全覆膜食管金属支架治疗高位食管疾病

目的评价全覆膜食管金属支架在高位食管狭窄和瘘以及术后吻合口狭窄和瘘治疗中的有效性和安全性。方法复旦大学附属中山医院内镜中心2005年5月至2013年7月间,应用16mm全覆膜食管金属支架对84例高位食管狭窄和瘘以及术后吻合口狭窄和瘘进行治疗。其中食管癌性狭窄31例,食管外压性狭窄2例,食管癌放疗后狭窄10例,食管癌术后复发致狭窄4例,吻合口狭窄27例,内镜黏膜下剥离术后食管狭窄1例,食管．气管瘘7例,食管一纵隔瘘1例,食管癌术后残胃瘘1例。狭窄或瘘口上缘距中切牙距离15～20cm者48例,大于20cm者36例。结果84例患者共置入100枚支架,术中无出血和穿孔等并发症发生。支架置入术后患者吞咽困难、呛咳症状均迅速缓解。术后并发症发生率为6．0％（5／84）,其中严重胸痛2例,经止痛药物缓解;气管塌陷1例,予气管切开术;支架移位2例,内镜下应用异物钳对支架位置进行调整。76例（90．5％）患者获得完整随访,5-3％（4／76）的患者出现再狭窄,2．6％（2／76）新发食管．气管瘘;其中5例接受再次内镜下置入全覆膜金属支架术并获成功,另1例经沙氏探条扩张及氩离子凝固术治疗效果满意。结论全覆膜食管金属支架治疗高位食管狭窄和瘘以及术后吻合口狭窄和瘘安全、有效,可考虑作为临床首选。     

Double stenting with silicone and metallic stents for malignant airway stenosis

For severe malignant airway stenosis, there are several types of commercially available airway stents, and each has its own advantages and disadvantages. We herein describe the safety and efficacy of combination stenting with silicone and metallic stents for patients with extended malignant airway stenosis. Seven patients with malignant airway stenosis were treated via combination stenting with a silicone stent and a metallic stent for extended airway stenosis from the central to peripheral airways. Five patients were diagnosed with advanced esophageal cancer, two of whom had tracheoesophageal fistulas. One patient had adenoid cystic carcinoma, and another had mediastinal tumor. There were no specific complications related to the double stenting. Combination stenting with silicone and metallic stents proved to be a safe option for patients with severe, extended, and complicated malignant airway stenosis.     

Stenting for airway obstruction in the carinal region

Background. Recent progress on airway stents has provided sufficient airway patency for patients with airway obstruction; however, when the stenosis exists in the carinal zone, establishing an excellent airway condition is still troublesome because of the anatomic structure.

Methods. We treated 15 patients with severe tracheobronchial stenosis involving a carinal bifurcation region, using several types of stenting devices (long T-tube, T-Y tube, wire reinforced Y tracheostomal tube, Freitag Dynamic stent [Karl Storz, Tuttlingen, Germany], and covered metallic stent). All patients had advanced inoperable tumors (lung cancer, n = 6; esophageal cancer, n = 3; thyroid cancer, n = 3; mediastinal tumor, n = 3).

Results. All but 2 patients had immediate relief of respiratory symptoms. One patient died of respiratory failure caused by pulmonary lymphatic spread 3 days after Dynamic stent insertion. In 1 patient with severe left main bronchial stenosis due to lung cancer, effective palliation was not achieved by insertion of a covered metallic stent because of its insufficient expansion against the stenosis. Mean survival after successful stenting was 4.3 months (range, 1 to 15 months). There were no complications directly attributable to the stents.

Conclusions. As evidenced by the clinical effectiveness, airway stenting for inoperable tumor is valuable in such patients. Choosing a stent that will fully cover the lesion and allow sufficient tolerance against compression is important to successful stenting. Benefits such as ease of phonation and stent maintenance should also be considered.     

