Accessing Intraabdominal Abscess for Percutaneous Drainage Using a Trocar Only Technique to Maneuver Intervening Bowel.

Conventional approaches to the drainage of abscess surrounded by bowel contraindicate percutaneous drainage and often involve more invasive laparotomy. We attempt to demonstrate the use of an image-guided blunt trocar to navigate obstructive bowel and access abdominal abscess. This report presents the use of a blunt trocar to safely maneuver obstructive bowel and perform successful percutaneous drainage of intraabdominal abscess in two separate cases: one presenting a left lower quadrant diverticular abscess and the other presenting an abscess in the right lower quadrant. Thus, traversing obstructive bowel using a blunt trocar under computed tomography-guidance allows for percutaneous drainage of an intraabdominal abscess, and provides a safer and more effective alternative to more invasive procedures.

Vertebral augmentation-related Clostridium septicum osteomyelitis.

We present a case of vertebral osteomyelitis following multiple vertebral augmentations in a patient with an insidious presentation. Vertebral augmentation (kyphoplasty and/or vertebroplasty) is a minimally invasive procedure that has become a fairly common and highly effective method in treating compression fractures. A large majority of patients that undergo this procedure suffer from osteoporosis. Numerous studies have shown that patients who undergo the procedure obtain substantial pain relief and improve functional status, often times to a greater extent than other surgical and nonsurgical management. Although its prevalence is low, infection after vertebral augmentation can be a serious consequence of the procedure. Blood cultures in this case were positive for Clostridium septicum. C septicum is a gram-positive, spore forming bacteria that is part of the normal gut flora in humans and is commonly associated with GI malignancy, necrosis, and inflammation. The patient did not respond to long-term intravenous antibiotics and required vertebral corpectomy and debridement with instrumentation. Vertebral body cultures obtained intraoperatively were positive for C septicum. It was noted historically that the patient had a hemorrhoidectomy 4 weeks prior to her initial fracture presentation. Although the risk of infection after vertebral augmentation is low, it is imperative that careful pre- and postoperative evaluation as well as follow-up is completed in order to prevent catastrophic consequences for patients. In patients with recent gastrointestinal tract manipulation/surgery, appropriate antibiotic prophylaxis should be considered prior to vertebral augmentation procedures.

A Novel approach to catheterizing the Left Gastric Artery for bariatric embolization.

We present the case of a 45 Y/o morbidly obese male who - unable to lose weight despite extensive lifestyle interventions, presented to us for an experimental procedure known as bariatric embolization. This arterial embolization procedure was performed targeting the left gastric artery with aims to restrict blood flow to the gastric fundus, and lowering serum ghrelin levels. In this case the left gastric artery arose cephalad from the celiac, earlier than where it normally branches; a variation known as a "false tripod", causing some initial difficulty with selection. We describe how introducing a tertiary curve on the guidewire proved successful. Adapting the guidewire for difficult anatomy is an often a very underutilized skillset for many interventionalists - but led to success in this rather nascent procedure.

t-PA power-pulse spray with rheolytic mechanical thrombectomy using cross-sectional image-guided portal vein access for single setting treatment of subacute superior mesenteric vein thrombosis.

BACKGROUND: Isolated superior mesenteric vein (SMV) thrombosis is a rare but potentially fatal condition if untreated. Current treatments include transjugular or transhepatic approaches for rheolytic mechanical thrombectomy and subsequent infusions of thrombolytics. Tissue plasminogen activator (t-PA) power-pulse spray can provide benefit in a single setting without thrombolytic infusions. Computed tomography (CT) guidance for portal vein access is underutilized in this setting. MATERIALS AND METHODS: Case 1 discusses acute SMV thrombosis treated with rheolytic mechanical thrombectomy alone using ultrasound guidance for portal vein access. Case 2 discusses subacute SMV thrombosis treated with the addition of t-PA power-pulse spray to the rheolytic mechanical thrombectomy, using CT guidance for portal vein access. RESULTS: With rheolytic mechanical thrombectomy alone, the patient in Case 1 had significant improvement in abdominal pain. Follow-up CT demonstrated no residual SMV thrombosis and the patient continued to do well in long-term follow-up. With the addition of t-PA power-pulse spray to rheolytic mechanical thrombectomy, the patient in Case 2 with subacute SMV thrombosis dramatically improved postprocedure with resolution of abdominal pain. Follow-up imaging demonstrated patency to the SMV and partial resolution of thrombus. The patient continued to do well at 2-year follow-up. CONCLUSIONS: Adding t-PA power-pulse spray to rheolytic mechanical thrombectomy can provide benefit in a single setting versus mechanical thrombectomy alone and prevent the need for subsequent infusions of thrombolytic therapy. CT guidance is a useful alternative of localization for portal vein access via the transhepatic route that is nonoperator-dependent and helpful in the case of obese patients.

