Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients

PURPOSE: To demonstrate the applicability, technique, and efficacy of percutaneous transabdominal catheter embolization or needle disruption of retroperitoneal lymphatic vessels in the treatment of high-output or unremitting chylothorax. MATERIALS AND METHODS: Forty-two patients (21 men, 21 women; mean age, 56 y; range, 19-80 y) who had chylothorax with various etiologies were referred from the thoracic surgery department for treatment as soon as chylothorax was documented. The thoracic duct was punctured and catheterized via a peritoneal cannula to facilitate embolization with use of microcoils, particles, or glue; if there were no lymph trunks that could be catheterized, attempts were made to disrupt lymph collaterals with use of needles. RESULTS: The thoracic duct was catheterized in 29 patients and embolized in 26 patients. In patients with lymph trunks that could be catheterized, treatment resulted in cure within 7 days in 16 patients and partial response with cure within 3 weeks in six patients. In the patients with lymph trunks that could not be catheterized (n = 16), disruption with use of needles resulted in cure in five patients and partial response in two patients. Cure and partial response rates after thoracic duct embolization and needle disruption were 73.8%, with no morbidity. Surgical thoracic duct ligation was performed in seven patients. The nonprocedural mortality rate was 19%. Follow-up was 3 months or longer. CONCLUSIONS: Effective percutaneous treatment of high-output or medically uncontrollable chylothorax was performed promptly and safely in more than 70% of referred cases. This procedure should be attempted, especially if patients are very ill, before riskier surgical thoracic duct ligation is considered.     

Intramuscular low flow vascular malformations: treatment by means of direct percutaneous embolization

Purpose: Intramuscular hemodynamically inactive vascular malformations are infrequent entities whose surgical treatment is often impossible, crippling, or inefficient. We describe a nonsurgical therapeutic approach consisting on embolization by direct puncture with schlerosant substances. Methods: Four patients have been treated from April to November 1994, three female and one male, ranging in age from 13 to 31 years. Three vascular malformations were located in the quadriceps and one in the deltoid muscle. The point of access was determined with information provided by MR. The skin was cleaned with an antiseptic solution and puncture was performed with a 22 gauge Chiva needle. Blood flow inside the malformation was slow in all cases and no afference to the normal venous system was detected. We embolized with 5–15 cc (mean 7.5 cc) of a mixture of ethibloc and ethanol. Results: The mean follow-up period was 17 months (range 14–21). All patients remain asymptomatic and have resumed normal daily life activities. There were no complications. Conclusion: Percutaneous embolization by direct puncture of intramuscular vascular malformations is a feasible and simple procedure. Our preliminary results are promising, although more extensive studies need to be to performed in order to reach definite conclusions.     

Benefits of 3D technique in guiding percutaneous retroperitoneal biopsies

Purpose

This study aimed to assess the usefulness and advantages of multiplanar reformations (MPR) during multidetector-row computed tomography (MDCT)-guided percutaneous fine-needle aspiration biopsy (FNAB) and core biopsy of retroperitoneal lesions that are difficult to access with the guidance of ultrasound and axial CT alone owing to overlying bony structures, large vessels or abdominal organs.

Materials and methods

MDCT-guided retroperitoneal FNAB and core biopsy was performed on 14 patients with suspected retroperitoneal neoplasm. We used MPR images (sagittal and coronal) obtained with a six-detector-row MDCT scanner and 20?C22 gauge Chiba needles.

Results

Using MDCT with 3D MPR allowed biological samples to be obtained in all cases (ten cytological and four histological) and diagnostic samples in 11/14 cases (78.5%). Histological samples were deemed adequate for diagnostic assessment in all cases and cytological samples in 7/10 cases (70%).

Conclusions

MPR images allowed sampling of retroperitoneal lesions until now considered unreachable with the guidance of axial MDCT alone. Compared with the conventional procedure, the use of MPR images does not increase the procedure time.     

Hepatic embolization through pancreaticoduodenal arcade: double catheter technique

Transcatheter arterial embolization through pancreaticoduodenal arcade was performed in a patient with hepatocellular carcinoma using double catheter technique. This method is very useful for hepatic embolization in patients with occlusion and stenosis of the celiac axis or common hepatic artery.     

