Fluoroscopy and CT Guided Translumbar Tunneled Dialysis Catheter for Hemodialysis Access Failure in a Case of Autosomal Dominant Polycystic Kidney Disease.

Vascular access in hemodialysis is essential to end-stage renal disease (ESRD) patients' survival. Unfortunately, even after years of recent advances, a significant number of patients may develop multi-access failure for many reasons. In this situation, arterial-venous fistula (AVF) or catheters placement in traditional vascular sites (jugular, femoral, or subclavian) are not feasible. In this scenario, translumbar tunneled dialysis catheters (TLDCs) may be a salvage option. The use of central venous catheters (CVC) is associated with an increased incidence of venous stenosis that can progressively limit future vascular access routes. The common femoral vein can be used for temporary access in patients in whom traditional approaches for permanent central venous access may not be feasible because of either chronically occluded or not accessible vasculature; however, this location is not preferred for long-term venous access because of the high rate of catheter related blood stream infections (CRBSI). In these patients, a direct translumbar approach to the inferior vena cava is a lifesaving alternative. This approach has been described by several authors as a bail-out option. Fluoroscopy-guided access via a translumbar approach into the inferior vena cava bares the risk of hollow-organ perforation or severe bleeding from the inferior vena cava or even the aorta. To minimize the risk of complications caused by a translumbar central venous access, we hereby present a hybrid approach with CT-guided translumbar access of the inferior vena cava followed by a conventional implantation of the permanent central venous catheter. CT scan-guided access of IVC that further helps in our case as patient has large bulky kidneys secondary to autosomal dominant polycystic kidney disease.

Adrenal Venous Sampling in Primary Aldosteronism: Single-Centre Experience from Western India.

Introduction: The protocols and criteria used for adrenal venous sampling (AVS) differ across centres. There are no studies from the Indian subcontinent describing AVS-based outcomes in primary aldosteronism (PA). We aim to describe our experience from a single centre. Methods: Retrospective records from 2018 to 2020 of patients with confirmed PA who underwent AVS were reviewed. Clinical, imaging, AVS data and outcomes (as per PASO criteria) were recorded. AVS was performed by sequential sampling with cosyntropin stimulation with intraprocedural cortisol and cut-off of selectivity >5 and lateralization >4 by a single radiologist. Results: Fifteen patients with median age of 50 years (41-58) and duration of hypertension of 156 (36-204) months were included. Ten had grade 3 hypertension, 13 had hypokalaemia and 3 had hypokalaemic paralysis. On CT scan, eight patients had bilateral adrenal lesions, four had unilateral adenoma and three patients had normal adrenals. AVS was bilaterally successful in all and showed lateralization of disease in 10 patients and was bilateral in the remaining 5 patients. Overall concordance of CT and AVS was 5/15 (33.3%). Among seven patients who underwent surgery, complete clinical success was seen in two and partial clinical success in the remaining five. Complete biochemical success was seen in two and partial in one. There were no major complications. Conclusions: AVS performed by a single radiologist with defined protocols has a good success rate. AVS has additional value over CT scan in lateralization, especially when CT shows bilateral disease.

Plugged percutaneous liver biopsy using Tru-cut needle and coils: A retrospective study.

BACKGROUND: Plugged percutaneous liver biopsy, though has been in use for many years, is being used more frequently in patients in whom percutaneous liver biopsy is contraindicated due to proven or probable bleeding tendencies. We report our experience with this procedure, its indications, efficacy, and complications in Indian population over 2 years. METHODS: A retrospective study of 127 consecutive patients who had undergone plug liver biopsy from April 2017 to May 2019 was done from the database maintained in our department. The indications, technical success, complications, and impact of histological diagnosis on the management of those patients were evaluated. RESULTS: A total of 127 biopsies were performed of which 68 were males and 59 were females, aged between 7 and 73 years. No procedures were abandoned; however, 13 cases needed ultrasonography (USG) guidance because of small size of the liver or presence of right perihepatic fluid. Out of 127 biopsies, none of the samples was inadequate and yielded adequate tissue for histopathological diagnosis. Seven patients required repeat study only because underlying liver disease was suspected clinically and the previous biopsy report had turned out to be normal. Histopathological examination in our study showed autoimmune hepatitis in 61, cirrhotic changes either hepatitis B virus (HBV) or hepatitis C virus (HCV) related in 40, veno-occlusive disease in 3, cholestatic disease in 2, and Wilson's disease in 2 patients. The remaining 19 were normal. Complications occurred in 3 patients - arterioportal fistula, pneumothorax, and inadequate coiling causing mild hemoperitoneum. CONCLUSION: Percutaneous liver biopsy followed by plugging of the tract with coils is a safe, easy, and effective method in patients with underlying bleeding tendencies, minimal ascites, and small liver.

