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PubMed1997

Stenosis of the subclavian vein. An unknown cause of resistant reflex sympathetic dystrophy.

The striking similarity of certain pain symptoms and neurologic changes in RSD and the findings of severe thoracic outlet and inlet syndrome were the reason why clinical diagnostic studies of this dystrophy were also completed by radiologic examinations of the vessel system. Surprisingly, more or less striking and differently configurated stenoses in the area of the subclavian vein, with a resulting impairment of the venous run-off, were found. Those findings have been documented in 20 of 21 patients with RSD since 1984 by functional venography and, in the meantime, they were confirmed intraoperatively in nine resistant cases. The stenoses led to a lesion-caused disproportion between increased arterial inflow and decreased venous outflow, with venous stasis. Consequently, they acted as a primary cause of an edema of the hand, with corresponding regional results, mainly on the function of the sympathetic nervous system. That shows a primarily increased activity in RSD that under the influence of local factors results in a pathologic positive feedback mechanism, as already was known. The stenosis of the subclavian vein, in my opinion, is the long-searched for cause of the so-called "individual predisposition." The use of functional venogram in diagnosis is essential because it gives important hints at the diagnostic and prognostic outlook for a possible surgical treatment of resistant RSD. It is also very important in understanding the pathogenesis. To improve the venous flow and diminish or interrupt the sympathetic efferences, we performed transaxillary decompression of the neurovascular bundle with additional upper thoracic sympathectomy in resistant cases of RSD. Nine patients experienced immediate improvement of the pain syndrome and edema, as well as the entire postoperative course. After an average follow-up of 7.5 years, we found an excellent result in seven patients, a good result in one, and a fair result in one. Intraoperative findings and the arteriograms we performed on seven surgically treated patients indicate the primarily increased sympathetic activity in RSD is mainly caused by irritations and compressions of the lower plexus roots as well as the postganglionic fibers in the area of the subclavian artery, mainly by the inner rim of the first rib and fibromuscular structures. So the two main pathogenetic factors of RSD are known, and now can be localized and documented radiologically. It now should be possible to study the pathophysiology of RSD in an appropriate animal model.

Adult↗

PubMed1987

Pathologic characteristics of recurrent carotid artery stenosis.

Recurrent carotid stenosis occurs randomly in approximately 10% of patients undergoing endarterectomy. Previous studies have described several histologic features but have failed to clearly elucidate the pathogenesis of this disorder. To improve our understanding of this disease, we reviewed pathologic lesions from 20 patients with recurrent stenosis. All specimens had been fixed in formalin and were embedded in paraffin and had undergone routine microscopic studies. In addition, immunoperoxidase staining with anti-factor VIII for endothelial cells and anti-desmin and anti-actin for smooth muscle cells was performed. Recurrent stenosis had developed in 16 of the 20 specimens within 2 years of endarterectomy (early), whereas the remaining four cases occurred from 2 to 7 years after the original carotid endarterectomy (late). Endothelial cells were found lining the luminal surface of both early and late recurrent lesions. Six of sixteen early and three of four late specimens had areas of luminal surface covered with cells exhibiting immunoreactivity for anti-factor VIII. Cells showing immunoreactivity for actin or desmin and demonstrating the morphology of smooth muscle cells were found in 9 of 16 early restenotic lesions but in no late ones. Areas of endothelial cell lining of the recurrent carotid lesions in a substantial number of patients in this study represent a finding not previously described. The presence of these cells implies that a phase of the arterial healing after endarterectomy involves re-endothelialization. Contrary to previous reports, no significant role of thrombosis and/or intraplaque hemorrhage could be found to contribute to development of recurrent stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed1984

Smoking as a risk factor for the development of arterial occlusive disease.

