Mechanical and enzymatic thrombolysis for massive pulmonary embolism.

PURPOSE: To assess the efficacy and safety of mechanical fragmentation combined with intrapulmonary thrombolysis in massive pulmonary thromboembolism (PTE) with hemodynamic impairment. MATERIALS AND METHODS: Fifty-nine patients diagnosed with massive PTE with hemodynamic impact were treated. The initial clinical symptoms were shock in 23 patients (38.9%), syncope in eight (13.5%), and dyspnea at rest in 28 (47.4%). Mean O2 saturation was 67.8%. Mean pulmonary artery pressure (PAP) was 42.1 mm Hg. During fragmentation, thrombolysis was administered in the form of a urokinase bolus of 200,000-500,000 U in 57 patients and 20 mg of recombinant tissue plasminogen activator (rt-PA) in two patients. The mean urokinase dose used was 2,500,000 IU, whereas the total dose of rt-PA was 100 mg. Heparin sodium infusion was performed to reach activated partial thromboplastin time ratios of 2. The follow-up consisted of clinical assessment, pulmonary scintigraphy, and echocardiography. The patients received treatment with dicoumarin for 6 months after the procedure. RESULTS: Clinical improvement was seen in 56 patients (94%). Three patients died. The mean PAP after the treatment was 21.8 mm Hg. The mean posttreatment Miller index was 0.35. Technical success was achieved in all cases and clinical symptoms improved in all cases except those in which the patients died. Pulmonary scintigraphy showed improved perfusion in all cases. Echocardiography was performed after 3-6 months, showing a mean pressure of 22.8 mm Hg (corrected values). There were no signs of recurrent PTE or arterial hypertension in the follow-up. CONCLUSION: The data provided confirm the efficacy and safety of mechanical fragmentation and pharmacologic thrombolysis in the treatment of massive PTE with hemodynamic impairment, showing improvement of symptoms and a decrease in PAP.

Animal experience in the Günther Tulip retrievable inferior vena cava filter.

PURPOSE: To assess the retrievability of the Günther Tulip temporary inferior vena cava filter from a technical viewpoint, and consider the histopathologic changes that occur at the anchoring site of the filter prongs to the vein endothelium in Landrace pigs. METHODS: Twenty-two Günther Tulip retrievable filters were inserted in 22 experimental Landrace pigs via the jugular vein. Device implantation time was 0, 3, 7, 12, 14, 15, 16, 20, 30, 35 and 56 days. Study subjects were divided into two groups. In one group the filter was retrieved percutaneously via the jugular vein whereas in the other group it was removed surgically. The specimens obtained (vena cava and filter) were histopathologically examined. Prior to filter retrieval, a venacavography was obtained in all cases. Degree of retrieval difficulty was rated as follows: no difficulty (N), slight (S), mild (M), high (H) and unretrievable (U). RESULTS: Of the 22 implanted filters, 11 should have been removed percutaneously but this was impossible in three cases (U). In four cases the device was retrieved with no difficulty (N); in two cases the degree of difficulty was mild (M) and in other two it was high (H) and slight (S) respectively. Retrieval difficulties were observed after 16 days. Starting from day 20, there was evidence of fibrosis with thick intimal proliferation and total filter prong involvement, which accounts for the difficulty in retrieving the device. CONCLUSIONS: It is advisable not to exceed a filter retrieval time of 16 days in view of the fibrotic changes reported. It might be necessary to perform a larger study with more animals and with retrieval times between 14 and 20 days.

Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery--results of a multicenter study.

PURPOSE: To evaluate the efficacy of treatment with self-expandable metallic stents for acute colonic obstruction before elective surgical resection. MATERIALS AND METHODS: In 71 patients with malignant obstruction seen from October 1993 through December 1996, lesions were located in the transverse colon in one patient, in the descending colon in 22 patients, and in the rectosigmoid region in 48. A total of 72 self-expandable metallic stents were implanted within 24 hours of diagnosis. RESULTS: Technical success was obtained in 64 patients (90%). In two cases (3%), it was not possible to advance across the obstructing mass. In five cases (7%), the prostheses were poorly positioned at the site of obstruction, requiring placement of a new stent in three cases. Clinical improvement and resolution of the obstruction were confirmed in 66 patients (93%) within 96 hours. Minor complications developed in nine cases (13%). One patient (1%) underwent surgery to resolve a colonic perforation caused by wires at the ends of the stent. The mean time between stent placement and surgery was 8.6 days (range, 6-16 days). CONCLUSION: Implantation of colorectal stents is a safe treatment of acute malignant colonic obstruction before resection.

Acute colorectal obstruction: stent placement for palliative treatment--results of a multicenter study.