Hepatocellular Carcinoma Evaluation and Management for Physicians: Joint Gastroenterology Research Society and Association of Physicians of India Guidelines.

Hepatocellular carcinoma (HCC) is the most common cause of, and accounts for almost 90% of all liver cancers. Data from India is limited especially due to cancer not being a reportable disease and in view of wide variation in diagnostic modalities. This document is a result of a consensus meeting comprising Hepatologists, Interventional Radiologists, Hepatobiliary surgeons, medical and surgical Oncologists nominated by the Association of Physicians of India and Gastroenterology Research Society of Mumbai. The following Clinical Practice Guidelines for practicing physicians is intended to act as an up to date protocol for clinical management of patients with hepatocellular carcinoma. The document comprises seven sections with statements and sub-statements with strength of evidence and recommendation.

Endovascular repositioning and resizing of the distal catheter of a ventriculoatrial shunt.

Ventriculoatrial (VA) shunts are an effective alternative to ventriculoperitoneal shunts for diversion of cerebrospinal fluid in patients with hydrocephalus. Accurate placement of the distal end of a VA shunt in the right atrium is imperative for appropriate drainage and can be technically challenging. Misplaced or dislodged shunt catheter needs urgent repositioning, which can be performed by endovascular techniques. We present a case of VA shunt placement related complication, in which the dislodged distal fragment was retrieved by endovascular techniques. The remaining distal catheter, found to be in the internal jugular vein, was not only repositioned, but also resized for accurate placement in the right atrium.

Gonadal dysfunction in male patients with Budd Chiari syndrome and its reversibility with treatment.

BACKGROUND AND AIMS: Budd Chiari syndrome (BCS) commonly affects adolescents and adults. With improved survival, important quality-of-life parameters such as sexual life and fertility become more relevant. This study was aimed to assess the gonadal function in male patients with BCS and the effect of treatment on gonadal function. METHODS: Thirty male patients with newly diagnosed BCS were prospectively assessed for the presence of gonadal dysfunction. Erectile function was assessed using standardized International Index of Erectile Function questionnaire (IIEF). Follicular stimulating hormone (FSH), luteinizing hormone (LH), sex hormone-binding globulin (SHBG), estradiol, total testosterone (TT), calculated free testosterone (cFT), calculated bioavailable testosterone (cBT), sperm count, and sperm motility were compared at baseline and at 6 months of treatment for the assessment of gonadal function. RESULTS: Sixteen (53.3%) out of 30 patients were sexually active at the time of study and 5/16 (31%) had erectile dysfunction. Hypogonadotropic hypogonadism (HH) was the most common pattern seen in 50% cases followed by hypergonadotropic hypogonadism (HyH) in 23% cases. 27% patients had eugonadism. At 6 months of treatment, 60% of patients in HH group became eugonadal as compared to only 14% in HyH group. Proportion of patients with erectile dysfunction reduced (5/16 vs 1/16) after 6 months of therapy. The improvement in sperm count and sperm motility was not significant. CONCLUSION: Gonadal dysfunction is common in male patients with BCS. HH remains the most common type of hypogonadism BCS and the type which improves significantly after treatment.

Left ventricular global longitudinal strain imaging in identifying subclinical myocardial dysfunction among covid-19 survivors.

BACKGROUND: Covid-19 is multi-system viral infection caused by SARS-CoV-2 virus. Apart from having acute severe respiratory illness causing high mortality, the disease also has a variety of cardiovascular manifestations contributing to morbidity as well as mortality. Cardiac dysfunction and myocarditis are well established complications of Covid-19 as evident in multiple studies after the Covid-19 pandemic. However it is not sufficiently studied in Indian patients either by Echocardiography or by any other imaging modalities like cardiac magnetic resonance imaging (MRI). METHODOLOGY: In this study, we analysed the severity of Left ventricular(LV) dysfunction in Covid-19 survivors. A total of 100 consecutive patients of Covid-19 after one month of discharge who had no underlying cardiovascular diseases underwent echocardiography and global longitudinal strain (GLS) imaging. This study cohort included patients with mild 42 (42%),moderate 46(46%) and severe 12(12%) Covid-19 disease as defined by computerised tomography (CT) severity score. RESULT: We observed that total 36(36%) patients had reduced ejection fraction(EF) which included 11 patients having EF <40% and remaining 25(25%) having EF 40-50% (p<0.002). Also 22 (22%) patients had abnormal global longitudinal strain (GLS) values with normal ejection fraction which is suggestive of subclinical myocarditis. We observed LV dysfunction in 7(19.5%) patients who had severe Covid-19 while mild to moderate LV dysfunction observed in 29(80.5%) non critical patients. CONCLUSION: In conclusion our study demonstrates that myocardial dysfunction is common in covid-19 regardless of disease severity. 2D-echocardiography with GLS is likely to detect early LV dysfunction among these patients.

