Biliopancreatic and biliary leak after pancreatoduodenectomy treated by percutaneous transhepatic biliary drainage.

BACKGROUND: Complementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication. METHODS: All patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014-2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage. RESULTS: Following 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21-60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2). CONCLUSION: Although drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy.

Dutch randomized trial comparing standard catheter-directed thrombolysis and ultrasound-accelerated thrombolysis for arterial thromboembolic infrainguinal disease (DUET).

PURPOSE: To report the results of the Dutch randomized trial comparing standard catheter-directed and ultrasound-accelerated thrombolysis (UST) for the treatment of arterial thromboembolic occlusions. METHODS: The DUET study ( controlled-trials.com ; identifier ISRCTN72676102) was designed to assess whether UST can reduce therapy time significantly compared with standard thrombolysis (ST). Sixty patients (44 men; mean age 64 years) with recently (7-49 days) thrombosed infrainguinal native arteries or bypass grafts causing acute limb ischemia (Rutherford category I or IIa) were randomized to ST (n = 32) or UST (n = 28). The primary outcome was the duration of thrombolysis needed for uninterrupted flow (> 95% thrombus lysis), with outflow through at least 1 below-the-knee artery. Continuous data are presented as means ± standard deviations. RESULTS: Thrombolysis was significantly faster in the UST group (17.7 ± 2.0 hours) than in the ST group (29.5 ± 3.2 hours, p = 0.009) and required significantly fewer units of urokinase (2.8 ± 1.6 × 10(6) IU in the ST group vs. 1.8 ± 1.0 × 10(6) IU in the UST group, p = 0.01) for uninterrupted flow. Technical success was achieved in 27 (84%) patients in the ST group vs. 21 (75%) patients in the UST group (p = 0.52). The combined 30-day death and severe adverse event rate was 19% in the ST group and 29% in the UST group (p = 0.54). The 30-day patency rate was 82% in the ST group as compared with 71% in the UST group (p = 0.35). CONCLUSION: Thrombolysis time was significantly reduced by UST as compared with ST in patients with recently thrombosed infrainguinal native arteries or bypass grafts.

Evaluation of a noise reduction imaging technology in iliac digital subtraction angiography: noninferior clinical image quality with lower patient and scatter dose.

PURPOSE: To determine whether equivalent-quality images can be obtained from digital subtraction angiography (DSA) of the iliac artery after implementation of a novel imaging technology that reduces patient and scatter x-ray dose. MATERIALS AND METHODS: Imaging using two randomly ordered DSA runs was performed in 51 adults scheduled for iliac artery angiography or intervention or both. One DSA run used standard acquisition chain and image processing algorithms (referred to as " reference DSA"), and the other DSA run used dose-reduction and real-time advanced image noise reduction technology (referred to as "study DSA"). The quality of each pair of runs, consecutively performed without changes in working projection or injection parameters, was independently rated by five radiologists blinded to the imaging technology used. Patient radiation dose was evaluated using air kerma and dose area product, and scatter dose was evaluated using three dosimeters (DoseAware, Philips Healthcare, Best, The Netherlands), located at fixed positions. RESULTS: Comparable image pairs were available in 48 patients. There were 44 patients undergoing treatment involving the common (n = 33) or external (n = 29) iliac arteries. Study DSA images were rated as equal to or better than reference DSA images for 96% of comparisons, with an average overall agreement among raters of 0.93 (95% confidence interval, 0.65-0.96). Mean patient radiation dose (n = 48) and scatter dose rate for the three dosimeters (n = 50) was 83% ± 5 and 69% ± 10 lower, respectively, using the study technology (P < .001). CONCLUSIONS: Iliac artery DSA performed using a dose-reduction and real-time advanced image noise reduction technology results in image quality that is noninferior to conventional DSA but with significantly lower patient and scatter radiation exposure (P < .001).

Pulmonary artery pseudoaneurysm after thoracic radiation therapy: A case report and review of the literature.

