Knotting of intracardiac flow-directed balloon catheter. Simple surgical method of removal

A complete knot occurred in a 7F flow-directed balloon catheter inserted through the right internal jugular vein. The patient was intubated and placed under positive pressure ventilation. After gaining surgical exposure of the venipuncture site, a purse-string of Prolene 4--0 suture was placed around it. The patient was placed in the Trendelenburg position and the knotted catheter withdrawn, while the purse-string suture was immediately tightened avoiding uncontrollable hemorrhage or massive air embolism.     

Direct videoscopic approach to the descending thoracic aorta for aortic arch endograft delivery: evaluation in a porcine model.

PURPOSE: To examine the feasibility of a direct videoscopic approach to the descending thoracic aorta for endograft delivery to the aortic arch. METHODS: A double purse-string suture was placed on the aorta of 3 pigs via a thoracoscopic approach. Subsequently, the aorta was cannulated in the center of the purse-string. A 22-F delivery catheter was advanced under fluoroscopic control over a guidewire via a trocar into the proximal aorta. After deployment of a tubular endograft, the catheter was withdrawn from the aorta while simultaneously tightening the purse-string suture, without aortic cross clamping. The outcome was evaluated by post implant angiography and autopsy results. RESULTS: The procedure was successfully completed in all animals, with a mean total procedure time of 126 minutes (range 118-137). Mean endograft implantation time from needle puncture to catheter extraction was 27 minutes (range 21-37). Hemostasis was obtained in all animals after withdrawal of the delivery catheter and tightening the purse-string suture. The mean blood loss was 143 mL (range 80-220). Autopsy proved all purse-string sutures to be adequately placed and all endografts deployed in the correct position. CONCLUSION: A direct videoscopic approach to the descending thoracic aorta proved a feasible technique for endograft delivery to the aortic arch in a porcine model.     

Portal and mesenteric vein and inferior vena cava thrombosis associated with antiphospholipid syndrome

We report a 48-year-old man with thrombosis of the portal and superior mesenteric vein and inferior vena cava associated with primary antiphospholipid syndrome (APS). Primary APS was diagnosed by a positive reaction with anticardiolipin antibody (aCL) and the absence of any evidence suggesting the presence of other disease states known to be associated with aCL. A coeliac angiography showed obstruction of the portal and superior mesenteric vein with prominent collaterals and cavernous transformation. Femoral vein angiography showed total obstruction of the external iliac vein and inferior vena cava, and dilation of the pelvic veins, with contrast medium in the lumbar vein. This case is noteworthy as a report of primary APS accompanied by extensive abdominal and pelvic venous thrombosis.     

Pseudo-Budd-Chiari syndrome: extrinsic deformity of the intrahepatic inferior vena cava mimicking membranous obstruction

Budd-Chiari syndrome secondary to membranous obstruction of the intrahepatic inferior vena cava is a treatable form of chronic liver disease. I report a patient with portal hypertension in whom distortion of the inferior vena cava by cirrhosis and increased intraabdominal pressure initially suggested this condition. The correct diagnosis was made by obtaining lateral views during inferior vena cavography, which demonstrated a tapered, rather than membranous, obstruction, along with normal hepatic venous anatomy and pressure and markedly increased portal vein pressure during transhepatic puncture with a thin needle. That extrinsic deformity of the inferior vena cava may mimic membranous obstruction has not been emphasized recently. This distinction is important as surgical membranotomy is not indicated in patients with cirrhosis and secondary deformity of the inferior vena cava.     

Simple, rapid, and effective method of producing aortocaval shunts in the rat

STUDY OBJECTIVE - The aim of the study was to develop a new procedure to produce abdominal aortocaval shunts in the rat without vascular microsurgery. PROCEDURE - The inferior vena cava and abdominal aorta were exposed by laparotomy. The aorta was punctured caudal to the left renal artery with an 18 gauge disposable needle which was advanced into the vessel, perforating the adjacent wall between aorta and vena cava and penetrating the latter. A bulldog vascular clamp was placed across the aorta cephalic to the puncture, the needle was withdrawn, and the aortic puncture point was sealed with a drop of cyanoacrylate glue. The clamp was removed 30 s later. Patency of the shunt was verified visually by swelling of the vena cava and admixture of arterial and venous blood. No local haemorrhages were seen. The laporatomy was then closed. The procedure takes less than 10 min. RESULTS - Of 11 rats which received this procedure, only one died within 24 h. All the other animals were killed 4 weeks after operation. Nine of these 10 animals had developed cardiac hypertrophy of about the same magnitude. There were no changes in sham operated controls. CONCLUSIONS - This is a reproducible, simple and rapid method of developing high output heart failure and cardiac hypertrophy in the rat which could be useful in many laboratories.     

