Alan J. Greenfield

Cigarette Smoking: An Independent Risk Factor for Atherosclerosis in the Hypogastric-Cavernous Arterial Bed of Men with Arteriogenic Impotence

We investigated the relationship between cigarette smoking and atherosclerosis of the hypogastric-cavernous arterial bed by evaluating arteriograms of young impotent men referred for selective pudendal angiography. Those patients with hemodynamically significant atherosclerosis had smoked more pack-years than had patients without arterial disease. These differences were statistically significant (p less than 0.05) for the common penile artery (32.8 pack-years, 40 patients versus 22.3 pack-years 57 patients) and the dorsal artery (31.3 pack-years, 48 patients versus 22.0 pack-years, 49 patients). The effect of cigarette smoking as an independent risk factor for atherosclerotic disease in the hypogastric-cavernous arterial bed was evaluated as well. When controlled for age, trauma history, hypertension and diabetes, cigarette smoking was independently associated with atherosclerosis in the internal pudendal artery (p less than 0.05). The relative risk (and 95% confidence interval) of developing internal pudendal artery atherosclerosis for each 10 pack-years smoked was 1.31 (1.05 to 1.64). A third analysis investigated the potential interactive effects of cigarette smoking and pelvic or perineal trauma. A significantly higher incidence (p less than 0.05) of cavernous artery atherosclerosis was found among smokers with a history of chronic perineal trauma (33 patients) compared to nonsmokers with a similar history (25 patients). The findings of this study indicate that cigarette smoking is an independent risk factor in the development of atherosclerotic lesions in the internal pudendal and common penile arteries of young impotent men. Cigarette smoking appears to predispose these patients to early atherosclerotic lesions in the cavernous artery following chronic perineal trauma.

Evolving Concepts in the Diagnosis and Treatment of Arterial High Flow Priapism

PURPOSE We investigated 2 evolving concepts in the management of arterial priapism: 1) the efficacy of perineal duplex Doppler ultrasound as a diagnostic alternative to arteriography and 2) the therapeutic alternative of expectant management. MATERIALS AND METHODS We evaluated 10 patients with high flow arterial priapism. RESULTS Compared to selective internal pudendal arteriography, perineal duplex Doppler ultrasonography was associated with 100% sensitivity and 73% specificity rates. Compared to physical examination, followup duplex ultrasonography had a sensitivity of 75% and specificity of 100%. Followup penile duplex ultrasound demonstrated restoration of antegrade flow in the cavernous artery after embolization. Patients on expectant management remained potent as long as 31 years. CONCLUSIONS Diagnostic perineal duplex Doppler ultrasonography and expectant management are valuable tools for the treatment of arterial priapism. A new algorithm for patient care is presented.

Transhepatic cannulation of the inferior vena cava.

Problems frequently develop in maintaining central venous access in patients who require long-term total parenteral nutrition. The authors describe transhepatic placement of a silicone rubber catheter into the inferior vena cava (IVC) in a patient with thrombosis of the superior vena cava, infrarenal IVC, and the great veins. The technique and potential complications are described.

Perineal abscess after embolization for high-flow priapism

High-flow priapism is unusual and is most often due to blunt perineal trauma with resultant laceration of the cavernosal artery, creating an arteriocavernosal fistula. Although few cases have been reported, the consensus on management appears to be embolization of the fistula with autologous clot, alone or in combination with Gelfoam. We present a case of high-flow priapism treated in this manner. The embolized pseudoaneurysm evolved into an abscess that eventually spread to the perineum. The rarity of this entity and the postprocedural morbidity are reported.

