Joaquín Medrano

The Günther Tulip Retrievable Filter: Prolonged Temporary Filtration by Repositioning within the Inferior Vena Cava

PURPOSE To report experience with the retrievable Günther Tulip filter (GTF) as a means of temporary caval filtration for the prevention of pulmonary embolism (PE) with use of a technique that prolongs filter dwell time beyond 14 days. MATERIALS AND METHODS Eighty-eight GTFs were implanted in 87 patients. The GTFs were placed with the intention of retrieval in all patients within 14 days after initial implantation. In 23 of the 87 patients (26%), there was a need to prolong temporary caval filtration beyond the recommended period of 14 days. This was successfully achieved with use of percutaneous techniques from the right internal jugular vein whereby the filter was repositioned to a different location within the inferior vena cava (IVC) before definitive device removal. RESULTS Of 88 GTFs implanted in 87 patients, 70 were successfully retrieved and 18 were left in place permanently. Forty-seven filters in 46 patients were removed after initial implantation with no need for percutaneous repositioning within the IVC to prolong dwell time (mean dwell time, 13 days). In the 23 patients who required repositioning of 23 GTFs within the IVC to prolong temporary caval filtration, the mean dwell time was 34.8 days; the mean number of repositioning procedures was 1.5, the mean time between repositioning procedures was 13.8 days, and the mean fluoroscopy time was 4.4 minutes in patients in whom filter retrieval was attempted. One patient underwent placement and subsequent removal of the GTF twice for perioperative prophylaxis against PE on two separate occasions. No filters were misplaced in an unintended location or tilted (>15 degrees ) in relation to the main caval axis after deployment. In one patient, a GTF became permanently fixed in the IVC 16 days after initial implantation and could not be removed percutaneously. Nine patients had mild or moderate-sized cervical hematomas. One patient had recurrent asymptomatic PE 2 months after filter insertion. CONCLUSION Dwell times of 14 days can be achieved in most patients before device removal. Prolongation of the dwell time beyond 14 days can be safely and easily achieved by performing percutaneous repositioning of the device within the IVC via a jugular approach.

Transcatheter intracavitary fibrinolysis of loculated pleural effusions: experience in 102 patients.

AbstractPurpose: To assess the efficacy of intrapleural urokinase instillation through smll-caliber catheters for the treatment of loculate and/or septate effusions. Methods: We inserted small-caliber catheters (8.2 Fr) in 102 patients with septate and/or loculate pleural effusions using ultrasonographic guidance. Urokinase (100,000 IU/2 hr, 3 times a day) was instilled through the catheter until the effusion resolved and D-dimer levels were <500 ng/ml. Patients were enrolled regardless of the etiology of the pleural effusion provided there were no contraindications for the use of urokinase. D-dimer levels were determined before and after treatment. Follow-up was performed by chest radiograph and sonography at 1 day, 7 days, and every 30 days thereafter for 6 months. Results: Successful catheter placement was achieved in all cases. The mean time catheters stayed in place was 5.7 days and the mean dose of drug instilled was 690,000 IU. Pleural effusion drainage was complete at the first assessment in all patients. Failure of the treatment, with recurrent effusion at 30 days, occurred in six patients (5.8%). Complete resolution without sequelae was observed in 19 patients (19.6%). In 75 cases (73.5%) resolution was partial, with pleural thickening (>2 mm). Two patients died from unrelated causes within 30 days after catheter placement. Complications were seen in 13 patients (12.74%): hydropneumothorax, nine cases (8.82%); infection of the puncture point, three cases (2.94%); and adverse reaction, one case (0.98%). No further treatment was required. Conclusions: The use of intrapleural fibrinolytic agents delivered through small-caliber catheters for the treatment of loculate and/or septate pleural effusion is a simple, effective, minimally invasive and inexpensive procedure that can prevent sequelae and shorten drainage time.

