Michael M. Herskowitz

Nonoperative Salvage of Computed Tomography--diagnosed Splenic Injuries: Utilization of Angiography for Triage and Embolization for Hemostasis

OBJECTIVES The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis. METHODS Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. RESULTS Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients). CONCLUSIONS (1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

Prospective Randomized Trial of a Metallic Intravascular Stent in Hemodialysis Graft Maintenance

PURPOSE To evaluate percutaneous transluminal angioplasty (PTA) alone versus PTA and flexible self-expanding stent placement for the management of hemodialysis access graft stenoses. MATERIALS AND METHODS Thirty-seven grafts in 34 patients were evaluated for abnormal intradialytic parameters (n = 27) or occlusion (n = 10). Angiography identified stenoses (mean, 69%; range, 50%-95%) at or within 3 cm of the vein-graft junction (70%) or in the peripheral outflow vein (30%) that had recurred within a 6-month period after previous PTA. They were randomized to PTA alone (n = 20) or PTA with Wallstent (n = 17). Additional lesions were treated by PTA alone, and a mean of 1.4 (range, 1-3) lesions were treated per patient. Significant differences existed in the mean number of previous accesses (1.8 and 0.8 in the PTA and stent groups, respectively) and in the mean number of previous interventions in the current access (1.8 and 2.9, respectively). End points were subsequent radiologic or surgical intervention, transplantation, and death. RESULTS Technical success was 100% (mean residual stenosis, 12%; range, 0%-30%). The primary patency of 128 days and secondary patency of 431 days were similar for both groups. Secondary patency required a mean of 1.8 and 1.6 additional interventions for the PTA and stent groups, respectively. The adjunctive stent placement increased the cost of the procedure by 90%. CONCLUSION Despite significant added costs, there was no advantage to stent placement for recurrent peripheral hemodialysis graft stenoses that were already adequately dilated with balloon angioplasty.

Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective, randomized comparison.

PURPOSE To compare the efficacy of radiologic guided placement of percutaneous gastrojejunostomy (PGJ) and percutaneous endoscopic gastrostomy (PEG). MATERIALS AND METHODS Patients were randomized to PGJ (n = 66) or PEG (n = 69). Indications for gastrostomy were need for prolonged enteral nutrition (97%) or gastrointestinal decompression (3%), with etiologies of neurologic impairment (81%), head and neck neoplasm (12%), bowel obstruction (3%), or other (4%). Mean follow-up was 202 days and 30-day follow-up was obtained for 85% of patients. RESULTS PEG was successful in 63 of 69 (91%) patients, while PGJ established access in all of 66 attempts (100%) (P = .014). Average procedural time was 53 minutes for PGJ and 24 minutes for PEG (P = .001). At 30-day follow-up, there were 33 and 45 complications in the PGJ and PEG groups, respectively. This difference was due to the greater incidence of pneumonia in the PEG group (P = .013). Long-term tube-related complications occurred with 17 PGJs and four PEGs (P = .007). The PGJ cost more than PEG, but this advantage was offset by the cost of complications. CONCLUSION PGJ had higher success rate and fewer complications, due to a lower incidence of pneumonia. PEG took less time to perform, cost less, and required less tube maintenance.

Percutaneous transhepatic coil embolization of a ruptured intrahepatic aneurysm in polyarteritis nodosa

Large visceral aneurysms in polyarteritis nodosa are relatively uncommon. We present a patient with polyarteritis nodosa who ruptured a large intrahepatic aneurysm which was treated by percutaneous transhepatic coil embolization.

Use of magnetic internal ureteral stents in pediatric urology: retrieval without routine requirement for cystoscopy and general anesthesia.

In children the use of internal ureteral stents has the added morbidity of requiring general anesthesia for stent retrieval. Magnetically tipped ureteral stents were developed to allow easy retrieval without the need for anesthesia or cystoscopy. For pyeloplasty we generally do not use a stent or nephrostomy tube but we treated 7 children 2 1/2 months to 11 years old in whom we believed there was an indication for stenting and in whom we used a magnetically tipped stent. The catheters were removed with a magnetically tipped catheter retriever without the need for anesthesia in 6 of the 7 cases and cystoscopy was not required in any case. Our initial impression is that when stenting is advised the magnetically tipped ureteral stent appears to be a good alternative, especially in children, since it avoids the need for anesthesia and cystoscopic retrieval.

Acute traumatic dissection of the common iliac arteries with spontaneous healing: Case report

Acute dissection of the abdominal aorta or common iliac arteries after blunt trauma is a very rare injury. We present an unusual case of acute traumatic dissection of the common iliac arteries. To our knowledge, this is the first reported case of acute traumatic dissection of the iliac arteries with ultimate spontaneous healing.

Cocaine-induced mesenteric ischemia: treatment with intra-arterial papaverine

Mesenteric vascular ischemia is a known complication of cocaine use. Although the majority of cases of cocaine-induced mesenteric ischemia present with ischemic colitis and rectal bleeding, several cases have been described presenting only with abdominal pain. We present a case of mesenteric vasoconstriction with angiographic documentation and treatment.

Interventional Radiology in the Treatment of Internal Carotid Artery Gunshot Wounds

PURPOSE To review the indications for and techniques and results of interventional radiology in the management of internal carotid artery gunshot wounds. PATIENTS AND METHODS The demographics, clinical presentations, angiographic findings, methods of treatment, and outcomes were reviewed in 20 patients who underwent 21 interventional procedures. RESULTS Seventeen coil embolizations were successful in controlling hemorrhage. One intimal flap was compressed with balloon angioplasty, with subsequent nonoperative healing. Temporary balloon occlusions were used as a method of preoperative assessment of intracranial collateral circulation or of preoperative vascular control in three patients. There were no complications. The mortality rate was 20%. CONCLUSION Penetration of the internal carotid artery is a very severe injury with a high mortality rate due to neurologic sequelae. Interventional radiology plays an important role in the management of these wounds, and it often obviates surgical exploration.

Direct sonographic-guided superior gluteal artery access for treatment of a previously treated expanding internal iliac artery aneurysm

Isolated internal iliac artery aneurysms are relatively uncommon compared with all aortoiliac aneurysms. Transcatheter treatment with coil embolization is an attractive noninvasive alternative to surgical resection. However, if the aneurysm is insufficiently treated with only proximal coil embolization without concurrent embolization of distal runoff vessels, there is a risk of aneurysm expansion from retrograde collateral flow. We present a case of previously treated internal iliac aneurysm that underwent late rapid expansion. Due to occlusion of the internal iliac artery, direct sonographic-guided puncture of the superior gluteal artery was made in order to access the aneurysm. We believe this is the first reported case of such treatment.

Intestinal plethora: An early sign of acute posttraumatic hepatic artery-portal vein arteriovenous fistula

Traumatic communications between the hepatic artery or its branches and the portal vein or its tributaries usually are clinically occult until the late sequelae of portal hypertension, such as esophageal and mesenteric varices, ascites, or congestive heart failure, become manifest. The authors describe the early diagnosis of such a lesion by computed tomography. The CT findings included a hepatic hematoma and, more significantly, diffuse thickening of the small and large bowel wall. This thickening represents vascular congestion of the bowel caused by acute portal hypertension prior to the development of decompressing portal collateral circuits.When this CT finding is not associated with other signs of intestinal ischemia or infarction, it should suggest portal hypertension and lead to arteriography for diagnosis and therapy of arterioportal fistula.