Hypersplenism in liver disease and SLE revisited: current evidence supports an active rather than passive process.

BACKGROUND: Active and passive theories have been advanced to explain splenomegaly and cytopenias in liver disease. Dameshek proposed active downregulation of hematopoiesis. Doan proposed passive trapping of blood components in a spleen enlarged by portal hypertension. Recent findings do not support a passive process. DISCUSSION: Cytopenias and splenomegaly in both liver disease and systemic lupus erythematosus (SLE) poorly correlate with portal hypertension, and likely reflect an active process allocating stem cell resources in response to injury. Organ injury is repaired partly by bone-marrow-derived stem cells. Signaling would thus be needed to allocate resources between repair and routine marrow activities, hematologic and bone production. Granulocyte-colony stimulating factor (G-CSF) may play a central role: mobilizing stem cells, increasing spleen size and downregulating bone production. Serum G-CSF rises with liver injury, and is elevated in chronic liver disease and SLE. Signaling, not sequestration, likely accounts for splenomegaly and osteopenia in liver disease and SLE. The downregulation of a non-repair use of stem cells, bone production, suggests that repair efforts are prioritized. Other non-repair uses might be downregulated, namely hematologic production, as Dameshek proposed. SUMMARY: Recognition that an active process may exist to allocate stem-cell resources would provide new approaches to diagnosis and treatment of cytopenias in liver disease, SLE and potentially other illnesses.

Ultrasound guided ureteroscopy for the definitive management of ureteral stones: a randomized, controlled trial.

PURPOSE: Ureteroscopy is central to the surgical management of ureteral stones. Fluoroscopy is conventionally used for intraoperative guidance, although there is growing effort to decrease the exposure of patients and staff to ionizing radiation. We developed a radiation-free approach to ureteroscopy using ultrasound guidance to manage ureteral stones. To our knowledge we present the first randomized trial to study its safety and efficacy. MATERIALS AND METHODS: This single center, randomized clinical trial from 2011 to 2013 enlisted patients who presented with symptomatic ureteral stones 8 mm or less without a significant ipsilateral stone burden. Patients were randomly assigned to ultrasound or fluoroscopic guided ureteroscopy after temporizing ureteral stent placement. Intraoperative ultrasound guidance was performed using real-time imaging with the transducer placed at the patient flank to visualize the collecting system of the ipsilateral kidney. We compared operative time, stone size, stone-free status and complication rates between the 2 groups. RESULTS: A total of 50 patients were enrolled in study with 25 per arm. There was no difference in stone size (5.9 vs 5.7 mm), patient age (56 vs 52 years) or body mass index (31 vs 30 kg/m(2)) in the test group compared to controls. The ultrasound guidance cohort showed no significant difference in the stone-free rate (86% vs 86%) or the complication rate (8% vs 16%) compared to controls. Operative time was no longer in the ultrasound guidance cohort. CONCLUSIONS: In this feasibility study we found that ureteral stones may be definitively managed in a timely, effective and safe fashion without ionizing radiation in the general population using this novel technique of ultrasound guided ureteroscopy.

Evaluation of the Pericardium with CT and MR.

The pericardium plays an important role in optimizing cardiac motion and chamber pressures and serves as a barrier to pathology. In addition to pericardial anatomy and function, this review article covers a variety of pericardial conditions, with mention of potential pitfalls encountered during interpretation of diagnostic imaging. Normal and abnormal appearance of pericardium on CT and MR imaging is emphasized, including dynamic imaging correlates of pericardial pathophysiology.

Single-institution results of image-guided nonplugged percutaneous versus transjugular liver biopsy.

PURPOSE: To retrospectively review patients who underwent transjugular and image-guided percutaneous biopsy and compare the relative risk of ascites, thrombocytopenia, and coagulopathy. MATERIALS AND METHODS: From August 2001 through February 2006, a total of 238 liver biopsies were performed. The radiologist reviewed all patient referrals for transjugular biopsy. These patients either underwent transjugular biopsy or were reassigned to percutaneous biopsy (crossover group). Patients referred to percutaneous image-guided liver biopsy underwent this same procedure. Biopsies were considered successful if a tissue diagnosis could be made from the samples obtained. RESULTS: A total of 36 transjugular biopsies were performed with 3 total (8.3%) and 1 major (2.8%) complications. A total of 171 percutaneous biopsies were performed with 10 (5.8%) total and 3 (1.8%) major complications. The crossover group showed a total of 4 (12.9%) complications with 1 (3.2%) major complication. Sample adequacy was 91.9% for transjugular and 99.5% for percutaneous biopsy. CONCLUSION: Both transjugular and percutaneous liver biopsy techniques are efficacious and safe. Contraindications such as thrombocytopenia, coagulopathy, and ascites are indicators of greater complications but are not necessarily prevented by transjugular biopsy. Percutaneous biopsy more frequently yields a diagnostic specimen than transjugular biopsy.