Comparison of plastic prostheses and self-expandable metallic stents in the treatment of malignant esophageal stenosis

OBJECTIVE: We compared the efficacy of plastic prostheses and self-expandable metallic stents in the treatment of malignant esophageal stenosis and/or fistula. SUBJECTS AND METHODS: Subjects were 31 patients with esophageal cancer, 4 with esophagotracheal fistula, and 1 with esophageal stenosis. A plastic prosthesis was inserted in 15 patients (group A) and a self-expandable metallic stent in 21 patients (group B). We evaluated food ingestion improvement, effectiveness, complications, mean survival, food ingestion duration, the percentage of food ingestion capability in total survival time, and inhospital mortality. RESULTS: No differences were seen in food intake improvement or in the effectiveness between groups, whereas fatal complications were higher in Group A. No significant differences were seen in mean survival, food ingestion duration, percentage of food ingestion capability, or inhospital mortality between groups. CONCLUSION: We concluded that a self-expandable metallic stent was safer than a plastic prosthesis because of fewer serious complications such as bleeding, and recommended the use of metallic stents in the treatment of malignant esophageal stenosis and/or fistula.     

Esophageal bypass using a gastric tube for a malignant tracheoesophageal/bronchoesophageal fistula: a report of 4 cases

Tracheoesophageal/bronchoesophageal fistulas are often caused by locally advanced esophageal cancer and lung cancer, and result in life-threatening conditions such as severe cough and dyspnea due to pneumonia. We herein report the clinical characteristics of 4 patients with tracheoesophageal/bronchoesophageal fistulas. All patients were men, and ranged in age from 40-69 years. Three patients had esophageal cancer and 1 had lung cancer. All 4 underwent esophageal bypass using a gastric tube with tube drainage of the distal side of the esophagus. Three patients died at 3, 4, and 5 months after surgery. However, these patients were allowed to enjoy food orally up until the last few days of life. One patient who underwent esophageal bypass and chemoradiotherapy has remained well for 5 years without any evidence of recurrence. This bypass procedure is therefore considered to be a feasible treatment choice for patients with tracheoesophageal/bronchoesophageal fistulas.     

Complications of thyroid surgery: cervical thoracic duct injuries

Thoracic duct injury is uncommon in surgery of the neck: relatively more common after laryngeal and esophageal surgery, rare in thyroid surgery. From January 1986 to June 2009 were treated 14 patients with lesions of the cervical thoracic duct undergo surgery for thyroid disease: 4 goitre cervico-mediastinal and 10 total thyroidectomy for cancer, 9 of which have laterocervical left lymphadenectomy. In 2 cases, the intraoperative detection has allowed immediate ligature. In 12 patients a cervical chylous fistula without chilothorax was found: 5 low-flow fistulas and 7 high-flow fistulas. Of the 5 cases of low-flow fistula, 4 were recovered after 1 month of conservative treatment, only 1 patient required surgical correction. The 7 patients with high-flow fistula were undergoing surgery: 4 in the first week post-operative and 3 after a period of more than 30 days of medical therapy. In patients with high-flow fistula prolonged medical treatment does not provide benefit and increase the risk of complications during and after surgery.     

Sequential Stenting for Extensive Malignant Airway Stenosis

Purpose: Malignant airway stenosis extending from the bronchial bifurcation to the lower lobar orifice was treated with airway stenting. We herein examine the effectiveness of airway stenting for extensive malignant airway stenosis.Methods: Twelve patients with extensive malignant airway stenosis underwent placement of a silicone Dumon Y stent (Novatech, La Ciotat, France) at the tracheal bifurcation and a metallic Spiral Z-stent (Medico’s Hirata, Osaka, Japan) at either distal side of the Y stent. We retrospectively analyzed the therapeutic efficacy of the sequential placement of these silicone and metallic stents in these 12 patients.Results: The primary disease was lung cancer in eight patients, breast cancer in two patients, tracheal cancer in one patient, and thyroid cancer in one patient. The median survival period after airway stent placement was 46 days. The Hugh–Jones classification and performance status improved in nine patients after airway stenting. One patient had prolonged hemoptysis and died of respiratory tract hemorrhage 15 days after the treatment.Conclusion: Because the initial disease was advanced and aggressive, the prognosis after sequential airway stent placement was significantly poor. However, because respiratory distress decreased after the treatment in most patients, this treatment may be acceptable for selected patients with extensive malignant airway stenosis.     

