Jason K. Wong

Results of type II hybrid arch repair with zone 0 stent graft deployment for complex aortic arch pathology

OBJECTIVEnTo review the early results of a less invasive, single-stage hybrid arch procedure involving replacement of the ascending aorta, arch debranching, and zone 0 antegrade stent graft deployment.nnnMETHODSnBetween May 2007 and January 2012, 20 patients with both acute and chronic aortic pathology were managed at 2 institutions with a type 2 hybrid arch procedure. Indications included diffuse atherosclerotic aneurysm, false lumen expansion of chronic aortic dissections, penetrating atherosclerotic ulcer, and acute type A dissection. Mean age was 67 ± 16.8 years with a mean European System for Cardiac Operative Risk Evaluation II score of 29.5 ± 19.4. Postoperative clinical and imaging follow-up was complete to a mean 18.5 ± 15.3 months.nnnRESULTSnSuccessful zone 0 stent graft deployment was achieved in all cases. There was 1 in-hospital mortality (5%). A second death occurred at 40 days postoperation. Other complications included a permanent neurologic deficit in 1 patient (5%), transient paraplegia in 4 patients (20%), and 3 patients had respiratory complications (15%). There were no cases of renal failure requiring dialysis. Stent-related complications were identified in 4 patients (20%), including 3 type I endoleaks, none of which were at zone 0. There was 1 type II endoleak and a case of stent infolding. Two patients required a second successful endografting procedure.nnnCONCLUSIONSnThis single-stage hybrid arch procedure offers an alternative approach to complex diffuse aortic pathology involving the arch. Replacement of the ascending aorta provides a safe location for zone 0 stent graft deployment, eliminating complications of proximal deployment in a native diseased aorta.

An Alternative Approach to Diffuse Thoracic Aortomegaly: On-Pump Hybrid Total Arch Repair Without Circulatory Arrest

Diffuse thoracic aortomegaly has conventionally been managed with a two-stage elephant trunk procedure, requiring prolonged circulatory arrest, with an inherent risk of major morbidity and mortality. Recently, to improve outcomes, several hybrid arch procedures have been proposed using off-pump techniques. We have adopted an alternative, single-stage hybrid strategy using cardiopulmonary bypass without circulatory arrest to replace the ascending aorta and perform arch debranching and antegrade endovascular stent graft deployment. Unlike off-pump procedures, pathology of the aortic valve, root, and ascending aorta is addressed while avoiding the complications of stent graft placement in the native ascending aorta.

Alternative surgical approach to repair of the ascending aorta.

We describe a case of complete endovascular repair of the ascending aorta using a transfemoral approach. A 59-year-old man with a history of two previous sternotomies experienced an ascending aortic pseudoaneurysm arising from the graft-to-graft anastomosis of a previous DeBakey type I aortic dissection repair. A custom-made Zenith TX2 (William Cook Europe ApS, Bjaeverskov, Denmark) thoracic aortic aneurysm endovascular graft, designed specifically for the ascending aorta, was introduced through the left femoral artery and deployed under a rapid ventricular pacing protocol to achieve precise placement between the sinotubular junction and the aortic arch.

Delayed Intimal Blowout after Endovascular Repair of Aortic Dissection

The authors have seen four cases of asymptomatic delayed intimal injury adjacent to a stent graft diagnosed 7 to 16 months after thoracic endovascular aortic repair. Endovascular repeat intervention was successfully performed in three of the four cases as described in the present report. A second consecutive intimal blowout in one patient remains under close radiologic surveillance. Possible causes for the intimal blowouts, including stent-graft size, landing zone anatomy, and intrinsically weak aortic tissue, are discussed.

Endovascular Therapy for Acute Trauma: A Pictorial Review

The traditional role of radiology in the multidisciplinary approach to modern trauma care has been primarily diagnostic and noninvasive. With the advent of more sophisticated and faster imaging equipment, computed tomography has further entrenched its role as the workhorse of trauma imaging. However, the specialty has evolved over the years with various therapeutic techniques now part of the interventional radiology armamentarium. Several of these techniques have become essential for the management of critically ill trauma patients. This article provides an overview of the common imaging findings of vascular and solid organ trauma from head to toe and subsequent endovascular interventions in these critically ill trauma patients.