There was examined a total of 982 males with arterial occlusive disease (908 males with atherosclerosis obliterans, 59 with thromboangitis obliterans and 15 males with this disease of uncertain aetiology), 30 females with atherosclerosis obliterans, 411 control males and 50 control females. Among the controls there were significantly more frequently non-smokers and occasional smokers (the latter, however, having atherosclerosis obliterans--with the exception of females, and males having thromboangitis obliterans). In the complex of occlusive disease there were, on the other hand, more frequently present regular smokers smoking 31-40 years (in thromboangiitics for a period up to 10 years), smoking proportionally throughout the day and having their starting age of smoking before their 20th year of life. In the group of the arterial occlusive disease there was also a significantly higher number of those who discontinued smoking for 1-2 years in their life, while in the control group there were chiefly males who had discontinued smoking for a period longer than 5 years. Among stop-smokers there occurred significantly more frequently patients having only occlusions and significantly less frequently those having both occlusions and stenoses. There were no significant differences between the group with a pathological arterial process and the control one in the prevalence of cigar smokers or in the existence of their different smoking habits. The situation was similar also with pipe smokers with one exception: in the occlusive disease and/or atherosclerosis obliterans there were found more frequently mixed smokers of more than one package of tobacco weekly, smoking 31-40 years, namely proportionally throughout the day. As significant there proved to be chiefly cigarette smoking, and that in the amount over 16 cigarettes a day. As critical was found to be the period of exposition of 31-40 years. But when the relationship between the average daily number of cigarettes smoked and the total duration of smoking was compared, there was found in males with atherosclerosis obliterans as significant the smoking of already 11-15 cigarettes a day for a period of 31-40 years. With the rising number of cigarettes smoked per day there was getting shorter the critical period of exposition. Of importance is likewise the starting age of cigarette smoking before the 20th year of life and the proportional time distribution of smoking in the course of the whole day. In the complex of the arterial occlusive disease there were significantly more "rapid" smokers, i.e. those smoking their cigarette within a time up to 6 minutes and, further, those in whom, 5-8 years prior to the onse

Adult↗

PubMed2006

Acute and chronic effects of extensive radiofrequency lesions in the canine caval veins: implications for ablation of atrial arrhythmias.

BACKGROUND: Although radiofrequency (RF) ablation within the caval veins has been increasingly used to treat a variety of atrial tachyarrhythmias, the consequences of RF ablation in the caval veins are unknown. We explored the acute and chronic angiographic and pathological effects of extensive RF ablation in the caval veins. METHODS: Under fluoroscopy guidance, conventional (4 mm tip, 60 degrees C, 60 seconds) RF applications (n = 6-7) were delivered in each vena cava (from +/-2 cm into the vein to the veno-atrial junction) of 15 dogs (10 +/- 3 kg). Animals were killed 1 hour and 5 weeks after ablation for histological analysis. Angiography was performed before ablation (acute dogs only) and at sacrifice to assess the degree of vascular stenosis. RESULTS: In acute dogs (n = 5), luminal narrowing was noted in 10/10 (100%) targeted veins (mild in two; moderate in three and severe in five, including two total occlusions). In the six chronic animals that completed the protocol (four died during follow-up), stenosis was also observed in 12/12 (100%) ablated veins (mild in six; moderate in four and severe in two). Of these, one superior vena cava was suboccluded with development of extensive collateral circulation. Histologically, acute lesions displayed typical transmural coagulative necrosis, whereas chronic lesions revealed intimal proliferation, necrotic muscle replaced with collagen, endovascular contraction, and disruption and thickening of the internal elastic lamina. CONCLUSION: In this model, extensive RF ablation in the caval veins may result in significant vascular stenosis. These findings may have implications for catheter ablation of arrhythmias originating within the caval veins.

Acute Disease↗

PubMed1988

Pancreas divisum: a case for surgical treatment.

