Pulmonary arteriography in the high-risk patient.

Pulmonary arteriography is an invasive but relatively safe diagnostic procedure. It is generally believed that the presence of pulmonary hypertension is one risk factor that increases the likelihood of a major complication. To assess the magnitude of risk, the reports on 1,434 patients who underwent pulmonary arteriography were retrospectively reviewed, and the occurrence of complications in the 388 (27%) patients with pulmonary hypertension was noted. Major complications related to contrast material injection (excluding allergic reactions) occurred in 30 (2%) of the 1,434 examinations and included two deaths from acute cor pulmonale. Six complications occurred in the 388 patients with pulmonary hypertension and/or elevated right ventricular end-diastolic pressure (RVEDP). The two deaths occurred in patients with severe pulmonary hypertension and elevated RVEDP. Most patients with severe cardiopulmonary compromise tolerated angiography well. The increased risk of studying this group of patients is modest and must be weighed against the potential therapeutic benefits to the patient.

Percutaneous balloon dilatation of ureteral strictures.

Percutaneous balloon dilatation of ureteral strictures has not gained widespread acceptance, despite proven success with the techniques for dilating stenotic blood vessels. Thirty-one ureteral strictures (in 30 patients) that were dilated during a 42-month period were reviewed to assess the results and to determine which patients are most likely to benefit from the procedure. Eighteen (58%) of 31 strictures were successfully dilated and remained patent for at least 6 months. Thirteen (42%) of 31 strictures resulted in failed patency either immediately (two patients) or within 3 months (seven patients), 6 months (three patients), or 21 months (one patient). Fourteen (64%) of 22 strictures less than 7 months of age were successfully dilated. All dilations for strictures more than 7 months of age failed. Four strictures were of unknown age. Nine (69%) of 13 strictures located in the proximal or midureter remained patent, and three (60%) of five dilations at a ureteroileal anastomosis were successful. Neither of two strictures at a ureterocolic anastomosis was treated successfully. We conclude that percutaneous balloon dilatation is an effective treatment of ureteral strictures in some patients, especially when the strictures are less than 7 months of age.

Percutaneous intervention in the solitary kidney.

The solitary kidney, either after nephrectomy or on a congenital basis, may be impaired by infection, stones, obstruction, and trauma. Because of the possibility of further renal compromise by damage of the remaining nephron units, there is reluctance to utilize percutaneous techniques in cases of solitary kidney, and surgery is often used as an alternative. We report 15 cases of solitary kidney in which interventional radiologic techniques (i.e., percutaneous nephrostomy, ureteral stenting, ureteral dilatation, and stone extraction) were attempted for the preservation of renal function, either as a permanent solution or as a temporizing maneuver prior to definitive therapy. In each case, these goals were achieved and there were no complications.

Partial nephrectomy using a new dissecting instrument.

The kidney is made of friable parenchyma with flexible blood vessels and collecting system structures. A dissecting clamp with interlacing blunt teeth was designed that, by repeated action of closing and opening over the renal parenchyma, crushes and dissects away the friable tissue, leaving the blood vessels and collecting system structures intact. Thus, individual ligation of blood vessels and collecting system structures can be performed at the line of resection. We report our experience in 10 dogs and 1 patient in whom partial nephrectomy was performed with this instrument.

Timing of chest film follow-up after transthoracic needle aspiration.

Transthoracic needle aspiration of pulmonary lesions is an extremely common procedure. Pneumothorax, the most common complication, is potentially life threatening. In an effort to determine the optimum time for obtaining chest radiographs to detect pneumothorax, all cases of pneumothorax that occurred after transthoracic needle aspiration between 1981 and 1984 were reviewed. During this period, 673 transthoracic-needle-aspiration procedures were performed. Pneumothorax occurred in 160 patients (23.8%), and 78 (11.5%) of these required a chest tube or aspiration. Of the total number of pneumothoraces, 142 (89%) were detected immediately, 15 (9%) were first seen after 1 hr, and only 3 (2%) were first seen on the 4-hr radiograph. Of the pneumothoraces requiring intervention, 69 (88%) were detected immediately while the remainder were first picked up after 1 hr. There were no significant pneumothoraces detected after the 1-hr radiograph. Immediate fluoroscopy and a routine chest radiograph 1-hour postprocedure are recommended. For outpatients 1-hr and 4-hr follow-up radiographs should be taken.

Chemical ablation of the canine kidney using sodium tetradecyl sulfate (Sotradecol). A histopathologic study.

We studied the histopathologic effect of intraarterial Sotradecol (Elkins-Sinn, Inc., Cherry Hill, NJ) on the kidney and examined the mechanism for destruction of renal parenchyma by Sotradecol. Sotradecol was injected into one renal artery distal to an occlusion balloon catheter in six dogs, and the kidneys were removed for histologic examination; four dogs within 20 minutes, and one each at 12 and 24 hours after embolization. The contralateral kidney of each dog underwent the same procedure but was injected with normal saline, and served as control. Histologic examination of the control kidneys was unremarkable. The embolized kidneys revealed extensive endothelial denudation and mural necrosis of the arteries and coagulation necrosis of the renal parenchyma. The changes were evident as early as 20 minutes after embolization, and necrosis became complete by 24 hours. The arteries were filled with red blood cell sludge. Sotradecol produces extensive tissue necrosis and complete renal parenchymal destruction through its direct cytotoxic action on the arterial wall, blood cell elements, and renal parenchyma.

Percutaneous lithotripsy of staghorn calculi.

Eleven cases of staghorn calculi managed by percutaneous lithotripsy were reviewed. Ten of 11 cases were successful, and 70% of the successfully treated patients were discharged free of any renal stones. The percentage of patients discharged with residual stone fragments was higher than those with either percutaneously managed nondendritic calculi or surgically treated staghorn calculi. The complication rate was higher than for nonbranched stones managed percutaneously and was comparable to that for surgically removed dendritic calculi. Hospital stay averaged 18 days, equal to that for staghorn calculi treated by conventional surgical approach, but considerably longer than for nonbranched stones. Overall results more closely approximated those for surgical removal of staghorn calculi than those for percutaneous removal of nonbranched calculi. However, the principal advantage of percutaneous lithotripsy of staghorn calculi over surgical management is the significant reduction in convalescence after discharge from the hospital.

Transcatheter embolization with sodium tetradecyl sulfate. Experimental and clinical results.

Sodium tetradecyl sulfate (Sotradecol), which has been employed for sclerotherapy of varicose veins, was evaluated in dogs and humans as an agent for selective arterial embolization. In dogs, intraarterial injection of Sotradecol 3% into the proximally occluded renal, hepatic, splenic, and deep femoral arteries produced arterial occlusion and tissue destruction. Transcatheter embolization with Sotradecol was performed in 11 patients and was successful in 10; in the remaining patient, failure was attributed to rapid dilution by unobstructed blood flow in arteriovenous malformations of the neck. The authors conclude that Sotradecol is a safe and efficient agent for selective arterial embolization.