Postprocedural Chest Research Articles

Postprocedure chest pain after coronary stenting: implications on clinical restenosis

ObjectivesThe goal of this study was to analyze the incidence and predictors of postprocedure chest pain (PPCP) after percutaneous coronary intervention (PCI) and its correlation with clinical restenosis. BackgroundChest pain after PCI occurs frequently even in the absence of procedural events and is considered to be due to vasospasm or coronary artery stretch. The short- and long-term significance of PPCP after otherwise successful stenting is not clear. MethodsWe analyzed 1,362 patients undergoing coronary stenting for PPCP, procedural and in-hospital events, 30-day major adverse cardiac events, and target vessel revascularization (TVR) at 6 to 9 months. ResultsThere were 488 patients with PPCP and, of these, 312 patients were excluded due to procedural events. The remaining 176 patients with PPCP were compared with 874 patients without PPCP. Creatine kinase-MB isoenzyme elevation occurred in 25.6% of the PPCP group versus 9.6% of the no PPCP group (p < 0.001). Despite similar reference vessel diameter, the PPCP group had larger postprocedure minimum lumen diameter, higher stent-to-vessel ratio, and higher inflation pressure versus the no PPCP group (p < 0.01). At 30 days, the emergency room visits and repeat catheterization (16% vs. 2.7%; p < 0.001) were higher in the PPCP group versus the no PPCP group, but repeat intervention was similar. At 6- to 9-month follow-up, the TVR was significantly higher in the PPCP group compared with the no PPCP group (29.5% vs. 16.6%; p < 0.01). ConclusionsOur analysis suggests micromyonecrosis and vessel stretch as causes of PPCP. Postprocedure chest pain is associated with similar short-term outcome as no PPCP, but has higher restenosis, perhaps mediated by deep vessel wall injury. Therefore, PPCP may identify patients at high risk for restenosis.

Percutaneous lung biopsies: a survey of UK practice based on 5444 biopsies.

Percutaneous transthoracic lung biopsies are commonly performed for the investigation of lung masses. We describe current practice and complication rates in the UK. A postal questionnaire was sent to all centres in the British Thoracic Society directory. 157 replies (61% response rate) were received, providing data on 5444 biopsies. Mean number of biopsies performed per annum was 30.5 per centre; 8% of centres did not perform biopsies, 36% performed <25 biopsies per annum, 34% <50, 16% <100 and 6% >100. Consultant radiologists perform 91% of biopsies. Written consent was obtained at all centres. The operator obtained consent at 50% of centres. Written information for patients was provided at 35 (24%) centres. Biopsies are performed on a day case basis at 103 (71%) centres. Prior to biopsy the following were obtained routinely: CT scan (73% of centres), platelet count (73%), full clotting screen (70%), lung function (55%). Complications included pneumothorax (20.5% of biopsies), pneumothorax requiring chest drain (3.1%), haemoptysis (5.3%) and death (0.15%). The timing of post-procedure chest radiography was variable. Those centres that performed predominantly cutting needle biopsies had similar pneumothorax rates to centres performing mainly fine needle biopsies (18.9% vs 18.3%). There is great variation in practice throughout the UK. Most procedures are performed on a daycase basis. Small pneumothoraces are common but infrequently require treatment. National guidelines are needed to ensure consistency of standards.

Reduction in periprocedural enzyme elevation by abciximab after rotational atherectomy of type B2 lesions: Results of the Rota ReoPro randomized trial

