Percutaneous Aspiration Research Articles

SJLA_2024_A18: Persistent Complex Seroma Treated by Capsulectomy and Argon Beam Coagulator

Background: Seroma formation is one of the most common events following ventral hernia repair. When mesh is used for the repair of larger and more complex incisional hernias, the risk of seroma formation increases. The mesh onlay technique, which requires more extensive dissection, is associated with an even greater incidence of seroma formation. Treatment options for postoperative seromas include observation for spontaneous resolution, percutaneous aspiration, closed suction drainage, abdominal binders, and sclerosant. Methods: The aim of this report is to present a definitive management of a very challenging case of abdominal wall chronic complex seroma following herniorrhaphy with mesh approached by open capsulectomy and scarification of the remnant pseudocapsule. Results: Our patient is a 60 years-old male a status post low anterior resection with covering loop ileostomy for rectal cancer. His diverting stoma was taken off after completing the adjuvant chemotherapy treatment. Seven months later, the patient has developed an enlarging midline incisional hernia. This hernia was subsequently repaired by primary fascial closure with suprafascial onlay polypropylene mesh. Postoperatively, he developed a subcutaneous seroma which was initially treated with an abdominal binder without success. Over the following 3 months of observation, seroma was increasing in size. Discussion: Having recovered his acute condition, surgical intervention was planned. The patient underwent an excision and evacuation of the complex seroma and pseudocapsule. A 12-cm midline incision was made in line with the previous incision used for the hernia repair. The pseudocapsule of the seroma was encountered when the subcutaneous tissue was incised. The incision was carried superior, inferior, and laterally, and the capsule was exposed. The seroma opening sinus was expanded and fluid was evacuated. There were some fibrous dead tissues and coagulated dark blood. The anterior and lateral aspects of the pseudo capsule were excised. Furthermore, the posterior aspect was cleaned carefully using the curettage instrument without affecting the integrity of the mesh which was looking healthy and intact and without causing injury to the intraabdominal contents. Argon beam coagulator was used to scarify the remaining posterior aspect attaching to the mesh. Hemostasis was secured, and the wound was closed over a Jackson–Pratt drain. A pressure dressing and abdominal binder were applied. Conclusion: Factors leading to seroma following incisional herniorrhaphy are poorly understood. Many options are available for treating complicated abdominal wall seroms. capsulectomy and scarification of the remnant pseudocapsule were good option for the treatment of persistence complex seroma.

EUS-guided endoscopic internal drainage with lumen-apposing metal stent for symptomatic hepatic cysts: a case series (with video).

Background and study aims Simple hepatic cysts (SHCs) are usually asymptomatic and detected incidentally. However, larger cysts may present with clinical signs and require treatment such as percutaneous aspiration or surgery with non negligeable rate of recurrence. We report a series of 13 consecutive patients who underwent EUS-guided lumen-apposing metal stent (LAMS) drainage of SHCs of the right and left liver. Patients and methods Nine men and four women, average age 71.9 years, underwent EUS-guided LAMS cyst drainage because of significant symptoms. At 1 month, LAMS was exchanged for a double pigtail stent (DPS), which was left in place for 3 months. Nine of the SHCs were located in the right liver and four in the left. The average diameter was 22.2 cm. Results Thirteen LAMS were successful delivered in all patients. However only 12 of 13 (92.3 %) remained in place. In one case, the LAMS slipped out immediately and was promptly removed and the cyst treated percutaneously. One of 12 patients experienced bleeding, which was treated conservatively. In seven patients, the LAMS was exchanged for a DPS; in the other five, it was successfully left in place until the patients died, given their comorbidities. At 10.5 months of follow-up, none of the SHCs had recurred. Conclusions EUS-guided LAMS drainage permits treatment of symptomatic SHCs without recurrence and with few adverse events. Comparative studies are needed to consider this approach as first intention.

