Coronary artery fistula diagnosed by transesophageal echocardiography.

Coronary artery fistulas have been traditionally diagnosed by angiography. This report describes a congenital and a traumatic coronary artery fistula diagnosed by transesophageal echocardiography. Transesophageal echocardiography was superior to transthoracic echocardiography in both cases and to angiography in one case. Transesophageal echocardiography may now be the procedure of choice in diagnosing coronary fistula.

Laser-assisted thermal angioplasty in human peripheral artery occlusions: mechanism of recanalization.

Recanalization of completely occluded superficial femoral or popliteal arteries was attempted in 18 patients with use of an Argon laser-mediated thermal probe. The length of the occluded segments varied between 0.5 and 26.0 cm, but 67% of the occlusions were greater than 9 cm long. The initial success rate was 67%. Arterial perforation occurred in six patients but was not associated with major complications. To study the mechanism of the laser-mediated thermal probe, thermal recanalization was performed on 11 human arterial segments in vitro obtained after amputation, and mechanical recanalization was performed in vitro in 10 human peripheral arteries with use of a guide wire and catheter technique. An additional four arteries were studied with the laser probe as a non-heated mechanical device. Both the mechanical and thermal devices appear to follow a similar pathway through a complete obstruction. These studies suggest that the thermal probe burns through soft fibrous tissue but is mechanically deflected away from hard fibrocalcific plaque. The probe then advances along the plane between the intimal plaque and the media for a variable length before perforating through the adventitia. These observations suggest that the major mechanism of thermal probe recanalization may be a mechanical process. It appears that thermal probe devices do not inherently seek the true lumen of an occluded artery and that better guidance systems need to be developed.

The role of IVP in blunt trauma.

To investigate the role of the IVP, we studied 139 patients with blunt abdominal trauma and hematuria. Multivariate analysis of clinical parameters was utilized in attempt to predict which patients would have abnormal IVP's and which would eventually require genitourinary operation. Thirty-four patients (25%) demonstrated abnormalities on IVP; however, no combination of clinical findings (including degree of hematuria) could reliably predict which patients would have abnormal IVP's. On the other hand, in 90% of the patients, the necessity for genitourinary operation could be reliably predicted based on: presence of blood at the urethral meatus, degree of hematuria, patient age, Injury Severity Score, and number of rib fractures. We conclude that to detect IVP abnormalities, IVP's need to be performed on all blunt trauma patients with hematuria. However, patients likely to have injuries requiring operative repair can be predicted. Those patients unlikely to have genitourinary injury requiring repair, therefore, may have IVP performed on a nonurgent basis.

Hypogammaglobulinemia in a renal transplant recipient with antiglomerular basement membrane disease.

A thirty-six-year-old woman developed antiglomerular basement membrane disease, necessitating bilateral nephrectomies. Subsequent to cadaveric renal transplant and 8 years of immunosuppressive treatment with prednisone and azathioprine, the patient developed multiple life-threatening infections. Quantitative immunoglobulins revealed IgG = 9, IgA less than 6.7, and IgM = 33. Lymphocyte population studies revealed absence of B-lymphocytes. It is suspected that prednisone or azathioprine may have caused a defect in B cell differentiation. In patients who are taking immunosuppressive medications and develop multiple infections, it is indicated to evaluate immunoglobulin and/or B lymphocyte status.

Hyperthermic pelvic isolation-perfusion in the treatment of refractory pelvic cancer.

Hyperthermic isolation-perfusion (I-P) was used to treat 27 patients with refractory pelvic cancer. All patients except one achieved pelvic isolation as manifested by selective pelvic heating and by pharmacologic monitoring. Patient response was good, with rapid pain relief in 75% and tumor control as detected by physical examination, computed tomographic scan, and decline in carcinoembryonic antigen levels. Pelvic drug exposure averaged 7.8 times that of systemic drug exposure. Of the 20 patients with recurrent rectal adenocarcinoma, one complete response (duration, eight months), seven partial responses (average duration, greater than or equal to 10 months), four patients with stable disease (average duration, greater than or equal to 12 months), and five with disease progression were observed. Three patients could not be evaluated due to late deaths as a consequence of their disease. There were two postoperative deaths in the remaining seven patients, one due to drug toxicity and one due to probable cardiac arrhythmia. Pelvic I-P has evolved with the avoidance of laparotomy and increased drug dose. We conclude that hyperthermic I-P for pelvic cancer is a safe, effective procedure and an excellent therapeutic option for patients with persistent pelvic cancer.

Digital subtraction ductography.

Digital subtraction techniques used in the examination of eight patients with salivary and nasolacrimal disease are described. Pleomorphic adenoma, ductal stricture, extrinsic masses, parotid-otic fistula, and a radiolucent calculus were demonstrated. The procedures are more easily performed than film techniques, and pathology is better demonstrated by digital ductography than on a film examination. Image subtraction, reregistration, and window manipulation allowed clear demonstration of ducts about the head and neck, overcoming limitations imposed by inherently high object contrast. Digital subtraction ductography is an important nonvascular application of digital imaging technology.

Digital tomography: description and preliminary clinical experience.

Digital tomography was performed in 30 patients using a new prototype system with a PET-Scope image tube. Twenty-eight exposures are obtained during a single revolution of the x-ray source over the volume of tissue to be imaged. The sum of the radiation produced by the 28 exposures is about equivalent to a single routine exposure of the part imaged. The data accumulated can provide up to 200 tomographic sections at intervals of 5 mm. Reconstruction time for each section is 3 sec. The raw images may be reconstructed as often as desired. Algorithms are being developed to allow axial and sagittal reformations. Further work is required to improve spatial resolution and contrast and to develop algorithms to allow subtraction of blurred images above and below the reconstructed site. The authors believe that digital tomography may eventually replace most routine tomograms.

Development of gallstone pancreatitis. The role of the common channel.

Whether bile reflux through a common channel into the pancreatic duct is a causative factor in the development of gallstone pancreatitis is controversial. To address this issue, we have reviewed a consecutive series of cholecystectomies performed with intraoperative cholangiograms. The cholangiograms and the patients' charts were reviewed independently to determine the incidence of a common channel in patients both with and without pancreatitis and to analyze their clinical courses. The group of patients who had pancreatitis showed a common channel in 19 (90%) of 20 cases, while those patients who did not have pancreatitis showed a common channel in 23 (35%) of 66 cases. The patients who had pancreatitis were less likely to have choledocholithiasis than were those patients who did not have pancreatitis, and these patients were less likely to require exploration of the common bile duct.