J. Mark Ryan

Antibiotic prophylaxis in interventional radiology

Despite several decades of advances in both minimally invasive techniques and antibiotic therapy, infection remains one of the more common complications of invasive procedures. Interventional radiology (IR) has traditionally been believed to be associated with lower infection rates than surgery. However, new interventional techniques, as well as more aggressive therapeutic interventions, have presented new challenges in relation to pharmacological management of postprocedural infection and pain. The risk of infection associated with IR procedures can never be completely eliminated, and the reasons for this are manifold, including more virulent organisms, ongoing and newly emerging antibiotic resistance, increased numbers of immunocompromised patients, and the adoption into everyday interventional practice of more aggressive interventional techniques such as chemoembolization, uterine fibroid embolization, and complex biliary intervention. Despite the widespread use of prophylactic antibiotics in IR, and the widely held belief that they are beneficial and are the standard of care, randomized controlled clinical trials have never validated the use of antibiotics in this setting. As such, an argument could be made not to use antibiotics at all for prophylaxis in IR. The purpose of this article is to discuss some of the issues relating to the use of prophylactic antibiotics, and what choice of antibiotics physicians make when they decide to use prophylaxis for IR procedures.

The Bispectral Index in the Diagnosis of Perioperative Stroke: A Case Report and Discussion

We discuss a case where the bispectral index (BIS; Aspect Medical, Natick, MA) was the earliest indicator of acute perioperative stroke during the removal of an Abiomed BVS 5000 ® (Penn State Cardiovascular Center, Hershey, PA) left ventricular assist device (LVAD). Up to 3% of cardiac surgical patients suffer serious, typically embolic, neurological complications, with an associated 20% mortality rate (1). The opportunity to make an earlier diagnosis may help improve outcome in this group as novel therapeutic options become available.

Coil embolization of segmental arterial mediolysis of the hepatic artery.

JVIR 2000; 11:865–868 SEGMENTAL arterial mediolysis was described as a distinct pathologic entity by Slavin et al (1) in 1976. The angiographic features of the disease were first described in 1990 by Heritz et al (2) and were subsequently described by other investigators (3–6). Slavin et al originally named the entity segmental mediolytic arteritis, but later changed the name to segmental arterial mediolysis when it became evident that the pathologic process was, in fact, quite dissimilar to the histologic appearances of arteritis. In 1949, Grunewald (7) described a pathologically similar process in the epicardial coronary arteries of neonates, and it is now generally believed that this was the first description of segmental arterial mediolysis in the literature (1,4). We describe a case of an elderly patient with a presumptive diagnosis of segmental arterial mediolysis who presented with abdominal pain and hemobilia. We report the use of coil embolization to treat the symptomatic aneurysmal abnormalities. We also describe the angiographic findings after 5 months of follow-up.

Conversion of indwelling chest port catheters to tunneled central venous catheters.

PURPOSE To determine the safety and efficacy of the conversion of subcutaneous chest wall infusion ports to tunneled central venous catheters. MATERIALS AND METHODS During a period of 34 months, 67 patients were referred for conversion of indwelling subcutaneous chest wall ports to tunneled central venous catheters as part of a bone marrow transplant protocol. Six patients were deemed unacceptable for conversion and the remaining 61 underwent successful conversion. All patients had functioning surgically placed single-lumen (n = 50) or double-lumen (n = 11) chest ports, which were removed to maintain the original venous access sites for placement of a tunneled central venous catheter, incorporating the chest wall pocket for tunneling, in 46 patients (75%). A new tunnel was created in the other 15 patients. There were no immediate complications and all patients were followed until catheter removal or patient demise with the catheter in place. RESULTS 57 of 61 (93%) catheters were used without evidence of infection for 23-164 days (mean, 57 d) after placement. Two (3%) were removed (both at 26 days) because of persistent neutropenic fever without physical signs or laboratory evidence of catheter infection, and two (3%) were removed (at 11 and 77 days) because of proven catheter infection, yielding an overall infection rate of 1.2 per 1,000 catheter days. Two catheters required exchange and two required stripping because of decreased function, resulting in an overall catheter-related complication rate of 2.4 per 1,000 catheter days. CONCLUSIONS Indwelling subcutaneous chest wall infusion ports can be safely converted to tunneled central venous catheters, even in an immunocompromised patient population, with a low risk of complications such as infection.