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An expanding false aneurysm in the infratemporal fossa followed this patient's complicated jaw fracture. Successful Gelfoam embolization of the maxillary artery has controlled haemorrhage, treated the aneurysm, and avoided the hazards of local operative intervention. The technique of embolization has a place in the management of various difficult vascular problems.
Eight cases of major haemobilia have been seen by the Surgical Hepatobiliary service at Westmead Hospital between 1979 and 1984. Two occurred following blunt abdominal trauma, three after percutaneous biliary drainage or liver biopsy, two in association with postoperative haemorrhagic pancreatitis and one because of an abscess complicating hepatic hydatid disease. Coeliac and superior mesenteric angiography were carried out in all patients, and false aneurysms were demonstrated in seven of the eight. A marked coagulopathy was present in the remaining patient, in whom bleeding stopped without intervention when the coagulopathy was reversed. Those with false aneurysms were treated by radiologically controlled transarterial embolization with gelfoam, acrylate or Gianturco coils, and bleeding was controlled in all. There was one death from overwhelming sepsis in the patient with the hepatic abscess. It is concluded that percutaneous radiologically controlled embolization is the treatment of choice for most cases of haemobilia, except when there is major hepatic sepsis.
BACKGROUND: Persistent intraperitoneal biliary fistulas are associated with significant morbidity and mortality. Percutaneous drainage, stenting, and endoscopic sphincterotomy or embolization of biliary radicals have largely replaced the need for hepatic resection or biliary reconstruction in managing such fistulas. When endoscopy is contraindicated, a previously undescribed technique of percutaneous embolization of intrahepatic and extrahepatic biliary fistula following penetrating liver trauma, and orthotopic liver transplant and its application in three patients, will be discussed. METHODS: Embolization procedures were performed by an interventional radiologist. Percutaneous trans-hepatic cholangiography via a standard right-side approach or via tube cholangiography was initially performed and the fistula defined. Coaxial catheter systems were used (5 Fr angiography catheters and Tracker 18 infusion catheters), and were positioned within the biliary tree as close as possible to the origin of the fistula. Embolization was performed using vascular Embolization 28 coils (WA Cook) 2-3 mm x 2 cm coils, straight Hilal 18 embolization coils (WA Cook) 5-7 cm, as well as Gelfoam (Upjohn) 1 mm pellets, and Histoacryl (B. Braun) 0.25-1 mL. Occlusion of the duct was confirmed by a selective intrahepatic cholangiogram. In cases of multiple fistulas several embolizations were performed at subsequent procedures. Follow-up is over 13 months without adverse event. RESULTS: The technique was used in the three cases and was successful in all. A peripheral biliary fistula required embolization twice and two cystic leaks were cured after a single attempt. CONCLUSIONS: Percutaneous embolization of biliary fistulas provides a management option in cases where conservative treatment has failed and other techniques are relatively contraindicated. The technique is effective and safe in skilled hands, and avoids major surgery. The long-term effect of microcoils in the biliary tree is unknown.
BACKGROUND: Haemodynamically unstable pelvic fracture patients have a high mortality, and decision-making is crucial. The present article discusses key clinical practice guidelines and options in the early management of these challenging patients. METHODS: A multidisciplinary consensus committee developed guidelines following standard scientific methodology, comprehensive Medline searches and level of evidence grading. Clinical practice guidelines and options addressed four key questions: (i) how to determine the source of haemorrhage?; (ii) how to control haemorrhage?; (iii) what is the optimal angiography and embolization technique?; and (iv) what is the optimal pelvic stabilization technique? RESULTS: The consensus best evidence recommends that the source of intra-abdominal haemorrhage should be assessed using diagnostic peritoneal aspiration and/or focused abdominal sonography in trauma within 30 min of patient arrival. Immediate laparotomy and concomitant pelvic stabilization control intra-abdominal haemorrhage and venous pelvic haemorrhage, followed by angiography if pelvic arterial bleeding is also present. If intra-abdominal bleeding is absent, non-invasive pelvic stabilization and transfer to angiography within 45 min of arrival is recommended to control venous and arterial pelvic haemorrhage. Optimal embolization is performed with steel coils or Gelfoam (Pharmacia & Upjohn, Peapack, NJ, USA) suspension. The optimal pelvic stabilization technique for rotationally unstable fractures with haemodynamic instability is non-invasive. CONCLUSION: The consensus committee successfully developed best evidence recommendations identifying the issues and providing guidelines and options for this challenging condition.
