Search

Percutaneous transhepatic procedures have gained a strong position in the diagnosis and treatment of malignant biliary obstruction. Diagnostic cholangiography can easily be converted into therapeutic drainage, which is often the first step towards further diagnostic work-up (biopsy, percutaneous cholangioscopy) and tumour ablation and/or intraductal irradiation. Plastic endoprostheses and balloon- or self-expandable metallic stents are the therapeutic alternatives to achieve permanent internal drainage of bile.

We report on a 42-year-old patient with a Wilms tumour (nephroblastoma) of the right kidney, which was detected incidentally by sonography. Both radiological examination and intraoperative examination of a quick-frozen section led to a diagnosis of malignant renal tumour. Post-operative histological examination showed a nephroblastoma of predominantly epithelial cell type with no signs of anaplasia. Only about 210 cases of Wilms tumours in adults have been reported in the world literature so far. Because of this low incidence and the frequent lack of any clear distinction from sarcomatoid renal cell carcinoma in terminology and histology, no standardized therapy regimens exist. The prognosis with a 3-year survival rate of 24%-44% is poor compared with that of Wilms tumours in children. In a literature review the current status of knowledge about nephroblastomas in adults is discussed.

Intravascular stent placement may be an effective treatment for percutaneous transluminal angioplasty (PTA)-induced dissection. Among the first 228 patients treated with Palmaz balloon-expandable intraluminal stents (BEISs) for iliac artery stenosis, stents were used to treat PTA-induced dissection in at least 12 iliac arteries in 11 patients. All 12 vessels were shown by angiography to be severely dissected. Stents were placed at the time of PTA in six vessels and as a separate procedure in the other six. An average of three stents per vessel were employed. All arteries showed marked improvement at angiography. Angiographic follow-up was obtained for eight vessels in seven patients at a mean follow-up time of 12.9 months. All had patent stent lumens with neointima formation, although one stented lumen had narrowed, and another clinical failure occurred despite a patent stented vessel and an ankle-arm index (AAI) of 1.35. With a mean clinical follow-up of 9.5 months, the mean AAI for the stented extremities in the nine remaining patients is 0.91 +/- 0.15. Palmaz BEISs are effective in the management of PTA-induced human iliac artery dissection.

The new concept of TIPSS (Transjugular Intrahepatic Portosystemic Stent-Shunt) using the Palmaz iliac stent was successfully accomplished in 9 patients with severe portal hypertension (7 alcoholic, 2 postinfectious liver cirrhosis) and histories of multiple life-threatening upper GI bleeding. All patients were considered noncandidates for surgical portal decompression. An intrahepatic central connection was made transjugularly between the right hepatic vein and the right portal vein in 8 patients and the left portal vein in 1. The portosystemic gradient dropped from an average of 29 +/- 7.2 mmHg to 17.8 +/- 2.9 mmHg immediately after, and to 15.7 +/- 2.8 mmHg at the latest follow-up control after the procedure. Seven patients survived the procedure and progressed to Child's A stage during the observation period of 1-10 months (mean 5 months). One patient died as a direct complication from the procedure, and another patient 11 days after the procedure from a severe nosocomial infection. In none of the surviving patients has bleeding from varices recurred or encephalopathic coma developed. In one patient the shunt diameter was moderately increased by a routine PTA catheter to further decrease the portosystemic gradient (23 to 14 mmHg) 3 months after the primary procedure. Autopsy in the two patients who died demonstrated open stent-shunts with early neoendothelial incorporation.

Four cases of intra- and extrahepatic aneurysms of the hepatic artery are discussed concerning the etiology, symptoms, therapy and complication rate. The diagnostic approach and problems in differential diagnosis are specified. Localization of the aneurysm and especially the relationship of the collateral circulation of the hepatic bed are essential to plan the therapy and are based on angiography. Interventional therapeutic techniques are favored for intrahepatic localization. Reconstructive or ablative surgery is indicated to treat the extrahepatic aneurysm.

