Interventional Radiology Approach Research Articles

Clinical spectrum, risk factors, management and outcome of patients with retroperitoneal hematoma: a retrospective analysis of 3-year experience

ABSTRACT Objective Retroperitoneal Hematoma (RPH) is an underdiagnosed and overlooked disease entity and has a high mortality rate if not diagnosed in a timely manner. This study aims to analyze the clinical characteristics, risk factors, treatment and the outcome of RPH cases at our medical center. Methods In this retrospective study, all cases who presented to the emergency room (ER) and/or admitted to our center with the diagnosis of RPH from Jan 2016 to Dec 2018 were included (3-year data). Results A total number of 78 RPH cases were included including both the traumatic and spontaneous bleed. The most common setting was spontaneous bleeding with no concurrent use of anti-thrombotic agents. Zone 3 (pelvic hematoma) bleed was the most common type of RPH. Most patients were successfully managed medically alone (59%). Others required surgical intervention, either laparoscopy, laparotomy or through the interventional radiological approach. There was a significant association between the need for vasopressors (OR-5.65, P-value of 0.039), spontaneous bleed (P-value of 0.001), bleed without antithrombotic agents (P-value of 0.002) with prolonged hospital stay (> 5 days). On follow-up, 83% of cases were reported to be alive. Only 2 patients died secondary to hemorrhagic shock. Conclusion Most cases of RPH had an excellent outcome with conservative management alone.

Interventional radiology approaches for intra-hepatic cholangiocarcinoma.

The use of loco-regional therapies for the management of patients with biliary tract cancer relies in addressing tumor growth and treat its local complications. This aims to reduce the risk of tumor-related liver failure, the most common cause of death among patients with intra-hepatic cholangiocarcinoma (ICC). Interventional radiology plays a critical role on the management of patients with ICC by providing loco- regional oncological, palliative, and bridging procedures for definitive therapy. In regards the oncological procedures offered by interventional radiology, current literature reports its main application for patients with ICC, with limited number of reports on the use of patients with extra-hepatic cholangiocarcinoma. In this review, we aim to provide a literature review on the use of interventional radiology procedures, specifically liver ablation, transarterial chemoembolization (TACE), and transarterial radioembolization (TARE) with Y90 for the loco-regional oncological treatment of patients with ICC. Finally, future directions on the role of such loco-regional oncological treatments offered by interventional radiology are discussed.

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.

IR-guided endoscopic pancreaticojejuostomy for post-whipple pancreaticocutaneous fistula

Presenter: Elliot Scott MD | Virginia Mason Medical Center Background: A 67yF presented with biliary obstruction and computed tomography (CT) suggested a distal bile duct tumor. She underwent an ERCP with brushings for stenting and to but unfortunately developed severe acute pancreatitis (SAP). Although technically resectable after complete staging without evidence of distant disease, she was not felt to be a surgical candidate and was referred for neoadjuvant chemotherapy while. Unfortunately, after one cycle of gemcitabine and cisplatin, her SAP progressed to walled-off necrosis (WOPN) requiring percutaneous and endoscopic drainage. Therefore, after a period of recovery, she was taken to the operating room for an attempt at curative resection. A pylorus-preserving pancreaticoduodenectomy (PD) was performed, however, the pancreas was scarred without a visible duct and adherent to a thrombosed splenic vein with sinistral portal hypertension form WOPN. Decision was made to suture the pancreatic remnant without an anastomosis. The patient did well until POD#4 when a CT performed for abdominal pain revealed a large fluid collection. This was drained percutaneously and was consistent with a pancreatic leak. The patient convalesced from her operation but was left with a pancreaticocutaneous fistula. Methods: Since transgastric internalization was not feasible post-PD, a combined interventional radiology (IR) and gastroenterology (GI) rendezvous approach was utilized. An endoscopic ultrasound (EUS) scope was passed into the afferent limb while a balloon catheter was passed through the drain tract. The balloon was visualized by EUS and punctured in order to grab an IR wire and pass it into the afferent jejunal limb. Two pigtail stents were then deployed in order to create a pancreaticojejunostomy (See Figure). Results: The patient did well post procedure and deemed ready for adjuvant therapy for her T2N1 distal cholangiocarcinoma. Conclusion: This challenging case highlights the multidisciplinary strategy required not only for optimal oncologic treatment of biliary tumors but also to manage the complications of therapy.

Malignant bowel obstruction.

