Prophylactic Greenfield filters: acute complications and long-term follow-up

The efficacy of prophylactic vena caval filters (VCF) in reducing morbidity and mortality from pulmonary embolism (PE) in high-risk trauma patients has been shown, but minimal follow-up data is currently available. VCFs were prophylactically placed in 110 patients between August 1991 and June 1995. There was an early VCF complication rate of 7%. Twenty-two patients died; the remaining 88 patients formed the basis for the follow-up study. Forty-five patients were located and interviewed by phone, and 30 of these patients (34%) returned for evaluation. The mean follow-up time was 18 months (range, 4-42 months). There was no incidence of caval thrombosis on follow-up. Eleven patients had physical findings, and duplex evidence consistent with postphlebitic syndrome. An additional three patients had evidence of old deep venous thrombosis (DVT) by duplex, but no significant symptomatology. VCF are effective in preventing PE related deaths and have few major complications. The long-term morbidity associated with posttraumatic venous thrombosis is significant. This morbidity is related not to PE or VCF, but to the underlying DVT. Improved strategies against DVT are necessary.     

Surgical prophylaxis for pulmonary embolism

The trauma patient population is at special risk for fatal pulmonary embolism. We experienced 11 fatalities in one 12-month period. Specific risk factors for both deep venous thrombosis and pulmonary embolism can be identified among trauma patients. The latter usually cannot be offered prophylactic anticoagulation, and the nature of their injuries (e.g., long bone fractures) makes not only bedside surveillance difficult but also precludes use of pneumatic compression, etc. We have developed a protocol for prophylactic inferior vena caval filtration for our trauma patients deemed at particular risk for pulmonary embolism. Since 1986 we have inserted 205 Greenfield filters in 201 patients. Two hundred were inserted prophylactically. There was no mortality, and morbidity was minimal. No patient with a Greenfield filter sustained a fatal pulmonary embolism during this period. Four patients died from pulmonary embolism before vena caval filters could be inserted. We believe that the trauma patient, at risk for pulmonary embolism, should be offered a Greenfield filter prophylactically as soon after hospitalization as logistically possible.     

Prophylaxis for venous thromboembolism in head and neck surgery: the practice of otolaryngologists

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are an important cause of morbidity and mortality in the surgical patient. The first guideline produced by the Scottish Intercollegiate Guidelines Network was for the prophylaxis of venous thromboembolism. Patients undergoing major head and neck cancer surgery commonly exhibit risk factors for venous thromboembolism. Currently, however, there are no data on its incidence in these patients. A questionnaire survey was performed to assess the current practice of consultant otolaryngologists regarding DVT prophylaxis in patients undergoing head and neck cancer surgery. Of those respondents who managed these patients, 57 per cent did not use routine DVT prophylaxis while 43 per cent did. A wide variety of techniques were employed among those practising DVT prophylaxis. A consensus is needed concerning the use of thromboembolism prophylaxis in head and neck surgery patients.     

Urinary excretion of proteolyzed alpha1-antitrypsin: specificity, quantitation, and relation to therapy response in patients with acute myeloid leukemia

The purpose of this study was to characterize the long-term safety and efficacy of the stainless-steel Greenfield filter. All patients who underwent Greenfield filter placement at three institutions during tenure of the senior author (L.J.G.) were entered prospectively into a filter registry and followed on an annual basis. Follow-up consisted of clinical examination to evaluate the status of venous disease or recurrence of pulmonary embolism, abdominal radiographs to determine the stability of the filter and an evaluation of the patency of the inferior vena cava and lower extremities. This report summarizes the 20-year experience. The rate of recurrent pulmonary embolism was 4% and the caval patency rate was 96%. Some filter movement of no clinical significance was seen in 8% of cases. There was no procedural mortality and morbidity was minimal. Greenfield filter insertion provides long-term protection from pulmonary embolism while preserving caval patency.     

