Push Technique Research Articles

In Vitro Modeling of Human Brain Arteriovenous Malformation for Endovascular Simulation and Flow Analysis

Current invitro models for human brain arteriovenous malformation (AVM) analyzing the efficacy of embolic materials or flow conditions are limited by a lack of realistic anatomic features of complex AVM nidus. The purpose of this study was to evaluate a newly developed invitro AVM model for embolic material testing, preclinical training, and flow analysis. Three-dimensional (3D) images of the AVM nidus were extracted from 3D rotational angiography from a patient. Inner vascular mold was printed using a 3D printer, coated with polydimethylsiloxanes, and then was removed by acetone, leaving a hollow AVM model. Injections of liquid embolic material and 4-dimensional (4D) flow magnetic resonance imaging (MRI) were performed using the AVM models. Additionally, computational fluid dynamics analysis was performed to examine the flow volume rate as compared with 4D flow MRI. The manufacture of 3D invitro AVM models delivers a realistic representation of human nidus vasculature and complexity derived from patients. The injection of liquid embolic agents performed in the invitro model successfully replicated real-life treatment conditions. The model simulated the plug and push technique before penetration of the liquid embolic material into the AVM nidus. The 4D flow MRI results were comparable to computational fluid dynamics analysis. An invitro human brain AVM model with realistic geometric complexities of nidus was successfully created using 3D printing technology. This AVM model offers a useful tool for training of embolization techniques and analysis of hemodynamics analysis, and development of new devices and materials.

3:18 PM Abstract No. 220 A randomized controlled trial of metoclopramide versus placebo to reduce fluoroscopy time during gastrojejunostomy tube placement

Gastrojejunostomy (GJ) tube placement is a common procedure performed to provide post pyloric nutritional support, but advancing a guidewire and the tube through the pylorus can be a tedious and time consuming step. The purpose of this study was to determine whether a single dose of the gastric promotility agent metoclopramide prior to GJ tube placement facilitates passage of the guidewire through the pylorus thus reducing fluoroscopy time. In this single-institution, randomized, double-blind, placebo-controlled trial, consecutive patients over 18 undergoing GJ tube placement were enrolled from April 9, 2018, to September 4, 2019. Patients unable to provide written consent or with metoclopramide allergy, altered pyloric anatomy (e.g., prior Whipple), long QT, extrapyramidal symptoms or seizure disorders were excluded. 51 patients were randomized to a single dose of metoclopramide 10 mg IV and 51 patients were randomized to placebo immediately prior to GJ tube placement. Balloon retained GJ tubes were placed using standard push technique. Fluoroscopy time, air kerma, and total procedure time were recorded. Groups were compared using t-tests and Fisher’s exact test. 43 of 51 patients (n = 33 males, mean age = 57) randomized to metoclopramide and 48 of 51 (n = 27 males, mean age = 54) randomized to placebo underwent GJ placement (P = 0.20). Mean fluoroscopy time to advance the guidewire from the stomach through the pylorus was 1.6 minutes (range, 0.3-10.1) in the metoclopramide group versus 4.2 minutes (range, 0.2-27.3) for placebo (P = 0.003). Mean total procedure fluoroscopy time was 5.8 minutes (range, 1.5-16.2) versus 8.7 minutes (range, 2.8-29.7) (P = 0.004). Mean air kerma was 90 mGy (range, 13-354) versus 124 mGy (range, 24-525) (P = 0.08). Mean total procedure time was 16.5 minutes (range, 8-51) versus 19.7 minutes (range, 6-53) (P = 0.07). There was no significant difference in the 30 day major complication rate (n = 1 in each group; P = 1.0). There were no drug related adverse events. A single dose of 10 mg metoclopramide immediately prior to GJ tube placement leads to a statistically significant reduction in fluoroscopy time by a factor of one third.

3:27 PM Abstract No. 221 Multicenter preliminary experience with percutaneous ultrasound gastrostomy: do interventional radiologists need fluoroscopy for gastrostomy placement?

