Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis

PURPOSE: To evaluate the efficacy of catheter-directed thrombolysis with urokinase in treating symptomatic iliofemoral deep venous thrombosis (DVT). MATERIALS AND METHODS: Twenty-one consecutive patients with iliofemoral DVT underwent treatment for 27 affected limbs (acute DVT, n = 20; chronic DVT, n = 7). The average urokinase dose was 4.9 million IU (range, 1.4 million to 16.0 million IU) infused over an average of 30 hours (range, 15-74 hours). RESULTS: Lysis was complete in 18 (72%), partial in five (20%), and not achieved in two (8%) of 25 treated limbs. Two chronically occluded iliac veins could not be crossed with a guide wire and did not receive urokinase. Sixteen limbs had underlying venous stenoses (> 50%) that were treated with angioplasty (n = 2) or angioplasty and stent placement (n = 14). There were no major complications or clinically detectable pulmonary emboli. The technical and clinical success rates were 85%. CONCLUSION: This initial experience suggests that catheter-directed thrombolysis with urokinase for treatment of symptomatic iliofemoral DVT is safe and effective.     

Benign biliary strictures associated with recurrent pyogenic cholangitis: treatment with expandable metallic stents

OBJECTIVE: The purpose of this study was to determine the long-term effectiveness of expandable metallic stents in benign biliary strictures associated with recurrent pyogenic cholangitis and the differences in primary patency of the various types of stents deployed. SUBJECTS AND METHODS: During a 20-month period, 26 metallic stents (19 Gianturco-Rosch Z stents and seven Strecker stents) were used to treat benign biliary strictures associated with recurrent pyogenic cholangitis in 23 patients (11 men and 12 women; mean age, 42 years; range, 30-78 years). Insertion routes were percutaneous transhepatic biliary drainage tracts for 16 stents, T-tube tracts for seven stents, and retrograde endoscopic routes for three stents. The deployed locations were common hepatic or common bile ducts for 11 stents, right or left hepatic ducts for 10 stents, and segmental ducts for five stents. RESULTS: The initial technical success rate was 100%. Two stents in one patient migrated spontaneously. Primary stent patency for the remaining 24 stents was 34 months (range, 3-58 months). Primary stent patency of the Gianturco-Rosch Z and Strecker stents was 50 and 10 months, respectively (p < .05). Primary stent patency for the intrahepatic and extrahepatic ducts was 50 and 18 months, respectively (p = .05). Primary patency rates for all stents at 6, 12, 24, and 36 months were 92%, 75%, 67%, and 46%, respectively. The causes of stent obstruction were recurrent stone or sludge in eight stents and epithelial hyperplasia in five stents. CONCLUSION: We believe that metallic stent placement is not an effective long-term treatment technique for benign biliary stricture associated with recurrent pyogenic cholangitis.     

Expandable metal mesh stents for treatment of tracheal stenoses and tracheomalacia

The treatment of tracheo-bronchial stenosis or tracheomalacia is mainly carried out by means of resection or tracheoplastic operative strategies. Since the introduction of metal-mesh stents, a definitive endoluminal therapy has to be considered under new aspects. Six patients with malignant stenosis or tracheomalacia due to compression were treated by implantation of Palmaz- or Wallstents. Immediately after the implantation, patients were relieved from dyspnoea, the forced inspiratory volume-1 (FIV1) was normalized. All implanted stents were well tolerated, even in the long-time follow-up (19 months). Bronchoscopic control showed overgrowth of the metal meshes by respiratory epithelium. The implantation of metal-mesh stents is an adequate alternative in the treatment of malignant stenosis and tracheomalacia.     

Results of treatment of inferior vena cava syndrome with expandable metallic stents

A 73-year-old male was admitted to our hospital because of detection of Shigella flexneri 2a from his stool. Antimicrobial treatment with levofloxacin (LVFX) was started, but could not eliminate the organism in the stool. In the examination of drug susceptibility, this strain was highly resistant to all new quinolones. The minimal inhibitory concentration of norfloxacin, ofloxacin and ciprofloxacin to this strain was 12.5 micrograms/ml, 6.25 micrograms/ml and 6.25 micrograms/ml, respectively. The dual mutations were detected in the codon 83 and 87 of the gyrA gene by sequencing the quinolone-resistance determining region (QRDR). There was, however, no significant difference between the intracellular uptake of ciprofloxacin in this strain and in the ciprofloxacin-sensitive strain. The amount of ciprofloxacin in this strain unchanged when carbonyl cyanide m-chlorophenyl hydrazone (CCCP) was added. These results suggest that the advanced resistance in Shigella flexneri against new quinolones could be acquired by only this dual mutations without the change of the active efflux mechanism.     

