Terence A.S. Matalon

Transjugular intrahepatic portosystemic shunt (TIPS) for Budd-Chiari syndrome or portal vein thrombosis : review of indications and problems

OBJECTIVE The aim of this study was to evaluate the role of transjugular intrahepatic portosystemic shunt (TIPS) in patients who present with portal vein thrombosis (PVT) or Budd-Chiari Syndrome (BCS). METHODS Nine patients with recent PVT and four patients with BCS underwent TIPS. The diagnosis was confirmed by color Doppler ultrasound and by angiogram in most patients. Patients were followed clinically and had TIPS checked periodically for patency. The end point was mortality, subsequent surgical shunting or orthotopic liver transplantation (OLT). RESULTS TIPS was placed in 13 of 15 (87%) patients with BCS or PVT. The mean decrease in pressure gradient was 56%. Median and mean follow-up were 14 months and 16.9 months. Procedure related complications occurred in two of 13 (15%), both in the PVT group. Direct procedural mortality was one of 13 (8%). The majority of patients with PVT (five of eight) underwent OLT. Of the remaining three, one patient subsequently developed a cavernous transformation of portal vein but is stable, one patient is stable, without further variceal bleeding, and one patient died because of multiple organ failure. In patients with BCS, three of four (75%) did well with TIPS, but one patient required immediate surgical shunting after occlusion of the TIPS. Two patients underwent OLT and the fourth patient is stable 2 yr later but has cirrhosis on biopsy. CONCLUSIONS In patients with BCS, TIPS placement is effective and can be used as a bridge to liver transplantation. TIPS in the noncavernous PVT group should only be recommended when cirrhosis and uncontrollable variceal bleeding are present.

Comparison of the AngioJet Rheolytic Catheter to Surgical Thrombectomy for the Treatment of Thrombosed Hemodialysis Grafts

PURPOSE To compare the clinical effectiveness of the AngioJet F105 rheolytic catheter to that of surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. MATERIALS AND METHODS This was a multicenter, prospective, randomized trial comparing technical success, primary patency, and complication rates. A total of 153 patients were enrolled: 82 patients in the AngioJet group and 71 patients in the surgical thrombectomy group. Patient follow-up was performed 24-48 hours, 1 month, and 6 months after the procedures. RESULTS Technical success, as defined by the patients ability to undergo hemodialysis treatment, was 73.2% for the AngioJet group and 78.8% for the surgical thrombectomy group (P = .41). The primary patency rates of the AngioJet group were 32%, 21%, and 15% at 1, 2, and 3 months, respectively. The primary patency rates for the surgical group were 41%, 32%, and 26% at 1, 2, and 3 months, respectively. This difference approached statistical significance (P = .053). The groups had similar complication rates-14.6% in the AngioJet group and 14.1% in the surgery group-although the surgery group had more major complications (11.3%). In the AngioJet group, there was a transient increase in plasma-free hemoglobin, which normalized within 24-48 hours. CONCLUSIONS The AngioJet F105 catheter provides similar clinical results when compared to surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. The difference in patency rates between these two techniques approached statistical significance. In addition, results of both thrombectomy methods were inferior to those suggested by the Dialysis Outcomes Quality Initiative guidelines.

Percutaneous Stent-Graft Management of Renal Artery Aneurysms

JVIR 2000; 11:1189–1193 RENAL artery aneurysms (RAAs) are rare, with a reported incidence of 0.015%–1.32% (1–3). Although most RAAs may be safely observed, indications for treatment include a size more than 2.5 cm, interval enlargement, renovascular hypertension, pain, hematuria, intrarenal thromboemboli, and lesions in women of childbearing age (1,2,4,5). Traditionally, the definitive management of RAA has consisted of operative repair or nephrectomy. Although stent-grafts have been used for the exclusion of aortic and iliac aneurysms (6), there exists, to our knowledge, only a single published case description of stentgraft exclusion for the treatment of RAA (7). In this report, we describe our experience with two cases of percutaneous RAA exclusion with use of polytetrafluoroethylene (PTFE)-covered Palmaz stents (Cordis, Warren, NJ).

Thrombolytic Therapy with Use of Alteplase (rt-PA) in Peripheral Arterial Occlusive Disease: Review of the Clinical Literature

PURPOSE The clinical literature describing the use of alteplase in the treatment of peripheral arterial occlusive (PAO) disease is reviewed. MATERIALS AND METHODS The literature database was acquired by a MEDLINE search using the Boolean keyword string: tissue plasminogen activator and/or rt-PA and peripheral not animal. A review was performed to identify the dose range of alteplase, technique of infusion, use of anticoagulation, clinical success rates, and risk of complications. RESULTS Forty-six clinical studies were identified. There are few prospective, randomized clinical trials and a lack of standardized protocols and endpoints. Use of catheter-directed infusions of recombinant tissue plasminogen activator (rt-PA) may be beneficial versus surgery in the initial management of acute limb ischemia (< 14 days) and in reducing the magnitude of subsequent surgical or percutaneous revascularization. For patients with chronic limb ischemia (> 14 days), irreversible acute limb ischemia, or advanced diabetic arteriopathy, catheter-directed infusion of rt-PA or other plasminogen activators may be unsuitable. The risk of adverse bleeding appears related to the overall dose and duration of infusion. These risks appear similar to those of urokinase. The role of heparin in increasing adverse bleeding during rt-PA therapy is unclear. CONCLUSIONS There is no generally accepted dose or technique for administering catheter-directed thrombolysis using alteplase; however, several studies have demonstrated its clinical safety and efficacy. Formal studies will be required to determine the optimal dose, technique of infusion, the role of anticoagulation, and complication rates when alteplase is used for PAO disease.

