Robert C. Sheley

Percutaneous Transluminal Angioplasty versus Endovascular Stent Placement in the Treatment of Venous Stenoses in Patients Undergoing Hemodialysis: Intermediate Results

PURPOSE This report describes intermediate findings from an ongoing prospective randomized trial comparing the results of percutaneous transluminal angioplasty (PTA) with results of endovascular stent placement in patients undergoing hemodialysis. PATIENTS AND METHODS Among 87 consecutive patients with venous stenoses or occlusions, 47 (54%) were treated with PTA alone and 40 (46%) were treated with PTA and stent placement. RESULTS For peripheral sites, the primary patency rates for PTA at 60, 180, and 360 days were 55%, 31%, and 10%, respectively, and for stents were 36%, 27%, and 11%, respectively (P = .6528). The secondary patency rates for PTA at 60, 180, and 360 days were 94%, 80%, and 71%, respectively, and for stents were 73%, 64%, and 64%, respectively (P = .1677). For central sites, the primary patency rates for PTA at 60, 180, and 360 days were 81%, 23%, and 12%, respectively, and for stents were 67%, 11%, and 11%, respectively (P = .4595). The secondary patency rates for PTA were 100% at each interval, and for stents were 100%, 89%, and 78%, respectively (P = .5408). CONCLUSION Intermediate results suggest that, overall, there is no difference in the patency rates for peripheral venous stenoses in dialysis patients treated with PTA or PTA and endovascular stent placement. At this time, the numbers of patients are too small to conclude if certain sites such as larger central veins will respond better to one treatment or the other.

The role of percutaneous needle biopsies in the original diagnosis of lymphoma: a prospective evaluation.

PURPOSE A prospective evaluation to determine if percutaneous needle biopsy yields enough tissue to establish the diagnosis of lymphoma and initiate therapy. PATIENTS AND METHODS Lymphoma was diagnosed in 43 patients for the first time. Patients underwent either a core needle biopsy (n = 41) or an aspiration-type needle biopsy (n = 2) performed with imaging guidance. Immunochemical studies were performed on specimens from 39 of 43 patients (91%); flow cytometry was performed formed on specimens from 10 patients (23%). Patient progress was followed to see if biopsy results were used as a basis for treatment or if additional material was obtained with an open surgical procedure. RESULTS On the basis of treatment decisions, needle biopsy results were sufficient for a diagnosis to be made in 36 of 43 patients (84%). In seven patients (16%), needle biopsy specimens were considered nondiagnostic, suspicious for lymphoma, or insufficient. None of the 43 patients responded to therapy in a manner that suggested the diagnosis of lymphoma to be incorrect. CONCLUSION Image-guided needle biopsy should be the first procedure performed in the diagnosis of lymphoma, except in easily accessible superficial neck, inguinal, and axillary nodal sites.

Helical CT in the evaluation of renal colic

This study assessed the clinical effectiveness of unenhanced helical (spiral) computed tomography (CT) for evaluation of patients presenting with symptoms of renal colic. Two hundred patients with symptoms and signs of renal colic (flank or groin pain, hematuria) were imaged. Unenhanced CT was performed using 5-mm collimation with a pitch of 1.5 to 1.8. Image reconstruction was performed at 3-mm intervals. Exam time was approximately 5 minutes. The financial charge at the study institution was the same as for an intravenous urogram. Clinical follow-up was performed by review of available medical records and patient interviews. The sensitivity for detecting clinically relevant ureteral and bladder calculi was 0.862 (0.95 confidence interval [CI] 0.771 to 0.927), the specificity was 0.914 (0.95 CI 0.837 to 0.962), and the accuracy was 0.89 (0.95 CI 0.833 to 0.931). Helical CT is an effective technique in the evaluation of suspected acute urinary tract obstruction.

