Sustained bacteremia associated with transjugular intrahepatic portosystemic shunt (TIPS).

Transjugular intrahepatic portosystemic shunt (TIPS) has become a routine procedure in patients with portal hypertension, yet there are few data concerning the incidence of bacteremia associated with this shunt. All patients who underwent TIPS placement at a university hospital from January 1992 through January 1999 were studied. Ninety-nine TIPS were placed, and 10 patients subsequently developed sustained bacteremia; 5 patients had no identifiable source of bacteremia despite rigorous evaluation and were presumed to represent TIPS infections, for an estimated annual incidence of 7 cases/1000 TIPS procedures. Case patients developed bacteremia a median of 100 days after TIPS placement (range, 6-732 days). Bacteremia resolved in all patients after treatment with appropriate intravenous antibiotics (median, 2 weeks of therapy). Although the incidence of TIPS-associated bacteremia appears low, the increasing frequency of this procedure suggests that more information is needed to define this entity and to develop appropriate treatment recommendations.

The relationship of clinical and academic productivity in a university hospital radiology department.

OBJECTIVE: The purpose of this study was to evaluate the relationship between clinical and academic productivity over a 2-year period in a university hospital radiology department. MATERIALS AND METHODS: Clinical productivity, as determined by the number of total professional relative value units generated, was compared with academic productivity, which was determined by the number of published peer-reviewed articles, published non-peer-reviewed articles, published abstracts, and presentations delivered by each full-time clinical faculty member. The relationships of age, academic rank, administrative position, and division within the department were also assessed for their effect on relative value units and academic productivity. RESULTS: We found a significant inverse relationship between relative value units and the number of published peer-reviewed articles, published abstracts, and presentations. Age, academic rank, and administrative responsibilities had no effect on the number of relative value units. Faculty in the neuroradiology and cardiovascular-interventional radiology divisions generated more relative value units than did other faculty members. CONCLUSION: Faculty members with higher levels of clinical productivity showed significantly lower levels of academic productivity. This finding is consistent with the idea that increases in the clinical workload may diminish research output.

Accuracy and safety of carbon dioxide inferior vena cavography.

PURPOSE: The purpose of this study was to assess the accuracy of carbon dioxide compared to iodinated contrast material for determining inferior vena cava (IVC) diameter prior to filter placement, and to assess the safety of CO2 when used for this purpose. PATIENTS AND METHODS: Consecutive patients undergoing inferior vena cavography prior to filter placement were prospectively evaluated with use of both CO2 and iodinated contrast material. The diameter of the IVC was measured and compared in the same four locations in each patient for both agents. The diameter was corrected for magnification and pin-cushion distortion. The ability of CO2 to correctly classify IVC diameter as < or =28 mm or >28 mm, based on the IVC diameter with iodinated contrast material, was determined. A consensus panel assessed renal vein visualization with CO2 and iodinated contrast material. Blood pressure and arterial oxygen saturation were measured immediately before and after CO2 injection. RESULTS: Among 30 patients, there was no significant difference in the measured diameter of the IVC with CO2 versus iodinated contrast material after correction for magnification and pin-cushion distortion. One of 30 patients (3.3%) in this study was misclassified as having an IVC < or =28 mm with CO2 when, in fact, the IVC diameter was >28 mm based on iodinated contrast material. This could be clinically significant for certain IVC filters. Forty-seven percent of renal veins identified on contrast venography were identified by CO2 vena cavography. There was no significant difference in the blood pressure or oxygen saturation values measured before and after CO2 injection. However, one patient with pulmonary artery hypertension did experience transient, symptomatic hypotension after CO2 injection. CONCLUSIONS: In most patients, CO2 vena cavography accurately evaluated IVC diameter prior to filter placement. In 3.3% of patients, the discrepancy in measurements between CO2 and iodinated contrast material could be clinically significant, depending on the type of filter placed. CO2 was less accurate than iodinated contrast material in identifying renal veins. Although CO2 vena cavography is safe in the majority of patients, it should be used with caution in patients with pulmonary hypertension.

Do interventional radiologists pose a significant threat to the practice of vascular surgery?

