Portal-systemic myelopathy after transjugular intrahepatic portosystemic shunt creation: report of four cases.

The authors attempted to describe the clinical manifestations of portal-systemic myelopathy (PSM) after transjugular intrahepatic portosystemic shunt (TIPS) creation. PSM was developed in four of 212 (1.89%) patients who underwent TIPS procedures in our hospital. Three men and one woman, ranging in age from 41 to 56 years, with a history of posthepatitis cirrhosis and recurrent bleeding from gastroesophageal varices had intrahepatic shunts created with 10-mm-diameter Wallstents. Shunt patency was confirmed by color Doppler ultrasonography (US) in each patient after TIPS creation. Progressive spastic paraparesis involving the lower extremities occurred between 5 weeks and 5 months after TIPS creation in the four patients. Neurologic examination showed evidence of spasticity in all cases, with ankle clonus, extensor plantar responses, and lower extremity hyperreflexia. All sensory modalities remained intact. Cytologic examination of cerebrospinal fluid from each patient was normal. There was no evidence of spinal cord compression on the imaging studies. PSM is a rare syndrome that includes spastic paraparesis with intact sensation. Initially noted in patients who have undergone surgical placement of a portacaval shunt, it also may occur after TIPS creation.

Isolated lower extremity chemotherapeutic infusion for treatment of osteosarcoma: experimental study and preliminary clinical report.

PURPOSE: To increase the dose of drug delivered to a tumor while maintaining tolerable systemic side effects, an interventional technique of isolated lower extremity infusion was investigated. MATERIALS AND METHODS: Experiments were performed in eight dogs. Four dogs were treated by a combination of intraarterial (IA) femoral cisplatin infusion at a dose of 2.0 mg/kg with drug removal from the ipsilateral extremity venous blood by a dialyzer. The other four dogs comprised the control group. In these animals, left femoral arterial IA cisplatin infusion was performed without dialysis. Leukocyte and platelet counts, blood urea nitrogen (BUN) levels, and serum creatinine levels were recorded before and after the treatment. Subsequently, two human patients with inoperable osteosarcoma were treated with the isolated infusion. RESULTS: In the experiments, 85%-90% of the free platinum that entered the dialyzer was removed. The peak systemic plasma cisplatin concentrations in animals undergoing dialysis were reduced by 81.25% compared to those in animals undergoing femoral IA infusion without hemodialysis. There were no significant changes in the hematologic profiles or BUN and serum creatinine levels in the experimental animals. However, in the control group, all dogs developed myelosuppression and severe renal toxicity after IA infusion of the same dose of cisplatin. Clinically, immediate relief of symptoms related to the primary tumor was achieved in both human patients after the combination of isolated IA infusion and embolotherapy. CONCLUSION: Single-pass hemodialysis removed a significant amount of cisplatin after regional IA infusion, reduced systemic toxicity, and permitted survival of the experimental animals. In two patients with osteosarcoma, percutaneous isolated lower extremity chemotherapeutic infusion therapy and embolotherapy were performed safely with partial responses.

Bronchial arteriography and transcatheter embolization in the management of hemoptysis.

PURPOSE: The purpose of this study was to determine the factors influencing the effect of bronchial artery embolization in treating massive hemoptysis and the value of bronchial arteriography in the evaluation of patients with hemoptysis. METHODS: Thirty-five patients with acute hemoptysis were evaluated by means of bronchial arteriography and treated with transcatheter embolization. Specific causes for bleeding were bronchiectasis (17), lung cancer (9), tuberculosis (4), tetralogy of Fallot (1), and idiopathic hemoptysis (4). The materials used for embolization were gelatin sponge in 33 patients, dextran microspheres in 2, and stainless coils in 1. RESULTS: The angiographic signs of hemorrhage encountered were extravasation of contrast media (14.2%), hypervascularization (94.5%), bronchopulmonary shunts (34.2%), and bronchial artery aneurysms (14.2%). Immediate control of bleeding occurred in 32 (91.4%) of 35 patients after embolization. The rate of recurrent hemoptysis was 20.0% after 2 weeks of the procedure, but the hemorrhage was less severe than before treatment. CONCLUSION: The data suggest that bronchial artery embolization is an effective method for managing patients with hemoptysis. Minor bleeding recurrences appear to be relatively frequent.

Transjugular intrahepatic portosystemic stent shunts. Preliminary results in 18 patients.

In 18 consecutive patients receiving the transjugular intrahepatic portosystemic stent shunts (TIPSS), 15 were male and 3 female. The patients aged from 34 to 66 years had liver cirrhosis with portal hypertension and esophageal varices. Twelve had recurrent bleedings from raptured gastroesophageal varices. Shunts were established in 16 of the 18 patients and no operative death was noted. Portal vein pressure was reduced from 3.98 +/- 0.24 kPa before shunting to 2.40 +/- 0.16 kPa after shunting. Doppler ultrasound examination revealed that the maximum blood flow velocity in the main portal vein increased from 14.0 +/- 4.5 cm/sec to 48.0 +/- 16.5 cm/sec. The mean follow-up time in the successful cases was 4.5 months (range 2-8 months). The shunt patency was determined with color Doppler ultrasound in 15 patients: occlusion in one and no accites in 4. Varices disappeared in 8 patients and became less evident in 7. No patients had recurrence of varices bleeding or encephalopathy during follow-up. The results suggest that TIPSS is a safe and effective method for portal decompression in the treatment of variceal hemorrhage, and that portal vein puncture is largely dependent on understanding the three-dimensional relationships between hepatic and portal veins. To achieve an adequate portal decompression, we recommend that a stent of 12 mm in diameter be used in severe cases.