Jonathan Tibballs

Commentary: The StarClose Vascular Closure Device in Antegrade and Retrograde Punctures: A Single-Center Experience

Purpose: To evaluate the StarClose device and compare its success rates in antegrade and retrograde puncture closures. Methods: A retrospective review of all StarClose deployments from April 2005 to July 2007 was performed in a single tertiary referral institution radiology department. In this time period, 143 StarClose devices were deployed in 132 patients (102 men; mean age 68±14 years). Of these, 40 (28%) were deployed after antegrade and 103 (72%) after retrograde common femoral arterial punctures. Hospital notes were reviewed to evaluate minor (managed conservatively with compression) and major (requiring surgical intervention) complication rates in the immediate postprocedure period and the following 24 hours. Late complications were also assessed. Results: There were 11 (7.7%) immediate failures of device deployment: 4/40 (10.0%) antegrade and 7/103 (6.8%) retrograde. Within these 11 punctures, 1 major complication occurred that required surgical retrieval of the device following a retrograde puncture. No other major and 12 (9.1%) minor complications occurred following the 132 successful StarClose deployments. No late complications were seen on clinical or radiological follow-up. The total major complication rate was 0.7% (1/143). The total minor complication rate was 15.4% (22/143): 9/40 (22.5%) following antegrade punctures and 13/103 (12.6%) following retrograde punctures. Conclusion: The StarClose device is associated with a low major complication rate. A higher rate of minor complications was observed following antegrade punctures but all were managed with simple compression. Prospective randomized trials comparing closure devices are needed to evaluate their relative efficacy and safety in antegrade and retrograde punctures.

Digital embolization due to partially uncovered left subclavian artery post TEVAR: management with amplatzer vascular plug occlusion.

Purpose: To describe the use of the Amplatzer vascular plug to treat a partially uncovered left subclavian artery (LSA) causing digital embolism following thoracic endovascular aneurysm repair. Case Report: A 70-year-old man presented with digital ischemia of the left index and middle fingers due to embolism from a partially covered LSA orifice during thoracic endovascular aneurysm repair for a type I thoracic aortic aneurysm. The orifice was successfully occluded using the vascular plug, supplemented by a left carotid-subclavian bypass to treat ongoing arm and hand claudication. The patient has had no further embolic episodes. Conclusion: A partially uncovered LSA during thoracic endovascular aneurysm repair poses a risk of thromboembolism, with resultant upper limb claudication or tissue loss. If recognized at the time of the procedure, this should be treated by proximal extension; otherwise, proximal LSA occlusion using an Amplatzer occluder may be a safe and effective option in preventing further embolic episodes.

Percutaneous aspiration versus catheter drainage of liver abscess: A retrospective review.