Suprarenal filter placement

PURPOSE: This study was undertaken to determine the clinical outcomes for patients with Greenfield filters placed in the suprarenal (SR) inferior vena cava (IVC). METHODS: We collected data prospectively from annual follow-up evaluations of patients with filters. Patients underwent venous color-flow duplex examinations of the IVC and lower extremities, abdominal radiographs, and physical assessment. The outcomes for those patients with filters in the SR IVC were compared with the outcomes previously reported and with the outcomes for patients with filters in the infrarenal cava. RESULTS: SR placement accounted for 7.6% (148/1932) of all filter placements. Follow-up data were available for 73 placements, or 49%. No cases of renal dysfunction were related to filter placement. The rate of recurrent pulmonary embolism (PE) was 8%, and the rate of long-term caval occlusion was 2.7%. These rates did not differ statistically from the rates for patients with infrarenal filters (P > .05). Male patients tended to be older by 15 years, to have more recurrent PE, and to experience more filter migration (6 vs 2 mm). Failure of SR filters to prevent PE was associated statistically with the primary indication for placement. Recurrent PE was the indication in 5 of 6 patients who sustained PE after SR filter placement (P = .007). Filter limb fracture was seen only with the stainless-steel Greenfield filter. CONCLUSION: Greenfield filters placed above the renal vein provide protection from PE with a minimal risk of occlusion. Twenty-five years of experience with Greenfield filters shows that they are safe and effective both in young female patients of child-bearing potential and in all patients with appropriate indications for SR placement.     

Arterial disease and thrombosis in the antiphospholipid syndrome: a pathogenic role for endothelin 1

PURPOSE: It has been proposed that inferior vena cava filter placement should be the initial treatment of deep venous thrombosis (DVT) or pulmonary embolus (PE) in patients with coexisting malignant disease. We have chosen instead to selectively place filters only in patients with either a contraindication to anticoagulation therapy or a subsequent complication from anticoagulation therapy. The treatment efficacy and mortality rates in patients with concomitant malignant disease and venous thromboembolism using this approach was determined. METHODS: We retrospectively reviewed all patients at our institution with malignant disease in whom venous thromboembolism developed between August 1991 through August 1996 and identified 166 patients with PE (n = 8), DVT (n = 147), and DVT/PE (n = 11). Of these patients, 138 (83.1%) were initially treated with anticoagulation therapy, and 28 (16.9%) had primary filter placement because of contraindications to anticoagulation therapy (10 for intracranial tumors, 11 for recent or upcoming operations, 6 for recent hemorrhage, and 1 for a malignant bloody pericardial effusion). RESULTS: Thirty-two (23%) of the 138 patients who initially underwent anticoagulation therapy subsequently required a filter for the following reasons: bleeding (n = 15, 10.9%); recurrent thromboembolism (n = 6, 4.3%); heparin-induced thrombocytopenia (n = 1, 0.7%); and perceived high risk for bleeding with continued anticoagulation therapy (n = 11, 8%). Both bleeding and recurrent thromboembolism developed in 1 patient. Sixty patients (36%) received filters. No major technical complications occurred from filter placement. Major recurrent thromboembolic complications developed in 10 patients: DVT (n = 6, 10%), PE (n = 2, 3.3%), inferior vena cava thrombosis and phlegmasia cerulea dolens (n = 1, 1.7%), superior vena cava thrombosis (n = 1, 1.7%). Venous gangrene developed in 1 patient with DVT. The 1-year actuarial survival rates for patients treated with filter and anticoagulation therapy were 35% and 38%, respectively (P = NS). CONCLUSION: In summary, our experience suggests that 64% of patients with malignant disease and venous thromboembolism are effectively treated with anticoagulation alone; 17% require primary filter placement for standard indications, and an additional 19% require subsequent filter placement because of complications (primarily bleeding) or failure of anticoagulation therapy. Although technical complications of filter placement are low, serious life-threatening or limb-threatening thromboembolic complications developed in 17% of patients. Survival was poor in all patients, regardless of treatment. These data support a conservative approach of routine anticoagulation therapy with selective filter placement.     

Psychiatric diseases presenting as infectious diseases

BACKGROUND: Cytomegalovirus (CMV) disease is an important cause of organ transplant-related morbidity and mortality. During the last 5 years at our institution, prophylactic ganciclovir and hyperimmune globulin have been routinely administered to lung transplant recipients whenever the donor or the recipient was CMV antibody-positive. We sought to assess the efficacy of prophylaxis on viremia, CMV disease, and bronchiolitis obliterans syndrome (BOS). METHODS: A retrospective chart review of 61 consecutive lung transplants performed between recipients between January 1993 and August 1995 was performed. Fifty-six patients who survived at least 1 month were analyzed. Patients were considered at risk for CMV disease whenever pretransplant donor or recipient serology was positive. RESULTS: Fourteen of the 39 patients at risk (36%) had viremia while on prophylaxis. The rate of CMV disease was 13% during the first 6 months following transplantation. A donor whose CMV serology was positive appeared to increase the risk of BOS in a Cox regression model (relative risk=2.4; 95% confidence interval=0.86-6.74; p=0.0957). Neither age, CMV infection (viremia or a positive specimen from BAL), recipient's serology at the time of transplantation, or CMV disease was associated with BOS. None of these variables was associated with mortality on Cox regression analysis or univariate analysis. CONCLUSIONS: Administration of combination ganciclovir and hyperimmune globulin prophylactic therapy to lung transplant recipients at risk for CMV infection and disease is associated with a relatively low incidence of disease, which appears only after prophylaxis treatment with ganciclovir is completed. Ganciclovir prophylaxis does not prevent CMV viremia; however, viremia while on prophylaxis is not predictive of disease.     

