Search

To examine the effectiveness of antithrombotic medications to prevent venous stent malfunction for iliocaval occlusive disease. A retrospective analysis was performed on 62 patients who underwent technically successful endovascular iliocaval stent placement between May 2008 and April 2017. Clinical records were reviewed for demographic information, procedure details, post-stenting antithrombotic prophylaxis and stent patency on follow-up. Stent malfunction was defined as > 50% stenosis or occlusion at follow-up. Risk factors for stent malfunction were assessed with univariable and multiple Cox proportional hazard models. The median follow-up period was 11.6 months (range 0.1–76.4). Overall primary and secondary cumulative patency rates at 12 months were 70.0% and 92.4%, respectively. After stent placement, 97% of patients received anticoagulation with warfarin, enoxaparin or a factor Xa inhibitor. In addition, 61% received antiplatelet prophylaxis with aspirin, clopidogrel or a combination. In multiple Cox regression analysis, post-stenting antiplatelet use remained significantly associated with primary stent patency (HR = 0.28, P = 0.022). After iliocaval venous stenting, stent patency was best predicted by concomitant antiplatelet and anticoagulation therapy rather than anticoagulation alone. This novel finding warrants further research underlying mechanisms leading to venous stent thrombosis, and has implications for optimal medical management after venous stenting.

OBJECTIVE. Transjugular intrahepatic portosystemic shunt (TIPS) creation increases the risk of hepatic encephalopathy due to overshunting. Techniques exist to secondarily reduce the shunt for refractory encephalopathy. The purpose of this article is to describe a technique for primary TIPS restriction using a balloon-expandable stent within the transvenous hepatic track followed by deployment of a self-expanding polytetrafluoroethylene–lined stent-graft within the balloon-expandable stent to create the TIPS. CONCLUSION. This technique enables control over the degree of portosystemic shunting in elective TIPS creation.

Purpose To describe the use of intravascular ultrasound (US) guidance for creation of transjugular intrahepatic portosystemic shunts (TIPSs) in humans. Materials and Methods The initial 25 cases of intravascular US–guided TIPS were retrospectively compared versus the last 75 conventional TIPS cases during the same time period at the same institution in terms of the number of needle passes required to establish portal vein (PV) access, fluoroscopy time, and needle pass–related complications. Results Intravascular US–guided TIPS creation was successful in all cases, and there was no statistically significant difference in number of needle passes, fluoroscopy time, or needle pass–related complications between TIPS techniques. Intravascular US–guided TIPS creation was successful in cases in which conventional TIPS creation had failed as a result of PV thrombosis or distorted anatomy. Intravascular US guidance for TIPS creation was additionally useful in a patient with Budd–Chiari syndrome and in a patient with intrahepatic tumors. Conclusions Intravascular US is a safe and reproducible means of real-time image guidance for TIPS creation, equivalent in efficacy to conventional fluoroscopic guidance. Real-time sonographic guidance with intravascular US may prove advantageous for cases in which there is PV thrombus, distorted anatomy, Budd–Chiari syndrome, or hepatic tumors.

Purpose: To evaluate the safety of inferior vena cava (IVC) filter retrieval in therapeutically anticoagulated patients in comparison to prophylactically or not therapeutically anticoagulated patients with respect to retrieval-related hemorrhagic complications. Materials and methods: This was a retrospective study of 115 consecutive attempted IVC filter retrievals in 110 patients. Filter retrievals were stratified as performed in patients who were therapeutically anticoagulated (group 1), prophylactically anticoagulated (group 2), or not therapeutically anticoagulated (group 3). The collected data included anticoagulant and antiplatelet medications (type, form and duration of administration, dosage) at the time of retrieval. Phone interviews and chart review was performed for the international normalized ratio (INR), activated partial thromboplastin time, platelet count, infusion of blood products, and retrievalrelated hemorrhagic complications. Results: Group 1 included 65 attempted filter retrievals in 61 therapeutically anticoagulated patients by measured INR or dosing when receiving low-molecular-weight heparin (LMWH). Four retrievals were not successful. In patients receiving oral anticoagulation, the median INR was 2.35 (range, 2 to 8). Group 2 comprised 23 successful filter retrievals in 22 patients receiving a prophylactic dose of LMWH. Group 3 included 27 attempted filter retrievals in 27 patients not receiving therapeutic anticoagulation. Six retrievals were not successful. Five patients were receiving oral anticoagulation with a subtherapeutic INR (median, 1.49; range, 1.16 to 1.69). No anticoagulation medication was administered in 22 patients. In none of the groups were hemorrhagic complications related to the retrieval procedures identified. Conclusions: These results suggest that retrieval of vena cava filters in anticoagulated patients is safe. Interruption or reversal of anticoagulation for the retrieval of vena cava filters is not indicated. (CHEST 2007; 132:31–36)

