Color Doppler assessment of folliculogenesis in in vitro fertilization patients.

OBJECTIVES: To characterize hemodynamics of human ovarian follicles in the course of their development and to compare the results in relation to the age of patients, pregnancy, location of the ovary, and the quality of the oocytes. DESIGN: Serial measurements of peak velocity and resistance index by color Doppler imaging. SETTING: The In Vitro Fertilization Clinic, Success Through Assisted Reproductive Technologies, Inc., Toronto, Ontario, Canada. PATIENTS: Fifty-two women undergoing hormonal stimulation for IVF. MAIN OUTCOME MEASURES: The perifollicular peak velocity and resistance index values. RESULTS: The perifollicular peak velocity values were gradually increasing with the increasing size of the follicles. Highly significant elevation of the peak velocity was observed especially after hCG injection. Such rapid rise of blood velocity was greater in the right ovary than in the left in the younger patients (mean age, 34 years) whereas in older patients (mean age, 41 years), the greater values were observed in the left ovary. There was no significant difference in peak velocity or resistance index between pregnant and nonpregnant patients. CONCLUSIONS: There is a strong, positive correlation between the size of ovarian follicles and their peak velocity, which suggests an increase of blood flow around developing follicles in the course of the follicular phase. Human chorionic gonadotropin plays an important role in inducing influx of blood within follicles; however, the significance of this event remains obscure. It appears that the resistance index is not a useful parameter for characterization of the intrafollicular flow. Changes in peak velocity did not correlate with oocyte quality and may have no predictive value for IVF outcome.

Transjugular intrahepatic portosystemic shunt: a nonoperative approach to life-threatening variceal bleeding.

Portosystemic venous shunts may be created nonoperatively with a Grüntzig balloon dilatation catheter using the transjugular route. The authors achieved technical success with this shunt in 15 of 20 patients with life-threatening gastrointestinal bleeding from variceal hemorrhage. All patients but one were considered at high risk for surgery because of end-stage liver disease; the exception was a patient in whom two previous operative portosystemic shunts had failed. An average decrease of 5.9 mm Hg in portal vein pressure was measured in 11 patients for whom sequential pressures could be obtained. Two patients survived longer than 12 months without subsequent operative procedures, and the shunt helped temporize in three other patients who later underwent operation. Nine patients with successful shunts died within 30 days of the procedure, comparing favourably with reported operative death rates of 40% to 80% in emergency shunt procedures. Follow-up portal venograms demonstrated shunt patency in six of nine patients, in one after 8 months. Tract patency was determined in four of seven patients on whom autopsy was performed, up to 6 months after the transjugular intrahepatic portosystemic shunt was created.

Transluminal angioplasty of complete iliac obstructions.

Of 64 complete iliac obstructions, 50 (78%) were recanalized using the Gruntzig balloon catheter. Life-table analysis of the patency rate over a 4-year period gives a cumulative success rate of 78%. Only three of eight obstructions that involved both the common and external iliac arteries were successfully dilated. The only serious complication was distal embolization, which occurred in two cases (3.1%). Although the procedure is difficult, with a relatively low technical success rate, the high cumulative patency rate should make it an option in the treatment of all patients with totally occluded iliac artery segments.

Transjugular liver biopsy: a review of 461 biopsies.

Transjugular liver biopsy was performed in a large series of patients for whom routine percutaneous biopsy was contraindicated; most of the patients had severe liver disease associated with coagulopathies or massive ascites. Of the 461 biopsies performed over a 7-year period, adequate specimens for histologic diagnosis were obtained in 425; in 14 (3.3%), the biopsy provided a false-negative result. Minor complications such as neck pain, hematoma at the puncture site, or pyrexia occurred in 79 patients (17.1%). Serious complications were encountered in six patients (1.3%) (two with cardiac arrhythmias; four with intraperitoneal hemorrhage following capsular perforation), with an overall mortality rate for the series of 0.22%. Modification of the technique--taking the biopsy with the catheter positioned centrally rather than wedged peripherally--has reduced the occurrence of capsular perforation without affecting the success rate. Transjugular liver biopsy is a valuable technique that provides diagnostic information in a high proportion of cases in which conventional percutaneous biopsy is contraindicated.

Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience.

Six patients with advanced cirrhosis and portal hypertension had life-threatening upper gastrointestinal hemorrhage from esophageal varices. The varices were obliterated angiographically, using the transjugular approach, after which an intrahepatic portosystemic shunt was created in each case by inflating the balloon of a Grüntzig dilatation catheter in the needle tract between the portal and hepatic veins. All of the patients were expected to succumb quickly to their severe liver disease and massive variceal bleeding, but three of the six survived the initial hemorrhage, and two of these were discharged from hospital. There was an initial reduction of portal venous pressure of 10-15 mm Hg in all patients. All six shunts were patent angiographically 12 hr after the procedure. Two patients had venograms 5 days later and both shunts were patent. All six patients died within 6 months, but in three of the four postmortem examinations the shunts were easily identified and shown to be patent, the last of these 6 weeks after the procedure. These findings suggest that the technique could be of therapeutic value in the management of patients with portal hypertension.

Percutaneous transluminal dilatation of the renal artery: follow-up studies on renovascular hypertension.

Percutaneous transluminal dilatation of 80 renal artery stenoses was attempted in 68 patients. The procedure was technically successful in 58 (85%) patients. Fifty (86%) of the 58 patients were initially cured or improved. Life-table analysis of this group gives a cumulative success rate of 81% for a 3 year period. Hypertension recurred in only seven patients. There were no deaths related to the procedure, but four major complications occurred, including two secondary nephrectomies.