Diagnosis and management of radiation cholecystitis as a complication of Y90 radioembolization for hepatocellular carcinoma.

Radiation induced cholecystitis is a known but rare complication of Yttrium90 (Y90) radioembolization of hepatic tumors due to nontarget embolization. Many documented cases of radiation induced cholecystitis have been treated with cholecystectomy, which is significant given the typical patient population undergoing radioembolization tends to be of higher surgical risk. Here, we present a case of a 68 year old male who developed radiation induced cholecystitis status post hepatic radioembolization that resolved with conservative management alone. This case highlights that radiation induced cholecystitis may be successfully and safely treated conservatively.

Comparing Outcomes of CT-Guided Percutaneous Pericardial Drainage with Surgical Pericardial Window in Patients with Symptomatic Pericardial Effusions.

RATIONALE AND OBJECTIVES: To compare short-term outcomes of CT-guided percutaneous pericardial drainage (PPD) versus subxiphoid surgical pericardial window (PW) drainage and analyze the risk factors associated with their outcomes. MATERIALS AND METHODS: A retrospective chart review of patients who underwent either percutaneous drainage with drainage catheter placement or PW with surgical drain placement for symptomatic pericardial effusion between January 1, 2006 and August 31, 2016 was performed after institutional review board approval (decision number 16-783). The primary objective was to test for associations between the short-term (≤30 days post procedure) complication and recurrence rates in patients with symptomatic pericardial effusions. The secondary objectives were to test for associations between short-term complications with changes in vital signs. RESULTS: Of the 257 procedures included in the final analysis, 142 were in the percutaneous drainage group. Short-term complication rate was significantly greater (p < 0.001) in patients undergoing PW, 17% (19/114), as compared with PPD, 2% (3/142). The estimated odds of having complications in the PW cohort was 9 times greater than the percutaneous drainage cohort (OR = 9.3, 95% CI:  2.7-32.3). No significant difference was observed between whether or not a patient experienced a short-term recurrence and any of the explanatory variables (patient demographics, imaging, and vital signs). CONCLUSION: CT-guided PPD is a safer alternative to surgical PW as it leads to fewer complications without a significant difference in recurrence rate of pericardial effusion.

Posttreatment Exposure Rates for 90Y-Microsphere Patients: A Comparison of Products.

There has been a significant increase in the use of 90Y-microspheres in treating liver malignancies. This increase could be seen over the last 30 y, and Food and Drug Administration approval of 2 products-Sirtex SIR-Spheres and Boston Scientific TheraSphere-has helped in the proliferation of these treatments. As the increase in use of both products rose at our institution, there was a need to determine whether there should be special considerations for patients who receive one product compared with patients who receive the other product. This determination was made by measuring exposure rates for several regions of the patient before and after implantation. An independent-samples t test analysis (ɑ = 0.05) was performed for 50 patients (25 TheraSphere and 25 SIR-Spheres) to determine whether the products behaved similarly to the extent that exposure to others was minimized and that as-low-as-reasonably-achievable principles were kept. The results showed that the products exhibited no significant differences in exposure rates, suggesting that no special considerations are needed for the procedure for one product compared with the other.

The use of an upper extremity hemodialysis access site for stenting of the superior mesenteric artery for chronic mesenteric ischemia.

We report the use of an upper extremity hemodialysis access site to facilitate endovascular treatment of the superior mesenteric artery in the setting of chronic mesenteric ischemia. A 64-year-old woman with end-stage renal disease on hemodialysis presented with worsening symptoms associated with chronic mesenteric ischemia. Her left upper extremity interposition graft within the fistula access site was selected to avoid a hostile aortoiliac system and in consideration of the potential benefits it provided over transfemoral, transbrachial, and transradial sites. The procedure was technically successful without complication. Hemodialysis access sites, such as the interposition graft within the fistula of this patient, are a potential route of upper extremity access for mesenteric interventions in patients with end-stage renal disease on hemodialysis.

Arterio-enteric fistula in failed enteric-drained pancreas transplants: an impending danger.

Enteric drainage is the preferred method of exocrine diversion in simultaneous kidney-pancreas transplantation. Because of improvements in immunosuppression, enteric drainage has become the preferred method of pancreas transplantation in general. Although associated with less potential complications than bladder-drained pancreas, potentially lethal arterio-enteric fistulas in the setting of nonfunctioning allografts represent a constant threat. We herein present a case report, a review of the literature, and a call for caution.

