J. Bayne Selby

Percutaneous Transluminal Angioplasty of Visceral Arterial Stenoses: Results and Long-term Clinical Follow-up

PURPOSE To determine the efficacy and safety of percutaneous transluminal angioplasty (PTA) of the visceral arteries. PATIENTS AND METHODS We retrospectively evaluated the results of PTA performed in 20 visceral arteries in 19 patients (10 men, nine women; mean age, 63 years). Eleven patients had symptoms characteristic of mesenteric ischemia, four had atypical abdominal pain, and four were undergoing prophylactic dilation before undergoing another procedure involving the abdominal aorta. Clinical follow-up was possible in all patients. RESULTS PTA was technically successful in 15 of 19 patients (79%); among these 15 patients, 12 (80%) did well clinically. Of the seven PTA procedures that were immediate failures, five failed secondary to an occult malignancy or to extrinsic arterial compression by the median arcuate ligament. Ten (83%) of the 12 patients in whom the procedures were immediate clinical successes are still clinically improved at 4-73 months follow-up (mean, 25 months). PTA was successful in only one of the four patients who had symptoms atypical of mesenteric ischemia, but it was successful in 11 of the 15 patients who had symptoms of mesenteric ischemia or who underwent prophylactic dilation. Major complications occurred in three (16%) of the 19 patients. CONCLUSION PTA of visceral artery stenoses is effective in patients with symptoms of mesenteric ischemia. It is also effective as prophylaxis in patients undergoing additional procedures in the abdominal aorta.

Isolated Right Segmental Hepatic Duct Injury Following Laparoscopic Cholecystectomy

PurposeLaparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. There is an increased incidence of bile duct injuries in LC compared with the open technique. Isolated right segmental hepatic duct injury (IRSHDI) represents a challenge not only for management but also for diagnosis. We present our experience in the management of IRSHDI, with long-term follow-up after treatment by a multidisciplinary approach.MethodsTwelve consecutive patients (9 women, mean age 48 years) were identified as having IRSHDI. Patients’ demographics, clinical presentation, management and outcome were collected for analysis. The mean follow-up was 44 months (range 2–90 months).ResultsThree patients had the LC immediately converted to open surgery without repair of the biliary injury before referral. Treatments before referral included endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage and surgery, isolated or in combination. The median interval from LC to referral was 32 days. Eleven patients presented with biliary leak and biloma, one with obstruction of an isolated right hepatic segment. Post-referral management of the biliary lesion used a combination of ERCP stenting, percutaneous drainage and stent placement and surgery. In 6 of 12 patients ERCP was the first procedure, and in only one case was IRSHDI identified. In 6 patients, percutaneous transhepatic cholangiography (PTC) was performed first and an isolated right hepatic segment was demonstrated in all. The final treatment modality was endoscopic management and/or percutaneous drainage and stenting in 6 patients, and surgery in 6. The mean follow-up was 44 months. No mortality or significant morbidity was observed.ConclusionSuccessful management of IRSHDI after LC requires adequate identification of the lesion, and multidisciplinary treatment is necessary. Half of the patients can be treated successfully by nonsurgical procedures.

Treatment of Hemodialysis Fistula Pseudoaneurysms with Detachable Balloons: Technique and Preliminary Results

Pseudoaneurysm formation is commonly encountered during the life of a dialysis fistula. When these become excessively large or numerous, surgical revision of the graft has been the only treatment option. The authors have treated seven patients by using percutaneous placement of a detachable balloon to occlude a pseudoaneurysm of an upper extremity graft. In four cases the balloon was directed into the pseudoaneurysm from a femoral artery approach. In three cases a direct puncture was made into the pseudoaneurysm for placement of the balloon. The patients were followed up from 1 week to 7 months. Initial technical success was achieved in all seven cases with no complications. Thrombosis of two grafts occurred during the first week after the procedure: one because of herniation of the balloon out of the pseudoaneurysm and one for unknown reasons. One balloon was inadvertently punctured and deflated during subsequent dialysis. Treatment in the other four cases was successful, as evidenced by no further enlargement of the pseudoaneurysms. Direct puncture of the pseudoaneurysm simplifies the procedure and probably decreases the likelihood of balloon herniation because of the orientation of the balloon.

