Risk factors for recurrent hemorrhage after successful mesenteric arterial embolization.

The objective of this study was to describe the risk factors and to determine the outcomes after recurrent gastrointestinal hemorrhage after successful mesenteric arterial embolization A retrospective analysis was undertaken of a single-center experience with mesenteric arterial embolization performed for gastrointestinal hemorrhage over a 5-year period. Statistical analyses including Student's t test and Fisher's exact test were used to compare results. For the years 2001 through 2005, 36 patients (10 women; average age, 60.8 years) underwent 37 technically successful mesenteric embolizations for acute gastrointestinal hemorrhage. Two (5.4%) cases required surgical intervention for cessation of hemorrhage, and six (16.2%) patients died during their hospitalization after technically successful embolization. Nine (24.3%) patients experienced in-hospital rehemorrhage, and of these, five (55.6%) died. Risk factors for rehemorrhage included intra-abdominal malignancy (P < 0.05), transfusion requirement greater than 10 units before angiography (P < 0.05), and the source of hemorrhage other than solitary gastroduodenal artery hemorrhage (P < 0.05). The failure of initial embolization was associated with an increased incidence of death (55.6% vs 5.0%; P < 0.05) and operative intervention to cease hemorrhage (P < 0.05). The failure of technically successful mesenteric embolization is not uncommon and is associated with identifiable risk factors. Risk factor awareness should assist in patient selection for and timing of mesenteric embolization.

TIPS versus peritoneovenous shunt in the treatment of medically intractable ascites: a prospective randomized trial.

OBJECTIVE: We undertook a prospective randomized clinical trial comparing TIPS to peritoneovenous (PV) shunts in the treatment of medically intractable ascites to establish relative efficacy and morbidity, and thereby superiority, between these shunts. METHODS: Thirty-two patients were prospectively randomized to undergo TIPS or peritoneovenous (Denver) shunts. All patients had failed medical therapy. RESULTS: After TIPS versus peritoneovenous shunts, median (mean +/- SD) duration of shunt patency was similar: 4.4 months (6 +/- 6.6 months) versus 4.0 months (5 +/- 4.6 months). Assisted shunt patency was longer after TIPS: 31.1 months (41 +/- 25.9 months) versus 13.1 months (19 +/- 17.3 months) (P < 0.01, Wilcoxon test). Ultimately, after TIPS 19% of patients had irreversible shunt occlusion versus 38% of patients after peritoneovenous shunts. Survival after TIPS was 28.7 months (41 +/- 28.7 months) versus 16.1 months (28 +/- 29.7 months) after peritoneovenous shunts. Control of ascites was achieved sooner after peritoneovenous shunts than after TIPS (73% vs. 46% after 1 month), but longer-term efficacy favored TIPS (eg, 85% vs. 40% at 3 years). CONCLUSION: TIPS and peritoneovenous shunts treat medically intractable ascites. Absence of ascites after either is uncommon. PV shunts control ascites sooner, although TIPS provides better long-term efficacy. After either shunt, numerous interventions are required to assist patency. Assisted shunt patency is better after TIPS. Treating medically refractory ascites with TIPS risks early shunt-related mortality for prospects of longer survival with ascites control. This study promotes the application of TIPS for medically intractable ascites if patients undergoing TIPS have prospects beyond short-term survival.

An evaluation of commonly employed central venous catheter kits and their potential risk for complications of excess guidewire introduction.

STUDY OBJECTIVE: To evaluate the components of commonly used central venous catheter kits with respect to the potential for guidewire-mediated complications during catheter placement.Prospective, nonrandomized, observational study. SETTING: Six academic hospitals across the United States. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 30 commercially manufactured catheter kits (15 tunneled, 15 nontunneled) were opened and evaluated. The catheter or sheath to be introduced was measured and a corresponding ideal guidewire length was calculated. The ideal length was then compared to the actual length, and differences were tabulated. Wire tip configuration and the presence and pattern of distance markings were recorded and, in conjunction with the catheter and wire length discrepancies, were used to grade the relative risk of introducing excess guidewire during catheter placement. Of 30 kits evaluated, 14 (46.7%) had guidewires more than 20 cm longer than necessary. The mean excess wire length was 15 cm (range: 8 to 55 cm) and did not differ significantly between tunneled and nontunneled catheter kits. Only 10 kits (33.3%) had distance markings of any type, and there was no standardization among them; none corresponded to previously published recommendations. There was potential risk of excess wire introduction in 18 catheter kits, of which seven were nontunneled devices designed for bedside placement. CONCLUSIONS: The design of commonly employed central venous access catheter kits is such that there is a mismatch between guidewire and catheter length and a general lack of guidewire markings. We believe that these designs may predispose to the introduction of excess guidewire and result in guidewire-mediated complications during catheter placement. This risk can likely be reduced by matching the guidewires to the devices placed over them and by standardizing guidewire distance markings.