Yuya Koike

Percutaneous Transvenous Embolization of the Thoracic Duct in the Treatment of Chylothorax in Two Patients

Editor: Persistent high-output chylothorax can result in lifethreatening malnutrition and metabolic deterioration. A minimally invasive approach is desirable for patients, many of whom are already medically fragile as a result of the underlying disease. In recent years, percutaneous transabdominal thoracic duct procedures, such as embolization or needle disruption, have been reported with good clinical outcomes (1–4). These procedures are feasible and less invasive than surgical thoracic duct ligation; however, they are difficult in patients who do not have a distinct cisterna chyli. Additionally, patients with a coagulation abnormality have a risk of hemorrhage with a transhepatic or transintestinal approach. We describe two patients with persistent chylothorax in whom embolization of the thoracic duct was successfully performed via a transvenous retrograde approach. Our institution did not require institutional review board approval for this retrospective technical report. Written informed consent was obtained from the patients before the procedure. The first patient, a man in his 60s, had undergone a graft replacement of the descending aorta for a saccular aneurysm 4 days earlier. The patient experienced progressive output from the surgical drain (158 mL/d). Analysis of fluid from the drain revealed triglyceride levels of 427 mg/ dL, which was consistent with postsurgical thoracic duct injury. After 2 weeks of failed conservative treatment measures, we were consulted for percutaneous treatment. Because of the patient’s tendency to bleed, we were unwilling to access the site by transabdominal puncture. We attempted embolization of the thoracic duct by a percutaneous transvenous retrograde approach. The second patient, a woman in her 50s, had undergone surgery for spinal arteriovenous malformation and paraplegia when she was 19 years old. The patient had edema of the right lower extremity and dyspnea. Computed tomography revealed a left pleural effusion, and analysis of the fluid from the drain revealed triglyceride levels of 1,343 mg/dL. Highoutput chylothorax (984 mL/d) was also diagnosed. After 4 weeks of conservative treatment measures failed, we were consulted for percutaneous treatment. Because of the absence of a suitable access target by lymphography, we attempted embolization of the thoracic duct via a percutaneous transvenous retrograde approach. We attempted to access the thoracic duct at its confluence with the left subclavian vein, as previously reported (4). After administration of local anesthesia, the procedure was performed under fluoroscopic guidance via the left brachial vein approach. A 5-F RIM catheter (Cook, Inc, Bloomington, Indiana) was used to seek and cannulate the thoracic duct (Fig 1). Retrograde cannulation of the thoracic duct was successful in both patients. After retrograde cannulation was confirmed by the injection of contrast material (Fig 2), a microcatheter (Renegade; Boston Scientific, Natick, Massachusetts, in patient 1; PROWLER PLUS; Codman, Raynham, Massachusetts, in patient 2) and a 0.014-inch or 0.016-inch wire (Transend; Boston Scientific, in patient 1; AQUA V-III; Cordis Corportion, Miami Lakes, Florida, in patient 2) were coaxially introduced and advanced into the lower thoracic duct. A clear yellow fluid was aspirated through the catheter. Selective lymphangiography revealed a thoracic duct with active extravasation that corresponded to chyle leakage (Fig 3). We crossed the source of the leakage with a wire and catheter to perform embolization of the region proximal to the leakage. A 33% mixture of N-butyl cyanoacrylate (NBCA; B. Braun, Melsaungen, Germany)

Dynamic Volumetric CT Angiography for the Detection and Classification of Endoleaks: Application of Cine Imaging Using a 320-Row CT Scanner with 16-cm Detectors

PURPOSE To assess the feasibility and diagnostic performance of dynamic volumetric computed tomography (CT) angiography with large-area detectors in the detection and classification of endoleaks after endovascular aneurysm repair (EVAR). MATERIALS AND METHODS Low-dose dynamic volumetric CT angiography performed with the patient in Fowler position was used to scan the entire stent graft with a 16-cm-area detector during the first follow-up examination after EVAR. There were 39 consecutive patients (36 men and 3 women; mean age, 74 y ± 8.7) examined with approximately 14-20 intermittent scans (temporal resolution, 2 s; scan range, 160 mm). The effective radiation dose, image quality, interobserver and intraobserver agreement for endoleak detection, and time delay between peak enhancement of the aorta and endoleaks were evaluated. RESULTS All examinations with the patient in Fowler position enabled the entire stent graft to be scanned and were rated as diagnostic. The mean effective radiation dose was 13.1 mSv. Endoleaks were detected in eight patients (type Ia, n = 1; type II, n = 6; type III, n = 1). Interobserver agreement (κ = 0.794) and intraobserver agreement (κ = 1.00) for detection of endoleaks were excellent. The mean time delay between peak enhancement of the aorta and the endoleaks was significantly less for type I/III endoleaks (2.0 s ± 0) compared with type II endoleaks (5.3 s ± 1.0; P < .001). CONCLUSIONS Low-dose dynamic volumetric CT angiography performed with the patient in Fowler position is feasible after EVAR. Dynamic information, including cine imaging, the timing of peak enhancement, and the Hounsfield units index, is useful in detecting and classifying endoleaks.

