Ralph Kickuth

Peripherally Placed Totally Implantable Venous-access Port Systems of the Forearm: Clinical Experience in 763 Consecutive Patients

The aim of this study is to evaluate the effectiveness and safety of percutaneously placed totally implantable venous-access ports (TIVAPs) of the forearm. Between January 2006 and October 2008, peripheral TIVAPs were implanted in 763 consecutive patients by ultrasound and fluoroscopic guidance. All catheters were implanted under local anesthesia and were tunneled subcutaneously. Indication, technical success, and complications were retrospectively analyzed according to Society of Interventional Radiology (SIR) criteria. Presence of antibiotic prophylaxis, periprocedurally administered drugs (e.g., sedation), and laboratory results at the time of implantation were analyzed. Maintenance during the service interval was evaluated. In total, 327,499 catheter-days were analyzed. Technical success rate was 99.3%. Reasons for initial failure of implantation were either unexpected thrombosis of the subclavian vein, expanding tumor mass of the mediastinum, or failure of peripheral venous access due to fragile vessels. Mean follow-up was 430xa0days. There were 115 complications observed (15.1%, 0.03 per 100 catheter-days), of which 33 (4.3%) were classified as early (within 30xa0days from implantation) and 82 (10.7%) as late. Catheter-related venous thrombosis was found in 65 (8.5%) of 763 (0.02 per 100 catheter-days) TIVAPs. Infections were observed in 41 (5.4%) of 763 (0.01 per 100 catheter-days) devices. Other complications observed included dislocation of the catheter tip (0.8%), occlusion (0.1%), or rupture (0.1%) of the port catheter. Dislocated catheters were corrected during a second interventional procedure. In conclusion, implantation of percutaneously placed peripheral TIVAPs shows a high technical success rate and low risk of early complications when ultrasound and fluoroscopic guidance are used. Late complications are observed three times as often as early complications.

Evaluation of magnetic resonance colonography at 3.0 Tesla regarding diagnostic accuracy and image quality.

Objectives:To assess magnetic resonance (MR)-colonography (MRC) for detection of colorectal lesions using two different T1w three-dimensional (3D)-gradient-recalled echo (GRE)-sequences and integrated parallel data acquisition (iPAT) at a 3.0 Tesla MR-unit. Materials and Methods:In this prospective study, 34 symptomatic patients underwent dark lumen MRC at a 3.0 Tesla unit before conventional colonoscopy (CC). After colon distension with tap water, 2 high-resolution T1w 3D-GRE [3-dimensional fast low angle shot (3D-FLASH), iPAT factor 2 and 3D-volumetric interpolated breathhold examination (VIBE), iPAT 3] sequences were acquired without and after bolus injection of gadolinium. Prospective evaluation of MRC was performed. Image quality of the different sequences was assessed qualitatively and quantitatively. The findings of the same day CC served as standard of reference. Results:MRC identified all polyps >5 mm (16 of 16) in size and all carcinomas (4 of 4) correctly. Fifty percent of the small polyps ≤5 mm (4 of 8) were visualized by MRC. Diagnostic quality was excellent in 94% (384 of 408 colonic segments) using the 3D-FLASH and in 92% (376 of 408) for the VIBE. The 3D-FLASH sequence showed a 3-fold increase in signal-to-noise ratio (8 ± 3.3 standard deviation (SD) in lesions without contrast enhancement (CE); 24.3 ± 7.8 SD after CE). For the 3D-VIBE sequence, signal-to-noise ratio doubled in the detected lesions (147 ± 54 SD without and 292 ± 168 SD after CE). Although image quality was ranked lower in the VIBE, the image quality score of both sequences showed no statistical significant difference (&khgr;2 > 0.6). Conclusions:MRC using 3D-GRE-sequences and iPAT is feasible at 3.0 T-systems. The high-resolution 3D-FLASH was slightly preferred over the 3D-VIBE because of better image quality, although both used sequences showed no statistical significant difference.

Identification of Risk Factors for Catheter-Related Thrombosis in Patients with Totally Implantable Venous Access Ports in the Forearm:

