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RESULTS: Opacification frequently developed in the rightupper lobe. The bronchial ostium stayed open in allcases. In some cases, development of granulation tissuein the region of the stent was noted. In a few cases, therealso seemed to be more accumulation of secretions inthe stented areas. One of the Palmaz stents was crushedduring the study.

CONCLUSIONS: Stents can be placed across the ostium ofbronchi without causing obstruction. The stents cause anincrease in granulation tissue, and secretions may not beas effectively cleared.

Take Home Points:1. Stents may be placed across the bronchial ostium.

2. Granulation tissue will form at the stent site.

3. Secretions may not clear as effectively and cause at­electases.

4. The stents differ in their applicability for the tracheo­bronchial tree.

3:30 pm

Clinical Experience with Expandable MetallicStents to Treat Tracheobronchial Obstructions

B.M. Hoppenfeld, MD, Newark, NJ • H. Mast, MD • R.Shoenfeld, MD • A. Novick, MD

PURPOSE: To study the efficacy of tracheobronchialstents to treat central airway obstructions.

MATERIALS AND METHODS: Twenty-two patients withairway obstruction received a total of 45 tracheobronchi­al stents (39 Wallstents® [Schneider Inc., Minneapolis,MN], three elastomer-covered Wallstents®, and three Gi­anturco Z-stents). Indications included symptomatic ma­lignant airway obstruction (n = 15), postintubation tra­cheal stenosis (n = 3), post-transplant anastomotic bron­chial stenosis (n = 1), exclusion of a dehiscedpneumonectomy stump (n = 1), transbronchial drainageof a postobstructive lung abscess (n = 1), and prophy­laxis of impending airway closure before radiotherapy(n = 1).

RESULTS: Symptoms, which included chronic lobar col­lapse, prophylactic stenting, tumor mass mistaken forcollapse, and left upper lobe collapse after stenting ofthe left lower lobe (our only complication), were notimproved in four of 22 patients. Six patients becameasymptomatic. Three others had tissue ingrowth throughthe stent that required restenting (two with coveredstents). Patient survival ranged from 1.5 weeks to 1.5years. Thirteen patients are still alive. Three died of co­morbid conditions and six died of progression of extra­pulmonary disease or progressive respiratory compro­mise.

CONCLUSION: Tracheobronchial stenting effectively re­lieves benign and malignant symptomatic airway ob­structions.

Take Home Points: Both benign and malignant tra­cheobronchial obstructions respond well to stenting. Inmost patients, symptoms improve dramatically. Stentingof chronic lobar collapse is ineffective because it doesnot restore functional patency.

3:45 pm

Percutaneous Transthoracic Duct Catheterizationto the Neck and Esophagus: A Feasibility Studye. Cope, MD, Philadelphia, PA

PURPOSE: To assess the feasibility of inserting a draincatheter percutaneously from the cysterna chyli (CC)through the thoracic duct (TD) wall to the neck oresophagus for potential long-term T-cell sampling anddrainage.

MA ThlUALS AND METHODS: Percutaneous transabdom­inal catheterization of the TD from the CC was per­formed in three animals to insert a 60-cm 21-gaugeneedle over a micro guide wire. In one dog, the distal TDwas perforated into the neck to insert a TD drain to anaccess port. In acute experiments on two swine, theesophagus was accessed by puncturing the mid-TD toinsert a catheter into the distal esophagus.

RESULTS: Transmediastinal TD-to-neck catheterizationwas well tolerated during 1 week of observation exceptfor a skin infection that developed over the port. Thetechnique for TD-to-esophagus catheterization in swinewas feasible with no acute complications.

CONCLUSIONS: Percutaneous inside-out transmuralcatheterization of the TD to reach the neck or theesophagus is feasible and may have clinical applicationsfor immunosuppression by T-cell depletion.

Take Home Points: Transabdominal percutaneoustransmural thoracic duct catheterization for lymph drain­age to the neck or esophagus is feasible in animals.

Scientific Session 18Central Venous AccessModerator: John Cardella, MD, Hershey, PA

2:30 pm

Ultrasound Guidance of the Internal Jugular Veinfor Central Venous Access].G. Caridi, MD, Gainesville, FL • I.P. Hawkins, Jr. MD

• BN. Wiechmann, MD .].e. Tonkin, MD • DJ.Pevarski, MD

PURPOSE: To prospectively demonstrate the safety andaccuracy of right internal jugular (RIJ) vein cannulationfor central venous access when guided by hand-heldultrasound.

MA7ERIALS AND METHODS: Eighty sequential patientshaving central venous access procedures were evaluatedwith hand-held ultrasound to determine the size, pa-

tency, and location of the Rl] vein before puncture. Peri­procedural complications were recorded and comparedhistorically with those of Rl] cannulation using visibleand palpable anatomic landmarks.

