Value of superficial cultures for prediction of catheter-related bloodstream infection in long-term catheters: a prospective study.

Cultures taken from the skin and from the hubs of short-term central venous catheters can help us to predict catheter-related bloodstream infections (C-RBSIs). The value of these cultures for such predictions has not been assessed in long-term catheters. Our objective was to assess the value of superficial cultures for the prediction of C-RBSI among patients with long-term catheters. Over a 2-year period, we prospectively obtained cultures from the skin overlying reservoir ports (group A) and from the skin insertion site and hubs of all tunneled catheters (group B). This routine was performed by vascular and interventional radiologists immediately before catheter removal (irrespective of the reason for withdrawal). Swabs were processed semiquantitatively. Catheter tips from both groups were cultured using Maki's semiquantitative technique and sonication. We also performed cultures of the reservoir ports at different sites. C-RBSI was defined as the isolation of the same species of microorganism(s) both in the colonized catheter and in at least 1 peripheral blood culture. We included 372 catheters (group A, 223; group B, 149) during the study period. The catheter colonization rate was 23.4% (87/372), and 28 patients had C-RBSI. Validity index values for the capacity of surface cultures to predict C-RBSI in groups A and B were, respectively, as follows: sensitivity, 23.5% and 45.5%; specificity, 59.7% and 63.0%; positive predictive value, 4.6% and 8.9%; and negative predictive value, 90.4% and 93.5%. Superficial cultures of patients with long-term catheters could help us to rule out the catheter as the portal of entry of bloodstream infections. Superficial cultures (from skin and hubs) proved to be a useful conservative diagnostic tool for ruling out C-RBSI among patients with long-term tunneled catheters and totally implantable venous access ports.

Use of universal 16S rRNA gene PCR as a diagnostic tool for venous access port-related bloodstream infections.

Amplification of the universal 16S rRNA gene using PCR has improved the diagnostic yield of microbiological samples. However, no data have been reported on the reliability of this technique with venous access ports (VAPs). We assessed the utility of 16S rRNA PCR for the prediction of VAP-related bloodstream infection (VAP-RBSI). During a 2-year period, we prospectively received all VAPs removed by interventional radiologists. PCR and conventional cultures were performed using samples from the different VAP sites. We compared the results of PCR with those of conventional culture for patients with confirmed VAP-RBSI. We collected 219 VAPs from 219 patients. Conventional VAP culture revealed 15 episodes of VAP-RBSI. PCR revealed a further 4 episodes in patients undergoing antibiotic therapy which would have gone undetected using conventional culture. Moreover, it had a negative predictive value of 97.8% for the prediction of VAP-RBSI when it was performed using biofilm from the internal surface of the port. In conclusion, universal 16S rRNA PCR performed with samples from the inside of VAPs proved to be a useful tool for the diagnosis of VAP-RBSI. It increased detection of VAP-RBSI episodes by 21.1% in patients undergoing antibiotic therapy whose episodes would have gone undetected using conventional culture. Therefore, we propose a new application of 16S rRNA PCR as a useful tool for the diagnosis of VAP-RBSI in patients receiving antibiotic therapy.

How should long-term tunneled central venous catheters be managed in microbiology laboratories in order to provide an accurate diagnosis of colonization?

Guidelines recommend the roll-plate technique for short-term central venous catheter (CVC) tip cultures. However, the issue of whether the roll-plate technique is better than the sonication method for long-term CVCs remains unresolved. In addition, no data are available for predicting the value of direct Gram staining in anticipating catheter colonization or catheter-related bloodstream infection (CRBSI) in these long-term CVCs. Our objectives were to compare the roll-plate technique and the sonication method and to define the validity values of Gram staining for the prediction of colonization and CRBSI in patients with long-term tunneled CVCs. During the study period, all tunneled CVCs removed at our institution were prospectively and routinely sent to the microbiology laboratory for Gram staining (first) and tip culture (the Maki technique and sonication, in a random order). We received 149 tunneled CVCs, 39 (26.2%) of which were colonized and 11 (7.4%) of which were associated with CRBSI. Overall, the roll-plate method detected 94.9% of the colonized catheters, whereas sonication detected only 43.6% (P < 0.001). The validity values of Gram staining for the detection of colonization and CRBSI were as follows: a sensitivity of 35.9% to 60.0%, a specificity of 100% to 94.2%, a positive predictive value of 100% to 42.9%, and a negative predictive value of 81.5% to 97.0%. The roll-plate technique proved to be better than sonication for the detection of bacteria in long-term tunneled CVCs. Gram staining of the tips of tunneled CVCs can anticipate a positive culture and rule out CRBSI. In our opinion, direct Gram staining should be incorporated into routine microbiological assessments of long-term catheter tips.

