Biomedical subjects
Publications and source records attributed to G B Lund.
Percutaneous transhepatic cholangiography and percutaneous biliary drainage are generally routine procedures in the majority of patients. However, when difficult clinical situations arise, advanced techniques for achieving biliary access may be required. Several advanced techniques for drainage are discussed.
PURPOSE: To evaluate the efficacy of percutaneous radiologic placement of peritoneal dialysis (PD) catheters. MATERIAL AND METHODS: Nineteen patients with end-stage renal disease were referred for percutaneous radiologic placement of a commercially available PD catheter. The patient group consisted of 11 men and eight women with a mean age of 58 years (range, 38-85 y). All procedures were performed on an outpatient basis with use of conscious sedation. Patients were followed up to determine technical success, complication rate, catheter survival (continuous patency without infection or mechanical dysfunction), and long-term outcome. RESULTS: The technical success rate for catheter placement was 95% (18 of 19). Complications included one (5%) failed attempt at catheter placement and one (5%) case of postplacement peritonitis. Mean and median catheter survival durations were 320 and 289 days, respectively (range, 33-823 d). A Kaplan-Meier survival analysis yielded 6-, 12-, and 24-month probabilities of catheter survival of 0.89 +/- 0.15, 0.81 +/- 0.20, and 0.81 +/- 0.20, respectively. Long-term outcomes included: continued PD, n = 9 (47%); death, n = 6 (32%; all related to comorbid disease); successful renal transplant, n = 2 (10.5%); and continued or resumed hemodialysis, n = 2 (10.5%). CONCLUSION: Percutaneous radiologic placement of PD catheters has a high technical success rate, low complication rate, and can be performed on an outpatient basis. Catheter survival is comparable to that achieved with surgical and percutaneous endoscopic methods of catheter placement.
PURPOSE: To determine rates and duration of patency achievable in forearm loop, upper arm straight, and brachial-internal jugular (IJ) vein hemodialysis grafts utilizing a combined percutaneous endovascular and surgical maintenance approach. MATERIALS AND METHODS: A retrospective analysis of 74 hemodialysis grafts (forearm loop, n = 22; upper arm straight, n = 34; and brachial-IJ vein, n = 18) in 50 patients with end-stage renal disease was conducted. Operative notes, interventional procedural reports, and hospital records were used to construct a history for each of these grafts from the time of surgical placement until the time the graft was abandoned for an alternative method of dialysis. All procedures performed to maintain and/or restore patency during the usable lifetime of the grafts were documented. RESULTS: Survival analysis using the Kaplan-Meier method demonstrated the following probabilities of primary patency at 6, 12, and 16 months, respectively: forearm loop graft = .46, .26, and .26; upper arm straight graft = .39, .22, and .16; and brachial-IJ vein graft = .19, .06, and .06 (forearm loop vs upper arm straight grafts, P > .05; forearm loop and upper arm straight vs brachial-IJ grafts, P < .001, P < .001, respectively). The probabilities of secondary patency at 12, 24, and 48 months, respectively, were: forearm loop graft = .89, .30, and NA; upper arm straight graft = .52, .35, and .17; and brachial-IJ vein graft = .54, .42, and .21 (P < .05 for all three comparisons: forearm loop > brachial-IJ > upper arm straight). Six percutaneous and two surgical procedures were compared and no significant differences in utilization were determined among the three graft types (ANOVA, P range, .38-.88). CONCLUSION: Kaplan-Meier analysis determined the probability of primary patency for forearm loop grafts to be similar to that for upper arm straight grafts, and both were significantly greater than for brachial-IJ vein grafts. The secondary patency rates for forearm loop grafts are greater than for upper arm and brachial-IJ vein grafts, while that for the brachial-IJ vein graft is greater than the upper arm straight graft. Utilization of interventional and surgical resources required to maintain patency do not significantly differ among the three types of upper extremity hemodialysis grafts.