To evaluate the initial feasibility and safety of percutaneous ultrasound gastrostomy (PUG) using the novel technique of magnetic gastropexy by interventional radiologists at two institutions. Institutional review board approval was obtained at both institutions, and all attempted PUG procedures were retrospectively reviewed. Data collected included BMI, procedural details, time to initiate feeds, and complications. Briefly, the stomach is coapted to the abdominal wall using an external high field magnet and orogastric tube with a ferromagnetic rod within an inflatable balloon. Direct ultrasound guidance is used to puncture the balloon and the balloon is used as a snare for a pigtail wire. A push technique self-dilating gastrostomy tube is then placed over the wire. Twenty patients underwent attempt at PUG. Patient demographics included a mean age of 67.3 ± 12 years and BMI of 24.0 ± 3.3 kg/m2. Most procedures were done with moderate sedation (17/20). Technically successful placement of PUG was achieved in 75% of patients (15/20), including one case performed completely at the bedside without fluoroscopy. Fluoroscopy was used for confirmation or assistance in placement during all other cases (median fluoro time, 1.5 ± 4.1 min). Three patients required adjunctive techniques for PUG placement. One patient with a gastroesophageal stricture required conversion to fluoroscopically guided gastrostomy tube placement. One major and one minor complication related to tube placement occurred. Additionally, one patient was admitted with aspiration pneumonia 16 days post procedure. Tube feeds were initiated in less than 24 hours in 16 patients. Percutaneous ultrasound gastrostomy (PUG) using a proprietary external magnet for coaptation gastropexy is a safe technique for gastrostomy placement, allowing prompt initiation of supplemental nutrition. This study demonstrates that as with all interventional radiology procedures, appropriate patient selection is critical. With continued experience and refinement of technique, fluoroscopy will not be required as was demonstrated with the successful bedside gastrostomy.

Outcome, complication and follow-up of patients with esophageal foreign body impaction: an academic institute's 15years of experience.

Esophageal foreign body impaction (EFBI) is a gastrointestinal emergency, mostly requiring endoscopic management. The aim of this study is to evaluate the epidemiology, adverse events, and outcomes of patients following the episode of EFBI. All esophagogastroduodenoscopy (EGD) reports of admitted patients for EFBI at the University of Kansas Medical Center between 2003 and 2018 were retrospectively reviewed. Of 204 patients, who met the inclusion criteria, 60% were male and the mean age was 54.7 ± 17.7years. The encounter was the first episode of EFBI in 76% of cases. EGD in less than 24hours of patients' admission was required in 79% of cases. The distal esophagus was the most common site of impaction (44%). Push and pull techniques were used in 38 and 35.2% of cases, respectively, while 11% were managed by a combination of both techniques. Structural causes were the most common etiologic findings including benign strictures and stenosis in 21.5% of patients, followed by Schatzki's ring (7.8%) and hiatal hernia (6.9%). Of all cases, 45% did follow-up in up to 1 year, and biopsy was done in 34% of cases. Out of 43 patients who had endoscopic findings suspicious for eosinophilic esophagitis (EoE), the diagnosis was confirmed by pathology in 37. The rate of recurrence EFBI was significantly higher in patients with EoE (P < 0.001). EFBI-related esophageal adverse events (AEs) occurred in 4.9% of cases. Cardiovascular and pulmonary AEs occurred in 1.5 and 2.9%, respectively. Logistic regression did not find any predictor for AEs occurrence. EFBI managed very well with endoscopic treatments. Despite the emerging data about the safety of the push technique, there are still concerns regarding its adverse events especially the risk of perforations. Our study shows no significant difference in adverse events between different types of techniques.

Abstract TP492: Novel in vitro Model of Arteriovenous Malformation for Endovascular Embolization and Flow Analysis