A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group

BACKGROUND: The efficacy and safety of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis is still a matter of debate. METHODS: Using a two-by-two factorial design, we randomly assigned 400 patients with proximal deep-vein thrombosis who were at risk for pulmonary embolism to receive a vena caval filter (200 patients) or no filter (200 patients), and to receive low-molecular-weight heparin (enoxaparin, 195 patients) or unfractionated heparin (205 patients). The rates of recurrent venous thromboembolism, death, and major bleeding were analyzed at day 12 and at two years. RESULTS: At day 12, two patients assigned to receive filters (1.1 percent), as compared with nine patients assigned to receive no filters (4.8 percent), had had symptomatic or asymptomatic pulmonary embolism (odds ratio, 0.22; 95 percent confidence interval, 0.05 to 0.90). At two years, 37 patients assigned to the filter group (20.8 percent), as compared with 21 patients assigned to the no-filter group (11.6 percent), had had recurrent deep-vein thrombosis (odds ratio, 1.87; 95 percent confidence interval, 1.10 to 3.20). There were no significant differences in mortality or the other outcomes. At day 12, three patients assigned to low-molecular-weight heparin (1.6 percent), as compared with eight patients assigned to unfractionated heparin (4.2 percent), had had symptomatic or asymptomatic pulmonary embolism (odds ratio, 0.38; 95 percent confidence interval, 0.10 to 1.38). CONCLUSIONS: In high-risk patients with proximal deep-vein thrombosis, the initial beneficial effect of vena caval filters for the prevention of pulmonary embolism was counterbalanced by an excess of recurrent deep-vein thrombosis, without any difference in mortality. Our data also confirmed that low-molecular-weight heparin was as effective and safe as unfractionated heparin for the prevention of pulmonary embolism.     

Venous dissection injuries during laparoscopic urological surgery

PURPOSE: The incidence of major venous dissection injuries during laparoscopic procedures is assessed and recommendations are made for management. MATERIALS AND METHODS: We evaluated our experience with all major intra-abdominal injuries occurring during 274 consecutive laparoscopic procedures performed within a 4-year period. Five patients (1.7%) had a total of 6 major vascular injuries, including gonadal vein avulsion in 1 case, lumbar vein avulsion in 1 and a tear in the inferior vena cava in 4. Two patients sustained inferior vena caval injuries during nephrectomy because of adhesions from previous surgery and 1 of them had 2 venacavotomies. RESULTS: All vascular injuries were venous and 5 of the 6 major vessel injuries were treated successfully endoscopically via intracorporeal suturing techniques. The injury requiring open repair was a gonadal vessel avulsion that occurred during retroperitoneal lymph node dissection early in our laparoscopic experience. Major vessel injuries were more likely to occur during complex laparoscopic procedures in patients who had undergone previous ipsilateral retroperitoneal surgery. CONCLUSIONS: In select situations new techniques can allow for safe endoscopic control and repair of venous injuries during laparoscopic surgery.     

Systemic venous collateral development after the bidirectional cavopulmonary anastomosis. Prevalence and predictors

