Technical and patient-related characteristics associated with challenging retrieval of inferior vena cava filters.

OBJECTIVE: To identify patient-related and device-specific predictors of challenging and failed inferior vena cava (IVC) filter retrievals. METHODS: Retrospective single center review of consecutive retrievable IVC filters placed between 2004 and 2009. Retrieval was defined as challenging when it was unsuccessful owing to reported technical failure or when adjunctive endovascular maneuvers or access sites were recruited. Data regarding patient- and filter-specific information were collected. Logistic regression models were used to identify predictors of the reported outcomes. Statistical significance was set at p < .05. RESULTS: Four hundred and one patients underwent retrievable IVC filter placement-the majority indicated for prophylaxis (67%). Two hundred and fifty-nine retrievals were attempted and 237 filters were successfully retrieved (overall retrieval rate: 59.1%). Eleven out of 259 (4.2%) attempts were aborted owing to significant thrombus within the filter and 11 (4.2%) were technically unsuccessful. In 142 patients no attempt for filter retrieval was made-the major reason being physician oversight (44.3%). Thirty-eight out of 248 (15.3%) non-aborted filter retrievals were recorded as challenging. Failed retrievals were predicted by prolonged dwell time (96.9 ± 111.9 vs. 29.5 ± 25.1 days, odds ratio [OR] 1.034, 95% confidence interval [CI] 1.016-1.053, p < .001), therapeutic indication (OR 5.197, 95% CI 1.200-22.511, p = .028), and filter wall apposition (OR 11.857, 95% CI 2.069-67.968, p = .006). Challenging retrievals were predicted by dwell time (51.1 ± 69.8 vs. 29.1 ± 24.5 days, OR 1.017, 95% CI 1.005-1.029, p = .007), filter tilt (OR 2.607, 95% CI 1.045-6.508, p = .040) and filter wall apposition (OR 6.149, 95% CI 2.398-15.763, p = <.001). CONCLUSIONS: Physician oversight leads to poor IVC filter retrieval rates. Retrievals can be challenging or fail when the dwell time is >50 days and >90 days, respectively, and when the filter hook apposes the caval wall. Filter tilt increases retrieval difficulty but not failure rates.

Options in the management of varicose veins, 2008.

Modern management of varicose veins requires knowledge of the principal procedures currently utilized, which are compression sclerotherapy, foam sclerotherapy, endovenous laser therapy, radiofrequency closure, microincision phlebectomy, transilluminated powered phlebectomy, radiofrequency closure of perforating veins, perforation invagination stripping, subfascial endoscopic perforator surgery, saphenous valvuloplasty and external laser therapy. A review of the above procedures is presented with a brief description of their indications, performance and results.

Delivery of endothelial cells to balloon-dilated rabbit arteries with use of a local delivery catheter.

PURPOSE: Experiments were performed to determine if a local delivery catheter could deliver endothelial cells that would be retained on the luminal surface of balloon-dilated arteries. MATERIALS AND METHODS: Six New Zealand White rabbits underwent carotid catheterization, arteriography, and balloon angioplasty of an external iliac artery. A local delivery catheter (Dispatch) was then positioned at the site of angioplasty and the 3-mm balloon was inflated. Cultured rabbit endothelial cells (1.26 +/- 0.3 x 10(6) ), previously stained with fluorescent dye PKH26, were delivered to the artery in three infusions separated by 10 minutes. The delivery balloon was deflated and removed 25 minutes after the last delivery. The arteries were then perfusion-fixed in situ at physiologic pressure, removed, and divided into four segments, and the segments were rapidly frozen and cryosectioned. Eight sections from each arterial segment were examined by means of epifluorescence microscopy. The luminal surface of each artery was visually divided into eight sectors of equal length and each sector was assigned a score based on the degree of endothelial coverage (0 = no coverage, 1 = <50% coverage, 2 = >50% coverage). RESULTS: The endothelial coverage score for the six arteries averaged 0.40 +/- 0.46 (SD; range, 0.04-1.24). Areas of each artery receiving scores of 0, 1, and 2 averaged 68%, 25%, and 7%, respectively. Average coverage scores were 0.42, 0.38, 0.51, and 0.28 for individual segments along the length of the artery. CONCLUSIONS: The Dispatch local delivery catheter is able to deliver endothelial cells that adhere to balloon-dilated arteries. Although the magnitude of cellular retention was modest and varied among arteries, the retention along the length of each artery was constant.

