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Biomedical subjects

R P Lieberman

Publications and source records attributed to R P Lieberman.

At least 19 recordsLinked to original sources
PubMed1992

Duplex scans before subclavian vein catheterization predict unsuccessful catheter placement.

Subclavian catheterization in patients with cancer is associated with up to a 38% incidence of subclavian vein thrombosis. These thrombi seldom recanalize. The persistent occlusion of the subclavian vein may hinder subsequent catheter placement. To determine the frequency of this occurrence and to determine if preoperative duplex scanning could identify these individuals, we performed preoperative duplex scanning in 22 patients who had previously had an indwelling subclavian catheter for chemotherapy. Subsequent subclavian vein catheterization was attempted without knowledge of the results of the duplex scan. Nineteen scans were normal. Of these, 18 patients underwent successful catheter placement. In one patient, catheterization was unsuccessful and an intraoperative venogram showed a focal obstruction of the proximal portion of the subclavian vein. Three scans showed noncompressibility of the vein, and catheter placement was unsuccessful in these three veins. In patients who have had previous subclavian catheters, persistent obstruction of the vein prevents subsequent catheter placement in 14%. Duplex scanning before subsequent catheter placement generally identifies these individuals.

Bone Marrow Transplantation↗
PubMed1992

Collection of blood mononuclear cells by leukapheresis for transplantation in a Yucatan miniature swine model.

A large animal model is needed to evaluate new apheresis technologies. These technologies include novel methods of harvesting the blood mononuclear cell population which contains the hematopoietic stem cells needed to restore hematopoiesis in recipients of hematopoietically lethal therapy and the use of cytokines to provide a safe and predictable method of manipulating these circulating hematopoietic stem cells. We describe the methods used to collect mononuclear cells by leukapheresis from Yucatan miniature swine. These animals are of sufficient size to tolerate the procedures and have many physiologic and hematologic similarities to man. They are of good temperament and are easily trained. Long-term venous access was obtained using single lumen silicone rubber catheters placed in the inferior vena cava. The animals were apheresed while fully awake using a Haemonetics Model V50 machine and a modified lymphocyte collection protocol. The procedure was highly efficient for the collection of mononuclear cells and a 10 pass procedure yielded a product which contained 19.7 x 10(9) mononuclear cells, 10.7 x 10(9) granulocytes, and 17 ml of erythrocytes in a volume of approximately 100 ml. This product can be cryopreserved and used for subsequent transplantation. The content of four apheresis procedures provides hematopoietic reconstitution of lethally irradiated swine on a time scale equivalent to transplantation of optimal numbers of bone marrow cells.

Animals↗
PubMed1992

Chronic catheterization of the inferior vena cava in Yucatan miniature swine.

Long-term venous access for leukapheresis, repeated blood sampling, and administration of drugs and fluids can be accomplished nonsurgically in Yucatan miniature swine. The catheter is placed under fluoroscopic guidance into the inferior vena cava using a needle and guidewire. This procedure has the advantage that it avoids a surgical incision, allows high flow rates, exists conveniently on the lower back, and can be replaced easily in the event of mechanical failure or thrombosis. Actuarial analysis of the duration of patency disclosed that of 41 catheters placed in 30 animals, the probability of function at 28, 42, and 54 days was 75%, 50%, and 25%, respectively. Eleven nonfunctioning catheters were replaced and nine of these continued to function until the completion of the experiment. No catheters were removed due to infection. Chronic catheterization of the inferior vena cava is a convenient method for long-term venous access in swine.

Animals↗
PubMed1991

Limitations of magnetic resonance imaging and ultrasound-directed (duplex) scanning in the diagnosis of subclavian vein thrombosis.

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)

Catheterization, Central Venous↗
PubMed1991

Utility of duplex ultrasound in the diagnosis of asymptomatic catheter-induced subclavian vein thrombosis.

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.

Blood Flow Velocity↗
PubMed1991

Thrombotic complications of silicone rubber catheters during autologous marrow and peripheral stem cell transplantation: prospective comparison of Hickman and Groshong catheters.

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.

Bone Marrow Transplantation↗
PubMed1991

Catheter-related thrombosis in patients with refractory lymphoma undergoing autologous stem cell transplantation.

