Impact of Chronic Kidney Disease on Clinical Outcomes of Endovascular Treatment for Femoropopliteal Arterial Disease.

PURPOSE: To evaluate effect of chronic kidney disease (CKD) on all-cause mortality, major adverse limb event (MALE), MALE and postoperative death (MALE + POD), and amputation after endovascular treatment of femoropopliteal disease. MATERIALS AND METHODS: A retrospective review from January 2002 to October 2011 was performed of 440 patients who underwent endovascular treatment of symptomatic femoropopliteal disease for claudication (n = 251) or critical limb ischemia (CLI) (n = 267). CKD stage was divided based on Kidney Dialysis Outcomes Quality Initiative classification. Outcomes and factors associated with amputation, MALE, and MALE + POD were determined. RESULTS: Patients with diabetes (hazard ratio [HR] = 2.2; 95% confidence interval [CI], 1.3-3.6; P = .002) and runoff score of 0 or 1 (HR = 2.0; 95% CI, 1.2-3.4; P = .01) relative to runoff score of 3 were at increased risk of amputation. Patients with baseline glomerular filtration rate < 45 mL/min/1.73 m(2) had a 17% increase in amputation for every 5-point decrease < 45 mL/min/1.73 m(2) (95% CI, 1.09-1.26; P < .001). Increase of 10 years in age (HR = 1.9; 95% CI, 1.5-2.3; P < .001), TransAtlantic Inter-Society Consensus class of C/D relative to A/B (HR = 1.6; 95% CI, 1.1-2.2; P = .01), and CLI (HR = 2.4; 95% CI, 0.5-0.9; P < .001) were associated with increased mortality. Female sex was associated with decreased risk of mortality (HR = 0.7; 95% CI, 0.5-0.9; P = .01). CONCLUSIONS: Worsening CKD is associated with higher amputation rates, all-cause mortality, and MALE + POD in patients undergoing endovascular treatment of femoropopliteal disease.

Percutaneous radiologic gastrostomy catheter placement without gastropexy: a co-axial balloon technique and evaluation of safety and efficacy.

PURPOSE: The purpose of this study is to evaluate the short-term safety and efficacy of a co-axial angioplasty balloon technique for percutaneous radiologic gastrostomy catheter placement (PRG). METHODS: A total of 65 percutaneous radiologic gastrostomy tube placements were performed with the co-axial angioplasty balloon technique from 10/1999 to 1/2014. This included 19 females and 46 males between the ages of 20-83. Without the use of T-fasteners for gastropexy, the gastrostomy tube was placed over a catheter-shaft angioplasty balloon as a co-axial system. The angioplasty balloon was used to sequentially approximate the stomach wall to the abdominal wall, dilate the tract, and was then used as a dilator to aid gastrostomy tube advancement into the gastric lumen. Technical success, complications, and dislodgements were evaluated by means of retrospective review of patient medical records and imaging. RESULTS: There was no procedural failure in any of the 65 placements. 30-day follow-up was available for 56 patients. 7 patients died within 30 days; none of the deaths were recorded as procedure-related. There was 1 major complication (1.5%) consisting of a colocutaneous fistula. There were 4 minor complications (6.2%). There was no occurrence of bleeding or skin infection while using this technique. CONCLUSIONS: PRG with the co-axial angioplasty-balloon technique is a safe and effective technique for gastrostomy placement.

Percutaneous Renal Tumor Ablation: Radiation Exposure During Cryoablation and Radiofrequency Ablation.

