Transarterial embolization of gastrointestinal hemorrhages: retrospective study in Siriraj Hospital.

Objective: To determine the technical and clinical results of transarterial embolization of nonvariceal gastrointestinal hemorrhages (GIH) which cannot be managed endoscopically. Methods: A retrospective review of 21 embolizations in 77 patients who underwent arteriography for acute nonvariceal GIH was performed. Gastrointestinal hemorrhage was classified by the site of bleeding as upper, lower, or transpapillar including hemobilia and pancreatic duct bleeding. Clinical parameters and embolized data were assessed for clinical success. In-hospital mortality was also reported. Results: Technical success (bleeding target devascularization) was achieved in all 21 patients (100%). The complete technical success rate was 71.4% (15 out of 21 patients) while the partial technical success rate was 28.6% (6 out of 21 patients). The complication rate was very low (9.5%) including only 2 cases of bowel ischemia. No other complications were found. Eight out of 21 patients (38.1%) had rebleeding within 3 days. Upper GIH seemed to recur more frequently (4 out of 7 patients representing 57.1%) within the first 3 days than did lower (4 out of 11 patients at 36.4%) and transpapillar (0 of 3) GIH. Clinical success (no rebleeding after 30 days) was achieved in 11 of 21 patients (52.4%) including 3 out of 7 patients (42.9%) with UGIH, 7 of 11 patients (63.3%) with LGIH, and all patients with transpapillar hemorrhage. The overall mortality rate was 42.9% (9 out of 21 patients), with 42.9% (3 of 7 patients) for UGIH, 27.3% (3 of 11 patients) for LGIH and none for transpapillar hemorrhage. GIH was the cause of death in 6 of 9 patients (66.7%) while 3 out of 9 patients (33.3%) died from the other causes. Conclusion: Transarterial embolization is an effective treatment modality for lower GIH and transpapillar hemorrhage but less effective in upper GIH.

Comparison of color doppler ultrasound with digital subtraction angiography or magnetic resonance angiography in the diagnosis of transplant renal artery stenosis.

Objective: To compare the sensivity and specificity of color Doppler ultrasound (CDU) with digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) in the evaluation of transplant renal artery stenosis (TRAS). Methods: A retrospective study of 36 patients with suspected TRAS who underwent CDU at Siriraj Hospital between May 2001-December 2005 were investigated. Both intrarenal vessels and the transplant main renal artery examination were reviewed. TRAS was diagnosed if the peak systolic velocity (PSV) of the main renal artery is more than 150 cm/sec. The result of CDU was confirmed by DSA , MRA or clinical follow up. The Chi-square test was used to determine statistical analysis. Results: 37 studies of CDU examinations (46.8%) of 77 cases were encountered in this study. 21 studies (56.8%) had diagnosis of TRAS by CDU (PSV ≥ 150 cm/sec) with a sensitivity of 100% and specificity of 80% by comparison to the results of DSA or MRA. Of 17 studies with TRAS, 12 studies had a prolonged acceleration time (AT) and 15 studies had a normal resistive index (RI) in the intrarenal arteries. Almost all patients in this study had no renal to iliac velocity ratio (RIR) measurement, however, the remainder of 3 cases with measurement showed no increased RIR ratio. Conclusion: The criteria for detection of TRAS using the peak systolic velocity of the main renal artery more than 150 m/sec is sensitive and specific enough to be used as a screening test. Intrarenal vascular study using acceleration time can be used to confirm the diagnosis of severe TRAS but the resistive index is not helpful to evaluate TRAS.

Endovascular abdominal aortic aneurysm repair in high risk patients: outcomes of management.

