Treatment of an Infected TEVAR with Extra- and Endovascular Bacteriophage Application.

Introduction: Graft infections are severe complications. Surgical resection of infected aortic stent grafts is associated with high mortality and morbidity. Therefore, alternatives or adjuncts to antibiotic treatment and extensive surgery are urgently needed. Report: A 67 year old woman was admitted with a methicillin sensitive Staphylococcus aureus infected stent graft in the thoracic aorta. Local infection was confirmed by PET-CT imaging. Surgical resection of the stent graft was not feasible because of comorbidities. Therefore, a three step approach for local bacteriophage treatment was performed as a last resort treatment. Firstly, the para-aortic tissue was debrided via left thoracotomy, a bacteriophage suspension was applied on the outer surface of the aorta, and a vacuum irrigation system was installed. After repeated alternating instillation of the bacteriophage suspension for three days, as a second step, the vacuum sponges were removed and a bacteriophage containing gel was applied locally on the outer surface of the aorta. In the third step, the bacteriophage containing gel was applied to a thoracic stent graft, which in turn was placed endovascularly into the infected stent. Discussion: After 28 days, the patient was discharged from hospital with normalised infection parameters. PET-CT imaging at three and 12 months post-intervention did not show signs of infection in or around the thoracic aorta. This Case demonstrates successful treatment of an infected endovascular stent graft by application of bacteriophages both to extravascular and, as a novel approach, endovascular sites using a bacteriophage coated stent graft.

Patient radiation dose in percutaneous biliary interventions: recommendations for DRLs on the basis of a multicentre study.

OBJECTIVE: Percutaneous biliary interventions (PBIs) can be associated with a high patient radiation dose, which can be reduced when national diagnostic reference levels (DRLs) are kept in mind. The aim of this multicentre study was to investigate patient radiation exposure in different percutaneous biliary interventions, in order to recommend national DRLs. METHODS: A questionnaire asking for the dose area product (DAP) and the fluoroscopy time (FT) in different PBIs with ultrasound- or fluoroscopy-guided bile duct punctures was sent to 200 advanced care hospitals. Recommended national DRLs are set at the 75th percentile of all DAPs. RESULTS: Twenty-three facilities (9 interventional radiology depts. and 14 gastroenterology depts.) returned the questionnaire (12%). Five hundred sixty-five PBIs with 19 different interventions were included in the analysis. DAPs (range 4-21,510 cGy·cm2) and FTs (range 0.07-180.33 min) varied substantially depending on the centre and type of PBI. The DAPs of initial PBIs were significantly (p < 0.0001) higher (median 2162 cGy·cm2) than those of follow-up PBIs (median 464 cGy·cm2). There was no significant difference between initial PBIs with ultrasound-guided bile duct puncture (2162 cGy·cm2) and initial PBIs with fluoroscopy-guided bile duct puncture (2132 cGy·cm2) (p = 0.85). FT varied substantially (0.07-180.33 min). CONCLUSIONS: DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. PBI with US-guided bile duct puncture did not reduce DAP, when compared to PBI with fluoroscopy-guided bile duct puncture. National DRLs of 4300 cGy·cm2 for initial PBIs and 1400 cGy·cm2 for follow-up PBIs are recommended. KEY POINTS: • DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. • PBI with US-guided bile duct puncture did not reduce DAP when compared to PBI with fluoroscopy-guided bile duct puncture. • DRLs of 4300 cGy·cm2for initial PBIs (establishing a transhepatic tract) and 1400 cGy·cm2for follow-up PBIs (transhepatic tract already established) are recommended.

Laparoscopic treatment of renal artery entrapment.

Renal artery entrapment by the diaphragmatic crus is a very infrequent cause of renovascular hypertension. We present the case of a young man who was assigned to our hospital with arterial hypertension and stenosis of the left renal artery. Extrinsic compression was diagnosed by duplex ultrasound and magnetic resonance angiography. We performed laparoscopic decompression using the transperitoneal retrorenal approach. Antihypertensive medication could be stopped thereafter and duplex ultrasound revealed a normal blood flow to the left renal artery. We therefore propose laparoscopic treatment of left renal artery entrapment as a minimally-invasive alternative to open surgery.

Intra-arterial instillation of microencapsulated, Ifosfamide-activating cells in the pig pancreas for chemotherapeutic targeting.

BACKGROUND: The therapeutic efficacy of intratumoral instillation of genetically engineered, CYP2B1-expressing, microencapsulated cells in combination with ifosfamide had been previously demonstrated in xenografted human pancreatic ductal carcinomas [Gene Ther 1998;5:1070-1078]. Prior to a clinical study, the feasibility of an intra-arterial application of microencapsulated cells to the pancreas and its consequences to the organ had to be evaluated. MATERIAL AND METHODS: Microencapsulated, CYP2B1-producing cells were instilled both in vivo (transfemoral angiographical access) and in vitro (perfusion model) in the splenic lobe of the pig pancreas. In vivo, animals were monitored clinically for 7 days, then treated with ifosfamide and sacrificed. In vitro, ifosfamide was administered intra-arterially. RESULTS: In all animals, 100 microcapsules could be instilled safely via the femoral route without clinical, biochemical or histological signs of pancreatitis. Histological examination revealed partial obstruction of small arteries by the capsules, without causing any parenchymal damage. In vitro, instillation reduced blood flow by half. Ifosfamide, also in combination with the capsules, did not add any damage to the pancreas. CONCLUSION: Intra-arterial instillation of microencapsulated cells to the pig pancreas is feasible and safe. Neither pancreatitis, foreign body reactions nor circulatory disturbances were observed. Clinical application of this genetically enhanced chemotherapeutic method seems possible.