Rajiv Sawhney

Endovascular aneurysm repair in high-risk patients☆☆☆★★★

PURPOSE The purpose of this study was to evaluate the role of endovascular aneurysm repair in high-risk patients. METHODS The elective endovascular repair of infrarenal aortic aneurysm was performed in 116 high-risk patients with either custom-made or commercial stent grafts. The routine follow-up examination included contrast-enhanced computed tomography (CT) before discharge, at 3, 6, and 12 months, and annually thereafter. Patients with endoleak on the initial CT underwent re-evaluation at 2 weeks. Those patients with positive CT results at 2 weeks underwent endovascular treatment. RESULTS Endovascular repair was considered feasible in 67% of the patients. The mean age was 75 years, and the mean aneurysm diameter was 6.3 cm. The American Society of Anesthesiologists grade was II in 3.4%, III in 65.5%, IV in 30.1%, and V in 0.9%. There were no conversions to open repair. Custom-made aortomonoiliac stent grafts were implanted in 77.6% of the cases, custom-made aortoaotic stent grafts in 11.2%, and commercial bifurcated stent grafts in 11.2%. The 30-day rates of mortality, major morbidity, and minor morbidity were 3.4%, 20.7%, and 12%, respectively, in the first 58 patients and 0%, 3.4%, and 3.4%, respectively, in the last 58. The late complications included five cases of stent graft kinking, two cases of femorofemoral graft occlusion, and three cases of proximal stent migration, one of which led to aneurysm rupture. At 2 weeks after repair, endoleak was present in 10.3% of the cases. All the type I (direct perigraft) endoleaks underwent successful endovascular treatment, whereas only one type II (collateral) endoleak responded to treatment. The technical success rate at 2 weeks was 86.2%, and the clinical success rate was 96.6%. The continuing success rate was 87.9%. Seventeen patients died late, unrelated deaths. CONCLUSION Endovascular aneurysm repair is safe and effective in patients at high risk, for whom it may be the preferred method of treatment.

Endovascular repair of abdominal aortic aneurysm using a pararenal fenestrated stent-graft.

Purpose: To report an unusual case of endovascular abdominal aortic aneurysm (AAA) exclusion in which a fenestrated stent-graft was used to seal a proximal Type I endoleak. Methods and Results: An 84-year-old man with a 6.0-cm AAA underwent an aortomonoiliac aneurysm exclusion procedure that was complicated by a proximal endoleak. Because the patient had no right kidney, an additional stent-graft was designed to cover the right renal artery stump while preserving left renal perfusion through a fenestration in the graft material. This approach was successful in obliterating the endoleak around the proximal attachment site, but flow through the lumbar arteries remained. Conclusions: The use of a fenestrated stent-graft is feasible, but the type of fenestration in this case has limited applicability owing to the rarity of patients with suitable anatomy.

A modular multi-branched system for endovascular repair of bilateral common iliac artery aneurysms.

PURPOSE To describe a modular stent-graft for cases of bilateral common iliac aneurysm. TECHNIQUE The aortic aneurysm is repaired using a standard bifurcated modular system (Zenith). A modified bifurcated component is deployed with its trunk in one limb of the original aortic stent-graft, its long limb in the external iliac artery, and its short limb in the iliac aneurysm just above the internal iliac orifice. A flexible extension is introduced from the right brachial artery and used to bridge the gap between the short limb of the modified bifurcated component and the left internal iliac artery. CONCLUSIONS Endovascular repair of bilateral iliac aneurysm is feasible using a modular stent-graft with separate branches to the internal and external iliac arteries.

Treatment of postoperative lymphoceles with percutaneous drainage and alcohol sclerotherapy.

PURPOSE To assess the efficacy and safety of percutaneous catheter drainage combined with alcohol sclerosis in the treatment of postoperative lymphoceles. PATIENTS AND METHODS Thirteen patients with 14 postoperative symptomatic lymphoceles were treated. Drainage catheters were inserted under ultrasound (n = 13) or computed tomographic (n = 1) guidance. Lymphocele sclerosis was performed by instilling 10-100 mL of absolute alcohol into the lymphocele cavity and aspirating the alcohol after 30 minutes. Sclerosis sessions were carried out one to three times per day, usually three times per week. Catheter sinograms were obtained and prophylactic antibiotics administered. Imaging was repeated if symptoms or signs of recurrence developed. RESULTS Successful drainage and sclerosis were achieved in all 13 patients. One patient with a recurrence was successfully treated with repeated drainage and alcohol ablation. No adverse effects of alcohol instillation were seen. The mean duration of catheterization was 36 days (range, 17-65 days; median, 30 days). CONCLUSION Percutaneous drainage combined with alcohol ablation is a safe and effective treatment of postoperative lymphoceles.

