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Placenta accreta/percreta is a leading cause of third trimester hemorrhage and postpartum maternal death. The current treatment for third trimester hemorrhage due to placenta accreta/percreta is cesarean hysterectomy, which may be complicated by large volume blood loss. To determine what role, if any, prophylactic temporary balloon occlusion and transcatheter embolization of the anterior division of the internal iliac arteries plays in the management of patients with placenta accreta/percreta. The records of 28 consecutive patients with a diagnosis of placenta accreta/percreta were retrospectively reviewed. Patients were divided into two groups. Six patients underwent prophylactic temporary balloon occlusion, followed by cesarean section, transcatheter embolization of the anterior division of the internal iliac arteries and cesarean hysterectomy (n = 5) or uterine curettage (n = 1). Twenty-two patients underwent cesarean hysterectomy without endovascular intervention. The following parameters were compared in the two groups: patient age, gravidity, parity, gestational age at delivery, days in the intensive care unit after delivery, total hospital days, volume of transfused blood products, volume of fluid replacement intraoperatively, operating room time, estimated blood loss, and postoperative morbidity and mortality. Patients in the embolization group had more frequent episodes of third trimester bleeding requiring admission and bedrest prior to delivery (16.7 days vs. 2.9 days), resulting in significantly more hospitalization time in the embolization group (23 days vs. 8.8 days) and delivery at an earlier gestational age than in those in the surgical group (32.5 weeks). There was no statistical difference in mean estimated blood loss, volume of replaced blood products, fluid replacement needs, operating room time or postoperative recovery time. Our findings do not support the contention that in patients with placenta accreta/percreta, prophylactic temporary balloon occlusion and embolization prior to hysterectomy diminishes intraoperative blood loss.

To perform a retrospective outcomes analysis of central venous catheters with peripheral venous access ports, with comparison to published data. One hundred and twelve central venous catheters with peripherally placed access ports were placed under sonographic guidance in 109 patients over a 4-year period. Ports were placed for the administration of chemotherapy, hyperalimentation, long-term antibiotic therapy, gamma-globulin therapy, and frequent blood sampling. A vein in the upper arm was accessed in each case and the catheter was passed to the superior vena cava or right atrium. Povidone iodine skin preparation was used in the first 65 port insertions. A combination of Iodophor solution and povidone iodine solution was used in the last 47 port insertions. Forty patients received low-dose (1 mg) warfarin sodium beginning the day after port insertion. Three patients received higher doses of warfarin sodium for preexistent venous thrombosis. Catheter performance and complications were assessed and compared with published data. Access into the basilic or brachial veins was obtained in all cases. Ports remained functional for a total of 28,936 patient days. The port functioned in 50% of patients until completion of therapy, or the patient's expiration. Ports were removed prior to completion of therapy in 18% of patients. Eleven patients (9.9% of ports placed) suffered an infectious complication (0.38 per thousand catheter-days)-in nine, at the port implantation site, in two along the catheter. In all 11 instances the port was removed. Port pocket infection in the early postoperative period occurred in three patients (4.7%) receiving a Betadine prep vs two patients (4.2%) receiving a standard O.R. prep. This difference was not statistically significant (p = 0.9). Venous thrombosis occurred in three patients (6.8%) receiving warfarin sodium and in two patients (3%) not receiving warfarin sodium. This difference was not statistically significant (p = 0.6). Aspiration occlusion occurred in 13 patients (11.7%). Intracatheter urokinase was infused in eight of these patients and successfully restored catheter function in all but two instances. These complication rates are comparable to or better than those reported with chest ports. Peripheral ports for long-term central venous access placed by interventional radiologists in the interventional radiology suite are as safe and as effective as chest ports.

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For lack of other suitable access, 10 consecutive patients received paired hemodialysis catheters for long-term hemodialysis using a translumbar approach to the inferior vena cava (IVC). All attempts were successful. Five paired catheters were placed using the single-puncture technique, and five using the dual-puncture technique. Catheters were in place for a total of 2252 catheter days. The average duration of catheter placement was 250 days (range 30-580 days). All catheters were functioning up to the time the study was completed or the patient died. The most common complication was partial dislodgment of the catheter in 3 of 23 catheters (13%), all occurring in obese patients. One episode of retroperitoneal hemorrhage was noted in a patient having the single-access technique. There were no episodes of infection or IVC thrombosis.

