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Resumen Introducción: El colangiocarcinoma intrahepático (CIH) corresponde al segundo tumor hepático primario y la resección quirúrgica es la única alternativa válida para el tratamiento curativo de esta enfermedad. Reporte de casos: Describimos 2 paciente portadores de CIH con compromiso de vena cava inferior (VCI) que fueron sometidos a resección en Clínica Alemana de Santiago (CAS). Ambas pacientes son de género femenino de 39 y 47 años de edad. Ambas fueron sometidas a resección mayor hepática izquierda, asociada a resección del segmento I y extendida a VCI. La reconstrucción de la VCI fue realizada con parche pericárdico bovino y cierre primario respectivamente. El período desde el posoperatorio hasta el alta, fue de 13 y 23 días respectivamente. Discusión: Aunque la reseccion quirúrgica es la única vía para la curación en el CIH, el compromiso de estructuras vasculares hacen que esto no sea posible. El manejo multidisciplinario asociado a una técnica meticulosa realizada por un equipo quirúrgico experimentado, hacen posible lograr buenos resultados. Introduction: Intrahepatic cholangiocarcinoma is the second most common primary liver tumor and surgical resection the only valid curative treatment. Case reports: We describe two patients harboring an intrahepatic cholangiocarcinoma with cava vein involvement who underwent resection at Clinica Alemana of Santiago. Both patients were females with ages of 39 and 47 years old. Both patients underwent left liver resection, associated to resection of segment I and of a portion of cava vein. Reconstruction of resected portion of the cava vein was performed by using a pericardium bovine patch and primary closure respectively. Postoperative period was uneventfully being discharged at 13 and 23 days respectively. Discussion: Although surgical resection is the only way to get curativeness, frequent involvement of large vascular structures make treatment unfeasible. A multidisciplinary approach associated with a meticulous technique performed by an experienced surgical team make possible to accomplish the above objective. more...

Objectives and Study: Protein losing enteropathy (PLE) is a rare complication following paediatric liver transplantation (LTx), mostly related to venous outflow obstruction of the liver. Here, we discuss diagnosing a thus far unknown cause of PLE following paediatric LTx and its surgical treatment. Method: Case-study Results: A boy received an LTx (segments 2 and 3, postmortal heart-beating donor, Roux-en-Y hepaticojejunostomy) at the age of 7 months because of ornithine transcarbamylase deficiency. At the age of 18 months, he developed generalized edema and ascites. PLE was diagnosed, as faecal alpha-1 antitrypsin levels were markedly increased. Clinically, he required suppletion of albumin intravenously every two weeks, for which a venous access port was implanted. Routine diagnostic work-up for PLE was negative. No infectious cause of PLE was found. Endoscopy (gastroduodeno-/ colonoscopy, capsule endoscopy) showed no mucosal injuries and no signs of lymphangiectasia. PET/CT scan showed no signs of post-transplant lymphoproliferative disorder. Vascular origin, most notably venous outflow obstruction, is a known cause of PLE following LTx. Therefore catheterisation was performed, which showed no signs of venous outflow obstruction (normal central venous pressure of 9 mm Hg in the inferior vena cava and normal pressure in the hepatic vein of 9 mmHg), and only a slightly increased wedge pressure in the hepatic vein (19 mmHg). A liver biopsy taken during the same procedure showed no relevant pathology. To find the localization of protein loss, an albumin scan (technetium-99m labeled albumin) was performed, which confirmed intestinal albumin loss. Of note, early recordings (dynamic 0-30 min and early static SPECT-CT recordings at 30, 60, 90 minutes after tracer injection instead of after 120 minutes) were done, to detect where albumin entered the intestine. The affected area on the albumin scan was where the Roux loop was expected. With regard to the albumin loss in the Roux loop, local bacterial overgrowth or local lymphangiectasia, possibly due to (venous) congestion, were considered. Treatment with Metronidazole did not improve albumin loss, rendering local bacterial overgrowth an unlikely cause of the PLE. Therefore a surgical revision of the Roux loop was performed. During the procedure, no torsion of the Roux loop was observed. The explanted loop macroscopically showed a small abnormal area with a thin hyperaemic mucosa (Figure 1A). Histological analysis showed focal lymphangiectasia (Figure 1B), which was considered the site of protein loss. Following surgical revision, PLE disappeared and serum albumin levels remained stable, up to now (6 months post-revision, Figure 1C). We suspect that the local PLE in the Roux loop arose from local congestion of lymphatic outflow. Conclusion: Here, we report diagnosing a thus far unknown cause of PLE following LTx in a child. The Roux loop was found to be the site of albumin loss using early SPECT-CT recordings during an albumin scan. Notably, this was in the absence of relevant portal hypertension. Surgical revision of the Roux loop has stopped the PLE up to now, 6 months post-revision (Figure presented). more...

