Tc-99m sulfur colloid scintigraphy for detecting perigraft flow following endovascular aortic aneurysm repair: A feasibility study

PURPOSE

To determine if scintigraphy with Tc-99m sulfur colloid can be used to detect perigraft flow after stent-graft repair of abdominal aortic aneurysm (AAA).

METHODS

Twenty-three men and two women aged 56-84 years (mean 71 years) underwent endoluminal AAA repair as part of the EVT Phase II trial [EVT = Endovascular Technologies (Menlo Park, CA, USA)]. Aneurysm size averaged 5.4 cm (range 3-8 cm). Sixteen bifurcated, seven tube, and two aorto-uniiliac grafts were placed. Two days after stent-graft placement, patients underwent both contrast-enhanced computed tomography (CT), including delayed views, and Tc-99m sulfur colloid scintigraphy.

RESULTS

Perigraft flow was found in only one patient at completion of angiography. Four additional patients had perigraft flow, discovered during their postoperative follow-up CT. Four patients had leaks at an attachment site and one had retrograde branch flow. Tc-99m sulfur colloid scintigraphy failed to diagnose any of the five leaks prospectively. In two of these patients, however, some abnormal paraaortic activity was noted in retrospect.

CONCLUSION

Tc-99m sulfur colloid scintigraphy was unable to demonstrate endoleak with either rapid flow (attachment site leak) or slow filling (branch flow).

Transrectal versus transvaginal abscess drainage: survey of patient tolerance and effect on activities of daily living

PURPOSE

To evaluate patient perception of pain related to transrectal and transvaginal drainage and the catheter's effect on activities of daily living.

MATERIALS AND METHODS

From July 1993 to August 1997, 22 male and 40 female patients (mean age, 41 years; age range, 4-80 years) underwent transrectal or transvaginal aspiration or drainage. Fifty-seven drainages were performed. In a follow-up survey, patients were asked to score pain experienced during the procedure and afterward on a scale of 1-10 and to rate the effect of the catheter on their activities of daily living.

RESULTS

Twenty-two patients participated in the telephone survey. For those able to recall the insertion procedure, the mean pain score was 3.2 for transrectal and 5.9 for transvaginal drainage. Mean indwelling catheter pain was 1.6 for transrectal and 4.8 for transvaginal drainage. Pain after removal was 1.4 for transrectal and 2.3 for transvaginal drainage. Only one patient with a transrectal catheter reported severe limitation (bowel movement), with no reports of any serious effect on urinating, bathing, sitting, or walking. Transvaginally placed catheters caused marked limitation in all categories and were more painful than transrectal catheters (P < .05).

CONCLUSION

Of the transrectal and transvaginal approaches, transrectal is better tolerated.

Randomized comparison of laparoscopic and open lymphadenectomy in pigs

OBJECTIVE

To compare the efficacy of open and laparoscopic lymphadenectomy and validate an objective model of lymph node retrieval using lymphangiography in pigs.

METHODS

Twenty-five pigs weighing 54-75 lbs were randomly assigned by side to open or laparoscopic pelvic and paraaortic lymphadenectomy. Lymph node yield, quantified by a masked pathologist, operative time, complications, blood loss, and other variables were recorded. Lymphangiography was done, and radiographs were taken before and after lymph node harvesting. Statistical analysis used McNemar test for nominal data and paired Student t test or Wilcoxon signed-rank test for continuous variables.

RESULTS

Lymph node yields were a mean of 11.5 with a standard deviation of 2.8 for open and 15.3 +/- 3.4 nodes for laparoscopic lymphadenectomy (P = .009). Mean operating time was 26.5 +/- 5.3 minutes for open versus 54.9 +/- 23.7 minutes for laparoscopy (P < .01). Mean blood loss was higher for laparoscopic cases, 35 mL for open versus 58 mL for laparoscopic lymphadenectomy (P = .048). The four major complications were evenly distributed between the two procedures. Lymphangiography was successful in 24 of 25 pigs. A total of 243 lymph nodes were identified with equal distribution by side. Lymphangiographic data correlated well with number of lymph nodes retrieved.

CONCLUSION

In this randomized trial, laparoscopic lymphadenectomy was at least as effective as open lymphadenectomy, although operating time and blood loss were greater. Lymphangiography was a reliable, objective mode for documentation and assurance of lymph node recovery.