Expanded PTFE-covered stent-grafts in the treatment of transjugular intrahepatic portosystemic shunt (TIPS) stenoses and occlusions.

BACKGROUND: We evaluated the efficacy of the VIATORR endoprosthesis for the management of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction. METHODS: Twelve consecutive patients (10 men and two women, mean age 52.7 years) with recurrent TIPS dysfunction underwent TIPS revision with use of the VIATORR endoprosthesis. Nine patients were asymptomatic and three patients had developed recurrent variceal bleeding. All patients had previous shunt revisions (mean 2.1 revisions per patient) with angioplasty or bare stents. Follow-up included clinical assessment, Doppler ultrasound, and portal venography. RESULTS: TIPS revision was successful in all patients, without complications. The mean portosystemic pressure gradient decreased from 16.8 +/- 2.7 mmHg to 6.5 +/- 2.6 mmHg. Hemostasis was achieved in all three patients who had recurrent variceal bleeding at the time of the procedure. Mean follow-up was 21.9 +/- 10.7 months. In two patients TIPS dysfunction occurred at 14 and 30 months after stent-graft placement, respectively. The primary patency rates were 100% after 12 months and 88.8% after 24 months. Two patients (16.6%) developed encephalopathy after stent graft placement. CONCLUSION: TIPS revision using the VIATORR endoprosthesis appears to be an effective and durable method to control shunt dysfunction.

Tratamiento endovascular de la patología de la aorta descendente: experiencia preliminar sobre cinco casos / Endovascular treatment of the descending thoracic aorta diseases: preliminary experience about five cases

Objetivo. Analizar nuestros resultados en el tratamiento endovascular de cinco casos con patología de la aorta torácica descendente. Pacientes y métodos. Hemos tratado mediante la colocación de endoprótesis recubierta a cinco pacientes varones, con una edad media de 63 años (54-72) y con diversa patología de la aorta torácica descendente. Las patologías fueron: dos aneurismas de aorta torácica descendente de 7 y 7,5 cm de diámetro, respectivamente, una fístula aortobronquial, una rotura traumática a nivel del itsmo y una disección aguda tipo B. Las endoprótesis implantadas fueron en cuatro tipo TalentÔ y una AneuRxÔ. Resultados. En todos los casos se consiguió el éxito técnico y clínico inmediato. Como complicación postoperatoria se presentó un caso de monoparesia radial no relacionada directamente con el procedimiento. La media de seguimiento ha sido de 11 meses (6-18). En todos los casos se realizó una TAC a los 3, 6 y 12 meses sin que se presentara ninguna complicación. Conclusión. La técnica endovascular ha resultado eficaz y segura para el tratamiento de las patologías de la aorta torácica descendente (AU)

Randomized controlled trial of aspiration needle versus automated biopsy device for transjugular liver biopsy.

