Tension pneumothorax after placement of a tunneled pleural drainage catheter in a patient with recurrent malignant pleural effusions.

A case of tension pneumothorax developed after placement of a tunneled pleural catheter for treatment of malignant pleural effusion in a patient with advanced lung cancer. The catheter placement was carried out by an experienced operator under direct ultrasound guidance, and the patient showed immediate symptomatic improvement with acute decompensation occurring several hours later. Possible mechanisms for this serious complication of tunneled pleural catheter placement are described, and potential strategies to avoid or prevent it in future are discussed.

Computed tomographic venography is specific but not sensitive for diagnosis of acute lower-extremity deep venous thrombosis in patients with suspected pulmonary embolus.

PURPOSE: Duplex ultrasound scanning (US) is the accepted standard means of diagnosis for lower-extremity suprageniculate deep venous thrombosis (LE-DVT). Computed tomographic venography (CTV) has been proposed as an alternative modality for diagnosis of LE-DVT in patients with suspected pulmonary embolism (PE). This study compared CTV with US as a means of diagnosing acute LE-DVT. METHODS: A retrospective review of US and CTV scans from 136 patients with suspected PE who underwent both studies to exclude acute LE-DVT at a single institution was performed. Studies were reviewed and coded in a blinded manner. US was considered to be the reference test. Direct costs of each study were determined by using commercial software. RESULTS: The sensitivity and specificity rates of CTV were 71% and 93%, respectively. The positive predictive value, negative predictive value, and accuracy rates of CTV were 53%, 97%, and 90%, respectively. DVT localization was the same in eight of 10 cases in which the results of both US and CTV were positive. CTV costs and charges per study were greater than those of US by $46.88 and $602.00, respectively. CONCLUSION: CTV is specific, but has a lower sensitivity rate and positive predictive value for the diagnosis of acute LE-DVT compared with US. Additionally, CTV is more costly than US scanning. Because of the lower sensitivity rate and positive predictive value and the increased cost of CTV, US remains the screening study of choice in cases of suspected acute LE-DVT.

Diagnosis and endovascular treatment of iliocaval compression syndrome.

PURPOSE: The purpose of this study was to evaluate the clinical presentation, diagnosis, and endovascular treatment of iliocaval compression syndrome (ICS). PATIENTS AND METHODS: During a 3-year period, 18 patients (17 women, 1 man; mean age, 42 years) presented with clinical and imaging findings consistent with ICS. All patients were evaluated with venography and Doppler ultrasound (DUS), 13 of 18 with intravascular pressure measurements, 12 of 18 with intravascular ultrasound, 9 of 18 with air plethysmography (APG), and 4 of 18 with magnetic resonance venography. Seventeen patients were treated with endovascular stenting, one was treated with angioplasty alone, and six received adjunct thrombolysis. RESULTS: Despite the presence of stenosis or occlusion in all cases, APG indicated no iliac vein obstruction (outflow fraction > or = 40%) in nine patients. DUS revealed acute (6) or chronic (7) unilateral iliofemoral deep venous thrombosis in 13 of 18 patients, whereas the results of five of 18 DUS studies were normal. Recanalization and stent placement (n = 17) or angioplasty (n = 1) was achieved in all patients. The average pressure gradient was 5.6 mm Hg preprocedure and 0.6 mm Hg postprocedure. The primary patency rate demonstrated with DUS (n = 17) and venography (n = 7) at 6 months was 89%. The primary patency rate at 12 months was 79%. CONCLUSIONS: ICS often presents as sudden unilateral left lower extremity pain and swelling in young to middle-aged female patients after pregnancy, surgery, or a period of inactivity. Venography, intravascular ultrasound, and magnetic resonance venography demonstrate high sensitivity, whereas APG-outflow fraction demonstrates low sensitivity in the diagnosis of ICS. Endovascular stenting and angioplasty provide safe and effective early and intermediate-term treatment of symptomatic ICS.

Change in peripherally inserted central catheter tip position with abduction and adduction of the upper extremity.

PURPOSE: This study examines whether the tip of peripherally inserted central catheters (PICCs) moves significantly with changes in arm position from abduction to adduction. MATERIALS AND METHODS: The catheters were inserted in the brachial or basilic veins under ultrasonographic guidance with the upper extremity in a 90 degrees abducted position. A flexible, radiopaque ruler was then placed on the anterior chest and digital images were obtained with the arm abducted and adducted in a similar phase of quiet respiration. Catheter tip movement was measured with use of the radiopaque ruler and fixed, bony anatomic landmarks. RESULTS: Sixty-one consecutive PICCs were placed and evaluated during the study period (eight patients were excluded). Thirty-three catheters were placed from the right arm and 20 from the left. Overall, 43 moved caudally, seven moved cephalad, and three did not move with movement of the arm from abduction to adduction. Of those that moved caudal, the mean distance of movement was 21 mm (range, 2-53 mm). Right arm PICCs tended to move more than left arm PICCs, but this did not attain significance (P = .29). CONCLUSIONS: There is a tendency for the PICC tip to move in a caudal direction with the change in arm position from abduction to adduction; 58% of PICCs moved 20 mm or more. This change in position should be considered during final catheter tip positioning.

Three-dimensional gadolinium-enhanced MR angiography of vascular complications after liver transplantation.

