Recanalization of occluded superior vena cava for replacement of LeVeen shunt catheter

Successful percutaneous replacement of the venous limb of a LeVeen peritoneovenous shunt with the use of angioplastic technique is reported. This method may be a first line of treatment in patients with intractable ascites and a failing shunt caused by chronic occlusion of the superior vena cava.

Failure to visualise the abdominal portion of the inferior vena cava with computed tomography: a clue to underlying abdominal pathology

Failure to visualise the intra-abdominal portion of the inferior vena cava (IVC) using contrast-enhanced computed tomography (CT) is unusual. A review of 1272 contrast-enhanced abdominal CT examinations revealed that the IVC was not visible at one or more levels in only 132 (10.4%). In 57 (43%), non-visualisation was due to pathological processes, most frequently metastatic carcinoma, causing compression or thrombosis of the IVC. In the remainder, technical factors or artefacts could explain the non-visualisation. Techniques and procedures to improve visualisation of the IVC are discussed. Failure to visualise the IVC on CT at any level unexplained by artefacts is abnormal.

Massive hemoptysis: control by embolization of the thyrocervical trunk

A case of recurrent hemoptysis following bronchial artery embolization is presented. The bleeding was successfully controlled by embolization of the thyrocervical trunk.

Retrieval of coil after unintentional embolization of ileocolic artery

An unusual case of unintentional release of a spring coil into the superior mesenteric artery is reported. The coil migrated distally into the ileocolic artery, and the situation was successfully resolved by retrieval of the coil with grasping forceps.

Exogastric leiomyoblastoma: a rare gastric neoplasm mimicking left hepatic mass on computed tomography

Leiomyoblastomas are rare gastric neoplasms that may occur as exogastric masses, producing difficulty in correct localization and diagnosis. Two exogastric leiomyoblastomas were misdiagnosed as primary hepatic lesions due to their appearance on computed tomography. A discussion of these rare neoplasms, the potential for their erroneous diagnosis, and ways to avoid this computed tomography pitfall is presented.

Embolic management of rare hemorrhagic gynecologic and obstetrical conditions

Severe life-threatening hemorrhage was controlled by angiographic management in 3 patients with bleeding due to unusual gynecological abnormalities and in 1 patient with a rare obstetrically related hemorrhage. Successful management of such rare causes of bleeding emphasizes that early angiographic intervention can, in selected patients, reduce the need for an immediate or subsequent surgical procedure and allow conservative management followed by disease-specific therapy.

Transcatheter control of postpolypectomy hemorrhage

Intraarterial vasopressin infusion of the inferior mesenteric artery was used in the treatment of 2 patients with massive hemorrhage following colonoscopic polypectomy. Both patients had multiple medical problems and were considered to be very-high-risk candidates for emergency surgery. Arteriography readily demonstrated the site of bleeding, and vasopressin infusion effectively controlled the hemorrhage in both patients without complication. Angiographic management allowed elective colonic resection 1 month later in 1 patient and prevented surgery in the other who has not bled again in the 6 months following the procedure. The role of arteriography in the management of postpolypectomy hemorrhage is discussed.

Hemiazygous continuation of a left inferior vena cava: misleading radiographic findings in chest trauma

A widened mediastinum was found on chest radiography following blunt chest trauma. Aortography alone could not adequately determine the etiology of the radiographic findings; on computed tomography (CT) benign mediastinal widening was confirmed owing to accessory hemiazygous continuation of a left inferior vena cava (IVC), with communication to the left brachiocephalic vein through an enlarged left superior (highest) intercostal vein. This unusual anatomic variant and its radiographic findings are reviewed, as well as the complementary role of CT in the evaluation of the traumatized thoracic aorta and mediastinum.

The effect of drainage tube size on adequacy of percutaneous abscess drainage

Fifty-one patients with documented abdominal abscess cavities were treated by percutaneous abscess and fluid drainage (PAFD). Drainage catheters made of various materials in sizes ranging from 5 through 18 French (Fr) were retrospectively studied and prospectively assigned to patients. No significant difference in the success or failure of PAFD as a function of these factors was found once an 8.3 Fr catheter with 0.045-inch diameter side-holes was reached; catheters larger than this were not associated with improved patient outcome. Failues of PAFD occurred primarily with the presence of phlegmonous collections and cavities with fistulous connection to bowel.

Hepatic rupture associated with pregnancy: treatment with transcatheter embolotherapy

Spontaneous rupture of the liver associated with pregnancy is a rare and very serious complication, usually occurring in association with eclampsia or preeclampsia. Survival has generally been dependent on early recognition of characteristic signs and symptoms and prompt surgical intervention. Even with surgery, maternal mortality approaches 40% and fetal mortality is even higher. The diagnosis can usually be firmly established based on the clinical and radiographic findings presented in this article. Reported is a patient with hepatic rupture successfully treated by transcatheter embolization of the hepatic artery. It is the authors' belief that if such a patient is clinically stable enough to undergo angiography, then transcatheter embolotherapy is a reasonable alternative to surgery.

