Background: Select patients with acute cholecystitis (AC) are not candidates for index cholecystectomy. We compared the influence of ERCP-guided transpapillary gallbladder drainage (ERGD) versus percutaneous cholecystostomy (PC) on delayed cholecystectomy outcomes. Methods: Consecutive patients undergoing ERGD or PC for AC from January 2007 to October 2018 were included. Primary outcome was the rate of conversion to open cholecystectomy and perioperative complications in groups.Results: The study included 52 patients with ERGD and 140 with PC prior to cholecystectomy (median 68 days [IQR: 47-105.5]). Technical success was higher in the PC group (100% vs 91%; P = 0.0004).There was a nonsignificant trend to lower postoperative complications with ERGD (30.7% vs 43.5%; P = 0.07). No difference in conversion to open cholecystectomy OR: 1.5 (95% CI: 0.68-3.65; P = 0.28) or severity of complications (Clavien-Dindo grade >2) OR: 0.60, (95% CI: 0.19-1.87; P = 0.38) was noted between the ERGD and PC groups. PC was associated with higher rates of unplanned repeat intervention (16.4% vs 7.7%; P = 0.02). Conclusion:ERGD is suitable for patients with AC who is candidates for delayed cholecystectomy and should be considered for gallbladder drainage in patients with concomitant choledocholithiasis or cholangitis who require ERCP.

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Purpose: To determine the effects of left gastric artery embolization (LGAE) on computed tomography (CT) body composition change.Materials and methods: Sixteen overweight or obese patients who had abdominal CT scans before and after LGAE for gastric bleeding were retrospectively reviewed. Body composition analysis was performed with semiautomated imaging processing algorithms (MATLAB 13.0, Math Works, MA). Adipose tissue and lean skeletal muscle were measured using threshold attenuation values. Total body fat index (BFI), subcutaneous fat index (SFI), visceral fat index (VFI), intramuscular fat index (IMFI), and skeletal muscle index (SMI) were determined ([tissue area (cm)] 2 /[height (m)] 2 ). Excess body weight (EBW) was determined based on the Lorentz formula for ideal body weight.Results: Mean follow-up was 1.5 ± 0.8 months. Following LGAE, patients experienced significantly decreased body weight (p=0.003), BMI (p=0.005), EBW (p=0.003), BFI (p=0.03), SFI (p=0.03), and SMI (p<0.001). Changes in VFI and IMFI did not significantly change (p=0.13 and p=0.83, respectively). Conclusions:Patients who underwent LGAE had significant unintended weight loss as a result of decreased body fat and skeletal muscle. Body composition analysis can readily assess the extent of fat loss and identify muscle wasting.

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Background: Peripherally inserted central catheters (PICC) are occasionally placed in the great saphenous vein (GSV) and anterior accessory great saphenous vein (AAGSV) in patients with inadequate upper extremity veins or contraindications to upper extremity placement. Outcomes on the placement of PICCs in these veins are limited. Objectives: This study aimed to determine technical success and safety of GSV/AAGSV PICCs. Materials and methods: This is a retrospective study that reviewed all GSV/AAGSV PICC placements between January 2011 and December 2019. A total of 29 PICC placements procedures were identified. The electronic medical record was queried for demographic, procedural, and complication data. Technical success was defined by whether the vein could be accessed and a PICC could be placed. Catheter-associated infections, dislodgement or migration, malfunction, and PICC-associated thrombosis were recorded. Results: Technical success of placement was 100%. Twenty-one (72%) catheters were placed in the GSV in the mid to upper thigh and eight (28%) were placed in the AAGSV. The median PICC dwell time was 13 days with a range of 3–155 days. PICC-associated complications occurred after 11 (37.9%) placements. Line associated infection was the most common complication (17.2%). Conclusion: Due to a high complication rate, GSV/AAGSV PICC placement should be considered only when upper extremity or cervical PICC placement is not feasible or contraindicated.

This study examined the potential correlation between pulmonary embolism (PE) attenuation on computed tomography pulmonary angiography (CTPA) and pulmonary artery hemodynamic response to catheter-directed thrombolysis (CDT) in 10 patients with submassive PE. Treatment parameters, PE attenuation, clot burden, computed tomography signs of right ventricle dysfunction and right ventricular systolic pressure at echocardiography were retrospectively analyzed to determine correlation with pulmonary artery pressure improvement using Spearman correlation. A single reader, blinded to the treatment results, measured PE attenuation of all patients. There was a significant positive correlation between PE attenuation and absolute pulmonary artery pressure improvement with a Spearman correlation of 0.741, p=0.014. When attenuation was greater than or equal to the median (44.5 HU, n=5), CDT was associated with significantly better pulmonary artery pressure improvement ( p=0.037). Clot attenuation at CTPA may be a potential imaging biomarker for predicting pulmonary artery pressure improvement after CDT.

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The interventional radiology-guided hepatic venous pressure gradient (IR-HVPG) can diagnose portal hypertension (P-HTN), predict sequelae, and guide its management. IR-HVPG measurements may be inaccurate due to presinusoidal P-HTN or inability to access hepatic vein (HV). This limitation is overcome by endoscopic ultrasound (EUS) direct portal vein and portosystemic pressure gradient (EUS PPG) measurement. We highlight a 51-year-old man with autosomal dominant polycystic kidney and liver disease who underwent bilateral nephrectomy with kidney transplantation complicated by inferior vena cava transection with expanded polytetrafluoroethylene interposition graft repair (a). He developed deteriorating renal function, ascites, and bowel wall thickening. Accurate IR-HVPG recordings were unobtainable because HV was nonaccessible due to distortion by hepatic cysts. He subsequently underwent EUS with the measurements of splenic vein pressure (23 mm Hg), and given HV cyst compression, direct inferior vena cava pressure (8 mm Hg) yielding a PPG of 15 mm Hg (b). EUS fluid aspiration (255 mL) from 4 cysts permitted HV visualization and Pulse Doppler flow detection that was undetectable preaspiration. Immediate retesting revealed an EUS PPG of 11 mm Hg, representing a significant decrease of 27%, implicating HV cyst compression as an etiologic factor in the patient's P-HTN. We subsequently performed simultaneous transabdominal ultrasound and EUS to target peripheral and central cysts, aspirating 490 mL of fluid, followed by an injection of 12 mL of 3% sotradecol as a sclerosant (c). Contrast injection with fluoroscopy confirmed absence of communication with blood vessels and bile ducts. Thereafter, the patient experienced a marked improvement in all clinical manifestations of his P-HTN and recovered his renal function. This report highlights the potential for EUS to: (i) establish the presence and degree of P-HTN when IR-HVPG measurements are unobtainable, (ii) perform measurements prehepatic and posthepatic cyst aspiration to implicate hepatic cyst