带膜支架在血管内治疗外伤性颈动脉海绵窦瘘中的应用

目的 探讨Jostent冠脉带膜支架对于颈动脉海绵窦瘘的血管内治疗效果. 方法 于2001年6月-2007年5月应用Jostent冠脉带膜支架治疗8例外伤性颈动脉海绵窦瘘. 结果 在8例患者中带膜支架被成功放置于靶动脉,导致瘘完全消除并保持载瘘动脉畅通,临床效果满意,无手术相关并发症发生.6例患者于带膜支架放置后6个月获造影随访,显示瘘口未再通,载瘘动脉畅通. 结论 带膜支架对于某些颈动脉海绵窦瘘是有用的血管内治疗手段.带膜支架的制作工艺仍有待发展和优化,以使之适用于脑血管系统.     

Metallic stent placement for treating peripheral outflow lesions in native arteriovenous fistula hemodialysis patients after insufficient balloon dilatation

OBJECTIVE: The purpose of this study was to report our experience with metallic stent placement in the peripheral outflow veins in native arteriovenous fistula (A-V fistula) hemodialysis patients after insufficient balloon dilatation. MATERIALS AND METHODS: During the past 4 years, 12 A-V fistula dialysis patients in our hospital underwent metallic stent placement in the peripheral outflow veins to restore vascular access. The indications for metallic stent placement in our study included (1) recoil stenosis of outflow vein in six patients; (2) outflow venous rupture in two patients and dissection in one patient; and (3) large residual adherent thrombus in outflow aneurysms in three patients with thrombosed (arteriovenous) access. Self-expandable Wallstent or Jostent (Jomed, Abbott Laboratories) of appropriate size (6-10 mm in diameter) was chosen for use in these patients. Kaplan-Meier survival analysis was used to calculate the access patency rates. RESULTS: Twelve patients received stents. Eleven patients (92%) underwent successful dialysis after the procedure. One patient experienced complications due to incorrect positioning of the stent at the anastomotic site, causing flow compromise. The primary patency (+/- standard error) of the vascular access at 3, 6, 12, and 24 months was 92% +/- 8%, 81% +/- 12%, 31% +/- 17%, and 31% +/- 17%, respectively. The secondary patency of the vascular access at 3 months was 92% +/- 8%, and 82% +/- 12% at 6, 12, and 24 months each. CONCLUSION: Metallic stent placement is safe and effective in treating peripheral venous lesions in native A-V fistula hemodialysis patients after unsatisfactory balloon dilatation.     

The importance of preoperative evaluation of the subclavian vein in dialysis access planning.

Adequate venous outflow is critical to the proper function of a vascular-access graft (arteriovenous fistula) used for chronic hemodialysis. Stenosis of the subclavian vein can significantly compromise this venous outflow. The development of such subclavian vein stenoses has been associated with the prior placement of temporary subclavian vein dialysis catheters. We evaluated the importance of preoperative detection of these stenoses before placement of a permanent vascular-access graft in the upper extremity. Upper extremity venography was performed before placement of a permanent vascular-access graft in 43 patients. A total of 62 extremities were evaluated. A 40% prevalence of moderate or severe subclavian vein stenosis was found in patients with prior or existing temporary dialysis catheters in the subclavian vein. No stenoses were found in patients without a history of dialysis catheters in the subclavian vein. This difference in the prevalence of subclavian vein stenosis is statistically significant (p less than .001). In no case was the stenosis suspected clinically. Before placement of a permanent vascular-access graft, the subclavian vein should be evaluated in all patients with a history of a temporary dialysis catheter in the subclavian vein. The use of sites other than the subclavian vein for temporary dialysis is strongly encouraged.     

CT of aortoenteric fistulas

We compared CT findings with endoscopic, angiographic and surgical results in ten patients suspected of having an aortoenteric fistula (AEF) because of gastrointestinal bleeding (seven) or recurrent sepsis (three). CT correctly diagnosed AEF in six patients and excluded it in the other four. CT findings of AEF consisted of perigraft fluid (PGF) (5/6) and/or gas within the bed of the graft (4/6) later than three months after graft surgery. All six patients with AEF had perigraft infections; PGF with gas was found in 50%, PGF alone in 33%, and in one patient perigraft gas alone was found. Angiography and endoscopy failed to identify AEF. Our findings indicate that CT should be the initial imaging procedure in patients with suspected AEF who do not require immediate surgical intervention.     

