- Email: [email protected]
Venous access and other intervention
was 16.4 hours (3 to 25 hours) for arterial occlusions and 21.2 hours (6 to 43 hours) in patients with deep vein thrombosis. CONCLUSION: Successful clot lysis, acute and chronic, arterial and venous thrombosis can be achieved with a high rate of success in a shorter time than conventional thrombolysis using ultrasound-enhanced thrombolysis. 3:09 PM
Abstract No. 114
A Novel Semipermeable Stent Graft for Endovascular Use. P. Gailloud, The Johns Hopkins Hospital, Baltimore, MD, USA 䡠 R. Hong 䡠 B. Kohler 䡠 D. Sasson 䡠 L. Rudakov PURPOSE: To evaluate a novel semipermeable stent graft device.
CONCLUSION: The semipermeable stent graft design allows keeping branches patent immediately after device placement and at follow-up angiography. This design may present a significant advantage over conventional stent grafts for placement in vascular segments providing functionally important side branches, including for instance intracranial perforators or thoraco-abdominal visceral arteries. The hemodynamic effect of this new stent graft design upon vascular lesions such as arterial aneurysms is currently under investigation. Branch # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Stent Type Semipermeable Semipermeable Semipermeable Semipermeable Semipermeable Semipermeable Semipermeable Nonperforated Nonperforated Nonperforated Nonperforated Nonperforated Nonperforated Nonperforated Jo-Stent Jo-Stent Jo-Stent
Immediate Open Open Open Open Open Open Open Occluded Occluded Occluded Occluded Occluded Delayed Delayed Occluded Occluded Delayed
14 Days Open Open
28 Days
Open Open Open Open Open Open Open Open Open Open Open
PURPOSE: To investigate the feasibility and safety of the new CiTop wire device in penetrating total occlusions of previously ‘failed to cross’ blocked blood vessels. MATERIALS AND METHODS: The CiTop wire is a 1 mm handle assembly device with torquer, and telescopically retracted grips that can be manually preshaped. The device includes standard 0.014-inch guide wire with radiopaque tip and allows push-torque control of the active flexible distal tip connected to the shaft. 20 amputated limbs (21 occluded segments) of patients with life-threatening critical limb ischemia were evaluated. Angiography was performed via the open-end of the artery to localize level and length of the occlusion. 10 limbs were excluded: 4 normal arteries, 4 successful recanalizations using standard guide wire, 2 occlusions observed in very distal (⬍ 1.5 mm) arteries. Amputated limbs of 10 patients (5 above and 5 below the knee) were included in the study. 11 occluded segments with failed attempts were negotiated using CiTop wire. As standard guide wire failed, the CiTop was advanced, positioned proximal to the occlusion and operated until passing the occlusion. Postprocedure angiography was performed followed by artery removal for histopathology. 11 segments specimens were selected. All tissues were studied within 1 hour post amputation. RESULTS: Preprocedure angiography documented 10 total occlusions of tibial and peroneal and 1 of popliteal arteries. Occlusion length varied: 0.5 to 25 cm (mean 7 cm). In 9/11 occluded segments no distal filling was observed. The CiTop was operated manually for 1 to 18 minutes (mean 5.5 minutes) until complete recanalization. Postprocedure angiography showed only 1/11 (9%) failure due to vessel perforation in a 6-cm-length occlusion. In all other successfully recanalized arterial segments (10/ 11) no macroscopic or microscopic damage, but intact endothelium, was noted. CONCLUSION: The new CiTop wire is safe (91% success rate) and showed the feasibility to recanalize chronic total occlusions in human amputation model where standard 0.014-inch guide wire failed to cross. Clinical evaluation is underway.
Scientific Session 13 Venous Access and Other Interventions Sunday, March 4, 2007 8:00 AM - 9:30 AM Room: 204 8:00 AM
Open Occluded Occluded Open
Evaluation of Ci-Top Active Guidewire Device for Recanalization of Chronic Total Occlusion in Human Amputation Model. A. Belenky, Rabin MC, Petach Tiqva, Israel 䡠 G. Bartal 䡠 U. Oppenhaim 䡠 A. Dahan 䡠 I. Ziv-Ner 䡠 M. Scheinowitz
Abstract No. 116
Tunneled Infusion Catheter Breakage: Incidence and Repair Kit Outcomes. F.R. Hwang, University of Pennsylvania Medical Center, Philadelphia, PA, USA 䡠 S.O. Trerotola 䡠 S.W. Stavropoulos 䡠 R.D. Shlansky-Goldberg 䡠 J.I. Mondschein 䡠 A.A. Patel, et al. S43
SUNDAY
RESULTS: The 7 branches covered with the semipermeable stent graft remained open immediately and at follow-up angiography. The 7 branches covered with the non-perforated stent graft were either occluded (5) or delayed (2) at immediate angiography; all were open at follow-up angiography. The 3 branches covered with the Jo-Stent were either occluded (2) or delayed (1) immediately; they were either occluded (2) or open (1) at follow-up angiography.
Abstract No. 115
Scientific Sessions
MATERIALS AND METHODS: A semipermeable stent graft made of a stainless steel stent covered with a biocompatible, microperforated membrane was evaluated in the iliac artery of the rabbit. A stent of similar design without microperforation and a commercially available stent graft (Jo-Stent) were used as control devices. Aspirin was started three days before the procedure and continued until sacrifice, while heparin (100 IU/kg) was administered at the time of procedure. Ten stents were placed, covering 17 branches. Immediate and follow-up (14 or 28 days) angiograms were analyzed for the patency of the covered branches, which were graded as open, delayed, or occluded.
