ABSTRACT
Fibrotic central venous occlusions in patients with thoracic malignancy and prior radiotherapy can be impassable with standard catheters and wires, including the trailing or stiff end of a hydrophilic wire. We report two patients with superior vena cava syndrome in whom we successfully utilized a radiofrequency guide wire (PowerWire, Baylis Medical, Montreal, Quebec, Canada) to perforate through the occlusion and recanalize the occluded segment to alleviate symptoms.
Subject(s)
Catheter Ablation/methods , Superior Vena Cava Syndrome/pathology , Superior Vena Cava Syndrome/surgery , Vena Cava, Superior/diagnostic imaging , Vena Cava, Superior/surgery , Catheterization , Constriction, Pathologic , Hodgkin Disease/pathology , Humans , Lung Neoplasms/pathology , Male , Middle Aged , Phlebography , Radio Waves , Stents , Superior Vena Cava Syndrome/diagnostic imagingABSTRACT
BACKGROUND: Best practices for peritoneal dialysis (PD) catheter insertion call for timely placement of catheters to reduce complications and increase the likelihood of a successful initiation of PD. The purpose of our study was to assess if a change in approach to PD catheter insertion, including a switch to radiological insertion of PD catheters and introduction of a dialysis access nurse to coordinate all patient care, was associated with more outpatient procedures and achievement of guideline-based outcomes, including timelier PD starts. ⢠METHODS: We conducted a single-center retrospective chart review of all patients that had their first PD catheter inserted at our center over a 7-year period ending in 2007. ⢠RESULTS: PD catheters were placed in 88 patients by interventional radiology and in 125 patients by surgical insertion during an earlier period. Insertion of PD catheters by interventional radiology was significantly associated with a higher rate of outpatient procedures (70% vs 32%, p < 0.0001) than surgical placement. At PD start, 82% of patients that underwent radiological insertions had an estimated glomerular filtration rate of over 8 mL/minute/1.73 m(2) and their mean serum albumin level was 38.2 g/L. ⢠CONCLUSIONS: The new procedure of radiological insertion of PD catheters, coordinated by a dedicated dialysis access nurse, was associated with more outpatient procedures than the earlier surgical method and allowed patients to receive a PD catheter with timing consistent with clinical practice recommendations.
Subject(s)
Catheters, Indwelling , Laparoscopy/methods , Peritoneal Dialysis/instrumentation , Peritoneal Dialysis/nursing , Radiography, Interventional/methods , Aged , Aged, 80 and over , Cohort Studies , Female , Follow-Up Studies , Humans , Male , Middle Aged , Patient Care Team/organization & administration , Peritoneal Dialysis/methods , Retrospective Studies , Specialties, Nursing , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND AND OBJECTIVES: Hemodialysis catheters are frequently complicated by dysfunction from fibrin sheaths. Previous studies of sheath disruption have methodologic limitations but suggest that the patency after disruption is short. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A randomized, controlled, pilot trial was conducted to investigate the impact of angioplasty sheath disruption on catheter patency and function. Forty-seven long-term hemodialysis patients with secondary, refractory catheter dysfunction underwent guidewire exchange to replace their catheters. RESULTS: Sheaths were present in 33 (70%) of the 47 patients. In 18 patients who were randomly assigned to disruption, the median time to repeat dysfunction was 373 d compared with 97.5 d in patients who did not undergo disruption (P = 0.22), and the median time to repeat catheter exchange was 411 and 198 d, respectively (P = 0.17). Mean blood flow (340 versus 329 ml/min; P < 0.001) and urea reduction ratio (72 versus 66%; P < 0.001) were higher in the disruption group. Fourteen patients had no sheaths, and their median times to repeat dysfunction and repeat exchange were 849 and 879 d, respectively. Patients with no sheaths had higher urea reduction ratio (73 versus 66%; P < 0.001) and a lower percentage of inadequate hemodialysis treatments (9.8 versus 27%; P = 0.01) and treatments that required thrombolytics (1.8 versus 5.0%; P = 0.03) than patients with sheaths that were not disrupted. CONCLUSIONS: Disrupting sheaths by angioplasty balloon results in durable catheter patency and modestly improves blood flow and clearance over the duration of catheter use.
