Salvage of immature forearm fistulas for haemodialysis by interventional radiology.
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BACKGROUND: The goal of this article is to assess the value of endovascular techniques for the salvage of fistulas that fail to mature. METHODS: Over a 6-year period, 52 dysfunctional and 17 thrombosed immature forearm fistulas (mean age 10 weeks) were treated by interventional radiology. Angiography was performed by puncture of the brachial artery but dilation of underlying stenoses was performed after cannulation of the fistula itself, whenever possible, with a balloon never smaller than 5 mm. Embolization or ligation of any type of vein was never indicated and never performed. For thrombosed fistulas, significant clots were removed by manual catheter-directed aspiration. A covered stent (Passager) was used in cases of dilation-induced rupture not controlled by balloon tamponade. RESULTS: An underlying stenosis was diagnosed in 100% of cases. Half of them were located in the anastomotic area. The initial success rate of interventional radiology was 97%. Dilation-induced rupture occurred in nine cases (13%) but stents were necessary in only two cases. The rate of significant clinical complications was 2.8% (bacteraemia, pseudoaneurysm). Primary and secondary patency rates at 1 year were 39 and 79%, respectively. CONCLUSIONS: Delayed maturation of native fistulas should lead systematically to imaging as an underlying stenosis is diagnosed in all cases. Interventional radiology can treat the majority of cases and achieve a 97% success rate but early recurrence of stenoses can occur. Multidisciplinary re-evaluation of the patient must, therefore, be performed after radiological salvage of the fistula. (+info)
Colonic necrosis subsequent to catheter-directed thrombin embolization of the inferior mesenteric artery via the superior mesenteric artery: a complication in the management of a type II endoleak.
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The optimal management of endoleaks after endovascular repair of abdominal aortic aneurysms remains to be established. In this report, we describe a persistent side-branch, or type II, endoleak 1 year after endograft implantation treated with catheter-directed embolization of the aneurysm sac and the inferior mesenteric artery via the superior mesenteric artery, with embolization agents including thrombin, lipiodol, and gelfoam powder. Shortly after the embolization procedure, colonic necrosis developed in the patient, manifested by peritonitis, which necessitated a partial colectomy. This case underscores the devastating complication of colonic ischemia as a result of catheter-directed embolization of the inferior mesenteric artery in the management of an endoleak. (+info)
The effect of transient balloon occlusion of the mitral valve on left atrial appendage blood flow velocity and spontaneous echo contrast: a comparison in sinus rhythm and atrial fibrillation patients.
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OBJECTIVE: To investigate the relationship between spontaneous echo contrast (SEC) and left atrial appendage (LAA) blood flow velocity using transesophageal echocardiography (TEE) during percutaneous balloon mitral valvotomy (PBMV) in patients with atrial fibrillation and sinus rhythm. METHODS: Thirty-five patients (21 in sinus rhythm and 14 in atrial fibrillation) with rheumatic mitral stenosis underwent PBMV with intraoperative transesophageal echocardiography monitoring. We measured LAA blood flow velocities and observed the left atrium for various grades of SEC (from 0 = none to 4 = severe), before and after each balloon inflation. RESULTS: Left atrial appendage maximal emptying velocity (LAA MEV) was reduced from 35 +/- 14 cm/s to 6 +/- 2 cm/s at peak balloon inflation and increased to 40 +/- 16 cm/s after balloon deflation. Comparison of the values before balloon inflation and after balloon deflation showed that LAA velocities were significantly lower (P < 0.001). During balloon inflation, both maximal emptying velocity (MEV) and maximal filling velocity (MFV) were significantly decreased, compared to those before inflation and after balloon deflation (P < 0.01). And both MEV and MFV were significantly higher after balloon deflation relative to those before balloon inflation. Patients with atrial fibrillation had significantly lower MEV and MFV before and during balloon inflation and after balloon deflation than patients with sinus rhythm. At peak balloon inflation, new or increased SEC grades were observed during 54 of 61 (88%) inflations and unchanged during 7 (12%) inflations. SEC grades were reduced after 55 balloon deflations (90%), completely disappeared after 18 deflations (30%) and remained unchanged after 6 deflations (10%). At peak balloon inflation, left atrium spontaneous echo contrast (LASEC) grade 4 was observed during 14 of 27 (93%) inflations in the atrial fibrillation patients, significantly higher than in patients with sinus rhythm (8 of 34, 24%; P < 0.05). LASEC completely disappeared after 16 of 34 deflations (47%) in the patients