Pasteur Rasuli

Diagnostic value of the electrocardiogram in suspected pulmonary embolism

The electrocardiogram is shown to be of limited diagnostic value for determining pulmonary embolism in a prospective cohort study of unselected patients with suspected pulmonary embolism.

LGM (Vena Tech) Vena Cava Filter: Clinical Experience in 64 Patients

LG-Medical (LGM) vena cava filters were inserted percutaneously in 64 patients. Each case was followed after the filter insertion. Clinical follow-up was available in all patients; in 11 patients it was the only form of follow-up. Findings were available from autopsies in seven patients, plain abdominal radiographs in 42, and duplex sonograms of the insertion vein and inferior vena cava (IVC) in 46. A filter was inserted without major complication in all patients. The filter failed to open fully in four patients and was tilted in the IVC in 15. Recurrent pulmonary embolism was found in two patients (fatal in one), and inconsequential filter migration occurred in 11. Introduction vein thrombosis occurred in four patients. IVC thrombosis, demonstrated at autopsy or sonography, was found in 14 patients (22%) and was symptomatic in six (9%). This report suggests that the LGM filter is easy to introduce, and few complications are associated with insertion. The rate of caval thrombosis, however, may be higher than previously reported.

Caliber-persistent artery of the stomach (Dieulafoy's vascular malformation)

Caliber-persistent artery of the stomach (also known as cirsoid aneurysm, Dieulafoys lesion, and submucosal arterial malformation) is clinically manifested as recurrent, massive, often fatal hematemesis. The lesion often is not seen endoscopically. Left gastric angiography in one patient with hematemesis showed a convoluted and ectatic artery in the gastric fundus, which proved to be caliber-persistent artery of the stomach on pathological examination. The tortuosity of the abnormal vessel in this condition has been attributed to artefactual contraction of the stomach following excision and formalin fixation. This is the first reported case in which a pathologically proven lesion has been clearly visualized by angiography. This demonstrates that the submucosal vessel is truly and not artifactually sinuous. It is proposed that angiographic demonstration of a nontapering, convoluted artery in the territory of the left gastric artery is highly suggestive of caliber-persistent artery of the stomach.

Spherical versus Conventional Polyvinyl Alcohol Particles for Uterine Artery Embolization

PURPOSE To compare the efficacy of spherical polyvinyl alcohol (PVA) particles versus conventional PVA particles for uterine artery embolization (UAE). MATERIALS AND METHODS Of 149 patients with 1-year follow-up after UAE, 96 received conventional PVA particles and 53 received spherical PVA particles. Severity of symptoms was ranked on an 11-point numeric rating scale (0-10). The changes in severity of symptoms after embolization, blood hemoglobin level, and the size of the dominant tumor depicted by ultrasonography were used to assess the efficacy of the two types of particles. The number of hysterectomies and myomectomies in each group was also recorded as evidence of UAE failure. RESULTS On 1-year follow-up, patients treated with conventional PVA showed average numeric rating scale score improvements of 4.6 in menorrhagia, 2.9 in dysmenorrhea, 3.7 in pressure sensation, and 3.4 in urinary frequency. With spherical PVA, the average improvements were 3.0 in menorrhagia, 2.4 in dysmenorrhea, 3.1 in pressure sensation, and 2.0 in urinary frequency. Except in dysmenorrhea, all differences were significant (P < .001). With conventional PVA, there was an 8-mg/mL increase in blood hemoglobin level versus a 3-mg/mL increase with spherical PVA (P < .05). With conventional PVA, there was a 28-mm (34%) average reduction in diameter of the dominant tumor versus a 15.7-mm (19%) reduction with spherical PVA (P = .01). Eight of 96 patients (8%) treated with conventional PVA underwent hysterectomy or myomectomy during the entire length of the study, versus six of 53 patients (11%) treated with spherical PVA (P = .6). No patient underwent multiple embolizations. CONCLUSIONS In comparison with conventional PVA particles, UAE with the use of spherical PVA particles resulted in less fibroid tumor shrinkage and less improvement in clinical symptoms.

