Fluoroscopically-guided manipulation of malfunctioning peritoneal dialysis catheters.

OBJECTIVE: To review our experience with fluoroscopic evaluation and manipulation of malpositioned, malfunctioning, peritoneal dialysis (PD) catheters. MATERIALS AND METHODS: Thirty-one patients, over a 5-year period (1 May 1992 to 30 April 1997) with malfunctioning PD catheters, who had fluoroscopically-guided manipulation were reviewed. Catheters were manipulated using a malleable aluminum bar and, if necessary, guide wires or other stiffeners. Technical success was assessed on the basis of adequate, fluoroscopically verified, catheter placement at the time of the procedure and improved flows. A functional PD catheter at 30 days post manipulation was considered to be a clinically successful manipulation. RESULTS: There were 41 manipulations [33 initial (IM) and 8 remanipulations (RM)] for malpositioned or kinked catheters. In 31 (19 male, 12 female) patients ranging in age from 31 to 76 years (mean age 60 years), the initial technical success rate was 85% for IM (n = 28/33) and 63% (n = 5/8) for RM. The overall clinical success rate, or 30-day primary patency, was 55% for IM (n = 18/33) and 63% for RM. Catheter function (combined IM and RM) continued for a median 869 days (95% CI: 118, 1620). No early complications were noted. CONCLUSIONS: Fluoroscopic manipulation, including attempts at remanipulation, of PD catheters is a safe procedure. The technique is a simple, inexpensive, and effective way of prolonging PD catheter life, thereby reducing the number of surgical interventions.

Management of upper extremity central venous obstruction using interventional radiology.

Upper extremity central vein stenosis/occlusion is responsible for significant morbidity. The objective of this report is to review our management using interventional radiological techniques and to determine the long-term clinical results. All radiological interventions for central vein stenosis/occlusion (n = 59) between July 1991 and July 1996 at our institution were reviewed. The interventions consisted of thrombolytic therapy alone in 10 cases, PTA in 40 cases (combined with initial thrombolytic therapy in 6 cases), and deployment of a venous stent in 9 cases. At follow-up, the cumulative success (patency and relief of symptoms) was determined (Kaplan-Meier method). The involved vein was the subclavian, axillary, or innominate (SUB-AX-INN) in 45 cases and the superior vena cava (SVC) in 14 cases. The etiology was secondary to an indwelling foreign body (catheter, pacemaker lead) in 53 cases (90%), and spontaneous in only 6 cases (10%). The average follow-up after intervention was 17.2 months, with a cumulative success of 70 +/- 7.5% at 2 years, with rapid decline thereafter. Analysis of the failure quantiles revealed that 25% failed by 17 months, 50% failed by 26.6 months, and 75% failed by 33.8 months. There were no subgroup differences (log-rank test) for stenosis versus occlusion (p = 0.526), SUB-AX-INN versus SVC (p = 0.744), or if the intervention was begun < 5 days versus > or =5 days after symptom onset (p = 0.240), or whether or not a stent was deployed (p = 0.893). Interventional radiological techniques should be considered when symptoms from upper extremity central vein stenosis/occlusion are severe and disabling, or when veno-access or maintenance of patency of an ipsilateral arteriovenous (A-V) access is necessary. These results suggest an acceptable short-to medium-term solution.

Complications of radiologically placed central venous ports and Hickman catheters in patients with AIDS.

OBJECTIVE: To determine any differences in the complications following radiologic placement of 2 devices--Hickman catheters and central venous ports--to permit long-term central venous access in patients with AIDS. PATIENTS AND METHODS: Thirty-eight patients with AIDS received 52 long-term central venous access catheters. Seventeen received 23 Hickman catheters and 27 received 29 central venous ports (hence, 6 patients received both). Complications rates were determined retrospectively from clinical records and radiologic studies. RESULTS: The only acute complications were pneumothoraces--3 in the patients receiving Hickman catheters and 2 in the patients receiving central venous ports. Infections developed in 12 of the patients receiving Hickman catheters a median of 53 and a mean of 96 days after placement. Infection developed in 8 of the patients receiving central venous ports a median of 125 days and a mean of 184 days after placement. This difference was statistically significant (p < 0.001). The most common organism in these infections was Staphylococcus aureus. The only other nonacute complication was 1 nonocclusive thrombosis of the superior vena cava, which occurred in a patient with a Hickman catheter 240 days after placement and resolved once the catheter was removed. CONCLUSION: Central venous ports are preferred over Hickman catheters for long-term central venous access in patients with AIDS.

