Combined Interventional Approach Research Articles

A Combined Interventional Approach to Train Interview Skills in Autistic Transition-Age Youth.

The job interview can be challenging for autistic adolescents considering the required social communication skills. Further, having decreased awareness of personal strengths may make it difficult to advocate for oneself to a future employer. The purpose of the current pilot randomized controlled trial (RCT) is to examine the preliminary efficacy and feasibility of a combined interventional approach using: the Virtual Interview Tool for Autistic Transition-Age Youth (VIT-TAY) and Kessler Foundation Strength Identification and Expression (KF-STRIDE). Twenty autistic transition-age youth (TAY) were randomly assigned to two groups: an intervention group (n = 10) that received 9h of VIT-TAY (interviewing practice with a virtual human), and three lessons of KF-STRIDE (positive psychology intervention to learn and discuss one's personal character strengths) and a services-as-usual (SAU) group (n = 10). The primary outcome was measured using a video-recorded mock job interview performed at pre- and post-test, which was rated by blinded assessors. Secondary outcomes included self-reports of job interview skill, interview anxiety, work readiness and recent job search behavior. Paired samples t-tests revealed significant differences between pre- and post-test in the intervention group (but not the control group) on the mock interview total score (p = 0.02, d = 0.76) and self-reported job interview skills total score (p = 0.02, d = 0.75). The intervention group (but not the control group) had improvements in work-readiness (p = 0.06, d = 0.53) and job search behavior (p = 0.07, d = 0.52) that were characterized by medium effect sizes. This pilot study suggests that combining VIT-TAY with KF-STRIDE leads to improvements in performance-based and self-reported job interview skills.

ID: 217093 Benefits of Early Treatment for Postherpetic Neuralgia With Serial Cervical Epidural Dexamethasone Injections and Multimodals

Post herpetic neuralgia (PHN) affects approximately 20% of patients with herpes zoster, can be debilitating, and significantly decreases quality of life. To date, there is limited literature that looks at a combined serial interventional and multimodal approach specifically in the early treatment of PHN.

S2812 Cholelithiasis Resulting in Partial Mirizzi Syndrome and Liver Abscess

Introduction: Mirizzi syndrome is defined as common hepatic duct (CHD) obstruction caused by extrinsic compression from an impacted stone in the cystic duct or gallbladder infundibulum. Failure to recognize it prior to cholecystectomy, can result in intraoperative bile duct injury and subsequently in significant morbidity. Patients present with one or more of the following: right upper quadrant pain, fever and jaundice; classically with elevated bilirubin and alkaline phosphatase. Case Description/Methods: A 67-year-old female presented with fever, right upper quadrant abdominal pain and emesis. Workup revealed leukocytosis, bilirubin 0.4 mg/dL (≤1.2), alkaline phosphatase 226 IU/L (35-104), aspartate aminotransferase 42 IU/L (< 32) and alanine transferase 86 IU/L (< 33). CT scan followed by magnetic resonance cholangiopancreatography showed a 7.2 x 6.1 cm heterogenous lesion in the right hepatic lobe of the liver consistent with a liver abscess, contracted gallbladder with cholelithiasis, and a large gallbladder neck/cystic duct stone externally compressing the right hepatic duct causing upstream dilatation resulting in a partial Mirizzi syndrome (Figure A). The left hepatic duct, CHD, and common bile duct (CBD) were unaffected. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed a large gallbladder neck stone compressing the right hepatic duct, with a normal left hepatic duct, CHD, and CBD (Figure B). Biliary sphincterotomy with basket sweep of the CBD and stent placement was performed. Follow up cholangiogram revealed a decompressed biliary tree. The liver abscess was drained percutaneously, and patient was discharged on intravenous antibiotics. She underwent elective cholecystectomy with right hepaticojejunostomy after 8 weeks. Postoperative imaging showed intact hepaticojejunostomy and no residual abscess. Discussion: This case is unique as patient did not develop classic obstructive jaundice due to intact drainage on the left but developed a liver abscess due to prolonged biliary stasis on the right. The patient required a combined endoscopic, interventional, and surgical approach for therapeutic success. Recognition of Mirizzi syndrome was key to planning therapeutic steps with ERCP followed by abscess drainage prior to surgery to ensure the best possible outcome for the patient.Figure 1.: A: MRCP showing right liver lobe abscess (white arrow). B: ERCP showing gallbladder (black arrow) with stone in gallbladder neck (block arrow) causing compression and upstream intrahepatic dilatation of right intrahepatic duct (white arrow). MRCP (magnetic resonance cholangiopancreatography), ERCP (endoscopic retrograde cholangiopancreatography).

