Video-thoracic surgery for treatment of end-stage bullous emphysema and chronic obstructive pulmonary disease.

Surgical treatment of emphysema and chronic obstructive pulmonary disease (COPD) has received renewed attention because of advances in instrumentation and techniques. Our approach includes video-assisted thoracotomy, neodymium-Yag and KTP laser plication of emphysematous bullae, pulmonary resection using reinforced stapling, and pleurodesis: reduction pneumonoplasty. In a 9-month period, 28 patients (age 52 to 78, 23 men and 5 women) with end-stage disease underwent reduction pneumonoplasty. Oxygen therapy was required in 82 per cent, steroid therapy was used in 86 per cent, and the preoperative FEV1 averaged 0.68 +/- 0.05. The most severely diseased lung was determined by physical, chest film, and CT scan, and this lung had reduction pneumonoplasty. There were no hospital mortalities. Prolonged postoperative air leaks occurred in 42 per cent of patients. Postoperatively FEV1 was 0.91 +/- 0.35. Lung size (chest film) showed 21.6 per cent reduction in volume. Subjective improvement was noted in 78.6 per cent (22/28) of patients, and no patient reported worse symptoms. Half of the steroid-using patients required a reduced steroid dose or no steroid therapy, and 5/23 (21.7%) patients had reduced oxygen requirements. Reduction pneumonoplasty can improve the symptoms of severe emphysema and COPD. Our results with treatment of one lung suggest that further improvement may be anticipated by proceeding with surgery for the contralateral lung.

Bilateral iliac vein filtration. An effective alternative to caval filtration in patients with megacava.

Greenfield filters were placed bilaterally in the iliac veins in five of 250 patients undergoing percutaneous filter placements. Four of the five patients had megacava (inferior vena cava diameter greater than 28 mm). In all patients, the filters were effective in preventing pulmonary embolism. Follow-up at 9 months in two patients revealed no changes of chronic venous insufficiency or venous stasis. Iliac filtration should be considered in patients in whom a caval filter cannot be placed because of large caval size or because it is technically difficult due to iliac vein tortuosity.

Acute limb ischemia due to arterial embolism of tumor.

Arterial tumor embolism is a rare occurrence. We report such an embolus causing acute limb ischemia which was the first indication of malignancy in a patient who subsequently proved to have malignant melanoma.

Thrombotic complications of indwelling central catheters used for chronic hemodialysis.

A new double-lumen silicone-rubber dialysis catheter, designed to be placed surgically in central veins, is now available. There is little published data concerning the long-term use of this catheter for hemodialysis, but a review of the literature suggests that pericatheter thrombus formation with or without occlusion of major veins has been a complication of chronic central venous catheterization with a variety of catheters, in both dialysis and nondialysis settings. We had this catheter placed in four diabetic patients who had severe problems related to maintenance of adequate vascular access. Two of the four patients underwent venography within 3 months of catheter placement because of impaired catheter function and were found to have thrombi on the outside of their catheters. These thrombi could not be dissolved with fibrinolytic agents, and the catheters were removed surgically without incident. The other two patients have no radiologic evidence of thrombus formation 4 and 7 months, respectively, after catheter placement. We suggest that proper selection of patients for this type of vascular access should be the subject of future studies and that patients with malfunctioning catheters undergo venography to rule out the presence of significant catheter related thrombosis.

Greenfield filter placement via the femoral vein: improved technique with extra-long sheath and purse-string suture.

An improved technique for percutaneous placement of Greenfield filters via the femoral vein is described. The technique involves the use of an extra-long sheath for filter placement and the application of a purse-string suture at the venipuncture site to facilitate hemostasis.

Coagulation of aneurysms by direct percutaneous thrombin injection.

We describe a new technique for clotting aneurysms by direct injection of diluted thrombin through a fine needle or cannula. The four patients treated had pseudoaneurysms of the iliac, femoral, and peroneal arteries, and a true aneurysm of an accessory hepatic artery. Five hundred to one thousand (500-1000) units of thrombin were injected into the aneurysmal sac only when there was blood stasis, either de novo or induced by occlusion of the feeding vessel. No significant complications ensued.

Arterial and venous embolization: declotting of dialysis shunts by direct injection of streptokinase.

