Marcos Herrera

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.

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.

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.

Use of an introducer sheath for colonic stent placement

Abstract. We describe a technical modification of Wallstent implantation for the treatment of malignant rectosigmoid and descending colonic obstructions. The modification is the routine placement of an introducer sheath via the rectum before stent implantation in order to straighten the rectosigmoid region. This device facilitates catheter and guide wire manipulations and obtaining specimen biopsies for histopathological studies. The introducer sheath has been used without complications in 21 consecutive patients.