Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival.

PURPOSE: To identify clinical and technical factors influencing the outcome of transcatheter embolotherapy for nonvariceal upper gastrointestinal (GI) hemorrhage and to quantify the impact of successful intervention on patient survival. MATERIALS AND METHODS: A retrospective review was performed of all patients (n = 163) who underwent arterial embolization for acute upper GI hemorrhage at a university hospital over an 11.5-year period. Clinical success was defined as target area devascularization that resulted in the clinical cessation of bleeding and stabilization of hemoglobin level. The clinical condition of each patient at intervention was defined by history, laboratory examination, and two composite indicator variables. With use of logistic regression, the dependent variable, clinical success, was modeled on two categories of clinical and technical variables. A final model regressed patient survival on clinical success and other clinical variables. RESULTS: None of the procedural variables analyzed had a significant influence on clinical success. Several clinical variables did impact clinical success, including multiorgan system failure (OR, 0.36; P =.030), coagulopathy (OR, 0.36; P =.026), and bleeding subsequent to trauma (OR, 7.1; P =.040) or invasive procedures (OR, 6.5; P =.009). Regardless of their clinical condition at intervention, patients who underwent clinically successful embolization were 13.3 times more likely to survive than those who had an unsuccessful procedure (CI, 4.54-39.2; P =.000). Nevertheless, patients with multiorgan system failure were 17.5 times more likely to die, independent of the outcome of the procedure (CI, 0.014-0.229; P =.000). CONCLUSION: Arresting nonvariceal upper GI hemorrhage with transcatheter embolotherapy has a large positive effect on patient survival, independent of clinical condition or demonstrable extravasation at intervention. Aggressive treatment with transcatheter embolotherapy is advisable in patients with acute nonvariceal upper GI hemorrhage.

Sarcomas metastatic to the liver: response and survival after cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol chemoembolization.

PURPOSE: To evaluate the response to and survival after chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol for patients with sarcomas metastatic to the liver that are surgically unresectable. MATERIALS AND METHODS: Sixteen patients were treated. Primary tumors included 11 gastrointestinal leiomyosarcomas, two splenic angiosarcomas, one leiomyosarcoma of the broad ligament, one leiomyosarcoma of the inferior vena cava, and one malignant fibrous histiocytoma of the colon. Chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol particles was performed 1-5 times at approximately monthly intervals (mean, 2.8). Pre- and posttreatment cross-sectional imaging was performed 1 month after completion of treatment and then every 3 months. Thirty-day response was graded according to World Health Organization/Eastern Cooperative Oncology Group criteria. Survival was calculated with use of Kaplan-Meier analysis. RESULTS: Two patients (13%) exhibited partial morphologic response, 11 patients (69%) were morphologically stable, and three (19%) demonstrated progression of disease 30 days after completion of treatment. Among the 13 responders, two underwent partial hepatectomy after initial treatment. Seven developed intrahepatic progression at a mean of 10 months and a median time of 8 months. The remaining four patients had no documented intrahepatic progression at the time of last imaging follow-up. Nine patients developed extrahepatic progression at a mean time of 6.3 months and a median time of 6 months, of whom four underwent additional surgical resection. Response to therapy was based on time of first intervention. Cumulative survival from time of diagnosis with use of Kaplan-Meier analysis was 81% at 1 year, 54% at 2 years, and 40% at 3 years. Median survival time was 20 months. Cumulative survival from initial chemoembolization was 67% at 1 year, 50% at 2 years, and 40% at 3 years, with a median survival time of 13 months. The thirty-day mortality rate was zero. CONCLUSION: Durable tumor response with chemoembolization is possible in this form of metastatic disease, which is highly resistant to systemic chemotherapy.

Investigation of antibiotic prophylaxis usage for vascular and nonvascular interventional procedures.

