Percutaneous Fenestration Research Articles

Technical note: durable resolution of hydrocephalus after ultrasound-guided percutaneous fenestration of giant suprasellar arachnoid cyst in a neonate.

Arachnoid cysts are relatively common, but rarely require intervention. While most arachnoid cysts in typical middle or posterior cranial fossa locations are seldom symptomatic, suprasellar cysts may become symptomatic due to the potential for ventricular outflow obstruction and hydrocephalus. Typical standard of care for the treatment of these lesions is endoscopic fenestration with third ventriculostomy, or the placement of ventriculoperitoneal or cystoperitoneal shunts. The surgical and anaesthetic risks of traditional interventions may be higher in the early neonatal period, including leak of cerebrospinal fluid, infection, and premature failure of ventriculostomy or shunts. This note describes a novel bedside ultrasound-guided technique to percutaneously fenestrate large suprasellar arachnoid cysts under local anaesthesia. The technique involves insertion of a 25-g spinal needle until contact with the membrane of the arachnoid cyst medially, followed by a lateral sweeping to widely incise/fenestrate the lesion into the ventricular space under continuous ultrasound visualisation. This note describes an example case which demonstrates durable radiological and clinical improvement after 2years of follow-up. This may represent a management option to temporise, or perhaps definitively manage suprasellar arachnoid cysts in the neonatal period.

Minimally Invasive Chevron Akin Osteotomy for Hallux Valgus Correction.

Minimally Invasive Chevron Akin Osteotomy for Hallux Valgus Correction.

A Meta-Analysis of the Therapeutic Effect of Percutaneous Fenestration of the Intervertebral Disc Compared to Laminectomy for Lumbar Disc Herniation

A Meta-Analysis of the Therapeutic Effect of Percutaneous Fenestration of the Intervertebral Disc Compared to Laminectomy for Lumbar Disc Herniation

Safety and efficacy of transcatheter closure of Fontan fenestration with atrial septal occluder

Objective: To assess the safety and efficacy of transcatheter fenestration closure following Fontan procedure with an atrial septal occluder. Methods: This is a retrospective study. The study sample consists of all consecutive patients who underwent closure of a fenestrated Fontan baffle at Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine between June 2002 and December 2019. The indications of Fontan fenestration closure included that normal ventricular function, targeted drugs for pulmonary hypertension and positive inotropic drugs were not required prior the procedure; and the Fontan circuit pressure was less than 16 mmHg (1 mmHg=0.133 kPa) and no more than a 2 mmHg increase during test occlusion of the fenestration. Electrocardiogram and echocardiography were reviewed at 24 hours, 1, 3, 6 months and annually thereafter post procedure. Follow-up information including clinical events and complications related to Fontan procedure was recorded. Results: A total of 11 patients, including 6 males and 5 females, aged (8.9±3.7) years old were included. The types of Fontan were extracardiac conduits (7 cases) and intra-atrial duct (4 cases). The interval between percutaneous fenestration closure and the Fontan procedure was (5.1±2.9) years. One patient reported recurrent headache after Fontan procedure. Successful fenestration occlusion with atrial septal occluder was achieved in all patients. Compared with prior closure, Fontan circuit pressure ((12.72±1.90) mmHg vs. (12.36±1.63) mmHg, P<0.05), and aortic oxygen saturation ((95.11±3.11)% vs. (86.35±7.26)%, P<0.01) were increased. There were no procedural complications. At a median follow-up of (3.8±1.2) years, there was no residual leak and evidence of stenosis within the Fontan circuit in all patient. No complication was observed during follow-up. One patient with preoperative headache did not have recurrent headache after closure. Conclusions: If the Fontan pressure is acceptable by test occlusion during the catheterization procedure, Fontan fenestration could be occluded with the atrial septum defect device. It is a safe and effective procedure, and could be used for occlusion of Fontan fenestration with varying sizes and morphologies.

Results of Medial Collateral Ligament percutaneous fenestration versus Arthroscopic release in arthroscopic partial medial meniscectomy

Results of Medial Collateral Ligament percutaneous fenestration versus Arthroscopic release in arthroscopic partial medial meniscectomy

Clinical Evaluation of Percutaneous Head and Neck Fenestration and Artificial Bone Grafting for the Treatment of Early Femoral Head Necrosis

Clinical Evaluation of Percutaneous Head and Neck Fenestration and Artificial Bone Grafting for the Treatment of Early Femoral Head Necrosis

Extracardiac Fontan Fenestration Device Closure with Amplatzer Vascular Plug II and Septal Occluder: Procedure Results and Medium-Term Follow-Up.