食管腔内置管预防食管腐蚀伤后瘢痕狭窄

目的介绍食管腔内置管预防食管腐蚀伤后瘢痕狭窄的手术方法,并评价其疗效。方法食管腐蚀伤后3周内入院33例,除1例发生食管穿孔外均经食管镜检查诊断为度或度烧伤,所有患者均采用食管腔内置管方法预防瘢痕狭窄,4～6个月后拔管。结果本组无手术死亡,拔管后患者均恢复正常进食,食管X线钡餐检查无狭窄。随访1～60个月,随访期间28例进食无梗阻,5例拔管后2～3个月发生食管狭窄,其中1例经食管扩张治愈,另4例施行食管重建手术,术后进普通食物无梗阻。结论食管腔内置管能预防食管腐蚀伤后瘢痕狭窄,加用异烟肼能增强其疗效。     

Palliation of advanced esophageal carcinoma by photodynamic therapy and irradiation

BACKGROUND: We wanted to determine the role of photodynamic therapy in a multimodal approach for the treatment of patients with advanced cancer of the esophagus. METHODS: We reviewed the cases of 119 patients with nonresectable esophageal carcinoma who underwent endoluminal palliation. Twenty-one patients required initial dilation and tumor obliteration with a neodymium: yttrium-aluminum-garnet laser prior to therapy. Forty-four patients received photodynamic therapy followed by brachyradiotherapy, and 75 patients were treated with brachyradiotherapy. In both groups, some patients also received external-beam irradiation. RESULTS: Photodynamic therapy produced a significant difference in relieving stenosis caused by tumor stenosis (mean, 6.6 mm; p = 0.0000). The dysphagia score improved by one to three levels in all patients, with a significant difference in favor of PDT (p = 0.0003). The mean number of overall treatment sessions was four (range, one to seven). The rate of major complications was 9.2%. Four esophageal perforations occurred, three after intervention and one spontaneously 5 months later. Four esophagorespiratory tract fistulas developed several months after combined PDT and irradiation. The mean overall survival was 7.7 months, and analysis of variance revealed a significant difference in favor of PDT and external-beam irradiation (p = 0.0129 and p = 0.0001, respectively). CONCLUSIONS: Photodynamic therapy has been shown to be an effective palliative treatment of advanced esophageal cancer. However, proper patient selection is necessary to prevent serious complications.     

Indication of the use of pedicled omentum in chest surgery

The omentum has been known to have a remarkable power of repair through neovascularization and scavenger function. Nine patients have been treated with the pedicled omentum. In 4 patients the omentum was used to obtain healing in the presence of infection. Bronchial fistulas were successfully closed in 3 patients with lung cancer and bronchial anastomotic leakage was repaired in one patient who received carinal reconstruction. In 5 patients, all of them had simultaneous resection of thoracic esophagus, the preventive use of omentum made a good result in two tracheoplasties, one pneumonectomy and one terminal tracheostomy. But one patient with esophago-tracheofistula after irradiation to esophageal cancer developed tracheal necrosis postoperatively. The omentum is useful in the case of postoperative empyema with bronchial fistula especially in patient with lung cancer. In the case of tracheobronchial resection after radiation therapy or with resection of thoracic esophagus, the suture line should be wrapped by omentum to prevent anastomotic leakage.     