Metal stents in patients with malignant and benign esophageal stenoses

The authors used between October 1993 and January 1997 in 131 patients with inoperable malignant or benign stenosis of the oesophagus an expansible metal stent. In 25 patients the stenosis was in the upper third of the oesophagus, in 44 in the medium part, in 53 in the lower third of the oesophagus and in 9 patients in the area of the anastomosis. All patients suffered at the time when the stent was introduced from marked dysphagia (stage 3-4 according to the international classification). In 45 patients the authors introduced more than one stent. 112 patients suffered from malignant stenosis (67 squamous cell carcinoma, 27 adenocarcinoma, 9 pulmonary or bronchogenic carcinoma, in two instances lymphoma, in two instances leiomyosarcoma and in five patients another type of tumour). Seventeen patients suffered from benign stenosis (8 complications of reflux oesophagitis, 3 stenosis in the anastomosis, in two instances corrosion by acid, 2 cases of epidermolysis bullosa oesophagi and one post-radiation stenosis). In these patients repeatedly before introduction of the stent dilatation of the stenosis by means of a balloon dilatation catheter was attempted. In two instances the etiology of the stenosis was obscure. Complications related to the procedure proper or after insertion of the stent were recorded in 49 patients-dislocation of the stent 23x, occlusion of the stent 17x, development of a fistula 6x, ulceration 16x, haemorrhage 4x, hyperplasia of the mucosa 21x, ileus 2x, inadequate expansion of the stent 8x.     

Ureteroileal anastomotic strictures: an innovative approach with metallic stents

PURPOSE: We report our experience with the use of self-expandable metallic stents to bypass anastomotic strictures after ureteroileal urinary diversion. MATERIALS AND METHODS: We evaluated 3 men and 1 woman with invasive bladder carcinoma who underwent radical cystectomy and ileal conduit urinary diversion. Ureteroenteric anastomotic strictures developed after a mean of 16 months. Self-expandable metallic stents were successfully placed (bilaterally in 2) comprising 6 stented ureters that bypassed strictures. Mean patient age was 64 years and mean followup was 12 months. RESULTS: No restenosis was observed in 3 patients during followup. The stricture recurred 1 month after stent placement in the remaining patient and additional intervention was necessary, consisting of placement of a totally coaxial overlapping metal stent. No sepsis or other complication was observed. One patient died of metastatic disease 12 months after stent placement. CONCLUSIONS: We propose the use of metal stents as an adequate, safe and effective alternative treatment for anastomotic strictures after ureteroileal diversion.     

Electron-microscopic examination of silicon-carbide-coated endovascular stents

The problem of restenosis in blood vessels after balloon angioplasty could not be overcome by the use of metallic stents as had been anticipated. With respect to restenosis, clinical and experimental results now focus the attention on the risk that stents could initiate or potentiate vascular lesions, especially by inhomogenous stent expansion. Here the stent design seems to dominante depending on the use of well rounded structural stent-elements with appropriate surfaces and a material deposition which is compatible with a homogeneous stent expansion. With respect to hemocompatibility the surface quality of the stents is of great importance, too. Coating of surfaces of metallic stents for the enhancement of hemocompatibility might create new risks of blood vessel damages and requires a careful consideration of the co-expansional behaviour of the metallic substrate and the coating material. With these problems in mind the surface coated stent Tensum 3 of the Biotronik company was investigated.     

Transbrachial endovascular exclusion of an axillary artery pseudoaneurysm with PTFE-covered stents

PURPOSE: Endovascular exclusion of arterial injuries associated with arteriovenous fistulas and pseudoaneurysms has only recently been described using various stent-graft prostheses. This report details a transbrachial technique used to exclude an axillary artery pseudoaneurysm developing at the axillary anastomosis of an axillofemoral graft. METHODS AND RESULTS: Thin-walled polytetrafluoroethylene was expanded with an angioplasty balloon catheter and used to cover standard Palmaz stents. Two covered stents were delivered under fluoroscopic guidance via open brachial artery access to the site, resulting in complete exclusion of the pseudoaneurysm. Follow-up duplex scanning confirmed aneurysm exclusion 3 months postprocedure. CONCLUSIONS: This technique can be applied in arteries of different sizes and lengths, using currently available materials. However, the long-term behavior of these devices in the arterial tree must be determined before their widespread use can be recommended for most indications.     

Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration

PURPOSE: The purpose of this study was to evaluate endovascular stenting (EVS) and balloon fenestration (BF) of intimal flaps for the management of lower extremity, renal, and visceral ischemia in acute or chronic aortic dissection. METHODS: Twenty-two patients (16 male, 6 female) with a median age of 53 years (range 35 to 77 years) underwent percutaneous treatment for peripheral ischemic complications of 12 type A (five acute, seven chronic) and 10 type B (nine acute, one chronic) aortic dissections. RESULTS: Ten patients had leg ischemia, 13 had renal ischemia, and 6 had visceral ischemia. Sixteen patients were treated with EVS including 11 with renal, 6 with lower extremity, 2 with superior mesenteric artery, and 2 with aortic stents. Three patients had BF of the intimal flap, and three had BF in combination with EVS. Revascularization with clinical success was achieved in all 22 patients. Two patients died 3 days and 13.4 months after the procedure was performed, respectively. Of the remaining 20 patients, 1 is lost to follow-up, and 19 have persistent relief of clinical symptoms. Mean follow-up time is 13.7 months (range 1.1 to 46.5 months). One case was complicated by guidewire-induced perinephric hematoma. CONCLUSION: EVS and BF provide a safe and effective percutaneous method for managing peripheral ischemic complications of aortic dissection.     

Use of metallic stents in relapsing polychondritis

Relapsing polychondritis is a rare multisystem disease. We describe the presentation and treatment of a patient with relapsing polychondritis and review the literature. This patient had involvement of the tracheobronchial tree requiring insertion of metallic stents.     

Therapy of venous stenosis using wall stents

OBJECTIVE: To evaluate the patency of Wallstents implanted for the treatment of venous stenoses in patients with benign or malignant disease. PATIENTS AND METHODS: 22 Wallstents (20 central venous; two peripheral) were implanted during a period of two years in 12 patients (nine men, three women; mean age 57.8 [26-76] years) with malignant venous stenoses (n = 9) or stenosed dialysis shunts (n = 3). Stent diameter ranged from 8-16 mm, length from 32-91 mm. Introduction of the stents were by percutaneous transfemoral catheterisation, in six patients with simultaneous wire placement from a cubital to the femoral vein. The superior vena cava was the involved vessel in six patients (in two each also the subclavian or brachiocephalic veins), in three only the subclavian vein, twice only the inferior vena cava and once the cephalic vein. RESULTS: The patency of the stents was checked after 4.7 +/- 3.6 (1-14) months, in seven patients clinically, by digital subtraction phlebography in three, by computed tomography in two. In nine patients there was no evidence of obstruction to flow or flow was normal. Stent occlusion had occurred in three patients, 4, 9 and 14 months after placement. There were no complications. Five patients died after a mean period of 4.8 +/- 3.6 (1-6.5) months from the underlying disease, without symptoms of obstruction to flow. CONCLUSION: Stent placement should be considered early, as it is a well-tolerated and effective palliative procedure for central venous stenoses associated with malignant disease or stenosis of dialysis shunts.     

Initial experience with venous stents in exertional axillary-subclavian vein thrombosis

PURPOSE: Exertional thrombosis of the axillary and subclavian veins, also known as Paget-Schr?tter syndrome, has been increasingly recognized in recent years as a cause of long-term morbidity. Recent aggressive approaches to treating Paget-Schr?tter syndrome have suggested the association of early failure with residual subclavian vein stenosis. As a result, the use of endoluminal stents has been proposed as an aid to venous percutaneous transluminal angioplasty for this disorder. METHODS: This report outlines the therapy of 11 consecutive patients with Paget-Schr?tter syndrome who were treated at our institution between October, 1992, and December, 1995. Stents were placed when percutaneous transluminal angioplasty was unsuccessful at achieving an adequate residual lumen. RESULTS: Stents were placed after initial thrombolysis in six patients and in late follow-up in two patients. Of the six patients who had stents placed at initial thrombolysis, first-rib resection was eventually performed in four. In two patients first-rib resection was not performed, and stent fracture occurred in both. Late patency was achieved in the stents of six of the eight patients. CONCLUSIONS: Trials to evaluate stents as an adjunct to conventional therapy seem warranted. The use of stents alone without first-rib resection, however, appears to be associated with stent fracture.     

Vertebral arteriovenous fistula: endovascular treatment with electrodetachable coils

We report a patient with an iatrogenic vertebro-vertebral fistula responsible for a cerebellar syndrome and a cervical bruit. Endovascular treatment of the fistula was carried out using electrically detachable coils. An angiogram 5 months after treatment showed that the fistula had totally disappeared.     

Treatment of malignant esophageal obstructions with covered metallic Z stents: long-term results in 52 patients

PURPOSE: To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-R?sch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. PATIENTS AND METHODS: GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. RESULTS: Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration (n = 5), food impaction (n = 2), chest pain (n = 2), membrane disruption with tumor ingrowth (n = 1), granulomatous reaction above the stent (n = 1), esophageal perforation with mediastinitis (n = 1), and upper gastrointestinal hemorrhage (n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). CONCLUSION: GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.     