Tratamiento de la hipertensión arterial pulmonar postembólica mediante técnicas mínimamente invasivas guiadas por imagen

Objetivo Aunque la tromboendarterectomia pulmonar quirurgica es el tratamiento de eleccion en la hipertension arterial cronica de origen tromboembolico, cuando no hay indicacion quirurgica o el paciente rechaza la cirugia se puede recurrir a tecnicas endovasculares de minima invasion (angioplastia y protesis metalica) con aceptables resultados. Pacientes y metodos Se trato a 8 pacientes (5 varones y 3 mujeres) con una media de edad de 62,6 anos, en clase III o IV de la clasificacion de la New York Heart Association (NYHA), con presion arterial pulmonar media de 40 mmHg o superior, presion capilar enclavada de 15 mmHg o menor e indice de Miller mayor de 0,5. En todos los casos el diagnostico se establecio por ecografia Doppler cardiaca, angio-grafia pulmonar, estudio hemodinamico y gammagrafia de ventilacion-perfusion. Se realizo tratamiento fibrinolitico seguido de angioplastia en todos los casos, y se coloco una protesis metalica en 3. Se realizaron revisiones clinicas al cabo de 1; 3; 6, y 12 meses mediante ecografia y gammagrafia. Resultados El exito tecnico del procedimiento fue del 100%. El seguimiento medio fue de 18,7 meses. Como complicaciones menores se produjeron extrasistoles en 3 casos; hematoma leve en la zona de puncion en un caso, y rectorra-gia, que remitio sin tratamiento, en otro. Una paciente murio por causa desconocida al cabo de 24 h. En todos los casos revisados se observaron una mejoria en la clasificacion de la NYHA, mejora hemodinamica evidenciada por ecografia y mejora morfologica objetivada por arteriografia y gammagrafia. Conclusiones Las tecnicas endovasculares de minima invasion pueden contribuir a mejorar la hipertension arterial pulmonar cronica debida a tromboembolia en la que no es posible otro tratamiento (farmacologico o quirurgico).

Ileocolic Arteriovenous Fistula with Superior Mesenteric Vein Aneurism: Endovascular Treatment

We report a case of a venous aneurysm secondary to an acquired ileocolic arteriovenous fistula in a 64-year-old woman with recurrent abdominal pain and history of appendectomy. The aneurysm was diagnosed by ultrasound and computed tomography. Angiography showed an arteriovenous fistula between ileocolic branches of the superior mesenteric artery and vein. This vascular abnormality was successfully treated with coil embolization.

[Image-guided minimally invasive treatment of pulmonary arterial hypertension due to embolic disease].

OBJECTIVE Although surgical pulmonary thromboendarterectomy is the treatment of choice for pulmonary hypertension due to chronic thrombotic and/or embolic disease, minimally invasive endovascular techniques such as angioplasty or placement of a metallic stent can provide acceptable results when surgery is not indicated or has been refused by the patient. PATIENTS AND METHODS Eight patients (5 men, 3 women; mean age, 62.6 years) were treated. The patients were in New York Heart Association (NYHA) class III or IV and had a mean pulmonary artery pressure of 40 mm Hg and more, a capillary wedge pressure of 15 mm Hg or less, or a Miller index greater than 0.5. In all cases, diagnosis was based on Doppler echocardiography, pulmonary angiography, hemodynamic evaluation, and ventilation-perfusion scintigraphy. All patients received fibrinolytic therapy and underwent angioplasty. A metallic stent was implanted in 3 patients. Follow-up echocardiographic assessment and ventilation-perfusion scans were scheduled at 1, 3, 6, and 12 months. RESULTS The procedures were technically successful in all cases. The mean follow-up period was 18.7 months. Minor complications were extrasystoles (3 cases), slight bruising at the site of puncture (1 case), and rectal bleeding that resolved without treatment (1 case). One patient died from an unknown cause 24 hours after the procedure. In all other cases, improvements were noted in NYHA functional class, in hemodynamics demonstrated by echocardiography, and in vascular structure as shown by arteriography and scintigraphy. CONCLUSIONS Minimally invasive endovascular interventions can help improve pulmonary arterial hypertension due to chronic thrombotic and/or embolic disease in patients for whom medical or surgical treatment is not possible.