INTRODUCTION: Once reserved solely for non-surgical cases, percutaneous ablation is becoming an increasingly popular treatment option for a wider array of patients with small renal masses and the radiation risk needs to be better defined as this transition continues. MATERIALS AND METHODS: Retrospective review of our renal tumor ablation database revealed 425 patients who underwent percutaneous ablation for treatment of 455 renal tumors over a 5-year time period. Imparted radiation dose information was reviewed for each procedure and converted to effective patient dose and skin dose using established techniques. Statistical analysis was performed with each ablative technique. RESULTS: For the 331 cryoablation procedures, the mean DLP was 6987 mGycm (SD = 2861) resulting in a mean effective dose of 104.7 mSv (SD = 43.5) and the mean CTDIvol was 558 mGy (SD = 439) resulting in a mean skin dose of 563.2 mGy (SD = 344.1). For the 124 RFA procedures, the mean DLP was 3485 mGycm (SD = 1630) resulting in a mean effective dose of 50.3 mSv (SD = 24.0) and the mean CTDIvol was 232 mGy (SD = 149) resulting in a mean skin dose of 233.2 mGy (SD = 117.4). The difference in patient radiation exposure between the two renal ablation techniques was statistically significant (p < 0.001). CONCLUSION: Both cryoablation and RFA imparted an average skin dose that was well below the 2 Gy deterministic threshold for appreciable sequela. Renal tumor cryoablation resulted in a mean skin and effective radiation dose more than twice that for RFA. The radiation exposure for both renal tumor ablation techniques was at the high end of the medical imaging radiation dose spectrum.

Lymphatic mapping and ligation for persistent ascites after surgery for gynecologic malignancy.

BACKGROUND: Ascites after lymphatic dissection, usually amenable to conservative management, may require surgery. We describe a technique in the context of treatment for gynecologic malignancy to localize and ligate lymphatic leaks. CASE: The patient was a 37-year-old woman with recurrent ovarian carcinoma, who developed recurrent chylous and lymphatic ascites after secondary cytoreduction surgery including lymph node resection in multiple basins. Ascites were refractory despite paracenteses, dietary modification, and octreotide therapy. Sclerotherapy was unsuccessful. Surgical ligation of the lymphatic leak was accomplished with injection of isosulfan blue dye into groin nodes to assist with localization. CONCLUSION: Select cases of persistent ascites after surgery for gynecologic malignancy will require surgery after conservative measures are attempted. Awareness of options for management is important for those caring for women with gynecologic cancer.

Hypersensitivity to nickel in a patient treated with coil embolization for pelvic congestion syndrome.

A 34-year-old woman had persistent symptoms of pelvic venous congestion syndrome and developed new symptoms of a systemic allergic reaction after coil embolization of both ovarian and internal iliac veins. Patch testing revealed hypersensitivity to nickel and palladium, both components of the coils used. After surgical removal of the coils and hysterectomy with salpingo-oophorectomy, all her symptoms resolved.

Retrievable inferior vena cava filters can be placed and removed with a high degree of success: Initial experience.

OBJECTIVES: Evaluate the success rate of retrievable inferior vena cava filter (IVC) removal in a tertiary care practice. BACKGROUND: Retrievable IVC filters became readily available in the United States following Food and Drug Administration approval in 2003, and their use has increased dramatically. They represent an attractive option for patients with contraindications to anticoagulation who may only need short-term protection against pulmonary embolism. METHODS: All patients who had undergone placement of a retrievable IVC filter at Mayo Clinic between 2003 and 2005 were retrospectively reviewed to evaluate our initial experience with retrievable inferior vena cava filters at a large tertiary care center. RESULTS: During a three-year-period of time, Mayo Clinic, Rochester, MN placed 892 IVC filters of which 460 were retrievable. Of the 460 retrievable filters placed (249 Günther Tulip®, 207 Recovery®, and 4 OptEase®), retrieval was attempted in 223 (48.5%). Of 223 initial attempts, 196 (87.9%) were initially successful and 27 (12.1%) were unsuccessful. Of the 27 unsuccessful initial retrieval attempts, 23 (85.2%) were because of the presence of significant thrombus within the filter and 4 (14.8%) were because of tilting and strut perforation. Of the 23 filters containing significant thrombus, 9 (39.1%) were later retrieved after a period of anticoagulation and resolution of the thrombus. CONCLUSIONS: Retrievable IVC filters can be removed with a high degree of success. Approximately one in ten retrievable IVC filter removal attempts may fail initially, usually because of significant thrombus within the filter. This does not preclude possible removal at a later date.

Outcomes of venoplasty with stent placement for chronic thrombosis of the iliac and femoral veins: single-center experience.

