Ahmed Kamel Abdel-Aal

Fluoroscopic and Sonographic Guidance to Place Peritoneal Catheters: How We Do It

OBJECTIVE The purpose of this article is to detail a percutaneous approach to placing peritoneal catheters using sonographic and fluoroscopic guidance. Fluoroscopic-assisted placement of these catheters has been previously described in the literature. We emphasize the use of additional sonographic guidance, including color Doppler sonography, to determine the safest puncture site and to guide the initial needle puncture to avoid bowel perforation and injury to the epigastric artery. CONCLUSION Imaging-guided-that is, sonography plus fluoroscopy-percutaneous placement of peritoneal catheters is a safe, minimally invasive, and effective alternative to blind or open surgical placement. The use of sonographic guidance together with fluoroscopic assistance makes placement of peritoneal catheters a safer and effective alternative to blind or open surgical placement.

Best Practices Consensus Protocol for Peritoneal Dialysis Catheter Placement by Interventional Radiologists

Peritoneal dialysis (PD) catheters can be placed by interventional radiologists, an approach that might offer scheduling efficiencies, cost-effectiveness, and a minimally invasive procedure. In the United States, changes in the dialysis reimbursement structure by the Centers for Medicare and Medicaid Services are expected to result in the increased use of PD, a less costly dialysis modality that offers patients the opportunity to receive dialysis in the home setting and to have more independence for travel and work schedules, and that preserves vascular access for future dialysis options. Placement of PD catheters by interventional radiologists might therefore be increasingly requested by nephrology practices, given that recent publications have demonstrated the favorable impact on PD practices of an interventional radiology PD placement capability. Earlier reports of interventional radiology PD catheter placement came from single-center practices with smaller reported experiences. The need for a larger consensus document that attempts to establish best demonstrated practices for radiologists is evident. The radiologists submitting this consensus document represent a combined experience of more than 1000 PD catheter placements. The authors submit these consensus-proposed best demonstrated practices for placement of PD catheters by interventional radiologists under ultrasonographic and fluoroscopic guidance. This technique might allow for expeditious placement of permanent PD catheters in late-referred patients with end-stage renal disease, thus facilitating urgent-start PD and avoiding the need for temporary vascular access catheters.

Use of Cryoablation and Osteoplasty Reinforced with Kirschner Wires in the Treatment of Femoral Metastasis

PurposeWe report the case of a 43-year-old man with metastatic breast carcinoma to the proximal right femur resulting in severe painful pathological fracture. The patient experienced severe pain despite large doses of analgesia, resulting in impaired functionality and quality of life. The patient had significant comorbidities, making him a high surgical risk.Materials and MethodsThe patient was treated with cryoablation and osteoplasty, followed by a novel technique consisting of osteoplasty reinforced with bone marrow Kirschner wires (K-wires) which will be described in details in this report.ResultsThe patient reported significant pain relief after the procedure, and gained right lower extremity functionality, as compared to total immobility before the procedure.ConclusionOur technique offers an alternative feasible treatment for patients at high surgical risk with pathological fractures in weight-bearing bones, in which osteoplasty alone has a high risk of cement leakage, inadequate fracture reduction, and early refracture. To our knowledge, our technique has not been previously described.

Primary Leiomyosarcoma of the Inferior Vena Cava Invading the Right Atrium A Technique for Intraluminal Biopsy Through a Transvenous Approach

Leiomyosarcoma of inferior vena cava (IVC) is a very rare tumor constituting less than 1% of all malignant tumors. However, it is the most common malignant primary IVC tumor. We report a case of primary leiomyosarcoma involving the entire IVC and extending into the right atrium. We also describe a simple endovascular technique that can be used to biopsy IVC masses through a transvenous approach. Our technique can be used as an alternative to percutaneous biopsy which carries a risk of bleeding when transgressing the IVC wall with a biopsy needle. To our knowledge, the use of this technique to biopsy IVC masses has not been described in literature.

Technique of Peritoneal Catheter Placement under Fluroscopic Guidance

Peritoneal catheters are mainly used for peritoneal dialysis in patients with end-stage renal disease. Other uses of this catheter include intraperitoneal chemotherapy and gene therapy for ovarian cancer and draining of uncontrolled refractory ascites in patients with liver cirrhosis. Traditionally, surgeons place most of these peritoneal catheters either by laparoscopy or open laparotomy. We detail our percutaneous approach to placing peritoneal catheters using fluoroscopic guidance. We emphasize the use of additional ultrasound guidance, including gray scale and color Doppler ultrasound, to determine the safest puncture site and to guide the initial needle puncture in order to avoid bowel perforation and injury to epigastric artery. We present our experience in placing peritoneal catheters using this technique in 95 patients with various indications. Fluoroscopic guided percutaneous placement of peritoneal catheters is a safe, minimally invasive, and effective alternative to open surgical or laparoscopic placement.