Introduction: 3D printed human vascular in vitro models of aneurysms and acute stroke have been utilized for training, simulation and device development. However, there are no realistic in vitro arteriovenous malformation (AVM) models. Current experimental models analyzing the efficacy of embolic materials or flow conditions are limited by their simplistic design, lacking complex AVM nidus anatomic features. The purpose of this study is to develop a new in vitro AVM model for embolic material testing and flow analysis. Methods: 3D images of the AVM nidus were extracted from 3D rotational angiography from a patient. Artificial feeders and drainers were added to the nidus and an inner vascular mold was printed using a 3D printer. The inner mold was coated with polydimethylsiloxanes. The inner plastic mold was removed by acetone, leaving a hollow AVM model. ONYX injection and 4DFlow MRI (Phase Contrast MRA) were performed using the AVM models. In addition, computational fluid dynamics (CFD) analysis was performed to compare flow rate with 4DFlow MRI. Results: An in vitro AVM model with realistic representation of nidus vasculature and complexity was successfully created. Liquid onyx injection performed in the in vitro model successfully replicated real-life treatment conditions. The model effectively simulated plug and push technique before penetration of the ONYX into the AVM nidus. 4DFlow MRI flow rates were similar to the CFD analysis. Conclusions: An in vitro AVM model using 3D printing technology was successfully created. The model demonstrated realistic pliability during ONYX injection. This in vitro AVM model may represent a useful tool for training and development of new materials, and have potential of highly-resolved flow quantifications.

A importância da amostragem de solo de perfil completo (ASPC) para a investigação de alta resolução em áreas contaminadas

A metodologia tradicional de investigação de áreas contaminadas no Brasil se baseia na instalação de poços de monitoramento não afogados com 3 m de seção filtrante e amostragem de solo somente na zona não saturada, realizada na mesma sondagem e com o mesmo equipamento utilizado para fazer a perfuração para a instalação do poço (normalmente trado manual ou helicoidal mecanizado). Essa metodologia não é capaz de fornecer informações suficientes para a elaboração de um modelo conceitual adequado para a área e é incompatível com as normas: NBR 16.434, NBR 15.495-1, ASTM D6282 e com a Decisão de Diretoria 038 (DD-038) da CETESB. Para que esses dispositivos sejam integralmente atingidos, é necessário que, durante a investigação, seja dada prioridade à execução de amostragens de solo de perfil completo (ASPC) que coletem amostras representativas de todo o perfil, inclusive na zona saturada. A ASPC deve permitir: a aquisição de amostras para análises químicas e físicas em laboratório; a realização de uma varredura vertical de contaminantes; e a identificação e caracterização das UH. Para isso, é preciso utilizar a técnica Direct Push, e dentro dessa técnica, as modalidades Dual Tube, Piston Sampler, ou em casos especiais, Single Tube revestida. Dessas, a que se mostrou mais eficiente para a execução da ASPC foi a Dual Tube.

Embolization of a Complex Facial Arteriovenous Malformation, Balloon-Assisted Flow Arrest, and Controlled n-BCA Injection with Dextrose Push Technique: 2-Dimensional Operative Video.

N-butyl cyanoacrylate glue (n-BCA, Cerenovus, Irvine, California) is commonly used to treat arteriovenous malformation (AVM). Even though Onyx (ethylene vinyl alcohol, Medtronic, Dublin, Ireland) presents more controlled injection, n-BCA is colorless, thus preferable for treatment of superficial facial malformations. N-BCA injection into AVM can result in premature distal migration or early precipitation and reflux into the feeder vessels. Here we describe a trans-arterial balloon assisted technique embolization of a complex facial AVM with n-BCA. A 22-yr-old female with chronic oral/gum bleeding presented with a complex facial AVM. She underwent selective transarterial n-BCA balloon assisted treatment with dextrose push. Informed written consent was obtained. A Scepter dual lumen balloon (MicroVention, Aliso Viejo, California) and a Prowler microcatheter (Cerenovus) were introduced via a 6-French Envoy guide catheter (Cerenovus) selectively into the AVM feeder. The balloon was positioned 3 cm proximal to the Prowler microcatheter tip and fully inflated to create flow arrest. Diluted 25% concentration of n-BCA in Ethiodol Oil was injected through the Prowler microcatheter. The distal migration of the n-BCA was modulated with simultaneous injection of Dextrose 5% in water via the Scepter balloon. This resulted in a controlled glue injection without early distal glue migration (because of the flow arrest) nor early proximal glue precipitation or reflux (because of the dextrose infusion), obtaining complete cure of the complex facial AVM. Glue embolization with flow arrest and dextrose push allows well controlled injection, and it represents a valid option also for high flow vascular lesions.

