Low Incidence Of Major Complications Research Articles

Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists

Serious complications of central neuraxial block (CNB) are rare. Limited information on their incidence and impact impedes clinical decision-making and patient consent. The Royal College of Anaesthetists Third National Audit Project was designed to inform this situation. A 2 week national census estimated the number of CNB procedures performed annually in the UK National Health Service. All major complications of CNBs performed over 1 yr (vertebral canal abscess or haematoma, meningitis, nerve injury, spinal cord ischaemia, fatal cardiovascular collapse, and wrong route errors) were reported. Each case was reviewed by an expert panel to assess causation, severity, and outcome. 'Permanent' injury was defined as symptoms persisting for more than 6 months. Efforts were made to validate denominator (procedures performed) and numerator (complications) data through national databases. The census phase produced a denominator of 707,455 CNB. Eighty-four major complications were reported, of which 52 met the inclusion criteria at the time they were reported. Data were interpreted 'pessimistically' and 'optimistically'. 'Pessimistically' there were 30 permanent injuries and 'optimistically' 14. The incidence of permanent injury due to CNB (expressed per 100,000 cases) was 'pessimistically' 4.2 (95% confidence interval 2.9-6.1) and 'optimistically' 2.0 (1.1-3.3). 'Pessimistically' there were 13 deaths or paraplegias, 'optimistically' five. The incidence of paraplegia or death was 'pessimistically' 1.8 per 100,000 (1.0-3.1) and 'optimistically' 0.7 (0-1.6). Two-thirds of initially disabling injuries resolved fully. The data are reassuring and suggest that CNB has a low incidence of major complications, many of which resolve within 6 months.

Laparoscopic sleeve gastrectomy for morbid obesity

The epidemic of obesity in the United States is a major public health issue and more than a third of adults are now considered obese (body mass index ≥ 30 kg/m 2). Surgery for morbid obesity, bariatric surgery, is the most durable treatment for this disease and about 140,000 cases are performed annually. Laparoscopic sleeve gastrectomy (LSG) has been advocated as the first of a 2-stage procedure for the high-risk, super-obese patient. More recently, LSG has been studied as a single-stage procedure for weight loss in the morbidly obese. LSG has been shown in initial studies to produce excellent excess weight loss comparable with laparoscopic Roux-en-Y gastric bypass in many series with a very low incidence of major complications and death. We describe our technique for LSG.

CT-guided percutaneous transthoracic needle biopsy of lung lesions - 2-year experience at the Institute of Radiology in Ljubljana

Background. In 1883, Leyden described percutaneous lung biopsy, but it was not until 1970s that image guided fine needle chest biopsy gained widespread acceptance. Haaga and Alfidi reported CT-guided thoracic biopsy in 1976. Currently, tissue sampling of a thoracic lesion is indicated when the diagnosis is not obtained by the endobronchial technique and when the cytological diagnosis will modify the stage of the disease or influence the therapeutic strategy. Cytology obtained by small-gauge needle aspiration biopsy confirms the nature of the lesion in 80 - 95% of cases and carry a low incidence of major complications according to the literature. The purpose of this retrospective analysis was to provide basic data about diagnostic accuracy and incidence of pneumothorax and chest tube insertion with respect to percutaneous transthoracic CT-guided needle biopsy of lung lesions.

Rectal suction biopsy in the diagnosis of intestinal dysganglionoses: 5-year experience with Solo-RBT in 389 patients

