Higher Technical Failure Rate Research Articles

Hepatic fibrosis: US elastography vs. MR elastography

Hepatic fibrosis is final results of a wide variety of types of liver injury and is a consequence of all chronic liver diseases and progresses more or less rapidly towards cirrhosis, and finally cancer. In terms of the tools used to quantitate fibrosis today, there are three kinds of tools; biochemical markers, conventional imaging, and functional imaging such as elastography (E) or stiffness imaging. Recent imaging tools for evaluation of hepatic fibrosis are US based techniques, MR based techniques, and perfusion imaging. US Elastography (USE) is classified into strain-based E and SW-based E. Strain-based E is subclassified into Static USE (Manual compression of the tissue) and Quasi-static USE (Physiologic vibrations (heartbeat, blood vessels pulse). SW-based E is subclassified into 1D such as fibroscan (Echosens), Point E such as virtual touch quantification (Siemens). ElastPQ (Philips) and 2D SWE such as supersonic shear imaging (Supersonic Imagine), and shear wave elastography (GE, Toshiba)). For the liver, USE is divided into 2 categories quasi-static E and shear wave based imaging. Quasi-static E is not popular. Shear wave based imaging is subdivided into two types based on generation method of shear wave: Controlled external vibration with a vibrator and acoustic radiation force impulse. Transient elastography is using mechanical push, and both ARFI imaging and supersonic shear wave elastography are using ARFI. Strengths of 1D SW-based elastography are the most extensively investigated technique with high portability. Limitations are no B-mode imaging, high technical failure rate (2.4-9.4%) and narrow applications outside of liver investigation. Strengths of point SW-based elastography are low technical failure rate ( In Summary, liver stiffness is determined by matrix deposition (fibrosis) and pressure change (hydrostatic, osmotic). Hepatic fibrosis (HF) is a consequence of all chronic liver diseases and progresses towards cirrhosis and finally cancer. Noninvasive diagnosis and staging is important clinical issue for hepatic fibrosis which is reversible. Elastrography is clinically acceptable for the prediction of liver fibrosis (≥F2) and confounders of stiffness measurement (intercostal approach to right lobe (S7/8), 1-3 cm below the liver capsule, biologic confounders can change stiffness values, fasting at least 2 hours, breath-hold at expiration). Elastography is one of important noninvasive methods to quantify HF more sensitively and objectively. USE is the first line examination for the assessment of HF. MRE is the second line examination, especially in cirrhosis. To avoid confounders of liver stiffness, comprehensive other imaging exams are needed.

Editor's Choice – A Comparison of Clinical Outcomes Between Primary Bypass and Secondary Bypass After Failed Plain Balloon Angioplasty in the Bypass versus Angioplasty for Severe Ischaemia of the Limb (BASIL) Trial

Chronic limb threatening ischaemia (CLTI) is a growing global health problem. The UK NIHR HTA funded BASIL trial is still the only randomised controlled trial to have compared a "bypass surgery first" with a "plain balloon angioplasty (PBA) first" strategy for the management of CLTI. In patients who were likely to survive for 2 years and had a suitable vein, primary bypass (PB) was associated with better clinical outcomes. Furthermore, PBA was associated with a high technical and clinical failure rate and many went on to have secondary bypass (SB). This study aimed at comparing clinical outcomes following PB and SB in the BASIL trial. Demographic, procedural, and outcome data were obtained from the BASIL case report forms. Outcomes were amputation free survival (AFS), limb salvage (LS), overall survival (OS), and freedom from revascularisation (FFR). The SB cohort comprises patients whose first trial intervention was PBA and who subsequently underwent bypass during follow up. The PB cohort comprises those patients whose first trial intervention was bypass. The 190 PB and 49 SB patients were well matched except that the SB patients were more likely to be current smokers. At a median of 7 years, PB was associated with better AFS (PB 60% vs. SB 40%; HR 1.58, p=.04), LS (PB 85% vs. SB 73%, p=.06), and OS (PB 68% vs. 51%, p=.06). FFR was equivalent (PB 53% vs. 53%, p=.3). In the BASIL trial, clinical outcomes following PB were significantly better than in patients undergoing SB after failed PBA. Prior to treating patients with CLTI with primary PBA, clinicians should consider that if this should fail, the outcome of attempted subsequent bypass is likely to be significantly worse than if PB were attempted.

