Extralobar pulmonary sequestration presenting as a mediastinal malignancy.

Pulmonary sequestration is an uncommon congenital anomaly usually diagnosed in childhood. It frequently presents as a lower lobe mass with symptoms from vascular shunting, anatomic impingements, or associated anatomic defects. This case report describes an adult with asymptomatic extralobar sequestration involving the mediastinum and left upper lobe. The unusual location and radiographic appearance, suggestive of malignancy, led to prompt surgical exploration. We review the literature on this topic, focusing on anatomic variability and difficulties with preoperative diagnosis.

Gianturco-Rösch expandable Z-stents in the treatment of superior vena cava syndrome.

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.

Accuracy of lower extremity arterial duplex mapping.

We performed lower extremity arterial duplex mapping from the aortic bifurcation to the ankle in 150 consecutive patients evaluated for aortic and lower extremity arterial reconstruction and compared lower extremity arterial duplex mapping in a blinded fashion to angiography. On the basis of history, physical examination, and four-cuff segmental Doppler pressures individual lower extremities were classified as normal, isolated aortoiliac disease, infrainguinal disease, and multilevel inflow and outflow disease. For vessels proximal to the tibial arteries, lower extremity arterial duplex mapping was analyzed for its ability to insonate individual arterial segments, detect a 50% or greater stenosis, and distinguish stenosis from occlusion. In the tibial arteries lower extremity arterial duplex mapping was evaluated for its ability to visualize tibial vessels and to predict interruption of tibial artery patency from origin to ankle. Lower extremity arterial duplex mapping visualized 99% of arterial segments proximal to the tibial vessels, with overall sensitivities for detecting a 50% or greater lesion ranging from 89% in the iliac vessels to 67% at the popliteal artery. Stenosis was successfully distinguished from occlusion in 98% of cases. In the tibial vessels lower extremity arterial duplex mapping was better at visualizing anterior tibial and posterior tibial artery segments (94% and 96%) than peroneal artery segments (83%), (p less than 0.001). Overall sensitivities for predicting interruption of tibial artery patency were 90% for the anterior tibial, 90% for the posterior tibial, and 82% for the peroneal. Clinical disease category did not influence in a major way the accuracy of lower extremity arterial duplex mapping in either above-knee or below-knee vessels.

Duplex ultrasound criteria for diagnosis of splanchnic artery stenosis or occlusion.

Mesenteric artery duplex scanning appears promising for detection of splanchnic artery stenosis or occlusion or both in patients with symptoms suggestive of chronic intestinal ischemia. However, no specific duplex criteria have been developed for detection of mesenteric artery stenosis. We obtained mesenteric artery duplex scans and infradiaphragmatic lateral aortograms in 34 patients to determine duplex criteria for mesenteric stenosis. Seventy percent or greater angiographic stenosis was present in 10 superior mesenteric arteries and 16 celiac arteries. Duplex scans were reviewed to determine if celiac artery and superior mesenteric artery ratios of peak systolic velocities and end-diastolic velocities to peak aortic systolic velocity, as well as celiac artery and superior mesenteric artery peak systolic velocities and end-diastolic velocities alone, could predict a greater than or equal to 70% angiographic stenosis or occlusion or both. The results obtained by use of receiver operator curves indicated peak systolic velocity alone was an accurate predictor of splanchnic artery stenosis. Specifically, a peak systolic velocity greater than or equal to 275 cm/sec in the superior mesenteric artery and greater than or equal to 200 cm/sec in the celiac artery or no flow signal (superior mesenteric artery and celiac artery) predicted a 70% to 100% stenosis with sensitivity, specificity, and positive predictive values of 89%, 92%, and 80% for the superior mesenteric artery. Similar values for the celiac artery were 75%, 89%, and 85%, respectively. End-diastolic velocities or calculated velocity ratios conveyed no additional accuracy in predicting splanchnic artery stenosis.

An unusual complication of cardiac transplantation--infected aortic pseudoaneurysm.

Infections after cardiac transplantation are a frequent cause of early morbidity and mortality. An unusual site for such a complication is at the aortic anastomotic suture line. We report a case of an infected aortic pseudoaneurysm, seen as recurrent septicemia, during the first 6 months after cardiac transplantation.

