Angioplasty for pediatric renovascular hypertension: a 13-year experience

PURPOSE

We aimed to evaluate the long-term outcome and efficacy of percutaneous transluminal renal angioplasty (PTRA) for pediatric renal artery stenosis (RAS), which is an important cause of medication-refractory pediatric hypertension.

MATERIALS AND METHODS

We retrospectively evaluated 22 hypertensive children (age range, 3–17 years) who underwent PTRA from February 2000 to July 2012. Sixteen patients had Takayasu arteritis and six fibromuscular dysplasia. Five were not included in the statistical analysis due to loss to follow-up.

RESULTS

Technical success was achieved in 32 of 34 procedures (94.1%). The stenosis rate decreased from 84.5% before PTRA to 20.1% after PTRA. Treatment was effective in 72.7% (16/22) of patients, including complete cure in 27.3% (6/22) and improvement in 45.5% (10/22). Systolic and diastolic blood pressures decreased from 153±19.1 to 131.7±21.4 mmHg and from 97.9±14.2 to 83.6±19.3 mmHg, respectively (P < 0.01). Number of antihypertensive agents decreased from 2.7 to 0.5 per patient. Restenosis was detected in 40.9% (9/22) of patients, with a restenotic interval of 11.8 months (range, 3–47 months). Lesion length was strongly correlated with clinical success (cure and improvement) (independent-sample t test, P < 0.001; binary logistic regression, P = 0.040).

CONCLUSION

Lesion length is an important determination of clinical success with PTRA for pediatric RAS. PTRA is an appropriate treatment option for pediatric renovascular hypertension due to Takayasu arteritis and fibromuscular dysplasia.Although hypertension affects only 1%–2% of children and adolescents based on reliable assessments (1, 2), it is a major risk factor for cerebrovascular disease, myocardial infarction, and renal failure. Renal artery stenosis (RAS), a vascular disease, leads to 5%–25% of pediatric hypertension. Although a few conditions, including Kawasaki disease, polyarteritis nodosa, Wegener’s granulomatosis, neurofibromatosis, Williams syndrome, and midaortic syndrome, may cause RAS in pediatric patients (3, 4), Takayasu arteritis (TA) is the most common cause of pediatric RAS in the East, especially in China, Korea, and India (5, 6). Fibromuscular dysplasia (FMD) is another important cause of RAS in children, particularly in Western countries. A substantial proportion of patients with RAS suffer from hypertension and poor sequelae. Additionally, pediatric hypertension is strongly associated with hypertension in adults (7). However, blood pressure is not frequently measured in children. Due to the lack of sufficient information on blood pressure, renovascular hypertension is often ignored and/or diagnosed with a considerable time delay by referring physicians (5). Despite many antihypertensive agents, valid control of blood pressure is often impossible. Moreover, normalized blood pressure with multiple drugs may result in underperfusion of the kidney and cerebral blood vessels, thereby aggravating multiple organ dysfunction. Therefore, surgical interventions are considered as an alternative strategy to achieve an adequate control of blood pressure in pediatric patients (8).Here, we present 13 years of data on the outcomes of 22 children with renovascular hypertension caused by TA or FMD following treatment with a percutaneous transluminal renal angioplasty (PTRA) procedure.     

Biliary leak in a child after liver transplant and value of delayed images

A 2-year-old child underwent liver transplant and was referred for postsurgical abdominal pain. Hepatobiliary scintigraphy with Tc-99m iminodiacetic acid (IDA) was performed and with the help of 24-hour delayed images, the diagnosis of biliary leak at the site of anastomosis was made possible. This case report confirms the value of delayed images to facilitate the diagnosis in unequivocal situations and reminds us of the usefulness of this noninvasive method, especially in pediatrics.     

Vascular complications after liver transplantation: a 5-year experience

During the past 5 years, 104 angiographic studies were performed in 87 patients (45 children and 42 adults) with 92 transplanted livers for evaluation of possible vascular complications. Seventy percent of the studies were abnormal. Hepatic artery thrombosis was the most common complication (seen in 42% of children studied, compared with only 12% of adults) and was a major complication that frequently resulted in graft failure, usually necessitating retransplantation. In six children, reconstitution of the intrahepatic arteries by collaterals was seen. Three survived without retransplant. Arterial stenosis at the anastomosis or in the donor hepatic artery was observed in 11% of patients. Portal vein thrombosis or stenosis occurred in 13% of patients. Two children and one adult with portal vein thrombosis demonstrated hepatopetal collaterals that reconstituted the intrahepatic portal vessels. Uncommon complications included anastomotic and donor hepatic artery pseudoaneurysms, a hepatic artery-dissecting aneurysm, pancreaticoduodenal mycotic aneurysms, hepatic artery-portal vein fistula, biliary-portal vein fistula, hepatic vein occlusion, and inferior vena cava thrombosis.     

