Biomedical subjects
Publications and source records attributed to G G Hartnell.
Gaining access for vena cavography may be difficult in patients with multiple venous occlusions. We report the use of selective azygous venography to demonstrate potency of the proximal inferior vena cava (IVC) when no alternative route was available and noninvasive techniques were not applicable. The proximal superior vena cava and the distal IVC were occluded.
PURPOSE: To determine the efficacy of the transfemoral vein approach to repositioning malpositioned central venous catheters. METHODS: During a 4(1/2)-year period, malpositioned central venous catheters were repositioned 91 times in 83 patients via the transfemoral vein approach. All repositioning was initially attempted with a Grollman catheter or other pigtail catheter and a tip-deflecting wire. If these techniques failed or the venous anatomy was unfavorable, gooseneck or long loop snares were used. RESULTS: During 48 repositionings, rotating a pigtail-type catheter alone was used successfully in 39 (81%). In 6 of 9 failures, the addition of a tip-deflecting wire also failed. A Grollman catheter and tip-deflecting wire were used initially in 39 repositionings (6 failures; 85% success). Successful repositioning required a snare in 8 (4 as the primary repositioning technique) and a long-loop technique in 5. All repositionings were ultimately successful and there were no complications. CONCLUSION: Central venous catheters can be repositioned consistently by the transfemoral route. Pigtail catheters or tip-deflecting wires alone are successful in over 80% of cases.
Primary melanoma is rarely diagnosed in the biliary tract; only three cases of primary melanoma of the bile ducts have been reported previously. The skin and squamous mucous membranes are the most common primary sites. We report two patients who represent the fourth and fifth reported cases of primary bile duct melanoma.
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PURPOSE: To determine if intraarterial lidocaine reduces pain during and after chemoembolization, and whether it influences postprocedure recovery. METHODS: Two patient cohorts undergoing selective hepatic chemoembolization were compared. Chemoembolization was performed without lidocaine (control group) in 27 patients and intraarterial lidocaine was used (lidocaine group) in 29 similar patients. Objective changes in patient management were assessed. Pain reduction in 31 more procedures with lidocaine (total 60) was assessed and related to tumor type. RESULTS: During chemoembolization, intraarterial lidocaine reduced the need for additional intravenous analgesics from 69% to 19%. After chemoembolization the mean Dilaudid dose in the first 24 hr was reduced from 9.5 mg to 4.15 mg; accordingly, the mean length of hospital stay was reduced from 67.5 to 53.5 hr. During the day of chemoembolization, the mean oral fluid intake increased from 420 ml (control group) to 487 ml (lidocaine group); the percentage of patients taking solid food on the day of chemoembolization increased from 3% to 43%. CONCLUSION: Intraarterial lidocaine during chemoembolization reduces the severity and duration of pain after chemoembolization resulting in faster recovery thus reducing the length of hospitalization.
Few previous studies of the accuracy of duplex Doppler in the assessment of carotid artery stenosis have looked at the accuracy in excluding disease in populations with a significant number of normal arteries. In addition, few studies have compared different criteria for stenosis. Duplex Doppler was used to evaluate the carotid arteries in 80 patients. Two well-described methods for analysing Doppler traces were used and the results were compared with those obtained from non-selective digital subtraction angiography. On the basis of these findings, the Doppler criteria used for carotid stenosis were redefined in terms of changes in peak velocity rather than Doppler frequency shift. Using these criteria, the sensitivity of Doppler in identifying carotid stenosis was 97% (98% sensitivity for greater than 50% stenosis) and specificity was increased from 84% to 93%.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
OBJECTIVE: Three-dimensional (3D) image reconstruction methods allied to spiral CT (SCT) or MR angiography (MRA) are used in clarifying the anatomy of complex aortic anatomy. MATERIALS AND METHODS: Two patients with superior mediastinal masses suggestive of aneurysms of the anomalous right subclavian artery were examined. Both patients were examined using breath-hold SCT and one by breath-hold MRA. Three-dimensional images were reconstructed using a surface rendering technique for the SCT examinations and by a maximum intensity projection technique for MRA. RESULTS: Two cases of aneurysmal anomalous right subclavian artery were diagnosed by SCT with 3D image reconstruction. One case was also examined by MRA with 3D image reconstruction which confirmed the findings of SCT. The use of the 3D techniques clarified the complicated anatomy and avoided the need for angiography. CONCLUSION: Two cases are illustrated of 3D imaging of complicated aortic branch anatomy due to aneurysms of anomalous right subclavian artery. Image quality was good and no further imaging by more invasive techniques was required.
