Safety and effectiveness of transsplenic access for portal venous interventions: a single-center retrospective study.

PURPOSE: To assess the safety and effectiveness of percutaneous transsplenic access (PTSA) for portal vein (PV) interventions among patients with PV disease. MATERIALS AND METHODS: Adult patients with PV disease were enrolled if they required percutaneous catheterization for PV angioplasty, embolization, thrombectomy, variceal embolization, or transjugular intrahepatic portosystemic shunt (TIPS) placement for a difficult TIPS or recanalization of a chronically occluded PV. The procedures were performed between January 2018 and January 2023. Patients were excluded if they had an active infection, had a chronically occluded splenic vein malignant infiltration of the needle tract, had undergone splenectomy, or were under age 18 years. RESULTS: Thirty patients (15 women, 15 men) were enrolled. Catheterization of the PV through PTSA succeeded for 29 of 30 patients (96.7%). The main adverse effect recorded was flank pain in 5 of 30 cases (16.7%). No bleeding events from the spleen, splenic vein, or percutaneous access point were recorded. Two cases (6.7%) each of hepatic bleeding and rethrombosis of the PV were reported, and a change in hemoglobin levels (mean [SD], - 0.5 [1.4] g/dL) was documented in 14 cases (46.7%). CONCLUSION: PTSA as an approach to accessing the PV is secure and achievable, with minimal risk of complications. Minimal to no bleeding is possible by using tract closure methods.

Ultrasound-Guided Phrenic Nerve Block for Lung Nodule Biopsy: Single-Center Initial Experience.

RATIONALE AND OBJECTIVES: Biopsy of lung nodules in the lower lung fields can be difficult because of breathing motion. Ipsilateral phrenic nerve block (PNB) before biopsy should make the biopsy safer, easier, and more precisely targeted. We describe the use of ultrasound-guided PNB before lung nodule biopsy, including relevant anatomy and variations, complications, and technique, along with our first 40 cases. MATERIALS AND METHODS: We retrospectively reviewed patients who underwent PNB before computed tomography (CT)- or ultrasound-guided lung nodule biopsy from April 2015 through March 2020. Patient demographics, CT fluoroscopy time, radiation dose, complications, diagnostic yield, and effectiveness of PNB were recorded. Effectiveness of PNB was based on direct observation of diaphragmatic motion. Control group data for biopsies during the same time frame were collected and matched with nodules ≤1 cm from the PNB group. RESULTS: Among 40 patients identified, no complications occurred related to the PNB. Mean (SD) nodule size was 12.4 (6.2) mm. True-positive results were obtained in 39 patients (98%), with 1 false-negative after an ineffective PNB. PNB was effective in 70%. When CT fluoroscopy was used for the biopsy, radiation dose was significantly lower after an effective PNB than an ineffective PNB (p < .001). Effective PNB was significantly more common with injection of ≥4 mL of local anesthetic (p = .01). Comparison with 19 matched controls showed significantly fewer instances of pneumothorax (p = .02) and greater diagnostic success (p = .03) for the PNB group. CONCLUSION: Ultrasound-guided PNB is safe and effective and can improve outcomes when used before lung nodule biopsy.

Percutaneous Image-Guided Ablation of Lung Tumors.

Tumors of the lung, including primary cancer and metastases, are notoriously common and difficult to treat. Although surgical resection of lung lesions is often indicated, many conditions disqualify patients from being surgical candidates. Percutaneous image-guided lung ablation is a relatively new set of techniques that offers a promising treatment option for a variety of lung tumors. Although there have been no clinical trials to definitively compare its efficacy to those of traditional treatments, lung ablation is widely practiced and generally accepted to be safe and effective. Especially encouraging results have recently emerged for cryoablation, one of the newer ablative techniques. This article reviews the indications, techniques, contraindications, and complications of percutaneous image-guided ablation of lung tumors with special attention to cryoablation and its recent developments in protocol optimization.

Normal inflammatory markers in giant cell arteritis with long-standing cranial and symptomatic large-vessel involvement.