Background Abciximab has been shown to reduce ischemic complications and creatine kinase-myocardial band (CK-MB) elevation of both simple and complex coronary interventions. In addition to the procedural complications, one of the important mechanisms for CK-MB elevation after rotational atherectomy is an interaction between platelets and the atheromatous debris. Methods This study was conducted to determine whether abciximab would limit the extent of periprocedural CK-MB release after rotational atherectomy of American Heart Association/American College of Cardiology type B2 lesions in a double-blind, randomized, placebo-controlled manner. A total of 100 lesions in 100 patients were randomized with the primary end point being a CK-MB elevation of >16 U/L. Results Procedural success was achieved in 100% in the abciximab arm compared with 98% in the placebo group with any CK-MB elevation >16 U/L of 8% in the abciximab versus 22% in the placebo group (P = .04). The peak creatine phosphokinase level (units per liter) was 102 ± 14 versus 153 ± 22 (P = .05) and the peak CK-MB level was 12.8 ± 1.8 versus 24.6 ± 3.5 (P = .06) between the abciximab and placebo groups, respectively. Slow-flow or postprocedure chest pain occurred in 14% in the abciximab group versus 30% in the placebo group (P = .04). There was 1 Q-wave myocardial infarction in the placebo arm and 1 nonhemorrhagic stroke in the abciximab group. Conclusions Therefore the Rota ReoPro randomized trial revealed the benefit of abciximab during rotational atherectomy in reducing procedural morbidity and CK-MB elevation, and its routine use can be justified even in moderately complex lesions undergoing rotational atherectomy. (Am Heart J 2001;142:965-9.)

Effects of clopidogrel pretreatment before percutaneous coronary intervention in patients treated with glycoprotein IIb/IIIa inhibitors ( abciximab or tirofiban)

T clinical efficacy and safety of clopidogrel pretreatment in addition to glycoprotein (GP) IIb/IIIa antagonists during percutaneous coronary intervention (PCI) is unknown. This study compares the in-hospital clinical outcome of patients who received clopidogrel pretreatment before PCI with that in patients who did not receive it as adjunctive antiplatelet therapy to GP IIb/IIIa antagonists. • • • Data were collected from the Memorial Hermann Heart Center Interventional Cardiology database. We examined a consecutive series of 299 patients undergoing PCI. All patients received GP IIb/IIIa inhibitor therapy in the form of abciximab or tirofiban. Use and type of GP IIb/IIIb antagonists was at the discretion of the operator. Abciximab was given as a bolus dose of 0.25 mg/kg body weight followed by continuous infusion of 10 g/min for 12 hours. Tirofiban was given as a loading dose of 0.4 g/kg/min for 30 minutes followed by a maintenance dose of 0.1 g/kg/min for 12 to 24 hours after the procedure. All patients were taking aspirin and received a heparin bolus to achieve an activated clotting time between 250 and 300 seconds. Patients presenting to the catheterization laboratory with a developing myocardial infarction (MI) for a primary or rescue angioplasty were excluded. Patients were divided into 2 groups: those who received clopidogrel pretreatment before PCI (starting within 5 days before PCI or a loading dose of 300 mg the morning of the day of the procedure at the discretion of the primary operator, group I), and those who received aspirin alone (group II) with clopidogrel (300 mg loading dose and 75 mg/day for 1 month) given after stent deployment. Therapy with clopidogrel (75 mg/day) was continued for 1 month in both groups if the stent was deployed during the procedure. Coronary angioplasty and intracoronary stent implantation were performed using standard percutaneous techniques. Balloon size was selected to match the reference vessel diameter obtained from on-line angiographic analysis (1.1:1 balloon/artery ratio). Different types of stents were used (excluding open coil type). After stent implantation, high-pressure balloon dilatation was performed for angiographic optimization. Intravascular ultrasonography–guided coronary stenting was not performed in most patients. Each operator relied on his own judgment or on other objective measurements, such as online quantitative coronary angiography, to assess PCI results. On completion of the procedure, patients were moved to a monitored unit and the arterial sheath was removed. Successful PCI was defined as final residual stenosis within the treated lesion of 20%, with achievement of Thrombolysis In Myocardial Infarction grade 3 flow, without in-lab occurrence of death, MI, or a complication requiring immediate coronary revascularization. A major adverse cardiac event was defined as any 1 of the following: (1) Q-wave or non–Q-wave MI, (2) need for urgent repeat target vessel revascularization, or (3) cardiovascular death that occurred during the period of hospitalization after the index coronary procedure. Postprocedural MI was defined as the occurrence of typical ischemic chest pain of 30 minutes duration with a creatine kinase elevation of 3 times the upper limit of normal with an associated increase in the MB fraction. There was no routine protocol for acquisition of postprocedure creatine kinase. All postprocedural cardiac enzymes were obtained for suspected recurrent myocardial ischemia, manifested by recurrent postprocedural chest pain, hemodynamic instability, or new electrocardiographic changes of ischemia. Urgent target vessel revascularization was defined as a repeat PCI or coronary artery bypass grafting of the index artery due to presumed recurrent ischemia manifested by recurrent angina, arrhythmias, or hemodynamic compromise. Adverse effects of therapy were recorded and compared between the 2 groups. These consist of major bleeding and thrombocytopenia. Major bleeding was defined as bleeding requiring transfusion of blood products or precipitating hemodynamic compromise. Intracerebral hemorrhage of any extent was considered a major adverse effect of therapy. Thrombocytopenia was defined as platelet count 100,000/mm. Chi-square and Fischer exact tests were used for analysis of categorical variables when appropriate, and Student t testing was used for analysis of continuous variables. Multivariate logistic regression analysis was performed to determine significance of variables related to an in-hospital major adverse cardiac From the Cardiology Division, University of Texas Medical School and Hermann Heart Center, Memorial Hermann Hospital, Houston, Texas. Dr. Rosales’ address is: Division of Cardiology, University of Texas Health Science Center-Houston, PO Box 20708, Houston, Texas 77225-0708. Manuscript received March 29, 2001; revised manuscript received and accepted May 30, 2001.

