Preoperative angiography and embolization of large pelvic tumors.

BACKGROUND AND OBJECTIVES: Pelvic tumors are often large and difficult to excise with appropriate surgical margins due to their size, proximity to neurovascular structures, and major intraoperative bleeding. The purpose of this study is to evaluate the yield of preoperative angiography and embolization so as to facilitate achievement of good surgical results. METHODS: Eighteen patients who suffered from large pelvic tumors (average size, 10.7 cm x 8.3 cm x 3.7 cm), 15 primary and 3 metastatic, underwent surgery at our institution between 1990 and 1995, after preoperative angiography and embolization of the tumors. RESULTS: The efficacy of the procedure was high. In all but one patient, the grade of vascularity of the tumor was reduced by at least two levels (based on our new tumor vascularity scale. In most patients, appropriate surgical margins were achieved. The average perioperative blood loss was only 750 cc. Procedure-associated complications were negligible. CONCLUSIONS: The results of this study call for the use of angiography and embolization in the management of patients with large pelvic tumors.

[Insertion of Hickman catheters in an interventional radiology suite].

In the past 20 years Hickman catheters have gained increasing acceptance for many uses, including bone marrow transplantation, long-term chemotherapy, total parenteral nutrition, dialysis, and administration of antibiotics and fluids. Until the past decade these catheters were inserted in the operating room. We present our experience in the percutaneous placement of 203 Hickman catheters in an interventional radiology suite in 190 consecutive patients within a period of 30 months. Catheter placement was successful in 202 (99.5%). The main complications were infections, necessitating removal of the catheter in 11 cases (5.4%) and unintentional dislodgement of the catheter in 8 (3.9%)-all in women and most on the right side. Pneumothorax and thrombosis in the catheter each occurred once. In another patient the guide wire broke during insertion and had to be percutaneously removed from the pulmonary artery. Late fracture of the catheter occurred in 2 others in whom the intravascular fragment was removed percutaneously. We believe that percutaneous Hickman catheter placement in the radiology suite offers advantages over traditional surgical placement.

[Angioplasty and stenting of the carotid artery].

Percutaneous endovascular techniques are well established procedures in the management of peripheral vascular disease and visceral arterial stenosis. They are now being adapted for use in the carotid artery as well. 8 patients with 9 extracranial carotid artery stenoses were successfully treated by percutaneous angioplasty, following which in 4 of them 5 stents were inserted. The stenotic lesions were situated in the proximal internal carotid artery and in its bifurcation and also in the common carotid artery. The indications for angioplasty in these patients were the same as for surgery. There were no major complications. 1 patient had transient hemiparesis lasting a few hours, and another had bradycardia following balloon dilation in the region of the carotid body. Percutaneous endovascular treatment of carotid artery stenosis is becoming a safe, feasible alternative to surgery.

Takayasu arteritis in Israel--update.

Takayasu disease in our Israeli series consists of 56 patients, and has been detected only in Sephardic and oriental Jews as well as in Arabs and Bedouin. Suspicion of Takayasu disease should be raised whenever renal artery stenosis and involvement of the aorta and its branches occur in patients from oriental origin.

True sagittal CT scanning of the elbow.

OBJECTIVE: A new method to obtain true sagittal CT scans of the elbow joint is described. MATERIALS AND METHODS: The patient is placed prone on the CT table with the arm around and under the table. RESULTS: True sagittal images of the elbow joints and all the articulating surfaces were easily obtained in a standard and reproducible manner. CONCLUSION: For CT scanning of the elbow, true sagittal scanning is superior to axial views and is readily obtained by the described method.

Intra-arterial thrombolytic therapy: a combined approach with angioplasty and/or minor surgery.

Low-dose intra-arterial treatment was performed in 124 patients who underwent a total of 142 procedures. The series included 87 occluded arteries and 55 occluded grafts. In only 29 instances (21%) was thrombolysis alone sufficient. In another 77 procedures (54%) the thrombolysis was followed by either angioplasty or minor surgery. In the remaining 36 treatments (25%) lysis of the occlusion failed. A successful end result of combined treatment was achieved in 67 of 77 (87%) procedures. Including the 29 patients in whom thrombolysis alone sufficed, a total of 96 of the 142 procedures (67%) were successful, with the overall success rate being better in grafts (78%) than in arteries (61%). The suprainguinal lesions had a significantly better response compared to the infra-inguinal ones. The evaluation of all procedures was done at the time of discharge from hospital. Complications were related either to local or systemic hemorrhage or distal embolization. Death related to treatment occurred in three patients.