The utility of sestamibi scanning in the operative management of patients with primary hyperparathyroidism.

BACKGROUND: The role of imaging studies before parathyroidectomy has been extensively debated and recent advances in unilateral parathyroidectomy intensify this controversy. The purpose of this study was to review the parathyroidectomy experience of a single surgeon, looking at the role of sestamibi scans and a standard postoperative care regimen. STUDY DESIGN: Retrospective review of office and hospital charts was completed on 90 patients with primary hyperparathyroidism who underwent parathyroidectomy from 1991 to 1998. Patient workup and outcomes were noted, as were results of preoperative imaging. True-positive scans visualized an abnormality ipsilateral to the adenoma found at operation. Statistics were performed using nonparametric testing and Student's t-test. RESULTS: There were 21 male and 69 female patients, with an average age of 54 years (range 29 to 81). There were zero mortalities, three morbidities (3.3%), and three patients who had persistent hypercalcemia, yielding a 96.7% success rate. Sixty-seven patients underwent preoperative sestamibi scanning, with a sensitivity of 74% and positive predictive value of 89%. Operative time in imaged patients averaged 103 +/- 49.9 minutes versus 121.5 +/- 85.9 minutes for patients without sestamibi scans. Operating time differences were not statistically significant and a preoperative sestamibi scan did not affect the success of parathyroidectomy. Discharge on postoperative day 1 was accomplished in 80% of patients and 13% were discharged the next day. There was no morbidity from hypocalcemia. CONCLUSIONS: A preoperative sestamibi scan does not improve efficacy or decrease operating time for primary hyperparathyroidism when bilateral neck exploration is performed. A postoperative care protocol including oral calcium and vitamin D supplementation allows the majority of patients to be discharged on postoperative day 1 with excellent results.

Long-term follow-up of reoperative carotid surgery.

BACKGROUND: We examined our long-term results of carotid reoperation to identify risk factors for morbidity and secondary recurrence. METHODS: Medical record review revealed 27 patients had reoperative surgery for recurrent stenosis. Demographics, operative details, pathology, clinical outcome, and follow-up imaging results were reviewed. RESULTS: No neurologic deficits and no mortalities were noted perioperatively. Long-term follow-up (average 54 months) revealed an 85% 5-year and 29% 10-year estimated survival. The 5- and 10-year estimated neurologic event rates were 15% and 35%, respectively. These included 3 ipsilateral strokes and 1 ipsilateral TIA; only the TIA involved secondary restenosis. Follow-up imaging revealed a 21% incidence of secondary restenosis, occurring more frequently in patients with hyperlipidemia (P < 0.05) and previous contralateral endarterectomy (P < 0.05). CONCLUSIONS: (1) Reoperation provides long-term protection from stroke due to recurrent stenosis. (2) Secondary restenosis rates appear higher than those for primary surgery. (3) Hyperlipidemia and contralateral endarterectomy are risk factors for secondary restenosis.

Lower extremity iatrogenic nerve injury due to compression during intraabdominal surgery.

BACKGROUND: latrogenic nerve injury due to poor positioning and external compression is a common surgical complication. However, sciatic neuropathy from external compression and femoral nerve injury after self-retaining retraction are less-published complications. METHODS: Surgical Morbidity and Mortality Reports from 1986 through 1995 were reviewed to identify femoral and sciatic neuropathies following intraabdominal vascular and general surgeries. RESULTS: Two sciatic and 5 femoral neuropathies were reported, an incidence of approximately 0.17% of abdominal cases. Sciatic injuries were attributed to external compression, whereas femoral neuropathies were due to compression by self-retaining retraction. The 3 female and 4 male patients had a mean age of 53.4 years, and no patient had a prior history of peripheral neuropathy. Mean operating time for sciatic injuries was 8.2 hours, versus 4.3 hours for femoral neuropathies. Both patients with sciatic neuropathy had complete resolution of symptoms, compared with 1 femoral neuropathy patient. Two femoral neuropathies were permanent, 1 had partial resolution and 1 had improvement at 4 months but was lost to follow-up. CONCLUSIONS: Sciatic and femoral compression neuropathies are rare but serious complications of abdominal surgery. When retracting in the deep pelvis, consideration should be given to using small, well-padded retractor blades and repositioning these regularly. Prevention of sciatic nerve compression requires careful padding of the table surface, especially for longer cases.