Cardioprotective Effect of Prior β-Blocker Therapy in Reducing Creatine Kinase-MB Elevation After Coronary Intervention

Both retrospective studies and prospective randomized trials have shown that beta-blockers improve survival and reduce the risk of reinfarction in patients with myocardial infarction. To evaluate whether beta-blockers exert similar protective benefits during and after coronary intervention, we studied the incidence of postprocedure creatine kinase (CK)-MB elevation in patients with or without prior beta-blocker therapy and its effect on intermediate-term ( approximately 1 year) survival. We prospectively analyzed 1675 consecutive patients undergoing coronary intervention; of these patients, 643 (38.4%) were on beta-blocker therapy before the intervention. The incidence of CK-MB elevation after coronary intervention was 13.2% in patients on beta-blocker therapy before intervention and 22.1% in patients who were not on beta-blockers (P<0.001). Patients with prior beta-blocker therapy had lower persistent/recurrent postprocedure chest pain and lower preprocedure and postprocedure heart rates and mean blood pressures compared with patients who were not on beta-blockers (P<0.001). Multiple linear regression analysis revealed prior beta-blocker therapy as the sole independent factor for lower CK-MB release after coronary intervention. During intermediate-term follow-up at 15+/-3 months, patients on beta-blocker therapy before intervention had lower mortality rates compared with those not on beta-blockers (0.78% versus 1.96%; P=0. 04), although the benefit was independent of the reduction in CK-MB release. Our nonrandomized, prospective analysis suggests that prior beta-blocker therapy has a cardioprotective effect in limiting CK-MB release after coronary intervention and that it is associated with a lower mortality at intermediate-term follow-up.

Factors Contributing to Pneumothorax After Thoracentesis

To the Editor: In Reply: Factors Contributing to Pneumothorax After ThoracentesisCHESTVol. 117Issue 2PreviewWe thank Dr. Diaz and colleagues for their interest in our article (July 1999). Their findings further confirm that thoracentesis is a particularly safe procedure, although the lack of routine chest radiographs in their study may have caused them to miss asymptomatic pneumothoraces. From a clinical standpoint, we agree that postprocedure chest radiographs need only be performed in case of clinical suspicions of a complication.1 Their selective use of pleural ultrasonography is logical. Of course, it also raises issues of logistics and institutional practice patterns. Full-Text PDF

A double-blind, randomized study of the effect of immediate intravenous nitroglycerin on the incidence of postprocedural chest pain and minor myocardial necrosis after elective coronary stenting

