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Purpose: To evaluate if implementation of the 2019 Society of Interventional Radiology (SIR) guidelines for periprocedural management of bleeding risk in patients undergoing percutaneous ultrasound guided liver biopsy is associated with increased haemorrhagic adverse events, change in pre-procedural blood product utilization, and evaluation of guideline compliance rate at a single academic institution. Methods: Ultrasound guided percutaneous liver biopsies from (January 2019-January 2023) were retrospectively reviewed (n = 504), comparing biopsies performed using the 2012 SIR pre-procedural coagulation guidelines (n = 266) to those after implementation of the 2019 SIR pre-procedural guidelines (n = 238). Demographic, preprocedural transfusion, laboratory, and clinical data were reviewed. Chart review was conducted to evaluate the incidence of major bleeding adverse events defined as those resulting in transfusion, embolization, surgery, or death. Results: Implementation of the 2019 SIR periprocedural guidelines resulted in reduced guideline non-compliance related to the administration of blood products, from 5.3% to 1.7% (P = .01). The rate of pre-procedural transfusion remained the same pre and post guidelines at 0.8%. There was no statistically significant change in the incidence of bleeding adverse events, 0.8% pre guidelines versus 0.4% post (P = 1.0). Conclusion: Implementation of the 2019 SIR guidelines for periprocedural management of bleeding risk in patients undergoing percutaneous ultrasound guided liver biopsy did not result in an increase in bleeding adverse events or pre-procedural transfusion rates. The guidelines can be safely implemented in clinical practice with no increase in major adverse events.
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PURPOSE: The Accelerated Diagnostic Assessment Program (ADAP) manages patients with imaging abnormalities, with or without concomitant symptoms, where cancer is suspected. The ADAP is offered to primary care practitioners and emergency departments with cases triaged by a medical oncologist. METHODS: We performed a retrospective patient chart review of electronic medical records from January 2019 until June 2021 to validate the program. We collected information on the referral pathways, patient demographics, wait-times, and diagnostic results. The control group consisted of outpatients who were referred for biopsy over a 1-year period outside the ADAP stream. Statistical analyses were performed using IBM SPSS software. RESULTS: Of the 97 patients included, 54% were female, with ages ranging from 18 to 96 years. Twenty-nine percent (n = 20) of the malignant cases were incidental findings. Most patients referred to the ADAP were diagnosed with a malignancy (71%; n = 69), comprising hematologic (45%; n = 31), GI (26%; n = 18), or other cancers (29%; n = 20). The ADAP had decreased wait-times from referral to biopsy collection (17.6 days ± 10.7 [standard deviation (SD)]; n = 43) when compared with the control group (41.2 days ± 40.0 [SD]; n = 67; P < .001). ADAP patients with malignancies saw a treating specialist 7.6 ± 7.6 days [SD] after their follow-up appointment at the ADAP. CONCLUSION: The ADAP accelerated time to biopsy in a statistically significant manner when compared with age-, referring physician-, and biopsy site-matched controls. It also outperformed national and provincial standards, suggesting that its model addresses a gap in care by providing an underserved population timely access to diagnosis and treatment.
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Diagnóstico por Imagen , Neoplasias , Humanos , Femenino , Adolescente , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Masculino , Estudios Retrospectivos , Neoplasias/diagnóstico , Neoplasias/epidemiología , Neoplasias/terapiaRESUMEN
BACKGROUND: Empyema is a common thoracic surgery presentation, defined as pus in the pleural space. Despite the commonality of empyema, consensus on initial management remains ambiguous. Two standard of care treatment options include inserting a chest tube (thoracostomy) and the administration of intrapleural fibrinolytics, or an initial surgical approach, surgical decortication. Due to the complexity of this pleural space infection, often repeat interventions are required after initial management in order to achieve source control and resolution of clinical symptoms. This study aims to identify the most effective initial management option for empyema. STUDY DESIGN: We present a study protocol for a randomized control trial (RCT) comparing adult individuals with empyema to one of two standard of care initial management options. Participants will be randomized into either interventional radiology guided chest tube insertion with intrapleural fibrinolytics (Dornase 5 mg and Alteplase 10 mg intrapleural twice daily for three days) or video-assisted thoracoscopic surgery (VATS) decortication. METHODS: All adults with empyema meeting inclusion criteria will be invited to participate. They will be randomized into one of two intervention groups; interventional radiology guided chest tube insertion with fibrinolytics or initial VATS decortication. Each intervention will take place within 48 hours of randomization. The primary outcome will be the rate of re-intervention within 30 days. Re-intervention is defined as repeat chest tube insertion, VATS decortication, or decortication via thoracotomy. Secondary outcomes include a change in the size of empyema, length of stay, morbidity, as well as 30-day and 90-day mortality, as well as quality of life measurements. ANTICIPATED IMPACT: This study is aimed at identifying the most effective initial management option for individuals with empyema.
