Andrew R. Forauer

Endovascular Stent-Graft or Open Surgical Repair for Blunt Thoracic Aortic Trauma: Systematic Review

PURPOSEnTo evaluate the available data on stent-graft repair of acute blunt traumatic thoracic aortic injury with regard to safety and efficacy compared with conventional open surgical repair.nnnMATERIALS AND METHODSnThe literature on endovascular repair of acute traumatic aortic injury since 1990 was systematically reviewed. Metaanalysis of publications with open and stent-graft repair cohorts was performed to evaluate whether there was a difference in treatment effect with regard to mortality and paraplegia. Case series were included to obtain an adequate population to assess the incidence of stent-graft procedure-related complications.nnnRESULTSnThere were no prospective randomized studies. Nineteen publications that compared the outcomes of 262 endograft repairs and 376 open surgical repairs were identified. The odds ratio for mortality after endovascular versus open repair was 0.43 (95% CI, 0.26-0.70; P = .001). The odds ratio for paraplegia after endovascular versus open repair was 0.30 (95% CI, 0.12-0.76; P = .01). In the pooled group of 667 endovascular repair survivors from 50 reports, the incidence of early endoleak was 4.2%, and late endoleak occurred in 0.9%. Stroke or transient ischemic attack was reported in 1.2%. Access site complications that required intervention occurred in 4.1%.nnnCONCLUSIONSnThe available cohort and case series data support stent-graft repair as a highly successful technique that may reduce mortality and paraplegia rates by half compared with open surgery. These data support endograft repair as first-line therapy for blunt thoracic aortic trauma.

Implantable subcutaneous venous access devices: is port fixation necessary? A review of 534 cases.

Conventional surgical technique of subcutaneous venous port placement describes dissection of the port pocket to the pectoralis fascia and suture fixation of the port to the fascia to prevent inversion of the device within the pocket. This investigation addresses the necessity of that step. Between October 8, 2004 and October 19, 2007, 558 subcutaneous chest ports were placed at our institution; 24 cases were excluded from this study. We performed a retrospective review of the remaining 534 ports, which were placed using standard surgical technique with the exception that none were sutured into the pocket. Mean duration of port use, total number of port days, indications for removal, and complications were recorded and compared with the literature. Mean duration of port use was 341xa0days (182,235 total port days, range 1–1279). One port inversion/flip occurred, which resulted in malfunction and necessitated port revision (0.2%). Other complications necessitating port removal included infection 26 (5%), thrombosis nxa0=xa02 (<1%), catheter fracture/pinch nxa0=xa01 (<1%), pain nxa0=xa02 (<1%), and skin erosion nxa0=xa03 (1%). There were two arrhythmias at the time of placement; neither required port removal. The overall complication rate was 7%. The 0.2% incidence of port inversion we report is concordant with that previously published, although many previous reports do not specify if suture fixation of the port was performed. Suture fixation of the port, in our experience, is not routinely necessary and may negatively impact port removal.

Sclerosis of postoperative lymphoceles: avoidance of prolonged catheter drainage with use of a fibrin sealant.

PURPOSEnTo review experience with fibrin-based tissue sealant sclerosis of postsurgical lymphoceles at a single institution.nnnMATERIALS AND METHODSnFifteen patients who presented with postsurgical lymphoceles were treated with injection of fibrin tissue sealant. Procedures were performed under fluoroscopic and sonographic guidance. All lymphoceles were drained and sclerosed with a mixture of fibrin sealant and gentamicin. No drainage catheter was left in place. Postprocedural follow-up consisted of imaging and clinical evaluations.nnnRESULTSnTwelve men and three women (mean age, 52 years) were treated. Eleven patients with lymphoceles were successfully treated with one session of sclerosis. Four patients required more than one treatment (two underwent two sessions, and two underwent three sessions). Seven patients undergoing a single treatment experienced complete resolution, and the remaining patients had smaller, persistent, asymptomatic collections. Imaging mean follow-up was 114 days (range, 5-339 d); mean clinical follow-up was 487 days (range, 195-856 d). There were no periprocedural complications.nnnCONCLUSIONnThe use of fibrin sealant is safe and effective in the sclerosis of postoperative lymphoceles.

Cancer-free survival and local tumor control after impendence-based radiofrequency ablation of biopsy-proven renal cell carcinomas with a minimum of 1-year follow-up

OBJECTIVESnThere are numerous reports describing the use of radiofrequency ablation (RFA) to treat renal cell carcinoma. Many series, however, describe heterogeneous populations, lack histologic descriptions, use various RFA systems, and indicate tumor destruction by different ablation end points. This study examined the outcomes of computed tomography-guided, impedance-based RFA of biopsy-proven renal cell carcinoma clinically staged as T1a with a minimum of 1 year of postablation follow-up.nnnMETHODS AND MATERIALSnThis retrospective study identified all consecutive patients who had undergone renal RFA since May 2005 at our institution. Patients without biopsy-proven renal cell carcinoma (RCCa) were excluded. Of the patients who met these criteria, evaluation was limited to patients with a minimum of 12 months of follow-up. Data collected from the patients electronic medical and radiologic records included demographic data, tumor-related data, procedural details, and clinical follow-up visits.nnnRESULTSnA total of 39 patients (46 lesions) met the inclusion criteria. The mean tumor diameter was 2.6 cm (range: 1.2-4.0 cm). The most common histologies were clear cell (n = 27) and papillary (n = 16) renal cancer. The lesion location was equally divided between upper pole (n = 16), middle pole (n = 16), and lower pole (n = 14). Overall, 83% of the tumors were exophytic. No residual or recurrent enhancing mass was identified in the ablation bed on post-RFA imaging during the mean follow-up period of 35.3 months (range: 12-83). All patients were treated in a single encounter and no lesion required a second ablation; technical success (absence of residual tumor) on the initial post-RFA imaging study was 46 of 46 (100%). Clinical success was achieved in 45 of 46 lesions (98%); residual, viable tumor was found in a pretransplant nephrectomy specimen on postprocedure day 127. The mean cancer-free survival was 36.2 months. Comparison of preablation and postablation renal function found no statistically significant change.nnnCONCLUSIONSnThe consistent outcomes in our post-RFA imaging and clinical surveillance allow us to offer image-guided ablation to patients with T1a RCCa as a valid treatment option offering long-term cancer-free survival. Impedance-based RFA in a carefully selected patient population with T1a RCCa is a reliable treatment option, with disease-free survival rates that are comparable to partial nephrectomy.