Clinical Effectiveness and Limitations of Percutaneous Suction Aspiration and Drainage for Pyogenic Spondylitis

Clinical Effectiveness and Limitations of Percutaneous Suction Aspiration and Drainage for Pyogenic Spondylitis

Percutaneous mechanical pulmonary thrombectomy: An emerging opportunity for vascular surgeons

ObjectivePercutaneous pulmonary artery (PA) mechanical thrombectomy is a minimally invasive treatment for patients with submassive pulmonary emboli (PE). Recent registry data suggest that only approximately 12% of these procedures are being performed by vascular surgeons. We conducted a single center, 1-year, prospectively collected, retrospectively reviewed original study of all patients who had percutaneous PA aspiration mechanical thrombectomy (PPAAMT) performed by vascular surgeons to treat acute, submassive PE. MethodsBetween January 2020 and January 2021, 5 vascular surgeons performed 21 percutaneous PPAAMTs, representing 72% of all the PPAAMT performed at our institution. The remaining 28% were performed by interventional radiology and cardiology physicians (4 patients each). Vascular surgeons used the Inari Flowtriever aspiration catheter in 90.4% of our cases. For the remaining 10% of cases, the Penumbra Indigo thrombectomy device was used. Device choice was determined by the surgeon. ResultsWe analyzed prospectively collected data and reviewed postprocedural outcomes including PA mean arterial pressures, interval improvement of respiratory function, and mortality. Among the patients treated with PPAAMT by vascular surgeons in this series, 76% demonstrated an improvement in oxygen requirements and 83% saw an improvement in their post-thrombectomy PA mean arterial pressure. There were three mortalities (16%), none of which were procedure related or attributable to the patients' acute presentation or to PE recurrence. ConclusionsIn this prospectively collected, retrospectively analyzed original study, vascular surgeons performed the majority of percutaneous PPAAMT to treat submassive PE at a single institution, with no procedure-related mortality and a high rate of clinical improvement as measured by improvements in oxygen requirements and PA mean arterial pressures. These results suggest that PPAAMT performed by vascular surgeons is safe and effective and can be strategically incorporated into an already busy tertiary care vascular surgery practice.

Follicular lymphoma of the thyroid and the role of core needle biopsy.

Primary thyroid lymphoma (PTL) is a rare malignancy, accounting for less than 5% of all thyroid neoplasms. The follicular subtype is even more rare, accounting for approximately 10% of all PTL cases. We report a case of a 64-year-old woman, who presented with a rapidly growing goitre with mass effect and B symptoms. She had a history of Hashimoto's thyroiditis and her thyroid ultrasound revealed diffuse goitre with a dominant nodule (56 × 63 × 60 mm) within the right thyroid lobe. Ultrasound-guided percutaneous fine-needle aspiration of the right thyroid nodule was classified as benign, according to Bethesda System, with lymphocytic thyroiditis. A CT scan of the neck showed diffuse enlargement of the thyroid gland extending towards the anterior mediastinum with tracheal deviation and lymphadenopathy within levels VII and right II-IV. The core needle biopsy of the right thyroid nodule revealed a follicular non-Hodgkin's B cell lymphoma with a Ki67 of 60%. According to the Ann Arbor staging system, she was at stage IIIE. She underwent chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) with remarkable clinical improvement and is currently in remission 2 years after the diagnosis. PTL is an extremely rare malignancy that usually arises in a lymphocytic thyroiditis background, presenting as a rapidly enlarging goitre, which can lead to compressive symptoms or airway comprise. Primary thyroid lymphoma (PTL) is a rare malignancy, accounting for less than 5% of thyroid neoplasms. PTL should be suspected when a patient presents with a rapidly enlarging goitre, especially in the setting of Hashimoto's thyroiditis. Fine-needle aspiration has a limited capacity for PTL diagnosis due to similar cytomorphological features of lymphoma with thyroiditis. Therefore, in case of clinical suspicion and if fine needle aspiration fails to diagnose PTL, a tissue biopsy should be performed. Treatment is dependent on both the stage and histology of PTL. Chemotherapy and local radiotherapy remain the mainstay treatment for PTL.

