Enhancing Hepatic Microcirculation in Postoperative Hepatic Failure With Intra-arterial Recombinant Tissue Plasminogen Activator Treatment.

Postoperative hepatic failure is one of the most severe complications after liver resection. Treatment protocols have varied from medical support to liver transplant. Here, we describe the clinical course of an 18-year-old female patient with postoperative hepatic failure. The combined use of intra-arterial tissue plasminogen activator infusion and concurrent liver support facilities resulted in successful treatment of postoperative hepatic failure. The role of thrombolytic treatment for postoperative hepatic failure may include future placement in routine treatment protocols, as seen in liver transplant.

Preoperative arterial embolization of large liver hemangiomas.

PURPOSE: We aimed to investigate the efficacy and safety of preoperative selective intra-arterial embolization (PSIAE) in the surgical treatment of large liver hemangiomas. METHODS: Data of 22 patients who underwent resection of large liver hemangiomas were retrospectively analyzed. PSIAE was performed in cases having a high risk of severe blood loss during surgery (n=11), while it was not applied in cases with a low risk of blood loss (n=11). RESULTS: A total of 19 enucleations and six anatomic resections were performed. Operative time, intraoperative bleeding amount, Pringle period, and blood transfusion were comparable between the two groups (P > 0.05, for all). The perioperative serum aspartate transaminase level was not different between groups (P = 1.000). Perioperative total bilirubin levels were significantly increased in the PSIAE group (P = 0.041). Postoperative hospital stay was longer in the PSIAE group. Surgical complications were comparable between groups (P = 0.476). CONCLUSION: Patients who underwent PSIAE due to a high risk of severe blood loss during resection of large liver hemangiomas had comparable operative success as patients with a low risk of blood loss who were operated without PSIAE. Hence, PSIAE can be used for the control of intraoperative blood loss, especially in surgically difficult cases.

[Percutaneous endovascular removal of intracardiac migrated port A catheter in a child with acute lymphoblastic leukemia]. / Remoção endovascular percutânea de cateter totalmente implantável com migração intracardíaca em criança com leucemia linfoblástica aguda.

A 2-year-old boy with acute lymphoblastic leukemia was presented with peripherally inserted central catheter dysfunction. Radiological examinations revealed a catheter remnant in the right atrium extending into pulmonary vein. The catheter remnant was successfully removed from the right atrium by percutaneous endovascular intervention without any complications.

Percutaneous endovascular removal of intracardiac migrated port A catheter in a child with acute lymphoblastic leukemia.

A 2-year-old boy with acute lymphoblastic leukemia was presented with peripherally inserted central catheter dysfunction. Radiological examinations revealed a catheter remnant in the right atrium extending into pulmonary vein. The catheter remnant was successfully removed from the right atrium by percutaneous endovascular intervention without any complications.

Percutaneous endovascular removal of intracardiac migrated port A catheter in a child with acute lymphoblastic leukemia / Remoção endovascular percutânea de cateter totalmente implantável com migração intracardíaca em criança com leucemia linfoblástica aguda / Retirada por vía intravenosa percutánea de catéter Port-A debido a la migración intracardiaca en niño con leucemia linfoblástica aguda

A 2-year-old boy with acute lymphoblastic leukemia was presented with peripherally inserted central catheter dysfunction. Radiological examinations revealed a catheter remnant in the right atrium extending into pulmonary vein. The catheter remnant was successfully removed from the right atrium by percutaneous endovascular intervention without any complications.

Menino com dois anos de idade com leucemia linfoblástica aguda foi apresentado com disfunção de cateter central perifericamente inserido. O exame radiológico revelou um fragmento do cateter no átrio direito que se estendia até a veia pulmonar. O fragmento foi removido com sucesso por intervenção endovascular percutânea, sem qualquer complicação.

Paciente del sexo masculino, de 2 años de edad, con leucemia linfoblástica aguda que se presentó con una disfunción del catéter central de inserción periférica. Los exámenes radiológicos acusaron un resto de catéter en la aurícula derecha, extendiéndose hacia la vena pulmonar. El catéter fue retirado con éxito de la aurícula derecha por vía intravenosa percutánea sin complicaciones.

Chemoembolization for neuroendocrine liver metastasis.

The liver is the most common site for neuroendocrine tumor metastasis. The characteristic feature of these tumors is related to the secretion of biologically active compounds in large amounts. Systemic chemotherapy has limited success in treating patients with neuroendocrine liver metastasis. Surgical management remains the only potentially curative option for these patients. According to the high incidence of recurrence after surgery, the role of intra-arterial therapy (IATs) in neuroendocrine tumor metastasis has been evolved. This review evaluates the potential role of IATs in the light of current literature.

