Percutaneous management of benign biliary strictures

The interventional radiologist plays an increasing role in the management of patients with benign biliary disease. This article summarizes the percutaneous management of patients with benign biliary strictures and includes a discussion of currently available techniques. The techniques of percutaneous transhepatic cholangiography and biliary drainage will be reviewed. This includes anatomic and technical considerations of the right midaxillary and left subxyphoid percutaneous approaches, a review of percutaneous dilation of biliary strictures and the management of patients with chronic indwelling biliary drainage catheters. (ie, periodic catheter exchanges, catheter flushing, etc). The article concludes with a discussion of biliary drainage catheters and the clinical and physiologic parameters used in making a decision to remove the tube.

Fenestration of extracardiac fontan and reversal of protein-losing enteropathy: case report

We describe a patient with protein-losing enteropathy who presented 6 months after undergoing a modified Fontan operation. After failing to respond to medical therapy, the Fontan tunnel was fenestrated by catheter intervention with immediate improvement and resolution of hypoproteinemia and enteric protein loss.

Portal venous system thrombosis: helical CT angiography before transjugular intrahepatic portosystemic shunt creation

PURPOSE

To evaluate the utility of helical computed tomographic (CT) angiography for depiction of thrombi in the portal venous system in patients under consideration for transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

Contrast material-enhanced helical CT was performed before TIPS creation in 25 patients. Axial, multiplanar, and three-dimensional images were evaluated to determine whether thrombus was present in the portal system and whether TIPS creation was contraindicated. CT findings were confirmed at visceral angiography (n = 3), direct portography (n = 20), or duplex ultrasonography (n = 2).

RESULTS

Ten (40%) of 25 patients, including 10 (56%) of 18 patients with refractory variceal hemorrhage, had thrombus in the portal venous system. Helical CT scans depicted thrombus in nine (90%) of 10 patients (95% confidence interval = 0.71, 1.00) and in 16 (94%) of 17 vessels (95% confidence interval = 0.83, 1.00), including the portal vein (eight of eight patients), splenic vein (three of four patients), and superior mesenteric vein (five of five patients). TIPS creation was canceled in four (16%) patients on the basis of CT findings.

CONCLUSION

Thrombi in the portal venous system are common in patients with refractory variceal hemorrhage. Helical CT angiography is sensitive and specific for portal venous system thrombosis and can provide information that alters treatment in these patients.

Guide wire directed manipulation of malfunctioning peritoneal dialysis catheters: a critical analysis

PURPOSE

To evaluate patency rates after guide wire directed manipulation of malfunctioning continuous ambulatory peritoneal dialysis (CAPD) catheters.

MATERIALS AND METHODS

During a 58-month period, 23 patients underwent 34 outpatient guide wire directed manipulations of their CAPD catheter to improve function (n = 30) or reduce pain and improve function (n = 4) during dialysis. Catheter patency rates were subsequently determined by review of departmental, hospital, and dialysis center charts; procedural reports; and patient telephone interviews.

RESULTS

Among 12 patients who underwent a single guide wire directed manipulation, long-term (> 30 days) catheter patency was achieved in seven (58%). With use of the Kaplan-Meier survival method, the 3-, 6-, and 12-month probability of patency after a single guide wire manipulation was 0.61, 0.54, and 0.11, respectively. The mean duration of patency achieved in this group was 131 days (range, 2-421 days). In those patients (n = 8) who underwent multiple catheter manipulations (n = 19), 11 (58%) procedures resulted in long-term patency, with each patient (100%) achieving at least one such period. The Kaplan-Meier survival method determined the probability of patency in this group at 3, 6, and 12 months to be 0.75, 0.69, and 0.54, respectively. The mean secondary catheter patency was 235 days (range, 2-646 days). Overall, 75% of patients followed up achieved at least one period of long-term catheter patency during the time of this study. One (3%) episode of postprocedure peritonitis occurred.

CONCLUSION

Guide wire directed CAPD catheter manipulation is a relatively simple outpatient procedure that restores long-term catheter function for most patients with minimal risk for a major complication. Patients with nonfunctioning CAPD catheters who do not have peritonitis or sepsis will most likely benefit from at least one attempt at radiologic manipulation of their catheter.

Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management

OBJECTIVE

The authors provide the results of follow-up evaluation after combined surgical and radiologic management of 89 patients with major bile duct injuries during laparoscopic cholecystectomy.

SUMMARY BACKGROUND DATA

The incidence and mechanism of injury of major bile duct injuries during laparoscopic cholecystectomy has been clearly defined. Furthermore, a number of series have described the management of these injuries by surgical, endoscopic, and radiologic techniques with excellent short-term results. Long-term follow-up data, however, are lacking in the management of these injuries.

METHODS

Data were collected prospectively on 89 patients treated at a single institution with major bile duct injuries after laparoscopic cholecystectomy managed between July 1, 1990, and July 1, 1996. Patients referred with injuries underwent early percutaneous transhepatic cholangiography and biliary drainage. Based on the cholangiographic appearance and clinical situation, patients were managed by either percutaneous balloon dilatation or surgical reconstruction with a Roux-en-Y hepaticojejunostomy with transanastomotic stenting. Follow-up was obtained by personal interview during October 1996.

RESULTS

Two patients died without an attempt at definitive therapy. Both deaths were caused by sepsis and multisystem organ failure present at the time of transfer to the authors' institution. The remaining 87 patients were managed initially by either balloon dilatation (N = 28) or surgical reconstruction (N = 59). Ten patients have not completed treatment and still have biliary stents in place. Evaluation of 25 patients completing treatment after balloon dilatation (mean follow-up, 27.8 months) showed a success rate of 64%. Evaluation of 52 patients completing treatment after surgical reconstruction (mean follow-up, 33.4 months) showed a success rate of 92%. All failures were managed successfully by either surgical reconstruction or balloon dilatation.

