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PURPOSE - Peripherally inserted central catheters (PICCs) have become an essential component of the management of an increasing number of patients, including patients who may require hemodialysis. Reported symptomatic venous thrombosis rates associated with PICC lines are based on clinical signs and symptoms and range from 1% to 4%. The purpose of this study is to evaluate the true rate of thrombosis of upper extremity veins after the placement of PICCs and the potential impact on future access in hemodialysis patients.
MATERIALS AND METHODS - A retrospective analysis was performed. Patients who had (i) normal findings during initial venography, (ii) PICC placement, and (iii) who underwent subsequent repeated venography were included. Age, sex, vein cannulated, catheter size, location, and incidence of thrombosis were analyzed.
RESULTS - Three hundred fifty-four PICCs were placed in 119 patients. Of the 144 extremities, 137 had normal findings during initial venography. Of the 137 extremities, 32 developed thrombosis of the cannulated vein (or central veins) after initial PICC placement (23.3%). When all extremities with multiple PICC lines placed were considered, 52 developed thrombosis, for an overall thrombosis rate of 38%. The incidence of thrombosis by site was cephalic 57%, basilic 14%, and brachial 10%. No significant differences were noted in the rates of thrombosis by age, sex, or catheter size.
CONCLUSIONS - There is a relatively high rate of venous thrombosis associated with PICCs, particularly cephalic thrombus. Because of the high rate of thrombosis associated with these catheters, an alternative mode of access should be considered in current or potential hemodialysis patients. All patients with a history of PICC line placement requiring dialysis access should undergo upper extremity venography prior to the placement of permanent access.
PURPOSE - Massive pulmonary embolus (PE) is often rapidly fatal. Surgical thrombectomy has a mortality rate as high as 74%. Multiple percutaneous methods have been tested with limited success. The purpose of this study was to evaluate the Arrow-Trerotola percutaneous thrombolytic device (PTD) for (i) the ability to clear pulmonary embolus and (ii) the effect on normal pulmonary vasculature. These were tested in a canine model.
MATERIALS AND METHODS - Iatrogenic unilateral massive PEs were created in nine canines. These PEs were then treated with the PTD. The device was also activated in the normal pulmonary artery. Immediately after treatment, six animals were killed. Three animals were allowed to recover and underwent pulmonary arteriography 1 month later to evaluate pulmonary hypertension, stenosis, or occlusion; they were then killed. Autopsy specimens were evaluated for histologic evidence of acute or chronic vascular injury.
RESULTS - Acutely, the PTD effectively thrombolysed the PE in all animals. Histologically, there was moderate intimal injury, but no evidence of pulmonary artery disruption. There was one device failure. One month after treatment, there was no radiographic evidence of pulmonary stenosis at device activation sites, no pulmonary hypertension, and only mild histologic evidence of scar formation.
CONCLUSION - In preliminary animal testing, the PTD is safe and effective for treating large central pulmonary emboli. Human clinical trials are warranted.
PURPOSE - Significant inferior vena cava (IVC) filter migration has been associated with deployment of some filter types in IVCs measuring more than 28 mm in diameter at inferior vena cavography. The purposes of this study were to (a) determine if significant differences exist between IVC measurements obtained using a gold standard technique and two other widely accepted methods, and (b) if differences exist, how often do these differences cause incorrect IVC sizing around a diameter of 28 mm, with its associated filter migration issues.
MATERIALS AND METHODS - One hundred thirteen consecutive inferior vena cavograms were retrospectively reviewed. The transverse diameter of the infrarenal IVC was determined by using a calibrated intravascular catheter (the gold standard), subtraction of 20% from the measured transverse IVC diameter on a cut-film radiograph, and a radiopaque ruler placed immediately posterior to the patient.
RESULTS - The concordance correlation of the 20% magnification method versus internal calibration was 0.94. Kappa analysis to determine agreement at a diameter of 28 mm yielded a Kappa coefficient of 0.490. The concordance correlation of an external ruler versus internal calibration was 0.43, with a Kappa coefficient of 0.
CONCLUSION - The poor Kappa correlations for both methods demonstrate that they are unreliable in identifying megacava. Inferior vena cavography prior to IVC filter placement should be performed with a calibrated intravascular catheter.
The current study was designed first to determine separately the prescribed and delivered dose of dialysis and, second, to determine what factors lead to failure to deliver the prescribed dose of dialysis in patients with acute renal failure (ARF). Forty patients, who collectively underwent 136 dialysis treatments, were studied prospectively at two institutions. The results showed that almost half the prescriptions (49%) were for a Kt/V less than 1.2 and, more importantly, nearly 70% of the treatments delivered a Kt/V less than 1.2, the minimally acceptable dose defined in the Dialysis Outcomes Quality Initiative (DOQI) guidelines for chronic hemodialysis (CHD) patients. Patient predialysis weight was the most important variable associated with a low prescribed and delivered dose of dialysis, as well as lack of delivery of the prescribed dose of dialysis. From the statistical model, it is estimated that for every 10-kg increase in predialysis weight, the chance of prescribing or delivering a Kt/V less than 1.2 increased 4.6- and 1.95-fold, respectively. The lower than prescribed blood flow achieved by the temporary catheters and patients not receiving anticoagulation were variables also associated with not receiving the prescribed Kt/V. It is concluded that patients with ARF are prescribed and receive a dose of dialysis that would be considered inadequate for CHD patients. Until the association between dose of dialysis and outcome is better defined, it would be prudent that both the dialysis prescription and the delivery of dialysis to patients with ARF should be performed with the same care and goals as that currently received by patients with end-stage renal disease (ESRD).