Endolymphatic Balloon-Occluded Retrograde Abdominal Lymphangiography (BORAL) and Embolization (BORALE) for the Diagnosis and Treatment of Chylous Ascites: Approach, Technical Success, and Clinical Outcomes.

BACKGROUND: To describe endolymphatic balloon-occluded retrograde abdominal lymphangiography (BORAL) and embolization (BORALE) for diagnosis and treatment of chylous ascites in patients with previously unidentifiable leakage site or failed lymphatic embolization. METHODS: Two (66%) men and 1 (33%) woman with mean age of 52 years (range: 14-79 years) presented with chylous ascites and underwent BORAL or BORALE between March 2016 and February 2017. Patients presented with chylous ascites (n = 3) and with renal cell carcinoma after left nephrectomy and lymph node dissection (n = 1), metastatic Merkel cell carcinoma after left nephrectomy and adrenalectomy (n = 1), and heart transplantation after failed Fontan procedure (n = 1). Pelvic lymphangiography technical successes, complications, radiation dose, contrast volume, clinical response, and follow-up were recorded. RESULTS: Pelvic lymphangiography and BORAL were technically successful in 3 (100%) patients. BORALE was attempted in 2 (66%) patients and was technically successful in both patients (100%). No minor or major complications occurred. Mean radiation dose was 1,037 mGy (range: 391-2,264 mGy). Mean contrast was 83 mL (range: 25-150 mL). Mean blood loss was 15 mL (range: 5-30 mL). Chylous ascites resolved in all 3 (100%) patients. CONCLUSIONS: BORAL and BORALE provide a rational and effective approach for the diagnosis and treatment of patients with chylous ascites and previously unidentifiable leakage site or failed lymphatic embolization.

Radiographic Findings of Distressed Venous Stents and Inferior Vena Cava Filters: Clinical Implications.

OBJECTIVE: The objective of our study was to describe an association between the radiographic appearance of distressed intravascular implants and venous stenosis or occlusion and to determine the success of reparative endovascular procedures. MATERIALS AND METHODS: Seventy-eight patients with distressed stents or inferior vena cava (IVC) filters characterized by pursing (short-axis contracture), straightening, longitudinal contraction (long-axis contracture), or fracture were identified from retrospective review of a venous registry for the period from February 2004 to October 2016. Patients originally presented with superior vena cava (SVC) syndrome (n = 25), arm swelling (n = 16), iliocaval thrombosis (n = 21), and lower extremity deep venous thrombosis (n = 16), and stents were initially placed in 65 and filters in 13. Implants were located in the IVC (n = 24), subclavian vein (n = 16), brachiocephalic vein (n = 15), common iliac vein (n = 10), multiple veins (n = 4), axillary vein (n = 4), common femoral vein (n = 3), SVC (n = 1), and internal jugular vein (n = 1). Implants included Wallstents in 63 patients; Smart stents in two patients; and Celect Platinum, Denali, Greenfield, and Trapease IVC filters in two, three, two, and six patients, respectively. Venographic indication, distress type, time from initial normal placement to identification of distress, venographic finding (patent, mild stenosis, high-grade stenosis, or occlusion), treatment, revascularization outcome, and complications were recorded. RESULTS: The mean time to distress was 23 months. Fifty-two (67%) patients underwent venography for symptoms and 26 (33%) for surveillance. Forty-five (58%) implants were pursed; 19 (24%), straightened; nine (12%), contracted; and five (6%), fractured. Venography depicted 48 (62%) high-grade stenoses, 19 (24%) complete occlusions, and six (8%) mild stenoses. Of the 73 patients who underwent an intervention, 29 (40%) underwent angioplasty, 15 (21%) underwent angioplasty and stenting, 15 (21%) underwent sharp recanalization, and five (7%) underwent thrombolysis. Revascularization was successful in 67 (92%). Three minor complications occurred. CONCLUSION: Distressed intravascular implants are associated with high-grade venous stenosis or occlusion. Reparative interventions are usually technically successful.

Gianturco Z-Stent Fixation of a Modified Iliac Limb Stent-Graft Endoprosthesis for the Treatment of Malignant Superior Vena Cava Syndrome.

Superior vena cava (SVC) syndrome, characterized by facial and arm swelling, is most frequently caused by intrathoracic malignancies. Decompression may be achieved with endovenous stent placement. Polytetrafluoroethylene-covered stents have shown to have higher long-term cumulative patency rates compared with uncovered stents for the treatment of malignant SVC syndrome. Unfortunately, polytetrafluoroethylene-covered stents are not readily available worldwide. Moreover, the existing armamentarium, including balloon-expandable iCAST stents (maximum diameter 10 mm) and heparin-coated Viabahn stent-graft endoprostheses (maximum diameter 13 mm), is too small to adequately treat malignant obstruction of the SVC. This report describes a patient with SVC syndrome and SVC tumor thrombus secondary to recurrent nonseminomatous germ cell carcinoma of the mediastinum treated with a Gianturco Z-stent-fixed modified EXCLUDER abdominal aortic aneurysm iliac limb endoprosthesis.

