Biliary strictures|Percutaneous biliary drainage|36|Male
Biliary strictures|Percutaneous biliary drainage|36|Male
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there we go, we'll just do it that way. So to begin, our patient. Presented originally status close right hepatectomy,

he had had a very large echinococcal cyst that had been resected, and after his surgery he had a persistent biloma that was also pretty impressive. Incidentally he grew up on a farm in India that had lots of dogs and cattle, and when he was sent over to us he had already been status post ERCP,

he'd have some dilatation. But now he was having nausea, vomiting, diarrhea, I'm sorry nausea, vomiting right upper quadrant pain and high volume output from his biliary drain that was cloudy. So he needed some intervention.

Sorry I skipped through some of the texts, some of the clinical that is available just to get to these impressive pictures. So these are the pre surgical pictures, and this first one is an axial CT demonstrating a large septated, or multi septated cystic structure consuming the right lobe of the liver.

In the coronal view you can see that it is lobulated and it takes up both the superior and the inferior aspect of the right lobe of the liver and that's why he got originally his hepatectomy, so the right hepatectomy. So before I go to the next slide, I just wanna I just wanna warn you if you are drinking coffee,

you might wanna set it down. If you had breakfast and you have a weak stomach, you may wanna look away. These are the gross pathology images of this echinococcal cyst. So if you haven't seen any echinococcal cyst,

all of these little cystic structures are the daughter cysts. Within them would be the scholes that if you were to Put it on ultrasound. You'd see them wiggling. So this was his echinococcal cyst status post as an en bloc left hepatectomy.

After surgery, I mentioned that he had a large biloma. This is his large biloma and this wasn't a diagnostic challenge to solve he ended up getting a percutaneous right biliary drain, and you can see very shortly after that there was a decompression of

that bile ailment. So that wasn't too much of a problem but now's where we come into the scene where IR was called for additional assistance because now he started having this increased output from his right billiary drain and experiencing multiple symptoms. So, we ordered an MRCP and I've placed some arrows on MRCP,

I've also created an illustration for you to help demonstrate the point. The green arrow is pointing to the left hepatic tree and the black arrow is pointing to the biloma that we've drained or that we've significantly improved with the right percutaneous biliary drain, and then the blue arrow is pointing to the common bile duct,

this is duodenum over here and the key thing to take away from this is we don't have any real significant connection between the left hepatic biliary tree and the biloma, not only that, we've got another focal either high grade stricture or complete occlusion between the biloma and the common bile duct. And so that explains why he's having all of this increased cloudy

output from his biliary drain. And then the question is how do we address that? So, I like to create some illusions from sports or from other parts of the world to try to paint the picture. What we wanted to do was thread the needle, so I don't know if you

can appreciate this guy here, he is in a winged suit that is not me if anybody's wondering if that was me, just to demonstrate the point you can see the little rock climber over there. So this is threading the needle and our goal was to find hopefully

a narrow orifice or maybe just something that's blocked with a little bit of soft debris that we could come through from the right biliary tree to try to then navigate into the common bile ducts, so we could produce some drainage. So again, all we wanted to do hopefully was to find a little bit

of at tract that might be clogged up with some debris. So our goal was to thread the needle. And this image is a percutaneous cholangiogram from our procedure coming in from the right. And this is not the common bile duct, this is the left hepatic tree.

The common bile duct is actually lightly opasified from behind, but you can't see any direct connection here. The angles weren't optimal, we tried to navigate it, we tried several different types of wires and not only did we not see a connection but we couldn't even tease one out.

So, our goal to thread the needle from the right was unsuccessful, and, we started feeling a little bit like George Hill here we're so close for about to lay it in, and then, for whatever reason LeBron blocked our shot. So our new strategy,

we're gonna come in with something a little bit more reliable. Again, use an example from the sports world we're gonna do a hand-off and this is something you see in the hospital all the time, everybody hands things off we called our friends from GI.

