Embolization therapy for pelvic arteriovenous malformations: a systematic review.

Management of arteriovenous malformations (AVMs) is challenging, and there is no consensus regarding either the ideal approach or the treatment timing. Percutaneous embolization is the most frequent approach currently used and is considered the first-line technique for AVMs. There is an ongoing discussion about the best technical approach to embolize AVMs. AVMs associated with a dominant outflow vein (DOV) are rare. Embolization of both the DOV and the nidus is considered more effective. Herein, we report a novel technique of transvenous embolization of a DOV under negative pressure from an arterial balloon catheter in a case of a peripheral AVM. This technique allows the embolization of the DOV and the nidus retrogradely.

Re: Systematic Review and Meta-Analysis of Prophylactic Transarterial Embolization for High-Risk Bleeding Peptic Ulcer Disease

Ovarian Vein Embolization: How and When Should It Be Done?

After almost three decades since the first description of colonic stents, the controversies of its safe application continue to impede the readiness of adoption by clinicians for malignant left bowel obstruction. This review seeks to address some of the controversial aspects of stenting and its impact on surgical and oncological outcomes. Medline, Embase, and CNKI were searched for articles employing SEMS for left colonic obstruction. Outcomes analyzed include success rates, complications, and long-term survival. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated. 36 studies were included with 2002 patients across seven randomized controlled trials and 29 observational studies. High technical (92%) and clinical (82%) success rates, and low rates of complications, including perforation (5%), were found. Those with > 8% perforation rates had poorer technical success rates than those with ≤ 8%, but there were no significant differences in 90-day in-hospital mortality and three and 5-year overall and disease-free survival. A significant increase was found in technical (RR = 1.094; CI, 1.041-1.149; p < 0.001) and clinical (RR = 1.158; CI, 1.064-1.259; p = 0.001) success rates when the duration between stenting and surgery was ≥ 2weeks compared to < 2weeks, but there were no significant differences in perforation rates, 90-day in-hospital mortality, and long-term survival. Colonic stenting is safe and effective with high success rates and low complication rates. However, outcomes of higher perforation rates and optimal timing from stent till surgery remain unclear, with only a few studies reporting on these outcomes, leaving areas for future research.

Angioplasty and stenting of the IA have been reported with high technical and clinical success rates, low complication rates and good mid-term patency rates. Different antegrade or retrograde endovascular catheter-based approaches and combinations with surgical exposure of the CCA are used. The purpose of this study was to determine safety, efficacy and mid-term clinical and radiological outcome of the stent-assisted treatment of atherosclerotic stenotic disease of the IA with special focus on the different technical approaches. Between 1996 and 2008, 18 patients (12 men, 6 women) with symptomatic high-grade stenosis (>80%) of the IA were treated with endovascular stent placement. Their mean age was 60.4 years (range, 48-78 years). Mean angiographic and clinical follow-up was 2.7 years (range, 0.3-9.1 years). Clinical follow-up was performed by using the mRS at hospital discharge, routine follow-up controls, and a questionnaire. In 11 patients, a percutaneous approach was used. In 7 patients, the lesions were accessed retrogradely through a cervical cut-down with common carotid arteriotomy. In 2 patients, a simultaneous ipsilateral carotid endarterectomy was performed. In all patients, primary stent placement was performed. There were 2 procedure-related transient complications (11.1%) due to cerebral embolism without permanent morbidity or mortality. During the follow-up, all patients showed improvement of the preprocedural symptoms. At the latest clinical follow-up (mean, 2.7 years), all patients showed an excellent or good outcome (mRS, 0 or 1). In 2 patients (11.1%), a secondary stent placement was needed due to a significant symptomatic in-stent stenosis. Percutaneous and open retrograde stenting of high-grade stenosis of the IA is a viable less invasive alternatives to open bypass surgery with good midterm clinical results and patency rates.

Endoscopic mucosal resection (EMR) for removal of large polyps is well established in adults. EMR technique in the pediatric population is less utilized due to lower incidence of large intestinal polyps in pediatric patients and limited EMR training for pediatric gastroenterologists. The aim of this study is to retrospectively review safety and efficacy of pediatric EMR cases at two large, tertiary referral centers with adult and pediatric EMR expertise. A retrospective chart review was conducted at Cedars-Sinai Medical Center and Cincinnati Children's Hospital Medical Center from January 2012 to May 2021. Demographic, clinical, technical and follow up data were collected for patients <18 years of age who underwent EMR during the study period. Fifteen pediatric EMR procedures were identified in 11 patients (five male, six female) during the study period. Indication was most frequently rectal bleeding. Polyp size removed ranged from 9 to 60 mm and pathology was consistent with juvenile inflammatory polyps in six patients. Technical success was achieved in 14 of 15 (93%) of EMRs with clinical success (desired clinical outcome) in all 13 procedures with clinical follow-up. There were no adverse events. This study identifies a case series of pediatric patients who underwent EMR at two tertiary care centers. This series demonstrates successful EMR in children and shows a high technical and clinical success rate with a low complication rate. More investigation into EMR in pediatric patients is necessary, and its use should be isolated to centers with endoscopists with specific experience in EMR techniques.

