Christopher Hannegan

Anatomic Relationship of the InternalJugular Vein and the Common Carotid Artery Applied to Percutaneous Transjugular Procedures

PurposeTo demonstrate the anatomic relationship of the internal jugular vein (IJV) with the common carotid artery (CCA) in order to avoid inadvertent puncture of the CCA during percutaneous central venous access or transjugular interventional procedures.MethodsOne hundred and eighty-eight consecutive patients requiring either central venous access or interventional procedures via the IJV were included in the analysis. The position of the IJV in relation to the CCA was demonstrated by portable ultrasonography. The IJV location was recorded in a clock-dial system using the carotid as the center of the dial and the angles were measured. Outcomes of the procedure were also recorded.ResultsThe IJV was lateral to the CCA in 187 of 188 patients and medial to the CCA in one patient. The left IJV was at the 12 o’clock position in 12 patients (6%), the 11 o’clock position in 17 patients (9%), the 10 o’clock position in 142 patients (75%) and at the 9 o’clock position in 17 patients (9%). The right IJV was at the 12 o’clock position in 8 patients (4%), the 1 o’clock position in 31 patients (16%), the 2 o’clock position in 134 patients (71%) and the 3 o’clock position in 17 patients (9%). In one patient the left IJV was located approximately 60° medial to the left CCA; this was recorded as 2 o’clock on the left since it is opposite to the 10 o’clock position.ConclusionKnowledge of the IJV anatomy and relationship to the CCA is important information for the operator performing an IJV puncture, to potentially reduce the chance of laceration of the CCA and avoid placement of a large catheter within a critical artery, even when ultrasound guidance is used.

Radiofrequency Wire for the Recanalization of Central Vein Occlusions that Have Failed Conventional Endovascular Techniques

PURPOSEnTo report the technique and acute technical results associated with the PowerWire Radiofrequency (RF) Guidewire used to recanalize central vein occlusions (CVOs) after the failure of conventional endovascular techniques.nnnMATERIALS AND METHODSnA retrospective study was conducted from January 2008 to December 2011, which identified all patients with CVOs who underwent treatment with a novel RF guide wire. Forty-two symptomatic patients (with swollen arm or superior vena cava [SVC] syndrome) underwent RF wire recanalization of 43 CVOs, which were then implanted with stents. The distribution of CVOs in central veins was as follows: six subclavian, 29 brachiocephalic, and eight SVC. All patients had a history of central venous catheter placement. Patients were monitored with regular clinical evaluations and central venography after treatment.nnnRESULTSnAll 42 patients had successful recanalization of CVOs facilitated by the RF wire technique. There was one complication, which was not directly related to the RF wire: one case of cardiac tamponade attributed to balloon angioplasty after stent placement. Forty of 42 patients (95.2%) had patent stents and were asymptomatic at 6 and 9 months after treatment.nnnCONCLUSIONSnThe present results suggest that the RF wire technique is a safe and efficient alternative in the recanalization of symptomatic and chronic CVOs when conventional endovascular techniques have failed.

Thrombosed dialysis access grafts: randomized comparison of the Amplatz thrombectomy device and surgical thromboembolectomy.

We report the final results of the trial comparing the Amplatz thrombectomy device (ATD) with surgical thromboembolectomy (ST) to declot thrombosed dialysis access grafts (DAG). The study population consisted of 174 DAG, 109 of which were randomized to mechanical thrombectomy using the ATD and 65 of which were randomized to conventional surgical thromboembolectomy. Forty grafts were re-enrolled in the trial when they failed beyond the 90 days follow-up after the initial treatment. Thirty-one were re-enrolled for mechanical thrombectomy and nine were re-enrolled for surgical thrombectomy, resulting in a total of 140 ATD procedures and 74 surgical thromboembolectomy. Immediate thrombectomy success was defined as greater than 90% thrombus removal followed by the ability to dialyze after treatment, and analysis of long term success based on graft patency at 30 and 90 days, with successful dialysis. Immediate thrombectomy success with the ATD procedure was achieved in 79.2% and with ST in 73.4%. Patency of the graft, with successful dialysis, at 30 days with the ATD procedure was 79.2% and with ST was 73.4%. Patency of the graft, with successful dialysis, at 90 days with the ATD procedure was 75.2% and with ST was 67.8%. The data collected in this study provided a prospective comparison of mechanical thrombectomy with the ATD and ST performance in thrombosed DAG. The results of the performance of both methods were comparable. No statistically significant differences were seen.

