Donald E. Schwarten

Percutaneous Transluminal Angioplasty of the Renal Artery

Percutaneous transluminal renal angioplasty (PTRA) has been employed in 70 renal arteries, utilizing the balloon angioplasty technique described by Grüntzig for peripheral vessels. The procedure has been employed both in patients with normal renal function and in selected patients with decreased renal function. The complication rate has been low (5.7%), and no patient has required operative intervention as a result of a complication sustained during PTRA. The early results of PTRA compare favorably to those achieved through operative revascularization. An assessment of the duration of PTRAs effects must however, await the results of long-term follow-up.

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.

Suture-mediated closure of the femoral access site after cardiac catheterization: results of the suture to ambulate aNd discharge (STAND I and STAND ii) trials

Despite advances in other aspects of cardiac catheterization, manual or mechanical compression followed by 4 to 8 hours of bed rest remains the mainstay of postprocedural femoral access site management. Suture-mediated closure may prove to be an effective alternative, offering earlier sheath removal and ambulation, and potentially a reduction in hemorrhagic complications. The Suture To Ambulate aNd Discharge trial (STAND I) evaluated the 6Fr Techstar device in 200 patients undergoing diagnostic procedures, with successful hemostasis achieved in 99% of patients (94% with suture closure only) in a median of 13 minutes, and 1% major complications. STAND II randomized 515 patients undergoing diagnostic or interventional procedures to use of the 8Fr or 10Fr Prostar-Plus device versus traditional compression. Successful suture-mediated hemostasis was achieved in 97.6% of patients (91.2% by the device alone) compared with 98.9% of patients with compression (p = NS). Major complication rates were 2.4% and 1.1%, and met the Blackwelders test for equivalency (p <0.05). Median time to hemostasis (19 vs 243 minutes, p <0.01) and time to ambulation (3.9 vs 14.8 hours, p <0.01) were significantly shorter for suture-mediated closure. Suture-mediated closure of the arterial puncture site thus affords reliable immediate hemostasis and shortens the time to ambulation without significantly increasing the risk of local complications.

Angioplasty and stenting of completely occluded iliac arteries

Percutaneous angioplasty and placement of balloon-expandable intraluminal stents were performed in 12 iliac occlusions in 12 patients. Indications were limb salvage in seven and claudication in five. After successful stenting, ankle-brachial indexes improved by 0.15 or more in 11 of 12 patients (mean increase, 0.40), transstenotic pressure gradients decreased to less than 5 mm Hg (mean, 0.58 mm Hg) in all patients, and improvement in clinical grade was seen in all patients. At follow-up at 1-14 months (median, 6 months), ankle-brachial indexes were stable (mean, 0.95), and clinical grades were unchanged in all patients. Complications occurred in two patients; both experienced distal embolization, and one, who was receiving corticosteroid therapy, also suffered stent thrombosis. Local surgical embolectomy was successful in both patients, and the thrombosed stent was recanalized with urokinase. This early experience suggests that stenting may play an important role in the management of iliac occlusions, especially in poor surgical candidates.

Transcatheter Occlusion of the Gastroduodenal Artery

The gastroduodenal arteries of 7 patients were occluded for treatment of duodenal bleeding in 4, hepatic devascularization in 2, and redistribution of blood flow for intra-arterial chemotherapy in one patient. In 6 patients, occlusion was performed with Gianturco coils, and with Gelfoam in one. No major complication was encountered. This approach was successful in the control of bleeding from peptic ulcers, arteriovenous malformation and invasion of duodenum by retroperitoneal metastatic lymph nodes from carcinoma of the testicle. Occlusion of the gastroduodenal artery was utilized for further dearterialization of hepatic neoplasms. Redistribution of hepatic blood flow was accomplished by the occlusion of the gastroduodenal and replaced right hepatic arteries allowing infusion of chemotherapeutic agents into the entire liver through the left hepatic artery.