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Biomedical subjects

J J Bookstein

Publications and source records attributed to J J Bookstein.

At least 19 recordsLinked to original sources
PubMed1995

Postangiographic femoral artery pseudoaneurysms: further experience with US-guided compression repair.

PURPOSE: To assess the efficacy of ultrasound-guided compression repair (UGCR) in postcatheterization femoral artery pseudoaneurysms. MATERIALS AND METHODS: One hundred thirty-three patients with pseudoaneurysms were considered for UGCR. Patients underwent compression with duplex and color Doppler ultrasound. Immediate and long-term successes were evaluated. RESULTS: Seven patients were not candidates for UGCR. UGCR was technically possible in 117 of the 126 patients who were candidates. UGCR was successful in 109 patients. The failure rate was significantly higher in patients who were receiving anticoagulant medication (P < .001). Pseudoaneurysm size, age, and structure (simple vs multiloculated) had no bearing on success or failure. The time required for successful compression was not related to treatment with anticoagulants but was related to pseudoaneurysm structure. Complications included one case of a distal embolus and two episodes of hypotension. CONCLUSION: UGCR is a simple and expedient method for the treatment of postcatheterization femoral artery pseudoaneurysms.

Aneurysm, False↗
PubMed1995

Hand ischemia in patients with hemodialysis access grafts: angiographic diagnosis and treatment.

PURPOSE: To determine the cause of symptoms and efficacy of transcatheter therapy in a series of patients with dialysis grafts and hand pain referred for arteriography. MATERIALS AND METHODS: Thirteen patients with 14 hemodialysis grafts underwent arteriography for possible hand ischemia. The sites of proximal graft anastomosis were the distal radial artery (n = 6) and the mid- to distal brachial artery (n = 6). Transcatheter therapy was performed via the graft or by antegrade brachical puncture. RESULTS: The cause of symptoms was ischemia from obstructive arterial disease in seven cases (three with superimposed steal), graft steal alone in three, ischemic monomelic neuropathy in two, and carpal tunnel syndrome in two. Five arterial stenoses were treated with angioplasty, with improvement or resolution of symptoms in four patients. CONCLUSION: In this group, symptoms were usually the result of inflow or outflow arterial disease, alone or in combination with graft steal. Transcatheter therapy (angioplasty or embolization) is effective in selected cases.

Adult↗
PubMed1995

Pulse-spray pharmacomechanical thrombolysis of thrombosed hemodialysis access grafts: long-term experience and comparison of original and current techniques.

OBJECTIVE: Pulse-spray pharmacomechanical thrombolysis is an evolving method for the treatment of vascular occlusions in which a highly concentrated fibrinolytic agent is injected as a high-pressure spray directly into thrombus. The purpose of this retrospective study was to analyze our long-term experience with this technique for the treatment of clotted hemodialysis grafts and to compare the efficacy and safety of the original and current methods. SUBJECTS AND METHODS: Over 6 years, 284 cases of dialysis graft thrombosis were considered suitable for treatment with pulse-spray thrombolysis. The original technique involved the injection of highly concentrated urokinase directly into a clot through two crisscross catheters with multiple side holes. The current technique includes early fragmentation of residual clot with a balloon catheter, intrathrombic injection of heparin, mechanical treatment of a lysis-resistant clot at the arterial anastomosis, and routine administration of aspirin. After thrombolysis, underlying obstructions were treated with balloon angioplasty, atherectomy, or stents. The technical success, immediate clinical success, and frequency of complications for the entire population were analyzed. In addition, the results for 36 cases treated with the original technique were compared with the results for 37 recent cases treated with the current technique. RESULTS: Of 284 cases considered suitable for treatment, thrombolysis was not done in eight cases because the venous anastomosis could not be crossed. Thrombolysis was discontinued in two cases because of extravasation of contrast material. The technical success for all grafts considered for treatment was 96%; 92% of treated grafts remained patent for at least 24 hr. Major complications occurred in 1% of cases, and minor complications occurred in 9% of cases. The clinical efficacies of the original and current techniques were 86% and 92%, respectively. The mean thrombolytic agent infusion time was reduced from 44 +/- 20 min to 23 +/- 13 min (p < .001). The overall procedure time for the recently treated subgroup was 67 +/- 26 min. There was no significant difference in the frequencies of major and minor complications between the treatment subgroups. CONCLUSION: Pulse-spray pharmacomechanical thrombolysis is a reliable, rapid, and safe method for recanalization of occluded dialysis grafts. The current technique has been proven as safe and effective as the original technique but offers the advantage of a significant reduction in the time required for the infusion of thrombolytic agent.