PURPOSE: Vascular surgeons have become concerned recently about perceived threats to their practices posed by the growth of interventional radiology. The authors studied nationwide 1996 Medicare Part B procedure data to determine the seriousness of these threats. MATERIALS AND METHODS: The national Health Care Financing Administration (HCFA) Physician/Supplier Procedure Summary Master File for 1996 was searched. Two hundred thirteen distinct Current Procedural Terminology (CPT-4) codes were identified for therapeutic surgical and percutaneous interventional procedures performed to treat noncardiac vascular diseases. For each code, determination was made of total volume, specialty of the physician providers, and Medicare Part B reimbursement dollars paid to the providers as professional fees. In view of the conflicts among various specialties over peripheral vascular interventions, the authors also determined the percentages of these procedures performed by radiologists, surgeons, cardiologists, and other physicians. RESULTS: A total of 759,548 noncardiac therapeutic vascular procedures (operations or percutaneous interventions) were performed during 1996 in patients receiving Medicare benefits. Radiologists performed 135,103 (17.8%) of these procedures but received only 10.4% of professional reimbursements. By contrast, surgeons performed 510,871 (67.3%) procedures, but received 78.0% of professional reimbursements. Cardiologists performed 4.7% of procedures and other specialists performed the remaining 10.3%. Radiologists performed 75.5% of percutaneous transluminal angioplasties, the majority of thrombolysis procedures, stent placements, and portal decompression procedures, and approximately half of inferior vena cava interruptions. Cardiologists performed 12.6% of percutaneous transluminal angioplasties, surgeons performed 6.3%, and other specialists performed 5.6%. CONCLUSIONS: In terms of overall physician workload and professional reimbursements paid for invasive treatment of all types of noncardiac vascular disease, surgeons predominate and do not appear to be seriously threatened by interventional radiologists. Radiologists perform three-fourths of noncardiac percutaneous transluminal angioplasties and a majority of other percutaneous interventional therapies for vascular disease, but some inroads have been made by cardiologists and surgeons, particularly the former.

Intravascular ultrasound as an alternative to positive-contrast vena cavography prior to filter placement.

PURPOSE: In a nonconsecutive series of patients, intravascular ultrasound (IVUS) was investigated for safety and efficacy as an alternative to positive-contrast vena cavography for evaluating the inferior vena cava (IVC) prior to filter placement. MATERIALS AND METHODS: In a 6.5-year period, 30 patients (15 women, 15 men) ranging in age from 22 to 98 years old (mean, 56 years) underwent vena cava filter placement without conventional positive-contrast vena cavography, after IVUS evaluation of the IVC with use of a 6.2-F, 12.5- or 20-MHz monorail catheter system. The rationale for using IVUS included contraindications to iodinated contrast material in 14 patients with renal insufficiency and in four patients with previous life-threatening anaphylactoid reaction to iodinated contrast material; limitations to radiation exposure in four pregnant patients; and inability to otherwise image the IVC of eight morbidly obese patients who exceeded the weight limits of available angiographic equipment. IVUS completely replaced positive-contrast vena cavography, although not fluoroscopy in the four pregnant patients and in the 18 patients with contrast material contraindications. In two of the eight obese patients, IVUS was the only imaging modality. RESULTS: In all 30 patients, IVUS successfully determined the patency of the filter delivery route veins and the vena cava, the absence of thrombus, the location of renal veins, the absence of anatomical variants, and the vena cava diameter at the desired filter deployment level. Successful filter placement was confirmed in all 30 patients either with plain film alone (n = 12), IVUS alone (n = 3), computed tomography alone (n = 1), external ultrasound alone (n = 1), IVUS and another imaging modality (n = 10), or by combinations of other imaging modalities (n = 3). There were no complications. CONCLUSIONS: IVUS is a safe and effective alternative to conventional positive-contrast vena cavography for imaging the IVC prior to filter placement in patients with contraindications to iodinated contrast material or ionizing radiation.

Carbon dioxide as a contrast agent to guide vascular interventional procedures.

