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Dislodgment of a Stainless-Steel Greenfield Filter during Exchange of a Central Venous Catheter
1080
Journal of Vascular and Interventional Radiology
Novembe~December1997
pseudoaneurysm to be completely thrombosed and significantlv decreased in volume. ~ n e u & s mformation &r iliac angioplasty is a known, but very rare, complication (1).ARer stent placement, an infected iliac pseudoaneurysm formed around an endovascular device as described by Weinberg et al(2). These authors suggest that the origin of the pseudoaneurysm in their case was an infected stent. In our case, the pseudoaneurysm developed around the distal end of the covered stent and became visible at sonography a year aRer placement. During the initial procedure, there was no suggestion of vessel perforation by the guide wire or catheter, no clinical signs of infection were seen, and blood analysis revealed no signs of infection. The origin of this pseudoaneurysm is unclear. In our opinion, the possible causes of pseudoaneurysm formation a t the distal end of the covered iliac stent are vessel wall dissection by an angioplasty balloon during stent expansion and local perivascular softtissue reactions, as described by Kellner et a1 (3). Although there may be interaction between the vessel wall and the stent-graft covering material, we chose to treat this isolated iliac artery aneurysm by placement of a covered graft (4). References 1. Vive J, Bolia A. Aneurysm formation a t the site of percutaneous transluminal angioplasty: a report of two cases and review of the literature. Clin Radio1 1993; 45:125-127. 2. Weinberg DJ, Cronin DW, Baker AG. Infected iliac pseudoaneurysm after uncomplicated percutaneous balloon angioplasty and (Palmaz) stent insertion: a case report and literature review. J Vasc Surg 1996; 23:162-166. 3. Kellner W, Kiiffer G, Pfluger T, Rosa FT, Hahn K. MR imaging of soft tissue changes after percutaneous transluminal angioplasty and stent placement. Radiology 1997; 202:327331. 4. Razavi MK, Dake MD, Semba CP, Nyman URO, Liddell RP. Percutaneous endoluminal placement of stent-grafts for the treatment of isolated iliac artery aneurysms. Radiology 1995; 197:801-804.
Vascular or Interventional Procedures in Patients with Diabetes
From: Brian Funaki, MD George X. Szyrnski, MD Craig A. Hackworth, MD Jordan D. Rosenblum, MD The University of Chicago Hospitals Department of Radiology 5841 S. Maryland Avenue, MC 2026 Chicago, IL 60637 Editor: We wish to congratulate Dr. Hirsch for the excellent review on patients with diabetes (I),and add another bit of information relevant to the interventional radiolo-
gist performing procedures on patients taking NPH (neutral rota mine Haeedorn) insulin. We recently had a g6-year-old woman referred to our section for polytetrafluoroethylene graft thrombolysis. During the procedure, the patient was given 500,000 U of urokinase and 5,000 U of heparin. Thrombolysis was successful but the patient exhibited prolonged bleeding from the puncture sites in the graft after the procedure. We administered 10 mg of protamine sulfate intravenously to reverse the effects of heparin and the patient became tachycardic (with a heart rate of 140 beats per minute), short of breath, and exhibited slight facial swelling. Intravenous epinephrine 1:10,000 was administered and anesthesia department support was requested urgently. Although symptoms abated rapidly, the patient was admitted for observation and had a n uneventful recovery. Sensitivity to protamine developing after NPH insulin administration is well documented in the cardiology and internal medicine literature (2-4). However, to our knowledge, it has not been reported in the radiology literature. Anaphylactoid reactions tend to be more common when large doses of protamine sulfate are administered, but can also occur in low doses, as demonstrated by our patient. As a general rule, protamine sulfate administration should be avoided in patients taking NPH insulin. Our current protocol for dialysis graft thrombolysis in diabetic patients is to decrease the administered heparin dose to approximately 3,000 U. Aggressive heparinization should not be pursued in this group of patients unless absolutely necessary. References 1. Hirsch IB. Approach to the patient with diabetes undergoing a vascular or interventional procedure. JVIR 1997; 8: 329-336. 2. Vincent GM, Janovski M, Menlove R. Protamine allergy reactions during cardiac catheterization and cardiac surgery: risk in patients taking protamine-insulin preparations. Cathet Cardiovasc Diag 1991; 23:164-168. 3. Weiler JM, Freiman P, Sharath MD, e t al. Serious adverse reactions to protamine sulfate: are alternatives needed? J Allerg Clin Immunol 1985; 75:297-303. 4. Holland CL, Singh AK, McMaster PR, Fang W. Adverse reactions to protamine sulfate following cardiac surgery. Clin Cardiol 1984; 7:157-162.
