John C. McDermott

Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease

Background: Renal transplant artery stenosis (RTAS) continues to be a problematic, but potentially correctable, cause of post‐transplant hypertension and graft dysfunction. Older transplant recipients, prone to peripheral vascular disease (PVD), may have pseudoRTAS with PVD involving their iliac system.Methods: We retrospectively analyzed 819 patients who underwent kidney transplantation between 1993 and 1997 to determine the contribution of pseudoRTAS to renal transplant renovascular disease. Univariate analyses were performed for donor and recipient variables, including age, weight, gender, race, renal disease, cholesterol and creatinine values, human leukocyte antigen (HLA) matching, cytomegalovirus (CMV) infection, and immunosuppressive medications. Significant variables were then analyzed by a Cox proportional hazards model.Results: Ninety‐two patients (11.2%) underwent renal transplant arteriogram (Agram) or magnetic resonance angiography (MRA) for suspected RTAS. RTAS or pseudoRTAS, defined as one or more hemodynamically significant lesions in the transplant artery or iliac system, was evident in 44 patients (5.4%). Variables significantly associated with RTAS by univariate analysis were weight at the time of transplant (p=0.0258), male gender (p=0.034), discharge serum creatinine> 2 mg/dL (p=0.0041), and donor age (p=0.0062). Variables significantly associated with pseudoRTAS by univariate analysis were weight at the time of transplant (p=0.0285), recipient age (p=0.0049), insulin‐dependent diabetes mellitus (IDDM; p=0.0042), panel reactive antibody (PRA) at transplant (p=0.018), and body mass index (p=0.04). Weight at transplant and donor age remained significantly associated with an increased risk for RTAS in a multivariate stepwise Cox proportional hazards model. IDDM, transplant PRA, weight at transplant, and donor age were significantly associated with an increased risk for pseudoRTAS in a multivariate stepwise Cox proportional hazards model. Importantly, both RTAS and pseudoRTAS were associated with poorer graft survival (p<0.007 for each).Conclusions: Renal transplant renovascular disease encompasses pre‐existing PVD acting as pseudoRTAS, as well as classical RTAS. Efforts to identify and correct renal transplant renovascular disease of either nature are important, given its negative impact on graft survival.

Use of magnetic resonance angiography for the preoperative evaluation of patients with infrainguinal arterial occlusive disease

PURPOSE This study was designed to determine whether magnetic resonance angiography (MRA) will allow preoperative management decisions without the need for contrast arteriography in patients with lower extremity ischemia caused by infrainguinal arterial occlusive disease. METHODS Forty-five patients with lower extremity ischemia in 50 limbs were evaluated by both two-dimensional time-of-flight MRA and intraarterial digital subtraction angiography (DSA) between February 1992 and June 1995. Independent management plans were based on clinical presentation, pulse volume recordings, and separate reviews of the MRA and DSA. RESULTS Of 50 limbs, 23 required arterial bypass, 19 percutaneous transluminal angioplasty, 5 patch angioplasty, and 3 amputation. MRA and DSA correlated exactly in 89.5% of infrainguinal arterial segments, whereas interpretations disagreed in 10.5% of arterial segments. Mismatches that had an influence on patient treatment decisions occurred in only 8 (2.3%) of 352 arterial segments. Independent MRA- and DSA-based revascularization plans agreed in 45 (90%) extremities. MRA predicted the level of arterial reconstruction in all 23 limbs that required arterial bypass. MRA identified focal stenoses amenable to percutaneous transluminal angioplasty in 18 (94.7%) of the 19 limbs that ultimately underwent percutaneous transluminal angioplasty. A strategy of preoperative planning by MRA with confirmatory intraoperative arteriography would represent a 31% cost savings per patient at our institution while eliminating the morbidity of preoperative DSA. CONCLUSIONS When used in combination with the patients physical examination and segmental limb pressures with plethysmography, MRA is sufficient for planning infrainguinal arterial bypass procedures and selecting patients for percutaneous transluminal angioplasty.

The Bird's Nest Inferior Vena Caval Filter: Review of a Single-Center Experience

PURPOSE To examine a large single-center experience with Birds Nest vena caval filters for indications, clinically evident recurrent thromboembolic disease, and other filter-related complications. MATERIALS AND METHODS During a 6-year period, 308 patients underwent percutaneous placement of an inferior vena caval filter. The 267 patients who received a Birds Nest filter are the subject of this retrospective review. The series included 162 men and 105 women who ranged in age from 16 to 88 years (mean, 57.1 +/- 17.0 standard deviation). RESULTS Indications for filter placement included contraindication to anticoagulation (n = 141), complication of anticoagulation (n = 23), failure of anticoagulation (n = 30), failure of previously placed filter (n = 1), and prophylaxis (n = 82). Ten patients had more than one indication. Acute lower extremity deep venous thrombosis was confirmed in 133 patients, pulmonary embolism (PE) was found in 44 patients, and both were positively diagnosed in 37 other patients. Fifty-three patients had no documented acute thromboembolic disease at the time of insertion. Mean follow-up was 13 months. Thirty-day mortality was 9.7%, including one death from recurrent PE and one major puncture-site bleeding episode that may have contributed to death. Recurrent PE was found at radionuclide scanning or autopsy in three patients (1.1%), whereas another eight patients (3.0%) had suspected recurrent PE without confirmatory studies. Eight patients (3.0%) developed early venous access site thrombosis, including two who progressed to phlegmasia cerulea dolens with fatal complications. Significant nonthromboembolic problems were encountered in 1.9% of patients. CONCLUSIONS The Birds Nest filter is a safe and effective device for patients with complicated venous thromboembolic disease.

