RESUMO
Vascular access is the primary lifeline for patients with end-stage renal disease. While arteriovenous fistulas and grafts are the conventionally favored methods for dialysis therapy, certain patients may deplete these traditional vascular access options due to various reasons. In the quest for alternatives, unconventional vascular pathways could be considered, including transhepatic, trans-lumbar and trans-renal approaches. We present a case of a 61-year-old male who exhausted all the traditional vascular access options, therefore trans-renal hemodialysis catheter placement was performed. Overall, this case highlights the challenges of securing a reliable vascular access to perform dialysis therapy and implementing unconventional methods whenever regular means are exhausted.
RESUMO
BACKGROUND: Emergency laparoscopic cholecystectomy has been advocated for the treatment of acute cholecystitis; however it can be a difficult task, especially in public hospitals, with relatively high conversion and complication rates. Percutaneous cholecystostomy is a simple and effective procedure allowing patients to recover from the acute event and undergo elective laparoscopic surgery at a later stage. METHODS: We prospectively assessed a protocol of initial conservative treatment in patients admitted with acute cholecystitis. Patients who did not respond to medical treatment were treated by percutaneous cholecystostomy. Following discharge the patients were seen in the outpatient clinic and elective laparoscopic cholecystectomy was considered and scheduled as necessary. The details of the operation were collected with emphasis on complications and conversion rate. RESULTS: During a 3-year period, 224 patients who were admitted with acute calculous cholecystitis entered the protocol. Fifty-four patients did not improve under medical treatment and percutaneous cholecystostomy was performed. In spite of adequate drainage, 5 patients still did not improve: 3 patients were successfully operated upon urgently and recovered, while 2 patients who had severe concomitant diseases and multi-organ failure, died. Forty-nine patients were discharged with the catheter and later re-evaluated for elective operation. In 7 patients common bile duct stones were found and were removed by ERCP prior to the elective operation. Twenty-five patients underwent delayed laparoscopic cholecystectomy with a low conversion rate (8%), and only minor complications (16%). CONCLUSIONS: Conservative treatment and delayed operation is still an acceptable choice in the treatment of acute cholecystitis. Percutaneous cholecystostomy is an effective tool, with high success rate and low morbidity, and allows for better pre-operative evaluation of the biliary system and safe interval laparoscopic surgery. Laparoscopic cholecystectomy after drainage of the gall bladder is a low morbidity procedure with relatively low conversion rate.
RESUMO
The aim of this paper is to report our experience with coil embolization for the treatment of vertebral artery transection in unstable trauma patients. The course of four patients admitted to our units between 1998 and 2003 with traumatic injuries of the upper thorax or neck is described. All had unstable hemodynamic parameters at presentation. Emergent arteriogram revealed vertebral artery transection, which was managed by immediate coil embolization proximal to the injury site. Initial technical success was achieved in all four patients, with hemodynamic improvement. No further treatment or surgery to control the vessel injury was needed. There were no immediate or late complications of the procedure and no neurological sequelae. Emergency coil embolization is an effective endovascular technique for use in unstable patients with angiography findings of a transected vertebral artery.
