Jane Phillips-Hughes

Acute upper limb ischemia: a complication of coronary artery bypass grafting

We present the case of a patient with acute upper limb ischemia after radial artery harvest for coronary artery bypass grafting. This occurred despite adequate preoperative and intraoperative assessment with the Allen test, hand-held Doppler and radial artery backbleeding. A successful outcome was achieved by performing brachioradial bypass grafting using reversed cephalic vein.

StarClose Vascular Closure Device: Prospective Study on 222 Deployments in an Interventional Radiology Practice

The StarClose device (Abbott Vascular Devices; Abbott Laboratories, Redwood City, CA) utilizes an externally placed Nitinol clip to achieve arterial closure following femoral artery puncture. The objectives of this study were to assess the efficacy and complications of the StarClose device in patients undergoing interventional radiological procedures. Preprocedural clotting status, pulse and blood pressure, severity of vessel calcification, sheath size, and time to deployment were recorded. Postdeployment complications immediately postprocedure, at 1 h, at 2 h, and at 1 week were recorded. A duplex scan was performed in the first 10 patients to assess any immediate vascular complications. Deployments were successful in 96% achieving immediate hemostasis. Mean deployment time was 48 s. There were no major complications. The StarClose device was found to have a high technical and clinical efficacy.

Percutaneous cholecystostomy: The radiologist's role in treating acute cholecystitis

Acute cholecystitis is a common condition, with laparoscopic cholecystectomy considered the gold-standard for surgical management. However, surgical options are often unfavourable in patients who are very unwell, or have numerous medical co-morbidities, in which the mortality rates are significant. Percutaneous cholecystostomy (PC) is an image-guided intervention, used to decompress the gallbladder, reducing patients symptoms and the systemic inflammatory response. PC has been shown to be beneficial in high-risk patient groups, predominantly as a bridging therapy; allowing safer elective cholecystectomy once the patient has recovered from the acute illness; or, in the minority, as a definitive treatment in patients deemed unfit for surgery. This review aims to develop a broader understanding of PC, discussing its specific indications, patient management, technical factors, imaging guidance, and outcomes following the procedure.

Sigmoid colonic perforation and pelvic abscess complicating biliary stent migration

Endoscopically placed biliary stents are a well-established procedure for the treatment of benign and malignant causes of obstructive jaundice in patients unfit for definitive surgical intervention. Stent migration has been described, though in most instances the stent will pass or remain in the bowel lumen for extended periods of time. Only a few cases of clinically significant complications of stent migration have been reported. This is the first case report of a pelvic abscess complicating stenting for choledocholithiasis. As the numbers of stenting procedures continue to increase it may be anticipated that the numbers of complications will similarly increase.

Management of patients with biliary sphincter of Oddi disorder without sphincter of Oddi manometry

BackgroundThe paucity of controlled data for the treatment of most biliary sphincter of Oddi disorder (SOD) types and the incomplete response to therapy seen in clinical practice and several trials has generated controversy as to the best course of management of these patients. In this observational study we aimed to assess the outcome of patients with biliary SOD managed without sphincter of Oddi manometry.MethodsFifty-nine patients with biliary SOD (14% type I, 51% type II, 35% type III) were prospectively enrolled. All patients with a dilated common bile duct were offered endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy whereas all others were offered medical treatment alone. Patients were followed up for a median of 15 months and were assessed clinically for response to treatment.ResultsAt follow-up 15.3% of patients reported complete symptom resolution, 59.3% improvement, 22% unchanged symptoms, and 3.4% deterioration. Fifty-one percent experienced symptom resolution/improvement on medical treatment only, 12% after sphincterotomy, and 10% after both medical treatment/sphincterotomy. Twenty percent experienced at least one recurrence of symptoms after initial response to medical and/or endoscopic treatment. Fifty ERCP procedures were performed in 24 patients with an 18% complication rate (16% post-ERCP pancreatitis). The majority of complications occurred in the first ERCP these patients had. Most complications were mild and treated conservatively. Age, gender, comorbidity, SOD type, dilated common bile duct, presence of intact gallbladder, or opiate use were not related to the effect of treatment at the end of follow-up (p > 0.05 for all).ConclusionsPatients with biliary SOD may be managed with a combination of endoscopic sphincterotomy (performed in those with dilated common bile duct) and medical therapy without manometry. The results of this approach with regards to symptomatic relief and ERCP complication rate are comparable to those previously published in the literature in cohorts of patients assessed by manometry.

The Timing and Frequency of Complications After Peripheral Percutaneous Transluminal Angioplasty and Iliac Stenting: Is a Change from Inpatient to Outpatient Therapy Feasible?

