Factors associated with rerupture of intracranial aneurysms after endovascular treatment: A retrospective review of 11years experience at a single institution and review of the literature.

Aneurysm rebleeding following initial endovascular management is uncommon, and the factors associated with its occurrence are poorly defined. We retrospectively analyzed a consecutive series of patients presenting with aneurysmal subarachnoid hemorrhage who underwent endovascular management to determine factors associated with rebleeding. Rebleeding occurred in 7/183 (3.8%) patients, 6 of which had an adjacent hematoma on initial neuroimaging. Aneurysms were located on the ACoA (n=5), PCoA (n=1), and MCA (n=1). Sizes ranged from 3.5 to 13.0mm (mean 8.0), with neck sizes ranging from 1.8 to 4.6mm (mean 3.2). Time-to-rerupture ranged from hours to years, with 3/7 cases rebleeding within 30days and 4/7 cases rebleeding later than 30days. Initial incomplete angiographic occlusion occurred in 2/3 cases of early rebleeding. The presence of adjacent intracerebral hematoma (ɸ=0.354, p<0.005), increasing Fisher Grade (t(9.4)=7.72, p<0.005), and aneurysmal outpouching (ɸ=0.265, p<0.005) were found to be the only factors associated with rerupture status. Recurrent hemorrhage following endovascular management of ruptured intracranial aneurysms is an uncommon but important source of morbidity, particularly in the early post-embolization period. The presence of high-risk features, such as an adjacent intracerebral hematoma or aneurysm outpouching, warrant early and frequent angiographic follow up to document stability and mitigate rupture risk.

Management of major bile duct injury associated with laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury is a major complication of laparoscopic cholecystectomy. The purpose of this study was to evaluate our management strategy and outcomes for the treatment of such injuries. METHODS: We studied 54 consecutive patients who had de novo bile duct injury (n = 20) or prior biliary injury repair (n = 34) associated with laparoscopic cholecystectomy. All patients were managed using a multidisciplinary approach. RESULTS: Definitive operation, almost always Roux-en-Y hepaticojejunostomy, was required in 85% of patients. We inserted external percutaneous biliary catheters in 98% of cases prior to surgery. There were no operative deaths, and the 30-day complication rate was 20%. Eight patients (15%) were managed nonoperatively. Overall, 96% of patients had no long-term, objectively definable biliary sequelae. CONCLUSIONS: Treatment of bile duct injury associated with laparoscopic cholecystectomy is optimally done using a multidisciplinary approach. Surgical reconstruction is required in most cases and can be safely accomplished with minimal morbidity and excellent long-term outcomes.

Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1,561 patients.

BACKGROUND: Thoracic aortic injury (TAI) is a devastating condition in which prompt recognition can obviate morbidity and mortality. It is a long-held belief that TAI is more likely when there is a "major mechanism of injury." The purposes of this prospective study were to determine mechanism characteristics that are predictive of TAI and to evaluate chest computed tomography (CT) as a screening tool for TAI. METHODS: Over a 5 1/2 year period, blunt chest trauma patients at two Level I trauma centers were evaluated for potential TAI. Patients were assigned mechanism and radiograph scores from 1 (low suspicion for TAI) to 5 (very high suspicion for TAI). Immediate aortography was obtained when suspicion for TAI was very high. The remaining patients were evaluated with contrast-enhanced chest CT. Confirmatory aortography was obtained on all positive chest CT scans and on all patients with mechanism scores of 4 or 5 even if the CT was negative. Mechanism and radiographic data were correlated with the results of aortic imaging. RESULTS: Of the 1,561 patients evaluated for TAI, 30 aortic injuries were found. The assessment of mechanism was imperfect with a reliance on often incomplete and subjective data. The subjective mechanism score proved to be the most useful predictor of TAI. Radiographic scores were useful but insensitive for intimal injuries. Computed tomography was found to have 100% and 100% NPV for TAI. CONCLUSION: Considering the inherent difficulties in identifying patients at risk for TAI and the effectiveness of chest CT as a screening tool for aortic injury, we recommend liberal use of chest CT in blunt chest trauma. Guidelines for determining the need for aortic imaging are outlined.

