Acute vertebrobasilar occlusion: treatment with high-dose intraarterial urokinase.

OBJECTIVE: The purpose of this study was to describe our successful experience with high-dose intraarterial urokinase therapy in treating acute, life-threatening vertebrobasilar occlusion. CONCLUSION: We successfully treated five patients with acute vertebrobasilar occlusion who presented up to 24 hr after the onset of symptoms. Higher doses of urokinase than are commonly reported in the literature were used in this series at a rapid infusion rate with a "pulse-spray" technique. The result was prompt thrombolysis and good clinical outcome.

Long bone surface osteomas: imaging features that may help avoid unnecessary biopsies.

OBJECTIVE: Our purpose is to show that a combination of imaging techniques and periodic radiologic follow-up offers an alternative to biopsy in certain patients with long bone surface osteomas. CONCLUSION: Asymptomatic lesions that are consistent with osteoma on a combination of imaging studies can be followed up clinically and radiographically, allowing patients to avoid unnecessary biopsies.

Percutaneous revascularization of complex iliac artery stenoses and occlusions with use of Wallstents: three-year experience.

PURPOSE: To assess the outcome of percutaneous placement of Wallstents for treatment of hemodynamically significant diffuse stenoses (> 3 cm in length), chronic occlusions, failed angioplasty procedures, and flow-limiting dissection in the iliac arteries. MATERIALS AND METHODS: Lesions in 94 iliac limbs were treated in 66 patients. Indications for stent placement included claudication in 49 limbs and limb-threatening ischemia in 45. Forty-two limbs were treated for diffuse disease, 39 for chronic occlusion, nine for failed angioplasty, and four for flow-limiting dissection. RESULTS: Technical success was achieved in 86 of 94 limbs (91%), with major complications in 9% of patients. One death occurred within 30 days (not procedure-related). Ankle-brachial indexes improved from 0.51 +/- 0.24 to 0.76 +/- 0.22 (P < .001). Eighty-five percent demonstrated improvement under Rutherford criteria. Follow-up was obtained up to 38 months (mean, 14 months +/- 8). Cumulative primary patency rates were 78% at 1 year and 53% at 2 and 3 years (standard error 10%). Secondary patency rates were 86% at 1 year and 82% up to 32 months (standard error > 10% after 32 months). No significant decrease in mean ankle-brachial index was observed during follow up. No difference in primary patency was observed based on lesion type, symptom severity, lesion location, or runoff status. The limb salvage rate for patients with limb-threatening ischemia was 98% at a mean follow-up of 14 months +/- 7. CONCLUSIONS: Technical success and complication rates for percutaneous iliac artery revascularization with use of Wallstents are favorable, symptoms improved in the majority of patients, and excellent secondary patency can be achieved. With use of Wallstents, most patients with iliac artery insufficiency as a result of long-segment disease or chronic occlusions can be treated percutaneously.

Tc-99m MDP uptake in osteopoikilosis.

A Tc-99m bone scan of a patient with classic roentgenographic findings of osteopoikilosis revealed multiple foci of increased activity that corresponded to many of the sclerotic foci on the roentgenograms. The authors presume that the abnormal bone scan in this patient reflects active osseous remodeling, similar to what has been observed in bone islands. Previous reports have emphasized the critical role of the radionuclide bone scan for distinguishing osteopoikilosis from osteoblastic bone metastases in patients with a known or suspected primary malignancy. In a young patient, an abnormal bone scan does not exclude the diagnosis of osteopoikilosis if the roentgenographic findings are characteristic of that entity.

Percutaneous drainage of 335 consecutive abscesses: results of primary drainage with 1-year follow-up.

