A review of percutaneous transhepatic biliary drainage at a tertiary referral centre.

AIM: To review percutaneous biliary drainage (PBD) procedures performed in Beaumont Hospital, Dublin, Ireland, over a 6-year period, to determine the 30-day morbidity and mortality. MATERIALS AND METHODS: A total of 119 patients undergoing 193 PBD procedures were identified over a 6 year period. Of the patients, 6.7% (eight patients) had stone disease, 63% (75 patients) had a malignancy, and the remainder were diagnosed with other conditions. Standard techniques of PBD and biliary stent insertion were applied, with 73 patients (61%) having same-day procedures and all undergoing gelfoam embolisation of percutaneous tracts. All patients received intravenous prophylactic antibiotics and intravenous hydration prior to PBD. RESULTS: The technical success rate was 97%, with a mean drop of 105 mmol/l between pre- and post-procedure bilirubin. Thirty-day mortality was 10.9% (13 deaths), with major and minor morbidities of 5% (six patients) and 7.6% (nine patients), respectively. Major complications included sepsis in two patients, major haemorrhage in two patients, and renal failure in two patients. Minor complications included infection in seven patients, bile leak causing self-limiting pain in one patient, and minor haemorrhage in one patient. CONCLUSION: The study confirms that PBD and stent insertion is a safe and effective technique in Beaumont Hospital, associated with an overall acceptable morbidity and mortality comparable with other studies.

How safe is internal iliac artery embolisation prior to EVAR? A 10-year retrospective review.

PURPOSE: Internal iliac artery (IIA) embolisation is commonly performed prior to endovascular aneurysm repair (EVAR) of aortoiliac aneurysms to prevent type 2 endoleaks via the internal iliac arteries. The safety of this procedure is controversial due to the high incidence of pelvic ischaemic complications. METHODS: We undertook a retrospective review of all patients undergoing IIA embolisation before EVAR from 2002 to 2012, to determine incidence of, and factors associated with pelvic ischaemia. RESULTS: Eight of 25 patients (32 %) experienced new-onset ischaemia, including erectile dysfunction (4 %), and buttock claudication (28 %) that persisted >6 months in only four patients (16 %). Both bilateral IIA embolisation and a shorter time interval to EVAR correlate with increased risk (p = 0.006 and p = 0.044). No co-morbidities or demographic factors were predictive. CONCLUSIONS: We conclude that IIA embolisation remains a beneficial procedure, however, to minimise the risk of buttock claudication we advise against both bilateral IIA embolisation and short time intervals between embolisation and subsequent EVAR.

Efficacy of a radiation absorbing shield in reducing dose to the interventionalist during peripheral endovascular procedures: a single centre pilot study.

PURPOSE: This prospective pilot study was undertaken to evaluate the feasibility and effectiveness of using a radiation absorbing shield to reduce operator dose from scatter during lower limb endovascular procedures. MATERIALS AND METHODS: A commercially available bismuth shield system (RADPAD) was used. Sixty consecutive patients undergoing lower limb angioplasty were included. Thirty procedures were performed without the RADPAD (control group) and thirty with the RADPAD (study group). Two separate methods were used to measure dose to a single operator. Thermoluminescent dosimeter (TLD) badges were used to measure hand, eye, and unshielded body dose. A direct dosimeter with digital readout was also used to measure eye and unshielded body dose. To allow for variation between control and study groups, dose per unit time was calculated. RESULTS: TLD results demonstrated a significant reduction in median body dose per unit time for the study group compared with controls (p = 0.001), corresponding to a mean dose reduction rate of 65 %. Median eye and hand dose per unit time were also reduced in the study group compared with control group, however, this was not statistically significant (p = 0.081 for eye, p = 0.628 for hand). Direct dosimeter readings also showed statistically significant reduction in median unshielded body dose rate for the study group compared with controls (p = 0.037). Eye dose rate was reduced for the study group but this was not statistically significant (p = 0.142). CONCLUSION: Initial results are encouraging. Use of the shield resulted in a statistically significant reduction in unshielded dose to the operator's body. Measured dose to the eye and hand of operator were also reduced but did not reach statistical significance in this pilot study.

Mid-term follow-up of stenting in chronic mesenteric ischaemia: a review of six cases.

