Direct Puncture Research Articles

A minimally invasive approach for the treatment of isolated type intracranial dural arteriovenous fistula in a neurosurgical hybrid operating room

ObjectivesIsolated-type intracranial dural arteriovenous fistulas (DAVFs) could hinder the effective use of the transvenous approach. Direct trans-sinus embolization (dTSE) with craniotomy remains the treatment method for isolated-type DAVFs. We report our experience in using a neurosurgical hybrid operating room (NHOR) to treat cases of isolated-type DAVFs by dTSE using a single burr hole. Patients and methodsBetween April 2007 and March 2017, 189 DAVFs were treated by an endovascular procedure at our institution. Among these cases, 27 patients (14.3%) had isolated-type DAVF and 7 patients (3.7%) were treated by dTSE. The procedure accuracy and invasiveness of dTSE were compared with those of the transvenous embolization (TVE) group.The NHOR was equipped with a biplane angiography system and used to perform 3D rotational angiography (3DRA). The burr hole site was precisely determined by 3DRA. Only one burr hole was made to expose the target sinus and allow for direct puncture. The target sinus was occluded by using coils and liquid embolic material. ResultsThe NHOR allowed the accurate placement of the burr hole. Only a single burr hole and small skin incision (with minimal bleeding) were required for each dTSE case. The mean total contrast volume was significantly reduced in the dTSE group compared with that in the TVE group. Moreover, the dTSE group required shorter operation times and lower total radiation doses compared with the TVE group. ConclusionUsing dTSE could be performed with a single burr hole using a NHOR equipped with biplanar fluoroscopy. This approach is a minimally invasive and effective treatment for isolated-type DAVFs.

Endoscopic gastrointestinal anastomoses with lumen-apposing metal stents: predictors of technical success.

Lumen-apposing metal stents (LAMS) may be inserted to create gastrointestinal anastomoses under endoscopic ultrasound (EUS) guidance. This new technique has mostly been evaluated as treatment for gastric outlet obstruction (GOO), especially of malignant origin. Technical success was high in the few and small available studies. Aim of this study was to report our experience with this technique and to identify predictors of success in the setting of a large teaching hospital in Germany. All subsequent patients who underwent EUS-guided gastrointestinal anastomosis with LAMS from 02/2016 to 08/2019 were included. We performed a retrospective chart analysis including technical procedural details, basic demographic, and health characteristics. Technical success was defined as successful insertion of LAMS. In patients with GOO, the GOO Scoring System was used; an improvement ≥ 1 point was defined as clinical success. Thirty-five patients (22 female, median age: 79years) were included. Indication for the anastomosis was malignant GOO in 33 patients. In ten patients LAMS was inserted over a guidewire, in 22 patients direct puncture with the electrocautery delivery system of LAMS was performed, and other techniques were used in two patients. Technical success rate was 80.0%. Adverse events occurred in 14.3%. Clinical success rate was 74.3%. Technical success increased and procedure time decreased significantly during the study period. Distance between the two lumina connected with LAMS was significantly shorter (median: 9mm) in patients with technical success compared to those without (median: 20mm, P = 0.004). This distance was identified as predictor of success on multivariate analysis. EUS-guided gastrointestinal anastomosis with LAMS is an emerging technique. Its success mainly depends on the distance between the two lumina that are going to be connected by the LAMS and is influenced by the endoscopist's experience.

Sex differences in blood pressure of aged Ren-2 transgenic rats.