Subject(s)
Angioplasty, Balloon/methods , Catheterization, Central Venous/instrumentation , Catheters, Indwelling , Graft Occlusion, Vascular/therapy , Renal Dialysis/adverse effects , Renal Dialysis/instrumentation , Aged , Female , Humans , Male , Pilot ProjectsABSTRACT
OBJECTIVE: To describe outcomes of transcatheter embolotherapy (TCE) in children with pulmonary arteriovenous malformations (PAVMs). STUDY DESIGN: Chart and imaging review of all children (age =18 years) treated for PAVMs by TCE at three hereditary hemorrhagic telangiectasia centers. RESULTS: All 42 treated patients were included, with a mean age of 12 years (range, 4 to 18). Cyanosis was present in 25 of 42 patients (60%). Hemoptysis had occurred in 3 of 42 patients (7%) and neurologic complications (stroke, cerebral abscess) occurred in 8 patients (19%) before assessment. PAVMs were focal in 30 of 42 (71%) and diffuse in 12 of 42 (29%) patients. TCE was performed for 172 PAVMs and 35 diffuse regions (regional TCE). Follow-up was obtained in 38 of 42 (90%) patients (mean, 7 years). After TCE in patients with focal PAVMs, oxygenation improved significantly, with no further complications from the PAVMs. Reperfusion was noted in 23 of 153 (15%) PAVMs. Eighteen of 23 (78 %) of these were retreated, with documented aneurysmal involution in 10 of 13 (77%) patients. TCE complications included pleuritic chest pain (24% of sessions) and deployment complications (device paradoxical embolization or device misplacement) (3% of sessions, 1% of PAVMs), with no long-term complications. CONCLUSIONS: PAVMs cause life-threatening complications in children; treatment with TCE is safe, with complication rates comparable to adult rates.
Subject(s)
Arteriovenous Malformations/therapy , Embolization, Therapeutic/methods , Lung/diagnostic imaging , Adolescent , Arteriovenous Malformations/complications , Arteriovenous Malformations/physiopathology , Child , Child, Preschool , Embolization, Therapeutic/adverse effects , Humans , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
STUDY OBJECTIVES: Pulmonary arteriovenous malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia (HHT) can cause hemorrhage, stroke, and cerebral abscess. Therapy consists of transcatheter embolotherapy (TCET) to occlude the PAVMs. Contrast transthoracic echocardiography (TTE) can be used to screen for PAVMs, but little is known about the performance of contrast TTE after TCET has been performed. Our objective was to determine the effect of the successful performance of TCET on the performance of contrast TTE, specifically, in what proportion of patients the findings of contrast TTE normalized or remained positive after the performance of TCET. DESIGN: Retrospective chart review. SETTING: HHT clinic at university teaching hospital. PATIENTS: Patients who have undergone TCET for the treatment of PAVMs. INTERVENTIONS: Patients were screened for PAVMs with a chest radiograph (CXR), oxygen shunt test (OST), and contrast TTE. Pulmonary angiography was recommended for patients with any positive findings on a screening test. PAVMs > or = 3 mm were occluded by TCET. Contrast TTE, OST, and CXR were performed approximately 1 month later. The results of contrast TTE before and after patients underwent TCET were compared. MEASUREMENTS AND RESULTS: Thirty-nine patients underwent contrast TTE prior to undergoing TCET, and 29 patients underwent contrast TTE both prior to and after undergoing TCET. In all patients, TTE findings were positive prior to TCET. All PAVMs with feeding vessels > or = 3 mm were successfully occluded based on completion angiography. After TCET, 48% of patients had no detectable residual PAVMs, and the remainder had small (ie, < 3 mm) residual PAVMs. Of the 29 patients, 90% had positive contrast TTE findings after undergoing TCET. In the subset of patients who had no residual PAVMs on the completion angiography, 80% had positive contrast TTE findings after undergoing TCET. CONCLUSIONS: In most patients, contrast TTE findings remain positive after they undergo TCET, even in patients without residual PAVMs seen on angiography. This may reflect residual PAVMs that are too small to visualize using angiography. These findings have important implications for the follow-up and management of HHT patients.