Commentary: Embolization of a Complex Facial Arteriovenous Malformation, Balloon-Assisted Flow Arrest, and Controlled n-BCA Injection With Dextrose Push Technique: 2-Dimensional Operative Video.

Commentary: Embolization of a Complex Facial Arteriovenous Malformation, Balloon-Assisted Flow Arrest, and Controlled n-BCA Injection With Dextrose Push Technique: 2-Dimensional Operative Video.

2189 Lavaging the Esophagus of Food Obstruction

INTRODUCTION: Esophageal obstructions are usually due to a food bolus or foreign body ingestion in the setting of underlying esophageal disease. They are medical emergencies, requiring endoscopy within 24 hours of presentation, as failure to intervene can lead to perforation, fistula formation, or aspiration. Standard treatment consists of using a fiberoptic endoscope to advance the object into the stomach or retrieving it proximally. We describe the case of an esophageal obstruction from mashed potatoes. Due to its consistency, the obstruction could not be fully cleared with standard techniques and required an off-label use of gastric lavage for removal. CASE DESCRIPTION/METHODS: A 94-year-old female presented to our hospital complaining of three weeks of nausea, vomiting, and poor oral intake. Despite primarily consuming mashed potatoes, her symptoms worsened, with emesis of any solid foods or medications. She denied any history of dysphagia, esophageal dysmotility, or food impaction. Vital signs were stable and her abdominal exam was benign with no peritoneal signs. Abdominal computed tomography demonstrated a distal esophageal obstruction with proximal dilation. Upper endoscopy revealed food impaction with thick fibrinous food particles extending the entire length of the esophagus. Proximal retrieval with Roth Net retrievers, biopsy forceps, and tripod forceps was attempted for over two hours with minimal clearance. Given poor visualization and extent of esophageal involvement, the push technique could not be safely performed. Food particles repeatedly clogged the endoscope despite the use of diet ginger ale to break up the food. Hours later, success was finally achieved through gastric irrigation with the Ewald tube. DISCUSSION: Esophageal obstruction due to mashed potatoes is rare, and the standard methods of clearance may be ineffective at clearing its fibrinous content. Gastric lavage, routinely used in drug overdose to clear toxic ingestions, consists of inserting a tube (such as an Ewald tube) into the stomach via the mouth with sequential passing of water or saline to remove stomach contents. The same approach was applied to our patient to clear the fibrinous remnants adhering to her esophagus. This case appears to be the first reported use of gastric lavage to clear esophageal obstructions. When available, gastric lavage appears to be an effective method of managing esophageal soft food obstructions and may be considered as a last resort measure when all other methods have failed.

565 Prophylactic Antibiotics for PEG Tube Placement: An Updated Meta-Analysis of Randomized Controlled Trials

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tube placement is associated with a risk of infection. It is currently a standard of practice to administer prophylactic antibiotics with PEG tubeplacement. However, several recent studies have reported mixed results. We performed an updated meta-analysis to assess the efficacy of prophylactic antibiotics for PEG tube placement. METHODS: MEDLINE, Google scholar, Embase PubMed, Cochrane Database, and abstracts from gastroenterology scientific meetings were searched. Only randomized controlled trials (RCTs) of adult subjects comparing prophylactic antibiotics to no prophylactic antibiotics for PEG tube placement were included. Study quality was accessed by assigning a quality score. Two independent reviewers used standard forms to extract data and the differences were resolved by mutual agreement. Meta-analysis for the effects of prophylactic antibiotics was analyzed by calculating pooled risk or odds ratio for peristomal infections, systemic infections, and mortality using both fixed and random effects models. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency. Publication bias was also assessed. RESULTS: Thirteen RCTs (636 controls/764 treatment arm) met the inclusion criteria. All trials were published between 1985 and 2016. Eight trials predominantly used cephalosporins and 5 trials used penicillins. Eleven trials reported the technique of PEG tube placement: 8 used pull technique, 1 push technique, 1 both and 1 used the introducer method. In the treatment arm 1.07% of the patients got peristomal infection and in the control arm it was 2.55%. Prophylactic antibiotics with PEG tube placement resulted in a significant reduction in the risk of peristomal infection (RR 0.49, 95% CI: 0.39–0.63, P &lt; 0.001, NNT = 8) and systemic infection. On subgroup analysis, both cephaloporins and penicillin based prophylaxis resulted in statistically significant reduction in risk of infections. Both single dose and multiple doses of antibiotics resulted in a reduction in the risk of infection. No significant difference was noted for mortality. Heterogeneity among studies was not significant. Funnel plots revealed no significant publication bias. Majority of the studies received a high score for quality. CONCLUSION: Current evidence supports the administration of prophylactic antibiotics prior to PEG tube placement. Further studies need to explore different PEG tube placement techniques that might obviate the need for antibiotics.

