A 'split-away technique' for percutaneous nephrostomy

The currently used techniques for nephrostomy sometimes fail to advance the drainage catheter through the nephrostomy track into the renal pelvis. To solve this problem a new technique has been developed. The improvement with this technique is the dilatation of the track with polypropylene dilators and a split-away sheath. The split-away sheath is threaded on the largest dilator. When the dilator is removed the drainage catheter is coaxially passed through the split-away sheath into the renal pelvis. The sheath is then removed. The technique has been used successfully in 32 patients without complications.     

Low-dose streptokinase for occluded Hickman catheters

In 14 patients, 16 episodes of occluded Hickman catheters were evaluated by contrast venography. In 13 instances, a fibrin sheath occluding the distal catheter was observed. A mechanical problem was responsible for occlusion in three catheters. Low-dose streptokinase effectively restored lumen patency in 12 catheters (92%) occluded by a fibrin sheath.     

Percutaneous nephrolithotomy through an intercostal approach

During a 5-year period percutaneous nephrolithotripsy through an intercostal space was performed in 56 of 231 procedures. Minimal thoracic complications were seen in 3 of 53 patients with 11th intercostal space tracts into a lower, middle, or upper pole calyx. A working sheath and a pyelostomy drainage catheter were used in all these cases. Hydro- and pneumothorax requiring treatment occurred in 2 of 3 patients with a 10th intercostal space approach into an upper pole calyx combined with improper use of the working sheath and/or the pyelostomy catheter. Review of the literature also indicates that an intercostal approach appears safe when performed via the 11th intercostal space into a lower or middle pole calyx. Thoracic complications occurred when punctures were made towards an upper pole calyx or above the 11th rib. The complications may be limited by identifying the posterior inferior lung border by fluoroscopy during puncture, and performing it under general anesthesia with controlled breath-holding. The use of a working sheath to seal the pleural opening during the procedure and an efficient pyelostomy drainage catheter to allow free drainage of urine and to tamponade the tract postoperatively are also recommended.     

Noninfectious complications of long-term central venous catheters: radiologic evaluation and management

During a 5-year period, 416 long-term double-lumen central venous catheters were inserted into 288 patients. In these patients, 106 catheter venograms and nine upper extremity venograms were performed. All studies were reviewed retrospectively to determine the nature and prevalence of noninfectious catheter-related complications, to evaluate the efficacy and safety of streptokinase therapy, and to determine if catheter venography should be performed before streptokinase therapy is started. Noninfectious complications occurred in 66 (23%) patients. Complications that resulted in catheter malfunction included deposition of fibrin around the catheter tip (formation of a fibrin sheath) in 44 (57%) instances, a constricting suture in six, abutment of the catheter tip against the venous wall in eight, catheter leak in two, and migration of the catheter completely out of the vein in three. Venous thrombosis developed in 11 patients. Treatment with low doses of streptokinase successfully relieved catheter obstruction due to a fibrin sheath in 27 (87%) of 31 instances. No bleeding complications occurred. Five patients had malpositioned catheters in the azygous, axillary, or internal jugular veins. By use of a deflector wire or snare inserted via the femoral vein, all five were relocated successfully into the superior vena cava. Recognition of noninfectious complications associated with use of long-term catheters is important for institution of appropriate therapy, which in many instances obviates removal of the catheter. Formation of a fibrin sheath in only 57% of cases of catheter malfunction provides an argument for performing catheter venography before streptokinase therapy is started. Low-dose streptokinase therapy for long-term central venous catheters occluded by a fibrin sheath is safe and efficacious.     

Petrosal sinus catheterization in sheep. Development of a method for sampling hormonal output from the pituitary

A relatively nontraumatic method has been developed to catheterize the petrosal sinus (PS) of sheep, via the internal jugular vein (IJV), using a percutaneous approach monitored by fluoroscopy. Preselection of suitable animals was facilitated by injecting radiopaque material through a cannula inserted into the deep facial vein to display the venous drainage from the pituitary. Further injections, via the same cannula, were later used to assist in the maneuvering of the catheter/wire guide combination as it passed up the IJV. To confirm catheter placement, plasma samples, collected simultaneously from PS and external jugular vein (EJV), were analyzed for growth hormone (GH). GH concentrations were consistently higher in the PS samples than in those found in the EJV, and more GH pulses were seen in PS samples than in the general circulation.     

