John H. Whiting

Fatal outcome after embolotherapy for hepatic arteriovenous malformations of the liver in two patients with hereditary hemorrhagic telangiectasia.

JVIR 2000; 11:855–858 PATIENTS with hepatic arteriovenous malformation (AVM) associated with hereditary hemorrhagic telangiectasia (HHT) present with diverse clinical manifestations ranging from cirrhosis to cholestasis and multiple biliary strictures (1–4). Left-to-right shunting may also lead to abdominal pain, weight loss, high output heart failure, pulmonary hypertension, and encephalopathy (5– 12). Therapeutic options reported for symptomatic AVMs include hepatic artery embolization, ligation, or liver transplantation (12–15). Hepatic artery embolization is assumed to be low risk and of benefit based on favorable results seen in the treatment of hepatomas, liver metastases, and hemangiomas (13,16,17). Although embolization is effective in the treatment of pulmonary AVMs in patients with HHT (18), successful implementation of this approach for the more complex HHT liver lesions remains unproven. Several previous reports (including ours) support embolization of HHT-related hepatic AVMs (8–10,12–15,19). However, the utility, morbidity, and mortality of the procedure has not been critically evaluated. We report the deaths of two patients with HHT after hepatic AVM embolization to treat their high flow-related symptoms.

Refractory abdominal-cutaneous fistulas or leaks : Percutaneous management with a collagen plug

BACKGROUND We report the results of abdominal-cutaneous fistula tract occlusion with a collagen plug in a series of patients with fistulas or leaks refractory to conservative therapy. STUDY DESIGN Seven patients were found to have persistent fistula or leak after percutaneous drainage of abdominal pelvic fluid collections. All patients but one were refractory to surgical or percutaneous drainage. Under fluoroscopic guidance, modified Vasoseal (Datascope Inc, Montvale, NJ) collagen plugs were deployed into the fistulas using catheter-directed techniques. The plugs were split longitudinally to fit into an 8F or 9F peel-away sheath, placed into the fistula, and deployed. Results were tabulated and patients were followed up. RESULTS Six of seven patients undergoing fluoroscopically guided, catheter-directed tract occlusion had resolution of the fistula, with no evidence of fistula or abscess recurrence from 30 to 180 days after closure. There were no procedural complications. The technique was unsuccessful in dosing a gastrocutaneous fistula after removal of a large-bore gastrostomy tube; this failure was believed to be secondary to the short length and large caliber of the tract in a patient with hypercortisolemia. CONCLUSIONS Closure of abdominal-cutaneous fistula tracts by occlusion with a modified Vasoseal collagen plug shows promise in the management of fistulas refractory to catheter drainage.

Bilateral fatigue fractures of the radial shaft in a gymnast

A 24-year-old female gymnast had a 3-month history of bilateral forearm pain. A Tc-99m MDP bone scan demonstrated focally increased activity in the radial shafts on blood pool and delayed images, characteristic of fatigue fractures. Fatigue fractures commonly occur in the lower extremities. Upper extremity fatigue fractures, in contrast, are uncommon and usually involve the humerus or ulna. Fatigue fracture of the radial shaft from gymnastic exercise has not been previously reported.

Scintigraphic appearance of bone during external beam irradiation

Separate imaging studies employing Tc-99m MDP, In-111 labeled leukocytes, and Tc-99m SC were performed in a patient receiving external beam radiation therapy to the mediastinum and left hemithorax. The leukocyte scan demonstrated greatly increased activity at the site of the radiation port. The bone marrow (sulfur colloid) scan was normal and the bone scan demonstrated only minimally increased activity in the irradiated region. The varying appearance of these scans may represent the difference in the early effect of radiation on bone and bone marrow elements.