Pulmonary hypertensive crisis following ethanol sclerotherapy for a complex vascular malformation.

Anhydrous ethanol is a commonly used sclerotic agent for treating vascular malformations. We describe the case of a full-term 15-day-old female with a complex venolymphatic malformation involving the face and orbit. During treatment of the lesion with ethanol sclerotherapy, she suffered acute pulmonary hypertensive crisis. We discuss the pathophysiology of pulmonary hypertension related to ethanol sclerotherapy, and propose that hemolysis plays a significant role. Recommendations for evaluation, monitoring and management of this complication are also discussed.

Endovascular abdominal aortic aneurysm repair in 144 patients: correlation of aneurysm size, proximal aortic neck length, and procedure-related complications.

PURPOSE: During endovascular abdominal aortic aneurysm (AAA) repair, larger aneurysms often present formidable anatomic challenges to the insertion of the delivery catheter and graft deployment. The authors sought to evaluate whether large-diameter aneurysms and those with short proximal aortic necks might be associated with a higher frequency of insertion-related and short-term complications. MATERIALS AND METHODS: From October 1999 to August 2000, 144 patients underwent elective endovascular graft placement for infrarenal AAA disease at the authors' institution. These patients were treated with use of the AneuRx bifurcated endoprosthesis. AAA size (maximum aneurysm diameter) and proximal aortic neck length were compared to estimated blood loss, operative time, accuracy of graft placement, presence of endoleak, intraoperative and postoperative complications (such as limb occlusion or vascular injury), length of hospital stay, and mortality. Statistical methods included correlation analysis and logistic regression. RESULTS: There were 121 men and 23 women whose aneurysms ranged in size from 3 cm to 9.8 cm (mean, 5.6 cm; 95% CI, 5.4-5.8 cm). Endograft insertion was successful in all cases. There were three deaths within 30 days (2.1%) and seven deaths overall (4.9%). There were 43 intraoperative complications (29.9%) in 31 patients (21.5%), most of them minor. Patients with major intraoperative complications had significantly longer procedure times than those without complications (337 vs. 149 min; P <.0001). In the postoperative period (within 30 days), 31 complications (21.5%) occurred in 28 patients (19.4%), again most of them minor. AAA size was unrelated in any way to the rate of complications, but short proximal aortic neck length was associated with more serious intraoperative and postoperative complications (P =.0404 and P =.0230, respectively), and decreased 30-day and overall survival (P =.0240 and P =.0152, respectively). CONCLUSIONS: Endovascular repair of large AAAs can be challenging; however, the size of the AAA does not influence the rate of complications. A short proximal aortic neck is the only significant risk factor for more serious complications.

Use of aortic cuffs to exclude iliac artery aneurysms during AneuRx stent-graft placement: initial experience.

PURPOSE: As many as 39% of patients who undergo aortic endografting for abdominal aortic aneurysm disease will have ectasia of the iliac arteries that will require intervention. Coil embolization of the internal iliac artery and extension of the graft to the external iliac artery is one solution to this problem. However, 19%-41% of these patients experience buttock claudication, which may be permanent, after unilateral embolization. The authors examined an alternative: the use of larger-sized aortic cuffs to seal the iliac limb. Outcomes and short-term results are presented in this article. MATERIALS AND METHODS: From October 1999 to August 2000, 144 AneuRx stent-grafts were placed at the authors' institution. Among the population receiving stent-grafts, 14 patients had 15 aortic cuffs placed across the distal iliac graft limbs to seal them and preserve flow to the internal iliac artery. One patient had bilateral cuffs placed. Five patients had embolization of the contralateral internal iliac artery because of bilateral disease. Patients were followed with computed tomography (CT) at 1, 6, and 12 months to evaluate for endoleaks. RESULTS: One- and 6-month endoleak rates, determined from only those patients with follow-up CT, were 0% and 10%, respectively. One type II endoleak was first discovered 9 months after graft placement. It sealed spontaneously at 15-month follow-up. One patient among the five who had internal iliac artery embolization had claudication. Mean CT follow-up was 7.8 months (range, 1-15). One patient declined CT but was alive and well 11 months after endografting. One patient moved across the country and declined follow-up. CONCLUSION: Placement of aortic cuffs in dilated iliac arteries can preserve flow to the ipsilateral internal iliac artery and provide an adequate seal. Additionally, the option of later treatment is maintained. Patients with bilateral iliac ectasia can undergo stent-graft placement without bilateral internal iliac artery embolization. Longer-term follow-up in larger numbers of patients will be important to determine the ultimate durability of this technique.