PURPOSE: To assess retrospectively 30-day, 1-year, and 3-year patency of chronically occluded iliofemoral venous thrombotic lesions treated with stent placement in a case series from a single institution. MATERIALS AND METHODS: Records of 189 consecutive patients treated by interventional radiology for iliofemoral venous occlusions between March 1, 2003, and December 1, 2008, were retrospectively reviewed. A total of 89 patients (27 men; median age, 46.2 y) with chronic iliac or iliofemoral deep vein thrombosis without involvement of the inferior vena cava met criteria for analysis. RESULTS: All patients (91 limbs) successfully underwent placement of venous self-expanding stents. Patency rate at discharge was 100%. Following the index procedure, mean pressure gradient across the lesion decreased from 5.63 mm Hg (95% CI, 3.51-7.75) to 0.71 mm Hg (95% CI, 0.08-1.34; P < .0001). There were no bleeding complications. Median follow-up was 11.3 months (range, 0.8-72.4 mo). Follow-up at 30 days demonstrated 90 of 91 limbs to be patent. Primary patency rates of treated limbs at 1 and 3 years were 81% and 71%, respectively. Primary patency was lost in 17 cases (19.1%); interventions to maintain or restore stent patency were performed in 13 cases (14.6%). Primary assisted limb patency rates at 1 and 3 years were 94% and 90%, respectively; secondary patency rate was 95%. CONCLUSIONS: Angioplasty with stent placement for treatment of chronically thrombosed iliofemoral veins is a low-risk procedure with acceptable patency rates for as long as 3 years. The outcomes in patients treated in a quaternary referral center are similar to those reported by other centers.

Percutaneous ultrasound-guided thrombin injection of a post-traumatic pancreatic pseudoaneurysm in a pediatric patient.

Non-operative management for blunt injuries to the proximal pancreas has become increasingly common. A bleeding pseudoaneurysm in the setting of a traumatic pancreatic pseudocyst presents a morbid operation. We present the case of a 15-year old with a grade V pancreatic injury that developed a bleeding pseudoaneurysm successfully treated with percutaneous ultrasound-guided thrombin injection.

Contemporary management of giant renal and visceral arteriovenous fistulae.

PURPOSE: To evaluate our experience with treatment of giant arteriovenous fistulae (AVFs) involving the renal and visceral vasculature and assess outcomes. METHODS: Clinical data from 12 consecutive patients (10 women; median age 58 years, range 37-79) undergoing intervention for 14 giant renal/visceral AVFs over a 15-year period (1994-2008) were retrospectively reviewed. Only patients with extra-parenchymal, wide arteriovenous communications were included. Thirteen were located in the renal artery and one in the splenic artery. The etiology was most likely post-traumatic/iatrogenic in 6 patients, idiopathic in 4 (1 bilateral), congenital in 1 (bilateral), and one was associated with fibromuscular dysplasia. In 4 cases, the lesion was asymptomatic. RESULTS: Two large renal AVFs were treated with open surgery: one elective AV fistula repair early in our experience and the other an emergent nephrectomy for rupture. Twelve AV fistulae were closed successfully using endovascular techniques performed solely through the feeding vessel without cannulating the draining vein. All symptomatic patients, except one with continued dyspnea from cardiac causes, had complete symptomatic relief. There was no mortality. Morbidity included 2 access site hematomas that were managed conservatively. Loss of renal parenchyma ranged from 5% to 30%, but median serum creatinine levels remained stable. CONCLUSION: Endovascular treatment of giant renal/visceral AVFs is challenging but feasible and safe, with good organ preservation. Endovascular techniques have replaced open surgical repair as a first-line treatment for these challenging lesions.

Bilateral traumatic chylothorax treated by thoracic duct embolization: a rare treatment for an uncommon problem.

Prolonged chylothorax is a rare, life-threatening, pleural effusion that may be encountered in the setting of trauma. Conservative treatment may be successful and is the traditional approach in cases of limited chyle output. Early surgical intervention is required in cases with large refractory chyle output, but may be associated with substantial morbidity and mortality. Percutaneous thoracic duct embolization is an uncommon, minimally invasive, safe and effective treatment alternative. We report a case of successful thoracic duct embolization to treat large-volume chylothorax due to blunt trauma.

In vivo evaluation of a MR-guided 980nm laser interstitial thermal therapy system for ablations in porcine liver.

