Biomedical subjects
Publications and source records attributed to M J Sharafuddin.
The treatment of psychotic symptoms in patients with a previous history of neuroleptic malignant syndrome (NMS) remains a dilemma. The authors describe a case in which clozapine caused NMS in a schizophrenic man who had previously experienced NMS during treatment with various antipsychotics. To their knowledge, this is the first report of "classical" NMS caused by clozapine alone.
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Facet dislocation is a rare finding in the thoracic spine. This article presents three cases of bilateral locked facets in the thoracic region. Two were due to car accidents and the third was secondary to a vertical fall. The level of the injury was T2-T3 in two cases and T9-T10 in the third. Two patients were completely paraplegic on admission, whereas the third was neurologically intact. All patients had various associated injuries and fractures. The diagnosis of locked facets was not suspected in any of the cases, but was later made by computerized tomography with parasagittal reconstructions. All patients underwent surgery. The radiological diagnosis was confirmed intraoperatively in two cases. The facets were relocated by manual traction in one case and by Harrington distraction in the other. Fixation and fusion were performed in all three. Stability and vertebral alignment were achieved in all cases postoperatively.
The "arterial plug" is a resistant thrombus that frequently persists at the arterial anastomosis of clotted hemodialysis grafts following thrombolytic therapy. We studied the physical and morphological characteristics of the plug and determined the feasibility of transcatheter removal in vitro using the tulip compression thrombectomy system. Sixteen thrombus plugs were recovered during surgical thrombectomy of clotted human dialysis grafts. The physical and gross physical characteristics of all plugs were analyzed. Eight specimens were evaluated microscopically. Transcatheter compression thrombectomy of eight plugs was attempted in vitro. Each plug was embedded in a polyvinyl tube filled with newly clotted blood and connected to a flow circuit. First, balloon-assisted aspiration thrombectomy (BAT) of soft thrombus was performed, while sparing the distal-most segment containing the plug. The tulip sheath was then introduced facing the "arterial end" of the tube. The thrombus segment containing the plug was pulled back into the tulip mesh using either a 3 Fr Fogarty balloon catheter or a self-expanding rake. The tulip was closed to compress and remove the trapped plug. Near-complete thrombectomy of soft clot was achieved in all tested tubes. Compression and retrieval of the entire arterial plug was successful in all except one, where only partial compression of the plug occurred, presumably due to fibrotic changes. No fragmentation or embolization occurred in the remaining procedures. Spongy consistency was noted in 94% of the specimens. Microscopic evaluation showed organized layered thrombus with compaction in five plugs. Transcatheter removal of a thrombus plug is feasible in vitro using the tulip compression-thrombectomy system.
PURPOSE: To present experience with percutaneous balloon-assisted aspiration thrombectomy (BAT) for the treatment of patients with clotted hemodialysis access grafts. MATERIALS AND METHODS: BAT was performed with use of 7-F intravascular sheaths and a Fogarty balloon catheter. It was tested with an in vitro flow-circuit model. Twenty consecutive BAT procedures were performed in 15 patients with clotted grafts. The balloon catheter was advanced through the sheath to the arterial anastomosis. The balloon was inflated and withdrawn while suction was applied from the sideport to recover thrombus. The procedure was repeated for the venous limb. BAT was used alone in 12 procedures and in combination with urokinase in eight procedures. RESULTS: Almost complete thrombectomy was achieved in all tubes (in vitro), with very low venous and arterial embolic fractions. Technical success (restored graft thrill and almost complete thrombectomy) was achieved in 18 cases (90%). Clinical success (patency after 1 week of dialysis) was achieved in 17 cases (85%). CONCLUSION: Percutaneous BAT is feasible in recently clotted dialysis grafts.
PURPOSE: To evaluate the efficacy and recanalization rates of a newly designed vascular occlusion device. MATERIALS AND METHODS: The self-expanding vascular occluder was braided from fine nitinol wires and filled with polyester fibers. The device was delivered through a 6-F polyethylene introducing sheath with use of a delivery cable with a microscrew adaptor. Comparison was made between one occlusion plug and two Gianturco coils placed in the corresponding contralateral arterial segment in nine dogs and six pigs. The mean diameter of the targeted vessels was 4.8 mm +/- 0.8. Two animals were killed immediately after occlusion, and the remaining 13 animals underwent follow-up angiography at 1 week and/or 1 month, after which the animals were killed and the vessels were explanted for gross and histopathologic examination. RESULTS: Significantly shorter time-to-occlusion was achieved with the nitinol plug compared with two Gianturco coils (1.73 minutes +/- 1.28 vs 5.73 minutes +/- 6.18; P = .021). The recanalization rate at 1 month was also significantly lower (36.4% vs 81.8%, P = .027). The occlusion time was strongly dependent on the target artery diameter with Gianturco coils (R = .79, P = .0007), and not with the nitinol plug. CONCLUSION: The nitinol vascular occluder appears highly effective and reliable, with one plug resulting in significantly faster and longer lasting occlusions compared with two Gianturco coils. The new device can be repositioned prior to release, therefore allowing optimal positioning.
