Morris L. Gavant

Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture.

OBJECTIVE There were two aims of this study. The first was to evaluate the application of helical computed tomography of the thorax (HCTT) for the diagnosis of blunt aortic injury (BAI). The second was to evaluate the efficacy of beta-blockers with or without nitroprusside in preventing aortic rupture. SUMMARY BACKGROUND DATA Aortography has been the standard for diagnosing BAI for the past 4 decades. Conventional chest CT has not proven to be of significant value. Helical CT scanning is faster and has higher resolution than conventional CT. Retrospective studies have suggested the efficacy of antihypertensives in preventing aortic rupture. METHODS A prospective study comparing HCTT to aortography in the diagnosis of BAI was performed. A protocol of beta-blockers with or without nitroprusside was also examined for efficacy in preventing rupture before aortic repair and in allowing delayed repair in patients with significant associated injuries. RESULTS Over a period of 4 years, 494 patients were studied. BAI was diagnosed in 71 patients. Sensitivity was 100% for HCTT versus 92% for aortography. Specificity was 83% for HCTT versus 99% for aortography. Accuracy was 86% for HCTT versus 97% for aortography. Positive predictive value was 50% for HCTT versus 97% for aortography. Negative predictive value was 100% for HCTT versus 97% for aortography. No patient had spontaneous rupture in this study. CONCLUSIONS HCTT is sensitive for diagnosing intimal injuries and pseudoaneurysms. Patients without direct HCTT evidence of BAI require no further evaluation. Aortography can be reserved for indeterminate HCTT scans. Early diagnosis with HCTT and presumptive treatment with the antihypertensive regimen eliminated in-hospital aortic rupture.

Blunt bowel and mesenteric injuries: the role of screening computed tomography.

BACKGROUND Early generation scanners have demonstrated poor sensitivity detecting blunt bowel/mesenteric injuries (BBMI). This study was aimed at determining the accuracy and role of helical scanners in BBMI. METHODS Retrospective chart review of patients with BBMI, or computed tomographic scans suspicious of BBMI, from August of 1995 to December of 1998. RESULTS One hundred of 8,112 scans (1.2%) were suspicious of BBMI. Of these suspicious scans, 53 patients had BBMI (true positive-TP) and 47 patients did not (false positive-FP). Seven patients with negative scans had BBMI (false negative-FN). Computed tomography contributed toward early surgery in 77% of patients who may have been delayed. Six patients developed intra-abdominal abscess. The abscess group had a significantly longer time interval from injury to surgery. Multiple findings were seen in 57% of true positive scans, whereas in 13% of false positive scans (p < 0.0001). An algorithm for management of BBMI is presented. CONCLUSION Helical scanners have high accuracy in detecting BBMI. Single versus multiple findings are useful in managing these injuries.

Minimal Aortic Injury: A Lesion Associated with Advancing Diagnostic Techniques

BACKGROUND With the increasing use of high-resolution diagnostic techniques, minimal aortic injuries (MAI) are being recognized more frequently. Recently, we have used nonoperative therapy as definitive treatment for patients with MAI. The current study examines our institutional experience with these patients from July 1994 to June 2000. METHODS All patients suspected of blunt aortic injury (BAI) by screening helical CT (HCT) underwent confirmatory aortography with or without intravascular ultrasound (IVUS). MAI was defined as a small (<1 cm) intimal flap with minimal to no periaortic hematoma. RESULTS Of the 15,000 patients evaluated by screening HCT, 198 (1.3%) were suspected of having BAI. BAI was confirmed in 87 (44%), and 9 (10%) of these had MAI. The initial aortogram was considered normal in five of the MAI patients. The correct diagnosis was made by IVUS (four patients), and video angiography (one patient). One MAI patient had surgery, and two (22%) died of causes not related to the aortic injury. Follow-up studies were done on the six MAI patients that were discharged. In two, the flap had completely resolved, and in one it remained stable. The remaining three patients formed small pseudoaneurysms. CONCLUSION Ten percent of BAI diagnosed with high resolution techniques have MAI. These intimal injuries heal spontaneously and hence may be managed nonoperatively. However, the long-term natural history of these injuries is not known, and hence caution should be exercised in using this form of treatment.

