Catherine M. Tuite

Experience with the recovery filter as a retrievable inferior vena cava filter.

PURPOSE This study evaluates clinical experience with the Recovery filter as a retrievable inferior vena cava (IVC) filter. MATERIALS AND METHODS One hundred seven Recovery filters were placed in 106 patients with an initial clinical indication for temporary caval filtration. Patients were followed up to assess filter efficacy, complications, eventual need for filter removal, time to retrieval, and ability to remove the filter. RESULTS The patient cohort consisted of 62 men and 44 women with a mean age of 48 years (range, 18-90 y). Mean implantation time was 165 days. Indications for filter placement in patients with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) included contraindication to anticoagulation (n = 33), complications of anticoagulation (n = 8), poor cardiopulmonary reserve (n = 6), large clot burden (n = 3), and PE while receiving anticoagulation (n = 1). Indications for filter placement in patients without proven PE or DVT included immobility after trauma (n = 35); recent intracranial hemorrhage, neurosurgery, or brain tumor (n = 18); and other surgical or invasive procedure (n = 3). Three patients (2.8%) had symptomatic PE after placement of the Recovery filter. No caval thromboses were detected. No symptomatic filter migrations occurred. Recovery filter removal was attempted in 15 of 106 patients (14%) at a mean of 150 days after placement. The Recovery filter was successfully retrieved in 14 of 15 patients (93%); one removal was unsuccessful at 210 days after placement. Ninety-two filters (87%) currently remain in place. CONCLUSIONS Although all the filters were placed with the intention of being removed, a large percentage of filters were not retrieved. The Recovery filter was safe and effective in preventing PE when used as a retrievable IVC filter.

Chemoembolization of colorectal liver metastases with cisplatin, doxorubicin, mitomycin C, ethiodol, and polyvinyl alcohol

Unresectable colorectal liver metastases have a 1‐ and 2‐year survival of 55% and 33% with current systemic therapies. The authors evaluated response and survival after transarterial chemoembolization.

Relationship between Chest Port Catheter Tip Position and Port Malfunction after Interventional Radiologic Placement

PURPOSE The relationship between catheter tip position of implanted subcutaneous chest ports and subsequent port malfunction was investigated. Tip movement from initial supine position to subsequent erect position was also evaluated. MATERIALS AND METHODS Patients who underwent imaging-guided internal jugular chest port placement between July 2001 and May 2003 were identified with use of a quality-assurance database. Sixty-two patients were included in the study (22 men and 40 women), with a mean age of 58 years (range, 27-81 years). Catheter tip location on the intraprocedural chest radiograph was determined with use of two methods. First, the distance from the right tracheobronchial angle (TBA) was recorded (TBA distance). Second, tip location was classified into six anatomic regions: 1, internal jugular veins; 2, brachiocephalic veins; 3, superior vena cava (SVC; n = 11); 4, SVC/right atrial junction (n = 22); 5, upper half of right atrium (n = 25); and 6, lower half of right atrium (n = 4). For the duration of follow-up, catheter tip location was documented, as were all episodes of catheter malfunction. RESULTS Patients with catheter tips initially placed in position 3 had a higher risk of port malfunction (four of 11; 36%) than patients with catheter tips located in position 5 (two of 25; 8%). This difference narrowly fell short of statistical significance (P =.057). When comparing intraprocedural chest radiographs to the first erect chest radiographs, significant upward tip movement was noted. The tips migrated cephalad an average of 20 mm (P =.003) and 1.0 position units (P =.001). DISCUSSION Catheter tips placed in the SVC tended to have a greater risk of port malfunction compared with those positioned in the right atrium. Chest ports migrated cephalad between the supine and erect positions.

