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J J Bookstein

Publications and source records attributed to J J Bookstein.

At least 37 records · Page 2Linked to original sources
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↗
PubMed1991

Pharmacomechanical thrombolysis and angioplasty in the management of clotted hemodialysis grafts: early and late clinical results.

The results of pharmacomechanical thrombolysis and angioplasty of 121 thrombosed hemodialysis grafts were reviewed. The initial pharmacomechanical method (used in 65 cases) employed clot maceration with hook-shaped catheters and clot lacing with highly concentrated urokinase. The current technique (used in 56 cases) consisted of pulsed-spray injection of urokinase into the clot. All fully treated grafts (117 cases) underwent complete or near-complete thrombolysis, and 93% remained patent after 1 day. Mean time for pulsed-spray lysis was 46 minutes +/- 21. One patient (less than 1%) had gastrointestinal bleeding and received a transfusion; minor complications occurred in 3% of patients. Primary and secondary graft patency rates for both methods at 1 year were 26% and 51%, respectively. While graft age and results of angioplasty did not influence future graft patency, shorter intervals between graft thromboses was predictive of earlier subsequent graft failure. Results suggest that pharmacomechanical thrombolysis and angioplasty provide rapid, consistent, and safe recanalization of clotted hemodialysis grafts and represent a promising additional therapeutic approach to long-term graft management.

Angioplasty, Balloon↗
PubMed1991

Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression.

Ultrasound-guided compression repair (UGCR) of catheterization-related femoral artery injuries was evaluated as a possible new imaging-guided interventional procedure. Thirty-nine femoral artery injuries (35 pseudoaneurysms, four arteriovenous fistulas) were detected with color Doppler flow imaging in patients with enlarging groin hematomas and/or groin bruits 6 hours to 14 days after catheterization procedures. UGCR was not performed in 10 patients due to spontaneous thrombosis (n = 4), infection (n = 1) or skin ischemia (n = 1), unsuitable anatomy (n = 3), or excessive discomfort (n = 1). The remaining 29 patients underwent a full trial of compression therapy, and the lesion was eliminated in 27. Follow-up color flow scans were obtained after 24-72 hours in all 27 successful cases and at 1-15 months in 19; no recurrences or complications occurred. UGCR for acute injuries is safe and technically simple and is promising as a cost-effective, first-line treatment for uncomplicated catheterization-related femoral artery injuries. UGCR is probably not appropriate for long-standing injuries.

Aged↗
PubMed1991

Pulsed-spray thrombolysis of arterial and bypass graft occlusions.

Pulsed-spray thrombolysis is accomplished through forceful injection of a spray of highly concentrated urokinase into clot by using catheters with multiple side holes. We previously reported the immediate technical efficacy of the method in eight arterial and 10 bypass graft occlusions. We now describe the clinical efficacy of the method in a second, larger series of 23 native artery occlusions and 25 bypass graft occlusions. Transluminal angioplasty was performed after thrombolysis in 21 of the arteries and 24 of the bypass grafts. Initial thrombolysis was observed in all artery occlusions and all but one bypass graft occlusion with an average time for pulsed-spray lysis of 65 +/- 28 min in native arteries and 93 +/- 38 min in bypass grafts. Recanalization with improvement in symptoms or distal pulses after thrombolysis and angioplasty was achieved in 74% of treated arterial occlusions and 92% of treated graft occlusions. Of the 15 arteries that were recanalized and did not require adjunctive surgery, seven remained patent at 3-28 months follow-up. Nine of 23 recanalized bypass grafts required early adjunctive surgery. Of the nine synthetic and five saphenous vein grafts successfully recanalized and not requiring surgical revision, the mean patency was 4.3 +/- 3.1 months and 3.0 +/- 2.2 months, respectively. Minor complications were seen in 23% of cases. The two major complications (4%) involved one groin hematoma requiring surgery and one episode of gastrointestinal hemorrhage. We conclude that combined pulsed-spray thrombolysis and angioplasty achieve rapid and consistent arterial and graft recanalization with minimal risk. The method offers a favorable alternative to standard thrombolytic therapy of arterial occlusions. In occluded synthetic and vein bypass grafts, the technique is sometimes beneficial, either alone or combined with surgical revision.

Angioplasty, Balloon↗
PubMed1990

Rapid progression of peripheral vascular disease after diagnostic angiography.

