Radiofrequency guidewire-facilitated recanalization of chronic thoracic central venous occlusions in hemodialysis patients.

PURPOSE: To assess the outcome and safety of radiofrequency (RF) wire recanalization in patients with end-stage renal disease (ESRD) and chronic central venous occlusions (CVO). MATERIALS AND METHODS: A retrospective review of ESRD patients who underwent RF-wire recanalization of symptomatic chronic thoracic CVO from January 2017 to August 2022 yielded 20 patients who underwent 21 procedures. All patients had undergone at least one prior unsuccessful attempt at central venous recanalization using conventional catheter-based techniques. Technical success was defined by the ability to cross the CVO using RF-wire recanalization enabling endovascular treatment. Access circuit patency was evaluated based on follow-up imaging and symptomatic improvement. RESULTS: Radiofrequency wire recanalization was successful in 17/21 procedures (81%) with all patients (100%) reporting resolution of arm ± facial swelling. Three major complications occurred (14%): two hemothoraces and one hemopericardium. Medial stent diameter was 13 mm (range, 9-14 mm). Mean duration of hospital stay was 2 days ± 3 days. Mean procedure time was 158 ± 46 min with a mean fluoroscopy time of 31.7 ± 16.3 min. Primary unassisted patency at 6 and 12 months was 94 ± 6% and 85 ± 10%, respectively. Additional interventions resulted in significantly increased stent graft patency (P = 0.006). CONCLUSION: Radiofrequency wire-enabled recanalization of CVO in symptomatic dialysis patients has a high rate of technical success with resolution of arm and facial swelling and resumed use of the ipsilateral dialysis access. Although a superior safety profile was seen than with needle-based techniques such as sharp recanalization, major complications were not infrequent indicating that this RF-wire procedure should be performed in centers equipped to manage central venous perforations.

Endovascular Management of Neurofibromatosis Type I-Associated Vasculopathy: A Case Series and Brief Review of the Literature.

PURPOSE: Neurofibromatosis type 1 (NF1) is an autosomal-dominant disorder found in approximately 1 of every 3000 individuals. Neurofibromatosis type 1 can have vascular manifestations including aneurysms, stenoses, and arteriovenous malformations. The purpose of this article is to describe the clinical manifestations of NF1 vasculopathy, discuss therapeutic options, and highlight endovascular therapies from our institutional experience. MATERIALS AND METHODS: The radiology information system was searched for cases of NF1. Cases with vasculopathy managed with endovascular therapies were included. Demographics, clinical histories, procedural details, and outcomes were recorded. A review of the literature for the management strategies of NF1 vasculopathy was performed. RESULTS: Two pediatric patients with NF1 were identified, both of whom presented with hypertension found to be secondary to renal artery stenosis. One of the patients also had infrarenal aortic narrowing. Both patients were successfully treated with balloon angioplasty, resulting in improved blood pressures. The review of the literature identified case series of pharmacologic, surgical, and endovascular therapies, although, endovascular therapies appear to be preferred due to lower morbidity and mortality. CONCLUSIONS: NF1 vasculopathy is a rare condition that most often presents with hypertension due to renal artery stenosis. In these situations, endovascular management is the preferred approach.

Survival Outcomes of Very Small Drug-Eluting Beads Used in Chemoembolization of Unresectable Hepatocellular Carcinoma.

