he re-presented with worsening symptoms. CT angiography confirmed the atypical pattern of lower limb arterial disease but also noted calcification of the renal parenchyma, myocardium and scrotum. A diagnosis of pseudo-xanthoma elasticum was confirmed by skin biopsy. Pseudo-xanthoma elasticum is a rare condition that presents infrequently to vascular surgeons. Early recognition should prompt aggressive risk factor management to slow accelerated atherosclerosis. Clinicians should be aware of the clinical features of this condition to allow early diagnosis.

Colonic anastomotic stenoses and Memotherm stent fracture: a report of three cases.

Deployment of a Memotherm colonic stent (Bard, Angiomed, Karlsruhe, Germany) across anastomotic strictures, following anterior resection, is described in three patients. Two patients presented with symptoms of colonic obstruction. Two of the patients had previously undergone unsuccessful balloon dilatation of the stricture. In the third, in addition to the anastomotic stricture, there was local tumor recurrence. Initially, stenting provided effective relief of symptoms. However, in all three patients, fracture of the stents occurred at intervals of 3-7 months after insertion. This use and complication of colonic stenting has not been reported previously.

Hemopericardium after superior vena cava stenting for malignant SVC obstruction: the importance of contrast-enhanced CT in the assessment of postprocedural collapse.

We report the complication of hemopericardium following superior vena cava (SVC) stenting with an uncovered Wallstent in a patient with malignant SVC obstruction. The patient collapsed acutely 15 min following stent placement with hypoxemia and hypotension. A CT scan demonstrated a hemopericardium which was successfully treated with a pericardial drain. The possible complications of SVC stenting, including hemopericardium, pulmonary embolism, mediastinal hematoma, and pulmonary edema from increased venous return resulting from improved hemodynamics, ensure a wide differential diagnosis in the postprocedural collapsed patient and this case emphasizes the important role of contrast-enhanced CT in the peri-resuscitation assessment of these patients.

Is minimal preparation computed tomography comparable with barium enema in elderly patients with colonic symptoms?

The barium enema (BE) examination in the elderly is often an unsatisfactory investigation. Recent papers have proposed computed tomography (CT) as an alternative method of investigation. They have used a variety of preparation techniques prior to the CT study such as bowel preparation, rectal air insufflation, tap water enemas and intravenous contrast medium. We wished to devise a minimal preparation, minimal supervision technique that could realistically replace the standard BE. One hundred and eighteen elderly patients admitted with symptoms referable to the large bowel had an unenhanced CT following oral contrast medium commenced the previous evening, followed at an interval by a BE performed to a standard technique. Both techniques congruently gave negative reports in 66 (68.8%) individuals. Ten tumours were confidently diagnosed on CT. One annular tumour of the sigmoid colon and one case of colitis were diagnosed on BE only and the severity of a diverticular stricture was underestimated on CT. CT raised the possibility of lesions in 3 (3.1%) patients where the BE was negative. Ten (8.5%) patients had significant abnormalities identified outside the colon using CT. Seven (5.9%) barium enemas were abandoned or severely limited. Minimal preparation, minimal supervision CT is a practical alternative to BE in the frail elderly patient. Radiologists and referring clinicians should be aware that occasionally lesions will not be identified on CT but CT has the advantage that other significant pathology unrelated to the colon may be detected.

Massive arterial haemorrhage from the lower gastrointestinal tract.

We have studied the clinical, radiological and pathological features of three patients with recurrent massive lower gastrointestinal arterial haemorrhage. Case 1 was an example of Dieulafoy's vascular malformation within the proximal ascending colon in a 46-year-old woman. Cases 2 and 3 were men aged 81 and 83 years with arterial erosions contained within small mucosal diverticula in the hepatic flexure and descending colon, respectively. All three patients presented with recurrent acute episodes of massive lower gastrointestinal haemorrhage. Selective mesenteric angiography was performed in cases 1 and 3 to localize the bleeding point in both patients. The features were very different to those of angiodysplasia, lacking the tuft of abnormal vessels and the early venous filling phase commonly seen in the latter condition. The patients were all successfully treated by partial colectomy. The aetiology of Dieulafoy's vascular malformation remains unclear. The ruptured arteries in cases 2 and 3 shared many histological features with the Dieulafoy lesion in case 1. The lesions in cases 1 and 2 were associated with recent oral non-steroidal anti-inflammatory therapy, suggesting coincidental mucosal ulceration as a contributory factor.

Case report: septic arthritis of the hip following ureteric stent insertion.

Urinary infection is a recognized complication of ureteric stent insertion. We present a case of pelvic abscess and avascular necrosis of the hip following insertion of a stent for ureteric obstruction.

Enteroclysis--the influence of tube design.

The performance of three 10F enteroclysis tubes with different tip designs (E. Merck Ltd) was assessed using double-contrast, gravity infusion enteroclysis, with methylcellulose solution as negative contrast. Intubation times, screening times, patient tolerability and examination quality were compared. The results show that a streamlined tip design facilitated passage through the nose. None of the tubes provided consistently reliable results due to inadequate flow rates. The Corsafe tube transmits a higher flow rate of methylcellulose and produced satisfactory examinations more frequently. Mechanically assisted infusion of methylcellulose is recommended when using 10F enteroclysis tubes.

Low-dose fibrinolytic therapy for recent lower extremity thromboembolism.