Malignant bowel obstruction (MBO) is a common problem for patients with advanced malignancy, especially colorectal and ovarian cancers. Symptoms include pain, bloating, nausea and vomiting, and inability to eat. Treatment options consist of a wide range of surgical and nonsurgical interventions (medications, endoscopic, or interventional radiology approaches). Outcomes are variable no matter the strategy, and the optimal approach is often not clear. Greater research is needed to assist decision-making for clinicians treating patients with MBO.

Integrated CT-Fluoroscopy Equipment: Improving the Interventional Radiology Approach and Patient Experience for Treatment of Musculoskeletal Malignancies.

Integrated CT-fluoroscopy equipment augments the comprehensive approach to the treatment of musculoskeletal (MSK) malignancy by interventional radiology techniques. As the role of minimally invasive treatment expands to meet the highly variable presentation of MSK malignancy, creative solutions to treatment challenges are required to improve locoregional tumor control and durability of pain palliation. Challenges to effective treatment can often be attributed to a combination of aggressive tumor biology, large size, forbidding location, and adverse vascularity. In these cases, a tailored treatment approach may necessitate the application of multiple interventional radiology (IR) techniques that require different image guidance capabilities. Integrated CT-fluoroscopy equipment provides the means to leverage both imaging modalities within the same procedural setting to facilitate the simultaneous application of multiple synergistic treatments and protective measures. This article examines the potential role of hybrid units in the IR treatment of challenging MSK malignancies as a means to empower a paradigm transition for a more comprehensive and patient-tailored approach.

Algorithm for the multidisciplinary management of hemorrhage in EUS-guided drainage for pancreatic fluid collections.

Pancreatic fluid collections (PFCs), common sequelae of acute or chronic pancreatitis, are broadly classified as pancreatic pseudocysts or walled-off necrosis according to the revised Atlanta classification. Endoscopic ultrasound (EUS)-guided drainage is often considered a standard first-line therapy preferable to surgical or interventional radiology approaches for patients with symptomatic PFC. EUS-guided drainage is effective and successful; it has a technical success rate of 90%-100% and a clinical success rate of 85%-98%. Recent studies have shown a 5%-30% adverse events (AEs) rate for the procedure. The most common AEs include infection, hemorrhage, perforation and stent migration. Hemorrhage, a severe and sometimes deadly outcome, requires a well-organized and appropriate treatment strategy. However, few studies have reported the integrated management of hemorrhage during EUS-guided drainage of PFC. Establishing a practical therapeutic strategy is an essential and significant step in standardized management. The aim of this review is to describe the current situation of EUS-guided drainage of PFCs, including the etiology and treatment of procedure-related bleeding as well as current problems and future perspectives. We propose a novel and meaningful algorithm for systematically managing hemorrhage events. To our limited knowledge, a multidisciplinary algorithm for managing EUS-guided drainage for PFC-related bleeding has not been previously reported.

Multidisciplinary Management of Oligometastatic Soft Tissue Sarcoma

Soft tissue sarcomas (STS) encompass a group of rare but heterogeneous diseases. Nevertheless, many patients, particularly those with oligometastatic disease can benefit from thoughtful multimodality evaluation and treatment regardless of the STS subtype. Here, we review surgical, interventional radiology, radiation, and chemotherapy approaches to maximize disease palliation and improve survival, including occasionally long-term disease-free survival. Surgical resection can include lung or other visceral, soft tissue and bone metastases with a goal of rendering the patient disease free. Staged resections can be appropriate, and serial resection of oligometastatic recurrent disease can be appropriate. Retrospective series suggest survival benefit from this approach, although selection bias may contribute. Interventional radiology techniques such as percutaneous thermal ablation (PTA) and arterial embolization can present nonoperative local approaches in patients who are not medically fit for surgery, surgery is too morbid, or patients who decline surgery. Similarly, radiation therapy can be delivered safely to areas that are inaccessible surgically or would result in excessive morbidity. Currently no randomized trials exist comparing interventional radiologic approaches or radiation therapy to surgery but retrospective reviews show relatively similar magnitude of benefit in terms of disease palliation and survival, although it is felt unlikely that these procedures will render a patient to long-term disease-free status. Chemotherapy has evolved recently with the addition of several new treatment options, briefly reviewed here. Importantly, if a patient sustains a good response to chemotherapy resulting in true oligometastatic disease, consideration of multimodality local therapy approaches can be considered in the appropriate patient.

Hepatic cystic echinococcosis in Australia: an update on diagnosis and management.

