CardioVascular and Interventional Radiology

© Springer-Verlag New York, Inc. 2000

Cardiovasc Intervent Radiol (2000) 23:485– 489 DOI: 10.1007/s002700010112

TECHNICAL NOTES

Carbon Dioxide and Gadopentetate Dimeglumine Venography to Guide Percutaneous Vertebroplasty J. Kevin McGraw, Bradley T. Strnad, Shayle B. Patzik, Jeffrey S. Silber, Antoinette L. LaValley, Jeffrey M. Boorstein Center for Vascular and Interventional Radiology, Department of Radiology, St. Vincent Mercy Medical Center, 2213 Cherry Street, Toledo, OH 43608, USA

Abstract Percutaneous vertebroplasty with polymethylmethacrylate (PMMA) is an effective procedure for relieving pain due to vertebral body compression fractures. The technique employs iodinated contrast venography to exclude needle placement directly within the basivertebral complex. We present two cases in which carbon dioxide (CO2) and gadopentetate dimeglumine venography was used to guide percutaneous vertebroplasty in patients with a contraindication to iodinated contrast. Key words: Vertebroplasty—Carbon dioxide—Gadodiamide— Venography Percutaneous vertebroplasty with polymethylmethacrylate (PMMA) was first introduced by Deramond et al. [1, 2]. The purpose of this percutaneous treatment is to provide pain control by vertebral body stabilization in patients whose pain is related to lesions weakening the bone. The technique for vertebroplasty was first described in the United States by Jensen et al. [3]. In their technique, before injecting the PMMA, venography is done to exclude needle placement directly within the basivertebral venous complex. Other authors also described venography prior to vertebroplasty [4]. However, some patients cannot undergo iodinated contrast venography, due either to severe allergy to iodine or chronic renal insufficiency. Carbon dioxide has been advocated as a non-nephrotoxic alternative to iodinated contrast material [5, 6]. Alternatively, gadolinium-based agents have been used safely as intravascular contrast media for angiographic procedures in selected patients [7–10]. To our knowledge this is the first report that describes the use of CO2 and Gadodiamide to perform venography prior to percutaneous vertebroplasty.

Patients and Procedures Two female patients, aged 57 and 74, developed back pain associated with compression fractures. The first patient, with a history of osteoporosis, developed acute, nontraumatic mid-back pain several months prior to treatment. A radionuclide bone scan demonstrated increased activity at the T12 level. A gadolinium-enhanced magnetic resonance imaging (MRI) scan

Correspondence to: J.K. McGraw, M.D.; e-mail: [email protected]

revealed a subtle superior endplate compression fracture of the T12 vertebral body. The second patient, also with osteoporosis and several chronic compression fractures, developed new low back pain. An MRI revealed new compression fractures at L4 and L5 and examination under fluoroscopy revealed that most of her pain was at L4. Both patients were initially treated with conservative measures which included oral narcotics for pain relief. Several months later, both patients continued to have severe, life-stylelimiting back pain and were referred for percutaneous vertebroplasty. Both patients had experienced severe urticaria after intravenous iodinated contrast. The vertebroplasty procedures were performed under intravenous sedation with fentanyl (Sublimase, Abbott Labs, Chicago, IL, USA) and midazolam (Versed, Roche, Manati, Puerto Rico). Both patients were given 1 mg of i.v. Cefazolin prior to the procedure. The patients were placed in the prone position on the angiographic table. The involved vertebrae were identified and the overlying skin was prepped and draped in usual sterile fashion. Local anesthesia was then applied to the skin and the deep structures, including the periosteum of the bone at the intended site of entry by the bone needle. The vertebroplasty procedure was then performed using the technique described by Jensen et al. [3]. Biplane fluoroscopic guidance allowed the placement of an 11 gauge Jamshidi bone biopsy needle (Mannnon Medical, Northbrooke, IL, USA) via a transpedicular approach to approximately the junction of the anterior and middle third of the vertebral body. Once the needle was felt to be in optimal position, venography with alternative contrast agents was performed. CO2 was delivered through a 60-cc syringe connected to extension tubing, by gentle hand injection [11]. CO2-enhanced anterior-posterior (AP) and lateral images were obtained at 85 kVp at four frames per sec for 3 sec followed by two frames per sec (Figs. 1, 2). To supplement the CO2 images, venography with Gadodiamide (OmniScan; Nycomed, Princeton, NJ, USA) was performed by gently hand injecting 8 –10 ml of full strength Gadodiamide (0.5 mol/L) (Figs. 3, 4). Gadodiamide angiograms were obtained at 96 kVp with a film rate of three frames per sec for 3 sec followed by two frames per sec. After optimal needle placement was obtained, the PMMA was prepared for injection. Polymethylmethacrylate (Codman Cranioplastic, CMN Laboratories, Blackpool, UK) was prepared by adding the sterile opacification agent barium sulfate (E-Z-Em, Westbury, NY, USA). This allowed visualization during AP and lateral fluoroscopy. Careful monitoring of the PMMA during injection is required in order to recognize any flow into an undesirable location such as the epidural space or inferior vena cava. Approximately 3–5 cc of PMMA was injected into each half of the vertebral body via separate, bihemispheric injections. Both patients tolerated the procedure well without adverse sequelae. Twelve hours after the procedure both patients reported complete pain relief. At 9-month follow-up both patients remain asymptomatic.