PURPOSE: To assess the safety and efficacy of transarterial chemoembolization using a 75-µm drug-eluting embolic (DEE) in patients with unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The medical records of 109 patients with a mean age of 64.1 years (range 85-49) treated for unresectable HCC between November 2013 and August 2016 with transarterial chemoembolization using a 75-µm DEE were retrospectively reviewed. Patients who had prior therapy for HCC were excluded. Child-Pugh A patients and Barcelona Clinic Liver Cancer stages A/B patients constituted 68.8% and 65.1% of the patients, respectively. The mean size of the index tumors was 5.8 cm (range 18.5-1.2) with 42 (39%) patients with central tumors around the porta-hepatis region. Portal vein invasion was seen in 10 (9.2%) patients. Tumor response was categorized according to the modified Response Evaluation Criteria in Solid Tumors 1.1, and the toxicity profile was assessed using Common Terminology Criteria for Adverse Events, version 4.03. RESULTS: At 1-month follow-up, complete response, objective response, and disease control was seen in 23%, 66%, and 90%, respectively. The median progression-free survival was 11.2 months. The median overall survival was 25.1 months (33.4 months for Child-Pugh A and 28.2 months for Barcelona Clinic Liver Cancer stages A/B), and transplant-free survival was 21.3 months. The 6-, 12-, and 24-month survivals were 91.7%, 75.5%, and 50.5%, respectively. Grade 3 toxicity was seen in 1.8% of the patients; no grade 4 or 5 toxicity was reported. CONCLUSIONS: Transarterial chemoembolization using 75-µm DEE is safe and efficacious in the treatment of HCC.

Infection of Small-Bore Tunneled Central Venous Catheters.

OBJECTIVE. The purpose of this study is to evaluate the association of common clinical variables with small-bore tunneled central venous catheter (CVC) infection. MATERIALS AND METHODS. Retrospective data were collected from all small-bore (6-French) tunneled CVCs placed by the interventional radiology service between 2012 and 2015. Only patients who had a documented reason for tunneled CVC removal were included in the analysis to capture all events. Transfemoral, transhepatic, and translumbar placements were excluded to reduce cohort heterogeneity. Multiple clinical variables were collected from a review of the medical record. The t test and Fisher exact test were used for two-group comparisons for continuous variables and categoric variables, respectively. Logistic regression analyses were further used to identify variables that were associated with catheter infection. RESULTS. One hundred eighty-two patients (105 women [57.7%] and 77 men [42.3%]) with a mean (± SD) age of 49.7 ± 16 years were included. Thirty-two catheters (17.6%) were removed because of infection. Noninfected lines were removed at a mean of 39 (SD, 57.3) days, whereas infected lines were removed at a mean of 95.9 (SD, 113.4) days after placement (p < 0.001). There was a statistically significant difference in the number of tunneled CVCs removed for infection when the indication for tunneled CVC placement was the administration of IV antibiotics (p = 0.04). By multivariate analysis, only time to removal (p = 0.002; odds ratio, 0.992; 95% CI, 0.986-0.998) and a history of tunneled CVC (p = 0.01; odds ratio, 0.306; 95% CI, 0.121-0.772) were associated with catheter removal for infection. CONCLUSION. Time to catheter removal and history of tunneled CVC were associated with an increased risk of tunneled CVC removal because of infection.

Erratum: Outcomes of fluoroscopic and ultrasound-guided placement versus laparoscopic placement of peritoneal dialysis catheters.

[This corrects the article DOI: 10.1093/ckj/sfx132.].

Outcomes of fluoroscopic and ultrasound-guided placement versus laparoscopic placement of peritoneal dialysis catheters.

BACKGROUND: Several peritoneal dialysis catheter (PDC) placement techniques have been described. The objective of this study was to compare the fluoroscopy and ultrasound guidance technique with the laparoscopic technique. METHODS: We retrospectively reviewed the medical records of 260 patients who had their first PDC placed between January 2005 and June 2016. We compared the outcomes of the fluoroscopic and ultrasound-guided catheter placement technique (radiologic group, n = 50) with the laparoscopic catheter placement technique (laparoscopic group, n = 190). The primary endpoint was complication-free catheter survival at 365 days. Secondary endpoints were complication-free catheter survival at 90 days, overall catheter survival at 90 and 365 days, median days to first complication and median days to catheter removal. RESULTS: In the radiologic group, the complication-free catheter survival at 90 and 365 days was 64% and 48%, respectively, while in the laparoscopic group it was 71% (P = 0.374) and 53% (P = 0.494), respectively. Catheter malfunction was significantly higher in the laparoscopic group (30%) compared with the radiologic group (16%, P = 0.048). The overall catheter survival at 90 and 365 days was 76% and 52%, respectively, in the radiologic group, while in the laparoscopic group it was 88% (P = 0.0514) an 48% (P = 0.652), respectively. There was no significant difference in the median days to first complication and the median days to catheter removal between the two groups (P = 0.71). CONCLUSION: The technique of fluoroscopic and ultrasound-guided PDC placement is a clinically effective and safe alternative to laparoscopic catheter placement with similar survival and complication rates.