A previously healthy 27-year-old woman (gravida 2 para 1) presented in the 42nd week of an otherwise ordinary pregnancy with right flank pain radiating to the groin. Membranes were intact, the cervix was long and closed, and no uterine contractions were present. Fundal height was appropriate (40 cm) and fetal assessment was unremarkable. She was afebrile with mild tachycardia (117 bpm) and was extremely tender in the right flank. Routine laboratory tests were within normal limits except for the urinalysis, which revealed 31 RBC. She was admitted to the labor and delivery unit for intravenous hydration with a presumed diagnosis of right renal colic. Within a few hours of admission, the flank pain evolved into generalized abdominal pain and physical examination revealed marked abdominal tenderness. Simultaneously, fetal heart tracings began to show ominous decelerations and loss of variability, prompting an emergency delivery for suspected placental abruption. In the operating room, a live male fetus weighing 7 lb 14 oz. was delivered by cesarean section (APGAR, 7/9). Placental abruption was not confirmed. Rather, inspection of the maternal abdomen revealed a hemoperitoneum of approximately 200 cm which was clotted and dark in color. A retroperitoneal hematoma was identified inferior to the liver which appeared to be the source of the intraperitoneal blood. No active bleeding was observed, so the abdomen was closed. However, her postoperative hematocrit level of 16.8% was lower than anticipated for the combined operative blood loss and hemoperitoneum (her hematocrit level on admission was 32.8%). A total of six units of blood were transfused postoperatively as the patient’s hematocrit level decreased on two further occasions. Computed tomography (CT) of the abdomen was performed to confirm the presence of a retroperitoneal hemorrhage on the right side as seen at surgery.

An inadvertent case of pericardial placement of a central venous catheter was successfully treated by direct thrombin injection.

To prospectively evaluate the clinical efficacy of polyethylene-covered metallic Z-stents in treatment of dysphagia secondary to malignant esophageal obstruction and esophagorespiratory fistula.Thirty-five patients with dysphagia due to malignant esophageal obstruction (n = 32) and esophagorespiratory fistula (n = 3) were treated with polyethylene-covered Gianturco-Rösch Z-stents.Thirty-nine stents were placed in 35 patients. Stent placement was technically successful in all patients. Improvement in dysphagia was achieved in 34 of 35 patients. The average dysphagia score decreased from 3.1 (dysphagia to liquids) to 0.6 (essentially normal diet). An esophagorespiratory fistula was completely sealed in two of three patients. All 35 patients were followed up clinically at 1 day and 1 week and at 3-month intervals (range, 1 week to 18 1/2 months; mean, 4.8 months). Recurrent dysphagia or aspiration occurred in only three of 34 (9%) patients whose disease was initially palliated and was easily treated in all cases. Nine complications occurred in eight patients (23%) and included chest pain that required analgesia (n = 3), food impaction (n = 1), stent migration (n = 2), and upper gastrointestinal tract hemorrhage (n = 3).Polyethylene-covered stents are a relatively safe and effective means of long-term palliation in patients with severe malignant esophageal obstruction and esophagorespiratory fistula. These stents are easily deployed, and the rate of stent migration is relatively low.

