Richard G. Fisher

Conservative management of aortic lacerations due to blunt trauma.

Three patients with angiographically documented thoracic aortic lacerations were managed conservatively over 8 years due to the nonthreatening appearance of the injuries in two and the presence of an associated major closed head injury in a third. The lesion(s) resolved in one, diminished in another, and remained unchanged in the third. At least ten other cases managed similarly are recorded in the literature. In certain selected circumstances this approach may represent a viable alternative to the current standard of immediate surgical correction of aortic injuries.

Diverticula of Kommerell and Aberrant Subclavian Arteries Complicated by Aneurysms

This is a retrospective evaluation of the incidence of aberrant subclavian arteries (ASAs) and diverticula of Kommerell, as well as the occurrence and significance of associated aneurysms. Thoracic aortograms obtained during a 12.5-year period were reviewed, seeking the presence of aberrant right and left subclavian arteries (ARSAs/ALSAs), diverticula of Kommerell, and the incidence of associated aortic aneurysms. Several cases were evaluated with computed tomography concomitantly. Results were correlated with a literature review. Twenty-two ASAs were identified. Nineteen were on the right (ARSAs) and three were on the left (ALSAs). A diverticulum of Kommerell (DOK) was also present on the right in seven and on the left in three. Five of these patients had complicating aneurysms. Four of these were associated with ARSAs and their diverticula. Two were atherosclerotic; one was a limited dissection and one of uncertain etiology was ruptured. One additional aneurysm (atherosclerotic) involved an ALSA/DOK. The patient with the ruptured aneurysm died in surgery; three were managed conservatively because of concomitant disease; and one is being followed because of the small size (2.5 cm) of the aneurysm. ARSAs are relatively uncommon and ALSAs are rare. Both ARSA and ALSA are frequently associated with a DOK. Aneurysms rarely involve ASAs (with or without a DOK), but they are associated with a high mortality rate if they are not discovered before rupture. Early diagnosis plus surgical and/or endovascular management can be lifesaving.

Traumatic injury of the internal mammary artery: embolization versus surgical and nonoperative management

Abstract. The purpose of the study was to compare the outcomes, complications, and effectiveness of embolization versus surgical and nonoperative management in patients with injury to the internal mammary artery. Eighteen cases of angiographically proven internal mammary artery injury were identified by a retrospective review. Patient age range was 17–71 years (mean 34 years). Causes of vascular injury were equally divided (9 each) between penetrating and blunt trauma. Type of trauma, associated injury, plain film findings, treatment complications (immediate and delayed), and overall outcomes were assessed. Results of embolization versus surgical and nonoperative management were compared. Angiographic findings included occlusion, active hemorrhage, and pseudoaneurysm of the internal mammary artery. Of the 18 patients studied, 12 underwent embolization; 2 underwent surgical ligation, and 4 were managed by nonoperative observation. No patient died as a direct result of vascular injury; one died of renal failure unrelated to chest trauma and one other died of myocardial contusion. One patient who underwent embolization had delayed bleeding and two patients with conservative management developed a delayed hemothorax. This small series demonstrates that embolotherapy offers an effective, efficient, and safe alternative to conventional surgical management of internal mammary artery injuries.

Mesenteric Arteriographic Findings in a Patient with Strongyloides stercoralis Hyperinfection

The authors present a case of a Latin American patient with systemic lupus erythematosus who was referred for a mesenteric arteriogram because of acute lower gastrointestinal bleeding. Multiple segments of dilation alternating with stenosis or spasm were noted in the superior mesenteric artery/inferior mesenteric artery distributions. At the time, these irregularities were thought to be representative of lupus vasculitis. Despite appropriate treatment for vasculitis, the patient continued to have bleeding episodes and ultimately died of multiple organ failure. Autopsy demonstrated no evidence of vasculitis, but did demonstrate the unexpected finding of Strongyloides stercoralis hyperinfection with vessel invasion.

Placement of Dual Bird's Nest Filters in an Unusual Case of Duplicated Inferior Vena Cava

The authors describe an unusual variant of inferior vena cava duplication, with azygos continuation of the right vena cava and hemiazygos continuation of the left vena cava, discovered at cavography in a patient with pulmonary embolism. Following unsuccessful attempts to advance titanium Greenfield filters through tortuous iliac veins, bilateral Birds Nest filters were placed successfully.

Incidence and Management of Catheter Occlusion in Implantable Arm Ports: Results in 391 Patients

PURPOSE To evaluate the incidence and management of catheter occlusion in implantable arm ports. MATERIALS AND METHODS Findings were prospectively examined in 391 patients in whom 393 arm ports were placed. The indications for port placement included chemotherapy (n = 347), antibiotic administration (n = 35), combination chemotherapy/antibiotic use (n = 7), transfusion (n = 3), and phlebotomy (n = 1). Of the total catheters, 323 (82.2%) underwent tip modification prior to placement. Malfunctioning catheters were usually treated with urokinase instillation. RESULTS Three hundred ninety-three devices were implanted with 247 mean days of catheter use (total, 97,256 days; range, 1-694 days). The overall incidence of catheter occlusion was 0.14 per 100 catheter days. A single catheter occlusion occurred in 90 (22.9%) catheters, with a mean of 90.1 days before the event. A second occlusion occurred in 36 (9.2%) of the above catheters, with a mean of 60.1 catheter days before the second event. Eighty-five (24.0%) of the 347 cancer patients had at least one occlusive event, yielding a complication rate of 0.098 per 100 catheter days at risk (95% confidence interval [CI]; 0.079-0.114). Of the 35 patients receiving antibiotics, three (8.6%) had at least one occlusive event. This represented a complication rate of 0.032 per 100 catheter days at risk (95% CI; 0.010-0.061). Seventeen (24.3%) of the nonmodified catheters developed an occlusion versus 72 (22.3%) of the modified (P > .05; Fisher exact test). Of the catheters with a first occlusive event, 75 (98.7%) were treated successfully with urokinase instillation. Four (1.0%) patients developed symptomatic subclavian vein thrombosis. No bleeding complications occurred. CONCLUSION Catheter occlusion is a common complication of long-term arm port placement, with a significantly higher incidence in the cancer patients in our series (P <. 05, Fisher exact test). Catheter tip modification, however, does not considerably affect the incidence of occlusion. Low-dose urokinase therapy is a safe and efficacious treatment of catheter occlusion, obviating the need for catheter removal.

