Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Endoscopic gastroenteric anastomosis using magnets

BACKGROUND

Current management of malignant obstruction of the upper digestive tract includes surgical gastrointestinal bypass or endoscopic insertion of self-expandable metal stents. The safety, efficacy, and long-term patency rates of anastomoses created using the novel technique of endoscopic gastroenteric anastomosis using magnets (EGAM) are evaluated in this study.

PATIENTS AND METHODS

15 patients (13 men, 2 women; mean age 64.5 years) with malignant obstruction, who underwent EGAM and had monthly follow-up between December 2001 and May 2003, were included in this study.

RESULTS

The procedure was successful in 13 patients (88.66 %). The mean survival was 5.23 months. There were four minor complications (30.76 %) during the follow-up period.

CONCLUSION

Our results demonstrate the feasibility, safety. and efficacy of this technique for creating a gastroenteric anastomosis. The success rate was 86.6 %, there were no immediate complications, and there was no mortality related to the procedure.

Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival

PURPOSE

To identify clinical and technical factors influencing the outcome of transcatheter embolotherapy for nonvariceal upper gastrointestinal (GI) hemorrhage and to quantify the impact of successful intervention on patient survival.

MATERIALS AND METHODS

A retrospective review was performed of all patients (n = 163) who underwent arterial embolization for acute upper GI hemorrhage at a university hospital over an 11.5-year period. Clinical success was defined as target area devascularization that resulted in the clinical cessation of bleeding and stabilization of hemoglobin level. The clinical condition of each patient at intervention was defined by history, laboratory examination, and two composite indicator variables. With use of logistic regression, the dependent variable, clinical success, was modeled on two categories of clinical and technical variables. A final model regressed patient survival on clinical success and other clinical variables.

RESULTS

None of the procedural variables analyzed had a significant influence on clinical success. Several clinical variables did impact clinical success, including multiorgan system failure (OR, 0.36; P =.030), coagulopathy (OR, 0.36; P =.026), and bleeding subsequent to trauma (OR, 7.1; P =.040) or invasive procedures (OR, 6.5; P =.009). Regardless of their clinical condition at intervention, patients who underwent clinically successful embolization were 13.3 times more likely to survive than those who had an unsuccessful procedure (CI, 4.54-39.2; P =.000). Nevertheless, patients with multiorgan system failure were 17.5 times more likely to die, independent of the outcome of the procedure (CI, 0.014-0.229; P =.000).

CONCLUSION

Arresting nonvariceal upper GI hemorrhage with transcatheter embolotherapy has a large positive effect on patient survival, independent of clinical condition or demonstrable extravasation at intervention. Aggressive treatment with transcatheter embolotherapy is advisable in patients with acute nonvariceal upper GI hemorrhage.

A new twist on the Waltman loop for uterine fibroid embolization

The usual ipsilateral approach for uterine artery embolization is to form a Waltman loop. Newer nonbraided 4-F catheters can be problematic because of their tendency to kink or unfold while the loop is being formed. Herein, a modification of the Cope suture technique is described by which a Waltman loop is formed with use of a 4-0 Tevdek suture that allows the catheter to be folded back on itself, drawing it into the ipsilateral iliac artery. If necessary, the catheter can be prevented from unlooping by twisting the catheter on itself to lock it in position. The technique allows for efficient catheterization of the ipsilateral uterine artery.

Long-term patency of experimental magnetic compression gastroenteric anastomoses achieved with covered stents

BACKGROUND

Our aim was to evaluate the efficacy of a prototype "YO-YO"-shaped covered stent for keeping experimental magnetic compression gastroenteric fistulas patent for 6 months.

METHODS

Magnets were introduced perorally with endoscopic and fluoroscopic guidance and were mated across the gastric and jejunal walls of 5 dogs. After a mean of 5.5 days a 12-mm diameter YO-YO stent was placed perorally in the resulting fistula. The gastroenteric anastomosis (GEA) with stent was observed endoscopically and gastrographically at 1- to 2-month intervals.

RESULTS

There was no morbidity and there were no significant weight changes. The GEA was widely patent at necropsy at 6 months (n = 4); partial membrane separation occurred at 5 months in the fifth dog. There was minor breakage of the stent prongs in 2 animals.

CONCLUSION

Peroral creation of a stented magnetic compression GEA is safe and provides long-term patency. This technique may be potentially useful for managing gastric outlet obstruction caused by malignancy.

Aneurysm sac pressure measurements after endovascular repair of abdominal aortic aneurysms

OBJECTIVES

The goal of endovascular grafting of abdominal aortic aneurysms (AAAs) is to exclude the aneurysm sac from systemic pressure and thereby decrease the risk of rupture. Unlike conventional open surgery, branch vessels in the sac (eg, lumbar artery and inferior mesenteric artery [IMA]) are not ligated and can potentially transmit pressure. The purpose of our investigation was to evaluate the feasibility of various interventional techniques for measuring pressure within the aneurysm sac in patients who had undergone endovascular repair of AAAs.

METHODS

Sac pressure measurements were performed in 21 patients who had undergone stent graft repair of AAAs. Seventeen of 21 patients had endoleaks demonstrated on 30-day computed tomographic (CT) scans. Access to the aneurysm sac in these patients was through direct translumbar sac puncture (5 patients), through a patent IMA accessed via the superior mesenteric artery (SMA) (9 patients), or by direct cannulation around attachment sites (3 patients). Four patients had perioperative pressure measurements obtained through catheters positioned along side of the endovascular graft at the time of its deployment. Two of these catheters were left in position for 30 hours during which time CT and conventional angiography were performed. Pressures were determined with standard arterial-line pressure transduction techniques and compared with systemic pressure in each patient.

RESULTS

Elevated sac pressure was found in all patients. The sac pressure in patients with endoleaks was found to be systemic (15 patients) or near systemic (2 patients) and all had pulsatile waveforms. Elevated sac pressures were also found in patients without CT or angiographic evidence of endoleak (2 patients). Injection of the sacs in two of these patients revealed a patent lumbar artery and an IMA.

