Guidewire Access Research Articles

Adjunctive Ultrasonography to Minimize Iodinated Contrast Administration During Carotid Artery Stenting:A Randomized Trial

To report a single-center, prospective randomized controlled trial that compared contrast use during ultrasound-assisted carotid artery stenting (CAS) to CAS procedures without ultrasound. Between August 2010 and November 2011, 22 patients (18 men; mean age 72.8 years, range 62-84) with 25 severe symptomatic (n=3) or asymptomatic (n=22) carotid stenoses undergoing an endovascular intervention were randomly allocated (~1.1) to ultrasonography-assisted (n=13) or stand-alone (n=12) CAS. The primary endpoints were contrast use and number of selective cerebral injections. Secondary endpoints were procedure time, fluoroscopy time, any stroke, renal function assessment, major adverse cardiac events (MACE), and death. In the study period, 23 of 25 scheduled CAS procedures (12 ultrasound-assisted, 11 control) were completed in 20 patients; 2 procedures were aborted owing to friable plaque and difficult guidewire access, respectively. There were no deaths, stroke, MACE, or precipitation of dialysis-dependent renal failure in either group. Iodinated contrast usage was reduced by 61% (45.4±24.4 vs. 17.8±11.9 mL, p=0.002) and number of selective cerebral contrast injections by 49% (8.3 vs. 4.2, p=0.002). Neither time taken to complete the procedure (32.5 vs. 35.4 minutes, p=0.38) nor fluoroscopy time (14.5 vs. 13.9 minutes, p=0.54) differed significantly between the groups. Creatinine levels remained stable after CAS and did not differ between groups. Ultrasonography-assisted CAS is feasible and safe. Its use can significantly lower the usage of iodinated contrast and the number of selective cerebral circulation injections while not prolonging the length of the procedure or the fluoroscopy time.

Use of fluoroscopically guided percutaneous antegrade urethral catheterization for the treatment of urethral obstruction in male cats: 9 cases (2000–2009)

To describe the technique and determine outcome for male cats with urethral obstruction treated with fluoroscopically guided percutaneous antegrade urethral catheterization (PAUC). Retrospective case series. 9 client-owned neutered male cats with urethral obstruction and inability to pass a retrograde urinary catheter. Information regarding the procedure and hospitalization was obtained from medical records. Long-term follow-up was obtained via medical record review or telephone interview. Diagnoses included iatrogenic urethral tear (n = 6), obstructive urethral calculi (1), urethral ulceration (1), and urethral stricture (1). Seven of the 9 procedures were successful. The 2 patients in which PAUC failed had mechanical obstructions preventing guide wire access across the urethral obstruction. Procedure times ranged from 25 to 120 minutes. No complications were noted in any patients during the procedure. One patient was euthanized because of unrelated disease. Follow-up information was available for 6 of 8 surviving patients. No complications that could be directly attributed to the procedure were noted. All 6 patients had a perineal urethrostomy performed 0 days to 6 weeks following the procedure because of reobstruction of the lower urinary tract. None of these patients had documented urethral strictures and none had recurrence of clinical signs following perineal urethrostomy. Results suggested that PAUC can be a simple, rapid, minimally invasive, and safe technique to facilitate transurethral catheterization in select cases. Patients with iatrogenic urethral tears may be good candidates. Patients with impacted urethral calculi, severe strictures or ulcerations, or a nondistended urinary bladder may be less amenable to PAUC.

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Use of indwelling, double-pigtail stents for treatment of malignant ureteral obstruction in dogs: 12 cases (2006–2009)