Dislodgment of a Stainless-SteelGreenfield Filter during Exchange of a Central Venous Catheter
From: Paul Arpasi, MD Matthias J. Kirsch, MD Department of Diagnostic Radiology William Beaumont Hospital 3601 West Thirteen Mile Road Royal Oak, MI 48073-6769
Letters to the Editor
1081
Volume 8 Number 6
Editor: As previously reported, dislodgment of inferior vena cava (IVC) filters can occur during placement or exchange of central venous catheters over J wires (1,2). All six reported cases in the literature have involved Vena-Tech filters (1). An in vitro evaluation of guide wire entrapment by IVC filters demonstrated entrapment occurring with only the Vena-Tech and the 12-F, stainless-steel Greenfield filter with 1.5-mm and 3-mm J guide wires. To the best of our knowledge, there have been no reports of in vivo dislodgment of a stainless-steel Greenfield IVC filter. We recently encountered a case in which this happened. An 82-year-old woman was sent from a nursing home to our facility in respiratory distress. She was treated for Klebsiella and methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. During her hospitalization, she developed bilateral lower extremity deep venous thromboses diagnosed by duplex sonography. This was initially treated with heparin. However, during treatment, she developed gastrointestinal bleeding. The heparin was discontinued and the patient was referred to our service for placement of a n IVC filter. With use of a 12-F system, a right inguinal approach was used to place a stainless-steel over-thewire Greenfield filter into the infrarenal IVC. The inferior vena cavogram demonstrated no evidence of thrombus, a s well as a normal-sized IVC. The filter deployed normally, and there were no complications during placement. One week later, during routine replacement of a right internal jugular central venous catheter, the 0.89-mm J wire became entangled with the filter. The wire was then withdrawn with extreme force resulting in successful removal. The radio&aph obtained after this procedure demonstrated the filter to be within the right internal jugular vein. The patient returned to our department. An inferior vena cavogram demonstrated intimal flaps a t the original filter site (Figure). Because the patient still required protection, a second IVC filter was placed in the infrarenal IVC. After consultation with the surgical service, it was decided not to attempt retrieval of the migrated filter. Two weeks later, the patient was discharged to a n extended care facility. ~t the time of discharge, no additional sequela related to the filter entanglement was noted. The Dresence of a n IVC filter should be ascertained prior to placement or exchange of a central venous catheter. We suggest t h a t fluoroscopic guidance be used to assist in the placement or exchange of central venous catheters in patients with IVC filters. Passage of the guide wire through the filter should be avoided. If resistance is encountered while attempting to remove a guide wire, the operator should avoid using excessive traction and further manipulation until guided by fluoroscopy. We also suggest, as described in the in vitro study, t h a t straight exchange wires be used for catheter exchange and t h a t J-tipped guide wires with a radius of 3 mm or less should be avoided. u
4
b.
Figure. (a)Normally positioned Greenfield IVC filter that ultimately became entrapped with the J wire during "blind catheter exchange. (b) Final resting position of the Greenfield filter in the patient's right internal jugular vein after forcible retrieval of the entangled wire (continues).
1082
Journal of Vascular and Interventional Radiology
November-December 1997
Figure. (continued) ( c ) Inferior vena cavogram demonstrates intimal flaps at original site.
