Direct sac puncture versus transarterial embolization of type II endoleaks: An evaluation and comparison of outcomes.

Purpose To determine the outcomes of type II endoleak embolization with aneurysm sac obliteration and whether the approach - direct sac puncture or transarterial - affects outcome. Methods A retrospective review of patients who underwent endovascular aneurysm repairs and subsequent type II endoleak embolization over 10 years was performed. Twenty-three patients (median age: 73 years, range: 40-88 years) underwent 35 embolizations. Embolization was performed with the goal of obliterating both the endoleak sac and feeding vessels. Embolization agents used include cyanoacrylate glue only (48%), glue and coils (36%), coils only (13%), and other (3%). Results Mean follow-up was 21.8 months. Patients underwent an average of 1.5 embolizations, with 35% requiring more than one. Technical success rate was 89%. Freedom from aneurysm sac expansion was achieved in 91%. Freedom from type II endoleak was accomplished in 70%. There were no ruptured aneurysms during the follow-up period. Direct sac puncture and transarterial approaches had similar incidences of aneurysm sac growth ( p = 0.74), persistent type II endoleak ( p = 0.32), and complications ( p = 0.64). However, direct sac puncture had significantly shorter fluoroscopy ( p < 0.001) and total procedure times ( p < 0.001) than transarterial embolizations. Conclusion Direct sac puncture and transarterial embolization of type II endoleak with aneurysm sac obliteration are similarly effective for the prevention of aneurysm sac growth. However, direct sac puncture is our preferred approach given its significantly shorter fluoroscopic and procedural times.

Evaluation of percutaneous ultrasound-guided biopsies of solid mass lesions of the pancreas: a center's 10-year experience.

OBJECTIVE: To assess the efficacy and complication rates of percutaneous ultrasound (US)-guided pancreatic mass biopsy and to determine if location of the mass or method of biopsy affects efficacy. METHODS: Imaging, pathology, and clinical records of all patients undergoing percutaneous US-guided pancreatic mass sampling from January 2001 until November 2011 were reviewed. Of 88 pancreatic masses, 13 underwent fine needle aspiration (FNA) only, 60 underwent core needle biopsy only, and 15 underwent both. Diagnostic rate, sensitivity, specificity, accuracy, and positive predictive value and negative predictive value (NPV) based on location of the mass (head/neck vs. body/tail) and method of biopsy (core vs. FNA vs. combined) were determined. The final diagnosis was determined on the basis of follow-up imaging, clinical course, and/or surgical pathology. Complications were assessed by reviewing clinical notes and postprocedural imaging. RESULTS: The overall diagnostic rate, sensitivity, accuracy, and NPV of all 88 biopsies were 94%, 93%, 93%, and 57%, respectively. Five samples were nondiagnostic and considered false negatives. There were no false-positive biopsy results. No significant difference was observed in the diagnostic rate, sensitivity, accuracy, and NPV between core biopsies, FNAs, and combined core and FNA biopsies. Furthermore, no significant difference was found between head/neck and body/tail samplings. In 96.7% (85/88) of the cases, the procedure was uneventful. There were no major complications. CONCLUSIONS: Percutaneous US-guided sampling of pancreatic mass is safe and effective irrespective of location of the mass and method of biopsy.

Prevalence and significance of extravascular incidental findings on computed tomographic angiography and magnetic resonance angiography.

Computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) are routinely used to evaluate patients with vascular disease. They have the ability to detect unexpected non-vascular pathology. The purpose of this study was to determine the prevalence and significance of extravascular incidental findings in patients undergoing CTA or MRA. A retrospective review of 737 patients who underwent CTA and 184 patients who underwent MRA during a five-year period was performed. Incidental findings were classified as low, moderate or high significance findings. For patients with high significance extravascular findings, assessment of the rates of appropriate follow-up was conducted. Among the CTA patients, 539 (73.1%) had incidental findings. Low, moderate and high significance findings were discovered in 514 (69.7%), 95 (12.9%) and 41 (5.6%) patients, respectively. Twenty (48.8%) patients with high significance findings received appropriate follow-up investigations. Among the MRA patients, 95 (51.6%) had extravascular findings. Low, moderate and high significance findings were present in 80 (43.5%), 27 (14.7%), and 3 (1.6%) patients, respectively. Two (66.7%) patients with high significance findings were properly followed up. In conclusion, incidental findings on CTA and MRA are very common. A small percentage of these findings could be serious and were not all adequately followed-up in our study population. Referring physicians should be aware of the potential for serious incidental findings and manage them appropriately.

Increased complexity and complications associated with multiple peripherally inserted central catheter insertions in children: the tip of the iceberg.

PURPOSE: To assess the effects of repeated placements of peripherally inserted central catheters (PICCs) on the venous system in children. MATERIALS AND METHODS: Children who underwent successful first-time PICC placements between 2005 and 2007 were retrospectively evaluated. Patient demographics, procedural data, and complications were obtained from hospital databases. Data from subsequent PICC insertions were compared with those from previous PICC insertions. A generalized estimating equation was used with appropriate statistical tests for data analysis. RESULTS: PICCs were grouped into four groups: first PICCs (n = 1,274), second PICCs (n = 167), third PICCs (n = 52), and fourth to seventh PICCs (n = 32). Successive PICCs were associated with progressively increased difficulty of access compared with earlier PICCs, as demonstrated by significant increases in procedural duration (P = .01) and fluoroscopy time (P = .005). Increased complexity was also evident through significant increases in the percentages of cases that required venography/digital subtraction angiography (P <.0001), multiple attempts to gain venous access (P <.0001), and a switch to another limb for venous access (P <.0001) between subsequent and first PICCs. In addition, rates of procedural complications also increased for subsequent PICCs compared with first PICCs (P <.0001). Furthermore use of the most preferred vein for vascular access significantly decreased in subsequent versus first PICC insertions (P <.0001). CONCLUSIONS: Increased procedural complexity and complications were found with successive PICC insertions. These results confirm the need for a prospective study to directly assess the long-term effects of PICCs on venous patency.