David L. Waldman

Superselective Microcoil Embolization for the Treatment of Lower Gastrointestinal Hemorrhage

PURPOSE To evaluate the safety and effectiveness of superselective microcoil embolization for the treatment of lower gastrointestinal (LGI) hemorrhage. MATERIALS AND METHODS A retrospective review of LGI superselective microcoil embolization data for a 10-year period was performed. During this period, twenty-two patients with evidence on angiography of LGI bleeding underwent superselective microcoil embolization. Hemorrhage was treated in the colon (n = 19) and jejunum (n = 3). Ivalon was used adjunctively in two patients and gelfoam was used as a secondary agent in two additional patients. Postembolization ischemia was evaluated objectively in 14 patients by colonoscopy (n = 10), surgical specimen (n = 3), and barium enema (n = 1). All patients were followed for clinical evidence of bowel ischemia. Four patients died before further follow-up could be performed. Additionally, 122 cases of LGI hemorrhage treated with superselective microcoil embolization were identified in a review of the literature. A meta-analysis was then performed, combining the data in this study and the data from the literature, to estimate the rate of major and minor ischemic complications on a total of 144 superselective microcoil embolizations. RESULTS Immediate hemostasis was achieved in all 22 patients in this study. Complete clinical success was achieved in 86% of patients (19 of 22 patients). Rebleeding occurred in 14% of patients (3 of 22 patients) and each underwent colonoscopic intervention with success. Postembolization objective follow-up was performed in 64% of patients (14 of 22 patients). Ten patients underwent follow-up colonoscopy; one patient received a follow-up barium enema; and three patients underwent subsequent surgery. Colonic resection (one partial and one total) was performed in two patients. The partial colectomy was performed in a patient who had been diagnosed with colonic polyps and dysplasia. The total colectomy was performed on a patient with history of chronic LGI bleeding complicated by long-term anticoagulation therapy and a history of tubular adenoma resection. The third surgical patient (16 months old) underwent a follow-up exploratory laparotomy after embolization of a proximal jejunal branch of the superior mesenteric artery. None of the three patients who underwent surgery were found to have postembolic ischemic changes in the bowel specimen. Four patients in this study died, for reasons unrelated to hemorrhage or embolization, before further follow-up could be performed. The last four patients were followed clinically and experienced no symptoms of intestinal ischemia. A minor ischemic complication was reported in 4.5% of patients (1 of 22 patients), and there were no major ischemic complications (0%) in this series. A review of the data from 122 cases of LGI superselective microcoil embolization in the literature is also presented. Combined with the data in this study, the minor complication rate was 9% (13 of 144 patients), and the major complication rate was 0% (0 of 144 patients). CONCLUSION Superselective microcoil embolization is a safe and effective treatment for LGI hemorrhage.

An Endoluminal Method of Hemorrhage Control and Repair of Ruptured Abdominal Aortic Aneurysms

Purpose: To report our initial experience with endovascular grafting to treat ruptured abdominal aortic aneurysms (AAAs). Methods: Three consecutive patients with severe comorbid illnesses and symptoms of aneurysm rupture and hemodynamic instability were treated with aortomonoiliac grafts. The Z-stent—based devices were implanted with the assistance of an occlusion balloon placed in the distal descending thoracic aorta. Results: All patients survived the procedure with successfully excluded AAAs. Two patients had relatively short hospital stays (4 and 14 days), while the third required prolonged treatment for pre-existing conditions. All patients required blood transfusions; 2 developed significant coagulopathies. Definitive management was delayed significantly by imaging protocols and graft construction. Conclusions: Endovascular repair of ruptured aortic aneurysms is feasible. Proximal aortic control is readily attainable with the use of an aortic occlusion balloon placed through the left axillary artery. The absence of a laparotomy, extensive retroperitoneal dissection, and aortic cross-clamping likely contributes to patient survival; however, the delay in operative therapy to obtain adequate imaging and construct an endograft could be a hindrance to the ultimate success of this approach. The concepts of alternative aortic imaging techniques and endograft design, construction, and storage must be addressed.

