PURPOSE: To assess the efficacy and durability of percutaneous transluminal angioplasty (PTA)/stent placement for treatment of chronic mesenteric ischemia (CMI). MATERIALS AND METHODS: A retrospective review of patients treated from January 1986 to August 2003 was conducted. Twenty-nine patients (mean age, 62 years) were treated for clinical symptoms consistent with CMI. Clinical diagnosis was verified with angiographic assessment and PTA with or without stent placement was performed based on angiographic and/or pressure gradient findings. Outcomes were estimated with the Kaplan-Meier method. RESULTS: A total of 63 interventions were performed in 29 patients during the study period. Of these 63 interventions, 46 PTA and 17 stent implantation procedures were performed. Thirty-four interventions were performed for SMA stenosis/occlusion, 17 interventions for celiac artery stenosis/occlusion, and four interventions were performed on aorto-mesenteric graft stenoses. Technical success was 97%, and clinical success (defined as clinical resolution of symptoms) was 90% (26 of 29 patients). Mean duration of follow-up was 28.3 months. Primary patency for all interventions at 3, 6, and 12 months was 82.7% (95% CI: 68.7-96.7), 78.9% (66.7-91.1), and 70.1% (55.1-85.6), respectively. Primary assisted patency for all interventions at 3, 6, and 12 months was 87.9% (79.0-95.3), 87.9% (79.2-95.1), and 87.9% (77.3-98.3), respectively. An average of 1.9 interventions per patient was required. One major complication occurred (3.4%). There were three minor complications (10.3%). CONCLUSIONS: Percutaneous intervention for CMI is safe with durable early and midterm clinical success. However, repeated intervention is often required for improved primary assisted patency.

Adult↗

PubMed2005

Pain after percutaneous liver biopsy for diffuse hepatic disease: a randomized trial comparing subcostal and intercostal approaches.

PURPOSE: To compare pain levels as measured by visual analog scale (VAS) and analgesic requirement between intercostal and anterior subcostal ultrasound (US)-guided biopsy. MATERIALS AND METHODS: Seventy consecutive patients were randomized to undergo biopsy via an intercostal (n = 33) or subcostal (n = 37) approach. The groups were matched with regard to baseline characteristics: mean age, 44 years; age range, 20-70 years; sex, 43 male and 27 female; and indications of hepatitis C in 69%, hepatitis B in 16%, and others in 15%. The VAS score was obtained immediately after biopsy and hourly for 4 hours until the patients were discharged. Analgesic requirements and postprocedural complications were documented. RESULTS: No significant difference in VAS scores was seen between the groups. At hours 0, 1, 2, 3, and 4, the VAS scores (on a scale of 100) in the intercostal and subcostal groups were 10.3 +/- 16.7 versus 11.8 +/- 16.0 (P = .70), 19.1 +/- 24.0 versus 13.9 +/- 16.2 (P = .30), 11.5 +/- 14.8 versus 11.8 +/- 15.1 (P = .93), 6.2 +/- 8.9 versus 7.5 +/- 11.5 (P = .63), and 5.4 +/- 8.2 versus 4.7 +/- 8.5 (P = .72), respectively. The average VAS was less than 10. In the intercostal biopsy group, 36.4% of patients required additional analgesia after biopsy, compared with 27.0% in the subcostal biopsy group (P = .64). One patient in the intercostal group refused to have future follow-up biopsy even if it was clinically indicated, compared with no such patients in the subcostal biopsy group. No differences in diagnostic samples or major complications were seen in either group. CONCLUSION: US-guided percutaneous liver biopsy performed with fentanyl and midazolam premedication is a well-tolerated procedure with minimal patient discomfort. The location of the biopsy does not influence the outcome of the procedure.

Adult↗

PubMed2004

Primary stenting of bilateral radiation-induced external iliac stenoses.

Radiation-induced arteritis is a described rare complication of radiotherapy, particularly in patients with cancer. We report bilateral radiation-induced arteritis leading to stenoses in the external iliac arteries, which was treated with primary percutaneous arterial stenting, and review the current literature on the topic.

Adenocarcinoma↗

PubMed2004

Peripheral high-flow arteriovenous vascular malformations: a single-center experience.