Mo1440 The Pure Endoscopic Drainage of Pancreatic Pseudocysts in Children - a Safe and Eficient Method - Case Series

Mo1440 The Pure Endoscopic Drainage of Pancreatic Pseudocysts in Children - a Safe and Eficient Method - Case Series

A modified method for heterotopic mouse heart transplantion.

Mice are often used as heart transplant donors and recipients in studies of transplant immunology due to the wide range of transgenic mice and reagents available. A difficulty is presented due to the small size of the animal and the considerable technical challenges of the microsurgery involved in heart transplantation. In particular, a high rate of technical failure early after transplantation may result from recipient death and post-operative complications such as hind limb paralysis or a non-beating heart. Here, the complete technique for heterotopic mouse heart transplantation is demonstrated, involving harvesting the donor heart and its subsequent implantation into a recipient mouse. The donor heart is harvested immediately following in situ perfusion with cold heparinized saline and transection of the ascending aorta and pulmonary artery. The recipient operation involves preparation of the abdominal aorta and inferior vena cava (IVC), followed by end-to-side anastomosis of the donor aorta with the recipient aorta using a single running 10-0 microsuture and a similar anastomosis of the donor pulmonary artery with the recipient IVC. Following the operation the animal is injected with 0.6 ml normal saline subcutaneously and allowed to recover on a 37 ° C heating pad. The results from 227 mouse heart transplants are summarized with a success rate at 48 hr of 86.8%. Of the 13.2% failures within 48 hr, 5 (2.2%) experienced hind limb paralysis, 10 (4.4%) had a non-beating heart due to graft ischemic injury and/or thrombosis, while 15 (6.6%) died within 48 hr.

Systematic Review and Meta-Analysis of Randomized Controlled Trials Comparing Single Incision versus Conventional Laparoscopic Appendectomy

Single incision laparoscopic appendectomy (SILA) has been proposed as an alternative to conventional laparoscopic appendectomy (CLA). The aim of this study was to evaluate the safety and efficacy of SILA when compared with CLA through a systematic review. We performed an electronic search of EMBASE, PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) that compared SILA with CLA were included. Six RCTs met eligibility criteria, which included a total of 800 patients, 401 in the SILA group and 399 in the CLA group. There were no significant differences in terms of overall complications (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.59-1.47; p = 0.77). SILA had a higher technical failure rate (OR 3.30; 95% CI 1.26-8.65; p = 0.01) and required a longer operative time (mean difference [MD] 4.67; 95% CI 1.76-7.57; p = 0.002). SILA was associated with better cosmetic results (standardized MD -0.4; 95% CI -0.64 to -0.16; p = 0.001) and earlier return to normal activity (MD -0.64; 95% CI -1.09 to -0.20; p = 0.005), although these advantages should be taken with caution due to the small number of studies reporting these two items and the short follow-up in the evaluation of cosmetic results. There were no significant differences in terms of postoperative pain or length of hospital stay between groups. SILA is comparable to CLA in selected patients, although it is associated with a higher technical failure rate and longer operative time. Further randomized trials are needed to determine if SILA really offers benefits over CLA.