abscess Background/Aims: A review of the effectiveness and outcomes in liver abscess drainage performed by different operators using percutaneous aspiration (PA) and catheter drainage (PCD), respectively, from 2008–2013 at Sir Charles Gairdner Hospital, a tertiary hospital in Australia. Methods: Forty-two patients (29 males and 13 females; aged between 28–93 years; median age of 67 years) with liver abscesses underwent either ultrasound or CT-guided PA (n=22) and PCD (n=20) in conjunction with appropriate antimicrobial therapy. A median of 18 Gauge needle and 10 French catheters were utilised. Results: Nineteen (86.4 per cent) PA cases and 12 (60 per cent) PCD cases were successfully drained on a single attempt (p=0.08). More male patients (69 per cent) than females (31 per cent) were observed. Portal sepsis (42.9 per cent) was the most common cause identified. Fever (47.6 per cent) was the most frequent clinical presentation on admission. Thirty-two patients (76.2 per cent) had solitary abscesses with a right lobe (59.5 per cent) predilection. CRP was significantly raised. The PCD group observed a significantly larger abscess size (p=0.01). Klebsiella What this study adds: 1. What is known about this subject? Liver abscess is a surgical dilemma with substantial morbidity and mortality. The treatment modalities include the use of potent broad-spectrum antibiotics in conjunction with minimally invasive percutaneous drainage under imaging guidance or surgical drainage. 2. What new information is offered in this study? There is an increasing change from benign biliary pathologies to more malignant causes of liver abscess. The emergence of Klebsiella pneumoniae replacing Escherichia coli as an important pathogen is now being recognised with virulent strains reported worldwide. Dissimilarities and inconsistencies between blood and pus cultures reflecting the possible causative liver abscess microbe were noted. The management of six prospective studies was also reviewed. 3. What are the implications for research, policy, or practice? Percutaneous intervention, either aspiration (PA) or catheter drainage (PCD), has become the preferred first 7 Percutaneous aspiration versus catheter drainage of liver abscess: A retrospective review Gurjeet Dulku, Geeta Mohan, Shaun Samuelson, John Ferguson, Jonathan Tibballs Department of Radiology, Interventional Specials, Sir Charles Gairdner Hospital, Nedlands, WA, Australia [AMJ 2015;8(1):7-18] 8 therapeutic choice for liver abscess drainage. However, to date, which should be the first-line treatment remains debatable. Background Liver abscess is a rare but potentially fatal disease. Historically, liver abscess has been managed exclusively by surgery. Advances in imaging technology have advocated the shift to minimally invasive interventional procedures. The advent and delivery of potent antimicrobials and improved ICU care have also improved patient outcomes. Surgery is now reserved for selected cases. Despite these advances, mortality rates remain high. The percutaneous intervention can either be a percutaneous aspiration (PA) or a percutaneous catheter drainage (PCD), but to date which should be the first-line treatment remains debatable. Subjects and methods Clinical data was retrieved from medical records, the hospital computer system, and the Picture Archiving and Communication System (PACS) for patients who underwent percutaneous aspiration and/or catheter drainage with the Interventional Radiology team at our tertiary medical centre from 2008–2013. Forty-two patients underwent a total of 57 procedures. Out of 22 PA patients, 19 had a single (n=19) successful aspirate (nine out of 10 cases as successful needle aspiration and 10 out of 12 cases as successful catheter aspiration). In the unsuccessful arm, two patients had two (n=4) procedures and one had three (n=3) procedures done, respectively. PCD was performed in 20 patients. In the successful arm, nine patients had a single (n=9) drainage, two patients had two abscesses drained separately on the same setting on a single attempt each (n=4), and one had three drainage procedures for three different abscesses (n=3) on a single attempt each. In the unsuccessful arm, one patient had a single drainage (n=1), while seven others had two (n=14) procedures done. A procedure was considered successful if there was no change in the initial procedure from aspiration to drainage or vice-versa, or subsequent surgery and successful drainage of the abscess allowing for clinical discharge. Procedural-related complications were noted independently but were not considered as a reason for failed treatment as the known risks were discussed with the patient prior to the procedure. Intervention Written consent, coagulation profile assessment, and coagulopathy correction were performed prior to the procedure. Ultrasonographic (US) guidance used the Phillips iU22 system with 3.5or 5-MHz convex transducers, while CT guidance was carried out with the Phillips Brilliance 64 row detector CT unit. Lignocaine 1 per cent was the choice for local anaesthesia and conscious sedation with Fentanyl and Midazolam was sometimes used. Aspiration PA was performed using either needle (size range 17–21 Gauge, median 18 Gauge) or pig-tail catheters (size range 6– 10 French, median 10 French). Once the needle tip or catheter is within the abscess cavity, it is aspirated until no more pus can be aspirated. This is followed by needle or catheter removal. Drainage PCD was performed using self-locking pig-tail catheters (size range 6–14 French, median 10 French). Under image guidance, the catheter was placed within the abscess cavity using the modified Seldingers technique. Aspiration of the abscess material was then performed until no more pus could be aspirated. The catheter was secured to the skin for continuous external drainage. Follow-up imaging was performed only in patients who were not improving clinically. The attending physician made the decision for drain removal. Dislodged catheters were either repositioned or removed with subsequent PA being performed. Procedure details including technique, and number and size of needle and catheter were recorded. Patients who subsequently required PA, PCD, or surgery after the initial procedure were also documented. Statistical analysis Quantitative variables (patient demographics, laboratory findings, abscess characteristics, and length of stay) were analysed using Welch t-test for normally distributed data or a non-parametric test (Kruskal-Wallis rank sum test). Test of normality was performed using Shapriro-Wilk test. Categorical variables (clinical features, mortality, treatment success, and complications) were analysed using the Fisher’s exact test. The level of significance was set at p value two-sided test <0.05. All statistical tests were done using the open source R language. Furthermore, the aetiologies of the abscesses were not uniform and formed a heterogeneous group. In addition, the type of interventional procedure performed was governed simply by operator preference and was certainly not random. [AMJ 2015;8(1):7-18]

Ad Libitum Mediterranean and Low‐Fat Diets Both Significantly Reduce Hepatic Steatosis: A Randomized Controlled Trial