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Fig. 1. Lateral CO2 venogram demonstrates filling of the basivertebral plexus (arrowhead) and inferior vena cava (arrows). Fig. 2. Lateral CO2 venogram demonstrates filling of the vertebral marrow space (arrowheads) and basivertebral plexus (arrows).

Fig. 3. Anterior-posterior Gadodiamide injection with filling of the marrow space (arrowheads) and paravertebral veins (arrows). Fig. 4. Anterior-posterior Gadodiamide injection demonstrates brisk filling of the inferior vena cava (arrowheads).

Comments Over the past few years, techniques of percutaneous vertebroplasty have been developed and are now being used extensively in some places for pain relief and strengthening of weakened vertebral bodies [12]. The procedure consists of injecting a biomaterial, usually methylmethacrylate polymer, into corporeal lesions. In the technique described by Jensen et al. [3] venography is performed prior to injecting the PMMA to exclude needle placement directly within the basivertebral venous complex and to insure continuity of the posterior vertebral wall as evidenced by containment of the contrast material within the bony trabecule. These authors feel that rapid flow of contrast material into the vena cava and/or perivertebral veins without visibility of intervening bone marrow indicates direct communication of the needle tip with a major venous outlet and requires needle advancement. Ganji et al. [4] also report performing vertebral venography prior to injecting polymethylmethacrylate in order to ascertain the

location of the vertebral venous plexus and to determine the diffusion of the polymethylmethacrylate. Deramond et al. [13] only performed venography in vertebral body angiomas. In patients who have a contraindication to iodinated contrast, either from a severe allergic reaction, as in our two patients, or having chronic renal insufficiency, alternative contrast agents can be used for venography as described. Recent improvements in CO2-enhanced digital subtraction angiography and delivery have resulted in improved visualization of blood vessels without the use of iodinated contrast [5, 6, 11]. This is useful in patients who are allergic to iodinated contrast or may have renal insufficiency. In addition to CO2, gadolinium-based contrast agents have also been used to image the vascular system. Several authors [7–10, 14 –16] have described their use in angiographic studies of the abdominal aorta and mesenteric vessels, pelvic vessels, peripheral circulation, and renal arteries. Spinosa et al. [7] describe the use of Gadodiamide-enhanced renal angiography to supplement CO2-en-

R.P. Davies et al.: Anti-Reflux Esophageal Stent Salvage

hanced renal angiography for the diagnosis and percutaneous treatment of renal artery stenosis. We found that the Gadodiamideenhanced images were superior to the CO2-enhanced images and we now only perform Gadodiamide venography in patients with a contraindication to iodinated contrast. In conclusion, Gadodiamide- and CO2-enhanced venography appear to be safe and useful for guiding percutaneous vertebroplasty in patients who may have a contraindication to iodinated contrast medium. To our knowledge this is the first report of the use of carbon dioxide and Gadodiamide to aid in percutaneous vertebroplasty. References 1. Galibert P, Deramond H, Rosat P, Le Gars D (1987) Note preliminaire sur le traitement des angiomes vertebraux par vertebroplastie acrylique percutanee. Neurochirurgie 233:166 –168 2. Deramond H, Darrason R, Galibert P (1989) La vertebroplastie percutanee acrylique dans le traitement des hemangiomes vertebraux agressis. Rachis 1:143–153 3. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE (1997) Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: Technical aspects. Am J Neuroradiol 18:1897–1904 4. Ganji A, Kastler BA, Dietemann JL (1994) Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy. Am J Neuroradiol 15:83– 86 5. Hawkins IF (1982) Carbon dioxide digital subtraction angiography. AJR 139:19 –24 6. Hawkins IF, Maynar M (1997) Carbon dioxide digital subtraction angiography. In: Castan˜eda-Zu´n˜iga WR (ed) Interventional Radiology. 3rd edn. Williams and Wilkens, Baltimore, pp 429 – 443

