Meta-analysis of outcomes of endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for the management of acute cholecystitis.

BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage is a novel method of treating acute cholecystitis in patients deemed too high risk for surgery. It involves endoscopic stent placement between the gallbladder and the alimentary tract to internally drain the infection and is an alternative to percutaneous cholecystostomy (PC). This meta-analysis assesses the clinical outcomes of high-risk patients undergoing endoscopic drainage with an acute cholecystoenterostomy (ACE) compared with PC in acute cholecystitis. METHODS: A literature search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Databases were searched for studies reporting outcomes of patients undergoing ACE or PC. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS: A total of 1593 citations were reviewed; five studies comprising 495 patients were ultimately selected for analysis. There were no differences in technical or clinical success rates between the two groups on pooled meta-analysis. ACE had significantly lower post-procedural pain scores (mean difference - 3.0, 95% CI - 2.3 to - 3.6, p < 0.001, on a 10-point pain scale). There were no statistically significant differences in procedure complications between groups. Re-intervention rates were significantly higher in the PC group (OR 4.3, 95% CI 2.0-9.3, p < 0.001). CONCLUSION: ACE is a promising alternative to PC in high-risk patients with acute cholecystitis, with equivalent success rates, improved pain scores and lower re-intervention rates, without the morbidities associated with external drainage.

ECG-gated multiecho Dixon fat-water separation in cardiac MRI: advantages over conventional fat-saturated imaging.

OBJECTIVE: The purpose of this pictorial essay is to explore the advantages of multiecho Dixon fat-water separation techniques in cardiac MRI. The clinical indications, potential artifacts, and imaging findings with this technique are reviewed. CONCLUSION: Multiecho Dixon fat-water separation can be used to help characterize cardiac masses, evaluate for myocardial lipomatous infiltration, and diagnose pericarditis. Advantages over conventional fat-saturation techniques include fewer artifacts from background inhomogeneity, improved contrast of microscopic fat, and capability for use in combination with cine and contrast-enhanced imaging.

Clinical correlates of size and number of collateral vessels in peripheral artery disease.

We studied associations of the number and size of magnetic resonance angiography (MRA)-assessed lower extremity collateral vessels with the ankle-brachial index (ABI), severity of superficial femoral artery (SFA) plaque, and leg symptoms in participants with peripheral artery disease (PAD). A total of 303 participants with PAD underwent time-resolved MRA at the thigh station. Collaterals were categorized by number (Category 1: 0-3 collaterals; Category 2: 4-7 collaterals; Category 3: ≥ 8 collateral vessels) and size (Grade 1: ≤ 5 small collaterals; Grade 2: > 5 small vessels; Grade 3: ≤ 5 large collaterals; Grade 4: > 5 large collaterals). Adjusting for age, sex, race, comorbidities and other covariates, more numerous collateral vessels were associated with lower ABI values (Category 1: 0.79; Category 2: 0.67; Category 3: 0.60; p trend < 0.001). Similarly, larger collateral vessels were associated with lower ABI values (Grade 1: 0.75; Grade 2: 0.65; Grade 3: 0.62; Grade 4: 0.59; p trend < 0.001). More numerous (p < 0.001) and larger (p < 0.001) collateral vessels were associated with greater mean SFA plaque area (p trend < 0.001). More numerous (p trend = 0.007) and larger (p trend = 0.017) collateral vessels were associated with a lower prevalence of asymptomatic PAD. In conclusion, among participants with PAD, larger and more numerous collaterals, measured by MRA, were associated with lower ABI values, greater plaque area in the SFA, and a lower prevalence of asymptomatic PAD. Further study is needed to determine the role of collateral vessels in maintaining functional performance in PAD.

Skills training after night shift work enables acquisition of endovascular technical skills on a virtual reality simulator.

