Value of superficial cultures for prediction of catheter-related bloodstream infection in long-term catheters: a prospective study.

Cultures taken from the skin and from the hubs of short-term central venous catheters can help us to predict catheter-related bloodstream infections (C-RBSIs). The value of these cultures for such predictions has not been assessed in long-term catheters. Our objective was to assess the value of superficial cultures for the prediction of C-RBSI among patients with long-term catheters. Over a 2-year period, we prospectively obtained cultures from the skin overlying reservoir ports (group A) and from the skin insertion site and hubs of all tunneled catheters (group B). This routine was performed by vascular and interventional radiologists immediately before catheter removal (irrespective of the reason for withdrawal). Swabs were processed semiquantitatively. Catheter tips from both groups were cultured using Maki's semiquantitative technique and sonication. We also performed cultures of the reservoir ports at different sites. C-RBSI was defined as the isolation of the same species of microorganism(s) both in the colonized catheter and in at least 1 peripheral blood culture. We included 372 catheters (group A, 223; group B, 149) during the study period. The catheter colonization rate was 23.4% (87/372), and 28 patients had C-RBSI. Validity index values for the capacity of surface cultures to predict C-RBSI in groups A and B were, respectively, as follows: sensitivity, 23.5% and 45.5%; specificity, 59.7% and 63.0%; positive predictive value, 4.6% and 8.9%; and negative predictive value, 90.4% and 93.5%. Superficial cultures of patients with long-term catheters could help us to rule out the catheter as the portal of entry of bloodstream infections. Superficial cultures (from skin and hubs) proved to be a useful conservative diagnostic tool for ruling out C-RBSI among patients with long-term tunneled catheters and totally implantable venous access ports.

Use of universal 16S rRNA gene PCR as a diagnostic tool for venous access port-related bloodstream infections.

Amplification of the universal 16S rRNA gene using PCR has improved the diagnostic yield of microbiological samples. However, no data have been reported on the reliability of this technique with venous access ports (VAPs). We assessed the utility of 16S rRNA PCR for the prediction of VAP-related bloodstream infection (VAP-RBSI). During a 2-year period, we prospectively received all VAPs removed by interventional radiologists. PCR and conventional cultures were performed using samples from the different VAP sites. We compared the results of PCR with those of conventional culture for patients with confirmed VAP-RBSI. We collected 219 VAPs from 219 patients. Conventional VAP culture revealed 15 episodes of VAP-RBSI. PCR revealed a further 4 episodes in patients undergoing antibiotic therapy which would have gone undetected using conventional culture. Moreover, it had a negative predictive value of 97.8% for the prediction of VAP-RBSI when it was performed using biofilm from the internal surface of the port. In conclusion, universal 16S rRNA PCR performed with samples from the inside of VAPs proved to be a useful tool for the diagnosis of VAP-RBSI. It increased detection of VAP-RBSI episodes by 21.1% in patients undergoing antibiotic therapy whose episodes would have gone undetected using conventional culture. Therefore, we propose a new application of 16S rRNA PCR as a useful tool for the diagnosis of VAP-RBSI in patients receiving antibiotic therapy.

How should long-term tunneled central venous catheters be managed in microbiology laboratories in order to provide an accurate diagnosis of colonization?

Guidelines recommend the roll-plate technique for short-term central venous catheter (CVC) tip cultures. However, the issue of whether the roll-plate technique is better than the sonication method for long-term CVCs remains unresolved. In addition, no data are available for predicting the value of direct Gram staining in anticipating catheter colonization or catheter-related bloodstream infection (CRBSI) in these long-term CVCs. Our objectives were to compare the roll-plate technique and the sonication method and to define the validity values of Gram staining for the prediction of colonization and CRBSI in patients with long-term tunneled CVCs. During the study period, all tunneled CVCs removed at our institution were prospectively and routinely sent to the microbiology laboratory for Gram staining (first) and tip culture (the Maki technique and sonication, in a random order). We received 149 tunneled CVCs, 39 (26.2%) of which were colonized and 11 (7.4%) of which were associated with CRBSI. Overall, the roll-plate method detected 94.9% of the colonized catheters, whereas sonication detected only 43.6% (P < 0.001). The validity values of Gram staining for the detection of colonization and CRBSI were as follows: a sensitivity of 35.9% to 60.0%, a specificity of 100% to 94.2%, a positive predictive value of 100% to 42.9%, and a negative predictive value of 81.5% to 97.0%. The roll-plate technique proved to be better than sonication for the detection of bacteria in long-term tunneled CVCs. Gram staining of the tips of tunneled CVCs can anticipate a positive culture and rule out CRBSI. In our opinion, direct Gram staining should be incorporated into routine microbiological assessments of long-term catheter tips.

