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Rostambeigi N, Guevara CJ. Prostatic Artery Perfusion from the Medial Circumflex Femoral Artery. J Vasc Interv Radiol 2023; 34:938-938.e1. [PMID: 37105667 DOI: 10.1016/j.jvir.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 04/29/2023] Open
Affiliation(s)
- Nassir Rostambeigi
- Division of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.
| | - Carlos J Guevara
- Division of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri
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Ushinsky A, Kim SK, Guevara CJ. Percutaneous Thermal Ablation for Refractory Thoracic Duct Leak after Esophageal Surgery. J Vasc Interv Radiol 2023; 34:501-502. [PMID: 36442742 DOI: 10.1016/j.jvir.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Alexander Ushinsky
- Department of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St Louis School of Medicine, 510 S Kings Highway Boulevard, Campus Box 8131, St Louis, MO 63110.
| | - Seung Kwon Kim
- Department of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St Louis School of Medicine, 510 S Kings Highway Boulevard, Campus Box 8131, St Louis, MO 63110
| | - Carlos J Guevara
- Department of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St Louis School of Medicine, 510 S Kings Highway Boulevard, Campus Box 8131, St Louis, MO 63110
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Crawford D, Guevara CJ, Kim SK. Thoracic Duct Embolization Using Transabdominal Antegrade and Transcervical Retrograde Accesses. J Vasc Interv Radiol 2022; 33:1536-1541. [PMID: 36028207 DOI: 10.1016/j.jvir.2022.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/25/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the technical success and clinical outcomes of thoracic duct embolization (TDE) using transabdominal antegrade and transcervical retrograde accesses to treat patients with chyle leak. MATERIALS AND METHODS This study was a retrospective, nonblinded, single-institution chart review of all patients aged 18 years or older over a 6-year time frame who underwent lymphangiography with attempted TDE for iatrogenic or spontaneous chyle leaks using transabdominal antegrade and/or transcervical retrograde accesses. RESULTS Ninety-nine patients underwent 113 procedures. Eighty-five patients underwent 1 procedure, and 14 patients required 2 procedures. The technical success rate of TDE was 68% (72/106) with transabdominal antegrade access and 44% (15/34) with transcervical retrograde access. The overall technical success rate of TDE, including both the access methods, was 77% (87/113). The most common reasons for transabdominal access failure were small caliber of the cisterna chyli and thoracic duct (TD) occlusion. Five patients were lost to follow-up. Overall clinical success, defined as resolution of the chyle leak, was achieved in 83% (78/94) of the patients. There were 6 Society of Interventional Radiology (SIR) level 1 adverse events (AEs), 5 SIR level 2 AEs, and 2 SIR level 3 AEs. Nontarget embolization occurred in 2 patients. CONCLUSIONS Although transcervical retrograde TDE is a challenging procedure, with a lower technical success rate than transabdominal antegrade access, retrograde access improved the technical and clinical success rates of the treatment of chyle leaks in cases of thoracic duct occlusion, small cisterna chyli, and leaks located in the abdomen.
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Affiliation(s)
- Daniel Crawford
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, Missouri
| | - Carlos J Guevara
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, Missouri
| | - Seung Kwon Kim
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, Missouri.
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Guevara CJ. Detailed Arterial Anatomical Knowledge of the Geniculate Arteries is Essential When Starting a GAE Program to Treat OA. Cardiovasc Intervent Radiol 2021; 45:91-92. [PMID: 34820692 DOI: 10.1007/s00270-021-02996-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Carlos J Guevara
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
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Ushinsky A, Guevara CJ, Kim SK. Intranodal lymphangiography with thoracic duct embolization for the treatment of chyle leaks after head and neck cancer surgery. Head Neck 2021; 43:1823-1829. [PMID: 33586824 DOI: 10.1002/hed.26646] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/03/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Thoracic duct injury is a rare complication of head and neck surgery. Thoracic duct embolization (TDE) has been proposed to manage postoperative chyle leaks. METHODS Twelve patients who underwent lymphangiography for a chyle leak after head and neck surgery (M:F = 5:7, mean 55 years) were retrospectively reviewed. Lymphangiographic findings, technical success, complications, and clinical outcomes were analyzed. RESULTS Chyle leak was identified and TDE attempted in 11 of 12 patients. Three patients required repeat TDE. Technical success of TDE was 86% (12/14). Clinical success for patients with technically successful TDE was 90% (9/10). Median time until drain removal was 2.1 days in nine patients with clinical success. Two major complications were encountered, chylothorax after initial TDE, requiring additional TDE and in one case surgical TD ligation. CONCLUSIONS TDE is a safe treatment for chyle leaks after head and neck surgery with high technical and clinical success rates.