394 Esophageal Food Impaction - A Retrospective Chart Review

INTRODUCTION: Esophageal Food Impaction (EFI) is the third most common non-biliary emergency in gastroenterology with an estimated annual incidence rate of 13 episodes per 100,000 person-year and resulting in 1500 deaths per year. Patient’s presenting with food impaction often have underlying esophageal pathology. Esophageal dysmotility is one of them which can be seen in diabetics and 60% of these patients have manometric abnormalities which may be associated with increased risk of food impaction but limited studies have been done to evaluate these correlations. The possible risk factors and association with diabetes in EFI was evaluated in our study. METHODS: Retrospective chart review of 455 patients who presented to the Staten Island University Hospital with symptoms of food impaction from 1999 to 2017. A retrospective analysis was undertaken on relevant clinical data such as age, risk factors, type of bolus, location, administration of glucagon, endoscopic technique, complications, and outcome. RESULTS: Overall, 174 patients had endoscopically confirmed FI with males 102/174 (58%). Esophageal pathology found in endoscopy includes esophagitis in 58/174 (33%), stricture in 43/174 (24%), hiatal hernia in 29/174 (17%), Schatzki ring in 15/174 (9%), normal endoscopy in 32/174 (19%) (Figure 1). Diabetes was reported in 20/174 (11%) (Figure 2). Type of food was meat in 73/174 (41%). Location of EFI mainly in the lower one-third of the esophagus in 94/174 (61%). Endoscopic push technique was used in 95/174 (55%), pull technique in 83/174 (48%). Endoscopy was successful for the first time in 165/174 (96%) patients. Complications were reported in only 5/174 (3%) including perforation and tear. Glucagon was given to 74/174 (43%) and mean door to endoscopy time (time of presentation to the emergency department to endoscopy procedure) was 10 hours in patients received glucagon, 13 hours in patients who didn’t receive glucagon (Figure 3). CONCLUSION: EFI is more common in males. Esophageal stricture and hiatal hernia were the most common pathologies found in endoscopy. Esophagitis is found in 33% of patients but whether it is the culprit for FI or consequence of FI is not clear. Diabetes is associated with food impaction in only 11% of patients but more studies are needed to find out the true association. Administration of glucagon resulted in the decreased door to scope time. Endoscopy is a safe and effective method for food impaction and complications reported were minimal.

374 Practice Patterns in Patients Admitted for Denovo Acute Food Impaction: A Multi-Center Retrospective Study

INTRODUCTION: Food impactions are a medical emergency for gastroenterologists. Despite their common occurrence, recent data shows high variability in self-reported practice patterns of how gastroenterologists approach food impactions. This may lead to delayed diagnosis and care for patients, particularly in eosinophilic esophagitis (EoE). There is limited data available assessing real life practice habits and recommendations based on endoscopic findings. METHODS: This is a multi-centered, single-system retrospective chart review of all patients admitted with de novo food impaction between Jan 2013 and Sept 2018. Data collected includes demographics, clinical, endoscopic, and discharge recommendations. Patients with diagnosis of achalasia, EoE, malignancy, or stricture were excluded. Our primary aim was to characterize GI practice habits and discharge planning. A planned secondary analysis comparing practice habits in patients with and without presumed EoE was done. RESULTS: 199 patients were admitted with food impaction during the study period, 157 meeting inclusion criteria. 36 had endoscopic features of EoE, with 33 having EoE as the presumptive diagnosis. 109 had a food bolus present on endoscopy. To remove this bolus, the ‘push through’ method was used in 29.9% of cases, roth nets in 26.1%, and graspers in 22.9%. On sub-group analysis, there was no statistical difference regarding endoscopic technique between those with and without presumed EoE. Esophageal biopsy was obtained in 40.1% of cases, but in 75.8% of patients with presumed EoE vs. 32.0% without (P ≤ 0.001) . At discharge, 79% of patients were started on a proton pump inhibitor (PPI), 43.9% were instructed to have a follow up endoscopy, with providers more likely to both start a PPI (P = 0.01) and refer for follow up (P = 0.02) if EoE was suspected. CONCLUSION: We conducted a multi-center, single-system study on the real life practice of gastroenterologists evaluating patients with de novo food impaction. EoE was suspected in 33 patients with a confirmed diagnosis in 63.6%. Push technique continued to be used as frequently in patients suspected of having EoE. Only 78.8% of patients underwent esophageal biopsy and 93% were started on PPI, though both statistically more frequent in patients with suspected EoE. There remains room for quality improvement in the treatment of de novo food impactions in patients suspected of having EoE and those who are not. A standardized protocol for food impactions would facilitate prompt diagnosis and treatment.

