Combined Antegrade Femoral Artery and Retrograde Popliteal Artery Recanalization for Chronic Occlusions of the Superficial Femoral Artery

PurposeTo evaluate the efficacy and safety of a dual femoral–popliteal approach in the supine position after failed antegrade recanalization attempts in chronic total occlusion (CTO) of the superficial femoral artery (SFA).Materials and MethodsFrom May 2011 to October 2012, 21 patients underwent dual femoral–popliteal recanalization for CTO of the SFA, with a mean lesion length of 87.4 mm ± 5.8. When contralateral antegrade recanalization of SFA occlusions via the common femoral artery could not be achieved, the occlusions were intrainterventionally accessed by retrograde approach via the popliteal artery, which was punctured anteriorly with gently flexed knee and crus extorsion. When the SFA had been recanalized, further angioplasty and stent placement procedures were completed via the femoral artery.ResultsA technical success rate of 100% (entailing puncture of the popliteal artery and SFA recanalization) was achieved, and no hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, or other complications developed. During a mean follow-up of 9.8 months ± 1.5, claudication severity, rest pain, and toe ulcers improved significantly. The pulse of the distal arteries, as well as the filling of the veins, could be distinctly felt. Ankle-brachial index changed from 0.48 ± 0.17 to 0.84 ± 0.11 at 1 year after intervention (P < .001), and patency rates at 1, 6, and 12 months after interventions were 100%, 80%, and 42%, respectively.ConclusionsA dual femoral–popliteal approach in the supine position is an alternative backup option after failed attempts at the antegrade approach for patients with proximal barriers in CTO or lesions with major extending collateral vessels.     

Percutaneous Metallic Stent Placement in Patients with Cancer Recurrence at Bilioenterostomy Site

PurposeTo investigate the outcomes of percutaneous metallic stent placement in patients with malignant bilioenterostomy obstruction and to assess the risk factors influencing stent patency.Materials and MethodsFrom August 2008 to January 2012, 53 patients with malignant bilioenterostomy obstructions were treated with percutaneous placement of biliary metallic stents; this included expanded polytetrafluoroethylene (ePTFE)–covered stent placement in 36 patients and uncovered stent placement in 17 patients.ResultsA total of 75 stents were successfully placed in 53 patients. No major complications occurred in any patients, and minor complications occurred in nine patients (17%). The mean serum bilirubin level, which was 3.6 mg/dL ± 0.7 before drainage, decreased significantly to 2.5 mg/dL ± 0.4 at 1 month after stent placement (P = .041). Successful internal drainage was achieved in 44 of the 53 patients (83%). Kaplan–Meier analysis showed a median overall survival time of 145 days (95% confidence interval, 100–190 d), a median stent patency time of 313 days (95% confidence interval, 46–580 d), and cumulative stent patency rates at 1, 3, 6, 9, and 12 months of 91%, 75%, 64%, 56%, and 45%, respectively. Multivariate Cox regression analysis showed that the use of uncovered stents (odds ratio, 2.924; P = .033) was the only significant independent factor associated with stent occlusion.ConclusionsPercutaneous metallic stent placement is a safe and effective method for the treatment of patients with malignant bilioenterostomy obstruction. Moreover, as uncovered stent placement is the only significant independent factor associated with stent occlusion, ePTFE-covered stent placement is preferable in these patients.     

SUPERA Interwoven Nitinol Stent Outcomes in Above-Knee IntErventions (SAKE) Study

