Local thrombolytic therapy for superior mesenteric artery embolism: complications and long-term clinical follow-up.

PURPOSE: To evaluate the effectiveness and complications of local intraarterial fibrinolysis in selected patients with superior mesenteric artery (SMA) embolism. MATERIALS AND METHODS: Intraarterial thrombolytic therapy was performed for acute SMA embolism in eight patients. Patients were selected for thrombolytic therapy on the basis of absence of peritoneal signs of intestinal necrosis at physical examination and absent findings of bowel infarction by CT. RESULTS: Clinical success was achieved in five patients and technical success in six. Complications included death due to massive shower emboli from the left ventricle in one patient and extravasation in one patient, who required surgery on the following day. Within one month after thrombolytic therapy, one patient each died of myocardial infarction and cerebral infarction due to emboli, and one patient underwent aorto-SMA bypass surgery due to residual stenosis. In the long-term follow-up period (2-7 years), four patients were still alive, with another embolic episode of a lower limb in one patient. One patient died of an unrelated cause without experiencing another embolic episode. CONCLUSION: Intraarterial fibrinolysis may be a therapeutic alternative in the management of SMA embolism in selected patients in whom an early diagnosis can be made. The long-term results depend on the occurrence of another embolic event.

Acute mesenteric ischemia. CT and plain radiographic analysis of 26 cases.

The purpose of this study was to assess the computed tomography (CT) and plain radiographic findings of acute mesenteric ischemia, in an effort to elucidate its poor prognostic signs. The study group consisted of 26 cases with pathologically or angiographically proven mesenteric ischemia. The pathologically proven longitudinal extent of the bowel ischemia was graded using six degrees, and correlated with the radiographic findings. The mortality of the patients depended primarily on the extent of infarctions and the age of the patient. Patients with bowel dilation or abnormal gas in the bowel wall or portal system were prone to have wider extents of ischemia.

Lower leg ischemia associated with aortic dissection.

Lower leg ischemia associated with aortic dissection is a potentially life-threatening condition requiring immediate treatment. To better understand the diagnostic factors and improve the treatment strategy of this serious complication, we analyzed our experience regarding the radiographic findings, treatment, and outcome in eight patients (aged 28-72 years, six men and two women). CT revealed type A aortic dissection in seven patients and type B in one. The obstructed site was in the iliac artery in five patients and in the abdominal aorta below the renal arteries in three. Surgical procedures included five ascending aortic graft replacements, three femoro-femoral bypasses, and one each of surgical fenestration, aorto-iliac bypass, and axillo-femoral bypass with thrombectomy. Endovascular treatment was performed in two patients, iliac stent placement in one, and thrombolysis of the iliac artery in one. Five patients survived and three died due to myonephrotic metabolic syndrome in two and postoperative bleeding in one. Treatment strategy depends on several issues regarding aortic dissection including ascending aortic involvement, patent false lumen, entry site, renal artery involvement, and thrombosis in a true or false lumen. CT and angiography are the most important methods for deciding upon appropriate therapy in each individual.

Indication of chemoembolization therapy without gelatin sponge for hepatocellular carcinoma.

This study evaluated the effect of chemoembolization (C-LIP) consisting of ethiodized oil (Lipiodol Ultra Fluid; André Guerbet, Aulnay-sous-Bois, France) and epirubicin, without gelatin sponge on hepatocellular carcinoma (HCC), administered by hepatic arterial infusion. We analyzed the cases from two points of view: the local recurrence rate for hypervascular solitary small HCC (tumor size: < or =3 cm in diameter) and the cumulative survival rate for advanced HCC (stage VI according to the criteria of Liver Cancer Group of Japan) following C-LIP therapy. The C-LIP also was compared with transcather arterial embolization (TAE; C-LIP followed by gelatin sponge) and percutaneous ethanol injection therapy (PEIT). In the small HCC cases, the recurrence rate at 1 year after C-LIP was 77% (10 of 13 patients), while the local recurrence rate was 46% (six of 13 patients) at 6 months and 61% (eight of 13 patients) at 1 year. The local recurrence rate at 1 year was 29% (four of 14 patients) after TAE and 20% (three of 15 patients) after PEIT. These results showed that the effect of local anticancer therapy by C-LIP was not as potent as that of TAE or PEIT. In advanced HCC cases, the cumulative survival rate for 13 patients treated by C-LIP was 72% at 6 months, 36% at 1 year, and 14% at 2 years. However, the survival rates for 13 patients at 6 months, 1 year, and 2 years after TAE were 46%, 23%, and 8%, respectively. There was no difference between the C-LIP patients and TAE patients with regard to the pretreatment liver function. Three patients died within 2 months after the initial TAE. These deaths were mainly due to damage to the noncancerous liver parenchyma. Therapy with C-LIP alone was not appropriate for hypervascular solitary small HCCs, and additional treatment was necessary. We think C-LIP therapy should be selected instead of TAE for advanced HCCs to avoid severe parenchymal damage.

