Incidence of important hemobilia following transhepatic biliary drainage: left-sided versus right-sided approaches.

Our purpose here is to describe our experience with important hemobilia following PTBD and to determine whether left-sided percutaneous transhepatic biliary drainage (PTBD) is associated with an increased incidence of important hemobilia compared to right-sided drainages. We reviewed 346 transhepatic biliary drainages over a four-year period and identified eight patients (2.3%) with important hemobilia requiring transcatheter embolization. The charts and radiographic files of these patients were reviewed. The side of the PTBD (left versus right), and the order of the biliary ductal branch entered (first, second, or third) were recorded. Of the 346 PTBDs, 269 were right-sided and 77 were left-sided. Of the eight cases of important hemobilia requiring transcatheter embolization, four followed right-sided and four followed left-sided PTBD, corresponding to a bleeding incidence of 1.5% (4/269) for right PTBD and 5.2% (4/77) for left PTBD. The higher incidence of hemobilia associated with left-sided PTBD approached, but did not reach the threshold of statistical significance (p = 0.077). In six of the eight patients requiring transcatheter embolization, first or second order biliary branches were accessed by catheter for PTBD. All patients with left-sided bleeding had first or proximal second order branches accessed by biliary drainage catheters. In conclusion, a higher incidence of hemobilia followed left-versus right-sided PTBD in this study, but the increased incidence did not reach statistical significance.

Endoleak after endovascular repair of abdominal aortic aneurysm.

PURPOSE: We sought to assess the role of endovascular techniques in the management of perigraft flow (endoleak) after endovascular repair of an abdominal aortic aneurysm. METHOD: We performed endovascular repair of abdominal aortic aneurysm in 114 patients, using a variety of Gianturco Z-stent-based prostheses. Results were evaluated with contrast-enhanced computed tomography (CT) at 3 days, 3 months, 6 months, 12 months, and every year after the operation. An endoleak that occurred 3 days after operation led to repeat CT scanning at 2 weeks, followed by angiography and attempted endovascular treatment. RESULTS: Endoleak was seen on the first postoperative CT scan in 21 (18%) patients and was still present at 2 weeks in 14 (12%). On the basis of angiographic localization of the inflow, the endoleak was pure type I in 3 cases, pure type II in 9, and mixed-pattern in 2. Of the 5 type I endoleaks, 3 were proximal and 2 were distal. All five resolved after endovascular implantation of additional stent-grafts, stents, and embolization coils. Although inferior mesenteric artery embolization was successful in 6 of 7 cases and lumbar embolization was successful in 4 of 7, only 1 of 11 primary type II endoleaks was shown to be resolved on CT scanning. There were no type III or type IV endoleaks (through the stent-graft). Endoleak was associated with aneurysm dilation two cases. In both cases, the aneurysm diameter stabilized after coil embolization of the inferior mesenteric artery. There were two secondary (delayed) endoleaks; one type I and one type II. The secondary type I endoleak and the associated aneurysm rupture were treated by use of an additional stent-graft. The secondary type II endoleak was not treated. CONCLUSIONS: Type I endoleaks represent a persistent risk of aneurysm rupture and should be treated promptly by endovascular means. Type II leaks are less dangerous and more difficult to treat, but coil embolization of feeding arteries may be warranted when leakage is associated with aneurysm enlargement.

Analysis of initial CT findings after endovascular repair of abdominal aortic aneurysm.

PURPOSE: To determine the spectrum and frequency of specific computed tomographic (CT) findings in the acute period after endovascular repair of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: CT images obtained 1--3 days after endograft placement were evaluated in 88 patients. The images were analyzed for stent position, appearance of endograft components, perigraft leak, and postoperative findings including air and acute thrombus within the aneurysm and air surrounding the femoral-femoral bypass graft. Findings that could be misinterpreted as perigraft leak were evaluated. RESULTS: Fifteen (17%) of 88 patients had perigraft leak in the acute postoperative period. The bare segment of the proximal self-expanding stent covered one or both renal arteries in 54 (61%) patients. One patient had CT evidence of renovascular compromise. Postoperative air was within the aneurysmal sac in 51 (58%) patients and surrounded the femoral-femoral bypass graft in 67 (94%) of 71 patients in whom the grafts were evaluated with CT. Mottled attenuation within the aneurysmal sac was seen in 50 (57%) patients. Forty-six (52%) patients had calcifications within longstanding thrombus. In 31 (35%) patients, findings that could have been misinterpreted as perigraft leak were identified. CONCLUSION: Accurate analysis of CT findings after endovascular AAA repair requires careful review of all available CT images (preprocedural and pre- and postcontrast) and clear understanding of specific stent-graft components and placement.

