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Selective Transcatheter Platelet Infusion for Gastrointestinal Bleeding after Failed Embolization with Resistant Thrombocytopenia
Letters to the Editor
Selective Transcatheter Platelet Infusion for Gastrointestinal Bleeding after Failed Embolization with Resistant Thrombocytopenia From: Julie L. Hvizda, RN Bradford J. Wood, MD Diagnostic Radiology Department Warren Grant Magnuson Clinical Center Bldg 10, Room 1C660 10 Center Dr., MSC 1182 Bethesda, MD 20892-1182 Editor: A 58-year-old woman with thrombocytopenia (platelet count of 49,000) was admitted for evaluation of high-grade, non-Hodgkin lymphoma. After undergoing chemotherapy, she became pancytopenic and developed recurrent gastrointestinal (GI) bleeding. Her thrombocytopenia was minimally
responsive to platelet transfusion because of a consumptive coagulopathy. Management was further complicated by a critical, region-wide platelet shortage; the blood bank had no platelets available. Upper endoscopy revealed bright red blood refluxing back from the descending duodenum, with fresh blood clot over an actively bleeding ulcer. Over the course of 48 hours, two subsequent attempts were unsuccessful in cauterizing the ulcer endoscopically with bicap coagulation and epinephrine injection. The patient presented to the interventional radiology department with life-threatening recurrent upper GI bleeding, and was a poor surgical candidate (hemoglobin, 8.4; hematocrit, 24.5; platelets, 15,000). Selective celiac and gastroduodenal arteriography failed to demonstrate the active bleeding site. However, hyperemia was seen in the postbulbar duodenum. The right gastroepiploic artery was embolized with two helical coils and the gastroduodenal artery (GDA)
Figure 1. (a) Digital subtraction angiography 10 minutes after embolization with three coils shows active extravasation (arrow) from the second portion of the duodenum, in which a bleeding ulcer was localized by endoscopy. The GDA is accessed via the inferior pancreaticoduodenal artery. (b) Digital subtraction angiography after selective transcatheter transfusion of three units of platelets demonstrates hemostasis and occlusion of vessel (arrow).
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Letters to the Editor
was embolized with use of Gelfoam pledgets until vascular stasis was achieved. This stabilized the patient for 48 hours, at which point she experienced rebleeding. Repeated endoscopic attempts at cauterization and epinephrine injection failed. Massive packed red blood cell resuscitation was required. Platelets remained at 28,000. Repeated arteriography demonstrated active bleeding in the descending duodenum and recanalization of the GDA. A microcatheter was used to selectively access the feeding vessel in the duodenal wall, where one helical and two straight coils were placed. Repeated arteriography showed a patent vessel with persistent bleeding (Fig 1a). Only six units of platelets were available in the hospital’s blood bank at this time. Three units were selectively injected into the bleeding vessel over 10 minutes. Post-transfusion angiography demonstrated interval coagulation with occlusion of the vessel and arresting of bleeding (Fig 1b). Given that multiple attempts at nonsurgical management had failed, the GDA and inferior pancreaticoduodenal artery (IPDA) were embolized with coils. In the presence of platelet shortage, resistant thrombocytopenia, consumptive coagulopathy, or sequestration, selective delivery of platelets with transcatheter transfusion may provide effective hemostasis during embolization. However, embolization alone can achieve hemostasis in the vast majority of patients with serious concomitant diseases in whom endoscopic management of massively bleeding duodenal ulcers fails (1). Synchronous embolization of the GDA and IPDA can control persistent duodenal bleeding after failed endoscopic treatment in poor surgical candidates. However, this aggressive therapy should be done only as a life-saving measure because of the risk of duodenal and pancreatic necrosis (2). References 1. Toyoda H, Nakano S, Takeda I, et al. Transcatheter arterial embolization for massive bleeding from duodenal ulcers not controlled by endoscopic hemostasis. Endoscopy 1995; 27:304 – 307. 2. Bell S, Ying Lau K, Sniderman K. Synchronous embolization of the gastroduodenal artery and the inferior pancreaticoduodenal artery in patients with massive duodenal hemorrhage. J Vasc Interv Radiol 1995; 6:531–536.
