Transcatheter embolotherapy of maternal pulmonary arteriovenous malformations during pregnancy.

STUDY OBJECTIVES: To determine if transcatheter embolotherapy is safe and effective for the treatment of pulmonary arteriovenous malformations during pregnancy. DESIGN: Prospective study. SETTING: Specialized hereditary hemorrhagic telangiectasia centers at Yale University School of Medicine and St. Michael's Hospital, University of Toronto. PATIENTS: Seven pregnant women (age range, 24 to 34 years; gestational age range, 16 to 36 weeks) undergoing transcatheter embolotherapy. INTERVENTIONS: Transcatheter embolotherapy in all patients. MEASUREMENTS AND RESULTS: Thirteen pulmonary arteriovenous malformations in seven patients were embolized with detachable silicone balloons and/or stainless steel coils without incident. The estimated fetal radiation dose ranged from < 50 to 220 mrad. No complications of pulmonary arteriovenous malformations occurred in any of the patients after transcatheter embolotherapy. The mothers went on to deliver healthy babies in all cases. CONCLUSIONS: Transcatheter embolotherapy of maternal pulmonary arteriovenous malformations performed by an experienced radiologist appears to be safe and effective after 16 weeks of gestational age.

CT-guided catheter drainage of loculated thoracic air collections in mechanically ventilated patients with acute respiratory distress syndrome.

OBJECTIVE: We report our experience with CT-guided percutaneous catheter drainage of loculated thoracic air collections in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome. MATERIALS AND METHODS: Nine critically ill patients had 17 air collections (13 pneumothoraces, three pneumatoceles, one tension pneumomediastinum) that either developed despite the presence of standard surgical chest tubes or were in loculated sites that were difficult to access. All nine patients were ventilated mechanically for a clinical diagnosis of acute respiratory distress syndrome. Catheter size ranged from 7- to 28-French. Response was measured by imaging follow-up, ventilatory parameters, and clinical outcome. RESULTS: On follow-up imaging studies, all 17 air collections were shown to have been evacuated successfully. Catheters remained in place for a mean of 11 days (range, 4-28 days). No major complications occurred. Sixteen air collections were treated successfully with CT-guided catheter placement alone; the remaining air collection, a pneumothorax, was treated with subsequent placement of a chest tube by the surgeon at the patient's bedside. No surgery was undertaken for the air collections. Improvement in gas exchange was documented by increase in the hypoxemia ratio (arterial oxygen pressure divided by the inspired fraction of oxygen) in seven of 12 drainages; the other drainages were accompanied either by no improvement or by deterioration. Eight (89%) of the nine patients eventually were extubated and discharged from the hospital. The ninth patient died. CONCLUSION: CT-guided percutaneous catheter drainage provided effective treatment for loculated thoracic air collections and obviated surgical intervention in these critically ill, high-surgical-risk patients.

Frameless laser-guided stereotaxis: A system for CT-monitored neurosurgical interventions.

OBJECTIVE: Since a simple, rapid and accurate stereotactic system allowing CT monitoring would offer the neurosurgeon several advantages, the feasibility and application accuracy of frameless laser-guided freehand point stereotaxis for neurosurgical interventions was studied. METHODS: A Cartesian coordinate grid mounted upon the far wall of a CT scan room defined a plane. The scanner isocenter defined the origin of a three-dimensional coordinate system. Phantom entry point and target point coordinates were determined by the positional CT cursor. These coordinates were entered into a computer which determined the coordinates of the grid intersection point with a line passing through the entry and target points. A tripod-mounted laser assembly comprising two encased lasers oriented retrograde and antegrade along opposite vectors, was positioned near the grid. The retrograde laser was positioned to illuminate the marked grid intersection point while the antegrade laser simultaneously illuminated the entry point; the beams were thereby aligned along the line of trajectory. The tip of a probe was placed on the entry point; the hub was then moved into the path of the antegrade laser, thereby aligning the probe with the line of trajectory. The probe was then inserted to the target at a trigonometrically calculated distance. RESULTS: Ten consecutive phantom tests averaged 17.5 min. Phantom test application accuracy averaged +/-2 mm at an average insertion distance of 7.1 cm. CONCLUSION: Phantom tests indicate that simple, rapid and accurate CT-monitored frameless laser-guided freehand point stereotaxis is feasible. Clinical investigation is warranted.

Percutaneous radiologic drainage of pancreatic abscesses.

OBJECTIVE: The purpose of our study was to review and report the patient selection, techniques, and results of percutaneous drainage of pancreatic abscesses by retrospective review. MATERIALS AND METHODS: Fifty-nine patients (46 men and 13 women) with a mean age of 44 years old had 80 pancreatic abscesses that were drained percutaneously under radiologic guidance (CT, n = 77; sonography, n = 2; and fluoroscopy, n = 1). Abscesses had a wide spectrum of causes, with alcoholic pancreatitis being most common, trauma second most common, and gallstones third. Ten patients had undergone surgery for pancreatic necrosis or abscess. Patients with pancreatic pseudocysts, necrosis, or acute fluid collections were excluded from this study. RESULTS: Of the 59 patients, 51 (86%) were cured with percutaneous drainage and antibiotic therapy. Of the patients who were not cured with percutaneous drainage, seven required surgery and one underwent repeat percutaneous drainage. In the 59 patients, complications included non-life-threatening bleeding in three patients. Ten of 59 patients (17%) had fistulas that spontaneously formed into the gastrointestinal tract. The duration of catheterization ranged from 4 to 119 days, with a mean duration of 33 days. The rate of mortality at 30 days after completion of percutaneous drainage was 8% (5 of 59). CONCLUSION: Percutaneous drainage was an effective therapy for this defined group of patients with pancreatic abscesses. Factors leading to the relatively high success rate described in this study likely included selection of patients; catheters of adequate size, number, and location; careful follow-up with appropriate catheter manipulations; and an integrated, cooperative approach whereby surgeons were willing to permit drainage to effect its benefits, rather than operating prematurely.

Alcoholism-associated spinal and femoral bone loss in abstinent male alcoholics, as measured by dual X-ray absorptiometry.

Although alcoholism is a known risk factor for osteoporosis, there are few published reports on alcoholism-associated bone loss. To study alcoholism-associated bone loss, this study used a dual X-ray absorptiometry (DXA) densitometer to measure lumbar and femoral bone mineral density (BMD) in a previously little-studied population: 32 relatively healthy, nonhospitalized, Caucasian, alcoholic men with a period of abstinence longer than that previously studied (median abstinence 4.0 months, range 3 days-36 months). DXA is a new, highly precise densitometric method with many advantages over the methods used in previous studies. The subjects had statistically significant bone loss at three sites: lumbar spine, femoral neck, and Ward's triangle (multiple correction adjusted two-tailed P < 0.008). Compared to the mean BMD of sex-, age-, and race-matched norms, the subjects' average femoral neck, Ward's triangle, and lumbar BMDs were, respectively, 0.56, 0.69, and 0.57 standard deviations (SDs) below the normative values.