A new percutaneous nephrostomy technique in the treatment of obstructive uropathy

PURPOSE: To describe the percutaneous nephrostomy technique used at our centre in the treatment of supravesical urinary tract obstruction and to analyse the results obtained. MATERIALS AND METHODS: Three-hundred and seventy-three patients underwent 412 percutaneous nephrostomies, most of which (78%) in an emergency setting, performed with a newly devised "mixed" technique. The procedure combines the positive elements of the two techniques employed to date in the management of upper urinary tract obstruction: the Seldinger angiographic technique and the Goodwin technique. Once the site for the placement of the nephrostomy catheter has been established, the kidney is punctured with an 18-gauge trocar needle to reach the renal pelvis. This occurs under real-time ultrasonographic (US) guidance. After having removed the mandrin and performed a pyelography with a small volume of contrast material, both a 0.038-inch Teflon-coated J-tipped guide wire and a 7-8 French catheter are introduced. RESULTS: The procedure time is from 7 to 15 minutes; the fluoroscopy time usually lasts less than 30 seconds. Only in one case of a mobile kidney with a non-dilated collecting system was it not possible to position the nephrostomy catheter. In 38 patients (9.2%) a second renal puncture with an 18-gauge needle was necessary, due to the absence of dilatation of the collecting system. In three cases the procedure had to be repeated because of a kinking of the wire which could not be corrected, even with the use of a fine soft dilator. We encountered five major complications (three cases of sepsis and two of haemorrhage requiring transfusion), 119 minor complications (50 cases of nephrostomy catheter dislodgement, three of malpositioning, 12 of mild infection, 20 of pelvicalyceal haemorrhage, five of subcapsular haematoma, 29 of renal pelvis perforation). DISCUSSION AND CONCLUSIONS: The technique adopted has a high success rate in the treatment of supravesical obstructive uropathy and very short procedure times, thanks to US guidance and elimination of the steps involving the use of dilators of progressive diameter. In addition, the radiation exposure was low, being limited to confirming the proper placement of the needle, the wire, and the catheter in the renal pelvis. In all the other steps of the procedure we used US guidance which enabled us to choose the puncture site and follow the needle advancement. The major limit to our "mixed" technique is the need to small-diameter catheters, which entails having to replace them with larger ones with greater biocompatibility.     

CT引导置管引流治疗单发性腹膜后脓肿

目的探讨单发性腹膜后脓肿CT引导下经皮穿刺置管引流治疗的疗效。方法回顾性总结采用CT引导下经皮穿刺引流治疗的13例腹膜后单发性脓肿,脓肿位于胰尾部4例,胰头旁3例,肾周间隙3例,肾后间隙2例,腰大肌旁1例;脓肿最大径3.5～8.0cm。结果8例患者行1次穿刺引流,3例行2次穿刺引流,2例行3次穿刺引流。13例患者平均引流16d,经过临床、超声及CT随访未发现残存感染灶或复发。结论CT引导下经皮穿刺引流治疗腹膜后脓肿疗效确切、创伤小。     

The value of direct percutaneous puncture technique in vertebral angiography

Summary The authors perform vertebral angiography with three techniques: 1. percutaneous puncture of the vertebral artery; 2. percutaneous puncture of the brachial artery; 3. catheterization via the femoral artery. In both vascular and neoplastic lesions of the posterior fossa the best results are obtained with the first technique, which, in expert hands, gives the same percentage of successful examinations as the other two methods. In the great majority of cases direct percutaneous vertebral angiography must be performed on both sides.

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Der Wert der direkten percutanen Punktion bei der Vertebralisangiographie

Zusammenfassung Die Verfasser geben ihre Anschauung wieder, daß sowohl bei vasculären als auch bei raumfordernden Prozessen im Bereich der hinteren Schädelgrube die besten Untersuchungsresultate erzielt werden, wenn die A. vertebralis direkt punktiert wird. Sie vergleichen diese Untersuchungsmethode mit der percutanen Punktion der A. brachialis und der Kathetermethode über die A. femoralis.

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La valeur de la technique de ponction percutanée directe en angiographie vertébrale

Résumé Les auteurs pratiquent l'angiographie vertébrale selon trois techniques: 1. La ponction percutanée de l'artère vertébrale. 2. La ponction percutanée de l'artère brachiale; 3. La cathétérisation par l'artère fémorale.—Tant dans les lésions vasculaires que dans les lésions néoplasiques de la fosse postérieure, les meilleurs résultats furent obtenus à l'aide de la 1ère technique qui, pratiquée par des mains expertes, donne le même pourcentage de résultats satisfaisants que les deux autres méthodes. Dans la grande majorité de cas de ponctions percutanées, l'angiographie vertébrale dut être réalisée des deux côtés.