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Affiliation(s)
- Alexander Ushinsky
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carlos J Guevara
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Seung Kwon Kim
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Pham KT, Balaguru D, Tammisetti VS, Guevara CJ, Rasmussen JC, Zvavanjanja RC, Hanfland R, Sevick-Muraca EM, Aldrich MB. Multimodality lymphatic imaging of postoperative chylothorax in an infant with Noonan syndrome: a case report. Eur J Med Res 2020; 25:55. [PMID: 33148331 PMCID: PMC7640692 DOI: 10.1186/s40001-020-00455-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/27/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Chylothorax is a rare complication of pediatric cardiac operations that occurs more frequently in children with Noonan syndrome, a genetic disorder associated with cardiac defects and lymphatic anomalies. CASE PRESENTATION We report a case of postoperative chylothorax in a 6-month-old infant with Noonan syndrome where multimodality lymphatic imaging guided management was followed. Drainage patterns of the lymphatic capillaries in the lower and upper extremities were visualized during near-infrared fluorescence lymphatic imaging (NIRFLI). Dynamic magnetic resonance lymphangiography (MRL) further identified the site of leakage in the thoracic duct and subsequently guided surgical intervention. CONCLUSIONS Application of multimodality imaging allows for greater individualization of treatment and should be considered in patients with complex cases such as those with syndromes associated with a higher incidence of chylothorax. IRB Number: HSC-MS-13-0754, December 10, 2013.
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Affiliation(s)
- Kay T Pham
- Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, UT Health, 1825 Pressler St, Houston, TX, 77030, USA.
| | - Duraisamy Balaguru
- Department of Pediatric Cardiology, McGovern Medical School At UTHealth, 6431 Fannin St, Houston, TX, 77030, USA
| | - Varaha S Tammisetti
- Department of Diagnostic & Interventional Imaging, 6431 Fannin St, Houston, TX, 77030, USA
| | - Carlos J Guevara
- Department of Diagnostic & Interventional Imaging, 6431 Fannin St, Houston, TX, 77030, USA
| | - John C Rasmussen
- Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, UT Health, 1825 Pressler St, Houston, TX, 77030, USA
| | - Rodrick C Zvavanjanja
- Department of Diagnostic & Interventional Imaging, 6431 Fannin St, Houston, TX, 77030, USA
| | - Robert Hanfland
- Division of Pediatric Cardiothoracic Surgery, 6431 Fannin St, Houston, TX, 77030, USA
| | - Eva M Sevick-Muraca
- Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, UT Health, 1825 Pressler St, Houston, TX, 77030, USA
| | - Melissa B Aldrich
- Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, UT Health, 1825 Pressler St, Houston, TX, 77030, USA
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Kim SK, Thompson RE, Guevara CJ, Ushinsky A, Ramaswamy RS. Intranodal Lymphangiography with Thoracic Duct Embolization for Treatment of Chyle Leak after Thoracic Outlet Decompression Surgery. J Vasc Interv Radiol 2020; 31:795-800. [PMID: 32359526 DOI: 10.1016/j.jvir.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 12/25/2022] Open
Abstract
From 2015 to 2019, 9 patients underwent ultrasound-guided intranodal lymphangiography for the treatment of a chyle leak following thoracic outlet decompression surgery. Chyle leaks were identified by Lipiodol (Guerbet, Roissy, France) extravasation near the left supraclavicular surgical bed in all patients. The technical success rate of thoracic duct embolization was 67% (6 of 9), including fluoroscopic transabdominal antegrade access (n = 4) and ultrasound-guided retrograde access in the left neck (n = 2). Clinical success was achieved in 89% of patients (8 of 9). The mean interval from lymphangiography to drain removal was 6.6 days (range, 4-18 d). No patients had a chyle leak recurrence during clinical follow-up (mean, 304 d).