CONCLUSIONS

Major bile duct injuries can be managed successfully by combined surgical and radiologic techniques. This series provides, for the first time, significant follow-up on a large number of patients with overall success rates of 64% after balloon dilatation and 92% after surgical reconstruction. The combination of surgery and balloon dilatation resulted in a successful outcome in 100% of patients treated.

Volumetric evaluation of blood flow in normal renal arteries with a Doppler flow wire: a feasibility study

PURPOSE

To evaluate the feasibility of direct intravascular determination of renal artery (RA) blood flow with a Doppler probetipped guide wire.

MATERIALS AND METHODS

Potential renal donors (n = 10) with normal RAs (n = 23) underwent evaluation of RA blood flow velocity with use of a 0.018-inch, 12-MHz Doppler guide wire. The RA average peak velocity (APV) was obtained with the flow wire. RA diameter was obtained from the filmed images with magnification corrected to a known standard or by a computerized quantification program. These data were used to determine the vessel's cross-sectional area (CSA).

RESULTS

The right and left RA APV, CSA, and blood flow differed insignificantly within the group and averaged 9.7 and 9.0 cm/sec (P = .43), 0.417 and 0.357 cm2 (P = .22), and 382 and 370 mL/min (P = .43), respectively. However, in individuals, the RA CSA and total volumetric blood flow varied by a mean of 29% (range, 4%-56%) and 50% (range, 19%-128%), respectively.

CONCLUSION

This study demonstrates that direct intravascular determination of RA blood flow with a Doppler-tipped wire is both feasible and relatively uncomplicated. Results indicate that blood flow can vary significantly, both in kidneys within the same individual and from person to person. The Doppler wire may facilitate measurements of RA blood flow during endoluminal interventions and help determine an optimal endpoint for these procedures.

Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster

OBJECTIVE

This study was designed to evaluate the total costs associated with repair of laparoscopic cholecystectomy (LC)-related bile duct injuries.

SUMMARY BACKGROUND DATA

The popularity of LC with both patients and surgeons is such that this procedure now exceeds open cholecystectomy by a ratio of approximately 4 to 10:1. However, costs associated with LC-related injuries, particularly regarding treatment patterns, have up to now not been explored fully.

METHODS

The complete hospital and interventional radiology (IR) billing records for 49 patients who have completed treatment for laparoscopic cholecystectomy-related bile duct injuries were divided into 8 categories. These records were totaled for comparison of costs between patient groups that experienced different injuries and treatment patterns.

RESULTS

Patients with LC-related bile duct injuries were billed a mean of $51,411 for all care related to repair of their bile duct injury. Patients incurred an average of 32 days of inpatient hospitalization and 10 outpatient care days. Postoperative treatment included long-term chronic biliary intubation averaging 378 days. Two patients (4%) died as a result of their LC-related complications. Patients with bile duct injuries that were recognized immediately at the time of the initial surgery ultimately experienced a total cost for their repair and hospitalization of 43% to 83% less than for patients in whom recognition of the injury was delayed (p < 0.019 to 0.070). In addition, the total hospitalization and outpatient care days was reduced by as much as 76% with early recognition of an iatrogenic injury.

CONCLUSIONS

Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.

Intraductal biliary biopsy: comparison of three techniques

PURPOSE

To compare the results obtained with three different techniques for percutaneous transhepatic intraductal biopsy.

MATERIALS AND METHODS

Eighty-eight patients with obstructive jaundice underwent placement of percutaneous biliary drainage catheters for biliary decompression. As part of the initial procedure or at a subsequent date, intraductal biliary biopsy (n = 109) was performed with use of one or more of three techniques including cytologic brush (n = 53), clamshell forceps under choledochoscopic guidance (n = 31), and clamshell forceps under fluoroscopic guidance (n = 25).

RESULTS

Forty-eight patients (55%) had a final diagnosis of malignant disease, and 40 (45%) had a diagnosis of benign disease. One hundred six (97%) biopsy procedures yielded technically adequate specimens. No complications directly related to the biopsy procedures occurred. Overall sensitivity and specificity for each biopsy technique were 26% and 96% for the cytologic brush technique, 30% and 88% for the clamshell forceps under fluoroscopic guidance technique, and 44% and 100% for the clamshell forceps under choledochoscopic guidance technique, respectively. The sensitivities of the biopsy techniques for pancreatic carcinoma and cholangiocarcinoma, respectively, were 47% and 0% for brush; 75% and 0% for fluoroscopic clamshell; and 100% and 27% for choledochoscopic clamshell.

CONCLUSION

The choledochoscope-directed biopsy technique had the greatest sensitivity and specificity of the three techniques evaluated, but this difference was not statistically significant versus the brush or fluoroscopic clamshell technique (P > .10). The sensitivity of all three techniques for pancreatic carcinoma was significantly greater than that for cholangiocarcinoma. Multiple biopsies did not increase the overall sensitivity of intraductal biliary biopsy as a diagnostic technique. All three techniques proved to be safe and easy to perform.

In situ formation of a loop snare for retrieval of a foreign body without a free end

A technique is described that allowed percutaneous retrieval of an endoscopically placed, obstructed biliary stent using loop snare capture of an angled hydrophilic wire which was wrapped around the stent initially.

Pyogenic hepatic abscess. Changing trends over 42 years

OBJECTIVE

The authors document changes in the etiology, diagnosis, bacteriology, treatment, and outcome of patients with pyogenic hepatic abscesses over the past 4 decades.

SUMMARY BACKGROUND DATA

Pyogenic hepatic abscess is a highly lethal problem. Over the past 2 decades, new roentgenographic methods, such as ultrasound, computed tomographic scanning, direct cholangiography, guided aspiration, and percutaneous drainage, have altered both the diagnosis and treatment of these patients. A more aggressive approach to the management of hepatobiliary and pancreatic neoplasms also has resulted in an increased incidence of this problem

METHODS

The records of 233 patients with pyogenic liver abscesses managed over a 42-year period were reviewed. Patients treated from 1952 to 1972 (n = 80) were compared with those seen from 1973 to 1993 (n = 153).

