Motohiro Takasaki

Peripheral insertion of a central venous access device under fluoroscopic guidance using a Peripherally Accessed System (PAS) port in the forearm

AbstractPurpose: We describe the technique, efficacy, and complications of fluoroscopy-guided implantation of a central venous access device using a peripherally accessed system (PAS) port via the forearm. Methods: Beginning in July 1994, 105 central venous access devices were implanted in 104 patients for the long-term infusion of antibiotics or antineoplasmic agents, blood products, or parenteral nutrition. The devices was inserted under fluoroscopic guidance with real-time venography from a peripheral route. Results: All ports were successfully implanted. There were no procedure-related complications. No thrombosis or local infection was observed; however, in six patients catheterrelated phlebitis occurred. Conclusion: Fluoroscopy-guided implantation of a central venous access device using a PAS port via the forearm is safe and efficacious, and injection of contrast medium through a peripheral IV catheter before introduction of the catheter helps to avoid catheter-related phlebitis.

Endoscopic injection sclerotherapy for esophageal variceal hemorrhage in a patient with idiopathic myelofibrosis

A 74-year-old female with idiopathic myelofibrosis (IMF) was admitted to our hospital because of massive hematemesis and melena. Immediate upper gastrointestinal endoscopy revealed an intermittent spurting hemorrhage from extensive esophageal varices. Endoscopic injection sclerotherapy (EIS) was carried out and the bleeding ceased. After five courses of EIS, all the esophageal varices were eradicated. About 15 months later, the patient died,due to a cerebral hemorrhage, without further variceal bleeding. A postmortem examination was carried out and the portal hypertension was considered to be due not only to extramedullary hematopoiesis in the sinusoids, but also to increased splenic blood flow. We are confident that EIS is an effective therapeutic procedure for patients with IMF showing esophageal variceal hemorrhage. EIS should be the preferred choice of treatment for esophageal varices in patients with IMF, since it is less invasive than splenectomy.

4646 “bare” versus “polyurethane covered” selfexpandable metallic stent for malignant biliary obstruction.

Background Obstruction of the self-expandable metallic stents (EMS) due to tumor ingrowth is the most important problem of biliary endoprosthesis. To prevent this complication, a polyurethane covered EMS (covered EMS) have been developed. The present study compared the clinical efficacy of the covered EMS to that of the uncovered EMS (bare EMS). Patients and Method One hundred forty-six patients with malignant biliary obstruction (96 males and 50 females; a mean age of 71.9 year-old) were enrolled in this study. Malignant tumors that caused the biliary obstruction include pancreatic carcinoma (n=45), bile duct carcinoma (n=45), gallbladder carcinoma (n=17), and others (n=39). Four kinds of EMS were employed for biliary endoprosthesis with or without polyurethane covering; Gianturco-Z stent (bare/covered, n=63/0),Wallstent (n=54/0), Spiral-Z stent (n=1/20), and Ultraflex Diamond Biliary Stent (n=3/5). The EMS was placed by the percutaneous transhepatic approach in 77 patients, and by the endoscopic approach in 69 others. Results During the follow-up period, obstruction of the stent was observed in 35 (28.9 %) of 121 bare EMS and 3 (12.0%) of 25 covered EMS. The 6 months patency rate of the bare EMS and covered EMS were 68.7 % and 87.1 %, and 1 year patency rate of them was 72.5 % and 39.7%, respectively. There was no statistical difference between bare EMS and covered EMS. Presumably, obstruction in the bare EMS was caused by tumor ingrowth in all cases, and obstruction of the covered EMS were tumor ingrowth due to damage of polyurethane membrane and overgrowth in 1 case and sludge formation inside the stent bore in 2 cases. Discussion Although it has been predicted that covered EMS stents may have a longer patency period than the bare EMS, there is no statistically significant difference in the stent patency. It may becomes some problems that the damage of polyurethane membrane during or after stent deployment, adhesion of biliary sludge to the stent bore and tumor overgrowth. Conclusion The clinical efficacy of polyurethane covered EMS for malignant biliary obstruction was not determined in this study.