Percutaneous mural fenestration and angioplasty for the treatment of a refractory hemodialysis-related venous stenosis

Venous stenoses are the leading cause of dialysis graft and mature dialysis fistula malfunction. We report a simple, inexpensive technique for treating stenoses that are refractory to conventional balloon angioplasty and present a case in which this technique was successfully applied.

Percutaneous declotting of virgin femoral hemodialysis grafts

OBJECTIVE

The objective of our study was to evaluate outcomes of percutaneous declotting procedures in patients with prosthetic femoral dialysis grafts.

MATERIALS AND METHODS

A retrospective review of all pharmacomechanical femoral dialysis graft declotting procedures performed in our hospital between May 11, 1993, and April 30, 2003, was performed. A total of 110 procedures were performed on 25 patients (nine males, 16 females; age range, 17-80 years; mean age, 49 years) with 30 grafts.

RESULTS

Technical success was 97.3%. Using life table analysis, 30-day postinterventional primary patency was 72%, 90-day primary patency was 46%, 180-day primary patency was 25%, and 365-day primary patency was 4%. The 30-day secondary postinterventional patency was 93%, 90-day secondary patency was 86%, 180-day secondary patency was 76%, and the 365-day secondary patency was 51%. An average of 1.96 declotting procedures were performed per year of dialysis.

CONCLUSION

Percutaneous declotting of femoral hemodialysis grafts has technical success and patency rates similar to those for percutaneous declotting in the upper extremities. Results of this series exceeded criteria established by the National Kidney Foundation in the "Dialysis Outcome Quality Initiative" for immediate patency and unassisted 3-month patency.

Removal of Günther Tulip Vena Cava Filter through Femoral Vein Approach

The Günther Tulip vena cava filter is designed for removal by the internal jugular vein approach with use of a blunted hook placed at the superior aspect of the filter. Removal of this filter was performed by the femoral approach in a patient with central venous occlusion that precluded removal by the conventional approach.

Balloon dilatation of biliary-enteric strictures in children

OBJECTIVE

The objective of our study was to evaluate the efficacy and safety of balloon dilatation in the treatment of anastomotic strictures in children with liver transplants.

MATERIALS AND METHODS

For a period of 7 years, we treated 20 consecutive biliary-enteric strictures in 19 children (age range, 13 months to 17.9 years, mean, 7.3 years) with balloon dilatation. Dilatation was performed between 30 days and 8.4 years (mean, 2.6 years) following surgical creation of the biliary-enteric anastomosis. Thirteen patients had left lateral segment liver transplant grafts, one patient had a split-liver, left-lobe graft, and five patients had whole liver grafts.

RESULTS

Technical success was 100% and there were no procedure-related complications. One patient with a patent anastomosis underwent repeat transplantation 183 days after the procedure for chronic rejection. In 58% (11/19) of the remaining procedures, balloon dilatation resulted in biliary-enteric patency at one year, and continued patency ranges from 1.4 to 5.4 years (mean, 3.6 years). In 40% (8/20) of the procedures, the biliary-enteric stricture persisted after balloon dilatation, and these patients eventually underwent surgical revision, retransplantation, or endobiliary metallic stent placement.

CONCLUSION

Balloon dilatation is a safe and effective treatment for biliary-enteric strictures following pediatric liver transplantation.

Comparison of single-stick and double-stick techniques for percutaneous nephrostomy