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PURPOSE: To evaluate the feasibility and safety of a novel balloon-expandable, heparin-bonded endoprosthesis (Viabahn VBX, W. L. Gore and Associates) when used as a bridging stent graft (BSG) with fenestrated and branched endovascular aneurysm repair (FB-EVAR). FB-EVAR and BSGs increase repair complexity with the potential for endoleak formation, stenosis, thrombosis, and graft migration. The mechanical construction of the Viabahn VBX and its antithrombogenic properties may provide an advantage for FB-EVAR over existing BSGs. The efficacy, safety, and clinical outcomes were assessed. MATERIALS AND METHODS: Research ethics board approved, prospective, single arm cohort, pilot study of patients undergoing FB-EVAR between February 2017 and January 2018. Fenestrated and branched endovascular aneurysm repair was performed per the standard institutional protocol by a team composed of vascular surgeons and interventional radiologists. Viabahn VBX endografts were used for all intended visceral branches as long as appropriately sized devices were available (Under Investigational Testing Authorization from Health Canada). Patient characteristics, procedural details, and technical and clinical outcomes were reviewed and summarized. RESULTS: FB-EVAR was performed in 13 patients (9 male and 4 female) mean age of 74 (range: 61-83) with a total of 41 Viabahn VBXs stents implanted. Mean maximum aneurysm size was 6.7 cm (range: 5.5-9.0 cm) and included 5 juxtarenal abdominal aortic aneurysms and 8 thoracoabdominal; 3 type V, 3 type IV, and 2 type III (Crawford Classification). The Viabahn VBX was successfully deployed in 40 (98%) of 41 of cases. At median follow-up of 223 days (range: 2-462), there was a (40/40) 100% Viabahn VBX patency rate. Seven endoleaks were identified intra- or post procedurally in 6 (46%) of 13 cases, including 1 type IB, 3 type II, 2 type III, and 1 unclassified. Nine complications occurred in 6 patients. CONCLUSION: The Viabahn VBX stent is a safe and effective BSG for FB-EVAR with no early stent thrombosis. Further evaluation is required to determine longer term stent efficacy.
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Anticoagulantes/administración & dosificación , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Materiales Biocompatibles Revestidos , Procedimientos Endovasculares/instrumentación , Heparina/administración & dosificación , Stents , Anciano , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/fisiopatología , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Estudios de Factibilidad , Femenino , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Oclusión de Injerto Vascular/prevención & control , Heparina/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , Diseño de Prótesis , Factores de Riesgo , Trombosis/etiología , Trombosis/fisiopatología , Trombosis/prevención & control , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular/efectos de los fármacosRESUMEN
PURPOSE: Proximal type 1A endoleaks on completion intra-operative angiography are not infrequently seen following endovascular abdominal aneurysm repair (EVAR). The natural course of these leaks is not well established. We sought to determine the rate of spontaneous resolution and a conservative treatment approach to these endoleaks. METHODS: All cases involving endovascular repairs of infra-renal abdominal aortic aneurysms resulting in proximal type 1A endoleak on final intra-operative completion angiography were retrospectively reviewed from 1 April 2010 and 30 March 2015. Demographic, pre and post-procedural imaging, and clinical outcomes were reviewed. Summarizing descriptive statistics are reported. RESULTS: Of the 337 patients who underwent an EVAR, 24 patients (7.1%) had a proximal type 1A endoleak on final intra-operative angiography. Twenty-two of 24 patients (92%) with proximal type 1A endoleaks had spontaneous resolution on follow-up imaging without any intervention, while two (8%) patients had a persistent endoleak. One of these patients required intervention. The median follow-up for patients with resolved endoleaks was 2.5 years vs. 4 and 6 years, respectively, for patients that did not resolve spontaneously. CONCLUSION: A conservative approach may be used in the management of patients with proximal type 1A endoleaks on completion angiography once maximum proximal seal was achieved intra-operatively as the vast majority of these leaks spontaneously seal.
