Jeffrey A. Solomon

Sutureless Securement Device Reduces Complications of Peripherally Inserted Central Venous Catheters

PURPOSE This study was conducted to evaluate the performance of a sutureless adhesive-backed device, StatLock, for securement of peripherally inserted central venous catheters (PICCs). Earlier studies have demonstrated that StatLock significantly reduces catheter-related complications when compared to tape. The purpose of this study was to determine whether a sutureless securement device offers an advantage over suture in preventing catheter-related complications. MATERIALS AND METHODS 170 patients requiring PICCs, which were randomized to suture (n = 85) or StatLock (n = 85) securement were prospectively studied. Patients were followed throughout their entire catheter course, and PICC-related complications including dislodgment, infection, occlusion, leakage, and central venous thrombosis were documented. Catheter outcome data were compared to determine if statistically significant differences existed between the suture and StatLock groups. RESULTS The groups had equivalent demographic characteristics and catheter indications. Average securement time with StatLock was significantly shorter (4.7 minutes vs 2.7 minutes;P <.001). Although StatLock was associated with fewer total complications (42 vs 61), this difference did not achieve significance. However, there were significantly fewer PICC-related bloodstream infections in the StatLock group (2 vs 10; P =.032). One securement-related needle-stick injury was documented during suturing of a PICC. CONCLUSION The sutureless anchor pad was beneficial for both patients and health care providers. Further investigation to determine how StatLock helps reduce catheter-related blood stream infections is necessary.

Experience with the recovery filter as a retrievable inferior vena cava filter.

PURPOSE This study evaluates clinical experience with the Recovery filter as a retrievable inferior vena cava (IVC) filter. MATERIALS AND METHODS One hundred seven Recovery filters were placed in 106 patients with an initial clinical indication for temporary caval filtration. Patients were followed up to assess filter efficacy, complications, eventual need for filter removal, time to retrieval, and ability to remove the filter. RESULTS The patient cohort consisted of 62 men and 44 women with a mean age of 48 years (range, 18-90 y). Mean implantation time was 165 days. Indications for filter placement in patients with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) included contraindication to anticoagulation (n = 33), complications of anticoagulation (n = 8), poor cardiopulmonary reserve (n = 6), large clot burden (n = 3), and PE while receiving anticoagulation (n = 1). Indications for filter placement in patients without proven PE or DVT included immobility after trauma (n = 35); recent intracranial hemorrhage, neurosurgery, or brain tumor (n = 18); and other surgical or invasive procedure (n = 3). Three patients (2.8%) had symptomatic PE after placement of the Recovery filter. No caval thromboses were detected. No symptomatic filter migrations occurred. Recovery filter removal was attempted in 15 of 106 patients (14%) at a mean of 150 days after placement. The Recovery filter was successfully retrieved in 14 of 15 patients (93%); one removal was unsuccessful at 210 days after placement. Ninety-two filters (87%) currently remain in place. CONCLUSIONS Although all the filters were placed with the intention of being removed, a large percentage of filters were not retrieved. The Recovery filter was safe and effective in preventing PE when used as a retrievable IVC filter.

Relationship between Chest Port Catheter Tip Position and Port Malfunction after Interventional Radiologic Placement

PURPOSE The relationship between catheter tip position of implanted subcutaneous chest ports and subsequent port malfunction was investigated. Tip movement from initial supine position to subsequent erect position was also evaluated. MATERIALS AND METHODS Patients who underwent imaging-guided internal jugular chest port placement between July 2001 and May 2003 were identified with use of a quality-assurance database. Sixty-two patients were included in the study (22 men and 40 women), with a mean age of 58 years (range, 27-81 years). Catheter tip location on the intraprocedural chest radiograph was determined with use of two methods. First, the distance from the right tracheobronchial angle (TBA) was recorded (TBA distance). Second, tip location was classified into six anatomic regions: 1, internal jugular veins; 2, brachiocephalic veins; 3, superior vena cava (SVC; n = 11); 4, SVC/right atrial junction (n = 22); 5, upper half of right atrium (n = 25); and 6, lower half of right atrium (n = 4). For the duration of follow-up, catheter tip location was documented, as were all episodes of catheter malfunction. RESULTS Patients with catheter tips initially placed in position 3 had a higher risk of port malfunction (four of 11; 36%) than patients with catheter tips located in position 5 (two of 25; 8%). This difference narrowly fell short of statistical significance (P =.057). When comparing intraprocedural chest radiographs to the first erect chest radiographs, significant upward tip movement was noted. The tips migrated cephalad an average of 20 mm (P =.003) and 1.0 position units (P =.001). DISCUSSION Catheter tips placed in the SVC tended to have a greater risk of port malfunction compared with those positioned in the right atrium. Chest ports migrated cephalad between the supine and erect positions.