Background: Mediastinal malignancies may involve the esophagus, leading to esophageal stenosis and dysphagia. Rigid and self-expanding esophageal stents have been used for effective palliation, but their use in extrinsic, compressive lesions is controversial. Methods: A retrospective review of self-expanding Gianturco-Rosch Z-stents that were successfully placed in 13 patients with malignant esophageal obstruction due to extrinsic lesions. Results: All patients had an improvement in dysphagia of at least two dysphagia grades. The mean dysphagia grade fell from 3.15 to 0.62. Mean survival was 2.2 months. Early (within 48 hours) procedure-related complications occurred in 4 of 13 patients and consisted of minor, transient chest pain that resolved within 6 hours (3 patients) and endoscopic stent dislodgment into the stomach (1 patient). Late complications (>48 hours) occurred in 2 patients and consisted of a partial proximal stent migration and the development of a benign stricture proximal to the stent. There was no procedural or stent related mortality. Conclusions: Esophageal obstruction and malignant dysphagia from extrinsic, compressive mediastinal malignancies can be effectively and safely palliated with self-expanding Gianturco-Rosch Z-stents. (Gastrointest Endosc 1996;43:483-9.)

Purpose To evaluate expandable metallic Gianturco-Rosch Z (GRZ) stents for treatment of benign and malignant tracheobronchial stenoses. Patients and Methods Six patients, ages 45–73 years, were treated for severe dyspnea with placement of GRZ stents. Three patients had benign tracheal lesions (one tracheomalacia, two postoperative) and received uncovered GRZ stents. Three patients had malignant stenoses at the level of the carina; one received an uncovered stent and the other two received silicone-covered GRZ stents. Results Two patients with benign lesions responded well to stent placement. One was asymptomatic for a year and then was lost to follow-up; the other improved substantially but died of end-stage lung disease 5 months after stent placement. A third patient with a benign high tracheal lesion did poorly; symptoms recurred secondary to inferior migration of a stent, which was removed surgically at 4 months. All patients with malignant lesions improved symptomatically after stent placement and remained without significant dyspnea until death (from 1 to 6 months). Conclusion Expandable GRZ stents are promising devices for treatment of benign lesions and offer effective palliation of malignant tracheobronchial stenoses.

Esophagogastric malignancies often are manifested with progressive dysphagia or esophagorespiratory fistulas. Palliative modalities currently available have significant limitations. A modified Gianturco-Rosch silicone-covered self-expanding metallic Z stent was used in 32 consecutive patients with malignant esophageal obstruction (n =24) or esophagorespiratory fistulas (n = 8). The stent was placed successfully in all patients. Dysphagia improved by at least two grades in 21 of the 24 patients (87.5%); the mean dysphagia grade fell from 3.21 to 1.08. Six of the 8 patients with fistulas were able to resume a normal diet, and the other 2 were able to eat solids without symptoms of aspiration. Complications occurred in 10/32 patients (31%) and included stent migration (4 patients), food impaction (2 patients), membrane disruption with tumor ingrowth (1 patient), tumor overgrowth (1 patient), early pressure necrosis with hemorrhage (1 patient), and late pressure necrosis with sepsis (1 patient). The latter 2 patients died, giving a mortality rate of 6.3%. Many complications were managed with endoscopic or interventional radiologic techniques. Although randomized prospective clinical trials are needed, the silicone-covered Gianturco-Rosch Z stent offers promise for the effective palliation of malignant esophageal obstruction and esophagorespiratory fistulas. (Gastrontest Endosc 1994;40:22-33.)