PURPOSE: To assess the long-term outcomes of patients with high-flow arteriovenous malformations (HFAVMs) of the extremities. MATERIALS AND METHODS: A retrospective review was performed to identify patients with HFAVMs referred for possible intervention between 1988 and 2003. Sixteen patients with upper-limb HFAVMs and 15 patients with lower-limb HFAVMs were identified (18 men, 13 women; mean age, 36.8 years; range, 21.1-72.2 years). Arteriography, duplex imaging studies, or magnetic resonance imaging were performed in all patients. RESULTS: Follow-up was completed in 30 patients (mean duration, 3.3 years; range, 0.2-13 years), with one patient lost to follow-up. Nineteen had symptoms that warranted endovascular treatment: 13 underwent embolotherapy and six were considered unsuitable because of challenging anatomy that rendered embolization unsafe or impossible. Eleven patients' symptomatology did not warrant treatment and these patients were treated conservatively. The 13 patients treated with embolotherapy underwent a total of 27 treatment sessions (mean, 2.1 sessions per patient; range, 1-5). N-butyl cyanoacrylate and polyvinyl alcohol were used as the embolic agent in 11 and two patients, respectively. Three patients had complete resolution of HFAVM clinically and angiographically, and five patients' symptoms were controlled despite persistence of the HFAVM angiographically. Five patients had no improvement after treatment. Two major complications occurred (7.4% per session or 15.4% per patient): one patient developed a tibial plateau compression fracture and one patient had temporary L5 neuropathy after embolization of the pelvis and thigh. Of the six patients who were considered unsuitable for embolotherapy, one patient died of hepatocellular carcinoma, two had significant progression of symptoms, and the remaining three patients' symptomatology was unchanged. Only one of the nine patients with mild symptoms at presentation had symptom progression during follow-up. CONCLUSIONS: Peripheral HFAVM is a rare and therapeutically challenging condition. Patients with minimal symptoms at presentation do well with conservative treatment, and symptomatic progression is infrequent. Only patients with significant symptomatology should undergo embolization therapy, which invariably requires multiple sessions and must be aimed at eradication of the nidus.

Adult↗

PubMed2004

Retrieval of the Bard recovery filter from the superior vena cava.

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Adult↗

PubMed2004

Risk of intrauterine infectious complications after uterine artery embolization.

PURPOSE: To identify risk factors for the development of intrauterine infection following uterine artery embolization. MATERIALS AND METHODS: A retrospective review of uterine artery embolizations (UAE) performed for the treatment of symptomatic fibroids from January 2000 to July 2003 was conducted. With logistic regression and the Fisher exact test, multiple variables were analyzed as predictors for intrauterine infectious complications requiring medical and/or surgical therapy, including the use of preprocedural antibiotics, embolic agent used, quantity of embolic material, location of fibroids (submucosal, nonsubmucosal), and size and location of the dominant fibroid. RESULTS: A total of 414 UAE procedures were performed in 410 patients with a technical success rate of 99%. Average age of the patient cohort was 42.8 years (SD, 5.8 years). One hundred forty-eight patients (36.1%) had submucosal fibroids or fibroids projecting submucosally, 262 patients (63.9%) had nonsubmucosal fibroids. Intrauterine infectious complications requiring intravenous antibiotic therapy and/or surgery occurred in five patients (1.2%). A total of five infectious complications requiring therapy occurred in the submucosal group (3.4%) and none in the nonsubmucosal group. Patients within the submucosal group were more likely to develop intrauterine infectious complications than patients with nonsubmucosal fibroids based on univariate analysis (P = .006) but with logistic regression, the association was not significant (P = .079). No significant difference with embolic agent, quantity of embolic particles, use of preprocedure antibiotics, or size of or location of the dominant fibroid was found. CONCLUSION: No specific risk factor for intrauterine infection following UAE was identified in this study. Infection after UAE is rare and appears to be a sporadic occurrence. Nevertheless, close surveillance is warranted in all women following UAE given the potential morbidity of this complication.

Adult↗

PubMed2004

Transplant renal artery stenosis: outcome after percutaneous intervention.