Arteriovenous fistulae complicating central venous catheterization: value of endovascular treatment based on a series of seven cases

OBJECTIVES: To point out the usefulness and effication of endovascular treatment of arteriovenous fistulae complicating the insertion of central venous catheter. MATERIAL AND METHOD: Retrospective study of 7 cases treated between 1983 and 1993. The central venous catheterization had involved the right internal jugular vein in 5 cases and the right subclavian vein in 2 cases. RESULTS: Isolated endovascular therapy was performed in 5 cases. Surgery was necessary in 1 case to remove an hematoma. In another case, occlusion of a large AVF was performed during intraoperative endovascular temporary occlusion of the AVF. The choice of the occluding agent was primarily dictated by the hemodynamic and anatomical conditions (releasable balloons, coils). Vertebro-vertebral fistulae (3 cases) could be treated with patency of this vessel. No complications were encountered. CONCLUSION: Endovascular approach is a reliable and safe method to perform occlusion of post catheter AVF.     

Biliary strictures in hepatic transplantation: treatment with self-expanding Z stents

Excellent and good results following different operations for TOS are close to 80%, using simple statistics, where results included many patients followed up for only a few months. Using life-table methods, the success rate is 6% to 9% less, close to 70%, at 5 years. The results were virtually identical for anterior and middle scalenectomy, transaxillary first rib resection, and combined supraclavicular scalenectomy and first rib resection. Secondary success, the results of reoperation on patients in whom the first operation failed, improved the results of the primary operation 15% and 17%, respectively, for transaxillary rib resection and anterior and middle scalenectomy. When the initial operation was combined rib resection and scalenectomy, fewer patients underwent reoperation, as only neurolysis could be performed, and the results improved only 3%. A significant variable in results was etiology: Work-related injuries versus non-work-related accidents, usually auto accidents. Results of three independent studies showed better success rates by 13% to 15%, in patients who had non-work-related auto accidents, as compared with work-related injuries.     

Saccular intracranial aneurysms: endovascular treatment with mechanical detachable spiral coils

PURPOSE: To evaluate endovascular treatment of saccular intracranial aneurysms with mechanical detachable spiral coils. MATERIALS AND METHODS: Fifty-three patients with 56 saccular aneurysms underwent endovascular treatment with spiral coils. All but five had symptomatic subarachnoid hemorrhage staged according to the Hunt and Hess classification as follows: stage IV or V (n = 20), stage III (n = 10), stage I or II (n = 20), and stage 0 (asymptomatic [n = 6]). RESULTS: Forty-seven aneurysms were occluded (100% occlusion) on follow-up angiograms with the following time distribution: 24 months for six aneurysms (six patients), 12 months for 14 aneurysms (11 patients), 6 months for 13 aneurysms (13 patients), 4 months for four aneurysms (four patients), and only immediate postprocedure study for 16 aneurysms (16 patients) (excludes two deaths and one failure). CONCLUSION: In this relatively small group, endovascular treatment with mechanical detachable spiral coils had a success rate of 90%, and it appears to be a rapid, reliable, and relatively safe technique in the treatment of life-threatening subarachnoid hemorrhage.     

Palliative treatment of malignant esophageal stenosis: experience with plastic versus metal stents

BACKGROUND/AIMS: We report on the palliative treatment of 44 patients with malignant dysphagia by placement of plastic (Celestin tubes, n = 24) vs metal stents (Wall stents, Nitinol stents, Gianturco stents, n = 20). METHODOLOGY: Prior to stent insertion, esophageal stenosis was dilated stepwise to 16 mm (plastic tube) and to 10 mm (metal stent). RESULTS: Stent insertion was technically successful in all cases and led to a reduction of dysphagia. Risk of perforation was comparable in both groups (n = 1 in each group). Most of the plastic stents were placed when the tumor was localized in the proximal part of the esophagus close to the upper esophageal sphincter, when esophageal-bronchial fistula was present and in the risk of fistula development after radiation. During follow-up, tumor ingrowth (TI) and stent migration (SM) were the major complications. Whereas tumor ingrowth predominantly occurred in metal stents (TI after 6 weeks, 45% vs. SM, 10%) that required repeated argon beamer therapy, tube migration and bolus impaction (BI) often occurred in patients with plastic stents (TI, 0% vs. SM, 16%; BI, 4%). CONCLUSIONS: The findings of the study suggest that the decision whether plastic tubes or metal stents used should be taken individually considering tumor localization, axis deviation and the presence of esophago-respiratory fistulas. When stepwise dilation of malignant stenoses is performed carefully, perforation risk appears not to be different between placement of plastic prostheses and metal stents.