Infected Bilomas in Liver Transplant Recipients: Clinical Features, Optimal Management, and Risk Factors for Mortality

BACKGROUND Infected hepatic fluid collections (bilomas) are a major infectious complication of liver transplantation. Limited data exist on management and outcome of biloma. METHODS We report a cohort study of 57 liver transplant recipients with posttransplantation bilomas undertaken to identify the clinical features of biloma, management strategies, and outcome. RESULTS Fever (44%) and abdominal pain (40%) were the most common presenting symptoms, but one-third of patients were asymptomatic; 79% had elevated hepatic enzyme levels. Patients without hepatic artery thrombosis (HAT) had the highest rates of resolution with percutaneous drainage and anti-infective therapy (64%). Retransplantation was necessary in 64% of patients with HAT and biloma. Independent predictors of resolution with nonsurgical therapy were absence of HAT (odds ratio [OR] 7.69; P=.01) and absence of Candida (OR, 9.09; P=.02) or enterococcal infection (OR, 7.69; P=.03). Patients with bilomas had significantly greater mortality (Cox proportional hazard ratio [HR], 2.38; P=.008, by log rank test) and graft loss (HR, 4.31; P<.0001). Predictors of mortality by multivariable analysis included renal insufficiency (OR, 12.51; P=.02) or infection with Candida species (OR, 4.93; P=.03) or gram-negative bacilli (OR, 9.12; P=.01). CONCLUSION Posttransplantation biloma should be suspected in patients with fever or abdominal pain or abnormalities of hepatic enzymes, and it can be confirmed by computerized tomography and radiographically guided aspiration. Bilomas are most likely to be successfully treated nonsurgically in patients without HAT and without Candida or enterococcus infection.

A new guidewire with kink-resistant core and low-friction coating

A new guidewire constructed from kinkresistant titanium-nickel alloy, polyurethane, and hydrophilic polymer is described. We have used this wire in 119 angiographic and 49 interventional procedures without complications. In numerous applications, it offers significant advantages over other guidewires. It is particularly helpful for angiography and interventional procedures requiring catheterization through markedly tortuos vessels, tight stenoses, or occlusions.

Abdominal abscesses associated with enteric fistulas: percutaneous management.

For many years, surgical dictum stated abdominal fistulas should be treated by means of surgical excision. Recent advances in percutaneous techniques have altered this. The authors reviewed 150 consecutive abdominal abscesses drained percutaneously over a 36-month period. Among these, 24 patients were found to have 26 fistulous communications to bowel, the pancreatic duct, or the biliary system. Initial drainage of their abscesses was performed in the hospital, but 17 of 24 patients were discharged with a tube in place and were followed up as outpatients. The duration of drainage ranged from 4 days to 3 months. Fistulas healed in 21 of 24 patients (88%) without surgical intervention. Complications were few and included inadvertent dislodgment requiring tube replacement (two patients) and inadvertent puncture of the transverse colon (one patient). Treatment of abdominal abscesses with fistulas by means of percutaneous methods is reliable and safe. Hospital stay may be minimized with outpatient management after drainage.

Lymphatic disruption following abdominal aortic surgery

Two cases of abdominal lymphatic disruption following surgery on the abdominal aorta are presented, one causing chylous ascites and the other resulting in a lymphocele. These complications have been only rarely described following abdominal vascular surgery. Both patients responded to percutaneous aspiration without recurrence. The radiologist has a major role in both the detection and management of this complication.

Pancreatic pseudocyst with fistula to the common bile duct: radiological diagnosis and management.

A patient was found to have fistulization of a pancreatic pseudocyst with the common bile duct. Resolution of the pseudocyst and the attendant biliary obstruction was achieved with percutaneous biliary drainage alone. The clinical and radiological features of this case are herein presented along with a brief review of the subject.

Percutaneous aspiration thromboembolectomy (PAT): An alternative to surgical balloon techniques for clot retrieval☆

Percutaneous aspiration thromboembolectomy (PAT) is an angiographic technique that can be used to remove thromboembolic debris from the distal lower extremity circulation. This procedure employs a specially designed catheter-sheath system, which can be used alone or in combination with balloon angioplasty or thrombolytic drugs (streptokinase 10,000 U/hr or urokinase 100,000 U/hr for 6 hours) to remove thromboembolic material. PAT is best suited for treating iatrogenic emboli resulting from intra-arterial catheterization or balloon angioplasty but can be used as a supplement to Fogarty embolectomy when retained distal clot cannot be retrieved by surgical means and for removal of primary distal emboli of peripheral vascular or cardiac origin. PAT was used in 42 patients with acute threatening limb ischemia. Successful clot retrieval and limb salvage were achieved in 40 of the 42 patients (95%). The major complication was groin hematoma (7 of 42 patients, 17%) and one death occurred as a result of myocardial infarction (2.4%). PAT enhances the therapeutic role of angiography and can be used as an alternative to surgical embolectomy in selected patients.

Percutaneous management of lymphatic fluid collections.

Eight lymphatic fluid collections were drained percutaneously. There were no immediate or late complications. Seven patients had follow-up; 1 required surgical drainage of a residual or recurrent lymphocele, and another had reaccumulated fluid in a lymphocele which was detected on autopsy. The remaining lymphatic collections responded to percutaneous drainage. Percutaneous drainage is safe and can be an effective tool in the management of lymphatic collections.