PurposeTo report experience with the novel interwoven-wire self-expanding nitinol SUPERA stent (IDEV Technologies, Inc/Abbott Laboratories, Inc, Webster, Texas) for the treatment of severely diseased superficial femoral and popliteal arteries.Materials and MethodsConsecutive patients with severely diseased superficial femoral and popliteal arteries who received SUPERA stents (n = 80 patients [98 limbs]; mean age, 70.8 y; 80% male) were retrospectively identified. Patients were followed for an average of 14.3 months after intervention.ResultsTotal occlusions were present in 39% of the lesions, 21% had tissue loss, and 61% demonstrated calcification on fluoroscopy. Patients were prescribed dual antiplatelet therapy (aspirin and clopidogrel) for at least 30 days unless contraindicated, followed by aspirin alone indefinitely. The mean (± SD) lesion length was 143 mm (± 98). Based on need for clinical intervention, primary patency was 96.9% at 6 months and 85.8% at 12 months (Kaplan-Meier estimates). Assisted primary patency and secondary patency rates at 12 months were 96.8% and 100%, respectively. Ankle-brachial index increased from 0.60 at baseline to 0.83 at last follow-up (P < .001). No stent fractures were found by fluoroscopy inspection in 19 limbs (16 patients) that required reintervention.ConclusionsBased on experience with multiple operators at a single clinical center, the interwoven nitinol stent design provides a viable option for high-grade obstructive disease in the femoropopliteal artery.     

Percutaneous Closure Devices Do Not Reduce the Risk of Major Access Site Complications in Patients Undergoing Elective Carotid Stent Placement

PurposeTo examine the risk of femoral access site complications in patients undergoing carotid stent placement who were treated with a closure device compared with patients who were not treated with a closure device.Materials and MethodsA national, multihospital patient database, the Premier Perspective database, was used to identify patients hospitalized for carotid stent placement from 2006–2011. To reduce potential selection bias, a propensity score was generated for each patient using relevant clinical variables. Propensity score adjustment via 1:1 matching was performed on patients who did and did not receive a closure device. Primary outcomes were minor femoral access site complications and major complications requiring procedural intervention. Secondary outcomes included in-hospital mortality, stroke, and blood transfusion.ResultsAmong 12,287 patients who underwent carotid stent placement at 217 hospitals, 6,398 (52%) received a closure device on the day of the procedure. After propensity score matching, patients who received a closure device had a lower likelihood of minor access site complications (4.2% vs 5.4%; odds ratio = 0.77; 95% confidence interval, 0.55–0.93; P = .0071) compared with patients who did not receive a closure device; however, this difference was small and likely not clinically relevant. Both groups had a similar risk of major access site complications (P = .32), in-hospital mortality (P = .0520), and stroke (P = .31).ConclusionsUse of a closure device was not associated with a substantially reduced risk of major adverse events after carotid stent placement and was associated with only a small improvement in minor access site complications.     

Natural History of Tunneled Dialysis Catheters Placed for Hemodialysis Initiation

PurposeMore than 80% of hemodialysis recipients in the United States initiate hemodialysis with a tunneled dialysis catheter (TDC). Published data on TDC outcomes are based on a case mix of prevalent and incident TDCs. The present study analyzes factors affecting patency and complications of first TDCs placed in a large cohort of incident hemodialysis recipients.Materials and MethodsA prospective, computerized vascular access database was retrospectively queried to identify 472 patients receiving a first-ever TDC. Multiple-variable survival analysis was used to identify clinical parameters affecting TDC patency (from placement to nonelective removal) and infection (from placement to first episode of catheter-related bacteremia [CRB]).ResultsThe median patency of all TDCs was 202 days. Left-sided placement of TDCs was the only variable associated with inferior TDC patency (hazard ratio, 1.98; 95% confidence interval, 1.39–2.81; P < .0001). The 6-month TDC patency rate was 37% for left internal jugular vein (LIJV) catheters, versus 54% for right internal jugular vein (RIJV) catheters. The 1-year patency rate was 6% for LIJV catheters, versus 35% for RIJV catheters. Catheter patency was not associated with patient age, sex, race, hypertension, diabetes, coronary artery disease, peripheral vascular disease, cerebrovascular disease, or heart failure. The median time to the first episode of CRB was 163 days. None of the clinical variables was associated with TDC infection.ConclusionsTDCs are plagued by high rates of infection. RIJV TDCs should be used preferentially to maximize catheter patency.     

