Pankaj Mehta

Arterial interventions in gastrointestinal bleeding.

The diagnosis and management of gastrointestinal (GI) bleeding are complicated. A multitude of pathologic processes results in GI bleeding, and often, the bleeding is intermittent in nature. Of the available diagnostic tools, angiography has been the gold standard. Management of patients requires a multidisciplinary approach involving gastroenterologists, interventional radiologists, and surgeons. Therapeutic arterial interventions include pharmacologic control with the use of intraarterial vasopressin, embolization with temporary and permanent embolizing materials, and catheter-induced vasospasm.

Efficacy and safety of USG-guided ethanol sclerotherapy in cystic thyroid nodules.

Objective: To study the effectiveness and safety of USG-guided ethanol sclerotherapy in cystic thyroid nodules. Materials and Methods: USG of the thyroid gland was performed in 54 patients suspected to have a thyroid nodule on clinical examination. All patients with a predominantly cystic nodule (i.e., when >2/3rd of the nodule was cystic) were included in the study. Ethanol was injected into the cyst under USG guidance. The amount of ethanol injected was about 50% of the amount of aspirated fluid. Follow-up USG was done every month for 3 months; ethanol was re-injected when there was no significant reduction in the cyst volume. The initial cyst volume was compared with the final volume; statistical significance was assessed using the paired t-test. Results: USG revealed predominant cystic nodules in 16 of the 54 patients. Fifteen patients were selected for the study. Following ethanol sclerotherapy, four out of the 15 patients (26.6%) showed complete disappearance of the cyst and nine (60%) showed significant reduction in the cyst volume (i.e., reduction of cyst volume by ≥50% of initial volume). Only two patients did not show significant reduction in cyst volume; both these patients had nodules with an initial volume of ≥20 cc. There were no complications attributable to ethanol injection during follow-up. Conclusion: Ethanol sclerotherapy is an effective and safe treatment for benign cystic thyroid nodules with volumes of <20 cc. Cystic nodules with volume >20 cc may need more number of alcohol injections and longer follow-up.

Covered coronary stent grafts as a treatment option for carotid-cavernous fistulas: Our initial experience

Treatment of Type 1 carotid-cavernous fistula (CCF) is complex and endovascular stent grafting is proving to be an excellent technique not only in successful treatment of fistula but also preserving patency of parent artery. We describe our initial experience in the use of covered coronary stent grafts in the treatment of three patients with Type 1 post-traumatic CCF. All patients were successfully treated with placement of stent grafts. Immediate closure of fistula was achieved in all the three patients. One patient developed partial in-stent thrombosis. In this patient antiplatelet therapy had to be stopped as he developed a small intracerebral hematoma post procedure. Subsequently, he was restarted on antiplatelets and recovered completely. Except for this no other complication was observed. Covered stent grafts may be the procedure of choice for treatment of post-traumatic Type 1 CCF especially in young patients with favorable anatomy.

Bipolar radiofrequency-induced thermotherapy of great saphenous vein: Our initial experience

The incidence of varicose veins in lower limbs is increasing in the Indian subcontinent. With the advent of radiofrequency ablation (RFA), an effective minimally invasive technique is now available to treat varicose veins. RFA can be performed with either unipolar or bipolar probes. We present a simple technique for bipolar radiofrequency-induced thermotherapy of the great saphenous vein. This can be a safe and effective alternative to surgical procedures.

Technical note: A simple and effective CO 2 delivery system for angiography using a blood bag.

Several angiographic techniques have been developed to image the arterial system, the commonest using iodinated contrast media. Useful as they may be, they are not without disadvantages. One other modality is angiography using CO2. Although CO2 can be used as an alternative contrast medium, delivery systems are expensive to procure. We describe an indigenous and effective delivery system developed at our institute.

Review: Interventional radiology in peripheral vascular disease

Peripheral vascular diseases (PVD) are referred to as diseases affecting the blood vessels other than the heart and the brain. Interventional endovascular treatment whenever feasible has become the first line of management in the treatment of PVD. Interventions may be aimed at either revascularization or deliberate occlusion of a diseased vessel(s). This article reviews the various peripheral vascular diseases with their appropriate endovascular management.

