A retrospective observational study assessing mortality after pelvic trauma embolisation

INTRODUCTION

Trauma to the pelvic ring and associated haemorrhage represent a management challenge for the multidisciplinary trauma team. In up to 10% of patients, bleeding can be the result of an arterial injury and mortality is reported as high as 89% in this cohort. We aimed to assess the mortality rate after pelvic trauma embolisation and whether earlier embolisation improved mortality.

METHODS

Retrospective study at single tertiary trauma and referral centre, between 1 January 2009 and 30 June 2022. All adult patients who received embolisation following pelvic trauma were included. Patients were excluded if angiography was performed but no embolisation performed.

RESULTS

During the 13.5-year time period, 175 patients underwent angiography and 28 were excluded, leaving 147 patients in the study. The all-cause mortality rate at 30-days was 11.6% (17 patients). The median time from injury to embolisation was 6.3 h (range 2.8-418.4). On regression analysis, time from injury to embolisation was not associated with mortality (OR 1.01, 95% CI 0.952-1.061). Increasing age (OR 1.20, 95% CI 1.084-1.333) and increasing injury severity score (OR 1.14, 95% CI 1.049-1.247) were positively associated with all-cause 30-day mortality, while non-selective embolisation (OR 0.11, 95% CI 0.013-0.893) was negatively associated.

CONCLUSION

The all-cause mortality rate at 30-days in or cohort was very low. In addition, earlier time from injury to embolisation was not positively associated with all-cause 30-day mortality. Nevertheless, minimising this remains a fundamental principle of the management of bleeding in pelvic trauma.

Malnutrition defined by GLIM criteria identifies a higher incidence of malnutrition and is associated with pulmonary complications after oesophagogastric cancer surgery, compared to ICD-10-defined malnutrition

BACKGROUND & OBJECTIVES

Low muscle mass, measured using computed tomography (CT), is associated with poor surgical outcomes. We aimed to include CT-muscle mass in malnutrition diagnosis using the Global Leadership Initiative on Malnutrition (GLIM) criteria, compare it to the International Classification of Diseases 10th Revision (ICD-10) criteria, and assess the impact on postoperative outcomes after oesophagogastric (OG) cancer surgery.

METHODS

One hundred and eight patients who underwent radical OG cancer surgery and had preoperative abdominal CT imaging were included. GLIM and ICD-10 malnutrition data were assessed against complication and survival outcomes. Low CT-muscle mass was determined using predefined cut-points.

RESULTS

GLIM-defined malnutrition prevalence was significantly higher than ICD-10-malnutrition (72.2% vs. 40.7%, p < 0.001). Of the 78 patients with GLIM-defined malnutrition, low muscle mass (84.6%) was the predominant phenotypic criterion. GLIM-defined malnutrition was associated with pneumonia (26.9% vs. 6.7%, p = 0.010) and pleural effusions (12.8% vs. 0%, p = 0.029). Postoperative complications did not correlate with ICD-10 malnutrition. Severe GLIM (HR: 2.51, p = 0.014) and ICD-10 (HR: 2.15, p = 0.039) malnutrition were independently associated with poorer 5-year survival.

CONCLUSIONS

GLIM criteria appear to identify more malnourished patients and more closely relate to surgical risk than ICD-10 malnutrition, likely due to incorporating objective muscle mass assessment.

Research output of radiologists in Australia and New Zealand: Strengths, weaknesses and future directions

INTRODUCTION

Clinical radiology is a popular career. However, academic radiology in Australia and New Zealand (ANZ) has not traditionally been a strength of the specialty which has a focus on clinical medicine and has been influenced by corporatisation of the specialty. The aim of this study was to review the source(s) of radiologist-led research in Australia and New Zealand, to identify areas of relative deficiency and propose plans to improve research output.

METHODS

A manual search was performed of all manuscripts in seven popular ANZ journals, where the corresponding or senior author was a radiologist. Publications between January 2017 and April 2022 were included.