BACKGROUND: Adoption of residents' working time restrictions potentially undermines surgical training by reduction of operating room exposure. Simulation has been proposed as a way to acquire necessary skills in a laboratory environment but remains difficult to incorporate into training schedules. This study assessed whether residents working successive nights could acquire endovascular skills similar to colleagues working day shifts. METHODS: This prospective observational cohort study recruited 20 junior residents, divided into day shift and night shift groups by their respective call schedule. After initial cognitive skills training, a validated renal artery stent module on an endovascular simulator was completed over a series of seven sequential shifts during 1 week. The primary outcome measure was serial technical skill assessments. Secondary measures comprised assessments of activity, cognitive performance, introspective fatigue, quality, and quantity of preceding sleep. RESULTS: Both groups demonstrated significant learning curves for total time at the first session median vs seventh session median (181 vs 564 seconds [P < .001]; night, 1399 vs 572 [P < .001]), fluoroscopy time (day, 702 vs 308 seconds, [P < .001]; night, 669 vs 313 [P < .001]), and contrast volume (day, 29 vs 13 mL [P < .001]; night, 40 vs 16 [P < .001]). Residents working day shifts reached plateau 1 day earlier in the above measures vs those on night duty. The night shift group walked more steps (P < .001), reviewed more patients (P < .001), performed worse on all cognitive assessments (P < .05), slept less (P < .05), had poorer quality of sleep (P = .001), and was more fatigued (P < .001) than the day shift group. Acquired skill was retained a week after completion of shifts. CONCLUSION: Technical skills training after night shift work enables acquisition of endovascular technical skills, although it takes longer than after day shift training. This study provides evidence for program directors to organize simulation-based training schedules for residents on night shift rotations.

Improved detection of subendocardial hyperenhancement in myocardial infarction using dark blood-pool delayed enhancement MRI.

OBJECTIVE: Delayed enhancement MRI using fast segmented k-space inversion recovery (IR) gradient-echo imaging is a well established "bright-blood" technique for identifying myocardial infarction and is used as the reference standard sequence in this study. The purpose of this study was to validate a recently developed dark blood-pool delayed enhancement technique in a porcine animal model, evaluate its performance in human patients, and quantify its performance compared with the reference standard in both. SUBJECTS AND METHODS: In an animal study, the reference standard and dark blood-pool delayed enhancement were assessed in three pigs with induced myocardial infarction. In a human study, 26 patients, 31-81 years old (19 men and seven women), with a known history of myocardial infarction were imaged using the reference standard and dark blood-pool delayed enhancement. Contrast-to-noise ratio (CNR), signal intensity ratio, signal-to-noise ratio (SNR), and qualitative scores of hyperenhancement were recorded. Measurements were compared using paired samples t test and Wilcoxon's signed rank test. RESULTS: In the animal study, the mean CNR of infarct to blood pool was 11 times higher for dark blood-pool delayed enhancement than for the reference standard. The mean SNR was 4.4 times higher for the reference standard. In the human study, the mean CNR and signal intensity ratio of hyperenhancing myocardium to the blood pool were 1.9 (p = 0.04) and 5.5 (p < 0.01) times higher, respectively, for dark blood-pool delayed enhancement compared with reference standard. The mean CNR and signal intensity ratio of hyperenhancing myocardium to normal myocardium and SNR were 2.8 (p < 0.01), 1.3 (p = 0.07), and 2.8 (p < 0.01) higher, respectively, for the reference standard. Qualitative analysis identified seven extra segments with grade 1 scars using dark blood-pool delayed enhancement (p < 0.01). CONCLUSION: Dark blood-pool delayed enhancement is complementary to the reference standard. It can detect more subendocardial foci of hyperenhancement, thus potentially identifying more infarcts and changing patient management.

Technical considerations for lower limb multidetector computed tomographic angiography.

Multidetector computed tomography (MDCT) enables imaging of the entire arterial tree non-invasively. Optimal technical considerations for performing MDCT angiography (MDCTA) are essential for accurate diagnosis and atherosclerotic disease stratification. This review article focuses on the various technical aspects necessary for peripheral computed tomographic angiography (CTA) acquisition. Common clinical indications for peripheral MDCTA and the latest scan protocols are described. The essential issue of radiation dose reduction is discussed, along with methods of optimal contrast bolus detection and delivery. Post-processing techniques are also presented. Previously, digital subtraction angiography was the only established reliable imaging technique to quantify atherosclerotic disease load; however, MDCTA may now challenge this old gold standard, along with other non-invasive techniques such as magnetic resonance angiography (MRA).

Accelerated two- and three-dimensional cine MR imaging of the heart by using a 32-channel coil.

