ABSTRACT
The transfemoral venous approach is the standard for Left Atrial Appendage Closure (LAAC) using the WATCHMAN device. However in patients without a patent inferior vena cava, an alternate access site can be utilized. We present a case of a patient with left sided inferior vena cava with hemiazygos continuation who had clinical indication for LAAC and in whom a transhepatic approach was successfully utilized.
Subject(s)
Atrial Appendage , Atrial Fibrillation , Cardiac Surgical Procedures , Stroke , Humans , Vena Cava, Inferior/diagnostic imaging , Atrial Fibrillation/diagnosis , Atrial Fibrillation/diagnostic imaging , Atrial Appendage/diagnostic imaging , Treatment OutcomeABSTRACT
GOALS: To present the results of a new protocol for provocative visceral arteriography. BACKGROUND: Acute lower gastrointestinal hemorrhage (LGIB) usually stops spontaneously. In the absence of an identifiable source, if bleeding is recurrent, provocative visceral arteriography has been advocated for diagnosis. Prior studies using Streptokinase, Urokinase, or tissue plasminogen activator have reported a 33% to 37.5% rate of identifying the site of hemorrhage. STUDY: We report a retrospective analysis of 9 patients in whom provocative visceral arteriography was performed using a new protocol with Reteplase as the fibrinolytic agent. All patients had recurrent, massive LGIB without definable source. Initial arteriography did not elicit a site of bleeding. Five units of Reteplase were administered over 1 minute into the inferior mesenteric artery, the superior mesenteric artery or both vessels sequentially. Arteriography was repeated after 5 to 10 minutes. RESULTS: Colonic hemorrhage was induced in 89% of patients. There were no procedure-related complications. CONCLUSIONS: Reteplase may prove safe and effective as a provocative agent, stimulating bleeding to allow localization, in patients with occult, recurrent, massive LGIB.
Subject(s)
Angiography/methods , Fibrinolytic Agents , Gastrointestinal Hemorrhage/diagnosis , Tissue Plasminogen Activator , Adult , Aged , Aged, 80 and over , Colon/pathology , Female , Fibrinolytic Agents/adverse effects , Humans , Infusions, Intra-Arterial , Lower Gastrointestinal Tract/pathology , Male , Mesenteric Artery, Inferior , Mesenteric Artery, Superior , Middle Aged , Recombinant Proteins/adverse effects , Retrospective Studies , Tissue Plasminogen Activator/adverse effects , Viscera/blood supplyABSTRACT
PURPOSE: Currently available 4-F and 5-F peripherally inserted central catheters (PICCs) were investigated to evaluate their possible application for contrast medium injection using power injectors. The study was performed using an in vitro model to demonstrate the feasibility of using PICCs for contrast-enhanced diagnostic studies. MATERIALS AND METHODS: An evaluation of 24 catheter versions consisting of 4-F single-lumen and 5-F dual-lumen PICCs from 13 different manufacturers was conducted. Six of the catheter types were silicone and 18 catheter types were polyurethane. Ten catheters of each type were evaluated with five at full length and five trimmed to 40 cm. With use of a silicone-based simulated SVC model, the catheters were infused with 50 mL of intravenous contrast medium at each flow rate increment. Catheters were tested at increasing flow rates from 0.5 to 5 mL/sec in 0.5-mL/sec increments using a Percupump CT injector. Catheters that failed to rupture were then infused at 1-mL/sec increments at flow rates from 5 to 17 mL/sec using a MedRad Mark V power injector. Tolerated and bursting pressures were recorded as well as the location of the catheter rupture. RESULTS: Polyurethane catheters ruptured at flow rates between 4 and 15.4 mL/sec, with one catheter not rupturing at the maximal flow rate (17 mL/sec). Silicone catheters ruptured at flow rates between 0.5 to 3.5 mL/sec. Average rupture locations by type and length were at the extension leg/hub connection area on five of the PICCs, on the extension legs on 21 of the PICCs, on the catheter/hub connection on four PICCs, and on the proximal catheter on 16 of the PICCs. CONCLUSION: The low burst rates at which all silicone catheters ruptured suggest that those catheters are not able to withstand typical flow rates used for CT arteriography. Conversely, although there is a wide range of discrepancy in the polyurethane catheter burst pressures, many polyurethane catheters can tolerate relatively high flow rates without rupture. This suggests that they may be safely used for CT arteriography with appropriate precautions and protocols in place.