Persistent left superior vena cava: multi-slice CT images and report of a case

Abnormalities of the vena cava system are usually asymptomatic and discovered incidentally during catheter placement or pacemaker implantation. Persistent left superior vena cava (PLSVC) is caused by failure of involution of the left anterior cardinal vein caudal to the left brachiocephalic vein during embryonic development. It is a benign condition, but becomes dangerous during pacemaker lead implantation, especially in emergency situations and when the right superior vena cava is absent. This is brought about by difficulty in pacemaker lead maneuvering into the right ventricle. A 64-cut multi-slice computed tomographic (MSCT) scan can show clear spatial relationship of the heart with its surrounding structures. We present a case of PLSVC discovered during pacemaker implantation, and viewed by 64-cut MSCT scan.     

Surgical treatment for an extrahepatic portosystemic shunt: a case report

An extrahepatic portosystemic shunt that has neither liver cirrhosis nor portal hypertension is rare. A 60-year-old Japanese woman who had been suffering chronic liver disease and anemia with mild disorientation was admitted to investigate general fatigue with dizziness and disorientation. The laboratory data revealed mild pancytopenia and liver dysfunction including hyperammoniemia, an increased Indocyanine Green 15-min retention rate, and a decreased Fischer's ratio. Color Doppler ultrasonography, computed tomography, and arterial portography revealed an extrahepatic portosystemic shunt that extended tortuously from the superior mesenteric vein into the inferior vena cava, and decreased blood flow in the main portal vein. Judging from intraoperative measurement of portal pressure and intraoperative portography, shunt ligations were performed at both the efferent portion of shunt from the superior mesenteric vein and the afferent portion of the shunt into the inferior vena cava, and resection of the spleen was also performed. On the postoperative laboratory data, pancytopenia disappeared, and liver function improved. Postoperative abdominal imaging showed increased blood flow in the main portal vein and disappearance of the shunt vessel. Moreover, symptoms present before surgery also disappeared. In conclusion, surgical treatment of extrahepatic portosystemic shunts may result in better postoperative quality of life if it is performed in carefully selected patients.     

Postsurgical chylous ascites in sarcoidosis with portal hypertension

A patient with extensive thromboses of portal and mesenteric veins and sarcoid of the liver developed recurrent pulmonary emboli, which necessitated the insertion of an umbrella into the inferior vena cava. Chylous ascites appeared shortly thereafter; the ascitic fluid fat content was strikingly reduced after reduction of dietary long chain triglycerides, but the ascitic fluid volume was reduced only after insertion of a peritoneovenous shunt (LeVeen). The shunt was found to be nonfunctioning 4 months later, but ascites did not recur. Seven years later, while eating a normal diet and still having a nonfunctioning shunt, he remains free of ascites. We postulate that iatrogenic obstruction of the inferior vena cava in the presence of mesenteric and portal vein thromboses, as well as obstruction of mesenteric lymphatics by sarcoid lymphadenopathy, led to the formation of chylous ascites and that establishment of adequate mesenteric and portal venous and/or lymphatic collateral circulation was responsible for his sustained improvement.     

门静脉收缩器建立犬门静脉高压食管静脉曲张模型的实验研究

目的 探讨建立稳定的门脉高压食管静脉曲张犬模型的可行性.方法 12只杂交犬,采用门静脉.下腔静脉侧侧分流术+门静脉主干环置amemid收缩器+下腔静脉头侧双线交叉缝合结扎的方法制作动物模型.6周后,胃镜和门静脉造影检查观察食管曲张静脉形成情况.结果 造模手术前门静脉压力为(11.0 ±1.1)mm Hg,造模后门静脉压力升高至(22.9±1.2)mm as(P=0.010).胃镜发现所有的杂交犬均形成了轻-中度食管曲张静脉,门静脉造影检杳证实食管中下段有曲张静脉形成,同时腹壁形成了肉眼可见的曲张静脉.结论 门静脉收缩器法能成功地建立门脉高压食管静脉曲张动物模型.     

