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The transjugular intrahepatic portosystemic stent-shunt is a non-surgical method for creating a portosystemic shunt. Early reports suggest that it is effective for treating portal hypertension and variceal bleeding. This review describes the technique and discusses the indications and complications.

This paper reports our experience in treating localized airway obstruction with expandable metal stents. Nine patients were treated for malignant obstruction and 6 for benign obstruction. The main indications for treatment were imminent asphyxia, breathlessness and/or repeated chest infections. All but 2 patients had received other treatments before referral. Seven patients with malignant obstruction had extrinsically compressed airways and all derived a sustained symptomatic improvement. Two patients with recurrent tracheal obstruction caused by intraluminal tumor gained lasting relief with the use of a covered expandable metal stent. All 6 patients with benign strictures were improved, although 2 developed recurrent obstruction caused by granulation tissue growing within and beyond the stent. It is concluded that the expandable metal stent provides an effective and noninvasive method of relieving large airway obstruction. As the long-term tissue tolerance to this type of stent is not known, caution is advised in the management of benign strictures. In patients with malignant obstruction, however, the expandable metal stent would appear to have considerable potential as a palliative treatment.

Twenty-five patients with stenosis of the vena cava (21) and other large veins (4) have been treated with self-expanding Gianturco metallic stents. Eighteen patients had superior vena cava syndrome. In 17, the stricture was due to malignant superior vena cava compression recurrent after maximum tolerance radiotherapy and/or chemotherapy. In 16 of these patients there was early symptomatic relief. In 1 patient with a benign posttraumatic superior vena cava stricture, the stenosis was not relieved, and occlusion occurred after 1 month. Stenoses associated with dialysis shunts were relieved in 2 other patients. Two malignant and one benign inferior vena cava stenoses were relieved either until death, or in the benign case, for 30 months. One malignant subclavian vein obstruction occluded after 24 h due to stent misplacement and another with extrinsic mediastinal compression remained patent until death, extensive thrombus having been lysed prior to stent placement. The results of this short series suggest that the Gianturco self-expanding stent in the vena cava and large veins is easy and safe to place, and in most cases produces almost immediate palliation of the distressing effects of venous obstruction, often in a preterminal and inoperable patient.

Of 1200 patients referred to the esophageal laboratory at Guy's Hospital for investigation of suspected esophageal motility disorders, 61 (5.1%) were diagnosed as diffuse esophageal spasm. Twenty of these patients whose symptoms were severe did not respond to conservative treatment and were treated by balloon dilatation. Results were good in 14 and poor in six patients, which included one esophageal perforation. Diffuse esophageal spasm was diagnosed where more than 30% nonperistaltic activity was demonstrated by manometry. Lower esophageal sphincter pressure and relaxation were normal in all cases except one. Gastroesophageal reflux was present in four of five poor responders who were examined by 24-h ambulatory pH monitoring, and in only one of 10 good responders. Three of the six patients in whom balloon dilatation was successful proceeded to full-length myotomy, with relief of symptoms in two. The indications for, and results of, balloon dilatation in this condition are discussed, and a new radiological sign is described.

Rapidly recurrent symptoms of airways obstruction by tumour may require repeated radiotherapy or endoscopic laser treatment--but these procedures may themselves be distressing. Use of a novel coated metal stent may reduce the frequency with which such palliative intervention is required.

In two patients, multiple hepatic abscesses secondary to obstructive cholangitis have resolved following the insertion of drains into the biliary tree by the percutaneous transhepatic route, under local anaesthesia. In the first case, the acute situation was relieved, allowing definitive management by an elective procedure rather than as an emergency. Useful short-term palliation was provided in the second case. Percutaneous transhepatic drainage is a safe and effective alternative to emergency surgery in selected cases.

