Percutaneous Biliary Endoscopy.

Biliary endoscopy is underutilized by interventional radiologists and has the potential to become an effective adjunctive tool to help both diagnose and treat a variety of biliary pathology. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration prior to intervention. In this article, clinical evaluation, perioperative management, and procedural techniques for percutaneous biliary endoscopy are reviewed.

Endoscopy as an Adjunct to Image-Guided Interventions: A New Frontier in Interventional Radiology.

Endoscopy is an underutilized technique in the practice of interventional radiology. The objectives of this article are to discuss potential uses of interventional radiology-operated endoscopy and to outline basic endoscopy setup and equipment uses. Endoscopy represents a new frontier to the fluoroscopically-guided procedures in biliary, gastrointestinal, and genitourinary disease that interventional radiologists commonly perform. It shows promise to improve interventional radiology procedure success rates and reduce procedure-associated risk for patients. Endoscopy has been traditionally performed by gastroenterologists and urologists and is relatively new in the practice of interventional radiology. The hand-eye coordination and manual dexterity required to perform standard image-guided procedures places interventional radiologists in a unique position to introduce endoscopy into standard practice. A focused and collaborative effort is needed by interventional radiologists to learn the techniques required to successfully integrate endoscopy into practice.

Biliary Endoscopy for Benign and Malignant Biliary Strictures.

Percutaneous endoscopy operated by interventional radiologists has the potential to become an effective tool to both help diagnose and treat benign and malignant biliary strictures. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically-altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration when pursuing percutaneous endoscopy. In this article, clinical evaluation, perioperative management, and procedural techniques for biliary endoscopy for benign and malignant strictures are reviewed.

Percutaneous Interventional Radiology-Operated Endoscopy for Foreign Body Removal.

Image-guided retrieval of endovascular devices such as inferior vena cava filters, guidewires, and stents is well reported, though there is a paucity of published reports on biliary, genitourinary, or gastrointestinal foreign body retrieval utilizing percutaneous endoscopy, particularly when it is performed solely by interventional radiologists. In cases of failed traditional endoscopic techniques or to evade more invasive surgical options, percutaneous endoscopy can be an adjunctive tool employed by interventional radiologists to extract foreign bodies. In this article, clinical evaluation, perioperative management, and procedural techniques for biliary, genitourinary, and gastrointestinal endoscopy for foreign body retrieval are reviewed.

Transnasal stent-assisted targeting technique for percutaneous jejunostomy placement in patients with hiatal hernias.

PURPOSE: To report the transnasal stent-assisted targeting technique for percutaneous jejunostomy placement in patients with hiatal hernias. MATERIALS AND METHODS: Four patients, including three (75%) females and one (25%) male, with mean age of 77.5 years (range 73-78 years), and with a hiatal hernia and intrathoracic stomach precluding gastrostomy placement and loop snare placement into the mid-jejunum underwent the transnasal stent-assisted targeting technique for percutaneous jejunostomy placement. In all patients, a duodenal stent was inserted into the jejunum in a transnasal fashion. The stent was partially unsheathed in an anterior loop of jejunum and percutaneously targeted using an 18-gauge needle through which a guidewire was advanced, trapped within the stent, and removed through the nose. The tract was serially dilated and a jejunostomy was placed. Technical success, procedure time, fluoroscopy time, radiation exposure, complications, time to enteral feeding, and follow-up were recorded. RESULTS: Technical success was 100% (4/4) with all four patients requiring only one needle pass before successful jejunal cannulation. Mean procedure time was 108 min. Mean fluoroscopy time was 44 min. Mean dose area product was 3969.3 µGym2. No minor or major complications occurred. All four patients received enteral feeding one day after the procedure. Mean follow-up was 366 days. CONCLUSION: The transnasal stent-assisted targeting technique is a novel method for primary jejunostomy placement in patients with hiatal hernias.

Endovascular Transpulmonary Retrieval of a Migrated Amplatzer Vascular Plug Following Balloon-Occluded Retrograde Transvenous Obliteration.

