- Email: [email protected]
Scientific Session 5 Thrombolysis and Thrombectomy
rCD in a group of patients with proved infected pancreatic necrosis. MATERIALS AND METHODS: Thirty patients with infected pancreatic necrosis, as determined by contrastenhanced computed tomography and guided-needle aspiration, underwent PCD. The degree of necrosis ranged from 30% to >50% (subtotal). The average computed tomography severity index was 7.8. One to three 1228-F catheters were placed in each patient and vigorously irrigated. RESULTS: Fourteen (47%) patients were cured and did not require surgery. Mean drainage time was 80 days (range, 21-153 days). Ten patients (33%) required necrosectomy because of uncontrolled sepsis or inadequate drainage, and three of these patients died (mortality rate, 10%). Six patients required elective pancreatic resection due to pancreatic fistulas, and three of these patients had central necrosis. No direct complications of catheter drainage occurred. CONCLUSION Infected pancreatic necrosis was treated effectively by PCD alone or with elective pancreatic resection in 67% of cases.
CONCLUSIONS: The success and complication rates for adult PAFD reported in the literature from academic centers are reproducible in a community practice of physicians with varying levels of training and experience. These published rates are appropriate for setting qualityimprovement thresholds for community practices. It may not be appropriate to set thresholds for complications at twice the published rates.
Take Home Points: 1. Percutaneous abscess and fluid drainage in a community hospital setting has success and complication rates similar to academic settings. 2. Published success rates for percutaneous abscess and fluid drainage are appropriate for setting qualityimprovement thresholds. 3. Setting thresholds for complications at twice the published rates may be too lenient to improve the quality of practice.
Scientific Session 5 Thrombolysis and Thrombectomy
Take Home Points: 1. Infected pancreatic necrosis is not a contraindication for PCD.
Moderator: Mark Mewissen, MD, Milwaukee, WI
2. PCD for infected necrosis may be effective in as many as 67% of patients.
1:30 pm
3. Central necrosis indicates a stronger likelihood of PCD failure.
2:45 pm Appropriateness of scvm Quality-Improvement Thresholds for Percutaneous Abscess and Fluid Drainage in Adults in Community Practice D. Sacks, MD, West Reading, PA • j.M. Painter, MD • Rj. Gregor, MD PURPOSE: To evaluate the generalizability to a community hospital practice of the quality-improvement thresholds for success and complications for percutaneous abscess and fluid drainage (PAFD) in adults. MATERIALS AND METHODS: Records of 200 PAFD procedures were reviewed retrospectively. Cases were evaluated for success, partial success, failure, and complications using the quality-improvement guidelines criteria of the Society of Cardiovascular and Interventional Radiology (SCVIR).
184
were performed by one physician, there was no association of procedure success or complication with the physician or physician experience.
RESULTS: Forty percent of collections were complex (defined in the SCVIR quality-improvement guidelines as multiple abscesses, abscess due to Crohn disease, pancreatic collections, drainage route that traverses the bowel or pleura, infected clot, and infected tumor). Drainage was successful (87%), partially successful (5%), or failed (8%). There were 3% complications, of which only 15% were major. Although 50% of the drainages
Long-Term Follow-up of Aggressive Catheter Technique for Massive Pulmonary Embolus Thrombolysis PE Tb01pe, MD, Omaha, NE • x.x. Zhan, MD PURPOSE: To evaluate the efficacy and long-term results of aggressive, catheter-embedded thrombolYSis for acute, severely symptomatic pulmonary embolus (PE). MATERIALS AND METHODS: Fourteen patients (seven women and seven men) received aggressive catheterdirected lysis for acute PE between January 1989 and July 1996. After diagnostic angiography and baseline pulmonary pressures, urokinase was delivered directly into the embolus with associated maceration when possible. A bolus of 500,000-1,000,000 IU was given over a period of 20-60 minutes for massive obstruction. An infusion of 100-300,000 IU/hour was continued, and interval angiograms and pressures were obtained. Urokinase was infused from 10--40 hours. An intravenous catheter filter was placed in eight (57%) of the patients. Severity and improvement of obstruction and flow were assessed using the Miller index (MI). RESULTS: Mean duration of infusion was 21 hours; the mean dose of urokinase was 3,500,000 IV. Twelve of 14 (86%) patients had documented deep venous thrombosis. Six patients were in class I shock (systolic blood pressure <90 mmHg), and the MI was 23 before lysis and 11.8 after lysis. Class II patients (systolic blood pressure
>90 mmHg) had a MI of 10.9 before lysis and 5.8 after lysis (P < .05). Immediate survival was 93% (n = 13), and the 36-month mean follow-up survival rate is 93% (n = 13), the recurrent deep venous thrombosis rate is 7% (n = 1), and recurrent PE rate is 0%. CONCLUSIONS: Aggressive catheter-directed thrombolysis for massive obstructive PE that causes hemodynamic instability can decrease mortality rates. Patients with symptoms from diffuse PE also respond rapidly to intrapulmonary lytic therapy. However, although patients with a diffuse nonobstructive pattern of PE may respond to systemic therapy, massive obstructive emboli require an aggressive catheter technique to ensure timely clinical improvement.
