Carlos Delgado

Percutaneous balloon pericardial window for patients with symptomatic pericardial effusion

Purpose: To describe the technique and our experience in percutaneous creation of a pericardial window in patients with recurrent pericardial effusion. Methods: Eleven consecutive patients (9 men, 2 women; mean age 61 years, range 37–79 years) with recurrent pericardial effusion were treated from December 1994 to October 2000. Malignant effusion was the cause of cardiac tamponade in nine patients. Puncture of the pericardial space was performed under ultrasound and fluoroscopic guidance. Once a guidewire was safely positioned in the pericardial cavity and the wall of the pericardium was identified, the pericardial keyhole was dilated with an 18 mm balloon catheter. A temporary (1–3 day) 8 Fr pigtail catheter was inserted in order to stabilize the tract and aspirate the fluid. Results: The aim of creating a pericardial window was achieved in all 11 patients. There were three recurrences (27%) of pericardial effusion and three early deaths (27%) due to progression of the underlying disease, which occurred within 30 days following the procedure. Follow-up ranged from 6 days to 382 days, mean 147 days. Conclusions: Percutaneous creation of a pericardial window can be a safe therapeutic alternative for patients with symptomatic pericardial effusion, particularly if this has a malignant etiology.

Central venous catheter placement in the inferior vena cava via the direct translumbar approach.

Abstract. The aim of this study was to evaluate the technical aspects and efficacy of placing tunneled central venous access catheters (CVA) in the inferior vena cava (IVC) via a direct translumbar approach. Between August 1994 and July 1998, 50 CVA (Hickman 13.5 F) were placed in the IVC via a direct translumbar approach in 46 patients (10 males, 36 females) with a mean age of 39.9 years (age range 10–87 years). The indications were chemotherapy administration plus leukoaphoresis (n = 39), bone marrow transplantation (n = 2) and hemodialysis (n = 5). The reasons for placing the CVA in the IVC were cosmetic (n = 34), supradiaphragmatic venous thrombosis (n = 8), previous catheter infection (n = 2), and non-functioning arteriovenous fistula (n = 2). There were no immediate complications. The mean period of time the CVA was in place was 3 months (15 days to 15 months), during which the function was excellent. The commonest late complication was infection (4 local, 6 bacteremia). Others included: pain (n = 2), ureteric fistula (n = 1), pericatheter fibrin sheath formation (n = 6) and catheter-tip impaction (n = 2). Two catheters were damaged due to postprocedural inappropriate manipulations and two others fell off due to incorrect fixation. Due to these complications, it was necessary to remove ten catheters, replace an additional four and reposition two. Direct translumbar catheterization of the IVC is a safe and effective way of placing a long-term CVA with a moderate complication rate.

Ascites due to anastomotic stenosis after liver transplantation using the piggyback technique: Treatment with endovascular prosthesis

Liver transplantation preserving the retrohepatic interior vena cava, the so-called piggyback technique, is becoming more frequently used because it avoids caval cross-clamping during the anhepatic phase of surgery. However, hepatic venous outflow blockade causing ascites seems to be less infrequent after piggyback than with cavo-caval anastomosis. We report a 62-year-old patient who underwent liver transplantation using the piggyback technique and developed a stenosis in the anastomosis between the hepatic veins and the inferior vena cava leading to severe postoperative ascites. Ascites was unresponsive to diuretic therapy and was associated with renal function impairment. Since the etiology of the stenosis was mechanical (torsion), percutaneous transluminal angioplasty was unsuccessful. Finally, an autoexpandable prosthesis was placed across the anastomosis resulting in rapid and permanent (3 years of follow-up) resolution of ascites.

Percutaneous extrahepatic portacaval shunt with covered prostheses: feasibility study.

PURPOSE To assess the anatomic feasibility of creating a percutaneous extrahepatic portosystemic shunt (PEPS) between the main portal vein (MPV) and the inferior vena cava (IVC) in patients with cirrhosis and to evaluate the feasibility of this approach in an animal model. MATERIALS AND METHODS In human studies, computed tomographic (CT) scans from 34 patients with cirrhosis were reviewed to assess the distance and anatomic structures found between the MPV and IVC. The MPV was divided into upper, middle, and lower thirds for analysis. In the experimental model, PEPS were created in 10 beagle dogs by placing between the MPV and IVC a tubular polyurethane-covered prosthesis with flared ends designed for this study. Different approaches, devices, and prostheses were assayed. RESULTS In human studies, the shortest mean distance between the IVC and the MPV was found in the lower third of the MPV (1.18 cm +/- 0.6). The lower third, the nearest to the confluence of splenic and superior mesenteric veins, also presented fewer intervening structures, and the spatial relationship between the veins at this level was predictable. In the experimental model, direct portography was performed, with a small mesenteric vein catheterized through a minilaparotomy and a transjugular access to the IVC. A needle was advanced from the MPV to the IVC, and a polyurethane cone-shaped covered prosthesis was placed to bridge the path between the veins. Six of 10 animals died from bleeding that occurred either because several punctures were made during the procedure or because the prosthesis became dislodged when the mesentery was moved before suturing the minilaparotomy. The remaining four were kept alive for 1, 5, 60, and 90 days after the procedure. CONCLUSIONS PEPS creation in patients with cirrhosis is anatomically possible. The lower third of the MPV should be the most suitable level at which to create the shunt. Preliminary studies carried out in beagle dogs support the feasibility of this approach. However, further work is needed to improve the efficacy of this technique.