References 1. Kaufman J, Thomas J, Geller S, et al. Guide wire entanglement by inferior vena caval filters: in vitro evaluation. Radiology 1996; 198:71-76. 2. Loesberg A, Taylor F, Awh M. Dislodgement of inferior vena cava filters during "blind" insertion of central venous catheters. AJR 1993; 161:637-638.
Venous Injection to Assess for Thoracic Aortic Trauma
From: Andrew F. Little, FRACR Oliver Hennessy, FRACR Consultant Radiologists Department of Medical Imaging St. Vincent's Hospital Victoria Parade Melbourne 3065 VIC Australia
Editor: We are writing in reference to a n article by Dr. Helen Redman that appeared in the MarchJApril 1997 issue of JVIR (1). Dr. Redman comments on the post-MVA evaluation of thoracic aortic injuries in circumstances where there is failure of guide-wire passage into the proximal thoracic aorta, and suggests many useful techniques to negotiate this occurrence. However, there is another technique for managing this problem. In those patients in whom there is failure of guidewire passage or in patients with weak femoral pulses prior to the procedure, t h e right side of t h e circulation can be entered via the common femoral vein or a n antecubital fossa vein and a pigtail catheter can be passed into the right atrium or t h e pulmonary outflow tract. The antecubital fossa vein, in particular, is a n expeditious site in unstable patients with documented or suspected pelvic fractures and/or pelvic hematomas. The arteriogram is then obtained utilizing a highvolume, high-flow-rate injection with initial filming a t 1 framelsecond through the pulmonary arterial and venous phase, and then a 2-3 framelsecond acquisition i n the aortic outflow phase. In these clinical situations, the thoracic aortic detail proves to be more t h a n optimal for accurately diagnosing significant aortic trauma. I n this way, the risk of negotiating a potential thoracic injury with a guide wire and catheter is obviated. This approach should not, and need not, be used in every patient with suspected thoracic aortic injury because an arterial injection is usually preferable.
Reference 1. Redman HC. Interventional radiologist at work: question and answer. JVIR 1997; 8:226-227.
Journal of Vascular and Interventional Radiology
Novembe~December1997
pseudoaneurysm to be completely thrombosed and significantlv decreased in volume. ~ n e u & s mformation &r iliac angioplasty is a known, but very rare, complication (1).ARer stent placement, an infected iliac pseudoaneurysm formed around an endovascular device as described by Weinberg et al(2). These authors suggest that the origin of the pseudoaneurysm in their case was an infected stent. In our case, the pseudoaneurysm developed around the distal end of the covered stent and became visible at sonography a year aRer placement. During the initial procedure, there was no suggestion of vessel perforation by the guide wire or catheter, no clinical signs of infection were seen, and blood analysis revealed no signs of infection. The origin of this pseudoaneurysm is unclear. In our opinion, the possible causes of pseudoaneurysm formation a t the distal end of the covered iliac stent are vessel wall dissection by an angioplasty balloon during stent expansion and local perivascular softtissue reactions, as described by Kellner et a1 (3). Although there may be interaction between the vessel wall and the stent-graft covering material, we chose to treat this isolated iliac artery aneurysm by placement of a covered graft (4). References 1. Vive J, Bolia A. Aneurysm formation a t the site of percutaneous transluminal angioplasty: a report of two cases and review of the literature. Clin Radio1 1993; 45:125-127. 2. Weinberg DJ, Cronin DW, Baker AG. Infected iliac pseudoaneurysm after uncomplicated percutaneous balloon angioplasty and (Palmaz) stent insertion: a case report and literature review. J Vasc Surg 1996; 23:162-166. 3. Kellner W, Kiiffer G, Pfluger T, Rosa FT, Hahn K. MR imaging of soft tissue changes after percutaneous transluminal angioplasty and stent placement. Radiology 1997; 202:327331. 4. Razavi MK, Dake MD, Semba CP, Nyman URO, Liddell RP. Percutaneous endoluminal placement of stent-grafts for the treatment of isolated iliac artery aneurysms. Radiology 1995; 197:801-804.
