Grigory Rozenblit

Renal Artery Stent Placement for the Management of Ischemic Nephropathy

PURPOSEnTo evaluate the angiographic and clinical results of percutaneously implanted renal artery endoprostheses (stents) for the treatment of patients with ischemic nephropathy.nnnMATERIALS AND METHODSnDuring a 52-month period, 45 patients with azotemia (serum creatinine > or = 1.5 mg/dL) and atheromatous renal artery stenosis untreatable by, or recurrent after, balloon angioplasty were treated by percutaneous placement of Palmaz stents. Stent implantation was unilateral in 32 cases and bilateral in 11 cases. Clinical results were determined by measurements of serum creatinine and follow-up angiography. Clinical benefit was defined as stabilization or improvement in serum creatinine level. Angiographic patency was defined as less than 50% diameter recurrent arterial stenosis.nnnRESULTSnStent placement was technically successful in 51 of 54 (94%) renal arteries. Technical failures were stent misdeployment requiring percutaneous stent retrieval (n = 2) and inadvertent placement distal to the desired position (n = 1). Complications included acute stent thrombosis (n = 1) and early initiation of hemodialysis (within 30 days; n = 1). There were two periprocedural deaths. With use of life-table analysis, clinical benefit was seen in 78% of patients at 6 months (n = 36), 72% at 1 year (n = 24), 62% at 2 years (n = 12), and 54% at 3 years (n = 3). In patients with clinical benefit, average creatinine level was reduced from 2.21 mg/dL +/- 0.91 before treatment to 2.05 mg/dL +/- 1.05 after treatment (P = .018). Lower initial serum creatinine level was associated with a better chance of clinical benefit (P = .05). No other variables affected outcome, including patient age, sex, diabetes, implanted stent diameter, unilateral versus bilateral stent placement, or ostial versus nonostial stent positioning. Conventional catheter angiography or spiral computed tomographic (CT) angiography performed in 19 patients (28 stents) at a mean interval of 12.5 months demonstrated primary patency in 75%. Maintained stent patency appeared to correlate with renal functional benefit.nnnCONCLUSIONSnPercutaneous renal artery stent placement for angioplasty failures or restenoses provides clinical benefit in most patients with ischemic nephropathy.

Livedo reticularis, rhabdomyolysis, massive intestinal infarction, and death after carbon dioxide arteriography

In patients with renal insufficiency or hypersensitivity to iodinated contrast material, carbon dioxide gas (CO2) is generally considered a safe alternative contrast media for digital subtraction angiography. However, we herein report a previously undescribed fatal complication of CO2 angiography in a patient with acute renal dysfunction and congestive heart failure. The possible pathogenetic mechanisms of this complication are discussed.

Transmesenteric-Transfemoral Method of Intrahepatic Portosystemic Shunt Placement with Minilaparotomy

PURPOSEnTo determine whether the transmesenteric-transfemoral method of intrahepatic portosystemic shunt (IPS) placement is safer and more efficient than the transjugular method.nnnPATIENTS AND METHODSnSixty-six consecutive patients with cirrhosis and bleeding varices underwent 67 IPS procedures. Sixty-one of these procedures were performed using a combination of transfemoral access to the hepatic vein with transmesenteric access to the portal system provided by means of minilaparotomy. Follow-up days were collected periodically by means of clinical evaluation and duplex sonography of the shunt. Angiographic evaluation was performed when necessary.nnnRESULTSnNo technical failures or periprocedural deaths occurred. The radiologic and surgical portions of the procedure were accomplished within 45 and 55 minutes, respectively. In cases without portal thrombosis, maximum fluoroscopy time was 12 minutes. During follow-up (mean, 16 months), eight shunt revisions including one additional shunt placement were necessary.nnnCONCLUSIONnTransmesenteric-transfemoral IPS placement requires surgical participation but may offer improved efficiency and safety compared with regular transjugular IPS placement.

Combined Transmesenteric and Transjugular Approach for Intrahepatic Portosystemic Shunt Placement

SCVIR. 1993 T H E basic method of intrahepatic portosystemic shunt placement, with some variations, as described by Richter et al, Ring et al, and Zemel et a1 (1-3) involves use of a transjugular technique. A transfemoral route has also been described (4). We created an intrahepatic portosystemic shunt from a combined approach to the portal system (provided by means of minilaparotomy) and the hepatic venous system (achieved by means of routine venous catheterization).

Percutaneous cholecystoduodenostomy: a case report.

Abbreviations: PC percutaneous cholecystostomy, PCD percutaneous conversion cholecystoduodenostomy TREATMENT of acute cholecystitis via cholecystectomy, in patients who have associated debilitating conditions, is associated with high mortality and morbidity rates, reaching 30% and 55%, respectively, for open surgical procedures (1), although a laparoscopic approach may reduce the risks (2). Therefore, percutaneous cholecystostomy (PC) as a safe, minimally invasive procedure remains a commonly accepted method of treatment of acute cholecystitis in patients who have contraindications to surgery (3). Percutaneous cholecystostomy could be curative in many, but not all, such high-risk cases (4). When PC fails to resolve cholecystitis, the patient may be cured by a subsequent surgical cholecystectomy, if the risk for surgery is reduced (5,6). However, in a few cases, when contraindications for surgical procedures persist, the patients may be bound to have protracted external drainage until the purulent discharge ceases and the signs of cholecystitis resolve. Such a period may last up to 7 months (7) or longer. The presence of a catheter draining purulent material into a bag imposes serious restrictions to the patient. The system requires constant care, such as irrigation, cleaning, and dressing of the insertion site, emptying the bag, and periodic catheter changes. In addition, the outside catheter and bag limit the physical activity of the patient. Such catheters could be inadvertently removed, which poses an unnecessary risk and may require urgent intervention. We present a case in which the disadvantages of external drainage after PC were eliminated by a percutaneous conversion to a cholecystoduodenostomy (PCD). CASE REPORTS

Intravascular brachytherapy via the inferior vena cava: an adjunctive treatment for pancreatic cancer.

JVIR 2000; 11:729–732 ADENOCARCINOMA is the most common tumor of the pancreas and is now the fifth leading cause of cancer deaths in the United States (1,2). Although multiple regimens and approaches have been used in attempts to treat pancreatic cancer, the overall survival rate remains dismal. Surgical resection has been the mainstay of attempted curative therapy for pancreatic carcinoma for many years. Only 10%–15% of patients with pancreatic cancer are able to undergo “potential” curative resection, and those who do have a 5-year survival of less than 20% (3). Because pancreatic cancer at presentation is rarely a localized process, surgery alone is unlikely to increase survival in the absence of adjuvant therapy (4). Current available adjuvant modalities include chemotherapy, neoadjuvant chemotherapy, intraperitoneal chemotherapy, external beam radiation, preoperative radiation, intraoperative radiation therapy and brachytherapy. Brachytherapy has been applied interstitially, intraluminally (within the biliary ducts), and appositionally (close to or actually touching the tumor) (5,6). We report a case of pancreatic adenocarcinoma treated with adjuvant brachytherapy through a catheter positioned in the inferior vena cava (IVC). To our knowledge, this approach has not been previously described.