Percutaneous transluminal aortic angioplasty: early and late results.

Percutaneous transluminal angioplasty of the infrarenal abdominal aorta (13 patients) and its bifurcation (15 patients) was performed in 28 patients with a total of 32 dilatation procedures. The group consisted of 16 female and 12 male patients and initial successful dilatation was achieved in all. Recurrence within 1 month requiring bypass surgery occurred in 1 patient. Three patients were lost to follow-up. Long-term follow-up in the remaining 24 patients ranged from 1 to 9 years with a mean of 4.5 years. During the follow-up period, repeat angioplasty of the original stenosis was performed in 3 patients and another patient underwent dilatation of a new lesion which developed in the aorta. According to clinical and noninvasive studies, these 4 patients, as well as the other 20, have maintained patency of the treated lesions and are symptom free. No immediate complications requiring surgery occurred. We conclude that angioplasty is the initial treatment of choice in focal lesions of the distal abdominal aorta and its bifurcation.

CT of the urinary tract after abdominoperineal resection for rectal carcinoma.

Computed tomography (CT) after abdominoperineal (AP) resection for rectal carcinoma is a routine procedure for the detection of recurrent tumor and distal metastases. We reviewed sequential CT scans after AP resection in 52 patients in order to see whether the urinary tract as a neighboring organ is involved in recurrent malignancy. Bladder displacement in itself was not associated with hydronephrosis. Such hydronephrosis developed, however, in 14 patients--13 with a presacral mass, and one with retroperitoneal lymphadenopathy. In 23 of the 52 patients a presacral mass appeared, either fibrosis, infection, or recurrence. Severe hydronephrosis was found only with malignancy. We suggest that marked hydronephrosis associated with a presacral mass after AP resection is an indirect sign of malignancy.

CT of pelvic infection after cesarean section.

The CT findings in 6 women with puerperal sepsis after Cesarean section were reviewed. In four patients a right-sided mass was palpated. CT scan confirmed the diagnosis of Tubo-ovarian abscess in two of the patients, puerperal ovarian vein thrombosis (POVT) in the third and an enlarged adnexa with no signs of abscess formation in the fourth patient. The last two patients had normal adnexae but a large amount of gas in the uterus. All patients recovered after appropriate treatment. In patients with severe puerperal sepsis who do not respond to antibiotic therapy, CT scanning of the abdomen and pelvis is useful. This study can demonstrate whether there is an abscess which requires surgical intervention or POVT which needs additional anticoagulant treatment.

Case report: broken intracholedochal stent.

Decompression of biliary obstruction by an internal stent is well accepted in patients with malignant strictures. Less frequent is the use of this technique for the management of benign disorders. In the latter situation the biliary stent may be left in place for a very long period. We report a rare complication of a broken intracholedochal stent which had been inserted for a benign post-operative stricture.

Vesicoureteral reflux simulating renal function: CT appearance.

Urine may enter the pelvicalyceal system of the kidney either through renal excretion or via the ureter by vesicoureteral reflux. Opacified cyalyces and pelvis after the administration of intravenous contrast material are therefore not necessarily proof that the kidney is functioning. This phenomenon, well known from intravenous urography, may be observed on computed tomography studies as well. We present a case in which a CT scan showed a normal left and a contracted pyelonephritic right kidney with contrast material in pelvis and calydes of both kidneys without parenchymal enhancement on the right side. Subsequently marked vescioureteral reflux to the right kidney was demonstrated on cystourethrography and the kidney was shown to have no function on a nuclear scan. Contrast material in the collecting system associated with a small non-enhancing kidney on CT scan should suggest vesicoureteral reflux.

Choledocholithiasis in infants: diagnostic and therapeutic problems.