Cap-Assisted Technique versus Conventional Methods for Esophageal Food Bolus Extraction: A Comparative Study.

Background/AimsFood bolus impaction is the most common form of esophageal foreign body impaction observed in adults. Clinical guidelines recommend using the push technique or retrieval methods in such cases. The push technique can cause injuries in certain clinical situations. Notably, conventional retrieval methods are time and effort consuming. Cap-assisted endoscopic extraction of an impacted food bolus is an easy and effective technique; however, more data are needed for its validation. This study compared the capassisted extraction technique with conventional methods. MethodsThis prospective observational multicenter study compared the success and en bloc removal rates, total procedure time, and adverse events in both techniques.. ResultsThe study included 303 patients who underwent food bolus extraction. The push technique was used in 87 patients (28.7%) and a retrieval procedure in 216 patients (71.3%). Cap-assisted extraction was performed in 106 patients and retrieval using conventional methods in 110 patients. The cap-assisted technique was associated with a higher rate of en bloc removal (80.2% vs. 15%, p<0.01), shorter procedure time (6.9±3.5 min vs. 15.7±4.1 min, p<0.001), and fewer adverse events (0/106 vs. 9/110, p<0.001). ConclusionsCap-assisted extraction showed no adverse events, higher efficacy, and a shorter procedure time compared with conventional retrieval procedures.

Procedural approaches and angiographic signs predicting first-pass recanalization in patients treated with mechanical thrombectomy for acute ischaemic stroke.

First-pass recanalization via mechanical thrombectomy (MT) has been associated with improved clinical outcome in patients with acute ischaemic stroke. The optimal approach to achieve first-pass effect (FPE) remains unclear. No study has evaluated angiographic features associated with the achievement of FPE. We aimed to determine the procedural approaches and angiographic signs that may predict FPE. We performed a prospective, multi-centre, observational study of FPE in patients with anterior circulation stroke treated with MT between February and June 2017. MTs were performed using different devices, deployment manoeuvres (standard versus 'Push and Fluff' technique), proximal balloon guide catheter (PBGC), distal aspiration catheter (DAC) or both. The angiographic clot protrusion sign (ACPS) was recorded. Completed FPE (cFPE) was defined as a modified thrombolysis in cerebral infarction score of 2c-3. Associations were sought between cFPE and procedural approaches and angiographic signs. A total of 193 patients were included. cFPE was achieved in 74 (38.3%) patients. The use of the push and fluff technique (odds ratio (OR) 3.45, 95% confidence interval (CI): 1.28-9.29, p = 0.010), PBGC (OR 3.81, 95% CI: 1.41-10.22, p = 0.008) and ACPS (OR 4.71, 95% CI: 1.78-12.44, p = 0.002) were independently associated with cFPE. Concurrence of these three variables led to cFPE in 82 vs 35% of the remaining cases (p = 0.002). The concurrence of the PBGC, the push and fluff technique, and the ACPS was associated with the highest rates of cFPE. Appropriate selection of the thrombectomy device and deployment technique may lead to better procedural outcomes. ACPS could be used to assess clot integration strategies in future trials.

The evolution of treatment and complications of esophageal food impaction.