PURPOSE: To compare accelerated real-time two-dimensional (2D) and segmented three-dimensional (3D) cine steady-state free precession magnetic resonance (MR) imaging techniques by using a 32-channel coil with a conventional 2D cine imaging approach for imaging the heart and to evaluate any difference caused by free breathing and breath holding for real-time imaging. MATERIALS AND METHODS: In this institutional review board-approved HIPAA-compliant study, 10 healthy volunteers and 22 consecutive patients who were suspected of having or were known to have heart disease underwent cardiac MR imaging by using a 32-channel coil. A conventional multisection 2D real-time cine sequence was used as the reference standard, and three additional accelerated cine sequences were implemented. Volumetric parameters, including ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume(SV), and myocardial mass, were derived. Wall motion and image quality were assessed by two radiologists. In addition, image time was registered. An additional set of images was acquired by using real-time sequences with free breathing, and quantitative measurements were compared with measurements on images obtained with breath holding. For quantitative analysis, repeated-measures analysis of variance, paired t test, and Bland-Altman analysis were used; for qualitative analysis, nonparametric Wilcoxon signed-rank test was used. RESULTS: All volumetric measurements were significantly correlated with those of the standard sequence (r > 0.80, P < .01). No significant difference among protocols was observed in terms of mean levels for EF or ESV (P > .05). However, a significant difference was indicated for EDV and SV (P < .01).The accelerated protocols had significantly shorter image times (P < .001). Wall motion scores were concordant with the standard sequence in 43-44 (93%-96%) segments for the accelerated protocols, with a strong interreader agreement (intraclass correlation coefficient, > or =0.93). No significant difference was identified between real-time protocols with free breathing and those with breath holding for measurement of volumetric parameters. CONCLUSION: Accelerated real-time 2D and segmented 3D cine techniques are comparable to the standard clinical protocol in assessment of left ventricular global and regional parameters in substantially shorter image times.

Role of virtual reality simulation in teaching and assessing technical skills in endovascular intervention.

Training in endovascular intervention ultimately aims to produce interventionalists who demonstrate competence in technical skills. Herein, the authors investigate the rationale for simulation-based training by providing an overview of the psychological theories underpinning acquisition of technical skills, training and assessment history, recent advances in simulation technology, and a critical appraisal of their role in training and assessment in endovascular intervention. Simulators have potential for training and assessment and promise solution to many shortcomings of traditional 'apprenticeship' training models. Before inclusion into the curriculum, further work is needed regarding fidelity, validity, reliability, and design of simulators to ensure accurate transfer of acquired endovascular skills from simulator to patient.

Limited-preparation CT colonography in frail elderly patients: a feasibility study.

OBJECTIVE: Full colonic preparation can be onerous and may be poorly tolerated in frail elderly patients. The purpose of this study was to prospectively assess the image quality and diagnostic yield of limited-preparation CT colonography (CTC) in elderly patients with suspected colorectal cancer who were deemed medically unfit or unsuitable for colonoscopy. SUBJECTS AND METHODS: A prospective study was performed of 67 elderly patients with reduced functional status referred for CTC. Participants were prescribed a limited bowel preparation consisting of a low-residue diet for 3 days, 1 L of 2% oral diatrizoate meglumine (Gastrografin) 24 hours before CTC, and 1 L of 2% oral Gastrografin over the 2 hours immediately before CTC. No cathartic preparation was administered. All colonic segments were graded from 1 to 5 for image quality (1, unreadable; 2, poor; 3, equivocal; 4, good; 5, excellent) and reader confidence. Clinical and conventional colonoscopy follow-up findings were documented, and all colonic and extracolonic pathologic findings were documented. RESULTS: Overall image quality and reader confidence in the evaluation of the colon was rated good or excellent in 84% of the colonic segments. Colonic abnormalities were identified in 12 patients (18%), including four colonic tumors, two polyps, and seven colonic strictures. Incidental extraintestinal findings were detected in 43 patients (64%), including nine patients with lesions radiologically consistent with malignancy. CONCLUSION: Limited-preparation low-dose CTC is a feasible and useful minimally invasive technique with which to evaluate the colon and exclude gross pathology (mass lesions and polyps > 1 cm) in elderly patients with diminished performance status, yielding good to excellent image quality.

Subintimal angioplasty: predictors of long-term success.