Predicting Infection in Localized Intraabdominal Fluid Collections: Value of pH and pO2 Measurements

PURPOSEnTo evaluate the use of pH, pO2, and the subjective opinion of the radiologist compared with bacterial culture in accurate diagnoses of bacterial infection in intraabdominal fluid collections.nnnMATERIALS AND METHODSnProspectively, 79 patients who were suspected of having an intraabdominal fluid collection underwent diagnostic fluid aspiration. The aspirate was cultured and measured for pH and pO2. A pH < or = 7.1 and a PO2 < or = 49 mm Hg were threshold values used to separate infected from sterile fluid collections.nnnRESULTSnpH alone had a 92% sensitivity and 79% specificity, whereas PO2 alone had a 51% sensitivity and 79% specificity. pH or pO2 combined yielded a 92% sensitivity and 60% specificity. The radiologists opinion produced a 83% sensitivity and 92% specificity. pH and the radiologists opinion combined produced a 78% sensitivity and 96% specificity. pH or the radiologists opinion combined had a 95% sensitivity and a 63% specificity.nnnCONCLUSIONnpH is the most sensitive indicator of infection and the radiologists opinion is the most specific. We recommend proceeding to drainage if the radiologist believes the collection to be infected and performing pH analysis if not. If the pH < or = 7.04, proceed to drainage. If neither of the above criteria are met, drainage could be delayed, pending the results of culture.

Endovascular Management of Hemorrhage: Playing Video Games

An intoxicated 37-year-old male has fallen four stories off of a roof and has a large contrast arterial blush in his spleen and left kidney on imaging. He also displays significant hemorrhagic blushes within his pelvis. He is a “responder” but clearly critically ill.

Clinical IR in Canada: The Evolution of a Revolution

PURPOSEnTo investigate the current status and evolution of both the interventional radiologists role as a clinician and the practice of interventional radiology (IR) over the past decade in Canada.nnnMATERIALS AND METHODSnIn 2015, an online survey was e-mailed to 210 interventional radiologists, including all Canadian active members of the Canadian Interventional Radiology Association (CIRA) and nonmembers who attended CIRAs annual meeting. Comparisons were made between interventional radiologists in academic versus community practice. The results of the 2015 survey were compared with CIRAs national surveys from 2005 andxa02010.nnnRESULTSnA total of 102 interventional radiologists responded (response rate 49%). Significantly more academic versus community interventional radiologists performed chemoembolization, transjugular intrahepatic portosystemic shunt, aortic interventions, and arteriovenous malformation embolization (P < .05). Ninety percent of respondents were involved in longitudinal patient care, which had increased by 42% compared with 2005; 46% of interventional radiologists had overnight admitting privileges, compared with 39% in 2010 and 29% in 2005. Eighty-six percent of interventional radiologists accepted direct referrals from family physicians, and 83% directly referred patients to other consultants. Sixty-three percent participated in multidisciplinary tumor board. The main challenges facing interventional radiologists included a lack of infrastructure, inadequate remuneration for IR procedures, and inadequate funding for IR equipment. Significantly more community versus academic interventional radiologists perceived work volume as an important issue facing the specialty in 2015 (60% vs 34%; Pxa0= .02).nnnCONCLUSIONSnOver the past decade, many Canadian interventional radiologists have embraced the interventional radiologist-clinician role. However, a lack of infrastructure and funding continue to impede more widespread adoption of clinical IR practice.

Successful Radiofrequency Guidewire Recanalization of a Chronic Portal Vein Occlusion That Failed Conventional Therapy.

A 59-year-old man presented with recurrent upper gastrointestinal bleeding (UGIB) following an initial episode of gallstone pancreatitis in 2003. He underwent cholecystectomy but then had multiple hospital admissions for recurrent pancreatitis complicated by a large inflammatory pancreatic head mass in 2009. A Whipple’s procedure was attempted, but extensive adhesions to multiple vascular structures prevented safe resection of the pancreatic head mass and the procedure was converted to a roux-en-Y procedure. Ongoing inflammation and fibrosis surrounding the portal vein led to noncirrhotic portal hypertension complicated by large varices. These were first recognized in November 2011 when the patient presented with UGIB, treated with endoscopic variceal injection with N-butyl-2-cyanoacrylate (NBCA) (Histoacryl, Tuttlingen, Germany). The patient had multiple hospitalizations (8 admissions over a 22-month period) including an intensive care unit admission for lifethreatening UGIB secondary to both gastric and duodenal varices. These were managed medically with multiple blood transfusions (over 10 U in total), octreotide, and pantoprazole. Endoscopy was performed at each admission and therapy consisting of NBCA injections and variceal banding was performed when active UGIB was identified. Additionally, a suspicion of sinistral portal hypertension was treated with splenic debulking using staged partial particle embolization of the spleen followed by main splenic artery embolization. This was complicated by splenic abscess requiring splenectomy and distal pancreatectomy in 2012. In April 2013, further surgical management with a side-to-side portocaval shunt at the level of the porta hepatis was performed. No varices were ligated at the time of surgery. Despite these multiple treatments, the patient had two further episodes of UGIB requiring hospitalization. CT examination in June 2013 demonstrated a 2.8-cm long occlusion of the main portal vein at the level of the pancreatic head mass in addition to large gastric and duodenal varices (Fig. 1). Endovascular recanalization of the portal vein occlusion was now considered his best treatment option. Under conscious sedation with fentanyl (Sandoz, QC, Canada) and midazolam (Pharmaceutical Partners of & Mollie C. M. Ferris Mollie.Ferris@albertahealthservices.ca