The objective of this study was to determine medium-term morbidity and mortality of patients who have undergone device closure of an extracardiac Fontan fenestration with an Amplatzer Vascular Plug II (AVPII) or Septal Occluder (ASO). A secondary objective was to compare medium-term morbidity and mortality between these patients and other fenestrated Fontan patients. A retrospective chart review was performed on patients who underwent an extracardiac fenestrated Fontan procedure between 1992 and 2015 at Cardinal Glennon Children's Medical Center. Procedural and follow-up data were obtained and compared between those who underwent fenestration closure and those who did not. Additional outcome measures included whether the fenestration had spontaneously closed, morbidity and mortality, oxygen saturations, and hemodynamics pre- and post-closure. Fifty-nine of 118 patients (50%) with a fenestrated Fontan underwent 60 device closures of the fenestration. Thirty-two (53%) of these were with the AVPII and 28 (47%) with the ASO. There was one device embolization. At a median follow-up of 3.9years, five patients suffered morbidity, including 2 with arrhythmias, 1 with plastic bronchitis, 1 with protein losing enteropathy, and 1 with stroke. There were no cardiopulmonary deaths in this group. Twenty-three of 118 patients (19%) had spontaneous closure. There was no difference in morbidity and mortality between patients who underwent percutaneous fenestration closure and those who either had spontaneous closure or a persistently patent fenestration. Device closure of Fontan fenestrations is a safe and effective procedure with minimal morbidity and mortality comparable to other patients with fenestrations.

Restoration of rostral cerebrospinal fluid flow to solve treatment failure caused by obstruction in long-term intrathecal baclofen administration

Objects: We describe five traumatic spinal cord injury (SCI) patients with an intrathecal baclofen administration (ITB) failure caused by a rostral CSF flow obstruction referred to our expert center between January 2014 and January 2019. We discuss the diagnostic workup, rostral CSF flow obstruction as the cause of the ITB failure and treatment. Methods: When we could not determine the cause of the ITB failure through the patient’s history, physical spasticity examination, pump readout, absence of fluid in the pump reservoir during aspiration, or plain radiography, we performed pump catheter access port (computed tomography [CT]) myelography. When CT myelography did not reveal the diagnosis, we used scintigraphy. In an obstruction, we aimed for CSF flow restoration. In three cases, we conducted a laminectomy with microsurgical adhesiolysis. In two of these patients, we could not achieve CSF flow restoration; thus, we placed an intradural catheter bypass. Recently, in three patients, we applied a less invasive technique of percutaneous fenestration of the obstruction. Results: In one case, we performed a successful catheter replacement. In another case using surgical adhesiolysis, spasticity control was complete. In two cases, we could obtain improvement with an additional intradural bypass, followed by a percutaneous fenestration of the obstruction, resulting in further improved CSF flow restoration. In one case, percutaneous fenestration was the first line of treatment. In all cases with percutaneous fenestration, we experienced spasticity control. Conclusion: Preliminary results showed that the restoration of rostral CSF flow might result in an effective ITB treatment in patients with an intrathecal obstruction.

Percutaneous Full-endoscopic Translamina Fenestration Approach for Treatment of A Lumbar Nerve Root Cyst and Literature Review

Physiological basis of epidural nerve root cyst formation is certain developmental vulnerabilities of nerve root sleeve [1].

Ultrasound-Guided Dry Needling of the Healthy Rat Supraspinatus Tendon Elicits Early Healing Without Causing Permanent Damage.

Overuse-induced tendinopathy is highly prevalent in the general population. Percutaneous fenestration, or dry needling, techniques have been increasing in popularity, but despite their current use, there are no controlled laboratory studies to provide fundamental support for this practice. The objective of this study was to establish a model for percutaneous needling of the rat supraspinatus tendon using ultrasound guidance and to evaluate the biological response of needling healthy tendon. A total of 44 male Sprague-Dawley rats (477 ± 39 g) were used to evaluate the effect of dry needling on healthy supraspinatus tendon properties. Ten rats were reserved as un-needled control animals, and the remaining animals underwent either mild or moderate bilateral needling protocols and were sacrificed at 1 or 6 weeks post-needling (n = 8-10/group). Color Doppler ultrasound imaging was performed to analyze blood flow within the tendon. Histological and immunohistochemical analyses were used to determine cellular, inflammatory, and extracellular matrix properties of the tissue. Finally, quasi-static tensile mechanical analysis was performed to obtain viscoelastic, structural, and material properties to evaluate the tendon healing outcome. Data were tested for normality, and then two-way analysis of variance tests were performed followed by post hoc tests for multiple comparisons. Both the mild and moderate needling groups caused a transient healing response at early time points as shown by a statistically significant (p < 0.05) reduction in mechanical properties, and increase in blood flow, inflammation, and production of collagen III and glycosaminoglycans as compared to the control. Furthermore, mild needling properties returned to or exceeded pre-needling values at the 6-week time point. Clinical significance: Needling the rat supraspinatus tendon is a feasible technique that causes a transient healing response followed by a return to, or improvement of, normal tendon properties, indicating potential applicability in understanding the effects of current practices utilizing dry needling of tendons in humans. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2035-2042, 2019.

