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PubMed2002

Risk of embolization after institution of antibiotic therapy for infective endocarditis.

OBJECTIVES: This study was designed to assess the risk of systemic embolization in patients with left-sided infective endocarditis, once adequate antibiotic treatment had been initiated, on the basis of prospective clinical follow-up. BACKGROUND: As one of the complications of infective endocarditis, embolization has a great impact on prognosis. Prediction of an individual patient's risk of embolization is very difficult. METHODS: We studied 217 episodes of left-sided endocarditis that were experienced among a cohort of 211 prospectively recruited patients. According to the Duke criteria, 91% of the episodes were definite infective endocarditis. Seventy-two episodes involved infections located on prosthetic valves. All patients were studied by transthoracic and transesophageal echocardiography. Clinical, echocardiographic and microbiologic data were entered in a data base. The mean follow-up interval was 151 days. RESULTS: Twenty-eight episodes (12.9%; group I) of endocarditis had embolic events after the initiation of antibiotic therapy. The remaining 189 episodes did not embolize (group II). Most emboli (52%) affected the central nervous system, and 65% of the embolic events occurred during the first two weeks after initiation of antibiotic therapy. Previous embolism was associated with new embolism (relative risk [RR] 1.73, 95% confidence interval [CI] 1.02 to 2.93; p = 0.05). There was an increase in the risk of embolization with increasing vegetation size (RR 3.77, 95% CI 0.97 to 12.57; p = 0.07). Vegetation size had no impact on the risk of embolization in streptococcal endocarditis or aortic infection. By contrast, large (> or = 10 mm) vegetations had a higher incidence of embolism when the microorganism was staphylococcus (p = 0.04) and the mitral valve was infected (p = 0.03). The increase in vegetation size at follow-up showed a higher risk for embolization (RR 2.64, 95% CI 0.98 to 7.16; p = 0.02). CONCLUSIONS: Embolism before antimicrobial therapy is a risk factor for new emboli. The risk of embolization seems to increase with increasing vegetation size, and this is particularly significant in mitral endocarditis and staphylococcal endocarditis. An increase in vegetation size, despite antimicrobial treatment, may predict later embolism.

Adult↗
PubMed1991

Treatment of cerebral arteriovenous malformations with a combination of preoperative embolization and surgery.

Forty-nine patients with cerebral arteriovenous malformations (AVMs) were treated with preoperative embolization followed by resection using a microsurgical approach. In 27 patients, the AVM was located in an eloquent area; in 32 patients, the volume of the AVM was over 20 cm3. Preoperatively, flow-directed embolization was performed in 10 patients (28 procedures), selective embolization with threads was performed in 35 patients (46 procedures), and a combination of flow-directed and selective embolization was performed in 4 patients (12 procedures). The percentage of reduction of the AVM volume averaged 36% after embolization. Five minor complications (transient neurological deficits, in 2 cases associated with ischemic areas on the CT scan) were observed after embolization. The interval between the last embolization and surgery was as follows: within 10 days in 7 patients; between 11 and 20 days in 3 patients; between 21 and 30 days in 10 patients; between 31 and 60 days in 11 patients; and 2 months later in 18 patients. The efficacy of this combined treatment (embolization plus surgery) was evaluated by the incidence of hyperemic complications and the clinical outcome. Hyperemic complications occurred more frequently in patients with an AVM volume greater than 20 cm3. When compared with flow-directed embolization, selective embolization was linked with decreased bleeding during surgery; postoperatively, the incidence of cerebral edema was also lower. Clinical outcome was better after selective embolization, with no occurrence of major deficits and no mortality. When the percentage of reduction of the AVM volume after embolization was 40% or more, the incidence of intraoperative hyperemic complications was lower; moreover, new permanent deficits were never observed in patients with this volume reduction. A retrospective clinical comparison of two groups of patients with similar AVM volumes (greater than 20 cm3)--those given combined treatment (n = 32) versus those treated by direct surgery alone (n = 27)--showed that intraoperative bleeding appeared to decrease in patients treated by embolization; the incidence of postoperative hyperemic complications was not different in the two groups. New major deficits and deaths were less frequent in patients treated by embolization (P = 0.05 for the incidence of major deficits); postoperative epilepsy was also less common in these patients. In conclusion, combined treatment with selective preoperative embolization and direct surgery may help the neurosurgeon in the treatment of large, high-flow AVMs, reducing the risks connected with their surgical removal.

