George X. Zaleski

Angioplasty and Bolus Urokinase Infusion for the Restoration of Function in Thrombosed Brescia-Cimino Dialysis Fistulas

PURPOSE To evaluate the use of urokinase and angioplasty in treatment of thrombosed Brescia-Cimino fistulas. MATERIALS AND METHODS From January 1994 to April 1997, 17 patients (10 women and seven men; age range, 17-78 years; mean 54 years) with complete thrombosis of their Brescia-Cimino fistulas were referred to our department for thrombolysis and angioplasty. Thrombosis of the fistula had occurred within 24 hours of attempted thrombolysis in 11 patients and between 24 and 72 hours in six patients. Urokinase was given as a bolus into the fistula, and heparin was administered into the central venous vasculature. Angioplasty was performed at the arterial inflow and the fistula itself. RESULTS Procedural success was 82% (14 of 17 patients). Primary patency was 71% at 6 months and 64% at 12 months. Primary assisted patency was 93% at 6 and 12 months. Secondary patency was 100% at 6 and 12 months. One fistula thrombosed within 24 hours of the initial procedure, and a repeat procedure was successfully performed. All other fistulas have remained patent with a maximum follow-up of 40 months (average function of 16 months). Two patients have died of unrelated causes. One Wallstent was deployed for treatment of an angioplasty-induced venous rupture. CONCLUSION Long-term function of Brescia-Cimino fistulas after thrombolysis and angioplasty is excellent with patency rates similar to those of newly placed, mature Brescia-Cimino fistulas.

Percutaneous imaging-guided solid organ core needle biopsy: coaxial versus noncoaxial method.

OBJECTIVE The purpose of our study was to compare the diagnostic yield and complication rate of coaxial technique with those of noncoaxial technique in percutaneous imaging-guided renal and hepatic core biopsies. We also compared bleeding complication rates with and without absorbable gelatin sponge occlusion of the biopsy track. MATERIALS AND METHODS The records of 1,060 consecutively registered patients who underwent percutaneous imaging-guided hepatic or renal biopsy at two hospitals were retrospectively reviewed. Core specimens were obtained in all biopsies. Indications for biopsy included acquisition of general tissue specimens to evaluate for hepatic (n = 495) or renal disease (n = 243) and acquisition of specimens of specific hepatic (n = 289) and renal (n = 33) lesions. Samples were acquired with a coaxial set of needles (n = 764) or with a noncoaxial needle (n = 296 patients). Absorbable gelatin sponge was injected before removal of the outer needle in 269 of the 764 coaxial biopsies. Gelatin sponge was not injected in the other 495 coaxial biopsies. Complication rates were evaluated in a comparison of the two methods and of the coaxial biopsies with and without postprocedural injection of gelatin sponge. Complications were considered minor if follow-up imaging in the 7 days after the procedure showed a complication that did not necessitate treatment other than conservative pain management. Complications were considered major if treatment such as blood product transfusion or surgery was needed or if the patient died. RESULTS Specimens were immediately given to a pathologist, who typically was present during the procedure. Specimens were evaluated and judged adequate for a specific diagnosis by the histopathology staff. The rates of minor complications were 3.4% (10/296) for the noncoaxial method and 2.6% (20/764) for the coaxial method. The rates of major complications were 1.0% (3/296) for the noncoaxial method and 0.9% (7/764) for the coaxial method. Six cases of major complications necessitating blood product transfusion were documented for the coaxial method and one case for the noncoaxial method. One (0.1%) of the patients undergoing coaxial biopsy died. One patient undergoing noncoaxial biopsy needed surgical repair of an arterial injury that was refractory to blood transfusion, and another developed pancreatitis and needed a blood transfusion. The percentage of minor complications of the coaxial method with absorbable gelatin sponge injection was 3.7% (10/269), and that of major complications was 0.7% (2/269). There was no statistical difference in complication rates between the various methods of percutaneous hepatic and renal biopsy. CONCLUSION In regard to complications, there are no differences between coaxial and noncoaxial biopsy methods or between the coaxial method with or without injection of absorbable gelatin sponge.

