Norbert Rilinger

Left iliac venous thrombosis caused by venous spur: Treatment with thrombectomy and stent implantation

PURPOSE To determine the frequency of iliac venous spurs in left iliofemoral venous thrombosis and to report the results of interventional management of venous spurs after transfemoral venous thrombectomy. METHODS From 1990 through 1996, 77 patients with acute iliac venous thrombosis (61 left and 16 right) underwent surgical treatment. Patients with malignant disease were excluded from this series. All patients had transfemoral venous thrombectomy with construction of an inguinal arteriovenous fistula and perioperative anticoagulation with heparin with a switch to warfarin sodium for at least 12 postoperative months. Immediate results of thrombectomy were documented by means of intraoperative completion venography. Arteriovenous fistulas were ligated 3 months after control arteriovenography. Since 1995 venous spurs eventually detected during thrombectomy were treated immediately by means of stent implantation. RESULTS Among 61 patients with left-sided thrombosis, intraoperative phlebography revealed common iliac venous obstruction suggestive of venous spurs in 30 patients (49%). In 16 of 22 patients (73%) with untreated spurs, postoperative rethrombosis of the iliac vein was documented despite adequate anticoagulation. Only one of eight patients (13%) with stented spurs had reocclusion (chi2 test P < .01). CONCLUSION Venous spurs are found among about half of patients with left-sided iliac venous thrombosis. As long as the underlying venous pathologic process is left untreated, thrombectomy will not restore patency. Stent implantation is a simple and safe means to correct central venous strictures and provides excellent long-term results.

Embolization for gastrointestinal hemorrhages

Abstract. Retrospective evaluation of interventional embolization therapy in the treatment of gastrointestinal hemorrhage over a long-term observation period from 1989 to 1997. Included in the study were 35 patients (age range 18–89 years) with gastrointestinal bleeding (GI) referred for radiological intervention either primarily or following unsuccessful endoscopy or surgery. Sources of GI bleeding included gastric and duodenal ulcers (n = 7), diverticula (n = 3), erosion of the intestinal wall secondary to malignancy (n = 6), vascular malformations (n = 4), and hemorrhoids (n = 2), as well as from postoperative (n = 6), posttraumatic (n = 2), postinflammatory (n = 4) or unknown (n = 1) causes. Ethibloc (12 cases) or metal coils (14 cases) were predominantly used as embolisates. In addition, combinations of tissue adhesive and gelfoam particles and of coils and Ethibloc were used (six cases). Finally, polyvinyl alcohol particles, a coated stent, and an arterial wire dissection were utilized in one case each. Bleeding was stopped completely in 29 of 35 cases (83 %). In one case (3 %) the source of bleeding was recognized but the corresponding vessel could not be catheterized. In five other cases (14 %) there was partial success with reduced, though still persistent, bleeding. The rate of complications was 14 %, including four instances of intestinal ischemia with fatal outcome in the first years, and, later, one partial infarction of the spleen without serious consequences. Gastrointestinal hemorrhage can be controlled in a high percentage of patients, including the seriously ill and those who had previously undergone surgery, with the use of minimally invasive interventional techniques. The availability of minicoils instead of fluid embolization agents has reduced the risk of serious complications.

Palliative and adjuvant regional chemotherapy in pancreatic cancer

To improve the dismal prognosis of patients (pts) with pancreatic cancer we treated 32 patients with non-resectable (UICC III, 17 pts; UICC IV, 15 pts--group 1) and 20 patients with resected (UICC I, 1 pt; UICC II, 3 pts; UICC III, 16 pts--group 2) pancreatic cancer with palliative (group I) and adjuvant post-operative (group II) coeliac axis intra-arterial cyclic infusions (CAI). CAI consisted of mitoxantrone 10 mg/m2 on day 1, folinic acid 170 mg/m2 and 5-FU 600 mg/m2 during days 2-4, and cis-platinum 60 mg/m2 on day 5 for up to 11 (group I) or six (group II) cycles. In a total of 211 cycles toxicities at the level of WHO III occurred in 0-6% and of WHO IV in 0%. The median survival times, compared with institutional historical controls (treated vs controls), were 12 vs 4.8 months in UICC III (P < 0.006) and 4 vs 2.9 months in UICC IV (P < 0.05) group I pts, and 21 vs 9.3 months in group II (P < 0.0003). Hepatic disease progression appeared to be suppressed with CAI, which also appears to be effective for palliative and adjuvant treatment in non-resectable and resected pancreatic cancer.

