Outcomes of Transarterial Embolization for Acute Nonvariceal Upper Gastrointestinal Bleeding: Correlation with Periprocedural Endoscopy.

PURPOSE: To evaluate gastric and intestinal mucosal changes on postembolic endoscopy and mortality after transarterial embolization (TAE) for upper gastrointestinal bleeding (UGIB). MATERIALS AND METHODS: An institutional review board-approved retrospective review of patients who underwent arteriography for refractory UGIB at a multicenter health system from December 2003 to August 2019 was performed. Two hundred sixty-nine patients underwent TAE for UGIB. Data on etiology of bleeding, embolization technique, pre-embolic and postembolic endoscopic results, blood product requirements, and mortality were collected from the medical record. Endoscopy results were compared at the site of the target lesion before and after TAE. Multivariable logistic regressions were performed to assess predictors of new adverse mucosal responses and mortality. RESULTS: The most common etiology of UGIB was peptic ulcer. Twenty-five percent (n = 68) of the patients had clinical evidence of rebleeding after TAE, and the 30-day mortality rate was 26% (n = 73). Eighty-eight (32%) patients underwent post-TAE endoscopy, with only 15% showing new adverse mucosal changes after embolization. Procedural characteristics, including vascular territory and embolic choice, were not significantly predictive of increased risk of development of adverse mucosal response after TAE or increased mortality risk. No patients in the study were found to have bowel lumen stenosis at the time of post-TAE endoscopy or at 6 year follow-up. CONCLUSIONS: TAE is a safe and effective intervention for patients with UGIB. Post-TAE endoscopy demonstrated that most patients had either stability or improvement in the target lesion after TAE, and only a minority of patients demonstrated adverse mucosal changes.

Outcomes after Transgastric Drainage of Pancreatic Duct Leaks.

PURPOSE: To determine the outcomes of transgastric drainage (TGD) of pancreatic duct leaks (PDLs), including fluid collections and pancreaticocutaneous fistulae (PCFs). MATERIALS AND METHODS: Fifty-four patients who underwent attempted TGD of a PDL from 1992 to 2020 were identified. Data regarding patient comorbidities, fluid collection characteristics, technical success, drain exchanges and removals, recurrent collections, and complications were analyzed. RESULTS: Forty-one patients (41/54, 76%) had a history of pancreatitis. Sixteen patients (16/54, 30%) had a history of recent abdominal surgery. Peripancreatic fluid collections were 11.2 cm ± 4.6 in greatest dimension prior to drainage. Twenty-one collections (21/54, 39%) demonstrated biochemical and/or imaging evidence of an active communication to the pancreatic duct, and 16 (16/54, 30%) of these patients had a PCF due to a direct percutaneous drain prior to TGD. TGD was technically successful in 53 patients (53/54, 98%). During the follow-up period, 46 patients (46/53, 87%) were able to undergo drain removal after resolution of the fluid collection, with a mean catheter indwelling time of 3 months and a median of 1 catheter exchange. There were 2 severe (2/53, 4%) and 4 moderate (4/53, 8%) complications, the most common of which was drain dislodgement requiring repeat transgastric puncture. Recurrent fluid collections were observed in 8 patients (8/53, 15%) after a mean of 5 months following drain removal. There were no recurrent PCFs. CONCLUSIONS: TGD of PDLs is technically feasible and efficacious in the vast majority of patients with a relatively low complication rate. This technique is effective in preventing or treating the long-term debilitating complication of PCF.

A large series of true pancreaticoduodenal artery aneurysms.