Gastric Artery Embolization Trial for the Lessening of Appetite Nonsurgically (GET LEAN): Six-Month Preliminary Data.

PURPOSE: To report 6-month safety and efficacy results of a pilot study of left gastric artery (LGA) embolization for the treatment of morbid obesity (ie, body mass index [BMI] > 40 kg/m(2)). MATERIALS AND METHODS: Four white patients (three women; average age, 41 y [range, 30-54 y]; mean weight, 259.3 lbs [range, 199-296 lbs]; mean BMI, 42.4 kg/m(2) [range, 40.2-44.9 kg/m(2)]) underwent an LGA embolization procedure with 300-500-µm Bead Block particles via right common femoral or left radial artery approach. Follow-up included upper endoscopy at 3 days and 30 days if necessary and a gastric emptying study at 3 months. Tracked parameters included adverse events; weight change; ghrelin, leptin, and cholecystokinin levels; and quality of life (QOL; by Short Form 36 version 2 questionnaire). RESULTS: Three minor complications (superficial gastric ulcerations healed by 30 d) occurred that did not require hospitalization. There were no serious adverse events. Average body weight change at 6 months was -20.3 lbs (n = 4; range, -6 to -38 lbs), or -8.5% (range, -2.2% to -19.1%). Average excess body weight loss at 6 months was -17.2% (range, -4.2% to -38.5%). Patient 4, who had diabetes, showed an improvement in hemoglobin A1c level (7.4% to 6.3%) at 6 months. QOL measures showed a general trend toward improvement, with the average physical component score improving by 9.5 points (range, 3.2-17.2) and mental component score improving by 9.6 points (range, 0.2-19.3) at 6 months. CONCLUSIONS: Preliminary data support LGA embolization as a potentially safe procedure that warrants further investigation for weight loss in morbidly obese patients.

Does age of fracture affect the outcome of vertebroplasty? Results from data from a prospective multicenter FDA IDE study.

PURPOSE: To evaluate whether the age of a fracture is a variable that can identify patients for whom vertebroplasty would be most beneficial. MATERIALS AND METHODS: Data from 256 patients with painful osteoporotic vertebral compression fractures (VCFs) who underwent vertebroplasty were examined to assess the effect of fracture age on outcomes. Patients ranged in age from 34-76 years, and the age of fractures ranged from 6 weeks or less (n = 117) to more than 52 weeks (n = 3). Most patients had a fracture age of 12 weeks or less (n = 207), with only 17% having a fracture age greater than 12 weeks. The duration of back pain was used as a surrogate for fracture age and was confirmed by edema on magnetic resonance (MR) imaging, abnormal bone scans, and the presence of central pain over the spinous process The primary outcome was pain reduction as determined by the change in the visual analog scale (VAS) pain score from baseline and at 1, 3, 6, and 24 months after vertebroplasty. RESULTS: A fracture age of 12 weeks or less versus greater than 12 weeks did not affect outcomes, with patients in both groups achieving equivalent benefit after vertebroplasty. Patients with a fracture age of 6 weeks or less had a slightly improved benefit at 3 months after vertebroplasty compared with those having a fracture age of greater than 6 weeks, but the benefit beyond 3 months was the same. CONCLUSIONS: Results of the study showed that the age of a fracture does not independently affect the outcomes of vertebroplasty.

