Richard A. Reed

Microcatheter Embolization of Non-neurologic Traumatic Vascular Lesions

PURPOSE The authors report their experience over a 28-month period with embolization of 23 non-neurologic traumatic vascular lesions in 21 patients with use of a coaxial microcatheter coil delivery system. PATIENTS AND METHODS The injuries included pseudoaneurysms (n = 17), arteriovenous fistulas (n = 3), and sites of extravasation (n = 3) and were caused by gunshot, shotgun, and stab wounds, as well as motor vehicle accidents and iatrogenic trauma. All microcatheter embolizations except one were performed with 2.2-F Tracker-18 catheters inserted coaxially through 5.0-5.5-F guiding catheters. In one case, a coaxial 3-F Teflon catheter was used. In all cases platinum microcoils (almost all non-fibril) and/or straight platinum embolization wires (with fibrils) were used. RESULTS Twenty-one (91%) of 23 vascular lesions were successfully occluded with use of the microcatheter system. The two cases in which microcatheter embolization failed were successfully managed by using larger catheters and steel coils. Two patients with hepatic vascular lesions (one site of extravasation and a pseudoaneurysm) and one patient with a lower extremity arteriovenous fistula required two procedures each for successful treatment. Procedures were life-saving in at least two patients. Two lesions recurred during follow-up ranging from 3 days to 17 months. Both of these recurrences were successfully treated with transcatheter embolization, in one case with use of microcatheters. CONCLUSION Microcatheter embolization with platinum coils and wires is an effective means for treating traumatic vascular lesions. A coaxial microcatheter system allows for easier, more rapid coil/wire delivery to smaller, spasm-prone arteries in such cases.

The use of inferior vena cava filters in pediatric patients for pulmonary embolus prophylaxis

PurposeTo report our experience with inferior vena cava (IVC) filters in pediatric patients.MethodsOver a 19-month period, eight low-profile percutaneously introducible IVC filters were placed in four male and four female patients aged 6–16 years (mean 11 years). Indications were contraindication to heparin in six patients, anticoagulation failure in one, and idiopathic infrarenal IVC thrombosis in one. Six of the eight devices placed were titanium Greenfield filters. One LGM and one Birds Nest filter were also placed. Two of the filters were introduced via the right internal jugular vein by cutdown, and the remainder were placed percutaneously via the right internal jugular vein or the right common femoral vein. Patients received follow-up abdominal radiographs from 2 to 13 months after IVC filter placement.ResultsAll filters were inserted successfully without complication. Three of the patients died during the follow-up period: two due to underlying brain tumors at 2 and 12 months and a third at 6 weeks due to progressive idiopathic renal vein and IVC thrombosis. The remaining five patients were all alive and well at follow-up without evidence of IVC thrombosis, pulmonary emboli, or filter migration.ConclusionIVC filter placement using available devices for percutaneous delivery is technically feasible, safe, and effective in children.

Portal venous branch targeting with a platinum-tipped wire to facilitate transjugular intrahepatic portosystemic shunt (TIPS) procedures

We describe a technique to aid in technically difficult transjugular intrahepatic portosystemic shunt (TIPS) procedures by sonographically guided transabdominal fine-needle portal vein puncture for placement of a 0.018-inch platinum-tipped target guidewire within an appropriate portal venous branch.

Prevalence of Infection Following Hepatic Chemoembolization with Cross-linked Collagen with Administration of Prophylactic Antibiotics

PURPOSE The authors present their experience with 494 hepatic chemoembolization (HCE) procedures in 236 patients with administration of a mixture of cross-linked collagen and chemotherapeutic agents. The prevalence of infectious complications was compared in patients who did and did not receive prophylactic administration of antibiotics as part of the HCE procedure. PATIENTS AND METHODS Fourteen HCE procedures in nine patients were performed without prophylactic antibiotics (PA). These patients underwent embolization with cross-linked collagen alone or with low-dose cisplatinum. All of the remaining 480 procedures in 227 patients were performed with PA. RESULTS One of the nine patients (11%) who did not receive PA experienced fatal sepsis within 24 hours of HCE. Of the 227 patients who did receive antibiotics, six (2.6%) developed hepatic abscess and no fatal sepsis was encountered. CONCLUSION Use of PA decreases the prevalence of infectious complications following HCE.

Use of the Bird's Nest filter in oversized inferior venae cavae.

An inferior vena cava (IVC) diameter of greater than 28 mm has been considered a contraindication to the intracaval placement of Greenfield, LG-Medical (LGM), and Simon nitinol filters, necessitating biiliac placement of these devices. With the Birds Nest filter (BNF), the maximum span of the struts, which immobilize the device, is 60 mm; this allows the placement of the BNF in an oversized IVC having a diameter of greater than 28 mm. Over a 44-month period, 799 IVC filters (547 BNF, 136 Greenfield filters, and 116 LGM filters) were inserted. BNFs were placed in 18 patients (2.3%) with an oversized IVC (diameter range, 29-42 mm); all filters were placed via the femoral route. Patient records were reviewed to determine if problems were associated with filter insertion (including insertion site femoral vein thrombosis) and to determine the prevalence of filter migration, caval thrombosis, and new or recurrent pulmonary emboli (PE) after insertion. No difficulties were encountered during insertion. There was no documented case of device migration, caval thrombosis, or clinically apparent new or recurrent PE. The data suggest that the BNF is the filtering device of choice in patients with an oversized IVC.

In Vitro flow phantom analysis and clot-capturing ability of incompletely opened vena tech-LGM vena caval filters

It has been shown recently that Vena Tech-LGM (B. Braun Vena Tech, Evanston, IL) filters inserted into the inferior vena cava via the jugular route may be deployed sometimes in an incompletely opened (IO) position. The flow characteristics and clot capturing ability of IO Vena Tech-LGM filters are not clearly understood. Using a vena cava flow phantom, the clot-capturing abilities of the IO and opened Vena Tech-LGM, filters were assessed. For 5 × 5-mm clots, the IO Vena Tech-LGM filter captured only 40% of thrombi compared with a 90% capture rate for the opened filter. The capture rates were 90 and 100% for the IO and opened filter, respectively, for larger 5 × 15-mm clots. It was found that the IO filter could capture 2–7 × 25 mm thrombi prior to the development of a turbulent bypass channel which prevented subsequent clot capture. Using 5 × 15 mm clots, this same phenomenon occurred with the capture of 6 and 11 thrombi by the IO and opened Vena Tech-LGM filters, respectively. Our results suggest a significantly reduced filtering efficiency for the IO Vena Tech-LGM device. However, there is a high rate of clot capture with the opened Vena Tech-LGM filter.