PURPOSE: To evaluate the usefulness of stent implantation as a palliative treatment in patients with acute colonic obstruction who are not surgical candidates. MATERIALS AND METHODS: Twenty-four patients (eight women, 16 men; age range, 60-98 years) with acute colonic obstruction underwent colonic stent placement. In nine patients, the procedure was considered a primary palliative treatment; seven patients had a previous diagnosis of disseminated neoplastic disease, and two were not surgical candidates because of their poor general condition. In the remaining 15 patients, stent placement was considered the definitive palliative treatment after tumor staging. The mean time of follow-up was 8.4 months (range, 1-24 months) for patients who lived and 6.3 months (range, 1-12 months) for those who died. RESULTS: Stent placement was successful in all patients. Clinical and radiographic findings of bowel obstruction resolved within 24 hours after stent placement in 23 (96%) patients. None of the patients required colostomy for bowel decompression after immediate stent placement. Complications developed in 10 (42%) patients: Two (8%) patients had mild rectal bleeding; three (12%), abdominal pain; two (8%), malpositioning of the stent; two (8%), pseudo-obstructive episodes due to fecal impaction; and one (4%), occlusive tumor ingrowth into the stent lumen. One (4%) patient underwent surgery to resolve stent malfunction due to poor positioning. Two (8.3%) patients--one with malpositioning of the prosthesis and the other with stent occlusion--required a new stent. The remaining complications required no further treatment. The mortality rate at 6 months was 24%. Eight patients were alive at the time this article was written. CONCLUSION: Colorectal stent placement resulted in successful palliation of acute colonic obstruction in patients with disseminated neoplastic disease.

[Treatment of acute colorectal obstructions by implantation of expandable metal prosthesis]. / Tratamiento de las obstrucciones colorrectales agudas mediante implantación de prótesis metálicas expandibles.

PURPOSE: To determine the efficacy of colorectal stents implanted through the anus for the treatment of acute intestinal occlusion before elective surgery. MATERIAL AND METHODS: 25 patients (3 females and 22 males) with a mean age of 62.5 years (range: 49-94), were diagnosed of lower intestinal occlusion due to neoplasm. In all cases, an expandable metallic stent was implanted through the anus during the first 24 h. X-ray studies, tumoral staging and surgical preparation were performed in all cases. RESULTS: Implantation of stent was successful in 23 patients (92%). Clinical improvement of intestinal occlusion was observed in 24 hours. Criteria of no-resectability were found in five patients (20%). The remaining patients (18 cases) were treated by tumoral resection and end-to-end anastomosis an average of 8.6 days there after. No complications were observed and the patients were discharged 8.3 days after surgery. CONCLUSION: The implantation of colorectal stents before elective surgery constitutes a good alternative to surgery in the acute lower intestinal occlusion (left colon and rectum-sigmoid emergency).

Traumatic aneurysm of the internal carotid artery: a late finding presenting as a mass in the sphenoid sinus.

We describe a case of a traumatic aneurysm of the cavernous portion of the internal carotid artery in a patient who had had craniofacial trauma 12 years before. MR and CT revealed a mass in the sphenoid sinus thought to be unrelated to the patient's symptoms. Carotid angiography gave the correct diagnosis.

New procedure for the treatment of colorectal neoplastic obstructions.

PURPOSE: A new procedure for the treatment of colorectal neoplastic obstructions is described. METHODS: This procedure involves the following phases: 1) placing a stent at the point of the stenosis of the colon, which enables the acute obstruction phase to be overcome; 2) recovering the general state of the patient, analyzing the development of the disease, and mechanically preparing the colon; 3) performing regulated and final surgery. RESULTS: In two patients, these three phases have been completed without complication and with excellent results. CONCLUSION: This procedure is both safe and effective and could become the method of choice for the treatment of colorectal neoplastic obstructions.

[Current status of transcatheter arterial embolization in urology]. / Actualidad de la embolización arterial transcatéter en urología.

We report our experience of 155 transcatheter arterial embolization (TAE) procedures performed over a period spanning 12 months. The changes relative to the therapeutic approach in renal tumors are discussed. Palliative TAE has increased in comparison to presurgical TAE and the range of possibilities in benign renal pathological conditions has been extended (trauma, hemorrhage, hypertension, etc.). The morbidity ascribable to this technique continues to be low. New embolization materials (ethanol, fine particles, etc.) that are more effective and produce less side effects have become available. To date, TAE continues to be a highly effective therapeutic modality with specific indications and scant morbidity.

[New permanent expandable prosthesis for the treatment of urethral stenosis]. / Nueva protésis autoexpandible permanente en el tratamiento de la estenosis de uretra.

The paper presents our initial experience in the treatment of urethral stenosis through implantation of a "Wallstent" self expanding resident prosthesis. A total of eleven prosthesis were placed in 10 patients with excellent results, from a clinical, urodynamic, radiological and endoscopic point of view, in 9 of them after 5 months. We believe that this kind of prosthesis can be a valid alternative to other established therapeutic options in the management of urethral stenosis. Long-term monitoring, however, will be necessary in order to corroborate the excellent results obtained in this short/medium-term observation.