3:21 PM
PURPOSE: Tunneled infusion catheter (TIC) breakage is common, and repair kits are often used to repair damage to the external catheter segment, avoiding catheter replacement. We sought to determine the incidence of TIC breakage and the durability of these repair kits. MATERIALS AND METHODS: Using a quality assurance database and with IRB approval, 724 silicone TICs placed between July 2002 and September 2005 were identified. The repair kit outcomes portion of the study focused on 10-F triple lumen (TL) TIC (n ⫽ 433), the type placed most frequently in our practice and that with the most repairs available for analysis. To compare durability, non-repaired (NR) catheters and those requiring repair (R) were compared using Cox proportion hazard regression. RESULTS: Breakage occurred in 12% of 10-F TL TIC (53/433), 5% of 10-F dual lumen (DL) TIC (3/64), 3% of 11-F TL TIC (4/159), 33% of 9.6-F single lumen TIC (4/12), and 14% of 9-F DL TIC (8/56). In the 10-F TIC subset, mean time to catheter breakage was 60 days. Mean catheter days between the NR group (143 days) and the R group (145 days) did not differ (Chi-square: 0.071, hazard ratio: 1.07, p ⫽ 0.79). Mean catheter dwell after repair was 79 days. 52 repairs were attempted in 48 catheters (4 catheters had 2 episodes of breakage and were repaired a second time); no attempt at repair was made in 5 catheters. One repair attempt was excluded for incomplete data. There was an 8% immediate repair kit failure rate (4/51 attempts) and 4 additional repairs lasted 1, 2, 3 and 10 days for an overall repair kit failure rate of 16% (8/51 attempts). CONCLUSION: TIC breakage is common. Although 11-F TL TICs appear to have a lower breakage rate, other limitations (such as flow rates) not considered here may affect catheter choice. Given the high breakage rates observed for many TIC designs, development of more durable catheters should be a priority for catheter manufacturers. Until more durable catheters are developed, catheter repair kits are an easy, effective, durable and relatively inexpensive solution for repair of external segment damage in TICs. 8:12 AM
Abstract No. 117
Peripherally Inserted Central Catheter (PICC) Placement in Patients with Central Venous Stenosis or Obstruction. K.B. Park, Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul, Korea 䡠 S.W. Choo 䡠 Y.S. Do 䡠 S.W. Shin 䡠 S.K. Cho 䡠 I.-W. Choo PURPOSE: To evaluate the feasibility and clinical results of PICC placement in patients with incidentally found central venous stenosis or obstruction. MATERIALS AND METHODS: In a retrospective review of 3272 PICC placements from January 1999 to July 2006, 57 patients were found to have central venous stenosis or obstruction during placement of PICC. 60 PICC placements were performed in 57 patients. 30 male and 27 female were included and their ages ranged from 14 to 88 years old (mean 59 years old). PICC placements in 57 patients were evaluated regarding location and severity of venous disease, underlying causes of venous stenosis or obstruction, catheter placement technique, technical success rate, maintenance period, and complication rate.
S44
RESULTS: Lesions were distributed in unilateral subclavian vein (SCV) (n ⫽ 22), left innominate vein (n ⫽ 10), left innominate vein ⫹ LSCV (n ⫽ 16), SVC (n ⫽ 1), SVC ⫹ L innominate vein (n ⫽ 2), SCV ⫹ axillary vein (n ⫽ 3),
SVC ⫹ SCV (n ⫽ 1), and left innominate vein ⫹ SCV ⫹ axillary vein (n ⫽ 5). Causes of central venous lesion were unidentifiable in 16 patients (30%). 36 of 57 (63%) patients had histories of previous central venous catheterization. Four patients had malignant obstruction and one had postsurgical central vein obstruction. Ipsilateral PICC placement was done in 26 of 60 (43%) procedures. In five patients, ipsilateral lesion passage had failed. Contralateral PICC placement without trial of lesion traverse was done in 26 patients. Ipsilateral internal jugular veins were used in two patients. In one patient, catheter tip was placed in ipsilateral axillary vein. There were 48 complete obstructions and 12 stenoses. Overall technical success rate was 100%. However, ipsilateral lesion passage rate was 84% (26 of 31 trials). PICC dwell time ranged from two days to 150 days (median 25.5days). Complications were seen in 4 of 57 patients (7%) and they were tube tip migration (n ⫽ 1), catheter occlusion (n ⫽ 1), and catheter infection (n ⫽ 2). CONCLUSION: Central venous stenosis or obstruction does not preclude the PICC placement and it does not have adverse influence on catheter function. 8:24 AM
Abstract No. 118
Common Femoral Vein Patency in Sickle Cell Disease Patients Undergoing Monthly Central Venous Catheterizations. M.S. Salomon, Wayne State University, Detroit, MI, USA 䡠 R.C. Navuluri 䡠 J. Kemppainen PURPOSE: Repeated central venous catheterizations are performed in patients with sickle cell disease (SCD) undergoing red blood cell exchange transfusion (RBCET) to prevent the clinical complications associated with SCD. The purpose of this study was to evaluate common femoral vein (CFV) patency and complications associated with repeated common femoral vein catheterizations in patients with SCD. MATERIALS AND METHODS: A retrospective chart review of all SCD patients undergoing monthly RBCET at our institution between Febuary 1999 and Febuary 2006 was performed. Data obtained included patient age, gender, SCD genotype, date of procedure (in order to calculate days between punctures), site of catheter placement, preprocedure CFV sonogram, postprocedure radiograph of catheter placement, and any reported complications. The end-point of vein patency was considered to be failure of catheter placement. All catheters were placed by Interventional Radiology using ultrasound and fluoroscopic guidance prior to RBCET. Temporary dual-lumen 11.5-F (20 or 24 cm) silicone catheters were used. Right and left CFVs were alternately punctured on a monthly basis. One blood volume exchange was performed over two hours in the pheresis lab. At the completion of RBCET, the catheter was removed by the pheresis personnel. RESULTS: Sixty-two patients were studied; 43 females, 19 males. The average age at the time of catheterization was 31.1 (14.9-62.1) years. A total of 1608 catheterizations were documented. An average of 25.9 catheters were placed in each patient; 15.7 in the right CFV, 10.2 in the left. An average of 59.8 and 53.5 days elapsed between catheterization of the right and left CFVs, respectively. Vein patency was demonstrated over an average of 1044 and 994 days in the right and left CFVs, respectively. There were no failed catheter placements and no incidences of venous occlusion. There were two reported complications (0.12%). A fractured catheter fragment had embolized into the right pul-
monary artery and was successfully retrieved, and a paravertebal vein was catheterized. CONCLUSION: Common femoral veins remain patent in SCD patients after repeated monthly central venous catheterizations for RBCET. 8:36 AM
Abstract No. 119
Over-the-Wire Tunneled Catheter Exchanges: Reduce the Risk of Air Emboli. K.J. Kolbeck, Dotter Interventional Institute, OHSU, Portland, OR, USA 䡠 S.W. Stavropoulos 䡠 S.O. Trerotola PURPOSE: Air emboli (AE) have been observed during both central venous catheter placement and over-the-wire (OTW) catheter exchanges. We propose that the use of the catheter clamp alone during OTW exchanges does not prevent AE. We have designed an in vitro model to measure the volumes of AE created during simulated OTW exchanges of a tunneled dialysis catheter (TDC). The aerostatic properties of the TDC clamp, an aerostatic valve (AngioValve, InterV, Gainesville, FL), and a sliding clamp (FloSwitch, Boston Scientific, Natick, MA) were examined both with and without a wire in place.