Treatment of Esophagopleural Fistulas Using Covered Retrievable Expandable Metallic Stents

PurposeTo evaluate the clinical efficacy of placement of covered retrievable expandable metallic stents for esophagopleural fistulas (EPFs).Materials and MethodsDuring the period 1997–2013, nine patients with EPF were treated using covered retrievable expandable metallic stents. The underlying causes of EPF were esophageal carcinoma (n = 6), lung cancer (n = 2), and postoperative empyema for Boerhaave syndrome (n = 1).ResultsTechnical success was achieved in eight patients (88.9%). In one patient, incomplete EPF closure was due to incomplete stent expansion. Clinical success, defined as complete EPF closure within 7 days, was achieved in five patients (55.6%). Overall fistula persistence (n = 1) or reopening (n = 4) occurred in five patients (55.6%) 0–15 days after stent placement. The causes of reopening were due to the gap between the stent and the esophagus (n = 3) or stent migration (n = 1). For fistula persistence or reopening, additional interventional management, such as gastrostomy, stent removal, or stent reinsertion, was performed. Stent migration occurred as a complication in one patient with EPF from a benign cause secondary to postoperative empyema. In the eight patients who died during the follow-up period, the mean and median survival times were 78.8 days and 46 days, respectively.ConclusionsPlacement of a covered expandable metallic esophageal stent for the palliative treatment of EPF is technically feasible, although the rate of clinical success was poor secondary to fistula persistence or reopening. Fistula reopening was caused by the gap between the stent and the esophagus or by stent migration, and additional interventional treatment was useful to ensure enteral nutritional support.     

Roll-in Experience from the Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) Study

PurposeTo describe the experience and results from the roll-in phase of the Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study.Materials and MethodsThe CORAL roll-in database was used to describe the baseline characteristics of the patients in the roll-in cohort, all of whom underwent renal artery stent placement; to evaluate CORAL site performance; to compare estimates of lesion (stenosis) severity made by site interventionalists with the central CORAL angiographic core laboratory readings; and to report outcomes after renal artery stent placement. During the roll-in phase, 239 patients (mean age, 70.2 y ± 9.0; 49% male) underwent renal artery stent procedures. Angiographic core laboratory analysis of renal arteriograms was done, and participants were followed at 1 month and 9 months.ResultsMajor angiographic complications were identified in 28 (13%) subjects. Kidney function remained unchanged at the short (2–4 weeks) follow-up interval. Improvement in systolic blood pressure with use of distal embolic protection devices (n = 161) did not show any clinical benefit over nonuse of such devices (n = 78) in this small series. At 9 months, there were significantly more endpoints reported by site in subjects with bilateral renal artery stenosis (P = .01) and prior history of stroke (P = .03).ConclusionsIn the roll-in phase of the CORAL study, a significant number of angiographic complications were identified. No effect was seen on estimated glomerular filtration rate after renal artery stent placement, but systolic blood pressure decreased significantly.     

Polydioxanone Biodegradable Stent Placement in a Canine Urethral Model: Analysis of Inflammatory Reaction and Biodegradation

PurposeTo investigate the inflammatory reaction and perform quantitative analysis of biodegradation after placement of a polydioxanone (PDO) biodegradable stent in a canine urethral model.Materials and MethodsPDO biodegradable stents were placed in the proximal and distal urethra of nine male mongrel dogs. The dogs were euthanized 4 weeks (group A; n = 3), 8 weeks (group B; n = 3), or 12 weeks (group C; n = 3) after stent placement. The luminal diameter of the stent-implanted urethra was assessed by follow-up retrograde urethrography, and histologic findings were obtained after the dogs were killed. Stents were removed after euthanasia, and their surface morphology and molecular weight were evaluated. Hematologic examination was performed to evaluate inflammatory reaction.ResultsStent placement was technically successful in all dogs. The average luminal diameter gradually decreased. The average number of epithelial layers (2.93 vs 4.42; P < .001), the average thickness of papillary projection (0.80 mm vs 1.28 mm; P < .001), and the average thickness of submucosal fibrosis (0.34 mm vs 0.49 mm ; P < .001) were significantly increased in group B versus group A. There were no significant differences between group B and group C. The average inflammatory cell infiltration did not differ significantly in the three groups. Molecular weight losses were 54% in group A and 84% in group B. In group C, PDO stents were completely decomposed.ConclusionsAn experimental study in a canine urethral model has demonstrated acceptable inflammatory reaction with gradually increasing granulation tissue but no luminal obstruction within 12 weeks.     