STUDY OF ETIOLOGY OF LIVER ABSCESS AND IT'S DIFFERENT WAYS OF MANAGEMENT

Background: Liver abscess are cystic, space occupying lesion within liver parenchyma. It has become one of the most common disease with more prevalence in underdeveloped and developing countries. Pyogenic liver abscess more common in western world while amoebic liver abscess are more common in underdeveloped countries and people living with lower socio-economic conditions. Liver abscess, undiagnosed and untreated, has a very high mortality rate. With early diagnosis and prompt institution of specic therapy, the prognosis is good and the mortality is very low. Surgical management was the mainstay for treating liver abscess earlier. However, USG guided percutaneous needle aspiration and percutaneous drainage procedure shown a favorable outcome with less average length of stay in hospital. In this study we aimed to study etiology of liver abscess and its different ways of management. To study the etiology of liver abscess Aim: Materials And Methods: and its different ways of management. This is a prospective, observational study was conducted in GSVM Medical College, LLR & Associated Hospitals, Kanpur (UP).Study was done on 100 patients with different types of liver abscess. Patient with ruptured liver abscess were not included. Outcomes were assessed on the basis of recurrence (with regular follow ups at one month, three months, six months and one year); relieving of symptoms and length of stay in hospital. Results: Out of 100 patients majority of patients were in the age range of 31-45 (56.0%) followed by 46-60 (22.0%) with mean age of 40.74±10.53 years. Most of the cases were males (98%), and females (2.0%). Majority of patients were with lower socioeconomic status (96%). Most of the patient having amoebic liver abscess (66%) with positive ELISA for antibodies, while 34 % of patient having pyogenic liver abscess with 10% having bacterial growth on culture examination having E.coli . 84% of cases having liver abscess in right lobe and were single (66.0%). On the basis of their personal history, comorbidities and clinical features, 14.05 were diabetic, 44.0% were alcoholic, 98% were having fever with 60% cases have chills and rigor and 100% having pain in right upper quadrant. Majority of cases undergone pigt Conclusion: ail treatment were pyogenic (76.4%) and majority of amoebic abscess were treated with aspiration (72.7%) and difference was found statistically signicant with p value of 0.001. Reduction in size of abscess cavity was observed in all the cases but recurrence was higher in conservative treatment (p=0.007) and length of stay was higher in pigtail (p<0.001).

Assessment of risk factors in pyogenic liver abscesses in children.

Pyogenic liver abscess (LA) is a significant contributor to morbidity and mortality in developing countries like India. The risk factors predisposing to the LA specifically in children are not known. Studies done in the past largely remain inconclusive and have identified only probable causes. The cause of LA in children with no coexisting illness remains unknown. This prospective observational study was conducted at a tertiary teaching hospital located in New Delhi, India. All children between 2 months and 12 years of age with sonographically confirmed LA presenting to the hospital were included and managed with appropriate intravenous antibiotics and relevant investigations. A total of 52 children were included. The mean age was 6 years and 4 months, and the male: female ratio was 1.4:1. Around 50% of the patients were malnourished. Fever, abdominal pain and loss of appetite were the most common symptoms. Nine patients (17%) were managed conservatively, 13 (25%) needed percutaneous needle aspiration and 30 (57.69%) required drainage using a pigtail catheter. Poor socioeconomic status and anaemia were found to be the most commonly associated risk factors. Selective immunoglobulin A (IgA) deficiency was the most common primary immunodeficiency disorder followed by T-cell defect. On multivariate analysis, it was seen that in those with clinical icterus, gamma-glutamyl transferases >350 IU/m, and those with impending rupture, the time to defervescence was significantly different (P = 0.05). Poor socioeconomic status causing malnutrition emerged as a significant risk factor for LA in children. Selective IgA deficiency was the most common immunodeficiency seen in a few children. Adopting a conservative approach like aspiration and percutaneous drainage led to lower mortality and good recovery rates.

Giant porta hepatis cystic lymphangioma mimicking intra-abdominal abscess

Background: Intra-abdominal lymphangiomas are very rare benign tumors in adults. Here we demonstrate a 22-year-old male who presented with abdominal pain and fevers. He underwent a CT of the abdomen and pelvis which showed multiple, large loculated fluid density lesions extending from the porta hepatis into the entire right hemi-abdomen and into the left upper quadrant. The largest cyst measured 10.4 cm by 1.9 by 26.4 cm. Due to ongoing fevers and concern for infection, the patient underwent percutaneous aspiration of the fluid for concern of intra-abdominal abscess. From the sampled fluid, cultures were negative for growth, cytology was negative for malignant cells, and cell count was within normal limits. The triglyceride level of the fluid was 2739 mg/dL. The patient had moderate relief, but the following day again developed abdominal distension, discomfort, and anorexia. Due to the symptomatic nature of the mass, the patient underwent an exploratory laparotomy with resection of the mass. 4.6 liters of chylous ascites were removed from within the cystic mass. The mass was noted to extend from the porta hepatis into the right retroperitoneum and extend to the left upper quadrant, abutting the pancreas and spleen. The pathology report was consistent with lymphangioma with marked acute fibrinopurulent inflammation and no evidence of malignancy. The patient had immediate relief postoperatively and recovered well from surgery.

