Ambulatory Phlebectomy at Radiologic Outpatient Clinic

PURPOSE: To evaluate safety, efficacy, and patient's satisfaction of an ambulatory phlebectomy, performed at a radiology outpatient clinic. MATERIALS AND METHODS: Between 2003 and 2006, an ambulatory phlebectomy was performed in 12 patients. Endovenous radiofrequency ablation was performed through a venotomy. The venotomy was ligated after RF ablation, and the ambulatory phlebectomy was performed. The patients visited the radiology outpatient clinic one day, one week, and 2 months after the procedure. The improvement in the clinical symptoms, cosmetic change in varicosity, and the procedure related complications were evaluated. The patient's satisfaction was evaluated using a 5-grade scale. RESULTS: RF ablation through a venotomy was performed successfully in all 12 patients. On average, 4.5 incisions were made, and 12.5 cm of varicosity had been removed. The mean procedure time was one hour and forty minutes. The complications of the ambulatory phlebectomy were bruising in one patient, and skin pigmentation in another. The complications associated with RF ablation were a hard palpable vein in 7 patients, numbness in 7 patients, and skin pigmentation along the vein in 2 patients. Follow-up duplex sonography was performed at 2 months after the procedure, showed complete occlusion in all 12 patients. The clinical symptoms had improved in 11 patients, and the varicosity disappeared cosmetically in 11 patients. CONCLUSION: An ambulatory phlebectomy, combined with RF ablation of the greater saphenous vein, can be performed safely and effectively at a radiology outpatient clinic.

Percutaneous Treatment of Failed Native Dialysis Fistulas: Use of Pulse-Spray Pharmacomechanical Thrombolysis as the Primary Mode of Therapy

OBJECTIVE: To determine the efficacy and outcome of percutaneous treatment in restoring the function of failed native arteriovenous fistulas (AVFs) where pulse-spray pharmacomechanical thrombolysis was used as the primary mode of therapy. MATERIALS AND METHODS: From June 2001 to July 2005, 14 patients who had thrombosis of native AVFs underwent percutaneous restoration following 20 episodes of thrombosis. These included 6 repeated episodes in one forearm AVF and two episodes in another forearm AVF. All patients except one were treated with urokinase injection utilizing the pulse-spray technique and had subsequent balloon angioplasty. One patient was treated by percutaneous angioplasty alone. We retrospectively evaluated the feasibility of percutaneous treatment in restoring the function of the failed AVFs. The primary and secondary patencies were calculated by using a Kaplan-Meier analysis. RESULTS: Both technical and clinical success were achieved in 15 (75%) of 20 AVFs. Four of the five technical failures resulted from a failure to cross the occluded segment. One patient refused further participation in the trial through a brachial artery access following failure to cross the occluded segment via an initial retrograde venous puncture. There were no major precedure related complications observed. Including the initial technical failures, primary patency rates at six and 12 months were 64% and 55%, respectively. Secondary patency rates at six and 12 months were 71% and 63%, respectively. CONCLUSION: Pulse-spray pharmacomechanical thrombolysis for treatment of the thrombosed AVFs is safe, effective and durable. This procedure should be considered as an option for the management of failed AVFs prior to surgical intervention.

Efficacy of Percutaneous Transluminal Angioplasty for Treating Non-Maturing Brescia-Cimino Fistulas

PURPOSE: We wished to report our experiences for the treatment of non-maturing Brescia-Cimino fistulas by using percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: From January 1997 and December 2003, we treated 22 patients with non-maturing Brescia-Cimino fistulas by using percutaneous transluminal angioplasty (PTA). A retrospective analysis was performed on the findings of the fistulograms, techniques and success rate of the PTA, and the patency rate. RESULTS: Seventeen segmental stenoses and 5 segmental occlusions of the cephalic veins were identified. Sixteen stenoses and 2 occlusions were located at the cephalic vein adjacent to the anastomosis site, and 3 occlusions and 1 stenosis are seen at the proximal vein near the elbow joint. In addition to venous stenosis, a focal arterial stenosis at the anastomosis site and two accompanying accessory veins that might hamper the maturation of main cephalic vein was seen in each of two patients, respectively, and the simultaneous occlusion of the left innominate vein as well as occlusion of the cephalic vein was noted in one patient. The initial success rate of the PTA procedures was 95.5% (21/22). The overall success rate including the 11 additional PTAs that were performed during follow-up was 96.9% (32/33). No major complication were noted to have occurred. The primary and secondary patency rates were 72% (16/22) and 95% (21/22) at 3 months, and 50% (11/22) and 77% (17/22) at 6 months, respectively. CONCLUSION: PTA is an effective and safe method for treating non-maturing Brescia-Cimino fistulas.