Vascular or Interventional Procedures in Patients with Diabetes
From: Brian Funaki, MD George X. Szyrnski, MD Craig A. Hackworth, MD Jordan D. Rosenblum, MD The University of Chicago Hospitals Department of Radiology 5841 S. Maryland Avenue, MC 2026 Chicago, IL 60637 Editor: We wish to congratulate Dr. Hirsch for the excellent review on patients with diabetes (I),and add another bit of information relevant to the interventional radiolo-
gist performing procedures on patients taking NPH (neutral rota mine Haeedorn) insulin. We recently had a g6-year-old woman referred to our section for polytetrafluoroethylene graft thrombolysis. During the procedure, the patient was given 500,000 U of urokinase and 5,000 U of heparin. Thrombolysis was successful but the patient exhibited prolonged bleeding from the puncture sites in the graft after the procedure. We administered 10 mg of protamine sulfate intravenously to reverse the effects of heparin and the patient became tachycardic (with a heart rate of 140 beats per minute), short of breath, and exhibited slight facial swelling. Intravenous epinephrine 1:10,000 was administered and anesthesia department support was requested urgently. Although symptoms abated rapidly, the patient was admitted for observation and had a n uneventful recovery. Sensitivity to protamine developing after NPH insulin administration is well documented in the cardiology and internal medicine literature (2-4). However, to our knowledge, it has not been reported in the radiology literature. Anaphylactoid reactions tend to be more common when large doses of protamine sulfate are administered, but can also occur in low doses, as demonstrated by our patient. As a general rule, protamine sulfate administration should be avoided in patients taking NPH insulin. Our current protocol for dialysis graft thrombolysis in diabetic patients is to decrease the administered heparin dose to approximately 3,000 U. Aggressive heparinization should not be pursued in this group of patients unless absolutely necessary. References 1. Hirsch IB. Approach to the patient with diabetes undergoing a vascular or interventional procedure. JVIR 1997; 8: 329-336. 2. Vincent GM, Janovski M, Menlove R. Protamine allergy reactions during cardiac catheterization and cardiac surgery: risk in patients taking protamine-insulin preparations. Cathet Cardiovasc Diag 1991; 23:164-168. 3. Weiler JM, Freiman P, Sharath MD, e t al. Serious adverse reactions to protamine sulfate: are alternatives needed? J Allerg Clin Immunol 1985; 75:297-303. 4. Holland CL, Singh AK, McMaster PR, Fang W. Adverse reactions to protamine sulfate following cardiac surgery. Clin Cardiol 1984; 7:157-162.
Dislodgment of a Stainless-SteelGreenfield Filter during Exchange of a Central Venous Catheter
From: Paul Arpasi, MD Matthias J. Kirsch, MD Department of Diagnostic Radiology William Beaumont Hospital 3601 West Thirteen Mile Road Royal Oak, MI 48073-6769
Letters to the Editor
1081
Volume 8 Number 6
Editor: As previously reported, dislodgment of inferior vena cava (IVC) filters can occur during placement or exchange of central venous catheters over J wires (1,2). All six reported cases in the literature have involved Vena-Tech filters (1). An in vitro evaluation of guide wire entrapment by IVC filters demonstrated entrapment occurring with only the Vena-Tech and the 12-F, stainless-steel Greenfield filter with 1.5-mm and 3-mm J guide wires. To the best of our knowledge, there have been no reports of in vivo dislodgment of a stainless-steel Greenfield IVC filter. We recently encountered a case in which this happened. An 82-year-old woman was sent from a nursing home to our facility in respiratory distress. She was treated for Klebsiella and methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. During her hospitalization, she developed bilateral lower extremity deep venous thromboses diagnosed by duplex sonography. This was initially treated with heparin. However, during treatment, she developed gastrointestinal bleeding. The heparin was discontinued and the patient was referred to our service for placement of a n IVC filter. With use of a 12-F system, a right inguinal approach was used to place a stainless-steel over-thewire Greenfield filter into the infrarenal IVC. The inferior vena cavogram demonstrated no evidence of