Introduction Since Noblett ( J Pediatr Surg 1969;4:406-409) described her innovative tool, rectal suction biopsy (RSB) has become the gold standard in the diagnosis of Hirschsprung's disease and other intestinal dysganglionoses. Many different instruments have been developed during the last 30 years, but none of them proved to be free of disadvantages. In 2000, at Gaslini Research Institute, we developed an improved tool to perform RSBs called Solo-RBT (SAMO Biomedica, Bologna, Italy), which has some advantages: (1) the procedure is easily performed by one operator alone; (2) the instrument can be adjusted for each patient according to age and weight; and (3) the instrument can be completely disassembled for decontamination and heat sterilization. This study describes our experience with Solo-RBT in the diagnosis of intestinal dysganglionoses. Materials and Methods Between February 2000 and January 2005, we performed RSBs on 389 patients. Detailed information regarding patients, technique, histochemical staining, diagnostic criteria, complications, and diagnoses are provided. Moreover, patients were divided in 3 age-related groups to compare results. Results One thousand twelve biopsies were performed on 389 patients. Age range at biopsy was 4 days to 66 years. Median age was 2.4 years. Each patient underwent a mean of 2.6 biopsies. Fifty-nine patients experienced complications, including 2 persistent rectal bleedings (0.5%) in patients younger than 1 year and 57 inadequate biopsies (14.5%). Neither perforation nor pelvic sepsis occurred. Sixty-five cases of Hirschsprung's disease and 58 of intestinal neuronal dysplasia have been diagnosed with Solo-RBT. Conclusions The very low incidence of major complications proved that Solo-RBT is safe and effective. The wide age range at biopsy confirms the great versatility of this tool. Our study demonstrated that age does not represent a risk factor for inadequacy of the specimen; however, it showed that patients younger than 1 year have a higher risk of major complications. Therefore, although Solo-RBT increases safety and reliability of RSBs, great attention should be paid when this procedure is performed in newborns and infants.

Long-Term Outcomes and Complications Associated with Brachioplasty: A Retrospective Review and Cadaveric Study

To determine the overall complication rates associated with brachioplasty, a retrospective review was performed of all brachioplasty procedures performed at the authors' institution over a 16-year period. Hospital charts were reviewed for patient demographics. Ten fresh frozen cadaveric arm dissections were performed to better evaluate the anatomy of the medial antebrachial cutaneous nerve as it relates to brachioplasty. Forty bilateral brachioplasties were performed over the 16-year period. Average patient age was 47 years, and all patients were women. Average length of follow-up was 50 months. The revision rate was 12.5 percent. The overall complication rate was 25 percent. Ninety-five percent of the complications were classified as minor. None of the complications required correction with surgery. Complications noted were seroma, hypertrophic scarring, cellulitis, wound dehiscence, subcutaneous abscess, and nerve injury. Two patients (5 percent) developed an injury to the medial antebrachial cutaneous nerve during the procedure. Nerve injuries were classified as major complications. In cadaveric studies, the medial antebrachial cutaneous nerve was found to penetrate the deep fascia of the forearm at 14 cm proximal to the media epicondyle. Brachioplasty can be performed with a very low incidence of major complications, but both surgeon and patient should be aware of the possible risks associated with brachioplasty. Cadaveric dissections revealed that the medial antebrachial cutaneous nerve lies within the plane of dissection of the standard brachioplasty technique and is therefore at risk of injury.

Complications in bilateral mandibular distraction osteogenesis using internal devices.

We sought to evaluate the possibility of distraction osteogenesis as an alternative to conventional bilateral sagittal split osteotomy. Complications (intraoperative, intradistraction, and postdistraction) were evaluated retrospectively. Seventy consecutive patients (40 males and 30 females, 11.2-37.3 years old; mean, 14.2 years) underwent distraction osteogenesis to lengthen the mandible. The surgical procedure was carried out with the patient under general anesthesia. After the osteotomy was performed, 2 intraoral monodirectional distraction devices were placed on the mandibular cortex in the third molar region. The rate of distraction was 1 mm/day. The different complications encountered during all phases of the distraction procedure were recorded. A total of 28 complications (40%) were recorded. In 10 patients (14.3%), the complications were technique- or device-related, or both, and occurred early in the learning period. Five patients (7.1%) had infection occur, and 3 patients (4.3%) had prolonged sensory loss in the distribution of the alveolar nerve. Severe complications occurred in 6 patients (8.6%). Rehospitalization was necessary in 5 patients (7.1%), 4 of whom (5.7% of the series) required further surgery under general anesthesia. Distraction osteogenesis can be considered a safe and predictable procedure for lengthening the mandible, with a low incidence of major complications. The infection rate and the incidence of damage to the inferior alveolar nerve (2.1%) are low. Compliance of both patients and parents during the whole treatment period is of the utmost importance.

