W. Saad

Outcomes of Percutaneous Management of Anastomotic Ureteral Strictures in Renal Transplantation: Chronic Nephroureteral Stent Placement with and without Balloon Dilatation

PurposeThis study was designed o evaluate outcomes of percutaneous management of anastomotic ureteral strictures in renal transplants using nephroureteral stents with or without balloon dilatation.MethodsA retrospective audit of 1,029 consecutive renal transplants was performed. Anastomotic ureteral strictures were divided into two groups: nephroureteral stent only (NUS) and NUS+PTA (nephroureteral stent plus percutaneous transluminal angioplasty), with each cohort subdivided into early versus late presentation (obstructive uropathy occurring <90xa0day or >90xa0days from transplant, respectively). Overall and 6-month technical success were defined as removal of NUS any time with <30xa0% residual stenosis (any time lapse less or more than 6xa0months) and at >6xa0months, respectively. Patency was evaluated from NUS removal to last follow-up for both groups and compared.ResultsSixty-seven transplant patients with 70 ureteric anastomotic strictures (6.8xa0%, nxa0=xa070/1,029) underwent 72 percutaneous treatments. 34xa0% were late (>90xa0days, nxa0=xa024/70), and 66xa0% were early (<90xa0days, nxa0=xa046/70). Overall technical success was 82xa0% (nxa0=xa059/72) and 6-month success was 58xa0% (nxa0=xa042/72). Major and minor complications were 2.8xa0% (nxa0=xa02/72), and 12.5xa0% (nxa0=xa09/72). NUS+PTA did not improve graft survival (pxa0=xa00.354) or patency (pxa0=xa00.9) compared with NUS alone. There was no difference in graft survival between treated and nontreated groups (pxa0=xa00.74).ConclusionsThere is no advantage to PTA in addition to placement of NUS, although PTA did not negatively impact graft survival or long-term patency and both interventions were safe and effective. Neither the late or early groups benefited from PTA in addition to NUS. Earlier obstructions showed greater improvement in serum creatinine than later obstructions.

Prone Transradial Catheterization for Combined Single-Session Transarterial Embolization and Percutaneous Posterior Approach Cryoablation of Solid Neoplasms

Transradial access (TRA) has been associated with improved post-procedure hemostasis and patient satisfaction, and decreased hemorrhagic complications, sedation requirements, recovery times, and procedure-related costs when compared with traditional transfemoral catheterization. Supine TRA has been described for the treatment of myocardial infarctions, aortoiliac and femoropopliteal stenoses, and a variety of neoplasms. This original research describes prone transradial catheterization to facilitate combined single-session transarterial embolization and percutaneous cryoablation of solid neoplasms from a posterior approach without repositioning. Prone TRA access, transarterial embolization, and percutaneous cryoablation were successful in all cases described. Mean procedure time was 210xa0min (range: 140–250xa0min). One minor complication, transient bacteremia which responded to antibiotics, was reported. No major complications occurred.

Pediatric lymphangiography, thoracic duct embolization and thoracic duct disruption: a single-institution experience in 11 children with chylothorax

BackgroundInterventional radiology treatment of chylothorax is well described in adults, with high technical and clinical success that decreases patient morbidity and mortality. However there is limited experience in children.ObjectiveTo report the technical and clinical success of lymphangiography, thoracic duct embolization and thoracic duct disruption in the pediatric population.Materials and methodsWe studied 11 pediatric patients (7 boys, 4 girls; median weight 6.0xa0kg) who underwent lymphangiography and thoracic duct embolization from November 2015 to May 2017. All 11 (100%) children presented with chylothorax, with 1 (9%) having concomitant chylous ascites and 1 (9%) having concomitant chylopericardium. Ten (91%) children had traumatic chylothorax and one (9%) had congenital chylothorax. We recorded technical success, clinical success and complications.ResultsTwelve procedures were completed in 11 children. Bilateral intranodal lymphangiography was technically successful in all (100%) patients. Central lymphatics were visualized in eight (67%) procedures. Access to central lymphatics was attempted in eight procedures and successful in five (63%). In three (37%) of the eight procedures, disruption was performed when the central lymphatics could not be accessed. Clinical success was achieved in 7/11 (64%) children. Three minor complications were reported. No major complications were encountered.ConclusionLymphangiography, thoracic duct embolization and thoracic duct disruption are successful interventional strategies in children with chylothorax and should be considered as viable treatment options at any age.