PURPOSE: To determine the clinical outcomes and success rates after percutaneous subintimal angioplasty (SIA) in patients with lower-limb occlusive lesions causing intermittent claudication (IC) or critical limb ischemia (CLI) at midterm to long-term follow-up. The secondary aim was to elicit factors predictive of a successful outcome. MATERIALS AND METHODS: Between January 1999 and June 2006, 75 consecutive patients (45 men; age range, 46-91 years; CLI in 79%) underwent SIA of iliac and infrainguinal (84%) occlusions. Outcomes were determined on an intent-to-treat basis. The composite endpoint of interest was major adverse clinical outcome (MACO) of the treated limb at follow-up, which was defined as the development of IC, CLI, or need for subsequent endovascular or surgical revascularization. Actuarial freedom from MACO was assessed via Kaplan-Meier curves and multivariable Cox proportional-hazards regression. RESULTS: SIA was performed on 75 lesions, with an initial procedure success rate of 83% (n = 62). Procedure failure was caused by heavily calcified lesions (n = 5) and failure of reentry (n = 8). A total of 56.3% of patients with claudication were free from ipsilateral claudication at follow-up (mean, 32 months; range, 1-64 months), and those with CLI had a 79.7% limb salvage rate at a mean follow-up of 30.7 months (range, 0.5-91 months). On Cox regression analysis, the following variables were identified as independent predictors of MACO within the limb treated with SIA: ABI after SIA (hazard ratio, 0.21; 95% CI, 0.05-0.89; P = .035) and number of patent runoff vessels (ie, /=2; hazard ratio, 0.29; 95% CI, 0.15-0.59; P = .001). CONCLUSIONS: SIA is a feasible therapeutic option for occlusive atherosclerotic lesions in IC and CLI and is the evolving preferred strategy in CLI and perhaps IC with long-segment occlusions.

Should incidental asymptomatic angiographic stenoses and occlusions be treated in patients with peripheral arterial disease?

PURPOSE: The clinical importance of angiographically detected asymptomatic lower-limb stenoses and occlusions is unknown. This study aims to (i) assess the clinical outcome of asymptomatic lesions in the lower limb, (ii) identify predictors of clinical deterioration, and (iii) determine which asymptomatic lower-limb lesions should be treated at presentation. MATERIALS AND METHODS: All 918 patients undergoing peripheral angiography with or without angioplasty over a period of 7.5 years (January 1999 through June 2006) at a single institution were retrospectively evaluated. One hundred twenty-two patients (54% men; mean age, 70.3 years; age range, 41-91 y) with angiographic stenoses (> or =50%) or occlusions on the asymptomatic leg were included. The composite endpoint of interest was major adverse clinical outcome (MACO) of the asymptomatic limb at clinical follow-up, which was defined as the development of intermittent claudication (IC), critical limb ischemia (CLI), or need for subsequent endovascular or surgical revascularization. Actuarial freedom from MACO was assessed with Kaplan-Meier curves and multivariable Cox proportional-hazards regression. RESULTS: During a 4.2-year mean follow-up in 122 patients with significant concomitant asymptomatic disease, 32.8% of patients developed symptoms (13.9% with IC, 18.9% with CLI); 42.5% of these cases required revascularization. Cox regression revealed two independent predictors of MACO on the asymptomatic side: contralateral below-knee amputation (BKA; hazard ratio, 2.93; 95% CI, 1.21-7.10; P = .01) and statin treatment (hazard ratio, 3.56; 95% CI, 1.56-8.13; P = .003). CONCLUSIONS: Asymptomatic peripheral angiographic stenoses and occlusions become symptomatic in one third of patients, necessitating treatment in 13.9% overall. Previous contralateral BKA and statin use were independent predictors of adverse outcome in this population. Close clinical follow-up and appropriate risk factor modification are recommended.

Successful endovascular treatment of a hemodialysis graft pseudoaneurysm by covered stent and direct percutaneous thrombin injection.

Vascular access for hemodialysis remains a challenge for nephrologists, vascular surgeons, and interventional radiologists alike. Arteriovenous fistula and synthetic grafts remain the access of choice for long-term hemodialysis; however, they are subject to complications from infection and repeated needle cannulation. Pseudoaneurysms are an increasingly recognized adverse event. At present, there are many minimally invasive methods to repair these wall defects. We present a graft pseudoaneurysm, which required a combination of endovascular stent graft placement and percutaneous thrombin injection for successful occlusion.

A prospective comparison of the performance and survival of two different tunnelled haemodialysis catheters: SplitCath® versus DuraMax®.