RESULTS

From 1973 to 1993, the incidence increased from 13 to 20 per 100,000 hospital admissions (p < 0.01. Patients managed from 1973 to 1993 were more likely (p < 0.01) to have an underlying malignancy (52% vs. 28%) with most of these (81%) being a hepatobiliary or pancreatic cancer. The 1973 to 1993 patients were more likely (p < 0.05) to be infected with streptococcal (53% vs. 30%) or Pseudomonas (30% vs. 9%) species or to have mixed bacterial and fungal 26% vs. 1%) infections. The recent patients also were more likely (p < 0.05) to be managed by percutaneous abscess drainage (45% vs. 0%). Despite having more underlying problems, overall mortality decreased significantly (p < 0.01) from 65% (in 1952 to 1972 period) to 31% (in 1973 to 1993 period). The reduction was greatest for patients with multiple abscesses (88% vs. 44%; p < 0.05) with either a malignant or a benign biliary etiology (90% vs. 38%; p < 0.05). Mortality was increased (p < 0.02) in patients with mixed bacterial and fungal abscesses (50%). From 1973 to 1993, mortality was lower (p = 0.19) with open surgical as opposed to percutaneous abscess drainage (14% vs. 26%).

CONCLUSIONS

Significant changes have occurred in the etiology, diagnosis, bacteriology, treatment, and outcome patients with pyogenic hepatic abscesses over the past 4 decades. However, mortality remains high, and proper management continues to be a challenge. Appropriate systemic antibiotics and fungal agents as well as adequate surgical, percutaneous, or biliary drainage are required for the best results.

Outcome of tunneled hemodialysis catheters placed by radiologists

PURPOSE

To compare the outcomes of hemodialysis catheters placed by interventional radiologists with those placed by surgeons.

MATERIALS AND METHODS

The outcomes were retrospectively analyzed of 237 hemodialysis catheters placed in 140 patients by a radiology service from January 1991 through December 1992. Follow-up data were available for 222 catheters (94%). Catheter secondary patency and freedom from infection were analyzed statistically and by means of life-table analysis.

RESULTS

Pneumothorax occurred after the placement of six catheters (2.5%); in two patients, a chest tube was required for decompression. Other short-term complications included air embolism with no clinical sequelae (two procedures) and prolonged oozing from the tunnel (two procedures). Long-term complications included infection and catheter failure. Infection occurred in 26 patients (18%) with 32 catheters (14%) and resulted in removal of 25 catheters. Ninety-three catheters (42%) failed, and 63 catheters (28%) were removed because of failure.

CONCLUSION

Hemodialysis catheters placed by radiologists do not have a higher rate of complications or failure than catheters placed by surgeons.

Subcutaneously tethered temporary filter: pathologic effects in swine

PURPOSE

To evaluate the histopathologic effects of the Tempo-filter, a temporary caval filter, on the caval wall and determine the feasibility of deployment and removal of the device in swine.

MATERIALS AND METHODS

Filters were placed in the infrarenal inferior vena cava of 11 swine. The tethering catheter was sutured in a subcutaneous pocket near the puncture site. The original tethering catheter used in humans and a stiffer catheter designed to prevent migration in swine were evaluated. Postplacement, mid-study, and preexplant vena cavography procedures were performed. Four swine underwent in situ dissection at 3-10 weeks. Filters were removed from seven animals just before they were killed at 1-6 weeks.

RESULTS

All filters were successfully placed. All seven filters were successfully removed at up to 6 weeks after placement. Cephalic migration of more than 1 cm was observed in 10 of 11 swine (100% of original catheters, 83% of stiff catheters). Other complications were more common with stiffer tethering catheters, including caval stenosis in 40% of original catheters and 100% of stiff catheters, filter cone thrombus in 0% and 67%, tethering catheter thrombus in 20% and 83%, pulmonary embolism in 0% and 50%, and death in 0% and 17%, respectively. There was mild vessel wall damage in the vena cava.

CONCLUSION

Placement of the Tempofilter and removal at up to 6 weeks after placement is feasible.

Percutaneous jejunostomy replacement in patients who have undergone esophagectomy

PURPOSE

The authors expand their experience with a technique for the percutaneous replacement of a feeding jejunostomy tube in patients who have undergone esophagectomy, in which markers placed during the initial surgical jejunostomy are used.

PATIENTS AND METHODS

During esophagectomy in eight patients, a loop of jejunum was intubated with a surgical jejunostomy tube. This loop was then fixed to the anterior abdominal wall and marked with metal clips. In eight patients who required late nutritional support, the surgically placed metal clips on the fixed jejunal loop were used as fluoroscopic guides to mark the site for percutaneous access into the jejunum. Once access was obtained and verified with use of the Seldinger technique, a feeding jejunostomy tube was placed percutaneously after tract dilation.

RESULTS

Percutaneous replacement of a feeding jejunostomy tube was successful in all eight patients; in one patient, two placement attempts on successive days were required. No immediate complications occurred. Only one replacement jejunostomy tube has required replacement due to leakage around the tube (mean follow-up, 3.1 months).

CONCLUSION

Percutaneous replacement of a feeding jejunostomy tube with use of surgically placed clips as guides for access is a safe and effective method for providing late nutritional support in the postesophagectomy patient.

Percutaneous transluminal atherectomy of the superficial femoral and popliteal arteries: long-term results in 48 patients

PURPOSE

Evaluate retrospectively the long-term primary patency of directional atherectomy (DA) in the femoropopliteal arteries.

MATERIALS AND METHODS

DA was used alone in 59 patients (47%) or in combination with predilatation to allow passage of the device (43%) or after thrombolysis (10%) to treat 127 (93%) excentric atherosclerotic stenoses and nine (7%) occlusions of the femoropopliteal arteries. Forty-eight patients were followed by telephone interview, scheduled outpatient visits, color-flow Doppler evaluation, and angiography for 1-36 months (mean 16.9 months).

