Postembolization Persistence of Pulmonary Arteriovenous Malformations: A Retrospective Comparison of Coils and Amplatzer and Micro Vascular Plugs Using Propensity Score Weighting.

BACKGROUND. Endovascular embolization of pulmonary arteriovenous malformations (PAVMs) was historically performed with embolic coils. The Amplatzer Vascular Plug device (AVP) was introduced for this purpose in 2007 and the Micro Vascular Plug device (MVP) in 2013. OBJECTIVE. The purpose of this study was to compare coils, AVPs, and MVPs in terms of risk of persistence after PAVM embolization by use of propensity score weighting to account for biases in device selection. METHODS. This retrospective study included 112 patients (78 women and girls, 34 men and boys; mean age, 45 years) who underwent embolization of 393 PAVMs with a single device type (coil, MVP, or AVP) from January 2003 to January 2020. Persistence was defined as less than 70% reduction in PAVM sac size or contrast enhancement of the sac on follow-up pulmonary CTA. A Cox proportional hazards regression model was used to assess associations between embolic device selection and PAVM persistence. Inverse propensity score weighting was used to account for differences in embolic device selection based on patient and PAVM characteristics. RESULTS. The median postembolization follow-up period was 1.5 years (IQR, 0.3-5.6 years). Persistence was found in 10% (41/393) of PAVMs, including 16% (34/207) of those treated with coils, 8% (7/88) of those treated with AVPs, and 0% (0/98) of those treated with MVPs. Variables associated with embolization device (p < .25) were age, sex, pediatric versus adult status, smoking status, PAVM complexity, PAVM laterality, number of feeding arteries, and feeding artery diameter. The Cox regression model incorporated inverse propensity score weighting to account for the differences between treatment groups in these variables and incorporated feeding artery diameter because of imbalance remaining after weighting. With coils as the referent, MVPs had a hazard ratio for persistence of less than 0.01 (95% CI, < 0.01 to < 0.01; p < .001), and AVPs had a hazard ratio of 0.37 (95% CI, 0.16-0.90; p = .03). CONCLUSION. The risk of persistence after PAVM embolization was significantly lower for MVPs alone than for coils or AVPs alone. In addition, the risk of persistence was lower for AVPs than for coils. CLINICAL IMPACT. The findings support the clinical use of MVPs as the preferred device for PAVM embolization over coils and polytetrafluoroethylene-covered plugs.

Lymphangiography with sclerotherapy: a novel therapy for refractory chylous ascites.

INTRODUCTION: We report the outcomes of a small series of patients with refractory chylous ascites following urologic surgery treated with lymphangiography +/- sclerotherapy. MATERIALS AND METHODS: Retrospective review revealed three patients who underwent lymphangiography for prolonged lymphatic leak following urological surgery. Contrast material is injected slowly into a lymphatic vessel on the dorsum of the foot and serial imaging is used to capture the location and degree of lymphatic leak in order to guide definitive treatment. Demographic and clinical details were collected and are reported. RESULTS: Three patients were identified from 2005-2008 (one following donor nephrectomy and two following retroperitoneal lymph node dissection). All patients presented with abdominal distension within 30 days of surgery. Traditional conservative measures failed in all patients. Lymphangiography localized all leaks (renal hilum, paraspinal, and retrocaval). One patient elected for successful surgical repair after localization. The remaining two patients resolved immediately following lymphangiography; one of these patients underwent percutaneous doxycycline sclerosis. With over 1 year of follow up there have been no recurrences or long term sequelae. CONCLUSIONS: Lymphangiography is a valuable management option for the rare patient with chylous ascites refractory to conservative therapy. Prompt resolution of prolonged chylous ascites following lymphangiography should encourage its use in such difficult cases.

Subtotal splenic embolization is a safe and effective treatment for isolated splenic vascular tumors associated with consumptive coagulopathy.

Consumptive coagulopathy is a known complication of large vascular tumors. We describe 2 episodes of consumptive coagulopathy in young children, which were secondary to isolated splenic vascular tumors. One child was successfully treated by subtotal embolization of the spleen, whereas the second child required splenectomy after an initial embolization improved--but did not fully control--his consumptive coagulopathy.

Update on pediatric extracranial vascular anomalies of the head and neck.