Coil embolization in 481 ruptured intracranial aneurysms: angiographic and clinical results.

PURPOSE: We aimed to report our 13-year experience with the embolization of ruptured cerebral aneurysms using detachable coils and postembolization angiographic and clinical results. MATERIALS AND METHODS: Between June 1998 and September 2011, 481 patients with ruptured aneurysms were referred for endovascular treatment with detachable coils at our center. The technical feasibility, procedural complications, morbidity, mortality, and initial angiographic and clinical results were evaluated. RESULTS: Endovascular treatment was successful in 95.6% of the patients. Postembolization angiography showed complete occlusion in 63.4%, a neck remnant in 30.8%, and incomplete occlusion in 5.8% of the aneurysms. A total of 331 patients were followed up. The overall angiographic results showed stable occlusion in 234 aneurysms (70.7%) and recurrence in 97 aneurysms (29.3%). During the follow-up period, stable angiographic occlusion was evident in 75% of the small, 61% of the large, and 38.5% of the giant aneurysms. Complications during the coiling procedure occurred in 75 procedures (15.6%). Ischemic complications were observed in 33 procedures (6.9%), and perforation of the aneurysm during the coiling occurred in 12 cases (2.5%). Five (41.7%) of 12 patients who had perforation during coiling died. The overall procedure-related morbidity and mortality were 5.6% and 2%, respectively. During the follow-up period, two patients (0.4%) had early rebleeding. None of the patients showed late rebleeding. In the follow-up, the retreatment rate was 12.6%. CONCLUSION: Our data confirm the feasibility, safety, and efficacy of endovascular coil embolization in patients with ruptured cerebral aneurysms.

Spontaneous thrombosis of a saccular iliac artery aneurysm induced by overlapping self-expandable bare metallic stents.

Isolated iliac artery aneurysms are rare lesions. Prompt diagnosis and timely intervention are essential in their management. In elderly patients with coexisting medical problems, endovascular procedures are preferred to avoid the risks of morbidity and mortality associated with general anesthesia and surgery. We report a case of a true saccular external iliac artery aneurysm that underwent spontaneous thrombosis after treatment with placement of two overlapping bare self-expandable metallic stents only.

Use of a balloon and N-butyl-2-cyanoacrylate for treatment of arteriovenous fistula.

We report a patient who developed a large arteriovenous fistula in right lower extremity after gunshot injury. Because other endovascular methods failed, the patient was successfully treated with concomitant use of detachable latex balloon and N-butyl-2-cyanoacrylate (NBCA). The combination of detachable balloon and NBCA can be effectively used for endovascular treatment of peripheral arteriovenous fistulas in selected cases when effective embolization could not be achieved with other embolizing agents or their various combinations.

Spinal subdural abscess: a rare cause of low back pain.

Spinal subdural abscess (SSA) is a rare but well-described entity. It may occur secondary to a systemic infectious focus or following a surgical procedure. There are only two SSA cases in the literature that are unrelated to such conditions and without any well-documented etiology. SSA is a neurosurgical emergency and diagnosis may be difficult. Progressive neurological deficits and severe pain with fever suggest the diagnosis. Surgical drainage and subsequent prompt antimicrobial therapy should be performed without delay. We report a patient with SSA unrelated to any predisposing condition and discuss underlying mechanisms of this disease.

Intractable postpartum hemorrhage resulting from uterine artery pseudoaneurysm: superselective arteriographic embolization via the collateral route.

We present a patient with intractable postpartum hemorrhage resulting from uterine artery pseudoaneurysm despite bilateral hypogastric artery ligation who was successfully treated by an endovascular approach via the collateral route. Although there is a good argument for postponing surgery until transcatheter embolization has been attempted, this case shows that embolization can still be successful even if the iliac vessels have been ligated.

Late angiographic and clinical follow-up results of 100 consecutive aneurysms treated with Onyx reconstruction: largest single-center experience.

