“olume
123
Number
2
Table
Brief Communications
I. Measurements
by intravascular
ultrasound
and angiography Angiography
Ultrasound Diameter
(mm)
Area
(mm2)
5 15
Diameter (% stenosis)
Area (% stenosis)
60%
Diameter (mm)
Diameter (X stenosis)
Pre PTCA
Proximal Lesion Distal Post PTCA After 5 mm After 6 mm
6.03
24.88
2.95 9.61
10.42 59.51
51%
3.69 5.14
13.55 25.04
40% 15%
5.8 3.5
40%
8.7
cutaneous transluminal angioplasty (PTA) morphologic assessment were done by IVUS (Fig. 1). This case is the first use of IVUS in PTA of a recurrent coarctation of the aorta in a child. Intravascular imaging quantitated the severity of stenosis before and after PTA. After using a 6.0 mm PTA balloon, the site of stenosis was dilated to the size of the proximal segment, so further balloon inflations were not performed. One should be cautious in performing the procedure and make all exchanges over a wire, as there have been incidences of catheter trauma to the site of dilation, resulting in rupture of the aorta or aneurysms at the site of dilation on long-term follow-up. Intravascular imaging reveals important details regarding the site of stenosis. We found the left subclavian artery to be widely patent both before and after PTA and confirmed that the stenosis was distal to its origin, involving the anastomosis. Another important assessment that can be made by intravascular ultrasound is the transluminal morphology of the atherosclerotic plaque and the changes in the plaque and vessel wall caused by balloon inflation. In our patient, the normal segment proximal to the site of stenosis had three distinct layers (intima, media, and adventitia) and was 1.17 mm thick with focal areas of increased ultrasound density suggesting focal areas of intimal thickening and fibrosis. After angioplasty there was no significant change in this region. At the site of stenosis the three layers could not be distinguished and the vessel wall was thickened with a decrease in lumen diameter. Also, there was a concentric increase in ultrasound density suggesting fibrosis and calcification (determined by IVUS as “dropout” of echoes). After angioplasty the lumen diameter at the site of stenosis was the same as the size of the PTA balloon, with a decrease in the concentric thickness and a localized tear, suggesting dilation of the aorta without recoil. In addition, the tear at the site of stenosis was not seen angiographically and did not extend into the left subclavian artery. Distal to the stenosis there was thinning of the layers of the aorta and there was no evidence of increased ultrasound density, suggesting minimal fibrosis. As expected, after angioplasty there was no change in the thickness or size of this segment. In summary, percutaneous intravascular ultrasound imaging is technically easy to perform in pediatric patients with coarctation of the aorta. When compared to two-
46% 0%
5.5
5%
dimensional, longitudinal images with angiography, the cross-sectional images of ultrasound provide a more accurate assessment of the arterial dimensions and morphology. The precision of the measurements with the cross-sectional ultrasound images may improve the selection of balloon size and help in assessing the angioplasty results. REFERENCES 1.
2.
3.
Shaddy RF, Snider AR, Silverman NH, et al. Pulsed Doppler findings in patients with coarctation of the aorta. Circulation 1986;73:82-8. Boxer RA, LaCorte MA, Singh S, et al. Nuclear magnetic resonance imaging in evaluation and follow-up of children treated for coarctation of aorta. J Am Co11Cardiol 1986;7:1095-8. Moodie DS, Yiannikas J, Gill CC, et al. Intravenous digital subtraction
angiography
normalities
of the aorta and aortic arch.
in the evaluation
of congenital AM
HEART
ab-
J 1982;
104628-34. 4. Stern H, Erbel
R, Schreiner G, Henkel B, Meyer J. Coarctation of aorta: quantitative analysis by transesophageal echocardiography. Echocardiography 1987;4:387-95. 5. Harrison JK, Shiekh KH, Davidosn CJ, et al. Balloon angioplasty of coarctation of the aorta evaluated with intravascular ultrasound imaging. J Am Co11 Cardiol 1990;15:906-9.