OBJECTIVE: To determine whether the high proportion of patients reported to have prominence of normal right atrial structures by MRI may lead to inappropriate diagnosis of intracardiac tumors. MATERIALS AND METHODS: One hundred forty-nine subjects were examined by spin-echo MRI: patients with cardiac (no. 40), pericardial (no. 30), or thoracic aortic disease (no. 40) and mediastinal tumor (no. 15), and normal volunteers (no. 24). Imaging was reviewed to determine the frequency of a prominent crista terminalis/Chiari network and the likelihood of misdiagnosis of cardiac tumor. RESULTS: Prominent intraatrial structures were seen in 59% of subjects, a single prominent nodule in 36%, an intraatrial strand in 13%, and both in 10%. In no case were these findings originally or on review thought to represent a pathological mass or was it felt likely that they could reasonably be misinterpreted as such. CONCLUSION: Normal structures within the right atrium, such as the crista terminalis and Chiari network, may be seen more commonly with MRI than with other imaging modalities. An appreciation of the frequency with which these findings are seen should prevent inappropriate misdiagnosis of pathological masses when none is present.
Chemoembolization of the liver for unresectable malignancy, although controversial, is being used with increasing frequency. Chemoembolization can be difficult, and there is great potential for causing complications. There are also findings after chemoembolization, particularly on computed tomographic scans, that may appear to indicate complications but are common and of no concern. Chemoembolization requires an understanding of the congenital and acquired variations of arterial anatomy that may be seen supplying the liver. Assessment of the patency of the portal vein is also required. An abnormal portal vein demands significant changes in technique to allow safe chemoembolization. Partial or complete occlusion of the portal vein is associated with significantly decreased survival but does not prevent a worthwhile response to chemoembolization and is not an absolute contraindication. The presence of chemoembolization material in the gallbladder is not uncommon; with the technique used by the authors, the chemoembolization material infrequently causes cholecystitis or gallbladder infarction. Extrahepatic chemoembolization material is commonly seen in other organs but usually does not cause problems, presumably because the dose deposited outside the liver is small compared with the dose delivered to the liver. Other complications include pseudocirrhosis, liver infarction and abscess formation, carcinoid crisis, hepatorenal syndrome, and liver rupture.
Conventional arteriography remains the usual method for preoperative assessment of severe peripheral vascular disease (PVD). Unfortunately, many peripheral arteriograms are still performed with a suboptimal technique, which can cause significant diagnostic errors in patients with severe PVD. A suboptimal technique may be due to poor collimation (causing incorrect exposure and incorrect gray scale), excessive patient-film distance (magnification unsharpness), inadequate volume or density of contrast material, poor contrast resolution (screen-film arteriography), nonselective injection, patient movement, and pressure from restraints or incorrect patient position (failure to profile lesions, pseudo-occlusion from external pressure or plantar flexion). The technique of selective digital subtraction arteriography (DSA) allows one to avoid these errors. The superior contrast resolution of DSA allows use of lower concentrations of contrast material. Selective injection into the external iliac artery allows proper positioning and improves image quality. Demonstration of distal vessels is best achieved by using biplane arteriography. For patients with severe resting ischemia, especially those with diabetes, high-quality selective DSA is essential to ensure that all distal vessels suitable for distal bypass grafting are identified. When properly performed, selective DSA remains the investigation of choice for reliably demonstrating arterial anatomy in high-risk patients with severe PVD.