Long-term indwelling central venous catheters have eased the administration of drugs, blood products, and hyperalimentation to patients with cancer. However, their use is associated with thrombotic complications. We report here on the thrombotic complications prospectively observed in 46 patients with refractory lymphoma (22 Hodgkin's disease, 24 non-Hodgkin's lymphoma) who had placement of one or more catheters in preparation for autologous stem cell transplantation (ASCT). Thrombosis of 26 catheters in 19 patients was observed. Specific abnormalities of hemostasis were equally common in patients who developed thrombosis and in those who did not. Thrombotic complications were more common in patients with Hodgkin's disease (13/22) than in patients with non-Hodgkin's lymphoma (6/24, p = 0.04). Although more patients with Hodgkin's disease had received prior splenectomy and/or irradiation to the area involved by thrombosis than patients with non-Hodgkin's lymphoma, the incidence of splenectomy and irradiation was similar for patients with Hodgkin's disease who developed thrombosis and those who did not. Therefore, although the etiology remains unexplained, patients with Hodgkin's disease undergoing intensive chemotherapy and ASCT appear to have a higher incidence of catheter-related thrombosis than patients with non-Hodgkin's lymphoma undergoing similar therapy.

Adult↗
PubMed1991

Successful liver transplantation in a patient with a thrombosed portomesenteric system after multiple failed shunts.

Combined portal and mesenteric vein thrombosis preventing restoration of adequate portal venous flow has been considered a contraindication to liver transplantation. We report a patient with failed splenorenal (SR), portocaval (PC), and mesocaval (MC) shunts, who despite the absence of any obvious means for supplying portal venous inflow to a hepatic graft, successfully underwent orthotopic liver transplantation. A method of reconstruction of the portal vein with the use of vein grafts anastomosed to a large splanchnic venous collateral is described. This technique can be used in selected patients in whom orthotopic liver transplantation might otherwise be considered technically impossible.

Adult↗
PubMed1991

Translumbar inferior vena cava 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.

Aspirin↗
PubMed1990

Obstructed central venous catheters. Restoring function with a 12-hour infusion of low-dose urokinase.

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.

Catheterization, Central Venous↗
PubMed1990

Hickman catheter-induced thoracic vein thrombosis. Frequency and long-term sequelae in patients receiving high-dose chemotherapy and marrow transplantation.

One hundred sixty-eight bone marrow transplant recipients and 49 patients who received high-dose chemotherapy were evaluated for symptomatic thrombosis after Hickman catheter placement. The timing of thrombotic complications was different between these two groups, with the transplant group having a significantly lower thrombus-free survival by 28 days after catheter placement. By 100 days after placement the thrombus-free survival rates of the two groups were similar. The platelet count at time of catheter placement was significantly lower in the nontransplant group, and the thrombus-free survival was longer in patients whose catheter was placed when their platelet count was less than 150,000, suggesting that thrombocytopenia delays thrombotic complications. Placement of two Hickman catheters resulted in a 12.9% thrombosis rate (21 of 162 patients) and was significantly more likely to be associated with thrombosis than placement of one catheter. Long-term follow-up evaluation of patients treated without successful fibrinolytic therapy showed no residual symptoms of venous obstruction. In those patients presenting with concomitant catheter obstruction resulting from thrombosis, low-dose fibrinolytic therapy was successful in restoring catheter function 70% of the time. Placement of two Hickman catheters is associated with an inordinate incidence of thrombosis. Thrombocytopenia at the time of catheter placement may delay this complication. Thrombotic catheter obstruction can be treated successfully with low-dose fibrinolytic therapy. Even without fibrinolytic therapy, catheter-induced subclavian vein thrombosis rarely causes long-term disability.

Bone Marrow Transplantation↗
PubMed1990

Translumbar inferior vena cava catheters for long-term venous access.

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.

Adult↗
PubMed1990

Celiac plexus neurolysis with the modified transaortic approach.

Celiac plexus block with alcohol was performed to relieve pain in 124 patients with abdominal malignancies. A transaortic technique was employed in which a single needle was advanced from a left posterior paramedian approach through the aorta to deposit anesthetic agent directly onto the celiac plexus. Ninety-one percent of patients experienced marked pain relief. No major hemorrhagic or neurologic complications were encountered. The transaortic method of celiac block is as effective as, easier to perform, and may be safer than the classic two-needle technique.