Expanded PTFE-covered stent-grafts in the treatment of transjugular intrahepatic portosystemic shunt (TIPS) stenoses and occlusions.

BACKGROUND: We evaluated the efficacy of the VIATORR endoprosthesis for the management of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction. METHODS: Twelve consecutive patients (10 men and two women, mean age 52.7 years) with recurrent TIPS dysfunction underwent TIPS revision with use of the VIATORR endoprosthesis. Nine patients were asymptomatic and three patients had developed recurrent variceal bleeding. All patients had previous shunt revisions (mean 2.1 revisions per patient) with angioplasty or bare stents. Follow-up included clinical assessment, Doppler ultrasound, and portal venography. RESULTS: TIPS revision was successful in all patients, without complications. The mean portosystemic pressure gradient decreased from 16.8 +/- 2.7 mmHg to 6.5 +/- 2.6 mmHg. Hemostasis was achieved in all three patients who had recurrent variceal bleeding at the time of the procedure. Mean follow-up was 21.9 +/- 10.7 months. In two patients TIPS dysfunction occurred at 14 and 30 months after stent-graft placement, respectively. The primary patency rates were 100% after 12 months and 88.8% after 24 months. Two patients (16.6%) developed encephalopathy after stent graft placement. CONCLUSION: TIPS revision using the VIATORR endoprosthesis appears to be an effective and durable method to control shunt dysfunction.

[Interventional radiology, angioplasty and TIPS in Budd-Chiari syndrome]. / Procedimientos radiológicos intervencionistas, angioplastia y DPPI en el tratamiento del síndrome de Budd-Chiari.

INTRODUCTION: Budd-Chiari syndrome consists of complete or partial obstruction of the hepatic veins. Many treatment options are available; new interventional radiology techniques may play an important role as an alternative to surgical shunting. PATIENTS AND METHOD: Of 11 patients diagnosed with Budd-Chiari syndrome, 7 were treated with percutaneous balloon angioplasty or transjugular intrahepatic portosystemic shunt (TIPS) (2 and 5 patients, respectively). The efficacy of both techniques in the treatment of this syndrome was evaluated. RESULTS: Two patients presented significant isolated stenosis of a suprahepatic vein and underwent percutaneous balloon angioplasty. In both patients outcome was favorable with resolution of ascites. Five patients underwent TIPS and four showed clinical improvement with significant reduction in Child-Pugh score (p < 0.05) and resolution of ascites. No shunt malfunction was detected during follow-up. One patient showed no improvement after placement of TIPS and died soon after the procedure and a further two died from their underlying disease during follow-up. CONCLUSIONS: Treatment of Budd-Chiari syndrome requires multidisciplinary evaluation and should be individualized. In patients with Budd-Chiari syndrome uncontrolled by medical therapy, TIPS may become the decompressive method of choice as an alternative to surgical shunting. Liver transplantation may be reserved to patients in whom these techniques are ineffective.

[Percutaneous intrahepatic portosystemic shunting as a treatment for refractory hepatic hydrothorax]. / Derivación portosistémica percutánea intrahepática como tratamiento del hidrotórax hepático refractario.

Hepatic hydrothorax is an infrequent complication of portal hypertension in liver cirrhosis. Treatment with saline restriction and diuretics is usually effective but when this fails, the therapeutic approach is difficult and multiple complications occur. Transjugular percutaneous intrahepatic portosystemic shunt (IPS) is associated with a marked decrease in portal pressure and consequently this technique has been used in the treatment of refractory ascites. The aim of this study was to analyze the efficacy, safety and outcome of refractory hepatic hydrothorax treated by IPS. The procedure was performed in 5 patients who were all grade B or C in the Child-Pugh classification. Three patients showed complete response to the treatment, of whom 1 underwent transplantation 20 days later. The fourth patient showed partial response with a reduction in the need to perform thoracocentesis and the fifth patient showed no response to IPS and died after 17 days of follow-up. Albumin levels and Child classification remained unchanged. Two patients presented recurrence with reappearance of hydrothorax due to shunt dysfunction and 2 patients presented hepatic encephalopathy that responded to medical treatment. Refractory hepatic hydrothorax can be controlled by IPS in a large number of patients but its efficacy is restricted by shunt dysfunction, the risk of encephalopathy and by its limited effect on survival.