We compared single- and double-stick techniques of percutaneous nephrostomy insertion by retrospectively reviewing 140 percutaneous nephrostomy procedures in 101 patients. All procedures were performed by residents or fellows with direct attending supervision. Either the single-stick or double-stick technique was used based solely on personal attending preference. There were no significant differences in groups in terms of age, sex, or degree of hydronephrosis. In the single-stick technique, the kidney was punctured with sonographic guidance and the tract was serially dilated to accept an 8.5 Fr. nephrostomy catheter. In the double-stick technique, the kidney was punctured with sonographic guidance and a mixture of air and contrast were injected into the collecting system. The affected side was then elevated and a posterior calyx was punctured using fluoroscopic guidance. Both groups were compared in terms of complications and early tube dysfunction using the chi-squared test. All procedures were successful without immediate complications. Bleeding requiring transfusion occurred in 4.7% (4/86) procedures in the single stick group and 3.7% (2/54) in the double stick group (p-value not significant). None of these patients required further interventions for bleeding. Tube dysfunction leading to premature tube exchange occurred in 3.5% (3/86) of catheters in the single stick group and 3.7% (2/54) of catheters in the double-stick group (p-value not significant). We found no significant difference between the single and double-stick methods of percutaneous nephrostomy in terms of success rates, complications, or tube function. We believe that the single-stick method should be adopted as the insertion technique of choice.

Microcatheter embolization of lower gastrointestinal hemorrhage: an old idea whose time has come

Early attempts of using embolization for lower gastrointestinal hemorrhage were fraught with complications, most notably ischemic colitis or bowel infarction. Embolotherapy was eventually abandoned in favor of catheter-directed vasoconstriction (i.e., vasopressin infusion). This latter therapy is time and labor intensive. With the advent of microcatheter technology, superselective embolization emerged and is rapidly becoming the endovascular therapy of choice for patients with severe lower gastrointestinal hemorrhage refractory to medical management. Numerous studies on the subject have consistently reported high clinical success with low ischemic complications. This article will review the current status of co-axial microcatheter embolization with an emphasis on the technical aspects of the procedure.

Patterns of referral for inferior vena caval filtration: delays and their impact

OBJECTIVE

We sought to study the referral patterns for inferior vena caval filtration and explore the relationship between delays in filter insertion and clinical outcomes.

MATERIALS AND METHODS

We retrospectively reviewed 101 consecutive inferior vena caval filters inserted in 101 patients in a university hospital between the June 2000 and July 2001. A time line was created listing the time of diagnosis of deep venous thrombosis or pulmonary embolism, contraindication or complication of anticoagulation therapy, and time of insertion of inferior vena caval filter.

RESULTS

The average elapsed time between the clinical indication for caval filtration and filter placement in all patients was 1.64 days (range, 0-17 days). Two patients (2%) sustained pulmonary emboli after being diagnosed with deep venous thrombosis before receiving a filter. The lengths of time between filter indication and insertion for these patients were 2 and 8 days.

CONCLUSION

In our hospital, there are wide variations in perceived urgency of vena caval filtration. In two patients, delays longer than 24 hr between indication and insertion of inferior vena caval filters resulted in symptomatic pulmonary emboli.

Superselective embolization of lower gastrointestinal hemorrhage: a new paradigm

In the past 5 years, there has been a rapid evolution in the endovascular treatment of lower gastrointestinal bleeding. Previously, most bleeding distal to the ligament of Treitz was managed with catheter-directed vasoconstrictive therapy. Currently, microcatheters allow superselective embolization of bleeding vessels, a technique that minimizes potential ischemic complications and obviates many drawbacks associated with vasopressin infusion. This article summarizes the current radiologic approach for patients with severe colonic hemorrhage.

Complication Rates and Patency of Radiologically Guided Mushroom Gastrostomy, Balloon Gastrostomy, and Gastrojejunostomy: A Review of 250 Procedures

PURPOSE

To compare complication rates and tube performance of percutaneous mushroom gastrostomy, balloon gastrostomy, and gastrojejunostomy.

METHODS

Between September 9, 1999 and April 23, 2001, 203 patients underwent 250 radiologically guided percutaneous gastrostomy and gastrojejunostomy procedures. Follow-up was conducted through chart reviews and review of our interventional radiology database. Procedural and catheter-related complications were recorded. Chi-square statistical analysis was performed.

