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Percutaneous radiologically guided gastrostomy tube placement: comparison of antegrade transoral and retrograde transabdominal approaches

Haber, Zachary M; Charles, Hearns W; Gross, Jonathan S; Pflager, Daniel; Deipolyi, Amy R
PURPOSE: We aimed to compare the antegrade transoral and the retrograde transabdominal approaches for fluoroscopy-guided percutaneous gastrostomy tube (G-tube) placement. METHODS: Following institutional review board approval, all G-tubes at two academic hospitals (January 2014 to May 2015) were reviewed retrospectively. Retrograde approach was used at Hospital 1 and both antegrade and retrograde approaches were used at Hospital 2. Chart review determined type of anesthesia used during placement, dose of radiation used, fluoroscopy time, procedure time, medical history, and complications. RESULTS: A total of 149 patients (64 women, 85 men; mean age, 64.4+/-1.3 years) underwent G-tube placement, including 93 (62%) placed via the retrograde transabdominal approach and 56 (38%) placed via the antegrade transoral approach. Retrograde placement entailed fewer anesthesiology consultations (P < 0.001), less overall procedure time (P = 0.023), and less fluoroscopy time (P < 0.001). A comparison of approaches for placement within the same hospital demonstrated that the retrograde approach led to significantly reduced radiation dose (P = 0.022). There were no differences in minor complication rates (13%-19%; P = 0.430), or major complication rates (6-7%; P = 0.871) between the two techniques. CONCLUSION: G-tube placement using the retrograde transabdominal approach is associated with less fluoroscopy time, procedure time, radiation exposure, and need for anesthesiology consultation with similar safety profile compared with the antegrade transoral approach. Additionally, it is hypothesized that decreased procedure time and anesthesiology consultation using the transoral approach are likely associated with reduced cost.
PMCID:5214078
PMID: 27911264
ISSN: 1305-3612
CID: 2329572

Percutaneous radiologically guided gastrostomy tube placement: Comparison of antegrade trans-oral and retrograde trans-abdominal approaches [Meeting Abstract]

Haber, Z; Charles, H; Gross, J; Deipolyi, A
Purpose: To compare the antegrade trans-oral and the retrograde trans-abdominal approaches for fluoroscopy-guided percutaneous gastrostomy tube (G-tube) placement. Materials: Following institutional review board approval, all G-tubes placed by Interventional Radiology at two academic hospitals between January 2014 and May 2015 were reviewed retrospectively. Chart review determined type of anesthesia used during placement, dose of radiation used, fluoroscopy time, total procedure time, medical history, and complications. Results: A total of 149 patients (64 women, 85 men; mean age, 64 years, range 18-100 y) underwent G-tube placement, including 93 placed via the retrograde trans-abdominal approach and 56 placed via the antegrade trans-oral approach. Retrograde placement entailed fewer anesthesiology consultations (37% vs. 98%, p <0.0001), less overall procedure time (28 minutes vs. 36 minutes, p=0.02), and less fluoroscopy time (2.1 minutes vs. 8.7 minutes, p <0.0001). A comparison of approaches for placement within the same hospital demonstrated that the retrograde approach led to significantly reduced radiation dose (4.9 mGy vs. 28.1 mGy, p=0.02). There were no differences in complication rates between the two techniques, with minor and major complication rates of 13-19% and 6-7%, respectively, for both approaches. Conclusions: G-tube placement using the retrograde trans-abdominal approach is associated with less fluoroscopy and procedure times, radiation exposure, and need for anesthe-siology consultation with similar safety profile compared with the antegrade trans-oral approach. Additionally, it is proposed that decreased procedure time and anesthesiology consultation using the trans-oral approach are likely associated with reduced cost
EMBASE:72229450
ISSN: 1051-0443
CID: 2094932

Unexpected Angiography Findings and Effects on Management

Neill, Matthew; Charles, Hearns W; Gross, Jonathan S; Farquharson, Sean; Deipolyi, Amy R
Despite progress in noninvasive imaging with computed tomography and magnetic resonance imaging, conventional angiography still contributes to the diagnostic workup of oncologic and other diseases. Arteriography can reveal tumors not evident on cross-sectional imaging, in addition to defining aberrant or unexpected arterial supply to targeted lesions. This additional and potentially unanticipated information can alter management decisions during interventional procedures.
PMCID:5029115
PMID: 27688932
ISSN: 2156-7514
CID: 2262792

