Lymphoceles: percutaneous treatment with povidone-iodine sclerosis

Although percutaneous procedures have gained a degree of acceptance for treatment of lymphoceles, success rates for aspiration and drainage have been less than optimal. The authors investigated transcatheter sclerosis of pelvic lymphoceles with povidone-iodine as a method to increase the success rate of percutaneous management. Eight patients with a total of nine pelvic lymphoceles were treated with this method. Eight of the nine lymphoceles (89%) resolved without complications. Four patients had undergone lymphadenectomy and four, renal transplantation. The duration of catheter drainage ranged from 15 to 37 days. Four of the lymphoceles were found to be infected at initial drainage, but this did not alter the amount of time the catheter was left in place. One lymphocele failed to heal with sclerotherapy and required internal drainage. The early results with transcatheter povidone-iodine sclerosis of postoperative lymphoceles are encouraging and warrant further evaluation.     

Adrenal cysts: imaging and percutaneous aspiration

Six patients with primary adrenal cysts were encountered during a period of 3 years. Multiple imaging modalities were used to characterize these lesions, including magnetic resonance imaging in one case. Percutaneous aspiration was performed on four of the six cysts - in one case, in the operating room prior to excision of the cyst. Cholesterol was detected in four cysts and cortisol in one cyst. Cytologic findings from aspiration biopsy were benign in all five cases. Two cysts were removed, one of them after reaccumulation of the fluid after needle aspiration. The findings in this small series of adrenal cysts suggest that in certain cases, complete cyst aspiration, rather than surgical excision, may be carried out initially for diagnosis and management of indeterminate suprarenal cystic lesions and symptomatic cysts of the adrenal gland.     

经皮肝穿刺胆道造影诊断胰胆管合流异常的价值

目的 探讨经皮肝穿刺胆道造影(PTC)诊断胰胆管合流异常(PBM)的临床价值及可行性,总结其影像特征.方法 回顾性分析连续的363例因阻塞性黄疸PTC下行介入治疗患者的临床及影像资料,并根据病例入选标准筛选出资料完整、胰管显影的病例.通过影像测量胆胰共同管长度、直径,汇合处胰胆管直径、汇合角度等,并经校正得到实际数值,结合PBM诊断标准进行诊断.采用t检验比较测量值与正常值有无统计学意义,采用独立样本秩和检验分析测量的胆胰共同管长度、汇合角度与十二指肠乳头位置的关系.结果 本组病例根据PTC结果共确诊PBM 38例,检出率为10.5%(38/363);PBM患者共同管长度为(12.6±7.9)mm,明显高于正常的6 mm(t=5.15,P<0.05).汇合处胆总管直径、胰管直径、共同管直径分别为(3.7±1.9)、(2.4±1.3)、(3.3±1.4)mm,与正常值(分别为6、3、2 mm)比较差异无统计学意义(t值分别为1.79、2.85、5.72,P值均>0.05).十二指肠乳头开口于降部中段1/3部位15例,共同管长度为(10.6±9.1)mm,汇合角度51.1°±28.0°;异常开口组:降部下1/3段10例、交界处8例、水平部5例,共同管长度分别为(9.9±3.7)、(18.6±8.9)、(13.9±3.5)mm,汇合角度分别为54.0°±18.6°、48.7°±12.6°、74.4°±18.5°.十二指肠乳头部位不同的患者间,共同管长度差异有统计学意义(X2=14.51,P<0.05),乳头部位距壶腹部越远,共同管越长.结论 PTC诊断PBM安全、可行,并具有一定的特征性.     

Biliary ascariasis: percutaneous transhepatic management

In a 60-year-old woman who underwent cholecystectomy and T-tube drainage for biliary ascariasis, postoperative bilirubin levels continued to increase. T-tube cholangiography revealed multiple filling defects in the bile ducts, which suggested roundworm reinfestation. Because the patient could not tolerate endoscopy, a percutaneous transhepatic approach with balloon dilatation of the ampulla of Vater and subsequent advancement of roundworms into the duodenum with an embolectomy balloon was used. The procedure was successful, with no major complications. The use of a percutaneous transhepatic treatment to advancement of roundworms into the duodenum is a feasible alternative to surgery when endoscopic extraction fails.     

Chronic mesenteric ischemia: imaging and percutaneous treatment.