Background Anginal chest pain without creatine kinase (CK) elevation is frequently observed in the first hours after coronary stenting. Possible causes of ischemic episodes are microembolism, side branch occlusion, coronary vasospasm, and disturbances of microvascular circulation. In a prospective, double-blind, randomized trial, we tested the effect of intravenous nitroglycerin on the incidence of angina and minor myocardial necrosis (MMN), as detected by cardiac troponin I increase, after elective coronary stenting. Methods and Results One hundred patients were randomly assigned to intravenous nitroglycerin (group A: n = 50, goal dose 100 μg/min) or placebo (group B: n = 50, NaCl 0.9%) during 12 hours after stenting. Patients with acute myocardial infarction, known intolerance to nitrates, and hemodynamic instability during angioplasty were excluded. The 2 groups were comparable in respect to baseline and interventional variables, except for age (group A: 60 ± 9 years, group B: 56 ± 10 years; P = .04). The incidence of chest pain was not influenced by nitroglycerin (group A: 18%, group B: 22%; P = not significant). However, the occurrence of MMN was significantly reduced by nitroglycerin (group A: 5%, group B: 19%, P = .036). A rise in CK with significant CK-MB fraction was observed in only 2 patients in group B (both less than twice upper limit). Only 4 of the 10 patients with MMN also had chest pain. Conclusions Routine use of intravenous nitroglycerin after coronary stenting significantly reduced the occurrence of minor myocardial necrosis. However, the incidence of postprocedural chest pain remained unchanged. (Am Heart J 2000;139:35-43.)

A double-blind, randomized study of the effect of immediate intravenous nitroglycerin on the incidence of postprocedural chest pain and minor myocardial necrosis after elective coronary stenting

A double-blind, randomized study of the effect of immediate intravenous nitroglycerin on the incidence of postprocedural chest pain and minor myocardial necrosis after elective coronary stenting

Percutaneous insertion of tunnelled central venous catheters is a safe out-patient procedure

The study was performed to evaluate prospectively the efficacy and safety of insertion of tunnelled central venous catheters as an out-patient procedure in the radiology department. Tunnelled central venous catheters were inserted via the jugular or subclavian veins in 94 patients. The insertion was guided by ultrasound or venography. A post-procedure chest radiograph was obtained and, if the patients were well, they were discharged from hospital after 2h. Insertion was successfully achieved in all patients. Early complications occurred in 19 patients (20.2%) but these were generally minor. A chest drain was inserted into one patient who had a pneumothorax on the post-procedure chest radiograph. All other patients were fit to go home. Late complications occurred in 32 patients (34%), resulting in death in one patient. This study suggests that, with appropriate precautions, out-patient percutaneous image-guided insertion of tunnelled central venous catheters is a safe procedure.

Chest pain—a strong predictor of adverse cardiac events following percutaneous intervention (from the Evaluation of Platelet IIb/IIIa Inhibitor for Stenting Trial [EPISTENT

Postprocedural chest pain remains a common problem, and irrespective of electrocardiographic changes, is associated with a higher incidence of early cardiac events. A return to the catheterization laboratory is unlikely to benefit patients with postprocedural chest pain without electrocardiographic changes with documented irreversible intraprocedural complications, or those with late postprocedural pain.

Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary?

To determine whether clinical features can be used in a decision rule to prospectively identify a subgroup of internal jugular catheter placements that are correctly positioned and free from mechanical complications, thus obviating the need for routine postprocedural chest radiographs in selected patients. Prospective cohort study. Tertiary care teaching hospital. A total of 107 consecutive patients who presented to our catheter service for internal jugular catheter insertion because of clinical indications between November 1995 and April 1996. Exclusion criteria were mechanical ventilation, an altered mental status, an age of <15 years, and a height of <152 cm. Right or left internal jugular vein catheter placement followed by a postprocedural chest radiograph. The operating physician completed a detailed questionnaire for each catheter insertion, designed to detect potential complications and to predict the necessity, or lack of necessity, for a postprocedural chest radiograph. The questionnaire documented patient characteristics, the number of needle passes, difficulty establishing access, operator experience, poor anatomical landmarks, number of previous catheter placements, resistance to wire or catheter advancement, resistance to aspiration of blood or flushing of the catheter ports, sensations in the ear, chest, or arm, and development of signs or symptoms suggestive of pneumothorax. After catheter insertion, chest radiographs were obtained to assess for mechanical complications and malpositioned catheters. In 46 cases, the decision rule predicted either a complication or a malposition and, thus, the need for a chest radiograph. In 61 cases, neither was predicted (no chest radiograph was needed). Radiographs confirmed one complication (pneumothorax) and 15 catheter tip malpositions (nine in the right atrium and six in the right axillary vein). Among the 46 cases predicted to have a potential complication or malposition, there were one actual complication (pneumothorax) and six actual malpositions (three axillary vein malpositions and three right atrial malpositions). The positive predictive value of this decision rule is 15%. Among the 61 cases predicted to be free from complications or malpositions and not to require a postprocedural chest radiograph, there were nine unexpected malpositions (three axillary vein malpositions and six right atrial malpositions). The negative predictive value is 85%. The overall sensitivity of the decision rule for detecting complications and malpositions is 44%, and the specificity is 55%. In experienced hands, internal jugular venous catheterization is a safe procedure. However, the incidence of axillary vein or right atrial catheter malposition is 14%, and clinical factors alone will not reliably identify malpositioned catheters. Chest radiographs are necessary to ensure correct internal jugular catheter position.

