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Peristomal varices occasionally form in patients with chronic liver disease who have surgically created intestinal anastomoses and stomas. Hemorrhage from these varices carries an estimated mortality of 3%-4% per episode, as opposed to the 30%-40% mortality associated with gastroesophageal variceal bleeding. The cases of four patients who underwent transhepatic mesenteric vein catheterization with embolization of stomal varices for recurrent, intractable bleeding are presented. In three of the four patients there was no additional hemorrhage for at least 5 months. One patient was lost to follow-up. There were no complications. Since stomal variceal hemorrhage has a low mortality, transhepatic embolization is presented as a means of hemorrhage control when sclerotherapy fails and when shunt surgery presents an unacceptably high rate of morbidity and mortality relative to the underlying disease.

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Suppurative thrombosis of a central vein is a serious complication of central venous catheter use. Surgical removal of the vein, the treatment usually recommended for peripheral vein suppuration, is technically difficult. We describe six patients with central venous septic thrombophlebitis. Four patients were receiving TPN; three from this group were successfully treated medically with removal of the catheter, intravenous antibiotics, and anticoagulants. The fourth patient improved clinically with 2 weeks of medical therapy prior to surgery, which showed the clot to be sterile. In contrast, two patients with suppuration adjacent to and secondarily involving a large vein required surgical drainage of the perivenous collection. Patients with central venous septic thrombophlebitis can be successfully managed with prompt catheter removal, intravenous antibiotics, and anticoagulation, but surgery should be considered when there is a suppurative focus around the vein.

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The diagnosis of biliary duct varices and portal vein occlusion should be considered when nodular or notched defects in the wall of the biliary duct system are shown by cholangiography or when pedunculated vascular structures in the bile ducts are seen at surgery. We present two cases of common hepatic and common bile duct varices due to portal vein occlusion.

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Forty-seven extremities with recurrent venous ulceration were treated by subfascial ligation of incompetent perforating veins. The limbs were observed for an average of 8.5 years (range, 0.5 to 13 years). The risk for recurrence was 22%, 41%, and 51% at 1, 3, and 5 years, respectively. Patients with bilateral ulceration or prior venous ligation were at the highest risk for recurrence, while those with prior excision of prominent varicose veins had a reduced risk. There has been no loss of limbs or life secondary to this venous problem during the 398 cumulative years of observation.

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As part of a general safety study of iopamidol, a nonionic iodinated contrast agent, urine N-acetyl-beta-glucosaminidase enzyme assays were done to compare the renal toxicity of iopamidol with that of iothalamate and diatrizoate. In a randomized study of 30 patients for computed body tomography and another 30 patients for angiography, 10 in each group were injected with iopamidol, 10 with iothalamate, and 10 with diatrizoate. After computed tomography or angiography with the three agents, there was no significant difference in urinary enzyme levels among the groups. The nephrotoxicity of iopamidol appears equivalent to that of diatrizoate and iothalamate.

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Since June 1974, 347 percutaneous transhepatic portal venographic studies were performed on 246 patients with portal hypertension who had had bleeding gastroesophageal varices. Of 234 patients in whom left gastric veins (LGV) (coronary) were demonstrated, 177 (75.6%) had a single LGV and 57 (24.4%) had multiple left gastric veins (21.8% had two LGVs, 2.1% had three LGVs, and 0.5% had five LGVs). Of 193 patients undergoing selective left gastric venography, spontaneous portosystemic communications to the left renal vein were found in 55, to the inferior vena cava in two, to the inferior pulmonary veins in five, to the pericardiophrenic vein in eight, to the right inferior phrenic vein in three, and to the left intercostal veins in one. Interportal communications with the left gastric vein and varices occurred from the left portal vein in 13, from the gastroepiploic vein in one, and from a superior mesenteric vein branch in one. The predominant drainage of esophageal varices was to the azygos vein in 78 of 155 patients, to the hemiazygos vein in 13, and to multiple small unnamed veins in the mediastinum in 57. Opacified varices did not extend above the level of the azygos vein arch in 71 of 130 patients; however, 59 continued cephalad to the azygos arch and drained through more superior veins of the thorax. Knowledge of the anatomy and incidence of each of these portosystemic or interportal venous communications is important to properly treat bleeding esophageal varices by surgery or angiographic embolization.

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Fifteen high-risk patients with threatened limb loss underwent combined operative iliac angiodilation and infrainguinal vascular reconstruction for iliac and femoropopliteal occlusive disease. The patients were poor candidates for combined surgical inflow and outflow reconstruction because of associated cardiopulmonary disease. The mean systolic pressure gradient across the iliac stenosis was 34 +/- 5 mm Hg. Iliac artery angiodilation was accomplished intraoperatively and reduced all gradients to zero. Stenoses in the distal portion of the deep femoral artery were endarterectomized in nine patients, and six cross-femoral and six distal popliteal or tibial grafts were constructed. Life-table analysis at 36 months showed iliac patency in 86% of cases and successful distal reconstruction in 76%. Our limb salvage rate of 86% suggests that combined intraoperative angiodilation by the angiographer and arterial reconstruction by the vascular surgeon may provide effective therapy for high-risk patients.