Aged↗
PubMed1989

Comparison of omnipaque with hypaque in temporomandibular arthrography.

Decreasing or alleviating pain experienced by some patients during or after temporomandibular arthrography would make this relatively inexpensive and highly accurate technique more attractive. This is particularly true for those patients without access to MR or those whose referring physicians prefer arthrography to other techniques for diagnosing internal derangements. Ionic and nonionic contrast agents were compared in a randomized, double-blind trial to determine if pain could be decreased by using a nonionic contrast material. Forty patients received either Omnipaque 300 (nonionic, iohexol) or Hypaque 60 (ionic, diatrizoate meglumine). Radiographs were assessed for diagnostic quality, and patients were asked to note their level of discomfort. No significant differences between the agents were detected. Maximal discomfort was noted at 24 hr. Discomfort was classified as none, mild, or moderate, with no patients describing marked discomfort. This study does not support the use of nonionic contrast agents over the less expensive ionic agents for decreasing pain or improving film quality in temporomandibular joint arthrography.

Adult↗
PubMed1989

Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation.

Biliary tract complications are a continuing source of morbidity after liver transplantation. In a 3.5-year period we performed 264 liver transplants in 226 patients (132 adults, 94 children). Biliary tract reconstruction was via Roux limb choledochojejunostomy (n = 144) or choledochocholedochostomy (n = 118). Fifty (19.1%) biliary complications occurred, and 35 (13.4%) necessitated operative repair. The incidence was similar in adults and children and after each method of reconstruction. Risk factors were vascular thrombosis and reduced-sized transplants. Diagnosis was based on the algorithmic use of multiple modalities with early biliary visualization. Roux limb complications usually occurred in the first month after transplant and necessitated operative intervention, whereas duct-to-duct problems appeared later and were more accessible to percutaneous or endoscopic manipulations. Eight (6.8%) patients required conversion to a Roux limb, whereas 8/15 (53.3%) cases of biliary stricture were successfully managed nonoperatively. Three (1.3%) patients and four (1.5%) grafts were lost as a result of biliary complications. One-year actuarial patient survival is 76.4% with a mean follow-up of 13.2 months. Early recognition of biliary complications and prompt interventional therapy can effectively prevent long-term sequelae. Although choledochocholedochostomy is more physiologic and expeditious, Roux-en-Y choledochojejunostomy remains a safe and versatile alternative and is the preferred method of reconstruction in select cases.

Adolescent↗
PubMed1988

Silicone rubber catheter venography using standard angiographic techniques.

Single- and double-lumen silicone rubber central venous catheters were subjected to in vitro destructive testing. Using this data we devised a clinical technique for the detection of central venous thrombosis incorporating mechanical injection of the catheters, serial filming, and magnification radiography. In 20 patients studied, thrombosis was detected in 12 and extravasation in 3. Two partially occluded catheters burst during forceful injection. Our technique demonstrated the presence and extent of thrombosis at the catheter tip more clearly than did other venographic methods and has been especially useful in assessing the results of thrombolytic therapy.

Catheterization, Central Venous↗
PubMed1988

Duplex ultrasonography as a noninvasive technique for assessing portal hemodynamics.

Duplex ultrasonography was evaluated as a noninvasive, quantitative technique of assessing portal hemodynamic characteristics. Portal blood flow measured by duplex ultrasonography was significantly decreased in patients with portal hypertension (450 +/- 86 ml/min) compared with control subjects (874 +/- 44 ml/min; p less than 0.001). Quantitative assessment of portal blood flow by duplex ultrasound correlated with qualitative portal perfusion grading by angiography, and direction of flow was always accurately determined by duplex ultrasonography. Although the angiographic portal perfusion grade did not change significantly in the early postoperative period after distal splenorenal shunting, a decrease in mean portal blood flow of more than 50 percent was documented by duplex ultrasonography. Duplex ultrasonography appears to be at least as accurate as angiography and is an acceptable alternative to this more invasive technique for the longitudinal assessment of portal blood flow.

Adult↗