Single-center Experience with the Arrow-Trerotola Percutaneous Thrombectomy Device in the Management of Thrombosed Native Dialysis Fistulas

PURPOSE The present study sought to evaluate the performance of the Arrow-Trerotola Percutaneous Thrombolytic Device (PTD) in the treatment of native fistula thrombosis in a U. S. hemodialysis population. Specifically, the technical success, clinical success, complication rate and type, primary and secondary patency rates, effect of adjunctive thrombolytic therapy, and any variables that affected outcomes of procedures in which this device was used were analyzed. MATERIALS AND METHODS Forty-two patients with 44 thrombosed native fistulas (17 radiocephalic, 10 brachiocephalic, 10 transposed or superficialized, five graft/fistula hybrids, and two leg fistulas) were treated with 62 mechanical thrombolysis procedures with use of the PTD. All patients had large clot burden. The device type was recorded in 43 procedures: standard (n = 21), over-the-wire (OTW; n = 19), or both (n = 3). No device was used in two cases because of inability to cross the anastomosis. Adjunctive therapies (n = 18) included the use of tissue plasminogen activator (tPA; n = 16) and deployment of the AngioJet device with (n = 1) or without tPA (n = 1). Stents were inserted in four procedures. Outcome variables included technical and clinical success, complications, and primary and secondary patency. Cox proportional-hazards regression and Kaplan-Meier analyses were performed. RESULTS The technical success rate was 87% (54 of 62) and the clinical success rate was 79% (49 of 62). Percutaneous transluminal angioplasty was performed in all but two procedures. Complications occurred in 13% of procedures (n = 8); three resulted in technical failure. The primary patency rates were 38% at 6 months and 18% at 12 months; secondary patency rates were 74% and 69%, respectively. Outcomes were not affected by adjunctive techniques, fistula type, age of fistula, device type (ie, OTW vs standard), or patient sex. Secondary patency was superior when no residual clot or stenosis was present (P = .003). CONCLUSIONS The PTD is effective for percutaneous treatment of thrombosed hemodialysis fistulas, with good short- and long-term outcomes in a U.S. population. Within the limitations of a retrospective study with a small sample size, use of an adjunctive thrombolytic agent did not appear to improve results compared with the use of the device alone.

Physical Examination versus Normalized Pressure Ratio for Predicting Outcomes of Hemodialysis Access Interventions

PURPOSE The ratio of intragraft venous limb pressure (VLP) to systemic pressure (S) has been proposed to help determine the endpoint of hemodialysis access interventions. It was hypothesized that physical examination of the access could be used in the same way and these techniques were compared as predictors of outcome. PATIENTS AND METHODS With use of a quality-assurance database, records from 117 hemodialysis access interventions were retrospectively reviewed. Only interventions in grafts were included. The database included physical examination (to establish thrill, thrill with slight pulsatility [TSP], pulse with slight thrill [PST], and pulse) at three locations along the graft (proximal, midportion, and distal), normalized pressure ratio calculated with S from a blood pressure cuff (S(cuff)) and S within the graft with outflow occluded (S(direct)), graft configuration and location, indication, operator, and time to next intervention (outcome of primary patency). Only procedures with complete follow-up data were included in the analysis (n = 97; declotting, n = 51; prophylactic percutaneous transluminal angioplasty [PTA], n = 46). Statistical analysis was performed with use of Cox proportional-hazards regression. RESULTS Graft configuration, location, side, VLP, S(direct), and S(cuff) did not affect outcomes. An operator effect was noted for two physicians and was adjusted for in all analyses. Pressure ratios were weak predictors of outcome (VLP/S(direct), P =.07; VLP/S(cuff), P =.08) and suggested that patency increased with increasing pressure ratio, contrary to earlier studies. Procedure type predicted outcome (declotting, median patency of 50 days; PTA, median patency of 105 days; P =.01). Thrill at distal physical examination was predictive of outcome (P =.04) and even more so when thrill and TSP combined were compared with PST and pulse combined (P =.03). Similar but less-pronounced effects were seen at midportion and proximal physical examinations. CONCLUSIONS The presence of a thrill or slightly pulsatile thrill at the distal (venous) end of a dialysis graft is the best predictor of outcome after percutaneous intervention. Based on the present study, the authors believe that physical examination of dialysis access should supplant pressure measurements as an endpoint of intervention and should serve as an essential component of quality assurance of access interventions.