PURPOSE: To evaluate the use of a 980-nm diode laser for magnetic resonance-guided laser interstitial thermal therapy (MR-guided LITT) ablations in liver tissue in an in vivo porcine model. MATERIALS AND METHODS: MR-guided guided LITT was performed on nine juvenile pigs placed under general anesthesia. Target ablation sites were selected in the left and right lobes of the liver. Laser applicators were placed in the liver using intermittent MR guidance. Up to four separate ablations were performed in each animal using a 15 or 30 W laser generator using one or two applicators. During the ablations, continuous MR-based temperature mapping (MR-thermal mapping), using a proton resonance frequency technique, was performed to monitor the size of the ablation in real-time. Extent of thermal tissue damage was continuously estimated based on Arrhenius model. Two-minute ablations were performed at each site. MR-thermal mapping of ablations within the posteroinferior liver were accomplished with continuous breathing at low tidal volume. In the mid right lobe of the liver, due to motion artefacts, MR-thermometry was performed intermittently during breath hold periods. In the left lobe of the liver, ablations were performed with ventilation using positive end expiratory pressure (PEEP) of 10 cm of water. Upon completion, MR imaging with gadolinium contrast was performed to assess the extent of treatment. Thermal lesions were subsequently measured using both, MR-thermal dose and MR gadolinium images, for comparison. Following the animal euthanasia, the liver was harvested and subjected to formalin fixation and paraffin embedding for histological examination. RESULTS: Between one and four focal liver ablations (total 24 ablations) were successfully performed in nine animals with either a 15 or 30 W laser generator. For the 15-W laser generator, the average single applicator ablation size was (2.0 ± 0.5) × (2.6 ± 0.4) cm(2) , as measured by magnetic resonance (MR) thermometry, or (1.7 ± 0.4) × (2.2 ± 0.6) cm(2) , as measured with gadolinium contrast, with the difference being not statistically significant. For the 30-W laser generator, the average single applicator ablation size was (2.4 ± 0.3) × (3.3 ± 0.5) cm(2) by MR thermometry and (2.1 ± 0.4) × (2.9 ± 0.3) cm(2) by gadolinium enhancement, with no statistically significant difference. Simultaneously activating two applicators with the 15 W generator demonstrated ablation sizes of (3.7 ± 0.9) × (3.2 ± 0.1) cm(2) using MR thermometry and (2.3 ± 0.6) × (2.4 ± 0.3) cm(2) with gadolinium contrast, while using two applicators in the 30-W laser generator, yielded (4.5 ± 0.6) × (3.9 ± 0.2) cm(2) using MR thermometry and (4.4 ± 1.1) × (3.6 ± 0.5) cm(2) with gadolinium contrast enhancement. CONCLUSION: In our experience, we found that liver ablations performed with a MR-guided 980-nm diode LITT system through the saline cooled catheter applicator could be performed throughout the liver. Additionally, liver ablations were safe and produced a clinically applicable ablation zone. These results suggest the 980-nm diode laser MR-guided LITT system could be effective in treatments of hepatic tumors.

Hepatic arterial chemoembolization using drug-eluting beads in gastrointestinal neuroendocrine tumor metastatic to the liver.

PURPOSE: This study was designed to evaluate short (<3 months) and intermediate-term (>3 months) follow-up in patients with metastatic neuroendocrine tumor to the liver who underwent hepatic arterial chemoembolization with drug-eluting beads at a single institution. METHODS: Institutional review board approval was obtained for this retrospective review. All patients who were treated with 100-300 or 300-500 µm drug-eluting LC Beads (Biocompatibles, UK) preloaded with doxorubicin (range, 50-100 mg) for GI neuroendocrine tumor metastatic to the liver from June 2004 to June 2009 were included. CT and MRI were evaluated for progression using Response Evaluation Criteria In Solid Tumors (RECIST) or European Association for the Study of the Liver (EASL) criteria. Short-term (<3 months) and intermediate-term (>3 months) imaging response was determined and Kaplan-Meier survival curves were plotted. RESULTS: Thirty-eight drug-eluting bead chemoembolization procedures were performed on 32 hepatic lobes, comprising 21 treatment cycles in 18 patients. All procedures were technically successful with two major complications (biliary injuries). At short-term follow-up (<3 months), 22 of 38 (58%) procedures and 10 of 21 (48%) treatment cycles produced an objective response (OR) with the remainder having stable disease (SD). At intermediate-term follow-up (mean, 445 days; range, 163-1247), 17 of 26 (65%) procedures and 8 of 14 (57%) treatment cycles produced an OR. Probability of progressing was approximately 52% at 1 year with a median time to progression of 419 days. CONCLUSIONS: Drug-eluting bead chemoembolization is a reasonable alternative to hepatic arterial embolization and chemoembolization for the treatment of metastatic neuroendocrine tumor to the liver.

