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Radiologic placement of long-term large bore venous catheters
ABSTRACTS PERCUTANEOUS ANGIOPLASTY FOR INTESTINAL ANGINA M. D. M c S H A N E , P. A. S. SPENCER, C. L. WELSH, A. PROCTER, A. BELLI and D. C U M B E R L A N D
Northern General Hospital, Sheffield Chronic intestinal ischaemia is a difficult clinical diagnosis. The diagnosis is often made after exclusion of other causes and the presence of mesenteric vascular disease demonstrated by selective angiography. Until recently the mainstay of treatment has been surgical. Percutaneous transluminal angioplasty (PTA) offers an attractive alternative, as it can be repeated if symptoms recur. In Sheffield since 1985, four patients with nine lesions have undergone mesenteric angioplasty. The clinical details and results are tabulated. Age/Sex
Symptoms
Angtography findings
Arterws dtlated
Result
63/female
Pain and weight loss Pare and weight loss
Coeliae stenosis SMA blocked Coeliac, SMA and IMA stenoses Coeliac and SMA stenoses
Coehac trunk Coehac and SMA
Coehac and IMA stenoses SMA block
Coehac and IMA ( × 2)
Two years pare free Initial rehef, symptoms recurnng (6/12) Marked Improvement in symptoms (6/12) Improvement m symptoms. IMA stenos~s recurred at 3/12. Coehac patent
63/female
69/female
Pam and weight loss
63/male
Pain arid weight loss
Coeliac and SMA
No significant complications occurred as a result of these procedures. These results are similar to 17 cases previously reported in the North American literature. We are currently evaluating the use of Duplex scanning for non-invasive diagnosis of mesenteric vascular disease and as part of the objective follow up of angioplasty. In this way patient selection should be improved, unnecessary angiography reduced and the role of angioplasty in the treatment of chronic intestinal ischaemia better defined.
PREDICTING T H E O U T C O M E OF TRANSHEPATIC EMBOLISATION TO C O N T R O L LIFE-THREATENING H A E M O R R H A G E F R O M O E S O P H A G E A L VARICES E. J. EVANSON, J. McIVOR, K. W. REYNOLDS, and 5. M. M U R R A Y - L Y O N
639
plasty in 16 patients. The retrograde approach was usually quick and effective. Patients with small arteries, vascular disease or in whom a stable balloon position could not be obtained were treated by transeptal valvoplasty. This technique gave better balloon stability and avoided arterial damage, though it could take longer. Methods and manoeuvres used to overcome technical problems are illustrated. Aortic valvoplasty was successful in fifteen patients, with mean falls in valve gradient of 59% transeptal group, 49% retrograde group. Four had early reversible complications and one a late complication (femoral artery pseudoaneurysm). After three months 13/15 patients reported continuing symptomatic improvement. At current follow up (mean 5.7 months) 8/13 remain improved, and two have died. Symptomatic improvement persisted even with Doppler evidence of restenosis. Using the appropriate approach, aortic valvoplasty produces useful and sustained relief of symptoms with an acceptable incidence of complications.
RADIOLOGIC PLACEMENT OF LONG-TERM LARGE BORE VENOUS CATHETERS P. F. JAQUES and M. A. M A U R O
North Carolina Memorial Hospital, Chapel Hill Placement of long-term, large, indwelling venous catheters for a variety of clinical purposes has traditionally involved surgery, as their silastic construction with Dacron subcutaneous cuffs are not well suited to over guide wire techniques. However the availability of 'peel away' sheaths now permits a percutaneous approach with the advantageous application of radiological controlled precision. We describe the technique, results, and complications o f introducing 64 'tunnelled' 11 gauge single or double lumen Hickman catheters, 20 13 gauge double lumen haemodialysis access catheters, and four single lumen 10 gauge Portacaths (entirely subcutaneous with a chamber for long-term chemotherapy access). Four of the 64 Hickman catheters were placed via a translumbar or transhepatic approach into the inferior vena cava for access in infants with thrombosed brachiocephalic veins. Major procedural and late complications are compared with published surgical series and shown to be similar. The advantages of the radiologic approach include economies of scarce and costly surgical resources, speedier patient management, greater precision in catheter positioning, and reduced patient morbidity. THORACIC CT IN DIVERS AND SUBMARINERS P. M. C A R V A L H O and D. M. DENISON
Charing Cross Hospital, London
Brompton Hospital, London
Twenty-five transhepatic embolisation procedures were carried out on 24 patients between 1984 and 1989 using various combinations o f gelfoam, dura mater, steel coils and ethanolamine. Successful occlusion of all collateral vessels was achieved in 18 procedures and in the other seven one small collateral remained patent as it could not be catheterised. There were two deaths related to the procedure, 10 patients died within one month of the procedure, seven survived between one month and one year and five patients survived over a year. Survival was not related to the patient's age, platelet count, blood urea, bilirubin level or technique. Low prothrombin ratio (PTR) values were significantly correlated with survival (r = --0.5, P < 0-02) and were less than 1.5 in all five patients who survived more than one year (P < 0.001). Aspartate transaminase (AST) values were normal in four out of five patients who survived for a year, but in only three out of the 19 who died within a year. This difference was significant (P < 0.01). We conclude that this technique can offer prolonged survival in some cases o f life-threatening haemorrhage due to oesophageal varices, the best prognosis being reserved for patients with PTR of less than 1.5 and normal AST.