Long-term Outcome of Percutaneous Interventions for Hepatic Venous Outflow Obstruction after Pediatric Living Donor Liver Transplantation: Experience from a Single Institute

PurposeTo evaluate retrospectively the long-term outcome of percutaneous interventions for hepatic venous outflow obstruction (HVOO) occurring after pediatric living donor liver transplantation (LDLT).Materials and MethodsBetween October 1997 and December 2012, 48 patients (24 boys, 24 girls; median age, 6 y) who had undergone LDLT were confirmed to have HVOO using percutaneous hepatic venography and manometry. All patients underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, patency rates, stent placement, and major complications were evaluated.ResultsTechnical success was achieved in 92 of 93 sessions (99.0%) and in 47 of 48 patients (97.9%), and clinical success was achieved in 41 of 48 patients (85.4%). During the follow-up period (range, 1–182 mo; median, 51.5 mo), 28 patients were treated with a single session of balloon angioplasty, and 20 patients who developed recurrent stenosis were treated with repeated percutaneous interventions. The rates of primary and primary-assisted patency at 1, 3, 5, and 10 years after balloon angioplasty were 64%, 57%, 57%, and 52% (primary patency) and 98%, 95%, 95%, and 95% (primary-assisted patency). Of six patients with stent placement, four had no recurrent HVOO after the stent placement, but two developed recurrent stenosis. The stent migrated to the right atrium in one patient.ConclusionsPercutaneous interventions were effective treatments for HVOO after LDLT.     

Percutaneous Interventions in Failing “Necklace” Hemodialysis Grafts: Long-Term Outcomes

PurposeTo determine primary and secondary patency after percutaneous interventions for malfunctioning anterior chest wall (“necklace”) arteriovenous grafts (AVGs) for hemodialysis.Materials and MethodsRecords of six consecutive patients with subclavian artery–to–contralateral subclavian vein necklace AVGs were reviewed. Patients underwent 34 procedures, including 28 balloon angioplasties, 24 pharmacomechanical thrombolyses, and six stent placements. Patency intervals after graft placement and after first intervention were calculated.ResultsAfter 3 months, primary and secondary patency rates were 33% (two of six grafts) and 67% (four of six grafts), respectively. At 12 months, primary and secondary patency rates were 17% (one of six grafts) and 50% (three of six grafts), respectively. Median and mean primary patency times were 49 and 374 days, and median and mean secondary patency times were 293 and 575 days, respectively. The anatomic success rate of percutaneous interventions in malfunctioning AVGs was 97% (33 of 34 cases). At 3 years after implantation, the graft patency rate was 57% (four of seven grafts).ConclusionsPercutaneous interventions were effective at maintaining patency in failing necklace AVGs. However, their primary and secondary patency were inferior to those cited in extremity AVG guidelines set forth by the Society of Interventional Radiology.     

The 1,470-nm Bare-Fiber Diode Laser Ablation of the Great Saphenous Vein and Small Saphenous Vein at 1-Year Follow-up Using 8–12 W and a Mean Linear Endovenous Energy Density of 72 J/cm