To determine the outcome of minimally invasive ureteral stent placement for dogs with malignant ureteral obstructions. DESIGN-Retrospective case series. 12 dogs (15 ureters) with ureteral obstruction secondary to a trigonal urothelial carcinoma. In all patients, indwelling, double-pigtail ureteral stents were placed by means of percutaneous antegrade needle and guide wire access under ultrasound and fluoroscopic guidance. Stents were successfully placed in all patients. In 11 of 12 patients, percutaneous antegrade access was accomplished. One patient required access via laparotomy because percutaneous access could not be achieved. The median survival time from the date of diagnosis was 285 days (range, 10 to 1,571 days), with a median survival time of 57 days (range, 7 to 337 days) from the date of stent placement. Three complications occurred in 1 patient. Seven patients required concurrent urethral stent placement for relief of urethral obstruction. All animals were discharged from the hospital (median hospitalization time after stent placement, 18 hours [range, 4 hours to 7 days]) with an indwelling, double-pigtail ureteral stent (3 bilateral and 9 unilateral) in place. All stents evaluated 0.25 to 11 months after placement were considered patent. Findings suggested that ureteral stent placement was safe, effective, and well tolerated in patients with malignant ureteral obstructions. Stents could be reliably placed in a minimally invasive manner and remain patent long-term. Ureteral stent placement should be considered as early as possible in patients with neoplasia, prior to the development of permanent renal damage.

Ongoing Challenges in the Endoscopic Management of Hilar Cholangiocarcinoma

The majority of patients with cholangiocarcinoma present with locally unresectable disease and the median survival with radiation and chemotherapy is 7–12 months. The endoscopic palliation of inoperable hilar cholangiocarcinoma remains one of the more challenging cases for the biliary endoscopist. The endoscopist must define the anatomy without injecting contrast into ducts that will not be drained, achieve guide-wire access for unilateral or bilateral stent placement and determine what type of stent—plastic or self-expanding metal (SEMS), will best serve the patient to relieve pain and jaundice and prevent cholangitis. Raju et al. [1] present a retrospective review of 100 patients who underwent endoscopic plastic or SEMS placement for inoperable hilar cholangiocarcinoma. Patients were regularly followed to death or reintervention, and stent patency and survival were examined. In 48 patients uncovered (as expected due to the hilar location of obstruction) SEMS were placed, with plastic stents (at least one of which was 10 French) in the other 52 patients. The Bismuth Classification of lesions was similar between the groups. There was however, a greater number of Type 3 and 4 cases that received plastic stents (73.1% vs. 56.3%), potentially favoring a better outcome with SEMS. The technical success rate was high in both groups (95.8% vs. 94.2%). Bilateral stenting was performed successfully in 20/23 plastic stent patients and 5/5 SEMS. The SEMS group demonstrated significantly better stent patency (5.56 vs. 1.86 months) and required fewer re-interventions for stent obstruction (1.53 vs. 4.6). The complication rate was similar in both groups (8.3% SEMS and 7.7% plastic) and there was a non-significant trend towards greater survival in the SEMS group (9.08 vs. 8.22 months). During the study time period, routine stent changes in patients with plastic stents were not performed; however, the median patency was only 1.5 months. No difference between the patency of straight and pigtail plastic stents was seen, nor was there a difference between unilateral and bilateral plastic stents or SEMS. All re-interventions were performed endoscopically, nine patients with plastic stents were converted to SEMS and plastic stents were placed within SEMS in four patients. The results of Raju et al. are similar to those of prior studies identifying less stent failure with the use of SEMS versus plastic stents for hilar tumors [2, 3]. There is scant information in the way of randomized comparisons between plastic and metal stents. A study by Wagner et al. [2] is the only prospective, randomized study. Twenty patients were randomized between metal stents placed percutaneously or endoscopic stents placed by a combination of endoscopic-percutaneous technique. Perdue et al. [3] reviewed a multicenter database of 62 consecutivelyreported endoscopically-placed metal or plastic stents for hilar obstruction. Outcomes in favor of metals stents were reported in both studies. The benefit of bilateral versus unilateral stenting continues to be debated [4, 5]. Injection of contrast into intrahepatic ducts which can not be adequately drained should be avoided as this is associated with worse outcomes [6]. MRCP has been advocated to assist in providing a guide to the ductal anatomy and formulating a plan for drainage [7]. Approximately one-fourth to one-third of the liver needs to be drained to relieve jaundice [8]. Raju et al. found no difference in patency between bilateral and unilateral stenting. H. R. Aslanian (&) P. A. Jamidar Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, CT, USA e-mail: harry.aslanian@yale.edu