Sex-related differences were observed not only in human but also in experimental hypertension. The aim of our study was to compare blood pressure (BP) of aged male and female heterozygous transgenic rats (TGR) harboring Ren-2 mouse gene, with their normotensive Hannover Sprague-Dawley (HanSD) controls. At the age of 9 months, systolic (SBP) and diastolic blood pressure (DBP) were measured by a direct puncture of carotid artery in rats awaking from isoflurane anesthesia. Thiobarbituric acid-reactive species (TBARS) formation was monitored as indicator of lipid peroxidation damage in heart, kidney and liver, whereas intracellular content of reduced glutathione was determined in the same organs as the main intracellular antioxidant. Furthermore, plasma triglycerides and total cholesterol as well as high-density lipoprotein (HDL) and low-density lipoprotein (LDL) fractions of cholesterol were measured. As compared to HanSD rats, we found significantly elevated BP only in male TGR (MAP: 123±1 vs. 171±5, SBP: 150±2 vs. 208±7, and DBP: 99±3 vs. 140±4 mm Hg), but not between TGR and HanSD females, which were both normotensive. We also did not find any significant differences in TBARS and reduced glutathione in the three above mentioned organs as well as in plasma cholesterol or its HDL and LDL fractions between transgene-negative HanSD and TGR animals of either sex. However, we found significant sex differences in TBARS, glutathione and plasma lipids in both rat strains. Our results confirmed that aged TGR exhibit a marked sexual BP dimorphism, which does not seem to be dependent on oxidative stress or abnormal cholesterol metabolism.

Development of Hypertension and Cardiac Hypertrophy is associated with Endothelial Cell Dysfunction in Npr1 Gene‐disrupted Mice

Atrial and brain natriuretic peptides (ANP and BNP) are cardiac hormones that elicit natriuretic, diuretic, vasorelaxant, and antiproliferative responses, all of which contribute to lowering blood pressure and blood volume. ANP and BNP bind to guanylyl cyclase ‐A/natriuretic peptide receptor ‐A (GC‐A/NPRA), which is considered to be the major natriuretic peptide receptor that synthesizes the intracellular second messenger cGMP. The objective of the present study was to examine the effect of Npr1 (coding for NPRA) gene‐disruption on the process of endothelial cell dysfunction in the development of hypertension and cardiac hypertrophy. We used six‐month old mice having different copies of Npr1 gene (0‐copy, 1‐copy, and 2‐copy). The blood pressure and echocardiographic measurements were performed in each group. Blood was collected by direct cardiac puncture and cardiac tissues were harvested and snap frozen in liquid nitrogen. The 0‐copy (Npr1−/−) mice showed 35–45 mmHg higher systolic blood pressure (SBP) as compared to 2‐copy (Npr1+/+) mice. Echocardiographic measurements of Npr1 gene‐disrupted 1‐copy (Npr1+/−) and 0‐copy mice showed significant increased LVEDD (27% in 0‐copy and 10% in 1‐copy mice), intraventricular septal wall thickness (IVSTDD, 30% in 0‐copy and 15% in 1‐copy mice), and reduced fractional shortening by 24% in 0‐copy and 12% in 1‐copy mice as compared with control mice. There was also a significant increase in plasma levels of plasminogen activator inhibitor‐1 (PAI‐1; 2.2‐fold), soluble intracellular adhesion molecule (sICAM; 1.8‐fold), soluble vascular cell adhesion molecule (sVCAM; 30%). In the present study, increased plasma levels of sICAM, sVCAM, and PAI‐1 suggested the involvement of endothelial cell dysfunction in producing cardiac hypertrophy in Npr1 null mutant mice. Our results implicate that ANP/NPRA signaling promotes inhibitory effect on the agents, which cause endothelial dysfunction in the heart leading to cardiac hypertrophy and cardiac remodeling.Support or Funding InformationThis work was supported by NIH grant (HL062147).

Chronic effects of methamidophos, endosulfan and carbamate pollutants on multi‐organic uptake of Gallium‐67 citrate in mice