A combined surgical and radiologic technique for creating a functional neo-endocervical canal in a case of partial congenital cervical atresia

OBJECTIVE

To recanalize the endocervical canal in a patient with partial congenital cervical atresia.

DESIGN

Case report.

SETTING

University hospital.

PATIENT

A 16-year-old girl referred with a history of primary amenorrhea, polycystic ovaries, and intermittent abdominal pain. Physical examination revealed a normal vagina and external cervical os, but magnetic resonance imaging revealed a solid endocervical tract.

INTERVENTION(S)

At laparotomy the endometrial cavity was accessed transfundally and outlined by injection of water-soluble contrast. A trocar needle was guided transvaginally into the uterus, the tract was dilated, and a 12F stent was placed. Oral contraceptives (OCs) and antibiotics were continued postoperatively.

MAIN OUTCOME MEASURE(S)

Hysterosalpingography and clinical follow-up.

RESULT(S)

The operation and postoperative course were uneventful. Withdrawal bleeding occurred at 8 weeks, after discontinuation of the OCs, at which time the stent was expelled. Later follow-up revealed recurrent narrowing, and the stent was replaced for 14 more weeks. After stent removal, regular menses continued (7 months to date).

CONCLUSION

In select cases of congenital cervical atresia, recanalization may be safely performed with the use of the combined surgical-radiologic technique described, with good short-term outcome.

Endovascular stent grafts for aneurysmal and occlusive vascular disease

BACKGROUND

This report details our initial experience with two types of endovascular grafts- one for the treatment of infrarenal abdominal aortic aneurysms and the other for the treatment of iliac artery occlusive disease.

METHODS

An abdominal aortic aneurysm was repaired in 34 patients using 3 different types of Ancure endografts (Menlo Park, California). Control patients (n = 9) had a standard aneurysm repair. Patients with chronic lower extremity ischemia (n = 7) secondary to iliac artery occlusive disease were treated with a Hemobahn endograft (W. L. Gore & Associates, Flagstaff, Arizona).

RESULTS

Ancure graft deployment was achieved in 33 of 34 (97.1%) patients. Perioperative mortality for the Ancure and control group patients was 2.9% and 0%, respectively. Periprosthetic leaks were identified within 48 hours of deployment in 6 (18.2%) Ancure graft patients. All but 2 of the leaks resolved on serial follow-up. Additional endovascular procedures were required in 11 (32.4%) Ancure graft patients at the initial procedure or during follow-up to correct graft or arterial stenoses. Patients treated with an endovascular graft had significantly less blood loss and shorter hospital stays than control group patients. For Hemobahn patients, the technical success for graft deployment was 100%. There were no perioperative deaths. The ankle/brachial index increased from a mean of 0.52 preoperatively to 0.86 postoperatively (P = 0.004). One patient required a Wallstent in follow-up to correct a graft wrinkle. Angiography at 6 months demonstrated mild intimal hyperplasia in the stent graft in 5 of 6 patients.

CONCLUSIONS

These early results support the potential for endovascular grafts in the treatment of aneurysmal and occlusive vascular disease. Further modifications in the devices and deployment techniques are necessary to reduce the incidence of periprosthetic leaks, graft limb stenoses, and intimal hyperplasia.

Deep pelvic abscesses: transperineal US-guided drainage

PURPOSE

To examine the efficacy of transperineal sonographically guided drainage of deep pelvic abscesses.

MATERIALS AND METHODS

Twelve drainage procedures were performed in 11 adults with symptoms of infection and cross-sectional images demonstrating a deep pelvic abscess. Eight patients had recently undergone abdominoperineal resection, seven of whom underwent preoperative radiation therapy. Two had chronic osteomyelitis with adjacent fluid collections, and one developed an infected hematoma after trauma. With ultrasound (US) guidance for initial access, catheters were placed for drainage in 11 procedures. One patient was treated with aspiration alone. Patients underwent clinical follow-up and subsequent imaging as necessary.

RESULTS

Transperineal needle placement was successful in 12 of 12 patients (100%). In procedures that required catheter placement, 10 of 11 placements (91%) were achieved with the transperineal approach. One patient required fluoroscopic transvaginal catheter placement after opacification of the collection transperineally. Catheter drainage was maintained for 2-146 days (mean, 40 days; median, 21 days). Clinical success was achieved in nine of 10 patients (90%) by means of transperineal drainage. There were no complications, although premature catheter removal occurred in two patients.