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Iopamidol was compared with Renografin-60 (meglumine diatrizoate, Squibb) in a controlled, randomized double-blind study of 40 patients undergoing peripheral arteriography for arteriosclerotic occlusive disease to determine which agent caused less discomfort. Each patient was evaluated for objective signs of discomfort and subjective feelings of pain and heat. Monitoring was achieved by multiple physical examinations, chemical tests, electrocardiograms, and intra-arterial pressure recordings. It is concluded that iopamidol is safe and causes significantly less patient discomfort than Renografin-60.

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Seven patients had severe deep venous insufficiency and recurrent ulceration in eight lower extremities. All incompetent perforating veins had been previously ligated. All limbs were evaluated by dynamic venous pressure measurements. The venous pressure reduction with exercise was recorded, as well as the recovery time. The most accurate indicator of venous valvular incompetence was a short postexercise recovery time. Abnormal hemodynamic findings were correlated with ascending and descending venographic findings. Based on these anatomic and pathophysiologic abnormalities, patients underwent valvular transposition, superficial femoral vein valvuloplasty, or superficial femoral vein ligation. Immediate postoperative recovery time (mean +/- SEM) was improved to 34.5 +/- 18.3 s from 7.9 +/- 2.9 s preoperatively. Postoperative venography demonstrated patency of all anastomoses and absence of reflux into previously incompetent venous systems. All limbs were symptomatically improved after operation, and no venous thrombosis or pulmonary emboll developed. Persistent ulceration, however, continued in one limb.

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The acute effects of intravenous nadolol (0.01 and 0.02 mg/kg) on cardiac electrophysiologic parameters were assessed with His bundle recording and programmed atrial stimulation. The higher dose of nadolol reduced resting heart rate (71 vs. 65 beats/min, P less than 0.02), and the degree of slowing was related to the initial heart rate (r = -0.68, P less than 0.05). Atrioventricular conduction time as defined by the paced A-H interval, rose by 12 msec (P less than 0.001) after nadolol (0.02 mg/kg) administration. Atrial refractoriness increased (by 10 msec, P less than 0.02) only at the higher dose level with nadolol. At both dose levels, atrioventricular nodal effective and functional refractory periods were increased (P less than 0.02) by a mean of 45 and 21 msec, respectively, suggesting greater sensitivity of atrioventricular nodal refractoriness to beta-adrenergic blockade. Nadolol's effects were generally similar to those of previously reported studies with other beta-adrenergic blockers. These data suggest that nadolol slows conduction through the atrioventricular node and increases atrial and atrioventricular nodal refractoriness.

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Ten patients undergoing peripheral arteriography with iopamidol were evaluated in a carefully controlled Phase I study using a variety of objective and subjective tests of discomfort. There was minimal objective evidence of pain, and the patients reported that they perceived minor discomfort and a warm sensation during the contrast injections. Five patients who had previously undergone arteriography using 2 mg of lidocaine per ml of methylglucamine diatrizoate noted a marked decrease in discomfort when iopamidol was used. Opacification of peripheral arteries was excellent. Multiple physical examinations, chemical tests, electrocardiograms, and intra-arterial pressure recordings showed that iopamidol is safe.

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Five high-risk patients received nonresective treatment of abdominal aortic aneurysms (AAAs). This treatment included ligation of the iliac arteries to induce acute thrombosis of AAA and a simultaneous axillobifemoral bypass for restoration of arterial flow to the lower extremities. Of these five patients, lethal complications associated with this procedure developed in four. The complications included rupture, infection of the thrombotic aortic aneurysm, visceral ischemia, and consumptive coagulopathy. This high incidence of lethal complications and the unacceptably high patient mortality in these five patients indicates extreme precaution in the application of nonresective treatment for AAA.

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Seventy-six above-knee amputations performed on elderly debilitated patients were reviewed. Fifty-one wounds healed without complications; 25 amputation wounds developed postoperative complications. The quality of the femoral pulse has a significant effect on wound healing after an above-knee amputation. Other significant conditions that appear to influence the frequency of wound complications are hypertension, a failed bypass procedure to the groin, and angiographic evidence of stenosis or occlusion of the common femoral or the profunda femoral artery. Multiple variable analysis suggests a beneficial effect of antibiotics in patients with a diminished or absent femoral pulse. Age, presence of cardiac disease, diabetes, associated diseases and the use of drains have no significant effect on the outcome. Before an above-knee amputation, patients with a diminished femoral pulse should undergo arteriography and perhaps reconstructive surgery. Primary hip disarticulation may be the initial procedure of choice in the presence of multiple risk factors.