PURPOSE: To evaluate a percutaneous thrombolytic device (PTD) designed for treating thrombosed hemodialysis access grafts. MATERIALS AND METHODS: To compare the PTD with pulse-spray pharmacomechanical thrombolysis (PSPMT) by using urokinase, 122 randomly chosen patients with synthetic, thrombosed hemodialysis access grafts from multiple centers prospectively underwent thrombolysis with the PTD (5-F, low-speed rotational mechanical device) or PSPMT. Major outcome variables included the procedure time, the immediate technical patency rate, the complication rate, and the 3-month patency rate. RESULTS: Sixty-four PTD and 58 PSPMT procedures were performed with intent to treat. The immediate technical patency rate was 95% (61 of 64 [PTD] and 55 of 58 [PSPMT]) in both procedures. Median procedure times were 75 minutes in the PTD group (range, 25-209 minutes) and 85 minutes in the PSPMT group (range, 50-273 minutes; P < .04). Major complications occurred in 8% (five of 64) of PTD procedures (none related to the PTD) and 9% (five of 58) PSPMT procedures (not significant). Two devices broke (one during training) with no clinical sequela. The 3-month primary patency rate was 39% (25 of 64) in the PTD group and 40% (23 of 58) in the PSPMT group (not significant). CONCLUSION: The PTD is safe and effective for treating thrombosed hemodialysis access grafts. The technical and long-term success rates are similar to those of PSPMT; procedure times are shorter.
OBJECTIVE: This study was designed to evaluate the total costs associated with repair of laparoscopic cholecystectomy (LC)-related bile duct injuries. SUMMARY BACKGROUND DATA: The popularity of LC with both patients and surgeons is such that this procedure now exceeds open cholecystectomy by a ratio of approximately 4 to 10:1. However, costs associated with LC-related injuries, particularly regarding treatment patterns, have up to now not been explored fully. METHODS: The complete hospital and interventional radiology (IR) billing records for 49 patients who have completed treatment for laparoscopic cholecystectomy-related bile duct injuries were divided into 8 categories. These records were totaled for comparison of costs between patient groups that experienced different injuries and treatment patterns. RESULTS: Patients with LC-related bile duct injuries were billed a mean of $51,411 for all care related to repair of their bile duct injury. Patients incurred an average of 32 days of inpatient hospitalization and 10 outpatient care days. Postoperative treatment included long-term chronic biliary intubation averaging 378 days. Two patients (4%) died as a result of their LC-related complications. Patients with bile duct injuries that were recognized immediately at the time of the initial surgery ultimately experienced a total cost for their repair and hospitalization of 43% to 83% less than for patients in whom recognition of the injury was delayed (p < 0.019 to 0.070). In addition, the total hospitalization and outpatient care days was reduced by as much as 76% with early recognition of an iatrogenic injury. CONCLUSIONS: Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.
PURPOSE: To compare the outcomes of hemodialysis catheters placed by interventional radiologists with those placed by surgeons. MATERIALS AND METHODS: The outcomes were retrospectively analyzed of 237 hemodialysis catheters placed in 140 patients by a radiology service from January 1991 through December 1992. Follow-up data were available for 222 catheters (94%). Catheter secondary patency and freedom from infection were analyzed statistically and by means of life-table analysis. RESULTS: Pneumothorax occurred after the placement of six catheters (2.5%); in two patients, a chest tube was required for decompression. Other short-term complications included air embolism with no clinical sequelae (two procedures) and prolonged oozing from the tunnel (two procedures). Long-term complications included infection and catheter failure. Infection occurred in 26 patients (18%) with 32 catheters (14%) and resulted in removal of 25 catheters. Ninety-three catheters (42%) failed, and 63 catheters (28%) were removed because of failure. CONCLUSION: Hemodialysis catheters placed by radiologists do not have a higher rate of complications or failure than catheters placed by surgeons.
