Mechanical thrombectomy with the Amplatz device: human experience.

PURPOSE: The authors present their early experience of mechanical arterial and graft thrombectomy with the Amplatz thrombectomy device. PATIENTS AND METHODS: Preliminary data are presented for 14 patients treated with the Amplatz thrombectomy catheter. The procedure was carried out in 10 arterial polytetrafluorethylene grafts, in two native arteries, and in two patients with venous thrombosis. RESULTS: The thrombectomy catheter completely removed the clot in 11 patients and partially removed clot in three patients. Mean thrombectomy time was 2 minutes 45 seconds. Despite distal blood pressure cuff occlusion, two instances of insignificant distal embolization occurred. Mechanical clot dissolution has consistently produced hemolysis without adverse clinical effects. The underlying causative factors such as stenoses were treated by means of angioplasty, atherectomy, or surgical endarterectomy. CONCLUSION: Mechanical thrombectomy with this device is a new, effective technique and can rapidly remove the thrombus. From preliminary results, the device seems most promising in clearing out thrombi in occluded synthetic femoral-to-popliteal bypass grafts. The device could have wider application if it were steerable and if it could be introduced from the contralateral approach.

Refractory ascites: early experience in treatment with transjugular intrahepatic portosystemic shunt.

PURPOSE: To evaluate the transjugular intrahepatic portosystemic shunt (TIPS) in treatment of refractory ascites. MATERIALS AND METHODS: Fourteen patients with chronic liver disease and portal hypertension were included in a prospective study. Six patients had Child-Pugh class B disease; eight had class C disease. Indications for TIPS were three previous hospital admissions over 9 months for treatment of tense ascites, no response to diuretic therapy, or an occluded peritoneovenous shunt with tense ascites. The volume of ascitic fluid was sonographically evaluated before and after TIPS placement. RESULTS: The technical success rate for TIPS creation was 93%. Mean portosystemic gradient decreased from 22.8 mm Hg +/- 7.2 before TIPS placement to 11.3 mm Hg +/- 3.6 after TIPS (P = .005). Complete resolution of ascites was achieved in seven (50%) patients. Treatment failed in seven; five had Child-Pugh class C disease, and four of these had a Child-Pugh score greater than 11. CONCLUSION: These results are comparable to those for other forms of treatment of ascites. The authors do not, however, recommend TIPS in patients with a Child-Pugh score greater than 11.

Experience with the Amplatz retrievable vena cava filter.

The Amplatz retrievable inferior vena cava filter was designed to be used as either a permanent indwelling filter or a short-term, percutaneously removable filter. The authors placed 52 filters in 52 patients. No deaths occurred as a result of filter placement or usage. Follow-up in 42 (81%) patients included inferior vena cavography (n = 31), computed tomography (n = 4), duplex ultrasound (n = 4), and autopsy (n = 3). Inferior vena cava thrombosis was found in seven (17.5%) of the 40 previously nonobstructed venae cavae studied. Two patients with caval thrombosis required a second filter to prevent embolization of thrombus that had extended to the lung side of the first filter. No clinically evident pulmonary emboli after filter placement have been noted. Six filters were successfully retrieved or repositioned percutaneously. The relatively high rate of caval thrombosis with extension above the filter may be due to a higher trapping efficiency or to filter geometry. The role of this filter in the treatment of deep venous thrombosis and pulmonary emboli is unclear.

Mortalities associated with use of a commercial suspension of polyvinyl alcohol.

Two cases of symptomatic neonatal hepatic arteriovenous malformation (AVM) are presented. Both were treated with percutaneous transcatheter embolization and a commercially available polyvinyl alcohol suspension. Both infants died soon after AVM embolization. The results of laboratory examination of particle-size homogeneity of this commercial suspension demonstrate marked inhomogeneity of particle size very probably contributed to the death of these patients. A protocol has been developed to help determine appropriate particle size in individual cases; this may help prevent such catastrophic results during transcatheter embolization.

Dual stiffness Malecot (Stamey) catheter.

A new catheter with a soft plastic shaft and a stiff mushroom has been developed for drainage of various fluid-filled cavities. It can be introduced with a flexible guidewire system. Its dual stiffness provides greater comfort for and acceptance by the patient.

Kimray-Greenfield vena cava filter: percutaneous introduction.

A percutaneous technique is described for the introduction of Kimray-Greenfield filters into the vena cava through either the internal jugular or femoral approach.

"Pseudo" intramural injection following percutaneous transluminal angioplasty.

An angiographic appearance of "pseudo" intramural injection is commonly produced following intraluminal balloon dilatation resulting from the dehiscence of the atheromatous intima that is an unavoidable consequence, and not a complication of angioplasty. These angioplasty-induced changes differ from true intramural dissections in that they are confined to the dilatation site and do not extend beyond this area.

Systemic-to-pulmonary collaterals in pathological states: a review.

Abnormal systemic-to-pulmonary-artery anastomoses can exist in many pathological conditions and result in a left-to-right shunt. Three such conditions are (a) congenital abnormalities, e.g., pulmonary vein atresia, (b) acquired states, e.g., chronic bronchiectasis, and (c) post-surgical states, e.g., a Mustard procedure for complete transposition. Regardless of the etiology, the anastomosis and resulting shunt produce increased oxygen saturation in the ipsilateral pulmonary artery. Four cases are presented, with emphasis on the angiographic and hemodynamic findings.

Single barbed stainless steel coils for venous occlusion: a simple but useful modification.

Embolization of coils into the lungs has been reported following their use for the obliteration of large arteriovenous fistulas. So far, except for a recent report, they have not been used on the venous side of the circulation. Experimental studies at our institution demonstrated that the placement of coils on the venous side can result in embolization to the lungs, even when oversized coils are introduced. A simple, easy to perform modification of the standard stainless steel coils (Gianturco-Wallace-Chuang spring embolus and coilons) makes these devices safe embolic agents for used on the venous side of the circulation, as for example in the obliteration of spermatic veins.

The three types of criss-cross heart: a simple rotational anomaly.

Criss-cross heart is an angiographically confusing malformation where apparent crossing but not mixing of contrast medium is seen at atrioventricular level. The malformation can be understood by a clockwise or counter-clockwise ventricular rotation. In the normal heart or one with complete transposition ventricular rotation is clockwise. With corrected transposition rotation occurs in a counter-clockwise fashion. One case of criss-cross heart with associated corrected transposition and two criss-cross hearts occurring with complete transposition are reported.

Syphilitic aneurysms of the innominate artery.

Syphilitic aortitis can cause formation of fusiform or saccular aneurysms of the ascending aorta or transverse arch. The authors report 3 cases in which a saccular aneurysm developed at the origin of the innominate artery and was seen as a mediastinal mass on the chest radiograph.

Angiodysplasia of the right colon treated by embolization with ivalon (polyvinyl alcohol).

Angiodysplasia of the colon is being recognized with increasing frequency as a source of lower gastrointestinal bleeding in the elderly. In one patient with colonic angiodysplasia, superselective segmental embolization of the ileo-colic artery with Ivalon resulted in the cessation of bleeding without causing bowel infarction. However, because of the development of collateral branches to the angiodysplastic malformation, bleeding recurred. While colectomy remains the treatment of choice in younger patients, in high risk patients embolization with a permanent embolic material, such as Ivalon, is an attractive alternative.