Adolescent↗
PubMed1995

The safety and effectiveness of brain arteriovenous malformation embolization using acrylic and particles: the experiences of a single institution.

The purpose of this article is to report on the safety and effectiveness of brain arteriovenous malformation (AVM) embolization for two series of patients, of which one was treated with particulate embolization and the other with acrylic embolization. Sixty-five consecutive patients from embolization logs and patient records from 1988 to 1993 were reviewed. AVMs were routinely treated with particulate embolization early in the review (1988-1991), and after a transition period, the technique was changed to acrylic embolization for the remainder of the study period (1992-1993). All patients were treated with the ultimate goal of complete AVM obliteration. AVMs were embolized and resected, if possible, and if unresectable, they were reduced in size with embolization and radiated. The course of treatment for each patient was reviewed. The effectiveness at the end of treatment was analyzed for the ability to resect the AVM and, if unresectable, the ability to reduce the AVM to radiation size. Additionally, the safety of each embolization technique was evaluated in the context of comprehensive care, in terms of the safety of the procedure itself, the surgical resection after embolization, and the outcome at the end of comprehensive treatment. This article outlines the safety and effectiveness of acrylic and particulate embolization at a single institution. The ability to surgically resect an AVM after embolization and to reduce nidus size with acrylic was at least comparable with that with particulate embolization. Comprehensive complication rates were lower after acrylic embolization and were heavily influenced by a decreased number of surgical complications in the acrylic series. These data support the need to conduct a randomized prospective clinical trial to compare the relative safety and effectiveness of the two methods of embolization.

Acrylic Resins↗
PubMed2002

Long-term results of initial and repeated partial splenic embolization for the treatment of chronic idiopathic thrombocytopenic purpura.

OBJECTIVE: Although splenectomy is a standard surgical treatment for chronic idiopathic thrombocytopenic purpura, partial splenic embolization is another treatment option. We retrospectively studied the long-term results of initial and repeated partial splenic embolization. MATERIALS AND METHODS: Thirty-nine patients, 15 men and 24 women, underwent initial embolization; 12 of the 39 underwent a repeated embolization. The therapeutic effects of the initial and repeated embolization were classified as a complete response if the patient's platelet count rose to more than 10 x 10(4)/ micro L without medication 1 year after the initial or repeated embolization, as a partial response if the platlet count reached 5-10 x 10(4)/ micro L under the same circumstances, or as no response. RESULTS: Twenty patients (51%) responded to the initial embolization (complete response in 11 and partial response in nine). No significant differences were found between those patients who responded to the treatment (responders) and those who did not respond to the treatment (nonresponders) in age, sex, lowest platelet counts, and steroid response before embolization. Peak platelet response was significantly higher in the responders (p = 0.029). One of the 11 complete responders and five of the nine partial responders relapsed after a median follow-up period of 34 months (range, 15-23 months) and underwent repeated embolization, resulting in complete response in one patient, partial response in the remaining four patients, and no response in one patient. However, in the six nonresponders (to the initial embolism), repeated embolization elicited a partial response in only one patient. The remission rate of 51% was maintained by means of repeated embolization for a median follow-up period of 76 months after the initial embolization. CONCLUSION: Partial splenic embolization combined with repeated embolization may be an effective alternative to splenectomy in the treatment of chronic idiopathic thrombocytopenic purpura.

Adolescent↗
PubMedDate not supplied

Changes in clinicopathological findings after portal vein embolization.

BACKGROUND/AIMS: Portal vein embolization is becoming more common as a method of preventing hepatic failure after an extended hepatectomy but its mechanism is not well understood. This clinicopathological study focused on its mechanism. METHODOLOGY: Thirty patients who underwent extended hepatectomy after portal vein embolization were evaluated. Liver volume was measured before and after portal vein embolization, and histological studies were performed to examine morphological changes, morphometric parameters and apoptosis of hepatocytes. RESULTS: The mean volume of the non-embolized lobe grew significantly from 392 to 462 mL after portal vein embolization (P < 0.0001). The hypertrophy ratio of the non-embolized lobe (100 x volume change during portal vein embolization/volume before portal vein embolization, %) was correlated closely with the volume of the non-embolized lobe before portal vein embolization (r = -0.65, P < 0.0001). Histological study showed the embolized lobe hepatocytes to be atrophic, partly necrotic and apoptotic. In the non-embolized lobe, the mean hepatocyte volume was 8686 micron 3 (control: 6544 micron 3) and the mean hepatocyte count was 109 x 10(6)/mL (control: 122 x 10(6)/mL). CONCLUSIONS: The enlargement of the non-embolized lobe was caused by hypertrophy rather than hyperplasia suggesting hyperfunction. The resection of the atrophic embolized lobe, leaving the hypertrophic non-embolized lobe was thought to be less surgically stressful than hepatectomy without portal vein embolization.