An endovascular system for thoracoabdominal aortic aneurysm repair.

PURPOSE: To describe a stent-graft system for endovascular repair of thoracoabdominal aortic aneurysm (TAAA) that preserves side branch perfusion. TECHNIQUE: The modular endograft system includes 3 components. The primary stent-graft is custom-made from conventional graft fabric and Gianturco Z-stents. Covered nitinol Smart Stents are used for the visceral and renal extensions, and the distal extension is made from a modified Zenith system. With the supine patient under general anesthesia, the components are delivered sequentially through surgically exposed femoral and right brachial arteries in an operation that requires prolonged periods of magnified high-resolution imaging. This system was first used in a 76-year-old man with a contained rupture of a supraceliac ulcer and a large abdominal aortic aneurysm ending proximally at the celiac artery. The endograft was implanted successfully, but the patient developed paraplegia on day 2; imaging documented an excluded aneurysm and excellent flow through the endograft and all prosthetic branches. DISCUSSION: Endovascular repair of TAAA appears to be feasible. If there are no serious, specific, unavoidable complications, the potential advantages are enormous.

Endovascular repair of a presumed aortoenteric fistula: late failure due to recurrent infection.

PURPOSE: To describe a case of presumed aortoduodenal fistula that was treated by endovascular implantation of a stent-graft. METHODS AND RESULTS: A 76-year-old man was transferred from another hospital where he had been treated for upper gastrointestinal hemorrhage over a 2-month period. Ten years previously, he had undergone aortobifemoral bypass, the right limb of which recently thrombosed. At the time of transfer, computed tomographic scanning showed a large false aneurysm between the aorta and the duodenum. Endoscopy disclosed mucosal erosions in the fourth portion of the duodenum. Following implantation of 2 overlapping stent-grafts, the bleeding ceased and the false aneurysm disappeared. At no time did the patient have a fever. The patient initially did well, but 8 months after treatment, he presented with fever and chills. Recurrent infection had caused erosion of the aorta so that a large portion of the stent-graft was visible from the duodenum. The infected graft and stent-grafts were removed in a two-part operation, from which the patient recovered satisfactorily. CONCLUSIONS: Endovascular stent-grafts may have a role to play in the management of aortoduodenal fistula, if only as a temporary measure to control bleeding.

Arteriographic detection of renovascular disease in potential renal donors: incidence and effect on donor surgery.

PURPOSE: To determine the arteriographic incidence and severity of renal arterial disease in potential renal donors and to evaluate the effect of identifying vascular abnormalities on subsequent donor surgery. MATERIALS AND METHODS: The records of 716 potential living renal donors who underwent conventional arteriography were reviewed. Abnormal arteriograms were reexamined to characterize vascular disease, and the effect of identifying renovascular disease on subsequent donor surgery was ascertained with chart review. RESULTS: Renovascular abnormalities were noted in the dictated reports in 78 patients (10.9%). The most common causes were fibromuscular dysplasia and atherosclerosis. The arteriograms of 64 patients were available for retrospective review. Abnormalities were characterized as minimal stenosis (<30% narrowing) in 42 patients and mild stenosis (30%-50% narrowing) in 19 of 61 patients with arteriographic abnormalities at retrospective review. In three patients, no significant abnormality was seen at retrospective review. The effect of detecting renovascular disease on donor selection was determined in 74 of the 78 patients. In 73 of these 74 patients (99%), detection of an abnormality directly affected donor surgery. CONCLUSION: In this population of potential renal donors, the arteriographic incidence of renovascular disease (10.9%) was higher than previously reported. Although renovascular abnormalities were mild, their detection influenced the plan for donor surgery in almost all patients.

Endovascular aneurysm repair in high-risk patients.