CONCLUSION

US-guided transperineal abscess drainage may be successfully performed in patients who cannot undergo conventional transabdominal, transvaginal, or transrectal catheter drainage.

Upper extremity central venous obstruction in hemodialysis patients: treatment with Wallstents

PURPOSE

To determine the effectiveness of using Wallstents to treat subclavian or brachiocephalic venous obstruction after unsuccessful angioplasty, in patients undergoing hemodialysis.

MATERIALS AND METHODS

Dialysis records, radiology reports, and procedural images of 20 hemodialysis patients who underwent Wallstent insertion into a subclavian (n = 11) or brachiocephalic (n = 9) vein were reviewed. Technical success and primary, assisted primary, and cumulative patency rates were calculated.

RESULTS

Twenty-three Wallstents were inserted for stenosis (n = 18) or occlusion (n = 2). Technical success was 100%. Eight patients underwent 11 reinterventions to maintain patency of the Wallstent during the follow-up period. Patency rates of the Wallstent were (a) primary at 1 month, 3 months, 6 months, and 1 year: 90%, 67%, 42%, and 25%; (b) assisted primary at 3 months, 6 months, and 1 year: 88%, 62%, and 47%; and (c) cumulative at 3 months, 6 months, 1 year, and 2 years: 89%, 64%, 56%, and 22%. Considerable shortening of the stent occurred in five patients. One occurred immediately during the deployment procedure, but four were discovered weeks to months later. No other complications occurred.

CONCLUSION

After suboptimal angioplasty, treatment of subclavian and brachiocephalic vein stenoses with a Wallstent can provide continued use of a hemodialysis access. Close clinical surveillance and multiple reinterventions are necessary to maintain Wallstent patency.

Transrectal and transvaginal abscess drainage

The TR and TV approaches to deep pelvic abscesses have been made safe and easy by improvements in endoluminal US technology. Most procedures take well under an hour, and standard intravenous sedation is usually sufficient for patient comfort. The simplest and safest technique employs a combination of endoluminal US, with biopsy guides for precision needle advancement, and fluoroscopy for dilating the tract and placing a drainage catheter. Patient acceptance of TR and TV catheters is high, and resolution can typically be expected within 3-5 days. In the majority of cases, catheter treatment, combined with antibiotic therapy, is curative.

Technique for performing direct lymphangiography in pigs

RATIONALE AND OBJECTIVES

The authors developed a porcine model for direct lymphangiography to be used as a reference for lymph node harvesting.

METHODS

A pilot animal was studied first to develop the protocol, which was used successfully in 24 pigs. An indicator dye was first injected into each foot to make the lymphatic vessels visible. Then, ethiodized poppy seed oil was injected directly through cutdowns in both groins. Radiographs were obtained before and after lymph node harvesting.

RESULTS

Images were of diagnostic quality in all animals. The pilot animal developed transient respiratory distress, which was thought to be due to the oil-based contrast material. The amount injected was reduced by half, and no episodes occurred thereafter in the study group. There were no other immediate or delayed complications.

CONCLUSION

Direct lymphangiography is safe, easy, and reliable in a porcine model.

Interventional radiologic placement of chest wall ports: results and complications in 161 consecutive placements

PURPOSE

To review the technical results and long-term follow-up of the first 157 consecutive patients undergoing placement of 161 chest wall ports at the authors' institution.

PATIENTS AND METHODS

All ports were placed in the interventional radiology suite with use of fluoroscopic and/or ultrasound guidance with a combination of standard interventional radiology and surgical techniques. The hospital records of all patients were reviewed, and telephone contact made when possible. Patients ranged in age from 21 to 87 years (average, 57 years). The most common indication for port placement was chemotherapy (88%).

RESULTS

Placement was technically successful in all 161 procedures. Minor procedural complications occurred in eight patients (5%). There were no major complications related to the procedure. Cumulative follow-up to date includes 35,992 port-days (average, 226 days per patient). The long-term complication rate was 8.7% or .39 per 1,000 access days, which includes nine infections and five migration-related complications.