Hemodynamics of portal blood flow shown by CT portography. Work in progress

Computed tomography and arterial portography were combined in 12 patients for studies of the anatomy and hemodynamics of the portal venous system. This technique was found to be more sensitive than conventional venous-phase angiograms of the superior mesenteric and splenic arteries for evaluation of the anatomy of the portal venous system and extent of thrombosis in patients with cavernous transformation and also facilitated recognition of subtle evidence of hepatofugal flow and portosystemic shunts. CT portography can be employed when conventional angiograms fail to show the portal vein adequately.

Embolotherapy of a mycotic pseudoaneurysm of the internal mammary artery in chronic granulomatous disease

We report a case demonstrating an unusual and previously unpublished complication of chronic granulomatous disease (CGD), that is massive hemorrhage from a mycotic pseudoaneurysm of the left internal mammary due to invasive Aspergillus fumigatus of the anterior chest wall. This brief report further illustrates the angiographic diagnosis and embolotherapeutic control of a mycotic pseudoaneurysm of the internal mammary artery.

Hemorrhagic renal angiomyolipoma: superselective renal arterial embolization for preservation of renal function

A 35-year-old woman with tuberous sclerosis and known bilateral renal angiomyolipomas presented with shock due to massive hematuria arising from the left kidney. The cause of bleeding was diagnosed angiographically as arising from a left upper pole renal artery aneurysm within the tumor. Cessation of bleeding and clinical stabilization occurred without deterioration of renal function after superselective embolization of the dorsal segmental renal artery with a single 5-mm Gianturco coil.

Identification of intrathoracic hemorrhage with Tc-99m sulfur colloid

Tc-99m sulfur colloid has been shown to be accurate in the detection of intrapulmonary bleeding (1,2). The present example demonstrates the usefulness of Tc-99m sulfur colloid in identifying an unusual manifestation of intrathoracic hemorrhage.

Computed tomography as an angiographic aid in evaluation of intraabdominal hemorrhage

The role of computed tomography in the evaluation of patients with intraabdominal hemorrhage in the absence of trauma history has received little attention. Representative cases are presented demonstrating how preangiographic, postangiographic, and combined computed tomography-angiography can aid in the diagnosis and localization of obscure causes of intraabdominal and gastrointestinal bleeding.

Interventional radiologic procedures in the renal transplant

Percutaneous interventional procedures can be valuable in the evaluation and treatment of urologic complications of renal transplantation. Thirty-three patients underwent percutaneous procedures, including relief of obstruction by catheter nephrostomy, diagnostic antegrade pyelography with Whitaker testing, aspiration of various fluid collections (lymphocele, hematoma, urinoma, and abscess), and renal artery angioplasty, during a three year period at three institutions, to provide temporizing treatment and anatomic data. Surgical intervention was sometimes avoided, but more often it could be deferred to allow the patient to stabilize prior to surgery. Complications that required surgery occurred in two patients.

An evaluation of the effectiveness of CT vs. other imaging modalities in the diagnosis of atypical renal masses

A retrospective review of 34 patients undergoing nephrectomy for suspected renal malignancy was undertaken to evaluate the effectiveness of computed tomography (CT), ultrasound, arteriography, and cyst puncture in providing a definitive preoperative diagnosis of benign vs. malignant renal abnormality. The predictive value of a test suggesting malignancy was 88% for angiography, 86% for ultrasound, 71% for cyst puncture, and 80% for CT. The predictive value of a test suggesting no malignancy for non-CT imaging modalities was poor. The predictive value of renal CT increased to 96%, when three or more characteristics are present which suggest the lesion is not a simple, benign renal cyst. Using these criteria all malignancies were identified, and all but one benign lesion excluded. Unusual lesions that have equivocal or indeterminate diagnostic studies and only one or two noncystic CT features should undergo selective exploration rather than radical nephrectomy.

Routine preoperative biliary drainage: effect on management of obstructive jaundice

The routine application of preoperative percutaneous transhepatic biliary drainage (PTBD) to patients who have obstructive jaundice has a significant effect on overall morbidity, mortality, and patient survival by allowing selective application of the most appropriate therapeutic modality. Surgical patients who undergo PTBD were compared with those for whom PTBD was not available. The surgical complication rate was 44% for those who did not undergo PTBD and 15% for those who did. The surgical procedure-related mortality rate was 30% for those who did not undergo PTBD and 12% for those who did. These differentials may have been due either to a beneficial effect of presurgical decompression or to the fact that only more favorable candidates were selected for operative internal bypass. There was an overall increase in length of survival following the application of PTBD, especially in those patients who were surgical candidates.