PURPOSE: To assess the outcome of percutaneous transluminal angioplasty (PTA) and stent placement as the primary treatment for transplant renal artery stenosis (TRAS). MATERIALS AND METHODS: A retrospective review of PTA and stent placement procedures performed for TRAS from April 1997 to July 2003 was conducted. Reviewed parameters included technical success, date of transplantation, dates of percutaneous intervention, mean arterial blood pressure, number of blood pressure medications, and serum creatinine level before and after intervention. Twenty-one interventions were performed in 18 allografts. The primary clinical indication for imaging and treatment was increased creatinine level in 12 allografts and hypertension in six allografts. Patency rates were estimated with use of the Kaplan-Meier method. RESULTS: The technical success rate of PTA/stent placement was 100% and the clinical success rate was 94% (17 of 18 allografts). Thirteen interventions involved PTA alone, with eight combined PTA and stent insertions. The mean preintervention serum creatinine level among 12 allografts presenting with elevated creatinine levels was 2.8 mg/dL +/- 1.4 (SD), compared with a 1-month postintervention mean of 2.2 mg/dL +/- 0.7 (P = .03). Of six allografts that presented with hypertension, significant improvement was seen between the preintervention and 1-month postintervention mean systolic (174 mm Hg vs 135 mm Hg, P = .003) and diastolic (99 mm Hg vs 82 mm Hg, P = .02) pressures. These patients required a mean of 2.3 medications for blood pressure control before intervention, compared with a mean of 1.0 medications at 1 month after intervention (P = .002). Primary patency rates at 3, 6, and 12 months (+/-95% CI) were 94% +/- 6%, 72% +/- 12%, and 72% +/- 12%, respectively. Secondary patency rates at 3, 6, and 12 months (+/-95 CI) were 100%, 85% +/- 10%, and 85% +/- 10%, respectively. Mean follow-up time was 27 months. Of the eight allografts that underwent stent placement, all eight remained patent at last follow-up (mean, 18.3 months +/- 9.2). One major complication of a puncture site pseudoaneurysm occurred (5%). CONCLUSION: Primary treatment of TRAS with PTA with or without stent placement has good intermediate-term patency and is associated with significant early improvement in blood pressure and creatinine level.

Adult↗

PubMed2004

Dysfunctional autogenous hemodialysis fistulas: outcomes after angioplasty--are there clinical predictors of patency?

PURPOSE: To determine the primary and secondary patency rates for fistulas treated with angioplasty, as well as clinical predictors of fistula patency after angioplasty. MATERIALS AND METHODS: The authors reviewed their institutional experience with autogenous fistulas from June 1997 to June 2002. A total of 104 men and 36 women were treated. Mean age +/- standard deviation of patient cohort was 62.4 years +/- 15.6. Patient age and sex, age of fistula at initial intervention, presence of diabetes, side and location of fistula, location of stenosis, and number of venous stenoses dilated were examined. Patency after angioplasty was estimated by using the Kaplan-Meier method, and predictors of patency were examined by using a Cox proportional hazards model. RESULTS: One hundred fifty-one dysfunctional fistulas (94 radiocephalic and 57 brachiocephalic) were treated with angioplasty initially. Clinical success rate was 98.0% (297 of 303 interventions). At 3, 6, and 12 months, respectively, primary patency rates +/- standard errors of the estimate were 73% +/- 6, 51% +/- 7, and 39% +/- 7 for brachiocephalic fistulas and 85% +/- 4, 75% +/- 5, and 62% +/- 5 for radiocephalic fistulas; secondary patency rates were 96% +/- 2.4, 89% +/- 4, and 85% +/- 5 for brachiocephalic fistulas and 91% +/- 3, 88% +/- 3, and 86% +/- 4 for radiocephalic fistulas. For all time points, there was a significant difference in primary (P =.004) but not secondary (P =.45) patency between radiocephalic and brachiocephalic fistulas. Stenosis was most prevalent within 3 cm of the arteriovenous anastomosis in 74 (64%) of the 116 dysfunctional radiocephalic fistulas and at the cephalic arch in 22 (30%) of the 74 dysfunctional brachiocephalic fistulas. The clinical variables examined did not influence outcome. Complications occurred in seven (2.3%) of 303 interventions. CONCLUSION: Patency after angioplasty in dysfunctional autogenous hemodialysis fistulas exceeds that observed in hemodialysis grafts. None of the clinical or anatomic variables examined affected patency outcome.

Aged↗

PubMed2004

Rupture of a stenotic hepatic artery after liver transplantation: endovascular salvage using a covered stent.

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Angiography↗

PubMed2003

The Woggle technique for suture closure of hemodialysis access catheterization sites.

The Woggle technique is a modification of the purse-string suture technique, which is used to achieve hemostasis at hemodialysis catheterization sites. A tension collar (plastic guide wire introducer or similar device) is placed over the ends of a purse-string suture and secured with a suture lock (hemostat or stopcock) to tighten the suture without making a knot. The device is left in place for 20 to 60 minutes after the sheath is removed and then the woggle device is released and, if hemostasis is achieved, the suture is removed. This technique allows the patient to be discharged without a suture in place.

Adult↗

PubMed2003

Prevalence and treatment of cephalic arch stenosis in dysfunctional autogenous hemodialysis fistulas.