Efficacy and Safety of Combined Embolization and Radiofrequency Ablation in Stage 1 Renal Cell Carcinomas.

To retrospectively evaluate outcomes of a combined interventional approach to stage 1 (cT1cN0cM0) renal cell carcinomas (RCCs) by transarterial embolization (TAE) followed by percutaneous CT-guided radiofrequency ablation (RFA) in patients ineligible for surgery. 13 patients (9 male, 4 female, 69.6 ± 16.6 y/o) with 14 RCCs (largest diameter: 40.4 ± 6.7 mm, cT1a: 4, cT1b: 10) were treated by RFA a median of one day after TAE in a single center. Indications for minimally invasive interventional therapy were bilateral RCCs (n = 4), RCCs in a single kidney after nephrectomy (n = 3), increased surgical risk due to comorbidities (n = 4), and rejection of surgical therapy (n = 2). Technical success, effectiveness, safety, ablative margin, cancer-specific survival, overall survival, and tumor characteristics were analyzed. All RCCs were successfully ablated after embolization with a minimum ablative margin of 1.2 mm. The median follow-up was 27 (1-83) months. There was no residual or recurrent tumor in the ablation zone. No patient developed metastasis. Two minor and two major complications occurred. Four patients with severe comorbidities died during follow-up due to causes unrelated to therapy. The 1-year and 5-year overall survival was 74.1 % each. Cancer-specific survival was 100 % after 1 and 5 years. There was no significant decline in mean eGFR directly after therapy (p = 0.226). However, the mean eGFR declined from 62.2 ± 22.0 to 50.0 ± 27.8 ml/min during follow-up (p < 0.05). The combination of TAE and RFA provides an effective minimally invasive therapy to stage 1 RCCs in patients ineligible for surgery. The outcomes compare favorably with data from surgery. · Interventional treatment by TAE and ablation is a safe and effective alternative to surgery in stage 1 RCCs.. · Focal therapy of RCCs preserves renal function.. · A small ablative margin appears to be sufficient in the ablation of RCCs.. · Wessendorf J, König AM, Heers H et al. Efficacy and Safety of Combined Embolization and Radiofrequency Ablation in Stage 1 Renal Cell Carcinomas. Fortschr Röntgenstr 2022; 194: 1020 - 1025.

Heart Rate Variability in Women with Systemic Lupus Erythematosus: Association with Health-Related Parameters and Effects of Aerobic Exercise.

Abnormal heart rate variability (HRV) has been observed in patients with systemic lupus erythematosus (SLE). In a combined cross-sectional and interventional study approach, we investigated the association of HRV with inflammation and oxidative stress markers, patient-reported outcomes, and the effect of 12 weeks of aerobic exercise in HRV. Fifty-five women with SLE (mean age 43.5 ± 14.0 years) were assigned to either aerobic exercise (n = 26) or usual care (n = 29) in a non-randomized trial. HRV was assessed using a heart rate monitor during 10 min, inflammatory and oxidative stress markers were obtained, psychological stress (Perceived Stress Scale), sleep quality (Pittsburg Sleep Quality Index), fatigue (Multidimensional Fatigue Inventory), depressive symptoms (Beck Depression Inventory), and quality of life (36-item Short-Form Health Survey) were also assessed. Low frequency to high frequency power (LFHF) ratio was associated with physical fatigue (p = 0.019). Sample entropy was inversely associated with high-sensitivity C-reactive protein (p = 0.014) and myeloperoxidase (p = 0.007). There were no significant between-group differences in the changes in HRV derived parameters after the exercise intervention. High-sensitivity C-reactive protein and myeloperoxidase were negatively related to sample entropy and physical fatigue was positively related to LFHF ratio. However, an exercise intervention of 12 weeks of aerobic training did not produce any changes in HRV derived parameters in women with SLE in comparison to a control group.