We report the case of a 78-year-old woman who presented with cardiovascular risk factors and a history of an atypical transient ischaemic attack. She was referred by her primary care physician to the vascular surgery department at our institution for evaluation of progressive weakness, fatigue, arm claudication and difficulty assessing the blood pressure in her right arm. She was being considered for surgical revascularisation, but a careful history and review of her imaging studies raised suspicion for vasculitis, despite her normal inflammatory markers. She was eventually diagnosed with biopsy-proven giant cell arteritis with diffuse large-vessel involvement. Her symptoms improved with high-dose glucocorticoids.

Dose reduction using digital fluoroscopy versus digital subtraction angiography in endovascular aneurysm repair: A prospective randomized trial.

OBJECTIVE: Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) vs the standard technique using digital subtraction angiography (DSA). METHODS: Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard treatment DSA cohort or a DF cohort in which two or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose-area product (DAP) and cumulative air kerma. Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization). RESULTS: For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Of the 26 DF patients, 5 (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than in the DSA cohort (132 vs 174 Gy·cm2; P = .04). When patients were separated by number of DSA acquisitions (two or fewer vs three or more), mean DAP decreased 41% (109 vs 185 Gy·cm2; P = .005) and cumulative air kerma decreased 40% (578 vs 964 mGy; P = .004). CONCLUSIONS: In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.

Sample content of kinesthetic educational training: Reducing scattered X-ray exposures to interventional physician operators of fluoroscopy.

Content used by Medical Physicists for fluoroscopy safety training to staff is deliverable via several formats, that is, online content or a live audience slide presentations. Here, we share one example of a kinesthetic (live, hands-on simulation) educational program in use at our facility for some time (~10 years). In this example, the format and content specifically target methods of reducing physician operator exposures from scattered x rays. A kinesthetic format identifies and promotes the adoption of exposure-reducing behaviors. Key kinesthetic elements of this type of training include: physician hands-on measurements of radiation levels at locations specific to their standing positions (e.g., primary arterial access points) in the room using handheld exposure rate meters, measurement of exposure rate reduction to physicians provided by using personal protective equipment, that is, wearable aprons, hanging lead drapes, and pull-down shields. Physician choice of procedure-specific tableside selectable controls affecting exposure rate from optional fluoroscopy, Cine or digital subtraction angiography (DSA), along with comparative measured contribution to physician exposure is demonstrated. The inverse square exposure rate reduction to physicians when stepping back from the table during DSA is a key observation. Kinesthetic simulations in the rooms used by physicians have been found to provide the highest level of understanding giving rise to adoption of practices that are impactful for physicians. Specific training scripts are in place for physician sub-specialization in interventional radiology, cardiology, neurosurgery, vascular surgery, and gastroenterology. This training is used for new physician staff while classroom presentations (whose content mimics in room training) are used with staff who have had previously had in room training.

Natural history and management outcomes of segmental arterial mediolysis.

BACKGROUND: Segmental arterial mediolysis (SAM) is a poorly understood, nonatherosclerotic, noninflammatory disease resulting from arterial medial degeneration. Patients may present with aneurysm, dissection, stenosis, or bleeding from visceral or renal arteries. Treatment algorithms are poorly characterized. METHODS: A retrospective review of all patients diagnosed with SAM was performed at our institution. Patients were identified by established criteria that include clinical presentation in combination with radiographic and serologic findings. Demographics, presenting symptoms, diagnostic evaluation, management, and outcomes were reviewed. RESULTS: There were 117 patients diagnosed with SAM between 2000 and 2016; 67.5% (n = 79) were male. Mean age was 52.7 years (range, 23.4-90 years); 69.2% (n = 81) presented with acute abdominal pain, 22.2% (n = 26) with flank pain, and 19.7% (n = 23) with back pain; 15.4% (n = 18) had abdominal pain longer than 30 days; 13.7% (n = 16) had acute hypertension, and 5.1% (n = 6) were hypotensive; 10.3% (n = 12) were asymptomatic. There were 93 (79.5%) dissections and 61 (52.1%) aneurysms. Hemorrhage was seen in 10 (8.5%). The celiac axis was affected in 54.7% (n = 64), renal arteries in 49.6% (n = 5 8), superior mesenteric artery in 43.6% (n = 51), and inferior mesenteric artery in 2.6% (n = 3). After diagnosis of SAM, aspirin was prescribed in 60.7% (n = 71). Statins were prescribed in 29.9% (n = 35). Antihypertensive medications were prescribed in 65% (n = 76), including beta blockers in 42.7% (n = 50); 40.2% (n = 47) of patients were prescribed anticoagulation. Interventions were performed in 26 (22%) patients; 13 had endovascular intervention only, 9 open surgery only, and 4 open and endovascular interventions. Of the 17 patients undergoing endovascular intervention, 19 procedures were performed, most commonly embolization (78.9% [n = 15]), followed by stenting (10.5% [n = 2]). Of the 13 patients undergoing open surgery, 14 procedures were performed, including arterial bypass (50% [n = 7]) and splenectomy with aneurysm ligation (15.4% [n = 2]). Other surgery involved thrombectomy (21.4% [n = 3]) and angioplasty (14.3% [n = 2]). Only 11.5% (n = 3) experienced a perioperative complication, including one hematoma, one abscess, and one death secondary to ongoing hemorrhage. Follow-up imaging was performed in 96.6% (n = 112). Mean follow-up was 1258 days (range, 2-5017 days). Of these, 27.7% (n = 31) had regression, 43.8% (n = 49) stability, and 28.6% (n = 32) progression. Average time between initial diagnosis and progression was 666 days. CONCLUSIONS: SAM is an uncommon disease that may require intervention; it is therefore important that the vascular surgery community be aware of this disease. Follow-up imaging is required to monitor for disease progression.

