This column alerts SIR members to abstracts that may have an impact on their practice and how they converse with referring clinicians. If you would like to suggest abstracts you feel should be included, email us at gandhi@baptisthealth.net or suvranu.ganguli@bmc.org.
Secondary prophylaxis of gastric variceal bleeding: A systematic review and network meta-analysis
Liver Transpl. 2022 Jun;28(6):945-958. doi: 10.1002/lt.26383. Epub 2021 Dec 27.
Osman KT, Nayfeh T, Abdelfattah AM, Alabdallah K, Hasan B, Firwana M, Alabaji H, Elkhabiry L, Mousa J, Prokop LJ, Murad MH, Gordon F
There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of available treatments. A comprehensive search of several databases from each database’s inception to March 23, 2021, was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. We included 9 RCTs with 647 patients who had histories of GVB and follow-ups >6 weeks. A total of 9 interventions were included in the NMA. Balloon-occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared with β-blockers (RR, 0.04; 95% CI, 0.01–0.26; low certainty), and endoscopic injection sclerotherapy (EIS)-cyanoacrylate (CYA) (RR, 0.18; 95% CI, 0.04-0.77; low certainty). β-blockers were associated with a higher risk of rebleeding compared with most interventions and with increased mortality compared with EIS-CYA (RR, 4.12, 95% CI, 1.50–11.36; low certainty), and EIS-CYA + nonselective β-blockers (RR, 5.61; 95% CI, 1.91–16.43; low certainty). Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding, whereas β-blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head-to-head RCTs are needed to validate these results.
Percutaneous radial artery access for peripheral vascular interventions is a safe alternative for upper extremity access
J Vasc Surg. 2022 Jul;76(1):174-179.e2. doi: 10.1016/j.jvs.2021.11.076. Epub 2021 Dec 23.
Levin SR, Carlson SJ, Farber A, Kalish JA, King EG, Martin MC, McPhee JT, Patel VI, Rybin D, Siracuse JJ
Objective: Percutaneous radial artery access has been increasingly used for peripheral vascular interventions (PVIs). Our goal was to characterize the practice patterns and perioperative outcomes among patients treated using PVI performed via radial artery access.
Methods: The Vascular Quality Initiative was queried from 2016 to 2020 for PVI performed via upper extremity access. Univariable and multivariable analyses were used to evaluate the periprocedural outcomes of radial artery access cases. A separate sample of brachial artery access cases was used as a comparator.
Results: A total of 520 radial artery access cases were identified. The mean age was 69 ± 10 years, and 41.3% were women. Most procedures were performed in the hospital outpatient setting (71.7%). The sheath size was ≤5F for 10%, 6F for 78%, and 7F for 12%. Ultrasound-guided access and protamine were used in 68.3% and 17.3% of cases, respectively. The interventions were aortoiliac (55%), femoropopliteal (55%) and infrapopliteal (9%). Stenting and atherectomy were performed in 55% and 19% of cases, respectively, and more often with 7F sheaths. Access site complications were any hematoma (4.8%), including hematomas resulting in intervention (0.8%), pseudoaneurysms (1%), and access stenosis or occlusion (0.8%). On multivariable analysis, sheath size was not associated with access site complications. Percutaneous brachial artery access (n = 1135) compared with radial access was independently associated with more overall hematomas (odds ratio, 1.73; 95% confidence interval, 1.06–2.81; P = .03). However, access type was not associated with hematomas resulting in intervention (odds ratio, 2.15; 95% confidence interval, 0.69–6.72; P = .19).
Conclusions: PVIs via radial artery access exhibited a low prevalence of postprocedural access site complications and were associated with fewer minor hematoma complications compared with interventions performed using brachial artery access. Radial artery access compared with brachial artery access should be the preferred technique for PVIs.
Percutaneous contrast-enhanced ultrasound-guided transabdominal sac embolization is an effective technique for treating complicated type II endoleaks after endovascular aneurysm repair
J Vasc Surg. 2022 Jun;75(6):1918-1925. doi: 10.1016/j.jvs.2021.12.053. Epub 2021 Dec 30.