多排螺旋CT在检出右侧肾上腺静脉应用价值的初步探讨

目的:探讨多排螺旋CT(MDCT)对右侧肾上腺静脉检出率及右侧肾上腺静脉解剖结构显示情况。方法:402例行MDCT腹部三期增强扫描的患者,由两个不同的影像科医师观察其右侧肾上腺静脉轴位像和三维重建图像,进而评价右侧肾上腺静脉的情况。评价要点:可视化程度;右侧肾上腺静脉的直径与长度;与副肝静脉和其他静脉间的关系;右侧肾上腺静脉的位置及与周围结构间的关系,与下腔静脉的方向关系。结果:402例患者检出右侧肾上腺静脉338例(84.1%),其中,有31例(9.2%)右侧肾上腺静脉与副肝静脉共干,右侧肾上腺静脉开口位于胸11~腰1之间。另307例患者中,在横断面上右侧肾上腺与下腔静脉横方向关系为向后和向右的占282例(91.9%),向后和向左的占25例(8.1%);在垂直面上右侧肾上腺朝向下腔静脉尾侧有292例(95.1%),头侧为15例(4.9%)。在这338例患者中,右侧肾上腺静脉的长度和直径分别为平均(3.8±1.7)mm和(1.7±0.6)mm。结论:MDCT有较高检出右侧肾上腺静脉的能力,并能大致显示其解剖特征,包括它的位置和与周围结构的关系。     

Methodology of renal vein renin study: comparison between simultaneous and sequential sampling (author's transl)

Purpose of this study has been to compare the results obtained using two different procedures in blood sampling from the renal veins for measuring renal venous renin. The first is the classical procedure which employs three catheters for simultaneous sampling from both renal veins and from the inferior vena cava, or from an artery. The other one is a simplified procedure which employs a single catheter that allows blood to be collected in the following rapid sequential manner: right renal vein, inferior vena cava, left renal vein, inferior vena cava. We have studied 13 patients (8 with essential hypertension, 5 with unilateral renal artery stenosis). Two catheters were introduced through a femoral vein and inserted into both renal veins; a third catheter was inserted into the femoral artery; then the blood sampling was performed strictly simultaneously. Soon after, the blood sampling was repeated according to the above mentioned sequential single catheter procedure. PRA was measured by Angiotensin I radioimmunoassay, then the Renal Vein Ratios (RVRR) were calculated. Even though as average of less than 20 seconds elapsed between the blood sampling in a renal vein and that in inferior vena cava, our results demonstrate that the release of renin can vary so quickly that erroneous informations may be obtained unless a strictly simultaneous sampling of blood is performed. In conclusion, our study demonstrates that the only reliable renal vein renin sampling procedure must employ the simultaneous renal venous and arterial (or inferior vena cava) blood collection.     

Congenital absence of the portal vein complicating hepatic tumors

Congenital absence of the portal vein (CAPV) is a rare malformation that is often accompanied by other anomalies such as cardiac and skeletal malformations and/or hepatic tumors. We describe here a case of CAPV complicating hepatic tumors in a 16-year-old Japanese girl. Abdominal ultrasonography revealed a hyperechoic tumor in the liver and dilatation of the portal vein that appeared to be connected directly with the inferior vena cava. Subsequent abdominal computed tomography (CT) revealed tumors and magnetic resonance angiography confirmed that the portal vein entered directly into the inferior vena cava just above the liver. In addition, there was absence of the right portal vein and the left intrahepatic branch except for the presence of left portal vein only within the porta hepatis. These findings led to a diagnosis of CAPV complicated hepatic tumors. Careful monitoring of these hepatic tumors is ongoing due to the possibility of malignant transformation.     

