Ioversol. Double-blind study of a new low osmolar contrast agent for peripheral and visceral arteriography

The new low-osmolar contrast agent ioversol was compared with the conventional ionic contrast agent diatrizoate in 60 patients undergoing routine abdominal (21 patients) and peripheral (39 patients) arteriography. The effects on hemodynamics, various laboratory parameters, and patient comfort were evaluated. In peripheral arteriography, there was less discomfort with ioversol as well as decreased magnitude and incidence of hypotension (P less than .001) after injection. In visceral arteriography, there was no significant difference between the two agents. Overall, the incidence of ECG changes was small in both groups (ioversol 2%, diatrizoate 8%). The two media were equivalent in incidence of adverse reactions (eg, nausea, vomiting, urticaria), the effect on laboratory parameters, and in the diagnostic adequacy of the radiographs. We conclude that ioversol is safe and efficacious for peripheral and visceral arteriography. In peripheral arteriography it causes less patient discomfort and, perhaps more importantly, fewer hemodynamic alterations than diatrizoate. These differences in hemodynamic effects may be important in patients with hemodynamic instability or limited cardiovascular reserve.     

TIPS术中胆汁漏出：刺激平滑肌细胞增生?

目的经颈内静脉肝内门腔静脉分流术（ＴＩＰＳ）中胆道损伤并胆汁漏出，可能是引起ＴＩＰＳ术后支架内平滑肌细胞（ＳＭＣ）增生和狭窄的重要因素。本研究以离体ＳＭＣ培养和ＴＩＰＳ猪模型实验评价胆汁对ＳＭＣ的作用。材料与方法离体ＳＭＣ培养分为三组：Ⅰ组＝１．０％血清＋１．０％胆汁；Ⅱ组＝１０．０％血清＋１．０％胆汁；Ⅲ组＝１０．０％血清。细胞收获点分别为３、１０、１４天。动物实验组共用４５只猪建立ＴＩＰＳ模型，术后处死时间为１０～１６天。结果此前预试验结果：使用２．５％、５．０％、１０．０％胆汁的培养基，ＳＭＣ在３天内全部死亡。离体细胞培养（１．０％胆汁）实验组（Ⅰ、Ⅱ组）中的脱氧核糖核酸（ＤＮＡ）和总蛋白量明显较对照组（Ⅲ组）少（Ｐ＜０．０５），且随着培养时间的延长其差异增加。动物实验组：２８．８９％的标本证实有胆汁漏出。定量分析示胆汁漏组中的ＳＭＣ增殖量较无胆汁漏组少。组织学检查发现有新生胆管在支架内生长。结论２．５％～１０．０％胆汁杀死ＳＭＣ，１．０％胆汁可抑制ＳＭＣ生长。动物实验示胆汁漏出导致ＳＭＣ增生减少，但血栓形成增加，从而使支架闭塞率增高。     

经颈内静脉肝内门腔分流术远期疗效分析

目的:探讨经颈静脉肝内门脉分流术(TIPS)后病人的远期分流道通畅率,生存期和生活质量。材料及方法:51例TIPS术后病人,随访时间平均为16.8±12.8月(1天-49月),用Kaplan-Meier法分析TIPS后病人的远期生存率,和分流道通畅率。用COX模型将生存期和通畅率与Child～Pugh肝功能分级和主要症状作相关分析,并预测影响生存期和分流道通畅率的因素。用SF～36问卷评估病人的生活质量。结果:1-4年累计生存率分别为65％,56％,32％,19％。累计原发通畅率分别为65％,56％,32％,19％。42个月原发再次通畅率为94％,18个月4继发通畅率为7l％。肝功能Child-Pugh分级与累积生存率有显著性差异。影响TIPS术后90天生存率的相关因素有:酒精性肝硬化,腹水,急性出血,分流腔道直径,静脉曲张需栓塞者,肝性脑病,分流通道再狭窄及再发出血。TIPS术后生活质量的所有9项指标均较术前提高,其中4项有显著性差异。结论:TIPS对控制出血,腹水及改善近期生活质量有肯定的疗效,但是对病人远期生活率的确切作用尚有待于进一步的研究。     

Therapeutic embolization of the gastroduodenal artery in hepatic artery infusion chemotherapy