Retrospective review of percutaneous abscess drainage (PAD) of 335 abscesses in 323 consecutive patients was undertaken. Particular attention was directed to body location, associated organ system, communications and fistulae, and to the underlying immunologic status of the patient. One-year follow-up was available in all patients. Overall, the cure rate was 62.4% (209 of 335 abscesses), with a failure rate of 8.95% (30 of 335 abscesses). There were 14.2% (46 of 323 patients) deaths in the follow-up period, of which 4.6% (15 of 323 patients) were believed attributable to sepsis or septic complications. The overall complication rate was 9.8% (33 of 335 abscesses), most of which were minor in nature. For the patient exhibiting immunocompromise, representing 53.1% (172 of 323 patients) of the patient population, the cure rate was 53.4% (95 of 178 abscesses), which was significantly lower than the cure rate of 72.6% (114 of 157 abscesses) for the immunocompetent patient population (n = 151) (P less than .001). The recurrence rate was 2.1% (seven of 335 abscesses), with all recurrences within 3 months of initial drainage. PAD is effective and permanent treatment for both immunocompromised and immunocompetent patients.

Percutaneous drainage of hepatic abscesses: comparison of results in abscesses with and without intrahepatic biliary communication.

Results of percutaneous drainage performed in eight patients with eight liver abscesses with intrahepatic biliary communication and 22 patients with 26 liver abscesses without biliary communication were analyzed to determine whether the presence of an intrahepatic biliary communication affected the outcome of treatment. The clinical features and response to treatment of both groups were compared. The presence or absence of biliary communication was determined by injection of contrast material into the abscess under fluoroscopic guidance either during or several days after initial drainage. Duration of drainage was longer (p less than .05) in patients with communication (range, 7-44 days; mean, 22 days) than in patients without communication (range, 1-33 days; mean, 13 days). Percutaneous drainage was curative in five (63%) and palliative or temporizing in one (13%) of eight patients with communication. It was curative in 15 (68%) and palliative or temporizing in five (23%) of 22 patients without communication (p = .317). Liver abscesses with intrahepatic biliary communication did not require percutaneous transhepatic biliary diversion for cure. Despite longer duration of drainage for abscesses with intrahepatic biliary communication, the cure rates of percutaneous drainage for both groups were similar. Patients in whom an intrahepatic biliary communication was shown did not require alternative interventional or surgical measures for cure.

Percutaneous abscess and fluid drainage: a critical review.

Pertinent radiologic and surgical literature regarding abscess drainage was reviewed. Noted is the heterogeneity of disorders categorized as abscesses, and the variety of therapeutic approaches presently available. Specific abscesses are discussed based on body location and/or associated organ system.

Extensive thromboembolic disease of the hand and forearm: treatment with thrombolytic therapy.

Six patients with extensive hand and forearm thromboembolic disease were treated by means of intraarterial infusion of urokinase, with good clinical results. Four significant complications occurred, including a possible stroke. Embolization of pericatheter thrombus was a possible etiologic factor in this case. Antegrade brachial artery puncture should be used in the setting of prolonged upper extremity thrombolytic therapy to avoid the cerebral vasculature. Thrombolysis is an effective technique for tissue salvage in cases of inoperable hand thrombosis.

Treatment of biliary leaks and fistulae by simultaneous percutaneous drainage and diversion.

Although biliary fistulae and bilomas are often adequately managed with percutaneous drainage, persistent bile duct leaks are difficult to control. The primary surgical goal in this situation is to decompress the biliary system through diversion of bile flow to facilitate healing of the defect in the bile ducts. We report 3 patients with large biliary duct defects who underwent percutaneous transhepatic cholangiography which demonstrated the site of the biliary leakage. Then, extrapolating the aforementioned surgical tenet to these patients, all 3 were successfully treated with interventional radiologic techniques: simultaneous percutaneous transhepatic biliary diversion to control biliary flow and percutaneous biloma drainage to facilitate closure of the cavity.

Percutaneous drainage of renal and perirenal abscesses: results in 30 patients.

