Transhepatic PermCath for hemodialysis.

The establishment and maintenance of a reliable vascular access continues to be a problem in hemodialysis. We report a patient with end-stage lupus nephritis who had no alternative for vascular access and failed peritoneal dialysis. A vascular access device (PermCath, Quinton Instrument Co, Bothell, WA) was inserted using a transhepatic approach. There were no bleeding or thrombotic complications. The catheter was replaced once through the same track due to poor blood flow and reinserted once after 5 days due to infection. The patient has been doing well and receiving adequate dialytic therapy for over 1 year with this form of vascular access.

Transcatheter coil occlusion for treatment of left internal mammary-anterior descending artery steal phenomenon.

A 60-yr-old female with previous bypass surgery including LIMA-LAD graft presented with unstable angina due to steal phenomenon caused by a large pectoral branch of LIMA. Transcatheter coil occlusion of the pectoral branch was successfully performed. This procedure should be considered in similar cases.

Use of polyvinyl alcohol in treatment of bladder and prostatic hemangioma.

Hemangiomas of the bladder and prostate are rare. There have only been approximately 80 cases described in the literature, the majority of which were of bladder origin. Treatment has varied from partial cystectomy to use of the neodymium yttrium aluminum garnet (Nd-YAG) laser. Herein, we report a case of vesical neck and prostatic hemangiomas successfully treated with super-selective intra-arterial injections of polyvinyl alcohol.

Bilateral iliac vein filtration. An effective alternative to caval filtration in patients with megacava.

Greenfield filters were placed bilaterally in the iliac veins in five of 250 patients undergoing percutaneous filter placements. Four of the five patients had megacava (inferior vena cava diameter greater than 28 mm). In all patients, the filters were effective in preventing pulmonary embolism. Follow-up at 9 months in two patients revealed no changes of chronic venous insufficiency or venous stasis. Iliac filtration should be considered in patients in whom a caval filter cannot be placed because of large caval size or because it is technically difficult due to iliac vein tortuosity.

Eccentric nephroscopy for the incarcerated nephrostomy.

Following a percutaneous stone extraction and demonstration of antegrade flow, conventional methods of traction and coaxial dilatation failed to allow removal of a Stamey-Malecot nephrostomy. An eccentric track was created for nephroscopy. Grasping forceps were used to cut the fibrous tissue from the "wings" of the nephrostomy tube to allow its easy withdrawal. The combined approach by the radiologist and urologist safely overcame the fibrous entrapment.

Retroperitoneal feeding tube for peritoneal dialysis patients.

Treatment of the cachetic, hypoalbuminemic, peritoneal dialysis patient represents a vexing patient management problem. In the past, when the cause of inanition was intractable vomiting secondary to gastroparesis, the solution was to create a transperitoneal percutaneous enterogastrostomy. This endoscopic procedure bypassed the nonfunctioning stomach and allowed for adequate nutrition. When hypoalbuminemia is present, the patient is predisposed to the possible complications of peritoneal sepsis, dialysis fluid leak, and wound dehiscence. The authors report a unique, enteric feeding tube that is a solution to the problem of continuing adequate, complication-free dialysis in a cachetic, hypoalbuminemic peritoneal dialysis patient with no available site for either temporary or permanent hemodialysis vascular access. The procedure does not violate the peritoneal cavity and has proven to be effective, acceptable to the patient, apparently safe, and easy for both staff and patient use.

Portal hypertension: angiographic and hemodynamic evaluation.

There has been a correlation of three hemodynamic parameters with the etiology of portal hypertension and one of the major determinants of therapeutic success, namely, the direction of portal flow. The presence of a 4 mm Hg or greater gradient between the right atrium and the intrahepatic inferior vena cava associated with a "lumpy" pull-back tracing between the wedged and free positions has been associated with alcoholic liver disease. Such patients have antegrade portal flow when their AoD/HWP ratio is in the range of 2.6 to 2.0, and flow becomes stagnant or reversed below this range. Nonalcoholic liver disease is characterized by the absence of a gradient between the right atrium and the inferior vena cava and by a pull-back tracing that falls smoothly and rapidly to the free hepatic vein value. These patients have antegrade portal flow with an AoD/HWP ratio in the range of 1.7 to 1.5. The correct characterization of the cause for diffuse liver disease and direction of portal flow applies to the selection process for patients being considered for the selective distal splenorenal shunt as well as for the newer procedure of orthotopic liver transplantation. It is hoped that the wider application of these physiologic parameters, in the context of an increasing array of imaging tools for the portal system, including high-resolution ultrasound, computed tomography, and magnetic resonance imaging (MRI), will continue to offer all clinicians interested in the problem of portal hypertension a reliable guide to prognosis and the success of the particular treatment provided.

Transvenous catheter pulmonary embolectomy.

Acute cardiovascular collapse in the hospitalized patient is associated with a high mortality rate and remains a therapeutic dilemma. Survival could be improved in the subgroup of patients with massive pulmonary thromboembolism if prompt surgical intervention is undertaken. This report presents the cases of two patients with cardiovascular collapse who survived transvenous catheter pulmonary embolectomy (herein described in detail). This procedure can be performed in any hospital with angiographic facilities and personnel trained in the technique. In our opinion it is the procedure of choice in patients with refractory cardiovascular collapse from massive pulmonary thromboembolism.

Hemodynamic guidelines for surgical therapy of portal hypertension.

A prospective study of 98 patients with portal hypertension who hemorrhaged revealed that certain hemodynamic parameters were valuable in confirming the cause of cirrhosis, aiding in the selection of patients best suited for a selective distal splenorenal shunt, and in providing an estimate of prognosis. The presence of a pressure gradient of 4 mmHg or more between the right atrium and inferior vena cava was observed only in patients with alcoholic cirrhosis. The shape of the "pull-back" tracing between the wedge and free hepatic vein positions was "smooth" in postnecrotic disease and "lumpy" in alcoholic disease. The ratio of the aortic diastolic pressure divided by the hepatic (vein) wedge pressure segregated patients by cause and direction of portal blood flow.

Pseudoobstruction of the anterior tibial artery.

Lower extremity arteriography is customarily performed in the anteroposterior projection with the feet in forced plantar flexion. A case is reported showing "pseudoobstruction" of the anterior tibial artery at the ankle in this projection, which was not present with the foot in the neutral position for a lateral view. To confirm the positional nature of this phenomenon in younger patients, pulse tracings of five volunteers were obtained. These showed that pulsatile flow could be repeatedly abolished in the anterior tibial artery by plantar flexion of the foot. The anatomic causes for this phenomenon are discussed.

Current trends on diagnostic work up of pulmonary thromboembolism.

This report describes a six month prospective double blind study of 30 consecutive patients who were evaluated at Jackson Memorial Medical Center for pulmonary emboli. In this series, 77 per cent of the patients with lung scans interpreted as high probability for pulmonary emboli had angiographic confirmation of emboli. In 90 per cent of the patients with lung scans interpreted as low probability for pulmonary emboli, angiography confirmed the absence of pulmonary emboli. Five patients had radionuclide scans that were interpreted as nondiagnostic. Although pulmonary arteriography remains the gold standard for the diagnosis of pulmonary emboli we feel it should not be used in the low probability category because of the accuracy of the ventilation perfusion scans. It should be used in the indeterminant group and in the high probability category when anticoagulation therapy is contraindicated; prior to embolectomy or Mobin-Uddin umbrella insertion.