经皮椎间孔镜与椎板开窗术治疗腰椎间盘突出症的Meta分析

经皮椎间孔镜与椎板开窗术治疗腰椎间盘突出症的Meta分析

Long-Term Effects of Percutaneous Fenestration Following the Fontan Procedure in Adult Patients with Congenital Univentricular Heart.

BackgroundThe Fontan procedure, performed for univentricular heart, may also include the technique of percutaneous fenestration to create a small atrial septal defect (ASD) and a right-to-left shunt. The aim of this study was to evaluate the long-term effects of fenestration in adult patients who had a Fontan procedure for univentricular heart.Material/MethodsFontan surgery was performed in 39 patients, including 19 (49%) patients with fenestration (Group I), and 20 (51%) patients without the fenestration procedure (Group II). Laboratory tests in both groups included echocardiography, plethysmography, cardiopulmonary exercise testing, and 24-hour Holter monitoring.ResultsCompared with patients in Group I, patients in Group II had a significantly increased level of N-terminal pro-brain natriuretic peptide (NT-proBNP) (p=0.04), alkaline phosphatase (ALP) (p=0.01) and a significant increase in frequency of atrial fibrillation (p=0.04). Patients in Group I had a significantly increased systemic ventricular ejection fraction (SVEF) (p=0.05) and increased heart rate (HR) (p=0.006), heart rate reserve (HRR) (p=0.02), ventilatory equivalent (VE) (p=0.01), and VO2 peak (p=0.05) on cardiopulmonary exercise testing (CPET). Renal, hematologic, and ventilatory parameters, and incidence of thromboembolism showed no significant differences between the groups.ConclusionsLong-term follow-up of patients who underwent Fontan procedures with percutaneous fenestration had improved single ventricular function, lower NT-proBNP levels, improved exercise capacity, and reduced ALP levels. These findings indicate that percutaneous fenestration closure should be considered for adult patients who have undergone Fontan procedure for univentricular heart.

1:45 PM, Abstract No. 112 - Percutaneous aortic fenestration for patients with symptomatic type B aortic dissection