Outcome of Computer-Assisted Sinus Surgery: A 5-Year Study

The aim of this work was to study the outcome and rate of complications in a cohort of patients who underwent computer-assisted surgery (CAS). A retrospective study was performed of all patients undergoing CAS at a tertiary care teaching hospital over a 5-year period. All patients who underwent computer-assisted sinus surgery with at least 1 year of follow-up were included in the study. Charts were reviewed for indication of CAS, incidence of major complications, and need for revision surgery after CAS. A total of 120 patients underwent CAS in the 5-year period. Ten patients were lost to follow-up and were not included in the analysis. Indications for the use of CAS were revision surgery in 85 patients, sphenoid sinus disease in 12 patients, isolated frontal sinus disease in 4 patients, combined sphenoid and frontal disease in 2 patients, and cerebrospinal fluid leak (CSF) leak in 7 patients. The mean postoperative follow-up was 2.6 years. There were no major complications. Fifteen (16.5%) patients required revision surgery: 10 patients required revision endoscopic sinus surgery (1-5 revisions using CAS), 3 patients required an external open procedure, and 3 patients required revision CSF leak closure (one patient required both revision sinus surgery and an external procedure). There were no cases of major intra- or postoperative bleeding, central nervous system damage, CSF leak, or orbital trauma in this study. CAS helps in avoiding trauma to the orbit and anterior skull base and has a low incidence of major complications. The need for revision surgery may occur in patients with frontal sinus disease, nasal polyposis, or recurrent CSF leak.

Percutaneous Management of Calculi Within Horseshoe Kidneys

Percutaneous treatment of patients with calculi in a horseshoe kidney can be challenging due to the altered anatomical relationship in the retroperitoneum. Therefore, we performed a multi-institutional review to assess the safety and efficacy of this minimally invasive technique. Of 37 patients identified with calculi in a horseshoe kidney at 3 institutions 24 (65%) underwent percutaneous nephrolithotripsy as primary treatment. Average patient age was 48.4 years and 75% of the patients were male. In 3 patients with staghorn calculi mean stone size as measured by computed digitized stone surface area was 448 mm2. Mean followup was 5.8 months. The stone-free rate, complication rate, need for secondary intervention and stone composition were evaluated. Renal access was obtained through an upper pole calix in 63% of the cases, a lower calix in 25% and a middle calix in 4%. Access location was not documented in 1 patient (4%). Of the 24 patients 21 (87.5%) were rendered stone-free after primary or second look procedures. Flexible nephroscopy was used in 84% of cases. Minor complications occurred in 4 patients (16.7%), whereas 3 (12.5%) experienced major complications, including significant bleeding necessitating early cessation, nephropleural fistula and pneumothorax. No deaths occurred as a result of this treatment choice. Stone analysis was available for 21 cases (87.5%). Calcium stones predominated (87.5%), followed by uric acid (9.5%) and struvite (4.8%). Percutaneous treatment of patients with renal calculi in a horseshoe kidney is technically challenging, usually requiring upper pole access and flexible nephroscopy due to the altered anatomical relationships of the fused renal units. The success rate based on stone-free results and a relatively low incidence of major complications suggest that this minimally invasive management option is an effective means of stone management in this complex patient population.

