VENOUS INTERVENTION Moderator: Iain Robertson / Kieran McBride
Free papers (8 mins presentation / 2 mins discussion)
Abstract 1
THE SUBCLAVIAN APPROACH TO THE TREATMENT OF MALIGNANT SUPERIOR VENA CAVA OBSTRUCTION WITH THE SELF-EXPANDING WALLSTENT
J H Miller, K McBride. Department of Radiology, Royal Infirmary of Edinburgh, Scotland, UK.
PURPOSE: To describe and demonstrate the efficacy of the percutaneous subclavian approach to stenting of symptomatic malignant superior vena cava obstruction with the self-expanding Wallstent endoprostheses.
MATERIALS and METHODS: 9 patients (age range 26-89 years) with malignant SVCO referred for interventional management over a three year period underwent central venography and deployment of a self-expanding Wallstent. 21 patients were approached using the subclavian route. Histology was available in all but 2 patients and included non-small cell lung carcinoma (n=7), small cell carcinoma (n=5), metastases (n=4), lymphoma (n=2), sarcoma (n=2) and mesothelioma (n=1). Retrospective analysis of the clinical records was used to assess symptom free survival and symptom recurrence.
RESULTS: All patients reported an improvement in symptoms within 24 hours of the procedure. Complications in the subclavian group were forward migration on deployment (n=2). No cases of pneumothorax, haemothorax, puncture site haematoma, pulmonary embolus, early post-stent thrombosis in- situ, infection, distant migration or procedure related deaths were encountered. The stent was used to exclude thrombus in the contralateral brachiocephalic vein (n=4). Primary patency (freedom from symptom recurrence) was obtained in 9 out of 10 patients to death and 9 out of 11 remaining patients to date with a mean follow-up of five months.
CONCLUSIONS: The subclavian route provides greater local control of hardware with no increase in complications and similar rates of patency compared with more conventional approaches. This is now our approach of choice for deploying the Wallstent. It has not been described before.
Abstract 2
THE ROLE OF INTERVENTIONAL RADIOLOGY IN THE TREATMENT OF VENOUS THORACIC SYNDROME.
D Kinsella, J Coote, N Talbot, J Thompson. Royal Devon & Exeter Hospital.
PURPOSE: To assess the role of interventional radiology (thrombolysis and angioplasty) in the treatment of venous Thoracic Outlet Syndrome (TOS), in combination with decompressive surgery.
MATERIALS AND METHODS: Ten successive patients presenting over a four year period with primary axillo-subclavian venous thrombosis. Six patients were treated with local venous thrombolysis and adjunctive venous angioplasty was performed in two individuals. Outcome measures were post-operative arm symptoms and venography (in neutral and stressed positions).
RESULTS: Two patients had undergone previous decompressive surgery and were referred due to worsening symptoms. There was no venographic evidence of fresh thrombus. Six patients with an acute presentation were initially treated with local TPA, with rapid lysis of the thrombus. This revealed the characteristic underlying venous defect in the thoracic outlet. Two of these patients underwent angioplasty due to marked limb symptoms. In one patient it was not possible to position a lysis catheter in the subclavian vein. A further patient treated for forty-eight hours with heparin showed no evidence of residual thrombus. Post-operative venography was performed in eight patients. A residual venous defect was present in each case with evidence of compression in the stress position. Residual symptoms were present in each case; these were most marked in the two patients who had undergone previous surgery. The remaining eight patients experienced mild to moderate but not limiting symptoms. No patients experienced contra- lateral arm symptoms. There were no bleeding complications post thrombolysis.
CONCLUSION: The ideal management of patients with venous TOS is uncertain. Local venous thrombolysis is logical and should be performed as soon as possible after presentation. Pre-operative angioplasty is of doubtful benefit. The role of post-operative angioplasty/stenting has not been assessed in this study.
Abstract 3
TREATMENT OF SUPERIOR VENA CAVAL OBSTRUCTION COMPLICATED BY EXTENSIVE THROMBOSIS
Bhartia B, Robertson I & Kessel D. St James's University Hospital, Beckett St, Leeds LS9 7TF
PURPOSE: To assess the outcome of SVCO complicated by extensive venous thrombosis.
MATERIALS AND METHODS: A retrospective review of 14 patients with SVCO complicated by thrombosis of the superior vena cava +/- the brachiocephalic veins. Most patients had contraindications to thrombolysis and were treated by stenting +/- mechanical thrombectomy. Patients were followed up by questionnaire to the referring clinician. Outcome was scored from 0-3 according to the degree of symptom relief.
Complete symptom relief 0
Persistent symptoms not interfering with daily life 1
Persistent symptoms interfering with daily life 2
No relief of symptoms 3
RESULTS: Mechanical thrombectomy was of limited utility and residual thrombus was covered by stenting. 1 to 5 stents (mean 1.6) were deployed per patient. A single patient experienced a pulmonary embolism during stent deployment. The mean post treatment survival was 9 weeks (range 4-17weeks). The average symptom score following treatment was 0.4. Complete symptom relief (0) was achieved in 60% of patients with 40% having minor residual symptoms (1) of SVCO. No patients had significant residual symptoms (2,3). One patient developed stent occlusion due to tumour invasion 9 weeks after treatment, a further stent was deployed with complete relief of symptoms.
CONCLUSION: SVCO associated with extensive thrombosis is treatable even when thrombolysis is contraindicated. Useful palliation of symptoms until death is achieved in the majority of patients.
Abstract 4
ENDOVASCULAR THERAPY FOR SUBCLAVIAN VEIN THROMBOSIS
C Soh, DF Ettles, AA Nicholson, JF Dyet. Hull Royal Infirmary, Anlaby Road, Hull
PURPOSE: To assess the efficacy of endovascular therapy in the treatment of non-malignant subclavian vein thrombosis (SVT).
