Selective Visceral Arteriography Research Articles

S3667 Severe Gastrointestinal Bleeding From Gastric Remnant Two Decades after Roux-en Y Gastric Bypass Controlled With Selective Visceral Arteriography With Embolization

S3667 Severe Gastrointestinal Bleeding From Gastric Remnant Two Decades after Roux-en Y Gastric Bypass Controlled With Selective Visceral Arteriography With Embolization

Systemic Polyarteritis Nodosa in the Young: A Single‐Center Experience Over Thirty‐Two Years

Polyarteritis nodosa (PAN) is a rare disease of childhood. The aims of this study were to describe the clinical features, treatment, and outcome of systemic childhood PAN and to identify predictors of relapse. A single-center retrospective medical records review of children with PAN fulfilling the European League Against Rheumatism (EULAR)/Paediatric Rheumatology European Society (PRES)/Paediatric Rheumatology International Trials Organisation (PRINTO) classification criteria who were seen over a 32-year period was performed. Data on demographic and clinical features, treatments, relapses (recurrence of clinical signs/symptoms or occurrence of new symptoms after initial remission requiring escalation or resumption of immunosuppressive therapy), and deaths were recorded. A disease activity score was retrospectively assigned using the Paediatric Vasculitis Activity Score (PVAS) instrument. Cox regression analysis was used to identify significant predictors of relapse. Sixty-nine children with PAN were identified; 55% were male, and their median age was 8.5 years (range 0.9-15.8 years). Their clinical features at presentation were fever (87%), myalgia (83%), skin (88%), renal (19%), severe gastrointestinal (GI) (10%), and neurologic (10%) involvement. The PVAS at presentation was 9 of 63 (range 4-24). Histopathologic analysis of the skin showed necrotizing vasculitis in biopsy samples from 40 of 50 children. Results of selective visceral arteriography suggested the presence of PAN in 96% of patients. Treatment included cyclophosphamide and corticosteroids (83%), plasma exchange (9%), and biologic agents (after 2002; 13%). The relapse rate was 35%, and the mortality rate was 4%. Severe GI involvement was associated with increased risk of relapse (P = 0.031), while longer time to induce remission (P = 0.022) and increased cumulative dose of cyclophosphamide (P = 0.005) were associated with lower relapse risk. Childhood PAN is a severe inflammatory disease of insidious onset and variable clinical presentation. Relapses occurred more frequently in those with severe GI involvement. A higher cumulative dose of cyclophosphamide was associated with a lower risk of relapse.

Hepatic artery aneurysm involving the proper hepatic and gastroduodenal artery treated using a gastroepiploic artery in situ bypass

We herein present the first known case of common hepatic artery aneurysm involving the proper hepatic artery treated with in situ bypass by using right gastroepiploic artery. A 55-year-old man was hospitalized after the incidental discovery of a low-echogenic mass with blood flow in the hepatic artery. Selective visceral arteriography demonstrated a hepatic artery aneurysm that filled via the superior mesenteric artery. The most proximal part of the common hepatic artery was occluded. A resection of aneurysm was performed, and the arterial blood flow was restored to the liver by mobilizing the right gastroepiploic artery and anastomosing the proper hepatic artery. This technique is preferable to grafting in that only one anastomosis is necessary and predicts that the results may be at least as good as with vein or prosthetic grafts.

SURGICAL MANAGEMENT OF GASTROINTESTINAL BLEEDING

Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.

Dieulafoy Disease: Arteriographic Findings and Treatment

Dieulafoy disease is an unusual cause of massive and frequently fatal gastrointestinal tract hemorrhage that results from the erosion of a submucosal artery. Although the lesion has been found throughout the gastrointestinal tract, it most commonly occurs in the proximal stomach. Nine patients with this condition have been treated at the authors' institution during the past 5 years. The bleeding lesion was located before surgery with selective visceral arteriography in three patients. Rapid extravasation was demonstrated from an eroded but otherwise normal-appearing artery in all three cases. Hemorrhage was controlled successfully in one patient with selective embolization of the involved left gastric artery branch. The remaining eight patients were treated with surgical ligation.

Filling defects at the hepatic hilum due to compression by the right hepatic artery in cholangiography.

It has been accepted widely that filling defects in cholangiography are attributed to stones or tumors. However, we have recognized that filling defects at the hepatic hilum in cholangiography are caused by compression of the hepatic duct by the right hepatic artery. We studied 125 cases by cholangiography. Of these, 34 cases were subjected to simultaneous percutaneous transhepatic cholangiography and selective visceral arteriography. Among 125 cases, 25 cases (20%) showed filling defects at the hepatic hilum from compression by the right hepatic artery.

