Fluoroscopy-Guided Percutaneous Gallstone Removal Using a 12-Fr Sheath in High-Risk Surgical Patients with Acute Cholecystitis

OBJECTIVE: To evaluate the technical feasibility and clinical efficacy of percutaneous transhepatic cholecystolithotomy under fluoroscopic guidance in high-risk surgical patients with acute cholecystitis. MATERIALS AND METHODS: Sixty-three consecutive patients of high surgical risk with acute calculous cholecystitis underwent percutaneous transhepatic gallstone removal under conscious sedation. The stones were extracted through the 12-Fr sheath using a Wittich nitinol stone basket under fluoroscopic guidance on three days after performing a percutaneous cholecystostomy. Large or hard stones were fragmented using either the snare guide wire technique or the metallic cannula technique. RESULTS: Gallstones were successfully removed from 59 of the 63 patients (94%). Reasons for stone removal failure included the inability to grasp a large stone in two patients, and the loss of tract during the procedure in two patients with a contracted gallbladder. The mean hospitalization duration was 7.3 days for acute cholecystitis patients and 9.4 days for gallbladder empyema patients. Bile peritonitis requiring percutaneous drainage developed in two patients. No symptomatic recurrence occurred during follow-up (mean, 608.3 days). CONCLUSION: Fluoroscopy-guided percutaneous gallstone removal using a 12-Fr sheath is technically feasible and clinically effective in high-risk surgical patients with acute cholecystitis.

Therapeutic Embolization for Pseudoaneurysm of the Anterior Tibial Artery after Tibial Nailing / 대한정형외과학회잡지

Closed intramedullary nailing is a favorite surgical technique for tibial shaft fracture. After closed interlocking intramedullary nailing, proximal and distal locking screws are inserted for increasing rotational force and axial stability. Vascular complications associated with tibial nailing for fractures are very rare. Here, we described a case of a pseudoaneurysm of the anterior tibial artery after tibial nailing. We opted for minimally invasive treatment consisiting of thrombin injection and vascular plug insertion. Because pseudoaneurysm of the anterior tibial artery can induce severe complications, one should, when performing closed intramedullary nailing, make a quick diagnosis and start treatment right away.

Hybrid Endovascular Repair of Thoracoabdominal Aortic Aneurysm Using Visceral Debranching Technique: 2 case reports / 대한흉부외과학회지

Surgical repair of thoracoabdominal aortic aneurysm (TAAA) remains a formidable challenge associated with significant rates of mortality and morbidity, especially in patients with high risk. Use of endovascular stent graft in aortic aneurysm disease is now accepted as an alternative treatment to surgery. But the saving of visceral arteries is the chief obstacle to endovascular repair of TAAA. We successfully treated two patients of TAAA with high risk by hybrid procedure including open visceral debranching and concomitant endovascular aneurysm exclusion.

A Case of Obstructive Jaundice Secondary to Traumatic Pancreatitis Treated with Percutaneous Transhepatic Biliary Drainage / 대한소아소화기영양학회지

Isolated pancreatic trauma and secondary obstructive jaundice in the pediatric population is unusual. Biliary tract obstruction can be a major cause of acute pancreatitis. We report a case of obstructive jaundice secondary to isolated traumatic acute pancreatitis in a previously healthy 32-month-old girl. In our case, secondary obstructive jaundice aggravated the pancreatic inflammation and was successfully treated with percutaneous transhepatic biliary drainage (PTBD).

A Case of Obstructive Jaundice Secondary to Traumatic Pancreatitis Treated with Percutaneous Transhepatic Biliary Drainage / 대한소아소화기영양학회지

Isolated pancreatic trauma and secondary obstructive jaundice in the pediatric population is unusual. Biliary tract obstruction can be a major cause of acute pancreatitis. We report a case of obstructive jaundice secondary to isolated traumatic acute pancreatitis in a previously healthy 32-month-old girl. In our case, secondary obstructive jaundice aggravated the pancreatic inflammation and was successfully treated with percutaneous transhepatic biliary drainage (PTBD).