MATERIALS AND METHODS: 16 patients presenting with non-malignant SVT over a 4 year period were reviewed. In all cases initial treatment involved catheter directed thrombolysis with subsequent balloon angioplasty and stent placement in selected cases. Clinical success was defined as complete obliteration of thrombus with restoration of venous patency and return to baseline activity with minimal or no symptoms. Venous patency was assessed using duplex ultrasound or venography.
RESULTS: Successful thrombolysis was achieved in all 16 cases. While early re-thrombosis occurred in 4 patients, only one underwent repeat thrombolysis with adjunctive therapy. Following thrombolysis 7 patients had additional balloon angioplasty for subclavian vein stenosis and 4 of these went on to be stented because of suboptimal angioplasty results. Oral anticoagulation was commenced in 10 cases with duration ranging from 3 months to lifelong. Mean follow-up was 25 months (range 1 to 52) and two patients died of unrelated causes during the period. Persisting clinical success was achieved in 12 cases and included all patients treated by adjunctive PTA or stenting. Chest radiographs revealed fracture of 3 stents, but all remained patent.
CONCLUSION : Endovascular treatment of non-malignant SVT offers excellent initial and longer term success. Caution is however required with regard to subclavian vein stenting because of the potential risks of stent fracture.
Abstract 5
JUGULAR VEIN PUNCTURE: IS A TILTING TABLE NECESSARY?
Bhartia B, Kessel D & Robertson I. St James's University Hospital Beckett Street, Leeds LS9 7TF
PURPOSE: To assess the effects of table tilting and physiological manoeuvres on jugular vein size.
MATERIALS AND METHODS: A prospective ultrasound evaluation of the effects of augmentation manoeuvres on jugular vein size in 20 healthy volunteers. The cross-sectional area of the right internal jugular vein was measured at a fixed point relative to the clavicle. A 7.5MHz probe was used for all scans and the area calculated using the ellipse function. Measurements were performed with the patient supine and with table tilt (+5%, 0%, -5% & -10%). In addition the effects of passive and active leg elevation and Valsalva manoeuvre were assessed.
RESULTS: The cross-sectional area and percentage change in area relative to at least 3 measurements in the supine position were recorded (table 1).
Table 1
See abstract book
CONCLUSION: In practice -5% is an appropriate degree of tilt for jugular vein puncture, passive leg elevation produces a comparable degree of venous distension. This simple manoeuvre is effective and renders a tilting table unnecessary for central venous cannulation. Physiological manoeuvres result in an even greater augmentation in vein size, however these are difficult to sustain during venous puncture.
Abstract 6
CENTRAL VENOUS CATHETERS PLACED BY INTERVENTIONAL RADIOLOGISTS - TECHNIQUE MODIFICATIONS AND RESULTS
Peter K. Ellis, David D Kidney, Elizabeth Vogler, Larry-Stuart Deutsch. University of California, Irvine Medical Center, California
PURPOSE: Central venous catheter usage continues to increase, with their placement becoming part of the workload of Interventional Radiology in a number of institutions. We review our initial experience, our technical modifications and results of 830 catheter placements over an eight year period.
MATERIALS AND METHODS: From June 1989 to May 1997 we prospectively collected data on all central venous access procedures performed in the Interventional Radiology Department. Eight hundred and thirty catheters were placed in patients who ranged in age from 3 months to 97 years. The major indications for central venous access were the administration of oncology chemotherapy in 313, antibiotic/antifungal therapy in 260 and for hemodialysis in 143 patients respectively.
RESULTS: The procedure was technically successful in all 830 cases and the 30 day complication rate was 4.2% (35). We modified our technique in 2 significant ways during our experience. We now, by choice, access the lateral most point of the subclavian vein as distinct from the subclavicular portion. Secondly in December 1995 we changed from using an 18-gauge needle to the 21-gauge needle supplied with the micropuncture set (Cook, Bloomington, IN) for the initial venous puncture. Our pneumothorax rate declined considerably after this change from 2.6% (15 of 573 cases) to 0.78% (2 of 257 cases).
CONCLUSION: We strongly recommend the use of the smaller access needle, and a lateral approach to the subclavian vein, with image guidance (either venographic or ultrasound) when performing central venous catheterisation to minimise complications.
UROLOGICAL INTERVENTION Moderator: Mike Collins / Sami Moussa
Free papers (8 mins presentation / 2 mins discussion)
Abstract 7
MALIGNANT URETERIC OBSTRUCTION: ANTEGRADE OR RETROGRADE STENT PLACEMENT?
N C Cowan, I McCafferty, S J Holt, M J Cowan, D W Cranston. Oxford Urological Imaging (OUI), The Churchill Hospital, Oxford, U K.
PURPOSE: To determine the optimum route for double pigtail stent placement for the relief of malignant ureteric obstruction.
MATERIALS AND METHODS: A prospective study was performed on a consecutive series of 25 patients, [15 male, 10 female] with malignant ureteric obstruction, over a 20 month period. Retrograde stent placement was attempted on 41 ureters in 25 patients. Procedures were performed using a flexible cystoscope and digital C-arm fluoroscopy, under intravenous sedation and analgesia by radiologists in the uroradiology suite. Antegrade stent placement was performed on all unsuccessful cases.
RESULTS: Retrograde stent placement was successful in 56% of ureters attempted [23/41]. Antegrade stent placement was successful in 94% [17/18] of the remaining 18 ureters. Causes of failure of retrograde stent placement included failure to identify the ureteric orifice [16], impassable UVJ stricture [1], impassable upper third ureteric stricture due to pyeloureteritis cystica [1].
CONCLUSION: If imaging studies identify ureteric orifice involvement by tumour, the antegrade approach should be the initial method of choice. Nephrostomy followed by antegrade stent placement is the preferred method of treatment for patients presenting with acute renal failure and malignant obstruction. The retrograde route is preferred for patients presenting less acutely with elevated serum creatinine or pain.