Take Home Points: Aggressive catheter manipulation and intrathrombic lytic therapy improve survival in patients with massive obstructive PE. A pattern of diffuse PE may respond to systemic therapy.
1:45 pm Popliteal Approach to Treat PWegmasia Cerulea Dolens T.O. McNamara, MD, Los Angeles, CA PURPOSE: To assess the safety and effectiveness of the use of the popliteal vein to introduce a thrombolysis infusion system to treat phlegmasia cerulea dolens. MATERIALS AND METHODS: Six consecutive patients with clinical findings of phlegmasia cerulea dolens and ultrasound evidence of thrombosis of the iliac, femoral, popliteal, and trifurcation veins were treated. Ultrasound was used to visualize the popliteal vein. A triaxial infusion system was introduced. Thrombolysis was accomplished with concomitant transcatheter infusions of urokinase and heparin. Underlying stenoses were treated with stents. RESULTS: Antegrade flow was restored with associated clearing of pain and reduction of leg swelling within 24 hours. No clinical evidence of pulmonary embolism was noted. All patients experienced complete clearing of swelling within 48 hours. One patient with a paraneoplastiC hypercoagulable state had recurrence and underwent amputation. There were no deaths and only one popliteal hematoma. CONCLUSION Transpopliteal thrombolysis provides a prompt, Simple, and effective method to treat limbthreatening phlegmasia cerulea dolens.
Take Home Points: 1. The popliteal approach is simple.
2. It provides for easier traversal of the valves and enables thrombolysis to immediately span the occlusion from the popliteal through the iliac levels.
2:00 pm Catheter-Directed Fibrinolysis and Intervention for Iliofemoral Deep Venous Thrombosis: Technique and Results
IF.
Benenati, MD, FACC, FACR, Miami, FL • G] Becker, MD • G. Zemel, MD • B. T. Katzen, MD • L.B. GoodWin, RN • S. Samuels, MD PURPOSE: Catheter-directed fibrinolytic infusion is a therapeutic option to treat iliofemoral deep venous thrombosis (DVT). This therapy was studied in 15 patients.
MATERIALS AND METHODS: Fifteen patients with iliofemoral DVT documented by duplex or venography were treated using catheter-directed fibrinolytic infusion. Symptoms lasted from 5 hours to 5 months. Access was obtained from either the internal jugular vein (n = 7) or from the ipsilateral popliteal vein (n = 8). Coaxial infusions of urokinase were performed with the dose ranging from 60,000 to 250,000 IV/hour (average, 83,000 IV/ hour). The duration of urokinase therapy ranged from 20 to 120 hours (mean, 23.5 hours). During thrombolytic infusion, patients were given heparin (partial thromboplastin time ranging from 1.5 to 2x normal). Lysis was continued until symptoms resolved or was terminated if no change occurred clinically or by imaging in 72 hours. An additional intervention was performed in 10 of 14 patients C7 stents, 3 venous angioplasties). In the remaining patients, no underlying lesions could be identified. All patients were given heparin and warfarin sodium for 6 months, except for one patient who required an inferior vena cava catheter filter because of intraperitoneal bleeding, which was the only major complication. Minor complications included three hematomas, one cases of cellulitis, and one intermittent fever. Immediate results showed restoration of patency in the iliac vein in 13 of 15 patients. Three of the 13 patients with patent iliac veins had residual distal thrombi. Two patients had no change when compared with results of their initial examinations. Follow-up ranges from 3 weeks to 18 months. One of 13 patients experienced rethrombosis. The remaining veins are patent and unchanged or improved from their postprocedure examination. CONCLUSIONS: Catheter-directed thrombolytic infusion is safe and effective for treating patients with symptoms secondary to iliofemoral DVT. After thrombolysis, underlying lesions frequently are found and should be treated to prevent rethrombosis. Results suggest this therapy may be effective in preventing long-term sequelae.
Take Home Points: 1. Catheter-directed thrombolytic infusion for an iliofemoral DVT is safe and effective.
2. Various techniques may be used, including internal jugular and direct popliteal vein access. 3. Underlying lesions are often responsible for the DVT.
