Arteriopathy after transarterial chemo-lipiodolization for hepatocellular carcinoma.

OBJECTIVES: The purpose of this study was to investigate the incidence of and the risk factors for arteriopathy in hepatic arteries after transarterial chemo-lipiodolization in patients with hepatocellular carcinoma and the subsequent treatment strategy changes due to arteriopathy. PATIENTS AND METHODS: A total of 365 arteries in 167 patients (126 men and 41 women; mean age, 60.4±15.0 [SD] years [range: 18-87 years]) were evaluated for the development of arteriopathy after chemo-lipiodolization with epirubicin- or doxorubicin-Lipiodol® emulsion. The development of arteriopathy after chemo-lipiodolization was assessed on arteriograms performed during subsequent transarterial treatments. The treatment strategy changes due to arteriopathy, including change in the chemo-lipiodolization method and the application of alternative therapies was also investigated. Univariate and multivariate binary logistic regression models were used to identify risk factors for arteriopathy and subsequent treatment strategy change. RESULTS: One hundred two (27.9%) arteriopathies were detected in 62/167 (37.1%) patients (45 men, 17 women) with a mean age of 63.3±7.1 [SD] years (age range, 50-86 years). The incidence of arteriopathy was highly patient dependent, demonstrating significant correlation in a fully-adjusted multivariate regression model (P<0.0001). Multivariate-adjusted regression analysis with adjustment for the patient effect showed a statistically significant association of super-selective chemo-lipiodolization (P=0.003) with the incidence of arteriopathy. Thirty of the 102 arteriopathies (29.4%) caused a change in treatment strategy. No factors were found to be significantly associated with the treatment strategy change. CONCLUSION: The incidence of arteriopathy after chemo-lipiodolization is 27.9%. Among them, 29.4% result in a change in treatment strategy.

Mechanisms of Günther Tulip filter tilting during transfemoral placement.

OBJECTIVE: The purpose of this study was to characterize the mechanisms of Günther Tulip filter (GTF) tilting during transfemoral placement in an experimental model with further validation in a clinical series. MATERIALS AND METHODS: In an experimental study, 120 GTF placements in an inferior vena cava (IVC) model were performed using 6 configurations of pre-deployment filter position. The angle between the pre-deployment filter axis and IVC axis, and the proximity of the constrained filter legs to IVC wall prior to deployment were evaluated. The association of those pre-deployment factors with post-deployment filter tilting was analyzed. The association noted in the experimental study was then evaluated in a retrospective clinical series of 21 patients. RESULTS: In the experimental study, there was a significant association between the pre-deployment angle and post-deployment filter tilting (P<0.0001). With a low pre-deployment angle (≤5°), a significant association was noted between filter tilting and the proximity of the constrained filter legs to the far IVC wall (P=0.001). In a retrospective clinical study, a significant association between the pre-deployment angle and post-deployment filter tilting was also noted with a linear regression model (P=0.026). CONCLUSION: Significant association of the pre-deployment angle with post-deployment GTF tilting was shown in both the experimental and clinical studies. The experimental study also showed that proximity of filter legs is relevant when pre-deployment angle is small. Addressing these factors may result in a lower incidence of filter tilting.

Long-term outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)-related airway disorder.

UNLABELLED: A strong link exists between gastroesophageal reflux disease (GERD) and airway diseases. Surgical therapy has been recommended as it is more effective than medical therapy in the short-term, but there is little data on the effectiveness of surgery long-term. We analyzed the long-term response of GERD-related airway disease after laparoscopic anti-reflux surgery (LARS). METHODS: In 2004, we contacted 128 patients with airway symptoms and GERD who underwent laparoscopic antireflux surgery (LARS) between 12/1993 and 12/ 2002. At median follow-up of 53 months (19-110 mo) we studied the effects on symptoms, esophageal acid exposure, and medication use and we analyzed the data to determine predictors of successful resolution of airway symptoms. RESULTS: Cough, hoarseness, wheezing, sore throat, and dyspnea improved in 65-75% of patients. Heartburn improved in 91% (105/116) of patients and regurgitation in 92% (90/98). The response rate for airway symptoms was the same in patients with and without heartburn. Almost every patient took proton pump inhibitors (PPIs) preoperatively (99%, 127/128) and 61% (n = 78) were taking double or triple dose. Postoperatively, 33% (n = 45) of patients were using daily antiacid therapy but no one was on double dose. The only factor that predicted a successful surgical outcome was the presence of abnormal reflux in the pharynx as determined by 24-hour pharyngeal pH monitoring. One hundred eleven (87%) patients rated their results as excellent (n = 78, 57%) or good (n = 33, 24%). CONCLUSION: LARS provides an effective and durable barrier to reflux, and in so doing improves GERD-related airway symptoms in approximately 70% of patients and improves typical GERD symptoms in approximately 90% of patients. Pharyngeal pH monitoring identifies those patients more likely to benefit from LARS, but better diagnostic tools are needed to improve the response of airway symptoms to that of typical esophageal symptoms.

