Hepatic arterial loop with accessory right hepatic artery aneurysm with celiac atresia: endovascular therapy with a stent and detachable coils.

The present report describes an unusual case of an aneurysm of a right hepatic artery (RHA) branching from the superior mesenteric artery; the accessory RHA was looped to the left hepatic artery arising from the celiac axis (CA) and was associated with congenital atresia of the CA. The accessory RHA aneurysm was treated with the placement of a bare stent and detachable coils through the mesh of the stent. Complete and prompt exclusion of the aneurysm was achieved with blood flow preservation in the parent artery at midterm follow-up.

Malignant duodenal obstructions: palliative treatment using self-expandable nitinol stents.

PURPOSE: To assess the efficacy of fluoroscopic per oral placement of self-expandable nitinol stents in the palliative treatment of malignant duodenal obstructions. MATERIALS AND METHODS: Under fluoroscopic guidance, 82 patients (56 male and 26 female; mean age, 62.3 y) with malignant duodenal obstructions were treated with per oral placement of four types of self-expandable nitinol stents. All patients presented with severe nausea and recurrent vomiting, and their obstructions were inoperable. RESULTS: Technical success was achieved in 78 of 82 patients (95.1%). After stent placement, food intake capacity improved in 74 of 78 patients (94.9%). Stent migration occurred in one patient 4 days after placement. A covered stent was placed to cover the ampulla of Vater in 15 patients without external biliary drainage; three of them (20%) became jaundiced. During the mean follow-up period of 74.7 days (range, 9-374 d), eight patients developed recurrent obstructive symptoms caused by tumor ingrowth (n=2) or tumor overgrowth (n=6). They were successfully treated by additional stent placement. The primary stent patency rates were 97.0%, 79.8%, and 44.0% at 30-, 90-, and 180 days, respectively (mean patency, 228.2 d; 95% CI, 153.9-302.5). CONCLUSIONS: Fluoroscopic per oral placement of self-expandable nitinol stents is an effective palliative treatment for malignant duodenal obstructions.

Bilateral adventitial cystic disease of the popliteal artery: a case report.

Adventitial cystic disease (ACD) of the popliteal artery is an uncommon vascular condition of unknown etiology. In the present case report, we describe a case of bilateral ACD of the popliteal artery in a 58-year-old male. To the best of our knowledge, this is the first case of bilateral ACD of the popliteal artery reported in the literature.

A modified technique to minimize filter tilting during deployment of the Günther Tulip filter: in vitro study.

With an in vitro model of the inferior vena cava, it was demonstrated that slight tension on the introducer during quick release of the jugular Günther Tulip filter led to less tilting of the filter compared with the technique recommended by the manufacturer. This technique may be useful to minimize significant filter tilting that may be associated with decreased filtration efficiency, and difficulty or impossibility of future filter retrieval.

Percutaneous transcholecystic biliary interventions using gallbladder anchors: feasibility study in the swine.

The purpose of this study was to report our initial experience with a swine model for biliary interventions by using a percutaneous transcholecystic access after suture anchor of the gallbladder. Telepaque tablets were given to five pigs to opacify the gallbladder. Under fluoroscopy, the opacified gallbladder was punctured percutaneously and three suture anchors were used to fix the anterior wall of the gallbladder to the abdominal wall. Two weeks later, the gallbladder was punctured and access into the distal common bile was obtained through the cystic duct. Balloon expandable stents were deployed into the distal common bile duct. Follow-up cholangiograms were obtained at 1 and 2 weeks. Necropsy was performed after 2 weeks to evaluate the relationship between the gallbladder and abdominal wall. Suture anchor placement was successful in all five pigs. One pig with a deep and highly positioned gallbladder developed fever, anorexia, and vomiting secondary to excessive stretch of the gallbladder. Placement of the guidewire through the extremely tortuous and small cystic ducts proved to be the most challenging step of the procedure. Metallic stents were successfully deployed in all four pigs in which it was attempted. Four animals tolerated the procedures without changes in their clinical conditions and no symptoms. Successful follow-up cholangiograms were performed at 1 and 2 weeks post-stent deployment without complications. All stents remained patent during the follow-up period. Necropsy demonstrated close attachment and adherence of the gallbladders to the antero-lateral abdominal wall in all four animals. Suture anchoring of the gallbladder is feasible in most pigs with superficially located gallbladders. This technique allows a safe and repeat access into the biliary system using a transcholecystic approach.