RESULTS

In patients receiving mushroom-retained gastrostomy catheters (n = 114), the major complication rate was 0.88% (n = 1), the minor complication rate was 5.3% (n = 6), and the tube complication rate was 4.4% (n = 5). In patients receiving balloon-retained gastrostomy tubes (n = 67), the major complication rate was 0, the minor complication rate was 4.5% (n = 3), and the tube complication rate was 34.3% (n = 23). In patients receiving gastrojejunostomy catheters (n = 69), the major complication rate was 1.4% (n = 1), the minor complication rate was 2.9% (n = 2), and the tube complication rate was 34.8% (n = 24). No statistically significant differences were found between procedural or peri-procedural complications among the different types of tubes. Mushroom-retained catheters had significantly fewer tube complications (p < 0.01).

CONCLUSIONS

Percutaneous gastrostomy and gastrojejunostomy have similar procedural and peri-procedural complication rates. Mushroom gastrostomy catheters have fewer tube-related complications compared with balloon gastrostomy and gastrojejunostomy catheters. In addition, mushroom-retained catheters exhibit the best overall long-term tube patency and are therefore the gastrostomy catheter of choice.

MR Imaging of arrhythmogenic right ventricular cardiomyopathy: morphologic findings and interobserver reliability

BACKGROUND

Magnetic resonance (MR) imaging is frequently used to diagnose arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). However, the reliability of various MR imaging features for diagnosing ARVC/D is unknown. The purpose of this study was to determine which morphologic MR imaging features have the greatest interobserver reliability for diagnosing ARVC/D.

METHODS

Forty-five sets of films of cardiac MR images were sent to 8 radiologists and 5 cardiologists with experience in this field. There were 7 cases of definite ARVC/D as defined by the Task Force criteria. Six cases were controls. The remaining 32 cases had MR imaging because of clinical suspicion of ARVC/D. Readers evaluated the images for the presence of (a) right ventricle (RV) enlargement, (b) RV abnormal morphology, (c) left ventricle enlargement, (d) presence of high T(1) signal (fat) in the myocardium, and (e) location of high T(1) signal (fat) on a Likert scale with formatted responses.

RESULTS

Readers indicated that the Task Force ARVC/D cases had significantly more (chi(2) = 119.93, d.f. = 10, p < 0.0001) RV chamber size enlargement (58%) than either the suspected ARVC/D (12%) or no ARVC/D (14%) cases. When readers reported the RV chamber size as enlarged they were significantly more likely to report the case as ARVC/D present (chi(2)(= )33.98, d.f. = 1, p < 0.0001). When readers reported the morphology as abnormal they were more likely to diagnose the case as ARVC/D present (chi(2) = 78.4, d.f. = 1, p < 0.0001), and the Task Force ARVC/D (47%) cases received significantly more abnormal reports than either suspected ARVC/D (20%) or non-ARVC/D (15%) cases. There was no significant difference between patient groups in the reported presence of high signal intensity (fat) in the RV (chi(2) = 0.9, d.f. = 2, p > 0.05).

CONCLUSIONS

Reviewers found that the size and shape of abnormalities in the RV are key MR imaging discriminates of ARVD. Subsequent protocol development and multicenter trials need to address these parameters. Essential steps in improving accuracy and reducing variability include a standardized acquisition protocol and standardized analysis with dynamic cine review of regional RV function and quantification of RV and left ventricle volumes.

Delayed 99mTc-labeled erythrocyte scintigraphy in patients with lower gastrointestinal tract hemorrhage: effect of positive findings on clinical management

RATIONALE AND OBJECTIVES

This study was performed to determine whether the results of delayed technetium 99m (99mTc)-labeled erythrocyte scintigraphy for lower gastrointestinal tract hemorrhage resulted in different clinical management and outcome from that in cases in which the results of initial scintigraphy were negative or equivocal.

MATERIALS AND METHODS

The authors retrospectively reviewed all 398 99mTc-labeled erythrocyte scintigraphic studies obtained emergently for lower gastrointestinal tract hemorrhage at their institution between January 1, 1994, and December 7, 2001. Of 67 patients who underwent delayed studies, 37 had positive findings (average delay, 18.4 hours; range, 6-25 hours) and 30 had negative findings (average delay, 20.1 hours; range, 8-26 hours). Clinical management and outcome were compared between these two groups with respect to duration of hospitalization, volume of blood transfusion, mortality, and the percentage who were treated conservatively or referred for angiography, endoscopy, and/or surgery.

