34 research outputs found
Percutaneous subclavian artery stent-graft placement following failed ultrasound guided subclavian venous access
BACKGROUND: Ultrasound guidance for central and peripheral venous access has been proven to improve success rates and reduce complications of venous cannulation. Appropriately trained and experienced operators add significantly to diminished patient morbidity related to venous access procedures. We discuss a patient who required an arterial stent-graft to prevent arterial hemorrhage following inadvertent cannulation of the proximal, ventral, right subclavian artery related to unsuccessful ultrasound guided access of the subclavian vein. CASE PRESENTATION: During pre-operative preparation for aortic valve replacement and aorto-coronary bypass surgery an anesthetist attempted ultrasound guided venous access. The ultrasound guided attempt to access the right jugular vein failed and the ultrasound guided attempt at accessing the subclavian vein resulted in inappropriate placement of an 8.5 F sheath in the arterial system. Following angiographic imaging and specialist consultations, an arterial stent-graft was deployed in the right subclavian artery rather than perform an extensive anterior chest wall resection and dissection to extract the arterial sheath. The patient tolerated the procedure, without complication, despite occlusion of the right internal mammary artery and the right vertebral artery. There were no neurologic sequelae. There was no evidence of hemorrhage after subclavian artery sheath extraction and stent-graft implantation. CONCLUSION: The attempted ultrasound guided puncture of the subclavian vein resulted in placement of an 8.5 F subclavian artery catheter. Entry of the catheter into the proximal subclavian artery beneath the medial clavicle, the medial first rib and the manubrium suggests that the operator, most likely, did not directly visualize the puncture needle enter the vessel with the ultrasound. The bones of the anterior chest impede the ultrasound beam and the vessels in this area would not be visible to ultrasound imaging. Appropriate training and supervised experience in ultrasound guided venous access coupled with quality ultrasound equipment would most likely have significantly diminished the likelihood of this complication. The potential for significant patient morbidity, and possible mortality, was prevented by implantation of an arterial stent-graft
Viable Tumor Tissue Adherent to Needle Applicators after Local Ablation: A Risk Factor for Local Tumor Progression
Background. Local tumor progression (LTP) is a serious complication after local ablation of malignant liver tumors, negatively influencing patient survival. LTP may be the result of incomplete ablation of the treated tumor. In this study, we determined whether viable tumor cells attached to the needle applicator after ablation was associated with LTP and disease-free survival. Methods. In this prospective study, tissue was collected of 96 consecutive patients who underwent local liver ablations for 130 liver malignancies. Cells and tissue attached to the needle applicators were analyzed for viability using glucose-6-phosphate-dehydrogenase staining and autofluorescence intensity levels of H&E stained sections. Patients were followed-up until disease progression. Results. Viable tumor cells were found on the needle applicators after local ablation in 26.7% of patients. The type of needle applicator used, an open approach, and the omission of track ablation were significantly correlated with viable tumor tissue adherent to the needle applicator. The presence of viable cells was an independent predictor of LTP. The attachment of viable cells to the needle applicators was associated with a shorter time to LTP. Conclusions. Viable tumor cells adherent to the needle applicators were found after ablation of 26.7% of patients. An independent risk factor for viable cells adherent to the needle applicators is the omission of track ablation. We recommend using only RFA devices that have track ablation functionality. Adherence of viable tumor cells to the needle applicator after local ablation was an independent risk factor for LT
Alteplase for Hemodialysis access graft thrombolysis
PURPOSE: To evaluate the efficacy and safety of alteplase, a recombinant
tissue plasminogen activator, in hemodialysis access graft thrombolysis.
MATERIALS AND METHODS: From November 1999 to May 2001, 68 episodes of
occlusion in 50 grafts (in 49 patients) were included in the study.
Occlusion was treated with pulse-spray (n = 41) or lyse-and-wait (n =
27) thrombolysis with use of alteplase. Balloon angioplasty of all
identified stenoses was performed. The arterial plug was mobilized with
the Fogarty maneuver.