WHEN Ehrlich introduced arsphenamine (N. N. R.) in 1909 it was his sincere hope that syphilis could be cured with a single injection of the drug. It soon became apparent that one injection was woefully inadequate and, moreover, that three, six or even more injections failed to yield the desired result. With the introduction of bismuth as a powerful ally, the campaign against syphilis moved closer to its goal. Two decades after Ehrlich's discovery, following the admirable work of the Clinical Cooperative Group, 1 it was generally recognized that the use of alternating courses of the arsenicals and bismuth preparations, given continuously over a period of approximately twelve to eighteen months, in a large percentage of cases, gave the result which Ehrlich had sought in vain. In the early 1930's, a group of physicians 2 once again envisioned the possibility of eradicating syphilis in a short time by utilizing an

EVER since 1905, when Donovan 1 described the peculiar intracellular and extracellular encapsulated organisms which he found in fresh spreads taken from ulcerative lesions of granuloma inguinale, the nature of the Donovan body has excited great interest. Though Donovan himself expressed the opinion that the organism is a protozoan, its position in the field of toxonomy was a moot point, eliciting much labor but little light, until Anderson, DeMonbreun and Goodpasture 2 successfully cultivated the Donovan body in the yolk of chick embryos. According to these investigators the organism is a bacillus, for which they proposed the generic name "Donovania" and the specific name "granulomatis." The therapy of the disease was ineffective until 1913, when intravenous administration of antimony and potassium tartrate was introduced by de Beaurepaire, Aragao and Vianna. 3 This drug was enthusiastically acclaimed by Low and Newham, 4 Pardo, 5 and Randall, Small and Belk. 6 Fraser

TWO REPORTS have been published recently, 1 showing spectacularly favorable results in the prevention of prenatal syphilis with the use of penicillin in the treatment of syphilitic pregnant women. It is well known that mothers with syphilis which is beyond the infectious state may deliver normal nonsyphilitic children in a varying but large percentage of cases. Transmission of syphilis to the fetus occurs much more frequently when pregnant women have syphilis in the early infectious stages than in the later stages of the disease. The efficacy of any therapeutic procedure in preventing prenatal syphilis, therefore, will be evaluated most reliably by the effect on the offspring of mothers who during pregnancy had indisputable early infectious syphilis. When rigidly selected, the number of patients whom we saw who had proved infectious syphilis during pregnancy was limited. To obtain a satisfactory number of cases for evaluation it is necessary to compile the

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.

Purpose To retrospectively review the indications and outcomes of transjugular liver biopsy (TJLB) with the left internal jugular vein (IJV) approach. Materials and methods A retrospective review of all TJLBs performed at one institution was performed. From August 1995 to October 2004, 293 liver biopsies were performed. Nineteen of the 293 procedures (6.5%) were performed from the left IJV in 17 patients. There were 11 men and six women aged 36–59 years (mean, 49.3 years). All patients were suspected of having diffuse hepatic parenchymal disease and had contraindications to conventional percutaneous liver biopsy. The stiff metal biopsy cannula was advanced across the mediastinum and through the heart over a stiff guide wire. Biopsy was performed from the right hepatic vein in 15 procedures, the middle hepatic vein in two, and the intrahepatic IVC in two. Results The indications for using the left IJV approach were nonusable right IJV in 12 procedures, difficult previous catheterization of the hepatic veins from the right IJV due to distorted hepatic anatomy in six procedures, and the operator’s predilection for this approach in one procedure (the patient had previously undergone liver transplantation). All biopsies were successful, with diagnostic tissue obtained in 100% of cases. Two patients had chest pain during the procedure associated with placement of the rigid cannula through the mediastinal veins. One patient had a vaso-vagal episode that necessitated the use of intravenous atropine but subsequently underwent successful biopsy. All episodes of chest pain resolved after the cannula was removed. There were no recorded hemorrhagic or cardiac complications. Conclusion TJLB can be safely and repeatedly performed from the left IJV when the right IJV is not available or the hepatic anatomy prevents catheterization of the hepatic veins from the right IJV.

Proper positioning of inferior vena cava (IVC) filters is necessary for effective protection from pulmonary embolism (PE). This report describes a case of an IVC filter malpositioned partially in the right common iliac vein that resulted in risk of recurrent PE caused by thrombus emanating from the left common iliac vein. A new filter was placed in the IVC above the first device, followed by retrieval of the malpositioned filter through the new filter.