Aged↗
PubMedDate not supplied

Preembolization functional evaluation in brain arteriovenous malformations: the ability of superselective Amytal test to predict neurologic dysfunction before embolization.

PURPOSE: To describe the incidence of neurologic dysfunction following embolization of supratentorial AVMs, and to correlate findings with results of preembolization Amytal tests. MATERIALS AND METHODS: Data from 147 embolizations of supratentorial AVMs following Amytal tests in 30 awake patients were analyzed retrospectively. RESULTS: Of five embolizations done after a positive Amytal test, two were followed by neurologic complications. Eighty-two embolizations done as single embolizations immediately after a negative Amytal test were associated with no neurologic complications. The remaining embolizations were parts of multiple series of embolizations, each beginning with an Amytal test and followed by a number of embolizations without catheter movement or repeat Amytal testing. Since any prior embolization in the series might reduce the sump effect of the AVM, embolic agent delivered later in the series could potentially reach functional brain tissue not fully tested by the Amytal test. Therefore, repeat embolizations (not immediately preceded by an Amytal test) were considered separately. In 60 repeat embolizations, six (10%) were associated with some neurologic complication. CONCLUSIONS: Repeat Amytal testing might detect the loss of sump effect as the AVM is embolized. We conclude that use of data from superselective Amytal tests adds to the safety of AVM embolizations and that repeat Amytal testing potentially could be valuable when serial embolization of a vessel is planned.

Adolescent↗
PubMed2003

A diagnostic strategy for pulmonary embolism based on standardised pretest probability and perfusion lung scanning: a management study.

Pulmonary embolism remains a challenging diagnostic problem. We developed a simple diagnostic strategy based on combination of assessment of the pretest probability with perfusion lung scan results to reduce the need for pulmonary angiography. We studied 390 consecutive patients (78% in-patients) with suspected pulmonary embolism. The pretest probability was rated low (<10%), intermediate (>10%, < or =50%), moderately high (>50%, < or =90%) or high (>90%) according to a structured clinical model. Perfusion lung scans were independently assigned to one of four categories: normal; near-normal; abnormal, suggestive of pulmonary embolism (wedge-shaped perfusion defects); abnormal, not suggestive of pulmonary embolism (perfusion defects other than wedge shaped). Pulmonary embolism was diagnosed in patients with abnormal scans suggestive of pulmonary embolism and moderately high or high pretest probability. Patients with normal or near-normal scans and those with abnormal scans not suggestive of pulmonary embolism and low pretest probability were deemed not to have pulmonary embolism. All other patients were allocated to pulmonary angiography. Patients in whom pulmonary embolism was excluded were left untreated. All patients were followed up for 1 year. Pulmonary embolism was diagnosed non-invasively in 132 patients (34%), and excluded in 191 (49%). Pulmonary angiography was required in 67 patients (17%). The prevalence of pulmonary embolism was 41% ( n=160). Patients in whom pulmonary embolism was excluded had a thrombo-embolic risk of 0.4% (95% confidence interval: 0.0%-2.8%). Our strategy permitted a non-invasive diagnosis or exclusion of pulmonary embolism in 83% of the cases (95% confidence interval: 79%-86%), and appeared to be safe.

Adolescent↗
PubMed2004

A prospective study on cardiovascular events after acute pulmonary embolism.

