Douglas M. Coldwell

The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome.

OBJECTIVE To determine the benefit of screening for blunt carotid arterial injuries (BCI) in patients who are asymptomatic. SUMMARY BACKGROUND DATA Blunt carotid arterial injuries have the potential for devastating complications. Published studies report 23% to 28% mortality rates, with 48% to 58% of survivors having permanent severe neurologic deficits. Most patients have neurologic deficits when the injury is diagnosed. The authors hypothesized that screening patients who are asymptomatic and instituting early therapy would improve neurologic outcome. METHODS The Trauma Registry of the authors Level I Trauma Center identified patients with BCI from 1990 through 1997. Beginning in August 1996, the authors implemented a screening for BCI. Arteriography was used for diagnosis. Patients without specific contraindications were anticoagulated. Endovascular stents were deployed in the setting of pseudoaneurysms. RESULTS Thirty-seven patients with BCI were identified among 15,331 blunt-trauma victims (0.24%). During the screening period, 25 patients were diagnosed with BCI among 2902 admissions (0.86%); 13 (52%) were asymptomatic. Overall, eight patients died, and seven of the survivors had permanent severe neurologic deficits. Excluding those dying of massive brain injury and patients admitted with coma and brain injury, mortality associated with BCI was 15%, with severe neurologic morbidity in 16% of survivors. The patients who were asymptomatic at diagnosis had a better neurologic outcome than those who were symptomatic. Symptomatic patients who were anticoagulated showed a trend toward greater neurologic improvement at the time of discharge than those who were not anticoagulated. CONCLUSIONS Screening allows the identification of asymptomatic BCI and thereby facilitates early systemic anticoagulation, which is associated with improved neurologic outcome. The role of endovascular stents in the treatment of blunt traumatic pseudoaneurysms remains to be defined.

Treatment of posttraumatic internal carotid arterial pseudoaneurysms with endovascular stents

BACKGROUND The sequelae of blunt injury to the carotid arteries are unusual, but pseudoaneurysms causing subsequent strokes are devastating. The utility of treatment of these pseudoaneurysms was examined. METHODS All patients at a Level I trauma center with previously documented traumatic risk factors were assessed for blunt injury to the carotid arteries and, when a pseudoaneurysm was present, a self-expanding metallic stent was placed across the lesion and the patient placed on anticoagulation. Follow-up arteriograms were obtained in 2 months and every 6 months thereafter. RESULTS Fourteen patients (7 men, 7 women) with an average age of 27 years, an Injury Severity Score of 38, had formed pseudoaneurysms in 16 extracranial internal carotid arteries. These were stented with metallic endoprostheses. No strokes occurred after the placement of the stents. Mean follow-up period has been 2.5 years. CONCLUSIONS Use of metallic endoprostheses is an effective method to treat this potentially devastating injury. However, longer follow-up and more patients studied are needed to further examine this promising treatment.

Critical appraisal of the angiographic portacaval shunt (TIPS)

The transjugular intrahepatic portacaval shunt (TIPS) is a novel angiographic method for achieving portal decompression without operation. Fifty-nine consecutive patients underwent a total of 80 consecutive TIPS procedures. The procedure was unsuccessful in 4 patients (7%) and initially succeeded in 55 (93%). Eighteen patients (30%) underwent 2 or more TIPS procedures during the same hospitalization due to technical difficulties, early rebleeding, shunt stenosis, or thrombosis. Early TIPS occlusion occurred in seven patients (12%) and led to recurrent variceal hemorrhage in five. Forty-two percent of the cases of persisting or recurrent bleeding were nonvariceal. Procedure-related complications occurred in 10% of TIPS procedures or 14% of patients. Twenty-three patients (39%) were actively bleeding at the time of the procedure, and, in 6 of these (26%), bleeding was never controlled. In-hospital mortality (25%) was related only to the presence of bleeding at the time of TIPS (56% for emergent versus 5.5% for non-emergent, p < 0.0001). Mortality was not related to the Child-Pugh classification. Hemodynamic stabilization, vasoconstrictor therapy, balloon tamponade, and sclerotherapy were underutilized in 30% to 40% of patients prior to TIPS. Aggressive medical management should be used to stop variceal hemorrhage prior to TIPS in all patients, regardless of the Child-Pugh classification. Prospective trials comparing TIPS with sclerotherapy and surgical shunt are required to demonstrate the proper role of this procedure in the management of portal hypertension and variceal hemorrhage.