Transjugular intrahepatic porto-systemic shunt in the elderly: Palliation for complications of portal hypertension.

AIM: To present a dedicated series of transjugular intrahepatic porto-systemic shunts (TIPS) in the elderly since data is sparse on this population group. METHODS: A retrospective review was performed of patients at least 65 years of age who underwent TIPS at our institutions between 1997 and 2010. Twenty-five patients were referred for TIPS. We deemed that 2 patients were not considered appropriate candidates due to their markedly advanced liver disease. Of the 23 patients suitable for TIPS, the indications for TIPS placement was portal hypertension complicated by refractory ascites alone (n = 9), hepatic hydrothorax alone (n = 2), refractory ascites and hydrothorax (n = 1), gastrointestinal bleeding alone (n = 8), gastrointestinal bleeding and ascites (n = 3). RESULTS: Of these 23 attempted TIPS procedure patients, 21 patients had technically successful TIPS procedures. A total of 29 out of 32 TIPS procedures including revisions were successful in 21 patients with a mean age of 72.1 years (range 65-82 years). Three of the procedures were unsuccessful attempts at TIPS and 8 procedures were successful revisions of our existing TIPS. Sixteen of 21 patients who underwent successful TIPS (excluding 5 patients lost to follow-up) were followed for a mean of 14.7 mo. Ascites and/or hydrothorax was controlled following technically successful procedures in 12 of 13 patients. Bleeding was controlled following technically successful procedures in 10 out of 11 patients. CONCLUSION: We have demonstrated that TIPS is an effective procedure to control refractory complications of portal hypertension in elderly patients.

Subclavian stenting in a hostile aortic arch facilitated by a low-profile brachial artery through-and-through access.

Subclavian stenting can be extremely difficult in a hostile type II aortic arch (with acute angulation of the subclavian artery origin) or type III aortic arch. This case illustrates use of a low-profile system to gain through-and-through (flossing) access through the brachial artery to facilitate stenting via the femoral approach. This approach can be useful in patients with small brachial arteries where the risk of complication may be high if a standard vascular sheath was placed for stenting via the brachial approach. This technique also avoids the use of a surgical cut down.

Percutaneous superficial temporal artery access for carotid artery stenting in patients with a hostile aortic arch.

PURPOSE: To describe an entirely percutaneous treatment for carotid artery stenting in a type IIa aortic arch via the superficial temporal artery (STA) for through-and-through guidewire access. TECHNIQUE: The technique is demonstrated in an 83-year-old man status post left carotid endarterectomy 3 months prior who presented with 2.5 hours of confusion and dysphasia following diagnostic carotid arteriography. The patient was known to have a type IIa bovine aortic arch and a severe 70% stenosis of the left internal carotid artery. The patient was referred for carotid artery stenting by his vascular surgeon. Due to the bovine arch, a percutaneous ultrasound-guided approach via the STA for through-and-through wire access facilitated carotid artery stenting from the right common femoral artery. The procedure was successful, and follow-up duplex ultrasound confirmed patency of the STA the next day. CONCLUSION: A percutaneous ultrasound-guided STA access can help facilitate transfemoral carotid artery stenting in an otherwise difficult type IIa aortic arch setting.

Renal vein stenting via the right internal jugular approach with a provocative Valsalva maneuver to reduce the risk of stent migration.

An adult male with nutcracker syndrome was treated successfully by placement of a self-expanding stent in the left renal vein via a right internal jugular vein approach with a provocative Valsalva maneuver. Previous case reports have described renal vein stenting for this condition via common femoral vein approach. However, this study proposes the right internal jugular vein approach as a safer method for the treatment of nutcracker syndrome since the stent can be easily captured along the guidewire if undersized. This technique is based on the realization that the left renal vein diameter may increase by 50% to 58% during the Valsalva maneuver.

Acute renal artery thrombosis treated with t-PA power-pulse spray rheolytic thrombectomy.

