Biomedical subjects
Publications and source records attributed to E J Ring.
The silicone rubber tubing of the LeVeen peritoneojugular shunt can be safely punctured with a 23 gauge needle. Radiopaque contrast material can be injected through the needle to delineate the cause of any obstruction to the venous tubing.
Ureteral obstruction after treatment for abdominal cancers is a common situation in which the thin needle biopsy presents an attractive low morbidity alternative to laparotomy for the diagnosis of malignant disease. A negative biopsy is still nonconclusive, although helpful in determining the next step in the patient's management. In our own series, biopsy in the region of ureteral obstruction revealed tumor rather than benign disease in four of five patients. No morbidity was encountered.
Renal venography may be an extremely useful adjunctive diagnostic procedure in selected cases of renal disease. The techniques utilized in renal phlebography are described, and the newer applications of this technique are discussed and illustrated.
Percutaneous transhepatic catheterization of the biliary tree was performed in 23 patients. In 21 the catheter was advanced past an obstructing lesion into the distal common bile duct and duodenum to establish antegrade biliary drainage. The catheter was left permanently in place as a form of endoprosthesis in 5 patients.
A total of 33 renal venograms were reviewed to determine the incidence of radiographically demonstrable valves. Valves were identified in five of 22 left renal venograms and two of 11 right renal venograms. On the right side in both patients the valve was located at the junction of the renal vein with the inferior vena cava. On the left, valves were located in the main renal vein proximal or distal to the gonadal vein and in one patient in a segmental upper pole tributary. These valves are significant because of the technical difficulties they can create during renal venography and their possible usefulness in selecting the site of anastomosis in patients undergoing distal splenorenal shunts.
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Vasopressin was successively infused into the hepatic and superior mesenteric arteries and a systemic vein, and its levels monitored by blood samples drawn from the portal and hepatic veins and a systemic vein. Blood flow was monitored in the hepatic and superior mesenteric arteries and in the ascending aorta. Hepatic blood flow was inversely correlated with mesenteric blood flow, rising about 50% above baseline levels during hepatic and systemic artery infusions and 96% during superior mesenteric artery infusion. Hepatic artery and systemic vein infusions caused a reduction in mesenteric flow about 20% less than that caused by direct superior mesenteric artery infusion.
Selective arterial infusions of vasopressin have often been successful in controlling arterial bleeding. When bleeding occurs in an area with a dual blood supply through a vascular arcade, situations may arise which can compromise angiographic management. These include: (1) artifacts caused by pressure injections of contrast material inaccurately depicting the usual distribution of blood flow in the arcade; (2) catheter-induced vasospasm altering the flow dynamics through the arcade; (3) vasopressin-induced constriction of the proximal portion of an arcade changing the origin of blood flow to the distal arcade; and (4) proximal occlusion of one limb of an arcade permitting continuation of bleeding through collateral channels. When angiographic techniques fail to control bleeding because of these circumstances, hemostasis may be achieved by treating both limbs of the vascular arcade.
Twenty-four patients with massive rectal hemorrhage and known or subsequently proved colonic diverticular disease had the bleeding site localized by mesenteric angiography and received intra-arterial infusion of vasopressin to arrest the bleeding. In twenty-two patients the bleeding was controlled with the vasopressin infusion whereas in the remaining two, hemorrhage did not stop and surgery was performed. Of the twenty-two patients in whom bleeding was arrested by vasopressin infusion, twelve received no further surgical therapy, five had elective prophylactic surgical resection after a period of hemostasis, and the remaining five underwent segmental resection for bleeding that recurred after cessation of the infusion. Of the twelve patients who were not operated on, three had rebleeding two, four, and twelve months after vasopressin infusion and two of these three patients required surgery. The remaining nine have had no recurrent bleeding for periods ranging from seven to thirty-four months. Of ten patients who had segmental resection after precise localization of the bleeding site and initial control with vasopressin, no one has had recurrent hemorrhage for periods ranging from two to eighteen months.
Angiographic methods were applied to control bleeding in 2 patients following genitourinary tract operations. In 1 patient hemorrhage into the prostatic bed after needle biopsy of the prostate was controlled with embolic occlusion of branches of the hypogastric arteries. In the second patient bleeding from the ileum following ileal loop cutaneous diversion was controlled with the infusion of vasopressin into the superior mesenteric artery. Therefore, angiography offers an attractive alternative to an operation in the management of postoperative hemmorrhage from the genitourinary tract.
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