Ivan Vujic

Treatment of Thrombosed Dialysis Access Grafts: Randomized Trial of Surgical Thrombectomy versus Mechanical Thrombectomy with the Amplatz Device

PURPOSE To report the preliminary results in a trial comparing the Amplatz mechanical thrombectomy (MT) device with surgical thrombectomy (ST) to declot occluded dialysis access grafts. PATIENTS AND METHODS Thirty-seven patients were randomly assigned by computer to either ST (n = 18) or MT (n = 19). Diagnostic fistulograms were obtained at the end of the procedure, and Doppler ultrasound was performed at 1-month follow-up. Plasma free hemoglobin levels were measured before, immediately after, and 24 hours after the procedure in the MT group. Success was defined as initial success with restoration of flow through the graft, primary patency at 30 days, and secondary patency at 30 days. RESULTS Technical success with MT was 89%. Primary patency in the MT series was 47% and secondary 30-day patency was 68%. Technical success with ST was 83%. Primary patency in the ST series was 77% and secondary patency at 30 days was 77%. Angioplasty (n = 18) and stent placement (n = 6) were performed in the MT cases. Angioplasty was impossible in one patient. Immediately after MT, plasma free hemoglobin levels above normal were noted in 63% of the cases, but these levels were within normal levels after 24 hours in 88% of the cases. CONCLUSION Initial success of MT in patients with occluded dialysis access grafts is comparable to that of ST. No statistically significant differences in primary or secondary patencies were seen.

Massive Pulmonary Embolism: Preliminary Results of Treatment with the Amplatz Thrombectomy Device

PURPOSE To determine the feasibility of using the Amplatz thrombectomy device (ATD) to treat massive pulmonary embolism (PE). PATIENTS AND METHODS Five patients (four men, one woman; mean age, 45.2 years) with massive PE underwent mechanical thrombectomy with the ATD, which creates a vortex that pulverizes and recirculates the clots within the pulmonary circulation. The patients were followed up for 7-18 months after thrombectomy. RESULTS Marked improvement in pulmonary perfusion was observed in three patients at angiography and ventilation-perfusion scanning. No changes could be assessed in one patient who died shortly after the procedure. One patient developed hemoptysis during the procedure, most likely because of a reperfusion syndrome. A reduction in pulmonary artery pressure was observed in only one patient; the remaining patients had increased pressure. The four surviving patients were discharged within 8 days. CONCLUSION Mechanical thrombectomy with the ATD provides rapid debulking of thrombus in some patients with massive PE and has the potential to improve treatment and outcomes of the most sick patients.

Transpapillary stenting of proximal biliary strictures: does biliary sphincterotomy reduce the risk of postprocedure pancreatitis?

BACKGROUND Pancreatitis after biliary stenting is a rare complication. To reduce this risk, some endoscopists routinely perform biliary sphincterotomy before stenting, but the value of this practice is not established. METHODS The incidence of pancreatitis was reviewed in patients undergoing biliary stenting with and without a biliary sphincterotomy. RESULTS Postprocedure pancreatitis occurred in 4 of 83 (4.8%) patients treated with transpapillary biliary stents. Patients with proximal biliary strictures were at significantly increased risk for postprocedure pancreatitis (4 of 24) versus those with distal or no strictures (0 of 59) (p = 0.006). The four patients with pancreatitis after stenting had not undergone sphincterotomy. Of those treated conservatively, two cases were graded severe (one fatal), and one was mild. The other patient was markedly symptomatic from pancreatitis, but improved dramatically after treatment with a needle-knife sphincterotomy done within 24 hours of the original ERCP. CONCLUSION The risk of pancreatitis following transpapillary biliary stenting is increased in patients with proximal biliary strictures. Such lesions (malignant or benign) may serve as a fulcrum, leading to medial deflection of the stent and compression of the pancreatic orifice. The hypothesis that sphincterotomy may decrease the risk of biliary stent-induced obstructive pancreatitis should be tested in patients with proximal biliary strictures.

Evaluation of biliary cystadenoma and cystadenocarcinoma

Biliary cystadenomas and cystadenocarcinomas are among the rare neoplasms of the biliary ductal system. This article presents 3 adult patients in whom such large multiloculated biliary tumors were diagnosed. The characteristic features noted on ultrasonography, computed tomography, and angiography of the liver are illustrated and the literature is reviewed.

