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   Table of Contents - Current issue
January-June 2020
Volume 4 | Issue 1
Page Nos. 1-52

Online since Wednesday, January 22, 2020

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Current status of interventional radiology in Pakistan p. 1
Muhammad Azeemuddin
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The status of interventional radiology training: The Egyptian experience p. 3
Karim A Abd El Tawab, Sameh Mohamed Abdel Wahab
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Bariatric Arterial Embolization: Position Statement by the Pan Arab Interventional Radiology and the Saudi Interventional Radiology Societies Highly accessed article p. 4
Mohammad Arabi, Karim A Abd El Tawab, Mohammad Almoaiqe, Abbas Chamsuddin, Majed Ashour, Andrew J Gunn, Ali Alzahrani
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Postthrombectomy cerebral hyperdensity: Usefulness as a predictor of future hemorrhage or infarction p. 11
Amgad Moussa, Ahmed El Serwi, Mohamed Amir Tork
Aim: This study aims to examine the association between the presence of postinterventional cerebral hyperdensities (PCHD) and the occurrence of hemorrhagic transformation. Materials and Methods: We retrospectively analyzed the data of 33 patients who underwent successful mechanical thrombectomy for emergent large vessel occlusion of the anterior circulation and received two computed tomography (CT) scans of the brain; the first (CT1) within 4.5 h from the procedure and the second (CT2) within 4 days from the procedure. In patients who showed PCHD on CT1, CT2 was checked to detect hemorrhage or infarction in the location of the noted PCHD. Statistical analysis was done through the Fisher's exact test to detect the association between PCHD and hemorrhagic transformation. Results: 28 of the 33 patients (84.8%) showed PCHD on CT1. 20 of the 28 patients (71.4%) showed infarction on CT2, while 8 patients (28.6%) showed hemorrhage. The 5 patients that did not show PCHD on CT1 all showed infarction on CT2. Analysis of our results revealed that although cases with hemorrhage had more frequent positive contrast compared to infarction, this difference did not reach a statistically significant level (P = 0.302). Conclusion: We concluded that the presence of PCHD may be associated with future risk of hemorrhagic transformation, but this association did not reach statistical significance. Further studies are needed to validate these results, which may affect the use of antiplatelets in the immediate postthrombectomy period in the presence of PCHD.
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Incidence of distal embolization during peripheral intervention using the NAV-6 embolic protection system p. 16
Timothy C Huber, Younes Jahangiri Noudeh, John F Angle, Daniel Sheeran, Megan Tracci, Luke Wilkins
Purpose: To compare the rates of embolic debris (ED) generation during lower extremity arterial interventions and evaluate the safety and efficacy of the using an embolic protection device (EPD). Methods: This was a single-center retrospective review of 111 patients (114 vessels) having undergone peripheral arterial intervention with the use of an EPD (Emboshield NAV-6 device). A database was created through review of the electronic health record and images in PACS. The presence of ED was determined through visual inspection after retrieval of the device or from filling defects identified during digital subtraction angiography with the device deployed. Descriptive statistics were used to report the demographic and clinical information. Relative frequencies of debris generation were determined for vessel type, trans-atlantic inter-society consensus (TASC) classification, and type of intervention. Differences in frequencies between groups weer evaluated with the Chi-square test, and associations were examined using the logistic regression analysis. Results: Of the 114 vessels treated, 16 (14%) demonstrated true distal embolization (DE) past the filter basket and 58 (51%) demonstrated generation of ED as determined by filling of the filter basket. This was significantly higher in patients undergoing atherectomy (70%) compared with those undergoing thrombolysis (38%) or angioplasty with or without stenting (29%) (P < 0.001). Of those patients undergoing atherectomy, laser atherectomy had the lowest rate of DE (26%) compared with either orbital (67%) or directional atherectomy (57%) (P < 0.05). In regression analysis, atherectomy was the only factor with significant association with detection of ED (odds ratio: 4.52, P < 0.0001). There was no statistically significant difference in the frequency of debris generated based on vessel type or TASC classification. Conclusion: The frequency of ED is higher in patients undergoing atherectomy versus patients undergoing lysis or percutaneous transluminal balloon angioplasty with or without stenting. Laser atherectomy has a lower frequency of debris generation when compared to either orbital or directional atherectomy.