When all is said and done, the case for an association between pancreas divisum and accessory papilla stenosis is empirical. In our experience, there are more persons with long-standing, persistent or increasing symptoms who respond favorably to accessory papilla sphincteroplasty than chance or placebo effect can reasonably explain. These same patients tend to have what is thought to be pathologically increased resistance to excretion of pancreatic secretions via the accessory papilla (positive secretin-ultrasound test), which is corrected by the accessory papilla sphincteroplasty (conversion to negative secretin-ultrasound test). At operation the orifice in the accessory papilla is tiny. Secretin-induced flow is only a trickle in these patients, but when the limiting membranous web is cut, pancreatic secretions gush forth. Symptoms present before the operation are perceived as absent as soon as the pain of operation has subsided enough to allow assessment. Symptoms recur if the papillary orifice scars down and restenoses. Problems remain. Accurate selection of candidates for accessory papilla sphincteroplasty is not yet possible because of the lack of a highly reliable test for accessory papilla stenosis. The secretin-ultrasound test helps in this regard but still has a 10%-20% false positive rate and a 30%-35% false negative rate. The operation demands fine, precise, meticulous technique to avoid failure and the creation of even bigger problems with iatrogenic pancreatic duct obstruction. The final caveat is this: pancreas divisum as an anatomic form is common; pancreas divisum as a cause of pancreatic symptoms is very uncommon. Accessory papilla sphincteroplasty is no more a panacea for abdominal pain than sphincteroplasty of the major papilla has been. Nonetheless past failures do not negate the successes. With appropriate attention to patient selection and surgical technique, success can be the rule.

Acute Disease↗

PubMed1984

[Evaluation of the degree of carotid stenosis by spectral analysis of the Doppler signal. Comparison of the results of spectral analysis, angiography and anatomo-pathology].

With the single Doppler spectrum analysis, one can appreciate the degree of the carotid stenosis according to the importance of the haemodynamic disturbances induced by the stenosis. The purpose of our study is to show the possibilities and the limitations of this method. Spectrum disturbances were classified in 5 grades, each of them being related to the importance of the stenosis. The degree of stenosis has been evaluated by the C.W. Doppler spectrum analysis, the angiographies and the anatomical study of the endarteriectomies. We considered that we had a perfect concordance between the results of the different methods when the degree of stenosis measured on the angiographies or on the endarteriectomies was compatible with the spectrum analysis classification: grade I: stenosis inferior to 40% (in area), 23% (in diameter); grade II: stenosis ranging between 40 and 60% in area (23 and 40 in diameter); grade III: stenosis of 60 to 75% in area (40 to 50% in diameter) and of particular shape (extended plaque); grade IV: stenosis ranging between 60 and 90% in area (40 to 70% in diameter); grade V: stenosis higher than 90% in area (70% in diameter). The confrontation of spectrum analysis and angiographic date concerns 58 bifurcations. We got a perfect correlation in 93% of the cases. The confrontation of the spectrum analysis method and the anatomical study of the endarteriectomies concerns 38 bifurcations. We got a perfect correlation in 92% of the cases. The appreciation of the carotid stenosis degree is now performed in routine at the Hospital. For some patients, the endarteriectomy has been decided from the clinical and the spectrum analysis data, and an electro-encephalogram with compression. However these date are generally completed with an angiography with venous punction.

Carotid Arteries↗

PubMed1981

Correlation of the width of the QRS complex with the pathologic anatomy of the cardiac conduction system in patients with chronic complete atrioventricular block.

A study correlating the electrocardiographic findings and the histology of the atrioventricular (AV) conduction system was carried out in 14 cases with chronic complete AV block and in 13 cases without chronic complete AV block. Patients with chronic complete AV block were divided into two groups, based on the width of the QRS complex. The QRS complexes were narrow (less than 0.12 second) in four cases (group 1) and wide (greater than or equal to 0.12 second) in 10 cases (group 2). In group 1, the main lesion was located in the penetrating portion of His bundle (Hisp) in one heart, in the branching portion of the His bundle (Hisb) in another and in the combined regions of Hisb and the left bundle branch in two. Three of the four cases in group 1 had idiopathic fibrosis of the conduction system and one had calcific nodules in the central fibrous body. In group 2, the main lesion was located in Hisb in two cases, in the combined regions of Hisb and the right bundle branch in one, in the Hisb and in the bilateral bundle branches in two, and in the bilateral bundle branches in five. All cases in group 2 were of the idiopathic type, except case 5, which had calcific aortic stenosis. In 13 cases without chronic complete AV block the AV conduction system was histologically normal, except for slight-to-moderate aging changes in the His bundle or the bundle branches. Lesions of the Hisb, which is believed to be the "distal His" electrophysiologically, may induce complete AV block with narrow or wide QRS complexes, depending upon the severity of the lesions in Hisb or adjacent bundle branches.

