A horseshoe kidney harboring large symptomatic renal angiomyolipoma with a false macro-aneurysm.

We report a case of a large angiomyolipoma in a horseshoe kidney associated with a macro-aneurysm bleeding into the retroperitoneum. The patient was successfully treated by embolization of the macro-aneurysm, using thrombogenic cois and Ivalon particles. He remains free of symptoms at 18 months of follow-up. CT scan and renal ultrasound confirm no flow to the previous area of the macro-aneurysm and no change in size of the benign tumor.

Accuracy of sonography in the evaluation of calf deep vein thrombosis in both postoperative surveillance and symptomatic patients.

OBJECTIVE: The purpose of this study was to determine the accuracy and to assess the interobserver variability of compression sonography (CS) in detecting isolated calf deep vein thrombosis (DVT) in postoperative and symptomatic patients without clinical or contrast venographic indication of previous lower extremity DVT. SUBJECTS AND METHODS: A prospective double-blinded study was undertaken on 287 consecutive legs using contrast venography (CV) as the gold standard. One hundred seventy-nine legs were from the postoperative group, and 108 legs were from the symptomatic group. The CS technique was used to diagnose DVT, and color Doppler imaging was used only as a road map. Calves were examined while the patient was sitting. Also, interobserver agreement was measured in the CS evaluation of calf veins of another group of 54 symptomatic legs. RESULTS: Forty (22%) CVs and 13 (7%) CS examinations for calf assessment were indeterminate in the postoperative group as compared with 33 (30%) and 10 (9%) in the symptomatic group. The sensitivity, specificity, negative predictive value, and positive predictive value of CS in detecting calf DVT with or without extension to above-the-calf veins were 92% (confidence interval [Cl], 82-100%), 100%, 98% (Cl, 95-100%), and 100%, respectively, in the postoperative group and 86% (Cl, 72-100%), 96% (Cl, 90-100%), 94% (Cl, 87-100%), and 90% (Cl, 77-100%), respectively, in the symptomatic group. The sensitivity of CS was 92% (Cl, 81-100%) in the postoperative and 88% (CL, 65-100%) in the symptomatic group with isolated calf DVT. Of all calf muscular branch DVTs, 52% were detected by CS alone as compared with 21% seen on CV alone. The kappa value for the CS assessment of isolated calf vein DVTs was 0.60. CONCLUSION: Sonography is a highly accurate test with acceptable reproducibility for the detection of DVT in calf veins in both postoperative and symptomatic patients. Technically adequate calf assessment can be achieved in the majority of patients if the calf examination is performed with the patient sitting.

Interobserver variability in the interpretation of contrast venography, technetium-99m red blood cell venography and impedance plethysmography for deep vein thrombosis.

Contrast venography (CV) is the standard technique for diagnosing deep vein thrombosis (DVT). Newer noninvasive tests have also proven efficacious. However, there is a lack of data on the level of agreement among observers in their interpretation of the results of the various tests. After agreeing on well-defined criteria, three experienced observers assessed, blindly, the results of tests performed over a 4-month period on 117 patients who were suspected clinically of having had a first episode of DVT. The kappa statistic was used to measure the level of agreement beyond chance for CV (69 patients), red blood cell venography (RBCV) (82 patients) and impedance plethysmography (76 patients). The results of CV were assigned to normal, abnormal or inadequate categories, and those of RBCV and IPG to normal, equivocal or abnormal categories. The kappa values for CV, RBCV and IPG ranged from 0.53 to 0.56, 0.42 to 0.56 and 0.90 to 0.91 respectively. Values greater than 0.75 represented excellent agreement beyond chance and those between 0.40 and 0.75 represented fair to good agreement. Excellent kappa values were obtained for IPG because interpretation of the results of this method is entirely objective. Although the values for CV and RBCV showed good to fair agreement, there was a greater degree of observer variation, despite the well-defined criteria, indicating the subjectivity of interpretation of these test results. It is concluded that the kappa statistic can be used to measure observer variation of the results of tests for diagnosing DVT and may serve as a quality control tool for studies in which more than one person interprets the results.

Hepatic malignancies: improved treatment with intraarterial Y-90.

