D.A. Valenti

Insertion of PICCs with Minimum Number of Lumens Reduces Complications and Costs

BACKGROUNDnInappropriate catheter requests at the McGill University Health Centre (MUHC) led to significantly increased costs and early catheter malfunction or infection. Dual-lumen catheters were often requested and inserted when only a single lumen was required, and inappropriate catheter care on the wards led to early infection or thrombosis.nnnMETHODSnA full-time registered nurse was hired to analyze and transform the vascular access program of the MUHC. Catheter selection was streamlined on the basis of clinical unit need. Clinical and cost data were collected between May 2011 and January 2012.nnnRESULTSnRequests for vascular access at the MUHC have been standardized and centralized. Single-lumen catheters are inserted unless a specific indication for a dual-lumen catheter is provided. To date, data have been collected on >4,000 catheter insertions, both before and after the switch to the single-lumen program. Dual-lumen catheters have been required in only 50% of cases. Reinsertion rates have decreased, leading to the first year-over-year reduction in peripherally inserted central venous catheter insertion since data collection began in 2002. The program has also resulted in significant reductions in central line-associated bloodstream infection and catheter-related thrombosis. Decreased maintenance and reinsertion costs have led to overall savings for the MUHC of approximately

Cardiac embolization of an implanted fiducial marker for hepatic stereotactic body radiotherapy: a case report

1.1 million.

Aortic Calcification Progression in Heterozygote Familial Hypercholesterolemia

IntroductionIn liver stereotactic body radiotherapy, reduction of normal tissue irradiation requires daily image guidance. This is typically accomplished by imaging a surrogate to the tumor. The surrogate is often an implanted metal fiducial marker. There are few reports addressing the specific risks of hepatic fiducial marker implantation. These risks are assumed to be similar to percutaneous liver biopsies which are associated with a 1-4% complication rate - almost always pain or bleeding. To the best of our knowledge, we present the first case of such a fiducial marker migrating to the heart.Case presentationAn 81-year-old Caucasian man (5 years post-gastrectomy for a gastric adenocarcinoma) was referred post-second line palliative chemotherapy for radiotherapy of an isolated liver metastasis. It was decided to proceed with treatment and platinum fiducials were chosen for radiation targeting. Under local anesthesia, three Nester embolization coils (Cook Medical Inc., Bloomington, IN, USA) were implanted under computed tomography guidance. Before the placement of each coil, the location of the tip of the delivery needle was confirmed by computed tomography imaging. During the procedure, the third coil unexpectedly migrated through the hepatic vein to the inferior vena cava and lodged at the junction of the vena cava and the right atrium. The patient remained asymptomatic. He was immediately referred to angiography for extraction of the coil. Using fluoroscopic guidance, an EN Snare Retrieval System (Hatch Medical L.L.C., Snellville, GA, USA) was introduced through a jugular catheter; it successfully grasped the coil and the coil was removed. The patient was kept overnight for observation and no immediate or delayed complications were encountered due to the migration or retrieval of the coil. He subsequently went on to be treated using the remaining fiducials.ConclusionImplanted fiducial markers are increasingly used for stereotactic radiotherapy. There is sparse literature on the risks of such procedures. Although uncommon, the risk of migration does exist and therefore physicians (surgeons, oncologists and radiologists) and patients should be aware of this possibility.

Use of Platinum Embolization Coils for Targeting Liver Lesions in Stereotactic Body Radiotherapy/Radiosurgery