Purpose To identify risk factors for the development of catheter-related thrombosis (CRT) in patients with totally implant-able venous access ports (TIVAP) in the forearm, and to analyze the effect of prophylaxis and treatment. Methods We retrospectively identified 200 patients (94 men, 106 women, mean age 57.7 +/-14 y) with TIVAP implantation in the forearm between 3/2010 and 11/2010. Type, number of punctures and sonographically defined diameter of the accessed vein were analyzed. Chemotherapy administered prior to the implantation procedure and history of thrombo-embolic events were assessed. Thrombo-embolic prophylaxis (TEP) following port implantation and treatment as well as course of CRT were analyzed. Results Twenty-one patients (10.5%) were diagnosed with CRT. Accessed vessels and mean diameter were basilic (n=150, 3.7 mm), brachial (n=39, 3.5 mm) and cephalic (n=11, 3.5 mm) vein. Neither type nor vessel diameter had effect on CRT development (P>.05). Implantation in the left forearm resulted in a significantly higher rate of CRT (P=.04). Ninety-five patients (47.5%) received chemotherapy and 30 patients (15.0%) had a history of thrombosis prior to implantation; both had no effect on development of CRT. Low molecular weight heparin (LMWH) was prescribed in 94/200 patients (47.0%) and had no effect on development of CRT (P>.05). Therapeutic anticoagulation with LMWH resulted in clinical improvement in 12/21 patients (57.4%). Conclusions TIVAPs of the forearm may be associated with a certain rate of early and late CRT. The simplest vein to puncture should be selected for vascular access. Thrombo-embolic prophylaxis appears to be rather ineffective for prevention of CRT.

Spontaneous liver rupture after treatment with drug-eluting beads.

Spontaneous rupture of hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) is a rare and life-threatening complication. Pathophysiologic mechanisms are not yet fully known; it is suggested that rupture is preceded by reactive tissue edema and intratumerous bleeding, leading to a rapid expansion of tumour mass with risk of extrahepatic bleeding in the case of subcapsular localisation. This case report discusses a sudden, unexpected lethal complication in a 74xa0year-old male patient treated with TACE using DC Bead loaded with doxorubicin (DEBDOX) in a progressive multifocal HCC.

Endovascular Treatment of Acute Limb Ischemia Secondary to Fracture of a Popliteal Artery Stent

The authors report the case of a patient with acute lower limb ischemia (category IIa) after occlusion of the popliteal artery due to fracture of a long indwelling stent. The patient refused surgical therapy for religious reasons, and an interventional revascularization was performed as acute rescue therapy. After reentry into the distal popliteal artery was achieved, the artery was dilated, and the fragmented stent was crushed, followed by implantation of two helical nitinol stents with high radial force and a third self-expandable nitinol stent. Sufficient primary technical success was achieved, and stent patency was present at midterm follow-up.

Optimizing of preoperative computed tomography for diagnosis in patients with peritoneal carcinomatosis.

Background and ObjectiveThis study evaluates whether Computer Tomography is an effective procedure for preoperative staging of patients with Peritoneal Carcinomatosis.MethodA sample of 37 patients was analyzed with contrast enhanced abdominal Computer Tomography, followed by surgical staging. All Computer Tomography scans were evaluated 3 times by 2 radiologists with one radiologist reviewing 2 times. The efficacy of Computer Tomography was evaluated using the Spearman correlation coefficient. Correlations were analyzed by abdominopelvic region to assess results of the Peritoneal Carcinomatosis Index (PCI) aggregating the 13 regions. Surgical findings were compared to radiological findings.ResultsResults indicate high correlations between the surgical and radiological Peritoneal Carcinomatosis Indices. Analyses of the intra-class correlation between the first and second reading of one radiologist suggest high intra-observer reliability. Correlations by abdominopelvic region show higher values in the upper and middle regions and relatively lower values in the lower regions and the small bowel (correlation coefficients range between 0.418 and 0.726, p < 0.010; sensitivities range between 50% and 96%; and specificities range between 62% and 100%).ConclusionComputer Tomography represents an effective procedure in the preoperative staging of patients with PC. However, results by abdominopelvic region show lower correlation, therefore suggest lower efficacy. These results are supported by analyses of sensitivity and accuracy by lesion size. This suggests that Computer Tomography is an effective procedure for pre-operative staging but less for determining a tumors accurate extent.

Iatrogenic perforation of the left heart during placement of a chest drain.

Chest drain placement is a standard procedure for treating pneumothorax and pleural effusions and has a low complication rate. It is a safe and efficient procedure if image guidance is used. If the anatomic orientation is hampered and neither air nor fluids can be initially aspirated, more complex imaging than a chest x-ray is indicated to avoid major complications. We report the case of an 88-year-old male patient suffering from chronic heart failure who was admitted to another hospital following acute cardiac decompensation. Because of dyspnea with voluminous bilateral effusions, an attempt was made to drain the left pleural cavity. A malposition of the chest drain was suspected because blood was initially draining from the catheter. The hemodynamically stable patient was referred to our university hospital, where computed tomography of the chest revealed the location of the intercostal drain. The drain had perforated the left ventricle, run through the mitral valve and exited the left atrium via a pulmonary vein, ending in the middle lobe. The patient was brought to the surgical theater, where cardiac surgeons performed a left anterolateral thoracotomy and extracted the drain successfully. Three days later, the patient was discharged from our hospital in a good general condition.

