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Purpose: Multiple approaches to radiologically inserted gastrostomy (RIG) exist. The goal of this study was to compare 30-day outcomes and associated complications between large bore balloon-retained (BR), loop-retained (LR), and pull-type (PT) RIG devices.Methods: Data on 1477 patients who underwent RIG between January 1, 2005 and December 31, 2016 were collected retrospectively using a dedicated interventional radiology database and electronic medical record. Statistical analysis was performed to compare complication rates between BR, LR, and PT devices.Results: Ninety-eight percent (1477/1507) of the procedures were successfully performed. A total of 752 BR, 323 LR, and 402 PT gastrostomy tubes were placed. The overall complication rate for BR catheters was 5.7% (25 major [3.3%] and 18 minor [2.4%]). The overall complication rate for PT catheters was 3.7% (8 major [2.0%] and 7 minor [1.7%]). The overall complication rate for LR catheters was 1.6% (4 major [1.4%] and 1 minor [0.8%]). Compared to BR catheters, LR catheters had significantly fewer total complications (P = 0.01) but not minor complications (P = 0.052). There were no significant differences in the number of complications between LR and PT catheters or between BR and PT catheters.Conclusions: Use of BR, LR, and PT devices for RIG is safe with a low incidence of complications. Compared to BR catheters, primary insertion of a LR gastrostomy was associated with significantly fewer overall complications within the first 30 days. Therefore, for initial tube placement, large bore LR catheters may be preferred over BR devices. [ABSTRACT FROM AUTHOR]

One of the crucial functions of the lymphatic system is maintenance of fluid balance. Nonetheless, due to lack of clinical imaging and interventional techniques, the lymphatic system has been under the radar of the medical community. The recently developed intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography provide new insight into lymphatic pathology. Thoracic duct embolization has become the method of choice for the treatment of patients with chylous leaks. Interstitial lymphatic embolization further expanded the lymphatic embolization approaches. Liver lymphatic lymphangiography and embolization allow treatment of postsurgical liver lymphorrhea and protein-losing enteropathy. The potential for further growth of lymphatic interventions is vast and includes liver lymphatic procedures and advanced thoracic duct interventions, such as thoracic duct externalization and stenting. These current and future advances will open up a realm of new treatments and diagnostic opportunities. [ABSTRACT FROM AUTHOR]

Purpose: Assess the effectiveness of conventional lymphangiography, MR lymphangiography, and lymphatic embolization for the diagnosis and treatment of refractory chylous ascites.Materials and Methods: A retrospective review of 31 patients (M/F:16/15, average age 52) who presented for the management of refractory chylous ascites was conducted to assess the diagnostic value of conventional and MR lymphangiography and outcome of lymphatic embolization.Results: Of the total 31 patients, 25 presented with chylous ascites secondary to iatrogenic trauma and six patients with a non-traumatic etiology. All patients underwent conventional lymphangiography and nine underwent MR lymphangiogram. The lymphatic leak was visualized in 17/31 (55%) of the patients (15 of which were traumatic) and in 7/9 MR lymphangiograms (six traumatic and one non-traumatic). Embolization with n-BCA glue and/or coils of the leak was performed in 11 of the 17 patients whose leak was identified (65%) with resolution of chylous ascites in 9/11 (82%) patients. Lymphangiogram alone was curative in 7/20 (35%) patients. Overall, 16/31 patients (52%) had clinical resolution of ascites. Ascites resolved in 13/17 (76%) patients in whom the site of leak could be identified compared to 3/14 (21%) of patients in whom the site of leak could not be identified (p = 0.0038).Conclusions: Lymphangiography and embolization can be used to treat chylous ascites. Identification of the site of leak is associated with significantly greater rate of clinical success compared to those whose site could not be identified. [ABSTRACT FROM AUTHOR]

Purpose: To examine effects of lower extremity sequential compression devices (SCDs) on lymphatic transit during intranodal lymphangiography (IL) and thoracic duct interventions.Materials and Methods: A retrospective review of 19 SCD-assisted IL (IL-SCD) procedures was performed. The control group comprised 18 consecutive IL-guided procedures performed in the immediately preceding time period. For IL-SCD procedures, SCDs were placed onto patients' calves before sterile preparation. Total procedure time and lymphatic transit time were measured. Mean age was 52 years in the IL-SCD group and 64 years in the control group. In the control group, 100% (18/18) of patients had a chylous leak, whereas only 74% (14/19) of patients in the IL-SCD group had a leak.Results: In the IL-SCD group, mean total procedure time was 75 minutes (range, 34-126 min), and mean lymphatic transit time was 29 minutes (range, 8-63 min). In the control group, mean total procedure time was 105 minutes (range, 51-203 min), and mean lymphatic transit time was 56 minutes (range, 28-117 min). Lymphatic transit time and procedure time were significantly reduced in the IL-SCD group (P < .01 and P < .05, respectively).Conclusions: Use of lower extremity SCDs reduces lymphatic transit time and IL-dependent procedure time. [ABSTRACT FROM AUTHOR]

