Fernando F. Illescas

Angioplasty for the Treatment of Visceral Ischemia

PURPOSE To evaluate percutaneous transluminal angioplasty (PTA) in the treatment of visceral ischemia. PATIENTS AND METHODS Over a 14-year period, 25 focal visceral artery stenoses were treated with PTA in 16 patients with acute or chronic visceral ischemia. Thirteen patients were women and three were men, with a mean age of 64.7 years (range, 54-79 years). PTA was performed in seven celiac arteries, 17 superior mesenteric arteries, and one inferior mesenteric artery. RESULTS PTA was technically successful in 14 of 16 patients (88%). Two patients were lost to follow-up. Nine of 12 patients (75%) demonstrated primary patency with relief of clinical symptoms at a mean follow-up of 2.3 years (range, 0.3-5 years). The remaining three patients underwent successful repeat PTA for recurrent symptoms. There was one postprocedural death, and one patient subsequently underwent successful surgical bypass for recurrent visceral ischemia. CONCLUSIONS Angioplasty of the visceral arteries may provide relief for select patients with intestinal ischemia, but redilation may be required in some patients.

Infectious complications of percutaneous biliary drainage

The infectious complications of percutaneous biliary drainage were reviewed in 132 patients with obstructive jaundice. Cholangitic or septic episodes occurred more frequently in patients with malignant (54%) than in those with benign (22%) disease, and frequently were not related to catheter insertions or manipulations. The frequency and mechanisms of bacterial colonization of bile and blood in patients with obstructive jaundice before and after biliary drainage are reviewed. The significant morbidity and mortality related to postdrainage infectious episodes is stressed, and the efficacy of antibiotic prophylaxis is discussed. The significant risks and complications of percutaneous biliary drainage must be considered prior to catheter placement, particularly in the most debilitated patients.

Renal streak artifact during contrast-enhanced CT: Comparison of low versus high osmolality contrast media

Two hundred abdominal computed tomographic (CT) scans in 200 patients, 100 performed with low osmolality contrast (ioversol 68%, 100 ml) and 100 performed with high osmolality contrast (diatrizoate meglumine 60%, 150 ml), were retrospectively evaluated for the presence of renal streak artifact. Contrast was administered by hand injection at a rate of approximately 1–2 ml/s and sequential scanning was employed. Of the scans performed with high osmolality contrast, 70% had no artifact, 28% had minimal artifact, and only 2% had marked artifact. Only 26% of the exams performed with low osmolality contrast were artifact-free, whereas 53% demonstrated minimal artifact and 21% demonstrated marked artifact. The likelihood of encountering renal streak artifact when using low osmolality contrast agents is almost seven times greater than when high osmolality contrast agents are used.

Bladder leiomyoma: Advantages of sonography over computed tomography

The complementary use of sonography in the evaluation of a bladder-base leiomyoma is reported. Sonography, as compared to computed tomography, was able to document the solid nature of the tumor, its submucosal location, and determined the site of origin and exact relationship to adjacent organs by virtue of the ability to image in multiple planes. The sonographic appearance of a submucosal, solid lobulated bladder-base mass is suggestive of a leiomyoma.

Biliary cytodiagnosis bile sampling for cytology

The records of 121 patients who presented for PTC and biliary drainage within a five-year period were reviewed. Fifty-eight bile samples had been obtained from 38 of these patients for cytologic analysis. Malignancy was detected in 14 of 32 patients with carcinoma (sensitivity 44%). Repeat sampling was positive in four of nine patients whose initial specimen contained no tumor cells. Bile duct carcinoma, pancreatic carcinoma, and metastatic disease were all detected. An approach to biliary cytodiagnosis is offered that, it is hoped, will further minimize future false negative results.

Fine needle aspiration biopsy in malignant obstructive jaundice.

Percutaneous cytodiagnosis of malignancy in patients with biliary tract obstruction is often useful in planning subsequent therapy. Of 121 patients presenting for percutaneous transhepatic cholangiography and biliary drainage, 45 had fine needle aspiration biopsies. Forty-one patients had malignant obstruction of the biliary tree, while benign disease was present in 4 patients. Neoplasia was diagnosed in 12 of 13 patients with bile duct carcinoma, 16 of 22 patients with pancreatic cancer, and 3 of 6 patients with other malignancies. Radiologic biopsy sensitivity was only slightly inferior to surgical biopsy sensitivity in the same patient population. A scheme for biliary cytodiagnosis is presented, which uses a percutaneous approach for patients with suspected pancreatic carcinoma and a transcatheter approach for patients with suspected bile duct carcinoma. The utility of this procedure and the low complication rate are stressed.

Intravenous Digital Subtraction Angiography in the Evaluation of Potential Renal Donors

Of 65 surgically removed donor kidneys intravenous digital subtraction angiography demonstrated accurately the number of renal arteries in 58 (89 per cent). All accessory vessels missed at digital subtraction angiography were small and their presence did not interfere with successful transplantation in those donated. Of 50 surgically removed donor kidneys examined with conventional aortography only before the routine use of intravenous digital subtraction angiography the number of renal arteries was demonstrated accurately in 46 (92 per cent). Intravenous digital subtraction angiography offers advantages over conventional aortography, including most importantly the routine performance on an outpatient basis, and decreased film cost and examination time. Although the accuracy of conventional aortography (92 per cent) in detecting the number of renal arteries is slightly greater than that for intravenous digital subtraction angiography (89 per cent), the advantages of the digital examination justify its use as the initial examination for the potential renal donor. Conventional aortography can be reserved for use in patients with equivocal or technically inadequate digital examinations.

Ultrasonically guided percutaneous transhepatic transcholecystocholangiography in the nondilated biliary tree

Five patients with CT or ultrasoundproven nondilated intrahepatic biliary radicles underwent ultrasound-guided percutaneous transhepatic transcholecystocholangiography (PTHTCC) for visualization of the biliary tree following failed endoscopic retrograde cholangiography. In no instance were more than 2 passes of a 22-gauge needle necessary to enter the gallbladder. Visualization of the biliary tree was excellent in all cases, and there were no complications. Therefore, PTHTCC is a safe and reliable method of visualizing the nondilated biliary tree.

ANGELCHIK ANTIREFLUX DEVICE: COMPUTED TOMOGRAPHY APPEARANCE

The Angelchik antireflux prosthesis is a silicon gel-filled, doughnut-shaped device with a tantalum tie strap that wraps around the gastroesophageal junction after reduction of a hiatal hernia. If dislodged, this prosthesis may produce a confusing picture on computed tomography, as it is of soft tissue density and may mimic a mass lesion. The computed tomography appearance of a normally placed prosthesis is demonstrated, and a case of prosthesis dislodgment diagnosed by computed tomography is reported.