RESULTS: RI] vein anatomy was typical in only 57(71.2%) patients. A medial position of the Rl] anterior tothe common carotid artery was shown in 13 (16.3%)patients. In three patients (3.7%) it was positioned later­ally by more than 1 cm; in the remaining seven patientsit was thrombosed. Its size varied (from .5 to 2 cm). Rl]cannulation was achieved in all patent veins with onepuncture in 68 patients (93.1%); two punctures in three(4.1%) patients; and three punctures in two patients(2.8%). There was only one complication and it was un­related to the puncture. There were no inadvertent com­mon carotid artery punctures.

CONCLUSIONS: When compared with a blind anatomicapproach, ultrasound guidance of the Rl] vein greatlyimproves the safety and efficiency of cannulation forcentral venous access.

Take Home Points:1. Rl] vein anatomy varies.

2. Ultrasound guidance improves accuracy and effi­ciency of Rl] cannulation.

3. Ultrasound guidance, through direct visualization,decreases the incidence of complications.

2:45 pm

Advantages of the Posterior Internal Jugular VeinApproach to Place Subcutaneous VenousAccess DevicesM. Rosenblatt, MD, New Haven, CT • IS. Pollak, MD •

E.B. Matros, BS • TK. Egglin, MD • K. W Dickey, MD •IF. Houston, MD

PURPOSE: To compare the incidences of pneumothoraxand symptomatic central venous occlusive disease(CVOD) after placing subcutaneous venous access de­vices (SVADs) using either a subclavian vein (SCV) orlow posterior internal jugular vein (I]V) approach.

MATERIALS AND METHODS: We compared 151 con­secutive SVADs placed via the posterior JJV approachwith 154 consecutively placed SCV SVADs. The groupswere similar in composition. We chose the posterior ap­proach because it permitted a smooth catheter course tothe chest wall reservoir. All procedures were performedin an interventional radiology suite. Patients were evalu­ated for pneumothorax and symptomatic CVOD usingpostprocedural upright chest radiographs and periodicpatient interviews.

RESULTS: Cumulative follow-up times for the SCV andI]V groups were 27,245 and 24,876 days, respectively.We noted three pneumothoraces (1.9%) and seven(4.5%) instances of symptomatic CVOD in the SCVgroup. In contrast, these complications did not occur in

the I]V group. This difference was highly significant (P <.005). Although the incidence of pneumothorax alonewas too low to be significant between the two groups,the difference in the occurrence of symptomatic CVODwas significant (P < .05).

CONCLUSION The posterior []V approach is safer thanthe SCV approach for implanting long-term central ve­nous catheters.

Take Home Points: Use of the posterior I]V approacheliminates most of the major, non-infectious complica­tions associated with placement of subcutaneous venousaccess devices.

3:00 pm

Image-Guided Long-Term Central Venous Accessin Immunocompromized PatientsB.P. Stainken, MD, Albany, NY. K. Dowling, MD • A.

Herr, MD • G. Siskin, MD • V.S. Mandell, MD

PURPOSE: Patients having bone marrow transplantationpresent unique challenges for vascular access. The initiallarge-caliber dual-lumen access reqUired for peripheralstem cell harvesting is frequently followed by the needfor multilumen small-caliber systems. Patients are com­monly thrombocytopenic and consistently immunocom­promized. We reviewed our experience with image­guided vascular access in this patient population andcompared it with contemporaneous single-institutionsurgical experience.

MATERIALS AND METHODS: Bone marrow transplantregistry records were accessed and charts were re­viewed. Data on type of catheter, surgeon, dwell time,complications, and flush regimen were compiled.

RESULTS: During a 3-year period, 113 centrally tunneledapheresis catheters were placed in 77 patients undergo­ing peripheral stem cell harvest and isogenic marrowtransplantation. Forty-seven lines were placed in the op­erating room by five surgeons and 65 were placed in anangiography suite under ultrasound and fluoroscopicguidance by five interventional radiologists. There wasno significant difference in average dwell time. Compli­cations resulting in failed placement or catheter removaloccurred in 17% of lines placed in the operating roomcompared with 5% of lines placed in the angiographysuite. Complications treated with continued catheter usewere identified in 34% of lines placed in the operatingroom and in 18% of lines placed in the angiographysuite. Catheter infection was identified in 6.3% of linesplaced in the operating room and all were removed.Three percent of lines placed in the angiography suitewere infected and all were successfully treated with an­tibiotics.

CONCLUSIONS: Large-caliber chronic central venous ac­cess devices can be safely placed in an immunocompro­mised population in the angiography suite using ultra­sound and fluoroscopic guidance with a lower risk of

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major and minor complication compared with similarlines placed in the operating room.

