Carlos J. Guevara

US-Guided, Direct Puncture Retrograde Thoracic Duct Access, Lymphangiography, and Embolization: Feasibility and Efficacy.

PURPOSE To describe technical details, success rate, and advantages of direct puncture of the thoracic duct (TD) under direct ultrasound (US) guidance at venous insertion in the left neck. MATERIALS AND METHODS All patients who underwent attempted thoracic duct embolization (TDE) via US-guided retrograde TD access in the left neck were retrospectively reviewed. Indications for lymphangiography were iatrogenic chyle leak, pulmonary lymphangiectasia, and plastic bronchitis. Ten patients with mean age 41.4 years (range, 21 d to 72 y) underwent US-guided TD access via the left neck. Technical details, procedural times, and clinical outcomes were evaluated. TD access time was defined as time from start of procedure to successful access of TD, and total procedural time was defined from start of procedure until TDE. RESULTS All attempts at TD access via the neck were successful. Technical and clinical success of TDE was 60%. There were no complications. Mean TD access time was 17 minutes (range, 2-47 min), and mean total procedure time was 49 minutes (range, 25-69 min). Mean follow-up time was 5.4 months (range, 3-10 months). CONCLUSIONS TDE via US-guided access in the left neck is technically feasible and safe with a potential decrease in procedure time and elimination of oil-based contrast material.

Technically Successful Geniculate Artery Embolization Does Not Equate Clinical Success for Treatment of Recurrent Knee Hemarthrosis after Knee Surgery.

PURPOSE To evaluate technical details, clinical outcomes, and complications in patients undergoing geniculate artery embolization for treatment of spontaneous hemarthrosis after knee surgery. MATERIALS AND METHODS During 2009-2014, 10 consecutive patients (seven women; mean age, 57.4 y) underwent geniculate artery embolization at a single tertiary care center. All patients except one had hemarthrosis after total knee replacement (TKR). One patient presented with hemarthrosis after cartilage surgery. Two patients in the TKR group had a history of TKR revisions before the embolization. Embolization was performed with polyvinyl alcohol particles (range, 300-700 µm). In one patient requiring repeat embolization, N-butyl cyanoacrylate/ethiodized oil was used. The endpoint for embolization was stasis in the target artery and elimination of the hyperemic blush. RESULTS In 10 patients, 14 embolizations were performed with 100% technical success. Hemarthrosis resolved in six patients. Four patients required repeat embolization for recurrent hemarthrosis, which subsequently resolved in two of four patients. Three of the four patients who required repeat embolization had serious comorbidities, either blood dyscrasias or therapeutic anticoagulation. There were two minor skin complications that resolved with conservative management. The average length of follow-up after embolization was 545 days (range, 50-1,655 d). One patient was lost to follow-up. CONCLUSIONS Geniculate artery embolization is a safe, minimally invasive treatment option for spontaneous and refractory knee hemarthrosis after knee surgery with 100% technical success. However, limited clinical success and higher repeat embolization rates were noted in patients with serious comorbidities.

An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations

We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.