Refractory chylous effusions in lymphangioleiomyomatosis patient post lung transplant

Lymphangioleiomyomatosis is a rare systemic disorder of unknown etiology that affects young women almost exclusively. Chylous effusions are known to be associated with lymphangioleiomyomatosis and may be difficult to treat. We present the case of a 37-year-old female who received bilateral lung transplantation for lymphangioleiomyomatosis complicated by refractory chylothorax and chylous ascites, ultimately controlled through repeated, open surgical procedures and percutaneous lymphatic embolization interventions. The combined surgical and interventional radiological approach, while not novel in their own right, suggests that a multi-modal interventional approach may be required in refractory cases.

Pulmonary hypertension secondary to takayasu's arteritis: management using a combined medical and interventional approach.

Pulmonary hypertension secondary to takayasu's arteritis: management using a combined medical and interventional approach.

Exercise and Arterial Stiffness in the Elderly: A Combined Cross-Sectional and Randomized Controlled Trial (EXAMIN AGE).

Introduction:Arterial stiffness (AST) is a main determinant of cardiovascular (CV) mortality. Long-term physical activity (PA) is considered to decrease age-related progression of AST but effects of short-term exercise interventions on AST remain unclear.Methods:In a combined cross-sectional and interventional study approach, we investigated the effects of long-term PA and short-term high-intensity interval training (HIIT) on AST in an older population. 147 older individuals (mean age 59 ± 7 years) were assigned to three groups according to their PA and CV risk profile and compared: healthy active (HA, n = 35), healthy sedentary (HS, n = 33) and sedentary at risk (SR, n = 79). In addition, SR were randomized to either 12 weeks of HIIT or standard recommendations. Pulse wave velocity (PWV) was measured by applanation tonometry. Cardiorespiratory fitness (CRF) was performed by symptom-limited spiroergometry to determine maximal oxygen uptake (VO2max).Results:Higher CRF was associated with lower PWV (p < 0.001) and VO2max explained 18% of PWV variance. PWV was higher in SR (8.2 ± 1.4 m/s) compared to HS (7.5 ± 1.6 m/s) and HA (7.0 ± 1.1 m/s; p < 0.001). 12 weeks of HIIT did not change PWV in SR. HIIT-induced reduction in systolic BP was associated with a reduction in PWV (p < 0.05).Discussion:SR show higher PWV compared to HS and long-term PA is associated with lower PWV. Reduction of AST following short-term HIIT seems to depend on a concomitant decrease in blood pressure. Our study puts into perspective the effects of long- and short-term exercise on arterial wall integrity as treatment options for CV prevention in an older population.Clinical Trial Registration:ClinicalTrials.gov: NCT02796976 (https://clinicaltrials.gov/ct2/show/NCT02796976).

‘Combined Interventional Approach vs. Conventional Utilization of Full Antenatal Care Services and Pregnancy Outcome in District Dehradun: A Cluster Randomized Controlled Trial’ a Study Protocol.

Introduction: MMR of Uttarakhand state is very high as comparison to national index and it is on 27th position in India out of 35 states and union territories to provide full ANC services. In Dehradun district, full ANC of urban and rural are quite low 15.3% and 23.2% respectively, even in urban region half than the national index 31.1%. Aim: To determine the effect of Combined Interventional Approach (CIA) to achieve full ANC among pregnant women and its impact on pregnancy outcome. Material and methods:-A cluster randomized controlled trial will be conducted in Dehradun district, Uttarakhand among all pregnant women registered in first trimester, will be selected by multi stage cluster sampling. Sample size will be calculated after pilot study. A precise inclusion and exclusion criteria will be followed. Study duration will be 10 months 15 days. Combined Interventional Approach (CIA): It includes multiple interventions (control room, mobile application, community participation, identification and utilization of alternative referral transport at community level and sensitization of community for high risk pregnancy) with conventional/routine ANC services. Tools: Subject data sheet, Mother and Child Protection Card, Reproductive and Child Health Register and Delivery register. Statistical analysis: Data will be collected and analyzed using descriptive and inferential statistics (p < 0.5). Discussion: This study, if proven effective, then without any extra cost and burden, ANC services can be strengthened with these interventions and full ANC coverage can be improved which ultimately improve pregnancy outcome as well as maternal and neonatal health that is a big need of time, especially in low resource countries like India.