Endovascular Management of Central Venous Stenoses in the Hemodialysis Patient: Results of Percutaneous Therapy

The purpose of this study was to determine the functional results of transvenous angioplasty for the treatment of central venous stenoses in patients with failing upper extremity arteriovenous access. Two hundred consecutive patients presented with threatened arteriovenous access from January 1999 through July 2002. Angiographic evidence of central venous stenosis was present in 35 patients (18%) (superior vena cava 5, brachiocephalic veins 14, and subclavian veins 18). Follow-up averaged 873 days from the date of initial intervention. The initial technical success rate was 89%. Primary patency for each intervention was 85% at 30 days, 55% at 6 months, 43% at 1 year, and 0% at 2 years. Assisted primary patency rates were 88% at 30 days, 80% at 1 year, and 64% at 2 years. Freedom from central venous dialysis catheter placement was 82% at 30 days, 63% at 3 months, 51% at 1 year, 37% at 2 years, and 25% at 3 years. Freedom from a dialysis catheter was superior in those patients with autogenous arteriovenous fistulas. Transvenous angioplasty appears to be beneficial for hemodialysis patients with central venous stenoses, and it helps preserve functional access in the affected extremity, particularly in patients with autogenous fistulas.

Internal carotid artery pseudoaneurysms: treatment with the Wallgraft endoprosthesis.

PURPOSE To report several cases illustrating the feasibility and mid-term efficacy of deploying a self-expanding stent-graft to treat traumatic ruptures, pseudoaneurysms, and a spontaneous dissection of the internal carotid artery (ICA). CASE REPORTS One patient suffered a stab wound and another developed a large pseudoaneurysm years after a gunshot to the neck. The third patient presented with a spontaneous rupture in the setting of fibromuscular dysplasia, and the final patient developed a pseudoaneurysm following carotid endarterectomy in an irradiated neck. All 4 patients were successfully treated with Wallgrafts deployed in the ICA using either an open carotid (first 3 cases) or percutaneous approach (fourth patient). There were no adverse neurological events. During a mean 16-month follow-up (range 6-24), duplex ultrasound and CT scanning found no evidence of restenosis, occlusion, or persistent perfusion of the pseudoaneurysm, which was noted to decrease in all cases. CONCLUSIONS The thin-walled fabric of the Wallgraft appears capable of completely excluding the pseudoaneurysm, resulting in decreased aneurysm size over time.

Sclerotherapy with Use of Doxycycline after Percutaneous Drainage of Postoperative Lymphoceles

PURPOSE To assess the use of doxycycline as a sclerosing agent after percutaneous drainage of postoperative lymphoceles. MATERIALS AND METHODS Symptomatic postoperative lymphoceles (n = 21) in 18 patients were treated by percutaneous tube drainage for an average of 10.8 days. Sclerosis was performed when the patient became asymptomatic, drainage had slowed to less than 30 mL/d and follow-up imaging (CT or US) showed either near complete or total resolution of the lymphocele. Doxycycline (500 mg) combined with 1% lidocaine (5 mL) was instilled into the cavity with use of a syringe after any remaining lymphocele fluid was removed through the tube. When possible, patients were instructed to perform a series of maneuvers for the next hour to distribute the sclerosing agent evenly throughout the cavity. After 1 hour, the sclerosing agent was aspirated from the cavity and the drainage tube was removed. Three patients with four lymphoceles underwent sclerotherapy immediately after percutaneous insertion of a drainage tube and aspiration of the lymphocele. No patients underwent previous sclerosis with any agent. RESULTS Successful treatment of postoperative lymphoceles was achieved in 17 of 18 patients. Primary success was achieved in 17 of 21 lymphoceles treated. There were four lymphocele recurrences in three patients. Three of the four recurrences were successfully treated by means of repeated drainage and sclerotherapy. One recurrent lymphocele persisted after re-treatment with 1 g of doxycycline. This patient underwent successful surgical repair. There were no complications related to doxycycline sclerosis. The mean duration of drainage for initial and recurrent lymphoceles was 10.8 days (range, 0-30 days). CONCLUSION Sclerotherapy with use of doxycycline after percutaneous drainage is an easy, safe, inexpensive, and effective means of treating postoperative lymphoceles.