CONCLUSION: AE can occur during OTW dialysis catheter exchanges even with the TDC clamp closed over the wire. No AE are formed with the addition of aerostatic protection devices. We recommend that OTW exchanges be done with the assistance of such measures. 8:48 AM
Abstract No. 120
Comparison between the Split-Tip Catheter and NonSplit-Tip Catheter for Hemodialysis. T.G. Van Ha, University of Chicago, Chicago, IL, USA 䡠 S.R. Santeler 䡠 J.M. Lorenz 䡠 B.S. Funaki PURPOSE: To compare the safety and efficacy of split-tip catheters (Hemosplit, Bard Medical, Covington, GA) to that of conventional non-split-tip catheters (Vaxcel, Boston Scientific, Natick, MA) in hemodialysis patients.
CONCLUSION: Hemosplit catheters appear to have longer patency rates and fewer complications than standard nonsplit-tip hemodialysis catheters. 9:00 AM
Abstract No. 121
Radiologic Placement of Tunneled Central Venous Catheter in Pediatric Patients. S.-Y. Song, Hanyang University Hospital, Seoul, Republic of Korea 䡠 J.H. Lee 䡠 Y. Kim 䡠 B.H. Koh 䡠 O.K. Cho 䡠 Y.H. Lee PURPOSE: To evaluate the technical success and complications associated with radiological placement of tunneled central venous catheters in oncologic pediatric patients. MATERIALS AND METHODS: Between July 1, 2005 and June 30, 2006, 30 tunneled central venous catheters (17 Hickmann catheters and 13 chemports) were placed in 27 children (14 girls, 13 boys; age range, 4 months-17 years; mean 8.2 years). In 97% (29/30) of the procedures, the right internal jugular vein was used for access. In one procedure, the left internal jugular vein was used. All procedures were performed under ultrasonographic and fluoroscopic guidance. Follow-up data were obtained through the retrospective review of the medical records. RESULTS: Technical success was 100%. Periprocedural complications were tracheal intubation due to hypoxia in two patients, and hematoma formation in one. The mean catheter life was 122 days (range, 8-369 days; total 3760 days). Twenty-one catheters are still in use. Six patients died and in one patient the treatment was finished. Three catheters were removed because of infection in two and malfunction in one. One patient was lost to follow-up. Infection rate was 7% (0.054/100 catheter days). Catheter malfunction rate was 3% (0.027/100 catheter days). S45
SUNDAY
RESULTS: As an internal control, no air entered the system when the catheter was in position and the clamp on the TDC closed. With the TDC clamp left open for 30 s, 43 ⫾ 4 mL of air entered the model. With the TDC clamp closed over a wire (simulating the OTW exchange), the volume of AE was 32 ⫾ 11 mL in 30 s. With the addition of aerostatic devices (closed sliding clamp and the aerostatic valve), no AE occurred with the wire in place over 60 s. As a positive control, with both the sliding clamp and TDC clamp open, the volume of AE was 44 ⫾ 5 mL in 30 s.
RESULTS: 100% technical and clinical success was achieved in both patient groups. The total days of follow-up for the Hemosplit group were 8600 with mean of 172 days (range of 23-533). For the control group, the total follow-up was 7940 days with a mean of 159 (range of 14-464). Within 30 days of placement, there were no infections in the Hemosplit group and 4 infections in the non-split-tip group. Infection rate per 100 catheter days for Hemosplit catheters was 0.07. Infection rate per 100 catheter days for non-splittip catheters was 0.16. Hemosplit malfunction from poor blood flow, inadvertent removal, catheter fracture, or any other process that required intervention occurred at rate of 0.05 per 100 catheter days. Non-split-tip catheter malfunction occurred at rate of 0.12 per 100 catheter days. For Hemosplit catheters, the 30-day patency rate was 95%, the 90-day patency rate was 80% and the 180-day patency rate was 76%, using Kaplan-Meier life table analysis. For nonsplit-tip catheters, the 30-day patency rate was 79%, the 90-day patency rate was 72%, and the 180-day patency rate was 59%.
Scientific Sessions
MATERIALS AND METHODS: The AE model simulated physiologic conditions with a flow of a 50% glycerol:water solution at 10 mL/s and a pressure differential of -6 to -8 mm Hg. A 14-F 28-cm split tip dialysis catheter was used in all experiments. A 60-second (s) test period prior to each iteration established no collateral sources of AE. A 0.038inch guide wire was introduced into the dialysis catheter. With the wire in place the volume of AE in 30 s with the TDC clamp open (n ⫽ 10), closed over the wire (n ⫽ 10), and an open sliding clamp (FloSwitch) was recorded. The volume of AE in 60 s was also recorded with the TDC clamp closed without a wire (n ⫽ 10) and with a guide wire through both the aerostatic valve (n ⫽ 10, AngioValve) and sliding clamp (FloSwitch) in a closed position (n ⫽ 10).
MATERIALS AND METHODS: A retrospective study was performed of 50 consecutive patients (18 men and 32 woman with average age of 60 years) following Hemosplit catheter placement and a control group of 50 consecutive patients (28 men and 22 women with average age of 57 years) with placement of non-split-tip catheters. Both catheter types were placed by the same physicians using standard techniques through the internal jugular veins. Clinical follow-up was performed. Technical and clinical success rates, procedural complications, primary patency rates, and infection rates were calculated.