We have previously shown that basic fibroblast growth factor (bFGF; 2 microg), when administered in gelfoams implanted to medullectomized adult rat adrenal glands, maintains target-deprived preganglionic neurons located in the intermediolateral column (IML) of the spinal cord. We show now that administration of 600 or 60 ng/implant/organ of the biologically active recombinant protein also maintains IML-neurons. The effects depend on an intact organ nerve supply since administration of bFGF-implants to the medullectomized and denervated (splanchnicotomized) organ abolishes the maintenance effects for IML-neurons. A possible regeneration of cholinergic nerve fibres was assessed by quantitative determination of choline acetyltransferase (ChAT)-activity and ultrastructurally under various treatments. When compared to a cytochrome-(Cyto)-C treatment, bFGF significantly increased ChAT-activity in the innervated adrenal gland after 4 weeks, suggesting that sprouting of cholinergic nerve fibres and/or recovery of enzyme activity had occurred. Electron microscopically, unmyelinated axons associated with Schwann cells were only found in bFGF, but not in Cyto-C-implants. We conclude that exogenous bFGF or a yet unidentified trophic molecule possibly induced by bFGF in the adrenal gland acts as a retrogradely transported messenger serving for the maintenance of spinal cord IML-neurons in vivo. By stimulating axonal sprouting, bFGF might facilitate access of trophic material to nerve fibres.
Ciliary neurotrophic factor (CNTF) is a pleiotropic molecule that acts as a neurotrophic factor for a wide range of embryonic neurons as well as a differentiation factor for sympathetic neuroblasts and O2A progenitor cells in culture. CNTF messenger RNA (mRNA) is present at very low levels in the normal adult rat central nervous system (CNS), but is dramatically up-regulated after an aspiration lesion of dorsal hippocampus and overlying cortex, in the area coincident with glial scar. The increased level of CNTF mRNA in lesioned hippocampus is maximal by 3 days and is sustained for up to 20 days, the longest time point examined. In contrast, mRNA levels for brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) were slightly decreased during the same period. In situ hybridization experiments revealed that cells expressing CNTF mRNA were concentrated at the margin of the wound, and also present within the gelfoam which filled the lesion cavity. This distribution of CNTF-expressing cells corresponded very closely to that of cells expressing high levels of glial fibrillary acidic protein mRNA at the wound site. Paralleling the observed increase in CNTF mRNA, increased levels of CNTF-like neurotrophic activity were apparent in soluble extracts of the lesioned tissues. This neurotrophic activity for ciliary ganglion neurons was completely blocked by the addition of neutralizing antiserum against CNTF. Basic fibroblast growth factor, which has been shown by others to increase after a similar lesion paradigm (Frautschy et al., Brain Res., 553, 291-299, 1991), does not contribute appreciably to this trophic activity.(ABSTRACT TRUNCATED AT 250 WORDS)
Transforming growth factors beta (TGF-beta), a family of pleiotropic cytokines, are widely distributed in the developing and adult nervous system. In order to further determine the neural functions of TGF-beta, we have localized the TGF-beta isoforms 1, 2 and 3 in the adult rat adrenal medulla and studied the neuroprotective capacity of one representative family member, TGF-beta 2, for those spinal cord neurons which innervate adrenal chromaffin cells and which die after destruction of the adrenal medulla. Unilateral electrothermal destruction of the adrenal medulla led to the disappearance of 25% of sympathetic preganglionic neurons, which are located in the intermediolateral (IML) column of thoracic spinal cord segments 7-10 and can be selectively marked by NADPH-diaphorase. The neurons which disappeared following adrenomedullectomy constitute the full set of neurons that innervate the adrenal medulla. Implantation of gelfoam soaked with 0.5 micrograms TGF-beta 2 into the adrenal wound cavity rescued all spinal cord neurons in the IML ipsilaterally to the lesioned side. Cytochrome c was not effective. Injections of [125I]TGF-beta 2 into the adrenal medulla did not result in retrograde transport and subsequent labelling of spinal cord neurons, suggesting that TGF-beta may exert its neuroprotective actions by indirect mechanisms. TGF-beta applied to cultured adrenocortical cells did not overtly increase the amount of mRNA for fibroblast growth factor-2, an established trophic molecule for sympathetic preganglionic spinal cord neurons. The mechanisms by which TGF-beta exerts its neurotrophic effect are therefore unclear. Even so, our data provide the first evidence that TGF-beta may play an important role in vivo in the control of maintenance of a population of spinal cord neurons.