RESULTS

Technical success (reduction of the stenosis or occlusion to less than 30% luminal diameter) was achieved in 110 lesions (80.3%) during 48 procedures in 37 patients. Mean luminal diameter was increased 54% with a concomitant increase in mean ankle/brachial indices of 0.33. According to Kaplan-Meier survival curves, patency at 12 and 24 months was 88% and 75%, respectively. When patients who retained patency but developed restenosis were excluded, the probability of patency at 12, 24, and 36 months was 76%, 58%, and 32%, respectively. Major and minor complications occurred in 15 (21.4%) procedures each for a total complication rate of 42.8%.

CONCLUSION

Based on our results, DA is an effective method for percutaneous treatment of atherosclerotic disease involving the femoropopliteal arteries. It has similar patency but a relatively high complication rate compared with PTA.

Biliary manometry versus clinical trial: value as predictors of success after treatment of biliary tract strictures

PURPOSE

To evaluate the biliary manometric-perfusion test (BMPT) and clinical trial as predictors of long-term success after percutaneous and surgical treatment of biliary tract strictures.

PATIENTS AND METHODS

After percutaneous intervention or surgical repair of extrahepatic bile duct strictures, 43 patients underwent long-term biliary intubation (mean, 13 months) with 61 internal-external stents. Before removal of the stents, all 43 patients underwent a BMPT (n = 65) and 24 underwent a 2-3-week clinical trial (n = 27) with stents positioned above the treated region. Patients were followed up 1-46 months (mean, 16 months) after stent removal, with clinical outcome determined by means of physical examination, biochemical evaluation, chart review, and telephone interview.

RESULTS

With logistic regression analysis, the BMPT and clinical trial were shown to have equal predictive value in determining treatment success or failure. Eighty-four percent of the clinical outcomes were correctly predicted with BMPT, versus 88% for the clinical trial. Kaplan-Meier survival curve analysis demonstrated the probability of remaining stricture free at 1 year after passing a BMPT and after passing a clinical trial to be 90% and 86% (P = .55), respectively.

CONCLUSION

BMPT and clinical trial have similar capabilities in the prediction of long-term patency after treatment of benign biliary tract strictures, but the BMPT is less costly and time consuming for the patient.

Thrombosed dialysis access grafts: percutaneous mechanical declotting without urokinase

PURPOSE

To evaluate percutaneous declotting of dialysis access grafts with available catheters without urokinase.

MATERIALS AND METHODS

Thirty-four clotted grafts were treated in 24 patients. Clot was macerated and pushed into the central circulation with balloon catheters.

RESULTS

Successful mechanical declotting was performed in all but two patients (94%). The procedure was abandoned after successful declotting in four patients with poor venous outflow, resulting in a 24-hour success rate of 82%. Mean total procedure time was 116 minutes. Eight grafts clotted within 1 week. Using successful dialysis beyond 1 week as the measure of clinical success, the authors report a 59% clinical success rate with mean primary patency of 126 days (range, 16-322 days). Two complications, both emboli to the brachial artery, were successfully treated with urokinase. No symptomatic pulmonary emboli occurred.

CONCLUSION

Mechanical thrombolysis of clotted grafts with currently available catheters yields results similar to those reported with mechanical devices and urokinase. The procedure is relatively inexpensive, safe, and well tolerated.

Intrahepatic stones. The transhepatic team approach

OBJECTIVE

The authors reviewed the combined interventional radiologic and surgical management of 54 patients with intrahepatic stones at the Johns Hopkins Hospital. The team approach used large-bore transhepatic stents to access the intrahepatic ducts until they were stone free.

SUMMARY BACKGROUND DATA

Intrahepatic stones are uncommon in western countries. As a result, few American institutions have had much experience, and multiple management algorithms have been suggested. Nonoperative, operative, and combination surgical and nonoperative approaches have been advocated. At Johns Hopkins, combined surgical and percutaneous management has been used for 18 years.

METHODS

This team approach includes (1) percutaneous placement of transhepatic access catheters, (2) surgery for underlying biliary disease and stone removal, and, when necessary (3) postoperative percutaneous choledochoscopy and stone removal through the transhepatic stents.

RESULTS

The median age of the 54 patients was 50 years, and 32 were men. Biliary disease included 27 benign strictures, 7 sclerosing cholangitis, 5 choledochal cysts, 5 parasitic infections, 5 choledocholithiasis, and 5 biliary tumors. Fourteen patients (26%) were treated exclusively with percutaneous techniques. Forty patients (74%) had surgery, including 36 Roux-en-Y hepatico- or choledochojejunostomies with large-bore transhepatic stents. Eighteen of these 40 patients (45%) with multiple intrahepatic stones, strictures, or both required additional procedures after operation. No hospital deaths occurred after any of the percutaneous or surgical procedures. With a mean follow-up of 60 months, 94% of patients were stone free, 87% of patients were symptom free, and 73% have had their transhepatic stents removed.

CONCLUSIONS

A combined radiologic and surgical approach with transhepatic stents is a safe and effective method for managing intrahepatic stones.

Repeat dilation of Palmaz stents in pulmonary arteries: study of safety and effectiveness in a growing animal model

PURPOSE

This study assessed the technical feasibility and safety of repeat dilation of Palmaz stents in growing pulmonary arteries.

MATERIALS AND METHODS

Palmaz stents (1.2 cm long) were placed percutaneously into the pulmonary arteries of 20 newborn lambs. After 4 months, pulmonary arteriography was performed. Where vessel growth in excess of stent diameter had created a stenosis (> 15%), stents were dilated again percutaneously. Six months later, pulmonary arteriography was performed, before the animal was killed and histologic examination performed.

