National Multicenter and Multiyear Review of Complications Following Fluoroscopic Gastrostomy in Patients Covered by Medicare and Medicaid

Objective This study aims to assess the postoperative complication rates associated with fluoroscopically placed gastrostomy tubes.

Background Fluoroscopically placed gastrostomy tubes are a relatively common procedure performed by interventional radiologists. Few studies have been performed in the United States to access the complication profile of fluoroscopically placed gastrostomy tubes.

Methods Total 51 million Medicare Standard Analytic Patient Records derived from Medicare parts A and B records from 2007 to 2012 were retrospectively analyzed. Only the patients undergoing fluoroscopic gastrostomy were included in this study. Patient demographics were stratified by age, sex, comorbidities, and peri- and postoperative complications as defined by International Classification of Diseases (ICD) 9 codes.

Results Total 30,327 patients undergoing fluoroscopic gastrostomy were analyzed. Perioperative complications following these procedures were low, with 61 (0.02%) patients experiencing pneumoperitoneum, 130 (0.43%) experiencing ileus, 16 (0.05%) experiencing esophageal/gastric perforation, and 30 (0.09%) patients experiencing intra-abdominal injury. Most common postoperative complications included abdominal wall pain (n = 2,808, 9.25%), bleeding (n = 1,353, 4.46%), and mechanical complications (n = 1,435, 4.73%).

Conclusion Fluoroscopic guidance is a safe method for gastrostomy placement, with exceedingly low rates of peri- and postoperative complications.

Fluoroscopic and Endoscopic Gastrostomy Tube Placement: Regional Variation and Their Prevalence

Objective This study aims to assess the regional variation and overall longitudinal prevalence of approaches to gastrostomy tube placement in patients covered by Medicare or Medicaid.

Background Gastrostomy tubes are most commonly inserted endoscopically given the approaches’ demonstrated safety, success, and patient outcomes as compared with laparoscopic approaches. Recently, the growth of interventional radiology services has provided patients with an alternative percutaneous approach. The safety and efficacy of this approach as opposed to endoscopic approaches has yet to be determined.

Methods From 2005 to 2014, Medicare Standard Analytic Files derived from Medicare parts A and B, which contain 100% of inpatient and outpatient facility records billed to Medicare, were retrospectively analyzed. Age, sex, year of placement, region, comparative quarterly ratio, regional cost variation, and overall financial cost were compared between both cohorts.

Results Our population included a total of 336,021 patients; of those, 30,327 patients underwent fluoroscopic guided procedures, and 305,694 patients underwent endoscopic procedures. Age (p < 0.001), region (p = 0.043), and year of placement (p < 0.001) varied significantly between these populations. Fluoroscopic-guided procedures were found to have a statistically significantly lower average cost of treatment compared with endoscopic gastrostomies ($2,018.62 vs. $2,471.33, respectively, p = 0.03).

Conclusion This study demonstrates an increasing prevalence of fluoroscopically placed gastrostomy tubes as compared with those placed endoscopically.

Primary constrained TIPS for treating refractory ascites or variceal bleeding secondary to hepatic cirrhosis

OBJECTIVE

To report an initial experience using a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) technique for treating cirrhotic patients with refractory ascites or variceal bleeding.

METHODS

All patients undergoing primary constrained (n = 9) and conventional (n = 18) TIPS between July 2014 and June 2016 were retrospectively reviewed. Preprocedure demographics, Child-Pugh, model for end-stage liver disease and technical variables were recorded. Outcomes measured included technical and clinical success, complications, 30-day mortality, as well as necessity for TIPS revision. Average (SD) and median follow-up was 237 (190) and 226 days.

RESULTS

All constrained and conventional TIPS were technically successful (100%). Clinical success as defined as a reduction or improvement in presenting symptoms was 88.9% (8/9) and 100% (18/18) in the constrained and conventional groups, respectively (p = 1). The average reduction in portosystemic gradient was lower in the constrained group, 6.1 mmHg compared with 10.6 mmHg in the conventional group (p = 0.73). The rate of hepatic encephalopathy following TIPS placement was higher in the conventional group [16.7% (3/18)] compared with 0% in the constrained group (p = 0.52). The percentage of patients requiring TIPS revision was lower in the constrained group, although the results were not significant (11.1 vs 22.2%, p = 0.63).