PURPOSE: Vascular anomalies most frequently present at birth or in early childhood, and the craniofacial region is the most common site of involvement. A long history of misleading nomenclature born of confusion about the presentation and natural history of various vascular anomalies has made appropriate diagnosis difficult. The present article emphasizes the importance of clarity of nomenclature for proper diagnosis, both clinically and radiographically, to guide appropriate therapy. In addition, updates on clinical concepts, imaging, and treatment strategies will be discussed. Pediatric vascular anomalies can be divided into two broad categories: vascular tumors and vascular malformations. This biologic classification is based on differences in natural history, cellular turnover, and histology. An updated classification was introduced in 1996 by the International Society for the Study of Vascular Anomalies (ISSVA) to include infantile hemangioma variants, other benign vascular tumors, and combined lesions. Widespread confusion propagated throughout the literature and in clinical practice stems from the continued improper use of many of the terms used to describe vascular tumors and malformations ignoring their pathophysiology. This leads to errors in diagnosis and the dissemination of misinformation to patients and clinicians. Certain terms should be abandoned for more appropriate terms. The clinical presentation usually identifies what general type of vascular anomaly is present, either vascular tumor or vascular malformation. Imaging provides crucial information about the initial diagnosis and aids in follow-up. CONCLUSIONS: Adoption and use of uniform nomenclature in the ISSVA classification system is the first vital step in correct diagnosis and treatment of often complicated vascular tumors and vascular malformations. A multidisciplinary team approach is necessary to provide optimal care for patients, and the necessity for specialists in all areas to communicate using standardized terminology cannot be overemphasized.

Delayed diagnosis of iliac vein thrombus in a sexually-active adolescent with Klippel-Trénaunay syndrome.

BACKGROUND: Although iliac vein thrombus is uncommon in adolescents, it can present with pelvic inflammatory disease (PID) symptoms. CASE: A 19-year-old sexually active female with Klippel-Trénaunay syndrome (KTS) presented with fever, abdominal and lower extremity pain. Physical findings included cervical motion tenderness and left lower extremity swelling and erythema. The patient was admitted for PID and cellulitis. Despite antimicrobial treatment her pain continued. Neisseriae gonorrhea and Chlamydia trachomatis cultures were negative. Abdominal and pelvic computed tomography scans revealed a left internal iliac vein thrombus. Anticoagulation therapy was initiated; her pain improved. On hospital day 7 she developed pulmonary emboli. SUMMARY AND CONCLUSION: In sexually active adolescents with known risk factors for thromboembolism such as KTS, symptoms and signs considered characteristic for PID can be present in association with an iliac vein thrombus.

Incorporating physician assistants and physician extenders in the contemporary interventional oncology practice.

Interventional radiology (IR) has been for the last few years undergoing a transformation from a service oriented to a clinically oriented specialty. With increasing oncologic procedures and patient volume, the balance between quality clinical care, and the time constraints on the busy interventionalist pull in opposing forces. The need for greater clinical support staff in the IR practice is unquestionable. Physician Assistants (and other Physician Extenders) have been in the medical field since the 1960s with intensive clinical training, capabilities of providing patient care and ability to generate revenue income more than justifies their place in the IR. The contemporary model of a clinical orientated service within IR for cancer patients undergoing interventional oncology procedures should include Physician Extenders as a vital part of the team allowing delivery of high-quality patient care.

The limitations of gastro-jejunal (G-J) feeding tubes in children: a 9-year pediatric hospital database analysis.

BACKGROUND: A gastro-jejunal (G-J) feeding tube is a safe and useful temporizing method of providing enteral access in children. Although G-J tubes are often used to obviate the need for a surgical jejunostomy, their long-term use is often associated with mechanical failure. AIM: To review the clinically effective durability of G-J feeding tubes in providing enteral access in children. METHODS: We performed a retrospective review of 102 patients at the Johns Hopkins Children's Center from 1994-2003 whose underlying diagnosis necessitated the need for postpyloric enteral access. RESULTS: Long-term follow-up was obtained in 85 (48 M; 37 F) patients with a median (range) age of 2.0 (0.1-18.0) yr. The most common indication for G-J tube placement was gastroesophageal reflux with aspiration in 51 patients and feeding intolerance and vomiting in 19 patients. The mean (range) number of tube replacements was 2.2 (1-14) over a median (range) duration of follow-up of 39 (2-474) days. The indication for G-J tube replacement included: tube displacement (58), a clogged tube (41), and a cracked tube or ruptured balloon (35). In 52 cases, the cause for G-J tube replacement was undetermined. CONCLUSIONS: G-J feeding tubes are associated with the frequent need for tube maintenance and replacement and may not be the most feasible clinical option in providing long-term (>1 month) enteral access in children intolerant to gastrostomy tube feeds. Future studies are needed to develop innovative percutaneous jejunostomy tube placement techniques that facilitate long-term enteral access.

