The Bird's Nest inferior vena caval filter: review of a single-center experience.

PURPOSE: To examine a large single-center experience with Bird's Nest vena caval filters for indications, clinically evident recurrent thromboembolic disease, and other filter-related complications. MATERIALS AND METHODS: During a 6-year period, 308 patients underwent percutaneous placement of an inferior vena caval filter. The 267 patients who received a Bird's Nest filter are the subject of this retrospective review. The series included 162 men and 105 women who ranged in age from 16 to 88 years (mean, 57.1 +/- 17.0 standard deviation). RESULTS: Indications for filter placement included contraindication to anticoagulation (n = 141), complication of anticoagulation (n = 23), failure of anticoagulation (n = 30), failure of previously placed filter (n = 1), and prophylaxis (n = 82). Ten patients had more than one indication. Acute lower extremity deep venous thrombosis was confirmed in 133 patients, pulmonary embolism (PE) was found in 44 patients, and both were positively diagnosed in 37 other patients. Fifty-three patients had no documented acute thromboembolic disease at the time of insertion. Mean follow-up was 13 months. Thirty-day mortality was 9.7%, including one death from recurrent PE and one major puncture-site bleeding episode that may have contributed to death. Recurrent PE was found at radionuclide scanning or autopsy in three patients (1.1%), whereas another eight patients (3.0%) had suspected recurrent PE without confirmatory studies. Eight patients (3.0%) developed early venous access site thrombosis, including two who progressed to phlegmasia cerulea dolens with fatal complications. Significant nonthromboembolic problems were encountered in 1.9% of patients. CONCLUSIONS: The Bird's Nest filter is a safe and effective device for patients with complicated venous thromboembolic disease.

Thrombolysis versus surgery as the initial management for native artery occlusion: efficacy, safety, and cost.

BACKGROUND: A controversy has evolved as to which therapy, thrombolysis or thromboembolectomy, represents the optimal initial treatment for acute native artery occlusion. METHODS: Forty-eight cases of acute class I or II limb ischemia caused by native artery occlusion were retrospectively analyzed between 1988 and 1993. Nineteen of the patients were initially treated with thrombolysis (group 1), and 29 underwent thromboembolectomy (group 2). RESULTS: Initial clinical improvement was seen in 11 (57.9%) of 19 extremities in group 1, with complete clot resolution in 21%, partial lysis in 47.4%, and no angiographic improvement in 31.6%. Significantly superior results were achieved in group 2; 28 (97%) of 29 limbs showed clinical improvement after initial surgical therapy (p = 0.001). Limb salvage was 88.2% in group 1 and 96.6% in group 2 (p = 0.5). Adjunctive procedures for limb salvage were necessary in 10 (52.6%) of 19 limbs in group 1 compared with only five (17.2%) of 29 limbs in group 2 (p = 0.013). Perioperative mortality was 10.5% and 10.3% (p = 1.0), whereas major postoperative complications occurred in 63.2% and 37% of patients in groups 1 and 2, respectively (p = 0.14). Hospital and professional patient charges were analyzed for the 12 most recent patients from each group. Total mean charges per patient were higher in group 1 ($45,171) than in group 2 ($24,898) (p = 0.046). CONCLUSIONS: Patients initially treated surgically achieved better immediate clinical results with significant cost savings and without significant differences in morbidity, mortality, or limb salvage compared with patients treated initially by thrombolysis.

Portal hypertension: surgical management in the 1990s.

BACKGROUND: Although liver transplantation offers definitive treatment for portal hypertension with end-stage liver failure, surgical portosystemic shunts avoid the risks of transplantation and immunosuppressive therapy, and transjugular intrahepatic portosystemic shunt (TIPS) creates a portosystemic shunt with minimal operative risk. The appropriate applications of these modalities are discussed. METHODS: All adults undergoing primary liver transplantation alone (PLT, n = 265), PLT after TIPS (n = 34), PLT after surgical shunts (n = 12), surgical shunt alone (n = 13), TIPS alone (n = 35), or surgical shunt after PLT (n = 5) served as the basis of this study. RESULTS: In contrast to surgical shunts before PLT, TIPS before PLT increased the 1-year graft survival. Surgical shunts alone were done in 18 patients with normal or near normal liver function with 100% survival. TIPS alone offered effective symptomatic relief to most patients, all of whom were judged not to be surgical candidates. CONCLUSIONS: TIPS, surgical shunts, and liver transplantation each have a logical role in management of portal hypertension. Surgical candidates with Child's B or C liver failure should be treated with liver transplantation, and TIPS offers effective treatment for nonsurgical candidates. Surgical shunts can be performed with excellent results in patients with Child's A liver disease. Portal vein occlusion with normal liver function can be successfully treated with surgical shunts.