Objectives and Study: Protein losing enteropathy (PLE) is a rare complication following paediatric liver transplantation (LTx), mostly related to venous outflow obstruction of the liver. Here, we discuss diagnosing a thus far unknown cause of PLE following paediatric LTx and its surgical treatment. Method: Case-study Results: A boy received an LTx (segments 2 and 3, postmortal heart-beating donor, Roux-en-Y hepaticojejunostomy) at the age of 7 months because of ornithine transcarbamylase deficiency. At the age of 18 months, he developed generalized edema and ascites. PLE was diagnosed, as faecal alpha-1 antitrypsin levels were markedly increased. Clinically, he required suppletion of albumin intravenously every two weeks, for which a venous access port was implanted. Routine diagnostic work-up for PLE was negative. No infectious cause of PLE was found. Endoscopy (gastroduodeno-/ colonoscopy, capsule endoscopy) showed no mucosal injuries and no signs of lymphangiectasia. PET/CT scan showed no signs of post-transplant lymphoproliferative disorder. Vascular origin, most notably venous outflow obstruction, is a known cause of PLE following LTx. Therefore catheterisation was performed, which showed no signs of venous outflow obstruction (normal central venous pressure of 9 mm Hg in the inferior vena cava and normal pressure in the hepatic vein of 9 mmHg), and only a slightly increased wedge pressure in the hepatic vein (19 mmHg). A liver biopsy taken during the same procedure showed no relevant pathology. To find the localization of protein loss, an albumin scan (technetium-99m labeled albumin) was performed, which confirmed intestinal albumin loss. Of note, early recordings (dynamic 0-30 min and early static SPECT-CT recordings at 30, 60, 90 minutes after tracer injection instead of after 120 minutes) were done, to detect where albumin entered the intestine. The affected area on the albumin scan was where the Roux loop was expected. With regard to the albumin loss in the Roux loop, local bacterial overgrowth or local lymphangiectasia, possibly due to (venous) congestion, were considered. Treatment with Metronidazole did not improve albumin loss, rendering local bacterial overgrowth an unlikely cause of the PLE. Therefore a surgical revision of the Roux loop was performed. During the procedure, no torsion of the Roux loop was observed. The explanted loop macroscopically showed a small abnormal area with a thin hyperaemic mucosa (Figure 1A). Histological analysis showed focal lymphangiectasia (Figure 1B), which was considered the site of protein loss. Following surgical revision, PLE disappeared and serum albumin levels remained stable, up to now (6 months post-revision, Figure 1C). We suspect that the local PLE in the Roux loop arose from local congestion of lymphatic outflow. Conclusion: Here, we report diagnosing a thus far unknown cause of PLE following LTx in a child. The Roux loop was found to be the site of albumin loss using early SPECT-CT recordings during an albumin scan. Notably, this was in the absence of relevant portal hypertension. Surgical revision of the Roux loop has stopped the PLE up to now, 6 months post-revision (Figure presented). more...

Objectives and Study: Protein losing enteropathy (PLE) is a rare complication following paediatric liver transplantation (LTx), mostly related to venous outflow obstruction of the liver. Here, we discuss diagnosing a thus far unknown cause of PLE following paediatric LTx and its surgical treatment. Method: Case-study Results: A boy received an LTx (segments 2 and 3, postmortal heart-beating donor, Roux-en-Y hepaticojejunostomy) at the age of 7 months because of ornithine transcarbamylase deficiency. At the age of 18 months, he developed generalized edema and ascites. PLE was diagnosed, as faecal alpha-1 antitrypsin levels were markedly increased. Clinically, he required suppletion of albumin intravenously every two weeks, for which a venous access port was implanted. Routine diagnostic work-up for PLE was negative. No infectious cause of PLE was found. Endoscopy (gastroduodeno-/ colonoscopy, capsule endoscopy) showed no mucosal injuries and no signs of lymphangiectasia. PET/CT scan showed no signs of post-transplant lymphoproliferative disorder. Vascular origin, most notably venous outflow obstruction, is a known cause of PLE following LTx. Therefore catheterisation was performed, which showed no signs of venous outflow obstruction (normal central venous pressure of 9 mm Hg in the inferior vena cava and normal pressure in the hepatic vein of 9 mmHg), and only a slightly increased wedge pressure in the hepatic vein (19 mmHg). A liver biopsy taken during the same procedure showed no relevant pathology. To find the localization of protein loss, an albumin scan (technetium-99m labeled albumin) was performed, which confirmed intestinal albumin loss. Of note, early recordings (dynamic 0-30 min and early static SPECT-CT recordings at 30, 60, 90 minutes after tracer injection instead of after 120 minutes) were done, to detect where albumin entered the intestine. The affected area on the albumin scan was where the Roux loop was expected. With regard to the albumin loss in the Roux loop, local bacterial overgrowth or local lymphangiectasia, possibly due to (venous) congestion, were considered. Treatment with Metronidazole did not improve albumin loss, rendering local bacterial overgrowth an unlikely cause of the PLE. Therefore a surgical revision of the Roux loop was performed. During the procedure, no torsion of the Roux loop was observed. The explanted loop macroscopically showed a small abnormal area with a thin hyperaemic mucosa (Figure 1A). Histological analysis showed focal lymphangiectasia (Figure 1B), which was considered the site of protein loss. Following surgical revision, PLE disappeared and serum albumin levels remained stable, up to now (6 months post-revision, Figure 1C). We suspect that the local PLE in the Roux loop arose from local congestion of lymphatic outflow. Conclusion: Here, we report diagnosing a thus far unknown cause of PLE following LTx in a child. The Roux loop was found to be the site of albumin loss using early SPECT-CT recordings during an albumin scan. Notably, this was in the absence of relevant portal hypertension. Surgical revision of the Roux loop has stopped the PLE up to now, 6 months post-revision (Figure presented). more...