Biliary duct stones: Percutaneous transhepatic removal

Percutaneous transhepatic removal of common bile duct stones was performed 57 times in 53 patients with a success rate of 93%. All patients had contraindications to surgery or had undergone unsuccessful attempts at endoscopic retrograde cholangiopancreatography and papillotomy. A modified Dormia basket was inserted through a percutaneous transhepatic approach and the stones or fragments were advanced into the duodenum. Monooctanoin (26 patients) or methyl tertiary butyl ether (4 patients) was infused to reduce stone size or remove residual debris. The average time for complete stone removal was 8.5 days. Morbidity was 12% and mortality was 4%, results which compare favorably with those of surgery.     

Percutaneous extraction of renal stones: experience in 100 patients

Recent developments in technology and instrumentation have made it possible to remove most kidney stones and many ureteral stones percutaneously. The first 100 cases at this institution were reviewed in which grasping, ultrasonic lithotripsy, basketing, and irrigation were used. In all cases, the follow-up was at least 1 year. The success rates were 92.4% for renal pelvic stones, 92% for caliceal stones, and 68% for ureteral stones. Ten of the 14 patients who required open operation after an unsuccessful percutaneous procedure were among the first 18 patients, whereas only one open operation was needed in the last 40 patients. Proper patient selection; the size, number, and location of stones; proper selection of the nephrostomy site; and the expertise of the operator are critical factors in determining the success rate. To date, the short-term results of percutaneous stone removal have been as good as those of open surgery.     

Biliary matrix: matrix stones as a cause of biliary obstruction.

The biliary tree secretes a mucous substance which serves as a matrix in gallstones. A case of biliary obstruction secondary to a matrix stone is reported. The characteristics and significance of biliary matrix are discussed.     

Complications after percutaneous saline-enhanced radiofrequency ablation of liver tumors: 3-year experience with 336 patients at a single center

OBJECTIVE: Our objective was to report the complications that occurred in a large series of patients with primary or metastatic liver tumors treated with percutaneous saline-enhanced radiofrequency ablation under sonographic guidance at a single center during 3 years of experience. SUBJECTS AND METHODS: Between September 2000 and October 2003, 336 consecutive patients (221 men and 115 women; age range, 44-78 years; mean, 67 years) with 407 malignant liver tumors were treated at our institution using radiofrequency ablation. Of these patients, 287 had hepatocellular carcinoma from cirrhosis, 47 had liver metastases (38 from colon, six from breast, two from lung, and one from cutaneous melanoma), and two had primary cholangiocarcinoma. Adverse events related to radiofrequency ablation were prospectively recorded. RESULTS: The number of sessions performed was 375 (39 patients had two sessions). The number of patients with major complications, including death, was three (0.9%). The overall mortality rate was 0.3% (1/336). One patient died because of worsening liver decompensation. Two other major complications occurred. In one patient (0.3%), liver abscess and sepsis developed and were successfully treated with percutaneous sonography-guided needle (18-gauge) aspiration and IV antibiotics. Mild posttreatment ascites occurred in one patient (0.3%). One patient showed self-limiting subcutaneous cellulitis along the electrode-needle path that healed in 2 weeks. Fever lasting 1-3 days and pain lasting 12-24 hr were observed in 141 patients (42%) and 211 patients (63%), respectively. So far, no cutaneous or abdominal wall seeding has been observed clinically or sonographically. CONCLUSION: Radiofrequency ablation of liver tumors can be considered safe. Life-threatening acute liver failure can be considered a rare possible complication.     

Locally advanced differentiated thyroid carcinoma: a 35-year mono-institutional experience in 280 patients