Challenges in Achieving Hemostasis in Gastroesophageal Variceal Bleeding

A 67-year-old man with cirrhosis secondary to non-alcoholic steatohepatitis (MELD score 16) presented to an outside facility with hematemesis and presyncope. At endoscopy, esophageal varices (EV) without bleeding stigmata and fundal varices with overlying clot were noted. CT showed a large splenorenal shunt (SRS). An attempt at transjugular intrahepatic portosystemic shunt (TIPS) was aborted due to a small portal vein. Upon transfer to our institution, gastroesophageal varices type II (GOV2) per Sarin classification with fibrin plug involving a fundal varix was noted on repeat endoscopy. Due to the high risk of glue embolization via the SRS, a combined interventional radiologic-endoscopic approach consisting of balloon-retrograde transvenous occlusion (BRTOcc) of the SRS with endoscopic cyanoacrylate-Lipiodol (4:1 ratio) injection was performed successfully with obturation of the fundal varices. Further bleeding episodes from EV and from recurrent gastric varices (GV) at 24 weeks prompted coil embolization of GV and TIPS placement. Patient is currently awaiting liver transplantation. This case illustrates several important points. First, the off-label use of cyanoacrylate injection is successful in treating bleeding GV at least in the short-term, but GV do recur. Second, the risk of systemic glue embolization via large SRS can be minimized via the BRTOcc technique. Third, TIPS remains a primary or salvage technique for bleeding gastroesophageal varices when technically feasible.

Mo1691 En Bloc Resection of Hepatoduodenal Ligament for Advanced Biliary Malignancy

Background: Intrahepatic stones are very uncommon in Western societies. In comparison, hepatolithiasis occurs more frequently in Southeast Asia because of the high prevalence of congenital biliary cysts and hepatobiliary parasites. Many Asian patients present with advanced disease which is usually managed with left hepatectomy. In North America both the underlying biliary pathology and the timing of presentation differ, but management has not been standardized, in part, because of the rarity of the disease. This analysis documents the etiology, presentation and outcomes of a transhepatic team approach for management of hepatolithiasis at a Western referral center. Methods: The records of patients with hepatolithiasis managed by interventional radiologists (IR) and surgeons from 2002 through 2012 were reviewed. Surgery was undertaken when required to repair the biliary pathology and/ or when the stone burden was extensive. All but one patient were managed with 20F transhepatic stent(s) placed either percutaneously or during surgery. Choledochoscopy was performed in almost all patients either percutaneously or intraoperatively to assist with stone removal. Laser lithotripsy and balloon dilation were undertaken for difficult stones and strictures. Transhepatic stents were removed when patients were stone and stricture free. A successful outcome was defined as stent removal without symptoms requiring more procedures. Results: Seventy-four patients were managed by IR alone (66%) or by IR and surgery (34%). The mean age was 55.6 years, and 51.4% were women. The majority of patients were Caucasian (80%), and only five (7%) were Asian. Underlying biliary pathology included benign strictures (55%), choledocholithiasis (22%), sclerosing cholangitis (12%), choledochal cysts (10%), and biliary parasites (1%). Twenty patients (27%) had biliary cirrhosis, and 17 of these patients developed hepatolithiasis after undergoing orthotopic liver transplantation. Fifteen additional patients (20%) had a prior biliary-enteric anastomosis. Upper abdominal pain (65%), cholangitis (47%) and jaundice (34%) were the most common presenting symptoms. The median number of IR procedures was 11, and choledochoscopy (88%) laser lithotripsy (68%) and balloon dilation (47%) were performed frequently. Surgical management included cholangioor hepatico-jejunostomy in 22 patients (88%) and hepatectomy in one (4%). Recurrent stone and stricture rates were both 26% and were managed with further biliary stenting. None of the patients have developed a cholangiocarcinoma with a median follow-up of 29 months. Conclusions: A combined interventional radiologic and surgical approach employing large bore transhepatic stents is a safe, but labor intensive, method for managing hepatolithiasis. This approach preserves hepatic parenchyma and prevents malignant degeneration.