The purpose of this study was to determine the efficacy of percutaneous drainage of renal and perirenal abscesses. Thirty-two abscesses, 10 renal and 22 renal with perirenal extension, in 30 patients (16 female, 14 male; age range, 5-83 years), were drained percutaneously. Twenty-one patients had had surgery recently and/or were immunosuppressed. Ten of the 13 postoperative patients had had surgical procedures involving the urinary tract. Size of the abscesses ranged from 10 to 650 ml, and all were drained via CT or fluoroscopic guidance. The type of drainage catheter used depended on the size of the abscess. Complications were unusual. A transient febrile episode without sequelae within the first 12 hr of catheter placement was the most common complication. All patients had their abscess catheter placed while in the hospital; 12 (40%) subsequently were followed up (2-50 days) as outpatients until their catheters were removed without complications. Percutaneous drainage alone was curative in 20 patients (67%) as determined by resolution of signs and symptoms or follow-up CT. Eight (27%) had improvement of signs and symptoms but required surgery to remove tumor (one patient) or a poorly functioning or nonfunctioning kidney (five patients), perform open pyelolithotomy (one patient), or drain a loculated abscess (one patient); all eventually were cured. Three patients (10%) with multiple medical problems died before resolution could be documented, although death was not thought to be directly related to failure of therapy. Our results indicate that percutaneous drainage alone is curative in the majority of cases of renal and perirenal abscesses. Many patients can be treated safely, in part, on an outpatient basis.

Percutaneous management of abscesses that involve native arteries or synthetic arterial grafts.

Retrospective analysis of 250 cases in which abscess drainage was performed revealed four abscesses in four patients that were associated with either underlying infected synthetic arterial bypass grafts (n = 3) or an underlying infected native artery (n = 1). Percutaneous drainage of the abscess coupled with intravenous antibiotic therapy resulted in palliation in three patients and possible long-term cure in one patient. No catheter-related complications resulted. In two patients, preoperative abscess sterilization allowed the substitution of alternative revascularization procedures of decreased morbidity and technical complexity. On rare occasions, when emergent surgery is absolutely contraindicated in the setting of graft or arterial infection, percutaneous drainage may play a role in palliative therapy.

Iatrogenic changes at the venotomy site after percutaneous placement of the Greenfield filter.

To determine the prevalence of iatrogenic abnormalities associated with percutaneous delivery of Greenfield filters, the authors prospectively evaluated 69 peripheral veins used for filter placement in 68 patients. Of the 69 venotomy sites, 63 were not associated with preexisting thrombosis and were evaluated with compression and Doppler ultrasound within 1 week of placement and over 13-541 days. New thrombosis developed at the puncture site in nine of 63 sites (14.3%), although clinical suspicion of clot was raised in only one patient. Fifty-four sites (85.7%) showed no evidence of acute deep venous thrombosis, even though three patients had signs and symptoms suggestive of thrombosis. During the follow-up, most new thromboses resolved, yielding a 96.3% long-term patency rate. The authors conclude that postplacement increase in symptoms of venous stasis and occlusion may not correlate with placement site thrombosis. New filters should be evaluated for their ability to capture potential pulmonary emboli while maintaining caval patency and for mechanical and biologic stability because placement site complications occur at low rates and resolve in most cases.

Antibiotics and nephrostomy tube care: preliminary observations. Part II. Bacteremia.

Bacteriuria occurs after long-term drainage of the kidney. This study was designed to determine if the risk of bacteremia increases at the time of tube or stent change, whether bacteremia correlates with clinical infection, and if prophylactic antibiotics are effective in the prevention of bacteremia. One hundred four tube changes in 74 patients with percutaneous nephrostomy tubes and documented positive urine cultures were studied. Patients were arbitrarily divided into groups receiving and not receiving antibiotics before nephrostomy tube change. Asymptomatic bacteremia was documented in 11 of 104 tube changes (11%). Results of five blood cultures were positive in the group receiving antibiotics, and six cases of bacteremia occurred in the group not receiving antibiotics (P = .96). Routine nephrostomy/stent change can cause frequent, asymptomatic bacteremia in patients with colonization of bacteria in the urinary tract. Antibiotic prophylaxis was unsuccessful in preventing transient bacteremia, a factor that may have implications in patients with underlying valvular heart disease and other patients at risk for bacteremia.