Esophageal food impaction is relatively common and increasing over time. Treatment ranges from medications to invasive endoscopic therapies. The endoscopic push technique has been advised against in favor of endoscopic retrieval for safety concerns. We sought to assess use patterns and safety of treatments for food impaction in a population-based retrospective review. A database of recorded esophageal food impactions in Olmsted County, MN, USA, from 1975-2011 was reviewed for patient demographics, treatment, and complications. A total of 645 impactions occurred, with increasing incidence over time, peaking at 23.2 per year (2000-2004). Medications (almost exclusively glucagon) were successful in relieving impactions 34.5% of the time when trialed. Urgent endoscopy was common (74.0%), as was the need for endoscopic therapy (67.1%). Endoscopic therapy increased over time, with the endoscopic push technique becoming most common. Esophageal complications (deep mucosal injury or perforation) increased over time but remained rare (peak 11%). There was no difference in complications between push and retrieval techniques. The endoscopic push technique is safe in comparison to endoscopic retrieval in esophageal food impactions. While complications surrounding impaction have increased, they remain rare. Medication trials are reasonable, as long as they do not delay endoscopy, and may prevent the need for emergent endoscopy in one-third of cases.

Abstract 7: Procedural Approaches and Angiographic Signs Predicting First-Pass Recanalization in Patients Treated With Mechanical Thrombectomy for Acute Ischemic Stroke

Background: First pass recanalization via mechanical thrombectomy (MT) has been associated with improved clinical outcome in patients with acute ischemic stroke. However, the optimal approach to achieve First Pass Effect (FPE) remains unclear. No study has evaluated angiographic features associated with the FPE. We aimed to determine the procedural approaches and angiographic signs that may predict FPE. Methods: We performed a prospective, multi-center, observational, study in patients with large vessel occlusion of the anterior circulation treated with MT between February and June 2017. MT was performed using different devices, deployment manoeuvres (standard unsheathing versus the “Push and Fluff” technique), Proximal Balloon Guide Catheter (PBGC), Distal Aspiration Catheter (DAC), or both. The Angiographic Clot Protrusion Sign (ACPS) was recorded. The modified Thrombolysis in Cerebral Infarction (mTICI) scale was used to score different levels of revascularization: FPE was defined as mTICI2b-3 and complete FPE (cFPE) as mTICI2c-3 after first pass. Associations were sought between FPE/cFPE and procedural approaches and angiographic signs. Adjusted logistic regression model was used to define independent predictors of succesful recanalization. Results: A total of 193 patients were included. FPE was achieved in 97 (50.3%) and cFPE in 74 (38.3%) patients. When the interventionalist decided to combine a PBGB and the Push and Fluff technique, FPE was achieved in 75% vs 47% of other cases (p&lt;0.01) and cFPE in 64% vs 34% respectively (p&lt;0.01). When the combination concurred with APCS, higher incidence of FPE (91% vs 47% p&lt;0.01) and cFPE (82% vs 35% p&lt;0.01) were observed. The use of PBGC (OR 3.81, 95%CI:1.41-10.22, p&lt;0.01), the use of Push and Fluff technique (OR 3.45, 95%CI:1.28-9.29, p=0.01) and the record of ACPS (OR 4.71, 95%CI:1.78-12.44, p&lt;0.01) were independently associated with higher rates of cFPE. Conclusions: In our experience, the concurrence of the PBGC, the Push and Fluff technique, and the ACPS was associated with the highest rates of FPE and cFPE. Appropriate selection of the thrombectomy device and deployment technique may lead to better procedural outcomes. ACPS could be used to assess clot integration strategies in future trials.

