George Pillari

Emergency Percutaneous Nephrostomy: Results and Complications☆

PURPOSE Percutaneous nephrostomy is a well-established standardized procedure in the management of patients with various urologic problems. The goal of this study was to evaluate the effectiveness and safety of percutaneous nephrostomy in an emergency setting. PATIENTS AND METHODS Emergency percutaneous nephrostomy was performed in 160 patients with ages ranging from 2 to 89 years (mean, 52 years). Access to the kidney was planned and achieved with C-arm fluoroscopic guidance. RESULTS The initial technical success rate was 98%. Overall complication rate was 34%; 6% were major and 28% were minor. Major procedure-related complications, including sepsis, occurred in 6% of patients. Hematuria requiring transfusion was noted in 2.4% of patients. Minor complications included catheter displacement or malposition (4.8%), pelvic perforation (4.3%), paralytic ileus (2.4%), pneumonia/atelectasis (1.8%), and pleural effusion (1.2%). High-risk patients included those with diabetes, hypertension, and obesity. No deaths or significant morbidity resulted from any complication. CONCLUSIONS Emergency percutaneous nephrostomy under fluoroscopic guidance is a simple, safe, and effective procedure and should be offered in all suitably equipped radiology departments.

Emergency Percutaneous Nephrostomy: Technical Success Based on Level of Operator Experience☆

PURPOSE The outcomes of emergency percutaneous nephrostomy procedures performed by operators with different levels of experience were analyzed. PATIENTS AND METHODS A prospective study of 160 patients undergoing 169 emergency percutaneous nephrostomies was conducted. Three categories of operator experience were compared based on the number of percutaneous nephrostomies performed each year (level 1 = more than 20, level 2 = 10-20, or level 3 = less than 10). RESULTS The level 1 operators (mean fluoroscopy time, 2 minutes; mean procedure time, 25 minutes) achieved success in 141 of 142 cases (99%) and failed in one case (1%), which was repeated successfully the next day. The level 2 operators (mean fluoroscopy time, 6 minutes; mean procedure time, 35 minutes) achieved initial success in all of 15 cases (100%), but three cases (20%) were repeated the next day because of catheter migration or malposition. Level 3 operators (mean fluoroscopy time, 10 minutes; mean procedure time, 42 minutes) were successful in 10 of 12 cases (83%), but in four cases (33%) the procedure had to be repeated. CONCLUSION The experience of the operators played little role in the initial success rate of the procedure after they had performed 10 or more per year. However, the level of experience did influence the number of procedures that needed to be repeated, the prevalence of minor complications, and the mean fluoroscopy and procedure time.

CT of gastric masses: Image patterns and a note on potential pitfalls

Computed tomography (CT) was performed in 9 consecutive cases of primary gastric neoplasm. Lesions were surgically or endoscopically proved; cross-sectional images are correlated to specific histopathology in each case. The CT images of leiomyoma and leiomyoblastoma are characterized as models of pure bulging intramural growth resulting in a lunate contrast distribution when imaged in the cross-sectional plane. In 5 cases of lymphoma, distortion of the contrast-filled hollow viscus is relatively consistent. Nodular growth is reflected on the CT image as a series of digitations encroaching on the opacified portion of the gastric lumen. Image pattern recognition, relative to histopathology, is of more than academic interest since endoscopy is frequently unreliable in cases of submucosal and exophytic pathology. Further, biopsy of such lesions is commonly non-diagnostic as a result of random choice of biopsy site or inadequate depth of tissue sample.Additionally, this report includes images of lesions that simulate the primary gastric pathology and may be a source of erroneous interpretation. These include: pseudocyst of the pancreas (2 cases) and enlargement of the left lobe of the liver with encroachment on the gastric lumen (1 case). Image specificity on CT examination is increasingly essential to diagnosis and surgical planning.

CT and angiographic correlates: Surgical image of renal mass lesions

Abstract Twenty-three consecutive patients with surgically proved renal mass lesions were examined preoperatively by means of computerized tomography (CT) and renal angiography. Histopathology of the 23 renal masses included the following: hypernephroma (17), transitional cell carcinoma (3), oncocytoma (2), benign cyst (1). Computed tomography was correct in the preoperative diagnosis of 21 of 23 masses (91 per cent); angiography diagnosis was correct in 18 of 23 consecutive masses (78 per cent). Correlation of the findings on CT and angiography resulted in correct diagnosis in 22 of the 23 lesions (96 per cent). Independently, CT and angiography each contribute essential information for diagnosis and preoperative planning. CT discloses anatomic detail, tissue consistency, organ system relationships, and relatively precise estimates of tumor bulk. Angiography remains a necessary complement providing a surgical image of tumor vascularity and vessel origins.