CONCLUSIONS

It is possible to measure pressures from within the aneurysm sac in patients with stent grafts with a variety of techniques. Patients may continue to have pressurized AAA sacs despite endovascular AAA repair. Endoleaks transmit pulsatile pressure into the aneurysm sac regardless of the type. It is possible to have systemic sac pressures without evidence of endoleaks on CT or angiography.

Use of the vascular closure staple clip applier for microvascular anastomosis in free-flap surgery

We report our initial experience using the vascular closure staple clip applier (a nonpenetrating titanium clip applied in an interrupted, everting fashion) for microvascular anastomosis in free-flap surgery. In total, 153 anastomoses were performed in 87 free flaps (174 potential anastomoses) using the vascular closure stapler between October of 1997 and June of 1999. In 66 flaps, both the arterial and venous anastomosis were performed with the clip applier, whereas in 21 flaps only the venous anastomosis was performed using the clips. A total of 146 anastomoses were performed in an end-to-end fashion, and seven were performed end-to-side. Of the 87 flaps there were 53 TRAM flaps, seven bilateral TRAM, five latissimus dorsi, four gastrocnemius, three rectus abdominis, two radial forearm fibula, and four Rubens fat-pad flaps. Seventy flaps were used for breast reconstruction, seven flaps for lower limb reconstruction, four flaps for head and neck reconstruction, and six flaps for chest wall/trunk reconstruction. There were no postoperative anastomotic complications of bleeding, thrombosis, or need for revision (100 percent patency rate), with a significantly reduced time for completion of anastomoses. The clip applier is a safe, reliable method for performing microvascular anastomoses, allowing reduced operating time and possible cost savings in free-flap surgery.

Stent placement of gastroenteric anastomoses formed by magnetic compression

PURPOSE

To evaluate the use of stents for prolonging the patency of gastroenteric anastomoses (GEA) induced by magnet compression.

MATERIALS AND METHODS

Rare earth magnets were inserted perorally and serially in 15 dogs so as to mate across the gastric and jejunal walls. After magnet excretion, the resulting GEA was identified endoscopically, dilated (n = 1), and stented with bare (n = 2) or partially covered (n = 6) flared 10-mm or 12-mm Z stents. The GEA was followed at 2-4-week intervals for patency; malfunctioning shunts were irrigated, or dilated with angioplasty balloons. Gross and histologic examination of the anastomotic tissues was performed in 14 animals.

RESULTS

Magnet pairs were excreted in 5-7 days. Of the 19 magnet placements in 15 animals, stent placement was not possible because of early GEA closure (n = 6), failure to locate (n = 2), pancreatic abscess (n = 1), and magnet perforation with peritonitis (n = 1). Estimated duration of GEA patency was 19 days after balloon dilation, 40-64 days with bare Z stents, and 58-147 days (mean, 90 days) with partially covered Z stents. Shunt function was commonly hindered by bezoars. Stent narrowing or occlusion was caused by tissue overgrowth through bare stents (n = 2), between covered stent struts and through partially detached membrane (n = 2). Serious morbidity (n = 2) was due to malpositioned magnets across the pancreas in one animal and gastric perforation in the other. One dog was euthanized because of unsuspected kidney infection.

CONCLUSION

Partially covered stents significantly extend the anatomic patency rate of magnetic GEA to 7 weeks or more. Functional patency is frequently impaired by bezoars. Ongoing improvements in covered stent design should provide longer-term GEA patency.

Ultrasonographic diagnosis of uterine artery pseudoaneurysm after hysterectomy

The development of an arterial pseudoaneurysm is a rare but reported complication of pelvic surgery. Typically the lesion is discovered because the patient has symptoms related to delayed rupture of the pseudoaneurysm, causing hemorrhage. We report a case in which an uterine artery pseudoaneurysm was detected 14 days after vaginal hysterectomy by TVUS, which was performed prior to a transvaginal drainage procedure to treat an infected pelvic hematoma.

Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial

PURPOSE

To prospectively assess the efficacy of percutaneous transabdominal thoracic duct catheterization and embolization in the management of patients with high-output chylothoracic effusions.

MATERIALS AND METHODS

Eleven consecutive patients (four women and seven men; mean age, 53 years) were referred with chylothorax secondary to esophagectomy (n = 4), lobectomy (n = 1), lung transplant (n = 1), coronary artery bypass (n = 1), aortic graft (n = 2), lymphangioleiomyomatosis (n = 1), and gunshot wound (n = 1). Two patients were brought by ambulance and referred back to their hospital on the same day. Pedal lymphography was used to opacify the cisterna chyli or major retroperitoneal lymphatic trunks. When patent, these were punctured under local anesthesia with a fine needle and the thoracic duct was catheterized over a microguide wire with use of a 3-F catheter; the duct was embolized with platinum coils. Patients were followed up for decrease in thoracic drainage output and morbidity.

RESULTS

There were no retroperitoneal ducts suitable for catheterization in six patients because of previous abdominal surgery, trauma, or lymphangioleiomyomatosis; the thoracic duct was successfully catheterized in five patients, a 45% technical success rate. Thoracic duct embolization was performed in four patients, with cure of effusion in two. In the other two patients, one with lymphangioleiomyomatosis and the other with nonchylous pleural fluid, continued effusion was successfully treated by means of pleurodesis. Of two patients with previous thoracic duct ligation, one was found to have the duct incompletely tied. The authors were surprised to find that previous major abdominal surgery, chronic aortic dissection, and lymphangioleiomyomatosis could obliterate major retroperitoneal lymphatic ducts and the cisterna chyli. Percutaneous study of the thoracic duct with aqueous contrast medium was more sensitive than lymphography with iodinated oil. There was no morbidity.

CONCLUSIONS

Catheterization of the thoracic duct was possible in all patients who had patent major retroperitoneal lymphatic trunks. Thoracic duct embolization was curative in patients with demonstrable duct leakage. Previous abdominal surgery, aortic dissection, and lymphangioleiomyomatosis can lead to silent occlusion of retroperitoneal lymphatic trunks. Percutaneous thoracic duct catheterization and embolization is safe and can replace surgical ligation in some patients.

