Hans van Overhagen

Hickman Catheter–Related Infections in Neutropenic Patients: Insertion in the Operating Theater Versus Insertion in the Radiology Suite

PURPOSE To determine the influence of microbial air quality during Hickman catheter insertion in the operating theater versus insertion in the radiology suite on the incidence of catheter-related infections (CRIs). PATIENTS AND METHODS Hemato-oncologic patients with prolonged neutropenia on antimicrobial prophylaxis were entered onto the study. Catheters were inserted by experienced radiologists under sonographic and fluoroscopic guidance. RESULTS Forty-eight Hickman catheters in 39 patients were inserted (23 in the operating theater, 25 in the radiology suite). CRIs were seen in 16 catheters (33%; six per 1,000 catheter days; eight in each group). Local infections were found in nine catheters (22%; six in the operating theater v three in the radiology suite; not significant [NS]), catheter-related bacteremia was found in 10 (29%; three in the operating theater v seven in the radiology suite; NS). Coagulase-negative staphylococci (CoNS) caused all CRIs. Despite early vancomycin therapy, 11 (69%; four in the operating room group v seven in the radiology suite group; NS) of the catheters with CRIs had to be removed prematurely. At 90 days after insertion, catheter survival was 78% and 60% (NS) for the operating room and radiology suite, respectively. Multivariate analysis showed that neutropenia increased the CRI risk 20-fold (P =.004) and was strongly related to premature catheter removal owing to infection (relative risk = 11.9; P =.009). Neutropenia on the day of insertion was also significantly correlated with CRI (P =.04) and premature catheter removal owing to infection (P =.03). Serial cultures of blood, exit site, and catheter hub did not predict the development of CRI. CONCLUSION The high incidence of Hickman CRI caused by CoNS was not associated with insertion location (operating theater v radiology suite). Neutropenia, including neutropenia on the day of insertion, was a significant risk factor for CRI and infection-related catheter removal.

Percutaneous cholecystostomy for patients with acute cholecystitis and an increased surgical risk

PurposeTo evaluated percutaneous cholecystostomy in patients with acute cholecystitis and an increased surgical risk.MethodsThirty-three patients with acute cholecystitis (calculous,n=22; acalculous,n=11) underwent percutaneous cholecystostomy by means of a transhepatic (n=21) or transperitoneal (n=12) access route. Clinical and laboratory parameters were retrospectively studied to determine the benefit from cholecystostomy.ResultsAll procedures were technically successful. Twenty-two (67%) patients improved clinically within 48 hr; showing a significant decreased in body temperature (n=13), normalization of the white blood cell count (n=3), or both (n=6). There were 6 (18%) minor/moderate complications (transhepatic access,n=3; transperitoneal access,n=3). Further treatment for patients with calculous cholecystitis was cholecystectomy (n=9) and percutaneous and endoscopic stone removal (n=8). Further treatment for patients with acalculous cholecystitis was cholecystectomy (n=2) and gallbladder ablation (n=2). There were 4 deaths (12%) either in hospital or within 30 days of drainage; none of the deaths was procedure-related.ConclusionPercutaneous cholecystostomy is a safe and effective procedure for patients with acute cholecystitis. For most patients with acalculous cholecystitis percutaneous cholecystostomy may be considered a definitive therapy. In calculous disease this treatment is often only temporizing and a definitive surgical, endoscopic, or radiologic treatment becomes necessary.

US and Fluoroscopic-guided Percutaneous Jejunostomy: Experience in 49 Patients

PURPOSE To assess the feasibility and safety of a variety of techniques for percutaneous jejunostomy. MATERIALS AND METHODS Percutaneous jejunostomy was attempted on 53 occasions in 49 patients under US and fluoroscopic guidance. During the study period, thicker needles, Cope anchors, and intravenous glucagon were introduced to improve access, dilate, and immobilize the jejunum. Technical success rates, complications, catheterization period, and reasons for catheter removal were prospectively studied. Prognostic factors for successful procedures and complications were determined. RESULTS Forty-six (87%) procedures were technically successful. Previous gastrointestinal surgery (P = .01) and a combination of thicker needles, Cope anchors, and intravenous glucagon (P = .0001) were associated with a higher technical success rate. Complications (n = 6; pericatheter leakage in four of six) were observed more frequently in older patients (P = .01). The 30-day mortality rate was 17%, one death may have been procedure related. Forty-three catheters were removed (elective, n = 36; other, n = 7) after 1-597 days (median, 49). Three catheters remained in situ for 139-482 days (median, 410). CONCLUSIONS Percutaneous jejunostomy is a feasible and relatively safe technique for long-term feeding. Leakage is the main problem, which warrants additional study.