Transcatheter Embolization for the Treatment of Renal Trauma

Chapter by: Gross, Jonathan S
in: Procedural dictations in image-guided intervention : non-vascular, vascular, and neuro interventions by Taslakian, Bedros; Al-Kutoubi, Aghiad; Hoballah, Jamal J [Eds]
[Cham], Switzerland : Springer, [2016]
pp. 463-466
ISBN: 9783319408453
CID: 2680632

Embolization of Pulmonary Arteriovenous Malformations

Chapter by: Gross, Jonathan S
in: Procedural dictations in image-guided intervention : non-vascular, vascular, and neuro interventions by Taslakian, Bedros; Al-Kutoubi, Aghiad; Hoballah, Jamal J [Eds]
[Cham], Switzerland : Springer, [2016]
pp. 537-540
ISBN: 9783319408453
CID: 2680682

Transjugular intrahepatic portosystemic shunt (TIPS) creation for refractory ascites: Post-TIPS gradient best predictor of clinical outcome [Meeting Abstract]

Wu, S; Farquharson, S; Gross, J S; Aaltonen, E T; Sridhar, D; Kovacs, S; Bryk, H; Teperman, L; Park, J S; Sigal, S; Charles, H; Deipolyi, A R
Purpose: TIPS creation fails to control ascites in 40% or more of patients, but the variables predicting outcome are unclear, with prior studies highlighting pre-TIPS portosystemic gradient (PSG) (Nair et al 2004; JVIR 15:1431). We studied which variables predict outcome of TIPS for refractory ascites. Materials and Methods: We retrospectively identified patients who underwent TIPS for refractory ascites between 1/12 and 5/14, yielding 40 patients. We excluded 17 patients due to insufficient peri-procedural documentation or technical failures, leaving 23 patients (16 men, 7 women, mean age 60 +/-2 yrs) for assessment of variables influencing osmotic (albumin and sodium levels) and hydrostatic (pre- and post- TIPS PSG and large varices) pressure. Responders were defined as those requiring fewer or no paracenteses; nonresponders had persistent ascites, with similar pre-TIPS frequency of therapeutic paracentesis. Complications within 1 month requiring hospitalization were noted. Multiple logistic regression, Mann-Whitney U tests, and one-tailed chi2 tests assessed group differences. Results: Ten patients (43%: responders) had documented improvement in ascites. Multiple logistic regression including pre- and post-TIPS PSG significantly impacted outcome (p=0.04). Post- but not pre-TIPS PSG predicted outcome (p=0.04 vs. p=0.84). Responders had significantly lower post- TIPS gradient (5.8) compared with non-responders (7.6) (p=0.02). In contrast, responders and non-responders did not differ in albumin (2.7 vs. 2.7) or sodium (136 vs. 134) levels, or pre-TIPS gradient (13.9 vs. 14.7 mmHg) (p>0.05). Similar numbers of responders (50%) had large varices compared to non-responders (61%) (p=0.3). Responders (50%) had significantly more complications compared to non-responders (15%) (p=0.04), mostly encephalopathy (85%) requiring hospitalization. Conclusion: Only post-TIPS PSG predicted which patients had significantly reduced ascites, in contrast to prior studies suggesting importance of pre-TIPS gradient. Findings suggest aggressively lowering the gradient below 6 mmHg may be the most reliable technique to improve outcomes, although with expected higher risk of complications
EMBASE:71805726
ISSN: 1051-0443
CID: 1514772

Denali, ALN, and Option/Option Elite filter retrieval: A single center experience [Meeting Abstract]