CONCLUSION: Radiologic placement of tunneled central venous catheter is an effective technique with high technical success rate and low complication rate. 9:12 AM
Abstract No. 122
Is Adrenal Venous Sampling Necessary in All Patients with Hyperaldosteronism Prior to Adrenalectomy? R. Zarnegar, University of California, San Francisco, San Francisco, CA, USA 䡠 A.I. Bloom 䡠 R.K. Kerlan 䡠 M.W. Wilson 䡠 Q.-Y. Duh, et al. PURPOSE: It has been proposed that adrenal venous sampling (AVS) should be employed universally in hyperaldosteronism to both characterize and lateralize disease before adrenalectomy. We hypothesized that with routine use of CT, more selective use of AVS may be warranted. MATERIALS AND METHODS: A retrospective cohort study of 59 consecutive patients with hyperaldosteronism, diagnosed biochemically, who underwent unilateral adrenalectomy at a single center, during a 10-year period. Group 1 (n ⫽ 30), had adrenalectomy based on CT and Group 2 (n ⫽ 29), based on CT and AVS. The indication for AVS was an equivocal CT (26), or patient request (3). Outcome parameters were postoperative serum potassium and aldosterone, the number of hypertensive medications, and mean arterial blood pressure (MAP) at 6 months. RESULTS: Preoperatively, both groups were matched for age, years of hypertension, MAP, and number of hypertensive medications. In Group 1, the average tumor size was 2 cm (range 1-3 cm), and in Group 2, 1 cm (range: 0-2.5 cm), using equivalent CT parameters. Unilateral tumor was identified on CT in 30 patients (100%) in Group 1 and in 17 patients (59%) in Group 2, p ⬍ 0.05. Postoperatively, aldosterone levels were lower in Group 1: 6.3 ⫾ 5.9 ng/dL, than in Group 2: 13.5 ⫾ 16 ng/dL, p ⬍ 0.05. However, both groups had similar improvements in hypertension with MAP at 6 months; 92 ⫾ 12 vs. 96 ⫾ 9, p ⫽ 0.14, reduction in number of hypertensive medications to 1.1 ⫾ 1.3 vs. 1.2 ⫾ 1.1, p ⫽ 0.4, and improvement in hypokalemia; 3.8 ⫾ 0.5 vs. 3.8 ⫾ 0.5 meq/L, p ⫽ 0.5. CONCLUSION: The clinical impact of adrenalectomy was similar in both groups. CT can reliably diagnose adenomas greater than 1.0 cm. AVS should be utilized when CT is equivocal or both adrenals are abnormal. 9:24 AM
Abstract No. 123
Venographic Anatomy and Glue Embolization of PostSurgical Recurrent Varicoceles. J.S. Kao, Stanford University, Stanford, CA, USA 䡠 J.K. Frisoli 䡠 M.K. Razavi 䡠 D.Y. Sze PURPOSE: Persistent or recurrent varicoceles after surgical or endovascular treatment are frequently attributed to duplications and collateralization of veins. We retrospectively reviewed the venographic anatomy of patients who presented for endovascular varicocele embolization after surgical failure. In addition, we reviewed the efficacy of liquid embolics in treating these vessels. MATERIALS AND METHODS: Sixteen patients were referred over a 46-month period, 11 for persistence and 5 for recurrence of varicoceles after surgical varicocelectomy. The patients ranged in age from 13 to 54 years, with a mean of 26 years. Of the recurrences, onset was recognized as soon as 1 month after surgery and as long as 18 years after S46
surgery, with a median of 1 year. Patients were studied by retrograde venography, and anatomy classified according to the system of Bahren. Gonadal veins, including collateral and duplicated vessels, were embolized with NBCA glue. Two patients underwent bilateral procedures. RESULTS: Immediate technical success was achieved in all patients. The large majority (13 varicoceles in 11 patients) had Bahren type 3 venographic anatomy with a single gonadal vein cranially and duplications more caudally extending into the inguinal canal, including both patients with bilateral varicoceles. One patient had type 1 anatomy (unduplicated single vein), two had type 2 (communicating with paravertebral plexus) and one each had type 4 (communicating with renal capsule) and 5 (circumaortic renal vein). Two patients had partial nutcracker physiology, one with type 2 and one with type 3 anatomy. At six month follow-up, one patient had residual grade I varicocele (improved from grade II). In those who underwent seminal exam, the mean increase in motile sperm was 9.0 ⫻ 10e6/ mL. The patient with persistent varicocele showed no improvement in seminal parameters. CONCLUSION: Gonadal vein duplications extending into or solely involving the sites of surgical ligation in or near the inguinal canal are a subset of the type 3 Bahren anatomy that account for most surgical failures. Liquid embolic materials appear to be effective in distributing into these duplications.
Scientific Session 14 Oncology: Embolization Sunday, March 4, 2007 8:00 AM - 9:30 AM Room: 205 8:00 AM Abstract No. 124 FEATURED ABSTRACT Combined Chemoembolization and Percutaneous Radiofrequency Ablation for Local Control of Liver Tumors. M.C.S.S. Higgins, University of Pennsylvania, Philadelphia, PA, USA 䡠 J.I. Mondschein 䡠 S.W. Stavropoulos 䡠 C.M. Tuite 䡠 T.W.I. Clark 䡠 M.C. Soulen PURPOSE: To estimate the local control rate for combined chemoembolization and radiofrequency ablation (RFA) of hepatic malignancies greater than 2 cm. MATERIALS AND METHODS: 53 tumors (37 HCC, 16 metastases) in 44 patients were chemoembolized with CAM/Ethiodol/PVA followed by RFA the next day. In one case, RFA was performed within 2 weeks. In 7 patients with bilobar disease, the other lobe was treated 4-6 weeks later. Mean tumor size was 4.4 ⫾ 1.7 cm (range, 2.2 to 9 cm). 46/53 tumors were treated using LeVeen probes, 5/ 53 with RITA probes, and 2/ 53 with a Radionics unit. 15 tumors received a single burn, 38 received multiple overlapping burns. Clinical, laboratory, and imaging evaluations were performed one month post-treatment and then every 3 months. Follow-up endpoints were liver transplant or death.Seven patients who neither have received a transplant or died have been followed for a median of 10 months (range 1-36). RESULTS: Technical success was 98%. In one case using a LeVeen probe, roll-off was not achieved. 9/53 (17%) tu-
Abstract No. 114
A Novel Semipermeable Stent Graft for Endovascular Use. P. Gailloud, The Johns Hopkins Hospital, Baltimore, MD, USA 䡠 R. Hong 䡠 B. Kohler 䡠 D. Sasson 䡠 L. Rudakov PURPOSE: To evaluate a novel semipermeable stent graft device.
