Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm formation: three case reports and a review of the literature.

The use of Swan-Ganz catheters has increased tremendously since they were first introduced in 1970. Their ability to give vital hemodynamic measurements in critically ill patients makes their use invaluable when providing quality medical care. The formation of pulmonary artery (PA) pseudoaneurysm from a Swan-Ganz catheter-induced perforation of the PA is a rare but potentially fatal complication of Swan-Ganz catheter use. Three case presentations and a review of the literature are presented.

Transcatheter interventions for the treatment of peripheral atherosclerotic lesions: part I.

Transcatheter endovascular procedures are increasingly used to treat symptomatic peripheral atherosclerosis. This two-part review identifies the existing evidence supportive of the application of transcatheter treatments for peripheral atherosclerotic lesions. The first part addresses the treatment of obstructive lesions that cause limb claudication and critical ischemia, renovascular hypertension and azotemia, and mesenteric ischemia. Studies were identified via a search of MEDLINE (January 1993 through April 1999) and reference lists of identified articles. When multicenter prospective randomized trials or other high-quality studies were unavailable, a preference was given to studies with at least 50 patients per treated group and a minimum mean follow-up duration of 6 months. Data presented in tables are proportionally weighted averages from included studies. For each application, the authors assessed the quality of evidence (QOE; efficacy, safety, and, where available, cost-effectiveness) and made recommendations with appropriate caveats. There is higher QOE supporting the more established treatments such as lower limb percutaneous transluminal angioplasty (PTA) with stent placement and thrombolysis. Treatments such as renal artery PTA and stent placement and mesenteric and brachiocephalic PTA are in wide use, but high QOE supporting general application is lacking. Blanket recommendations based on established efficacy and cost-effectiveness cannot be made. However, the use of transcatheter therapies can be supported in specific circumstances based on an expected reduction in procedure-related morbidity and/or mortality rates. It is hoped that the identification of deficiencies in the literature will inform and inspire critically needed research in this area.

Traumatic ileocolic pseudoaneurysm: diagnosis and transcatheter treatment.

Injuries to branches of the superior mesenteric artery are unusual and often difficult to diagnose, yet require prompt recognition and treatment to prevent exsanguinating hemorrhage or bowel ischemia. This report describes a unique case of an ileocolic artery pseudoaneurysm diagnosed using delayed CT imaging and definitively treated by transcatheter embolization. Cathet. Cardiovasc. Intervent. 48:217-219, 1999.

Balloon angioplasty or stent placement in patients with azotemic renovascular disease: a retrospective comparison of clinical outcomes.

In this study comparing functional outcomes of renal angioplasty alone (PTRA) or angioplasty with stent placement in patients with renal artery stenosis (> or =60%) and renal insufficiency, 69 patients were treated with PTRA or stent placement. After censoring, the PTRA group included 15 patients with a mean age of 75 years, mean serum creatinine (Cr) of 2.9 +/- 1.4 mg/dL, and mean follow-up of 10 months. The stent placement group included 40 patients with a mean age of 71 years, mean Cr of 2.6 +/- 1.2 mg/dL, and mean follow-up of 12 months. Stenting was performed primarily in four cases and after suboptimal angioplasty in the remainder. Benefit was defined as either stabilization (+/-20%) or improvement in serum Cr levels. Technical success was achieved in 16 of 17 (94%) PTRA patients and 55 of 58 (95%) patients receiving stents. Complications included one surgically repaired axillary pseudoaneurysm, one distal stent positioning requiring a second stent, one stent protruding 5 mm into the aorta, two dissections requiring additional stents, one retroperitoneal hematoma, and one intrarenal atheroembolism treated with thrombolysis. Three patients (mean initial Cr 3.9 mg/dL) required hemodialysis within 30 days of stenting. One patient discontinued dialysis after stenting. There were two procedure-related deaths. An overall benefit was seen in 40% of patients after PTRA and 66% of patients after stent placement. For the stent placement and PTRA groups, cumulative clinical benefit was 77% and 80%, respectively, at 3 months; 69% and 64%, respectively, at 6 months; 61% and 41%, respectively, at 12 months; and 48% and 14%, respectively, at 24 months. A 50% loss of cumulative benefit was seen 34 months after stenting and 11.5 months after PTRA. In the stent and PTRA groups, benefit was noted in 77% and 57%, respectively, of patients with an initial Cr of 2.3 or less, 53% and 25%, respectively, of patients with an initial Cr level higher than 2.3, and 44% and 17%, respectively, of patients with an initial Cr level of 3.0 mg/dL or more. For patients with renal insufficiency, renal artery stenting provides superior clinical results compared with PTRA, mostly because late deterioration occurs after PTRA. Outcomes are related to pretreatment serum Cr level.

Venous rupture complicating hemodialysis access angioplasty: percutaneous treatment and outcomes in seven patients.

OBJECTIVE: To evaluate percutaneous treatment options for preserving hemodialysis access after angioplasty-related venous rupture, we retrospectively reviewed the charts for all dialysis access angioplasties performed over a 33-month period. Seven cases of venous rupture after venous angioplasty were identified (four men and three women; mean age, 63.5 years). Treatment included observation only (n = 1), a second prolonged balloon inflation at the rupture site (n = 2), stent insertion (n = 5), and manual graft occlusion (n = 1). Treatment was successful in eliminating contrast extravasation in all patients while maintaining immediate graft function in six out of seven patients. None of the patients required emergent surgical intervention. The mean primary and secondary patency rates of the salvaged grafts after intervention were 2.3 and 9.3 months, respectively. Five of seven access sites were still patent at the most recent follow-up. CONCLUSION: Prolonged balloon inflation or placement of a stent may salvage hemodialysis access in most patients after angioplasty-related venous rupture. Primary and secondary patency have proven to be satisfactory.