Aged↗

PubMedDate not supplied

Percutaneous intraductal sampling for cyto-histologic diagnosis of biliary duct strictures.

BACKGROUND: Percutaneous transhepatic biliary drainage (PTBD) allows ductal material to be collected for cyto-histologic examination. We evaluated the data from a large series of patients with a PTBD in whom endobiliary cyto-histologic sampling techniques were employed in order to define a strategy for their use in the diagnostic work-up. PATIENTS AND METHODS: Ductal samples for cyto-histologic examination were obtained from 409 consecutive patients with a PTBD for stenosing lesions of the biliary tree. Bile aspirate cytology was performed for all patients and ductal biopsy specimens were obtained, generally after negative cytology, from 49 of them (11.9%), all candidates for a therapeutic procedure. The cyto-histologic results of intraductal sampling were compared with pathologic surgical data in 210 patients and with clinical-radiologic follow-up in 199. RESULTS: Overall, 22 out of the 409 patients had a final diagnosis of benign stenosis and 177 had samples positive for neoplastic disease. The sensitivity of bile cytology was 43.8% while ductal biopsies showed a sensitivity of 60.4%. The combination of the two sampling techniques achieved a sensitivity of 65.1%. For both sampling methods the specificity was 100%. Hilar metastases from neoplastic lesions of the GI tract and primary lesions of the biliary ducts showed the highest sensitivity. CONCLUSION: Cyto-histologic assessment of stenosing lesions of the biliary ducts is mandatory when highly sophisticated interventions (e.g. wide hepatic resection or liver transplantation) or non-surgical treatments are envisaged. The collection of cyto-histologic samples from bile ducts, in patients with a percutaneous bile drainage, is an easy, safe and valuable method to obtain the diagnosis. In view of the absence of false positive results in our series and in others, intraductal biopsy serves no purpose when positive exfoliative cytology is positive for malignancy. In the presence of negative cytology it is felt that an intraductal biopsy should be mandatory when the choice of a therapeutic program depends on the result of the cyto-histologic diagnosis.

Adolescent↗

PubMed1994

Percutaneous angioplasty, endothelial markers, and fibrin turnover.

PURPOSE: A number of thrombotic mediators have been related to peripheral arterial disease in both epidemiological and pathological studies. METHODS: We measured preoperative levels of fibrinogen, cross-linked fibrin degradation products (FDP), and the endothelial markers, von Willebrand factor (vWF), tissue plasminogen activator (tPA), and plasminogen activator inhibitor (PAI), in the venous blood of 43 claudicants undergoing percutaneous transluminal angioplasty (PTA). Samples were repeated 4 months later, and changes in the levels of thrombotic mediators were compared with ten controls undergoing angiography alone. Additional perilesional arterial samples were obtained from 11 of the patients. RESULTS: Arterial sampling indicated that successful PTA led to an immediate fall in tPA levels and a rise in arterial vWF (p < 0.05), together with a trend toward a significant rise in cross-linked FDP levels. Only the increase in FDP following successful PTA (36 cases) (p < 0.05) was observed in 4-month postangioplasty venous samples, whereas all variables remained unchanged in cases of restenosis (4 patients) and in controls (all comparisons made by Wilcoxon matched pairs test). CONCLUSIONS: These findings suggest that successful PTA in patients with intermittent claudication results in acute endothelial disturbance and increased fibrin turnover at the site of angioplasty and in sustained increases in fibrin turnover (as reflected by FDP levels). The observation that this increase in fibrin turnover is absent in cases of restenosis within 4 months of PTA merits further study to determine whether increases in fibrin turnover are necessary to maintain patency following PTA.

Angioplasty, Balloon↗

PubMed1992

Arterial hypertension and neurovascular compression at the ventrolateral medulla. A comparative microanatomical and pathological study.

