Outcomes following extracranial carotid artery stenting in high-risk patients.

BACKGROUND: Carotid artery angioplasty and stenting has become a viable alternative to carotid endarterectomy (CEA), especially for patients considered at high risk for post-operative complications. This study investigated the feasibility, safety and long-term outcome of carotid artery stenting (CAS) in high-risk patients. METHODS: From July 1995 to November 2000, sixty-two consecutive patients considered to be at high risk for post-operative complications of CEA were followed prospectively after undergoing extracranial CAS procedures. RESULTS: Sixty-two patients [37 men (60%) and 25 women (40%)] underwent a total of 69 CAS procedures. The mean age was 67 +/- 9 years (range, 32-89 years). Comorbid conditions included hypertension in 95% and severe coronary artery disease in 58%. Sixteen patients (26%) had a previous ipsilateral CEA, twenty-one percent had a history of neck radiation and 32% had a history of significant contralateral carotid artery disease. Fifty-two patients (84%) were symptomatic. All 69 CAS procedures were technically successful. The major post-operative complications were two minor strokes (2.8%), one major stroke (1.4%) and one fatal major stroke (1.4%). The mean length of follow-up was 17 months (range, 4 months to 5.6 years). Two patients (2.8%) have suffered ipsilateral neurologic events following CAS. Long-term follow-up revealed restenosis at 6 months in 4 patients (5.7%). CONCLUSIONS: Carotid artery angioplasty and stenting is safe and feasible. This procedure produces satisfactory outcomes in patients who are at high risk for post-operative complications of CEA.

Patency and life-spans of failing hemodialysis grafts in patients undergoing repeated percutaneous de-clotting.

We set out to determine retrospectively the primary and secondary patency rates, as well as the life-spans, of failing polytetrafluoroethylene dialysis grafts after repeated percutaneous mechanical de-clotting. The study group consisted of all patients who had undergone percutaneous mechanical de-clotting, balloon angioplasty, or angiography of theirpolytetrafluoroethylene hemodialysis grafts at our institution from 1 January through 30 April 1999. Patency of the hemodialysis grafts was calculated using Kaplan-Meier analysis. A total of 161 percutaneous de-clotting procedures were performed on 59 of 71 patients. At 1 year, the primary and secondary surgical patency rates of the grafts were 29% and 61.4%, respectively The life-spans of the polytetrafluoroethylene grafts after repeated percutaneous de-clotting and surgical interventions was 93.5% at 6 months, 78% at 1 year, 58.8% at 2 years, and 35% at 3 years. The patency rates after the 1st, 2nd, and 3rd de-clotting procedures were 55.9%, 61.9%, and 55.8% at 3 months and 32.2%, 40.8%, and 31.4% at 6 months, respectively (P=0.40). The patency rate of grafts after mechanical de-clotting using the Arrow-Trerotola thrombectomy device was not statistically different from that of the crossed angioplasty balloon technique alone (P=0.38). Further, there was no difference in the life-spans of grafts whether they were located in the upper or lower extremity Because reocclusion rates are similar following 1st, 2nd, and 3rd occlusions, regardless of the percutaneous mechanical de-clotting technique used, repeated percutaneous management should be undertaken to preserve each graft regardless of the number of previous de-clotting procedures.

Carotid stenting for post-endarterectomy restenosis and radiation-induced occlusive disease.

Surgical treatment of carotid restenosis and radiation-induced occlusive disease is challenging because of the high morbidity and mortality associated with this procedure. Carotid stenting has been proposed as an alternative approach. We report a series of 8 patients who were treated via the percutaneous approach for either carotid restenosis (n = 4) or radiation-induced occlusive disease (n = 4). Technical success was achieved in all of the cases. There have been no deaths or strokes during the periprocedural or follow-up period. After dilation of the extracranial vessel, 1 patient experienced severe intracranial internal carotid arterial spasm that required stent placement. Wallstents were used in 6 patients and S.M.A.R.T. stents were used in the remaining 2. Restenosis occurred in 2 patients and was treated successfully with redilation or restenting. Carotid stenting appears to be a feasible and safe alternative to surgery for restenosis after carotid endarterectomy and for radiation-induced occlusive disease.

Venous leaks: anatomical and physiological observations.