Paravalvular leak (PVL) is an uncommon yet serious complication associated with the implantation of mechanical or bioprosthetic surgical valves and more recently recognized with transcatheter aortic valves implantation (TAVI). A significant number of patients will present with symptoms of congestive heart failure or haemolytic anaemia due to PVL and need further surgical or percutaneous treatment. Until recently, surgery has been the only available therapy for the treatment of clinically significant PVLs despite the significant morbidity and mortality associated with re-operation. Percutaneous treatment of PVLs has emerged as a safe and less invasive alternative, with low complication rates and high technical and clinical success rates. However, it is a complex procedure, which needs to be performed by an experienced team of interventional cardiologists and echocardiographers. This review discusses the current understanding of PVLs, including the utility of imaging techniques in PVL diagnosis and treatment, and the principles, outcomes and complications of transcatheter therapy of PVLs.

To evaluate efficacy of percutaneous transluminal angioplasty (PTA) for the endovascular management of arteriovenous fistula (AVF) dysfunction in patients with end-stage renal disease (ESRD). A total of 135 consecutive patients with ESRD (mean±SD age: 58.8±9.4 years, 74.8% were males) who underwent endovascular treatment for a dysfunctional native AVF were included in this retrospective single-center study. Data on patient demographics, etiology of ESRD, characteristics of AVF, stenotic segments, PTA parameters and postoperative recurrence and patency rates within the 12 months were recorded. Technical and clinical success rates of PTA were 100.0% and 97.0%, respectively. Dysfunction recurrence rate was 30.4%. In patients with vs. without presence of recurrent AVF dysfunction, there was higher percentage of males (P=0.030), older age (P=0.018), diabetic or hypertensive rather than polycystic etiology (P<0.001), younger AVF (P<0.001), longer-segment stenosis (P=0.019) and lower median number (P=0.038) of stenotic segments. Presence of hypertension (OR 12.23, 95% CI: 4.29 to 34.85, P<0.001) and age of the AVF (OR 1.04, 95% CI: 1.00 to 1.08, P=0.029) were significant determinants of increased risk of recurrent AVF dysfunction. Our findings emphasize favorable safety and efficacy of PTA in the management of dysfunctional hemodialysis AVFs in terms of high technical and clinical success and low rates of residual stenosis, complications and post-PTA recurrence of AVF dysfunction. Male gender, older patient age, younger AVF and longer-segment stenosis were associated with higher likelihood of AVF failure, whereas hypertension and age of AVF were the two significant determinants of increased risk of post-PTA recurrence of AVF dysfunction.

Aims To summarize the evidence available thus far on the safety and efficacy of percutaneous cholecystolithotomy (PCCL). So, the research question we set out to answer is: Is PCCL a safe and efficacious procedure? Methods This is a secondary research project involving a literature search to gather evidence on the research question raised above. An SR protocol and search strategy are developed, literature search is conducted using two search engines: Ovid Medline and Ovid Embase. The two search terms used were: (a) (Percutaneous and (removal or extract) and (Gallstones* or Gall stone* or cholelithiasis or cholecystolithiasis*)), (b) Cholystolithomy. Our inclusion/exclusion criteria are clear and appropriate. PRISMA protocol was followed. Results The collected data from the 29 studies that fit our criteria is analyzed, and the results showed that the procedure is safe and effective compared to the gold standard which is laparoscopic cholecystectomy. The clinical and technical success is over 90%, and the combined complication rate is 14.8%, 9.3% major complication rate, and 6.9% minor complication rate. The 30-day mortality of the procedure is 0.8%. Conclusions This systematic review shows that PCCL is a safe and efficacious procedure with high technical and clinical success rates. The reported low 30-day mortality and major complication rates, despite multiple comorbidities and frequently old and sick patients, make PCCL outcomes comparable to the gold standard treatment. However, the current evidence is based on single-center data with heterogeneous reporting standards. Further research should aim at an appropriate sample size, a clear definition of recorded variables, and a refinement of current technologies and techniques.