Jugular Vein Placement of a Small-Caliber DualLumen Catheter in Patients with Chronic Renal Insufficiency or Chronic Renal Failure From: J. Kevin McGraw, MD Jeffrey S. Silber, MD Shayle B. Patzik, MD Center for Vascular and Interventional Radiology St. Vincent Mercy Medical Center 2213 Cherry Street Toledo, Ohio 43608
April 2001
JVIR
Editor: Often, patients with chronic renal insufficiency or chronic renal failure require placement of central venous catheters for intravenous access unrelated to hemodialysis. As a result of the high incidence of arm vein thrombosis from peripherally inserted central catheters (1) and the need to preserve arm veins for possible arteriovenous fistula creation, we recently developed a technique for small-caliber catheter insertion into the jugular vein. Over a 2-week period, we were consulted to provide central venous access in 10 patients who had either chronic renal insufficiency or chronic renal failure. After informed written consent was obtained, the patients were placed in a supine position in the angiography suite. A Vaxcel peripherally inserted central catheter kit (Boston Scientific/Meditech, Watertown, MA) was used. The kit contains a 21-gauge needle, which was used for US-guided puncture of the jugular vein. A measuring wire is also provided. This was used to measure the length of catheter needed. The catheter was trimmed to the appropriate length. This catheter was then placed in standard fashion through the peel-away sheath that is also contained within the kit. The catheter was then secured to the skin with suture and a dressing was applied. All patients tolerated the procedure well without immediate postprocedural complications. All the catheters functioned properly throughout the course of the patients’ hospitalization and were subsequently removed at the time of discharge. Allen et al (1) showed an increased risk of cephalic vein and arm vein thrombosis with peripherally inserted central catheters. After initial PICC placement in 137 extremities, 32 developed thrombosis of the cannulated vein (23.3%). In extremities with multiple PICC lines placed, 52 (38%) developed thrombosis. Also, the cephalic vein had the highest thrombosis rate by site (1). Dialysis Outcomes Quality Initiative guidelines recommend the use of arteriovenous fistulas for hemodialysis with the radiocephalic (BrescioCimino) fistula being the fistula of greatest preference (2). In an effort to preserve arm veins in patients with renal insufficiency or chronic renal failure, we devised this method of placing a small-caliber (5-F) catheter into the jugular vein. We believe that this method should be considered in all patients with renal insufficiency or failure when a peripherally inserted central catheter is requested. References 1. Allen AW, Brown DB, Lynch FC, Megargell JL, Singh H, Waybill PN. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol 2000; 11:1309 –1314. 2. Schwab S, Besasab A, Beathard G, et al. NKF-DOQI clinical practice guidelines for vascular access. Am J Kidney Dis 1997; 30(suppl 3):150 –191.
Selective Transcatheter Platelet Infusion for Gastrointestinal Bleeding after Failed Embolization with Resistant Thrombocytopenia From: Julie L. Hvizda, RN Bradford J. Wood, MD Diagnostic Radiology Department Warren Grant Magnuson Clinical Center Bldg 10, Room 1C660 10 Center Dr., MSC 1182 Bethesda, MD 20892-1182 Editor: A 58-year-old woman with thrombocytopenia (platelet count of 49,000) was admitted for evaluation of high-grade, non-Hodgkin lymphoma. After undergoing chemotherapy, she became pancytopenic and developed recurrent gastrointestinal (GI) bleeding. Her thrombocytopenia was minimally
responsive to platelet transfusion because of a consumptive coagulopathy. Management was further complicated by a critical, region-wide platelet shortage; the blood bank had no platelets available. Upper endoscopy revealed bright red blood refluxing back from the descending duodenum, with fresh blood clot over an actively bleeding ulcer. Over the course of 48 hours, two subsequent attempts were unsuccessful in cauterizing the ulcer endoscopically with bicap coagulation and epinephrine injection. The patient presented to the interventional radiology department with life-threatening recurrent upper GI bleeding, and was a poor surgical candidate (hemoglobin, 8.4; hematocrit, 24.5; platelets, 15,000). Selective celiac and gastroduodenal arteriography failed to demonstrate the active bleeding site. However, hyperemia was seen in the postbulbar duodenum. The right gastroepiploic artery was embolized with two helical coils and the gastroduodenal artery (GDA)
Figure 1. (a) Digital subtraction angiography 10 minutes after embolization with three coils shows active extravasation (arrow) from the second portion of the duodenum, in which a bleeding ulcer was localized by endoscopy. The GDA is accessed via the inferior pancreaticoduodenal artery. (b) Digital subtraction angiography after selective transcatheter transfusion of three units of platelets demonstrates hemostasis and occlusion of vessel (arrow).