Percutaneous balloon membranotomy combined with prolonged streptokinase infusion for management of inferior vena cava obstruction Satyavan Sharma, Y. S. Loya, and B. V. Daxini. Bombay, Maharashtra, India Obstruction of the hepatic or suprahepatic portion of the inferior vena cava (IVC) producing hepatic outflow obstruction is relatively common in the Orientlm4 and, if left
From the Department ical College. Reprint Medical 4/4/34Q95
requests: College,
of Cardiology,
B. Y. L. Nair
Hospital
and T. N. Med-
Dr. Satyavan Sharma, B. Y. L. Nair Hospital Bombay 400 008, Maharashtra, India.
and
T. N.
5 16
Brief Communications
American
Fig. 1. Simultaneous inferior vena cava (I.V.C.) and right atria1 (R.A.) pressure recordings excellent (A and 6) and suboptimal result (C and D) following balloon membranotomy.
Table
I. Clinical
Patient No.
WC,
1
30/M
2
20/M
3
22/M 35/M
Inferior
vena
an
data
Age (yr)l Sl?X
4
showing
February 1992 Heart Journal
cava;
Symptom duration (YT) 7 3 3112 2
HV,
hepatic
Ultrasound
Presentation Icterus, hepatosplenomegaly, veins over the abdomen Ascites, veins over the abdomen Ascites, hepatomegaly, edema in feet Ascites, hepatosplenomegaly
No definite membrane, dilated IVC & HV Membrane (IVC + hepatic), dilated IVC Discrete membrane (IVC), dilated IVC, HV Long segment narrowing, dilated IVC
veins.
untreated, carries a poor prognosis5-‘j The obstruction is caused by a membranous web, discrete coarctation, or thrombosis. Surgical excision of the membrane or creation of a cavoatrial bypass graft remain the traditional surgical procedures.2-4 These are difficult, risky, and are associated with graft occlusion over the long term. Successful management of membranous obstruction of the IVC by balloon angioplasty has been reported.5-g We report four cases successfully treated by balloon angioplasty preceded by a Brockenbrough needle puncture in three and by prolonged streptokinase infusion in one case. All had excellent symptomatic and hemodynamic benefits that are sustained during 8 to 32 months of follow-up in three cases. Between May 1988 and June 1990, four patients were evaluated and their clinical and ultrasound findings are listed in Table I. Serum bilirubin was elevated. The other
liver function tests were usually normal. Esophagogastroscopy revealed grade 1 to 4 esophageal varices. Liver scan and biopsy suggested cirrhosis. The percutaneous balloon membranotomy in patients No. 1 to 3 was performed by the technique described by us previously.7 The only exception in patient No. 3 was that balloon dilatation could be performed without a Brockenbrough needle puncture of the membrane, as he had incomplete obstruction to the IVC. In patient No. 2, there was additional involvement of the hepatic veins. The totally blocked hepatic veins could be approached by passing a guide wire through the collateral vessel. However, the balloon catheter could not be passed and obstruction to the hepatic veins could not be relieved. In patient No. 4, an IVC angiogram suggested a membrane with superimposed thrombus. All attempts to cross the obstruction with guide wire(s) failed. Streptokinase
Volume 123 NUmDBr 2
Brief Communications
5 17
Fig. 2. IVC angiogram in posteroanterior and lateral views (A and C) reveal partial obstruction to antegrade flow as a result of a membrane. Following dilatation, no membrane is visualized and free flow of blood to the right atrium can be seen (B and D).
II. Hemodynamic
Table
and angiographic
data Gradient
Patient
No.
Suprahepatic obstruction of IVC 1 Membrane 3 4
Discrete, thin membrane Long segment (membrane + thrombus)
Intervention
vena cava; redilatation
BA4, balloon for restenosis
membranotomy; with residual
Brockenbrough needle puncture, BM BM STK infusion X 48 hr, Brockenbrough needle puncture, BM
STK, gradient
Before
After
25
27
3
20 25
22 28
2 4
20
28
16
size (mm)
Obstruction of IVC + hepatic vein obstruction 2 Long segment Brockenbrough needle puncture, BM WC, Inferior *Underwent
(mm
Hg)
Balloon
Nature of block
Follow-up
2
(32
18* (8 3 (8
17
(18
mo) mo) mo)
mo)
streptokinase of 3 mm.
was administered at the rate of 2000 units/min by positioning an infusion catheter in the IVC below the site of obstruction. Coagulation parameters and angiograms were repeated every 12 hours. An IVC angiogram after 48 hours of streptokinase infusion revealed a thin streak of contrast
passing from the IVC to the right atrium. At this stage, the patient was taken for balloon membranotomy and the procedure was performed as reported previously,7 with excellent results. In all, heparin (500 units/hr) was infused for 24 hours followed by oral anticoagulation for 3 months.