Venous Port Salvage Utilizing Low Dose tPA

This study was performed to evaluate the efficacy of low dose tPA for catheter salvage in cases of fibrin sheath formation in patients with venous access ports. Prospective evaluation was accomplished in patients who had venous ports with catheter malfunction. There were a total of 50 patients and 56 occlusive events. Each patient had a catheter injection documenting a fibrin sheath. Patient population included 45 for chemotherapy and 5 for antibiotics. A low dose tPA regimen was instilled into the port and upon successful return of function, a completion venogram was accomplished. Fifty patients were enrolled in the study with the average time between placement and dysfunction of 99 days. Five patients had a second occlusive event (38.5 days) and one had a third event (27 days). All patients had a venogram confirming a fibrin sheath as the cause of catheter malfunction. The average dose of tPA was 2.29 mg (range 1 mg–4 mg). Success was achieved in 52 of the 56 occlusive events (92.9%). There were no bleeding complications. Catheter occlusion is a common complication of long-term venous access ports. Aggressive therapy with low-dose tPA can salvage function. It provides safe and effective therapy for venous port malfunction secondary to fibrin sheath.

Persistent hemothorax secondary to malposition of a subclavian venous catheter.

In a group of seven patients with percutaneous subclavian catheters in the pleural space, three were found to have continued blood loss from the catheter tip, and in four patients thoracotomy was prevented by discontinuing blood administration through the subclavian catheter during a re-evaluation phase.

Infectious complications of 393 peripherally implantable venous access devices in HIV-positive and HIV-negative patients.

PURPOSE To compare and investigate the rate of infection in patients with and without human immunodeficiency virus (HIV) who have implantable venous access devices placed by interventional radiologists. MATERIALS AND METHODS Three hundred ninety-one patients undergoing radiologically guided placement of peripheral arm ports were grouped according to their HIV serologic status. Findings were prospectively reviewed in 393 peripherally placed arm ports that were implanted in the basilic, cephalic, or brachial vein under fluoroscopic or sonographic guidance over a 4-year span. Infectious complications were categorized according to severity (local or systemic) and time (periprocedural or late). RESULTS Three hundred ninety-three ports have been indwelling for a total of 97,256 patient days (range, 1-694; mean duration, 247 days). Among the 30 catheter placements in 29 HIV-positive patients with a total exposure time of 7,242 days, five (one local and four systemic) infections occurred, resulting in a 16.6% overall infection rate, yielding 0.069 infections per 100 catheter days at risk (95% confidence interval [CI], 0.032-0.127). In the remaining 362 HIV-negative patients, 27 (14 local and 13 systemic) infectious complications (7.4%) occurred, translating into 0.030 infections per 100 catheter days (95% CI, 0.021-0.042). The odds ratio of getting an infection from the implantable arm ports in the HIV-positive group was 2.5 times higher than that of the HIV-negative group. The relative risk was similar and was calculated to be 2.3. The P value was .084 (P < .05 required to be considered significant). CONCLUSIONS These results suggest a significant difference in the infectious complication rate encountered in HIV-positive patients compared with the general population. However, the HIV-positive peripheral arm port infection rate compares favorably with the surgically placed catheters and ports. Many more arm ports in HIV-positive patients must be evaluated for the data to achieve an acceptable level of statistical significance.

Interventional management of infrapopliteal arterial injury

Purpose: Recent advances in angiographic and occlusive techniques have given the interventional radiologist a significant role in the management of below-the-knee arterial trauma. We wish to present our experience involving nine patients with ten infrapopliteal arterial injuries successfully managed with interventional embolotherapy. Methods and materials: Nine male patients with a mean age of 29.4 years (range 17–63 years) presented to our interventional department for evaluation of injury to the lower extremity. Mechanisms of injury were penetrating trauma, shotgun blast, or auto–pedestrian injury. Digital subtraction or cut-film angiography of the lower extremity was performed using standard Seldinger technique via the common femoral artery approach. Injuries managed were arteriovenous fistulas (30 %), transection (40 %), and pseudoaneurysm (30 %) involving the posterior tibial (20 %) and/or peroneal (80 %) arteries. Agents used included Gelfoam, Gianturco coils, and/or vasopressin. Patients were followed until discharge and as outpatients when possible. Results: All patients were successfully managed in regard to their acute injuries. Hemostasis was achieved, and surgical exploration was avoided. There were no procedure-related complications, and limb salvage rate was 100 %. Conclusion: Our experience demonstrates that current angiographic and embolotherapy techniques enable the interventionalist to successfully treat acute infrapopliteal arterial injury.