PURPOSE: To investigate current antibiotic prophylactic usage for arteriography, angioplasty, vascular stent placement, transjugular intrahepatic portosystemic shunt placement (TIPS), tunneled-port placement, inferior vena cava (IVC) filter placement, biliary drainage, genitourinary drainage, abdominal drainage, and enteral tube placement with an aim to better clarify indications and regimens for prophylaxis. METHODS: A questionnaire regarding antibiotic prophylactic usage was sent to 2,039 members of the Society of Cardiovascular and Interventional Radiology (SCVIR). There were 401 respondents. Replies were evaluated for frequency and indications of prophylaxis, specific prophylaxis used, and clarity of indications for prophylaxis. RESULTS: A majority of responders never used prophylaxis for arteriography, angioplasty, vascular stent placement, IVC filter placement, abdominal drainage, and enteral tube placement. Infective complication rates from nonusage ranged between 1% and 15%. Approximately 45% always used prophylaxis for tunneled-port placement and TIPS with a 13%-16% infective complication rate among nonusers. In contrast, a majority of responders always used prophylaxis for biliary and genitourinary drainage, with a 40%-58% infective complication rate in nonusers. More than 70% of responders believed that the indications for prophylaxis were not clear for arteriography, angioplasty, vascular stent placement, tunneled-port placement, TIPS, IVC filter placement, and enteral tube placement, and in contrast, that the indications for prophylaxis for biliary and genitourinary drainage were clear. Fifty-one percent of responders believed that indications for prophylaxis for abdominal drainage were clear. CONCLUSIONS: Indications for antibiotic prophylaxis are not clear to interventionalists for a large number of vascular and nonvascular interventional procedures. Prophylaxis appears unnecessary for routine arteriography, angioplasty, IVC filter placement, vascular stent placement, or enterostomy tube placement. Antibiotic prophylaxis is warranted for TIPS and tunneled-port placement. Conversely, indications for antibiotic prophylaxis are clear to interventionalists for biliary and genitourinary drainage procedures. Routine prophylaxis remains warranted for both.

Value of radiography in diagnosing complications of cardioverter defibrillators implanted without thoracotomy in 437 patients.

OBJECTIVE: This study evaluated the usefulness of radiography in assessing the frequency and cause of complications of nonthoracotomy-implanted cardioverter defibrillators. MATERIALS AND METHODS: Between May 1992 and December 1995, 437 consecutive patients at our institution underwent cardioverter defibrillator placement. Routine follow-up included external device testing at 6 weeks after placement and every 3 months thereafter. Chest radiographs were obtained immediately after placement, annually, and at the time of any suspected complication. Retrospective review of radiographs and medical charts was done for all patients with clinical complications. RESULTS: Forty-five complications (10%) were clinically diagnosed: lead or patch fracture in fifteen (33%) patients, electric lead dysfunction in eight (18%), infection in eight (18%), lead retraction in six (13%), patch fold in two (5%), hematoma in two (5%), and other complications in four (9%) patients. Eighteen complications (40%) were radiographically evident. Lead retraction, hematoma, patch fold, patch migration, and the twiddler syndrome were radiographically confirmed in 100% of cases. The average time for these complications to be detected was 68 days; 92% were detected within 23 days. Conversely, only four (27%) lead fractures, one (13%) electric lead dysfunction, and one (13%) infection were radiographically confirmed. These latter complications were discovered an average of 579 days after cardioverter defibrillator placement. CONCLUSION: Radiography plays a secondary role in the diagnosis of cardioverter defibrillator complications and is particularly limited beyond 1 month after placement. Radiographs may be helpful in the first month after placement because early complications are the most radiographically apparent.

Persistent iliac endarteritis with pseudoaneurysm formation following balloon-expandable stent placement.

We present a patient who developed endarteritis and pseudoaneurysm formation complicating iliac artery stent placement. Blood cultures grew Staphylococcus aureus. Three weeks after antibiotic treatment, the aortic bifurcation and the stents were removed, together with the left common iliac artery pseudoaneurysm. As with any other implantable device, septic complications are dreaded and should be recognized and treated early. Consideration may be given to the use of appropriate prophylactic antibiotics.

Cardioverter-defibrillator systems implanted without thoracotomy: radiographic findings.

Ventricular arrhythmias are the primary cause of sudden death from heart disease in the United States. In the past decade, management of these arrhythmias has been revolutionized by the development of implantable cardioverter-defibrillators (ICDs). Earlier devices required thoracotomy for implantation (Fig. 1). Complications associated with the earlier devices include pneumothorax, pleural effusion, mediastinal infection, and, notably, crinkling of the patch and migration. The morbidity of median sternotomy has led to the development of ICDs that can be implanted without thoracotomy. We illustrate the normal radiographic appearance and complications of two recently developed ICD lead systems.

Retained anchoring suture after removal of a Cope-loop drainage catheter: use of the retract-and-cut method.

A method is described for managing retention of the anchoring suture within the tract after a Cope-loop drainage catheter has been removed. In the authors' experience, the overwhelming majority of such strings can be extracted by sliding a dilator over the suture and using gentle manipulation at the site of adherence. However, in 12 patients, this technique was not successful. In these patients, the retract-and-cut method was used: The suture is pulled taut and cut at the surface, allowing it to retract into the tract. This provided a safe and simple solution for this complication.