     

Balloon-assisted ultrasound-guided direct percutaneous embolization of a peripheral pseudoaneurysm with n-butyl cyanoacrylate

We report the ultrasound-guided direct percutaneous injection of n-butyl cyanoacrylate to embolize an iatrogenic peripheral pseudoaneurysm secondary in a 33-year-old patient undergoing hemodialysis. We protected the parent artery with inflation of an angioplasty balloon across the neck during the cyanoacrylate injection. Complete occlusion of the pseudoaneurysm was achieved without ischemic complication.     

Computed-tomography-guided direct percutaneous transhepatic embolization of a bleeding hepatic artery branch aneurysm

A case of successful direct percutaneous transhepatic coil embolization of a ruptured intrahepatic aneurysm under computed tomography (CT) guidance is presented. The patient had a history of multiple operations for liver echinococcosis and was transferred to the emergency department in a deteriorating clinical condition due to active hemorrhage. The aneurysm was treated with percutaneous transhepatic embolization under CT guidance. The procedure is not time-consuming and keeps the time interval between diagnosis and treatment to a minimum, thereby limiting subsequent blood loss.     

Vascular injuries after percutaneous renal procedures: treatment by transcatheter embolization

Percutaneous renal procedures have become the standard technique for diagnosis and treatment of a number of renal pathologies. Hemorrhage and vascular lesions are the most serious complications. We report our experience with 15 patients treated by hyperselective vascular embolization. Fifteen patients (10 men and 5 women; mean age 55 years) had severe perioperative hemorrhage after percutaneous renal procedures, due to arterial renal major injury. All patients underwent duplex US, CT, and renal arteriography demonstrating the presence of arteriovenous fistulas (n=2), renal hematoma (n=3), pseudoaneurysms (n=3), and hematoma with pseudoaneurysm (n=7). Four patients showed transient renal dysfunction, with an increase in serum creatinine levels. One patient had a solitary transplanted kidney. Hyperselective arterial embolization was performed successfully by means of coils (n=14), associated with gelfoam in 4 cases; homologous blood clot was used in 1 patient. No major complications occurred, and renal function rapidly normalized in the 4 patients with transient renal failure. Imaging follow-up confirmed the successful devascularization of the lesion. Renal arterial hemorrhage following percutaneous procedures is a rare but severe complication. Hyperselective renal artery embolization, with particles and/or coils, represents the first-choice treatment option, being safe and effective in stopping the bleeding.     

Bleeding after percutaneous radiofrequency ablation: Successful treatment with transcatheter embolization

PURPOSE: This knowledge will provide an ability to earlier detect bleeding complications after radiofrequency ablation (RFA), to manage these complications appropriately with endovascular procedures and minimize the sequelae. MATERIALS AND METHODS: From 2002 to 2005, 96 patients with 150 hepatic tumours underwent 126 RFA sessions. Fifty-eight patients had HCC, 34 had liver colorectal metastases and 4 had cholangiocellular carcinoma. Sixty-one patients were men and 35 were women (mean age 69.82 years, age range 39-89). The lesions number ranged from 1 to 7 per patients (mean 1.6 nodules) with a mean diameter of 28.5 mm (range 80-10 mm). Seventy-seven patients underwent a single ablative session, 13 patients underwent 2 sessions, 4 patients underwent 3 sessions and 2 patients underwent 4 sessions. The number of tumours treated in each ablative session was 1 in 106, 2 in 18 and 4 in 2 patients. RESULTS: Two cases of serious haemorrhages occurred after the procedures in two patients treated for liver metastases. An endovascular embolization was proposed for both patients using polyvinyl-alcohol and micro-coils. The absence of bleeding was first confirmed during angiography and then by CT performed the day after the angiographic procedure. CONCLUSION: Transarterial embolization (TAE) represents the treatment of choice in the management of iatrogenic bleeding after RFA since it is minimally invasive, have a high success rate and a low incidence of complications compared to the more complex and dangerous surgical or laparoscopic options in patients who are often haemodynamically unstable and therefore at high anaesthetic and surgical risk.     