with sinus rhythm, significantly higher than in the atrial fibrillation patients (2 of 27 deflations; P < 0.01). The mean time to achieve maximal SEC grade (2.5 +/- 1.2 s) correlated with the mean time to trough LAA velocities (2.3 +/- 1.1 s) after balloon inflation. Both the time to lowest LAA velocity and the time to highest LASEC were significantly longer in the patients with sinus rhythm than in the atrial fibrillation patients (2.6 +/- 1.1 s vs 1.7 +/- 1.0 s, P < 0.05 and 2.8 +/- 1.4 s vs 1.9 +/- 1.3 s, P < 0.05, respectively). Upon deflation, the mean time to lowest SEC grade (2.9 +/- 1.8 s) correlated with the mean time to achieve maximal LAA velocities (2.7 +/- 1.6 s). Both intervals are significantly shorter in the patients with sinus rhythm than in the atrial fibrillation patients (2.0 +/- 1.6 s vs 3.5 +/- 1.5 s, P < 0.01 and 2.2 +/- 1.7 s vs 3.6 +/- 1.6 s, P < 0.05). CONCLUSION: Reducing the blood flow velocity in the human left atrium by balloon occlusion of the mitral valve may enhance SEC, whereas restoring blood flow after balloon deflation would cause enhanced echogenic blood to disappear or decrease in both groups of patients. Patients with atrial fibrillation demonstrate more severe blood stagnation of the left atrial body and appendage during transient balloon inflation at mitral valve orifice and slower recovery from the stagnation, decreasing to a lesser extent after balloon deflation, when compared to patients with sinus rhythm. (+info)
Transesophageal echocardiography for quantifying size of patent foramen ovale in patients with cryptogenic cerebrovascular events.
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BACKGROUND AND PURPOSE: Patent foramen ovale (PFO) is a risk factor for paradoxical embolism, and severe shunting and wide opening of PFO are risk factors for severe and recurrent cerebrovascular events. Neither contrast echocardiography nor 2-dimensional (2D) measurement of PFO size have been validated or compared with invasive balloon sizing. METHODS: We performed transesophageal echocardiography (TEE) in 100 patients with cryptogenic stroke and catheter closure of PFO. The amount of contrast shunting through the PFO during cubital and femoral contrast delivery and the PFO size measured by 2D TEE were compared with balloon sizing. RESULTS: There was a significant correlation (r(2)=0.8; P<0.0001) between 2D TEE measurement and invasive balloon sizing. Mean balloon-sized PFO diameter was significantly larger than mean PFO diameter measured by 2D TEE (8.3+/-2.6 versus 5.2+/-1.7 mm). Semiquantitative contrast TEE correlated with PFO size (r(2)=0.7; P<0.0001) only if the contrast agent was administered through a femoral vein. Correlation was poor when the contrast agent was administered via a cubital vein. CONCLUSIONS: We conclude that 2D TEE measurement of a PFO size is more accurate than the traditionally used contrast technique. (+info)
Endovascular treatment of aneurysms in the cavernous sinus: a systematic review on balloon occlusion of the parent vessel and embolization with coils.
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BACKGROUND AND PURPOSE: Balloon occlusion of the parent vessel and endosaccular coiling are both frequently used for treatment of intracavernous aneurysms of the carotid artery. We performed a systematic review of studies reporting on these two treatment modalities to assess the rate of complications, rate of successful aneurysm occlusion, and clinical condition after treatment. METHODS: We performed a MEDLINE search for studies published between January 1974 and May 1999 and hand-searched recent volumes of 21 journals. Two authors independently extracted data by means of a standardized data extraction form. RESULTS: We found 35 studies reporting on 316 patients. Only 9 of the 35 studies reported on more than 5 patients; in only 9 studies (totaling 85 patients), well-defined outcome measures were used. Twenty-five studies (with 78% of all patients included in the review) reported on balloon occlusion. Complications during or in the first 24 hours after the balloon occlusion occurred in 4 of 247 patients (1.6%; 95% CI, 0.01% to 3.2%) and late ischemic complications in 5 of 148 patients (3.4%; 95% CI, 0.43% to 6.4%). Clinical follow-up was performed in 21 of 25 studies on treatment by means of balloon occlusion (148 [60%] of the 247 patients). None of the 68 patients treated by embolization with coils had a complication (0%; 95% CI, 0% to 4.3%). Of 157 aneurysms treated by balloon occlusion, 153 were completely thrombosed (97.5%; 95% CI, 95% to 100%). After coiling, 52 of 65 aneurysms (80%; 95% CI, 70% to 90%) were occluded by >90%. CONCLUSIONS: Many studies included in this review had methodological weaknesses. The available data suggest that both balloon occlusion and endosaccular coiling are reasonably safe and result in occlusion of the aneurysm in the majority of patients. However, long-term outcomes have not yet been reported. (+info)
Transcatheter closure of high pulmonary artery pressure persistent ductus arteriosus with the Amplatzer muscular ventricular septal defect occluder.