OBJECTIVE: The purpose of this study was to assess the value and limitations of carbon dioxide (CO2) as a contrast agent to guide vascular interventional procedures. SUBJECTS AND METHODS: Twenty-two adults underwent 26 vascular interventional procedures (21 arterial, five venous). We aimed to use only CO2 if possible because these patients had renal insufficiency (n = 21; mean creatinine level, 2.8 mg/dl) or were allergic to contrast material (n = 1). Arterial procedures performed included renal angioplasty or stent (n = 6), iliac angioplasty or stent (n = 5), infrainguinal angioplasty (n = 5), arterial bypass graft angioplasty (n = 3), and thrombolysis (n = 2). Venous procedures included transjugular intrahepatic portosystemic shunt recanalization (n = 3), angioplasty of the venous anastomosis of a thigh dialysis graft (n = 1), and angioplasty of the inferior vena cava (n = 1). RESULTS: Twenty-five of the 26 procedures were successfully performed. Of the 26 procedures, eight required no iodinated contrast material and 11 required less than or equal to 20 ml of contrast material. CO2 proved to be inadequate for the remaining seven procedures. Iliac artery angioplasty or stent placement required an average of 9 ml of iodinated contrast material; infrainguinal angioplasty required an average of 22 ml of iodinated contrast material. CONCLUSION: CO2 can be successfully used as a contrast agent in a variety of vascular interventional procedures. Such procedures can usually be performed in the iliac and infrainguinal arteries using minimal supplemental iodinated contrast material. However, CO2 failed to provide satisfactory guidance in half of the intraabdominal procedures in our study.

Deep pelvic abscesses: transperineal US-guided drainage.

PURPOSE: To examine the efficacy of transperineal sonographically guided drainage of deep pelvic abscesses. MATERIALS AND METHODS: Twelve drainage procedures were performed in 11 adults with symptoms of infection and cross-sectional images demonstrating a deep pelvic abscess. Eight patients had recently undergone abdominoperineal resection, seven of whom underwent preoperative radiation therapy. Two had chronic osteomyelitis with adjacent fluid collections, and one developed an infected hematoma after trauma. With ultrasound (US) guidance for initial access, catheters were placed for drainage in 11 procedures. One patient was treated with aspiration alone. Patients underwent clinical follow-up and subsequent imaging as necessary. RESULTS: Transperineal needle placement was successful in 12 of 12 patients (100%). In procedures that required catheter placement, 10 of 11 placements (91%) were achieved with the transperineal approach. One patient required fluoroscopic transvaginal catheter placement after opacification of the collection transperineally. Catheter drainage was maintained for 2-146 days (mean, 40 days; median, 21 days). Clinical success was achieved in nine of 10 patients (90%) by means of transperineal drainage. There were no complications, although premature catheter removal occurred in two patients. CONCLUSION: US-guided transperineal abscess drainage may be successfully performed in patients who cannot undergo conventional transabdominal, transvaginal, or transrectal catheter drainage.

Evaluation of a new percutaneous stainless steel Greenfield filter.

PURPOSE: To evaluate a new percutaneous Greenfield filter with an alternating hook design and over-the-wire delivery system. MATERIALS AND METHODS: The alternating hook stainless steel Greenfield filter was evaluated in a prospective clinical trial between March 10, 1994, and January 27, 1995. Filters were placed in 75 patients in nine clinical centers and follow-up with radiographs and ultrasound scans was carried out at 30 days. RESULTS: Clinical trial results revealed successful placement in all patients. There were four cases of filter limb asymmetry (5.3%) without clinical sequelae, with one incidence of failure to span the cava. No significant migration was found. There were no clinically suspected pulmonary emboli, but one instance of probable caval penetration (1.7%) did occur. Caval occlusion was documented in three patients (5%). CONCLUSION: The percutaneous stainless steel Greenfield filter provides ease of insertion and improved deployment while maintaining the high standards of efficacy and safety associated with the standard and titanium Greenfield filters.

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy.

