CIRSE Standards of Practice on Oesophageal and Gastroduodenal Stenting.

BACKGROUND: Image-guided insertion of stents in the upper gastrointestinal trunk is an effective, minimally invasive treatment option to provide immediate relief of symptoms caused by upper gastrointestinal tract obstruction related to advanced-stage malignant causes or benign causes that lead to lumen narrowing. PURPOSE: This document, as with all CIRSE Standards of Practice documents, is not intended to impose a standard of clinical patient care but will recommend a reasonable approach to best practices for performing stenting of the upper gastrointestinal tract, namely the oesophageal and gastroduodenal segments. Our purpose is to provide up-to-date recommendations for placement of upper gastrointestinal tract stents based on the previously published guidelines on this topic in 2005 and 2007. METHODS: The writing group was established by the CIRSE Standards of Practice Committee and consisted of a group of internationally recognised experts in performing upper gastrointestinal stenting. The writing group reviewed the existing literature using PubMed to search for relevant publications in the English language up to September 2021. The final recommendations were formulated through consensus. CONCLUSION: Insertion of stents in the oesophageal and gastroduodenal tracts has an established role in the successful management of malignant or benign obstructions. This Standards of Practice document provides up-to-date recommendations for the safe performance of upper gastrointestinal stent placement.

Safety and efficacy of the Mynx Control vascular closure device in peripheral arterial procedures: A prospective study.

OBJECTIVES: This article aims to present a prospective study investigating the safety and efficacy of the Mynx Control extravascular closure device (Cordis Corporation, FL, USA), for femoral arterial closure in patients undergoing peripheral arterial procedures. METHODS: Between January 2020 and February 2021, 100 Mynx Control devices were deployed in 91 consecutive patients (mean age: 67.5 ± 16.9 years) who underwent peripheral arterial procedures. We used ultrasound and/or fluoroscopy during Mynx Control deployment and ultrasound post-procedure to detect complications. Femoral artery punctures included 62 (62%) antegrade and 38 (38%) retrograde punctures. The mean activated clotting time at time of device deployment was 221s. The primary endpoints were technical success, device failure, and complication rates up to 30 days. RESULTS: A 5F vascular sheath was used in 43 cases (43%) (36 (36%) 6F and 21 (21%) 7F). The majority of our cases had antegrade access (62%). Overall technical success rate was 97% in both antegrade and retrograde cases. In total, there were 4 minor complications: 3 (3%) cases of pseudoaneurysm and 1 (1%) case of haematoma. No major complications were recorded post-procedure or 30 days post index procedure. CONCLUSION: The Mynx Control vascular closure device is safe and effective in achieving haemostasis in patients undergoing antegrade and retrograde peripheral angioplasty procedures.

Pre-Operative Embolisation of an Aberrant Pharyngeal Arterial Branch Arising From the Internal Carotid Artery and Contributing Significantly to the Supply of a Large Juvenile Nasopharyngeal Angiofibroma.

Preoperative embolisation of juvenile nasopharyngeal angiofibromas (JNAs) is a well-established treatment that reduces intraoperative blood loss and improves surgical outcomes. While the bulk of arterial supply to the tumour is derived from the external carotid system, some degree of contribution from the internal carotid artery (ICA) is common. ICA branch embolisation in this setting has previously been avoided due to concerns over ischaemic neurological complications, possibly contributing to the increased intraoperative blood loss observed in patients with tumours with ICA supply. There is a marked paucity of reports of embolisation of ICA branches supplying JNA in the medical literature. We present a case of successful embolisation of an aberrant pharyngeal branch of the ascending pharyngeal artery arising from the proximal cervical ICA, which was making a significant contribution to tumour blood supply in a male adolescent with a very large JNA.

Transcatheter Embolization of the Inferior Epigastric Artery: Technique and Clinical Outcomes.