Thromboembolectomy with the Transluminal Extraction Catheter (TEC) as an Adjunct to Thrombolysis

Multiple surgical and percutaneous interventional radiologic techniques have been used to restore blood flow in an acutely ischemic extremity. The transluminal extraction catheter (TEC) system was used as a mechanical thromboembolectomy device to supplement pharmacologic thrombolysis in one patient. In this case, 40 hours of direct intraarterial infusion of urokinase into the occluded vascular segments of a threatened lower extremity resulted in incomplete thrombolysis. Therefore, a 7-F TEC system was advanced percutaneously through the occluded vessels with restoration of luminal patency in all vessels treated. No distal embolization occurred. The TEC system facilitated prompt recanalization of vessels occluded by acute thrombus superimposed on atherosclerotic disease.

Comparative results of doppler sonography after TIPS using covered and bare stents

OBJECTIVE Our purpose was to evaluate the role of sonography in the early follow-up of patients with a covered transjugular intrahepatic portosystemic shunt (TIPS). CONCLUSION Routine baseline Doppler sonography should occur 7-14 days after shunt placement unless malfunction or procedural complications are suspected.

Recent development of rigors during infusion of urokinase: is it related to an endotoxin?

PURPOSE This study was undertaken to determine the prevalence of rigors associated with the use of urokinase (UK) and to assay for the presence of an endotoxin in the UK solution. PATIENTS AND METHODS Records of 75 patients who underwent 86 UK infusions between January 1988 and July 1992 were reviewed to evaluate for the development of UK-associated rigors. A modified chromogenic limulus amebocyte lysate (LAL) test was performed to determine the presence of endotoxin in four samples of UK from lots associated with rigors, one sample of UK not associated with rigors, sterile water, nonionic contrast medium, and ionic contrast medium. RESULTS Between January 1, 1988, and July 10, 1990, 43 patients underwent 46 UK treatments (group 1) with no documented rigors (0% prevalence). In 45 of these 46 treatments, a standard, non-pulse-spray bolus of 75,000-500,000 IU of UK (mean dose, 182,222 IU) was used. Between July 11, 1990, and July 6, 1992, 38 patients underwent 40 UK treatments (group 2). In 33 of these 40 treatments, a standard bolus was given. Five patients received a pulse-spray bolus. The mean bolus was 213,768 IU (range, 100,000-500,000 IU). Eleven group 2 patients developed rigors (28% prevalence; P = .0005 vs group 1). The chromogenic LAL tests demonstrated no endotoxin in sterile water, nonionic contrast media, or ionic contrast media. Endotoxin was detected in small concentrations in the four samples of UK associated with rigors and in the UK sample not associated with rigors. CONCLUSION The increase in the prevalence of rigors associated with the use of UK does not appear to be related to an endotoxin in UK, since the concentration of endotoxin detected is well below the threshold pyrogenic dose in humans.

Interventional Radiology of Trauma

Percutaneous transcatheter embolization has become an integral part of the trauma teams armamentarium. Still, it is probably underused in many centers because of lack of familiarity on the part of both the trauma team and the radiologists. Recognition of the role of interventional radiology in vascular trauma can have a significant impact in decreasing the morbidity and mortality associated with this ever-growing problem in our society.

Evolution of a Specialty: The Case for the Association of Chiefs of Interventional Radiology

Most physicians are students of the history of their profession. Some come by it naturally, others become intrigued during their training, while others simply hear it again and again from their professors until they embody an appreciation for where medicine has been and where it might go. In the big scheme of things, the history of interventional radiology (IR) is relatively short. Much of the earliest work predates even the definition of the specialty. But defined it became. And like so many other fields of study and practice, it has undergone a series of developments that have led to a maturing specialty that is now better organized and widely appreciated. Form follows function, and the administrative structure has followed device and technique breakthroughs. Academic centers have for quite a while supported increasingly focused IR divisions, while most moderate-to-large size private practice groups restrict the performance of advanced procedures to an IR section. Studying the development of other specialties and professions and applying those lessons to the current state of IR, we propose that a next logical step is a mechanism to allow IR chiefs to communicate better together, develop and refine skills particular to running an IR division, and facilitate sharing of data crucial to running an effective and efficient practice. We believe a new association, an Association of Chiefs of Interventional Radiology, would best provide such a mechanism. This communication will review the history of IR leadership, look at similar efforts by other fields, provide justification for such a group, and present a proposal for next steps in the process.