Background Cor triatriatum dexter (CTD) is a rare congenital cardiac malformation with various manifestations and has been sporadically described in dogs. Clinically the dogs present with nonspecific signs of right heart failure or Budd-Chiari-like syndrome. Other associated concurrent cardiovascular anomalies are commonly reported. Diagnosis and full characterization of this complex malformation requires careful investigation and often a multimodal imaging approach. Case presentation A 10-week-old, male intact, Golden Retriever was presented with clinical signs of stunted growth, anorexia, and progressive ascites. CTD imperforate with sole separation of the caudal vena cava (CdVC) and concurrent venous wall mineralization was conjointly diagnosed and fully characterized by echocardiography, non-selective angiography, computed tomography angiography and cardiac magnetic resonance imaging (MRI). This was successfully treated surgically and the dog returned to normal activity. Conclusion To the author’s knowledge, this is the first case of CTD imperforate separating the CdVC from the right atrium (RA) with presumed secondary CdCV wall and hepatic parenchyma mineralization reported in a dog. CTD is an important and potentially correctable cause for the development of ascites in a young puppy. Accurate diagnosis of this complex cardiac anomaly is important for selection of the most appropriate curative treatment option. more...

PURPOSE: We aimed to investigate the safety and functionality of tunneled transhepatic hemodialysis catheters in chronic hemodialysis patients. METHODS Thirty-eight patients (20 women aged 56±10 years and 18 men aged 61±11 years) with transhepatic tunneled hemodialysis catheters were evaluated. The date of the first transhepatic catheterization, indications, procedure details, functional time periods of catheters, reasons for the removal or revision of catheters, catheter-related complications, and current conditions of patients were retrospectively analyzed. RESULTS A total of 69 catheters were properly placed in all patients (100% technical success) under imaging guidance during the 91-month follow-up period. The functionality of 35 catheters could not be evaluated: five catheters were removed because of noncomplication related reasons (surgical fistulas were opened in two cases [2/35, 5.7%], transplantation was performed in three cases [3/35, 8.6%]), 18 patients died while their catheters were functional (18/35, 51.4%), and 12 catheters were still functional at the time of the study (12/35, 34.3%). The functionality of catheters was evaluated the remaining 34 catheters that necessitated revision because of complications. Furthermore, only half of the catheters were functional on day 136 when evaluated using Kaplan- Meier analysis. The four main complications were thrombosis (16/34, 47%; complication rate of 0.37 days in 100 catheters), infection (8/34, 23.5%; 0.18 days in 100 catheters), migration (8/34, 23.5%; 0.18 days in 100 catheters), and kinking (2/34, 6%; 0.04 days in 100 catheters). CONCLUSION Transhepatic venous catheterization is a safe and functional alternative route in chronic hemodialysis patients without an accessible central venou route. The procedure can be performed with high technical success and low complication rates under imaging guidance. © Turkish Society of Radiology 2016. more...

Venous thromboembolism (VTE) is most commonly initially treated with low molecular weight heparin (LMWH), fondaparinux, or unfractionated heparin, in combination with vitamin-K antagonists (VKA) for long-term treatment. VKA have some drawbacks, however, which has led to the development of new anticoagulants. Most of these new drugs can be administered orally, and have been investigated in several phase III clinical trials. The benefits of these anticoagulants include their stable therapeutic effect, reduced interactions with other medication and food, and, therefore, the reduced need for regular monitoring. The duration of anticoagulant treatment for VTE is usually 3-12months, but depends on the balance between the risks of recurrent thrombosis, major bleeding, and the patient's preference. Clinical decision rules to assess the risk of recurrence to tailor the duration of anticoagulant treatment are being investigated. The beneficial aspects of novel anticoagulants may prolong the duration of treatment. VTE treatment should be adjusted in special patient groups, such as in cases of malignancy, renal failure, pregnancy, or obesity. In this review, the current and future aspects of the treatment of VTE are explored. © 2011 International Society on Thrombosis and Haemostasis. more...