PurposeTo demonstrate 1-year outcomes after low-energy endovenous laser ablation (EVLA) of incompetent saphenous veins with linear endovenous energy density (LEED) of 80 J/cm or lower with the use of a 1,470-nm diode laser.Materials and MethodsIncompetent saphenous veins in 236 patients (355 limbs; Clinical/Etiology/Anatomy/Pathophysiology classifications of C2–C4) were treated by EVLA with a bare-tipped 1,470-nm laser with LEED no greater than 80 J/cm (mean, 72.4 J/cm) and laser power of 8–12 W. Patients were evaluated clinically and with duplex ultrasonography at 1 week and 1, 3, 6, and 12 months after EVLA to assess the technical and clinical success and complication rates.ResultsIn the 355 limbs, the technical success rate was 100%. The great saphenous vein (GSV) remained occluded in all 229 limbs (100%) after 1 week, 202 of 203 limbs (99.5%) after 1 month, 157 of 158 limbs after 3 months (99.3%), all 99 limbs after 6 months (100%), and all 41 limbs after 1 year (100%). The small saphenous vein (SSV) remained occluded in all 103 limbs (100%) after 1 week, all 94 limbs (100%) after 1 month, 68 of 69 limbs (98.5%) after 3 months, 40 of 41 limbs (97.5%) after 6 months, and all 14 limbs after 1 year (100%). Two GSVs and two SSVs were recanalized and underwent repeated EVLA. No major complications occurred, although bruising (21% of cases), pain (15%), and paresthesia (4%) were observed.ConclusionsLow-energy EVLA with the use of a 1,470-nm laser with LEED of 80 J/cm or lower is an effective, safe, and technically successful option for the treatment of incompetent saphenous veins.     

Long-Term Outcome of Percutaneous Transhepatic Balloon Angioplasty for Portal Vein Stenosis after Pediatric Living Donor Liver Transplantation: A Single Institute’s Experience

PurposeTo evaluate retrospectively the long-term outcomes of percutaneous transhepatic balloon angioplasty performed for portal vein stenosis (PVS) after pediatric living donor liver transplantation (LDLT).Materials and MethodsBetween October 1997 and December 2013, of 527 pediatric patients (age < 18 y) who underwent LDLT in a single institution, 43 patients (19 boys, 24 girls; mean age, 4.1 y ± 4.1) were confirmed to have PVS at direct portography with or without manometry and underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, laboratory findings, manometry findings, patency rates, and major complications were evaluated. Follow-up periods after initial balloon angioplasty ranged from 5–169 months (mean, 119 mo).ResultsTechnical success was achieved in 65 of 66 sessions (98.5%) and in 42 of 43 patients (97.7%), and clinical success was achieved in 37 of 43 patients (86.0%). Platelet counts improved significantly. Of 32 patients undergoing manometry, 19 showed significant improvement of pressure gradient across the stenosis after percutaneous transhepatic balloon angioplasty. At 1, 3, 5, and 10 years after balloon angioplasty, the rates of primary patency were 83%, 78%, 76%, and 70%, and the rates of primary-assisted patency were 100%, 100%, 100%, and 96%. Two major complications subsequent to balloon angioplasty were noted: severe asthma attack and portal vein thrombosis.ConclusionsPercutaneous transhepatic balloon angioplasty is a safe and effective treatment with long-term patency for PVS after pediatric LDLT.     

Single-Center Experience in Prostate Fiducial Marker Placement: Technique and Midterm Follow-up

PurposeTo describe the technique, technical success, and complications of prostate fiducial marker implantation using transrectal ultrasound (US) guidance in patients undergoing image-guided radiation therapy.Materials and MethodsA retrospective review was performed of patients who underwent fiducial marker placement from January 2010–April 2013. In each case, gold markers were placed in the prostate using transrectal US guidance. Computed tomography (CT) was performed after the procedure and evaluated to confirm correct placement. Technical success, complications, and development of symptoms during radiotherapy were reviewed.ResultsTransrectal US–guided fiducial marker placement was performed on 75 patients (mean age, 62 y; range, 48–79 y) with a mean Gleason score of 7.25 (range, 6–10). Fiducial marker placement was confirmed in the intended location of the prostate or prostate bed for 297 of 300 markers (99%) on follow-up CT imaging. Two markers were placed just outside the prostate capsule, and one marker was lost. Complications included sepsis (n = 1; 1.3%), self-limiting perirectal or intraprostatic hemorrhage (n = 3; 4%), nausea (n = 1; 1.3%), transient hypotension (n = 1; 1.3%), epididymitis (n = 1; 1.3%), and urinary tract infection (n = 1; 1.3%). Complications were seen more frequently in patients with high tumor grade (P = .001) and in patients who developed metastatic disease (P = .01).ConclusionsTransrectal US–guided implantation of fiducial markers is technically feasible, is well tolerated, and has a good safety profile.     