AIMS: To evaluate the incidence of cardiovascular events in the long-term clinical course of patients with a first episode of symptomatic, objectively confirmed pulmonary embolism. METHODS AND RESULTS: Three hundred and sixty patients with a first episode of pulmonary embolism were included in a prospective study: 209 with idiopathic pulmonary embolism and 151 with pulmonary embolism associated with transient risk factors. The study outcomes were cardiovascular events (recurrent venous thrombo-embolism, acute myocardial infarction, stroke, sudden otherwise unexplained death), cardiovascular death, and death due to any cause. The median follow-up was 38 months. Sixty-four patients had at least one cardiovascular event (5.5% patient-year). Recurrent venous thrombo-embolism occurred in 45 patients (3.9% patient-year), acute myocardial infarction in 12 patients (1.0% patient-year), stroke in six patients (0.5% patient-year), and sudden otherwise unexplained death in four patients (0.3% patient-year). A cardiovascular event occurred in 47 patients with idiopathic pulmonary embolism (7.5% patient-year) and in 17 patients with pulmonary embolism associated with transient risk factors (3.1% patient-year) (RR 2.0; 95% CI 1.20-3.34; P=0.006). Twenty patients with idiopathic pulmonary embolism (3.2% patient-year) and two patients with pulmonary embolism associated with transient risk factors (0.4% patient-year) presented an arterial cardiovascular event (RR 7.2; 95% CI 1.71-30.45; P=0.001). Thirty-three patients died (9.2%). Cardiovascular mortality and cancer mortality accounted for 42.4 and 21.2% of overall mortality, respectively. Idiopathic pulmonary embolism was an independent predictor of cardiovascular events after adjusting for age. CONCLUSIONS: Cardiovascular events are more common in patients with idiopathic pulmonary embolism than in patients with pulmonary embolism associated with transient risk factors. Cardiovascular events are the major cause of death in patients with idiopathic pulmonary embolism.

Acute Disease↗
PubMed2006

Repeat uterine artery embolization: indications and technical findings.

PURPOSE: To determine the indications and technical aspects of procedures in patients undergoing repeat uterine artery embolization (UAE). MATERIALS AND METHODS: At a single center, 24 patients underwent repeat embolization for recurrent or persistent symptoms. The magnetic resonance (MR) imaging findings before repeat embolization were compared with those of earlier studies. The extent of tumor infarction after the first procedure was determined, and the status of existing or new tumors before the second procedure was assessed. The angiographic studies from the initial and repeat embolization studies were reviewed and summarized. These findings were assessed with the use of summary statistics. RESULTS: Twenty-four patients underwent repeat embolization 6-66 months after the initial embolization. The most common symptom at representation was pressure and/or bulk symptoms (n=15), followed by recurrent heavy bleeding (n=12) and pelvic pain or cramping (n=7). MR imaging studies before repeat embolization revealed incomplete infarction of tumors present before the first embolization in 22 of 24 patients. New tumors were identified in 12 patients, two of whom had new tumors only. During repeat embolization, nine patients (37%) required ovarian artery embolization to occlude ovarian supply to the uterus. Among 21 women with clinical follow-up after the second embolization, 19 (90%) had symptom control. CONCLUSIONS: Repeat embolization prompted by recurrent uterine leiomyomas usually occurs in the setting of regrowth of incompletely infarcted tumors. Although ovarian embolization was often needed, on the basis of this limited experience, symptoms appear to respond well to repeat embolization.

Adult↗
PubMed1989

Effects of volume loading during experimental acute pulmonary embolism.

Volume loading is used to treat hemodynamically compromised patients with acute pulmonary embolism despite data to suggest that volume loading after embolism might cause a leftward shift of the ventricular septum with a subsequent decrease in left ventricular (LV) end-diastolic volume and stroke work. We studied 10 closed-chest, anesthetized, and ventilated dogs to assess the effects of volume loading after pulmonary embolism caused by autologous clot. LV, right ventricular, and right atrial pressures as well as LV anteroposterior, septum-to-right ventricular, and septum-to-LV free wall diameters (sonomicrometry) were measured. Pericardial pressure was measured with flat, liquid-containing balloons. The effects of volume loading were assessed before embolism, after one episode of embolization, and after repeated embolizations. The LV area index (as a reflection of LV volume) increased during volume loading before embolism (2,870 +/- 430 to 3,080 +/- 520 mm2; p less than 0.05), did not change significantly during infusion of fluid after one embolization (2,850 +/- 470 to 2,860 +/- 500 mm2; p = NS), and decreased significantly during volume expansion after repeated embolizations (2,760 +/- 440 to 2,660 +/- 420 mm2; p less than 0.01). An index of LV stroke work increased (188 +/- 85 to 260 +/- 101 mm Hg x mm2; p less than 0.05), did not change significantly (188 +/- 39 to 203 +/- 52 mm Hg x mm2; p = NS), and decreased markedly (133 +/- 64 to 45 +/- 27 mm Hg x mm2; p less than 0.001) before embolism, after one embolization, and after repeated embolizations, respectively. The decrease in LV area index during volume loading after repeated embolizations was associated with an increase in septum-to-right ventricular free wall diameter (31 +/- 8 to 34 +/- 8 mm; p = 0.001) and a decrease in the septum-to-LV free wall diameter (44 +/- 5 to 42 +/- 5 mm; p less than 0.001), whereas the LV anteroposterior diameter did not change (62 +/- 5 to 63 +/- 5 mm; p = NS). This is compatible with a leftward septal shift being partially responsible for the decrease in LV end-diastolic volume; such a shift would be expected with the observed decrease in transseptal end-diastolic pressure gradient (-3 +/- 2 to -5 +/- 2 mm Hg; p = 0.001). In addition, after repeated embolizations, LV transmural pressure decreased in response to the volume load reflecting a marked increase in pericardial pressure.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute Disease↗
PubMed2002