Gastric varices are a common manifestation of portal hypertension and are associated with a high rate of mortality and rebleeding. Balloon-occluded retrograde transvenous obliteration (BRTO) is a commonly used method to sclerose gastric varices and has a high clinical success. Common complications following BRTO include portal or splenic vein thrombosis, systemic sclerosant extravasation, pulmonary emboli, and inferior vena cava thrombosis. This report describes a patient with vascular plug migration into the left pulmonary artery with subsequent endovascular retrieval.

Advanced stage breast cancer is associated with catheter-tip thrombus formation following implantable central venous port placement.

PURPOSE: Catheter-tip associated thrombosis is not uncommon in patients with implantable central venous ports; however, the prevalence and clinical impact of this complication on patient management is unclear. This study aims to identify risk factors for thrombus formation in a large population receiving serial echocardiograms (echo) following port placement. METHODS: A total of 396 female breast cancer patients underwent internal jugular vein chest port placement between 2007 and 2013 and received echo studies every third month. Catheter tip position was measured from chest radiography and catheter associated thrombus was identified by echo. RESULTS: Sixteen out of 396 patients (4%) had catheter-tip thrombus. No patients were symptomatic or prophylactically anticoagulated. Patients with thrombus were significantly younger than those without (46.4 years versus 53.4 years, respectively, p = 0.02) and had higher stage breast cancer with 75% versus 44.7% having stage III or IV cancer ( p = 0.017). Thrombus was identified after a median of 91 days. No significant difference was identified in anatomic ( p = 0.1) or measured ( p = 0.15) tip position, port laterality ( p = 0.86), or number of port lumens ( p = 0.65). CONCLUSIONS: In this large cohort, younger patients and those with more advanced stage breast cancer were more associated with catheter-tip-related thrombus after port placement.

Three-Dimensional Printing Facilitates Creation of a Biliary Endoscopy Phantom for Interventional Radiology-Operated Endoscopy Training.

PURPOSE: To create a three-dimensional endoscopic model of the biliary tract from magnetic-resonance cholangiopancreatography imaging and to evaluate its effectiveness as a tool for training in endoscopic biliary interventions. MATERIALS AND METHODS: A magnetic-resonance cholangiopancreatography study was performed on a patient with biliary obstruction secondary to a distal bile duct cholangiocarcinoma. Using Vitrea, a three-dimensional volume-rendered image was created, and exported as a standard tessellated language file. The standard tessellated language model was then edited with MeshMixer. Three cylindrical entry ports were created. The ports were aligned and overlapped with the dominant ducts in three separate areas of the model and fused to the model. A 0.2 cm shell was created around the model and the model was hollowed. The ends of the ports were cut off, allowing access to the hollowed-out model. The model was printed at 125% scale to allow easy access with a 9.5-French (≤3.23 mm) endoscope. The model was printed using a Stratasys Dimension Elite Plus printer. After printing, the model was post-processed to remove support materials. A 10-question survey was administered to all trainees before and after use of the printed phantom to practice endoscopy skills. RESULTS: 11 trainees participated in the three-dimensional endoscopy simulation with most of the trainees (73%) having no prior formal endoscopy training. Using a 10-point Likert scale, the mean comfort-level of the trainees to use endoscopy alone for cholecystostomy, percutaneous biliary drainage, percutaneous nephrostomy, and percutaneous gastrostomy increased by 38.9%, 32.8%, 32.8%, and 34.3%, respectively, following the training experience. CONCLUSION: The use of a three-dimensionally printed endoscopic model as a simulation tool has the potential to improve trainee comfort using endoscopy during interventional radiology procedures.

Lymphatic interventions for isolated, iatrogenic chylous ascites: A multi-institution experience.

