Michael G. Tal

Pelvic embolization for intractable postpartum hemorrhage: long-term follow-up and implications for fertility

OBJECTIVE To determine the long-term sequelae of pelvic embolization for postpartum hemorrhage and to study the effect on fertility and menses. METHODS Twenty-eight consecutive patients who underwent pelvic embolization for postpartum hemorrhage between the years 1977 and 2002 were included in the study. Chart review and telephone interviews were conducted to gather data regarding the type of delivery, causative factors of the bleeding, preembolization treatments, total blood loss, length of time between delivery and embolization, complications, long-term side effects, and subsequent pregnancies. RESULTS The average (± standard deviation) time to follow-up was 11.7 ± 6.9 years. The most common causes of hemorrhage were vaginal/cervical laceration, placenta accreta, and placenta previa. In only one case was the embolization unsuccessful, during which there was an accidental perforation of an internal iliac artery resulting in a retroperitoneal hematoma and subsequent total abdominal hysterectomy. All of the interviewed patients that desired to get pregnant after embolization were able to do so. Six patients reported a total of six uncomplicated pregnancies and deliveries in the years after their embolization. Of the remaining patients interviewed, none made subsequent attempts to get pregnant. The most commonly reported long-term side effects were transient buttock numbness (n = 2) and urinary frequency (n = 2). In no patients were the side effects severe enough to seek further medical attention. CONCLUSION Pelvic arterial embolization is a safe and effective procedure and offers patients a fertility-preserving alternative to hysterectomy for treatment of intractable postpartum hemorrhage.

Comparison of Recirculation Percentage of the Palindrome Catheter and Standard Hemodialysis Catheters in a Swine Model

PURPOSE The purpose of this study was to evaluate in vivo recirculation of a new bi-directional dialysis catheter with a symmetric tip design and compare it to currently marketed staggered and split tip catheters. MATERIALS AND METHODS Twelve catheters were placed in three 70-kg male swine. The catheters were connected to a roller type peristaltic pump. Blood flow and recirculation rates were measured with ultrasound (US) dilution. Recirculation was measured in blood flow rates of 300 mL/min, 400 mL/min, and 500 mL/min. The dialysis lines were then reversed and recirculation was measured in flow rate of 400 mL/min. Measurements were conducted with the catheter tip in the right atrium (RA) and repeated with the catheter tip in the superior vena cava (SVC). RESULTS Recirculation rates measured with the Palindrome catheter tip (Tyco Healthcare Group LP, Mansfield, MA) in the SVC and in the RA were 0%. When the dialysis lines were reversed, the Palindrome catheter average recirculation was 0% with the tip in the SVC and 1% (0%-3%) with the tip in the RA. The average recirculation rates measured with the split tip catheter were 1% (0%-10%) in the SVC and 0% when the catheter tip was in the RA. When the dialysis lines were reversed split tip catheter recirculation was 11% (9%-16%) with the tip in the SVC and 13% (7%-18%) with the tip in the RA. With the staggered tip catheter, 1% (0%-5%) recirculation was measured. When the dialysis lines were reversed, the average recirculation in the staggered tip catheter measured 23% (18%-30%). Recirculation rate with reversal of dialysis lines was significantly lower with the Palindrome catheter when compared to the split tip and staggered tip designs (P < .05). CONCLUSIONS Preliminary results in vivo indicate that the Palindrome catheter demonstrates minimal recirculation with reversal of the dialysis lines compared to currently marketed split tip and staggered tip catheters.

Right Atrial Migration and Percutaneous Retrieval of a Günther Tulip Inferior Vena Cava Filter

This report describes a 67-year-old trauma victim in whom a retrievable Günther Tulip (Cook, Bloomington, IN) inferior vena cava filter was placed. The filter migrated to the right atrium immediately after placement. Initial attempts to retrieve the filter with Amplatz Goose Neck snares (Microvena, White Bear Lake, MN) were unsuccessful. A second attempt performed a week later with the addition of the new EnSnare (MDTech, Gainesville, FL) was successful. Possible causes of the migration are discussed and the difficulties encountered while removing this retrievable filter are described.