BACKGROUND: Despite their well-recognised shortcomings, haemodialysis catheters (HDCs) remain an important form of haemodialysis access for many patients. There are several HDCs commercially available, each differing considerably in design, which is known to significantly influence performance and survival. We sought to determine which of two tunnelled HDCs, DuraMax® (Angiodynamics, NY, USA) or SplitCath® (MedComp, PA, USA) delivers the best performance, safety and reliability for dialysis patients. METHODS: Eighty-six patients were prospectively randomised to receive either DuraMax® (DM) or SplitCath® (SC). Outcomes included: (i) mean flow rates (mL/min) averaged over the first 10 weeks of dialysis, and urea reduction ratio (URR); and (ii) long-term catheter survival with appraisal of any events leading to catheter dysfunction and early removal. RESULTS: Median flow rates (interquartile range) in the DM and SC groups were 321 (309-343) and 309 (294-322) mL/min, respectively (p = 0.002). URR values for the DM and SC groups were 71 (65-76) and 74 (70-78), respectively, (p = 0.094). There was no significant difference in long-term survival or frequency of incidents that required early HDC removal (9/43 in the DM group, 5/43 patients SC). A slightly higher incidence of HDC dislodgement was noted in the DM group, although this study was not statistically powered to determine its significance. CONCLUSIONS: We conclude that DM yields slightly higher flow rates in the first 10 weeks of dialysis, and a similar low incidence of complications and long-term survival for both DM and SC HDCs.

Insertion of balloon retained gastrostomy buttons: a 5-year retrospective review of 260 patients.

PURPOSE: Radiologically inserted gastrostomy (RIG) is an established way of maintaining enteral nutrition in patients who cannot maintain nutrition orally. The purpose of this study was to evaluate the safety and efficacy of primary placement of a wide bore button gastrostomy in a large, varied patient population through retrospective review. METHODS: All patients who underwent gastrostomy placement from January 1, 2004 to January 1, 2009 were identified. 18-Fr gastrostomy buttons (MIC-Key G) were inserted in the majority. Follow-up ranged from 6 months to 4.5 years. RESULTS: A total of 260 patients (M:F 140:120, average age 59.2 years) underwent gastrostomy during the study period. Overall success rate for RIG placement was 99.6 %, with success rate of 95.3 % for primary button insertion. Indications included neurological disorders (70 %), esophageal/head and neck malignancy (21 %), and other indications (9 %). Major and minor complication rates were 1.2 and 12.8 %, respectively. Thirty-day mortality rate was 6.8 %. One third of patients underwent gastrostomy reinsertion during the study period, the main indication for which was inadvertent catheter removal. Patency rate was high at 99.5 %. The maximum number of procedures in any patient was 8 (n = 2), and the average tube dwell time was 125 days. CONCLUSIONS: Primary radiological insertion of a wide bore button gastrostomy is a safe technique, with high success rate, high patency rate, and low major complication rate. We believe that it is feasible to attempt button gastrostomy placement in all patients, once tract length is within limits of tube length. If difficulty is encountered, then a standard tube may simply be placed instead.

Proximal superficial femoral artery occlusion, collateral vessels, and walking performance in peripheral artery disease.

OBJECTIVES: We studied associations of magnetic resonance imaging (MRI)-measured superficial femoral artery (SFA) occlusions with functional performance, leg symptoms, and collateral vessel number in peripheral artery disease (PAD). We studied associations of collateral vessel number with functional performance in PAD. BACKGROUND: Associations of MRI-detected SFA occlusion and collateral vessel number with functional performance among individuals with PAD have not been reported. METHODS: A total of 457 participants with an ankle brachial index (ABI) <1.00 had MRI measurement of the proximal SFA with 12 consecutive 2.5-µm cross-sectional images. An occluded SFA was defined as an SFA in which at least 1 segment was occluded. A nonoccluded SFA was defined as absence of any occluded slices. Collateral vessels were visualized with magnetic resonance angiography. Lower extremity functional performance was measured with the 6-min walk, 4-m walking velocity at usual and fastest pace, and the Short Physical Performance Battery (SPPB) (0 to 12 scale, 12 = best). RESULTS: Adjusting for age, sex, race, comorbidities, and other confounders, the presence of an SFA occlusion was associated with poorer 6-min walk performance (1,031 vs. 1,169 feet, p = 0.006), slower fast-paced walking velocity (1.15 vs. 1.22 m/s, p = 0.042), and lower SPPB score (9.07 vs. 9.75, p = 0.038) compared with the absence of an SFA occlusion. More numerous collateral vessels were associated with better 6-min walk performance (0 to 3 collaterals-1,064 feet, 4 to 7 collaterals-1,165 feet, ≥8 collaterals-1,246 feet, p trend = 0.007), faster usual-paced walking speed (0 to 3 collaterals-0.84 m/s, 4 to 7 collaterals-0.88 m/s, ≥8 collaterals-0.91 m/s, p trend = 0.029), and faster rapid-paced walking speed (0 to 3 collaterals-1.17 m/s, 4 to 7 collaterals-1.22 m/s, ≥8 collaterals-1.29 m/s, p trend = 0.002), adjusting for age, sex, race, comorbidities, ABI, and other confounders. CONCLUSIONS: Among PAD participants, MRI-visualized occlusions in the proximal SFA are associated with poorer functional performance, whereas more numerous collaterals are associated with better functional performance. (Magnetic Resonance Imaging to Identify Characteristics of Plaque Build-Up in People With Peripheral Arterial Disease; NCT00520312).