Elevated plasma levels of matrix metalloproteinase-9 in patients with abdominal aortic aneurysms: a circulating marker of degenerative aneurysm disease.

PURPOSE: Matrix metalloproteinase-9 (MMP-9) is abundantly expressed in abdominal aortic aneurysms (AAAs), where it plays a pivotal role in connective tissue destruction. Elevated plasma concentrations of MMP-9 (MMP-9PL) also have been reported in patients with AAAs, but it is unclear if this can distinguish patients with AAAs from those with atherosclerotic occlusive disease (AOD). The purpose of this study was to further define the utility of elevated MMP-9PL levels in the diagnosis and evaluation of AAAs, and to examine if changes in MMP-9PL can be used as a functional biomarker of degenerative aneurysm disease. MATERIALS AND METHODS: Peripheral venous blood was obtained from 25 patients with AAAs, 15 patients with AOD, and five normal control subjects. MMP-9PL levels were determined by an enzyme-linked immunosorbent assay. In four patients undergoing open AAA repair, MMP-9PL levels were directly compared with the amount of MMP-9 produced in aortic tissue. Six additional patients undergoing operative AAA repair were followed for 3-10 months to determine how treatment affected elevated MMP-9PL concentrations. RESULTS: Mean (+/- SE) MMP-9PL was 36.1 +/- 7.7 ng/mL in normal control subjects, 54.7 +/- 10.5 ng/mL in patients with AOD, and 99.4 +/- 17.4 ng/mL in patients with AAAs (P < .05 versus normal control subjects and patients with AOD). Elevated MMP-9PL levels (> 87.8 ng/mL) were found in 12 of 25 (48%) patients with AAA but in only one of 15 (7%) patients with AOD (P < .05). MMP-9PL levels did not correlate significantly with either age, gender, or aneurysm diameter, although there was a trend toward the highest values in male patients with large AAAs. Production of MMP-9 in aneurysm tissues paralleled MMP-9PL levels, and elevated MMP-9PL levels decreased by 92.7% +/- 3.2% after surgical AAA repair. CONCLUSIONS: Elevated MMP-9PL levels were observed in approximately one half of patients with AAAs and less than 10% of those with AOD (positive predictive value of 92.3%), but normal MMP-9PL levels had limited utility in excluding the presence of an aortic aneurysm (negative predictive value, 52%). MMP-9PL levels in patients with AAAs appeared to directly reflect the amount of MMP-9 produced within aneurysm tissue, and MMP-9PL levels decreased substantially after aneurysm repair. Measures of circulating MMP-9 may provide a biologically relevant marker of connective tissue metabolism in patients with AAAs.

A review of selective salpingography and fallopian tube catheterization.

Use of selective salpingography and fallopian tube recanalization has revolutionized the diagnosis and treatment of infertility. Selective salpingography, a diagnostic procedure in which the fallopian tube is directly opacified through a catheter placed in the tubal ostium, has been used since the late 1980s to differentiate spasm from true obstruction and to clarify discrepant findings from other tests. In fallopian tube recanalization, a catheter and guide wire system is used to clear proximal tubal obstructions. The recanalization procedure is simple for interventional radiologists to perform and is successfully completed in most patients (71%-92%). Pregnancy rates after the procedure have been variable, with an average rate of 30%. The combination of selective salpingography with fallopian tube recanalization has improved the overall management of infertility caused by tubal obstruction. The same catheterization technique used in fallopian tube recanalization is currently being explored for use in tubal sterilization.

