Danial Jilani

Radiologically Guided Placement of Mushroom-retained Gastrostomy Catheters: Long-term Outcomes of Use in 300 Patients at a Single Center

PURPOSE To assess long-term outcomes including risk of complications and nutritional benefits of mushroom-retained (pull-type) gastrostomy catheters placed in patients by interventional radiologists. MATERIALS AND METHODS All patients who received pull-type gastrostomy tubes between 2010 and 2013 were retrospectively reviewed, including 142 men (average weight, 169.6 lb [76.32 kg]; mean age, 65.2 years; range, 22-92 years) and 158 women (average weight, 150.4 lb [67.68 kg]; mean age, 65.2 years; range, 18-98 years). Indications for placement were cerebrovascular accident (n = 80), failure to thrive (n = 71), other central nervous system disorder (n = 51), head and neck cancer (n = 47), and other malignancy (n = 51). Complications were recorded per Society of Interventional Radiology practice guidelines. Patient weight was documented at specific follow-up intervals. Statistical analysis was performed by using the Student t test and one-way analysis of variance for the effects of sex and indication for placement, respectively, on average weight change. RESULTS The technical success rate was 98.4% (300 of 305 patients). Major and minor complications occurred at a rate of 3.7% (n = 11) and 13% (n = 39), respectively. Follow-up weight during the early (≤45 days), intermediate (≤180 days), and long-term (>180 days) periods was available for 71% (n = 214), 36% (n = 108), and 15% (n = 44) of the 300 patients, respectively. Weight gain occurred in 77% (160 of 214), 60% (65 of 108), and 73% (32 of 44) of the patients, respectively. Patients who gained weight gained 6.7, 10.6, and 16.3 lb (3.02, 4.77, and 7.34 kg) during each follow-up period, respectively. Average weight gain at follow-up in all patients was 4.2, 0.6, and 5.4 lb (1.89, 0.27, and 2.43 kg), respectively. No significant differences in average weight change were seen among groups when they were classified according to sex or indication for placement. CONCLUSION Placement of mushroom-retained gastrostomy catheters is a viable long-term treatment option for enteral nutrition, with complication rates similar to those reported for other gastrostomy techniques. Improvement in nutrition status measured as weight gain was seen in most patients in both early and long-term periods.

Effectiveness of Collateral Vein Embolization for Salvage of Immature Native Arteriovenous Fistulas

PURPOSE To investigate the value of collateral vein embolization (CVE) as a salvage treatment for nonmaturing native arteriovenous fistulae (AVFs) in patients requiring hemodialysis. MATERIALS AND METHODS A total of 49 patients undergoing CVE (N = 65) for immature native AVFs at a single institution were reviewed. The study included 42 patients treated by 56 embolizations. Average fistula age at time of intervention was 18.2 weeks. Each patient underwent angiographic evaluation for fistula immaturity, with clinical success defined by initiation of single-session hemodialysis through the native fistula. RESULTS Fistula maturity was achieved in 32 of 42 patients (76.2%). No major complications occurred. Average time from CVE to fistula maturity was 38.4 days. Angioplasty done with CVE was found in a statistically higher percentage of patients with fistula success versus failure (31.3% vs 8.3%; P = .039). Radiocephalic fistulae were seen in a higher percentage of fistula failures compared with successes, but the results were not statistically significant (83.3% vs 59.4%; P = .054). Thirty-four patients underwent CVE without angioplasty, which resulted in successful fistula maturation in 22 cases (64.7%). Radiocephalic fistulae were again seen in a higher percentage of fistula failures compared with successes, but the findings did not meet statistical significance (81.8% vs 54.5%; P = .052). CONCLUSIONS Coil embolization of competing collateral vessels as a salvage treatment for nonfunctioning autologous AVFs is a viable treatment option in the majority of patients. Patients with radiocephalic fistulae may be at higher risk for primary fistula failure, but the present data are inconclusive.