Lymphatic malformations (LMs; especially those involving the central conducting lymphatic channels) are characterized by dysplastic and incompetent lymphatic channels in multiple tissues and organs. The major cause of mortality and morbidity in patients with thoracic LM is deterioration of pulmonary function due to chronic chylous effusions and progressive interstitial lung disease. The etiology of these pulmonary processes is unknown, although lymphatic involvement is certain. Understanding of the changes in the lymphatic anatomy in patients with LM has been hindered by difficulty of imaging of the lymphatic system. Recently developed dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) allows dynamic MR imaging of the lymphatic system by injecting gadolinium contrast agent in the groin lymph nodes. Using this technique, pathological lymphatic flow from the central lymphatic system and/or retroperitoneal and mediastinal masses into lung parenchyma ("pulmonary lymphatic perfusion syndrome") has been demonstrated in patients with LM. This abnormal lymphatic perfusion overflows pulmonary parenchyma and results in deterioration of pulmonary function due to interstitial process and/or compression effect of chylous effusions. Percutaneous thoracic duct embolization or lymphatic interstitial embolization of the lymphatic masses results in cessation of the pulmonary lymphatic overflow and significant improvement in pulmonary symptoms in these patients. [ABSTRACT FROM AUTHOR]

Recent development of new lymphatic imaging and intervention techniques, such as intranodal lymphangiogram, dynamic contrast enhanced magnetic resonance lymphangiography and lymphatic embolization, have resulted in the resurgence of interest in the lymphatic anatomy. The lymphatic system is a continuous maze of interlacing vessels and lymph nodes and is extremely complex and variable. This presents a significant challenge for interpretation of imaging and performance of interventions on this system. There is an embryological reason for this complexity and variability; the lymphatic system sprouts off of primordia from several locations in the body, which later fuse together at different stages of development of the embryo. The lymphatic system can be divided in three distinct parts: soft tissue lymphatics, intestinal lymphatics, and liver lymphatics. Liver and intestinal lymphatics generate approximately 80% of the body lymph and are functionally the most important parts of the lymphatic system. However, their normal anatomy and pathological changes are relatively unknown. In this chapter we will explore the anatomy of these three systems relevant to lymphatic imaging and interventions. [ABSTRACT FROM AUTHOR]

Pulmonary lymphatic diseases have been recognized for many years and have been referred as pulmonary lymphangiectasia, pulmonary lymphangiomatosis, plastic bronchitis, and idiopathic chylothorax or chylopericardium. The lymphatic etiology of these conditions has been determined by detection of cystic lymphatic structures on biopsy or postmortem examination. Development of new imaging techniques such as dynamic contrast-enhanced magnetic resonance lymphangiography has allowed better understanding of pathophysiology of these conditions. Dynamic contrast-enhanced magnetic resonance lymphangiography demonstrated that the common denominator of these disorders is an abnormal pulmonary lymphatic flow from the thoracic duct toward pulmonary parenchyma. This abnormal lymphatic flow propagates into mediastinum, lung parenchyma, pleural surfaces, and bronchial submucosa and has been termed as pulmonary lymphatic perfusion syndrome (PLPS). Known clinical presentation of PLPS includes spontaneous chylothorax or pericardium, neonatal chylous effusions, and plastic bronchitis. PLPS has been observed in all age groups and can be considered as a congenital anatomical lymphatic variant. The onset of the clinical symptoms can be provoked by increase of the lymphatic flow owing to elevated central venous pressure that results in lymphatic distention, trauma, and severe upper respiratory infection. Reported treatment of PLPS is obliteration of these abnormal lymphatic pathways by percutaneous embolization, a technique similar to thoracic duct embolization in chylothorax. [ABSTRACT FROM AUTHOR]

