Robert E. Lambiase

Percutaneous Revascularization of Complex Iliac Artery Stenoses and Occlusions with Use of Wallstents: Three-year Experience

PURPOSE To assess the outcome of percutaneous placement of Wallstents for treatment of hemodynamically significant diffuse stenoses (> 3 cm in length), chronic occlusions, failed angioplasty procedures, and flow-limiting dissection in the iliac arteries. MATERIALS AND METHODS Lesions in 94 iliac limbs were treated in 66 patients. Indications for stent placement included claudication in 49 limbs and limb-threatening ischemia in 45. Forty-two limbs were treated for diffuse disease, 39 for chronic occlusion, nine for failed angioplasty, and four for flow-limiting dissection. RESULTS Technical success was achieved in 86 of 94 limbs (91%), with major complications in 9% of patients. One death occurred within 30 days (not procedure-related). Ankle-brachial indexes improved from 0.51 +/- 0.24 to 0.76 +/- 0.22 (P < .001). Eighty-five percent demonstrated improvement under Rutherford criteria. Follow-up was obtained up to 38 months (mean, 14 months +/- 8). Cumulative primary patency rates were 78% at 1 year and 53% at 2 and 3 years (standard error 10%). Secondary patency rates were 86% at 1 year and 82% up to 32 months (standard error > 10% after 32 months). No significant decrease in mean ankle-brachial index was observed during follow up. No difference in primary patency was observed based on lesion type, symptom severity, lesion location, or runoff status. The limb salvage rate for patients with limb-threatening ischemia was 98% at a mean follow-up of 14 months +/- 7. CONCLUSIONS Technical success and complication rates for percutaneous iliac artery revascularization with use of Wallstents are favorable, symptoms improved in the majority of patients, and excellent secondary patency can be achieved. With use of Wallstents, most patients with iliac artery insufficiency as a result of long-segment disease or chronic occlusions can be treated percutaneously.

Treatment of biliary leaks and fistulae by simultaneous percutaneous drainage and diversion

Although biliary fistulae and bilomas are often adequately managed with percutaneous drainage, persistent bile duct leaks are difficult to control. The primary surgical goal in this situation is to decompress the biliary system through diversion of bile flow to facilitate healing of the defect in the bile ducts. We report 3 patients with large biliary duct defects who underwent percutaneous transhepatic cholangiography which demonstrated the site of the biliary leakage. Then, extrapolating the aforementioned surgical tenet to these patients, all 3 were successfully treated with interventional radiologic techniques: simultaneous percutaneous transhepatic biliary diversion to control biliary flow and percutanous biloma drainage to facilitate closure of the cavity.

Percutaneous abscess and fluid drainage: A critical review

Pertinent radiologic and surgical literature regarding abscess drainage was reviewed. Noted is the heterogeneity of disorders categorized as abscesses, and the variety of therapeutic approaches presently available. Specific abscesses are discussed based on body location and/or associated organ system.

Antibiotics and Nephrostomy Tube Care: Preliminary Observations Part II. Bacteremia

Bacteriuria occurs after long-term drainage of the kidney. This study was designed to determine if the risk of bacteremia increases at the time of tube or stent change, whether bacteremia correlates with clinical infection, and if prophylactic antibiotics are effective in the prevention of bacteremia. One hundred four tube changes in 74 patients with percutaneous nephrostomy tubes and documented positive urine cultures were studied. Patients were arbitrarily divided into groups receiving and not receiving antibiotics before nephrostomy tube change. Asymptomatic bacteremia was documented in 11 of 104 tube changes (11%). Results of five blood cultures were positive in the group receiving antibiotics, and six cases of bacteremia occurred in the group not receiving antibiotics (P = .96). Routine nephrostomy/stent change can cause frequent, asymptomatic bacteremia in patients with colonization of bacteria in the urinary tract. Antibiotic prophylaxis was unsuccessful in preventing transient bacteremia, a factor that may have implications in patients with underlying valvular heart disease and other patients at risk for bacteremia.

Perforation of the Common Bile Duct During Endoscopic Sphincterotomy: Recognition on Computed Tomography and Successful Percutaneous Treatment

Retroperitoneal common bile duct (CBD) perforation is a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). We describe such a case with delayed diagnosis made by computed tomography (CT) and successful percutaneous management of the injury.

Percutaneous alternatives in nutritional support: a radiologic perspective

As alternatives to per os feeding and nutritional support increase in number and complexity, the interventional radiologist has come to play a more significant role in the creation and maintenance of nutritional access. In very difficult access cases, the concerted effort of the nutritional surgeon and the radiologist is often required. We describe several such situations which have been successfully managed at our institution. The indications for and techniques of percutaneous reestablishment of surgically placed jejunostomy tubes, the percutaneous conversion of gastrostomy to jejunostomy tubes with retention of the gastrostomy tube, and percutaneous placement of an inferior vena caval Hickman catheter are all described in detail.

A previously unrecognized connection between occipital condyle fractures and internal carotid artery injuries (carotid and condyles)

Occipital condyle fractures (OCF) were once considered rare, but are increasingly recognized with computed tomography [1]. Utilizing the classification scheme of Anderson and Montesano [2] proposed mechanisms include direct axial-loading of the skull onto the atlas (Type I), direct blow to the skull (Type II), or forced rotation (Type III). A fracture of the occipital condyles may suggest a specific pattern of injury to adjacent structures. The occipital condyles form the boundaries of the foramen magnum through which the medulla, vertebral arteries, and inferior cranial nerves pass. Injury to the occipital condyles places those structures at greatest risk. As the carotid arteries do not course near the occipital condyles, injury to them is generally unexpected in OCFs without concomitant craniocervical injuries. To date, there have been no published reports of carotid injuries associated with any type OCFs. We present two patients with isolated type III occipital condylar fractures in whom injury to the carotid arteries was present. Case 1

Extensive Thromboembolic Disease of the Hand and Forearm: Treatment with Thrombolytic Therapy

Six patients with extensive hand and forearm thromboembolic disease were treated by means of intraarterial infusion of urokinase, with good clinical results. Four significant complications occurred, including a possible stroke. Embolization of pericatheter thrombus was a possible etiologic factor in this case. Antegrade brachial artery puncture should be used in the setting of prolonged upper extremity thrombolytic therapy to avoid the cerebral vasculature. Thrombolysis is an effective technique for tissue salvage in cases of inoperable hand thrombosis.

Ancillary radiographic projections of the hand and wrist

In addition to frontal, lateral, and oblique views of the hand and wrist, multiple ancillary views have been described that are of use in specific clinical circumstances. The techniques of these views are discussed and shown.