Technical Success, Sample Adequacy, and Complications of Pediatric Transjugular Liver Biopsy: A Systematic Review and Meta-Analysis.

BACKGROUND: Transjugular liver biopsy (TJLB) procedurally samples liver tissue through the internal jugular vein. It is indicated in the presence of coagulopathies and/or ascites. AIMS: This meta-analysis aimed to assess the safety and efficacy of TJLB in children. METHODS: A literature search of several databases was conducted from inception to August 2022. Eligible studies reported pediatric patients (< 18 years old) who underwent TJLB. The pooled proportion was analyzed using a random-effects model. This review was registered in PROSPERO (CRD42022354421). RESULTS: From 921 initial studies screened, eight met the eligibility criteria, with a total of 361 pediatric patients who underwent 374 TJLBs. All eight studies reported pooled rates of technical success at 99.1% (95% CI 0.982, 1.001; I2 = 0%) and histological adequacy of sampling at 97.5% (95% CI 0.954, 0.995; I2 = 27.66%). A total of 49 complications were reported across six studies, the most common being bleeding from the entry site (38.78%), fevers for less than 24 h (12.24%), red blood cells transfusion requirement (10.2%), supraventricular tachycardia (8.16%), and pain requiring analgesia (8.16%). CONCLUSION: Pediatric TJLB demonstrates high rates of technical success and adequate liver core biopsy samples, with a low rate of complications. These results suggest that TJLB is an effective method for diagnostic yield and postprocedural outcomes, especially in patients with preexisting coagulopathies and ascites where percutaneous liver biopsy is contraindicated. Additional studies evaluating larger groups of pediatric patients may provide further support for the use of TJLB in this population.

Atypical use of PICC as centrally inserted central catheter in infants and neonates: Report of a 10-year experience.

PURPOSE: The aim was to determine the success, safety and post procedure complications of peripherally inserted central catheters as centrally inserted central catheters (CICC). MATERIALS AND METHOD: One hundred and sixty-one consecutive infants and neonates, who underwent image guided tunnelled central venous catheter insertion were retrospectively evaluated between April 2008 and April 2018. Patient's demographics, site of access and procedure details were recorded. Outcomes included technical success and post procedure complications. RESULTS: One hundred and eighty-two CICCs were inserted in 161 patients (49.7%, n = 80 male). Mean patient age was 100 days (range: 0-342) with a mean weight of 4.20 kg (range 1.80-9.40). The most common indication was for antibiotics administration (41%; n = 66). Technical success was 99% (181/182). Early complications (<7 days) were seen in 8.8% (n = 13). This included inadvertent line removal in 5.5%, catheter-related bloodstream infection in 1.1% and catheter occlusion in 2.2% (n = 4). Average line functional duration prior to removal was 26 days (range 0-180). 77.5% of the lines lasted for the intended duration of treatment. In the neonate subgroup, 84.1% (37/44 lines) of lines remained in situ for the intended duration of treatment. CONCLUSION: Tunnelled central venous catheters using non-cuffed peripherally inserted central catheters in infants is a safe technique with excellent success rate and minimal complications rates.

Peripheral Stent Thrombosis Leading to Acute Limb Ischemia and Major Amputation: Incidence and Risk Factors in the Aortoiliac and Femoropopliteal Arteries.

PURPOSE: To report the real-world incidence and risk factors of stent thrombosis in the aortoiliac and femoropopliteal arteries in case of bare nitinol stent (BNS) or covered nitinol stent (CNS) placement from a single-centre retrospective audit. MATERIALS AND METHODS: Medical records of consecutive patients treated with peripheral stent placement for claudication or critical limb ischemia were audited for definite stent thrombosis defined as imaging confirmed stent thrombosis that presented as acute limb-threatening ischemia. Cases were stratified between aortoiliac and femoropopliteal anatomy. Cox regression analysis was employed to adjust for baseline clinical and procedural confounders and identify predictors of stent thrombosis and major limb loss. RESULTS: 256 patients (n = 277 limbs) were analysed over a 5-year period (2009-2014) including 117 aortoiliac stents (34 CNS; 12.8 ± 5.0 cm and 83 BNS; 7.8 ± 4.0 cm) and 160 femoropopliteal ones (60 CNS; 21.1 ± 11.0 cm and 100 BNS; 17.5 ± 11.9 cm). Median follow-up was 1 year. Overall stent thrombosis rate was 6.1% (17/277) after a median of 43 days (range 2-192 days) and affected almost exclusively the femoropopliteal segment (12/60 in the CNS cohort vs. 4/100 in the BNS; p = 0.001). Annualized stent thrombosis rates (per 100 person-years) were 12.5% in case of CNS and 1.4% in case of BNS (HR 6.3, 95% CI 2.4-17.9; p = 0.0002). Corresponding major amputations rates were 8.7 and 2.5%, respectively (HR 4.5, 95% CI 2.7-27.9; p = 0.0006). On multivariable analysis, critical leg ischemia and CNS placement were the only predictors of stent thrombosis. Diabetes, critical leg ischemia, femoropopliteal anatomy, long stents and CNS were independent predictors of major amputations. CONCLUSIONS: Placement of long femoropopliteal covered nitinol stents is associated with an increased incidence of acute stent thrombosis and ensuing major amputation. Risks are significantly lower in the aortoiliac vessels and with use of bare nitinol stents.