Hepatocyte transplantation in acute liver failure.

The majority of patients with acute liver failure (ALF) die waiting for orthotopic liver transplantation (OLT). No other treatment modality is shown to improve survival. This study was conducted to assess the safety and feasibility of hepatocyte transplantation (HT) and subsequent engraftment and function of donor cells. Functional and structural integrity of cryopreserved and thawed human hepatocytes were assessed by their morphological characteristics, induction of P-4501A1 transcription, and survival in vivo by xenotransplantation into rats. Five patients with severe ALF underwent intrasplenic (4 patients) and/or intrahepatic (2 patients) HT through angiography under cyclosporine immunosuppression. All patients had grade III to IV encephalopathy and factor V levels less than 0.5 U/mL, were ventilator and dialysis dependent, and were not OLT candidates. Three of the 5 patients who survived 48 hours after HT had substantial improvement in encephalopathy scores, arterial ammonia levels, and prothrombin times. Clinical improvement was paralleled by an increase in aminopyrine and caffeine clearances. All 3 patients lived substantially longer than expected based on clinical experience after HT (12, 28, and 52 days) but eventually died. Postmortem examination showed the presence of transplanted hepatocytes in liver and spleen by light microscopy and fluorescent in situ hybridization (FISH). Cryopreserved and thawed human hepatocytes can be transplanted into recipients with ALF with some acceptable but definite complications. Engraftment of donor hepatocytes was proven by histological examination and FISH by both transjugular biopsy and at autopsy. Improvement in brain edema, encephalopathy grade, and clearance of antipyrine and caffeine suggested function, albeit with a 24- to 72-hour delay posttransplantation.

Can chest CT be used to exclude aortic injury?

PURPOSE: To determine whether chest computed tomography (CT) can be used to exclude aortic injury. MATERIALS AND METHODS: Patients in whom there was very high suspicion of traumatic aortic injury were examined with aortography only. Other patients were examined with contrast material-enhanced CT. Follow-up aortography was performed in all patients with moderate to high suspicion of traumatic aortic injury and in all patients with CT scans that were positive for traumatic aortic injury. CT scans were regarded as positive when they showed mediastinal hematoma or direct findings of aortic injury. During a 4 1/2-year period, 1,009 patients (263 female, 746 male; age range, 3-90 years) were evaluated for possible traumatic aortic injury. RESULTS: Of the 207 patients who underwent aortography directly without CT, 10 had traumatic aortic injury. Of the 802 patients who were examined with CT, 382 underwent follow-up aortography. In this group, there were 10 true-positive and no false-negative CT scans. CT had 100% sensitivity and a 100% negative predictive value for the detection of traumatic aortic injury.

Acute arterial occlusions of the small vessels of the hand and forearm: treatment with regional urokinase therapy.

PURPOSE: Arterial occlusions of the small vessels of the forearm and hand may have the same consequences as arterial occlusions in the distal lower extremity. There is limited reported experience with the regional thrombolytic therapy in this setting. The authors reviewed their experience with thrombolytic therapy in acute and subacute arterial occlusions of the distal upper extremity to further clarify its role. MATERIALS AND METHODS: Twelve patients with acute or subacute arterial occlusions of the forearm and hand who had ischemic digits and were treated with regional urokinase infusion were identified retrospectively. Their medical and radiology records were reviewed. RESULTS: All 12 patients demonstrated angiographic improvement and 11 patients demonstrated clinical improvement after treatment. Tissue necrosis in four patients led to partial amputation of one digit in two patients and three digits in two patients. Three of these patients had category III ischemia at presentation. The level of resulting amputation was altered in all but one patient. Vasospasm was noted frequently but responded to vasodilators. No significant complications occurred. CONCLUSIONS: When therapeutic alternatives are limited to anticoagulation and expectant amputation, regional urokinase infusion can optimize distal runoff, obviate or improve the options for distal surgical bypass, and limit tissue loss.

Role of TIPS as a bridge to hepatic transplantation in Budd-Chiari syndrome.