BACKGROUND: Chronic mesenteric angina is a rare condition with high morbidity and mortality, which occurs due to stenosis or occlusion in the mesenteric vessels commonly due to atherosclerosis. Typically, patients present with worsening postprandial abdominal pain, chronic weight loss and fear of food. The condition can be treated by surgical bypass, but also by percutaneous transluminal angioplasty and stenting of the affected mesenteric arteries. AIM: To assess the mid-term outcomes in patients treated by endovascular stenting for chronic mesenteric ischaemia (CMI). METHODS: Six patients were treated for symptomatic CMI. In total, six severely stenosed vessels were stented including the superior mesenteric artery (n = 5) and coeliac artery (n = 1). A retrospective review of these patients was performed with end points including symptom recurrence, major morbidity and mortality. The mean follow-up was 16.5 months (range 5-28 months). RESULTS: Initial clinical success was observed in all six patients. Four patients were clinically asymptomatic, but died within 18 months after the procedure from other conditions. One patient suffered from recurrence of symptoms. Only one patient died as a consequence of mesenteric artery re-stenosis. CONCLUSION: Stenting of mesenteric vessels has shown excellent early and mid-term clinical success in selected patients. Though no direct comparison with open revascularization surgery was performed in this case series, technical and mid-term clinical success is promising.

Vertebroplasty in the management of traumatic burst fractures: a case series.

This study aimed to assess the role of percutaneous vertebroplasty (VP) in the management of acute traumatic burst fractures. We describe three cases where percutaneous VP was carried out for traumatic non-osteoporotic burst vertebral fractures. For clinical symptoms and the effect of the VP procedure to be assessed, all patients completed a visual analogue scale and a mobility score before the procedure and at day 1 and 3 months post procedure. Improvements in both pain and mobility scores immediately post procedure were seen in all patients, and these results persisted at 3-month follow up. Percutaneous VP provided a successful, minimally invasive treatment of these patients' traumatic fractures while avoiding major surgical procedures and associated surgical morbidity and complications.

Initial experience in 115 patients with the retrievable Cook Celect vena cava filter.

The aim of this study was to evaluate our experience with the retrievable Cook Celect inferior vena cava (IVC) filter (William Cook, Europe) with regard to insertion, efficiency, ease of retrieval, and any associated complications. A retrospective review was performed of 115 patients (41 female, 74 male, mean age 47.97 years) who underwent Cook Celect IVC filter insertion between December 2005 and October 2007. Filter insertion was successful in all patients. Of the 115 filters inserted, 57 have been successfully retrieved (49.6%) to date. The successful retrieval rate from attempted retrieval was 93.4%. The mean dwell time of successfully retrieved filters was 114.9 days (range 14-267 days). Failed retrievals were due to a thrombosed vena cava (n = 1) and endothelialisation of the filter (n = 3). In the failed retrieval group the mean implantation time was 142 days (range 78-211 days). While this is the first retrospective clinical study on the Cook Celect filter, results to date are promising. We demonstrated an efficacious filter with a high successful retrieval rate of 93.4% and a low complication rate. The filter was assessed with extended dwell times (range 14-267 days). Failed retrieval secondary to hook endothelialisation continues to be an issue with this filter. We recognize that a limitation of our study was the lack of systematic follow-up for clinically silent complications. Further studies to evaluate longer term outcomes and effectiveness of this filter are warranted.

Removal of T-fasteners 2 days after gastrostomy is feasible.

T-fastener gastropexy is widely performed as part of gastrostomy insertion. The current literature recommends removal of T-fasteners at 2 weeks. We present a series of patients in whom T-fasteners were removed at 2 days with no major complications. We removed T-fasteners in 109 patients (male-to-female ratio 59:50, age range 18 to 88 years, mean age 62 years) at 2 days after gastrostomy insertion. Indications for gastrostomy included amytrophic lateral sclerosis, cerebrovascular accidents, head and neck carcinoma, multiple sclerosis, and others, including brain tumours and chronic inflammatory demyelinating polyneuropathy. No peritubal leaks or other major complications were seen in the study population. In the study group, 15 minor complications were recorded (14%), including localised infection and pain, both of which resolved on removal of T-fasteners. We conclude that it is feasible and safe to remove T-fasteners at 2 days.

Retrievable Gunther Tulip inferior vena cava filter: experience in 317 patients.