Tao S, Li L, Xiang Z, Xiu-Jing X, Zhenjiang L, Qinglong Z, Yangyan H, Lu T, Zi-Heng W, Hong-Kun Z, Dong-Lin L
Objective: In the present study, we evaluated and compared the outcomes of transarterial embolization with those of percutaneous contrast-enhanced ultrasound-guided transabdominal sac embolization (PUSE) for type II endoleaks (T2ELs).
Methods: A retrospective review was conducted of consecutive patients who had undergone T2EL embolization between January 2015 and December 2020 at our center. The cohort was divided into two groups according to the embolization approach: PUSE vs transarterial. Freedom from aneurysm growth, safety, immediate technical success, freedom from persistent T2ELs, and the repeat embolization rate were assessed.
Results: A total of 25 patients and 28 embolization procedures (PUSE, n = 16; transarterial embolization, n = 12) were examined. Both the fluoroscopic time (13.3 ± 3.2 minutes vs 35.0 ± 7.0 minutes; P < .001) and the procedural time (84.9 ± 8.4 minutes vs 117.1 ± 14.8 minutes; P < .001) were significantly shorter in the PUSE group than in the transarterial group. After the embolization procedure, the patients were followed up for a mean duration of 24.7 ± 14.9 months for the PUSE group and 35.9 ± 21.1 months for the transarterial group (P = .1323). Five patients in the transarterial group had undergone unsuccessful embolization, with success in seven of the 12 patients in the transarterial group and all 16 patients in the PUSE group (P = .0081). Failure had resulted from failed transarterial access or a recurrent T2EL. Three of the five patients had undergone subsequent PUSE during follow-up. No patient in the PUSE group had experienced sac expansion compared with four patients in the transarterial group (P = .0242). Similarly, no patient in the PUSE group had developed a newly discovered T2EL vs four patients in the transarterial group (P = .0242). Thus, the outcomes were markedly better for the PUSE group than were those for the transarterial group. A major procedure-related complication (abdominal abscess) occurred in one patient in the transarterial group.
Conclusions: PUSE is safe and effective for managing T2ELs. It yields better outcomes in terms of preventing aneurysm growth, decreasing the incidence of repeat embolization and complications, minimizing the recurrence of T2ELs, and reducing the fluoroscopic and procedural times. We, thus, regard it as the preferred approach for the management of T2ELs.
Utility and outcome of angioembolization for high-grade renal trauma management in a large hospital-based trauma registry
J Urol. Adult Urology 1 May 2022
Hakam N, Amend GM, Nabavizadeh B, Allen IE, Shaw NM, Cuschieri J, Wilson MW, Stein DM, Breyer BN
Purpose: We evaluated angioembolization (AE) use for high-grade renal trauma (HGRT) management and compared AE vs surgical repair (SR) in requiring nephrectomy.
Materials and Methods: Using National Trauma Data Bank® 2013–2018, we identified patients with HGRT who underwent AE or SR as initial management. Therapy failure was defined as performing subsequent nephrectomy, partial nephrectomy, SR or AE. Logistic regression was performed to assess the association between intervention type (AE vs SR) and nephrectomy. Analysis was repeated in a propensity score-matched cohort constructed by matching AE to SR patients on American Association for the Surgery of Trauma (AAST) grade, injury mechanism (blunt vs penetrating) and hemodynamic instability (systolic blood pressure <90 mmHg).
Results: There were 266 patients in the AE group and 215 in the SR group. Median age was 29.5 years and 212 patients (44.1%) had penetrating injuries. AE was successful in 94.2% and 85.3% of grade IV and V injuries, respectively, whereas SR was successful in 82.1% and 56%, respectively. Grade V injury was associated with AE failure in the adjusted analysis (OR 3.55, 95% CI 1.22–10.2, p=0.02). Nephrectomy was less likely to be performed after AE vs after SR in HGRT (6.4% vs 17.2%, p=0.01), AAST grade IV (4.2% vs 13.7%, p=0.001) and AAST grade V (12% vs 44%, p=0.001). The matched cohort comprised 528 patients. In post-match regression, AE, compared to SR, was associated with lower odds of nephrectomy (OR 0.18, 95% CI 0.04–0.70, p=0.013).
Conclusions: AE achieved superior kidney salvage compared to SR in this observational cohort. These results inform both clinical practice and future prospective trials.
