Richard D. Shlansky-Goldberg

Renal angiomyolipoma: Long-term results after arterial embolization

PURPOSE Selective arterial embolization of renal angiomyolipomas (AMLs) was performed to prevent hemorrhage in patients with AMLs larger than 4 cm. This study was conducted to evaluate the long-term efficacy of AML embolization. MATERIALS AND METHODS Nineteen patients underwent embolization for 30 renal AMLs between July 1991 and June 2002. Of these, 10 patients had tuberous sclerosis (TS) with multiple AMLs and nine patients had a solitary sporadic AML. Embolization was performed with use of ethanol mixed with iodized oil (Ethiodol) in 29 tumors; coils were used in addition to the ethanol/Ethiodol mixture in one case. All tumors were completely embolized according to angiographic criteria including vascular stasis and absence of arterial feeders. The efficacy of embolization was determined over a mean follow-up period of 51.5 months (range, 6-132 months). Recurrence was defined as an increase in tumor size of greater than 2 cm on follow-up imaging and/or recurrent symptoms that required repeat embolization. An institutional review board exemption was obtained to perform this retrospective study. RESULTS Embolization of the renal AMLs was technically successful in all 19 patients and for all 30 lesions. AML recurrence was noted in 31.6% of patients (n = 19) and for 30% of lesions overall (n = 9). Six of 10 patients in the TS group had AML recurrences. No recurrences occurred in the patients with sporadic AML. In the TS group of 10 patients, there was a total of 21 AMLs and the overall tumor recurrence rate was 42.9% (nine of 21). Six lesions in four patients had to be reembolized because of recurrent symptoms, including one hemorrhage, and three lesions in two patients required repeat embolization because of a greater than 2 cm increase in size. The median time interval from embolization to recurrence was 78.7 months (range, 13-132 months). Statistical testing with use of the Fisher exact test demonstrated that patients with TS were significantly more likely to develop recurrence than those without TS (P = .01). CONCLUSIONS Transarterial embolization is effective in preventing hemorrhage in patients with renal AMLs. However, long-term follow-up revealed a high AML recurrence rate in patients with TS. Lifelong surveillance for recurrence after AML embolization is essential in patients with TS.

Endovascular management of splenic artery aneurysms and pseudoaneurysms

Splenic artery aneurysms and pseudoaneurysms are being diagnosed with increasing frequency by modern imaging. The question of appropriate treatment—surgical or endovascular—arises more often. We review our experience and that of others as documented in the literature. The information available suggests that endovascular management of a splenic artery aneurysm or pseudoaneurysm offers a lower complication rate than surgery, but postprocedure imaging to ensure obliteration is recommended.

Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival.

PURPOSE To identify clinical and technical factors influencing the outcome of transcatheter embolotherapy for nonvariceal upper gastrointestinal (GI) hemorrhage and to quantify the impact of successful intervention on patient survival. MATERIALS AND METHODS A retrospective review was performed of all patients (n = 163) who underwent arterial embolization for acute upper GI hemorrhage at a university hospital over an 11.5-year period. Clinical success was defined as target area devascularization that resulted in the clinical cessation of bleeding and stabilization of hemoglobin level. The clinical condition of each patient at intervention was defined by history, laboratory examination, and two composite indicator variables. With use of logistic regression, the dependent variable, clinical success, was modeled on two categories of clinical and technical variables. A final model regressed patient survival on clinical success and other clinical variables. RESULTS None of the procedural variables analyzed had a significant influence on clinical success. Several clinical variables did impact clinical success, including multiorgan system failure (OR, 0.36; P =.030), coagulopathy (OR, 0.36; P =.026), and bleeding subsequent to trauma (OR, 7.1; P =.040) or invasive procedures (OR, 6.5; P =.009). Regardless of their clinical condition at intervention, patients who underwent clinically successful embolization were 13.3 times more likely to survive than those who had an unsuccessful procedure (CI, 4.54-39.2; P =.000). Nevertheless, patients with multiorgan system failure were 17.5 times more likely to die, independent of the outcome of the procedure (CI, 0.014-0.229; P =.000). CONCLUSION Arresting nonvariceal upper GI hemorrhage with transcatheter embolotherapy has a large positive effect on patient survival, independent of clinical condition or demonstrable extravasation at intervention. Aggressive treatment with transcatheter embolotherapy is advisable in patients with acute nonvariceal upper GI hemorrhage.

Experience with the recovery filter as a retrievable inferior vena cava filter.