MR elastography of liver disease: State of the art

Hepatic fibrosis is a common result of different chronic liver diseases caused by viral infections, alcohol abuse, nonalcoholic fatty liver disease (NAFLD), autoimmune disease and metabolic/genetic disorders. Hepatic fibrosis is a dynamic process which can, in some cases, be reversible with effective treatment (1, 2). Otherwise, it can progress to more advanced stages including cirrhosis where liver function is impaired and severe complications can occur such as variceal bleeding, ascites, portal hypertension, hepatocellular carcinoma and death (3). In 2009, chronic liver disease and cirrhosis were responsible for 143,000 hospitalizations, 11,000 in-hospital deaths (7.7% death rate), and 6.7 billion dollars of hospital charges in total (4). Accurately detecting and staging fibrosis is important in the management of chronic liver disease for initiating treatment and monitoring its effects on the liver. Chronic viral hepatitis C (HCV) infection is a significant cause of hepatic disease and its treatment may depend on the presence of substantial fibrosis (5, 6). It is well known that liver biopsy is the current reference method for the detection and staging of fibrosis. However, it is an invasive method and can cause undesired complications including bleeding (1.7%) (7) and death (0.01-1%) (7-9). The accuracy of liver biopsy is affected by sampling errors (20-33% of patients can have fibrosis stage misclassified by 1 category) (10, 11), and intra- and inter-operator inconsistency (Kappa coefficient 0.62 – 0.89, where 1 means perfect agreement) (11, 12). Furthermore, this approach is not well accepted by patients and physicians alike (13). Conventional noninvasive imaging techniques (ultrasound, computed-tomography, MRI) can visualize the morphologic changes of liver due to fibrosis and cirrhosis. However, the sensitivity and accuracy of these modalities are low for detecting earlier stages of fibrosis and thus are not suitable for staging liver fibrosis over its entire spectrum (14). Over the last several years, new noninvasive methods of assessing liver fibrosis have been developed and investigated, including serum tests, diffusion-weighted MR imaging (DWI), contrast enhanced MR imaging (CE-MRI), ultrasound based transient elastography (UTE) and MR elastography (MRE). Accumulated data showed that the AUROC (area under receiver operating characteristic curve) values are between 77%-91% for serum tests (15-20), 88% for DWI (21), and 83% for CE-MRI (22) to detect the presence of liver fibrosis due to different disease causes. As one of the two existing methods of measuring liver stiffness, UTE has higher AUROC values (0.79-0.98) (23-25), yet it is less accurate for detecting early fibrosis stages and has a high technical failure rate in certain patient subsets (ascites, narrow intercostals space, obesity) (26-28). The other method of measuring liver stiffness, MR elastography (MRE) is the most accurate (AUROC = 92% - 100%) method for detecting and staging liver fibrosis to date, especially in early stages of fibrosis because of its capability of measuring cross-sectional areas of hepatic parenchyma, and the technique is not affected by the ascites and obesity (3, 21, 26, 27, 29-31). In one study, MRE even detected necroinflammation before the onset of fibrosis in patients with NAFLD (32). The detection of early stage fibrosis is of clinical significance as treatments for liver disease are thought to be more effective when compared to later stages of fibrosis. Given its technical advantages and high diagnostic accuracy, this article reviews the application of MR elastography to address clinical questions involving HCV, NAFLD, and methotrexate (MTX) exposure.

The Use of Blood Counts and Blood Cultures to Screen Neonates Born to Partially Treated Group B Streptococcus-carrier Mothers for Early-onset Sepsis

No clear recommendations exist regarding the approach to evaluate neonates born to partially treated group B Streptococcus (GBS)-carrier mothers for early-onset GBS (EO-GBS) sepsis. To determine the yield and drawbacks of screening, all neonates born to GBS-carrier mothers who received only one dose of IV antibiotic, less than 4 hours, before delivery (partially treated). A retrospective analysis was performed of all complete blood counts (CBCs) and blood cultures obtained from infants born during the period 2005 to 2009 to GBS-positive screened mothers treated with only one dose of antibiotic prior to delivery. A review was conducted of all neonatal EO-GBS sepsis cases during the study period. : Of 5845 GBS-carrier mothers, 1648 (28%) received only one dose of antibiotic less than 4 hours before delivery. We traced the CBCs and blood cultures, which were taken from 1413/1648 (86%) infants after birth. In 234 (18%) of these 1413 neonates, a second CBC sample was taken due to abnormal result of the CBC (leukocytosis, leukopenia, or thrombocytopenia) or secondary to technical failure in obtaining the blood. None of the blood cultures taken in that screening protocol was GBS positive, but in 10 cases contamination with coagulase-negative Staphylococcus was reported. During the study period, EO-GBS sepsis was diagnosed in 11 neonates; all had clinical symptoms upon presentation. The use of CBC and blood culture to screen neonates born to GBS-carrier mothers who received only one dose of IV antibiotic before delivery led to a negligible clinical yield and a high rate of technical failure. Although these findings are in line with the recent change in the Centers for Disease Control guidelines, they put in question the cost of this practice in terms of neonatal pain and parental anxiety.