PURPOSE: The purpose of this study was to evaluate the role of endovascular aneurysm repair in high-risk patients. METHODS: The elective endovascular repair of infrarenal aortic aneurysm was performed in 116 high-risk patients with either custom-made or commercial stent grafts. The routine follow-up examination included contrast-enhanced computed tomography (CT) before discharge, at 3, 6, and 12 months, and annually thereafter. Patients with endoleak on the initial CT underwent re-evaluation at 2 weeks. Those patients with positive CT results at 2 weeks underwent endovascular treatment. RESULTS: Endovascular repair was considered feasible in 67% of the patients. The mean age was 75 years, and the mean aneurysm diameter was 6.3 cm. The American Society of Anesthesiologists grade was II in 3.4%, III in 65.5%, IV in 30.1%, and V in 0.9%. There were no conversions to open repair. Custom-made aortomonoiliac stent grafts were implanted in 77.6% of the cases, custom-made aortoaotic stent grafts in 11.2%, and commercial bifurcated stent grafts in 11.2%. The 30-day rates of mortality, major morbidity, and minor morbidity were 3.4%, 20.7%, and 12%, respectively, in the first 58 patients and 0%, 3.4%, and 3.4%, respectively, in the last 58. The late complications included five cases of stent graft kinking, two cases of femorofemoral graft occlusion, and three cases of proximal stent migration, one of which led to aneurysm rupture. At 2 weeks after repair, endoleak was present in 10.3% of the cases. All the type I (direct perigraft) endoleaks underwent successful endovascular treatment, whereas only one type II (collateral) endoleak responded to treatment. The technical success rate at 2 weeks was 86.2%, and the clinical success rate was 96.6%. The continuing success rate was 87.9%. Seventeen patients died late, unrelated deaths. CONCLUSION: Endovascular aneurysm repair is safe and effective in patients at high risk, for whom it may be the preferred method of treatment.

Tesio catheter: radiologically guided placement, mechanical performance, and adequacy of delivered dialysis.

PURPOSE: Tunneled catheters are an alternative means of vascular access for patients in need of hemodialysis who cannot undergo dialysis through a surgical shunt. This study was undertaken to evaluate the performance of the Tesio dialysis catheter. MATERIALS AND METHODS: A prospective study of the Tesio catheter was performed. Follow-up data regarding catheter function and adequacy of dialysis were obtained from nine hemodialysis facilities. RESULTS: Seventy-nine Tesio catheters were placed in 71 patients. Immediate technical success was 99% (78 of 79 catheters). The procedure complication rate was 9% (seven catheters). Only two complications required intervention: one fatal air embolism and one chest wall hematoma. Sixty-seven catheters in 60 patients were followed up for a total of 4,367 catheter days. Overall, catheter-related infection occurred in 9% (six of 67 catheters). Primary catheter patency was 87% at 1 week, 82% at 1 month, 72% at 3 months, and 66% at 6 months. Mean blood flow was 286 mL/min immediately after insertion, 301 mL/min at 3 months, and 306 mL/min at 6 months. Adequate dialysis dose as reflected by a urea reduction ratio of 60 or more or a urea kinetic modeling, or Kt/V, value of 1.2 or more was observed on at least one occasion for 74% and 76% of catheters, respectively. CONCLUSION: The Tesio catheter is a reasonable means of vascular access for patients who undergo dialysis but are not candidates for surgical shunt placement.

Aortomonoiliac endovascular grafting combined with femorofemoral bypass: an acceptable compromise or a preferred solution?

The relative merits of aortomonoiliac and bifurcated stent-graft configurations depend on the patient's arterial anatomy and clinical status. Aortomonoiliac stent-grafts are simple to make, simple to insert, and versatile. They are most useful when the iliac artery anatomy is severely distorted and the patient is old, sick, and inactive. The main problems with this approach are all consequences of femorofemoral bypass. The bifurcated stent-graft is the preferred alternative in healthy patients, because it ensures flow to both common iliac arteries, thereby eliminating the need for femorofemoral bypass. However, bifurcated stent-grafts and their delivery systems are difficult to make and difficult to deploy, especially when the iliac anatomy is distorted or emergency circumstances preclude preoperative sizing. This article addresses the advantages and disadvantages of the aortomonoiliac graft.

Talc pleurodesis through small-bore percutaneous tubes.

Pleurodesis using talc as the sclerosing agent is an effective procedure for preventing reaccumulation of malignant pleural effusions. Because of its thickness, the talc slurry is usually instilled through large bore (20-28 Fr), surgically placed thorocostomy tubes. However, these tubes often cause considerable patient discomfort. Herein we report a series of eight patients in whom the talc slurry was inserted through 10 and 12 Fr percutaneous chest tubes. Six of the eight patients (75%) had a successful pleurodesis without a reaccumulation of fluid. We conclude that this is an acceptable method for treating patients with malignant pleural effusions.

Transcatheter embolization for the treatment of misperfusion after hepatic artery chemoinfusion pump implantation.