Intravenous, contrast-enhanced MR colonography using air as endoluminal contrast agent: impact on colorectal polyp detection.

PURPOSE: To compare diagnostic accuracy and patient tolerance of MR colonography with intravenous contrast and luminal air (MRC) to conventional colonoscopy (CC). MATERIALS AND METHODS: IRB approval and written informed consent were obtained. Forty-six patients, both screening and symptomatic, underwent MRC followed by CC. The MRC technique employed 3D T1W spoiled gradient echo sequences performed after the administration of gadopenetate dimeglumine, with parallel imaging. The diagnostic accuracy and tolerance of patients for MRC was compared to CC. RESULTS: Twenty-four polyps were detected in eighteen patients with CC (5 polyps ≥ 10 mm, 4 polyps 6-9 mm, 15 polyps ≤ 5 mm). MRC was 66.7% (12/18) sensitive and 96.4% (27/28) specific for polyp detection on a per-patient basis. When analyzed by polyp size, sensitivity and specificity of MRC was 100% (5/5) and 100% (19/19), respectively, for lesions greater than 10mm, 100% (4/4) and 100% (20/20) for lesions 6-9 mm, and sensitivity of 20% (3/15) lesions less than 5mm. The sensitivity and specificity of MRC for detecting significant lesions (>6mm) was 100% (9/9) and 100% (15/15), respectively. Regarding tolerance of the exams, there were no significant differences between MRC and CC. Thirty-five percent (n=16) of patients preferred MRC as a future screening test compared to 33% (n=15) for CC. CONCLUSION: MRC using air as an intraluminal contrast agent is a feasible and well-tolerated technique for detecting colonic polyps ≥ 6 mm in size. Further studies are warranted.

Percutaneous balloon dilatation of stenotic calyceal diverticular infundibula in patients with recurrent urinary tract infections.

AIM: Renal calyceal diverticula are usually detected as incidental findings on intravenous pyelograms (IVPs) and rarely manifest any clinical signs or symptoms. However, they can interfere with patient's quality of life in a number of instances causing pain, recurrent urinary tract infections (UTIs), abscess, systemic sepsis and calculus formation. The purpose of this study was to review the clinical indications, procedure technique and clinical outcome in all patients referred to Interventional Radiology for the percutaneous management of renal calyceal diverticula. MATERIALS AND METHODS: A retrospective review of all patients treated with percutaneous balloon dilatation of calyceal diverticular infundibula in the Interventional Radiology Department over a 10-year period was performed. Data collected included clinical details, laboratory indices, IVP and CT findings, procedure details and clinical outcome. RESULTS: A total of three patients were treated over the course of the study period. All patients were young females who presented as a result of recurrent urinary tract infections. The calyceal diverticula were diagnosed incidentally on routine IVPs, with CT eloquently confirming the plain film findings in two cases. Technical procedure success was achieved in all cases, avoiding surgical intervention. Clinical follow-up revealed no further UTIs following dilatation. CONCLUSION: Fluoroscopic guided percutaneous balloon dilatation of renal calyceal diverticular infundibula following direct diverticular puncture is a safe and well tolerated method to reduce UTI and potentially avoid future stone formation.