Echinococcosis is an uncommonly encountered zoonotic disease caused by the taeniid Echinococcus. The only endemic species in Australia, Echinococcus granulosus, forms cysts in the liver in 70% of cases. The aim of this study was to review the literature to provide an evidence-based narrative update on the diagnosis and management of hepatic cystic echinococcosis in Australia. We reviewed the literature, utilizing multiple research databases and citation tracking. Original research and review articles examining the diagnosis and management of hydatid disease in adults, published prior to 2016 and in the English language were included in our review. Ultrasound is the gold-standard screening test, whilst computed tomography has a role in emergency presentations and screening for multi-organ involvement. Magnetic resonance imaging is the preferred second-line imaging and better demonstrates biliary involvement. Medical therapy or PAIR (percutaneous aspiration, irrigation with scolicide and re-aspiration) may be appropriate in selected cases; however, surgery remains the definitive treatment for active, large (>5 cm), symptomatic or complicated cysts. A variety of surgical techniques have been described, including conservative, radical and minimally invasive procedures. There is currently no consensus approach; surgical modality should be tailored to patient factors, relevant anatomy, local facilities and surgeons' expertise. Diagnosis and therapy in hepatic hydatid cysts have been significantly advanced by imaging, interventional radiology and surgical approaches in recent years. Surgery remains the mainstay of treatment for large, active, complicated or symptomatic hepatic hydatid cysts.

Advances in Endoscopic Procedures: Large Pancreatic Fluid Collection Drained Utilizing Endoscopic Cystgastrostomy

Recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) can result in the formation of fluid-filled pseudocysts communicating with the pancreas, a complication which occurs in 20-40% of patients. Advances in both interventional radiology and endoscopy have made it possible to perform therapeutic, non-invasive cystgastrostomy. We report a case of pancreatic pseudocyst treated endoscopically via cystgastrostomy with drainage of an extremely large amount of fluid. A 54-year-old alcoholic man with a recent hospitalization for acute pancreatitis presented to an outside facility after experiencing abdominal distention associated with generalized weakness for 2 weeks. Upon transfer to our institution for further management of a large fluid collection found on CT (> 22 cm), endoscopic ultrasound (EUS) showed it to be a large pseudocyst. Laboratory results were significant for a Hgb of 8.0 g/dL, MCV of 78 fL, INR of 1.4, and an albumin of 2.9 g/dL. Cystgastrostomy via EUS utilizing a lumen apposing metal stent drained 4.75 L of fluid. After a hospital course complicated by MRSA pneumonia, the patient was transferred to a long-term acute care facility. EGD with necrosectomy was performed 2 weeks later, but he was then hospitalized for continuing fevers, undergoing laparotomy with necrosectomy and closure of gastrostomy with drain placement. The patient was transferred to a skilled nursing facility for continued management 6 weeks later. Cautery assisted Lumen Apposing Metal Stents (LAMS), while not familiar to many physicians, offers a safe, cost effective, method of drainage of pancreatic pseudocysts. It has a similar success rate when compared to surgical or interventional radiology approaches, specifically when the patient has progressed clinically to pseudocyst containing necrotic debris. In our patient, the size of the cyst and the severity of his pancreatitis made initial surgery a difficult proposition due to potential morbidity, and IR drainage unfavorable due to possible fistula formation. Over time, pseudocysts can spontaneously resolve if the circumstances are right. The size and amount of fluid present in this pseudocyst made our patient an unlikely candidate for spontaneous resolution of his pseudocyst, thus making drainage an acceptable option. Endoscopic guided cystgastrostomy, when available, is quickly becoming the preferred method of fluid drainage.Figure: Endoscopic ultrasound showing fluid consistent with a pancreatic pseudocyst.Figure: Endoscopic view of the gastric lumen as fluid (arrow) is being drained via a lumen apposing metal stent.

Hepatocellular carcinoma in a patient with congenital porto-systemic shunt

Congenital porto-caval shunt is a rare anomaly that can result in direct shunt-related complications (encephalopathy, pulmonary hypertension) or indirect complications such as the development of benign or malignant hepatic neoplasms. Treatment consists of management of the complications and occlusion of the porto-caval shunt in one or two stages by either a surgical or an interventional radiology approach.