PURPOSE: To evaluate the effect of combined-modality therapy including intraluminal iridium-192 on stent patency and survival in patients with malignant biliary obstruction treated with Gianturco stents. MATERIALS AND METHODS: Twenty-two patients with unresectable biliary obstruction caused by cholangiocarcinoma (n = 11) or by secondary extrahepatic bile duct malignant tumors (n = 11) were treated with percutaneous biliary drainage followed by intraluminal Ir-192 wire placement (mean dose, 25 Gy) before insertion of Gianturco metal stents. Eleven patients also received external-beam radiation therapy, and 13 patients received chemotherapy. Patency was defined as absence of jaundice or cholangitis that necessitated hospitalization, or as seen on hepatobiliary scans. Survival was determined from the time of stent insertion after brachytherapy. RESULTS: Patients with cholangiocarcinoma had extended mean stent patency of 19.5 months (range, 2-46 months) and mean survival of 22.6 months (range, 2-72 months). Patients with secondary malignant tumors had a mean patency of 4.8 months (range, 1.5-8 months) and a mean survival of 5.3 months (range, 2-9 months). CONCLUSION: Radiation therapy including intraluminal Ir-192 appears to extend stent patency and survival in patients with inoperable cholangiocarcinoma treated with Gianturco metal stents compared with patients with other extrahepatic bile duct malignant diseases and patients treated without combined-modality therapy in other studies.

Transvaginal uterine cervical dilation with fluoroscopic guidance: preliminary results in patients with infertility.

PURPOSE: To assess efficacy of uterine cervical dilation performed with fluoroscopic guidance to treat patients with infertility who have cervical stenosis, false channels within the endocervical canal, or both. MATERIALS AND METHODS: Fifteen patients in whom infertility was diagnosed were referred because the uterine lumen could not be accessed. Three of the patients had endometriosis. With fluoroscopic guidance, the cervix was cannulated and the endocervical canal was dilated with an angioplasty balloon or with dilators. Five patients underwent simultaneous fallopian tube recanalization. Five of 15 patients who underwent dilation subsequently underwent in vitro fertilization for embryo transfer (IVF-ET) or intrauterine insemination. RESULTS: Four patients became pregnant. Of those four, one underwent IVF-ET and one underwent intrauterine insemination. Two patients became pregnant spontaneously. In the five patients who underwent IVF-ET or intrauterine insemination and in the remaining eight patients, the cervix could be easily cannulated up to 7 months after dilation. CONCLUSION: Dilation of the uterine cervix may provide options for treatment in selected patients with infertility. The effect of dilation on patients with other sequelae of cervical obstruction such as endometriosis remains uncertain.

Osteochondroma: an unusual cause of vascular disease in young adults.

Vascular complications such as pseudoaneurysm, arterial thrombosis, luminal stenosis due to extrinsic compression, deep venous thrombosis, and arteriovenous fistula are known complications of osteochondroma. The authors describe three cases of vascular injury caused by osteochondroma: popliteal artery impingement, popliteal artery pseudoaneurysm formation, and superficial femoral artery pseudoaneurysm with peripheral occlusion of the tibial and peroneal arteries due to embolization. Fifty-six cases of vascular complications due to osteochondroma from the English literature are also reviewed. This entity should be considered in young patients with evidence of peripheral vascular insufficiency or in patients with known osteochondroma who develop symptoms of local pain and swelling in the involved extremity.

Treatment of pelvic abscesses and other fluid collections: efficacy of transvaginal sonographically guided aspiration and drainage.

OBJECTIVE: The purpose of this study was to evaluate the clinical efficacy of transvaginal sonographically guided aspiration and drainage of pelvic fluid collections. MATERIALS AND METHODS: Forty patients underwent transvaginal sonographically guided aspiration of a possible pelvic abscess (41 pelvic collections). In patients with clinical findings highly suggestive of infection, both purulent and nonpurulent collections were immediately drained via a catheter. In patients with clinical findings moderately suggestive of infection, nonpurulent collections were completely removed by aspiration and the aspirates were cultured; however, purulent collections were immediately drained via a catheter. RESULTS: All collections were successfully accessed by transvaginal sonography. For 27 of the 41 collections, the aspirate was purulent (18 collections) or the patient's clinical findings were highly suggestive of infection (nine collections) and catheter drainage was performed. Seventeen of the 27 collections completely resolved and surgery was not required. Four of the 27 collections were in patients who had surgery for reasons other than persistent infected collection. For six of the 27 collections, catheter treatment was not successful and surgery was required. The overall success rate of catheter drainage was 78%. In the remaining 14 of the 41 collections, the aspirate was serous or serosanguineous, and the patient's clinical findings were moderately suggestive of infection. Cultures of aspirates of seven collections were positive for microorganisms. Eleven collections were successfully treated with antibiotics or no therapy was required (based on culture results); for three, surgery was required. Two complications occurred: one vaginal fistula after catheter drainage and one disruption of vaginal sutures after aspiration. CONCLUSION: Transvaginal sonographically guided drainage is effective treatment of pelvic abscess, being either completely curative or temporizing in 78% of patients. Catheter treatment was unsuccessful and surgery was necessary in 22% of patients. For nonpurulent collections, catheter drainage is indicated only when clinical findings are highly suggestive of infection.