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Continuous aspiration mechanical thrombectomy for treatment of thrombosed hemodialysis reliable outflow grafts p. 21
Osman Ahmed, Mohamad Omar Hadied, Sreekumar Madassery, Merve Ozen, Patrick Tran, Adolfo E Lizardo, Jordan C Tasse, Ulku Cenk Turba, Bulent Arslan
Aims: To determine the safety and feasibility of continuous aspiration mechanical thrombectomy (CAT) for restoring patency to thrombosed hemodialysis reliable outflow (HeRO) arteriovenous grafts. Subjects and Methods: Between December 2016 and August 2017, eleven consecutive patients (average age 63, range 39–80 years) with thrombosed HeRO grafts underwent percutaneous thrombectomy procedures (n = 21) using the Penumbra Indigo® CAT 8 or CAT D (Alameda, CA, USA) thrombectomy catheter as the primary device to clear the venous outflow tract before removing the arterial plug with a compliant balloon. A total of 21 hemodialysis declot procedures using CAT were documented and analyzed. Average procedure length and fluoroscopy time, length of thrombus cleared, blood loss, complications, and time between thrombectomy procedures were recorded and compared to the same patient's previous three thrombectomy procedures. Results: All procedures were technically successful (100%) at restoring graft patency; however, reocclusion within 5 days occurred in four (19.0%) cases. Three (14.3%) interventions required additional balloon maceration or sweep to clear the venous outflow following thrombectomy. Average thrombus length treated by suction thrombectomy measured 23.15 cm (range 2.2–65 cm). Average blood loss was 162.6 mL (range 50–250 mL). No procedure-related complications were recorded. The average procedure length and fluoroscopy time using suction thrombectomy was 74.7 and 14.2 min, respectively, compared with 82.0 and 14.0 min, respectively, in the previous thrombectomy procedures using standard methods (P > 0.05). Seventeen (81%) HeRO grafts treated by CAT presented with rethrombosis at a mean of 42.47 days (range 1–208 days, median 22 days, standard deviation [SD] 28.2 days) since CAT procedure compared to patients treated by conventional methods who presented for rethrombosis at a mean of 55.33 days (range 1–321 days, median 34 days, SD 43.1 days) since standard thrombectomy – no statically significant difference (P > 0.05). Conclusion: CAT is a safe and feasible method for removing thrombus and restoring patency to thrombosed HeRO grafts. Further studies are required to elucidate the advantages of CAT over standard thrombectomy techniques.
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New technique of embolization of the hemorrhoidal arteries using embolization particles alone: Retrospective results in 33patients p. 27
Karim A Abd El Tawab, Amr Muhammad Abdo Salem, Rana T. M Khafagy
Purpose: The purpose of this study was to assess the safety and efficacy of using particles only in the embolization of the hemorrhoidal arteries for the management of hemorrhoids. Subjects and Methods: This is a retrospective study for patients treated between March 2015 and December 2018. We treated 33patients, 13 men and 20 women with a mean age of 37years (range: 18–70years), in which 11patients had GradeII hemorrhoids and 22 had GradeIII hemorrhoids. Technical and clinical successes together with procedural complications were assessed. Results: The technical success rate was 100%. No minor or major complications have been reported. No cases of anorectal ischemia, anal incontinence, hemorrhoidal thrombosis, or complications related to femoral arterial puncture have occurred. Follow-up was at 3months and 12months postembolization. Clinical success was observed in 32patients(96.9%) with improvement by at least 2 points of the French bleeding score at 3months postembolization. Conclusion: The use of particles alone in the embolization of hemorrhoidal arteries whether from the superior rectal artery and/or from the middle and inferior rectal arteries can offer a safe and effective treatment option.
