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