CONCLUSION

Interventional radiologic placement of chest wall ports is safe and has a high technical success rate, in large part due to the integration of interventional radiology techniques to the procedure. The short and long-term complication rates are equal to or less than those of current surgical series.

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy

PURPOSE

To evaluate the effect of combined-modality therapy including intraluminal iridium-192 on stent patency and survival in patients with malignant biliary obstruction treated with Gianturco stents.

MATERIALS AND METHODS

Twenty-two patients with unresectable biliary obstruction caused by cholangiocarcinoma (n = 11) or by secondary extrahepatic bile duct malignant tumors (n = 11) were treated with percutaneous biliary drainage followed by intraluminal Ir-192 wire placement (mean dose, 25 Gy) before insertion of Gianturco metal stents. Eleven patients also received external-beam radiation therapy, and 13 patients received chemotherapy. Patency was defined as absence of jaundice or cholangitis that necessitated hospitalization, or as seen on hepatobiliary scans. Survival was determined from the time of stent insertion after brachytherapy.

RESULTS

Patients with cholangiocarcinoma had extended mean stent patency of 19.5 months (range, 2-46 months) and mean survival of 22.6 months (range, 2-72 months). Patients with secondary malignant tumors had a mean patency of 4.8 months (range, 1.5-8 months) and a mean survival of 5.3 months (range, 2-9 months).

CONCLUSION

Radiation therapy including intraluminal Ir-192 appears to extend stent patency and survival in patients with inoperable cholangiocarcinoma treated with Gianturco metal stents compared with patients with other extrahepatic bile duct malignant diseases and patients treated without combined-modality therapy in other studies.

Percutaneous gallstone removal: long-term follow-up

PURPOSE

To evaluate gallstone and symptom recurrence rates, long-term complications, and life expectancy after percutaneous gallstone removal.

PATIENTS AND METHODS

Medical records of 87 patients (mean age, 69 years +/- 14 [standard deviation]) undergoing percutaneous gallstone removal between 1987 and 1992 were reviewed. Physicians and patients (or their families) were contacted for clinical follow-up. Thirty-one patients returned for follow-up ultrasound (US).

RESULTS

The final study group consisted of 65 patients. Mean survival from the time of initial gallbladder drainage was 33 months +/- 19. Over a mean clinical follow-up period of 33 months, eight of 65 patients (12%) developed recurrent symptoms; six of these eight had recurrent gallstones shown at US. Of 30 patients with technically adequate US images (mean follow-up, 14 months +/- 12), 12 (40%) had recurrent gallstones. Six of these 12 patients had recurrent symptoms. No long-term complications were identified.

CONCLUSION

The risk of gallstone recurrence after percutaneous removal is notable, but the symptom recurrence rate is much lower. Percutaneous gallstone removal is beneficial for patients at prohibitive surgical or general anesthetic risk.

Accuracy of DSA in the evaluation of patency of infrapopliteal vessels

PURPOSE

To evaluate the accuracy of intraarterial digital subtraction angiography (DSA) in the demonstration of patent infrapopliteal vessels.

PATIENTS AND METHODS

One-hundred sixty-five arteriograms were obtained in 153 consecutive patients prospectively enrolled to evaluate lower extremity ischemia. In 86 cases a follow-up angiogram of the infrapopliteal vessels was obtained during surgery or after endovascular intervention (n = 57). Twenty-nine arteriograms were followed by surgical exploration of the infrapopliteal vessels. Standard angiographic technique was performed with intraarterial DSA of the most symptomatic foot. Visualization of distal vessels was compared with intraoperative or postintervention imaging or with the results of surgical exploration.

RESULTS

Of the 57 procedures after which either intraoperative or post-endovascular intervention angiography was performed, DSA results were equivalent in 47 (82%) and worse in five (9%). When individual vessels were evaluated, the sensitivity of DSA in the identification of patent named vessels was 95%, and the specificity was 92%. Among 29 cases with a surgical standard of reference, 28 patients underwent bypass to a vessel correctly identified as patent at DSA; one patient was incorrectly identified as having no patent named vessels.

CONCLUSION

Intraarterial DSA is accurate and reliable in the assessment of patency in infrapopliteal vessels before surgery or endovascular intervention in patients with infrainguinal atherosclerotic disease.