Two patients had inferior epigastric artery pseudoaneurysms after therapeutic paracentesis for ascites caused by portal hypertension. The first patient, a 62-year-old man, had a two-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. A left inferior epigastric artery pseudoaneurysm measuring 10 cm in diameter and 20 cm in length was diagnosed by means of Duplex ultrasound and arteriography. The patient was treated with percutaneous embolization, with successful thrombosis of the pseudoaneurysm. The second patient, a 33-year-old woman, had a six-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. Computerized tomography and arteriography showed a left inferior epigastric artery pseudoaneurysm, measuring 7 cm in diameter and 9 cm in length. The patient was treated with percutaneous embolization with successful thrombosis of the pseudoaneurysm. Both patients were discharged in good condition 2 days after embolization. Inferior epigastric artery pseudoaneurysm is a complication of paracentesis, and percutaneous embolization may be preferable to surgical repair in patients with chronic liver failure and portal hypertension. (J Vasc Surg 1998;28:566-9.)

To analyze in detail the location and types of stenosis and occlusion that occur after transjugular intrahepatic portosystemic shunt (TIPS) creation and to determine the relative contribution of these various types of TIPS malfunction to recurrent symptoms of variceal bleeding or ascites.In 116 of 217 patients who underwent TIPS creation between June 1990 and July 1995, follow-up portal venography was performed at 6-month intervals and for symptoms of recurrent variceal bleeding or ascites.Cumulative primary venographic patency by means of Kaplan-Meier survival analysis was 55% at 6 months and 5% at 2 years. Secondary patency was 92% at 2 years. Stenosis or occlusion occurred in 63 of 116 patients (54%). In 20 patients (17%), acute shunt occlusions developed less than 30 days after TIPS creation; in 24 patients (21%), tract abnormalities were detected after 30 days; and in 19 patients (16%), hepatic vein stenoses were detected after 30 days. Abnormalities of the parenchymal tract were more often correlated with recurrent variceal bleeding or ascites than were hepatic vein stenoses (odds ratio, 3.6; P = .02). Ten of 14 patients (71%) with detected biliary fistulas to their TIPS had symptoms, and all patients with biliary fistulas had tract abnormalities.Tract stenoses and occlusions were the major cause of symptomatic shunt failure after TIPS creation. Substantial bile duct transections are often associated with tract abnormalities and recurrent symptoms. Although common, hepatic vein stenoses were rarely associated with recurrent symptoms in our patient population.

Background Intrahepatic abscess (IA) is an uncommon complication after liver transplantation (OLTx) usually found in the setting of hepatic arterial thrombosis (HAT) often with associated biliary tree necrosis and/or stricture. Conventional treatment of IA in this setting has required retransplantation. Methods A retrospective review of 274 patients (287 OLTx) from September 1991 through September 1996 was performed. Median follow-up was 3.6 years. Diagnosis of HAT was confirmed by arteriography and IA was documented by computerized tomography. Percutaneous drainage of the abscess and stenting of biliary strictures, if present, was achieved using conventional interventional radiology techniques. Results The diagnosis of hepatic artery complication was made in 14 patients (5.1%), 2 of whom required retransplantation. Hepatic artery thrombosis associated with solitary IA was found in 3 patients (1%) who were transplanted in our center and in 1 additional patient followed up at our center but transplanted elsewhere. All 4 patients had complete resolution of IA using this approach. Three of the 4 patients are alive and well, with the fourth patient succumbing to recurrent hepatitis B infection resulting in allograft failure. Conclusions Solitary hepatic allograft abscesses associated with HAT respond to percutaneous drainage and antibiotics, obviating the need for retransplantation in this setting.

Purpose To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-Rosch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. Patients and Methods GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. Results Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration ( n = 5), food impaction ( n = 2), chest pain ( n = 2), membrane disruption with tumor ingrowth ( n = 1), granulomatous reaction above the stent ( n = 1), esophageal perforation with mediastinitis ( n = 1), and upper gastrointestinal hemorrhage ( n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). Conclusion GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.

