Experience and technique for the endovascular management of iatrogenic subclavian artery injury.

BACKGROUND: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries. METHODS: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20 min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20 min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. RESULTS: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. CONCLUSION: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair.

Herpes simplex virus hepatitis: expanding the spectrum of disease.

We describe 2 transplant patients with herpes simplex virus (HSV) hepatitis who were minimally symptomatic throughout their illness. The spectrum of disease caused by HSV hepatitis is more variable than previously reported in this population. HSV hepatitis should be considered in immunocompromised hosts with elevated transaminases without evidence of fulminant hepatic necrosis.

Ileal pouch salvage following failed ileal pouch- anal anastomosis.

Attempts have been made to salvage failed ileal pouch-anal anastomoses (IPAA) performed for ulcerative colitis or familial polyposis coli. These can be categorized as total reconstruction of the IPAA, partial transabdominal approach, and partial transperineal approach. The aims of our study were to determine the overall success of pouch salvage; to examine the demographics, indications, and outcomes for each approach; and to assess anorectal physiology and patient satisfaction in those with successful salvage operations. We reviewed data, including results of anorectal manometry, from 29 patients undergoing salvage procedures for failed IPAA. Seventeen salvage attempts were successful, 11 attempts failed, and one patient was lost to follow-up. Success rates were 100% in the total reconstruction group, 25% in the partial transabdominal group, and 55% in the transperineal group. In those undergoing total reconstruction of the IPAA (n = 9), functional outcome, as measured by incontinence, improved with 50% reporting incontinence preoperatively compared to 0% postoperatively (P = 0.055). Mean 24-hour stool frequency and nighttime stool frequency declined. All patients reported satisfaction with their outcomes. Sixty percent of patients who underwent ileal pouch salvage following IPAA have been successful in avoiding permanent ileostomy. These results suggest that a continued effort to salvage failed IPAA, including the use of total reconstruction, is a viable alternative to permanent ileostomy.

Primary structure and functional expression of a cDNA encoding the thiazide-sensitive, electroneutral sodium-chloride cotransporter.

Electroneutral Na+:Cl- cotransport systems are involved in a number of important physiological processes including salt absorption and secretion by epithelia and cell volume regulation. One group of Na+:Cl- cotransporters is specifically inhibited by the benzothiadiazine (thiazide) class of diuretic agents and can be distinguished from Na+:K+:2Cl- cotransporters based on a lack of K+ requirement and insensitivity to sulfamoylbenzoic acid diruetics like bumetanide. We report here the isolation of a cDNA encoding a thiazide-sensitive, electroneutral sodium-chloride cotransporter from the winter flounder urinary bladder using an expression cloning strategy. The pharmacological and kinetic characteristics of the cloned cotransporter are consistent with the properties of native thiazide-sensitive sodium-chloride cotransporters in teleost urinary bladder and mammalian renal distal tubule epithelia. The nucleotide sequence predicts a protein of 1023 amino acids (112 kDa) with 12 putative membrane-spanning regions, which is not related to other previously cloned sodium or chloride transporters. Northern hybridization shows two different gene products: a 3.7-kb mRNA localized only to the urinary bladder and a 3.0-kb mRNA present in several non-bladder/kidney tissues.

Isolated systolic hypertension in the elderly: pathophysiology and treatment.

Isolated systolic hypertension (ISH) is a common clinical finding in the elderly population and appears to be a risk factor for cardiovascular morbidity and mortality. It appears feasible and safe to treat patients with various antihypertensive drugs; however, the morbidity and mortality benefits still need to be determined.

Twice-daily nicardipine in the treatment of essential hypertension.

The antihypertensive effect of twice-daily nicardipine, an investigational calcium-channel blocker, was evaluated in a placebo-controlled, single-blind trial in 18 adult patients with essential hypertension (supine diastolic blood pressure [BP] of greater than or equal to 95 and less than or equal to 120 mmHg). Following a 4-week run-in period in which patients received placebo for the final 2 weeks, nicardipine was administered for 12 weeks with a treatment goal of a supine diastolic BP of less than 90 mmHg at 12 hours postdosing or to a maximum dose of 60 mg twice daily. Supine and standing BPs and heart rates were determined at 1 hour and 12 hours postdosing. At all dose levels, supine and standing BPs were reduced at 1 hour after dosing, with partial loss of efficacy seen at 12 hours. Increases in heart rate seen at 1 hour were not significant at 12 hours. Eight patients withdrew from the study for minor, although troublesome, side effects, such as palpitations and headaches. These data suggest that nicardipine monotherapy given in a twice-daily dosing regimen has only a limited role to play in the chronic treatment of patients with essential hypertension.

Twice-daily administration of oral verapamil in the treatment of essential hypertension.

The antihypertensive effect of twice-daily administration of verapamil hydrochloride was evaluated in 21 adult patients with mild to moderate essential hypertension. Following four weeks of placebo therapy, verapamil was given for four weeks with a treatment goal of sitting diastolic blood pressure (BP) of less than 90 mm Hg, or to a maximum dose of 160 mg twice daily. Sitting and standing BPs, heart rate, and verapamil plasma levels were determined weekly, ten to 12 hours post dose. At the maximal dose (mean, 154 +/- 19.2 mg), heart rate was not affected, side effects were minimal, and sitting diastolic BP was significantly reduced from placebo baseline, with 12 of 21 patients having a fall in sitting diastolic BP of 10 mm Hg or more or less than 90 mm Hg. A trough verapamil plasma level of greater than 80 ng/mL was associated with a good hypotensive response. These data indicate the safety and utility of twice-daily verapamil administration for the treatment of essential hypertension and suggest the value of obtaining verapamil plasma levels as a guide to dosage determination.

Rest and exercise hemodynamic and adrenergic responses to enalapril, hydrochlorothiazide, and combination treatment in patients with systemic hypertension.

The effects of enalapril (10-20 mg twice daily), hydrochlorothiazide (25-50 mg twice daily), and combination enalapril-hydrochlorothiazide therapy (10-20 mg enalapril/25-50 mg hydrochlorothiazide in combination tablet twice daily) were evaluated and compared to no therapy (control) in eight patients with mild to moderate hypertension at rest and during treadmill exercise. All active treatments reduced standing blood pressure in patients at rest compared to the control group (p less than 0.05); however, none produced significant reductions of standing blood pressure in patients at peak exercise. Standing heart rates of patients at rest and at peak exercise were not changed with active therapy. However, standing heart rate in patients at rest was lower with enalapril than with hydrochlorothiazide and combination therapy (p less than 0.05). Heart rate of patients on hydrochlorothiazide was higher than with control and other therapies at Stage I of exercise (p less than 0.01). Supine norepinephrine levels in patients at rest were elevated with both hydrochlorothiazide and combination therapy when compared to that in patients with enalapril and control (p less than 0.05). Treatment with enalapril alone produced no changes in plasma catecholamine levels compared to control. There were no differences between control and all treatment regimens in peak exercise levels of catecholamines. Thus, enalapril, hydrochlorothiazide, and combination therapy, although effective in lowering resting blood pressure, may not be effective in blunting the blood-pressure response to exercise. The drugs do not appear to have any significant effects on catecholamine levels in patients at peak exercise.