PURPOSE: The efficacy and safety of transjugular liver biopsy used to obtain liver specimens in patients with coagulation disorders have been widely proven. However, histopathologic examination is not always possible because of fragmented samples provided by the aspiration technique. Recently, an automated device with a Tru-Cut-type needle was designed. In this randomized controlled trial, the use of this new device is compared with the traditional method in terms of efficacy and safety. METHOD: Fifty-six patients were included in the study; 28 were randomized to undergo the aspiration technique and 28 were randomized to undergo the automated biopsy technique. RESULTS: Correct positioning of the device was achieved in 93% of patients undergoing the aspiration technique and 96% of patients undergoing the automated biopsy technique (P = NS). Mean duration of the procedure and total number of passes were significantly higher in the aspiration needle group than in the automated device group (22.6 min +/- 12.6 vs 15.5 min +/- 9.4; P = .03, and 3.3 min +/- 1.9 vs 1.5 min +/- 0.63; P < .001, respectively). The number of portal tracts was significantly higher in the automated device group (4.7 +/- 2.5 vs. 2.7 +/- 3.4; P < .05). Adequate specimens for histopathologic evaluation were obtained in 26 patients in the automated device group and 24 patients in the aspiration needle group (92.8% vs 85.7%; P = NS), but a definite histopathologic diagnosis was more frequently obtained with the automated biopsy device (68% vs 43%; P = .05). No significant differences were observed in complication rates (7.14% vs. 10.7%; P = NS). CONCLUSION: The automated biopsy device for transjugular liver biopsy is more effective than an aspiration needle in obtaining good samples for a definite histologic diagnosis.

Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation.

PURPOSE: To determine the effectiveness and safety of metallic stents in the treatment of malignant colorectal obstruction before surgery and for palliation. MATERIALS AND METHODS: Eighty patients with acute malignant colorectal obstruction presumed to be malignant were treated by means of implanting self-expanding metallic stents. RESULTS: Stent placement was successful in 70 of the 80 patients and resolved bowel obstruction in 67 patients (96%). Two patients had colonic perforation and developed peritonitis 18 and 24 hours after stent placement; one patient died as a consequence. Thirty-three patients underwent elective surgery after 7 days +/- 3 (SD; range, 4-10 days), and adequate tumoral coverage and cleansing of the colon were observed in all patients. Stent placement was used as final palliative treatment in another 35 patients. Patient follow-up lasted a mean of 138 days +/- 93 (range, 36-334 days). The survival rate for the palliative group was 55% at 3 months, 44% at 6 months, and 25% at 9 months. The estimated primary stent patency rate was 91% at 3 and 6 months. CONCLUSION: Management of colorectal obstruction by using metallic stents was effective and safe, although colonic perforation is a potential complication. In cases of palliation, the method may obviate palliative colostomy.

[Prognostic factors for survival following transarterial chemoembolization in advanced hepatocellular carcinoma]. / Factores pronósticos de supervivencia del carcinoma hepatocelular avanzado tras quimioembolización transarterial.

The efficacy of transarterial chemoembolization in the palliative treatment of non-resectable hepatocellular carcinoma is controversial. To determine the possible existence of clinical and analytical variables with independent predictive value for survival related to the tumor and the treatment given, a multivariate analysis in a series of 111 patients who underwent transarterial chemoembolization was carried out. Overall actuarial survival was 54%, 31% and 24% at 1, 2 and 3 years respectively. Child-Pugh score (p < 0.05), tumor size (p < 0.05) and arterial occlusion after intraarterial chemotherapy (p < 0.05) reached independent predictive value. The group of patients in whom two or three of these factors were simultaneously present had a very poor prognosis with a survival of 20% and 0% at 1 and 2 years respectively, compared with 60%, 50% and 37% at 1, 2 and 3 years respectively in the group with one or none of these factors (p < 0.01). Grouping on the basis of these variables may be useful in the design of future controlled prospective studies that aim to determine the efficacy of transarterial chemoembolization.

[Uretero-iliac fistula]. / Fístula uretero-iliaca.

OBJECTIVE: To describe a case of uretero-iliac fistula, an extremely rare condition that is not easily diagnosed. METHODS/RESULTS: Herein we describe a 76-year-old female who had undergone repeated pelvic surgery for adenocarcinoma of the sigmoid. She had a right ureteral fistula that had been managed conservatively by insertion of a ureteral catheter. Diagnosis was made by selective arteriography of the iliac arteries. The patient was submitted to surgery; primary closure of the arterial fistula and nephroureterectomy were performed. CONCLUSIONS: Uretero-iliac fistula should be suspected in patients with a history of repeated pelvic surgery and ureteral catheter placement that present with massive hematuria.

