Kent A. Stevens, M.D. Stevens, M.D.

• Director, Adult Trauma Services
• Associate Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0023389/kent-stevens

Images are reconstructed using a smooth kernel into one data set of thicker slices at 5 do erectile dysfunction pills work buy cheap kamagra effervescent 100 mg on-line. When stenosis is present erectile dysfunction 27 kamagra effervescent 100 mg generic, the determination of severity is typically by visual estimation rather than a computer-based technique erectile dysfunction systems purchase kamagra effervescent cheap online. The outcome measures included the clinical utility erectile dysfunction treatment in kl order discount kamagra effervescent online, functional patient outcomes impotence pumps buy generic kamagra effervescent on line, quality of life erectile dysfunction pills side effects cheap kamagra effervescent online master card, and diagnostic and therapeutic costs related to the initial imaging test during 6 months of follow-up. As mentioned before, the assessment of infrapopliteal lesions was worse (sensitivity 91. Maximal intensity projection (A) and three-dimensional computed tomographic angiography volume-rendered (B) images showing bilateral common iliac aneurysms with distal runoff disease of the right lower extremity. The definition of a popliteal artery aneurysm is when the arterial diameter is greater than 7 mm, and a femoral artery aneurysm is when the diameter is greater than 10 mm. Three-dimensional computed tomographic angiography volume-rendered images showing a focal aneurysmal dilatation of the distal portion of the left common iliac artery (arrow, A); aneurysms of the common femoral arteries bilaterally (arrows, B), extending to the origins of the superficial femoral arteries; and focal aneurysmal dilatation of the bilateral popliteal arteries (arrows, C). The angiographic appearance is one of abrupt vessel occlusion or focal high-grade concentric stenoses associated with extensive collateral circulation resulting in a "corkscrew appearance. This may require reconstruction with alternate kernels and adjustment of window levels. Assessment of the graft should include careful evaluation of the proximal anastomotic area to exclude stenosis or aneurysm, the body of the graft, and the touch-down site of the graft. Arteriovenous malformations and fistulas may be well delineated by acquiring images during the arterial and venous phase. Three-dimensional computed tomographic angiography volume-rendered image (posteroanterior view) of a young patient with right calf pain on exertion. The medial head of the right gastrocnemius muscle demonstrates an abnormal origin lateral to the popliteal artery (closed arrowhead). Inset image shows complete occlusion of the right popliteal artery (arrow) with multiple superficial collateral arteries originating just proximal to this level. The normal origin of the medial head of the left gastrocnemius medial to the popliteal artery (open arrowhead) is shown for comparison. Biography: history of developments in imaging techniques: Egas Moniz and angiography. Contrast media as extracellular fluid space markers: adaptation of the central volume theorem. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. Radiation dose and image quality of prospective triggering with dual-source cardiac computed tomography. Carotid Doppler ultrasound criteria for internal carotid artery stenosis based on residual lumen diameter calculated from en bloc carotid endarterectomy specimens. Imaging of the ulcerated carotid atherosclerotic plaque: a review of the literature. Trends in the incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients. Stratification, imaging, and management of acute massive and submassive pulmonary embolism. Right ventricular enlargement on chest computed tomography: prognostic role in acute pulmonary embolism. Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept. Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma. Current evidence and implications for treatment strategies: a review and meta-analysis of 92 patients. Technology insight: magnetic resonance angiography for the evaluation of patients with peripheral artery disease. Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms. Patterns of aortic involvement in Takayasu arteritis and its clinical implications: evaluation with spiral computed tomography angiography. White Abstract Catheter-based invasive contrast angiography is the standard method for diagnosing peripheral artery disease, and against which all other methods are compared for accuracy. Knowledge of the vascular anatomy, technical considerations, and potential complications is a core element in the skill set required to safely perform peripheral vascular angiography and interventions. Knowledge of the vascular anatomy and its normal variations is a core element in the skill set required to safely perform peripheral vascular angiography and interventions. Imaging equipment There are many radiographic equipment vendors and many different room layout schemes suitable for performing peripheral vascular angiography. However, if both cardiac and noncardiac types of peripheral vascular angiography are to be performed in the same room, equipment options become much more limited. A dual-plane system economically provides a layout with two