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Affiliation(s)
- Seung Kwon Kim
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO 63110.
| | - Russell E Thompson
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO 63110
| | - Carlos J Guevara
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO 63110
| | - Alexander Ushinsky
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO 63110
| | - Raja S Ramaswamy
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO 63110
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Ramaswamy RS, Tiwari T, Darcy MD, Kim SK, Akinwande O, Dasgupta N, Guevara CJ. Cryoablation of low-flow vascular malformations. ACTA ACUST UNITED AC 2020; 25:225-230. [PMID: 31063139 DOI: 10.5152/dir.2019.18278] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE We aimed to evaluate the safety and effectiveness of cryoablation in the treatment of low-flow malformations, specifically venous malformation (VM) and fibroadipose vascular anomaly (FAVA). METHODS We conducted a retrospective review of 11 consecutive patients with low-flow malformations (14 lesions; 9 VM, 5 FAVA), median lesion volume 10.8 cm3, (range, 1.8-55.6 cm3) with a median age of 19 years (range, 10-50 years) who underwent cryoablation to achieve symptomatic control. Average follow-up was at a median of 207 days postprocedure (range, 120-886 days). Indications for treatment included focal pain and swelling. Technical success was achieved if the cryoablation ice ball covered the region of the malformation that corresponded to the patient's symptoms. Clinical success was considered complete if all symptoms resolved and partial if some symptoms persisted but did not necessitate further treatment. RESULTS The technical success rate was 100%. At 1-month follow-up, 13 of 14 lesions (93%) had a complete response and one (7%) had a partial response. At 6-month follow-up 12 of 13 (92%) had a complete response and 1 (8%) had a partial response. A total of 6 patients underwent primary cryoablation. Out of 9 VM cases, 7 had prior sclerotherapy and 2 had primary cryoablation. Out of the 5 FAVA cases, 1 had prior sclerotherapy and the remaining 4 cases underwent primary cryoablation. There were 3 minor complications following cryoablation including 2 cases of skin blisters and 1 case of transient numbness. These complications resolved with conservative management. CONCLUSION Cryoablation is safe and effective in the treatment of low-flow vascular malformations, either after sclerotherapy or as primary treatment.
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Affiliation(s)
- Raja S Ramaswamy
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Tatulya Tiwari
- Department of Radiology, Division of Endovascular Surgery and Interventional Radiology, Lexington Veterans Affairs (VA) Medical Center, Lexington, Kentucky, USA
| | - Michael D Darcy
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Seung K Kim
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Olaguoke Akinwande
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Niloy Dasgupta
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carlos J Guevara
- Department of Diagnostic and Interventional Radiology, University of Texas Health Center, Houston, Texas, USA
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Ramaswamy RS, Charalel R, Guevara CJ, Tiwari T, Akinwande O, Kim SK, Salter A, Darcy M, Malone CD. Propensity-matched comparison of transjugular intrahepatic portosystemic shunt placement techniques: Intracardiac echocardiography (ICE) versus fluoroscopic guidance. Clin Imaging 2019; 57:40-44. [PMID: 31103908 DOI: 10.1016/j.clinimag.2019.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/12/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare procedure characteristics and outcomes when TIPS is performed under intracardiac echocardiography guidance (iTIPS) compared to conventional fluoroscopic guidance (cTIPS). MATERIALS AND METHODS A retrospective propensity-matched study of 30 iTIPS and 30 cTIPS procedures from January 2014 to March 2017 at a single US high volume academic medical center was performed. iTIPS and cTIPS cases were propensity score matched using predictive variables: age, race, gender, etiology of liver disease, indication for TIPS, MELD score, and portal vein patency. Procedure characteristics and post- procedure outcomes were compared between propensity-matched groups including: total procedure time, technical success, radiation dose, contrast volume, complication rate, 30- day mortality, and revision rate within 3 months. RESULTS Radiation dose (875.3 vs 457.4 mGY, p = 0.039) and contrast volume (141 vs 103 mL, p = 0.005) were significantly decreased in the iTIPS versus the cTIPS group. There was no significant difference in procedure time (81.5 cTIPS vs 84 min iTIPS) or rate of TIPS revisions within 3 months. Average operator experience in the iTIPs group was 4.2 years and cTIPS group 11.0 years (p = 0.0004). All procedures were technically successful with no mortalities within 30 days. CONCLUSION iTIPS resulted in significantly reduced radiation dose and contrast volume. However, there was no difference in total procedure time or overall outcomes despite greater operator experience in the cTIPS group.