The purpose of this experimental study in dogs is to evaluate the influence of restricted flow on the thrombogenicity of balloon-expandable intravascular stents (Palmaz type). We implanted 24 Palmaz stents in the femoral artery of mongrel dogs. 12 dogs experienced a 75% flow restriction by means of an artificial stenosis distal to the start in the outflow tract. We used 111In labelled thrombocytes as a marker for thrombus detection within the stent. The results presented demonstrate that there is no considerable risk of thrombus formation if the stent is implanted into vessels with good outflow tracts and therefore high blood flow velocities within the stent. Under conditions of highly impaired flow, a 68% rate of stent occlusion occur if no anticoagulation therapy is performed. After i.v. administration of 100 IU/kg body weight of heparin the occlusion rate drops to zero. It can be concluded that even under low-flow conditions as a result of a restricted outflow tract situation the Palmaz stent can be implanted without any risk of stent occlusion as long as a sufficient anticoagulation protocol is maintained.

Balloon-expandable intraluminal stents were used to treat iliac artery stenoses or occlusions that failed to respond to conventional balloon angioplasty. One hundred seventy-one procedures were performed in 154 patients, of whom 48 had a limb at risk for amputation. Thirty-six had severe and 70 had moderate intermittent claudication. At the latest follow-up examination (average, 6 months; range, 1-24 months), 137 patients demonstrated clinical benefit, 113 of whom had become asymptomatic. Eleven patients showed no initial benefit, and six improved initially but later developed new vascular symptoms. Complications occurred in 18 patients. In three patients, complications were directly related to the device. Two occlusions were successfully recanalized, and an intramural collection of contrast material secondary to balloon perforation evolved favorably. The remaining patients had groin hematoma (n = 6), distal embolization (n = 4), extravasation (n = 2), transient renal failure (n = 1), pseudoaneurysm at the puncture site (n = 1), or subintimal dissection (n = 1). All stents have remained patent to the latest follow-up examination without evidence of migration or aneurysm formation.

A percutaneous transjugular, intrahepatic portacaval shunt was created by means of a combined jugular and transhepatic approach. In the hepatic tissue track joining the portal and hepatic veins balloon-expandable stents were placed. Two of three patients with life-threatening variceal bleeding and Child C liver cirrhosis benefited from the procedure. One patient in severe hepatorenal failure prior to the procedure died 11 days after the shunt procedure of pulmonary complications. This procedure may be a promising alternative to current therapy in high-risk patients with esophageal bleeding.

We have been able to display the hyaline hip joint cartilage clearly and with high signal strength in the magnetic resonance image with a gradient echo sequence with 2 different fresh hip specimens from corpses and with 10 healthy test subjects (5 m, 5 f). The chemical shift artifact at the bone-cartilage boundary could be clearly reduced by optimizing the geometrical scanning parameters. A comparison between the cartilage thickness at the head of the femur measured on the anatomical specimen with the thickness measured in the magnetic resonance tomogram showed a good correlation on suitable selection of the read-out gradient. The hyaline cartilage at the head of the femur could be differentiated from the acetabular cartilage in the region of the loading zone by magnetic resonance tomography in all 10 test subjects.

Massive osteolysis is a very rare tumour-like lesion usually affecting young adults. There are 132 reported cases which we have reviewed, including 31 single cases of pelvic involvement. The term "massive osteolysis" is based on the typical radiological findings, such as increasing translucency and loss of bone density. The diagnosis of the Gorham-Stout syndrome must be confirmed by the microscopic finding of intramedullary vascular structures. Our patient was a 23 year old white Caucasian, who had the full clinical signs of Gorham-Stout syndrome. She had achieved 2 normal pregnancies and deliveries in spite of her massive pelvic osteolysis.

Nine patients with renal cell carcinoma and severe hematuria were palliatively treated with a new type of angioocclusion: the concept of capillary embolization. The so-called occlusion gel Ethibloc was used as embolizing agent. Each patient was followed up until death or for at least 4 years. All patients had a stage T3 or T4 tumor, 3 patients had metastases to multiple organs, 3 had lung metastases, and 3 were free of metastatic disease. In all cases, very high volumes (14-40 ml) of the embolizing agent were necessary to achieve total occlusion of the entire arterial compartment. Patients without metastatic disease had a mean survival time of 6 years and 4 months, all of them without signs of malignant disease. Patients with metastases had a mean survival time of 3 years. Compared with the natural history of renal cell carcinoma treated otherwise, this represents a substantial prolongation of survival time. Contrary to other angioocclusive treatment modalities, the concept of capillary occlusion with Ethibloc seems to achieve total tumor destruction.

