Coronary arteriography performed by a physician assistant

Funding constraints and an oversupply of cardiologists mitigate against continued training of increasing numbers of cardiology fellows. In some institutions, the workload of the catheterization laboratory is an overriding factor. The ability of a physician assistant to perform some of this work was tested to determine if the number of fellows and the content of the fellowship training program could be uncoupled from the catheterization laboratory workload. Among the first 150 patients in whom coronary arteriography was performed by a physician assistant, no patient died or had a myocardial infarction or stroke. Two patients (1.3%) had minor complications: a retinal embolus and an infected puncture site. The complication rate in 150 consecutive cases performed by fellows was also 1.3%, a small myocardial infarction and a transient ischemic attack. Procedure times for the physician assistant and for the fellows were 41 +/- 13 and 44 +/- 18 minutes for preoperative patients and 62 +/- 24 and 70 +/- 20 minutes for postoperative patients. Corresponding fluoroscopy times were 11 +/- 5 and 12 +/- 7 minutes for the preoperative and 22 +/- 12 and 20 +/- 6 for postoperative patients. Only preoperative fluoroscopy times were statistically different (p = 0.02). Thus, substituting a physician assistant for a fellow to perform coronary arteriography is an option in institutions at which the number of studies exceeds the training needs of fellows.     

Transjugular liver biopsy: Comparison with percutaneous liver biopsy

Abstract A transjugular liver biopsy was performed on 60 patients. Specimens were successfully obtained from 57 (95%) patients. Specimens obtained from cirrhotic patients were frequently small-sized/fragmented. The wedge hepatic venous pressure and hepatic venous pressure gradient were higher in patients with small-sized/fragmented specimens than those with non-fragmented specimens (16.3 ± 6.4 vs 12.3 ± 4.9 and 10.9 ± 6.2 vs 7.3 ± 3.4 mmHg, P <0.05, respectively). During the same period of time, percutaneous liver biopsies were consecutively performed on 277 patients. The liver specimens by transjugular method were generally smaller (0.63±0.58 vs 1.50±0.86 cm, P <0.001) and more fragmented (63% vs 16%, P <0.01) than those obtained by percutaneous method. Biopsy specimens obtained for diagnosis by the former method were inadequate from 6 (10%) patients and by the latter route were inadequate from 7 (2%) patients. Subcapsular haematoma in one patient was associated with the transjugular liver biopsy. Minor complications occurred in three patients: neck haematoma in two and paroxysmal supraventricular tachycardia during the procedure in one. In comparison, percutaneous liver biopsy was followed by minor complications in 20 patients and major complications in four patients. It is concluded that transjugular liver biopsy is a safe, valuable and alternative procedure to obtain liver specimens, especially in patients who were contraindicated for percutaneous liver biopsy.     

Ultrasound-assisted percutaneous liver biopsy: superiority of the Tru-Cut over the Menghini needle for diagnosis of cirrhosis

A total of 1192 consecutive patients with diffuse liver disease were randomized to have percutaneous liver biopsy specimens taken with the Menghini or the Tru-Cut needle, to compare tissue yield, safety, and accuracy of the two needles for diagnosing cirrhosis. The sites of puncture were determined by prebiopsy ultrasound scans. Adequate samples were obtained from 94% with the Tru-Cut needle and from 79.2% with the Menghini needle (p less than 0.001). Accuracy in diagnosing cirrhosis was 89.5% for the Tru-Cut needle and 65.5% for the Menghini needle (p less than 0.05). Complication rates were very low and similar for both needles. Under these conditions, the Tru-Cut needle is superior to the Menghini needle for diagnosing cirrhosis.     

Complications of percutaneous liver biopsy

Complications that arose after 861 percutaneous liver biopsies performed from 1997 to 2001 were reviewed. They were analysed in relation to the underlying liver disease. Minor complications as the severe pain requiring intravenous analgetics administration occurred in 60 cases (6.9%) within two hours after the biopsy. Twelve cases (1.4%) of major complications as haemoperitoneum, haemo- or pneumothorax, severe hypotension due to vaso-vagal reaction, septic shock and puncture of another viscera were noted within 12 hours after procedures. Half of those complications and the most serious ones as haemoperitoneum occurred in cirrhotic patients and were connected with more than one needle pass. No biopsy-related deaths were observed.     

Midazolam sedation for percutaneous liver biopsy

Control of patient respiration is needed to safely perform percutaneous liver biopsy (PLB) and may be adversely affected by sedation. The purpose of this study was to evaluate the safety of PLB with intravenous midazolam and to evaluate patient acceptance of PLB with and without sedation. Two hundred seventeen consecutive patients underwent 301 percutaneous liver biopsies. One hundred fifty-one of the biopsies were done after the patients were sedated with intravenous midazolam immediately before the biopsy. The last 61 patients were questioned after the biopsy to evaluate the discomfort of the procedure, their memory of the procedure, and their willingness to undergo another PLB. The major complication rate was similar in the midazolam-treated (0.7%) and untreated (0.7%) groups. The midazolam-treated patients had a numerically lower mean pain score (1.5±0.4 vs 4.0±0.7) ( ±SEM) (P=0.07) and significantly lower mean memory score (4.8±0.7 vs 9.9±0.1) (P<0.01) than the untreated patients. The treated and untreated groups had similar mean willingness for repeat PLB scores (9.3±0.3 vs 9.1±0.6). We conclude that: (1) there is no increased risk of PLB with midazolam and (2) patients have less memory of the procedure with midazolam.This work was supported by a grant from the Burns Clinic Foundation.     