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Interventional radiology awareness among the final-year medical students in Riyadh p. 32
Abdullah Bader Abohimed, Yousof Al Zahrani, Mohammad Arabi
Objective: Interventional radiology(IR) is experiencing massive growth in the medical scene as new interventions are being introduced continuously to contribute to patient care. However, IR does not go without its fair share of challenges. Personnel shortages, turf wars, and a vague understanding of the role of IR in the hospital setting by medical students are a few. The latter could negatively impact the recruitment of young prospects and contribute to further personnel shortage. To combat this, we aimed to assess the final-year medical students' awareness of IR. Methods: This was a cross-sectional, self-administered questionnaire study. Our target population was all final-year medical students at university-based medical schools. Surveys were sent to 822 students, and a total of 719 final-year medical students responded(87.5%). The survey was distributed anonymously during November and December 2018. The survey consists of 21-closed and open-ended questions. Results: The vast majority of the respondents felt that their knowledge of IR was poor(83%), while a few reported that they had a good grasp of IR(16%). Half of the respondents believe that an Interventional Radiologist (IRs) must complete training in radiology. However, 42% thought that radiology and surgery was the correct route of training for IRs. Seventy-one percent and 73% of the final-year medical students correctly identified that IRs perform uterine artery embolization and lower limb angioplasty, respectively. Amajority(68%) of the respondents believe that IRs perform cardiac angioplasty and stenting, whereas 57% believe that they perform femoral-popliteal bypass. Conclusion: Our data suggest that knowledge, awareness, and exposure of the final-year medical students to IR are overwhelmingly poor in the region. This can be ameliorated through a number of means, such as directly involving IRs in the medical student curriculum, IR awareness campaigns, and IR symposiums.
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Portosystemic encephalopathy in a noncirrhotic patient treated by vascular plug embolization of mesoiliac shunt p. 38
Othman Alshehre, Faisal Alahmari, Sultan Alammari, Abdulaziz Almathami, Hatim Alobaidi, Ibrahim Alrashidi, Marwan Alosaimi, Fares Garad
Mesoiliac shunts in the absence of liver cirrhosis are rarely reported as a cause of hyperammonemia with encephalopathy. Here, we report the case of a 65-year-old female patient with no history of liver disease, who developed significant confusion. Workup showed hyperammonemia and encephalopathy due to spontaneous mesoiliac shunt with no imaging signs of portal hypertension. Liver biopsy showed no evidence of cirrhosis. The shunt was occluded using a vascular plug, resulting in complete resolution of symptoms with no recurrence at 8-year follow-up.
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Benign prostatic hyperplasia treated entirely by unilateral prostate artery embolization p. 40
Mohamed Shaker, Essam Hashem
Prostate artery embolization (PAE) is a minimally invasive, safe, and effective treatment for benign prostatic hyperplasia. PAE can often be technically challenging due to atherosclerosis and tortuous anatomy, leading to failure of catheterizing one side of prostatic supply, resulting in unilateral PAE, which markedly reduces clinical success. Major anastomosis between both prostatic halves can be exploited for embolizing the entire prostate from a unilateral approach when one side cannot be catheterized. If this anastomosis is extensive enough, clinical success is assumed to be equivalent to bilateral PAE. There is a limited number of published cases in this regard; our case report shows how to detect and exploit this anastomosis.
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Intracardiac migration following percutaneous computed tomography-guided fiducial marker implantation for pulmonary metastasis: A rare complication p. 44
Duaa Alhindi, Yousof AbdulRahman Al Zahrani, Azzam Khankan
A 41-year-old female with rectal cancer and lung metastasis underwent percutaneous transthoracic placement of fiducial marker. Postprocedure scan showed the migration of one of the fiducial markers to the left ventricle. Intracardiac fiducial marker migration is a rare complication but can happen, especially with centrally located lesions. Physicians and patients should be aware of this risk.
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Percutaneous endovascular retrieval of a dislodged left atrial appendage closure device from the juxtarenal aorta p. 47
Yousof Abdulrahman Al Zahrani, Mohammad Arabi, Abdul Aziz Al Harbi, Essam Al Dulaigan, Ali Al Ghamdi, Mohammed Al Moaiqel
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Inferior vena cava filter retrieval with rigid endobronchial forceps resulting in redeployment in the superior vena cava p. 49
Emilio Cazano, Andrew John Gunn
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Endovascular Aneurysm Repair without Procedural Sedation p. 51
Eric Mastrolonardo, Harout Dermendjian, John Do, Geogy Vatakencherry
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