independent C-arm image intensifiers operated by a single x-ray generator and one computer. In a dual-plane system, the cardiac C-arm is a three-mode, 8- or 9- inch flat-panel image intensifier, and the noncardiac C-arm should be as large as possible, usually a 15- or 16-inch flatpanel image intensifier. For peripheral vascular imaging, particularly bilateral lower-extremity runoff angiography, an image intensifier smaller than 15 inches may not be able to include both legs in the same field. Note two C-arm image intensifiers (9- and 16-inch), with catheterization table able to rotate 90 degrees. The ability to angulate (rotational as well as cranial and caudal) the image intensifier is necessary to resolve bifurcation lesions and optimally image aorto- ostial branch lesions. Radiographic contrast Ionic low-osmolar or nonionic iodinated radiographic contrast is preferred for angiography of the peripheral vessels to avoid patient discomfort. In addition, low-osmolar agents deliver a lesser osmotic load and thereby a lower intravascular volume, which may be important in patients with impaired left ventricular or renal function. Gadolinium, traditionally used with magnetic resonance angiography, is relatively nontoxic in patients with adequate renal function at a recommended dose not exceeding 0. Imaging technique Many of the technical aspects of diagnostic cardiac imaging also apply to performing angiography of the aorta and peripheral vasculature. The basic principle of vascular angiography is not only to visualize the target lesion but also to demonstrate the inflow and outflow vascular segments. Inflow anatomy constitutes the vascular segment preceding the target lesion, and outflow constitutes the vascular segment immediately distal to the target vessel and includes the runoff bed. The use of pressure monitoring during selective angiography can prevent a myriad of complications, including the creation of dissections and air injection. Angiography may be performed using a "bolus chase" cineangiographic method or with a digital subtraction stepping mode. The bolus chase technique involves injecting a bolus of contrast at the inflow of the territory, then "panning" or manually moving the image intensifier or table to follow the bolus of contrast through the target lesion and into the run-off segment. In digital subtraction stepping mode, the patient lies motionless on the angiographic table. The table moves in steps to image the contrast-filled vessels, from which the mask is then subtracted, leaving only the contrast-filled vascular structures. For diagnostic, nonselective lower extremity run-off angiography, 4 F catheters inserted into the radial artery and positioned in the infrarenal aorta is becoming more common. The most common complications of angiographic procedures occur at vascular access sites. The femoral artery and vein lie below the inguinal ligament, which is a band of dense fibrous tissue connecting the anterior superior iliac spine to the pubic tubercle. The inguinal skin crease, which is variable in location, is shown as a dotted line in the figure. The most important anatomic landmark for femoral arterial access is the head of the femur. Anatomical landmarks are initially identified by palpation of the anterior superior iliac spine and pubic tubercle to locate the inguinal ligament; the position of the femoral head is confirmed fluoroscopically. Depending on the amount of subcutaneous fat, a skin incision should be made 1 to 2 cm caudal to the level of the center of the femoral head. Keeping the bifurcation at the inferior edge of the screen also aids in avoiding a high puncture. If fluoroscopy demonstrates a puncture above the femoral head, the needle is removed and reinserted lower. The presence of loose connective tissue in the retroperitoneal space can lead to large hematomas that can result in lifethreatening hemorrhage. Lack of osseous support and the presence of a tense inguinal ligament at the arterial puncture site make manual compression difficult. Either biplane angiography may be obtained or, if needed, two separate angiograms with single-plane systems. The renal arteries originate from the lateral aspect of the abdominal aorta at the level of L1 to L2. When this occurs, selective angiography of the renal artery may be required to visualize the origin of this vessel. Pigtail catheter contrast injection of 20 mL/s for 30 mL (5 degrees left anterior oblique) using a digital subtraction angiography technique. Generally, a nonselective abdominal aortogram is obtained before selective renal angiography, using a large format (9- to 16-inch) image intensifier with digital subtraction imaging. The nonselective aortogram demonstrates the level at which the renal arteries arise, the presence of any accessory renal arteries and their location, the severity and location of aortoiliac pathology, and the presence of significant renal artery stenosis. Selective Renal Angiography Selective renal angiography is indicated to identify suspected renovascular disease. Selective renal artery engagement allows the measurement of pressure gradients, particularly if ostial lesions are suspected. When measuring pressure gradients across lesions, it is important to use the smallest catheter possible. Caudal or cranial angulation (15 to 20 degrees) may occasionally be necessary for