PURPOSE: To describe a new application of tissue plasminogen activator (t-PA) power-pulse spray rheolytic (pharmacomechanical) thrombectomy in the treatment of acute renal artery thrombosis. CASE REPORT: Acute renal artery thrombosis is a relatively rare, but serious condition in which it is imperative to restore perfusion as quickly as possible. Percutaneous pharmacomechanical thrombectomy technique was utilized to provide an effective means of restoring renal flow and function. We therefore present two unique cases of spontaneous and iatrogenic renal artery thromboses that were treated successfully with t-PA power-pulse spray rheolytic thrombectomy. CONCLUSION: t-PA Power-pulse spray rheolytic (pharmacomechanical) thrombectomy has the potential to be a useful means to restore perfusion and function in the setting of acute renal artery thrombosis.

Vertebral osteomyelitis following vertebroplasty: is acne a potential contraindication and are prophylactic antibiotics mandatory prior to vertebroplasty?

We present a case of vertebral osteomyelitis following vertebroplasty in a patient with acne of the back. Vertebral biopsy revealed Corynebacterium species and blood cultures were positive for Propionibacterium species. The patient did not respond to long-term intravenous antibiotics and required vertebral corpectomy and debridement with instrumentation. Interventionalists should be able to recognize acne of the back and consider this as a potential contraindication to vertebroplasty. Prophylactic antibiotics should be considered in all patients prior to vertebroplasty since subepidermal organisms are not eliminated with the standard skin prep.

Accurate localization of life threatening colonic hemorrhage during nuclear medicine bleeding scan as an aid to selective angiography.

PURPOSE: To describe a new technique to help localize life threatening colorectal bleeding during nuclear medicine bleeding scan to aid in selective angiography. METHODS: During the gastrointestinal bleeding scan, a simple metallic marker (paper clip) was used to localize the bleeding site on the patient body. Angiography was then performed within 2 hours. The marker was then used to guide superselective angiography and embolization. RESULTS: 5 cases of patients with colorectal bleeding were performed using this technique with cessation of bleeding in 4/5 initial attempts. 1 patient required a repeat angiogram that did demonstrate the bleeding on the second attempt allowing superselective angiography and embolization that resulted in cessation of bleeding. This patient with a rectal bleed required selection of additional vessels guided by the marker on the second attempt. CONCLUSION: The dilemma of positive scintigraphic evidence of colonic bleeding with negative arteriography can be resolved with the use of a metal marker during the scintigram to guide superselective angiography. Although in our small series of patients this technique appears to be simple and effective, further clinical investigation is warranted with a larger patient population. This technique may offer a role in therapy in coordination with the colorectal surgeon for the high risk patient in an otherwise life threatening situation.

Transesophageal echocardiogram causing denture dislodgement with upper airway partial obstruction.

A 30-year-old female was evaluated with transesophageal echocardiography to exclude an atrial septal defect. The patient denied having dentures or partial dentures during her pre-procedure history and immediately prior to the procedure. Following the transesophageal echocardiography it was discovered that the patient had a partial airway obstruction caused by dislodgement of her partial dentures. The case illustrates the importance of not only asking patients if they have dentures, partial dentures, or any dental appliances, but also manually checking and directly looking into patients' mouths prior to transesophageal echocardiography for any dental appliances.

Vertebroplasty: a systematic approach.

BACKGROUND: Though vertebroplasty is a well-known and extremely effective procedure in experienced hands, it is a much more difficult procedure to learn than standard spinal pain injection procedures. We therefore present a simplified, methodical approach to vertebroplasty that can be adopted by trained interventionalists. Many practitioners who attend hands-on cadaver workshops lack confidence to apply this technique in live patients. OBJECTIVES: To present a methodical, reproducible, and proven technique. To provide strategies on pre-procedure and post-procedure care in order to optimize outcomes in vertebroplasty patients. STUDY DESIGN: A step-by-step tutorial is presented outlining the steps in the vertebroplasty procedure. A discussion of anatomic considerations, pre-procedure patient selection issues, and post-procedure management is also presented. METHODS: Sections are presented on anatomy, patient selection, a 10-step technique on performance of vertebroplasty, a discussion of how this technique is advantageous, and post-procedure management. RESULTS: This technique has been proven in clinical practice for over 1,500 vertebroplasties and has been well-received the past 4 years by hundreds of trainees taught at numerous hands-on courses (Stryker Interventional Pain, Arthrocare, and Society of Interventional Radiology). CONCLUSION: A basic tutorial is presented for the beginner who is interested in vertebroplasty. This safe and reproducible technique has been proven in clinical practice. The anatomic considerations, patient selection issues, technique, and post-procedure management has been taught and well received by hundreds of physicians at numerous hands on courses within the United States and Canada.