Complication rates and outcomes of 536 implanted subcutaneous chest ports: do rates differ based on the primary operator's level of training?

RATIONALE AND OBJECTIVES: Totally implanted subcutaneous central venous access devices (chest ports) are an attractive option for patients in need of intermittent, recurrent venous access. In our department, these are placed by different operator types including interventional radiology (IR) attending physicians, dedicated IR nurse practitioners (NP), and IR fellows/radiology residents. The purpose of our study is to assess the rate of complications of subcutaneous chest port placement among the different operator types. MATERIALS AND METHODS: A retrospective review of all subcutaneous central venous access devices implanted in our department between October 8, 2004, and October 19, 2007, was undertaken. Total numbers of port days, overall complication rates for all operators, as well as complication rates for the various operator types were calculated and were compared using the chi square test. RESULTS: A total of 558 patients had totally implanted subcutaneous central venous access devices placed during the period of study. Of these, 536 had documented follow-up and comprise the study population. A total of 89 were placed by attending physician alone, 133 by an NP, and 314 by an IR fellow or resident, with supervision by an attending physician. Mean duration of port usage was 341 days with 182,522 total port days. A total of 39 complications occurred (7.28%), including 27 infections (5%). There was no statistically significant difference in overall complication rates, including infection rates, among operator groups (P = .925). CONCLUSIONS: Our results confirm that well-trained physician extenders and trainees can safely perform chest port placement and that these providers, under appropriate supervision, can help provide improved access to chest port placement for patients and referring clinicians.

Implantable subcutaneous venous access devices: is port fixation necessary? A review of 534 cases.

Conventional surgical technique of subcutaneous venous port placement describes dissection of the port pocket to the pectoralis fascia and suture fixation of the port to the fascia to prevent inversion of the device within the pocket. This investigation addresses the necessity of that step. Between October 8, 2004 and October 19, 2007, 558 subcutaneous chest ports were placed at our institution; 24 cases were excluded from this study. We performed a retrospective review of the remaining 534 ports, which were placed using standard surgical technique with the exception that none were sutured into the pocket. Mean duration of port use, total number of port days, indications for removal, and complications were recorded and compared with the literature. Mean duration of port use was 341 days (182,235 total port days, range 1-1279). One port inversion/flip occurred, which resulted in malfunction and necessitated port revision (0.2%). Other complications necessitating port removal included infection 26 (5%), thrombosis n = 2 (<1%), catheter fracture/pinch n = 1 (<1%), pain n = 2 (<1%), and skin erosion n = 3 (1%). There were two arrhythmias at the time of placement; neither required port removal. The overall complication rate was 7%. The 0.2% incidence of port inversion we report is concordant with that previously published, although many previous reports do not specify if suture fixation of the port was performed. Suture fixation of the port, in our experience, is not routinely necessary and may negatively impact port removal.

Summation of CT scans during radiofrequency ablation for assessing target lesion coverage.

OBJECTIVE: In radiofrequency ablation of lesions that require probe repositioning, distinguishing between treated and untreated regions can be difficult. We describe a method of using existing CT equipment to summate images of a current probe placement with those of earlier placements or scans of transiently enhancing targets. CONCLUSION: Summation of CT scans during radiofrequency ablation involving multiple probe placements is feasible and results in a better appreciation of probe positioning relative to the target lesion.

Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review.

PURPOSE: To evaluate the available data on stent-graft repair of acute blunt traumatic thoracic aortic injury with regard to safety and efficacy compared with conventional open surgical repair. MATERIALS AND METHODS: The literature on endovascular repair of acute traumatic aortic injury since 1990 was systematically reviewed. Metaanalysis of publications with open and stent-graft repair cohorts was performed to evaluate whether there was a difference in treatment effect with regard to mortality and paraplegia. Case series were included to obtain an adequate population to assess the incidence of stent-graft procedure-related complications. RESULTS: There were no prospective randomized studies. Nineteen publications that compared the outcomes of 262 endograft repairs and 376 open surgical repairs were identified. The odds ratio for mortality after endovascular versus open repair was 0.43 (95% CI, 0.26-0.70; P = .001). The odds ratio for paraplegia after endovascular versus open repair was 0.30 (95% CI, 0.12-0.76; P = .01). In the pooled group of 667 endovascular repair survivors from 50 reports, the incidence of early endoleak was 4.2%, and late endoleak occurred in 0.9%. Stroke or transient ischemic attack was reported in 1.2%. Access site complications that required intervention occurred in 4.1%. CONCLUSIONS: The available cohort and case series data support stent-graft repair as a highly successful technique that may reduce mortality and paraplegia rates by half compared with open surgery. These data support endograft repair as first-line therapy for blunt thoracic aortic trauma.

