Mark Bratby

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.

Radiology and mesenteric ischaemia

This review focuses on the radiology of mesenteric ischaemia. Covering the acute and chronic presentations, both of which result from impaired vascularisation of the gastrointestinal tract, we evaluate the role of radiographs, ultrasound, CT, MRI, and catheter angiography in the diagnosis of these conditions. Looking to the future, we also assess some of the emerging imaging techniques. Across medicine and surgery there has been a significant shift towards minimally invasive interventions. Although percutaneous revascularisation of chronic mesenteric ischaemia has been performed for some time, there has been a developing trend for the use of such techniques in acute mesenteric ischaemia. We evaluate the available evidence for the use of these percutaneous interventions and assess how they compare with or in some instances compliment traditional surgical alternatives.

Successful fibroid embolization of pelvic and inferior mesenteric artery collaterals after previous uterine artery embolization.

A 47-year-old woman with a history of myomectomies and uterine artery embolization 15 years previously presented with increasing menorrhagia and dysmenorrhea. Magnetic resonance imaging (MRI) demonstrated multiple enhancing fibroids, extensive uterine supply from what appeared to be patent uterine arteries, and significant supply from what appeared to be the left ovarian artery. Aortography demonstrated no ovarian supply, but extensive collateral supply from distal branches of the inferior mesenteric artery (IMA), with further collateral supply from the anterior division of both internal iliac arteries. There was no filling of the uterine arteries distal to the coils. Embolization was performed with technical and clinical success. This case highlights the potential for recruitment of collateral vessels following coil embolization and is the first reported case of successful fibroid embolization from distal IMA branches.

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.

Preliminary Dual-Center Experience with the Bolton Treovance Endograft

Purpose: To present the performance and safety of the Treovance stent graft for endovascular aortic aneurysm repair in a “real-world” patient cohort. Methods: Patients from 2 centers, deemed unfit for open repair, were electively treated with the Treovance endograft. Clinical preoperative, operative, and up to 1-year postoperative follow-up data of patients were retrospectively analyzed. Results: This study included 46 patients with abdominal aortic aneurysm (44 male), mean age of 78 years ± 8 standard deviation (SD; range: 58-93 years). All met the manufacturer’s recommended anatomical requirements: average maximum sac diameter 63 mm ± 10 SD (range: 52-86 mm), proximal neck length 29 mm ± 12 SD (range: 11-60 mm), and neck angulation 30° ± 21 SD (range: 0°-70°). Fourteen had moderate to severe iliac tortuosity. A primary technical success rate of 80% was achieved (100% assisted primary technical success rate): 7 patients required adjunctive procedures intraoperatively and 2 successful treatments for type I endoleaks, which occurred within 24 hours postoperatively. There was 100% survival at 1-year follow-up; however, 4 (8.7%) patients required reintervention: 1 for a type I endoleak, 2 for limb stenosis, and 1 for a type II endoleak with an enlarging sac. No other device-related complications were identified. Reintervention and complication rates in hostile versus nonhostile anatomies were not statistically significant (P = .28 and P = .42, respectively). Conclusion: The Treovance stent graft has a comparable safety profile to other next-generation stent grafts during the first year after endovascular aneurysm repair, which provides a rationale for further interrogation of its outcomes through clinical trials.

Retrograde transileal conduit stent placement for obstructed uropathy--success of primary and exchange stent placement.

PURPOSE To assess the safety, success, and complications associated with retrograde ureteric stent insertion via the ileal conduit. MATERIALS AND METHODS The study population comprised 35 consecutive patients (17 men and 18 women; mean age, 55 y; age range, 40-75 y) requiring primary (20 stents) and exchange (70 stents) retrograde ureteric stent insertion via the ileal conduit over a 3-year period. Patient demographic data, procedural and technical data, and clinical follow-up data were collected. RESULTS Technical success was 90% (18 of 20) for primary stent placement and 100% (70 of 70) for stent exchange. There were two immediate complications (< 24 h) of sepsis and ureteric injury and one early complication (> 25 h but < 30 d) of sepsis requiring observation and medical management. Difficult procedures (defined as a fluoroscopy screening time > 31 min) and technical failures were found to be associated with encrusted stents visualized on prior computed tomography (P = .012), increased length of ileal conduit (> 20 cm) (P = .023), and ileal conduit kink (< 90 degrees) (P = .032). Only the occurrence of encrusted stents visualized on prior computed tomography (P = .022) was associated with complications. CONCLUSIONS Retrograde placement of ureteric stents via the ileal conduit is safe and effective. Retrograde stent placement should be considered the treatment option of choice for a first-time occurrence of obstructive uropathy at the ureteroileal anastomosis.