BACKGROUNDnPatients with homozygous and heterozygous familial hypercholesterolemia (HeFH) develop severe aortic calcifications in an age- and gene dosage-dependent manner. The purpose of this study was to determine the rate of progression of aortic calcification in patients with HeFH.nnnMETHODSnWe performed thoracoabdominal computed tomography scans and quantified aortic calcium (AoCa) score in 16 HeFH patients, all with the null low-density lipoprotein (LDL) receptor DEL15Kb mutation. Patients (12 men, 4 women) were rescanned an average of 8.2 ± 0.8 years after the first scan.nnnRESULTSnMean LDL cholesterol (LDL-C) during treatment was 2.53 mmol/L; all patients were receiving high-dose statin/ezetimibe; 5 of 16 were receiving evolocumab. Baseline LDL-C was 7.6 ± 1.3 mmol/L. Aortic calcifications increased in all patients in an exponential fashion with respect to age. Age was the strongest correlate of AoCa score. Cholesterol, LDL-C, or agexa0× cholesterol did not correlate with AoCa score or its progression. Control patients (nxa0= 31; 8 male, 23 female; mean age 61 ± 11 years) who underwent virtual colonoscopy were rescanned over the same period and showed an abdominal AoCa score of 1472 ± 2489 compared with 7916 ± 7060 Agatston U (P < 0.001) in patients with HeFH during treatment (mean age, 60 ± 14 years). The rate of progression was 159 vs 312 Agatston U/y in control participants vs those with HeFH.nnnCONCLUSIONSnHeFH patients exhibit accelerated aortic calcification that increases exponentially with age. LDL-C at baseline or during treatment seems to have little effect on the rate of progression of AoCa score. Strategies to prevent aortic calcifications with statins have not met with clinical success and novel approaches are required; statins might also contribute to the process of arterial calcification.

Superior Hypogastric Nerve Block as Post–Uterine Artery Embolization Analgesia: A Randomized and Double-Blind Clinical Trial

Background: Liver lesions cannot be directly visualized at the time of radiation treatments using conventional imaging techniques. Metal markers are often used as surrogates of tumo

Retrospective review of intrapleural therapy for pleural infections: “Real life” outcomes and challenges

Purpose To evaluate the effectiveness of superior hypogastric nerve block (SHNB) in reducing narcotic use after uterine artery embolization (UAE). Materials and Methods This study was a prospective, randomized, double-blind, parallel clinical trial in patients referred to a tertiary care university teaching hospital for UAE. Forty-four participants were enrolled (mean age, 46 years; range, 32-56 years). No consenting patient was excluded. All participants were randomized 1:1 to undergo either a sham procedure or SHNB. There were 22 participants in each group. One participant was lost to follow-up regarding home survey results. Use of narcotics and antiemetics was recorded in-hospital. Pain scores were recorded at home for 10 days with use of a visual analog scale (range, 1-10). Statistical analysis was performed by using the t test and χ2 test, with P < .05 considered indicative of a statistically significant difference. The full study protocol can be found at www.clinicaltrials.gov (NCT02270255). Results Participant demographic characteristics, fibroid volume, symptoms, and perceived sensitivity to pain were similar in both groups. Immediately after embolization, the pain score was lower in the SHNB group than in the sham group (mean, 1.0 ± 2.1 vs 2.6 ± 2.0, respectively; P = .01). The total need for fentanyl in the postanesthesia care unit was lower in the SHNB group than in the sham group (mean, 56 μg ± 67 vs 124 μg ± 91, respectively; P = .009). The morphine-equivalent dose needed was lower in the SHNB group than in the sham group (mean, 5.1 mg ± 5.8 vs 11.0 mg ± 9.0, respectively; P = .014). Of the 22 participants in the SHNB group, five (23%) needed antiemetics versus 12 of 22 participants (55%) in the sham group (P = .03). No difference in hospital admissions was observed between the two groups, and no major complications occurred from the SHNB. Conclusion Use of superior hypogastric nerve block reduces the amount of pain-related narcotics and antiemetics after uterine artery embolization.

Percutaneous cholecystostomy: A simple bridge to surgery or an alternative option for the management of acute cholecystitis?

