Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study

Clinical question
Can cystic duct embolization followed by chemical gallbladder ablation provide an alternative to permanent external drainage for non-surgical patients with calculous cholecystitis?

Take-away point
In non-surgical patients with calculous cholecystitis treated with permanent external drainage, coil cystic duct embolization followed by chemical ablation with a sclerosing agent can facilitate eventual catheter removal.

Reference
Atar E, Khasminsky V, Friehmann T, Choen A, Bachar GN. Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study. J Vasc Interv Radiology. 2020; 31:644-648

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Study design
Single Arm, Prospective Cohort study

Funding
No reported Funding

Setting
Single Center, Academic Hospital. Rabin Medical Center, Tel Aviv University, Israel






Figure. An 80-year-old man with acute calculous cholecystitis who was ineligible for surgery because of severe comorbidities. (a) Cholangiography via the gallbladder drain demonstrates gallstones in the gallbladder but not in the common bile duct (arrow). (b) The cystic duct is blocked by means of Nester coils (arrow). (c) Gallbladder ablation is performed via the gallbladder drainage tube tract (arrow). (d) On fuoroscopy performed after 1 month, the gallbladder is still shrunken (arrow), and the drain is removed. (e) On ultrasound performed after 3 months, the gallbladder is shrunken and filled with stones (arrow).

Summary

Standard treatment for calculous cholecystitis is surgical cholecystectomy, however in elderly patients with high risk comorbidities there is increased morbidity and mortality after cholecystectomy. Percutaneous cholecystostomy provides a bridge or definitive therapy, however, eventual tube removal is associated with recurrent cholecystitis and prolonged percutaneous drainage requires follow-up maintenance procedures and is associated with decreased quality of life.

In this study, the authors demonstrate that following percutaneous cholecystostomy tube placement, cystic duct embolization followed by chemical gallbladder ablation is a viable alternative to definitive external drainage. 10 non-surgical patients were enrolled and underwent urgent cholecystostomy tube placement for acute cholecystitis. Nine (9) of the patients proceeded to have cholangiography via the external drain with any biliary duct stones successfully pushed into duodenum. A 10-Fr multipurpose drainage catheter was left in place, bridging the cystic duct to the duodenum to avoid future cannulation of cystic duct. After an asymptomatic interval period of 2-3 weeks, patients were considered for cystic duct coil embolization. A capped external drain was left in gallbladder with the option of drainage for symptomatic patients. After an additional asymptomatic interval of 3 weeks, cystic duct occlusion was confirmed with cholangiography followed by chemical gallbladder ablation with 3% aethoxysklerol. Interval sonography 3 weeks following this was performed to confirm gallbladder collapse (<25mm) and pericholecystic fluid absence. External drains were removed if asymptomatic. If gallbladder was >25mm, patient kept external drain for another 3 weeks with periodic sonography.

9 of 10 patients successfully proceeded with the full series of drainage, embolization, and ablation. After coil embolization, cholangiography on patient 1 demonstrated contrast spillage along the drain with transcolonic passage of contrast. This patient was initially planned for subsequent ablation, however the gallbladder remained non-dilated and the patient asymptomatic so no additional intervention was performed. Patient 2 experienced coil migration (4mm-5mm diameter) into the common bile duct. The coil was snared and replaced with a larger-caliber coil (8 mm). Patient 3 had undergone prior cystic duct embolization and gallbladder ablation, that resulted with subcutaneous leaks at previous the access site. Repeat cholangiography demonstrated intact cystic duct embolization and the patient requested repeat chemical ablation, which was successful. Patient 8 had continuous gallbladder secretions despite multiple ablations. A drain was left in place until secretions ceased and the drain was eventually removed. The patient was asymptomatic for 9 months.

Sonography was performed at 1 month after external drain removal for all patients. Patients were followed by their own surgeons or family physicians with return to Vascular Radiology only if needed. 3 of the 10 patients were reported as deceased during the follow up period due to unrelated causes with minimum follow up time of 7 months.

Commentary

Non-surgical patients with cholecystotomy tubes in place have decreased quality of life and require, at minimum, interval procedures for routine catheter maintenance. This paper introduces the concept of a “percutaneous cholecystectomy” via cystic duct embolization followed by chemical gallbladder ablation. None of the patients experienced short or long-term complications; however, several patients had persistent external bilious drainage up to 14 months after the procedure. So while technically feasible, the procedure requires further refinement and comparison to other methods of ablation. 