Intramuscular gluteal implants: 15 Years' experience

Background: The history of gluteoplasty augmentation includes only a few reported clinical series. Objective: We report our experience in performing gluteal augmentation using an intramuscular technique in 160 cases over 15 years. We also establish guidelines for performing this procedure. Methods: All patients were women, ranging in age from 18 to 65 years, who underwent intramuscular gluteoplasty between June 1986 and September 2000. Of these patients, 104 (65%) received textured silicone gel implants and 56 (35%) received textured silicone elastomer implants. Thirty patients (18.7%) received 250-cc implants, 100 (62.5%) received 300-cc implants, and 30 (18.5%) received 350-cc implants. Results: Satisfactory aesthetic results were obtained in 144 of 160 patients (90%). Complications presented in 16 patients (10%), including seroma in 7 patients (4%), asymmetry in 4 patients (2.66%), capsular contracture in 3 patients (2% ), overcorrection in 1 patient (0.66%), and rupture of the implant in 1 patient (0.66% ). Conclusions: Intramuscular gluteal augmentation offers long-term, predictable, and pleasing aesthetic results with a low incidence of major complications. (Aesthetic Surg J 2003;23:86-91.)

Percutaneous tracheostomy with the Blue Rhino™ technique: presentation of 100 consecutive patients

Summary We assessed the peri‐operative, early and late complications in 100 percutaneous tracheostomies performed with the Blue Rhino™ kit. The success rate was 98%. Peri‐operative complications occurred in 30 patients. Six major complications occurred; these included bleeding which required surgical exploration (n = 3), and pneumothoraces (n = 2) and one false passage. Cannula insertion was made easier by blunt dissection of the cervical tissues anterior to the trachea. The median duration of the procedure was 8.5 min, which is significantly longer than other authors' results. Only one major complication occurred while the patient was cannulated (serious bleeding requiring exploration). Finally, in a single patient a tracheal stenosis occurred as a major late complication which eventually was treated by a successful tracheal resection. Percutaneous tracheostomy with the Blue Rhino™ kit is safe with a low incidence of major complications.

Feasibility of pylorus-preserving gastrectomy with a wider scope of lymphadenectomy.

To demonstrate the feasibility and safety of pylorus-preserving gastrectomy (PPG) accompanied by complete suprapyloric and infrapyloric lymph node dissection. Retrospective review. A university hospital in Japan. Fifteen patients underwent PPG, and 28 patients underwent conventional distal gastrectomy (CDG) with Billroth I anastomosis. All patients had early gastric cancer, with either limited invasion in the mucosal layer or invasion into the submucosal layer. In the PPG procedure, the distal part of the stomach was resected while retaining a 1.5-cm pyloric cuff. The right gastroepiploic artery, the right gastric artery, and hepatic and pyloric branches of the vagus nerve were divided, and the infrapyloric artery was preserved. A modified D1 or D2 lymphadenectomy accompanied the PPG. Patients undergoing the PPG and CDG procedures were assessed 1 year after their surgical procedure. Changes in body weight, serum total protein levels, and serum albumin levels, the incidence of dumping syndromes, and endoscopic findings in the gastric remnant were compared between the 2 groups. Weight loss was significantly less in the PPG group than in the CDG group (P=.02). The incidences of early dumping syndromes, especially vasomotor symptoms, were significantly lower in the PPG group than in the CDG group (P=.03 and P=.02, respectively). The pyloric sphincter function was preserved, and there was no anastomotic leakage in the PPG group. The PPG procedure with complete D2 lymphadenectomy can be performed safely with a low incidence of major complications and a better postoperative outcome than the CDG procedure. The PPG procedure can be recommended for the treatment of early gastric cancer with broader indications.

Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage

Background—The management of major colonic bleeding is problematic. A proportion of patients require emergency surgery which is associated with high morbidity and mortality. Percutaneous embolotherapy, previously considered a high risk...

Relation of operator volume and experience to procedural outcome of percutaneous coronary revascularization at hospitals with high interventional volumes.