185
2:15 pm Transcatheter Regional Urokinase Therapy to Manage Inferior Vena Cava Thrombosis ].F. Angle, MD, Charlottesvitte, VA .].K. McGraw, MD • A.H. Matsumoto, MD PURPOSE: To study the efficacy of local infusions of urokinase to treat symptomatic inferior vena cava (lVC) thrombosis. MElliODS: Seven patients with IVC thrombosis underwent local catheter-directed infusion of a thrombolytic agent. Catheter-directed thrombolysis was performed using as many as three access sites. Urokinase was infused for an average of 79 hours for a mean total dose of 7.1 million units. Clinical or radiographic follow-up was obtained in all patients. RESULTS: lnfrarenal IVC thrombus was identified in all patients. Three had extension of thrombus proximal to the renal veins. Six of seven (86%) IVCs were successfully thrombolysed with minimal residual thrombus. Three of the seven patients (43%) had a preexisting IVC filter, one had a filter placed at the time of thrombolysis, and two had a Neuhaus infusion catheter placed as a temporary filter. Adjunctive balloon angioplasty was performed in three patients. No vascular stents were placed. Four patients had a hypercoagulable state and one patient had an occult metastatic malignancy. No serious complications were encountered, although one patient died of an unrelated cause 5 days after therapy. Clinical follow-up in the remaining six patients ranged from 2 to 24 months. All six patients had continued improved lower extremity swelling after the procedure. None of the patients had symptoms of recurrent IVC thrombosis. CONCLUSIONS: Local infusions of urokinase are a reliable and safe method to manage acute IVe thrombosis.
Take Home Points: 1. Catheter-directed thrombolysis is effective treatment for acute Ive thrombosis. 2. Regional therapy of IVC thrombus is a safe therapy with good long-term results.
RESULTS: Excellent anatomic patency of IVC was restored in all 23 animals. Mean device activation time was 4.35 ± 2.5 minutes. Post-thrombectomy venography showed smooth IVC walls in 14 dogs, whereas mural thrombus remained in nine dogs without significant flow restriction (less than 20% narrowing in seven, 20-30% narrowing in two). No angiographic or histopathologic evidence of mechanical IVC wall damage was present, although phlebitic changes were common. No new pulmonary emboli were noted on post-thrombectomy angiograms. However, a slight increase in mean pulmonary artery pressure occurred, with a corresponding decrease in arterial oxygen saturation. Examination of explanted lungs from 11 animals showed 100-500-pm pulmonary arteriolar microemboli in four (three of three transjugular, one of eight transfemoraO. CONCLUSION: ATD is effective in clearing 1-2-week-old IVC thrombosis.
Take Home Points: 1. Mechanical thrombectomy using ATD is highly effective in treating subacute IVC thrombosis. 2. Pulmonary microembolization is well tolerated and much less common using the transfemoral approach.
2:45 pm Percutaneous Hydrodynamic Thrombectomy Using the Hydrolyser System M. Henry, MD, Essey Les Nancy, France • M. Amor, MD • I. Henry, MD • ].M. Porte, MD • O. Tricoche, MD • E. Leborgne, MD PURPOSE: To present our clinical experience with a new mechanical hydrodynamic thrombectomy system (Hydrolyser) using the Venturi effect. This device was used to remove thrombi from native arteries, arterial grafts, the venous system, and pulmonary arteries.
PURPOSE: To evaluate the efficacy of the Amplatz thrombectomy device (ATD) in an experimental model of subacute inferior vena cava (IVC) thrombosis.
MATERIALS AND MElliODS: The Hydrolyser is a recently developed 7-Fr, double-lumen, over-the-wire catheter. The device has been used in 50 patients (29 men, 21 women; mean age, 66,2 ± 13.1 years [range, 40-90 years]) with recent thromboses. Occlusion time ranged from 1 to 30 days (mean, 8.2 ± 7.3 days); thrombus length ranged from 4 to 35 em (mean, 17.7 ± 10.2 em). Thrombi were located in native arteries (n = 35: femoropopliteal, 28; iliac, 7), arterial grafts (n = 9), superior vena cava (n = 2), axillary vein (n = 2), and pulmonary artery (n = 2). Approaches were arterial femoral antegrade (n = 22), retrograde (n = 7), contralateral (n = 14), popliteal arterial (n = 1), venous femoral (n = 5), and venous humeral (n = 1).
MATERIALS AND MElliODS: ATD is an 8-Fr recirculation-type mechanical thrombectomy device that uses a recessed helical impeller, coaxially driven up to 150,000
RESULTS: Technical success was achieved in 41 patients (82%) in native arteries (27 of 35, 77%), arterial grafts (8 of 9,89%), pulmonary artery (2 of 2), superior vena cava
3. Vascular stents are not required for good long-term results. 2:30 pm
Percutaneous Mechanical Thrombectomy of Inferior Vena Cava Thrombosis with the Amplatz Thrombectomy Device X. Gu, MD, Minneapolis, MN • Mj. Sharafuddin, MD • M. Urness .].1. Titus, MD • K. Amplatz, MD
186
rpm. Thrombectomy was performed in 23 dogs, in which 6-15-day-old infrarenal IVC thrombosis was induced by placing an occlusion balloon. The transjugular approach was used in five animals, and a two-step transfemoral approach was used in 18.