Endovascular Repair of Aortic Aneurysms: Treatment of Complications

Purpose: To evaluate the use of interventional procedures for treating complications following endovascular repair of aortic aneurysms. Methods: Fifty-five patients (49 men; mean age 67.5 years) underwent endoluminal stent-graft repair of traumatic (n = 4) or arteriosclerotic (n = 51) aortic aneurysms in the thoracic (n = 3) or infrarenal (n = 52) aorta. Follow-up of therapeutic success included periodic clinical examination, angiography, and spiral computed tomography. Results: Discounting the 25 (45%) cases of postimplantation syndrome that did not require treatment, there were 22 complications observed in 20 (36%) patients over a mean 10-month follow-up (range 1 to 27). There were 2 transrenal endograft maldeployments, 1 case of twisted graft limbs, 2 access site problems (1 patient), 12 endoleaks (11 patients), 1 late graft limb thrombosis, 1 symptomatic internal iliac artery occlusion, 2 myocardial infarctions, and 1 transient psychosis. Seven (13%) patients did not undergo specific therapy, while 4 (7%) required operation (2 crossover bypass grafts, 1 suture revision, and 1 graft replacement). Among 9 (16%) patients treated with interventional techniques, 7 underwent percutaneous coil embolization for 8 endoleaks (7 successfully resolved). One late stent-graft disconnection required an additional stent-graft, and 1 of the 2 malpositioned endografts was repositioned. All patients remain alive with no increase in the diameter of the aneurysm in any patient. Conclusions: Technical problems resulting from the endovascular repair of aortic aneurysms often respond to interventional treatment.

Short-term Results with Use of the Amplatz Thrombectomy Device in the Treatment of Acute Lower Limb Occlusions☆

PURPOSE To evaluate the clinical efficacy of the Amplatz device for the treatment of acute occlusions of the lower limb arteries. MATERIALS AND METHODS Forty patients with acute occlusion of the lower limb arteries (3 hours to 8 days; mean, 2 days) were treated using the Amplatz clot macerator. Acute thrombotic lower limb occlusion was due to an embolic event in 32 patients and to atherosclerotic disease in eight patients. RESULTS Complete success, with complete clearing of thrombotic material without an adjunctive procedure, was achieved in 75% (30 of 40) of the patients. Mean thrombectomy time in these patients was 75 seconds. Partial success, with incomplete clearing of the thrombus, requiring additional procedures such as local thrombolysis, angioplasty, or atherectomy, was achieved in 20% (eight of 40) of the patients. The Doppler index increased significantly (P < .001) from .45 before intervention to .96 after intervention. There were two failures (5%). No major complications occurred. CONCLUSION Mechanical thrombectomy with use of the Amplatz device is a promising approach for quick recanalization of acute peripheral thromboembolic occlusions. Further studies are needed to prove the long-term patency after mechanical thrombectomy with use of this device.

Non-operative management of arterial liver hemorrhages

Abstract. A retrospective evaluation of embolotherapy in patients with arterial liver hemorrhages was carried out. Twenty-six patients, ranging in age from 10 days to 77 years with active arterial liver hemorrhages, underwent non-surgical embolotherapy. Bleeding was attributed to trauma (n = 21), tumor (n = 3), pancreatitis (n = 1), or unknown cause (n = 1). Twenty-nine embolizations were performed via a transfemoral (n = 26) or biliary (n = 2) approach. One bare Wallstent was placed into the common hepatic artery via to an axillary route to cover a false aneurysm due to pancreatitis. Treatment was controlled in 4 patients by cholangioscopy (n = 2) or by intravascular ultrasound (n = 2). Prior surgery had failed in 3 patients. Intervention controlled the hemorrhage in 24 of 26 (92 %) patients within 24 h. Embolotherapy failed in 1 patient with pancreatic carcinoma and occlusion of the portal vein. In 1 patient with an aneurysm of the hepatic artery treated by Wallstent insertion, total occlusion was not achieved in the following days, as demonstrated by CT and angiography. However, colour Doppler flow examination showed no flow in the aneurysm 6 months later. Complications were one liver abscess, treated successfully by percutaneous drainage for 10 days, and one gallbladder necrosis after superselective embolization of the cystic artery. Embolization is a effective tool with a low complication rate in the treatment of liver artery hemorrhage, even in patients in whom surgery has failed.

Regional Treatment of Advanced Nonresectable and of Resected Pancreatic Cancer via Celiac Axis Infusion

Thirty-two patients with advanced nonresectable pancreatic cancer of UICC stages III (17 patients) and IV (15 patients; palliative group) received regional chemotherapy with mitoxantrone, 5-FU + folinic acid, and cisplatin via celiac axis infusion with the Seldinger technique. Twenty patients received this treatment after resection of their primary tumors (adjuvant group). Overall 202 cycles [4(1-11)/patient] were applied. Toxicities in all cycles were as follows: gastrointestinal ulcers 6%, gastritis 5%, severe stomatitis 0.5%, nausea/vomiting WHO I+ 11 44%, leukopenia WHO I+ II 11% and WHO III 0.5%. A false aneurysm and a hematoma developed in 1 patient each. The median survival times were 7.5 months in the palliative group (UICC III 12 months, UICC IV 4 months) and 15.1 months in the adjuvant group. Pain decreased significantly in the palliative group.

