Robin R. Gray

US-guided Puncture of the Internal Jugular Vein: Complications and Anatomic Considerations

PURPOSE To examine success and complication rates for ultrasound (US)-guided cannulation of the internal jugular vein (IJV) in comparison with blind techniques and to present the variations in anatomy of the IJV. MATERIALS AND METHODS Data were prospectively collected for 869 cases of sonographically guided cannulation of the IJV. In all cases, the side of the puncture, procedural success or failure, and any immediate complications were recorded. In 764 (88%) cases, the number of passes required and whether a single- or double-wall puncture was used were recorded. In 690 (79%) cases, IJV diameter and depth were recorded, while its relationship to the common carotid artery (CCA) was noted in 659 (76%) cases. RESULTS Cannulation was successful in 868 (99.9%) cases. Complications occurred in 20 (2.3%) cases. Eighty-seven percent of cannulations were achieved with one pass and 83% with a single-wall puncture. Success at first pass was significantly correlated with right-sided puncture and the diameter of the IJV. In 5.5% of cases, the IJV lay medial to the CCA, making successful cannulation with use of the landmark technique unlikely. CONCLUSIONS US-guided cannulation of the IJV is superior to blind techniques, increasing the success rate and incidence of first pass cannulation and reducing the incidence of complications.

Potential for inter-observer and intra-observer variability in x-ray review to establish stone-free rates after lithotripsy.

The potential for variability among observers interpreting diagnostic tests is well known but has not been well established for radiological imaging of urolithiasis. We measured the inter-observer and intra-observer variability in the reporting of plain abdominal films and tomograms from patients who had undergone extracorporeal shock wave lithotripsy (ESWL). Unlabeled copies of the plain abdominal films and tomograms for 58 patients were individually submitted to 3 different radiologists. Selected films from 25 patients were resubmitted to the same radiologists. We found differences among radiologists reporting plain abdominal films alone 52% of the time and even by the same radiologist rereading the films 24% of the time. Tomograms alone decreased the uncertainty but differences still occurred among radiologists 24% of the time and with themselves 16% of the time. When plain abdominal films and tomograms were read together there were differences among radiologists 28% of the time and with themselves 7% of the time but these were usually minor. We concluded from this study that the plain abdominal film alone was frequently difficult to interpret, resulting in uncertainty about the presence or absence of residual stone fragments. Tomograms alone or a plain abdominal film plus tomograms is superior to a plain abdominal film alone. Finally, radiological assessment with all modalities probably overestimates stone-free rates after ESWL even without consideration of the potential for reporting variability among observers.

Percutaneous gastrostomy and gastro-jejunostomy

Percutaneous gastrostomy and gastro-jejunostomy are new techniques which may be used instead of surgical or endoscopic gastrostomy to feed patients with an intact small bowel. We have successfully performed 72 gastrostomies on 67 patients who had had unsuccessful procedures and required surgery. Two patients developed peritonitis when their catheter dislodged into the peritoneal space.

Abdominal plexiform neurofibromatosis simulating pseudomyxoma peritonei on computed tomography.

We present and discuss an unusual case of extensive abdominal plexiform neurofibromatosis that simulated pseudomyxoma peritonei on CT. Multiple low density subdiaphragmatic masses caused scalloped liver margins and thickening of the mantle, which displaced bowel loops centrally, suggesting the diagnosis of pseudomyxoma peritonei. However, open biopsy revealed plexiform neurofibromatosis.

Pathologic Fracture Through a Unicameral Bone Cyst of the Pelvis: CT–guided Percutaneous Curettage, Biopsy, and Bone Matrix Injection

Unicameral bone cysts of the pelvis are extremely rare. A 19-year old man presented with a pathologic fracture through a pelvic unicameral bone cyst. He was treated with computed tomography-guided percutaneous curettage, biopsy, and demineralized bone matrix injection. Treatment has proven successful in short-term follow-up.

Ureteral stenting in urosepsis: A cautionary note

Double-J internal ureteral stents have become a popular, comfortable method of urinary drainage in patients with ureteral obstruction. We describe a case of sepsis leading to rapid death following insertion of a stent. The indications for stent insertion and the potential complications are presented. Special reference is made to the danger of inadvertently creating a conduit for ascending urosepsis.

Cholangiographic demonstration of carcinoma of the colon metastatic to the lumen of the common bile duct

A case of adenocarcinoma of the colon with a secondary lesion in the lumen of the common bile duct shown by transhepatic cholangiography is described. The differential diagnosis includes stones, blood clot, and benign and malignant tumors.

Computed tomographic diagnosis of pulmonary sequestration

Two cases of pulmonary sequestration demonstrated by CT scans of the chest are described. In one, CT demonstrated the anomalous artery. This finding may obviate the need for angiography when surgery is not contemplated.

Severity of Disease Score as a Predictor of Mortality after Caval Filter Insertion

PURPOSE To estimate 30-day mortality after vena caval filter insertion and assess the usefulness of a severity of disease score in predicting postprocedure 30-day survival. PATIENTS AND METHODS Records of 40 consecutive patients undergoing inferior vena caval filter insertion over a 2 1/2-year period were retrospectively reviewed. A severity of illness score for each patient was calculated based on the weighting system described for the APACHE (Acute Physiology and Chronic Health Evaluation) II system. In addition, 30-day postprocedure survival was determined. RESULTS Seven patients died within 30 days of the procedure (18%). The use of a severity of disease score of greater than 15 as a predictor of postprocedure 30-day mortality had a sensitivity of 50%, specificity of 97%, positive predictive value of 75%, a negative predictive value of 91.4%, and accuracy of 90%. CONCLUSIONS The 30-day mortality after caval filter insertion is significant. A severity of disease score is a useful predictor of patients likely to survive following caval filter insertion. On this basis it may be possible to establish criteria for more beneficial use of vena caval filters.

Angiographic Assessment of Arterial Outflow: Predictive Value of a New Classification System☆

A prospective study with 4 years of follow-up involving 127 consecutive symptomatic patients (60.6% with claudication, 39.4% with critical ischemia) who underwent aortobifemoral bypass surgery is described. A new grading system for the classification of arterial outflow was applied to determine its usefulness in predicting the outcome of surgery. Preoperative angiograms were numerically scored according to the arterial outflow status at the level of main segmental involvement. Higher scores corresponded to worse outflows. Outflow scores ranged between 1 and 10 with a mean of 3.6 +/- 0.24. The main comparison was between patients with scores of less than 5 (group A, n = 80) and patients with scores of 5 or more (group B, n = 47). Better outflow was associated with higher postoperative mean increases in the ankle-brachial index (ABI) (group A, 0.35 +/- 0.03; group B, 0.17 +/- 0.04; P less than .001) and transcutaneous oximetry (PtcO2) (group A, 15.4 mm Hg +/- 1.8; group B, 8.4 mm Hg +/- 3.0; P = .01). At 4-year follow-up, group A had higher cumulative rates of patency (98.3% vs 78.0%, P less than .001), symptomatic relief (84.0% vs 23.3%, P less than .001), and palliation (67.0% vs 19.9%, P less than .001). In conclusion, angiographic outflow, as evaluated with the system described, successfully helped predict postoperative increases in ABI and PtcO2 and the cumulative rates of graft patency, symptomatic relief, and palliation.