PURPOSE: A new self-expanding patent ductus arteriosus (PDA) occluder was designed. MATERIALS AND METHODS: Percutaneous closure of surgically created aortopulmonary shunts was attempted in 19 dogs. The occlusion device consisted of a nitinol wire frame tightly woven into a cylinder with a flat retention disc. A polyester-filled frame was used in the last six procedures. A 6-F introducing sheath was advanced across the aortopulmonary conduit into the descending thoracic aorta. The prosthesis (attached on a stiff delivery cable) was advanced through the introducing sheath. The retention disc was first released in the descending thoracic aorta, then the cylindrical device frame was expanded within the conduit by withdrawing the sheath. RESULTS: Subtotal misplacement into the descending aorta occurred in one procedure (overall technical success rate, 95%), and one animal died before the 1-week follow-up. Complete angiographic shunt closure was achieved in seven of 18 (39%) animals at 30 minutes, 12 of 17 (71%) animals at 1 week, 14 of 17 (82%) animals at 1 month, and 11 of 12 (92%) animals at 3 months. Significantly higher 30-minute closure rates occurred with polyester-filled occluders compared with nonfilled occluders (five of five [100%] vs one of 13 [15%]; P = .002). Persistent shunt at 3 months occurred in only one nonfilled device (6%). In the remaining 16 animals, both orifices of the shunt were covered by a smooth glistening neoendothelium at postmortem examination. CONCLUSION: This device combines the advantages of small delivery system, easy placement, self-centering, and repositionability. Immediate shunt closure can be reliably accomplished with the polyester-filled prosthesis.
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PURPOSE: A preclinical evaluation of the safety of the AngioJet-F105 rheolytic thrombectomy catheter. MATERIALS AND METHODS: The AngioJet-F105 catheter uses multiple retrograde high-speed fluid jets impinging on a primary aspiration lumen to create a hydrodynamic recirculation vortex that traps and fragments adjacent thrombus, with simultaneous evacuation of the resulting debris through the aspiration lumen. The effect of the AngioJet on treated vessels was evaluated in 10 canines. Vascular integrity on histopathologic examination and endothelial coverage on scanning electron microscopic study were examined in 15 vessel segments treated with the AngioJet-F105 catheter, compared with four vessel segments subjected to the Fogarty balloon maneuver, and 10 untreated vessel segments. The size distribution of particulate debris, upstream and downstream, after thrombectomy was determined in a flow-circuit model simulating the superficial femoral artery. Aliquots from the downstream effluent were then injected into the renal arteries of two healthy canines. RESULTS: The device caused only minimal focal endothelial denudation and no significant deep injury. No significant difference in endothelial coverage occurred in AngioJet-treated vessel segments compared to untreated control vessels (mean +/- standard deviation: 88.0% +/- 7.9% vs 89.7% +/- 11.6%, P = .77). Vessels treated with the Fogarty balloon pullback maneuver had significantly less residual endothelial coverage (58.0% +/- 8.0%, P < .03). Particulate microemboli in the effluent of the flow model accounted for 12% of the initial thrombus volume (0% > 100 microm, 99.83% < or = 10 microm). Histopathologic evaluation of the four renal beds injected with the resulting debris demonstrated no signs of necrosis. A moderate transient increase in plasma-free hemoglobin occurred, with a mild corresponding decrease in hematocrit. CONCLUSIONS: The AngioJet-F105 catheter resulted in only mild and focal injury to the treated vessels. The vast majority of resulting particulate debris consist of microscopic particles, without significant ischemic effect.
PURPOSE: To study the efficacy and delayed outcome of mechanical thrombectomy with the Amplatz thrombectomy device (ATD) in an experimental model of subacute inferior vena cava (IVC) thrombosis. MATERIALS AND METHODS: Mechanical thrombectomy was performed in 23 dogs with subacute infrarenal IVC thrombosis (6-15 days old). Heparin was administered during thrombectomy in all procedures (activated clotting time > or = 300 sec). Thirteen animals were killed immediately after thrombectomy, and the remaining 10 were allowed to survive for up to 1 month with no anticoagulation therapy. RESULTS: Venographic patency of the IVC was restored in all animals, although residual mural thrombus remained in nine dogs (< 20% narrowing in seven, 20%-30% narrowing in two). No histopathologic evidence of mechanical wall disruption attributed to mechanical thrombectomy was seen. However, foci of organizing residual thrombus with associated transmural phlebitic changes with round-cellular infiltration were present in all acute specimens, including those appearing clear at venography. Venography at 1 week or 1 month after thrombectomy showed IVC rethrombosis in eight dogs (80%) who were not receiving anticoagulants. During mechanical thrombectomy, a small increase in mean pulmonary artery pressure occurred, with a corresponding decrease in systemic arterial oxygen saturation. No acute emboli were noted on the post-thrombectomy pulmonary angiograms. However, histopathologic examination of acutely explanted lungs in 11 animals showed arteriolar microemboli (100-500 microm) in four. CONCLUSION: Mechanical thrombectomy with use of the ATD can effectively clear subacute IVC thrombus. However, rethrombosis is common and may be due to the high prevalence of phlebitis and residual thrombus. Anticoagulation may need to be continued after successful thrombectomy to prevent progression of residual thrombus and allow mural phlebitic changes to subside.
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