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The aim of our study was to assess the feasibility of using Doppler sonography for the detection of acute intestinal ischemia due to occlusion of the superior mesenteric artery. Between September 1993 and March 1995, abdominal sonography with Doppler imaging of the mesenteric vessels was performed in 770 patients with emergency admissions for acute abdominal pain. In six cases, the diagnosis, based on surgery or arteriography and computed tomography, was acute intestinal ischemia due to complete or localized occlusion of the superior mesenteric artery. Five cases of occlusion of the superior mesenteric artery were correctly detected by Doppler sonography. These results suggest that Doppler sonography may be a feasible method for detecting acute intestinal ischemia due to proximal superior mesenteric artery occlusion.

Detection of acute intestinal ischemia is a diagnostic challenge. Color Doppler sonography of the abdomen may contribute to its diagnosis by showing lesions of the gut wall associated with occlusion or stenosis of the mesenteric vessels. Our overview of the sonographic findings of acute intestinal ischemia is presented as well as a proposition of algorithm for the working up to the diagnosis based on recent clinical experience.

The results of liver transplantation are compromised in cirrhotic patients presenting with renal insufficiency from hepatorenal syndrome. A case of cirrhosis and hepatorenal syndrome, treated sequentially with transjugular intrahepatic porto-systemic stent shunting (TIPSS) and liver transplantation, is discussed. TIPSS may be useful for correcting renal dysfunction and/or hepatorenal syndrome in end-stage cirrhotics, thus permitting subsequent elective liver transplantation under good conditions.

Varicocele is a benign pathology, for which the less invasive treatment is percutaneous embolisation. Literature reports results from 70 to 85% (1,2). Laparoscopic treatment seems to be a good alternative for patients suffering from a recurrence, or patients who can not be embolised. We report our experience concerning the first 13 patients treated with laparoscopic technic. In all 13 cases it was possible to practice the technic, and patients were cured.

Inferior vena cava thrombosis is a well-recognized complication of filter insertion. We report on two patients who presented with progressive exertion dyspnoea and lipothymia revealing a complete inferior vena cava thrombosis below the filter. Haemodynamic exploration demonstrated that cardiac output could not adapt during upright exercise owing to inappropriate cardiac preload. Since these general manifestations can precede any symptom of lower limb venous stasis, thrombosis of inferior vena cava has to be carefully searched in this setting. The pathogenesis of this unusual complication is reviewed in the light of experimental models of vena cava ligation.

The varicocele is benign pathology which sometimes involves disorders of testicular growth. Those can cause a hypofertility. We saw in a retrospective way the 243 patients having been treated by percutaneous embolisation from May 1985 to August 1993. At 150 patients being 1 year at least of postoperative retreat, 70% of cases present a cure, 15% of patients repeated and were taken again surgically. At 8% of patients, the embolisation was not technically possible for reasons of vascular anomalies or spasm of the vein during the procedure. The morbidity of this technique is low, this involves therefore a right choice of the treatment of the varicocele which does not prevent any surgical treatment in the event of repetition or in the event of technical failure.

The right gastroepiploic artery is currently regarded as a most valuable arterial conduit for myocardial revascularization. We have documented a particular case wherein the proximal (pyloric) part of the right gastroepiploic artery could not be freed and was damaged because of previous cholecystectomy. The pedicle was divided at the pyloric side and raised up to be anastomosed to the posterior descending artery in a retrograde fashion. The purpose of this report is to emphasize the fact that a previous abdominal operation does not necessarily hamper the use of the gastroepiploic artery as a pedicled graft. It is also pointed out that retrograde flow in the pedicle was sufficient in this case to provide good revascularization.

Renal infarction can be complicated by arterial hypertension, which is sometimes severe and may present as hypertensive encephalopathy and epilepsy. We report such a case in whom angiographic studies revealed a stenosis of the left renal artery and a post-stenotic aneurysmal dilation, containing a large thrombus with distal embolization. Thrombolysis associated with angioplasty resulted in the disappearance of the thrombus and correction of the stenosis. The pathophysiology of hypertension secondary to renal infarction is discussed. Therapeutic modalities are reviewed.

Twelve caucasian patients with intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma were treated by emergency transcatheter arterial embolization (n = 9) or chemoembolization (n = 3). Pretreatment angiography showed active bleeding (extravasation of contrast medium) in two patients only. Successful hemostasis was initially achieved in all patients. Early recurrence of hemorrhage was noted in 3 patients with large tumors; two were successfully treated by a second embolization and one died immediately after the first embolization. Of the 12 patients, two underwent subsequent chemoembolization while two had surgical resection of their tumors. The mean length of survival was 7 months from the time of rupture. No serious complications related to embolization or chemoembolization were noted. Our data suggest that emergency embolization or chemoembolization is an effective treatment in caucasian patients with intraperitoneal hemorrhage from hepatocellular carcinoma. Prognosis of ruptured hepatocellular carcinoma in those patients, however, remains poor.

Surgical endoscopy combined with electro-hydraulic lithotripsy was done on 17 patients selected for complex multiple bilio-pancreatic lithiasis. In the biliary tract (7 patients), per operatory lithotripsy was performed on 3 patients (impacted main duct stones n = 2, impacted left hepatic stones n = 1); it was done through a T-tube in 1 young patient with an impacted stone in the ampulla and percutaneously in 3 patients (1 gall bladder and 2 intra hepatic lithiasis, one of them with biliary cirrhosis and portal hypertension). Four of this patients had had iterative surgery, extracorporeal lithotripsy or retrograde endoscopy. Complete desobstruction was obtained in all patients with minimal morbidity (minor hemobilia n = 2, hemorrhage from oesophageal varicose n = 1). In the pancreas, the technique was performed on 10 patients with impacted stones in the Wirsung duct and cephalic obstruction. Mean duct diameter was 7 mm. Complete desobstruction was obtained in 9 cases and endoscopic maneuvers were associated with "double stream" operation: sphincterotomy and cephalic desobstruction plus latero-lateral wirsungo-jejunostomy. Morbidity was small (minor hemorrhage n = 3). To conclude, endoluminal electro-hydraulic lithotripsy is an interesting adjuvant technique for the treatment of obstruction from stones in complex bilio-pancreatic lithiasis, either during open surgery or trans-cutaneously.

A pulmonary hydatid cyst was diagnosed and cured by percutaneous CT guided aspiration. Pleural effusion related to incomplete aspiration of the loculated cyst was observed. No deleterious effect occurred, after a follow-up of 22 months.

The authors report the case of a patient treated by subcutaneous injection of calcium heparin after deep vein thrombosis with floating thrombus and pulmonary embolism. She was readmitted to hospital after 16 days' treatment because of a massive aorto-iliac thrombosis due to heparin-induced thrombocytopenia (platelet count = 29.000). This thrombosis was treated by local injection of Urokinase (total dose = 7.425.000 U) over 93 hours without any major complications. The aorto-iliac circulation was completely restored to normal after treatment. Thrombotic complications secondary to immuno-allergic heparin-induced thrombocytopenia are relatively common because of the widespread use of heparin. From the therapeutic point of view, it is imperative to stop the heparin, which makes surgery very difficult, and the platelet-fibrin composition of these thrombi suggests that local thrombolysis with Urokinase is the treatment of choice in this syndrome.

Two patients with acute occlusion of the lower abdominal aorta have been successfully treated with total of 7,425,000 and 8,850,000 units of urokinase infused locally over 93 and 86 hours, respectively, with restoration of flow. No complication occurred.