RESULTS

Patients with positive delayed studies were referred more frequently for angiography than those with negative studies (35% vs 0%, P < .01). There were no significant differences between patients with positive findings and patients with negative findings with respect to mortality (8% vs 0%, P < .32), transfusion requirements (5.6 vs 3.2 units, P < .20), hospitalization (9.5 vs 6.1 days, P < .11), the percentage treated conservatively (35% vs 37%, P < .90), or the percentages referred for endoscopy (49% vs 60%, P < .50) or for surgery (24% vs 17%, P < .64).

CONCLUSION

Positive findings at delayed scintigraphy resulted in increased referrals for angiography but had no other effect on clinical course or outcome of lower gastrointestinal tract hemorrhage.

Long-term venous complications after full-size and segmental pediatric liver transplantation

OBJECTIVE

To assess the long-term incidence of venous complications, including portal vein and hepatic vein stenoses, in both whole cadaveric and reduced-size cadaveric and living related liver transplants in a pediatric population, and to assess the therapeutic modalities in the treatment of these lesions.

SUMMARY BACKGROUND DATA

A shortage in appropriate-sized liver grafts for pediatric patients led to the use of segmental liver grafts, which became the predominant graft used in 325 of 600 (54%) transplants at the authors' institution. To assess the long-term impact of this strategy, the authors examined the incidence of late (>90 days) venous complications and the efficacy of all therapeutic interventions.

METHODS

Six hundred pediatric liver transplants were performed in 325 patients, with reduced-size or split (RSS; n = 207), living related (LRD; n = 118), or full-size cadaveric grafts (FS; n = 275) from 1988 to 2000. All transplants identified with late portal vein or vena caval stenoses or thromboses from a cohort of 524 grafts with survival greater than 90 days were reviewed for demographics, symptoms, therapeutic intervention, recurrence, morbidity, and mortality.

RESULTS

Fifty lesions were identified in 49 patients (38 portal vein and 12 hepatic vein-cava stenoses). Sex distribution was similar between portal vein and hepatic vein to cava, as was the mean patient age. Portal vein stenoses occurred in 32 LRD, 3 RSS, and 3 FS, while hepatic vein-cava stenoses occurred in 2 LRD, 8 RSS, and 2 FS. In the 38 portal vein stenoses, 9 had prior perioperative portal vein and/or 5 hepatic artery thrombectomies. Portal vein stenoses were identified after bleeding (17/38), ascites (6/38), increased liver function tests (6/38), splenomegaly (5/38), or screening ultrasound (4/38). Portal vein stenosis was associated most often with cryopreserved vein for portal conduits. Excluding conduits, the incidence of late portal vein complications was reduced to 1%. Lesions became symptomatic at a mean of 50.8 +/- 184.2 months posttransplant. All patients underwent venous angioplasty with a 66% (25/38) success rate, while 7 of 25 required further angioplasty and stenting. In the 13 unsuccessful angioplasties, 8 required surgical shunts for complete portal vein thrombosis. Recurrence occurred in 9 patients: all were amenable to stenting. Nine patients (24%) eventually died of sepsis (4) and surgical deaths at shunt or retransplant (5). Hepatic vein-cava stenoses occurred after a mean of 37.2 +/- 35.2 months, presenting with ascites (n = 10), increased liver function tests (n = 2), and splenomegaly (n = 2). All patients were diagnosed by venogram and managed by balloon dilatation alone (n = 6) or stented (n = 4), with an 80% (10/12) success, with two late recurrences amenable to repeat angioplasty or stenting. Long-term survival was 80% at 1 year.

CONCLUSIONS

The use of segmental grafts without venous conduits is not associated with a significant rate of long-term venous complication. When late venous complications do occur, venous angioplasty and stenting are both a safe and effective management modality. If necessary, venous angioplasty may be repeated with the placement of a stent. When this is required, care must be taken to place the stent in a position where the metallic object will not interfere with future surgical manipulations should retransplantation be necessary.