An improved treatment method for hepatic malignancies with yttrium-90 incorporated into the matrix of glass microspheres was evaluated prospectively. Fifteen patients with 12 metastatic colorectal cancers, one carcinoid, one islet cell tumor, and one hepatoma were treated with three dose levels: 5,000 cGy (5,000 rad), ten patients; 7,500 cGy (7,500 rad), three patients; and 10,000 cGy (10,000 rad), two patients. Mean follow-up was 7 months (range, 2-12 months). Stable disease in the liver was seen in ten patients, four of whom had concurrent progression of extrahepatic disease, which resulted in two deaths. Two additional deaths were not directly related to the malignant process. Progression of liver disease was found in five patients, with three deaths occurring at 7-8 months. No procedural, hematologic, or pulmonary complications occurred. Late gastroduodenal ulceration occurred at 6-8 weeks in three patients who had histories of chronic alcohol abuse. This method of therapy seems to be feasible and efficient. Caution is necessary with high doses or with patients with a history of or predisposition to gastroduodenal ulcers.

Intravascular tumors: transvenous biopsy.

A technique is described for transfemoral biopsy of intravenous tumors. Positive results were obtained at biopsy in three patients who had an intraluminal mass in the inferior vena cava and in one patient with a mass in the iliac vein. Transvenous biopsy is helpful in obtaining a histologic diagnosis and provides an alternative method to surgery or percutaneous transabdominal needle biopsy.

Replaced or right accessory hepatic artery: can ultrasound replace angiography?

The accuracy of ultrasonography in detecting the right hepatic artery was prospectively assessed in 128 patients undergoing abdominal angiography. Twenty-five (19%) of the ultrasound studies were technically inadequate mainly because of gas superimposition. Of the remaining 103 cases, 14 had a replaced hepatic artery, which was diagnosed in 10 cases with ultrasound (sensitivity 71%). Eighty-nine did not have a replaced hepatic artery and the ultrasound assessment was falsely positive in four of them (specificity 96%). Two of the four false negative results could be explained by a stenosis of the superior mesenteric artery in front of the origin of the replaced hepatic artery. Two of the four false positive results could be explained by the presence of a stenosis of the celiac trunk with hypertrophy of the pancreaticoduodenal arteries, one of them being misdiagnosed as a replaced hepatic artery.

Chronic mesenteric vascular insufficiency with gastric ulceration.

Four middle-aged women presented with long histories of severe progressive weight loss and chronic abdominal pain. Endoscopically atypical gastric ulcers were identified in all; the ulcers were multiple and antral in location, with irregular shapes, sloping edges, and whitish sclerotic bases, and were surrounded by mottled and erythematous mucosa containing numerous superficial erosions. They did not heal with conservative therapy. All 4 patients were found to be suffering from chronic mesenteric vascular insufficiency. Balloon dilatation of the superior mesenteric artery in one and surgical revascularization in the others resulted in progressive clinical improvement and healing of the ulcers. The striking feature in these patients with mesenteric ischemia was the finding of gastric ulcers with a morphology different from the ordinary gastric ulcer, which healed only with revascularization. Future observation of similar lesions should suggest the possible diagnosis and expedite early treatment of mesenteric insufficiency in patients with this disorder.

Cholangiocarcinoma as a late complication of choledochoenteric anastomoses.

Two cases of cholangiocarcinoma developing several years after choledochoenteric anastomoses are reported. It is speculated that these may represent heretofore unrecognized late complications of this procedure. The intermittent chronic obstruction with bile stasis and recurrent inflammation may be causative factors in the development of cholangiocarcinoma after choledochoenterostomy.

Ambulatory hepatic artery infusion chemotherapy for cancer of the liver.

We have used continuous hepatic arterial infusion chemotherapy to treat 105 patients with cancer of the liver originating from colorectal, other gastrointestinal, and nongastrointestinal sites. The response rate seen in colorectal metastases was two to three times that expected for systemic chemotherapy. The median survival of responders of 16 months was significantly better then for nonresponders (6 months). The median duration of response was 9 months. The results for patients with other tumor types were less encouraging. Although minor problems developed in about 30 percent of the patients, major complications requiring removal of the catheter were not common. Expertise derived from managing many patients and a team approach, with a defined protocol for catheter care and follow-up, contributed to the success of the ambulatory program. However, the role of hepatic arterial infusion chemotherapy remains under debate. At the root of the controversy is the lack of randomized, controlled trials supporting the superiority of hepatic arterial infusion over systemic chemotherapy in the treatment of colorectal liver metastases. This and other issues, including the current liberal use of implanted infusion pumps, should be studied.

Percutaneous cecostomy for decompression of the massively distended cecum.

Massive dilatation of the cecum developed in an elderly man following admission for an acute episode of upper gastrointestinal hemorrhage complicated by myocardial infarction, ventricular fibrillation, and pulmonary edema. A diagnosis of pseudo-obstruction was made. After an unsuccessful attempt at colonoscopy, percutaneous cecostomy was performed under computed tomographic guidance, using trocar technique. The cecal distention resolved and did not recur. Percutaneous cecostomy is an alternative to colonoscopy and to surgical cecostomy in the treatment of massive cecal distention.