Initial experience with remote magnetic navigation for left ventricular lead placement

Background — A novel magnetic navigation system allows remote steering of guidewires and catheters.This system may be used for left ventricular lead placement for cardiac resynchronization therapy (CRT).We sought to evaluate the feasibility and safety of magnetic guidewire navigation for CRT procedures.Methods — 123 consecutive patients underwent CRT implantation/revision procedures (including pacemaker upgrades in n = 22 and left ventricular lead placement after dislocation in n = 4 patients). Left ventricular lead placement in a coronary sinus side branch was performed either conventionally or using magnetic navigation. The magnetic navigation system (Niobe) consists of two permanent magnets creating a steerable magnetic field. Guidewires with integrated magnets align to the magnetic field and were used for over-the-wire implantation of pacemaker leads in the coronary sinus. Patients were assigned to conventional (n = 93) or magnetic (n = 30) navigation according to room availability.Venography of the coronary venous system was performed to select a target vessel for lead implantation.Results — Guidewire access to the target vessel was achieved in 100% using magnetic navigation compared to 87% with the conventional approach (P < 0.05). Implantation success rates, total procedure and fluoroscopy times did not differ significantly between groups. No periprocedural death and no intraoperative device dysfunction occurred in either group.The magnetic guidewire ruptured in one patient.Conclusion — Left ventricular lead placement using magnetic guidewire navigation to engage the desired coronary sinus side branch can be successfully performed for CRT.

A novel stenting technique for coronary artery bifurcation stenosis

A novel stenting technique, using one stent strategy, designed to treat type Medina 1,0,0 coronary bifurcation lesions, is described. The atherosclerotic plaque burden in this category of bifurcation lesions is located in the proximal segment of the main branch (MB) of a coronary bifurcation in which the side branch has a sharp angulation (T- or reverse-shaped) relative to the MB. The advantages of this technique are the accurate placement of the stent tailored to cover solely the bifurcation lesion, shoving the plaque burden away from the side branch ostium during stent expansion and the ability to maintain guide wire access in the branch at highest risk of occlusion obviating the need for more cumbersome and time consuming percutaneous coronary intervention procedure.

Successful recanalization of a chronic occluded left anterior descending coronary artery with a modification of the retrograde proximal true lumen puncture technique: The antegrade microcatheter probing technique

Chronic total occlusions (CTO) still remain one of the most technically challenging fields in interventional cardiology. Here we report a case of successful retrograde recanalization of an occluded proximal left anterior descending coronary artery with a modification of the "retrograde proximal true lumen puncture" technique. By combining this strategy with a novel antegrade guide wire access through a microcatheter which was placed into the antegrade guiding catheter with the "reverse anchoring balloon" technique (the "antegrade microcatheter probing" technique), the need for retrograde CTO lesion dilatations has been eliminated, making the procedure easier and faster. This modified retrograde approach might provide a feasible and safe technique for antegrade guide wire access during retrograde CTO recanalization.

Fully-Covered Self-Expandable Metallic Stents Facilitate Effective Endoscopic Pancreatic Necrosectomy