Abstract RATIONALE: The mainstay of treatment for pleural infections includes antibiotics, chest tube drainage and intrapleural fibrinolytics (tPA) and mucolytics (DNase). We aimed to review the outcomes of patients treated with intrapleural therapy for pleural infection at our institution. METHODS: We conducted a single-center retrospective review of adults who received intrapleural tPA/DNase for a pleural infection from 2013 to 2016. Cases were identified through the pharmacy database. RESULTS: A total of 109 patients were eligible for analysis. Treatment with tPA/DNase was successful in 85 patients (78.0%), using the composite outcome of survival to hospital discharge without the need for surgery. Median length of stay, from first dose of tPA/DNase to discharge (or death), was 10.5u2009days. The rate of surgical intervention was 13.8% and intrahospital mortality was 11.0%. Additionally, the mean delay from the detection of effusion to chest drain insertion was 3.5u2009days and the mean delay from chest drain insertion to the initial dose of tPA/DNase was 5.0u2009days. Insertion of a second chest drain was needed in 61.5% of patients, most commonly for upsizing. A low proportion of patients (25.3%) benefited from a complete first cycle course of intrapleural therapy. At least one serious adverse event related to tPA/DNase therapy happened in 13.5% of patients. CONCLUSION: In this retrospective study, outcomes of intrapleural tPA/DNase for pleural infections were less favorable than previously reported. Delays at various steps in the management, suboptimal adherence to treatment and complications were identified. These issues are currently being targeted with quality improvement initiatives.

Interventional Radiology in Canada: Current Challenges and Future Directions

BACKGROUNDnPercutaneous cholecystostomy (PC) is an alternative among high-risk surgical patients or those with multiple comorbidities, but its indications have not been clearly established in the literature. The aim of this paper is to provide the reader with an updated review of the literature summarizing what is known on this topic.nnnDATA SOURCESnWe reviewed articles from 1979 to 2016 using the PubMed/Medline Database on PC and especially those evaluating this option as a bridge to surgery.nnnCONCLUSIONSnThere remains a paucity of randomized control trials to ascertain the use of PC as a definitive treatment for acute cholecystitis. In most studies, more than 50% of patients underwent PC as a definite treatment without subsequent cholecystectomy. A newer avenue of endoscopic ultrasound is also discussed, which requires rigorous trials to determine its appropriate applications.

Circle nephrostomy tube revisited

OBJECTIVEnWe aim to define the practice of interventional radiology (IR) in Canada, barriers that have been faced by interventional radiologists, and ways in which the Canadian Interventional Radiology Association (CIRA) have attempted to address these issues.nnnCONCLUSIONnIR has faced significant challenges in the Canadian setting. Recognizing the need to address these challenges, leaders in the field of IR in Canada founded the CIRA to serve as our national voice and lobby group.

Bidirectional asynchronous arterial flow in monochorionic twins – a precursor to the twin reverse arterial perfusion sequence

INTRODUCTIONnThere are few options for patients requiring chronic urinary drainage using nephrostomy tubes. Although circle nephrostomy tube (CNT) was invented in 1954, it is rarely used. Its advantages include longer indwelling time such that it is changed semi-annually when compared with the standard nephrostomy tube (SNT), which is changed monthly. However, there are no studies comparing indwelling times and costs with these two tubes. The aim of the present study was to compare CNT with SNT in terms of frequency of tube changes, reasons for earlier tube changes, and associated costs.nnnMETHODSnPatients who had CNT inserted between 2009 and 2015 were reviewed. The indications for chronic indwelling nephrostomy tubes were tabulated. The frequency of tube changes was compared between CNT and SNT in the same patients. Furthermore, costs associated with insertion and exchange of CNT and SNT were analyzed.nnnRESULTSnSeven patients with mean age of 71.9 ± 7.6 years (range 43-96) had a total of 36 CNT changes. The mean number of CNT changes was four (range 2-5) at a mean interval of 168.3 ± 15.6 days (range 120-231). All patients had SNT prior to converting to CNT. When compared with the mean interval for SNT changes, the mean interval for CNT changes was significantly longer (44.8 ± 19.4 vs. 168.3 ± 41.3 days; p=0.028). Tube blockage and urinary leakage were the most common reasons for earlier than scheduled CNT changes. In our centre, CNT insertion and exchange cost