RESULTS

There were 285 manuscripts from ANZ radiologists during the study period. This equates to 10.7 manuscripts per 100 radiologists based on RANZCR census data. Radiologists in Northern Territory, Victoria, Western Australia, South Australia and the Australian Capital Territory all produced manuscripts above the corrected mean incidence rate of 10.7 manuscripts per 100 radiologists. However, locations including Tasmania, New South Wales, New Zealand and Queensland were below the mean. The majority of manuscripts arose from public teaching hospitals with accredited trainees (86%), and there were a higher proportion of manuscripts published by female radiologists (11.5 compared to 10.4 per 100 radiologists).

CONCLUSION

Radiologists in ANZ are academically active; however, interventions aimed at increasing output could be targeted at certain locations and/or areas within a busy private sector. Time, culture, infrastructure and research support are vital, but personal motivation is also extremely important.

Complications in Interventional Radiology: the role of clinical governance and iterative hospital systems in quality improvement

As modern Interventional Radiology (IR) evolves, and expands in scope and complexity, it will push the boundaries of existing literature. However, with all intervention comes risk and it is the shared judgement of the risk-benefit analysis which underpins the ethical and legal principles of care in IR.Complications in medicine are common, said to occur in 9.2% of in-hospital healthcare interactions. Healthcare complications also come at considerable cost. It is estimated that in the UK, prolonging hospital stays to manage complications can cost ₤2 billion per year.However, complications can't be viewed in isolation. Clinical governance is the umbrella within which complications are viewed. It can be defined as a broadly integrated and systematic approach to clinical care and accountability, that seeks to focus on quality of healthcare. This concept incorporates complications but acknowledges their interplay within a complex healthcare system in which negative adverse events are influenced by a range of intrinsic and extrinsic factors. It also includes the processes that result from monitoring and learning from complications, with feedback leading to systems-based improvements in care moving forward. The reality is that complications are uncommonly the result of medical negligence, but rather they are an unfortunate by-product of a healthcare industry with inherent risk.It is also important to remember that complications are not just a number on an audit sheet, but a potentially life-changing event for every patient that is affected. The events that follow immediately from an adverse outcome such as open disclosure are vital, and have implications for how that patient experiences healthcare and trusts healthcare professionals for the rest of their life. We must ensure that the patient and their family maintain trust in healthcare professionals into the future.Credentialling and accreditation are imperative for Interventional Radiologists to meet existing standards as well deal with challenging situations. These should integrate and align within the structure of an organization that has a safety and learning culture. It is the many layers of organisational clinical governance that arguably play the most important role in IR-related complications, rather than apportioning blame to an individual IR.

A retrospective cohort study assessing the incidence of inferior vena cava (IVC) occlusion following prophylactic IVC filter insertion: Is anticoagulation necessary during filter dwell?

BACKGROUND

Inferior vena cava (IVC) filters play a role in preventing venous thromboembolism after major trauma where deep venous thrombosis (DVT) risk is up to 80%. It has been suggested that IVC filters are thrombogenic and many patients are therefore placed on therapeutic anticoagulation during IVC filter dwell citing concern of in situ IVC thrombosis, even in the absence of existing DVT.

METHODS

Between 1 June 2018 and 31 December 2021, this retrospective study assessed the incidence of IVC thrombosis following prophylactic IVC filter insertion. Groups were defined according to the presence or absence of therapeutic anticoagulation during filter dwell. The primary outcome was the presence or absence of IVC thrombus at retrieval.

RESULTS

A total of 124 patients were included. Anticoagulation was prescribed in 29 and anticoagulation was not prescribed in 63. A further 32 patients developed a new thrombosis episode after the prophylactic IVC filter was placed, and 29 were prescribed anticoagulation part-way during filter dwell as a result of this diagnosis. No cases of IVC occlusion were observed in any patient group.

CONCLUSIONS

Caval thrombosis was not observed after prophylactic filter placement, with or without the prescription of anticoagulation. While prospective trials are needed to increase the level of evidence, based on these results the use of therapeutic anticoagulation during IVC filter dwell should not be dictated by the presence of an IVC filter alone but rather by the presence of a related thrombosis event.