Recurrence rates of ischial sores in para- and tetraplegics treated with hamstring flaps: an 8-year study

We have collected data on the second follow-up of 27 patients who underwent musculocutaneous flap closure of their ischial pressure sores. Thirty-seven ulcers were operated on between 1988 and 1993 using the V-Y advancement hamstring musculocutaneous island flap. At the initial follow-up (mean = 20 months) in 1993, despite 33% of patients having had recurrent ulcers and 14.8% having undergone re-advancements, only 14% of patients had non-healing ulcers. In 1997, follow-up period ranged from 18 to 90 months, with a mean of 62 months. Four patients were lost to follow-up resulting in 23 patients (n = 23) for the current study. Nine patients were tetraplegic and the remaining 14 were paraplegic. Four of the 23 patients had died at follow-up therefore making the number of living patients 19 (n = 19). The total number of ulcers operated on in the current study was 29 (U = 29). Overall, ulcer and patient recurrence rates were 41.4% and 47.8% respectively. Despite this, 89.5% of patients had intact flaps at the time of follow-up. We recommend the use of the hamstring V-Y musculocutaneous flap as a reliable and safe reconstructive modality in the management of ischial pressure sores and by identifying the group of patients susceptible to ulcer recurrence we have proposed a protocol for their long-term follow-up.

Chemoembolization of hepatocellular carcinoma with cisplatin, doxorubicin, mitomycin-C, ethiodol, and polyvinyl alcohol: prospective evaluation of response and survival in a U.S. population

PURPOSE

To evaluate response and survival after hepatic chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol in a U.S. population of patients with hepatocellular carcinoma.

MATERIALS AND METHODS

Thirty-eight consecutive patients were treated: 35% stage I, 62% stage II, 3% stage III. Fifty-one percent had cirrhosis. Chemoembolization was performed at approximately monthly intervals for one to seven sessions (mean, 2.2). Pretreatment and posttreatment cross-sectional imaging and alpha-fetoprotein (AFP) levels were obtained prospectively 1 month after treatment and then every 3 months. Thirty-day response was calculated by means of the the World Health Organization/Eastern Cooperative Oncology Group criteria.

RESULTS

One patient was lost to follow-up. In seven patients, lesions became resectable after chemoembolization. Among 13 evaluable patients with initially elevated AFP level, 70% had a partial biologic response (>50% decrease in AFP), 15% had a minor response (25-50% decrease), and the remaining 15% remained stable. Among 25 patients evaluable for morphologic response, 36% had a partial response, 32% had a minor response, and 32% remained stable. No patients had progression of disease while receiving therapy. The cumulative survival was 60% at 1 year, 41% at 2 years, and 16% at 3 years. Two patients developed progressive hepatic failure. Thirty-day mortality was 3% (one patient).

CONCLUSION

These results compare favorably to published response and survival data for chemoembolization of advanced hepatocellular carcinoma from Asia and Europe.

Direct percutaneous jejunostomy: techniques and applications--ten years experience

PURPOSE

To present 10 years experience with direct fluoroscopically guided percutaneous jejunostomy.

MATERIALS AND METHODS

Percutaneous jejunostomy was performed in 62 patients, most of whom had undergone major abdominal surgery. A new or replacement jejunostomy was created for alimentation in 20 and 21 patients, respectively. Jejunostomy was performed for interventional procedures of the bile ducts or intestine in 13 patients and for retrograde gastroesophageal drainage in eight. The distended jejunum was accessed with a 21-gauge needle, immobilized with a gastric anchor, and catheterized with a 10-14-F locking loop drain.

RESULTS

The technical success rate was 19 of 20 (95%) for new feeding jejunostomy and 17 of 21 (81%) for replacement feeding jejunostomy. Jejunostomy facilitated drainage, dilation, stone extraction, and recanalization in the bile ducts or intestine in all 13 patients. Retrograde jejunoesophagogastrostomy suction effectively replaced painful nasogastric suction in all eight patients. Two patients who underwent replacement jejunostomy required laparotomy for possible leakage; there was no important procedure-related morbidity and no procedure-related mortality.

CONCLUSION

The technical success and complication rates of feeding percutaneous jejunostomy compare favorably with those of surgery or endoscopy. Percutaneous jejunostomy is a useful and underused approach to managing bowel and biliary obstruction.

Sensory recovery in noninnervated radial forearm free flaps in oral and oropharyngeal reconstruction

BACKGROUND

Reinnerveration of free flaps used in oral and oropharyngeal reconstruction may provide a high level of sensory return. Spontaneous recovery of sensation in noninnervated flaps may also occur.

OBJECTIVE

To evaluate the extent of spontaneous sensory return among patients who underwent radial forearm free flap reconstruction in the oral cavity and oropharynx.

METHODS

A total of 40 patients were evaluated by 2 independent examiners. The median patient age was 60 years, and the median time from surgery was 47 months. A total of 29 patients had received postoperative radiotherapy. The mean flap size was 25 cm2. The following sensory modalities were tested: light touch, pinprick, hot and cold, and moving and static 2-point discrimination.

RESULTS

Recovery of sensation of at least 1 modality was noted in 32 patients (80%), however, only 5 patients (13%) had return of all 5 modalities. Eight patients (20%) had no sensory return. There was a trend to improved sensory recovery in flaps placed in the alveolar and retromolar trigone areas; however, on multivariate analysis, sensory return could not be predicted by any of the following factors: patient age, flap site, flap size, length of follow-up, and use of postoperative radiotherapy.

CONCLUSIONS

Complete sensory recovery was uncommon, unpredictable, and variable, although some recovery of sensation occurred in 80% of patients. It is not valid to rely on spontaneous sensory recovery for sensory innervation of free flaps. Correlation of sensory return with function is still needed.

Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study

PURPOSE

To assess the feasibility of percutaneous transabdominal puncture and catheterization of the cisterna chyli or lymphatic ducts (PTCLD) in patients with postoperative chyloperitoneum and chylothorax, and to identify and possibly embolize the chylous fistula.

MATERIALS AND METHODS

Five patients had postoperative uncontrolled chyle fistulas. Two patients with chylothorax had thoracic duct (TD) ligation after esophagectomy and neck surgery. The other three patients had chylous ascites after surgery of the pancreas, the aorta, and the esophagus, respectively. After lymphographic opacification, the cisterna chyli (CC) or retroperitoneal lymph ducts were punctured transabdominally with a 21-gauge needle and catheterized with a 3-F catheter to reach the TD if possible. Microcoils were used to embolize a TD laceration.