Self-expanding Polyflex plastic stents in esophageal disease: various indications,complications, and outcomes

Background Esophageal stenting has become an important technique in the treatment of different clincal problems such as malignant or benign stenosis, anastomotic leaks after surgery, or fistulas. In this study we present our experience with the self-expanding Polyflex plastic stent in various indications, arising complications, and patient’s outcomes. Methods Over a three-year period, 35 patients underwent self-expanding Polyflex plastic stent placement for esophageal stenosis (n = 23) with 22 malignant, and for perforations, fistulas, or anastomotic leaks after surgery (n = 12). The short-term efficacy and long-term outcomes were analyzed. Results In patients with stenosis, implantation was performed without any complications in 91% (21/23). In one patient perforation occurred while passing the stenosis; in another patient the stent dislocated during the insertion procedure. Dysphagia score improved from 3.0 to 1.0 after stenting. In all patients with perforations, fistulas, or anastomotic leaks (n = 12), stents were placed successfully without any complication. Complete sealing of the mucosal defect was proven by radiography in 92% (n = 11) and healing was seen in 42% (n = 5). If indicated, stent removal was performed without any complications. Stent migration (n = 13; 37%) was the most common long-term complication. Conclusions The placement of self-expanding Polyflex plastic stents is a highly sufficient and cost-effective treatment for malignant and benign esophageal disorders. Because the long-term results were highly favorable, self-expanding plastic stent placement could be used as the initial treatment for various conditions.     

Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer

PURPOSE: Prostate cancer (PCa) radiotherapy (RT), including brachytherapy, may lead to significant morbidity, including urinary fistulas. If conservative measures fail, urinary and/or fecal diversion is often required. In this study we examined a series of patients with fistulas that developed after pelvic radiation therapy and explored potential predisposing factors and treatment recommendations for refractory fistulas. MATERIALS AND METHODS: Patients were identified who received radiation therapy for PCa between 1977 and 2002, and subsequently had a fistula to the urinary tract. Patients were excluded who had diverticulitis, inflammatory bowel disease, a history of recent radical retropubic prostatectomy (possible iatrogenic etiology) or cancer in the excised fistula. Data were extracted from patient charts, mailed questionnaires and outside records. RESULTS: A total of 51 patients were identified with a history of radiation for PCa who subsequently had a urinary fistula. Of 20 patients meeting inclusion criteria 30% received external beam RT alone, 30% received brachytherapy and 40% received combined external beam RT/brachytherapy. Most fistulas (80%) were from the rectum to the urinary tract with an average diameter of 3.2 cm. Of patients with rectal fistulas 81% had a history of rectal stricture, urethral stricture, rectal biopsy, rectal argon beam therapy or transurethral prostate resection after radiation. All patients with rectourethral fistulas who achieved symptomatic resolution required urinary and fecal diversion. CONCLUSIONS: Conservative treatment is generally ineffective in the management of large urinary fistulas. Surgical intervention offers symptomatic relief and improved quality of life in most patients.     

Evaluation and outcome of different surgical techniques for postintubation tracheoesophageal fistulas

