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Cardiovasc Intervent Radiol

The optimal dose of nicardipine for enhancement of indirect portography.

Inoue Y. Nakamura H. Akaji H.
Department of Radiology, Minoo City Hospital, 5-7-1 Kayano, Minoo, Osaka 562, Japan.
PURPOSE: To determine the optimal dose of nicardipine (NCR) for enhancement of indirect portography. METHODS: Forty-eight patients underwent conventional film indirect portography via the superior mesenteric artery (SMA) first without and then with preinjection of 1/64-2 mg of NCR into the SMA. RESULTS: NCR (1/8-2 mg) shortened the arterial phase to 50% and the portal appearance time to 60% of control without reflux of contrast medium into the aorta. Portal enhancement was excellent at doses of 1/32 mg or more. Blood pressures and pulse rate showed no significant change at 1/4 mg or less. CONCLUSION: NCR (1/8-1/4 mg) into the SMA is the optimal dose for achieving sufficient contrast enhancement on indirect portography while reducing the transit time of contrast medium and minimizing effects on the systemic circulation.

Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study.

Sonomura T. Sato M. Kishi K. Terada M. Shioyama Y. Kimura M. Suzuki K. Kutsukake Y. Ushimi T. Tanaka J. Hayashi S. Tanaka S.
Department of Radiology, Wakayama Medical College, 27 Banchi, 7 Bancho, Wakayama City 640, Japan.
PURPOSE: To evaluate the clinical feasibility of balloon-occluded retrograde transvenous obliteration (BORTO) for gastric varices. METHODS: BORTO was performed in 14 patients with gastric varices due to liver cirrhosis. The gastric varices were confirmed by endoscopy, and their feeding and draining veins were identified by contrast-enhanced computed tomography (CT) and angiography. A 6 Fr Simmons-shaped balloon catheter was inserted into the gastrorenal shunt. The balloon was inflated, and 5% ethanolamine oleate iopamidol was infused slowly through the catheter. Patients were followed up with endoscopy and enhanced CT at 1 week, 1, 3, and 6 months after the procedure and every 6 months thereafter. RESULTS: The gastric varices completely disappeared in 12 of 14 patients and was partially resolved in the remaining 2 patients. Neither a recurrence nor an aggravation of gastric varices were found. No major complications were experienced. CONCLUSION: BORTO is a safe and effective treatment for gastric varices.

Gastrointestinal hemorrhage due to duodenal erosion by a biliary wallstent.

Roebuck DJ. Stanley P. Katz MD. Parry RL. Haight MA.
Department of Radiology, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
A self-expanding metallic stent (Wallstent) was used to relieve obstruction of the common bile duct in a young male with a desmoplastic small cell tumor of the abdomen. Two months after insertion and following a course of chemotherapy the lower end of the stent eroded the mucosa of the second part of the duodenum causing severe gastrointestinal hemorrhage which necessitated laparotomy and trimming of the stent. This complication may have been due to shrinking of the tumor as well as thrombocytopenia following chemotherapy.

Transjugular core liver biopsy with a 19-gauge spring-loaded cutting needle.

Choh J. Dolmatch B. Safadi R. Long P. Geisinger M. Lammert G. Dempsey J.
Department of Radiology, Desk Hb6, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
One hundred and five sequential transjugular core liver biopsies (TJLBx) were performed in 101 patients with coagulopathy and/or ascites using the 19-gauge Quick-Core Biopsy (QCB) needle. Two-hundred and seventy-three cores were obtained in 295 passes (92. 5%). One-hundred and two of the 105 procedures (97.1%) led to a histopathologic diagnosis. One of the three nondiagnostic biopsies was done because of severe autolysis of the liver. There was one subcapsular hematoma, one hepatic arteriovenous fistula, and one liver capsular puncture. Two minor neck hematomas occurred. One death was reported (unrelated to the procedure). QCB needle TJLBx is an effective and relatively safe way to obtain core liver samples.

Treatment of TIPS stenosis with ePTFE graft-covered stents.

Year 1998
DiSalle RS. Dolmatch BL.
Department of Radiology, Desk Hb6, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
Midshunt stenosis and recurrent variceal bleeding occurred in 2 patients after transjugular intrahepatic portosystemic shunts (TIPS). Repeat angioplasty was performed in both cases but recurrent stenosis again led to hemorrhage. Expanded polytetrafluoroethylene (ePTFE) graft-covered stents were expanded in each of the TIPS at the midshunt, reducing the portosystemic gradient for both patients. Variceal bleeding ceased, and follow-up studies showed no evidence of recurrent stenosis in either case.

Maturation of the tract after percutaneous cholecystostomy with regard to the access route.