Peritoneovenous shunt occlusion. Etiology, diagnosis, therapy

Electronic pressure testing of every LeVeen valve has practically eliminated mechanical malfunction as a cause of shunt failure. Nonetheless, failures do occur and in a series of 240 cases, early or late shunt failure occurred in 29 patients. Thirty-five additional cases of failures were either referred by other physicians over a period of 6 years or information and x-rays were accumulated by direct contact. Shunt failure becomes manifest by a sudden reaccumulation of ascites in patients with a previously functioning shunt. In immediate failure, the ascites may fail to disappear after surgery or reaccumulate if removed. Ideally, caval clotting should be first excluded by x-ray visualization of the superior vena prior to injection of the shunt with contrast agent. Shuntograms are done with fine-bore needles. The venous pressure is also measured. The entry of contrast into the vena cava without pooling indicates a patent venous limb. The contrast will empty from the venous tubing with forceful inspiration if the entire system is patent. The venous tube will not clear if the valve or peritoneal collecting tubes are blocked. Only the valve and collecting tube need then be replaced if contrast enters the cava but does not leave the venous tubing. Occluded valves must not be flushed to restore patency since inflammatory exudate and cellular debris are erroneously identified as "fibrin flecks." Histology and culture are mandatory. Immediate and early failure are often caused by malposition of the venous tubing. Malplacements can often be diagnosed simply by chest x-rays. Intraoperative injection of methylene blue into the venous tubing establishes a satisfactory washout prior to wound closure. Fresh clots in the vena cava can be dissolved by the slow injection of streptokinase into the venous tubing. Other patent veins are chosen for access. Patients having repeat surgery after clotting must be heparinized to prevent a similar recurrence. Flushing blood clots from the cava can be fatal.

Thoracic biopsy: CT guidance of thin-needle aspiration

CT-guided percutaneous thin-needle aspiration biopsy of 23 mediastinal and 27 other thoracic masses was performed in 40 patients over a 2-year period. Although biplane fluoroscopy is considered the optimal guidance mechanism for thoracic biopsy, CT was required in this group of patients to ensure accurate needle placement within the lesions or within the most appropriate subsegment of necrotic lesions. A specific diagnosis was obtained in 34 cases, an overall diagnostic accuracy of 85%. Although CT guidance allowed an extrapleural needle trajectory in 23 patients, five of the remaining 17 patients sustained a pneumothorax for which two required tube thoracotomy.

Percutaneous catheter aspiration and drainage of suspected mediastinal abscesses

The authors describe CT-guided percutaneous aspiration of 13 apparent mediastinal abscesses in 12 extremely ill patients, excluding the diagnosis in 3 and establishing it in 9. Six patients subsequently underwent percutaneous catheter drainage, facilitating elective surgery in 1 and proving curative in 5.

Treatment of acute embolus of the superior mesenteric artery by topical infusion of streptokinase

Two patients with sudden onset of acute abdominal pain caused by embolic disease of the superior mesenteric artery (SMA) were evaluated angiographically. In one patient, the study was performed soon after the clinical onset of symptoms, and successful treatment with low-dose topical streptokinase infusion produced total lysis of the clot over a period of 30 h. In the second patient, the angiogram was obtained 6 days following the initial episode of pain. Radiographic and clinical findings indicated advanced gastrointestinal ischemia with bleeding which contraindicated the use of fibrinolytic therapy. Surgical resection of infarcted intestine was required. Early angiographic detection of acute mesenteric thrombus or embolus is crucial for the selection of patients for fibrinolytic therapy. Our cases suggest that with early diagnosis, streptokinase infusion is an alternative to surgical management of selected patients with acute mesenteric ischemia.

Radiofrequency thermotherapy, local chemotherapy, and arterial occlusion in the treatment of nonresectable cancer

Localized radiofrequency thermotherapy (RFTT) has been effective by itself in debulking cancers but has not accomplished total eradication by itself. Occlusion of the regional artery supplying the tumor drastically reduces the arterial pressure distal to occlusion and further impairs tumor blood flow leading to an accentuation of the temperature differentiation achieved by the normal tissue and tumor. Radiofrequency thermotherapy with vascular occlusion is combined with direct injection of an effective chemotherapeutic agent into the tumor. Radiofrequency thermotherapy is performed after injection of chemotherapy using bleomycin and mitomycin C for squamous cell cancers and Adriamycin and mitomycin C for adenocarcinoma. There are no adverse systemic responses to the small dose of chemotherapy used and the combination therapy is effective in destroying the tumor.