Take Home Points:1. Large-bore tunneled central lines can be placed safely

in the angiography suite.

2. Ultrasound and fluoroscopic guidance simplify place­ment and allow for improved outcomes.

3:15 pm

Implanted Chest Ports Placed by InterventionalRadiologists: Immediate and DelayedComplications in 350 Cases

M.K. Mody, MD, Detroit, MI. P.e. Shetty, MD • Dj.

Kastan, MD • RP. Sharma, MD • M. W. Burke, MD

PURPOSE: To determine the incidence of immediate anddelayed complications of implanted chest ports placedby interventional radiologists.

MATERIALS AND MElliODS: Between June 1993 andJuly 1996, five interventional radiologists at a single in­stitution placed 350 implanted infusion ports in 346 pa­tients by the subclavian vein approach. The medical re­cords of these patients were reviewed to identify theimmediate and delayed complications.

RESULTS: Ports were implanted for chemotherapy (341),blood transfusion (7), or antibiotics (2). Immediate com­plications included seven (2%) pneumothoraces and one(0.3%) hematoma. Four 0.1%) of the pneumothoracesrequired hospital admission and treatment with a chesttube. The remaining three were managed on an outpa­tient basis. One was successfully treated in the interven­tional suite by catheter suction. Two were observed andresolved spontaneously. The mean time of follow-upwas 260 days (range, 22 to 929 days). Follow-up timetotalled 91,000 catheter-days. Delayed complicationswere 10 cases (2.9%) of thrombosis of the subclavianvein, four cases 0.1%) of infection, four cases 0.1%) ofcatheter coiling or malposition, three cases (0.9%) ofcatheter occlusion, and one case (0.3%) of catheter leak.Six (1.7%) ports had to be removed because of delayedcomplications.

CONCLUSIONS: Implanted chest port placement by in­terventional radiologists in the radiology department is asafe and successful procedure with lower complicationrates than those reported in surgical placement series.

Take Home Points: In our series, the immediate com­plications of implanted chest ports placed by interven­tional radiologists were pneumothorax (2%) and hema­toma (0.3%). Delayed complications were venousthrombosis (2.9%), infection 0.1%), catheter coiling ormalposition (1.1%), catheter occlusion (0.9%), and cath­eter leak (0.3%). These complication rates compare fa­vorably to those reported in surgical series.

3:30 pm

Predictive Factors for Long-term Venous AccessRemoval Due to Infectionj.M. Llerena, MD, Lafayette, LA • j. Garcia Medina,

MD • M. Casal, MD • V Garcia-Medina, MD • e.Lopez-Ramon y Cajal, MD • j. Vieito, MD

PURPOSE: To define factors that may predict an in­creased risk for infection and subsequent removal oflong-term venous access devices in immunosuppressedpatients.

MATERIAIS AND MElliODS: We studied 198 long-termvenous access devices in patients with hematologic neo­plasms (n = 104), solid tumors (n = 77), or positive hu­man immunodeficiency virus (HIV) status (n = 17). Pa­tients' mean age was 43.1 years. Access devices weresubcutaneous ports (n = 156) or tunneled Hickman cath­eters (n = 42). Venous approaches were the internaljugular (n = 187), external jugular (n = 4), subclavian (n

= 2), or basilic (n = 5) veins. Eighty-nine procedureswere performed on an outpatient basis. Various factorswere evaluated using the lineal regression analysis.

RESULTS: Mean follow-up time was 215.7 days. Duringthis time, 29 04.6%) central venous accesses were re­moved because of infection. A statistically significantnumber of line infections were noted in patients withhematologic neoplasms (P < .05), HIV+ status (P < .05),and tunneled Hickman catheters (P < .05). No significantnumber of infections were noted in patients with solidtumors or subcutaneous ports. There was also no rela­tion between line infection and patient age, site of ve­nous approach, or outpatient or inpatient status.

CONCLUSIONS: Removal of long-term venous access de­vices is commonly due to infection. Specific attention to

possible predictive factors for infection in immunosup­pressed patients may help to decrease complicationrates.

Take Home Points: Immunosuppressed patients withlong-term venous access devices showed an increasedprobability of infection and line removal when an he­matologic neoplasm or HIV+ status were present orwhen the central venous access device was a tunneledHickman catheter.

3:45 pm

Clinician Referral Selection in Central VenousCatheter Placementj. Underwood, IV; MD, Omaha, NE • Te. McCowan,MD. Te. Goertzen, MD. R.F. LeVeen, MD

PURPOSE: To evaluate clinicians' decisions for referral ofcentral venous catheter (CVC) placement to interven­tionaI radiologists.