Stent migration complicating treatment of inferior vena cava stenosis after orthotopic liver transplantation

A case of inferior vena cava (IVC) stenosis after orthotopic liver transplantation was treated with balloon angioplasty and Wallstent placement. There was stent migration into the right atrium (RA), and percutaneous removal of the stent was attempted without success. Open cardiac surgery was required for stent removal and repair of aortic/RA fistula. Months later, recurrent IVC stenosis was successfully treated with placement of large Z stents after additional failed surgical repair. At 2 years follow-up, the patient is asymptomatic and Doppler ultrasonography demonstrated the stent to be patent and well-positioned.

Stent-Graft Treatment of Pseudoaneurysms and Arteriovenous Fistulae in the Carotid Artery

The purpose of this study was to assess the safety and efficacy of stent-graft placement in the management of arteriovenous fistulae (AVF) and pseudoaneurysms (PAs) involving the carotid artery (CA). Twenty-two patients (16 men, 6 women) with a CA AVF (n = 5) or PA (n = 17) owing to a gunshot or stab wound, carotid endarterectomy, blunt trauma, a tumor, spontaneous dissection, or a central venous catheter were treated with percutaneous placement of stent grafts. The patients presented with tumor, bruit, headache, mouth and tracheostomy bleeding, transitory hemiparesis, seizure, or stroke. Diagnoses were made by using computed tomographic angiography (CTA) and digital subtraction angiography. Fourteen lesions were in the common CA; eight were in the internal CA. Homemade devices and stent grafts from a variety of manufacturers were employed. Follow-up evaluations included clinical, CTA, and Doppler ultrasound assessments. All patients had resolution of the PA or AVF. In one patient with a large petrous PA, acute occlusion of the CA developed after placement of three balloon-expandable stent grafts, but there were no neurologic complications because the circle of Willis was functional. During follow-up ranging from 2 months to 13 years, asymptomatic 90% stenosis owing to stent compression was observed on Doppler ultrasound and angiographic examinations in a patient with an autologous vein–covered stent graft in the internal CA. Three other patients died of causes unrelated to stent-graft placement. In all other patients, the stent graft remained patent. Our results indicate that stent grafting is an acceptable alternative to surgery in the treatment of AVF and PAs in the CA.

Percutaneous retrieval of an Amplatzer septal occluder device that had migrated to the aortic arch.

The secundum type atrial septal defect (ASD) is a relatively common finding in the general population, occurring at a reported rate of 3.78 per 100,000 live births [1], and comprising approximately 6–10% of all congenital cardiac defects [2]. When faced with a symptomatic ASD, there are several methods of treatment available. Open surgery with occlusion of the ASD is the time-honored treatment [3], but percutaneous placement of an occluder device has been the preferred treatment for several years [4]. The choice for the closure method is mainly based on the severity of symptoms, the underlying medical condition, cardiovascular anatomy [5, 6], and the size of the septal defect [7]. Surgical repair has been practiced for more than 50 years and often is preferred when the ASD size is larger and the symptoms are more severe [3]. However, percutaneous occluder device placement has largely replaced surgery when the patient is incapable of withstanding a major procedure, when the septal defect is24 mm [8], and when the septal defect is not located near other vital cardiovascular structures [6]. The Amplatzer septal occluder (ASO) device has been extensively studied for the percutaneous closure of both ventricular as well as atrial septal defects [9, 10]. Using the approach first described in 1976 by King and Mills [4], the Amplatzer device can be placed via a venous route, and may be secured without placing the patient under general anesthesia or using cardiopulmonary bypass. Although percutaneous device placement has been found to have a lower rate of overall complications than surgical closure [5], there have been several reports of adverse events in the literature [5, 6, 8]. The case presented here describes a complication that has not yet been reported, related to the migration of the device to the aortic arch.

