Christian Sengel

Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures.

OBJECTIVE The purpose of this study was to describe a blinded intra-aortic balloon occlusion (IABO) procedure in pelvic fractures (PF) for patients with critically uncontrollable hemorrhagic shock (CUHS). METHODS Of 2,064 patients treated for PF, 13 underwent IABO during initial resuscitation to control massive pelvic bleeding leading to CUHS. Our IABO procedure consists of internal aortic occlusion without fluoroscopy, using a latex balloon inflated in the infrarenal aorta. Retrospectively collected data included demographics, fracture classification, additional injuries, blood transfusions, surgical interventions, angiographic procedure, physiologic parameters, and survival. RESULTS All balloons were successfully placed, and a significant increase in systolic blood pressure (70 mm Hg, p = 0.001) was observed immediately after IABO. Twelve of 13 patients became transferrable. Angiography performed after IABO was positive for arterial injury in 92% of patients, and 9 patients benefitted from arterial embolization. Survival rate was 46% (6 of 13) and was inversely related to the length of inflation (p = 0.026) and the mean Injury Severity Score (p = 0.011). CONCLUSION This IABO procedure can be life saving in the management of patients with CUHS from PF, permitting transport to angiography. However, the decision for such treatment must be as quickly as possible after trauma to reduce the time of occlusion.

Blunt splenic injury: Outcomes of proximal versus distal and combined splenic artery embolization

PURPOSE To assess clinical outcomes of blunt splenic injuries (BSI) managed with proximal versus distal versus combined splenic artery embolization (SAE). MATERIALS AND METHODS All consecutive patients with BSI admitted to our trauma centre from 2005 to 2010 and managed with SAE were reviewed. Outcomes were compared between proximal (P), distal (D) or combined (C) embolization. We focused on embolization failure (splenectomy), every adverse events occurring during follow up and material used for embolization. RESULTS Fifty patients were reviewed (P n = 18, 36%; D n = 22, 44%; C n = 8, 16%). Mean injury severity score was 20. The technical success rate was 98%. Four patients required splenectomy (P n = 1, D n = 3, C n = 0). Clinical success rate for haemostasis was 92% (4 re-bleeds: P n = 2, D n = 2, C n = 0). Outcomes were not statistically different between the materials used. Adverse events occurred in 65% of the patients during follow up. Four percent of the patients developed major complications and 56% developed minor complications attributable to embolization. There was no significant difference between the 3 groups. CONCLUSION SAE had an excellent success rate with adverse events occurring in 65% of the patients and no significant differences found between the embolization techniques used. Proximal preventive embolization appears to protect in high-grade traumatic injuries.

Arterial Embolization in the Management of Mesenteric Bleeding Secondary to Blunt Abdominal Trauma

IntroductionMesenteric bleeding is a rare but potentially life-threatening complication of blunt abdominal trauma. It can induce active hemorrhage and a compressive hematoma leading to bowel ischemia. Emergency laparotomy remains the gold standard treatment. We aimed to study the effectiveness and complications of embolization in patients with post-traumatic mesenteric bleeding.Materials and MethodsThe medical records of 7 consecutive patients with active mesenteric bleeding treated by embolization in a level-one trauma center from 2007 to 2014 were retrospectively reviewed. All patients presented with active mesenteric bleeding on CT scans without major signs of intestinal ischemia. We focused on technical success, clinical success, and the complications of embolization.ResultsSix endovascular procedures were successful in controlling hemorrhage but 1 patient had surgery to stop associated arterial and venous bleeding. One patient suffered from bowel ischemia, a major complication of embolization, which was confirmed by surgery. No acute renal failure was noted after angiography. For 1 patient we performed combined management as the endovascular approach allowed an easier surgical exploration.ConclusionIn mesenteric trauma with active bleeding, embolization is a valuable alternative to surgery and should be considered, taking into account the risk of bowel ischemia.

Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?