Technetium-99m monoclonal antibody fragment (Fab) scintigraphy in the evaluation of small cell lung cancer: a preliminary report.

Small cell lung cancer (SCC) has the most rapid growth rate of the four cell types and metastasizes early. Present imaging modalities for staging include chest x-ray, CT, MRI and bone scans. In this preliminary study, we assessed the clinical role of 99mTc-monoclonal antibody (MOAB) scintigraphy in five patients with histologically proven SCC. Each patient was infused with 20-30 mCi of 99mTc labeled Fab fragment of MOAB (NR-LU-10, NeoRx, Seattle, Wash.). Total body simultaneous anterior and posterior images were obtained 14-16 h post injection. SPECT images of the chest were obtained through a 360 degrees rotation of the gamma camera and recorded on a 62 x 64 x 16 matrix. Images (1.2 cm thick) were generated in transaxial, sagittal and coronal views. Fourteen of fifteen chest lesions detected by CT were confirmed by 99mTc MOAB scintigraphy. Scintigraphy detected one additional chest lesion not seen by CT. Scintigraphy failed to detect a brain lesion (2 cm), a chest lesion, and two adrenal lesions, all of which were seen by CT. In one patient with multiple (more than 10) lesions in the liver, both scintigraphy and CT detected all lesions. Three spine lesions seen on 99mTc MDP scan and positive for metastasis on MRI concentrated 99mTc MOAB, but two rib lesions seen on 99mTc MDP bone scan did not concentrate 99mTc MOAB. It is concluded from these preliminary results that the potential usefulness of 99mTc MOAB scintigraphy as a complementary imaging modality in the staging of small cell lung cancer should be investigated further.

Evaluation of primary lung cancer with indium 111 anti-carcinoembryonic antigen (type ZCE-025) monoclonal antibody scintigraphy.

A study was undertaken to test whether indium 111 (111In)-labeled anti-carcinoembryonic antigen (CEA) (type ZCE 025) monoclonal intact antibody (MoAb) would concentrate in primary lung cancer enabling its detection and localization by scintigraphy. The scintigraphic results were correlated with chest radiograph, computed tomograph (CT), bronchoscopy, surgical resection, and tumor CEA analysis. Twenty adult male patients with clinical suspicion of primary lung cancer were studied. Each subject was infused with 4 to 5 mCi of 111In anti-CEA ZCE 025 MoAb, and planar and tomographic scintiphotos were obtained on days 3 and 6 or 7 postinfusion. The scintigraphy was true-positive in 12 of 16 patients with primary lung cancer, eight of nine patients with squamous cell carcinoma, and four of seven with adenocarcinoma; it was true-negative in three of four patients with benign lung disease with an overall accuracy of 75%. In seven patients with confirmed primary lung cancer, but with negative bronchoscopic findings, the scintigraphy was true-positive in four. In 11 patients with definitely positive or suspicious malignancy by bronchoscopy the monoclonal scintigraphy was positive in eight. In true-positive cases, the location and size of the lesion by 111In anti-CEA ZCE 025 MoAb imaging correlated well with CT findings and also tumor mass at surgery. Only one of 12 tumors stained positive for CEA had serum CEA levels greater than 10 ng/ml, indicating nonleakage of the tumor antigen into general circulation in early lung cancer. It is concluded that 111In anti-CEA ZCE 025 MoAb planar and tomographic imaging shows potential to serve as a noninvasive diagnostic test in the evaluation of primary lung cancer. The lung lesion is likely to be malignant if it concentrates 111In anti-CEA ZCE 025 MoAb and benign if it does not. Further studies in large number of patients with suspected primary lung cancer are needed to define the ultimate role for MoAb scintigraphy.

Superior vena cava syndrome associated with massive thrombosis: treatment with expandable wire stents.

Two patients with superior vena cava syndrome (SVCS) associated with massive thrombosis were treated by means of local thrombolytic therapy and placement of modified Gianturco expandable wire stents. Treatment resulted in complete resolution of the SVCS symptoms. The combination of local thrombolytic therapy and stent placement allows a more aggressive approach to treatment of SVCS and provides longer-term palliation of symptoms even for patients with later stages of the disease.