Ultrasound guidance for pericardiocentesis

Sonographic guidance with 41 punctures and 38 catheterizations was employed in 68 patients. The approach was either intercostal or subxiphoid. Most punctures were performed with a 1.4-mm-thick plastic-sheathed cannula after local anesthesia. Complications were observed in 7 patients. In one patient a catheter introduced with a movable core-type guidewire pierced the right ventricle wall with uneventful recovery after surgery. Intercostal drainage caused pleural pain in 2 patients, and in 2, leakage to the pleural space. Two patients with heart transplants had severe bradycardia and drop of blood pressure, one after needle drainage and the other during guidewire manipulation. Direct monitoring generally ensures a correct position of the instruments and hazards to adjacent organs can be avoided. In small effusions a simple needle aspiration with a plastic-sheathed cannula is safer than catheter drainage.     

Balloon-assisted coiling through a 5-French system

Introduction We present a catheter technique that utilizes a 5F system for the purpose of balloon-assisted coiling in the setting of intracranial aneurysms. Methods A standard 5F short sheath is placed in the common femoral artery, and a 5F diagnostic catheter is placed through the sheath and used for selective vessel angiography. When endovascular intervention is pursued, the diagnostic catheter is placed in the appropriate vessel and systemic heparinization is ensured. Over an exchange length wire, the 5F vertebral catheter and 5F short sheath are exchanged for a 5F Shuttle (Cook) sheath. We then routinely place a 10, 14 or 18 microcatheter over an appropriately gauged microguidewire into the aneurysm. As needed, balloon catheters are then placed across the neck of the aneurysm for remodeling purposes. During the course of the procedure, control angiography is performed through the Shuttle sheath. Following the placement of coils, the microcatheter and balloon catheter are removed and a final biplane image is obtained via the 5F Shuttle sheath. Results This technique has been employed in 15 patients who required balloon-assisted coiling of an intracranial aneurysm. There were no technical difficulties or arterial access site complications from the procedures. Catheter mobility and torque were not affected, nor was the quality of our imaging. Conclusion We conclude that this small-diameter system provides ample “room” for catheter placement and interventional treatment while reducing the known risks of postprocedural complications. Angiographic images remain excellent and are comparable to those obtained by larger catheters.     

Association Between Disruption of Fibrin Sheaths Using Percutaneous Transluminal Angioplasty Balloons and Late Onset of Central Venous Stenosis

To compare the rates of central venous stenosis in patients undergoing hemodialysis who underwent disruption of fibrin sheath with percutaneous transluminal angioplasty balloons and those who underwent over-the-wire catheter exchange. This study is a retrospective review of 209 percutaneous transluminal angioplasty balloon disruption and 1304 over-the-wire catheter exchange procedures performed in 753 patients. Approval from the Human Investigations Committee was obtained for this study. Up to 10-year follow-up was performed. A χ² test was used to compare the rates of central venous stenosis after balloon disruption versus catheter exchange. A t-test was used to compare time to central venous stenosis development. Of the 753 patients in the study, 127 patients underwent balloon disruption of fibrin sheath and 626 had catheter exchange. Within the balloon disruption group, 18 (14.2%) of 127 patients subsequently developed central venous stenosis, compared with 44 (7.0%) of 626 in the catheter exchange group (P < 0.01, χ² test). Time to central venous stenosis development was approximately 3 years in both groups and not significantly different (1371 and 1010 days, P = 0.20). A total of 25.2% of patients in the balloon disruption group had four or more subsequent catheter exchanges, versus 12.6% in the catheter exchange group (P < 0.01, χ² test). In conclusions, there is a possible association between percutaneous transluminal angioplasty balloon disruption of fibrin sheath and late-onset central venous stenosis. Because venography was not routinely performed in catheter exchange patients, future randomized studies are necessary to confirm these findings.     

Management of visceral interventional radiology catheters: a troubleshooting guide for interventional radiologists.