PURPOSE: Symptomatic rectus muscle sheath hematoma may be the result of bleeding originating from the inferior epigastric artery. We report the technique and the results from a series of consecutive patients treated by transcatheter embolization, evaluating both ipsilateral and contralateral retrograde approaches. METHODS: This was a retrospective study including patients with verified rectus muscle sheath hematoma as a result of active extravasation from the inferior epigastric artery referred for transcatheter embolization. Technical success, clinical success and major complications were calculated. In addition, minor complications, blood transfusions required after a technically successful embolization, length of stay, peri-procedural and 30-day mortality and overall survival at 6 months were obtained. All statistical analysis was performed using SPSS. RESULTS: Twenty-one patients (mean age = 59.67 ± 19.51 years old) were included. The cause of the bleeding in the vast majority was iatrogenic trauma (n = 12/21, 57.14%). Both contralateral (n = 12/21, 57.14%%) and ipsilateral (n = 9/21, 42.86%) retrograde approaches were used. Embolic materials included micro-coils (n = 13/20, 65%), microspheres (PVA) (n = 1/20, 5%), a combination of PVA and micro-coils (n = 5/20, 25%) and gel-foam (n = 1/20, 5%). Overall technical success was 95.2% (n = 20/21) while clinical success was achieved in all but one of the technically successful cases 95% (n = 19/20). One patient died peri-procedurally due to profound hemodynamic shock. There were no other major complications. Additional transfusion was necessary in 7 patients (n = 7/21, 33.33%). There was a significant increase in the hemoglobin levels after the embolization (7.03 ± 1.78 g/dL pre-procedure Vs 10.91 ± 1.7 g/dL post-procedure, p = 0.048). The median hospital stay was 8 days. The peri-procedure and 30-day mortality was 4.8% (n = 1/21) and 28.6% (n = 6/21) respectively. The 6-month survival was 61.9% (13/21). CONCLUSION: Percutaneous embolization of the inferior epigastric artery is a minimally invasive method with satisfactory results. Both ipsilateral and contralateral retrograde approaches are feasible.

Audit of electronic operative documentation in interventional radiology: the value of standardised proformas.

BACKGROUND: On the background of the interventional radiology department of a tertiary hospital converting its periprocedural documentation from paper-based to electronic using a standardised proforma, a study was performed to ascertain the effects of this change on the standard of clinical documentation for radiologically-guided angiographic procedures. Using a retrospective approach, perioperative records were analysed in reverse chronological order for inclusion in the study. The standard for this audit was developed in the form of minimum criteria that all clinical documentation of angiographic procedures were expected to meet. RESULTS: The audit was performed at three equally spaced intervals of 6 months, yielding a total of 99 records. The baseline audit of paper-based records concluded > 80% completeness for 8 out of the 14 of parameters measured, with only two of parameters meeting the target of 100% completeness. The second audit cycle performed on electronic records found 7 out of 14 parameters demonstrating absolute improvement in completeness, when compared to paper-based, but with the number of parameters exceeding 80% completeness falling to only 4 out of 14. Again, 100% completeness was observed in only 2 of the parameters. In the final audit cycle, after the introduction of a standardised electronic proforma, performance improved in every dimension with 6 out of 14 parameters reaching completeness of 100% and the 80% completeness threshold met by 12 out of 14 parameters. CONCLUSION: The construction of a procedure-specific perioperative electronic proforma can save clinicians valuable time and encourage safe and effective clinical documentation.

Extravascular findings during upper limb computed tomographic angiography focusing on undiagnosed malignancy.