Venous Rupture Complicating Hemodialysis Access Angioplasty: Percutaneous Treatments and Outcomes

PURPOSE: To evaluate the usefulness of percutaneous management and prognosis in venous rupture during angioplasty of hemodialytic arteriovenous fistulas. MATERIALS AND METHODS: Among 814 patients who underwent angioplasty on account of inadequate hemodialysis, 63[39 women and 24 men aged 20-78 (mean, 55.8) years] were included in this study. All 63 had peripheral venous stenosis. Venous rupture was diagnosed when contrast leakage was seen at venography after percutaneous angioplasty (PTA). In order to manage venous rupture, the sites at which this occurred were compressed manually for 3-5 minutes or blood flow was blocked with a balloon catheter for the same period. In one case, a stent was inserted at the rupture site. Using the Kaplan-Meier method, we investigated the patency rate of arteriovenous fistula (AVF) in cases of successful PTA. We also compared PTA patency rates in cases with and without peripheral venous rupture. RESULTS: Venous rupture occurred in 38 cephalic, 16 brachial, and 9 basilic veins. In 63 patients, bleeding stopped and in 54 (85.7%) of these, PTA was successful. Among the nine failed cases, dilatation was incomplete in five, though bleeding had stopped. In patients with brachial and cephalic vein rupture, the venous tract at the rupture site was not located. Two patients underwent surgery: one of these experienced brachial venous rupture, with incontrollable bleeding, and the other had nerve compression symptoms due to hematoma. Among 54 patients in whom PTA was successful, the primary and secondary six-month rates for angioaccess were 47.9% and 81.2%, and the mean patency period was 6.1 and 15.8 months, respectively. In cases of non-venous rupture, the mean patency period was 9.6 months, significantly longer than in cases involving venous rupture (p=0.02). CONCLUSION: Venous rupture occurring during the PTA of hemodialytic AVF can be managed percutaneously.

Percutaneous Intervention in the Management of Insufficient Native Arteriovenous Hemodialysis Fistulae

PURPOSE: To determine the effectiveness and patency of percutaneous intervention in insufficient native arteriovenous hemodialysis fistulae (AVFs). MATERIALS AND METHODS: Between March 1997 and September 2001, 67 cases of insufficient native AVF in 56 patients were treated by endovascular intervention. Except eight cases of insufficient native AVFs resulted from central vein lesion, PTA was performed in 48 cases, and thrombolytic therapy with or without PTA in 11. In eight of the cases, in which central vein stenosis had led to the insufficency, percutaneous transluminal angioplasty (PTA) was performed, and in three of the eight, a stent was inserted. Angiographic findings and complications, as well as success and patency rates in the non-thromobosis and thrombosis group, were evaluated; the central vein lesion group was analysed separately. RESULTS: Among 84 lesions observed at angiography, there were 54 cases of stenosis, 17 of occlusion, and 13 of combined thrombosis. The lesions were located in a proximal vein (n=51), distal vein (n=14), artery (n=6), and at the site of anastomosis (n=13). In the central vein lesion group (n=8), seven cases of stenosis and one of occlusion were noted. The overall procedural success rate was 79.1% (53/67). That is, in patients with no central vein lesion, the procedural success rate of PTA of native AVFs was 85.4% (41/48) and the patency rates of this were 83.1% at 6 months and 67.4% at 12 months. In cases of thrombolysis with/without PTA, the procedural success rate was 54.5% (6/11) and the patency rates were 83.3% at 6 months and 62.5% at 12 months. Finally, in patients with a central vein lesion, the procedural success rate was 75% (6/8) and the patency rates were 80% at 6 months and 30% at 12 months. There was one case of pseudoaneurysm formation at the puncture site of the brachial artery, which was used as the access route for intervention; one embolism in the brachial artery; and three cases of vascular spasm and two of hematoma which did not require active treatment. CONCLUSION: Percutaneous intervention offers effective and safe management of insufficient AVFs. The procedural success rate was higher for stenosis than for thrombotic occlusion.