Superior hypogastric nerve block for pain control in outpatient uterine artery embolization

PURPOSE To assess the efficacy of the superior hypogastric nerve block (SHNB) in permitting uterine artery embolization (UAE) to be performed as a routine outpatient procedure. MATERIALS AND METHODS One hundred thirty-nine patients who underwent UAE in a prospective single-arm clinical trial in an academic institution underwent SHNB from an anterior abdominal approach to control acute postprocedural pain, in addition to conventional conscious sedation. They were discharged and prescribed one of two drug combinations started during the in-hospital recovery period. Regimen A included short-acting morphine tablets and indomethacin rectal suppositories and regimen B included long-acting morphine tablets for baseline pain supplemented with short-acting morphine tablets for breakthrough pain, and naproxen rectal suppositories. All patients were contacted by phone on the third and fifth postprocedural days and their peak pain experience was recorded on a scale of 0 to 10. RESULTS All patients were able to be discharged the day of the procedure. Seven patients (5%) returned to the hospital because of pain. One was discharged after undergoing a second SHNB and four were discharged after receiving intravenous analgesics; two required longer admission for intravenous analgesia. The mean (+/-SD) peak pain score in the first 5 days after the procedure for all patients was 4.8 +/- 2.6. There was a significant difference between regimens A (mean pain score, 5.7 +/- 2.2) and B (mean pain score, 2.7 +/- 2.5; Mann-Whitney, 5.94; P < .01). CONCLUSION The addition of SHNB to the more conventional post-UAE pain management methodology enhances pain control, enabling the procedure to be offered with minimum pain on a routine outpatient basis.

Intra-Arterial Cisplatin for Bladder Cancer

Cisplatin (25 to 120 mg. per m.2) was injected into the internal iliac arteries of 33 patients with locally advanced bladder cancer. Of the patients 9 were inevaluable for response to the cisplatin, since they began radiotherapy to the bladder before course 2 of cisplatin as part of a preplanned therapeutic approach. One patient received the treatment as postoperative adjuvant therapy, 1 did not return for followup and 1 with metastatic disease did not undergo repeat cystoscopy. Of 21 evaluable patients 3 (14 per cent) achieved complete remission, 12 (57 per cent) achieved partial remission, 2 (14 per cent) were stable and 4 (19 per cent) failed. The response rate was higher in patients receiving 100 to 120 mg. per m.2 per course than in patients receiving lower doses (all except 1 of whom received 60 or less mg. per m.2 per course) (86 versus 64 per cent) and it was higher in patients without prior radiotherapy or chemotherapy. The response rate in patients with previously untreated invasive transitional cell carcinoma was 88 per cent. Of the 33 patients 21 were alive at last followup, with a median duration of followup of 32 weeks. Toxicity was dose-related and local neurotoxicity was excessive at cisplatin doses of 100 to 120 mg. per m.2. Diabetic patients were particularly prone to have neurotoxicity. Other toxicity generally was not severe and consisted of ototoxicity, nephrotoxicity, myelosuppression, nausea, vomiting and diarrhea. Even elderly patients and patients with cardiac disease tolerated the treatment well. We plan to proceed with further intra-arterial cisplatin studies in which all patients except those more than 80 years old will be treated with an intra-arterial cisplatin dose of 90 mg. per m.2 per course combined with radiotherapy with or without cystectomy.

