Marcelle J. Shapiro

Venography with carbon dioxide as a contrast agent

PurposeThe purpose of this study was to evaluate the feasibility, safety, and potential role of carbon dioxide (CO2) as a contrast agent for venography.MethodsConsecutive patients with contraindications to iodinated contrast agents or with unsatisfactory iodinated contrast studies underwent CO2 digital subtraction venography. The images were rated by three experienced angiographers. Image quality and complications were assessed.ResultsOver a 14-month period, 66 vein segments were studied in 21 patients. There was good correlation between experienced angiographers on CO2 image quality (Ri = 0.80) and good agreement on diagnosis (k = 0.62). In 91% of the vein segments evaluated with CO2 there was interobserver agreement on the diagnosis. Upper extremity veins were adequately imaged with CO2 alone in all (6/6) patients with contraindications to iodinated contrast. Following suboptimal iodinated contrast studies in six patients, CO2 produced significantly better quality upper extremity central vein images (p < 0.05). Pain following injection into peripheral veins was the only CO2-related complication. Inferior vena cava (IVC) filters were successfully deployed with CO2 alone in 78% (7/9) of patients; two required iodinated contrast.ConclusionBased upon initial experience, CO2 venography can be recommended in patients with contraindications to iodinated contrast or unsatisfactory iodinated contrast studies.

Intraarterial Chemotherapy with Limb-sparing Resection of Large Soft-Tissue Sarcomas of the Extremities

Fifteen patients with large (average, 15-cm), high-grade soft-tissue sarcomas of the extremities received prolonged selective intraarterial infusions of chemotherapeutic agents in an attempt to permit limb-sparing resection of these tumors, which would otherwise have required amputation. There were seven malignant fibrous histiocytomas, four liposarcomas, two fibrosarcomas, one leiomyosarcoma, and one rhabdomyosarcoma; 73% were grade III. Seven patients underwent two catheterizations, for a total of 22 infusions, which averaged 11.3 days each. There were four catheterization-related complications, including catheter occlusion or dislodgement in one patient each and two cases of arterial thromboembolism in patients in whom anticoagulant dose was not adequate. Both of the latter patients required thrombectomy; one developed gangrene, which precluded limb-sparing surgery. Thirteen of the 15 patients underwent limb-sparing resections, and two underwent amputations. No wound complications occurred. With a median follow-up of 36 months (mean, 34 months), life-table analysis indicates overall and disease-free survivals of 72% and 59%, respectively, at 2 years and 64% and 59% at 3 years. In comparison to other reported therapies, this technique permits limb salvage in most patients without the high wound complication rate associated with preoperative radiation therapy, with equivalent local disease control and survival.

Recanalization of an Occluded Aortoiliac Bypass Graft with Palmaz Stents

Four tandem Palmaz balloon-expandable vascular stents were used to recanalize the completely occluded limb of an aortoiliac bypass graft after failure of thrombolysis and conventional angioplasty. The resting peak-systolic pressure gradient across the occluded limb was reduced from 68 to 13 mm Hg. The patients rest pain resolved, and the ankle-brachial index rose from 0.54 to 0.78. No embolization or stent-related complications occurred. The graft remains patent as determined with noninvasive studies obtained 8 months later.

Biliary Venous Fistula: An Unusual Complication of Fine-Needle Aspiration Biopsy of the Liver

© SCVIR, 1995 THE incidence of complications following fine-needle (external diameter < 1 mm; 20-23-gauge) aspiration biopsies (FNABs) in the abdomen is low, with a reported rate of 0.55%. Major complications including bile peritonitis, bacterial peritonitis, intrahepatic hematoma, tumor seeding, and death have been reported to occur in 0.003%-0.1% of cases (1,2). Blood may enter the biliary system in association with hepatic trauma, cholelithiasis, surgery, or percutaneous interventional procedures resulting in hemobilia. Bile entering the vascular system, or hyperbilirubinemia, is a rare clinical situation that has been reported in association with biliary obstruction from common bile duct stones and a normal blood vessel (3-11). However, we describe a patient with a nondilated biliary system and cavernous transformation of the portal vein (CTPV) who developed an acute biliary-venous fistula associated with severe hyperbilirubinemia or bilemia following percutaneous FNAB of the liver.

Transhepatic Laser Lithotripsy of Choledocholithiasis: Initial Clinical Experience

Three patients with symptomatic intra- and extrahepatic choledocholithiasis who were not good candidates for retrograde endoscopy, surgery, or extracorporeal shock wave lithotripsy (ESWL) were treated successfully with endoscopically guided tunable dye laser lithotripsy via a 12-F transhepatic sheath. There were no complications secondary to the use of the laser. On the basis of this initial experience, transhepatic laser lithotripsy is a technically feasible and safe alternative when choledocholithiasis cannot be managed with retrograde endoscopy, ESWL, or surgery. Its role in the management of choledocholithiasis relative to other transhepatic techniques remains to be determined.