Treatment of hemodialysis fistula pseudoaneurysms with detachable balloons: technique and preliminary results.

Pseudoaneurysm formation is commonly encountered during the life of a dialysis fistula. When these become excessively large or numerous, surgical revision of the graft has been the only treatment option. The authors have treated seven patients by using percutaneous placement of a detachable balloon to occlude a pseudoaneurysm of an upper extremity graft. In four cases the balloon was directed into the pseudoaneurysm from a femoral artery approach. In three cases a direct puncture was made into the pseudoaneurysm for placement of the balloon. The patients were followed up from 1 week to 7 months. Initial technical success was achieved in all seven cases with no complications. Thrombosis of two grafts occurred during the first week after the procedure: one because of herniation of the balloon out of the pseudoaneurysm and one for unknown reasons. One balloon was inadvertently punctured and deflated during subsequent dialysis. Treatment in the other four cases was successful, as evidenced by no further enlargement of the pseudoaneurysms. Direct puncture of the pseudoaneurysm simplifies the procedure and probably decreases the likelihood of balloon herniation because of the orientation of the balloon.     

Dialysis needle puncture of Wallgrafts placed in polytetrafluoroethylene hemodialysis grafts

This study evaluates the effect of routine venipuncture at hemodialysis on the durability of Wallgraft covered stents. Thirteen covered stents were placed in six aging, failing polytetrafluoroethylene grafts for treatment of pseudoaneurysms and recurrent stenoses. Four patients did not experience significant graft complications. One graft was ligated for an infected overlying skin ulcer. After surgical revision, the graft remains functional. Another patient experienced fraying of the stent edges and recurrence of a small pseudoaneurysm. Our experience suggests that the Wallgraft covered stent can withstand routine venipuncture at dialysis without flow-limiting stent distortion.     

Pilonidal sinus disease: MR imaging distinction from fistula in ano

PURPOSE: To describe magnetic resonance (MR) imaging features in patients with proved pilonidal sinus disease and to compare these features with those in a matched group of patients with proved fistula in ano to determine the accuracy with which MR imaging can be used to distinguish between the two diseases. MATERIALS AND METHODS: Seven patients with pilonidal sinus disease underwent MR imaging with a body coil. The site and morphology of sepsis were noted, with particular reference to natal cleft sepsis and deep-seated sepsis, including intersphincteric anal canal sepsis and any enteric communication. Comparison was made with 14 age- and sex-matched patients with fistula in ano. Categoric frequencies were compared to calculate differences between the groups and sensitivities, specificities, and predictive values. RESULTS: All patients with pilonidal sinus had natal cleft sepsis, but five (71%) had sepsis at deep-seated sites more characteristic of fistula in ano. Eight patients with fistula in ano (57%) had natal cleft sepsis that was thought characteristic of pilonidal sinus. No patient with pilonidal sinus had intersphincteric sepsis or an enteric communication, in contrast to all patients with fistula in ano having both (P <.001). Natal cleft sepsis reached the subcutaneous tissues overlying the coccyx and sacrum in only one patient with fistula (7%), in contrast to six (86%) with pilonidal sinus (P <.001). MR imaging had a sensitivity of 86% (six of seven), specificity of 100% (14 of 14), positive predictive value of 100% (six of six), and negative predictive value of 93% (14 of 15) for diagnosis of pilonidal sinus disease. CONCLUSION: MR imaging features of perianal and deep-seated sepsis, characteristic of fistula in ano, are also found in patients with pilonidal sinus, but the absence of intersphincteric sepsis or enteric opening allows reliable MR imaging distinction between the two.     

Angiographic signs of aortic graft-enteric fistulae

Angiograms of four patients with intestinal bleeding from aortic graft-enteric fistulae collected over 4 years have been reviewed. All showed a bulging dilatation of the graft and aortic anastomosis. False aneurysms of the proximal aortic anastomosis were demonstrated twice. A patent fistula was never demonstrated. Angiograms performed in the same period of 18 consecutive patients without fistulae, after aortic graft reconstruction, were reviewed for comparison. None of these displayed the bulging of the graft seen in the group of graft-enteric fistulae. Thus in a patient with gastrointestinal bleeding and a high suspicion of aortic graft-enteric fistula, the diagnosis is supported angiographically by the presence of this bulge.     