OBJECTIVES: Lymphangiography and thoracic duct embolization are established treatments for post-surgical chylothorax. There is only limited experience in their application to treat post-surgical chylous ascites. A multi-center analysis of the technical and clinical success of lymphangiography and lymphatic interventions in the treatment of isolated, iatrogenic chylous ascites is reported. METHODS: 21 patients (14 males; 7 females) aged 3-84 years (mean 56.9 years; median 63 years) were treated for isolated, iatrogenic chylous ascites between August 2012 and January 2018. Initial referrals occurred between 5-330 days (mean 72.7 days; median 40 days) after failing conservative therapy. Daily leak volumes ranged from 100 to 3000 mL. Lymphangiographic findings, techniques, clinical outcomes, and complications were recorded. RESULTS: 21 patients underwent 29 procedures. Seven patients underwent multiple procedures after chylous ascites persisted. Bilateral nodal lymphangiography (NL) was technically successful in all (100%) patients. Lymphangiography identified a leak in 14/21 (67%) patients and in 16/29 procedures (55%). Ten procedures (34%) consisted of NL alone and one (3.4%) consisted of NL combined with lymphatic disruption (LD). Six procedures (21%) consisted of nodal glue embolization (NGE) while nine procedures (31%) were catheter-based lymphatic embolization. Three separate patients underwent three procedures (10%) consisting of balloon-occluded retrograde abdominal lymphatic embolization. Clinical success, defined as no additional drainage of chylous ascites at 15 days, was ultimately achieved in 18/21 patients (86%). There were no major or minor complications. CONCLUSION: Lymphatic interventions can successfully treat post-surgical chylous ascites. Given the low risk of procedural complication, early intervention is encouraged.

Bleeding diverticulum of the colon treated with CT-guided percutaneous injection of epinephrine and cyanoacrylate.

Hematochezia may be a result of anatomic, vascular, inflammatory, infectious, or neoplastic diseases. Colonoscopic evaluation and therapy may be limited because of intermittent bleeding in the setting of numerous diverticula. This report describes a patient with diverticulosis who presented with hematochezia and hemodynamic instability with failed colonoscopic and arteriographic evaluations, and was treated with percutaneous transcolonic diverticular cyanoacrylate and epinephrine injection.

#VascularSurgery.

BACKGROUND: To characterize the vascular surgery Twitter network. METHODS: A total of 20,841 consecutive tweets by 8,282 unique Twitter accounts regarding vascular surgery from October 23, 2014 to January 15, 2018 were analyzed. Twitter analytics, including activity metrics, content analysis, user characteristics, engagement, and network analysis were performed using Symplur Signals, a health care social media analytics platform. RESULTS: Vascular surgery tweets, the number of users tweeting about vascular surgery, and vascular surgery tweet impressions have increased by an annual average of 77.8%, 55.3%, and 209.1% from 2015 to 2017, respectively. Twitter activity trend analysis showed consistent growth over the study period with an average of 25.7 ± 2.6 additional tweets per month (P < 0.001). As for tweet content, 2,220 tweets (10.7%) were pertaining to patients, and 2,198 tweets (10.5%) were regarding new or innovative topics. 15,422 tweets (74.0%) included links to journals or websites and 6,826 tweets (32.8%) contained at least 1 image. Deep venous thrombosis, pulmonary embolism, diabetes, endovascular interventions, trauma, and practice guidelines were among the most commonly discussed health topics. Physicians composed 5,618 tweets (27%), while patients submitted 2,447 tweets (11.7%). As for engagement, 8,886 tweets (42.6%) were retweets, 11,816 tweets (56.7%) mentioned at least 1 other user, and 786 tweets (3.8%) were replies. Network analysis revealed central hubs to be vascular surgery societies, academic institutions, academic journals, and physicians. CONCLUSIONS: The use of Twitter to discuss vascular surgery is growing rapidly with increasing use by vascular surgeons and vascular medicine physicians. An effort to involve more patients in the vascular surgery Twitter social network may allow for more opportunities to educate, and garner interest and support for vascular surgery.

Endovascular management of acute aortic dissection.

Acute dissection of the thoracic aorta is a potentially life-threatening condition which requires collaborative treatment from multiple specialties for optimal patient outcomes. Dissections involving the ascending aorta and aortic arch have traditionally been managed entirely by surgery, while dissections beyond the arch vessels have most commonly been relegated to medical management. This algorithm has been undergoing a paradigm shift over the past two decades due to improvements in stent graft technology, better understanding of the hemodynamic interactions of the true and false lumen and their influence on organ and limb perfusion, and improvements in medical management and long term surveillance for dissection-related complications. This manuscript includes a brief discussion of the pathogenesis and etiology of dissection, followed by an in-depth review of the medical and endovascular techniques utilized to treat patients afflicted by this condition.

