G. Louis

Ethylene vinyl alcohol copolymer (Onyx®) in peripheral interventional radiology: indications, advantages and limitations.

Onyx(®) is a remarkable liquid embolizing agent that may allow a well-trained operator to undertake challenging embolization procedures. In multiple interventional radiology indications, the physico-chemical properties of Onyx(®) allow safe embolization. The purpose of this article is to review the advantages and disadvantages of Onyx(®) and identify its main indications.

Prognostic value of preoperative coronary computed tomography angiography in patients treated by orthotopic liver transplantation.

Objectives The aim of this study was to assess the feasibility of 64-slice coronary computed tomography (CT) angiography in patients treated by orthotopic liver transplantation, and to compare prognostic values of CT angiography and dobutamine stress echocardiography in the same population. Methods Eighty-two consecutive patients, without known coronary artery disease, who underwent orthotopic liver transplantation, were included in this study. A CT angiography was performed along with usual explorations including dobutamine stress echography. A one-year minimal follow-up was performed to seek cardiac events. Results Fifty-two (65.8%) patients underwent a CT angiography. Thirty-seven (71%) were totally normal or showed nonobstructive coronary plaque, six (12%) showed at least one obstructive coronary plaque greater than 50%. Nine (17%) of the examined patients had at least one nonassessable segment. A total of six (7.6%) major cardiac events occurred in a mean-time follow-up of 17.8±12.7 months. Conclusion CT angiography that is normal or with a nonobstructive coronary plaque has a negative predicting value of 95% [0.82–0.99] for major cardiac adverse events, and of 100% [0.91–1] for clinical coronary events in patients undergoing orthotopic liver transplantation. The prognostic value of CT angiography was comparable with that of dobutamine stress echography.

Image fusion-guided portal vein puncture during transjugular intrahepatic portosystemic shunt placement.

PURPOSEnThe purpose of this study was to assess the feasibility and utility of image fusion (Easy-TIPS) obtained from pre-procedure CT angiography and per-procedure real-time fluoroscopy for portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) placement.nnnMATERIALS AND METHODSnEighteen patients (15 men, 3 women) with a mean age of 63 years (range: 48-81 years; median age, 65 years) were included in the study. All patients underwent TIPS placement by two groups of radiologists (one group with radiologists of an experience<3 years and one with an experience≥3 years) using fusion imaging obtained from three-dimensional computed tomography angiography of the portal vein and real-time fluoroscopic images of the portal vein. Image fusion was used to guide the portal vein puncture during TIPS placement. At the end of the procedure, the interventional radiologists evaluated the utility of fusion imaging for portal vein puncture during TIPS placement. Mismatch between three-dimensional computed tomography angiography and real-time fluoroscopic images of the portal vein on image fusion was quantitatively analyzed. Posttreatment CT time, number of the puncture attempts, total radiation exposure and radiation from the retrograde portography were also recorded.nnnRESULTSnImage fusion was considered useful for portal vein puncture in 13/18 TIPS procedures (72%). The mean posttreatment time to obtain fusion images was 16.4minutes. 3D volume rendered CT angiography images was strictly superimposed on direct portography in 10/18 procedures (56%). The mismatch mean value was 0.69cm in height and 0.28cm laterally. A mean number of 4.6 portal vein puncture attempts was made. Eight patients required less than three attempts. The mean radiation dose from retrograde portography was 421.2dGy.cm2, corresponding to a mean additional exposure of 19%.nnnCONCLUSIONnFusion imaging resulting from image fusion from pre-procedural CT angiography is feasible, safe and makes portal puncture easier during TIPS placement.

Embolization of the hemorrhoidal arteries (the emborrhoid technique): a new concept and challenge for interventional radiology.

Elective transanal Doppler-guided hemorrhoidal artery ligation (DG-HAL) has recently been shown to be effective in hemorrhoidal disease. It consists of ligating the terminal branches of the superior rectal artery under Doppler guidance, in order to reduce the hemorrhoidal arterial blood flow and improve the symptoms. By analogy, we propose performing this arterial occlusion using the emborrhoid technique (embolization of the hemorrhoidal arteries), in which arterial occlusion is achieved via the endovascular route using coils placed in the terminal branches of the superior rectal arteries. Three patients have been treated by this new technique, and the observations show that it is feasible and reproducible, with no ischemic complications or pain. Additional studies are needed to evaluate the efficacy of this technique for the treatment of hemorrhoidal disease.

