Image guided percutaneous gastrostomy catheter placement: How we do it safely and efficiently.

Gastrostomy tube is an effective and safe long-term feeding access that is well-tolerated by patients. The typical placement routes include surgical, endoscopic and interventional radiologic placement. In particular, percutaneous interventional radiologic gastrostomy (PIRG) has increasingly become the preferred method of choice in many practices. Although many PIRG techniques have been developed since the 1980s, there is still a paucity of evidence supporting the choice of a most-optimal PIRG technique. Hence, there is a large variation in institutional approach to PIRG. We are a large, quaternary academic institution with an extensive experience in PIRG. Therefore, we aim to present the "push" PIRG technique utilized in our institution, to review the current literature, to discuss the optimal choice of PIRG technique and to generate further interests in comparison studies.

Outcomes of the TrapEase inferior vena cava filter over 10 years at a single health care system.

PURPOSE: To retrospectively investigate the safety, efficacy, and complications associated with TrapEase inferior vena cava filters. METHODS: All patients who received a TrapEase filter at a single institution between April 2003 and January 2013 were identified, and outcomes were reviewed and analyzed. RESULTS: During the study period, 594 patients (278 women; mean age, 68.9 ± 13.6 years; range, 19.2-96.3 years) received a TrapEase filter. The duration of this study was 88 months, with a median clinical follow-up of 3.6 months (range, 0-148.3 months). During follow-up, 489 of 594 patients (82.3%) died and 105 remained alive with filters in situ. Nine cases of breakthrough pulmonary embolism occurred among the 582 patients with clinical follow-up (1.5%). Among 128 patients with imaging that contained the filter, there were 17 cases of filter fracture (13.3%). Of the 39 patients with available computed tomography scans, eight had filling defects within the filter suggestive of thrombus or embolus (20.5%), including two patients with complete caval occlusion. Recurrent deep vein thrombosis occurred in 109 out of 582 patients (18.7%) with clinical follow-up. CONCLUSIONS: Most patients who received TrapEase filters died during follow-up, possibly because operators chose to implant a permanent filter in patients with known terminal illnesses. The filter fracture rate seemed to be high, but there were no instances of free fracture fragment or distant migration. Although the filter may theoretically be effective in preventing thrombus migration owing to the double basket design, pulmonary embolism breakthrough rates were comparable with rates seen with other filters.

Current understanding and management of splenic steal syndrome after liver transplant: A systematic review.

BACKGROUND: Splenic steal syndrome (SSS) is a condition that can occur after orthotopic liver transplant (OLT). However, limited information is available about this condition. METHODS: A systematic literature search of studies performed through May 2016 was conducted to identify reports of angiographically confirmed SSS and its variants. All of the factors relevant to this disorder were collected and analyzed. RESULTS: A total of 219 cases of SSS and its variants were identified. The condition occurred in 4.7% of patients after OLT, and 93.7% of cases were diagnosed within the first 2 months after OLT. Conventional arteriography demonstrated nonocclusive hepatic artery hypoperfusion in all affected patients. Abnormal liver function was the most common clinical presentation, reported in 71.9% of cases. Less common presentations included thrombocytopenia, acute graft failure, and persistent ascites. On Doppler ultrasound, a high resistance index of the hepatic artery was present in 84.1% of patients. Increased spleen volume (≥829 mL) before OLT was suggestive of a potential risk for SSS. Splenic artery embolization (SAE) was performed in 94.7% of cases; this procedure immediately reversed flow abnormalities on Doppler ultrasound and improved liver function tests in 96.3% of cases. CONCLUSIONS: The risk factors and potential etiologies of SSS remain largely unknown. Future studies should investigate the possible role of pre-OLT portal hypertension and portal hyperperfusion after OLT in the development of this syndrome. Collecting intraoperative hemodynamic data and performing Doppler ultrasound screening after OLT could potentially help clinicians to identify patients at high risk of arterial hypoperfusion and prevent potential complications from hepatic artery hypoperfusion.

Retrospective Review of 516 Implantations of Option Inferior Vena Cava Filters at a Single Health Care System.