Technical note: A preliminary comparative study between classical and interventional radiological approaches for multi-phase post-mortem CT angiography

PurposeMulti-phase post-mortem computed tomography angiography (MPMCTA) is a new diagnostic tool, used in forensic pathology. On the one hand, this technique allows a better and direct visualization of vascular and solid organ lesions. On the other hand, the invasiveness of the procedure—which requires surgical denudation (inguinal and/or cervical) and the insertion of surgical cannulas—leads to many relatives refusing scientific autopsies. Our hypothesis states that a minimally-invasive procedure combining interventional radiological techniques with MPMCTA (replacement of surgical cannulas by radiological catheters) will improve the approval rate of scientific autopsies by families. The aim of this study was to evaluate the feasibility of the minimally-invasive MPMCTA approach and to compare its performance to the current reference-standard (the conventional approach). Material and methodsWe included consecutively 16 corpses divided in two groups according to the contrast enhancement approach: radiological catheters (n=8), and surgical cannulas (n=8). Corpses were chosen and assigned randomly from our local data. The quality of the imaging procedure was compared according to four items: global vascular opacification, cerebral venous opacification, and lower limbs opacification (arterial and venous). ResultsA minimally-invasive approach for scientific autopsies is feasible through a radiological catheter. Vascular opacification was optimal in 8 out of 8 cases and was no less effective than the control reference group using surgical cannula incision associated with their non-occlusive aspects.

Management of Ureteroenteric Stricture: Predictive Modeling to Compare Cost.

Ureteroenteric stricture occurs in as many as 15% of patients after cystectomy with urinary diversion. First-line management is typically percutaneous nephrostomy (PCN) drainage. We sought to compare costs of a urologic approach of retrograde stenting through flexible endoscopy and an interventional radiology (IR) approach of PCN and antegrade stenting using predictive modeling. The purpose of this study is to inform best practice for initial stricture management based on existing literature regardless of the benign stricture rate following radical cystectomy. Our hypothesis is that initial management by a urologist may be superior to IR management. The primary outcome measure was cost based on 2015 Medicare reimbursement rates by Current Procedural Technology codes with a secondary endpoint of number of procedures a patient undergoes. We developed a simulation model to replicate the experience of stricture patients. The model describes three arms: urologic management with retrograde stent placement, sequential management by IR, and single-stage IR management. We simulated 10,000 patients through the model with the percentage of patients pursuing each treatment arm and success rates chosen based on a review of relevant literature and clinic experience. The average cost of urologic management is $703.23 compared with the average cost of $838.09 for patients using radiologic management. Within radiologic management, the average cost is $862.98 for sequential IR management and $639.44 for single-stage IR management. Patients would undergo an average of 2.53 procedures for those patients initially sent to urology and 2.91 procedures for those sent to radiology. For sequential IR, the average is 3.02 procedures, and for single-stage IR, it is 2.03 procedures. From a cost perspective, the success rate at which retrograde stent placement becomes worth attempting is 35%. If radiologic management is attempted initially, sequential IR management represents a cost-conscious option that limits the total number of procedures. The disparity in cost between IR and urologic management of ureteral stricture provides a rationale for rural practices that may not have immediate access to IR to manage the patient.

Percutaneous radiofrequency ablation of a bleeding pseudoaneurysm during CT-guided renal cancer treatment. A case report.

We describe a new emergency interventional radiology approach in percutaneous procedure complications. We present the case of an 81-year-old male with small renal cancer, approached with percutaneous radiofrequency ablation (RTA) and complicated by pseudoaneurysm bleeding of a renal artery branch. In the emergency setting, pseudoaneurysm was treated in the CT room by the same RTA needle, without any complications or local tumor recurrence during the next 6-month follow-up.

Interventional radiologic approach to hilar malignant biliary obstruction

Interventional radiologic approach to hilar malignant biliary obstruction

EUS-guided portal pressure gradient measurement with a novel 25-gauge needle device versus standard transjugular approach: a comparison animal study

Portal hypertension (PH) is a serious adverse event of liver cirrhosis. The hepatic venous pressure gradient (HVPG) accurately reflects the degree of PH and is the single best prognostic factor in liver disease. Currently, portal pressure gradient (PPG) measurement is performed at interventional radiology (IR) with a standard transjugular approach requiring radiation and intravenous contrast. The aim of this study was to develop a novel EUS-guided system using a 25G FNA needle and compact manometer to directly measure PPG and to evaluate its performance and clinical feasibility. Experiments were performed in 3 swine that were under general anesthesia. Manometry was performed in venous (baseline and PH) and arterial (aorta) systems. The PH model was created by rapid Dextran-40 infusion peripherally. Under EUS guidance a 25G FNA needle with attached manometer was used to puncture (transgastric-transhepatic approach) and measure pressures in the portal vein, right hepatic vein (RHV), inferior vena cava (IVC), and aorta. With the IR approach, RHV (free and wedged), IVC, and aorta pressure were measured with an occlusion balloon. Pressure correlation was divided into 3 groups; low pressure (baseline), medium pressure (noncirrhotic portal hypertensive model), and high pressure (arterial). Correlation between the 2 methods of measurement was charted in scatter plots, and the Pearson's correlation coefficient (R) was calculated. EUS identification, access, and manometry was successful in all targeted vessels. There was excellent correlation (R, .985-.99) between EUS and IR methods in all pressure ranges. No adverse event occurred. This novel technique of EUS-PPG measurement using a 25G needle and novel manometer was feasible and demonstrated excellent correlation with the standard transjugular method throughout low, medium, and high pressure ranges.