Evaluating Patency Rates of an Ultralow-Porosity Expanded Polytetrafluoroethylene Covered Stent in the Treatment of Venous Stenosis in Arteriovenous Dialysis Circuits

PurposeTo evaluate the efficacy of an ultralow-porosity expanded polytetrafluoroethylene (ePTFE) covered stent in the treatment of autogenous arteriovenous fistula (AVF) and prosthetic arteriovenous graft (AVG) venous outflow stenoses.Materials and MethodsClinical and angiographic outcomes of 20 consecutive patients with arteriovenous dialysis circuits treated with the endoprosthesis were reviewed following institutional review board approval. Patients were followed routinely at 2 months and 6 months after stent placement, or earlier if clinically warranted. The primary endpoint was 2- and 6-month primary treatment area patency. Secondary endpoints included primary circuit patency, primary assisted patency, and secondary patency.ResultsEleven patients with AVFs and nine patients with AVGs were treated successfully with the covered stent. Primary treatment area patency rates were 85% ± 16 at both 2 months and 6 months. Primary circuit patency rates were was 65% ± 21 and 45% ± 22, respectively; primary assisted patency rates were 90% ± 13 and 85% ± 16, respectively; and secondary patency rates were 100% and 90% ± 13, respectively. Of the three cases of lost primary treatment area patency, two developed thrombosis and one developed recurrent stenosis. No significant differences were found between patients with AVFs and AVGs.ConclusionsData from this preliminary study suggests that the ultralow-porosity ePTFE covered stent may be a clinically viable option for treatment of venous outflow stenoses in arteriovenous vascular access circuits.     

Know Your Market: Use of Online Query Tools to Quantify Trends in Patient Information-seeking Behavior for Varicose Vein Treatment

PurposeTo analyze Internet search data to characterize the temporal and geographic interest of Internet users in the United States in varicose vein treatment.Materials and MethodsFrom January 1, 2004, to September 1, 2012, the Google Trends tool was used to analyze query data for “varicose vein treatment” to identify individuals seeking treatment information for varicose veins. The term “varicose vein treatment” returned a search volume index (SVI), representing the search frequency relative to the total search volume during a specific time interval and region. Linear regression analysis and Kruskal-Wallis one-way analysis of variance were employed to characterize search results.ResultsSearch traffic for varicose vein treatment increased by 520% over the 104-month study period. There was an annual mean increase of 28% (range, −18%–100%; standard deviation [SD], 35%), with a statistically significant linear increase in average yearly SVI over time (R² = 0.94, P < .0001). All years showed positive growth in mean SVI except for 2008 (18% decrease). There were statistically significant differences in SVI by month (Kruskal-Wallis, P < .0001) with significantly higher mean SVI compared with other months in May (190% increase; range, 26%–670%; SD, 15%) and June (209% increase; range, 35%–700%; SD, 20%). The southern United States showed significantly higher search traffic than all other regions (Tukey-Kramer, P < .00001).ConclusionsThere have been significant increases in Internet search traffic related to varicose vein treatment in the past 8 years. Reflected in this trend is an annual peak in search traffic in the late spring months with an overall geographic bias toward southern states. Rigorous analysis of Internet search queries for medical procedures may prove useful to guide the efficient use of limited resources and marketing dollars.     