Low muscularity increases the risk for post-operative pneumonia and delays recovery from complications after oesophago-gastric cancer resection

BACKGROUND

Low muscularity is associated with adverse surgical outcomes. We aimed to determine whether low muscularity is associated with an increased risk of post-operative complications and reduced long-term survival after oesophago-gastric cancer surgery.

METHODS

Patients who underwent radical oesophago-gastric cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Low skeletal muscle index (SMI), measured by CT, was determined using pre-defined cut-points. Oncological, surgical, complications and outcome data were obtained from a prospective database.

RESULTS

Of 108 patients, 61% (n = 66) had low SMI preoperatively. Patients with low SMI had a higher rate of post-operative pneumonia (30 vs. 7% normal muscularity, P = 0.004). Median length of stay (LOS) was higher in patients with low SMI if they had any complication (19.5 vs. 14 days, P = 0.026) or pneumonia (21 vs. 13 days, P = 0.018). On multivariate analysis, low SMI (OR 3.85, CI 1.10-13.4, P = 0.025), preoperative weight loss (OR 1.13, CI 1.01-1.25, P = 0.027), and smoking (OR 5.08, CI 1.24-20.9, P = 0.024) were independent predictors of having a severe complication. There was no difference in 5-year overall (62% vs. 69%, P = 0.241) and disease-free (11% vs. 21.4%, P = 0.110) survival between low SMI and normal muscle mass groups.

CONCLUSION

Low SMI is associated with a significantly increased risk of pneumonia and increased LOS for patients with complications. Assessment of muscle mass may require additional muscle quality, strength, and physical performance measures to enhance preoperative risk assessment.

A 10-year retrospective review of management and outcomes of pseudoaneurysms at a tertiary referral centre

INTRODUCTION

Pseudoaneurysms are uncommon but potentially life-threatening. Treatment may involve a variety of interventions including observation, manual compression, ultrasound-guided thrombin injection and a variety of endovascular and surgical techniques. Current treatments are largely based on observational data and there is no consensus on management. This study aimed to provide evidence for guiding clinical decisions regarding visceral artery pseudoaneurysm and peripheral artery pseudoaneurysm management.

METHODS

Retrospective single-centre review of patients diagnosed with visceral and peripheral artery pseudoaneurysms at a tertiary hospital (2010-2020).

RESULTS

There were 285 patients included in this study. A total of 86 patients were diagnosed with a visceral artery pseudoaneurysm, and 49 of these (57%) were caused by trauma. A total of 199 patients were identified with a peripheral pseudoaneurysm; 76 of these (38%) were caused by trauma and 69 (35%) were due to access site complication during an endovascular procedure. Initial technical success was achieved in 266 patients (93.3%) with 19 requiring an additional treatment to achieve success. Conservative treatment (100% success), endovascular treatment (98.1%) and surgery (100%) were more successful than ultrasound-guided compression (63.6%) and thrombin injection (83.8%). The median time from diagnosis to intervention was <9 h for visceral artery pseudoaneurysms and 24 h for peripheral artery pseudoaneurysms. There was no change in survival outcomes with respect to time from diagnosis and intervention.

CONCLUSION

In this study, pseudoaneurysms were treated with a high degree of success by observation or by using an endovascular approach, and those requiring endovascular intervention did not need to be treated immediately in an emergent setting.

A warning for warming catheters: interventional radiology's role

Concerns have been raised in the literature, regarding the risk of venous thromboembolic events associated with the use of thermoregulatory catheters. Inferior vena cava (IVC) filters are commonly used to prevent venous thromboembolic events. We demonstrate the usefulness of IVC filter placement prior to the removal of thermoregulatory warming catheters. The management of thermoregulatory warming catheter associated venous thromboembolism is outlined through a retrospective case series of three patients. In one case IVC thrombus was incidentally detected at ultrasonography one-week post removal. The second case describes the occurrence of pulseless electrical activity arrest secondary to massive pulmonary embolism immediately post removal of the thermoregulatory catheter, and subsequent interventional radiology management including pulmonary thrombectomy and caval filter placement. The third case is of a patient in whom the removal of the warming catheter was performed in the angiography suite, with placement of IVC filter prior to removal. Venography displayed a large thrombus burden within the IVC filter. There is limited data in the literature regarding the use of IVC filters as prophylaxis in patients with thermoregulatory catheters, particularly warming catheters. We advocate the placement of an IVC filter prior to the removal of warming catheters. We raise awareness regarding the potential risks of venous thromboembolism in this population and the key role interventional radiology has in the management of these patients.