Catheter-directed middle hemorrhoidal artery embolization for life-threatening rectal bleeding.

Over the past 10 years, arteriography has become a well-established technique for the diagnosis of acute lower gastrointestinal bleeding, but not particularly for rectal bleeding. However, to the authors' knowledge, the technique of middle hemorrhoidal artery embolization has rarely been reported in the literature. In the present report, three patients with life-threatening rectal bleeding are presented, which was controlled by superselective embolization of the middle hemorrhoidal artery or selective embolization of the internal iliac artery as a last resort.

Coccygeoplasty: treatment for fractures of the coccyx.

Percutaneous vertebroplasty and sacroplasty are becoming common modalities of treatment for vertebral body compression fractures and sacral insufficiency fractures, respectively. The present report describes a case of a coccygeal fracture treated with injection of polymethylmethacrylate cement, which resulted in immediate relief of symptoms. It is suggested that this procedure be called coccygeoplasty.

Intradiskal extravasation with low-volume cement filling in percutaneous vertebroplasty.

BACKGROUND AND PURPOSE: Adjacent fracture formation after percutaneous vertebroplasty has been reported in literature. The purpose of this study was to determine whether intervertebral disk extravasation is related to adjacent fracture formation in low-volume cement-filling vertebroplasty. METHODS: A retrospective analysis of 308 patients having vertebroplasty was undertaken. Anteroposterior and lateral procedural fluoroscopy radiographs were analyzed for mild, moderate, or severe disk extravasation. Symptomatic refracture location relative to the presence or absence of extravasation was analyzed on follow-up fluoroscopy radiographs. RESULTS: Of the 308 patients in the study, 81 patients had disk extravasation at a total of 85 vertebral levels; 40 levels had mild extravasation, 38 levels had moderate extravasation, and 7 had severe extravasation. Of the 40 levels with mild extravasation, 6 new adjacent fractures occurred next to the disk leakage. Of the 38 with moderate extravasation, 6 new adjacent fractures occurred. Of the 7 levels of severe extravasation, only one new adjacent fracture occurred. Hence, a total of 13 adjacent fractures occurred next to disk extravasation; 13 nonadjacent fractures also occurred in the patients with disk extravasation. In the patients without disk extravasation, 28 adjacent and 24 nonadjacent subsequent fractures occurred. The average available cement volumes injected into vertebral bodies causing disk leakage ranged from 4.78 to 5.60 mL. CONCLUSIONS: With low-volume cement-filling percutaneous vertebroplasty, we cannot conclude (level of significance alpha = .05) that for patients who have a new fracture there is significance between the location of the fracture and the occurrence of disk extravasation.

New symptomatic vertebral compression fractures within a year following vertebroplasty in osteoporotic women.

BACKGROUND AND PURPOSE: Percutaneous vertebroplasty has been performed in the United States in an increasing volume since the mid-1990s. The purpose of this study is to analyze the risk of a new symptomatic vertebral compression fractures within 1 year of having an acute/subacute fracture treated with vertebroplasty. METHODS: A retrospective analysis was performed in which 253 female patients were found to have acute/subacute vertebral compression fractures secondary to osteoporosis treated with percutaneous vertebroplasty. Occurrences of new symptomatic vertebral compression fractures were recorded for a year following initial vertebroplasty. RESULTS: Fifty-five patients (21.7%) of the 253 osteoporotic women with one or more initial fractures experienced a new symptomatic vertebral compression fracture within 1 year. CONCLUSION: Roughly one-fifth of osteoporotic women with acute/subacute fracture treated with vertebroplasty will have a subsequent fracture within 1 year.