Background: Endoscopic necrosectomy of devitalized pancreatic tissue has been performed in selected patients with pancreatic necrosis. A limitation of endoscopic necrosectomy is not being able to remove sufficient necrotic retroperitoneal debris, which may be related to the size of the gastro-retroperitoneal (G-R) fistula. Prior reports have described the use of plastic pigtail stents to maintain the G-R track, necessitating subsequent dilation of the track before an endoscope can be passed. Using fully-covered self-expandable metallic stents (CSEMS) larger G-R tracks can be created and maintained. Methods: Patients with severe pancreatic necrosis that were referred to a tertiary-care center specialized in pancreatico-biliary disease were considered for endoscopic necrosectomy. Fluoroscopy and linear-EUS with color flow was used create a G-R fistula. After guidewire access and dilation of the G-R track, a CSEMS was deployed across the track. After maturation of the track, the CSEMS was removed and a therapeutic gastroscope was inserted into the retroperitoneum. Stone retrieval baskets, Roth nets, and cold snares were used to remove necrotic debris and devitalized pancreatic tissue. Results: Three male patients with severe pancreatic necrosis (ages 58, 60, 65) underwent endoscopic necrosectomy. Gallstones (n = 2) and a left-sided pancreatectomy for IPMN (n = 1) were the etiologies of necrotizing pancreatitis. The G-R track was stented with a Gore-Viabil CSEMS (10 × 60 mm or 10 × 100 mm) in two patients and with an Alimaxx-E CSEMS (22 × 70 mm) in one patient. CSEMS were left for a median of 45 days (range: 14-67 days) prior to stent removal and endoscopic necrosectomy. One patient with a 10 × 60 mm CSEMS had proximal stent migration into the stomach, requiring removal of the first stent and placement of a second 10 × 60 mm CSEMS 15 days later. That same patient also had significant bleeding from a pseudoaneurysm 34 days after deployment of the second CSEMS, which required embolization of the left GDA. All CSEMS were removed without complications. Follow-up CT imaging was available in two patients, which showed complete resolution of the necrotic retroperitoneal debris. Median duration of follow-up was 206 days (range: 14-232 days). In the patient with the 22 × 70 mm CSEMS, a 4-inch (10.0 × 3.5 × 2.0 cm), intact piece of devitalized pancreas was endoscopically removed from the retroperitoneum via the mouth without complications. Conclusions: The use of large-diameter CSEMS is effective in creating and maintaining G-R tracks for endoscopic pancreatic necrosectomy. CSEMS can be reliably removed and enable the debridement of large pieces of necrotic retroperitoneal tissue.

Intracystic wire exchange facilitating insertion of multiple stents during endoscopic drainage of pancreatic pseudocysts

Endoscopic drainage of pancreatic pseudocysts and abscesses has been shown to be an effective treatment modality. A major determinant for successful cyst resolution is the insertion of multiple endoprostheses and/or placement of a nasocystic drain, which require repeated entries of a catheter into the pseudocyst to reintroduce the guidewire. We describe a novel and easy technique to prevent the need for repeated access into the pseudocyst, thereby facilitating the placement of multiple endoprostheses by using a commercially available guiding system for stent introduction. Case series. Academic Medical Center, The Netherlands. Eight consecutive patients with symptomatic pancreatic pseudocysts after acute pancreatitis. Intracystic wire exchange for the insertion of multiple stents in endoscopic treatment of pancreatic pseudocysts by using an echoendoscope. Feasibility of intracystic wire exchange and complications. No guidewire access to the pseudocyst was lost. The procedure was well tolerated by the patients. Complete pseudocyst resolution was established in all patients. The endoscopic appliance of multiple stents becomes easier when using intracystic wire exchange for transgastric pancreatic pseudocyst drainage.

EUS-Guided Pancreatic and Biliary Ductal Drainage (EUS-PBD): a First Line Strategy After Unsuccessful ERCP Drainage

