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Biomedical subjects

S J Savader

Publications and source records attributed to S J Savader.

At least 19 recordsLinked to original sources
PubMed2001

The Legs for Life screening for peripheral vascular disease: compliance with physician recommendations in moderate- and high-risk assessed patients.

PURPOSE: To determine compliance within a community with recommendations made by physicians during the 1999 Legs for Life National Screening for Peripheral Vascular Disease (PVD) and Leg Pain. MATERIALS AND METHODS: Patients were initially screened for PVD by completion of the Legs for Life risk factor questionnaire and determination of bilateral ankle/brachial indexes (ABIs). Each patient subsequently met with an interventional radiologist or vascular surgeon. Patients with normal ABIs (>1.0 bilaterally) or mildly abnormal ABI(s) (<1.0 but >0.90) were classified at no and low risk for PVD, respectively; patients with ABI(s) of 0.70-0.89 were classified at moderate risk for PVD; and patients with ABI(s) <0.69 were classified at high risk for PVD. Risk factors for PVD were assessed by the consulting physician and discussed with all patients. Recommendations were made for additional evaluation and/or follow-up care, if necessary. Seven months after screening, patients who were assessed at moderate and high risk for PVD were contacted by telephone to determine if they had pursued additional care or testing. RESULTS: A total of 205 patients were screened for PVD, 48 (23%) of whom were determined to be at moderate to high risk. Forty-four (92%) patients were available for follow-up. At 7 months after screening, 31 (70%) patients had received no further medical advice or treatment. Thirteen (30%) of these patients had completed a follow-up appointment, but only three with a physician specializing in peripheral vascular disease. None of the patients had clinical follow-up with an interventional radiologist. Five (11%) patients had undergone noninvasive Doppler evaluation and one (2%) had undergone diagnostic arteriography. No patient had undergone any form of percutaneous or surgical intervention. CONCLUSION: Patient compliance with physician recommendations after outpatient screening for PVD is low. The Legs for Life screening program could be considered successful in that it provides for patient education and the identification of moderate to high-risk patients. Physicians participating in this program may have to modify their approach to patient screening and follow-up if a concomitant goal is to deliver specialty care.

Adult↗
PubMed2001

Treatment of hemodialysis catheter-associated fibrin sheaths by rt-PA infusion: critical analysis of 124 procedures.

PURPOSE: To prospectively evaluate the efficacy of a low-dose, 3-hour infusion of recombinant tissue plasminogen activator (rt-PA) for the treatment of hemodialysis catheter (HDC)-associated fibrin sheaths. This report expands the authors' experience with this technique over that previously reported. MATERIALS AND METHODS: Fifty-five patients with end-stage renal disease (38 women, 17 men) undergoing catheter-directed hemodialysis treatment were evaluated for 124 episodes of HDC dysfunction. This patient group had a mean age of 57 years and an age range of 23-92 years. Radiographic contrast studies and/or clinical evaluation were consistent with the presence of a fibrin sheath on the arterial and/or venous port in all cases. Each patient underwent a thrombolytic infusion consisting of 2.5 mg rt-PA in 50 mL normal saline at 17 mL/h (3-hour infusion) per port. All infusions were performed in the interventional radiology recovery room on an outpatient basis. Patients were followed prospectively for technical success, complications, catheter patency, and long-term outcome. RESULTS: The technical success rate, defined as return of effortless manual aspiration and infusion capability from both ports followed by at least one successful dialysis session, was 91%. No patient was excluded from rt-PA therapy because of contraindications, and the procedure-related complication rate was zero percent. A Kaplan-Meier survival analysis yielded primary patency rates at 30, 60, 90, and 120 days of 0.55, 0.36, 0.25, and 0.15 (SE <.10), respectively; secondary patency rates at 60, 120, 180, and 240 days were 0.70, 0.46, 0.30, and 0.27 (SE <.10), respectively (P < 001). At the end of the study period, all 52 surviving patients continued to undergo catheter-directed hemodialysis and 34 (65%) were using the same catheter present at the time of entrance into the study. Of the 18 patients (35%) requiring catheter exchange, 16 (89%) did for persistent malfunction after rt-PA therapy, one (5.5%) for infection, and one (5.5%) for a fractured hub. CONCLUSION: Thrombolytic therapy with use of a 2.5-mg rt-PA infusion through each port over a 3-hour period would appear to be a safe method for treating HDC-associated fibrin sheaths. Immediate return of catheter function is achieved in most patients, obviating more invasive techniques. Primary patency rates are relatively short, but catheters that fail can be retreated, resulting in secondary patency rates that are substantial and significantly improved.

Adult↗
PubMed2001

The Legs For Life Screening for Peripheral Vascular Disease: results of a prospective study designed to improve patient compliance with physician recommendations.