BACKGROUND: Computer tomography angiography (CTA) has been an established method for diagnostic vascular disease of lower limbs. Recently, the method is widely used for diagnosis of vascular pathologies in the upper limbs too. It also has increased the possibilities of this scans being reviewed by no specially trained radiologists. This increases the risk of incidental non vascular findings to be missed or misinterpreted. The study is focusing in the frequency of extravascular incidental finding (EVIF) and highlights the importance for both the reporting radiologist and the referring physician recognizing the frequency of EVIFs. AIM: To analyse the frequency of EVIF identified on computed angiography (CT) of the upper limb. METHODS: A total of 1383 CT angiographic studies of the peripheral arterial system were performed between August 2015 and August 2017. All upper limb CTAs (n = 79) were retrospectively reviewed for the presence of non-vascular incidental findings within the chest, abdomen/pelvis, musculoskeletal system or head and neck. These EVIFs were subsequently grouped into 3 categories based on clinical significance. EVIFs of immediate clinical relevance were included in category A, findings considered indeterminate but most likely benign were placed in category B, while incidental findings of no clinical significance were included in category C. RESULTS: Complete imaging datasets were available in 74/79 (93.7%). Patient demographics included 39 (52.7%) females and 35 (47.2%) males with a mean age of 59 ± 19.5 years (range 19-93 years). A total of 153 EVIFs were reported in 52 patients (70.3%). Of these, 44 EVIFs (28.7%) were found in the chest, 83 (54.2%) in the abdomen, 14 (9.2%) in the musculoskeletal system and 9 (5.8%) in the head and neck. Thirteen EVIFs (8.4%) identified in 11 patients were noted to be of immediate clinical significance (Category A), 50 EVIFs (32.3%) were identified in 20 patients and were considered indeterminate but most likely benign, while the remaining 91 EVIFs (59.5%) identified in 21 patients were determined to be of no clinical significance (Category C). One index case of malignancy (1.3%) and four cases of new disseminated metastatic disease (5.4%) were identified. CONCLUSION: Our study of upper limb CTA examinations demonstrated a frequency of 8.4% for extravascular incidental findings of immediate clinical significance. We highlight the importance for both the reporting radiologist and the referring physician of the need to recognize the frequency with which EVIFs are identified in the upper limb peripheral arterial system and of the necessity for further clinical and imaging work-up.

Renal Angiomyolipoma: Mid- to Long-Term Results Following Embolization with Onyx.

PURPOSE: Percutaneous transcatheter embolization is currently the preferred treatment for ruptured or enlarging renal angiomyolipoma (AML), although the optimum choice of embolic material has not yet been established. We present mid- to long-term outcomes following embolization of AMLs with Onyx. MATERIALS AND METHODS: Ten AMLs in seven patients (including two with tuberous sclerosis) were embolized with Onyx. Patients were followed-up clinically, with tumour size and renal function measured pre- and post-procedure. RESULTS: Mean pre-treatment AML size was 63.4 mm (range 42-100). Mean clinical follow-up was 431.4 days (range 153-986) and imaging follow-up 284.2 days (range 30-741). There was no haemorrhage from treated lesions within the follow-up period. Of patients who had cross-sectional imaging pre- and post-procedure, mean decrease in AML size of 22 mm was seen after Onyx embolization (p = 0.0058, 95 % CI 9.13-34.87). No significant difference between serum creatinine was seen pre- and post-procedure (p = 0.54, 95 % CI 8.63-4.85). CONCLUSIONS: Onyx embolization of renal AMLs is effective in the medium to long term, with theoretical benefits in safety and durability of result.

Innovative percutaneous antegrade clearance of intrahepatic and extrahepatic biliary stones with the use of a hysterosalpingography catheter.

OBJECTIVES: We present a novel modified technique of percutaneous antegrade clearance of intrahepatic and common bile duct stones with the use of a hysterosalpingography balloon (HSG) catheter. METHODS: Technical tips and techniques used, along with the clinical results obtained in six patients whom we treated over a 6-month period have been described. RESULTS: The HSG balloon catheter is shown to demonstrate superior pushability, flexibility, and maneuverability in comparison with other previously described compliant balloons. CONCLUSIONS: The HSG balloon catheter is shown to be a really good device to remove intrahepatic and common bile duct stones percutaneously, allowing, where required, access to both the right and the left intrahepatic biliary systems from a single and smaller Fr hepatic bile duct access.

Fluoroscopic-guided insertion of self-expanding metal stents for malignant gastroduodenal outlet obstruction: immediate results and clinical outcomes.