Post authors
Lucas Fass, BS - Rush Medical College 2021 MD Candidate
Lucas_fass@rush.edu

Joshua Okero, BS - Rush Medical College 2023 MD Candidate 

David M Tabriz
Assistant Professor
Department of Vascular & Interventional Radiology
Rush University Medical Center, Chicago, IL
@DrDaveTabriz

Radiofrequency Ablation of Facial Venolymphatic Malformations: Assessment of Efficacy and Safety and the Role of Injectable Electrodes

Clinical questions
Is ultrasound-guided radiofrequency ablation safe and effective in treating facial microcystic lymphatic and venolymphatic malformations; and how does safety and efficacy compare when using a newer injectable electrode with induced-paralysis technique versus a standard noninjectable electrode?

Take-away point
US-guided RF ablation is effective and safe in the treatment of facial microcystic lymphatic and venolymphatic malformations. The induced-paralysis technique with an injectable electrode demonstrated noninferior safety and efficacy compared to noninjectable alternatives.


Reference
Cho, Se Jin. et al. Radiofrequency Ablation of Facial Venolymphatic Malformations: Assessment of Efficacy and Safety and the Role of Injectable Electrodes. Journal of Vascular and Interventional Radiology, Volume 31, Issue 4, 544 - 550.

Click here for abstract

Study design
Retrospective chart review

Funding source
Self-funded or unfunded 

Setting
Single-center

Figure 2. Images from a 19-year-old woman with a mixed VLM. (a,b) Coronal contrast-enhanced CT (a) and fat-suppressed T2-weighted MR (b) images demonstrate a mixed VLM at the right sublingual and submandibular spaces. Note that the lesion is located close to the lower edge of the mandibular body, which is the location of the marginal mandibular branch of the facial nerve. (c) US image during RF ablation depicts the lesion (arrows) with an injectable electrode positioned at the center. (d) Coronal fat-suppressed T2-weighted image shows that the lesion is markedly decreased (volume reduction ratio, 79%) 11 months after a single-session ablation, without any complications.

Summary

Facial venolympathic malformations (VLMs) located in the head and neck can cause significant cosmetic disfigurement. Treatment has classically been accomplished with surgery, which can lead to scarring and neurovascular injury, ultimately leading to unsatisfying resolution. Ablation with sclerosing agent, however, has risen as an alternative therapy with investigations showing favorable efficacy. There is inadequate evidence of its utility in the treatment of microcystic lymphatic malformations (mLMs) and mixed VLMs, however, as sclerosing agent has not been shown to reduce mLM volume. RF ablation has been studied in mLM treatment with efficacy and safety, but the potential risk of thermal damage to functional nerve structures (e.g. cranial nerve branches) still exists. The authors proposed a novel technique for RF ablation for facial mLMs called “induced paralysis.” Using a novel electrode with multiple side holes at the non-insulated tip, the proceduralist can identify small motor and/or sensory nerves by injecting local anesthetic to the area around the tip prior to RF ablation, preventing inadvertent nerve damage.

In this retrospective chart review, 15 patients who had undergone RF ablation of a symptomatic facial VLM with ultrasound guidance within a 3-year period were identified. The group consisted of 3 males and a median age of 29 years. 6 patients were treated with the injectable electrode, while the remaining 9 were treated with the standard non-injectable electrode. The median number of treatments per patient was 1 (1-2 treatments). Median follow-up was 10 months (1-44 months). All patients underwent an initial cosmetic grading score (CGS) assessment as well as ultrasound and contrast-enhanced CT or MR imaging for initial volume assessment. Follow-up metrics included volume at 1 and 3 months with ultrasound and 6-month volume with CT or MRI. CGS and complications were also collected. Complete improvement was defined with a change of CGS from 4 to 1, whereas partial improvement was defined as a CGS of 4 to 2-4. Immediate and delayed procedure-related complications, including burns, bleeding, infection, necrosis, or sensory/motor nerve symptoms, parotid duct injury, and vascular damage were assessed with ultrasound.

Median CGS at final follow-up was 1 in all patients. This was not significantly different between injectable and noninjectable groups. 2 of 9 patients (22%) treated with the non-injectable probe experienced partial improvement versus 5 of 6 patients (83.3%) in the injectable probe group. Median volume decrease was 81% in the 13 patients with follow-up volume data. There was no significant difference between outcomes between non-injectable and injectable electrode groups despite similar incidence of a functional structure near the lesion on pre-procedure imaging (p<0.05). There was, however, a significant difference in outcomes between patients who had a nearby functional structure on imaging versus those without (p<0.05).

Two cases of nerve injury with partial improvement occurred in patients treated with the noninjectable electrode (22%). Specifically, 1 case of facial palsy with mild reduction of function (House-Brackmann grade II) and 1 case of hypoesthesia secondary to submental nerve injury were reported. Both of these patients experienced partial improvement of nerve injury symptoms. 1 case of intermittent sharp pain near the ablation zone was reported in a patient treated with the injectable probe (16.7%) which subsided after 1 month.

Commentary

This study confirms previous findings demonstrating the efficacy of US-guided RF ablation of facial VLMs and mLMs. It also suggests non-inferiority of the induced-paralysis technique with an injectable RF ablation probe to avoid nerve injury. RF ablation therapy has shown significant potential as a safe and effective alternative to surgical therapy for facial vascular lesions, and is specifically associated with lesion volume reduction of mLMs while chemical ablation is not. The study is limited by its small sample size, discrepancy in lesion volumes between groups, retrospective design, and selection bias. These make the results inconclusive on their own. Future studies will be needed with larger patient groups in order to reduce heterogeneity of the study population and confirm the true potential of these modalities.

Post Author
Jared Edwards
4th Year Medical Student
Oregon Health & Science University School of Medicine, Portland, OR

Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment

Clinical question
How do outcomes after conversion to arteriovenous (AV) access to Hemodialysis Reliable Outflow (HeRO) graft vs stent deployment in patients with arm swelling due to central vein stenosis compare?

Take-away point
Both HeRO graft conversion and stent deployment are effective in alleviating arm swelling in the short term in these patients, but the HeRO graft has more durable results.

Reference
Cline, Brendan C. et al. Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment. Journal of Vascular and Interventional Radiology, Volume 31, Issue 2, 243 – 250.

Click here for abstract

Study design

Retrospective review

Funding source

Self-funded or unfunded

Setting

Single institution

Summary

Arm swelling can cause significant morbidity for AV access patients with central venous stenosis. Angioplasty is often performed to improve symptoms and to maintain satisfactory function of the AV access; however, central lesions have the propensity to resist angioplasty or to recur. Additionally, patients with treatment resistant central lesions may require access ligation in order to resolve symptoms. Therefore, the authors of this study evaluated two methods for symptom relief and access salvage in the AV access patient with central venous stenosis: HeRO graft creation vs central venous stent placement.

The authors reviewed 192 patients who underwent HeRO graft insertion over a 10-year period in addition to 27 patients who underwent central venous stent placement over the same time period. All patients studied had a central venous stenosis (with central veins being defined as the superior vena cava, brachiocephalic vein or subclavian vein) and documented clinically significant arm swelling. Factors favoring HeRO graft placement included patients with concerns about the quality of the existing cannulation segment, the presence of pacemaker leads, predicted poor central venous patency due to bony compression, or excessive length or multifocality of stenosis, although such factors were infrequently documented. The patients in the 2 treatment groups had similar characteristics, however, patients undergoing HeRO conversion were statistically significantly more likely to have > 1 stenotic segment than the stent group (43% vs 11%, P=.02) and also more likely to have SVC occlusions than the stent group (43% vs 15%, P=05). The outcomes of interest were symptomatic improvement in arm swelling, primary access patency and secondary access patency.

All HeRO graft insertions and stent deployments were technically successful. After stent deployment, improvement or resolution in arm swelling was found in 86% of patients compared with 95% after conversion to a HeRO graft (P =.35). Swelling recurred within 1 year in 16 patients (59%) treated with stents compared with 1 patient (5%) who underwent HeRO conversion (P < .001). Median primary access patency was significantly longer for HeRO conversions than stent deployments (15.6 months vs 5.4 months, P < .001). Primary patency for HeRO graft placement at 6, 12, and 24 months was 89%, 72%, and 9% and for stent deployment was 47%, 11%, and 0%. Secondary patency was also longer for HeRO conversions than stent deployment (P=.006), with 6-, 12-, and 24- month secondary patency rates of 95%, 95%, and 89% for HeRO grafts and 79%, 58%, and 51% for stent deployment. Finally, mean number of interventions to maintain secondary patency was 2.9 per 1,000 access days for HeRO conversions and 6.2 per 1,000 access days for stent deployments. There was only 1 severe complication observed in the analysis, which occurred in a patient in the HeRO group who had an anastomotic dehiscence 1 week after surgery. No severe complications occurred in the stent group.

Commentary

The data presented here suggests that, while both conversion to HeRO graft and stent deployment are effective for treating arm swelling in the short term, HeRO grafts are less likely in the long term to result in return of arm swelling and are associated with longer primary and secondary patency rates. This may be attributed to the high level of experience with HeRO graft implantation at the authors’ institution and the question remains as to whether or not this is generalizable. Should better patency be expected in the HeRO conversion patient considering that culprit central venous lesions, oftentimes exacerbated by external compression, are bypassed and that typical venous outflow stenosis and neointimal hyperplasia concerns are not to be expected? Intuitively, this makes sense. Future studies, including a potential head-to-head comparison of HeRO graft to costoclavicular bypass are anticipated with interest.

Post authorZagum Bhatti, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Science Center at Houston, Houston, TX
@ZagumBhatti