PURPOSE: To determine how compliance with recommendations made by physicians during the 2000 Legs For Life National Screening for Peripheral Vascular Disease (PVD) and Leg Pain is affected through the use of (i) simple and concise patient information and recommendation cards and (ii) a "targeted" postscreening follow-up plan. MATERIALS AND METHODS: Patients were initially screened for PVD by completion of the Legs For Life Risk Factor Assessment form and determination of bilateral ankle/brachial indexes (ABIs). Each patient then met with an interventional radiologist or vascular surgeon. Patients with normal ABIs (>1.0 bilaterally) or mildly abnormal ABIs (<1.0 but >0.90) were classified as having no risk and low risk, respectively. Patients with ABIs of 0.70-0.89 were classified as having moderate risk for PVD and patients with ABIs <0.69 were classified as having high risk for PVD. Physicians reviewed the Risk Factor Assessment form with each patient and made specific lifestyle improvement recommendations. For the year 2000 screening, patients classified at moderate and high risk for PVD received special instructions and a card containing clearly printed information on the purpose of the Legs For Life screening, their level of risk for PVD, specific recommendations for follow-up, and phone numbers to call to help arrange for that follow-up. Two weeks after the screening, a second copy of this card was mailed to each moderate- and high-risk assessed patient. Four months later, each of these patients was contacted by telephone to determine if they had pursued additional care or testing. RESULTS: A total of 185 patients were screened, 42 (23%) of whom were determined to be at moderate or high risk for PVD. Four months after the screening, 39 (93%) of these patients were available for follow-up. Twenty (51%) patients had received no further medical advice or treatment. Nineteen (49%) patients had pursued further medical care which included physician consultation (n = 19; 100%), noninvasive Doppler evaluation (n = 10; 26%), diagnostic arteriography (n = 2; 5%), initiation of pharmacologic therapy for claudication (n = 1; 3%), percutaneous intervention (n = 1; 3%), or vascular surgery (n = 1; 3%). Seventeen of 39 patients (44%) reported that claudication-type leg pain was still a concern and/or lifestyle-limiting problem. CONCLUSION: Patients can be provided with problem-focused information and succinct physician recommendations at and soon after a screening for PVD, which can contribute to enhanced patient compliance. However, a host of personal, social, health, and physician-related issues still prevent a large percentage of patients from achieving relief of PVD-associated leg pain.

Adult↗
PubMed2000

Percutaneous radiologic placement of peritoneal dialysis catheters: long-term results.

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.

Adult↗
PubMed2000

Hemodialysis catheter-associated fibrin sheaths: treatment with a low-dose rt-PA infusion.

PURPOSE: To prospectively evaluate the efficacy of a low-dose, 3-hour recombinant tissue plasminogen activator (rt-PA) infusion for the treatment of hemodialysis catheter (HDC)-associated fibrin sheaths. MATERIALS AND METHODS: Seventeen patients with end-stage renal disease (female, n = 11; male, n = 6), who were undergoing catheter-directed hemodialysis, were evaluated for 28 episodes of HDC dysfunction. This patient group ranged in age from 25 to 92 years (mean, 57 years). Radiographic contrast and/or clinical evaluation were consistent with the presence of a fibrin sheath on either the arterial and/or venous port in all cases. Patients subsequently underwent a thrombolytic infusion consisting of 2.5 mg rt-PA in 50 mL normal saline at a rate of 17 mL/h (3-hour infusion) per port. All infusions were performed in the interventional radiology recovery room, on an outpatient basis. Patients were followed-up prospectively for technical success, complications, catheter patency, and long-term outcome. RESULTS: The immediate technical success rate, defined as return of manual aspiration and infusion capabilities to both ports, was 100%. No potential patients required exclusion from thrombolytic therapy secondary to contraindications, and no procedure-related complications occurred. The arithmetic mean and median catheter patency at the end of the study was 41 and 25 days, respectively (range, 1-116 days). A Kaplan-Meier survival analysis yielded a 30-, 60-, and 90-day probability of patency of 0.67, 0.61, and 0.51, respectively. At the end of the study period, all 17 patients remained on catheter-directed hemodialysis and 13 (76%) were utilizing the same catheter present at the time of entrance into the study. CONCLUSION: Thrombolytic therapy utilizing a 2.5-mg rt-PA infusion through each port during a 3-hour period would appear to be a safe, efficient method for treating HDC-associated fibrin sheaths. Three-month patency rates are comparable to those reported for other methods of restoring function to HDC catheters, including new catheter placement, catheter exchange over a guide wire, thrombolytic infusions with urokinase, and percutaneous fibrin sheath stripping.

Adult↗
PubMed1999

Forearm loop, upper arm straight, and brachial-internal jugular vein dialysis grafts: a comparison study of graft survival utilizing a combined percutaneous endovascular and surgical maintenance approach.

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.

Arm↗
PubMed1997

Biliary fistulae and haemorrhage.

Percutaneous biliary drainage is the most common aetiology of haemobilia. Bile duct fistulae can also arise from the hepatic or portal vein, most commonly as a result of trauma. Percutaneous methods for treating haemobilia from all these sources are discussed in detail.