Neuroprotective effects of the spin trap agent disodium-[(tert-butylimino)methyl]benzene-1,3-disulfonate N-oxide (generic NXY-059) in a rabbit small clot embolic stroke model: combination studies with the thrombolytic tissue plasminogen activator.

BACKGROUND AND PURPOSE: It has been proposed that the novel spin trap agent disodium-[(tert-butylimino)methyl]benzene-1,3-disulfonate N-oxide (NXY-059) may be useful in the treatment of ischemic stroke. However, there is little information concerning the neuroprotective properties of NXY-059 when administered after an embolic stroke. Moreover, there is no information available concerning the combination of NXY-059 with the only Food and Drug Administration-approved pharmacological agent for the treatment of acute stroke, the thrombolytic tissue plasminogen activator (tPA). Thus, we determined the effects of NXY-059G, a generic form of NXY-059, on behavioral outcome after an embolic stroke when administered alone or in combination with tPA. METHODS: Male New Zealand White rabbits were embolized by injecting a suspension of small blood clots into cerebral circulation via a carotid catheter. NXY-059G (100 mg/kg) was infused intravenously 5 minutes or 3 hours after embolization, whereas control rabbits received infusions of the saline vehicle. In tPA studies, the thrombolytic was administered intravenously starting 60 minutes or 3 hours after embolization (3.3 mg/kg). In combination studies, NXY-059G was given 5 minutes after embolization, followed by the administration of tPA beginning either 60 minutes or 3 hours after embolization. Behavioral analysis was conducted 24 hours after embolization. RESULTS: In the vehicle control group, the ES50 value (calculated as the amount of microclots [milligrams] that produce neurological dysfunction [impairment] in 50% of the rabbits within a specific treatment group) measured 24 hours after embolism was 1.04+/-0.31 mg, and this was increased by 153% to 2.54+/-0.72 mg if NXY-059G was administered beginning 5 minutes after embolization. However, if NXY-059G was administered beginning 3 hours after embolization, the ES50 was 2.01+/-0.40 mg. The rabbits treated with tPA alone had an ES50 of 2.64+/-0.66 or 0.63+/-0.35 mg if tPA administration started 60 minutes or 3 hours after embolization, respectively. If tPA was administered after NXY-059G (started at 5 minutes), the ES50 values were 3.15+/-0.50 or 2.66+/-0.82 if tPA administration started 60 minutes or 3 hours after embolization, respectively. CONCLUSIONS: This study suggests that NXY-059G is neuroprotective and can increase behavioral ratings if administered early after an embolic stroke. In addition, the study shows that NXY-059G can be used in combination with tPA without negative side effects. The drug combination can improve behavioral function and increase ES50 values. However, during the short time course of the behavioral analysis, the combination was not statistically better than either drug alone.

Animals↗
PubMed1995

Importance of time-window overlap in the detection and analysis of embolic signals.

