Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
.pdf
239
What were the salient
results of the COOL-1,
COOL-2, and CAPS
trials regarding the
use of alteplase for
treating occluded
catheters?
COOL-1 and COOL-2:
Adult patients
74–75% efficacy of one dose of
alteplase with an indwelling time of
120min. (versus 17% after placebo),
88% efficacy of two doses, in catheters
occluded up to 14days (72% in
occlusions greater than 14days)
74% cumulative patency at 30days
52% and 84% patency in one and two
doses with 30min. indwelling times,
respectively
CAPS:
Pediatric patients
75% patency after one dose of
alteplase, and 83% patency after two
doses, with indwelling time of 120min.
(53% and 80% with 30-min. dwell
times)
All demonstrated overall safety of using
alteplase for occluded catheters, without
increased risk of bleeding or intracranial
hemorrhages.
Common Questions
What is the preferred
location for central
venous access?
Right internal jugular vein
What should be avoided
in patients with CKD
and DM, and/or those
on HD?
PICC and midline placement
Placement of catheter on the same side
as a maturing AVG or AVF
(continued)
24 Central Venous Access
https://t.me/med1917
240
What is the main factor
in deciding between
placing a tunneled and
non-tunneled catheter?
Length of access
Non-tunneled: Days to 1–2weeks
Tunneled: Weeks or longer
In general, what is the
ideal catheter to use?
The smallest bore (lowest risk of
venous stenosis), least lumen (lower
risk of occlusion as lumens often
get smaller in diameter as more are
added), and most temporary device
possible for the needed indication is
the best.
Is there an emergent
indication for tunneled
central venous access?
No, a non-tunneled central venous
catheter can be placed for emergent
indications.
During placement,
what is the best way
to confirm access into
the venous system
fluoroscopically?
Guidewire should pass below the
diaphragm.
How can an air
embolism be managed
immediately?
Place the patient in left lateral
decubitus position.
Keeps the air bubble trapped against
the nondependent aspect of the right
ventricle and away from the right
ventricular outflow tract
Use a catheter to access the bubble
under fluoroscopy and suction it out.
G. Gadodia
https://t.me/med1917
241
How can suspected
catheter-associated
infections be managed?
Non-tunneled CVC:
Exchange catheter (over wire, or
with new access site)
Tunneled CVC:
Remove and place temporary access
(non-tunneled) as needed.
Dialysis catheter:
Bacteremic or infected tunnel:
exchange catheter over wire +/−
new tunnel.
If symptoms persist over 36hours,
remove tunneled catheter; place
non-tunneled dialysis catheter if
needed:
48-hour line holiday before
replacing
Septic patient with any type of
catheter: remove emergently; place
temporary access as needed.
What can be done in a
malfunctioning catheter
that is not kinked/
fractured and is in
proper position?
Attempt declotting agents:
tPA (alteplase) 2mg in each port for
30–120min
Repeat x 1 if flow does not
improve.
Further Reading
Baskin KM, Jimenez RM, Cahill AM, Jawad AF, Towbin
RB.Cavoatrial junction and central venous anatomy: implica-
tions for central venous access tip position. J Vasc Interv Radiol.
2008;19:359–65.
Beathard GA.Management of bacteremia associated with tunneled-
cuffed hemodialysis catheters. J Am Soc Nephrol. 1999;10:1045–9.
Blaney M, Shen V, Kerner JA, Jacobs BR, Gray S, Armfield J, etal.
Alteplase for the treatment of central venous catheter occlusion
in children: results of a prospective, open-label, single- arm study
(the Cathflo Activase pediatric study). J Vasc Interv Radiol.
2006;17:1745–51.
24 Central Venous Access
https://t.me/med1917
242
Dariushnia SR, Wallace MJ, Siddiqi NH, Towbin RB, Wojak JC,
Kundu S, Cardella JF.Quality improvement guidelines for cen-
tral venous access. J Vasc Interv Radiol. 2010;21:976–81.
Deitcher SR. Safety and efficacy of Alteplase for restoring func-
tion in occluded central venous catheters: results of the
cardiovascular thrombolytic to open occluded lines trial. J Clin
Oncol. 2002;20:317–24.
Ferral H, Lorenz J.Radcases interventional radiology. New York:
Thieme; 2018.
Funaki B.Central venous access: a primer for the diagnostic radiolo-
gist. Am J Roentgenol. 2002;179:309–18.
Gilbert RE, Harden M.Effectiveness of impregnated central venous
catheters for catheter related blood stream infection: a system-
atic review. Curr Opin Infect Dis. 2008;21:235–45.