(2 of 2), and axillary vein (2 of 2). Thrombi were estimated angiographically to be removed by the Hydrolyser 72.5% ± 22%. Adjunctive therapy included angioplasty (n = 38, 19 immediate stents implantations), thromboaspiration (n = 17), and reduced-time fibrinolysis (n = 11). One complication occurred-a distal embolism cured by thromboaspiration. In nine patients the procedure failed and required surgery (bypass or Fogarty). At 30 days, 37 vessels remained patent (74%). CONCLUSIONS: The Hydrolyser system is a promising concept for percutaneous thrombectomy. It is quick, reliable, efficient, can be combined with other techniques such as thromboaspiration, and completed by reducedtime fibrinolysis. This technique also may offer an alternative to thrombolysis and surgical thrombectomy.
Take Home Points: The Hydrolyser system is a promising concept for percutaneous thrombectomy. It is quick, reliable, efficient, can be combined with other techniques such as thromboaspiration, and completed by reduced-time fibrinolysis. This technique also may offer an alternative to thrombolysis and surgical thrombectomy.
Scientific Session 6 Venous Access and Dialysis Catheters Moderator: Gwen Nazzarian, MD, Minneapolis, MN 1:30 pm
Ultrasound-guided Cannulation of the Internal Jugular Vein: Complications and Anatomic Considerations A.C. Gordon, MBBS, FRCR, Calgary, Alberta, Canada • ]. Saliken, MD, FRCPC • D. johns • R. Gray, MD, FRCPC PURPOSE: To examine success and complication rates for ultrasound-guided cannulation of the internal jugular vein (lJV) compared with blind techniques and to observe the effect of variations in the anatomy of the vein. MAIERIALS AND METHODS: Data were collected prospectively for 621 cases of sonographically guided cannulation of the lJV. In all cases the side of puncture, whether the procedure was successful, and any immediate complications were recorded. In 519 cases the number of passes required was recorded, and in 524 the number of walls punctured was noted. In 431 cases, the location of the I]V relative to the carotid artery was recorded. Finally the diameter of the I]V and its distance from the skin were noted in 557 cases. RESULTS: Cannulation was successful in all of the cases. There were 483 (77.8%) cannulations of the right and 138 (22.2%) of the left I]V. Complications occurred in 13 cases (2.09%). Only one required therapy. There were 450 (85.9) single-wall punctures, and 465 (89.6%) of the punctures were made with one pass. In 199 cases
(46.2%) the vein was anterolateral to the carotid artery. In 22 cases (5.1%) the vein lay medial to the artery. CONCLUSIONS: Ultrasound-guided cannulation of the I]V is superior to blind techniques. Sonographic visualization reduces the effect of variations in anatomy and operator experience on the success of cannulation.
Take Home Points: Ultrasound guidance will decrease the complication rate and thus is advisable for cannulation of the I]V when available. 1:45 pm Effect of Vitacuffs on the Short-term Infection Rate of Tunneled Central Catheters G.K. Nazarian, MD, Minneapolis, MN • C.A. Dietz, jr., MD • H. Bjarnason, MD • D. w: Hunter, MD PURPOSE: To determine whether VitaCuffs (Arrow International, Reading, FA) reduce the infection rate of tunneled central venous catheters. MA TERIALS AND METHODS: Sixty-seven patients having bone marrow transplants received tunneled central venous catheters during a 33-month period. Twenty-nine patients received Hickman catheters (Bard Access Systems, Salt Lake City, un with VitaCuffs and 38 patients received Hickman catheters without VitaCuffs. Infection was defined as bacteremia with no clear source other than the catheter. The medical records were reviewed retrospectively up to 30 days after line placement. The number of catheter-related infections were compared for the two groups using the Cox F-test. RESULTS: Catheters were in place 790 catheter-days for catheters with and 1,055 catheter-days for catheters without VitaCuffs. Before 30 days, three patients died, six catheters were removed due to suspected infection, two inadvertently, two for access thrombosis, and one because it was no longer needed. Two catheters with and eight catheters without VitaCuffs were removed for catheter-related infection (P < .05). CONCLUSION VitaCuffs significantly reduce the number of catheter-related infections in patients having bone marrow transplants.