MR Findings of Flexor Hallucis Longus Dysfunction

PURPOSE: To find the MR findings and evaluate the usefulness of MR in flexor hallucis longus(FHL) dysfunction. MATERIALS AND METHODS: From 1992 to 2003, fourty patients were found to have surgically confirmed FHL dysfunction. 24 cases of 22 patients who had performed MR were included in this study. We analyzed the signal intensity of FHL tendon and muscle, tendon sheath, sheath effusion, and bone lesions, retrospectively. RESULTS: Non-specific, increased sheath effusion of FHL tendon was seen in 12 cases (50%). Large amount of sheath effusion(grade 3) was observed in 5 cases (21%). The signal intensity of FHL tendon was normal in all cases. High signal intensity at the FHL muscle, proximal to musculotendinous junction was seen in 1 case (4%). One case (4%) of marrow edema of the talus and another one case (4%) of osteochondritis dissecans of the talus was seen. CONCLUSION: Non-specific, increased sheath effusion of FHL tendon was observed on MR in FHL dysfunction patients. Therfore, MR has a limited role in diagnosis of FHL dysfunction and is useful to exclude other bone and tendon diseases causing medial ankle pain.

Diffusion-weighted MR Imaging of Hypoxic-Ischemic Encephalopathy

PURPOSE: The purpose of this study was to determine the characteristics of hypoxic-ischemic encephalopathy (HIE) on diffusion-weighted imaging (DWI) and the role of DWI for the diagnosis of HIE. MATERIALS AND METHODS: Six patients with HIE underwent MRI including DWI. MR examinations were performed within 4 - 32 days (mean, 11.8 days) after hypoxic brain insult. We assessed the distribution of the lesions and compared the DWI and T2, FLAIR images for the subjective conspicuity of the lesions. RESULTS: In all patients, symmetrical hyperintense lesions were demonstrated in the bilateral basal ganglia on T2, FLAIR, and DWI. On ADC map image, the lesions were hypointense in four of six patients and isointense in other two patients. Lesion conspicuity on DWI was higher than on T2 and FLAIR images in four of six patients and similar in other two patients. For the involvement of the cortex and subcortical white matter, in five of six patients, bilateral symmetric hyperintense lesions were seen on T2, FLAIR, and DWI. Lesion conspicuity on DWI was higher than on T2 and FLAIR images in three of them and similar in other two patients. On ADC map image, the lesions showed hypointensity in three of five patients and isointensity in other two patients. For the involvement of the deep cerebral white matter, T2, FLAIR, and DWI showed bilateral symmetric hyperintense lesions in four of six patients. Among them, Lesion conspicuity on DWI was higher than on T2 and FLAIR images in only one patient. CONCLUSION: HIE is characterized by symmetrical hyperintense lesions in the bilateral basal ganglia, cerebral cortex, and white matter on DWI and the lesions are more conspicuously demonstrated on DWI than on T2 and FLAIR images.

Parallel Wire Balloon Angioplsty for Undilatable Venous Stenosis in Hemodialysis Fistula

PURPOSE: The purpose of this study was to assess the value of the parallel wire balloon angioplasty technique for treating dysfunctional hemdialysis fistula with rigid stenosis, and this type of lesion was resistant to conventional angioplasty. MATERIALS AND METHODS: Between March 2002 and August 2003, we included 6 patients (mean age: 59, males: 2, females: 4) who were treated via parallel the wire balloon angioplasty technique and their hemodialysis fistula has stenoses that were resistant to conventional angioplasty. We performed conventional angioplasty in all patients, but we failed to achieve sufficient dilatation. In the cases of highly resistant stenosis, an additional 0.016 inch wire was inserted into the 7 F vascular sheath. During angioplasty, a 0.016 inch guide wire was inserted between the balloon and the stenosis and then it was pushed to and fro until the balloon indentation disappeared. After the procedure, we performed angiography to identify the residual stenosis and the procedure-related complications. RESULTS: The undilatable stenoses in 5 patients were successfully resolved without complications via the parallel wire angioplasty technique. In one patient, indentation of balloon was not resolved, but the residual stenosis was both minimal and hemodynamically insignificant. CONCLUSION: The parallel wire angioplasty technique seems to be a feasible and cost-effective method for treating a dysfunctional hemodialysis fistula with undilatable and rigid stenosis.

