Shyamkumar N Keshava

Transjugular liver biopsy: What to do and what not to do

The presence of ascites or deranged bleeding parameters in patients with significant liver parenchymal disease precludes percutaneous liver biopsy (PLB). Transjugular liver biopsy (TJLB) is an important and safer alternative to the traditional method of PLB. This article highlights the technical aspects of the procedure and describes the standard way of performing the procedure, the common problems encountered, and the ways of overcoming them. A transjugular approach to reach the liver was first described by Weiner et al. Transjugular liver biopsy (TJLB)[1,2] is a technique for obtaining liver biopsy without causing a transcapsular injury. Using a transvenous approach, the biopsy needle is inserted into the liver via the hepatic vein, avoiding the peritoneum and the liver capsule. Thus, if there is any bleeding related to the procedure, it will be back into the venous system. Earlier, when aspiration needles[3] were used for biopsy, the quality of the specimen was considered to be inferior to that obtained by percutaneous liver biopsy (PLB). With the advent of the Tru-Cut (Quick-Core biopsy needle, Cook, Bloomington), TJLB specimens have been found to be of the same quality as the PLB specimens.[4–7]

Dual arterial supply to normal lung: within the sequestration spectrum

We report a rare case of dual arterial supply to an otherwise normal left lower lobe. In addition to normal pulmonary arterial supply, the lower lobe of the left lung also received systemic arterial supply from the coeliac axis. The relevant anatomy and literature are reviewed. To the best of our knowledge, there are no other reported cases of anomalous systemic arterial supply from the coeliac axis to the basal segments of the left lower lobe with normal bronchial branching and pulmonary arterial supply.

An open-labelled randomized controlled trial comparing costs and clinical outcomes of open endotracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients ☆,☆☆,★,★★

PURPOSE Closed endotracheal suctioning (CES) may impact ventilator-associated pneumonia (VAP) risk by reducing environmental contamination. In developing countries where resource limitations constrain the provision of optimal bed space for critically ill patients, CES assumes greater importance. MATERIALS AND METHODS In this prospective, open-labeled, randomized controlled trial spanning 10 months, we compared CES with open endotracheal suctioning (OES) in mechanically ventilated patients admitted to the medical intensive care unit (ICU) of a university-affiliated teaching hospital. Patients were followed up from ICU admission to death or discharge from hospital. Primary outcome was incidence of VAP. Secondary outcomes included mortality, cost, and length of stay. RESULTS Two hundred patients were recruited, 100 in each arm. The incidence of VAP was 23.5%. Closed endotracheal suctioning was associated with a trend to a reduced incidence of VAP (odds ratio, 1.86; 95% confidence interval, 0.91-3.83; P = .067). A significant benefit was, however, observed with CES for late-onset VAP (P = .03). Mortality and duration of ICU and hospital stay were similar in the 2 groups. The cost of suction catheters and gloves was significantly higher with CES (Rs 272 [US

Technical note: Reduction of radiation dose using ultrasound guidance during transjugular intrahepatic portosystemic shunt procedure

5.81] vs Rs 138 [US

Breast filariasis: real-time sonographic imaging of the filarial dance.

2.94], P < .0001). Nine patients need to be treated with CES to prevent 1 VAP (95% confidence interval, -0.7 to 22). CONCLUSIONS In the ICU setting in a developing country, CES may be advantageous in reducing the incidence of VAP, particularly late-onset VAP. These results mandate further studies in this setting before specific guidelines regarding the routine use of CES are proposed.

Percutaneous Cyanoacrylate Glue Embolization for Peripheral Pseudoaneurysms: An Alternative Treatment

The transjugular intrahepatic portosystemic shunt (TIPS) procedure for decompression of the portal venous system generally performed under fluoroscopic guidance has undergone continuous technical modifications recently. Due to the length of the procedure, the fluoroscopy times are reasonably high, thus increasing the risk from ionizing radiation. Radiation doses were measured for 19 patients using dose area product (DAP) meter. The average DAP value for the TIPS procedure was 63.86 Gy cm2 (21.12-117.07). Radiation doses to patients can be reduced with the use of USG guidance and intermittent fluoroscopy screening.

Measurement of hepatic venous pressure gradient revisited: Catheter wedge vs balloon wedge techniques

A 50‐year‐old woman presented with a palpable tender nodule in the upper quadrant of the breast that was clinically thought to be a fibroadenoma, with mammographic findings of a well‐defined lobulated density. Sonographic examination revealed a “filarial dance sign” within the cystic lesion, which is diagnostic of lymphatic breast filariasis. In endemic areas, sonographic examination is recommended to search for this pathognomonic real‐time diagnostic feature and, if present, to initiate treatment without delay.

Cannula-Assisted and Transabdominal Ultrasound-Guided Hepatic Venous Recanalization in Budd Chiari Syndrome: A Novel Technique to Avoid Percutaneous Transabdominal Access

Post-traumatic pseudoaneurysms are rare in the peripheral arteries and usually occur as a late sequel of trauma. Surgery has traditionally been considered as the gold standard of therapy for traumatic peripheral pseudoaneurysms. We report 2 cases of post traumatic pseudoaneurysms successfully treated by percutaneous cyanoacrylate glue (N-Butyl 2 cyanoacrylate) embolization. This method offers complete exclusion of the pseudoaneurysm, at the same time avoiding the morbidity of open surgery.

Placement of a Catheter through the Struts of a Previously Placed Stent for Maintenance Hemodialysis: A Case Report

Aims: To evaluate the accuracy of measurement of hepatic venous pressure gradient by catheter wedge as compared to balloon wedge (the gold standard). Materials and Methods: Forty-five patients having a clinical diagnosis of intrahepatic portal hypertension were subjected to the two different types of pressure measurements (catheter wedge and balloon wedge) during transjugular liver biopsy under fluoroscopic guidance. Statistical Analysis: Spearmans rank correlation coefficient, Bland–Altman plot for agreement, and single measure intraclass correlation were used for analysis of data. Results: There was a close correlation between the results obtained by both the techniques, with highly significant concordance (P < 0.0001). Hepatic venous pressure gradients as measured by the catheter wedge technique were either equal to or less than those obtained by the balloon wedge technique. Conclusions: The difference in hepatic venous pressure gradients measured by the two techniques is insignificant.

Imaging evaluation of hemophilia: musculoskeletal approach.

We describe a technique for facilitating recanalization of hepatic veins via the transjugular approach in patients with Budd Chiari syndrome, where a transjugular liver biopsy cannula provides support to the catheter–glidewire combination and transabdominal ultrasound helps in positioning the tip of the cannula at the hepatic venous ostium.