Angioscopic observations after percutaneous thrombectomy of thrombosed hemodialysis grafts.

PURPOSE: To use angioscopy to evaluate and compare the amount of residual thrombus and endoluminal wall damage in hemodialysis grafts after percutaneous thrombectomy procedures. MATERIALS AND METHODS: Thirty-nine thrombectomy and angioscopy procedures were performed in 35 patients. Percutaneous thrombectomy methods included eight different mechanical thrombectomy devices and the "lyse and wait" technique. Videotaped images of 33 angioscopic examinations were independently reviewed by three radiologists. Two parameters-the amount of residual thrombus and degree of endoluminal wall damage-were scored on a scale of 1 to 5. Data were initially analyzed to validate the grading system and then further studied to compare the different thrombectomy techniques. RESULTS: The Spearman rank order analysis validated the data pertaining to the amount of residual thrombus (r = 0.71, P < .0001), but there was poor correlation between reviewers regarding the degree of endoluminal wall damage. Combined scores from three reviewers revealed that the Cragg brush and Percutaneous Thrombectomy Device (PTD) left the smallest amounts of residual thrombus. The other methods tested, listed by increasing amount of residual thrombus, were the Endovac, Hydrolyser, Amplatz Thrombectomy Device, AngioJet, Oasis, and the lyse and wait technique. There were two complications related to angioscopy procedures. CONCLUSION: Subjective observations reveal that wall-contact thrombectomy devices leave less residual thrombus than hydrodynamic devices, aspiration devices, or the lyse and wait technique.

Tc-99m sulfur colloid scintigraphy for detecting perigraft flow following endovascular aortic aneurysm repair: A feasibility study.

PURPOSE: To determine if scintigraphy with Tc-99m sulfur colloid can be used to detect perigraft flow after stent-graft repair of abdominal aortic aneurysm (AAA). METHODS: Twenty-three men and two women aged 56-84 years (mean 71 years) underwent endoluminal AAA repair as part of the EVT Phase II trial [EVT = Endovascular Technologies (Menlo Park, CA, USA)]. Aneurysm size averaged 5.4 cm (range 3-8 cm). Sixteen bifurcated, seven tube, and two aorto-uniiliac grafts were placed. Two days after stent-graft placement, patients underwent both contrast-enhanced computed tomography (CT), including delayed views, and Tc-99m sulfur colloid scintigraphy. RESULTS: Perigraft flow was found in only one patient at completion of angiography. Four additional patients had perigraft flow, discovered during their postoperative follow-up CT. Four patients had leaks at an attachment site and one had retrograde branch flow. Tc-99m sulfur colloid scintigraphy failed to diagnose any of the five leaks prospectively. In two of these patients, however, some abnormal paraaortic activity was noted in retrospect. CONCLUSION: Tc-99m sulfur colloid scintigraphy was unable to demonstrate endoleak with either rapid flow (attachment site leak) or slow filling (branch flow).

Transrectal versus transvaginal abscess drainage: survey of patient tolerance and effect on activities of daily living.

PURPOSE: To evaluate patient perception of pain related to transrectal and transvaginal drainage and the catheter's effect on activities of daily living. MATERIALS AND METHODS: From July 1993 to August 1997, 22 male and 40 female patients (mean age, 41 years; age range, 4-80 years) underwent transrectal or transvaginal aspiration or drainage. Fifty-seven drainages were performed. In a follow-up survey, patients were asked to score pain experienced during the procedure and afterward on a scale of 1-10 and to rate the effect of the catheter on their activities of daily living. RESULTS: Twenty-two patients participated in the telephone survey. For those able to recall the insertion procedure, the mean pain score was 3.2 for transrectal and 5.9 for transvaginal drainage. Mean indwelling catheter pain was 1.6 for transrectal and 4.8 for transvaginal drainage. Pain after removal was 1.4 for transrectal and 2.3 for transvaginal drainage. Only one patient with a transrectal catheter reported severe limitation (bowel movement), with no reports of any serious effect on urinating, bathing, sitting, or walking. Transvaginally placed catheters caused marked limitation in all categories and were more painful than transrectal catheters (P < .05). CONCLUSION: Of the transrectal and transvaginal approaches, transrectal is better tolerated.

