Percutaneous Endovascular Management of a Splenic Vein Pseudoaneurysm Secondary to Pancreatic Pseudocyst

CLINICAL IMPACT

This case report sheds light on a rare complication of pancreatitis, splenic vein pseudoaneurysm. The pseudoaneurysm was successfully treated percutaneously using a covered stent. The article also emphasizes the utilization and safety of transhepatic approach to interventions related to portal vein and its tributaries.

Subclinical high-resolution chest CT scan features in psoriasis

BACKGROUND

Although psoriasis is considered a systemic disease, no clear association has been established between psoriasis and lung diseases. This study aims to detect and describe subclinical pulmonary involvement in psoriasis patients with various degrees of cutaneous manifestations.

METHODS

Adult psoriasis patients with no known active pulmonary disease or respiratory symptoms were screened for subclinical pulmonary manifestations and possible parenchymal changes using high-resolution computed tomography (HRCT) scan of the chest. Patients were classified according to the severity of skin manifestations. The clinical characteristics and radiographic findings of these patients were evaluated.

RESULTS

Fifty-nine patients with psoriasis were included, among which 47 (79.7%) had abnormal HRCT scan features. Micronodules were the most common detected lung lesions (66.1%), followed by nonspecific interstitial changes (32.2%), including pleuro-parenchymal band/atelectasis, scarring, and focal ground-glass opacities. Other HRCT findings included emphysematous changes and calcified granulomas. Abnormal HRCT findings correlated with older age and duration of psoriasis but not with the severity of skin manifestations.

CONCLUSIONS

Micronodules and minor focal nonspecific interstitial changes were the most detected lung alterations in patients with psoriasis. These findings of the pilot study highlight a possible pulmonary involvement in patients with psoriasis. Larger multicenter studies are needed to clarify these findings further.

LIMITATIONS

A major limitation of the study, is the lack of a control group with similar radiologic findings of different conditions done in the same geographical region.

The prognostic significance of duodenal wall invasion in pancreatic adenocarcinoma

OBJECTIVE

The most recent edition of the American Joint Committee on Cancer Staging Manual (AJCC, 8th edition) relies only on tumor size for staging resectable pancreatic adenocarcinoma, and the presence of duodenal wall invasion (DWI) no longer has an impact on staging. However, very few studies have evaluated its significance. In this study, we aim to evaluate the prognostic significance of DWI in pancreatic adenocarcinoma.

METHODS

We reviewed 97 consecutive internal cases of resected pancreatic head ductal adenocarcinoma, and clinicopathologic parameters were recorded. All cases were staged according to the 8th edition of AJCC, and the patients were divided into two groups based on the presence or absence of DWI.

RESULTS

Out of our 97 cases, 53 patients had DWI (55%). In univariate analysis, DWI was significantly associated with lymphovascular invasion and lymph node metastasis (AJCC 8th edition pN stage). In univariate analysis of overall survival, age > 60, absence of DWI, and African American race were associated with worse overall survival. In multivariate analysis, age > 60, absence of DWI, and African American race were associated with worse progression-free survival and overall survival.

CONCLUSION

Although DWI is associated with lymph node metastasis, it is not associated with inferior disease-free/overall survival.

Primary placement of low-profile or 'button' versus traditional balloon-retention radiologically inserted gastrostomy catheters in adults: a retrospective review

OBJECTIVE

De novo percutaneous placement of radiologically inserted low-profile or 'button-type' gastrostomy catheters (LPG) is infrequently reported in adults. This study compares the safety and clinical outcomes of primary percutaneous placement of LPG catheters and traditional balloon-retention gastrostomy catheters (TG) using image guidance at a single institution.

DESIGN

This was a retrospective, single-institution review comparing initial LPG and TG radiologically inserted catheter placements in a 36-month time period. The age, gender, indication, catheter type and method of anaesthesia of 139 consecutive initial gastrostomy placement procedures were recorded. Total catheter days without intervention, major and minor complications, reasons for reintervention, and procedure fluoroscopy times were compared.