Myosteatosis predicts higher complications and reduced overall survival following radical oesophageal and gastric cancer surgery

INTRODUCTION

Low muscle attenuation, as governed by increased intramuscular fat infiltration (myosteatosis), may associate with adverse surgical outcomes. We aimed to determine whether myosteatosis is associated with an increased risk of postoperative complications and reduced long-term survival after oesophago-gastric (OG) cancer surgery.

METHODS

Patients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Myosteatosis was evaluated using previously defined cut-points for low skeletal muscle attenuation measured by CT. Oncological, surgical, complications, and outcome data were obtained from a prospective database.

RESULTS

Of 108 patients, 56% (n = 61) had myosteatosis. Patients with myosteatosis were older (69.1 ± 9.1 vs. 62.8 ± 9.8 years, p = 0.001) and had a similar body mass index (BMI) (23.4 ± 5.3 vs. 25.9 ± 6.7 kg/m², p = 0.766) compared to patients with normal muscle attenuation. Patients with myosteatosis had a higher rate of anastomotic leaks (15% vs. 2%, p = 0.041). On multivariate analysis, myosteatosis was an independent predictor of overall (OR 3.03, 95% CI 1.31-6.99, p = 0.009) and severe complications (OR 4.33, 95% CI 1.26-14.9, p = 0.020). Patients with myosteatosis had reduced 5 year overall (54.1% vs. 83%, p = 0.004) and disease-free (55.2% vs. 87.2%, p = 0.007) survival.

CONCLUSION

Myosteatosis is associated with a significantly increased risk of overall and severe complications as well as substantially reduced long-term survival. Assessment of muscle attenuation provides analysis beyond standard anthropometrics and may form part of preoperative physiological staging tools used to improve surgical outcomes.

Radiologically Inserted Gastrostomy (RIG) at a Tertiary Center: Periprocedural Safety including Rationalization of Antibiotic Prophylaxis

Introduction Long-term percutaneous enteral nutrition forms an important part of treatment for patients with an inability to meet nutrient requirements orally. Radiologically inserted gastrostomy (RIG) is an alternative to the traditionally performed percutaneous endoscopic gastrostomy technique. However, there is marked heterogeneity in the way that RIG is performed. In addition, the role for antibiotic prophylaxis during RIG insertion is not clearly established. This study aimed to assess the safety of RIG insertion using our technique including the role of antibiotics in RIG insertion.

Method Retrospective study over 5 years at a tertiary teaching hospital. Periprocedural or early complications within the first 2 weeks of the procedure were collected and correlated with the use of prophylactic antibiotics.

Results A total of 116 patients met the inclusion criteria. 18-French tube was used in 96.6%. Note that 58.6% of procedures were done with intravenous sedation. Prophylactic 1 g cefazolin was used in 70 patients with 1 case of infection. Procedures were performed without antibiotics in 46 patients with 3 infections, p = 0.20.

There were two major complications (1.7%) consisting of right gastric artery injury requiring embolization and gastric wall injury requiring laparotomy. There were 12 minor complications (10.3%) including 4 cases of infection, 3 of severe pain, 1 of minor bleeding, 2 of early dislodgement, and 2 of leak/bypass of gastric contents around the tube.

Conclusion The technique used for RIG insertion at our institution results in a low complication rate. In addition, this study shows no significant difference in early peristomal infection rate with the use of antibiotic prophylaxis.

Splenic Artery Embolization after Delayed Splenic Rupture Following Blunt Trauma: Is Nonoperative Management Still an Option in This Cohort?