A total of 50 patients with impotence underwent cavernosometry and cavernosography with intracavernous injection of vasoactive drugs. Several hemodynamic parameters were analyzed, including the pressure response curve after injection of vasoactive drugs and infusion of saline, the volume required to achieve erection, venous outflow resistance, erection maintenance infusion rate, rate of pressure decrease after discontinuation of infusion and post-infusion steady state pressure. On the basis of cavernosometric findings, venous leakage was ruled out in 4 patients. In the remaining 46 patients leak sites visualized during cavernosography included superficial dorsal vein in 1 (2.2%), deep dorsal vein in all 46 (100%), cavernous veins in 32 (69.6%), glans in 19 (41.3%) and corpus spongiosum in 14 (30.4%). Aberrant veins were documented in 7 patients (15.2%) communicating with the saphenous vein in 4 (8.9%), scrotal veins in 2 (4.4%) and femoral veins in 1 (2.2%). Eight patients (17.4%) had leakage through the deep dorsal vein as the only venous site, 17 (36.9%) had leakage through 2 venous sites, 14 (30.4%) had leakage through 3 venous sites and 7 (15.2%) had leakage through 4 venous sites. Correlations among hemodynamic and radiographic observations allowed the identification of 4 different types of cavernosometric findings. While type I represented normal penile vascular findings, types III and IV represented venous leakage. Type II could represent no leak, a mild leak or an undetected arterial problem. Accuracy of interpretation of a study may be improved by taking more than 1 parameter into consideration, including erection maintenance infusion rate, intracavernous pressure decrease within the first 5 seconds after discontinuation of infusion and the final steady state intracavernous pressure. The majority of patients have more than 1 leak site (82.6%). The most commonly combined sites of leakage are the deep dorsal and cavernous veins.

Percutaneous cholecystolithotomy. A minimally invasive alternative to cholecystectomy and to shock wave lithotripsy.

Recently introduced treatment alternatives for gallstones include peroral pharmacological chemolysis plus shock wave lithotripsy and percutaneous cholecystolithotomy. Herein we report on the treatment preferences of 23 patients with symptomatic gallstones and our initial experience with percutaneous cholecystolithotomy in 6 of these patients. All patients were rendered stone free after one procedure. Percutaneous cholecystolithotomy, which is applicable to all types of gallstones, is a safe, practical, low-morbidity alternative to cholecystectomy in selected patients.

Endourological reconstruction of posterior urethral disruption.

While conventional methods of urethroplasty for posterior urethral disruption usually are successful technically, they may be associated with complications and often require the expertise of a specialist. Therefore, the option of an endourological approach to the treatment of the obliterated posterior urethra would be highly desirable if a comparable surgical outcome could be achieved. We describe a closed controlled method of posterior urethral reconstruction following traumatic avulsion of the posterior urethra. Urethral continuity was re-established by endoscopic identification of the true prostatic outlet, its fixation with an angiography wire and a Goodwin sound, retrograde visual urethrotomy through the fibrotic segment and balloon dilation of the entire posterior channel. Postoperative anatomical and functional results were excellent, and were achieved with much less risk and cost to the patient than those of a perineal or transpubic urethroplasty.

Gallbladder enhancement following angiography: a normal CT finding.

The authors reviewed computed tomography (CT) studies that had been preceded within 2 days by angiography. Twenty-one patients were selected who showed no laboratory evidence of liver or renal disease. Eighteen patients received greater than 37 g of iodine at angiography. Eight of these underwent CT within 2 h of angiography and showed enhancement of the gallbladder wall, nine underwent CT 15 to 48 h after angiography and showed enhancement of the gallbladder contents, and one had no gallbladder enhancement. Three patients received less than 22 g of iodine at angiography and none had gallbladder enhancement on CT. The necessity of differentiating normal gallbladder enhancement from pathology on CT is stressed. In addition, the physiologic mechanisms responsible for gallbladder enhancement are presented, and the relationship of our findings to the total body opacification effect and to infusion tomography of the gallbladder is discussed.

Evaluation of a sequence of diagnostic tests using the workup of ureteral stone as a model.