Mechanical versus Chemical Thrombolysis: An In Vitro Differentiation of Thrombolytic Mechanisms

PURPOSE To assess differing mechanisms of thrombolysis determining time to reperfusion, completeness of thrombus dissolution, and embolic potential. MATERIALS AND METHODS An in vitro perfusion model designed to mimic arterial flow conditions was created. Bifurcated limbs allowed continuous flow through one channel and the placement of radiolabeled (iodine-125) thrombus housed in a 5-cm segment of polytetrafluoroethylene graft in the other. The three experimental groups consisted of a standard continuous urokinase infusion, a pulsed pressurized injection of saline, and a similar injection with urokinase. A continuous infusion of 5% dextrose served as a control group. Time to reflow (as assessed with ultrasonic flow monitoring), completeness of thrombus dissolution (I-125 liberated into solution), and the number and size of embolic particles produced (detected by a series of graduated filter sizes) were analyzed. RESULTS Time to reflow was significantly faster for both groups when pressurized injections were used (P < .001). There was no reflow in the control arm at 90 minutes. Completeness of thrombus dissolution was higher when a continuous infusion of urokinase was used in comparison to either of the power injection groups or the control (P < .05). The amount of embolic debris produced was significantly lower with a continuous infusion of urokinase compared with either of the power lysis groups (P < .05), but significantly greater than the control arm (P < .001). The size of the embolic particles in the power pulsed lysis groups was significantly decreased by the addition of urokinase (P < .05). CONCLUSIONS Reflow is more rapidly established by the use of mechanical means. However, a less complete dissolution of thrombus in conjunction with a greater amount of embolic debris is achieved with this approach. The size of the embolic particles produced is reduced by the addition of a thrombolytic agent.

Digital Radiography Reject Analysis: Data Collection Methodology, Results, and Recommendations from an In-depth Investigation at Two Hospitals

Reject analysis was performed on 288,000 computed radiography (CR) image records collected from a university hospital (UH) and a large community hospital (CH). Each record contains image information, such as body part and view position, exposure level, technologist identifier, and—if the image was rejected—the reason for rejection. Extensive database filtering was required to ensure the integrity of the reject-rate calculations. The reject rate for CR across all departments and across all exam types was 4.4% at UH and 4.9% at CH. The most frequently occurring exam types with reject rates of 8% or greater were found to be common to both institutions (skull/facial bones, shoulder, hip, spines, in-department chest, pelvis). Positioning errors and anatomy cutoff were the most frequently occurring reasons for rejection, accounting for 45% of rejects at CH and 56% at UH. Improper exposure was the next most frequently occurring reject reason (14% of rejects at CH and 13% at UH), followed by patient motion (11% of rejects at CH and 7% at UH). Chest exams were the most frequently performed exam at both institutions (26% at UH and 45% at CH) with half captured in-department and half captured using portable x-ray equipment. A ninefold greater reject rate was found for in-department (9%) versus portable chest exams (1%). Problems identified with the integrity of the data used for reject analysis can be mitigated in the future by objectifying quality assurance (QA) procedures and by standardizing the nomenclature and definitions for QA deficiencies.

Transhepatic Dilation of Anastomotic Biliary Strictures in Liver Transplant Recipients with Use of a Combined Cutting and Conventional Balloon Protocol: Technical Safety and Efficacy

PURPOSE To determine the safety and technical efficacy of a transhepatic dilation protocol involving the use of a combined cutting and conventional balloon protocol in the management of anastomotic biliary strictures in adult liver transplant recipients. MATERIALS AND METHODS Retrospective review of adult transplant recipients undergoing transhepatic cutting balloon dilation for anastomotic biliary strictures was performed over a period of 8 months. Cutting balloon dilation was followed by conventional balloon dilation with use of a balloon with a diameter at least as large as that of the initial cutting balloon. Technically successful dilation was defined by improvement of the biliary stricture. A technically successful regimen was defined by a residual stenosis less than 30% after a maximum of three sessions. The technical results were stratified according to lesions treated for the first time and those with restenosis. Comparison among institutions in terms of published methods and technical results were made. RESULTS Twenty-two patients with liver transplants underwent 49 cutting balloon dilation sessions as part of 27 regimens (1.8 sessions per regimen): 12 cases of primary treatment, 10 cases of restenosis, four for intraprocedural failures of conventional balloon dilation, and one for the latter two indications. Technical success rates of regimens for primary stenoses, restenoses, and all cases were 100%, 90%, and 93%, respectively. These results compare favorably with historic intrainstitutional results, which are 89%, 73%, and 85% for primary stenoses, restenoses, and all cases, respectively. In addition, no biliary ruptures or cases of major hemobilia were encountered. Minor hemobilia was encountered in 10% of cases. CONCLUSIONS The use of commercially available cutting balloons augmented subsequently with larger conventional balloons is safe for transhepatic balloon dilation and can increase the technical success rate of percutaneous management of transplant biliary strictures.