PURPOSE: To retrospectively evaluate the safety, efficacy, and retrievability of Option inferior vena cava (IVC) filters. MATERIALS AND METHODS: All patients (N = 516; 247 women; mean age, 67.1 y ± 15.1; range, 19.5-101.6 y) who received an Option filter between August 2009 and March 2015 at a single health care system were analyzed. RESULTS: The study duration was 68 months, with median clinical follow-up of 7.1 months (range, 1 d to 61.8 mo). During follow-up, 73 of 83 patients (88.0%) underwent successful filter retrieval, 153 died (including three after successful retrieval), and 293 remained alive with filters in situ. Seventeen cases of breakthrough pulmonary embolism (PE) occurred (3.4%). Among 323 patients with direct filter imaging, there were two cases of tilt > 15°, one case of filter deformity, 16 cases of intracaval migration > 2 cm, and no cases of filter fracture. There were six cases of caval occlusion, nine cases of thrombus trapped inside the filter, and 57 cases of limb penetration on computed tomography scans or radiographs of the IVC. Retrieval failures were attributed to filter tilt or tip embedment in the caval wall (n = 4), complete IVC thrombosis (n = 3), thrombus inside the filter (n = 2), or inability to disengage filter legs (n = 1). Recurrent deep vein thrombosis occurred in 34 patients, including 32 with filters in situ and two whose filters had been removed. CONCLUSIONS: Most Option filters were left in situ for permanent indications. Rates of successful retrieval, device-related complications, and breakthrough PE were similar to those associated with other retrievable filters.

Visceral artery embolization after endoscopic injection of Enteryx for gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) can be difficult to manage medically and may require endoscopic or surgical interventions. The Enteryx procedure was designed to enhance the gastroesophageal barrier function by endoscopic injection of a copolymer into the lower esophageal sphincter. We present a rare case of a patient who was found to have migration of the copolymer into the celiac trunk and bilateral renal arteries during a work-up for persistent intermittent hematuria, which began shortly after Enteryx therapy for GERD.

Prevalence and clinical consequences of fracture and fragment migration of the Bard G2 filter: imaging and clinical follow-up in 684 implantations.

PURPOSE: To investigate the prevalence and clinical sequelae of G2 filter (Bard Peripheral Vascular, Tempe, Arizona) fractures and fragment migration. MATERIALS AND METHODS: Patients who underwent G2 filter placement between October 2005 and February 2010 were assessed for filter fractures and complications. Fracture prevalence was estimated at various time points based on data from patients with known fracture status. RESULTS: Among 829 patients who underwent G2 filter placement, 684 had follow-up imaging and qualified for the study (381 men and 303 women; average age, 60.3 y; range, 15.8-95.2 y). For 541 (79%) patients, at least one image was available that contained the filter (imaging follow-up interval, 14.9 mo ± 20.0; range, 0-78.6 mo); images that did not include the filter but may have shown the migrated fracture fragment were available for 143 (21%) patients (follow-up interval, 11.2 mo ± 19.3; range, 0-83.4 mo). There were 16 fractured limbs identified in 13 patients (incidence, 1.9%; follow-up interval, 30.4 mo ± 18.7; range, 5.5-76.5 mo). Fracture fragments were identified in the pulmonary arteries (n = 4), right ventricle (n = 2), pericardium (n = 1), iliac vein (n = 1), and kidney (n = 1). Four fracture limbs remained near the filter; the remaining three could not be located. All patients with filter fracture were asymptomatic. The estimated 5-year fracture prevalence was 38% (95% confidence interval, 22.9%, 54.8%). CONCLUSIONS: The early occurrence of G2 filter fractures was low, but the incidence increased over time. No life-threatening events occurred in patients with filter fracture during the study time frame.

Penetration of Celect inferior vena cava filters: retrospective review of CT scans in 265 patients.

OBJECTIVE: The purpose of this study is to retrospectively evaluate the prevalence and extent of Celect inferior vena cava (IVC) filter penetration. MATERIALS AND METHODS: All patients with Celect filters who underwent CT between 2007 and 2012 were assessed for penetration and related complications. RESULTS: Of the 690 patients with Celect filters placed at our institution, 265 underwent CT for various reasons. The mean (SD) interval between filter placement and last CT was 167.8±264.8 days (median, 56 days; range, 0-1592 days). Penetration of primary leg was observed in 39% (95% CI, 29-51%) of patients within 30 days and 80% (95% CI, 70-87%) of patients within 90 days after placement. The mean number of penetrated legs per patient was 1.8 at 30 days and 2.1 at 90 days after placement. Penetration into adjacent organs occurred in 35 of 265 (13.2%) filters (in 45 IVC filter limbs); penetration into two structures occurred with 10 filters. The sites involved were the duodenum (n=22), aorta (n=9), psoas muscle (n=4), vertebral body (n=3), pancreas (n=2), adrenal gland (n=1), liver (n=1), right kidney (n=1), lymph node (n=1), and diaphragm (n=1). One patient presented with abdominal pain related to penetration. CONCLUSION: This study confirms a high penetration rate for Celect IVC filters and shows that CT can characterize the extent of leg penetration. Most cases of penetration were asymptomatic, but the likelihood of penetration increased over time.