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550
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Letters to the Editor
was embolized with use of Gelfoam pledgets until vascular stasis was achieved. This stabilized the patient for 48 hours, at which point she experienced rebleeding. Repeated endoscopic attempts at cauterization and epinephrine injection failed. Massive packed red blood cell resuscitation was required. Platelets remained at 28,000. Repeated arteriography demonstrated active bleeding in the descending duodenum and recanalization of the GDA. A microcatheter was used to selectively access the feeding vessel in the duodenal wall, where one helical and two straight coils were placed. Repeated arteriography showed a patent vessel with persistent bleeding (Fig 1a). Only six units of platelets were available in the hospital’s blood bank at this time. Three units were selectively injected into the bleeding vessel over 10 minutes. Post-transfusion angiography demonstrated interval coagulation with occlusion of the vessel and arresting of bleeding (Fig 1b). Given that multiple attempts at nonsurgical management had failed, the GDA and inferior pancreaticoduodenal artery (IPDA) were embolized with coils. In the presence of platelet shortage, resistant thrombocytopenia, consumptive coagulopathy, or sequestration, selective delivery of platelets with transcatheter transfusion may provide effective hemostasis during embolization. However, embolization alone can achieve hemostasis in the vast majority of patients with serious concomitant diseases in whom endoscopic management of massively bleeding duodenal ulcers fails (1). Synchronous embolization of the GDA and IPDA can control persistent duodenal bleeding after failed endoscopic treatment in poor surgical candidates. However, this aggressive therapy should be done only as a life-saving measure because of the risk of duodenal and pancreatic necrosis (2). References 1. Toyoda H, Nakano S, Takeda I, et al. Transcatheter arterial embolization for massive bleeding from duodenal ulcers not controlled by endoscopic hemostasis. Endoscopy 1995; 27:304 – 307. 2. Bell S, Ying Lau K, Sniderman K. Synchronous embolization of the gastroduodenal artery and the inferior pancreaticoduodenal artery in patients with massive duodenal hemorrhage. J Vasc Interv Radiol 1995; 6:531–536.
Jugular Vein Placement of a Small-Caliber DualLumen Catheter in Patients with Chronic Renal Insufficiency or Chronic Renal Failure From: J. Kevin McGraw, MD Jeffrey S. Silber, MD Shayle B. Patzik, MD Center for Vascular and Interventional Radiology St. Vincent Mercy Medical Center 2213 Cherry Street Toledo, Ohio 43608
April 2001
JVIR
Editor: Often, patients with chronic renal insufficiency or chronic renal failure require placement of central venous catheters for intravenous access unrelated to hemodialysis. As a result of the high incidence of arm vein thrombosis from peripherally inserted central catheters (1) and the need to preserve arm veins for possible arteriovenous fistula creation, we recently developed a technique for small-caliber catheter insertion into the jugular vein. Over a 2-week period, we were consulted to provide central venous access in 10 patients who had either chronic renal insufficiency or chronic renal failure. After informed written consent was obtained, the patients were placed in a supine position in the angiography suite. A Vaxcel peripherally inserted central catheter kit (Boston Scientific/Meditech, Watertown, MA) was used. The kit contains a 21-gauge needle, which was used for US-guided puncture of the jugular vein. A measuring wire is also provided. This was used to measure the length of catheter needed. The catheter was trimmed to the appropriate length. This catheter was then placed in standard fashion through the peel-away sheath that is also contained within the kit. The catheter was then secured to the skin with suture and a dressing was applied. All patients tolerated the procedure well without immediate postprocedural complications. All the catheters functioned properly throughout the course of the patients’ hospitalization and were subsequently removed at the time of discharge. Allen et al (1) showed an increased risk of cephalic vein and arm vein thrombosis with peripherally inserted central catheters. After initial PICC placement in 137 extremities, 32 developed thrombosis of the cannulated vein (23.3%). In extremities with multiple PICC lines placed, 52 (38%) developed thrombosis. Also, the cephalic vein had the highest thrombosis rate by site (1). Dialysis Outcomes Quality Initiative guidelines recommend the use of arteriovenous fistulas for hemodialysis with the radiocephalic (BrescioCimino) fistula being the fistula of greatest preference (2). In an effort to preserve arm veins in patients with renal insufficiency or chronic renal failure, we devised this method of placing a small-caliber (5-F) catheter into the jugular vein. We believe that this method should be considered in all patients with renal insufficiency or failure when a peripherally inserted central catheter is requested. References 1. Allen AW, Brown DB, Lynch FC, Megargell JL, Singh H, Waybill PN. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol 2000; 11:1309 –1314. 2. Schwab S, Besasab A, Beathard G, et al. NKF-DOQI clinical practice guidelines for vascular access. Am J Kidney Dis 1997; 30(suppl 3):150 –191.