Intraoperative observations and animal experiments suggest that neurovascular compression at the left ventrolateral medulla is a possible etiological factor in essential hypertension. In pursuing this hypothesis, the authors examined the neurovascular relations in the posterior cranial fossa of 24 patients with essential hypertension, of 10 with renal hypertension, and of 21 normotensive control patients. Artificial perfusion of the vessels and microsurgical investigations during autopsy identified the vascular relations at the brain stem and at the root entry zone of the caudal cranial nerves. There was no evidence of neurovascular compression at the ventrolateral medulla on the left side in any patient from the control group or among those with renal hypertension. Two normotensive patients had neurovascular compression at the right ventrolateral medulla by the posterior inferior cerebellar artery. In contrast, all patients with essential hypertension had definite neurovascular compression at the left ventrolateral medulla. Additional compression of the right side was seen in three of these patients. Based on the anatomical appearance, it was possible to define three distinct types of neurovascular compression at the ventrolateral medulla. Common to all three types is the compression of the medulla oblongata at its rostral part just caudal to the pontomedullary junction and lateral to the olive in the retro-olivary sulcus. Comparative histopathological study of the microsurgically examined brain-stem specimens revealed no differences between patients with essential hypertension, those with renal hypertension, and normal controls. There was a structural integrity at the site of neurovascular compression at the ventrolateral medulla. The microanatomical findings of this study show that neurovascular relations at the ventrolateral medulla in essential hypertension give rise to pulsatile compression on the left. This supports Jannetta's hypothesis of neurovascular compression at the left ventrolateral medulla as an etiology of essential hypertension.

Adult↗

PubMed1995

Effect of germinal matrix hemorrhage on terminal vein position and patency.

PURPOSE: Pathologic studies have suggested that periventricular intraparenchymal hemorrhages (IPH) occur as the result of compression and occlusion of terminal veins (TV) by germinal matrix hemorrhages (GMH). This study used color Doppler ultrasound techniques to test this hypothesis in vivo. MATERIALS AND METHODS: Twenty-four infants with 32 intracranial hemorrhages (20 GMH, 12 GMH/IPH) were evaluated during routine sonography with color and duplex Doppler ultrasound using an ACUSON 128 XP unit with 7-MHz linear and vector transducers. Maximum transverse dimension was obtained for each GMH. On coronal color Doppler ultrasound images, TVs were evaluated for displacement, presence of flow, and time average velocity (TAV). RESULTS: Abnormalities of the TV were common with ipsilateral GMH. Of 48 terminal veins evaluated, no flow was identified in 13 (27 %), and flow in a displaced vein was seen in eight (17 %). TV abnormality occurred more frequently with GMH/IPH (90 %) than with GMH alone (52 %), and complete occlusion of the TV was more common in GMH/IPH (82 %) than in GMH alone (16 %, p < 0.002). GMH size correlated with increasing TV abnormality. Mean transverse GMH dimensions with unaffected TV, displaced TV, and occluded TV were 8.2 +/- 1 mm, 10.3 +/- 1 mm, and 12.6 +/- 1 mm, respectively (p = 0.008). A small but significant trend was observed between maximum GMH dimension and decreasing TV velocities (r = - 0.5, p < 0.01). CONCLUSIONS: Obstruction of terminal veins by germinal matrix hemorrhage may play an important role in the pathogenesis of periventricular white matter hemorrhage.

Cerebral Hemorrhage↗

PubMed1996

Vascular manifestations of small solitary pulmonary masses. Angiographic-pathologic correlations and clinical significance.