Year 1998
Hatjidakis AA. Karampekios S. Prassopoulos P. Xynos E. Raissaki M. Vasilakis SI. Gourtsoyiannis NC.
Department of Radiology, Hospital Heraklion, Medical School of Crete, Crete, Greece.
PURPOSE: To assess the shortest time for catheter removal with regard to the transhepatic or transperitoneal approach in patients undergoing percutaneous cholecystostomy (PC). METHODS: In this prospective study, 40 consecutive high-risk patients with acute cholecystitis (calculous, n = 22; acalculous, n = 18) underwent PC by means of a transhepatic (n = 20) or transperitoneal (n = 20) access route. In 28 patients (70%) computed tomography was used for puncture guidance, while in the remaining 12 (30%) the procedures were formed under ultrasound control. A fistulography was performed on the 14th postprocedural day in al patients and was repeated weekly if the tract was found to be immature. The catheter was removed only if a mature tract without evidence of leakage was delineated. RESULTS: In 36 of 40 patients the procedure was technically successful (90%). Three of the unsuccessful punctures were attempted transperitoneally and one transhepatically. Thirty-five of 36 patients showed rapid improvement within the first 48 hr following the procedure (96%). Three of them died of their severe underlying disease (7.5%) and in another three the catheter was accidentally removed prior to the first fistulography (7.5%) A total of 30 patients could be fully evaluated after the procedure: 15 with a transhepatic, and 15 with a transperitoneal PC. Whereas 14 of 15 patients (93%) with transhepatic gallbladder access developed a mature tract after 14 days and the remaining patient after 3 weeks, only 2 of 15 patients (13%) with a transperitoneal route presented a mature tract after 2 weeks (p < 0.0001; chi2 test with Yates' correction). Eleven patients (73%) with transperitoneal access required 3 weeks and two patients (13%) 4 weeks for complete tract formation. CONCLUSION: A period of 2 weeks suffices for the majority of patients to develop a mature tract when the transhepatic access route is used; when using the transperitoneal route at least 3 weeks are required. We suggest that the transhepatic route is preferable since it allows earlier removal of the catheter and reduces the incidence of complications and discomfort for the patients.

Arterial hepatic embolization of unresectable hepatocellular carcinoma using a cyanoacrylate/lipiodol mixture.

Year 1998
Berghammer P. Pfeffel F. Winkelbauer F. Wiltschke C. Schenk T. Lammer J. Muller C. Zielinski C.
Department of Internal Medicine I, University of Vienna Medical School, Austria.
PURPOSE: A survival analysis in 16 patients with unresectable hepatocellular carcinoma (HCC) undergoing transcatheter arterial embolization (TAE) using a combination of lipiodol and N-butyl-2-cyanoacrylate (5:1) was performed in a retrospective study. METHODS: A combination of lipiodol and N-butyl-2-cyanoacrylate (5:1) was used for TAE. All patients had disease compatible with Okuda stages I and II. RESULTS: Twenty-four embolizations were done; five patients had more than one embolization. Median alpha-fetoprotein levels declined from 116 to 48.6 ng/ml. A median of 0.3 ml cyanoacrylate was administered per patient. Median survival was 8.5 months (range 2-49 months). After a median follow-up of 4 years, 12 patients have died (75%). Okuda stage I and II patients had a median survival time of 34.4 and 5.5 months respectively. Few side effects (19%) were seen. CONCLUSION: We conclude that the TAE procedure used [lipiodol and N-butyl-2-cyanoacrylate (5:1)] is safe and produced only few side effects, thus constituting a valuable therapeutic option for patients with Okuda stage I and II HCC.

Patency and reintervention rates during routine TIPSS surveillance.

Year 1998
Latimer J. Bawa SM. Rees CJ. Hudson M. Rose JD.
Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK.
PURPOSE: To assess the medium-term outcome of transjugular intrahepatic portosystemic stent shunts (TIPSS) by measuring the incidence of shunt obstruction or failure during routine surveillance and the number of interventions performed. METHODS: This is a retrospective study covering a 4-year period, from 1992 to 1996, during which 102 TIPSS procedures were performed. Indications for treatment were variceal bleeding (76%) and refractory ascites (24%). Follow-up protocol after TIPSS included transfemoral or transjugular portal venography and measurement of portosystemic pressure gradient (PPG) at 3 months, 12 months, and then at yearly intervals. The results of the first 155 venograms on 62 patients (mean follow-up 14 months) have been reviewed and Kaplan-Meier analysis performed. RESULTS: One hundred and thirty-seven of 155 (88%) examinations showed patent shunts. Fifty-six of 137 (41%) of the patent TIPSS had elevated PPG with signs of stenosis. The majority (41/56) of shunt stenoses with elevated pressure gradients were related to neointimal hyperplasia in the hepatic venous aspect of the shunt. Interventions used to reduce the pressure gradient or to restore patency included: angioplasty (62/102 interventions), additional stents (21/102), a second TIPSS procedure (2/102), and thrombolysis or thrombectomy (4/102). The primary patency rate was 66% at 1 year (52% at 2 years). Primary assisted patency was 72% at 1 year (58% at 2 years). Secondary patency was 86% at 1 year (63% at 2 years). CONCLUSION: The majority of TIPSS shunts will remain patent when regular portal venography, with appropriate intervention, is undertaken. Although there is a high reintervention rate this mainly takes the form of balloon angioplasty.

Cholecystoduodenal fistula: a complication of inserted self-expandable metallic biliary stents.

Year 1998
Nishida H. Inoue H. Ueno K. Nagata Y. Kato T. Miyazono N. Nakajo M.
Department of Radiology, Faculty of Medicine, Kagoshima University, Japan.
We encountered a case of hepatic hilar cholangiocarcinoma resulting in cholecystoduodenal fistula after insertion of self-expandable metallic biliary stents (EMBSs). To our knowledge, there has been no report of cholecystoduodenal fistula after insertion of EMBSs. This case suggests that immediate gallbladder decompression may be necessary if acute cholecystitis occurs after insertion of EMBSs.

A triple coaxial catheter system for subselective visceral artery catheterization and embolization: preliminary clinical experience.

Year 1998
Kaminou T. Nakamura K. Matsuo R. Hayashi S. Matsuoka T. Takashima S. Yamada R.
Department of Radiology, Osaka City University Medical School, Japan.
We developed a triple coaxial catheter system (TCCS) which consists of a 6.1 Fr outer, a 4.1 Fr intermediate, and a 3.0 Fr inner catheter, all coated with a lubricant. The TCCS was used in seven patients with hepatic tumors, after several attempts to access a targeted vessel with conventional catheters and guidewires failed to reach the targeted vessel. No complications were encountered with the use of this system. TCCS may be a useful device for selective abdominal arteriography.

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