[Effects of long-term endurance training on left ventricular dimensions and function in female distance runners].

Ultrasoundcardiogram (UCG) was measured to evaluate the effects of 2 years of endurance training on left ventricular dimensions and function in 3 female collegiate runners (mean age 19.7 years). All subjects had had an experience in endurance training as athletes and underwent the endurance training at the college for two years. Training consisted mainly of about 2 hours of running, 3 to 4 days a week. Training effects were found as measured by a 5000m-run pretraining (mean 19: 40.3 min) and post-training (mean 18: 49.3 min). The average increase in maximal oxygen uptake (VO2max/kg) after training was 9.4% (P < 0.05). UCG's dimensional variables such as LVDd, LVPWT and IVST in the post-training period did not reveal any increase. However, LVDs as a cardiac dimension showed a tendency to decrease, and functional variables such as SV, EF, FS showed a tendency to increase. This functional improvement appeared to be due to a decrease in LVDs. From these results, it is likely that the endurance training prior to this study might have helped an effective adaptation in their cardiac dimensions. Thus, we suggest that prior to this study cardiac dimensions had extended and enlarged to a certain extent, and then cardiac function might be improved as the subsequent physiological phenomenon.

[MR imaging of corpus callosal injuries].

The MR imaging and CT findings of corpus callosal injury were analyzed in 32 of 224 patients with acute head injuries. MR imaging was more sensitive than CT in the detection of callosal injuries. All 9 hemorrhagic lesions were visualized on both MR imaging and CT. Fifteen of 23 nonhemorrhagic lesions were not visualized on CT, although all nonhemorrhagic lesions were visualized on MR imaging. Twenty-four lesions of the corpus callosum were located in the splenium, but no lesion was located in the rostrum. Diffuse axonal shear injuries were visualized in 25 patients with callosal injury as associated traumatic lesions. Twenty-three patients with callosal injury had low initial Glasgow Coma Scale scores (less than 9), but 9 patients had high scores. Associated diffuse axonal shear injuries, especially in the brain stem could be a possible explanation for this difference. MR imaging is useful to detect traumatic lesions of the corpus callosum.

Membranous lipodystrophy: MR imaging appearance of the brain.

Five patients with membranous lipodystrophy (lipomembranous polycystic osteodysplasia with progressive dementia) underwent magnetic resonance (MR) imaging of the brain. T2-weighted MR images showed atrophied cerebral white matter with dilated ventricles; increased signal intensity of the white matter; and decreased signal intensity of the thalamus, putamen, caudate nucleus, and cerebral cortex. Although each single finding is not specific, the combination of the above MR findings when coupled with skeletal lesions strongly suggests this rare disease.

Measurement of thyroid iodine by CT.

For evaluation of thyroidal iodine kinetics and thyroid nodules, we carried out quantitative in vivo measurement of thyroid iodine concentration by CT. Neuron activation analysis of iodine content was conducted on 48 thyroid fragments without calcification operatively obtained from 18 patients who had undergone CT of the thyroid without contrast enhancement. The CT attenuation values were obtained from the regions of interest in the CT image that corresponded to the analyzed fragment. When iodine concentration in the thyroid tissue was greater than 0.02 mg/g, the CT values correlated linearly with the iodine concentrations in thyroid nodules, thyroids with diffuse thyroid disease, and normal thyroids. The relationship is represented by the following formula: iodine concentration (mg/g) = (CT value-65)/104. The relationship between iodine concentration and CT value in diffuse thyroid disease, thyroid nodules, and normal thyroids was not significantly different.