AIM: Debate exists in the literature about the optimal treatment to be adopted in patients with locally advanced differentiated thyroid carcinoma. We aimed to better define the most appropriate diagnostic and therapeutic protocol for this type of tumour. METHODS: The clinical and histopathological records of 280 consecutive patients with locally advanced differentiated thyroid carcinoma, studied and operated on by the same surgical team in the period between 1967 and 2002, were reviewed. RESULTS: With regard to overall survival, at univariate statistical analysis, the patient's age at diagnosis (threshold, 45 years), primary tumour size, local cancer extension at diagnosis (subtypes of T4), extent of thyroidectomy, performance of lymph node dissection and performance of post-surgical external radiotherapy were found to be significant prognostic variables. With regard to the appearance of recurrent disease during follow-up, at univariate statistical analysis, the patient's age at initial diagnosis (threshold, 45 years), primary tumour size, local cancer extension at diagnosis (subtypes of T4), extent of thyroidectomy, performance of lymph node dissection, presence of metastatic lymph nodes, performance of post-surgical 131I therapy and performance of post-surgical external radiotherapy were found to be significant prognostic variables. At multivariate statistical analysis, the patient's age at initial diagnosis, extent of tumour, extent of thyroidectomy and performance of lymph node dissection were the only independent prognostic variables. CONCLUSIONS: In our experience, an aggressive surgical approach at first diagnosis appears to offer a better prognosis in terms of both overall survival and disease-free time interval in patients with locally advanced differentiated thyroid carcinoma, especially those over 45 years of age.     

Treatment of malignant inferior vena cava obstruction with Gianturco-Rosch-Z stents: a single center 13-year experience

Rationale and objectivesMalignant obstruction of the IVC can cause severe morbidity and impairment of quality of life in end-stage oncology patients. However, medical literature regarding minimally-invasive palliation using large diameter percutaneous stents, particularly the Gianturco-Rosch-Z (GRZ) stent is limited.Materials & methodsA retrospective review from January 2004 to February 2017, revealed 17 subjects with malignant obstruction of the IVC who were treated with a total of 34 GRZ stents. Pre- and post-stent pressure gradients were measured in 10. Available data regarding clinical presentation and follow-up were recorded.ResultsTechnical success for stent deployment was 100%. A median of 2 stents (range 1 to 5) were deployed per patient, with median stent diameter 20 mm (range 15 to 30 mm). The median pre-treatment pressure gradient of 17.5 mmHg (range 9–31 mmHg) decreased to a median of 4.5 mmHg (range 0–21 mmHg, p < .0004) after stent placement. One subject developed recurrent stent occlusion due to disease progression requiring additional intervention, for a primary patency rate of 94%. Lower extremity edema improved or resolved in 58% of those for whom follow-up data was recorded. Median survival after treatment was only 28 days (range 5 to 607 days). There were no procedural complications.ConclusionEndovascular treatment of malignant IVC obstruction can be safely performed with GRZ stents. Although overall survival is poor, this technique can effectively palliate lower extremity edema symptoms.     

Removal of unexploded ordnance from patients: a 50-year military experience and current recommendations

BACKGROUND: Retained unexploded ordnance in a patient presents the surgeon with unique emotional and technical challenges. This report is a compilation of data to determine management strategies for these potentially catastrophic injuries. METHODS: All identified military cases from World War II to the present were reviewed. Cases were reviewed for site of injury, type of munition, personnel and equipment precautions, and outcome. Interviews were conducted with available involved surgeons. RESULTS: Thirty-six patients were identified with retained ordnance. Four were moribund upon arrival and died before operation. All of the remaining 32 patients survived the removal of the unexploded ordnance. Thirteen injuries involved the trunk, 4 involved the head and neck, and 18 involved extremities. The majority of missiles (51%) were 40-mm projectiles. No incident was identified in which a round exploded during transportation, preparation, or removal. Explosive Ordnance Disposal assistance was available to the surgical team for all but one patient during and after the Vietnam War. Measures used to reduce the chance of premature explosion are discussed. CONCLUSIONS: Isolation of the operating room and protection of personnel and equipment are essential. Patients should be triaged in the delayed category, because most are not morbund on arrival and all patients operated on survived. Explosive Ordnance Disposal expertise should be used. Knowledge of and adherence to several basic principles will protect personnel and equipment while permitting optimal patient care.     

Navigated MRI-guided liver biopsies in a closed-bore scanner: experience in 52 patients

Objectives

To evaluate clinical effectiveness and diagnostic efficiency of a navigation device for MR-guided biopsies of focal liver lesions in a closed-bore scanner.

Methods

In 52 patients, 55 biopsies were performed. An add-on MR navigation system with optical instrument tracking was used for image guidance and biopsy device insertion outside the bore. Fast control imaging allowed visualization of the true needle position at any time. The biopsy workflow and procedure duration were recorded. Histological analysis and clinical course/outcome were used to calculate sensitivity, specificity and diagnostic accuracy.

Results

Fifty-four of 55 liver biopsies were performed successfully with the system. No major and four minor complications occurred. Mean tumour size was 23?±?14 mm and the skin-to-target length ranged from 22 to 177 mm. In 39 cases, access path was double oblique. Sensitivity, specificity and diagnostic accuracy were 88 %, 100 % and 92 %, respectively. The mean procedure time was 51?±?12 min, whereas the puncture itself lasted 16?±?6 min. On average, four control scans were taken.