The authors retrospectively reviewed records of percutaneous transluminal angioplasties performed at three institutions. Seven stenotic lesions in peripheral vessels were identified that had progressed to total occlusion in the interval between the time that diagnostic run-off angiography and attempted angioplasty were performed. The post-angiographic occlusions were 3-16 cm long (mean, 9 cm), and the interval between diagnostic angiography and discovery of the occlusions ranged from 1 hour to 91 days (median, 2 days). Treatment of the occlusions was riskier and more difficult than simple angioplasty of the original stenoses. The authors conclude that some aspect of the angiographic procedure probably precipitated the transition from stenosis to occlusion. This complication can be prevented by preparation for angioplasty immediately after diagnostic run-off angiography or perhaps by use of heparin during the diagnostic study.

Adult↗
PubMed1990

The cavernosal acetylcholine/papaverine response. A practical in vivo method for quantification of endothelium-dependent relaxation. Rationale and experimental validation.

An in vivo method has been developed for quantifying cavernosal endothelium-dependent relaxation. The method is based on the fact that relaxation of the smooth muscle around the sinusoids of the penile corpora cavernosa activates the erectile veno-occlusive mechanism, and the degree of veno-occlusion can be precisely quantified by the pharmacologic maintenance erectile flow (PMEF) method. Pharmacologic maintenance erectile flows are determined after intracavernosal infusion of the endothelium-dependent relaxant acetylcholine (ACh) and the endothelium-independent relaxant papaverine, and expressed as an acetylcholine/papaverine ratio (APR). Control rabbits showed no changes from the test procedures themselves. In 12 test rabbits, control PMEFs after approximately 10(-7) mol ACh or papaverine averaged 0.7 and 0.5 ml/minute, respectively; APR averaged 1.3. Endothelial injury of the corpus cavernosum was produced by intracavernosal injection of 100 micrograms (16 x 10(-8) mol) of the detergent CHAPS or 1 ml of Renografin-76. Within 1 hour of injection of either agent, PMEF(ACh) increased markedly to approximately 6, PMEF(pap) increased minimally to approximately 0.9, and APR increased to about 7. These values gradually decreased to normal limits at six weeks. Endothelial injury and recovery were confirmed by electron microscopy. Thus, reduced cavernosal response to ACh relative to papaverine was indicative of endothelial injury. The ACh/papaverine response ratio offers promise as a practical and reliable in vivo method for quantifying endothelial-dependent relaxation.

Acetylcholine↗
PubMed1989

Ultralong, reverse-curve angiographic catheter.

An ultralong, reverse-curve angiographic catheter has been developed to facilitate selective internal pudendal arteriography for evaluation of vasculogenic impotence. The catheter has enabled successful selective catheterization of the internal pudendal arteries in 95% of more than 200 attempts. The catheters have also been used in approximately 100 vascular procedures other than pudendal arteriography.

Angiography↗
PubMed1989

Pulsed-spray pharmacomechanical thrombolysis: preliminary clinical results.

Pulsed-spray pharmacomechanical thrombolysis was used to treat 41 patients with 47 complete thrombotic occlusions of hemodialysis grafts (n = 29), arterial bypass grafts (n = 10), or peripheral native arteries (n = 8). The procedure involves the use of small pulses of highly concentrated urokinase, which are forcefully sprayed throughout the thrombus during systemic heparinization. Virtually complete lysis was achieved in 46 of 47 occlusions. In the 46 thrombi that lysed, mean time for completion of lysis was 63 +/- 35 min and initial partial return of flow required 26 +/- 18 min. Complications included small peripheral emboli in one treated bypass graft (which cleared promptly after further pulse-spray therapy) and bleeding in three cases (one case of hematoma in the infused field at the site of recent surgery, one case of bilateral hematomas at the femoral puncture site, and one minor delayed self-limited gastrointestinal hemorrhage). Results to date suggest that the pulsed-spray pharmacomechanical method augments the speed, consistency, safety, and cost efficacy of clinical thrombolysis. Further study is warranted.

Arteriovenous Shunt, Surgical↗
PubMed1988

Pharmacoangiographic assessment of the corpora cavernosa.