The purpose of this study was to evaluate the percutaneous translumbar approach for long-term hemodialysis catheter access. Seventeen double-lumen hemodialysis catheters were placed percutaneously from the right flank to the inferior vena cava in 12 patients. Catheter placement was successful in all patients. Adequate flow rates were obtained. Seven episodes of thrombosis-related access failure occurred (0.33 episodes/100 days at risk). Two catheters were removed and five catheters were managed with urokinase infusion. Six episodes of infection occurred (0.28 episodes/100 days at risk). Four required catheter removal. Two catheters were removed after defects developed in the catheter. Five catheters were removed electively because catheter hemodialysis was discontinued. Four catheters remained in place. Cumulative patency was 52% at 6 months and 17% at 12 months. Translumbar inferior vena cava hemodialysis catheters represent a valuable alternative in cases in which traditional catheter sites have failed.
PURPOSE: To assess the safety and efficacy of redilation of central venous stents in a growing animal model. MATERIALS AND METHODS: Palmaz stents were placed in the inferior vena cava (IVC) in 18 newborn lambs. After 5 months, vena cavography was performed. Those animals in which growth of the IVC adjacent to the stent and/or neointimal hyperplasia had resulted in a stenosis were considered candidates for redilation. Repeat vena cavography, intravascular ultrasound, and histologic examination were performed at 2 or 6 months. RESULTS: A stenosis of > 20% was demonstrated in 13 animals. Redilation was performed, and a 50% mean increase in stent diameter was achieved. There were no immediate complications. Late complications included nonocclusive laminar clot (n = 2), and a bar of tissue dividing but not occluding the caval lumen (n = 1). Moderate neointimal hyperplasia occurred in all stents. Stent compression (unrelated to redilation) occurred in seven animals. CONCLUSION: Palmaz stents can be redilated safely and effectively in an animal model of growing central veins.
PURPOSE: To evaluate percutaneous declotting of dialysis access grafts with available catheters without urokinase. MATERIALS AND METHODS: Thirty-four clotted grafts were treated in 24 patients. Clot was macerated and pushed into the central circulation with balloon catheters. RESULTS: Successful mechanical declotting was performed in all but two patients (94%). The procedure was abandoned after successful declotting in four patients with poor venous outflow, resulting in a 24-hour success rate of 82%. Mean total procedure time was 116 minutes. Eight grafts clotted within 1 week. Using successful dialysis beyond 1 week as the measure of clinical success, the authors report a 59% clinical success rate with mean primary patency of 126 days (range, 16-322 days). Two complications, both emboli to the brachial artery, were successfully treated with urokinase. No symptomatic pulmonary emboli occurred. CONCLUSION: Mechanical thrombolysis of clotted grafts with currently available catheters yields results similar to those reported with mechanical devices and urokinase. The procedure is relatively inexpensive, safe, and well tolerated.
PURPOSE: To evaluate the risk of spinal cord revascularization and ascertain the relationship between preoperative spinal arteriography and the frequency of postoperative neurologic injury and overall morbidity and mortality in patients who require surgical repair of thoracoabdominal aortic aneurysms. MATERIALS AND METHODS: Fifty patients scheduled for surgical repair of a thoracoabdominal aortic aneurysm underwent spinal arteriography. All patients were divided into a positive spinal artery group (in which the spinal artery was identified) or negative spinal artery group (in which the spinal artery was not identified) and further divided based on extent of disease. RESULTS: The complication rate of spinal arteriography was 4.6%; no patient had a permanent neurologic injury. No significant difference existed between the positive and negative spinal artery groups in occurrence of neurologic injury (P = .88) or combined morbidity and mortality (P = 51). CONCLUSION: Patients who require spinal cord revascularization do not have greater frequency of neurologic injury or overall morbidity and mortality than those without this requirement. Spinal arteriography enables definitive spinal cord revascularization and thereby reduces the risk of neurologic injury.