Approaches for safe transarterial chemoembolization of multifocal hepatocellular carcinoma with retrograde flow in a retroportal artery.

We report a case of an 81-year-old woman with multifocal hepatocellular carcinoma who underwent transarterial chemoembolization. The patient had significant superior mesenteric artery (SMA) ostial stenosis, which led to retrograde flow in the retroportal artery to the SMA. The authors adopted several approaches to avoid potential nontarget embolization that might result from the change in the hemodynamics in the hepatoenteric arteries by initially stenting the SMA ostial stenosis as well as the use of the Surefire infusion system and balloon occlusion for delivery of chemoembolization material to tumors in the hepatic lobes. To our knowledge, the collective use of these approaches to avoid potential risks related to SMA ostial stenosis and retrograde flow in a retroportal artery has not been previously described in the literature.

Persistent Pulmonary Arteriovenous Malformations: Percutaneous Embolotherapy.

Pulmonary arteriovenous malformations (PAVM) are an uncommon entity that interventional radiologists may face in their clinical practice. Many of these lesions are treated successfully using endovascular techniques with satisfactory long-term results. However, some PAVMs respond poorly to initial interventional techniques. This article reviews the signs and symptoms of persistent PAVMs, illustrates different imaging modalities used to diagnose these lesions, and outlines mechanisms by which these lesions may persist. The article highlights techniques and embolic agents used for percutaneous transcatheter embolotherapy of persistent PAVMs and discuss the outcomes of these interventions.

Accidental Concentrated Hydrogen Peroxide Ingestion Associated with Portal Venous Gas.

A case of a 52-year old male patient who presented to the emergency department with severe nausea and vomiting following accidental ingestion of H2O2. A computed tomography (CT) abdomen performed at our institution demonstrated extensive portal venous gas throughout the liver with few gas droplets seen in the extrahepatic portal vein portion. Pneumatosis was also noted in the wall of the gastric antrum. Upper GI Endoscopy was done revealing diffuse hemorrhagic gastritis and mild duodenal bulb erosion. The patient was treated with hyperbaric oxygen. On the second day of admission, the patient was able to eat without difficulty or pain. Accidental ingestion of high concentration H2O2 solution has been shown to cause extensive injury to surrounding tissues. The injury occurs via three main mechanisms: corrosive damage, oxygen gas formation, and lipid peroxidation. We report a case of accidental ingestion of a highly concentrated (35%) solution of H2O2 causing portal venous gas.

Embolization of congenital intercostobronchial trunk-pulmonary artery fistula using Amplatzer vascular plugs.

We present the case of a 54-year-old male patient diagnosed with a right upper lobe lung cancer and was referred for resection. Positron emission tomography-computed tomography scan showed a prominent vascular structure in the right lung, suspicious for vascular malformation. A computed tomography angiography was done, demonstrating an intercostobronchial trunk-pulmonary artery fistula. There was also non-tapering dilated wandering pulmonary artery coursing through the right lower lung without any abnormal connection with pulmonary veins and were supplying normal lung parenchyma. Amplatzer vascular plugs were used for the treatment of the intercostobronchial trunk-pulmonary artery fistula. Our case highlights these very rare vascular anomalies, and their management.

Percutaneous embolization of cystic duct stump leak following failed endoscopic management.

A case of a 79-year-old man, status post laparoscopic cholecystectomy with a drainage catheter placed at the gallbladder fossa is presented. The case was complicated postoperatively by abdominal pain and bilious discharge from the drainage catheter. Endoscopic retrograde cholangio-pancreatography demonstrated leakage through the cystic duct stump into the gallbladder fossa. Placement of a covered metal stent endoscopically failed to seal the leak. We performed percutaneous embolization of the cystic duct stump using a combination of coils and gelatin sponge through the drainage catheter in the gallbladder fossa. To our knowledge, this technique has not been previously described in the literature.