5 18
Brief Communications
Liver function tests, esophagogastroscopy, and liver scan were repeated at the end of 1 week. The angiographic and hemodynamic features are shown in Table II. All patients had marked dilatation of the IVC, hepatic veins (except patient No. 2), and dilated tortuous collaterals coursing transdiaphragmatically and draining into the superior vena cava. The mean pressure gradient across the membrane ranged between 26.25 -t 2.48 and 6.25 t- 5.67 mm Hg (p < 0.001). The gradient reduction was remarkable in patients with suprahepatic obstruction (Table II, Fig. 1, A and B); however, the gradient decreased suboptimally in patients with additional involvement of hepatic veins (Fig. 1, C and D). After the intervention, the membranous or long segment narrowing was relieved in patients No. 1,3, and 4, as confirmed by angiography (Fig. 2, A to D). There was good antegrade flow to the right atrium with regression of collaterals. No complications were observed. Follow-up hemodynamic and angiographic studies performed at the end of 32 (patient No. 1) and 8 months (patient No. 4) revealed sustained benefits. Patient No. 2, restudied at 18 months, continues to have sustained but suboptimal benefits. Patient No. 3 developed restenosis within 8 months and underwent redilatation with excellent results. Hirooka and Kimural made the first unsuccessful attempt to perform balloon membranotomy of the BuddChiari web. During recent years, balloon angioplasty has been utilized for treating obstruction of the native IV@,: g and also cavoatrial graft sten0sis.s The technique has been applied to discrete membranes as well as to long segment obstructions. Yamazaki et a1.g under ultrasonography performed control transvenous membranotomy with a specially designed instrument and reported excellent results. In the present study, we performed membranotomy by balloon catheters after puncturing the obstructing membrane with a Brockenbrough needle. We did not utilize specially designed instruments and the procedure could be performed safely under local anesthesia. The immediate clinical, hemodynamic, and angiographic results are gratifying. The technique is simple and was performed by us under fluoroscopy. In patient No. 4, a thrombus superimposed over a membrane was suspected because of the angiographic appearance of long segment narrowing, an abrupt cut-off, and a large filling defect. A recent innovation’O in treating previously uncrossable total saphenous vein graft occlusions is the use of prolonged urokinase drips to open a sufficient channel for coronary angioplasty. That report prompted us to administer a prolonged streptokinase infusion. The infusion created a channel that we could penetrate and therefore we could perform a successful balloon membranotomy. All patients were advised to take anticoagulants for 3 months. The intermediate term results are gratifying in patients No. 1 and 4 and were sustained in patient No. 2 (Table II). We encountered restenosis in patient No. 3 at 8 months and the patient underwent redilatation with excellent results. Restenosis following balloon angioplasty has also been reported by 0thers.s ’ Balloon membranotomy (with or without Brockenbrough needle puncture) appears to be a safe and effective method
American
February 1992 Heart Journal
of treating patients with complete or incomplete obstruction to the IVC. Prolonged streptokinase infusion seems worth a trial in patients with suspected thrombus. The dilatation of associated hepatic venous obstruction remains a challenge, and the results of balloon membranotomy may remain suboptimal in such cases. REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Hirooka M, Kimura C. Membranous obstruction of the hepatic portion of the inferior vena cava: surgical correction and etiology study. Arch Surg 1970;100:656-63. Madangopalan N, Solomon V, Jayanthi V, et al. Clinical spectrum of Budd-Chiari syndrome and surgical relief for coarctation of inferior vena cava. J Gastroenterol Hepatol1986;1:35969. Kimura C, Matsuda S, Koie H, Hirooka M. Membranous obstruction of the hepatic portion of the inferior vena cava: clinical study of nine cases. Surgery 1972;72:551-9. Victor S, Jayanthi K, Kadasamy I, Ranasabapathy A, Madangopalan N. Retrohepatic cavoatrial bypass for coarctation of inferior vena cava with a polytetrafluoroethylene graft. d Thorac Cardiovasc Surg 1986;91:99-105. Hosie KB, Bolia A, Watkin DFL. Treatment of the BuddChiari syndrome by percutaneous transluminal angioplasty (Letter). Lancet 1988;2:158-9. Sparano J, Chang J, Trasi S, Bonanno C. Treatment of the Budd-Chiari syndrome with percutaneous