Randomized comparison of laparoscopic and open lymphadenectomy in pigs.

OBJECTIVE: To compare the efficacy of open and laparoscopic lymphadenectomy and validate an objective model of lymph node retrieval using lymphangiography in pigs. METHODS: Twenty-five pigs weighing 54-75 lbs were randomly assigned by side to open or laparoscopic pelvic and paraaortic lymphadenectomy. Lymph node yield, quantified by a masked pathologist, operative time, complications, blood loss, and other variables were recorded. Lymphangiography was done, and radiographs were taken before and after lymph node harvesting. Statistical analysis used McNemar test for nominal data and paired Student t test or Wilcoxon signed-rank test for continuous variables. RESULTS: Lymph node yields were a mean of 11.5 with a standard deviation of 2.8 for open and 15.3 +/- 3.4 nodes for laparoscopic lymphadenectomy (P = .009). Mean operating time was 26.5 +/- 5.3 minutes for open versus 54.9 +/- 23.7 minutes for laparoscopy (P < .01). Mean blood loss was higher for laparoscopic cases, 35 mL for open versus 58 mL for laparoscopic lymphadenectomy (P = .048). The four major complications were evenly distributed between the two procedures. Lymphangiography was successful in 24 of 25 pigs. A total of 243 lymph nodes were identified with equal distribution by side. Lymphangiographic data correlated well with number of lymph nodes retrieved. CONCLUSION: In this randomized trial, laparoscopic lymphadenectomy was at least as effective as open lymphadenectomy, although operating time and blood loss were greater. Lymphangiography was a reliable, objective mode for documentation and assurance of lymph node recovery.

A combined surgical and radiologic technique for creating a functional neo-endocervical canal in a case of partial congenital cervical atresia.

OBJECTIVE: To recanalize the endocervical canal in a patient with partial congenital cervical atresia. DESIGN: Case report. SETTING: University hospital. PATIENT: A 16-year-old girl referred with a history of primary amenorrhea, polycystic ovaries, and intermittent abdominal pain. Physical examination revealed a normal vagina and external cervical os, but magnetic resonance imaging revealed a solid endocervical tract. INTERVENTION(S): At laparotomy the endometrial cavity was accessed transfundally and outlined by injection of water-soluble contrast. A trocar needle was guided transvaginally into the uterus, the tract was dilated, and a 12F stent was placed. Oral contraceptives (OCs) and antibiotics were continued postoperatively. MAIN OUTCOME MEASURE(S): Hysterosalpingography and clinical follow-up. RESULT(S): The operation and postoperative course were uneventful. Withdrawal bleeding occurred at 8 weeks, after discontinuation of the OCs, at which time the stent was expelled. Later follow-up revealed recurrent narrowing, and the stent was replaced for 14 more weeks. After stent removal, regular menses continued (7 months to date). CONCLUSION: In select cases of congenital cervical atresia, recanalization may be safely performed with the use of the combined surgical-radiologic technique described, with good short-term outcome.

Deep pelvic abscesses: transperineal US-guided drainage.

PURPOSE: To examine the efficacy of transperineal sonographically guided drainage of deep pelvic abscesses. MATERIALS AND METHODS: Twelve drainage procedures were performed in 11 adults with symptoms of infection and cross-sectional images demonstrating a deep pelvic abscess. Eight patients had recently undergone abdominoperineal resection, seven of whom underwent preoperative radiation therapy. Two had chronic osteomyelitis with adjacent fluid collections, and one developed an infected hematoma after trauma. With ultrasound (US) guidance for initial access, catheters were placed for drainage in 11 procedures. One patient was treated with aspiration alone. Patients underwent clinical follow-up and subsequent imaging as necessary. RESULTS: Transperineal needle placement was successful in 12 of 12 patients (100%). In procedures that required catheter placement, 10 of 11 placements (91%) were achieved with the transperineal approach. One patient required fluoroscopic transvaginal catheter placement after opacification of the collection transperineally. Catheter drainage was maintained for 2-146 days (mean, 40 days; median, 21 days). Clinical success was achieved in nine of 10 patients (90%) by means of transperineal drainage. There were no complications, although premature catheter removal occurred in two patients. CONCLUSION: US-guided transperineal abscess drainage may be successfully performed in patients who cannot undergo conventional transabdominal, transvaginal, or transrectal catheter drainage.