PURPOSE We aimed to compare clinical outcomes and early adverse events of operative management (OM), nonoperative management (NOM), and NOM with splenic artery embolization (SAE) in blunt splenic injury (BSI) and identify the prognostic factors. METHODS Medical records of 136 consecutive patients with BSI admitted to a trauma center from 2005 to 2010 were retrospectively reviewed. Patients were separated into three groups: OM, NOM, and SAE. We focused on associated injuries and early adverse events. Multivariate analysis was performed on 23 prognostic factors to find predictors. RESULTS The total survival rate was 97.1%, with four deaths all occurred in the OM group. The spleen salvage rate was 91% in NOM and SAE. At least one adverse event was observed in 32.8%, 62%, and 96% of patients in NOM, SAE, and OM groups, respectively (P < 0.001). We found significantly more deaths, infectious complications, pleural drainage, acute renal failures, and pancreatitis in OM and more pseudocysts in SAE. Six prognostic factors were statistically significant for one or more adverse events: simplified acute physiology score 2 ≥25 for almost all adverse events, age ≥50 years for acute respiratory syndrome, limb fracture for secondary bleeding, thoracic injury for pleural drainage, and at least one associated injury for pseudocyst. Adverse events were not related to the type of BSI management. CONCLUSION Patients with BSI present worse outcome and more adverse events in OM, but this is related to the severity of injury. The main predictor of adverse events remains the severity of injury.

Stent-graft Narrowed with a Lasso Catheter: An Adjustable TIPS Reduction Technique

The authors describe an endovascular technique to reduce shunt diameter in the management of transjugular intrahepatic portosystemic shunt (TIPS)-induced refractory hepatic encephalopathy. Five patients were treated with a constrained stent-graft by using a commercially available balloon-expandable stent-graft narrowed by using a lasso catheter. This offers the possibility of an adjustable reduction of the shunt diameter. All procedures were technically successful, resulting in a significant increase in the portosystemic gradient and reopacification of the intrahepatic portal vein branches, findings that correlated with clinical improvement. This technique provides the ability to titrate the portosystemic gradient to the desired endpoint during shunt reduction.

Polytraumatism and solid organ bleeding syndrome: The role of imaging

In multiple injuries, features of bleeding from solid organs mostly involve the liver, spleen and kidneys and may be treated by embolization. The indications and techniques for embolization vary between organs and depend on the pathophysiology of the injuries, type of vascularization (anastomotic or terminal) and type of embolization (curative or preventative). Interventional radiologists should have a full understanding of these indications and techniques and management algorithms should be produced within each facility in order to define the respective place of the different treatment options.

Carcinome hépatocellulaire à stroma lymphoïde extrahépatique: À propos d’un cas

Hepatocellular carcinoma (HCC) with lymphocytic infiltration is a rare entity recently described, sometimes associated with hepatitis C. Histologically, remarkable inflammatory cell infiltration of cancer nests is observed, mostly composed of T cytotoxic lymphocytes. When prominent, this inflammatory cell component can obscure the neoplastic cells, leading to diagnostic difficulty. Alike tumors showing dense lymphocytic infiltrate, it discloses a better prognosis than other HCC. We report a case of HCC with lymphocytic infiltration arising in the right suprarenal space, in a 45-year-old man with no chronic liver disease. The patient is alive without recurrence three years after surgical resection. This report is original because HCC growing ectopically are rare and need to be distinguished, specially in the right retroperitoneal, from metastatic adrenal HCC.

Prostatic Fragment Requiring Endoscopic Management After Prostatic Artery Embolization for Indwelling Bladder Catheter