Radiologic studies and interventional procedures were performed in a series of 13 patients with biliary complications following laparoscopic cholecystectomy, and the results were evaluated. Two categories of ductal complication--minor and major--were found. Minor complications (n = 6) included bile leaks and bilomas; these were managed with percutaneous techniques or simple surgical repair. Major complications (n = 8), consisting primarily of common hepatic duct injuries or strictures, were markedly resistant to percutaneous therapy, requiring major surgical repair (hepaticojejunostomy). Percutaneous treatment of recurrent strictures after primary repair was undertaken in three patients. Diagnostically, radionuclide imaging appeared most helpful in screening for biliary complications of laparoscopic cholecystectomy, supplemented by endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography for definitive diagnosis.
To investigate the potential role of magnetic resonance imaging and duplex scanning in the diagnosis of catheter-induced subclavian vein thrombosis, we correlated the results of 43 arm phlebograms with duplex scans; 28 of these phlebograms were also correlated with magnetic resonance imaging scans of the thoracic veins. Eighteen of the 43 phlebograms were normal, and all had normal magnetic resonance imaging and duplex studies. Eleven subclavian veins were totally occluded on phlebography; all had duplex scans, and five were also scanned with magnetic resonance imaging. Duplex scans detected 6 of 11 occlusions, whereas magnetic resonance imaging detected 4 of the 5 occlusions scanned. The five occlusions that were not detected by either magnetic resonance imaging or duplex scans were short segmental occlusions of the medial one third of the left subclavian vein. Of 14 nonocclusive thrombi seen on phlebography, duplex scans correctly identified 8. Magnetic resonance imaging was done on eight nonocclusive thrombi but identified only two. All abnormal findings on duplex scanning and magnetic resonance imaging were confirmed by phlebography. Short occlusions of the proximal portion of the left subclavian vein were often undetected by duplex scanning but occasionally seen with magnetic resonance imaging. Neither modality was sensitive to the presence of nonocclusive mural thrombi. Magnetic resonance imaging is highly reliable in ruling out the presence of a thrombotic process in the subclavian vein, but it may on occasion fail to detect the presence of subclavian thrombi. For this reason, in cases with suspected subclavian vein thrombosis magnetic resonance imaging cannot be used as the only diagnostic modality.(ABSTRACT TRUNCATED AT 250 WORDS)
Asymptomatic thrombosis of the subclavian vein is common after placement of indwelling catheters. The sequelae of these thrombi are not known. Investigation is hampered by the requirement for venography for diagnosis; consequently, a noninvasive method of diagnosis would be welcome in this context. We have studied prospectively 32 subclavian catheters to determine the usefulness of duplex ultrasound in diagnosing asymptomatic thrombosis. Sixteen arm venograms were normal and all gave normal duplex scans. No false-positive scans were obtained. Eleven venograms demonstrated nonocclusive mural thrombi. Only three of these were seen with duplex ultrasound. Five totally occlusive thrombi were seen on venography, of which only two were detected with duplex sonography. The three thrombi not found with duplex ultrasound were short proximal venous occlusions. The insensitivity of this technique to asymptomatic subclavian thrombi limits its usefulness as a screening tool.
Thrombosis is common after placement of silicone rubber subclavian vein catheters in patients with malignancy receiving conventional doses of chemotherapy. To determine the incidence of this complication in marrow transplant patients and the effect of different catheter designs on thrombosis rates, patients were randomized to receive either open-ended Hickman catheters or valve-ended Groshong catheters for venous access during the transplantation procedure. A total of 35 catheters were placed, of which 23 were double-lumen (11 Groshong and 12 Hickman) and 12 were single-lumen (six Groshong and six Hickman). Arm venograms were performed on all patients at the time of hematopoietic recovery or occurrence of symptoms of subclavian vein thrombosis. There were 10 cases of total subclavian vein thrombosis (three were symptomatic) and 12 cases of asymptomatic non-occlusive mural thrombi. Only 13 normal veins were found. There was no difference in thrombosis rate between the Hickman and Groshong catheters. Double lumen catheters tended to be more likely to cause total venous occlusion (nine of 23) than single lumen catheters (one of 12) (p = 0.06, Fisher's exact test). We conclude that subclavian vein thrombosis is a common occurrence after placement of silicone rubber catheters for venous access during marrow transplantation. Most cases are asymptomatic. Groshong catheters are just as likely to cause this complication as Hickman catheters.