OBJECTIVES: To determine the prevalence of systemic venous collaterals after the bidirectional cavopulmonary anastomosis and the factors associated with their development. BACKGROUND: Systemic venous collaterals have been found after cavopulmonary anastomosis. Methods. Cardiac catheterization was performed in 103 patients before and after a bidirectional cavopulmonary anastomosis. RESULTS: After surgery, 51 venous collaterals were identified in 32 patients (31%). Collateral development was associated with an abnormal superior vena caval connection (56% incidence vs. 26% with a single right superior vena cava, p = 0.01) and postoperative factors including pulmonary artery distortion (53% incidence vs. 22% without distortion, p = 0.002); increased superior vena caval mean pressure (14 +/- 5 mm Hg versus 11 +/- 4 mm Hg with no collaterals, p = 0.0002); increased pulmonary artery mean pressure (13 +/- 4 mm Hg vs. 11 +/- 4 mm Hg with no collaterals, p = 0.02); lower right atrial mean pressure (5 +/- 2 mm Hg vs. 6 +/- 3 mm Hg with no collaterals, p = 0.04); and increased mean gradient between superior vena cava and right atrium (8 +/- 3 mm Hg vs. 5 +/- 4 mm Hg with no collaterals, p = 0.0002). Using multiple logistic regression, only this last factor was independently associated with collateral development with an odds ratio per 1 mm Hg of 1.33 (95% CI 1.12-1.58, p = 0.001) for their presence. CONCLUSIONS: Systemic venous collaterals occur frequently after a bidirectional cavopulmonary anastomosis and are found postoperatively when a significant pressure gradient occurs between cava and right atrium.     

Hepatic outflow study after piggyback liver transplantation

BACKGROUND: Hepatic vein outflow is discussed in liver transplantation after preservation of recipient retrohepatic vena cava. The aim of this study was to compare two methods of suparahepatic caval anastomosis. METHODS: From January 1993 to January 1995, 81 patients received 88 liver transplants because of liver cirrhosis (n = 70), acute liver failure (n = 7), elective retransplantation after hepatic artery thrombosis (n = 2), giant hemangioma (n = 1), and combined liver-small bowel transplantation (n = 1). Seven patients underwent urgent retransplantation, 12 had preoperative transjugular intrahepatic portocaval stent, and 11 had portal vein thrombosis. Five patients required extracorporeal venous shunt. A total of 82 liver transplantations had preservation of RHVC, and 70 patients received temporary end-to-side portacaval shunt. Suprahepatic caval anastomosis was carried out in 52 patients (group 1) between the graft suprahepatic vena cava and the ostia of recipient left and median hepatic veins. Thirty patients (group 2) had associated 3 cm vertical cavotomy with partial clamping of RHVC. In the fourth postoperative month 20 patients from each group had pressure and gradient measurement made among the hepatic veins, right atria, and the RHVC. RESULTS: Mean pressure gradient between hepatic veins and right atria was 0.75 +/- 0.49 mm Hg in group 1 and 2.06 +/- 0.85 mm Hg in group 2. Between the RHVC and the right atria it was 0.63 +/- 0.5 mm Hg in group 1 and 2.22 +/- 1.29 mm Hg in group 2. A pressure gradient higher than 3 mm Hg was considered hemodynamically significant. This pressure gradient was found between the hepatic veins and right atria in 10% of patients in group 1 and 40% of patients in group 2 (p = 0.03) and between the RHVC and right atria in 15% of patients in group 1 and 30% of patients in group 2 (p = 0.3). CONCLUSIONS: Preservation of the recipient RHVC with recipient caval anastomosis at the ostia of the median and left hepatic veins is a reliable technique without any hepatic venous outflow alteration. Associated cavotomy is not necessary.     

Vena cava duplex imaging before caval interruption

PURPOSE: Venacavograms are routinely obtained before vena cava filter placement to evaluate cava size, patency, and the presence of thrombus or venous anomalies. The objective of this study was to determine the ability of duplex ultrasonography to adequately evaluate the inferior vena cava (IVC) for size, patency, and the presence of thrombus before Greenfield filter (GF) insertion. METHODS: Duplex ultrasonographic scans were performed in 40 patients who had documented lower-extremity deep venous thrombosis diagnosed by duplex scan before GF placement. The infrarenal transverse and anteroposterior diameters of the IVC were measured, and the entire IVC was imaged for patency and the presence of thrombus or anomalies. Preoperative venacavograms were not obtained in any patients who had GFs placed in the operating room, but was performed during surgery during filter insertion. An additional 26 patients who had deep venous thrombosis and did not have caval interruption underwent IVC duplex to determine the patency and proximal extent of venous thrombosis. RESULTS: The indications for GF placement were contraindication to anticoagulation in 72.5% (29 patients); five filters were placed prophylactically; three for failure of anticoagulation; two after a complication of anticoagulation; and one before pulmonary embolectomy. The filters were placed in the operating room by surgeons in 82.5% of patients, with the remainder inserted in an angiography suite by an interventional radiologist. The ability of duplex to measure a transverse diameter of 26 mm or less had a sensitivity of 97.5%, positive predictive value of 100%, and overall accuracy of 97.5% using venacavography as the standard. Measurements of IVC diameter by duplex correlated with those based on venacavograms (r = 0.766; p < 0.001). Of the entire group of 66 IVC duplex examinations, one (1.5%) was incomplete because of technical limitations. IVC thrombus was noted by duplex in two patients who underwent GF insertion, which was confirmed with venacavography. No IVC anomalies were noted by duplex scans or venacavograms. CONCLUSION: Duplex ultrasonography is a useful and accurate method for assessment of the IVC before vena cava filter placement.     