CONCLUSION: The semipermeable stent graft design allows keeping branches patent immediately after device placement and at follow-up angiography. This design may present a significant advantage over conventional stent grafts for placement in vascular segments providing functionally important side branches, including for instance intracranial perforators or thoraco-abdominal visceral arteries. The hemodynamic effect of this new stent graft design upon vascular lesions such as arterial aneurysms is currently under investigation. Branch # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Stent Type Semipermeable Semipermeable Semipermeable Semipermeable Semipermeable Semipermeable Semipermeable Nonperforated Nonperforated Nonperforated Nonperforated Nonperforated Nonperforated Nonperforated Jo-Stent Jo-Stent Jo-Stent
Immediate Open Open Open Open Open Open Open Occluded Occluded Occluded Occluded Occluded Delayed Delayed Occluded Occluded Delayed
14 Days Open Open
28 Days
Open Open Open Open Open Open Open Open Open Open Open
PURPOSE: To investigate the feasibility and safety of the new CiTop wire device in penetrating total occlusions of previously ‘failed to cross’ blocked blood vessels. MATERIALS AND METHODS: The CiTop wire is a 1 mm handle assembly device with torquer, and telescopically retracted grips that can be manually preshaped. The device includes standard 0.014-inch guide wire with radiopaque tip and allows push-torque control of the active flexible distal tip connected to the shaft. 20 amputated limbs (21 occluded segments) of patients with life-threatening critical limb ischemia were evaluated. Angiography was performed via the open-end of the artery to localize level and length of the occlusion. 10 limbs were excluded: 4 normal arteries, 4 successful recanalizations using standard guide wire, 2 occlusions observed in very distal (⬍ 1.5 mm) arteries. Amputated limbs of 10 patients (5 above and 5 below the knee) were included in the study. 11 occluded segments with failed attempts were negotiated using CiTop wire. As standard guide wire failed, the CiTop was advanced, positioned proximal to the occlusion and operated until passing the occlusion. Postprocedure angiography was performed followed by artery removal for histopathology. 11 segments specimens were selected. All tissues were studied within 1 hour post amputation. RESULTS: Preprocedure angiography documented 10 total occlusions of tibial and peroneal and 1 of popliteal arteries. Occlusion length varied: 0.5 to 25 cm (mean 7 cm). In 9/11 occluded segments no distal filling was observed. The CiTop was operated manually for 1 to 18 minutes (mean 5.5 minutes) until complete recanalization. Postprocedure angiography showed only 1/11 (9%) failure due to vessel perforation in a 6-cm-length occlusion. In all other successfully recanalized arterial segments (10/ 11) no macroscopic or microscopic damage, but intact endothelium, was noted. CONCLUSION: The new CiTop wire is safe (91% success rate) and showed the feasibility to recanalize chronic total occlusions in human amputation model where standard 0.014-inch guide wire failed to cross. Clinical evaluation is underway.
Scientific Session 13 Venous Access and Other Interventions Sunday, March 4, 2007 8:00 AM - 9:30 AM Room: 204 8:00 AM
Open Occluded Occluded Open
Evaluation of Ci-Top Active Guidewire Device for Recanalization of Chronic Total Occlusion in Human Amputation Model. A. Belenky, Rabin MC, Petach Tiqva, Israel 䡠 G. Bartal 䡠 U. Oppenhaim 䡠 A. Dahan 䡠 I. Ziv-Ner 䡠 M. Scheinowitz
Abstract No. 116
Tunneled Infusion Catheter Breakage: Incidence and Repair Kit Outcomes. F.R. Hwang, University of Pennsylvania Medical Center, Philadelphia, PA, USA 䡠 S.O. Trerotola 䡠 S.W. Stavropoulos 䡠 R.D. Shlansky-Goldberg 䡠 J.I. Mondschein 䡠 A.A. Patel, et al. S43
SUNDAY
RESULTS: The 7 branches covered with the semipermeable stent graft remained open immediately and at follow-up angiography. The 7 branches covered with the non-perforated stent graft were either occluded (5) or delayed (2) at immediate angiography; all were open at follow-up angiography. The 3 branches covered with the Jo-Stent were either occluded (2) or delayed (1) immediately; they were either occluded (2) or open (1) at follow-up angiography.
Abstract No. 115
Scientific Sessions
MATERIALS AND METHODS: A semipermeable stent graft made of a stainless steel stent covered with a biocompatible, microperforated membrane was evaluated in the iliac artery of the rabbit. A stent of similar design without microperforation and a commercially available stent graft (Jo-Stent) were used as control devices. Aspirin was started three days before the procedure and continued until sacrifice, while heparin (100 IU/kg) was administered at the time of procedure. Ten stents were placed, covering 17 branches. Immediate and follow-up (14 or 28 days) angiograms were analyzed for the patency of the covered branches, which were graded as open, delayed, or occluded.