Targeted True Lumen Re-Entry With the Outback Catheter: Accuracy, Success, and Complications in 100 Peripheral Chronic Total Occlusions and Systematic Review of the Literature.

PURPOSE: To report a single-center experience with the Outback re-entry device for targeted distal true lumen re-entry during subintimal recanalization of chronic total occlusions (CTOs) and compare the results with a systematic review of the literature. METHODS: Between February 2011 and July 2013, 104 Outback devices were employed in 91 patients (mean age 64±9 years; 57 men) for subintimal recanalization of 100 vessels with CTOs after initial failure of spontaneous reentry. Fifty-two cases involved a retrograde approach to aortoiliac occlusions and 48 were re-entry attempts in infrainguinal CTOs. Outcome measures included complications and technical success, defined as successful targeted re-entry at the preplanned site of the distal true lumen. To evaluate device accuracy, the re-entry distance (between the point of true vessel reconstitution and the eventual re-entry point) was measured. RESULTS: Outback success was 93% (93/100); only 7 cases failed owing to heavy calcification (5/52 aortoiliac vs 2/48 infrainguinal, p=0.44). Re-entry was highly accurate, with a re-entry distance of ~1 cm in both subgroups (1.2±0.1 cm in aortoiliac vs 1.3±0.1 cm in infrainguinal, p=0.40). There were no major and 17 minor complications (9/52 aortoiliac vs 8/48 infrainguinal, p=0.93). Results are in line with the systematic review that identified 11 studies (only 1 randomized trial) involving mostly the femoropopliteal segment (119 aortoiliac and 464 infrainguinal segments). The pooled Outback success rate was 90% (95% confidence interval 85% to 94%) and the pooled complication rate was 4.3% (95% confidence interval 1.6% to 8.3%). CONCLUSION: The Outback device is safe and has a very high rate of achieving targeted true lumen re-entry, which minimizes the sacrifice of healthy vessel in the aortoiliac and infrainguinal arteries.

Use of a New Hybrid Heparin-Bonded Nitinol Ring Stent in the Popliteal Artery: Procedural and Mid-term Clinical and Anatomical Outcomes.

PURPOSE: To report the immediate and mid-term clinical and anatomical outcomes of a novel, hybrid, heparin-bonded, nitinol ring stent (TIGRIS; Gore Medical) when used for the treatment of lesions located in the popliteal artery. MATERIALS AND METHODS: This was a prospective single-centre registry. Patients eligible for inclusion were individuals suffering from symptomatic popliteal arterial occlusive disease (Rutherford-Becker stage 3-6; P1-P3 segments) and treated with placement of the TIGRIS stent(s). Patients were prospectively scheduled for clinical review and duplex ultrasound follow-up after 6 and 12 months. Outcome measures included immediate technical success, primary vessel patency, in-stent binary restenosis (evaluable by Duplex at 50 % threshold; PSVR > 2.0), freedom from target lesion revascularization (TLR) and amputation-free survival (AFS) estimated by Kaplan-Meier (K-M) survival analysis. Cox proportional-hazards regression analysis was also performed to adjust for confounders and search for independent predictors of outcomes. RESULTS: From August 2012 to March 2014, a total of 54 popliteal TIGRIS stents were implanted in 50 limbs of 48 patients (27 men and 21 women; mean age 76.0 ± 1.7 years). Median Rutherford-Becker stage was five at baseline and 37/50 (74.0%) were chronic total occlusions. Technical success was achieved in all cases (100%). Stented lesion length was 114.2 ± 36.9 mm (range 6-20 cm). Median follow-up was 11.8 ± 0.8 months. After 12 months, primary patency of the TIGRIS stent was 69.5 ± 10.2% with an 86.1 ± 5.9% freedom from TLR and 87 ± 5.0% AFS (K-M estimates). CONCLUSION: The TIGRIS hybrid heparin-bonded nitinol ring stent is a safe and effective endovascular option for complex occlusive disease of the popliteal artery.