Abstract 8
ACCURATE PERCUTANEOUS ACCESS OF NON-DILATED CALYCES - THE ADVANTAGES OF GASEOUS CONTRAST MEDIA.
U Patel. Dept. of Radiology, St.George's Hospital and Medical School, London, SW17 0QT, United Kingdom
PURPOSE: Safe, accurate access of the non-dilated calyx remains a challenge. The density of iodinated contrast media means that in the prone position it empties out of the posterior calyces and down the unobstructed ureter within minutes, providing only transient calyceal visualisation and distension. Forceful or repeated contrast injection merely provokes increased peristalsis. In comparison buoyant, light contrast agents e.g. air or C02, seek out non-dependent calyces and should have particular advantages in unobstructed, undilated kidneys. The period of opacification and distension was compared using iodinated and buoyant agents.
MATERIALS and METHODS: Patients with non-dilated calyces on Ultrasound and Intravenous pyelography) requiring percutaneous access were studied. First, direct needle entry (22G) was made into the renal pelvis. Baseline renal pelvic pressure was measured and antegrade pyelography carried out to exclude obstruction. Iodinated contrast was then injected until a suitable target calyx (posteriorly placed) was seen. Volume of contrast necessary and period of visibility recorded. Experiment repeated with gas and similar recordings taken. 18G Needle entry gained into target calyx.
Results: Of 15 renal units studied so far iodinated contrast opacified target calyx for <2 mins, compared to a mean of 13 mins (range 2-30 mins) for gas. Gas also results in greater distension. Target calyx entry successful at first attempt in all cases. All were unobstructed and had renal pelvic pressures <12cm H20.
CONCLUSION: Carefully introduced gaseous contrast media is significantly better than iodinated contrast for calyceal visualisation and distension in non-dilated systems; and allows first pass percutaneous access into all non- dilated kidneys. Details of technique and equipment will be presented.
Abstract 9
PRIMARY ANTEGRADE URETERIC STENTING - SUCCESS RATE, COST ADVANTAGES AND TECHNICAL FACTORS
U Patel. Dept. of Radiology. St George's Hospital and Medical School, London, SW17 0QT, U.K.
PURPOSE: Conventionally antegrade ureteric stenting is performed after a few days of decompression because of ureteral tortousity and mucosal oedema. Primary stenting promises cost and bed occupancy savings and has been studied prospectively.
MATERIALS AND METHODS: Patients with obstructive hydronephrosis were studied. Calyx for puncture selected using gas contrast guidance, and stricture entry gained using shaped catheter and curved hydrophilic wire (first choice equipment);and a stent inserted over a stiff wire. End-point measurements : successful ureteric stenting(fluoroscopic and/or clinical assessment), procedural time and additional equipment used. Cost advantages evaluated.
RESULTS: So far 36/44(81%) ureters (Group 1) have been successfully, primarily stented. In 28/36 nephrostomy removed within 1 day. Chronicity of obstruction, ureteral tortousity or access route(upper v. lower pole) did not influence success. First choice equipment alone successful in the majority (20/36). Additional equipment frequently used were VanAndel dilatation catheters and peelaway sheaths. Hydrophilic catheters, Balloons and shapable wires were rarely necessary (6/25, 1/25,1/25 respectively). The remainder (8/44: Group 2) stented successfully as a second procedure - after a mean of 4 days external drainage. Screening time was mean: 12.6mins(Group 1) vs. 14.8mins (Group 2). In this hospital there was a minimal saving of £720 per successful patient.
CONCLUSION: The majority of obstructed ureters (81%) can be stented without preliminary drainage, and using simple equipment. Chances of success cannot be predicted from pre-morbid factors. Improvement in bed occupancy and patient costs is significant.
Abstract 10
EXTRA-ANATOMIC URINARY STENTING FOR URETERIC OBSTRUCTION
Irving HC, Eardley I, Lloyd SN, Joyce AD. St James's University Hospital, Leeds, UK.
PURPOSE: Ureteric stent insertion via conventional antegrade and retrograde approaches may be impossible due to ureteric occlusion by tumour. Conservation of renal function via percutaneous nephrostomy is an option, but external tube drainage detracts from the quality of remaining life. Extra-anatomic urinary diversion is an alternative, and we wish to report our experience of using a modification of the technique originally described by others (1 & 2).
MATERIALS and METHODS: We have placed 17 extra-anatomic stents in 11 patients with ureteric obstruction following unsuccessful attempts to pass ureteric stents via antegrade and retrograde routes. One end of a double- pigtail stent was placed in the renal pelvis via a percutaneous nephrostomy, the stent was tunnelled subcutaneously, and the distal end inserted into the bladder.
RESULTS: Urinary diversion was successful in all patients. 2 patients survived more than one year with stent changes at 6 monthly intervals, whilst 4 patients remain alive with functioning stents, 3 patients have died from malignant disease with stents in situ, and in 4 patients stents were replaced by percutaneous nephrostomies because of problems with leakage or infection.
CONCLUSION: In the face of impassable ureteric obstruction, extra-anatomic stent placement provides a therapeutic alternative to longterm percutaneous nephrostomy. However, careful patient selection is necessary as complications may occur.
References
1. Ahmadzadeh M. Clinical Experience with Subcutaneous Urinary Diversion: New Approach Using a Double Pigtail Stent. Br J Urol 1991, 67,596-599
2. Lingham et al. Subcutaneous Urinary Diversion: An Alternative to Percutaneous Nephrostomy. J Urol 1994, 152, 70-72
Abstract 11
OUTPATIENT URETERIC PROCEDURES USING A FLEXIBLE CYSTOSCOPE COMBINED WITH DIGITAL C-ARM FLUOROSCOPY PERFORMED BY RADIOLOGISTS
Cowan NC, McCafferty IJ, Holt SJ, Cowan MJ, Cranston DW. Oxford Urological Imaging (OUI), The Churchill Hospital, Oxford, U.K.