Treatment of pelvic abscesses and other fluid collections: efficacy of transvaginal sonographically guided aspiration and drainage

OBJECTIVE

The purpose of this study was to evaluate the clinical efficacy of transvaginal sonographically guided aspiration and drainage of pelvic fluid collections.

MATERIALS AND METHODS

Forty patients underwent transvaginal sonographically guided aspiration of a possible pelvic abscess (41 pelvic collections). In patients with clinical findings highly suggestive of infection, both purulent and nonpurulent collections were immediately drained via a catheter. In patients with clinical findings moderately suggestive of infection, nonpurulent collections were completely removed by aspiration and the aspirates were cultured; however, purulent collections were immediately drained via a catheter.

RESULTS

All collections were successfully accessed by transvaginal sonography. For 27 of the 41 collections, the aspirate was purulent (18 collections) or the patient's clinical findings were highly suggestive of infection (nine collections) and catheter drainage was performed. Seventeen of the 27 collections completely resolved and surgery was not required. Four of the 27 collections were in patients who had surgery for reasons other than persistent infected collection. For six of the 27 collections, catheter treatment was not successful and surgery was required. The overall success rate of catheter drainage was 78%. In the remaining 14 of the 41 collections, the aspirate was serous or serosanguineous, and the patient's clinical findings were moderately suggestive of infection. Cultures of aspirates of seven collections were positive for microorganisms. Eleven collections were successfully treated with antibiotics or no therapy was required (based on culture results); for three, surgery was required. Two complications occurred: one vaginal fistula after catheter drainage and one disruption of vaginal sutures after aspiration.

CONCLUSION

Transvaginal sonographically guided drainage is effective treatment of pelvic abscess, being either completely curative or temporizing in 78% of patients. Catheter treatment was unsuccessful and surgery was necessary in 22% of patients. For nonpurulent collections, catheter drainage is indicated only when clinical findings are highly suggestive of infection.

Fallopian tube recanalization in an unrestricted patient population

PURPOSE

To review the effectiveness of fallopian tube recanalization (FTR) when performed without restriction based on history or tubal condition.

MATERIALS AND METHODS

From October 1989 to July 1992 in 37 consecutive women, aged 22-44 years (mean, 35 years), 42 FTRs were performed (five patients each underwent two FTRs). Water-soluble contrast material and selective ostial salpingography and/or microcatheter technique were used exclusively. Eighty tubes were evaluated, since four patients had previously undergone unilateral salpingectomy. Sixty-three tubes (79%) were occluded at the outset of the procedure.

RESULTS

Complete recanalization was achieved in 45 of 63 (71%) occlusions. Adhesions were present in 25 of 80 (31%) tubes, salpingitis isthmica nodosa in 12 (15%), and hydrosalpinx in nine (11%). The 42 procedures resulted in 14 (33%) conceptions, nine (64%) of which involved pathologic tubes. Eleven intrauterine pregnancies resulted in five spontaneous first-trimester abortions, five full-term deliveries, and one continuing pregnancy.

CONCLUSION

Favorable conception and live birth rates can be achieved with FTR, despite a high prevalence of tubal disease.

MR evaluation of renal space-occupying lesions: diagnostic criteria

In order to assess the ability of magnetic resonance (MR) imaging to distinguish simple renal cysts from renal tumors, images from 53 patients with 74 lesions were reviewed. MR image characteristics, including signal strength and homogeneity for each lesion, were evaluated and compared with the final diagnoses. There were 53 cysts and 21 tumors. For 56 lesions (76%), MR allowed accurate diagnosis; on T1-weighted images, homogeneous low-intensity lesions were always cysts and inhomogeneous medium- or high-intensity lesions were always tumors. The remaining 18 lesions (24%) could not be distinguished, and T2-weighted images failed to improve differential diagnostic ability. In our experience, MR imaging allows differentiation of renal cysts and tumors less frequently than does computed tomography (CT) or ultrasound (US). MR criteria for simple renal cysts and tumors are offered, with the understanding that modification may be necessary as experience with these lesions increases.

Penile prosthetic implants: a radiographic atlas

This article provides an atlas of penile prosthetic implants currently in use. It is believed that an understanding of the structure and mechanism of these prostheses is essential to an accurate radiologic assessment of their integrity and to the recognition of the cause in cases of malfunction.