J. Medrano

Mechanical and Enzymatic Thrombolysis for Massive Pulmonary Embolism

PURPOSE To assess the efficacy and safety of mechanical fragmentation combined with intrapulmonary thrombolysis in massive pulmonary thromboembolism (PTE) with hemodynamic impairment. MATERIALS AND METHODS Fifty-nine patients diagnosed with massive PTE with hemodynamic impact were treated. The initial clinical symptoms were shock in 23 patients (38.9%), syncope in eight (13.5%), and dyspnea at rest in 28 (47.4%). Mean O2 saturation was 67.8%. Mean pulmonary artery pressure (PAP) was 42.1 mm Hg. During fragmentation, thrombolysis was administered in the form of a urokinase bolus of 200,000-500,000 U in 57 patients and 20 mg of recombinant tissue plasminogen activator (rt-PA) in two patients. The mean urokinase dose used was 2,500,000 IU, whereas the total dose of rt-PA was 100 mg. Heparin sodium infusion was performed to reach activated partial thromboplastin time ratios of 2. The follow-up consisted of clinical assessment, pulmonary scintigraphy, and echocardiography. The patients received treatment with dicoumarin for 6 months after the procedure. RESULTS Clinical improvement was seen in 56 patients (94%). Three patients died. The mean PAP after the treatment was 21.8 mm Hg. The mean posttreatment Miller index was 0.35. Technical success was achieved in all cases and clinical symptoms improved in all cases except those in which the patients died. Pulmonary scintigraphy showed improved perfusion in all cases. Echocardiography was performed after 3-6 months, showing a mean pressure of 22.8 mm Hg (corrected values). There were no signs of recurrent PTE or arterial hypertension in the follow-up. CONCLUSION The data provided confirm the efficacy and safety of mechanical fragmentation and pharmacologic thrombolysis in the treatment of massive PTE with hemodynamic impairment, showing improvement of symptoms and a decrease in PAP.

Animal experience in the Günther Tulip retrievable inferior vena cava filter.

AbstractPurpose: To assess the retrievability of the Gunther Tulip temporary inferior vena cava filter from a technical viewpoint, and consider the histopathologic changes that occur at the anchoring site of the filter prongs to the vein endothelium in Landrace pigs. Methods: Twenty-two Gunther Tulip retrievable filters were inserted in 22 experimental Landrace pigs via the jugular vein. Device implantation time was 0, 3, 7, 12, 14, 15, 16, 20, 30, 35 and 56 days. Study subjects were divided into two groups. In one group the filter was retrieved percutaneously via the jugular vein whereas in the other group it was removed surgically. The specimens obtained (vena cava and filter) were histopathologically examined. Prior to filter retrieval, a venacavography was obtained in all cases. Degree of retrieval difficulty was rated as follows: no difficulty (N), slight (S), mild (M), high (H) and unretrievable (U). Results: Of the 22 implanted filters, 11 should have been removed percutaneously but this was impossible in three cases (U). In four cases the device was retrieved with no difficulty (N); in two cases the degree of difficulty was mild (M) and in other two it was high (H) and slight (S) respectively. Retrieval difficulties were observed after 16 days. Starting from day 20, there was evidence of fibrosis with thick intimal proliferation and total filter prong involvement, which accounts for the difficulty in retrieving the device. Conclusions: It is advisable not to exceed a filter retrieval time of 16 days in view of the fibrotic changes reported. It might be necessary to perform a larger study with more animals and with retrieval times between 14 and 20 days.

Retrieval of Gunther Tulip optional vena cava filters 30 days after implantation: a prospective clinical study.

PURPOSE To report on the feasibility and safety of retrieval of the Günther Tulip optional vena cava filter 30 days after initial implantation. MATERIALS AND METHODS From March 2004 to September 2005, a single-center prospective study was undertaken in 35 patients who required inferior vena cava (IVC) filtration. All the Günther Tulip filters (GTFs) were implanted with the intention to be removed 30 days after initial implantation. A modified commercial dynamometer was used to measure the force required to remove the device. The degree of difficulty to remove the GTF was classified into four levels: N (no difficulty, force of 0-4.41 N), M (medium difficulty, force of 4.41-5.88 N), G (great difficulty, force of 5.88-9.8 N), and U (unable to remove). Clinical follow-up was performed 1, 3, 6, and 12 months after filter retrieval by review of medical records and imaging. RESULTS Two of the 35 patients experienced extensive thrombosis in the IVC as revealed by abdominal computed tomography, and their filters were left in place on a permanent basis. One patient died of respiratory and cardiac failure during follow-up within the first 30 days after GTF insertion. Filter retrieval was attempted in the remaining 32 patients, and 31 of these attempts were successful (98%). The force necessary to disengage the GTF from the caval wall was less than 9.8 N (N, 79%; M, 13%; G, 6%). Attempts to remove the GTF failed in only one patient (2%). On follow-up times ranging between 14 and 640 days (mean, 342.5 d), no complications or cases of recurrent pulmonary embolism were observed in this patient population. CONCLUSION The Günther Tulip optional IVC filter can be safely placed and retrieved percutaneously 30 days after initial implantation.