Pulmonary barotrauma and secondary arterial gas embolism are serious hazards in diving and submarine escape that result from rapid ascent, when an air space does not empty fast enough and ruptures. This is more likely to occur in disordered than healthy lungs. Forty-eight divers and submariners, and 16 would-be trainees were referred here for CT scans following suspected barotrauma, poor spirometry, chest injury or a history o f lung disease; which cast doubts on their fitness to dive. Contiguous 10 mm scans were obtained in full inspiration and in full expiration. Only one of the subjects showed bullae or defective emptying that could be seen on an expiratory chest radiograph but 11 subjects showed such defects on expiratory CT. These defects were present in eight of 16 divers with barotrauma but only in one of 32 divers without barotrauma. They were also present in two of 16 would-be trainees. Expiratory CT scanning enabled us to return 40 o f 48 experienced men to work and 14 o f 16 aspirants to training. The scans also showed that a higher proportion of unsuspected bullae and emptying defects were associated with pulmonary barotrauma, suggesting the investigation is valuable in the assessment of that condition.
TWO M E T H O D S FOR AORTIC VALVOPLASTY; TECHNICAL PROBLEMS, RESULTS AND PATIENT SELECTION M. J. WESTON, R. C R O O K and G. G. H A R T N E L L
HIGH DEFINITION C O M P U T E D T O M O G R A P H Y IN R H E U M A T O I D ARTHRITIS ASSOCIATED PLEUROPULMONARY DISEASE I. McGOWAN, H. FEWINS, G. H. W H I T E H O U S E and J. WILLIAMS
Bristol Royal Infirmary, Bristol
Royal Liverpool Hospital, Liverpool Balloon aortic valvoplasty relieves the symptoms of aortic stenosis when valve surgery is contraindicated, but there are doubts about its safety and efficacy. Arterial damage using the retrograde approach is a significant risk, especially in patients with small arteries or peripheral vascular disease. We used retrograde or antegrade (transeptal) balloon aortic valvo-
The purpose of the study was to describe the CT appearance of lung disease associated with rheumatoid arthritis, and to assess the role of CT as a diagnostic examination in this condition. Eighteen patients with rheumatoid arthritis (American Rheumatism Association definition) were selected from a rheumatology clinic. All patients were examined
Northern General Hospital, Sheffield Chronic intestinal ischaemia is a difficult clinical diagnosis. The diagnosis is often made after exclusion of other causes and the presence of mesenteric vascular disease demonstrated by selective angiography. Until recently the mainstay of treatment has been surgical. Percutaneous transluminal angioplasty (PTA) offers an attractive alternative, as it can be repeated if symptoms recur. In Sheffield since 1985, four patients with nine lesions have undergone mesenteric angioplasty. The clinical details and results are tabulated. Age/Sex
Symptoms
Angtography findings
Arterws dtlated
Result
63/female
Pain and weight loss Pare and weight loss
Coeliae stenosis SMA blocked Coeliac, SMA and IMA stenoses Coeliac and SMA stenoses
Coehac trunk Coehac and SMA
Coehac and IMA stenoses SMA block
Coehac and IMA ( × 2)
Two years pare free Initial rehef, symptoms recurnng (6/12) Marked Improvement in symptoms (6/12) Improvement m symptoms. IMA stenos~s recurred at 3/12. Coehac patent
63/female
69/female
Pam and weight loss
63/male
Pain arid weight loss
Coeliac and SMA
No significant complications occurred as a result of these procedures. These results are similar to 17 cases previously reported in the North American literature. We are currently evaluating the use of Duplex scanning for non-invasive diagnosis of mesenteric vascular disease and as part of the objective follow up of angioplasty. In this way patient selection should be improved, unnecessary angiography reduced and the role of angioplasty in the treatment of chronic intestinal ischaemia better defined.
PREDICTING T H E O U T C O M E OF TRANSHEPATIC EMBOLISATION TO C O N T R O L LIFE-THREATENING H A E M O R R H A G E F R O M O E S O P H A G E A L VARICES E. J. EVANSON, J. McIVOR, K. W. REYNOLDS, and 5. M. M U R R A Y - L Y O N
639
plasty in 16 patients. The retrograde approach was usually quick and effective. Patients with small arteries, vascular disease or in whom a stable balloon position could not be obtained were treated by transeptal valvoplasty. This technique gave better balloon stability and avoided arterial damage, though it could take longer. Methods and manoeuvres used to overcome technical problems are illustrated. Aortic valvoplasty was successful in fifteen patients, with mean falls in valve gradient of 59% transeptal group, 49% retrograde group. Four had early reversible complications and one a late complication (femoral artery pseudoaneurysm). After three months 13/15 patients reported continuing symptomatic improvement. At current follow up (mean 5.7 months) 8/13 remain improved, and two have died. Symptomatic improvement persisted even with Doppler evidence of restenosis. Using the appropriate approach, aortic valvoplasty produces useful and sustained relief of symptoms with an acceptable incidence of complications.