RATIONALE AND OBJECTIVES: By performing pulmonary specimen angiographies, the authors attempted to determine the pathologic correlations of the vascular-related radiologic manifestations within, at the edge of, and adjacent to the small solitary pulmonary masses, and to evaluate their usefulness in differentiating small bronchogenic carcinomas from tuberculomas. METHODS: A total of 29 resected lobe specimens with 1.5- to 3.5-cm solitary pulmonary masses, including 24 carcinomas and 5 tuberculomas, were studied prospectively with preoperative radiographs, postoperative specimen arteriographies (in 19 carcinomas and 5 tuberculomas), and venographies (in 5 carcinomas), 10- to 15 micrograms-thick whole-mount sections, and 5-micrograms-thick slices for the examination of angiographic-pathologic correlation. Another series of chest radiographs and conventional tomographs of 100 patients with 1- to 3-cm peripheral pulmonary masses, including 60 carcinomas and 40 tuberculomas, were reviewed retrospectively and analyzed with the chi-square test. RESULTS: Specimen angiographies showed the intralesion avascularity, small arterial speculation, and lobulation or notch at the mass margin with arterial compression, as well as vascular convergence to the mass, in both carcinoma and tuberculoma groups. The irregular arterial wall (79.2%) and venous dilation distal to the mass (100%) were found in the carcinoma group only. Microscopically, arterial or venous fibrous hyperplasia was observed in both carcinomas and tuberculomas, whereas the arterial erosion by tumor tissue and tumor emboli within the vessels were found in carcinomas only. The retrospective review of the 100 patients showed that two radiologic signs of the vascular convergence to the mass and the vascular dilation distal to the mass occurred at similar frequencies (12%-13%) between the carcinoma and tuberculoma groups. CONCLUSIONS: In addition to compression of vessels by tumor and vessel occlusion by tumor embolus, pulmonary vascular fibrotic hyperplasia can cause intramass avascularity. Small vessels running vertically into or from the mass margin can construct the spiculation sign of the tuberculomas. Any evidence of pulmonary vascular irregularity will indicate a bronchogenic carcinoma. The vascular convergence to the mass and the vascular dilation distal to the mass are not specific radiologic signs for small solitary bronchogenic carcinomas.

Adenocarcinoma↗

PubMed2005

Sex difference in vascular injury and the vasoprotective effect of valsartan are related to differential AT2 receptor expression.

The angiotensin II type 2 (AT2) receptor is upregulated in pathological conditions such as vascular injury and exerts antagonistic effects against AT1 receptor-mediated actions. We examined the possibility that the sex difference in vascular remodeling is associated with altered AT2 receptor expression, which is located on the X chromosome. In this study, we examined this possibility by using AT2 receptor-null (Agtr2-) mice. Vascular injury was induced by polyethylene cuff placement around the femoral artery of wild-type (Agtr2+) and Agtr2- mice. In Agtr2+ mice, AT2 receptor expression in the injured artery was enhanced, and this increase was greater in female than in male mice, with no significant difference in AT1 receptor expression between male and female mice. Increases in neointimal formation, DNA synthesis, expression of monocyte chemoattractant protein-1, production of superoxide anion, and NADPH oxidase activity in the injured artery were attenuated in female compared with male mice. These parameters were augmented in Agtr2- mice, whereas the sex differences in these parameters were smaller in Agtr2- than in Agtr2+ mice. Treatment with a nonhypotensive dose of the AT1 receptor blocker valsartan decreased these parameters significantly in Agtr2+ mice, and these inhibitory effects of valsartan were greater in female mice. This sex difference in valsartan's inhibitory effect was less marked in Agtr2- mice. Our results suggest that the sex difference in response to vascular injury could be at least partially attributed to the exaggerated AT2 receptor expression in the injured vessel in female mice.

Angiotensin II Type 1 Receptor Blockers↗

PubMed1995

Surgical repair in children with the Budd-Chiari syndrome.

Membranous obstruction of the inferior vena cava at the level of the diaphragm is a rare cause of Budd-Chiari syndrome in children. Medical therapy usually fails. Surgical intervention aims at reestablishing patency of the inferior vena cava and hepatic venous outflow to the right atrium. We report on the management of this condition in 19 children of whom 7 were treated surgically. Indications for operation were persistent ascites, deteriorating liver function, and hepatic and inferior vena caval obstruction without significant collateral circulation. Three pathologic types were identified by ultrasonography and cavography and were confirmed at operation. These were type I (4 cases), with a thin membrane occluding the inferior vena cava at the level of the diaphragm; type II (12 cases), with segmental fibrotic obstruction of the inferior vena cava with variable involvement of hepatic veins; and type III (3 cases), with complete absence or nonvisualization of the inferior vena cava. All procedures were done with an extended midline sternotomy incision, cardiopulmonary bypass, core cooling to 16 degrees to 20 degrees C, and periods of circulatory arrest. Type I lesions necessitated membranectomy; type II lesions necessitated transcaval resection of the occluded confluence of the inferior vena cava and the hepatic vein with repair of the defect with an autogenous pericardial patch. One type II lesion, in addition, called for use of a 14 cm polytetrafluoroethylene tube graft to restore inferior vena caval flow. After the operation, marked clinical improvement was observed with an immediate reduction in liver and spleen size and resolution of ascites. Repeat cavography 10 to 30 days after the operation revealed complete patency in four cases and residual stenosis, which required transiliac balloon angioplasty to normalize the inferior vena cava/right atrial pressure gradient, in 3 cases. Thus eventual relief of hepatic venous outflow obstruction and inferior vena caval flow was restored in all cases. We advocate transcardiac membranectomy and pericardial patch grafting for symptomatic and deteriorating membranous obstruction of the inferior vena cava in children.