INTRODUCTION: True pancreaticoduodenal artery aneurysms (PDAAs) are rare, and prior reports often fail to distinguish true aneurysms from pseudoaneuryms. We sought to characterize all patients who presented to our health system from 2004 to 2019 with true PDAAs, with a focus on risk factors, interventions, and patient outcomes. METHODS: Patients were identified by querying a single health system picture archiving and communication system database for radiographic reports noting a PDAA. A retrospective chart review was performed on all identified patients. Patients with pseudoaneurysm, identified as those with a history of pancreatitis, abdominal malignancy, hepatopancreaticobiliary surgery, or abdominal trauma, were excluded. Continuous variables were compared using t-tests, and categorical variables were compared using Fisher's exact tests. RESULTS: A total of 59 true PDAAs were identified. Forty aneurysms (68%) were intact (iPDAAs) and 19 (32%) were ruptured (rPDAAs) at presentation. The mean size of rPDAAs was 16.4 mm (median size, 14.0 mm; range, 10-42 mm), and the mean size of iPDAAs was 19.4 mm (median size, 17.5 mm; range, 8-88 mm); this difference was not statistically significant (P = .95). Significant celiac disease (occlusion or >70% stenosis) was noted in 39 aneurysms (66%). Those with rupture were less likely to have significant celiac disease (42% vs 78%; P = .017) and less likely to have aneurysmal wall calcifications (6% vs 53%; P = .002). Thirty-seven patients underwent intervention (63%), with eight (22%) undergoing concomitant hepatic revascularization (two stents and six bypasses) due to the presence of celiac disease. Eighteen patients with occluded celiac arteries underwent aneurysm intervention; of those, 11 were performed without hepatic revascularization (61.1%). Those with rPDAAs experienced an aneurysm-related mortality of 10.5%, whereas those with iPDAAs experienced a rate of 5.6%. One patient with celiac occlusion and PDA rupture who did not undergo hepatic artery bypass expired postoperatively from hepatic ischemia. rPDAAs showed a trend toward the increased need for aneurysm-related endovascular or open reintervention, but this was not statistically significant (47% vs 28%; P = .13). CONCLUSIONS: These findings support previous reports that the rupture risk of PDAAs is independent of size, their development is often associated with significant celiac stenosis or occlusion, and rupture risk appears decreased in patients with concomitant celiac disease or aneurysm wall calcifications. Endovascular intervention is the preferred initial treatment for both iPDAAs and rPDAAs, but reintervention rates are high in both groups. The role for hepatic revascularization remains uncertain, but it does not appear to be mandatory in all patients with complete celiac occlusion who undergo PDAA interventions.

Fibroid expulsion: a unique presentation of mechanical small bowel obstruction 11 years after uterine artery embolization: a case report.

BACKGROUND: Uterine artery embolization in the treatment of uterine leiomyoma has been rarely associated with dislodgement and expulsion of infarcted uterine fibroids through the vagina, peritoneum, or bowel wall, predominantly occurring within 6 months of uterine artery embolization. CASE PRESENTATION: We present the case of a 54-year-old African American woman who underwent uterine artery embolization 11 years prior and developed mechanical small bowel obstruction from the migration of fibroid through a uteroenteric fistula with ultimate impaction within the distal small bowel lumen. Small bowel resection and hysterectomy were curative. CONCLUSIONS: Uteroenteric fistula with small bowel obstruction due to fibroid expulsion may present as a delayed finding after uterine artery embolization and requires heightened awareness.

Recurrent massive hemoptysis in a patient with cystic fibrosis: balloon assisted Onyx embolization after bronchial artery coil recanalization.

BACKGROUND: Although not standard of care, Cystic Fibrosis patients with recurrent hemoptysis occasionally have coil embolization of bronchial arteries. In the event of recanalization of these arteries in this specific subset of patients, the presence of indwelling coils makes the prospect of conventional particle embolization more difficult, preventing both adequate catheterization of the coiled segment and reflux of the particles. CASE PRESENTATION: In this report, we describe a case of bronchial artery embolization of a complex Cystic Fibrosis patient with massive hemoptysis from recanalized coiled bronchial arteries utilizing a Scepter Balloon Catheter® (Microvention Terumo, USA) in administration of the liquid embolic agent Onyx® (Medtronic, USA). CONCLUSIONS: The Scepter occlusion balloon catheter allowed for careful placement of the tip within the interstices of the pre-existing coils, allowing for Onyx injection directly into the coil mass without reflux, reconfirming the benefits of Onyx embolization in bronchial artery embolization and providing evidence that the Scepter occlusion balloon catheter should be added to the armamentarium of devices used in complex bronchial artery embolization for Cystic Fibrosis patients with massive hemoptysis.

Percutaneous Fluoroscopic-Guided Creation of Neoanastomosis for the Treatment of Biliary Occlusions.