Percutaneous thrombolysis of acute-on-chronic inferior vena cava thrombosis after previous insertion of an Adams-DeWeese clip.

We describe the successful percutaneous treatment of acute-on-chronic IVC thrombosis 30 years following previous placement of Adams-DeWeese clip.

Successful coil embolization of circumflex iliac artery pseudoaneurysms following paracentesis.

Abdominal paracentesis complicated by perforation of a penetrating arterial branch is an extremely rare complication. We report 2 patients who presented with abdominal wall pseudoaneurysms following abdominal paracentesis for the evaluation and treatment of their hepatic dysfunction. We subsequently review the treatment modalities and interventions performed in each case.

The minimally invasive management of visceral artery aneurysms and pseudoaneurysms.

OBJECTIVE: Minimally invasive methods (MIMs) are now available for the management of visceral artery aneurysms and pseudoaneurysms (visceral artery aneurysms [VAA]). The purpose of this study was to review our 10-year experience with the MIM of treating VAA. METHODS: All patients evaluated from June 1999 to June 2009 with VAAs were reviewed. Demographics, therapy, and results were analyzed. RESULTS: MIM was attempted in 185 aneurysms in 176 patients. Initial intervention was successful in 98% ofaneurysms. Sixty-three (34%) aneurysms were located in the splenic artery, 56 (30%) in the hepatic, 28 (15%) in the gastroduodenal, 16 (8.6%) in the pancreaticoduodenal, six (3.2%) in the superior mesenteric, four (2.1%) in the gastric, four (2.1%) in the celiac, four (2.1%) in the gastroepiploic, two (1%) in the inferior mesenteric, and one (0.5%) in the middle colic artery. Pseudoaneurysms were more common than true aneurysms (64% vs 36%). Bleeding was the indication for intervention in 86 aneurysms (46%). Initial treatment was successful in 177 aneurysms (98%). Reintervention was required in five (3%) aneurysms within 30 days. Coiling was used alone in 139 aneurysms (75%) and in combination with at least one other technique in 20 (11%) cases. Thirty-day aneurysm-related mortality was 3.4% (six deaths). Five additional deaths occurred during 30-day follow-up, although none was related to complications of the aneurysms (2.8%). CONCLUSIONS: MIM for visceral artery aneurysms can be used alone or in combination to effectively treat VAAs in elective or emergent conditions.

Antiplatelet medications: old and emerging therapies.

Antiplatelet medications have been proven to enhance outcomes in patients with cardiovascular disease. The ideal platelet inhibitor would be quick and reversible and would have universal response, an excellent safety profile, and proven benefit. Currently available antiplatelet medications have been demonstrated to have variable patient response. In light of this medication resistance, emerging therapies to inhibit platelet aggregation are under investigation. We review the currently available antiplatelet medications and the current state of these emerging therapies.