PURPOSE: To evaluate the combined use of the flexible cystoscope with C- arm digital fluoroscopy for outpatient retrograde ureteric procedures.
MATERIALS AND METHODS: Flexible cystoscopy and digital fluoroscopy were used in the interventional radiology suite for retrograde ureteropyelography and stent placement. Procedures were performed under intravenous sedation and analgesia, with oral antibiotic prophylaxis on an outpatient basis by radiologists.
RESULTS: A total of 223 procedures were performed on 157 adult patients (83 males and 74 females) over a 1 year 9 month period. Procedures included 80 retrograde ureteropyelograms, 63 retrograde stent placements and 74 retrograde stent replacements. The success rate for retrograde pyelography was 90% (72/80). The success rate for retrograde stent placement for malignant obstruction was 67% (20/30) and for stone obstruction 91% (20/22). Immediate complications included rigors and sepsis (1), ureteric perforation (1), stent misplacement (1), torn calyx (1).
CONCLUSION: Using this method retrograde ureteropyelography and retrograde ureteric stent placement may be performed satisfactorily on an outpatient basis. Implementation of this technique has decreased the following: the waiting list for urological services, hospital admissions, general anaesthetics, theatre time, the cost of investigations, and the complication rate for ureteric procedures.
Abstract 12
TREATMENT OF RECURRENT BULBAR URETHRAL STRICTURES WITH REMOVABLE METALLIC STENTS
Johnstone RD, Machan LS. Department of Radiology, University of British Columbia Hospital, Vancouver, B.C. Canada.
PURPOSE: To evaluate the effectiveness of a removable nitinol stent as treatment for urethral strictures recurrent after endoscopic dilatation or urethotomy
MATERIALS AND METHODS: 13 men aged 31-75 years (mean 49.2yrs) with refractory bulbar urethral strictures were treated by insertion of a removable articulated nitinol stent. All patients had symptoms of bladder outflow obstruction refractory to endoscopic dilatation or urethotomy.
RESULTS: Stents were easily inserted in 13/13 men without complication. One stent migrated distally and was easily replaced. Three men could not tolerate the presence of a urethral stent and their stents were easily removed at 20-28 days (mean 23 days). In the remaining 10 men stents were satisfactorily tolerated and 9 had their stents removed after a treatment period of 86-270 days (mean 165.4). One patient has refused removal of his stent. Obstructive symptoms are completely resolved in 9, and remarkably improved in 1 of these 10 patients at 10.3-49.7 months follow up (mean 22.2 months).
CONCLUSION: Temporary urethral stenting is a simple and effective therapy for difficult recurrent bulbar urethral strictures. It allows easy removal in men who do not tolerate the presence of a stent.
VASCULAR INTERVENTION Moderator: Tony Nicholson / Bill Shaw
Free papers (8 mins presentation / 2 mins discussion)
Abstract 13
PREDICTORS OF SUCCESS FOR ILIAC STENTS
PA Gaines, TJ Cleveland, S Nawaz, P Chan.
Sheffield Vascular Institute, Northern General Hospital, Sheffield S5 7AU.
PURPOSE: To evaluate the factors that affect the outcome of stenting in the iliac system. Design: Retrospective study
MATERIALS and METHODS: 140 patients (163 limbs) underwent iliac artery stenting in the period 1994-1997. 98 occlusions and 65 stenoses were treated, either with primary stenting (n=129) or after failed balloon angioplasty (n=34). Median follow-up was 18 months (1-66). The following factors were analysed for their affect on outcome by multifactorial analysis on the SPSS software package: gender, age, clinical presentation, ankle-brachial pressure index, type of lesion, length of lesion, site of lesion, primary stenting or failed balloon angioplasty, stent type, blood pressure, smoking, diabetes mellitus, aspirin treatment, cholesterol, residual gradient, whether the stent was overhanging the contra-lateral iliac artery and run-off.
RESULTS: The immediate success was 95%. The cumulative primary patency was 94% at 12 months and 85% at 36 months; the primary assisted patency was 96% at 12 months and 94% at 36 months and the secondary patency was 97% at 12months and 94% at 36months. Factors significantly affecting outcome were: residual pressure gradient (>10mmHg) and treatment with aspirin (p<0.05).
CONCLUSION: Stenting in the iliac system has good short term and long term patency rates with low morbidity and mortality. Factors that might improve results further are: to ensure patients are taking aspirin prior to stenting and to ensure that any residual pressure gradient is abolished at the time of treatment.
Abstract 14
ILIAC ARTERY RUPTURE DURING PTA: STENT GRAFT TREATMENT OF A RARE COMPLICATION
MA Tomlinson, N Sellars, JA Reekers, R Balm, T Cleveland, AM Belli, TM Buckenham.
Department of Vascular Radiology, ST George's Hospital, London UK
PURPOSE:. To report the technical feasibility and outcome for percutaneous endovascular stent graft treatment of arterial ruptures complicating Iliac PTA in 6 patients from 3 centres.
MATERIALS & METHODS: Mean age of patients was 62.5years (range 42-82) with a 3:3 ratio for sex, side of rupture and stenosis: occlusion. Clinical indication was short distance claudication in 5 and rest pain with ulceration in one. Primary procedures performed were 2 PTAs and 4 primary stents, using 7 or 8mm balloons. Vessel rupture occurred in 1 common iliac and 5 external iliac arteries. Features associated with rupture were sudden hypotension and pain after stenosis dilatation. Upon confirmation immediate balloon tamponade was employed for 10 -30 minutes; none sealed spontaneously. Stent grafts deployed were 3 Passager (12x100mm, 10x100mm and 10x60mm), 1 Cragg Endopro (10x100mm), and 2 polyester fabric-covered Sinus stents (both 8x90mm).