PurposeTo evaluate outcomes for percutaneous fenestration in patients with symptomatic type B aortic dissection.Materials and MethodsFive percutaneous aortic fenestration procedures performed between 2011 and 2014 were retrospectively reviewed. All patients were symptomatic (lower extremity claudication (n=1), mesenteric hypoperfusion (n=3), renal insufficiency (n=1)) at the time of procedure with CT angiograms demonstrating differential perfusion between true and false lumen. After review of abdominal and pelvic CTA, procedures were performed using a common femoral artery approach under fluoroscopic guidance. Punctures were made using a catheter with a flexible trocar stylet followed by 6-10 mm angioplasty. Primary outcomes were relief of pressure gradient between true and false lumen, and relief from signs and symptoms of mesenteric, renal or peripheral ischemia.ResultsTechnical success was 100%. All patients had improved perfusion and symptom resolution after fenestration procedure, and there were no intra- or periprocedural complications. Follow up CTA demonstrated equalization of flow in all cases.ConclusionPercutaneous aortic fenestration is rarely performed but very effective in alleviating ischemic symptoms attributable to symptomatic type B dissection. PurposeTo evaluate outcomes for percutaneous fenestration in patients with symptomatic type B aortic dissection. To evaluate outcomes for percutaneous fenestration in patients with symptomatic type B aortic dissection. Materials and MethodsFive percutaneous aortic fenestration procedures performed between 2011 and 2014 were retrospectively reviewed. All patients were symptomatic (lower extremity claudication (n=1), mesenteric hypoperfusion (n=3), renal insufficiency (n=1)) at the time of procedure with CT angiograms demonstrating differential perfusion between true and false lumen. After review of abdominal and pelvic CTA, procedures were performed using a common femoral artery approach under fluoroscopic guidance. Punctures were made using a catheter with a flexible trocar stylet followed by 6-10 mm angioplasty. Primary outcomes were relief of pressure gradient between true and false lumen, and relief from signs and symptoms of mesenteric, renal or peripheral ischemia. Five percutaneous aortic fenestration procedures performed between 2011 and 2014 were retrospectively reviewed. All patients were symptomatic (lower extremity claudication (n=1), mesenteric hypoperfusion (n=3), renal insufficiency (n=1)) at the time of procedure with CT angiograms demonstrating differential perfusion between true and false lumen. After review of abdominal and pelvic CTA, procedures were performed using a common femoral artery approach under fluoroscopic guidance. Punctures were made using a catheter with a flexible trocar stylet followed by 6-10 mm angioplasty. Primary outcomes were relief of pressure gradient between true and false lumen, and relief from signs and symptoms of mesenteric, renal or peripheral ischemia. ResultsTechnical success was 100%. All patients had improved perfusion and symptom resolution after fenestration procedure, and there were no intra- or periprocedural complications. Follow up CTA demonstrated equalization of flow in all cases. Technical success was 100%. All patients had improved perfusion and symptom resolution after fenestration procedure, and there were no intra- or periprocedural complications. Follow up CTA demonstrated equalization of flow in all cases. ConclusionPercutaneous aortic fenestration is rarely performed but very effective in alleviating ischemic symptoms attributable to symptomatic type B dissection. Percutaneous aortic fenestration is rarely performed but very effective in alleviating ischemic symptoms attributable to symptomatic type B dissection.

Sonographically Guided Patellar Tendon Fenestration

Objectives The purpose of this study was to determine whether any sonographic features of jumper's knee can predict the outcome after sonographically guided percutaneous patellar tendon fenestration. Methods Patients were identified between July 2001 and March 2009 who had clinical and sonographic findings of jumper's knee, who had failed conservative treatment, and who had sonographically guided percutaneous fenestration of the patellar tendon. Pain levels were assessed before and 4 weeks after fenestration. Sonograms were retrospectively characterized with regard to echogenicity, size, definition, location, calcification, and hyperemia of the abnormal patellar tendon region. Sonographic findings before fenestration were correlated with clinical outcomes. Results A total of 45 patellar tendons (32 consecutive patients) were included in the study. The average prefenestration functional pain score was 3.6 (range, 2–5), and the average postprocedure functional pain score after 4 weeks was 1.4 (range, 0–5). The preprocedure sonographic finding that correlated with an improved clinical outcome after tendon fenestration was the presence of a well-defined tendon abnormality. No other sonographic findings were associated with the clinical outcome. After fenestration, 76% (34 of 45) showed clinical improvement; 24% (11 of 45) showed no change; and 0% (0 of 45) had worse symptoms at 4 weeks. Conclusions The presence of a well-defined area of tendinosis on sonography was associated with clinical improvement after percutaneous sonographically guided fenestration of the patellar tendon. All tendons either improved (76%) or showed no change (24%) in the functional pain score at 4 weeks after fenestration.

Sonographically Guided Patellar Tendon Fenestration: Prognostic Value of Preprocedure Sonographic Findings

The purpose of this study was to determine whether any sonographic features of jumper's knee can predict the outcome after sonographically guided percutaneous patellar tendon fenestration. Patients were identified between July 2001 and March 2009 who had clinical and sonographic findings of jumper's knee, who had failed conservative treatment, and who had sonographically guided percutaneous fenestration of the patellar tendon. Pain levels were assessed before and 4 weeks after fenestration. Sonograms were retrospectively characterized with regard to echogenicity, size, definition, location, calcification, and hyperemia of the abnormal patellar tendon region. Sonographic findings before fenestration were correlated with clinical outcomes. A total of 45 patellar tendons (32 consecutive patients) were included in the study. The average prefenestration functional pain score was 3.6 (range, 2-5), and the average postprocedure functional pain score after 4 weeks was 1.4 (range, 0-5). The preprocedure sonographic finding that correlated with an improved clinical outcome after tendon fenestration was the presence of a well-defined tendon abnormality. No other sonographic findings were associated with the clinical outcome. After fenestration, 76% (34 of 45) showed clinical improvement; 24% (11 of 45) showed no change; and 0% (0 of 45) had worse symptoms at 4 weeks. The presence of a well-defined area of tendinosis on sonography was associated with clinical improvement after percutaneous sonographically guided fenestration of the patellar tendon. All tendons either improved (76%) or showed no change (24%) in the functional pain score at 4 weeks after fenestration.