The serotonin receptor 5-HT2c agonist m-chlorophenylpiperazine (mCPP) has been widely used to induce anxiety-like states in animals and anxiety in humans. We here addressed the effect of an intraperitoneal injection of mCPP on the perception of tinnitus in a behavioural protocol based on an active avoidance paradigm. In control saline-treated animals, mCPP did not change compound action potential audiograms or measurable tinnitus. In contrast, mCPP to animals demonstrating salicylate-induced tinnitus exacerbated tinnitus perception by nearly twofold. We went on to test whether manipulation of the peripheral generator of tinnitus (i.e. the cochlea) could extinguish this exacerbated perception by applying the N-methyl-d-aspartate (NMDA) antagonist 7-chlorokynurenate (7-CK) into cochlear fluids using a 7-CK-soaked Gelfoam ball placed on the round window of each of the animals' two ears. In addition to blocking the tinnitus induced by salicylate alone, 50 microm of 7-CK clearly abolished tinnitus in animals receiving salicylate and an injection of mCPP. The demonstration that cochlear NMDA receptor blockade abolishes the exacerbated perception of tinnitus is highly relevant in terms of treatment. In addition to psychotherapeutic treatment that may help to attenuate an individual's perception of tinnitus, targeting cochlear NMDA receptors represents a promising therapeutic strategy, even in depressed or chronically anxious patients.
OBJECTIVE: To review current indications and techniques for renal artery embolization (RAE) and more specifically to review cases of RAE before nephrectomy for treating patients with a large renal mass. PATIENTS AND METHODS: All RAEs done at our institution between May 1993 and December 2005 were reviewed. Patients were identified using a database assembled by the Division of Cardiovascular Interventional Radiology. Indications, techniques and RAE-related complications were then obtained from a retrospective review of medical records. Additional data for patients undergoing preoperative infarction were acquired, including estimated blood loss (EBL), transfusion requirement, pathological size, subtype, grade, stage, and level of tumour thrombus if present. RESULTS: In all, there were 121 RAEs, 69 in males and 52 in females (mean age 57.6 years, range 11-89). Metallic microcoils were the most often used embolization agent, followed by acrylic microspheres (embospheres), polyvinyl alcohol particles, absolute ethanol, and Gelfoam (Pharmacia & Upjohn, USA). The most common indication for RAE was infarction before nephrectomy (54.5%). Other indications included symptomatic angiomyolipomas, palliation of unresectable renal cancer, haemorrhage, perinephric bleeding in end-stage renal disease, vascular lesions, malignant hypertension, and sequelae of end-stage renal disease. RAE-associated complications including coil migration, incomplete embolization, and groin haematoma (in 5.0%). Symptoms of post-infarction syndrome were common, with 74.4% of patients having flank pain, nausea, or vomiting; the vast majority of these symptoms were mild and self-limited. In patients having nephrectomy after RAE the median (range) interval from RAE was 2 (0-78) days. The mean tumour size was 11.2 (3.5-25) cm and 46% of patients had tumour thrombus present in either the renal vein or inferior vena cava (IVC). The mean (median) overall EBL in patients having nephrectomy after RAE was 1048 (725) mL. The mean transfusion requirement over the course of hospitalization was 3.9 units of packed red blood cells. CONCLUSIONS: RAE is a safe and effective therapeutic tool for many urological, renal and vascular conditions. Its use has increased at our institution due to improved techniques, embolization materials, and our increasing use of RAE as an adjuvant procedure for patients requiring nephrectomy with or without IVC thrombectomy. There are many potential operative advantages for patients having RAE before surgery, with minimal morbidity. It is likely that the lack of prospective randomized trials is the primary reason why it is underutilized in the preoperative setting.