Image-guided insertion of the Uldall tunneled hemodialysis catheter: technical success and clinical follow-up.

PURPOSE: To evaluate the technical success, complication rates, and survival time of the Uldall double-lumen catheter placed by interventional radiologists in patients presenting to a hemodialysis clinic. MATERIALS AND METHODS: Patients eligible for this study included those with end-stage renal disease (ESRD) who had failed peripheral vascular access or who were awaiting access at a hemodialysis unit between June 1993 and March 1996. All catheters were placed under fluoroscopic and ultrasound guidance in the angiography suite. RESULTS: Attempts were made to insert 130 catheters into jugular veins in a consecutive series of 61 patients with ESRD. The accumulated catheter experience in this cohort was 15,380 days and the median survival time was 141 days (95% confidence interval [CI]; 116 days-166 days). One hundred twenty-one catheters (93%) were successfully inserted, mainly (94%) into the internal jugular vein. Excellent dialysis blood flow rate was obtained-on average 365 mL/min (95% CI; 350-379 mL/min). The overall infection rate, including exit site (n = 13), sepsis (n = 19), and clavicular osteomyelitis (n = 1), was 2.1 episodes per 1,000 catheter days. CONCLUSIONS: This catheter is recommended for acute and longer term hemodialysis for patients without peripheral vascular access. It can be inserted percutaneously, the same internal jugular vein can be used repeatedly with few complications and good blood flow, and the technique can be easily learned by any experienced angiographer.

Nonvascular stents.

Stents or endoprostheses have evolved since their introduction. Initially used only in the vascular system, the use of stents has expanded to use in the biliary, urinary, and gastrointestinal tracts and in the tracheo-bronchial tree. Current use of stents includes treatment of both benign and malignant conditions, with the greatest impact in the palliation of malignant strictures. The biomechanics and types of stents used in each region is reviewed. The indications, insertion techniques, results, and complications of stents in each of the aforementioned regions are also reviewed.

A prospective randomized clinical trial comparing two film-screen systems for chest radiography.

OBJECTIVE: To compare conventional and asymmetric film-screen chest radiography systems in a prospective, randomized trial. PATIENTS AND METHODS: Posteroanterior and lateral films were obtained with each system for one healthy volunteer and 49 consenting patients referred from pulmonary clinics and wards (for a total of 27 male and 23 female subjects ranging in age from 16 to 82 [mean 58] years). The radiographs, obtained and presented in random order, were reviewed and rated independently by two experienced radiologists and one resident in radiology; all observers were blinded to patient identification and film type. The Wilcoxon signed rank sum nonparametric test for paired samples was used to test for significant differences between the two film-screen systems. A second evaluation involving direct (blinded) comparison of the two types of films was then performed for each of the 25 patients in whom abnormality was noted during the first evaluation. RESULTS: For the posteroanterior radiographs, the asymmetric film-screen system was significantly better for assessing the trachea and mainstem bronchi, the descending thoracic-aortic edge, the left paraspinal line, the thoracic vertebral body interspace and the azygo-esophageal line (p < 0.05), whereas the conventional system had superior conspicuity in the lateral subpleural zones (p < 0.05). For the lateral radiographs, the asymmetric system was superior for assessing retrosternal lung markings (p < 0.05) but inferior for assessing fissures (p < 0.05). CONCLUSIONS: In general, the asymmetric system was superior for assessing mediastinal features and inferior for assessing the lateral subpleural zones in the posteroanterior radiographs. The asymmetric system was superior for assessing retrosternal lung markings and inferior for assessing fissures in the lateral radiographs. The results for the posteroanterior radiographs were consistent with the results of nonblinded studies reported elsewhere.

Clinical effects and maternal and fetal plasma concentrations of epidural ropivacaine versus bupivacaine for cesarean section.