Platypnea-orthodeoxia Syndrome (POS) in Moderate COVID-19: An Uncommonly Common Bedside Sign?

Platypnoea-Orthodeoxia syndrome (POS) is the presence of postural hypoxaemia along with breathlessness in recumbent position. It is an uncommon syndrome with elusive pathophysiologic mechanisms. We observed POS in patients of moderate COVID-19 who required hospital admission to our indoor facility and oxygen supplementation when saturation was documented in sitting and supine positions for evaluation of platypnea. MATERIALS AND METHODS: We conducted an observational, cross sectional, retrospective analysis of pulse oximetry readings of patients with stage 2 COVID-19 admitted in ward during the period from 15th May 2020 to 30th May 2020. The difference in the peripheral oxygen saturation in sitting and supine positions, documented as a routine standard of care, especially in patients with platypnea, was calculated and demographic details and co-morbidities were noted from indoor record forms. RESULTS: Of the 53 patients of stage 2 COVID-19 who were included in the study, 15 (28%) had platypnoea-orthodeoxia syndrome at the time of presentation and 18(33.9%) patients with platypnoea had ≥ 3% desaturation in sitting position as compared to supine position. Rest of the 20 (37.7%) patients had neither platypnoea nor orthodeoxia. All the patients presenting with platypnoea-orthodeoxia required oxygen therapy during the course of treatment. Amongst the 33 patients who were hypoxic and required oxygen supplementation, 15 patients (45.4%) had oxygen saturation of ≥94% in the supine position at presentation. CONCLUSION: Platypnoea-orthodeoxia syndrome is common in patients with stage 2 COVID 19 infection who require oxygen therapy. POS can be easily documented by using pulse oximeter without the need of any specialised equipment. Hence, we propose that documentation of POS at the time of admission in primary health care or resource depleted settings would help in successful triage of the patients needing oxygen therapy. We also propose that oxygen saturation in sitting position be documented as far as possible. Further clinical studies are necessary to validate this observation.

Budd-Chiari syndrome: consensus guidance of the Asian Pacific Association for the study of the liver (APASL).

Budd Chiari syndrome (BCS) is a diverse disease with regard to the site of obstruction, the predisposing thrombophilic disorders and clinical presentation across the Asia-Pacific region. The hepatic vein ostial stenosis and short segment thrombosis are common in some parts of Asia-Pacific region, while membranous obstruction of the vena cava is common in some and complete thrombosis of hepatic veins in others. Prevalence of myeloproliferative neoplasms and other thrombophilic disorders in BCS varies from region to region and with different sites of obstruction. This heterogeneity also raises several issues and dilemmas in evaluation and approach to management of a patient with BCS. The opportunity to recanalize hepatic vein in patients with hepatic vein ostial stenosis or inferior vena cava stenting or pasty among those membranous obstruction of the vena cava is a unique opportunity in the Asia-Pacific region to restore hepatic outflow closely mimicking physiology. In order to address these issues arising out of the diversity as well as the unique features in the region, the Asia Pacific Association for Study of Liver has formulated these guidelines for clinicians.

Budd-Chiari Syndrome With Spontaneous Intrahepatic Portosystemic Shunts: A Case Series.

Intra-hepatic portal-venous collaterals are characteristic of Budd-Chiari syndrome (BCS) and are usually of small caliber and seen on Doppler. Creation of large portal-systemic shunt, either radiologically (Transjugular intrahepatic porto-systemic shunt) or surgically results in excellent long term outcomes in BCS. Here, we report a series of three rare cases of asymptomatic BCS, who had spontaneous large intra-hepatic portal-systemic shunts.

Percutaneous Transhepatic Biliary Drainage in the Management of Post-surgical Biliary Leaks.