Budd-Chiari Syndrome↗

PubMed2001

Brush cytology in the assessment of pancreatico-biliary strictures: a review of 406 cases.

AIMS: To assess the accuracy of brush cytology in patients investigated for pancreatico-biliary strictures. METHODS: All pancreatico-biliary brush cytology specimens submitted from two major teaching hospitals over a 6.5 year period were reviewed. Four hundred and forty eight satisfactory specimens from 406 patients with adequate clinical and/or pathological follow up data were examined in the study period. RESULTS: Two hundred and forty six patients (60.6%) were shown to have neoplastic strictures. One hundred and forty seven tumours were identified cytologically, including 87 of 146 pancreatic carcinomas, 29 of 47 cholangiocarcinomas, one of one bile duct adenoma, four of seven carcinomas of the gallbladder, eight of 13 ampullary carcinomas, two of three ampullary adenomas, 10 of 16 malignancies of undetermined origin, none of two islet cell tumours, one of three hepatocellular carcinomas, and five of eight metastatic tumours. The three adenomas identified on brush cytology could not be distinguished from adenocarcinoma morphologically. One hundred and sixty patients (39.4%) had benign strictures, most often as a result of chronic pancreatitis and bile duct stones. There were three false positive cytological diagnoses mainly as a result of the misinterpretation of cases with relatively scant and/or degenerative atypical epithelial cells. Forty one cases were reported as atypical or suspicious of malignancy on brush cytology, of which 29 were ultimately shown to have carcinoma. The overall diagnostic sensitivity and specificity were 59.8% and 98.1%, respectively. The sensitivity increased from 44.3% in the initial third of cases to 70.7% in the final third of cases examined in the series. CONCLUSIONS: Brush cytology, in conjunction with other clinical and radiological investigations, is a useful technique in the assessment of patients with suspected pancreatico-biliary neoplasia.

Adult↗

PubMed2005

Differentiating malignant from benign common bile duct stricture with multiphasic helical CT.

PURPOSE: To evaluate retrospectively the use of multiphasic helical computed tomography (CT) to differentiate malignant and benign common bile duct (CBD) strictures in patients with only a focal CBD stricture and to determine predictors for this differentiation. MATERIALS AND METHODS: Institutional review board approval and informed patient consent were not required. Fifty patients (35 men, 15 women; age range, 35-87 years; mean age, 61.6 years) with only a focal CBD stricture comprised the sample for this study (32 malignant and 18 benign strictures). The diagnosis of all malignant and five benign CBD strictures was confirmed by reviewing patients' surgical and pathology records; in 13 benign CBD strictures, the diagnosis was confirmed by means of clinical features. Multiphasic CT findings were analyzed with regard to the wall thickness, location, length, and enhancement pattern of the involved CBD, the upstream CBD diameter, and other findings. CT features to identify benign and malignant CBD strictures were compared by means of univariate analysis and multivariable stepwise logistic regression analysis. RESULTS: Malignant strictures were longer (17.9 mm +/- 6.6 [+/- standard deviation]) than benign strictures (8.9 mm +/- 6.8) (P < .0001), and upstream CBD diameters were larger in malignant cases (22.0 mm +/- 5.4) than in benign cases (17.8 mm +/- 4.6) (P = .033). The involved wall thickness was more than 1.5 mm in 26 malignant cases and three benign cases (P < .0001). During both hepatic arterial and portal venous phases, greater enhancement than that in the normal CBD were more frequently observed in malignant cases (in 27 and 30 patients for hepatic arterial and portal venous phase scans, respectively) than in benign cases (in two and three patients, respectively) (P < .0001). Results of multivariable stepwise logistic regression analysis showed that hyperenhancement of the involved CBD during the portal venous phase was the only variable that could be used to independently differentiate malignant from benign strictures. CONCLUSION: Hyperenhancement of the involved CBD during the portal venous phase is the main factor distinguishing malignant from benign CBD strictures.