PURPOSE: Complete biliary occlusions at different anatomic locations that are not amenable to surgical, endoscopic, or routine percutaneous methods pose a challenge to physicians. Biliary ductal neoanastomosis technique can play a very important role in solving such clinical problems. MATERIALS: Between October 2004 and January 2018, six patients were treated in our institution for biliary drainage using biliary ductal neoanastomosis technique via sharp recanalization and a staged approach to achieve internal/external biliary drainage. All procedures were performed in an angiography suite by an interventional radiologist after multidisciplinary discussion. RESULTS: The mean patient age of the cohort was 54 years and 50% of the patients were female (three/six patients). The cause of obstruction was complications or disease progression after  Whipple procedure in four patients, partial hepatectomy in one patient and benign biliary stricture after radioembolization in one patient. All patients were treated with percutaneous biliary neoanastomosis. All procedures were successfully performed in all six patients (100% technical success) without any major complications. All patients were successfully managed by capped drainage catheters for the duration of the follow up (one patient was transitioned to endoscopically inserted biliary stent, and in one patient the tube was eventually removed after establishment of patent neoanastomosis). CONCLUSIONS: Biliary ductal neoanastomosis is an effective treatment option when the anatomy has been significantly altered in the post-surgical setting and wire cannot be safely passed into target draining organ or the remainder of biliary system. When performed by an experienced operator, this technique is safe and effective with a high technical success rate.

Deep Learning Based on MR Imaging for Predicting Outcome of Uterine Fibroid Embolization.

PURPOSE: To develop and validate a deep learning model based on routine magnetic resonance (MR) imaging obtained before uterine fibroid embolization to predict procedure outcome. MATERIALS AND METHODS: Clinical data were collected on patients treated with uterine fibroid embolization at the Hospital of the University of Pennsylvania from 2007 to 2018. Fibroids for each patient were manually segmented by an abdominal radiologist on a T1-weighted contrast-enhanced (T1C) sequence and a T2-weighted sequence of MR imaging obtained before and after embolization. A residual convolutional neural network (ResNet) model to predict clinical outcome was trained using MR imaging obtained before the procedure. RESULTS: Inclusion criteria were met by 727 fibroids in 409 patients. At clinical follow-up, 85.6% (n = 350) of 409 patients (590 of 727 fibroids; 81.1%) experienced symptom resolution or improvement, and 14.4% (n = 59) of 409 patients (137 of 727 fibroids; 18.9%) had no improvement or worsening symptoms. The T1C trained model achieved a test accuracy of 0.847 (95% confidence interval [CI], 0.745-0.914), sensitivity of 0.932 (95% CI, 0.833-0.978), and specificity of 0.462 (95% CI, 0.232-0.709). In comparison, the average of 4 radiologists achieved a test accuracy of 0.722 (95% CI, 0.609-0.813), sensitivity of 0.852 (95% CI, 0.737-0.923), and specificity of 0.135 (95% CI, 0.021-0.415). CONCLUSIONS: This study demonstrates that deep learning based on a ResNet model achieves good accuracy in predicting outcome of uterine fibroid embolization. If further validated, the model may help clinicians better identify patients who can most benefit from this therapy and aid clinical decision making.

Impact of PTFE-covered stent position and extension on TIPS patency.

PURPOSE: The objectives of this study were to determine the effects of expanded polytetrafluoroethylene (PTFE)-covered stent location and TIPS extension on primary patency. METHODS: This retrospective cohort study examined patients with PTFE-covered TIPS creation between 07/2002 and 06/2016. Clinical information and patency outcomes at 24 months were extracted. At TIPS creation, extension was performed at the discretion of the operator. Kaplan-Meier curves of primary patency were generated with conditional variables of HVO-HCJ distance, extension status, and covered versus uncovered extensions. Additional logistic regression analyses of distances were performed. RESULTS: Of 393 patients, 115 patients (29%) underwent stent extension, 79 (20% of total cohort) of which were at the HVO end alone. Primary patency for all TIPS was 75%, 68%, and 54% at 3, 6, and 12 months. The data endpoint were transplant or death in 92 (23%) and 116 (30%). Kaplan-Meier curves showed no statistically significant difference between the variables and primary patency at 12 and 24 months: distance up to versus greater than 10 mm (p = 0.32, 0.81); extension versus no extension (p = 0.83, 0.85); uncovered versus covered extensions (p = 0.58, 0.70). Logistic regression analyses showed a trend toward statistical significance. CONCLUSION: In the setting of PTFE-covered TIPS creation, extended TIPSs and unextended well-positioned TIPSs have no difference in primary patency rates. Stent position and extension length may have an effect on primary patency, but were likely obscured by "user recognition" effects.

Single-Step Method for Pull-Type Gastrostomy Tube Placement.

Single-step pull-type gastrostomy tube (PGT) placement is a method involving gastric puncture with a curved 18-gauge trocar needle allowing retrograde cannulation of the gastroesophageal junction without use of a sheath or snare. This retrospective review of 102 patients who underwent single-step PGT placement demonstrated 91% success in advancing the wire up the esophagus using only the curved trocar. Successful placement of a gastrostomy tube was 100%. Two major and 2 minor complications occurred within 30 days, all unrelated to the single-step technique. Mean fluoroscopy time for all patients was 5.1 min (range, 1.5-19.2 min). Single-step PGT placement is an effective, safe, fast, and equipment-sparing method for gastrostomy placement.