Reply to the Article Entitled “Emergency Renal Ablation for Life-Threatening Hemorrhage from Multiple Capsular Branches During Renal Artery Stenting” by Aytekin et al.

We had a case of life-threatening renal hemorrhage after renal artery stenting, as described by Aytekin and colleagues [1]. In our case. we managed to control the bleeding with microcoils and renal preservation rather than renal ablation. We discuss our case to further establish renal parenchymal hemorrhage after renal artery stenting as a distinct clinical entity and also to highlight a different management strategy. An 82-year-old man underwent right renal artery stenting for atherosclerotic renal artery origin disease before endovascular abdominal aortic aneurysm repair (EVAR). The patient had impaired renal function (creatinine 190–250 lmol/l) and an atrophied left kidney. The right kidney had a dual blood supply, one by the stenotic right main renal artery and the other by a lower-lobe accessory renal artery. Because of the anatomy of the abdominal aortic aneurysm neck, we planned to cover the right lower pole accessory artery with the stent graft to obtain a good seal on the proximal neck of the stent graft. In view of the atrophic left kidney, we chose to electively stent the right renal artery 1 week before the planned EVAR to optimize the right renal blood flow to what was functionally a solitary right kidney. A 6 9 24-mm stent (Cordis Europa, Roden, The Netherlands) was placed across the right renal artery origin stenosis and dilated to 7 mm (Wanda, Boston Scientific, Galway, Ireland) with good angiographic result. The patient was then admitted to our day case unit for recovery. Within 1 h of the procedure, the patient developed severe right flank pain, and his systolic pressure dropped to 90 mm Hg from a baseline of 160 mm Hg. An ultrasound showed a large perinephric collection. He was taken back to the interventional suite. A right renal angiogram showed a blush of contrast from an upper pole cortical vessel, which was embolized with microcoils (Fig. 1). One hour later, the patients’ blood pressure dropped again, and he complained of increasing right flank pain. A further computed tomographic angiogram showed active bleeding from a right lower pole vessel, and again, the patient was returned to the interventional suite. There was a blush of contrast from the lower pole renal cortical arteries. The subsegmental renal artery supply the lower pole segment was further embolized with microcoils (Fig. 2). The patient settled after the second embolization but required temporary dialysis for contrast-induced nephropathy. The renal impairment was probably caused by a combination of a large intravenous contrast load (approximately 300 ml Omnipaque) and a large perirenal hematoma, which compromised renal perfusion. EVAR was performed 2 weeks later. The patient subsequently recovered renal function to baseline preprocedural levels. The multifocal nature of the renal hemorrhage did not correspond to guide wire perforation. We think this is best explained by hemorrhage from multiple capsular branches, as described previously [2, 3]. Reperfusion of the kidney may play a role in the underlying etiology. Our experience demonstrates that selective embolization is an alternative management strategy, particularly in the setting of a functionally solitary kidney. Appropriate intensive care aftercare is important to minimize renal damage from contrast load. V. Shrivastava (&) S. Anthony M. Bratby R. Uberoi Radiology Department, John Radcliffe Hospital, Oxford, UK e-mail: vivshriv@yahoo.com

Prospective study evaluating technical and clinical outcomes from the use of low profile angioplasty (LOPA) systems.