A Randomized, Prospective Evaluation of the Tesio, Ash Split, and Opti-flow Hemodialysis Catheters

PURPOSE A randomized, prospective evaluation of three high-flow hemodialysis catheters. MATERIALS AND METHODS Ninety-four patients were randomly assigned 113 Tesio, Ash split, and Opti-flow catheters from December 1998 through June 1999. Insertion times, procedural complications, and ease of insertion were recorded. Mean catheter flow rates were recorded at first dialysis, 30 days, and 90 days. Patency, catheter survival, and catheter-related infections were evaluated. RESULTS Thirty-eight Ash split, 39 Opti-flow, and 36 Tesio catheters were placed. Tesio mean insertion time (41.5 min) was significantly longer than Ash split (29.4 min) or Opti-flow (29.6 min) (P =.004). There were four complications related to Tesio catheters (three cases of pericatheter bleeding, one air embolism), one related to an Opti-flow catheter (pericatheter bleeding), and zero related to Ash split catheters. Opti-flow and Ash split catheters were significantly easier to insert than Tesio catheters (P =.041). Mean flow rates were not significantly different among the catheters initially (P =.112), at 30 days (P =.281), or at 90 days (P =.112). Catheter-related infection rates per 100 catheter days were 0.12 for Ash split, 0.35 for Opti-flow, and 0.14 for TESIO: Median catheter survival was 302 days for Ash split, 176 days for Opti-flow, and 228 days for TESIO: CONCLUSIONS Opti-Flow and Ash split catheters were faster and easier to place than Tesio catheters. There was no difference in hemodialysis flow rates or catheter survival.

Multicenter evaluation of the safety and efficacy of radioembolization in patients with unresectable colorectal liver metastases selected as candidates for (90)Y resin microspheres.

BACKGROUND Metastatic colorectal cancer liver metastases Outcomes after RadioEmbolization (MORE) was an investigator-initiated case-control study to assess the experience of 11 US centers who treated liver-dominant metastases from colorectal cancer (mCRC) using radioembolization [selective internal radiation therapy (SIRT)] with yttrium-90-((90)Y)-labeled resin microspheres. METHODS Data from 606 consecutive patients who received radioembolization between July 2002 and December 2011 were collected by an independent research organization. Adverse events (AEs) and survival were compared across lines of treatment using Fishers exact test and Kaplan-Meier estimates, respectively. RESULTS Patients received a median of 2 (range, 0-6) lines of prior chemotherapy; 35.1% had limited extrahepatic metastases. Median tumor-to-liver ratio and -activity administered at first procedure were 15% and 1.17 GBq, respectively. Hospital stay was <24 hours in 97.8% cases. Common grade ≥3 AEs over 184 days follow-up were: abdominal pain (6.1%), fatigue (5.5%), hyperbilirubinemia (5.4%), ascites (3.6%) and gastrointestinal ulceration (1.7%). There was no statistical difference in AEs across treatment lines (P>0.05). Median survivals [95% confidence interval (CI)] following radioembolization as a 2(nd)-line, 3(rd)-line, or 4(th)-plus line were 13.0 (range, 10.5-14.6), 9.0 (range, 7.8-11.0), and 8.1 (range, 6.4-9.3) months, respectively; and significantly prolonged in patients with ECOG 0 vs. ≥1 (P=0.009). Statistically significant independent variables for survival at radioembolization were: disease stage [extrahepatic metastases, extent of liver involvement (tumor-to-treated-liver ratio)], liver function (uncontrolled ascites, albumin, alkaline phosphatase, aspartate transaminase), leukocytes, and prior chemotherapy. CONCLUSIONS Radioembolization appears to have a favorable risk/benefit profile, even among mCRC patients who had received ≥3 prior lines of chemotherapy.