Importance of Delayed Imaging for Blunt Renal Trauma

The advent of noninvasive computed tomography of the abdomen and pelvis for evaluation of blunt renal trauma has led to the practice of expectant management for hemodynamically stable patients. Although expectant management of higher grade injuries (American Association for the Surgery of Trauma Renal Injury Scale) would intuitively result in an increased frequency of urologic complications, this has not been previously examined in a large series of patients utilizing contemporary radiologic imaging techniques. A retrospective review of patients from a single institution within a recent 4-year period revealed 4 grade I, 13 grade II, 21 grade III, 7 grade IV, and 4 grade V injuries. None of grade I, 15% of grade II, 38% of grade III, 43% of grade IV, and 100% of grade V injuries had one or more (15 major and 11 minor) urologic complications. The incidence of urinary complications correlated significantly with increasing grade (0%, 15%, 38%, 43%, and 100% for grades I to V, respectively; r = 0.94, p = 0.0158). Of the delayed urologic complications, 50% were diagnosed on follow-up imaging studies and 33% of them required intervention. Therefore we advocate repeat imaging 2 to 4 days after trauma resulting in grade III to V blunt renal lacerations to identify delayed complications that may require intervention.

Bronchial arteriography and embolotherapy for hemoptysis in patients with cystic fibrosis

Bronchial arteriography and embolotherapy were performed to control hemoptysis in 11 patients with advanced stages of cystic fibrosis. Two patients suffered massive, 1 moderate, and 8 mild but recurrent hemoptysis. The embolization procedures were performed with Gelfoam, Ivalon, and coils in one to four separate procedures. Altogether, 19 of 20 procedures were successful, with follow-up periods ranging from 9 months to 8 years. No serious complications were encountered except for one femoral artery pseudoaneurysm which required surgical repair. Rapid digital subtraction angiography and “roadmapping” were considered helpful in avoiding the complication of reflux embolization and expediting the procedures. Bronchial embolization is a life-saving procedure for severe hemoptysis in patients with cystic fibrosis and is considered safe enough to include the indications of moderate and mild/recurrent hemoptysis to improve the quality of life in these patients.

Distention arthrography in the treatment of adhesive capsulitis of the shoulder.

PURPOSE Adhesive capsulitis involving the glenohumeral joint (frozen shoulder) is an insidious and painful condition that results in gradual loss of joint motion. Recovery is frequently prolonged despite multiple therapeutic maneuvers. The authors investigate the mechanism of action and the long-term clinical result of distention arthrography for the treatment of patients with frozen shoulder. PATIENTS AND METHODS Sixteen patients with adhesive capsulitis of the shoulder were treated with therapeutic capsular distention by using intra-articular injection of a 30-mL mixture of lidocaine, corticosteroid, and contrast media immediately following diagnostic arthrography. RESULTS Capsular disruption was demonstrated in all cases. Thirteen patients (80%) experienced immediate pain relief and increased shoulder mobility. This improvement was maintained over a follow-up interval of 6 months or more. Disruption occurred at the subscapular bursa in eight patients, the subacromial bursa in six, and the distal bicipital tendon sheath in two. These latter two patients had no pain relief. CONCLUSION Arthrographic distention of the constricted capsule appears to be an excellent therapeutic intervention for achieving rapid symptomatic relief from adhesive capsulitis.

Initial experience with a universal-length copolymer ureteral stent

A universal-length ureteral stent made of a biocompatible copolymer was designed specifically for easy antegrade internal placement. The doublelooped distal end of the stent eliminates the need to measure the distance from the ureteropelvic to ureterovesical junction. If additional length is required, a portion of the distal loop is incorporated into the stent shaft. Interventional radiology practices benefit economically, as the universal-length stent is the only size required for the treatment of most ureteral obstructions.