We present the long-term clinical and angiographic follow-up results of 100 consecutive intracranial aneurysms treated with Onyx liquid embolic system (MTI, Irvine, Calif.), either alone or combined with an adjunctive stent, in a single center. A total of 100 aneurysms in 94 patients were treated with endosaccular Onyx packing. Intracranial stenting was used adjunctively in 25 aneurysms including 19 during initial treatment and 6 during retreatment. All aneurysms except two were located in the internal carotid artery. Of the 100 aneurysms, 35 were giant or large/wide-necked, and 65 were small. Follow-up angiography was performed in all 91 surviving patients (96 aneurysms) at 3 and/or 6 months. Follow-up angiography was performed at 1, 2, 3, 4 and 5 years in 90, 41, 26, 6 and 2 patients, respectively. Overall, aneurysm recanalization was observed in 12 of 96 aneurysms with follow-up angiography (12.5%). All 12 were large or giant aneurysms, resulting in a 36% recanalization rate in the large and giant aneurysm group. One aneurysm out of 25 treated with the combination of a stent and Onyx showed recanalization. There was also no recanalization in the follow-up of small internal carotid artery aneurysms treated with balloon assistance only. At final follow-up, procedure- or device-related permanent neurological morbidity was present in eight patients (8.3%). There were two procedure-related and one disease-related (subarachnoid hemorrhage) deaths (mortality 3.2%). Delayed spontaneous asymptomatic occlusion of the parent vessel occurred in two patients, detected on routine follow-up. Onyx provides durable aneurysm occlusion with parent artery reconstruction resulting in perfectly stable 1-year to 5-year follow-up angiography both in small aneurysms treated with balloon assistance only (0% recanalization rate) and large or giant aneurysms treated with stent and Onyx combination (4% recanalization rate). Endosaccular Onyx packing with balloon assistance may not be adequate for stable long-term results in those with a large or giant aneurysm. However, the recanalization rate of 36% in these aneurysms is better than the reported results with other techniques, i.e., coils with or without adjunctive bare stents.

Losartan renography for the detection of renal artery stenosis: comparison with captopril renography and evaluation of dose and timing.

PURPOSE: Radionuclide renography with angiotensin converting enzyme (ACE) inhibition plays an important role in the diagnosis of haemodynamically significant renal artery stenosis. Angiotensin receptor antagonists inhibit the renin angiotensin system at different levels from ACE inhibitors by selectively blocking the binding of angiotensin II to AT1 receptors. The AT1 angiotensin receptor antagonist losartan has recently been used clinically in the treatment of hypertension. However, the available data on the use of losartan with renography for the detection of renovascular hypertension are limited and contradictory. The purpose of this prospective study was to compare the effectiveness of losartan renography and captopril scintigraphy in revealing renal artery stenosis. METHODS: A total of 61 renal units in 32 patients with hypertension were studied in two groups based on the losartan dosage (50 mg in group A and 100 mg in group B). Group A consisted of 17 patients, in whom 19 renal units had angiographically proven renal artery stenosis (>or=50%). In group B, there were 15 patients, in whom 20 renal arteries were stenotic. All of the patients underwent three renographies (baseline, captopril renography and early losartan renography). Early losartan renography was performed at 1 h after oral losartan administration in both groups. In group B, seven patients underwent additional losartan renography (late losartan) performed 3 h after oral losartan administration; these patients composed group B1. RESULTS: The sensitivities of captopril and losartan studies were 63.2% and 42% in group A, 65% and 65% in group B and 55.6% and 66.6% in group B1, respectively. CONCLUSION: From our preliminary results, we conclude that losartan is not superior to captopril renography for the detection of haemodynamically significant renal artery stenosis. However, a high dose (100 mg) of losartan provided higher sensitivity than the lower dose (50 mg). Late losartan scintigraphy provided similar diagnostic efficacy to early losartan renography.

Treatment of internal carotid artery aneurysms with a covered stent: experience in 24 patients with mid-term follow-up results.

BACKGROUND AND PURPOSE: We present our preliminary experience, including mid-term angiographic and clinical follow-up results, with an alternative technique for the endovascular treatment of intracranial aneurysms in a series of patients. This new method, previously described in anecdotal case reports, consists of endovascular deployment of an artificial vessel graft (stent graft or covered stent) in the parent vessel to exclude the intracranial aneurysm sac from circulation. METHODS: Twenty-five internal carotid artery (ICA) aneurysms in 24 patients were successfully treated by using a Jostent coronary stent graft deployed in the parent artery across the aneurysm neck. All except four aneurysms were extradural, located in the petrous or cavernous portion of the ICA. The four intradural aneurysms were located in the carotico-ophthalmic region. Seventeen aneurysms in 16 patients occurred posttraumatically, secondary to motor vehicle accidents or surgical injury. RESULTS: Twenty-three aneurysms were immediately excluded from circulation after stent graft placement. In two aneurysms, a slow contrast material filling (endoleak) into the aneurysm cavity was observed immediately after treatment. One was thrombosed, as shown by late control angiography; in the other one, a second larger bare stent was used to appose the stent graft's distal end to the ICA wall, thus sealing the endoleak into the distal graft. No technical adverse event, including vessel dissection, vessel perforation, or thromboembolism, occurred with or without clinical consequence. No mortality or morbidity developed during or after the procedure, including the follow-up period. Two-year control angiography in one patient, 1.5-year control angiography in two patients, 1-year control angiography in six patients, and 6-month control angiography in 12 patients were performed, revealing reconstruction of the ICA with no aneurysm recanalization. All symptoms resolved after treatment in the patients who had initially presented with mass effect. CONCLUSION: Initial anatomic, clinical and mid-term follow-up results in this small series of patients are encouraging. This technique has been proved to have potential in the reconstructive treatment of intracranial aneurysms. Further research and development are needed to optimize the stent graft technology for the cerebrovascular system.