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Affiliation(s)
- Raja Siva Ramaswamy
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America.
| | - Resmi Charalel
- Weill Cornell Medicine, Department of Radiology, 525 East 68th Street, New York, NY 10065, United States of America
| | - Carlos J Guevara
- University of Texas - Houston, Department of Diagnostic and Interventional Imaging, 6431 Fannin St, Houston, TX 77030, United States of America
| | - Tatulya Tiwari
- Veterans Affairs Medical Center - Lexington, Division of Endovascular Surgery, 1101 Veterans Drive, Lexington, KY 40502, United States of America
| | - Olaguoke Akinwande
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
| | - Seung K Kim
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
| | - Amber Salter
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
| | - Michael Darcy
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
| | - Christopher D Malone
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 S Kingshighway Blvd, CB 8131, Saint Louis, MO 63139, United States of America
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Krohmer SJ, Pillai AK, Guevara CJ, Bones BL, Dickey KW. Image-Guided Nephrostomy Interventions: How to Recognize, Avoid, or Get Out of Trouble. Tech Vasc Interv Radiol 2018; 21:261-266. [PMID: 30545505 DOI: 10.1053/j.tvir.2018.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Image-guided percutaneous nephrostomy is a relatively safe and successful procedure for access to the renal collecting system for multiple purposes including relief of urinary obstruction, urinary diversion, access for endourologic procedures, and diagnostic testing. Although placing a percutaneous nephrostomy catheter is most times straightforward, providing immediate benefit for the patient and satisfaction for the practitioner, there can be situations that make the procedure more difficult or risky. A thorough review of the patient's imaging and medical record will help to set a path for success. However, there may be innuendos and unforeseen circumstances that occur. Having knowledge of most of these "stumbling blocks" and how to deal with them will keep you on the path. This paper serves to fill some of that mental file with the aim to increase clinical success.
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Affiliation(s)
- Steven J Krohmer
- Department of Interventional Radiology, University of Kentucky HealthCare, Lexington, KY.
| | - Anil K Pillai
- Department of Diagnostic Imaging and Intervention, University of Texas, Houston, TX
| | | | - Brian Lee Bones
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Kevin W Dickey
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
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Krohmer SJ, Pillai AK, Guevara CJ, Bones BL, Dickey KW. Image-Guided Biliary Interventions: How to Recognize, Avoid, or Get Out of Trouble. Tech Vasc Interv Radiol 2018; 21:249-254. [PMID: 30545503 DOI: 10.1053/j.tvir.2018.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Percutaneous biliary interventions have a well-established role in the management of hepatobiliary diseases. Good outcomes include recognizing and avoiding complications. This section will cover the "standard" technique of percutaneous biliary drainage, pearls to decrease the risk of problems, and approaches to treat those complications in patients undergoing percutaneous transhepatic cholangiography and percutaneous transhepatic biliary drainage.
