Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation.

OBJECTIVE: The aim of this paper is to describe and evaluate the technique of prophylactic balloon occlusion of hypogastric arteries in abnormal placentation. Five patients with suspected placenta accreta, placenta percreta, or placenta increta underwent perioperative balloon occlusion of hypogastric arteries after classic cesarean delivery and before hysterectomy with hypogastric artery ligation. Two patients did not require transfusions; of the three who did, the estimated blood loss ranged from 1100 to 4000 mL. CONCLUSION: We conclude that balloon occlusion of the hypogastric arteries is a safe and effective adjunct to cesarean hysterectomy in an attempt to minimize blood loss in patients with abnormal placentation.

A randomized trial of transcutaneous extraction atherectomy in femoral arteries: intravascular ultrasound observations.

OBJECTIVES: The purpose of this study was to test the hypothesis that in occlusions of the superficial femoral artery, removal of atherosclerotic plaque would result in a higher long-term patency rate compared to balloon dilatation alone. A secondary hypothesis was that long term patency would be proportional to the amount of plaque removed. METHODS: A randomized controlled study of patients with occluded superficial femoral arteries was performed comparing balloon dilatation alone versus a 2.7 mm or a larger (4.0 mm or 4.7 mm) transcutaneous extraction catheter (TEC) atherectomy device followed by balloon dilatation. The effect of these devices on plaque area was assessed directly by intravascular ultrasound imaging. RESULTS: The mean occlusion length was 19.4 cm +/- 11.7 cm. The mean lumen area increased from 4.7 mm2 to 15.1 mm2, primarily due to balloon dilatation, but the mean atheroma area of 19.8 mm2 did not change with either size of TEC device. Although the initial procedure success rate was high (79%), the 6 month patency was only 45%. There was no difference in 6 month patency between the 3 groups. CONCLUSIONS: The data indicate that the TEC atherectomy devices do not remove a significant amount of atherosclerotic plaque in occluded superficial femoral arteries. The 6 month patency is no different with these atherectomy devices than with balloon dilatation alone. The larger (4.0 mm or 4.7 mm) TEC device does not remove any more tissue than the smaller (2.7 mm) device. The use of intravascular ultrasound to quantitate the effects of this atherectomy device provides important insights into the mechanism of action and lack of efficacy of the TEC atherectomy catheter.

Open fractures of the patella: long-term functional outcome.

Seventy-nine open patella fractures in 76 patients were treated between 1986 through 1994, with an 80% incidence of multiple injuries. All were treated with irrigation and debridement, open reduction, internal fixation, and reconstruction of the extensor mechanism. In no case was a primary patellectomy performed, even with severe comminution. There were three failures of initial fixation and one asymptomatic nonunion. Average range of motion for all groups was 112 degrees, at an average follow-up of 21 months. Secondary surgical procedures were performed in 65% of knees, the majority for symptomatic hardware. To determine long-term functional outcome, a modified Hospital for Special Surgery knee score was used. At an average of 36 months, good to excellent knee scores were observed in 17 of 22 patients. We conclude that all attempts for preservation of bone substance and precise reconstruction of the extensor should be attempted, reserving total patellectomy as a salvage procedure.

Early exchange intramedullary nailing of distal femoral fractures with vascular injury initially stabilized with external fixation.

Fracture of the femur with accompanying arterial injury represents approximately 1% of all femoral fractures. Controversy exists regarding the choice of fixation and the sequence of fixation and vascular repair. We report on the treatment of six patients with seven distal femoral fractures and angiographically documented arterial injuries treated over a 20-month period. The treatment protocol consisted of angiography followed by provisional external fixation and early primary exchange to an intramedullary nail. Five of the seven fractures were open. Three fractures were caused by blunt trauma, and four were secondary to shotgun blasts. Average follow-up was 12 months (range, 6-25 months). All fractures healed with an average time to union of 25 weeks. There were no complications related to the vascular repair. One case of an acute deep infection resolved after debridement and placement of polymethylmethacrylate cement beads impregnated with antibiotics and a course of intravenous antibiotics. All patients returned to their previous levels of activity. Based on the results of our experience with a small group of patients, we feel that this treatment protocol will prove to be a safe and efficient method of management of these difficult injuries.