Translumbar inferior vena cava catheters are a safe method of providing venous access for the collection of peripheral blood stem cells for transplantation. One of the most frequent and consistent problems with these catheters is thrombotic obstruction, occurring in one-fourth of the cases. Aspirin at a dose of 325 mg daily beginning after catheter placement and continuing until completion of stem cell collection has been associated with a reduction in the frequency of catheter thrombosis from 12/60 (20%) to 1/31 (3.2%) (p = 0.007) and an increase in the number of thrombus-free apheresis procedures (p = 0.024) compared to historical controls. No adverse effects of aspirin during stem cell collection have been noted. Daily aspirin ingestion should be considered in patients undergoing peripheral stem cell collection via translumbar inferior vena cava catheters.
Thrombotic obstruction frequently prohibits infusion through or withdrawal of blood from central venous catheters and can occur in conjunction with symptomatic thrombosis of the subclavian vein. Thirty catheters were radiographically proved to be obstructed by thrombus and had not responded to at least one instillation of 5000 units of urokinase. All catheters were treated with a 12-hour infusion of urokinase at the rate of 40,000 units/hour. The obstructing thrombus was either eliminated or reduced in size in all instances and full function was restored in all but one catheter. No bleeding complications were seen. Six patients with obstructed catheters also had symptoms of subclavian vein thrombosis. All patients with symptoms of subclavian vein obstruction became asymptomatic on anticoagulant therapy even though no attempt at dissolving the thrombus obstructing the subclavian vein was made. A 12-hour infusion of low doses of urokinase can safely salvage function of obstructed catheters that otherwise may require replacement. Patients with concomitant subclavian vein thrombosis become asymptomatic on anticoagulant therapy without need to dissolve the obstructing thrombus.
Most patients who need peripheral stem cell transplantation do not have peripheral venous access to allow apheresis for stem cell collection. Subclavian apheresis catheters have an unacceptably high incidence of thrombosis-related access failure. We have used a technique for translumbar insertion of permanent, subcutaneously tunnelled silicone rubber apheresis catheters into the inferior vena to place 58 catheters in 54 patients for stem cell collection. 37 catheters have been left in place for venous access during the transplantation procedures. These catheters had a very low rate of apheresis-related complications (3.6%). Access failure occurred due to thrombosis in 14 catheters (24%) and mechanical complications in 8 (14%) but these responded to standard therapy in all except 3 cases. Catheters functioned well as venous access devices during transplantation with only rare complications during this time. Withdrawal venograms at time of removal of 20 catheters showed a fibrin sheath in 17 cases but caval occlusion in none. There was no clinical or CT scan evidence of bleeding after placement or removal of the catheters. Percutaneously placed translumbar inferior vena cava apheresis catheters are an effective route for peripheral stem cell collection and can be left in place for venous access during transplantation.
Forty-six silicone rubber catheters were placed in the inferior vena cava (IVC) of 40 patients via a translumbar approach. No patient suffered retroperitoneal bleeding as determined by means of clinical observation (n = 46), computed tomography (CT) (n = 31), or autopsy (n = 5). Twenty-four catheters were removed after a mean of 51 (range, 2-137) days. No bleeding occurred after catheter removal, as determined by means of clinical observation (n = 24), CT (n = 13), or autopsy (n = 2). Nineteen catheters remained in place after a mean of 65 (range, 13-236) days. Thrombosis-related catheter dysfunction occurred in eight patients, two of whom developed IVC occlusion. Thrombolytic therapy restored catheter function and dissolved clots in all patients. Ten catheter malpositions resulted in venous access failure. Five of these catheters were replaced, four were repositioned, and one spontaneously resumed the original position. It is concluded that percutaneous placement of silicone rubber catheters in the IVC is a satisfactory alternative when catheter placement in the subclavian vein is not feasible.