Conclusions

Using this navigation device, biopsies of poorly visible and difficult accessible liver lesions could be performed safely and reliably in a closed-bore MRI scanner. The system can be easily implemented in clinical routine workflow.

Key Points

? Targeted liver biopsies could be reliably performed in a closed-bore MRI. ? The navigation system allows for image guidance outside of the scanner bore. ? Assisted MRI-guided biopsies are helpful for focal lesions with a difficult access. ? Successful integration of the method in clinical workflow was shown. ? Subsequent system installation in an existing MRI environment is feasible.

     

Imaging features of gastrointestinal toxicity in non-small cell lung cancer patients treated with erlotinib: A single institute 13-year experience

ObjectivesTo investigate the imaging features of erlotinib-associated gastrointestinal toxicity (GT) in patients with non-small cell lung cancer (NSCLC).Materials and methodsThe electronic medical records of 157 patients with NSCLC who received erlotinib between 2005 and 2018 were retrospectively reviewed to identify patients with GT. Clinical and radiologic evidence of erlotinib-associated GT was evaluated. Imaging findings were cross-referenced with clinical presentation, management, and outcomes.Results24 (15%) patients (16 women; median age, 68 years) with radiologic evidence of GT were identified. The median time to detection of GT on imaging was 4.5 months (range: 0–58 months). 3/24 (12.5%) patients had no clinical symptoms, but GT was radiologically identified. Erlotinib-associated GT manifested in the large bowel in either a diffuse (42%) or segmental (58%) pattern. The most common imaging finding was fluid-filled bowel (23/24, 96%).ConclusionErlotinib-associated GT was identified in 15% patients with NSCLC. Fluid-filled colon and segmental involvement were the most common imaging manifestations.     

Long-term safety and outcome of a temporary self-expanding metallic stent for achalasia: a prospective study with a 13-year single-center experience

To prospectively evaluate the long-term clinical safety and efficacy of a newly designed self-expanding metallic stent (SEMS) in the treatment of patients with achalasia. Seventy-five patients with achalasia were treated with a temporary SEMS with a 30-mm diameter. The SEMSs were placed under fluoroscopic guidance and removed by gastroscopy 4–5 days after stent placement. Follow-up data focused on dysphagia score, technique and clinical success, clinical remissions and failures, and complications and was performed at 6 months, 1 year, and within 3 to 5 years, 5 to 8 years, 8 to 10 years, and >10 years postoperatively. Stent placement was technically successful in all patients. Complications included stent migration (n = 4, 5.33%), chest pain (n = 28, 38.7%), reflux (n = 15, 20%), and bleeding (n = 9, 12%). No perforation or 30-day mortality occurred. Clinical success was achieved in all patients 1 month after stent removal. The overall remission rates at 6 months, 1, 1–3, 3–5, 5–8, 8–10, and >10 year follow-up periods were 100%, 96%, 93.9%, 90.9%, 100%, 100%, and 83.3%, respectively. Stent treatment failed in six patients, and the overall remission rate in our series was 92%. The median and mean primary patencies were 2.8 ± 0.28 years (95% CI: 2.25–3.35) and 4.28 ± 0.40 years (95% CI: 3.51–5.05), respectively. The use of temporary SEMSs with 30-mm diameter proved to be a safe and effective approach for managing achalasia with a long-term satisfactory clinical remission rate. Supported by the National Key Medical Research and Development Program of China during the 9th Five-year Plan Period (no. 96–907–03–04), Shanghai Nature Science Funds (no. 02Z1314073), Shanghai Medical Development Funds (no. 00419), the National Natural Science Foundation of China (no. 30670614).     

Percutaneous treatment of varicocele. 13-year experience with the transbrachial approach