Transhepatic balloon dilation of anastomotic biliary strictures in liver transplant recipients : The significance of a patent hepatic artery

PURPOSE To determine the significance of hepatic artery steno-occlusive disease on the patency of anastomotic biliary strictures in liver transplant recipients after transhepatic balloon dilation. MATERIALS AND METHODS A retrospective review of records of all patients undergoing transhepatic balloon dilation for anastomotic biliary strictures after orthotopic liver transplantation was performed over an 8-year period. Patency of the anastomosis was based on subsequent cholangiography. The presence of hepatic artery steno-occlusive disease was determined by Doppler ultrasound and/or angiography. The anastomotic biliary stricture patency rates were calculated by the Kaplan-Meier method. RESULTS Thirty-eight patients who had undergone liver transplants underwent 53 balloon dilations for anastomotic biliary strictures (nine patients for arterial disease, 26 patients had patent arteries and three patients had arteries of indeterminate patency). Eight of the 53 strictures treated (15%) were refractory to balloon dilation: 10.5% of first comers and 27% of restenotic lesions. Two of the 53 strictures treated (4%) had significant complications: hemobilia requiring blood transfusion and ductal rupture. One-year cumulative primary patency rates for anastomotic biliary strictures for patients with arterial disease, patent hepatic arteries, and all-comers were: 0%, 45% (P = .01), and 36%, respectively. One-year cumulative primary patency rates for choledocho-choledocal and choledocho-jejunal anstomoses in patients with patent arteries were 43% and 48%, respectively (P = .10). CONCLUSIONS In the presence of hepatic artery disease there is a lower patency of anastomotic biliary strictures after balloon dilation. Imaging of the hepatic artery should be considered to stratify patients who will have a successful outcome.

Impact of Chronic Kidney Disease on Outcomes of Superficial Femoral Artery Endoluminal Interventions

While aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of chronic kidney disease (CKD) on long-term outcomes in this population are unclear. We examined the consequences of endovascular treatment of the SFA in patients with and without varying stages of CKD. A database of patients undergoing endovascular treatment of the SFA between 1986 and 2007 was queried, and two groups were defined: estimated glomerular filtration rate (eGFR) <or=60 and >60 mL/min/1.73 cm(2). Intention-to-treat analysis was performed. Results were standardized to TransAtlantic Inter-Society Consensus (TASC-II) and Society for Vascular Surgery criteria. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- standard deviation where appropriate. There were 525 limbs in 535 patients (68% male, average age 66 +/- 14 years) that underwent endovascular treatment for claudication or chronic critical limb ischemia (51%). Patients with eGFR <or=60 were older and had significantly more coronary artery disease, congestive heart failure, diabetes mellitus, and hyperlipidemia. TASC-II lesion distribution was equivalent (37% for TASC-II C and D), but tibial runoff was significantly worse in the eGFR <or=60 group. In addition, there were more inflow and outflow interventions in the eGFR <or=60 group. In patients with claudication, there was no difference in patency or limb salvage between those with eGFR <or=60 and >60. In patients with critical limb ischemia, there was no difference in patency between those with eGFR <or=60 and >60. Limb salvage was worse in patients with eGFR <or=60 compared to eGFR >60. With respect to limb salvage, six factors were significantly associated with a reduction in rates: presence of tissue loss at presentation (relative risk [RR] = 6.45, p = 0.003), 0 or 1 vessel tibial runoff (RR = 2.56, p < 0.01), progression of distal disease noted in follow-up (RR = 4.62, p < 0.01), embolization at the initial intervention (RR = 2.70, p < 0.05), diabetes mellitus (RR = 3.71, p < 0.01), and a history of congestive heart disease (RR = 2.42, p < 0.01). Notable factors that were not significantly associated included lesion calcification (p = 0.64), TASC C or D lesion categorization (p = 0.99), acute occlusion at initial intervention (p = 0.40), and adjuvant stenting (p = 0.67). CKD does not impact the patency of SFA interventions. Limb salvage in patients with critical ischemia is significantly worse when the eGFR is <or=60 mL/min/1.73 cm(2).