The aim of this study was to evaluate the efficacy of percutaneous transhepatic biliary drainage (PTBD) in the treatment of post-surgical biliary leaks and its efficacy in restoring the integrity of bile ducts. One hundred and fifty-seven patients with a post-surgical biliary leak were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to laparoscopic procedures in 114 patients, while 43 patients had postoperative leak following open surgery. Percutaneous transhepatic biliary drainage was performed with an 8- to 10-F catheter, with the side holes positioned proximal to the site of extravasation to divert bile flow away from the leak site. The established biliary leaks at the site of origin were diagnosed at an average of 7 days (range 2-150 days) after surgery. In all cases, percutaneous access to the biliary tree was achieved. In 62 patients, biliary leak completely healed after drainage for 10-50 days (mean, 28 days) while 89 patients underwent surgical reconstruction subsequently. PTBD is a feasible, effective, and safe procedure for the treatment of post-surgical biliary leaks. It is therefore a reliable alternative to surgically repair smaller biliary leaks, while in patients with large defects, it helps prepare patients for surgical reconstruction.

Endovascular treatment of Budd-Chiari syndrome: Single center experience.

BACKGROUND AND AIM: Percutaneous radiologic interventions are increasingly being used in management of Budd-Chiari syndrome (BCS). Minimal invasive approach has resulted in excellent long-term outcomes. We evaluated the treatment efficacy and safety of radiological intervention in patients with BCS. METHODS: Between January 2008 and June 2014, 190 patients with BCS underwent endovascular procedures (hepatic vein, collateral vein or inferior vena cava [IVC] plasty with or without stenting, or transjugular intrahepatic portosystemic shunting [TIPSS]). Clinical features, biochemical profile, and stent patency were monitored pre-procedure and post-procedure, and for a median duration of 42 (12-88) months. RESULTS: Of 190 patients (mean [SD] age = 26.9 [11.5] years; 102 men), imaging revealed hepatic vein obstruction in 147 patients, IVC obstruction in 40 patients, and concomitant hepatic vein and IVC obstruction in three patients. At presentation, the radiological interventions included hepatic vein plasty/stenting in 38 patients, collateral vein stenting in three patients, IVC plasty/stenting in 40 patients, both IVC and hepatic vein stenting in three patients, and TIPSS in 106 patients. Response was seen in 153 patients (80.5%). Repeat interventions were required in 19 patients (10.0%). Complications were noted in nine patients (4.7%). CONCLUSION: Our study demonstrates that venous recanalization and TIPSS for BCS are safe and efficacious.

Mediastinal Fibrosis Treated with Endovascular Stent Placement.

We report an interesting case of mediastinal fibrosis causing significant narrowing of both pulmonary arteries (right > left) which led to progressively increasing dyspnoea and pulmonary hypertension. This was treated with endovascular stenting of the right pulmonary artery with good clinical outcome.

Evaluation of Dexmedetomidine as an Adjuvant to Intrathecal Bupivacaine in Infraumbilical Surgeries.

INTRODUCTION: Various adjuvants like morphine, buprenorphine and fentanyl, clonidine, ketamine are being used in anaesthetic practice since long for improvement of peri-operative analgesia following spinal anaesthesia. Such adjuvants have been helpful in induction of early ambulation but at the cost of their associated adverse effects. Therefore search for an effective adjuvant is still going on. Currently Dexmedetomidine, a highly selective α2-adrenoreceptor agonist is being studied for its adjuvant action in spinal anaesthesia. AIM: The present study aims to evaluate the efficacy of intrathecal Dexmedetomidine as an adjuvant to Bupivacaine in spinal anaesthesia in patients undergoing infra-umbilical surgeries. MATERIALS AND METHODS: It was a prospective, double blind study among 60 patients undergoing infraumbilical surgeries under spinal anaesthesia. The patients were randomly allocated to 2 groups (Group I and Group II) of 30 each. Group I received hyperbaric bupivacaine (15 mg) alone and Group II received hyperbaric bupivacaine (15 mg) with Dexmedetomidine (5mcg). The onset time of sensory and motor block, regression time of sensory and motor block, duration of analgesia, haemodynamic parameters were recorded both intra and postoperatively. The primary efficacy parameters were to determine the onset and duration of sensory block, motor block and duration of postoperative analgesia. Secondarily any associated haemodynamic changes and adverse effects of Dexmedetomidine were also recorded. STATISTICAL ANALYSIS: Continuous data were analysed using the Student's t-test and categorical variables by two-tailed Fisher-exact test or Chi-square test. RESULTS: Onset of sensory block was 129.33±14.8 seconds in Group II as compared to 208.33±19.18 seconds in Group I with total duration of sensory block as 317.70±16.16 minutes in Group II and 188±11.86 minutes in Group I. Similarly, onset of motor block was 226.33±31.86 minutes and 320.33±29.81 minutes, with total duration of motor block as 286.33±15.15 minutes and 166.5±12.11 minutes in Group II and in Group I respectively. Duration of analgesia was 333.6±20.67 minutes with Dexmedetomidine but 193.67±7.06 minutes in bupivacaine alone group. CONCLUSION: Dexmedetomidine as an adjuvant had shown early onset of sensory and motor block with longer duration of analgesia and haemodynamic stability in the present study as compared to bupivacaine alone.