Phase 2, randomized, open-label study on catheter-directed thrombolysis with plasmin versus rtPA and placebo in acute peripheral arterial occlusion.

Background: Patients with acute peripheral arterial occlusion (aPAO) are candidates for operative thrombectomy, bypass, or catheter-directed thrombolysis (CDT) using a plasminogen activator. Human plasma-derived plasmin may offer another CDT option. Objectives: To evaluate the efficacy, safety, and tolerability of two intrathrombus delivery methods and two doses of plasmin compared with recombinant tissue plasminogen activator (rtPA) and placebo in patients with aPAO. Patients/methods: This was a phase 2, randomized, open-label study of intra-arterial CDT of plasmin in patients with aPAO. The study used infusion catheters with or without balloon occlusion (BOC) to evaluate 150 mg plasmin (2 and 5 h post-infusion) and 250 mg plasmin (5 h post-infusion). The efficacy of plasmin, rtPA and placebo was assessed. Results: One hundred and seventy-four subjects were enrolled. Overall, the thrombolytic efficacy (>50% thrombolysis) was 59% (58/99) for 150 mg plasmin without BOC, which is comparable to 89% (8/9) for rtPA without BOC (p = 0.149) and 40% (2/5) for placebo control (p = 0.648). The thrombolytic efficacy was 33% of the 250 mg plasmin group. There was no difference (p > 0.999) in thrombolytic efficacy with BOC (59%, 58/99) or without BOC (59%, 17/29). Plasmin-treated groups experienced treatment-emergent adverse events (TEAEs) at 71% (76/107) without BOC and 63% (24/38) with BOC; 78% (7/9) of the rtPA-treated group and 89% (8/9) of the placebo group had TEAEs. Serious AEs (SAEs) occurred in 29% (31/107) of the 150 mg plasmin group without BOC and 24% (9/38) with BOC. No SAEs occurred in the 250 mg plasmin group. Conclusions: Plasmin demonstrated less bleeding during catheter-directed administration at 150 mg and 250 mg doses compared to rtPA. BOC utilization did not improve efficacy. CDT with plasmin has a potential thrombolytic benefit in patients presenting with aPAO. ClinicalTrials.gov Identifier: NCT01222117.

Complication rates of percutaneous biliary drainage in the presence of ascites.

BACKGROUND: Ascites is a relative contraindication to percutaneous biliary drainage (PBD), but patients with biliary obstruction presenting with ascites may still undergo PBD insertion. We hypothesized that ascites increases the major complication rate of PBD. MATERIALS: PBDs placed between January 2005 and August 2016 were identified (n = 491). Etiology and location of obstruction, the presence, and distribution of ascites based on abdominal imaging within 2 weeks of PBD, INR, WBCE, and peri-procedural complications were reviewed in the EMR. RESULTS: A total of 491 PBD were placed during the study period of which 26.2% had ascites (n = 129), and 73.7% did not have ascites (n = 362). Ascites was categorized as perihepatic in 41 patients (32%), diffuse in 82 patients (64%), and non-perihepatic in 6 patients (4%). Overall, a significantly higher rate of major complications occurred in patients with ascites (19%) compared to that in patients without ascites (7.7%, P = 0.0004). Diffuse ascites was associated with a significantly higher major complication rate (26%) when compared to perihepatic ascites (7.3%, P = 0.014). In ascites patients, no association between the etiology of biliary obstruction or laterality of the PBD and the rate of major complications was identified. CONCLUSIONS: The major complication rate in patients with ascites not only exceeds SIR suggested threshold of 10% but is also significantly higher than that patients without ascites. The distribution of ascites had a significant effect on complication rate, with diffuse ascites being associated with increased major complication rates compared to those with perihepatic. These findings suggest careful consideration of patients for PBD with ascites, particularly diffuse ascites.

Retrospective comparison of outcomes and associated complications between large bore radiologically inserted gastrostomy tube types.