Routine chest radiographs after central line insertion: mandatory postprocedural evaluation or unnecessary waste of resources?

To study the cost and impact on patient management of the routine performance of chest radiographs in patients undergoing imaged-guided central venous catheter insertion. Six hundred and twenty-one catheters placed in 489 patients over a 42-month period formed the study group. Catheters were placed in the right internal jugular vein (425), left internal jugular vein (133), and subclavian veins (63). At the end of the procedure fluoroscopy was used to assess catheter position and check for complications. A postprocedural chest radiograph was obtained in all patients. Postprocedural chest fluoroscopy showed no evidence of pneumothorax, hemothorax, or mediastinal hematoma. Inappropriate catheter tip position or catheter kinks were noted with 90 catheters. These problems were all corrected while the patient was on the interventional table. Postprocedural chest radiographs showed no complications but proximal catheter tip migration was noted in six of 621 catheters (1%). These latter six catheters required further manipulation. The total technical and related charges for the postprocedural chest radiographs in this series were estimated at pound15,525. Postprocedural chest radiographs after image-guided central venous catheter insertion are not routinely required. A postprocedural chest radiograph can be performed on a case-by-case basis at the discretion of the interventional radiologist.

Evaluation of Patient-Related and Procedure-Related Factors Contributing to Pneumothorax Following Thoracentesis

To evaluate patient-related and procedure-related risk factors for thoracentesis-related pneumothorax. Prospective, nonrandomized cohort study. Pulmonary Special Procedures Unit of a university medical center. Thoracentesis using either a 22-gauge, a Boutin, or a Cope needle (depending on availability and operator preference) was performed by the pulmonary faculty or by pulmonary physicians-in-training under faculty supervision. In order to control for effusion size and the presence of loculations, chest radiography and pleural ultrasonography were performed prior to each thoracentesis. Potential patient-related and procedure-related risk factors for pneumothorax were analyzed at the procedure level using the presence or absence of pneumothorax on the postprocedure chest radiograph as the sole outcome variable. Two hundred fifty-five thoracenteses were performed in 205 adult patients (113 men and 92 women; mean age, 58.8+/-18 years) over a 3(1/2)-year period. One hundred fifty procedures were performed for diagnostic purposes, 28 procedures were performed for therapeutic purposes, and 77 procedures were performed for both diagnostic and therapeutic purposes. Based on the radiographic criteria, 152 effusions (60%) were small. Loculations were present in 76 patients (30%). Pneumothoraces occurred in 14 instances (5.4%), and chest tube drainage was required in 2 instances (0.78%). Hospitalization status, critical illness, effusion size or type, presence of loculations, operator, needle type, amount of fluid withdrawn, occurrence of dry tap, and type of thoracentesis were not associated with an increased frequency of pneumothorax. The only predictor variable demonstrating statistical significance was repeated thoracentesis. The results of a bivariate analysis suggest that pneumothorax following thoracentesis is a rare event that is not easily predictable when the procedure is performed by experienced operators in a controlled setting.

Chest pain after coronary interventional procedures. Incidence and pathophysiology.