Anastomosis, Surgical↗
PubMed1994

Is thrombolysis of occluded popliteal and tibial bypass grafts worthwhile?

PURPOSE: We analyzed the short- and long-term results for patients undergoing thrombolysis of occluded infrainguinal bypass grafts at our institution over a 62-month period. METHODS: Thirty-one patients with 40 episodes of graft thrombosis in 33 grafts managed by thrombolysis were retrospectively reviewed. The effects of graft age, material, and anatomy, symptoms, treatment, anticoagulation, and occlusion duration were evaluated for impact on patency after thrombolysis. Dose and duration of therapy with use of the technique of pulse-spray thrombolysis was assessed. RESULTS: Thrombolysis successfully reestablished patency in 92% of grafts treated. Mean lysis time and urokinase dose were 118 minutes and 607,000 units, respectively. Responsible lesions were identified and treated by angioplasty or surgery in 35 of 37 cases. The patency rate after thrombolysis was 28% at 30 months, and the secondary patency rate was 46% at 18 months. Duration of occlusion, symptoms, treatment, graft anatomy, and prior graft revision did not impact on patency. Mean secondary patency was 21.5 months in grafts in place over 1 year and 7.0 months in grafts in place for less than 1 year. Mean secondary patency was 23.8 months in polytetrafluoroethylene grafts and 8.4 months in vein grafts. The limb salvage rate was 84% at 30 months, and the patient survival rate was 84% at 42 months. CONCLUSIONS: Pulse-spray thrombolysis is effective in rapidly recanalizing thrombosed infrainguinal grafts. Grafts failing in the first year after placement should generally be replaced, reserving thrombolysis and revision for grafts greater than 1 year old. Vein grafts tolerate thrombosis less well than synthetic conduits and have decreased long-term patency.

Adult↗
PubMed1994

Overdilation of the Wallstent to optimize portal decompression during transjugular intrahepatic portosystemic shunt placement.

PURPOSE: To optimize shunt size with overdilation of the Wallstent during creation of a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: A TIPS was created in 25 patients with variceal bleeding (n = 22) or intractable ascites (n = 3). All shunts were created with one or more Wallstents that were dilated with an 8- or 10-mm balloon. In 11 patients with inadequate portal decompression or persistent filling of varices, shunts were overdilated with a 12-mm balloon. RESULTS: Mean portosystemic pressure gradient fell from 18.0 mm Hg +/- 6.4 (standard deviation) to 6.8 mm Hg +/- 2.8 after shunt placement. In 11 patients in which shunts were overdilated, the mean gradient fell from 12.7 mm Hg +/- 5.6 after 10-mm dilation to 6.9 mm Hg +/- 2.8 (P = .01) after 12-mm dilation. In six, variceal filling occurred after 10-mm dilation but diminished or ceased after overdilation. Stent disruption did not occur. New or worsened encephalopathy occurred in four of 14 patients with 10-mm and six of 11 patients with 12-mm shunt dilation and responded to medical therapy in all but two. CONCLUSION: Overdilation of the Wallstent during TIPS placement is effective and safe in patients with inadequate portal decompression after 10-mm shunt dilation.