Although diet‐induced weight loss is first‐line treatment for patients with nonalcoholic fatty liver disease (NAFLD), long‐term maintenance is difficult. The optimal diet for improvement in either NAFLD or associated cardiometabolic risk factors, regardless of weight loss, is unknown. We examined the effect of two ad libitum isocaloric diets (Mediterranean [MD] or low fat [LF]) on hepatic steatosis (HS) and cardiometabolic risk factors. Subjects with NAFLD were randomized to a 12‐week blinded dietary intervention (MD vs. LF). HS was determined by magnetic resonance spectroscopy (MRS). From a total of 56 subjects enrolled, 49 completed the intervention and 48 were included for analysis. During the intervention, subjects on the MD had significantly higher total and monounsaturated fat, but lower carbohydrate and sodium, intakes compared to LF subjects (P < 0.01). At week 12, HS had reduced significantly in both groups (P < 0.01), and there was no difference in liver fat reduction between groups (P = 0.32), with mean (SD) relative reductions of 25.0% (±25.3%) in LF and 32.4% (±25.5%) in MD. Liver enzymes also improved significantly in both groups. Weight loss was minimal and not different between groups (–1.6 [±2.1] kg in LF vs –2.1 [±2.5] kg in MD; P = 0.52). Within‐group improvements in Framingham Risk Score (FRS), total cholesterol, serum triglyceride (TG), and glycated hemoglobin (HbA1c) were observed in the MD (all P < 0.05), but not with the LF diet. Adherence was higher for the MD compared to LF (88% vs. 64%; P = 0.048). Conclusion: Ad libitum low‐fat and Mediterranean diets both improve HS to a similar degree.

Transjugular intrahepatic portosystemic shunt: Indications, complications, survival and its use as a bridging therapy to liver transplant in Western Australia.

Insertion of transjugular intrahepatic portosystemic shunt (TIPS) is an established therapeutic option to treat the complications of portal hypertension. The purpose of this study is to review the experience of a single Australian institute with TIPS and evaluation of result to emphasize the indication, aetiology of portal hypertension, prognostic factors, complications and survival. Use of TIPS as a bridge to liver transplantation was also analysed.

Aspiration Thrombectomy versus Conventional Catheter-Directed Thrombolysis as First-Line Treatment for Noniatrogenic Acute Lower Limb Ischemia

PURPOSE To examine the efficacy, safety, and procedural costs of percutaneous aspiration thrombectomy (PAT) as a first-line treatment for noniatrogenic acute lower limb ischemia (ALI) compared with conventional catheter-directed thrombolysis (CDT). MATERIALS AND METHODS All patients who underwent endovascular intervention for ALI from January 2015 to August 2017 were included. Fifteen patients were treated with the use of primary PAT and 27 patients were treated with the use of primary CDT. The primary end point was complete thrombus clearance with improvement in Thrombolysis in Myocardial Infarction (TIMI) score. Adjunctive treatment for thrombus removal was considered to indicate technical failure. Treatment of underlying chronic disease was not considered to indicate technical failure. Procedural costs for each patient were calculated by itemizing all disposable equipment, facility overheads, and staff costs. RESULTS Of the 15 primary PAT patients, technical success was achieved in 8 (53%); the remaining 7 (47%) required adjunctive CDT. Of the 27 primary CDT patients, technical success was achieved in 25 (89%); the remaining 2 (11%) required adjunctive PAT. There were 4 complications in the primary PAT group: 2 were procedure related and of a minor grade. There were 8 complications in the primary CDT group: All were procedure-related, including 2 major groin/retroperitoneal hemorrhage and 1 death from intracranial hemorrhage. Limb salvage was attained in all patients. There were no significant differences in average procedural costs per patient between the 2 groups. CONCLUSIONS First-line use of PAT for endovascular treatment of ALI can reduce the need for CDT, with no significant cost difference.

Selective internal radiation therapy (SIRT) with yttrium-90 microspheres for unresectable intrahepatic cholangiocarcinoma

Unresectableintrahepaticcholangiocarcinoma has a very poor prognosis despite various treatment options. The case presented describes the diagnostic challenges of a young pregnant woman with unresectable cholangiocarcinoma. The current treatment options for cholangiocarcinoma have limited evidence and high recurrence rate. Given the young age of this patient, selective internal radiotherapy was trialled with traditional chemotherapy with a clinically significant result. This case highlights the delays when diagnosing cholangiocarcinoma in younger patients and the possibility of selective internal radiation therapy in combination with chemotherapy as a potential first-line treatment for a complete response in unresectable disease.

Removal of Peritnoeo-venous-atrial shunt thrombus without cardiopulmonary bypass

Thrombus formation is not uncommon in longstanding intracardiac catheters, but formation of a thrombus at the tip of a Peritnoeo-venous-atrial shunt, causing obstruction of the tricuspid valve, is a rare complication and frequently unrecognized. A large intracardiac thrombus causing valve obstruction requires surgical removal with the support of cardiopulmonary bypass which is associated with significant morbidity. We successfully removed a thrombus attached to the tip of peritoneovenous shunt without cardiopulmonary bypass in a 25-year-old man.