Percutaneous treatment of intrabdominal abscess: urokinase versus saline serum in 100 cases using two surgical scoring systems in a randomized trial

The purpose of this study was to assess whether regular instillation of urokinase during abscess drainage leads to an improved outcome compared to saline irrigation alone. One hundred patients referred for image-guided abdominal abscess drainage were randomized between thrice daily urokinase instillation or saline irrigation alone. At the end of the study, patient medical records were reviewed to determine drainage, study group, Altona (PIA II) and Mannheim (MPI) scoring, duration of drainage, procedure-related complications, hospital stay duration, and clinical outcome. The technical success rate of the percutaneous abscess drainage was 100%. The success or failure of abscess remission did not differ significantly between groups (success rate of 91.5% in the urokinase group vs. 88.8% in the saline group; failure rate was of 8.5 vs. 21.2%, respectively); however, days of drainage, main hospital stay, and overall costs were significantly reduced in patients treated with urokinase compared to the control group (P < 0.05). No adverse effects from urokinase were observed. Surgical scores were a useful homogeneity factor, and MPI showed a good correlation with prognosis, while PIA results did not have a significant correlation. For drainage of complex abscesses (loculations, hemorrhage, viscous material), fibrinolytics safely accelerate drainage and recovery, reducing the length of the hospital stay and, therefore, the total cost.

Endovascular Treatment of Massive Hemoptysis by Bronchial Artery Embolization: Short-Term and Long-Term Follow-Up Over a 15-Year Period

OBJECTIVE To present our experience of using arterial embolization for the endovascular treatment of massive hemoptysis along with the results of follow-up over a 15-year period. PATIENTS AND METHODS A total of 401 patients with hemoptysis were referred to the minimally invasive surgery unit of the Hospital Universitario Lozano Blesa de Zaragoza between April 1989 and September 2004 for diagnosis and possible endovascular treatment. Of those patients, 314 met criteria for massive hemoptysis and treatment was attempted using embolization in 287 (91.4%). The most common cause of hemoptysis was bronchiectasis (n=99, 31.5%), followed by lesions due to tuberculosis (n=57, 18.1%) and chronic bronchitis (n=47, 14.9%). RESULTS Angiography of the bronchial arteries provided evidence to account for the hemoptysis in 287 patients (91.4%). The affected arteries were satisfactorily embolized in 281 (97.9%). Endovascular treatment was clinically successful in 256 of those patients (91.1%). Embolization had to be repeated during the hospital stay in 19 patients (6.7%) and was effective in 52.6% of those cases. The 6 patients in whom embolization was not satisfactory underwent thoracotomy. The mean follow-up in 201 patients (71.5%) was 2372.5 days (range, 61-5475 days). Eighty patients (28.4%) were lost to follow-up for various reasons and at different points. Recurrence of hemoptysis occurred on 1 or more occasions in 45 patients (22.3%) but only 21 (10.4%) required repeat embolization. Minor complications that did not require treatment were observed in 88 patients (28.0%). CONCLUSIONS Embolization of bronchial arteries is a nonsurgical treatment that is safe and effective in patients with massive hemoptysis.

Nasolacrimal polyurethane stent placement: preliminary results.

PURPOSE To present our initial results in the treatment of nasolacrimal obstruction by placing a polyurethane stent. METHODS 74 nasolacrimal stents were implanted under fluoroscopic guidance in obstructed nasolacrimal systems of 64 patients. Dacryocystography and CT were used to verify the position and patency of the stents. Mean follow-up was 15 months. Clinical examinations were done at the first week, first month, third month and sixth month after stent placement. RESULTS Polyurethane stents were successfully inserted and permeable in 59 patients (92.1%), but could not be inserted in 5 patients (7.8%). Epiphora was solved and permeable in 53 cases (82.8%), it was not permeable but asymptomatic in 2 cases (3.1%), and was not permeable but symptomatic in 4 (6.2%). In 5 cases (7.8%) stents remained permeable although patients complained of epiphora. CONCLUSIONS Polyurethane stent placement is a non-invasive technique that can replace dacryocystorhinostomy, giving better results and tolerance.