BACKGROUND: The concomitant cardiopulmonary disease precluded the elective repair for abdominal aortic aneurysm (AAA) with acceptable risk. The endovascular abdominal aortic aneurysm repair (EVAR) has become an alternative method for the treatment of AAA with high-risk comorbidities. OBJECTIVE: Evaluate the results of EVAR in high-risk patients with large AAA. MATERIAL AND METHOD: A prospective study of high-risk patients with large AAA and suitable morphology who underwent EVAR between August 2003 and August 2005 was conducted. The long-term outcomes were observed up to December 2006. The comorbidities, size of aneurysm, types of procedures, operative time, amount of blood loss and transfusion, length of postoperative stay in intensive care unit and hospital, postoperative complications and mortality were analyzed. RESULTS: Eight patients (7 males and 1 female) with the mean age of 71.4 years (range 66-83 years) were included in the present study. The comorbidities were six of compromised cardiac status, one of severe pulmonary disease and one of morbid obesity. The average size of aneurysm was 6.2 +/- 0.64 centimetres. One patient also had large bilateral iliac artery aneurysms. Seven patients underwent EVAR with bifurcated aortic stent graft and one proceeded with aorto uni-iliac stent graft. Three patients underwent preoperative coil embolisation into internal iliac arteries when the distal landing zones at the external iliac arteries were considered. The mean estimated blood loss was 369cc and the mean blood transfusion was 0.88 units. There were no perioperative mortality, early graft occlusion, AAA rupture and open conversion in the present study. One patient had cardiac arrest due to upper airway obstruction but with successful treatment. Type II endoleak was observed in one patient and successfully treated by expectant management. One limb of bifurcated stent graft was occluded at the 5th month post EVAR and was successfully treated by artery bypass surgery at both groins. The 3-year primary graft limb patency was 87.5% (7/8). The survivals of patients at 1, 2 and 3 years were 100%, 100% and 87.5% respectively. The cause of death in one patient was not related to EVAR. CONCLUSION: EVAR may be a safe and effective alternative to open AAA repair especially in high-risk patients.

Effect of short-term folate and vitamin B supplementation on blood homocysteine level and carotid artery wall thickness in chronic hemodialysis patients.

OBJECTIVE: Hyperhomocysteinemia is an independent risk factor for atherosclerotic vascular disease in chronic hemodialysis patients. This stratified randomized controlled trial was designed to measure the effect of high dose oral vitamin B6, vitamin B12, and folic acid on homocysteine levels, and to evaluate the effect on atherosclerosis as measured by Intima-Media Thickness (IMT) of carotid arteries. MATERIAL AND METHOD: Fifty-four chronic hemodialysis patients with hyperhomocysteinemia were randomized to receive oral 15 mg folic acid, 50 mg vitamin B6, and 1 mg vitamin B12 daily (treatment group) or oral 5 mg folic acid alone (control group) for 6 months. Homocysteine level and IMT were measured in both groups. RESULTS: At 6 months, homocysteine levels in the treatment group were significantly reduced from 27.94 +/- 8.54 to 22.71 +/- 3.68 mmol/l (p = 0.009) and were not significantly increased from 26.81 +/- 7.10 to 30.82 +/- 8.76 mmol/l in control group (p = 0.08). Mean difference between both groups was statistically significant (p = 0.002). There was no significant difference of IMT of carotid arteries, however, a tendency that the treatment group would have less thickness was observed (0.69 +/- 0.29 mm and 0.62 +/- 0.16 mm, p = 0.99). CONCLUSION: Treatment of hyperhomocysteinemia in chronic hemodialysis patients with daily oral 15 mg folic acid, 50 mg vitamin B6, and 1 mg vitamin B12 for 6 months decreases homocysteine levels and tends to reduce IMT of carotid arteries. A long term study for the prevention of atherosclerosis is warranted.

Rapidly enlarging and asymptomatic abdominal aortic aneurysm in a male patient with chronic obstructive pulmonary disease: A case report of early experience of endovascular aortic aneurysm repair (EVAR).

Objective: to report a case of an incidental large asymptomatic AAA in an ex-smoker with severe COPD successfully treated by EVAR and to delineate the results and complications of EVAR performed in operative theater of Siriraj Hospital. Methods: A retrospective review of selected high-risk patients with asymptomatic AAA treated by EVAR in operative theater of our hospital from August 2003 to December 2005 was performed. Results: All nine cases (100%), including reported case (100%), were successfully treated by EVAR. Merely one of 30-day peri-operative death (11.1%), of post-operative cardiopulmonary arrest (11.1%), of early AAA rupture (11.1%), of early graft limb occlusion (11.1%), of late graft limb occlusion (11.1%), and of early type II endoleak (11.1%) took place in this study. Neither late AAA rupture, AAA sac enlargement, nor graft migration happened. Conclusion: EVAR was achieved as a minimal invasive treatment of an incidental large asymptomatic AAA in an ex-smoker with severe COPD. Although EVAR provides an excellent alternative of AAA in high-risk patients, its high peri-operative mortality rate around 10 % should be taken into account.