Transcatheter embolization of the gastroduodenal artery with Gelfoam was performed in 12 patients undergoing percutaneous hepatic artery catheterization for infusion chemotherapy of metastatic liver disease. The purpose of the embolization was to prevent chemotherapeutic drugs from reaching the stomach and duodenum and thereby inducing gastrointestinal toxicity in patients in whom the catheter tip could not be satisfactorily positioned beyond the gastroduodenal origin. Embolization proved safe and effective in eight cases. Three other patients experienced clinical problems that may or may not have been related to embolization. The final patient had a significant complication (necrosis of the pancreatic head and gastric mucosa) that was felt to be directly related to the embolization. Transcatheter gastroduodenal occlusion may help reduce gastrointestinal toxicity of intraarterial infusion chemotherapy. However, it may on occasion be associated with significant complications, particularly in patients who are debilitated due to metastatic disease.     

Retrospective assessment of risk factors to predict tunneled hemodialysis catheter outcome

PURPOSE: To identify factors that may influence the function, outcome, and complications associated with tunneled hemodialysis catheters. MATERIALS AND METHODS: Radiology reports and hemodialysis, medical, and Clinical Information System (computerized patient medical record system) records were retrospectively reviewed in 221 consecutive patients who underwent tunneled hemodialysis catheter placement by interventional radiologists between January 11, 1996 and January 13, 2000 at Dartmouth-Hitchcock Medical Center. Various patient characteristics (diabetes, smoking, hypertension, age, sex, atherosclerotic cardiovascular disease, history of cardiac catheterization, coumadin use, functional status, and obesity) were assessed for their relationship to the outcome of hemodialysis catheters. Catheter outcome was examined by calculating infection rate, thrombosis rate, fibrin formation rate, mechanical malfunction rate, and total complication rate. With these patient characteristics and outcome variables, multiple regression analysis was performed with STATA (College Station, TX) statistical analysis software. RESULTS: Of the 221 patients reviewed, 39 patients were lost to follow-up. Among the remaining 182 patients, 427 catheters were placed for a total number of 36994 catheter-days. For overall complication rate, multiple regression analysis revealed a statistically significant positive correlation only for hypertension (P =.032). Total complication rate was 0.76 events per 100 catheter-days (95% CI: 0.53-1.00) for patients with a documented history of hypertension and 0.27 events per 100 catheter-days (95% CI: 0.08-0.45) for patients without (P =.024, paired student t test). For patients with diabetes versus patients without, the infection rates were 0.34 episodes per 100 catheter-days (95% CI: 0.15-0.53) and 0.12 episodes per 100 catheter-days (95% CI: 0.06-0.18), respectively, (P =.011, paired student t test). Thrombosis rate for patients on coumadin was 0.13 events per 100 catheter-days (95% CI: -0.14-0.40), while thrombosis rate for patients not taking coumadin was 0.03 events per 100 catheter-days (95% CI: 0-0.05) (P =.036, paired student t test). CONCLUSION: Hypertension is a risk factor for poor outcome of tunneled hemodialysis catheters as measured by total complication rate requiring catheter removal or exchange. In this retrospective study, no other specific risk factors predicted an increased need for removal or exchange of tunneled hemodialysis catheters.     

Operating expenses for the diagnosis and treatment of peripheral vascular disease in an academic interventional radiology department: cost calculations according to a microeconomic method

PURPOSE: A correct understanding of the true costs of a procedure is necessary to make informed decisions in cost-effectiveness analyses. The actual comprehensive costs of performing cardiovascular and interventional radiology (CVIR) procedures were analyzed in the present study, as opposed to charges or ratios of costs to charges (RCCs), as often used in the literature. MATERIALS AND METHODS: Costs included labor, equipment, administration, facility establishment and maintenance, overhead, and consumable supplies. Cost identification was initially performed with use of an hourly rate that reflected the cost of operating the CVIR section. This was then combined with the costs of the consumable supplies used during each type of procedure. Eight types of vascular procedures were studied in 235 consecutive patients to determine mean procedure duration and supplies consumption. Costs were then compared with charges and RCCs of these procedures. RESULTS: The hourly rate for operating one angiography suite was 690 dollars. Average cost by procedure, including hourly rate plus consumable supplies, were: aortic arteriogram, 1,442 dollars; aortobifemoral arteriogram, 1,554 dollars; unilateral limb arteriogram, 1,307 dollars; simple iliac or femoropopliteal angioplasty, 2,119 dollars; arterial stent placement, 2,780 dollars; percutaneous thrombectomy, 1,998 dollars; arterial in situ thrombolysis, 3,133 dollars; and arteriogram after thrombolysis, 926 dollars. RCCs calculated for each procedure ranged from 0.39 (thrombectomy) to 1.92 (control arteriography during or after thrombolysis) and were lower than expected based on previous reports. CONCLUSIONS: The average actual costs of several common diagnostic and therapeutic procedures for peripheral vascular occlusive disease were established, allowing determination of the relative importance of different cost components. This methodology may serve as a template for future cost analyses.     