OBJECTIVE: We evaluated the outcome of different surgical techniques for postintubation tracheoesophageal fistula. METHODS: Thirty-two consecutive patients aged 51 +/- 23 years had tracheoesophageal fistulas resulting from a median of 30 days of mechanical ventilation via endotracheal (n = 12) or tracheostomy (n = 20) tubes. Tracheoesophageal fistulas were 2.5 +/- 1.2 cm long and were associated with a tracheal (n = 10) or subglottic (n = 3) stenosis in 13 patients. RESULTS: All but 3 patients were weaned from respirators before repair. All operations were done through cervical incisions and included direct division and closure (n = 9), esophageal diversion (n = 3), muscle interposition (n = 6), or, more recently, tracheal or laryngotracheal resection and anastomosis with primary esophageal closure (n = 14). Nine thyrohyoid and two supralaryngeal releases reduced anastomotic tension. Twenty-three patients (74%) were extubated after the operation (n = 16) or within 24 hours (n = 7), and 7 required a temporary tracheotomy tube. One postoperative death (3%) was associated with recurrent tracheoesophageal fistula. Seven complications (22%) included recurrent tracheoesophageal fistula (n = 1), delayed tracheal stenosis (n = 2), dysphagia (n = 2), and recurrent nerve palsy (n = 2). Complications necessitated reoperation (n = 1), dilation (n = 2), definitive tracheostomy (n = 1), Montgomery T tubes (n = 1), and Teflon injection of the vocal cords (n = 1). Twenty-nine patients (93%) had excellent (n = 24) or good (n = 5) anatomic and functional long-term results. Complications have been less common (7% vs 38%) and long-term results better (93% vs 65%) recently with tracheal or laryngotracheal resection and anastomosis with primary esophageal closure as compared with previous procedures. CONCLUSIONS: Postintubation tracheoesophageal fistula is usually best treated with tracheal or laryngotracheal resection and anastomosis with primary esophageal closure even in the absence of tracheal damage.     

Equivalent secondary patency rates of upper extremity Vectra Vascular Access Grafts and transposed brachial-basilic fistulas with aggressive access surveillance and endovascular treatment

OBJECTIVES: The 2006 update of the DOQI guidelines has stated that in patients with end-stage renal disease, autogenous radial-cephalic, or brachial-cephalic fistulas are the preferred access modalities, followed by transposed brachial-basilic (TBB) fistulas and prosthetic arteriovenous (AV) grafts. AV grafts are in general least preferred; however, there is very limited data comparing directly the last two modalities. The aim of the present study is to compare outcomes of the TBB fistula and the Vectra Vascular Access Graft. METHODS: Seventy-six patients had a prosthetic brachial-axillary Vectra graft placed, while in 41 patients brachial-basilic upper arm transposition was performed. Graft surveillance to detect a failing/failed access was followed by endovascular treatment, rheolytic thrombectomy (AngioJet, Possis Medical), and/or angioplasty +/- stenting of the responsible anatomical lesion(s). RESULTS: Use of Vectra grafts and TBB fistulas started after a median (interquartile range) of 14 (7-30) and 70 (52-102) days, respectively (P < .001), as early as the operative day in some patients with grafts. Postoperative complications were more frequent in TBB fistulas and late complications (mainly access thrombosis) in Vectra grafts. Total number of thrombectomy sessions performed for graft or fistula occlusion was 45 and 7, respectively (P = .032); total number of isolated angioplasty sessions, performed for failing graft or fistula was 31 and 45, respectively (P = .004). Although primary patency of the two access modalities was equivalent, primary assisted patency was significantly reduced in Vectra grafts (70% at 12 months and 58% at 18 months), compared with TBB fistulas (82% at 12 months and 78% at 18 months, P = .033); however, as a result of endovascular intervention, secondary patency rates at 12 months (87% vs 88%) and 18 months (87% vs 83%) were equivalent (P = .91). Presence of arterial anastomosis stenosis treated with angioplasty at any stage had a significant negative predictive value on secondary patency rates at 12 and 18 months which were 61%, compared with 96% for Vectra grafts that had any intra-graft, venous outflow, draining or central vein stenosis treated with angioplasty at any stage (P = .010). CONCLUSIONS: Aggressive graft surveillance and endovascular treatment methods can yield equivalent long-term secondary patency rates between Vectra graft and TBB fistulas. The advantage of earlier use of Vectra graft must be balanced against the need for more frequent secondary interventions and the risk of graft infection.     