Blood Flow Measurements during Hemodialysis Vascular Access Interventions - Catheter-Based Thermodilution or Doppler Ultrasound?

To test the clinical performance of catheter-based thermodilution and Doppler ultrasound of the feeding brachial artery for blood flow measurements during hemodialysis vascular access interventions. Thirty patients with arteriovenous fistulas who underwent 46 interventions had access blood flow measured before and after every procedure. Two methods, catheter-based thermodilution and Doppler ultrasound, were compared to the reference method of ultrasound dilution. Catheter-based thermodilution and Doppler ultrasound were performed during the endovascular procedures while flow by ultrasound dilution was determined within three days of the procedure. The methods were compared using regression analysis and tested for systematic bias. Failure to position the thermodilutional catheter correctly was observed in 8 out of 46 (17%) pre-intervention measurements. Post-intervention measurements and ultrasound measurements were feasible in all patients. The average level of agreement was good when comparing catheter-based thermodilution to ultrasound dilution. However, blood flow by ultrasound dilution may differ by ±130 mL/min (±22%) at a flow level of 600 mL/min by thermodilution. Results from Doppler ultrasound displayed a moderate level of agreement on average when compared to ultrasound dilution. Blood flow by ultrasound dilution may differ by ±160 mL/min (±27%) at a flow level of 600 mL/min by Doppler ultrasound. No systematic bias was detected by either method. On average, results from catheter-based thermodilution were more in agreement with results from the ultrasound dilution technique compared to Doppler ultrasound. However, considering the cost and the high technical failure rate of the thermodilutional system, we recommend the use of ultrasound.

Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study

BACKGROUND AND AIM: The diagnosis of gastrointestinal stromal tumors (GISTs) has important prognostic and therapeutic implications. The specific diagnosis of GIST has to be based on immunocytochemistry. This study aimed to prospectively compare in a crossover manner the accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB) in the specific diagnosis of gastric GISTs. We hypothesized that EUS-TCB is superior to EUS-FNA in this respect. PATIENTS AND METHODS: Forty patients with gastric subepithelial tumors suspected on the basis of EUS of being a GIST underwent both EUS-FNA and EUS-TCB. The sequence in which the techniques were employed was randomly assigned to avoid bias. RESULTS: Forty tumors were sampled (mean number of passes: 2.1 ± 0.9 with EUS-TNB and 1.9 ± 0.8 with EUS-FNA; P = not significant, NS). Final diagnoses were: GIST (n = 27), carcinoma (n = 2), leiomyoma (n = 1), schwannoma (n = 1), and no diagnosis possible (n = 9). Device failure occurred in 6 patients with EUS-TCB. A cytohistological diagnosis of mesenchymal tumor (n = 29) and carcinoma (n = 2) was made in 70 % of cases by EUS-FNA and in 60 % of cases by EUS-TCB ( P = NS). Among the samples that were adequate, immunohistochemistry could be performed in 74 % of EUS-FNA samples and in 91 % of EUS-TCB samples ( P = 0.025). When inadequate samples were included, the overall diagnostic accuracy of EUS-FNA was 52 % and that of EUS-TCB was 55 % ( P = NS). There were no complications. CONCLUSIONS: EUS-TCB is not superior to EUS-FNA in GISTs because of the high rate of technical failure of trucut. However, when an adequate sample is obtained with EUS-TCB, immunohistochemical phenotyping is almost always possible. EUS-TCB can be safely performed in this set of patients.

Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study

The diagnosis of gastrointestinal stromal tumors (GISTs) has important prognostic and therapeutic implications. The specific diagnosis of GIST has to be based on immunocytochemistry. This study aimed to prospectively compare in a crossover manner the accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB) in the specific diagnosis of gastric GISTs. We hypothesized that EUS-TCB is superior to EUS-FNA in this respect. Forty patients with gastric subepithelial tumors suspected on the basis of EUS of being a GIST underwent both EUS-FNA and EUS-TCB. The sequence in which the techniques were employed was randomly assigned to avoid bias. Forty tumors were sampled (mean number of passes: 2.1 +/- 0.9 with EUS-TNB and 1.9 +/- 0.8 with EUS-FNA; P = not significant, NS). Final diagnoses were: GIST (n = 27), carcinoma (n = 2), leiomyoma (n = 1), schwannoma (n = 1), and no diagnosis possible (n = 9). Device failure occurred in 6 patients with EUS-TCB. A cytohistological diagnosis of mesenchymal tumor (n = 29) and carcinoma (n = 2) was made in 70 % of cases by EUS-FNA and in 60 % of cases by EUS-TCB ( P = NS). Among the samples that were adequate, immunohistochemistry could be performed in 74 % of EUS-FNA samples and in 91 % of EUS-TCB samples ( P = 0.025). When inadequate samples were included, the overall diagnostic accuracy of EUS-FNA was 52 % and that of EUS-TCB was 55 % ( P = NS). There were no complications. EUS-TCB is not superior to EUS-FNA in GISTs because of the high rate of technical failure of trucut. However, when an adequate sample is obtained with EUS-TCB, immunohistochemical phenotyping is almost always possible. EUS-TCB can be safely performed in this set of patients.

Long-Term Outcome of Endoscopic Colorectal Stenting for Malignant and Benign Disease

Although the technical success rate of endoscopic stenting has been defined, there is a paucity of outcome data. The purpose of this study was to evaluate the long-term results of colorectal stenting for both malignant and benign disease. A retrospective review was conducted of patients who underwent stenting at a tertiary center over 4 years. One surgeon performed all stents under endoscopic and fluoroscopic guidance. A total of 49 stent procedures were performed in 36 patients (19 females, mean age 65 years). Mean follow-up was 15 months. Twenty-eight patients (78%) underwent stenting for malignant disease and eight patients (22%) for benign conditions. The most common reason for intervention was obstruction (81%). Technical success rate was 72 per cent. Carcinomatosis was associated with a higher technical failure rate. Procedural related complications occurred in two patients (6%). Long-term stent migration rate was 24 per cent and was more common in patients with benign disease and patients who received nonmetal stents or stents with diameter < 25 mm. Endoscopic reintervention was required in 33 per cent of patients with initial technical success. Long-term need for subsequent operative intervention was 14 per cent. Endoscopic stenting is a viable option for a select group of patients with colorectal disease. Patient's selection and stent choice influence outcome.

Einsatz der C-Arm-CT zur Verbesserung der Trefferquote bei selektiver Nebennierenvenen-Blutentnahme

Primary hyperaldosteronism is the most common curable cause of hypertension with a prevalence of up to 12% among patients with hypertension. Selective blood sampling from adrenal veins is considered the diagnostic gold standard. However, it is underutilized due to the high technical failure rate. The use of C-arm CT during the sampling procedure can reduce or even eliminate this failure rate. If adrenal vein sampling is augmented by native C-arm CT to check for the correct catheter position, the technical success rate increases substantially. General use of this technique will result in correct diagnosis and treatment for patients with primary hyperaldosteronism.