Günther Tulip filter retrievability multicenter study including CT follow-up: final report

PURPOSE: To evaluate the safety and effectiveness of retrieval of the Günther Tulip inferior vena cava (IVC) filter. MATERIALS AND METHODS: This was a nonrandomized, single-armed, multicenter prospective investigation. Patients at temporary high risk for pulmonary embolism (PE) or deep vein thrombosis (DVT) who did not require a permanent filter were eligible. Forty-one patients received 42 Günther Tulip filters: 22 men and 19 women with a mean age of 47.7 years. Indications for filter placement included prophylaxis, PE, and DVT. Three months after filter retrieval, contrast agent-enhanced computed tomography of the abdomen, jugular vein ultrasonography, and clinical follow-up were performed. RESULTS: The filter retrieval rate was 57% (23 of 41). Günther Tulip filters were removed at a mean of 11.1 days (range, 2-14 d). The technical and clinical success rates for filter retrieval were both 100%. One placement complication and two protocol deviations occurred. These patients were excluded in terms of retrieval-related outcomes. One case of PE occurred with a filter in place, and one filter migrated to the heart. There were no acute complications caused by filter retrieval. At 3-month follow-up, there was no recurrent PE, DVT, jugular vein occlusion, or IVC stenosis or occlusion. CONCLUSION: In this multicenter study, retrieval of the Günther Tulip filter was safe and without recurrent thromboembolic events or evidence of IVC or jugular vein damage at 3-month follow-up.     

The durability of endovascular treatment of multisegment iliac occlusive disease

PURPOSE: The effectiveness of endovascular treatment of multisegment iliac occlusive disease (involving two or more common and/or external iliac arteries) was determined. METHODS: All patients who underwent angioplasty or stenting of at least two separate iliac artery segments were identified. Demographic data were recorded. Technical success, hemodynamic success, and aortoiliac primary and primary-assisted patency were analyzed by using the Society for Vascular Surgery and International Society for Cardiovascular Surgery (SVS/ISCVS) criteria. Multivariate, life table analysis was used as a means of determining outcome predictors. RESULTS: Eighty-seven patients underwent 207 iliac artery angioplasties and 115 iliac artery stents, which were performed in 210 iliac segments for disabling claudication in 60% of cases, for rest pain in 17% of cases, and for tissue loss in 23% of cases. Two iliac segments were treated in 64% of patients, three segments were treated in 28% of patients, and four segments were treated in 8% of patients. The complication rate was 11%. Initial hemodynamic success was achieved in 72% of cases. Clinical improvement occurred in 88% of patients. Subsequent endovascular reintervention was required in 29% of patients, whereas surgical inflow procedures were required in 14% of patients to maintain aortoiliac patency. The mean time from the primary intervention to the first reintervention was 10 +/- 3 months. At 6, 12, and 36 months after intervention, the primary patency rates of the aortoiliac segment were 76%, 61%, and 43%, respectively, and the primary assisted patency rates were 95%, 87%, and 72%, respectively. Only the presence of an external iliac artery stenosis adversely affected both primary and assisted-primary patency. At 6, 12, and 36 months, the aortoiliac primary patency rates in patients without the presence of an external iliac artery stenosis were 88%, 78%, and 69%, respectively, compared with 68%, 47%, and 18%, respectively, in patients with external iliac artery lesions (P <. 0001). CONCLUSION: Endovascular therapy for multisegment aortoiliac occlusive disease has acceptable patency rates; however, reintervention is often needed. The presence of external iliac artery disease is a significant predictor of poor outcome.