Eleven patients with benign strictures (after choledochojejunostomy, n = 10; chronic pancreatitis, n = 1) and 16 with malignant biliary strictures (cancer of the pancreas, n = 7; cholangiocarcinoma, n = 5) were treated with a self-expanding metallic biliary stent. The patients with benign disease had failed treatment with surgical reconstruction and transhepatic balloon dilation. All patients had immediate relief of jaundice and cholangitis. In a follow-up period of 6-21 months, nine of the 11 patients with benign disease had no difficulties with infection, pruritus, or recurrent jaundice. In patients with malignant strictures, the stent produced relief of biliary obstruction unless recurrent tumor invaded the bile ducts. With careful patient selection, this stent appears to be useful in the management of biliary obstruction, particularly in benign disease.

An expandable metal stent has been used to treat bronchial collapse due to polychondritis in one patient and extrinsic bronchial compression secondary to bronchogenic tumour in another.

Forty-four hypertensive transplant patients were investigated by digital vascular imaging of the graft and simultaneous selective venous sampling for plasma renin activity to attempt to identify those patients whose hypertension may be amenable to surgical treatment. Localization of renin hypersecretion was possible in 12 patients. In ten of these, hypersecretion originated from the native kidney and in two from the graft. Localization was possible in a significantly higher proportion of patients with severe hypertension (8 of 17), and all of these had native kidney hypersecretion. Bilateral nephrectomy may be indicated in these patients. No cases of functionally significant renal artery stenosis were identified. The other major types of abnormal vascular pattern found on digital vascular imaging, diffuse intra-renal arterial attenuation and lower pole hypoperfusion may be secondary to hypertension. This combined technique may be useful in the evaluation of post-transplant hypertension, especially when hypertension is severe.

Malignant oesophago-respiratory fistula is an incurable and distressing condition. Surgery is difficult, unsatisfactory or impossible, and standard oesophageal tubes often fail to occlude the fistula. A new tube is described which relieves dysphagia and occludes the fistula without risk of pressure necrosis. After insertion of the tube, the patients may be treated by radiotherapy.

Nine postoperative colonic and rectal strictures were treated using dilatation balloons passed over a guide-wire introduced endoscopically. Six strictures resolved after a single dilatation. The method is simple, safe, effective and avoids further surgery.

Vertebral trephine biopsy is a safe and swift method of diagnosis of vertebral abnormality. The procedure is no more disturbing for the patient than lumbar puncture, and saves the patient, radiologist and clinician, considerable time and effort.

Closed needle aspiration/biopsy was performed in 19 patients with suspected spinal disc space infection. A precise diagnosis was made, from the material obtained in 13 (68%); the infecting organism was isolated in 11 and malignant tumour diagnosed histologically in two. There were no important complications. The procedure which is described in detail is simple to perform and can be carried out early in the course of a patient's stay in hospital, thereby enabling prompt treatment.

The effectiveness of a 72 h. intra-arterial prostacyclin infusion has been compared to that of naftidrofuryl oxalate (Praxilene) in a double blind study of 29 patients with ischaemic rest pain in 30 legs. Long-term relief of symptoms was achieved in 14 legs (47%) and major limb amputation avoided in 18 (60%). No significant difference was demonstrated between the results of prostacyclin infusion and those of Praxilene.

Sixty-five renal transplant recipients underwent digital vascular imaging of the graft and simultaneous selective venous sampling for plasma renin activity. Renal artery stenosis was found in seven patients but did not appear to be functionally important. Diffuse intrarenal arterial attenuation was found in seven patients and was associated with impaired graft function and perfusion; it may indicate chronic rejection. Lower pole hypoperfusion was found in nine patients without impaired graft function or perfusion; its clinical relevance is uncertain. Aneurysmal dilatation of the main renal artery was found in two patients. Severe hypertension was common in patients with these three major abnormalities, but a causal association between the abnormality and hypertension could rarely be inferred. It may be the abnormalities on digital vascular imaging, especially diffuse intrarenal arterial attenuation and lower pole hypoperfusion, are secondary to severe hypertension. Digital vascular imaging with simultaneous selective venous sampling for plasma renin activity is useful in evaluating the vascular anatomy of the grafted kidney and in assessing any abnormality found. The combined procedure was well tolerated by all patients with no complications and no incidence of acute tubular dysfunction or proteinuria after the investigation.