Endovascular stent grafts for aneurysmal and occlusive vascular disease.

BACKGROUND: This report details our initial experience with two types of endovascular grafts- one for the treatment of infrarenal abdominal aortic aneurysms and the other for the treatment of iliac artery occlusive disease. METHODS: An abdominal aortic aneurysm was repaired in 34 patients using 3 different types of Ancure endografts (Menlo Park, California). Control patients (n = 9) had a standard aneurysm repair. Patients with chronic lower extremity ischemia (n = 7) secondary to iliac artery occlusive disease were treated with a Hemobahn endograft (W. L. Gore & Associates, Flagstaff, Arizona). RESULTS: Ancure graft deployment was achieved in 33 of 34 (97.1%) patients. Perioperative mortality for the Ancure and control group patients was 2.9% and 0%, respectively. Periprosthetic leaks were identified within 48 hours of deployment in 6 (18.2%) Ancure graft patients. All but 2 of the leaks resolved on serial follow-up. Additional endovascular procedures were required in 11 (32.4%) Ancure graft patients at the initial procedure or during follow-up to correct graft or arterial stenoses. Patients treated with an endovascular graft had significantly less blood loss and shorter hospital stays than control group patients. For Hemobahn patients, the technical success for graft deployment was 100%. There were no perioperative deaths. The ankle/brachial index increased from a mean of 0.52 preoperatively to 0.86 postoperatively (P = 0.004). One patient required a Wallstent in follow-up to correct a graft wrinkle. Angiography at 6 months demonstrated mild intimal hyperplasia in the stent graft in 5 of 6 patients. CONCLUSIONS: These early results support the potential for endovascular grafts in the treatment of aneurysmal and occlusive vascular disease. Further modifications in the devices and deployment techniques are necessary to reduce the incidence of periprosthetic leaks, graft limb stenoses, and intimal hyperplasia.

Upper extremity central venous obstruction in hemodialysis patients: treatment with Wallstents.

PURPOSE: To determine the effectiveness of using Wallstents to treat subclavian or brachiocephalic venous obstruction after unsuccessful angioplasty, in patients undergoing hemodialysis. MATERIALS AND METHODS: Dialysis records, radiology reports, and procedural images of 20 hemodialysis patients who underwent Wallstent insertion into a subclavian (n = 11) or brachiocephalic (n = 9) vein were reviewed. Technical success and primary, assisted primary, and cumulative patency rates were calculated. RESULTS: Twenty-three Wallstents were inserted for stenosis (n = 18) or occlusion (n = 2). Technical success was 100%. Eight patients underwent 11 reinterventions to maintain patency of the Wallstent during the follow-up period. Patency rates of the Wallstent were (a) primary at 1 month, 3 months, 6 months, and 1 year: 90%, 67%, 42%, and 25%; (b) assisted primary at 3 months, 6 months, and 1 year: 88%, 62%, and 47%; and (c) cumulative at 3 months, 6 months, 1 year, and 2 years: 89%, 64%, 56%, and 22%. Considerable shortening of the stent occurred in five patients. One occurred immediately during the deployment procedure, but four were discovered weeks to months later. No other complications occurred. CONCLUSION: After suboptimal angioplasty, treatment of subclavian and brachiocephalic vein stenoses with a Wallstent can provide continued use of a hemodialysis access. Close clinical surveillance and multiple reinterventions are necessary to maintain Wallstent patency.

