Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis.

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Efficacy of Shadow-Based Needle Positioning System in Performing CT Image-Guided Percutaneous Biopsy of Lung Lesions: Our Initial Experience.

Context Computerized tomography (CT) is widely used for various interventions and there is a need for an effective navigation tool, for best outcomes. Aim The study was performed to evaluate the efficacy of light- and shadow-based needle positioning assistance device, an innovative navigation tool over the conventional freehand technique, in performing CT image-guided percutaneous interventions. Settings and Design This randomized control trial was performed among patients undergoing CT-guided percutaneous intervention for lung pathologies. Methodology A total of 60 participants were randomized into an intervention group and a control group. The accuracy of needle insertion and other efficacy parameters were assessed for both groups. Post needle placement, CT images were used to evaluate the study endpoints. Statistical Analysis Statistical analysis was performed using SPSS ver. 20 software. Results The mean needle positioning accuracy was 2.1 mm in the experimental group compared with 7.2 mm in the control group freehand procedures. The average time to position the needle at the desired target location was 2.5 minutes in the assisted procedure as compared with 5.3 minutes in the freehand procedure ( p < 0.05). The total number of check scans required to position the needle was 1.3 for assisted procedures and 1.9 for freehand procedures. Conclusion The use of shadow-based assistance device for CT-guided interventions is proven to be efficient and safer with high needle positioning accuracy.

Utility of spinal angiography and arterial embolization in patients undergoing CT guided alcohol injection of aggressive vertebral hemangiomas.

PURPOSE: The purpose of this study is to evaluate the role of spinal angiography and arterial embolization in avoiding spinal cord ischemia in patients undergoing CT-guided alcohol injection of aggressive vertebral hemangiomas. METHODS: In this retrospective study, patients with vertebral hemangioma who underwent CT-guided direct alcohol injection between January 2007 and October 2018 were identified. Of 28 such patients, 26 had neurological deficits, and 2 had only back pain or radiculopathy. Direct alcohol injection without prior arterial embolization was done in 17 patients. Direct alcohol injection with prior arterial embolization was done in 11 patients. Clinical outcome was assessed immediately after the intervention and at follow-up. RESULTS: Three patients, who underwent alcohol injection without trans-arterial embolization, had worsening of neurological deficits in the post procedure period due to spinal cord ischemia. No complications related to spinal cord ischemia were noted in the embolization group. There was no significant difference in the outcomes between the two groups if the three patients with complications are excluded (p = 0.34). CONCLUSION: While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure.

Technical and Medium-Term Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt with Fluoroscopy and Additional Trans-abdominal Ultrasound Guidance.

Background and Objective The aim of the study is to evaluate the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) performed with additional transabdominal ultrasound guidance. Material and Methods Patients who underwent TIPS between January 2004 to January 2020 in our center were studied. Technical, hemodynamic, angiographic, and clinical outcome were recorded up to 1 year of follow-up. Results TIPS was attempted in 162 patients (median [range] age 37[3-69] years; 105 were males and 57 were females; Etiology: Budd-Chiari syndrome [BCS] 91, cirrhosis 65, symptomatic acute portal venous thrombosis [PVT] 3, veno-occlusive disease [VOD] 2, congenital portosystemic shunt [CPSS] 1) during the study period. Indication for TIPS was refractory ascites in 135 patients (BCS 86, cirrhosis 49) and variceal bleed in 21 patients (BCS 5, cirrhosis 16). Technical success was seen in 161 of the 162 (99.4%) patients. The tract was created from hepatic vein in 55 patients and inferior vena cava (IVC) in 106 patients. Complications within 1 week post TIPS were seen in 29 of the 162 (18%) patients, of whom one developed unexplained arrhythmia and hypotension and died. Of the patients with available follow-up, clinical success was noted in 120 (81%), while 14 (9%) patients had partial nonresponse and six (4%) had complete nonresponse. Eight (5%) patients died during the follow-up period. Conclusion The technical success of TIPS creation with additional transabdominal ultrasound guidance is very high with low peri-procedural complication rate. It has enabled the inclusion of a wider spectrum of cases like acute PVT and obliterated hepatic veins which were otherwise considered contraindications.

Successful Management of a Life-threatening Endotracheal Bleed with Angiographic Stenting.

Several operative and postoperative complications have been reported after tracheostomy, including fatal hemorrhage from erosion of a major vessel. We present here a case of hemorrhage after a surgical tracheostomy. This case is being reported on account of the unusual etiology of the hemorrhage and associated high fatality rates. All concerned need to be aware of this complication and its emergency management. How to cite this article: Joseph MM, Benjamin R, Padmanabhan A, Bal D, Nair S. Successful Management of a Life-threatening Endotracheal Bleed with Angiographic Stenting. Indian J Crit Care Med 2020;24(3):210-211.

Transnasal tracheobronchial stenting for malignant airway narrowing under local anesthesia: Our experience of treating three cases using this technique.

PURPOSE: To study the technical feasibility of tracheobronchial stenting via transnasal route under bronchoscopy and fluoroscopic guidance in severe malignant airway strictures using self-expandable nitinol stents. MATERIALS AND METHODS: We describe three patients with malignant airway strictures, treated entirely via transnasal route under local anesthesia using bronchoscopic and fluoroscopic guidance. Nasal route allowed convenient access to the airway for the bronchoscope across the stricture and a guidewire was introduced through its working channel. The 18F tracheal stent and the 6F bronchial stent assembly could be easily introduced and deployed under bronchoscopic (reintroduced through the other nostril) and fluoroscopic guidance. RESULTS: We achieved technical success in all the three patients with immediate relief of dyspnea. CONCLUSION: Transnasal airway stenting with self-expandable nitinol stent using bronchoscopic and fluoroscopic guidance under local anesthesia is a safe and effective method with minimal patient discomfort.