Complicated Acute Type B Thoracic Aortic Dissections: Endovascular Treatment For Visceral Malperfusion And Pseudoaneurysms

Morbidity and mortality of acute type B thoracic aortic dissections remain alarmingly high. Endoluminal options are promising. A single-center 5-year review of 17 acute type B aortic dissections complicated by visceral malperfusion (11) or pseudoaneurysm formation (6) treated with endovascular intervention. Interventional techniques included endografting (15) and/or percutaneous fenestration (4). Median follow-up is 28 months (range 0-76 months). Median age was 55 years; 30-day death, stroke, and paraplegia rates were 0%, 17.6%, and 5.9%. Success reversing visceral ischemia or sealing a pseudoaneurysm was 100%. Cross-sectional imaging demonstrated that the false lumen was thrombosed in 9 patients, partially thrombosed in 6 patients. Late events include 1 delayed proximal type I endoleak, 1 delayed rupture of the thoracic aorta requiring successful emergent open surgical repair, and 2 unrelated late deaths. Endovascular approaches to type B dissections presenting with visceral malperfusion and/or pseudoaneurysm can achieve acceptable early results.

Fenestration of an Iatrogenic Aortic Dissection After Endovascular Aneurysm Repair

To present a case of percutaneous fenestration of a type B aortic dissection after endovascular aneurysm repair (EVAR). An 82-year-old patient with an earlier conventionally inserted aortobi-iliac prosthesis presented with a proximal anastomotic pseudoaneurysm, which was excluded successfully by EVAR. Standard follow-up computed tomographic angiography (CTA) 48 hours after the procedure, however, revealed a type B aortic dissection. Despite conservative antihypertensive therapy, the patient developed abdominal and back pain, and intervention was indicated. Endovascular balloon fenestration of the intimal flap was performed, resulting in relief of pain even though the false lumen remained patent. At 8 months after the procedure, the patient was symptom free, and CTA showed no progression of the persistent type B dissection. Percutaneous fenestration can be used as a therapy of first choice in patients with an acute aortic dissection post EVAR.

Percutaneous Fenestration and Stent Placement for Aortic Dissection that Relieved Occluded Infrarenal Abdominal Aortic Flow: A Case Report

Here we report a case of infrarenal abdominal aortic occlusion secondary to Stanford type A acute aortic dissection, which was successfully treated with percutaneous fenestration and aortic stent placement. Adequate flow to the occluded infrarenal abdominal aorta was not restored by means of percutaneous fenestration alone, so an additional procedure, aortic stent placement, was required to buttress the true lumen and fenestra. We discuss ischemic complications of aortic dissection and related percutaneous intervention and review the literature.

Letters

STUDY DESIGN Clinical case series. OBJECTIVE To present a new innovative treatment option for cysts of the terminal ventricle. SUMMARY OF BACKGROUND DATA Invasive surgery including laminectomy and cyst fenestration has been the sole reported method of treatment for this rare pathology. METHODS Four cases of symptomatic cyst of the terminal ventricle of the spinal cord were treated by percutaneous aspiration using real-time guidance with magnetic resonance imaging (MRI) and optically-tracking navigation. RESULTS Three patients were treated successfully by this percutaneous method, and for 1 patient the treatment was converted to conventional surgery after a single unsuccessful trial of percutaneous puncture. All patients were relieved of their symptoms without any complication. Follow-up MRI revealed continued shrinkage of the cysts after both surgery and MRI-guided percutaneous fenestration. CONCLUSION MRI-navigated percutaneous aspiration can be a minimally-invasive treatment option for symptomatic cysts of the terminal ventricle, and therefore, can be indicated before more invasive surgery might be scheduled.

Percutaneous transthoracic fenestration of an intramedullary neurenteric cyst in the thoracic spine with intraoperative magnetic resonance image navigation and thoracoscopy

Neurenteric cysts are rare congenital cysts typically located in the anterior cervical or thoracic spinal canal. The authors report on their experience with the successful treatment of a midthoracic neurenteric cyst in an 8-year-old boy. Percutaneous fenestration via a transthoracic, transvertebral approach with combined thorascopy and intraoperative MR imaging guidance was used, and the cyst showed lasting shrinkage. The authors discuss this minimally invasive technique and its limitations.