The value of preoperative needle core biopsy for diagnosing benign lesions among small, incidentally detected renal masses: Shannon BA, Cohen RJ, de Bruto H, Davies RJ, Tissugen Pty. Ltd., Perth, Western Australia, Australia

Purpose We determined the safety and accuracy of preoperative needle core biopsy for diagnosing benign lesions among small incidental asymptomatic renal masses. Materials and Methods Between February 2000 and December 2007, we received a total of 235 preoperative core biopsies from 222 less than 5 cm incidental renal masses. Biopsy results were correlated with surgical specimen final pathology findings or with patient followup if surgery was avoided. Results Of the 235 biopsies, 184 (78%) were diagnostic, whereas 51 (22%) were nondiagnostic due to insufficient material or contents of only normal, inflammatory, fibrotic or necrotic tissue, or blood clot. Diagnostic biopsies revealed 138 malignant (75%) and 46 benign (25%) lesions. Of these patients, 108 (59%) underwent renal surgery, which showed a 100% biopsy accuracy rate for distinguishing malignant from benign lesions and a 98% rate for determining histological tumor type. Follow-up with radiological imaging was performed for 59 lesions in patients with nondiagnostic biopsies or benign masses, and for 16 low grade malignant tumors in elderly patients. Lesions remained stable in 61 cases, showed minor size changes in 9, and resolved in 5. No patient has shown symptoms or required renal surgery to date. Significant biopsy related complications were noted in only 2 patients (0.9%). Conclusions We found that needle core biopsy was a safe and accurate technique for distinguishing between malignant and benign tumors in small, asymptomatic, incidentally detected renal masses. Biopsy of small tumors is associated with a relatively high rate of technical biopsy failure, although this may be addressed by adopting improved biopsy techniques, as discussed.

The Value of Preoperative Needle Core Biopsy for Diagnosing Benign Lesions Among Small, Incidentally Detected Renal Masses

We determined the safety and accuracy of preoperative needle core biopsy for diagnosing benign lesions among small incidental asymptomatic renal masses. Between February 2000 and December 2007 we received a total of 235 preoperative core biopsies from 222 less than 5 cm incidental renal masses. Biopsy results were correlated with surgical specimen final pathology findings or with patient followup if surgery was avoided. Of the 235 biopsies 184 (78%) were diagnostic, whereas 51 (22%) were nondiagnostic due to insufficient material or contents of only normal, inflammatory, fibrotic or necrotic tissue, or blood clot. Diagnostic biopsies revealed 138 malignant (75%) and 46 benign (25%) lesions. Of these patients 108 (59%) underwent renal surgery, which showed a 100% biopsy accuracy rate for distinguishing malignant from benign lesions and a 98% rate for determining histological tumor type. Followup with radiological imaging was performed for 59 lesions in patients with nondiagnostic biopsies or benign masses and for 16 low grade malignant tumors in elderly patients. Lesions remained stable in 61 cases, showed minor size changes in 9 and resolved in 5. No patient has shown symptoms or required renal surgery to date. Significant biopsy related complications were noted in only 2 patients (0.9%). We found that needle core biopsy was a safe and accurate technique for distinguishing between malignant and benign tumors in small asymptomatic incidentally detected renal masses. Biopsy of small tumors is associated with a relatively high rate of technical biopsy failure, although this may be addressed by adopting improved biopsy techniques, as discussed.

Radiofrequency Ablation Using a Monopolar Wet Electrode for the Treatment of Inoperable Non-Small Cell Lung Cancer: a Preliminary Report

ObjectiveTo assess the technical feasibility and complications of radiofrequency ablation (RFA) using a monopolar wet electrode for the treatment of inoperable non-small cell lung malignancies.Materials and MethodsSixteen patients with a non-small cell lung malignancy underwent RFA under CT guidance. All the patients were non-surgical candidates, with mean maximum tumor diameters ranging from 3 to 6 cm (mean: 4.6 ± 1.1 cm). A single 16-gauge open-perfused electrode with a 2 cm exposed tip was used for the procedure. A 0.9% NaCl saline solution was used as the perfusion liquid with the flow adjusted to 30 mL/h. The radiofrequency energy was applied for 10-40 minutes. The response to RFA was evaluated by performing contrast-enhanced CT immediately after RFA, one month after treatment and then every three months thereafter.ResultsTechnical failure was observed in six (37.5%) of 16 patients: intractable pain (n = 2) and non-stop coughing (n = 4). The mean follow-up interval was 15 ± 8 months (range: 9-31 months). The mean maximum ablated diameter in the technically successful group of patients ranged from 3.5 to 7.5 cm (mean 5.1 ± 1.3 cm). Complete necrosis was attained for eight (80%) of 10 lesions, and partial necrosis was achieved for two lesions. There were two major complications (2/10, 20%) encountered: a hemothorax (n = 1) and a bronchopleural fistula (n = 1).ConclusionAlthough RFA using a monopolar wet electrode can create a large ablation zone, it is associated with a high rate of technical failure when used to treat inoperable non-small cell lung malignancies.