Pulmonary arteriovenous malformation embolization: how we do it.

We report our experience with an embolization technique that allows safe, controllable exclusion of pulmonary arteriovenous malformations using detachable coils, a single venous access site, coaxial catheter guidance, and 1 or 2 microcatheters. This technique is particularly useful when treating central lesions with a short feeding artery and when high flow increases the risk of coil migration and nontarget embolization. It affords precise placement and repositioning of coils prior to detachment. The technique facilitates safe and successful endovascular closure of these challenging lesions.

Significance of elevated transplant renal artery velocities in the postoperative renal transplant patient.

INTRODUCTION: Non-invasive imaging studies can provide visualization of allograft perfusion in the postoperative evaluation of newly transplanted renal allografts. AIM: The purpose of our study was to evaluate the significance of elevated renal artery velocities in the immediate postoperative period. METHODS: Peak systolic velocities (PSVs) were obtained in the transplanted renal artery of 128 patients immediately after transplantation. Repeat allograft Doppler ultrasonography was performed on patients with elevated values. RESULTS: Of the 128 patients, 57 (44.5%) had severely elevated Doppler velocities >400 cm/s on the initial studies. Three patients within this category had persistently elevated values of >400 cm/s, warranting angiographic visualization of the renal vessels. Stent placement within the transplanted renal artery was required in two of these patients. There was normalization of the PSV in the remaining patients. CONCLUSIONS: Routine allograft Doppler ultrasonography in the immediate postoperative period allows for visualization of allograft perfusion. Elevated renal artery velocities in the immediate postoperative period do not necessarily represent stenosis requiring intervention. Failure of the PSV to normalize may require further intervention, and angiography continues to be the gold standard.

Investigating the benefit of adding a vena cava filter to anticoagulation with fondaparinux sodium in patients with cancer and venous thromboembolism in a prospective randomized clinical trial.

BACKGROUND: The benefit of adding a vena cava filter to anticoagulation in treating cancer patients with venous thromboembolism remains controversial. We initiated this study as the first prospectively randomized trial to evaluate the addition of a vena cava filter placement to anticoagulation with the factor Xa inhibitor fondaparinux sodium in patients with cancer. METHODS: Sixty-four patients with deep vein thrombosis (86 %) and/or pulmonary embolism (55 %) were randomly assigned to receive anticoagulation with fondaparinux sodium with or without a vena cava filter. Endpoints included rates of complications by treatment arm, recurrent thromboembolism, complete resolution of thromboembolism, and survival rates. RESULTS: No patient had a recurrent deep vein thrombosis; two (3 %) patients had new pulmonary emboli, one in each randomized cohort. Major bleeding occurred in three patients (5 %). Two patients on the vena cava filter arm (7 %) had complications from the filter. Median survivals were 493 days in the anticoagulation only arm and 266 days for anticoagulation + vena cava filter (p < 0.57). Complete resolution of venous thromboembolism occurred in 51 % of patients within 8 weeks of initiating anticoagulation. CONCLUSIONS: No advantage was found for placement of a vena cava filter in addition to anticoagulation with fondaparinux sodium in terms of safety, recurrent thrombosis, recurrent pulmonary embolism, or survival in this prospective randomized trial evaluating anticoagulation plus a vena cava filter in cancer patients. Favorable complete resolution rates of thrombosis were observed on both study arms.

Percutaneous insertion of peritoneal ports.

OBJECTIVE: To describe a technique for image-guided percutaneous insertion of peritoneal ports in patients without ascites who have undergone surgical debulking for stage III ovarian cancer. MATERIALS AND METHODS: Between 2006 and 2010, 29 intraperitoneal ports were placed percutaneously in 29 patients who presented after debulking surgery for stage III ovarian cancer. Ultrasound and fluoroscopy guidance were used to assist in the port placement. RESULTS: We demonstrated a technical success rate of 100% in 29 patients. The ports remained in place for an average of 186 days; and during that time, only 2 complications (6.9%) arose. One patient presented with kinking and looping of the catheter/port reservoir connection, and the redundant loop was removed. The other patient presented with a suspected wound infection over the port pocket, and the port was removed. CONCLUSIONS: Placement of percutaneous intraperitoneal ports is feasible with an acceptably low complication rate of 6.9% in patients without abdominal ascites.