Sclerosis of postoperative lymphoceles: avoidance of prolonged catheter drainage with use of a fibrin sealant.

PURPOSE: To review experience with fibrin-based tissue sealant sclerosis of postsurgical lymphoceles at a single institution. MATERIALS AND METHODS: Fifteen patients who presented with postsurgical lymphoceles were treated with injection of fibrin tissue sealant. Procedures were performed under fluoroscopic and sonographic guidance. All lymphoceles were drained and sclerosed with a mixture of fibrin sealant and gentamicin. No drainage catheter was left in place. Postprocedural follow-up consisted of imaging and clinical evaluations. RESULTS: Twelve men and three women (mean age, 52 years) were treated. Eleven patients with lymphoceles were successfully treated with one session of sclerosis. Four patients required more than one treatment (two underwent two sessions, and two underwent three sessions). Seven patients undergoing a single treatment experienced complete resolution, and the remaining patients had smaller, persistent, asymptomatic collections. Imaging mean follow-up was 114 days (range, 5-339 d); mean clinical follow-up was 487 days (range, 195-856 d). There were no periprocedural complications. CONCLUSION: The use of fibrin sealant is safe and effective in the sclerosis of postoperative lymphoceles.

Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: a comparison of indications, complications and outcomes in 370 patients.

OBJECTIVE: Percutaneous access to the stomach can be achieved by endoscopic or fluoroscopic methods. Our objective was to compare indications, complications, efficacy and outcomes of these two techniques. METHODS: Records of 370 patients with feeding tubes placed either endoscopically by gastroenterology, or fluoroscopically by radiology, at our university-based tertiary care center over a 54-month period were reviewed. RESULTS: 177 gastrostomies were placed endoscopically and 193 fluoroscopically. Nutrition was the most common indication in each group (94 and 92%), but the most common underlying diagnosis was neurologic impairment in the endoscopic group (n=89, 50%) and malignancy in the fluoroscopic group (n=134, 69%) (p<0.001). Complications in the first 30 days were more common with fluoroscopic placement (23% versus 11%, p=0.002), with infection most frequent. Correlates of late complications were inpatient status (OR 0.26, 95%CI: 0.13-0.51) and a diagnosis of malignancy (OR 2.2, 95%CI: 1.03-4.84). Average follow-up time was 108 days in the fluoroscopic group and 174 days in the endoscopic group. CONCLUSIONS: Both endoscopic and fluoroscopic gastrostomy tube placement are safe and effective. Outpatient status was associated with greater early and late complication rates; minor complications such as infection were greater in the fluoroscopic group, while malignancy was associated with late complications.

Dialysis needle puncture of Wallgrafts placed in polytetrafluoroethylene hemodialysis grafts.

This study evaluates the effect of routine venipuncture at hemodialysis on the durability of Wallgraft covered stents. Thirteen covered stents were placed in six aging, failing polytetrafluoroethylene grafts for treatment of pseudoaneurysms and recurrent stenoses. Four patients did not experience significant graft complications. One graft was ligated for an infected overlying skin ulcer. After surgical revision, the graft remains functional. Another patient experienced fraying of the stent edges and recurrence of a small pseudoaneurysm. Our experience suggests that the Wallgraft covered stent can withstand routine venipuncture at dialysis without flow-limiting stent distortion.

Liver biopsy 2005: when and how?

Clinical imaging and serologic testing are increasingly replacing biopsy for diagnosing hepatic diseases. However, more biopsies are being done to stage and grade hepatitis C and fatty liver disease, to diagnose space-occupying lesions (typically with fine-needle aspiration biopsy), and to assess response to therapy. If biopsy is planned, it is important to evaluate its indications and risks and, if other physicians are involved, who is responsible for what.

Utility of covered stents for revision of aging failing synthetic hemodialysis grafts: a report of three cases.

Three aging failing hemodialysis polytetrafluoroethylene bypass shunts, average age 44 months, previously percutaneously revised with balloon angioplasty, presented with pseudoaneurysms and recurrent thrombosis. All were treated with percutaneous covered stent placement within their affected limbs. One graft was ligated 1 month after treatment for infected overlying skin ulcer, though this graft was subsequently surgically revised with interposition graft and the covered stent portion remains functional at 19 month follow-up. The 18- and 13- month follow-up of the remaining 2 patients shows that the covered stents remained patent and they are functional and being successfully and routinely punctured for dialysis. In this elderly population, the use of covered stents may prolong the functional life of failing hemodialysis bypass grafts, reducing the number of percutaneous and surgical interventions and further sparing other vascular access sites.