Image-guided percutaneous cholecystostomy: challenging the norms.

Image-guided percutaneous cholecystostomy (IGPC) is a widely recognized and regularly employed procedure in numerous institutions, serving as an indispensable cornerstone in the management of patients with acute cholecystitis. The most up-to-date literature has found that the transperitoneal route is at least as safe as the transhepatic route and that both the trocar and Seldinger techniques are equally safe and effective. The above novel insights may offer reassurance and alleviate concerns among operators performing IGPC by dispelling the fixation on previously established beliefs and thus providing flexibility, which lightens the load on the operator. Future studies could further investigate these findings and shed light on potential disparities in the safety and efficacy profiles associated with the subcostal and intercostal approaches, different drainage catheter sizes, and/or the impact of operator experience on complication rates.

Percutaneous cholecystostomy: techniques and applications.

Acute cholecystitis (AC) is a critical condition requiring immediate medical attention and treatment and is one of the most frequently encountered acute abdomen emergencies in surgical practice, requiring hospitalization. Laparoscopic cholecystectomy is considered the favored treatment for patients with AC who are fit for surgery. However, in high-risk patients considered poor surgical candidates, percutaneous cholecystostomy (PC) has been suggested and employed as a safe and reliable alternative option. PC is a minimally invasive, nonsurgical, image-guided intervention that drains and decompresses the gallbladder, thereby preventing its perforation and sepsis. It can act as a bridge to surgery, but it may also serve as a definitive treatment for some patients. The goal of this review is to familiarize physicians with PC and, more importantly, its applications and techniques, pre- and post-procedural considerations, and adverse events.

Feasibility and Clinical Value of Intraprocedural Doppler Ultrasonography Blood Flow Parameters During Peripheral Endovascular Procedures for Limb Salvage: A Pilot Study.

PURPOSE: To investigate whether Doppler ultrasound (DUS) blood flow parameters could serve as quantifiable functional endpoints of peripheral endovascular arterial procedures for chronic limb-threatening ischemia (CLTI), influencing wound healing. METHODS: This is a prospective single-center study investigating intraprocedural DUS parameters (pulsatility index [PI] and pedal acceleration time [PAT]) in quantifying immediate hemodynamic alterations in consecutive CLTI patients with wound, ischemia, and foot infection wound class ≥1 undergoing endovascular interventions. Primary endpoints were feasibility of preendovascular and postendovascular treatment measurements of PI/PAT, quantification of immediate PI/PAT modifications of the posterior and anterior foot circulation following revascularization, the correlation between PI and PAT, and 6-month complete wound healing. Secondary endpoints included the 6-month limb salvage (no major amputation) and complete and partial wound healing rates. RESULTS: A total of 28 patients (75.0% male) were enrolled, and 68 vessels were treated. The overall mean PAT values significantly decreased from 154.15±70.35 ms preprocedural to 107.21±49.6 ms postprocedural (p<0.01), and the mean PI values significantly increased from 0.93±0.99 to 1.92±1.96 (p<0.01). Postprocedural PAT at the anterior tibial (r2=0.804; p=0.346) and the posterior tibial arteries (r2=0.784; p=0.322) had a strong correlation and postprocedural PI at the anterior tibial (r2=0.704; p=0.301) and the posterior tibial arteries (r2=0.707; p=0.369) had a good correlation with 6-month complete wound healing. The 6-month complete and partial wound healing rates were 38.1% and 47.6%, respectively. Limb salvage was 96.4% and 92.4% at 6 and 12 months of follow-up, respectively. CONCLUSIONS: Pedal acceleration time and PI accurately detected immediate hemodynamic changes of foot perfusion following revascularization and could serve as prognostic factors of wound healing in patients with CLTI. CLINICAL IMPACT: Intraprocedural measurement of simple Doppler ultrasound blood flow parameters, Pulsatility Index (PI) and Pedal Acceleration Time (PAT), accurately detected immediate hemodynamic changes of foot perfusion following endovascular revascularization and could therefore serve as intraprocedural prognostic factors of wound healing in patients with chronic limb-threatening ischemia. This is the first time that PI has been proposed as a hemodynamic index of successful angioplasty outcome. The optimization of intraprocedural PAT and PI could be used to guide angioplasty and predict clinical success.

