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Clinical results of Greenfield filter use in patients with malignancy
Venous Surgery 14.14
Pulmonary Embolism: Diagnosis, Incidence and Implications M.C. PROCTOR L.J. GREENFIELD and Ann Arbor, Michigan, USA The true incidence of pulmonary embolism (PE) and its implications for survival are unknown. When based solely on discharge diagnoses and autopsy reports it is frequently underestimated. We refined our estimate by chart review, radiology and nuclear medicine reports, and caval filter registry data cross referenced with financial records. Classification errors included 14 patients with positive angiograms who had no discharge diagnosis of PE while 16 with negative angiograms had a positive discharge diagnosis. Sixteen patients with 415.1 as a cause of death (COD) had no objective diagnosis and 21 patients with PE at autopsy did not have it listed as a COD. Between January 1, 1987 and December 31, 1989, PE was verified in 320 patients for an incidence of 3.5/1000 admissions. The 182 males and 138 females had a mean age of 56 years. Eighty-eight PE were found at autopsy yet only 17 (19%) had ante-mortem testing. The odds of dying while hospitalized were higher among those with PE (OR -- 15.4 95% CI[12.3, 19.7]). Patients discharged alive (66%) had an excellent prognosis for five-year survival (54%) although nine (2.8%) had recurrent PE within the next two years. Patients with Greenfield filters (73) had a lower mortality rate than those without (P --- 0.0005). Those diagnosed by angiography also had improved survival. These findings suggest the need for prophylaxis, sound criteria for diagnostic testing, accuracy of documentation and effective treatment for patients at risk of PE.
< 0.01). Our findings support the use of the Greenfield filter in patients with malignancy as the ongoing risk of new or recurrent thromboembolism is high and anticoagulation is often contraindicated or ineffective.
14.16
Treatment of Budd-Chiari Syndrome H. G UAN, C.W. LIU and N. JIN , Beijing, P.R. China The Budd-Chiari syndrome is an unusual form of portal hypertension caused by hepatic vein occlusion. Its prognosis is often poor. Surgical therapy offers a better outlook. In indicated cases using percutaneous balloon catheter dilatation of the inferior vena cava (IVC) and hepatic vein (HV) stenting even better results are obtained. From 1984 to 1993, 74 cases of Budd-Chiari syndrome were treated at PUMC hospital. Diagnosis was mostly made by simultaneous venography of the inferior and superior vena ava. The diagnoses were confirmed with intraluminal pressure measurement of the IVC and diameter measurement of the IVC with Doppler ultrasound. In the first 5 years, digital membranotomy via the right atrium was performed in 34 cases, percutaneous balloon catheter dilatation of the IVC in seven cases, and other surgical treatments including meso-atriai shunt and inferior vena cava to atrial shunt were performed in 19 cases. During the subsequent 5 years, only six cases underwent surgery. Percutaneous balloon catheter dilatation with stents for IVC and HV obstruction weere used in 14 cases. This solved the difficult initial problem of hepatic vein obstruction.
14.17 14.15 Clinical
Results of Greenfield Filter Use in Patients with Malignancy L.I. GREENFIELD, M.C. PROCTOR and A. SALUJA, Ann Arbor, Michigan, USA The utility of vena caval filters in patients with malignancy is widely debated, but most reports lack sufficient numbers of contemporary patients to provide a basis for clinical decisionmaking. We reviewed information from our tumor registry and filter database for 166 patients treated with Greenfield filters since 1988. There were 82 females and 84 males with a mean age of 57.8 years. The majority had distant metastases at the time of diagnosis. Treatment prior to filter placement included surgery in 64%, radiation in 44% and chemotherapy in 40% of cases. Mean survival following filter placement was 10 months. DVT was objectively documented for 115 at the time of filter placementand 90% of these had a contraindication to anticoagulation. Following filter placement 31% had a thromboembolic event and one quarter of these were first occurrences. The timing of recurrent thromboembolic events was highly correlated to the recurrence of malignancy (r = 0.71, P < 0.001). Cancer patients who develop thromboembolism should be carefully evaluated for recurrent malignancy for this reason. Pulmonary embolism was suspected in 13 patients but documented in only two. Anticoagulation was used in 37% of cases post-placement and nine (15%) had a significant complication. Recurrent thromboembolism was significantly higher among those who were anticoagulated (P
CARDIOVASCULAR SURGERY SEPTEMBER 1995
Radical Correction for Budd-Chiari Syndrome K. KOIA, A. KUSABA, Y. KUNIYOSHI, K. IHA, M. AKASAKI, K. MIYAGI, M. SHIMOJI, M. KUDAKA, A. SAKUDA and Y. KAMADA, Okinawa, Japan Controversy exists regarding the treatment of choice for the relief of Budd-Chiari syndrome. From 1979-1994, we treated 30 patients with Budd-Chiari syndrome by direct correction. Through a right thoracoabdominal approach, open endvenectomy at the IVC and reopening of the occluded hepatic veins were performed in all patients. Partial extracorporeal circulation (F-F bypass) was used as an assist with IVC clamping during the surgery. Twenty one of the patients were men and nine were women, with ages in the range from 24 to 73 years (mean 47). In two patients with hepatocellular carcinoma, direct reconstruction for Budd-Chiari syndrome and partial resection of the liver for the hepatoma were simultaneously performed. Early death or severe postoperative hepatic dysfunction was not observed. All patients showed significant clinical improvement with good patency of the reconstructed IVC postoperatively. Two patients showed restenosis of the hepatic IVC, at two years and six years after the operation. Percutaneous transluminal angioplasty was effective in one patient and successful reoperation was performed for another one. In five patients, hepatoma developed postoperatively at three to nine years after the operation. Partial hepatic resection was done in these patients. There were three late deaths two to
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Pulmonary Embolism: Diagnosis, Incidence and Implications M.C. PROCTOR L.J. GREENFIELD and Ann Arbor, Michigan, USA The true incidence of pulmonary embolism (PE) and its implications for survival are unknown. When based solely on discharge diagnoses and autopsy reports it is frequently underestimated. We refined our estimate by chart review, radiology and nuclear medicine reports, and caval filter registry data cross referenced with financial records. Classification errors included 14 patients with positive angiograms who had no discharge diagnosis of PE while 16 with negative angiograms had a positive discharge diagnosis. Sixteen patients with 415.1 as a cause of death (COD) had no objective diagnosis and 21 patients with PE at autopsy did not have it listed as a COD. Between January 1, 1987 and December 31, 1989, PE was verified in 320 patients for an incidence of 3.5/1000 admissions. The 182 males and 138 females had a mean age of 56 years. Eighty-eight PE were found at autopsy yet only 17 (19%) had ante-mortem testing. The odds of dying while hospitalized were higher among those with PE (OR -- 15.4 95% CI[12.3, 19.7]). Patients discharged alive (66%) had an excellent prognosis for five-year survival (54%) although nine (2.8%) had recurrent PE within the next two years. Patients with Greenfield filters (73) had a lower mortality rate than those without (P --- 0.0005). Those diagnosed by angiography also had improved survival. These findings suggest the need for prophylaxis, sound criteria for diagnostic testing, accuracy of documentation and effective treatment for patients at risk of PE.