In a 49-year-old male patient suffering from severe symptoms of end-stage portal hypertension and Child's stage C metabolic status, an intrahepatic stent-assisted portosystemic shunt was established for the first time exclusively by means of interventional radiology. Via transjugular access, a modified Brockenbrough needle was used to puncture the right branch of the portal vein via the right liver vein. As a target, a Dormia-basket was used that had previously been exposed in the right main portal branch. After successful puncture and balloon dilation of the artificial tract, two Palmaz stents were implanted to keep the tract permanently open. The portosystemic pressure gradient dropped from 38 to 18 mm Hg. The clinical status of the patient improved substantially during the following days. However, the patient died on day 11 after the procedure because of sudden onset of acute respiratory distress arising from acute nosocomial fungus and cytomegalovirus infection worsened by his primary immunoincompetence. Autopsy demonstrated a totally patent shunt without superficial thrombus. Microscopically, a thin endothelial layer on the inner shunt surface was found to be present.

The problems of the phaeochromocytoma are in its rareness, its appearance--every patient with hypertension can be a carrier of a phaeochromocytoma--, its localisation--10% are situated outside the adrenal glands--, its operability with following permanent normalisation of the pressure. As hypertension is very frequent and the diagnostics is very expensive the finding of carriers of phaeochromocytomas is possible only by means of screening methods. Thus cases with an urgent suspicion are found. Such a method is described, the basis of which is a semiquantitative determination of the vanillic amygdalic acid. Instead of the usually used diazocolour-reagent in connection with a non-optimal buffer a complete nitrophenylantiazotate with a buffer of high ionic strength is taken. The pH-value 10 of the urine which is to be demanded for the colour reaction is thus reached in every case. In order to avoid falsely normal results with every urinary test a preparation with added vanillic amygdalic acid is performed and thus the presence of colour inhibitors is recognized. If the result is pathological a quantitative determination is necessary.

Methods of interventional radiology have achieved a significant importance for the treatment of acute iliac artery occlusion if either local or general clinical controindications preexclude routine surgical means of vessel repair. The newly developed balloon-expandable metal mesh vascular endoprosthesis is shown to accomplish percutaneously a definitive reconstruction of heavily diseased iliac artery vessel segments which very well compares with the hemodynamic and morphologic aspect of surgical treatment such as thrombectomy combined with TEA or bypass surgery. Both, short and long-term results one year after the implantation of two balloon-expandable metallic vascular stents reflect a much higher efficacy in functional treatment of iliac artery related claudication than a routine percutaneous transluminal angioplasty alone. In addition, it is shown that local lysis based on a standard protocol of selective intrathrombus instillation of urokinase helps to clear totally clogged iliac arteries.

A new nonoperative catheter technique to perform an intrahepatic portosystemic shunt by transjugular approach was applied to ten patients with recurrent bleeding from oesophageal and fundal varices. Therefore a balloon-expandable stent was placed between a portal vein and a hepatic vein. Implantation of the stent was successful in seven of the ten patients. Two of these seven patients died 10 and 11 days, respectively, after the procedure, one of them in consequence of respiratory failure, the other due to an uncontrollable bleeding from the site of the percutaneous transhepatic puncture because of a marked clotting disorder. The intrahepatic shunt construction led to a mean reduction of the pressure gradient between portal and hepatic vein of 40%. No recurrence of variceal haemorrhage occurred during the average follow-up time of 5.6 months (3-9 months). One patient developed several episodes of portosystemic encephalopathy. The transjugular intrahepatic portosystemic shunt is effective in the treatment of portal hypertension and might become an alternative to shunt surgery.