Organic‐persistent pollutants (POP’s, e.g., herbicides, pesticides) are chemicals used in multiple sectors of daily life. However, chronic overexposure of these endocrine disruptors represents a severe problem in public health worldwide since it is a risk factor for inflammation linked diseases. In nuclear medicine, 67Ga‐Ci is a radiopharmaceutical used for scanning deep neoplastic or inflammatory lesions difficult to diagnose.ObjectiveEvaluate the multi‐organic uptake of 67Ga‐Ci as a possible inflammatory biomarker in POP’s exposure.MethodsThe study used four CD1 male mice groups (n=4; 10 wk‐age); I‐control (CT); and animals that received daily low lethal doses of pollutants for 30d orally; II‐methamidophos (organophosphate compound) (M) (1 mg/kg/d); II‐endosulfan (organochlorine compound) (E) (1 mg/kg/d); and III‐carbamate (C) (10 mg/kg/d). At the end of the study, 180.3±15.1 micro‐Curies (μCi) of 67Ga‐Ci were injected into each mouse intraperitoneally. 24 hr. Later were sacrificed; blood was obtained by direct cardiac puncture. The organs were removed, washed, weighed, and placed in tubes for radioactivity quantification in a Counter Well. The absorption (counts per minute) of 67Ga‐Ci was corrected by physical decomposition (decrease in radioactivity concerning time). Absorption was normalized by organs mass (g) and total activity administered in (μCi) to obtain % absorption activity [(μCi/g)/μCi‐adm].ResultsRegarding control (CT), the compartments with significant increase of 67Ga‐Ci uptake or similar trend were: Blood (CT) 0.3±0.002 vs. (M) 0.08±0.01*, (C) 0.057±0.01, (E) 0.06±0.01; Heart (CT) 0.053±0.01 vs. (M) 0.1±0.02*, (C) 0.09±0.01, (E) 0.1±0.013; and Kidney (CT) 0.19±0.02 vs. (M) 0.25±0.068, (C) 0.22±0.014, (E) 0.2±0.001. Contrary, the organs that presented less 67Ga‐Ci uptake were: Liver (CT) 0.08±0.008 vs.(M) 0.06±0.007, (C) 0.06±0.009, (E) 0.047±0.009*; Lung (CT) 0.314±0.08 vs. (M) 0.178±0.022*, (C) 0.151±0.012*, (E) 0.183±0.03*; Pancreas (CT) 0.067±0.044 vs. (M) 0.23±0.06*, (C) 0.234±0.015*, (E) 0.36±0.02*; Gonads (CT) 0.38±0.03* vs. (M) 0.135±0.017*, (C) 0.113±0.01*, (E) 0.1±0.001*; and Spleen (CT) 1.12±0.07 vs. (M) 1.01±0.046, (C) 0.306±0.04*, (E) 0.48±004*. 67Ga‐Ci is an iron analog; therefore, the increase‐decrease could indicate that the inflammatory processes or the metabolic iron behavior may not coincide. In this study, the increase of 67Ga‐Ci uptake could indicate specific organ inflammation or greater iron requirements due to a severe deficiency; contrary, the decreased uptake could be the result of the anti‐inflammatory response, tissue iron overload or alterations in it is transport mechanisms. The chronic dose‐dependent effects of POP’s may have divergent responses respect to 67Ga‐Ci utility since chronic inflammatory processes could cause iron deficiency. Additional biochemical and molecular studies are required to determine if both responses are consistent.Support or Funding Informationcollaborative funding

Effects of Acute SGLT2 Blockade and Dietary NaCl on Glomerular Hemodynamics in Diabetic Rats