Gastroduodenal stent placement: current status.

Gastroduodenal obstruction is a preterminal event in patients with advanced malignancies of the stomach, pancreas, and duodenum. It severely limits the quality of life in affected patients due to constant emesis and associated malnutrition. Surgical gastrojejunostomy has been the traditional palliative treatment but is associated with a high complication rate, and delayed gastric emptying is a frequent problem. Gastroduodenal stent placement is a very safe and effective palliation method in patients with unresectable malignant tumors causing gastric outlet obstruction, with adequate palliation obtained in most cases. The procedure can be performed under fluoroscopic guidance or with a combination of fluoroscopic and endoscopic techniques. Advantages of gastroduodenal stent placement over surgical palliation include suitability as an outpatient procedure, more rapid gastric emptying, greater cost effectiveness, fewer complications, and improved quality of life. Covered duodenal stents are currently being evaluated and may play an increasingly important role in preventing recurrent obstruction secondary to tumor ingrowth. Moreover, simultaneous palliation of biliary and duodenal malignant strictures is possible with the use of metallic stents. Gastroduodenal stent placement is a promising new alternative for the palliation of malignant gastroduodenal obstruction.

Endovascular treatment of complicated type-B aortic dissection with stent-grafts:: midterm results.

PURPOSE: To report the midterm results of the endovascular treatment of complicated type-B aortic dissection with use of stent-grafts. MATERIALS AND METHODS: Ten patients with acute (n = 4) or chronic (n = 6) complicated type-B dissection were treated with custom-made stent-grafts. Indications for treatment included uncontrollable hypertension with dissection extension (n = 3), renal ischemia (n = 1), and false lumen aneurysm (n = 6). Stainless-steel Z-stents covered with polyester grafts were placed in the initial six patients. Nitinol stents covered with ultrathin polytetrafluoroethylene were used in the remaining four patients. The patients were followed-up with helical computed tomography for a maximum of 30 months (mean, 20 mo). RESULTS: There was one technical failure related to the access site. Early complications included deep venous thrombosis (n = 1) and embolic stroke (n = 1). Complete thrombosis of the thoracic false lumen was achieved in six patients and partial thrombosis was achieved in three. Aneurysms developed at the ends of the stainless-steel stents in two patients, requiring additional stent-graft placement. Despite successful remodeling of the thoracic aorta, three of four patients with distal reentry into the abdominal aorta experienced progressive abdominal aortic aneurysm (AAA). AAA rupture developed in two patients; one rupture was fatal and the other was treated with emergency surgery. CONCLUSIONS: Endovascular treatment of complicated type-B aortic dissection is technically feasible and effective. Closely monitoring the treated aorta is essential to detect early aneurysm formation at the ends of rigid stents. Despite adequate sealing of the tears in the thoracic aorta, dissection with distal reentry phenomenon into the abdominal aorta may evolve into AAA with late rupture.

Acute duodenal obstruction after percutaneous placement of metallic biliary stents: peroral treatment with enteral stents.

Three patients with malignant biliary obstruction were treated with placement of metallic biliary stents. Two patients had known partial duodenal stenosis but had no symptoms of gastrointestinal obstruction. The patients developed symptomatic duodenal obstruction early after biliary metallic stent placement. The symptomatic duodenal obstructions were successfully treated with peroral placement of duodenal stents, which obviated the need for surgical intervention.

Percutaneous transhepatic treatment of symptomatic mesenteric venous thrombosis.