BACKGROUND AND PURPOSE: The detection of asymptomatic embolic signals by Doppler ultrasound may offer a powerful investigational tool in the management of cerebrovascular disease. However, early studies, particularly in patients with carotid artery disease, have reported very different frequencies of embolic signals. While this may reflect differences in patient groups and the criteria used for embolic signal identification, the degree of time-window overlap may be important. If this is insufficient, some embolic signals may fall between two time windows and not appear on the spectral display. Furthermore, the use of nonrectangular time windows, such as the Hanning window, may result in variation of the intensity of an embolic signal depending on where it is detected within the time window. METHODS: To test the importance of this potential problem, the same 25 embolic signals recorded as the audio signal on digital audiotape were each played repeatedly through a transcranial Doppler ultrasound (TCD) system using fast Fourier transform analysis. An older system with no time-window overlap was used, and a more modern system was also used in which three different degrees of overlap were used: -9%, 27%, and 57%. The number of signals audible but not appearing on the spectral display was recorded. The variability in the relative intensity increase for the same embolic signal played repeatedly was estimated by calculating the coefficient of variation of the relative intensity increase. RESULTS: With the older system, 39/500 (7.8%) of embolic signals were missed. With the newer system, the number of embolic signals missed was fewer and decreased with increasing degrees of overlap (10/500 for -9% overlap, 1/500 for 27% overlap, and 0/500 for 57% overlap). For those setups in which embolic signals were missed, there was a highly significant relationship between duration of embolic signal and number of signals missed. In parallel with these results, the coefficient of variation of the relative intensity increase became progressively less with increasing degrees of time-window overlap. For all processing setups, the coefficient of variation was greater for the less intense and shorter duration signals, but this dependence, as estimated by the slope of the regression line, became less strong with higher degrees of overlap. CONCLUSIONS: Inadequate degrees of fast Fourier transform time-window overlap will result in the failure of current TCD machines to detect embolic signals. Furthermore, this and the time windowing currently usually used may result in variability in the relative intensity increase of identical embolic signals. These factors need to be taken into account when comparing data on the frequencies of embolic signals recorded by different researchers and in the design of future TCD equipment.

Humans↗
PubMed1992

Hemodynamic effects of preoperative embolization in cerebral arteriovenous malformations: evaluation with transcranial Doppler sonography.

A series of 83 patients with cerebral arteriovenous malformations is presented. All patients were evaluated with transcranial Doppler sonography. Thirty-two patients were treated with staged embolization and surgery: 19 of these patients were operated on within 4 weeks of the last embolization, and the remaining 13 patients underwent surgery 6 months or more from embolization. Transcranial Doppler sonography performed 1 day after embolization showed a significant (> 60%) reduction of main feeder flow velocity in 72% of patients after the first embolization and in 45% of patients after the second embolization. In no case did such a significant reduction occur after the third embolization. A flow redistribution in the basal vessels (defined as an increase in flow velocity of at least 30% of the initial value) occurred only in patients after the first embolization (64%). On delayed post-embolization studies, complete recovery of flow velocity in the embolized vessel occurred in 46% of patients, and sonographic recruitment of new feeders occurred in the remaining 54%. When main feeder flow velocity (mean) was higher than 120 cm/s after embolization and before surgery, the incidence of postoperative hyperemic complications (cerebral edema and/or intracerebral hematoma) was significantly higher than in patients with a mean flow velocity under 120 cm/s. It is concluded that transcranial Doppler sonography is a valuable method for a noninvasive hemodynamic assessment of shunt flow in arteriovenous malformations, and it permits a physiological monitoring of hemodynamic changes after embolization and allows more precise indications regarding further stages of embolization and timing of surgery after embolization.

Adult↗
PubMed1993

[Preoperative embolization using absolute ethanol for renal cell carcinoma--including the questionnaire survey in Japan].

The usefulness of transvascular embolization before radical nephrectomy using absolute ethanol was studied in thirty-two cases with renal cell carcinoma, among them, 30 cases received radical nephrectomy one day after transvascular embolization. And a nation wide questionnaire survey regarding the embolization was also reported. These results were as follows: 1. The infarcted areas were very extensive and among 28 cases examined, 26 cases showed more than 75% of infarct in the whole area of the cortex. 2. Among 32 cases, 22 cases complained of no pain after the embolization using absolute ethanol only by the preventive epidural administration of analgesics. 3. The questionnaire survey showed that the embolization before radical nephrectomy was performed in 62% of the hospitals as a whole, including 81 hospitals (41%) in which the embolization was performed case by case. In the whole of hospitals, 21% performed the embolization principally by evaluating the significance of the embolization. On the other hand, 19% of the hospitals did not perform by the reason of no significance of the embolization on the treatment of renal cell carcinoma. As shown in this questionnaire survey, the significance of the embolization before radical nephrectomy was still debatable in our country. 4. In 62% of the hospitals where the embolization is carried out, as a whole, the period from embolization to the nephrectomy was 3-7 days. And in 42% of the hospitals as a whole absolute ethanol was principally used as an embolizing agent. In conclusion we believe that absolute ethanol was useful and should find further application as an embolizing agent before the radical nephrectomy.