Utility of Vascular Enhancement Technique (ClarifyTM) in Ultrasonographic Evaluation of Abdominal Vessels

PURPOSE: Vascular enhancement (VE) technology(ClarifyTM) is a new technique in vascular, B-mode imaging. The purpose of this study was to evaluate the value of VE technology in ultrasonographic diagnosis of abdominal vasculature. MATERIALS and METHODS: Seventy-one adult patients (39 men and 32 women; age range, 25-89 years; mean age, 56 years) who had undergone abdominal ultrasonography were included in this study. The imaging was performed with a 1.8-4.0 MHz convex array transducer (SONOLINE, Antares, Siemens Medical Solutions, WA) by an abdominal radiologist. The radiologist obtained images of the same vascular area with each of conventional ultrasonography imaging (CUS), tissue harmonic imaging (THI), CUS plus VE technique and THI plus VE technique. Images were divided into normal (56) and abnormal (15) groups. The vessel visibility, conspicuity of the vascular wall and contrast resolution with adjacent structures were evaluated in the normal group, and the lesion conspicuity and border sharpness were evaluated in the abnormal group. On the PACS monitor, the images were graded into four grades by two radiologists in consensus. Statistical analysis was performed using Wilcoxon signed rank test. RESULTS: In the normal group, all parameters of the ultrasonographic imaging which applied the VE technique were superior to those of the imaging without VE technique (p < 0.05). In the abnormal group, combined use of VE technique with CUS or THI provided better results than CUS or THI alone in terms of lesion conspicuity and border sharpness (p < 0.05). THI combined with VE technique provided the best image quality among the 4 ultrasonographic methods examined in this study for the evaluation of both normal and abnormal abdominal vessels (p < 0.05). CONCLUSION: VE technology was a helpful technique to evaluate the abdominal vasculature. Furthermore, VE technique combined with THI provided better image quality than other ultrasonographic methods in the evaluation of abdominal vessels.

Congenital Hepatoportal Arteriovenous Fistula associated with Intrahepatic Portal Vein Aneurysm and Portohepatic Venous Shunt: Case Report

A congenital hepatoportal arteriovenous fistula associated with an intrahepatic portal vein aneurysm is a rare type of arteriovenous malformation. Only 14 pediatric cases have been reported to the best of the authors' knowledge. An intrahepatic shunt between the portal and systemic veins is also relatively rare. We report a case of a congenital hepatoportal arteriovenous fistula associated with an intrahepatic portal vein aneurysm and a portohepatic venous shunt in a neonate who presented with tachypnea and melena.

Three Dimensional Volume Rendering Virtual Endoscopy of the Ossicles Using a Multi-Row Detector CT: Applications and Limitations

PURPOSE: This study was conducted to know the applications and limitations of three dimensional volume rendering virtual endoscopy of the ossicles using a multi-row detector CT. MATERIALS AND METHODS: This study examined 25 patients who underwent temporal bone CT using a 16-row detector CT as a result of hearing problems or trauma. The axial CT scan of the temporal bone was performed with a 0.6 mm collimation, and a reconstruction was carried out with a U70u Sharp of kernel value, a 1 mm thickness and 0.5-1.0 mm increments. After observing the ossicles in the axial and coronal images, virtual endoscopy was performed using a three dimensional volume rendering technique with a threshold value of -500 HU. The intra-operative otoendoscopy was performed in 12 ears, and was compared with the virtual endoscopy findings. RESULTS: Virtual endoscopy of the 29 ears without hearing problems demonstrated hypoplastic or an incomplete depiction of the stapes superstructures in 25 ears and a normal depiction in 4 ears. Virtual endoscopy of 21 ears with hearing problems demonstrated no ossicles in 1 ear, no malleus in 3 ears, a malleoincudal subluxation in 6 ears, a dysplastic incus in 5 ears, an incudostapedial subluxation in 9 ears, dysplastic stapes in 2 ears, a hypoplastic or incomplete depiction of the stapes in 16 ears and no stapes in 1 ear. In contrast to the intra-operative otoendoscopy, 8 out of 12 ears showed a hypoplastic or deformed stapes in the virtual endoscopy. CONCLUSION: Volume rendering virtual endoscopy using a multi-row detector CT is an excellent method for evaluation the ossicles in three dimension, even though the partial volume effect for the stapes superstructures needs to be considered.