Adult↗
PubMed1993

Pulse-spray pharmacomechanical thrombolysis for treatment of thrombosed dialysis access grafts.

The results of pulse-spray pharmacomechanical thrombolysis (PSPMT) of 209 thrombosed hemodialysis grafts were reviewed. In PSPMT, concentrated urokinase is injected forcefully through catheters with multiple tiny sideholes or sideslits. Catheters placed in a crisscross fashion cover the entire clot simultaneously. This therapy was successful in treating patients with thrombosed grafts. Of the 200 grafts with complete therapy, 197 grafts (99%) were patent at the end of the procedure. Mean time for pulsed-spray lysis was 40 minutes. Etiologies for graft thrombosis were anastomotic venous outflow stenosis, stenosis of the venous outflow away from the anastomosis, arterial stenosis, intragraft stenosis, pseudoaneurysms, and no identifiable cause in a small percentage. There were 16 complications, 8 of which required additional therapy or potentially compromised the graft. These results suggest that pharmacomechanical thrombolysis and angioplasty provide rapid, consistent, and safe recanalization of thrombosed hemodialysis grafts and represent an additional therapeutic approach to graft management.

Angioplasty, Balloon↗
PubMed1993

Effects of intrathrombic administration of prostaglandin E1 during pulse-spray thrombolysis with tissue-type plasminogen activator in experimental thrombosis.

The effects of intrathrombic and intravenous injection of prostaglandin E1 (PGE1) during pulse-spray thrombolysis were studied in a rabbit model. Thrombi were produced in the inferior vena cava of 46 rabbits by means of vessel wall injury and placement of steel coils. At 2 days, pulse-spray thrombolysis was performed by using a catheter with multiple side holes spanning the clot. A control group received injections of saline. In all other rabbits, 3 mg of tissue-type plasminogen activator (tPA) was injected into the thrombus over 1 hour, and 500 U of heparin was intravenously administered. PGE1 was administered either intravenously (50 micrograms) or directly into the thrombus (10, 25, or 50 micrograms) in four groups. After treatment, the rabbits were killed and the residual clot was weighed. The relationship between clot length and volume measured on angiograms and clot weight was assessed in 13 additional untreated rabbits. Linear regression analysis was used to estimate the initial clot weight on the basis of measured clot length in treated animals. The extent of clot lysis was significantly greater with injection of tPA and 10-, 25-, or 50-micrograms PGE1 directly into the thrombous than with administration of tPA alone.

Alprostadil↗
PubMed1993

Occluded peripheral arteries and bypass grafts: lytic stagnation as an end point for pulse-spray pharmacomechanical thrombolysis.

Angiographic demonstration of luminal narrowing during pulse-spray pharmacomechanical thrombolysis (PSPMT) may reflect residual lysable clot, organized thrombus, platelet-rich clot, atherosclerosis, neointimal hyperplasia, or functional narrowing. The authors evaluated the efficacy and safety of lytic stagnation (initial rapid lysis followed by insubstantial further lysis with additional treatment) as an end point for PSPMT. Lytic stagnation was evaluated with serial angiography in 16 arterial and five bypass graft occlusions. Substantial lysis occurred after administration of mean doses of 512,000 units +/- 182,000 of urokinase or 5.3 mg +/- 2.0 of tissue-type plasminogen activator. Additional treatment with either of those agents produced minimal or no further change in the appearance of residual disease. Recanalization was successful in all patients after angioplasty. Distal emboli were noted in four cases, in three of which angioplasty of large intraluminal filling defects had been performed. The authors conclude that lytic stagnation is a reliable and safe end point for PSPMT in the absence of large intraluminal filling defects.

Adult↗
PubMed1993

Diagnosis of arteriogenic impotence: efficacy of duplex sonography as a screening tool.