thrombus, a s well as a normal-sized IVC. The filter deployed normally, and there were no complications during placement. One week later, during routine replacement of a right internal jugular central venous catheter, the 0.89-mm J wire became entangled with the filter. The wire was then withdrawn with extreme force resulting in successful removal. The radio&aph obtained after this procedure demonstrated the filter to be within the right internal jugular vein. The patient returned to our department. An inferior vena cavogram demonstrated intimal flaps a t the original filter site (Figure). Because the patient still required protection, a second IVC filter was placed in the infrarenal IVC. After consultation with the surgical service, it was decided not to attempt retrieval of the migrated filter. Two weeks later, the patient was discharged to a n extended care facility. ~t the time of discharge, no additional sequela related to the filter entanglement was noted. The Dresence of a n IVC filter should be ascertained prior to placement or exchange of a central venous catheter. We suggest t h a t fluoroscopic guidance be used to assist in the placement or exchange of central venous catheters in patients with IVC filters. Passage of the guide wire through the filter should be avoided. If resistance is encountered while attempting to remove a guide wire, the operator should avoid using excessive traction and further manipulation until guided by fluoroscopy. We also suggest, as described in the in vitro study, t h a t straight exchange wires be used for catheter exchange and t h a t J-tipped guide wires with a radius of 3 mm or less should be avoided. u
4
b.
Figure. (a)Normally positioned Greenfield IVC filter that ultimately became entrapped with the J wire during "blind catheter exchange. (b) Final resting position of the Greenfield filter in the patient's right internal jugular vein after forcible retrieval of the entangled wire (continues).
1082
Journal of Vascular and Interventional Radiology
November-December 1997
Figure. (continued) ( c ) Inferior vena cavogram demonstrates intimal flaps at original site.
References 1. Kaufman J, Thomas J, Geller S, et al. Guide wire entanglement by inferior vena caval filters: in vitro evaluation. Radiology 1996; 198:71-76. 2. Loesberg A, Taylor F, Awh M. Dislodgement of inferior vena cava filters during "blind" insertion of central venous catheters. AJR 1993; 161:637-638.
Venous Injection to Assess for Thoracic Aortic Trauma
From: Andrew F. Little, FRACR Oliver Hennessy, FRACR Consultant Radiologists Department of Medical Imaging St. Vincent's Hospital Victoria Parade Melbourne 3065 VIC Australia
Editor: We are writing in reference to a n article by Dr. Helen Redman that appeared in the MarchJApril 1997 issue of JVIR (1). Dr. Redman comments on the post-MVA evaluation of thoracic aortic injuries in circumstances where there is failure of guide-wire passage into the proximal thoracic aorta, and suggests many useful techniques to negotiate this occurrence. However, there is another technique for managing this problem. In those patients in whom there is failure of guidewire passage or in patients with weak femoral pulses prior to the procedure, t h e right side of t h e circulation can be entered via the common femoral vein or a n antecubital fossa vein and a pigtail catheter can be passed into the right atrium or t h e pulmonary outflow tract. The antecubital fossa vein, in particular, is a n expeditious site in unstable patients with documented or suspected pelvic fractures and/or pelvic hematomas. The arteriogram is then obtained utilizing a highvolume, high-flow-rate injection with initial filming a t 1 framelsecond through the pulmonary arterial and venous phase, and then a 2-3 framelsecond acquisition i n the aortic outflow phase. In these clinical situations, the thoracic aortic detail proves to be more t h a n optimal for accurately diagnosing significant aortic trauma. I n this way, the risk of negotiating a potential thoracic injury with a guide wire and catheter is obviated. This approach should not, and need not, be used in every patient with suspected thoracic aortic injury because an arterial injection is usually preferable.
Reference 1. Redman HC. Interventional radiologist at work: question and answer. JVIR 1997; 8:226-227.