US-guided trocar versus Seldinger technique for percutaneous cholecystostomy (TROSELC II trial).

OBJECTIVES: The purpose of this study is to investigate the safety and effectiveness of the US-guided bedside trocar vs. the Seldinger technique for percutaneous cholecystostomy (PC) procedures. METHODS: This is a prospective single-center, randomized, controlled trial (RCT) comparing the trocar (group T; 50 patients [27 men]; mean [± SD] age, 74.16 ± 15.59 years) with the Seldinger technique for PC (group S; 50 patients [23 men]; mean [± SD] age, 80.78 ± 14.09 years) in consecutive patients undergoing the procedure in a bedside setting with the sole employment of US as a guidance modality. Primary outcomes consisted of technical success and complications associated with the procedure. Secondary outcome measures involved procedure duration, intra-/post-procedure pain evaluation, and clinical success. RESULTS: PC was technically successful for all 100 patients. Clinical success rates were similar between group T and S (94% vs. 92%, respectively; p = 0.34). Equal total procedure-related complications were noted in both groups (4% vs. 4%; p = 0.5). A minor bleeding event (bile mixed with blood) occurred in one patient (2%) in group T and one patient (2%) in group S; accidental catheter dislodgement in one patient (2%) from group T, and a small biloma in one patient (2%) from group S. No procedure-related deaths or major bleeding events were noted. PC was significantly faster in group T (1.41 ± 1.13 vs. 4.41 ± 2.68 min; p < 0.001). Mean pain score during PC was significantly lower in group T compared with group S at 12 h of follow-up (1.43 ± 1.45 vs. 3.36 ± 2.05; p < 0.01). CONCLUSION: US-guided bedside trocar technique for PC was equally effective and safe as the Seldinger technique, but it was faster and simpler to perform and led to reduced pain following the procedure.

An update on locoregional percutaneous treatment technologies in colorectal cancer liver metastatic disease.

INTRODUCTION: Liver-dominant metastatic colorectal cancer is noted in approximately 20%-35% of the patients. Systemic chemotherapy remains the first-line treatment for mCRC, but the prognosis is poor due to liver failure. Novel minimally invasive technologies have enabled the optimization of locoregional treatment options. AREAS COVERED: This is a comprehensive review of novel locoregional treatment technologies, both percutaneous ablation and transcatheter arterial treatments, which can be used to decrease hepatic disease progression in patients with mCRC. Trans-arterial radioembolization is the most recently developed locoregional treatment for metastatic liver disease, and robust evidence has been accumulated over the past years. EXPERT OPINION: Image-guided techniques, endovascular and ablative, have gained wide acceptance for the treatment of liver malignancies, in selected patients with non-resectable disease. The optimization of dosimetry and microsphere technological advancement will certainly upgrade the role of liver radioembolization segmentectomy or lobectomy in the upcoming years, due to its curative intent. Also, ablative interventions provide local curative intent, offering significant and sustained local tumor control. Standardization protocols in terms of predictability and reliability using immediate treatment assessment and ablation zone software could further ameliorate clinical outcomes.

Irreversible electroporation for the management of pancreatic cancer: Current data and future directions.

Pancreatic cancer is currently the seventh leading cause of cancer death (4.5% of all cancer deaths) while 80%-90% of the patients suffer from unresectable disease at the time of diagnosis. Prognosis remains poor, with a mean survival up to 15 mo following systemic chemotherapy. Loco-regional thermal ablative techniques are rarely implemented due to the increased risk of thermal injury to the adjacent structures, which can lead to severe adverse events. Irreversible electroporation, a promising novel non-thermal ablative modality, has been recently introduced in clinical practice for the management of inoperable pancreatic cancer as a safer and more effective loco-regional treatment option. Experimental and initial clinical data are optimistic. This review will focus on the basic principles of IRE technology, currently available data, and future directions.