Obstrucción de vía lagrimal tratada mediante Stent lacrimonasal

espanolObjetivo: Analizar los resultados de la implantacion de stents lacrimonasales de poliuretano y las caracteristicas de los pacientes y las intervenciones realizadas. Material y metodos: Estudio de 125 casos de obstruccion del conducto lacrimonasal en 115 pacientes, 30 varones y 85 mujeres. Obstrucciones del lado derecho 51 (40,8%) y del lado izquierdo 74 (59,2%). Edad media de los enfermos: 65 DE 14,61 anos. La clinica de los pacientes fue epifora 65 casos (52%), dacriocistitis aguda 33 (26,4%), mucocele 6 (4,8%), conjuntivitis de repeticion 4 casos (3,2%). Un total de 17 pacientes nos fueron remitidos con el diagnostico de obstruccion de via lagrimal. El tiempo de seguimiento fue de 1 ano. Resultados: Implante realizado con exito en 120 casos (96%). Las complicaciones intraoperatorias mas importantes fueron dolor 5,83%, inflamacion palpebral 5%, falsa via y epistaxis, 0,83% cada una. La epifora desaparecio en 82 casos (68,3%) y persistio en 38 (31,7%). Tiempo medio de fallo del stent en este ultimo grupo 178 dias. En los stents que fallaron se encontro tejido de granulacion en un 63,15% y material mucoide en 36,85%. La principal complicacion postoperatoria fue mucocele en el 7,5% de los casos. Conclusiones: Consideramos esta tecnica una buena alternativa para el tratamiento de la obstruccion de la via lagrimal, aunque sin alcanzar los resultados de la dacriocistorrinostomia externa o endonasal. EnglishObjective: To analyze a series of patients with lacrimal duct obstruction treated with polyurethane stents. Material and Methods: We studied 125 cases of lacrimal duct obstruction corresponding to 115 patients, of whom 30 were males (26.08%) and 85 females (73.91%). The obstruction involved the right side in 51 cases (40.8%) and the left side in 74 (59.2%). Mean age was 65 ± 14.64 years. Symptoms included chronic epiphora in 65 patients (52%), acute lacrimal sac inflammation in 33 (26.4%), mucocele in 6 (4.8%) and recurrent conjunctivitis in 4 (3.2%). Seventeen patients came to us diagnosed with lacrimal duct obstruction. Time of follow up was one year. Results: Stents were successfully implanted in 120 cases (96%). Surgical complications included pain in 5.83%, eyelid inflammation in 5%, nasal bleeding in 0.83% and false duct in 0.83%. Functional success was achieved in 82 patients (68.3%), and surgical failure occurred in 38 patients (31.7%). Mean time of stent failure was 178 days. In these cases, inner granulation tissue was found in 63.15% of the cases and mucoid material in 36.85%. The most common postoperative complication was mucocele formation, which ocurred in 7.5% of the patients. Conclusions: In our experience, polyurethane stent implantation is a good alternative for treating nasolacrimal obstruction, but not as effective as endonasal or external dacryocystorhinostomy.

Hemoptysis Workup Before Embolization: Single-Center Experience with a 15-year Period Follow-Up

The objective of this work was to present our experience in arterial embolization in the endovascular treatment of massive hemoptysis and remark on the importance of the workup before embolization. We present some clinical aspects to keep in mind before carrying out a bronchial embolization in a patient with severe hemoptysis. The main causes of hemoptysis are presented, as well as diagnosis means and the most important therapeutic procedures aimed to stabilize the patient who will undergo a bronchial arterial embolization. Likewise, we present our own experience with 401 patients with over a 15-year period of follow-up.