Biliary complications in right lobe living donor liver transplantation

Living donor liver transplantation is an alternative to deceased donor liver transplantation in the face of insufficient deceased donor liver grafts. Unfortunately, the incidence of biliary complication after living donor liver transplantation is significantly higher than that after deceased donor liver transplantation using grafts from non-cardiac-death donations. The two most common biliary complications after living donor liver transplantation are bile leakage and biliary anastomotic stricture. Early treatment with endoscopic and interventional radiological approaches can achieve satisfactory outcomes. If treatment with these approaches fails, the salvage measure for prompt rectification will be surgical revision, which is now seldom performed. This paper also discusses risk factors in donor biliary anatomy that can affect recipients.

High Dose, Prolonged Epsilon Aminocaproic Acid Infusion, and Recombinant Factor VII for Massive Postoperative Retroperitoneal Hemorrhage following Splenectomy.

The antifibrinolytic agent ε-aminocaproic acid is used to decrease procedural blood loss in a variety of high risk surgeries. The utility of recombinant factor VII administration in massive hemorrhage has also been reported in a variety of settings, though the impact in a surgical context remains unclear. We describe the case of a patient who underwent massive open splenectomy and developed diffuse retroperitoneal bleeding on postoperative day one. Massive transfusion was initiated, but attempts to control hemorrhage with surgical and interventional radiology approaches were unsuccessful, as was recombinant factor VII administration. Commencement of a high dose aminocaproic acid infusion was followed by a prominent rise in fibrinogen levels and stabilization of the hemorrhage. Indications, dosages, and adverse effects of ε-aminocaproic acid as described in the literature are reviewed.

Site-Specific Impact of a Regional Hydrodynamic Injection: Computed Tomography Study during Hydrodynamic Injection Targeting the Swine Liver.

A hemodynamic study of hydrodynamic gene delivery (HGD) from the tail vein in rodents has inspired a mechanism and an approach to further improve the efficacy of this procedure. However, there is no report on the hemodynamics of a regional HGD, which is an inevitable approach in large animals. Here, we report the hemodynamics of a regional hydrodynamic injection in detail based on 3D volume data and the dynamism of tissue intensity over time by using computed tomography (CT) both during and after a regional hydrodynamic injection that targeted the liver of a pig weighing 15.6 kg. Contrast medium (CM) was injected at a steady speed of 20 mL/s for 7.5 s under the temporal balloon occlusion of the hepatic vein (HV). A retrograde flow formed a wedge-shaped strong enhancement area downstream of the corresponding HV within 2.5 s, which was followed by drainage into another HV beginning from the target area and the portal vein (PV) toward a non-target area of the liver. After the injection, the CM was readily eliminated from the PV outside the target area. These data suggest that an interventional radiology approach is effective in limiting the hydrodynamic impacts in large animals at a target area and that the burden overflowing into the PV is limited. A further investigation that simultaneously evaluates gene delivery efficiency and hemodynamics using CT is needed to establish feasible parameters for a regional HGD in large animals.

Dealing with stuck hemodialysis catheter: state of the art and tips for the nephrologist.

The term stuck catheter refers to the condition in which a catheter is not removable from a central vein using standard techniques. Although it is a rare complication, in the last few years it has been reported ever more frequently in hemodialysis due to the widespread use of tunneled catheters. Poor knowledge of the correct procedures and limited experience and training of the specialist in facing this problem are the main reasons for catheter internalization. Stuck catheter is often diagnosed by the nephrologist, who should be competent enough to manage this clinical complication. Among the many options for removing a stuck catheter from the fibrin sleeve, an interventional radiology approach, mainly with endoluminal balloon dilatation, probably provides the best solution. Vascular surgery should be reserved to selected cases in which percutaneous techniques have failed. Nephrologists must play a central role in organizing the treatment of this complication with other specialists in order to avoid making mistakes that may preclude future positive results.