RESULTS

Lymph ducts as small as 2-3 mm were catheterized successfully in three patients. The TD was catheterized in two patients; one TD fistula was embolized with cure of chylothorax. In one patient with a surgically tied TD, duct occlusion was confirmed despite continued pleural effusion. Three fistulas, not seen with lymphography, were identified in two of three chylous ascites and one chylothorax. There was no morbidity. As a result of this procedure, four of five patients did not require repeated operation.

CONCLUSIONS

PTCLD in the study of chyle fistulas was feasible and safe in the management of five patients and clinically useful in four patients; transabdominal catheter lymphography with aqueous contrast medium is more sensitive than pedal lymphography. Further evaluation is necessary.

Morphology of the distal tip of the upper mandible of the ostrich (Struthio camelus) embryo during hatching

1. The morphology of the distal part of the upper mandible in ostrich embryos was investigated using scanning electron microscopy just prior to and during hatching. 2. Although a keel-like structure on the tip of the upper mandible superficially resembles an egg tooth it appears to play no role during hatching. 3. The distal tip of the upper mandible is covered by an amorphous layer, the right side of which disappears during the hatching process. This layer acts to protect the beak during the rubbing process which creates a hole in the inner shell membrane during hatching.

Limb development and evolution: a frog embryo with no apical ectodermal ridge (AER)

The treefrog Eleutherodactylus coqui is a direct developer--it has no tadpole stage. The limb buds develop earlier than in metamorphosing species (indirect developers, such as Xenopus laevis). Previous molecular studies suggest that at least some mechanisms of limb development in E. coqui are similar to those of other vertebrates and we wished to see how limb morphogenesis in this species compares with that in other vertebrates. We found that the hind limb buds are larger and more advanced than the forelimbs at all stages examined, thus differing from the typical amniote pattern. The limb buds were also small compared to those in the chick. Scanning and transmission electron microscopy showed that although the apical ectoderm is thickened, there was no apical ectodermal ridge (AER). In addition, the limb buds lacked the dorsoventral flattening seen in many amniotes. These findings could suggest a mechanical function for the AER in maintaining dorsoventral flattening, although not all data are consistent with this view. Removal of distal ectoderm from E. coqui hindlimb buds does not stop outgrowth, although it does produce anterior defects in the skeletal pattern. The defects are less severe when the excisions are performed earlier. These results contrast with the chick, in which AER excision leads to loss of distal structures. We suggest that an AER was present in the common ancestor of anurans and amniotes and has been lost in at least some direct developers including E. coqui.

Replacement of failing tunneled hemodialysis catheters through pre-existing subcutaneous tunnels: a comparison of catheter function and infection rates for de novo placements and over-the-wire exchanges

PURPOSE

Tunneled hemodialysis catheter dysfunction often occurs from fibrin sheath formation. As a way to preserve existing catheter venous access sites, the authors evaluated over-the-wire exchange of catheters through pre-existing subcutaneous tunnels as an alternative to catheter removal and de novo catheter replacement.

PATIENTS AND METHODS

One hundred nineteen catheters were placed in 68 patients. Seventy-seven catheters were placed de novo and 42 catheters were placed through the pre-existing subcutaneous tunnels of failing catheters. Technical success, short-term complications, infection rates, and functional catheter longevity were evaluated.

RESULTS

Technical success for catheter exchange was 93%. Infection rates were comparable to those of de novo catheter placement: 0.15 and 0.11 infections per 100 catheter days for de novo and exchanged catheters, respectively. Catheter duration of function was not significantly different for de novo versus exchanged catheters: 63% and 51% at 3 months, 51% and 37% at 6 months, and 35% and 30% at 12 months, respectively.

CONCLUSIONS

Over-the-wire exchange of tunneled hemodialysis catheters is safe and easily performed. It causes no increase in infectious complications and provides similar catheter longevity to de novo catheter placement. The procedure is an important option for prolonging tunneled hemodialysis catheter access sites.

Percutaneous management of a bladder-drained pancreas transplant pseudocyst by a transcystic approach

BACKGROUND

We describe a 35-year-old male type 1 diabetic who underwent a cadaveric combined kidney-bladder-drained pancreas transplant with a duodenocystostomy for exocrine drainage who developed a large pelvic pseudocyst associated with a dilated pancreatic duct and an elevated serum amylase level.

METHODS

Due to the risk of surgical revision and the possibility of creating a cutaneous fistula with conventional percutaneous drainage, a pseudocyst-to-bladder drainage was performed. After the procedure, the catheter was capped to allow drainage of the pancreatic secretions into the bladder.

RESULTS

After drainage, the patient's serum amylase and lipase normalized along with resolution of the pseudocyst. The tube was removed after 19 weeks with no evidence of a recurrent pseudocyst and a normal serum amylase level.

CONCLUSION

The percutaneous pseudocyst-cystostomy obviated the need for surgical revision of the exocrine gland drainage and thus eliminated the morbidity and the potential risk of graft loss associated with such surgery.

Percutaneous varicocele embolization versus surgical ligation for the treatment of infertility: changes in seminal parameters and pregnancy outcomes

PURPOSE

To compare the success of percutaneous varicocele embolization to surgical ligation with regard to changes in semen characteristics and pregnancy outcome.

MATERIALS AND METHODS

Infertility records from 346 men who underwent correction of their varicocele for infertility (surgical ligation 149; embolization 197) were reviewed retrospectively. Preprocedural and postprocedural semen analyses and pregnancy outcomes were obtained with use of chart and telephone follow-up.

RESULTS

In men who successfully impregnated their partners, there were significant improvements in sperm density, percent total improvement, motility, and progression. Postprocedural (embolization vs surgery) percentage increases in seminal parameters were density, 156.8% versus 138.5%; total, 168.8% versus 157.91%; and motility, 2.7% versus 3.2%. The percent of individuals who had a change in sperm progression was 31% versus 41%. There was no statistical difference between the techniques based on t tests. The pregnancy rates were similar for the two groups, 39% and 34% for embolization and surgery, respectively.

CONCLUSION

There is no significant statistical difference in seminal values or pregnancy outcome between the two techniques.

