Investigation of antibiotic prophylaxis usage for vascular and nonvascular interventional procedures

PURPOSE

To investigate current antibiotic prophylactic usage for arteriography, angioplasty, vascular stent placement, transjugular intrahepatic portosystemic shunt placement (TIPS), tunneled-port placement, inferior vena cava (IVC) filter placement, biliary drainage, genitourinary drainage, abdominal drainage, and enteral tube placement with an aim to better clarify indications and regimens for prophylaxis.

METHODS

A questionnaire regarding antibiotic prophylactic usage was sent to 2,039 members of the Society of Cardiovascular and Interventional Radiology (SCVIR). There were 401 respondents. Replies were evaluated for frequency and indications of prophylaxis, specific prophylaxis used, and clarity of indications for prophylaxis.

RESULTS

A majority of responders never used prophylaxis for arteriography, angioplasty, vascular stent placement, IVC filter placement, abdominal drainage, and enteral tube placement. Infective complication rates from nonusage ranged between 1% and 15%. Approximately 45% always used prophylaxis for tunneled-port placement and TIPS with a 13%-16% infective complication rate among nonusers. In contrast, a majority of responders always used prophylaxis for biliary and genitourinary drainage, with a 40%-58% infective complication rate in nonusers. More than 70% of responders believed that the indications for prophylaxis were not clear for arteriography, angioplasty, vascular stent placement, tunneled-port placement, TIPS, IVC filter placement, and enteral tube placement, and in contrast, that the indications for prophylaxis for biliary and genitourinary drainage were clear. Fifty-one percent of responders believed that indications for prophylaxis for abdominal drainage were clear.

CONCLUSIONS

Indications for antibiotic prophylaxis are not clear to interventionalists for a large number of vascular and nonvascular interventional procedures. Prophylaxis appears unnecessary for routine arteriography, angioplasty, IVC filter placement, vascular stent placement, or enterostomy tube placement. Antibiotic prophylaxis is warranted for TIPS and tunneled-port placement. Conversely, indications for antibiotic prophylaxis are clear to interventionalists for biliary and genitourinary drainage procedures. Routine prophylaxis remains warranted for both.

Value of radiography in diagnosing complications of cardioverter defibrillators implanted without thoracotomy in 437 patients

OBJECTIVE

This study evaluated the usefulness of radiography in assessing the frequency and cause of complications of nonthoracotomy-implanted cardioverter defibrillators.

MATERIALS AND METHODS

Between May 1992 and December 1995, 437 consecutive patients at our institution underwent cardioverter defibrillator placement. Routine follow-up included external device testing at 6 weeks after placement and every 3 months thereafter. Chest radiographs were obtained immediately after placement, annually, and at the time of any suspected complication. Retrospective review of radiographs and medical charts was done for all patients with clinical complications.

RESULTS

Forty-five complications (10%) were clinically diagnosed: lead or patch fracture in fifteen (33%) patients, electric lead dysfunction in eight (18%), infection in eight (18%), lead retraction in six (13%), patch fold in two (5%), hematoma in two (5%), and other complications in four (9%) patients. Eighteen complications (40%) were radiographically evident. Lead retraction, hematoma, patch fold, patch migration, and the twiddler syndrome were radiographically confirmed in 100% of cases. The average time for these complications to be detected was 68 days; 92% were detected within 23 days. Conversely, only four (27%) lead fractures, one (13%) electric lead dysfunction, and one (13%) infection were radiographically confirmed. These latter complications were discovered an average of 579 days after cardioverter defibrillator placement.

CONCLUSION

Radiography plays a secondary role in the diagnosis of cardioverter defibrillator complications and is particularly limited beyond 1 month after placement. Radiographs may be helpful in the first month after placement because early complications are the most radiographically apparent.