Use of the Endurant stent graft system for ruptured infrarenal aortic aneurysms: short-term experience in nine patients.

PURPOSE To report the early results of use of the Endurant stent graft in the treatment of ruptured abdominal aortic aneurysms (AAAs). MATERIALS AND METHODS Nine consecutive patients (seven men and two women; mean age, 76 y; range, 65-87 y) underwent endovascular aneurysm repair (EVAR) for a ruptured AAA with the Endurant stent graft between April and December 2012. EVAR was emergent in all cases. Early technical success, clinical success, major complication, and mortality rates were analyzed. RESULTS Intraoperative immediate technical success was achieved in all nine patients. The 30-day clinical success rate was 67% (six of nine patients). The 30-day mortality rate was 33% (three of nine patients). During a mean follow-up of 6 months (range, 3-10 mo), none of the cases required reintervention; there was one late death attributed to probable endograft infection. CONCLUSIONS The short-term results of EVAR with the Endurant stent graft in patients with ruptured AAAs are encouraging.

The Upside Down Endurant Iliac Limb Stent Graft for Treatment of a Common Iliac Artery Aneurysm

Endovascular repair of the coverage from the common iliac artery to the external iliac artery after the internal iliac artery embolization has been proven to be a safe and effective treatment in isolated iliac artery aneurysms. But in cases in which the diameter of the proximal sealing zone is larger than that of the distal sealing zone, a reverse-tapered device is needed. We described the off-label use of the Endurant iliac limb stent graft in an upside down configuration to accommodate this diameter mismatch.

Bilateral approach of redistributed subclavian arterial infusion chemotherapy for locally advanced breast cancer spreading to the contralateral chest wall.

A catheter port system technique called redistributed subclavian arterial infusion chemotherapy (RESAIC) for locally advanced breast cancer was reported and seemed to be effective for local control and as a palliative treatment. However, when the cancer spreads beyond the medial line to the contralateral chest wall, ipsilateral RESAIC would not achieve a favorable drug distribution. We report on two patients with advanced breast cancer spreading to the contralateral chest wall in whom bilateral RESAIC was attempted. In summary, when advanced breast cancer spreads to the contralateral chest wall, bilateral RESAIC may be useful for local control or palliation.

Differences in Trocar Positioning within the Vertebral Body Using Two Different Positioning Methods: Effect on Trainee Performance

Purpose. To evaluate the educational effect of the Japanese Society of Interventional Radiology 7th Academic Summer Seminar from a technical perspective. Materials and Methods. Nineteen trainees participated in the seminar. The seminar consisted of vertebroplasty trainings using swine with the single-plane landmark method and with the ISOcenter Puncture (ISOP) method. All trainees were advised by an instructor as they operated the instruments and punctured the vertebra. For each trainee, the accuracy in the final position of the needle tip of the initial puncture in each swine training was evaluated. Results. Error in the final position of the needle tip of ≥5 mm from the target puncture site occurred in the lateral direction in 42% (8/19) of trainees with the landmark method and 5% (1/19) with the ISOP method. No error ≥5 mm occurred in the vertical or anteroposterior directions. In terms of puncture accuracy, error in the lateral direction was significantly lower with the ISOP method than with the landmark method (2.2 ± 1.5 mm versus 5.6 ± 3.2 mm). Conclusion. This seminar was effective training for trocar placement for beginners. The puncture was more accurate with the ISOP method than with the landmark method.