Single-center Experience with the Arrow-Trerotola Percutaneous Thrombectomy Device in the Management of Thrombosed Native Dialysis Fistulas

PURPOSE The present study sought to evaluate the performance of the Arrow-Trerotola Percutaneous Thrombolytic Device (PTD) in the treatment of native fistula thrombosis in a U. S. hemodialysis population. Specifically, the technical success, clinical success, complication rate and type, primary and secondary patency rates, effect of adjunctive thrombolytic therapy, and any variables that affected outcomes of procedures in which this device was used were analyzed. MATERIALS AND METHODS Forty-two patients with 44 thrombosed native fistulas (17 radiocephalic, 10 brachiocephalic, 10 transposed or superficialized, five graft/fistula hybrids, and two leg fistulas) were treated with 62 mechanical thrombolysis procedures with use of the PTD. All patients had large clot burden. The device type was recorded in 43 procedures: standard (n = 21), over-the-wire (OTW; n = 19), or both (n = 3). No device was used in two cases because of inability to cross the anastomosis. Adjunctive therapies (n = 18) included the use of tissue plasminogen activator (tPA; n = 16) and deployment of the AngioJet device with (n = 1) or without tPA (n = 1). Stents were inserted in four procedures. Outcome variables included technical and clinical success, complications, and primary and secondary patency. Cox proportional-hazards regression and Kaplan-Meier analyses were performed. RESULTS The technical success rate was 87% (54 of 62) and the clinical success rate was 79% (49 of 62). Percutaneous transluminal angioplasty was performed in all but two procedures. Complications occurred in 13% of procedures (n = 8); three resulted in technical failure. The primary patency rates were 38% at 6 months and 18% at 12 months; secondary patency rates were 74% and 69%, respectively. Outcomes were not affected by adjunctive techniques, fistula type, age of fistula, device type (ie, OTW vs standard), or patient sex. Secondary patency was superior when no residual clot or stenosis was present (P = .003). CONCLUSIONS The PTD is effective for percutaneous treatment of thrombosed hemodialysis fistulas, with good short- and long-term outcomes in a U.S. population. Within the limitations of a retrospective study with a small sample size, use of an adjunctive thrombolytic agent did not appear to improve results compared with the use of the device alone.

Removal of retrievable inferior vena cava filters with computed tomography findings indicating tenting or penetration of the inferior vena cava wall.

PURPOSE To examine the feasibility and safety of removing retrievable inferior vena cava (IVC) filters with struts external to the IVC wall on computed tomography (CT) imaging. MATERIALS AND METHODS This retrospective study included 64 IVC filter retrievals from 62 patients over a 5-year period. CT images obtained before retrieval were used to describe the various imaging characteristics of filter interactions with the IVC wall. Patient medical records were reviewed for filter type, results of filter removal with standard or nonstandard techniques, and complications. RESULTS Filter struts outside the IVC wall were a common finding on CT with 55 (85.9%) filters showing some degree of perforation. Of 64 filters, 57 (89.1%) were removed successfully; 7 (10.9%) filters could not be removed because of incorporation of filter struts or tip into the IVC wall. Before retrieval, filter fracture was detected in eight (12.5%) cases, and IVC stenosis was present in three (4.7%) cases. No major complications occurred during any retrieval. Two (3.1%) cases were complicated by postprocedure abdominal pain. Both cases clinically resolved, and no abnormalities were detected on postprocedure CT. CONCLUSIONS The appearance of filter struts tenting or penetrating the IVC wall is a common finding on CT performed before filter retrieval. IVC filters with these findings can be removed safely and should not be a contraindication for IVC filter retrieval.

Wall-embedded recovery inferior vena cava filters: imaging features and technique for removal.

Retrievable inferior vena cava (IVC) filters may be removed when no longer needed or left in place as permanent filters. Removal of any of the currently available optionally retrieved IVC filters becomes more difficult when they are tilted. Tilting of an IVC filter can also lead the tip of the filter to become embedded into the wall of the IVC. This report describes a method for removal of the Recovery IVC filter with use of rigid bronchoscopy forceps when the tip of the filter is tilted and embedded in the IVC.