The aim of our study was to assess our experience with the retrievable Gunther Tulip (GT) inferior vena cava (IVC) filter, with regard to its insertion, efficacy, ease of placement and retrieval, and associated complications. Between November 2001 and October 2005, 322 GT filters were placed in 317 patients. Insertion indications included the following: pulmonary embolus (PE) prophylaxis in trauma patients (n = 232), PE prophylaxis in perioperative patients (n = 27), PE prophylaxis in moribund intensive care unit patients (n = 22), recent PE (n = 48), extensive deep venous thrombosis (n = 66), contraindication to anticoagulation (n = 63), anticoagulation complication (n = 8) and deep venous thrombosis with failed anticoagulation (n = 8). Some patients had more than one indication for caval filter placement. Two hundred and five attempted retrievals have been carried out, with 15 failures. Our successful retrieval rate is 92%. Nineteen filters were originally inserted permanently. There have been three minor complications associated with insertion and five with retrieval. The mean time from filter insertion to attempted retrieval was 76.95 days. The ideal filter implantation time gives the patient the benefit of PE protection, while avoiding the long-term risks associated with caval filters. Although GT retrieval times have lengthened considerably, our data suggest that this is at the expense of successful retrieval rates.

Extremities--indications and techniques for treatment of extremity vascular injuries.

Traumatic vascular injuries involving the extremity are rare and penetrating trauma accounts for the majority of such injuries. The remaining arterial injuries are as a result of either blunt or iatrogenic injuries. The rapid detection, localisation and characterisation of vascular injuries in patients who have a traumatic extremity injury is essential for the effective management and treatment of such injuries. This review will discuss the expanding role of multi-detector computed tomography angiography in diagnosing vascular injuries and its implications on conventional diagnostic angiography. The roles of other non-invasive imaging modalities are reviewed. The presentation and types of vascular injuries in blunt and penetrating injuries are discussed. While surgery remains the gold standard in the management of vascular extremity injuries it has significant morbidity rates. Endovascular techniques are increasingly being used for the treatment of vascular traumatic injuries and various techniques including balloon occlusion, embolisation and stent/stent graft placement are discussed.

Fine-needle trucut biopsy versus fine-needle aspiration cytology with ultrasound guidance in the abdomen.

Historically, fine-needle aspiration cytology (FNAC) has varying sensitivity, specificity and accuracy in the diagnosis of abdominal lesions with a high insufficient sampling rate. We compared 20-G fine-needle trucut biopsy (FNTB) with FNAC results in the biopsy of solid abdominal tumours. A retrospective review of 171 (128x 20-G FNTB and 43x FNAC) ultrasound-guided biopsies of abdominal tumours on 157 patients (male : female 85:72, mean age 61.25 years) were carried out. One hundred and seventy-one biopsies were carried out: liver 109, pancreas 19, lymph node 10, omentum 5, right iliac fossa mass 6, adrenal 6 and others 16. An average of 2.06 and 1.97 passes (range 1-4) were carried out per FNTB and FNAC, respectively. A definitive diagnosis was made in 122/128 biopsies (95.3%) and 32/43 biopsies (74.4%) for FNTB and FNAC, respectively. Diagnoses consisted of metastatic liver disease (74/171), pancreatic adenocarcinoma (10/171), lymphoma (8/171) and others (33/171) and benign (29/171). No significant complications occurred in either group. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 87, 100, 100, 50, 84.4 and 93.1, 100, 100, 60, 71.4 for FNTB and FNAC, respectively. A greater and more consistent positive diagnosis rate is yielded by 20-G FNTB (95.3%) than FNAC (74.4%). The diagnostic accuracy of FNTB is 84.4% compared with 69.8% for FNAC. A greater insufficient sampling rate occurs with FNAC (25.6%) than with FNTB (4.7%). For abdominal biopsy, 20-G FNTB needles have a much higher yield than FNAC with no increase in complications. FNTB is the preferred choice, particularly where cytological assistance at the time of biopsy is unavailable.

Percutaneous radiological management of high-output chylothorax with CT-guided needle disruption.

We present the study of a 58-year-old man who underwent percutaneous management of a high-output chylothorax following cardiac bypass graft surgery. The patient presented to a peripheral hospital 3 weeks postoperatively following cardiac bypass graft surgery with shortness of breath. A chest radiograph taken on arrival to the emergency department showed a large left-sided pleural effusion. Subsequent intercostal chest tube insertion drained a large amount of chylous fluid. The patient was treated conservatively with no improvement until undergoing a CT-guided needle disruption of lymphatics with good effect. This case is presented to show the minimally invasive treatment methods that are available in the management of high-output chylothorax.