Blood Patch Rates After Lumbar Puncture with Whitacre Versus Quincke 22- and 20-Gauge Spinal Needles

OBJECTIVE The objective of our study was to compare the incidence of blood patch as the best objective indicator of postdural puncture headache after elective fluoroscopic lumbar puncture with the use of a 22-gauge Whitacre (pencil point) needle versus standard 22- and 20-gauge Quincke (bevel-tip) needles and to determine the best level of puncture. MATERIALS AND METHODS The records of 724 consecutive patients who were referred to St. Marys Medical Center department of radiology for fluoroscopic lumbar puncture from January 2003 through April 2007 were retrospectively reviewed. Emergency requests (191) were discarded along with those for patients with clinical signs of pseudotumor cerebri (21), normal pressure hydrocephalus (3), and failed attempts (4). The collective total was 505 elective lumbar punctures. RESULTS The blood patch rate for the 22-gauge Whitacre needle was 4.2%. The result for the 22-gauge Quincke point needle was 15.1% whereas that for the 20-gauge Quincke point needle was 29.6%. In addition, the level of puncture showed a blood patch rate that increased as the level of lumbar puncture lowered. The highest level of lumbar puncture was L1-L2 with the lowest recorded level being L5-S1. CONCLUSION The Whitacre needle is associated with a significantly lower incidence of blood patch rate after lumbar puncture. The highest level of puncture (L1-L2) also provides the lowest level of blood patch rate.

Reinsertion of accidentally removed tunneled central venous catheter via the existing subcutaneous tract.

AbstractBackground. A technique for reinsertion of an inadvertently removed tunneled central venous catheter is presented. A 6-year-old boy with short-gut syndrome caused by necrotizing enterocolitis accidentally removed his tunneled central venous catheter. Materials and methods. The existing subcutaneous catheter tract was recanalized using a hydrophilic guidewire and 5-French end-hole catheter with the child unter conscious sedation, and a new catheter was placed over a guidewire. Results. This obviated the need for a new venipuncture and creation of a new subcutaneous tunnel, which are performed under general anesthesia in our hospital.

Re: Use of an Amplatz Goose Neck Snare as a Target for Collateral Neck Vein Dialysis Catheter Placement

Editor: The recent article by Hagen and associates, “Use of an Amplatz Goose Neck Snare as a target for collateral neck vein dialysis catheter placement” (1), describes an effective method for hemodialysis catheter insertion. However, it is not, as the authors maintain, the first description of this technique. It is not even the first time the technique has been reported in JVIR (2). The identical procedure has been described at least four times previously (2–5). Figure 2 in the article by Nazarian et al (3) cited by the authors (Reference 5 in their article) describes the identical technique. To our knowledge, Ferral and associates (2) also reported the first series of six patients treated with use of this procedure in JVIR less than 5 years ago. We reported our initial experience with this technique in 1998 in AJR and more recently in Radiology in 2001 (4,5). To be fair, the authors could not have known about the most recent publication in Radiology at the time of manuscript preparation. As we have gained experience with the use of collateral neck veins for central access, we have modified the procedure slightly. One danger when using fluoroscopic guidance only for venipuncture is accidental through-and-through arterial puncture. To avoid this complication (particularly in the neck), sonography is helpful before venipuncture to identify and avoid superficial arteries. When a vein is successfully catheterized, retracting a 5-F dilator from the vein to the skin puncture (over a 0.018-inch guide wire) while injecting contrast material via a side-arm adapter also will identify inadvertent arterial puncture. Incidentally, it appears that the catheterized vessel shown in Figure 1 labeled “small patent branch emptying into the subclavian vein” is the external jugular vein. This vein is an excellent choice for central access in bilateral jugular vein occlusions. It is usually possible to identify and puncture this vessel with use of sonography, thereby obviating the need for retrograde recanalization. In our hospitals, many anesthesiologists use this vein preferentially for central access.

Letter to the Editor Re: Peripheral Venous Access Ports: Outcomes Analysis in 109 Patients

No Abstract