Crack and aortic dissection.

Aortic dissection represents a medical and, potentially, surgical emergency. Hypertension and cystic degeneration of the media are predisposing risk factors in the pathogenesis. Sporadic reports of aortic dissection in association with drug abuse especially crack cocaine are now appearing. We present such a patient whom we recently treated at University of Wisconsin Hospital.

Transthoracic 2D echocardiographic guidance for percutaneous removal of a nonopaque intracardiac catheter fragment.

A radiolucent fragment of a fractured central venous catheter embolized to the right heart resulting in life-threatening dysrhythmias in a middle-aged male patient who had undergone orthotopic liver transplantation 1 day earlier. The fragment was removed via the right transjugular route using sonographic guidance to entrap the fragment with a brightly echogenic snare. The technique described protects the caval anastomoses in the liver transplant recipient and overcomes the limitation of fluoroscopy in removing radiolucent bodies.

Abdominal abscesses associated with enteric fistulas: percutaneous management.

For many years, surgical dictum stated abdominal fistulas should be treated by means of surgical excision. Recent advances in percutaneous techniques have altered this. The authors reviewed 150 consecutive abdominal abscesses drained percutaneously over a 36-month period. Among these, 24 patients were found to have 26 fistulous communications to bowel, the pancreatic duct, or the biliary system. Initial drainage of their abscesses was performed in the hospital, but 17 of 24 patients were discharged with a tube in place and were followed up as outpatients. The duration of drainage ranged from 4 days to 3 months. Fistulas healed in 21 of 24 patients (88%) without surgical intervention. Complications were few and included inadvertent dislodgment requiring tube replacement (two patients) and inadvertent puncture of the transverse colon (one patient). Treatment of abdominal abscesses with fistulas by means of percutaneous methods is reliable and safe. Hospital stay may be minimized with outpatient management after drainage.

Pancreatic pseudocyst with fistula to the common bile duct: radiological diagnosis and management.

A patient was found to have fistulization of a pancreatic pseudocyst with the common bile duct. Resolution of the pseudocyst and the attendant biliary obstruction was achieved with percutaneous biliary drainage alone. The clinical and radiological features of this case are herein presented along with a brief review of the subject.

Milk of calcium pericardial effusion: case report.

A patient with milk of calcium (MOC) pericardial fluid secondary to radiation therapy is presented. We have been unable to identify a previous report of MOC pericardial fluid.

A safe route for deep pelvic biopsy with distention of the iliacus muscle.

To avoid bowel perforation during deep pelvic biopsy, the authors describe a technique in which the iliacus muscle is distended by injecting it with a solution of lidocaine and saline. This muscle distention causes sufficient bowel displacement to allow safe advancement of biopsy needles as large as 14 gauge through the distended muscle belly to the region of interest.

A new guidewire with kink-resistant core and low-friction coating.

A new guidewire constructed from kink-resistant titanium-nickel alloy, polyurethane, and hydrophilic polymer is described. We have used this wire in 119 angiographic and 49 interventional procedures without complications. In numerous applications, it offers significant advantages over other guidewires. It is particularly helpful for angiography and interventional procedures requiring catheterization through markedly tortuous vessels, tight stenoses, or occlusions.

Review of the uses of digital "road map" techniques in interventional radiology.

The "road map" technique, an outgrowth of digital subtraction arteriography, is a little-appreciated but most helpful technique in performing numerous interventional angiographic and non-angiographic procedures.

Percutaneous dilation of ureteral strictures in renal transplant patients.

Percutaneous dilation of benign ureteral strictures was performed as an alternative to surgical therapy in 14 patients with renal transplants. Dilations were performed with balloon catheters in 13 patients and with a tapered angiographic catheter in one patient. Eleven strictures were successfully dilated (79%). There were three recurrences (21%). Follow-up in nine of the 11 successful cases ranged from 12 to 61 months (mean, 29 months; median, 24 months). There were no complications directly related to balloon dilation. The high success rate in this series may be related to the early diagnosis of strictures in these closely followed patients.