Covered Stents and Coil Embolization for Treatment of Postpancreatectomy Arterial Hemorrhage.

PURPOSE: To evaluate the efficacy and clinical outcomes associated with stent-graft placement and coil embolization for postpancreatectomy arterial hemorrhage (PPAH). MATERIALS AND METHODS: Retrospective review of 38 stent-graft and/or embolization procedures in 28 patients (23 men; mean age, 65.1 y) for PPAH between 2007 and 2014 was performed. Time of bleeding, source of hemorrhage, intervention and devices used, repeat intervention rate, time to recurrent bleeding, complications, and 30-day mortality were assessed. Independent risk factors for recurrent bleeding and 30-day mortality were identified. RESULTS: Median onset of hemorrhage was at 39 days (mean, 27.9 d; range, 5-182 d). Covered stents were used in 65.7% of interventions, coil embolization in 23.6%, stent-assisted embolization in 5.2%, and stent-graft angioplasty in 2.6%. A total of 28 stent-grafts were placed, of which 19 were self-expandable and nine were balloon-mounted. Mean stent-graft diameter was 6.6 mm (range, 5-10 mm). Recurrent bleeding occurred following 26.3% of interventions in seven patients at a mean interval of 22 days. The site of recurrent bleeding was new in 80% of cases. There was no significant difference in recurrent bleeding rate in early-onset (< 30 d; n = 22) versus late-onset PPAH (> 30 d; n = 6; P > .05). No ischemic hepatic or bowel complications were identified. The 30-day mortality rate was 7.1% (n = 2) and was significantly higher in patients with initial PPAH at ≥ 39 days (n = 5; P = .007). CONCLUSIONS: Covered stents and coil embolization are effective for managing PPAH and maintaining distal organ perfusion to minimize morbidity and mortality. Recurrent bleeding is common and most often occurs from new sites of vascular injury rather than previously treated ones.

The Impact of Tunneled Catheters for Ascites and Peritoneal Carcinomatosis on Patient Rehospitalizations.

PURPOSE: The aim of the study is to assess patient outcomes, complications, impact on rehospitalizations, and healthcare costs in patients with malignant ascites treated with tunneled catheters. MATERIALS AND METHODS: A total of 84 patients with malignant ascites (mean age, 60 years) were treated with tunneled catheters. Patients with peritoneal carcinomatosis and malignant ascites treated with tunneled drain catheter placement over a 3-year period were studied. Overall survival from the time of ascites and catheter placement were stratified by primary cancer and analyzed using the Kaplan-Meier method. Complications were graded by the Common Terminology Criteria for Adverse Events v3.0 (CTCAE). The differences between pre- and post-catheter admissions, hospitalizations, and Emergency Department (ED) visits, as well as related inpatient expenses were compared using paired t tests. RESULTS: There were no significant differences in gender, age, or race between different primary cancer subgroups. One patient (1%) developed bleeding (CTCAE-2). Four patients (5%) developed local cellulitis (CTCAE-2). Three patients (4%) had prolonged hospital stay (between 7 and 10 days) to manage ascites-related complications such as abdominal distention, discomfort, or pain. Comparison between pre- and post-catheter hospitalizations showed significantly lower admissions (-1.4/month, p < 0.001), hospital stays (-4.2/month, p = 0.003), and ED visits (-0.9/month, p = 0.002). The pre- and post-catheter treatment health care cost was estimated using MS-DRG IPPS payment system and it demonstrated significant cost savings from decreased inpatient admissions in post-treatment period (-$9535/month, p < 0.001). CONCLUSIONS: Tunneled catheter treatment of malignant ascites is safe, feasible, well tolerated, and cost effective. Tunneled catheter treatment may play an important role in improving patients' quality of life and outcomes while controlling health care expenditures.

Peroneal arteriovenous fistula and pseudoaneurysm: an unusual presentation.

Peroneal artery arteriovenous fistulas and pseudoaneurysms are extremely rare with the majority of reported cases due to penetrating, orthopedic, or iatrogenic trauma. Failure to diagnose this unusual vascular pathology may lead to massive hemorrhage or limb threatening ischemia. We report an interesting case of a 14-year-old male who presented with acute musculoskeletal pain of his lower extremity. Initial radiographs were negative. Further imaging workup revealed a peroneal arteriovenous fistula with a large pseudoaneurysm. After initial endovascular intervention was unsuccessful, the vessels were surgically ligated in the operating room. Pathology revealed papillary endothelial hyperplasia consistent with an aneurysm and later genetic testing was consistent with Ehlers-Danlos syndrome Type IV. This case illustrates an unusual cause of acute atraumatic musculoskeletal pain and uncommon presentation of Ehlers-Danlos syndrome.

Combined interventional radiology followed by endoscopic therapy as a single procedure for patients with failed initial endoscopic biliary access.

BACKGROUND: Percutaneous transhepatic cholangiography (PTC) assisted endoscopic retrograde cholangiopancreatography (ERCP) usually requires two separate sessions. There are no reports to support performing the procedures in a single session. AIM: The purpose of this study was to assess the feasibility and safety of the ERCP rendezvous technique via PTC in a single session for patients with initially failed endoscopic biliary intervention. METHOD: We conducted a retrospective cohort study in a high volume tertiary referral center. A single experienced endoscopist and two interventional radiologists performed all the procedures. Patient demographics and all the related clinical data from January 2009 to July 2011 were obtained from hospital records. Outcome measures were the overall success rates of completion of the combined PTC and ERCP sessions for biliary drainage. Procedure-related complications (bleeding, perforation, hemobilia, bile leak, pancreatitis or cholangitis) were also assessed. RESULT: Twenty-three patients (14 men) with a median age of 68 years (range 47-89 years) underwent 26 combined PTC-ERCP as a single procedure. PTC and ERCP were both performed within 6 h of failed ERCP in 19 cases (73 %) and the others within 72 h. A total of 91 % of patients had underlying gastrointestinal metastatic cancers, and a surgically altered pancreaticobiliary system was found in 26 % of patients. Percutaneous biliary access was obtained via PTC in all procedures and successful rendezvous therapy was performed in 23 cases (88 %), which include biliary stone removal with a balloon catheter (n = 7) and biliary prostheses (n = 19). The median procedure length for successful PTC-ERCP rendezvous was 60 min (range 14-147 min). With the mean follow-up of 202 days (range 8-833 days), three immediate procedural complications [asymptomatic pneumoperitoneum (n = 2) and post biliary sphincterotomy bleeding (n = 1)] and two delayed complications (a hemorrhagic shock from a damaged branch of hepatic artery and a biloma with secondary infection) occurred, and there was no procedure-associated mortality. CONCLUSION: This is the first report assessing the feasibility and safety of a combined procedure of ERCP and PTC in a single session. In experienced hands, the combined approach in a single session is appropriate in selected patients with an acceptable risk.

An uncommon cause of gross hematuria: two cases of ureteroarterial fistula.

Ureteroarterial fistula (UAF) is a rare but potentially fatal cause of hematuria seen in patients with prolonged ureteral stenting in the setting of surgery or abdominal radiation. It presents as episodic, transfusion-dependent hematuria with formation of clots. There is no current consensus for the optimal way to diagnose or treat UAF. We report two cases of UAF that required repeated studies and provocative testing to confirm the diagnosis. Both were successfully managed by endovascular stenting. Clinicians must recognize the diagnostic difficulties involved and maintain a high index of suspicion for UAF in stented patients with intermittent, severe hematuria.