better visualization of some ostial lesions. An optimal image will reveal the ostial portion of the renal artery and distal branches at the cortex of the kidney. There are usually collaterals between the mesenteric vessels, and it is uncommon for stenosis or occlusion of a single branch to cause clinical symptoms. Alternatively, upper-extremity vascular access allows the mesenteric arteries to be engaged with a multipurpose-shaped catheter. Analogous to the renal arteries, selective engagement of the mesenteric arteries also allows measurement of the pressure gradient. Selective angiographic images in multiple views are obtained with hand injections of contrast. A single bolus of contrast is injected from the catheter at the aortic bifurcation at 8 to 12 mL/s for 8 to 10 seconds, and sequential images are obtained from the aorta to the feet. Selective angiograms performed in angulated views of a particular artery or arterial segments are useful when clarification of a potential stenosis is needed. One option is to place a diagnostic catheter at different levels in the iliac, femoral, or popliteal artery for a more detailed examination of a particular arterial segment. Several angiographic views are important to mention because they help clarify anatomical detail. In that case, slight angulation will move the artery in question off the bony density to allow better visualization. The thoracic aorta gives rise to the brachiocephalic trunk in the proximal portion of the arch, the left common carotid artery in the mid-portion, and the left subclavian artery in the distal portion. Other common variations include the left vertebral artery originating directly from the aortic arch, between the left common carotid artery and left subclavian artery, and the right subclavian artery originating from the aortic arch distal to the origin of the left subclavian artery. Digital subtraction angiogram injection of 15 mL/s of contrast material for 3 seconds, with image obtained at 30 degrees left anterior oblique. Thoracic aortography is commonly performed to diagnose pathological entities, such as stenoses of the origin of the great vessels, aneurysms, aortic dissection, coarctation of the aorta, patent ductus arteriosus, and vascular rings, and to evaluate vascular injuries caused by blunt or penetrating chest trauma. A pigtail catheter is advanced into the ascending aorta and positioned proximal to the brachiocephalic trunk. Using a power injector, radiographic contrast material is injected at 15 to 20 mL/s for a total of 2 to 3 seconds. The brachiocephalic trunk, left common carotid artery, and subclavian arteries originate from the transverse thoracic aorta. The brachiocephalic trunk or innominate artery divides into the right common carotid artery and the right subclavian artery. Once the origin of the common carotid artery has been engaged with a guidewire, the catheter is advanced into the common carotid artery over the wire. Care must be taken to clear the catheters and manifold of air and debris before injecting into the carotid artery. Because of the dense bony structure of the skull, it is preferable to use digital subtraction techniques for diagnostic images of the intracranial vascular anatomy. This enables assessment of the circle of Willis and demonstrates the presence of any collateral circulation. The vertebral artery, the first and usually largest branch of the subclavian artery, arises from the superior and posterior surface of the subclavian. Vertebral Angiography the vertebral arteries are identified on the aortic arch aortogram. Often, a nonselective injection of contrast in the subclavian artery near the origin of the vertebral artery is performed to view ostial lesions.

For this erectile dysfunction rates buy kamagra effervescent 100 mg visa, markings on the catheter at the level of the ureteral orifice arc noted erectile dysfunction cycling proven 100 mg kamagra effervescent. Next erectile dysfunction treatment portland oregon kamagra effervescent 100mg without prescription, the double-pigtail scene is threaded over the same guide wire and advanced by a pusher device until its distal end enters the bladder erectile dysfunction other names purchase kamagra effervescent discount. The guide wire is partially removed erectile dysfunction walgreens order 100 mg kamagra effervescent with visa, allowing the upper curl to form in the renal pelvis impotence low testosterone purchase kamagra effervescent once a day. To help avoid patient discomfort and irritative voiding symptoms, the coil should not cross the sagittal midline of the bladder (Al-Kandari, 2007). Longer duration may lead to greater patient discomfort, pyclonephritis, and stent encrustation. However, pyclonephritis may occur in patients with stems, and diagnosis = requires prompt mmauon of intravenous antibiotics (Table 3-14, p. Although not generally recommended, we then continue daily antibiotic prophylaxis after treating pyelonephritis until the stent is removed. Stent-related suprapubic pain or bladder spasm is common and can be treated with an anticholincrgic agent (Table 23-5, p. One aample of the latter is tamsulosin hydrochloride (Flomax), which is prescribed as a 0. The physiologic rationale for these both drug groups is outlined in Chapter 23 p. Notably, pain or obstructive symptoms may reflect stent