Primary stenting of subclavian and innominate artery occlusive disease: a single center's experience.

PURPOSE: To review immediate and midterm results of primary stenting for innominate and subclavian artery occlusive lesions. METHODS: Retrospective data were collected from 48 consecutive symptomatic patients (27 men and 21 women, median age 64 years) having 49 subclavian and innominate artery lesions treated with stenting. Of the patients 52% had concomitant ischemic heart disease, and 30% had carotid and/or vertebral artery disease. Indication for treatment was vertebrobasilar insufficiency (VBI) in 16.6% of the patients; upper limb ischemia (ULI) in 31.3%; VBI and ULI in 12.5%; transient ischemic attack in 16.7%; angina in 12.5% before or after left internal mammary artery-to-coronary artery bypass grafting; and leg claudication in 10.4% before or after axillofemoral bypass grafting. Balloon-expandable stents were used in 44 lesions and self-expandable stents in 5 lesions. In total, 53 stents were placed in 48 patients. RESULTS: Technical success was 96%, and clinical success 94%. We encountered four complications (two puncture site hematomas, one distal hand embolization and one transient cerebral ischemia). Two patients died within 30 days from other causes, and seven patients were lost to follow-up. Mean follow-up time was 16.7 months (range 0.3 to 68.2). Five patients had recurrent lesions treated by surgical (n = 2) or endovascular (n = 3) means. Cumulative primary patency rate was 91.7% and 77% at 12 and 24 months, respectively. Cumulative secondary patency rate was 96.5% and 91.7% at 12 and 24 months, respectively. CONCLUSION: Stenting of subclavian and innominate artery lesions resulted in immediate resolution of patients' symptoms with durable midterm effect and few complications in a larger patient group with serious comorbid conditions.

Regression of perianeurysmal fibrosis and ureteral dilation following endovascular repair of inflammatory abdominal aortic aneurysm.

An inflammatory component to abdominal aortic aneurysms (AAA) is thought to occur in approximately 5% of cases. Accompanying ureteral entrapment may be involved in 20% of these. Transabdominal repair of inflammatory AAA with ureterolysis may result in increased complications. Many authorities have recommended a retroperitoneal approach to decrease dissection. Similarly, an endovascular approach has been utilized. We report here the results of a patient with an inflammatory AAA with bilateral ureteral obstruction successfully treated with endovascular stent graft repair and bilateral ureteral stents with exclusion of the aneurysm and resolution of hydronephrosis.

Hospital costs for elective endovascular and surgical repairs of infrarenal abdominal aortic aneurysms.

PURPOSE: To determine and compare the average in-hospital costs of elective open surgical and endovascular repairs of infrarenal abdominal aortic aneurysms. MATERIALS AND METHODS: Total actual cost data for patients undergoing elective endovascular (n = 181) or open surgical (n = 273) repair of abdominal aortic aneurysms between 1997 and 1999 were retrieved. The mean total hospital cost (including stent-graft costs and excluding attending physician fees) and mean postoperative length of stay were calculated for each treatment group. Costs were expressed in 1999 U.S. dollars. RESULTS: Endovascular repair yielded a shorter postoperative length of stay than did open surgery (mean stay, 3.4 vs 8.0 days; P <.001) and a lower proportion of patients who were admitted to the intensive care unit for 1 full day or longer (2.8% vs 36.3%; P <.001). The mean total hospital cost was significantly higher for endovascular repair than for open surgery ($20,716 vs $18,484; P <.001). CONCLUSION: Hospital costs were higher for endovascular repair than for open surgical repair. However, endovascular repair was associated with a decreased length of stay and fewer intensive care unit admissions. The increased mean hospital cost for endovascular repair was smaller than one would expect, considering the higher costs of endovascular grafts, as compared with those for surgical grafts (approximately $6,400 according to literature data).

Utility of nonselective abdominal aortography in demonstrating ovarian artery collaterals in patients undergoing uterine artery embolization for fibroids.