Inhibitors of the main proximal tubular Na‐glucose cotransporter (SGLT2) mitigate diabetic glomerular hyperfiltration and are approved by FDA for slowing the progression of diabetic kidney disease. It has been proposed that SGLT2 inhibitors improve hard renal outcomes by reducing the glomerular capillary pressure gradient (ΔP) through TGF signaling, which begins with a decrease in fluid reabsorption by the proximal tubule (Jprox). However, the effect of SGLT2 inhibition on ΔP has not been measured up to now.We studied effects of acute SGLT2 blockade (ertugliflozin) on Jprox and glomerular hemodynamics by 2‐period micropuncture in STZ‐diabetic rats fed high or low NaCl diets (HS/LS). ΔP was measured by direct capillary puncture in Wistar Froemter rats (MWF), which have surface glomeruli suitable for this purpose. ΔP was computed from tubular stop‐flow pressure in Wistar rats (Wis), which lack surface glomeruli. Hence, TGF was allowed to operate normally while measuring ΔP in MWF but rendered inoperative while measuring ΔP in Wis. SGLT2 blockade was confirmed to reduce Jprox by collecting fluid from late proximal tubules for volume and inulin clearance.Summary and Conclusions about the diabetic kidney under conditions of moderate hyperglycemia: SGLT2 blockade acutely reduces Jprox, which leads to a decrease in glomerular capillary pressure, but only when TGF is permitted to operate normally. Baseline glomerular capillary pressure varies inversely with dietary NaCl and the impact of SGLT2 blockade applies across a wide range of dietary NaCl.Support or Funding InformationNIDDK RO1 DK112042 Merck Group (n) Glucose (mg/dl) GFR(ml/min) ΔP (mmHg) Jprox' (nl/min) control SGLT2 blocked control SGLT2 blocked control SGLT2 blocked MWF LS (6) 344±41 4.2±0.5 3.5±0.5 * 41.2±1.5 33.0±1.9 * MWF HS (8) 408±35 4.1±0.3 3.3±0.4 * 36.6±1.3 ** 32.4±1.6 * Wis LS (6) 355±41 4.8±0.4 3.8±0.5 * 43.6±1.9 43.7±2.4 18.9±1.3 10.2±1.1 * Wis HS (9) 400±52 4.5±0.5 3.8±0.6 * 32.6±2.3 ** 35.7±3.0 18.1±1.3 12.6±1.1 * *P<0.01 vs control period. **P<0.01 vs LS. Jprox’ is Jprox adjusted for single nephron GFR by ANCOVA to obtain the "primary" effect of SGLT2 blockade on the tubule.

Preoperative Squid embolization of carotid paragangliomas with direct puncture.

Preoperative embolization of carotid paragangliomas is a common procedure in interventional neuroradiology. Direct puncture embolization has shown less morbidity and mortality than endovascular embolization and a higher percentage of devascularization. We describe our experience using Squid® as the only embolic agent in direct puncture glomus embolization. We retrospectively reviewed pre-embolization imaging tests, emphasizing the volume of the lesion, clinical history data, technical aspects of the procedure, as well as the approximate amount of blood lost during the surgical procedure in all patients with preoperative embolization of carotid paragangliomas performed at our tertiary care hospital. Six patients met our criteria from May 2017 to August 2018. The volume of the mass ranged from 1.4-18.5 mL and the quantity of Squid® injected varied from 1.1-15 mL. Total devascularization was achieved in almost all cases (>90%), with one puncture needed in all but one patient, who was punctured two times. No hemorrhagic complications were described in surgery, no blood transfusions were needed, and the mean decrease of hemoglobin after surgery was 1.04 g/dL. Direct puncture embolization of carotid paragangliomas only using Squid® is a safe and relatively simple procedure that facilitates the subsequent surgery with minimal blood loss.

Safety and efficacy of plasma exchange via direct femoral vein puncture in autoimmune blistering diseases.

Plasma exchange (PE) is performed for patients with autoimmune blistering diseases by using multiple vascular access routes. We retrospectively examined the safety and the efficacy of PE using direct femoral vein puncture (FVP) technique, by comparing with that using double-lumen catheter (DLC). The troubles related to vascular route, such as catheter occlusion, insufficient blood flow and hematoma, were not different between the FVP group (4.6%) and the DLC group (6.7%), whereas access-related infections occurred more frequently in the DLC group (6.7%) than the FVP group (0.4%). Regarding the efficacy, the removal rate of autoantibodies in PE using the FVP technique was similar or lower, as compared with that using the DLC. These results suggest that PE with the FVP technique is able to be performed safely in patients with autoimmune blistering diseases, although the removal of autoantibodies is not superior to that using the DLC.

Giant Serpentine Internal Carotid Artery Aneurysm with Complex Aortic and Supra-aortic Vascular Anatomy: Endovascular Treatment through Direct Percutaneous Carotid Puncture

AbstractGiant serpentine aneurysm (GSA) with rare aortic and supra-aortic vascular anomaly is technically difficult to treat. Often such patients suffer without treatment. We have treated a patient by a different approach which is not regularly followed. This case has many developmental anomalies with complicated anatomy, and it is a challenge to the treating interventionist.