Chest pain following successful percutaneous coronary interventions is a common problem. Although the development of chest pain after coronary interventions may be of benign character, it is disturbing to patients, relatives and hospital staff. Such pain may be indicative of acute coronary artery closure, coronary artery spasm or myocardial infarction, but may also simply reflect local coronary artery trauma. The distinction between these causes of chest pain is crucial in selecting optimal care. Management of these patients may involve repeat coronary angiography and additional intervention. Commonly, repeat coronary angiography following percutaneous transluminal coronary angioplasty (PTCA) in patients with chest pain demonstrates widely patent lesion sites suggesting that the pain was due to coronary artery spasm, coronary arterial wall stretching or was of non-cardiac origin. As reported by the National Heart, Lung and Blood Institute PTCA Registry, 4.6% of patients after angioplasty have coronary occlusions, 4.8% suffer a myocardial infarction, and 4.2% have coronary spasm. The frequency of chest pain after new device coronary interventions (atherectomy and stenting) seems to be even higher. However, only the minority of patients with post-procedural chest pain have indeed an ischemic event. Therefore, the vast majority of patients have recurrent chest pain without any signs of ischemia. There is some evidence that non-ischemic chest pain after coronary interventions is more common after stent implantation as compared to PTCA (41% vs. 12%). This may be due to the continuous stretching of the arterial wall by the stent as the elastic recoil occurring after PTCA is minimized. In conclusion, chest pain after coronary interventional procedures may potentially be hazardous when due to myocardial ischemia. However, especially after coronary stent placement, cardiologists must consider "stretch pain" due to the overdilation and stretching of the artery caused by the stent in the differential diagnosis. Clinically, it is, therefore, important to recognize that in addition to ischemia-related chest pain other types of chest pain do exist with cardiac origin.

Comparison of immediate and in-hospital results of conventional balloon and perfusion balloon angioplasty using intracoronary ultrasound

Angiographic studies have demonstrated that perfusion balloon percutaneous transluminal coronary angioplasty (PTCA) may result in modestly improved luminal gains and fewer major dissections than conventional balloon PTCA. However, intracoronary ultrasound (ICUS), which is more sensitive than angiography in evaluating the incidence, extent, and severity of dissection, was not used. We randomized 48 patients with 54 coronary stenoses to conventional or perfusion balloon PTCA. Four 2-minute inflations were permitted with conventional balloon PTCA. Two 10-minute inflations were allowed with perfusion balloon PTCA. Quantitative coronary angiography and ICUS were performed before and after treatment. In-hospital clinical events were recorded. Conventional and perfusion balloon PTCA achieved similar improvements in lumen diameter (1.25 ± 0.51 vs 1.28 ± 0.51 mm) and reductions in percent stenosis (−45 ± 21% vs −44 ± 15%) by quantitative coronary angiography. Comparable gains in lumen diameter (0.62 ± 0.39 vs 0.50 ± 0.38 mm) and lumen area (2.70 ± 1.96 vs 2.05 ± 1.52 mm 2) were observed on ICUS. Angiography demonstrated similar rates of any dissection (36% vs 21%) and major dissection (12% vs 7%). ICUS identified a similar incidence of any dissection (60% vs 76%) and type II dissection (52% vs 62%). The relative dissection area was also similar (9.2 ± 5.6% vs 7.8 ± 5.8%). One conventional balloon patient experienced postprocedural chest pain. No patient in either group died, or had myocardial infarction, abrupt closure, or urgent revascularization.

Subcutaneous access ports with fenestrated catheters for improved management of recurrent pleural effusions

Repeated percutaneous thoracentesis can involve serious complications, such as pneumothorax or infection. Alternatives such as placement of chest tubes or pleurodesis have their own potential complications. Creative options such as pleuroperitoneal shunting and video thoracoscopy have previously been used to avoid the disadvantages of repeated percutaneous thoracentesis. This paper describes an easy and effective method for managing these patients without repeated percutaneous thoracentesis. A port is inserted that can be accessed percutaneously and immediately for needed aspirations. We have successfully performed this procedure on 6 patients. Our hope is that the easy access using a short needle into the port aperture will allow the thoracentesis to be performed by appropriately instructed and supervised paramedical personnel. Also, with fewer postprocedure chest radiographs or hemothoraceses, future benefits from this procedure could include cost effectiveness.