Tension Pneumothorax After Placement of a Tunneled Pleural Drainage Catheter in a Patient with Recurrent Malignant Pleural Effusions

A case of tension pneumothorax developed after placement of a tunneled pleural catheter for treatment of malignant pleural effusion in a patient with advanced lung cancer. The catheter placement was carried out by an experienced operator under direct ultrasound guidance, and the patient showed immediate symptomatic improvement with acute decompensation occurring several hours later. Possible mechanisms for this serious complication of tunneled pleural catheter placement are described, and potential strategies to avoid or prevent it in future are discussed.

Tunneled Hemodialysis Catheter Outcomes in Elderly Patients

PURPOSEnThis retrospective study evaluated tunneled catheter outcomes in patients aged 75 years and older undergoing hemodialysis.nnnMATERIALS AND METHODSnPatients aged 75 years or older receiving hemodialysis comprised the study group. A control group of patients 40-60 years of age was randomly selected from the same dialysis quality assurance database. Demographic data, medical comorbidities, and catheter-specific data regarding indwelling time, function, interventions, and complications were recorded.nnnRESULTSnSixty-nine tunneled catheters were identified in 23 patients who comprised the study group (13 men and 10 women; mean age, 81.3 years; range, 75-88 y). The mean number of catheters per patient was three (range, 1-8). The mean indwelling time was 137.4 days (range, 2-622 d). Seventy-eight catheters were identified in the control group (n = 29; 14 men and 15 women; mean age, 50.6 years; range, 41-59 y). The mean number of catheters per patient was 2.7 (range, 1-9). The mean indwelling time was 139.7 days (range, 1-994 d). There was no statistically significant difference in the mean number of catheters per patient (P = .83) or the mean indwelling time (P = .93) between the two groups. There was no significant difference between the two groups in the indications for catheter removal or exchange: infection (P = 1.0), catheter no longer needed (P = 1.0), and physical catheter malfunction (P = .48). The calculated infection rates in the elderly patient and younger control groups were 0.30 per 100 catheter-days and 0.26 per 100 catheter-days, respectively.nnnCONCLUSIONSnTunneled catheter outcomes in patients aged 75 years and older undergoing hemodialysis do not vary significantly compared with those in a younger cohort.

Image-Guided Embolization Coil Placement for Identification of an Endophytic, Isoechoic Renal Mass During Robotic Partial Nephrectomy

Abstract Background: Intraoperative ultrasonography has proven to be a useful tool for tumor identification during robot-assisted laparoscopic partial nephrectomy (RALPN). However, its utility is limited in renal tumors that are completely endophytic and isoechoic in nature. We present a novel approach to intraoperative tumor identification using preoperative percutaneous intratumoral embolization coil placement that may be utilized in the management of such cases. Case Presentation: A 42-year-old Caucasian male was referred with an incidentally discovered right renal mass that was posterior and completely endophytic. He desired a RALPN; however, preoperative renal ultrasound demonstrated an isoechoic lesion. Thus, the patient underwent preoperative image-guided placement of an embolization coil within the tumor. This facilitated identification of the tumor intraoperatively using intracorporeal ultrasound centered on the coil and enabled resection with negative margins. Conclusion: Utilizing a novel approach analogous to preoperative localization of other solid malignancies, such as breast cancer, we were able to effectively identify and resect an isoechoic renal mass during RALPN.

Access of Dysfunctional Arteriovenous Fistulas via Outflow Vein Side Branches

Editor: The patterns of stenosis in dysfunctional arteriovenous (AV) fistulas (AVFs) are not as predictable as in synthetic AV grafts. Accessing of AV fistula venous side branches has the potential to provide bidirectional access to the fistula and may reduce the need for multiple fistula puncture sites via the use of the technique described here. Institutional review board approval was not required for the present report. A 58-year-old man with stage 5 chronic kidney disease who underwent creation of a left radiocephalic AVF 4 months earlier was referred to the interventional radiology unit for evaluation of delayed maturation. The AVF was pulsatile, but no thrill was detected on palpation. There was no arm swelling or edema. Initial ultrasound (US) examination revealed moderate narrowing of the juxta-anastomotic fistula. A prominent venous side branch was identified in the mid-forearm, joining the cephalic vein at an approximately 901 angle (Fig 1). The branch was accessed by micropuncture technique under US guidance. The favorable angle with the outflow cephalic vein allowed treatment of the