Combination of Various Percutaneous Techniques in the Treatment of Pylephlebitis

JVIR 2000; 11:777–780 PYLEPHLEBITIS (suppurative inflammation of the wall of the portal vein associated with thrombosis) is a rare entity with a high mortality rate. It should be suspected in patients with abdominal sepsis and liver function abnormalities (1). It generally occurs as a complication of intraabdominal inflammatory disease (appendicitis, diverticulitis, pancreatitis, ulcers), which may give rise to thrombosis of the portal vein and/or liver abscess by hematogenous dissemination. Despite antibiotic treatment, pylephlebitis is still a very serious disease, with mortality rates ranging from 50% to 80%, according to different series (2–7). The diagnosis of pylephlebitis is difficult because the signs and symptoms are often nonspecific (8). Radiologists should familiarize themselves with the findings presented by imaging techniques, such as ultrasound (US) and computed tomography (CT), to make a rapid diagnosis so that treatment is not delayed, because this determines the course of the disease. We describe a case of pylephlebitis of unknown origin that was resolved by transhepatic thrombolysis and extraction of the intraportal thrombi followed by intraarterial, intraportal, and systemic intravenous infusion of antibiotics.

Myocardial Ischemia Evaluation With Dual-source Computed Tomography: Comparison With Magnetic Resonance Imaging

INTRODUCTION AND OBJECTIVES Computed tomography does not accurately determine which coronary lesions lead to myocardial ischemia and consequently further tests are required to evaluate ischemia induction. The aim of this study was to compare diagnostic accuracy between dual-energy computed tomography and magnetic resonance imaging in the assessment of myocardial perfusion and viability in patients suspected of coronary artery disease. METHODS A prospective study was performed in 56 consecutive patients (39 men [69.6%]; mean age [standard deviation], 63 [10]; range, 23-81). Computed tomography was performed with the following protocol: 1, adenosine stress perfusion; 2, coronary angiography; and 3, delayed enhancement. Magnetic resonance imaging for the evaluation of stress perfusion and delayed enhancement was performed within 30 days. Two observers in consensus analyzed the perfusion and delayed enhancement images. RESULTS We studied 952 myocardial segments and 168 vascular territories. In a per-segment analysis, the sensitivity, specificity, and positive and negative predictive values of computed tomography compared with magnetic resonance were 76%, 99%, 89%, and 98% for perfusion defects, and 64%, 99%, 82%, and 99% for delayed enhancement, respectively. In a per-vascular territory analysis, the same measures were 78%, 97%, 86%, and 95% for perfusion defects, and 72%, 99%, 93%, and 97% for delayed enhancement, respectively. The mean radiation dose was 8.2 (2) mSv. CONCLUSIONS Dual-source computed tomography may allow accurate and concomitant evaluation of perfusion defects and myocardial viability and analysis of coronary anatomy.

Consejos útiles para la realización de una TC-coronariografía

Las tomografias computarizadas multidetectores comienzan a generalizarse en los hospitales y con ellas la posibilidad de realizar estudios cardiacos. La tecnica es tecnico-dependiente y es necesario conocer ciertas consideraciones que ayudaran a mejorar el resultado del estudio. Se resumen en cuatro puntos. La preparacion del paciente para decidir si usaremos bloqueadores beta o no, aspectos en el uso rutinario del vasodilatador, algunas normas para ensayar la apnea del paciente, etc. La segunda parte se centra en la adquisicion, cuando usar una adquisicion con multisegmentacion o la posibilidad incluso de hacer estudios con adquisicion prospectiva que disminuye la dosis de radiacion. La tercera esta referida a la administracion de contraste para conseguir un buen realce en los vasos. El ultimo apartado resume las tecnicas de postprocesado, y se comentan los posibles errores con las reconstrucciones 3D o la necesidad de hacer una reconstruccion que abarque todo el torax para despistar otras patologias.

Pulmonary Hemorrhage in a Patient with Acute Coronary Syndrome

WEB This is a Web exclusive article. assive pulmonary hemorrhage after treatment with antiplatelet drugs is a rare event that can occur in patients with acute coronary syndrome (ACS). The use of medications such as tirofiban (Aggrastat, Merck) and abciximab (ReoPro, Eli Lilly) has been associated with improvement in short-term outcome among patients with ACS who undergo coronary angioplasty [1]. Pulmonary hemorrhage appears as bilateral alveolar infiltrates on chest radiographs and can be easily mistaken for acute pulmonary edema in the context of ACS [2]. When the infiltrates do not resolve with administration of diuretics, the radiologist must be aware of the possibility of pulmonary hemorrhage because early treatment can increase the probability of survival. We report the clinical and radiologic features of a patient with ACS complicated by massive pulmonary hemorrhage due to use of tirofiban.

Estudio de las arterias coronarias mediante tomografía computarizada multidetector

Radiological study of coronary arteries has undergone major advances, especially with the incorporation of new CT multidetectors which afford temporary spatial resolution sufficient for the acquisition of high-quality images and diagnoses concerning various coronary artery abnormalities. The technique is described in terms of both facilitating data within a procedure making use of beta-blockers to slow heart rate and postprocess image reconstruction. Accordingly, our experience with a 16-detector CT and its clinical applications are illustrated.

Isolated papillary muscle hypertrophy: A gap in our knowledge of hypertrophic cardiomyopathy?

Increased thickness of left ventricular walls is the predominant characteristic and one of the diagnostic criteria of hypertrophic cardiomyopathy (HCM). This case illustrates an uncommon but important finding of isolated hypertrophy of the papillary muscles (PMs), observed in a young woman in whom an abnormal electrocardiogram was initially detected. During the investigation isolated PM hypertrophy was identified. The structural characteristics of the PMs have received scant attention in this setting and there is little information in the literature on this entity, whose real prevalence and clinical significance remain to be determined. The available information relates solitary PM hypertrophy with an early form or a different pattern of HCM. In this case PM hypertrophy was only detected due to the finding of an abnormal electrocardiogram, which prompted further diagnostic tests and a search for possible etiologies.