Chronic mesenteric ischemia (CMI) is rare and is often diagnosed late. Fatal malabsorption-related complications or acute ischemic events occur in the absence of treatment. Diagnosis depends on careful acquisition of a medical history and elimination of other conditions. No sensitive and specific tests are available for functional diagnosis of CMI. If other causes of abdominal pain and weight loss have been confidently ruled out, evidence of visceral artery occlusion at noninvasive imaging (Doppler ultrasonography, computed tomographic angiography, and magnetic resonance angiography) suggests CMI. Until the 1990s, open surgery was considered the treatment of choice; percutaneous transluminal angioplasty (PTA) was reserved for patients for whom surgery carried a high risk. However, open surgery carries a nonnegligible risk of morbidity and mortality. In recent years, PTA with stent placement has been recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate and consequently has been suggested for primary treatment of CMI. New treatments including administration of fibrinolytic agents before PTA of chronic occlusions, routine revascularization of one or more arteries, and stent placement will probably be validated in the near future. Similarly, new data on selection of the best approach will become available soon.     

Abscess-fistula association: radiologic recognition and percutaneous management

Thirty-five patients with postoperative enteric and/or biliary fistulae were diagnosed and treated by percutaneous catheter drainage. All were initially considered to have postoperative abdominal abscesses, and the enteric or biliary communications were unrecognized before radiologic intervention. In addition, at the time of initial catheter insertion, only six of the 35 abscesses were recognized as being associated with an underlying fistula. In the other 29 patients the fistulae were found either by clinical follow-up or contrast sinogram after 24-72 hr of catheter drainage. Percutaneous catheter drainage was the definitive treatment in 28 (80%) of the 35 patients. The seven failures were either from inadequate catheter positioning or inability to treat the primary cause of the fistula (e.g., radiation enteritis, perforated cancer). These data suggest that even abscesses with underlying fistulae, traditionally an indication for surgical intervention, may be successfully managed by percutaneous methods.     

Coronary subclavian steal syndrome: non-invasive imaging and percutaneous repair

Although coronary subclavian steal syndrome (CSSS) is relatively uncommon, it is a well documented cause of graft failure in patients having undergone coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA). Here we report a case of CSSS induced by restenosis of a left subclavian artery (SCA) origin stent, identified by increased velocities within the stent and an abnormal ipsilateral vertebral artery (VA) waveform on Duplex ultrasound imaging. This was successfully treated percutaneously by re-stenting, resulting in restoration of normal SCA waveforms and velocities, and normalization of the ipsilateral VA waveform.     

门静脉血栓形成的TIPS治疗和临床结果

目的 研究和评价经皮治疗门静脉及其属支血栓的技术可行性和临床效果。方法 16例有门静脉及其属支闭塞症状的患，门静脉及其属支血栓均为非海绵状血管变性所致。通过建立经颈静脉肝内门腔静脉分流通道(TIPS)、带膜支架旁路术和经皮抽吸取栓法清除门静脉及其属支血栓提高门静脉的血流输出量。结果 13例采用经皮技术治疗获得成功。门静脉及其属支血栓所致的门脉高压均得到纠正，静脉曲张破裂出血立即停止；顽固性腹水和黄疸症状得到缓解。结论 经颈静脉门腔静脉分流术、门静脉内带膜支架旁路术和经皮门静脉及其属支抽吸取栓法对于治疗非海绵状血管变性和非瘤栓所致的门静脉闭塞是安全有效的。     

Peripheral vascular malformations: diagnosis and percutaneous management.

Vascular malformations are complex lesions, and their management presents a challenging set of problems. Because VMs are usually treated electively, referral to a centre with a multidisciplinary team approach and with experience diagnosing and treating VMs is recommended. The cornerstone of therapy, embolization, provides both the opportunity for interventional radiologists to become involved in primary patient care and unique challenges that are traditionally not the purview of radiologists.     

Intracranial infections: clinical and imaging characteristics

The radiologist plays a crucial role in identifying and narrowing the differential diagnosis of intracranial infections. A thorough understanding of the intracranial compartment anatomy and characteristic imaging findings of specific pathogens, as well incorporation of the clinical information, is essential to establish correct diagnosis. Specific types of infections have certain propensities for different anatomical regions within the brain. In addition, the imaging findings must be placed in the context of the clinical setting, particularly in immunocompromised and human immunodeficiency virus (HIV)-positive patients. This paper describes and depicts infections within the different compartments of the brain. Pathology-proven infectious cases are presented in both immunocompetent and immunocompromised patients, with a discussion of the characteristic findings of each pathogen. Magnetic resonance spectroscopy (MRS) characteristics for several infections are also discussed.     