3:21 PM
PURPOSE: Tunneled infusion catheter (TIC) breakage is common, and repair kits are often used to repair damage to the external catheter segment, avoiding catheter replacement. We sought to determine the incidence of TIC breakage and the durability of these repair kits. MATERIALS AND METHODS: Using a quality assurance database and with IRB approval, 724 silicone TICs placed between July 2002 and September 2005 were identified. The repair kit outcomes portion of the study focused on 10-F triple lumen (TL) TIC (n ⫽ 433), the type placed most frequently in our practice and that with the most repairs available for analysis. To compare durability, non-repaired (NR) catheters and those requiring repair (R) were compared using Cox proportion hazard regression. RESULTS: Breakage occurred in 12% of 10-F TL TIC (53/433), 5% of 10-F dual lumen (DL) TIC (3/64), 3% of 11-F TL TIC (4/159), 33% of 9.6-F single lumen TIC (4/12), and 14% of 9-F DL TIC (8/56). In the 10-F TIC subset, mean time to catheter breakage was 60 days. Mean catheter days between the NR group (143 days) and the R group (145 days) did not differ (Chi-square: 0.071, hazard ratio: 1.07, p ⫽ 0.79). Mean catheter dwell after repair was 79 days. 52 repairs were attempted in 48 catheters (4 catheters had 2 episodes of breakage and were repaired a second time); no attempt at repair was made in 5 catheters. One repair attempt was excluded for incomplete data. There was an 8% immediate repair kit failure rate (4/51 attempts) and 4 additional repairs lasted 1, 2, 3 and 10 days for an overall repair kit failure rate of 16% (8/51 attempts). CONCLUSION: TIC breakage is common. Although 11-F TL TICs appear to have a lower breakage rate, other limitations (such as flow rates) not considered here may affect catheter choice. Given the high breakage rates observed for many TIC designs, development of more durable catheters should be a priority for catheter manufacturers. Until more durable catheters are developed, catheter repair kits are an easy, effective, durable and relatively inexpensive solution for repair of external segment damage in TICs. 8:12 AM
Abstract No. 117
Peripherally Inserted Central Catheter (PICC) Placement in Patients with Central Venous Stenosis or Obstruction. K.B. Park, Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul, Korea 䡠 S.W. Choo 䡠 Y.S. Do 䡠 S.W. Shin 䡠 S.K. Cho 䡠 I.-W. Choo PURPOSE: To evaluate the feasibility and clinical results of PICC placement in patients with incidentally found central venous stenosis or obstruction. MATERIALS AND METHODS: In a retrospective review of 3272 PICC placements from January 1999 to July 2006, 57 patients were found to have central venous stenosis or obstruction during placement of PICC. 60 PICC placements were performed in 57 patients. 30 male and 27 female were included and their ages ranged from 14 to 88 years old (mean 59 years old). PICC placements in 57 patients were evaluated regarding location and severity of venous disease, underlying causes of venous stenosis or obstruction, catheter placement technique, technical success rate, maintenance period, and complication rate.
S44
RESULTS: Lesions were distributed in unilateral subclavian vein (SCV) (n ⫽ 22), left innominate vein (n ⫽ 10), left innominate vein ⫹ LSCV (n ⫽ 16), SVC (n ⫽ 1), SVC ⫹ L innominate vein (n ⫽ 2), SCV ⫹ axillary vein (n ⫽ 3),
SVC ⫹ SCV (n ⫽ 1), and left innominate vein ⫹ SCV ⫹ axillary vein (n ⫽ 5). Causes of central venous lesion were unidentifiable in 16 patients (30%). 36 of 57 (63%) patients had histories of previous central venous catheterization. Four patients had malignant obstruction and one had postsurgical central vein obstruction. Ipsilateral PICC placement was done in 26 of 60 (43%) procedures. In five patients, ipsilateral lesion passage had failed. Contralateral PICC placement without trial of lesion traverse was done in 26 patients. Ipsilateral internal jugular veins were used in two patients. In one patient, catheter tip was placed in ipsilateral axillary vein. There were 48 complete obstructions and 12 stenoses. Overall technical success rate was 100%. However, ipsilateral lesion passage rate was 84% (26 of 31 trials). PICC dwell time ranged from two days to 150 days (median 25.5days). Complications were seen in 4 of 57 patients (7%) and they were tube tip migration (n ⫽ 1), catheter occlusion (n ⫽ 1), and catheter infection (n ⫽ 2). CONCLUSION: Central venous stenosis or obstruction does not preclude the PICC placement and it does not have adverse influence on catheter function. 8:24 AM
Abstract No. 118
Common Femoral Vein Patency in Sickle Cell Disease Patients Undergoing Monthly Central Venous Catheterizations. M.S. Salomon, Wayne State University, Detroit, MI, USA 䡠 R.C. Navuluri 䡠 J. Kemppainen PURPOSE: Repeated central venous catheterizations are performed in patients with sickle cell disease (SCD) undergoing red blood cell exchange transfusion (RBCET) to prevent the clinical complications associated with SCD. The purpose of this study was to evaluate common femoral vein (CFV) patency and complications associated with repeated common femoral vein catheterizations in patients with SCD. MATERIALS AND METHODS: A retrospective chart review of all SCD patients undergoing monthly RBCET at our institution between Febuary 1999 and Febuary 2006 was performed. Data obtained included patient age, gender, SCD genotype, date of procedure (in order to calculate days between punctures), site of catheter placement, preprocedure CFV sonogram, postprocedure radiograph of catheter placement, and any reported complications. The end-point of vein patency was considered to be failure of catheter placement. All catheters were placed by Interventional Radiology using ultrasound and fluoroscopic guidance prior to RBCET. Temporary dual-lumen 11.5-F (20 or 24 cm) silicone catheters were used. Right and left CFVs were alternately punctured on a monthly basis. One blood volume exchange was performed over two hours in the pheresis lab. At the completion of RBCET, the catheter was removed by the pheresis personnel. RESULTS: Sixty-two patients were studied; 43 females, 19 males. The average age at the time of catheterization was 31.1 (14.9-62.1) years. A total of 1608 catheterizations were documented. An average of 25.9 catheters were placed in each patient; 15.7 in the right CFV, 10.2 in the left. An average of 59.8 and 53.5 days elapsed between catheterization of the right and left CFVs, respectively. Vein patency was demonstrated over an average of 1044 and 994 days in the right and left CFVs, respectively. There were no failed catheter placements and no incidences of venous occlusion. There were two reported complications (0.12%). A fractured catheter fragment had embolized into the right pul-
monary artery and was successfully retrieved, and a paravertebal vein was catheterized. CONCLUSION: Common femoral veins remain patent in SCD patients after repeated monthly central venous catheterizations for RBCET. 8:36 AM
Abstract No. 119
Over-the-Wire Tunneled Catheter Exchanges: Reduce the Risk of Air Emboli. K.J. Kolbeck, Dotter Interventional Institute, OHSU, Portland, OR, USA 䡠 S.W. Stavropoulos 䡠 S.O. Trerotola PURPOSE: Air emboli (AE) have been observed during both central venous catheter placement and over-the-wire (OTW) catheter exchanges. We propose that the use of the catheter clamp alone during OTW exchanges does not prevent AE. We have designed an in vitro model to measure the volumes of AE created during simulated OTW exchanges of a tunneled dialysis catheter (TDC). The aerostatic properties of the TDC clamp, an aerostatic valve (AngioValve, InterV, Gainesville, FL), and a sliding clamp (FloSwitch, Boston Scientific, Natick, MA) were examined both with and without a wire in place.