Comparison of side hole versus non side hole high flow hemodialysis catheters

Current literature suggests that side holes may be detrimental to dialysis catheter performance. Today, these catheters are primarily available with side holes. The purpose of this study was to compare flow rates, infection rate, and survival of side hole vs. non side hole hemodialysis catheters. Over a 16‐month period patients were arbitrarily assigned to either a 14.5 F MAHURKAR® MAXID™ cuffed dual lumen tunneled catheter with side holes or a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter without side holes (“non side hole catheters”). We performed a retrospective analysis of catheter flow rates, patency, catheter survival, and catheter‐related infections. Information was gathered for the life of the catheter or up to 28 weeks. A total of 54 patients were enrolled in the study. Thirty‐seven of 54 (68%) patients received a catheter with side holes for a total of 3,930 catheter days and 17/54 (32%) received a similar catheter without side holes for a total of 2,188 catheter days. Catheter infection necessitating removal of the catheter occurred in 10/37 catheters with side holes and 1/17 without side holes. Infection rates per 1,000 catheter days were 2.545 with side holes and 0.254 without side holes (p<0.001). Slightly improved catheter survival (p<0.05) was recorded with the non side hole catheters. No insertion complication (e.g., air embolization, bleeding, or kinking) occurred with either catheter. One catheter without side holes had to be repositioned 5 days after insertion because of poor flows. No significant difference was recorded in mean blood flow rates between the catheters. Results indicate reduced catheter infection rate in hemodialysis patients with the use of non side hole dual lumen tunneled cuffed catheters.

Comparison of Four Embolic Materials at Uterine Artery Embolization by Using Postprocedural MR Imaging Enhancement

PURPOSE To test the hypothesis that not all embolic materials are equivalent by using postprocedural magnetic resonance (MR) imaging enhancement of uterine fibroids in patients treated with uterine artery embolization (UAE). MATERIALS AND METHODS Approval and a waiver of consent from the institutional human investigations committee was received for this study. The study was HIPAA compliant. A total of 84 women who underwent 6-month MR imaging follow-up constituted this retrospective study. Within this group, 25 women were treated with Contour polyvinyl alcohol (PVA) particles, 23 were treated with Contour SE particles, 19 were treated with Embosphere microspheres, and 17 were treated with Bead Block microspheres. Pre- and postprocedural MR imaging results were analyzed for the total number of fibroids present in the uterus of each patient and for the percentage of individual fibroid enhancement. Enhancement of individual fibroids was measured with quartile intervals. Greater than 25% residual enhancement of a fibroid after embolization was considered an incomplete infarction. The overall percentage change in enhancement was calculated for each patient. Bivariate analysis by using generalized linear modeling and one-way analysis of variance was used to assess differences in infarction with different embolic materials. RESULTS Among patients treated with Contour and Embosphere, there was a mean reduction in enhancement by 76.60% and 83.07%, respectively, compared with a mean reduction of 52.53% and 49.78% in patients treated with Bead Block and Contour SE, respectively. There was a significant difference in postembolization enhancement between Bead Block and Embosphere, Bead Block and Contour, Contour SE and Embosphere, and Contour SE and Contour. CONCLUSION Patients treated with Bead Block or Contour SE demonstrated a reduced degree of infarction at follow-up MR imaging compared with patients treated with Contour or Embosphere.

Selecting Optimal Hemodialysis Catheters: Material, Design, Advanced Features, and Preferences

Hemodialysis catheters are a necessary evil. They provide an immediate and effective lifeline for hemodialysis patients, and their use is steadily increasing. This increasingly important role has lead to the development of many generations of dialysis catheters. Some aspects of novel designs have shown potential to reduce complications, while others provide options for physician insertion preference. The two major biomaterials for catheter construction are currently polyurethane and silicone, while copolymers such as carbothane are becoming more widespread. Catheter coatings such as heparin, antibiotics, and silver ion are designed to minimize thrombosis and infection. Finally, many lumen and tip designs are also available. These new features were designed to address common problems, including maintenance of adequate flow rate and prevention of thrombosis, fibrin sheath, and catheter-related infection. However, reliable data directly comparing these different designs and coatings are currently lacking. This communication reviews current hemodialysis catheters, including materials, design, and advanced features.

