Charles A. Dietz

Iliofemoral Deep Venous Thrombosis: Safety and Efficacy Outcome during 5 Years of Catheter-directed Thrombolytic Therapy

PURPOSE To prospectively evaluate the angiographic and clinical results of using catheter-directed thrombolytic therapy for the treatment of acute iliofemoral deep venous thrombosis (IFDVT). MATERIALS AND METHODS All consecutive patients with acute IFDVT referred for thrombolytic treatment from July 1990 to December 1995 were included in this clinical data analysis. Infusions of urokinase were administered via a multisidehole infusion catheter. Angioplasty, stent placement, mechanical thrombectomy, and other procedures were often performed in conjunction with the thrombolytic procedure. RESULTS Seventy-seven patients and 87 limbs were treated. The overall technical success rate was 79%, and was 86% for iliac veins and 63% for femoral veins. The primary and secondary patency rates at 1 year were 63% and 78%, respectively, for the iliac veins, and 40% and 51%, respectively, for the femoral veins. Patients with malignant disease fared worse. Patients requiring stent placement appeared to have inferior outcomes. A previous history of DVT did not appear to affect the results. Bleeding requiring transfusion and hematomas were the major complications encountered. Pulmonary embolus was not a significant problem. Technical success rates were lower in patients who had had symptoms for more than 4 weeks compared to those who had a more recent onset of symptoms. CONCLUSION Current data suggest that catheter-directed thrombolytic therapy is safe and effective in achieving intermediate-term venous Patency. The long-term clinical benefits of this procedure remain, however, to be established.

Changes in Tunneled Catheter Tip Position when a Patient Is Upright

PURPOSE To determine the relative changes in position of tunneled catheters from supine to upright patient position and factors affecting catheter tip migration. MATERIALS AND METHODS One hundred forty-six different tunneled catheters were placed through the subclavian or jugular veins radiologically, and catheter positions were documented with use of cine radiography at the time of placement. Follow-up chest radiographs were obtained with the patient in the upright position within 48 hours after placement. Catheter tip positions were numbered from 1 to 8, with 1 representing the innominate/superior vena cava junction and 8, the lower right atrium. Patient sex and weight, the site of catheter entry, and the size and type of catheter were correlated with the relative change in position on the follow-up chest radiogrpahs. RESULTS There was a statistically significant (P < .0001) change in catheter position on the follow-up chest radiographs, with a mean difference of 1.5 catheter positions (usually mid-right atrium initially to low superior vena cava on follow-up). Catheter tip migration was greater for catheters in the subclavian veins, in females, and in obese patients. CONCLUSIONS The catheter tip migrates significantly from the initial position at the time of placement as compared to when the patient assumes the upright position. This knowledge is important in achieving the desired final catheter position.

Liver regeneration after adult living donor and deceased donor split-liver transplants.

As the number of living donor (LD) and deceased donor (DD) split‐liver transplants (SLTs) have increased over the last 5 years, so too has the interest in liver regeneration after such partial‐liver transplants. We looked at liver regeneration, as measured by computed tomography (CT) volumetrics, to see if there were significant differences among LDs, right‐lobe LD recipients, and SLT recipients. We measured liver volume at 3 months postoperatively by using CT, and we compared the result to the patients ideal liver volume (ILV), which was calculated using a standard equation. The study group consisted of 70 adult patients who either had donated their right lobe for LD transplants (n = 24) or had undergone a partial‐liver transplant (right‐lobe LD transplants, n = 24; right‐lobe SLTs, n = 11; left‐lobe SLTs, n = 11). DD (vs. LDs) were younger (P < 0.01), were heavier (P = 0.06), and had longer ischemic times (P < 0.01). At 3 months postoperatively, LDs had attained 78.6% of their ILV, less than the percentage for right‐lobe LD recipients (103.9%; P = 0.0002), right‐lobe SLT recipients (113.6%; P = 0.01), and left‐lobe SLT recipients (119.7%; P = 0.0006). When liver size at the third postoperative month was compared with the liver size immediately postoperatively, LDs had a 1.85‐fold increase. This was smaller than the increase seen in right‐lobe LD recipients (2.08‐fold), right‐lobe SLT recipients (2.17‐fold), and left‐lobe SLT recipients (2.52‐fold). In conclusion, liver regeneration, as measured by CT volume, seems to be greatest in SLT recipients. LD recipients seem to have greater liver growth than their donors. The reason for this remains unclear. (Liver Transpl 2004;10:374–378.)