Transarterial Embolization of Acute Intercostal Artery Bleeding

PURPOSE: To report our experiences of transarterial embolization for acute intercostal artery bleeding. MATERIALS AND METHODS: A retrospectively analysis of the causes, clinical manifestations, angiographic findings and transarterial embolization technique in 8 patients with acute intercostal artery bleeding, with a review of the anatomical basis. RESULTS:The causes of intercostal artery bleeding were iatrogenic and traumatic in 88 and 12% of cases, respectively. Active bleeding from the collateral intercostal or posterior intercostal arteries was angiographically demonstrated in 75 and 25% of cases, respectively. Transarterial embolization successfully achieved hemostasis in all cases. However, two patient with hypovolemic shock expired due to a massive hemothorax, despite successful transarterial embolization. CONCLUSION: Intercostal access should be performed through the middle of the intercostal space to avoid injury to the collateral intercostal artery. Transarterial embolization is an effective method for the control of intercostal artery bleeding.

Intrahepatic Transneedle Inoculation of VX2 Particles for Obtaining a Solitary Hepatic Tumor in an Animal Model

PURPOSE: The purpose of this study was to develop a large animal (rabbit) model which has a proper solitary intrahepatic tumor with lower leakage rates through less traumatic methods. Consequently, we evaluated tumor progression following the intrahepatic inoculation of VX2 cells into New Zealand white rabbits to acquire baseline data on the progression of a VX2 tumor. MATERIALS AND METHODS: Twenty New Zealand white rabbits, each weighting 2.5-3 kg, were selected for this study. A 1 mm3 VX2 tumor fragment was created and then minced to enable the particles to pass through a 21 G needle mounting in a tuberculin syringe with 0.1 ml of normal saline. The minced VX2 tumor particles were injected into the subcapsular parenchyma of the left hepatic lobe. A 21 G needle was used to avoid penetrating large hepatic vessels. In order to prevent hemorrhage or leakage of the VX2 tumor cells through the injection route, a purse-string suture around the puncture site was made using black silk 4-0. The tumor particles were then injected through the center of the suture. While removing the needle, the suture was tightened to prevent hemorrhage or leakage of the VX2 tumor cells through the injection route. Finally, the injection site was covered with a Surgicel(R) patch. The inoculated intrahepatic VX2 tumors were then imaged with a 16 channel multidetector CT every week for the duration of the study. The CT images covered from the lung apex to the pelvic floor. Two radiologists evaluated the size, location, and peritoneal seeding of the tumors as well as metastasis of other organs. Three rabbits were sacrificed at random beginning in the second week, and this process continued on a weekly basis for the duration of the study. The CT images and pathologic findings for the sacrificed rabbits were correlated. RESULTS: The inoculated intrahepatic VX2 tumors were not visible in the first week. By the second week 66.7% were visible on CT images and by the third week all tumors were visible. Of the twenty rabbits, three (15%) had tumor growth both in the liver and the peritoneal cavity, suggesting tumor leakage from the injection site into the peritoneal cavity. The remaining rabbits (n=17) had successful inoculation in the liver parenchyma as a solitary mass. Three of twenty rabbits (15%) showed tumor regression after successful inoculation. Tumor metastasis in extratumoral regions, including the liver and peritoneal seeding, increased beginning in the fourth week and more than 12x103 mm3 in volume after the initial inoculation of the VX2 tumors. CONCLUSION: This new technique using innoculated intrahepatic VX2 tumor particles seems to be a simple and effective method for obtaining a solitary hepatic tumor in animal models. Results of this study suggest that a solitary intrahepatic tumor model without metastasis can be maintained. However, the evaluation of any therapeutic effects or any planned intervention should not occur until the fourth week following innoculation or less than 12x103 mm3 in volume after the inoculation of the VX2 tumor. The second highlighted section does not seem to fir with the rest of the sentence. Consider rephrasing the last part of the sentence.