Background: Initial experience suggests that EUS-PBD holds promise. Aims & Methods: To assess the feasibility, technical requirements, safety and efficacy of EUS-BPD in pts with previously failed standard ERCP drainage. Between Nov03-Nov06, 58 pts out of 2514 consecutive ERCPs had failed biliary or pancreatic drainage (2.3%). The indication was revised in 17 cases and EUS-BPD considered for the remaining 41 (male/female: 26/15; age range: 36-91 yr). Indications, drainage techniques, technical & clinical success and complications were reviewed. Therapeutic EUS-scopes (Pentax 38-UX in 27 & Olympus GF-UCT160 in 14), EUS-FNA needles of 19 or 22 G (30/8) with .035" & .018" guidewires, and fluoroscopy were used. Trends over the 3-yr period were also analyzed. Results: Pancreatic ductal drainage was attempted in 4/41 (2 Whipple's, 2 chronic pancreatitis) and biliary drainage in 37 (12 malignant papillary involvement,11 contralateral duct access problems in hilar strictures, 8 prior Roux-en-Y & 6 miscellaneous), all but 4 with malignant obstructive jaundice (20 primary, 13 metastatic, 4 unknown). In 3/41 ductal puncture was precluded by lack of an obvious target, interposed vessels, ascites and/or scope instability. Ductography was obtained in 37/38 punctures (1 parenchymal injection), ductal guidewire access in 34, and stent placement in 30, 16 metal & 14 7F plastic stents. Thus, EUS-BPD was technically successful in 30/38 punctures (79%), 21 transmural (through the liver/bile-duct/pancreas = 16/4/1) & 9 transpapillary (rendezvous/antegrade = 6/3). Clinical success (resolution of jaundice or pain) was achieved in 22/30 (63%) and failed in 2, whereas the outcome could not be assessed in 6 pts with early deaths not procedure-related. There were 7/38 (18.4%) complications, 4 mild (bile leaks that settled in 3-7 days), and 3 severe (pseudocyst, biloma & hemoperitoneum, 1 death). Cumulative technical success/complications rates at 1,2 & 3 yrs were in% 50/38, 73/31 & 79/18.4 (p < 0.05). Qualitative aspects judged relevant for improved outcomes include: Video Vs Fiber EUS scopes, 19 Vs 22G needles, cautery Vs dilators for access, OTW protrected Vs freehand stent exchange. Conclusions: EUS-PBD is a demanding procedure, with a success rate of around 80%, and with a morbidity close to 20%. These results are less encouraging than previously reported. However they reflect a learning curve effect and initial equipment & device selection limitations with a strong time trend to be overcome. EUS-PBD currently offers unique advantages for selected patients, and may soon realize the expected advantages over PTC for the vast majority of patients with failed ERCP drainage.

Total Percutaneous Endovascular Repair of Abdominal Aortic Aneurysms Using Perclose ProGlide Closure Devices

To describe a technique for access site closure in percutaneous abdominal aortic aneurysm (AAA) repair using double Perclose ProGlide devices to overcome the problems associated with the bulky delivery system and braided suture of the antecedent (Prostar) device. After obtaining guidewire access, 2 Perclose ProGlide sutures are deployed at 90 degrees to each other. The appropriate sheaths are placed over the stiff guidewires. After the stent-graft procedure is completed, an assistant holds pressure while the knots are tightened with the stiff guidewire still in the artery. Once the second knot is tightened with the knot pusher and after confirming adequate hemostasis, the wire is removed, pressure is applied, and heparin reversed. This method has been used in 17 consecutive patients (age range 65-85 years) undergoing endovascular AAA repair. One patient needed patch angioplasty and 2 required small incisions for additional suture placements (81% primary success rate for total percutaneous repair, 90% success rate for all sites). We have found the double Perclose ProGlide technique to be easy to use, safe, and feasible for total percutaneous AAA repair. More experience with longer follow-up is needed to assess its potential to replace the Perclose Prostar closure device for total percutaneous AAA repairs.

Multicenter comparative trial of the V-scope system for therapeutic ERCP

A new duodenoscope (the V-scope), with a modified elevator used in combination with a dedicated short guide wire, constitutes the V-system. This system is intended to allow fixation of the guide wire at the elevator lever, thereby enhancing the speed and reliability of accessory exchange over a guide wire during ERCP. The aim of this study was to evaluate the extent to which the V-system provides improved efficiency in comparison with conventional duodenoscope and guide wire combinations. This was an industry-sponsored multicenter randomized trial. Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) procedures in which treatment was anticipated were randomly assigned to the V-system or to a conventional duodenoscope and accessories used routinely in each center. The parameters recorded included the total case time, fluoroscopy time, catheter/guide wire exchange time, guide wire repositioning, loss of guide wire access, and success or failure of guide wire fixation when using the V-system. Fifty patients were included, 22 in the conventional group and 28 in the V-system group. A total of 135 exchanges were carried out. The patients had up to six exchanges. The median exchange time was 19.4 s with the V-system and 31.7 s with the conventional systems ( P < 0.001). Guide wire repositioning was required less often in the V-system group ( P = 0.0005). The V-system effectively locked the guide wire in 63 of 71 exchanges (89 %). Loss of guide wire access occurred in two patients in the conventional group and four in the V-system group, attributable to failure to lock the guide wire early during the experience (no significant differences). The V-system can effectively secure the guide wire during accessory exchange in ERCP and reduces the time required to exchange accessories. This may enhance overall efficiency during ERCP.