Three-dimensional contrast-enhanced magnetic resonance angiography (3-D CE-MRA) in the evaluation of hemodialysis access complications, and the condition of central veins in patients who are candidates for hemodialysis access

BACKGROUND: Arteriovenous (AV) fistulas are crucial in patients requiring long-term hemodialysis (HD). Dysfunctions of these fistulas are the most common causes of recurrent hospitalizations. This study aimed to evaluate the feasibility, safety and usefulness of contrast-enhanced magnetic resonance angiography (CE-MRA) in the evaluation of HD fistulas complications, and the condition of the central veins before HD access. METHODS: This study comprised 30 consecutive patients (15 females, 15 males; age range 25-66 yrs, mean +/- SD 51.2 +/- 9.9 yrs). Of 30 patients, 26 had native AV fistulas and the remaining four patients, who had a history of previous subclavian vein catheterization, were candidates for HD fistulas. Nine patients had a radiocephalic fistula, 15 had a brachiobasilic fistula, one had a saphenous vein graft, and one had brachiobasilic vein transposition. To observe the fistula complications in these cases, three-dimensional (3-D) CE-MRA using gadolinium was performed. RESULTS: The results were considered normal in three patients (10%), who were candidates for AV fistula construction; one patient had central vein occlusion due to previous catheterization. Thirteen patients (43.3%) had venous stenosis or occlusion; three of them (10%) had low CE arteries distal to fistula region, leading to ischemic complications, and six (20%) had stenosis at the fistula region. Seven patients (23.3%) had venous pseudoaneurysms, whereas two of them had both pseudoaneurysms and fistula region stenosis, and one had both venous stenosis and pseudoaneurysm. There were no adverse or allergic-like reactions or heat and taste sensations observed in our series. CONCLUSIONS: 3-D CE-MRA is a useful, safe and a practical imaging modality in complicated fistula diagnosis with fewer complications and side-effects in comparison to fistulography.     

Polyflex self-expanding,removable plastic stents: assessment of treatment efficacy and safety in a variety of benign and malignant conditions of the esophagus

Background Historically, esophageal fistulas, perforations, and benign and malignant strictures have been managed surgically or with the placement of permanent endoprostheses or metallic stents. Recently, a removable, self-expanding, plastic stent has become available. The authors investigated the use of this new stent at their institution. Methods The study reviewed all the patients who received a Polyflex stent for an esophageal indication at the authors’ institution between January 2004 and October 2006. Duration of placement, complications, and treatment efficacy were recorded. Results A total of 37 stents were placed in 30 patients (14 women and 16 men) with a mean age of 68 years (range, 28–92 years). Stent placement included 7 for fistulas, 3 for perforations, 1 for an anastomotic leak, 7 for malignant strictures, and 19 for benign strictures (8 anastomotic, 1 caustic, 5 reflux, 2 radiation, and 2 autoimmune esophagitis strictures, and 1 post-Nissen gas bloat stricture). The mean follow-up period was 6 months. Stent deployment was successful for all the patients, and no complications resulted from stent placement or removal. Nine stents migrated spontaneously. Three of three perforations and three of five fistulas sealed. Only one stent was removed because of patient discomfort. One patient with a radiation stricture experienced tracheoesophageal fistulas secondary to pressure necrosis. Of 20 patients with stricture, 18 experienced improvement in their dysphagia. Conclusion Self-expanding, removable plastic stents are easily and safely placed and removed from the esophagus. This has facilitated their use in the authors’ institution for an increasing number of esophageal conditions. Further studies to help define their ultimate role in benign and malignant esophageal pathology are warranted.     

The efficacy of self-expanding metal stents for palliation of malignant esophageal strictures and fistulas.