Although an inverse relation between physician caseload and complications has been conclusively demonstrated for several surgical procedures, such data are lacking for percutaneous coronary intervention, and the ACC/AHA guidelines requiring > or = 75 cases per year for operator "competency" are considered by some physicians to be arbitrary. From quality-controlled databases at five high-volume centers, models predictive of death and the composite outcome of death, Q-wave infarction, or emergency bypass surgery were developed from 12,985 consecutively treated patients during 1993 through 1994. Models had moderate to high discriminative capacity (area under ROC curves, 0.65 to 0.85), were well calibrated, and were not overfitted by standard tests. These models were used for risk adjustment, and the relations between both yearly caseload and years of interventional experience and the two adverse outcome measures were explored for all 38 physicians with > or = 30 cases per year. The average physician performed a mean +/- SD of 163 +/- 24 cases per year and had been practicing angioplasty for 8 +/- 5 years. Risk-adjusted measures of both death and the composite adverse outcome were inversely related to the number of cases each operator performed annually but bore no relation to total years of experience. Both adverse outcomes were more closely related to the logarithm of caseload (for death, r = .37, P = .01; for death, Q-wave infarction, or bypass surgery, r = .58, P < .001) than to linear caseload. In this analysis, high-volume operators had a lower incidence of major complications than did lower-volume operators, but the difference was not consistent for all operators. If these data are validated, their implications for hospital, physician, and payer policy will require exploration.

Hydatid cysts of the liver: long-term results of percutaneous treatment using a cutting instrument.

We previously reported a technique for percutaneous drainage of hydatid cysts of the liver using a cutting instrument. The purpose of this study was to review the efficacy of this procedure in a large series of patients. The study included 32 patients each with a single hydatid cyst of the liver. Sixteen cysts were univesicular, nine were multivesicular, and four had a ruptured membrane. Two were infected, and one was calcified. Using a coaxial system, a large-bore cutting aspiration device was percutaneously introduced. Initial success consisted of complete evacuation of cyst contents plus absence of laminated membranes and daughter cysts on a cystogram performed 2 weeks later. Catheter drainage was continued until it was < 20 ml/day (mean, 4 weeks; median, 3 weeks). Patients underwent clinical and imaging follow-up examinations for between 9 and 48 months (mean, 25.5 months; median, 20 months). Follow-up imaging included monthly sonographic examinations for 6 months, control CT at 6 months, and sonographic and CT studies at 1-year intervals. All complications were recorded. A single aspiration and drainage procedure removed the liquid and solid cyst contents in 90% of the patients. Minor complications were limited to transient vasovagal reaction, mild fever that cleared without antibiotics, and reactive pleural effusion (19%). Three patients (10%) required a second intervention either to evacuate residual laminated membrane or to drain an abscess that developed within an incompletely evacuated cyst (one case). Eleven patients had bile in the drainage fluid. A biliary fistula was seen in five of those. No sign of recurrence was observed. Complete obliteration of the cavity was observed within six months in all cases. Complete reconstitution of hepatic parenchyma was shown by either sonographic or CT examinations within 1 year in 21 cases (66%). Results in a large group of patients indicate that the treatment of hydatid liver cysts with a cutting aspiration device is safe, effective, and reliable. It provides a high incidence (90%) of initial success with a low incidence of major complications (3%). Long-term follow-up has demonstrated no recurrence in the follow-up period.

Directional atherectomy of coronary and saphenous vein graft ostial stenoses

Directional coronary atherectomy (DCA) has been proposed as an alternative to balloon dilatation for treating coronary ostial stenoses, but the long-term efficacy of this procedure has not been well studied. To determine the procedural success and long-term efficacy of DCA for ostial stenoses, clinical data from 1 large registry database and from 2 single centers were retrospectively reviewed. Patients included in the study underwent DCA of aortocoronary (left main or right coronary artery), non-aortocoronary (left anterior descending or circumflex), or vein graft ostial stenoses. In 158 patients undergoing DCA of 160 lesions (30 left main or right coronary, 73 left anterior descending or circumflex, and 57 vein graft stenoses), overall procedural success, defined as < 50% residual stenosis without death, Q-wave myocardial infarction, or need for urgent bypass graft surgery, was 87%. The major complication rate was 0.6%. There were no deaths or Q-wave infarctions; only 1 patient required urgent bypass surgery. Other complications included non-Q-wave myocardial infarction (9%), arterial dissection (9%), abrupt closure (4%), and distal coronary embolization (4%). Angiographic follow-up was available for 65% of the 138 eligible patients. The overall 6-month angiographic restenosis rate, defined as >50% diameter stenosis at the site of DCA, was 48% (de novo lesions 40% and restenotic lesions 61%). Restenosis rates for de novo and restenotic lesions were: aortocoronary ( 33% 50% ), native coronary ( 38% 35% ), and vein graft ( 47% 93% ), respectively. We conclude that DCA of ostial stenoses is an effective revascularization strategy associated with a high procedural success rate and a low incidence of major complications. Restenosis, especially in restenotic saphenous vein graft lesions, continues to limit the long-term efficacy of the procedure.