PURPOSE: To review the incidence of ovarian collateral supply to uterine fibroids as demonstrated by nonselective abdominal aortography before uterine artery embolization (UAE) and to evaluate the effect of such visualization on interventional management. MATERIALS AND METHODS: The aortograms of 51 consecutive patients (mean age, 42.4 y; range, 30--53 y) undergoing UAE for symptomatic uterine fibroids were reviewed retrospectively for the visualization of ovarian arteries extending into the pelvis. If ovarian arteries were visualized, their size relative to the ipsilateral external iliac artery was measured. Arteries believed large enough to represent a significant blood supply to the uterine fibroids were further evaluated after UAE to determine whether flow persisted. RESULTS: In 13 of 51 patients (25%), a total of 18 ovarian arteries were identified. They were bilateral in five patients and unilateral in eight. Their sizes relative to the ipsilateral external iliac artery ranged from 8% to 57% (mean, 26%). Eight ovarian arteries with a relative size > or = 25% were further evaluated. Five of the eight (62.5%) were not visible after UAE. Of the three persistent ovarian collateral arteries, two were successfully embolized. The patient with the untreated collateral artery experienced persistent menorrhagia. CONCLUSION: Preembolization aortography with the catheter tip at level of the renal arteries demonstrated ovarian collateral arteries in 25% of patients with uterine fibroids. However, their detection influenced treatment in only 6% of the reported cases.

Inpatient costs of routine endovascular repair of abdominal aortic aneurysm.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the inpatient cost of routine (ie, without emergent conversion to open repair during the hospital stay) endovascular stent-graft placement in a consecutive series of patients undergoing elective endovascular repair of abdominal aortic aneurysm (AAA) at a single institution. MATERIALS AND METHODS: Inpatient hospital costs of 91 patients who underwent initial elective endovascular repair of AAA were analyzed retrospectively. All patients had participated in clinical trials at the authors' institution during the previous 6 years. Financial data were derived from the hospital's cost-accounting system; additional procedural data were collected from a departmental database and with chart review. Stent-graft and professional costs were excluded. RESULTS: The mean total cost for endovascular repair was $11,842 (standard deviation [SD], $5,127), mean procedure time was 149 minutes (SD, 79 minutes), and mean length of stay was 3.5 days (SD, 2.3 days). Total cost depended on stent-graft type (means, $12,428 [bifurcated] vs $9,622 [tube]; P = .0002) and strongly correlated with procedure time and length of hospital stay (r = 0.78 and 0.66, respectively; P < .0001). Ninety-six percent of total costs for all patients were attributable to the following departments: operating theater (31%), radiology (31%), nursing (22%), and anesthesia (12%). CONCLUSION: Overall costs are greater with bifurcated than with tube stent-grafts. Total procedure-related costs are divided relatively equally between the operating theater, the radiology department, and the combination of the nursing and anesthesia departments.

Endovascular stent-graft in abdominal aortic aneurysms: the relationship between patent vessels that arise from the aneurysmal sac and early endoleak.

PURPOSE: To determine the association of patent sac branch vessels (lumbar and inferior mesenteric arteries [IMAs]) with early endoleak rate after stent-graft repair of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: Pre- and postoperative computed tomographic (CT) angiograms in 158 patients who underwent stent-graft AAA repair were retrospectively reviewed to determine the preoperative patency of IMAs and other sac branch vessels (feeders) and presence or absence of immediate postoperative endoleak. Relationships of early endoleak rate with total branch vessel, IMA, and lumbar artery patency and graft type were evaluated. RESULTS: There was a significant association between patency of sac feeders and rate of early endoleak, especially type 2. As total patent feeders increased from zero to three to four to six, total endoleak rate increased from 6% (one of 17) to 35% (30 of 86); type 2 endoleak rate, from 0% to 25%. IMA patency was significantly associated with total early endoleak rate. Increasing lumbar artery patency also was associated with significantly higher total and type 2 endoleak rates: With zero to three lumbar arteries, the total endoleak rate was 17% and type 2 endoleak rate was 13%, as compared with 60% and 50%, respectively, with more than six patent lumbar arteries. CONCLUSION: Sac branch vessel patency is associated with significantly higher early total and type 2 endoleak rates after stent-graft repair of AAAs; thus, patent sac branches play an important role in the pathogenesis of endoleaks.

Abdominal aortic aneurysms before and after endograft implantation: evaluation by computed tomography.

The evaluation of patients with abdominal aortic aneurysms for endograft candidacy and their follow-up after treatment are heavily dependent on radiologic imaging. Factors never considered during conventional open repair have become crucial to patient selection and procedural success, and the new and developing nature of the field of endovascular repair necessitates close surveillance of these devices after deployment. Computed tomography (CT) has emerged as the single most effective imaging tool for the preprocedural assessment and subsequent follow-up of these patients. This article outlines the technical parameters for obtaining pre- and postoperative CT examinations in endograft patients and discusses the important imaging findings.