Endovascular intervention for the treatment of acute arterial gastrointestinal hemorrhage

The treatment of arterial gastrointestinal hemorrhage continues to evolve. Currently, most interventional radiologists approach bleeding both in the upper and lower gastrointestinal tract with intention to treat. Embolization has replaced local vasoconstrictive therapy as the catheter-based treatment of choice in many hospitals. Coaxial microcatheters have simplified embolotherapy and enabled lower gastrointestinal bleeding to be treated safely and effectively.

Subcutaneous chest ports via the internal jugular vein. A retrospective study of 117 oncology patients

PURPOSE

To review image-guided chest port insertion using the right internal jugular vein as the access site of choice.

MATERIAL AND METHODS

One hundred and eighteen subcutaneous chest ports were placed via the internal jugular vein in 117 patients with malignancies using both fluoroscopic and US guidance in interventional radiology suites.

RESULTS

The technical success rate was 100% with no procedural complications. Follow-up was obtained in all patients with total access days of 40,450 days (mean, 342.8 days). Premature catheter removal was required in 8 patients (6.8%, 0.20 per 1,000 access days) due to non-treatable complications: 2 catheter occlusions/malfunctions (1.7%, 0.05 per 1,000 access days), 1 catheter-related skin erosion (0.85%, 0.024 per 1,000 access days), and 5 infections (4.2%, 0.15 per 1,000 access days). Two symptomatic right upper extremity venous thromboses also occurred (1.7%, 0.05 per 1,000 access days) that were treated successfully with anticoagulation.

CONCLUSION

Image-guided placement of internal jugular vein chest ports has a high success rate and low complication rate compared with reported series of unguided subclavian vein port insertion. The internal jugular vein should be used as the preferred venous access site compared to the subclavian vein.

Subcutaneous chest ports via the internal jugular vein. A retrospective study of 117 oncology patients

PURPOSE

To review image-guided chest port insertion using the right internal jugular vein as the access site of choice.

MATERIAL AND METHODS

One hundred and eighteen subcutaneous chest ports were placed via the internal jugular vein in 117 patients with malignancies using both fluoroscopic and US guidance in interventional radiology suites.

RESULTS

The technical success rate was 100% with no procedural complications. Follow-up was obtained in all patients with total access days of 40,450 days (mean, 342.8 days). Premature catheter removal was required in 8 patients (6.8%, 0.20 per 1,000 access days) due to non-treatable complications: 2 catheter occlusions/malfunctions (1.7%, 0.05 per 1,000 access days), 1 catheter-related skin erosion (0.85%, 0.024 per 1,000 access days), and 5 infections (4.2%, 0.15 per 1,000 access days). Two symptomatic right upper extremity venous thromboses also occurred (1.7%, 0.05 per 1,000 access days) that were treated successfully with anticoagulation.

CONCLUSION

Image-guided placement of internal jugular vein chest ports has a high success rate and low complication rate compared with reported series of unguided subclavian vein port insertion. The internal jugular vein should be used as the preferred venous access site compared to the subclavian vein.

Devastating and fatal complications associated with combined vascular and bile duct injuries during cholecystectomy

HYPOTHESIS

Multiple centers have reported on bile duct injuries after cholecystectomy, but few have reported on the impact of concomitant vascular injuries.

DESIGN

Twenty-seven life-threatening complex injuries (CIs) (Bismuth level III, IV, or V or combined arterial-ductal injuries) were retrospectively compared with 22 noncomplex injuries (NCs) (level I or II).

SETTING

Tertiary referral center.

MAIN OUTCOME MEASURES

The incidence and level of biliary and arterial injuries and their resulting morbidity and mortality.