Mo1693 Percutaneous Transhepatic Gallbladder Drainage Without Cholecystectomy Is Optimum Procedure in High-Risk Patients

Background: Intrahepatic stones are very uncommon in Western societies. In comparison, hepatolithiasis occurs more frequently in Southeast Asia because of the high prevalence of congenital biliary cysts and hepatobiliary parasites. Many Asian patients present with advanced disease which is usually managed with left hepatectomy. In North America both the underlying biliary pathology and the timing of presentation differ, but management has not been standardized, in part, because of the rarity of the disease. This analysis documents the etiology, presentation and outcomes of a transhepatic team approach for management of hepatolithiasis at a Western referral center. Methods: The records of patients with hepatolithiasis managed by interventional radiologists (IR) and surgeons from 2002 through 2012 were reviewed. Surgery was undertaken when required to repair the biliary pathology and/ or when the stone burden was extensive. All but one patient were managed with 20F transhepatic stent(s) placed either percutaneously or during surgery. Choledochoscopy was performed in almost all patients either percutaneously or intraoperatively to assist with stone removal. Laser lithotripsy and balloon dilation were undertaken for difficult stones and strictures. Transhepatic stents were removed when patients were stone and stricture free. A successful outcome was defined as stent removal without symptoms requiring more procedures. Results: Seventy-four patients were managed by IR alone (66%) or by IR and surgery (34%). The mean age was 55.6 years, and 51.4% were women. The majority of patients were Caucasian (80%), and only five (7%) were Asian. Underlying biliary pathology included benign strictures (55%), choledocholithiasis (22%), sclerosing cholangitis (12%), choledochal cysts (10%), and biliary parasites (1%). Twenty patients (27%) had biliary cirrhosis, and 17 of these patients developed hepatolithiasis after undergoing orthotopic liver transplantation. Fifteen additional patients (20%) had a prior biliary-enteric anastomosis. Upper abdominal pain (65%), cholangitis (47%) and jaundice (34%) were the most common presenting symptoms. The median number of IR procedures was 11, and choledochoscopy (88%) laser lithotripsy (68%) and balloon dilation (47%) were performed frequently. Surgical management included cholangioor hepatico-jejunostomy in 22 patients (88%) and hepatectomy in one (4%). Recurrent stone and stricture rates were both 26% and were managed with further biliary stenting. None of the patients have developed a cholangiocarcinoma with a median follow-up of 29 months. Conclusions: A combined interventional radiologic and surgical approach employing large bore transhepatic stents is a safe, but labor intensive, method for managing hepatolithiasis. This approach preserves hepatic parenchyma and prevents malignant degeneration.

Mo1690 Hepatolithiasis: Transhepatic Team Management

Background: Intrahepatic stones are very uncommon in Western societies. In comparison, hepatolithiasis occurs more frequently in Southeast Asia because of the high prevalence of congenital biliary cysts and hepatobiliary parasites. Many Asian patients present with advanced disease which is usually managed with left hepatectomy. In North America both the underlying biliary pathology and the timing of presentation differ, but management has not been standardized, in part, because of the rarity of the disease. This analysis documents the etiology, presentation and outcomes of a transhepatic team approach for management of hepatolithiasis at a Western referral center. Methods: The records of patients with hepatolithiasis managed by interventional radiologists (IR) and surgeons from 2002 through 2012 were reviewed. Surgery was undertaken when required to repair the biliary pathology and/ or when the stone burden was extensive. All but one patient were managed with 20F transhepatic stent(s) placed either percutaneously or during surgery. Choledochoscopy was performed in almost all patients either percutaneously or intraoperatively to assist with stone removal. Laser lithotripsy and balloon dilation were undertaken for difficult stones and strictures. Transhepatic stents were removed when patients were stone and stricture free. A successful outcome was defined as stent removal without symptoms requiring more procedures. Results: Seventy-four patients were managed by IR alone (66%) or by IR and surgery (34%). The mean age was 55.6 years, and 51.4% were women. The majority of patients were Caucasian (80%), and only five (7%) were Asian. Underlying biliary pathology included benign strictures (55%), choledocholithiasis (22%), sclerosing cholangitis (12%), choledochal cysts (10%), and biliary parasites (1%). Twenty patients (27%) had biliary cirrhosis, and 17 of these patients developed hepatolithiasis after undergoing orthotopic liver transplantation. Fifteen additional patients (20%) had a prior biliary-enteric anastomosis. Upper abdominal pain (65%), cholangitis (47%) and jaundice (34%) were the most common presenting symptoms. The median number of IR procedures was 11, and choledochoscopy (88%) laser lithotripsy (68%) and balloon dilation (47%) were performed frequently. Surgical management included cholangioor hepatico-jejunostomy in 22 patients (88%) and hepatectomy in one (4%). Recurrent stone and stricture rates were both 26% and were managed with further biliary stenting. None of the patients have developed a cholangiocarcinoma with a median follow-up of 29 months. Conclusions: A combined interventional radiologic and surgical approach employing large bore transhepatic stents is a safe, but labor intensive, method for managing hepatolithiasis. This approach preserves hepatic parenchyma and prevents malignant degeneration.