Randomized Trial Comparing the Primary Patency following Cutting Versus High-Pressure Balloon Angioplasty for Treatment of de Novo Venous Stenoses in Hemodialysis Arteriovenous Fistulae

PURPOSE A single-center randomized clinical trial was performed to compare postinterventional primary patency rates achieved by cutting balloon angioplasty and high-pressure balloon angioplasty in the treatment of de novo stenoses within autogenous arteriovenous (AV) fistulae for hemodialysis. MATERIALS AND METHODS Forty-eight patients undergoing their first angioplasty were prospectively randomized to undergo angioplasty with a cutting balloon or high-pressure balloon 4-8 mm in diameter because cutting balloons larger than 8 mm are not available. Nine patients were excluded after angiography, with seven requiring balloons larger than 8 mm. In the remaining 39 patients, there were 42 stenoses in the following regions: juxtaanastomotic (38%), perianstomotic (38%), midcephalic (9%), and cephalic arch (14%). Patients in the cutting balloon group were younger (mean age difference, 9 y; P = .04), but other demographic variables were comparable (range, P = .08-.89). The mean follow-up period was 8.5 mo (range, 24 d to 32 mo). Kaplan-Meier analysis was used to compare duration of patency. Mann-Whitney rank-sum t test and χ2/Fisher exact tests were used to compare continuous and categoric variables, respectively. RESULTS Technical success was achieved in all 39 patients. At 3, 6, and 12 months, the postinterventional primary patency rates for the cutting balloon group were 61.1% (95% confidence interval [CI], 35.75%-82.70%), 27.7% (95% CI, 9.69%-53.48%), and 11.1% (95% CI, 1.38%-34.71%), respectively, compared with 70.0% (95% CI, 45.72%-88.11%), 42.1% (95% CI, 20.25%-66.50%), and 26.3% (95% CI, 9.15%-51.20%), respectively, for the high-pressure balloon group (P < .3 at each interval). CONCLUSIONS Compared with high-pressure balloon angioplasty, cutting balloon angioplasty does not improve postinterventional primary patency of de novo stenotic lesions in autogenous arteriovenous fistulae.

Intra-Arterial Cisplatin Treatment of Unresectable or Medically Inoperable Invasive Carcinoma of the Bladder

Five patients between 72 and 82 years old received 5 to 6 treatments of 50 to 75 mg. per m.2 cisplatin by bilateral internal iliac artery infusion for unirradiated invasive transitional cell carcinoma of the bladder. Of the patients 3 also were diabetics and 1 had congestive heart failure. Treatment was tolerated extremely well, although most courses were associated with moderate to severe nausea and vomiting lasting several hours. Of 4 evaluable patients 3 achieved complete remission and 1 achieved a good partial remission. An additional 55-year-old woman with a large invasive bladder carcinoma fixed to surrounding structures was treated with 4 courses of 100 mg. per m.2 intra-arterial cisplatin. This patient had a marked decrease in tumor size, permitting surgical resection of all known residual tumor. A 49-year-old patient with large pelvic lymph node metastases from a squamous cell carcinoma of the bladder achieved only minimal decrease in tumor size after 3 courses of 100 mg. per m.2 intra-arterial cisplatin. We conclude that intra-arterial cisplatin can be highly effective for localized invasive bladder cancer even when relatively low doses are used. With proper care the regimen can be used safely and effectively in elderly patients with medical contraindications to an operation.

Percutaneous Retrieval of a Retained Appendicolith

Retained appendicolith is a known complication of appendectomy, and a cause of abdominal abscess formation occurring months after the surgery. This report describes a case of postoperative abscess formation due to a retained appendicolith that was retrieved without surgery. For retrieval, a flexible cystoscope was inserted through a 34 Fr sheath percutaneously placed in the abscess cavity under fluoroscopic guidance. The retained appendicolith was located and captured within minutes with a urological stone basket.

Vertebral Pseudolesion on Lateral Chest Radiograph

OBJECTIVE The purpose of this study was to describe and explain the basis for the lateral chest radiographic finding of a pseudolesion simulating a sclerotic vertebral lesion. CONCLUSION Superimposition of the scapula on the upper thoracic spine causes a vertebral pseudolesion that simulates a sclerotic lesion.