Percutaneous Robotics in Interventional Radiology.

The accuracy of the robotic device not only relies on a reproducible needle advancement, but also on the possibility to correct target movement at chosen checkpoints and to deviate from a linear to a nonlinear trajectory. We report our experience in using the robotic device for the insertion of trocar needles in CT guided procedures. The majority of procedures were targeted organ biopsies in the chest abdomen or pelvis. The accuracy of needle placement after target adjustments did not significantly differ from those patients where a linear trajectory could be used. The steering capabilities of the robot allow correction of target movement of the fly.

Prevalence of Central Venous Stenosis among Black and White ESKD Patients with Dysfunctional Dialysis Access.

In the United States, significant racial and ethnic disparities exist in chronic kidney disease (CKD) and its management. Hemodialysis constitutes the main stay of renal replacement therapy for end-stage kidney disease (ESKD), which is initiated using central venous catheters (CVC) in most CKD patients in the United States. Black ESKD patients have higher usage and greater time on CVC for hemodialysis compared to White patients. This trend places Black patients at a potentially higher risk for CVC-related complications such as central venous stenosis (CVS). We posited that Black patients would have a higher prevalence and a greater risk of CVS. A retrospective review was performed of ESKD patients who underwent a fistulogram for dialysis access malfunction. CVS was defined as > 50% stenosis in the central veins. Fistulograms of 428 ESKD patients were adjudicated, and CVS was noted in 167 of these patients. Of the entire cohort, 370 fistulograms belonged to self-reported unique Black and White ESKD patients, of whom 137 patients were noted to have CVS. There was no difference in the of CVS between Black (40%) and White (41%) ESKD patients. However, a higher severity of stenosis (>70%) (P = 0.03) was noted in White ESKD patients. An unadjusted model showed a significant association between CVS and cardiovascular disease and the use of CVCs. The risk-adjusted model showed a significant association between diabetes and CVS. Unlike arterial stenotic lesions, this work for the first time demonstrated higher prevalence of severe venous stenotic lesions in White ESKD patients and linked diabetes to stenotic venous disease. This work paves the way for future studies investigating the risk and influence of race and ethnicity on CVS using a larger and diverse data set.

Single center experience with ultrasound guided axillary vein port placement.

PURPOSE: To retrospectively review a single institution experience of ultrasound guided axillary vein port placement. METHODS: In this retrospective study, a patient list was generated after searching our internal database from 1/1/2012 to 10/1/2018. Patients who had undergone axillary vein port placement were included. Chart review was performed to confirm approach, laterality and to gather demographic data, clinical indications, technical outcomes, and complications. Descriptive statistics were used to analyze this cohort. Chi-square statistics were used to compare outcomes by laterality. RESULTS: Three hundred seven patients (51% female) with an average age of 58 years were included. The port was placed via the right axillary vein in 85% (261/307), predominantly for the indication of chemotherapy access (296/307). Technical success was achieved in all 307 cases. Peri procedural complications occurred in 1% (4/307) of cases and included port malpositioning requiring replacement and a case of port pocket hematoma. Post procedural complications including deep vein thrombosis and port malfunction occurred in 17% (52/307) of cases and port removal as a result of complication occurred in 9% (29/307) of cases. CONCLUSIONS: Ultrasound guided placement of an axillary port is a safe procedure to perform and demonstrates good clinical outcomes.

Periprocedural Outcomes in Patients on Chronic Anticoagulation Undergoing Fistulograms.

BACKGROUND: Management of antithrombotic therapy with warfarin in patients undergoing fistulograms and possible interventions is controversial and difficult because of lack of adequate outpatient bridging options. Our goal was to assess periprocedural outcomes in patients managed using different anticoagulation strategies. METHODS: A retrospective, single-institution analysis of all patients on chronic anticoagulation with warfarin undergoing fistulograms from 2011 to 2017 was performed. Anticoagulation management strategies were classified as suspended warfarin (SW), continued warfarin (CW), and a heparin bridge with suspended warfarin (HB). Periprocedural outcomes were analyzed. RESULTS: There were 87 patients on chronic anticoagulation with warfarin who underwent 175 fistulograms. Median age was 63 years, and 43.4% were women. Indications for warfarin included atrial fibrillation (53%), prior pulmonary embolism/deep vein thrombosis (29%), and hypercoagulable state (14%). Distribution was SW (60%), CW (26%), and HB (14%). Approximately half (53%) were same-day procedures, 30% occurred during access-related admissions, and 14% were performed during nonaccess-related admissions. Common indications for a fistulogram included difficulty with dialysis (63.4%), access thrombosis (20.6%), and poor maturation (10.3%). Interventions included angioplasty (82.9%), thrombectomy/embolectomy (20.6%), and stenting (8.6%). Thirty-day outcomes for SW versus CW versus HB were similar for bleeding complications (5.7%, 6.5%, 8.3%; P = 0.89), systemic thrombotic complications (3.8%, 2.2%, 0%; P = 0.569), access rethrombosis (7.6%, 13%, 12.5%; P = 0.517), and tunneled dialysis catheter placement (11.4%, 13%, 12.5%; P = 0.958). After excluding procedures performed during a nonaccess-related admission, length of stay (LOS) was highest among HB (9.6 ± 7.8 days) compared with SW (2.6 ± 5.9 days) and CW (1 ± 2.8 days), (P < 0.0001). CONCLUSIONS: CW therapy in patients undergoing fistulograms was not associated with increased morbidity and was associated with shorter LOS. Bridging with heparin is not associated with improved outcomes, warranting a thorough consideration of continuing warfarin is safe and may streamline preservation of dialysis accesses without significantly increasing resource utilization.