And our GI friends said, oh yeah, we can do an ERCP, we can come up to common bile duct, we'll be able to engage that right biloma from the impure aspect and that should solve, at least address

the drainage problem that this patient's having or the obstruction problem. And so here is their imaging from the ERCP, you can see the endoscope is in purple, the underscopic equipment is coming up the common bile duct and based on poor angles again,

they weren't able to cannulate, they were unable to create a connection and they called us and said, unfortunately we're not able to make that connection so now our hand off is denied. And once again, LeBron demonstrates that sometimes you can be really close and not score the goal.

So Once again we were shut down and we decided we needed to maybe find a new strategy. So maybe the problem wasn't that we had a bad strategy maybe we were just trying to thread the wrong needle. So we had already come in from the right side we had tried to gain

access in which came from below. There's one other access point that we could attempt to navigate Navigate, maybe we could thread a different needle, and if you look here this is kinda needle shaped, there's another example

of somebody threading the needle and our goal was maybe what we can do is come along the left hepatic, and gain access and we had already gained access through the left. We could at least pass a wire through here we thought maybe the angles would be better if we come in from the left side, and

you can see the skier here is the GoPro shot of him coming down I just thought it was really impressive and fine. I don't know if anybody saw this, this is actually Cody Townsend's line of the year from 2014. He flew out to Southern Alaska and found this canyon, and he and

his crew won't actually tell anybody where this is. But at the bottom right here at the shoot he said he was travelling over 60 miles an hour and he whipped up the canon there was 6 feet he could reach out if he wanted to and touch the rocks on either side. If anybody's Canadian that's 2 meters,

so what we wanted to do again is essentially thread the needle but then we are gonna put a twist on it, we are also gonna do a hand off and at the bottom if we're able to thread the needle we would have our GI folks endoscopically help us out with manipulating the instruments. So that's our goal we're gonna come in from the left, access the

biloma, hopefully gain a better angle to deliver our equipment down to the CBD and our GI would be waiting down to help us. So here's our imaging of this procedure, you can see the left hepatic duct we've crossed our wire into the biloma but unfortunately these angles weren't successful. We've got our GI folks here waiting for us anxiously,

patiently and yet this isn't looking promising We're starting to hear Lebron's footsteps again. We're worried because we've tried old school. We've tried threading the needle from the right. We've tried threading the needle from the left.

We've tried coming in from underneath and we needed to come up with something new. We needed to approach this case with a little more energy and we needed to maybe step it up and go beast mode. And if anybody is familiar there's Marshawn Lynch plays for the Seattle Seahawks breaking tackles,

insulting people's mothers, and running all the way to the end zone with no abandon. He certainly goes beast mode. So our goal then was to find a way to more aggressively make a way from the right percutaneous biliary access into the common bile duct. And so this is an illustration where Dr.

Hardley knows the tools in her shed. She knows what the equipment is. She knows the appropriate use of them but she also knows what they are capable of. And so she was innovative enough to be able to take a transjugular

biopsy sheath, exchange that over into the right biloma. So that way she could direct sharp recanalization to connect our right biloma into the common bile duct. In doing so that creates a platform that we can then exchange equipment over and we can start getting to a solution for this patient. So this is the intraoperative cholangiogram.

You can see the transjugular biopsy sheath. This is actually amplatz wire that was loaded backwards and then pushed to create that sharp recanalization. Underneath we've got our GI folks that are still happy that we're able to rendezvous. And then this is the left hepatic duct and I think it's covered

here but we actually do have the wire extending into the biloma from the left side as well. So now we've got a three way connection. This is additional imaging. What we did was cut the hub off of a pigtail,

load it backwards on the Amplatzer. And our friends and advanced it down the common bile duct where our friends in GI could snare it. They could pull it all the way down into the duodenum and the loop the pigtail loop was actually then positioned in the biloma.

