Michael A. Kleinhoffer

Prevalence of Local Venous Thrombosis after Transfemoral Placement of a Bird's Nest Vena Caval Filter

Birds Nest vena caval filters were placed in 63 patients over a 6-month period by means of a transfemoral (n = 62) or transjugular (n = 1) approach. To determine the prevalence of access-site thrombosis, compression color Doppler flow imaging was performed 1-11 days after the procedure in 48 patients without suspected or documented preexisting thrombus. Clinical follow-up was from 5 to 289 days (mean, 100 days). Findings at ultrasound (US) examination were normal in 38 patients, and all of these patients remained clinically asymptomatic. Nonocclusive thrombus was seen in nine patients, eight of whom remained asymptomatic. A single patient had an occlusive thrombus at US. This patient had leg swelling. Nonocclusive thrombus did not predispose patients to the development of clinically evident occlusive thrombosis. The authors conclude that the transfemoral placement of the Birds Nest vena caval filter is associated with a low prevalence (2%) of femoral vein occlusion documented at US follow-up. This contrasts with results from a similarly designed study demonstrating a 17% prevalence after percutaneous Greenfield filter placement.

Multilevel Infusion Catheter for Use with Thrombolytic Agents

A new multilevel infusion catheter for administration of thrombolytic agents is described that provides near equal flow distribution through each of four infusion ports. Advantages of the catheter include fluoroscopically visible infusion length markers, small size (4.7 F), and secure positioning of the catheter within the occluded segment of graft or vessel. This catheter was used for infusion of urokinase in the treatment of 20 peripheral vascular occlusions. Complete or near complete thrombolysis was achieved in all cases.

Fluoroscopically Guided Percutaneous Gastrostomy in Children

Percutaneous gastrostomy was performed in 27 patients with ages ranging from 7 months to 18 years (mean, 8 years). Patient weights ranged from 4.7 to 73 kg (mean, 25 kg). Access to the stomach was planned and achieved with only fluoroscopic guidance. The technical success rate was 100%. Major procedure-related complications including death, sepsis, hemorrhage, peritonitis, or early tube removal did not occur. The minor complication of local skin infection occurred in six patients. Twenty-six patients (96%) tolerated tube feedings well. Mean follow-up was 184 days, and median follow-up was 103 days. At 30 days, 26 patients (96%) were alive. Percutaneous gastrostomy under fluoroscopic guidance is a safe and effective method of obtaining long-term nonparenteral nutritional access in pediatric patients.

Choledochoscopic Stone Removal through a T-Tube Tract: Experience in 75 Consecutive Patients

Retained biliary stones remain a common clinical problem in patients after surgery. Since 1984, the authors have used choledochoscopy in the treatment of suspected retained biliary stones in 75 patients. These procedures were performed in the radiology department with use of local anesthesia supplemented by an intravenously administered sedative and analgesic. A 15-F flexible fiberoptic choledochoscope was used. Fifty-one of the 75 patients were treated as outpatients. Treatment was successful in 74 of 75 patients; in one patient, intrahepatic stones were not completely removed. Electrohydraulic lithotripsy was used to fragment calculi in 11 patients (15%). Biopsies were performed in four patients (5%). Five minor complications occurred; three required overnight admission. Choledochoscopic-assisted removal of retained biliary calculi is a highly effective and safe procedure. Advantages over standard fluoroscopic stone removal include the ability to directly visualize and fragment adherent or impacted stones and visualize noncalculous filling defects, such as air bubbles, mucus, and biliary tumors.

Fragmentation of Biliary Calculi in 71 Patients by Use of Intracorporeal Electrohydraulic Lithotripsy

PURPOSE Failure of percutaneous or endoscopic removal of biliary calculi is often associated with impacted stones or stones larger than 1.5 cm. In these difficult cases, intracorporeal electrohydraulic lithotripsy (EHL) is a method that allows large stones to be fragmented and removed percutaneously or endoscopically. In this study, the authors expand their experience with EHL and further evaluate the safety and efficacy of this technique to remove biliary tract calculi. PATIENTS AND METHODS Intracorporeal electrohydraulic lithotripsy was used to treat 71 patients with calculi in the bile ducts (n = 35) or gallbladder (n = 36). Access was obtained by means of a surgical T-tube tract (n = 16), percutaneous transhepatic biliary drainage (n = 14), percutaneous cholecystostomy (n = 36), an intraoperative approach during common duct exploration (n = 2), and at endoscopic retrograde cholangiopancreatography (n = 3). RESULTS EHL lithotripsy was effective in fragmenting all biliary stones in 69 of the 71 patients (97%). All of the stone fragments were removed in 67 of these 69 patients (94%). Major complications, including bile peritonitis and gallbladder necrosis, occurred in five patients; however, all major complications were related to the initial percutaneous drainage or tract dilation. No significant complications were directly attributable to the EHL procedure. CONCLUSION Intracorporeal EHL is a safe and effective method that can be used to improve the success of percutaneous and endoscopic biliary calculi removal.

Percutaneous Gastrostomy and Gastrojejunostomy after Gastric Surgery

The authors reviewed their experience with percutaneous gastrostomy and gastrojejunostomy in 30 consecutive patients who had undergone prior gastric surgery consisting of either partial resections (n = 24) or alteration of normal gastric anatomy (n = 6). Parameters evaluated included indications for the procedure, procedural modifications, type of prior gastric surgery, major and minor procedural complications, tube efficacy, and follow-up data. Gastrostomy tubes were placed in 27 patients for enteral feeding and in three for decompression. The success rate (100%), as well as the prevalence of major (0%) and minor (23%) morbidity--transient fever, skin infection, and high gastric residuals--were similar to those reported in patients who had not undergone prior gastric surgery. Thirty-day mortality was 13% (four patients); no deaths were related to the gastrostomy tube placement. Minor procedural modifications such as an extra-long needle, a peel-away sheath, or additional rotational fluoroscopy were necessary in 18 patients (60%). Knowledge of the postsurgical gastric anatomy is crucial in this subset of patients. Prior gastric surgery is no longer a contraindication to percutaneous gastrostomy or gastrojejunostomy tube placement.

Comparison of nonsubtracted digital angiography and conventional screen-film angiography for the evaluation of patients with peripheral vascular disease.

Recently, x-ray equipment manufacturers have produced systems capable of generating nonsubtracted digital angiograms (NSDA) of the arteries of the lower extremities with a high-resolution 1,024 x 1,024 matrix. One such system was compared with conventional screen-film angiography (CSFA) for the evaluation of peripheral vascular disease. Both NSDA and CSFA were performed prospectively in an identical fashion on 47 patients. The images were evaluated, and diagnostic adequacy (ie, information sufficient to direct subsequent therapy) and a variety of image quality attributes--vessel opacification, correct timing, complete anatomic coverage, and ease of reading--were compared. CSFA and NSDA provided similar diagnostic information. NSDA was judged superior to CSFA with regard to timing (P less than .001). CSFA was judged superior with regard to anatomic coverage (P less than .001) and ease of reading (P less than .01). NSDA is a promising method for evaluating patients with peripheral vascular disease. Further work is needed to provide more complete anatomic coverage and to improve the quality of the hard-copy images.