RESULTS

Bismuth classifications of all injuries were as follows: level I in 6 patients (12%), II in 19 (39%), III in 12 (24%), IV in 8 (16%), and V in 4 (8%). Diagnosis was based on peritonitis (n = 13 [27%]), endoscopic retrograde pancreatography (n = 19 [39%]), and percutaneous transhepatic cholangiography (n = 7 [14%]). Delayed referral was more common in levels I through IV (100 days) than in level V (15 days) (P<.001). Repairs were attempted in level IV (75%), III (67%), V (25%), and II (11%). Thirteen arterial injuries (26%) occurred irrespective of ductal injury level: I (n = 1), II (n = 3), III (n = 1), IV (n = 5), and V (n = 3). There was, however, a higher incidence of repairs before referral in the CI group (59% vs 5%; P<.01), with resulting higher rates of complication (70% vs 23%; P<.01). Five deaths occurred in the CI group vs 1 in the NC group (P =.14). In univariate analysis, the presence of arterial injury vs no arterial injury was a predictor of mortality (5 [38%] of 13 patients vs 1 [3%] of 36 patients; P<.001).

CONCLUSION

Bile duct injuries after cholecystectomy can be morbid and lethal with the incidence of arterial injury grossly underestimated.

Using pullback pressure measurements to identify venous stenoses persisting after successful angioplasty in failing hemodialysis grafts

OBJECTIVE

We used pullback pressure measurements to identify venous stenoses persisting after angioplasty of failing hemodialysis grafts.

MATERIALS AND METHODS

Fifty angioplasty procedures were performed in 32 patients with elevated venous pressures at dialysis. Grafts were initially evaluated on digital subtraction angiography, and all stenoses measuring greater than 50% on angiography underwent angioplasty. In successful cases (residual stenosis < 30%), pullback pressure measurements were obtained from the superior vena cava to the graft to identify hemodynamically significant (> 10 mm Hg) stenoses. These lesions were then treated with repeated angioplasty.

RESULTS

Hemodynamically significant stenoses with a gradient range of 10-27 mm Hg (mean, 16 mm Hg) were found in nine (18%) of 50 procedures. All gradients occurred at sites of previous angioplasty. Repeated angioplasty of these stenoses performed with larger angioplasty balloons reduced gradients to less than 3 mm Hg in six stenoses and to 5 mm Hg in three stenoses. In this subgroup, primary patency was eight (89%) of nine stenoses at 1 month and 2 months and five (56%) of nine stenoses at 6 months. Using life table analysis, we found that primary patency of the entire population was 84% at 1 month, 66% at 2 months, and 47% at 6 months. The mean time between interventions was 6 months, and the thrombosis rate was 0.32 per year.

CONCLUSION

Pullback pressure measurements are a useful adjunct to angiography to evaluate the hemodynamic results of angioplasty in patients with failing hemodialysis grafts.

Gender does not influence outcomes after iliac angioplasty

The current study was undertaken to evaluate the potential influence of gender on iliac angioplasty outcomes. All iliac angioplasty procedures performed at a tertiary care center from 1994 to 1999 were reviewed. One hundred four angioplasties with or without stenting were performed in 44 women (56 limbs) and 40 men (48 limbs). Age and atherosclerotic risk factors were similar in men and women. Iliac angioplasty was performed for limb salvage in 41% of patients (39% female vs. 44% male; p = 0.65). There were no differences in degree of stenosis, lesion length, or initial angioplasty site. Female iliac arteries were more likely to be occluded (21% vs. 6%; p = 0.03); mean iliac artery luminal diameter was smaller in women than in men (6.5 +/- 0.5 mm vs. 8.2 +/- 0.6 mm; p < 0.001). After a median follow-up of 13 months, there were no significant differences in 2-year primary patency, endovascular primary-assisted patency, or limb salvage rates between women and men. Despite having smaller iliac arteries and a higher incidence of arterial occlusion before treatment, women had outcomes similar to those of men after iliac angioplasty. The current results support the initial use of angioplasty to treat common and external iliac artery occlusive disease in both women and men.