Alteplase as an Alternative to Urokinase

Abbreviations: DVT deep vein thrombosis, PAOD peripheral arterial occlusive disease, rt-PA recombinant tissue plasminogen activator, UK urokinase For the past 20 years, urokinase (UK) has been the primary agent used in the United States for catheter-directed thrombolytic therapy of acute limb ischemia and deep vein thrombosis (DVT), and for restoration of patency in hemodialysis access and clotted intravenous access devices (1–4). However, in 1999, the Food and Drug Administration suspended the sales and distribution of UK (Abbokinase; Abbott Laboratories, Abbott Park, IL) in the United States (5). Unfortunately, few American interventionalists had previous experience in the use of alternative agents to UK. To address this urgent clinical crisis, a multidisciplinary Advisory Panel on Catheter-Directed Thrombolytic Therapy consisting of vascular specialists was organized by the Society of Cardiovascular and Interventional Radiology (SCVIR) and convened in New York, NY, on August 9, 1999, to develop preliminary recommendations for the benefit of SCVIR members. The goal of the advisory panel was to: (i) identify alternative plasminogen activators; (ii) review the published literature on alternative plasminogen activators; (iii) review the multidisciplinary advisory panel experience with the use of alternative agents; and (iv) develop preliminary clinical guidelines for managing acute limb ischemia, DVT, thrombosed dialysis grafts, and clotted intravascular catheters and ports. This document is a summary of the Advisory Panel meeting and is intended for the establishment of guidelines in the use of alternative agents to UK in clinical practice. The meeting was supported by an unrestricted educational grant from Genentech, Inc. (South San Francisco, CA) and sponsored by the SCVIR.

Biliary Strictures in Hepatic Transplantation

Between August 1985 and December 1990, 198 liver transplantations were performed. Among 18 patients, 20 biliary strictures were identified, which were categorized as anastomotic (n = 6), nonanastomotic central hilar (n = 8), and nonanastomotic peripheral (n = 6). Pretransplant disease, hepatic artery patency, presence of acute or chronic rejection, and donor cold ischemia times were tabulated for each case. Among the six patients with peripheral strictures, three had sclerosing cholangitis prior to transplantation. Three patients with nonanastomotic strictures experienced chronic rejection. The mean cold ischemia time for patients with nonanastomotic strictures was 9.75 hours versus 8.1 hours for nonstrictured transplants (P = .025). Balloon dilation was performed in 13 patients; follow-up longer than 6 months was available for nine patients. Dilation was successful in four cases. Among the five failures, only one patient has needed surgery. An association was noted between nonanastomotic biliary strictures and prolonged donor cold ischemia time, between peripheral nonanastomotic strictures and pretransplant sclerosing cholangitis, and between nonanastomotic strictures and chronic rejection. Percutaneous balloon dilation was found useful in the treatment of the strictured transplant.

Quality Improvement Guidelines for the Performance of Cervical Carotid Angioplasty and Stent Placement

Developed by a Collaborative Panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology

Quality improvement guidelines for the performance of cervical carotid angioplasty and stent placement: Developed by a collaborative panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology

John D. Barr, MD, John J. Connors, III, MD, David Sacks, MD, Joan C. Wojak, MD, Gary J. Becker, MD, John F. Cardella, MD, Bohdan Chopko, MD, PhD, Jacques E. Dion, MD, Allan J. Fox, MD, Randall T. Higashida, MD, Robert W. Hurst, MD, Curtis A. Lewis, MD, MBA, Terence A.S. Matalon, MD, Gary M. Nesbit, MD, J. Arliss Pollock, MD, Eric J. Russell, MD, David J. Seidenwurm, MD, and Robert C. Wallace, MD, for the ASITN, ASNR, and SIR Standards of Practice Committees

CAVITARY PERIVENTRICULAR LEUKOMALACIA: INCIDENCE AND SHORT-TERM OUTCOME IN INFANTS WEIGHING ≥1200 GRAMS AT BIRTH

One hundred surviving infants with birthweights ≥1200g were examined longitudinally, using real‐time ultrasonography of the brain. Five infants were diagnosed as having cavitary periventricular leukomalacia (PVL). One infant expired within a month following discharge; the remaining four entered a follow‐up program and received developmental assessments. Three infants had moderate‐severe spastic diplegia and the fourth had spastic quadriplegia. Cavitary PVL can be diagnosed in vivo and predicts future motor delay or cerebral palsy. Since the typical site of PVL involves the optic radiations, and the incidence of visual‐perceptual disturbances is high in premature infants, fürther research is needed to explore the possible relationship between these two abnormalities.

Ultrarapid urokinase in hemodialysis access occlusion.

Over a 3-month period, 14 consecutive hemodialysis access occlusions were treated with 1-1.25 million IU of urokinase (UK) delivered at a rate of 20,000 IU/min. After systemic heparin administration, lytic infusion via the crossed-catheter technique was performed with use of pediatric microdrip pumps, with determination of success within 1 hour. Patency was established radiographically in 11 of 14 occlusions, for a 79% immediate success rate. At 285-day mean follow-up, 9% (one of 11) remained patent without further radiologic or surgical intervention; graft survival was 64% (seven of 11). No significant complications occurred with use of ultrarapid UK. The 1-hour outpatient procedure safely allowed for rapid triage between surgical and radiologic intervention, minimal catheter manipulation or physician dependency, shorter duration compression of any bleeding venipuncture sites during UK administration, and greater patient comfort because of shortened procedure times.