Prevalence of enlarged mediastinal lymph nodes in heavy smokers—a comparative study

ObjectiveTo evaluate the frequency of enlarged hilar or mediastinal lymph nodes in heavy smokers (more than 10 pack years) compared with non- smokers.Material and methodsIn a prospective study the CT findings of 88 consecutive patients (44 heavy smokers, 44 non- smokers) were analysed. Exclusion criteria were history of thoracic malignancy, sarcoidosis, occupational dust exposure or clinical evidence of pneumonia. Prevalence, size and site of enlarged lymph nodes were assessed by multidetector computed tomography (MDCT) and correlated with the cigarette consumption and the CT- findings of bronchitis and emphysema.ResultsTwenty-three of the 44 heavy smokers (52%) showed enlarged mediastinal lymph nodes. Non- smokers showed enlarged lymph nodes in 9% (4/44). The most common site of enlarged lymph nodes was the regional station 7 according to the ATS mapping (subcarinal). The difference between the frequency of enlarged lymph nodes in heavy smokers and non- smokers was significant (chi- square 19.3, pu2009<u20090.0001). Airway wall thickening and emphysema were often associated with an increased number of enlarged nodes.ConclusionThe present study demonstrates that enlarged mediastinal lymph nodes may occur in a rather high percentage of heavy smokers, especially in those with a MDCT finding of severe bronchitis.

Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm

Background Conventional totally implantable venous access ports (TIVAPs) are not approved for power contrast injections but often remain the only venous access site in oncologic patients. Therefore, these devices can play an important role if patients with a TIVAP are scheduled for a contrast-enhanced computed tomography (ceCT) as vascular access may become more difficult during the course of chemotherapy. Purpose To evaluate the feasibility and safety of power injections in conventional TIVAPs in the forearm and to analyze the feasibility of bolus triggering during CT scans. Material and Methods In this retrospective study we analyzed 177 power injections in 141 patients with TIVAPs in the forearm. Between October 2008 and March 2010 all patients underwent power injections (1.5 mL/s, 150 psi) via the TIVAP for ceCT because conventional vascular access via a peripheral vein had failed. Adequate functioning and catheters tip location after injection were evaluated. Peak injection pressure and attenuation levels of aorta, liver and spleen were analyzed and compared with results of 50 patients who were injected via classical peripheral cannulas (3 mL/s, 300 psi). Feasibility of automatic scan initiation was evaluated. In vitro the port was stressed with 5 mL/s (300 psi). Results One TIVAP showed tip dislocation with catheter rupture. Three (2.1%) devices were explanted owing to assumed infection within 4 weeks after the injection. Mean injection pressure was 121.9 +/−24.1 psi. Triggering with automatic scan initiation succeeded in 13/44 (29.6%) scans. Injection via classical cannulas resulted in significantly higher enhancement (p < 0.05). In vitro the port system tolerated flow rates of up to 5 mL/s, injection pressures of up to 338 psi. Conclusion Power injection is a safe alternative for patients with TIVAPs in the forearm if classic vascular access ultimately fails. Triggering was successful in one-third of the attempts. Image quality in the arterial phase scan may be hampered. In vitro results suggest that the device tolerates even higher flow rates.

Femoral placement of totally implantable venous power ports as an alternative implantation site for patients with central vein occlusions

PurposeTo evaluate the indication, technical success, clinical outcome and safety of percutaneously placed totally implantable venous power ports (TIVPPs) in a femoral position in patients with contraindications to implantation in a standard position.MethodsRetrospectively, we screened our interventional radiology department database between 12/2,009 and 3/2,013 to identify 1,729 patients with a port implantation. In 8/1,729 (0.47xa0%) patients (1 male, 7 female, mean age 55.5u2009±u20099.6xa0years) the TIVPP was implanted via the common femoral vein with the port placed in the anterior thigh. All devices were high-pressure injectable, implanted under local anaesthesia with sonographic as well as fluoroscopic guidance, and were tunnelled subcutaneously. Indication, technical success and complications were retrospectively analysed according to the Society of Interventional Radiology (SIR) criteria.ResultsIndications were planned chemotherapy for breast (nu2009=u20096) and oesophagus cancer (nu2009=u20091) as well as need for long-term central venous access for intravenous therapy (nu2009=u20091) with a contraindication to or failed implantation in a standard position owing to central vein occlusions. Technical success was 100xa0%. A number of five devices were placed in the right, three in the left thigh. Altogether 1,979 catheter days were analysed. One device was explanted owing to infection after 84xa0days (late complication, 0.05/100 catheter days). No early complication was observed.ConclusionsOur data suggest that if implantation of a TIVPP is not favourable in a standard chest, upper arm or forearm position, femoral placement of the device may alternatively be used safely and with high technical success.