Bailout percutaneous external shunt to restore carotid flow in a patient with acute type A aortic dissection and carotid occlusion.

Purpose: To report the use of an external common femoral to carotid artery shunt in the setting of acute type A aortic dissection associated with carotid occlusion and stroke. Technique: The procedure is illustrated in a 52-year-old man who presented with a type A dissection extending into the innominate trunk, with associated occlusion of the right common carotid artery (CCA). Angiography showed no collateral circulation to the right cerebral hemisphere. To re-establish brain perfusion in this setting, a percutaneous external shunt was installed from the common femoral artery to the right CCA. The 5-F femoral sheath used during diagnostic angiography was replaced by an 8-F femoral introducer securely fixed to the skin with silk sutures. Ultrasound-guided percutaneous CCA access was obtained using an 18-G needle and a 6-F introducer, also sutured to the skin. The ICA and intracranial branches showed no evidence of thrombosis at this level. A plastic tube was used to connect the femoral and carotid sheath side arms to restore ICA flow. Transcranial Doppler showed normal flow at the right middle cerebral artery after shunt placement. The patient was immediately transferred to the operating room for aortic surgery, during which an intrapericardially ruptured aorta was found. The ascending aorta and proximal arch were replaced under cardiopulmonary bypass and circulatory arrest, but the patient died during the procedure due to uncontrolled bleeding. Conclusion: A temporary percutaneous external femoral-carotid shunt can restore blood flow to the brain whenever the carotid artery is occluded by the dissection flap and adequate collateral flow is absent.

Comparative results of doppler sonography after TIPS using covered and bare stents

OBJECTIVEnOur purpose was to evaluate the role of sonography in the early follow-up of patients with a covered transjugular intrahepatic portosystemic shunt (TIPS).nnnCONCLUSIONnRoutine baseline Doppler sonography should occur 7-14 days after shunt placement unless malfunction or procedural complications are suspected.

The rise and fall of arterial interventions: presentations at the Society of Interventional Radiology annual scientific meeting.

PURPOSEnTo address hypotheses concerning a decline in presentations pertaining to vascular interventions by interventional radiologists and the loss of ground in other areas, such as oncology, of presentations in vascular interventions at the Society of Interventional Radiology (SIR) Annual Scientific Meeting.nnnMATERIALS AND METHODSnAll abstracts for scientific presentations and scientific exhibits from the program book of the SIR annual meeting were reviewed from the period 1996-2006. The abstracts were grouped in different classes, such as (a) type of methodology, (b) reports on arterial interventions, (c) reports on oncologic interventions, and (d) geographic origin.nnnRESULTSnScientific abstracts presented at the SIR annual meeting totaled 3,162. Presentations ranged from 177-407 (1996-2003) plus 250 in 2006 with a mean of 288 presentations per year. The overall number of abstracts reporting arterial interventions had a peak of 89 presentations in 2000 and declined to 34 presentations in 2006. Reports of arterial interventions from the United States had a peak of 48 presentations in 2003 and declined to 12 in 2006. Reports of arterial interventions from Europe had a peak of 37 presentations in 2000 and declined to 11 in 2006. Reports of arterial interventions from Asia had a peak of 10 presentations in 1999 and declined to 6 in 2006. The trends are similar for the three components of arterial interventions when analyzed individually. In 1997, 26.6% of all the presentations were arterial interventions; in 2000, 25.1%; and in 2006, only 13.6%. There was a trend in the increase of oncology presentations starting in 2004. In 2003, it was 10%, and it was 22.4% in 2006.nnnCONCLUSIONSnThere has been a decline in the overall number of abstracts presented at the SIR annual meeting after a peak in 2003. There has been a decline in the number of arterial intervention reports. The decline in presentations of arterial interventions that originated in the United States was also observed in presentations that originated from Europe and Asia. There has been an increasing trend in interventional oncology reports starting in 2004.