transluminal angioplasty. Am J Med 1987;82:821-8. Loya YS, Sharma S, Amrapurkar DN, Desai HG. Complete membranous obstruction of inferior vena cava: case treated by balloon dilatation. Cathet Cardiovasc Diaen 1989:17:164-7. Dev V, Kaul U, Jain P, et al. Percutaneous translnminal balloon angioplosty for obstruction of the suprahepatic inferior vena cava and cavoatrial graft stenosis. Am J Cardiol 198%64:397-g. Yamazaki Y, Eguchi S, Rerashima M, et al. Inferior vena caval obstruction: transvenous instrumental membranotomy. Cardiovasc Intervent Radio1 1988,11:18-20. Grill HP, Brinker JA. Late thrombotic occlusion of saphenous vein grafts. Successful recanalization using thrombolytic therapy. Cathet Cardiovasc Diagn 1988;15:252-9.
Acute thrombotic coronary occlusion secondary to chest trauma treated with intracoronary thrombolysis Gary S. Ledley, MD, Shahriar Yazdanfar, MD, Oren Friedman, MD, and Morris N. Kotler, MD. Philadelphia, Pa.
Blunt chest trauma is a rare cause of cardiac damage including myocardial contusion, ventricular rupture, ventricular septal defect, valvular damage,’ and coronary artery occlusion with myocardial infarction.2-6 Coronary artery occlusion has been reported to be secondary to intimal
From
the Albert
Einstein
Reprint requests: Gary sional Bldg., 3rd Floor, 4/4/34086
Medical
Center.
S. Ledley, MD, 5401 Suite 363, Philadelphia,
Old York Road, PA 19141.
Klein
Profes-
123
Number
2
Table
Brief Communications
I. Measurements
by intravascular
ultrasound
and angiography Angiography
Ultrasound Diameter
(mm)
Area
(mm2)
5 15
Diameter (% stenosis)
Area (% stenosis)
60%
Diameter (mm)
Diameter (X stenosis)
Pre PTCA
Proximal Lesion Distal Post PTCA After 5 mm After 6 mm
6.03
24.88
2.95 9.61
10.42 59.51
51%
3.69 5.14
13.55 25.04
40% 15%
5.8 3.5
40%
8.7
cutaneous transluminal angioplasty (PTA) morphologic assessment were done by IVUS (Fig. 1). This case is the first use of IVUS in PTA of a recurrent coarctation of the aorta in a child. Intravascular imaging quantitated the severity of stenosis before and after PTA. After using a 6.0 mm PTA balloon, the site of stenosis was dilated to the size of the proximal segment, so further balloon inflations were not performed. One should be cautious in performing the procedure and make all exchanges over a wire, as there have been incidences of catheter trauma to the site of dilation, resulting in rupture of the aorta or aneurysms at the site of dilation on long-term follow-up. Intravascular imaging reveals important details regarding the site of stenosis. We found the left subclavian artery to be widely patent both before and after PTA and confirmed that the stenosis was distal to its origin, involving the anastomosis. Another important assessment that can be made by intravascular ultrasound is the transluminal morphology of the atherosclerotic plaque and the changes in the plaque and vessel wall caused by balloon inflation. In our patient, the normal segment proximal to the site of stenosis had three distinct layers (intima, media, and adventitia) and was 1.17 mm thick with focal areas of increased ultrasound density suggesting focal areas of intimal thickening and fibrosis. After angioplasty there was no significant change in this region. At the site of stenosis the three layers could not be distinguished and the vessel wall was thickened with a decrease in lumen diameter. Also, there was a concentric increase in ultrasound density suggesting fibrosis and calcification (determined by IVUS as “dropout” of echoes). After angioplasty the lumen diameter at the site of stenosis was the same as the size of the PTA balloon, with a decrease in the concentric thickness and a localized tear, suggesting dilation of the aorta without recoil. In addition, the tear at the site of stenosis was not seen angiographically and did not extend into the left subclavian artery. Distal to the stenosis there was thinning of the layers of the aorta and there was no evidence of increased ultrasound density, suggesting minimal fibrosis. As expected, after angioplasty there was no change in the thickness or size of this segment. In summary, percutaneous intravascular ultrasound imaging is technically easy to perform in pediatric patients with coarctation of the aorta. When compared to two-
46% 0%
5.5
5%
dimensional, longitudinal images with angiography, the cross-sectional images of ultrasound provide a more accurate assessment of the arterial dimensions and morphology. The precision of the measurements with the cross-sectional ultrasound images may improve the selection of balloon size and help in assessing the angioplasty results. REFERENCES 1.