Gastrointestinal complications of aortic bypass surgery.

Gastrointestinal bleeding following abdominal aortic bypass surgery is not uncommon, as approximately 20% of patients with abdominal aortic aneurysms have peptic ulcer disease. We have recently seen three patients who presented with gastrointestinal bleeding secondary to the complications of their surgery. The cause of the bleeding was aortoduodenal fistula, graft erosion into the sigmoid colon and ischaemic colitis respectively. The correct diagnosis was only considered in one patient, although in retrospect it should have been suggested in all three. Our experiences with these complications and their clinical and radiological presentation form the basis for this paper.     

The cerebral circulation in cases of carotid cavernous fistula

Summary Ten patients with carotid cavernous fistula (CCF) were reviewed. Single photon emission computed tomography (SPECT) for regional cerebral blood flow (rCBF) study was performed in six patients with fast flow shunt. Five of these six patients with fast flow shunt angiographically demonstrated cortical venous drainage, and two of these patients suffered intracerebral hemorrhage. The rCBF decreased in the region demonstrating the cortical venous drainage in five patients, and in one patient the angiography demonstrated arterial steal and the rCBF decreased in a part of the ipsilateral cerebral hemisphere. SPECT proved to be useful in assessing the cerebral circulation in cases of CCF.     

Percutaneous Mural Fenestration and Angioplasty for the Treatment of a Refractory Hemodialysis-Related Venous Stenosis

Venous stenoses are the leading cause of dialysis graft and mature dialysis fistula malfunction. We report a simple, inexpensive technique for treating stenoses that are refractory to conventional balloon angioplasty and present a case in which this technique was successfully applied.     

Pancreas Transplant Venous Thrombosis: Role of Endovascular Interventions for Graft Salvage

Venous thrombosis of pancreas transplant allografts often leads to graft loss. We evaluated the efficacy of emergent endovascular techniques to salvage thrombosed pancreatic allografts in a series of six patients. Of the 76 pancreas transplants performed between 2002 and 2006, six patients were diagnosed with venous thrombosis on MRI between 2 and 28 days posttransplant (mean, 9 days). Five patients were systemic-enteric (donor portal vein anastomosis to recipient iliac vein) and one patient was portal-enteric (donor portal vein anastomosis to recipient superior mesenteric vein). Conventional venography confirmed the diagnosis of venous thrombosis in all patients. One patient was treated with catheter-directed venous thrombolysis and balloon thrombectomy. Another patient was treated with rheolytic thrombectomy alone. The remaining four patients were treated with a combination of these mechanical and thrombolytic techniques. Completion venography revealed >50% clot reduction and resumption of venous drainage in all patients. One patient required additional intervention 16 days later for recurrent thrombosis. Two patients required metal stent placement for anastomotic stenoses or kinks. One patient required pancreatectomy 36 h after attempted salvage secondary to a major hemorrhage and graft necrosis. Two patients recovered pancreatic function initially but lost graft function at 8 and 14 months, respectively, from severe chronic rejection. Patient survival was 100%, long-term graft survival was 50%, rethrombosis rate was 16.6%, and graft loss from rejection was 33%. In conclusion, early recognition and treatment of venous thrombosis after pancreas transplantation has acceptable morbidity and no mortality using short-term endovascular pharmacomechanical therapy.     

