Julia Gates

Transfemoral repositioning of malpositioned central venous catheters.

PurposeTo determine the efficacy of the transfemoral vein approach to repositioning malpositioned central venous catheters.MethodsDuring a 41/2-year period, malpositioned central venous catheters were repositioned 91 times in 83 patients via the transfemoral vein approach. All repositioning was initially attempted with a Grollman catheter or other pigtail catheter and a tip-deflecting wire. If these techniques failed or the venous anatomy was unfavorable, gooseneck or long loop snares were used.ResultsDuring 48 repositionings, rotating a pigtailtype catheter alone was used successfully in 39 (81%). In 6 of 9 failures, the addition of a tip-deflecting wire also failed. A Grollman catheter and tip-deflecting wire were used initially in 39 repositionings (6 failures; 85% success). Successful repositioning required a snare in 8 (4 as the primary repositioning technique) and a longloop technique in 5. All repositionings were ultimately successful and there were no complications.ConclusionCentral venous catheters can be repositioned consistently by the transfemoral route. Pigtail catheters or tip-deflecting wires alone are successful in over 80% of cases.

Hepatic chemoembolization: effect of intraarterial lidocaine on pain and postprocedure recovery.

AbstractPurpose: To determine if intraarterial lidocaine reduces pain during and after chemoembolization, and whether it influences postprocedure recovery. Methods: Two patient cohorts undergoing selective hepatic chemoembolization were compared. Chemoembolization was performed without lidocaine (control group) in 27 patients and intraarterial lidocaine was used (lidocaine group) in 29 similar patients. Objective changes in patient management were assessed. Pain reduction in 31 more procedures with lidocaine (total 60) was assessed and related to tumor type. Results: During chemoembolization, intraarterial lidocaine reduced the need for additional intravenous analgesics from 69% to 19%. After chemoembolization the mean Dilaudid dose in the first 24 hr was reduced from 9.5 mg to 4.15 mg; accordingly, the mean length of hospital stay was reduced from 67.5 to 53.5 hr. During the day of chemoembolization, the mean oral fluid intake increased from 420 ml (control group) to 487 ml (lidocaine group); the percentage of patients taking solid food on the day of chemoembolization increased from 3% to 43%. Conclusion: Intraarterial lidocaine during chemoembolization reduces the severity and duration of pain after chemoembolization resulting in faster recovery thus reducing the length of hospitalization.

When urokinase was gone: commentary on another year of thrombolysis without urokinase.

A shortage of urokinase developed in the United States in 1999 as a result of a U.S. Food and Drug Administration (FDA) intervention. Although not banned by the FDA, the manufacturers stopped production and marketing of urokinase in the United States. This was the result of concerns raised by a routine, 1998 inspection of Abbott Laboratories, the only provider of recombinant urokinase (Abbokinase; Abbott Laboratories, Abbott Park, IL) in the United States, and BioWhittaker, the only source of the human neonatal kidney cells used by Abbott (1,2). Consequently, new approaches to peripheral vascular thrombolysis were developed, most notably using recombinant tissue plasminogen activator (rt-PA) (Alteplase; Genentech, South San Francisco, CA) based regimens. Most practitioners quickly exhausted their urokinase supplies and altered their practice of pharmacologic peripheral vascular thrombolysis (3). Shortly after the withdrawal of urokinase from the U.S. market, we conducted a pilot e-mail survey of the practice of peripheral vascular thrombolysis (3). The findings of this survey suggested that there were substantial problems in making the transition from the use of urokinase to rt-PA, although expert opinion at the time stated that the two agents should have similar efficacy and safety (4) and the FDA encouraged “physicians to consider the appropriateness of other treatment options” while listing the alternative agents (1). Most respondents to the pilot survey reported a reduction in efficacy and an increase in hemorrhagic complications. This was reflected in several reports and numerous anecdotes of an increased risk of bleeding complications, leading to a need to reduce the dose of rt-PA and the level of heparin anticoagulation (5–7). Some of these initial problems seem to have been related to incorrect dosing and the use of full anticoagulation with heparin, which had been the usual practice when using urokinase (6). Over time, the recommended dose of rt-PA for peripheral vascular thrombolysis was reduced. The use of heparin infusion was either discontinued or continued at a subtherapeutic level (5–8). Others recommended the use of r-PA (reteplase; Centocor, Malvern, PA), which was reported to cause fewer bleeding complications (8). To assess the effects of the withdrawal of urokinase on the practice of peripheral vascular thrombolysis after this initial period of adjustment, we conducted a larger survey just more than 1 year after the cessation of production and marketing of urokinase in the United States. This provides some insight into the way in which the practice of pharmacologic thrombolysis has changed and the effect of these changes on outcomes.

Demonstration of inferior vena cava patency by retrograde azygous venography

Gaining access for vena cavography may be difficult in patients with multiple venous occlusions. We report the use of selective azygous venography to demonstrate potency of the proximal inferior vena cava (IVC) when no alternative route was available and noninvasive techniques were not applicable. The proximal superior vena cava and the distal IVC were occluded.