Strategies for prevention of iatrogenic inferior vena cava filter entrapment and dislodgement during central venous catheter placement.

BACKGROUND: Iatrogenic migration of inferior vena cava (IVC) filters is a potentially life-threatening complication that can arise during blind insertion of central venous catheters when the guide wire becomes entangled with the filter. In this study, we reviewed the occurrence of iatrogenic migration of IVC filters in the literature and assessed methods for preventing this complication. METHODS: A literature search was conducted to identify reports of filter/wire entrapment and subsequent IVC filter migration. Clinical outcomes and complications were identified. RESULTS: A total of 38 cases of filter/wire entrapment were identified. All of these cases involved J-tip guide wires. Filters included 23 Greenfield filters, 14 VenaTech filters, and one TrapEase filter. In 18 cases of filter/wire entrapment, there was migration of the filter to the heart and other central venous structures. Retrieval of the migrated filter was successful in only four of the 18 cases, and all of these cases were complicated by strut fracture and distant embolization of fragments. One patient required resuscitation during retrieval. Successful disengagement was possible in 20 cases without filter migration. CONCLUSIONS: Iatrogenic migration of an IVC filter is an uncommon complication related to wire/filter entrapment. This complication can be prevented with knowledge of the patient's history, use of proper techniques when placing a central venous catheter, identification of wire entrapment at an early stage, and use of an appropriate technique to disengage an entrapped wire.

Nonvascular and portal vein applications of cone-beam computed tomography: current status.

C-arm cone-beam computed tomography (CBCT) is a relatively new imaging technology that uses a conical-shaped radiation beam and a 2-dimensional flat-panel detector to produce 3-dimensional volumetric datasets with excellent spatial resolution. Recently, this technology has been implemented in angiographic units across the country. This imaging modality is particularly useful when both images of "CT-like" quality and real-time fluoroscopic imaging are required for pretreatment planning and intraprocedural guidance. In this article, we describe the use of cone-beam CT technology in various nonvascular and portal venous interventions, including percutaneous vertebroplasty or kyphoplasty, transjugular intrahepatic portosystemic shunt, percutaneous needle biopsy and ablation of pulmonary nodules and renal masses, gastrostomy tube insertion, hepatic radiofrequency ablation, and biliary interventions.

Fracture and migration of Celect inferior vena cava filters: a retrospective review of 741 consecutive implantations.

PURPOSE: To determine the incidence of fracture and migration of the Celect inferior vena cava (IVC) filter at a single tertiary-care center. MATERIALS AND METHODS: Images obtained after placement of Celect IVC filters between August 2007 and January 2013 were retrospectively reviewed for evidence of device fracture and migration. The probability of filter fracture at 6 and 12 months after filter placement was estimated, and a 95% upper confidence bound was constructed. RESULTS: A total of 741 consecutive Celect filters were placed, and the following studies were subsequently evaluated: 301 abdominal radiographs, 282 abdominal computed tomography (CT) scans, 154 cavagrams, 19 lumbar spine radiographs, 462 chest radiographs, 108 chest CT scans, and 31 pelvic radiographs. The mean imaging follow-up interval was 5.78 months ± 8.80 (range, 0.01-56.03 mo). There was no filter fracture or en-bloc migration outside the IVC. Upper 95% confidence bounds for the probability of fracture were 1.8% at 6 months and 4.3% at 12 months. Intracaval filter migration of more than 2 cm (mean, 2.43 ± 0.12 cm; range, -2.54 to 2.99 cm) was seen in 3.9% of patients (21 of 534; 12 cranial and nine caudal). CONCLUSIONS: No fracture of a Celect filter was observed in this large cohort over a relatively short follow-up interval. The results also suggest that the Celect filter has an adequate securing mechanism to prevent distant en-bloc or significant intracaval migration.