BACKGROUND: The use of surgically implanted chemoinfusion pumps for the treatment of hepatic metastases from colorectal carcinoma can be complicated by intra- or extrahepatic misperfusion. This may result in suboptimal tumor exposure to the chemotherapeutic agent and injury to other gastrointestinal organs. Misperfusion can be managed by selective arterial transcatheter embolization. METHODS: Between 1989 and 1996, 16 patients with liver metastases from colorectal carcinoma and with hepatic artery chemoinfusion pump misperfusion were treated using transcatheter coil embolization. Six female and 10 male patients (age range, 34-84 years; median, 51.5 years) were identified by retrospective review of the records of the Department of Interventional Radiology. After pump placement, abnormal liver perfusion scan or methylene blue endoscopy study results prompted angiography with coil embolization. After embolization, the imaging studies were repeated and patients were monitored in the Oncology Clinic. RESULTS: Eight patients exhibited intrahepatic misperfusion (group 1) and eight extrahepatic misperfusion (group 2). Coil embolization was immediately successful in 100% of patients in group 1, with restoration of normal hepatic perfusion, and in 75% in group 2. There were no immediate procedure-related complications. Follow-up periods ranged from 1 to 23 months (median, 13.5 months). Embolization was unsuccessful for two patients (in group 2), who tolerated a modified chemotherapeutic regimen, with follow-up periods of 18.5 and 22 months. CONCLUSIONS: Transcatheter coil embolization is the therapy of choice for the management of hepatic artery chemoinfusion pump misperfusion. It is rapid, effective, and well tolerated by patients and obviates the need for additional surgical intervention.

Percutaneous biopsy of a posterior mediastinal mass through an extrapleural window created with dilute contrast.

Extrapleural administration of dilute contrast was used to facilitate biopsy of a posterior mediastinal mass.

Pulmonary function improves after expandable metal stent placement for benign airway obstruction.

STUDY OBJECTIVE: To determine whether expandable metal stent placement for benign airway lesions improves pulmonary function. DESIGN: Case series. SETTING: University medical center. PATIENTS: Nine patients who underwent balloon-mediated expandable metal stent deployment for airway obstruction due to benign etiologies. RESULTS: All nine patients had expandable stents deployed for benign airway lesions using fiberoptic bronchoscopy and fluoroscopic guidance. Pulmonary function improved after stent placement. The mean FVC increased by 388 mL (95% confidence interval [CI], 30 to 740 mL), the mean peak expiratory flow (PEF) increased by 1,288 mL (95% CI, 730 to 1,840 mL), the mean FEV1 increased by 550 mL (95% CI, 240 to 860 mL), and the mean forced expiratory flow between 25% and 50% of vital capacity (FEF25-75%) increased by 600 mL (95% CI, 110 to 1,090 mL). Corresponding relative measurements included increases in FVC (12%), PEF (95%), FEV1 (38%), and FEF25-75% (87%). The complete characterization of a benign airway obstruction generally required a multimodal approach. CONCLUSIONS: Expandable metal stent placement appears to be an effective therapy for benign airway obstruction.

Abdominal aortic aneurysm in high-risk patients: short- to intermediate-term results of endovascular repair.

PURPOSE: To assess the safety and efficacy of endovascular repair of abdominal aortic aneurysm in high-risk patients during the short to intermediate term. MATERIALS AND METHODS: Endovascular aneurysm repair was performed in 50 patients considered too high risk for conventional repair. Stent-grafts were inserted through surgically exposed femoral arteries with fluoroscopic guidance. The anesthetic technique was epidural in 36 patients, general in 12, and local in two. Aortouniiliac stent-grafts were inserted in 42 patients and aortoaortic in eight. RESULTS: There were no deaths and no conversions to open surgical repair. The primary success rate (complete aneurysm exclusion according to CT criteria) was 88% (44 of 50). The secondary, clinical, and continuing success rates were all 98% (49 of 50). Surgical time was 196 minutes +/- 67 (mean +/- SD), blood loss was 284 mL +/- 386, and volume of contrast material administered was 153 mL +/- 64. The time from the end of the surgery to resumption of a normal diet was 0.58 days +/- 0.56, to ambulation was 1.22 days +/- 0.77, and to discharge from the hospital was 3.63 days +/- 1.60. Wound problems accounted for the majority of complications. There were no instances of pulmonary failure, renal failure, stent-graft migration, or late leakage. CONCLUSION: Endovascular repair of abdominal aortic aneurysm is feasible in two-thirds of high-risk patients, with a low mortality and high success rate during the short to intermediate term.