So as we advance, the next thing that we can do is we advanced a 7-French Ansel along the left side through that we put a 15 mm GooseNeck snare. So that way as our friends in GI pull this pigtail down we we're able to snare it. There's an illustration I created an animation to show how we snared

it and pulled it out through the leftopadic duct, through the skin. So now we've got one complete contiguous connection. I'll let that play one more time. [BLANK_AUDIO]

And so that's out platform we were working with right now. And what's great about this is now we've got a platform that we can serially dilate up. We dilated it up to 14-French. We placed a customized internal-external drain with extra holes

placed in the level of the biloma and this is our intraoperative angiogram. You can see this is coming from the skin through the left hepatic duct all the way up into the biloma extending down the common bile duct and into the duodenum. And then this is just our endoscope that is kind of overlying the

field. This is additional imaging from that procedure showing that we cannulated into the duodenum. And again this is our additional illustration demonstrating the path of our customized internal-external drain. This is a ten day post procedure image demonstrating that the biloma

was decompressed. The biliary drainage was patent all through from the left side all the way down through the biloma through the common bile duct and into the duodenum and more importantly, this patient's symptoms had improved.

He no longer had right upper quadrant pain, he no longer had nausea, vomiting and his drain was capped, and he was draining easily into the duodenum without any issues. So now I'm gonna take a moment and I'm gonna give a question. This is not on the Sam systems say you don't need to get out your

So fortunately most of the absesses that we're asked

to drain are pretty relatively of this straight forward. Straight forward in terms of access and approach and straight forward in terms of evacuating the fluid that's causing patients bacteremia sepsis or whatever the case may be that leads to the requirement of an abscess drainage. And there are times however when despite adequate placement of the

catheter, perfect positioning the fluid it can diminish inside but not completely go away. This is the case here that may give you an indication that this may be such type of a fluid collection. This is the same, the ultra sound image of what we see, here this patient is a

cool as starters post called the vasectomy. Who had a subhepatic fluid collection in the gallbladder fossa likely a bioloma. And when we interrogate that fluid collection by ultra sound you can see that there are complex strands and material within the collection.

I don't know if this mouse is showing on the screen. But there're complex stranding within this collection. >> Just remove that mouse to the extreme right, it will show up on the screen. >> There we go.

Okay. So I just wanna put this slide and to remind everyone that within most exudative collection which are abscesses, that fibron is a component of these fluid collections. Their serum is of course is fibron and the abundance of white cells

and as the fibron as sometimes can be a kicker in the abscess, drainage. It can be the fibron component that leads to the complexity of the fluid collection and calcitrene if you will of complete evacuation. So in those cases, one of the things we want to consider is a thrombolytic.

In particular, tissue plasminogen activator. As we all know, this is a serine protease, it acts on plasminogen to activate plasmin, which in turn breaks down fibrin. This is a molecular structure of the same molecule.

And in this case here, again despite what looks to be pretty good adequate catheter drainage and several days of drainage. Their outputs went down, we repeated the CT Scan and there's still a persistent fluid collection in the clinical setting a persistent

white count and fever in this patient. So in this case, we went ahead and delivered TPA and effected pretty much complete drainage of this collection . So TPA, It's not necessary for all abscess drainages.

When to give it, how much to give and how to give. So for these questions, what we do is look at our experience. So this is a few years back. Looking at multiple abscess drainages in delivering TPA and the usual indications for giving TPA are for collections that number

one, for which the catheter is adequately placed. So by whatever image guidance that we view, whether it's ultrasound or a CT, you'll always wanna make sure that the catheter is properly placed within the collection. So that it's not a catheter malposition,

malfunction. And in the setting of persistent fluid collection as well as clinical science and persistent elevation of white count or persistent fever, So in those cases we usually pull the trigger and go ahead to administering TPA, this paper we look at 46 cases most of them were post operative collections other causes of collection were about

39%. We administer the intracavitary tPA. Again, emphasizing the satisfactory catheter position within the collection, that the contents indeed were highly viscous and that there were minimal drainage on followup, usually by imaging.

Also, taking into account patients' clinical scenarios. We use four to six milligrams of tPA diluted and about 20cc or so in 0.9% normal saline. We administer that through the catheter twice daily. We inject, if it's a single catheter that we're draining we'll administer the whole dose within the catheter.