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Aneurisma de la Aorta Abdominal/cirugía , Aortografía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Tratamiento Conservador , Endofuga/diagnóstico por imagen , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Anciano de 80 o más Años , Angiografía de Substracción Digital , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aortografía/métodos , Angiografía por Tomografía Computarizada , Endofuga/etiología , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
PURPOSE: Placement of peritoneal ports has become a favorable technique for direct chemotherapy infusion in treating peritoneal metastases from ovarian cancer. We aim to outline an approach to the percutaneous insertion of peritoneal ports and to characterize success and complication rates compared to surgically inserted ports. MATERIALS AND METHODS: Retrospective analysis was collected from 87 patients who had peritoneal port insertion (28 inserted surgically and 59 percutaneously) for treatment of peritoneal metastases from ovarian cancer from July 2004 to July 2014. Complications were classified according to the SIR Clinical Practice Guidelines as major or minor. RESULTS: Technical success rates for surgically and percutaneously inserted ports were 100 and 96.7 %, respectively (p = 0.44), with the two percutaneous failures successful at a later date. There were no major complications in either group. Minor complication rates for surgically versus percutaneously inserted ports were 46.4 versus 22.0 %, respectively (p = 0.02). The infection rate for surgically inserted versus percutaneously inserted ports was 14.3 and 0 %, respectively (p = 0.002). The relative risk of developing a complication from percutaneous peritoneal port insertion without ascites was 3.4 (p = 0.04). For percutaneously inserted ports, the mean in-room procedure time was 81 ± 1.3 min and mean fluoroscopy time was 5.0 ± 4.5 min. CONCLUSION: Percutaneously inserted peritoneal ports are a safe alternative to surgically inserted ports, demonstrating similar technical success and lower complication rates.
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Neoplasias Ováricas/patología , Neoplasias Ováricas/cirugía , Neoplasias Peritoneales/secundario , Neoplasias Peritoneales/cirugía , Dispositivos de Acceso Vascular/estadística & datos numéricos , Femenino , Fluoroscopía/métodos , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Ováricas/tratamiento farmacológico , Cavidad Peritoneal/cirugía , Neoplasias Peritoneales/tratamiento farmacológico , Estudios Retrospectivos , Resultado del Tratamiento , Dispositivos de Acceso Vascular/efectos adversosRESUMEN
OBJECTIVE: Rectal cancers are the second most common GI carcinoma. Prognosis and therapeutic decisions hinge on the extent of disease. We present a comprehensive structured approach for staging rectal cancer using MRI to ensure the clear, concise, and standardized communication of disease extent to guide optimal treatment planning. CONCLUSION: MRI is crucial for local staging of rectal cancer. A standardized approach to reporting of rectal MRI focused on communication of essential treatment planning and prognostic indicators ensures maximal added value to referring physicians to guide appropriate management.
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Imagen por Resonancia Magnética , Neoplasias del Recto/patología , Humanos , Recto/patologíaRESUMEN
PURPOSE: To evaluate the feasibility of using micron-sized superparamagnetic iron oxide particles (MPIOs) as an effective labeling agent for monitoring bone marrow-derived mesenchymal stromal cell (BMSC) migration in the brain using magnetic resonance imaging (MRI) in a rat model of stroke and whether the accumulation of MPIO-labeled BMSCs can be differentiated from the accumulation of free MPIO particles or hemoglobin breakdown at a site of neuronal damage. MATERIALS AND METHODS: In this study BMSCs were labeled with iron oxide and their pattern of migration following intravenous injection in a rat stroke model was monitored using a clinical MRI system followed by standard histopathology. The migration pattern was compared between intravenous injection of BMSCs alone, BMSCs labeled with MPIOs, and MPIO particles alone. RESULTS: The results demonstrated that while MRI was highly sensitive in the detection of iron oxide particle-containing cells in areas of neuronal ischemia, the true origin of cells containing iron oxide particles remains ambiguous. Therefore, detection of iron particles may not be a suitable strategy for the detection of BMSCs in the brain in a stroke model. CONCLUSION: This study suggests that the use of MPIOs as labeling agents are insufficient to conclusively determine the localization of iron within cells in regions of neuronal ischemia and hemorrhage.