Percutaneous transthoracic duct catheterization to the neck and esophagus: a feasibility study

PURPOSE

To assess the feasibility of inserting a drain catheter percutaneously from the cisterna chyli (CC) through the thoracic duct (TD) wall to the neck or esophagus for potential long-term T-cell sampling or drainage in acute or short-term experiments.

MATERIALS AND METHODS

Percutaneous transabdominal catheterization of the TD from the CC was performed in four animals to insert a 65-cm, 21-gauge needle over a microguidewire. In two dogs, the distal TD was perforated into the neck to connect the TD drain to an access port. In acute experiments on two swine, the esophagus was accessed by puncturing an intraluminal Foley-catheter balloon through the mid TD wall. In one animal, the TD catheter tip was left to drain in the distal esophagus; in the other animal, the catheter distal tip was pulled back through a gastrostomy until the proximal end had retracted into the proximal TD.

RESULTS

TD-to-neck port connection was well tolerated short-term. One dog developed dehiscence over the port at 10 days necessitating its removal; in the other dog, the whole drain retracted into the neck from the proximal TD. The technique for TD-to-esophagus catheterization in swine was feasible with no acute complications or mediastinal leakage of contrast medium.

CONCLUSIONS

Transabdominal percutaneous inside-out TD puncture for drainage to a neck port or to the esophagus is feasible in dogs and swine, respectively.

Use of articulated catheters in the treatment of biliary strictures

We have used a single articulated catheter to obviate the need for multiple catheters in patients with complex biliary strictures or strictures associated with small or immature tracts. Two- and three-arm articulated drains (8-14 Fr) made from segments of biliary catheters were placed in 16 patients. Nine were placed transhepatically, 6 transperitoneally through existing T-tube tracts, and 1 through a cystic duct fistula. Six malignant and 10 benign strictures were stented with various catheter configurations through a single tract. Fifteen patients had two catheter components with one articulation and 1 patient had three catheter components with two articulations. The average duration of catheter drainage was 7.0 +/- 4.2 months. Routine catheter exchanges were performed; two spontaneous occlusions occurred. In patients where internal stenting may be difficult or undesirable, articulated catheters allow satisfactory external and internal drainage of complex benign and malignant strictures through a single tract, avoiding the need for multiple transhepatic catheters.

Balloon occlusion portography to diagnose new-onset left hepatic vein thrombosis and widening of an existing Wallstent TIPS by Palmaz stents for recurrent portal hypertension and variceal bleeding

A 31-year-old man with Child's class A micronodular cirrhosis, left lobe hypertrophy, and a transjugular intrahepatic portosystemic shunt (TIPS) which had been placed 6 months earlier, was admitted for recurrent esophageal bleeding and a portosystemic gradient of 42 mmHg. Balloon occlusion portography documented unsuspected ostial thrombosis of the previously patent left hepatic vein. This was considered the cause of the pressure rise. As it was not possible to insert a second TIPS in parallel, the shunt, stented originally with 10-mm Wallstents, was overdilated to 12 mm, and two 12-mm Palmaz stents were placed coaxially, reducing the portosystemic pressure gradient to 13 mmHg.

Percutaneous transabdominal embolization of thoracic duct lacerations in animals

PURPOSE

To develop percutaneous techniques for lacerating the thoracic duct (TD) and to assess the efficacy of percutaneous TD embolization.

MATERIALS AND METHODS

The TD was catheterized by means of antegrade or antegrade-retrograde techniques after the lymphographically opacified cisterna chyli (CC) was punctured in five swine and one dog. The TD was lacerated by fluid overdistention (n = 1), perforated with stiff guide wires (n = 3) or a 5-F styletted catheter (n = 1), or macerated by rotational guide-wire trauma (n = 1). The TD was percutaneously embolized in five animals with steel (n = 2) and platinum (n = 3) coils. The CC containing a metal target was recatheterized 2-7 days after embolization.

RESULTS

All types of TD trauma led to mediastinal extravasation. The one chylothorax was induced by the 5-F styletted catheter. The TD of four animals was promptly thrombosed with coils. In the fifth animal, the TD failed to thrombose 3 days after embolization, probably because of the use of an undersized platinum are coil. There were no immediate or delayed complications. Necropsy in five animals was unremarkable. The sixth animal was alive and well at 4 months.

CONCLUSIONS

Percutaneous transcatheter TD trauma led to mediastinal extravasation in all six animals, but chylothorax occurred in only one animal. TD coil embolization led to duct thrombosis in four of five animals with no early or late complications. The technique has potential clinical applications for localization and selective embolization of TD leaks in debilitated patients.

Temporary use of a Bird's Nest filter during iliocaval thrombolysis

A jugular Bird's Nest filter (Cook, Bloomington, Ind) was partially deployed in the suprarenal cava for prophylaxis to prevent pulmonary embolism in a young woman with phlegmasia cerulea dolens. It was effective in capturing large emboli during thrombolysis of a loose iliocaval thrombus. It was safely removed 6 1/2 hours later, after lysis of most retained filter clots.

Cell proliferation in rat forestomach following oral administration of styrene oxide

A series of range-finding studies was conducted in a limited number of male F344 rats on the relation between cell proliferation and styrene oxide (SO) given as gavage doses in corn oil ranging from 550 to 1500 mg SO/kg. In each study, rats were injected with [3H]thymidine (0.50 mCi/g, ip) at intervals from 1 to 48 hr after dosing with SO. One hour later, stomachs were removed and fixed in formalin. Autoradiograms were prepared and labeling index (LI) was determined as the percentage of epithelial cells with 3H-labeled nuclei. Mean LI increased with a peak at approximately 15 hr after one or nine doses of SO. The increases were multifocal and not restricted to the area near the limiting ridge. The magnitude of the response in LI at 24 hr after dosing tended to decrease with progressive multiple doses (3/week). Dose-related morphologic lesions from SO (particularly submucosal) were multifocal and variable across the forestomach; they appeared unrelated to LI in a given area. In a final study, groups of 10 rats were given a single dose of 0, 20, 50, 125, 250, 500, or 800 mg/kg and LI was determined 15 hr later. Mean LI was dose-related with increases up to 250 mg/kg. A maximum response had apparently been reached and higher doses did not cause any further increase in LI. The degree of involvement of cell proliferation in the tumorigenicity of SO remains uncertain; additional studies are suggested to help in the understanding of such a possible relation.