A cavity was made in the brain (entorhinal cortex) of developing or adult rats, and a small piece of Gelfoam was emplaced to collect fluid secreted into the wound. The neuronotrophic activity of the fluid was assayed with sympathetic and parasympathetic neurons in culture. The results show that wounds in the brain of developing or adult rats stimulate the accumulation of neuronotrophic factors and that the activity of these factors increases over the first few days after infliction of the damage.
Certain foreign materials have been demonstrated to enhance the infectivity of aerobic and anaerobic bacteria. Whole blood and other protein compounds encountered in surgical settings or trauma were tested for their effect on infectivity of nonsporeforming anaerobic bacteria. Infectious synergistic mixtures of Bacteroides fragilis plus Peptostreptococcus anaerobius and Bacteroides melaninogenicus plus Fusobacterium necrophorum were each diluted to a barely noninfectious or minimally infectious concentration (subinfective inoculum) that was injected intraperitoneally into mice alone and in combination with test proteins. Infectivity was measured by deaths from sepsis or abscess(es) within the abdominal cavity at autopsy at 1 week. Two hemostatic agents, Gelfoam powder and Avitene (final concentrations, 10 mg/ml), and crystalline hemoglobin (4 g/100 ml) each produced a marked increase (P < 0.001) in the rate of infection when mixed with a normally subinfective inoculum of either bacterial mixture. Fresh homologous mouse blood (0.25 ml) injected intraperitoneally without anticoagulant also significantly enhanced infectivity (P < 0.01) of a subinfective inoculum of B. fragilis plus P. anaerobius. These studies demonstrated the capacity of whole blood, hemoglobin, and hemostatic agents to enhance the infectivity of certain nonsporeforming anaerobic bacteria. The high concentrations of anaerobic bacteria in the gastrointestinal, female genital, and respiratory tracts produce an increased risk of human infection after surgery or trauma in these sites; the protein agents studied here may further enhance infection.