Aged↗
PubMedDate not supplied

Experimental and clinical studies on liver regeneration following transcatheter portal embolization.

BACKGROUND/AIMS: We studied compensatory hypertrophy following transcatheter portal embolization experimentally in dogs and clinically under the condition of cholestasis. METHODOLOGY: Experimental study: Sixteen dogs were used for this study. Transcatheter portal embolization was performed in the left lobes (70% of the total liver) using Gelfoam powder in dogs with 2-week obstructive jaundice. Liver weight, liver blood flow and the intracellular adenosine triphosphate content of isolated hepatocytes were measured after transcatheter portal embolization. Clinical Study: transcatheter portal embolization of the right portal branch was performed in 13 patients with cancer of the biliary tract and 3 patients with hepatocellular carcinoma before (extended) right lobectomy, using Gelfoam powder and thrombin. Six patients who had a total bilirubin level > 5 mg/dLunderwent a percutaneous transhepatic biliary drainage before transcatheter portal embolization. Liver function tests, a volumetric study with computed tomography and immunohistochemical staining for profilerating cell nuclear antigen and apoptosis in the resected livers were performed. RESULTS: Experimental study: The weight ratio of the non-embolized lobes to the total liver, 2 weeks after transcatheter portal embolization in the dogs with jaundice, was significantly lower than that of the normal dogs with transcatheter portal embolization (40.5 +/- 4.5% vs. 47.6 +/- 3.2%), but significantly larger than that of the dogs without transcatheter portal embolization. The cellular adenosine triphosphate content and tissue blood flow in the embolized lobes were significantly lower than those in the nonembolized lobes in the normal and cholestatic livers. Clinical study: The postoperative course in all patients was uneventful, with no serious complication or liver dysfunction. Extended right lobectomy with caudate lobectomy was equivalent to 65% before transcatheter portal embolization and to 56% after, transcatheter portal embolization owing to compensatory hypertrophy of the left lobe. However, there was no significant difference in liver volume in the patients with or without obstructive jaundice. Apoptosis was observed in the embolized lobe. CONCLUSIONS: Preoperative transcatheter portal embolization with percutaneous transhepatic biliary drainage for the purpose of liver regeneration would be useful for treating extended hepatectomy with obstructive jaundice.

Animals↗
PubMed2001

Spinal metastases from renal cell carcinoma: effect of preoperative particle embolization on intraoperative blood loss.

BACKGROUND AND PURPOSE: Surgical repair of spinal metastases from renal origin is often complicated by excessive bleeding. The purpose of this study was to assess the effect of preoperative particulate embolization on intraoperative blood loss. METHODS: Twenty spinal metastases from renal origin (17 patients) treated by preoperative embolization with polyvinyl alcohol particles were analyzed retrospectively. Surgical decompression was performed within 2 days after embolization. A control group of 10 patients with 11 spinal metastases of renal origin underwent surgery without embolization. The effect of preoperative embolization, of completeness of embolization, and of particle size on the estimated intraoperative blood loss was analyzed using nonparametric statistical tests. RESULTS: Complete embolization was achieved in 10 cases and partial embolization in the other 10. The estimated blood loss of 19 embolized and 11 control cases was available from the surgical report. Median intraoperative blood loss in 19 embolized lesions was 1500 mL (range, 300-8000 mL), compared with 5000 mL (range, 1440-15000 mL) in the control group. Even after partial embolization, blood loss (median, 2000 mL) was significantly lower than in the control group. No significant differences in estimated blood loss were noted between the use of particles smaller than 250 microm and those larger than 250 microm. No embolization-related permanent neurologic deficit or skin or muscle necrosis occurred. CONCLUSION: Preoperative embolization of spinal metastases of renal origin with polyvinyl alcohol particles is safe and might reduce intraoperative blood loss significantly. Even partial embolization seems to be effective.

Aged↗
PubMedDate not supplied

Long-term hematological and biochemical effects of partial splenic embolization in hepatic cirrhosis.