Comparison of Barbed versus Conventional Sutures for Wound Closure of Radiologically Implanted Chest Ports

PURPOSE To retrospectively compare the incidences of complications with barbed suture versus conventional interrupted suture for incision closure in implantable chest ports. MATERIALS AND METHODS A total of 715 power-injectable dual-lumen chest ports placed between 2011 and 2013 were studied. Primary outcomes included wound dehiscence, local port infection, local infections treated by wound packing, early infections within 30 days, and total infections. A multivariate analysis of independent risk factors for port infection was also performed. RESULTS A total of 442 ports were closed with nonbarbed suture, versus 273 closed with barbed suture. Mean catheter-days in the traditional and barbed groups were 257.9 (range, 3-722) and 189.1 (range, 13-747), respectively (P < .01). The rate of dehiscence with traditional suture (1.6%; seven of 442) was significantly higher than that with barbed suture (zero of 273; P = .04). Percentage of total infections was also significantly higher with traditional suture (9.5% vs 5.1%; P = .03). No difference in rate of infection per 1,000 catheter-days was seen between traditional and barbed suture groups (0.0035 vs 0.0026; P = .17). The rate of local infection with traditional suture was significantly higher (2.7% vs 0.4%; P = .02). Additionally, multivariate analysis identified the use of traditional suture as the only independent risk factor for infection (39% vs 25%; P = .03). CONCLUSIONS Barbed suture for incision closure in implantable dual-lumen chest ports was associated with lower rates of dehiscence and potentially lower rates of local infectious complications compared with traditional nonbarbed suture.

Computed tomography-guided percutaneous lung biopsy: impact of lesion proximity to diaphragm on biopsy yield and pneumothorax rate.

Purpose: The purpose of this study was to investigate the impact of lesion proximity to the diaphragm on computed tomography (CT)-guided percutaneous biopsy yield and pneumothorax rates. Materials and Methods: An Institutional Review Board–approved retrospective review of all CT-guided percutaneous core lung biopsies at a single institution performed between August 1, 2011 and July 31, 2013 yielded 168 patients who underwent a total of 174 lung biopsies. The shortest distance of the target lesion from the diaphragm was measured on preprocedure sagittal reformatted CT images. Pathology and 2-hour postprocedure chest radiograph results were then collected from these patients. Results: The average distance of the target lesion from the diaphragm was 8.3 cm, and biopsies resulted in nondiagnostic pathology in 27 (16%) cases. Proximity to the diaphragm was a significant predictor of nondiagnostic biopsy, with the odds of a successful biopsy increased by 67% for every 5 cm the target lesion is farther from the diaphragm (P=0.026). Distance from the diaphragm was not a significant predictor of postbiopsy pneumothorax or need for chest tube placement. These relationships hold true after adjusting for patient demographic parameters, presence of emphysema, operator level of experience, distance of the lesion from the pleural surface, target lesion size, and cavitary nature. Conclusions: The odds of nondiagnostic biopsy increase for lesions closer to the diaphragm; however, the odds of pneumothorax are not significantly different.

Bronchial artery embolization for malignant hemoptysis: a single institutional experience

OBJECTIVE To assess the effectiveness of bronchial artery embolization (BAE) in patients with malignant hemoptysis. METHODS An IRB-approved retrospective study at our academic institution was conducted on all patients treated by BAE for hemoptysis from lung malignancy. Outcome and safety measures were documented according to Society of Interventional Radiology (SIR) practice guidelines. RESULTS A total of 26 patients (13 male, 13 female) with lung malignancy underwent BAE for hemoptysis from 2003-2013. Histologic analysis revealed 80% (21/26) of cases were from primary lung malignancies, while the remaining 20% (4/26) represented metastatic disease. Sixty-five percent (17/26) of patients underwent bronchoscopy prior to BAE. Follow-up ranged from 2 to 1,909 days, with average of 155 days. Technical success was achieved in 77% of patients (20/26). Clinical success rate was 75% (15/20). Eighty-five percent of embolized patients (17/20) were treated with particles, 15% (3/20) with gelfoam, and 20% (4/20) with coils. Single-vessel embolization was performed in 70% (14/20), two-vessel in 20% (4/20), and multiple vessels in 10% (2/20). No complications were reported. Six-month all-cause mortality of treated cases was 55% (11/20) with an in-hospital mortality of 25% (5/20). Ten percent (2/20) had remote re-bleeding events beyond 6 months. Statistically significant predictors of mortality were intubation status, hemoglobin/hematocrit at presentation, and thrombocytopenia. CONCLUSIONS BAE is a safe and useful treatment for clinically significant hemoptysis in patients with primary or metastatic lung masses despite high overall mortality. Intubation status, low hemoglobin/hematocrit, and thrombocytopenia may represent clinical predictors of short term mortality following BAE. ADVANCES IN KNOWLEDGE Most patients undergoing BAE for malignant hemoptysis achieve high clinical success despite suffering a high mortality from underlying disease.

Long-term results of microcoil embolization for colonic haemorrhage: how common is rebleeding?