RESULTS: All leaks sealed immediately. Five stent grafts remain patent with complete resolution of symptoms though 2 suffered access site complications: 1 required surgical repair of the CFA, the other coil embolisation of a distal EIA pseudoaneurysm at a high puncture site. One occluded, underwent successful surgical thrombectomy, reoccluded and required femoro-femoral crossover.
CONCLUSIONS: Endovascular stent grafting of acute arterial rupture complicating iliac PTA is technically feasible and is the treatment of choice. It resolves the acute situation rapidly, avoids emergency anaesthesia and surgery in unstable high risk patients, and restores the normal anatomical circulation. The EIA is most at risk of rupture. Before performing PTA/stenting one should ensure that appropriately sized stent grafts are immediately available for use should such an emergency arise. Careful attention should be directed to the large puncture site.
Abstract 15
PERCUTANEOUS ENDOVASCULAR GRAFT REPAIR OF COMMON ILIAC ANEURYSM, OUR THREE YEAR EXPERIENCE.
Sellars NA, O'Sullivan GJ, Sandu C, Belli A-M, Buckenham TM. Department Of Radiology, St. George's Hospital,, London, U.K.
PURPOSE: To report our experience with percutaneous polytetrafluroethylene (PTFE) self expandable endovascular grafts in excluding common iliac artery (CIA) aneurysm from the circulation.
METHODS: Between June 1995 and April 1998, eleven CIA aneurysms (7 atherosclerotic, 3 anastomotic and 1 pseudoaneurysm) were treated in eight patients by percutaneous placement of fifteen stent grafts. The endovascular grafts (4 Cragg Endopro (Mintec Ltd) and 11 Passager stents (Boston Scientific Ltd) were all coated PTFE and self expandable. There were five cases in which the CIA aneurysm involved the origin of the internal iliac artery (IIA). In four of these cases the IIA was embolised using coils and in one case coils and Polyvinyl alcohol particles. Intra- arterial pressures and check angiograms were performed on all patients immediately post procedure. Follow-up was by colour doppler range 6-24 months with an average of 14 months,.
RESULTS: Immediate Results: All fifteen stent grafts were deployed successfully across the 11 CIA aneurysms. Technical success in stent placement was 100%, however clinical success was 73% with two primary endoleaks noted on the immediate post procedure angiogram. One of these patients was successfully treated two weeks later with further embolisation of the IIA. The other patient has a small leak which has not closed, further intervention is planned. One patient developed a thrombosis in the right leg after treatment of the left CIA aneurysm and required immediate surgery and a left to right femoro-femoral cross over. No procedure related deaths occurred. The results of 6-24 months, mean 14 month follow- up with doppler ultrasound will be presented.
CONCLUSION: Percutaneous stent grafting provides a minimally invasive means of excluding non infected iliac aneurysm. It appears to be a safe and effective treatment option.
Abstract 16
OUTCOME OF ILIAC PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA) WITH AND WITHOUT THE USE OF STENTS IN PATIENTS WITH INTERMITTENT CLAUDICATION.
GC Beattie, J Brittenden, I Gillespie*, K McBride**, G McInnes, AW Bradbury. Department of Vascular Surgery Radiology, University Department of Surgery and Department of Radiology*, Edinburgh Royal Infirmary.
PURPOSE: Despite the lack of controlled data supporting endovascular treatment of iliac disease in patients with intermittent claudication, there has been an increase in iliac PTA, particularly stenting, in recent years. To assess the clinical outcome of iliac PTA with and without the use of stents in patients with intermittent claudication.
MATERIALS and METHODS: Analysis of a prospectively gathered database of iliac PTAs performed between 1991 and 1997.
RESULTS: 331 iliac PTAs were performed for claudication, 96 (29%) were stented. Stents were not used prior to 1991. The use of iliac stents is associated with an increased complication rate with no improvement in the initial or medium term clinical success.
Stent n = 96 Angioplasty alone n = 235
Occlusion 18 (19%)* 15 (6%)*
Technical failure 7 (7%) 14 (6%)
Clinical success 78 (81%) 201 (85%)
Morbidity 14 (15%)* 7 (3%)*
Median follow-up (range) 14 (1-59) 30 (1-85)
Clinical Outcome: Better 59 (70%) 126 (65%)
No change 11 (13%) 30 (15%)
Worse 14 (17%) 38 (20%)
CONCLUSION: These results do not support the increased expense and complication rate associated with the routine use of iliac stents. Iliac PTA is associated with a high initial success rate. However, medium follow- up results are similar to that reported in the literature for conservative management. There is a need for a randomised control trial to evaluate the role of iliac PTA with and without stents in the management of intermittent claudication.
Abstract 17
ENDOVASCULAR REMOTE ENDARTERECTOMY IN FEMOROPOPLITEAL OCCLUSION.
M Gibson, MS Whitley*, TS Magee*, RB Galland*, EPH Torrie. Departmentsof Radiology and Vascular Surgery*, Royal Berkshire Hospital, London Rd, Reading, Berkshire RG1 5AN
PURPOSE: To evaluate a new minimally invasive technique using a ring stripper and Moll ring cutter for the treatment of long femoropopliteal occlusions.
MATERIALS AND METHODS: The popliteal artery is cannulated using a smart needle and the distal end of the occlusion defined. From an arteriotomy in the SFA a ring stripper is advanced antegradely in the dissection plane, under radiological control, until the occlusion is passed. A Moll ring cutter is then used to transect the distal intimal core and the occluding core is removed. A guide-wire is passed retrogradely from the popliteal artery to the arteriotomy and a balloon-expandable stent is placed antegradely to tack down the distal circumferential intimal flap. The arteriotomy is then extended into the CFA and closed with a vein patch to ensure good in-flow. 33 long femoropopliteal occlusions and patent distal popliteal arteries with at least a one-vessel run-off were treated. All had disabling claudication.