Fragmentación mecánica y fibrinólisis intrapulmonar en el tratamiento del tromboembolismo pulmonar masivo con repercusión hemodinámica

Objetivos Evaluar la eficacia y seguridad de la fragmen-tacion mecanica asociada a trombolisis intrapulmonar en el tromboembolismo pulmonar (TEP) masivo con alteracion hemodinamica. Material y metodo Un total de 51 pacientes diagnosti-cados de TEP masivo con repercusion hemodinamica. Se in-cluyeron bajo este epigrafe pacientes con TEP agudo con un indice de Miller superior a 0,50 y una presion medida en la arteria pulmonar principal superior 30 mmHg. Cuadro cli-nico de inicio: 19 shock, 6 sincope y 26 disnea intensa de reposo. La saturacion de O 2 medida por pulsioximetria: 71,4%. Presion media en arteria pulmonar: 46,1 mmHg. Se realizo fragmentacion de los tromboembolos mas importan-tes. Durante la fragmentacion se administro un bolo de fi-brinolitico. A traves del cateter se administro infusion de fibrinolitico. El seguimiento se realizo con valoracion clini-ca, gammagrafica pulmonar y ecocardiografica. Resultados Tras la fragmentacion y administracion del bolo de trombolitico se observo mejoria clinica en 49 pacien-tes (97,2%). La presion media postratamiento mecanico y farmacologico fue de 24,1 mmHg. Exito tecnico del 100%. Conclusiones Los datos aportados avalan la eficacia y se-guridad de la fragmentacion mecanica y trombolisis farma-cologica en el tratamiento del TEP masivo con afectacion hemodinamica, mejorando la sintomatologia y disminuyen-do la presion arterial pulmonar.

Colon Stenting: A Review

Up to 85% of patients who present with colonic obstruction have a colorectal cancer. Between 7% and 29% of these patients present with total or partial intestinal obstruction. Only 20% of these patients presenting with acute colonic obstruction due to malignancy survive 5 years. Emergent surgical intervention in patients with colonic obstruction is associated with significant morbidity and mortality rates. Only 40% of patients with obstructive carcinoma of the left colon can be treated with surgical resection without the need for a colostomy. The use of a temporary or permanent colostomy has a significant impact on quality of life. The decompressive effect seen with colonic stenting is a durable, simple, and effective palliative treatment of patients with advanced disease. Stent deployment provides an effective solution to acute colonic obstruction and allows surgical treatment of the patient in an elective and more favorable condition. In addition, colonic stenting reduces costs and avoids the need for a colostomy.

Seguimiento clínico y por medios de imagen a largo plazo de los filtros de vena cava inferior. Estudio transversal

Hemos realizado un estudio transversal con el fin de evaluar los hallazgos morfologicos, incidencias y complicaciones observadas en 77 filtros de vena cava inferior implantados en 75 pacientes desde abril de 1990 hasta enero de 1994. El tiempo de seguimiento de los pacientes oscilo entre los 3 y los 61 meses (media, 38,5 meses), realizando encuesta telefonica, evaluacion clinica, iliocavografia y, en algunos casos, ecografia-Doppler y tomografia computarizada (TC). Los hallazgos observados demostraron trombosis de vena cava en el 38% de los casos, edemas en EE1I en el 63,4% de los casos, angulacion > 15° en 8 pacientes, defecto de apertura en 4 pacientes, fibrosis de vena cava con estenosis en 2 casos y perforacion de vena cava inferior en 3 pacientes. Segun nuestro estudio si bien la incidencia de la trombosis de VCI posfiltro es mas alta que la sospechada habitualmente, la trascendencia clinica resulta irrelevante.

Estado actual y experiencia clínica en el tratamiento de las estenosis traqueobronquiales con prótesis metálicas autoexpandibles

La aparicion de una estenosis sintomatica en el arbol bronquial puede provocar a los pacientes una situacion de alto riesgo vital por asfixia. La implantacion de protesis ( stents ) metalicas puede resolver la estenosis de una forma paliativa y aliviar el estado clinico de estos pacientes. Evaluamos la efectividad de las protesis metalicas expandibles como metodo terapeutico en diferentes tipos de estenosis traqueobronquiales. Se han implantado en la sala de radiologia intervencionista (RI), bajo control fluoroscopico y endoscopico, un total de 16 protesis metalicas autoexpandibles tipo Wallstent en 16 pacientes con estenosis traqueobronquiales (12 malignas y 4 benignas). Las protesis fueron ubicadas en el lugar correcto, sin apreciarse complicaciones, obteniendose una mejoria clinica inmediata en todos los pacientes. Tres pacientes con estenosis postintubacion necesitaron tratamiento adicional con laser endoscopico durante el control evolutivo. Todos los pacientes con patologia de origen maligno fallecieron por su enfermedad de base, manteniendose sin sintomatologia traqueal y con su luz permeable. Las protesis metalicas constituyen una alternativa terapeutica paliativa valida en las estenosis traqueobronquiales malignas.