Pneumocele of the frontal sinus producing orbital roof defect: case report and review of literature

Type III frontal recess air cell as a cause of frontal sinus pneumocele has not been previously reported in literature. A 31-year-old woman with chronic history of sinusitis presented with pressure in the left eye on blowing the nose. Computed tomography examination of the orbits and paranasal sinuses with coronal and sagittal reformatted images showed abnormal collection of gas in the soft tissues at the superior aspect of the left orbit contiguous with the overlying left frontal sinus through a large defect in the orbital roof and a type III frontal recess air cell narrowing the left frontal recess.

Innumerable Bilateral Pulmonary Arteriovenous Malformations Percutaneous Transcatheter Embolization Using Amplatzer Vascular Plug

We report an unusual and distinct case of innumerable bilateral pulmonary arteriovenous malformation (PAVM) in a 42-year-old patient presenting with significant right-to-left shunt resulting in severe dyspnea and with a history of stroke due to paradoxical embolization related to his PAVM. Because it was impossible to treat all his PAVMs, our aim was to treat those with a feeding artery measuring 3 mm or more in diameter, aiming to improve the patient’s dyspnea and decrease the risk of paradoxical embolization. We safely and successfully embolized 8 of the patient’s PAVMs, using a single Amplatzer vascular plug for each PAVM. The procedure did not result in significant improvement of the patient’s symptoms. In similar cases with innumerable PAVMs, the expectations of symptom relief should be lowered and the patient should be informed that treatment will only offer protection from paradoxical embolization. To our knowledge, there are no similar cases previously described in the literature.

Persistence of pulmonary arteriovenous malformations after successful embolotherapy with Amplatzer vascular plug: long-term results

PURPOSE We aimed to evaluate the frequency of persistence and complication rates of pulmonary arteriovenous malformations (PAVMs) treated with Amplatzer vascular plug (AVP) or Amplatzer vascular plug type 2 (AVP2). METHODS We retrospectively reviewed a total of 22 patients with 54 PAVMs between June 2004 and June 2014. We included 12 patients with 35 PAVMs who received percutaneous embolization using AVP or AVP2 only without the use of any other embolic devices. The mean follow-up was 54±24.3 months (range, 31-97 months). The primary end-points of the study were the efficacy of embolotherapy, the increase in oxygen saturation, and the persistence of PAVM on follow-up. Secondary end point was the incidence of complications. RESULTS The study included 10 female and two male patients with a mean age of 50.2±13.7 years (range, 21-66 years). All PAVMs had a simple angioarchitecture. The technical success of the procedure for PAVM occlusion was 100%. There was a significant increase in the oxygen saturation following embolotherapy (P < 0.0001). Follow-up computed tomography angiography revealed successful treatment in 34 PAVMs (97%) and failed treatment in one PAVM (3%). Twenty-three aneurysmal sacs (67%) showed complete disappearance. The failed treatment was due to persistence of PAVM caused by subsequent development of systemic reperfusion, which did not require further intervention. There were two minor complications but no major complications were encountered. CONCLUSION Embolotherapy of PAVMs using AVP or AVP2 devices is safe and effective, with high technical success rate, low persistence and complication rates, and with excellent long-term results.

Endovascular treatment of acute portal vein thrombosis using ultrasound-accelerated catheter-directed thrombolysis.

We report a case of extensive acute portal vein thrombosis (PVT) presenting with severe diffuse abdominal pain and impending small bowel infarction. The patient was successfully treated with ultrasound-accelerated catheter-directed thrombolysis (EKOS endowave system; Covidien, Mansfield, Massachusetts), which resulted in prompt recanalization of his portal vein (PV) and its tributaries. The patient eventually had ischemic stricture that necessitated bowel resection. However, we believe that our technique was successful in rapidly restoring the patency of the PV and its tributaries, and therefore, avoiding a life-threatening complication of more extensive bowel infarction. To our knowledge, the use of ultrasound-accelerated thrombolysis in treatment of PVT has not been previously described in the literature.

Percutaneous Embolization of a Postnephrectomy Arteriovenous Fistula With Intervening Pseudoaneurysm Using the Amplatzer Vascular Plug 2

Although renal arteriovenous fistula (AVF) is an uncommon condition, it may lead to high cardiac output heart failure and renal insufficiency. Recently, percutaneous transcatheter embolization has replaced traditional surgery as the first line of treatment. We report a case of a 68-year-old male who presented with a renal AVF and was treated by percutaneous transcatheter embolization using the Amplatzer Vascular Plug 2 (AVP 2; St Jude Medical, Plymouth, Minnesota) through an arterial access. To our knowledge, the use of AVP 2 device in the treatment of renal AVF as a single embolotherapy device through the transarterial route has not been previously reported in the literature. Our technique demonstrates the feasibility and safety of AVP 2 device in the treatment of renal AVF.