Dear Editor, We read with interest the paper by Moreira et al. [1], published recently in Cardiovascular and Interventional Radiology (CVIR), concerning expected and nonexpected adverse events following prostatic artery embolization (PAE). This procedure has gained in popularity in the last few years due to its low rate of morbidity and the low risk of sexual dysfunction after the intervention. It is especially useful for patients with an enlarged prostate who are not suitable for surgery. After the procedure, voiding of small prostatic gland fragments has been rarely reported, with a favorable outcome after spontaneous expulsion [2, 3]. We report the case of a patient with large prostatic fragments after embolization, requiring endoscopic retrieval. This 78-year-old man presented acute urinary retention in August 2016, during hospitalization for stroke. Catheter removal had failed, and he retained an indwelling urinary catheter. He was treated with anticoagulation and antiplatelet therapy, but considering the hemorrhagic risk, he was not eligible for surgery. A multidisciplinary team considered that PAE was an option. Preoperative MRI revealed an enlarged prostatic gland estimated at 160 ml without contraindication to the procedure. Embolization was performed in an interventional suit (Artis Zeego, Siemens, Germany) using right femoral artery access. A cone beam CT with a pigtail catheter in the distal aorta was used to plan the procedure. The left prostatic artery was branched from a common vesico-prostatic trunk, and the right prostatic artery trifurcated from the anterior hypogastric trunk. These two arteries were catheterized using a 2.0 French microcatheter (Progreat, Terumo, Japan). Embolization was performed using the ‘‘Proximal Embolization First, Then Embolize Distal’’ (PERFECTED) technique with 5 ml of 250 lm Embozene microspheres (Boston Scientific, Natick, Massachusetts, USA) for the left side and 5 ml for the right side. Immediate postoperative care was straightforward, and the patient was discharged the following day without any early complication. Three weeks after the procedure, the urinary catheter was successfully removed. During the next 3 months, the patient reported worsening of the urinary symptoms, & Julien Ghelfi JGhelfi@chu-grenoble.fr

Is There a Place for Repeat Lymphangiography in Postoperative Chylous Ascites

Dear Editor, We read with interest the article by Nadolski et al. concerning lymphatic embolization for the treatment of refractory chylous ascites [1]. While lymphangiography alone has a therapeutic effect in some cases, embolization [1] or sclerotherapy [2] shows better results. We report the case of a large chylous ascites occurring after ovarian surgery with lymph node resection, successfully treated by two lymphangiography sessions that revealed two different leaks. A 55-year-old female presented with ovarian malignancy that was treated with extensive pelvic surgery. One month after the surgery, the patient suffered from abdominal pain and distension. A CT scan revealed a voluminous peritoneal fluid collection of 25 cm (Fig. 1) requiring percutaneous drainage that evacuated 7 L of chylous liquid. Despite dietary therapy and fasting, the leakage remained. An intranodal lymphangiography was planned [3] with bilateral inguinal punctures using 25-G needles. Lymphangiography revealed extensive leakage from the left external iliac lymph node resection (Fig. 2). By the end of the lymphangiography using Lipiodol Ultra-Fluide (Guerbet, Villepinte, France), the leakage had disappeared. The patient was discharged the following day. Lymphatic leakage persisted with an output of about 3 L per week. A second lymphangiography was planned, using a left inguinal approach (Fig. 2), as the first leakage was on the left iliac lymph nodes. This revealed a second leak downstream of a pre-obturative lymph node. After a cone beam computed tomography acquisition (CBCT), the lymph node was punctured under CT guidance (Fig. 3) and opacification confirmed the leak. Local anaesthetic was injected in

Complication majeure d’un traitement par radiofréquence d’une tumeur bronchique inopérable

Resume Introduction La chirurgie reste le seul traitement curatif du carcinome bronchique primitif non a petites cellules. Elle concerne majoritairement des lesions de petite taille. Or, certains patients presentent une contre indication a la chirurgie. La radiofrequence est alors une alternative peu invasive et rarement compliquee. Elle se pratique sous anesthesie generale par un abord percutane. Les principales complications sont d’ordre mecanique avec essentiellement des pneumothorax. Les complications infectieuses sont peu frequentes et, en general, peu severes. Observation Nous rapportons le cas d’un sujet traite par radiofrequence pour une tumeur bronchique de petite taille. Le geste s’est complique de facon precoce d’une infection de la zone traitee rapidement disseminee aux deux champs pulmonaires necessitant une antibiotherapie lourde et prolongee. La resolution de l’infection a ete lente sous traitement adapte. Sa rapidite d’installation et de dissemination s’explique par le traitement fortement immunosuppresseur du patient. Conclusion La radiofrequence des tumeurs bronchiques est une technique recente et qui connait un fort developpement. Bien qu’elle soit grevee d’une faible morbi-mortalite, la possibilite de complications infectieuses potentiellement letales chez certains patients fragiles doit etre connue.