PURPOSE: Cephalic arch stenosis (CAS) is a recently recognized cause of dysfunction in autogenous hemodialysis fistulas. The prevalence of this lesion among dysfunctional autogenous fistulas is described, as are outcomes after percutaneous therapy. MATERIALS AND METHODS: A cohort of 177 dysfunctional autogenous fistulas treated over a 48-month period was retrospectively analyzed for the presence of CAS. Of these, 116 (66%) were radiocephalic fistulas and 61 (34%) were brachiocephalic fistulas. CAS was identified in 26 fistulas among 24 patients. Fifty dilations and three stent placements in the cephalic arch were performed. Surveillance was conducted after percutaneous therapy by means of ultrasound dilution technique and measurement of dialysis flow rates. Patency rates were estimated with use of the Kaplan-Meier method. No patients were lost to follow-up. RESULTS: The prevalence of CAS was 15% (26 of 177). There was a significant difference in the prevalence of CAS between brachiocephalic and radiocephalic fistulas (39% vs 2%; P <.001). High-pressure noncompliant balloon catheters were required in 29 of 50 dilations (58%) to efface the lesion. Primary patency rates (+/-SE) at 3, 6, and 12 months were 76% +/- 8, 42% +/- 10, and 23% +/- 9, respectively. Primary assisted patency rates (+/-SE) at 3, 6, and 12 months were 96% +/- 4, 83% +/- 8, and 75% +/- 10. Complications occurred in three cases (6%). A major complication with rupture of the cephalic arch resulted in thrombosis and fistula loss (n = 1); two minor complications of cephalic arch rupture were salvaged with placement of a Wallstent (n = 1) or prolonged balloon inflation (n = 1). CONCLUSIONS: CAS is common among failing brachiocephalic arteriovenous fistulas. With aggressive percutaneous intervention and surveillance, favorable primary assisted patency rates can be achieved.

Aged↗

PubMed2003

Efficacy of embolization in traumatic uterine vascular malformations.

PURPOSE: To evaluate the efficacy of embolotherapy in patients with bleeding traumatic uterine arteriovenous malformations (AVMs). MATERIALS AND METHODS: A retrospective review of all patients who underwent pelvic arterial embolization at our institution between July 1992 and September 2002 was performed. Fifteen patients were diagnosed with a uterine vascular malformation on duplex ultrasonography and correlative MR imaging. Serial beta-human chorionic gonadotropin levels were measured to exclude gestational trophoblastic neoplasia. All patients underwent transcatheter embolization of the uterine arteries. Embolizations were performed with use of standard 4-5-F catheters and microcatheters when necessary. Embolic agents in the 25 procedures included glue only (n = 13), polyvinyl alcohol (PVA) particles and glue (n = 4), PVA particles (n = 2), Gelfoam (n = 2), coils (n = 1), PVA particles and coils (n = 1), glue and Gelfoam (n = 1), and glue and coils (n = 1). PVA particle size ranged from 350 to 1,000 micro m. Outcomes assessed were cessation of bleeding, persistence or resolution of the AVM, complications, and pregnancy after embolization. These were assessed by chart, laboratory, and imaging reviews. RESULTS: A total of 25 embolization procedures were performed in 15 patients. Six patients required repeat embolization (one patient underwent embolization on six occasions; five patients had two embolization procedures each) for recurrence of bleeding. Sixteen procedures were performed on an elective basis and nine were performed on an emergent basis. The technical success rate of embolization was 100%. The clinical success rate was 93%: bleeding was controlled in 14 of 15 patients and one patient underwent a hysterectomy. Four of the 15 patients subsequently had a total of five uneventful intrauterine pregnancies carried to term. The 14 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 3-124 months) after treatment. Three patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred. CONCLUSION: Percutaneous embolotherapy is a safe and effective treatment for traumatic AVMs. This procedure allows for preservation of uterine function with the possibility of future pregnancy and should be considered as a primary treatment option.

Adult↗

PubMed2002

Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts: results of a multivariate analysis.