Adult↗

PubMed2004

[Treatment of benign stenoses of the large airways at the Faculty Hospital Praha-Motol during 1998-2003].

The authors present diagnostic and therapeutical results in the group of 80 patients with benign stenoses of large airways, who were hospitalized at the TRN ward (Department of TB and respiratory disorders) of the Faculty hospital Motol in Prague between the years 1998-2003. 62 patients sufferred from stenoses in cosequence of their tracheal intubation or tracheostomy. In 18 cases the stenoses resulted from other disorders or pathological condidtions (Wegener's granulomatosis, status post lung transplantation, etc.) 38 patients were sent for surgery. Up until the date of the assessment (September 2003), 8 of them had had a relaps of the condiditon. 6 operated subjects had their restenosis corected using bronchological methods, 2 subjects had to undergo reoperation, which is 5.2% of the total number of the operated subjects. The remaining 42 patients were treated using the interventional bronchological methods (electrocauther, laser, stents) which proved curative in 35 patients, i.e 44% of the whole group. In 7 inoperable patients the above methods failed, 6 of them having a permanent tracheostomy and one female-patient exited 2 days after an incomplete recanalization. In the subgroup of 18 patients with other than postintubation stenoses, stent operations were the most frequent (12 times), 4 patients were cured using other methods of interventional bronchology, and resection of the stenosis was indicated in two cases. Up until the date of the assessment, 65 subjects had survived and 15 exited. 5 of them died 3-14 months (median of 4 months) following the surgical procedure of other disorders than of the respiratory airways stenoses. 10 unoperated patients, with a single exception, also died due to other causes than the tracheobroncheal lesions (the survival rate median was 9 months). Following the initial freeing of the airways, the authors call for considering a surgical therapeutical option in each case. Provided the surgical approach was contraindicated, the interventional bronchological methods would replace it appropriately.

Adolescent↗

PubMed1986

[Coronary vasomotor activity in man. Description of a method of quantification and normal values].

The role of vasomotor tone is important in coronary pathology but it has not yet been quantified. The aim of this study was to evaluate the normal maximal variation of diameter between vasoconstriction and vasodilation or the coronary vasomotor capacity: greater diameter-smallest diameter/smallest diameter %. This was performed by two successive pharmacological tests, ergometrine and isosorbide dinitrate (ISDN), the doses of which and modes of administration were defined in a group of 70 patients: Contrast medium: no variations were observed after 5 opacifications at a least 2 minute intervals in 6 patients. Ergometrine test: a single 0.4 mg dose (6 patients) gave a maximal response equal to that obtained with progressive increments 0.1, 0.2, 0.3, 0.4 mg (9 patients). Two opacifications at 3 and 5 minutes were adequate to assess the vasoconstriction with an underestimation of less than 3% compared with a 10 minute control. ISDN test: 3 mg was the maximal haemodynamically well tolerated dose in the majority of patients. This dose gave the same response whether administered by intracoronary (18 patients) or intravenous injection (10 patients). Maximal vasodilatation was obtained after 2 to 4 minutes. A single coronary opacification 2 minutes after injection of ISDN underestimated the vasomotor capacity by 9.3% compared to that calculated after 5 opacifications performed over a 10 minute period. We propose the following protocol: intravenous injection of 0.4 mg of ergometrine with 2 opacifications of the coronary arteries after 3 and 5 minutes respectively. This followed by intravenous or intracoronary injection of 3 mg of ISDN followed by opacification 2 minutes later.(ABSTRACT TRUNCATED AT 250 WORDS)

Constriction, Pathologic↗