RESULTS

Twenty-four pulmonary artery stent placements were attempted; 23 were successful. One stent placement was unsuccessful owing to stent displacement from the balloon. Acute complications included branch pulmonary artery occlusion (n = 3) and stent displacement from the delivery balloon (n = 2). At 4 months, the desired degree of stenosis (> 15%) was achieved in 11 animals. The average stenosis was 35% (standard deviation, 16%; range, 17%-66%). The mean predilation stent diameter was 6 mm +/- 1.1 (range, 4-8 mm), and the final diameter of 8 mm +/- 1.4 (range, 6-10 mm), represented a 35% mean increase (P < .001). Complications included stent (n = 1) and branch vessel (n = 1) thrombosis. At 6-month follow-up, all stents were patent. Areas of previously noted branch thrombosis were fully recanalized in all cases. At histologic inspection, only a thin layer of neointima was found on the stents.

CONCLUSION

Repeat dilation of Palmaz stents may be safely performed in growing pulmonary arteries in an animal model. Neointimal hyperplasia is minimal in pulmonary artery stents.

Percutaneous varicocele occlusion: long-term follow-up

PURPOSE

The authors summarize their 11-year experience with percutaneous varicocele occlusion at the Johns Hopkins Hospital.

PATIENTS AND METHODS

Data were obtained from the patients' medical records and from a mailed questionnaire. Most of the data analysis is based on the 182 patients who responded to the questionnaire.

RESULTS

Most of the occlusions were performed for infertility. The mean length of time couples had been attempting to conceive was approximately 44 months. Occlusion was technically successful in 95.7% of cases. Patients were followed up for a mean period of 59 months. Success is difficult to define because many patients and/or their wives received additional infertility treatment. Fifty-seven percent of all couples and 60% of a subgroup of couples who received no other treatment eventually conceived.

CONCLUSION

Percutaneous occlusion is a well-established treatment for varicoceles. Pregnancy rates and recurrence rates are comparable to those following surgical varicocelectomy. It is unlikely that resultant pregnancies occur from random chance alone.

Palmaz stent in the treatment of central venous stenosis: safety and efficacy of redilation

PURPOSE

To assess the safety and efficacy of redilation of central venous stents in a growing animal model.

MATERIALS AND METHODS

Palmaz stents were placed in the inferior vena cava (IVC) in 18 newborn lambs. After 5 months, vena cavography was performed. Those animals in which growth of the IVC adjacent to the stent and/or neointimal hyperplasia had resulted in a stenosis were considered candidates for redilation. Repeat vena cavography, intravascular ultrasound, and histologic examination were performed at 2 or 6 months.

RESULTS

A stenosis of > 20% was demonstrated in 13 animals. Redilation was performed, and a 50% mean increase in stent diameter was achieved. There were no immediate complications. Late complications included nonocclusive laminar clot (n = 2), and a bar of tissue dividing but not occluding the caval lumen (n = 1). Moderate neointimal hyperplasia occurred in all stents. Stent compression (unrelated to redilation) occurred in seven animals.

CONCLUSION

Palmaz stents can be redilated safely and effectively in an animal model of growing central veins.

Percutaneous embolotherapy of adolescent varicocele: results and long-term follow-up

PURPOSE

The authors evaluated the technical success and immediate and long-term results of percutaneous varicocele embolotherapy in the adolescent population.

PATIENTS AND METHODS

Fifty-nine adolescent patients were referred for outpatient spermatic venography and possible varicocele embolotherapy. Embolization was attempted with use of detachable balloons, coils, "sandwiched" dextrose, or a combination of these techniques. Data regarding follow-up were obtained through telephone interviews or mailed questionnaires.

RESULTS

The technical success rate for spermatic vein occlusion was 90%. Follow-up, obtained in 79% of the patients, ranged from 6 months to 8.75 years (mean, 4 years). Thirty-nine of 42 patients (93%) reported disappearance (n = 31) or only a slight, asymptomatic residual varicocele (n = 8). Three patients reported a recurrence of their varicocele. Complications occurred in three of 59 cases (5%), none had any long-term sequelae. In six cases, embolization was not feasible because of multiple collateral vessels or venous spasm.

CONCLUSIONS

Given the convenience of performing the procedure on an outpatient basis, the rapid recovery time, and long-term success and complication rates comparable to those with surgical ligation, we believe spermatic venography and percutaneous embolization is the treatment modality of choice for adolescent varicocele.

Preoperative localization of occult medullary carcinoma of the thyroid gland with single-photon emission tomography dimercaptosuccinic acid

BACKGROUND

Patients who undergo thyroidectomy for medullary carcinoma of the thyroid gland (MTC) often have elevations of postoperative serum calcitonin levels, which are indicative of metastatic or residual disease. It has been extremely difficult to localize tumor in these patients with standard diagnostic studies such as ultrasonography, computed tomography, or magnetic resonance imaging scans. Previous studies have suggested that planar technetium 99m (V) dimercaptosuccinic acid (DMSA) scintigraphic scans can localize MTC in these patients. We have recently increased the sensitivity of planar scintigraphic images by using single-photon emission tomography (SPECT). This study was performed to compare the sensitivity of planar DMSA scans with that of SPECT DMSA scans.

METHODS

Two normal volunteers and three patients with occult MTC after previous total thyroidectomy underwent planar and SPECT DMSA scans. Each patient subsequently underwent surgical exploration based on the DMSA scans.

RESULTS

Physiologic DMSA uptake was noted in the nasopharynx, axial skeleton, breast, liver, spleen, heart, kidneys, urinary bladder, great vessels, and skeletal muscles in both normal volunteers and patients with occult MTC. Planar DMSA scans and dynamic computed tomographic scans failed to localize MTC in any of these patients who had minimal disease. SPECT DMSA scans correctly localized cervical MTC in two of three patients, as proved by subsequent surgical resection. One patient who had a negative cervical exploration is presumed to have had a false-positive SPECT DMSA scan.

CONCLUSIONS

SPECT DMSA scans appear to be a sensitive, safe, and noninvasive localization technique for patients with occult MTC who have undergone previous thyroidectomy.