RADIOLOGIC PLACEMENT OF LONG-TERM LARGE BORE VENOUS CATHETERS P. F. JAQUES and M. A. M A U R O
North Carolina Memorial Hospital, Chapel Hill Placement of long-term, large, indwelling venous catheters for a variety of clinical purposes has traditionally involved surgery, as their silastic construction with Dacron subcutaneous cuffs are not well suited to over guide wire techniques. However the availability of 'peel away' sheaths now permits a percutaneous approach with the advantageous application of radiological controlled precision. We describe the technique, results, and complications o f introducing 64 'tunnelled' 11 gauge single or double lumen Hickman catheters, 20 13 gauge double lumen haemodialysis access catheters, and four single lumen 10 gauge Portacaths (entirely subcutaneous with a chamber for long-term chemotherapy access). Four of the 64 Hickman catheters were placed via a translumbar or transhepatic approach into the inferior vena cava for access in infants with thrombosed brachiocephalic veins. Major procedural and late complications are compared with published surgical series and shown to be similar. The advantages of the radiologic approach include economies of scarce and costly surgical resources, speedier patient management, greater precision in catheter positioning, and reduced patient morbidity. THORACIC CT IN DIVERS AND SUBMARINERS P. M. C A R V A L H O and D. M. DENISON
Charing Cross Hospital, London
Brompton Hospital, London
Twenty-five transhepatic embolisation procedures were carried out on 24 patients between 1984 and 1989 using various combinations o f gelfoam, dura mater, steel coils and ethanolamine. Successful occlusion of all collateral vessels was achieved in 18 procedures and in the other seven one small collateral remained patent as it could not be catheterised. There were two deaths related to the procedure, 10 patients died within one month of the procedure, seven survived between one month and one year and five patients survived over a year. Survival was not related to the patient's age, platelet count, blood urea, bilirubin level or technique. Low prothrombin ratio (PTR) values were significantly correlated with survival (r = --0.5, P < 0-02) and were less than 1.5 in all five patients who survived more than one year (P < 0.001). Aspartate transaminase (AST) values were normal in four out of five patients who survived for a year, but in only three out of the 19 who died within a year. This difference was significant (P < 0.01). We conclude that this technique can offer prolonged survival in some cases o f life-threatening haemorrhage due to oesophageal varices, the best prognosis being reserved for patients with PTR of less than 1.5 and normal AST.
Pulmonary barotrauma and secondary arterial gas embolism are serious hazards in diving and submarine escape that result from rapid ascent, when an air space does not empty fast enough and ruptures. This is more likely to occur in disordered than healthy lungs. Forty-eight divers and submariners, and 16 would-be trainees were referred here for CT scans following suspected barotrauma, poor spirometry, chest injury or a history o f lung disease; which cast doubts on their fitness to dive. Contiguous 10 mm scans were obtained in full inspiration and in full expiration. Only one of the subjects showed bullae or defective emptying that could be seen on an expiratory chest radiograph but 11 subjects showed such defects on expiratory CT. These defects were present in eight of 16 divers with barotrauma but only in one of 32 divers without barotrauma. They were also present in two of 16 would-be trainees. Expiratory CT scanning enabled us to return 40 o f 48 experienced men to work and 14 o f 16 aspirants to training. The scans also showed that a higher proportion of unsuspected bullae and emptying defects were associated with pulmonary barotrauma, suggesting the investigation is valuable in the assessment of that condition.
TWO M E T H O D S FOR AORTIC VALVOPLASTY; TECHNICAL PROBLEMS, RESULTS AND PATIENT SELECTION M. J. WESTON, R. C R O O K and G. G. H A R T N E L L
HIGH DEFINITION C O M P U T E D T O M O G R A P H Y IN R H E U M A T O I D ARTHRITIS ASSOCIATED PLEUROPULMONARY DISEASE I. McGOWAN, H. FEWINS, G. H. W H I T E H O U S E and J. WILLIAMS
Bristol Royal Infirmary, Bristol
Royal Liverpool Hospital, Liverpool Balloon aortic valvoplasty relieves the symptoms of aortic stenosis when valve surgery is contraindicated, but there are doubts about its safety and efficacy. Arterial damage using the retrograde approach is a significant risk, especially in patients with small arteries or peripheral vascular disease. We used retrograde or antegrade (transeptal) balloon aortic valvo-
The purpose of the study was to describe the CT appearance of lung disease associated with rheumatoid arthritis, and to assess the role of CT as a diagnostic examination in this condition. Eighteen patients with rheumatoid arthritis (American Rheumatism Association definition) were selected from a rheumatology clinic. All patients were examined