Effectiveness of an Aggressive Antibiotic Regimen for Chemoembolization in Patients with Previous Biliary Intervention

PURPOSE Liver abscess occurs in most patients with biliary stents or bypass undergoing chemoembolization despite the use of standard prophylactic antibiotics. The present study was conducted to investigate the efficacy of an aggressive prophylactic regimen to prevent abscess in such patients. MATERIALS AND METHODS Between November 2002 and July 2005, 16 chemoembolization procedures were performed in seven patients who had undergone biliary intervention. Prophylaxis was initiated with levofloxacin 500 mg daily and metronidazole 500 mg twice daily 2 days before chemoembolization and continued for 2 weeks after discharge. A bowel preparation regimen was given with neomycin 1 g plus erythromycin base 1 g orally at 1 p.m., 2 p.m., and 11 p. m. the day before chemoembolization. With the Fisher exact test, the incidence of infectious complications was compared with previously reported data for patients with and without earlier biliary intervention who had received standard prophylaxis. RESULTS Liver abscess occurred in two of seven patients after two of 16 procedures. Previously reported incidences were six of seven patients (P=.103) and six of 14 procedures (P=.101) among patients with previous biliary intervention receiving standard prophylaxis and one of 150 patients (P=.005) and one of 383 procedures (P=.004) among patients with no previous biliary intervention. CONCLUSIONS There was a trend toward a lower rate of abscess formation among patients at high risk who received more aggressive antibiotic prophylaxis, but the difference did not reach statistical significance. The rate of infection remained significantly higher than among patients without previous biliary intervention.

Role of Ultrasound Surveillance of Transjugular Intrahepatic Portosystemic Shunts in the Covered Stent Era

PURPOSE To assess ultrasound (US) surveillance of expanded polytetrafluoroethylene (ePTFE)-covered stents in transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS Procedural data, including stent size and portosystemic gradients (PSG) before and after creation of TIPS, were obtained retrospectively in 55 patients (33 men, 22 women). Chart review provided clinical information, including etiology of liver disease, indication for TIPS creation, and Child-Pugh class. Radiology reports provided US venography data and pathology reports confirmed shunt status in transplant recipients. Patients had baseline US examinations 3-7 days after TIPS creation with scheduled follow-up at 1, 3, 6, and 12 months after the procedure. Clinical and radiology reports were compared to evaluate US surveillance of Viatorr stents. RESULTS One hundred fifty-nine US examinations were performed on 52 patients, for an average 3.1 studies per patient (range, 1-7) over a mean follow-up duration of 173 days (range, 0-1,013 d). Sixty-four US studies (40%) were baseline studies, 88 studies (55%) were routine follow-up studies, and seven (4%) were interval studies. US predicted TIPS abnormalities in 30 of 159 studies (19%); venography followed 15 of 30 abnormal US findings (50%) and clinical examinations complemented 10 of 15 venograms (67%). Venography and US were concordant in eight of 15 paired studies (53%); clinical examinations, when conducted, accurately predicted shunt status in all but one case. US findings changed management in six of 159 studies (4%): five of six (83%) were baseline evaluations and the other one (17%) was a routine follow-up examination. A total of five baseline US examinations (8%) and one surveillance examination (1%) altered patient management. CONCLUSIONS A single US examination after a TIPS procedure to confirm immediate function may be valuable, but routine US is not effective for long-term surveillance of ePTFE-covered stents.

Mechanical Thrombectomy of Hemodialysis Fistulae and Grafts

In this article, the authors present approaches they use in performing dialysis access intervention—in particular clotted access. It is not meant to be a comprehensive review of dialysis access management. At our institution, mechanical thrombectomy is the primary mode of treatment for clotted hemodialysis access. We will present physical examination findings in clotted dialysis access and contraindications for mechanical thrombectomy in dialysis access. We will also discuss the devices for mechanical thrombectomy and the techniques we use. Finally, we will discuss the difficulties encountered in these procedures and their solutions.