Thoracopancreatic fistula: clinical and imaging findings

PURPOSE: The goal of this work was to describe the clinical and imaging features of thoracopancreatic fistula, a rare complication of pancreatitis. METHOD: Nine cases of thoracopancreatic fistula proved by thoracentesis, endoscopic retrograde cholangiopancreatography (ERCP), or surgery were retrospectively and independently reviewed by two abdominal radiologists. All available imaging examinations [chest radiographs = 9, CT = 9, MR and MR cholangiopancreatography (MRCP) = 2, and ERCP = 6] were analyzed, and findings were recorded on a standardized datasheet. Available medical records (n = 7) were reviewed to determine the clinical presentation of the patients and thoracentesis results. RESULTS: Seven of the nine patients presented with pulmonary symptoms such as dyspnea or cough. Of the seven patients with pleural fluid analysis, all demonstrated elevated amylase levels (mean 13,007 U/L). Imaging examinations revealed pancreaticopleural fistulas in six patients, a mediastinal pseudocyst in one patient, and both a pancreaticopleural fistula and a mediastinal pseudocyst in two patients. Chest radiography showed pleural fluid collections in eight patients. CT demonstrated a fluid-containing fistula in all nine patients. MR and MRCP depicted a fistula extending from the abdomen to the pleural space in the two patients with MR correlation. ERCP showed pancreatic ductal changes characteristic of chronic pancreatitis in the six patients with ERCP correlation but failed to demonstrate the fistula in two of the six patients. CONCLUSION: The CT, MR, MRCP, or ERCP finding of a fluid-filled tract extending from the pancreas to the thorax is characteristic of a thoracopancreatic fistula, particularly when identified in a patient who presents with pulmonary symptoms and a history of chronic pancreatitis.     

Stent Placement on Fresh Venous Thrombosis

Purpose: To report on the efficacy of fixing fresh venous thrombus to the venous wall by stent placement. Methods: Seven patients underwent stenting to treat acute venous thrombosis. In two patients, the hemodialysis fistula was thrombosed with the thrombus extending into the brachial veins. In three patients, the hemodialysis fistula was patent but massive swelling of the ipsilateral arm was caused by proximal venous thrombosis. Two patients presented with iliac venous thrombosis within stented pelvic veins. Stent placement was preceded by other mechanical thrombectomy methods in all cases. Results: Attachment of thrombus to the venous wall was successful in all cases treated. Acute rethrombosis did not occur. Follow-up patency in dialysis patients was 7.2 ± 2.1 months. One patient had rethrombosis of the dialysis graft 3 months after primary treatment. Three patients developed restenosis within a mean period of 7.7 months. One shunt remained patent for 10 months with no event of reobstruction during follow-up. In both patients with iliac stent placement, the vein remained patent over a follow-up period of 8 and 12 months respectively. Conclusion: Stenting fresh venous thrombus can achieve immediate venous patency. It may be used as an alternative approach when all other percutaneous methods fail. Frequent restenosis within stented veins limits its use to very selected cases. Received: 0/00/00/Accepted: 0/00/00     

Angiography of upper extremity access fistulas for dialysis

One-hundred twenty-five cases of upper extremity internal arteriovenous and graft fistulas were reviewed. Clinical problems requiring study were poor fistula flow during dialysis, difficulty in cannulation, diminished graft pulsations, extremity edema or varicosities, the appearance of pulsatile or nonpulsatile masses in the graft or fistula, and distal ischemia. Angiography demonstrated venous occlusion (13 cases), venous stenosis at or near the anastomotic site (32 cases), thrombi within shunts (9 cases), venous aneurysms or pseudoaneurysms related to either proximal obstruction or traumatic dialysis (23 cases), distal venous overdistention due to proximal obstruction or overcirculation (15 cases), and radial artery steal of blood from the distal extremity (15 cases). The causes and predisposing factors leading to the complications are presented along with a discussion of the angiographic techniques that were used.     

Coronary artery fistulae without adudible murmur in adults

Retrospective analysis of 4886 adults undergoing coronary arteriography for evaluation of angina between October 1988 and December 1991, revealed coronary artery fistulae in eight patients (all men, aged 36–69 years). No murmur was audible in any of these eight patients. Associated significant coronary artery disease was detected in five patients. The feeder arteries to the fistula were both the left main coronary artery and the left anterior desending artery (LAD) in two, the LAD in six, and the right coronary artery in two patients. The fistula terminated in the pulmonary artery in seven patients and in the right atrium in one patient. Successful operative treatment (coronary artery bypass grafting and ligation of the fistula) was undertaken in four patients with severe obstructive coronary artery disease with satisfactory results. Follow-up for up to 2 years of the three patients with coronary artery fistula and no associated coronary artery disease who did not undergo surgery revealed continuing good prognosis. We conclude that coronary artery fistula in adults is a distinct, though rare (incidence in present series 0.11%) entity, without audible murmur, commonly associated with coronary artery obstructive disease, and that the diagnosis is mostly incidental during routine coronary arteriography.     