Transarterial Embolotherapy in Patients with Duodenal Hemorrhage Using Microcoils and Gelfoam Particles

PURPOSE: To assess the efficacy and safety of arterial embolotherapy in patients with massive duodenal hemorrhage. MATERIALS AND METHODS: Between January 1999 and June 2002, 25 patients (age: 34-81, mean 58, male: 19, female: 6) underwent arterial embolization for duodenal hemorrhage after failed endoscopic therapy. The hemorrhage originated from duodenal ulcer in sixteen patients, from cancer with duodenal invasion in five patients, from endoscopic sphincterectomy in two patients, and from pseudoaneurysm complicating acute pancreatitis in two patients. Hemorrhage was detected at endoscopy and an attempt was made to treat it endoscopically in all patients, but failed in each case. At angiography, direct bleeding signs such as contrast extravasation or pseudoaneurysm were demonstrated in nineteen patients. In the six patients without angiographic evidence of bleeding, blind embolization of the gastroduodenal artery was performed based on the endoscopic examination. Microcoil and gelfoam particles were used as embolic agents. RESULTS:Hemostasis was achieved immediately after embolotherapy in 21 patients (84%). Bleeding recurred in 4 patients (16%), and of these cases, one was successfully treated purely by endoscopic means, a second was reembolized three times due to bleeding from the collateral vessels of the tumor and the two others were treated by surgery. After the procedure, six patients died (24%). The causes of death were disseminated intravascular coagulopathy, multiorgan failure, sepsis and acute renal failure. The underlying diseases of the deceased patients were cancers with duodenal invasion (n=4) and abdominal aortic aneurysm with ischemic colitis (n=1). CONCLUSION: Transarterial embolotherapy in the case of massive duodenal hemorrhage is a safe and effective procedure. Even in the absence of angiographic evidence of bleeding, blind embolization of the gastroduodenal artery is effective for patients in the surgically high risk group.

Perfusion Imaging of the Brain Using Z-Score and Dynamic Images Obtained by Subtracting Images from before and after Contrast Injection

OBJECTIVE: The aim of this study was to examine the feasibility of perfusion imaging of the brain using the Z-score and subtraction dynamic images obtained from susceptibility contrast MR images. MATERIALS AND METHODS: Five patients, each with a normal MRI, Moya-moya, a middle cerebral artery occlusion, post-trauma syndrome, and a metastatic brain tumor, were selected for a presentation. A susceptibility-contrast echo-planar image after a routine MRI was taken as the source image with a rapid manual injection of 0.1 mmol/kg of Gd-DTPA. The inflow and washout patterns were observed from the time-signal intensity curve of the serial scans using the standard program of an MRI machine. The repeated Z-score images of the peak and late phases were made using the threshold Z-score values between 1.4 and 2.0 in four to five studies of the pre-contrast, peak, and late phases. Dynamic subtraction images were produced by subtracting sequential post-contrast images from a pre-contrast image and coloring these images using a pseudocolor mapping method. RESULTS: In the diseases with perfusion abnormalities, the Z-score images revealed information about the degree of perfusion during the peak and late phases. However, the quality varied with the Z-score threshold and the studies selected in a group. The dynamic subtraction images were of sufficient quality with no background noise and more clearly illustrated the temporal changes in perfusion and delayed perfusion. CONCLUSION: The Z-scores and dynamic subtraction images illustrated the degree of perfusion and sequential changes in the pattern of perfusion, respectively. These images can be used as a new complimentary method for observing the perfusion patterns in brain diseases.

