Tony Nicholson

Hepatic Artery Angiography and Embolization for Hemobilia Following Laparoscopic Cholecystectomy

AbstractPurpose: The effectiveness of angiography and embolization in diagnosis and treatment were assessed in a cohort of patients presenting with upper gastrointestinal hemorrhage secondary to hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. Methods: Over a 6-year period 1513 laparoscopic cholecystectomies were carried out in our region. Nine of these patients (0.6%) developed significant upper gastrointestinal bleeding, 5–43 days after surgery. All underwent emergency celiac and selective right hepatic artery angiography. All were treated by coil embolization of the right hepatic artery proximal and distal to the bleeding point. Results: Pseudoaneurysms of the hepatic artery adjacent to cholecystectomy clips were demonstrated in all nine patients at selective right hepatic angiography. In three patients celiac axis angiography alone failed to demonstrate the pseudoaneurysm. Embolization controlled hemorrhage in all patients with no further bleeding and no further intervention. One patient developed a candidal liver abscess in the post-procedure period. All patients are alive and well at follow-up. Conclusion: Selective right hepatic angiography is vital in the diagnosis of upper gastrointestinal hemorrhage following laparoscopic cholecystectomy. Embolization offers the advantage of minimally invasive treatment in unstable patients, does not disrupt recent biliary reconstruction, allows distal as well as proximal control of the hepatic artery, and is an effective treatment for this potentially life-threatening complication.

Managing inadvertent arterial catheterization during central venous access procedures.

AbstractPurpose: Approximately 200,000 central venous catheterizations are carried out annually in the National Health Service in the United Kingdom. Inadvertent arterial puncture occurs in up to 3.7%. Significant morbidity and death has been reported. We report on our experience in the endovascular treatment of this iatrogenic complication. Methods: Retrospective analysis was carried out of 9 cases referred for endovascular treatment of inadvertent arterial puncture during central venous catheterization over a 5 year period. Results: It was not possible to obtain accurate figures on the numbers of central venous catheterizations carried out during the time period. Five patients were referred with carotid or subclavian pseudoaneurysms and hemothorax following inadvertent arterial catheter insertion and subsequent removal. These patients all underwent percutaneous balloon tamponade and/or stent-graft insertion. More recently 4 patients were referred with the catheter still in situ and were successfully treated with a percutaneous closure device. Conclusion: If inadvertent arterial catheterization during central venous access procedures is recognized and catheters removed, sequelae can be treated percutaneously. However, once the complication is recognized it is better to leave the catheter in situ and seal the artery percutaneously with a closure device.

Fibroid Calcification after Uterine Artery Embolization: Ultrasonographic Appearance and Pathology

PURPOSE To describe the ultrasonographic (US) appearance of fibroid calcification occurring after uterine artery embolization (UAE) and discuss its etiology and pathology. MATERIALS AND METHODS Twenty-seven of a total of 38 patients were followed up clinically and with duplex US for longer than 6 months after UAE for uterine fibroids. At US, changes in uterine size, fibroid vascularity, and morphology have been recorded. Pathologic studies were performed by one of the authors on resected specimens from a different cohort of patients, at intervals ranging from 4 months to 1 year after UAE. RESULTS Twenty patients reported complete resolution of symptoms. In 16 of these, a reduction in fibroid volume of 70%-85% was recorded and, at US, the development of a peripheral hyperechoic rim around an increasingly hypoechoic fibroid was noted. Computed tomography in two patients revealed it to be a rim of calcium. Histologic studies in a different cohort of patients who had undergone hysterectomy at variable intervals after UAE demonstrated early aggregation of polyvinyl alcohol (PVA) particles, an intermediate giant cell inflammatory reaction, and calcification in the periphery of the infarcted fibroid at 6-12 months. CONCLUSION Calcification is the end stage of hyaline degeneration. However, its peripheral location is unlike that of natural fibroid involution and hyaline necrosis. Pathologic studies in resected human fibroids after embolization suggest that its development is the end result of aggregation of PVA particles in peripheral fibroid arteries.

CIRSE guidelines: quality improvement guidelines for endovascular treatment of traumatic hemorrhage.

This quality improvement guideline outlines the place of interventional radiology (IR) in trauma management and indicates how imaging and IR can be used in the context of hemorrhage in the severely injured patient, and when IR is appropriate and when it is contraindicated. Vascular injury may also lead to occlusion, and this will be discussed where relevant. There is no intention for this document to be proscriptive; CIRSE and the writing committee recognize that successful centres may practice differently. The intention is to indicate how to develop the multidisciplinary linkages and infrastructure required for successful integration of imaging and IR in the trauma pathway. It is hoped that this will help prepare the way for greater consensus in the adoption of imaging and intervention in the management of the critically injured patient. The information presented here reflects available evidence and draws on pathways already in clinical use. It is intended for local consideration and adaptation according to current and future resources. Recommendations for practice and quality improvement are indicated throughout, and a checklist for safe use of intervention in the management of traumatic hemorrhage is included. Wherever possible, levels of evidence and grades of recommendation are based on those proposed by Oxford Centre for Evidence-based Medicine. A fuller version of this document is available at the CIRSE Web site.

Selective Embolization of Large Symptomatic Iatrogenic Renal Transplant Arteriovenous Fistula

We report on the successful treatment of hypertension by occlusion of a large iatrogenic renal transplant arteriovenous fistula using detachable embolization coils with concomitant flow reduction by occlusion balloon in two patients.

Percutaneous transluminal angioplasty and enclosed thrombolysis versus percutaneous transluminal angioplasty in the treatment of femoropopliteal occlusions : Results of a prospective randomized trial

Purpose: To determine whether percutaneous transluminal angioplasty (PTA) and enclosed thrombolysis (ET) is superior to PTA alone in the treatment of femoropopliteal occlusions. Methods: Twenty-five patients with 5–15-cm-long occlusions in the femoropopliteal segments, with otherwise normal run-in arteries and at least one normal tibioperoneal artery to the foot, were randomized to ET/PTA or PTA alone. Ankle brachial systolic index (ABI) was measured before the procedure and at 24 hr and 12 months after the procedure, when a duplex scan was also carried out. End points in the study were patency at, or repeat intervention before, 12 months. Results: Procedures were successful in 23 of 25 patients. There was one immediate occlusion of tibioperoneal arteries, and one early reocclusion of a reopened segment in the ET/PTA group. There was one early reocclusion in the PTA group. At 12 months patency was 70% and 69.2% in the ET/PTA and PTA groups respectively. Covariant analysis showed no significant difference in ABI between the two groups at any of the three measurement times. Conclusion: This trial demonstrated no difference between ET/PTA and PTA alone in femoropopliteal occlusions associated with normal proximal arteries and at least one normal tibioperoneal artery.

Secondly, improve availability of interventional radiology

An important element of the SIGN guidelines is evidence based advice about the management of patients who fail medical and endoscopic or sigmoidoscopic therapy.1 SIGN advocates computed tomography angiography for diagnosis and embolisation for treatment of non-variceal haemorrhage, as well as transjugular portosystemic shunting for variceal haemorrhage. NHS …

Michael John Imrie

Michael John Imrie (“Mike,” “Nim”) was born in Newcastle and studied medicine at Manchester University, where he was “rag committee” secretary. After doing house jobs in the Manchester area, Mike did a year’s research into circadian rhythms, which led to an MSc. He trained in radiology in Liverpool and …

The limitations of the “Stanford 25”

In their editorial, Verghese and Horwitz fail to point out the limitations of many of the “Stanford 25” tests.1 For example, examining Traube’s space has a 72% specificity and 62% sensitivity.2 …