Transjugular insertion of biliary stents (TIBS) in two patients with malignant obstruction, ascites, and coagulopathy

Two patients with pancreatic malignancies presented with biliary obstruction which could not be treated from an endoscopic approach. Standard transhepatic biliary drainage was relatively contraindicated because of moderate ascites and coagulopathy related to underlying liver disease. In one patient, a transjugular, transvenous approach was used to deliver a Wallstent endoprosthesis across the distal common bile duct obstruction in a single step procedure. In the second case, a previously placed biliary Wallstent was revised with an additional stent from a similar approach. Transjugular biliary catheterization offers a valuable alternative approach for primary stent placement or revision in patients with contraindication to standard transhepatic drainage.

Transjugular intrahepatic portosystemic shunt-related arterial injuries: prospective comparison of large- and small-gauge needle systems

PURPOSE

The authors prospectively compared the nature and incidence of hepatic arterial injuries resulting from creation of a transjugular intrahepatic portosystemic shunt (TIPS) with large- and small-gauge needle systems.

PATIENTS AND METHODS

Fifty patients underwent hepatic and superior mesenteric angiography immediately before and after shunt creation. A sheathed 16-gauge needle system was used to locate and puncture the portal vein in 24 patients. A 21-gauge needle system was used in 26 patients.

RESULTS

Shunts were successfully created in all patients. Three inadvertent hepatic arterial punctures were recognized during shunt placement, two with the small needle and one with the large needle system. No hepatic arterial lesions were detected in any patient. Two incidental hepatomas were identified at angiography.

CONCLUSION

TIPS-related hepatic arterial injuries are rare. In this series, large and small needle systems were indistinguishable with respect to this complication.

Sterilization with methyl cyanoacrylate-induced fallopian tube occlusion from a nonsurgical transvaginal approach in rabbits

PURPOSE

To evaluate a nonsurgical, nonhormonal sterilization procedure performed with use of transvaginal microcatheterization techniques and methyl cyanoacrylate (MCA) as a sclerosing agent

MATERIALS AND METHODS

Seventeen adult virgin female rabbits underwent bilateral fallopian tube cannulation through a nonsurgical transvaginal approach with use of a coaxial catheter system with fluoroscopic guidance. Fourteen of the rabbits underwent bilateral fallopian tube occlusion with direct MCA injection; the remaining three rabbits were separated as controls. Three of the rabbits with occlusions were killed as temporal histologic controls. The remaining 11 rabbits with occlusions and the initial three controls underwent 6 months of mating trials. All 17 rabbits were killed. Gross inspection was performed and histologic specimens of their fallopian tubes were obtained.

RESULTS

None of the 11 rabbits with occlusions that underwent mating became pregnant. All three control rabbits became pregnant. Histologic examination of the occluded fallopian tubes demonstrated long-segment tubal wall fibrosis with varying degrees of occlusion. No peritoneal abnormalities were identified. Histologic findings for the three control animals were normal.

CONCLUSION

With use of a nonsurgical transcervical coaxial catheter system, MCA can be placed directly into fallopian tubes without difficulty. MCA administration leads to fallopian tube fibrosis and occlusion. A 100% nonpregnancy rate was demonstrated. Further investigation may lead to a safer, more convenient, and less expensive form of permanent sterilization.

Creation of compression gastroenterostomy by means of the oral, percutaneous, or surgical introduction of magnets: feasibility study in swine

PURPOSE

The use of magnets placed surgically, percutaneously, and orally to create compression gastroenteric anastomoses was evaluated in 11 swine.

MATERIALS AND METHODS

Disc-shaped, jacketed rare-earth magnets with cutting edges varying in diameter from 0.250 inch (6.4 mm) to 0.500 inch (12.7 mm) were used in seven swine, and rectangular types were used in three swine. Magnets were implanted surgically in five and introduced by means of standard interventional techniques through a gastrostomy in two and perorally in four animals. Anastomoses (n = 8) were studied grossly and histologically for acute changes at 5-13 days and for 30-day patency in one.

RESULTS

Of the nine surviving pigs, there were seven completely patent anastomoses and one partially patent anastomosis at 7-13 days. At 5 days the anastomosis was not patent in the remaining animal. One anastomosis became occluded at 30 days. There was no anastomotic leakage, infection, or bleeding.

CONCLUSIONS

Leak-free gastrojejunostomies can be created by inserting magnets perorally, percutaneously, or surgically.

Evaluation of compression cholecystogastric and cholecystojejunal anastomoses in swine after peroral and surgical introduction of magnets

PURPOSE

To assess the efficacy of rare-earth magnets for creating a cholecystogastrostomy (CG) or cholecystojejunostomy (CJ) in nine swine.

MATERIALS AND METHODS

Neodymium-iron-boron magnets or rare-earth cobalt magnets of various configuration and strength were coupled in pairs to form four CGs and five CJs. Magnets were implanted surgically in the gallbladder and jejunum, and perorally in the stomach. Gross and histologic examinations of anastomoses were performed 8-16 days later.

RESULTS

All anastomoses showed good adhesion with no leakage and minimal inflammation. Anastomoses were fully patent in four CJs and one CG (mean, 12 days), partially patent in one CJ and one CG (mean, 15 days), and not patent in two CGs. Best results were noted with jacketed disc magnets with cutting rims and a 400-600-g pull. The rare-earth magnets were significantly weakened by gas sterilization in the first four CG experiments. Two of four magnets used in CJ were retained despite a fully patent anastomosis.

CONCLUSION

Leak-free patent or partially patent cholecystenteric anastomoses were created by magnet compression in 9-16 days. This technique may have clinical interventional applications.

Percutaneous thoracic duct cannulation: feasibility study in swine

PURPOSE

To assess the feasibility of percutaneous catheterization of the thoracic duct (TD) in 15 pigs.