Balloon-assisted N-butyl-2-cyanoacrylate closure of an iatrogenic femoral arteriovenous fistula.

Femoral arteriovenous fistula (AVF) is an abnormal communication between femoral artery and vein, which is frequently caused by an iatrogenic or traumatic event. Surgery and endovascular approach with coil and stent graft placement are the most frequent choices of treatment. Herein, we present 2 cases of iatrogenic superficial femoral AVF, which were treated with percutaneous balloon-assisted N-butyl-2-cyanoacrylate glue (N-BCA). Both fistulae had a short tract, and 1 of the patients had previously undergone a failed coil embolization. The occlusions with N-BCA were achieved immediately, and both fistulae remained obliterated at 1 and 12 months of follow-up.

Challenges in interventional radiology: the pregnant patient.

A pregnant patient presenting to interventional radiology (IR) has a different set of needs from any other patient requiring a procedure. Often, the patient's care can be in direct conflict with the growth and development of the fetus, whether it be optimal fluoroscopic imaging, adequate sedation of the mother, or the timing of the needed procedure. Despite the additional risks and complexities associated with pregnancy, IR procedures can be performed safely for the pregnant patient with knowledge of the special and general needs of the pregnant patient, use of acceptable medications and procedures likely to be encountered during pregnancy, in addition to strategies to protect the patient and her fetus from the hazards of radiation.

Retrospective review of 120 celect inferior vena cava filter retrievals: experience at a single institution.

PURPOSE: To evaluate retrospectively the safety and retrievability of the Celect IVC filter. MATERIALS AND METHODS: All patients undergoing Celect filter placement and retrieval during the period 2007-2012 were assessed for complications and retrievability. RESULTS: Of 620 patients who underwent Celect filter placement, 120 presented for removal. The indwelling time in these patients was 158.1 days±103.0 (range, 2-518 d). There were 106 filters (88.3%) removed; 14 filters were left in situ for the following reasons: filter embedment (n=6), caval occlusion (n=3), retained thrombus (n=2), large floating thrombus in IVC (n=2), or tilt >15° (n=1). With filters in place, five patients developed new pulmonary embolism (PE), and two others presented with severe abdominal pain. The available 115 pairs of placement and removal cavagrams suggested limb penetration in 99 cases (86.1%), intracaval migration >2 cm in 5, secondary tilt >15° in 8, filter deformity in 10, retained thrombus within filters in 12, and IVC occlusion in 3. Among 38 available computed tomography (CT) scans, 9 scans (24%) showed asymptomatic limb penetration to the duodenum (n=6), aortic wall (n=2), or kidney (n=1). No filter fracture was found. CONCLUSIONS: This study showed a high penetration rate for Celect IVC filters, including penetrations that were symptomatic or involved adjacent structures. Penetration appears to correlate with indwelling time, suggesting that the filter should be removed as soon as PE protection is no longer indicated. Although most of the filters were removed, 5.8% of retrievals were unsuccessful because of technical failure.

Prophylactic antibiotic guidelines in modern interventional radiology practice.

Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treatments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percutaneous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice.

Incidence and risk factors for surgical intervention after uterine artery embolization.

OBJECTIVE: To determine the incidence and risk factors for surgical intervention after uterine artery embolization for symptomatic uterine fibroids. STUDY DESIGN: Electronic medical records of all patients who underwent uterine artery embolization for symptomatic uterine leiomyomata were reviewed. Logistic regression was used to identify independent risk factors for any surgical intervention and for hysterectomy alone after uterine artery embolization. RESULTS: Uterine artery embolization was performed in 454 patients during the study period, with a median follow-up time (range) of 14 (0-128) months. Overall, 99 patients (22%) underwent any surgical intervention after uterine artery embolization in the operating room. Risk factors for any surgical intervention included younger age (P < .003), bleeding as an indication for uterine artery embolization (P < .01), presence of significant collateral ovarian vessel contribution to the uterus (P < .01), or use of 355-500 mum particles (P < .008). CONCLUSION: Patients undergoing uterine artery embolization have a 22% risk for requiring additional surgical intervention, but overall uterine artery embolization is an effective minimally invasive option.