PURPOSE: To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients. Clinical follow-up and portograms were obtained in all patients until death or transplantation. RESULTS: TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites. Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL). Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL). Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list. CONCLUSION: Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS. Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.

Partial splenic embolization in five children with hypersplenism: effects of reduced-volume embolization on efficacy and morbidity.

PURPOSE: To evaluate the effects of reducing the volume of spleen infarcted during partial splenic embolization (PSE) for treatment of hypersplenism in children. MATERIALS AND METHODS: Five children with hypersplenism underwent embolization of 30%-40% of the splenic volume. The results were compared with those of a previous study of 70%-80% PSE performed in 17 children. RESULTS: The hospital stay after the procedure was reduced from 16.0 days +/- 8.0 to 6.6 days +/- 5.6. The febrile period decreased from 15.0 days +/- 8.1 to 5.0 days +/- 6.6. The peak white blood cell count was 8,300/mm3 +/- 4,600 (8.3 x 10(9)/L +/- 4.6) versus 19,400/mm3 +/- 7,800 (19.4 x 10(9)/L +/- 7.8) in the earlier study. The peak platelet count was 153,000/mm3 +/- 65,000 (153 x 10(9)/L +/- 65) versus 636,000/mm3 +/- 406,000 (636 x 10(9)/L +/- 406). The platelet count after a mean follow-up of 14 months was 70,000/mm3 +/- 7,000 (70 x 10(9)/L +/- 7) versus 230,000/mm3 +/- 62,000 (230 x 10(9)/L +/- 62) after a mean follow-up of 45 months. The frequency of variceal hemorrhage decreased from 3.5 to 0.5 episodes per year. The frequency of epistaxis decreased from 30 to 15 episodes per month. CONCLUSION: Reduced-volume embolization decreased morbidity. All patients maintained a platelet count above baseline, and no patient required repeat embolization.

Failing and failed hemodialysis access sites: management with percutaneous catheter methods.

Chronic dialysis access is plagued with the formation of stenoses and access thrombosis, with a thrombosis rate of 0.5 to 0.8 episodes per year. Surgical management of thrombosed accesses, including thrombectomy, patch angioplasty, and bypass, has been the traditional treatment for thrombosed grants. Percutaneous catheter-directed thrombolysis of thrombosed accesses, coupled with angioplasty of underlying stenoses, offers comparable results to surgical revascularization. The technical success of thrombolysis is between 75% and 92%, similar to surgical results, with the advantage of sparing vein as potential conduit for future access sites. Surgical therapy may successfully reestablish access function for those stenoses that fail angioplasty. Long-term patencies after a single revascularization procedure are poor (median patency, < 90 days) for both catheter-directed and surgical procedures, and repeat maintenance procedures are necessary. Access surveillance using various means with timely fistulography coupled with angioplasty of stenoses has been shown to decrease the rate of access thromboses by a factor of 3 and to increase patency of grafts. A combined approach with catheter-directed therapies and surgical interventions leads to maximal longevity of each access site.

Course of thrombocytopenia of chronic liver disease after transjugular intrahepatic portosystemic shunts (TIPS). A retrospective analysis.

Thrombocytopenia associated with chronic liver disease presents a difficult management issue. Most reports conclude that portocaval and distal splenorenal shunts do not improve platelet counts in this setting. The response of thrombocytopenia after transjugular intrahepatic portosystemic shunt placement has not been studied. All platelet counts of 21 patients undergoing intrahepatic shunt placement were determined retrospectively to accumulate values at one month prior to procedure, weekly for the first month after the procedure, and monthly thereafter to six months. Comparison of pre- and postshunt platelet means showed a significant increase in counts in patients with a postshunt portal pressure gradient < 12 mm Hg, with the increment evident by one week after the procedure. This response was not seen when preshunt thrombocytopenia was used as the lone variable. This study suggests that the transjugular intrahepatic portosystemic shunt may improve the thrombocytopenia associated with liver cirrhosis when these pressure gradients are attained.

Improved treatment of thrombosed hemodialysis access sites with thrombolysis and angioplasty.