To evaluate the technical and clinical success rates of percutaneous stent revascularization in the treatment of chronic mesenteric ischemia (CMI). 17 patients (12 female) with typical symptoms of CMI were treated by percutaneous stent placement for stenoses of the splanchnic arteries (celiac trunk; superior mesenteric artery, SMA; inferior mesenteric artery, IMA). The primary and secondary technical success, primary and secondary clinical success, and the long-term clinical outcome were determined. A total of 24 stents were implanted in 21 splanchnic arteries (12 stents in the celiac trunk, 11 in the SMA and 1 in the IMA). The primary technical success rate was 91% (19/21 arteries), the secondary technical success rate was 95% (21/22 arteries). Clinical follow-up was available for 16 patients. The primary clinical success rate was 81% (13/16 patients). Following two secondary interventions, the secondary clinical success rate was 94% (15/16 patients). Long-term clinical success was achieved in 15 of 16 patients (94%) with a mean follow-up of 26 months. One patient died within 30 days of the intervention and two patients demonstrated major complications (1 dissection, 1 stent dislocation). None of the patients required surgical revascularization and none of the patients died due to recurrent mesenteric ischemia. Percutaneous stent placement for the treatment of CMI can be performed with a high technical and clinical success rate as well as an excellent long-term clinical outcome.

BACKGROUNDPancreatic duct stones can lead to significant abdominal pain for patients. Per oral pancreatoscopy (POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct calculi (PDC) in chronic pancreatitis. POP uses two techniques: Electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL). Data on the safety and efficacy are limited for this procedure. We performed a systematic review and meta-analysis with a primary aim to calculate the pooled technical and clinical success rates of POP. The secondary aim was to assess pooled rates of technical success, clinical success for the two individual techniques, and adverse event rates.AIMTo perform a systematic review and meta-analysis of POP, EHL and LL for management of PDC in chronic pancreatitis.METHODSWe conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Cochrane, Google Scholar and Web of Science databases (from 1999 to October 2019) to identify studies with patient age greater than 17 and any gender that reported on outcomes of POP, EHL and LL. The primary outcome assessed involved the pooled technical success and clinical success rate of POP. The secondary outcome included the pooled technical success and clinical success rate for EHL and LL. We also assessed the pooled rate of adverse events for POP, EHL and LL including a subgroup analysis for the rate of adverse event subtypes for POP: Hemorrhage, post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), perforation, abdominal pain, fever and infections. Technical success was defined as the rate of clearing pancreatic duct stones and clinical success as the improvement in pain. Random-effects model was used for analysis. Heterogeneity between study-specific estimates was calculated using the Cochran Q statistical test and I2 statistics. Publication bias was ascertained, qualitatively by visual inspection of funnel plot and quantitatively by the Egger test.RESULTSA total of 16 studies including 383 patients met the inclusion criteria. The technical success rate of POP was 76.4% (95%CI: 65.9-84.5; I2 = 64%) and clinical success rate was 76.8% (95%CI: 65.2-85.4; I2 = 66%). The technical success rate of EHL was 70.3% (95%CI: 57.8-80.3; I2 = 36%) and clinical success rate of EHL was 66.5% (95%CI: 55.2-76.2; I2 = 19%). The technical success rate of LL was 89.3% (95%CI: 70.5-96.7; I2 = 70%) and clinical success rate of LL was 88.2% (95%CI: 66.4-96.6; I2 = 77%). The incidence of pooled adverse events for POP was 14.9% (95%CI: 9.2-23.2; I2 = 49%), for EHL was 11.2% (95%CI: 5.9-20.3; I2 = 15%) and for LL was 13.1% (95%CI: 6.3-25.4; I2 = 31%). Subgroup analysis of adverse events showed rates of PEP at 7% (95%CI: 3.5-13.6; I2 = 38%), fever at 3.7% (95%CI: 2-6.9; I2 = 0), abdominal pain at 4.7% (95%CI: 2.7-7.8; I2 = 0), perforation at 4.3% (95%CI: 2.1-8.4; I2 = 0), hemorrhage at 3.4% (95%CI: 1.7-6.6; I2 = 0) and no mortality. There was evidence of publication bias based on funnel plot analysis and Egger’s test.CONCLUSIONOur study highlights the high technical and clinical success rates for POP, EHL and LL. POP-guided lithotripsy could be a viable option for management of chronic pancreatitis with PDC.