Evaluation of a new paclitaxel-coated balloon catheter in an in vivo porcine peripheral venous model: Feasibility, safety, and drug deliverability.

PURPOSE: To evaluate in vivo the feasibility, safety, and paclitaxel (PTX) deliverability of a newly developed non-commercially available Paclitaxel-Coated Balloon (PCB) catheter in the swine healthy peripheral vein model. MATERIALS AND METHODS: In total 12 PCBs were deployed in 12 venous segments. Primary feasibility endpoint was the successful application of the devices to the veins of the animals. Primary efficacy endpoint was the determination of the drug content in the venous tissue at 24 h and 7 days after balloon expansion, as assessed by analysis of the vein tissue with High Performance Liquid Chromatography (HPLC) coupled with tandem mass spectrometry. Primary safety endpoint was freedom from any major adverse event. Secondary endpoint was the investigation of any independent factor affecting the primary endpoints. RESULTS: Paclitaxel was detected in five out of six tissue samples 24 h post-intervention and five out of six tissues at 7 days following the procedure (10 tissue samples out of 12). The mean weight of tissue that was examined was 0.20604 ± 0.29822 g (range: 1.02823-0.03377 g) and the mean PTX concentration detected was 8.4 ± 13.1 µg/g (range: 0-36.1 µg/g). The average drug content detected at 24 h (17.1 ± 17.1 µg/g) was numerically superior, but non-statistically significant, compared to 7 days (3.1 ± 3.6 µg/g). An average of 33.8% of the drug remained on the balloon after retrieval. According to the multiple linear regression analysis, there was no significant correlation between transition time, PTX remaining on the balloon, time of analysis (24 h/7 days) and PTX tissue concentration. No abnormalities were noted during autopsy. CONCLUSION: The newly developed PCB successfully delivered within the healthy venous wall a dose of Paclitaxel that inhibits neointimal hyperplasia. No safety issues were raised at short-term follow-up.

Direct Percutaneous Glue Embolization of the Splenic Artery following Iatrogenic Puncture during CT-Guided Core Needle Biopsy: a Case Report.

Background:Direct percutaneous embolization, has been deliberately employed before on various occasions. However, to our knowledge, there is no report in the literature, of its use in order to achieve urgent hemostasis after iatrogenic erroneous arterial puncture. Case presentation: A 75-year-old female patient underwent a CT-guided biopsy of a pancreatic body necrotic mass encasing the patent splenic artery and thrombosed splenic vein. Following the second biopsy needle pass, brisk arterial flow occurred through the 17G coaxial needle, raising concern for a splenic artery puncture. The central stylet was instantly repositioned into the coaxial needle in order to tamponade the bleeding, while a mixture of glue/lipiodol (1:3 ratio) was prepared. The mixture was injected through the coaxial needle while the latter remained in its position and while it was being withdrawn from the abdomen, in order to achieve track sealing. CT angiography revealed a hyperdense-embolic material in the course of the coaxial system throughout the lumen of the splenic artery/intrasplenic branches and in the gastrohepatic space. Additionally, reduced/absent flow was noted in the splenic artery, while almost no contrast enhancement was eminent in the splenic parenchyma. Importantly, no contrast extravasation or additional complications were noted. The patient remained hemodynamically stable, with no drop of the Hct/Hb counts and no clinical signs or symptoms of bleeding throughout the procedure and remaining hospitalization. Conclusions:Percutaneous, direct glue embolization of the splenic artery following its erroneous puncture with a 17G coaxial needle was fast, safe and effective, resulting though in asymptomatic occlusion of a large volume of splenic parenchyma.

Surgical Management of a Pancreaticopleural Fistula After Failed Endoscopic Therapy.

