[Endovascular treatment of massive hemoptysis by bronchial artery embolization: short-term and long-term follow-up over a 15-year period]. / Tratamiento endovascular mediante embolización arterial bronquial en la hemoptisis masiva. Seguimiento a corto y largo plazo durante 15 años.

OBJECTIVE: To present our experience of using arterial embolization for the endovascular treatment of massive hemoptysis along with the results of follow-up over a 15-year period. PATIENTS AND METHODS: A total of 401 patients with hemoptysis were referred to the minimally invasive surgery unit of the Hospital Universitario Lozano Blesa de Zaragoza between April 1989 and September 2004 for diagnosis and possible endovascular treatment. Of those patients, 314 met criteria for massive hemoptysis and treatment was attempted using embolization in 287 (91.4%). The most common cause of hemoptysis was bronchiectasis (n=99, 31.5%), followed by lesions due to tuberculosis (n=57, 18.1%) and chronic bronchitis (n=47, 14.9%). RESULTS: Angiography of the bronchial arteries provided evidence to account for the hemoptysis in 287 patients (91.4%). The affected arteries were satisfactorily embolized in 281 (97.9%). Endovascular treatment was clinically successful in 256 of those patients (91.1%). Embolization had to be repeated during the hospital stay in 19 patients (6.7%) and was effective in 52.6% of those cases. The 6 patients in whom embolization was not satisfactory underwent thoracotomy. The mean follow-up in 201 patients (71.5%) was 2372.5 days (range, 61-5475 days). Eighty patients (28.4%) were lost to follow-up for various reasons and at different points. Recurrence of hemoptysis occurred on 1 or more occasions in 45 patients (22.3%) but only 21 (10.4%) required repeat embolization. Minor complications that did not require treatment were observed in 88 patients (28.0%). CONCLUSIONS: Embolization of bronchial arteries is a nonsurgical treatment that is safe and effective in patients with massive hemoptysis.

Tratamiento endovascular mediante embolización arterial bronquial en la hemoptisis masiva. Seguimiento a corto y largo plazo durante 15 años / Endovascular treatment of massive hemoptysis by bronchial artery embolization: short-term and long-term follow-up over a 15-year period

Objetivo: Presentar nuestra experiencia en el tratamiento endovascular de la hemoptisis masiva mediante embolización arterial y su seguimiento a lo largo de 15 años. Pacientes y métodos: Desde abril de 1989 hasta septiembre de 2004 se remitió a la Unidad de Cirugía Mínimamente Invasiva del Hospital Universitario Lozano Blesa de Zaragoza a 401 pacientes por hemoptisis para diagnóstico y posible tratamiento endovascular. De ellos, 314 cumplían criterios de hemoptisis masiva y se intentó tratar mediante embolización a 287 (91,4%). La principal causa de hemoptisis observada fueron las bronquiectasias (n = 99; 31,5%), seguidas de lesiones de tuberculosis (n = 57; 18,1%) y bronquitis crónica (n = 47; 14,9%). Resultados: La angiografía bronquial reveló alteraciones arteriales que justificaban la hemoptisis en 287 pacientes (91,4%). Se pudo embolizar las arterias patológicas de forma satisfactoria en 281 (97,9%). El tratamiento endovascular tuvo éxito clínico en 256 (91,1%). En 19 pacientes (6,7%) se requirió durante su ingreso otra embolización, que fue eficaz en el 52,6%. En los 6 restantes se realizó toracotomía. El seguimiento medio, en 201 pacientes (71,5%), fue de 2.372,5 días (rango: 61-5.475 días). Se perdieron para el estudio 80 pacientes (28,4%) por diversas causas y en distintos momentos del seguimiento. El 22,3% (n = 45) presentó hemoptisis recidivante en una o más ocasiones, pero tan sólo 21 pacientes (10,4%) requirieron una nueva embolización. Se constataron 88 (28,0%) complicaciones menores que no precisaron otras medidas terapéuticas. Conclusiones: La embolización de arterias bronquiales es un tratamiento no quirúrgico seguro y efectivo en los pacientes que presentan hemoptisis masiva