MATERIALS AND METHODS

After opacification of the cisterna chyli (CC) with pedal lymphography, the CC is punctured transabdominally with a 21-gauge needle and the TD is catheterized with a 3-F catheter over a guide wire. For retrograde TD catheterization, the guide wire is advanced cephalad to a neck vein, snared, retrieved through the jugular or femoral vein, and used to insert a catheter retrogradely through the lymphovenous junction. The transabdominal wire is removed.

RESULTS

Of 15 pigs studied, successful TD catheterization was performed in 13 (antegrade [n = 4], antegrade-retrograde [n = 9]). Two failures were due to CC anomalies. No acute complications were noted. A marker was left in the CC, and TD catheterization was repeated in two pigs, 2 and 5 days later.

CONCLUSIONS

Percutaneous transabdominal TD catheterization in the swine is feasible, safe, and repeatable. This technique has potential clinical applications in organ transplantation and management of TD laceration.

Thrombosed hemodialysis grafts: percutaneous mechanical balloon declotting versus thrombolysis

PURPOSE

To compare a technique of mechanical balloon declotting of thrombosed hemodialysis grafts with conventional pulsed-spray thrombolysis.

MATERIALS AND METHODS

Forty patients had 53 episodes of graft thrombosis over a 19-month period. Twenty-nine grafts were randomly treated with thrombolysis with urokinase and 24 grafts with mechanical declotting by placement of crossed balloon catheters within the graft. Patency was determined by retrospective review of hemodialysis records.

RESULTS

Successful hemodialysis for 1 week after the procedure was achieved in 21 (88%) of the 24 grafts treated mechanically and 26 (90%) of 29 grafts treated with thrombolysis. Continuous pulse oximetry showed no change in oxygen saturation in either group, and no clinical signs or symptoms of pulmonary embolism were noted. Average total procedure times were 2.2 hours for mechanical declotting and 3.5 hours for thrombolysis (P < .05). Probability of patency (mechanical vs thrombolysis) was 42% vs 45% at 3 months, 36% vs 25% at 6 months, and 8% vs 4% at 12 months. One major complication of ulnar artery embolization occurred in the thrombolysis group.

CONCLUSION

Mechanical declotting of hemodialysis grafts is faster and as effective as thrombolysis.

V-Y advancement hamstring myocutaneous island flap repair of ischial pressure ulcers

Thirty-seven ischial pressure ulcers were repaired in 27 patients (eight quadriplegic, 19 paraplegic) between 1988-1993 using the V-Y advancement hamstring myocutaneous island flap. Twenty-one ulcers (57%) arose de novo and 16 were recurrent, with five patients having bilateral ulcers. The average duration of the ulcer was 5 months (range 1-30). All ulcers extended through the deep fascia (clinical grade IV), with the average diameter being 4.7 cm (range 2-10). There were four major flap complications (11%). All but one of the ulcers healed at discharge (97%). Mean follow up was 20 months (range 5-54) in 21 patients (78%), with six patients being lost to follow up. Seven of the 21 (33%) patients developed recurrent ulcers, with four of these having flap re-advancement with successful healing, and one patient having two re-advancements. Overall, 18 of the 21 (86%) patients with follow up had healed ulcers at time of follow up. The V-Y advancement hamstring myocutaneous island flap is versatile, reliable, easy to perform, has few complications, and can be re-advanced in the event of recurrence.

Intentional reversible thrombosis of transjugular intrahepatic portosystemic shunts

PURPOSE

To assess whether balloon occlusion of a transjugular intrahepatic portosystemic shunt (TIPS) will allow permanent yet reversible shunt thrombosis.

MATERIALS AND METHODS

A balloon catheter was inflated in the midportion of the TIPS in two women with severe, uncontrollable encephalopathy or liver failure (aged 42 and 65 years, respectively) to allow occlusive thrombus to develop below the balloon.

RESULTS

Balloon occlusion led to rapid TIPS thrombosis, which was readily reversible.

CONCLUSION

Balloon thrombosis is a simple technique for complete occlusion of a TIPS. This technique may also be useful for occlusion of surgical mesocaval H-graft shunts or dialysis access shunts.

Transjugular intrahepatic portosystemic shunting: decreased survival for patients with high APACHE II scores

OBJECTIVES

To determine which clinical characteristics are associated with decreased survival after transjugular intrahepatic portosystemic shunting (TIPS).

METHODS

Forty-nine consecutive patients were treated with TIPS; 46 of them had refractory variceal bleeding. Univariate statistics and logistic regression analyses were used to determine the relationship between clinical, biochemical, and hemodynamic variables and 30-day) survival.

RESULTS

Shunt insertion was successful in 48 (98.0%) of 49 cases. Median portal-systemic gradient was reduced from 22.5 (range 9-36) [median (5th-95th percentile)] to 12 (range 4-20) mm Hg. Thirty (61.2%) of 49 patients survived more than 30 days; four patients died more than 30 days after TIPS in mean follow-up of 8.4 months. Significant differences (p < 0.05) were found between those who survived more than 30 days and those who did not, with respect to preprocedural prothrombin time, bilirubin, albumin, alanine aminotransferase, and treatment with vasopressin and nitrates, balloon tamponade, or mechanical ventilation. Whereas there were no significant differences between the pre- and post-TIPS portal vein pressures and portal-systemic gradients in survivors and non-survivors, the pre- and post-TIPS hepatic vein pressures were significantly lower in survivors. Survival was inversely proportional to Child-Pugh class (p < 0.01) and to APACHE II score (p < 0.01). The single determinant most closely associated with decreased survival in the month after TIPS was the APACHE II score, a score of 18 stratifying patients into those at low and high risk of mortality [odds ratio 21.7 (CI 3.6-131.7)]. Only 1 (7.7%) of 13 patients with Child-Pugh C cirrhosis and an APACHE II score exceeding 18 survived more than 30 days.

CONCLUSIONS

Patients with advanced cirrhosis, especially those with high pre-TIPS APACHE II scores, are at high risk for reduced survival after TIPS, despite adequate portal decompression.

Transjugular intrahepatic portosystemic shunt stenosis and revision: early and midterm results

OBJECTIVE

The purpose of this study was to define the pattern, rate, and interval during which stenosis develops in transjugular intrahepatic portosystemic shunts (TIPS) and to assess the effect of revision in prolonging shunt patency.