BACKGROUND: Application of self-expanding metal stents (SEMS) to treat patients suffering from malignant gastroduodenal outlet obstruction (GDOO) is today considered a well-recognized palliative treatment. Use of SEMS has emerged as an attractive alternative to surgical treatment of such patients. PURPOSE: To report the immediate and the mid-term clinical outcomes from a series of consecutive patients treated with exclusively fluoroscopic-guided insertion of SEMS. MATERIAL AND METHODS: This was a retrospective study including patients suffering from GDOO that were either ineligible for or unwilling to undergo surgery. Patients with potentially curable disease, uncorrectable coagulopathy, gastrointestinal perforation, sepsis, presence of distal small bowel obstruction, and bowel ischemia were excluded. Technical success, clinical success, and major complications were calculated. In addition, stent migration, stent re-obstruction, restenosis, and overall re-interventions due to recurrent symptoms were considered. Kaplan-Meier survival analysis was used for patient survival estimation while both bivariable and multivariable analysis were performed to identify any independent predictors of outcomes. RESULTS: Fifty-one patients, (mean age, 63.73 ± 15.62 years) met the study's criteria and were included in the final analysis. Technical and clinical success were 90.19% (n = 46/51) and 91.30% (n = 42/46), respectively. Major complications rate was 3.92%. Stent migration was noted in four cases. Restenosis and re-obstruction rates were 19.57% and 10.87%, respectively. No cases of peri-procedural mortality were noted, while Kaplan-Meier estimates for 1- and 2-year survival were 16.8% and 7.2%, respectively. Clinically successful cases and patients with primary GI tumor were related with more favorable survival compared to unsuccessful and patients suffering from GDOO due to extrinsic compression by neoplastic or lymph node disease. CONCLUSION: Exclusively fluoroscopically inserted SEMS for GDOO is safe and highly effective method for palliative treatment.

Emergency endovascular management of pulmonary artery aneurysms and pseudoaneurysms for the treatment of massive haemoptysis.

INTRODUCTION: In this study we report the results of endovascular techniques for the management of pulmonary artery aneurysms (PAA) and pseudoaneurysms (PAPS). METHODS: Cases with massive haemoptysis due to PAA and/or PAPS that were managed by endovascular means were included in the study. Clinical history and procedure details were analysed. Primary endpoints were immediate technical success and re-intervention rate; secondary endpoints were survival rate and relapse of bleeding. RESULTS: Among the 72 patients with massive haemoptysis who were treated in our department during an 8-year period, 6 patients with 6 lesions (2 PAA, 4 PAPS) fulfilled the inclusion criteria and were included in the study. The mean age was 46.5 years; mean lesion diameter was 12.7 mm (range 4-22 mm); underlying pathologies were vasculitis (n=2), erosion by necrotic tumour (n=1), previous lung surgery (n=1) and infectious disease (n=2). Four lesions were treated with coils, 1 with coils and a bare stent, and 1 with a covered stent. The technical success was 100%. Mean follow-up was 20.4 months. The re-intervention rate was 50%, but in only 16.6% was it related to the treated lesions. Survival rate was 66.6%. There were no major or minor complications. CONCLUSION: Endovascular management offers a safe and effective solution for the emergency treatment of massive haemoptysis due to PAA and PAPS. A variety of endovascular devices may be used, according to the size and the anatomical location of the lesion.

Bayesian network meta-analysis of nitinol stents, covered stents, drug-eluting stents, and drug-coated balloons in the femoropopliteal artery.

OBJECTIVE: Several randomized controlled trials (RCTs) have shown the superiority of some of these technologies over balloon angioplasty, but direct comparisons between these treatment options are lacking. The authors conducted a network meta-analysis of RCTs comparing bare nitinol stents, covered nitinol stents, paclitaxel- or sirolimus-eluting stents (PES or SES), and paclitaxel-coated balloons (PCB) with plain balloon angioplasty or with each other in the femoropopliteal artery (PROSPERO registry: CRD42013004845). METHODS: Sixteen RCTs comprising 2532 patients with 4227 person-years of follow-up were analyzed on an intention-to-treat basis. Bayesian random effects Poisson and binomial models were used for mixed treatment comparisons (WinBUGS). Clinical heterogeneity was accounted for by incorporating a meta-regression model on trial-specific baseline risk. End points included technical success, vascular restenosis, target lesion revascularization, and major amputations. Pairwise odds ratios and rate ratios (ORs and RRs) of absolute treatment effects were calculated, and the probabilities of each treatment being best are reported. Summary estimates are reported as the posterior median and associated credible intervals (CrIs) that serve the same purpose as confidence intervals in the context of the Bayesian framework. Extensive sensitivity, meta-regression, and network consistency analyses were performed to evaluate heterogeneity. RESULTS: Technical success was highest with covered stents (pooled OR, 13.6; 95% CrI, 3.3-31.1, probability best 82%) followed by uncovered stents (pooled OR, 7.0; 95% CrI, 2.6-129, probability best 18%) when compared with balloon angioplasty (reference treatment). Vascular restenosis was lowest with PES (RR, 0.43; 95% CrI, 0.16-1.18, probability best 45%) followed by PCB (RR, 0.43; 95% CrI, 0.26-0.67, probability best 42%). Target lesion revascularization was lowest with PCB (RR, 0.36; 95% CrI, 0.23-0.55, probability best 56%) followed by PES (RR, 0.42; 95% CrI, 0.16-1.06, probability best 33%). Major amputations were rare in all treatment and control groups (pooled amputation rate of 0.7 events per 100 person-years). CONCLUSIONS: Immediate technical success is better with the use of covered stents, whereas paclitaxel-eluting stents and paclitaxel-coated balloons offer the best long-term results in the femoropopliteal artery.