Hipertensión vasculorrenal y nefropatía isquémica secundaria a radioterapia / Radiation-induced renovascular hypertension

Se describe el caso de un paciente de 24 años de edad que desarrolló lesiones isquémicas en distintos órganos provocadas por la administración de radioterapia por un orquioblastoma en la infancia. Más de 20 años después de recibir irradiación con cobalto a altas dosis sobre la región abdominogenital presentó una pancreatitis crónica y una colangitis esclerosante, una nefropatía isquémica, con hipertensión arterial vasculorrenal secundaria a estenosis bilateral de arterias renales y un infarto isquémico del cono medular. De todas las lesiones, la que evolucionó más favorablemente fue la renal, ya que aunque la arteria renal derecha tenía una obstrucción prácticamente completa, la izquierda se consiguió dilatar mediante angioplastia transluminal percutánea, con buen resultado final y progresiva mejoría de la función renal. Sin embargo, fue necesario mantener la mayoría de los fármacos antihipertensivos, probablemente debido al efecto presor que seguía ejerciendo la arteria renal derecha ocluida. Tras más de dos años de seguimiento la función renal sigue siendo prácticamente normal y no existen datos de reestenosis de la arteria renal izquierda (AU)

Tratamiento endovascular de la patología de la aorta descendente: experiencia preliminar sobre cinco casos / Endovascular treatment of the descending thoracic aorta diseases: preliminary experience about five cases

Objetivo. Analizar nuestros resultados en el tratamiento endovascular de cinco casos con patología de la aorta torácica descendente. Pacientes y métodos. Hemos tratado mediante la colocación de endoprótesis recubierta a cinco pacientes varones, con una edad media de 63 años (54-72) y con diversa patología de la aorta torácica descendente. Las patologías fueron: dos aneurismas de aorta torácica descendente de 7 y 7,5 cm de diámetro, respectivamente, una fístula aortobronquial, una rotura traumática a nivel del itsmo y una disección aguda tipo B. Las endoprótesis implantadas fueron en cuatro tipo TalentÔ y una AneuRxÔ. Resultados. En todos los casos se consiguió el éxito técnico y clínico inmediato. Como complicación postoperatoria se presentó un caso de monoparesia radial no relacionada directamente con el procedimiento. La media de seguimiento ha sido de 11 meses (6-18). En todos los casos se realizó una TAC a los 3, 6 y 12 meses sin que se presentara ninguna complicación. Conclusión. La técnica endovascular ha resultado eficaz y segura para el tratamiento de las patologías de la aorta torácica descendente (AU)

Randomized controlled trial of aspiration needle versus automated biopsy device for transjugular liver biopsy.

PURPOSE: The efficacy and safety of transjugular liver biopsy used to obtain liver specimens in patients with coagulation disorders have been widely proven. However, histopathologic examination is not always possible because of fragmented samples provided by the aspiration technique. Recently, an automated device with a Tru-Cut-type needle was designed. In this randomized controlled trial, the use of this new device is compared with the traditional method in terms of efficacy and safety. METHOD: Fifty-six patients were included in the study; 28 were randomized to undergo the aspiration technique and 28 were randomized to undergo the automated biopsy technique. RESULTS: Correct positioning of the device was achieved in 93% of patients undergoing the aspiration technique and 96% of patients undergoing the automated biopsy technique (P = NS). Mean duration of the procedure and total number of passes were significantly higher in the aspiration needle group than in the automated device group (22.6 min +/- 12.6 vs 15.5 min +/- 9.4; P = .03, and 3.3 min +/- 1.9 vs 1.5 min +/- 0.63; P < .001, respectively). The number of portal tracts was significantly higher in the automated device group (4.7 +/- 2.5 vs. 2.7 +/- 3.4; P < .05). Adequate specimens for histopathologic evaluation were obtained in 26 patients in the automated device group and 24 patients in the aspiration needle group (92.8% vs 85.7%; P = NS), but a definite histopathologic diagnosis was more frequently obtained with the automated biopsy device (68% vs 43%; P = .05). No significant differences were observed in complication rates (7.14% vs. 10.7%; P = NS). CONCLUSION: The automated biopsy device for transjugular liver biopsy is more effective than an aspiration needle in obtaining good samples for a definite histologic diagnosis.

Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation.