Adult aortic coarctation discovered incidentally after the rupture of sinus of Valsalva aneurysm: combined surgical and interventional approach

Combination of ruptured sinus of Valsalva aneurysm (SVA), and a coexisting asymptomatic adult aortic isthmic coarctation is extremely rare. The timing and sequence of surgical and/or interventional repair of these two pathologies are controversial. We present a case of a 37-year-old male who was admitted to our department because of severe acute congestive heart failure and signs of ruptured aneurysm of the SV into the right ventricle. Transthoracic and transoesophageal echocardiography confirmed the communication between an important right coronary SVA and right ventricle, bicuspid aortic valve, mild aortic regurgitation, and revealed severe aortic coarctation. Because of the severe dilation of right sinus of Valsalva a surgical repair of the ruptured aneurysm was performed. Aortic coarctation was treated four weeks later by a percutaneous stent-graft implantation. This case report supports the concept that hybrid approach is feasible in patients with ruptured SVA and aortic coarctation in adulthood.

A POPULATION-BASED ASSESSMENT OF PERIOPERATIVE MORTALITY AFTER CYSTECTOMY FOR BLADDER CANCER

Traumatic high-flow priapism caused by a pathologic influx from lacerated arteries to the cavernous bodies is usually treated by transcatheter arterial embolisation. The purpose of this study was to evaluate a combined interventional approach with intraoperative perineal colour Doppler ultrasound (US) while performing the embolisation procedure. Our aim was to reduce radiation exposure and application of iodinised contrast media. To achieve an optimal position of the angiography catheter directly before or in the fistula, instead of several x-ray examinations with contrast media, a perineal colour Doppler US examination was performed while saline or US contrast media were injected through the catheter. The flow pattern allows the assessment of the occlusion of the fistula and the intact flow in the arteries that were not damaged. In four patients (unilateral fistula: 1, bilateral fistulas: 3) with traumatic high-flow priapism, this technique was performed combined with a conventional angiographic control of the embolisation. Seven embolisation sessions were performed. Only in one case, a dislocation of a microcoil required a second session. In all cases, the priapism disappeared immediately after the final session, leading to a restored erectile function. This combined approach may reduce the exposure to radiation and contrast media, especially in children, who often suffer from multiple fistulas and need more than one session. The procedure also prevents an occlusion of intact arteries that affects the penile perfusion and increases the risk of erectile dysfunction. (E-mail:[email protected])

Extraction of Chronic Pacing Lead and Angioplasty for Complete Superior Baffle Obstruction in Complex Congenital Heart Disease

Laser lead extraction in adult patients with congenital heart disease is safe and effective. Baffle angioplasty for obstruction in patients with a Mustard procedure is well established. We describe a unique combined interventional and electrophysiological approach on a patient with superior baffle obstruction. This technique utilized the channel created after extracting the chronic pacing lead to cross the obstruction and stent angioplasty of the superior baffle.