PURPOSE This study evaluates clinical experience with the Recovery filter as a retrievable inferior vena cava (IVC) filter. MATERIALS AND METHODS One hundred seven Recovery filters were placed in 106 patients with an initial clinical indication for temporary caval filtration. Patients were followed up to assess filter efficacy, complications, eventual need for filter removal, time to retrieval, and ability to remove the filter. RESULTS The patient cohort consisted of 62 men and 44 women with a mean age of 48 years (range, 18-90 y). Mean implantation time was 165 days. Indications for filter placement in patients with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) included contraindication to anticoagulation (n = 33), complications of anticoagulation (n = 8), poor cardiopulmonary reserve (n = 6), large clot burden (n = 3), and PE while receiving anticoagulation (n = 1). Indications for filter placement in patients without proven PE or DVT included immobility after trauma (n = 35); recent intracranial hemorrhage, neurosurgery, or brain tumor (n = 18); and other surgical or invasive procedure (n = 3). Three patients (2.8%) had symptomatic PE after placement of the Recovery filter. No caval thromboses were detected. No symptomatic filter migrations occurred. Recovery filter removal was attempted in 15 of 106 patients (14%) at a mean of 150 days after placement. The Recovery filter was successfully retrieved in 14 of 15 patients (93%); one removal was unsuccessful at 210 days after placement. Ninety-two filters (87%) currently remain in place. CONCLUSIONS Although all the filters were placed with the intention of being removed, a large percentage of filters were not retrieved. The Recovery filter was safe and effective in preventing PE when used as a retrievable IVC filter.

Sarcomas metastatic to the liver: response and survival after cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol chemoembolization.

PURPOSE To evaluate the response to and survival after chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol for patients with sarcomas metastatic to the liver that are surgically unresectable. MATERIALS AND METHODS Sixteen patients were treated. Primary tumors included 11 gastrointestinal leiomyosarcomas, two splenic angiosarcomas, one leiomyosarcoma of the broad ligament, one leiomyosarcoma of the inferior vena cava, and one malignant fibrous histiocytoma of the colon. Chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol particles was performed 1-5 times at approximately monthly intervals (mean, 2.8). Pre- and posttreatment cross-sectional imaging was performed 1 month after completion of treatment and then every 3 months. Thirty-day response was graded according to World Health Organization/Eastern Cooperative Oncology Group criteria. Survival was calculated with use of Kaplan-Meier analysis. RESULTS Two patients (13%) exhibited partial morphologic response, 11 patients (69%) were morphologically stable, and three (19%) demonstrated progression of disease 30 days after completion of treatment. Among the 13 responders, two underwent partial hepatectomy after initial treatment. Seven developed intrahepatic progression at a mean of 10 months and a median time of 8 months. The remaining four patients had no documented intrahepatic progression at the time of last imaging follow-up. Nine patients developed extrahepatic progression at a mean time of 6.3 months and a median time of 6 months, of whom four underwent additional surgical resection. Response to therapy was based on time of first intervention. Cumulative survival from time of diagnosis with use of Kaplan-Meier analysis was 81% at 1 year, 54% at 2 years, and 40% at 3 years. Median survival time was 20 months. Cumulative survival from initial chemoembolization was 67% at 1 year, 50% at 2 years, and 40% at 3 years, with a median survival time of 13 months. The thirty-day mortality rate was zero. CONCLUSION Durable tumor response with chemoembolization is possible in this form of metastatic disease, which is highly resistant to systemic chemotherapy.

Embedded Inferior Vena Cava Filter Removal: Use of Endobronchial Forceps

PURPOSE Removing a retrievable inferior vena cava (IVC) filter can be extremely difficult with the use of standard techniques if the filter is tilted and embedded in the wall of the IVC. The use of rigid endobronchial forceps has been described in case reports to remove embedded IVC filters, and the present report describes the use of this technique to remove a series of tip-embedded IVC filters in two separate institutions. MATERIALS AND METHODS The medical records were reviewed of 21 consecutive patients at two institutions who underwent attempted IVC filter removal with rigid endobronchial forceps over a 34-month period. The mean age of patients was 32.4 years (range, 14.1-54.1 y). The patients had the following filters: Recovery (n = 6), G2 (n = 10), Günther Tulip (n = 4), and OptEase (n = 1). RESULTS Rotational or biplane venography was used to confirm that the filters were tilted and embedded in the wall of the IVC in all 21 patients. Rigid endobronchial forceps were used successfully to remove 20 embedded IVC filters in 21 patients. There was one case of failure to remove an embedded suprarenal G2 filter. There were no major complications. CONCLUSIONS Rigid endobronchial forceps may be used as a reliable option for removal of embedded IVC filters.