OBJECTIVE: The results of duplex sonography of the cavernosal artery were compared with the results of pharmacoarteriography in a series of impotent men in order to assess the validity of sonography as a screening tool for the diagnosis of arteriogenic impotence. SUBJECTS AND METHODS: Duplex sonography was performed in 30 impotent men after intracavernosal injection of papaverine and phentolamine. Maximal acceleration, peak systolic velocity, and resistive index were determined for the cavernosal artery. All patients had selective pharmacoarteriography and cavernosometry, which were used to diagnose arterial disease (bilateral hemodynamically significant stenoses or occlusions), suspected arteriolar dysfunction (inconspicuous helicine arterioles), or venoocclusive insufficiency (pharmacologic maintenance erectile flow greater than 25 ml/min). Seventeen patients had arterial insufficiency, four had arteriolar dysfunction, and nine had no significant arterial disease. RESULTS: Significant differences in Doppler measurements were found between patients without significant arterial disease and those with arterial insufficiency, including peak systolic velocity (50 +/- 25 cm/sec vs 33 +/- 17 cm/sec, p = .04), acceleration (524 +/- 261 cm/sec2 vs 199 +/- 111 cm/sec2, p < .001), and resistive index (88 +/- 12% vs 73 +/- 11%, p = .002). Differences were also noted between the group without significant arterial disease and the group with arteriolar dysfunction. When peak systolic velocity of less than 25 cm/sec or acceleration less than 400 cm/sec2 was used as an indication of inadequate arterial patency, the sensitivities were 35% and 100%, the specificities were 61% and 46%, and the negative predictive values were 42% and 100%, respectively, in the diagnosis of arterial insufficiency. CONCLUSION: Duplex sonography of the cavernosal arteries may be a useful screening tool in patients with suspected arteriogenic impotence only when acceleration is evaluated in addition to peak systolic velocity. The specificity of the method may be partially limited by the inability to distinguish between arterial and arteriolar disease.

Adolescent↗
PubMed1992

Angiographic embolization in the management of hemorrhagic complications of pregnancy.

Obstetric hemorrhage continues to be a major cause of maternal mortality and morbidity. Recent developments in percutaneous angiographic embolization techniques have afforded the ability to control persistent bleeding from pelvic vessels while avoiding the morbidity of surgical exploration. We report the use of angiographic embolization in 10 cases of pregnancy-related hemorrhage, including persistent postcesarean bleeding (three cases), vaginal wall hematomas (four cases), cervical ectopic pregnancies (two cases), and postpartum bleeding as a secondary complication of uterine myomas (one case). The embolization procedures were successful in all cases. Nine of 10 patients experienced postprocedural fever with eight cases resolving with antibiotic therapy alone and one patient requiring vaginal drainage of the hematoma-abscess. The mean length of time for the procedure was 167 minutes (range 70 to 270). The average length of hospitalization was 8 days (range 2 to 13). These data indicate that angiographic embolization is effective in treating hemorrhagic complications of pregnancy in hemodynamically stable patients and is preferable to surgery in selected cases.

Angiography↗
PubMed1992

Efficacy of adjunctive intrathrombic heparin with pulse spray thrombolysis in rabbit inferior vena cava thrombosis.