CONCLUSION

Primary constrained TIPS is a feasible modification to conventional TIPS with similar technical and clinical success rates. A trend towards a smaller reduction in the portosystemic gradient and need for revision was observed in the constrained group. Advances in knowledge: Primary constrained TIPS allows for greater stepwise control over shunt diameter and may represent an improved technique for patients at risk for hepatic encephalopathy.

Primary constrained TIPS for treating refractory ascites or variceal bleeding secondary to hepatic cirrhosis

OBJECTIVE

To report an initial experience using a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) technique for treating cirrhotic patients with refractory ascites or variceal bleeding.

METHODS

All patients undergoing primary constrained (n = 9) and conventional (n = 18) TIPS between July 2014 and June 2016 were retrospectively reviewed. Preprocedure demographics, Child-Pugh, model for end-stage liver disease and technical variables were recorded. Outcomes measured included technical and clinical success, complications, 30-day mortality, as well as necessity for TIPS revision. Average (SD) and median follow-up was 237 (190) and 226 days.

RESULTS

All constrained and conventional TIPS were technically successful (100%). Clinical success as defined as a reduction or improvement in presenting symptoms was 88.9% (8/9) and 100% (18/18) in the constrained and conventional groups, respectively (p = 1). The average reduction in portosystemic gradient was lower in the constrained group, 6.1 mmHg compared with 10.6 mmHg in the conventional group (p = 0.73). The rate of hepatic encephalopathy following TIPS placement was higher in the conventional group [16.7% (3/18)] compared with 0% in the constrained group (p = 0.52). The percentage of patients requiring TIPS revision was lower in the constrained group, although the results were not significant (11.1 vs 22.2%, p = 0.63).

CONCLUSION

Primary constrained TIPS is a feasible modification to conventional TIPS with similar technical and clinical success rates. A trend towards a smaller reduction in the portosystemic gradient and need for revision was observed in the constrained group. Advances in knowledge: Primary constrained TIPS allows for greater stepwise control over shunt diameter and may represent an improved technique for patients at risk for hepatic encephalopathy.

Prevalence, presentation, and endovascular management of hemodynamically or clinically significant arterio-portal fistulae in living and cadaveric donor liver transplant recipients

PURPOSE

To compare the prevalence (cadaveric vs. living donor transplants), clinical features, and the effectiveness of endovascular management of significant arterio-portal fistulae (APF) in liver transplant recipients.

METHODS

A retrospective audit of liver transplant recipients in two institutions was performed (1996-2009). Significant APF were included and were defined as symptomatic and/or hemodynamically significant (causing graft dysfunction and/or having abnormal Doppler findings in the portal vein). Patients with significant APF were evaluated for presenting symptoms, imaging features, size/branch order portal vein involvement, and effectiveness of the endovascular management (coil embolization).

RESULTS

Four significant APF were found in 1992 (0.2%) liver transplants. Two were symptomatic and two were asymptomatic but were hemodynamically significant with liver function test abnormalities. All four APF were found in cadaveric donor graft recipients (0.23%, N = 4/1753) and none in 239 living donor graft recipients. However, there was no statistical difference between cadaveric and living donor graft recipients (p = 1.0, odds ratio = 1.23). Coil embolization was technically and clinically successful in all 4 without complications and causing normalization of the abnormal Doppler findings.

CONCLUSION

Significant APF are a rare diagnosis (0.2% of transplants). Coil embolization is a safe and effective treatment option for APF in transplants.

Contrast-enhanced magnetic resonance angiography following subintimal recanalization

PURPOSE

To describe the appearance of lower extremity runoff vessels following subintimal recanalization (SIR) on contrast-enhanced magnetic resonance angiography (ceMRA) and compare 2 different ceMRA techniques.

METHODS

A total of 6 patients underwent stepping table 3-dimensional (3D) ceMRA and time-resolved 2-dimensional (2D) MRA within 1 to 3 days (mean 1.83 days) following SIR. The 2 techniques were compared with intra-arterial digital subtraction angiography (DSA).

RESULTS

A total of 15 arteries were recanalized in 6 patients. Three-dimensional ceMRA allowed evaluation of patency in all segments above the knee. Postprocedural hyperemia impaired the assessment of the trifurcation vessels on 3D ceMRA. Due to its higher temporal resolution 2D MRA was not affected by venous contamination and allowed reliable confirmation of patency of the recanalized vessels.

CONCLUSIONS

Diagnostic MRA studies of the lower extremity runoff vessels following SIR is possible, but a hybrid technique using a stepping table MR DSA and a time-resolved sequence like 2D MRA of the calf station is necessary for runoff assessment.