If we wanna spread it out over x number of catheters we divide accordingly. We instill for at least 15 minutes. There are some reports where people have left the tPA in for up to an hour. And then just simply open up the catheter again to gravity drainage and effect the flow.

Usually another couple of days of drainage after TPA is what's sufficient to completely drain the collections. In our series we had complete drainage following tPA in almost 83% of the cases. There was no need for subsequent surgery in most of these cases and only in 6.5% percent of cases where we administered

the tPA that we had incomplete drainage necessitating the surgery or pulling the catheter and keeping our fingers crossed. All patients, in 28 of the 46 patients, it's about 61% of patients were receiving full-anticoagulation either warfarin or other

anticoagulant factors. And there were no cases of systemic or intra cathetery bleeding in our series. Doesn't mean it doesn't happen but in our series that was the case.

so you need to TIPS this patient. We've now evolved and moved to doing things transsplenically now. It makes a big difference. So how do you TIPS this patient, cavernoma?

A lot of ascites. Now there's a lot of different feelings about draining the ascites. I don't drain the ascites usually but here it is right here in the axials. You it's complete cavernoma. I start with a wedge venogram and I use 20 cc of contrast and 40 of saline with a 60 cc syringe. You can see my cavernoma but left and right PVs are patent.

Now how do you do this? You identify on MR this spot right here. This is the spot that will go straight out the splenic vein. So you have to look for this area here, and under ultrasound guidance, this is

the spot that you want to puncture. That's the technique and this is published in TVIR so the techniques of this is published, and here's this case. I'll show you how I did this in a second. So again this is the same person,

puncture here and again straight line. You've got to stick the right spot. You don't want to get caught in the varices and tortuosity. People have had problems with it and have had bleeds so be very careful. 5 French sheath and again remember what the observation that I learned from years ago is this is your target now,

not this. It's here and I'll zoom that in in a second. So here it is, you pull back, wire goes straight up, very straight forward. There it is.

My catheter's now through so there's my thrombosed PV that you don't see on MR, you don't see on anything else. But we're through. We pull back, we pull back and then we advance into the right and I like to do very peripheral TIPS, even in general I do the peripheral TIPS.

So here I am in the right portal vein. That's my snare, we puncture through the snare, exchange length stiff glide, pull back, pull my sheath and there's the system. I leave a short stent as I mentioned before.

Notice how it's completely thrombosed. The PV is completely thrombosed. Notice again how you think you should be drilling back here, it's actually up above that works better. This is what it looks like at the end of the procedure.

No lytics, nothing fancy, no mechanical thrombectomy devices etc. This is pre and this is post-transplant. So there is this whole narrative of the transplant surgeons being able to transplant something like this and putting in complex conduits and endovenoctemies and arterial portal shunts etc,

but the reality is those outcomes are very poor by their own literature. Ideally your target when you talk to your transplant surgeon is, I will help you create an end to end anastomosis. This is a big thing for them cuz the survivals now mimic regular transplant survivals.

Survivals of these patients are about 50% to 70% worse than normal transplantation when you do conduits. So anybody can do anything, conduits, all sorts of things. The outcomes are just very poor. Thank you. >> [APPLAUSE]

who had a recent radical cystectomy and bilateral pelvic lymph node dissection. They all just created Struder neobladder seven days prior referral to us.

And he's presenting with fever and pelvic pain. His exam is only significant for a low grade fever. He got a CT scan just prior to referral and you can see fluid collection medial to the left lateral pelvic sidewall. As we dream up or think of different approaches into that collection we can see the internal lateral aspect is limited by the common femoral vessels, anteriorly

we have multiple loops of bowel. Posteriorly he had a sciatic nerve, superior gluteal artery. Obviously in this kind of collection we generally wanna stick along the lateral margin of the sacrum but even then we may actually transgress and pass the collection. At this point we thought maybe we

could use a curve needle. A curve needle is generally very useful if the target is difficult to access collections. There have been multiple papers written about targeting collections as well as targeting legions for tissue sampling. In terms of the curve needle approach,

it's benefit is that it circumvents these intervening structures which really shouldn't be transgressed. When placed coaxially it can compensate for introducer malplacement. To create one, we generally take our 22 gauge Chiba needle and take the distal 2 to 3 cm of it and curve it roughly 20 to 40 degrees.