Transanal self-expanding metal stents as an alternative to palliative colostomy in selected patients with malignant obstruction of the left colon.

BACKGROUND: Palliative colostomy is still unavoidable in many patients with malignant obstruction of the left colon. This report describes an initial experience and follow-up in a small series of patients with left-sided colon obstruction in whom transanal self-expanding metal stent (SEMS) placement was attempted for palliative purposes. METHODS: Palliative transanal SEMS placement was attempted in 11 patients with malignant obstruction of the rectosigmoid region. The selection criteria included patients with advanced pelvic disease, peritoneal carcinomatosis and/or multiple parenchymatous metastatic disease. Wallstent oesophageal endoprostheses were used, and the technique was carried out by interventional radiologists. RESULTS: The technique succeeded in relieving the obstruction in seven patients, and surgical intervention was prevented in six. Five of these six patients died with an unobstructed colon from 26 days to 7 months after SEMS placement. The technique failed in four patients, three of whom underwent emergency colostomy. CONCLUSION: Transanal SEMS placement is an appealing method for the relief of obstruction in selected patients, obviating the need for palliative colostomy.

Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding.

OBJECTIVE: Endoscopic sclerotherapy and pharmacological therapy are widely used in the treatment of acute variceal hemorrhage. However, they fail at arresting acute bleeding in 20-30% of bleeding episodes. The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of recurrent variceal bleeding has been proved recently, but the effectiveness and safety of urgent TIPS in the treatment of acute variceal bleeding refractory to conventional therapy are still under evaluation. METHODS: Over 4.5 yr, 358 variceal hemorrhage episodes were treated in our hospital. Pharmacological and endoscopic therapy failed to control hemorrhage in 93 episodes. Thirty-two patients died because of uncontrolled massive bleeding. In 56 patients, TIPS (Strecker stent) was performed after temporary control of the episode with balloon tamponade. RESULTS: Eleven of 56 patients with urgent TIPS belonged to Child-Pugh class A, 22 to class B, and 23 to class C. The mean time between indication and insertion was 17 +/- 10 h (range 4-24 h). Control of bleeding was achieved in 53 patients (95 %). Eight patients had recurrent bleeding at 1 month after TIPS, seven of them during the first week after the procedure. The 1-month actuarial probability of rebleeding was 22%. The main complications of the procedure were massive hemoperitoneum (n = 1), cardiorespiratory arrest (n = 2), cardiac failure (n = 1), acute renal failure (n = 2), and bacteremia (n = 7). Operative mortality (30 days) was 28%. The actuarial probability of survival at 30 days was significantly lower in Child-Pugh class C than in class A or B (48% vs 90%; p < 0.001). The presence of ascites, hepatic encephalopathy, and serum albumin level before TIPS were independent prognostic factors associated with the risk of operative mortality. CONCLUSIONS: Urgent TIPS is an effective alternative for the treatment of acute variceal bleeding refractory to endoscopic and pharmacological therapy, but sometimes is associated with major complications. Because of the high operative mortality rate in patients with severe liver failure, careful selection of patients is required before TIPS.

Superior mesenteric arterial embolism: local fibrinolytic treatment with urokinase.

PURPOSE: To evaluate the efficacy of intraarterial urokinase in the treatment of superior mesenteric arterial (SMA) embolism. MATERIALS AND METHODS: Within 3 years, 10 patients (six men, four women; aged 62-82 years) with angiographically proved SMA emboli were selected on the basis of absence of peritoneal signs of intestinal necrosis at physical examination and normal abdominal plain radiographs to undergo local lysis with urokinase. RESULTS: The procedure was performed without complications in all 10 patients. The embolus was successfully lysed in nine patients (90%). Clinical success was achieved in seven patients (70%); however, in one patient laparotomy was required to confirm the clinical finding. None of these patients had recurrent embolism or postischemic intestinal stenosis during follow-up (mean, 11.2 months). The three remaining patients (30%) underwent laparotomy subsequent to failure of intraarterial treatment with urokinase. CONCLUSION: Fibrinolytic treatment with urokinase may be an effective alternative to surgical embolectomy in patients with SMA embolism without clinical or radiologic signs of intestinal infarction. In this small series, abatement of abdominal pain in the 1st hour of fibrinolytic treatment was the best indicator of clinical success. Pain persisted in patients with intestinal infarction.