Haas B, Chittams JL, Trerotola SO. Large-bore tunneled central
venous catheter insertion in patients with coagulopathy. J Vasc
Interv Radiol. 2010;21:212–7.
Hua C, Dreifuss R.Dialysis catheter access RFS Pre IR rotation mod-
ule. In: Common IR procedures. http://rfs.sirweb.org/medical-
student- section/introduction- to- ir/common- ir- procedures/. Oct
2018.
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. Philadelphia: Lippincott Williams &
Wilkins; 2016.
Kaufman JA, Lee MJ. Vascular and interventional radiology: the
requisites. Philadelphia: Elsevier/Saunders; 2014.
Kohli MD, Trerotola SO, Namyslowski J, Stecker MS, Mclennan
G, Patel NH, Johnson MS, Shah H, Seshadri R. Outcome of
Polyester Cuff retention following traction removal of tunneled
central venous catheters. Radiology. 2001;219:651–4.
Lund GB, Trerotola SO, Scheel PF, Savader SJ, Mitchell SE, Venbrux
AC, Osterman FA.Outcome of tunneled hemodialysis catheters
placed by radiologists. Radiology. 1996;198:467–72.
Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS,
Walker TG, Saad WA. Consensus guidelines for periprocedural
management of coagulation status and hemostasis risk in per-
cutaneous image-guided interventions. J Vasc Interv Radiol.
2012;23:727–36.
Ponec D, Irwin D, Haire WD, Hill PA, Li X, Mccluskey
ER.Recombinant tissue plasminogen activator (Alteplase) for
restoration of flow in occluded central venous access devices:
a double-blind placebo-controlled trial—the Cardiovascular
G. Gadodia
https://t.me/med1917
243
Thrombolytic to Open Occluded Lines (COOL) efficacy trial. J
Vasc Interv Radiol. 2001;12:951–5.
Ramos ER, Reitzel R, Jiang Y, etal. Clinical effectiveness and risk of
emerging resistance associated with prolonged use of antibiotic-
impregnated catheters: more than 0.5 million
catheter days and
7 years of clinical experience*. Crit Care Med. 2011;39:245–51.
Sasadeusz KJ, Trerotola SO, Shah H, Namyslowski J, Johnson MS,
Moresco KP, Patel NH.Tunneled jugular small-bore central cath-
eters as an alternative to peripherally inserted central catheters
for intermediate-term venous access in patients with hemodi-
alysis and chronic renal insufficiency. Radiology. 1999;213:303–6.
Shaffer D.Catheter-related sepsis complicating long-term, tunnelled
central venous dialysis catheters: management by guidewire
exchange. Am J Kidney Dis. 1995;25:593–6.
Trerotola SO, Johnson MS, Harris VJ, Shah H, Ambrosius WT,
Mckusky MA, Kraus MA.Outcome of tunneled hemodialysis
catheters placed via the right internal jugular vein by interven-
tional radiologists. Radiology. 1997;203:489–95.
Trerotola SO, Stavropoulos SW, Mondschein JI, Patel AA, Fishman
N, Fuchs B, Kolansky DM, Kasner S, Pryor J, Chittams J.Triple-
lumen peripherally inserted central catheter in patients in
the critical care unit: prospective evaluation. Radiology.
2010;256:312–20.
Tritle B, McLennan G.Central venous access. Cleveland Clinic radi-
ology resident morning conference, 2018.
Venkatesan AM, Kundu S, Sacks D, etal. Practice guideline for adult
antibiotic prophylaxis during vascular and interventional radiol-
ogy procedures. J Vasc Interv Radiol. 2010;21:1611–30.
Weijmer MC, Vervloet MG, Wee PMT.Prospective follow-up of a
novel design haemodialysis catheter; lower infection rates and
improved survival. Nephrol Dial Transpl. 2007;23:977–83.
24 Central Venous Access
https://t.me/med1917
245© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_25
Evaluating Patient
How do patients with
internal carotid artery
(ICA) stenosis usually
present?
Asymptomatic, with incidentally
detected stenosis (majority)
When present, what
are symptoms that may
indicate ICA stenosis?
Non-disabling or transient ischemic
attack (TIA) or transient retinal
(amaurosis fugax) symptoms within
6months
What physical exam
finding might be present
in a patient with carotid
stenosis?
Carotid bruit
What is the imaging
modality of choice for
screening for carotid
stenosis in patients with
symptoms?
