Primary Gianturco stent placement for inferior vena cava abnormalities following liver transplantation.

PURPOSE: To determine the efficacy of primary Gianturco stent placement for patients with inferior vena caval (IVC) abnormalities following liver transplantation. MATERIALS AND METHODS: From August 1996 through March 1999, nine adult patients developed significant IVC abnormalities following liver transplantation. Patients were referred for vena cavography on the basis of abnormal clinical findings, laboratory values, liver biopsy results, Doppler findings, or a combination. Those patients demonstrating a significant caval or hepatic venous gradient were treated with primary Gianturco stent placement. Patients were followed clinically (nine patients), with duplex ultrasound (nine patients), vena cavography (four patients), and biopsy (seven patients). RESULTS: Original pressure gradients ranged from 3 to 14 mm Hg, with a mean of 9 mm Hg. Gradients were reduced to 3 mm Hg or less in all nine patients; presenting signs and symptoms either resolved or improved in eight of nine patients. The ninth patient required repeated transplantation 2 days later. A second patient died 433 days after stent placement of recurrent hepatitis C. Another initially improved following caval stent placement, but underwent repeated transplantation 7 days later due to hepatic necrosis from hepatic arterial thrombosis. Follow-up for the remaining six patients has averaged 491 days, with no clinical, venographic, or ultrasound evidence for recurrent caval stenosis. CONCLUSIONS: Intermediate term results suggest that primary Gianturco stent placement for IVC stenosis, compression, or torsion resulting after liver transplantation is safe and effective.

Bronchial artery embolization for the treatment of hemoptysis in patients with cystic fibrosis.

Hemoptysis is common in patients with cystic fibrosis (CF). Bleeding may vary in severity, ranging from minor blood-streaking of sputum to expectoration of significant quantities of blood. Major hemoptysis, defined as bleeding greater than 240 ml/24 h, represents a medical emergency. Bronchial artery embolization (BAE) is one of the treatment options for hemoptysis. We reviewed the 10-yr experience at the University of North Carolina Hospitals in the treatment of hemoptysis by BAE. Eighteen patients with CF were hospitalized on 29 occasions and underwent 36 BAE procedures for the control of hemoptysis. Most patients (n = 11) had very severe lung disease (FEV1 < 35%) with a high incidence (n = 9, 50%) of multi-drug-resistant bacteria. Fifteen patients (n = 33 procedures) were followed for a mean of approximately 22 mo after BAE. The overall efficacy of BAE for initial control of hemoptysis was 75% (n = 22) after one session, 89% (n = 26) after two sessions, and 93% (n = 27) after three sessions. The overall recurrence rate per episode was 46% (12/26 presentations in four patients) with a mean time for recurrence of approximately 12 mo. There was a high incidence (75%) of bleeding from nonbronchial systemic collateral vessels among patients (n = 7) who had undergone a previous BAE. There were two deaths associated with massive hemoptysis despite BAE. Three patients had transient neurologic deficits during BAE. We concluded that BAE is a relatively safe and effective means of treating significant hemoptysis in patients with CF.

Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts.

PURPOSE: Salvage of thrombosed prosthetic dialysis shunts can be performed using surgical or endovascular techniques. A prospective randomized trial was designed to compare the efficacy of these two methods in restoring dialysis access function. METHODS: One hundred fifteen patients with thrombosed dialysis shunts were randomized prospectively to surgical (n = 56) or endovascular (n = 59) therapy. In the surgical group, salvage was attempted with thrombectomy alone in 22% and with thrombectomy plus graft revision in 78%. In the endovascular group, graft function was restored with mechanical (82%) or thrombolytic (18%) graft thrombectomy followed by percutaneous angioplasty. RESULTS: Stenosis limited to the venous anastomotic area was the cause of shunt thrombosis in 55% of patients, and long-segment venous outflow stenosis or occlusion was the cause in 30%. In 83% of the surgical group and in 72% of the endovascular group, graft function was immediately restored (p = NS). The postoperative graft function rate was significantly better in the surgical group (p < 0.05). Thirty-six percent of grafts managed surgically remained functional at 6 months and 25% at 12 months. In the endovascular group, 11% were functional at 6 months and 9% by 12 months. Patients with long-segment venous outflow stenosis or occlusion had a significantly worse patency rate than those with venous anastomotic stenosis (p < 0.05). CONCLUSIONS: Neither surgical nor endovascular management resulted in long-term function for the majority of shunts after thrombosis. However, surgical management resulted in significantly longer primary patency in this patient population, supporting its use as the primary method of management in most patients in whom shunt thrombosis develops.