Free microvascular transfer of coccygeofemoral muscle in rabbits.

A new experimental free flap model, the cocygeofemoral muscle flap of the rabbit, is introduced in this study. The coccygeofemoral muscle is a superficially located triangular muscle originating from the sacrum and inserting into the lateral condyle of the tibia, and it abducts the thigh. Anatomical dissection and microangiographic studies revealed that it has a major and a minor pedicle, the former originating from the caudal gluteal artery, and the latter originating from the caudal femoral artery. Its major pedicle contains the 0.7-mm artery, 1-mm vein, and the single nerve originating from the inferior gluteal nerve. In flap studies in 10 animals, the distal minor pedicle was ligated, and muscle was dissected up to its major pedicle and denervated, and the free muscle was transferred to the contralateral inguinal region via end-to-end anastomosis to the recipient vessels (i.e., the femoral artery and vein). At postoperative day 7, the transferred muscles were harvested and histologically examined. Nine of 10 muscles were viable; the coccygeofemoral muscle free flap is believed to be an easy-to-dissect and bulky flap model, having a relatively thick pedicle. It may serve as a good model in free muscle flap studies.

Takayasu's arteritis: results of a university hospital of 45 patients in Turkey.

BACKGROUND: Takayasu's arteritis (TA) is a rare disease which appears to be most common in East Asia. However, the disease has been reported to be worldwide. The clinical features of the disease can show variations in different geographical areas. The aim of this study is to evaluate clinical, laboratory and radiological features and the outcome of patients with TA in our hospital. METHODS: The hospital files of patients who were followed with the diagnosis of TA between the years 1973 and 2003 in Hacettepe University Hospital were retrospectively evaluated. RESULTS: Male/female ratio was 5/40, and the mean age was 34 years (18-59). Constitutional symptoms were present in 71% of the patients. Claudication and pallor of the extremity, decreased extremity pulsations, arterial hypertension, and arterial bruits were present in 44%, 56%, 58%, and 27% of the patients, respectively. Aortic valvular insufficiency, abdominal aortic aneurism, and cardiomegaly were present in four, one, and four patients, respectively. The initial complaint of six patients was cerebrovascular events. The distribution of the patients according to the angiographic findings was as follows, 56% Type I, 18% Type II, 22% Type III, and 4% Type IV arteritis. The need for vascular surgical interventions were significantly less common in patients who were treated with immunosuppressives plus alternate dose steroids (6%) compared to patients who were treated only with antiaggregant agents (33%). CONCLUSIONS: The demographic and angiographic findings of our patients were similar to previous observations from Japan and Italy, and disclose distinct clinical features in comparison to other Asian countries. Alternate-day glucocorticoids plus cytotoxic drugs may be beneficial and safe in patients with TA.

Comparison of MR signal intensities of cerebral perivascular (Virchow-Robin) and subarachnoid spaces.

PURPOSE: The purpose of this work was to compare quantitatively the T2-weighted MR signal intensity values of the perivascular (Virchow-Robin) spaces and the cerebrospinal fluid (CSF). METHOD: Coronal 3D T2-weighted turbo spin echo MR images of the brain were evaluated in 44 subjects without any significant cerebral pathology. MR signal intensity values of the perivascular spaces around the anterior commissure and the CSF in the ventricles and the subarachnoid space were measured. RESULTS: A statistically significant difference between the mean MR signal intensity values of the perivascular spaces and the CSF both in the ventricles and in the subarachnoid space was found. The intensity values in the ventricles and in the subarachnoid space were not statistically significantly different. CONCLUSION: The perivascular spaces have a different MR signal intensity than the CSF-containing structures within and around the brain. This finding is in keeping with the statement that the perivascular spaces represent entrapments of interstitial fluid and are not the invagination of CSF-filled subarachnoid sheaths.