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The fate of 359 consecutive alcoholic cirrhotic male patients with bleeding esophageal varices was determined through chart review and personal interview. Three historical periods (1966-70; 1971-75; 1976-80) were defined based on availability of different therapeutic modalities. Management of acutely bleeding varices by conservative, nonsurgical means, including embolization, was preferable to emergency surgery when considering 30-day mortality rates. Percutaneous transhepatic embolization of esophagogastric varices significantly improved the rate of control of hemorrhage and 30-day survival over previously employed nonsurgical methods. The combination of nonsurgical management of acute variceal hemorrhage followed by selective distal splenorenal shunting resulted in maximum salvage of the alcoholic cirrhotic patient.

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Computed tomographic angiography performed by the intravenous administration of contrast medium was evaluated in 86 vascular patients. This experience demonstrates a new approach to the evaluation of patients with symptomatic aortic aneurysms, in whom computed tomographic angiography will aid in evaluating the need for emergency surgery. Nonoperative patients are serially evaluated by computed tomographic angiography to detect significant changes in the geometric configuration of their aneurysms. Computed tomographic angiography was beneficial in the evaluation of the patency of vascular reconstructive procedures such as femoropopliteal bypass, aortoiliac bypass and application of a vena caval device. More clinical experience and possibly a rapid sequence technique are needed to evaluate patients with portasystemic shunts.

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A prospective controlled comparison of portal-systemic (PSS) and distal splenorenal shunts (DSRS) in cirrhotic patients who had survived hemorrhage from esophagogastric varices was undertaken 5 yr ago at five hospitals by the Boston-New Haven Collaborative Liver Group. The clinical and endoscopic criteria for massive hemorrhage were satisfied in 155 patients. Thirty-four patients were excluded, primarily because of uncontrolled hemorrhage. Thirty-four were rejected because the were poor operative risks and 21 because they did not satisfy criteria. Thirteen patients refused to participate; the remaining 53 were randomized; 29 to receive PSS and 24, DSRS. The two groups were similar in clinical, laboratory, and manometric characteristics. The DSRS group was older and tended to have had more previous hemorrhages. Followup ranged from 1 to 56 months (mean 21). After PSS, which was performed by 10 different surgeons, 6 patients died during the hospital admission (21%) compared to 2 after DSRS (12%). There were 6 late deaths in the PSS group and 4 in the DSRS group. Portal-systemic encephalopathy occurred in 5 of the 23 survivors of PSS (23%), and in 6 of the 19 who survived DSRS (32%. Two patients in the PSS group bled (9%), 1 after thrombosis and 1 after stenosis of the shunt. Three patients in the DSRS group bled (16%) and all had thrombosis of the shunt. PSS was associated with an unexplained but inordinately high operative mortality. Although the DSRS was accomplished with an acceptably low operative mortality, it was associated with frequent portal-systemic encephalopathy, shunt occlusion, and recurrent hemorrhage. Similar incidences of portal-systemic encephalopathy, shunt occlusion, and recurrent hemorrhage were observed in the PSS group. More patients and longer followup are necessary to determine which of these portal decompressive procedures is superior.

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An assessment was made of the treatment of 120 consecutive, alcoholic, cirrhotic patients with bleeding esophageal varices. Percutaneous, transhepatic embolization of the esophagaogastric varices resulted in control of the hemorrhage and this approach was more effective than were the non-surgical methods used. Management of acute variceal bleeding by conservative non-surgical means, including embolization, appears preferable to emergency portal-systemic shunts. The combination of non-surgical control of the acute variceal hemorrhage plus subsequent selective distal splenorenal shunting resulted in minimal encephalopathy and the most effective treatment.

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Although noninvasive CT scanning and ultrasonography have assumed a prominent position in the armamentarium of the radiologist, invasive procedures still play a complementary role in diagnosis and a primary role in the interventional management of liver diseases. Among the procedures detailed are hepatic artery embolization, transhepatic occlusion of bleeding esophageal varices, transhepatic cholangiography, and the removal of stones from the common bile duct.

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Eight patients with patent distal splenorenal shunts were studied after a 22- to 36-month interval. Evolution of hemodynamic and anatomical changes was documented by percutaneous transhepatic portal catheterization, cinefluorography using ethiodized oil droplets, transfemoral splenorenal shuntography, and celiac arteriography. Changes included (a) a decrease in the portosystemic venous pressure gradient, (b) an increase in the size of and flow through both the shunt and the hepatic artery, (c) reversal of portal venous flow, (d) marked dilatation of collaterals and diversion of flow from the superior mesenteric vein to the shunt, and (e) an increase in cardiac output.

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