Inferior vena caval filters: review of a 26-year single-center clinical experience.

PURPOSE: To review a 26-year single-center clinical experience with inferior vena caval filters. MATERIALS AND METHODS: During 1973-1998, 1,765 filters were implanted in 1,731 patients. Hospital files were reviewed, and data were collected about the indications, safety, effectiveness, numbers, and types of caval filters. Fatal post-filter pulmonary embolism (PE) was considered the primary outcome. Morbidity and mortality were determined as secondary outcomes. Survival and morbidity-free survival curves were calculated. RESULTS: The prevalence of observed post-filter PE was 5.6%. It was fatal in 3.7% of patients. In most patients, fatal PE occurred soon after filter insertion (median, 4.0 days; 95% CI: 2.2, 5.8 days). Major complications occurred in 0.3% of procedures. The prevalence of observed post-filter caval thrombosis was 2.7%. The 30-day mortality rate was 17.0% overall, higher among patients with neoplasms (19.5%) as compared with those without neoplasms (14.3%; P =.004). Filter efficacy and associated morbidity were not different in 46 patients with suprarenal filters. The rate of filters placed for prophylaxis was 4.7% overall and increased to 16.4% in 1998. From 1980 to 1996, there was a fivefold increase in the number of caval filter implants. In recent years, more filters were implanted in younger patients. CONCLUSION: Inferior vena caval filters provide protection from life-threatening PE, with minimal morbidity.

Clinical outcome of internal iliac artery occlusions during endovascular treatment of aortoiliac aneurysmal diseases.

PURPOSE: To determine the clinical outcome of hypogastric artery occlusion in patients who underwent endovascular treatment of aortoiliac aneurysmal disease. MATERIAL AND METHODS: From January 1994 to March 1998, 94 patients underwent endovascular treatment of aneurysmal diseases involving the infra-abdominal aorta or iliac arteries. Preoperative and intraoperative radiologic data were reviewed. Discharge summaries, clinic visits, and phone calls formed the basis for clinical follow-up, with a mean follow-up period of 7.3 months (range, 1-24 months). RESULTS: Because of the anatomy of the aneurysms, 28 patients required occlusion of one or more hypogastric arteries. One of the 28 patients died of unrelated causes before follow-up. Seven (26%) of the remaining 27 patients developed symptoms attributable to the hypogastric artery occlusions. Five patients developed new buttock or thigh claudication; of these five patients, three with initially mild symptoms noted complete or near complete resolution of symptoms upon follow-up. One patient with originally significant claudication at 2-year follow-up noted near resolution of symptoms. The other patient with severe pain did not improve significantly on final 1-year follow-up before his death (of unrelated causes). Other clinical complications were worsening sexual function in one patient and a nonhealing sacral decubitus ulcer that developed in a debilitated patient in the postoperative setting, which required surgery. No bowel ischemia was observed. CONCLUSION: When treating aortoiliac aneurysmal disease through an endovascular approach, the occlusion of internal iliac artery is often necessary but carries with it a small but finite chance of morbidity.

Interventional radiologic procedures: patient anxiety, perception of pain, understanding of procedure, and satisfaction with medication--a prospective study.

PURPOSE: To prospectively assess patient anxiety, understanding of the procedure being performed, perception of pain level, and satisfaction with medication given for a variety of diagnostic and therapeutic vascular and visceral (nonvascular) interventional procedures. MATERIALS AND METHODS: The authors interviewed 204 patients before and after they underwent an interventional radiologic procedure. Patients responded to a series of questions by using a visual analog scale. Patients were grouped according to (a) their level of experience with the procedure and (b) the type of procedure performed (diagnostic or therapeutic visceral procedure or diagnostic or therapeutic vascular procedure). RESULTS: Patients who had previous experience with a procedure, whether visceral or vascular, were less anxious, had more understanding, and anticipated less pain than did those who did not have experience with a procedure. Patients who had only local anesthesia for visceral biopsy experienced greater pain than did those who had both local and intravenous anesthesia. Satisfaction scores, however, were similar throughout all groups. CONCLUSION: Patients have a moderate amount of anxiety about interventional procedures and anticipate some discomfort. Most patients have a high level of satisfaction despite the amount of pain they experience during the procedure. Patients experienced with a procedure tend to have a greater understanding of the procedure and less anxiety.

Utility and reliability of endovascular aortouniiliac with femorofemoral crossover graft for aortoiliac aneurysmal disease.