Molecular MRI of Cerebral Venous Sinus Thrombosis Using a New Fibrin-Specific MR Contrast Agent

Imaging of cerebral vein thrombosis is still challenging. Currently, diagnosis is based on CT venography and MRI including MRA and conventional digital subtraction angiography. However, especially in chronic cases, each method has shown its limitations. Newer strategies for MRI are found on molecular imaging using targeted contrast agents. The aim of this study was to prove the feasibility of a novel fibrin-targeted MR contrast agent (EP-2104R; EPIX Pharmaceuticals) for selective imaging of sinus venous thrombosis in an animal model. Thrombosis of the superior sagittal sinus with human blood was induced in 6 pigs using a combined microsurgical and interventional approach. MRI was then performed before and up to 120 minutes after injection of 4 micromol/kg body weight EP-2104R. Molecular imaging was performed with a 3-dimensional high-resolution T1-weighted gradient echo sequence. Time courses of signal-to-noise ratio and contrast-to-noise ratio were analyzed. Thrombi were then surgically removed and the Gadolinium concentration was assessed. In all cases the thrombosis could be successfully induced; the complete MR protocol could be performed in 5 animals. In these cases the thrombi showed selective enhancement after injection of the molecular contrast agent. However, a continuous contrast-to-noise ratio increase was seen up to 120 minutes after contrast administration, achieving a contrast-to-noise ratio of 14.2+/-0.7 between clot and the blood pool. The novel fibrin-targeted molecular MR contrast EP-2104R allows selective and high-contrast imaging of cerebral sinus vein thrombosis in an animal model.

New experimental model of sinus and cortical vein thrombosis in pigs for MR imaging studies

Diagnosis of cerebral sinus vein thrombosis is still a challenge for imaging. MRI and MRA play a major role in sinus imaging. For further development of MR techniques, MR-compatible animal models are required. The aim of this study was to develop an animal model for sinus thrombosis and additional cortical vein thrombosis with a clot of human blood for MR imaging studies. A combined surgical and interventional approach was carried out in 13 pigs. After minimal invasive surgical access to the anterior superior sagittal sinus and cortical vein, thrombosis with human blood was induced using an interventional catheter approach. MR imaging was performed prior to and after thrombus induction. Sinus thrombosis was induced in 12 of 13 animals. Three animals suffered acute subdural haemorrhage; one of these animals died during the intervention, and one died after thrombus induction. MR imaging of the thrombosed sinus could easily be performed without significant artefacts in 11 of 13 animals. This new model of sinus and cortical vein thrombosis with a clot of human blood allows artefact-free imaging studies on MR.

Palliation of irresectable hilar cholangiocarcinoma with biliary drainage and radiotherapy.

Twelve patients with irresectable or recurrent hilar cholangiocarcinoma were treated with internal biliary drainage followed by intraluminal (iridium-192) and external-beam radiotherapy. Biliary drainage was accomplished by means of a combined surgical and interventional radiological approach. Initial biliary decompression was performed surgically by tumour resection, intrahepatic biliary enteric bypass or distal biliary-enteric anastomosis with a temporary stent. Maintenance of internal biliary drainage and application of intraluminal radiotherapy were accomplished radiologically with the use of percutaneous dilatation and metallic expandable biliary endoprostheses. Median survival was 14.5 months; all 12 patients survived for at least 6 months. Early complications during radiotherapy were minor and included two patients with cholangitis and one with transient haemobilia. Jaundice was relieved in ten of 12 patients, while episodes of cholangitis were seen during long-term follow-up in 11 (median 1.5 episodes per patient). Internal biliary drainage, in conjunction with radiotherapy, appears to be safe and effective palliation of irresectable or recurrent hilar cholangiocarcinoma. Patients can maintain a reasonable quality of life with an acceptable incidence of cholangitis, without the hindrance of external drainage devices.

Haemoptysis in a patient with tetralogy of Fallot: a combined surgical and interventional approach

Haemoptysis may occur in patients with tetralogy of Fallot and major aorto-pulmonary collateral arteries. We describe such a patient in whom bleeding from a major aorto-pulmonary collateral artery produced severe pulmonary haemorrhage. Interventional closure of the artery could not be performed because it perfused the native pulmonary arteries. Instead, we inserted a conduit between the right ventricle and the native pulmonary arteries, followed by percutaneous closure of the collateral artery. Our patient demonstrates the increasing necessity for combined surgical and interventional procedures.