A comparative randomized trial with 20 Fr pulls and 20 Fr push technique for percutaneous endoscopic gastrostomy using a new device

A comparative randomized trial with 20 Fr pulls and 20 Fr push technique for percutaneous endoscopic gastrostomy using a new device

Glucagon Use During Endoscopy to Assist Push Technique in Food Impactions

Introduction: Esophageal food impactions are a common indication for urgent upper endoscopy. Preprocedural glucagon, given to relax esophageal smooth muscle, increase spontaneous bolus passage, and thus avoid the need for endoscopy, has been shown to have limited efficacy. Endoscopic therapies, including push and extraction techniques, are often challenging, prolonged, and associated with increased risk of complications. We aim to investigate the effectiveness of perioperative glucagon administration on the success rate of bolus advancement with simple push technique and its impact on procedural duration. Methods: A retrospective, single center, chart review was performed utilizing an electronic medical record over a three-year period selecting for patients age 18 or older with an ICD-9 code of 935.1 (foreign body in esophagus) who underwent an EGD. The measured outcomes were success rate, defined as advancement of food bolus into the stomach with gentle pressure without reduction of bolus size or retrograde extraction, and procedural time between two groups, with and without use of periprocedural glucagon. Results: 150 total patient encounters were identified, 53 of which were excluded due to spontaneous bolus passage, presence of a nonfood foreign body, missing data, suspected underlying dysmotility, or patient refusal of procedure. 97 patients remained in the study; 11 received perioperative glucagon based on physician preference. Glucagon use was associated with a higher success rate (73%) than without (67%), however this was not statistically significant (p=0.579) when controlled for age and gender. Mean procedure time was shorter in the glucagon group at 7.54 min vs 14.93 min in the control group, but did not reach statistical significance (p=0.077). All procedure related complications occurred in the non-glucagon group, but the small sample size precluded it reaching statistical significance. Conclusion: The use of perioperative glucagon trended with an increased success rate of esophageal food bolus advancement into the stomach, decreased procedural duration and lower procedural complications. Though these results were not found to be statistically significant in our small sample size, we feel they hold promise to support further research.498_A Figure 1 No Caption available.498_B Figure 2 No Caption available.498_C Figure 3 No Caption available.

Experimental Direct Measurement of Clot-Capturing Ability of Stent Retrievers

Stent retrievers (SRs) can be used to perform mechanical thrombectomy for the treatment of acute major arterial occlusion. Recanalization is faster, and outcomes are better with treatment involving these devices than with internal treatment. Although several SRs are available, their clot-capturing abilities are unclear. Therefore in the present study, we numerically evaluated the clot-capturing abilities of SRs in an experimental vascular model. A sham clot (urethane foam) was fixed with sutures at the middle of a vascular model (polyvinyl chloride tube). One end of the tube was connected to a measuring instrument. From the other end, an SR was inserted and deployed over the sham clot. The delivery wire of the stent was then withdrawn at a constant velocity using an automatic withdrawal machine. The maximum frictional force before the stent left the clot was measured. Five stents (Trevo ProVue [2 sizes], Revive, and Solitaire [2 sizes]) and three stent-deployment techniques (standard, push-and-fluff, and wire-push techniques) were evaluated. The clot-capturing ability (maximum withdrawing force [N: newton]) was greater for large-diameter stents than for small-diameter stents (mean 0.39 ± 0.11 vs. 0.56 ± 0.18). For Trevo and Revive, the clot-capturing ability was highest with the push and fluff technique (mean 0.43 ± 0.05). For Solitaire, the ability was the highest with the simple wire-push technique (mean 0.705 ± 0.16). We successfully numerically evaluated the clot-capturing abilities of SRs. The clot-capturing ability differed among SRs and among stent-deployment techniques.

Retreat and push technique in double-J sent insertion during retroperitoneal laparoscopic ureterolithotomy

Objective To investigate the new method of " retreat and push" in double-J sent insertion during retroperitoneal laparoscopic ureterolithotomy. Methods From March 2015 to March 2017, 42 cases of upper ureteral calculi were performed retroperitoneal laparoscopic ureterolithotomy, retreat and push technique technique in double-J sent insertion were adopted during operations, the experiences of placement and the data of postoperation were summarized. Results The processes of double-J sent insertion were completed in (1.81±0.71)min(from 1 to 4 min), and the positions were showed normal in KUB after operations. The catheters were removed 4-6 days after operation and drainage tubes one day later, while the double-J sents were pulled out 1 to 2 months after operation. No cases of infection or leakage of urine were found. Conclusions Retreat and push technique is simple, fast and effective in retroperitoneal laparoscopic ureterolithotomy. Key words: Ureteral Calculi; Laparoscopy; Catheters, Indwelling