Proximal venous outflow obstruction in patients with upper extremity arteriovenous dialysis access.

To evaluate the impact of central venous obstruction on upper extremity hemodialysis access failure, we retrospectively analyzed our recent experience in managing this problem. We reviewed 158 upper extremity hemodialysis access procedures performed in 122 patients during a 1-year period. Fourteen (11.5%) patients had central vein obstruction as the cause of severe arm swelling, graft thrombosis, or graft malfunction. All 14 patients had had bilateral temporary subclavian vein dialysis catheters and failed upper extremity arteriovenous access. Seventeen lesions were treated in 14 patients including eight subclavian vein occlusions, six subclavian vein stenoses, two internal jugular vein stenoses, and one superior vena cava stenosis. Twenty-one procedures were performed including 17 percutaneous transluminal balloon angioplasties (PTAs) with stent placement in 13, two axillary to innominate vein bypasses, and two axillary to internal jugular vein bypasses. All patients had resolution of symptoms. Thirteen (76%) PTAs were initially successful but in four (24%) cases it was impossible to recanalize the vein. Eight (47%) PTAs provided functional hemodialysis access for 2 to 9 months, two (12%) restenosed at 3 and 10 months and were successfully redilated, two occluded at 2 and 4 months and were unable to be recanalized, and one failed immediately after a successful PTA. Four PTA failures were followed by venous bypass, which remained patent and provided functional access 7 to 13 months after surgery. Of nine stenotic venous lesions six (67%) were successfully dilated without restenosis, whereas of eight occluded veins only two (25%) were successfully treated without recurrence. Temporary central hemodialysis catheters produce a significant number of symptomatic central vein obstructions in patients with upper extremity arteriovenous access.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiologic placement of long-term central venous catheters: a review.

The need for long-term placement of catheters within the central venous system is continually expanding and follows the increasing use of hemodialysis, total parenteral nutrition, and long-term chemotherapy for neoplastic and infectious diseases. Whereas these catheters have traditionally been placed by surgeons in an operating room, it is now clear that they can be effectively placed by interventional radiologists using percutaneous techniques within an interventional/angiographic suite. This review is based on the radiologic percutaneous placement of nearly 1,500 central venous catheters including approximately 500 tunneled Hickman/Leonard catheters, 350 double-lumen cuffed dialysis catheters, and 150 chest wall subcutaneous ports.

Long term results of percutaneous catheter drainage of pancreatic pseudocysts.

Percutaneous catheter drainage (PCD) has become an established and often preferred alternative to surgical treatment in the management of pancreatic pseudocysts. However, the long term results of percutaneous drainage of pancreatic pseudocysts remain uncertain. In an effort to determine the long term outcome of this therapy, 42 patients undergoing PCD of a pancreatic pseudocyst were analyzed retrospectively. Forty-two pancreatic pseudocysts were drained percutaneously in 42 patients. Sixty-seven percutaneous drainage procedures were performed--22 patients underwent one, 15 had two and five patients required three procedures. Percutaneous drainage was considered not to be effective when the pseudocyst persisted or when it recurred after initial resolution. Twenty-three pseudocysts were infected at the time of drainage and 19 were not infected. In 30 patients, the cause of the pseudocyst was alcoholic pancreatitis. There were no deaths related to the procedures and seven complications occurred, including hemorrhage, pancreatic fistula and empyema. Mean follow-up evaluation time of the patients was ten months. In nine patients, the pseudocyst was successfully drained and resolved. There were 33 treatment failures, among which 26 pseudocysts failed to resolve and seven recurred after initial resolution. Eventually, 25 patients underwent a surgical procedure, 20 for persistent pseudocyst and five for recurrence. Using contingency table analysis, the size of the pseudocyst, amount of fluid drained, amylase concentration in the aspirate, presence of infection, number of drainage procedures performed and duration of catheter drainage had no influence on the likelihood of success in long term pseudocyst resolution after PCD. Pseudocysts not related to alcoholic pancreatitis seemed to be less likely (p < 0.05) to resolve with percutaneous drainage than those caused by alcohol. PCD is a safe and valuable procedure in the acute management of patients with pancreatic pseudocyst. However, the current data suggest that despite early success with percutaneous drainage, the lack of resolution and recurrence rate of pancreatic pseudocyst is high. Therefore, it should not be considered as the definitive form of therapy in most patients. Close surveillance of patients undergoing percutaneous drainage and communication between surgeons and radiologists are critical in the management of pancreatic pseudocysts.

Percutaneous translumbar and transhepatic inferior vena caval catheters for prolonged vascular access in children.