During the past 33 months, thrombolysis of 79 clotted hemodialysis shunts was attempted by injecting small quantities of dilute streptokinase solution directly into the clotted shunt, followed by massage of the clot. Embolization of clot fragments in six of 79 cases (7.6%) was demonstrated angiographically. In four of the six cases embolization involved the brachial artery or its branches. In one case embolization involved an arm vein, and in one case embolization involved both the brachial artery and axillary vein. All patients remained asymptomatic, and repeat angiographic study, usually performed the following day, showed resolution of the emboli in four of five cases. The incidence of embolization in direct-injection thrombolysis reported in this study appears to be comparable to that reported in studies using the streptokinase infusion technique.

Failed hemodialysis shunts. One year of experience with aggressive treatment.

Thirty-three failed hemodialysis access shunts in 26 patients were treated by streptokinase declotting and/or transluminal angioplasty over a period of one year. Seventeen (52%) were restored to function without surgical intervention; 7 (21%) had restoration of flow but required surgical correction of an underlying problem such as a pseudoaneurysm or vascular stenosis which resisted angioplasty; and 9 (27%) showed no improvement. The authors discuss their technique as well as causes of shunt failure, those lesions likely to be improved by declotting and/or angioplasty, and reasons for treatment failure and recurrent thrombosis.

Optimal use of tolazoline in arteriography.

Intraarterial tolazoline, injected before the contrast medium in peripheral and visceral arteriography, has been shown to enhance the diagnostic value of the examination by inducing vasodilation. The time of maximal dilatation after injection, however, has not been clearly established. Photophlethysmography (PPG) was used to measure blood flow changes in 20 consecutive patients with lower-extremity arterial disease at rest and during the first 10 min after intraarterial tolazoline injection. Neither time to maximal dilatation (mean, 5.9 +/- 2.1 min) or PPG amplitude increase (mean, 251 +/- 177.2%) was significantly affected by the level of disease, severity of disease, or number of vessels present at the ankle. To make optimal use of tolazoline's vasodilatory effect, a waiting period of 6 min is recommended between tolazoline administration and contrast-medium injection in peripheral arteriography.

Angiographic, radiographic, and computed tomographic findings in tuberculosis of the jejunum.

Tuberculous involvement of the jejunum with thickening and infiltration of the bowel wall and subsequent gastrointestinal hemorrhage from multiple bleeding points was encountered. Bleeding could not be controlled by intra-arterial vasopressin infusion. To our knowledge this is the first report of angiographically demonstrated and treated tuberculous gastrointestinal hemorrhage.

Pseudoaneurysms after nephrostomy.

Significant persistent or recurrent bleeding associated with renal arterial pseudoaneurysms was noted in three of 300 nephrostomy procedures. The angiographic diagnosis was made at 9, 6, and 21 days after nephrostomy. The lesions were successfully treated by embolization in two and by intimal dissection in one. The arterial tears were caused by a 16 gauge Teflon-sheathed needle inserted too deeply into the kidney. It is suggested that the lesions can be largely prevented by using only 22 gauge needles for renal puncture and dilating the skinny needle tract by a special guide wire exchanger. A renal angiogram should be obtained promptly if the urine continues to be grossly bloody 3-4 days after nephrostomy. Embolization of a bleeding segmental renal vessel is simple and safe, whereas a conservative approach may lead to severe complications.

Hypertrophy of the parotid gland: computed tomographic findings.

Parotid gland hypertrophy, usually bilateral, is associated with a number of altered metabolic states. Occasionally unilateral hypertrophy occurs, suggesting parotid neoplasia. Because of increased lipid material within the hypertrophied gland, computed tomographic (CT) scanning may suggest the diagnosis, obviating surgery. Sialographic and CT appearances of parotid hypertrophy and the relationship between it and parotid lipoma are discussed.

Enterolithiasis associated with ileal perforation in Crohn's disease.

Calcified enteroliths are an uncommon sign of stasis of intestinal contents in the distal small intestine, usually caused by Meckel's diverticulum, Crohn's disease or other stenosing lesion. Although enteroliths are occasionally associated with intestinal obstruction the clinical picture in this case was dominated by perforation of the ileum by a small enterolith. The relevant literature is discussed.

Angioneurotic edema following ingestion of iocetamic acid.

A case of angioneurotic edema involving the left upper extremity following iocetamic acid ingestion is reported. This is the fifth reported case of a severe cutaneous reaction following ingestion of this material. The author suggests that iocetamic acid not be used in outpatients.