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Células de la Médula Ósea/patología , Rastreo Celular/métodos , Dextranos , Imagen por Resonancia Magnética/métodos , Nanopartículas de Magnetita , Trasplante de Células Madre Mesenquimatosas , Células Madre Mesenquimatosas/patología , Accidente Cerebrovascular/patología , Animales , Encéfalo/patología , Encéfalo/cirugía , Medios de Contraste , Dextranos/química , Nanopartículas de Magnetita/química , Masculino , Tamaño de la Partícula , Ratas , Ratas Long-Evans , Coloración y Etiquetado/métodos , Accidente Cerebrovascular/cirugíaRESUMEN
BACKGROUND AND PURPOSE: There is a high incidence of intracranial aneurysms of the AcomA suggesting the possibility of an anatomic risk factor. There also exists an association of termination-type aneurysms with anatomic variations of 1 anterior cerebral artery trunk (A1) as the exclusive or dominant supply to both pericallosal arteries (A2). This yields the hypotheses of aneurysm formation from straight jets of A1 blood. MATERIALS AND METHODS: The anatomy and contrast filling of A1 and A2 segments and AcomAs were studied for a subset of cases entered into the Cerecyte Coil Trial for patients with AcomA (n = 105) and other aneurysms (n = 123) that were selected from imaging available at the Cerecyte Core Trial angiographic Core Lab. These cases were analyzed for A1 vessel dominance by measurement of the vessel diameter and dilution of angiographic contrast agent in A2s due to the differential flow source on selective angiography. A control group without aneurysms was assessed anatomically, using a large sequential CTA series (n = 159), acquired during acute stroke assessment. RESULTS: A1 dominance configuration is strongly associated with the presence of AcomA aneurysms for patients with intracranial aneurysms (odds ratio, 17.8). This association is also present compared with the incidence of A1 dominance in the large sequential control series of patients without aneurysms undergoing CTA for other reasons (odds ratio, 7.5). Outflow dilution of selective angiographic images augments anatomic information. CONCLUSIONS: A flow-based assessment of contrast flowing from the A1 to the A2 segments after injection pressure is superior to an A1 diameter based categorization when A1 vessel diameters are not strikingly different. The anatomic variant of asymmetric A1 configurations likely facilitates the development of AcomA aneurysms by flow stresses, providing further evidence to support the role of biophysical factors in intracranial aneurysm development.
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Arteria Cerebral Anterior/diagnóstico por imagen , Angiografía Cerebral/métodos , Circulación Cerebrovascular/fisiología , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Arteria Cerebral Anterior/anomalías , Femenino , Humanos , Incidencia , Técnicas de Dilución del Indicador , Aneurisma Intracraneal/fisiopatología , Masculino , Persona de Mediana Edad , Modelos Cardiovasculares , Factores de RiesgoRESUMEN
BACKGROUND: Abnormal intercellular communication caused by connexin dysfunction may contribute to atrial fibrillation (AF). The present study assessed the effect of the gap junction conduction-enhancing antiarrhythmic peptide GAP-134 on AF inducibility and maintenance in a dog model of atrial cardiomyopathy. METHODS AND RESULTS: Twenty-four dogs subject to simultaneous atrioventricular pacing (220 bpm for 14 days) were randomly assigned to placebo treatment (PACED-CTRL; 12 dogs) or oral GAP-134 (2.9 mg/kg BID; PACED-GAP-134; 12 dogs) starting on day 0. UNPACED-CTRL (4 dogs) and UNPACED-GAP-134 (4 dogs) served as additional control groups. Change in left atrial (LA) systolic area from baseline to 14 days was calculated using transoesophageal echocardiography. At 14 days, animals underwent an open-chest electrophysiological study. PACED-CTRL dogs (versus UNPACED-CTRL) had a shorter estimated LA wavelength (8.0+/-1.4 versus 24.4+/-2.5 cm, P<0.05) and a greater AF vulnerability (mean AF duration, 1588+/-329 versus 25+/-34 seconds, P<0.05). Oral GAP-134 had no effect on AF vulnerability in UNPACED dogs. Compared with PACED-CTRL dogs, PACED-GAP-134 dogs had a longer estimated LA wavelength (10.2+/-2.8 versus 8.0+/-1.4 cm, respectively, P<0.05). Oral GAP-134 did not significantly reduce AF inducibility or maintenance in the entire group of 24 PACED dogs; in a subgroup of dogs (n=11) with less than 100% increase in LA systolic area, oral GAP-134 reduced AF induction from 100% to 40% and mean AF duration from 1737+/-120 to 615+/-280 seconds (P<0.05). CONCLUSIONS: Oral GAP-134 reduces pacing-induced decrease in LA wavelength and appears to attenuate AF vulnerability in dogs with less atrial mechanical remodeling. Gap junction modulation may affect AF in some circumstances.