RESULTS

During the 36-month study period, 61 LPG and 78 TG catheters were placed. Mean total catheter days prior to intervention was 137 days in the LPG group and 128 days in the TG group (p=0.70). Minor complications including cellulitis, pericatheter leakage and early catheter occlusion occurred in 4.9% (3/61) in the LPG group and 9% (7/78) in the TG group (p=0.5). Major complications including early catheter dislodgement and bleeding requiring transfusion (in one patient) occurred in 4.9% (3/61) in the LPG group and 7.7% (6/78) in the TG group (p=0.4). Procedure fluoroscopy time was lower in the LPG group (2.56 min) compared with the TG group (4.21 min) (p<0.005).

CONCLUSION

Primary placement of low-profile or 'button-type' gastrostomy catheters is technically feasible with a low complication rate similar to that of traditional radiologically inserted gastrostomy catheters.

De Novo Central Vein Stenosis in Hemodialysis Patients Following Initial Tunneled Central Vein Catheter Placement

Background

Central vein stenosis (CVS) is a common complication in hemodialysis patients following tunneled central venous catheter (CVC) insertion. Little is known about its incidence, association with patient characteristics, or relationship with duration of CVC placement. We systematically evaluated central vein stenosis in hemodialysis patients receiving their first CVC exchange at a large medical center.

Methods

All new hemodialysis patients underwent an ultrasound before their internal jugular tunneled CVC placement, to exclude venous stenosis or thrombosis. After the initial CVC insertion, if the patients were referred for CVC exchange due to dysfunction, a catheterogram/venogram was performed to assess for hemodynamically significant (≥50%) central vein stenosis. During a 5-year period (January 2016 to January 2021), we quantified the incidence of CVS in patients undergoing CVC exchange. We also evaluated the association of central vein stenosis with patient demographics, comorbidities, and duration of CVC dependence before exchange.

Results

During the study period, 273 patients underwent exchange of a tunneled internal jugular vein CVC preceded by a catheterogram/venogram. Hemodynamically significant CVS was observed in 36 patients (13%). CVS was not associated with patient age, sex, race, diabetes, hypertension, coronary artery disease, peripheral artery disease, or CVC laterality. However, the frequency of CVS was associated with the duration of CVC dependence (26% versus 11% for CVC duration ≥6 versus <6 months: odds ratio (95% CI), 3.17 (1.45 to 6.97), P=0.003).

Conclusions

Among incident hemodialysis patients receiving their first tunneled internal jugular CVC exchange, the overall incidence of de novo hemodynamically significant central vein stenosis was 13%. The likelihood of CVS was substantially greater in patients with at least 6 months of CVC dependence.

Feasibility of Creation of an Endovascular Arteriovenous Fistula in Patients Undergoing Preoperative Vascular Mapping

Background

The first endovascular arteriovenous fistula (endoAVF) device (WavelinQ), a novel percutaneous technique of AVF creation, was approved by the Food and Drug Administration in 2018 and has been placed in a small number of United States patients on hemodialysis. It is unknown how often patients with advanced CKD have vascular anatomy suitable for WavelinQ creation. The goal of this study was to determine the proportion of patients with vascular anatomy suitable for WavelinQ creation and to assess patient characteristics associated with such suitability.

Methods

All patients referred for vascular access placement at a large academic medical center underwent standardized preoperative sonographic vascular mapping to assess suitability for an AVF. During a 2-year period (March 2019 to March 2021), we assessed the suitability of the vessels for creation of WavelinQ. We then compared the demographic characteristics, comorbidities, and vascular mapping measurements between patients who were or were not suitable for WavelinQ.

Results

During the study period, 437 patients underwent vessel mapping. Of these, 51% of patients were eligible for a surgical AVF, and 32% were eligible for a WavelinQ AVF; 63% of those suitable for a surgical AVF were also suitable for a WavelinQ AVF. Patients with a vascular anatomy suitable for WavelinQ were younger (age 55±15 versus 60±14 years, P=0.01) but similar in sex, race, diabetes, hypertension, coronary artery disease, and peripheral artery disease.

Conclusions

Among patients with CKD with vascular anatomy suitable for a surgical AVF, 63% are also suitable for a WavelinQ endoAVF. Older patients are less frequently suitable for WavelinQ.