RATIONALE AND OBJECTIVES: The efficacy and speed of pharmacomechanical thrombolysis may be limited by thrombotic effects of activated platelets and thrombin within the lysing clot. The authors designed an animal model of subacute venous thrombosis which was used to evaluate the effect of intrathrombic versus intravenous heparin during thrombolysis. METHODS: Inferior vena cava (IVC) thrombosis was induced in rabbits by balloon catheter injury and placement of steel coils. Venacavagrams were obtained 48 hours later to document clot formation and for angiographic estimation of clot volume. Pulse-spray thrombolysis was performed by forceful injections of various agents through a catheter with multiple side holes spanning the clot. Most animals were given aspirin (30 mg orally) before treatment. After 1 hour of therapy, repeat venacavography was performed. Animals were killed, and residual clot weight was determined. RESULTS: Occlusive IVC thrombi were present in 94% of rabbits at 2 days. Mean residual clot weight per milliliter of estimated initial clot volume (mg/mL) for the various treatment groups was as follows: saline (n = 5) 632 +/- 54; tissue-type plasminogen activator (t-PA) 3 mg, (n = 6) 443 +/- 162; t-PA 3 mg + heparin 750 U intravenously, (n = 7) 408 +/- 128; t-PA 3 mg + heparin 500 U intrathrombic + heparin 250 U intravenously, (n = 8) 213 +/- 166. Differences among these groups (except t-PA alone versus t-PA + intravenous heparin) were significant. The extent of lysis with intrathrombic + intravenous heparin was not significantly retarded by withholding aspirin (n = 6, 194 +/- 72), or improved by giving half the intrathrombic heparin before t-PA injections (n = 6, 280 +/- 158). CONCLUSIONS: The results demonstrate the advantage of adjunctive intrathrombic + intravenous heparin over intravenous heparin alone in increasing the extent of pulse-spray thrombolysis in this IVC thrombosis model.

Animals↗
PubMed1992

Gastrointestinal hemorrhage in AIDS: arteriographic diagnosis and transcatheter treatment.

The usefulness of arteriography and transcatheter treatment was studied in nine patients with gastrointestinal hemorrhage and acquired immunodeficiency syndrome (AIDS). Selective arteriography was performed in all patients; transcatheter treatment was performed by means of embolotherapy or selective vasopressin infusion. Medical records were reviewed to determine the cause of hemorrhage and clinical outcome. Arteriography enabled identification of the site of hemorrhage in seven patients. Hemorrhage was caused by Kaposi sarcoma (n = 2), cytomegalovirus colitis (n = 1), lymphoma (n = 2), or unknown causes (n = 4). Neovascularity and dense parenchymal stain were present in patients with Kaposi sarcoma. Transcatheter treatment consisted of embolization (n = 3), vasopressin infusion (n = 2), or both (n = 1). Hemorrhage was controlled in six cases in which transcatheter treatment was administered. Complications included thrombosis of the femoral artery in a 7-month-old infant and formation of a pseudoaneurysm of the femoral artery, which was treated successfully with ultrasound-guided compression. In patients with AIDS and profuse gastrointestinal hemorrhage, arteriography often enables identification of a specific site of hemorrhage, which can be stopped with transcatheter treatment.

Acquired Immunodeficiency Syndrome↗
PubMed1991

Results of a multicenter study of the modified hook-titanium Greenfield filter.

Initial efforts to modify the stainless steel Greenfield filter for percutaneous insertion led to development of a titanium Greenfield filter, which could be inserted by use of a 12F carrier. This device functioned well as a filter but had an unacceptable 30% rate of migration, tilting, and penetration. Therefore a titanium Greenfield filter with modified hooks was developed and has been tested in 186 patients at 10 institutions. Successful placement occurred in 181 (97%); placement of the remainder was precluded by unfavorable anatomy. A contraindication to anticoagulation was the most frequent indication for insertion (75%). All but two were inserted percutaneously, predominantly via the right femoral vein (70%). Initial incomplete opening was seen in four patients (2%), which was corrected by guide wire manipulation and asymmetry of the legs in 10 (5.4%). Insertion site hematoma occurred in one patient, and apical penetration of the cava during insertion occurred in a second patient. Both events were without sequelae. Follow-up examinations were performed at 30 days at which time 35 deaths had occurred. Recurrent embolism was suspected in six patients (3%) and two of three deaths were confirmed by autopsy. Filter movement greater than 9 mm was seen in 13 patients, (11%) and increase in base diameter greater than or equal to 5 mm was seen in 17 patients (14%). CT scanning showed evidence of caval penetration in only one patient (0.8%). Insertion site venous thrombosis was seen in 4/46 (8.7%) patients screened. The modified hook titanium Greenfield filter is inserted percutaneously or operatively through a sheath, eliminating concern for misplacement from premature discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