Percutaneous angioplasty and placement of balloon-expandable intraluminal stents were performed in 12 iliac occlusions in 12 patients. Indications were limb salvage in seven and claudication in five. After successful stenting, ankle-brachial indexes improved by 0.15 or more in 11 of 12 patients (mean increase, 0.40), transstenotic pressure gradients decreased to less than 5 mm Hg (mean, 0.58 mm Hg) in all patients, and improvement in clinical grade was seen in all patients. At follow-up at 1-14 months (median, 6 months), ankle-brachial indexes were stable (mean, 0.95), and clinical grades were unchanged in all patients. Complications occurred in two patients; both experienced distal embolization, and one, who was receiving corticosteroid therapy, also suffered stent thrombosis. Local surgical embolectomy was successful in both patients, and the thrombosed stent was recanalized with urokinase. This early experience suggests that stenting may play an important role in the management of iliac occlusions, especially in poor surgical candidates.

We report on 554 bone tumors and tumor-like lesions of the foot, which have been diagnosed within the period from 1945-1985 in the Department of Diagnostic Radiology, in the Surgical and Orthopedic Departments and in the Division of Pathology of Bone Tumors of the University of Freiburg. Schajowicz' WHO classification criteria for bone tumors were used. Morphological aspects, clinical symptoms and pattern of distribution differ widely from lesions of other skeletal regions. Bone tumors of the foot are much more frequently associated with pain caused by the special anatomy of the foot. Malignant lesions are very rare in the foot. We found only 42 malignant tumors corresponding to 1.4% of all malignant bone tumors. By contrast 13% of all benign bone tumors are localized in the foot. However, 90% of them are osteochondromas and chondromas. Other benign lesions are rare, especially tumors arising from connective tissue of bone. In several cases correct diagnosis was only possible by histologic examination whereas modern digital imaging did not substantially add to conventional plain film and tomographic examination. Preoperative CT scans were very useful for exact planning of surgical procedures especially in benign tumors.

Fifteen patients with symptomatic iliac artery stenosis were treated with intraluminal placement of balloon-expandable stents. Before treatment, 14 patients had intermittent claudication, and one had a limb at risk for amputation. One patient had diabetes mellitus, nine had hypertension, and all were long-term smokers. Two patients had surgical placement of the stent; in one patient this was part of a combined revascularization procedure. All other stents were placed percutaneously. The transstenotic gradient after injection of vasodilating drugs distal to the lesion decreased from a mean of 32.3 mm Hg +/- 16.7 to 3.1 mm Hg +/- 4.2 after stent placement. Ankle-arm Doppler systolic pressure index increased from a mean of 0.68 +/- 0.22 to 0.96 +/- 0.24 after the procedure. The treatment eliminated intermittent claudication in 14 patients and increased exercise tolerance to 500 m in the patient with a limb at risk for amputation before the procedure. The improved condition persisted in all patients during the follow-up of 6-12 months. Stent placement may be a valuable adjunct in the management of iliac artery disease.

Experimental results of embolization of normal organs did not clarify the value of transcatheter vessel occlusion in the treatment of renal carcinoma. In experimental embolization of chemically induced renal rat tumors the concept of capillary embolization was developed and showed excellent results even in end-stage tumors. In consequence this concept was adapted and transferred to clinical tumor embolization. Of 30 patients, that have been embolized up to now using Ethibloc in combination with 40% glucose as occlusion medium, one case is reported herein with a very favourable outcome. The female patient had intensive venous infiltration of a renal carcinoma accompanied by severe hematuria (T3NxM0V2). Because a patient that seems to be practically cured 30 months after embolization demonstrating massive tumor shrinkage to less than 10% of the original size in CT-controls the use of transcatheter vessel occlusion should again be investigated in association with surgical alternatives.

A 74-year-old patient suffering from severe iliac artery stenosis and claudication was chosen to be the first candidate in the world to receive the Palmaz stent, a balloon-expandable intraluminal stent. This procedure was done in the Department of Radiology, University of Freiburg, FRG. The intervention and postprocedural course were uneventful. His walking distance improved from less than 100 m to unlimited walking capacity. The intra-arterial pressure gradient and ankle-arm pressure ratio also returned to normal.