A multicenter randomized trial comparing a percutaneous collagen hemotasis device with conventional manual compression after diagnostic angiography and angioplasty

Objectives. A new percutaneous collagen hemostasis device was compared with conventional compression techniques after diagnostic catheterization and angioplasty.Background. Peripheral vascular complications diagnostic catheterization or more complex interventional procedures, as well as the discomfort of manual compression and prolonged bed rest, represent significant morbidity for invasive cardiac procedures.Methods. A prospective, multicenter, randomized trial was designed to compare the hemostasis time in minutes and the incidence of vascular complications in patients receiving a vascular hemostasis device with those undergoing conventional compression techniques.Results. After diagnostic catheterization, hemostasis time was significantly less with the vascular hemostasis device than with conventional manual compression (4.1 ± 2.8 min [n = 90 patients] vs. 17.6 ± 9.2 min [n = 75], p < 0.0001). This difference was greater in patients undergoing angioplasty and was unrelated to the anticoagulation states (4.3 ± 3.7 min [n = 71 not receiving heparin], 7.6 ± 11.6 min [n = 85 receiving heparin], 33.6 ± 24.2 min [n = 134 control patients not receiving heparin], p < 0.0001 vs. control patients). The time from the start of the procedure to ambulation was slightly less after diagnostic catheterization in patients treated with the device (13.3 ± 12.1 h vs. 19.2 ± 17.8 h, p < 0.05). It was also less in patients who underwent angioplasty when the device was used after discontinuation of anticoagulation (23.0 ± 11.1 h, without heparin), as compared with control compression techniques (32.7 ± 18.8 h, p < 0.0001). Time to ambulation was even shorter (16.1 ± 11.1 h, p < 0.0001) in patients in whom the device was placed immediately after angioplasty while they were still fully anticoagulated with a prolonged activated clotting time (336 ± 85 s). There were no major complications (surgery or transfusion) after diagnostic catheterization and a low incidence of major complications in patients who underwent angioplasty (0.7% in control patients, 1.4% with the device without heparin, 1.2% with the device and heparin, p = NS). After angioplasty, there was a trend toward fewer hematomas when the device was used in the absence of heparin (4.2% vs. 9.7% in control patients, p = 0.14).Conclusions. A new vascular hemostasis device can significantly reduce the puncture site hemostasis time and the time to ambulation without significantly increasing the risk of peripheral vascular complications. The role of this technology in reducing complications, length of hospital stay and cost remains to be determined.

Angiographic and clinical outcome of intracoronary stenting: Immediate and long-term results from a large single-center experience

Objectives. The purpose of this study was to determine the immediate and long-term angiographic and clinical results of coronary stenting.Background. Although preliminary trials of endovascular stenting have demonstrated promising results, lack of long-term follow-up has limited the critical evaluation of the role of coronary stenting in the treatment of obstructive coronary artery disease.Methods. A total of 250 procedures using the Palmaz-Schatz stent, performed in 220 patients between June 1988 and July 1991, were examined. Minimal lumen diameter of the treated segments was measured on angiograms obtained before, after and 6 months after intervention.Results. Stent placement was successful in 246 (98%) of 250 lesions, reducing diameter stenosis from 77% to −2.5%. There were nodeaths or Q wave myocardial infarctions. One patient (0.4%) required emergency bypass surgery and one (0.4%) developed subacute thrombosis. Femoral vascular complications occurred in 36 patients (16%).Six-month angiographic follow-up was obtained in 91% of eligible patients. The overall angiographic restenosis rate (stenosis ≥50%) was 25%. By univariable analysis, the rate of restenosis was significantly higher for stents in the left anterior descending versus the right coronary artery (44% vs. 12%; p = 0.002); in diabetic patients (56% vs. 20%; p = 0.006), and in vessels with post-stent lumen diameter <3.31 mm (34% vs. 16%; p = 0.05). Stenting of the left anterior descending artery was the strongest predictor (p = 0.01) of restenosis in a multivariable model. Total survival was 97% and event-free survival (freedom from death, myocardial infarction or revascularization) was 70% at 36 months.Conclusions. Palmaz-Schatz stents can be placed successfully with a low incidence of major complications. The angiographic restenosis rate was 25%, and 70% of patients remained free of cardiovascular events at 3 years. Diabetes, small postprocedure lumen diameter and stenting of the left anterior descending artery are associated with higher rates of restenosis.