Direct Puncture Tunnel Method for Establishing the Retroperitoneal Cavity: Anatomic Confirmation and Clinical Experience.

Purpose: The feasibility and safety of the direct puncture tunnel method to establish the retroperitoneal cavity was assessed by CT and clinical experience. Materials and Methods: Ten patients who underwent retroperitoneoscopic procedure were scanned by CT in the lateral decubitus position. The distance between the lumbar fascia and psoas major muscle (L-P distance) on the puncture line was measured. The angle between the puncture line and the posterior colon margin (P-C angle) was also measured. In total, 292 patients who underwent retroperitoneoscopic procedure were used to establish the retroperitoneal cavity using the direct puncture tunnel method, and complications in these patients were evaluated. Results: The average L-P distance was 25.0 mm (left side) and 25.5 mm (right side) in the lateral decubitus position. The average P-C angle was 26.8° (left side) and 29.7° (right side). The retroperitoneal cavity was well established in all 292 patients, and no visceral or blood vessel injury occurred. Conclusions: CT scans in the lateral recumbent position indicate that there are no visceral and large blood vessels on the puncture path. The scans also provide a window for inserting the first trocar blindly into the retroperitoneum. A high success rate and low complication rate were observed clinically for the direct puncture tunnel method. We consider the direct puncture tunnel method to be a simple, effective, and safe way to establish the retroperitoneal cavity.

3:45 PM Abstract No. 151 Factors affecting adverse events in percutaneous lung biopsy for lesions contacting to pleura

To retrospectively evaluate factors affecting adverse events in percutaneous lung biopsy for lesions contacting to pleura. From August 2016 to July 2019, 132 consecutive patients with lung tumors measuring 0.6 to 15.0 cm (median, 3.1 cm) and contacting to the pleura underwent percutaneous needle biopsy. There were 87 males and 45 females with their median age of 73-years-old (range, 32–91 years-old). Biopsy was performed under CT fluoroscopic guidance using an 18-gauge end-cut needle. Factors affecting adverse events (AEs) were evaluated by uni- and multivariate analysis including variables such as patient demography, tumor backgrounds, emphysema, puncture number, and needle trajectory (trans-lung or direct puncture). Diagnosis was malignant in 104 patients (78.8%), and benign in 28 patients (21.2%). As a major AEs, pneumothorax requiring chest tube placement developed in 5 patients (3.8%, 5/132), and bacterial or tumor pleural dissemination in 6 patients (2 mycobacterial tuberculosis and 4 carcinoma dissemination) (4.3%, 6/132). Bacterial dissemination developed until 2 weeks after biopsy, and tumor dissemination until 7.9 months (median, 6.2 months). Trans-lung approach was found to be a significant factor for the former AE in both uni- (P = 0.004) and multivariate analysis (P = 0.004). Although there was no significant statistic difference found, the latter AE was only found in patients with direct puncture biopsy {7.0%, 6/86, P = 0.09 as compared with patients with trans-lung biopsy (0%, 0/46)}. Although direct puncture of the target lesion significantly reduces the major pneumothorax rate, it might be associated with a higher risk of tumor or bacterial pleural dissemination in lung lesions contacting to the pleura.

Abstract No. 682 Updates for extremity arteriovenous malformations involving the bone: approach for embolization and its therapeutic outcomes