Endovascular aneurysm repair with a bifurcated endovascular graft at a primary referral center: Influence of experience, age, gender, and aneurysm size on suitability

OBJECTIVE The purpose of this study was to assess the suitability for endovascular repair of abdominal aortic aneurysm (EVAR) in an unselected patient population. PATIENTS AND METHODS Between February 1999 and May 2002 all consecutive patients with a nonemergent abdominal aortic aneurysm (AAA) were prospectively examined with contrast material-enhanced spiral computed tomography (CT). Those patients probably suitable for EVAR on the basis of CT findings underwent calibrated angiography. A panel of radiologists and vascular surgeons reviewed the clinical data and vascular anatomy, and decided on the appropriateness of EVAR with the bifurcated Zenith AAA endovascular graft. RESULTS One hundred seven patients were included. Fifty-six patients (52%) had one or more contraindications for EVAR. Unsuitability was most frequently (88%) related to the proximal neck. Inadequate neck length was the most common specific reason. Inadequate iliac anatomy was the reason for unsuitability in 59% of patients. The rate of unsuitability decreased from 61% during the first half of the study to 40% during the second half (P =.03) Unsuitability was equal between men and women. Age and maximum diameter did not differ between candidates and noncandidates. CONCLUSION Almost half (48%) of patients with an infrarenal AAA referred to a primary referral center are suitable for EVAR with the bifurcated Zenith AAA endovascular graft. Neck anatomy was the most frequent reason for rejection. Rate of suitability increased over time, probably as a result of increasing experience. Suitability was not influenced by gender, age, or aneurysm size.

Ultrasound and ultrasound-guided fine needle aspiration biopsy of supraclavicular lymph nodes in patients with esophageal carcinoma

The use of ultrasound combined with ultrasound‐guided fine‐needle aspiration biopsy (UGFAB) of supraclavicular lymph nodes in the pretreatment staging of 37 patients with squamous cell carcinoma of the esophagus is described. All patients underwent computed tomography (CT) scans of the chest and the abdomen and ultrasound of the abdomen and supraclavicular regions. Supraclavicular lymph node metastases (Stage IV disease according to the tumor nodes metastasis [TNM] classification) were cytologically diagnosed in seven (18.9%) of the 37 patients. In two of these patients, no other metastases were found. In the other five patients, UGFAB replaced more invasive diagnostic procedures. Due to their superficial location, ultrasound and UGFAB of the supraclavicular lymph nodes was relatively simple to perform, and contributed to an improved staging of squamous cell carcinoma of the esophagus.

STENT PLACEMENT FOR TREATMENT OF RENAL ARTERY STENOSIS GUIDED BY INTRAVASCULAR ULTRASOUND

PURPOSE To study the impact of intravascular ultrasound (IVUS) during renal artery stent placement. MATERIALS AND METHODS Patients (n = 22) with atherosclerotic renal artery stenosis were studied with IVUS after predilation and after angiographically successful stent deployment (diameter stenosis < 10%). After predilation, IVUS was used to assess whether the balloon size selected angiographically was correct (discrepancy balloon-reference lumen diameter < 20%). After stent placement, IVUS images were assessed for (i) complete stent-vessel wall apposition; (ii) complete stent expansion (discrepancy stent-reference lumen diameter < 20%), and (iii) complete lesion covering by the stent. Modification based on IVUS included selection of a larger balloon, additional dilation, and placement of a second stent. Clinical outcome was based on blood pressure, amount of antihypertensive drugs, and glomerular filtration rate during follow-up of 3 months. RESULTS Stent placement and ultrasound imaging were completed successfully in 18 patients. After predilation, IVUS warranted the use of a larger balloon in five patients. After stent placement, incomplete stent apposition (n = 1), discrepancy between stent and reference lumen diameter (n = 3), and lesion distal to the stent (n = 2) seen on IVUS were treated with additional dilation in five patients and with a second stent in one patient. A larger balloon was used in three patients. Mean blood pressure and amount of antihypertensive drugs decreased (P < .05). CONCLUSIONS In a number of patients, IVUS monitoring during renal artery stent placement resulted in additional lumen enlargement not considered necessary at angiography.

Percutaneous Transluminal Angioplasty and Drug-Eluting Stents for Infrapopliteal Lesions in Critical Limb Ischemia (PADI) Trial