Carotid duplex ultrasound
Chapter 25
Carotid Artery Stenosis
GauravGadodia
G. Gadodia (*)
Department of Radiology, Imaging Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: ggadodia.md@gmail.com
(continued)
https://t.me/med1917
246
What are possible
indications for evaluating
asymptomatic patients
with carotid duplex
ultrasonography
(along with ASA/ACC
recommendation classes
and level of evidence)?
Asymptomatic patients with known
or suspected carotid stenosis (class I,
level of evidence: C)
Asymptomatic patients with carotid
bruit (IIa, C)
Annual assessment of progression or
regression of disease and response to
therapeutic intervention in patients
with atherosclerosis and stenosis of
>50% (IIa, C)
Asymptomatic patients with
symptomatic PAD, CAD, and AAA
(IIb, C)
Asymptomatic patients with two or
more risk factors, including HTN,
hyperlipidemia, tobacco smoking,
family history of first-degree relative
with atherosclerotic issues manifested
before 60years, or family history of
ischemic stroke (IIb, C)
When does evaluation
of ASYMPTOMATIC
patients with carotid
duplex ultrasonography
confer no benefit (class
III recommendation to
screen)?
Routine screening of asymptomatic
patients who have no clinical
manifestations of or risk factors for
atherosclerosis
Routine screening of asymptomatic
patients with neurological or
psychiatric disorders unrelated
to ischemia (i.e., brain tumors,
degenerative diseases, infectious or
inflammatory conditions, psychiatric
disorders, or epilepsy)
Routine serial imaging in patients
without risk factors
Has screening
asymptomatic patients
with ultrasound been
shown to reduce the risk
of stroke?
No
G. Gadodia
https://t.me/med1917
247
Is screening of
asymptomatic patients
for carotid stenosis
recommended per the
US Preventive Services
Task Force?
No
What are the indications
for evaluating
SYMPTOMATIC
patients with carotid
duplex ultrasonography?
Initial evaluation in patients with
transient retinal or hemispheric
neurological symptoms (I, C)
Evaluation of patients with focal
neurological symptoms corresponding
to the territory supplied by the left or
right carotid artery (I, C)
Can be considered when nonspecific
neurological symptoms may be caused
by ischemia (IIb, C)
What are other
indications for evaluation
using carotid duplex
ultrasonography?
Cervical bruit in an asymptomatic
patient
Follow-up of known stenosis (>20%)
in asymptomatic individuals
Vascular assessment in a patient
with multiple risk factors for
atherosclerosis
Stroke risk assessment in a patient
with CAD or PAD
Stroke in a candidate for carotid
revascularization
Follow-up after a carotid
revascularization procedure
Intraoperative assessment during
CEA or CAS
(continued)
25
Carotid Artery Stenosis
https://t.me/med1917
248
What are parameters
to evaluate on
ultrasonography?
Primary parameters:
Peak systolic velocity (PSV) of
blood flow in the carotid artery
Direct estimation of plaque
thickness
Secondary parameters:
End-diastolic velocity (EDV)
Ratio of ICA to common carotid
artery (CCA) PSV
What are pros and
cons of duplex
ultrasonography?
Pros
No ionizing radiation
No contrast needed
Often cheaper and more readily
available
Better for screening/initial
evaluation as per above indications
Cons
Operator variability
Uses velocity to estimate degree
of stenosis as opposed to direct
visualization of stenotic diameter:
Degree of stenosis may be over-
or underestimated.
May overestimate severity
of stenosis contralateral to ICA
occlusion (increased contralateral
velocity may mimic stenosis on
sonography).
Cannot assess intrathoracic or
intracranial lesions
May not be able to differentiate
between subtotal and complete
arterial occlusion
Poor evaluation of heavily
calcified lesions due to acoustic
shadowing
G. Gadodia
https://t.me/med1917
249
When is CTA/MRA
indicated for the
evaluation of carotid
artery stenosis?
When ultrasonography cannot
be obtained or yields equivocal/
nondiagnostic results in patients with
acute, focal neurologic symptoms
corresponding to territory supplied
by the left or right ICA (I, C) or in
candidates for revascularization (IIa, C)
For confirmatory and planning
imaging in patients who are
candidates for revascularization to
evaluate severity of stenosis and
identify intrathoracic or intracranial
vascular lesions (IIa, C):
In practice, MRA is often the test
of choice to confirm US findings and
further evaluate intrathoracic and
intracranial anatomy.
What techniques can be
used for carotid stenosis
evaluation via MRA?
Time of flight (no contrast)
Phase-contrast MRA
Contrast-enhanced
(continued)
25
Carotid Artery Stenosis
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана