Postbiopsy splenic bleeding in a dog model: comparison of cauterization, embolization, and plugging of the needle tract

Feasibility and safety of bipolar radiofrequency track cautery during percutaneous image-guided abdominal biopsy procedures

PURPOSE

The purpose of this study was to assess the feasibility and safety of using a bipolar radiofrequency track cautery device during percutaneous image-guided abdominal biopsy procedures in at-risk patients.

METHODS

Forty-two patients (26-79 years old; female 44%) with at least one bleeding risk factor who underwent an abdominal image-guided (CT or US) biopsy and intended bipolar radiofrequency track cautery (BRTC) were retrospectively studied. An 18G radiofrequency electrode was inserted through a 17G biopsy introducer needle immediately following coaxial 18G core biopsy, to cauterize the biopsy track using temperature control. Bleeding risk factors, technical success, and adverse events were recorded.

RESULTS

BRTC was technically successful in 41/42 (98%) of procedures; in one patient, the introducer needle retracted from the liver due to respiratory motion prior to BRTC. BRTC following percutaneous biopsy was applied during 41 abdominal biopsy procedures (renal mass = 12, renal parenchyma = 10, liver mass = 9, liver parenchyma = 5, splenic mass or parenchyma = 4, gastrohepatic mass = 1). All patients had one or more of the following risk factors: high-risk organ (spleen or renal parenchyma), hypervascular mass, elevated prothrombin time, renal insufficiency, thrombocytopenia, recent anticoagulation or anticoagulation not withheld for recommended interval, cirrhosis, intraprocedural hypertension, brisk back bleeding observed from the introducer needle, or subcapsular tumor location. No severe adverse events (grade 3 or higher) occurred. Two (2/41, 5%) mild (grade 1) bleeding events did not cause symptoms or require intervention.

CONCLUSION

Bipolar radiofrequency track cautery was feasible and safe during percutaneous image-guided abdominal biopsy procedures. IRB approval: MBG 2022P002277.

Transsplenic tract closure after transsplenic portalvenous access using gelfoam-based tract plugging

BACKGROUND

To assess the feasibility and safety of a gelfoam torpedo plugging technique for embolization of the transsplenic access channel in adult patients following transvenous portal vein interventions.

MATERIALS AND METHODS

Between 09/2016 and 08/2021, an ultrasound guided transsplenic portalvenous access (TSPVA) was established in twenty-four adult patients with a 21-G needle and 4-F microsheath under ultrasound guidance. Afterwards, sheaths ranging from 4-F to 8-F were inserted as needed for the procedure. Following portal vein intervention, the splenic access tract was embolized with a gelfoam-based tract plugging (GFTP) technique. TSPVA and GFTP were performed twice in two patients. Patients' pre-interventional and procedural characteristics were analyzed to assess the feasibility and safety of the plugging technique according Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system. Values are given as median (minimum;maximum). Subgroup analysis of intercostal vs. subcostal puncture site for TSPVA was performed using the two-sided Mann-Whitney-U test or Student's t-test and Fisher's exact test. Level of significance was p < 0.05.

RESULTS

The study population's age was 56 (29;71) years and 54% were female patients. Primary liver disease was predominantly liver cirrhosis with 62% of the patients. Pre-interventional model for end-stage liver disease score was 9 (6;25), international normalized ratio was 1.15 (0.86;1.51), activated partial thromboplastin time was 33s (26s;52s) and platelet count was 88.000/µL (31.000;273.000/µL). Ascites was present in 76% of the cases. Craniocaudal spleen diameter was 17cm (10cm;25cm). Indication for TSPVA was assisted transjugular intrahepatic portosystemic shunt placement in 16 cases and revision in two cases, portal vein stent placement in five cases and variceal embolization in three cases. TSPVA was successfully established in all interventions; interventional success rate was 85% (22/26). The splenic access time was 33min (10min;133min) and the total procedure time was 208min (110min;429min). Splenic access was performed with a subcostal route in 11 interventions and with an intercostal route in 15 interventions. Final sheath size was 4-F in 17 cases, 5-F in three cases, 6-F in five cases, 7-F in two cases and 8-F in one case. A median of two gelfoam cubes was used for GFTP. TSPVA- and GFTP-related complications occurred in 4 of 26 interventions (15%) with a subcapsular hematoma of the spleen in two patients (CIRSE grade 1), access-related infection in one patient (CIRSE grade 3) and both in one patient (CIRSE grade 3). In detail, one access-related complication occurred in a patient with subcostal TSPVA (CIRSE grade 1 complication) and the other three complications occurred in patients with intercostal TSPVA (one CIRSE grade 1 complication and two CIRSE grade 3 complication) (p = 0.614). No patient required interventional or surgical treatment due to puncture tract bleeding.

CONCLUSION

Gelfoam-based plugging of the puncture tract was feasible and safe for transsplenic access in adult patients undergoing percutaneous portal vein interventions. The lack of major bleeding complications and complete absorption of the gelatine sponge make it a safe alternative to transjugular and transhepatic access and re-interventions via the splenic route.

Embolization of the Transhepatic Tract after Percutaneous Portal Vein Interventions: Single-Centre Retrospective Study Comparing n-butyl Cyanoacrylate Versus Coils

PURPOSE

The aim of this study was to compare the safety and efficacy of transhepatic puncture tract embolization with n-butyl cyanoacrylate (n-BCA) versus coils after percutaneous transhepatic portal vein interventions in patients with hepatocellular carcinoma (HCC). It was also the aim of the study to evaluate the extent of artifacts in CT exams during FU.

METHODS

Single-center retrospective study from 2017-2019 in 190 patients who underwent percutaneous transhepatic portal vein interventions. The transhepatic puncture tracts were embolized with n-BCA in 88 patients (Group A) and with coils in 102 patients (Group B). Procedure-related complications and image noise around coils and n-BCA were compared between the groups. No significant differences were noted at baseline between both groups (platelets, coagulation, liver disease, types of procedures, liver function, liver tumors).

RESULTS

All patients underwent transhepatic puncture tract embolization. Procedure-related complications were only observed in patients from Group B: subcapsular hemorrhage (n = 2; 1.96%), hepatic artery hemorrhage (n = 1; 0.98%), and pseudoaneurysms combined with hemobilia occurred (n = 1; 0.98%). In Group A, the distal part of the punctured portal vein branch was embolized with n-BCA in 1 patient (1.14%). Four major complications in Group B Vs 0 in Group A were observed, respectively (p < 0.0001). The image noise around n-BCA was significantly lower than that around coils (10.7 ± 1.7 HU vs. 54.3 ± 15.0 HU, p < .001).

CONCLUSIONS

n-BCA tract embolization is more effective than using coils, with fewer bleeding events, at the cost of a higher potential for unintended embolization of portal vein branches.

Laser-heated needle for biopsy tract ablation: In vivo study of rabbit liver biopsy

PURPOSE

To investigate the efficacy of a newly-developed laser-heated core biopsy needle in the thermal ablation of biopsy tract to reduce hemorrhage after biopsy using in vivo rabbit's liver model.

MATERIALS AND METHODS

Five male New Zealand White rabbits weighed between 1.5 and 4.0 kg were anesthetized and their livers were exposed. 18 liver biopsies were performed under control group (without tract ablation, n = 9) and study group (with tract ablation, n = 9) settings. The needle insertion depth (~3 cm) and rate of retraction (~3 mm/s) were fixed in all the experiments. For tract ablation, three different needle temperatures (100, 120 and 150 °C) were compared. The blood loss at each biopsy site was measured by weighing the gauze pads before and after blood absorption. The rabbits were euthanized immediately and the liver specimens were stained with hematoxylin-eosin (H&E) for further histopathological examination (HPE).

RESULTS

The average blood loss in the study group was reduced significantly (p < 0.05) compared to the control group. The highest percentage of bleeding reduction was observed at the needle temperature of 150 °C (93.8%), followed by 120 °C (85.8%) and 100 °C (84.2%). The HPE results show that the laser-heated core biopsy needle was able to cause lateral coagulative necrosis up to 14 mm diameter along the ablation tract.

CONCLUSION

The laser-heated core biopsy needle reduced hemorrhage up to 93.8% and induced homogenous coagulative necrosis along the ablation tract in the rabbits' livers. This could potentially reduce the risk of tumor seeding in clinical settings.

Safety and efficacy of percutaneous microwave ablation for post-procedural haemostasis: a bi-central retrospective study focusing on safety and efficacy

OBJECTIVE

To review safety and efficacy of percutaneous microwave ablation (MWA) for post-procedural haemostasis.

METHODS

Institutional databases retrospective research identified 10 cases of iatrogenic bleeding who underwent percutaneous MWA for post-procedural haemostasis. Ultrasound examination with Doppler and contrast enhancement identified a source of active bleeding prior to ablation; additionally they were used as guiding modality for antenna insertion whilst, post-ablation, assessed the lack of active extravasation. Target locations included liver intercostal space spleen and thyroid gland. Technical success was defined as positioning of the antenna on the desired location. Treatment end point was considered the disappearance of active extravasation in both Doppler imaging and contrast-enhanced ultrasound.

RESULTS

Technical success (i.e. positioning of the antenna on the desired location) was achieved in all cases. No complications were noted. All patients post MWA remained haemodynamically stable with no need for transfusion and were discharged from the hospital the next morning. Imaging and clinical follow-up in all patients before exiting the hospital did not depict any sign of active extravasation or bleeding.

CONCLUSION

Our limited experience reports preliminary data showing that MWA could be added in the armamentarium of percutaneous therapies for iatrogenic bleeding. More prospective studies with larger patient samples are necessary for verification of this technique as well as for drawing broader conclusions in order to evaluate the place of percutaneous ablation in the treatment algorithm of haemorrhage.

ADVANCES IN KNOWLEDGE

Percutaneous ablation might have a role in haemostasis in well-selected cases.

Successful Living-Donor Liver Transplantation With Intraoperative Endovascular Recanalization via Transsplenic Access in a Recipient With Grade III Portal Vein Thrombosis: A Case Report

Extensive portosplenomesenteric thrombosis is regarded as a relative contraindication to liver transplantation because of the complexity of the surgical procedure. This report describes a case of living-donor liver transplantation (LDLT) for a patient with extensive portosplenomesenteric thrombosis, in whom portal flow was successfully restored by intraoperative transplenic portal vein and superior mesenteric vein stenting after surgical thrombectomy. The patient's liver function remained normal with a patent portal vein stent 6 months after LDLT, and Doppler ultrasonography demonstrated a normal wave form for portal flow. To the best of our knowledge, this is the world's first case of endovascular management of the portal vein via percutaneous transsplenic access during LDLT, demonstrating that transsplenic access can be an alternative approach without liver graft injury when the superior mesenteric vein branch and inferior mesenteric vein cannot be used as access routes.

New Radiofrequency Device to Reduce Bleeding after Core Needle Biopsy: Experimental Study in a Porcine Liver Model

OBJECTIVE

To evaluate the in vivo efficiency of the biopsy tract radiofrequency ablation for hemostasis after core biopsy of the liver in a porcine liver model, including situations with bleeding tendency and a larger (16-gauge) core needle.

MATERIALS AND METHODS

A preliminary study was performed using one pig to determine optimal ablation parameters. For the main experiment, four pigs were assigned to different groups according to heparinization use and biopsy needle caliber. In each pig, 14 control (without tract ablation) and 14 experimental (tract ablation) ultrasound-guided core biopsies were performed using either an 18- or 16-gauge needle. Post-biopsy bleeding amounts were measured by soaking up the blood for five minutes. The results were compared using the Mann-Whitney U test.

RESULTS

The optimal parameters for biopsy tract ablation were determined as a 2-cm active tip electrode set at 40-watt with a tip temperature of 70-80℃. The bleeding amounts in all experimental groups were smaller than those in the controls; however they were significant in the non-heparinized pig biopsied with an 18-gauge needle and in two heparinized pigs (p < 0.001). In the heparinized pigs, the mean blood loss in the experimental group was 3.5% and 13.5% of the controls biopsied with an 18- and 16-gauge needle, respectively.

CONCLUSION

Radiofrequency ablation of hepatic core biopsy tract ablation may reduce post-biopsy bleeding even under bleeding tendency and using a larger core needle, according to the result from in vivo porcine model experiments.

Diagnosis and management of hemorrhagic complications of interventional radiology procedures

Image-guided interventions have allowed for minimally invasive treatment of many common diseases, obviating the need for open surgery. While percutaneous interventions usually represent a safer approach than traditional surgical alternatives, complications do arise nonetheless. Inadvertent injury to blood vessels represents one of the most common types of complications, and its affect can range from inconsequential to catastrophic. The interventional radiologist must be prepared to manage hemorrhagic risks from percutaneous interventions. This manuscript discusses this type of iatrogenic injury, as well as preventative measures and treatments for postintervention bleeding.

Portal vein recanalization and embolization of the transsplenic puncture tract using an Amplatzer® vascular plug: a case report

BACKGROUND

A transsplenic access for the catheterization of the portal venous system to treat a portal vein thrombosis and/or stenosis entails the risk of intra-abdominal or intrasplenic bleeding complications and has to be seen as an approach of last resort. This is one of few reported cases in the literature where a transsplenic puncture tract was successfully embolized using an Amplatzer® vascular plug 4 (8 mm; St. Jude Medical).

CASE PRESENTATION

This is the case report of a 58 years old Caucasian male patient who had received right sided extended hemihepatectomy with partial resection of the portal vein due to hilar cholangiocarcinoma three years ago. The patient suffered from portal hypertension with difficult controllable bleeding of esophageal varices due to chronically progressive thrombosis of the portal vein caused by chronic anastomosis stenosis of the reconstructed left portal vein branch (confirmed in a Magnetic Resonance Imaging (MRI) examination 6 months after the portal vein reconstruction). A transsplenic access (6 French) was chosen to allow recanalization of the portal vein, stent-angioplasty of the anastomosis and coiling of the gastric varices. The transsplenic tract was successfully embolized with an Amplatzer® Vascular Plug 4 and gelfoam pledgets.

CONCLUSION

Amplatzer® Vascular plugs in combination with gelatin sponges can be used to efficiently and precisely seal transsplenic puncture sites.

Contrast-enhanced sonographically guided thermal ablation for treatment of solid-organ hemorrhage: preliminary clinical results

The purpose of this series was to preliminarily evaluate the use of contrast-enhanced sonographically guided percutaneous thermal ablation in the evaluation and treatment of solid-organ bleeding by retrospectively analyzing 6 cases observed in clinical practice. Six patients who underwent contrast-enhanced sonographically guided thermal ablation for treatment of solid-organ bleeding (5 in liver and 1 in spleen) from December 2005 to August 2012 were included in this series. Clinical information, contrast-enhanced sonograms before and after ablation, and the ablation method were retrospectively collected and analyzed. In 5 of the 6 patients, the location of the bleeding lesion was clearly seen. Hemostasis was successfully achieved in 4 of these 5 patients: 1 by radiofrequency ablation and 3 by microwave ablation. Ablation failed to achieve hemostasis in 1 patient who had postbiopsy splenic arterial bleeding because the bleeding vessel was a thick branch of the splenic artery. In the sixth remaining patient, who had bleeding after liver biopsy, hemostasis failed because contrast-enhanced sonography did not precisely locate the bleeding lesion; hence, the ablation zone did not cover the whole lesion. Contrast-enhanced sonographically guided ablation can be an alternative choice for treating solid-organ bleeding because of its effectiveness and minimal invasiveness. However, it should be carefully investigated for those in whom the bleeding lesion cannot be located by contrast-enhanced sonography and in those who have bleeding in a large vessel.

Clinical application of partial splenic embolization

Partial splenic embolization (PSE) is one of the intra-arterial therapeutic approaches of diseases. With the development of interventional radiology, the applications of PSE in clinical practice are greatly extended, while various materials are developed for embolization use. Common indications of PSE include hypersplenism with portal hypertension, hereditary spherocytosis, thalassemia, autoimmune hemolytic anemia, splenic trauma, idiopathic thrombocytopenic purpura, splenic hemangioma, and liver cancer. It is also performed to exclude splenic artery aneurysms from the parent vessel lumen and prevent aneurysm rupture, to treat splenic artery steal syndrome and improve liver perfusion in liver transplant recipients, and to administer targeted treatment to areas of neoplastic disease in the splenic parenchyma. Indicators of the therapeutic effect evaluation of PSE comprise blood routine test, changes in hemodynamics and in splenic volume. Major complications of PSE include the pulmonary complications, severe infection, damages of renal and liver function, and portal vein thrombosis. The limitations of PSE exist mainly in the difficulties in selecting the arteries to embolize and in evaluating the embolized volume.

Embolization of percutaneous transhepatic portal venous access tract with N-butyl cyanoacrylate

OBJECTIVE

To evaluate the safety and feasibility of N-butyl cyanoacrylate (N-BCA) embolization of percutaneous transhepatic portal venous access tract and to establish an appropriate technique.

METHODS

40 consecutive patients underwent percutaneous transhepatic portal venous intervention for various reasons. Embolization of percutaneous transhepatic portal venous access tract was performed after the procedure in all of the patients using N-BCA and Lipiodol® (Lipiodol Ultra Fluide; Laboratoire Guerbet, Aulnay-sous-Bois, France) mixture. Immediate ultrasonography and fluoroscopy were performed to evaluate perihepatic haematoma formation and unintended embolization of more than one segmental portal vein. Follow-up CT was performed, and haemoglobin and haematocrit levels were checked to evaluate the presence of bleeding.

RESULTS

Immediate haemostasis was achieved in all of the patients, without development of perihepatic haematoma or unintended embolization of more than one segmental portal vein. Complete embolization of percutaneous access tract was confirmed in 39 out of 40 patients by CT. Seven patients showed decreased haemoglobin and haematocrit levels. Other complications included mild pain at the site of embolization and mild fever, which resolved after conservative management. 16 patients died during the follow-up period owing to progression of the underlying disease.

CONCLUSION

Embolization of percutaneous transhepatic portal vein access tract with N-BCA is feasible and technically safe. With the appropriate technique, N-BCA can be safely used as an alternate embolic material since it is easy to use and inexpensive compared with other embolic materials.

ADVANCES IN KNOWLEDGE

This is the first study to investigate the efficacy of N-BCA for percutaneous transhepatic portal venous access tract embolization.

Image-guided percutaneous splenic biopsy and drainage

Percutaneous splenic biopsy and drainage are relatively safe and accurate procedures. The risk of major complication (1.3%) following percutaneous splenic biopsy does not exceed that of other solid intra-abdominal organ biopsies, and it has less morbidity and mortality than splenectomy. Both computed tomography and ultrasound can be used to provide image guidance for biopsy and drainage. The safety profile of fine-needle aspiration cytology is better than core needle biopsy, but core biopsy has superior diagnostic accuracy.

Early posttransplantation portal vein stenosis following living donor liver transplantation: percutaneous transhepatic primary stent placement

Surgical treatments have usually been preferred for early posttransplantation portal inflow abnormalities. However, these treatments are limited due to their technical difficulty and multiple complicating factors. The present study reports the efficacy and safety of percutaneous transhepatic primary stent placement to treat early posttransplantation (<or=1 month) portal vein (PV) stenosis. A total of 9 patients who had undergone living donor liver transplantation underwent percutaneous stent placement to treat PV stenosis. The average interval between liver transplantation and stent placement was 13 +/- 10 days. Technical and clinical success was obtained in 7 (77.8%) of the 9 patients. Of the 7 patients with clinical success, 1 died of cerebral hemorrhage within 1 month following stent placement. The remaining 6 patients have remained healthy and without recurrence of PV stenosis until the time this manuscript was completed, and follow-up Doppler ultrasound (US) or computed tomography (CT) obtained 66.6 +/- 16.1 months after stent placement revealed patent portal inflow in all of these 6 patients. Major complications occurred in 3 patients, i.e., 2 cases of hemoperitoneum caused by blood oozing from a transhepatic tract of the liver grafts and 1 case of intrahepatic pseudoaneurysm. These complications were successfully treated using surgical ligation (n = 2) or transarterial coil embolization (n = 1). In conclusion, although we did experience some procedural complications, the percutaneous transhepatic primary stent placements in our study showed acceptable technical and clinical results for treating early posttransplantation PV stenosis. In addition, long-term PV patency following stent placement was excellent. However, additional experience and further studies will be needed to verify the usefulness of primary stent placement in the early posttransplantation period.

Prophylactic Gelatin Sponge Tract Injection to Prevent Bleeding after Percutaneous Renal Cryoablation in a Swine Model

PURPOSE

Achievement of hemostasis can be a challenge during percutaneous renal cryoablation (PRC). This study describes the use of a porcine model to test the ability of gelatin sponge injection into the tract to limit bleeding at the site of cryoprobe puncture.

MATERIALS AND METHODS

A total of nine swine (18 kidneys) underwent bilateral ultrasound-guided PRC with double freeze/thaw cycle protocol with use of a 2.4-mm cryoprobe. The cryoablation location and protocol were applied identically to both kidneys in each pig; however, only one side received gelatin sponge injection after cryoablation through a coaxial sheath (3 mm). After removal of the sheath, a midline laparotomy incision was performed and sponges were placed around the kidneys. Blood loss was measured by calculating the change in weight of the sponges after 30 minutes of absorption time. Acute blood loss was compared between the two groups. The kidneys treated with gelatin sponge were removed and grossly and histologically examined to identify the gelatin sponge at the puncture cryolesion.

RESULTS

The use of gelatin sponge resulted in significantly less blood loss (mean, 8.24 mg +/- 4.68) compared with the control kidneys (mean, 20.24 mg +/- 8.14; P = .001). Gross and histopathologic results confirmed that the gelatin sponge was in the cryoablation puncture sites. Mean diameters of cryoablation ice balls on the gelatin sponge and control sides were 3.9 cm +/- 0.2 and 3.8 cm +/- 0.4, respectively. The lesions were not significantly different between sides.

CONCLUSION

Percutaneous tract injection of gelatin sponge appears promising as a method to decrease acute blood loss from PRC.