Inflammatory diseases of the pancreas or pancreatic trauma result in ductal cell disruption, which in turn may lead to leakage of pancreatic fluid, mostly in the retroperitoneal space. Pancreatopleural fistulas are uncommonly encountered following pancreatic injury; however, they often prove a difficult problem to manage. Herein, we present a rare case of a 68-year-old male suffering from a pancreaticopleural fistula (PF) between the pancreatic tail and the left pleural space one year following splenectomy for trauma. About three months after percutaneous drainage of a left pleural effusion and left upper quadrant abdominal collection and endoscopic pancreatic duct stent placement, surgical management was decided. Distal pancreatectomy and Roux-en-Y drainage of the pancreatic remnant were successfully performed.

VOLume flow assistance for optimizing outcomes of dysfunctional autologous arteriovenous fistula Angioplasty: the VOLA Pilot Study.

OBJECTIVES: To investigate the feasibility of VF-assisted angioplasty (VFA) in dysfunctional AVF using sequential intraprocedural duplex ultrasound (DUS), to utilize intraprocedural VF as a quantifiable, functional endpoint in endovascular treatment. METHODS: This prospective study included 20 consecutive patients (23 lesions; 16 men; mean age 67 ± 16 years) with dysfunctional AVF undergoing fluoroscopically guided balloon angioplasty between June 2019 and May 2020. Primary endpoints were quantification of outcome using sequential DUS VF analysis following each dilation, 6-month target lesion re-intervention (TLR)-free rate, standard technical success, procedural success (achievement of a postprocedural VF value equal (or 10% less) or superior to the baseline steady-state access), and correlation between procedural success and TLR-free rate. Secondary endpoints included 6-month lesion late lumen loss (LLL), correlation between balloon diameter used and intraprocedural VF values, and correlation between VF and LLL at 6 months follow-up. RESULTS: Mean VF increase was 168.5% ± 102.5% (range: 24.24-493.33%). Procedural success was 80% (16/20 cases). VFA improved procedural success by 20% (4/20 cases) compared to standard assessment (< 30% residual stenosis and palpable thrill). TLR-free rate was 78.3% and 67.3% at 6 and 12 months. Significantly less TLR was noted in cases of procedural success (82.4% vs. 66.7% 6 months; p = 0.041). Unweighted linear regression showed a significant positive relationship between diameter of balloon and VF (146.9 ± 42.3 mL/min VF gain per mm of balloon diameter; p = 0.001, R2 = 0.23) and a significant negative relationship between LLL and VF decline at follow-up (102.0 ± 34.6 mL/min loss per mm of LLL; p = 0.01, R2 = 0.35). Optimal VF cutoff value and percentile increase to predict access failure were 720 mL/min (sensitivity 58.3%, specificity 71.4%) and 153% (sensitivity 66.7%, specificity 85.7%), respectively. CONCLUSION: Intraprocedural VF assessment could be used to optimize AVF angioplasty. KEY POINTS: • A newly proposed functional endpoint of angioplasty in dysfunctional dialysis fistula was evaluated and angioplasty outcome was quantified using volume flow (VF) assessment with sequential intraprocedural DUS. • Intraprocedural VF assessment improved immediate procedural success; increased balloon diameter was correlated with VF gain and late lumen loss with VF decline. • Intraprocedural VF values ≥ to baseline steady-state values were correlated with less re-interventions.

MDCTA volumetric analysis for the quantification and grading of acute non-cerebral, non-gastrointestinal hemorrhage: a feasibility study.