Aaltonen, E T; Obele, C; Bryk, H; Deipolyi, A R; Farquharson, S; Gross, J S; Kovacs, S; Sridhar, D; Charles, H W
Purpose: To evaluate if there is a significant difference in retrieval difficulty as determined by fluoroscopy time and equipment use when comparing three different filters: Denali, ALN, and Option/Option Elite. Materials and Methods: Retrospective analysis was performed of 33 filter retrievals performed over a 24 month period (12 men, 21 women; mean age 60). There were 8 Denali (Bard Peripheral Vascular), 9 ALN (ALN Implants), and 16 Option/ Option Elite (Argon Medical Devices) filter retrievals. Demographics, filter dwell time, fluoroscopy time during retrieval, and equipment used for retrieval were collected for each case. One Option case was excluded due to unsuccessful retrieval. Kruskal-Wallis H, two sample t-test and Chi-square analysis were used to determine significant differences in fluoroscopy time and equipment use between the three filter groups. Results: There were no significant differences between groups based on demographics or filter dwell time. Mean retrieval times were 4.9 min (SD: 3.6, range 1.2-10.3) for Denali, 9.9 min (SD: 5.5, range 2.9-18.6) for ALN, and 23.9 min (SD: 20.0, range 2.5 - 58) for Option/Option Elite. A Kruskal-Wallis H test showed a significant difference in these times (chi2=7.17, p=0.028), subsequent post-hoc analysis showed a significant difference only between Denali and Option but not between Denali and ALN or ALN and Option. Given normal distribution of fluoroscopy times for Denali and ALN, a separate t-test comparing these two filters did demonstrate a significant difference in fluoroscopy time (p=0.023). None of the Denali retrievals required additional equipment beyond a snare and sheath, 1/9 (11%) of ALN and 10/15 (67%) of Option retrievals required at least a tip deflecting wire or angled catheter (chi2=11.07, p=0.004). Sub-analysis separating Option and Option Elite filters did not change any results significantly. Conclusion: Denali filter retrieval involves significantly less fluoroscopy time than ALN or Option/Option Elite filter retrieval. In this series, Option/Option Elite retrieval also required significantly more equipment to achieve technical success compared to Denali and ALN retrieval. A larger sample size is required to corroborate these early results. (Table Presented)
EMBASE:71806042
ISSN: 1051-0443
CID: 2664492

Objective non-angiographic endpoint of uterine artery embolization as defined by parametric uterine artery blood pressure differences [Meeting Abstract]

Charles, H; Song, C; Kovacs, S; Babb, J S; Gross, J; Aquino, T
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)
EMBASE:70682027
ISSN: 1051-0443
CID: 2664502

Utility of positive nuclear gastrointestinal bleeding imaging parameters to predict subsequent successful angiographic localization [Meeting Abstract]

Chamarthy M.; Shapoval A.; Golowa Y.; Gross J.; Cynamon J.
Purpose: Digital subtraction angiography (DSA) is performed in cases of lower gastrointestinal (GI) bleeding for diagnostic and therapeutic purposes. Appropriate selection of patients that might benefit from the interventional procedure is important to minimize the associated risks. This study evaluates the various clinical, laboratory and nuclear imaging parameters in patients with a positive GI bleeding study to predict the likelihood of a subsequent successful angiogram. Materials and Methods: A retrospective IRB approved medical record and imaging review was performed from 2006-09. A total of 44 patients who had a positive GI bleeding study followed by a subsequent angiogram within 24 hours were included for the study. Analyzed clinical parameters include: unstable vitals (BP < 100/60 with HR >100), number of packed RBC transfusions (within the 48 hours prior to the angiogram procedure), and decrease in hematocrit (HCT; drop in the 48 hours preceding the angiogram). Nuclear imaging parameters include the delayed angiogram time (time interval for angiogram after a positive GI bleeding study), appearance of the bleed within the first image frame, exact time of appearance of the bleed, and the extent of the bleed (large defined as > one segment length). A binomial regression analysis was performed to evaluate the above parameters. Results: From a total of 44 patients, 16 (36%) had positive angiogram following a positive GI bleeding study. The delayed angiogram time, recent decrease in HCT, stability, and number of administered packed RBCs were not significantly different between the angiogram positive and negative groups. On regression analysis, appearance of the bleed within the first frame of the GI bleeding study (86% vs 18, p = 0.001), and extent of bleeding on the scan (86% vs 28%, p = 0.03), were found to be significant. Conclusion: Clinical and laboratory parameters are highly variable and might not be useful to predict the likelihood of a successful angiogram in patients with a positive nuclear GI bleeding study. An early visualization of the bleeding within the first frame and increased extent of the distribution on the nuclear GI bleeding study could be useful to predict successful angiographic localization
EMBASE:70368263
ISSN: 1051-0443
CID: 129331

Artificial ascites and radiofrequency ablation of subdiaphragmatic hepatocellular carcinoma [Meeting Abstract]

Aquino T.; Aaltonen E.; Charles H.W.; Kovacs S.; Gross J.; Richard L.; Hillel B.
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
EMBASE:70368469
ISSN: 1051-0443
CID: 129332