Transrectal and transvaginal abscess drainage.

The TR and TV approaches to deep pelvic abscesses have been made safe and easy by improvements in endoluminal US technology. Most procedures take well under an hour, and standard intravenous sedation is usually sufficient for patient comfort. The simplest and safest technique employs a combination of endoluminal US, with biopsy guides for precision needle advancement, and fluoroscopy for dilating the tract and placing a drainage catheter. Patient acceptance of TR and TV catheters is high, and resolution can typically be expected within 3-5 days. In the majority of cases, catheter treatment, combined with antibiotic therapy, is curative.

Technique for performing direct lymphangiography in pigs.

RATIONALE AND OBJECTIVES: The authors developed a porcine model for direct lymphangiography to be used as a reference for lymph node harvesting. METHODS: A pilot animal was studied first to develop the protocol, which was used successfully in 24 pigs. An indicator dye was first injected into each foot to make the lymphatic vessels visible. Then, ethiodized poppy seed oil was injected directly through cutdowns in both groins. Radiographs were obtained before and after lymph node harvesting. RESULTS: Images were of diagnostic quality in all animals. The pilot animal developed transient respiratory distress, which was thought to be due to the oil-based contrast material. The amount injected was reduced by half, and no episodes occurred thereafter in the study group. There were no other immediate or delayed complications. CONCLUSION: Direct lymphangiography is safe, easy, and reliable in a porcine model.

Interventional radiologic placement of chest wall ports: results and complications in 161 consecutive placements.

PURPOSE: To review the technical results and long-term follow-up of the first 157 consecutive patients undergoing placement of 161 chest wall ports at the authors' institution. PATIENTS AND METHODS: All ports were placed in the interventional radiology suite with use of fluoroscopic and/or ultrasound guidance with a combination of standard interventional radiology and surgical techniques. The hospital records of all patients were reviewed, and telephone contact made when possible. Patients ranged in age from 21 to 87 years (average, 57 years). The most common indication for port placement was chemotherapy (88%). RESULTS: Placement was technically successful in all 161 procedures. Minor procedural complications occurred in eight patients (5%). There were no major complications related to the procedure. Cumulative follow-up to date includes 35,992 port-days (average, 226 days per patient). The long-term complication rate was 8.7% or .39 per 1,000 access days, which includes nine infections and five migration-related complications. CONCLUSION: Interventional radiologic placement of chest wall ports is safe and has a high technical success rate, in large part due to the integration of interventional radiology techniques to the procedure. The short and long-term complication rates are equal to or less than those of current surgical series.

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy.

PURPOSE: To evaluate the effect of combined-modality therapy including intraluminal iridium-192 on stent patency and survival in patients with malignant biliary obstruction treated with Gianturco stents. MATERIALS AND METHODS: Twenty-two patients with unresectable biliary obstruction caused by cholangiocarcinoma (n = 11) or by secondary extrahepatic bile duct malignant tumors (n = 11) were treated with percutaneous biliary drainage followed by intraluminal Ir-192 wire placement (mean dose, 25 Gy) before insertion of Gianturco metal stents. Eleven patients also received external-beam radiation therapy, and 13 patients received chemotherapy. Patency was defined as absence of jaundice or cholangitis that necessitated hospitalization, or as seen on hepatobiliary scans. Survival was determined from the time of stent insertion after brachytherapy. RESULTS: Patients with cholangiocarcinoma had extended mean stent patency of 19.5 months (range, 2-46 months) and mean survival of 22.6 months (range, 2-72 months). Patients with secondary malignant tumors had a mean patency of 4.8 months (range, 1.5-8 months) and a mean survival of 5.3 months (range, 2-9 months). CONCLUSION: Radiation therapy including intraluminal Ir-192 appears to extend stent patency and survival in patients with inoperable cholangiocarcinoma treated with Gianturco metal stents compared with patients with other extrahepatic bile duct malignant diseases and patients treated without combined-modality therapy in other studies.