PURPOSE: To assess the feasibility of multi-detector computed tomography angiography (MDCTA) volumetry for the quantification and grading of acute non-cerebral, non-gastrointestinal bleeding. METHODS: This retrospective, single-center study investigated consecutive patients with MDCTA positive for active non-cerebral, non-gastrointestinal bleeding, between January 2020 and June 2020. Outcome measures were the quantification of active extravasation at the arterial and parenchymal phase using volumetry measurements, the calculation of active bleeding rate and bleeding grading, 30-day mortality rate, identification of independent predictors of mortality and correlation between volumetric analysis, various clinical features, and the decision to proceed with an intervention. RESULTS: In total 30 patients (17 females; 56.6%; mean age 70.0 ± 16.0 years) were analyzed. Volumetric analysis was feasible in all cases resulting in excellent inter-observer variability (interclass correlation coefficient 0.999 for arterial and 0.919 for venous volume measurements). Mean volume of contrast extravasation was 1.06 ± 1.09 ml and 3.07 ± 2.48 ml at the arterial and parenchymal phases, respectively. Mean bleeding rate was 6.95 ± 7.82 ml/min. High bleeding volume at arterial phase (grade 4 bleeding) was the only independent predictor of 30-day mortality (HR 1383.58; p = 0.042). There was a positive correlation between bleeding volume at arterial phase (rs = 0.340; p = 0.033) and arterial bleeding rate (rs = 0.381; p = 0.019) with the decision to proceed with an intervention. Bleeding volume of 0.6 ml was the cutoff value for the prediction of intervention (sensitivity 96.3%; specificity 66.7%). CONCLUSIONS: MDCTA volumetric analysis for the quantification and grading of acute hemorrhage was feasible with excellent inter-observer agreement. The proposed bleeding grading system could optimize decision making and predict clinical outcomes.

CIRSE Standards of Practice on Below-the-Knee Revascularisation.

The CIRSE Standards of Practice Committee established a writing group that was tasked with producing up-to-date recommendations for performing below-the-knee revascularisation, taking into account data on novel techniques, devices, and long-term outcomes that have emerged over the last decade. CIRSE Standards of Practice documents are not clinical practice guidelines or systematic reviews of the literature. This document is not intended to impose a standard of clinical patient care but recommends a reasonable approach to and best practices for performing below-the-knee revascularisation.

Feasibility and safety of percutaneous computed tomography guided radiofrequency ablation of lymph nodes in oligometastatic patients: a single center's experience.

OBJECTIVES: To retrospectively evaluate feasibility and safety of CT-guided percutaneous radiofrequency ablation (RFA) of metastatic lymph nodes (LN) in terms of achieving local tumor control. METHODS: Institutional database research identified 16 patients with 24 metastatic LNs who underwent percutaneous CT-guided radiofrequency ablation. Mean patient age was 66.6 ± 15.70 years (range 40-87) and male/female ratio was 8/8. Contrast-enhanced CT or MRI was used for post-ablation follow-up. Patient and tumor characteristics and RFA technique were evaluated. Technical and clinical success on per tumor and per patient basis as well as complication rates were recorded. RESULTS: Mean size of the treated nodes was 1.78 ± 0.83 cm. The mean number of tumors per patient was 1.5 ± 0.63. The mean procedure time was 56.29 ± 24.27 min including local anesthesia, electrode(s) placement, ablation and post-procedural CT evaluation. Median length of hospital stay was 1.13 ± 0.34 days. On a per lesion basis, the overall complete response post-ablation according to the mRECIST criteria applied was 75% (18/24) of evaluable tumors. Repeat treatment of an index tumor was performed on two patients (three lesions) with complete response achieved in 87.5% (21/24) of evaluable tumors following a second RFA. On a per patient basis, disease progression was noted in 10/16 patients at a mean of 13.9 ± 6.03 months post the ablation procedure. CONCLUSION: CT-guided percutaneous RFA for oligometastatic LNs is a safe and feasible therapy. ADVANCES IN KNOWLEDGE: With this percutaneous therapeutic option, metastatic LNs can be eradicated with a very low complication rate.

A Bicentric Propensity Score Matched Study Comparing Percutaneous Computed Tomography-Guided Radiofrequency Ablation to Magnetic Resonance-Guided Focused Ultrasound for the Treatment of Osteoid Osteoma.