Effects of transjugular intrahepatic portasystemic shunt (TIPS) on splanchnic and systemic hemodynamics, and hepatic function in patients with portal hypertension. Preliminary results.

The purpose of this study was to evaluate the short-term splanchnic and systemic hemodynamics and hepatic function after TIPS creation. Fifteen cirrhotics with portal hypertension underwent TIPS placement for treatment of variceal hemorrhage, and extensive hemodynamic studies including right heart catheterization, portal pressure measurement, hepatic blood flow, and indocyanine green (ICG) clearance were performed before and 1 month after the procedure. Self-expandable metal stents (Strecker 11 mm diameter) were placed in all cases. Portasystemic gradient significantly diminished (18.3 +/- 4.2 vs 8 +/- 2.8; 54% +/- 18 mm Hg) after the technique, mainly due to a decrease in portal pressure, and remained stable in the final study. Cardiac output and mean arterial pressure increased (6.2 +/- 1.4 vs 8.2 +/- 1.8 liters/min, 80.1 +/- 10.1 vs 91 +/- 11.2 mm Hg, respectively), and a decrease in systemic vascular resistance was registered (1018 +/- 211 vs 872 +/- 168 dyne/sec/cm5); the hepatic blood flow and ICG clearance also decreased significantly (1.5 +/- 0.7 vs 0.68 +/- 0.2 liters/min, 0.4 +/- 0.2 vs 0.24 +/- 0.06 liters/min, respectively). There was an increase in the preload at the final study, as evidenced by a marked increase in right atrial (3.1 +/- 1.6 vs 4.35 +/- 2.2 mmHg, +15%, P < 0.05), pulmonary arterial (12.2 +/- 2.4 vs 15.9 +/- 3.2 mm Hg, +31.8%, P < 0.001), and wedge pulmonary arterial pressures (6.9 +/- 2.4 vs 9.8 +/- 3.1 mm Hg, +53%, P < 0.001). These results suggest that TIPS worsens the hyperdynamic syndrome associated to portal hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Stenosis of the inferior vena cava after liver transplantation: treatment with Gianturco expandable metallic stents.

PURPOSE: Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT). METHODS: Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses. RESULTS: One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months. CONCLUSIONS: Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.

[Hemolysis associated with intrahepatic percutaneous portosystemic shunt]. / Hemólisis asociada a la derivación portosistémica percutánea intrahepática.

Two cases of intravascular hemolysis in patients with intrahepatic percutaneous portosystemic shunt are described. This is a recently reported complication, the incidence of which currently remains unknown. Following analysis of different possible mechanisms, it is suggested that a relationship may exist between the hemolysis and the number of the inserted prosthesis and length of the intraportal segment of the stent.

Variceal hemorrhage: efficacy of transjugular intrahepatic portosystemic shunts created with Strecker stents.

PURPOSE: To evaluate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in treatment of variceal hemorrhage. MATERIALS AND METHODS: Forty-five patients with cirrhosis underwent TIPS placement for treatment of acute (n = 12) or recurrent (n = 33) variceal hemorrhage. Shunts were created with Strecker stents. RESULTS: Shunts were established by deployment of stents in 42 patients. The portosystemic pressure gradient decreased from an average of 20.4 mm Hg +/- 5.4 to 9.2 mm Hg +/- 4.1. Complications included hepatic failure (n = 1), acute shunt thrombosis (n = 2), right jugular vein thrombosis (n = 1), bacteremia (n = 1), and stent misplacement (n = 1). Acute bleeding was controlled in 12 patients. The 30-day mortality rate was 2%; four other patients have since died. During follow-up (mean, 8.9 months), variceal bleeding recurred in six patients. Hepatic encephalopathy developed in six patients. Shunt stenosis or occlusion requiring further intervention occurred in 20 patients. CONCLUSION: TIPS are safe and effective in treatment of variceal hemorrhage; however, secondary interventions are often required to preserve shunt function.