Transjugular Intrahepatic Portosystemic Shunt Reduction Using the GORE VIATORR Controlled Expansion Endoprosthesis: Hemodynamics of Reducing an Established 10-mm TIPS to 8-mm in Diameter

To the Editor, Transjugular intrahepatic portosystemic shunt (TIPS) involves the creation of a shunt between the portal and hepatic veins to treat portal hypertension and its complications, including refractory ascites, hepatic hydrothorax, and variceal bleeding [1]. Complications, however, may result from excessive shunting of portal venous blood to the systemic circulation. 17–46% of patients present with hepatic encephalopathy (HE) following a TIPS [2–4]. Although the majority of patients with TIPS-associated HE may be medically managed, 3–7% of patients develop refractory encephalopathy as a result of this high volume shunting [2, 5–7]. TIPS reduction or occlusion may be effective in decreasing the incidence and severity of hepatic encephalopathy. Complete occlusion of the TIPS returns patients to the baseline risk of variceal bleeding and other portal hypertension complications present prior to TIPS [2, 5]. TIPS reduction has become the preferred method of treatment for excessive portal to systemic shunting of blood that is refractory to first-line medical management. The goal of TIPS reduction is to reduce the volume of shunted blood and divert it back to the intrahepatic portal veins by decreasing the diameter of the existing stent. Ideally, achieving a balance between portal and systemic blood flow to maintain the benefit of TIPS in reducing portal hypertension while concurrently treating the encephalopathy is desired. Numerous TIPS reduction methods using various stents and stent grafts have been previously detailed in the literature [5, 6]. TIPS are commonly reduced to a 6–7 mm residual diameter and usually, but not always, require complicated in vivo or backtable techniques [5, 6]. With the advent of the newly introduced Viatorr Controlled Expansion Endoprosthesis (Gore & Associates, Flagstaff, AZ, USA), there is the potential of a simple single-stent deployment for TIPS reduction leaving a residual TIPS diameter of 8 mm. Two patients with hepatic encephalopathy underwent TIPS reduction using the Viatorr Controlled Expansion Endoprosthesis (Gore) (Fig. 1). Pre and post-reduction pressures and hemodynamics were measured using a pressure transducer and a 6-French ReoCath Retrograde Flow Catheter (Transonic Systems), respectively. Mean increase in portosystemic gradient was 4 mmHg (range 2–6 mmHg) with mean percentage increase of 30.5% (range 18.1–42.8%). Mean reduction in portal vein blood flow was 222.5 mL/min (range 45–400 mL/min) with mean percentage reduction of 16.3% (range 4.6–27.9%). Mean reduction in TIPS blood flow was 187 mL/min (range 87–287 mL/min) with mean percentage reduction of 15.9% (range 12.0–19.7%). No minor or major procedural complications occurred. Mean follow-up was 81 days (range 38–124 days). Both patients showed a 1 grade improvement in HE symptoms using West Haven HE criteria. A 69-year-old male with history of alcoholic cirrhosis and portal hypertension complicated by esophageal varices and ascites had a TIPS placed 1278 days prior to presentation (Fig. 2 and Table 1). Since that time he developed & Ravi N. Srinivasa rnsriniv@med.umich.edu

Fibrillar collagen injection for organ protection during thermal ablation of hepatic malignancies

Percutaneous image-guided ablation is performed throughout many areas of the body for various pathologies including hepatic malignancies. Heat and cold-based ablative technologies are effective and well-tolerated with an acceptable safety profile. However, ablative therapies may be technically more challenging and cause collateral thermal injury if the targeted lesion is adjacent to critical organs. Previously, techniques including artificial ascites and pneumoperitoneum have been utilized to displace or insulate critical structures from the ablation zone. This technical innovation describes (10-30 mL) fibrillar collagen dissolved in fluid as a focal thermal insulation technique. Small volume fibrillar collagen instillation, and thermal ablation were technically successful in three cases without complication. Clinical follow-up and 3-month imaging confirmed complete ablation of all hepatic malignancies without collateral injury.

Erratum: Pediatric Portal Interventions

[This corrects the article DOI: 10.1055/s-0038-1642043.].

Lymphatic Interventions for Isolated, Iatrogenic Chylous Ascites: A Multi-Institution Experience

OBJECTIVESnLymphangiography and thoracic duct embolization are established treatments for post-surgical chylothorax. There is only limited experience in their application to treat post-surgical chylous ascites. A multi-center analysis of the technical and clinical success of lymphangiography and lymphatic interventions in the treatment of isolated, iatrogenic chylous ascites is reported.nnnMETHODSn21 patients (14 males; 7 females) aged 3-84 years (mean 56.9 years; median 63 years) were treated for isolated, iatrogenic chylous ascites between August 2012 and January 2018. Initial referrals occurred between 5-330 days (mean 72.7 days; median 40 days) after failing conservative therapy. Daily leak volumes ranged from 100 to 3000u2009mL. Lymphangiographic findings, techniques, clinical outcomes, and complications were recorded.nnnRESULTSn21 patients underwent 29 procedures. Seven patients underwent multiple procedures after chylous ascites persisted. Bilateral nodal lymphangiography (NL) was technically successful in all (100%) patients. Lymphangiography identified a leak in 14/21 (67%) patients and in 16/29 procedures (55%). Ten procedures (34%) consisted of NL alone and one (3.4%) consisted of NL combined with lymphatic disruption (LD). Six procedures (21%) consisted of nodal glue embolization (NGE) while nine procedures (31%) were catheter-based lymphatic embolization. Three separate patients underwent three procedures (10%) consisting of balloon-occluded retrograde abdominal lymphatic embolization. Clinical success, defined as no additional drainage of chylous ascites at 15 days, was ultimately achieved in 18/21 patients (86%). There were no major or minor complications.nnnCONCLUSIONnLymphatic interventions can successfully treat post-surgical chylous ascites. Given the low risk of procedural complication, early intervention is encouraged.