2.
3.
Shaddy RF, Snider AR, Silverman NH, et al. Pulsed Doppler findings in patients with coarctation of the aorta. Circulation 1986;73:82-8. Boxer RA, LaCorte MA, Singh S, et al. Nuclear magnetic resonance imaging in evaluation and follow-up of children treated for coarctation of aorta. J Am Co11Cardiol 1986;7:1095-8. Moodie DS, Yiannikas J, Gill CC, et al. Intravenous digital subtraction
angiography
normalities
of the aorta and aortic arch.
in the evaluation
of congenital AM
HEART
ab-
J 1982;
104628-34. 4. Stern H, Erbel
R, Schreiner G, Henkel B, Meyer J. Coarctation of aorta: quantitative analysis by transesophageal echocardiography. Echocardiography 1987;4:387-95. 5. Harrison JK, Shiekh KH, Davidosn CJ, et al. Balloon angioplasty of coarctation of the aorta evaluated with intravascular ultrasound imaging. J Am Co11 Cardiol 1990;15:906-9.
Percutaneous balloon membranotomy combined with prolonged streptokinase infusion for management of inferior vena cava obstruction Satyavan Sharma, Y. S. Loya, and B. V. Daxini. Bombay, Maharashtra, India Obstruction of the hepatic or suprahepatic portion of the inferior vena cava (IVC) producing hepatic outflow obstruction is relatively common in the Orientlm4 and, if left
From the Department ical College. Reprint Medical 4/4/34Q95
requests: College,
of Cardiology,
B. Y. L. Nair
Hospital
and T. N. Med-
Dr. Satyavan Sharma, B. Y. L. Nair Hospital Bombay 400 008, Maharashtra, India.
and
T. N.
5 16
Brief Communications
American
Fig. 1. Simultaneous inferior vena cava (I.V.C.) and right atria1 (R.A.) pressure recordings excellent (A and 6) and suboptimal result (C and D) following balloon membranotomy.
Table
I. Clinical
Patient No.
WC,
1
30/M
2
20/M
3
22/M 35/M
Inferior
vena
an
data
Age (yr)l Sl?X
4
showing
February 1992 Heart Journal
cava;
Symptom duration (YT) 7 3 3112 2
HV,
hepatic
Ultrasound
Presentation Icterus, hepatosplenomegaly, veins over the abdomen Ascites, veins over the abdomen Ascites, hepatomegaly, edema in feet Ascites, hepatosplenomegaly
No definite membrane, dilated IVC & HV Membrane (IVC + hepatic), dilated IVC Discrete membrane (IVC), dilated IVC, HV Long segment narrowing, dilated IVC
veins.