Endovascular versus surgical treatment for thrombosed hemodialysis grafts: A prospective, randomized study

Purpose: The objective of this study was to compare clinical outcome and costs for two widely used treatment strategies for hemodialysis graft thrombosis. Methods: During a 4-year period, 80 patients with thrombosed dialysis grafts were randomly assigned to surgical thrombectomy with or without graft revision (SURG) or thrombolytic therapy with urokinase with the pulse-spray technique (ENDO), with adjunctive percutaneous transluminal angioplasty as indicated. All the procedures were performed in an endovascular operating suite with fistulography. The clinical and cost data were tabulated, and the outcome was analyzed with the life-table method. Results: Fifty-six women and 24 men ranged in age from 33 to 90 years (mean, 63.7 years). The patients had undergone a mean of 2.8 prior access procedures in the ipsilateral extremity. All the grafts were upper extremity expanded polytetrafluoroethylene grafts. Lesions that were presumed to be the primary cause of graft thrombosis were identified in 73 of 80 grafts, and 60 of these were at the venous anastomosis. The procedure time averaged 99 minutes for the patients in the SURG group and 113 minutes for the patients in the ENDO group ( P = .12). Eleven patients in the ENDO group crossed over to surgical revision as compared with two patients in the SURG group who required adjunctive percutaneous transluminal angioplasty ( P = .005). The mean cost of treatment (including room and supply costs but not professional fees) was significantly higher for the ENDO group than for the SURG group ($2945 vs $1512; P < .001). There were no procedure-related complications in either group. At a median follow-up time of 24 months, there was no difference in primary or assisted primary patency between groups, which averaged 6 and 7 months, respectively. Conclusion: Although thrombolytic therapy combined with endovascular treatment can extend the life of dialysis grafts with results similar to surgical revision, there is a high rate of technical failure necessitating surgery and a substantially higher cost for thrombolysis. (J Vasc Surg 1999;30:1016-23.)

Doppler spectrum analysis versus direct femoral artery pressure measurement for rapid assessment of aortoiliac obstruction.

Adequate patient selection is required to limit the clinical workload and improve the cost-effectiveness of noninvasive hemodynamic evaluation of the aortoiliac system. In a prospective blinded fashion the traditional invasive technique of direct femoral artery pressure measurements and the computerized Doppler spectrum analysis of blood flow velocities in the common femoral artery were studied. Both tests for rapid assessment of aortoiliac obstruction were compared with duplex ultrasonographic imaging, using a peak systolic velocity ratio of 2.5 to demonstrate stenoses of 50% or more. In a series of 17 consecutive patients (34 aortoiliac segments) with suspected aortoiliac obstructive disease, a good level of agreement (kappa = 0.6) was found for both methods when compared with duplex scanning. Analysis of deviations from the duplex registrations indicated an overestimation of the pathologic cases using femoral artery pressure measurements and an underestimation using Doppler spectrum analysis of blood flow velocities in the common femoral artery. Both methods were well tolerated, but femoral artery pressure measurements had a higher technical failure rate. Because of its noninvasive character and its feasibility the Doppler technique is preferred for the selection of patients for more extensive duplex sonographic investigation.

Decreased mortality from technical failure improves results in pediatric liver transplantation.