The present section presents further observations regarding cavernosometry and cavernosography, emphasizing the value of intracavernosal injection of a papaverine-phentolamine combination. Subsequent pharmacocavernosometry during fluid infusion then enables (1) precise quantitation of cavernosal leak by the pharmacologic maintenance erection flow (PMEF) method, and (2) determination of cavernosal pressure pulsations, a useful reflection of arterial sufficiency. In patients with excessive cavernosal leak, pharmacocavernosography supplements the examination by indicating the routes of persistent major venous drainage, key information in planning venoablative therapy. Compared with nonpharmacologic methods for cavernosometry and cavernosography, we feel the pharmacologic technique offers the following advantages: (1) it enables the highly accurate and reproducible PMEF method for quantitating cavernosal leakage; (2) the sites of abnormal leakage can be evaluated by cavernosography only after the pharmacologic technique; (3) the infusion volumes required to produce erection are smaller, more physiologic, and more conveniently administered; (4) the amplitude of the cavernosal pressure pulsation becomes useful as an index of arterial sufficiency; and (5) pulsations of the dorsal penile artery are amplified to the point of easy palpability, or more reliable Doppler detection.

Angiography↗
PubMed1988

Angiography of posttraumatic impotence.

Of 135 patients who underwent penile angiography at our institution, impotence was related to noniatrogenic trauma in 16. Impotence developed immediately following an isolated traumatic event in 14 patients, and months or years after repeated blunt perineal trauma in 2. Invasive vascular assessment facilitated diagnosis in all patients. Although the mechanism of trauma varied greatly, most patients had vasculogenic (arteriogenic or venogenic) impotence. Complete vascular assessment required selective magnification pharmacoarteriography in multiple projections, pharmacocavernosography, and pharmacocavernosometry. Therapeutic choices were based largely on the angiographic findings, and included venous ligation, arterial bypass or angioplasty, self-injection of papaverine, or insertion of a prosthesis.

Adolescent↗
PubMed1988

Transluminal angioplasty in the treatment of arteriogenic impotence.

Factors bearing on the role of transluminal angioplasty in the management of arteriogenic impotence are considered. Our clinical experience indicates that arteriogenic impotence is frequent, either alone or combined with venogenic impotence. High quality diagnostic angiographic studies and their accurate interpretation are the prime requirements for proper patient selection. Numerous arteriographic adjuncts are required: vasodilation with intracavernosal injection of a papaverine-phentolamine mixture, selective internal pudendal injections, direct magnification, nonionic contrast agents, and tailored radiographic projections. Venogenic impotence must be excluded by cavernosometry and cavernosography. In impotent patients with bilateral leg and hip claudication, dilatation of common or internal iliac stenoses should benefit many cases with pure arteriogenic impotence. In the absence of claudication, angioplasty will be most frequently indicated for distal internal pudendal lesions, using 2-3 mm balloon-catheter systems. Stenoses of intrapenile branches, while common, must await further technological developments before they too may become amenable to transluminal recanalization. Unilateral transluminal angioplasty, when technically successful, should prove clinically successful when patients have been properly selected. Transluminal angioplasty can reduce the cost and morbidity of penile revascularization and may assume a modest role in the treatment of arteriogenic impotence.

Angioplasty, Balloon↗
PubMed1988

Transluminal penile venoablation for impotence: a progress report.

Based on theoretical advantages and successful pilot experiments in dogs, therapeutic transluminal penile venoablation underwent clinical trials in 13 impotent men. Catheter access to the penile venous structures was gained via (1) direct percutaneous puncture of the deep dorsal penile vein, (2) cut-down over the dorsal vein of the penis, or (3) retrograde catheterization of internal or external pudendal veins from a femoral vein. Alternatively, needle access only was gained into (4) the preprostatic plexus or the pudendal vein, (5) the superficial penile vein, or (6) the crura. Once venous access had been gained, selective venography was performed to clarify the relevant anatomy in each case. After catheterization, venoocclusion was produced by embolization with combinations of coils and Gelfoam, followed by sclerosant. Results to date indicate high feasibility of access by a variety of methods, and the safety of transluminal venoablation. Clinical efficacy to date seems only moderate. Eight of 13 patients report subjective improvement in the quality of erections after a mean follow-up period of 5.2 +/- 2.4 months. With regard to sexual activity, 2 patients are considered cured, 2 improved sufficiently for sexual intercourse, and 9 were insufficiently improved for intercourse. Of the nine failures, two were considered cures for 3 weeks, but then relapsed for unknown reasons. Two of the 4 patients that regained potency had concomittant unilateral or bilateral pudendal arterial occlusions. Technical modifications for improving results are under continuing investigation.

Adult↗