Relationship of Thrombus Length to Number of Stent Retrievals,Revascularization, and Outcomes in Acute Ischemic Stroke

PurposeTo study the relationship between intracranial thrombus length and number of stent retrievals, revascularization rates, and functional outcomes in stroke.Materials and MethodsRetrospective data were collected from consecutive cases of stroke treated with endovascular procedures at a single institution from April 2012–September 2013. Thrombus length was measured in the anterior cerebral circulation. Demographic and clinical details; involved vessels; and procedural details, including the number of devices used and number of retrievals used for each device, were recorded. Revascularization rates and 90-day functional outcomes were recorded.ResultsData regarding the length of thrombus in the anterior cerebral circulation were available for 28 patients. There was no significant association between thrombus length and number of stent retrievals (P = .3780), final thrombolysis in cerebral infarction (TICI) score (P = .4835), or 90-day modified Rankin Scale score (P = .4146). There was a significant difference (P = .0280) between number of retrievals and final TICI score, with lower number of retrieval passes corresponding to higher final TICI scores.ConclusionsThe data suggest no relationship between thrombus length and number of stent retrievals, final TICI score, or functional neurologic outcomes at 90 days in stent retrieval thrombectomy for acute ischemic stroke. These results do not support a predictive value for thrombus length quantification in the evaluation of stroke.     

Fluoroscopic versus Laparoscopic Implantation of Peritoneal Dialysis Catheters: A Retrospective Cohort Study

PurposeA previous clinical trial showed that radiologic insertion of first peritoneal dialysis (PD) catheters by modified Seldinger technique is noninferior to laparoscopic surgery in patients at low risk in a clinical trial setting. The present cohort study was performed to confirm clinical effectiveness of radiologic insertion in everyday practice, including insertion in patients with expanded eligibility criteria and by fellows in training.Materials and MethodsBetween 2004 and 2009, 286 PD catheters were inserted in 249 patients, 133 with fluoroscopic guidance in the radiology department and 153 by laparoscopic surgery. Survival analyses were performed with the primary outcome of complication-free catheter survival and secondary outcomes of overall catheter survival and patient survival. Outcomes were assessed at last follow-up, as long as 365 days after PD catheter insertion.ResultsIn the radiologic group, unadjusted 365-day complication-free catheter, overall catheter, and patient survival rates were 22.6%, 81.2%, and 82.7%, respectively, compared with 22.9% (P = .52), 76.5% (P = .4), and 92.8% (P = .01), respectively, in the laparoscopic group. Frequencies of individual complications were similar between groups. Adjusting for patient age, comorbidity, and previous PD catheter, the hazard ratio (HR) for catheter complications by radiologic versus laparoscopic insertion is 0.90 (95% confidence interval [CI], 0.62–1.31); the HR for overall catheter survival is 1.25 (95% CI, 0.59–2.65); and that for death is 2.47 (95% CI, 0.84–7.3).ConclusionsRadiologic PD catheter insertion is a clinically effective alternative to laparoscopic surgery, although there was poorer long-term survival with radiologic catheter placement, possibly because of preferential selection of radiologic insertion for more frail patients.     

High-Frequency Jet Ventilation under General Anesthesia Facilitates CT-Guided Lung Tumor Thermal Ablation Compared with Normal Respiration under Conscious Analgesic Sedation

PurposeTo determine whether technical difficulty of computed tomography (CT)–guided percutaneous lung tumor thermal ablations is altered with the use of high-frequency jet ventilation (HFJV) under general anesthesia (GA) compared with procedures performed with normal respiration (NR) under conscious sedation (CS).Materials and MethodsThermal ablation treatment sessions performed with NR under CS or HFJV under GA with available anesthesia records and CT fluoroscopic images were retrospectively reviewed; 13 and 33 treatment sessions, respectively, were identified. One anesthesiologist determined the choice of anesthesiologic technique independently. Surrogate measures of procedure technical difficulty—time duration, number of CT fluoroscopic acquisitions, and radiation dose required for applicator placement for each tumor—were compared between anesthesiologic techniques. The anesthesiologist time and complications were also compared. Parametric and nonparametric data were compared by Student independent-samples t test and χ² test, respectively.ResultsPatients treated with HFJV under GA had higher American Society of Anesthesiologists classifications (mean, 2.66 vs 2.23; P = .009) and smaller lung tumors (16.09 mm vs 27.38 mm; P = .001). The time duration (220.30 s vs 393.94 s; P = .008), number of CT fluoroscopic acquisitions (10.31 vs 19.13; P = .023), and radiation dose (60.22 mGy·cm vs 127.68 mGy·cm; P = .012) required for applicator placement were significantly lower in treatment sessions performed with HFJV under GA. There was no significant differences in anesthesiologist time (P = .20), rate of pneumothorax (P = .62), or number of pneumothoraces requiring active treatment (P = .19).ConclusionsHFJV under GA appears to reduce technical difficulty of CT-guided percutaneous applicator placement for lung tumor thermal ablations, with similar complication rates compared with treatment sessions performed with NR under CS. The technique is safe and may facilitate treatment of technically challenging tumors.     