We treated percutaneously 135 expanded polytetrafluoroethylene (PTFE) prosthetic grafts which had thrombosed using thrombolysis with urokinase followed by balloon angioplasty. Functional patency was re-established in 38 of 62 (61%) using single catheter technique, and in 62 of 73 (85%) using crossed catheter technique (P < 0.01). Hemorrhagic complications were reduced from 12.9% in the single catheter technique to 1.4% in the crossed catheter technique (P < 0.01). Median "primary patency after treatment" of the PTFE accesses after successful restoration of function was 98 days. Cumulative "primary patency after treatment" from the time of successful recanalization of the thrombosis for the PTFE grafts was 70.5% at one month, 45.8% at 6 months, and 16.2% at 12 months. Among a smaller group of 26 PTFE patients who were treated with only interventional radiologic procedures (repeat thrombolysis and/or angioplasty), without surgical revision, "secondary patency after treatment" from the time of thrombosis was 92.3% at 1 month, 80.2% at 6 months, 69.4% at 12 months, and 36.5% at 24 months. We conclude that lysis/angioplasty is a valuable means of treating thrombosed hemodialysis access sites. The crossed catheter technique produces superior initial technical success compared with single catheter infusion of the lytic agent. "Primary patency after treatment" after successful recanalization is relatively short, but long-term patency is improved substantially with retreatment of recurrent failure of the access with repeat thrombolysis and/or angioplasty.

Reexploration and angiographic ablation for hyperparathyroidism.

OBJECTIVE: Persistent and recurrent hyperparathyroidism remains a challenging clinical problem. The purposes of this study were to determine the causes of initial failure, the accuracy of preoperative localization tests, the role of angiographic parathyroid ablation, and the safety and efficacy of reexploration for hyperparathyroidism. DESIGN: A retrospective review of 42 patients undergoing reexploration or angiographic ablation for hyperparathyroidism was done, with a mean follow-up of 3 years, 7 months (range, 1 month to 13 years). SETTING: This study was carried out in a university medical center and a Veterans Affairs hospital. PATIENTS: All patients who underwent reexploration or angiographic ablation for hyperparathyroidism were included. INTERVENTION: All patients underwent preoperative localization studies. The cervical approach was used when the abnormal gland was suspected to be in the neck or the mediastinum superior to the aortic arch; sternotomy was used for deeper mediastinal glands not resectable through a cervical approach. Angiographic ablation of mediastinal glands was performed using contrast administration after a catheter was wedged into the selective feeding artery. MAIN OUTCOME MEASURES: End points included causes of initial treatment failure, accuracy of preoperative localization studies, long-term correction of hypercalcemia with repeated treatment, need for subsequent intervention for hypercalcemia, and complications of therapy. RESULTS: The most common reasons for initial failure were mediastinal glands (18 patients), surgeon's inexperience (12 patients), supernumerary glands (six patients), and other anatomic anomalies. Hyperplasia accounted for hyperparathyroidism in 11 patients (26%) and adenomas in 31 patients (74%). Preoperative localization studies included technetium-Tc-99m-sestamibi scanning (sensitivity, 86%), technetium-thallium scanning (67%), arteriography (63%), venous sampling (52%), computed tomography (42%), magnetic resonance imaging (33%), and ultrasonography (27%). Thirty-three (89%) of 37 patients who underwent reexploration had resolution of hypercalcemia. Localization study results were negative in all four patients who experienced failure. Angiographic ablation was successful in four (67%) of six patients. One of the patients with a failed ablation had successful mediastinal exploration. Hypoparathyroidism occurred in six patients (14.3%) and there was no instance of recurrent nerve injury. CONCLUSIONS: The most common causes of initial failure were ectopic mediastinal glands and incomplete surgical exploration; the most sensitive preoperative localization study is the technetium-Tc-99m-sestamibi scan; angiographic ablation of parathyroid tissue is most useful for poor-risk surgical patients or to avoid median sternotomy; and reexploration and angiographic ablation yield a high success rate with acceptable morbidity and mortality.

Angioplasty/thrombolytic treatment of failing and failed hemodialysis access sites: comparison with surgical treatment.