Background—Endovascular infrapopliteal treatment of patients with critical limb ischemia using percutaneous transluminal angioplasty (PTA) and bail-out bare metal stenting (BMS) is hampered by restenosis. In interventional cardiology, drug-eluting stents (DES) have shown better patency rates and are standard practice nowadays. An investigator-initiated, multicenter, randomized trial was conducted to assess whether DES also improve patency and clinical outcome of infrapopliteal lesions. Methods and Results—Adults with critical limb ischemia (Rutherford category ≥4) and infrapopliteal lesions were randomized to receive PTA±BMS or DES with paclitaxel. Primary end point was 6-month primary binary patency of treated lesions, defined as ⩽50% stenosis on computed tomographic angiography. Stenosis >50%, retreatment, major amputation, and critical limb ischemia–related death were regarded as treatment failure. Severity of failure was assessed with an ordinal score, ranging from vessel stenosis through occlusion to the clinical failures. Seventy-four limbs (73 patients) were treated with DES and 66 limbs (64 patients) received PTA±BMS. Six-month patency rates were 48.0% for DES and 35.1% for PTA±BMS (P=0.096) in the modified-intention-to-treat and 51.9% and 35.1% (P=0.037) in the per-protocol analysis. The ordinal score showed significantly worse treatment failure for PTA±BMS versus DES (P=0.041). The observed major amputation rate remained lower in the DES group until 2 years post-treatment, with a trend toward significance (P=0.066). Less minor amputations occurred after DES until 6 months post-treatment (P=0.03). Conclusions—In patients with critical limb ischemia caused by infrapopliteal lesions, DES provide better 6-month patency rates and less amputations after 6 and 12 months compared with PTA±BMS. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00471289.

Plaque area increase and vascular remodeling contribute to lumen area change after percutaneous transluminal angioplasty of the femoropopliteal artery: An intravascular ultrasound study☆☆☆

OBJECTIVE The aim of the study was to assess the change in lumen area (LA), plaque area (PLA), and vessel area (VA) after percutaneous transluminal angioplasty (PTA) of the femoropopliteal artery. METHODS This was a prospective study. Twenty patients were studied with intravascular ultrasound (IVUS) immediately after PTA and at follow-up examination. Multiple corresponding IVUS cross-sections were analyzed at the segments that were dilated by PTA (ie, treated sites; n = 168), including the most stenotic site (n = 20) and the nondilated segments (ie, reference sites; n = 77). RESULTS At follow-up examination, both the PLA increase (13%) and the VA decrease (9%) resulted in a significant LA decrease (43%) at the most stenotic sites (P =.001). At the treated sites, the LA decrease (15%) was smaller and was caused by the PLA increase (15%). At the reference sites, the PLA increase (15%) and the VA increase (6%) resulted in a slight LA decrease (3%). An analysis of the IVUS cross-sections that were grouped according to LA change (difference >/=10%) revealed a similar PLA increase in all the groups: the type of vascular remodeling (VA decrease, no change, or increase) determined the LA change. At the treated sites, the LA change and the VA change correlated closely (r = 0.77, P <.001). At the treated sites, significantly more PLA increase was seen in the IVUS cross-sections that showed hard lesion or media rupture (P <.05). No relationship was found between the presence of dissection and the quantitative changes. CONCLUSION At the most stenotic sites, lumen narrowing was caused by plaque increase and vessel shrinkage. Both the treated sites and the reference sites showed a significant PLA increase: the type of vascular remodeling determined the LA change at follow-up examination. The extent of the PLA increase was significantly larger in the IVUS cross-sections that showed hard lesion or media rupture.

Assessment of distant metastases with ultrasound-guided fine-needle aspiration biopsy and cytologic study in carcinoma of the esophagus and gastroesophageal junction

The use of ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) for the assessment of distant metastases was prospectively studied in 135 consecutive patients with carcinoma of the esophagus and gastroesophageal junction. Patients with accessible lesions on US and computed tomographic (CT) studies of the supraclavicular regions and the abdomen underwent US-guided FNAB. In patients with multiple lesions biopsies were preferentially performed on enlarged supraclavicular nodes. Forty-nine patients underwent US-guided FNABs of 53 lesions. A cytologic diagnosis was established in 46 of 53 (87%) biopsies. Seven of 53 (13%) biopsies were nondiagnostic. Distant metastases were diagnosed by means of cytologic study in 33 of 135 (24%) patients. Supraclavicular metastases were diagnosed in 22 patients and abdominal metastases were diagnosed in 12 patients, including one patient who also had supraclavicular metastases. US-guided FNAB can improve the selection of patients for surgical and nonsurgical treatment by diagnosing distant metastases in an important number of patients.

Ruptured Internal Iliac Artery Aneurysm: Staged Emergency Endovascular Treatment in the Interventional Radiology Suite

Ruptured aneurysms of the internal iliac artery (IIA) are rare and challenging to treat surgically. Due to their anatomic location they are difficult to operate on and perioperative morbidity is high. An endovascular approach can be helpful. We recently treated a patient with a ruptured IIA aneurysm in the interventional radiology suite with embolization of the side-branch of the IIA and placement of a covered stent in the ipsilateral common and external iliac arteries. A suitable stent-graft was not available initially and had to be brought in from elsewhere. An angioplasty balloon was temporarily placed across the ostium of the IIA to obtain hemostasis. Two hours later, the procedure was finished by placing the stent-graft.