Patients with a history of RYGB present a technical challenge for excluded gastric remnant gastrostomy placement. As the RYGB population increases and ages, obtaining and maintaining access to the gastric remnant is likely to become an important part of interventional radiology's role in the management of the bariatric patient.
A 38-week pregnant patient with history of cesarean delivery was admitted to the hospital for induction of labor after diagnosis of fetal demise. When the clinical picture became concerning for uterine scar dehiscence, an ultrasound was ordered. After targeted ultrasound of the lower uterine segment, the sonographer initially reported thin but intact lower uterine segment and normal positioning of the fetus. By keeping a high level of suspicion, the radiologist analyzed the images submitted and found other clues suggesting possible dehiscence or rupture. Additional images were then obtained, ultimately demonstrating uterine rupture with fetus external to uterus.
A retrospective review of technique and peri-procedural complications was performed for each patient. Major and minor complications were stratified based on the SIR reporting standards (2). Insufflation of the stomach was achieved under fluoroscopic guidance using one of three methods: nasogastric tube; direct stick with a 21G Chiba needle; or Effervescent Granules with subsequent direct stick. Results: PRG was successful in 88% of patients. PRG was not attempted in 3 patients due to an elevated left hemidiaphragm or prior surgery. Minor complications were seen in 27.2% (leakage (4.5%), granulation tissue (9.1%), and local infection (13.6%)), lower than reported PRG rates of 32% (3). One major complication occurred (4.5%), which is lower than reported rates (14.3%) in endoscopic gastrostomy placement (3). This patient developed aspiration pneumonia and respiratory distress 5 days post-operatively and required ICU admission. Direct stick (33.3%) and effervescent (25%) techniques had lower minor complication rates than NGT insufflation (33.3%). Conclusions: The presented techniques for PRG placement are safe and effective for enteral nutrition in ALS patients with the added benefit of not requiring intubation or ventilatory support.
Transcaval transcatheter aortic valve replacement is a new approach in performing percutaneous aortic valve replacement in which aortic access is obtained by way of the femoral vein and inferior vena cava. Computed tomographic angiography is used to determine patient suitability and in preprocedural planning. CTA is also part of routine follow-up care to assess for potential caval-aortic access site complications. Postprocedural imaging findings at the caval-aortic site include aortocaval fistula, aortic dissection, retroperitoneal hemorrhage, and pseudoaneurysm. The purpose of this manuscript is to familiarize the reader with the technical aspects of this new procedure and the periprocedural assessment of the caval-aortic access site with CTA.
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