Minimally invasive procedure for removal of infected ventriculoatrial shunts

Background: Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances. Methods: We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution. Results: We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved. Conclusion: Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting

One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a standard procedure for the treatment of portal hypertension complications. When this conventional approach is not feasible, alternative procedures for systemic diversion of portal blood have been proposed. A one-step interventional approach, combining minilaparotomy-assisted transmesenteric (MAT) antegrade portal recanalization and TIPS, is described in an adolescent with recurrent esophageal varice bleeding and portal cavernoma (PC). A 16-year-old girl was admitted to our Unit because of repeated bleeding episodes over a short period of time due to esophageal varices in the context of a PC. A portal vein recanalization through an ileocolic vein isolation with the MAT approach followed by TIPS during the same session was performed. In the case of failed portal recanalization, this approach, would also be useful for varice endovascular embolization. Postoperative recovery was uneventful. Treatment consisting of propanolol, enoxaparin and a proton pump inhibitor was prescribed after the procedure. One month post-op, contrast enhanced computed tomography confirmed the patency of the portal and intrahepatic stent grafts. No residual peritoneal fluid was detected nor opacification of the large varices. Endoscopy showed good improvement of the varices. Doppler ultrasound confirmed the accelerated flow in the portal stent and hepatopetal flow inside the intrahepatic portal branches. Three months post-op, TIPS maintained its hourglass shape despite a slight expansion. Portal hypertension and life threatening conditions related to PC would benefit from one-step portal recanalization. MAT-TIPS is feasible and safe for the treatment of PC even in children. This minimally invasive procedure avoids or delays surgical treatment or re-transplantation when necessary in pediatric patients

Green Tattoo Pre-Operative Renal Embolization for Robotic-Assisted and Laparoscopic Partial Nephrectomy: A Practical Proof of a New Technique

Background: Our aim is to describe a new mixed indocyanine-non-adhesive liquid embolic agent (Onyx-18) pre-operative renal embolization technique for assisted-robotic and laparoscopic partial nephrectomy with near-infra-red fluorescence imaging. (2) Methods: Thirteen patients with biopsy-proven renal tumors underwent pre-operative mixed indocyanine–ethylene vinyl alcohol (EVOH) embolization (Green-embo) between June 2021 and August 2022. All pre-operative embolizations were performed with a super selective stop-flow technique using a balloon microcatheter to deliver an indocyanine-EVOH mixture into tertiary order arterial branch feeders and the intra-lesional vascular supply. Efficacy (evaluated as complete embolization, correct tumor mapping on infra-red fluorescence imaging and clamp-off surgery) and safety (evaluated as complication rate and functional outcomes) were primary goals. Clinical and pathological data were also collected. (3) Results: Two male and eleven female patients (mean age 72 years) received pre-operative Green-embo. The median tumor size was 29 mm (range 15–50 mm). Histopathology identified renal cell carcinoma (RCC) in 9 of the 13 (69%) patients, oncocytoma in 3 of the 13 (23%) patients and sarcomatoid RCC in 1 of the 13 (8%) patients. Lesions were equally distributed between polar, meso-renal, endo- and exophytic locations. Complete embolization was achieved in all the procedures. A correct green mapping was identified during all infra-red fluorescence imaging. All patients were discharged on the second day after the surgery. The median blood loss was 145 cc (10–300 cc). No significant differences were observed in serum creatinine levels before and after the embolization procedures. (4) Conclusions: The Green-tattoo technique based on a mixed indocyanine-non-adhesive liquid embolic agent (Onyx-18) is a safe and effective pre-operative embolization technique. The main advantages are the excellent lesion mapping for fluorescence imaging, reduction in surgical time, and definitive, complete and immediate tumor devascularization based on the deep Onyx-18 penetration, leading to a very low intra-operative blood loss

Status Update and Interim Results from the Asymptomatic Carotid Surgery Trial-2 (ACST-2)

Objectives: ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization. Methods: Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012. Results: A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%. Conclusions: Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions. Clinical trial: ISRCTN21144362. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Sistema vascolare epatico