< 0.01). Our findings support the use of the Greenfield filter in patients with malignancy as the ongoing risk of new or recurrent thromboembolism is high and anticoagulation is often contraindicated or ineffective.
14.16
Treatment of Budd-Chiari Syndrome H. G UAN, C.W. LIU and N. JIN , Beijing, P.R. China The Budd-Chiari syndrome is an unusual form of portal hypertension caused by hepatic vein occlusion. Its prognosis is often poor. Surgical therapy offers a better outlook. In indicated cases using percutaneous balloon catheter dilatation of the inferior vena cava (IVC) and hepatic vein (HV) stenting even better results are obtained. From 1984 to 1993, 74 cases of Budd-Chiari syndrome were treated at PUMC hospital. Diagnosis was mostly made by simultaneous venography of the inferior and superior vena ava. The diagnoses were confirmed with intraluminal pressure measurement of the IVC and diameter measurement of the IVC with Doppler ultrasound. In the first 5 years, digital membranotomy via the right atrium was performed in 34 cases, percutaneous balloon catheter dilatation of the IVC in seven cases, and other surgical treatments including meso-atriai shunt and inferior vena cava to atrial shunt were performed in 19 cases. During the subsequent 5 years, only six cases underwent surgery. Percutaneous balloon catheter dilatation with stents for IVC and HV obstruction weere used in 14 cases. This solved the difficult initial problem of hepatic vein obstruction.
14.17 14.15 Clinical
Results of Greenfield Filter Use in Patients with Malignancy L.I. GREENFIELD, M.C. PROCTOR and A. SALUJA, Ann Arbor, Michigan, USA The utility of vena caval filters in patients with malignancy is widely debated, but most reports lack sufficient numbers of contemporary patients to provide a basis for clinical decisionmaking. We reviewed information from our tumor registry and filter database for 166 patients treated with Greenfield filters since 1988. There were 82 females and 84 males with a mean age of 57.8 years. The majority had distant metastases at the time of diagnosis. Treatment prior to filter placement included surgery in 64%, radiation in 44% and chemotherapy in 40% of cases. Mean survival following filter placement was 10 months. DVT was objectively documented for 115 at the time of filter placementand 90% of these had a contraindication to anticoagulation. Following filter placement 31% had a thromboembolic event and one quarter of these were first occurrences. The timing of recurrent thromboembolic events was highly correlated to the recurrence of malignancy (r = 0.71, P < 0.001). Cancer patients who develop thromboembolism should be carefully evaluated for recurrent malignancy for this reason. Pulmonary embolism was suspected in 13 patients but documented in only two. Anticoagulation was used in 37% of cases post-placement and nine (15%) had a significant complication. Recurrent thromboembolism was significantly higher among those who were anticoagulated (P
CARDIOVASCULAR SURGERY SEPTEMBER 1995
Radical Correction for Budd-Chiari Syndrome K. KOIA, A. KUSABA, Y. KUNIYOSHI, K. IHA, M. AKASAKI, K. MIYAGI, M. SHIMOJI, M. KUDAKA, A. SAKUDA and Y. KAMADA, Okinawa, Japan Controversy exists regarding the treatment of choice for the relief of Budd-Chiari syndrome. From 1979-1994, we treated 30 patients with Budd-Chiari syndrome by direct correction. Through a right thoracoabdominal approach, open endvenectomy at the IVC and reopening of the occluded hepatic veins were performed in all patients. Partial extracorporeal circulation (F-F bypass) was used as an assist with IVC clamping during the surgery. Twenty one of the patients were men and nine were women, with ages in the range from 24 to 73 years (mean 47). In two patients with hepatocellular carcinoma, direct reconstruction for Budd-Chiari syndrome and partial resection of the liver for the hepatoma were simultaneously performed. Early death or severe postoperative hepatic dysfunction was not observed. All patients showed significant clinical improvement with good patency of the reconstructed IVC postoperatively. Two patients showed restenosis of the hepatic IVC, at two years and six years after the operation. Percutaneous transluminal angioplasty was effective in one patient and successful reoperation was performed for another one. In five patients, hepatoma developed postoperatively at three to nine years after the operation. Partial hepatic resection was done in these patients. There were three late deaths two to
73