Single muscle fibre analyses in 2 brothers with succinate dehydrogenase deficiency

Thrombosis of the access site and occlusion of the inferior vena cava after placement of an inferior vena caval filter are known complications of caval interruption. 30 patients were evaluated with colour-coded Doppler sonography 4 to 66 months (average 2.5 years) after percutaneous placement of either a Günther filter, a Bird's Nest filter or a Simon-Nitinol filter. One right internal jugular vein had post-thrombotic alterations. One inferior vena cava was found to be occluded 15 months after Simon-Nitinol filter placement. The long-term occlusion rates of access site and inferior vena cava after percutaneous filter introduction are low. These two factors need not be considered if implantation of a caval filter is contemplated.     

Vena cava filter ensnarement and delayed migration: an unusual series of cases

PURPOSE: To review delayed and guidewire-induced morbidity associated with vena cava filters. METHODS: The records from the Johns Hopkins Hospital, a tertiary care referral center, of all patients who had vena cava filter complications from August 1993 through July 1996 were retrospectively reviewed. RESULTS: Five patients had filter migration or ensnarement with a guidewire. One patient had delayed extrusion of a filter strut into the duodenum. Four patients had filters ensnared by guidewires, including one during initial filter placement and one several years after placement. CONCLUSIONS: Delayed complications of vena cava filters should be considered whenever unusual patient signs or symptoms cannot be easily explained, even in the absence of a history of filter placement. To prevent guidewire ensnarement of filters, simple techniques should modify endovascular procedures when vena cava filters are present.     

Cloning and sequencing of a 16S/23S ribosomal spacer from Haemophilus parainfluenzae reveals an invariant, mosaic-like organisation of sequence blocks

The aim of this study was to evaluate the clinical efficacy, mechanical stability, and safety of the Simon nitinol inferior vena cava filter (SNF). The SNF was inserted in 114 consecutive patients at two institutions for prophylaxis of pulmonary embolism (PE). Clinical follow-up data were obtained retrospectively on all patients, and 38 patients underwent a dedicated radiologic follow-up protocol consisting of abdominal radiography, Doppler sonography, and CT. There was no immediate complication following filter insertion. Fifty patients died, on average, 5.6 (1-23) months after filter insertion, and 64 patients were alive, on average, 27 (3-62) months after filter insertion. Recurrent pulmonary embolism was documented in 5 patients (4.4 %) but originated distal to the filter in 1 patient. Deep venous thrombosis (DVT) was documented in 5.3 %, thrombosis at the access site in 3.5 %, and thrombosis of the inferior vena cava in 3.5 %. The rate of thromboembolic complications was similar in patients who did receive long-term anticoagulation and in those who did not. Radiologic follow-up showed no filter migration after, on average, 32 (5-62) months. A CT examination showed that struts of the SNF had penetrated the vena cava in 95 %, and were in contact with adjacent organs in 76 %; however, there were no clinical symptoms attributable to the filter. Filters were in an eccentric position in 63 % and partial filter disruption was found in 16 %; however, this did not affect filter function. The rate of recurrent pulmonary embolism after insertion of the SNF is 2.4 % per patient per year. Regardless of long-term anticoagulation, the rate of caval thrombosis is acceptably low. Except for occasional access-site thrombosis, no other filter-related morbidity was observed.     

Vena caval resection for bulky metastatic germ cell tumors: an 18-year experience