Angioplasty is a valuable alternative to surgical revision of failing hemodialysis access sites and may be the treatment of choice because no further vein is compromised during the revision and because patency rates with repeat dilatations approach or equal those of surgical revision. Thrombolysis/angioplasty is a worthy substitute for surgical thrombectomy/revision in thrombosed access sites because dialysis can be resumed immediately, without the need of placement of a temporary subclavian vein access catheter, and lysis can be performed on an outpatient basis. Long-term secondary patency also approaches that of surgical therapy. Again, future access sites are not compromised. Either with percutaneous catheter or surgical therapy, it must be recognized that repeat treatment will be necessary to maintain patency of the access site after it has thrombosed. Close follow-up of these patients to observe for signs of recurring deterioration is mandatory. Because the number of vascular access sites is limited, the preservation of each site for as long as possible is important for the long-term management of these patients.

Planned delayed nephrectomy after ethanol embolization of renal carcinoma.

Planned delayed nephrectomy after preoperative ethanol infarction was done in 6 patients with renal carcinoma. Three patients had intracaval extension of tumor, 2 had renal vein but no vena caval extension and 1 had no renal vein or vena caval involvement. Nephrectomy was delayed 22 to 44 days after embolization. In the patients with inferior vena caval extension shrinkage of tumor thrombus after embolization allowed for easier surgical resection. Furthermore, delay of nephrectomy after preoperative infarction was of value in improving the clinical status of high risk patients.

Popliteal artery entrapment: findings at MR imaging.

Magnetic resonance (MR) imaging can noninvasively demonstrate the anatomic relationships between the popliteal artery and the muscles within the popliteal fossa, making it an ideal screening test for popliteal artery entrapment prior to angiography or surgery. The authors describe a patient with bilateral type II popliteal artery entrapment in whom the anomaly was diagnosed in the asymptomatic extremity with MR imaging.

Direct catheterization of the mesenteric vein: combined surgical and radiologic approach to the treatment of variceal hemorrhage.

Minilaparotomy and direct catheterization of the mesenteric vein for variceal embolization was attempted in 15 patients in whom medical and endoscopic treatment of variceal hemorrhage had failed. Hemorrhage was controlled immediately after the procedure in 11 patients. The 30-day survival rate was 60% (n = 9). The cause of death in six patients was variceal bleeding (n = 2), liver failure (n = 3), and respiratory failure (n = 1). The 6-month survival rate was 33% (n = 5), and the 1-year survival rate was 27% (n = 4). Bleeding recurred in 67% of surviving patients; however, fatal variceal bleeding occurred in only 22% (n = 2). Direct mesenteric vein catheterization allows simplified entry into the portal vein for embolization of bleeding esophageal or gastric varices. Early experience suggests that the results are similar to those of percutaneous transhepatic embolization, without the complications and technical demands of a transhepatic approach.

Proximal fallopian tube occlusion: diagnosis and treatment with transcervical fallopian tube catheterization.

Transcervical fallopian tube catheterization (TFTC) was performed in 22 infertile patients with bilateral fallopian tube obstruction and a mean duration of infertility of 3.3 years. A high prevalence of previous ectopic pregnancy (n = 8, 36%), tubal ligation and/or reconstruction (n = 5, 23%), spontaneous or therapeutic abortion (n = 6, 27%), and previous intrauterine device use (n = 14, 64%) was noted. The authors successfully catheterized 40 (98%) of 41 tubes without serious complication and visualized the distal tube in 36 (88%) of 41 tubes. Free spill in at least one tube was seen in 17 (77%) of 22 patients. Nineteen patients had a history of previous laparoscopy or laparotomy for tubal disease, in 16 of whom laparoscopic results were available for review. Retrospectively, in 15 (94%) of 16 patients all clinically relevant abnormalities would have been detected by means of TFTC alone. Five patients conceived, three with intrauterine and two with ectopic pregnancies. Patients with intrauterine pregnancies had normal-appearing tubes after TFTC, while those with ectopic pregnancies had residual tubal abnormalities after recanalization. TFTC is a safe, accurate diagnostic procedure that provides more information than hysterosalpingography and, in most cases, as much or more information about the fallopian tubes than laparoscopy.