Patients treated with splenic artery embolization (SAE) >48 hours after a blunt injury for a delayed splenic rupture (DSR) were assessed for the need for a subsequent splenectomy. Thirty-four patients underwent SAE for DSR over 10 years at our level 1 trauma center, performed at a median of 4.5 days after the injury (interquartile range = 5.5), and the patients were followed up for a median of 11 months (interquartile range = 31). There were 3 occurrences of rebleeds, and 2 patients required splenectomy (5.9%). This study showed that treatment with SAE after DSR results in splenic salvage in 94.1% of patients.

SPLEnic salvage and complications after splenic artery EmbolizatioN for blunt abdomINal trauma: the SPLEEN-IN study

BACKGROUND

As an adjunct to non-operative management, splenic artery embolization (SAE) has been increasingly utilized throughout the world and is now the standard of care for hemodynamically stable patients. This study aimed to retrospectively assess the rate of splenic salvage and complications after SAE for blunt trauma at a level 1 trauma center using the 2018 update to the AAST criteria, and further sub-stratify the role of angiography in AAST grade III injuries with significant hemoperitoneum. All patients between 1 January 2009 and 1 January 2019 who underwent blunt trauma and proceeded to embolization were included. Data was collected concerning initial injury grade, location of embolization, type of embolic material used, complications, and need for subsequent splenectomy. Technical success was defined as successful angiographic occlusion of the target artery at the conclusion of embolization. Clinical success was defined as splenic salvage at discharge. Vascular lesions were characterized including those with active bleeding, pseudoaneurysm, and arterio-venous fistula.

RESULTS

Two hundred thirty-two patients were included in the study. Treatments were performed at a median of 0 days (range 0-28 days) and the median AAST grade was IV (range III-V). Technical success was achieved in all patients. There were 13 complications (5.6%) consisting of re-bleed (9, 3.9%), infarction (3, 1.3%), and access site haematoma (1, 0.43%). Clinical success was achieved in 97% of patients with 7 patients requiring splenectomy after SAE (3.0%) at a median time of 4 days (range 0-17 days). Angiography in patients with grade III injuries identified 18 occult vascular injuries not identified at initial CT (p < 0.0001).

CONCLUSIONS

The SPLEEN-IN study shows that treatment of intermediate-high grade blunt force traumatic splenic injuries using SAE resulted in a low rate of complication and splenic salvage in 97% of patients, providing a safe and effective treatment in stable patients. In addition, angiography of grade III injuries identified occult vascular lesions and may warrant treatment of select patients in this cohort.

LEVEL OF EVIDENCE

Level 3.

ArtVentive endoluminal occlusion system for proximal splenic artery embolization

We aimed to discuss and evaluate the technical success and efficacy of the ArtVentive endoluminal occlusion system (EOS) device for splenic embolization. A retrospective review was undertaken for all patients in whom the EOS device was deployed for the purpose of splenic embolization. Data was collected by a search of splenic artery embolization procedures in the hospital computer database. Data was reviewed for all patients in whom an EOS plug was deployed. Patient demographics, technical aspects of the procedure and follow-up at one month were reviewed. We review the technical success and efficacy of this occlusion device. Six patients underwent splenic embolization with the EOS plug. There were 5 male and 1 female patients; age range was 24-88 years. Five 8 mm and one 5 mm EOS plugs were deployed for the occlusion of the splenic artery. The technical success rate was 100% occurring in all 6 splenic arteries. One patient underwent a second angiogram and subsequent splenectomy for persistent splenic hemorrhage. One patient had a subsequent splenectomy for bacteremia with the spleen as the suspected source. This early data supports the efficacy of the EOS plug for the embolization of the proximal splenic artery.

Prognostic role of alpha-fetoprotein in patients with hepatocellular carcinoma treated with repeat transarterial chemoembolisation

BACKGROUND

Repeat transarterial chemoembolisation (rTACE) is often required for hepatocellular carcinoma (HCC) to achieve disease control, however, current practice guidelines regarding treatment allocation vary significantly. This study aims to identify key factors associated with patient survival following rTACE to facilitate treatment allocation and prognostic discussion.