Take Home Points: 1. Catheter-related infection is a serious problem in immunocompromised patients. 2. Tunneled catheters come with and without VitaCuffs. 3. Reduced catheter-related infections occurred when catheters with VitaCuffs were placed. 2:00 pm
Randomized Study of Silver Coating (Silvergard) to Prevent Infection in Tunneled Hemodialysis Catheters: Interim Report S.O. Trerotola, MD, Indianapolis, IN. M.S. johnson, MD • H. Shah, MD • V j. Harris, MD • M. Kraus, MD • M. McKusky, RN
PURPOSE: To determine whether silver coating (Silvergard, SG) applied to tunneled hemodialysis catheters re-
187
CONCLUSIONS: The success and complication rates for adult PAFD reported in the literature from academic centers are reproducible in a community practice of physicians with varying levels of training and experience. These published rates are appropriate for setting qualityimprovement thresholds for community practices. It may not be appropriate to set thresholds for complications at twice the published rates.
Take Home Points: 1. Percutaneous abscess and fluid drainage in a community hospital setting has success and complication rates similar to academic settings. 2. Published success rates for percutaneous abscess and fluid drainage are appropriate for setting qualityimprovement thresholds. 3. Setting thresholds for complications at twice the published rates may be too lenient to improve the quality of practice.
Scientific Session 5 Thrombolysis and Thrombectomy
Take Home Points: 1. Infected pancreatic necrosis is not a contraindication for PCD.
Moderator: Mark Mewissen, MD, Milwaukee, WI
2. PCD for infected necrosis may be effective in as many as 67% of patients.
1:30 pm
3. Central necrosis indicates a stronger likelihood of PCD failure.
2:45 pm Appropriateness of scvm Quality-Improvement Thresholds for Percutaneous Abscess and Fluid Drainage in Adults in Community Practice D. Sacks, MD, West Reading, PA • j.M. Painter, MD • Rj. Gregor, MD PURPOSE: To evaluate the generalizability to a community hospital practice of the quality-improvement thresholds for success and complications for percutaneous abscess and fluid drainage (PAFD) in adults. MATERIALS AND METHODS: Records of 200 PAFD procedures were reviewed retrospectively. Cases were evaluated for success, partial success, failure, and complications using the quality-improvement guidelines criteria of the Society of Cardiovascular and Interventional Radiology (SCVIR).
184
were performed by one physician, there was no association of procedure success or complication with the physician or physician experience.
RESULTS: Forty percent of collections were complex (defined in the SCVIR quality-improvement guidelines as multiple abscesses, abscess due to Crohn disease, pancreatic collections, drainage route that traverses the bowel or pleura, infected clot, and infected tumor). Drainage was successful (87%), partially successful (5%), or failed (8%). There were 3% complications, of which only 15% were major. Although 50% of the drainages
Long-Term Follow-up of Aggressive Catheter Technique for Massive Pulmonary Embolus Thrombolysis PE Tb01pe, MD, Omaha, NE • x.x. Zhan, MD PURPOSE: To evaluate the efficacy and long-term results of aggressive, catheter-embedded thrombolYSis for acute, severely symptomatic pulmonary embolus (PE). MATERIALS AND METHODS: Fourteen patients (seven women and seven men) received aggressive catheterdirected lysis for acute PE between January 1989 and July 1996. After diagnostic angiography and baseline pulmonary pressures, urokinase was delivered directly into the embolus with associated maceration when possible. A bolus of 500,000-1,000,000 IU was given over a period of 20-60 minutes for massive obstruction. An infusion of 100-300,000 IU/hour was continued, and interval angiograms and pressures were obtained. Urokinase was infused from 10--40 hours. An intravenous catheter filter was placed in eight (57%) of the patients. Severity and improvement of obstruction and flow were assessed using the Miller index (MI). RESULTS: Mean duration of infusion was 21 hours; the mean dose of urokinase was 3,500,000 IV. Twelve of 14 (86%) patients had documented deep venous thrombosis. Six patients were in class I shock (systolic blood pressure <90 mmHg), and the MI was 23 before lysis and 11.8 after lysis. Class II patients (systolic blood pressure
>90 mmHg) had a MI of 10.9 before lysis and 5.8 after lysis (P < .05). Immediate survival was 93% (n = 13), and the 36-month mean follow-up survival rate is 93% (n = 13), the recurrent deep venous thrombosis rate is 7% (n = 1), and recurrent PE rate is 0%. CONCLUSIONS: Aggressive catheter-directed thrombolysis for massive obstructive PE that causes hemodynamic instability can decrease mortality rates. Patients with symptoms from diffuse PE also respond rapidly to intrapulmonary lytic therapy. However, although patients with a diffuse nonobstructive pattern of PE may respond to systemic therapy, massive obstructive emboli require an aggressive catheter technique to ensure timely clinical improvement.
