Audrey R. Wilson

Extraction and Replacement of Permanent Pacemaker Leads Through Occluded Vessels: Use of Extraction Sheaths as Conduits - Balloon Venoplasty as an Adjunct

Patients (pts) may present for lead extraction with symptomatic or asymptomatic subclavian vein or superior vena cava thrombosis. Replacement of permanent pacemaker leads (PPLs) in these pts may be difficult and may require accessing a new site. We examined the utility of replacing PPLs through completely occluded vessels using extraction sheaths as conduits through the total occlusion.Over six years, a total of 210 atrial and/or ventricular PPLs were extracted from 137 pts. Two pts presented with angiographically documented thrombotic occlusion of the subclavian vein. One additional pt, who had presented with a superior vena cava (SVC) syndrome, had a totally occluded innominate vein and SVC occlusion. Balloon venoplasty was used as an adjunct to dilate the SVC.In all pts, after PPLs were removed via a subclavian extraction sheath through the occluded vessel, the retained sheath was used to place a guide wire, then a peel away dilating sheath, to insert new PPLs, in each case on the side of total venous occlusion. Seven PPLs and two lead fragments were extracted, and five new PPLs replaced, ipsilateral to the venous occlusion.These data show that extraction of PPLs through thrombosed veins may be performed successfully and may not require replacing the leads through a new site. This technique spares the pt the need to access the opposite subclavian vein, and it avoids an excessive number of PPLs in the subclavian vein and SVC. The procedure illustrates an efficient means to reintroduce new PPLs with the potential to reduce associated morbidity, since repeat puncture of the subclavian vein is not required. Safety of the procedure as a whole must be considered with regard to the known risks of lead extraction, some complications of which may be substantial using current techniques.

Thrombolytic therapy of synthetic graftocclusions before vascular reconstructive procedures

The objective of this study was to evaluate the impact of thrombolysis of synthetic grafts before urgent vascular reconstruction. In 29 patients, 41 thrombosed synthetic grafts that underwent intraarterial thrombolysis were studied. The cases were divided into three groups: group I--complete thrombolysis followed by reconstruction; group II--complete thrombolysis alone; and group III--incomplete lysis requiring reconstruction or sympathectomy. Follow-up ranged from 1 to 556 days (mean: 149 days). Kaplan-Meier analysis was used to determine patency and limb salvage rates. One-year patency and limb salvage rates were 53% and 95%, 34% and 67%, and 38% and 48%, respectively, for groups I, II, and III. Eighteen complications occurred in 16 of the 41 (39%) episodes. One patient died of intracranial hemorrhage. The best results were achieved when complete lysis was followed by appropriate reconstruction. Patency was equally poor in complete thrombolysis alone and reconstructions required by incomplete thrombolysis. Limb salvage was better after complete thrombolysis, regardless of the appropriate reconstruction.

Thrombolysis therapy in patients with femoropopliteal synthetic graft occlusions

Background The aim of this study was to evaluate the efficiency of thrombolysis in the presence of an occluded femoropopliteal synthetic graft. Patients and methods Over a 3-year period, 46 occluded femoropopliteal grafts were treated with urokinase and reconstruction. The cases were divided into three groups: group 1 (n = 25), complete thrombolysis followed by reconstruction or angioplasty or both; group 2 (n = 5), complete thrombolysis alone; and group 3 (n = 16), failure of thrombolysis requiring reconstruction or leading to amputation. Patients were closely observed after the treatment for more than 1 year. Results There are no fatal complications among patients with thrombolytic therapy. In group 1, the 3-year patency rates were 12% and the 3-year limb salvage rates were 77%. In group 2, the 3-year patency rates and the limb salvage rates were 20% and 80%, respectively. The group 3 patency rates and the limb salvage rates were 8% and 40%, respectively. The best results were achieved in patients who had thrombolysis followed by reconstruction (group 1) and in those who had thrombolysis alone (group 2). Limb salvage was poor in patients with failure of lytic therapy regardless of the reconstruction ( P Conclusion The use of intra-arterial urokinase followed by secondary vascular reconstructive procedures was studied. The patient with synthetic graft occlusion still has a reasonably favorable prognosis for long-term limb salvage when thrombolysis is successful.

Delayed Traumatic Arteriovenous Fistula following Hemodialysis Vascular Catheterization

Arteriovenous fistula formation is a rare complication of percutaneous femoral vein cannulation for hemodialysis. Symptoms and physical findings may be elusive and the lesion can proceed unnoticed for extended periods of time. This complication is easily managed with surgical repair following rapid clinical and angiographic diagnosis. It is the purpose of this paper to report a case of delayed arteriovenous fistula formation 7 months following percutaneous insertion of an acute hemodialysis catheter into the femoral vein.

Effect on Thrombolysis and its Complication of Graft Occlusion and Specific Risk Factors

The objective of this study was to correlate the initial outcome of thrombolytic therapy in patients with specific risk factors who presented with an occluded synthetic graft. Seventy-seven angiographically documented occluded synthetic grafts were treated with urokinase. All patients presented within thirty days of occlusion. The cases were investi gated according to specific risk factors: smoking (SM), hypertension (HT), coronary artery disease (CAD), and diabetes mellitus (DM). A high number of occlusions occurred in patients had a history of heavy smoking (84.4%). Complete thrombolysis was achieved in 46 of 77 (59.7%) graft occlusions. Thirty-eight of 65 (58.5%) occlusions in patients who smoked, 29 of 47 (61.7%) occlusions in patients with HT, 22 of 36 (61.1%) occlu sions in patients with CAD, and 18 of 25 (72.0%) occlusions in patients with DM were completely lysed. When comparison was made between the specific risk factors, no signif icant difference was found in complete lysis. Forty-seven complications occurred in 31 (40.3%) of 77 cases. One patient (1.3%) suffered from a fatal intracranial hemorrhage. No significant increase in complications was seen when the various risk factors were compared. In conclusion, no relation was observed between the initial success rate with throm bolytic therapy and multiple risk factors in patients with arterial graft occlusion.

The Diagnostic Imaging Information Center

The authors have developed a Diagnostic Radiology Imaging Information Center, in which the physician can see at a glance, with minimum expenditure of time and maximum emphasis on relevance, a summary of the patients studies and procedures done in the x-ray department.