Biliary-shunt fistula following transjugular intrahepatic portosystemic shunt placement.

Sepsis following the placement of a transjugular intrahepatic portosystemic shunt (TIPS) has been reported in up to 10% of cases. This report describes an unusual case of polymicrobial gram-negative sepsis after placement of TIPS associated with a cholangiographically documented fistulous connection between the biliary tree and shunt. The patient was treated with temporary biliary stent placement, endoscopic sphincterotomy, and broad-spectrum antibiotics with rapid closure of the fistula and resolution of sepsis. In the absence of hemobilia, it is hypothesized that flow through the fistula allowed bilious contamination of the systemic circulation and subsequent inoculation with enteric flora. The prevalence of biliary-vascular fistula after placement of TIPS is unknown. It may be a previously unsuspected source of sepsis after placement of TIPS and is likely to be overlooked unless endoscopic retrograde cholangiopancreatography is performed.

Renal secretion and hepatic clearance of human multiple renin forms.

Human active renin can be separated into at least five forms by isoelectric focusing. The present study assessed the preferential renal secretion and hepatic degradation of renin forms in humans. The renin form profile of secreted renal renin was determined before transplant in an ex vivo kidney donor perfusion system and compared with the peripheral plasma multiple renin form profile of normal subjects. The effect of hepatic degradation on renin forms was assessed in hepatic vein plasma in comparison with infrarenal vena cava plasma in hypertensive patients during renal vein renin studies. The results revealed a significantly greater proportion of the more basic forms in the perfusate of donor kidneys compared with normal plasma. In hypertensive patients the proportion of the more basic renin forms in the hepatic vein was significantly decreased in comparison with the infrarenal vena cava. Thus, the human kidney may preferentially secrete the more basic renin forms. In contrast, the liver preferentially degrades the more basic forms, giving these forms a shorter plasma half-life. The preferential secretion and clearance of the more basic forms of renin may contribute to short-term control of human renin-angiotensin system activity.

An improved radiolabeling technique of ivalon and its use for dynamic monitoring of complications during therapeutic transcatheter embolization.

Transcatheter embolization by Ivalon particles for treatment of arteriovenous malformations has been an accepted therapeutic technique for many years. We describe a new and efficient radiolabeling technique of Ivalon particles using [99mTc]sulfur colloid. Continuous and dynamic monitoring of injected radiolabeled Ivalon particles is made possible by viewing the persistence scope of a portable gamma camera whose head is positioned over the patient undergoing therapeutic embolization. Therefore, if inadvertent pulmonary embolism or reflux migration of radiolabeled Ivalon particles has occurred, the angiographer is immediately aware of this potentially serious or fatal complication and can take corrective action. We describe two patients, each with an arteriovenous malformation, who had therapeutic embolization with radiolabeled Ivalon particles, one resulting in reflux migration and the other resulting in inadvertent pulmonary embolism.

Unusual transplant renal angioplasty complication: case report.

We report an avulsion of a transplant upper pole renal artery following apparently successful percutaneous transluminal angioplasty (PTA) of a stenosis involving main, upper, and lower pole renal arteries. We believe that the use of a high pressure balloon was the causative factor. If the branches at the bifurcation cannot be protected and if the stenoses fail to resolve under moderate balloon insufflation pressures (less than 5-6 atmospheres), consideration should be given to surgical revascularization.

Left ventricular thromboembolic occlusion of the popliteal artery treated nonoperatively with local urokinase infusion--a case report.

Recently streptokinase and urokinase have been shown to be useful in the nonoperative treatment of thromboembolic disease. Urokinase is emerging as a safer and more effective thrombolytic agent when applied either to definitively lyse spontaneous thrombosis where no underlying structural lesion is present or to serve as an adjunct prior to surgical reconstruction or transluminal angioplasty. The authors report a case of a high-risk cardiac patient in whom an embolic occlusion of the distal popliteal artery was completely recanalized by using a localized catheter infusion of urokinase. The source of the embolus was a left ventricular thrombus. No serious bleeding or proximal or distal embolic complications occurred. The potential hazards of fragmentation of the embolic source in the presence of systemic thrombolysis, distal trifurcation embolization, and concomitant use of heparin are reviewed.