Abdominal Intervention

PURPOSE: To investigate the role of endovascular stents in the treatment of traumatic jugular vein occlusions and intracranial hypertension.

CONCLUSION This technique for treatment of obstruction of the nasolacrimal system is simple and safe, and may obviate the use of more invasive procedure.

MATERIALS AND METHODS: Over a 15 month period, five patients were diagnosed with acute post-traumatic bilateral (n = 3) and unilateral (n = 2) jugular vein occlusions. Four patients had sustained blunt head injury and one had been strangled. All injuries were diagnosed on carotid arteriography. The indication for jugular vein stenting was refractory intracranial hypertension. Follow-up imaging was obtained on two patients with a mean interval of 4.5 months (range: 1-8 months). Patients were maintained on heparin and converted to coumadin.

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RESULTS: Jugular vein occlusions were successfully stented in four of five (80%) patients. After stent deployment, intracranial pressure decreased an average of 9.5 mmHg (range: 0-28). Both patients with follow-up imaging have widely patent stents. One patient is neurologically normal. One patient remains hemiparetic secondary to an unassociated stroke. Two patients died within one week of traumatic brain injury. CONCLUSIONS: Endoluminal stents can effectively relieve jugular vein occlusions. Improved venous outflow after stenting may help relieve intracranial hypertension.

9:00 am Nonsurgical Placement of Nasolacrimal Stents: Our Experience Juan Maria Pulido-Duque, MD, Las Palmas, Canary Islands, Spain. Maria Dolores Pardo, MD. Elias G6m:::, MD. Ricardo Reyes, PhD. Jose Martin Carreira, PhD. Manuel Maynar, PhD PURPOSE: To present our experience in the treatment of nasolacrimal occlusion inserting polyurethane stents. MATERIALS AND METHODS: Ninety three polyurethane stents were placed under fluoroscopic guidance in 79 consecutive patients with epiphora due to total or partial obstructions of the nasolacrimal system. The set designed by Song was used in all patients. The procedure was performed introducing a guide-wire through the superior punctum into the canaliculus and advancing it acroSE the obstructions into the inferior meatus of the nasal cavity. After pulling out the guidewire, the stent is advanced retrograde and released into the sac and the lacrimonasal duct. The average time of the procedure was 20 minutes (range 6-90). RESULTS: The technical success rate was 100%. Complete resolution of epiphora was accomplished in 83 eyes and partial resolution in 8, two patients did not improve. No major complications ocurred. After a mean of 180 days follow-up 75 out 93 stents were patent (80%) in the control dacryocystography.

Percutaneous Vertebroplasty for Spine Stabilization and Pain Control John Dean Barr, MD, Hershey, PA. Michelle Sniveley Barr, MD. ThomasJames Lemley, PA-C. Richard Michael McCann, R1R(CV) PURPOSE: Pain relief and spinal stabilization were assessed following treatment of vertebral compression fractures by percutaneous vertebroplasty (PV). MATERIALS AND METHODS: 35 vertebrae in 21 patients were treated. 16 patients with 28 vertebrae had symptomatic, osteoporotic fractures and had failed medical therapy. 5 patients with 7 vertebrae had metastatic disease. Prevention of vertebral collapse with spinal cord or nerve injury was desired and these patients were poor surgical candidates. Using CT and fluoroscopic gUidance, 11-15 gauge needles were advanced into the vertebrae using transpedicular approaches. Polymethylmethacrylate cement mixed with barium sulfate and tungsten powder to increase radiopacity was injected into the vertebrae. RESULTS: Among the 16 patients treated for osteoporotic fractures, 8 had complete or marked pain relief, 6 moderate relief and 2 no significant change. Only one of the 5 patients with malignancies had significant pain relief. No further vertebral compression occurred in these patients and spinal canal compromise was prevented in 4 patients. One patient required open resection for an aggressive tumor. One patient developed a transient radicular neuritis. No other complications occurred. CONCLUSIONS: PV proVided significant pain relief in a high percentage of patients with osteoporotic fractures. PV produced spinal stabilization in patients with malignancies, but rarely proVided significant pain relief.

Thursday, March 5, 1998 1:00 pm-2:30 pm Scientific Session 28 Hepatobiliary/Abdominal Intervention Moderator: David J. Eschelman, MD

1:00 pm The Biliary Manometric Perfusion Test-Long Term Predictive Value of Success After Treatment of Benign Bile Duct Injuries: 10 Year Experience Scott Jeffrey Savader, MD, Baltimore, MD. Gunnar Bendix Lund, MD. Anthony Charles Venbrux, MD. Carol Angela Prescott, RN. Sally Elizabeth Mitchell, MD