MATERIALS AND MElliODS: A multiquestion survey ofthe CVC referral base, primarily physicians specializingin hematology/oncology and nephrology, with scaled

responses in two categories: service (eg, scheduling, pa­tient satisfaction, and so on) and technical (eg, compli­cation rate, success rate, and so on) was used. Clinicianswere also requested to list their preference of radiology,surgery, or none for each question in both sections.

RESULTS: The radiology department was the preferredreferral (22 of 30 choices, 73%) in the service section. Inthe technical category, most respondents listed no pref­erence (19 of 30 choices, 63%) and the rest (11 of 30choices, 37%) listed the radiology department. Prompt­ness in catheter placement received the highest impor­tance score, and patient comfort received the least scoreon the survey. The radiology department received ahigher preference score from hematologists/oncologiststhan from nephrologists.

CONCLUSIONS: Referral to radiologists for CVC place­ment is based primarily on service factors, especially thepromptness of response to insertion requests. Referringphysicians had no preference in relation to technicalquality.

Take Home Points:1. Clinical referrals for central venous catheter place­

ment are based primarily on the service quality of theinterventional radiology department.

2. Referring clinicians had no overall preference for ra­diology versus surgery in regards to technical perfor­mance of catheter placement.

3. Recognition of the true reasons for patient referral areimportant in starting and maintaining central venouscatheter placement service.

Wednesday, March 12, 19978:00 - 9:30 am

Scientific Session 19Cantral Venous InterventionsModerator: Anthony C. Venbrux, MD, Baltimore, MD

8:00 am

Sharp Recanalization of Long-term CentralVenous OcclusionsT. Farrell, MD, Iowa City, IA • E. V. Lang, MD

PURPOSE: We describe a sharp puncture technique forrecanalization of long-term central venous occlusionsthat could not be traversed by guide wires.

MATERIALS AND METHODS: Six central venous occlu­sions were treated in five patients after unsuccessfulthrombolysis. Causes included SVC syndrome due tolung tumors (n = 2), previous indwelling catheters (n =

2), and porphyria (n = 1). The length of venous occlu­sion was determined by simultaneously advancing trans­brachial and transfemoral catheters to the site of occlu­sion. A curved gUiding catheter with a Rosch needleinitially and in subsequent cases a prototype puncture

system with a 21-gauge stylet was used. The recanalizedsegments were then stented

RESULTS: Recanalization was technically successful infour of the five patients. The occlusion was too long totraverse safely in one patient. The three surviving pa­tients are asymptomatic 4 to 8 months after the proce­dure.

CONCLUSION This new technique offers an effectivealternative to surgery to treat central venous occlusion.

Take Home Points: Using a customized kit, sharp re­canalization of central venous occlusions may be per­formed using combined transfemoral and transbrachialroutes.

8:15 am

Asymptomatic Superior Vena Cava Occlusion:Recanalization and Stenting for CentralVenous AccessWS. Rilling, MD, Milwaukee, WI • M. W Mewissen,

MD • M.R. Crain, MD • R. Paz-Fumagalli, MD • j.D.

Lane, MD. D. Bair, MD

PURPOSE: To determine the safety and efficacy of re­canalizing and stenting asymptomatic superior vena cava(SVC) occlusions for long-term central venous access.

MATERIALS AND METHODS: From January 1995 to Au­gust 1996, five patients with known asymptomatic SVCocclusion were referred for placement of large-bore cen­tral venous catheters. Recanalization and stenting of theSVC was attempted using the "through and through"venous access technique from the common femoral andinternal jugular veins.

RESULTS: SVC recanalization and stenting was successfulin four of five patients (Z-stents, n = 3; Wallstents®[Schneider Inc., Minneapolis, MNJ, n = 1), allowing suc­cessful placement of long-term central venous catheters(dialysis, n = 2; other, n = 2). In one patient, the SVCocclusion could not be crossed and the patient wasplaced on peritoneal dialysis. There were no complica­tions and no known episodes of SVC thrombosis afterstenting and catheter placement.

CONCLUSIONS: SVC recanalization and stenting is a safeand useful procedure to obtain long-term central venousaccess in patients with SVC occlusion. This approachmay have some advantages over the limited alternativeoptions in this patient population.

Take Home Points: Percutaneous recanalization ofasymptomatic SVC occlusions is feasible in patients whoneed long-term central venous access.

8:30 am

Percutaneous Treatment of Central VenousStenoses and Occlusions Using Self-expandingStents: Long-term ResultsN. Rilinger, MD, Ulm, Germany • j. G6rich, MD • V

Mickley, MD • R. Sokiranski, MD • R. Tomczak, MD •

H. Brambs, MD219