Visceral interventional radiology catheters can be difficult to exchange or remove for a variety of reasons. These reasons include exit of the guide wire through the side holes of the catheter, blockage of the catheter, difficulty unlocking the pigtail, retention of the string after catheter removal, migration of the string ahead of the guide wire, catheter fracture, and snaring of an adjacent stent by the pigtail. Secure fixation of the catheter to the skin is important. A technique that allows secure fixation without direct puncture and suturing of the catheter to the skin is recommended. If a catheter falls out or is inadvertently removed, access can occasionally be regained and the catheter can be replaced without repuncture. The timing of catheter removal is based on the clinical condition of the patient and the daily output from the catheter. "Tractography" is a useful study before removal of any catheter that requires a mature tract for removal, particularly cholecystostomy catheters and transpleural catheters. In biliary catheter exchange, the most vital issue is the position of the side holes of the catheter. If an abscess cavity remains large after catheter drainage, the catheter can be repositioned or a second catheter can be placed.     

A new pyeloureteral drainage catheter

We describe a new pyeloureteral drainage catheter that can be used for both genitourinary tract stenting and drainage, as well as tamponade of bleeding from the renal parenchyma or subcutaneous tissue. Primary indications for the use of this catheter and recommendations on insertion techniques are presented. With the exception of one case of minor kinking of the catheter, we have had no complications or failures with this catheter. While insertion through an unprotected tissue track is somewhat difficult, we have had good success introducing the catheter through a 24-F or larger Teflon working sheath. The catheter has excellent patient retention properties. It can be converted from external to internal drainage or vice versa simply and quickly on the ward.     

Transbrachial approach for aortic and selective supraaortic vessel catheterization using a safe and easy technique to reform the Simmons II catheter tip.

A total of 286 patients (158 outpatients) were examined by intra-arterial DSA in the evaluation of cerebrovascular disease using a transbrachial approach. In all cases a 5F introducer sheath, a 5F pigtail catheter for aortic arch injection and a 5F Simmons II catheter for selective catheterization were used. Excellent demonstration of aortic arch and supraaortic arteries (including intracranial circulation) was obtained (92.2-100%). The complication rate was favorable, with only one major complication (thrombosis of an axillary artery). The use of an introducer sheath minimizes local complications and vessel wall damage during catheter exchange. Aortic arch injection must always be performed prior to selective catheterization. The results of selective catheterization prove the suitability of the Simmons II catheter, whose typical shape was easily and safely obtained using the configuration of the pigtail catheter and a 180 cm long guide wire for catheter exchange. Using the technique as described, the transbrachial approach is a safe and easy way for optimal vascular evaluation in cerebrovascular disease, especially useful in outpatients.     

Percutaneous catheterization of the kidney and perinephric space: Trocar technique

Percutaneous nephrostomy can be accomplished by using a trocar-cannula assembly without resorting to serial dilations of the tube tract or utilizing stiff catheters. After puncture the trocar is removed and a catheter inserted through the cannula; then the cannula is removed. A large number of these procedures have been performed and have been found to be simple and quite safe. The method is able to provide nephrostomy drainage in virtually any case of ureteral obstruction or leak, and can be used to drain perinephric fluid collections as well. Antegrade pyelography precedes trocar puncture; puncture is most easily guided by fluoroscopy. The technique is described in detail; indications, applications, complications, and contraindications are outlined.     

Upper ureteral calculi: extraction via percutaneous nephrostomy

Symptomatic calculi in the upper ureter are usually removed using surgical and endoscopic techniques. Extraction via percutaneous nephrostomy was successful in 35 of 37 patients using sequentially the techniques of retrograde catheter push, basket sheath exchange, and steerable loop-snare. In 12 patients, the calculus was dislodged into the renal pelvis by the retrograde ureteral catheter; extraction was then easily done. Stone basket retrieval was used for an additional 17 patients. A steerable loop-snare was necessary in six other patients when basket retrieval failed.     

CT-guided drainage of pelvic abscesses: the peranal transrectal approach.

Five patients with deep pelvic abscesses underwent computed tomography (CT)-guided catheter drainage using a transrectal approach. The use of an outer removable plastic sheath over the catheter to facilitate positioning and prevent inadvertent damage to the mucosal wall is described. This new approach using CT guidance is discussed and the alternative routes reviewed.     

Chronic Total Occlusion of the Iliac Artery: Endoluminal Reentry Using a Metal Stiffening Cannula

When chronic total occlusion of the iliac artery cannot be crossed with traditional guide wires and catheters, the metal stiffener from a universal drainage catheter kit can be shaped and used to direct a guide wire from a subintimal tract into the true lumen. In the present report, reentry was achieved in 12 of 12 patients with the use of the cannula. This technique provides a useful alternative for treatment of chronic total iliac occlusions.     