Take Home Points: Aggressive catheter manipulation and intrathrombic lytic therapy improve survival in patients with massive obstructive PE. A pattern of diffuse PE may respond to systemic therapy.
1:45 pm Popliteal Approach to Treat PWegmasia Cerulea Dolens T.O. McNamara, MD, Los Angeles, CA PURPOSE: To assess the safety and effectiveness of the use of the popliteal vein to introduce a thrombolysis infusion system to treat phlegmasia cerulea dolens. MATERIALS AND METHODS: Six consecutive patients with clinical findings of phlegmasia cerulea dolens and ultrasound evidence of thrombosis of the iliac, femoral, popliteal, and trifurcation veins were treated. Ultrasound was used to visualize the popliteal vein. A triaxial infusion system was introduced. Thrombolysis was accomplished with concomitant transcatheter infusions of urokinase and heparin. Underlying stenoses were treated with stents. RESULTS: Antegrade flow was restored with associated clearing of pain and reduction of leg swelling within 24 hours. No clinical evidence of pulmonary embolism was noted. All patients experienced complete clearing of swelling within 48 hours. One patient with a paraneoplastiC hypercoagulable state had recurrence and underwent amputation. There were no deaths and only one popliteal hematoma. CONCLUSION Transpopliteal thrombolysis provides a prompt, Simple, and effective method to treat limbthreatening phlegmasia cerulea dolens.
Take Home Points: 1. The popliteal approach is simple.
2. It provides for easier traversal of the valves and enables thrombolysis to immediately span the occlusion from the popliteal through the iliac levels.
2:00 pm Catheter-Directed Fibrinolysis and Intervention for Iliofemoral Deep Venous Thrombosis: Technique and Results
IF.
Benenati, MD, FACC, FACR, Miami, FL • G] Becker, MD • G. Zemel, MD • B. T. Katzen, MD • L.B. GoodWin, RN • S. Samuels, MD PURPOSE: Catheter-directed fibrinolytic infusion is a therapeutic option to treat iliofemoral deep venous thrombosis (DVT). This therapy was studied in 15 patients.
MATERIALS AND METHODS: Fifteen patients with iliofemoral DVT documented by duplex or venography were treated using catheter-directed fibrinolytic infusion. Symptoms lasted from 5 hours to 5 months. Access was obtained from either the internal jugular vein (n = 7) or from the ipsilateral popliteal vein (n = 8). Coaxial infusions of urokinase were performed with the dose ranging from 60,000 to 250,000 IV/hour (average, 83,000 IV/ hour). The duration of urokinase therapy ranged from 20 to 120 hours (mean, 23.5 hours). During thrombolytic infusion, patients were given heparin (partial thromboplastin time ranging from 1.5 to 2x normal). Lysis was continued until symptoms resolved or was terminated if no change occurred clinically or by imaging in 72 hours. An additional intervention was performed in 10 of 14 patients C7 stents, 3 venous angioplasties). In the remaining patients, no underlying lesions could be identified. All patients were given heparin and warfarin sodium for 6 months, except for one patient who required an inferior vena cava catheter filter because of intraperitoneal bleeding, which was the only major complication. Minor complications included three hematomas, one cases of cellulitis, and one intermittent fever. Immediate results showed restoration of patency in the iliac vein in 13 of 15 patients. Three of the 13 patients with patent iliac veins had residual distal thrombi. Two patients had no change when compared with results of their initial examinations. Follow-up ranges from 3 weeks to 18 months. One of 13 patients experienced rethrombosis. The remaining veins are patent and unchanged or improved from their postprocedure examination. CONCLUSIONS: Catheter-directed thrombolytic infusion is safe and effective for treating patients with symptoms secondary to iliofemoral DVT. After thrombolysis, underlying lesions frequently are found and should be treated to prevent rethrombosis. Results suggest this therapy may be effective in preventing long-term sequelae.
Take Home Points: 1. Catheter-directed thrombolytic infusion for an iliofemoral DVT is safe and effective.
2. Various techniques may be used, including internal jugular and direct popliteal vein access. 3. Underlying lesions are often responsible for the DVT.
