Two-Device Closure Method for Large Diameter Arteriotomies in Percutaneous Endovascular Aortic Repair.

BACKGROUND: Percutaneous endovascular aortic repairs (pEVARs) are associated with access site complications. Two-device technique using 2 Perclose devices has been well established. Combined Perclose and Angioseal technique has been described as well. We sought to determine whether a hybrid Perclose and Angioseal closure technique would safely and effectively establish hemostasis in large-bore arteriotomies up to 20F. METHODS: Patients were identified as candidates for percutaneous access based on preoperative computed tomography findings, perioperative ultrasound of femoral vessels, or a combination of the 2 modalities. Prior to sheath insertion, 1 Perclose device was predeployed. At the end of pEVAR, device sheath and introducer were withdrawn over a 0.035″ wire, and partially deployed Perclose was fully deployed. The sheath and introducer were fully withdrawn and the arteriotomy was closed with a 6F Angioseal vascular closure device and completion deployment of the Perclose. Patients were followed at day 1 and day 30 and at least 1 year postintervention. RESULTS: A composite end point of complications was defined as an access site-related bleed or hematoma that required blood transfusion or an extended hospital stay, pseudoaneurysm, arteriovenous fistula, dissection, or retroperitoneal hematoma. The combined technique was initially successful in 44/45 arteriotomies (97.8%) in 24/25 patients (96.0%) with no conversions to cutdown. Sheath sizes ranged from 10F to 20F outer diameter (OD), with an average of 15.89F OD. The single-device failure was caused by a failure of the footplate to catch during deployment in the Angioseal with a 20F arteriotomy. Consequently, that was the only patient in which this closure was attempted for an arteriotomy larger than 19F. There were no early or late complications in this series. CONCLUSIONS: Large-bore arteriotomies may be safely and effectively closed using a hybrid percutaneous closure technique for sheaths up to 19F OD. Evaluation of this technique in closure of large-bore arteriotomies is ongoing and further investigation is needed to assess the value of this closure in 20F OD sheaths and above.

Role of intra-arterial steroid administration in the management of steroid-refractory acute gastrointestinal graft-versus-host disease.

We report here a case of severe steroid-refractory gastrointestinal graft-versus-host disease treated with intra-arterial administration of corticosteroids. A 53-year-old female with non-Hodgkin's lymphoma received peripheral blood hematopoietic stem cell transplant from her HLA-matched sibling. She developed grade II skin and grade IV gastrointestinal graft-versus-host disease with no hepatic involvement. Therapy with oral prednisone easily controlled her skin rash but she had profuse diarrhea that did not respond to high dose intravenous corticosteroids and denileukin diftitox. Infusion of methyl-prednisolone into superior and inferior mesenteric arteries produced dramatic improvement of diarrhea, with complete resolution of gastrointestinal graft-versus-host disease.

Skin entrance radiation dose in an interventional radiology procedure.

Monitoring of skin entrance radiation exposure in lengthy interventional procedures has been recommended because of the potential for skin injury. Fluoroscopy duration and dose-area product (DAP) are readily available real-time measurements. It would be of interest to study the correlation of these parameters and skin entrance radiation. Twenty neurological interventional procedures performed through the aortic arch were monitored. Two pieces of GafChromic XR Type R film were placed between the patient and the examination table. An observer recorded the fluoroscopy duration and DAP for each phase of the procedure. Each film was scanned post-procedure in RBG mode, and then the image was analyzed for peak skin entrance radiation dose (in air kerma). All DAP values were corrected according to a calibration with an ion chamber. With the DAP values for the respective phases of a procedure, the effective dose in a Reference Man was calculated. For these twenty cases, the means and standard deviations were 17.2+/-6.4 min for x ray on-time, 256+/-65 Gy cm (-2) for DAP, 94+/-34 cGy for peak skin entrance dose in air kerma, and 19.2+/-5.0 mSv for effective dose, respectively. The peak skin entrance dose was correlated to fluoroscopy duration, DAP, and effective dose with the r(2)-values of 0.48, 0.46, and 0.09, respectively. The correlation with DAP or fluoroscopy duration was not sufficiently strong to infer skin entrance dose from either of these parameters. Therefore, skin entrance dose should be determined directly.

Measurement of dose-area product with GafChromic XR Type R film.

Many of the newer X-ray machines are equipped with electronic means to provide dose-area product (DAP) information. For machines without that ability, an alternative method is to record radiation on a film that can handle a large amount of cumulative exposure. The use of GafChromic XR Type R film was investigated for this purpose by placing it at the X-ray tube assembly to record the radiation in interventional radiological procedures. Dose-area product was determined with a reflective densitometer and then with a flatbed scanner. Precisions were demonstrated to be 5% and 2%, respectively. In a comparison with the machine-recorded DAP, a regression analysis showed the validity of both techniques for values less than 1200 Gy-cm2.