Post traumatic avulsion of lumbar artery: a rare cause of retroperitoneal haemorrhage treated by glue embolization

Lumbar arterial injury after trauma is a rare cause of significant retroperitoneal haemorrhage. Early diagnosis followed by endovascular transcatheter embolization is a very effective treatment to control bleeding in patients who do not respond to conservative management. We present a case of post traumatic avulsion of left fourth lumbar artery which was successfully treated with percutaneous transcatheter arterial embolization with glue

Treatment of intracranial aneurysms using detachable coils; initial results at a university hospital in Pakistan

OBJECTIVE: To evaluate the technical success, safety and outcome of endovascular coiling procedure in intracranial aneurysms. METHODS: From April 2003 to April 2009, 43 patients (23 males and 20 females), age range 11 to 70 years, mean age 46.67 +/- 11.57 years were treated for intracranial aneurysms by detachable coil deployment at Radiology Department of Aga Khan University Hospital. Aneurysm rupture with subarachnoid haemorrhage was the cause of presentation in 39 patients while 4 patients were diagnosed with un-ruptured aneurysms. At time of presentation, grading of subarachnoid haemorrhage was done according to Hunt and Hess grading system. Eleven patients presented with Grade I haemorrhage, other 11 presented with grade II haemorrhage, 8 patients had grade III haemorrhage and 9 patients had grade IV haemorrhage. Preliminary diagnostic workup was performed by cross sectional imaging, CT angiography or digital substraction angiography. Coiling procedures were performed under general anaesthesia through femoral artery approach. Detachable platinum coils were densely packed in all aneurysms by endovascular technique. Patient files and radiology reports were retrospectively reviewed. Technical success and safety of the procedure were analyzed. Modified Rankin Score was used to determine clinical outcome. Score 0-2 represented good outcome, score 3-5: dependency (Can not attend own bodily needs and carry out daily activities without assistance) and score 6: death. RESULTS: Aneurysm size ranged from 3mm - 22mm (mean size 8 mm +/- 4). 74.4% aneurysms had narrow necks while 25.6% aneurysms were wide necked. Most common aneurysm site was anterior communicating artery. Technical success rate for endovascular intracranial aneurysm coiling was 95.3% (n = 41). Major complication rate was 11.6 % (n = 5). Mortality rate was 2.3% (n = 1). 78% patients showed good clinical outcome after coiling including 4 patients with un ruptured aneurysms (n = 32). CONCLUSION: Results of endovascular aneurysm coiling at our center showed high technical success rate (95.3%) and good short term clinical outcome in 78% patients

Transjugular intrahepatic portosystemic shunt (TIPS); review of initial experience at Aga Khan University Hospital

OBJECTIVE: To retrospectively assess the therapeutic effectiveness and safety of transjugular intrahepafic portosystemic shunt (TIPS) in patients with portal hypertension related complications. METHODS: Over a period of 7.5 years 19 patients (10 males and 9 females, age range 25-69 years) were referred for TIPS at our radiology department. Thirteen patients suffered from liver cirrhosis while 6 had Budd Chiari syndrome. All patients were evaluated with colour doppler ultrasonography and cross sectional imaging. Shunt procedures were performed under sedation or general anaesthesia through internal jugular approach. Metallic self expandable uncovered stents were placed in 15 patients and covered stent in 1 patient. Follow up of patency was evaluated with ultrasound in majority and by venography in some patients. Safety of the procedure and clinical outcome were analyzed. RESULTS: Indications of procedure included variceal bleeding (n=8), ascites (n=4), ascites and bleeding (n=1) and Budd-Chiari syndrome (n=6). Technical success rate was 84.21%. Complication rate was 10.53%. Three days mortality was 15.79%. Mean primary shunt patency was 306.62 +/- 533 days. During follow-up stent occlusion occurred in 5 patients (31.25%). Four of these patients underwent successful reintervention. Recurrence of symptoms occurred in 68.75% patients. CONCLUSION: TIPS is useful for management of complications of portal hypertension that are refractory to pharmacological and endoscopic treatment, however shunt stenosis or occlusion may cause recurrence of symptoms. Repeated interventions are often required to maintain shunt patency

Determination of intravascular volume status in critically ill patients using portable chest X-rays: Measurement of the vascular pedicle width

Background and Aims: Traditionally, invasive hemodynamic pressure measurements have been used to assess the volume status in critically ill patients. The vascular pedicle, as seen on chest radiographs, is the mediastinal silhouette of the great vessels. It is measured by drawing a perpendicular line from the point at which the left subclavian artery emerges from the aortic arch and measured across to the point at which the superior vena cava crosses the right main stem bronchus. We carried out this study to establish a correlation between the width of the vascular pedicle as seen on chest radiographs and daily fluid balance or pulmonary capillary occlusion pressure in mechanically ventilated, critically ill patients. Materials and Methods: In this prospective clinical study, 50 consecutive adult patients in a tertiary care, multidisciplinary intensive care unit underwent simultaneous measurements of the width of the vascular pedicle as seen on standardized, portable chest radiographs in the supine position and pulmonary capillary occlusion pressure measurements. Twenty-four hour fluid balance calculations were also recorded for each patient. Results: Vascular pedicle width measurements correlated closely with positive fluid balance, r = + 0.88, P 0.000. A Receiver Operating Characteristic curve demonstrated that a vascular pedicle width of 86.5 mm had a 100% sensitivity and an 80% specificity (area under the curve 0.823, 95% confidence intervals 0.714-0.932) for predicting fluid overload equal to and greater than 1200 ml. The correlation between pulmonary capillary occlusion pressures and width of the vascular pedicle was poor, r = 0.41, P 0.02. Conclusions: Our findings suggest that the vascular pedicle width on daily chest radiographs can be used to assess hypervolemia in the intensive care unit. Serial changes in the pedicle width could possibly be used to increase the accuracy of predictions