AbstractPurpose: A prospective study was performed to assess the frequency and timing of complications after transluminal angioplasty and stent placement with a view to changing our practice and performing these procedures on an outpatient basis. Method: A total of 266 angioplasties and 51 stent deployments were attempted on 240 consecutive patients. Immediate complications were documented by the radiologists. The timing and nature of any complications during and beyond the first 24 hr were reported by the vascular surgeons. Results: There were 14 complications in 240 patients, giving a complication rate of 4.8% per vessel segment dilated. There were five major and nine minor complications. Eighty-six percent of complications were evident before the patient had left the angiography suite. All complications were evident within 4.5 hr of the procedure. Conclusion: The timing of complications suggests it would be reasonable to perform percutaneous transluminal angioplasties and iliac stenting on an outpatient basis in suitable patients.

The role of interventional radiology and imaging in pancreatic islet cell transplantation

Pancreatic islet cell transplantation (PICT) is a novel treatment for patients with insulin-dependent diabetes who have inadequate glycaemic control or hypoglycaemic unawareness, and who suffer from the microvascular/macrovascular complications of diabetes despite aggressive medical management. Islet transplantation primarily aims to improve the quality of life for type 1 diabetic patients by achieving insulin independence, preventing hypoglycaemic episodes, and reversing hypoglycaemic unawareness. The islet cells for transplantation are extracted and purified from the pancreas of brain-stem dead, heart-beating donors. They are infused into the recipients portal vein, where they engraft into the liver to release insulin in order to restore euglycaemia. Initial strategies using surgical access to the portal vein have been superseded by percutaneous access using interventional radiology techniques, which are relatively straightforward to perform. It is important to be vigilant during the procedure in order to prevent major complications, such as haemorrhage, which can be potentially life-threatening. In this article we review the history of islet cell transplantation, present an illustrated review of our experience with islet cell transplantation by describing the role of imaging and interventional radiology, and discuss current research into imaging techniques for monitoring graft function.

Repeat endoscopic retrograde cholangiopancreaticography after failed initial precut sphincterotomy for biliary cannulation.

AIM To investigate the outcome of repeating endoscopic retrograde cholangiopancreaticography (ERCP) after initially failed precut sphincterotomy to achieve biliary cannulation. METHODS In this retrospective study, consecutive ERCPs performed between January 2009 and September 2012 were included. Data from our endoscopy and radiology reporting databases were analysed for use of precut sphincterotomy, biliary access rate, repeat ERCP rate and complications. Patients with initially failed precut sphincterotomy were identified. RESULTS From 1839 consecutive ERCPs, 187 (10%) patients underwent a precut sphincterotomy during the initial ERCP in attempts to cannulate a native papilla. The initial precut was successful in 79/187 (42%). ERCP was repeated in 89/108 (82%) of patients with failed initial precut sphincterotomy after a median interval of 4 d, leading to successful biliary cannulation in 69/89 (78%). In 5 patients a third ERCP was attempted (successful in 4 cases). Overall, repeat ERCP after failed precut at the index ERCP was successful in 73/89 patients (82%). Complications after precut-sphincterotomy were observed in 32/187 (17%) patients including pancreatitis (13%), retroperitoneal perforations (1%), biliary sepsis (0.5%) and haemorrhage (3%). CONCLUSION The high success rate of biliary cannulation in a second attempt ERCP justifies repeating ERCP within 2-7 d after unsuccessful precut sphincterotomy before more invasive approaches should be considered.

The frequency and significance of silent myocardial ischemia due to hyoscine butylbromide use in peripheral angiography.

AbstractPurpose: Hyoscine-N-butylbromide (HB) is an anticholinergic drug used in digital subtraction angiography of the aortoiliac region because it decreases bowel gas movement artifact. HB also causes an increase in heart rate. We investigated whether this could cause silent myocardial ischemia (SMI) in susceptible patients during peripheral angiography. Methods: Thirty-six patients undergoing peripheral angiography were randomized into two groups, with 17 patients receiving 20 mg HB intraarterially during the angiogram and 19 patients receiving no drug. All patients were fitted with a Holter monitor that recorded the electrocardiogram before, during, and after the angiogram. Heart rate trends and ST segments were then analyzed. Results: Patients given HB had a statistically significant rise in heart rate compared with the control group. Although the difference was not statistically significant, two (12%) patients receiving HB had procedural ST depression compared with none in the control group. Pre- and postprocedural episodes of ST depression were common, occurring in 41% of patients receiving HB and 37% of patients receiving no drug, and were associated with an increase in heart rate. Conclusion: The infrequent episodes of procedural SMI, potentially caused by the positive chronotropic effects of HB, are probably insignificant when compared with the high frequency of SMI episodes occurring outside the procedure.

Thrombin Injection for Acute Hemorrhage Following Angiography

Femoral arterial puncture is the main access for diagnostic and therapeutic intervention in vascular disease. Significant complications are unusual and include uncontrolled bleeding which usually requires surgery. We report the use of ultrasound-guided thrombin injection that prevented any immediate need for surgery in 2 cases of uncontrolled bleeding following femoral arteriography. Clinical presentations and treatment are reported, together with a review of the literature.