Diagnostic value of spiral-CT angiography in comparison with digital subtraction angiography before and after peripheral vascular intervention

To evaluate spiral-computed tomography (CT) angiography in primary diagnosis and/or in noninvasive follow-up after vascular intervention, we compared spiral-CT angiography and conventional angiography before and after vascular intervention. Helical-CT exam inations before and after percutaneous transluminal angioplasty (PTA) or stent implan tation were performed in 10 patients (mean age 63 years) with symptomatic peripheral arteriosclerotic disease. Stenoses were located in the iliac, femoral, or popliteal artery. CT examinations were done with a spiral-CT in double detector technique (CT Twin, Elscint). The parameters were as follows: slice thickness: 5.5 mm, increment: 2.7 mm, pitch: 1.5, contrast medium: 150 mL, flow rate: 2.5 mL/second, delay: 30 seconds. For evaluation, transverse planes as well as maximum intensity projections and 3-D reconstructions were used. The possible scan length reached from the aortic bifurcation down to about 10 cm below the ankle trifurcation. Preinterventional digital subtraction angiography (DSA) was superior to CT angiography (CTA: 94%, maximum intensity projection [MIP] alone: 65%), although high-grade stenoses were detected by both methods. After intervention, a resolved stenosis and improved peripheral flow could be detected by helical-CT as well as by intraarterial angiography in every patient (100%). In the primary diagnosis of vascular changes, intraarterial DSA remains the method of choice. Nevertheless, spiral-CT angiography shows comparable results after percutaneous intervention and becomes a noninvasive alternative in the postinterventional follow-up.

Endovascular stenting in patients with Iliac compression syndrome. Experience in three cases.

The authors report their experience in the percutaneous treatment of the iliac compression syndrome in three women (20-53 years old) with acute iliofemoral deep venous thrombosis; in one case, there was an additional thrombus in the inferior caval vein. They were treated by percutaneous implantation of Palmaz stents in the left common iliac vein 1 day after surgical thrombectomy and construction of an arterial venous fistula. All patients showed marked improvement, as determined from venograms obtained immediately after stent implantation. The arteriovenous fistulae were closed 3 months later. At 6 months follow-up, the median clinical and color-coded duplex ultrasound indicates that all stents are patent and all patients are free of symptoms.

Celiac artery adjuvant chemotherapy. Results of a prospective trial.

SummaryConclusionCeliac artery infusion (CAI) seems to be a qualified and successful method for adjuvant treatment of pancreatic cancer. To improve the dismal prognosis of resected pancreatic cancer patients, we performed postoperative regional chemotherapy via the celiac axis.BackgroundFrom 1994–1995, 20 patients with pancreatic cancer (18 ductal adenocarcinoma, 2 cystadenocarcinoma) received adjuvant celiac axis intra-arterial infusions (CAI) after resection of their tumors. Sixteen patients had macroscopically complete tumor removal (R0/R1 resection, 80% of the patients), whereas four patients had gross residual disease remaining after resection (R2 resection, 20% of the patients). Postoperative tumor stages were UICC I in 1 patient, UICC II in 3 patients, and UICC III in 16 patients.MethodsCAI was performed for six postoperative cycles via catheters placed into the celiac artery using Seldingers technique. The chemotherapeutic protocol consisted of mitoxantrone (Novantron®), Wyeth-Lederle (Münster, Germany) 10 mg/m2 (d 1), folinic acid (Leucovorin®, Wyeth-Lederle, or Rescuvolin®, Medac, Hamburg, Germany) 170 mg/m2 for 10 min, followed, by 5-FU (Fluoroblastin®, Farmitalia, Freiburg, Germany), 600 mg/m2 for 120 min (d 2–4), and Cisplatin (Cisplatin-medac®, Medac) 60 mg/m2 (d5). The cycles were repeated after a rest period of 4 wk. Cisplatin infusions were accompanied by supportive antiemetic (8 mg Tropisetrone iv [Navoban®, Sandoz, Nürnberg, Germany] and 8 mg Dexametason iv) and diuretic measures.ResultsToxicity WHO III occurred in 8%, of 100 cycles, and no toxic side effects WHO IV were encountered. The median survival of 21 mo in the treated group was nearly twice as long as the 9.3 mo of a historical matched control group (p<0.0003) CAI seems to be a qualified and successful method for adjuvant treatment of pancreatic cancer.