Percutaneous Vertebroplasty for Vertebral Compression Fractures with Intravertebral Cleft: Cement Injection under Vacuum Aspiration

PURPOSE To evaluate the efficacy of cement injection under vacuum aspiration (CIVAS) of cleft contents in percutaneous vertebroplasty for osteoporotic vertebral compression fractures with an intravertebral cleft. MATERIALS AND METHODS From April 2008 to October 2010, vertebroplasty for single-level osteoporotic vertebral compression fractures with clefts was performed in 34 patients (seven women, 27 men; mean age, 77 y) with CIVAS and in 41 patients (three women, 38 men; mean age, 77 y) by conventional injection (control group). In this retrospective study, the cement volume, cement ratio, visual analog scale (VAS) pain score, and incidences of leakage, new vertebral compression fracture, and nonhealing were compared between groups. Vertebral height changes in the CIVAS group were also evaluated. RESULTS There were significant decreases in VAS scores in both groups (P < .001). There were no significant differences in complications between groups (cement leakage, P = .70; new vertebral compression fracture, P = .17; nonhealing, P = .086). Vertebral height was significantly decreased by vacuum aspiration and increased by cement injection (P < .001). The mean cement volume was significantly higher (P = .0057) in the CIVAS group (4.87 mL) than in the control group (3.58 mL). Cement filling was achieved more sufficiently in the CIVAS group (P = .014). CONCLUSIONS The CIVAS method is feasible and appears to improve cleft filling in the treatment of single-level vertebral compression fractures with a cleft, compared with conventional cement injection.

Which dose abdominal compartment syndrome occur after endovascular repair of ruptured infra-renal abdominal aortic aneurysm or not?

No. 349 Which dose abdominal compartment syndrome occur after endovascular repair of ruptured infrarenal abdominal aortic aneurysm or not? J. Nishimura, Y. Koike, S. Hase, N. Hosaka, M. Yamasaki, N. Moriya, H. Nishimaki; Department of Interventiona Radiology, Kawasaki Saiwai Hospital, Kawasaki, Japan; Department of Cardiovascular surgery, St. Marianna Medical University, Kawasaki, Japan Purpose: Abdominal compartment syndrome (ACS) have been increasingly recognized as significant causes of mortality in patients with endovascular repair (EVAR) of ruptured infrarenal abdominal aortic aneurysms (rAAAs). If there is high rate of falling into the ACS in the patient with rAAA, EVAR with the procedure of leak reduction and continuous decompression surgery of intra-abdominal pressure are able to be performed. Otherwise, the shock index (SI), defined as the ratio of heart rate to systolic blood pressure, is a simple marker for situation in emergent patients. This study is presented to determine whether the SI is a useful marker for ACS in patients with EVAR of rAAAs. Materials and Methods: In 14 cases with rAAAs, 12 Men and 2 women, mean age 77.2 6.5, EVAR were performed emergency in our institution between March in 2012 and July in 2013. SI calculated from heart rate and systolic blood pressure just before putting the patients under an anesthetic. SI was analyzed between patients with ACS and without ACS. Results: Intraoperative immediate technical success were obtained in all cases. 4 patients fall into the ACS, 2 patients of them died, and reminded 2 patients could leave hospital on foot. SI of patients with ACS and without ACS were 1.86 0.30 (1.44 2.08) and 1.28 0.45 (0.67 1.86), respectively. There is significant difference between SI with ACS and without ASC (P o 0.05). 4 patients died in our hospital after EVAR. SI of the death and survive cases were 1.86 0.23 (1.55 2.08) and 1.29 0.43 (0.67-1.86), respectively. Also, there is significant difference between SI with death and survive cases (P o 0.05). All patients with SI less than 1.4 could be survive, and all patient more than 2.0 died. There is the same trend about ACS between patients in our institusion with EVAR of rAAA and ruptured solitary iliac artery’s aneurysm. Conclusion: SI is simple and useful marker for ACS in patients with EVAR of rAAAs. When SI is over 1.4, there is possibility patient falling into ACS, the procedure for leak control during EVAR and decompression of the abdomen after EVAR are considered to be prepared.

A New Method of an Axial Puncture Approach for Draining Loculated Pleural Effusions

PurposeThe authors devised a new method of an axial puncture approach through the pulmonary apex (PA) for percutaneous catheter drainage (PCD) of loculated fluid collections extending to the PA. The purpose of this report is to introduce the new procedure.MethodsPercutaneous catheter drainage by the axial puncture approach was performed in two patients with limited supine position and loculated pleural fluid collection in the posteromedial part of thoracic cavity.ResultsThe procedures succeeded in two patients without difficulties while keeping them in a supine position, even if the loculated fluids exist in the posterior side of thoracic cavity.ConclusionsPercutaneous catheter drainage by the axial puncture approach is particularly effective in patients with limited supine positions and loculated pleural fluid collection in the posteromedial part of thoracic cavity.