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Affiliation(s)
- Steven J Krohmer
- Department of Interventional Radiology, University of Kentucky HealthCare, Lexington, KY.
| | - Anil K Pillai
- Department of Diagnostic Imaging and Intervention, University of Texas, Houston, TX
| | | | - Brian Lee Bones
- Wake Forest School of Medicine, Medical Center Boulevard Winston-Salem, NC
| | - Kevin W Dickey
- Department of Interventional Radiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
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Kim SK, Sauk S, Guevara CJ. Transjugular intrahepatic portosystemic shunts versus balloon-occluded retrograde transvenous obliteration for the management of gastric varices: Treatment algorithm according to clinical manifestations. Int J Gastrointest Interv 2016. [DOI: 10.18528/gii150030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven Sauk
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Carlos J. Guevara
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
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Guevara CJ, Rialon KL, Ramaswamy RS, Kim SK, Darcy MD. US-Guided, Direct Puncture Retrograde Thoracic Duct Access, Lymphangiography, and Embolization: Feasibility and Efficacy. J Vasc Interv Radiol 2016; 27:1890-1896. [PMID: 27595470 DOI: 10.1016/j.jvir.2016.06.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/02/2016] [Accepted: 06/25/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To describe technical details, success rate, and advantages of direct puncture of the thoracic duct (TD) under direct ultrasound (US) guidance at venous insertion in the left neck. MATERIALS AND METHODS All patients who underwent attempted thoracic duct embolization (TDE) via US-guided retrograde TD access in the left neck were retrospectively reviewed. Indications for lymphangiography were iatrogenic chyle leak, pulmonary lymphangiectasia, and plastic bronchitis. Ten patients with mean age 41.4 years (range, 21 d to 72 y) underwent US-guided TD access via the left neck. Technical details, procedural times, and clinical outcomes were evaluated. TD access time was defined as time from start of procedure to successful access of TD, and total procedural time was defined from start of procedure until TDE. RESULTS All attempts at TD access via the neck were successful. Technical and clinical success of TDE was 60%. There were no complications. Mean TD access time was 17 minutes (range, 2-47 min), and mean total procedure time was 49 minutes (range, 25-69 min). Mean follow-up time was 5.4 months (range, 3-10 months). CONCLUSIONS TDE via US-guided access in the left neck is technically feasible and safe with a potential decrease in procedure time and elimination of oil-based contrast material.
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Affiliation(s)
- Carlos J Guevara
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO 63110.
| | - Kristy L Rialon
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Raja S Ramaswamy
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO 63110
| | - Seung K Kim
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO 63110
| | - Michael D Darcy
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO 63110
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Guevara CJ, Lee KA, Barrack R, Darcy MD. Technically Successful Geniculate Artery Embolization Does Not Equate Clinical Success for Treatment of Recurrent Knee Hemarthrosis after Knee Surgery. J Vasc Interv Radiol 2016; 27:383-7. [DOI: 10.1016/j.jvir.2015.11.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 02/02/2023] Open
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Guevara CJ, Gonzalez-Araiza G, Kim SK, Sheybani E, Darcy MD. Sclerotherapy of Diffuse and Infiltrative Venous Malformations of the Hand and Distal Forearm. Cardiovasc Intervent Radiol 2015; 39:705-710. [PMID: 26678548 DOI: 10.1007/s00270-015-1277-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 11/22/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Venous malformations (VM) involving the hand and forearm often lead to chronic pain and dysfunction, and the threshold for treatment is high due to the risk of nerve and skin damage, functional deterioration and compartment syndrome. The purpose of this study is to demonstrate that sclerotherapy of diffuse and infiltrative VM of the hand is a safe and effective therapy. MATERIALS AND METHODS A retrospective review of all patients with diffuse and infiltrative VM of the hand and forearm treated with sclerotherapy from 2001 to 2014 was conducted. All VM were diagnosed during the clinical visit by a combination of physical examination and imaging. Sclerotherapy was performed under imaging guidance using ethanol and/or sodium tetradecyl sulfate foam. Clinical notes were reviewed for signs of treatment response and complications, including skin blistering and nerve injury. RESULTS Seventeen patients underwent a total of 40 sclerotherapy procedures. Patients were treated for pain (76%), swelling (29%) or paresthesias (6%). Treatments utilized ethanol (70%), sodium tetradecyl sulfate foam (22.5%) or a combination of these (7.5%). Twenty-four percent of patients had complete resolution of symptoms, 24% had partial relief of symptoms without need for further intervention, and 35% had some improvement after initial treatment but required additional treatments. Two skin complications were noted, both of which resolved. No motor or sensory loss was reported. CONCLUSION Sclerotherapy is a safe and effective therapy for VM of the hand with over 83% of patients experiencing relief.