New type of asymptomatic congenital portosystemic shunt

Congenital extrahepatic portosystemic shunt (CEPS) is an extremely rare anomaly. In these malformations splanchnic blood bypasses the liver and drains into the systemic circulation through the inferior vena cava (IVC) or the left renal vein (LRV). Extrahepatic shunts may be divided into type 1 [end-to-side mesenterico-caval fistula with congenital absence of the portal vein (PV)] and type 2 (partial portocaval shunt caused by side-to-side mesenterico-caval fistula with normal or hypoplasic PV). Type 2 shunts typically are wholly extrahepatic between the PV or its right branch and the retrohepatic IVC. This report describes an asymptomatic case of CEPS not previously documented and not classifiable as type 1 or 2. CT revealed a normal PV with communication between the inferior mesenteric vein (IMV) and the LRV. The inferior mesenteric vein appeared tortuous, abnormally long and with a large calibre, and presented a connection with the LRV, in addition to a normal confluence into the splenic vein. Colour Doppler revealed hepatopetal normal flow in the PV and superior mesenteric vein with mild portal hypertension and an inversion of flow in the IMV directed to the LRV. Biochemical parameters showed a normal liver function without hyperammonaemia.     

Leiomyosarcoma of the inferior vena cava--an unusual case

Primary tumors arising from great vessels like the aorta, pulmonary artery or inferior vena cava (IVC) are rare. The latter is the commonest site of its occurrence. It arises from the smooth muscle cells of the vessel wall. Aggressive surgical management should be attempted to excise it whenever possible. We describe a case of primary inferior vena cava tumor involving all three segments of the abdominal inferior vena cava infrarenal, suprarenal and retrohepatic vena cava, along with right kidney, right adrenal as well as right hepatic vein and left renal vein. We resected it completely without reconstruction of the IVC. The patient is doing well seven months after surgery without having any renal insufficiency, hepatic insufficiency or leg edema and having optimum quality of life. To our knowledge, this is the first case of such a long segment IVC leiomyosarcoma treated without IVC reconstruction, and despite its extent and concomitant involvement of the right kidney, right adrenal, right hepatic vein and left renal vein, it had a favorable response combining prolongation of survival and satisfactory quality of life.     

Relationship between encephalopathy and portal vein-vena cava shunt： Value of computed tomography during arterial portography

AIM: TO assess the value of computed tomography during arterial portography (CTAP) in portal vein-vena cava shunt,and analysis of the episode risk in encephalopathy.METHODS: Twenty-nine patients with portal-systemic encephalopathy due to portal hypertension were classified by West Haven method into grade Ⅰ(29 cases), gradeⅡ(16 cases), grade Ⅲ(10 cases), grade Ⅳ( 4 cases). All the patients were scanned by spiraI-CT. Plane scans, artery phase and portal vein phase enhancement scans were performed, and the source images were thinly reconstructed to 1.25 mm. We reconstructed the celiac trunk, portal vein,inferior vena cava and their branches and subjected them to three-dimensional vessel analysis by volume rendering(VR) technique and multiplanar volume reconstruction (MPVR) technique. The blood vessel reconstruction technique was used to evaluate the scope and extent of portal vein-vena cava shunt, portal vein emboli and the fistula of hepatic artery- portal vein. The relationship between the episode risk of portal-systemic encephalopathy and the scope and extent of portal vein-vena cava shunt,portal vein emboli and fistula of hepatic artery- portal vein was studied.RESULTS: The three-dimensional vessel reconstruction technique of spiraI-CT could display celiac trunk, portal vein,inferior vena cava and their branches at any planes and angles and the scope and extent of portal vein-vena cavashunt, portal vein emboli and the fistula of hepatic artery- portal vein. In twenty-nine patients with portal-systemicencephalopathy, grade Ⅰ accounted for 89.7% esophageal varices, 86.2% paragastric varices; grade Ⅱ accounted for 68.75% cirsomphalos, 56.25% paraesophageal varices,62.5% retroperitoneal varices and 81.25% dilated azygos vein; grade Ⅲ accounted for 80% cirsomphalos, 60%paraesophageal varices, 70% retroperitoneal varices, 90% dilated azygos vein, and part of the patients in grades Ⅱand Ⅲ had portal vein emboli and fistula of hepatic arteryportal vein; grade Ⅳ accounted for 75% dilated left renal vein, 50% paragallbladder varices, all the patients had fistula of hepatic artery- portal vein.CONCLUSION: The three-dimensional vessel reconstruction technique of spiraI-CT can clearly display celiac trunk, portal vein, inferior vena cava and their branches at any planes and angles and the scope and extent of portal vein-vena cava shunt. The technique is valuable for evaluating the episode risk in portal-systemic encephalopathy.     