Epidural Balloon Placement for Protection of the Spinal Canal During Cryoablation of Paraspinal Lesions.

Ablation of paraspinal lesions close to the spinal canal and neuroforamina requires protective measures in order to protect the spinal cord and nerve roots. Various methods of protection have been previously described including infusion of saline and CO2. Regardless, neuromonitoring should be adjunctively performed when ablating spinal lesions close to neuronal structures. Balloon protection has been previously described during ablation of renal masses. The benefit of balloon protection in paraspinal mass ablation is it physically displaces the nerve roots as opposed to CO2 or saline which has the potential to insulate but because of its aerosolized or fluid nature may or may not provide definitive continuous protection throughout an ablation. This report details three paraspinal lesions, two of which were successfully ablated with the use of a balloon placed in the epidural space to provide protection to the spinal cord and nerve roots.

Correction to: Epidural Balloon Placement for Protection of the Spinal Canal During Cryoablation of Paraspinal Lesions.

In the published article the first sentence under the section heading Case Reports ("This study was conducted with the institutional review board approval and complied with the Health Insurance Portability and Accountability Act.") is incorrect. That sentence should be replaced with: "Case reports are exempt from IRB approval at the authors' institution. This study complied with the Health Insurance Portability and Accountability Act."

Percutaneous transgastric interventional radiology-operated duodenoscopy for the identification of duodenal perforation and Graham patch dehiscence.

Patients with a Roux-en-Y gastric bypass may be challenging diagnostic and therapeutic dilemmas for gastroenterologists and endoscopists due to anatomic considerations. Pancreaticobiliary limb pathology is particularly difficult to diagnose from standard endoscopic approaches as it often requires double balloon enteroscopy. Percutaneous access and gastrostomy placement into the gastric remnant, however, is a commonly performed procedure by interventional radiology. This report describes the identification of duodenal perforation and Graham patch dehiscence in the pancreaticobiliary limb of a patient with a prior Roux-en-Y gastric bypass who had failed traditional endoscopic measures, using transgastric remnant interventional duodenoscopy and confirmed with methylene blue injection into a periduodenal abscess.

Intra-arterial Thrombolysis for Extremity Frostbite Decreases Digital Amputation Rates and Hospital Length of Stay.

PURPOSE: To report outcomes of intra-arterial thrombolysis versus non-thrombolytic management of severe frostbite with respect to digital amputation rates and hospital length of stay (LOS). MATERIALS AND METHODS: Seventeen patients with severe frostbite were identified from 2000 to 2017. Eight (47%) patients with mean age of 40 years underwent intra-arterial thrombolysis and served as the treatment group. Nine (53%) patients with mean age of 53 years received non-thrombolytic management and served as the control group. 2/8 (25%) treatment and 3/9 (33%) control patients had underlying vascular comorbidities (p = 0.25). Number of digits at risk, duration of thrombolysis, thrombolytic agents used, digits amputated, hospital LOS, and complications were recorded. RESULTS: Seven upper and nine lower extremities for a total of 80 digits were at risk in the treatment cohort. Eight upper and 12 lower extremities for a total of 100 digits were at risk in the control group. Mean duration of thrombolysis was 26 h. All treatment patients received tissue plasminogen activator in addition to systemic heparin. 4/16 (25%) limbs received intra-arterial alprostadil, 2/16 (13%) received nitroglycerin, and 2/16 (13%) received nicardipine. 12/80 (15%) treatment digits and 77/100 (77%) control digits required amputation (p = 0.003). Average hospital LOS was 14 days in the treatment group and 38 days in the control group (p = 0.011). No major complications occurred in the treatment group; however, 2/9 (22%) patients in the control group required extended hospitalizations secondary to amputation complications. CONCLUSIONS: Intra-arterial thrombolysis reduces digital amputation rates and hospital LOS in the setting of severe frostbite.

Prone Transradial Catheterization for Combined Single-Session Transarterial Embolization and Percutaneous Posterior Approach Cryoablation of Solid Neoplasms.

Transradial access (TRA) has been associated with improved post-procedure hemostasis and patient satisfaction, and decreased hemorrhagic complications, sedation requirements, recovery times, and procedure-related costs when compared with traditional transfemoral catheterization. Supine TRA has been described for the treatment of myocardial infarctions, aortoiliac and femoropopliteal stenoses, and a variety of neoplasms. This original research describes prone transradial catheterization to facilitate combined single-session transarterial embolization and percutaneous cryoablation of solid neoplasms from a posterior approach without repositioning. Prone TRA access, transarterial embolization, and percutaneous cryoablation were successful in all cases described. Mean procedure time was 210 min (range: 140-250 min). One minor complication, transient bacteremia which responded to antibiotics, was reported. No major complications occurred.