CONCLUSION: AE can occur during OTW dialysis catheter exchanges even with the TDC clamp closed over the wire. No AE are formed with the addition of aerostatic protection devices. We recommend that OTW exchanges be done with the assistance of such measures. 8:48 AM
Abstract No. 120
Comparison between the Split-Tip Catheter and NonSplit-Tip Catheter for Hemodialysis. T.G. Van Ha, University of Chicago, Chicago, IL, USA 䡠 S.R. Santeler 䡠 J.M. Lorenz 䡠 B.S. Funaki PURPOSE: To compare the safety and efficacy of split-tip catheters (Hemosplit, Bard Medical, Covington, GA) to that of conventional non-split-tip catheters (Vaxcel, Boston Scientific, Natick, MA) in hemodialysis patients.
CONCLUSION: Hemosplit catheters appear to have longer patency rates and fewer complications than standard nonsplit-tip hemodialysis catheters. 9:00 AM
Abstract No. 121
Radiologic Placement of Tunneled Central Venous Catheter in Pediatric Patients. S.-Y. Song, Hanyang University Hospital, Seoul, Republic of Korea 䡠 J.H. Lee 䡠 Y. Kim 䡠 B.H. Koh 䡠 O.K. Cho 䡠 Y.H. Lee PURPOSE: To evaluate the technical success and complications associated with radiological placement of tunneled central venous catheters in oncologic pediatric patients. MATERIALS AND METHODS: Between July 1, 2005 and June 30, 2006, 30 tunneled central venous catheters (17 Hickmann catheters and 13 chemports) were placed in 27 children (14 girls, 13 boys; age range, 4 months-17 years; mean 8.2 years). In 97% (29/30) of the procedures, the right internal jugular vein was used for access. In one procedure, the left internal jugular vein was used. All procedures were performed under ultrasonographic and fluoroscopic guidance. Follow-up data were obtained through the retrospective review of the medical records. RESULTS: Technical success was 100%. Periprocedural complications were tracheal intubation due to hypoxia in two patients, and hematoma formation in one. The mean catheter life was 122 days (range, 8-369 days; total 3760 days). Twenty-one catheters are still in use. Six patients died and in one patient the treatment was finished. Three catheters were removed because of infection in two and malfunction in one. One patient was lost to follow-up. Infection rate was 7% (0.054/100 catheter days). Catheter malfunction rate was 3% (0.027/100 catheter days). S45
SUNDAY
RESULTS: As an internal control, no air entered the system when the catheter was in position and the clamp on the TDC closed. With the TDC clamp left open for 30 s, 43 ⫾ 4 mL of air entered the model. With the TDC clamp closed over a wire (simulating the OTW exchange), the volume of AE was 32 ⫾ 11 mL in 30 s. With the addition of aerostatic devices (closed sliding clamp and the aerostatic valve), no AE occurred with the wire in place over 60 s. As a positive control, with both the sliding clamp and TDC clamp open, the volume of AE was 44 ⫾ 5 mL in 30 s.
RESULTS: 100% technical and clinical success was achieved in both patient groups. The total days of follow-up for the Hemosplit group were 8600 with mean of 172 days (range of 23-533). For the control group, the total follow-up was 7940 days with a mean of 159 (range of 14-464). Within 30 days of placement, there were no infections in the Hemosplit group and 4 infections in the non-split-tip group. Infection rate per 100 catheter days for Hemosplit catheters was 0.07. Infection rate per 100 catheter days for non-splittip catheters was 0.16. Hemosplit malfunction from poor blood flow, inadvertent removal, catheter fracture, or any other process that required intervention occurred at rate of 0.05 per 100 catheter days. Non-split-tip catheter malfunction occurred at rate of 0.12 per 100 catheter days. For Hemosplit catheters, the 30-day patency rate was 95%, the 90-day patency rate was 80% and the 180-day patency rate was 76%, using Kaplan-Meier life table analysis. For nonsplit-tip catheters, the 30-day patency rate was 79%, the 90-day patency rate was 72%, and the 180-day patency rate was 59%.
Scientific Sessions
MATERIALS AND METHODS: The AE model simulated physiologic conditions with a flow of a 50% glycerol:water solution at 10 mL/s and a pressure differential of -6 to -8 mm Hg. A 14-F 28-cm split tip dialysis catheter was used in all experiments. A 60-second (s) test period prior to each iteration established no collateral sources of AE. A 0.038inch guide wire was introduced into the dialysis catheter. With the wire in place the volume of AE in 30 s with the TDC clamp open (n ⫽ 10), closed over the wire (n ⫽ 10), and an open sliding clamp (FloSwitch) was recorded. The volume of AE in 60 s was also recorded with the TDC clamp closed without a wire (n ⫽ 10) and with a guide wire through both the aerostatic valve (n ⫽ 10, AngioValve) and sliding clamp (FloSwitch) in a closed position (n ⫽ 10).
MATERIALS AND METHODS: A retrospective study was performed of 50 consecutive patients (18 men and 32 woman with average age of 60 years) following Hemosplit catheter placement and a control group of 50 consecutive patients (28 men and 22 women with average age of 57 years) with placement of non-split-tip catheters. Both catheter types were placed by the same physicians using standard techniques through the internal jugular veins. Clinical follow-up was performed. Technical and clinical success rates, procedural complications, primary patency rates, and infection rates were calculated.