Obstructive jaundice caused by cavernous transformation of the portal vein

Extrahepatic portal obstruction developing in the neonatal period usually presents with manifestations of portal hypertension. Obstructive jaundice has not previously been described as a complication of this condition. A 22 year-old white male presented with jaundice, decreased appetite and tiredness for six months. He was known to have portal hypertension which followed neonatal omphalitis and portal vein thrombosis. At age four, splenectomy and lieno-renal shunt was done because of bleeding from oesophageal varices. Two further, self-limiting episodes of gastrointestinal bleeding occurred in his teens. He was normally developed and showed no other abnormalities apart from jaundice. Total bilirubin was 10.4 mgm % with a direct fraction of 7.2 mgm%. Alkaline phosphatase was elevated to 344 K.A. units, but liver function tests were otherwise normal. Liver biopsy was unsuccessful, but was complicated by puncture of the gall-bladder with haemorrhage into it, necessitating laparotomy. The wall of the gallblad...

Crutch-induced axillary artery injury

PurposeTo describe the spectrum of radiologic findings in crutch-induced axillary artery injury and the effects of its unique pathophysiology on diagnostic evaluation and treatment.MethodsThree patients with axillary crutch-induced axillobrachial injury were studied angiographically and percutaneous intervention was performed in two cases.ResultsOne patient required surgical bypass of a thrombosed axillary artery aneurysm. One patient responded to percutaneous transluminal angioplasty (PTA) of a focal axillary artery stenosis. One patient with an axillary artery aneurysm and distal thromboembolic disease was treated by both thrombolysis and surgical thromboembolectomy and later by PTA of an axillary artery intimal disruption.ConclusionChronic axillary crutch use may be associated with axillary artery stenosis, aneurysm formation, and secondary axillobrachial thromboembolic disease. Mural injury can be successfully treated by PTA and thromboembolic disease by thrombolytic therapy. Early identification of the axillary artery lesion is critical for long-term therapeutic results.

The Effect of Drainage Tube Size on Adequacy of Percutaneous Abscess Drainage

Fifty-one patients with documented abdominal abscess cavities were treated by percutaneous abscess and fluid drainage (PAFD). Drainage catheters made of various materials in sizes ranging from 5 through 18 French (Fr) were retrospectively studied and prospectively assigned to patients. No significant difference in the success or failure of PAFD as a function of these factors was found once an 8.3 Fr catheter with 0.045-inch diameter sideholes was reached; catheters larger than this were not associated with improved patient outcome. Failues of PAFD occurred primarily with the presence of phlegmonouscollections and cavities with fistulous connection to bowel.

Treatment of acute embolus of the superior mesenteric artery by topical infusion of streptokinase

Two patients with sudden onset of acute abdominal pain caused by embolic disease of the superior mesenteric artery (SMA) were evaluated angiographically. In one patient, the study was performed soon after the clinical onset of symptoms, and successful treatment with low-dose topical streptokinase infusion produced total lysis of the clot over a period of 30 h. In the second patient, the angiogram was obtained 6 days following the initial episode of pain. Radiographic and clinical findings indicated advanced gastrointestinal ischemia with bleeding which contraindicated the use of fibrinolytic therapy. Surgical resection of infarcted intestine was required. Early angiographic detection of acute mesenteric thrombus or embolus is crucial for the selection of patients for fibrinolytic therapy. Our cases suggest that with early diagnosis, streptokinase infusion is an alternative to surgical management of selected patients with acute mesenteric ischemia.

Hemorrhagic renal angiomyolipoma: Superselective renal arterial embolization for preservation of renal function

A 35-year-old woman with tuberous sclerosis and known bilateral renal angiomyolipomas presented with shock due to massive hematuria arising from the left kidney. The cause of bleeding was diagnosed angiographically as arising from a left upper pole renal artery aneurysm within the tumor. Cessation of bleeding and clinical stabilization occurred without deterioration of renal function after superselective embolization of the dorsal segmental renal artery with a single 5-mm Gianturco coil.

Biloma: Aspiration for diagnosis and treatment

Post-traumatic and postsurgical collections of encysted bile (biloma) can be difficult to diagnose. Certain radiographic features may suggest the diagnosis, but puncture of the cystic lesion is essential. Moreover, the lesions may be treated by percutaneous insertion of a drainage catheter without need for surgical exploration. In the last 3 1/2 years we have encountered 3 patients with this condition, 2 of whom were successfully drained by percutaneous technique. In 1 patient the overall radiographic appearance was suggestive of delayed rupture of the spleen, and the biloma was drained by simple needle aspiration intraoperatively.