Clinical Outcomes after Median Arcuate Ligament Release in Patients Responsive to Celiac Plexus Block.

PURPOSE: To determine if symptom relief with celiac plexus block (CPB) is associated with favorable clinical outcomes after median arcuate ligament release (MALR) surgery. MATERIALS AND METHODS: A retrospective review was performed from January 2000 to December 2021. Fifty-seven patients (42 women, 15 men; mean age, 43 years [range, 18-84 years]) with clinical and radiographic features suggestive of median arcuate ligament syndrome (MALS) underwent computed tomography (CT)-guided percutaneous CPB for suspected MALS. Clinical outcomes of CPB and MALR surgery were correlated. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines. RESULTS: CT-guided percutaneous CPB was successfully performed in all 57 (100%) patients with suspected MALS. A cohort of 38 (67%) patients showed clinical improvement with CPB. A subset of 28 (74%) patients in this group subsequently underwent open MALR surgery; 27 (96%) responders to CPB showed favorable clinical outcomes with surgery. There was 1 (4%) CPB-related mild adverse event. There were no moderate, severe, or life-threatening adverse events. CONCLUSIONS: Patients who responded to CPB were selected to undergo surgery, and 96% of them improved after surgery.

Complications during Lymphangiography and Lymphatic Interventions.

Lymphangiography as a diagnostic procedure dates back to the 1950s and was widely performed for several decades until being supplanted by other advanced imaging techniques. With the advent of thoracic duct embolization to treat chylothorax, Constantin Cope ushered in a transition from lymphangiography as a diagnostic procedure to a precursor for lymphatic intervention. Subsequently, technical modifications and applications of lymphatic embolization to other medical conditions have greatly expanded the scope and application of lymphangiography and lymphatic intervention. Although there is increasing familiarity with lymphatic interventions, few interventionalists have performed a high enough volume to be aware of potential complications and their management. Potential complications of lymphangiography and those encountered while performing lymphatic interventions are discussed along with approaches to minimize their risk and management strategies should they occur.

Percutaneous Transesophageal Access for Enteral Feeding Tube Placement.

BACKGROUND: The purpose of this study was to describe our experience with percutaneous transesophageal enteral feeding tube placement when percutaneous gastrostomy tube placement is not feasible. MATERIALS AND METHODS: A retrospective review was performed from July 2018 to March 2019. Thirteen patients (9 females, 4 males), (age range 22-80 years; mean age, 55 years; mean body mass index of 24.6) underwent placement of 14 percutaneous transesophageal enteral feeding tubes. Relative contraindications to standard gastrostomy tube placement included: prior gastric surgery (5 patients), severe contractures/large body habitus (2), abdominal mesh (1), high riding stomach (1), interposition of bowel (1), ascites (1), and refractory gastrostomy tract leak (1). Patients were evaluated for functionality of the tube, complications, and patients' satisfaction with physical examination at 24 h, review of electronic medical record and phone interviews at 1 month, and 3-month follow-up. Complications were classified according to the CIRSE guidelines. RESULTS: Technical success rate was 100% with placement of seven percutaneous transesophageal gastrostomy tubes and seven percutaneous transesophageal jejunostomy tubes. One patient underwent tube placement twice after dislodgement. At 3-month follow-up, two patients had died, one patient was lost to follow-up, and 11 patients had properly working tubes. No major complications occurred. Minor complication rate was 43% (6/14). Patient's satisfaction scores ranged from "poor" 2/11 (18%) or "neutral" 4/11 (36.4%) to "satisfied/very satisfied" 5/11 (45.3%). CONCLUSION: Percutaneous transesophageal enteral feeding tube placement is feasible with a low complication rate. A majority of patients were either satisfied or neutral with the transesophageal enteral tube.

Pulmonary artery pseudoaneurysm causing massive hemoptysis in hyperimmunoglobulin E syndrome: a case report.

BACKGROUND: Hyperimmunoglobulin E syndrome (HIES) is a rare primary immunodeficiency disorder defined by high serum immunoglobulin E titers that is associated with recurrent respiratory infections, formation of pneumoatoceles, recurrent skin abscesses, and characteristic dental and skeletal abnormalities. CASE PRESENTATION: We report a case of a 56-year-old male with a history of HIES, cavitary mycetomas, and allergic bronchopulmonary aspergillosis who presented with recurrent massive hemoptysis. Bronchial artery angiography and bronchoscopy failed to identify active hemorrhage, and two embolizations of the bronchial artery did not resolve the bleeding. Subsequently, selective pulmonary artery angiography was conducted that demonstrated a subsegmental pulmonary artery branch pseudoaneurysm with extravasation into an adjacent lung cavity. This was treated successfully with transcatheter embolization. CONCLUSIONS: To our knowledge, this is the first case reported of pulmonary artery pseudoaneurysm in HIES in the medical literature. Pulmonary artery pseudoaneurysm should be considered in the differential diagnosis in patients with HIES and massive hemoptysis.