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Affiliation(s)
- Carlos J Guevara
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO, 63110, USA.
| | - Guillermo Gonzalez-Araiza
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO, 63110, USA
| | - Seung K Kim
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO, 63110, USA
| | - Elizabeth Sheybani
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO, 63110, USA
| | - Michael D Darcy
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Boulevard, Box 8131, St. Louis, MO, 63110, USA
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Rialon KL, Englum BR, Gulack BC, Guevara CJ, Bhattacharya SD, Shapiro ML, Rice HE, Scarborough JE, Adibe OO. Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population. Am J Surg 2015; 212:786-793. [PMID: 26303881 DOI: 10.1016/j.amjsurg.2015.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 05/31/2015] [Accepted: 06/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Splenic angioembolization (SAE) is increasingly used in the management of splenic injuries in adults, although its value in pediatric trauma is unclear. We sought to assess outcomes related to splenectomy vs SAE. METHODS The National Trauma Data Bank was queried for patients 0 to 15 years of age from 2007 to 2011. Subgroup analysis of splenectomy vs SAE was performed for high-grade injuries using propensity analysis and inverse probability weighting. RESULTS Of 11,694 children presenting with splenic trauma, over 90% were treated nonoperatively. Adjusted analysis of high-grade injuries included 265 children who underwent splenectomy and 199 who underwent SAE. The Injury Severity Score, number of transfusions, and complications rates were not significantly different between the 2 groups. Overall adjusted mortality for children with high-grade injuries was 13.4% following splenectomy and 10.0% following SAE (P = .31) CONCLUSION: Patients undergoing SAE for high-grade splenic trauma have comparable morbidity and mortality with splenectomy.
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Affiliation(s)
- Kristy L Rialon
- Division of General Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian R Englum
- Division of General Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian C Gulack
- Division of General Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Carlos J Guevara
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Syamal D Bhattacharya
- Division of Pediatric Surgery, Department of Surgery, Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Mark L Shapiro
- Division of Trauma and Critical Care, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Henry E Rice
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, HAFS Building, Room 6680, Durham, NC 27710, USA
| | - John E Scarborough
- Division of Trauma and Critical Care, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Obinna O Adibe
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, HAFS Building, Room 6680, Durham, NC 27710, USA.