Laser angioplasty for limb salvage: Observations on early results

During a 27-month period laser thermal angioplasty (LTA) was attempted in 15 patients who had totally occluded segments of their superficial femoral--popliteal arteries (SFA) with limb-threatening ischemia (rest pain or tissue necrosis). In five patients (33%) laser perforation of the SFA precluded successful angioplasty, and those five patients have been excluded from further analysis. In the remaining 10 patients the prelaser angiogram demonstrated an average SVS/ISCVS runoff score of 7.7 (best possible score, 1; worst possible score, 10). Seven patients (70%) had occlusions of all infrapopliteal arteries. All 10 patients were available for clinical follow-up, and follow-up angiograms were available for eight patients (80%). Clinical failure was defined as recurrence of the clinical signs or symptoms for which the LTA was performed. After 6 months of follow-up clinical failures occurred in nine patients (90%). Four patients had no clinical improvement. Five patients had transient clinical improvement after LTA, and all subsequently had early recurrence of symptoms. The average time from LTA to recurrence of symptoms was 1.7 months. Seven patients had subsequent bypasses or amputations an average of 2.2 months after laser angioplasty. The SFA patency rate by life-table analysis was 25% at 6 months. The single patient with clinical success (at 12 months) had no tibial vessel disease evident on his prelaser angiogram, and he underwent a concomitant inflow procedure at the time of his LTA. We believe that the disappointing results in this small series of patients can be attributed to tibial vessel disease that was not addressed by this technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Iatrogenic arterioportal fistulae: Diagnosis and management

Arterioportal fistulae can develop from a variety of causes, either congenital, iatrogenic, or acquired. They can have a varied clinical presentation including acute upper gastrointestinal bleeding, ischemic colitis, abdominal pain, ascites, and abdominal bruit. In the past the treatment has been ligation and surgical excision of the fistula with repair of the artery and vein or hepatic lobectomy. We report two patients with arterioportal fistulae between the hepatic artery and portal vein as a result of liver biopsy and transhepatic portography. Both patients were treated successfully by nonoperative radiologic intervention.

Arteriography for proximity of injury in penetrating extremity trauma.

Arteriography for proximity of injury was studied prospectively at a trauma center. Findings in 85 patients with penetrating extremity wounds were analyzed to determine the prevalence and types of vascular abnormalities seen with these injuries. Ninety-two limb segments were studied for 77 gunshot and 15 stab wounds. Arteriographic findings were positive in 24% overall but in only 5% for injuries confined to major vessels. A 60% positive rate was seen in a small subgroup of 10 patients with fractures due to gunshot wounds. The most frequently injured vessels were muscular branches of the deep femoral artery (59%); the most common injury was focal, non-occlusive spasm (42%). All patients were treated conservatively, without sequelae at follow-up. In this study, the vascular injuries found at arteriography for proximity of injury in penetrating trauma due to bullets of knives, particularly in the thigh, did not require surgical or radiologic intervention.

Arteriography and radiology of impotence

SummaryBoth arterial and venous dysfunction are now recognized as significant causes of organic impotence. Numerous therapeutic modalities are currently available, including surgical bypass, venous ligation, transluminal angioplasty, and transcatheter vessel occlusion. The specific nature of this patient population requires correlation of angiographic findings with the patient’s history and physical examination to determine the appropriate intervention and obtain a satisfactory outcome.

Endoscopic pulsed dye laser lithotripsy of gallbladder calculi in vivo

We have evaluated the efficacy and safety of pulsed dye laser lithotripsy of gallbladder calculi using a percutaneous endoscopic technique in a porcine model. Fragmentation was readily achieved in vivo. Using a combination of laser lithotripsy and saline lavage, complete removal of all stone debris was feasible through a 24 F tract (N = 3). However, the degree of fragmentation required rendered removal through a smaller tract inefficient, a mean 53% of stone mass being retrievable through a 16 F tract (N = 11). Repeated laser activation at 1 mm from the gallbladder mucosa produced minimal injury, regardless of pulse energy. When the laser fiber was pressed against the mucosa, perforation of the gallbladder was possible at therapeutic pulse energy, but this did not lead to clinical sequelae. We conclude that the pulsed dye laser is a safe and effective means of fragmenting gallbladder calculi in vivo.