PURPOSE: To determine the effectiveness and safety of metallic stents in the treatment of malignant colorectal obstruction before surgery and for palliation. MATERIALS AND METHODS: Eighty patients with acute malignant colorectal obstruction presumed to be malignant were treated by means of implanting self-expanding metallic stents. RESULTS: Stent placement was successful in 70 of the 80 patients and resolved bowel obstruction in 67 patients (96%). Two patients had colonic perforation and developed peritonitis 18 and 24 hours after stent placement; one patient died as a consequence. Thirty-three patients underwent elective surgery after 7 days +/- 3 (SD; range, 4-10 days), and adequate tumoral coverage and cleansing of the colon were observed in all patients. Stent placement was used as final palliative treatment in another 35 patients. Patient follow-up lasted a mean of 138 days +/- 93 (range, 36-334 days). The survival rate for the palliative group was 55% at 3 months, 44% at 6 months, and 25% at 9 months. The estimated primary stent patency rate was 91% at 3 and 6 months. CONCLUSION: Management of colorectal obstruction by using metallic stents was effective and safe, although colonic perforation is a potential complication. In cases of palliation, the method may obviate palliative colostomy.

[Prognostic factors for survival following transarterial chemoembolization in advanced hepatocellular carcinoma]. / Factores pronósticos de supervivencia del carcinoma hepatocelular avanzado tras quimioembolización transarterial.

The efficacy of transarterial chemoembolization in the palliative treatment of non-resectable hepatocellular carcinoma is controversial. To determine the possible existence of clinical and analytical variables with independent predictive value for survival related to the tumor and the treatment given, a multivariate analysis in a series of 111 patients who underwent transarterial chemoembolization was carried out. Overall actuarial survival was 54%, 31% and 24% at 1, 2 and 3 years respectively. Child-Pugh score (p < 0.05), tumor size (p < 0.05) and arterial occlusion after intraarterial chemotherapy (p < 0.05) reached independent predictive value. The group of patients in whom two or three of these factors were simultaneously present had a very poor prognosis with a survival of 20% and 0% at 1 and 2 years respectively, compared with 60%, 50% and 37% at 1, 2 and 3 years respectively in the group with one or none of these factors (p < 0.01). Grouping on the basis of these variables may be useful in the design of future controlled prospective studies that aim to determine the efficacy of transarterial chemoembolization.

[Percutaneous intrahepatic portosystemic shunting in the treatment of veno-occlusive disease of the liver after bone marrow transplantation]. / Tratamiento de la enfermedad venooclusiva hepática tras trasplante de médula ósea mediante derivación portosistémica percutánea intrahepática.

Veno-occlusive disease of the liver is a frequent cause of morbidity and mortality after bone-marrow transplantation. Its clinical manifestations are primarily related to the development of portal hypertension and sinusoidal congestion. The efficacy of the different therapeutic options used is controversial. We present a 22-year-old woman with veno-occlusive liver disease histologically confirmed after autologous bone-marrow transplantation, with progressive alteration in liver biochemistry and ascites. She was treated by percutaneous intrahepatic portosystemic shunting. After the procedure there was a marked improvement in ascites and an increase in diuresis with liver function progressively returning to normal. The safety and efficacy of this approach in the treatment of patients with veno-occlusive liver disease should be evaluated in controlled studies.

Unilateral breast enlargement secondary to right brachiocephalic vein occlusion.

We describe a 56-year-old woman who received dialysis through a right jugular catheter and developed a progressive right breast enlargement 1 year after arteriovenous graft shunt construction in the right forearm. Arm edema was not observed. A fistulography showed retrograde long thoracic and lateral thoracic veins flow secondary to a right brachiocephalic vein occlusion. Breast enlargement disappeared completely 2 weeks after a transfemoral balloon angioplasty and stent placement.

[Paratesticular rhabdomyosarcoma. Report of a case and review of the literature]. / Rabdomiosarcoma paratesticular. Aportación de un caso y revisión de la literatura.

Case report of an embryonary paratesticular rhabdomyosarcoma. The paper includes a literature review and discusses the current diagnostic, prognostic and therapeutic criteria analyzing in detail the current role of retroperitoneal lymphadenectomy and the value of adjuvant radiotherapy or chemotherapy.

Renal artery stenosis after kidney transplantation: diagnostic and therapeutic approach.