Pulmonary tuberculosis: up-to-date imaging and management

OBJECTIVE: Pulmonary tuberculosis (TB) is a common worldwide infection and a medical and social problem causing high mortality and morbidity, especially in developing countries. The traditional imaging concept of primary and reactivation TB has been recently challenged, and radiologic features depend on the level of host immunity rather than the elapsed time after the infection. We aimed to elaborate the new concept of the diagnosis and treatment of pulmonary TB, to review the characteristic imaging findings of various forms of pulmonary TB, and to assess the role of CT in the diagnosis and management of pulmonary TB. CONCLUSION: Fast and more accurate TB testing such as bacterial DNA fingerprinting and whole-blood interferon-gamma assay has been developed. Miliary or disseminated primary pattern or atypical manifestations of pulmonary TB are common in patients with impaired immunity. CT plays an important role in the detection of TB in patients in whom the chest radiograph is normal or inconclusive, in the determination of disease activity, in the detection of complication, and in the management of TB by providing a roadmap for surgical treatment planning. PET scans using 18F-FDG or 11C-choline can sometimes help differentiate tuberculous granuloma from lung malignancy.     

Impassable ureteral strictures: management with percutaneous ureteroneocystostomy

Sixteen of 227 patients referred for percutaneous placement of a ureteral stent had impassable stenoses. Stenoses were benign (n = 8) or attributed to malignant retroperitoneal neoplasm (n = 8). Electrocautery was used to create a neotract between the stenosed ureter and the bladder or ileal loop. A double-J stent was placed after dilation of the tract by use of angioplasty. Neotracts were established and stents were placed in all patients. Complications (digestive tract fistulas) developed in two patients. This technique is safe if the electrode is placed close to the bladder or ileal loop. The procedure can be used as an alternative to surgery or permanent nephrostomy or in initial treatment of benign anastomotic stenosis.     

Inadvertent discontinuation of percutaneous nephrostomy catheters in adult native kidneys: incidence and percutaneous management

PURPOSE: To evaluate the incidence and consequences of complete inadvertent percutaneous nephrostomy catheter discontinuation in native kidneys of adults. In addition, this study evaluated the success rate of nephrostomy tract recannulation. MATERIALS AND METHODS: Retrospective analysis was performed in adult patients who underwent percutaneous nephrostomy between January 2000 and December 2005. Patients' conditions were evaluated for complete inadvertent discontinuation of use of the nephrostomy catheters and success of subsequent recannulation procedures. Habitual discontinuation was defined by three catheter discontinuation episodes in one patient. Conditions of patients with inadvertent discontinuation were assessed for major complications before and after the recannulation, including the need for de novo nephrostomy to reestablish clinically needed access. The incidences of inadvertent discontinuation and primary assisted recannulation tract maintenance were calculated according to the Kaplan-Meier method. Successful versus unsuccessful recannulation procedures were compared for tract age, length of time the drain was out of the tract, and catheter diameter with use of the Mann-Whitney U test. RESULTS: A total of 283 patients underwent 325 percutaneous nephrostomies. The inadvertent catheter discontinuation rates at 6, 12, 24, and 36 months were 26%, 36%, 53%, and 62%, respectively. For the same time intervals, the primary recannulation assisted tract maintenance rates were 94%, 86%, 77%, and 72%, respectively. Habitual discontinuation was seen in 3.2% of the total population and 19.1% of discontinuation cases. The technical success rates of all and first-time recannulations were 85% and 74%, respectively. Tract maturity was the only variable that was statistically significant between successful and unsuccessful recannulations (P < .0001). A total of 3.5% of patients required new nephrostomies. CONCLUSION: Despite the high incidence of inadvertent discontinuation of nephrostomy catheters, the major complication rate was only 3.5%, indicating the efficacy of tract recannulation, especially in mature tracts.     

Posttraumatic bilhemia: Conservative management by percutaneous drainage

Posttraumatic bilhemia complicating liver trauma has been managed surgically so far. A case report of a biliary-venous fistula resulting from blunt hepatic trauma managed successfully by percutaneous drainage is presented. A catheter was placed in the right hepatic lobe for reducing intrahepatic pressure. This procedure was followed by a dramatic decrease of bilirubin blood level. This management emphasizes the role of interventional radiology in the treatment of complicated blunt hepatic trauma.     

Indwelling ureteral stents: percutaneous management of complications

Complications of indwelling ureteral stents were managed percutaneously in 13 patients. These complications consisted of three fractured, three heavily encrusted, and seven migrated stents. While most ureteral stent malfunctions are routinely managed with retrograde techniques, the percutaneous approach allows effective clinical management in selected cases in which extensive renal stone material or brittle intrarenal stent fragments are present or when previous surgery or ureteral strictures do not permit a retrograde approach. Fluoroscopically guided removal of migrated stents and percutaneous endoscopic techniques, for complex cases such as those requiring stone removal, were successful and without complications.     