Central Venous Obstruction in Hemodialysis Patients: The Usefulness of Percutaneous Treatment

PURPOSE: To analyse the effectiveness of percutaneous treatment of central venous obstruction in patients undergoing hemodialysis. MATERIALS AND METHODS: In 100 patients, 107 central venous strictures [56 subclavian (occlusion:21, stenosis:35) and 51 innominate (occlusion:23, stenosis:28)] were assessed, and 170 percutaneous angioplasty procedures were performed. Balloon dilation of the venous lumen was the preferred mode, but if dilation was incomplete we inserted a stent at the site of the stricture. Technical success, procedural complications and the long-term patency rate were evaluated, and the patency difference according to location and degree of stricture, the existence of DM, and any history of central catheter insertion were also determined. RESULTS: We inserted 52 stents in 170 procedures, in 157 (92.4%) of which initial technical success was achieved. Stent migration occurred in two cases and balloon rupture in three. The 6- and 12-month primary patency rates were 46.2% and 24.1%, respectively, and the mean patency rate was 8.5 months. The 1-, 2- and 3-year accumulative patency rates were 59.8%, 47.5% and 35.7%, respectively, and the mean patency rate was 23.5 months. Other than in the history of central catheter insertion, there were no statistically significant differences in patency rates (p=0.0128). CONCLUSION: In hemodialysis patients with a central venous stricture, percutaneous angioplasty is a safe and useful procedure, but to maintain long-term central venous patency, repeated interventions are required.

The Usefulness of Wire-Loop Technique for Percutaneous Angioplasty of Insufficient Hemodialysis Fistula

PURPOSE: To evaluate the usefulness of the Wire-Loop technique, used to perform percutaneous transluminal angioplasty (PTA) in occluded arteriovenous fistula when standard methods fail to pass the balloon catheter. MATERIALS AND METHODS: In 30 patients [M:F=14:16; aged 27 -77 (mean, 51.3) years], the Wire-Loop technique was used to perform percutaneous transluminal angioplasty of insufficiently hemodialysed arteriovenous fistula where a balloon catheter had failed to pass through the stenotic lesion after a guide wire had successfully passed. Native and Goretex fistula were used in 22 and eight cases, respectively. Sixteen stenoses were located in the central vein, and fourteen in the peripheral. The punture sites used in order to perform the technique were the femoral vein in all cases of central stenosis; three basilic, four cephalic, and five femoral veins in cases of peripheral stenosis and one femoral and one radial artery in cases of anastomotic stenosis. The guide wire was passed through the stenotic lesion, pulled out using the snare technique, and then stretched in order to tighten it. The balloon catheter was then passed through the lesion and traditional balloon angioplasty was performed. The technical success rate and complications of the technique, and the patency rate of recanalized arteriovenous fistula, were evaluated. RESULTS: In 26 of the thirty patients, (86.7%), the procedure was technically successful. In the remaining four cases, failure was due to venous dissection (n=1), marked residual stenosis (n=2), or cardiac arrest (n=1) during the procedure. The average procedure time was 105 (range, 40 -210) minutes, and in three cases rupture of the vein occurred. The patency rate of PTA was 80% (24/30) at four months, 63% (19/30) at six months, and 30% (9/30) at twelve months. The expected technical success rate of traditional PTA, without the Wire-Loop technique, would have been 79.3%, but using the technique, the rate increased to 86.7%. CONCLUSION: The Wire-Loop technique appears to be a safe and valuable procedure in patients with insufficiently hemodialysed arteriovenous fistula, and is therefore useful in cases in which traditional PTA fails.

Percutaneous Transluminal Angioplasty and Stent Insertion in Central Venous Steno-occlusion

PURPOSE: To evaluate the efficacy of percutaneous transluminal angioplasty (PTA) and stent insertion incentral venous steno-occlusion. MATERIALS AND METHODS: Between August 1992 and January 1998, 11 patients with symptomatic central venous steno-occlusion(six stenoses and five occlusions) underwent pereutaneous treatment. Eleven PTAs were performed and stents were introduced in two patients because of incomplete PTA. During follow-up, a total of eight revisions were performed in five patients with recurrence(six stenoses and two occlusions). Success and long term patency rates were evaluated. The length and degree of the lesion and degree of residualstenosis, as well as pressure gradient through the lesion and decrease of the gradient after PTA, were correlated with patency rates. Complications during the procedures and follow-up period were evaluated. RESULT: The overall success rate was 89.5%; those of primary and revision intervention were 90.9% and 87.5%, respectively. Primary and revision patency rates were 72.7% and 50%, respectively, at 6 months, and 40% and 25% at 12 months. In five patients who underwent revision, primary and secondary patency rates were 80% and 100% at 6 months, 40% and 80% at 12 months, and 0% and 60% at 18 months. Only reduction of the pressure gradient after PTA correlated significantly with patency rates. No significant complications observed during the procedures follow-up period. CONCLUSION: PTA and stent insertion is effective for the treatment of central venous steno-occlusion.

