Gastric and duodenal stents: follow-up and complications.

PURPOSE: To assess the efficacy of self-expanding metallic stents in treating inoperable gastric and duodenal stenoses during follow-up and to evaluate the complications encountered. METHODS: A total of 31 patients suffering from gastroduodenal obstruction (29 malignant, 2 benign) were treated with a self-expanding metallic stent (Wallstent). In 24 cases insertion was by the peroral route, in seven cases via gastrostomy. RESULTS: All the strictures were successfully negotiated under fluoroscopic guidance without having to resort to endoscopy. A total of 27 patients (87%) were able to resume a regular diet, a soft diet, or a liquid diet orally. Complications included one case of stent malpositioning, one case of leakage of ascitic fluid through the gastrostomy orifice, one case of perforation and fistula to the biliary tree, and two cases of hematemesis. In two patients (6%) additional stents were implanted to improve patency. In all patients follow-up was maintained until death. Recurrence of symptoms immediately before death occurred in seven cases (23%). Mean survival time of patients was 13.3 weeks (SE +/- 4.6). CONCLUSIONS: The deployment of gastroduodenal stents resulted in good palliation of inoperable gastric and duodenal stenoses. Certain technical aspects, e.g., adaptation of stents to bowel morphology, is critical to proper stent function and avoidance of complications.

Nasolacrimal polyurethane stent placement for epiphora: technical long-term results.

PURPOSE: To assess technical problems related to implantation of a polyurethane stent to treat obstructive epiphora, and to assess the long-term patency of the nasolacrimal system. MATERIALS AND METHODS: Fluoroscopically guided placement of a polyurethane nasolacrimal stent was performed in 70 obstructed lacrimal systems of 62 patients with grade 3-4 obstructive epiphora. Follow-up was conducted for 1-20 months (average, 11.3 months). The obstruction was at the lacrimal sac in six systems, at the junction between the lacrimal sac and the nasolacrimal duct in 60 systems, and at the nasolacrimal duct in four systems. The cause of the obstruction was idiopathic in all cases but was probably residual to dacryocystitis. RESULTS: Of these 70 procedures, stent placement was technically successful in 61 systems (87%). On long-term follow-up, 41 (67.2%) stents remained in place, with resolution or clinical improvement, and 18 (29.5%) stents were removed (because of occlusion in 17 systems), with stent malpositioning in the duct in six cases. There were seven cases of malpositioning in all. Statistical analysis was performed to evaluate patency, compare patency in properly positioned stents and malpositioned stents, and establish the relationship between malpositioning and the need for irrigation to maintain stent patency. Of the total 70 stents originally placed, 41 (58.6%) were still in place and functional at long-term follow-up. At 1 year, 73% of properly positioned stents remained patent versus 0% of improperly positioned stents. Median stent patency in the former group was 20 months and was 1 month in the latter group (P = .00002). Eleven percent of properly positioned stents required irrigation versus 57% of incorrectly positioned stents (P = .01). CONCLUSION: After follow-up for 1 year, recurrence of epiphora brought on by stent obstruction was 28%. Early stent blockage and the need for periodic irrigation may be indicative of malpositioning of the stent.

Assessment of CO2 arteriography in arterial occlusive disease of the lower extremities.

PURPOSE: To compare the diagnostic ability and usefulness of carbon dioxide arteriography with that of angiography using iodinated contrast medium in ischemia of the lower extremities. METHODS: Between April 1997 and February 1998 arteriography was performed systematically in 50 consecutive patients (42 men, eight women; average age, 65 years), who presented with peripheral vascular disease of the arteries of the lower extremities, with use of both CO2 and iodinated contrast medium. Untoward events that occurred during the examinations and the resulting clinical problems were recorded. Subsequently, two radiologists carried out a double-blind evaluation of the images obtained for each segment (aorta, pelvis, thighs, knees, legs, and feet) using the two different contrast agents to diagnose the arterial condition (normal, aneurysm, stenosis, and occlusion). Afterward, the two types of study performed for each patient were compared to assess the overall quality of CO2 arteriography as opposed to arteriography performed with use of iodinated contrast material. RESULTS: Forty-eight percent of the patients reported discomfort during the CO2 examinations and 18% of the studies had to be discontinued as a result. When problems relating to poor image quality were included, only 36% of the arteriograms obtained with use of CO2 were complete. Evaluation was possible in only 25% of CO2 studies of the feet. On average, the overall quality of the arteriograms obtained with use of CO2 was insufficient for diagnosis. CONCLUSION: In the authors' experience, CO2 arteriography cannot replace procedures performed with use of iodinated contrast medium for routine examination of ischemia of the lower limbs. In most cases, because of lower tolerance to the procedure and poorer image quality, CO2 imaging was not of sufficient quality to permit diagnosis, particularly at the infrapopliteal level.

Mitral atresia with normal aortic valve: a study of eighteen cases and a review of the literature.

Eighteen cases of mitral atresia with normal aortic valve plus 68 cases from the literature are analyzed. A new classification based on anatomical findings is proposed. Pulmonary stenosis or atresia is frequent in the type with transposition of the great arteries. The rare instances of normal or large left ventricle are due to a large ventricular septal defect, or to straddling or displaced tricuspid valve. The clinical, radiologic and electrocardiographic findings have been summarized and correlated with the different physiopathological situations. In our catheterized cases an oxygen saturation step-up was found in the right atrium together with left atrial hypertension. In seven cases mitral atresia was demonstrated by selective left atrial contrast injection. The average age at death was six months. Among the cases surviving one year or more, the association of atrial septal defects or pulmonary stenosis was frequent. Enlargement of the interatrial communication, accompanied by other palliative measures, is the only available surgical procedure.

[Right ventricle with double outlet associated to total anomalous pulmonary venous drainage to innominate vein]. / Ventrículo derecho de doble salida asociado a retorno venoso pulmonar anómalo total a la vena innominada

The clinical findings of 2 patients are studied with an association of malformations not previously reported: double outlet right ventricle and total anomalous pulmonary venous connection to the innominate vein. The following features are worth while to be underlined: 1. Both patients showed a discordance between viscero-atrial situs and direction of the apex; 2. In both cases, particularly in case 2, there existed a very unusual spacial relationship between ventricles, the right ventricle being superior with respect to the left ventricular cavity; 3. From the embryological viewpoint, this ventricular arrangement is supposed to be due to an arrest of the development of the heart in the straight tube stage, there being, however, an upwards expansion of the atrioventricular canal and common atrium; 4. An accurate diagnosis of the common or divided nature of the atrioventricular valves has been impossible in these cases; 5. These combination of lesions constitutes a challenge to cardiologists and surgeons as far as the surgical indication is concerned. In that sense, the simple anastomosis of the common pulmonary vein to the left atrium, although is not a radical cure, may be a feasible and beneficial procedure.