METHOD

Patients with HCC undergoing rTACE at six Australian tertiary centers from 2009 to 2014 were included. Variables encompassing clinical, tumour, treatment type and response factors were analysed against the primary outcome of overall survival. Univariate analysis and multivariate Cox regression modelling were used to identify factors pre- and post-TACE therapy significantly associated with survival.

RESULTS

Total of 292 consecutive patients underwent rTACE with mainly Child Pugh A cirrhosis (61%) and BCLC stage A (57%) disease. Median overall survival (OS) was 30 months (IQR 15.2-50.2) from initial TACE. On multivariate analysis greater tumour number (p = 0.02), higher serum bilirubin (p = 0.007) post initial TACE, and hepatic decompensation (p = 0.001) post second TACE were associated with reduced survival. Patients with serum AFP ≥ 200 ng/ml following initial TACE had lower survival (p = 0.001), compared to patients with serum AFP level that remained < 200 ng/ml post-initial TACE, with an overall survival of 19.4 months versus 34.7 months (p = 0.0001) respectively.

CONCLUSION

Serum AFP level following initial treatment in patients undergoing repeat TACE for HCC is a simple and useful clinical prognostic marker. Moreover, it has the potential to facilitate appropriate patient selection for rTACE particularly when used in conjunction with baseline tumour burden and severity of hepatic dysfunction post-initial TACE.

Omental apoplexy: Unravelling the mystery

INTRODUCTION

To describe cases omental haemorrhage and to review the literature on this topic.

METHODS

We describe three cases of spontaneous omental haemorrhage and discuss various management strategies, in an attempt to provide direction for similar cases in the future.

RESULTS

A number of case reports of spontaneous or idiopathic omental haemorrhage exist in the literature. These cases are often attributed to an underlying vasculopathy, such as segmental arterial mediolysis (SAM). Appropriate resuscitation is paramount for best outcome. Severe bleeding may require surgery or transcatheter arterial embolisation, which is best performed early if required. Endovascular management using selective catheterisation of the bleeding vessel and embolisation is a minimally invasive alternative to emergent operative intervention. In the three cases we present, endovascular embolisation was performed in two patients, and surgical ligation in a third. Segmental arterial mediolysis is considered the likely aetiology in at least 2 of the 3 cases, based on imaging findings. No further episodes of haemorrhage occurred at follow-up (ranging from 6 months to 2 years).

CONCLUSIONS

Acute omental haemorrhage is a rare condition; however, it may be associated with significant morbidity and mortality. CT angiography is the imaging of choice. Management strategies include both endovascular and surgical intervention.

Evaluation of a radiographer-led peripherally inserted central catheter insertion service

INTRODUCTION

To evaluate a radiographer-led peripherally inserted central catheter (PICC) insertion service within an interventional radiology suite using ultrasound and fluoroscopic guidance.

METHODS

Data from 366 consecutive PICC insertions by five trained angiography-specialized radiographers were prospectively collected over a 12-month period. For each PICC insertion, patient demographics, including past medical history of cystic fibrosis (CF), number of punctures, vein used, final tip position, contrast administration and screening time were recorded. Institutional review board approval was obtained.

RESULTS

The overall PICC insertion success rate was 100%. Fifty-five (15%) had a known medical history of CF. Three hundred and thirty-one (90%) PICC insertions required a single puncture and 32 (9%) required two punctures. The remaining three insertions required three punctures. The basilic vein was most commonly used (69%) followed by the brachial vein (29%), and the cephalic vein was used only in 2%. Administration of contrast medium was necessary during 27 (7%) PICC insertions. Mean screening time was 10.7 s.

CONCLUSION

Our specifically trained, radiographer-led PICC insertion service proved to be successful. Both straightforward and complex insertions, for example in CF patients could be adequately and efficiently performed.

The cost to perform uterine fibroid embolisation in the Australian public hospital system

INTRODUCTION

Uterine fibroids have the potential to cause morbidity, and there is a substantial cost to both the healthcare system and society. There is support for minimally invasive intervention, and uterine fibroid embolisation (UFE) is an established cost-effective option for women wishing for an alternative to surgery. There is a lack of local Australian costing data to compliment use in the public hospital system, and we offer a costing analysis of running a public hospital service.