Magnetic Resonance Imaging of Focal Splenic and Hepatic Lesions in the Dog

Focal hepatic and splenic lesions in the dog are common, and approximately half of such lesions are malignant. Both incidentally discovered lesions and lesions in patients with known malignancies represent diagnostic dilemmas. Ultrasound often fails to characterize such lesions adequately. This uncertainty may result in unnecessary splenectomies and liver biopsies for benign lesions or noncurative surgery for advanced-stage malignancies. In humans, ultrasound largely has been supplanted by computed tomography and magnetic resonance imaging (MRI) for the characterization of focal hepatic and splenic lesions. The inherently high soft tissue contrast of MRI allows the differentiation of benign from malignant hepatic and splenic lesions in the human patients. In this prospective study, 35 focal lesions of either the spleen (n = 8) or the liver (n = 27) were characterized by MRI in 23 dogs. Lesions were presumptively classified as malignant or benign on the basis of MRI findings. Imaging results then were correlated with histopathologic (29) or cytologic (6) evaluation of the lesions. The overall accuracy in differentiating malignant from benign lesions was 94% (33 of 35 lesions). The overall sensitivity and specificity were 100% (95% CI, 78-100%) and 90% (95% CI, 68-99%), respectively. MRI classified malignant hepatic lesions as hepatocellular carcinoma (HCC) in all confirmed cases and correctly predicted the histologic grade of 5 HCC lesions. These results suggest that MRI is a useful modality for abdominal imaging in veterinary patients, and MRI accurately differentiated benign from malignant focal hepatic and splenic lesions in this sample of patients.

Gadolinium Arteriography Complicated by Acute Pancreatitis and Acute Renal Failure

Editor: Several studies have supported the intravenous use of gadolinium as a paramagnetic contrast agent with a favorable safety profile (1,2). The relative safety of gadolinium-based contrast agents over iodine-based contrast agents in patients with renal insufficiency is also well established (3–5). Recently, however, reports of severe adverse reactions to standard doses of gadolinium have surfaced (6,7). Adding to this growing body of literature, we report a case of acute pancreatitis and acute renal failure after the administration of a gadoliniumbased contrast agent for iliac arteriography in a patient with diabetes mellitus and chronic renal insufficiency. A 68-year-old woman with long-standing bilateral lower extremity claudication was admitted to the interventional radiology service for right iliac artery stent placement. Preoperative MR angiography demonstrated a 90% ostial stenosis of the right common iliac artery and occlusion of the left common iliac artery. The patient also had a history of hypertension, hyperlipidemia, diabetes mellitus, and chronic renal insufficiency (creatinine 5 3.8 mg/dL). Given the patient’s baseline renal insufficiency and the attendant risk of nephrotoxicity from an iodine-based contrast agent, arteriography was performed with a gadolinium contrast agent, gadodiamide (Omniscan; Nycomed-Amersham, Princeton, NJ). Arteriography confirmed the presence of a critical (90%) ostial stenosis of the right common iliac artery. The patient received intravenous conscious sedation consisting of 1 mg of midazolam and 100 mg of fentanyl citrate. A total of 6,000 U of intravenous heparin was given to induce systemic anticoagulation before intervention. Subsequently, angioplasty and stent placement across the ostial lesion of the right common iliac artery were performed without immediate complication. Six hours after the procedure, the patient reported nausea, mild epigastric pain radiating to the back, and two episodes of vomiting. The patient received 10 mg of intravenous perchlorperazine, with transient improvement. Eleven hours after the procedure, the patient again reported epigastric discomfort and received 80 mg of oral simethicone, with minimal relief. Amylase and lipase levels at this time were noted to be 246 U/L and 1,314 U/L, respectively (laboratory normal ranges: amylase, 0–140 U/L; lipase, 0–200 U/L). Laboratory measurements obtained the next morning showed an increase in amylase and lipase to 684 U/L and 1,646 U/L. Results of liver function tests were within the reference range. A right upper quadrant ultrasound scan yielded findings that were within normal limits. The patient subsequently developed superimposed acute renal failure, electrolyte imbalance, and pulmonary edema, necessitating transfer to the intensive care unit. Microscopic urinalysis on the second postoperative day demonstrated muddy brown casts consistent with acute tubular necrosis. The patient’s respiratory status improved rapidly after aggressive diuresis, and she was stable for transfer to the renal service on the fifth postoperative day. With conservative management, her renal function improved and she never required dialysis. Her pancreatitis also resolved, without any further complications, and she was discharged from the hospital on the tenth postoperative day. In view of its relative safety in the setting of renal insufficiency, gadolinium is increasingly being used as an alternative contrast agent in interventional radiology. Despite its safety, however, there have been several recent reports of adverse events associated with gadolinium administration. Specifically, case reports of acute renal failure after gadoteridol intraarterially and acute pancreatitis after intravenous gadolinium-DTPA have surfaced (6,7). This case adds to a growing body of evidence that pancreatitis and renal failure are potential complications associated with gadolinium administration. To our knowledge, this is the first report of both acute pancreatitis and acute renal failure occurring in the same patient after a single administration of intraarterial gadolinium. While this case offers no definitive answers, it does suggest that further study of gadolinium dosing and adverse reactions in both animals and humans is necessary. There is currently no recommendation for the maximum safe dose of gadolinium, nor is there a minimum recommended creatinine clearance below which gadolinium should not be administered. Until such limits are established, care should be taken when administering large doses of gadolinium compounds.