none6Il fegato è un organo con una vascolarizzazione peculiare, essendo da un lato interposto tra due sistemi venosi, dall’altro possedendo una irrorazione arteriosa afferente ad un sistema venoso, quello dei sinusoidi, condiviso con l’afferenza venosa. Il sistema venoso afferente è quello costituito dal sistema portale che comprende l’efflusso splenico, quello pancreatico e quello gastroenterico. Dal punto di vista funzionale l’affluenza epatica del sangue refluo dal pancreas ha importanza dal punto di vista endocrino-metabolico mentre l’affluenza del sangue refluo dalla milza è importante per l’emocateresi. Il flusso portale è il risultato dell’efflusso splenico e mesenterico ed è quindi regolato solo dall’afflusso splenico e mesenterico. Il fegato a tal riguardo svolge solo il ruolo di modificare le resistenze per mantenere un regime pressorio constante. Il sitema prevede invece una regolazione dell’afflusso arterioso controllata prevalentemente dal flusso portale, con un sistema buffer di vasocostrizione arteriosa epatica in seguito all’aumento del flusso portale che si verifica fasicamente ad esempio in occasione dei pasti. Vi possono essere delle variazioni di resistenze al flusso portale In condizioni patolologiche, quale la cirrosi, l’ostruzione portale o delle vene sovraepatiche, le resistenze al flusso portale aumentano determinando conseguenze a monte con aumento della pressione (ipertensione portale), formazione di circoli collaterali che rappresentano degli shunts porto-sistemici. Le conseguenze sono quindi di tipo emodinamico e metabolico. Lo studio della vascolarizzazione epatica è effettuabile in maniera completa e dinamica mediante l’eco-color-Doppler. Tale metodica consente di ottenere informazioni sulla morfologia dei vasi e sul flusso ematico, valutandone la presenza o assenza, le velocità nelle diverse fasi del ciclo cardiaco, e numerosi indici di resistenza o compliance sia a livello arterioso che venoso. La fattibilità di un esame eco-color-Doppler completo è circa del 70%. Il mezzo di contrasto può consentire una migliore visualizzazione dei vasi epatici in condizioni di scarsa visualizzazione (1) ed in particolare nel trapianto di fegato in cui il monitoraggio della pervietà venosa ed arteriosa è di fondamentale importanza (2-4). Vi sono dati in letteratura che dimostrano il miglioramento della capacità diagnostica dell’eco-Doppler con l’uso del mezzo di contrasto ed anche una riduzione dei tempi di esecuzione degli esami, in particolare dopo trapianto di fegato (1). A tal riguardo è consigliabile, anche per motivi economici, riservare l’uso del mezzo di contrasto ai soli casi dubbi. Da un punto di vista pratico è molto importante conoscere la cinetica dei mezzi di contrasto ecografici a livello epatico, al fine di poter usare in modo razionale l’ecografia con mezzo di contrasto a scopo diagnostico, non solo vascolare ma anche per lo studio delle lesioni focali epatiche. Se noi somministriamo del Levovist in bolo attraverso una vena periferica otterremo la visualizzazione sequenziale dell’arteria epatica, dei rami portali epatici e successivamente delle vene sovraepatiche. Come illustrato nella fig. 1, dopo circa 15 secondi il mezzo di contrasto consentirà la visualizzazione dei rami arteriosi epatici, dopo 20 secondi quella dei rami portali, dopo 40 secondi quella delle vene sovraepatiche. Mentre il ritardo di opacizzazione dei rami portali è di facile interpretazione, dovendo il mezzo di contrasto attraversare il letto arterioso, capillare e venoso gastroenterico e splenico, di più difficile interpretazione è il ritardo di opacizzazione delle vene sovraepatiche. Esso è verosimilmente dovuto al tempo di transito sinusoidale. Il mezzo di contrasto permette quindi di ottenenere un’ottima visualizzazione dei rami principali arteriosi e venosi portali e sovraepatici. Disponendo dell’idonea tecnologia è poi possibile costruire le curve di transito del mezzo di contrasto nei diversi distretti vascolari. Tali curve, ottenute con il Levovist usando la seconda armonica, la pulse-inversion e un indice meccanico piuttosto basso (MI=1,0) ed un frame rate di 1/battito cardiaco (circa 1/sec), sono illustrate nella figura 2. Delle curve si possono valutare molteplici parametri. I più usati sono: il tempo di comparsa del contrasto, il tempo di picco massimo, il livello del picco massimo, l’inclinazione della retta.noneCascina ; Azzaretti A; Sacerdoti D; Quaretti P; Garbagnati F; Rossi SCascina, ; Azzaretti, A; Sacerdoti, David; Quaretti, P; Garbagnati, F; Rossi, S

Valutazione della dose al paziente in radiologia interventistica

none7L. D’Ercole; L. Mantovani; Ottolenghi Andrea; F. Lisciandro; L. Andreucci; P. Quaretti; F. Zappoli Thyrion.L., D’Ercole; L., Mantovani; Ottolenghi, ANDREA DAVIDE; F., Lisciandro; L., Andreucci; P., Quaretti; F., Zappoli Thyrio