Additional tests are not always beneficial and can increase costs significantly while increasing the group of patients with an equivocal diagnosis. In general, diagnostic testing should cease for a group of patients when the tests that have been performed result in a sufficiently high level of diagnostic certainty and also result in the largest group of true positive or true negative diagnoses. Evaluation of diagnostic tests must include consideration of the results of sequences of tests, equivocal results of tests, and the effect of added costs on both advantageous sequences of tests and total expenditures. Evaluation of the diagnostic tests performed for ureteral stone in the emergency ward demonstrates that a significant group of patients, on whom an intravenous urogram could be avoided can be selected. As an alternative to the IVU in this selected group, hydration and diuresis could be considered. The IVU could be reserved for those patients who did not experience classic relief of pain and passage of stone.

Multiseptate gallbladder.

A case of multiseptate gallbladder and nine previously reported, well documented cases are reviewed. Our patient, like most of those previously reported, had biliary symptoms, which were relieved by cholecystectomy.

Posterior urethral injuries after pelvic fracture.

Rupture of the posterior urethra is an uncommon but serious complication of anterior pelvic arch fracture. It is commonly believed that such injuries occur at the apex of the prostate and on urethrography result in extravasation of contrast material above the urogenital diaphragm. In 1977, Colapinto and McCallum proposed a different classification of such injuries. This paper presents experience in 18 proven cases of posterior urethral injury using this new classification. All patients were studied with retrograde urethrography before any attempt at urethral catheterization. The data support the contention that the traditional concept of posterior urethral injury is, in fact, unusual. Of 18 patients, 12 had complete or partial urethral injuries extending both above and below the urogenital diaphragm as demonstrated by urethrography. Only three of 18 patients had the classical injury, that is, extravasation into pelvic fascial planes limited inferiorly by an intact urogenital diaphragm.

Computed tomographic evaluation of blunt renal injuries.

Adequate radiologic demonstration of the extent of renal injury following blunt abdominal trauma is an important guide to therapy. Traditionally, the evaluation has been based on urographic and/or angiographic studies. This report details the results of computed tomographic (CT) evaluation of suspected renal injuries in ten patients. Renal injuries were demonstrated by CT in nine of these patients. Abnormalities demonstrated were subcapsular/perinephric hematomas, intrarenal hematomas, renal lacerations, segmental infarcts, and contrast material extravasation. This study suggests that CT is valuable in providing further definition of urographic abnormalities and in avoiding the necessity for angiography in otherwise stable patients.

Computed tomography of chest trauma.

Computed tomography (CT) and radiography were used to study 20 patients with chest injuries. Excluding rib fractures, CT revealed 50 traumatic lesions ranging from extrapleural hematomas to pericardial fluid collections. In contrast, only 12 lesions were detected on the corresponding radiographs. While many of the processes demonstrated on CT were not life-threatening, substantial abnormalities such as pericardial effusion and diaphragmatic rupture were detected.

Computed tomography of the nonvisualizing gallbladder.

A prospective computed tomography (CT) study of a group of patients suspected of having gallbladder disease was performed. Ten patients were evaluated who had gallbladder nonvisualization on two consecutive oral contrast medium administrations. Evaluation of the gallbladder and common bile duct by CT disclosed specific abnormalities including gallstones, unsuspected common bile duct obstruction, and acute and chronic cholecystitis. Additional information on the physiologic processes involved in gallbladder nonvisualization is offered.

Unusual inflammatory processes involving the colon.

Six patients with unusual inflammatory lesions of the colon are presented. Several of these cases demonstrated unusual presentations of an unusual disease. The clinical and radiologic features (which together are of paramount importance in suggesting the correct diagnosis) are discussed. Important differential diagnostic considerations are listed.

Radiology of the bladder and urethra in blunt pelvic trauma.

Appropriate radiologic studies are mandatory for assessing the extent and nature of lower urinary tract injuries following blunt pelvic trauma. A flow sheet summarizing these radiographic studies is presented in Figure 24. With pelvic fracture, two injuries may be found--extraperitoneal rupture of the bladder and rupture of the posterior urethra. In some patients, these injuries may be combined. Intraperitoneal rupture of the bladder occurs as a result of a blow to the lower abdomen or pelvis in patients whose urinary bladder is distended at the time of injury. A pelvic fracture may or may not be present. Anterior urethral injuries are more commonly associated with instrumentation in the male patient; they may, however, occur as a result of blunt injury to the external genitalia or perineum.