CONCLUSION: Radiologic placement of tunneled central venous catheter is an effective technique with high technical success rate and low complication rate. 9:12 AM
Abstract No. 122
Is Adrenal Venous Sampling Necessary in All Patients with Hyperaldosteronism Prior to Adrenalectomy? R. Zarnegar, University of California, San Francisco, San Francisco, CA, USA 䡠 A.I. Bloom 䡠 R.K. Kerlan 䡠 M.W. Wilson 䡠 Q.-Y. Duh, et al. PURPOSE: It has been proposed that adrenal venous sampling (AVS) should be employed universally in hyperaldosteronism to both characterize and lateralize disease before adrenalectomy. We hypothesized that with routine use of CT, more selective use of AVS may be warranted. MATERIALS AND METHODS: A retrospective cohort study of 59 consecutive patients with hyperaldosteronism, diagnosed biochemically, who underwent unilateral adrenalectomy at a single center, during a 10-year period. Group 1 (n ⫽ 30), had adrenalectomy based on CT and Group 2 (n ⫽ 29), based on CT and AVS. The indication for AVS was an equivocal CT (26), or patient request (3). Outcome parameters were postoperative serum potassium and aldosterone, the number of hypertensive medications, and mean arterial blood pressure (MAP) at 6 months. RESULTS: Preoperatively, both groups were matched for age, years of hypertension, MAP, and number of hypertensive medications. In Group 1, the average tumor size was 2 cm (range 1-3 cm), and in Group 2, 1 cm (range: 0-2.5 cm), using equivalent CT parameters. Unilateral tumor was identified on CT in 30 patients (100%) in Group 1 and in 17 patients (59%) in Group 2, p ⬍ 0.05. Postoperatively, aldosterone levels were lower in Group 1: 6.3 ⫾ 5.9 ng/dL, than in Group 2: 13.5 ⫾ 16 ng/dL, p ⬍ 0.05. However, both groups had similar improvements in hypertension with MAP at 6 months; 92 ⫾ 12 vs. 96 ⫾ 9, p ⫽ 0.14, reduction in number of hypertensive medications to 1.1 ⫾ 1.3 vs. 1.2 ⫾ 1.1, p ⫽ 0.4, and improvement in hypokalemia; 3.8 ⫾ 0.5 vs. 3.8 ⫾ 0.5 meq/L, p ⫽ 0.5. CONCLUSION: The clinical impact of adrenalectomy was similar in both groups. CT can reliably diagnose adenomas greater than 1.0 cm. AVS should be utilized when CT is equivocal or both adrenals are abnormal. 9:24 AM
Abstract No. 123
Venographic Anatomy and Glue Embolization of PostSurgical Recurrent Varicoceles. J.S. Kao, Stanford University, Stanford, CA, USA 䡠 J.K. Frisoli 䡠 M.K. Razavi 䡠 D.Y. Sze PURPOSE: Persistent or recurrent varicoceles after surgical or endovascular treatment are frequently attributed to duplications and collateralization of veins. We retrospectively reviewed the venographic anatomy of patients who presented for endovascular varicocele embolization after surgical failure. In addition, we reviewed the efficacy of liquid embolics in treating these vessels. MATERIALS AND METHODS: Sixteen patients were referred over a 46-month period, 11 for persistence and 5 for recurrence of varicoceles after surgical varicocelectomy. The patients ranged in age from 13 to 54 years, with a mean of 26 years. Of the recurrences, onset was recognized as soon as 1 month after surgery and as long as 18 years after S46
surgery, with a median of 1 year. Patients were studied by retrograde venography, and anatomy classified according to the system of Bahren. Gonadal veins, including collateral and duplicated vessels, were embolized with NBCA glue. Two patients underwent bilateral procedures. RESULTS: Immediate technical success was achieved in all patients. The large majority (13 varicoceles in 11 patients) had Bahren type 3 venographic anatomy with a single gonadal vein cranially and duplications more caudally extending into the inguinal canal, including both patients with bilateral varicoceles. One patient had type 1 anatomy (unduplicated single vein), two had type 2 (communicating with paravertebral plexus) and one each had type 4 (communicating with renal capsule) and 5 (circumaortic renal vein). Two patients had partial nutcracker physiology, one with type 2 and one with type 3 anatomy. At six month follow-up, one patient had residual grade I varicocele (improved from grade II). In those who underwent seminal exam, the mean increase in motile sperm was 9.0 ⫻ 10e6/ mL. The patient with persistent varicocele showed no improvement in seminal parameters. CONCLUSION: Gonadal vein duplications extending into or solely involving the sites of surgical ligation in or near the inguinal canal are a subset of the type 3 Bahren anatomy that account for most surgical failures. Liquid embolic materials appear to be effective in distributing into these duplications.
Scientific Session 14 Oncology: Embolization Sunday, March 4, 2007 8:00 AM - 9:30 AM Room: 205 8:00 AM Abstract No. 124 FEATURED ABSTRACT Combined Chemoembolization and Percutaneous Radiofrequency Ablation for Local Control of Liver Tumors. M.C.S.S. Higgins, University of Pennsylvania, Philadelphia, PA, USA 䡠 J.I. Mondschein 䡠 S.W. Stavropoulos 䡠 C.M. Tuite 䡠 T.W.I. Clark 䡠 M.C. Soulen PURPOSE: To estimate the local control rate for combined chemoembolization and radiofrequency ablation (RFA) of hepatic malignancies greater than 2 cm. MATERIALS AND METHODS: 53 tumors (37 HCC, 16 metastases) in 44 patients were chemoembolized with CAM/Ethiodol/PVA followed by RFA the next day. In one case, RFA was performed within 2 weeks. In 7 patients with bilobar disease, the other lobe was treated 4-6 weeks later. Mean tumor size was 4.4 ⫾ 1.7 cm (range, 2.2 to 9 cm). 46/53 tumors were treated using LeVeen probes, 5/ 53 with RITA probes, and 2/ 53 with a Radionics unit. 15 tumors received a single burn, 38 received multiple overlapping burns. Clinical, laboratory, and imaging evaluations were performed one month post-treatment and then every 3 months. Follow-up endpoints were liver transplant or death.Seven patients who neither have received a transplant or died have been followed for a median of 10 months (range 1-36). RESULTS: Technical success was 98%. In one case using a LeVeen probe, roll-off was not achieved. 9/53 (17%) tu-