Pulmonary artery pseudoaneurysm (PAP) is a rare cause of hemoptysis. Potential causes include trauma, infection, or medical interventions. There is a risk of rupture, which is associated with a high mortality rate. We describe a 72-year-old patient, with a past medical history of a lung carcinoma for which she was treated with chemoradiotherapy 6 years prior, who presented with hemoptysis. She was hemodynamically stable and there were no other complaints. CT angiography of the thorax showed a PAP originating from a branch of the right pulmonary artery in the previously irradiated area. The patient was successfully treated by an embolization with plugs. Treatment of lung carcinoma with chemoradiotherapy can result in the development of a PAP. Clinicians should be aware of this complication, even years after the therapy. In literature, only a few cases of PAP in patients treated with (chemo)radiotherapy for lung cancer are described, with a maximum interval up to 7 years.

Percutaneous transluminal angioplasty and stenting as first-choice treatment in patients with chronic mesenteric ischemia.

PURPOSE: Open revascularization in patients with chronic mesenteric ischemia (CMI) is considered the gold standard. Percutaneous transluminal angioplasty and stenting (PTAS) is often reserved for patients not suitable for open revascularization. In our institute, endovascular revascularization is the first-choice treatment. The purpose of this study was to report the technical and clinical success rates after endovascular revascularization as the first-choice treatment in a series of 51 consecutive patients with CMI at a single tertiary vascular referral center. METHODS: A retrospective review was performed of all consecutive patients with CMI who underwent PTAS from July 2001 to July 2008. Only symptomatic patients treated for atherosclerotic CMI were included. Patency was evaluated using computed tomography angiography (CTA). Kaplan-Meier curves were used to calculate patency rates of the treated mesenteric arteries. RESULTS: Sixty mesenteric arteries (30 celiac trunks, 24 superior mesenteric, and 6 inferior mesenteric arteries) were treated in 51 patients (26 men). Major morbidity was 4%. After dissection of the superior mesenteric artery (n = 1) and brachial artery (n = 1), respectively, both patients underwent endarterectomy and patch plasty. In three arteries, the lesion could not be crossed endovascularly and they were deemed immediate intention-to-treat failures. The initial technical success rate was 93%. No 30-day mortality was observed. Median follow-up was 25 months. During follow-up, 2 patients died from intestinal ischemia. Complete symptom relief was achieved in 78% of patients. Primary 1- and 2-year patency rates were 86% +/- 5% and 60% +/- 9%, respectively; primary-assisted patency rates were 88% +/- 5% and 79% +/- 7%, respectively. During follow-up, 6 patients underwent open revascularization due to failure of PTAS. CONCLUSION: The initial technical success rate of PTAS as first-choice treatment of CMI is >90%. The 2-year primary patency rate dropped to 60%, but symptomatic in-stent stenoses could often be treated successfully with renewed endovascular techniques. Including one conversion, 14% of patients needed open revascularization during follow-up.

Gallstone formation after weight loss following gastric banding in morbidly obese Dutch patients.

BACKGROUND: Obesity is a risk factor for the development of gallstones. Rapid weight loss may be an even stronger risk factor. We retrospectively assessed the prevalence and risk factors of gallstone formation after adjustable gastric banding (AGB) in a Dutch population. METHODS: All patients who underwent AGB between Jan 1992 and Dec 2000 for morbid obesity were invited to take part in this study. Transabdominal ultrasonography of the gallbladder was performed in those patients without a prior history of cholecystectomy (Group A). Additionally, 45 morbidly obese patients underwent ultrasonography of the gallbladder before weight reduction surgery (Group B). RESULTS: 120 patients were enrolled in the study (Group A). Prior history of cholecystectomy was present in 21 patients: 16 before and 5 after AGB. Ultrasonography was performed in 98 patients: gallstones were present in 26 (26.5%). On multivariate analysis, neither preoperative weight, nor maximum weight loss, nor the interval between operation and the postoperative ultrasonography were determinants of the risk for developing gallstone disease. Prevalence of gallstones was significantly lower in the morbidly obese patients who had not yet undergone weight reduction surgery (Group B). CONCLUSIONS: Rapid weight loss induced by AGB, is an important risk factor for the development of gallstones. No additional determinants were found. Every morbidly obese patient undergoing bariatric surgery must be considered at risk for developing gallstone disease.