Effects of abdominal aneurysmectomy, aortoiliac bypass grafting and angioplasty on male sexual potency: a prospective study.

The preoperative frequency and postoperative status of male sexual potency was studied prospectively in 46 patients who underwent abdominal aortic aneurysmectomy, aortoiliac and aortofemoral bypass grafting, or percutaneous transluminal angioplasty of the iliac artery. The patients with aortic aneurysms were older; approximately half of them were potent. The frequency of impotence was highest in patients who underwent aortoiliac bypass, and correlated well with their low penile to brachial pressure index. Patients who had angioplasty had more localized lesions, a higher penile to brachial pressure index and the lowest rate of impotence. Postoperatively, 13% of the patients regained nocturnal erection and 10% became functionally potent (defined as the ability to achieve penetration). The improvements were similar in bypass and angioplasty patients. No patient experienced deterioration in sexual potency and all showed a markedly improved thigh to brachial pressure index postoperatively. Routine aortoiliofemoral artery angiograms were of limited value in predicting the status and outcome of sexual potency in this series of patients.

Local infusion of low-dose streptokinase for renal artery thromboembolism.

Although local low-dose therapy with streptokinase has been found to be effective in patients with recent arterial occlusions, there have been few reports of its use in those with renal artery occlusion, perhaps because this condition is difficult to diagnose early. This paper describes a patient with acute renal artery thromboembolism and intermittent tachyarrhythmias in whom treatment with a local low-dose infusion of streptokinase resulted in complete recanalization of the main artery and good recovery of renal function.

Percutaneous transluminal angioplasty of iliac arteries: the importance of functional studies.

Results of percutaneous transluminal angioplasty of 60 iliac arteries are presented, with a follow-up of 3 to 12 months. The patency rate at 1 year was 95% using the thigh-brachial index as the criterion and 86% with the ankle-brachial index. Study of the patients with an exercise test component improved the sensitivity of the evaluation, demonstrating that both indices tend to underestimate the functional improvement. The authors propose a simple, cost-effective way for practitioners to follow-up their patients after percutaneous transluminal angioplasty.

Giant hemangioma of the liver.

Six patients with hemangioma of the liver larger than 5 cm in diameter were treated at the Montreal General Hospital between 1968 and 1981. Two patients were symptomatic, complaining of nonspecific right upper quadrant pain. One man presented in a dramatic fashion when he bled from a ruptured hemangioma after a fall. Arteriography in three of the patients revealed characteristic filling of the vascular spaces commencing in the arterial phase with persistent dense accumulation in the venous phase. A timed, infusion computerized axial tomogram in one case revealed prolonged opacification, occurring from the periphery of the lesion towards the centre over several minutes. All six hemangiomas were benign; they consisted of large blood spaces separated by fine fibrous septae. They appeared to expand by incorporating marginal liver sinusoids. Organizing thrombus was often seen; this could account for the right upper quadrant pain. The patients were treated by partial or total hepatic lobectomy to relieve symptoms and prevent hemorrhage due to trauma. On two occasions, nodules of hemangioma were left behind but none of the six patients showed evidence of recurrence on follow-up.

Thoracopulmonary hypogenesis with systemic artery-pulmonary vessel fistulae: report of a case.

A patient seen with recurrent hemoptysis was found to have large systemic artery-pulmonary vessel fistulae. Associated anomalies were unique, and included hypogenetic left thorax, hypoplastic unilobar left lung, and dextrocardia. Left pneumonectomy was curative.

Experience with polytetrafluoroethylene grafts in patients on long-term hemodialysis.

Expanded polytetrafluoroethylene (PTFE) is a new material now being used to create subcutaneous arteriovenous anastomoses for vascular access in hemodialysis. The authors have been impressed with the versatility of grafts made from this material and, where failure occurs, the ease with which surgical revision can be carried out. Two cases are described to illustrate the adaptability of this material to reconstruction. The authors' initial impression based on 22 months' experience is that PTFE grafts have appreciably modified the management with respect to vascular access, of many patients on long-term hemodialysis.

Complications in expanded polytetrafluoroethylene arteriovenous grafts: an angiographic study.

Expanded polytetrafluoroethylene grafts were used for creation of arteriovenous shunts in 35 patients on chronic hemodialysis. When flow studies or mechanical factors indicated abnormal flow in the graft, angiography was performed. Detection of venous backflow or obstruction, arterial stenosis, aneurysm formation, or graft kinking facilitated correction and thus salvage of the grafts.