Percutaneous Transcatheter Ethanol Sclerotherapy and Catheter Drainage of Postoperative Pelvic Lymphoceles

The aim of this study is to investigate the efficacy and long-term results of percutaneous transcatheter ethanol sclerotherapy (PTES) for postoperative pelvic lymphocele treatment. Fifty-two patients who were referred for lymphocele treatment were included in this study. Sixty lymphoceles of 52 patients were treated by percutaneous treatment with or without ethanol sclerotherapy. Lymphoceles developed in 47 and 5 patients, who underwent gynecologic malignancy operation (31 ovarian cancer, 6 cervix cancer, 10 endometrial cancer) and renal transplantation, respectively. Lymphoceles were catheterized by ultrasonography and fluoroscopy guidance using the Seldinger technique. Lymphoceles smaller than 150 mL underwent single-session ethanol sclerotherapy and the others were treated by multiple-session ethanol scleortherapy. In 10 patients, percutaneous ethanol sclerotherapy could not be performed and they were treated only by percutaneous catheter drainage. The mean lymphocele volume was 329 mL (15–2900 mL). The mean catheterization duration was 11.8 days (1–60 days). The mean follow up time was 25.8 months (2–64 months). The initial treatment was successful in 46 out of 50 (91%) lymphoceles treated with PTES and 7 out of 10 (70%) lymphoceles treated with percutaneous catheter drainage. Minor complications (secondary infection and catheter dislodgement) were noted in seven (11.6%) patients. Recurrence developed in four and three patients who were treated by PTES and percutaneous catheter drainage, respectively. Five of these patients were treated with PTES without further recurrence. Percutaneous transcatheter ethanol sclerotherapy is an effective and reliable method for the treatment of postoperative lymphoceles.     

Management of Postoperative Lymphoceles After Lymphadenectomy: Percutaneous Catheter Drainage With and Without Povidone-Iodine Sclerotherapy

Purpose

To report our single-center experience in managing symptomatic lymphoceles after lymphadenectomy for genitourinary and gynecologic malignancy and to compare clinical outcomes of percutaneous catheter drainage (PCD) alone versus PCD with transcatheter povidone-iodine sclerotherapy (TPIS).

Methods

The medical records of patients who presented for percutaneous drainage of pelvic lymphoceles from February 1999 to September 2007 were retrospectively reviewed. Catheters with prolonged outputs >50 cc/day were treated with TPIS. Technical success was defined as the ability to achieve complete resolution of the lymphocele. Clinical success was defined as resolution of the patient’s symptoms that prompted the intervention.

Results

Sixty-four patients with 70 pelvic lymphoceles were treated. Forty-six patients (71.9 %) had PCD, and 18 patients (28.1 %) had multisession TPIS. The mean initial cavity size was 294.9 cc for those treated with TPIS and 228.2 cc for those treated with PCD alone (range 15–1,600) (p = 0.59). Mean duration of catheter drainage was 19 days (29 days with TPIS, 16 days with PCD, p = 0.001). Mean clinical follow-up was 22.6 months. Technical success was 74.3 % with PCD and 100 % with TPIS. Clinical success was 97 % with PCD and 100 % with TPIS. Postprocedural complications included pericatheter fluid leakage (n = 4), catheter dislodgement (n = 3), catheter occlusion (n = 9), and secondary infection of the collection (n = 4).

Conclusion

PCD of symptomatic lymphoceles is an effective postoperative management technique. Initial cavity size is not an accurate predictor of the need for TPIS. When indicated, TPIS is safe and effective with catheter outputs >50 cc/day.     

Border zone infarcts: pathophysiologic and imaging characteristics

Border zone or watershed infarcts are ischemic lesions that occur in characteristic locations at the junction between two main arterial territories. These lesions constitute approximately 10% of all brain infarcts and are well described in the literature. Their pathophysiology has not yet been fully elucidated, but a commonly accepted hypothesis holds that decreased perfusion in the distal regions of the vascular territories leaves them vulnerable to infarction. Two types of border zone infarcts are recognized: external (cortical) and internal (subcortical). To select the most appropriate methods for managing these infarcts, it is important to understand the underlying causal mechanisms. Internal border zone infarcts are caused mainly by hemodynamic compromise, whereas external border zone infarcts are believed to result from embolism but not always with associated hypoperfusion. Various imaging modalities have been used to determine the presence and extent of hemodynamic compromise or misery perfusion in association with border zone infarcts, and some findings (eg, multiple small internal infarcts) have proved to be independent predictors of subsequent ischemic stroke. A combination of several advanced techniques (eg, diffusion and perfusion magnetic resonance imaging and computed tomography, positron emission tomography, transcranial Doppler ultrasonography) can be useful for identifying the pathophysiologic process, making an early clinical diagnosis, guiding management, and predicting the outcome.