Biliary Fistula↗
PubMed1997

Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster.

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.

Adult↗
PubMed1997

Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management.

OBJECTIVE: The authors provide the results of follow-up evaluation after combined surgical and radiologic management of 89 patients with major bile duct injuries during laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: The incidence and mechanism of injury of major bile duct injuries during laparoscopic cholecystectomy has been clearly defined. Furthermore, a number of series have described the management of these injuries by surgical, endoscopic, and radiologic techniques with excellent short-term results. Long-term follow-up data, however, are lacking in the management of these injuries. METHODS: Data were collected prospectively on 89 patients treated at a single institution with major bile duct injuries after laparoscopic cholecystectomy managed between July 1, 1990, and July 1, 1996. Patients referred with injuries underwent early percutaneous transhepatic cholangiography and biliary drainage. Based on the cholangiographic appearance and clinical situation, patients were managed by either percutaneous balloon dilatation or surgical reconstruction with a Roux-en-Y hepaticojejunostomy with transanastomotic stenting. Follow-up was obtained by personal interview during October 1996. RESULTS: Two patients died without an attempt at definitive therapy. Both deaths were caused by sepsis and multisystem organ failure present at the time of transfer to the authors' institution. The remaining 87 patients were managed initially by either balloon dilatation (N = 28) or surgical reconstruction (N = 59). Ten patients have not completed treatment and still have biliary stents in place. Evaluation of 25 patients completing treatment after balloon dilatation (mean follow-up, 27.8 months) showed a success rate of 64%. Evaluation of 52 patients completing treatment after surgical reconstruction (mean follow-up, 33.4 months) showed a success rate of 92%. All failures were managed successfully by either surgical reconstruction or balloon dilatation. CONCLUSIONS: Major bile duct injuries can be managed successfully by combined surgical and radiologic techniques. This series provides, for the first time, significant follow-up on a large number of patients with overall success rates of 64% after balloon dilatation and 92% after surgical reconstruction. The combination of surgery and balloon dilatation resulted in a successful outcome in 100% of patients treated.

Adult↗
PubMed1996

Outcome of tunneled hemodialysis catheters placed by radiologists.

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.

Case-Control Studies↗
PubMed1996

Radial artery pseudoaneurysm complicating a Brescia-Cimino dialysis fistula.

The authors describe an unusual case of radial artery pseudoaneurysm in a patient with a Brescia-Cimino fistula. Evaluation of a pulsatile mass on the patient's forearm which occurred after hemodialysis led to a nondiagnostic fistulogram. Color flow ultrasound was helpful in identifying the nature of the abnormality, which was subsequently confirmed arteriographically. This case illustrates that fistulography is not 100% sensitive and should be supplemented with other imaging modalities when the clinical and fistulographic findings are discordant.

Adult↗
PubMed1994

Thrombosed dialysis access grafts: percutaneous mechanical declotting without urokinase.

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.

Adult↗
PubMed1993

Preoperative spinal artery localization and its relationship to postoperative neurologic complications.

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.

Adult↗
PubMed1993

US-guided pseudoaneurysm repair with a compression device.

A simple commercially available compression device allowed intermittent ultrasound scanning of the compression site during compression repair of a femoral artery pseudoaneurysm in six patients. All six of the pseudoaneurysms (five superficial femoral and one common femoral) were compressed without compression of the underlying vessels. The procedure was successful in four of the six patients, without complications. Use of this device may decrease operator fatigue during compression repair of pseudoaneurysm.

Aneurysm↗
PubMed1992

Hemobilia after percutaneous transhepatic biliary drainage: treatment with transcatheter embolotherapy.

Thirteen of 333 patients who underwent percutaneous biliary drainage (PBD) developed severe hemobilia. Hepatic arteriography successfully demonstrated the source of hemorrhage in all 13 patients. Lesions included hepatic artery pseudoaneurysm in nine, hepatic artery-bile duct fistulas in four, and a hepatic artery-portal vein fistula in one patient. Hemobilia occurred from 1 day to 1.8 years (mean, 100 days) following catheter placement. Embolization agents used included Hilal embolization microcoils, occluding spring emboli, cyanoacrylate, detachable balloons, and gelatin sponge pledgets. A single agent was used in eight cases (62%), multiple agents were used in four cases (31%), and in one case (7%), spontaneous thrombosis of the pseudoaneurysm occurred during catheter manipulation. In five patients, the source of the hemorrhage could only be demonstrated following removal of the biliary catheter(s) over guide wire(s). Initial embolization was successful in stopping hemobilia in 12 patients. One patient required repeat embolization after 4 months. Postembolization complications included hepatic abscess formation in two patients and a sterile hepatic infarct in one patient. This series indicates that transcatheter embolotherapy is an effective method for the treatment for severe hemobilia.

Aged↗