Low-dose catheter-directed fibrinolytic therapy (LDCF) using streptokinase (35) and urokinase (7) was performed on 42 separate occasions in 36 patients for recent lower extremity thromboembolic occlusion. Twenty-seven grafts and 15 native arteries were treated. Causes of occlusion were known in 32 instances: native artery proximal or distal occlusive disease or both (18 vessels); bypass graft stenosis (6); aneurysm (2); embolus (4); and postangiography thrombosis (2). Twenty-nine infusions were technically successful, and patients were clinically improved by 26 of the treatments. Twelve patients had unsuccessful infusions and six underwent subsequent amputation. In all patients, infusions longer than 12 hours resulted in prolonged thrombin times and lowered plasma fibrinogen concentrations; one infusion was discontinued due to a low fibrinogen concentration. Complications occurred on 17 occasions and included hemorrhage (6), distal embolization (3), compartment syndrome (1), retrograde thrombosis during infusion (5), hypotension (1), and systemic fibrinogenolysis (1). The cumulative success rate was 44% +/- 9% at 24 months. Late rethrombosis (five instances) was more common in patients who had inflow or outflow structural lesions not corrected following successful fibrinolysis. LDCF is a useful alternative to other methods of treatment for recent onset lower extremity thromboembolic occlusion. Structural vascular lesions uncovered by successful infusion should be corrected immediately after infusion to ensure long-term patency.

Percutaneous transluminal angioplasty of abdominal aortic stenoses.

Percutaneous transluminal angioplasty (PTA) was performed on 25 patients with localized distal abdominal aortic stenoses. All patients were smokers and all complained of bilateral lower limb claudication. Eleven patients had small distal aortas and iliac vessels. Technically successful dilatation was achieved in all patients. Long-term follow-up was available on 17 of the patients. The mean follow-up period was 38 months. Cumulative patency at 5 years was 70%. Thirteen patients remain asymptomatic 15-83 months following PTA. Late failure occurred in 4 patients, 1-38 months following PTA. No complications related to PTA were experienced. PTA of localized aortic stenoses is a safe alternative to surgery and should be the treatment of choice in this condition.

Hepatic venography in the surgical assessment of hepatic tumours.

Hepatic venography was performed on 80 patients with hepatic tumours for the pre-operative assessment of resectability. Sixty-six patients subsequently underwent laparotomy, 27 undergoing hepatic resection. Forty-two patients had metastases from colo-rectal primaries, 19 hepatocellular carcinoma and 19 a variety of other tumours. The type and frequency of the abnormalities shown on venography were noted for each tumour category and for their hepatic segmental distribution. The results of venography were compared with those of arteriography, computed tomography and ultrasound and with the findings at laparotomy. Displacement was the commonest abnormality seen while encasement or obstruction occurred less frequently and tumour invasion was rare. The sensitivity of venography in correctly identifying the segmental distribution of tumour deposits was 41%. Sensitivity was poorest with tumours in the left lobe (31%) and bilobar tumours (0%). Venography was most sensitive in detecting tumour involvement of the major segmental hepatic veins and inferior vena cava (100%). Peripheral colo-rectal metastases frequently produced no venographic abnormality. Hepatic venography provides no additional information to arteriography, computed tomography or ultrasound in patients with peripheral or bilobar tumour deposits. Some additional information may be obtained with central tumours and venography is the most accurate means of detecting tumour involvement of the major segmental hepatic veins.

Intestinal angina: percutaneous transluminal angioplasty of the celiac and superior mesenteric arteries.

Percutaneous transluminal angioplasty (PTA) was performed in ten patients with chronic ischemia of the mesenteric arteries and stenoses of the celiac artery and/or the superior mesenteric artery (SMA). PTA was performed on 14 occasions, with attempted dilation of 19 arteries. PTA was technically unsuccessful in two patients. Seventeen of 19 arteries (90%) were successfully dilated in eight patients, resulting in relief of symptoms that lasted from 6 to 24 months. Symptoms recurred in five patients, and redilation in three of them relieved the symptoms. Three patients, one of them following redilation, remained asymptomatic 7-9 months following PTA. An asymptomatic intimal dissection of the SMA was the only complication attributable to the procedure. PTA of celiac and SMA stenoses is an alternative to surgical revascularization and can be repeated if symptoms recur.

Hepatic arterial embolisation in patients with metastatic carcinoid tumours.

Hepatic arterial embolisation was performed in six patients with malignant carcinoid tumours; five with the carcinoid syndrome and the other with intractable pain due to pleural and hepatic metastases. A total of 11 embolisations was performed, each time producing noticeable symptomatic relief, especially of facial flushing and diarrhoea. Apart from occasional episodes of the post-embolisation syndrome, no significant complications were experienced. Relief of symptoms lasted 2 months to 18 months in all patients with the carcinoid syndrome. Repeat embolisation was performed in three of the six patients. Three of the six patients have died at intervals ranging from 3 weeks to 20 months after the last embolisation. The cause of death was not related to embolisation. Hepatic embolisation is an effective, safe and repeatable method of palliating the symptoms of the carcinoid syndrome.

A controlled study of single dosage cefamandole in the prophylaxis of wound infections in appendectomy.

A series of 102 consecutive patients undergoing appendectomy through an incision in the right iliac fossa entered a prospective randomized trial to compare the effects of a 2 gram intravenous bolus dose of cefamandole with a control study. No differences occurred in the incidence of wound infection in the two groups. We conclude that there is no place for a single preoperative dosage of cefamandole in the management of appendicitis.