Changes in Total Cerebral Blood Flow with Aging, Parenchymal Volume Changes, and Vascular Abnormalities: a Two-dimensional Phase-Contrast MRI Study

PURPOSE: To evaluate changes in total cerebral blood flow (tCBF) with aging, parenchymal volume changes and vascular abnormalities, using 2 dimensional (D) phase-contrast magnetic resonance imaging (PC MRI). MATERIALS AND METHODS: Routine brain MRI including T2 weighted image, time-of-flight (TOF) MR Angiography (MRA) and 2D PC MRI were performed in 73 individuals, including 12 volunteers. Normal subjects (12 volunteers, and 21 individuals with normal MRI and normal MRA) were classified into groups according to age (18 -29, 30 -49 and 50 -66 years). For the group with abnormalities in brain MRIs, cerebral parenchymal volume changes were scored according to the T2 weighted images, and atherosclerotic changes were scored according to the MRA findings. Abnormal groups were classified into 4 groups: (i) mild reduction in volume, (ii) marked reduction in volume by parenchymal volume and atherosclerotic changes, and (iii) increased volume and (iv) Moya-moya disease. Volumetric flow was measured at the internal carotid artery (ICA) and vertebral artery bilaterally using the velocity-flow diagrams from PC MRI, and combined 4 vessel flows and tCBF were compared among all the groups. RESULTS: The age-specific distribution of tCBFs in normal subjects were as follows: 12.0 +/- 2.1 ml/sec in 18 -29 years group, 11.8 +/- 1.9 ml/sec in 30 -49 years group, 10.9 +/-2.2 ml/sec in 50 -66 years group. The distribution of tCBFs in the different subsets of the abnormal population were as follows: 9.5 +/-2.5 ml/sec in the group with mild reduction in volume, 7.6 +/-2.0 ml/sec in the group with marked reduction in volume, and 7.3 +/-1.2 ml/sec and 7.0 +/- 1.1 ml/sec in the increased parenchymal volume and Moya-moya disease groups respectively. CONCLUSION: Total cerebral blood flow decreases with increasing age with a concomitant reduction in parenchymal volumes and increasing atherosclerotic changes. It is also reduced in the presence of increased parenchymal volume and Moya-moya disease. 2D PC MRI can be used as a tool to evaluate tCBF with aging and in the presence of various conditions that can affect parenchymal volume and cerebral vasculature.

Radiologic Placement of Implantable Chest Ports in Pediatric Patients Under Sedation

PURPOSE: To evaluate the safety and efficacy of the radiologic placement of implantable chest ports under intravenous sedation in pediatric patients with malignancy. MATERIALS AND METHODS: Between October 2001 and June 2002, 20 chest ports were placed in 19 pediatric patients [13 boys and six girls aged 1-11 (mean, 4.7) years] for the purpose of long-term chemotherapy. In three patients, tunneled central venous catheters had been removed because of catheter extraction, infection, and tearing. Under intravenous sedation, the right internal jugular vein was used for access in 19 cases, and the left internal jugular vein in one. Venipucture was performed using a micropuncture needle with real-time ultrasound guidance. A port chamber was created at the infraclavicular fossa, and to prevent catheter kinking, a smooth-angled tunnel was created between the venipuncture site and the subcutaneous pocket. The catheter tip was positioned under fluoroscopy at the junction of the superior vena cava and right atrium. We observed techincal success, complications arouse during and after the procedure, and duration of catheter use. RESULTS: Implantation of the port system was successful in all cases, though slight hematoma, treated with manual compression, occurred at a chamber pocket in one case. In addition, the port system was removed from one patient because of wound infection leading to dehiscence and catheter malpositiong. A new port system was implanted through the left internal jugular vein. The median period during which catheter use was followed up was 118 (range, 18-274) days. CONCLUSION: For long-term chemotherapy in pediatric patients with malignancy, radiologic placement of an implantable chest port under intravenous sedation shows a high technical success rate, with few complications. This method may thus be used instead of surgical port placement.

Hemoptysis and Hemoperitoneum due to Metastatic Gestational Choriocarcinma: Bronchial Artery Embolization and Superselective Splenic Artery Embolization: A Case Report

Gestational choriocarcinoma is easily disseminated hematogenously and its hypervascular nature places the patient at risk of significant hemorrhage both at the sites of metastatic lesions and in the uterus. In addition, its tends to give rise to pseudoaneurysm formation. Treatment of the condition by percutaneous embolization has been reported in several published articles, and hemoperitoneum secondary to rupture of splenic metastasis of gestational choriocarcinoma has also been reported, as has angiographic embolization. Hemoptysis resulting from pulmonary metastasis and treatment by means of embolization of the bronchial artery have not been reported, however. In this article, we describe a case of hemoptysis and hemoperitoneum due to pulmonary and splenic metastasis of gestational choriocarcinoma. Treatment of the condition involved embolization of the bronchial artery and superselective embolization of the splenic artery.

Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Variceal Bleeding patient

PURPOSE: To evaluate the technical feasibility and clinical efficacy of balloon-occluded retrograde transvenous obliteration (BRTO) in the treatment of gastric variceal bleeding. MATERIALS AND METHODS: Between September 2001 and March 2002, ten patients with gastric variceal bleeding and gastrorenal shunt, underwent BRTO. Three of the ten also had hepatic encephalopathy. To evaluate the gastrorenal shunt and exclude portal vein thrombosis, all patients underwent pre-procedural CT scanning. An occlusion balloon catheter was inserted from the right internal jugular vein and on ballooning was wedged into the left adrenal vein. A sclerosing agent (5% ethanolamine oleate-lipiodol mixture) was injected until the varices were completely filled. In four patients, the collateral veins seen at balloon-occluded adrenal venography were embolized with coils prior to sclerotherapy. Post-procedural follow-up CT (n=3) or endoscopy (n=8) was performed 1-4 weeks later, and both before and after the procedure, hepatic function was also monitored. RESULTS: Treatment was successful in nine cases: the failure involed rupture of the occlusion balloon during inflation, and a transjugular intrahepatic portosystemic shunt was performed. The cessation of bleeding was confirmed endoscopically or clinically; in three patients, follow-up CT showed complete obliteration of the varices. Hepatic function improved in eight patients, but three weeks after the procedure, one expired due to progressive infiltrative hepatoma. The clinical symptoms of the three patients with hepatic encephalopathy showed remarkable improvement. CONCLUSION: Although more extensive studies and long-term follow up are needed to overcome the limitations of our study, we believe that BRTO is a technically feasible and clinically effective treatment for gastric varices and hepatic encephalopathy.

Percutaneous Intervention in the Management of Insufficient Native Arteriovenous Hemodialysis Fistulae

PURPOSE: To determine the effectiveness and patency of percutaneous intervention in insufficient native arteriovenous hemodialysis fistulae (AVFs). MATERIALS AND METHODS: Between March 1997 and September 2001, 67 cases of insufficient native AVF in 56 patients were treated by endovascular intervention. Except eight cases of insufficient native AVFs resulted from central vein lesion, PTA was performed in 48 cases, and thrombolytic therapy with or without PTA in 11. In eight of the cases, in which central vein stenosis had led to the insufficency, percutaneous transluminal angioplasty (PTA) was performed, and in three of the eight, a stent was inserted. Angiographic findings and complications, as well as success and patency rates in the non-thromobosis and thrombosis group, were evaluated; the central vein lesion group was analysed separately. RESULTS: Among 84 lesions observed at angiography, there were 54 cases of stenosis, 17 of occlusion, and 13 of combined thrombosis. The lesions were located in a proximal vein (n=51), distal vein (n=14), artery (n=6), and at the site of anastomosis (n=13). In the central vein lesion group (n=8), seven cases of stenosis and one of occlusion were noted. The overall procedural success rate was 79.1% (53/67). That is, in patients with no central vein lesion, the procedural success rate of PTA of native AVFs was 85.4% (41/48) and the patency rates of this were 83.1% at 6 months and 67.4% at 12 months. In cases of thrombolysis with/without PTA, the procedural success rate was 54.5% (6/11) and the patency rates were 83.3% at 6 months and 62.5% at 12 months. Finally, in patients with a central vein lesion, the procedural success rate was 75% (6/8) and the patency rates were 80% at 6 months and 30% at 12 months. There was one case of pseudoaneurysm formation at the puncture site of the brachial artery, which was used as the access route for intervention; one embolism in the brachial artery; and three cases of vascular spasm and two of hematoma which did not require active treatment. CONCLUSION: Percutaneous intervention offers effective and safe management of insufficient AVFs. The procedural success rate was higher for stenosis than for thrombotic occlusion.