Ufuk, Furkan/0000-0002-8614-5387; Ufuk, Furkan/0000-0002-8614-5387 WOS:000459432000025 PubMed: 30629460 Objective: We aimed to determine the diagnostic performance of the contrast-enhanced and unenhanced combined pulmonary arterial MRI and magnetic resonance venography techniques in the diagnosis of venous thromboembolism (VTE). Methods: 44 patients who underwent CT pulmonary angiography (CTPA) for suspected PE constituted the study population. Patients underwent combined pulmonary and lower extremity MRI, and Doppler ultrasonography within 72 h after CTPA. Combined MRI included two sequences: unenhanced steady-state free precession (SSFP) and contrast-enhanced three-dimensional (3D) gradient echo (GRE). The presence of emboli in pulmonary arteries and thrombi in lower extremity veins on 3D-GRE and SSFP sequences was recorded. Results: CTPA showed a total of 244 emboli in 33 (75%) patients whereas contrast-enhanced 3D-GRE MRI showed deep vein thrombosis (DVT) in 34 (77%) subjects. Sensitivities for SSFP vs 3D-GRE MRI respectively in PE detection were 87.9 vs 100% on a per-patient basis, and 53.7 vs 73% on a per-embolus basis. Of 34 patients with established DVT, 31 (91%) were detected by Doppler ultrasound and 29 (85%) were detected by SSFP technique respectively. Conclusion: Both contrast-enhanced and unenhanced combined MRI of acute PE and DVT are feasible one-stop-shopping techniques in patients with suspected thromboembolism. Advances in knowledge: Pulmonary VTE is a common disease with high mortality. Non-invasive techniques withhigh accuracy are required for the assessment of VTE. CT-related radiation and contrast material risks cause concerns. MRI is a radiation-free technique evaluating the vessels with and without contrast. Combined contrast enhancedor unenhanced pulmonary and lower extremity MRI is feasible in patients with suspected thromboembolism. more...

The clinical presentation of pulmonary embolism (PE) varies widely, ranging from only limited symptoms to severe cardiogenic shock. Treatment of PE comprises initial therapy - with low-molecular-weight heparin (LMWH), fondaparinux, or unfractionated heparin - and long-term treatment, most commonly with vitamin-K antagonists (VKAs). Methods of risk stratification, to determine whether a patient will benefit from thrombolysis, are currently under investigation. However, at present, insufficient evidence exists that hemodynamically stable patients who demonstrate echocardiographic right ventricular strain (submassive PE) benefit from thrombolysis. By contrast, thrombolysis is a widely accepted treatment strategy for patients with hemodynamic shock (massive PE). The duration of VKA treatment is commonly 3-12 months and depends on the type of PE and on the balance between the risks of recurrent PE, major bleeding, and the patient's preference. In patients with a malignancy, treatment with LMWH during the first 6 months after diagnosis of PE is recommended. Several new oral anticoagulants, such as factor IIa and factor Xa inhibitors, are now being investigated. For prevention of recurrent PE in situations where anticoagulation is contraindicated, a temporary inferior vena cava filter might be useful. Some patients with PE can be safely treated at home, but few outcome studies in this setting have been published. © 2010 Macmillan Publishers Limited. All rights reserved. more...

INTRODUCCIÓN. El ultrasonido es fundamental en la medicina de emergencias, no se conoce cual debería ser la curva de aprendizaje para obtener las competencias técnicas y operativas; ACEP recomienda por cada ventana ecográfica realizar 25 repeticiones. No existe una curva de aprendizaje para ventana de VCI en la población de residentes colombianos. OBJETIVO: Determinar la curva de aprendizaje necesaria para obtener una proporción mayor al 80% de éxitos en la toma de la ventana ecográfica de la VCI, usando la escala de calificación para el aseguramiento de la calidad sugerida por ACEP, en residentes de I a III año de medicina de emergencias. METODOLOGÍA: Estudio experimental no comparativo, que evaluó la proporción de éxito en función del las tomas repetidas de la VCI por ultrasonido, mediciones que se tomaron luego de participar en una capacitación teórica y demostrativa de la técnica propuesta; se calificaron los videos según la escala publicada por ACEP. El análisis estadístico se realizó con un modelo logístico multinivel para la proporción del éxito, agrupado por repetición y agrupado por sujeto. RESULTADOS: Se obtuvo información de 8 residentes, cada uno realizo 25 repeticiones a 3 modelos sanos con asignación aleatoria. Se realizó la curva de aprendizaje obteniendo en 11 repeticiones una proporción de 0.80 (rango 0.54 a 0.92) y en 21 repeticiones una proporción de 0.9 (rango 0.75 a 0.96), datos ajustados por numero de repetición y residente. CONCLUSIÓN: La curva de aprendizaje para la ventana ecográfica de la VCI es de 11 y 21 repeticiones para obtener el 80% y 90% de éxito en residentes de medicina de emergencias de I a III año de la universidad del rosario. INTRODUCTION. Ultrasound is essential in emergency medicine. However, learning curve to obtain technical and operative is unknown. ACEP suggests a minimum of 25 repeats by every ultrasound window. This study evaluated learning curve for ultrasound window of Inferior Vena Cava (IVC). AIM: To establish learning curve in emergencies medical residents needed to obtain a proportion of success above 80% in ultrasound window for IVC, measured by ACEP scale for quality assurance. METHODS: An experimental non-comparative study was designed to evaluate the success proportion of IVC ultrasound window after repetitive attempts. An expositive class of the technique was made prior to the experiment. Videos were assessed based on ACEP scales. For statistical analysis a multilevel logistic model was used for success proportion grouped by data and subject. RESULTS: Data were obtained from 8 residents. Each one made 25 repeats to 3 randomized healthy models. Learning curve adjusted by subject and number of repeats showed a proportion of 0. 81 (range from 0. 57 to 0. 93) after 11 repeats and 0. 9 (0. 75 to 0. 96) after 21 repeats. CONCLUSION: For a success proportion of 80 and 90% in IVC ultrasound window, 11 and 21 repeats are needed, respectively. more...