PURPOSE: To assess the safety and efficacy of computed tomography-guided radiofrequency (RF) ablation and magnetic resonance-guided focused ultrasound (MRgFUS) in the treatment of osteoid osteoma with a long-term follow-up study. MATERIALS AND METHODS: Database research was performed at 2 different centers with experience in musculoskeletal interventions. Both centers, one performing RF ablation and the other MRgFUS, identified 116 patients who underwent either RF ablation or MRgFUS procedures for the treatment of symptomatic osteoid osteoma and retrospectively evaluated data regarding pain scores using a visual analog scale (VAS). Complications were recorded according to the Cardiovascular and Interventional Radiological Society of Europe classification system. Propensity score matching for multiple variables was performed. Pain scores before and after therapy were compared. RESULTS: Of 116 patients treated, 61 and 55 underwent RF ablation and MRgFUS, respectively. Before treatment, the mean reported pain in the 2 groups were 9.1 ± 0.88 (RF ablation) and 8.7 ± 0.73 (MRgFUS) VAS units. After treatment, a statistically significant (P < .00001) overall reduction in pain symptomatology was recorded. No statistically significant difference was observed between the mean values of pain after treatment in both groups (P = .256). Over a mean of >2 years of follow-up, 4 cases of relapse (RF ablation, 1; MRgFUS, 3) and 1 complication (RF ablation) were observed. The analysis from propensity score matching that identified a matched cohort of 48 patients showed similar results. CONCLUSIONS: The 2 techniques for the treatment of osteoid osteoma resulted in profound and similar pain relief. The presence of thick cortical bone over the nidus can reduce the effectiveness of MRgFUS.

Long-term results of super-selective trans-catheter embolization of the vesical arteries for the treatment of intractable bladder haematuria.

PURPOSE: To evaluate the feasibility, safety and long-term efficacy of super-selective trans-catheter arterial embolization for the management of intractable bladder bleeding. MATERIALS AND METHODS: The records of 20 patients with intractable haematuria referred urgently for selective arterial embolization after failed conventional therapy, between 2013 and 2018, were retrospectively analyzed. Primary outcomes were technical (cessation of extravasation and/or stasis of flow within the target vessel) and clinical (bleeding control) success. Secondary outcomes included complication and re-intervention rates. RESULTS: Technical success was 90% (18/20 cases), as in 2 cases, embolization was not feasible. Super-selective embolization of the vesical arteries was feasible in 15/18 cases (83.3%). Selective proximal occlusion of the anterior division of the internal iliac artery was performed in two cases (11%) and embolization of the anterior division after coil blockage of the posterior division was performed in one case (5%). Bilateral and unilateral embolization was performed in 10 and 8 cases, respectively. Peri-procedural mortality rate was 5% (1/18 patients). One possible procedure-related death occurred due to myocardial infarction ten days following non-target embolization of the buttocks and the anterior abdominal wall. Mean time follow up was 35 ± 15 months. Bleeding reoccurred in three patients (16.6%), all successfully managed (one conservatively and two with further embolization). Clinical success was 85% (17/20 cases). During follow up 11 more patients died, due to underlying conditions not related to bleeding or the procedure. CONCLUSIONS: Super-selective angiographic embolization is feasible, safe and effective to control refractory, life threatening bladder bleeding and should be considered as a first line treatment, as to obviate the need for emergency surgery.

Multicenter retrospective study of transcatheter arterial embolisation for life-threatening haemorrhage in patients with uncorrected bleeding diathesis.