Clinical Utility of Cytology from Preoperative Percutaneous Fine Needle Aspirates of Solitary Liver Masses in 220 Dogs: A Retrospective Study (2009-2019).

When a solitary liver mass is identified in a dog, a fine-needle aspirate (FNA) is commonly employed to attempt to obtain a diagnosis. Little information is provided in the literature evaluating the sensitivity/specificity of FNA cytology for solitary liver masses. We hypothesized that liver lesion size nor the presence of cavitation would impact the success of cytological diagnosis. Medical records were obtained for 220 client-owned dogs. Inclusion criteria included preoperative abdominal imaging, percutaneous FNA of a solitary hepatic mass with cytologic interpretation by a board-certified pathologist, and a surgical biopsy or mass excision yielding a histopathological diagnosis. Six dogs (2.7%) experienced a complication after FNA, none considered severe. The agreement rate for correct cytologic diagnosis was 22.9% (49/220). Of the neoplastic masses 18.9% (35/185) were correctly diagnosed via cytology. The overall sensitivity was 60%, and the specificity was 68.6%. Neither institution (P = 0.16), lesion size (P = 0.88), cavitation (P = 0.34), or needle gauge (P = 0.20) had an association with correct diagnosis. This study demonstrates that, although there is a low risk of complications following FNA of a hepatic mass, overall success rate for correct cytologic diagnosis based on FNA was low compared to histopathologic diagnosis.

Fine-needle aspiration biopsy diagnosis of histiocyte-rich rhabdomyoblastic tumor (inflammatory leiomyosarcoma): A case report.

Histiocyte-rich rhabdomyoblastic tumor (HRRMT) is an exceedingly rare soft tissue tumor of primitive myogenic differentiation. We report herein a case involving the soft tissue in the left lateral peri-scapular region in a 68-year-old female with a 2-month history of a non-painful soft tissue mass. Ultrasound revealed a solid, ovoid subcutaneous mass lesion that lacked significant internal vascularity. Percutaneous fine-needle aspiration (FNA) biopsy with concomitant core needle biopsy was performed, and a diagnosis of HRRMT was rendered. Cytologic smears were hypercellular, composed of a mixture of foamy histiocytes and a variably cohesive population of epithelioid and plasmacytoid to vaguely spindled cells in cohesive clusters and singly dispersed. Histologic material showed sheets of epithelioid and plasmacytoid to spindled cells with admixed foamy histiocytes with distended, vacuolated cytoplasm. To our knowledge, this is the first reported example of HRRMT evaluated by FNA biopsy.

Ultrasound-Guided Drainage of Breast Abscess

Objective: To assess the efficacy of ultrasound-guided drainage of breast abscesses with special attention to the risk of recurrence and the need for surgical treatment, to avoid postoperative morbidity, to reduce the hospital stay and cost of treatment, to determine the need for termination of breast feeding. Methods: 100 patients with breast were selected conveniently among those who were admitted in Dinajpur Medical College hospital or visited to surgery OPD with breast abscess. They were evaluated by short history, clinical examination and ultrasonogram. After counseling and taking consent they were treated with ultrasound-guided drainage, by needle or pigtail catheter under local anaesthesia. Follow-up punctures were performed at 2 or 3 day intervals until the clinical condition and ultrasound findings had improved. All patients were treated with oral antibiotics. Mammography was performed to search for underlying cancer. Results: Among the 100 cases included in the study, ninety-seven 97% patients with puerperal abscesses and 81% with non-puerperal abscesses recovered after the first round of ultrasound-guided drainage. One patient in each group had recurrence in loco but recovered after further ultrasound-guided drainage. Seven patients, 6 with non-puerperal and 01 with puerperal abscesses, underwent surgical excision of the abscess cavity or fistulas. Breastfeeding continued and 23 patients were treated as outpatients. The median number of follow up examinations in the ultrasound-department was four (range 1–10) for the group of patients with puerperal abscess and three (range 1–7) in the group of patients with non- puerperal abscess. The corresponding figure for the median number of punctures was for both groups one (range 1–6 and 1–4). There were no reports of newly diagnosed breast cancer in the 1-year follow-up period. Conclusion: Treatment of breast abscess with US-guided Percutaneous aspiration or Pigtail catheter drainage both in puerperal and .......