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Objectives: Retrograde cerebral perfusion (RCP) has been employed to protect the brain during cardiovascular surgery, requiring temporary hypothermic circulatory arrest (HCA). However, the protocol used for RCP remains to be modified if prolonged HCA is expected. The aim of this study was to determine the efficacy of a modified protocol for this purpose. Methods: After establishment of HCA at 15°C, 14 pigs were subjected to 90-min RCP using either the conventional protocol (i.e. alpha-stat strategy, 25-mmHg perfusion pressure and occluded inferior vena cava, Group I, n = 7) or the new protocol (i.e. pH-stat strategy, 40-mmHg perfusion pressure and unoccluded inferior vena cava, Group II, n = 7). After being rewarmed to 37°C, pigs were perfused for another 60 min. Phosphorus-31 magnetic resonance spectroscopy was used to track the changes of brain high-energy phosphates [i.e. adenosine triphosphate and phosphocreatine (PCr)] and intracellular pH (pHi). At the end, brain water content was measured. Results: During RCP, high-energy phosphates decreased in both groups, whereas adenosine triphosphate decreased much faster in Group I (10.4 ± 4.3 vs 30.4 ± 4.4% of the baseline, P = 0.007, 60-min RCP). After rewarming, the recovery of high-energy phosphates and pHi was much slower in Group I (PCr: 55.7 ± 9.1 vs 78.4 ± 5.1% of the baseline, P = 0.046; adenosine triphosphate: 26.6 ± 10.6 vs 64.8 ± 4.6% of the baseline, P = 0.007; pHi: 6.5 ± 0.4 vs 7.1 ± 0.1, P = 0.021 at 30-min normothermic perfusion after rewarming). Brain tissue water content was significantly higher in Group I (81.1 ± 0.4 vs 79.5 ± 0.4%, P = 0.016). Conclusions: Application of the modified RCP protocol significantly improved cerebral energy conservation during HCA and accelerated energy recovery after rewarming. © The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. more...

Objective: Retrospective analysis of hemodialysis catheters implanted using transhepatic venous route in terms of safety and functionality in patients with exhausted conventional venous access routes. Material and Methods: Ten patients underwent placement of 22 transhepatic 14F tunneled hemodialysis catheters at our center in the period 2007-2011. Catheter safety was assessed by means of complications encountered. Catheter functionality was assessed by means of the data derived from the electronic documents and digital images captured during the device problems and catheter revisions. Catheter patency was described using Kaplan-Meier survival curve. Results: Technical success was achieved in all patients. There was no hepatic injury or bleeding related to the procedure. Catheter functionality was impared due to the complications such as thrombosis, migration and infection. The catheter thrombosis rate was 0.18, the catheter migration rate was 0.12, and catheter-related infection rate was 0.08 per 100 catheter-days. Mean device patency was 132 (28-214) catheter days. Fifty percent of the catheters functioned longer than 182 catheter days. Mean catheter stay in-situ was 283 (20-629) catheter days. Mean single access patency was 217 (20-571) catheter days. Conclusion: By using transhepatic venous route, effective and safe hemodialysis can be performed in long term in patients with limited venous access. Geleneksel venöz erişim yolları tükenmiş olgularda transhepatik venöz yolla yerleştirilen hemodiyaliz kateterlerinin güvenilirliği ve işlevselliğinin geriye dönük değerlendirilmesi. Ge reç ve Yön tem ler: Merkezimizde 2007-2011 yılları arasında yaşları 23-71 arasında değişen 10 olguya 22 adet 14F tünelli diyaliz kateteri transhepatik yolla yerleştirildi. Kateter güvenilirliği, gelişen komplikasyonlar analiz edilerek değerlendirildi. Kateterlerin işlevselliği için, kateter problemleri ve değişimlerinde tutulan elektronik doküman ve dijital görüntü kayıtlarına ait veriler kullanıldı. Kateterlerin işlevselliği kateterin işlev gördüğü gün temel alınarak Kaplan-Meier analizi ile değerlendirildi. Bul gu lar: Tüm girişimlerde teknik başarı sağlandı. İşleme ait masif kanama ya da parankimal yaralanma gelişmedi. Kateter işlevinin kateter trombozu, migrasyon ve enfeksiyon gibi komplikasyonlara bağlı bozulduğu görüldü. Her 100 kateter günü için kateter tromboz oranı 0,18, migrasyon oranı 0,12, enfeksiyon oranı 0,08 bulundu. Ortalama kateter açıklığı 132 (28-214) gün bulundu. Kateterlerin %50’sinin 182. günde işlevsel olduğu görüldü. Bir hastanın ortalama kateterli kaldığı süre 283 (20-629) gün olarak bulundu. Tek giriş hattından sağlanan ortalama açıklık 217 (20-571) kateter günü idi. Sonuç: Venöz erişimi kısıtlı olgularda uzun sü more...