Palliation of esophageal cancer with a double-layered covered nitinol stent: long-term outcomes and predictors of stent migration and patient survival.

PURPOSE: To evaluate the long-term clinical outcomes and the negative predictors after the deployment of double-layered stents in malignant esophageal strictures. METHODS: This is a single-center study of patients who received a double-layered covered stent for the palliation of dysphagia due to malignant esophageal strictures in a 3-year period. 56 patients fulfilled the inclusion criteria. The study's primary end points were technical success, dysphagia improvement, stent migration, and complication rates; secondary end points were the stent's primary patency and overall survival. Cox regression analysis was used to adjust for confounding variables and to identify predictors of survival outcomes. RESULTS: Technical success was 95%. Median dysphagia score improved significantly after stenting (p < 0.0001). Stent migration rate was 7.1% and occurred exclusively in the group of patients who received chemoradiotherapy (p < 0.01). The median stent patency was 87 days (range 5-444 days). Dysphagia reoccurred in 39.3% and was successfully managed with restenting in 98.2%. The median survival was 127 days (range 15-1480 days). Chemoradiotherapy and baseline histology did not influence survival outcomes. Survival was adversely affected by metastases (p = 0.005) and poor oral intake (p = 0.048). Patient survival was improved by repeat stenting in case of tissue overgrowth (p = 0.06). CONCLUSION: The device is safe and effective for the treatment of patients with dysphagia due to esophageal cancer. Migration rate is zero for patients who do not receive chemoradiotherapy. Reintervention when required is a positive survival predictor.

Association of thrombotic microangiopathy and intimal hyperplasia with bleeding post-renal biopsy in antiphospholipid antibody-positive patients.

OBJECTIVE: Renal biopsy remains the gold standard investigation for both diagnostic and prognostic purposes in the clinical management of lupus nephritis. However, it is not without potentially significant complications. The objectives of this study were to determine the rate of significant bleeding post-renal biopsy in patients with lupus nephritis and to identify risk factors associated with hemorrhagic complications. METHODS: Clinical data were retrospectively collected on 215 renal biopsies performed over a 13-year period (1999-2012). Patients were categorized into 3 groups: a diagnosis of systemic lupus erythematosus (SLE) alone, SLE with coexisting antiphospholipid syndrome (APS), or a diagnosis of SLE with either positive anticardiolipin antibodies and/or lupus anticoagulant (LAC) without clinical APS manifestations. RESULTS: Major bleeding complications were significantly more common in those with coexisting APS and/or antiphospholipid antibodies (aPL). LAC, presence of thrombotic microangiopathy (TMA) on renal biopsy, older age at the time of the biopsy (age >40 years), and elevated serum creatinine (>400 µmoles/liter) were independent risk factors for increased risk of bleeding. TMA and severe fibrous intimal hyperplasia on renal biopsy were significantly more prevalent in those who developed severe bleeding complications. CONCLUSION: Based on these findings, lupus nephritis patients with coexisting APS, positive LAC, and histologic evidence of TMA and/or fibrous intimal hyperplasia are at increased risk of bleeding post-renal biopsy. aPL should be checked in all lupus nephritis patients before undergoing renal biopsy, as this subset of patients warrants particular caution pre- and postprocedure.