Computed Tomographic Cavo-Urography: Lower-Extremity Contrast Infusion Simultaneous with Computed Tomography of the Retroperitoneum

Successful opacification and distention of the inferior vena cava was obtained simultaneously with computed tomography by contrast infusion through a lower-extremity vein. Images obtained by this method displayed retroperitoneal anatomical relationships to better advantage, permitting more accurate interpretation of the upper retroperitoneum, particularly in lymphoma.

Seminoma: improved imaging and tumor characterization with computed tomography.

We report 2 cases of metastatic seminoma to emphasize the use of computed tomography in defining accurately the extent and volume of tumor before treatment. Computed tomography permits more direct visualization of the retroperitoneum, mesenteric and abdominal lymph nodes, and extra nodal extension of the tumor to other organ systems. Additionally, characteristic tissue densities are displayed (that is cyst and hemorrhage), which may serve as an index to the dynamics of tumor growth and change. Lymphography and venacavography are invasive studies and both share inherent limitations in imaging for seminoma. Cross-sectional imaging is more precise in describing treatment fields for radiation therapy. Results of treatment are monitored more confidently with computed tomography.

Occult aortic dissection: diagnosis by ultrasound.

Dissecting aortic aneurysms may present with atypical signs and symptoms. In some patients radiographic studies and laboratory findings, as well as the patients clinical course, may obscure the underlying vascular disorder. The value of ultrasound in the diagnosis of aneurysms of the abdominal aorta is well known (Nusbaum et al., 1971; Winsberg et al., 1974). In the present report we describe the fortuitous discovery of an abdominal aortic dissection (Type I) by means of static grey scale ultrasound in a patient under evaluation for jaundice, with emphasis on the usefulness of ultrasound as a non-invasive imaging modality in screening the abdominal aorta.

The lateral view in selective renal angiography.

Use of the lateral view in selective renal angiography is helpful in differentiating cysts from tumors. The position of the cyst is better defined, facilitating aspiration if necessary, while in malignant masses this technique gives a better idea of the dimensions and vascularity of the tumor. Three illustrative cases are presented.

Bilateral Common Femoral Artery Stenosis Mimicking Aortic Stenosis—Case Report

Isolated bilateral common femoral artery stenoses or occlusions are an ex tremely rare arterial lesion and have not been previously reported. Herein the authors report 2 patients with this lesion with remarkable similarities. Both are similarly aged women, diabetic, hypertensive, and cigarette smokers. Both pa tients had thigh and calf claudication, diminished or absent femoral pulses, and diminished Doppler pressures from the thigh down. Common femoral endar terectomy and patch angioplasty with and without distal bypass was successful in the management of these 2 patients. The signs and symptoms of this lesion are identical to those of patients with aortic stenosis or bilateral iliac artery stenoses.

DIFFUSE ARTERIOVENOUS (AV) MALFORMATION OF BOTH KIDNEYS

AV malformations of the kidneys are rare and AV malformations replacing the normal vasculature of both kidneys, so far as we are aware, has not been previously described. The purpose of this abstract is to describe such an abnormality in a girl aged 3 years and 10 months. She presented with hypertension (190/140mmHg), a hemolytic anemia with red cell fragmentation (Hb 6.1 G/dl, Reticulocytes 6.2%,haptog1obin 00 mg/dl), thrombocytopenia (platelets 72000/cmm) and decreased renal function (S.Creatinine 1.4 mg/dl, BUN 32 mg/dl, GFR 35ml/min/1.73m2). There was no evidence of intravascular coagulation. Blood renin was normal. She also had hypertrophy of the left leg, with prominent veins, probably due to an associated AV malformation of the leg. Arteriography showed that the vasculature throughout both kidneys, was replaced by multiple AV malformations. Drainage was through large, tortuous veins anastomosing with periureteral and pelvic veins. The inferior vena cava was visualized early. She has been treated with chlorothiazide, propranolol, hydrallazine, methyldopa, aspirin and dlpyridamole for 9 months. The hypertension is controlled, and the platelet count has returned to normal. The Hb has risen to 10.5 G/dl but Red cell fragmentation persists. The GFR has risen to only 57 ml/min/1.73m2.