Conventional and hydrocolonic US of the appendix with CT correlation performed by on-call radiology residents

RATIONALE AND OBJECTIVES

The purpose of this study was to assess the feasibility and accuracy of emergent hydrocolonic ultrasonography (US) performed by on-call residents in patients suspected of having appendicitis.

MATERIALS AND METHODS

Thirty-one patients with a clinically equivocal diagnosis of appendicitis were prospectively evaluated with conventional US, hydrocolonic US, and appendiceal computed tomography (CT). Midlevel radiology residents performed the US examinations while they were on call. Sensitivity, specificity, and accuracy for diagnosing appendicitis were calculated for conventional and hydrocolonic US by using clinical outcome as the standard. Results of US and CT of the appendix were also correlated. Residents recorded their diagnostic confidence for conventional and hydrocolonic US. All patients were able to hold the rectally administered contrast material until completion of both hydrocolonic US and appendiceal CT.

RESULTS

The sensitivity for detecting appendicitis with conventional US, hydrocolonic US, and appendiceal CT was 50%, 75%, and 100%, respectively. Specificity was 96%, 93%, and 93%, respectively. Identification of the normal and abnormal appendix improved from 13% (four of 31 patients) with conventional US to 35% (11 of 31 patients) with hydrocolonic US. The radiology residents' diagnostic confidence increased from 0.74 with conventional US to 0.83 with hydrocolonic US.

CONCLUSION

Hydrocolonic US is a feasible addition to conventional US examination for patients suspected of having appendicitis. It improves sensitivity, increases radiology residents' confidence, and is well tolerated by patients.

Superselective microcoil embolization of colonic hemorrhage

OBJECTIVE

We evaluated therapeutic microcoil embolization in a group of patients with severe colonic hemorrhage.

MATERIALS AND METHODS

Twenty-seven patients with severe colonic bleeding due to diverticular disease (n = 19), angiodysplasia (n = 6), cecal ulcer (n = 1), or unknown cause (n = 1) underwent attempted microcoil embolization (n = 25). Microcatheters were used in all procedures, and embolization was performed at the level of the vasa recta or the marginal artery of Drummond. Branches of the superior mesenteric artery were embolized in 12 patients, branches of the inferior mesenteric artery were embolized in 12 patients, and branches of both the superior and inferior mesenteric arteries were embolized in one patient.

RESULTS

Technical success was achieved in 93% (25/27) of the procedures. However, immediate hemostasis occurred in 96% (26/27) of patients because in one failed procedure, an occlusive dissection of the inferior mesenteric artery arrested bleeding. Three patients rebled within 24 hr. One patient was treated with endoscopic cauterization, and two patients underwent right hemicolectomy. One patient who underwent right hemicolectomy for rebleeding had ischemic changes found on pathologic analysis of the resected specimen, and a second patient who underwent embolization of branches of the superior and inferior mesenteric arteries developed bowel infarction requiring left hemicolectomy. Prolonged clinical success occurred in 81% (22/27) of patients.

CONCLUSION

Therapeutic microcoil embolization for severe colonic hemorrhage is an effective and well-tolerated procedure.

Comparison of balloon- and mushroom-retained large-bore gastrostomy catheters

OBJECTIVE

We conducted a retrospective study to evaluate two different types of percutaneous fluoroscopic gastrostomy procedures and catheters.

MATERIALS AND METHODS

Between July 8, 1999, and August 4, 2000, 80 percutaneous gastrostomy catheters were placed in 80 patients in 80 attempts. Twenty-five 16-, 18-, or 20-French balloon-retained catheters and 55 20-French mushroom-retained catheters were inserted. Typically, the type of catheters placed was based on operator preference. However, balloon-retained tubes were preferred for use in patients with obstructive head and neck or esophageal malignancies, and mushroom-retained catheters were preferred for use in demented or combative patients. Follow-up was conducted through chart reviews and telephone interviews. The technical success, procedural complications, and catheter complications were recorded. Chi-square statistical analysis was performed.