Drenaje de colecciones abscesificadas abdominales. Ventajas del uso de fibrinolíticos

Image-guided percutaneous abscess drainage has become the standard method of treatment for most abdominal abscesses. In many cases, it should be considered the treatment of choice, but there are certain circumstances that require specific approaches and methods. Typical abscesses within solid parenchymal organs or those in the peritoneal spaces can be reliably detected by imaging techniques and efficiently drained. Abscesses that are multiple or long and circuitous require careful placement of one or more catheters. Management of the drainage catheters includes irrigation with saline solution to prevent obstruction. Despite the use of saline irrigations and large caliber catheters, catheter drainage sometimes fails and conventional surgery is required. In selected cases, fibrinolytic agents have been proved to be effective in shortening drainage times and length of hospital stay. The use of fibrinolytic agents in the drainage of some anatomical sites, such as the spleen and pancreas, is controversial and the technique should be meticulously selected. Successful treatment is most likely when an interdisciplinary approach is used. The present article reviews the state of the art of the use of fibrinolytic agents to improve percutaneous abdominal abscess drainage.

Tratamiento endovascular mediante fibrinolisis y fragmentación del embolismo pulmonar masivo con inestabilidad hemodinámica. Experiencia de un solo centro en 111 pacientes. ¿Por qué no seguimos las recomendaciones de la ACCP?

INTRODUCTION Fibrinolysis is recommended in several consensus documents for the treatment of a haemodynamically unstable massive pulmonary embolism (HUMPE). MATERIAL AND METHODS A total of 111 patients were treated in a single centre from January 2001 to December 2009. They were 55 males and 56 females diagnosed with HUMPE (systolic arterial pressure>90 mmHg) with at least two of the following criteria: Miller index>0, ventricular dysfunction, and need of vasoactive drugs. Local fibrinolysis with urokinase was performed in all cases, and fragmentation with a pig-tail catheter in the majority of them. An inferior vena cava (IVC) filter was implanted in 94 patients as a prophylactic measure. RESULTS Technical success was 100%. The Miller index improved from 0.7 ± 0.12, pre-treatment, to 0.09 ± 0.16. The mean pulmonary arterial pressure fell from 39.93 ± 7.0 mmHg to 20.47 ± 3.3 mmHg in the 30-90 days review. Of the 94 patients with IVC filters implanted, 79% were withdrawn satisfactorily. Seven patients died: 3 due to their neoplasia, 3 due to right cardiac failure at 1, 7 and 30 days, and another died of a brain haemorrhage in the first 24 hours. There were complications in 12.6% of the cases, of which 4.5% were major. CONCLUSION Local fibrinolysis with fragmentation achieves a rapid return to normal of the pulmonary pressure and is a safe and effective method for the treatment of HUMPE.

Endovascular Treatment of a Haemodynamically Unstable Massive Pulmonary Embolism using Fibrinolysis and Fragmentation. Experience with 111 Patients in a Single Centre. Why don't we follow ACCP Recommendations?

Abstract Introduction Fibrinolysis is recommended in several consensus documents for the treatment of hemodynamically-unstable massive pulmonary embolism (MPE). Material and methods A total of 111 patients were treated in a single center from January 2001 to December 2009. Fifty-five were male and 56 female, all diagnosed with hemodynamically-unstable MPE (systolic arterial pressure > 90 mmHg) with at least two of the following criteria: Miller index > 0, ventricular dysfunction, and need for vasoactive drugs. Local fibrinolysis with urokinase was performed in all cases as was fragmentation with a pig-tail catheter in most. An inferior vena cava (IVC) filter was implanted in 94 patients as a prophylactic measure. Results Technical success was 100%. The Miller index improved from 0.7 ± 0.12, pre-treatment, to 0.09 ± 0.16. Mean pulmonary arterial pressure went from 39.93 ± 7.0 mmHg to 20.47 ± 3.3 mmHg at the 30-90 day follow-up. Ninety-four patients had IVC filters implanted, 79% of which were withdrawn satisfactorily. Seven patients died: 3 due to neoplasia; 3 due to right cardiac failure at 1, 7 and 30 days; and another died of a brain hemorrhage within the first 24 hours. There were complications in 12.6% of the cases, of which 4.5% were major. Conclusion Local fibrinolysis with fragmentation achieves rapid normalization of the pulmonary pressure and is a safe and effective method for the treatment of hemodynamically-unstable MPE.