Transplant renal artery stenosis (TRAS) is a common complication after transplantation and an important cause of graft dysfunction. Many factors have been implicated as possible causes of TRAS, such as damage from trauma and atherosclerosis. We reviewed all 286 patients transplanted in our unit from January 1990 to July 1997 to study the prevalence, clinical features, and diagnostic and therapeutic approach. Thirteen patients with TRAS were identified, and their mean age was 40 +/- 15 years. The detected incidence was 4.5%. They were treated with triple therapy (prednisone, azathioprine and cyclosporine A). The mean age of the donors was 28 +/- 27 years. TRAS was diagnosed within nine months after transplant. All patients were studied with Doppler ultrasound, renography with captopril and angiography. The preferred initial therapy was percutaneous transluminal balloon renal angioplasty. Angioplasty was performed in four patients with good results. Two patients underwent surgery because angioplasty was not possible. Blood pressure control could be achieved with less antihypertensive medication after angioplasty. Transplantectomy was performed in one patient because of surgical complications. In conclusion, most patients with TRAS can be treated successfully with percutaneous transluminal angioplasty as the initial interventional treatment of choice for high-grade renal artery stenosis, and surgical revascularization is indicated when percutaneous transluminal angioplasty cannot be done or is unsuccessful.

Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings.

BACKGROUND & AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are increasingly being used, but the relationship between the hemodynamic effects of TIPS and the clinical events on follow-up remains undefined. Hence, we have investigated the hemodynamic correlations of portal hypertension-related events after a TIPS procedure. METHODS: Prospective follow-up of 122 cirrhotic patients who had a TIPS procedure performed because of variceal hemorrhage was conducted. RESULTS: The portacaval pressure gradient (PPG) significantly decreased after the TIPS procedure (from 19.7 +/- 4.6 to 8.6 +/- 2.7 mm Hg; P > 0.001), but increased thereafter and at rebleeding (n = 25) was > 12 mm Hg in all patients (18.4 +/- 4.6 mm Hg). Twenty-six patients developed ascites; the PPG (measured in 19) was always > 12 mm Hg. Increasing the PPG to > 12 mm Hg occurred very frequently (83% at 1 year). Within 1 year, 77% of patients underwent balloon angioplasty or restenting. However, 80% had again a PPG of > 12 mm Hg 1 year after reintervention. Hepatic encephalopathy developed in 31% of patients at 1 year; 21 of 23 patients had a PPG of < 12 mm Hg. CONCLUSIONS: Total protection from the risk of recurrent complications of portal hypertension after a TIPS procedure requires that the PPG be decreased and maintained < 12 mm Hg. However, reintervention will be required in most patients within 1 year and again the second year. On the other hand, such portal decompression is associated with an increased risk of hepatic encephalopathy.

Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding.

OBJECTIVE: Endoscopic sclerotherapy and pharmacological therapy are widely used in the treatment of acute variceal hemorrhage. However, they fail at arresting acute bleeding in 20-30% of bleeding episodes. The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of recurrent variceal bleeding has been proved recently, but the effectiveness and safety of urgent TIPS in the treatment of acute variceal bleeding refractory to conventional therapy are still under evaluation. METHODS: Over 4.5 yr, 358 variceal hemorrhage episodes were treated in our hospital. Pharmacological and endoscopic therapy failed to control hemorrhage in 93 episodes. Thirty-two patients died because of uncontrolled massive bleeding. In 56 patients, TIPS (Strecker stent) was performed after temporary control of the episode with balloon tamponade. RESULTS: Eleven of 56 patients with urgent TIPS belonged to Child-Pugh class A, 22 to class B, and 23 to class C. The mean time between indication and insertion was 17 +/- 10 h (range 4-24 h). Control of bleeding was achieved in 53 patients (95 %). Eight patients had recurrent bleeding at 1 month after TIPS, seven of them during the first week after the procedure. The 1-month actuarial probability of rebleeding was 22%. The main complications of the procedure were massive hemoperitoneum (n = 1), cardiorespiratory arrest (n = 2), cardiac failure (n = 1), acute renal failure (n = 2), and bacteremia (n = 7). Operative mortality (30 days) was 28%. The actuarial probability of survival at 30 days was significantly lower in Child-Pugh class C than in class A or B (48% vs 90%; p < 0.001). The presence of ascites, hepatic encephalopathy, and serum albumin level before TIPS were independent prognostic factors associated with the risk of operative mortality. CONCLUSIONS: Urgent TIPS is an effective alternative for the treatment of acute variceal bleeding refractory to endoscopic and pharmacological therapy, but sometimes is associated with major complications. Because of the high operative mortality rate in patients with severe liver failure, careful selection of patients is required before TIPS.