RESULTS

Technical success was 100% (80/80 patients), and no procedural complications occurred. In patients who received balloon-retained catheters, the major complication rate was 0%, the minor complication rate was 8% (2/25 patients), and the tube complication rate was 68% (17/25 patients). The following complications occurred: catheter dislodgment (n = 17), superficial cellulitis (n = 1), and bleeding gastric ulcer (n = 1). In patients who received mushroom-retained catheters, the major complication rate was 0%, the minor complication rate was 3.6% (2/55 patients), and the tube complication rate was 3.6% (2/55 patients). The following complications occurred: superficial cellulitis (n = 2), tube occlusion (n = 1), and peristomal tube leakage (n = 1). No significant differences in major or minor complications were found between the gastrostomy procedures. Balloon-retained catheters had a significantly higher rate of tube complications (p < 0.001).

CONCLUSION

Compared with balloon-retained catheters, mushroom-retained gastrostomy catheters are significantly more durable, more secure, and less prone to tube dysfunction. Mushroom-retained catheters should be the preferred type of gastrostomy catheter to place in patients whenever possible.

Metallic Stents Deployed in Synthetic Arteriovenous Hemodialysis Grafts

OBJECTIVE

The purpose of our study was to review the success of metallic stent treatment of intragraft stenoses in patients with synthetic arteriovenous hemodialysis grafts.

MATERIALS AND METHODS

Between May 1993 and May 1997, 19 metallic stents were placed in 11 patients (seven women, four men; age range, 41-83 years) to treat elastic intragraft stenoses or graft dissections. Before stent placement, all patients had experienced multiple episodes of graft thrombosis, had very limited vascular access for hemodialysis, and were considered poor surgical candidates.

RESULTS

The technical success rate was 100%, and there were no procedural complications. Using life-table analysis, we found primary patency to be 36% at 6 months after stent placement, 12% at 12 months, and 12% at 18 months. Secondary patency was 91% at 6 months after stent placement, 71% at 12 months, and 47% at 18 months. The mean and median patencies per intervention were 4.2 and 3.6 months, respectively. Mean and median secondary graft patencies were both 14 months (range, 3 days-32 months). Puncture through the stents occurred during dialysis, causing stent distortion and fracture. Eight stents had a linear fracture suggesting compression contributed to the stent distortion. No clinically evident complications related to stent placement occurred.

CONCLUSION

Metallic stent deployment can salvage access in synthetic arteriovenous grafts by alleviating intragraft stenoses. Patency of intragraft stents is similar to venous stents used to treat other hemodialysis-related stenoses; however, fracture of Wall-stents occurs with prolonged graft use, especially in areas of needle punctures.

Radiologic placement of implantable chest ports in pediatric patients

OBJECTIVE

We evaluated the technical success and complications associated with radiologic placement of implantable chest ports in children for long-term central venous access.

MATERIALS AND METHODS

Between May 1, 1996 and January 11, 2000, 29 chest ports were placed in 28 children (15 girls, 13 boys; age range, 2-17 years; mean, 11.7 years). The patient's right internal jugular vein was used for access in 93% (27/29) of the procedures, and a collateral neck vein was used as a conduit to recanalize the central veins in two procedures because of bilateral jugular and subclavian vein occlusion. All procedures were performed in interventional radiology suites. Both real-time sonography and fluoroscopy were used to guide venipuncture and port insertion. Follow-up data were obtained through the clinical examination and electronic review of charts.

RESULTS

Technical success was 100%. Fourteen percent of the catheters were removed prematurely, including one catheter removed 17 days after placement because the patient's blood cultures were positive for Candida albicans. No patients experienced hematoma, symptomatic air embolism, symptomatic central venous thrombosis, catheter malposition, or pneumothorax. The median number of days for catheter use by patients was 280 days (total, 9043 days; range, 17-869 days). The rate of confirmed catheter-related infection was 14% or 0.04 per 100 venous access days. One catheter occluded after 132 days.

CONCLUSION

In pediatric patients, radiologists can insert implantable chest ports using real-time sonographic and fluoroscopic guidance with high rates of technical success and low rates of complication.