Michael V. Beheshti

Percutaneous Isolated Liver Perfusion for Treatment of Hepatic Malignancy: Preliminary Report

Chemotherapy for primary or metastatic hepatic malignancy is limited by poor tumor response and dose-related systemic toxicity. As an alternative to chemotherapy infusion by vein or by the hepatic artery, the authors have developed a percutaneous technique of isolated liver perfusion that allows the regional delivery of high-dose chemotherapy to the liver with little systemic toxicity. After placement of a hepatic artery infusion catheter, an 18-F double-balloon catheter is placed into the inferior vena cava through the opposite femoral vein. Balloons are inflated above and below the hepatic veins, thus isolating hepatic venous outflow. The effluent passes through fenestrations in the catheter and is pumped through charcoal hemoperfusion filters where the drug is removed. The filtered blood is returned to the patient through the internal jugular vein. Fifteen treatments have been conducted in eight patients in a phase I dose-escalation study with use of 5-fluorouracil (5-FU). While it is premature to assess tumor response to isolated liver perfusion, the data demonstrate that the procedure is safe and is tolerated by patients. Pharmacokinetic studies show a 5-FU extraction of up to 85%, with minimal drug leakage into the systemic circulation. This technique shows potential for improving liver tumor response while decreasing systemic toxicity.

Management of Pulmonary Arteriovenous Malformations

Pulmonary arteriovenous malformations are rare lesions with significant clinical complications. These lesions are commonly seen in patients with hereditary hemorrhagic telangiectasia (formerly Osler-Weber-Rendu syndrome). Interventional radiologists are a key part of the treatment team in this complex disease, and a thorough understanding of the disease process is critical to providing good patient care. In this article, the authors review the disease course and its association with hereditary hemorrhagic telangiectasia, discusses the clinical evaluation and treatment of these complex patients, and outlines complications and follow-up.

A Concise History of Central Venous Access

Central venous access has become a mainstay of modern interventional radiology practice. Its history has paralleled and enabled many current medical therapies. This short overview provides an interesting historical perspective of these increasingly common interventional procedures.

Principles of Non-Tunneled Central Venous Access

Non-tunneled central venous access has become an important tool in the management of the sick patient, particularly in the intensive care unit. Image guidance allows more precise placement of lines with overall lower complication rates compared with guidance by physical landmarks. The use of image guidance has brought a procedure traditionally performed by surgeons into the realm of the interventional radiologist. Techniques for placement of non-tunneled central venous catheters, hemodialysis catheters, and peripherally inserted central catheter lines will be discussed.

The Interventional Radiology Business Plan

Strategic planning and business planning are processes commonly employed by organizations that exist in competitive environments. Although it is difficult to prove a causal relationship between formal strategic/business planning and positive organizational performance, there is broad agreement that formal strategic and business plans are components of successful organizations. The various elements of strategic plans and business plans are not common in the vernacular of practicing physicians. As health care becomes more competitive, familiarity with these tools may grow in importance. Herein we provide an overview of formal strategic and business planning, and offer a roadmap for an interventional radiology-specific plan that may be useful for organizations confronting competitive and financial threats.

Percutaneous transhepatic cholangioscopy using a flexible digital ureteroscope through a 10-fr vascular sheath: a novel method to evaluate bile duct injury in patients with Roux-en-Y gastric bypass surgery.

Patients with long afferent limb Roux-en-Y gastric bypass (RYGB) surgery represent a subset of patients in whom endoscopic management of bile duct pathology is challenging. We describe a 53-year-old woman with long afferent limb RYGB surgery for weight loss who presented with worsening abdominal pain 2 weeks after computed tomography (CT)guided biopsy of pancreatic head fullness. An inadvertent common bile duct (CBD) injury resulting in bile duct leak was confirmed on nuclear scan. A subsequent percutaneous transhepatic cholangiogram (PTC) revealed moderate intrahepatic and extrahepatic biliary duct dilatation with CBD stricture distal to the cystic duct (Fig. 1). We used the technique of percutaneous cholangioscopy (PCS) using an Invisio DUR-D flexible digital ureteroscope (FDU) from Gyrus ACMI (Southborough, MA, USA) (Fig. 2) through a 10-Fr vascular sheath to successfully evaluate and biopsy the CBD at the site of the stricture and ampulla (Video S1). This scope has a 65-cm working length with a diameter of between 8.7 Fr at the tip to 9.3 Fr at the shaft. It has a 3.6-Fr working channel that allows the use of instruments such as biopsy forceps, laser fibers and baskets up to 3 Fr, while still permitting adequate irrigation. The tip houses dual LED-driven light carriers and a 1-mm digital camera that eliminates the need for fragile fiber optics. The scope is capable of dual 250 degrees of deflection which improves maneuverability. The images by this ureteroscope can be digitally magnified to 135% and have a higher resolution of effective pixel counts, 12-fold fiberoptic scopes. PCS using DFU provides many advantages over peroral and percutaneous fiberoptics cholangioscopy; the use of a vascular sheath to access the bile duct percutaneously eliminates the need for fistula maturation as required in endoscopic retrograde cholangiopancreatography through a gastrostomy tract. It provides a means to irrigate the bile duct which improves the visual field. Digital flexible ureteroscopes are more durable and maneuverable than fiberoptic cholangioscopes and provide better-quality imaging.