Comparison of Results of Virtual-Reality Simulator and Training Model for Basic Ureteroscopy Training

The traditional method of acquiring surgical skills is by apprenticeship and involves an extensive period of training with patients. Model-based and virtual reality simulation is gaining interest as alternative training, allowing repetitive practice in a low-risk environment. The objective of this study was to determine if a materials, model-based training format and an interactive virtual-reality simulator could provide equivalent teaching of basic ureteroscopy skills to the inexperienced medical student. Sixteen first-year medical students received the same didactic session and video viewing on cystoscopy, guidewire access to the upper urinary tract, and ureteroscopy with intracorporeal laser lithotripsy and stone extraction by the same instructor. The participants were then randomized into two study groups: Group 1 was trained on the ureteroscopy training model (TMU) from Limbs & Things and Group 2 on the Simbionix UROMentor virtual-reality simulator (VRS) until the participants could perform the procedure independently. Two months later, the participants independently performed a ureteroscopic procedure on a pig kidney/ureter model and were graded from 1 to 5 on their ability to complete the steps of the procedure and the quality of their performance (handling of tissue, efficiency, instrument handling, knowledge of instruments, flow of operation, use of assistants, and knowledge of the specific procedure) for a possible total of 35 points. All participants were able to perform the steps of the procedure correctly. The TMU group and the VRS group received a mean of 22.9 +/- 4.8 and 23.6 +/- 5.4 points, respectively (P = 0.38) for their qualitative assessment. The medical students' skills and ability to perform a basic ureteroscopic stone-management procedure was independent of the training modality (VRS or TMU). Incorporating either of these devices into the preliminary training of urology residents may improve their initial clinical performance of these skills.

Pre-arteriotomy Guidewire Access (PAGA): A Crucial Maneuver for Securing Inflow and/or Outflow in Patients with Bulky Iliofemoral Occlusive Disease Undergoing Combined (Open/Endovascular) Procedures

Purpose To present our technique of pre-arteriotomy guidewire access (PAGA). Summary Placement of a guidewire across inflow lesions before performing the arteriotomy during combined endovascular/open procedures while treating patients with complex iliofemoral occlusive disease is a crucial maneouvre. We routinely utilize this approach in patients in whom endarterectomy and/or patch angioplasty is planned as the central part of the revascularization procedure, or when we find an unsuspected severely diseased EIA in a patient undergoing leg revascularization.

Endoscopic Stricturoplasty (ES) of Hepaticojejunostomy Anastomotic Strictures (HAS): A Novel and Effective ERCP Technique