Central venous access for children with caval occlusion remains a major challenge to pediatric surgeons. Traditionally, children with superior and inferior vena cava (SVC, IVC) thrombosis have often required a thoracotomy to directly cannulate the azygos system or right atrium (RA). Recently, the possibility of placing tunneled RA catheters (RACs) by a percutaneous translumbar or transhepatic approach has become available. We report our experience of seven children with SVC and IVC obstruction who have received 11 transhepatic and 4 translumbar RACs from 1987 to 1991. All but one child was less than 2.5 years old and all were chronically dependent on parenteral nutrition. All catheters were placed in the angiography suite under general anesthesia using ultrasound guidance and Seldinger technique. This technique was successful in all seven children. Perioperative complications included accidental extubation in one patient and aspiration pneumonia in another. Mechanical complications requiring RAC replacement occurred 5 times in three infants (greater than 2,650 catheter days) and included catheter dislodgement (2) and thrombosis (3). In the patients with catheter thrombosis, the existing tract was successfully wired and the catheter exchanged on three occasions. Thrombolytic therapy was effective in restoring catheter patency on three other occassions. Nine episodes of catheter sepsis occurred in five children. Two late deaths occurred from infection. Of the five remaining children, four are dependent on total parenteral nutrition and have a translumbar or transhepatic catheter in situ and one child has adapted successfully to enteral feedings. Percutaneous translumbar or transhepatic IVC catheters provide excellent alternative routes for prolonged central venous access in those patients whose traditional vascular access sites are no longer available. Complications of the technique itself were minimal and although late catheter complications were not infrequent, they appear to be comparable to the standard approaches reported.

Chronic posttraumatic aortic pseudoaneurysm. Recognition before rupture.

Few patients survive transection of the aorta caused by blunt trauma. However, among those who do are a small number who go on to live with an unrecognized pseudoaneurysm that may rupture at any time. Because these aneurysms may be mistaken for more common disease processes, such as hilar adenopathy, atherosclerotic aneurysm, or neoplasia, the authors describe radiographic findings that suggest the correct diagnosis.

Percutaneous inferior vena cava placement of tunneled silastic catheters for prolonged vascular access in infants.

In infants and children requiring prolonged and multiple central venous catheterizations, conventional cannulation sites may become thrombosed or stenotic, making inability to gain vascular access a life-threatening problem. The technique we use for the percutaneous placement of inferior vena caval tunneled silastic catheters via the translumbar and transhepatic approaches is described. Three translumbar placements and one transhepatic placement in three children without immediate complications have been performed. We conclude that percutaneous inferior vena caval cannulation via the translumbar or transhepatic routes offers a viable alternative in these patients with difficult vascular access.

Cervical vessel injury after blunt trauma.

Blunt trauma accounts for 3% to 10% of cervical vessel injuries. Death and severe neurologic impairment have been reported in more than 80% of blunt carotid injuries. In our recent experience, 10 patients sustained 18 blunt cervical arterial injuries: two internal carotid artery (ICA) dissections, three ICA transections with pseudoaneurysm, five ICA thromboses, two vertebral artery dissections, one vertebral artery transection with pseudoaneurysm, one vertebral artery thrombosis, one minimal vertebral artery injury, and three caroticocavernous fistulas. A delay of more than 12 hours in making the diagnosis occurred in seven of the 10 patients. The mental status was initially normal in seven patients. The subsequent development of focal neurologic findings incongruent with CT scanning of the head prompted four-vessel angiography. Treatment was individualized and included supportive management, intravenous heparin, ligation, extracranial-intracranial bypass, and radiologic embolization. We have developed an angiographic classification that may aid management. Early angiography in patients with neurologic findings incongruent with head CT scan or in whom a normal sensorium and hemiparesis are present may permit improved outcomes. We advocate direct operative repair for accessible lesions of recent onset. For surgically inaccessible lesions, those with delayed presentation or in some cases with a fixed neurologic deficit, intravenous heparin can be started and follow-up angiography, head CT scanning, and the patient's clinical status determine further therapy.

Percutaneous abscess drainage in Crohn's disease.