OBJECTIVES: Esophageal strictures and esophagorespiratory fistulas are complications of malignant esophageal tumors, which are difficult to manage. The efficacy of self-expanding metal stents (SEMS) for palliation of malignant esophageal strictures and fistulas was investigated prospectively. METHODS: Forty-three SEMS were inserted in 41 patients with malignant esophageal stricture or fistula. Our series included 32 men and nine women, of whom median age was 61.4 years. Twenty nine stents were inserted for stricture, ten for esophago-tracheal fistula, and four esophago-pleural fistula. Stents were inserted endoscopically under fluoroscopic control. RESULTS: SEMS implantation was technically successful in 40 of 41 patients. A second stenting was needed in two patients. Median dysphagia score improved from 3.4 to 1.3. The covered SEMS was succesful in completely sealing 85.7% of the fistulas. Complication occurred in 11 (26.8%) patients. Especially in the case of tumor stenoses in the distal esophagus, complication rate was higher (44%). In total six patients (14.6%) died after stent placement during early postoperative period. Procedure-related mortality was 4.8% (2/41). CONCLUSIONS: We conclude that treatment of malignant esophageal obstructions, including esophagorespiratory fistulas, with SEMS is an alternative palliative procedure. Furthermore SEMS implantation seems more safe in the case of tumor stenoses locating in the middle esophagus.     

Reappraisal of Primary Balloon Angioplasty without Stenting for Patients with Symptomatic Middle Cerebral Artery Stenosis

There is a controversy regarding the safety and efficacy of intracranial stenting. We describe our experience with primary balloon angioplasty without stenting for symptomatic middle cerebral artery (MCA) stenosis. All patients who underwent balloon angioplasty without stenting for MCA stenosis between 1996 and 2010 were retrospectively reviewed. We evaluated technical success rates, degrees of stenosis, and stroke or death within 30 days. Among patients who were followed-up for > 1 year we evaluated latest functional outcomes, stroke recurrence at 1 year, and restenosis. In total 45/47 patients (95.7%) were successfully treated. Average pre- and postprocedure stenosis rates were 79.9% and 39.5%, respectively. Three neurological complications occurred within 30 days: one thromboembolism during the procedure; one lacunar infarction; and one fatal intraparenchymal hemorrhage after the procedure. Stroke or death rate within 30 days was 6.4%. Thirty-three patients were available for follow-up analysis with a mean period of 51.5 months. The combined rate of stroke or death within 30 days and ipsilateral ischemic stroke of the followed-up patients within 1 year beyond 30 days was 9.4%. Restenosis was observed in 26.9% of patients and all remained asymptomatic. In our retrospective series, balloon angioplasty without stenting was a safe, effective modality for symptomatic MCA stenosis. For patients refractory to medical therapy, primary balloon angioplasty may offer a better supplemental treatment option.     

Three cases of successful stenting for radiation-induced carotid arterial stenosis

We report three cases of radiation-induced carotid arterial stenosis that underwent successful angioplasty with stenting. The patients had received radiation therapy for tongue or laryngeal cancers and developed minor completed strokes 6 to 14 years after irradiation. All patients had multiple and bilateral stenosis, measuring more than 50%, of the carotid arteries. The stenosis was located in the internal, external, and common carotid arteries. We performed percutaneous transluminal angioplasty with stenting. All interventions were successful and carotid stenosis decreased to less than 28%. No permanent complications occurred. During follow-up periods of up to 26 months, all of these cases were free from ischemic symptoms. Neither carotid angiography nor ultrasound sonography showed evidence of restenosis. The present results suggest the usefulness of angioplasty with stenting for radiation-induced carotid arterial stenosis.     

Fistulas of the upper urinary tract: percutaneous management

We treated 40 patients with urinary fistulas by interventional radiology. The antegrade percutaneous route, catheterization of the ureter and bypassing of the fistula enabled ureteral stenting in 36 patients (90 per cent). Criteria for successful treatment were healing of the fistula, normal renal function (evaluated by excretory urography and radionuclide studies) and absence of secondary stenosis at 6 months. Of the patients 28 (70 per cent) were treated successfully. The number of nephrectomies after failure of percutaneous techniques (5 of 40, or 12.5 per cent) seems lower than in the case of surgery. The results were excellent for fistulas occurring after endourology (all 9 successful) or after ureterointestinal anastomoses (7 of 8). On the other hand, the results appear disappointing in patients with fistulas in transplanted kidneys (3 of 4 failures).