Gallbladder ablation with gallstones in situ in an animal model.

RATIONALE AND OBJECTIVES: The authors evaluated a method of gallbladder sclerosis in the presence of cholelithiasis. METHODS: The study was performed in 20 pigs. The gallbladders of 16 pigs contained surgically placed human gallstones. Control groups included animals that had their gallbladders sclerosed in the absence of stones, as well as a surgical sham control. Sclerosis followed cystic duct ligation to prevent extravasation of the sclerosing agent (95% Ethanol with 2 mole% trifluoroacetic acid) into the biliary tree. After sclerosis, a pigtail catheter was placed in the gallbladder to drain any post-procedure fluid accumulations. Catheters were removed after all drainage had ceased. Animals were killed at either 8 weeks (n = 6) or 6 months (n = 14). RESULTS: Stones were enveloped within the sclerosed and fibrotic gallbladder remnant in 13 of 15 test animals (87%). CONCLUSIONS: Sclerosis of gallbladders with stones in situ was achievable. Total mucosal obliteration did not appear to be required to produce a dysfunctional gallbladder in the time frame of this study.

Perforation of the superior vena cava by a subclavian hemodialysis catheter: early detection by angiography.

A dual-lumen subclavian catheter was placed for temporary dialysis access in a 36-year-old woman. Clinical suspicion for a possible vena caval perforation by the catheter tip was confirmed by injection of contrast through the catheter. This technique allowed rapid diagnosis and prevented further potential complications related to catheter malposition.

Accelerated destruction of large, calcified gallstone burdens by performing lithotripsy in the presence of methyl t-butyl ether: an in vitro study.

Numerous, large, or calcified gallstones hinder successful extracorporeal fragmentation. The purpose of this study was to investigate an in vitro method that could accelerate the destruction of these types of gallstone burdens. Matched sets of partially calcified gallstones, each set having a combined stone diameter greater than 3 cm, underwent lithotripsy while immersed in either 15 cc of bile, methyl t-butyl ether (MTBE), or dimethyl sulfoxide (DMSO), with a fourth set serving as a control. Results showed a 20% reduction in the relative weight of all fragments, an eightfold reduction of the relative weight of fragments greater than 3 mm, and a 50% reduction of the number of large fragments when the stones were immersed and shocked in MTBE rather than when shocked in bile. Dimethyl sulfoxide hindered gallstone destruction. These results indicate that large, partially calcified gallstone burdens can be more successfully destroyed if lithotripsy is performed in the presence of a small quantity of MTBE rather than in bile alone or in the presence of DMSO. If proven safe in vivo, this technique could expand the applicability of lithotripsy to those with larger, partially calcified stone burdens.

Simplified percutaneous gastrostomy.

By using 16-F self-retaining feeding catheters, fluoroscopically guided percutaneous gastrostomy was performed in 68 consecutive adult patients without the use of gastric fixation devices. Short-term (2-week) follow-up of all patients was available, with 30-day follow-up obtained in 94% of the study group (n = 64). Thirty-day mortality was 12%, with no procedure-related deaths. Major and minor morbidity rates were 4.7% and 7.8%, respectively. The mean procedure time was 7 minutes. These data compared favorably with those of series employing smaller catheters placed with and without the use of gastropexy, as well as surgical gastrostomy and gastropexy procedures. Percutaneous placement of large-caliber (16-F) gastrostomy catheters is safe, effective, and rapid in the adult population and can be accomplished routinely without the use of prior gastropexy.

Intraoperative peripheral rotary atherectomy: early and late clinical results.

Early and late clinical results of intraoperative peripheral atherectomy using the Auth Rotablator are analyzed. Twenty patients (15 males and 5 females age 39-89 years, mean 70 years) underwent 25 atherectomy procedures for peripheral arterial occlusive disease from August 1987 to October 1989. All patients underwent serial history, physical exam, and Doppler pressure measurements preoperatively and then postoperatively at 24 hours, one week, one month, and six months during a follow-up period of 15 to 41 months, mean 27 months. Preoperative and intraoperative completion follow-up arteriography was done in all cases and follow-up arteriography in 19 of 25 cases. Initial arteriographic success was achieved in 23/25 (92%) cases and in 39/41 (93%) arterial segments (superficial femoral artery 12/13, popliteal 14/15, tibial 12/13, profunda-femoral 1/1). Complications included intimal dissection (1), equipment breakage (2), minor emboli (3), major emboli with thigh skin loss (1), transient hemoglobinuria (4), wound hematoma (1), wound infection (1), and limb loss (1). Early thrombosis occurred in five cases to give an in-hospital success rate of 18/25 (72%). Primary patency was 66% at six months but only 12% at two years. Rotary atherectomy effectively recanalizes femoral, popliteal and tibial arteries. However, early thromboembolic complications occurred frequently, and the two year patency was dismal. Rotary atherectomy is not recommended for general use until problems of thromboemboli and intimal hyperplasia are solved.