Evaluation of the lacrimal apparatus with digital subtraction macrodacryocystography.

Patients who suffer from epiphora can benefit from reconstructive surgery in many cases of obstructive and nonobstructive lesions of the lacrimal apparatus. We describe our technique of digital subtraction macrodacryocystography (DSM) and discuss its efficacy in the evaluation of various abnormalities involving the lacrimal drainage pathway. A variety of pathologic conditions of the lacrimal apparatus are portrayed. DSM is an accurate, easy to perform, but relatively unrecognized method of anatomic localization of obstructive lesions within the lacrimal drainage system.

Cerebrovascular disease: outpatient evaluation with selective carotid DSA performed via a transbrachial approach.

A total of 355 outpatients and 73 inpatients were studied for cerebrovascular disease with intraarterial digital subtraction angiography (DSA). The studies were performed by means of selective carotid and vertebral artery catheterization from a transbrachial approach. Selective catheterization of the carotid artery was possible in 95% of patients, with definitive examinations of both extra- and intracranial circulation obtained in 95%-100% of all patients. Vessel opacification was very good to excellent, and the technique was inherently free from artifact caused by vessel overlap or involuntary motion. There were 25 complications, of which 20 were local in nature. Iodine load per case was extremely low, averaging 4.2-7.0 g. Selective carotid and vertebral catheterizations by the brachial route proved to be as safe as intravenous DSA and aortic arch intraarterial DSA with less contrast material load and superior images.

Angioplasty of bilateral renal artery occlusion--a case report.

Percutaneous transluminal angioplasty of the renal arteries is a commonly performed procedure. The authors report a case of bilateral recanalization and dilation of occluded renal arteries in a young female. In this case, the procedure allowed for conservative management rather than emergency surgery, which would have been exceedingly hazardous to the patient's renal function and life.

Angiogenic activity of adipose tissue.

Adipose tissue has been used to promote wound healing and to revascularize ischemic myocardium. We explored whether fat from various sources was angiogenic in the cornea. Rabbit subcutaneous and omental fat induced grossly visible neovascularization of all rabbit corneas studied, and at a similar rate and intensity. Neovascularization was not observed in any cornea following control implantation of liver or muscle. Neovascularization was blocked in all rabbits in which indomethacin was administered orally 3 days before implantation of fat and continued following implantation, suggesting that prostaglandins are associated with fat induced angiogenesis.

Transluminal angioplasty of the renal arteries.

Transluminal dilatation of renal artery stenosis for hypertension produces results similar to those of surgery for renal vascular hypertension while avoiding the major morbidity and mortality associated with surgery. In combination with intravenous digital subtraction angiography, it allows the work-up and treatment of this commonly suspected disease with minimal morbidity. It is a much less expensive procedure than surgery. The previously advocated, very involved and expensive preprocedural work-up is also now unnecessary. In patients with suitable lesions and, particularly, in patients who have already experienced some renal dysfunction, percutaneous angioplasty is the technique of choice for improving both renal function and hypertension in the presence of renal artery stenosis.

Economic impact of transluminal angioplasty.

Using actual bills and follow-up records we attempted to determine the economic impact of percutaneous transluminal angioplasty. The patients selected included forty angioplasties performed early in our experience as well as forty comparable patients who had operations in the same period of time. Clinical follow-up was obtained over four years. The statistics obtained demonstrate the hospital bills for angioplasty were only 24% that of surgical treatment for femoral lesions ($1,329.00 versus $6,112.00) and 16% for iliac lesions ($1,353.00 versus $7,732.00). Using this patient sample and readily available statistical data, we calculated direct national savings for using angioplasty on all patients suitable and used a standard value of life analysis to estimate the value of lives saved by doing the less dangerous procedure. The sum total savings in the United States from using angioplasty in all suitable candidates as opposed to surgery would be $180 million per year for femoral lesions and $117 million for iliac lesions. This could produce a significant savings in medical costs over the coming years.

Angiography of skeletal disease.

Recent technical advances have produced two new applications for arteriography in the management of patients with bone tumors: angiography can be used in the planning of free vascularized grafts and in interventional radiologic therapy for bone tumors. Also discussed is the role of angiography in trauma.

Transgastrostomy jejunal intubation for enteric alimentation.