Endoscopic Stricturoplasty (ES) of Hepaticojejunostomy Anastomotic Strictures (HAS): A Novel and Effective ERCP Technique Simon K. Lo, Shahab Mehdizadeh, Gary C. Chen HAS are difficult to treat endoscopically, surgically or transhepatically with a high recurrence rate. Technical failure and treatment complications are common. Aim: To assess the therapeutic efficacy of a new ES technique in the management of HAS. Methods: Retrospective review of ERCP for presumed or confirmed HAS. A pediatric variable stiffness colonoscope or push enteroscope was used except in post-Whipple cases where a therapeutic duodenoscope was favored. SKL introduced the method of ES in 1998 and performed all the procedures. When technically feasible, a guidewire was used to pass a standard sphincterotome to perform ES. Needle knife was used when guidewire access failed. Cutting was done in a 4-quadrant fashion for 4–5 mm each. Balloon dilation was then done with an 8 mm balloon. Stenting was not routinely carried out. Results: Data of 18 patients (mean 51 y.o., range 19–78) suspected of HAS was reviewed. Presentations: cholangitis (50%), abdominal pain (39%), itching (44%), abnormal liver enzymes (89%). Three groups of patients were identified: hepatojejunostomy for lap chole injuries (nZ10), Whipple’s (nZ4), and liver transplantation (nZ4). Symptom duration prior to treatment ranged from 1 month to 10 years (median 6 months). The bilioenteric anastamosis could not be reached in 4 (22%) patients. The remaining 14 patient underwent 18 ERCPs and all had technically successful ES. Needle knife was used in 4 patients. Five early cases included stent placement after sphincterotomy. Stone extraction was performed on 6 patients. 3 patients experienced 4 complications including 2 post-sphincterotomy bleeding (1-self limited; 1-treated endoscopically) and 2 cases of self-limited retroperitoneal air leak. The median follow up period was 15 months (range 0–50 months). Two patients had recurrences or did not improve despite ES and were referred for surgical therapy. Nine had successful ES without need for additional interventions in 20 months (range 4–50 months). 44% (8/18) of all patients remained asymptomatic at last follow up. Conclusions: ES is a novel technique to treat HAS. It is a single-session treatment and it does not require stenting that would mandate repeated procedures. Acquiring the skill is difficult as its prerequisite is successful passage through the long, tortuous afferent jejunal limb. It is reasonably safe and about half of the patients in this study enjoyed long term symptom-free living. T1284 Is Malnutrition a Cause of Post ERCP Cholangitis? Mohandas K. Mallath, Vivek Hande, Mrunal Shirodkar, Shaehta Mehta Background: Cholangitis is a serious complication of endoscopic biliary drainage. Malnutrition predisposes to infection in many clinical settings. This study was done to test a hypothesis that patients with malignant obstructive jaundice (MOJ) develop progressive malnutrition, which predisposes them for ERCP induced cholangitis. Methods: A prospective observational study design was used in the setting of a tertiary cancer center. Consecutive patients with MOJ undergoing endoscopic biliary drainage were eligible. Patients with cholangitis at presentation and those who had undergone ERCP, PTBD or biliary surgery were excluded. All patients were screened for malnutrition 1-2 days before the ERCP using subjective global assessment (SGA). Explanatory variables included bilirubin, albumin, anemia, leucocytosis, coagulopathy, and co-morbid diseases. All patients received antibiotic prophylaxis before ERCP. Other variables included duration of ERCP, proximal biliary obstruction, multiple instrumentation during ERCP, inadequate biliary drainage and type of biliary stent. All patients were followed up for 2 weeks for the development of cholangitis. Cholangitis was defined as the development of fever O100 F for more than 12 hours after an ERCP. Results: 77 patients (45 females, 32 males) aged 27 to 78 years (mean 51 years) were included. The cancer sites included gall bladder (37), pancreas (17), bile duct (13) and others (10). The malnutrition grade were SGA-A (7%), SGA-B (53%) and SGA-C (40%). 25 patients had leucocytosis and 14 had coagulopathy. ERCP was successful in 95%. 4 patients underwent PTBD. 26 (33.8%) patients developed cholangitis. It was mild in 80% and treated with oral antibiotics. 6 needed prolonged hospitalization and 4 needed early stent exchange. One severely malnourished patient developed duodenal perforation, septicemia and died. The cholangitis rates in mild, moderate and severely malnourished patients were 0%, 16% and 51% respectively (p!0.0001). Univariate analysis identified 5 explanatory variables to be associated with cholangitis: leucocytosis, severe malnutrition, proximal biliary obstruction, passage of multiple instruments and the use of plastic stents over metal stents by univariate analysis. In multivariate model, cholangitis was associated with malnutrition (OR 3.5, 95%CI 1.1–11.0) and multiple biliary instrumentation (OR 3.3, 95%CI 1.03– 10.7). Conclusions: Malnutrition is an independent risk factor for ERCP.