Chronic splenic artery occlusion with gastric wall arterial ectasia, an unusual cause of massive upper gastrointestinal hemorrhage

Life-threatening upper gastrointestinal (GI) hemorrhage can occur as a result of bleeding from a variety of arterial and venous sources. We present an unusual cause of life-threatening upper GI hemorrhage arising from ectatic gastric wall arterial branches in a 49-year-old male with previously unrecognized chronic splenic artery thrombosis. The patient developed a recurrence of bleeding despite coil embolization of an accessory left gastric artery branch supplying the gastric fundus suspected to be the site of active bleeding. The patient subsequently underwent splenectomy and surgical ligation of a bleeding gastric artery branch. This case emphasizes the importance of recognizing this unusual cause of upper GI hemorrhage for proper management and prevention of recurrence. Informed consent was obtained from the patient for publication of the case report including accompanying images.

Clinicopathological features of incidental parotid lesions

Background

The purpose of this study is to determine the histopathological spectrum and risk of primary malignancy of asymptomatic parotid lesions incidentally discovered on cross-sectional imaging.

Methods

Over a 10-year period, 154 patients underwent 163 ultrasound-guided parotid lesion biopsies at our institution. This retrospective chart review included 89 lesions in 87 patients with asymptomatic parotid lesions discovered on cross-sectional imaging studies performed for unrelated clinical indications. The histopathologic findings of all sampled lesions were reviewed. We evaluated the patient demographics and pathological diagnoses of sampled parotid lesions to determine the histopathological spectrum and risk of malignancy.

Results

The average age was 67.5 years and 92 % were males. 25 % of patients had bilateral lesions. The average size of the parotid lesions was 1.5 cm and 91 % were located in the superficial lobe. 92.1 % of lesions were benign with Warthin tumor being the most common diagnosis followed by pleomorphic adenoma. 2.3 % of lesions were primary parotid malignant neoplasms, while 5.6 % were metastatic lesions in patients with known malignancy.

Conclusions

The incidence of primary parotid malignant neoplasm in asymptomatic incidentally discovered parotid lesions is low. Imaging or clinical follow-up may be considered in patients with incidental parotid lesions who prefer to avoid biopsy.

Fallopian tube recanalisation using dedicated radiographic tubal assessment set in angiography suite

INTRODUCTION

Fallopian tube recanalisation (FTR) for proximal fallopian tube obstruction (PFTO) is considered a good treatment option for tubal infertility. The aim of this study was to assess the safety and the technical and clinical success rates of FTR using a dedicated radiographic tubal assessment set (FluoroSet(®) ) in the angiography suite.

METHODS

This study is a retrospective analysis of data prospectively collected between February 2007 and June 2011 at King Abdullah University Hospital, Irbid, Jordan. During this period, 61 patients affected by PFTO underwent FTR using FluoroSet(®) at our institution. The mean age of patients was 34 years (range 20-45 years), and the mean duration of infertility was 4 years (range 2-14 years). The procedure was performed with conscious sedation under fluoroscopic guidance in the angiography suite. The obstructed tube was accessed with a 5-Fr multipurpose catheter, and the obstruction was crossed with a 0.35-Fr hydrophilic guide wire until the wire coiled freely into the peritoneal cavity. Patency of the tube was then confirmed by selective salpingiogram. Technical success rate was recorded, and patients were followed up for evidence of pregnancy over 12 months.

RESULTS

The procedure was technically successful in all patients. Minor bleeding and postprocedural pain occurred in most patients; however, there were no major complications encountered. Twenty-five patients (41%) became pregnant. Successful deliveries of full-term infants were reported in 21 patients (84%). Miscarriage was reported in four patients (16%). No ectopic pregnancies were detected, and all deliveries were full-term. The technical success rate was 100% and the clinical success rate was 41%.

CONCLUSION

Selective salpingography and FTR using FluoroSet(®) is a safe and effective method. FTR is recommended as the first intervention in patients with PFTO. In experienced hands with dedicated equipment and in an appropriate setting, the success rate is high, and this treatment should be offered to infertile women with PFTO before other, more complex techniques are attempted.

Renal impairment and hydronephrosis in a premature infant following morphine infusion: case report

This is a case report of an association between morphine administration and occurrence of hydronephrosis with acute renal failure. This premature female infant born at 27 weeks of gestation had moderate hydronephrosis with acute renal impairment while receiving morphine infusion for pain management after chest-tube insertion. All these findings were reversed after stopping morphine and urinary catheterization. Follow-up renal ultrasound and voiding cystourethrogram showed resolution of hydronephrosis with no evidence of vesicoureteral reflux. Morphine is associated with reversible hydronephrosis and renal impairment in premature infants.