犬肺静脉肌袖电生理随龄性改变

目的对比研究老龄和成年犬肺静脉肌袖电生理特性.方法采用经导管房间隔穿刺技术,应用程序刺激和短阵快速起搏分别对正常自然老龄和成年实验犬肺静脉、上腔静脉、左房、右房、以及冠状静脉窦的有效不应期、激动传导及心房颤动诱发阈值进行标测.结果老龄犬的左、右心房,上腔静脉,冠状静脉窦和肺静脉的有效不应期较成年犬均有不同程度的缩短,其中左心房,上腔静脉和肺静脉有效不应期的随龄性变化有统计学差异(P＜0.01).老龄犬的肺静脉不应期较其左房的不应期明显缩短,而成年犬肺静脉与左房的不应期则无显著性差异.老龄犬的肺静脉和上腔静脉内激动传导呈显著递减性传导.在多数老龄犬的肺静脉、左心房和上腔静脉,快速短阵起搏及程序刺激能诱发持续时间＞30s的房颤.结论老龄犬肺静脉肌袖有易于房颤发生的电生理变化,提示心脏老龄化可能是房颤发生的潜在基质.     

A simple technique for placement of a portacaval shunt tube in rats

We devised a new technique for the placement of portacaval shunts in rats. Using a Teflon tube with a commercially available puncture needle, we placed the tube between the infrarenal inferior vena cava (IVC) and the main portal branch. An upper laparotomy was performed, after which the tube attached to the needle was used to puncture the IVC from the right dorsal wall through toward the left side. Subsequently, the needle was advanced further to puncture the main portal vein. After each end of the tube had been successfully placed in the lumina of the IVC and portal vein, the needle was gently pulled out. Bleeding was controlled by compressing the puncture site gently for approximately 30s. Seven shunts out of ten were found to be patent at second laparotomies carried out 1 week after the primary tubing operation. The remaining three were occluded with white and red thrombi. No dislodging of the tube was noted, and radiography confirmed the patency of the shunt. This method is fast and simple, and yields a high patency rate, even in the hands of relatively inexperienced surgeons. It can be recommended as an experimental model for additional studies.     

Inadvertent Port: Catheter Placement in Azygos Vein

Totally implantable ports are safe and effective means of venous access for administration of chemotherapy. One of the usual vessels accessed, through which the port is placed, is the subclavian. Herein, we report a case where the central access was obtained through the left subclavian vein. But the catheter when it was placed was found to be in the azygos vein. This was confirmed with dye study. This is the first report of such an occurrence with subclavian access. The catheter was later withdrawn and repositioned in the superior vena cava. We recommend that the entire procedure of catheter placement must be done under fluoroscopy guidance to ensure safe and error-free positioning.     

A case of liver cirrhosis with an unusual portosystemic shunt via the right testicular vein.

We report a case of liver cirrhosis with a rare portosystemic shunt via the right testicular vein. Angiographic examination demonstrated two major hepatofugal collateral pathways. First, the enlarged and tortous left gastric and short gastric veins which drain into the left renal vein after forming varices in the stomach. Second, the superior mesenteric vein forms the large mesenteric varices which drain into the inferior vena cava via the enlarged right testicular vein, which is a very rare shunt.     

Catheter interventional therapy in an elderly patient with deep vein thrombosis and a brain tumor

A 92-year-old woman with a brain tumor developed swelling of the left lower extremity. Venography showed considerable thrombi from the left common iliac vein to the femoral vein. Following implantation of a temporary inferior vena cava filter, catheter aspiration therapy and catheter-directed thrombolysis were performed. Venography after 3 days showed disappearance of the thrombi and an improvement in vein flow. A permanent inferior vena cava filter was implanted. Local intensive thrombectomy and thrombolysis by catheter together with a temporary inferior vena cava filter were effective treatments in this elderly patient with deep vein thrombosis.