To evaluate the ability of stent-grafts made with polytetrafluoroethylene (PTFE) graft material to improve transjugular intrahepatic portosystemic shunt (TIPS) patency.TIPS were created in 13 swine by using PTFE-covered stent-grafts. Uncovered TIPS were placed in 13 other swine. Twenty-one of 26 animals were followed up with portal venography for 3 months or until the shunt became severely stenotic. Five animals without severe stenosis were sacrificed before 3 months because of illness.At 4 weeks after TIPS placement, nine of 13 stent-graft TIPS were patent (50% diameter narrowing) compared with only one patent stent in 13 uncovered TIPS. Six of 13 stent-graft TIPS remained patent until the animals were sacrificed. In 11 of 12 uncovered TIPS, stenosis was most prominent in the parenchymal tract. In five of seven stent-graft TIPS, stenosis was most prominent in the hepatic vein above the end of the graft material. Bile leaks were discovered in six occluded uncovered TIPS and in two of the stent-graft TIPS.PTFE-covered stent-grafts significantly improved TIPS patency in swine (P.01). However, stenosis in the hepatic vein led to late shunt malfunction in selected cases.

Purpose To prospectively evaluate the clinical efficacy of covered metallic Z stents in the treatment of esophagorespiratory fistulas (ERFs). Patients and Methods Twelve patients with severe aspiration symptoms from malignant ERFs were treated with silicone-covered, metallic, self-expanding Gianturco-Rosch Z (GRZ) stents. Results Fluoroscopically guided stent placement was successful and well tolerated in all patients. Immediate postprocedural endos-copy and esophagography showed excellent coverage of the fistulas in all cases. Aspiration symptoms were completely relieved in eight of 12 patients (67%). Four of 12 patients (33%) were improved and able to eat a soft diet. There were no stent-related deaths. Nine patients have died and three patients are alive. Mean follow-up for the entire group was 3.9 months (range, 1 week to 10.5 months). Nonfatal complications occurred in three of 12 patients (25%). Complications included one membrane disruption and one granulomatous reaction with a slight upward stent migration. Conclusion GRZ stents are an effective and safe means of palliation in patients with malignant esophagorespiratory fistulas.

A magnetic resonance (MR) imaging strategy, SLIP (spatially separated lipid presaturation), which can be incorporated into existing MR imaging and MR angiographic techniques, has been developed to suppress lipid signal. The authors report the clinical application of this technique, with a triple comparison of two-dimensional inflow MR angiography, with and without SLIP, and x-ray angiography in patients with aortoiliac disease. SLIP improved visualization of arterial segments, with 50 of 63 (79%) arterial segments visualized versus 41 of 63 (65%) for non-SLIP MR angiography. The SLIP strategy aids in the depiction of slow or turbulent flow, because the lipid signal is suppressed while the intravascular signal is left undisturbed. Image quality improves because of the combination of decreased background lipid signal intensity and use of the maximum-intensity-projection algorithm. Compared with x-ray arteriography, non-SLIP MR angiography had a sensitivity and specificity of 60% and 56%, respectively, for detection of lesions with 50%-100% diameter reduction, while SLIP MR angiography had a sensitivity and specificity, respectively, of 53% and 67%.

P R O P E R entry into a large intrahepatic portal venous branch is the crucial part of successfully performing a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The Brockenbrough or modified Ross transseptal needle, the Colapinto transjugular biopsy needle, and micropuncture coaxial needle have been used for liver puncture (1-4). In 1986, after traumatic experience with the modified Ross needle in experimental work, we designed a coaxial catheter-needle for an "atraumatic" transjugular portal vein entry in swine (5). We modified this set for clinical use in performing TIPS and describe our experience with it in 50 patients.

In an effort to more effectively use critical care facilities and to reduce costs, during a 2 1/2-year period, the condition of 32 patients who received 37 local intraarterial urokinase (UK) infusions was monitored in a non-intensive care unit (ICU) setting. Techniques of infusion, mean total dose of lytic agent used (1.7 million IU), and mean duration of infusion (22 hours) were similar to those reported previously in series of patients monitored in the ICU. Complete lysis (no angiographically detectable residual clot within the treated segment) was achieved in 28 of 37 infusions (76%). Major complications occurred during two infusions (5.4%). In 33 of the 37 cases, systemic heparin was administered during UK infusion. No cases of pericatheter thrombosis were encountered. At the authors' institution, patients can be safely monitored during local UK infusion in a non-ICU setting without compromising effectiveness of therapy. This approach has resulted in enhanced cost-effectiveness of thrombolytic therapy and more effective use of critical care facilities.