During the 3-year period, January 1986 through December 1988, 7 of 24 infants evaluated for cholestatic liver disease were found to have choledocholithiasis with or without associated gallbladder disease. Five were born prematurely with associated predisposing factors, especially systemic infection and total parenteral nutrition. The clinical course varied from spontaneous recovery in two patients to ongoing liver disease requiring surgical or endoscopic intervention in five infants. Asymptomatic patients with normal liver function and persistently dilated extrahepatic biliary trees posed the most difficult therapeutic problems. Endoscopic retrograde cholangiography appeared to be an effective and rewarding therapeutic approach.

Gossypiboma in the early post-operative period: a diagnostic problem.

A gossypiboma (a retained surgical sponge) usually has the characteristic appearance on CT of a soft tissue mass with air-bubbles and a whirl-like pattern. This finding may be confused in the early post-operative period with an abscess, especially when a fistula is present. We describe two patients, in whom this diagnosis was initially missed. A soft tissue mass containing air-bubbles in the early post-operative period with or without a fistula should include a retained pad, in the differential diagnosis.

Aortobronchial fistula as a complication of surgery for correction of congenital aortic anomalies.

An aortobronchial fistula is a rare condition that is invariably fatal if not diagnosed and surgically treated. Aortic aneurysms, both atherosclerotic and infective, were the main causes in the originally described cases. However, thoracic cardiovascular surgery has recently become the predominant cause. The authors describe two such patients who presented 4 1/2 and 5 years after surgery for the correction of congenital anomalies. Both patients had severe hemoptysis, and angiography helped establish the diagnosis of an aortobronchial fistula. This diagnosis should be considered in patients with hemoptysis and a history of thoracic surgery.

Femoral neuropathy: the role of computed tomography in diagnosis and management in 27 patients.

The computed tomography findings in 27 patients with an ultimate diagnosis of femoral neuropathy were reviewed. Haemorrhagic disorders were responsible for the neuropathy in 10 patients, neoplasia in eight, infection in five and in the remaining four patients no abnormality was noted on CT and the aetiology remained uncertain. Unilateral enlargement of the iliopsoas muscle or a soft tissue mass involving the iliopsoas compartment was noted in the 23 patients with positive studies. The exact nature of the mass could not be determined by CT alone, but, when considered together with clinical history and examination, a definitive diagnosis was possible in most instances. Whenever necessary, percutaneous needle biopsy or drainage was performed. Computed tomography should be performed at an early stage in all patients suspected of femoral neuropathy. It accurately demonstrates and delineates retroperitoneal masses causing this condition and allows further definitive diagnostic procedures such as biopsy or drainage to be performed when necessary.

Total femoral replacement.

Between 1973 and 1983, 19 patients with sarcoma of the femur were treated by adjuvant chemotherapy, excision of the entire femur, and replacement by a total femoral prosthesis. Five patients had excellent and nine had good functional results. Twelve patients died an average of 23 months after the procedure and seven are at present disease free. This limb-saving procedure permits rapid rehabilitation, prevents severe psychological problems, and improves the quality of life.

Percutaneous transluminal recanalization of common iliac artery occlusions.

Percutaneous transluminal recanalization of occluded iliac arteries was attempted in 25 patients (26 limbs). In 22, successful recanalization was achieved, although 4 patients required additional surgical thrombectomy. The remaining 4 patients had surgical bypass procedures. The early and late results of percutaneous recanalization are presented as well as the technique used. We conclude that percutaneous recanalization of iliac occlusion is an effective procedure in the majority of cases. The option of surgical treatment remains viable when the percutaneous approach is unsuccessful.

Percutaneous transluminal angioplasty of the distal abdominal aorta and its bifurcation.

Percutaneous transluminal angioplasty (PTA) of stenotic lesions in the distal abdominal aorta and its bifurcation was performed in 14 patients, 6 of whom were women. The stenotic segment in the aorta or aortic bifurcation was usually the only significant lesion. The double-balloon technique was used in 12 patients via bilateral femoral artery catheterizations. In 2 other patients with aortic lesions, a single large balloon sufficed. Good results were achieved in all but 1 patient, with minor complications occurring in 3 instances. The follow-up period varied from 6 months to 5 years. We believe that PTA is the procedure of choice in treating localized lesions of the distal abdominal aorta and its bifurcation, especially when distal vessels are relatively uninvolved.