Vinu Moses

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]

Mechanical thrombectomy for acute ischemic stroke in pregnancy using the penumbra system

Even though intravenous thrombolysis with tissue plasminogen activator (IV tPA) is the standard of care in acute ischemic stroke, its use in pregnancy is not clearly defined. Mechanical thrombectomy devices can be an option; however, literature on the use of such mechanical devices in stroke in pregnancy is lacking. Here we describe two cases that developed acute embolic stroke during pregnancy who were successfully treated by mechanical clot retrieval using the Penumbra system 28 (Penumbra Inc., Alameda, California, USA). To the best of our knowledge, these are the only case reports on the use of the Penumbra device in pregnant patients with acute ischemic stroke.

Percutaneous Cyanoacrylate Glue Embolization for Peripheral Pseudoaneurysms: An Alternative Treatment

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.

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

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.

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

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.

Intrahepatic Collateral Recanalization in Symptomatic Budd-Chiari Syndrome: A Single-center Experience

The authors present a single-institutional experience with intrahepatic collateral vessel recanalization as a treatment option in symptomatic Budd-Chiari syndrome (BCS). Over a period of 26 months, this procedure was performed in four symptomatic patients in whom standard hepatic vein recanalization was not feasible or had failed, with a follow-up duration ranging from 7 to 44 months. Based on these cases, intrahepatic collateral vessel recanalization is a promising treatment option in suitable patients with symptomatic BCS and is deserving of further study.

Endovascular management of posttraumatic arteriovenous fistulae.

Surgery is considered to be the treatment of choice for vascular injuries caused by trauma. However, endovascular techniques are emerging as an alternative means of treatment. In this article, we describe three patients with posttraumatic arteriovenous fistulae in different body regions that were managed using endovascular techniques. Each case had its unique set of associated problems requiring innovative methods and a multidisciplinary approach. While the short-term results are encouraging, long-term follow-up of posttraumatic arteriovenous fistulae that have been treated with endovascular techniques is still required.

Role of penumbra mechanical thrombectomy device in acute dural sinus thrombosis

Background: In dural venous sinus thrombosis (DVST), the mortality ranges 5–30%. Deep venous system involvement and septic dural sinus thrombosis have a higher mortality rate. In acute occlusion, collateral flow may not be established, which may result in significant edema and mass effect. Endovascular interventions may be considered as a treatment option in appropriate high-risk patients with DVST. Materials and Methods: Eight patients with magnetic resonance imaging (MRI)-confirmed dural sinus thrombosis, who did not respond to the conventional standard medical treatment, were subsequently treated with mechanical thrombectomy using the Penumbra System®. In all cases, medical treatment including anticoagulants were continued following the procedure for a minimum period of 1 year. Results: Recanalization of the dural sinus thrombosis was achieved in all 8 cases. There were no immediate or late endovascular-related complications. One death occurred due to an unrelated medical event. At 6 months, there was notable improvement in the modified Rankin Score (mRS), with 5/8 (62%) patients achieving mRS of 2 or less. The follow-up ranged between 3 months and 26 months (mean: 14.5 months), and there were no new neurological events during the follow-up period. Conclusion: Cerebral venous sinus thrombosis is a rare but life-threatening condition that demands timely diagnosis and therapy. In cases of rapidly declining neurological status despite standard therapy with systemic anticoagulation and anti-edema measures, mechanical thrombectomy could be a lifesaving and effective option. In this study, good outcomes were observed in the majority of patients at long-term follow up.

Outcomes of catheter-directed treatment of lower extremity deep vein thrombosis of patients presenting to a tertiary care hospital

Background: Lower extremity deep vein thrombosis (DVT) is a common illness with an annual incidence of 1 per 1000 adults. The major long-term complication of DVT is post-thrombotic syndrome (PTS) which occurs in up to 60% of patients within 2 years of an episode of DVT. Aims: We aim to evaluate the outcomes of catheter-directed treatment (CDT) for symptomatic acute or subacute lower extremity DVT. Materials and Methods: A retrospective 12-year study was conducted on the outcomes of CDT on 54 consecutive patients who presented with acute or subacute lower extremity DVT to our hospital. Statistical Analysis: Descriptive summary statistics and the Chi-square test were used to measure the outcomes of CDT. Results: Grade 3 thrombolysis was achieved in 25 (46.3%) patients, grade 2 thrombolysis in 25 (46.3%) patients, and grade 1 thrombolysis in 4 (7.4%) patients. Significant recanalization (grade 2 or 3 thrombolysis) was possible in 50 (92.6%) patients. There was no statistically significant difference in the percentage of significant recanalization that could be achieved between patients who underwent CDT before and after 10 days. There was no significant difference between the thrombolysis achieved between urokinase and r-tPA. PTS was seen in 33% of the patients. Major complications were seen in 5.5% of the patients. Conclusion: CDT is a safe and effective therapeutic technique in patients with acute and subacute lower extremity DVT, if appropriate patient selection is made.

Ethanol sclerotherapy for treatment of venous malformations of face and neck— a single centre experience

Due to complicated anatomy of the face and neck, complete surgical excision of venous malformation is rarely possible and may lead to bleeding, nerve damage and cosmetic deformity. Sclerotherapy is an alternative method of treatment with few complications. Ethanol shows the lowest rate of malformation recurrence and is the most reliable substance of all of the sclerosing agents. This study aims to evaluate the efficacy of ethanol instillation in venous malformation of the face and neck. Between July 20, 2008, to December 30, 2009, 15 patients with venous malformation of the face and neck were included in the study. After confirmation of diagnosis (combination of history, physical findings and magnetic resonance imaging), percutaneous ethanol (99.5% ethyl alcohol) sclerotherapy was used under DSA road mapping using general anaesthesia. Sclerotherapy provided significant improvement of symptoms for all patients, with no major complications. All patients experienced pain and swelling to a variable degree in the immediate post procedure period that resolved over few days. Ethanol sclerotherapy for venous malformations of the face and neck is a safe and effective treatment option.