MATERIALS AND METHODS

TIPS were created in 100 patients during a 34-month period. Sixty-one shunt venograms were obtained in 38 consecutive patients between 1 and 24 months after TIPS placement. Eighteen patients were examined because of recurrent symptoms, and all 38 had routine follow-up.

RESULTS

Stenoses attributed to neointimal hyperplasia developed within both the TIPS stent and the outflow hepatic veins. Stenoses of greater than 50% developed in 12 patients within 6 months of TIPS placement. In addition to focal stenoses, the outflow hepatic veins diffusely shrank an average of 51% in diameter. Thirty-six shunt interventions were required: eleven balloon dilatations and 25 placements of an additional stent. Life-table analysis showed that patency of the primary shunt was 75% at 6 months, 50% at 1 year, and 32% at 2 years. The primary-assisted patency of the shunt was 85% at 12 months after shunt creation.

CONCLUSION

The results indicate that TIPS are prone to significant and frequent early stenosis, warranting follow-up within 3-6 months in all cases. Stenosis of the outflow hepatic vein is the most common cause of shunt malfunction. Revision of a shunt significantly prolongs shunt patency.

Elective embolization for prevention of hemorrhage from renal angiomyolipomas

PURPOSE

Among angiomyolipomas 4 cm or larger, 82%-94% are symptomatic and 50%-60% bleed spontaneously. Up to one-third of patients with these lesions present in shock. The effectiveness of elective embolization was evaluated in the prevention of bleeding from large (> or = 4 cm) angiomyolipomas while sparing the normal renal parenchyma.

PATIENTS AND METHODS

Five cases from the authors' institution and 21 cases from the literature were reviewed retrospectively.

RESULTS

Embolization as the sole means of treatment was effective in 90% of patients over a follow-up period from 2 months to 7 years (mean, 21 months). There were no complications at the authors' institution. Serious procedure-related complications reported in the literature were limited to two cases of aneurysm rupture and two necrotic tumors requiring percutaneous drainage.

CONCLUSION

Embolization of renal angiomyolipomas is safe and well tolerated and may be of benefit in preventing life-threatening hemorrhage.

Endovascular management of splenic artery aneurysms and pseudoaneurysms

Splenic artery aneurysms and pseudoaneurysms are being diagnosed with increasing frequency by modern imaging. The question of appropriate treatment--surgical or endovascular--arises more often. We review our experience and that of others as documented in the literature. The information available suggests that endovascular management of a splenic artery aneurysm or pseudoaneurysm offers a lower complication rate than surgery, but postprocedure imaging to ensure obliteration is recommended.

Magnetic resonance angiography of the aorta, iliac, and femoral arteries

BACKGROUND

Successful management of patients with peripheral vascular disease requires detailed vascular imaging, usually performed by contrast arteriography. Recently, magnetic resonance angiography (MRA) has been shown to be a noninvasive technique with greater sensitivity than contrast arteriography for detecting distal runoff vessels in patients with peripheral arterial occlusive disease. However, to supplant the need for contrast arteriography and provide a completely noninvasive evaluation of patients with occlusive disease, accurate imaging of the inflow vessels and the runoff vessels is necessary.

METHODS

We used both conventional arteriography and MRA in preoperative studies of the aorta, iliac, and femoral vessels of 47 patients. Conventional arteriography and MRA studies were compared for their ability to detect vessel patency and the presence of hemodynamically significant stenoses. Independent interventional plans were developed based on the information provided by each technique. The findings of conventional and MRA studies were verified by intraoperative arteriography or direct operative exploration.

RESULTS

Results of the two studies were identical in 41 (87%) of 47 patients or 600 (98%) of 614 segments imaged. MRA accurately detected patent and occluded arterial segments (sensitivity 99.6%, specificity 100%, positive predictive value 100%, negative predictive value 98.6%) and hemodynamically significant stenoses. Therapeutic plans based on either MRA or conventional arteriography were identical for each patient.

CONCLUSIONS

MRA provides comparable results to contrast arteriography in the proximal arterial system and superior results for imaging the distal vasculature. This noninvasive technique may replace contrast arteriography in a large number of patients in the future.

Double-blind study of the safety, tolerance, and diagnostic efficacy of iopromide as compared with iopamidol and iohexol in patients requiring aortography and visceral angiography

RATIONALE AND OBJECTIVES

Nonionic contrast media have been shown to be more effective, better tolerated, and safer than standard high-osmolality contrast media when given intravascularly. The aim of this study was to assess the diagnostic efficacy, tolerance, and safety of a new nonionic contrast agent, iopromide (370 mg I/mL), in comparison with two available similar agents, iopamidol (370 mg I/mL) and iohexol (350 mg I/mL), in two randomized, double-blind clinical studies of patients undergoing abdominal aortography and visceral angiography.

METHODS

The iopromide group included 80 patients, and the comparator group consisted of 36 iopamidol and 45 iohexol patients. The quality and diagnostic efficacy of all three contrast agents was rated equally as either good or excellent.

RESULTS

On a scale of 0 (none) to 3 (severe) for heat and pain, respectively, the mean scores were 1.08 and 0.43 for iopromide in comparison with 1.15 and 0.35 for the comparator media. Minor adverse clinical experiences were noted in 23% of the iopromide group versus 20% of the comparator group. Nausea and vomiting were more common in the comparator group (7% versus 3%), and headache was noted only in the iopromide group (4%). There were no clinically significant changes in laboratory values in any group. Three severe adverse experiences occurred, but all were deemed unrelated to the contrast agents.

CONCLUSION

Based on the results of this study, iopromide appears to be efficacious, safe, well tolerated, and comparable with iohexol and iopamidol for use in abdominal aortography and visceral angiography.

Life-threatening pulmonary emboli and cor pulmonale: treatment with percutaneous pulmonary artery stent placement

Large, central bilateral pulmonary emboli led to cor pulmonale and severe hypoxemia in a patient who had recently undergone cardiac surgery. After percutaneous catheter fragmentation and thrombolysis of the emboli failed, the left and right interlobal pulmonary arteries were recanalized by placement of self-expanding Wallstent endoprostheses through the clots. Pulmonary perfusion was restored to the lower lobes, and the patient demonstrated rapid clinical improvement.