BACKGROUND: Transcatheter arterial chemoembolisation, a procedure for the treatment of hepatocellular carcinoma, provokes a pronounced but transient increase in hepatic cytolysis parameters. A definite evaluation of the impairment of liver function after this treatment, performed by adequate techniques, is still lacking. AIMS: To assess and quantify the impairment of liver metabolic activity after arterial chemoembolisation in patients with cirrhosis. The variations of hepatic vein pressure gradient provoked by this procedure were evaluated. PATIENTS: 15 patients with cirrhosis (Child's class A and B) and hepatocellular carcinoma. METHODS: 17 transcatheter arterial chemoembolisations with epirubicin, iodised oil, and gelfoam were performed; liver function was assessed before, the following day, and after seven days measuring galactose elimination capacity; aminopyrine breath test was also performed in six patients before the procedure and seven days after. In 10 patients intrinsic hepatic clearance of indocyanine green and hepatic vein pressure gradient were measured by hepatic vein catheterisation before and 30 minutes after chemoembolisation. RESULTS: Intrinsic hepatic clearance of indocyanine green decreased significantly from (mean (SEM)) 355 (140) ml/min to 277 (98) ml/min after the procedure (p = 0.0007). Galactose elimination capacity did not show significant changes, being 4.00 (0.90) mg/min/kg body weight at baseline, 4.20 (0.90) mg/min/kg body weight after one day, and 3.95 (0.87) mg/min/kg body weight seven days after chemoembolisation. Aminopyrine breath test was 2.31 (1.09)% and remained unchanged after treatment, being 2.39 (2.04)% at day 7. Baseline hepatic vein pressure gradient was 17.0 (5.5) mm Hg, and 14.4 (3.7) mm Hg 30 minutes after chemoembolisation (p = 0.09). CONCLUSIONS: A single transcatheter chemoembolisation in cirrhotic patients was detected by galactose elimination capacity and aminopyrine breath test one and seven days after the procedure. Therefore it can be considered a safe therapeutic tool for hepatocellular carcinoma in Child's class A and B cirrhotic patients.
Percutaneous embolization of parathyroid adenomas was attempted in three hypercalcemic patients with previously unsuccessful neck explorations. Two adenomas were in the mediastinum and the third was within the thyroid lobe. Autologous clot, Gelfoam, and silicone rubber were used to obstruct feeding arteries. The intrathyroidal adenoma failed to respond but both mediastinal adenomas were infarcted. Hyperparathyroidism recurred after 7 months in one patient but the other remains normocalcemic 8 months postembolization.
The vessels supplying a rare congenital tumor (neurogenic hamartoma) were deliberately occluded by emboli. This extensive tumor presented both in the oropharynx and in the left middle cranial fossa. Using a 3.7 French catheter, Gelfoam emboli suspended in contrast medium were injected into the vessels of the tumor under fluoroscopic visualization. The once vacular tumor was then removed in two stages with little blood loss.
Radiological and clinical experience with transcatheter intravascular occlusion of abdominal and pelvic tumors in 55 patients is presented. Major indications include control of hemorrhage, palliation of local tumor symptoms, and preoperative management of facilitate surgery. Methods of occlusion included embolization (clot, subcutaneous tissue, and Gelfoam), introduction of a stainless steel coil into larger vessels, and balloon catheters. Hemorrhage was controlled in 8 of 12 patients with bleeding gastrointestinal and pelvic tumors. Experience in 36 patients with hypernephroma is discussed. Initial observations are presented, including occlusion of the hepatic artery for dearterialization of primary and secondary neoplasms and of the splenic artery for hypersplenism.
Intractable, chronic vaginal and/or vesicle bleeding complicating pelvic cancers in five women was treated by transcatheter embolization of the hypogastric artery or its branches. Bleeding was presumed to be from hypervascular granulation tissue formed in response to irradiation in two patients and from tumor tissue in three. The embolic materials were Gelfoam and Oxycel reinforced autologous clots. Bleeding was stopped or reduced in volume by at least 90% in each patient. This form of therapy was useful even though bleeding site was not demonstrated angiographically.
Pain associated with a large hemangioma of the thigh was relieved by embolization of a portion of the lesion with Gelfoam. The branch to be occluded was selected when the distribution of the heat associated with the injection of contrast material corresponded to the distribution of the patient's pain.
Five patients with Mallory-Weiss tears of the esophagus and massive uncontrolled upper gastrointestinal bleeding were treated by Gelfoam embolization of the left gastric artery. Four of the five required no further therapy. In one case permanent hemostasis was not achieved due to extension of the tear to branches of the inferior phrenic artery. Since Mallory-Weiss tears are usually self-healing, embolization is potentially the primary treatment modality. Surgery can be reserved for treatment of transmural perforation or recurrent bleeding.