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PURPOSE: To evaluate the predictive value of the biliary manometric perfusion test (BMPT) and clinical trial (CTr) for determining patency after treatment of benign bile duct strictures. MATERIALS AND METHODS: 118 patients were treated surgically (n = 70) or percutaneously (n = 48) followed by biliary intubation. Prior to removal of biliary stents, a BMPT (n = 196) or CTr (n = 114) was performed to evaluate the treated site for long-term patency. Clinical outcomes were followed. Sensitivities and specificities for both tests were determined and Kaplan-Meier Survival Curves (KMSC) were generated. RESULTS: For identifying a clinically significant (recurrent) stricture, the sensitivity and specificity of the BMPT at 0, 2, 4, and 6 years was 0.67, 0.93; 0.50, 0.89; 0, 0.94; and 0, 1.0, respectively. For the CTr, the sensitivity and specificity (same intervals) was 0.69, 1.0; 0, 1.0; 0, 1.0; and 0, 1.0; respectively. The probability of patency (KMSC) after passing the BMPT and CTr was 0.99, 0.96; 0.94,0.83; 0.80, 0.62; and 0.80,0.62, respectively (>0.10) at 0, 2, 4, and 6 years. CONCLUSION The BMPT and CTr allow for prediction of long-term biliary patency with considerable specificity. The KMSCs allows one to predict the probability of patency after passing one of these two tests out to at least six years of follow-up.

1:15 pm Percutaneous Drainage of Bilomas Paul Francis Balen, MD, San Diego, C4 _ Horacio B. D'Agostino, MD - Eric van Sonnenberg, MD _ Sean Murray, MD PURPOSE: To evaluate the results of percutaneous drainage of bilomas. METHODS: Thirty patients with bilomas underwent percutaneous drainage. Etiologies of bilomas included post operative (trauma n = 10, cholecystectomy n = 9, liver transplant n = 4, liver biopsy n = 2 and Kasai operation n = 1), embolization/infarct n = 3, and gall bladder perforation n = 1. There were extrahepatic n = 14 and intrahepatic n = 6 collections. Patients received antibiotics and catheter sinograms. Mean duration of catheterization (MDC) was measured. Criterion for successful drainage was resolution of biloma.

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RESULTS: 29/30 patients had a successful outcome. One patient with an ischemic biloma had persistent drainage until death. Overall MDC was 29 days. MDC by etiology was: post embolization 39 days, post traumatic 31 days, post liver transplant 31 days, post cholecystectomy 23 days and post liver biopsy 14 days. MDC related to communication with biliary tree during sinogram: present 40 days, and absent 15 days. MDC related to location: intrahepatic 40 days, and extrahepatic 15 days.

CONCLUSION Most biliary fluid collections resolve with percutaneous drainage. Ischemic and intrahepatic bilomas, and communication with the biliary tree during catheter sinogram are associated with prolonged catherization.

1:30 pm Transcatheter Ethanol Ablation of Fluid Collections: An In Vitro Study of the Effect of Ethanol on Catheter Materials Marsha Roberts, MD, San Diego, CA _ Horacio B. D'Agostino, MD _ Henry Hsue, MD _ Susan Delach, RT PURPOSE: The purpose of the study is to evaluate commercially available drainage catheters that may undergo weakening and breakage when used for ethanol sclerosis. MATERIALS AND METHODS: Twelve 8F locking pigtail drainage catheters were used in the study. The catheters were divided into two equal groups. The study group catheters were immersed in 100% ethanol for four 30 minute sessions. Control group catheters were immersed in normal saline solution. At the end of each immersion session, static force (1000 grams) was applied to each catheter for 15 minutes. Gross changes in the materials were recorded. RESULTS: Ethanol caused deleterious effects in four different catheters: Flexima Firm (Meditech) and General Purpose (Manan) drainage catheters broke within the pigtail after the initial 30 minutes immersion in ethanol; cracks in the hub of the catheter occurred in the Optidrain (Navarre) and Dawson-Mueller (Cook Inc.) drainage catheters after 1 hour of ethanol immersion. No changes were noted in the General Purpose (Uresil) or Percuflex (Meditech) drainage catheters. CONCLUSION: Ethanol caused material breakdown on four commercially available drainage catheters "in vitro." These data may be useful when selecting drainage catheters for ethanol ablation in the clinical setting.

1:45 pm Transvenous liver Biopsy: Comparison of Tissue Sample Adequacy Using Two Automated Core Biopsy Sets Mark William Mewissen, MD, Milwaukee, WIWilliam Richard Crain, MD - William Samuel Rilling, MD

PURPOSE To determine tissue sample adequacy following transvenous liver biopsy using 18 Gauge (l8G) or 19 Gauge (l9G) automated core biopsy needles (Quickcore, Cook). MATERIALS AND METHODS: From May 1995 to March 1997, 44 transjugular liver biopsies were performed on 41 patients with ascites and/or severe coagulopathy, prospectively alternating between 18G (n = 22) or 19G (n = 22) needles. Tissue sample adequacy was determined by an independent pathologist, blinded to the

technique of obtaining the biopsy core specimen. Pathology results were then reviewed and compared for the 2 techniques used.