RESULTS: The initial success rate was 27/33 cases (82%). All patients were discharged within 24 hours. The patency rate at 6 weeks was 25/33 (76%). Those in whom the procedure failed underwent femoropopliteal bypass. The longer-term results from this on-going trial will be presented.
CONCLUSION: The technique is safe and effective. After the learning phase is passed the initial success rate is high and compares favourably with similar new techniques.
Abstract 18
FEMOROPOPLITEAL STENT GRAFTING: 2 YEAR FOLLOW-UP OF A PROTOTYPE DEVICE
Kessel D, Robertson I, Scott DJA, Wijesinghe LT, Raat H, Nevelsteen A, Stockx L. St James's University Hospital, Beckett Street, Leeds LS9 7TF
PURPOSE: To evaluate a novel percutaneously placed femoropopliteal stent graft
MATERIALS and METHODS: A prospective study using a balloon mounted expandable PTFE graft to treat long segment SFA disease. 20 patients with severe intermittent claudication were enrolled into the trial at 2 sites. Inclusion criteria were disease free proximal and distal anchor sites with a minimum diameter of 4 mm and at least two patent crural vessels. The diseased segments were traversed using standard endovascular techniques and then predilated to allow passage of the graft. Intravascular ultrasound was performed to determine vessel diameters and to assess deployment. Follow up with Duplex ultrasound was performed at 1,3,6, 12 and 24 months. A doubling of velocity was taken to represent a 50% stenosis and indicate graft failure.
RESULTS: 14 patients were successfully treated. 6 patients were excluded, 5 by the study protocol and 1 technical failure. ABPI rose from 0.6 pre- treatment to 1.0. The treated limbs became asymptomatic. Two acute failures were related to graft compression. Late failures were associated with NIH at the graft artery interface.12-month primary, primary assisted and secondary patency rates of treated patients were 29%, 50% and 64%. The two- year patency rates will be presented.
CONCLUSION: Endovascular stent grafting of the femoral segment is a straightforward procedure in selected patients. Patency rates are disappointing and are significantly inferior to surgical bypass grafting.
Abstract 19
EARLY RESULTS OF STENTING USING THE INSTENT VASCUCOIL
Dyet JF, Ettles DF, Nicholson AA. Royal Hull Hospitals, Hull Royal Infirmary.
PURPOSE: To assess the early results of femoro-popliteal stenting using the Instent Vascucoil.
MATERIALS & METHODS: 59 stents were implanted in 23 limbs of 22 patients. Age range was from 44 years to 91 years (mean 63.75). There were 17 males and 5 females. Minimum number of stents used was 1, maximum 6. Indications for stenting were:
4 as part of a randomised trial
6 for recurrent disease after previous endovascular treatment
12 for angioplasty result with either abrupt occlusion or 50% loss of luminal gain
RESULTS: All patients have been followed up by duplex at 1 month, 3 months, 6 months and one year. At the time of presentation all patients will have a minimal follow-up of 6 months. Of the 22 patients, 1 occluded at 4 months, 1 has new disease above the stent and 1 has intimal hyperplasia within 6 stents. Primary patency is thus to date 86.4%.
CONCLUSION: Femoro-popliteal stenting appears to offer improved results over angioplasty but the results of a randomised trial of stents against PTA are awaited.
HEPATOBILIARY and GASTROINTESTINAL INTERVENTION Moderator: Peter Rowlands, Derrick Martin
Free papers (8 mins presentation / 2 mins discussion)
Abstract 20
INTERPLEURAL BLOCK FOR ANALGESIA DURING PERCUTANEOUS BILIARY PROCEDURES.
R.Razzaq, R.E.England, D.F.Martin. Department of Radiology, South Manchester University Hospitals, Withington Hospital, Manchester, M20 2LR UK
PURPOSE: To describe a technique of interpleural block for regional anaesthesia during biliary intervention and present our preliminary results.
MATERIALS and METHODS: In the left lateral decubitus position an epidural needle is inserted under local anaesthesia 8-10cm from the midline in the right 8th intercostal space. This is advanced, with saline running via a three way tap, through the chest wall. Entry into the pleural cavity is indicated by loss of resistance to the flow. An epidural catheter is passed into the pleural cavity. 20mls of 1% lignocaine are injected and the catheter is left in situ during the procedure. The patient remains in the decubitus position for 10 minutes after injection. Continuous pulse and O2 saturation monitoring and intermittent measurement of BP is performed. An assessment of discomfort during the procedure is made objectively by the nurse and radiologist according to a four point (0 to 3) scale.
RESULTS: The technique has been used in 19 patients. Effective analgesia throughout the procedure was provided in 14 patients who had a pain score of 0 or 1. One patient required sedation due to anxiety but experienced no pain. Four patients did experience some pain during the procedures but all settled with small doses of analgesia. No adverse effect was detected.
CONCLUSION: Interpleural block is a safe and efficacious method of pain control during percutaneous biliary procedures. It can be performed easily by radiologists requiring only simple interventional skills.
Abstract 21
PLASTIC PROSTHESES AND METAL SELF EXPANDING STENTS FOR PALLIATION OF DYSPHAGIA IN PATIENTS WITH INOPERABLE OESOPHAGEAL CANCER.
C Alexiou*, AR Manhire, M Watson*, J Stutz , D Beggs*, FD Salama*, WE Morgan*. Radiology and Thoracic Surgery * Units , City Hospital, Nottingham NG5 1PB, UK.
PURPOSE: To evaluate the outcome of surgical plastic prostheses (Celestin) and metal self expanding stents for palliation of dysphagia in inoperable oesophageal cancer.