Outcome of kidney transplantation in patients on peritoneal dialysis]

The initial experience suggested that kidney transplantation could be hazardous for patients on peritoneal dialysis due to the high risk of peritonitis and a possible high incidence of acute rejection. In this paper we have presented our experience with kidney transplantation in these patients. During the last four years kidney transplantation was performed in 9 patients on peritoneal dialysis. The average time spent on peritoneal dialysis was 20.6 +/- 7.6 months. In all patients peritoneal catheter was removed during the surgery. During the posttransplantation period a triple immunosuppressive therapy including steroids, cyclosporin and azathioprineor mycophenolate mofetil was administered in all patients. In comparison to patients on hemodialysis no significant difference in the incidence of acute rejection episodes, delayed graft function, graft arterial thrombosis and graft function recovery was observed. Patients on peritoneal dialysis had significantly greater and longer wound drainage in comparison to patients on hemodialysis. It was concluded that peritoneal dialysis had no negative influence on short-term outcome of kidney transplantation.     

Renal transplant vein stenosis: demonstration and percutaneous venoplasty of a new vascular complication in the transplant kidney

Stenosis of the renal transplant vein has been demonstrated in eight patients undergoing investigation for renal dysfunction arising 3 weeks to 3 years after transplantation. The stenoses were diagnosed by duplex Doppler ultrasound in three cases and by angiography in the presence of arterio-venous fistula in five cases. In four patients percutaneous venous dilatation was performed with technical success in three. In two patients this was repeated for recurrent stenosis but sustained improvement in renal function was not observed. Progression of the venous stenoses was documented with one patient suffering graft loss due to complete venous occlusion.     

Esophageal strictures: treatment with a new design of modified Gianturco stent. Work in progress.

To overcome the drawbacks of the modified Gianturco stent tube with barbs, a new barbless stent tube was constructed. Twenty-two barbless stent tubes 4.5-14.0 cm long were placed with a new introducing tube in 21 patients: 10 stent tubes in 10 patients with recurrent dysphagia after radiation therapy or chemotherapy, 10 in 10 patients with esophageal cancer in whom surgical management was contraindicated, and two in one patient with postoperative benign stricture. No technical failure or procedural complications occurred. After the procedure, all but two patients could ingest most or all foods. In two patients with an esophagorespiratory fistula and one patient with esophageal rupture, the barbless stent tube successfully occluded the fistula and rupture site. The stent tube migrated in one patient. Fifteen patients are surviving, with the stent tubes patent for 3-35 weeks (mean patency, 13 weeks); the six other patients died 7-24 weeks (mean, 16 weeks) after stent placement. It is concluded that barbless stent tubes show promise in the management of dysphagia caused by esophageal strictures.     

Improved patency of transjugular intrahepatic portosystemic shunts in humans: creation and revision with PTFE stent-grafts

PURPOSE: To determine whether polytetrafluoroethylene (PTFE) stent-grafts yield longer patency for creation or revision of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: Fourteen PTFE-covered Wallstents were placed in 13 patients with TIPS: seven at shunt creation and seven during revision of TIPS with one to five prior thromboses at 1 day to 1 year after initial TIPS formation. In six cases, prior to stent-graft placement persistent biliary-TIPS fistulas were demonstrated despite repeated shunt revisions with additional metallic stents. RESULTS: All but one graft-lined TIPS were widely patent at a mean duration of venographic follow-up of 19 months (median, 17 months; range, 5-32 months). The limiting percentage of stenosis within the grafted shunts was 0%-10%. One patient developed stent-graft thrombosis; the prior biliary-TIPS fistula was seen despite the graft. A second, parallel PTFE-lined transcaval shunt was created in this patient; it was widely patent at 11-month follow-up. In two asymptomatic patients, stenoses developed in the short, nongrafted portions of the outflow hepatic veins. CONCLUSION: PTFE stent-grafts can markedly prolong TIPS patency, potentially reducing the need for shunt follow-up and revision and the risk of recurrent symptoms associated with shunt stenosis or occlusion.