Outpatient percutaneous liver biopsy: Still a good option

ObjectiveTo assess security of “blind” percutaneous liver biopsy as an ambulatory procedure.Material and MethodsDefining inclusion criteria, surveillance protocol, data from ultrasonography done 6 h after procedure and complications.ResultsWe analysed 192 percutaneous liver biopsies done between 2000-2007. There were no major complications and only a small number of minor complications. There were no deaths related to the procedure.ConclusionIt is possible to perform percutaneous liver biopsy as an ambulatory procedure not expecting to find threatening complications.     

Statement on outpatient percutaneous liver biopsy

This document represents a consensus statement dealing with optimum patient care in a significant clinical area. The statement has been prepared by the Patient Care Committee of the American Gastroenterological Association with the advice of other experts and with peer review. As with all such guidelines, this should be interpreted in a nondogmatic manner, so as not to exclude other therapies or opinions in any particular situation. Based on present knowledge, limited at times, future modifications or other changes in this statement may be necessary.     

Hemobilia and other complications caused by percutaneous ultrasound-guided liver biopsy

Hemobilia accounts for approximately 3%of all major percutaneous liver biopsy complications,and rarely results from arterioportal fistula.We report a patient who suffered from four complications over 11 d after ultrasound-guided percutaneous liver biopsy:hemobilia,acute pancreatitis,acute cholecystitis,and multiple stomach ulcers.Digital subtraction angiography was done after consultation with doctors,and showed obvious arteriovenous fistula of the right liver.The hepatic artery was selected and embolized by spring orbs.The active bleeding was stopped after embolization of the hepatic artery.The patient was discharged home on day 12 after embolization and remained well.     

Sampling variability on percutaneous liver biopsy.

Sampling variability of liver biopsy was determined in three consecutive biopsy specimens obtained from each of 118 patients immediately prior to autopsy. No sampling variability was found for fatty liver, alcoholic hepatitis, nonspecific hepatitis, fulminant hepatitis, leukemic infiltrate, and venous congestion. Cirrhosis was diagnosed in 80% of cases at the first biopsy but in all cases after three biopsies. Chronic aggressive and chronic persistent hepatitis were diagnosed correctly in two of three cases each at the first biopsy, and in all cases after three biopsies. Metastatic carcinoma was detected in 46% of cases at the first biopsy and in 69% after three biopsies. Granulomas were missed once on the first biopsy, but found on a subsequent biopsy. The amounts of fat and fibrosis in the biopsy specimens often were not representative of the amounts present at autopsy.     

Use of midazolam for percutaneous liver biopsy

The standard procedure for percutaneous liver biopsy (PLB) involves only the use of local anesthesia. However, at times, a PLB can be frightening and uncomfortable. Such experiences often limit the willingness of patients to undergo subsequent follow-up biopsies. To investigate the ability of midazolam, a new water-soluble benzodiazepine preparation, noted for its potency, rapid onset of action, and amnestic qualities, to enhance patient acceptability of a follow-up liver biopsy, a sedative dose of midazolam (2 mg) or saline was administered immediately prior to and following a percutaneous liver biopsy. The initial dose was used to sedate the subject while not impairing patient cooperation during the biopsy procedure; the second dose was used to induce amnesia for the biopsy procedure. The next morning patient recollection for the preceding biopsy procedure and their willingness to undergo a future PLB were assessed using a questionnaire. Forty-one patients (ages 18–78) were randomized to receive either midazolam (N=21) or saline/ placebo (N=20) treatment. All PLBs were obtained with a Trucut needle. All subjects were given 2–5 cc of 2% xylocaine local anesthetic at the biopsy site. The questionnaire utilized evaluated patient experience of the procedure with respect to their recall, level of anxiety during the procedure, and willingness to undergo a repeat procedure. The data obtained revealed that those receiving midazolam admitted to experiencing less discomfort during the biopsy procedure (P<0.04) and had less memory for the procedure (P<0.001). More importantly, 79% of those receiving midazolam stated they would have little or no trouble undergoing a subsequent PLB as compared to 55% of those given saline. These data suggest that midazolam (1) reduces subject anxiety and perceived discomfort before and during PLB; (2) produces partial amnesia for the biopsy experience; and (3) thereby may improve patient acceptance of follow-up liver biopsies should such be required.This work was supported by grants AA06601 and AM32556.     

Complications of percutaneous liver biopsy in patients after liver transplantation

Percutaneous liver biopsy is an important diagnostic tool for the management of patients following liver transplantation. However, it may be associated with severe complications. To evaluate the incidence and type of complications after liver biopsy, we retrospectively analyzed 919 patients who underwent orthotopic liver transplantation (OLT) from September 1988 to May 1998. A total 3,670 biopsies were performed with ultrasound guidance and use of the Menghini needle (1.6 mm diameter). The biopsies were performed according to the protocol on the 7th postoperative day and one, three, five years after OLT, or when clinically indicated. Patients with severe coagulopathy (thrombocytes < 30,000/nl and Quick < 40%) were excluded from this protocol. Biopsy was complicated by bleeding in 13 of 919 patients (1.41%). The incidence of procedure related complications was 13 of 3,670 (0.35%). Five patients showed intrahepatic hematoma, four patients developed a hematothorax, three patients had intraabdominal bleeding and one patient suffered from hemobilia. Seven of 13 patients (53%) required surgical intervention (laparotomy four, thoracotomy two, retransplantation one). Graft dysfunction after liver transplantation requires rapid assessment and specific treatment to achieve good results. Percutaneous liver biopsy is an important procedure in the evaluation and identification of graft dysfunction such as acute rejection, hepatitis reinfection or toxic alterations. From our data we conclude that percutaneous liver biopsy is a safe procedure and advocate is liberal use.