The “needle re-entry” technique for infrainguinal arterial calcified occlusive lesions

Background Vascular calcification is a predictor of poor clinical outcome during and after endovascular intervention. Guidewire crossing techniques and devices have been developed, but chronic total occlusions (CTOs) with severe calcification often prevent subintimal re-entry. We propose a novel guidewire crossing approach combined needle rendezvous with balloon snare technique, named the “needle re-entry” technique, for treatment of complex occlusive lesions. Main text A 73-year-old female with severe claudication in her right calf with ankle brachial index of 0.62, and a computed tomography angiogram showed a long occlusion with diffuse calcification in superficial femoral artery. She was referred to our department to have peripheral interventions. Since the calcified vascular wall of the lesion prevented the successful re-entry, the “needle re-entry” was performed. First, a retrograde puncture of the SFA, distally to the occlusion, was performed and an 0.018-in. guidewire with a microcatheter was inserted to establish a retrograde fashion. Second, an antegrade 5.0-mm balloon was advanced into a subintimal plane and balloon dilation at 6 atm was maintained. Third, an 18-gauge needle was antegradely inserted from distal thigh to the dilated 5.0-mm balloon. After confirming a balloon rupture by the needle penetration, we continued to insert the needle to meet the retrograde guidewire tip. Then, a retrograde 0.014-in. guidewire was carefully advanced into the needle hole, named the “needle rendezvous” technique. After further guidewire advancement to accomplish a guidewire externalization, the needle was removed. Finally, since the guidewire was passing through the 5.0-mm ruptured balloon, the balloon was withdrawn, and the guidewire was caught with the balloon and successfully advanced into the antegrade subintimal space, named the “balloon snare” technique. After the guidewire was advanced into the antegrade guiding sheath and achieved a guidewire externalization, an endovascular stent graft and an interwoven stent were deployed to cover the lesion. After postballoon dilation, an angiography showed a satisfactory result without complications. No restenosis, reintervention, and limb loss have been observed for one year follow-up period after this technique. Conclusions The “needle re-entry” technique is a useful guidewire crossing technique to revascularize femoropopliteal complex CTOs with severe calcification which prevent the achievement of guidewire crossing with the conventional procedures.

Choledocholithiasis: modern possibilities of diagnosis and surgical treatment

Studies have examined various approaches in the diagnosis and surgical treatment of patients with cholelithiasis complicated by choledocholithiasis, evaluated the possibilities of using modern methods of treating the disease, and proposed a strategy to prevent the abandonment of bile duct concretions. The relevance of this problem is related to the variety of diagnostic and surgical treatment methods of choledocholithiasis, high disease frequency, and nonexistence of a unified approach to the examination and choice of surgical treatment in patients with cholelithiasis complicated by choledocholithiasis. These issues indicate the need to study this problem and identify optimal approaches to examination and treatment, including modern minimally invasive methods of treatment. The analysis of the diagnostic value of various examination methods and surgical outcomes was based on the experience of treating 154 patients with cholelithiasis complicated by choledocholithiasis in the clinic of the S.P. Fedorov Faculty of Surgery of the S.M. Kirov Military Medical Academy. An algorithm for examining patients with cholelithiasis was formed based on the diagnostic value of various research methods, which allows timely detection of choledocholithiasis. The results of various approaches to the surgical treatment of patients with cholelithiasis complicated by choledocholithiasis were analyzed. In the absence of general somatic contraindications and the availability of technical capabilities, a one-stage approach to surgical treatment was suggested. Moreover, an individual approach is necessary for the treatment of patients with cholelithiasis complicated by choledocholithiasis, taking into account the nature of the disease course and its complications, comorbid status of the patient, and technical capabilities of a particular hospital. The sequence and timing of operations with a two-stage approach should be determined, taking into account the acute conditions and comorbidities of the patient. The use of modern minimally invasive technologies, such as transpapillary and trans-bubble choledochoscopy, dosed papillotomy, and rendezvous technique for the cannulation of the large papilla of the duodenum, allows us to improve the results of surgical treatment and reduce the risk of complications. Transpapillary and trans-bubble nanoelectroimpulse lithotripsy are alternative methods of resolving major choledocholithiasis in both one-stage and two-stage treatment.

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

Endoscopic Reconstruction of an Oral Feeding Route Using a Rendezvous Approach

<b><i>Background:</i></b> The approach to esophageal obstruction or discontinuity remains challenging and often involves complex reconstructive surgeries. The rendezvous endoscopic technique might be interesting in cases of complete esophageal obstruction. <b><i>Case Presentation:</i></b> Herein we describe a successful case of endoscopic recanalization of the esophageal lumen in a patient with a long-standing esophageal discontinuity resulting from several surgeries and chemoradiation for a squamous cell carcinoma of the hypopharynx, ending in a major cervical amputation, construction of a neopharynx, and definitive surgical closure of the superior esophagus with a PEG placement. With a rendezvous technique (peroral and through the gastrostomy) and under radiographic guidance, puncture from the neopharynx into the distal esophagus was performed, followed by balloon dilation and covered metal stent placement in order to reconstruct a neoesophagus. Five weeks later, the stent was removed (using a stent-in-stent technique). No complications occurred. The patient has been able to eat soft food and is being kept under regular endoscopic surveillance to control/treat a luminal stenosis of the neoesophagus. <b><i>Conclusions:</i></b> This case report illustrates a successful endoscopic treatment of post-surgical complete esophageal obstruction. This approach should be considered in the therapeutic armamentarium of these difficult clinical settings.

Interventional radiology in rendezvous technique for choledocholitiasis in elderly patients

Aim. Define the safety and effectiveness of rendezvous technique for choledocholithiasis.Material and methods. We performed a retrospective and prospective analysis of the results in percutaneous transhepatic access to the bile ducts and endoscopic intervention in the rendezvous technique for choledocholithiasis in 100 elderly patients. The patients were divided into 2 groups for 50 people. The implementation of the rendezvous began from the antegrade stage in patients from group I; in patients of group II – from the retrograde stage. Postmanipulation complications and failures were When analyzed. The control point of the study is the identification of complications associated with manipulation from the next stages of the rendezvous technique.Results. We revealed a direct dependence of the results in sequence of rendezvous technique for elderly patients with choledocholithiasis and obstructive jaundice. This fact allows recommending percutaneous transhepatic access before endoscopic intervention for these patients with statistical significance. The frequency of complications and failures in patients of group I was 18%, in group II – 52%. This allows for such patients percutaneous transhepatic access before endoscopic intervention in the rendezvous technique. The frequency of complications and failures in patients of group I was 18%, in group II – 52%.Conclusion. Dilatation of intrahepatic segmental and subsegmental 2 and 3 biliary ducts with moderate and severe obstructive jaundice is a predictor of complications with ineffective endoscopic approach. In such situations, preventive antegrade drainage of the biliary tract with rendezvous technique makes possible to prevent cholangitis, effectively eliminate biliary hypertension, clarify the severity of stenosis of the papilla with antegrade balloon revision, and also secure delayed endoscopic resolution of biliary pathology.