Malnourished patients who cannot maintain an adequate oral intake but have normal intestinal absorption and motility are candidates for enteric alimentation. When impaired gastric peristalsis or an increased risk for aspiration makes gastrostomy feeding unsafe, direct jejunal infusion is the preferred route of alimentation. Angiographic techniques were used to convert previously placed, simple gastrostomies to combined gastrostomy-jejunostomies in 14 patients. In 17 additional patients, a combined gastrostomy-jejunal tube was placed under local anesthesia; angiographic techniques assisted in the placement of 11 of these tubes.

Treatment of acute peripheral arterial and graft thromboses with low-dose streptokinase.

Seventeen patients with acute peripheral arterial or graft occlusion were treated with local low-dose intra-arterial streptokinase. The series includes eight patients with native vessel occlusion, six patients with vein graft occlusion, two patients with prosthetic graft occlusion, and one patient with renal allograft artery occlusion. The duration of occlusion prior to streptokinase therapy varied from 2 hours to 5 weeks. The treatment was successful in 14 of the 17 instances. In conjunction with the successful thrombolytic therapy, percutaneous transluminal angioplasty was performed subsequently in 10 of the patients and reconstructive surgery in three. One major and five minor hemorrhagic complications occurred and were considered to be secondary to the streptokinase therapy. In follow-up of up to 9 months, 11 of the 14 successfully treated patients continued to have a good result, without any indication of recurrent arterial occlusion. Two patients have died of causes unrelated to thrombolytic therapy and one patient required bypass grafting for recurrent thrombosis. None of the successfully treated patients lost a limb. Of the three patients in whom thrombolysis was unsuccessful, two required amputation. Local intra-arterial low-dose streptokinase appears to be a promising alternative to immediate operative treatment in carefully selected cases of arterial occlusion. Definitive treatment of the underlying cause of the thrombus usually is required and changes of success may be enhanced by the thrombolytic therapy.

Percutaneous transluminal angioplasty treatment of renal transplant artery stenosis.

Since June 1979, percutaneous transluminal angioplasty (PTA) has been the procedure of choice for renal transplant artery stenosis (RTAS) at the Hospital of the University of Pennsylvania. Of 241 renal allograft recipients, 17 (7%) when studied by arteriogram because of suspected RTAS proved to have significant stenosis (the mean reduction in luminal width for the group being 68%) and underwent PTA. RTAS was equally prevalent in cadaver and related kidney allografts and was no less common in HLA-identical related donor grafts, arguing against the importance of immune factors in etiology. RTAS was equally prevalent whether the anastomotic technique was end to end or end to side. However, when RTAS occurred after end to side anastomoses, it was usually postanastomotic. Fifteen of 17 of the attempts at dilation by PTA were successful by angiographic analysis. Thirteen of the 15 successfully dilated patients had long-term allograft survival and in all of these instances blood pressure (BP) was decreased after PTA. After a mean of 67 weeks, BP decreased from a systolic of 184 +/- 24 mm Hg pre-PTA to 135 +/- 15 mm Hg (P less than 0.001) and from a diastolic of 115 +/- 10 mm Hg pre-PTA to 87 +/- 11 mm Hg (P less than 0.001). The majority of patients continue to require antihypertensive drugs but in a less vigorous regimen than pre-PTA. Serum creatinine level fell following PTA from 1.9 +/- 0.6 to 1.7 +/- 0.5 mg/100 ml (P less than 0.01). Repeat angiographic study was done in nine patients, an average of 61 weeks after PTA, and no recurrent RTAS was identified. Three minor complications of PTA occurred but none led to long-term sequelae. Thus, we believe PTA of RTAS is relatively safe, carrying less mortality and morbidity than operative treatment, and is capable of improving BP control and renal allograft function.

Therapeutic alternatives in the treatment of intrahepatic biliary obstruction.

Intrahepatic biliary obstruction was treated in 60 patients (49 with cholangiocarcinoma and 11 with sclerosing cholangitis) who were classified according to the upper limit of their obstruction (Group I, proximal common hepatic duct; Group 2, right and left main hepatic ducts; Group 3, intrahepatic bile ducts). Thirty-six patients underwent percutaneous transhepatic biliary drainage, and 14 underwent catheterization through a T-tube track, Five of this latter group had the T-tube placed to establish a route of access for later interventional radiologic manipulations. Since most diseases that produce intrahepatic biliary obstruction are progressive, the use of any single approach is limited. The advantages of a surgically created route of access combined with the flexibility of interventional radiologic techniques help to maximize the therapy and extend the palliation that many of these patients receive.