Comparison of Outcome between Percutaneous Aspiration, Incision and Drainage In Case of Lactational and Non-Lactational Breast Abscess

A breast abscess is a localised collection of purulent material within the breast. Its first-line treatment was incision and drainage under general anaesthesia. But it prolonged the morbidity, whereas aspiration developed as a less invasive solution to the problem. Therefore, this study was conducted to compare the outcome of breast abscess management with both aspiration and incision and drainage techniques. It comprised 60 patients presented at LRH, Peshawar and LUMHS, Jamshoro, (July 2021 to December 2021). The mean age of the presented gyne patients was 34.78+10.55 years. Females with breast abscesses were allocated into two groups carrying 31 and 29 patients in lactational and non-lactational phases, respectively. Results revealed that post-surgical complications including scarring, breast asymmetry, mammary fistula and sepsis were significantly higher (p<0.05) in patients treated with incision and drainage as compared to the aspiration-managed women. Therefore, percutaneous aspiration was found more successful and effective than incision drainage. Keywords: Breast scarring; Mammary fistula; Pus drainage; Surgical complications.

Abstract 15294: Right Atrial Thrombus Extraction Through Angiovac - A Challenge Based on Chronicity

Case Presentation: 23-year-old woman with right ovarian dysgerminoma, treated with debulking surgery and bleomycin, etoposide, and platinum, found to have a right atrial (RA) mass on post-chemotherapy surveillance CT and referred to the cardiology clinic. Her vitals were stable, lungs were clear to auscultation, RRR without murmurs, no JVD or LE edema. On labs, hgb:11g/dL and LDH:283 units/L(135 to 214 units/L). A transthoracic echocardiogram (TTE) and a cardiac MRI revealed a mass of RA at the junction of inferior vena cava (IVC) entry into RA, measuring 3x1.3 cm in the 2-chamber view and 2.4x1.8 cm in the 4-chamber view (Fig A,B) with prolapse into the right ventricle (RV) in diastole. Based on cardiac MRI’s short and long inversion time imaging characteristics, thrombus was the most likely diagnosis (Fig C). Shared decision-making with the patient included options: 1) open heart surgery for removal; 2) interventional aspiration thrombectomy; or 3) conservative treatment with anticoagulation (AC). After six weeks of AC with enoxaparin, TTE revealed a RA thrombus of the same size as previously (2.8x1.2 cm). Given the lack of improvement, she agreed to an invasive procedure to remove the mass using an AngioVac aspiration system (AngioDynamics, Latham, NY). The AngioVac cannula maneuvered in the RA under fluoroscopic and TEE guidance to capture the RA mass. However, the mass broke into two pieces, one piece still attached to the RA and the other piece lodged in the AngioVac cannula (Fig D,E). She remained hemodynamically stable after the procedure. The pathology of the RA mass revealed an organized thrombus (Fig F). She had no complaints on follow-up in the clinic and continued on AC for 6 months. Discussion: Percutaneous aspiration thrombectomy using the AngioVac system has become a novel option for removing commonly encountered intravascular material, such as fresh thrombi or emboli in the RA, RV, SVA, IVC, and the iliofemoral vein, but may be complicated in old thrombi.

Percutaneous aspiration thrombectomy as an optional treatment for pulmonary embolism

Percutaneous aspiration thrombectomy as an optional treatment for pulmonary embolism

Ultrasound-Guided Percutaneous Aspiration for the Treatment of Breast Abscess at a Tertiary Care Center in the Developing World.