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BACKGROUND: The design of devices currently used for closure of persistent ductus arteriosus (PDA) with high pulmonary artery pressure is not ideal and there is a risk of embolisation into the aorta. OBJECTIVE: To investigate the use of the Amplatzer muscular ventricular septal defect occluder (AMVSDO) for treatment of PDA with high pulmonary artery pressure. PATIENTS AND DESIGN: Seven patients, aged 5-12 years, with large PDAs and systemic or near systemic pulmonary artery pressure underwent attempted transcatheter closure using the AMVSDO. The device consists of two low profile disks made of a nitinol wire mesh with a 7 mm connecting waist. Balloon occlusion of the duct was performed before closure from the venous side, and prosthesis size was chosen according to the measured diameter of the occluding balloon. A 7 French sheath was used to deliver the device. All patients underwent a complete haemodynamic and angiographic study one year after occlusion. RESULTS: The mean (SD) angiographic PDA diameter was 9.8 (1.7) mm (range 7-13 mm) and the mean AMVSDO diameter was 11.4 (1.8) mm (range 9-16 mm). Q(p)/Q(s) ranged from 1.9-2.2 (mean 2.0 (0.1)). Successful device delivery and complete closure occurred in all patients (100% occlusion rate, 95% confidence interval 59.04% to 100.00%). Mean systolic pulmonary artery pressures were as follows: before balloon occlusion, 106 (13) mm Hg; during occlusion, 61 (6) mm Hg; immediately after the procedure, 57 (5) mm Hg; and at the one year follow up catheterisation, 37 (10) mm Hg. Fluoroscopy time was 10.4 (4.3) min (range 7-18 min). No complications occurred. CONCLUSIONS: AMVSDO is an important adjunct for closure of large PDAs associated with high pulmonary artery pressure. Further studies are required to document its efficacy, safety, and long term results in a larger number of patients. (+info)
A new use for the amplatzer duct occluder device.
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We report a case in which the Amplatzer device for percutaneous occlusion of ductus arteriosus was successfully used for occluding a large systemic-pulmonary collateral vessel in a patient who had previously undergone surgery for correction of pulmonary atresia and ventricular septal defect (Rastelli technique), and was awaiting the change of a cardiac tube. In the first attempt, the device embolized to the distal pulmonary bed and, after being rescued with a Bitome, it was appropriately repositioned with no complications and with total occlusion of the vessel. (+info)
Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography.
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OBJECTIVE: To assess the impact of routine follow-up arteriography on the management and outcome of patients with acute blunt cerebrovascular injuries (BCVI). SUMMARY BACKGROUND DATA: During the past 5 years there has been increasing recognition of BCVI, but the management of these lesions remains controversial. The authors previously proposed a grading system for BCVI, with grade-specific management guidelines. The authors have noted that a significant number of injuries evolve within 7 to 10 days, warranting alterations in therapy. METHODS: A prospective database of a regional trauma center's experience with BCVI has been maintained since 1990. A policy of arteriographic screening for BCVI based on injury mechanism (e.g., cervical hyperextension) and injury patterns (e.g., cervical and facial fractures) was instituted in 1996. A grading system was devised to develop management protocols: I = intimal irregularity; II = dissection/flap/thrombus; III = pseudoaneurysm; IV = occlusion; V = transection. RESULTS: From June 1990 to October 2001, 171 patients (115 male, age 36 +/- 1 years) were diagnosed with BCVI. Mean injury severity score was 28 +/- 1; associated injuries included brain (57%), spine (44%), chest (43%), and face (34%). Mechanism was motor vehicle crash in 50%, fall in 11%, pedestrian struck in 11%, and other in 29%. One hundred fourteen patients had 157 carotid artery injuries (43 bilateral), and 79 patients had 97 vertebral artery injuries (18 bilateral). The breakdown of injury grades was 137 grade I, 52 grade II, 32 grade III, 25 grade IV, and 8 grade V. One hundred fourteen (73%) carotid and 65 (67%) vertebral arteries were restudied with arteriography 7 to 10 days after the injury. Eight-two percent of grade IV and 93% of grade III injuries were unchanged. However, grade I and II lesions changed frequently. Fifty-seven percent of grade I and 8% of grade II injuries healed, allowing cessation of therapy, whereas 8% of grade I and 43% of grade II lesions progressed to pseudoaneurysm formation, prompting interventional treatment. There was no significant difference in healing or in progression of injuries whether treated with heparin or antiplatelet therapy or untreated. However, heparin may improve the neurologic outcome in patients with ischemic deficits and may prevent stroke in asymptomatic patients. CONCLUSIONS: Routine follow-up arteriography is warranted in patients with grade I and II BCVIs because most of these patients (61% in this series) will require a change in management. A prospective randomized trial will be necessary to identify the optimal treatment of BCVI. (+info)