PURPOSE: To report our experience using the transbrachial approach, which is easily accepted by the patient, in the treatment of varicocele. MATERIAL AND METHODS: Between January 1986 and December 1998, 1490 patients with clinical or subclinical varicocele, but with seminal fluid alterations, underwent spermatic phlebography using the transbrachial approach. Since 1991 the procedure has also been adopted at the Unit of Pediatric Surgery of our hospital, which proposes it as a first choice treatment in adolescents with varicocele. The procedure consists in accessing the basilic vein at the elbow level percutaneously and using a hydrophile guidewire and multipurpose angiographic catheter to reach and catheterise the spermatic vein responsible for the varicocele. During the first years, we used sclerotherapy alone; subsequently, if the varicocele recurred or if the reflux was refractory to sclerotherapy or if the veins were large we adopted vein embolisation. Follow-up was one year and consisted of testicular ultrasound, Doppler flowmetry and/or color Doppler ultrasound at one, six and twelve months after the procedure. Patients were considered restored if they were free of symptoms, showed no venous reflux and/or had normal seminal fluid parameters and improved if they were free of symptoms but still presented venous reflux. Varicocele was considered persistent if the procedure failed to produce any beneficial effects, and recurrent if, although absent at the first follow up, it reappeared after the fifth month. RESULTS: We found 1296 (86.9%) cases of left varicocele, 25 of right varicocele and 169 (11.3%) of bilateral varicocele. In all cases, the symptoms disappeared after the percutaneous procedure. Duration of radioscopy was reduced to 3.5'; the procedure lasted 90' for the monolateral varicoceles and 120' for the bilateral forms. 313 diagnostic procedures were performed (20.7%). The procedure could not be completed in 104 patients (6.8%) due to basilic vein spasms, difficulties encountered in catheterizing the spermatic vein and, particularly in pediatric patients, anatomic variations. A total of 1195 (79.2%) procedures were completed: sclerotherapy alone in 642 patients and sclerotherapy followed by scleroembolisation in 527. Sclerotherapy alone was sufficient to restore 524 patients (86.6%), while 384 (78.5%) required scleroembolization. A small number of patients underwent scleroembolization alone, which brings the success rate for the two procedures to 82% and 84%, respectively. No serious side-effects were noted. DISCUSSION: The transbrachial approach in spermatic phlebography has proved to be a safe and effective technique for the treatment of both monolateral and bilateral varicocele. Furthermore, the procedure is well accepted by patients and can be performed in a day-care setting. In some cases, we only obtained partial results because of the large caliber of the spermatic vein; in other cases, we were unable to complete the procedure due to anatomic variations or to the spasm of the basilic vein. CONCLUSION: The safety and effectiveness of this procedure make it a valid alternative to traditional surgery, that should be considered as a possible first-choice treatment for varicocele in adolescents.     

Mushroom-cage gastrostomy tube placement in patients with amyotrophic lateral sclerosis: a 5-year experience in 104 patients in a single institution

To review our experience of placement of a mushroom-cage gastrostomy tube (Entristar®, Tyco Healthcare, Mansfield, MA), using radiological guidance, in patients with amyotrophic lateral sclerosis (ALS). All procedures were performed under local anaesthesia without sedation. Complications were recorded as peri-procedural, early (<24 h), late (>24 h), major or minor. Deaths were recorded as related to the underlying ALS or secondary to radiological-inserted gastrostomy (RIG) placement. Replacement RIG tube rate was recorded. Over a 5-year period RIG tubes were placed in 104 patients with ALS (male n?=?52, female n?=?52), with a median age of 62 years (range 34-86 years). All procedures were technically successful. Of the RIG procedures, 21/104 (20.2%) were performed with respiratory support. The 30-day mortality rate was 7/104 (6.7%); no patient died as a result of the procedure. There were 23/104 (22.1%) complications overall; 20/104 (19.2%) were minor and 3/104 (2.9%) major, requiring surgery (n?=?2) and radiological-guided abscess drainage (n?=?1). A median interval between replacement RIG procedures in 20/104 (19.2%) patients was 141.5 days (range 43-537 days). A mushroom-cage RIG tube may be safely and effectively inserted in a ‘one-step’ radiological procedure and may replace endoscopic-inserted gastrostomy tubes in the nutritional management of ALS.     

Biliary complications after liver transplantation in patients with preexisting sclerosing cholangitis

To determine if biliary complications after liver transplantation are more frequent in patients with preexisting sclerosing cholangitis and to clarify the role of interventional procedures in this setting, the authors reviewed all 40 adult cases in which liver transplantation was performed at their institution over a 3 1/2-year period. Biliary complications, particularly strictures at the choledochojejunostomy and debris in the intrahepatic and common ducts, were seen in six of ten liver transplant patients (60%) with preexisting sclerosing cholangitis; this is six times the frequency of biliary complications seen in other adult recipients (10%). Biliary complications were definitively diagnosed and managed with interventional radiologic procedures. Obstruction due to anastomotic strictures required treatment with balloon dilation in all six of the affected patients. Obstructive biliary complications occur in many liver recipients with preexisting sclerosing cholangitis. These complications require aggressive radiologic assessment and intervention but to date have not adversely affected survival.