Jean-François De Wispelaere

CONGENITAL ANOMALIES OF THE INFERIOR VENA CAVA AND LEFT RENAL VEIN : EVALUATION WITH SPIRAL CT

PURPOSE To determine with spiral computed tomography (CT) the incidence and caval location of left renal vein (LRV) variants that may affect inferior vena cava (IVC) filter placement, spermatic vein embolization, and adrenal or renal venous sampling. MATERIALS AND METHODS Contrast material-enhanced spiral CT scans of 1,014 patients were evaluated for the incidence and configuration of LRV variants and for the distribution of the entrances of these veins into the IVC. RESULTS In this series, variants detected were as follows: one azygos continuation of the IVC (0.1%), three bilateral IVCs (0.3%), and 102 LRV variants (10%) including 38 retroaortic renal veins (3.7%) and 64 circumaortic venous rings (6.3%). In the retroaortic renal vein group, the distance between the entrance of the LRV into the IVC and the confluence of the iliac veins was +62.5 mm +/- 8.7. In the circumaortic venous ring group, the distance between the entrances of the retroaortic and preaortic limbs into the IVC was -39.0 mm +/- 17.4; the distance between the entrance of the left retroaortic limb into the IVC and the confluence of the iliac veins was +63.2 mm +/- 17.1. CONCLUSIONS Detailed knowledge of these anomalies is crucial for IVC filter placement, spermatic vein embolization, and adrenal or renal venous sampling.

Selective blocks of the motor nerve branches to the soleus and tibialis posterior muscles in the management of the spastic equinovarus foot

OBJECTIVE To identify the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor nerve blocks in the management of the spastic equinovarus foot. DESIGN Descriptive study by computed tomography (CT) scan of 12 hemiplegic legs. SETTING Spasticity group at a university hospital. PARTICIPANTS Twelve patients with hemiplegia (6 men, 6 women) with spastic equinovarus foot. INTERVENTION Three-dimensional location of the motor nerve branches to the soleus and tibialis posterior muscles with CT scan, followed by selective motor branch blocks with anesthetics. MAIN OUTCOME MEASURES Vertical, horizontal, and deep coordinates determined by CT scan in relation to anatomic surface landmarks (upper extremity of the fibula and vertical metallic element). Soleus and tibialis posterior spasticity (Ashworth Scale), soleus H-wave maximum (Hmax)/M-wave maximum (Mmax) ratio, and sensory testing before and after the blocks. RESULTS The mean coordinates +/- standard deviation for the soleus motor branch were 10+/-5 mm (vertical), 17+/-9 mm (horizontal), and 30+/-4 mm (deep); for the tibialis posterior motor branch they were 45+/-6mm (vertical), 17+/-8mm (horizontal), and 47+/-4 mm (deep). Spasticity and Hmax/Mmax ratio decreased after the blocks, confirming their efficiency. No subjects experienced additional sensory deficit. CONCLUSION Our study determined the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor branch blocks and neurolytic procedures. These coordinates allow us to perform selective motor blocks without CT scan.

Systemic supply to a pulmonary arteriovenous malformation: Potential explanation for recurrence

A pregnant woman presented with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) and a single pulmonary arteriovenous malformation (AVM) that had been embolized 5 years previously. Partly due to pregnancy, recanalization of the aneurysm occurred with subsequent hemoptysis. Despite successful therapeutic reembolization of the afferent pulmonary artery, hemoptysis recurred 5 days later. At this time, recanalization of the pulmonary artery was not demonstrated by pulmonary angiography, but a systemic angiogram revealed a bronchial arterial supply to the pulmonary AVM. A systemic supply should always be sought in cases of recurrent hemoptysis after technically successful embolization of the feeding pulmonary artery.

Acute cardiogenic shock after lumbar sympathectomy by phenol injection

Accepted: 10 October 2001 Published online: 23 November 2001

Endobronchial drainage in case of infected posttraumatic pulmonary pseudocyst: an alternative to surgery?

Dear Editor, A 52-year-old man required urgent splenectomy after a motorbike accident. In addition to multiple bone fractures, thoracic computed tomography (CT) scan showed lung contusions, right pneumothorax and left hemopneumothorax requiring drainage, and a left lower lobe bloodfilled pseudocyst (Fig. 1a). Three days later, purulent sputa, hemoptysis, and fever (38.7 C) were observed. The patient developed respiratory distress with respiratory rate of 25/min (blood gases: pH 7.41, pO2 53 mmHg, pCO2 42 mmHg, saturation 90.9%), and mechanical ventilation was required despite noninvasive ventilation attempt. Control CT scan showed a growing left lower lobe pseudocyst with air–fluid level and an acute respiratory distress syndrome (ARDS) (Fig. 1b, c). Endotracheal aspirate grew Klebsiella pneumoniae. After 4 weeks of well-conducted antibiotherapy, as no improvement was observed, we hypothesized that persistent infiltrates were coming from continuous flooding originating from the infected pseudocyst. Although surgical option or percutaneous drainage were first considered, they were finally discarded: the former to avoid left pneumonectomy in case of suprainfected ARDS and the latter to avoid bronchopleural fistula and consequent empyema (hemopneumothorax still being present). Therefore, as described by Herth [1], the pseudocyst was drained via a 7-French pigtail catheter (Cordis , Miami, FL) introduced into the cavity through the tube connector and the tracheobronchial tree (Fig. 1d–f). This allowed continuous drainage and twice-a-day lavage (250 ml 0.9% NaCl solution followed by injection of 10 units Colimycin). Connector air leakages were avoided by a plug. After 12 days, dramatic improvement was observed, the drain was removed, and the patient extubated. Soon after, fluid recurred in the pseudocyst, leading to a new bilateral supra-infection. Since we anticipated the patient would not tolerate another endobronchial drain when extubated, and as the risk of empyema was less probable following hemopneumothorax disappearance, the cavity was percutaneously drained, allowing drainage and lavage. As purulent sputa persisted and to avoid a new supra-infection, three endobronchial plugs (WatanabeEWS ; Novatech, La Ciotat, FR) were inserted, under CT guidance, into subsegmental bronchi draining the pseudocyst. Further evolution was uneventful, allowing discharge from intensive care unit (ICU) after 3 months and from hospital 2 weeks later. The last radiological images showed spectacular regression of the lesions (Fig. 1g, h). Pulmonary pseudocyst rarely occurs after blunt chest trauma [2–4]. Secondary complications are exceptional, but cavity infection is the most severe and regularly leads to surgery [5]. Our patient developed such pseudocyst supra-infection, and despite prolonged antibiotherapy, lung infection persisted, precluding extubation. Therefore, surgery was considered [5], but left pneumonectomy (the sole surgical option) was judged prohibitive during uncontrolled infection and ARDS. In presence of uncured hemopneumothorax and bronchopleural fistula, percutaneous drainage carried the risk of empyema. Therefore, a catheter was endobronchially inserted into the pseudocyst, allowing drainage, lavage, and local antibiotic instillation. To our knowledge, this is the first application in a ventilated patient with protracted infected pseudocyst. The procedure was well tolerated, and like in nonintubated patients [1], surgery could be avoided and the patient extubated. In summary, endobronchial drainage could be an alternative to surgery in infected posttraumatic pseudocysts even in mechanically ventilated patients.