Perioperative and long-term outcomes after percutaneous thrombectomy of arteriovenous dialysis access grafts.

OBJECTIVE: Maintenance of functional arteriovenous grafts (AVGs) for dialysis is difficult secondary to low primary patency, need for reinterventions, and limited alternative dialysis access options. We assessed our experience with percutaneous thrombectomy for treatment of occluded AVGs. METHODS: We performed a retrospective analysis of all percutaneous thrombectomies for AVGs from 2015 to 2017. These were generally performed using mechanical thrombectomy and occasional chemical tissue plasminogen activator thrombolysis, over-the-wire balloon embolectomy for inflow, and adjunctive inflow and outflow interventions as necessary. Perioperative outcomes, long-term patency, reinterventions, and need for new permanent access placement were analyzed. RESULTS: There were 218 percutaneous thrombectomies performed on 86 AVGs in 77 patients. Approximately half (53.2%) of the patients were male and 68.8% were black. Mean age was 61.1 ± 13.0 years. At the time of thrombectomy, 73.8% underwent venous outflow interventions and 4.5% underwent arterial inflow interventions. Within 30 days, 24.8% of declotted grafts underwent repeated percutaneous thrombectomy, 14.3% required tunneled dialysis catheter placement, 4% developed minor access site or graft infections, and one patient underwent surgical arterial thrombectomy for arm ischemia. There were no venous thromboembolic, cardiopulmonary, or cerebrovascular complications or clinically significant pulmonary embolism. At 1 year and 3 years after percutaneous thrombectomy, freedom from repeated thrombosis was 37% and 18%, respectively, and freedom from new dialysis access placement was 66% and 51%, respectively. Overall patient survival was 82% at 3 years. CONCLUSIONS: Percutaneous thrombectomy of AVGs is safe and is associated with acceptable patency rates. This minimally invasive method extends AVG use for these high-risk patients with limited dialysis access options.

Management of life-threatening hemoptysis.

It is estimated that 5-14% of patients presenting with hemoptysis will have life-threatening hemoptysis, with a reported mortality rate between 9 and 38%. This manuscript provides a comprehensive literature review on life-threatening hemoptysis, including the etiology and mechanisms, initial stabilization, and management of patients. There is no consensus on the optimal diagnostic approach to life-threatening hemoptysis, so we present a practical approach to utilizing chest radiography, computed tomography, and bronchoscopy, alone or in combination, to localize the bleeding site depending on patient stability. The role of angiography and embolization as well as bronchoscopic and surgical techniques for the management of life-threatening hemoptysis is reviewed. Through case presentation and flow diagram, an overview is provided on how to systematically evaluate and treat the bronchial arteries, which are responsible for hemoptysis in 90% of cases. Treatment options for recurrent hemoptysis and definitive management are discussed, highlighting the role of bronchial artery embolization for recurrent hemoptysis.

Endovascular management of anastomotic blowout of proper hepatic to common hepatic artery saphenous vein bypass with coil embolization and hepatic artery stent placement.

Mesenteric and visceral artery pseudoaneurysms in the abdomen are a relatively rare complication after abdominal surgery. It is a complication primarily associated with pancreatic and hepatobiliary surgery, trauma, iatrogenic causes and inflammatory diseases. Regardless of etiology, visceral artery pseudoaneurysms of the abdomen reportedly occur only in 0.01% to 2% of the population. Although rare, these are associated with life-threatening bleeding complications and need to be appropriately managed. We present the case of a patient who presented with bleeding after developing a pseudoaneurysm at the distal anastomotic site of a common hepatic to proper hepatic artery interposition saphenous vein bypass that was subsequently excluded by coil embolization and stent graft placement.

Collapse of Viabahn stent-graft secondary to rheolytic thrombectomy: a rare complication of the AngioJet device.

There is increased use of percutaneous mechanical thrombectomy for treatment of occluded dialysis access. The AngioJet rheolytic thrombectomy device is one such device available. Reports have shown safety and efficacy of these techniques with relatively few complications. We describe a case report of a collapsed Viabahn endoprosthesis in an arteriovenous fistula during treatment with an AngioJet device.

Lymphangiography in the diagnosis, localization, and treatment of a lymphaticopelvic fistula causing chyluria: a case report.

We present a 25-year-old man with chyluria resulting from a posttraumatic, postinflammatory lymphaticopelvic fistula. This aberrant connection between the lymphatic system and the urinary tract is rarely seen in the United States and can be difficult to diagnose. In this particular case, lymphangiography and postprocedure computed tomography (CT) imaging were used to diagnose and localize a fistula involving the right renal pedicle lymphatics and right urinary collecting system. This fistula ultimately resolved after the procedure and did not require sclerotherapy or surgical intervention. Lymphangiography is now rarely performed at most centers due to advancements in alternative diagnostic imaging modalities. However, this procedure remains a useful tool for the investigation and treatment of chyluria and other chyle leaks.