BACKGROUND: We retrospectively investigated outcomes of emergency TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding diathesis. MATERIALS AND METHODS: This multicenter, retrospective, study, was designed to investigate the safety and efficacy of percutaneous TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding disorder at the time of embolization. All consecutive patients with uncorrected coagulation who underwent TAE for the treatment of haemorrhage, between January 1st and December 31th 2019 in three European centers were included. Inclusion criteria were thrombocytopenia (platelet count < 50,000/mL) and/or International Normalized Ratio (INR) ≥2.0, and/or activated partial thromboplastin time (aPTT) > 45 s, and/or a pre-existing underlying blood-clotting disorder such as factor VIII, Von Willebrand disease, hepatic cirrhosis with abnormal liver function tests. Primary outcome measures were technical success, rebleeding rate and clinical success. Secondary outcome measures included patients' 30-day survival rate, and procedure-related complications. RESULTS: In total, 134 patients underwent TAE for bleeding control. A subgroup of 17 patients with 18 procedures [11 female, mean age 70.5 ± 15 years] which represent 12.7% of the total number of patients, presented with pathological coagulation parameters at the time of TAE (haemophilia n = 3, thrombocytopenia n = 1, cirrhosis n = 5, anticoagulants n = 7, secondary to bleeding n = 1) and were analyzed. Technical success was 100%, as in all procedures the bleeding site was detected and successfully embolised. Clinical success was 100%, as none of the patients died of bleeding during hospitalization, nor was surgically treated for bleeding relapse. Only one rebleeding case was noted (5.9%) that was successfully treated with a second TAE. No procedure-related complications were noted. According to Kaplan-Meier analysis the estimated 30-day survival rate was 84.2%. CONCLUSION: TAE in selected patients with uncorrected bleeding diathesis should be considered as a suitable individualized management approach. Emergency TAE for life threatening haemorrhage in patients with coagulation cascade disorders should be used as an aid in realistic clinical decision making.

Two-Center Prospective Comparison of the Trocar and Seldinger Techniques for Percutaneous Cholecystostomy.

OBJECTIVE. The purpose of this study is to compare the safety and efficacy of the bedside ultrasound (US)-guided trocar technique versus the US- and fluoroscopy-guided Seldinger technique for percutaneous cholecystostomy (PC). SUBJECTS AND METHODS. This prospective noninferiority study compared the bedside US-guided trocar technique for PC (the trocar group; 53 patients [28 men and 25 women]; mean [± SD] age, 74.31 ± 16.19 years) with the US- and fluoroscopy-guided Seldinger technique for PC (the Seldinger group; 52 patients [26 men and 26 women], mean age, 79.92 ± 13.38 years) in consecutive patients undergoing PC at two large tertiary university hospitals. The primary endpoints were technical success and procedure-related complication rates. Secondary endpoints included procedural duration, pain assessment, and clinical success after up to 3 months of follow-up. RESULTS. PC was successfully performed for all 105 patients. The clinical success rate was similar between the two study groups (86.8% in the trocar group vs 76.9% in the Seldinger group; p = 0.09). Mean procedural time was significantly lower in the trocar group than in the Seldinger group (1.77 ± 1.62 vs 4.88 ± 2.68 min; p < 0.0001). Significantly more procedure-related complications were noted in the Seldinger group than in the trocar group (11.5% vs 1.9%; p = 0.02). Among patients in the Seldinger group, bile leak occurred in 7.7%, abscess formation in 1.9%, and gallbladder rupture in 1.9%. No procedure-related death was noted. Minor bleeding occurred in one patient (1.9%) in the trocar group, but the bleeding resolved on its own. The mean pain score during the procedure was significantly lower in the Seldinger group than in the trocar group (3.2 ± 1.77 vs 4.76 ± 2.17; p = 0.01). At 12 hours after the procedure, the mean pain score was significantly lower for patients in the trocar group (0.78 ± 1.0 vs 3.12 ± 1.36; p = 0.0001). CONCLUSION. Use of the bedside US-guided trocar technique for PC was equally effective as the Seldinger technique but was associated with fewer procedure-related complications, required less procedural time, and resulted in decreased postprocedural pain, compared with fluoroscopically guided PC using the Seldinger technique.

Carotid artery stenting: an update.

PURPOSE OF REVIEW: To present the latest evidence about carotid artery stenting (CAS) including indications, safety, efficacy, and available equipment. RECENT FINDINGS: The micromesh stent, a new stent design which offers excellent flexibility and embolic protection, has been associated with promising outcomes. SUMMARY: CAS has emerged as a minimally invasive treatment method for carotid artery stenosis with comparable outcomes with surgical management. The implementation of new technology combined with operator experience has led to a paradigm shift; however, to date, no robust evidence exists about patient and lesion selection. Many studies are underway to clarify the technical aspects of CAS as well as the optimal treatment of carotid artery stenosis for each patient population.