MATERIALS AND METHODS: 176 patients had either a Celestin tube or metal stent inserted between 1990 and 1997. The plastic prostheses were positioned through a gastrostomy at thoracotomy (on discovery of a non resectable tumour) or at laparotomy. The metal stents were inserted radiologically under fluoroscopic guidance. Ability to swallow was expressed as a dysphagia score. Follow up occurred at six weeks intervals until death.
RESULTS: 101patients with a mean age of 68.4 years had a Celestin prosthesis (group I) and 75 with a mean age of 70.1 years received a metal oesophageal stent of various types (group II). Technical success rate of insertion of metal stents was greater than the celestin group (100 v 97%: n.s.). Mean dysphagia score was similar for the two groups (n.s.). Prosthesis related complications were more frequent in group I than in group II, (p=0.03). Six patients died as a result of oesophageal perforation and leak in group I but none in group II,( p=0.03). Dysphagia improvement was less in group I than in group II,( p=0.01). There were no statistically significant differences, in the late recurrence of dysphagia, re-intervention and mean survival rates between the two groups.
CONCLUSION: These data suggest that use of metal self expanding stents is associated with significantly lower prosthesis related morbidity and mortality and provide more effective immediate palliation of dysphagia than the Celestin prosthesis.
Abstract 22
TREATMENT OF ACHALASIA OF THE OESOPHAGUS WITH FLUOROSCOPIC GUIDED BALLOON DILATATION. MB Matson, MG Cowling, M Farrugia, W Owen*, AN Adam. Departments of Radiology and Surgery*, Guy's Hospital, London
PURPOSE: To evaluate the outcome and complications of fluoroscopically guided balloon dilatation of the oesophagus for treatment of achalasia.
MATERIALS AND METHODS: Thirty-six patients (17 male: 19 female, mean age 55) underwent 47 balloon dilatations under sedation. The ball oon size was initially 20mm in all patients, increasing incrementally until blood was seen on the balloon. The final balloon size was 20mm on 2 occasions, 30mm on 36, 35mm on 5, 40mm on 3 and 50mm on 1 occasion. All patients had contrast oesophagography following the procedure to look for perforation.
RESULTS: No patient suffered a complication during the procedure. Thirty- four patients reported symptomatic relief initially. The 2 patients who did not have symptomatic relief (after 2 dilatations in 1 patient and 1 dilatation in the other) underwent treatment with surgical myotomy. Twenty- five patients had prolonged symptom relief for a mean period of follow-up of 22 months. Nine patients had recurrent dysphagia after a mean period of 6.5 months. All were treated with repeat balloon dilatation, resulting in symptomatic relief in 8 patients followed up for a further mean period of 11 months. The remaining patient had initial improvement from the second balloon dilatation, but required a further dilatation after 23 months, resulting in symptom relief.
CONCLUSION: Balloon dilatation is a safe and effective treatment for achalasia of the cardia. Recurrent symptoms can be treated with repeat dilatation.
Abstract 23
PERCUTANEOUS GASTROSTOMY IN PATIENTS WHO FAIL OR ARE UNSUITABLE FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY F. Thornton, J. Varghese, FP McGrath, MJ. Lee. Academic Department of Radiology. Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin.
PURPOSE: Percutaneous endoscopic gastrostomy (PEG) is widely performed but is not possible or fails in some patients. We studied the use of percutaneous gastrostomy (PG) in these selected patients.
MATERIALS & METHODS: 25 patients (M:F, 14:11, mean age 74, range 21-92) who either failed PEG (10) or where PEG was not possible (15), underwent PG. PEG failure was due to lack of transillumination (7/10) and obesity (3/10). PEG was not possible due to recent oral surgery (2/15), oesophageal stricture (5/15), colonic interposition (2/15) and previous upper GI tract surgery (6/15). N/G tubes were used for stomach distension where possible otherwise gas granules were administered. T-fastener gastropexy was used in all patients and 14-18 Fr catheters inserted.
RESULTS: PG was successful in 23 of 25 patients (92%). Fluoroscopic guidance was used in 19 patients and CT guidance in 6. In patients who failed to transilluminate, the stomach was located in a high left subcostal position and required intercostal PG placement in 4/7 patients. PG failed in two patients. The tube was inadvertently placed in the peritoneal cavity in one patient with a high subcostal stomach in whom a subcostal approach was used, but was removed the next day without feeding. In a second patient, CT guided PG failed because of inability to distend the stomach remnant. There were no major complications and PG tubes remained in situ for 3 weeks - 9 months.
CONCLUSION: PG is often technically more difficult after failed PEG. CT guidance, intercostal tube placement and T-fastener gastropexy may be required.
Abstract 24
PERCUTANEOUS STENTING OF HILAR STRICTURES IN THE BILIARY TREE; RESULTS, COMPLICATIONS, FOLLOW UP. MJ. Lee, D. Malone, S. Abbass, M. Blake, R. Gibney, FP Mc Grath. Academic Department of Radiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin.
PURPOSE: We reviewed patients with hilar strictures who were percutaneously stented to correlate Bismuth classification and type of stenting with outcome.
METHODS & MATERIALS: 31 patients (M:F, 15:14, age range 55-87, mean age 71) had percutaneous metal stents placed for hilar strictures. Underlying diseases included cholangiocarcinoma in 17, GB cancer in 7 and metastases in 7. Bilateral stents were placed in 7, right sided stents in 12 and left sided in 12. Wallstents (10mm x 90mm) were used in all patients. Bismuth classification was Stage 1 (12/31), Stage 2 (5/31), Stage 3A (5/31), Stage 3B (3/31), Stage 4 (6/31)
RESULTS: Metal stents provided effective palliation in 23/31 (74%) with a 10 patency of 129 days (range 28-370) and 20 patency of 192 days (range 32- 481). Metal stents failed to provide palliation in 8 patients (5 Stage 4, 2 Stage 3A, 1 Stage2). Overall patency was significantly different (P<0.01) for bilateral (mean patency 267 days) vs unilateral (mean patency 148 days) stents. Overall mean patency by Bismuth stage was 215 days (1), 155 days (2), 220 days (3A), and 96 days (3B). A mean of 3 procedures was required per patient, mean hospital stay was 19 days and 30 day mortality was 22%. Complications (sepsis, bile leak, inadequate stenting and arterial fistula) occurred in 25% and were treated percutaneously.