Stephen T. Kee, MD, Palo Alto, CA. Gillian McFarlane, RN. Mahmood K. Razavi, MD. Bruce Daniels, MD. Robert Herjkins • Michael D. Dake, MD

RESULTS: At least 3 liver biopsy cores were successfully obtained and submitted for analysis in all patients without complication, for a technical success rate of 100% Adequacy of tissue sample was reported for all biopsies, irrespective of the core biopsy needle used.

PURPOSE: To assess the capability of rapid acquisition of multiplanar images in performing interventional needle biopsies using a 0.5 Tesla open-configuration MRI.

CONCLUSION 18G and 19G automated core biopsy needles are equally safe and effective in obtaining adequate liver tissue in patients with contraindications to a conventional transperitoneal biopsy.

2:00 pm Percutaneous Abdominopelvic Interventional Procedures Utilizing CT Fluoroscopic Guidance Barry D. Daly, MD, Baltimore, MD. Thorsten 1. Krebs, MD. Jade j. Wong- YOU-Cheong, MD. Geoffrey S. Hastings, MD PURPOSE To assess the use of CT fluoroscopic guidance for percutaneous abdominopelvic biopsy and therapeutic procedures. MA Th1?1ALS AND METHODS: 114 percutaneous diagnostic and therapeutic procedures were performed in 105 patients: fluid aspiration/drainage catheter insertion (n = 59), biopsy (n = 42), hepatoma alcohol ablation (n = 5), chemoneurolysis (n = 4), gastrostomy or brachytherapy catheter insertion (n = 4). Guidance was performed by a helical CT scanner with near real-time reconstruction at 6 frames/second, (Xpress/SX, Toshiba, Tokyo, Japan). A control panel and video monitor beside the gantry allowed direct operator controL RESULTS: 108 (95%) procedures were successfully performed utilizing continuous CT fluoroscopy with standoff needle holders or conventional manual needlelcatheter insertion utilizing intermittent CT fluoroscopy to confirm position. Image quality using low rnA was adequate for needle/tube placement in all but 3 low contrast liver lesions, Imaging of alcohol distribution during injection facilitated tumor ablation and neurolytic procedures. CT fluoroscopy allowed rapid assessment of needle and catheter placement, especially in non-axial planes, Average CT fluoroscopy time for biopsy and therapeutic procedures was 127 (range 37-336) and 186 (range 20-660) seconds respectively. CONCLUSION CT fluoroscopy is a practical clinical tool which facilitates rapid and effective performance of percutaneous abdominopelvic interventions,

2:15 pm Magnetic Resonance Guided Needle Biopsies Using Multi-Planar Spoiled Grass Rapid Imaging (MPSPGR)

METHODS: 45 patients (25 men, 20 women; mean age 56 years) underwent MR guided biopsy of mass lesions. Sites biopsied included liver (N = 27), retroperitoneum (N = 8), renal/adrenal (N = 4), bone (N = 3), and soft-tissue (N = 3), Lesion localization was performed using standard T1 and T2 sequences, biopsies using a MPSPGR sequence. (TE 2,1 ms, TR = 130 ms). A coaxial system with an 18 gauge nickel-titanium stabilizing needle and a 21 gauge aspiration needle was used to obtain the samples. A cyto-technologist was present to determine adequacy of sample, RESULTS: Average time to obtain a MPSPGR image was 10 seconds. Needle artifact was negligible. Diagnostic tissue was obtained in 33 of 45 patients (73%). There were no complications. CONCLUSION Image guided needle biopsy using an open-configuration 0.5 Tesla MRI is safe and accurate. MPSPGR sequences can be used to localize needle position rapidly and accurately, with little needle artifact.

Scientific Session 29 Embolotherapy Moderator: Anthony C. Venbrux, MD

1:00 pm Transcatheter Embolization of Upper Gastrointestinal Hemorrhage Diagnosed by Endoscopy Ravi Kodali, MD, Detroit, MI. Chandrasekar Venugopal, MD. P.e. Shetty, MD. Matthew Burke, MD • David Kastan, MD. Rajinder Sharma, MD PURPOSE To analyze outcomes of patients who underwent transcatheter embolization of upper gastrointestinal (UGI) hemorrhage diagnosed but unsuccessfully treated by endoscopy. To determine if transcatheter embolization should be aggressively pursued in patients without angiographic evidence of bleeding. MATERIALS AND METHODS: We retrospectively reviewed 111 cases of active UGI bleeding treated by transcatheter embolization. All had endoscopic evidence of active GI bleeding. Outcome analysis was performed by chart review to determine if the patient went home with no other therapy, required surgery for continued bleeding, or died from bleeding or multiorgan failure on this hospital admission,

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