Interventional radiology in the provision and maintenance of long-term central venous access.

Establishing and maintaining venous access forms an increasing proportion of the workload in interventional radiology. Several patient groups require medium-term to long-term venous catheters for a variety of purposes, including chemotherapy, long-term antimicrobials, parenteral nutrition, short-term access for haemodialysis or exhausted haemodialysis. Often, these catheters are required for treatment and frequent blood testing, which can quickly exhaust the peripheral veins. Long-term venous access devices minimize the discomfort of frequent cannulation while preserving the peripheral veins. Venous access devices include implantable catheters (ports), tunnelled catheters and peripherally inserted central catheters, which have different functions, advantages and limitations. Imaging-guided placement is the preferred method of insertion in many institutions because of higher success rates and radiologists are well suited to address catheter complications.

Secretin-assisted CT of the pancreas: improved pancreatic enhancement and tumour conspicuity.

PURPOSE: The primary aim of this prospective pilot study was to determine if the administration of intravenous secretin prior to contrast-enhanced computed tomography (CT) improves pancreatic enhancement and pancreatic tumor conspicuity. The second aim was to determine the optimal timing for secretin administration prior to contrast-enhanced CT. METHODS: Local ethics committee approval was obtained. 35 patients (18 men, 17 women; mean age, 67.6 years; age range; 25 to 86 years) with known or suspected pancreatic malignancy or an abdominal malignancy underwent a helical CT of the pancreas. The pancreas was first localised on an unenhanced scan using 10mm sections. Following 120 ml of intravenous 300 mg/ml of non ionic contrast medium (CM), injected at a rate of 5 ml/s, images of the pancreas (3mm slice thickness) and liver (8mm slice thickness) were obtained at 40 and 70 seconds respectively. A second CT was obtained 1-5 days after the first one using the same CT and intravenous contrast medium injection parameters. However 100 IU of secretin was given as an intravenous bolus between 0 and 5 min prior to intravenous contrast medium administration. Each patient acted as their own control. The attenuation in Hounsfield Units (HU) was recorded on non-contrast, pancreatic phase and portal venous phases for both secretin and non-secretin CTs, in the pancreas and pancreatic tumors (where present). Tumor conspicuity was calculated (in the 19 patients with pancreatic adenocarcinomas) by subtracting pancreatic tumor attenuation from pancreatic attenuation. Statistical evaluation comparing pre and post secretin enhancement was performed using matched paired t-tests. RESULTS: A significant increase in pancreatic enhancement was observed when secretin was injected at 2 to 3 min before contrast material injection (the increase in pancreatic density following secretin at 2 min was 31.5+/-10 HU (29.2%) (p=.035); and at 3 min was 23.2+/-7.8 HU (22.7%) (p=.041). Pancreatic tumor conspicuity in the pancreatic phase was most marked when secretin was injected between 2 to 4 min before contrast medium, with 4 min showing a statistically significant increase in tumor conspicuity, 48.2+/-14.2 HU (p=.04). CONCLUSION: Imaging in the pancreatic phase 2 to 4 min after administration of intravenous secretin leads to greater enhancement of the pancreas with greater tumor conspicuity, than imaging without secretin.

Efficacy and safety of the angioseal vascular closure device post antegrade puncture.

In this study, the efficacy and safety of the Angioseal vascular closure device post antegrade puncture of the common femoral artery (CFA) for lower limb vascular interventional procedures are evaluated. A retrospective analysis of the medical records of 60 consecutive patients who were referred for interventional procedures in the superficial femoral artery (SFA) or popliteal artery (popl. art.) was performed. Antegrade puncture was successfully performed in 58 of 60 patients (96.6%). Indications included right SFA angioplasty (n = 35), left SFA angioplasty (n = 17), right popl. art. angioplasty (n = 5), and left popl. art. angioplasty (n = 1). Hemostasis was achieved by, on an intention-to-treat basis, the Angioseal vascular closure device in 46 patients and manual compression in 12 patients. Manual compression was used instead of Angioseal because of severe calcified arterial wall plaques (n = 7), failed deployment of the Angioseal (n = 4), and left SFA dissection (n = 1). There were no major recorded complications in the Angioseal group despite the use of antiplatelet or anticoagulant medications. Twenty-three (50%) of the patients in the Angioseal group were discharged within 24 h. Thirty-seven of the 46 patients who received an Angioseal device had undergone a previous ipsilateral CFA puncture (time range, 2 days to 56 months; mean, 6.2 months). Nine of these patients had undergone ipsilateral Angioseal deployment in the previous 3 months. We conclude that the Angioseal vascular closure device is a safe and efficient means of achieving hemostasis post antegrade puncture.