Fifty-five patients suffering from low back pain with or without sciatica were submitted to ascending lumbar venography. Six patients had anatomical variations which prevented adequate catheterization and 6 had equivocal radiographic appearances, which we could not assess. Fourteen patients had normal venograms but in 29 an abnormality was demonstrated. These 43 patients were then submitted to radiculography and, where appropriate, surgery. The 14 patients with normal venograms also had normal radiculograms; while the 29 with abnormal venograms had an abnormality confirmed on radiculography and/or surgery. However, in 10 of the patients the lesion was found to be one disc space lower than that demonstrated on venography; Side-effects were very few, and the procedure can be used on out-patients. This technique would appear to be a useful addition to the radiological investigation of the spine.

Emergency arteriography was carried out on 35 patients with acute gastrointestinal bleeding, in 31 of them within two hours of active bleeding (a haematemisis; a diagnostic change in central venous pressure, pulse rate, or blood pressure; or gastric aspiration of fresh blood). A definite site of bleeding was identified in 27 patients (77%)-this being a small-intestinal vascular abnormality in three--and a probable site in three. Confirmation of the bleeding site was obtained in 20 out of 23 patients treated surgically. An intra-arterial vasoconstrictor infusion was given as a temporary measure before surgery in seven patients, only one of whom showed active bleeding at operation. An intra-arterial vasoconstrictor infusion was tried as definitive treatment in an additional 10 patients, but in four out of seven with a chronic ulcer bleeding recurred after 5-68 hours and was therefore treated surgically. We recommend the diagnostic use of arteriography in patients with reliable evidence of active bleeding if its site cannot be determined by endoscopy. We do not recommend its therapeutic use in those with a chronic ulcer, except to facilitate resuscitation before surgery; further studies are needed to define its role in those with an acute lesion.

Eighty-seven patients with malignant obstruction of the biliary tract from three centres and deemed unsuitable for surgery underwent insertion of the 'Carey-Coons' transhepatic endoprosthesis. It was successfully introduced in all, with early relief of cholestasis in 97%. The 30 day mortality rate was 11.5%, which is lower than reported in series using different endoprostheses. Two fifths of patients had complications, especially cholangitis. Despite its ease of insertion the design of the endoprosthesis may be related to the high incidence of cholangitis and to formation of biliary sludge and occlusion found in follow up. Although the anchoring threads prevented migration, they may have played a role in infection at the skin entry site in four patients and in tumour seeding to the skin in a further two. Still further improvements in endoprosthesis design are desirable.

We assessed the nephrotoxicity of ionic and non-ionic radiocontrast material (CM) in two groups of patients in a prospective study. One group of 25 potential live kidney donors was studied following conventional renal angiography, carried out as part of the routine pre-operative assessment. The other group of 49 renal transplant patients with varying degrees of renal impairment was studied following digital vascular imaging carried out for investigation of hypertension. Plasma creatine, urinary N-acetyl-D-glucosaminidase (NAG), urinary microglobulin (B2M) and urinary protein excretion were measured before and after the imaging procedure. There were no significant changes in these parameters following digital vascular imaging, but there were increases in plasma creatinine (p less than 0.005) and urinary NAG creatinine ratio (p less than 0.002) in the conventional angiography group following the procedure. Substantial proteinuria developed in 35% of patients following conventional angiography. The differences in nephrotoxicity of radiocontrast agents during the two procedures could not be accounted for by the dose of material used, but probably reflect the effect of differences in the route of administration on the maximal concentration of the material reaching the kidney. Non-ionic radiocontrast material proved less toxic than ionic and may be preferable in conventional angiography.