Pelvic trauma and vascular emergencies.

Pelvic ring injuries carry a high mortality rate, the main cause of which, in the first 24hours, is exsanguination. Injured patients are managed by a multidisciplinary damage-control strategy. Unstable patients should have instrumentalized hemostasis without delay. Arterial embolization is an effective way of achieving this and justifies this approach being permanently available in levelxa01 trauma-centers. After CT assessment of injuries, stable patients can undergo arterial embolization if active arterial bleeding or vascular damage is present. The embolization methods (selective or unselective) and agents used depend on the patients hemodynamic stage and assessment of the injury whenever possible.

Late postpancreatectomy hemorrhage: Predictive factors of morbidity and mortality after percutaneous endovascular treatment

PURPOSEnThe objective of this study was to evaluate the effectiveness of endovascular treatment in patients presenting with late hemorrhage after pancreatectomy (LPPH).nnnMATERIAL AND METHODnBetween 2008 and 2012, 53 percutaneous arterial procedures were performed in 42 patients with LPPH. There were 27 men and 15 women (mean age, 61.8 years±14.5 [SD]; range: 19-81 years). Clinical and technical success along with frequency of complications associated with the use of different endovascular techniques in patients with and without arterial anatomical variation were assessed.nnnRESULTSnClinical success was observed in 35/42 patients (85%). The technical success was 37.5% in patients with anatomical variation versus 82.8% for those with modal anatomy (P=0.003). Repeat bleeding (P=0.029), complications (P=0.013) and mortality (P=0.045) were more frequent in patients with variation of celiac artery than in those with modal anatomy. For hepatic and gastroduodenal artery stump bleeding, the rate of complications was higher (60%) in the group treated by hepatic artery embolization (P=0.028) by comparison with gastroduodenal artery stump selective embolisations or treatments by covered stent. A significant difference in mortality rate was found between patients with anatomical variations of celiac artery (36.4%) and those with normal anatomy (6.5%) (P=0.032).nnnCONCLUSIONnPercutaneous endovascular treatment is effective in patients presenting with LPPH. The presence of an anatomical variation of the celiac artery increases the rate of complications and mortality in patients with LPPH.

Risk factors of exocrine and endocrine pancreatic insufficiency after pancreatic resection: A multi-center prospective study

Management of functional consequences after pancreatic resection has become a new therapeutic challenge. The goal of our study is to evaluate the risk factors for exocrine (ExoPI) and endocrine (EndoPI) pancreatic insufficiency after pancreatic surgery and to establish a predictive model for their onset.nnnPATIENTS AND METHODSnBetween January 1, 2014 and June 19, 2015, 91 consecutive patients undergoing pancreatoduodenectomy (PD) or left pancreatectomy (LP) (72% and 28%, respectively) were followed prospectively. ExoPI was defined as fecal elastase content<200μg per gram of feces while EndoPI was defined as fasting glucose>126mg/dL or aggravation of preexisting diabetes. The volume of residual pancreas was measured according to the same principles as liver volumetry.nnnRESULTSnThe ExoPI and EndoPI rates at 6 months were 75.9% and 30.8%, respectively. The rate of ExoPI after PD was statistically significantly higher than after LP (98% vs. 21%; P<0.001), while the rate of EndoPI was lower after PD vs. LP, but this difference did not reach statistical significance (28% vs. 38.5%; P=0.412). There was no statistically significant difference in ExoPI found between pancreatico-gastrostomy (PG) and pancreatico-jejunostomy (PJ) (100% vs. 98%; P=1.000). Remnant pancreatic volume less than 39.5% was predictive of ExoPI.nnnCONCLUSIONnExoPI occurs quasi-systematically after PD irrespective of the reconstruction scheme. The rate of EndoPI did not differ between PD and LP.