Charles J. Tegtmeyer

Multicenter Trial of the Wallstent in the Iliac and Femoral Arteries

PURPOSE To report the results of the FDA phase II, multicenter trial of the Wallstent in the iliac and femoral arteries. PATIENTS AND METHODS Two hundred twenty-five patients entered the trial. Stents were placed in the iliac system in 140 patients and in the femoral system in 90 (five patients required both iliac and femoral stents). Clinical patency was measured over 2 years by means of life-table analysis with use of clinical and hemodynamic data and the Rutherford scale. Angiographic patency was measured at 6 months. RESULTS In the iliac system the primary clinical patency was 81% at 1 year and was 71% at 2 years. The secondary clinical patency was 91% and 86%, respectively. The 6-month angiographic patency was 93%. In the femoral system the primary clinical patency was 61% at 1 year and 49% at 2 years. The secondary patency was 84% and 72%, respectively. The 6-month angiographic patency was 80%. CONCLUSIONS The results are similar to those with the Palmaz stent in the iliac system and with angioplasty alone in the iliac and femoral systems.

Percutaneous Transluminal Angioplasty of Visceral Arterial Stenoses: Results and Long-term Clinical Follow-up

PURPOSE To determine the efficacy and safety of percutaneous transluminal angioplasty (PTA) of the visceral arteries. PATIENTS AND METHODS We retrospectively evaluated the results of PTA performed in 20 visceral arteries in 19 patients (10 men, nine women; mean age, 63 years). Eleven patients had symptoms characteristic of mesenteric ischemia, four had atypical abdominal pain, and four were undergoing prophylactic dilation before undergoing another procedure involving the abdominal aorta. Clinical follow-up was possible in all patients. RESULTS PTA was technically successful in 15 of 19 patients (79%); among these 15 patients, 12 (80%) did well clinically. Of the seven PTA procedures that were immediate failures, five failed secondary to an occult malignancy or to extrinsic arterial compression by the median arcuate ligament. Ten (83%) of the 12 patients in whom the procedures were immediate clinical successes are still clinically improved at 4-73 months follow-up (mean, 25 months). PTA was successful in only one of the four patients who had symptoms atypical of mesenteric ischemia, but it was successful in 11 of the 15 patients who had symptoms of mesenteric ischemia or who underwent prophylactic dilation. Major complications occurred in three (16%) of the 19 patients. CONCLUSION PTA of visceral artery stenoses is effective in patients with symptoms of mesenteric ischemia. It is also effective as prophylaxis in patients undergoing additional procedures in the abdominal aorta.

Percutaneous transluminal angioplasty for renovascular hypertension in children

Percutaneous transluminal angioplasty (PTA) has been developed over the past 8 years as an alternative to reconstructive surgery for renovascular hypertension. We report three cases and review the use of PTA in children with renal artery stenosis. At least 37 cases of PTA have been reported in patients whose ages ranged from 1.3 to 17 years (mean 10 years). Of these, 10 had fibromuscular dysplasia; 13 unspecified unilateral renal artery stenosis; 4 bilateral stenosis; 4 neurofibromatosis; 4 renal transplant; 1 atherosclerosis; and 1 postsurgical stenosis. Nine of 10 patients with fibromuscular dysplasia were cured and 3 of 4 with renal transplant arterial stenosis were cured or improved. There were 11 failures of PTA, including all 4 patients with neurofibromatosis and 1 with transplant arterial stenosis. We conclude that PTA is the treatment of choice for children with hypertension due to fibromuscular dysplasia and should be attempted for stenosis of the transplanted renal artery. Other lesions resulting in renal artery stenosis may not be as amenable to dilation and should be considered on an individual basis.

Identification and differentiation of surgically correctable hypertension due to primary aldosteronism

During a protocol study for the evaluation of patients with primary aldosteronism, a variety of diagnostic studies were employed in an attempt to identify patients with primary aldosteronism and to differentiate patients with adrenal adenoma from patients with idiopathic adrenal hyperplasia. In this study, we are able to demonstrate the utility of (1) absent postural increase in plasma aldosterone concentration, (2) adrenal scanning and (3) normalization of blood pressure with spironolactone therapy in identifying patients with primary aldosterone excess who have an adrenal adenoma, surgical removal of which results in eliminating their hypertension.

False aneurysm of the pulmonary artery: a complication of pulmonary artery catheterization.

Abstract A case of Swan-Ganz catheter–induced pulmonary artery injury is discussed. Iatrogenic pulmonary artery injury probably occurs more frequently than is clinically suspected. Pulmonary angiography is urged when hemoptysis occurs in a patient with an indwelling pulmonary artery catheter.