RESULTS: Procedural success was achieved in 64 of 68 episodes (94%)
with a dose of 2-10 mg (mean = 4.13 mg) of alteplase, allowing
successful hemodialysis within 24 hours. Failures (6%) were the result
of PTA perforation (one of 68), nonnegotiable outflow occlusion (one of
68), delayed bleeding (one of 68), and balloon bursting and shearing
becoming occlusive within the graft (one of 68). Primary and secondary
patency rates were 72% and 87% at 30 days, 57% and 80% at 90 days,
and 44% and 72% at 180 days, respectively. Arterial emboli (two of 68)
were treated by Fogarty balloon retrieval and alteplase infusion locally
over the course of 20 minutes. One of two PTA perforations was
controlled by balloon tamponade.
CONCLUSION: Alteplase can be used successfully for hemodialysis graft
thrombolysis
Percutaneous treatment of complications occurring during hemodialysis graft recanalization
Introduction/objective: To describe and evaluate percutaneous treatment
methods of complications occurring during recanalization of thrombosed
hemodialysis access grafts.
Methods and materials: A retrospective review of 579 thrombosed
hemodialysis access grafts revealed 48 complications occurring during
urokinase thrombolysis (512) or mechanical thrombectomy (67). These
include 12 venous or venous anastomotic ruptures not controlled by
balloon tamponade, eight arterial emboli, 12 graft extravasations, seven
small hematomas, four intragraft pseudointimal ‘dissections’, two
incidents of pulmonary edema, one episode of intestinal angina, one
procedural death, and one distant hematoma.
Results: Twelve cases of post angioplasty ruptures were treated with
uncovered stents of which 10 resulted in graft salvage allowing
successful hemodialysis. All arterial emboli were retrieved by Fogarty
or embolectomy balloons. The 10/12 graft extravasations were
successfully treated by digital compression while the procedure was
completed and the graft flow was restored. Dissections were treated with
prolonged Percutaneous Trasluminal Angioplasty (PTA) balloon inflation.
Overall technical success was 39/48 (81%). Kaplan-Meier Primary and
secondary patency rates were 72 and 78% at 30, 62 and 73% at 90 and 36
and 67% at 180 days, respectively. Secondary patency rates remained
over 50% at 1 year. There were no additional complications caused by
these maneuvers.
Discussions and conclusion: The majority of complications occurring
during percutaneous thrombolysis/thrombectomy of thrombosed access
grafts, can be treated at the same sitting allowing completion of the
recanalization procedure and usage of the same access for hemodialysis.
(C) 2002 Published by Elsevier Science Ireland Ltd
Angiographic findings and embolotherapy in renal arterial trauma
Purpose: To evaluate the angiographic findings and embolotherapy in the
management of traumatic renal arterial injury. Methods: This is a
retrospective review of 22 patients with renal trauma who underwent
arteriography and percutaneous embolization from December 1995 to
January 2002. Medical records, imaging studies and procedural reports
were reviewed to assess the type of injury, arteriographic findings and
immediate embolization results. Long-term clinical outcome was obtained
by communication with the trauma physicians and by clinical chart
review. Results: Arteriography was performed in 125 patients admitted to
a State Trauma Center with suspected internal bleeding. Renal arterial
injury was documented in 22 and was the result of a motor-vehicle
accident (10), auto-pedestrian accident (1), gunshot (4) or stab wounds
(6) and a fall (1). Percutaneous renal arterial embolization was
undertaken in 22 of 125 (18%) patients to treat extravasation (11).
arterial pedicle rupture (5), abnormal arteriovenous (3) or
arteriocalyceal (2) communication and pseudoaneurysm (3). One of the
pseudoaneurysms and one of the arteriovenous fistulae were found in
addition to extravasation. All 22 patients (16 men, 6 women) were
hemodynamically stable, or controlled during arteriography and
embolotherapy. Selective and/or superselective embolization of the
abnormal vessels was performed using coils in 9 patients, microcoils in
9 patients and Gelfoam pledgets in 3 patients. In one patient Gelfoam
pledgets mixed with polyvinyl alcohol (PVA) particles were used for
embolization. Immediate angiographic evidence of hemostasis was
demonstrated in all cases. Two initial technical failures were treated
with repeat arteriography and embolization. There was no
procedure-related death. There was no non-target embolization. One
episode of renal abscess after embolization was treated by nephrectomy
and 3 patients underwent elective post-embolization nephrectomy to
prevent infection. Follow-up ranged from 1 month to 7 years (mean 31
months). No procedure-related or delayed onset of renal insufficiency
occurred. Conclusion: In hemodynamically stable and controlled patients
selective and superselective embolization is a safe and effective method
for the management of renal vascular injury