To evaluate long-term data of the therapeutic outcomes, complications of embolotherapy retrospectively and establish therapeutic approach of embolotherapy of extremity arteriovenous malformations (AVMs) involving the bone. From December 1996 to July 2019, 36 patients (18 male, 18 female; mean age 25.1; age range, 1–64 years) with extremity AVMs involving the bone underwent staged embolotherapy using ethanol, coils and NBCA (n-butyl cyanoacrylate). Nineteen patients had pure bone AVMs and 17 had mixed bone and soft-tissue AVMs. Embolotherapy was performed by direct puncture, transvenous, and intraarterial approach (range, 1–18 procedures; mean, 4.9 procedures). Therapeutic outcomes were established by evaluation of the clinical response of symptoms and signs, as well as the degree of devascularization at follow-up angiography or computed tomography. Major and minor complications were also investigated during the follow-up at vascular malformation clinic. The clinical success (combined cure and markedly improvement outcomes) rate of embolotherapy of pure bone AVM was significantly better than that of mixed bone and soft tissue AVM (84.2% vs. 17.6%, P <0.001). Complete devascularization rate of bone AVM component of mixed bone and soft tissue AVM was 70.6%, but cure rate of mixed bone and soft tissue AVM was 0% because of skin and subcutaneous involvement of AVM. Twelve patients (11 minor; skin and transient peripheral nerve injury, 1 major; longstanding nerve palsy) experienced complications. The difference of complication rate between pure bone AVM and mixed bone and soft tissue AVM was not statistically significant (42.1% vs. 23.5%, P = 0.409). Embolotherapy of extremity AVMs involving the bone is effective and safe treatment to eliminate or improve symptoms with long-term follow-up data, especially in pure bone AVM.

3:09 PM Abstract No. 183 Let’s get straight to the point: direct sac puncture for type II endoleak embolization is technically superior to endovascular management

3:09 PM Abstract No. 183 Let’s get straight to the point: direct sac puncture for type II endoleak embolization is technically superior to endovascular management

Abstract No. 723 Direct gastric puncture using fluoroscopy or cone-beam computed tomography for insufflation prior to gastrostomy tube placement: An alternative approach in patients unable to tolerate nasogastric intubation

Abstract No. 723 Direct gastric puncture using fluoroscopy or cone-beam computed tomography for insufflation prior to gastrostomy tube placement: An alternative approach in patients unable to tolerate nasogastric intubation

3:54 PM Abstract No. 253 Single transplant center’s experience with transjugular intrahepatic portosystemic shunt creation in patients with portal venous thrombosis

To characterize the creation of TIPS in patients with difficult anatomy due to portal venous thrombosis including indications for TIPS, technical feasibility, and adjunctive techniques. An internal database at a single transplant institution was queried for all patients with primary TIPS creation between January 2014 and June 2019. This patient list was then filtered for patients with presence of portal venous thrombosis demonstrated on cross-sectional imaging prior to TIPS creation. The charts of these patients were searched for preprocedural patient characteristics including etiology of portal venous thrombosis, indications for TIPS creation, procedural details including use of adjunct techniques, and technical success of TIPS creation. A total of 89 patients were identified in our retrospective review. Patients ranged in age from 12 years to 89 years. The top 3 locations for venous thrombosis in patients were the main portal vein (58%), superior mesenteric vein (52%), and splenic vein (21%). 25 patients had occlusive thrombosis of the portal system with cavernous transformation. Etiology of portal system thrombosis was most often secondary to NASH cirrhosis (25%), alcoholic cirrhosis (16%), and HCV cirrhosis (15%). The most common indications for TIPS placement were refractory thrombosis (37%), refractory ascites (33%), and recurrent upper GI bleeding (16%). 79 patients underwent technically successful TIPS creations (89%); of these 79 cases, 13 cases required splenic venous access via direct transsplenic needle puncture, 11 cases utilized the “Gunsight” technique for TIPS creation. Average fluoroscopic time for TIPS creation was 42.3 minutes. 19 patients in this study received liver transplantation following the successful placement of a TIPS. Portal venous thrombosis may present a technical anatomic challenge in patients presenting for TIPS creation. Use of intraprocedural adjunct techniques such as splenic access or gunsight technique can help increase technical success of TIPS creation in this patient population to treat a variety of symptoms secondary to portal hypertension and portal venous clot burden.