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.

Self-expanding metal stents in palliative malignant oesophageal dysplasia.

Oesophageal cancer is the sixth leading cause of cancer-related death worldwide. At the time of presentation, more than half of patients with oesophageal cancer have advanced disease not eligible for curative resection. Due to this, the treatment of oesophageal malignancy is usually palliative, with the main aim to relieve dysphagia, maintain nutritional intake and occlusion of tracheoesophageal fistulas. Palliative surgery offers the optimal alleviation for oesophageal obstruction symptoms such as dysphagia and vomiting. However, due to the poor prognosis, the short survival time, the significant morbidity and mortality rate for surgical intervention, this treatment option cannot be justified to less invasive non-surgical techniques such as oesophageal stenting. Oesophageal stenting has now become the treatment option of choice for palliative oesophageal malignancy. The previously used covered plastic stents were related with high migration rates and nowadays have been superseded by self-expandable metal stents (SEMS) which comparably have significantly lower migration rates, whilst at the same time provide safe, rapid and effective symptomatic relief. Herein, we present an up to date review of the current literature regarding malignant oesophageal stenting. In particular, the authors will detail important factors in patient selection, indications, contraindications, procedural steps, complications and stent design.

Synchronous renal masses in patients with a nonrenal malignancy: incidence of metastasis to the kidney versus primary renal neoplasia and differentiating features on CT.

OBJECTIVE: The purpose of this study was to establish the contemporaneous frequency of metastases within the kidney as opposed to primary renal tumors in patients with an active primary nonrenal malignancy and to identify the differentiating features. MATERIALS AND METHODS: We retrospectively identified all patients with an active primary nonrenal malignancy (group 1) who had also undergone at least 2 contrast-enhanced abdominal CT examinations spaced 1 year apart. The radiologic and pathologic data of these cases were reviewed and the incidence of metastasis to the kidney versus primary renal tumors established. These data were compared with a separate group who presented with primary renal malignancy from the outset (group 2). RESULTS: In the study were 2340 patients with primary nonrenal malignancy (group 1) and 231 patients with a primary renal malignancy (group 2). For group 1, the mean age was 63 years and 51% were men; for group 2, the mean age was 59 years, and 58% were men. The differences were not statistically significant. Thirty-six patients in group 1 had a malignant renal mass; 21 were a result of kidney metastasis and the remaining 15 were a synchronous primary renal tumor (0.9% vs 0.6%). The kidney was the eighth most common site of metastatic spread. Metastases to the kidney were statistically more likely with higher tumor stage of the primary nonrenal malignancy (68% vs 46%, p = 0.0006) and in those with other sites of metastasis (p = 0.012, positive likelihood ratio [LR+] = 6.75). Compared with primary renal tumors, metastases to the kidney were more often solid (86% vs 53%, p = 0.019, LR+ = 3.7) and endophytic (76% vs 33%, p = 0.017, LR+ = 2.29). There were too few cases with calcification and bilateral tumors to reach a statistically significant conclusion. Tumor size, polar predominance, and enhancement pattern were similar in the two groups. The primary renal tumors seen in group 1 versus group 2 were similar regarding age and sex distribution, cell type, median size, and tumor stage. CONCLUSION: Metastases to the kidney are uncommon in modern radiologic practice (0.9%, 21/2340 in this study), and a renal mass seen in a patient with nonrenal malignancy is nearly as likely to be an incidental primary renal tumor. Metastasis is more likely in those with higher tumor stage or if other viscera are also affected and is usually an asymptomatic, small, endophytic, and solid mass. If a renal mass seen in a patient with primary nonrenal malignancy proves to be a synchronous primary renal tumor, its cell type and stage will be similar to sporadic primary renal tumors.