OBJECTIVE: The goal of this study was to evaluate three-dimensional gadolinium-enhanced MR angiography as a tool for examination of liver transplant patients with potential vascular complications. MATERIALS AND METHODS: Thirty-eight consecutive three-dimensional gadolinium-enhanced MR angiograms were obtained in 34 patients. Results were retrospectively reviewed and correlated with conventional angiography in 20 of the 38 cases and sonography in 37 of the 38 cases. MR angiograms were evaluated for technical adequacy, vascular patency, and parenchymal abnormalities, and results were compared with angiography and sonography. Conventional angiography and surgery were used as gold standards when available. RESULTS: Thirty-four (90%) of 38 MR angiograms were technically adequate. Vascular abnormalities were identified in 20 patients, and 19 of these patients subsequently underwent angiography, surgery, or both. There were seven cases of hepatic artery thrombosis; all were detected with MR angiography with no false-positive or false-negative interpretations. Seven patients had moderate to severe hepatic artery stenosis (>50% narrowing as determined by conventional angiography). MR angiography revealed this stenosis in six of the seven patients, with one false-negative and three false-positive interpretations. Portal vein thrombosis was detected in three patients, and portal vein stenosis was detected in two patients. CONCLUSION: Three-dimensional gadolinium-enhanced MR angiography is useful in the examination of liver transplant patients and offers a noninvasive adjunct in patients with difficult or indeterminate sonographic examinations.

Importance of US findings in access planning during jugular vein hemodialysis catheter placements.

PURPOSE: To evaluate the significance of internal jugular vein ultrasound (US) findings in long-term hemodialysis patients and to assess how frequently these findings lead to a change in access approach. MATERIALS AND METHODS: One hundred consecutive hemodialysis catheter placements in 79 patients were retrospectively analyzed. Prior to catheter insertion, each patient underwent an US examination of the proposed access site by an interventional radiologist or interventional radiology fellow. The examinations were recorded on VHS tapes. The procedure notes, dictated radiology reports, and VHS tapes were reviewed for evidence of total occlusion, non-occlusive thrombus, presence of venous collaterals, stenosis, or variation in normal anatomy. The number of months that the patient required hemodialysis prior to catheter placement was also noted. RESULTS: Significant US findings were present in 28 patients (35%). Findings included total occlusion (n = 18), non-occlusive thrombus (n = 11), stenosis (n = 5), and anatomic variation (n = 1). These required a change in access approach in 21 patients. Unexpectedly, 54% of the patients with US findings had been undergoing dialysis for 12 months or less. CONCLUSION: These results underscore the importance of sonography in planning and performing vascular access procedures. A thorough US examination of the internal jugular veins is warranted prior to hemodialysis catheter placement, especially in patients with previous temporary or tunneled catheters. Three-quarters of patients with sonographic abnormalities required a change in access approach.

Primary stenting of the superior mesenteric artery for treatment of chronic mesenteric ischemia--a case report.

Percutaneous transluminal angioplasty (PTA) has been well described in the treatment of mesenteric artery stenoses but has met with limited success in ostial lesions. The authors describe a case of a 79-year-old woman diagnosed with chronic mesenteric ischemia associated with a 22-pound weight loss and postprandial pain. The celiac axis and inferior mesenteric artery were occluded. A high-grade, calcified stenosis was present in the proximal superior mesenteric artery. This was treated with primary stent placement using a Palmaz stent deployed from an axillary approach. A brief discussion of mesenteric ischemic and visceral artery PTA is included.

Clinical follow-up of patients after a negative digital subtraction pulmonary arteriogram in the evaluation of pulmonary embolism.

PURPOSE: This study was designed to examine the clinical course of patients following digital subtraction pulmonary arteriography (DSPA) interpreted as negative for pulmonary emboli (PE). MATERIALS AND METHODS: Sixty-three patients underwent DSPA interpreted as negative for PE over a 27-month period. Follow-up data were collected by means of medical and diagnostic radiology record review, interviews of referring physicians, and patient telephone interviews. RESULTS: Of 63 patients, two were excluded and seven were lost to follow-up, leaving a study population of 54 patients. Mean follow-up was 12.1 months (range, 0-28.5 months). Thirty-one reported no symptoms of PE. Of 13 patients reporting intermittent chest pain and/or dyspnea during their mean follow-up of 13.6 months, 10 had a history of cardiac, nonthrombotic pulmonary, or gastroesophageal reflux disease. There were no subsequent positive angiograms or ventilation/perfusion scans. Comorbid conditions in the 10 patients who died included cardiac events (n = 4), advanced cancer (n = 2), sepsis/pneumonia (n = 2), sarcoidosis (n = 1), and cerebrovascular accident (n = 1). No documented PE was identified. CONCLUSION: The technique of DSPA is sufficiently sensitive to exclude clinically significant PE. The advantages of image post-processing, in addition to the savings in cost, time, and contrast media, support its use in the angiographic diagnosis of PE.

Axillosubclavian vein thrombosis: case report.

Deep-vein thrombosis of the upper extremity, that is, axillosubclavian vein thrombosis, is a relatively rare and potentially overlooked diagnosis in the emergency department (ED). It can be the cause of significant morbidity and it may be life-threatening. Reported here is the case of a 23-year-old man who presented to the ED with left upper extremity pain and swelling. Venography confirmed the diagnosis of axillosubclavian vein thrombosis. Hospitalization and treatment with intravenous heparin led to a satisfactory recovery. The clinical presentation, predisposing factors, diagnosis, treatment, and complications of this rare entity are discussed.