Double microcatheter single vascular access embolization technique for complex peripheral vascular pathology.

The authors describe an embolization technique that allows safe, controllable exclusion of complex vascular pathologies using a single vascular access and 2 microcatheters. This technique is particularly useful in situations where high flow increases the risk of coil migration and nontarget embolization and in large aneurysms. It affords precise placement and repositioning of coils. This method was used to treat patients with pulmonary arteriovenous malformations, renal arteriovenous fistulae and aneurysms, visceral arterial aneurysms and pseudoaneurysms, an aortic pseudoaneurysm, and occlusion of native parent vessels. The technique facilitated safe and successful endovascular closure in all cases.

Doppler sonographic criteria for the diagnosis of inferior mesenteric artery stenosis.

OBJECTIVE: The purpose of this study was to define the optimal Doppler criteria for the diagnosis of inferior mesenteric artery (IMA) stenosis in patients with suspected chronic mesenteric ischemia (CMI). METHODS: A retrospective review of 205 dedicated color and pulsed Doppler sonographic studies of mesenteric arteries was performed in 205 patients. All studies were performed in patients with suspected CMI. Correlative angiography was available in 50 patients. RESULTS: The IMA was visualized in 176 of 205 Doppler sonographic examinations (86%) and in 92% of the correlative studies. The visualization rate for the detection of a patent IMA by Doppler sonography in this series was 90%. The ranges of the peak systolic velocity (PSV), end-diastolic velocity (EDV), and mesenteric-aortic velocity ratio (MAR) in the nonstenotic IMA were 70 to 200 cm/s, 0 to 33 cm/s, and 0.7 to 3.7, respectively. The ranges of the PSV, EDV, and MAR in IMA stenosis were 200 to 485 cm/s, 0 to 177 cm/s, and 0.69 to 8.1. The threshold values for severe IMA stenosis by logistic regression analysis (n = 42) were as follows: PSV, greater than 200 cm/s; EDV, greater than 25 cm/s; and MAR, greater than 2.5, with sensitivities of 90%, 40%, and 80%; specificities of 97%, 91%, and 88%; positive predictive values (PPVs) of 90%, 57%, and 67%; negative predictive values (NPVs) of 97%, 83%, and 93%; and accuracy of 95%, 79%, and 86%, respectively. CONCLUSIONS: We found that a PSV of greater than 200 cm/s was the best criterion for the diagnosis of IMA stenosis. The sensitivity, specificity, PPV, NPV, and accuracy for the PSV were 90%, 97%, 90%, 97%, and 95%, respectively.

Bronchobiliary fistula successfully treated with n-butyl cyanoacrylate via a bronchial approach.

A bronchobiliary fistula is an abnormal communication between the biliary tree and the airway that can result in debilitating amounts of bilioptysis, or bile-stained sputum. The authors present an approach for the conservative management of a bronchobiliary fistula in a patient who failed traditional conservative therapy and refused surgical intervention.

Standardizing vascular surgery residency: merger of two programs to create one model.

The practice of vascular surgery has been transformed in the last decade. It is now necessary to change the way we train vascular surgeons, to keep pace with this rapidly evolving specialty.

Isolated injury of the cuboid bone.

The purpose of this study was to describe isolated injury of the cuboid bone as a potentially radiographically occult cause of foot pain. The imaging studies of 17 patients, 13 women and 4 men aged 17-79 years (average 45 years), who presented with pain over the lateral aspect of the midfoot were retrospectively reviewed. Frontal, lateral, and inversion-oblique radiographs were available for all patients. In addition, MR imaging was performed in eight patients, CT in two, conventional tomography in two, and bone scan in one. Conventional radiographs revealed cuboid fracture in seven patients. Of the remaining ten, eight underwent MR imaging which demonstrated four fractures, three bone bruises, and one stress reaction, and two had tomography, CT, and/or bone scan, all of which documented an isolated cuboid fracture. Isolated fracture of the cuboid may be radiographically occult. Other imaging modalities, particularly MR imaging, can document this injury as the source of pain.