Endovascular management of a coronary artery to pulmonary artery fistula with detachable balloons: a case report

Coronary arteriovenous (AV) fistulae are rare congenital anomalies and encompass a wide variety of communications between the coronary artery and the pulmonary or systemic vasculature. Symptoms depend on the presence and severity of myocardial malperfusion secondary to coronary artery steal phenomenon at rest or exertion. These fistulae are traditionally treated by open surgery. Endovascular therapy has been reported with the use of fibered coils. We report a case of a large left anterior descending (LAD) coronary artery to the main pulmonary artery fistula that was incidentally discovered during a pre-operative work up in a 28-year-old woman. The fistula was successfully treated with detachable balloons, however the patient developed delayed thrombosis of the coronary artery after 7 years of endovascular therapy requiring surgical bypass to the coronary artery.

First Indian single center experience with pipeline embolization device for complex intracranial aneurysms

BACKGROUND Flow diversion is a novel method of therapy wherein an endoluminal sleeve, the flow diverter stent is placed across the neck of complex aneurysms to curatively reconstruct abnormal vasculature. We present the first Indian single center experience with the pipeline embolization device (PED) and 6 months follow-up results of 5 patients. SUBJECTS AND METHODS Five complex or recurrent intracranial aneurysms in five patients were treated with PED. The patients were followed-up with magnetic resonance angiography (MRA) after 4 weeks and conventional angiography after 6 months. Feasibility, complications, clinical outcome, early 1-month MRA and 6 months conventional angiographic follow-up results were analyzed. RESULTS Of the five aneurysms treated, four were in the anterior circulation and one in the posterior circulation. All five patients were treated with a single PED in each, and additionally coils were used in one patient. At 1-month MRA follow-up, complete occlusion was seen in 2 (40%) of the five cases. Post 6 months conventional angiography showed complete occlusion of the aneurysm sac in all five cases (100%). Side branch ostia were covered in three patients, all of which were patent (100%). There was no incidence of major neurological morbidity or mortality. One patient (20%) who had basilar top aneurysm experienced minor neurological disability after 5 days which partially improved. CONCLUSIONS Pipeline embolization device for complex and recurrent aneurysms is technically feasible, safe, offers low complication rate, and definitive vascular reconstruction. PED can be used without fear of occlusion of covered eloquent side branches and perforators.

Outcomes of Endovascular Coiling in Patients with Intracranial Aneurysms Presenting with Poor Clinical and SAH Grade.

Although the treatment of intracranial aneurysms has made significant advances, prediction of outcomes in poor grades has always been difficult. We present our findings of patients in poor clinical and SAH grade treated with endovascular coiling. We aimed to evaluate the clinical outcomes in patients presenting with poorer neurological and SAH grades treated by endovascular techniques. Of 190 patients who presented with SAH over a period of nine years, 34 were of poorer clinical grade (Hunt & Hess Grades 4 and 5), of whom 30 presented with H&H grade 4 and four with grade 5. 44.1% of the 34 patients belonged to Fischer grade 4. We assessed the technical success and final outcomes based on the Glasgow outcome scale. Of the 30 patients with grade 4, 81.4% had a good outcome. Two out of four patients with grade 5 had a poor outcome. 82.5% of the patients with Fischer grade 4 had a good outcome. None of the poor outcomes were procedure-related. Endovascular treatment with its higher rates of technical success, lower complication rates and better outcomes should be recommended as the treatment of choice in patients with intracranial aneurysms even in patients with poorer clinical and SAH grades.

An unusual case of coil migration. A case report.

Migration of endovascular coils from aneurysms has been reported in the past. However, we report a case where the entire coil mass migrated out of the aneurysm into the anterior cerebral artery with associated doubling of aneurysm diameter in the intervening two weeks period post-coiling.