Hepatic Artery Embolization: Factors Predisposing to Postembolization Pain and Nausea

PURPOSE Analysis of preprocedural factors that may be helpful in predicting the severity of pain and nausea after hepatic arterial embolization (HAE) for liver neoplasms. MATERIALS AND METHODS During a 2-year period, 62 patients (33 men, 29 women) underwent 130 palliative lobar HAEs for unresectable liver neoplasms. The hepatic lobe was embolized with 150-250-microm polyvinyl alcohol particulates with or without lipiodol and/or chemotherapeutic agents. Postembolization pain was rated at rest and during movement with use of an 11-point verbal pain scale, and postembolization nausea was assessed with use of a four-point verbal scale, each at two separate time periods. Daily morphine use was also recorded. Primary analysis was made using the first embolization procedure. One-way analysis of variance and Spearman correlation coefficients were used to identify associated predictors. Plots of the outcomes versus the pre-embolization liver function tests and sensitivities and specificities were used to identify the strength of the associations for prediction purposes. A secondary analysis was performed in patients who underwent multiple embolizations. RESULTS No strong categorical predictors were found from the ANOVA on the severity of postembolization pain or nausea. There were significant (P < .05) associations between the pre-embolization liver function tests and the pain outcomes only. However, while these laboratory values demonstrate strong associations with resultant pain, they are not strong predictors of pain and morphine requirements for any individual patient. The morphine requirements were highly associated (P < .0001) with the pain scores at rest and with movement. The authors did not find significant differences on any of the pain outcomes or morphine requirements between the first and second embolizations. CONCLUSION Laboratory values and patient age are not predictors for the severity of postembolization pain and nausea. Postembolization pain is a significant complication and poses a continuing challenge to the physician with regards to patient management.

Use of a TrapEase device as a temporary caval filter.

Inferior vena cava (IVC) thrombosis in younger patients presents a difficult management problem and is associated with a significant incidence of pulmonary embolism (PE). Treatment options include anticoagulation, mechanical thrombectomy, or thrombolytic therapy, often in combination with placement of a filter above the thrombus. The authors report the use of a permanent filter in a temporary fashion while performing thrombectomy and thrombolysis of an IVC thrombus.

Transcatheter arterial embolization of two symptomatic giant cavernous hemangiomas of the liver

Cavernous hemangiomas are usually asymptomatic; however, a small percetage may cause symptoms. This case report discusses palliation by transcatheter arterial embolization with polyvinyl alcohol particles.

Percutaneous placement of self-expanding stent for acute traumatic arterial injury

The frequency of arterial injury continues to rise primarily urban violence and invasive interventional procedures. 1,2 Becker et al. described the use of a silicone-coated balloon-expandable intraluminal stent to control a life-threatening subclavian iatrogenic arterial hemorrhage. 3 Although the use of intraluminal arterial stents in peripheral vascular occlusive disease has been described in the treatment of both spontaneous and angioplasty-induced dissections, 4-11 their use in the management of traumatic vascular injuries has not been previously noted. The two cases described are the first report of the use of self-expanding, noncoated stents in the emergent treatment of acute noniatrogenic arterial trauma.

Angiosarcoma Diagnosis and Clinical Course

The findings at radiography, computed tomography and angiography and the clinical course of 30 cases of angiosarcoma were reviewed. The variety of primary sites results in a multitude of findings but the most common finding was that of a hypervascular soft tissue mass seen on CT and angiography. Additional findings of well demarcated cortical defects in long bones were also frequently noted. The general clinical behavior of these aggressive malignant tumors was also reviewed and it was noted that they had a deceptively benign presentation.