Diabetes mellitus is the most frequent cause of end stage renal disease. Simultaneous kidney and pancreas transplantation is an option for patients with end stage renal disease due to diabetes, since it relieves them from insulin dependency. 1 Hematuria and recurrent urinary tract infections are the most common, occasionally life threatening complications of simultaneous kidney and pancreas transplantation. We report a case of severe recurrent hematuria from the duodenal patch successfully managed with transcatheter arterial embolization. CASE REPORT A 38-year-old woman underwent simultaneous kidney and pancreas transplantation, drained into the bladder with the duodenal segment sutured to the cystotomy. A Lich ureteroneocystostomy was performed for urinary drainage. Preoperatively vancomycin, imipenem and fluconazole were given intravenously. Immunosuppression was induced with antithymocyte globulin, methylprednisolone and azathioprine. After a normal cystogram on postoperative day 13, the Foley catheter was removed. Recurrent gross hematuria required many hospital admissions and cystoscopies with fulguration of a bleeding lesion in the duodenal stump. The patient underwent arteriography, which demonstrated active extravasation into the bladder from a small branch of the allograft pancreaticoduodenal artery. The artery was selectively embolized using a 3Fr microcatheter with multiple helical microcoils. Arteriography after embolization demonstrated occlusion of the segment and no further extravasation (see figure). There was no evidence of recurrent bleeding at 6-month followup. DISCUSSION

Noninvasive imaging of portomesenteric venous anatomy in prospective pediatric liver transplant recipients may be limited by the small size of the vessels. A simple technique of percutaneous transhepatic portal venography was developed that involves the use of a 22-gauge needle and hand injection of contrast material. The technique was used in six infants (aged 4-15 months) with portal hypertension and end-stage liver disease due to biliary atresia. The portal vein was diagnostically opacified in four of the six patients. There were no complications related to the procedure.

In summary we wish to emphasize the relatively infrequent occurrence of acceptable cases of congenital complete heart block as reported in American literature. A review of the literature reveals that only twenty-six cases of complete heart block in pregnant women have been reported. A report of a patient with congenital complete heart block who experienced normal pregnancy and uneventful recovery has been presented. This report adds emphasis to the current belief that patients with complete heart block who become pregnant should be allowed to continue a normal pregnancy, provided that the associated congenital defects do not constitute an indication for therapeutic abortion. It is our hope that the report of this case of congenital complete heart block in pregnancy may stimulate interest in this rare condition and ultimately lead to better understanding and proper recognition of this entity.

Autotransfusions of previously frozen red cells in patients undergoing elective gynecologic surgery are reported. When red cell volume and total circulating hemoglobin levels are used as criteria, a 4 week interval between the initial and second bleed proved better than a 2 week interval for the collection of two units of blood. The clinical responses to the autologous transfusions were satisfactory.

Herpes zoster in its common form, involving one side of the body and manifested by grouped umbilicated vesicles on an erythematous base, is a disease which many patients are able to diagnose. Often, in addition to the zonal distribution of the herpes zoster eruption, umbilicated vesicles ranging in number from five to thirty may appear at various sites remote from the initial lesions, usually concurrently on the trunk. These widespread lesions were first described by Tenneson, 1 in 1893, as vesicules aberrantes . He concluded that 90 per cent of patients who had herpes zoster presented these lesions, an opinion not shared by Barker. 2 Bluefarb and Morris 3 found them in 66 per cent of their patients. A rarer manifestation of herpes zoster is known as herpes zoster generalisatus, in which scores or even hundreds of umbilicated vesicles appear in a widely generalized distribution over the body in conjunction