Aortoenteric Fistula in Advanced Germ Cell Tumor: A Rare Lethal Complication

A 28-year-old man presented with low back pain and cough. Computerized tomography demonstrated diffuse pulmonary and hepatic metastases as well as bulky retroperitoneal nodal disease encasing vasculature and bowel. Sonography showed right testicular atrophy, and right orchiectomy revealed anaplastic seminoma. Relevant laboratory studies included an elevated -human chorionic gonadotropin of 12,444 IU/ml. (normal less than 5), an elevated lactate dehydrogenase of 384 units per l. (normal 100 to 190) and absent -fetoprotein. The patient was treated with 2 cycles of a standard chemotherapy regimen using bleomycin, etoposide and cisplatin. Approximately 4 weeks following course 2 of bleomycin, etoposide and cisplatin the patient had a syncopal episode, and hematemesis and hematochezia developed. He presented to the emergency department in hypovolemic shock and required extensive fluid resuscitation. Upper endoscopy revealed a massive amount of bright red blood gushing up from the duodenum. The bleeding was too brisk to identify the source. Emergent aorto-visceral angiography demonstrated an aortoduodenal fistula (part A of figure). An endovascular stent graft was subsequently placed across the fistula, with immediate control of the hemorrhage (part B of figure). Definitive surgical repair awaited patient recovery from multiple organ insult. Unfortunately, massive bleeding recurred 10 days after the first hemorrhage, and angiography showed development of a new larger fistula. Attempts at resuscitation and placement of 2 additional endovascular stent grafts were unsuccessful, and the patient died. Autopsy confirmed the presence of aortic necrosis and an aortoenteric fistula secondary to extensive metastatic choriocarcinoma.

“Accordion” Deformity of a Tortuous External Iliac Artery after Stent-Graft Placement

Purpose: To identify a complication of endograft deployment in aneurysmal iliac arteries. Case Report: A 71-year-old man was referred for endovascular treatment of a 60-mm diameter right common iliac artery aneurysm; however, deployment of a homemade covered stent (Palmaz-Schatz and polytetrafluoroethylene) induced shortening of the tortuous external iliac artery, causing an “accordion” deformity. The anomaly proved difficult to treat with serial Wallstent deployment, because the convolution tightened and migrated caudally with each stent deployed, threatening outflow. Finally, after 3 Wallstents were implanted, the contour of the external iliac artery was straight, and flow was unimpeded. However, 3 weeks later, the external iliac artery had recoiled to its original redundant appearance, but flow remained satisfactory. The aneurysm remains excluded, with satisfactory distal flow after 24 months. Conclusions: Implanting endografts in redundant, tortuous arterial segments may prove problematic, since induced straightening by the device precipitates kinking in the redundant system. Although treatment may be required in some situations, the vessels may return to a noncompressed state by removing the delivery system and guidewire.

Percutaneous inferior vena cava-to-portal vein shunt (PIPS) using a stent-graft: preliminary results.

Purpose: To present preliminary results of an inferior vena cava (IVC)–to—portal vein shunt (PIPS) that is created through the caudate lobe of the liver. Methods: Sixteen patients (13 men; mean age 50 years, range 32–63) were referred for PIPS procedures because of bleeding varices (n = 11), intractable ascites (n = 4), and hepatorenal syndrome (n = 1). The severity of liver disease was Childs B in 2 and Childs C in 14. The PIPS was created by a transhepatic puncture through the IVC and the portal vein; an endograft made of polytetrafluoroethylene sutured to a Palmaz stent was placed through a jugular approach. Results: In 13 (81%) patients, the portal vein—to—IVC tracts were successfully created. The postprocedural portal vein—IVC gradients varied from 1 to 9 mm Hg (mean 5). There were 2 deaths in the 30-day periprocedural period from adult respiratory distress syndrome and hepatorenal syndrome. A third patient died at 31 days from liver failure owing to continuing alcohol abuse. In addition, there was 1 case of peritoneal bleeding treated with blood product replacement. The follow-up period ranged from 14 to 671 days (mean 343). None of the patients treated for variceal bleeding had another bleeding episode, but 2 patients who had a PIPS procedure for refractory ascites did not benefit from the procedure. Postprocedure, 46% (6/13) of the patients had hepatic encephalopathy, which was unchanged from baseline. The primary and secondary patency rates at 365 days were 60% and 65%, respectively. Conclusions: The preliminary results using a stent-graft to create an IVC-portal vein shunt are encouraging and support further work to better determine the role of this procedure.

Local Delivery of Heparin with Balloon Angioplasty: Results of a Prospective Randomized Trial

PURPOSE To evaluate the effectiveness of local delivery of heparin via hydrogel-coated balloons in the treatment of vascular stenoses associated with hemodialysis access. MATERIALS AND METHODS This was a randomized, prospective trial comparing treatment with hydrogel-coated balloon catheters delivered with heparin coating (n = 33) and without (n = 26). All patients were undergoing hemodialysis, and all stenoses involved the venous anastomosis of a dialysis graft or a native vein. The heparin-treated balloons were soaked in concentrated heparin and delivered in a protected manner to help prevent washout of heparin. RESULTS The mean primary patencies were 143 days with heparin treatment and 214 days without heparin (P = .174). The mean assisted primary patencies were 165 days with heparin and 194 days without (P = .315). The mean secondary patencies were 351 days with heparin and 384 without (P = .81). CONCLUSION In this population with this technique, the treatment outcome of venous outflow stenosis in patients with dialysis grafts is not improved with local delivery of heparin.