Initial evaluation of a duodenoscope modified to allow guidewire fixation during ERCP

Catheter/guidewire exchanges during ERCP require the coordinated efforts of an endoscopist and endoscopy assistant. A prototype duodenoscope was developed to improve the control of catheter/guidewire exchange by enabling fixation of guidewires at the elevator lever. An initial prototype duodenoscope and a subsequent modification of this instrument were used to perform ERCP in 7 and 10 patients, respectively. The following were recorded: total procedure time, fluoroscopy time, catheter/guidewire exchange time, guidewire repositioning, loss of guidewire access, success or failure of fixation, and endoscopist satisfaction. The initial and the modified prototype duodenoscopes were used in a variety of catheter/guidewire exchanges (n=46). Guidewire fixation was achieved in 75% of catheter/guidewire exchanges with the initial prototype and in 93% with the modified prototype and was reflected in shorter exchange times. Access to the desired duct was not lost during any exchange, and the need for repositioning was eliminated. A new prototype duodenoscope with an elevator lever that enables guidewire fixation will improve the ease and efficiency of catheter/guidewire exchange during ERCP. Modifications made to the original prototype improved reliability of guidewire fixation.

Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents

Background: Endoscopic management of malignant hilar biliary obstruction is controversial with respect to optimal types of stents and extent of drainage. This study evaluated outcomes of selective MRCP and CT-targeted drainage with self-expanding metallic stents. Methods: Consecutive patients undergoing attempted palliative ERCP for malignant hilar biliary obstruction were prospectively followed. Whenever possible, management strategy included evaluation and staging for potential resectability before ERCP, with primary placement of metallic stents at the first ERCP in nonsurgical candidates, and early conversion to a metallic stent when a tumor proved to be unresectable. MRCP and/or CT were used to plan selective guidewire access, opacification, and drainage only of the largest intercommunicating segmental ducts. Unilateral stent placement was intended in all cases except for selected patients with Bismuth II cholangiocarcinoma. Results: Thirty-five patients were included. Bismuth classification was I, 10; II, 6; III, 8; and IV, 11. Tumor origin was bile duct (17), gallbladder (5), and metastatic (13). Metallic stents were placed in 27 patients as the initial stent, and in 8 after plastic stent placement. Initial stents were placed endoscopically in 33 patients and percutaneously in 2 patients in whom lumenal tumor precluded ERCP. Stent placement was unilateral in 31 patients and bilateral in 4 patients. There were no episodes of cholangitis or other complications within 30 days after any procedures. Initial metallic stents were clinically effective in 27 (77%) of the 35 patients. Additional percutaneous drainage in 3 patients who did not respond to initial stent placement did not resolve jaundice. Median patency of first metallic stents was 8.9 months for patients with primary bile duct tumors and 5.4 months for all patients, and was not related to Bismuth classification. No further intervention was needed in 25 (71%) patients. Conclusions: Unilateral metallic stent placement by using MRCP and/or CT to selectively target drainage provides safe and effective palliation in most patients with malignant hilar biliary obstruction. (Gastrointest Endosc 2003;58:41-9.)

Entrapment of the Limb of an Endovascular Graft: A Peril of Saccular Aneurysms

Endoluminal repair of an infrarenal saccular aortic aneurysm was undertaken with a modular endovascular stent graft in a 74-year-old man. After deployment of the main body and right iliac limb of the graft, an attempt was made to gain guide wire access to the open short left limb of the graft for placement of the left iliac prosthesis. Attempts to gain access to the left limb graft from the left femoral artery area were unsuccessful. Since we were unable to pass the wire into the iliac system or snare it from below, can nulation from the left brachial artery was attempted. This resulted in the guide wire coiling up within the aneurysm. Eventual conversion to an open procedure confirmed that the short open left limb of the modular graft had deployed such that the opening was completely impacted against the inferior wall of the saccular aneurysm, preventing successful passage of a guide wire. The distance from the aortic neck to the base of the aneurysm is generally not considered an important parameter whe...

Directed balloon-assisted guidewire access into intrahepatic ducts

Directed balloon-assisted guidewire access into intrahepatic ducts