Flow characteristics of peripherally inserted central catheters

PURPOSE Clinical applications of peripherally inserted central catheters (PICCs) are limited by the relatively small lumina and long lengths of these devices. Quantitative analysis of the flow capabilities of a variety of PICCs was performed to aid in deciding which patients should have a PICC and in selecting the appropriate catheter. MATERIALS AND METHODS Sixteen different PICCs from six manufacturers were infused at flow rates of 25-270 mL/h. Infusions were performed with distilled water, normal saline, total parenteral nutrition solution, intralipids, and blood. Flow versus pressure curves were generated for each PICC and infusate. Additional catheter data recorded included the working length, outer diameter (OD), and inner diameter (ID) of the PICCs. RESULTS Because of the thin wall construction of polyurethane catheters, PICCs made from polyurethane showed much better flow rates than silicone PICCs of a comparable OD. The measured ODs of the PICCs were 4-6 F, whereas the IDs ranged from 0.012 to 0.032 inch. Because of the small ID of some PICCs, infusing blood or intralipids is not practical. CONCLUSION There is significant variability in the flow capabilities of available PICCs. Many of the PICCs require pressures greater than those that can be generated by commercially available infusion pumps. Matching PICC characteristics to the desired application will avoid many of the clinical problems currently encountered with PICCs.

Treatment of Hemodialysis Fistula Pseudoaneurysms with Detachable Balloons: Technique and Preliminary Results

Pseudoaneurysm formation is commonly encountered during the life of a dialysis fistula. When these become excessively large or numerous, surgical revision of the graft has been the only treatment option. The authors have treated seven patients by using percutaneous placement of a detachable balloon to occlude a pseudoaneurysm of an upper extremity graft. In four cases the balloon was directed into the pseudoaneurysm from a femoral artery approach. In three cases a direct puncture was made into the pseudoaneurysm for placement of the balloon. The patients were followed up from 1 week to 7 months. Initial technical success was achieved in all seven cases with no complications. Thrombosis of two grafts occurred during the first week after the procedure: one because of herniation of the balloon out of the pseudoaneurysm and one for unknown reasons. One balloon was inadvertently punctured and deflated during subsequent dialysis. Treatment in the other four cases was successful, as evidenced by no further enlargement of the pseudoaneurysms. Direct puncture of the pseudoaneurysm simplifies the procedure and probably decreases the likelihood of balloon herniation because of the orientation of the balloon.

Catheter tract seeding after percutaneous biliary drainage for pancreatic cancer

Percutaneous biliary drainage is frequently used to decompress obstruction of a malignant origin. The development of a tumor along the drainage tract is rare and has been reported only where the catheter has transgressed the obstruction. The authors report seeding of a percutaneous drainage tract after short‐term decompression of obstructive jaundice in a patient who underwent curative resection for pancreatic carcinoma and in whom the catheter was not passed through the tumor. Exfoliated cancer cells in the bile duct are believed to be responsible. Caution is suggested in the use of percutaneous biliary drainage for temporary drainage in the patient who is a candidate for curative resection.

Real-time ultrasound for the detection of deep venous thrombosis

PURPOSE Accurate diagnosis of deep venous thrombosis (DVT) is a clinical problem in emergency practice. A prospective trial was conducted comparing real-time ultrasound with contrast venography in the diagnosis of proximal DVT. METHODS Seventy patients whose clinical presentations mandated diagnostic evaluation for DVT had real-time ultrasound of the involved leg followed by contrast venography. Initial readings of ultrasound and venography were compared with each other and with final readings to assess reliability of interpretation. RESULTS Final ultrasound readings agreed with final venogram readings in all patients. Negative initial ultrasound readings agreed with final venogram readings in 56 of 56 patients (negative predictive value, 100%; 95% confidence interval, 94 to 100). Eighteen patients had positive initial ultrasound readings compared with 14 who had positive final venogram readings (positive predictive value, 78%; 95% confidence interval, 55 to 91). CONCLUSION Negative real-time ultrasonography reliably excludes proximal DVT. Positive ultrasound reliably diagnoses proximal DVT only in experienced hands.

Arthrography of the knee: a comparative study of the accuracy of single and double contrast techniques.

Single and double contrast arthrographic techniques were compared in 951 patinets with suspected meniscal injuries. Exploratory surgery of the knee was performed in 384 of these patients and good clinical follow-up was obtained in 135 patients. In the latter two groups of patients, the single contrast technique was 97% accurate in assessing the medial meniscus and 96% accurate in assessing the lateral meniscus. Double contrast arthrography was 97% accurate in assessing the medial meniscus and 93% accurate in assessing the lateral meniscus. Numerical differences in the results from the two techniques were not statistically significant. Therefore both techniques can be considered equally effective diagnostically.