METHODS

We reviewed the costs for 10 sequential uterine fibroid embolisation cases, by assessing the direct and indirect hospital costs.

RESULTS

The total cost of providing a uterine fibroid embolisation service using our model in a public hospital including initial outpatient assessment, procedure costs, overnight hospital ward stay and outpatient follow-up is $3995 per admission.

CONCLUSION

Using our model, the overall cost to perform this procedure is low, and lower than prior estimates for surgical alternatives. We encourage government and regulatory bodies to support UFE through guidelines and remuneration models, and encourage more public Australian interventional radiology departments to offer this service.

Use of the Magellan Robotic System for Conventional Transarterial Chemoembolization (cTACE): A 6-Patient Case Series Showing Safety and Technical Success

Robotic endovascular technology is an emerging concept, and is being developed to allow more precise navigation of anatomy in challenging endovascular cases. The Magellan Endovascular System allows either direct or remote steerability of a 2-point articulating robotic platform with the ability to place a conventional microcatheter through the catheter tip. Such flexibility may help to reach an otherwise difficult anatomic location, especially in variant anatomy. To date, this platform has been shown to be technically successful in a small number of different settings. This case series shows another potential platform for such technology and explores the technical use and overall safety in conventional transarterial chemoembolization (cTACE). The study retrospectively assessed 6 patients undergoing selective cTACE. Treatments were performed in a single center by two experienced interventional radiologists. Fluoroscopy time, radiation dose, anatomic target, and adverse events were logged. In spite of a longer than expected average fluoroscopy time, which can be expected for a first-generation technology, the average radiation dose was comparable to literature and technical success was able to be shown in all 6 patients with no adverse events. This technology has wide scope for future use and once overcoming a learning curve, may allow us to avoid repeat procedure attempts thus reducing fluoroscopy time and leading to earlier successful treatment. Providing a platform of interest and usability in the interventional radiology world may also lead to further development of smaller, cheaper, and more widely-accessible devices.

Variables associated with pulmonary thromboembolism in injured patients: A systematic review

BACKGROUND

Pulmonary thromboembolism (PTE) is a dangerous complication of traumatic injury, with varied risk profiles and treatment options. This review aims to describe reported incidence and variables associated with PTE among severely injured patients.

METHODS

Searches were conducted using PubMed, Cochrane and MEDLINE. Relevant studies were identified by two independent reviewers based on predetermined inclusion criteria. Incidence of PTE was the primary outcome measure. Variables associated with PTE was the secondary outcome measure. The Newcastle-Ottawa Scale was used to assess quality of included studies.

RESULTS

There were eight studies that satisfied inclusion criteria. The diagnosed incidence of PTE in these populations ranged from 0.35 to 24%. The most common variables associated with PTE were pelvic or lower limb injury, chest injury, higher total Injury Severity Score, male sex and age. Variables that were less commonly associated with PTE were previous warfarin use, head injury, high serum lactate, soft tissue injury, more than one operation, more than three days on a ventilator, presence of a subclavian central venous catheter, need for a blood transfusion, systolic blood pressure <90mmHg, abdominal injury, presence of a deep venous thrombosis, inferior vena cava filter placement and isolated liver spleen or spinal injuries.

CONCLUSIONS

The reported incidence of PTE after major trauma is variable and dependent on inclusion criteria, diagnostic criteria and study design. Identified variables differed to those reported for venous thromboembolism in other populations. It is difficult to predict populations at risk of clinically significant PTE following injury using available evidence. Further studies linked to patient-specific variables will assist in more precise risk-stratification and interventions.

Radiological insertion of Tenckhoff catheters for peritoneal dialysis: a 1-year single-centre experience

Background

Peritoneal dialysis (PD) is an important home-based dialysis modality for patients with end-stage kidney disease (ESKD). The initiation of PD requires timely and skilled insertion of a Tenckhoff catheter (TC). At most centres, TCs are inserted laparoscopically by surgeons under general anaesthetic. This requires access to increasingly scarce surgical, anaesthetic and hospital inpatient resources. Radiological insertion of TCs performed as a day procedure under local anaesthetic allows for easier access to the TC insertion with reduced resource requirements. We report our 1-year experience following the introduction of this technique to our PD programme.