Type II endoleaks: diagnosis and treatment algorithm.

Elective abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm, symptomatic, or rapidly expanding more than 0.5 cm in 6 months. Seventy-five percent of AAAs today are treated with endovascular aneurysm repair (EVAR) rather than open repair. This is fostered by the lower periprocedural mortality, complications, and length of hospital stay associated with EVAR. However, some studies have demonstrated EVAR to result in higher reintervention rates than with open repair, largely due to endoleaks. Type II is the most common, making up 10-25% of all endoleaks. Type II endoleaks, can potentially enlarge and pressurize the aneurysm sac with a risk of rupture. However, many type II endoleaks spontaneously resolve or never lead to sac enlargement. Imaging surveillance and approaches to management of type II endoleaks are reviewed here.

Percutaneous transgastrostomic interventional radiology-operated endoscopy facilitates foreign body removal using rigid endobronchial forceps.

Retained foreign bodies within the stomach and proximal small bowel may be problematic in patients with prior cerebrovascular injury or head, neck and esophageal malignancy, given the increased vulnerability of this patient population to complications from aspiration and increased difficulty of esophagogastroduodenoscopy in cases of tumoral obstruction. This article presents an alternative method for foreign body retrieval through an existing gastrostomy tract, which offers the benefits of fast procedure times, reduction in radiation dose and fluoroscopy time, and allows for safer retrieval of foreign bodies by using direct visualization. This technique may be performed entirely by interventional radiologists.

Retrieval characteristics of the Bard Denali and Argon Option inferior vena cava filters.

OBJECTIVE: The purpose of this study was to compare the retrieval characteristics of the Option Elite (Argon Medical, Plano, Tex) and Denali (Bard, Tempe, Ariz) retrievable inferior vena cava filters (IVCFs), two filters that share a similar conical design. METHODS: A single-center, retrospective study reviewed all Option and Denali IVCF removals during a 36-month period. Attempted retrievals were classified as advanced if the routine "snare and sheath" technique was initially unsuccessful despite multiple attempts or an alternative endovascular maneuver or access site was used. Patient and filter characteristics were documented. RESULTS: In our study, 63 Option and 45 Denali IVCFs were retrieved, with an average dwell time of 128.73 and 99.3 days, respectively. Significantly higher median fluoroscopy times were experienced in retrieving the Option filter compared with the Denali filter (12.18 vs 6.85 minutes; P = .046). Use of adjunctive techniques was also higher in comparing the Option filter with the Denali filter (19.0% vs 8.7%; P = .079). No significant difference was noted between these groups in regard to gender, age, or history of malignant disease. CONCLUSIONS: Option IVCF retrieval procedures required significantly longer retrieval fluoroscopy time compared with Denali IVCFs. Although procedure time was not analyzed in this study, as a surrogate, the increased fluoroscopy time may also have an impact on procedural direct costs and throughput.

Feasibility and Acceptance of a Telehealth Intervention to Promote Symptom Management during Treatment for Head and Neck Cancer.

Patients undergoing treatment for head and neck cancers have a myriad of distressing symptoms and treatment side effects which significantly alter communication and lower quality of life. Telehealth technology has demonstrated promise in improving patient-provider communication by delivering supportive educational content and guidance to patients in their homes. A telehealth intervention using a simple telemessaging device was developed to provide daily education, guidance, and encouragement for patients undergoing initial treatment of head and neck cancer. The goal of this article is to report the feasibility and acceptance of the intervention using both quantitative and qualitative measures. No eligible patients declined participation based on technology issues. Participants completed the intervention over 86% of the expected days of use. Direct nursing contact was seldom needed during the study period. Satisfaction with the technology and the intervention was very high. In this study a telehealth intervention was shown to be feasible, well accepted, and regularly used by patients experiencing extreme symptom burden and declining quality of life as a result of aggressive treatment for head and neck cancer.