Ectopic Pancreas Causing Massive Upper Gastrointestinal Hemorrhage: Report of a case diagnosed arteriographically

Although the clinical, radiographical, surgical, and pathological manifestations of ectopic pancreas have been extensively described, conclusive documentation by any method of gastrointestinal hemorrhage from an ectopic pancreas is rare.1 The authors report a case of an ectopic pancreas in the second portion of the duodenum which was proven to be the source of massive gastrointestinal bleeding by selective visceral arteriography and was confirmed by surgical exploration. To our knowledge, angiographical documentation of active gastrointestinal hemorrhage from an ectopic pancreas has not been reported.

Angiographic management of postoperative bleeding.

Selective visceral arteriography was performed in 11 patients with unremitting bleeding directly related to gastrointestinal surgery. In each case the site of hemorrhage was localized and posterior pituitary extract was infused into the bleeding artery to achieve hemostasis. In nine patients the infusion was successful in providing angiographic and clinical control of the bleeding, and further therapy was not required. In the remaining two patients the infusion failed to arrest the hemorrhage and both patients needed re-exploration. There were no complications, and all patients were discharged from the hospital.

Arterial injury in dogs after multiple percutaneous catheterizations at the same site of entry.

Seventeen dogs which had undergone selective visceral arteriography 3 to 10 times over a period of three years were catheterized repeatedly via the femoral arteries. Seven dogs showed arteriographically demonstrable abnormalities of the arterial wall, corresponding to the histological findings of intimal hyperplasia with collagen deposition and fibroblastic proliferation in the media. The presence of these lesions did not correlate with the number of catheterizations. None of the dogs demonstrated signs of peripheral arterial insufficiency. These findings may be of greater significance when applied to human patients, due to their higher incidence of arteriosclerotic disease and their less pronounced collateral circulation.

Angiography in the diagnosis and management of bleeding stress ulcers and gastritis

Eighteen patients with upper gastrointestinal hemorrhage from erosive gastritis or stress ulcers were studied by selective visceral arteriography. Thirteen patients had positive results on arteriography. Vasopressin (Pituitrin) was administered intra-arterially to six patients. Bleeding was controlled completely in four patients and partially in one patient. There was no control in one patient in whom the left gastric artery was not selectively infused.

Pitfalls in arteriography of islet-cell tumors of the pancreas.

Selective visceral arteriography can be a significant aid in the diagnosis of and surgical approach to islet-cell tumors of the pancreas. Unfortunately, the characteristic vascular blush in the pancreatic region is neither specific nor always present. The cases presented, which either did simulate or could have simulated an islet-cell tumor, include an accessory spleen, hyper-plastic lymph node, focal nodular hyperplasia of the liver, chronic recurrent pancreatitis, and bleeding into a pancreatic pseudocyst.

The diagnosis of traumatic laceration of the spleen by selective arteriography, direct serial magnification angiography, and intra-arterial epinephrine.

ARTERIOGRAPHY in emergency situations I1will often provide definitive diagnoses which expedite and facilitate life-saving treatment (9). Although the literature contains examples of isolated cases of splenic rupture diagnosed by arteriography (1, 2, 7, 8, 10), the problem had not received adequate attention until the recent reports of Love et al. (6) and Berk and Wholey (3). The purpose of this paper is to report the roentgen findings in five proved cases that are presumed to be representative and diagnostic. In addition, the use of intra–arterial aqueous epinephrine and serial magnification angiography as diagnostic adjuncts will be discussed. Material And Methods Ten patients suspected of having a ruptured spleen were examined via the percutaneous transfemoral route using the Seldinger technic. A yellow or red endhole J–shaped Odman-Kifa catheter was used for selective visceral arteriography. Films were obtained with a Schonander 14 × 14 cut–film changer in the frontal projection and were exposed at 3 per second for three seconds followed by one film per second for twelve additional seconds. Approximately 0.5 ml/kg of body weight of Hypaque–M 75 per cent was injected into the celiac artery by means of a ViamonteHobbs injector, with flow rates of 10 ml/ sec. Direct serial magnification angiography was accomplished with an x–ray tube with a 0.3 mm focal spot, positioned 20 inches from the object. Serial films were exposed at one per second for eight seconds using a Sanchez–Perez serialograph positioned 20 inches below the object. The diagnosis of ruptured spleen was made angiographically and confirmed at surgery in 5 patients. In 3 of these, aqueous epinephrine was injected into the celiac artery, and the examination was repeated within thirty seconds, fifteen minutes after the initial study suggested the diagnosis. The celiac arteriograms in 5 additional patients were interpreted as being normal; each of these patients was ultimately discharged and remained in good health. No complications were encountered as a result of any of the examinations. Case Reports CASE I (G. G.): This 12–year–old boy was admitted to Nassau Hospital after tripping and falling on the abdomen in school during gym class. The patient complained of upper abdominal pain, radiating to the left scapula. Physical examination revealed tenderness in the left upper quadrant and left flank. The bowel sounds were normal, and no masses were palpable. Pertinent laboratory findings included a hemoglobin of 13.9 g/100 ml, hematocrit of 40 per cent; white blood count of 1O,000/mm3 with a normal differential. An abdominal tap of the left upper quadrant was performed, and findings were negative.