The consumption of sweeteners, natural as well as synthetic sugars, is implicated in an array of modern-day health problems. Therefore, natural nonsugar sweeteners are of increasing interest. We identify here the biosynthetic pathway of the sweet triterpenoid glycoside mogroside V, which has a sweetening strength of 250 times that of sucrose and is derived from mature fruit of luohan-guo (Siraitia grosvenorii, monk fruit). A whole-genome sequencing of Siraitia, leading to a preliminary draft of the genome, was combined with an extensive transcriptomic analysis of developing fruit. A functional expression survey of nearly 200 candidate genes identified the members of the five enzyme families responsible for the synthesis of mogroside V: squalene epoxidases, triterpenoid synthases, epoxide hydrolases, cytochrome P450s, and UDP-glucosyltransferases. Protein modeling and docking studies corroborated the experimentally proven functional enzyme activities and indicated the order of the metabolic steps in the pathway. A comparison of the genomic organization and expression patterns of these Siraitia genes with the orthologs of other Cucurbitaceae implicates a strikingly coordinated expression of the pathway in the evolution of this speciesspecific and valuable metabolic pathway. The genomic organization of the pathway genes, syntenously preserved among the Cucurbitaceae, indicates, on the other hand, that gene clustering cannot account for this novel secondary metabolic pathway. [ABSTRACT FROM AUTHOR]

Background: Inferior vena cava (IVC) filters are commonly implanted with the intent to prevent life-threatening pulmonary embolism in at-risk patients with contraindications to anticoagulation. Various studies have reported increases in the rate of venous thromboembolism within the pediatric population. The utility and safety of IVC filters in children has not yet been fully defined.Objective: To describe the technique and adjunctive maneuvers of IVC filter removal in children, demonstrate its technical success and identify complications.Materials and Methods: A retrospective 10-year review was performed of 20 children (13 male, 7 female), mean age: 15.1 years (range: 12-19 years), who underwent IVC filter retrieval. Eleven of 20 (55%) were placed in our institution. Electronic medical records were reviewed for filter characteristics, retrieval technique, technical success and complications.Results: The technical success rate was 100%. Placement indications included: deep venous thrombosis with a contraindication to anticoagulation (10/20, 50%), free-floating thrombus (4/20, 20%), post-trauma pulmonary embolism prophylaxis (3/20, 15%) and pre-thrombolysis pulmonary patient (1/20, 5%). The mean implantation period was 63 days (range: 20-270 days). Standard retrieval was performed in 17/20 patients (85%). Adjunctive techniques were performed in 3/20 patients (15%) and included the double-snare technique, balloon assistance and endobronchial forceps retrieval. Median procedure time was 60 min (range: 45-240 min). Pre-retrieval cavogram demonstrated filter tilt in 5/20 patients (25%) with a mean angle of 17° (range: 8-40). Pre-retrieval CT demonstrated strut wall penetration and tip embedment in one patient each. There were two procedure-related complications: IVC mural dissection noted on venography in one patient and snare catheter fracture requiring retrieval in one patient. There were no early or late complications.Conclusion: In children, IVC filter retrieval can be performed safely but may be challenging, especially in cases of filter tilt or embedding. Adjunctive techniques may increase filter retrieval rates. [ABSTRACT FROM AUTHOR]

Purpose: To assess the feasibility of validating the position of the needle in groin lymph nodes using injection of ultrasound (US) contrast prior to magnetic resonance (MR) lymphangiography.Materials and Methods: In 28 patients (average age, 52 y; 15 women, 13 men), 25G needles were placed in bilateral groin lymph nodes using US guidance outside the MR suite. The confirmation of the position of the needles in lymph nodes and efferent lymphatic flow was performed by injecting 1 mL of the US contrast agent (Lumason) mixed with 2 mL of lidocaine and observing contrast enhancement of the efferent lymphatic ducts leading to the pelvis from the lymph node. The patients were then transferred to the MR suite, and MR lymphangiography was performed.Results: In 6 patients, the needle was repositioned due to nonvisualization of the efferent lymphatic flow toward pelvis at the first attempt. MR lymphangiogram was then performed in all patients with good opacification of the central lymphatic system. No extravasation of gadolinium contrast agent was observed.Conclusions: Injection of US contrast to confirm the position of the needles inside the lymph nodes is a safe and effective technique. This technique can serve as a substitute for fluoroscopic confirmation of needle position, allowing performance of MR lymphangiography on any MR machine with a detachable table. [ABSTRACT FROM AUTHOR]