Is a history of radiation therapy a contraindication for carotid surgery?

Advances in surgical and medical oncology have seen a significant increase in survival of patients suffering from head and neck malignancies. Many of these patients are treated with radiotherapy to the neck, including the cervical carotid artery. Cervical irradiation (CI) may induce carotid stenosis. Prior CI in association with carotid artery stenosis poses potential challenges, when revascularization is considered. As the focus of radiotherapy determines the level of the resultant obstruction it may be in a location that is difficult to reach surgically. Also scar tissue from CI may increase the risk of cranial nerve injury. Carotid angioplasty and stenting (CAS) may be an alternative for CEA in post CI cases. This manuscript aims to derive a treatment algorithm for post CI stenosis from the available literature, answering three questions: 1) do symptomatic post CI stenoses require revascularization?; 2) Do asymptomatic post CI stenoses require revascularization?; 3) What is the preferred revascularization modality? The answers to those questions are the following: 1) as several studies have shown the increased likelihood of stenosis after CI and its potential for embolic events, symptomatic stenosis should be treated; 2) patients after CI have a much greater chance of serious events from their malignancies than from their carotid disease, therefore most asymptomatic stenoses probably do not warrant revascularization; 3) CEA post CI carries less peri procedural risk than previously supposed and CAS is hampered by increased restenosis rates, so CEA should be the preferred treatment if feasible. An individual patient tailored approach for post CI carotid stenosis is warranted, the guideline being: "If symptomatic: revascularize; if possible: operate; if not: consider stenting".

[A splenic arteriovenous fistula]. / Een arterioveneuze fistel van de miltvaten.

BACKGROUND: Splenic arteriovenous fistula is a rare entity which can present as portal hypertension and related symptoms. CASE DESCRIPTION: A 60-year-old female attended the emergency department with haematemesis. She had microcytic anaemia and was admitted to the Gastroenterology and Hepatology Department. Gastroduodenoscopy revealed three grade II-III varices in the distal oesophagus. The ultrasound image was suggestive of liver cirrhosis and showed signs of portal hypertension such as ascites, splenomegaly and dilated vessels near the splenic hilum. CT angiography showed an enlarged splenic vein in the arterial phase suggestive of arteriovenous fistula. This was confirmed by selective angiography of the splenic artery. The splenic arteriovenous fistula was treated with percutaneous transarterial embolization. CONCLUSION: Patients with an arteriovenous fistula in the spleen are generally treated by splenectomy. However, in our patient embolization treatment was effective.

Feasibility study of needle placement in percutaneous vertebroplasty: cone-beam computed tomography guidance versus conventional fluoroscopy.

OBJECTIVE: To investigate the accuracy, procedure time, fluoroscopy time, and dose area product (DAP) of needle placement during percutaneous vertebroplasty (PVP) using cone-beam computed tomography (CBCT) guidance versus fluoroscopy. MATERIALS AND METHODS: On 4 spine phantoms with 11 vertebrae (Th7-L5), 4 interventional radiologists (2 experienced with CBCT guidance and two inexperienced) punctured all vertebrae in a bipedicular fashion. Each side was randomization to either CBCT guidance or fluoroscopy. CBCT guidance is a sophisticated needle guidance technique using CBCT, navigation software, and real-time fluoroscopy. The placement of the needle had to be to a specific target point. After the procedure, CBCT was performed to determine the accuracy, procedure time, fluoroscopy time, and DAP. Analysis of the difference between methods and experience level was performed. RESULTS: Mean accuracy using CBCT guidance (2.61 mm) was significantly better compared with fluoroscopy (5.86 mm) (p < 0.0001). Procedure time was in favor of fluoroscopy (7.39 vs. 10.13 min; p = 0.001). Fluoroscopy time during CBCT guidance was lower, but this difference is not significant (71.3 vs. 95.8 s; p = 0.056). DAP values for CBCT guidance and fluoroscopy were 514 and 174 mGy cm(2), respectively (p < 0.0001). There was a significant difference in favor of experienced CBCT guidance users regarding accuracy for both methods, procedure time of CBCT guidance, and added DAP values for fluoroscopy. CONCLUSION: CBCT guidance allows users to perform PVP more accurately at the cost of higher patient dose and longer procedure time. Because procedural complications (e.g., cement leakage) are related to the accuracy of the needle placement, improvements in accuracy are clinically relevant. Training in CBCT guidance is essential to achieve greater accuracy and decrease procedure time/dose values.