Renal artery stent placement for the management of ischemic nephropathy.

PURPOSE: To evaluate the angiographic and clinical results of percutaneously implanted renal artery endoprostheses (stents) for the treatment of patients with ischemic nephropathy. MATERIALS AND METHODS: During a 52-month period, 45 patients with azotemia (serum creatinine > or = 1.5 mg/dL) and atheromatous renal artery stenosis untreatable by, or recurrent after, balloon angioplasty were treated by percutaneous placement of Palmaz stents. Stent implantation was unilateral in 32 cases and bilateral in 11 cases. Clinical results were determined by measurements of serum creatinine and follow-up angiography. Clinical benefit was defined as stabilization or improvement in serum creatinine level. Angiographic patency was defined as less than 50% diameter recurrent arterial stenosis. RESULTS: Stent placement was technically successful in 51 of 54 (94%) renal arteries. Technical failures were stent misdeployment requiring percutaneous stent retrieval (n = 2) and inadvertent placement distal to the desired position (n = 1). Complications included acute stent thrombosis (n = 1) and early initiation of hemodialysis (within 30 days; n = 1). There were two periprocedural deaths. With use of life-table analysis, clinical benefit was seen in 78% of patients at 6 months (n = 36), 72% at 1 year (n = 24), 62% at 2 years (n = 12), and 54% at 3 years (n = 3). In patients with clinical benefit, average creatinine level was reduced from 2.21 mg/dL +/- 0.91 before treatment to 2.05 mg/dL +/- 1.05 after treatment (P = .018). Lower initial serum creatinine level was associated with a better chance of clinical benefit (P = .05). No other variables affected outcome, including patient age, sex, diabetes, implanted stent diameter, unilateral versus bilateral stent placement, or ostial versus nonostial stent positioning. Conventional catheter angiography or spiral computed tomographic (CT) angiography performed in 19 patients (28 stents) at a mean interval of 12.5 months demonstrated primary patency in 75%. Maintained stent patency appeared to correlate with renal functional benefit. CONCLUSIONS: Percutaneous renal artery stent placement for angioplasty failures or restenoses provides clinical benefit in most patients with ischemic nephropathy.

Balloon angioplasty for an unusual aortic coarctation.

Percutaneous balloon angioplasty is an alternative therapy for the treatment of the typical type of coarctation. Its associated morbidity and mortality compares favorably when compared to the standard treatment surgery. While atypical coarctations are rare, the described cases have been treated surgically. We present a case of unusually located aortic coarctation successfully treated with percutaneous balloon angioplasty.

Livedo reticularis, rhabdomyolysis, massive intestinal infarction, and death after carbon dioxide arteriography.

In patients with renal insufficiency or hypersensitivity to iodinated contrast material, carbon dioxide gas (CO2) is generally considered a safe alternative contrast media for digital subtraction angiography. However, we herein report a previously undescribed fatal complication of CO2 angiography in a patient with acute renal dysfunction and congestive heart failure. The possible pathogenetic mechanisms of this complication are discussed.

Percutaneous renal artery stent placement for hypertension and azotemia: pilot study.

To evaluate the efficacy of balloon-expandable (Palmaz) stents in the treatment of atheromatous renal artery stenosis, prospective placement of stents in 24 arteries in 20 patients was performed over an 18-month period. Indications were hypertension in 18 patients and renal insufficiency (serum creatinine > 1.5 mg/dL) in 11, and all lesions failed conventional transluminal angioplasty. Technical success was achieved in 96% of cases. Hypertension benefit was noted in 77% of patients followed for 6 months (n = 13) and 67% of patients at 1 year (n = 8). Improvement in serum creatinine was seen in 71% (n = 7) and 100% (n = 3) of azotemic patients evaluated at 6 and 12 months, respectively. Six-month angiographic patency was identified in 13 of 16 treated sites. Renal artery stent placement resulted in one asymptomatic segmental branch occlusion; there were no other procedural complications. In conclusion, renal artery stent placement is a technically and clinically effective treatment for hypertension and azotemia due to renal artery stenosis.

Transmesenteric-transfemoral method of intrahepatic portosystemic shunt placement with minilaparotomy.

PURPOSE: To determine whether the transmesenteric-transfemoral method of intrahepatic portosystemic shunt (IPS) placement is safer and more efficient than the transjugular method. PATIENTS AND METHODS: Sixty-six consecutive patients with cirrhosis and bleeding varices underwent 67 IPS procedures. Sixty-one of these procedures were performed using a combination of transfemoral access to the hepatic vein with transmesenteric access to the portal system provided by means of minilaparotomy. Follow-up days were collected periodically by means of clinical evaluation and duplex sonography of the shunt. Angiographic evaluation was performed when necessary. RESULTS: No technical failures or periprocedural deaths occurred. The radiologic and surgical portions of the procedure were accomplished within 45 and 55 minutes, respectively. In cases without portal thrombosis, maximum fluoroscopy time was 12 minutes. During follow-up (mean, 16 months), eight shunt revisions including one additional shunt placement were necessary. CONCLUSION: Transmesenteric-transfemoral IPS placement requires surgical participation but may offer improved efficiency and safety compared with regular transjugular IPS placement.