Toe-walking attributable to venous malformation of the calf muscle.

Soft tissue venous malformations of muscles may produce musculoskeletal deformities caused by contracture of the involved muscle. When the venous malformation involves the flexor muscles of the leg, equinus deformity and toe-walking may occur. Three patients with unilateral toe-walking secondary to venous malformation of the calf muscle, showing the classic presentation of this unusual condition, are presented. Several methods of treating the deformity and the underlying venous malformation are discussed, and the current literature on intramuscular venous malformations, including their natural history, diagnoses, treatment options, and outcomes, is reviewed. Based on our experience and review of the literature, percutaneous sclerotherapy may be a viable option for treatment of venous malformations of the calf musculature that result in a toe-walking deformity.

Pancreaticoduodenectomy: role of interventional radiologists in managing patients and complications.

Although the mortality rate after pancreaticoduodenectomy has decreased, the morbidity rate remains high. Major morbidity is often managed with the aid of interventional radiologists. The objective of this study was to evaluate the cooperative roles of interventional radiologists and pancreatic surgeons in complex pancreatic surgery, specifically pancreaticoduodenectomy. Our pancreaticoduodenectomy database was reviewed for all patients undergoing pancreaticoduodenectomy between January 1, 1995 and December 31, 2000. The interventional radiologic procedures for each patient were evaluated. A total of 1061 patients underwent pancreaticoduodenectomy. The overall mortality and morbidity rates were 2.3% and 35%, respectively. Five hundred ninety patients (56%) had no interventional radiologic procedures, whereas 471 patients (44%) had interventional radiologic procedures. Of those, 342 (32%) had preoperative biliary drainage (PBD) and 129 (12%) required postoperative interventional radiologic procedures. Percutaneous aspiration/catheter drainage was required in 84 patients for intra-abdominal abscess, biloma, or lymphocele, with 24 requiring two or more abscess drains. Thirty-nine patients underwent postoperative PBD for bile leaks due to anastomotic disruption, undrained biliary segments, or T-tube/bile stent dislodgment. Eighteen patients had hemobilia/gastrointestinal bleeding treated by angiography with embolization. The reoperation rate for the entire cohort of 1061 patients was 4.1% (n = 43). Nineteen of the 129 patients (15%) requiring postoperative radiologic intervention required reoperation. Although 4 of 18 patients who required embolization for bleeding subsequently required surgical intervention for the same reason, only 4 of 84 patients undergoing abscess drainage later required operation for anastomotic disruption or unsuccessful percutaneous drainage. As would be expected, the patients who required postoperative radiologic intervention (n = 129) had a higher incidence of postoperative complications including pancreatic fistula (20% vs. 6%, P < 0.01), bile leakage (22% vs. 1%, P < 0.01), and wound infection (16% vs. 8%, P < 0.01). With the complications in these 129 patients, the postoperative mortality rate was only 6.2% compared to 1.7% in patients who did not require radiologic intervention (n = 932, P < 0.01). The median postoperative length of stay was 15 days in those patients requiring postoperative radiologic intervention, 10 days in those not requiring intervention (P < 0.01; postoperative interventional radiology vs. no postoperative interventional radiology), and 29.5 days for patients needing reoperation. Interventional radiologists play a critical role in the management of some patients undergoing pancreaticoduodenectomy. Although complications such as anastomotic leaks, abscess formation, and bleeding can result in increased mortality and a longer hospital stay, the skills of the interventional radiology team provide expert management of some life-threatening complications, thus avoiding reoperation, speeding recovery times, and minimizing morbidity.