Sildenafil Has No Effect on Portal Pressure but Lowers Arterial Pressure in Patients With Compensated Cirrhosis

BACKGROUND & AIMS The reduction of portal pressure in patients with early compensated cirrhosis may be more responsive to drugs increasing intrahepatic vasodilatation than those reducing portal venous inflow. The phosphodiesterase-5 (PDE-V) inhibitor sildenafil can potentially reduce portal pressure by decreasing intrahepatic resistance, but its systemic vasodilatory effects may be deleterious. The aim of this study was to evaluate the effect of sildenafil on systemic and portal hemodynamics in an open-label pilot study. METHODS Twelve patients with compensated cirrhosis and baseline hepatic venous pressure gradient (HVPG) >5 mm Hg received 25 mg of oral sildenafil. Mean arterial pressure (MAP), heart rate (HR), and HVPG were repeated after 30 and 60 minutes in 9/12 patients at 90 minutes (after an additional 25 mg of sildenafil). HVPG tracings were read by 3 blinded observers. RESULTS All 12 patients were Child A with median MAP of 92 mm Hg (interquartile range, 83-94) and HVPG 10.4 mm Hg (interquartile range, 6.6-13.0). While MAP decreased significantly at all time points, sildenafil had no effect on HVPG. CONCLUSIONS As shown with other vasodilators in compensated cirrhotic patients, sildenafil at therapeutic doses for erectile dysfunction reduces MAP without reducing portal pressure. The search should continue for specific intrahepatic vasodilators.

Vein of Galen Technique for Occluding the Aneurysmal Sac of Pulmonary Arteriovenous Malformations

In seven of 255 consecutive patients (2.7%) who underwent pulmonary arteriovenous malformation (PAVM) embolization at our center between July 1, 1996, and July 1, 2000, the feeding artery was considered too short for safe occlusion with use of standard stainless-steel coils or detachable balloons. These patients were successfully treated with use of a modified vein of Galen technique similar to the one used for managing intracranial vein of Galen aneurysms. In this article, the authors report their experience with this technique in safely occluding the aneurysmal sacs of PAVMs in patients with short (<2 cm) feeding pulmonary arteries.

Initial clinical experience with a new heparin‐coated chronic hemodialysis catheter

In this paper we wish to report our clinical experience with a new heparin‐coated dialysis catheter with a symmetric tip. Over a 16‐month period, 60 heparin‐coated Tal Palindrome™ catheters were placed in 57 patients. Catheter patency, catheter‐related complications, and reasons for catheter removal were recorded. The patients initial cause of end‐stage renal disease, underlying diseases, and site of access were recorded as well. Patients were specifically followed for development of heparin‐induced thrombocytopenia. Patient ages were 34–91 (average 66). Fifty‐four percent of patients had a history of diabetes. Sixty catheters were placed for a total of 5353 catheter‐days. The average catheter indwell time was 107 days (range of 2–381 days). Catheter‐related infection occurred in 6 patients over the study period, with a rate of 1.12/1000 catheter‐days. Bacteremia occurred in 3 patients with a rate of 0.56/1000 catheter‐days. Six catheters were removed or exchanged due to malfunction. There was no incidence of heparin‐induced thrombocytopenia. Initial clinical experience with the heparin‐coated Tal Palindrome™ hemodialysis catheter demonstrated safe, reliable use, and low infection rates.

Comparison of MRI Outcomes of Uterine Artery Embolization for Uterine Leiomyoma Using Tris-acryl Gelatin Microspheres, Polyvinyl Alcohol Spheres, and Polyvinyl Alcohol Particles

Objective: Comparison of recurrence of magnetic resonance imaging (MRI) enhancement of uterine fibroids treated with uterine artery embolization (UAE) among embolic agents: polyvinyl alcohol (PVA), spherical PVA (SPVA), and tris-acryl gelatin microspheres (GM). Methods: Pre/post-UAE gadolinium-enhanced MRIs were evaluated for residual enhancement of fibroids after UAE. Data were analyzed using 2-tail Fisher exact test to determine the likelihood of recurrence of enhancement post-UAE among embolic agents. Results: One hundred one women underwent UAE. A total of 24 (41%) of 59 embolized with PVA, 18 (75%) of 24 with SPVA, and 4 (22%) of 18 with GM showed residual enhancement in some or all fibroids. Statistically significant differences in presence of residual enhancement on follow-up were found between SPVA and PVA (P = 0.0072), and SPVA and GM (P = 0.0015), but not between PVA and GM (P = 0.1756). Conclusions: Patients embolized with SPVA have a higher risk of having residual enhancement on follow-up MRI than those embolized with PVA or GM.