Cardiac Catheterization through the Internal Jugular Vein in Pediatric Patients: An Alternative to the Usual Femoral Vein Access

The percutaneous femoral vein approach is used routinely for cardiac catheterization in the pediatric age but in some children, it may be impossible as in the case of iliac vein or inferior vena cava thrombosis due to previous cardiac catheterization, or inconvenient as for right ventricular endomyocardial biopsies. In the period between 1982 and 1990, 160 cardiac catheterizations or right ventricular endomyocardial biopsies were performed in 102 children. Patients ranged in age between 2 months and 17 years (mean, 3.8 years) and in weight from 3.2 to 57.3 kg (mean, 14.4 kg). Indications for the internal jugular vein approach were as follows: (1) thrombosis of the inferior vena cava due to previous cardiac catheterization in 42 patients (41 percent); (2) right ventricular endomyocardial biopsy after cardiac transplant in 19 patients (19 percent); (3) control catheterization of the pulmonary arteries following classic or bidirectional cavopulmonary anastomosis in 16 patients (16 percent); (4) superior vena cava obstruction following Mustard's procedure in 14 patients (14 percent); (5) failed percutaneous femoral venous approach in six patients (6 percent); and (6) absence of the hepatic segment of the inferior vena cava in four patients (4 percent). The right or left internal jugular vein could be entered in all but three procedures (98 percent). Seventeen patients had more than one procedure through the same internal jugular vein and the vein was found patent in all. A complete right heart cardiac catheterization was performed using this route. Right ventricular endomyocardial biopsy and interventional procedure were performed through this route. Two major complications occurred. A patient developed a central transient ischemic attack and another patient developed a persistent Horner syndrome. Accidental carotid puncture occurred in five patients without consequences. Our data indicate that cardiac catheterization in infants and children can be performed safely through the internal jugular vein, with a high success rate and a low incidence of major complications.

Staghorn renal calculi: Personal experience with PCN

We report the results on 47 patients treated for staghorn renal calculi (partial and complete) by PCN-monotherapy and PCN-debulking. According to Rocco's classification the renal stones were 34 C4 and 13 C5. The PCN-monotherapy was used for 34 C4 and 6 C5, and showed itself to be resolutive in 83.4%. We resorted to the PCN-debulking in 7 cases, all C5: subsequent treatment with Extracorporeal Shock Wave Lithotripsy (ESWL) was performed or planned in other Centres. We emphasize the feasibility of PCN in staghorn renal calculi for the low incidence of major complications and for sometimes reducing the wait, both before and after treatment of complex renal lithiasis.

External Iliac Artery Rupture During Angioplasty

Transluminal angioplasty, particularly of stenoses of the iliofemoral arteries, is an excellent technique with a success rate greater than 90%, an overall complication rate of less than 5%, and a low incidence of major complications. Of these major complications, arterial rupture is one of the most urgent. We have presented a case of external iliac artery rupture during angioplasty that graphically demonstrates the value of balloon tamponade in managing this potentially catastrophic event. The angiographer's sensitivity to the possibility of arterial rupture and prompt management, combined with close collaboration with the vascular surgeon, can lead to a good clinical outcome.