Faculty Bibliography

Purpose: Various endpoints of embolization have been advocated by investigators during uterine artery embolization (UAE) for the treatment of symptomatic uterine fibroids. Described endpoints are based on angiographic appearance. Our intent is to objectively define a non-imaging endpoint of embolization in patients undergoing UAE. Materials and Methods: 55 consecutive patients with symptomatic uterine fibroids underwent UAE using an outer 5- and inner 3-Fr. catheters. Prior to and following embolization, systolic, diastolic, and mean intra-arterial blood pressures (BP) were measured within the ipsilateral internal iliac and the uterine (UA) arteries. For uniformity, the fluoroscopic endpoint was defined as the clearing of contrast within the main UA in or after 5 cardiac cycles. The mean+/-standard deviation of the within-subject percentage change in BPs from pre- to post-embolization were measured. p values, statistically significant at <=0.05, were assigned from a paired sampled t and Wilcoxon matched-pairs signed rank tests to assess whether the percentage change in BP was relevant. Results: Mean changes (pre- and post-embolization) in systolic, diastolic, and mean left UA BP measurements were: 17.74+/-17.87, 9.15+/-12.39, and 13.24+/-12.98, respectively. In the right UA, 29.76+/-24.05, 13.44+/-11.33, and 20.88+/-15.66. All assigned p values were <0.0001. Conclusion: In this study, parametric differences in uterine artery blood pressures before and after UAE were shown to correlate to an accepted angiographic endpoint. UA BP measurements can be used as an equivalent parametric non-imaging endpoint to UAE. A non-angiographic endpoint may lead to the reduction of radiation dosage to the patient and the interventional radiologist when performing UAE. (Table Presented)

BACKGROUND: Major thoracic or neck surgery or penetrating trauma can cause injury to the thoracic duct and development of a chylothorax. Chylothorax results in metabolic and immunologic disorders that can be life threatening, with a mortality rate reaching 50%. The management of chyle leaks is dependent on the etiology and daily output. Interventions are used to treat only leaks unresponsive to medical management or those with an output exceeding 1,000 ml/day. METHODS: This study reviewed the existing literature on the percutaneous management of chyle leaks. The authors evaluated five case series and three case reports inclusive of 90 patients in which percutaneous treatment for chylothorax was attempted between 1998 and 2004. RESULTS: For 71 patients, percutaneous treatment was technically successful, and chylothorax resolved in 49 of the patients (69%). Percutaneous treatment of chylothorax was associated with a 2% morbidity rate and no mortality. For 19 patients whose percutaneous approach failed, either surgical ligation or pleurodesis was performed. CONCLUSIONS: The percutaneous management of chyle leak is feasible, with low morbidity and mortality rates and a high rate of effectiveness. This approach should be considered before more invasive procedures

Learning Objectives: Learn to utilize artificial ascites to safely perform radiofrequency ablation of subdiaphragmatic hepatocellular carcinoma. Background: RFA is an effective treatment of HCC. A relative contraindication is subdiaphragmatic tumor location because the diaphragm is at increased risk of thermal injury. Artificial ascites of 5-10 mm thickness creates a protective space between the tumor and diaphragm. 5% dextrose in water (D5W) is used because it provides greater electric isolation than normal saline. The ascites decreases post-procedural pain and recovery time without sacrificing efficacy because there is no significant associated heat sink effect. Clinical Findings/Procedure Details: Ultrasound guidance is used to advance a 20-gauge needle into the peritoneal cavity. If the tumor is in the right hepatic lobe, a subcostal approach along the anterior axillary line is used. If the tumor is in the left hepatic lobe, a subcostal epigastric approach is used. A small amount of D5W (20-50 mL) is injected to create a space for placement of an 8 French pigtail catheter. Placement of the catheter close to the tumor, between the liver and diaphragm is desirable. The catheter is infused with D5W and creation of artificial ascites is monitored under ultrasound or CT. Artificial ascites improves the sonic window for ultrasound guided placement of the RFA probe. If the tumor remains difficult to visualize, CT guidance is used for probe placement. Following completion of ablation, the catheter is drained to gravity. Blood tinged fluid is common following the procedure. The catheter is left in place 12-24 hours to drain residual ascites and prevent hemoperitoneum. Other potential complications include peritonitis, pleuritic chest pain, and pleural effusion. Conclusion and/or Teaching Points: Artificial ascites can effectively decrease risk of thermal injury to the diaphragm, post-procedural pain, and recovery time without sacrificing efficacy of subdiaphragmatic HCC radiofrequency ablation. The infusion catheter should be placed close to the tumor, between the liver and diaphragm, to create 5-10 mm thickness of D5W artificial ascites. The catheter should be drained for 12-24 hours post-procedurally to remove residual ascites and decrease risk of hemoperitoneum

Catheter coatings have the potential to decrease infection and thrombosis in patients with chronic dialysis catheters. We report our midterm experience with a heparin-coated dialysis catheter. This retrospective, case-control study was approved by our Institutional Review Board. A total of 88 tunneled dialysis catheters were inserted over a 13-month period via the internal jugular vein. Thirty-eight uncoated split-tip catheters and 50 heparin-coated catheters were inserted. Primary catheter patency was compared between the two groups using the log rank test, with infection and/or thrombosis considered as catheter failures. Dialysis parameters during the first and last dialysis sessions, including pump speed, actual blood flow, and arterial port pressures, were compared using unpaired t-tests. Primary patency of the uncoated catheters was 86.0 +/- 6.5% at 30 days and 76.1 +/- 8.9% at 90 days. Primary patency of heparin-coated catheters was 92.0 +/- 6.2% at 30 days and 81.6 +/- 8.0% at 90 days (p = 0.87, log rank test). Infection requiring catheter removal occurred in four patients with uncoated catheters and two patients with heparin-coated catheters (p = 0.23). Catheter thrombosis requiring catheter replacement or thrombolysis occurred in one patient with an uncoated catheter and two patients with heparin-coated catheters (p = 0.9). No differences in catheter function during hemodialysis were seen between the two groups. In conclusion, the heparin-coated catheter did not show a significantly longer patency compared to the uncoated catheter. The flow characteristics of this device were comparable to those of the conventional uncoated catheter. A demonstrable benefit of the heparin-coated catheter in randomized trials is needed before a recommendation for routine implementation can be made