The clinical presentation of pulmonary embolism (PE) varies widely, ranging from only limited symptoms to severe cardiogenic shock. Treatment of PE comprises initial therapy - with low-molecular-weight heparin (LMWH), fondaparinux, or unfractionated heparin - and long-term treatment, most commonly with vitamin-K antagonists (VKAs). Methods of risk stratification, to determine whether a patient will benefit from thrombolysis, are currently under investigation. However, at present, insufficient evidence exists that hemodynamically stable patients who demonstrate echocardiographic right ventricular strain (submassive PE) benefit from thrombolysis. By contrast, thrombolysis is a widely accepted treatment strategy for patients with hemodynamic shock (massive PE). The duration of VKA treatment is commonly 3-12 months and depends on the type of PE and on the balance between the risks of recurrent PE, major bleeding, and the patient's preference. In patients with a malignancy, treatment with LMWH during the first 6 months after diagnosis of PE is recommended. Several new oral anticoagulants, such as factor IIa and factor Xa inhibitors, are now being investigated. For prevention of recurrent PE in situations where anticoagulation is contraindicated, a temporary inferior vena cava filter might be useful. Some patients with PE can be safely treated at home, but few outcome studies in this setting have been published. © 2010 Macmillan Publishers Limited. All rights reserved. more...

Sir, I read with great interest the paper by Drs Schaefer-Prokop and Prokop [1] in the December 2008 issue of European Radiology, highlighting the protocols to optimize the image quality of CT pulmonary angiography (CTPA) in pregnant individuals. I appreciate the authors’ editorial work, which comprehensively overviewed the limitations of CTPA related to physiological changes during pregnancy and summarized the options to overcome them. In an attempt to shed further light on the effect of altered caval blood flow deteriorating the quality of CTPA, I would like to draw attention to a recent paper by Kuzo et al. [2], who quantitatively measured caval blood flow in healthy subjects by velocity-encoded cine MRI. They found that caval blood flow significantly increases during continuous inspiration and decreases during the Valsalva manoeuvre compared with free breathing. When the ratio of inferior vena cava to superior vena cava blood flow was taken into consideration, it increases during continuous inspiration (2.37), and decreases during breath-hold at end inspiration (1.90), breath-hold at end expiration (1.94), and at Valsalva manoeuvre (1.51) compared with free breathing (2.04). They concluded that CTPA should be performed with only a small inspiration or no inspiration before acquiring CT data. It has also been demonstrated by a Doppler study that hepatic venous pulsatility is decreased during pregnancy, being completely flat with increasing gestational age, which is attributed to increased cardiac output and the pressure effects of the enlarged gravid uterus [3]. Similarly, the compliance of the inferior vena cava is likely to be decreased during pregnancy by the same mechanism, leading to continuous forward flow of unopacified blood into the right atrium. Knowledge of physiological changes taking place during pregnancy will enable us to modify our acquisition protocols accordingly. more...