Methods

This is a retrospective review of the outcomes for all patients who had TCs inserted radiologically (percutaneously with the assistance of ultrasound and fluoroscopy) over the 12-month period from December 2011 to December 2012. Relevant patient demographics collected included age, gender, body mass index (BMI), previous abdominal surgery and cause of ESKD. Extended details of the insertion procedure were also obtained including length of stay, early complications and time to first use of the catheter for PD.

Results

Thirty Argyle^™ Swan Neck TCs were inserted under radiological guidance during the study period. The mean age of patients was 56 (SD ± 14). The male-to-female ratio was 2:1. The mean BMI was 25.7 (SD ± 4.8). PD was the initial dialysis modality in 22 (73%) patients. Of the 30 patients, 14 (46.7%) had previously undergone extraperitoneal abdominal surgery. All catheters were inserted successfully as day cases except four patients (13.3%) who had catheters inserted during an inpatient hospital admission. Most catheters were not accessed for a minimum of 10 days to reduce the chance of exit site leakage, in two cases the catheters were used within 5 days without complication. There were no cases of peritonitis or exit site infection during the observation period. Catheter migration occurred in four patients (13.3%) but only one required surgical intervention. Minor pain issues were noted in six patients (20%) and bleeding around the exit site requiring suturing in two patients (6.7%). The introduction of this technique at our institution saw a 67% increase in the number of patients performing PD.

Conclusions

Radiological insertion of TCs for PD provided improved access to catheter insertion in a timely manner with reduced resource requirements. Over the 12-month observation period we noted a high technical success rate with very few complications. Our study supports radiological insertion of TCs under local anaesthetic as a viable alternative to catheter insertion in theatre under general anaesthetic. The relative ease of radiological TC insertion has resulted in a significant increase in patient uptake of PD at our centre.

Contemporary management of renal trauma

In the management of renal trauma, surgical exploration inevitably leads to nephrectomy in all but a few specialized centers. With current management options, the majority of hemodynamically stable patients with renal injuries can be successfully managed nonoperatively. Improved radiographic techniques and the development of a validated renal injury scoring system have led to improved staging of injury severity that is relatively easy to monitor. This article reviews a multidisciplinary approach to facilitate the care of patients with renal injury.

Predictors of outcome for blunt high grade renal injury treated with conservative intent

PURPOSE

Management for blunt high grade renal injury is controversial with most disagreement concerning indications for exploration. At our institution all patients are considered candidates for conservative treatment regardless of injury grade or computerized tomography appearance with clinical status the sole determinant for intervention. We define clinical factors predicting the need for emergency intervention as well the development of complications.

MATERIALS AND METHODS

We analyzed the records of 117 patients with high grade renal injury (III to V) secondary to blunt trauma who presented to our institution in an 8-year period. Patients were categorized by the need for emergency intervention and, in those treated conservatively, by complications. We generated logistic regression models to identify significant clinical predictors of each outcome.

RESULTS

Grade III to V injury occurred in 48 (41.1%), 42 (35.9%) and 27 patients (23%), respectively. Of the 117 patients 20 (17.1%) required emergency intervention. On multivariate analysis only grade V injury (RR 4.4, 95% CI 1.9-10.5, p = 0.001) and the need for platelet transfusion (RR 8.9, 95% CI 2.1-32.1, p < 0.001) significantly predicted the need for intervention. A total of 90 patients (82.9%) who did not require emergency intervention underwent a trial of conservative treatment, of whom 9 (9.3%) experienced complications requiring procedural intervention. On multivariate analysis only patient age (RR 1.06, 95% CI 1.02-1.1, p = 0.004) and hypotension (RR 12, 95% CI 1.9-76.7, p = 0.009) were significant predictors.

CONCLUSIONS

High grade injury can be successfully managed conservatively. However, grade V injury and the need for platelet transfusion predict the need for emergency intervention while older patient age and hypotension predict complications.