Preoperative spinal artery localization and its relationship to postoperative neurologic complications

PURPOSE

To evaluate the risk of spinal cord revascularization and ascertain the relationship between preoperative spinal arteriography and the frequency of postoperative neurologic injury and overall morbidity and mortality in patients who require surgical repair of thoracoabdominal aortic aneurysms.

MATERIALS AND METHODS

Fifty patients scheduled for surgical repair of a thoracoabdominal aortic aneurysm underwent spinal arteriography. All patients were divided into a positive spinal artery group (in which the spinal artery was identified) or negative spinal artery group (in which the spinal artery was not identified) and further divided based on extent of disease.

RESULTS

The complication rate of spinal arteriography was 4.6%; no patient had a permanent neurologic injury. No significant difference existed between the positive and negative spinal artery groups in occurrence of neurologic injury (P = .88) or combined morbidity and mortality (P = 51).

CONCLUSION

Patients who require spinal cord revascularization do not have greater frequency of neurologic injury or overall morbidity and mortality than those without this requirement. Spinal arteriography enables definitive spinal cord revascularization and thereby reduces the risk of neurologic injury.

Complications of interventional radiology: an imaging overview

The growth of interventional radiology has contributed to the development of more complex procedures applicable to an increasing patient population, with maintenance of low complication rates. However, due to its invasive nature, potential complications will always be associated with each procedure. Prompt recognition of these complications allows for rapid treatment with decreased patient morbidity and mortality. This overview provides detailed statistics and diagnostic imaging for evaluation of a wide spectrum of complications from hepatobiliary, renal, and vascular interventional procedures.

US-guided pseudoaneurysm repair with a compression device

A simple commercially available compression device allowed intermittent ultrasound scanning of the compression site during compression repair of a femoral artery pseudoaneurysm in six patients. All six of the pseudoaneurysms (five superficial femoral and one common femoral) were compressed without compression of the underlying vessels. The procedure was successful in four of the six patients, without complications. Use of this device may decrease operator fatigue during compression repair of pseudoaneurysm.

Percutaneous removal of "dropped" gallstones after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is becoming increasingly popular in the treatment of symptomatic gallstones, offering improved patient satisfaction and decreased hospital stays. The authors describe a patient in whom infected bile and gallstones were spilled or "dropped" during laparoscopic cholecystectomy. Most of the gallstones ranged from 5 to 8 mm in diameter; one gallstone was 11 x 17 mm. An abscess formed around the stones, and percutaneous stone removal was performed 1 week after abscess drainage. The size of the retained gallstones is important. Stones smaller than 1 cm in diameter can usually be removed via a 30-F sheath by conventional means, whereas stones larger than 1 cm in diameter require fragmentation before removal.

Randomized double-blind clinical trial of celiac plexus block for percutaneous biliary drainage

PURPOSE

This study was undertaken to determine the efficacy of celiac plexus block (CPB) as a method of providing analgesia for percutaneous biliary drainage (PBD).

PATIENTS AND METHODS

Thirty-two patients scheduled to undergo PBD were prospectively assigned randomly into placebo (30 mL of normal saline) and treatment (30 mL of 0.25% bupivacaine) CPB groups. Each patient received .03 mg/kg of midazolam for premedication before PBD and had access to a patient-controlled analgesia pump during the procedure. The pump was set to deliver 0.2 mg of midazolam and 25 micrograms of fentanyl per dose with a 3-minute lockout time. Vital signs, including heart rate and blood pressure, were continuously monitored during the procedure and recorded for comparison with baseline values. Patients completed a 10-point visual analogue pain scale following completion of their procedure.

RESULTS

Patients in the placebo and treatment groups self-administered a mean of 2.0 and 1.85 mg of midazolam, respectively (P = .40), and a mean of 247 and 231 micrograms of fentanyl, respectively (P = .40). On a 10-point pain scale, the mean postprocedure versus preprocedure elevation in pain was 2.1 points in the placebo group versus 1.6 points in the treatment group (P = .60). Overall, the degree of satisfaction with the analgesia was equal in both groups.

CONCLUSION

This study indicates that CPB is not an effective means of providing additional visceral pain relief over and above that which can be accomplished with self-administered intravenous medication for patients who undergo PBD.

Giant pseudoaneurysm of the hepatic artery--CT demonstration. Case report

Noninvasive imaging studies, particularly computed tomography (CT), are the first step in evaluation of patients with suspected hepatic trauma. Iatrogenic injury, accounting for up to one-third of cases, may commonly result in hepatic artery pseudoaneurysm formation. We present a case in which a giant hepatic artery pseudoaneurysm was misinterpreted as an intrahepatic hematoma on sequential CT scans due to the failure to employ dynamic contrast-enhanced scan techniques.

Ultrasound guided ablation of pseudoaneurysm following coronary artery stent placement: a preliminary report

A femoral artery pseudoaneurysm in a 47 year old woman following coronary artery stent placement was treated with color-flow duplex ultrasound guided compression. This technique may be useful following stent placement because of the requirement for continued anticoagulation post-procedure.

Biliary tract complications following laparoscopic cholecystectomy: imaging and intervention

Radiologic studies and interventional procedures were performed in a series of 13 patients with biliary complications following laparoscopic cholecystectomy, and the results were evaluated. Two categories of ductal complication--minor and major--were found. Minor complications (n = 6) included bile leaks and bilomas; these were managed with percutaneous techniques or simple surgical repair. Major complications (n = 8), consisting primarily of common hepatic duct injuries or strictures, were markedly resistant to percutaneous therapy, requiring major surgical repair (hepaticojejunostomy). Percutaneous treatment of recurrent strictures after primary repair was undertaken in three patients. Diagnostically, radionuclide imaging appeared most helpful in screening for biliary complications of laparoscopic cholecystectomy, supplemented by endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography for definitive diagnosis.