Objective: To present our experience of using arterial embolization for the endovascular treatment of massive hemoptysis along with the results of follow-up over a 15-year period. Patients and methods: A total of 401 patients with hemoptysis were referred to the minimally invasive surgery unit of the Hospital Universitario Lozano Blesa de Zaragoza between April 1989 and September 2004 for diagnosis and possible endovascular treatment. Of those patients, 314 met criteria for massive hemoptysis and treatment was attempted using embolization in 287 (91.4%). The most common cause of hemoptysis was bronchiectasis (n=99, 31.5%), followed by lesions due to tuberculosis (n=57, 18.1%) and chronic bronchitis (n=47, 14.9%). Results: Angiography of the bronchial arteries provided evidence to account for the hemoptysis in 287 patients (91.4%). The affected arteries were satisfactorily embolized in 281 (97.9%). Endovascular treatment was clinically successful in 256 of those patients (91.1%). Embolization had to be repeated during the hospital stay in 19 patients (6.7%) and was effective in 52.6% of those cases. The 6 patients in whom embolization was not satisfactory underwent thoracotomy. The mean follow-up in 201 patients (71.5%) was 2372.5 days (range, 61-5475 days). Eighty patients (28.4%) were lost to follow-up for various reasons and at different points. Recurrence of hemoptysis occurred on 1 or more occasions in 45 patients (22.3%) but only 21 (10.4%) required repeat embolization. Minor complications that did not require treatment were observed in 88 patients (28.0%). Conclusions: Embolization of bronchial arteries is a nonsurgical treatment that is safe and effective in patients with massive hemoptysis

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.

Transcatheter intracavitary fibrinolysis of loculated pleural effusions: experience in 102 patients.

PURPOSE: To assess the efficacy of intrapleural urokinase instillation through small-caliber catheters for the treatment of loculate and/or septate effusions. METHODS: We inserted small-caliber catheters (8.2 Fr) in 102 patients with septate and/or loculate pleural effusions using ultrasonographic guidance. Urokinase (100,000 IU/2 hr, 3 times a day) was instilled through the catheter until the effusion resolved and D-dimer levels were <500 ng/ml. Patients were enrolled regardless of the etiology of the pleural effusion provided there were no contraindications for the use of urokinase. D-dimer levels were determined before and after treatment. Follow-up was performed by chest radiograph and sonography at 1 day, 7 days, and every 30 days thereafter for 6 months. RESULTS: Successful catheter placement was achieved in all cases. The mean time catheters stayed in place was 5.7 days and the mean dose of drug instilled was 690,000 IU. Pleural effusion drainage was complete at the first assessment in all patients. Failure of the treatment, with recurrent effusion at 30 days, occurred in six patients (5.8%). Complete resolution without sequelae was observed in 19 patients (19.6%). In 75 cases (73.5%) resolution was partial, with pleural thickening (>2 mm). Two patients died from unrelated causes within 30 days after catheter placement. Complications were seen in 13 patients (12.74%): hydropneumothorax, nine cases (8.82%); infection of the puncture point, three cases (2.94%); and adverse reaction, one case (0.98%). No further treatment was required. CONCLUSION: The use of intrapleural fibrinolytic agents delivered through small-caliber catheters for the treatment of loculate and/or septate pleural effusion is a simple, effective, minimally invasive and inexpensive procedure that can prevent sequelae and shorten drainage time.

[Right upper lobar mass of the lung caused by subclavian artery aneurysm]. / Masa pulmonar lobar superior derecha por aneurisma de la arteria subclavia.

Subclavian artery aneurysm is a rare condition. The main causes are degenerative disease and, less often, trauma. We report the case of a sawmill worker with a large mass in the upper right lobe found in a routine X-ray. Imaging studies revealed the aneurysm to be 12.2 x 13.1 cm, partially thrombosed and located in the right subclavian artery. Our experience suggests that this cause of lung mass should be considered early in the diagnostic process, before undertaking invasive diagnostic (puncture-biopsy) or therapeutic procedures that might place the patient at risk.

Radiation myelopathy in over-irradiated patients: MR imaging findings.

The objective of this work is to report the MRI findings in patients with radiation myelopathy due to accidental local over-irradiation syndrome. Eight patients (seven males and one female) were suffering from over-irradiation syndrome as a result of treatments from a malfunctioning linear electron accelerator. The mean accidental estimated dose was 136 Gy delivered to the "open-neck" (seven cases) and to the thoracic wall (one case), during a mean of 5.4 sessions (range 1-9 sessions). Paresthesia and weakness in the upper extremities were the earliest symptoms (87.5 %), with evolution to paralysis in all patients. No patient is alive (mean survival time 64 days). In all cases MRI was negative for neurologic lesions in the acute phase ( < 90 days from irradiation; Radiation Therapy Oncology Group scoring system). Late signs of radiation myelitis manifested as high-intensity signals on T2-weighted images in three patients, and as Gd-DTPA enhancement of T1-weighted images in one case. Autopsies performed on four patients who died in acute phase showed morphologic alterations in white matter: edema in 75 %, and necrosis and glial reaction as well as obliterative vasculitis in all cases. In cases of over-irradiation, MRI may be normal in acute phase even if the patients have severe neurologic deficit, as positive MRI findings appear only in delayed radiation myelitis.