OBJECTIVE To determine the long-term results of patients undergoing transcatheter coil embolization for the treatment of acute colonic haemorrhage. METHODS Patients undergoing angiography for suspected colonic bleeding between January 2002 and December 2012 were reviewed (average age, 60 years; 38.4% male). Baseline, procedural and outcome parameters were recorded following the Society of Interventional Radiology guidelines. Primary outcome measures included early (<30 days) and delayed (>30 days) rebleeding events and adverse procedure-related complication. Average follow-up time was 996 days (median, 232 days; range, 30-3663 days). RESULTS One or multiple sites of bleeding were identified in 40 cases. Coil embolization was performed in 39 patients, 26 (66.7%, 26/39) of whom were treated successfully without technical/clinical failure (n = 12) or loss to follow-up (n = 1). Three patients (11.5%, 3/26) rebled in the early period within 30 days; one patient went on to hemicolectomy. Four patients (15.3%, 4/26) experienced delayed rebleeding after 30 days; two of whom also underwent hemicolectomy. No major complication occurred. One minor complication of short segment arterial dissection was seen in the clinical failure group. One case of asymptomatic ischaemia was identified on a patient undergoing pre-operative colonoscopy for elective bowel resection. No instances of ischaemic stricture were seen. All-cause mortality of successfully treated and all patients at 1 year was 31% (8/26) and 30% (12/40), respectively. CONCLUSION Transcatheter coil embolization is a durable treatment option with a technical and clinical success rate of 67% in the setting of acute colonic haemorrhage. A modest level of rebleeding was seen among successfully treated patients in both the early and delayed periods; in the majority of patients, embolization proved to be definitive therapy. ADVANCES IN KNOWLEDGE Transcatheter coil embolization is a durable and potentially definitive therapy in the management of acute colonic haemorrhage.

Core Lung Biopsy for Biomarker Analysis: Is There Increased Risk Compared With Conventional Biopsy?

Purpose: The aim of the study was to compare the rate of pneumothorax and chest tube placement in patients undergoing conventional lung biopsy with those undergoing core lung biopsy for biomarker analysis. Materials and Methods: Twenty-three patients had biopsies performed for biomarker analysis (5 male, 18 female patients, mean age 67 y), and 173 patients underwent standard diagnostic lung biopsy (86 male, 87 female patients, mean age 68 y). All biopsies were performed under computed tomography guidance using the coaxial technique (19 G introducer needle and 20 G core biopsy needle). The number of core samples was noted for each case, and all complications were recorded in accordance with Society of Interventional Radiology guidelines. Results: In the biomarker analysis group, a mean of 5.1 core samples (range, 1 to 10) was obtained. In the conventional biopsy group, a mean of 2.9 core samples (range, 1 to 6) was obtained. The pneumothorax rate was 37.6% in the conventional biopsy group and 30.4% in the biomarker analysis group (P=0.505). The rate of chest tube placement was 16.8% in the conventional biopsy group and 8.7% in the biomarker analysis group (P=0.319). Lesion size was found to be an independent predictor of pneumothorax (P=0.031), whereas biopsy tract length was found to be an independent predictor of both pneumothorax (P<0.001) and chest tube placement (P=0.005) upon multivariate analysis. Conclusions: There is no statistically significant difference in the incidence of pneumothorax or chest tube placement between patients undergoing standard diagnostic lung biopsy and those requiring increased core samples for biomarker analysis.

Imaging Unusual Causes of Pancreatitis

Acute pancreatitis occurs when pancreatic enzymes are prematurely activated within the acinar cells leading to pancreatic inflammation, which can cause abdominal pain, nausea, vomiting, and other systemic symptoms. Despite technological advances and improvement in critical care, the mortality rate of treated severe pancreatitis has failed to decline. Traditionally, imaging has played a role not only in assessing the severity of pancreatitis but also in recognizing its associated complications, such as pancreatic necrosis and pseudocyst formation. Furthermore, in certain circumstances, imaging may help identify the etiology of acute pancreatitis. Although alcoholism and cholelithiasis account for up to 75% of cases of acute and chronic pancreatitis, there are other unusual causes of pancreatitis. These unusual causes can have unique imaging features, although they are otherwise clinically indistinguishable. Unusual causes of pancreatitis include but are not limited to pancreatic divisum, inflammation of heterotopic pancreatic tissue, autoimmune pancreatitis, groove pancreatitis, and pancreatitis secondary to an underlying malignancy.