Replacement of Failing Tunneled Hemodialysis Catheters through Pre-existing Subcutaneous Tunnels: A Comparison of Catheter Function and Infection Rates for De Novo Placements and Over-the-Wire Exchanges

PURPOSE Tunneled hemodialysis catheter dysfunction often occurs from fibrin sheath formation. As a way to preserve existing catheter venous access sites, the authors evaluated over-the-wire exchange of catheters through pre-existing subcutaneous tunnels as an alternative to catheter removal and de novo catheter replacement. PATIENTS AND METHODS One hundred nineteen catheters were placed in 68 patients. Seventy-seven catheters were placed de novo and 42 catheters were placed through the pre-existing subcutaneous tunnels of failing catheters. Technical success, short-term complications, infection rates, and functional catheter longevity were evaluated. RESULTS Technical success for catheter exchange was 93%. Infection rates were comparable to those of de novo catheter placement: 0.15 and 0.11 infections per 100 catheter days for de novo and exchanged catheters, respectively. Catheter duration of function was not significantly different for de novo versus exchanged catheters: 63% and 51% at 3 months, 51% and 37% at 6 months, and 35% and 30% at 12 months, respectively. CONCLUSIONS Over-the-wire exchange of tunneled hemodialysis catheters is safe and easily performed. It causes no increase in infectious complications and provides similar catheter longevity to de novo catheter placement. The procedure is an important option for prolonging tunneled hemodialysis catheter access sites.

Relationship between Chest Port Catheter Tip Position and Port Malfunction after Interventional Radiologic Placement

PURPOSE The relationship between catheter tip position of implanted subcutaneous chest ports and subsequent port malfunction was investigated. Tip movement from initial supine position to subsequent erect position was also evaluated. MATERIALS AND METHODS Patients who underwent imaging-guided internal jugular chest port placement between July 2001 and May 2003 were identified with use of a quality-assurance database. Sixty-two patients were included in the study (22 men and 40 women), with a mean age of 58 years (range, 27-81 years). Catheter tip location on the intraprocedural chest radiograph was determined with use of two methods. First, the distance from the right tracheobronchial angle (TBA) was recorded (TBA distance). Second, tip location was classified into six anatomic regions: 1, internal jugular veins; 2, brachiocephalic veins; 3, superior vena cava (SVC; n = 11); 4, SVC/right atrial junction (n = 22); 5, upper half of right atrium (n = 25); and 6, lower half of right atrium (n = 4). For the duration of follow-up, catheter tip location was documented, as were all episodes of catheter malfunction. RESULTS Patients with catheter tips initially placed in position 3 had a higher risk of port malfunction (four of 11; 36%) than patients with catheter tips located in position 5 (two of 25; 8%). This difference narrowly fell short of statistical significance (P =.057). When comparing intraprocedural chest radiographs to the first erect chest radiographs, significant upward tip movement was noted. The tips migrated cephalad an average of 20 mm (P =.003) and 1.0 position units (P =.001). DISCUSSION Catheter tips placed in the SVC tended to have a greater risk of port malfunction compared with those positioned in the right atrium. Chest ports migrated cephalad between the supine and erect positions.

Percutaneous Transhepatic Venous Access for Hemodialysis

Percutaneous transhepatic venous access is an option for hemodialysis patients who have exhausted more traditional sites of venous access. Thirty-six transhepatic dialysis catheters were placed in 12 patients. The mean time of the catheters in situ was 24.3 days. Twenty-one catheters were replaced or removed because of catheter thrombosis, yielding a catheter thrombosis rate of 2.40 per 100 catheter-days. The line sepsis rate was 0.22 per 100 catheter-days. Poor patency rates were seen because of a high rate of late thrombosis. Transhepatic dialysis catheters should only be used as a last resort unless limitations of catheter thrombosis can be overcome.

Transvenous Removal of Fibrin Sheaths from Tunneled Hemodialysis Catheters

PURPOSE Long-term hemodialysis catheters are prone to significant dysfunction due to fibrin accumulation around their tips. The authors assessed the efficacy of transvenous snare removal of fibrin to prolong function of these catheters. PATIENTS AND METHODS Twenty-four procedures were performed in 20 patients with tunneled hemodialysis central venous catheters. Technical success was gauged by venography and the ability to infuse and aspirate catheters. Durable efficacy was assessed by improvement in hemodialysis. RESULTS Twenty-two of 24 procedures were performed successfully. In two cases residual material remained despite repeated stripping. Mean preprocedure hemodialysis blood-liters processed per hour increased from 15.1 to 19.1 L/h in the first dialysis session after stripping, and blood flow rates of 300 mL/min or greater were restored. By the fifth dialysis session after stripping, the blood-liters processed per hour dropped to 15.9 L/h as catheter flow rates returned to unacceptable levels. CONCLUSIONS Percutaneous fibrin removal with a loop snare provides no durable benefit in improving function of failing hemodialysis catheters.