To evaluate the feasibility and complications of placement of a low-profile venous access port in the chest in children requiring long-term venous access. A low-profile peripheral arm port (PAS port; Sims Deltec, St. Paul, MN, USA) was implanted in the chest in 22 children over a 4-year period. The mean age of the study group was 6 years (range: 9 months to 20 years). Ports were placed for the administration of chemotherapy, hyperalimentation and frequent blood sampling. Sonographic guidance was used to access the internal jugular or subclavian vein in each case. A review of all inpatient and outpatient charts was undertaken to assess catheter performance and complications. Access to the central venous circulation was successfully achieved in each case without complication. Ports remained implanted for 6579 catheter-days (mean: 299 days). Ten ports have been removed. Of three patients (13%) experiencing device-related infections (0.45 infections/1000 catheter days), two (9.1%) were unresponsive to antibiotics and removed (0.3 infections/1000 catheter days). One port was removed because of pain in the shoulder adjacent to the port implantation site. One port was removed because of difficult access. The final port was removed in order to place a dual-lumen catheter prior to bone marrow transplant. Twelve ports remain implanted. Aspiration occlusion occurred in four patients (18%). Deep venous thrombosis did not occur in any patient. Low-profile chest ports placed by interventional radiologists in the interventional radiology suite can be placed in children as safely as traditional chest ports placed in the operating room. The incidence of infection, venous thrombosis and aspiration occlusion is comparable to that of ports placed operatively.

Purpose: To evaluate the feasibility and complications of placement of a low-profile venous access port in the chest in children requiring long-term venous access. Method: A low-profile peripheral arm port (PAS port; Sims Deltec, St. Paul, MN, USA) was implanted in the chest in 22 children over a 4-year period. The mean age of the study group was 6 years (range: 9 months to 20 years). Ports were placed for the administration of chemotherapy, hyperalimentation and frequent blood sampling. Sonographic guidance was used to access the internal jugular or subclavian vein in each case. A review of all inpatient and outpatient charts was undertaken to assess catheter performance and complications. Results: Access to the central venous circulation was successfully achieved in each case without complication. Ports remained implanted for 6579 catheter-days (mean: 299 days). Ten ports have been removed. Of three patients (13%) experiencing device-related infections (0.45 infections/1000 catheter days), two (9.1%) were unresponsive to antibiotics and removed (0.3 infections/1000 catheter days). One port was removed because of pain in the shoulder adjacent to the port implantation site. One port was removed because of difficult access. The final port was removed in order to place a dual-lumen catheter prior to bone marrow transplant. Twelve ports remain implanted. Aspiration occlusion occurred in four patients (18%). Deep venous thrombosis did not occur in any patient. Conclusion: Low-profile chest ports placed by interventional radiologists in the interventional radiology suite can be placed in children as safely as traditional chest ports placed in the operating room. The incidence of infection, venous thrombosis and aspiration occlusion is comparable to that of ports placed operatively.

To assess how radiologic intervention altered the hospital course of patients undergoing continent urinary diversion. Thirty-seven consecutive patients with bladder cancer invading the muscular layer were treated with total cystectomy and construction of a continent urinary reservoir. Eleven of 37 patients suffered early and late anastomotic leakage; six had prolonged extraperitoneal leakage at the urethroenteric anastomosis, three had prolonged intraperitoneal pouch leaks, and two had delayed ureteroenteric leaks. Seven of these patients required radiologic intervention. Intervention in the form of drainage catheter manipulation (n = 4), percutaneous nephrostomy (n = 4), or ureteral stent placement (n = 2) resulted in cessation of leakage without surgical intervention in all seven patients. Intraperitoneal pouch leaks were more difficult to control than extraperitoneal leakage and required longer drainage intervals. Interventional radiologic procedures played a key role in the management of continent urinary diversion complications, obviating the need for repeat surgical intervention in all instances.