Percutaneous ultrasound (US)-guided aspiration is the first line of management for breast abscess. Our study aimed to look at the success of US-guided percutaneous drainage in managing breast abscesses at a tertiary care center and additionally to look for any correlation between US features and failure rate. Methods: A retrospective review of the radiology database at a tertiary care hospital in Pakistan was done to identify 54 patients through non-probability convenience sampling who underwent a US-guided percutaneous aspiration with laboratory confirmation of abscess. A treatment course was observed for the development of complications or failure of treatment. A chi-square test was performed to correlate US features and patient characteristics with outcomes of treatment (p<0.05). Fisher's exact test was applied to evaluate the success of aspiration in small versus large abscesses, and in lactating versus non-lactating patients. Results: 75% of all women were successfully able to avoid surgery. Specifically, 80.6% of all lactating women and 66.7 %of non-lactating women with breast abscesses were successfully managed with US-guided percutaneous aspiration. Across a variety of parameters measured, including pathological and etiological factors, as well as features on imaging, no significant association was established between the variables and the failure of the intervention. Lowmorbidity and high patient satisfaction rates make percutaneous aspiration preferable to surgical intervention as a first-line treatment of breast abscess. Early use of antibiotics is recommended as an adjunct to drainage.

Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: an updated systematic review and meta-analysis.

Liver abscesses differ in their aetiology, location, and number. Image-guided percutaneous drainage techniques are the currently used management for liver abscesses. We conducted our study to compare the clinical safety and efficacy of percutaneous needle aspiration (PNA) to percutaneous catheter drainage (PCD). A systematic review of major reference databases was undertaken in February 2022 for randomized controlled trials (RCTs) that compare PNA to PCD in treating liver abscess patients. The quality of the included trials was assessed using the Cochrane tool. Statistical meta-analysis was conducted using RevMan and open meta-analyst software. Fifteen RCTs were included in this review, with 1676 patients enrolled. The overall quality of the included trials was moderate, with most domains of unclear risk. PCD was superior to PNA in the success rate (RR=1.23; 95% CI [1.12, 1.36], P< 0.00001), time for achieving 50% reduction of cavity size (MD=-2.32; 95% CI [-3.07, -1.57], P< 0.00001), and time for clinical improvement (MD=-1.92; 95% CI [-2.55, -1.28], P< 0.00001). The two modalities did not differ in the days of hospital stay, duration of IV antibiotics, and time needed for total or subtotal reduction of cavity size (P= 0.36, P= 0.06 and P= 0.40, respectively). High heterogeneity levels were detected. Regarding major complications, the two modalities were equally safe (P= 0.39). PCD has a higher success rate and results in a faster 50% reduction in the abscess cavity size and clinical improvement. The two modalities are equally safe.

Severe Klebsiella pneumoniae pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism: A case report

Klebsiella pneumoniae (K. pneumoniae) is a clinically common Gram-negative bacillus that can cause community- and hospital-acquired infections and lead to pneumonia, liver abscesses, bloodstream infections, and other infectious diseases; however, severe pneumonia caused by hypervirulent K. pneumoniae (hvKp) complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism is rarely seen in the clinical setting and has not been reported in the literature. A 51-year-old man was hospitalized with fever and dyspnea. Persistent mild pain in the middle and upper abdomen began at dawn on the 3rd day following admission and developed into persistent severe pain in the left upper abdomen 8 h later. Based on chest computed tomography (CT), bronchoscopy, bronchoalveolar lavage fluid metagenomic next-generation sequencing, abdominal aortic CT angiography (CTA), and culture of the superior mesenteric artery embolus, adult community-acquired severe hvKp pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism was diagnosed. Notably, he recovered and was discharged from the hospital after receiving effective meropenem anti-infection, endovascular contact thrombolytic, and systemic anticoagulant therapies and undergoing percutaneous thrombus aspiration. Ten days later, the patient returned to the hospital for abdominal CTA examination, which indicated blocked initial common pathway of the celiac trunk and superior mesenteric artery, and local stenosis. Therefore, celiac trunk artery stenting was performed in Chongqing Hospital, and postoperative recovery was good. We report a case of hvKp severe pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism and suggest that clinicians should consider the possibility of a Gram-negative bacillus infection and conduct effective pathogen detection in a timely fashion when managing patients with severe community-acquired pneumonia before obtaining bacteriologic and drug sensitivity results. At the same time, when patients have severe pulmonary infection complicated by severe abdominal pain, an acute mesenteric artery embolism should be considered to avoid delays in treatment.