An Association of Chronic Hyperaldosteronism with Medullary Nephrocalcinosis.

BACKGROUND: An association between chronic hyperaldosteronism and medullary nephrocalcinosis has rarely been made, with only a handful of cases described in literature. CASE REPORT: We describe five cases of hyperaldosteronism with a long- standing history in whom associated medullary nephrocalcinosis was established. CONCLUSIONS: We infer that a chronic hyperaldosteronic status, whether primary or secondary, is a causal factor in the etiopathogenesis of medullary nephrocalcinosis. This article illustrates and summarizes various postulated theories that support our proposed association between hyperaldosteronism and nephrocalcinosis. We conclude that chronic hyperaldosteronism should be included as one of the causes of nephrocalcinosis and that our case series emphasizes the need of a well-organized retrospective study to prove it further.

Hemangioma of rib: a different perspective.

BACKGROUND: Hemangiomas are one of the common primary benign tumors of the intraosseous and soft tissue compartments in humans. Vertebral hemangiomas being the most common of all are seen in daily radiological practice. Hemangioma of the rib is rarely seen. CASE REPORT: We reported on a case of a rib lesion which had a classic imaging pattern of hemangioma. We highlighted the use of pre-operative embolization of such a vascular rib lesion before surgically removing the lesion by thoracotomy to reduce the risk of bleeding. CONCLUSIONS: We also emphasized overt complications of overzealous needling of such a vascular lesion for histopathological diagnosis as in our case.

Pseudoaneurysm of anomalous cystic artery due to calculous cholecystitis.

Pseudoaneurysm of the cystic artery is a rare cause of haemobilia resulting from either an inflammatory process in the abdomen or abdominal trauma. We report a case of a patient with chronic calculous cholecystitis associated with a pseudoaneurysm arising from an anomalous cystic artery who presented with haemobilia. The patient was managed successfully with multimodality treatment that included angioembolisation of the pseudoaneurysm and stenting of the common bile duct to relieve jaundice followed by elective open cholecystectomy.

Optimisation and in vivo evaluation of pectin based drug delivery system containing curcumin for colon.

The higher incidences of side effects of existing drugs have shifted researchers and clinicians to explore the dietary phytoconstituents for its therapeutic potentials. The present study is based on compression coated curcumin tablet for the colon. Curcumin has anti-inflammatory and antioxidant properties. Curcumin presents a bioavailability problem due to poor solubility. An inclusion complex was formed with hydroxypropyl-ß-cyclodextrin to enhance the solubility. In this study, the core tablet of curcumin inclusion complex was compressed between the layers of polymer blend of pectin and Eudragit S100. The 3(2) full factorial design was utilised for optimization of the formulation. The polymer ratio (X1) and coat thickness (X2) presented significant effects on the selected responses, i.e., percent drug release after 4 hours (Y240) and difference in percent drug release between 4th and 6th hour (Y diff) in presence of pectinase enzyme. The results revealed that higher coat weight (600 mg) and higher level of pectin ratio (70% w/w) protected the curcumin tablet till ascending colon. The in vivo studies by roentgenography method using human volunteers supported these observations. Hence, it can be concluded that the combination of pectin and Eudrgit S100 makes the system biodegradable and pH dependent for targeting the drug to the colon.

Spectrum of imaging in Budd Chiari syndrome.

Budd Chiari syndrome is an uncommon heterogeneous group of disorders which occur due to obstruction at any level from the hepatic venules to the junction of inferior vena cava and right atrium of heart which has significant morbidity and mortality. An early diagnosis of the disease is required for appropriate treatment. Due to the diffuse nature of the disease, normal biopsy findings do not exclude the disease. Proper clinical history and imaging are essential for definitive diagnosis. In this pictorial essay, we discuss the imaging spectrum of Budd Chiari syndrome.