When a curve needle is used without an introducer, it's important to remember that you have to account for that radius of curvature cuz it will be persistent throughout the advancement of the needle. Wanna introduce this new product, it's created by AprioMed. It's called the Morrison Steerable Needle. It's produced

by a company AprioMed which is out of Sweden and it comes in one size, 21 gauge and it's shaft is about 17 cm. It allows you to kind of incrementally increase the rotation of curve of your distal tip. And so as you pull down on the lever, the distal 4 cm of that needle will begin to turn and the radius of curvature begins

at about 4 cm proximal to that tip in order to deflect up to 1 cm based on how much the lever you're depressing. And so here you can see the needle being advanced from an anterior approach kinda hooking around the right femoral head and sampling a lesion posterior to the greater trochanter. I guess my one problem with this image is why they didn't just didn't

take a straight posterior approach, I don't know. But it makes for a good image and I think they tried to crop it out anyway for us. Nonetheless, ex vivo here's what you're looking at. So here is the needle, it's non beveled tip, 21 gauge, 17 cm.

And here is the inner stylet, and when you depress the stylet you do get a curvature here, again 4 cm to the distal tip. And so how much resistance does this provide to kind of tamper how much of the radius of curvature you then lose. Well when you put the two in together you do lose a little bit, and

when we measured it with a handy approach factor ex vivo we found that it was about a 20 degree deflection that you obtained. So we decided to use it for this case. We entered along the lateral margin of the sacrum, again avoiding the superior gluteal artery and sciatic nerve, but if we were to continue advancing that needle

we would miss along the medial margin of the collection. So we deflected the lever to maximum projection and we created a 20 degree kinda arc radius here and we advanced it and sure enough, the needle did advance along the expected path. And we were able to successfully drain this,

need to focus on when you need to do the next step is this is not where the portal vein is, everybody would wanna sort of recanalize starting from here, that's not where the thrombus portal vein is,

it actually migrates cranially, it's here, this is the thrombus portal vein and we know this is small cardiac veins so we pull the catheter back and this is where we advance our catheter, our wire and now we're through.

So notice now that we've gotten through we have our sheath, went through the thrombus portal vein and here's the cavernoma and the cavernoma almost always maintains profusion of the peripheral portal vein, that's a nice feature of this whole thing and then we pull back, we advance into the right portal vein,

we advance a snare and just like Mark was describing we then puncture into the snare and then we pull, we puncture through, and then we pull our system, and now we have through and through access, jugular access out the

splenic vein. Notice the short TIPS that we place, we did not dilate it yet, we dilate the thrombus portal vein, it's completely thrombosed but we just dilated it and we dilate the TIPS and the vein,

it looks like this immediately after. No anticoagulation, no urokinase, streptokinase, TPA etc. it looks like this immediately after and the pressure is so high that this will remain patent

and this person was transplanted. Another case here, complete cavernomas transformation, wedge venogram as I describe, trans splenic access, huge varices, very easy to do this maneuver, it's actually so much easier to go this way than our first 40 cases or so where we were going through the liver and drilling

back. So it's much easier to go this way and here we are into the peripheral portal vein that again is perfused by the cavernoma. It maintains peripheral perfusion of the portal vein and we puncture the same thing through and through, we have large varices,

we dilate the same thing as I mentioned before. This is at the end of the TIPS procedure, this is a completely thrombosed portal vein. It looks like this at the end of the procedure, we leave the varices

alone for the first time. We bring them back a month or so later, that's how we have one month venography and we've learnt about what happens to that and after we embolize the varices, this is

the portal vein. So this vein did not exist a couple of months ago but this person underwent a liver transplantation. This is pre, no portal vein and this is post, native portal vein anastomosis.

I'm sorry. No, this is pre and post 18 months because the TIPS are still there, and this person was transplanted eventually. So here are the results

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