Initial results of catheter-directed ultrasound-accelerated thrombolysis for thromboembolic obstructions of the aortofemoral arteries: a feasibility study.

PURPOSE: This article reports the 30-day technical and clinical outcome of ultrasound (US)-accelerated thrombolysis in patients with aortofemoral arterial thromboembolic obstructions. METHODS: A prospective cohort study was conducted from December 2008 to December 2009 of patients who were treated with US-accelerated thrombolysis for thromboembolic obstructions of aortofemoral arteries or bypasses. Urokinase was infused in a dosage of 100,000 IU per hour. Twice daily, a control angiography was performed. Thirty-day follow-up consisted of duplex scanning, combined with magnetic resonance angiography. RESULTS: The study included 21 consecutive patients (20 men; median age, 66 (range, 52-80) years) with 24% artery versus 76% bypass occlusions. Median duration of symptoms was 11 (range, 7-140) days. Median occlusion length was 32 (range, 6-80) cm. In 20 patients (95%), an US-accelerated thrombolysis catheter could be successfully placed. In one patient, placement of an US-accelerated thrombolysis catheter was technically not feasible, and therefore a standard catheter was placed. Median thrombolysis time was 26.5 (range, 8.5-72) hours. Complete thrombolysis (>95% lysis of thrombus) was achieved in 20 patients; in 9 patients within 24 hours. Median ankle-brachial index (ABI) increased from 0.28 (range, 0-0.85) to 0.91 (range, 0.58-1.35). One patient had a thromboembolic complication and needed surgical intervention. No hemorrhagic complications, and no deaths occurred. At 30-day follow-up, 17 of 21 patients (81%) had a patent artery or bypass. CONCLUSIONS: This feasibility study showed a high technical success rate of US-accelerated thrombolysis for aortofemoral arterial obstructions. US-accelerated thrombolysis led to complete lysis within 24 hours in almost half of patients, with a low 30-day major complication rate.

Dutch randomized trial comparing standard catheter-directed thrombolysis versus ultrasound-accelerated thrombolysis for thromboembolic infrainguinal disease (DUET): design and rationale.

BACKGROUND: The use of thrombolytic therapy in the treatment of thrombosed infrainguinal native arteries and bypass grafts has increased over the years. Main limitation of this treatment modality, however, is the occurrence of bleeding complications. Low intensity ultrasound (US) has been shown to accelerate enzymatic thrombolysis, thereby reducing therapy time. So far, no randomized trials have investigated the application of US-accelerated thrombolysis in the treatment of thrombosed infra-inguinal native arteries or bypass grafts. The DUET study (Dutch randomized trial comparing standard catheter-directed thrombolysis versus Ultrasound-accElerated Thrombolysis for thrombo-embolic infrainguinal disease) is designed to assess whether US-accelerated thrombolysis will reduce therapy time significantly compared with standard catheter-directed thrombolysis. METHODS/DESIGN: Sixty adult patients with recently (between 1 and 7 weeks) thrombosed infrainguinal native arteries or bypass grafts with acute limb ischemia class I or IIa, according to the Rutherford classification for acute ischemia, will be randomly allocated to either standard thrombolysis (group A) or US-accelerated thrombolysis (group B). Patients will be recruited from 5 teaching hospitals in the Netherlands during a 2-year period. The primary endpoint is the duration of catheter-directed thrombolysis needed for uninterrupted flow in the thrombosed infrainguinal native artery or bypass graft, with outflow through at least 1 crural artery. DISCUSSION: The DUET study is a randomized controlled trial that will provide evidence of whether US-accelerated thrombolysis will significantly reduce therapy time in patients with recently thrombosed infrainguinal native arteries or bypass grafts, without an increase in complications. TRIAL REGISTRATION: Current Controlled Trials ISRCTN72676102.