Three patients were seen with acute mesenteric venous thrombosis. With a transhepatic access, percutaneous pharmacologic thrombolysis was performed in one patient with extensive thrombosis of the portal and mesenteric veins, resulting in complete thrombolysis of the portal vein and partial thrombolysis of the superior mesenteric vein. In two patients with focal thrombosis, the use of mechanical devices achieved complete thrombolysis. Percutaneous thrombolysis of portal and mesenteric veins with a transhepatic approach, followed by coil embolization, is a promising endovascular technique for treatment of symptomatic acute mesenteric venous thrombosis.

Fístula portosistémica con prótesis intrahepática por vía transyugular: comunicación del primer caso en México y revisión de la literatura / Portosystemic fistula with intrahepatic prothesis via transjugular: a first case report in Mexico and a review of the literature

Las derivaciones portosistémicas con prótesis intrahepáticas por vía percutánea constituyen un método relativamente nuevo y revolucionario en el tratamiento de algunas de las principales complicaciones de la hipertensión portal, como las várices esofágicas o gástricas y la ascitis intratable. Su técnica se describió en animales desde 1969 por Josef Rösch, misma que se ha perfeccionado y utilizado en seres humanos, ganando gran admiración por sus importantes resultados. En México, en el Hospital Central Militar, se efectuó con éxito la colocación de la primera prótesis intrahepática en una paciente con cirrosis criptogénica y sangrado por várices esofágicas. Se informa el caso clínico, la técnica utilizada y los resultados obtenidos a 17 meses de su colocación

Técnica para la aplicación de la derivación portosistémica transyugular / The technique of transjugular intrahepatic portosystemic stent shunts (TIPS)

En este trabajo se describe la técnica para la aplicación de la Derivación Portosistémica transyugular (TIPS). Las indicaciones de este procedimiento son las manifestaciones clínicas secundarias a la hipertensión portal, tales como la hemorragia por várices esofágicas, ascitis, etc. El TIPS consiste en realizar un tracto fistuloso intrahepático, que comunique la vena porta (VP) con una vena suprahepática (VSH), por vía percutánea a través de la vía transyugular. El trayecto se mantiene permeable mediante la colocación de una prótesis metálica expandible. Se realiza un análisis de este procedimiento radiológico, sus indicaciones, contraindicaciones, complicaciones y el panorama a futuro dentro de la medicina mexicana

Interventional radiology and endoscopic procedures in removal of a large biliary duct stone: report of a case

Existen en la actualidad múltiples procedimientos para el manejo no quirúrgico del paciente ictérico. El progreso y desarrollo de técnicas para el manejo de cálculos urinarios ha estimulado su aplicación en los conductos biliares en asociación con procedimientos endoscópicos como la papilotomía transendoscópica. El manejo de grandes cálculos biliares mediante técnicas de fragmentación con aparatos especiales (fragmentador electrohidráulico) puede ser considerado como una alternativa a procedimientos quirúrgicos, especialmente en aquellos pacientes con alto riesgo. Se presenta el manejo exitoso de un paciente recientemente visto en nuestra Institución, mediante abordaje percutáneo

Angioplastía transluminal percutánea / Percutaneous transluminal angioplasty

Desde la primera descripción, la angioplatía transluminal percutánea (ATP), ha sufrido una serie de cambios en relación a la técnica y no fue sino hasta 10 años después en que el procedimiento ha tenido mayor aceptación debido al advenimiento del catéter de dilatación con balón. Originalmente el procedimiento fue descrito para tratar obstrucciones debido a lesiones arterioscleróticas, sin embargo en la actualidad también se utiliza para tratarr estenosis por otros procesos patológicos como enfermedades fibromusculares e inflamatorias, estenosis de injertos venosos fístulas arteriovenosas para diálisis, anastomosis postoperatorias arteriales en transplante renal y dilatación de coartación de la aorta. La experiencia ha demostrado que la ATP es un método efectivo y seguro así como más simple que la reconstrucción quirúrgica. En base solo a las ventas de catéteres de angioplatía, en 1982 se ahorraron más de 100 millones de dólares en costos médicos y como alternativa a la cirugía aortofemoral ha salvado más de 500 vidas