EUS-guided choledochoduodenostomy by use of electrocautery-enhanced lumen-apposing metal stents: a French multicenter study after implementation of the technique (with video)

EUS-guided biliary drainage is indicated in cases of impossibility or failure of classic biliary drainage by ERCP. Recently we reported good efficiency of EUS-guided choledochoduodenostomy (EUS-CDS) using the electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) in a retrospective multicenter study. Use of the recommended technique (direct puncture with the ECE-LAMS with use of a pure cut current and a 6-mm stent) was the only predictive factor of clinical success. We re-evaluated this procedure after 1 year in the same centers. This was a French retrospective multicenter study of a prospective database including all cases of EUS-guided CDS with ECE-LAMS in the 7 centers that participated in the first study. Seventy consecutive patients were included in this study between September 1, 2017, and September 22, 2018. Failure of primary ERCP was due to duodenal stenosis in 44% of cases and to tumoral infiltration of the papilla in 22% of cases. The mean duration of the procedure was 5 ± 3 minutes. The recommended technique was used in 98.5% of cases. The technical and clinical success rates were both 97.1% (69/70). Short-term adverse events (periprocedural and intrahospital) occurred in 1.6%. EUS-CDS with the ECE-LAMS is efficacious and safe in distal malignant obstruction of the common bile duct in cases of ERCP failure with impressive results once expertise is acquired and the recommended technique (direct fistulotomy, pure cut current, and 6-mm stent) is followed.

Cookie cutter technique for percutaneous direct puncture glue embolization of high-flow craniofacial arteriovenous malformations

BackgroundDirect puncture embolization with glue is an effective technique for pre-operative devascularization of craniofacial arteriovenous malformations. Venous outflow and arterial inflow of the lesion need to be limited during injection of embolic material. Manual compression is the standard procedure for flow reduction, but when an AVM has multiple channels of venous drainage, achieving successful blockage of blood is technically difficult. This study demonstrates the use of a circumferential cookie cutter ring to reduce flow, with better results compared to manual compression. Design and methodsThis is a retrospective study of ten patients, over a period of two years, with craniofacial arteriovenous malformations who were treated with direct percutaneous injection of glue. Pre-embolization angiography was performed to see arterial feeders and venous draining veins. Adjunctive maneuvers were used during embolization, including external compression of venous pouch with circular cookie cutter rings of different sizes varying based on lesion size. Glue cast was localized within and around the margins of circular cookie cutter ring without any distal migration. ResultsNo neurological complications secondary to the embolization procedure were observed. The arteriovenous shunts were successfully occluded in all cases. There was partial occlusion in two cases. Total occlusion achieved in five cases when embolization was followed by surgery. Only one case required a second session to achieve total occlusion. Post embolization, there was minimal residual flow in one patient, who declined further treatment due to mitigation of symptoms. The shape of glue cast was changed in two cases after removal of cookie cutter when low concentrated glue was used. No skin necrosis was seen post embolization. ConclusionsPercutaneous direct puncture embolization with glue saves time and is a safer method for superficial craniofacial AVMs with prominent venous pouch when external compression was applied with circumferential cookie cutters to reduce venous outflow.

Why we fail: mechanisms and co-factors of unsuccessful thrombectomy in acute ischemic stroke

PurposeMechanical thrombectomy (MT) is an effective treatment for patients suffering from acute ischemic stroke. However, recanalization fails in about 16.5% of interventions. We report our experience with unsuccessful MT and analyze technical reasons plus patient-related parameters for failure.MethodsFive hundred ninety-six patients with acute ischemic stroke in the anterior circulation and intention to perform MT with an aspiration catheter and/or stent retriever were analyzed. Failure was defined as 0, 1, or 2a on the mTICI scale. Patients with failing MT were analyzed for interventional progress and compared to patients with successful intervention, whereby parameters included demographics, medical history, stroke presentation, and treatment.ResultsOne hundred of the 596 (16.8%) interventions failed. In 20 cases, thrombus could not be accessed or passed with the device. Peripheral arterial occlusive disease is common in those patients. In 80 patients, true stent retriever failure occurred. In this group, coagulation disorders are associated with poor results, whereas atrial fibrillation is associated with success.The administration of intravenous thrombolysis and intake of nitric oxide donors are associated with recanalization success. Intervention duration was significantly longer in the failing group.ConclusionIn 20% of failing MT, thrombus cannot be reached/passed. Direct carotid puncture or surgical arterial access could be considered in these cases.In 80% of failing interventions, thrombus can be passed with the device, but the occluded vessel cannot be recanalized. Rescue techniques can be an option. Development of new devices and techniques is necessary to improve recanalization rates. Assessment of pre-existing illness could sensitize for occurring complications.