OBJECTIVE: The purpose of this study was to determine the early efficacy of endovascular aortouniiliac stent grafts with femorofemoral bypass graft in the treatment of aortoiliac aneurysmal disease. METHODS: We analyzed 51 consecutive patients from January 1997 to March 1999 with a mean follow-up of 15.8 months. Patients ranged in age from 44 to 93 years (mean, 75 years) with a mean aortic aneurysm diameter of 6.2 cm. Technical success was achieved in 50 patients; one patient required conversion to open repair intraoperatively. We placed 28 custom-made and 22 commercial devices. The mean operative time was 223 minutes. The endograft was extended to the external iliac artery in 42% of cases. The contralateral common iliac artery was occluded using either a closed covered stent or intraluminal coils. RESULTS: The median hospital stay was 4 days with an average intensive care unit stay of 0.25 days. There were no operative mortalities. Two patients died during follow-up from unrelated conditions. Endoleaks occurred in 11 patients (22%); seven patients (14%) required intervention (four catheter based, three operative). Other complications occurred in 38% of patients but were largely remote or wound related. One femorofemoral bypass graft occluded immediately postoperatively as a result of an intraprocedural external iliac dissection yielding a 98% primary patency and 100% secondary patency. Clinical success was achieved in 88% of patients. CONCLUSIONS: These data suggest that this strategy represents a reliable method of repair of aortoiliac aneurysmal disease and extends the capability of an endoluminal approach to patients with complex iliac anatomy.

Weekly prophylactic urokinase instillation in tunneled central venous access devices.

PURPOSE: To determine the safety and efficacy of weekly prophylactic urokinase therapy in tunneled central venous access devices (VADs). MATERIALS AND METHODS: A prospective, randomized study was performed in 105 patients who underwent tunneled VAD placement between March 1997 and April 1998. The patients were randomized to receive either twice-daily heparin flushes (14 heparin flushes per week; group A, n = 52) or twice-daily heparin flushes with once-weekly urokinase (UK) instillation (13 heparin flushes, one UK flush per week; group B, n = 53). Patients were followed up by examination and/or interview at 1, 3, and 6 months for signs and symptoms of delayed catheter-related complications. RESULTS: The total number of indwelling catheter-days was similar between groups (5,450 in group A, 5,276 in group B). The total number of infectious complications and fibrin sheaths formed was greater for group A (n = 11; 21.1%) than group B (n = 3; 5.7%) (P = .02). There were no side effects noted from the prophylactic UK administrations. CONCLUSION: Prophylactic UK is advantageous in preventing delayed catheter-related complications.

Custom bifurcated stent-graft for abdominal aortic aneurysms: initial experience.

PURPOSE: To describe a custom bifurcated stent-graft for possible treatment of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: Five male patients (mean age, 76 +/- 6 years), who had AAA (mean diameter, 4.7 +/- 0.4 cm) and who were considered to be at high risk for conventional surgery, were treated with a custom modular bifurcated stent-graft constructed with bifurcated 24-mm x 12-mm (upper body diameter x iliac limb diameter) Cooley Veri-Soft Woven polyester grafts and Gianturco-Rösch Z stents. The stent-graft body was delivered through 20-22-F sheaths, and the contralateral iliac limb was delivered through a 16-F sheath by means of surgical exposure of the common femoral arteries. A flared distal limb extender (12 mm to 14 mm) was created for one patient to accommodate a large common iliac artery. RESULTS: Stent-grafts were successfully deployed without complications in all five patients. There were no proximal or distal leaks. A lumbar-to-inferior mesenteric artery leak was seen in one patient at 24 hours. At 6-month follow-up, all devices were intact, with complete exclusion and shrinkage of the aneurysm in four of five patients. Aneurysm size remained stable in the one patient with a lumbar-to-inferior mesenteric artery leak. CONCLUSION: A custom, bifurcated stent-graft was utilized for endovascular treatment of AAA. Long-term follow-up is necessary for the device.

Gadolinium-based contrast agents as an alternative at vena cavography in patients with renal insufficiency--early experience.

The authors reviewed results of digital subtraction vena cavography with a gadolinium-based contrast agent in 14 patients with serum creatinine levels greater than or equal to 1.5 mg/dL (133 mumol/L). All cavograms were diagnostic. In 11 patients, there was no impairment of renal function. In three patients, a rise in serum creatinine level of greater than or equal to 0.5 mg/dL (44 mumol/L) was attributable to concurrent medical problems. Gadolinium-based contrast agents may be suitable for digital subtraction vena cavography in patients with renal insufficiency.