Purpose: To determine if, with use of magnetic resonance (MR) imaging guidance alone, transcaval puncture of the superior mesenteric vein (SMV) and/or portal vein is feasible with a percutaneous femoral vein approach. Materials and Methods: The Institutional Animal Care and Use Committee approved the animal studies. Ten inferior vena cava (IVC)-SMV punctures were performed in six pigs. An active MR intravascular needle system was used for all transvascular punctures, and all procedures were performed with a 1.5-T MR unit. The needle was introduced via a 12-F femoral vein sheath and advanced into the IVC by using a real-time gradient-recalled-echo sequence (3.4/1.2 [repetition time msec/echo time msec], 45° flip angle, and six to eight frames per second). Fast transverse spoiled gradient-recalled acquisition in the steady state (SPGR) (6.0/1.5, 60° flip angle, one frame per second) was performed to confirm needle trajectory. The needle system was advanced under real-time MR imaging to puncture the SMV. The location of the needle tip was confirmed with a fast spin-echo sequence (1904/4.5, 36-cm field of view). A direct MR portogram was obtained after the administration of gadopentetate dimeglumine at a concentration of 25% with fast SPGR (6/1.3, 90° flip angle, no section selection, three frames per second). Success was defined as entry into the mesehteric venous system without traversal of any retroperitoneal organs or adjacent vasculature. Results: Successful MR imaging-guided IVC-SMV punctures were performed in all 10 procedures (100%). The needle was fully visualized as it traversed the retroperitoneum and entered the SMV. MR portograms were successfully obtained following all punctures through the needle. Conventional transverse MR imaging helped confirm that the needle did not traverse any retroperitoneal organs or vessels. Conclusion: With use of only MR imaging guidance and an active MR imaging intravascular needle system, the authors were able to successfully puncture the SMV from the IVC with direct visualization of the needle and and retroperitoneal structures. © RSNA, 2006. more...

Objectives: Renal cell carcinoma (RCC) propagation into the inferior vena cava is rare (10-25%) and is described as an extension above the hepatic veins up to the right atrium or even into the right ventricle. Venous tumour invasion is associated with several prognostic factors such as local infiltration of perinephric tissue, lymph nodes metastases, caval infiltration, and the presence of distant metastases. We reviewed our experience with surgical treatment of RCC with vena cava involvement. Methods: We analysed the Urological Genoa School results from 1970 to 1985 on 28 consecutive cases (Giuliani's series) and between 1986 and 2005 on 59 of 81 cases from three Italian urologic academic centres (Trieste, Bologna, and Genoa). Results: For 1970-1985, the overall survival rate for all patients was 30% at follow-up periods of 36-66 mo. With caval infiltration, the overall survival rate at 12 mo was 0%. For the period 1986-2005, the overall survival rate at 8 yr was about 80%. Nonsignificant differences for nodal stage and caval infiltration were observed during the two time periods. Conclusions: Our data confirm, as reported by others, that nonmetastatic RCC with extension into vena cava is potentially curable. © 2006 European Association of Urology. more...

PURPOSE: A new inferior vena cava filter was evaluated in vivo to determine the percutaneous retrievability after an implantation period of up to 18 days. MATERIALS AND METHODS: The inferior venae cavae of six goats were percutaneously implanted with three filters, and one animal received two filters. To assess filter stability, a plain radiograph was obtained after 7-9 days and on the day of retrieval. After cavography, filter retrieval with an endovascular snare and retrieval catheter was performed in three animals after 12 days and in three others after 14 days. In one animal, retrieval of one filter was performed after 18 days, and one filter was intended to be permanent. Twenty-eight days after filter retrieval, cavography was performed before inferior vena cava removal for gross and histologic examination. RESULTS: All filters (N = 20) were implanted without complications. There was no migration during the implantation period. Preretrieval cavography demonstrated all filters to be patent and centered. Filters intended for retrieval (n = 19) were all successfully extracted at 12 (nine filters), 14 (nine filters), and 18 days (one filter). For the animal with the filter extracted at 18 days, one filter remained in situ intentionally. Postretrieval cavography showed no visible signs of vessel wall anomalies. There were no complications during the 28 days of follow-up after retrieval. Presacrifice cavography showed no evidence of caval wall abnormalities. In all animals, gross examination of the inner wall of the explanted vena cava showed only minimal macroscopic changes. The struts of the filter in situ for 46 days (18 days with 28 days of follow-up) were overgrown with neointima. Histological study of the 19 filter retrieval sites revealed no to moderate intima proliferation, minimal residual signs of hemorrhages, and no or only occasional slight inflammatory reaction. CONCLUSIONS: In this animal model, the new vena cava filter demonstrated event-free retrieval, without postretrieval complications, up to 18 days postimplantation. After implantation of 46 days, the filter showed neointima overgrowth of the struts. more...