The acceleration of gallstone destruction with synchronous biliary lithotripsy and contact dissolution in vitro using three cholesterol-solubilizing solvent.

In the first-known application of its kind, shockwave lithotripsy and contact-solvent dissolution of large, calcified gallstone burdens were performed simultaneously with three chemical solvents, each tested separately in an in vitro model, with the combined effects on gallstone eradication examined. Two solvents, ethyl propionate and isopropyl acetate, were chosen for their solubilizing ability and potentially high level of patient safety. The third solvent, a 70%:30% mixture of methyl tert-butyl ether (MTBE) and dimethyl sulfoxide (DMSO), was chosen for its known ability to accelerate the dissolution of calcium-containing gallstones. All stones were matched for size, weight, and number. Gallstone lithotripsy performed in ethyl propionate was significantly more effective (P less than .02) in the production of fragments less than 2 mm when compared with bile; lithotripsy with isopropyl acetate and the MTBE/DMSO mixture showed no statistically significant effect. Biliary lithotripsy performed in an ethyl propionate medium may enhance gallstone dissolution and the production of small fragments (diameter less than 2 mm).

Laser-assisted versus mechanical recanalization of femoral arterial occlusions.

A randomized clinical trial was performed to test the hypothesis that a laser-heated probe is superior to standard techniques to reopen occluded femoral arteries. Twenty patients were treated with a standard guidewire and balloon dilation method. In a second group of 20 patients, the laser probe was initially used as a nonheated mechanical device. If the probe was unsuccessful in mechanically reopening the artery, an Argon laser was activated to heat the probe. The mean length of occlusion was 15.9 +/- 10.3 cm. The success rate for the laser probe was 15 of 20 (75%), which was not significantly different from the standard method, 19 of 20 (95%). Most of the success in the laser-probe group was due to the probe's mechanical properties. The laser probe was successful as a cold, mechanical device in 13 of 15 (87%) arteries. It was necessary to heat the probe in 5 patients. When heated, the laser probe assisted recanalization in 2 but perforated the artery in 3 cases. The results of this randomized trial do not support the hypotheses behind the use of the thermal laser probe. The laser probe functions primarily as a mechanical device. The thermal activation does not significantly improve the success rate without increasing the risk of perforation. This small additional benefit does not justify the large cost of current thermal laser devices. This controlled study also demonstrates a higher success rate in long occlusions than previous reports of mechanical balloon recanalization. This is due to a combination approach of retrograde and anterograde probing of the occluded segment.

Risks of percutaneous transhepatic drainage in patients with cholangitis.

Percutaneous transhepatic biliary drainage (PTD) has been advocated as a method of achieving biliary decompression in patients with cholangitis. However, the risk of PTD in these patients has not been determined. Therefore, we reviewed the records of 95 consecutive PTD patients, 30 (32%) of whom had cholangitis. Forty-four (46%) of the 95 patients underwent PTD as a preoperative measure; the remaining 51 (54%) had PTD for palliation of end-stage malignancies. Thirty-day mortality and overall morbidity were 17% and 30%, respectively, in the patients with cholangitis and 15% and 28% in the patients without cholangitis. These differences were not statistically significant. However, patients with cholangitis had a significantly higher (p less than .05) incidence of post-PTD bacteremia. In patients undergoing PTD for palliation, both mortality (25%, p less than .01) and morbidity (35%) were higher than in those being drained preoperatively. This analysis suggests that PTD can be performed safely in patients with cholangitis and that the patient's underlying disease process is more important than the presence of cholangitis in determining the outcome.