Percutaneous glue embolization for recalcitrant iatrogenic portal hemorrhage.

N-butyl cyanoacrylate glue is well established as a transcatheter or direct injection embolic agent. Herein, targeted glue embolization was performed by direct needle injection into peripheral portal branches and along the surface of the liver to directly treat actively extravasating portal venous injury. In both cases, hemodynamically unstable patients underwent exploratory laparotomy, which was not able to definitively treat the hemorrhage. Subsequently, emergent visceral angiography and indirect portography revealed active portal phase extravasation. Transhepatic direct needle injection of the peripheral portal active extravasation with glue was successful in both cases and the patients stabilized, demonstrating this as an efficacious salvage approach.

Removal of T-Fasteners Immediately After Percutaneous Gastrostomy Tube Placement: Experience in 488 Patients.

OBJECTIVE: The purpose of this article is to evaluate the safety of T-fastener removal immediately after percutaneous gastrostomy tube placement by assessing difference in complication rates between early and delayed gastropexy removal. MATERIALS AND METHODS: A retrospective review was performed of the electronic medical records of all patients who underwent percutaneous gastrostomy at our institution from January 2015 to June 2017. A total of 722 patients successfully underwent gastrostomy tube insertion during this period. Two hundred twenty-two patients were excluded from analysis on the basis of our exclusion criteria. Twelve patients were lost to follow-up. The remaining patients were divided into two groups: group 1 included 350 patients who had their T-fasteners released immediately after gastrostomy, and group 2 included 138 patients whose T-fasteners were left in place for 2 weeks. Electronic medical records were reviewed for postprocedure complications for up to 1 month. Complications were classified according to Society of Interventional Radiology classification. Statistical analysis was performed using a logistic regression model with calculation of odds ratios, power, p values, and 95% CIs. RESULTS: Seven (2.0%) major and 24 (6.8%) minor complications occurred in group 1. Two (1.4%) major and 11 (7.9%) minor complications occurred in group 2. There was no statistically significant difference in complication rates between immediate and delayed gastropexy removal. CONCLUSION: In our study, immediate removal of T-fasteners was not associated with a higher complication rate.

Vascular Closure Devices: Technical Tips, Complications, and Management.

Vascular closure devices (VCDs) are used to obtain hemostasis at the vascular access site while limiting the need for manual compression. They have gained significant popularity since their introduction in the mid-1990s. In the past 20 years, there has been a multitude of different devices introduced with various mechanisms of action. Manual compression remains the gold standard but can be very time consuming and painful for the patient. VCDs are advantageous in that they can reduce time to hemostasis and patient recovery and improve patient comfort. However, a large number of catheter-based procedures are performed without these closure devices owing to lack of operator familiarity, risk of complications, and cost. Most VCDs are approved for arteriotomies between 5 and 8F, with 1 device approved for up to 21F. Major complications include infection and limb ischemia. This article provides an update on currently approved VCDs, a brief overview of the literature, and our institutional experience with these devices.

Short-term clinical importance of osseous injuries diagnosed at MR imaging in patients with anterior cruciate ligament tear.

PURPOSE: To determine the association between osseous injuries and short-term clinical outcome in patients with anterior cruciate ligament (ACL) tear. MATERIALS AND METHODS: The retrospective study was performed with institutional review board approval, and the requirement to obtain informed consent was waived. The study group consisted of 114 patients (57 male and 57 female patients with a mean age of 26.1 and 25.1 years, respectively) with ACL tear who underwent magnetic resonance (MR) imaging and ACL reconstruction surgery and who filled out International Knee Documentation Committee (IKDC) knee evaluation questionnaires before and 1 year after surgery. All MR images were independently reviewed by two radiologists to determine the presence of a cortical depression fracture on each surface of the knee joint. Bone marrow edema volume was quantified by using segmentation software. Correlation coefficients were used to determine the association between bone marrow edema volume and IKDC score. A multivariate analysis model was used to compare IKDC scores in patients without fracture, patients with a single fracture, and patients with multiple fractures. RESULTS: There was no significant association between total bone marrow edema volume and preoperative or postoperative IKDC score (P = .32 and P = .91, respectively). The mean preoperative and postoperative IKDC scores were 53.4 ± 18.6 and 93.0 ± 5.0, respectively, for patients without fracture, 54.8 ± 13.6 and 87.3 ± 10.8 for patients with a single fracture, and 53.1 ± 17.2 and 83.4 ± 12.7 for patients with multiple fractures. Patients with single and multiple fractures had similar (P = .91) preoperative IKDC scores but significantly lower (P < .001) postoperative IKDC scores compared to patients without fracture. CONCLUSION: Cortical depression fractures in patients with ACL tear are associated with decreased clinical outcome scores 1 year after ACL reconstruction surgery.