AIM To compare the success and complication associated with 4 and 5 F access systems prospectively in the treatment of infra-inguinal vascular disease. MATERIALS AND METHODS One hundred and twenty consecutive patients were treated for lower limb vascular disease via a 4 F (n = 60) or 5 F (n = 60) access sheath over a 12 month period. All common femoral arteries were punctured in an antegrade direction with ultrasound guidance. Seven minutes of manual compression was applied and the groin assessed with ultrasound to document complications. Repeated manual compression was applied until haemostasis was achieved in all cases. Time to haemostasis, equipment used, patient biochemical data, and demographics were recorded. Patients were followed-up at a mean of 12 weeks post-procedure. RESULTS Antegrade access and sheath insertion was achieved in all cases. The technical success of the procedure was 56/60 (93%) cases using 4 F access and 57 (95%) cases using 5 F access. The time to haemostasis was reduced to a mean of 8.2 min (range 7-12 min) with a 4 F system compared to a mean of 12 min (range 7-30 minutes) with a 5 F system (p = 0.045). Overall there were 12 complications (10%; 11 <2 cm haematomas and one pseudoaneurysm) noted on ultrasound post-haemostasis, although there was no statistically significance difference between the two groups. Hypertension and renal dysfunction were associated with complications (p < 0.05). A 4 F system used an additional average of 5.1 (range 3-8) wires and catheters compared to an additional average of 3.5 (range 2-6) wires and catheters when using a 5 F system (p = 0.002). A 4 F technique cost three-times that of a 5 F technique. CONCLUSION Four and 5 F access sheaths allow safe and successful infra-inguinal angioplasty with a low complication rate. Hypertensive patients and those with impaired renal function are at increased risk of complications. There are increasing costs using a 4 F system offset by a decrease in time to haemostasis following manual compression but no reduction in complication rate.

Letter Reply Re: “Endoscopy-Guided Empiric Arterial Embolization for Angiographically Negative Upper Gastrointestinal Bleeding: Use it Without Fear!”

To the Editor, We thank the author’s constructive comments and appreciate the opportunity to respond to the comments about our article [1]. We agree with the comment that the rate of active bleeding at angiography in our study was low at 32.5 % comparable to some studies [2, 3]. However, our figure is similar to a study by Padia et al. [4] where approximately 33% of patients showed active contrast extravasation during angiography. In our study, a majority of the patients who underwent empiric embolization had prior endoscopy (82 %, 14/17) with either refractory or failed attempted endoscopic treatment. This attempt to achieve hemostasis combined with the known intermittent nature of upper gastrointestinal bleeding (UGIB) may have been contributing factors to the low contrast extravasation rates observed. The use of provocative angiography was first described in 1982 [5]. In our institution, we do not routinely use vasodilator and anticoagulants to induce bleeding. This may have increased the number of positive cases; however, in the few cases for which we have used them, we did not find them particularly useful. There is increasing evidence for using empiric GDA embolization [1–4, 6]. The literature has demonstrated that provocative angiography has been useful and safe in lower gastrointestinal hemorrhage [6], but there is little evidence for its use in UGIB. In patients who are already compromised, there is still a theoretical risk of provocative-related hemorrhage, thereby making them further unstable. We agree that empiric embolization of the suspected culprit artery is important and the role of a multidisciplinary team is fundamental. As we adopt an increasingly aggressive approach to empiric embolization, the need for provocative angiography also will decrease.

The Changing Face of Vascular Interventional Radiology: The Future Role of Pharmacotherapies and Molecular Imaging

Interventional radiology has had to evolve constantly because there is the ever-present competition and threat from other specialties within medicine, surgery, and research. The development of new technologies, techniques, and therapies is vital to broaden the horizon of interventional radiology and to ensure its continued success in the future. In part, this change will be due to improved chronic disease prevention altering what we treat and in whom. The most important of these strategies are the therapeutic use of statins, Beta-blockers, angiotensin-converting enzyme inhibitors, and substances that interfere with mast cell degeneration. Molecular imaging and therapeutic strategies will move away from conventional techniques and nano and microparticle molecular technology, tissue factor imaging, gene therapy, endothelial progenitor cells, and photodynamic therapy will become an important part of interventional radiology of the future. This review looks at these new and exciting technologies.