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Objectives Direct intrahepatic portosystemic shunt (DIPS) stent placement is an effective treatment for patients with Budd-Chiari syndrome (BCS); however, thrombotic occlusion of DIPS stent remains a cause of concern. The purpose of this study is to describe a novel technique of balloon-occluded-thrombolysis (BOT) for occluded DIPS stent, and compare it with the conventional catheter-directed-thrombolysis (CDT). Methods In this retrospective study, the hospital database was searched for BCS patients who underwent DIPS revision for thrombotic stent occlusion between January 2015 and February 2021. Patients were divided into CDT group and BOT group. The groups were compared for technical success, total dose of thrombolytic agent administered, duration of hospital stay, and primary assisted stent patency rates at 1- and 6-month follow-up. Results CDT was performed in 12 patients, whereas 21 patients underwent BOT. Complete recanalization was achieved in 66.7% (8 of 12) patients of CDT group as compared to 81% (17 of 21) patients of BOT group (nonsignificant difference, p = 0.420). BOT group had a short hospital stay (1.8 ± 0.7 vs. 3.5 ± 1.0 days) and required less dose of thrombolytic agent ([2.2 ± 0.4]x10 5 IU versus [8.3 ± 2.9]x10 5 IU of urokinase) as compared to the CDT group and both differences were statistically significant ( p < 0.001). Further, 6-month patency rate was higher in BOT group as compared to CDT group ( p = 0.024). Conclusion The novel BOT technique of DIPS revision allows longer contact time of thrombolytic agent with the thrombi within the occluded stent. This helps in achieving fast recanalization of thrombosed DIPS stent with a significantly less dose of thrombolytic agent required, thus reducing the risk of systemic complications associated with thrombolytic administration.
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INTRODUCTION: Thrombosed arteriovenous fistulas (AVFs) are either treated by thrombectomy or pharmaco-mechanical thrombolysis with or without percutaneous balloon angioplasty. In this study, we have described an effective and economical technique of salvaging these fistulae using a 20-22-gauge spinal needle and urokinase and have named it direct percutaneous thrombolysis (DPT). MATERIALS AND METHOD: This prospective study comprised of 148 patients out of which 120 patients presented with AVF thrombosis and were divided into two groups; those with no obvious stenosis on ultrasound (n = 38) and second with venous stenosis (n = 82). Remaining 28 patients developed thrombosis post angioplasty for venous stenosis. Percutaneous injection of urokinase into the thrombus was done under ultrasound guidance, followed by balloon angioplasty if there was associated stenosis. RESULTS: In 38 patients who didn't have any stenosis, 32 AVFs were successfully thrombolysed by DPT, with technical success of 84.2%. Remaining six patients required angioplasty because of chronic nature of clot. In 82 patients who had venous stenosis, 80 cases were treated successfully by DPT followed by angioplasty with technical success of 97.5%. In third group (n = 28), who developed thrombosis post angioplasty, 100% success rate was noted. The mean length of thrombus was 31.4 ± 4.6 mm and mean diameter of thrombosed vein was 10.5 ± 1.2 mm. There were no major complications encountered during the procedure. Minor complications were seen in 19 patients which included prolonged oozing from puncture site and local hematoma formation. CONCLUSION: Ultrasound guided DPT with urokinase is a safe and economical option for salvaging thrombosed AVF without vascular stenosis that does not need angioplasty.
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BACKGROUND: Amebic liver abscess is the most common type of liver abscess on a worldwide basis, with caudate lobe being a relatively uncommon location for its occurrence. Abscess in caudate lobe of liver is often considered a challenging location for image-guided percutaneous drainage due to its difficult-to-access location along with close relationship with major vessels at porta hepatis. PURPOSE: This study aims to demonstrate safety and efficacy of percutaneous drainage for caudate lobe amebic abscess. MATERIALS AND METHODS: In this retrospective study, hospital database was electronically searched for patients having caudate lobe amebic abscess that underwent percutaneous catheter drainage/needle aspiration (PCD/PNA) between January 2016 and January 2021. The etiology, risk factors, microbiology, complications, different approaches for PCD/PNA, and their outcome were studied and reported. RESULTS: Of 30 patients having caudate lobe amebic abscess treated with PCD/PNA, solitary caudate lobe abscess was seen in 29, whereas one patient had more than one abscesses in caudate lobe. Contained and free intraperitoneal rupture of the abscess were seen in 9 (30%) and one patient, respectively. Ten (32%) patients had associated vascular thrombosis, while 2 patients were found to have abscess-biliary communication. Twenty-six (86.7%) patients were treated with PCD, while remaining 4 (13.3%) with PNA. On Univariate analysis, factors such as volume, multilocularity, and contained rupture of the abscess were found to be significantly increasing the duration of percutaneous drainage (PCD), while only multilocularity (p value 0.007) continued to show statistical significance on Multivariate analysis. Venous thrombosis and duration of catheter drainage were the two factors found to have significant influence on the length of hospital stay on Univariate as well as Multivariate analysis (p value 0.05 and 0.001, respectively). The rates of catheter manipulation were also significantly higher in patients with abscess showing complex internal configuration (heteroechoic contents and/or multilocularity). Technical and clinical success rates of 100% and 96.7% were achieved through percutaneous interventions (PCD/PNA), despite the complex location of abscesses and associated complications, with no incidence of vascular injury. CONCLUSION: Liver abscess in caudate lobe can be accessed by different routes for percutaneous drainage, despite being surrounded by large vessels and its deep location, without major complications. Thus, PCD/PNA may be considered as a first-line therapy for the management of caudate lobe amebic abscesses in adjunct to medical therapy.
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Drainage , Liver Abscess, Amebic , Humans , Liver Abscess, Amebic/diagnostic imaging , Liver Abscess, Amebic/therapy , Retrospective Studies , SuctionABSTRACT
BACKGROUND: The dynamic contrast enhanced magnetic resonance imaging (DCE MRI) has currently become the most utilized technique for the detection of pituitary microadenoma. However, owing to differential enhancement of normal pituitary, high rate of false positivity remains a concern in its interpretation. PURPOSE: Our aim was to assess the utility of precontrast T1 signal intensity ratio (SIR) of the lesions suspected on DCE MRI, in prediction of presence of microadenoma. MATERIALS AND METHODS: We retrospectively reviewed MRI of 23 patients referred for DCE MRI of pituitary (group 1, 15 patients with diagnosis of pituitary microadenoma; and group 2, patients not clinically labeled as microadenoma). STC were plotted and T1-SIR at t = 0 s was obtained at the suspicious zone of differential enhancement (SIR T) and normal pituitary (SIR P). SIR difference (SIR P - SIR T) and relative SIR difference (SIR P - SIR T/SIR P) were calculated for each patient and was compared between the two groups. RESULTS: Mean T1 SIR is lower in patients with microadenoma than those without (P = 0.065). SIR difference and relative SIR difference was higher in patients with microadenoma (P = 0.003 and 0.005, respectively). Receiver-operated characteristic curve analysis demonstrated that a cut-off of 26 and 0.107 for SIR difference and relative SIR difference, respectively, could diagnose microadenoma with 100% specificity and reasonable sensitivities. CONCLUSION: The baseline precontrast T1 SIR evaluation of the lesion suspected to be microadenoma on DCE MRI, derived through STC curve, can increase diagnostic confidence in diagnosis of microadenoma.