untreated, carries a poor prognosis5-‘j The obstruction is caused by a membranous web, discrete coarctation, or thrombosis. Surgical excision of the membrane or creation of a cavoatrial bypass graft remain the traditional surgical procedures.2-4 These are difficult, risky, and are associated with graft occlusion over the long term. Successful management of membranous obstruction of the IVC by balloon angioplasty has been reported.5-g We report four cases successfully treated by balloon angioplasty preceded by a Brockenbrough needle puncture in three and by prolonged streptokinase infusion in one case. All had excellent symptomatic and hemodynamic benefits that are sustained during 8 to 32 months of follow-up in three cases. Between May 1988 and June 1990, four patients were evaluated and their clinical and ultrasound findings are listed in Table I. Serum bilirubin was elevated. The other
liver function tests were usually normal. Esophagogastroscopy revealed grade 1 to 4 esophageal varices. Liver scan and biopsy suggested cirrhosis. The percutaneous balloon membranotomy in patients No. 1 to 3 was performed by the technique described by us previously.7 The only exception in patient No. 3 was that balloon dilatation could be performed without a Brockenbrough needle puncture of the membrane, as he had incomplete obstruction to the IVC. In patient No. 2, there was additional involvement of the hepatic veins. The totally blocked hepatic veins could be approached by passing a guide wire through the collateral vessel. However, the balloon catheter could not be passed and obstruction to the hepatic veins could not be relieved. In patient No. 4, an IVC angiogram suggested a membrane with superimposed thrombus. All attempts to cross the obstruction with guide wire(s) failed. Streptokinase
Volume 123 NUmDBr 2
Brief Communications
5 17
Fig. 2. IVC angiogram in posteroanterior and lateral views (A and C) reveal partial obstruction to antegrade flow as a result of a membrane. Following dilatation, no membrane is visualized and free flow of blood to the right atrium can be seen (B and D).
II. Hemodynamic
Table
and angiographic
data Gradient
Patient
No.
Suprahepatic obstruction of IVC 1 Membrane 3 4
Discrete, thin membrane Long segment (membrane + thrombus)
Intervention
vena cava; redilatation
BA4, balloon for restenosis
membranotomy; with residual
Brockenbrough needle puncture, BM BM STK infusion X 48 hr, Brockenbrough needle puncture, BM
STK, gradient
Before
After
25
27
3
20 25
22 28
2 4
20
28
16
size (mm)
Obstruction of IVC + hepatic vein obstruction 2 Long segment Brockenbrough needle puncture, BM WC, Inferior *Underwent
(mm
Hg)
Balloon
Nature of block
Follow-up
2
(32
18* (8 3 (8
17
(18
mo) mo) mo)
mo)
streptokinase of 3 mm.
was administered at the rate of 2000 units/min by positioning an infusion catheter in the IVC below the site of obstruction. Coagulation parameters and angiograms were repeated every 12 hours. An IVC angiogram after 48 hours of streptokinase infusion revealed a thin streak of contrast
passing from the IVC to the right atrium. At this stage, the patient was taken for balloon membranotomy and the procedure was performed as reported previously,7 with excellent results. In all, heparin (500 units/hr) was infused for 24 hours followed by oral anticoagulation for 3 months.
5 18
Brief Communications
Liver function tests, esophagogastroscopy, and liver scan were repeated at the end of 1 week. The angiographic and hemodynamic features are shown in Table II. All patients had marked dilatation of the IVC, hepatic veins (except patient No. 2), and dilated tortuous collaterals coursing transdiaphragmatically and draining into the superior vena cava. The mean pressure gradient across the membrane ranged between 26.25 -t 2.48 and 6.25 t- 5.67 mm Hg (p < 0.001). The gradient reduction was remarkable in patients with suprahepatic obstruction (Table II, Fig. 1, A and B); however, the gradient decreased suboptimally in patients with additional involvement of hepatic veins (Fig. 1, C and D). After the intervention, the membranous or long segment narrowing was relieved in patients No. 1,3, and 4, as confirmed by angiography (Fig. 2, A to D). There was good antegrade flow to the right atrium with regression of collaterals. No complications were observed. Follow-up hemodynamic and angiographic studies performed at the end of 32 (patient No. 1) and 8 months (patient No. 4) revealed sustained benefits. Patient No. 2, restudied at 18 months, continues to have sustained but suboptimal benefits. Patient No. 3 developed restenosis within 8 months and underwent redilatation with excellent results. Hirooka and Kimural made the first