Biomedical subjects
Publications and source records attributed to J Rösch.
A new device for the removal of ureteral stents by the percutaneous nephrostomy route is presented. We used this device successfully in a 4-month-old male child. Its advantages in the removal of unwanted intracorporeal wanderers such as lost catheters are discussed.
Between July 1980 and July 1983, we occluded 30 pulmonary arteriovenous fistulas (PAVFs) in four patients by percutaneous placement of coil springs. All patients had significant right-to-left shunts and hypoxemia. One presented with recurrent cerebral abscesses following bilateral thoracotomy and lobectomy. The technique requires advancement of the catheter superselectively into the feeding artery just proximal to the fistula. Occlusion at this site preserves the maximum amount of functioning pulmonary parenchyma. Frequently more than one coil spring is required for occlusion. In our experience, the coil spring is a safe, effective, economical vaso-occlusive device for management of PAVFs.
Four cases of hemobilia treated by transcatheter arterial occlusion are presented and reviewed with 30 similar cases reported in the literature. Transcatheter vascular occlusion successfully controlled hemorrhage in all 34 patients. No obvious liver parenchymal damage appeared in 26 patients; transient elevation of liver enzymes occurred in 6 patients (18%) including one in our series; two of the patients reviewed died of acute hepatic insufficiency following nonselective hepatic artery embolization. Hemobilia should be considered when gastrointestinal hemorrhage occurs after abdominal trauma, liver biopsy or other manipulative liver procedures. Hepatic angiography establishes the diagnosis and selective vascular occlusion is the treatment of choice for control of intractable or recurrent hemorrhage. Techniques and precautions for the diagnosis and transcatheter therapy of hemobilia are discussed.
Transarterial renal embolization has been used in the management of renal cancer. We report on 9 patients who underwent selective and superselective renal arterial embolization for nonmalignant renal lesions. Embolization was done in 5 patients for hemorrhage owing to renal angiomas, renal artery, pseudoaneurysm, percutaneous renal biopsy and adult polycystic kidney disease, and in 2 patients with end stage renal disease because of massive proteinuria. Another chronic renal failure patient with severe hypertension was treated successfully with bilateral renal embolization. A postoperative renal arteriovenous fistula was treated successfully by catheter vaso-occlusion. Renal embolization may be a suitable alternative to surgery in poor operative risk patients and for technically difficult benign lesions. Renal infection is a contraindication to embolization.
Absolute ethanol was evaluated as a vaso-obliterative agent in 15 patients with bleeding of gastroesophageal varices. Initial control of hemorrhaging was obtained in 13 (87%). Two patients died from unrelated causes within 48 hours of the procedure. Variceal bleeding recurred in seven of the 11 remaining patients (64%) from one week to 13 months after embolization. Four patients did not rebleed; two of them died (4 weeks and 6 months after the procedure), and two are alive (14 and 16 months after the procedure). Significant disadvantages of ethanol for obliteration of gastroesophageal varices (marked prolongation of procedure time and lack of radio-opacity) probably contributed to the high incidence of portal vein thrombosis (3 patients [20%]).
Eight patients with tumors of the bony pelvis underwent embolization with isobutyl-2-cyanoacrylate (IBCA). Five patients had primary bone tumors, of which 2 were malignant and 3 were benign; 3 patients had metastases to the bony pelvis from the thyroid gland, kidney, and femur, respectively. Embolization was performed to minimize blood loss during resection of a giant-cell tumor in one patient and insertion of a hip prosthesis in another who had metastatic renal carcinoma. It was also done prior to scheduled surgery in one of the patients with aneurysmal bone cyst, but healing was sufficient to cancel the operation; in the other patient, embolization was the only therapy. Palliative embolization was performed in 4 patients with malignant tumors after other means failed to control pain or slow progression. IBCA appears to be an efficient means of occluding the vessels feeding selected primary bone tumors and metastases.
A method is described for the percutaneous catheter placement of expandable nitinol coil stents for the nonoperative restoration and maintenance of patency in internal flow pathways, especially the lumina of blood vessels and biliary ducts.
A 4.5-yr experience with percutaneous transhepatic obliteration of gastroesophageal varices in 49 patients is reviewed with respect to technical success, control of active hemorrhage, rebleeding frequency, survival, and complications to better define clinical guidelines regarding its application. The procedure was successfully completed in 94% (46 of 49) of patients, and complete obliteration of all variceal feeder vessels was achieved in approximately one-half (52%). Variceal hemorrhage was controlled in three-quarters (76%) of actively bleeding patients, and recurrent hemorrhage occurred in 65% of patients at mean follow-up of 33 wk. Complete obliteration of all variceal feeder vessels was found not to be necessary from a technical standpoint, because the frequency of control of active hemorrhage and rebleeding were not significantly different in those patients having partial as compared with complete obliteration. In comparison with the reported outcome following standard medical therapy of bleeding varices, survival after variceal obliteration appears similar, but death from hemorrhage may be reduced. The interval to rebleeding is longer in patients having elective variceal obliteration after medical control of hemorrhage than in actively bleeding patients undergoing urgent obliteration of varices. The complication rate of obliteration was acceptable, but Child's class C patients with uncontrolled hemorrhage were a subgroup that experienced high mortality and derived little benefit from obliteration. Variceal obliteration is most appropriate in the bleeding but medically stabilized patient or the inoperable patient with recurrent bleeding. Active bleeding is most often controlled and recurrent bleeding may be prevented for several months, thus allowing consideration of elective shunt surgery.