PURPOSE: To examine the prognostic utility of the serum bilirubin level before transjugular intrahepatic portosystemic shunt (TIPS) creation as an independent predictor of 30-day mortality in patients who underwent TIPS creation for treatment of variceal hemorrhage. MATERIALS AND METHODS: Multiple covariates from a cohort of 220 consecutive patients undergoing TIPS creation were analyzed with use of univariate and multivariate logistic regression. These included pre-TIPS total bilirubin levels, modified Child-Pugh class, APACHE II score, intubation status, etiology of liver disease, and acute versus elective shunting. RESULTS: The mean pre-TIPS serum total bilirubin level was 3.2 mg/dL (range, 0.4-40.3 mg/dL). The bilirubin level was <3 mg/dL in 102 patients, > or = 3.0 mg/dL in 58, > or = 4.0 mg/dL in 34, and > or = 5.0 mg/dL in 27. Each 1.0-mg/dL increase in total bilirubin was associated with 40% greater odds of 30-day mortality (odds ratio = 1.4; 95% CI = 1.2-1.7). Using each threshold as its own referent, bilirubin levels at or greater than 3.0, 4.0, and 5.0 mg/dL stratified patients into increased odds of early death by 5.7, 9.7, and 19.2 times, respectively (all P <.001). A pre-TIPS APACHE II score of >18 increased the odds of early death by a factor of 5.6 (95% CI = 2.4-8.7); modified Child-Pugh class C (vs classes A and B combined) alone increased the odds by a factor of 8.1 (95% CI = 3.6-18.1). Only one of 20 patients (5%) with a pre-TIPS bilirubin level >6.0 mg/dL survived more than 30 days after TIPS creation. In acutely bleeding patients (n = 122) undergoing TIPS creation, bilirubin levels > or = 3.0, > or = 4.0, and > or = 5.0 mg/dL stratified patients into odds ratios of 4.4, 7.1, and 9.8, respectively, compared with 7.1, 13.2, and 9.2 for patients undergoing elective TIPS creation. Combining endotracheal intubation (n = 72) and bilirubin strata yielded mortality odds of 8.3, 12.5, and 20.8 compared with odds of 2.3, 4.6, and 11.2 in nonintubated patients. Combining alcoholic cirrhosis (n = 129) with bilirubin levels yielded mortality odds of 8.0, 10.6, and 18.0 compared with other etiologies of liver disease (odds ratios = 2.9, 7.3, and 22.7). CONCLUSION: An elevated pre-TIPS bilirubin level is a powerful independent predictor of 30-day mortality after TIPS creation with a 40% increased risk of death for each 1-mg/dL increase above 3.0 mg/dL. The predictive value of this criterion is increased in patients who undergo TIPS procedures electively. The magnitude of the effect on mortality is similar to that of APACHE II scores and modified Child-Pugh class but is simpler to ascertain.

APACHE↗

PubMed2002

Procedural success and patency after percutaneous treatment of thrombosed autogenous arteriovenous dialysis fistulas.

PURPOSE: To retrospectively evaluate success and midterm patency after percutaneous thrombectomy, lytic therapy, and angioplasty for thrombosed autogenous arteriovenous dialysis fistulas. MATERIALS AND METHODS: From March 1996 to September 2001, 24 patients with 25 fistulas presented with 30 episodes of thrombosis of their autogenous fistulas, including 19 forearm radiocephalic fistulas in 18 patients and six upper arm brachiocephalic fistulas in six patients. Patients presented for percutaneous therapy within 48 hours of fistula thrombosis, with the exception of one patient who presented 7 days after thrombosis. Lytic therapy with urokinase or recombinant tissue plasminogen activator (rt-PA) was administered as a bolus into the fistula in 24 cases, with the exception of one case in which a 16-hour infusion of rt-PA was initiated. A mechanical thrombectomy device was used in a single case. Balloon thrombectomy was performed for residual clot. Angioplasty was performed at the arterial inflow, fistula, and outflow veins as required for identified areas of stenosis and/or maceration of thrombus. RESULTS: Clinical success was achieved in 73% of cases (22 of 30). All patients were followed for a maximum of 66 months (mean, 12 mo). Primary patency rates were 36% at 3 months (95% CI, 18%-54%), 28% at 6 months (95% CI, 12%-46%), and 24% at 1 year (95% CI, 10%-42%). The assisted primary patency rate was 40% (95% CI, 21%-58%) at 3 months and stabilized at 32% at 6 months (95% CI, 15%-50%). The secondary patency rate stabilized at 3 months at 44% (95% CI, 24%-62%) for 15 months. Patency rates after clot removal were not significantly different between upper and lower arm fistulas (P =.14). Total observation time of the cohort of 25 fistulas was 296 months. The complication rate was 7% (two of 30), with one major complication and one minor complication. CONCLUSION: Salvage of function after percutaneous clot removal from autogenous fistulas involves a steep learning curve initially and is possible with 3-month patency rates that approximate Kidney Disease Outcomes Quality Initiative recommendations for clot removal from polytetrafluoroethylene grafts.

Adult↗