Arterial portography: patterns of venous flow.

Over the last fifteen years splenoportography has provided an understanding of flow patterns that may be seen with the various forms of portal venous obstruction (1, 2). Although the entire portal system is seldom visualized by this technic of injection of contrast medium into the spleen, many basic hemodynamic principles have been determined and correlation made with a variety of types of pathology that involve the portal system (3, 4). With the introduction of selective visceral arteriography (celiac and superior mesenteric) it has been possible to recognize certain of the same venous patterns that are seen with splenoportography (5–8). However, there are certain differences which can be readily appreciated and understood when the site of injection is kept in mind. Opacification of the venous side after injection into an artery has always been fraught with the problem of the dilution effect which occurs in the transcapillary passage of the contrast medium, especially when injection is made into an artery that has a wide distribution. In our experience, placement of the tip of the catheter directly into the splenic artery rather than in the celiac axis has resulted in better opacification of the splenoportal axis. Others (6) report a success rate of more than 90 per cent with splenic artery injections. Attempts have been made to induce dilatation of the arterial side during injection by the use of drugs and thereby produce greater flow into the venous side (9, 10). These trials have been only fairly successful. The use of larger amounts of contrast medium has also resulted in better opacification of the portal system (6). In this study, 60 cc of 76 per cent Renografin was injected into the celiac or superior mesenteric artery at a rate of 15 ml per second. The Normal Venous Pattern In the normal portal system, blood flow is hepatopetal in direction. Therefore, in the normal patient certain veins of the portal system will be seen depending on the site of injection (Fig. 1). If injection is made directly into the normal portal system only those veins between the site of injection and the liver are opacified. Consequently, when injection is made into the spleen (the splenoportogram) only the splenic and portal veins will be visualized. If a tributary of the superior mesenteric vein is injected at surgery, only those major vessels between the site of injection and the liver, i.e., the superior mesenteric and the portal veins, will be opacified. When a celiac artery injection is made (Fig. 1, B) contrast agent will flow over the several branches of the celiac artery—the left gastric, the common hepatic, and the splenic arteries. Therefore, contrast medium will return to the venous system over the veins that drain the territories supplied by these several arteries and their branches (Fig. 2, A).

Severe gastrointestinal haemorrhage: haemangiomata demonstrated by selective visceral arteriography.

Selective visceral arteriography was found to be invaluable in the management of two cases of severe gastrointestinal haemorrhage associated with cavernous haemangiomata (a large gastric haemangioma and a small jejunal haemangioma). It is suggested that arteriography may be indicated in cases where a previous laparotomy has not shown the cause of bleeding, when the patient's general condition precludes a prolonged operation, and when superficial haemangiomata are found.

Experimental visceral arteriography in blunt abdominal trauma.

EXPERIMENTAL VISCERAL ARTERIOGRAPHY IN BLUNT ABDOMINAL TRAUMAMELVYN H. SCHREIBER, M.D., FRED J. WOLMA, M.D., ARNOLD O. MANKSE, M.D. and CHARLES H. MOORE, M.D.Audio Available | Share

Use of arteriography in the diagnosis of occult gastrointestinal and traumatic intra-abdominal hemorrhage

Selective visceral arteriography has proved to be a reliable diagnostic adjunct in evaluating selected cases of gastrointestinal hemorrhage or blunt abdominal trauma. Its use is advocated in gastrointestinal hemorrhage which cannot be localized by conventional diagnostic methods. Experimental work suggests that active bleeding at the rate of at least 0.6 ml. per minute may be identified by the appearance of intraluminal contrast medium during late phases of the arteriogram. Such observations were made clinically in two patients. In the absence of active bleeding other arteriographic features characteristic of aneurysm or tumor may demonstrate the responsible lesion. After blunt abdominal trauma, arteriography has proved useful in evaluating the presence or absence of intraabdominal visceral injury in five patients. Hepatic laceration and hematoma, thrombosis of the renal artery, and two cases of splenic tear were demonstrated by arteriography in four patients. The clinical evidence against the need for operative intervention was substantiated by a visceral arteriogram revealing no abnormalities in an eighth patient.