unsuccessful attempt to perform balloon membranotomy of the BuddChiari web. During recent years, balloon angioplasty has been utilized for treating obstruction of the native IV@,: g and also cavoatrial graft sten0sis.s The technique has been applied to discrete membranes as well as to long segment obstructions. Yamazaki et a1.g under ultrasonography performed control transvenous membranotomy with a specially designed instrument and reported excellent results. In the present study, we performed membranotomy by balloon catheters after puncturing the obstructing membrane with a Brockenbrough needle. We did not utilize specially designed instruments and the procedure could be performed safely under local anesthesia. The immediate clinical, hemodynamic, and angiographic results are gratifying. The technique is simple and was performed by us under fluoroscopy. In patient No. 4, a thrombus superimposed over a membrane was suspected because of the angiographic appearance of long segment narrowing, an abrupt cut-off, and a large filling defect. A recent innovation’O in treating previously uncrossable total saphenous vein graft occlusions is the use of prolonged urokinase drips to open a sufficient channel for coronary angioplasty. That report prompted us to administer a prolonged streptokinase infusion. The infusion created a channel that we could penetrate and therefore we could perform a successful balloon membranotomy. All patients were advised to take anticoagulants for 3 months. The intermediate term results are gratifying in patients No. 1 and 4 and were sustained in patient No. 2 (Table II). We encountered restenosis in patient No. 3 at 8 months and the patient underwent redilatation with excellent results. Restenosis following balloon angioplasty has also been reported by 0thers.s ’ Balloon membranotomy (with or without Brockenbrough needle puncture) appears to be a safe and effective method
American
February 1992 Heart Journal
of treating patients with complete or incomplete obstruction to the IVC. Prolonged streptokinase infusion seems worth a trial in patients with suspected thrombus. The dilatation of associated hepatic venous obstruction remains a challenge, and the results of balloon membranotomy may remain suboptimal in such cases. REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Hirooka M, Kimura C. Membranous obstruction of the hepatic portion of the inferior vena cava: surgical correction and etiology study. Arch Surg 1970;100:656-63. Madangopalan N, Solomon V, Jayanthi V, et al. Clinical spectrum of Budd-Chiari syndrome and surgical relief for coarctation of inferior vena cava. J Gastroenterol Hepatol1986;1:35969. Kimura C, Matsuda S, Koie H, Hirooka M. Membranous obstruction of the hepatic portion of the inferior vena cava: clinical study of nine cases. Surgery 1972;72:551-9. Victor S, Jayanthi K, Kadasamy I, Ranasabapathy A, Madangopalan N. Retrohepatic cavoatrial bypass for coarctation of inferior vena cava with a polytetrafluoroethylene graft. d Thorac Cardiovasc Surg 1986;91:99-105. Hosie KB, Bolia A, Watkin DFL. Treatment of the BuddChiari syndrome by percutaneous transluminal angioplasty (Letter). Lancet 1988;2:158-9. Sparano J, Chang J, Trasi S, Bonanno C. Treatment of the Budd-Chiari syndrome with percutaneous transluminal angioplasty. Am J Med 1987;82:821-8. Loya YS, Sharma S, Amrapurkar DN, Desai HG. Complete membranous obstruction of inferior vena cava: case treated by balloon dilatation. Cathet Cardiovasc Diaen 1989:17:164-7. Dev V, Kaul U, Jain P, et al. Percutaneous translnminal balloon angioplosty for obstruction of the suprahepatic inferior vena cava and cavoatrial graft stenosis. Am J Cardiol 198%64:397-g. Yamazaki Y, Eguchi S, Rerashima M, et al. Inferior vena caval obstruction: transvenous instrumental membranotomy. Cardiovasc Intervent Radio1 1988,11:18-20. Grill HP, Brinker JA. Late thrombotic occlusion of saphenous vein grafts. Successful recanalization using thrombolytic therapy. Cathet Cardiovasc Diagn 1988;15:252-9.
Acute thrombotic coronary occlusion secondary to chest trauma treated with intracoronary thrombolysis Gary S. Ledley, MD, Shahriar Yazdanfar, MD, Oren Friedman, MD, and Morris N. Kotler, MD. Philadelphia, Pa.
Blunt chest trauma is a rare cause of cardiac damage including myocardial contusion, ventricular rupture, ventricular septal defect, valvular damage,’ and coronary artery occlusion with myocardial infarction.2-6 Coronary artery occlusion has been reported to be secondary to intimal
From
the Albert
Einstein
Reprint requests: Gary sional Bldg., 3rd Floor, 4/4/34086
Medical
Center.
S. Ledley, MD, 5401 Suite 363, Philadelphia,
Old York Road, PA 19141.
Klein
Profes-
