Cardiac perforation and tamponade during transjugular intrahepatic portosystemic shunt placement.

A patient developed acute severe hemodynamic compromise during a transjugular intrahepatic portosystemic shunt (TIPS) procedure for intractable ascites. Rapid clinical and radiographic evaluation of the patient disclosed pericardial blood and cardiac tamponade as the cause, probably due to right heart perforation from guidewire and catheter manipulation. The tamponade was successfully treated percutaneously, and the patient survived. Cardiac tamponade should be considered in the differential diagnosis of patients who develop hypotension during TIPS placement.

Relative ultrasonographic echogenicity of standard, dimpled, and polymeric-coated needles.

PURPOSE: To use quantitative ultrasonographic measurements to compare the effect of a polymeric coating designed to increase needle echogenicity to commercially available needles. MATERIALS AND METHODS: Commercially available standard smooth and dimpled echogenic tip 21-gauge needles established reference levels of echogenicity in gelatin-based and turkey breast phantoms. Examples of both types of needles were coated with a thin polymeric film that utilizes entrapped microbubbles of air on its surface to increase echogenicity. Samples of each type in both coated and noncoated versions were placed in phantoms in matched positions and imaged with clinical ultrasound machines. Similar numbers of each category were evaluated at various angles of insonation for a total of 109 images. Similar numbers of each category were imaged at 5-minute intervals for up to 38 minutes for a total of 226 images. Images were recorded, digitized, and evaluated for relative echo strength in arbitrary echogenic brightness units. RESULTS: Coating increased peak echogenicity over the entire needle to a level that closely approximates the peak echogenicity of dimpled needle tips (means: dimpled = 834, coated smooth = 803, coated dimpled = 823; P = .54). Smooth is lower than this group at 468 (P = .0001). Representative area echogenicity increased with coating or dimpling (smooth = 377 vs coated smooth = 778, coated dimpled = 690, dimpled = 775; P = .0001). Coating increased peak values 74% and area values 95% compared to smooth. Decreased angles of insonation moderately reduced echogenicity on coated smooth, coated dimpled, and dimpled, while it decreased to below good visibility threshold on standard smooth needles. The echogenicity of the coated needles fades in saline with time (1%/min). CONCLUSION: Objective measurements show that this coating significantly increases echogenicity of entire needles to match that obtained with a dimpled tip.

Complications and technical limitations of hepatic arterial infusion catheter placement for chemotherapy.

PURPOSE: To determine the rate of complications associated with hepatic arterial infusion (HAI) catheter placement, as well as technical success related to liver perfusion. MATERIALS AND METHODS: The authors reviewed 44 patients who underwent 106 HAI catheter placements, including 15 men and 29 women with an average age of 55 years (range, 32-82 years). One to nine placements were performed per patient with 61 (58%) via the left brachial artery, 40 (38%) via the right femoral artery, and five (4%) via the left femoral artery. Chemoinfusion lasted 4 days, with initial catheter placement assessed on technetium-99m macroaggregated albumin (MAA) perfusion scans, as well as daily abdominal radiographs. RESULTS: One hundred attempted hepatic arterial catheter placements were completed. Liver perfusion was global in 66 (66%) cases, in the right lobe only in 28 (28%) cases, and in the left lobe only in six (6%) cases. Eight (8%) had gastrointestinal (GI) tract perfusion; this was eliminated in seven cases (7%) after catheter repositioning. Forty-six (43%) placement attempts required embolization of 62 GI vessels to preclude GI chemoinfusion. Complications included one cerebrovascular accident (related to removal of a left brachial catheter), eight brachial artery thromboses (four that required emergent thrombectomy), six hepatic arterial dissections, four hepatic arterial thromboses, and four catheter malfunctions. CONCLUSIONS: HAI catheter placement via the left brachial artery has increased complications. Nearly one-half of placements required embolization of GI vessels to preclude GI perfusion. Global perfusion is possible in two-thirds of cases.

Demonstration of intraluminal duodenal diverticulum by computed tomography.

Intraluminal duodenal diverticulum is a rare congenital anomaly consisting of a saclike projection within the duodenum. Small diverticula may be asymptomatic; however, when these enlarge, patients may develop recurrent episodes of pain, obstruction, or pancreatitis. Normally, the diagnosis is made by barium luminal examination. We report a case where the findings were seen on computed tomography and confirmed by upper gastrointestinal series.

Distribution of disease in cystic fibrosis: correlation with pulmonary function.

STUDY OBJECTIVE: We hypothesized that the radiographic distribution of disease is important in determining pulmonary function, with the lower lung zones of more importance than the upper lung zones. To test this hypothesis, we retrospectively studied patients with cystic fibrosis, a disease with a known proclivity for the upper lung zones. SUBJECTS AND METHODS: Two hundred seventy-six chest radiographs obtained at 2- to 3-year intervals from 51 patients were scored by two radiologists using a 100-point visual severity scale. The distribution of disease was assessed by dividing the lungs into four equal horizontal zones and scoring each zone for the severity of disease. There were 146 concurrent chest radiographs and pulmonary function tests from which multiple linear regression was used to correlate these zonal scores with FEV1/FVC percent predicted. RESULTS: There was excellent interobserver agreement, intraclass correlation coefficients >0.7. The distribution of disease became predominant in the upper lung zones as the patients aged. Although the median score in the upper lung zones was nearly twice that of the lower lung zones, the lower lung zones were nearly three times (partial F ratio; 6.9 lower zone score vs 2.4 upper lung zone score) as important in determining pulmonary function. CONCLUSION: The regional distribution of disease is important in determining pulmonary function. Sparing of the lower lung zones is important in preserving pulmonary function.