Growth dynamics of plexiform neurofibromas: a retrospective cohort study of 201 patients with neurofibromatosis 1

BackgroundTo examine the natural growth dynamics of internal plexiform neurofibromas (PNs) in patients with neurofibromatosis 1 (NF1).MethodsTwo hundred and one NF1 patients underwent whole body MRI (WBMRI). Tumour burden was estimated volumetrically. Non-parametric Spearman’s rho correlation coefficients were used to analyse the relationship of growth rate to tumour volume and age. Chi-squared and Mann–Whitney U tests were used for analysing the association of tumour occurrence with sex or age. Chi-squared tests were used to analyse the association of tumour growth with age group.ResultsSeventy-one of 171 patients with serial WBMRI exams had internal PNs (median follow up 2.2 years [1.1 to 4.9 years]). Median whole body tumour volume was 86.4 mL [5.2 to 5878.5 mL]) with a median growth rate of 3.7%/year (−13.4 to 111%/year) that correlated with larger whole body tumour volume (P<0.001) and lower age (P=0.004). No new PNs developed in 273.0 patient-years among patients without tumours. Rate of new tumour development among patients with PNs was 0.6%/year (95% confidence interval 0.02 to 3.4%). Twenty-seven (13.5%) tumours increased significantly and were more frequent among children (P<0.001). Growth rate of tumours was inversely correlated with age (Spearman’s rho=−0.330, P<0.001). Seventy-one (35.5%) tumours had smaller volumes on follow up (median −3.4%/year [−0.07% to −35.9%/year]).ConclusionChildren with NF1 and internal PNs are at risk for tumour growth. Most PNs grow slowly or not at all, and some decrease in size. New tumours are infrequent in NF1 patients with PNs and unlikely in patients without PNs.

Transluminal endosurgery: novel use of endoscopic tacks for the closure of access sites in natural orifice transluminal endoscopic surgery (with videos)

BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) is a novel and potentially less-invasive alternative to laparoscopic surgery. Successful reproducible secure closure of the transluminal access site represents one of the largest obstacles in the evolution of this discipline. AIM To study the feasibility and efficacy of a novel transluminal closure device in a live porcine model. DESIGN Experimental endoscopic study of transgastric incision and closure with a novel device in a porcine survival model. Six survival experiments were conducted on Yorkshire pigs that weighed 22 to 25 kg. INTERVENTIONS After general anesthesia was administered, a therapeutic endoscope was inserted into the stomach. Two gastrotomies were made in each pig by using a needle-knife with blended current, a guidewire, and an 18-mm through-the-scope dilating balloon. The peritoneum was easily accessed in all pigs without complications. One gastrotomy was closed with T-tag fasteners and the other one with endoscopic tacks. Two different closure methods were used with the tacks: the anchor-and-loop technique (ALT) and the serosa-to-serosa closure (SSC). All closures were immediately completely sealed, with no carbon dioxide (CO(2)) leak detected at 25 cm of water pressure. After recovery from anesthesia, all the animals resumed feeding and returned to preprocedure activities on the same day as the procedure. The animals were monitored daily for signs of peritonitis and sepsis. Preplanned euthanasia of the animals was performed after 7 to 14 days. The peritoneal cavity was studied at necropsy for evidence of wound dehiscence, abscess formation, and gross adhesions. MAIN OUTCOME MEASUREMENTS Full-thickness healing of the gastric-wall incisions without intraperitoneal complications on postmortem examination. RESULTS All animals survived without complications. Transgastric closure was successful in all the animals by using both study techniques (ALT and SSC) and the T-tag closure. The deployment device performed well, and accurate closure was rapid and reproducible. CONCLUSIONS This prototype closure device holds promise in solving some of the problems of closure for transluminal access for NOTES. Both the ALT and the SSC technique hold promise for threadless closure and for simplifying endoscopic techniques. The SSC technique holds promise to maintain surgical principles of serosa-to-serosa apposition. Further studies are recommended before in vivo human use.