Transrectal sonographically guided drainage of deep pelvic abscesses.

OBJECTIVE: As an alternative to traditional surgical transrectal and transgluteal drainage, we have examined the efficacy of transrectal sonographically guided drainage for deep pelvic abscesses not accessible by percutaneous transabdominal or transvaginal routes. SUBJECTS AND METHODS: In nine patients (five males and four females) 5-51 years old, sonography or CT showed pelvic abscesses that were deemed unapproachable by percutaneous transabdominal or transvaginal routes because of interposed bowel (five patients), presacral location (two patients), or inability of the pediatric vagina to accommodate a transvaginal probe (one patient). One patient refused both transvaginal and transgluteal routes in preference to transrectal drainage. IV sedation (adults) or general anesthesia (children) was used for all drainages. A 7.5-MHz end-fire transrectal sonographic probe fitted with a biopsy guide was inserted into the rectum, and the collection was localized. With sonographic guidance, an 18-gauge needle and then a guidewire were advanced into the collection. Then with fluoroscopic guidance, a self-retaining drainage catheter was placed by using the Seldinger technique. RESULTS: All nine collections were successfully accessed and effectively drained without complication. Catheters were removed after 1-24 days (mean, 7 days; median, 5 days) without recurrent abscesses. CONCLUSION: Transrectal sonographically guided drainage of deep pelvic abscesses is a safe, well-tolerated, effective alternative to the more traditional surgical transrectal drainage or transgluteal approach, especially in pelvic abscesses that cannot be safely drained via a percutaneous transabdominal or transvaginal route.

Fallopian tube recanalization in an unrestricted patient population.

PURPOSE: To review the effectiveness of fallopian tube recanalization (FTR) when performed without restriction based on history or tubal condition. MATERIALS AND METHODS: From October 1989 to July 1992 in 37 consecutive women, aged 22-44 years (mean, 35 years), 42 FTRs were performed (five patients each underwent two FTRs). Water-soluble contrast material and selective ostial salpingography and/or microcatheter technique were used exclusively. Eighty tubes were evaluated, since four patients had previously undergone unilateral salpingectomy. Sixty-three tubes (79%) were occluded at the outset of the procedure. RESULTS: Complete recanalization was achieved in 45 of 63 (71%) occlusions. Adhesions were present in 25 of 80 (31%) tubes, salpingitis isthmica nodosa in 12 (15%), and hydrosalpinx in nine (11%). The 42 procedures resulted in 14 (33%) conceptions, nine (64%) of which involved pathologic tubes. Eleven intrauterine pregnancies resulted in five spontaneous first-trimester abortions, five full-term deliveries, and one continuing pregnancy. CONCLUSION: Favorable conception and live birth rates can be achieved with FTR, despite a high prevalence of tubal disease.

Occluded coloanal anastomosis: transrectal US-guided balloon dilation.

Balloon dilation is a well-described, nonoperative, alternative treatment for postoperative strictures of the colon and rectum. This procedure may not be technically feasible when an occluded lumen prevents passage of a guide wire across the obstruction. The authors describe the use of transrectal ultrasound guidance to initially pass a needle across an occlusive web at the coloanal anastomosis after proctosigmoidectomy. This allowed placement of a guide wire across the occlusion and subsequent successful balloon dilation.

Use of a Colapinto needle in US-guided transvaginal drainage of pelvic abscesses.

The ultrasound-guided transvaginal approach offers a direct, nonsurgical means for drainage of deep pelvic abscesses. It is often difficult, however, to place drainage catheters through the vaginal wall by using routine Seldinger technique. The authors describe four recent drainage procedures facilitated through use of a Colapinto needle as a dilator. In two cases, the Colapinto needle also served as a stiffening cannula for the passage of a fascial dilator.