185
2:15 pm Transcatheter Regional Urokinase Therapy to Manage Inferior Vena Cava Thrombosis ].F. Angle, MD, Charlottesvitte, VA .].K. McGraw, MD • A.H. Matsumoto, MD PURPOSE: To study the efficacy of local infusions of urokinase to treat symptomatic inferior vena cava (lVC) thrombosis. MElliODS: Seven patients with IVC thrombosis underwent local catheter-directed infusion of a thrombolytic agent. Catheter-directed thrombolysis was performed using as many as three access sites. Urokinase was infused for an average of 79 hours for a mean total dose of 7.1 million units. Clinical or radiographic follow-up was obtained in all patients. RESULTS: lnfrarenal IVC thrombus was identified in all patients. Three had extension of thrombus proximal to the renal veins. Six of seven (86%) IVCs were successfully thrombolysed with minimal residual thrombus. Three of the seven patients (43%) had a preexisting IVC filter, one had a filter placed at the time of thrombolysis, and two had a Neuhaus infusion catheter placed as a temporary filter. Adjunctive balloon angioplasty was performed in three patients. No vascular stents were placed. Four patients had a hypercoagulable state and one patient had an occult metastatic malignancy. No serious complications were encountered, although one patient died of an unrelated cause 5 days after therapy. Clinical follow-up in the remaining six patients ranged from 2 to 24 months. All six patients had continued improved lower extremity swelling after the procedure. None of the patients had symptoms of recurrent IVC thrombosis. CONCLUSIONS: Local infusions of urokinase are a reliable and safe method to manage acute IVe thrombosis.
Take Home Points: 1. Catheter-directed thrombolysis is effective treatment for acute Ive thrombosis. 2. Regional therapy of IVC thrombus is a safe therapy with good long-term results.
RESULTS: Excellent anatomic patency of IVC was restored in all 23 animals. Mean device activation time was 4.35 ± 2.5 minutes. Post-thrombectomy venography showed smooth IVC walls in 14 dogs, whereas mural thrombus remained in nine dogs without significant flow restriction (less than 20% narrowing in seven, 20-30% narrowing in two). No angiographic or histopathologic evidence of mechanical IVC wall damage was present, although phlebitic changes were common. No new pulmonary emboli were noted on post-thrombectomy angiograms. However, a slight increase in mean pulmonary artery pressure occurred, with a corresponding decrease in arterial oxygen saturation. Examination of explanted lungs from 11 animals showed 100-500-pm pulmonary arteriolar microemboli in four (three of three transjugular, one of eight transfemoraO. CONCLUSION: ATD is effective in clearing 1-2-week-old IVC thrombosis.
Take Home Points: 1. Mechanical thrombectomy using ATD is highly effective in treating subacute IVC thrombosis. 2. Pulmonary microembolization is well tolerated and much less common using the transfemoral approach.
2:45 pm Percutaneous Hydrodynamic Thrombectomy Using the Hydrolyser System M. Henry, MD, Essey Les Nancy, France • M. Amor, MD • I. Henry, MD • ].M. Porte, MD • O. Tricoche, MD • E. Leborgne, MD PURPOSE: To present our clinical experience with a new mechanical hydrodynamic thrombectomy system (Hydrolyser) using the Venturi effect. This device was used to remove thrombi from native arteries, arterial grafts, the venous system, and pulmonary arteries.
PURPOSE: To evaluate the efficacy of the Amplatz thrombectomy device (ATD) in an experimental model of subacute inferior vena cava (IVC) thrombosis.
MATERIALS AND MElliODS: The Hydrolyser is a recently developed 7-Fr, double-lumen, over-the-wire catheter. The device has been used in 50 patients (29 men, 21 women; mean age, 66,2 ± 13.1 years [range, 40-90 years]) with recent thromboses. Occlusion time ranged from 1 to 30 days (mean, 8.2 ± 7.3 days); thrombus length ranged from 4 to 35 em (mean, 17.7 ± 10.2 em). Thrombi were located in native arteries (n = 35: femoropopliteal, 28; iliac, 7), arterial grafts (n = 9), superior vena cava (n = 2), axillary vein (n = 2), and pulmonary artery (n = 2). Approaches were arterial femoral antegrade (n = 22), retrograde (n = 7), contralateral (n = 14), popliteal arterial (n = 1), venous femoral (n = 5), and venous humeral (n = 1).
MATERIALS AND MElliODS: ATD is an 8-Fr recirculation-type mechanical thrombectomy device that uses a recessed helical impeller, coaxially driven up to 150,000
RESULTS: Technical success was achieved in 41 patients (82%) in native arteries (27 of 35, 77%), arterial grafts (8 of 9,89%), pulmonary artery (2 of 2), superior vena cava
3. Vascular stents are not required for good long-term results. 2:30 pm
Percutaneous Mechanical Thrombectomy of Inferior Vena Cava Thrombosis with the Amplatz Thrombectomy Device X. Gu, MD, Minneapolis, MN • Mj. Sharafuddin, MD • M. Urness .].1. Titus, MD • K. Amplatz, MD
186
rpm. Thrombectomy was performed in 23 dogs, in which 6-15-day-old infrarenal IVC thrombosis was induced by placing an occlusion balloon. The transjugular approach was used in five animals, and a two-step transfemoral approach was used in 18.