Protocols for Paget-Schroetter Syndrome and Late Treatment of Chronic Subclavian Vein Obstruction

BACKGROUND Paget-Schroetter syndrome is a serious condition that if not treated promptly and properly leads to severe sequelae and permanent disability. In its late stage, chronic fibrous obliteration of the vein is rarely amenable to surgical treatment, except in very few select cases. METHODS We treated 126 Paget-Schroetter syndrome patients (group I) by implementing an emergency protocol of thrombolysis by catheter-directed infusion, followed by immediate surgery through an anterior subclavian approach entailing (1) decompression of the thoracic inlet and (2) repairing the vein with a vein patch to reestablish its normal caliber. In addition, we treated another selective group of 81 patients (group II) for chronic fibrotic obstruction several months after their original event, but only when the inflow was adequate. RESULTS Our acute emergency care resulted in a 100% long-term patency rate in group I, with no sequelae. The patency rate in group II was 100% as well, but in 74% a long vein patch, endovascular stents, or homograft implants were used. CONCLUSIONS Implementation of an emergency approach to treat Paget-Schroetter syndrome is highly recommended to prevent the delayed sequelae of permanent subclavian vein obliteration and disability. In chronic obstruction, when feasible, we recommend a long saphenous vein patch, followed by endovascular stent implant.

Esophageal stenting in children: indications, application, effectiveness, and complications

BACKGROUND Use of esophageal stents is uncommon in children, and there are few reports. We report the first experience in predominantly small children and infants with retrievable, flexible stents designed for tracheobronchial use. OBJECTIVE Evaluation of initial experience with placement of esophageal stents for benign esophageal disorders in children. DESIGN A retrospective study. SETTING A pediatric, academic, tertiary-referral center. PATIENTS This study involved 7 pediatric patients. INTERVENTIONS Covered tracheobronchial stents were endoscopically placed in pediatric patients with benign esophageal conditions. Removal involved using forceps to pull the purse-string suture into the endoscope channel and collapsing the top of the stent for easy removal. MAIN OUTCOME MEASUREMENTS To evaluate the safety and feasibility of performing endoscopic stent placement in children and to establish criteria for early stent removal. RESULTS Six of 7 patients benefitted from stenting. There were no complications of placement. Novel techniques were developed for difficult retrievals. One patient did not benefit from esophageal stent placement, because the stent migrated downward from the uppermost part of the esophagus. One patient had some gagging, which led to early removal of the stent. A stent was removed emergently in 1 patient for respiratory distress. LIMITATION Small number of patients. CONCLUSIONS Retrievable, covered stents are easily placed and removed from the esophagus in small children. They should be considered for severe unrelenting strictures, especially when associated with esophageal leaks. A need exists for development of esophageal stents designed for pediatric use.

Fatal hemorrhage from androgen-related hepatic adenoma after hematopoietic cell transplantation.

Fanconi anemia is a rare genetic disorder that leads to bone marrow failure. Hematopoietic cell transplantation (HCT) is currently the only treatment option with curative potential. When a suitable HLA-matched sibling donor is not available, patients are often treated with androgenic steroids before considering HCT. Such androgen treatments can lead to the development of hepatic adenomas, which usually regress upon stopping androgen therapy. A patient with Fanconi anemia is described who underwent an unrelated umbilical cord blood transplant with a history of a hepatic adenoma related to androgen therapy. No adenomas were detected on an ultrasound examination prior to HCT. Soon after HCT, he died due to sudden rupture and hemorrhage of a hepatic adenoma. This case illustrates the need for extra vigilance in the detection and management of hepatic adenomas in patients treated with androgens, especially prior to HCT.

Tracheobronchial metal stents: Effects of covering a bronchial ostium in pigs

RATIONALE AND OBJECTIVES The purpose of this study was to examine the effects of placing a metal stent across a bronchial orifice. MATERIALS AND METHODS Nine pigs were used as test subjects, because the right upper lobe bronchus comes directly off the trachea in these animals. One of three types of metal stents was placed into the trachea of each pig and covered the orifice of the right upper lobe bronchus. Follow-up studies were performed at 1 and 3 months to evaluate the right upper lobe for signs of bronchial obstruction, infection, and atelectasis. The animals were sacrificed at 3 months to study the histopathologic changes of the trachea and lungs. RESULTS Two upper lobe bronchi remained patent; seven were obstructed by granulation tissue or plugs of mucus and inflammatory cells. Right upper lobe infiltration and atelectasis were seen in eight animals. Interestingly, radiographic opacities were also common in other lung segments. There was a tendency toward fewer and less extensive lung opacities at 3 months compared with that at 1 month. At histopathologic examination, areas of both acute and chronic pneumonia were found in the right upper lobe of all animals. The segment of trachea covered by the stent was lined with a thin layer of granulation tissue containing neutrophils, monocytes, and lymphocytes. The stent luminal surface was covered with columnar, cuboidal, and stratified squamous epithelium. Tracheal stenosis was seen in three animals because of excessive granulation tissue in two and a collapsed stent in one. CONCLUSION Placement of metal stents in pig trachea covering the orifice of the right upper lobe bronchus resulted in retention of secretions and secondary infection in the right upper lobe and other distant lung segments.

Radiology of the Stomach in Infants and Children

Imaging the stomach in infants and children requires techniques which are age- and patient condition-specific. Radiography, fluoroscopy, ultrasound, plain radiography, and scintigraphy are the primary modalities for imaging the pediatric stomach, while computed tomography (CT) and magnetic resonance imaging (MRI) typically play complimentary roles. Imaging is useful in the workup of congenital, developmental, iatrogenic, inflammatory, neoplastic, emergent, and postoperative stomach conditions in children.