Implementation of a multidisciplinary treatment team for hepatocellular cancer at a Veterans Affairs Medical Center improves survival

Several methods of treatment for hepatocellular carcinoma (HCC) are often used in combination for either palliation or cure. We established a multidisciplinary treatment team (MDTT) at the San Francisco Veterans Affairs Medical Center in November 2003 and assessed whether aggressive multimodality treatment strategies may affect survival. A prospective database was established and follow-up information from patients with presumed HCC was collected up to November 2006. Information from the American College of Surgeons (ACS) cancer registry from January 2000 to November 2003 identified patients with HCC that were evaluated at the same institution prior to the establishment of the MDTT. The establishment of a MDTT resulted in the doubling of patient referrals for treatment. Significantly more patients were evaluated at earlier stages of disease and received either palliative or curative therapies. The overall survival (p<0.0001) and length of follow-up (p<0.05) were significantly improved after the establishment of the MDTT. Stage-by-stage comparisons indicate that aggressive multimodality therapy conferred significant survival advantage to patients with American Joint Commission on Cancer (AJCC) stage II HCC (odds ratio 15.50, p<0.001). Multidisciplinary collaboration and multimodality treatment approaches are important in the management of hepatocellular carcinoma and improves patient survival.

Massive Abdominal Wall Hemorrhage from Injury to the Inferior Epigastric Artery: A Retrospective Review

PURPOSE To identify the etiology of inferior epigastric artery injury (IEAI) in patients referred to the interventional radiology service and determine the efficacy of diagnostic imaging and embolization in these patients. MATERIALS AND METHODS A retrospective review of patients referred to the interventional radiology departments at three university-affiliated hospitals from 1995 through 2007 was performed. Patients were identified and data were extracted from case log books and the electronic medical record. RESULTS Twenty IEAIs were identified in 19 patients. The etiology of arterial injury was paracentesis in eight (40%), surgical trauma in three (15%), percutaneous drain placement in three (15%), blunt trauma in two (10%), subcutaneous injection in one (5%), stabbing in one (5%), and unknown in two (10%). Fifteen of 19 patients (79%) had an underlying coagulopathy. The diagnosis was confirmed by contrast medium-enhanced computed tomography (CT) in 14 (70%), tagged red blood cell scan in two (10%), and noncontrast CT in one (5%). Three patients (15%) had no diagnostic imaging. Contrast medium-enhanced CT showed active extravasation in nine of 14 patients (64%) and 13 of 14 exhibited active extravasation on subsequent arteriography. The sensitivity and specificity of contrast medium-enhanced CT for demonstrating active arterial bleeding were 70% and 100%, respectively. All 20 IEAIs were treated with transcatheter embolization, with an overall success rate of 90% and no complications. CONCLUSIONS IEAI is most often an iatrogenic injury in a coagulopathic patient. Contrast medium-enhanced CT can be diagnostic for active bleeding, but in the setting of ongoing hemorrhage a negative study result should not preclude arteriography. Embolization is an effective means to control hemorrhage.

Retrograde Catheterization of the Inferior Mesenteric Artery to Treat Endoleaks: Anatomic and Technical Considerations