CONCLUSION: Patients with hilar strictures require a significant time commitment. Bilateral stenting is associated with a better long-term patency. Patients with Bismuth Stage IV lesions should not be treated aggressively because of high failure rate.
Abstract 25
THE USE OF METALLIC STENTS IN THE TREATMENT OF MALIGNANT GASTRODUODENAL OBSTRUCTION.
A Watt, J Tuson, JG Moss, RD Edwards. Department of Radiology, Gartnavel General Hospital, Glasgow UK
PURPOSE: To assess the safety and efficacy of self-expanding metallic stents in the treatment of malignant gastroduodenal obstruction.
MATERIALS AND METHODS: 7 patients (median age 64 y, range 45-84) with inoperable malignant gastroduodenal obstruction were referred for treatment during a 2 year period from January 1996. Pathology included neoplasia of oesophagus (1), stomach (3), gall bladder (1) or pancreas (2). In 3 patients recurrent disease was responsible for symptoms and in the remainder, upper gastrointestinal obstruction was the presenting feature. Lesions were situated in the gastric antrum / proximal duodenum (4), second part of duodenum (2) and third part of duodenum (1). All patients were assessed by contrast studies and endoscopy. The procedure was performed with intravenous sedation (6) or general anaesthesia (1). All patients were treated by insertion of large diameter Wallstents; 16mm (1) and 22 mm diam (6). Stents were placed via the peroral route in 4 cases and through a percutaneous gastrostomy in3 cases. Patency was confirmed with a contrast study within 24 hours.
RESULTS: All patients experienced symptomatic relief and were able to swallow fluids within 24 hours. There were no significant procedural complications. All patients were able to take a low residue diet and a normal diet was possible in 3 cases. Patency was maintained in 5 cases until death or last follow-up and median patency was 60 days (30-77 days). Recurrent symptoms developed in 1 patient with a 16mm Wallstent, after 65 days due to tumour overgrowth.
CONCLUSIONS: Large calibre self-expanding metallic stents can provide prolonged, effective palliation of malignant gastroduodenal obstruction.
Abstract 26
THE ROLE OF CO2 ARTERIOGRAPHY IN THE INVESTIGATION OF ACUTE GASTROINTESTINAL HAEMORRHAGE
C Sandhu, N Sellars, T Buckenham, AM Belli. Department Of Radiology, St. George's Hospital,, London, U.K.
PURPOSE: To determine the benefits of CO2 arteriography compared to standard iodinated contrast arteriography in the identification of bleeding sources in the GI tract.
MATERIALS and METHODS: Over a 3 month period 11 consecutive patients referred for angiography for the investigation of active GI haemorrhage underwent both iodinated contrast arteriography (Niopam 300) and CO2 arteriography (AngioDynamics CO2JECT). Selective mesenteric catheterisation was performed in all cases.
RESULTS: Eight male and three female patients, with a median age of 64 years (range 29-81 years) were studied. In total N= 30 vessels were imaged using Niopam 300 and of these N=24 were also imaged using carbon dioxide. Potential sources of haemorrhage were identified in 4 cases using iodinated contrast. Two of these had active bleeding demonstrated on the iodinated contrast study and this was seen on one of the CO2 arteriograms. The other two patients had an abnormality demonstrated on iodinated contrast angiography although no active haemorrhage was seen at the time. CO2 angiography in these two patients showed no active haemorrhage and failed to demonstrate the abnormality.
CONCLUSION: Although claims have been made that the physical properties of CO2 may be advantagous in identifying sources of bleeding, in this study CO2 arteriography demonstrated no significant advantage over standard iodinated arteriography in the investigation of acute GI haemorrhage and its diagnostic capacity to identify a non- bleeding vascular lesion was inferior to iodinated contrast arteriography.
Abstract 27
AVOIDING THE COMPLICATIONS OF THROMBOLYSIS: WHAT CAN WE LEARN FROM NATALI? S.M. Thomas, P.A. Gaines on behalf of the Thrombolysis Study Group. Sheffield Vascular Institute, Northern General Hospital, Sheffield S5 7AU, England.
PURPOSE: NATALI is a voluntary database of patients undergoing peripheral vascular thrombolysis run on behalf of the TSG. The data set should allow analysis to identify predictors of outcomes and complications. These may be patient factors or related to the technique used.
MATERIALS AND METHODS: Since its inception on 1st January 1990, 798 thrombolysis events have been recorded. Details are collected on a wide range of factors: perceived risk factors; details of thrombolysis technique; complications; outcome; and adjunctive procedures. Using univariate and multivariate analysis factors associated with an increased risk of complications can be investigated.
RESULTS: Death and complications perilysis occur in 25.9% (n=207) of cases. Patient factors are the main influence on the risk of complications. Increasing age, use of aspirin and thrombolysis of grafts are significantly associated with an increased risk of complications after adjustment for confounders (p<0.05). Female sex, the presence of peripheral vascular disease and Fontaine class are of borderline significance. Other patient factors are not associated with any increased risk of complication. Radiological technique such as: agent used, sheath size, length of lysis, dose of lysis, use of heparin or adjunctive procedures, have no relationship to the rate of complications.
CONCLUSION: Case selection is the most important factor influencing the occurrence of complications. Radiological technique does not seem to influence the occurrence of complications.
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Last Update: 21st October 1998
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