PURPOSE: The operative management and followup of vena caval resection for bulky metastatic germ cell tumors have been previously described in 3 series. In 1989 Ahlering and Skinner described their experience with 12 patients. We now update this experience with the most recent followup on 19 patients. MATERIALS AND METHODS: From April 1978 to May 1995, 19 men underwent retroperitoneal lymph node dissection for stage B3 (N3) or C (N3, M+) germ cell tumor after induction chemotherapy. In all cases the inferior vena cava was resected because of extensive thrombosis or direct involvement of the vessel wall by a tumor. The inferior vena cava was resected from just below the renal veins to beyond the level of disease involvement. Complete resection of retroperitoneal disease was accomplished in all patients. Morbidity and mortality were examined. RESULTS: The mean hospital stay was 10 days (range 7 to 13) for uncomplicated recoveries (9 patients) versus 19 days (range 6 to 32) for complicated recoveries (10 patients). Followup ranged from 1 month to 16 years. Complications included prolonged ileus, small bowel obstruction, fascial dehiscence and pneumonia with pleural effusion. Chronic edema persisted in 3 of 11 patients with followup of greater than 6 months. Of the 6 patients who died of disease recurrence 4 did not have normalization of tumor markers before surgery, and all 4 had persistence of cancer in the resected specimen. Seven patients are without disease at followup of 24 months to 16 years. All survivors had normalized tumor markers before surgery. Only 1 patient (5%) had retroperitoneal recurrence. CONCLUSIONS: En bloc vena caval resection for tumor involvement or extensive thrombosis can be associated with short and long-term morbidity, is feasible, and may contribute to a prolonged tumor-free interval and a chance for cure.     

Thromboembolism following total hip-replacement arthroplasty. The efficicy of dextran-aspirin and dextran-warfarin in prophylaxis

The efficacy of two antithrombotic regimens, combined dextran and aspirin and combined dextran and warfarin, was analyzed by comparing the incidence of thromboembolism following total hip replacement in two groups of similar patients. Of the 427 who received dextran and aspirin, 7 per cent had thromboembolic complications, including one case of fatal pulmonary embolus and one case of recurrent emboli that required vena caval ligation, and 15 per cent had wound-healing complications. Of the 197 patients who received dextran and warfarin, 5 per cent had thromboembolism and 24 per cent had wound healing complications. Although both prophylactic regimens seemed effective, dextran and aspirin appeared less effective in reducing thromboembolic complications than dextran and warfarin, but there were fewer wound complications in that group. One-fourth of the patients on dextran-warfarin were not adequately anticoagulated despite close supervision. In forty-five patients with a history of thromboembolism who were excluded from the study and analyzed separately, warfarin alone and the two described regimens were equally ineffective in preventing thromboembolism, and the incidence of thromboembolic complications was high. Dextran-aspirin and dextran-warfarin appear to be satisfactory and relatively simple methods of thromboembolic prophylaxis.     

Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis

BACKGROUND & AIMS: Antibiotic prophylaxis has been shown to decrease the incidence of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites. The aim of this study was to test whether antibiotic prophylaxis for SBP is cost-effective and to compare the costs associated with different patient groups and treatment strategies. METHODS: A cost-effectiveness analysis was performed using a Markov chain model. The costs incurred during 1-year treatment with prophylactic antibiotics vs. no prophylaxis in patients with cirrhosis and ascites were calculated. The incidence rates of primary and recurrent SBP and the mortality rate of SBP were obtained from the literature. Total direct costs of SBP treatment were determined from the wholesale price of drugs and from disbursements by the Health Care Financing Administration. RESULTS: Norfloxacin prophylaxis resulted in savings between $2216 and $8545 per patient per year, depending on the patient group studied. Trimethoprim-sulfamethoxazole prophylaxis resulted in savings between $2934 and $9251 per patient per year. The groups that benefited most from prophylaxis were patients with an ascitic fluid total protein concentration of < or = 1 g/dL and those with a previous history of SBP. CONCLUSIONS: The use of prophylactic antibiotics to decrease the incidence of SBP is a cost-saving strategy in patients with cirrhosis and ascites.     

Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access

Access to the central venous circulation for hemodialysis has traditionally been achieved via the subclavian or jugular venous routes. With ongoing improvements in medical management, many hemodialysis recipients develop exhaustion of these routes and require alternative means of central venous access. Inferior vena caval (IVC) catheters have been placed with a percutaneous translumbar approach to allow central venous access for chemotherapy, harvesting of stem cells, and total parenteral nutrition. Translumbar placement of IVC catheters has become accepted by some as a useful and reliable alternative in patients who require long-term hemodialysis but have exhausted traditional access sites. IVC catheters have been placed in patients with IVC filters, and IVC filters have been placed in patients with IVC catheters. Complications include those associated with central venous catheters, for example, sepsis, fibrin sheaths, and thrombosis. A complication specific to placement of IVC hemodialysis catheters is migration of the catheter into the subcutaneous soft tissues, retroperitoneum, or iliac veins. Translumbar placement of IVC catheters is performed only in patients considered to have few or no other medical options and is not intended as a primary means of central venous access.