BACKGROUND/AIMS: Partial splenic embolization was developed as a non-surgical treatment for hypersplenism, but recently splenic embolization has been reported to improve the hepatic function. We undertook long-term evaluation of partial splenic embolization in patients with hepatic cirrhosis in comparison with patients not undergoing embolization. METHODOLOGY: We performed embolization in 26 patients with cirrhosis. The controls consisted of 26 with cirrhosis patients who were not undergone embolization. RESULTS: Red blood cell counts of embolized patients had increased significantly at 6 months after the procedure, remaining increased for up to 7.5 years. Platelet counts increased maximally by 2 weeks after embolization, followed by a gradual decrease. Nonetheless, platelets remained significantly more numerous than before embolization for up to 8 years. Neither aspartate aminotransferase nor alanine aminotransferase activities in serum changed significantly during follow-up. Choline esterase activity increased significantly by 6 months after embolization and remained increased for more than 7 years. Serum albumin concentration increased significantly, beginning at 6 months after embolization; this increase was maintained for 6 years. Survival did not differ between embolized and non-embolized groups. CONCLUSIONS: Partial splenic embolization is a beneficial non-surgical treatment that enhances hepatic protein synthetic capacity as well as alleviating hypersplenism in patients with cirrhosis.

Alanine Transaminase↗
PubMedDate not supplied

[Post-traumatic pulmonary and systemic fat embolism in forensic practice. Prospective histological study].

INTRODUCTION: The more or less subclinical presence of fat emboli in the lungs and other vital organs, without ischaemic changes in them, whose presence could be postmortem established only by microscopic examination, is termed in forensic medicine systemic fat embolism. On the other hand, Fat Embolism Syndrome (FES) is a clinical manifestation of the presence and influence of fat emboli in organs, with clearly defined neurological, respiratory and cutaneous signs and various symptoms, grouped in the so called major and minor signs [8-11]. PURPOSE: The purpose of this paper is to establish the frequency of post-traumatic occurrence of fat emboli in capillaries of the lungs and other organs in cases where the cause of death was not related to pulmonary or systemic fat embolism, but where the typical fat depot injury was established. MATERIAL AND METHOD: A prospective autopsy histological study was carried out. The sample included 56 cases. The clinical and autopsy data were analyzed and compared in order to establish the value of injury Severity Score--ISS. Histological samples of all vital organs were stained by special technique (Sudan III) and the findings in the lungs and kidneys were graded according to Sevitt's criteria [12]. All data were statistically analyzed (chi 2 test, ANOVA). RESULTS AND DISCUSSION: The sample included 38 males (average age 53.10 years) and 18 females (average age 54.84 years). The older (ANOVA; p = 0.0017) males (chi 2 = 7.14; p < 0.01), injured as pedestrians (ANOVA, p-->0) were statistically significantly more represented. The most common determined causes of death were: cerebral contusions (30), exsanguination (22), respiratory disorders (9), combustion (6), spinal cord contusions (1), and others (complication of injuries, such as inflammations or sepsis--4). These causes were singular or competitive plural. The average value of ISS was 34.59 (SD = 13.16) and that of outliving period 3.70 days (SD = 5.88). The distribution of outliving period was log-normal. Pulmonary fat embolism was established in all cases: in 14 cases pulmonary fat embolism of the first degree; in 16 of the second grade and in 26 of the third degree. Pulmonary fat embolism of the third degree could be the precipitate singular or concurrent cause of death. The presence of fat emboli in glomeruli was established in 39 cases: in 30 cases the kidney fat embolism of the first degree was established, in 6 of the second degree and in 3 cases of the third degree. In 11 cases the presence of fat globules in brain capillaries was established and in 3 cases in the capillaries of other organs (heart, liver, spleen). By analyzing the clinical and autopsy data, as well as microscopic findings, we concluded that in four cases the cause of death was associated with systemic fat embolism, what previously had been missed. CONCLUSION: In all our sample cases pulmonary fat embolism was verified, and in a great number of them systemic fat embolism. According to medicolegal principles, pulmonary and systemic fat embolism that develop a few hours after trauma can be considered as a consequence of typical body fat depot injury. The later developed FES could be considered as the complication of such an injury. Pulmonary and systemic fat embolism could complicate the basic trauma, e.g. craniocerebral, abdominal or thoracic, and could be considered as the precipitating cause of death. Because of non-specific and non-characteristic macroscopic autopsy findings, pulmonary and systemic fat embolism could be missed as the cause of death.

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