Tube thoracostomy: a review for the interventional radiologist.

Small-caliber tube thoracostomy is a valuable treatment for various pathologic conditions of the pleural space. Smaller caliber tubes placed under image guidance are becoming increasingly useful in numerous situations, are less painful than larger surgical tubes, and provide more accurate positioning when compared with tubes placed without image guidance. Basic anatomy and physiology of the pleural space, indications, and contraindications of small caliber tube thoracostomy, techniques for image-guided placement, complications and management of tube thoracostomy, and fundamental principles of pleurodesis are discussed in this review.

Outpatient vascular and interventional radiology practice from 2001-2008.

PURPOSE: To describe experience with an outpatient vascular interventional radiology (IR) practice with respect to number of patients seen, number of procedures performed, and number of imaging studies ordered in follow-up. MATERIALS AND METHODS: The outpatient vascular IR practice at the authors' institution was established in 2001 with two physicians spending one half-day per week; a third physician joined in 2004. A retrospective review was done of all patients seen by an interventional radiologist from 2001 to July 2008. The following data were collected for each physician per year: the number of new and established patients seen, the number and type of procedures performed, and the number and type of imaging studies ordered. Data are presented as mean ± standard deviation per physician per year and total number. RESULTS: In 2001, the average number of new patients seen was 61 ± 11 (total number = 122), which peaked in 2006 at 127 ± 28 (total number = 380). A similar trend occurred with the established patients. In 2001, the procedure performed with the greatest frequency was abdominal aortogram with stent placement, which started at 18 ± 2 (total number = 35) and peaked by 2006 at 37 ± 23 (total number = 122). The number of ancillary imaging studies ordered by each physician increased each year and by 2006 was nearly 93 ± 77 (total number = 278). CONCLUSIONS: A robust outpatient IR practice in vascular disease can be developed in 3-5 years with downstream imaging studies being ordered for the radiology department.

Embolization of nonliver visceral tumors.

Catheter-directed embolization of visceral tumors, with the exception of the liver, has received limited attention in the literature. The visceral arterial anatomy can be complex and its understanding is critical for procedure planning and limiting complications. Embolization of splenic neoplasms is exceedingly rare. Preoperative embolization for adrenal, renal, and gut tumors plays an important role in select patients. Embolization has been used successfully in the treatment of pancreatic insulinomas and in limited cases of unresectable pancreatic adenocarcinomas. Embolization of bleeding visceral tumors can be accomplished with a high likelihood of success.

Interobserver agreement for the diagnosis of venous thromboembolism on computed tomography chest angiography and indirect venography of the lower extremities in emergency department patients.

OBJECTIVES: To determine interobserver agreement between radiologists for computed tomography (CT) angiography and venography. CT venography of the lower extremities combined with standard CT angiography of the chest may result in an increased overall diagnosis rate of venous thromboembolism (pulmonary embolism or deep venous thrombosis). METHODS: The study had a retrospective cohort design. The population consisted of emergency department patients who were evaluated for suspected pulmonary embolism. A random sample of 50 patients diagnosed and treated for venous thromboembolism and 50 age- and gender-matched patients whose CT angiograms and venograms were read as negative were enrolled. The original reading (R1) was compared with readings of two study radiologists: R2, a general radiologist, and R3, a radiologist with fellowship training in cross-sectional imaging. All readers were blinded to each other. RESULTS: Both R2 and R3 found both CT angiogram and venogram components technically adequate in 95% (95% CI = 89% to 98%) and 86% (95% CI = 78% to 92%) of studies, respectively. The agreement was very good for CT angiography (lowest agreement = 92%; lowest kappa = 0.83) and was good for CT venography (85%, kappa = 0.65). In nine cases, R1 read the CT angiogram as negative but the venogram as positive for DVT, whereas both R2 and R3 read both components as negative in four of these nine, suggesting a false-positive isolated DVT rate of 44% (95% CI = 19% to 73%). In no case did R1 read both scan components as negative when R2 and R3 agreed on presence of pulmonary embolism or DVT. CONCLUSIONS: Diagnosis of pulmonary embolism on CT angiography is more reliable than diagnosis of isolated DVT on CT venography.

