Transcatheter treatment of myelomatous AV shunting causing high-output failure

Intraarterial digital subtraction arteriography (DSA) was performed in a 39-year-old man with multiple myeloma, high-output congestive heart failure unresponsive to correction of anemia, and a pelvic bruit suspicious for an arteriovenous malformation. DSA revealed extensive neovascularity of all the visualized skeletal structures with rapid arteriovenous shunting in the pelvis. Temporary embolization of both hypogastric arteries with Gelfoam and autologous clot produced immediate and dramatic clinical relief of the shortness of breath, orthopnea, and hyperdynamic circulation. Following return of symptoms, repeat permanent occlusion with Ivalon and Gianturco coils produced minimal clinical response, but a decrease in cardiac output from approximately 23 L/min to 19 L/min. The etiology of congestive heart failure in myeloma, the implications of the use of intraarterial DSA, and the arteriographic findings in myeloma are discussed.     

Management of TIPS-related refractory hepatic encephalopathy with reduced Wallgraft endoprostheses

The purpose of this study is to evaluate the feasibility of constrained endografts used for the treatment of transjugular intrahepatic portosystemic shunt (TIPS)-related refractory hepatic encephalopathy (HE). Because the clinical status of two patients worsened (return of intractable ascites requiring transplantation, n = 1; death, n = 1) after complete balloon occlusion, six patients were treated with constrained/modified Wallgraft endoprostheses placed within the preexisting TIPS. Shunt reductions were technically successful in all six patients, as shown by an immediate mean portosystemic gradient increase of 9.3 mm Hg. Clinical improvement was achieved in five patients within 72 hours of reduction. The remaining patient continued to decline and died 3 weeks later. Two endografts completely occluded within 8 months without HE recurrence. This technique offers an attractive alternative to previously described shunt reduction methods.     

Outcomes following extracranial carotid artery stenting in high-risk patients

BACKGROUND: Carotid artery angioplasty and stenting has become a viable alternative to carotid endarterectomy (CEA), especially for patients considered at high risk for post-operative complications. This study investigated the feasibility, safety and long-term outcome of carotid artery stenting (CAS) in high-risk patients. METHODS: From July 1995 to November 2000, sixty-two consecutive patients considered to be at high risk for post-operative complications of CEA were followed prospectively after undergoing extracranial CAS procedures. RESULTS: Sixty-two patients [37 men (60%) and 25 women (40%)] underwent a total of 69 CAS procedures. The mean age was 67 +/- 9 years (range, 32-89 years). Comorbid conditions included hypertension in 95% and severe coronary artery disease in 58%. Sixteen patients (26%) had a previous ipsilateral CEA, twenty-one percent had a history of neck radiation and 32% had a history of significant contralateral carotid artery disease. Fifty-two patients (84%) were symptomatic. All 69 CAS procedures were technically successful. The major post-operative complications were two minor strokes (2.8%), one major stroke (1.4%) and one fatal major stroke (1.4%). The mean length of follow-up was 17 months (range, 4 months to 5.6 years). Two patients (2.8%) have suffered ipsilateral neurologic events following CAS. Long-term follow-up revealed restenosis at 6 months in 4 patients (5.7%). CONCLUSIONS: Carotid artery angioplasty and stenting is safe and feasible. This procedure produces satisfactory outcomes in patients who are at high risk for post-operative complications of CEA.     

Venous leaks: anatomical and physiological observations

A total of 50 patients with impotence underwent cavernosometry and cavernosography with intracavernous injection of vasoactive drugs. Several hemodynamic parameters were analyzed, including the pressure response curve after injection of vasoactive drugs and infusion of saline, the volume required to achieve erection, venous outflow resistance, erection maintenance infusion rate, rate of pressure decrease after discontinuation of infusion and post-infusion steady state pressure. On the basis of cavernosometric findings, venous leakage was ruled out in 4 patients. In the remaining 46 patients leak sites visualized during cavernosography included superficial dorsal vein in 1 (2.2%), deep dorsal vein in all 46 (100%), cavernous veins in 32 (69.6%), glans in 19 (41.3%) and corpus spongiosum in 14 (30.4%). Aberrant veins were documented in 7 patients (15.2%) communicating with the saphenous vein in 4 (8.9%), scrotal veins in 2 (4.4%) and femoral veins in 1 (2.2%). Eight patients (17.4%) had leakage through the deep dorsal vein as the only venous site, 17 (36.9%) had leakage through 2 venous sites, 14 (30.4%) had leakage through 3 venous sites and 7 (15.2%) had leakage through 4 venous sites. Correlations among hemodynamic and radiographic observations allowed the identification of 4 different types of cavernosometric findings. While type I represented normal penile vascular findings, types III and IV represented venous leakage. Type II could represent no leak, a mild leak or an undetected arterial problem. Accuracy of interpretation of a study may be improved by taking more than 1 parameter into consideration, including erection maintenance infusion rate, intracavernous pressure decrease within the first 5 seconds after discontinuation of infusion and the final steady state intracavernous pressure. The majority of patients have more than 1 leak site (82.6%). The most commonly combined sites of leakage are the deep dorsal and cavernous veins.     

Endovascular management of ureteral-iliac artery fistulae with Wallgraft endoprostheses

BACKGROUND: Ureteral-iliac artery fistulae are rare, yet potentially life-threatening, causes of hematuria. Treatment has traditionally been surgical, but advances in endovascular technology have led to a few recent reports of therapy with covered stents. We report two cases of patients diagnosed with ureteral-iliac artery fistulae who were treated with Wallgraft endoprostheses, a new, commercially available covered stent. CASES: We report two patients with gynecologic malignancies who presented with massive hematuria and hypotension and were subsequently proven to have ureteral-iliac arterial fistulae. Both patients had prior pelvic surgery, radiation, and chronic indwelling ureteral stents. Once the diagnosis was established, both patients were managed with endovascular covered stent placement. The patients' conditions stabilized, hematuria ceased, and both were discharged from the hospital without additional transfusion or surgical treatment. CONCLUSION: Endovascular therapy with covered stents is a safe, effective, and readily available method for the treatment of ureteral-iliac artery fistulae.