Treatment of a recurrent traumatic carotid-cavernous fistula: Vertebro-basilar approach after surgical occlusion of the internal carotid artery

Summary A case of a post-traumatic carotid-cavernous fistula treated by endovascular approach through the vertebrobasilar system is reported. The 16 year old female patient was hurt in a car accident. The instantly-occuring carotid-cavernous fistula was treated with a Fogarty catheter, the internal carotid artery being occluded during this procedure. Ten years later the fistula recurred with a predominantly cortical venous drainage. The fistula was closed with two detachable balloons by an endovascular approach from the vertebrobasilar system via the posterior communicating artery. The small residual fistula, fed by the external artery was occluded by a venous approach via the internal jugular.     

Balloon Sheaths for Gastrointestinal Guidance and Access: A Preliminary Phantom Study

Objective

We wanted to evaluate the feasibility and usefulness of a newly designed balloon sheath for gastrointestinal guidance and access by conducting a phantom study.

Materials and Methods

The newly designed balloon sheath consisted of an introducer sheath and a supporting balloon. A coil catheter was advanced over a guide wire into two gastroduodenal phantoms (one was with stricture and one was without stricture); group I was without a balloon sheath, group ll was with a deflated balloon sheath, and groups III and IV were with an inflated balloon and with the balloon in the fundus and body, respectively. Each test was performed for 2 minutes and it was repeated 10 times in each group by two researchers, and the positions reached by the catheter tip were recorded.

Results

Both researchers had better performances with both phantoms in order of group IV, III, II and I. In group IV, both researchers advanced the catheter tip through the fourth duodenal segment in both the phantoms. In group I, however, the catheter tip never reached the third duodenal segment in both the phantoms by both the researchers. The numeric values for the four study groups were significantly different for both the phantoms (p < 0.001). A significant difference was also found between group III and IV for both phantoms (p < 0.001).

Conclusion

The balloon sheath seems to be feasible for clinical use, and it has good clinical potential for gastrointestinal guidance and access, particularly when the inflated balloon is placed in the gastric body.     

Use of an Amplatz dilator to facilitate transrectal abscess drainage in children

Image-guided transrectal drainage is an effective treatment option for many deep pelvic abscesses in children. Currently, a variety of imaging and catheter techniques are used to access and drain these abscesses. The present report describes an approach for introducing the transrectal catheter by using transabdominal ultrasound guidance to direct transrectal advancement of an Amplatz dilator with coaxial placement of the metal cannula and inner trocar from a pigtail catheter set, followed by placement of the pigtail catheter via Seldinger technique. This approach eliminates some of the limitations of other transrectal techniques. The present report describes a single-institutional experience with this technique in 13 patients.     

Percutaneous biopsy and drainage procedures in the abdomen using a modified coaxial technique

A modified coaxial technique for biopsy and drainage procedures in the abdomen is described. This technique involves initial placement of a 23-gauge needle into an abdominal organ or mass. Once proper position is obtained, the hub of the needle is removed and a 19-gauge or larger needle is placed over the 23-gauge needle. Through this larger needle, either multiple biopsies are performed or guidewire exchange for a larger catheter is accomplished. The technique was used in performance of seven biopsy procedures, one biliary drainage procedure, and three nephrostomies.     

Femoral-to-port through-and-through wire access to reestablish subcutaneous port function

OBJECTIVE: Central venous catheter malfunction often results from fibrin sheath formation and is routinely addressed with thrombolytic therapy or mechanical stripping. Mechanical stripping from a distant access site such as a femoral vein is the only option for a subcutaneous port that has failed thrombolytic therapy. When a fibrin sheath has rendered the catheter tip inaccessible to snaring, catheter salvage cannot be achieved, requiring port exchange. We report two cases in which an inaccessible catheter tip was mobilized via advancing a wire through the port and through the catheter, allowing for successful snaring, mechanical stripping, and return of normal port function. CONCLUSION: Passage of a hydrophilic wire through a subcutaneous port and beyond the catheter tip is technically possible. The wire can be snared from a femoral access to achieve successful catheter stripping when direct catheter snaring is not possible.