Interventional Recanalization of Artificial Arteriovenous Fistula and Graft for Hemodialysis: Angioplasty andPulsed-Spray Thrombolysis with Urokinase

PURPOSE: To evaluate the effectiveness of percutaneous transluminal angioplasty (PTA) and pulsed-spraypharmacomechanical thrombolysis (PSPMT) using urokinase for the management of insufficient hemodialysis access. MATERIALS AND METHODS: Between September 1996 and May 1998, 21 insufficient hemodialysis accesses were treated in16 patients (3 artificial arteriovenous fistulae, AVF ; and 13 arteriovenous graft, AVG). PTA and PSPMT were performed in 6 and 15 and 15 cases, respectively, and success and long-term patency rates were evaluated. RESULTS: The overall success rate of PTA and PSPMT for insufficient hemodialysis access was 76.2%(16/21). The success rates of PTA and PSPMT were 83.3%(5/6) and 73.3%(11/15), respectively. the primary patency rates of PSPMT were 69+/-12.8% at 6 months and 38+/-18.6% at 12 months. One of the two initially successful PTAs had been patent for 7months, and the second PTA was performed at that time due to venous stenosis. The other was patent for 15 months throughout the follow-up period. CONCLUSION: PTA and PSPMT are effective primary methods for the treatment of insufficient hemodialysis access ; success and patency rates were high, and the procedures can be performed repeatedly.

Radiologic Findings of Pulmonary Endometriosis

PURPOSE: To evaluate the effectiveness of percutaneous transluminal angioplasty (PTA) and pulsed-spraypharmacomechanical thrombolysis (PSPMT) using urokinase for the management of insufficient hemodialysis access. MATERIALS AND METHODS: Between September 1996 and May 1998, 21 insufficient hemodialysis accesses were treated in 16 patients (3 artificial arteriovenous fistulae, AVF ; and 13 arteriovenous graft, AVG). PTA and PSPMT were performed in 6 and 15 and 15 cases, respectively, and success and long-term patency rates were evaluated. RESULTS: The overall success rate of PTA and PSPMT for insufficient hemodialysis access was 76.2%(16/21). The success rates of PTA and PSPMT were 83.3%(5/6) and 73.3%(11/15), respectively. the primary patency rates of PSPMT were 69+/-12.8% at 6 months and 38+/-18.6% at 12 months. One of the two initially successful PTAs had been patent for 7months, and the second PTA was performed at that time due to venous stenosis. The other was patent for 15 months throughout the follow-up period. CONCLUSION: PTA and PSPMT are effective primary methods for the treatment of insufficient hemodialysis access ; success and patency rates were high, and the procedures can be performed repeatedly.

Early Detection and Percutaneous Transluminal Angioplasty of Hemodialysis Fistula Stenoses: Correlation withVenous Dialysis Pressure and Urea Recirculation Rate

PURPOSE: To evaluate the usefulness of venous dialysis pressure(VDP) and urea recirculation rate(URR) for theearly detection of venous stenoses, the most common cause of hemodialysis fistular failure. To correlate theoutcome of early percutaneous transluminal angioplasty(PTA) with VDP and URR after PTA. MATERIALS AND METHODS: Eighty one chronic hemodialysis patients were monitored for VDP and URR during each session of hemodialysistreatment. Twenty-eight patients with elevated VDP and URR underwent fistulography, and the results wereprospectively analysed. PTA was performed in twelve discrete stenoses(>70% reduction of the lumen) in sixpatients. Following PTA, VDP and URR were reevaluated. RESULT: Fistulogramas showed that 15 of 28 patients had 22stenoses. All of these lesions occurred in the proximal vein of an arteriovenous fistula, showing less than 50%reduction of the lumen in six stenoses, 50-70% in four, more than 70% in twelve, and no complete occlusion.Stenosis length was less than 1cm in twelve lesions, 1-3cm in seven, and 3-6cm in three. In 11 of 12 stenoses,angioplasty was successful with no significant residual stenosis remaining. After PTA, mean VDP and URR fellsignificantly : 117.8+/-20.6 mmHg to 99.8+/- 8.2 mmHg (p=0.025), and 22.9+/-16.1 to 7.6+/-7.2(p=0.014), respectively. CONCLUSION: Early detection and early PTA of venous stenoses led to a high initial patency rate when used inconjuction with elective measurement of VDP and URR. After PTA, VDP and URR fell significantly, and there wasclose correlation with the outcome of PTA.