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Luks VL, Kamitaki N, Vivero MP, Uller W, Rab R, Bovée JV, Rialon KL, Guevara CJ, Alomari AI, Greene AK, Fishman SJ, Kozakewich HP, Maclellan RA, Mulliken JB, Rahbar R, Spencer SA, Trenor CC, Upton J, Zurakowski D, Perkins JA, Kirsh A, Bennett JT, Dobyns WB, Kurek KC, Warman ML, McCarroll SA, Murillo R. Lymphatic and other vascular malformative/overgrowth disorders are caused by somatic mutations in PIK3CA. J Pediatr 2015; 166:1048-54.e1-5. [PMID: 25681199 PMCID: PMC4498659 DOI: 10.1016/j.jpeds.2014.12.069] [Citation(s) in RCA: 336] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 12/08/2014] [Accepted: 12/23/2014] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To test the hypothesis that somatic phosphatidylinositol-4,5-bisphospate 3-kinase, catalytic subunit alpha (PIK3CA) mutations would be found in patients with more common disorders including isolated lymphatic malformation (LM) and Klippel-Trenaunay syndrome (KTS). STUDY DESIGN We used next generation sequencing, droplet digital polymerase chain reaction, and single molecule molecular inversion probes to search for somatic PIK3CA mutations in affected tissue from patients seen at Boston Children's Hospital who had an isolated LM (n = 17), KTS (n = 21), fibro-adipose vascular anomaly (n = 8), or congenital lipomatous overgrowth with vascular, epidermal, and skeletal anomalies syndrome (n = 33), the disorder for which we first identified somatic PIK3CA mutations. We also screened 5 of the more common PIK3CA mutations in a second cohort of patients with LM (n = 31) from Seattle Children's Hospital. RESULTS Most individuals from Boston Children's Hospital who had isolated LM (16/17) or LM as part of a syndrome, such as KTS (19/21), fibro-adipose vascular anomaly (5/8), and congenital lipomatous overgrowth with vascular, epidermal, and skeletal anomalies syndrome (31/33) were somatic mosaic for PIK3CA mutations, with 5 specific PIK3CA mutations accounting for ∼ 80% of cases. Seventy-four percent of patients with LM from Seattle Children's Hospital also were somatic mosaic for 1 of 5 specific PIK3CA mutations. Many affected tissue specimens from both cohorts contained fewer than 10% mutant cells. CONCLUSIONS Somatic PIK3CA mutations are the most common cause of isolated LMs and disorders in which LM is a component feature. Five PIK3CA mutations account for most cases. The search for causal mutations requires sampling of affected tissues and techniques that are capable of detecting low-level somatic mosaicism because the abundance of mutant cells in a malformed tissue can be low.
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Affiliation(s)
- Valerie L. Luks
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | - Nolan Kamitaki
- Department of Genetics, Harvard Medical School, Boston, MA
| | | | - Wibke Uller
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | - Rashed Rab
- Howard Hughes Medical Institute, Boston Children’s Hospital, Boston, MA
| | - Judith V.M.G. Bovée
- Department of Pathology, Leiden University Medical Center, Leiden, Netherlands
| | - Kristy L. Rialon
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | | | - Ahmad I. Alomari
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | - Arin K. Greene
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | | | | | | | - John B. Mulliken
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | - Reza Rahbar
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | | | | | - Joseph Upton
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | - David Zurakowski
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | | | - Andrew Kirsh
- Departments of Pediatrics and Surgery, University of Washington, Seattle WA
| | - James T Bennett
- Departments of Pediatrics and Surgery, University of Washington, Seattle WA
| | - William B Dobyns
- Departments of Pediatrics and Surgery, University of Washington, Seattle WA
| | - Kyle C. Kurek
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA
| | - Matthew L. Warman
- Vascular Anomalies Center, Boston Children’s Hospital, Boston, MA,Department of Genetics, Harvard Medical School, Boston, MA,Howard Hughes Medical Institute, Boston Children’s Hospital, Boston, MA
| | | | - Rudy Murillo
- Vascular Anomalies Center, Boston Children's Hospital, Boston, MA.