The feasibility of percutaneous transhepatic gallbladder aspiration for acute cholecystitis after self-expandable metallic stent placement for malignant biliary obstruction: a 10-year retrospective analysis in a single center.

Patients with acute cholecystitis (AC) after metallic stent (MS) placement for malignant biliary obstruction (MBO) have a high surgical risk. We performed percutaneous transhepatic gallbladder aspiration (PTGBA) as the first treatment for AC. We aimed to identify the risk factors for AC after MS placement and the poor response factors of PTGBA. We enrolled 401 patients who underwent MS placement for MBO between April 2011 and March 2020. The incidence of AC was 10.7%. Of these 43 patients, 37 underwent PTGBA as the first treatment. The patients' responses to PTGBA were divided into good and poor response groups. There were 20 patients in good response group and 17 patients in poor response group. Risk factors for cholecystitis after MS placement included cystic duct obstruction (p<0.001) and covered MS (p<0.001). Cystic duct obstruction (p=0.003) and uncovered MS (p=0.011) demonstrated significantly poor responses to PTGBA. Cystic duct obstruction is a risk factor for cholecystitis and poor response factor for PTGBA, whereas covered MS is a risk factor for cholecystitis and an uncovered MS is a poor response factor of PTGBA for cholecystitis. The onset and poor response factors of AC after MS placement were different between covered and uncovered MS. PTGBA can be a viable option for AC after MS placement, especially in patients with covered MS.

Pharmacomechanical Aspiration Thrombectomy of Iliofemoral Deep Venous Thrombosis to Salvage the Transplanted Kidney - A Case Report

Ipsilateral acute iliofemoral deep venous thrombosis (DVT) after a renal transplantation, although rare, has a high morbidity, causing complications such as allograft failure, rupture, or death. Treatment modalities are limited due to the risk of bleeding and impaired renal function. We report successful treatment of a case of iliofemoral DVT in a 58-year-old male recipient of a living donor renal transplantation. The immediate postoperative course of the patient was uneventful, and he was discharged on 6th postoperative day (POD) with serum creatinine of 0.8 mg/dl. On POD 26, the patient was admitted with diarrhea, dehydration, and decreased urine output. His serum creatinine rose from 0.8 mg/dl to 2.6 mg/dl and he developed pain and swelling of the right lower extremity. Duplex ultrasonography was suggestive of acute DVT with noncompressible right distal external iliac vein, common femoral, superficial femoral and popliteal veins, absence of color flow from the right femoral vein to the common iliac vein, dilatation of allograft renal vein and an increased renal graft resistive index of 0.97. After inferior vena cava filter insertion, initial treatment with percutaneous balloon angioplasty and catheter-directed thrombolysis could not restore blood flow. Subsequently, percutaneous transluminal pharmacomechanical aspiration was performed with complete removal of the thrombus leading to restored renal allograft vein patency and normalization of allograft function and Duplex findings.

Interventional treatment of pulmonary embolism - where do we currently stand?

Acute pulmonary embolism is the third most common cause of cardiovascular mortality in the world. The sudden pressure overload of the right ventricle, caused by the thrombotic masses in the pulmonary artery, may quickly progress to profound cardiogenic shock. That results in a mortality rate of more than 50% in patients with a massive form of pulmonary embolism. In such cases, systemic fibrinolysis is warranted, which leads to rapid improvement of the right ventricular function and hemodynamic stabilization. The thrombolytic effect of systemic fibrinolysis is, unfortunately, accompanied by an almost 5 times increased risk of bleeding, especially intracranial one. Therefore, in most cases, for patients with uncompromised hemodynamics, only anticoagulation treatment is offered. Interventional treatment of acute pulmonary embolism consists of the usage of very low-dose fibrinolytic devices or percutaneous thrombus aspiration devices. The goal is to provide rapid removal of the thrombotic masses from the pulmonary artery circulation while keeping the hemorrhagic risk at a minimum. This paper will try to provide a concise review of the most widely used and available devices, together with the latest clinical data, supporting their use. Also, the future perspectives in the field of endovascular treatment of acute pulmonary embolism will be presented.