(2 of 2), and axillary vein (2 of 2). Thrombi were estimated angiographically to be removed by the Hydrolyser 72.5% ± 22%. Adjunctive therapy included angioplasty (n = 38, 19 immediate stents implantations), thromboaspiration (n = 17), and reduced-time fibrinolysis (n = 11). One complication occurred-a distal embolism cured by thromboaspiration. In nine patients the procedure failed and required surgery (bypass or Fogarty). At 30 days, 37 vessels remained patent (74%). CONCLUSIONS: The Hydrolyser system is a promising concept for percutaneous thrombectomy. It is quick, reliable, efficient, can be combined with other techniques such as thromboaspiration, and completed by reducedtime fibrinolysis. This technique also may offer an alternative to thrombolysis and surgical thrombectomy.
Take Home Points: The Hydrolyser system is a promising concept for percutaneous thrombectomy. It is quick, reliable, efficient, can be combined with other techniques such as thromboaspiration, and completed by reduced-time fibrinolysis. This technique also may offer an alternative to thrombolysis and surgical thrombectomy.
Scientific Session 6 Venous Access and Dialysis Catheters Moderator: Gwen Nazzarian, MD, Minneapolis, MN 1:30 pm
Ultrasound-guided Cannulation of the Internal Jugular Vein: Complications and Anatomic Considerations A.C. Gordon, MBBS, FRCR, Calgary, Alberta, Canada • ]. Saliken, MD, FRCPC • D. johns • R. Gray, MD, FRCPC PURPOSE: To examine success and complication rates for ultrasound-guided cannulation of the internal jugular vein (lJV) compared with blind techniques and to observe the effect of variations in the anatomy of the vein. MAIERIALS AND METHODS: Data were collected prospectively for 621 cases of sonographically guided cannulation of the lJV. In all cases the side of puncture, whether the procedure was successful, and any immediate complications were recorded. In 519 cases the number of passes required was recorded, and in 524 the number of walls punctured was noted. In 431 cases, the location of the I]V relative to the carotid artery was recorded. Finally the diameter of the I]V and its distance from the skin were noted in 557 cases. RESULTS: Cannulation was successful in all of the cases. There were 483 (77.8%) cannulations of the right and 138 (22.2%) of the left I]V. Complications occurred in 13 cases (2.09%). Only one required therapy. There were 450 (85.9) single-wall punctures, and 465 (89.6%) of the punctures were made with one pass. In 199 cases
(46.2%) the vein was anterolateral to the carotid artery. In 22 cases (5.1%) the vein lay medial to the artery. CONCLUSIONS: Ultrasound-guided cannulation of the I]V is superior to blind techniques. Sonographic visualization reduces the effect of variations in anatomy and operator experience on the success of cannulation.
Take Home Points: Ultrasound guidance will decrease the complication rate and thus is advisable for cannulation of the I]V when available. 1:45 pm Effect of Vitacuffs on the Short-term Infection Rate of Tunneled Central Catheters G.K. Nazarian, MD, Minneapolis, MN • C.A. Dietz, jr., MD • H. Bjarnason, MD • D. w: Hunter, MD PURPOSE: To determine whether VitaCuffs (Arrow International, Reading, FA) reduce the infection rate of tunneled central venous catheters. MA TERIALS AND METHODS: Sixty-seven patients having bone marrow transplants received tunneled central venous catheters during a 33-month period. Twenty-nine patients received Hickman catheters (Bard Access Systems, Salt Lake City, un with VitaCuffs and 38 patients received Hickman catheters without VitaCuffs. Infection was defined as bacteremia with no clear source other than the catheter. The medical records were reviewed retrospectively up to 30 days after line placement. The number of catheter-related infections were compared for the two groups using the Cox F-test. RESULTS: Catheters were in place 790 catheter-days for catheters with and 1,055 catheter-days for catheters without VitaCuffs. Before 30 days, three patients died, six catheters were removed due to suspected infection, two inadvertently, two for access thrombosis, and one because it was no longer needed. Two catheters with and eight catheters without VitaCuffs were removed for catheter-related infection (P < .05). CONCLUSION VitaCuffs significantly reduce the number of catheter-related infections in patients having bone marrow transplants.
Take Home Points: 1. Catheter-related infection is a serious problem in immunocompromised patients. 2. Tunneled catheters come with and without VitaCuffs. 3. Reduced catheter-related infections occurred when catheters with VitaCuffs were placed. 2:00 pm
Randomized Study of Silver Coating (Silvergard) to Prevent Infection in Tunneled Hemodialysis Catheters: Interim Report S.O. Trerotola, MD, Indianapolis, IN. M.S. johnson, MD • H. Shah, MD • V j. Harris, MD • M. Kraus, MD • M. McKusky, RN
PURPOSE: To determine whether silver coating (Silvergard, SG) applied to tunneled hemodialysis catheters re-
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