Relationship between hyperhomocysteinemia and atherosclerosis in chronic hemodialysis patients.

BACKGROUND: Hyperhomocysteinemia is an independent risk factor of coronary artery heart disease (CAHD) and atherosclerosis in a normal population. However, it is still controversial in end-stage kidney disease patients who underwent long-term dialysis. Carotid intima-media thickness (IMT) is the standard non-invasive measurement of atherosclerosis. The aims of the present study were to determine the homocysteine (Hcy) level, and to evaluate its role as a risk factor of atherosclerosis in hemodialysis (HD) patients. MATERIAL AND METHOD: Clinical data and blood chemistries were assayed in 62 HD patients. Atherosclerosis was defined by clinical presentations of CAHD, cerebrovascular or peripheral vascular diseases, or carotid plaque by ultrasound. IMT was also measured by ultrasound RESULTS: Plasma Hcy level in HD patients was significantly higher in HD patients than normal controls (28.3 +/- 8.3 vs 9.7 +/- 2.9 micromol/l, p < 0.001). Older age (p < 0.001), male sex (p = 0.05), longer duration of HD (p = 0.05), and higher plasma Hcy level (p = 0.01) correlated with atherosclerosis by univariate analysis, but plasma Hcy did not show significant correlation by multivariable analysis. There was also correlation between IMT and atherosclerosis in HD patients (p < 0.001) but no correlation was observed between plasma Hcy level and lMT. CONCLUSION: Hyperhomocysteinemia is not an independent factor in the genesis of atherosclerosis in HD patients. Advanced age plays a major role of hyperhomocysteinemia and IMT is a useful marker of atherosclerosis in these patients.

Novel aspects in the management of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is one of the commonest cancers in Thailand, which usually develops on a background of cirrhosis. We report a multimodal approach to the management of HCC. Though surgical treatment is the only opportunity for curing HCC, it is only feasible in a minority of patients. Various non-surgical treatment modalities have been developed and used extensively, but their efficacy is far from satisfactory and the prospect for the development of more effective treatments is dismal. Multidisciplinary treatment such as the combination of transcatheter oily chemoembolization and percutaneous ethanol injection appears to be the current trend of management for nonresectable HCC, and improvement in survival can be achieved compared to single mode treatment. Portal vein embolization is useful in patient in need of wide hepatectomy to induce pre-operative hypertrophy of future remnant liver, which would have been insufficient for safe resection. Moreover, intra-arterial 131-Iodine-Lipiodol given after curative resection significantly decreased the rate of recurrence and increased disease-free and overall survival in patients with HCC.

Management of high-flow priapism: A case report and review.

A case of high-flow priapism was presented. Diagnosis was based on the history of painless and persistent erection for 20 days. Cavernous blood gas showed arterial type. The arteriocavernous fistula was detected by either a perineal duplex Doppler ultrasonography or an internal pudendal arteriography. The treatment of choice was selective embolization with a good result and no immediate complication. Detumescence was noticed within 10 days. Follow up of perineal and penile duplex Doppler ultrasonographies showed no turbulent flow and low inflow of cavernous blood. Erectile function partially recovered at 2 months after the treatment.

Iliopsoas abscess detectedy ultrasonography and CT; a report of two cases.

Nowadays the cause of iliopsoas abscess has changed from tuberculous to non-tuberculous infection. The disease may be classified by primary source of infection. The source of primary iliopsoas abscess is uncertain. Secondary iliopsoas abscess occurs either by direct extension from the inflammatory process in the adjacent structures of from hematogenous spreading. Two cases of iliopsoas abscess were reported; one was primary and the other was secondary infection. The diagnosis depended upon ultrasonography, computed tomography and correlation with clinical context. The final results of the two patients were satisfactory.

Superior mesenteric artery aneurysm: A report of two cases.

Two cases of superior mesenteric artery (SMA) aneurysm were reported; one with atherosclerosis and the other was mycotic in origin. Preoperative investigations included plain radiography, ultrasonography, computed tomography with contrast injection, angiography and nuclearscanning. SMA aneurysm was then diagnosed and the patient underwent operation. Results of the operations were satisfactory. It is suggested that early and correct diagnosis is critical in minimizing morbidity and mortality in the patients with SMA aneurysm.