Cystic retroperitoneal lymphangioma: treatment by image-guided percutaneous catheter drainage and sclerotherapy

Retroperitoneal cystic lymphangiomas are extremely rare and the majority are symptomatic during childhood. Although benign, they can compress and infiltrate vital structures. Surgery is curative but is associated with a high complication rate. An alternative treatment strategy is image-guided percutaneous catheter drainage of the lymphangioma followed by sclerotherapy. Resolution of a large retroperitoneal cystic lymphangioma in a 4-year-old child treated by this technique is reported. To our knowledge, this technique has not been previously described in this condition and we believe that it offers significant advantages over surgery. Received: 15 June 2000 Revised: 10 August 2000 Accepted: 11 August 2000     

Transvenous embolization of a direct carotid cavernous fistula through the pterygoid plexus

Closure of a direct carotid cavernous fistula with detachable coils by transpterygoid venous approach to the cavernous sinus is an alternative technique that may be applied in cases in which other techniques offer increased risk or in which other techniques have failed. In this case report, we present the details of the management of a direct carotid cavernous fistula by this method.     

A novel modified PAIR technique using a trocar catheter for percutaneous treatment of liver hydatid cysts: a six-year experience

PURPOSE

We aimed to demonstrate the success and reliability of a novel puncture, aspiration, injection, and reaspiration (PAIR) technique in liver hydatid cysts.

METHODS

Percutaneous treatment with ultrasonographic guidance was performed in 493 hepatic hydatid cysts in 374 patients. Patients were treated with a new PAIR technique by single puncture method using a 6F trocar catheter. The results of this novel technique were evaluated with regards to efficacy and safety of the procedure and complication rates.

RESULTS

Out of 493 cysts, 317 were Gharbi type I (WHO CE 1) and 176 were Gharbi type II (WHO CE 3A). Of all cysts, 13 were referred to surgery because of cystobiliary fistulization. Recurrence was observed in 11 cysts one month later. Therefore, the success rate of the PAIR technique was 97.7% (469/480). Minor complications (fever, urticaria-like reactions, biliary fistula) were seen in 44 treated patients (12%, 44/374); the only major complication was reversible anaphylactic shock which was observed in two patients (0.5%, 2/374).

CONCLUSION

This novel modified PAIR technique may be superior to catheterization by Seldinger technique due to its efficiency, easier application, lower severe complication rate, and lower cost. Further comparative studies are required to confirm our observations.Hydatid disease is a parasitic infection caused by the larval stage of the tapeworm Echinococcus. E. granulosus is the most common cause of hydatid disease in humans and is found throughout the world. It is endemic in large sheep raising areas like the Mediterranean region, the Middle East, Southeast and Central Russia, Northern China, South America, Australia, and New Zealand (1). Hydatid disease usually affects the liver (50%–70%) and less frequently lung, peritoneum, kidney, brain, mediastinum, heart, bone, soft tissues, spinal cord, spleen, pleura, adrenal glands, bladder, ovary, scrotum, and thyroid gland (2). Treatment approaches include medical, surgical, and minimally invasive procedures. Medical treatment with albendazole or mebendazole alone has a low rate of success and high rate of relapse, making this treatment option controversial (3). The surgical approach has been the gold standard therapy for the hydatid disease for a long time (4). However, in recent years, percutaneous treatment of the hydatid cyst emerged as a potential alternative to surgery, because of its efficiency, reliability, and low morbidity and mortality rates. The puncture, aspiration, injection, and reaspiration (PAIR) technique, which involves puncture of the cyst wall, aspiration of cyst contents, instillation, and reaspiration of the scolicidal agent, has gained international recognition. PAIR technique can be achieved by using a coaxial catheter system to aspirate the cyst content and infuse scolicidal agent at the same time (5). Another technique can be performed by catheterization (3, 6). In our study, we performed the PAIR procedure by directly entering into the hydatid cyst cavity through a single puncture using a trocar catheter instead of placing a catheter through stiff wire after puncturing with a Seldinger needle. The primary goal of the current study was to determine the success and reliability of this technique in patients with hydatid disease.     

血管造影及栓塞术在创伤性腹膜后血肿中的应用

腹膜后血肿因其解剖特点和症状不典型,具有确诊率低、治疗困难、病死率高等特点,腹膜后血肿的治疗方法主要有非手术治疗和开腹手术。非手术治疗观察时间长,不确定因素多,中途转开腹也比较常见,而开腹手术存在止血困难、易感染、创伤较大等棘手问题。近年来随着血管造影及介入栓塞技术快速发展,对于出血严重的腹膜后血肿,可以通过血管造影及介入栓塞技术明确出血源、出血速度,同时给予相应栓塞治疗,较传统手术方式有创伤小、效率高、风险低的特点,为患者赢得了时间,降低了病死率。