Embolization of spontaneous hemarthrosis post total knee replacement.

Spontaneous nonhemophiliac hemarthrosis is an unusual entity, which has been little described. We present three cases of spontaneous recurrent hemarthrosis post total knee replacement (TKR) and successful management with embolization. Three male patients were referred to our service for angiography and treatment of recurrent hemarthrosis post TKR. In all three patients antegrade ipsilateral common femoral artery punctures and selective angiography of the geniculate branches were performed with a microcatheter. Abnormal vasculature was noted in all cases. Subsequent embolization was performed with Contour (Boston Scientific, Target Vascular, Cork, Ireland) embolization particles (150-250 and 250-355 microm) in two patients and microcoils in the third (TornadoR; Cook Inc., Bloomington, IN, USA). Technical success was 100%. One patient had a recurrence of symptoms requiring a repeat procedure 6 months later. No complications were encountered. Selective angiography and particle embolization is an effective technique for management of this unusual but problematic postoperative sequelae.

Percutaneous antegrade ureteric stent removal using a rigid alligator forceps.

To evaluate the safety and efficacy of percutaneous antegrade ureteric stent removal using a rigid alligator forceps. Twenty patients were included in our study. Indications for ureteric stent insertion included stone disease (n = 7), malignancy (n = 8) and transplant anastomotic strictures (n = 5). Stent retrieval was carried out for proximal stent placement/migration in seven patients and encrustation in the remaining 13. Twenty-two stents were successfully retrieved in 20 patients. There was one technical failure (5%). There were no major complications. We had four minor complications, which included nephrostomy site pain (n = 2), periprocedural sepsis (n = 1) and a small urinoma (n = 1). All patients settled with conservative management. Percutaneous radiologically guided antegrade ureteric stent removal with an alligator forceps is safe and effective, particularly when initial surgical removal has failed.

Iatrogenic stenosis following suture-mediated closure device.

The use of percutaneous closure devices post arterial punctures has been introduced to reduce time to haemostasis, reduce haemorrhage, improve patient comfort and reduce time to ambulation. Their increased use has been a result of larger access sites for more complicated procedures, periprocedural anticoagulation and concomitant use of anti-platelet therapy. Although complication rates are not increased with their use as compared with mechanical compression, complications may be more severe and are an important consideration in their use. We report two cases of iatrogenic stenoses secondary to suture-mediated closure device. The first managed with open surgical repair and the second with cutting balloon angioplasty.

Direct percutaneous portocaval shunt creation for haematemesis: case report.

Creating a direct intrahepatic portocaval shunt (DIPS) is a procedure similar to a transjugular intrahepatic portosystemic shunt (TIPS) in patients for whom the latter is not appropriate due to unsuitable hepato-venous and porto-venous anatomy. We present a patient for whom TIPS was not possible, and DIPS successful.

Pulsed UV-light inactivation of poliovirus and adenovirus.

AIMS: To study the pulsed ultraviolet (UV) inactivation of poliovirus and adenovirus. METHODS AND RESULTS: Viral suspensions of 2 ml volume were exposed to varying numbers of polychromatic light pulses emitted from a xenon flashlamp. Ten pulses produced an approximately 4 log(10) reduction in poliovirus titre, and no infectious poliovirus remained after 25 pulses. With adenovirus, 10 pulses resulted in an approximately 1 log(10) reduction in infectivity. Adenovirus required 100 pulses to produce an approximately 3 log(10) reduction in infectivity, and 200 pulses to produce a greater than 4 log(10) reduction. CONCLUSIONS: Adenovirus was more resistant to pulsed UV treatment than poliovirus although both viruses showed susceptibility to the treatment. SIGNIFICANCE AND IMPACT OF THE STUDY: Pulsed UV-light treatment proved successful in the inactivation of poliovirus and adenovirus, and represents an alternative to continuous-wave UV treatment.