Until recently, pediatric liver transplantation was associated with a high rate of technical failure, which contributed substantially to the overall prognosis. To assess the impact of technical failure on outcome in pediatric liver transplantation. We retrospectively analyzed 90 pediatric transplant procedures in a university medical center. Between February 1988 and December 1995, 80 children ( < 15 years old) received 90 transplants. Fifty-three percent (n = 42) were less than 2 years of age, 45% (n = 36) had cholestatic liver disease, 26% (n = 21) had metabolic errors, and 11% (n = 9) had fulminant hepatitis. Patients underwent grafting using previously reported techniques, including cadaveric whole (61% [n = 55]), reduced-size (17% [n = 15]), and living related (22% [n = 20]) liver transplantation. Patient and graft survival and selected surgical complications. Outcomes were compared before (group 1) and after (group 2) the introduction of living related transplantation in July 1992. In group 1, 32 patients received 36 grafts (4 retransplants [13%]), and in group 2, 48 patients received 54 grafts (6 retransplants [13%]). Six- and 12-month patient survival rates were 78% (n = 25) and 75% (n = 24), respectively, for group 1 and 98% (n = 47) and 94% (n = 45) for group 2. Of the 9 deaths in group 1, 6 occurred early as a consequence of surgical complications, while in group 2, all 5 deaths that occurred were caused by the consequences of immunosuppression (lymphoproliferative disease, n = 2; late infections, n = 3). These results suggest that mortality caused by surgical complications has been reduced by improvement in management in recent years. Living related grafts have supplemented the graft supply and may be associated with the improved overall results. Despite these advances, children receiving transplants continue to experience the consequences of imperfect immunosuppression.

Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain: a caution.

Percutaneous radiofrequency neurotomy has been used in the treatment of pain from the cervical zygapophysial joints, but the results have been modest and not compelling. Several factors might account for its apparent poor success rate, including inadequate patient selection, inaccurate surgical anatomy, and technical errors. In an effort to overcome these confounders, we used comparative local anesthetic blocks to preoperatively, definitively diagnose cervical zygapophysial joint pain and developed an amended operative technique based on formal anatomical studies. An audit was conducted of our experience with 19 patients to determine whether there was sufficient merit in the amended procedure to justify a randomized, double-blind, controlled trial. The duration of complete pain relief was the principal outcome measure. Side effects and complications were also monitored. Of the 10 patients who underwent third occipital neurotomy for the treatment of C2-C3 zygapophysial joint pain, only 4 obtained long-lasting relief. The other six patients reported an early return of their pain and constituted technical failures; the third occipital nerve was inadequately coagulated and recovered in the immediate postoperative period. Of the 10 patients who underwent lower cervical medial branch neurotomy, 7 obtained complete pain relief for clinically useful periods and were able to resume their activities of daily living and employment. After procedures at all levels, a brief period of postoperative pain was experienced by the patients and ataxia was a side effect of third occipital neurotomy. There were no cases of postoperative infection or anesthesia dolorosa. Given the high technical failure rate of third occipital neurotomy, we recommend that this procedure be abandoned until the technical problems can be overcome.(ABSTRACT TRUNCATED AT 250 WORDS)

SURGERY AND PERCUTANEOUS ANGIOPLASTY IN THE MANAGEMENT OF RENOVASCULAR HYPERTENSION

Unfortunately, no randomized trials have compared PTRA for renovascular hypertension with surgical or medical treatment. PTRA appears to be a safe and relatively simple procedure with complication rates lower than those of operation. The outcome of renal angioplasty depends on the type of stenosis. In all published series, the cure rates for fibromuscular disease are significantly higher than for atherosclerotic disease, and PTRA appears to be the procedure of choice in the treatment of hypertension in patients with fibromuscular disease. The role of renal angioplasty in patients with renovascular hypertension due to atherosclerotic diseases is uncertain. Most large published series describing the success of angioplasty in patients with atherosclerotic lesions have been highly selective, primarily including patients with focal stenotic lesions. Despite this selectivity, the cure rate has been only 19%. In completely unselected patients, atherosclerotic lesions are associated with a very high rate of technical failure, possibly as high as 60%. From the data available, focal isolated stenotic lesions of the renal artery due to atherosclerotic disease can be treated with a reasonable rate of success. The success rate in patients with bilateral disease, osteal stenosis, or total occlusion of the renal arteries appears to be very limited. In these patients, angioplasty should be attempted only when a surgical contraindication exists.