Routine chest radiographs following central venous recatheterization over a wire are not justified

Background: Subclavian vein central venous catheterization and the subsequent exchange of subclavian catheters over a guidewire are frequently performed procedures. We hypothesized that the policy of obtaining a routine postprocedure chest radiograph to confirm appropriate catheter placement and to rule out complications after exchanging central venous catheters over a wire was no longer justifiable. Methods: A retrospective study of 295 patients with Swan-Ganz catheters (SGC) was performed between July 1, 1994 and June 30, 1996. One hundred fourteen of these SGCs were exchanged over a guidewire for a central venous catheter (CVC). Postexchange chest radiograph and associated radiologist’s report, as well as age, gender, and duration of catheter placement were all recorded. Since July 1996, this study has been extended prospectively. Results: Of the 380 documented over-a-wire exchanges, none has resulted in a complication, including catheter malposition. Conclusion: We conclude from these data that a routine chest radiograph following the replacement of a CVC over a guidewire is not necessary when good clinical judgment and discrimination are used in a monitored setting.

Are routine chest radiographs necessary after image-guided placement of internal jugular central venous access devices?

The purpose of this study was to determine the value and cost of obtaining routine chest radiographs after image-guided placement of internal jugular central venous catheters. We reviewed the records of 424 patients in whom 572 internal jugular catheters were placed by sonographic and fluoroscopic guidance over a 2-year period. Inspiratory and expiratory chest radiographs obtained immediately after each procedure were also reviewed. Routine postprocedural chest radiographs revealed no complications and did not alter the treatment of any patient. Delayed pneumothorax was detected after placement of two catheters (0.5%) when patient symptoms prompted additional radiographs. Immediate postprocedural chest radiographs are not routinely needed after image-guided insertion of internal jugular central venous catheters and unnecessarily add to the cost of patient care.

Fine Needle Aspiration Biopsy of Peripheral Pulmonary Lesions under Real-time Sonographic Guidance

DOI: http://dx.doi.org/10.5915/30-1-16283The utility of fine needle aspiration biopsy (FNAB) guided by real-time ultrasonography was studied in 25 patients referred with peripheral lung opacities on chest x-ray examination and in whom fiberoptic bronchoscopy was negative. The lesion, as seen on a chest x-ray, was visualized sonographically in 22 (88%) patients, and aspiration biopsy was performed in 20 of these 22 patients, two patients being excluded due to sonographic evidence of a hydatid cyst. Aspiration biopsy was diagnostic in 17 (85%) of the 20 patients studied including 12 patients with malignancy and five patients with benign lesion. One patient developed a small asymptomatic pneumothorax, detected on routine postprocedure chest x-ray examination. Thus fine needle aspiration biopsy underultrasonographic guidance is a safe, economical method with a high diagnosticyield in the evaluation of peripheral lung opacities, especially in developing countries where computed tomography scan facilities are limited and costly.

Complications associated with insertion of jugular venous catheters for hemodialysis: The value of postprocedural radiograph

It is routine in hemodialysis units to require a chest radiograph after the insertion of an internal jugular line for venous access before dialysis is commenced. There are two principal reasons for this: (1) to ensure that no procedural complications have occurred and (2) to verify correct catheter placement. Knowledge of the time delay involved may prompt nephrologists to opt for femoral access (with increased hemodialysis recirculation and need for repeated line placement). The benefit of the postprocedural chest radiograph has never been evaluated in the hemodialysis population. We retrospectively reviewed the data on internal jugular access placement from two large nephrology training centers. Over a 36-month period, 460 internal jugular dialysis catheters were placed in 312 patients. Wherever possible, 15-cm lines were used for the left internal jugular vein and 12-cm lines for the right internal jugular vein. Ultrasound guidance was used in 105 cases (22.8%). There were a total of 90 (19.6%) clinical complications in 62 patients (13.5%) These consisted of carotid artery puncture (n = 35, 7.6%) and hematoma (n = 55, 12%). All of these patients had a normal post-internal jugular chest radiograph. Carotid artery puncture did not occur if ultrasound guidance was used. There was no case of associated pneumothorax. Of the 370 line insertions in 250 patients in whom it was believed clinically that no complication had occurred, the chest radiograph only showed unsuspected line malposition in four cases (1.08%). Routine chest radiographs rarely contribute to the diagnosis of any procedural complications and are of little value after internal jugular access placement, especially if it is believed clinically that no complication occurred.