Hemobilia after percutaneous transhepatic biliary drainage: treatment with transcatheter embolotherapy

Thirteen of 333 patients who underwent percutaneous biliary drainage (PBD) developed severe hemobilia. Hepatic arteriography successfully demonstrated the source of hemorrhage in all 13 patients. Lesions included hepatic artery pseudoaneurysm in nine, hepatic artery-bile duct fistulas in four, and a hepatic artery-portal vein fistula in one patient. Hemobilia occurred from 1 day to 1.8 years (mean, 100 days) following catheter placement. Embolization agents used included Hilal embolization microcoils, occluding spring emboli, cyanoacrylate, detachable balloons, and gelatin sponge pledgets. A single agent was used in eight cases (62%), multiple agents were used in four cases (31%), and in one case (7%), spontaneous thrombosis of the pseudoaneurysm occurred during catheter manipulation. In five patients, the source of the hemorrhage could only be demonstrated following removal of the biliary catheter(s) over guide wire(s). Initial embolization was successful in stopping hemobilia in 12 patients. One patient required repeat embolization after 4 months. Postembolization complications included hepatic abscess formation in two patients and a sterile hepatic infarct in one patient. This series indicates that transcatheter embolotherapy is an effective method for the treatment for severe hemobilia.

Percutaneous replacement jejunostomy

After esophagectomy in which a surgical jejunostomy is performed, there is a small group of patients whose jejunostomy tube has been removed who require late postoperative nutritional support. For these patients, a percutaneous replacement jejunostomy technique is described that is simple and safe and that allows for enteral alimentation.

Percutaneous intervention in portosystemic shunts in Budd-Chiari syndrome

Budd-Chiari syndrome is a rare, often fatal illness resulting from hepatic venous outflow obstruction. Surgically created portosystemic shunts are frequently necessary in these patients for portal decompression. Over the past 15 years, 30 patients have been surgically treated for this condition at the Johns Hopkins Hospital. Of the 22 long-term survivors (range, 6 months to 13 years), five (23%) have required further surgical intervention and five (23%) have required percutaneous intervention for shunt complications. Percutaneous procedures included angioplasty (n = 10), atherectomy (n = 1), and urokinase therapy (n = 1). Of the five patients treated percutaneously, one has died of complications from her disease. The remaining four have been followed up for a mean of 16.2 months (range, 5-31 months) and all are in stable condition. None of the five treated with percutaneous interventional procedures have required additional surgical procedures or shunt revisions. Although this series is small, the findings indicate that percutaneous intervention may play a strong adjunctive role to surgery in the treatment of selected patients with portosystemic shunt complications.

Use of a guard wire during transjugular liver biopsy with the Colapinto needle. Technical note

The authors describe a simple modification of the Colapinto transjugular biopsy needle in which a 0.045-inch stainless steel guide wire is used. The technique allows easier and safer passage of the needle through the introducer sheath to avoid complications such as sheath puncture and expedite the procedure. The technique and successful results in seven patients are described.

Endoscopy as an adjuvant to biliary radiologic intervention

Twenty-two patients underwent 24 percutaneous biliary procedures guided with choledochoscopy, an adjunctive percutaneous biliary technique. All but four procedures were performed through established percutaneous tracts; the others, through tracts less than 4 weeks old. The procedures were done for the following reasons: removal of calculi (n = 15), electrohydraulic lithotripsy (n = 1), biliary duct biopsies (n = 8), cauterization of a bleeding tract (n = 1), and evaluation of biliary-enteric anastomoses (n = 11). The only complication was one case of severe nausea after choledochoscopy. This patient required overnight hospitalization and medical treatment. All procedures were technically successful, except one case in which the tract was undersized. All patients received intravenously administered antibiotics before and after the procedure. It is concluded that choledochoscopy is a safe, atraumatic, and well-tolerated method of evaluating and treating biliary disease and that it markedly reduces radiation exposure. It can be performed rapidly with minimal sedation on an in- or outpatient basis.

Choledochal cysts: role of noninvasive imaging, percutaneous transhepatic cholangiography, and percutaneous biliary drainage in diagnosis and treatment

Choledochal cysts are an uncommon anomaly of the biliary system; findings include cystic dilatation of the extrahepatic biliary tree, intrahepatic biliary tree, or both. In the past 7 years, 13 patients with choledochal cysts have been seen at the authors' institution for evaluation and presurgical intervention. Percutaneous transhepatic cholangiography (PTC) was performed in 13 patients. Sixteen percutaneous biliary drainage (PBD) procedures were performed in 11 patients, computed tomography was performed in six patients, and ultrasound was performed in two. PTC proved to be an important imaging modality because of its superior ability to define the cyst anatomy, site of biliary origin of the cyst, and extent and detail of both extrahepatic and intrahepatic disease, that is, intraductal strictures and calculi. PBD proved valuable in preoperative intervention, as an aid in surgical reconstruction, and in postoperative care. The role of these two modalities in the diagnosis and treatment of patients with choledochal cysts, in addition to clinical aspects of the disease, is discussed.

Pancreatic response to percutaneous biliary drainage: a prospective study

To evaluate the effects of percutaneous biliary drainage (PBD) on the pancreas, serum amylase levels were measured for 7 consecutive days after PBD and compared with baseline values in 50 patients who underwent a total of 53 PBD procedures. Of the 45 patients with normal baseline serum amylase levels, 12 patients (24%) developed postprocedural hyperamylasemia without clinical symptoms and five patients (10%) developed postprocedural hyperamylasemia with clinical signs of pancreatitis. Five patients who presented with elevated baseline serum amylase levels demonstrated decreases into the normal range after placement of stents without initiation of bowel rest or liquid diet. The level of biliary obstruction proved insignificant, as did the nature of the obstructing disease, in determining which patients would experience hyperamylasemia or pancreatitis after PBD. It is concluded that the frequency of pancreatic insult from PBD may be more common than previously reported and that patient susceptibility is not dependent on the level of biliary obstruction or the nature of the disease.