Percutaneous management of chronic pancreatic duct strictures and external fistulas with long-term results.

THE treatment of chronic pancreatitis with severe intermittent abdominal pain or chronic low-output pancreaticocutaneous fistulas remains a major challenge. The 20%–40% of patients who do not respond to intensive medical therapy, including abstinence from alcohol, are traditionally treated by surgical resection or drainage of the diseased pancreas; surgery leads to partial or complete pain relief in 60%– 90% of cases of ductal obstruction, but with a mortality rate of 2%–5% and a serious complication rate of 20%–40% (1–3). Evolving endoscopic pancreatic duct drainage and stent placement procedures (4–7) for treating pancreatic duct (PD) strictures, sealing PD disruptions, and draining PD pseudocysts can offer an alternative to surgery with low major morbidity and mortality. There remains a small group of patients for whom endoscopic and surgical treatment of PD obstruction or fistulas is not possible or advisable; it has been shown in a few case reports that the management of these patients by percutaneous PD drainage with or without stent placement can be effective (8–10). We describe a variety of interventional techniques that we have used to successfully treat five patients with chronic fistula or severe pancreatic pain syndrome, after both surgery and endoscopic catheterization had failed. A follow-up of 5–10 years was possible in most cases.

Portal Flow and Arterioportal Shunting after Transjugular Intrahepatic Portosystemic Shunt Creation

PURPOSE It was postulated that a transjugular intrahepatic portosystemic shunt (TIPS) produces arterioportal shunting and accounts for reversed flow in the intrahepatic portal veins (PVs) after creation of the TIPS. This study sought to quantify this shunting in patients undergoing TIPS creation and/or revision with use of a direct catheter-based technique and by measuring changes in blood oxygenation within the TIPS and the PV. MATERIALS AND METHODS This prospective study consisted of 26 patients. Median Model for End-stage Liver Disease and Child-Pugh scores were 13 and 9, respectively. Primary TIPS creation was attempted in 21 patients and revision of failing TIPS was undertaken in five. In two patients, TIPS creation was unsuccessful. All TIPS creation procedures but one were performed with use of polytetrafluoroethylene-covered stent-grafts. Flow within the main PV (Q(portal)) was measured with use of a retrograde thermodilutional catheter before and after TIPS creation/revision, and TIPS flow (Q(TIPS)) was measured at procedure completion. The amount of arterioportal shunting was assumed to be the increase between final Q(portal) and Q(TIPS), assuming Q(TIPS) was equivalent to the final Q(portal) plus the reversed flow in the right and left PVs. Oxygen saturation within the TIPS and the PV was determined from samples obtained during TIPS creation and revision. RESULTS Mean Q(portal) before TIPS creation was 691 mL/min; mean Q(portal) after TIPS creation was 1,136 mL/min, representing a 64% increase (P = .049). Mean Q(TIPS) was 1,631 mL/min, a 44% increase from final Q(portal) (P = .0009). Among cases of revision, baseline Q(portal) was 1,010 mL/min and mean Q(portal) after TIPS revision was 1,415 mL/min, a 40% increase. Mean Q(TIPS) was 1,693 mL/min, a 20% increase from final Q(portal) (P = .42). Arterioportal shunting rates were 494 mL/min after TIPS creation and 277 mL/min after TIPS revision, representing 30% of total Q(TIPS) after TIPS creation and 16% of Q(TIPS) after TIPS revision. No increase in oxygen tension or saturation was seen in the PV or TIPS compared with initial PV levels. Q(TIPS) did not correlate with the portosystemic gradient. CONCLUSION TIPS creation results in significant arterioportal shunting, with less arterioportal shunting seen among patients who undergo TIPS revision. Further work is necessary to correlate Q(TIPS) with the risk of hepatic encephalopathy and liver failure.