Clinical Performance Status and Technical Factors Affecting Outcomes from Percutaneous Transhepatic Biliary Interventions; A Multicentre, Prospective, Observational Cohort Study.

PURPOSE: The purpose of this study was to evaluate the predictive value of a 'Modified Karnofsky Scoring System' on outcomes and provide real-world data regarding the UK practice of biliary interventions. MATERIALS AND METHODS: A prospective multi-centred cohort study was performed. The pre-procedure modified Karnofsky score, the incidence of sepsis, complications, biochemical improvement and mortality were recorded out to 30 days post procedure. RESULTS: A total of 292 patients (248 with malignant lesions) were suitable for inclusion in the study. The overall 7 and 30 day mortality was 3.1% and 16.1%, respectively. The 30 day sepsis rate was 10.3%. In the modified Karnofsky 'high risk' group the 7 day mortality was 9.7% versus 0% for the 'low risk' group (p = 0.002), whereas the 30 day mortality was 28.8% versus 13.3% (p = 0.003). The incidence of sepsis at 30 days was 19% in the high risk group versus 3.3% at the low risk group (p = 0.001) CONCLUSION: Percutaneous biliary interventions in the UK are safe and effective. Scoring systems such as the Karnofsky or the modified Karnofsky score hold promise in allowing us to identify high risk groups that will need more careful consideration and enhanced patient informed consent but further research with larger studies is warranted in order to identify their true impact on patient selection and outcomes post biliary interventions.

Blunt Thoracic Aortic Injury and Acute Trauma: The Effect on Aortic Diameter and the Consequences for Stent-graft Sizing.

BACKGROUND: Blunt thoracic aortic injury (BTAI) is associated with a high mortality and large trauma burden. Trauma and resuscitation after injury affect cardiovascular status, which may in turn affect aortic diameter. Measurement of aortic diameter is necessary to guide stent-graft sizing as part of BTAI management. Inaccurate measurement may lead to stent-graft complications. This pilot study aimed to assess the effect of acute major trauma on stent-graft sizing and stent-graft complications, in the context of BTAI and to assess whether any effect could be predicted. METHODS: Patients who were admitted to a UK major trauma center between January 2007 and December 2017, and were diagnosed with BTAI, were identified. The thoracic aortic diameter was measured at six points on initial and surveillance computed tomography imaging. Data on patient demographics, admission heart rate, mean arterial pressure (MAP), and serum lactate were gathered. RESULTS: Thirty-two patients were identified. Twenty met inclusion criteria. Of these, 12 were managed operatively and eight nonoperatively. The mean age was 40, the mean injury severity score was 43, and 85% were male. A mean increase in diameter between initial trauma scan and surveillance scan was noted throughout the thoracic aorta (P < 0.05). Stent-graft oversizing relative to aortic diameter changed significantly from initial trauma imaging to surveillance imaging (P < 0.05). Admission heart rate, MAP, and serum lactate were not predictive of the percentage change in aortic diameter. There were no complications at surveillance imaging (mean 45 days) or during medium term follow-up (mean 532 days). CONCLUSIONS: Aortic diameter is affected by BTAI, acute major trauma, and resuscitation in a significant and variable manner. Measurements of the aorta in a patient with BTAI in the acute trauma setting should be viewed with uncertainty. A lack of complications in the short term is suggestive of a wide tolerance range regarding stent-graft sizing, but long-term results are unknown.

Myriad manifestations of infective endocarditis.

Aneurysmal disease of the visceral arteries is rare, often found incidentally and carries significant mortality when ruptured. Of these, superior mesenteric artery (SMA) aneurysms represent a small minority of visceral artery aneurysms. This case highlights a man in his late 50s who presented to the emergency department with right upper quadrant and lower back pain. A CT scan revealed an aneurysm in the SMA. Increasing abdominal pain and increasing aneurysmal size with concurrent diagnosis of infective endocarditis suggestive of mycotic aneurysm prompted urgent treatment. The man was treated successfully by endovascular method.

Closure Devices for Iatrogenic Thoraco-Cervical Vascular Injuries.

INTRODUCTION: The unintentional arterial placement of a central venous line can have catastrophic complications. The purpose of this systematic review is to assess and analyse the available evidence regarding the use of the various vascular closure devices (VCDs) for the management of iatrogenic thoraco-cervical arterial injuries (ITCAI). METHODS: A systematic review was performed according to PRISMA guidelines. RESULTS: Thirty-two relevant case series and case reports were identified with a total of 69 patients having being studied. In the majority of the studies, plug-based VCDs were used (81%) followed by suture-based devices (19%). The majority of studies reported successful outcomes from the use of VCDs in terms of achieving immediate haemostasis without any acute complications. Long-term follow-up data were only available in nine studies with only one case of carotid pseudoaneurysm being reported after 1-month post-procedure. All other cases had no reported long-term complications. Five studies performed direct or indirect comparisons between VCDs and other treatments (open surgery or stent grafting) suggesting no significant differences in safety or effectiveness. CONCLUSION: Although there is limited evidence, VCDs appear to be safe and effective for the management of ITCAIs. Further research is warranted regarding the effectiveness of this approach in comparison to surgery and in order to identify those patients who are more likely to benefit from this minimally invasive approach.

Case report: spontaneous resolution of an established iatrogenic vertebral arteriovenous fistula.

Vertebral artery injuries can complicate attempted cannulation of the internal jugular vein including arteriovenous fistula formation. Such a fistula may occlude spontaneously in the acute phase but once established, spontaneous occlusion is extremely unusual. To the best of our knowledge, this has not been reported in the medical literature. We present a case of a patient who developed a right-sided vertebral arteriovenous fistula following instrumentation of the neck vessels but formal angiography/intervention was declined. The reason to report this case is that follow-up magnetic resonance angiography was performed, with spontaneous resolution of the right-sided vertebral arteriovenous fistula occurring postoperatively between days 30 and 135. Endovascular treatment options are available but for those who decline intervention, this report highlights the fact that spontaneous resolution of vertebral arteriovenous fistulae can occur.

Radiological manifestations of metastasis to the ovary.

MRI is an effective tool for detection of ovarian neoplastic lesions. However, there are no highly specific radiological features that differentiate primary from metastatic ovarian masses. Histological diagnosis preoperatively is not always possible as there is a risk of disseminating an otherwise early stage primary ovarian cancer. The preoperative diagnosis of an ovarian lesion is therefore heavily dependent on the radiological features. The radiologist must rely on a combination of knowing the natural history of any known primary cancer, together with the radiological features such as bilaterality, mucinous appearance, pseudomyxoma as well as the clinical progress of the primary tumour in order to evaluate and predict the likelihood of metastatic disease. Even if a non-ovarian primary cancer is known, an ovarian mass cannot always be assumed to be a secondary lesion. Some tumours, such as BRAC-positive breast cancer, are known to have a high rate of concomitant primary ovarian cancer. Conversely, other tumours, such as gastric and appendiceal cancer, are known to have a high rate of ovarian metastatic disease. However, histology remains the only true way to determine an ovarian metastasis from a primary lesion.