Palliative gastrostomy in the setting of voluminous ascites.

OBJECTIVE: We report the indications, methods, and complications of percutaneous gastrostomy/gastrojejunostomy (G/GJ) in patients with voluminous ascites. METHODS: Following institutional review board approval, 69 patients (14 male, 55 female, mean age 58±12 years, range 32-89 years) who underwent percutaneous G/GJ with paracentesis were identified from a prospectively acquired database. Electronic medical record data extracted included diagnosis, method of G/GJ insertion, clinical course, and complications, which were graded by The Society of Interventional Radiology (SIR) criteria. Statistics were performed using Graphpad Instat. RESULTS: Sixty-six G and three GJ catheters were placed in 62 patients with malignant and 7 patients with benign disease; 47 procedures were conducted using fluoroscopy and 22 using computed tomography (CT; 10 patients had failed fluoroscopy). Sixty-six patients had 1980±1371 mL (range, 20-5000 mL) ascites drained (more in males, p=0.01) 0.8±1.6 days (range, 0-5 days) prior to placement. Forty-one patients had significantly less ascites (1895±1426 mL; range, 100-5400 mL) drained after G/GJ (p>0.0.5). Mean survival after insertion was 43±57 days (range, 1-252 days) among 38 patients for whom data were available. Fifty-six patients had a mean postprocedure hospital stay of 8.6±8.4 days (range, 0-45 days); 3 were outpatients and 10 patients died in the hospital. Successful gastropexy was confirmed on subsequent cross-sectional imaging in 22 of 25 patients. There were 25 tube maintenance issues that included catheter displacement and leakage, one patient experienced hemorrhage, and there were two deaths. All except one patient had satisfactory gastrostomy function. CONCLUSION: Effective G/GJ placement is possible in most patients with voluminous ascites provided ascites is drained and gastrocutaneous fistula formation occurs. Caution is advised; placement is generally for fragile terminal patients, and fluoroscopy or CT guidance is required.

Hemodynamically significant arterial inflow stenosis in dysfunctional hemodialysis arteriovenous fistulae and grafts.

PURPOSE: Hemodynamically significant arterial inflow stenosis in dysfunctional fistulae and grafts is poorly understood. No reliable clinical methods exist to detect arterial inflow stenosis. In this study, we assessed the accuracy of a novel screening method to detect arterial inflow stenosis in dysfunctional fistulae and grafts following successful juxta-anastomotic and venous outflow intervention. METHODS: We prospectively evaluated all patients (N= 204) referred to our academic center for angiographic evaluation of a dysfunctional dialysis fistula/graft from May 1, 2006 to June 30, 2007. Following successful angioplasty/stenting of the venous outflow and juxta-anastomotic areas, patients were screened for arterial inflow stenosis. The screening method involved detection of 1) weak thrill, or sluggish blood flow on the post-intervention angiogram, 2) low mean arterial blood pressures in the dialysis access arm compared to the contralateral arm, and 3) inadequate blood flow at the first hemodialysis session post-intervention. If patients screened positive for any of these, they were further evaluated for arterial inflow stenosis. RESULTS: Fifteen patients (15/204) were positive for arterial inflow stenosis on screening study. Eleven of those 15 had arterial stenosis on angiography, giving our screening method a positive predictive value of 73.3%. Eight patients were successfully treated by angioplasty/stenting. Two patients successfully underwent surgical intervention. Two year patency of revascularization was 91% (10/11). CONCLUSIONS: Hemodynamically significant arterial inflow stenosis occurs and can be detected by simple clinical methods. Interventions for correction of the arterial inflow stenosis are successful.