Protective effects of thymoquinone and diallyl sulphide against malathion-induced toxicity in rats.

Malathion is a potent organophosphate insecticide that inhibits acetylcholinesterase (AChE) enzyme. Our experimental objective was to investigate the beneficial effects of diallyl sulphide (DAS) and thymoquinone (TQ) against malathion-induced oxidative stress in rat cerebral, hepatic, and renal tissues. For 30days, rats received corn oil alone (negative control) or malathion by intragastric gavage (200mg/kg daily), either alone (positive control) or combined with oral DAS (200mg/kg daily) or TQ (10mg/kg daily) (treatment groups). Later, blood samples were collected via direct cardiac puncture and tissue samples were obtained for biochemical analysis. Malathion administration was associated with significant increases (p < 0.05) in the serum levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, lactate dehydrogenase, γ-glutamyl transferase, cholesterol, urea, creatinine, and 8-OHdG (DNA damage biomarker), as well as significant (p < 0.05) decreases in theserum levels of total proteins, albumin, triglycerides, and AChE. Moreover, it significantly increased thetissue concentrations of malondialdehyde and nitric oxide and reduced tissue glutathione concentration and activities of antioxidant enzymes (glutathione peroxidase, superoxide dismutase, and catalase). Treatment of malathion-intoxicated rats with DAS or TQ significantly minimized these biochemical and oxidative effects with more frequent reversal to normal ranges of serum biomarkers, tissue oxidative markers, and antioxidant enzymes in the TQ group. In conclusion, treatment with DAS or TQ ameliorated the biochemical and oxidative effects of malathion, probably through reducing the generation of reactive oxygen and nitrogen radicals, as well as enhancing the antioxidant defense mechanisms.

A Canine Model for Lymphangiography and Thoracic Duct Access.

ObjectiveTo evaluate the technical feasibility of intranodal lymphangiography and thoracic duct (TD) access in a canine model.Materials and MethodsFive male mongrel dogs were studied. The dog was placed in the supine position, and the most prominent lymph node in the groin was accessed using a 26-gauge spinal needle under ultrasonography (US) guidance. If the cisterna chyli (CC) was not opacified by bilateral lymphangiography, the medial iliac lymph nodes were directly punctured and Lipiodol was injected. After opacification, the CC was directly punctured with a 22-gauge needle. A 0.018-in microguidewire was advanced through the CC and TD. A 4-Fr introducer and dilator were then advanced over the wire. The microguidewire was changed to a 0.035-in guidewire, and this was advanced into the left subclavian vein through the terminal valve of the TD. Retrograde TD access was performed using a snare kit.ResultsUS-guided lymphangiography (including intranodal injection of Lipiodol [Guerbet]) was successful in all five dogs. However, in three of the five dogs (60%), the medial iliac lymph nodes were not fully opacified due to overt Lipiodol extravasation at the initial injection site. In these dogs, contralateral superficial inguinal intranodal injection was performed. However, two of these three dogs subsequently underwent direct medial iliac lymph node puncture under fluoroscopy guidance to deliver additional Lipiodol into the lymphatic system. Transabdominal CC puncture and cannulation with a 4-Fr introducer was successful in all five dogs. Transvenous retrograde catheterization of the TD (performed using a snare kit) was also successful in all five dogs.ConclusionA canine model may be appropriate for intranodal lymphangiography and TD access. Most lymphatic intervention techniques can be performed in a canine using the same instruments that are employed in a clinical setting.