PURPOSE: Multiple approaches to radiologically inserted gastrostomy (RIG) exist. The goal of this study was to compare 30-day outcomes and associated complications between large bore balloon-retained (BR), loop-retained (LR), and pull-type (PT) RIG devices. METHODS: Data on 1477 patients who underwent RIG between January 1, 2005 and December 31, 2016 were collected retrospectively using a dedicated interventional radiology database and electronic medical record. Statistical analysis was performed to compare complication rates between BR, LR, and PT devices. RESULTS: Ninety-eight percent (1477/1507) of the procedures were successfully performed. A total of 752 BR, 323 LR, and 402 PT gastrostomy tubes were placed. The overall complication rate for BR catheters was 5.7% (25 major [3.3%] and 18 minor [2.4%]). The overall complication rate for PT catheters was 3.7% (8 major [2.0%] and 7 minor [1.7%]). The overall complication rate for LR catheters was 1.6% (4 major [1.4%] and 1 minor [0.8%]). Compared to BR catheters, LR catheters had significantly fewer total complications (P = 0.01) but not minor complications (P = 0.052). There were no significant differences in the number of complications between LR and PT catheters or between BR and PT catheters. CONCLUSIONS: Use of BR, LR, and PT devices for RIG is safe with a low incidence of complications. Compared to BR catheters, primary insertion of a LR gastrostomy was associated with significantly fewer overall complications within the first 30 days. Therefore, for initial tube placement, large bore LR catheters may be preferred over BR devices.

Proposed standards for reporting outcomes of treating biliary injuries.

BACKGROUND: There is no standard nor widely accepted way of reporting outcomes of treatment of biliary injuries. This hinders comparison of results among approaches and among centers. This paper presents a proposal to standardize terminology and reporting of results of treating biliary injuries. METHODS: The proposal was developed by an international group of surgeons, biliary endoscopists and interventional radiologists. The method is based on the concept of "patency" and is similar to the approach used to create reporting standards for arteriovenous hemodialysis access. RESULTS: The group considered definitions and gradings under the following headings: Definition of Patency, Definition of Index Treatment Periods, Grading of Severity of Biliary Injury, Grading of Patency, Metrics, Comparison of Surgical to Non Surgical Treatments and Presentation of Case Series. CONCLUSIONS: A standard procedure for reporting outcomes of treating biliary injuries has been produced. It is applicable to presenting results of treatment by surgery, endoscopy, and interventional radiology.

Passive expansion of sub-maximally dilated transjugular intrahepatic portosystemic shunts and assessment of clinical outcomes.

AIM: To assess for passive expansion of sub-maximally dilated transjugular intrahepatic portosystemic shunts (TIPS) and compare outcomes with maximally dilated TIPS. METHODS: Polytetrafluoroethylene covered TIPS (Viatorr) from July 2002 to December 2013 were retrospectively reviewed at two hospitals in a single institution. Two hundred and thirty patients had TIPS maximally dilated to 10 mm (mTIPS), while 43 patients who were at increased risk for hepatic encephalopathy (HE), based on clinical evaluation or low pre-TIPS portosystemic gradient (PSG), had 10 mm TIPS sub-maximally dilated to 8 mm (smTIPS). Group characteristics (age, gender, Model for End-Stage Liver Disease score, post-TIPS PSG and clinical outcomes were compared between groups, including clinical success (ascites or varices), primary patency, primary assisted patency, and severe post-TIPS HE. A subset of fourteen patients with smTIPS underwent follow-up computed tomography imaging after TIPS creation, and were grouped based on time of imaging (< 6 mo and > 6 mo). Change in diameter and cross-sectional area were measured with 3D imaging software to evaluate for passive expansion. RESULTS: Patient characteristics were similar between the smTIPS and mTIPS groups, except for pre-TIPS portosystemic gradient, which was lower in the smTIPS group (19.4 mmHg ± 6.8 vs 22.4 mmHg ± 7.1, P = 0.01). Primary patency and primary assisted patency between smTIPS and mTIPS was not significantly different (P = 0.64 and 0.55, respectively). Four of the 55 patients (7%) with smTIPS required TIPS reduction for severe refractory HE, while this occurred in 6 of the 218 patients (3%) with mTIPS (P = 0.12). For the 14 patients with follow-up computed tomography (CT) imaging, the median imaging follow-up was 373 d. There was an increase in median TIPS diameter, median percent diameter change, median area, and median percent area change in patients with CT follow-up greater than 6 mo after TIPS placement compared to follow-up within 6 mo (8.45 mm, 5.58%, 56.04 mm2, and 11.48%, respectively, P = 0.01). CONCLUSION: Passive expansion of smTIPS does occur but clinical outcomes of smTIPS and mTIPS were similar. Sub-maximal dilation can prevent complications related to over-shunting in select patients.