Abbreviations: IMA inferior mesenteric artery, SMA superior mesenteric artery ENDOVASCULAR stent-graft placement is a promising new therapy for the treatment of infrarenal abdominal aortic aneurysm (1,2). The procedure can be successfully accomplished with low procedural morbidity in most cases. However, persistent aneurysm perfusion after stent-graft placement is an important complication of this new innovative therapy that is observed in 5%–40% of patients (3,4). The best method for managing patients with postimplantation perigraft perfusion (endoleak) is not yet known and, consequently, many approaches to the management of this problem are being explored (5–7). Some endoleaks are due to backbleeding from infrarenal aortic sidebranches (4). These sidebranches receive inflow from arterial collaterals. Blood typically flows in through one sidebranch, such as the inferior mesenteric artery (IMA), traverses the perigraft space, and then flows out through another sidebranch, such as a lumbar artery. Endoleaks of this type can be prevented by occluding the involved aortic sidebranches. Sidebranch vessels can be accessed for embolization in two ways: (i) via a systemic collateral (superior mesenteric artery [SMA] or iliolumbar arteries)—in this way, the sidebranch vessel and perigraft space are catheterized from an “outside-in” approach, or (ii) via the perigraft space, which can be entered directly, around the proximal or distal end of the stent-graft—in this way, the sidebranch vessel is catheterized from an “inside-out” approach. In the past few years, we have gained experience with retrograde catheterization of infrarenal aortic sidebranches for this purpose. The purpose of this article is to highlight the anatomic and technical considerations relevant to retrograde IMA catheterization used to treat endovascular stent-graft leaks.

Aortic stent-grafts in patients with renal transplants.

Purpose: To report the endovascular treatment of abdominal aortic aneurysms (AAA) in 2 patients with pelvic renal transplants. Methods and Results: Two men with multiple comorbidities and pelvic transplant kidneys underwent endovascular AAA repair using an aortomonoiliac system with femorofemoral bypass grafting. The arterial end-to-side anastomosis in both patients was to the external iliac artery. Tapered aortomonoiliac grafts were fashioned from Gianturco Z-stents covered with Dacron graft material and implanted with the distal attachment site in the iliac system ipsilateral to the transplant kidney arterial anastomosis. The body of the stent-graft was reinforcement with a Wallstent in each case before the contralateral common iliac artery was occluded and the cross-femoral bypass constructed. Both patients recovered uneventfully from the procedure and are free of endoleak or other complications related to their aneurysm repair at 7 and 34 months. Conclusions: The presence of a pelvic renal transplant in a patient undergoing endovascular AAA repair increases the complexity of procedural planning and endograft implantation, but a good outcome can be achieved.

Hepatic Infarction: Unusual Complication of a Transjugular Intrahepatic Portosystemic Shunt

O SCVIR, 1997 THE transjugular intrahepatic portosystemic shunt (TIPS) procedure has been used with increasing frequency as a safe and effective method for treating variceal bleeding and ascites in patients with portal hypertension. The technical aspects and success rates of the procedure have been well delineated in several reports (1-3). Most short-term and long-term followup reports have focused on the wellknown problems of postprocedural shunt stenosis or occlusion, and new or worsening encephalopathy. Less common ( ~ 1 0 % ) procedure-related complications that have been reported include semis. contrast material. , related nephropathy, puncture site hematoma, cardiac arrhythmia, stent malposition, and extracapsular needle puncture with associated bleeding (2-5). TIPS-related hepatic artery injury and associated traumatic hepatic artery occlusion are distinctly uncommon, with TIPS-associated hepatic infarction being extremely rare (6-9). Hepatic infarction, in general, is unusual because of the dual vascular supply to the liver via the portal vein and hepatic artery. We describe a patient who developed hepatic infarction after TIPS, which was not initially identified with ultrasound (US) but was seen a t computed tomography (CT). The infarction was noted to resolve almost completely over the course of 3 weeks without clinical consequence.

Periprocedural complications by Child-Pugh class in patients undergoing transcatheter arterial embolization or chemoembolization to treat unresectable hepatocellular carcinoma at a VA medical center

BACKGROUND For patients with compensated cirrhosis, transcatheter arterial embolization with and without additive chemotherapy has been shown to improve survival. The aim of this study was to compare periprocedural complications in a population with hepatitis C virus-related hepatocellular carcinoma to evaluate for differences in complications by severity of liver disease. METHODS Patients with unresectable hepatocellular carcinoma treated by transcatheter arterial embolization with or without additive chemotherapy procedures from 2003 to 2006 were retrospectively reviewed and compared by Child-Pugh (CP) class. A total of 141 embolizations were done in 76 patients. RESULTS Complication rates were seen in 27% of CP class A and 17% of CP class B patients. There was no significant difference in the grade of complications between the 2 groups or between procedure types. Survival rate was dependent on the degree of liver dysfunction (3-year CP class A, 49%; CP class B, 13%; P = .0048). CONCLUSION Embolization procedures to treat hepatitis C virus-related hepatocellular carcinoma can be performed safely with low morbidity and mortality rates, even in patients with a compromised hepatic reserve.