Gianturco expandable wire stents in the treatment of superior vena cava syndrome recurring after maximum-tolerance radiation.

Two patients with superior vena cava syndrome (SVCS) recurring after maximum-tolerance radiation were treated by placing a Gianturco expandable wire stent (GEWS) into the obstructed superior vena cava. The SVCS symptoms rapidly disappeared and good short-term (6 months) palliation was achieved. GEWS placement is a promising therapeutic alternative for palliation of SVCS symptoms when other therapeutic modes cannot be used or are not effective.

Treatment of hemobilia by transcatheter vascular occlusion.

Four cases of hemobilia treated by transcatheter arterial occlusion are presented and reviewed with 30 similar cases reported in the literature. Transcatheter vascular occlusion successfully controlled hemorrhage in all 34 patients. No obvious liver parenchymal damage appeared in 26 patients; transient elevation of liver enzymes occurred in 6 patients (18%) including one in our series; two of the patients reviewed died of acute hepatic insufficiency following nonselective hepatic artery embolization. Hemobilia should be considered when gastrointestinal hemorrhage occurs after abdominal trauma, liver biopsy or other manipulative liver procedures. Hepatic angiography establishes the diagnosis and selective vascular occlusion is the treatment of choice for control of intractable or recurrent hemorrhage. Techniques and precautions for the diagnosis and transcatheter therapy of hemobilia are discussed.

Stenosis of the popliteal vein caused by an osteochondroma of the distal femur: a case report.

This report describes a 14-year-old girl presenting with unilateral distal leg edema which developed on the basis of popliteal vein compression by a large osteochondroma of the distal femur. Excision of the osteochondroma relieved the venous obstruction, and the leg returned to normal. Lesions of tibial arteries and veins caused by osteochondromas of the distal femur are discussed.

The importance of temperature in angiography of the hand.

Angiograms of the hand of a normal volunteer taken at skin temperatures ranging from 22 to 33 degrees C revealed that visualization of the arteries was highly dependent on the temperature. Lower temperatures produced vasospasm beginning in the smaller vessels and proportionally involving medium-sized and major arteries. Moderate warming led to optimum filling and is recommended prior to angiography of the hand. Prior injection of contrast material caused no perceptible change in the filling or appearance of the arteries.

Infusion hepatic angiography in diagnosis of liver metastases.

Infusion hepatic angiography was used, together with conventional angiography, for diagnosis in 68 patients with liver metastases. The combination of both techniques led to a diagnostic accuracy of 97%. Metastases were missed in only two patients, both of whom had underlying liver or biliary disease. In a comparison of the two techniques, the infusion study was found diagnostically essential in five patients (7%) and afforded improved diagnosis in 49 others (72%). In 10 patients (15%), it gave equivalent information; and in four patients (6%) less information than the conventional technique. Infusion hepatic angiography is a useful complementary technique in antatomic liver diagnosis, especially in its ability to improve upon the diagnostic accuracy of the capillary phase of hepatic angiography.

Current angiographic approach to diagnosis and therapy of acute gastrointestinal bleeding.

The author's current angiographic approach to the diagnosis and therapy of acute gastrointestinal (GI) bleeding is summarized and discussed. It is based on the authors' experience with diagnostic studies in more than 300 acute GI bleeders and the use of various angiotherapeutic techniques in 138 of them as well as the experience of others. A "moderately aggressive angiographic approach" is advocated for the diagnosis of acute GI bleeding in most patients with angiography used as needed after emergency endoscopy and preliminary medical therapy. Vasoconstrictive angiotherapy with selective intraarterial use of vasopressin is partially giving way to low dose, intravenous infusion of vasopressin and, where possible, to direct vascular occlusion. Selective transcatheter embolic occlusion of bleeding vessels is in indicated cases an accepted method for controlling arterial bleeding. Medical gelatin (Gelfoam) is the current authors' embolization material of choice. Selective variceal occlusion offers promising means for management of bleeding from gastroesophageal varices. Its possible combination with transcatheter intrahepatic portosystemic shunting might also provide non-surgical relief of portal hypertension.