BACKGROUND: Ropivacaine is a new amide local anesthetic structurally similar to bupivacaine and mepivacaine. Previous studies showed that ropivacaine has a similar clinical effect as bupivacaine with regard to sensory anesthesia and slightly less motor blockade than bupivacaine. Ropivacaine appears to be less cardiotoxic and arrhythmogenic than bupivacaine. The clinical and pharmacokinetic effects of 0.5% ropivacaine (5 mg/ml) versus 0.5% bupivacaine (5 mg/ml) when used epidurally for elective cesarean section were investigated. METHODS: Using a randomized, double-blind study design, 60 ASA physical status 1 or 2 term parturients presenting for elective cesarean section received either 0.5% bupivacaine (150 mg) or 0.5% ropivacaine (150 mg) epidurally in appropriate fractionated doses over a 10-min period. Onset, duration, and regression of sensory and motor blockade were noted until complete resolution was observed. Quality of intraoperative anesthesia and abdominal wall muscle relaxation were noted. Maternal plasma concentrations of local anesthetic were determined before anesthetic administration and 5, 10, 20, 30, and 60 min and 2, 3, 6, 8, 12, and 24 h after drug injection in 20 subjects. Umbilical cord blood was obtained at time of delivery for acid-base values and determination of the free and total plasma concentration of local anesthetic. Neonates also were examined for neurobehavioral assessments by Scanlon's and Neurologic and Adaptive Capacity Scores at 2 and 24 h after delivery. RESULTS: All patients received satisfactory anesthesia for operation. The onset, duration, and regression of sensory blockade were similar for both groups. Onset of degree 1 and 2 motor blockade was faster, and duration of degree 1 motor block was longer in the group receiving bupivacaine. Hemodynamic sequelae were similar between groups. All neonates had 5-min Apgar scores of 7 or greater and normal acid-base values and neurobehavioral assessments. Pharmacokinetic analysis showed that the Cmax was similar for both drugs (1.3 +/- 0.09 for ropivacaine and 1.1 +/- 0.09 micrograms/ml for bupivacaine). The T1/2 of the terminal decline in plasma concentration was shorter for ropivacaine versus bupivacaine (5.2 +/- 0.60 versus 10.9 +/- 1.08 h, respectively; P < 0.01). The free (i.e., unbound) concentrations of ropivacaine were approximately twice those of bupivacaine in both maternal and neonatal blood at the time of delivery. The ratio of umbilical vein to maternal vein concentration of unbound drug was 0.72 for ropivacaine and 0.69 for bupivacaine. CONCLUSIONS: Ropivacaine, 0.5%, epidurally provided satisfactory and similar sensory anesthesia compared to 0.5% bupivacaine for elective cesarean section. The Cmax was similar for both drugs, although the terminal half-life of ropivacaine was significantly shorter, and the blood concentrations of free ropivacaine were significantly greater than that for bupivacaine. These values were less than concentrations shown to be toxic in animals.

A questionnaire to evaluate disability in osteoporotic patients with vertebral compression fractures.

BACKGROUND: Few studies have reported on the functional disability due to vertebral compression factors in osteoporosis. The Osteoporosis Functional Disability Questionnaire (OFDQ) was developed to assess disability in patients with osteoporosis and back pain due to vertebral fractures. The domains of the OFDQ include: quantitative indices of pain, a standard 20-item depression scale, 26 items relating to functional abilities, a scale of social activities, and confidence in the ability of prescribed osteoporosis treatment to reverse disability. METHODS: Reliability of the OFDQ was assessed using test-retest and internal consistency methods. Criterion validity was demonstrated by correlating disability against radiographic evidence of vertebral fractures. Construct validity was demonstrated through comparisons of 81 patients with osteoporosis and fractures to 37 healthy age-matched controls. Additional evidence was found in comparing 45 of the 81 cases who were actively engaged in an exercise program with 36 cases who were sedentary. RESULTS: The test-retest reliabilities ranged from .76 to .93, with internal consistencies from .57 to .96. The OFDQ correlated significantly with relevant spinal pathology, and showed significant improvements in activities of daily living and socialization when active exercisers were compared to inactive patients with osteoporosis. CONCLUSIONS: The OFDQ is a reliable instrument which correlates well with objective measures of osteoporotic spinal damage. It is also sensitive to changes in disability brought about by participation in our aerobic exercise program. The OFDQ may be a useful adjunct to measuring outcomes in other osteoporotic treatment protocols.