migration, which is reported in approximately 4 percent of cases (Breau, 2001). If displacement is suspected, a plain abdominal radiograph will display stent position. In this study, the symphysis pubis serves as a general marker of the midsagittal plane. In pregnant patients, coil position can be verified sonographically to avoid radiation exposure. For malpositioning, the stent can be exchanged over a guide wire in an outpatient setting. The lower pigtail of the scent is identified, grasped, and pulled out concurrently with the cystoscope. Small mucosal lesions can be biopsied with minimal risk or discomfort to the patient. Large lesions highly suspicious for bladder cancer should be referred to a urologic oncologist. Biopsy is performed, and the cystoscope and instrument are withdrawn through the urethra together. In this way, a biopsy specimen is not pulled through the sheath and possibly lost. For brisk bleeding, electrosurgical coagulation can be used if a nonconducting solution such as water or glycine was selected as the distention medium. Electrolyte solutions such as saline cannot be used with monopolar electrosurgcry. These solutions conduct current, dissipating the energy, and thereby rendering the instrument useless. Foreign bodies, such as small stones that can pass transurethrally, arc removed using the same technique as biopsy. The instrument is used to grasp the foreign body and then removed together with the cystoscope. Surgeries for Pelvic Floor Disorders 2-0 absorbable suture then is cttated at the bladder dome, with $titcha placed deeply into the bladder mu. The two suture ends are pulled upward and held tightly to prevent dimnding fluid escape. To allow viNalharlon of the trlgone and ureteral orifices, die Foley bulb is ddlatcd but left in place. Ifthe ureteral orifice$ still cannot be visuilizcd, the bladder incision is enended inferiorly into the rca:opubic portion to allow direct trigone visualization. A wfde purse-string U$ing Office cym>scopy does not require specific postoperative management. Instead, anteroinferiorly and laterally, the bladder abuts the loose connective tissue that fills the retropubic space, and here, the bladder lacks a peritoneal covering. An injury in this relatively sequestered retropubic portion carries the lowest risk of fistula formation, because it does not contact abdominopelvic organs. Injuries bdow the vesicouterine perironeal fold and thus in the vesicovaginal space carry risk of fistula formation. Moreover, injuries here may approximate or extend into the trigone, which raises repair oomplcxity and posroperative complication races. Overall, small defects measuring <2 mm in diameter, such as those from a Veress needle, can be managed expectantly. Small dome injuries measuring:S 1 cm in diameter, such as those from a 5-mm laparoscopic trocar or a midurethral-sling needle, may be repaired or may be managed conservatively. For small laceration in the portion of dome covered by peritoneum, cystography can be performed prior to catheter removal to confirm bladder integrity. This practice generally is advised because of greater urine cxtravasation risk at this site. For midurethral-sling trocar injuries into the retropubic part of the bladder, cystography typically is not required prior to catheter removal due to the enclosed anatomy describe earlier. For a bladder dome laceration measuring:S 1 cm and noted during abdominal or laparoscopidrobotic surgery, we prefer one-layer closure using 2-0 or 3-0 delayed-absorbable suture and interrupted stitches. If bladder injury is diagnosed postoperatively but within 5 days from the primary procedure, early repair may be considered. For example, postoperatively diagnosed injuries measuring < 1 cm at the dome can be managed by prolonged bladder drainage and then later cystography. Otherwise, a delay of approximately 6 weeks and bladder drainage is recommended to permit tissue inflammation resolution. These tests help exclude concomitant ureteral injury or complex bladder injuries, defined earlier. The urethra, instead, is particularly vulnerable with antiincontinence operations, urethral diveniculum excision, or a large cystotomy that extends into the bladder trigone. A description of the epidemiology and prevention of these injuries is presented in Chapter 40 (p. Although these may not be identified until after surgery, primary repair intraoperativdy lowers risks of later urogenital fistula formation and other serious complications. For delayed repair, counseling also explains possible scent placement, ureceral surgery, and prolonged bladder or ureteral drainage. Risk of urinary tract or wound infection, irritative voiding symptoms, hematuria, and suprapubic pain from the repair or the indwelling cathetcr(s) are reviewed. Although rare, repair breakdown, fistula formation, and reoperation are other risks. Thus, if an injury is diagnosed intraoperatively, no further antibiotics are indicated soldy for cystotomy repair. However, antibiotics may be redosed for cases lasting > 3 hours or associated with > 1500 mL blood loss. For delayed repairs, the American College of Obstetricians and Gynecologists (2018b) recommends antibiotic prophylaxis prior to urogynecologic surgery, and appropriate broad-spectrum choices mirror those for hysterectomy (Table 39-8, p. Smaller lacerations in the bladder dome