Four patients with metastatic glucagonoma are described. Angiography demonstrated a small avascular primary tumor of the tail of the pancreas in one patient and large hypervascular tumors of the pancreatic head in the other three. Liver metastases, were hypervascular in all four. Including our 4 with 21 cases from the literature, glucagonomas show a 92% incidence of increased tumor vascularity--thus increasing the likelihood of successful angiographic diagnosis. The awareness of clinically subtle or atypical glucagonomas and use of plasma glucagon determination are important factors leading to early diagnosis of these neoplasms. Since angiography can localize the tumor, assess its extent, and detect hepatic metastases, it is essential to the detailed evaluation of glucagonomas.
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The source of recurrent massive lower gastrointestinal bleeding can sometimes escape detection by conventional diagnostic measures. In such situations, bleeding can be directly provoked by pharmacoangiography using vasodilators, anticoagulants, and/or fibrinolytic agents. Heparin, streptokinase, and tolazoline, used separately or in combination, can augment, prolong, or reactivate transient, covert bleeding, thereby facilitating angiographic identification and localization of the lesion. Physiological, clinical, and angiographic factors are discussed. Although rarely needed, this useful and sometimes crucial diagnostic approach demands the combined skills and support of the radiologist, clinician, and surgeon.
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Percutaneous, nonsurgical interventions using angiographic catheter techniques and radiologic guidance were used in the management of seven cases of various lesions of the chest and lungs. Successful catheter therapy included the embolization of a large, acquired, postinflammatory vascular malformation causing massive hemoptysis and a cavernous hemangioma of the chest wall. Sixteen pulmonary arteriovenous fistulas (one patient), an iatrogenic internal mammary artery-to-innominate vein fistula, and a persistent, postbiopsy bronchopleural fistula were successfully closed. Percutaneous drainage of a pyogenic lung abscess and the nonoperative retrieval of an intravascular foreign body that had embolized to the left pulmonary artery were also successfully achieved. Performed under local anesthesia with minimal morbidity, stress, and risk, interventional catheter therapy is remarkably cost-effective. Primary chest physicians are encouraged to consider this mode of therapy whenever applicable.
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During the past decade percutaneous therapeutic vascular occlusion was performed on 152 occasions in 124 patients. The primary indication for vasoocclusive therapy was acute or recurrent bleeding. Upper gastrointestinal bleeding from arterial sources was controlled in 92 percent of patients and acute variceal bleeding in 83 percent. Renal embolization was performed for palliation of severe pain and hematuria from unresectable renal primary or secondary malignancies, to decrease blood loss and facilitate surgery in operable renal tumors, and for ablation of renal function to control chronic protein loss or severe hypertension. Our encouraging experience convinces us that transcatheter embolization is a useful, safe and effective procedure in selected patients. It seems certain that the technique of therapeutic embolization will be improved, its indications extended and its application become commonplace whenever angiographic skills and facilities exist.
Accurate diagnosis of the type of the left ventricular aneurysm (LVA) is essential for selection of appropriate surgical therapy. To assess the efficacy of angiography including conventional and dynamic ventriculography and coronary angiography in determining the LVA nature, 41 consecutive patients with various types of LVA, proven by surgery or autopsy, were evaluated. In all 22 patients with a "true", anatomical LVA, the angiographic diagnosis was correct. Nineteen patients had a "functional" LVA. In 16 of them studied by all three methods, the determination of the underlying pathologic process in the regions of wall motion abnormalities was correct; it corresponded to the findings at surgery in 15 patients, at autopsy in 1 patient, and also to follow-up angiographic studies in 12 patients. False diagnoses of an anatomical LVA were made at the beginning of the series in 3 patients in whom dynamic ventriculography was not used. On the basis of reported experience and review of the literature, findings important for differential diagnosis of individual lesions are emphasized. It is concluded, that a comprehensive evaluation of conventional left ventriculography complemented when necessary by dynamic ventriculography, together with coronary angiography, enables an accurate diagnosis in most cases. It is suggested that the term LVA be used for an anatomical aneurysm only; in patients with "functional" LVA an attempt should be made to determine the nature of the underlying processes, in particular to differentiate reversible from irreversible wall motion abnormalities.
A cirrhotic patient who had previously undergone both mesocaval shunting and transthoracic esophageal and gastric devascularization with splenectomy (Sugiura procedure) presented with recurring intractable variceal hemorrhage. Diagnostic visceral angiography demonstrated a large splenic arterial-venous fistula and gastroesophageal varices. Transarterial occlusion of the fistula and transheptic obliteration of the varices successfully done at one sitting prevented further bleeding. Follow-up angiography nine months later revealed persistent occlusion of the previous fistula and no evidence of esophageal varices.