Choledochal cysts: classification and cholangiographic appearance

A classification scheme for choledochal cysts is outlined and their appearance on cholangiograms is illustrated. Choledochal cysts are uncommon anomalies of the biliary system and are probably congenital in origin. They are manifested by cystic dilatation of the extra- or intrahepatic biliary tree or both. The classification system described here divides choledochal cysts into one of five main types. The most common, which is manifested by cystic or focal segmental dilatation of the common bile duct or fusiform choledochal dilatation, accounts for 80-90% of cases.

Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia

Forty-seven patients underwent selective catheterization of middle and lower thoracic intercostal and upper lumbar arteries to define the origin of the artery of Adamkiewicz. One patient had significant atheroembolism, and a second had transient lower extremity paresthesias. No other complications occurred. The origin was found in 26 (55%), and 21 patients underwent thoracoabdominal aneurysm repair with this knowledge. When the critical lumbar or intercostal artery could be included as part of a long proximal or distal anastomosis, all 12 patients could be included as part of a long proximal or distal anastomosis, all 12 patients survived, and one was paralyzed. However, if the aneurysm repair mandated a midgraft anastomosis to intercostal arteries critical to spinal cord perfusion, seven of nine patients either died or were paralyzed (p less than 0.05). In the group of 19 patients operated on in whom spinal cord blood supply was not identified three patients had a technically unsuccessful operation; two died, and one was paralyzed. Twelve of 16 patients who had an adequate, but unsuccessful attempt at localization were treated by intercostal "neglect" and survived. Late paresis developed in two patients, but they are walking now. One of the patients who died had multiple systems failure and awakened paraplegic. She had a patent, enlarged, thoracic radicular artery at T-5 which probably supplied to spinal cord and which was missed angiographically. Paralysis was associated with aneurysm extent (group 2 and III B, dissections vs group 1 & 3, p less than 0.05). Selective intercostal angiography requires further refinement, but it is safe and offers the promise of understanding the mechanisms and risks of spinal cord complications after repair of extensive thoracoabdominal aneurysms.

Balloon dilatation versus surgical revision of infra-inguinal autogenous vein graft stenoses: long-term follow-up

Although infra-inguinal autogenous vein graft stenoses may be treated by balloon dilatation (PTA) or surgical revision, the optimal approach is undefined. Over the last 7 years 24 PTA procedures were performed on 37 vein graft stenoses in 19 grafts. Graft stenoses were diagnosed from 2 to 72 (mean = 17.3) months after implantation. PTA was successfully completed in 23 (96%) of the 24 procedures including 18 (95%) of the primary, and 5 (100%) of the secondary procedures. Recurrent vein graft stenosis or graft thrombosis developed in 12 (67%) grafts from 3 to 47 (mean = 12.5) months after primary PTA. Long-term patency after primary PTA was 69% at 6, 29% at 12, and 22% at 36 months; secondary patency was 81% at 6, 45% at 12, and 27% at 36 months. During the same period vein graft stenosis in 7 fem-pop and 2 fem-tib grafts were surgically revised with an initial success rate of 100%, and 2 (22%) complications. Four (44%) of these grafts occluded from 1-17 (mean 6.2) months after repair, yielding a primary 5-year patency of 62%. Although vein graft stenosis may be safely, effectively, and repeatedly treated with PTA, long-term durability appears to be superior after surgical revision.

Fibrinolytic therapy for upper-extremity arterial occlusions

Acute upper-extremity arterial occlusion may be due to embolic phenomena or de novo thrombosis. If the occlusion is left untreated, claudication or ischemia necessitating amputation can occur. Operative Fogarty-balloon embolectomy has been the treatment of choice for this entity. In a 6-year period the authors used fibrinolysis on nine occasions in eight patients to treat acute upper-extremity arterial occlusions. Concomitant balloon angioplasty was helpful in four cases. Success, defined as a normal hand with at least one artery that was continuously patent to the wrist, was achieved in all patients. A single significant groin hematoma was seen. Neither stroke nor death occurred in any case, and no amputations were necessary. Local transcatheter intraarterial administration of urokinase can be considered a first-line treatment for brachial artery embolus and other causes of acute upper-extremity arterial occlusion.

Immediate post-operative urokinase infusion: extending the limits of limb salvage surgery

We report the case of a 74-year-old woman with multi-level arterial occlusive disease and severe ischemia of the right lower extremity who underwent a re-operative femoro-femoral and a right femoro-popliteal bypass graft. Her right foot remained non-viable post-operatively despite patent grafts. She then underwent a 12-hour infusion of urokinase through a percutaneously placed popliteal artery catheter during that first post-operative day, with salvage of the right leg.

Percutaneous laser probe femoropopliteal angioplasty: a preliminary experience

Percutaneous laser probe "hot tip" angioplasty procedures were performed on 47 occluded femoropopliteal artery segments in 27 men and 10 women ranging in age from 31 to 92 (mean, 64.7) years. Indications for the procedure included claudication in 29 (78%) segments, and the occlusion lased was greater than 7 cm in length in 51% of the procedures. Failure to recanalize the occlusion occurred in 14 (30%) segments, and recanalization followed by in-hospital reocclusion occurred in seven (15%) segments, yielding an initial failure rate of 45%. Initial failures were noted in 40% of the less than 3 cm occlusions, 33% of the 4 to 7 cm occlusions, and 54% of the greater than 7 cm occlusions. In nine (43%) instances in these 21 failures there was extension of the occluded segment or decline of the ankle/brachial index or both, precipitating the need for surgery in three (18%) of these 17 patients. Among the successfully treated group, 17 (65%) of these vessels in 15 patients reoccluded from 1 to 14 (mean, 3 1/2) months after the procedure. Cumulative patency among the successfully lased vessels was 69% at 1-month, 38% at 6 months', 29% at 12 months', and 14% at 15 months' follow-up. Fifteen-month patency was 7% of the entire series of 47 vessels treated. Eighteen complications occurred after 15 (32%) of these 47 procedures. Based on these results, the widespread application of laser probe angioplasty cannot be justified without further clinical and laboratory investigation.