MR portography: preliminary comparison with CT portography and conventional MR imaging

Magnetic resonance (MR) imaging with arterial portography (MRAP) was compared with computed tomography with arterial portography (CTAP) and conventional MR imaging for preoperative evaluation of hepatic masses in eight patients (nine studies). Twenty contiguous, 10-mm-thick-section CTAP images were obtained. MR imaging included T1- and T2-weighted spin-echo and fast multiplanar SPGR (spoiled gradient-recalled acquisition in the steady state) techniques. For MRAP, 0.1 mmol/kg gadopentetate dimeglumine was injected into the superior mesenteric artery. Portographic-phase, 8-mm-thick-section, axial SPGR images were first obtained, followed by "systemic phase" SPGR images. Lesions were seen best on the portographic-phase MRAP images and were less conspicuous on the systemic-phase MRAP, CTAP and conventional MR images. Of 19 visualized lesions, 18 were seen with MRAP; however; five subcentimeter lesions seen with MRAP were not seen with conventional MR imaging or CTAP. Systemic recirculation of iodinated contrast material from the bolus and from previous angiography is a potential limitation of CTAP. For both CTAP and MRAP, optimal results are expected if all images are obtained during a single breath hold, within seconds of the onset of contrast agent administration.

Gastric stump lymphoma

Lymphoma occurring in the post-operative stomach would appear to be very rare with only five previously recorded cases. In three of these, focal lymphoid hyperplasia or pseudolymphoma had been found at the time of the original ulcer surgery, or at subsequent biopsies of the gastric stump or anastomotic sites. These latter three cases developed lymphoma within 11 years of the ulcer surgery as against the 20 years or longer generally found in cases of gastric stump carcinoma. Two cases presenting with gastric stump lymphoma approximately 20 years after Billroth 2 partial gastrectomy are reported. In neither of these two cases, nor in the other two patients previously recorded with post-operative gastric lymphoma 20 or more years following gastric surgery, was luminal focal lymphoid hyperplasia reported at the time of the original gastric surgery. It is postulated that these two small groups may have developed lymphoma due to differing malignant stimuli.

Arterial abnormalities following orthotopic liver transplantation: arteriographic findings and correlation with Doppler sonographic findings

OBJECTIVE

We studied the findings on conventional arteriography in patients who had suspected graft ischemia after orthotopic liver transplantation to determine the value of a single Doppler signal in predicting these lesions.

MATERIALS AND METHODS

We retrospectively reviewed selective visceral arteriograms with abnormal findings from 20 adults who had suspected graft ischemia after orthotopic liver transplantation and a single Doppler signal from the hepatic artery at the porta hepatis on sonograms obtained before arteriography. Arteriographic abnormalities were categorized according to morphology and location as follows: stenosis of recipient's hepatic artery, occlusion or stenosis of the transplanted extrahepatic artery, and occlusion or stenosis of the transplanted intrahepatic artery.

RESULTS

Twenty-three arteriographic abnormalities were detected: four recipient celiac axis stenoses, seven extrahepatic occlusions, nine extrahepatic stenoses, and two occlusions and one stenosis of the transplanted intrahepatic artery. Six of the extrahepatic occlusions, two of the extrahepatic stenoses, and none of the recipient artery stenoses or the intrahepatic occlusions or stenoses were correctly diagnosed on the basis of Doppler findings. One patient with both an extrahepatic stenosis and an extrahepatic occlusion was thought to have an intrahepatic occlusion, and two patients with mild (< 50%) extrahepatic stenoses and one with an intrahepatic occlusion were thought to have an extrahepatic occlusion.

CONCLUSION

A wide spectrum of abnormalities in the recipient's celiac axis or the transplanted arteries that may be associated with graft ischemia after orthotopic liver transplantation are often not detected or findings are misinterpreted on routine Doppler examination. In patients with suspected graft ischemia, visceral arteriography should be performed promptly to confirm the diagnosis and to allow early intervention.

Role of selective arteriography in the diagnosis of a ruptured middle colic artery aneurysm

A case of a ruptured middle colic artery is reported. The diagnosis was initially overlooked and eventually made by selective arteriography. Aneurysms of visceral arteries are rare and rupture of them even more infrequent. Awareness of this potentially fatal and treatable entity should enable early detection by selective visceral arteriography. The roles of embolization and surgery in the management of visceral aneurysms are discussed.