Electrocardiographic findings in Emergency Department patients with pulmonary embolism.

To assess the pre-study, null hypothesis that there is no difference in the electrocardiogram (EKG) findings for Emergency Department (ED) patients who rule in vs. rule out for suspected pulmonary embolism, a retrospective review of a cohort of patients with pulmonary embolism and their controls was conducted in an academic, suburban ED. Patients who were evaluated in the ED during a one-year study period for symptoms suggestive of pulmonary embolism were eligible for inclusion. All patients with pulmonary embolism and sex- and age-matched controls comprised the final study groups. Two board-certified cardiologists reviewed each patient's EKG. There were 350 eligible patients identified; 49 patients with pulmonary embolism and 49 controls were entered into the study. The most common rhythm observed in both groups was normal sinus rhythm (67.3% cases vs. 68.6 % controls; p = 1.0). Abnormalities believed to be associated with pulmonary embolism occurred with similar frequency in both case and control groups (sinus tachycardia [18.8 % vs. 11.8%, respectively; p = 0.40]), incomplete right bundle branch block (4.2% vs. 0.0%, respectively; p = 0.24), complete right bundle branch block (4.2% vs. 6.0, respectively; p = 1.0), S1Q3T3 pattern (2.1 vs. 0.0, respectively; p = 0.49), S1Q3 pattern (0.0 vs. 0.0), and extreme right axis (0.0 vs. 0.0). New EKG changes were identified more frequently for patients with pulmonary embolism (33.3% vs. 12.5% controls; p = 0.03), but specific findings were rarely different between cases and controls. In our cohort of ED patients, we did not identify EKG features that are likely to help distinguish patients with pulmonary embolism from those who rule out for the disease.

Prevalence and significance of nonthromboembolic findings on chest computed tomography angiography performed to rule out pulmonary embolism: a multicenter study of 1,025 emergency department patients.

OBJECTIVES: To evaluate the hypothesis that computed tomography (CT) angiography often yields a result interpreted as an alternative diagnosis to pulmonary embolism (PE) in emergency department (ED) patients. METHODS: This was a multicenter, retrospective, and secondary analysis of consecutive patients in three academic emergency departments. ED patients with symptoms suspicious for PE were included. CT angiography was ordered at the discretion of the treating physician; patients were identified by query of the electronic medical record. Board-certified radiologists gave CT readings, which were reviewed by two independent emergency physicians who categorized the non-PE findings into one of four acuity categories: A = requiring specific and immediate intervention, B = requiring specific action on follow-up, C = requiring no action, and D = indeterminate findings. RESULTS: The prevalence of PE among the 1,025 patients studied was 10% (95% CI = 8% to 12%). In the 921 patients without PE, the mean prevalences (ranges between sites) of concordant categorized non-PE findings were: A = 7% (range 3%-11%), B = 10% (7%-13%), C = 17% (10%-20%), D = 4% (0%-8%), and no ancillary finding = 41% (29% to 45%). The most common category A findings included infiltrate or consolidation suggesting pneumonia (81%), aortic aneurysm or dissection (7%), and mass suggesting undiagnosed malignancy (7%). The overall unweighted agreement was 80% (kappa = 0.72) and weighted agreement was 93% (kappa(w) = 0.84). CONCLUSIONS: In ED patients with suspected PE, the CT angiogram frequently provides evidence suggesting an important alternative diagnosis to PE. Pulmonary infiltrate suggesting pneumonia was the most common non-PE finding.