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Guevara CJ, El-Hilal AH, Darcy MD. Percutaneous Antegrade Varicocele Embolization Via the Testicular Vein in a Patient with Recurrent Varicocele After Surgical Repair. Cardiovasc Intervent Radiol 2014; 38:1325-9. [DOI: 10.1007/s00270-014-0978-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 07/11/2014] [Indexed: 11/30/2022]
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Chaudry G, Guevara CJ, Rialon KL, Kerr C, Mulliken JB, Greene AK, Fishman SJ, Boyer D, Alomari AI. Safety and efficacy of bleomycin sclerotherapy for microcystic lymphatic malformation. Cardiovasc Intervent Radiol 2014; 37:1476-81. [PMID: 24938907 DOI: 10.1007/s00270-014-0932-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 05/08/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Sclerotherapy is the mainstay of treatment of macrocystic lymphatic malformation (LM), but the response using traditional sclerosants is much less beneficial in microcystic lesions. Intralesional bleomycin has been reported to be effective in microcystic LM; however, its use is limited by concerns about pulmonary fibrosis. The purpose of this study was to evaluate the safety and efficacy of bleomycin sclerotherapy in microcystic LM. METHODS The medical records and imaging studies of all patients with microcystic or combined LM who underwent percutaneous image-guided sclerotherapy using bleomycin were retrospectively reviewed. Only patients with pre- and postprocedure imaging were included. Thirty-one patients with a mean age of 13.4 years (range 3 months-31 years) were treated. Response was graded as complete (>90% size reduction), partial (25-90%), or minimal/no response (<25%). Pulmonary function tests (PFT) and chest X-rays were performed before the procedure. PFT were repeated at 6 months and 1 year postprocedure. Annual postprocedure chest X-rays were also performed. RESULTS The malformations were located in the head and neck (n = 27) and trunk (n = 4). The number of procedures ranged from 1 to 4 (mean 1.7). Up to 1 U/kg of bleomycin was injected per session, with a maximum of 15 U. The mean follow-up period was 3.2 years (range 1.5-5 years). There was complete response in 38% (n = 12), partial response in 58% (n = 18), and no response in 3% (n = 1). No complications were identified. CONCLUSIONS Preliminary indicate that sclerotherapy of microcystic LMs using bleomycin is effective and safe.
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Affiliation(s)
- Gulraiz Chaudry
- Vascular Anomalies Center, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA,
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Abstract
The interdisciplinary model for the management of vascular anomalies relies essentially on effective collaboration and communication between various medical disciplines. In this paper, we discuss the various facets of an organized institutional collaborative model for managing these patients. The case for interdisciplinary collaboration, use of proper terminology, the vascular anomalies center (structure and work flow), referral bases, and collaboration with support group are briefly illuminated. The role of the interventionalists as primary members and leaders in this field is buttressed by the clinical knowledge and competent use of imaging modalities and minimally invasive interventions.
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Affiliation(s)
- Carlos J Guevara
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA 22115, USA
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Lang JE, Guevara CJ, Aitken GSE, Pietrobon R, Vail TP. Results of contralateral total knee arthroplasty in patients with a history of stiff total knee arthroplasty. J Arthroplasty 2008; 23:30-2. [PMID: 18165025 DOI: 10.1016/j.arth.2006.12.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2006] [Accepted: 12/10/2006] [Indexed: 02/01/2023] Open
Abstract
This study seeks to evaluate the clinical outcomes of a second primary total knee arthroplasty in patients whose initial (contralateral) primary total knee arthroplasty was complicated by stiffness. We retrospectively compared the preoperative and postoperative range of motion and Knee Society Scores from a study group of 15 patients with an age-matched control group. Statistical analysis did not reveal a significant difference in final postoperative range of motion or Knee Society Scores between the 2 groups. However, there was a statistically significant higher rate of closed manipulation in the study group. Therefore, although the study group did show a higher rate of early stiffness, eventual functional outcome was comparable with a nonstiffness control group.
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Affiliation(s)
- Jason E Lang
- Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Abstract
A torn acetabular labrum is a well-documented source of hip pain, but the mechanism of injury is debated because the relationship between the bone morphology and labral tears is poorly understood. We compared hips with and without labral abnormalities to determine the relative incidence of morphologic abnormalities. The study group consisted of patients with a labral tear confirmed by arthroscopy or arthrotomy at the time of open débridement or periacetabular osteotomy. We compared the affected hip with the contralateral, unaffected hip to ascertain signs of hip dysplasia and impingement. We observed differences in the center edge angle, acetabular depth to width index, acetabular index of elevation, femoral head extrusion, lateral and superior subluxation, Sharp's angle, peak to edge distance, and acetabular retroversion. Similar differences occurred in the subgroup analyses. Symptomatic labral tears correlated with abnormal hip morphology as reflected by radiographic measurements of dysplasia and impingement. This relationship occurred in patients with hip dysplasia and patients without obvious femoral head uncovering. Our findings suggest abnormal hip morphology may be a risk factor for labral tears.
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