The effect of 18 percutaneous abscess drainage procedures on the clinical management of 10 patients with Crohn's disease was evaluated. Two abscesses occurred immediately after surgery (two patients), five were in the liver (three patients), and 11 were the result of direct spread of disease from adjacent transmural bowel involvement (seven patients). Both postoperative and all five hepatic abscesses were treated successfully with percutaneous drainage. In two of the seven patients with abscesses secondary to transmural bowel disease, percutaneous drainage resulted in resolution of the abscess without the need for any further surgical intervention. The remaining five patients had subsequent elective intestinal surgery in which a single-stage surgical resection and primary reanastomosis were performed successfully. Two of these patients had abscesses recur at the same location, prompting a repeat percutaneous drainage before surgery. No enterocutaneous fistulas secondary to percutaneous drainage developed in any of the 10 patients. These results indicate that percutaneous abscess drainage can be a valuable technique for treating abscesses that result as a complication of Crohn's disease.

Nonoperative management of peripancreatic arterial aneurysms. A 10-year experience.

The surgical approach to bleeding visceral artery aneurysms has a mortality rate of 16-50% that is dependent primarily on anatomic location and underlying cause. Nineteen patients were studied over a 10-year period who were definitively treated by embolization. There was a 79% success rate and no mortality. The cause of the aneurysms was pancreatitis in 13 patients, trauma in four patients, subacute bacterial endocarditis in one patient, and secondary to biliary tract surgery in one patient.

Major gastrointestinal hemorrhage from peripancreatic blood vessels in pancreatitis. Treatment by embolotherapy.

Seven cases of gastrointestinal bleeding originating from peripancreatic blood vessels seen between 1977 and 1982 are presented. The bleeding originated either from true aneurysms, formed when the pancreatic inflammatory processes weaken the walls of peripancreatic blood vessels, from pseudoaneurysms which occurred after vascular leakage into pancreatic pseudocyst, or from veins. Gastrointestinal bleeding occurs when these entities rupture into gastrointestinal viscera. Hemorrhage of this nature must be considered in the clinical setting of patients who have a history of alcoholism, chronic relapsing pancreatitis, and known pseudocysts. Endoscopy, bleeding scans, and barium contrast studies are only occasionally helpful in diagnosis. Selective visceral angiography during acute hemorrhage is often diagnostic and concomitant arterial embolization techniques may offer a temporizing or permanent modality for hemostasis. This technique may be especially useful in the unstable, acutely ill patient with alcoholic hepatitis, sepsis, or an immature pseudocyst who poses a poor operative risk.

A fatal eosinophilic process in a Laotian refugee.

A 17-year-old Laotian refugee developed an ultimately fatal disease process characterized by formation of an abdominal eosinophilic mass, peripheral eosinophilia, and elevated serum IgE. No parasitic pathogens that could explain her disease were isolated during life or identified at autopsy. Furthermore, the disease was not consistent with previously described neoplastic, inflammatory, or idiopathic diseases. We believe this process represents a unique, aggressive variation of the hypereosinophilic syndrome, and that immunosuppressive therapy may be warranted.

Polyarteritis nodosa in hairy cell leukemia.

A patient with polyarteritis nodosa (PAN) developing after splenectomy and previously diagnosed hairy cell leukemia is presented. This rare association may provide an insight into the nature of PAN.

Drainage of hepatic, intraabdominal, and mediastinal abscesses guided by computerized axial tomography. Successful alternative to open drainage.

Opens surgical drainage of intraabdominal, intrahepatic, and mediastinal abscess is well established. Although this may be the procedure of choice when there are indications for treatment of concurrent intraabdominal and mediastinal surgical disease, with the advent of computerized axial tomography and ultrasonography we have identified a patient population best served by percutaneous catheter drainage. The procedure involves precise localization using ultrasound or CAT scanning, fine needle aspiration for confirmation of diagnosis, and injection of radiopaque contrast medium with fluoroscopic observation to localize the abscess. Catheter placement is usually achieved by a Seldinger technique, although a trochar-cannula method is occasionally required. Our experience with 4 patients, as well as review of the world literature provides a cumulative experience of 252 patients, has led us to believe that this approach is successful 83 percent of the time with a minimal incidence of complications. Percutaneous catheter drainage of intrahepatic, intraabdominal, and mediastinal abscess guided by computerized axial tomography is the treatment of choice in patients who do not have other indications for exploration.

The failed transhepatic cholangiogram.

A study of percutaneous transhepatic cholangiograms in 94 consecutive patients revealed that success is largely determined by the number of passes attempted. Two of 43 patients with dilated intrahepatic ducts had unsuccessful cholangiograms, but in these patients only two and three passes were attempted. In the remaining 41 patients fewer than seven passes were required. In patients with nondilated ducts, the success rate bears an almost linear relationship to the number of attempted passes beyond the fourth pass. Since patient tolerance often limits the number of passes, careful technique is important; one such technique is described. In the cholangiogram failures with nondilated ducts, subsequent liver biopsy had a high diagnostic yield.