Diphenylhydantoin sodium (phenytoin sodium; dilantin sodium [sodium 5,5-diphenyl-hydantoinate]) has been used extensively both in the United States and abroad in the control of chronic convulsive disorders since it was first introduced by Merritt and Putnam in 1937.1Most observers are enthusiastic regarding the anticonvulsant merits of the drug, but nearly all emphasize the high incidence of toxic reactions. These may affect the gastrointestinal, the central nervous, the hemopoietic, the cardiovascular or the cutaneous system. Fairly frequently, reactions are noted concurrently in more than one system. Lesion on arm showing fixed pigmentary eruption. A large variety of cutaneous reactions have been attributed to the drug. The incidence of cutaneous signs of toxicity differs widely, from 0 or 1.3 to 35 per cent, although most observers estimate the incidence of cutaneous eruptions to range from 5 to 12 per cent. The types of cutaneous reactions differ considerably. While erythema

Demonstrable penicillin levels in the cerebrospinal fluid have been reported after intravenous or intramuscular administration only in patients who had inflammatory processes of the meninges 1 or when the penicillin was given by direct instillation. 2 Attainment of significant 3 penicillin activity in the cerebrospinal fluid of patients who did not show evidence of meningeal involvement is not reported in the available literature. McDermott and Nelson 4 and Mackie, 5 utilizing intramuscular doses as high as 500,000 Oxford units, failed to achieve significant cerebrospinal fluid concentration. Our own efforts, during the past twenty-two months, after intramuscular doses of 20,000, 40,000 and 200,000 units have likewise been unsuccessful. Neymann, Heilbrunn and Youmans 6 recently concluded that the intravenous and intramuscular methods of administration of penicillin were ineffective because "the hematoencephalic barrier cannot be breached." We are presenting a series of cases in which significant levels of penicillin were obtained in the

THE PUBLICATION of a report by Mahoney, Arnold and Harris. 1 in 1943 on the effectiveness of 1,200,000 units of penicillin given over an eight day period stirred the world of syphilotherapy profoundly. It was not long before other investigators published their results of treatment in early syphilis with similar amounts of the drug. Thus, Binkley and Kile 2 reported their observation on 10 patients, who had received 1,200,000 units of penicillin over varying periods of time, 7 of whom were seronegative and clinically well one year after treatment. In a recent article by the Committee on Medical Research of the Office of Scientific Research and Development and the United States Public Health Service 3 the results of treatment were given in 1,073 patients with early syphilis; 1,200,000 units of penicillin were used over a seven and one-half day period in intramuscular injections given every three hours. Of these

In his textbook published toward the close of the nineteenth century Kaposi 1 described a complication of infantile eczema, not previously recorded, based on his observation of 10 patients with a "varicelliform eruption." His description has scarcely been improved on in the subsequent half century. Inasmuch as the disease is rare, even in childhood, we should like to report 2 cases in which the patients were adults. Both had chronic atopic dermatitis. REPORT OF CASES Case1.—A white physician aged 30 years had been seen repeatedly by members of the dermatologic staff since June 1939, because of atopic dermatitis (disseminated neurodermatitis) from which he had been suffering since infancy. Off and on there had been characteristic remissions and relapses. There was no history of hay fever, asthma, migraine or urticaria. He had been vaccinated against smallpox at the ages of 5, 9, 14 and 22 years. On the last

THE LARGE shifts of population which accompanied the recent war created a hitherto unprecedented number of cases of granuloma in the North. Thus, in the space of three years, in the city of Chicago, where the disease was a relative rarity, almost 100 patients were seen and treated at the Chicago Intensive Treatment Center. It appears timely, in view of the large increase in the number of cases seen in northern cities recently, to review the literature on this disease, with particular attention to the newer methods of treatment. McLeod 1 in India first described the disease as a "serpiginous ulceration of the genitals," and Conyers and Daniels 2 in 1896 first recognized the disease as a distinct clinical entity. In 1905 Donovan 3 in India demonstrated the organism which today bears his name. In 1913 Aragao and Vianna 4 introduced antimony potassium tartrate in the treatment of the disease.