[Current status and clinical experience in the treatment of tracheobronchial stenoses with self-expanding metallic stents]. / Estado actual y experiencia clínica en el tratamiento de las estenosis traqueobronquiales con prótesis metálicas autoexpandibles.

The development of symptomatic stenosis in the bronchial tree can lead to high risk asphyxia. The implantation of metallic prostheses (stents) can provide palliative resolution of stenosis and alleviate the acute symptoms of these patients. We assess the efficacy of expandable metallic stents for treating various types of tracheobronchial stenosis. Sixteen Wallstent type expandable metallic prostheses were implanted in 16 patients with tracheobronchial stenosis (12 malignant and 4 benign) in the interventional radiology unit under fluoroscopic and endoscopic guidance. The prostheses were placed correctly and no complications were observed, such that symptoms improved immediately. Three patients with post-intubation stenosis required additional treatment with laser therapy during follow-up examinations. All the patients with malignancies died from the underlying disease, but with open airways and no tracheal symptoms. Metallic prostheses are a valid alternative for palliative treatment of malignant tracheobronchial stenosis.

[Pulmonary artery aneurysm and thrombosis caused by vasculitis in Behçet's disease]. / Aneurisma y trombosis arterial pulmonar por vasculitis en la enfermedad de Behçet.

Behcet's disease in a 27-year-old male is described. The patient presented fever, dyspnea and hemoptysis. A chest X-ray revealed right hilar enlargement. Exploratory thoracotomy revealed a pulsating mass in the superior lobar artery consistent with aneurysm. Pulmonary biopsy confirmed necrotizing vasculitis of the tissue consistent with Behcet's disease. Pulmonary arteriography showed and aneurysmatic enlargement of the bifurcation between the mid and righ inferior lobar arteries, with thrombosis of the upper right and lower left lobar arteries. Resolution of symptoms was achieved through treatment with corticoids and azathioprine.

[Drainage of loculated and/or multiloculated pleural effusions using a small caliber catheter and urokinase (pleuro-fibrinolysis)]. / Drenaje de derrames pleurales loculados y/o tabicados mediante catéter de pequeño calibre y urocinasa (pleurofibrinólisis).

The main causes of pleural fluid drainage failure are known to be the formation of fibrin septa, increased viscosity in pleural fluid and inappropriate placement of chest tubes. Reports also tell us that such problems can be solved by using ultrasound as a guide for tube placement and by infusing intrapleural fibrinolytic agents to prevent the formation of septa and reduce the viscosity of pleural fluid. To assess our experience, the role and efficacy of administering intercavitary urokinase (UK) through a small caliber catheter (SCC) implanted with ultrasound guidance as part of the treatment for pleural effusions (PE) that are multiloculated and/or loculated. Fifty multiloculated and/or loculated PE were drained through a pig-tail type SCC between 8.2 and 10 F caliber inserted with ultrasound guidance. The criteria for prescribing the procedure were as follows: PE of any etiology with ultrasound confirmation of fibrin septa and/or multiloculation and absence of contraindication off UK administration. UK was given at a dose of 100,000 i.u. every two hours until disappearance of PE. Before and after treatment the levels of D-dimer were measured in order to monitor pleural fibrinolytic activity. The SCC was properly placed in all patients. UK administration was 366,000 i.u. and time the SCC were in place was 4.7 days. All PEs were initially drained completely. We examined the patients 30 days later, finding that PE had recurred in 2 (4%), resolution was complete and without sequelae in 8 (16%), nearly complete but with slight pleural thickening in 32 (64%) and partial with pleural opacities larger than 2 mm in 8 (16%). Use of SCC and UK (pleural fibrinolysis) is a moderately invasive procedure that is effective and well tolerated and that shortens drainage time, prevents sequelae and is relatively inexpensive for the treatment of PE with fibrin septation and/or multiloculation.

[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).