PURPOSE: A new inferior vena cava filter was evaluated in vivo to determine the percutaneous retrievability after an implantation period of up to 18 days. MATERIALS AND METHODS: The inferior venae cavae of six goats were percutaneously implanted with three filters, and one animal received two filters. To assess filter stability, a plain radiograph was obtained after 7-9 days and on the day of retrieval. After cavography, filter retrieval with an endovascular snare and retrieval catheter was performed in three animals after 12 days and in three others after 14 days. In one animal, retrieval of one filter was performed after 18 days, and one filter was intended to be permanent. Twenty-eight days after filter retrieval, cavography was performed before inferior vena cava removal for gross and histologic examination. RESULTS: All filters (N = 20) were implanted without complications. There was no migration during the implantation period. Preretrieval cavography demonstrated all filters to be patent and centered. Filters intended for retrieval (n = 19) were all successfully extracted at 12 (nine filters), 14 (nine filters), and 18 days (one filter). For the animal with the filter extracted at 18 days, one filter remained in situ intentionally. Postretrieval cavography showed no visible signs of vessel wall anomalies. There were no complications during the 28 days of follow-up after retrieval. Presacrifice cavography showed no evidence of caval wall abnormalities. In all animals, gross examination of the inner wall of the explanted vena cava showed only minimal macroscopic changes. The struts of the filter in situ for 46 days (18 days with 28 days of follow-up) were overgrown with neointima. Histological study of the 19 filter retrieval sites revealed no to moderate intima proliferation, minimal residual signs of hemorrhages, and no or only occasional slight inflammatory reaction. CONCLUSIONS: In this animal model, the new vena cava filter demonstrated event-free retrieval, without postretrieval complications, up to 18 days postimplantation. After implantation of 46 days, the filter showed neointima overgrowth of the struts. more...

Coronary artery fistulas are the second most frequently seen coronary anomaly following abnormalities of coronary artery origin and distribution. A coronary fistula is defined as a direct communication between a coronary artery and any cardiac chamber or vessel. Treatment options include percutaneous embolization and surgical intervention. Herein, we present a case of a giant coronary artery fistula and right atrial tachycardia that was induced during a diagnostic electrophysiologic study but was not inducible after the successful treatment of the fistula. This is the first case indicating this association. Resumo: As fístulas coronárias são a segunda anomalia mais frequente das artérias coronárias a seguir às anomalias coronárias da câmara de saída. A fístula define-se como uma comunicação direta entre as artérias coronárias e uma cavidade cardíaca ou estrutura vascular. As opções terapêuticas incluem a embolização percutânea e o tratamento cirúrgico. Apresentamos aqui um caso de uma fistula coronária gigante e taquicardia auricular direita induzida durante um estudo electrofisiológico diagnóstico e que não foi possível induzir após o tratamento bem sucedido da fístula. Este é o primeiro caso que reporta esta associação. Keywords: Coronary artery fistula, Atrial tachycardia, Coil embolization, Palavras-chave: Fistula arterial coronária, Taquicardia auricular, Embolização com coil more...

Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-27T11:18:03Z No. of bitstreams: 0Bitstream added on 2014-05-27T14:44:05Z : No. of bitstreams: 1 2-s2.0-0029960922.pdf: 63831 bytes, checksum: ac46307cb7c8710c19599d89e6d7682b (MD5) Made available in DSpace on 2014-05-27T11:18:03Z (GMT). No. of bitstreams: 0 Previous issue date: 1996-01-01 Background and Objectives - A controversy exists in the literature regarding the effects of the acute administration of magnesium on the cardiovascular system of animals and humans. The purpose of this study was to evaluate the effects of hypermagnesemia on the cardiovascular hemodynamics of dogs. Methods - Sixteen mongrel dogs were anesthetized with pentobarbitone 30 mg.kg-1 and submitted to volume expansion with Ringer's solution (0.4 ml.kg-1.min-1 and mechanical ventilation with room air. In this model, the hemodynamic repercussions of the following drugs and doses were studied. pentobarbitone 5 mg.kg-1 Group 1, control - and the association of pentobarbitone and magnesium sulphate (MS), at the dose of 140 mg.kg-1 injected in 15 minutes, followed by an infusion of 80 mg.kg-1.h-1 - Group 2. The parameters studied were: heart rate, blood pressure, inferior vena cava pressure, cardiac index, systolic index and peripheral resistance index, evaluated at 5 different moments: 15(M1), 30(M2), 60(M3) and 75(M4) minutes after the first suppplementary dose of pentobarbitone and 15 minutes (M5) after the second supplementary dose. In Group 2, the moments M3, M4, M5 corresponded to 15, 30 and 60 minutes after the priming dose of magnesium sulphate. Results - Group 1 animals exhibited tachycardia since the beginning of the experiment. There was a decrease in the cardiac index, in the systolic index and an increase in the inferior vena cava pressure. Group 2 animals also exhibited tachycardia, but heart rate decreased after MS infusion. The blood pressure and the peripheral resistance index decreased. The systolic index increased and the cardiac index decreased only at the end of the experiment. Conclusions: The antiadrenergic effects of MS could have been responsible for the decrease in heart rate. The vasodilating effects of the magnesium induced the decrease in the peripheral resistance index. The systolic index increased, showing that myocardial depression did not occur. Dept de Anestesiologia de FMB-UNESP Distrito de Rubiao Junior, 18618-970 Botucatu - SP Dept de Anestesiologia de FMB-UNESP Distrito de Rubiao Junior, 18618-970 Botucatu - SP more...