Infectious complications of implantable venous access devices in patients with sickle cell disease.

PURPOSE: To evaluate the incidence of implantable venous access device infection in patients with sickle cell disease. MATERIALS AND METHODS: The authors performed a retrospective search of their hospital's information system from January 1, 1996 to December 31, 2001 to identify hospital admissions with ICD-9 codes related to sickle cell anemia. This search yielded 2703 admissions in 293 patients. A search of the radiology information system identified 23 of these patients who had placement of an implantable venous access device. Excluding two patients who were lost to follow-up, the population of this study included eight men and 13 women aged 23 to 62 years old (mean, 37 years). A total of 30 implantable venous access devices (25 venous ports, five tunneled catheters) were placed by interventional radiologists. Cases of device infection were identified based on clinical data, microbiology, reports of device removal, and clinical follow-up. Infections were defined according to the Centers for Disease Control criteria for catheter-related bloodstream infection. The incidence of infection, organism, and time from device placement to infection was determined. RESULTS: In 21 patients with 30 devices, 18 device infections (60%) occurred in 12 patients (57%) involving 15 venous ports and three tunneled catheters. There were a total of 12389 days of catheter use and a rate of 1.5 infections per 1000 catheter days. Infections occurred from 16 to 1542 days (mean, 349 days) after device placement. Blood, wound, and catheter tip cultures yielded solitary organisms in 13 cases and mixed organisms in four cases. Staphylococcus aureus was the most common pathogen (59%). One patient was considered infected based on clinical signs and purulent discharge from the port site, despite negative cultures after partial antibiotic treatment. One patient died of sepsis resulting from an infected port. CONCLUSION: This study shows a high incidence of infection associated with placement of implantable venous access devices in patients with sickle cell disease. Therefore, the authors avoid placing these devices in this patient population.

Complications of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure: a case-controlled study.

PURPOSE: To evaluate the incidence and types of complications encountered with use of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure in a retrospective case-controlled study. MATERIALS AND METHODS: The authors identified 100 consecutive patients, 15 men and 85 women 21-85 years of age (mean, 50 years), between December 2000 and July 2001 in whom the Closer percutaneous suture-mediated closure device was used during 65 uterine artery embolization (UAE) procedures, 11 hepatic chemoembolization procedures, nine diagnostic angiography procedures, seven peripheral vascular interventions, six visceral arterial interventions, and two thrombolysis procedures. An age-, sex-, and procedure-matched control population was identified in which manual compression was performed. Procedure reports and clinical charts were reviewed for the presence of puncture-site complications, as categorized according to Society of Interventional Radiology reporting standards, and for risk factors and comorbid conditions (hypertension, diabetes, stroke, smoking, and coronary artery disease). Follow-up visits and imaging studies were reviewed for patients with complications. RESULTS: In the Closer group, there were seven device failures, four minor complications, and three major complications. Minor complications included two groin hematomas and two cases of persistent pain at the arteriotomy site. Three major complications consisted of two cases of external iliac artery dissection, one with distal embolization, and one case of common femoral artery (CFA) occlusion and distal embolization. All major complications occurred in women undergoing UAE. One patient required thromboendarterectomy and patch angioplasty to repair the CFA occlusion, as well as amputation of a gangrenous toe. In the manual-compression group, there was one minor complication (a groin hematoma) and no major complications. There were significantly more complications in the Closer group than in the manual compression group (P =.02). CONCLUSIONS: Significantly more complications were associated with use of a percutaneous suture-mediated closure device than with manual compression for arteriotomy-site hemostasis. Major complications and associated morbidity may be seen with use of percutaneous suture-mediated closure devices. In particular, an unexpectedly high frequency of device-related complications was demonstrated in young women undergoing UAE.

Picture archiving and communication system: effect on reporting of incidental findings.

PURPOSE: To determine the effect of a picture archiving and communication system (PACS) on reporting of incidental findings outside the area of interest, with a focus on lumbar spinal magnetic resonance (MR) imaging. MATERIALS AND METHODS: Results of 2,500 lumbar spinal 1.5-T MR examinations were reviewed. These included 500 consecutive lumbar spinal MR reports for each of 5 years: 1 year prior to PACS introduction, 1 year during transition to PACS, and 3 consecutive years thereafter. Incidental findings cited in the reports were tabulated, and the frequency, organ system involved, and radiologist recommendations in each case were noted and compared, as were projected expenses based on the Medicare payment scale for recommended follow-up studies. Results of available follow-up studies were also reviewed. RESULTS: The number of incidental findings increased from 19 before PACS to 31 during transition and 53, 49, and 50 after PACS implementation, which resulted in a maximum increase of 179%. The increase was statistically significant during each post-PACS year. The most common incidental findings involved potential renal, pelvic, hepatic, pulmonary, and lymph node abnormalities. The total number of recommended follow-up studies increased from five before PACS to 15 during transition and 32, 22, and 18 after PACS implementation, with a maximum increase of as much as 540%. Recommended ultrasonographic studies increased the most from two in the pre-PACS year to 11 during transition and 27, 17, and 14 in the 3 post-PACS years. Follow-up expense increased by a mean of 146% after PACS implementation from 4,221 dollars per 1,000 studies in the pre-PACS year to 9,307 dollars, 13,426 dollars, 10,558 dollars, and 8,252 dollars thereafter. Of the 202 incidental findings, four represented occult malignancy, which is an expense of 5,721 dollars per diagnosis. CONCLUSION: The introduction of PACS into radiology practice for lumbar spinal MR imaging appears to be associated with an increased number of reported incidental findings and recommended follow-up studies.

Shoulder instability: accuracy of MR imaging performed after surgery in depicting recurrent injury--initial findings.

PURPOSE: To analyze a series of postoperative magnetic resonance (MR) images obtained in patients with recurrent signs or symptoms of instability in whom subsequent surgical correlation was performed to determine the accuracy in diagnosing recurrent injury. MATERIALS AND METHODS: The authors identified 24 patients who underwent MR imaging after shoulder instability surgery and had recurrent instability requiring repeat surgery. Twelve nonenhanced MR images and six indirect and six direct MR arthrograms were retrospectively reviewed with consensus to determine the presence or absence of recurrent labral or rotator cuff tear. Operative reports were reviewed to confirm the presence or absence of labral or rotator cuff tear. The mean interval between initial surgery and MR imaging was 10 months. The mean interval until repeat surgery was 2 months. RESULTS: Overall, the accuracy of postoperative MR imaging was 79% in depicting recurrent labral tear and 88% in depicting recurrent rotator cuff tear. Indirect MR arthrography had 100% accuracy for recurrent labral tear detection, whereas direct MR arthrography and nonenhanced MR imaging had accuracies of 67% and 75%, respectively. Direct MR arthrography was more sensitive, 100% versus 71%, but less specific, 60% versus 80%, than nonenhanced MR imaging in depicting recurrent labral tears. Direct MR arthrography had 100% accuracy in depicting rotator cuff tear, whereas both indirect MR arthrography and nonenhanced MR imaging had 83% accuracy. CONCLUSION: MR imaging, indirect MR arthrography in particular, appears to be an accurate means of evaluating the shoulder following instability surgery.