Subcutaneous ports in the radiology suite: an effective and safe procedure for care in cancer patients.

The purpose of the study is to present our experience and compare the results of the three types of ports used as a central venous access and performed in the radiology suite. Between March 1989 and November 1993 we performed 288 implantations (100 Implantofix Seldinger, 100 plastic Hickman port, and 88 stainless steel Port-a-cath) for chemotherapeutic treatment on the same number of patients diagnosed as having cancer. In all cases access was obtained via a subclavian vein (the left one in 185 cases and the right one in 103). All the system ports were implanted in the radiology suite. In all cases the procedure was successfully performed. Complications occurred in 26.3% of cases, most notably thrombosis in 13 cases (4.5%) and infection in 12 cases (4.1%). Duration of the port systems placement varied between 17 and 1467 days (a mean of 315 days). A total of 133 systems have been removed to date, 80 (60.%) due to termination of chemotherapy, and 53(40%) for treatment of complications. Significant differences (complications and port duration time) were not observed between the three types of reservoir used. Subcutaneous ports are safe, comfortable, and effective devices for central venous access.

[The long-term clinical and imaging follow-up of inferior vena cava filters. A cross-sectional study]. / Seguimiento clínico y por medios de imagen a largo plazo de los filtros de vena cava inferior. Estudio transversal.

We carried out a cross-sectional study to assess morphological findings and incidence of complications in 77 inferior vena cava filters (IVC) implanted in 75 patients between April 1990 and January 1994. Follow-up ranged from 3 to 61 months (mean, 38.5 months) and was carried out by telephone interview, clinical examination, X-rays of the ilium/vena cavum and, in some cases, by Doppler sonogram and computed tomography. Findings revealed IVC thrombosis in 38% of patients, edema in the lower extremities in 63.4%, angling > 15 degrees in 8 patients, defective opening in 4, fibrosis of the vena cava with stenosis in 2 and perforation of the IVC in 3. Although our study shows that the incidence of IVC thrombosis after implantation of filters is higher than suspected, its clinical importance is slight.

[Self-expandable metal prostheses. A new alternative palliative therapy of malignant stenotic lesions of the esophagus]. / Prótesis metálicas autoexpandibles. Una nueva alternativa terapéutica paliativa de las lesiones estenóticas malignas de esófago.

The treatment of malignant esophageal stenoses is a serious problem which may have a surgical solution at diagnosis in only a selected number of cases. Chemotherapy and radiotherapy are the main palliative treatments; surgery has a high morbidity and mortality rate. The insertion of esophageal prostheses could be an alternative palliative treatment. From January 1991 to November 1993, 41 autoexpandable metallic prostheses (12 Wallstent type, 19 Strecker type and 1 Rosch-Uchida type) have been implanted in 30 patients with esophageal cancer one with lung cancer and two with radiation induced esophagitis. Technical success resulted in 28 patients; an initial failure requiring a new prosthesis insertion occurred in 5 patients. Technical aspects and results are analyzed.

[The percutaneous retrieval of vascular foreign bodies]. / Recuperación de cuerpos extraños vasculares por vía percutánea.

Intravascular foreign bodies can cause significant complications: thrombosis, pulmonary and peripheral embolism, etc. It is therefore necessary to remove them, and this may be accomplished through surgery or by means of radiotherapy techniques. In the past year we have percutaneously extracted three foreign bodies originating in vascular access pathways.

A prospective and immunologic study of factory workers exposed to TDI (toluene diisocyanate).

Thirty factory workers whose annual exposure to TDI amounted to 280 hours were examined. Seven of them had been removed from their jobs for presenting respiratory symptomatology and a further five were removed for presenting bronchial asthma. Their medical histories were consulted and further measures were taken such as a radiological thorax study, total IgE, TDI, MDI and HDI RAST, a basal spirometric study and finally a provocation test. The Rast proved negative in every case. In the spirometric study carried out on the provocation test, four cases showed a significant decrease in the FEV1 over 20% and over 40% in the FMEF and PEFR. There was no connection between the four patients who presented an elevated total IgE and the four who presented a positive provocation test. The provocation test proved negative in five of the seven patients removed from their places of work. Two of the four workers who responded positively to the provocation test remained in their places of work during the TDI foam test without showing any symptoms. The patients who presented symptoms did not appear to present bronchial obstruction during the provocation test. Nonetheless, patients who seemingly had not shown any symptoms presented what appeared to be bronchial obstruction.