are suitable for repair by most gynecologists. However, complex injuries benefit from the expert assistance of a urogynecologist, gynecologic oncologist, or urologist. Complex injuries are those that approximate or involve the bladder trigone, are multifocal, or occur in tissue that is anticipated to heal poorly. During laparoscopy, the Foley bag also may distend with gas from the pneumoperitoneum. For diagnosis, sterile milk or vital dye such as diluted methylene blue, instilled retrograde through a catheter, confirms injury if the solution is noted in the operative fic:ld. Prior to repair, cystoscopy to assess uretcral patency is indicated for any injury to the bladder base. Women usually can remain positioned from their primary surgery if it permits cyscoscopy. If supine for laparotomy, a patient is repositioned to low lithotomy position in booted support stirrups. Many cystotomies occur during hysterectomy, which serves as a reference during several of the subsequently described steps. However, injuries that extend laterally can involve ureters directly or during repair. Catheters delineate 8 Surgeries for Pelvic Floor Disorders and later may be replaa:d by stcnts, whic. Ifmultiple small cystotomies lie adjacent to each omer and away 6:om me bladder uigone, sharp incision of the intervening bladder wall acgments aean:s a sinf. For repair, the bladder mucosa edges are reapposed wim 3-0 delayccl-absorbable sunue in a numing fashion. Imponandy, latge tissue purchases that may tear the bladder wall or compromise ureter. A voiding trial and postvoid ruidual volume m~ent after catheter removal are ~nable and desc:ribed in Chapter 42 (p. If the closed vag;nal cuff and qstctomy repair site appose one another, the expected inflammatory response that attends nonnal healing may risk fistula formation. The omentum then is sutured to the anterior vaginal wall at a site distal to the cuff and thereby covers the c:uE incision (p. This approach offen comparable: sua:css rates, lower morbidity, and faster patient recovery. Of vaginal methods, the one most commonly performed by gynecologists is the Latzko technique. The tract then is rc:sected, but the portion opening into the bladder is not excised. If performed fur fistulas at the vaginal apex, then both anterior and posterior vaginal wall cpithelia are reflected for tract ~. This is preferred by many if the fistulous opening is <5 mm in diameter and lies away from ureteral orifices. At times, an abdominal approach may be necessary for women in whom fistula location prohibits effective surgical access or in whom prior vaginal repairs have failed. With any abdominal approach, omencum or peritoneum can be partially freed and interposed between the bladder and vagina in an attempt to prevent recurrence. One principle of fistula repair dictates that repair is performed in noninfected and noninB. If these guidelines arc followed, success rates are typically good and approximate 95 percent (Rovner, 2012). In the United States, most fistulas follow hysterectomy for benign causes, and their repair is associated with high cure rates. In contrast, fistulas associated with gynecologic cancer and radiation therapy may require adjunctive surgical procedures such as vascular or myocutaneous 6. These flaps provide supportive blood supply to defects that develop in poorly vascularized or fibrotic tissue. This is away from the ureters, which enter the bladder at the midlcngth of the vagina However, lateral fistulas raise concern for ureteral involvement or proximity. Whether surgery can be performed vaginally largely depends on the ability to adequately expose the fistula. However, a final decision on the repair route is sometimes made intraoperatively, when muscle relaxation from aneschesia allows bener assessment. Placing a pediatric Foley through the fistula and into the bladder may allow sufficient traction (Cardenas-Trowers, 2018; KiesermanShmokler, 2019). If it is identified, fistula repair is delayed approximately 6 weeks until resolution. However, fistulas recognized within the few days following hysterectomy may be repaired immediately and prior to the brisk inflammatory response associated with is placed in standard lithotomy position, and the vagina is surgically prepared. This is performed to delineate the location of the fistulous opening and assess its proximity to the ureceral orifices. Later, cystoscopy is repeated at different stages to document ureteral patency and assess bladder integrity. During inspection, if a tract is wide enough to accept a pediatric Foley catheter, the tube is threaded through the fistulous tract, and the balloon is inflated within the bladder. If a tract cannot be delineated in this manner, lacrimal duct probes, ureteral scents, or other suitable narrow dilators are used to trace the tract course and direction. Subsequently, attempts are made to dilate the tract and then place the pediatric catheter. Consent Fistulas may redevelop following repair, and patients are counseled that initial surgery may not be curative.

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Syndromes

• Oxygen therapy
• Pale skin
• Horseradish
• Cough that last longer than 10 days, or produces yellow-green or gray mucus
• Injury or trauma including sprains and strains
• Genitals appear well differentiated.
• Fever
• Fatigue
• Chest pain