When endoscopic retrograde cholangiopancreatography (ERCP) fails in patients with malignant distal biliary obstruction, endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is an alternative. It has high technical and clinical success rates, but also has high adverse event rates. This prospective cohort study was aimed to evaluate the clinical efficacy and safety of EUS-CDS with our newly developed partially covered self-expandable metal stent with a thin delivery system. Patients consisted of all consecutive patients in three tertiary referral centers with unresectable malignant distal obstruction in whom ERCP failed and in whom EUS-CDS with the thin delivery system was selected as the second-line approach. Rates of clinical success, technical success, technical success in cases not requiring fistulous tract dilation, adverse events, and stent dysfunction were determined. In the 20 patients, technical and clinical success rates were 95.0% (19/20) and 100% (19/19), respectively. In 31.6% (6/19), the delivery system was successfully inserted into the bile duct without requiring a fistulous-tract dilatation device. These patients had significantly shorter procedure times than patients requiring fistulous-tract dilatation (12.7±3.1 vs 23.2±2.1min; P<0.01). One patient (5.0%) who required fistulous dilation had an adverse event, which was managed conservatively. There were no procedure-related deaths. During follow up, four patients (21.1%) developed stent dysfunction. Reintervention was successful in all cases. The EUS-CDS approach had 95% technical and 100% clinical success rates, with adverse events reported in 5% of cases. EUS-CDS may become safer if efforts are made to avoid the dilation step (UMIN 000023938).

BackgroundWe describe two patients who underwent low‐dose‐rate prostate brachytherapy after embolization for pelvic arteriovenous malformation.Case presentationCase 1: A 76‐year‐old man was referred for definitive treatment of intermediate‐risk prostate cancer (prostate‐specific antigen 8.667 ng/mL, cT2aN0M0, Gleason score 3 + 4 = 7). We planned low‐dose‐rate brachytherapy. However, magnetic resonance imaging and computed tomography demonstrated a large pelvic arteriovenous malformation. We performed embolization of the arteriovenous malformation before initiating treatment to lower the risk of rupture of the arteriovenous malformation during low‐dose‐rate brachytherapy. Case 2: A 69‐year‐old man was referred for the definitive treatment of high‐risk prostate cancer (prostate‐specific antigen 5.81 ng/mL, cT2aN0M0, Gleason score 4 + 4 = 8) with a pelvic arteriovenous malformation. Similar to Case 1, we performed embolization of the arteriovenous malformation before initiating treatment. In both cases, low‐dose‐rate brachytherapy could be performed without complications.ConclusionsLow‐dose‐rate brachytherapy after transcatheter embolization of pelvic arteriovenous malformations can safely and effectively treat localized prostate cancer with pelvic arteriovenous malformations.

International multicenter comprehensive analysis of adverse events associated with lumen-apposing metal stent placement for pancreatic fluid collection drainage

There are different types of vena cava filter (VCF) available in clinical practice. However, limited data exist to determine whether one type is superior to another, and no single VCF is universally recommended in clinical guidelines. The objective of this study was to investigate the safety and efficacy of a novel VCF, Octoparms, for the prevention of pulmonary embolism (PE) and to compare it with the Celect filter. This multicenter, randomized, open-label, parallel, positive-controlled, noninferiority trial was conducted in 10 centers across 6 provinces in China from October 2017 to March 2019. Patients who had confirmed lower extremity deep vein thrombosis or PE or who were at risk of PE with a clinical indication for VCF placement due to contraindication to or failure of anticoagulant therapy were included in the trial. The sample size for this trial was based on the assumption that the clinical success rate would be 95% and the noninferiority margin would be 10% for both filters. Each patient underwent baseline testing and was randomized using a web-based central system. Any additional interventions or standard treatments patients received along with the VCF placement were recorded. The primary endpoint was the overall clinical success rate, including technical and clinical success of filter placement and retrieval. The secondary endpoint was the safety of filter placement and retrieval, encompassing procedure-related and filter-related complications. A total of 188 patients were included and were divided into two groups: the Octoparms group (n=94) and the Celect group (n=94). Baseline characteristics and demographics were comparable between the two groups (P>0.05). Technical and clinical success rates for filter placement were achieved in 100% (188/188) of patients. The median dwelling time was 12.0 days (range, 4-190 days). Ten VCFs were left in situ as permanent devices. Of the remaining 178 patients, technical success and clinical success rates for filter retrieval were both achieved in 100% of cases (178/178). Clinical success rates were 92.6% (87/94) for the Octoparms group and 96.8% (91/94) for the Celect group, with a difference of -4.2% (hazard ratio 2.441, 95% confidence interval 0.612-9.741; P=0.206). The lower limit was greater than the noninferiority margin of -10%. Eight patients experienced a total of eight procedure-related complications. No filter-related complications, such as migration, deformation, inferior vena cava (IVC) penetration, peripheral organ damage, or IVC stenosis/occlusion, were observed (P>0.05). The Octoparms filter exhibited a high rate of clinical success and a low rate of complications during placement and retrieval, demonstrating noninferiority to the Celect filter.