Institution of a Hospital-Based Central Venous Access Policy for Peripheral Vein Preservation in Patients with Chronic Kidney Disease: A 12-Year Experience

PurposeTo describe the implementation of nursing-based venous access team (VAT) and standardized interventional radiology (IR) protocols in accordance with Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines to provide central venous access while preserving peripheral veins in patients with chronic kidney disease (CKD).Materials and MethodsReview of peripherally inserted central catheter (PICC) and small-bore central catheter (SBCC) referral and placement data from VAT and IR databases was conducted over a 12-year period. SBCC referral was automatic for patients with creatinine levels ≥ 3 mg/dL or a renal transplant regardless of creatinine level unless dialysis was not planned. All SBCC insertions, regardless of referral source, were identified and reviewed, and SBCC placements prompted by K/DOQI PICC contraindication were identified. Catheter types, indications, access sites, technical success, and complications were ascertained.ResultsA total of 35,781 requests for PICC placement were made to the VAT; 1,889 (5%) were referred to IR for SBCC placement per institutional policy, and 2,200 SBCCs were attempted or newly placed during this period, 1,879 (85%) based on K/DOQI contraindications. Primary indication for SBCC placement was antibiotic therapy (59%). Access sites included right internal jugular vein (IJV) (70%), left IJV (24%), right external jugular vein (EJV) (3%), left EJV (2%), right common femoral vein (CFV) (0.3%), and left CFV (0.2%). Technical success rate of SBCC insertion was 99%. Six minor (0.3%) and three major (0.1%) complications occurred.ConclusionsAutomatic referral for SBCC placement in patients with CKD via VAT and IR protocols may eliminate PICC placement and thereby protect peripheral veins needed for hemodialysis. SBCC placement has high technical success and low complication rates.     

Incidence of Pulmonary Cement Embolism after Real-Time CT Fluoroscopy–guided Vertebroplasty

PurposeTo prospectively evaluate the incidence of pulmonary cement embolism (PCE) after vertebroplasty in procedures performed under real-time computed tomographic (CT) fluoroscopy guidance.Materials and MethodsA total of 85 vertebroplasties were performed in 51 consecutive patients (31 women, 20 men; mean age, 71.9 y; range, 48–92 y) in 51 sessions. The needle was inserted with guidance from intermittent single-shot CT scans, and intermittent CT fluoroscopy was used during cement injection only. To reduce the risk of extravertebral or extraosseous leakage, several procedures (cement injection stopping/slowing, needle position changes) were employed. The chest and treated bone were scanned immediately after vertebroplasty. These CT images included the entire thorax as well as the treated vertebrae.ResultsNo cement emboli were observed on CT after vertebroplasty. After 85 vertebroplasty procedures, 44 extravertebral leaks were detected. Epidural leaks were observed on CT in six treated vertebrae (7%), in 12 cases in the anterior external venous plexus (14.1%), in five in the azygos vein (5.8%), in 19 in the disc space (22%), and in two in the foraminal space (2.3%). On a per-patient basis, the odds of leaks increased with the number of vertebroplasties (P = .05) and the volume of cement used (P = .0412). There was also a higher probability of leak (P < .05) for osteoporotic vertebral compression fractures (67.9%; 95% confidence interval, 47.7%–84.1%) than osteolytic spinal metastases (34.8%; 16.4%–57.3%).ConclusionsPCE did not occur after vertebroplasty under CT fluoroscopy guidance. Further larger prospective vertebroplasty studies are needed to compare the rates of PCE for CT versus conventional fluoroscopic guidance.