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7. Spinosa DJ, Matsumoto AH, Angle JF, Hagspiel KD, McGraw JK, Ayers C (1999) Renal insufficiency: Usefulness of gadodiamide-enhanced renal angiography to supplement CO2-enhanced renal angiography for diagnosis and percutaneous treatment. Radiology 210:663– 672 8. Kinno Y, Odagiri K, Andoh K, Itoh Y, Tarao K (1993) Gadopentetate dimeglumine as an alternative contrast agent for use in angiography. AJR 160:1293–1294 9. Matchett WJ, McFarland DR, Russel DK, Sailors DM, Moursi MM (1996) Azotemia: Gadopentetate dimeglumine as contrast agent at digital subtraction angiography. Radiology 201:569 –571 10. Spinosa DJ, Matsumoto AH, Angle JF, Hagspiel KD (1998) Use of gadopentetate dimeglumine as a contrast agent for percutaneous transluminal renal angioplasty and stent placement. Kidney Int 53:503–507 11. Hawkins IF, Caridi JG, Kerns SR (1995) Plastic bag delivery system for hand injection of carbon dioxide. AJR 165:1487–1489 12. Cotton A, Boutry N, Cortet B, Assaker R, Demondion X, Leblond D, Chastanet P, Duquesnoy B, Deramond H (1998) Percutaneous vertebroplasty: State of the art. Radiographics 18:311–320 13. Deramond H, Depriester C, Galibert P, Le Gars D (1998) Percutaneous vertebroplasty with polymethylmethacrylate. Radiol Clin North Am 36(3):533–546 14. Fobbe F, Wacker M, Wagner S (1996) Arterial angiography in high kilovoltage technique with gadolinium as a contrast agent: First clinical experience. Eur Radiol 6:224 –229 15. Kaufman JA, Galler SC, Waltman AC (1996) Renal insufficiency: Gadopentetate dimeglumine as a radiographic contrast agent during peripheral vascular interventional procedures. Radiology 198:579 –581 16. Schild HH, Weber W, Boeck E, Mildenberger P, Strunk H, Duber C, Grebe P, Schadmand-Fischer S, Thelen M (1994) Gadolinium-DTPA (Magnevist) als kontrastmittel fur die arterielle DSA. ROFO 160:218 – 221

Treatment of Post-Stent Gastroesophageal Reflux by Anti-Reflux Z-Stent Roger Philip Davies,1 Jacqueline Kew,1 Peter D. Byrne2 1

Department of Radiology, North Western Adelaide Health Service, The Queen Elizabeth Hospital Campus, 28 Woodville Road, Woodville South, Adelaide 5011, South Australia 2 Department of Surgery, North Western Adelaide Health Service, The Queen Elizabeth Hospital Campus, 28 Woodville Road, Woodville South, Adelaide 5011, South Australia

Abstract Severe symptoms of heartburn and retrosternal pain consistent with gastro-esophageal reflux (GER) developed in a patient following placement of a conventional self-expanding 16 –24-mm-diameter ⫻ 12-cm-long esophageal stent across the gastroesophageal junction to treat an obstructing esophageal carcinoma. A second 18-mmdiameter ⫻ 10-cm-long esophageal stent with anti-reflux valve was deployed coaxially and reduced symptomatic GER immediately. Improvement was sustained at 4-month follow-up. An anti-reflux stent can be successfully used to treat significant symptomatic GER after conventional stenting.

Key words: Esophageal stent, anti-reflux valve—Esophageal carcinoma

Placement of expandable metallic stents is accepted as palliative treatment of malignant esophageal obstructions not responding to dilatation [1– 6]. However, in patients with inoperable tumors in the cardia, placement of a stent often results in symptomatic gastroesophageal reflux (GER) [3, 5, 6]. This may be avoided by using a stent with an anti-reflux valve. We present a patient in whom an anti-reflux esophageal stent was placed after initial treatment with a conventional stent which had caused significant GER.

Case Report Correspondence to: R.P. Davies, M.D.; e-mail: [email protected] DOI: 10.1007/s002700010113

A 77-year-old man with inoperable squamous carcinoma of the esophagus and dysphagia was referred for palliative treatment by endoprosthetic metallic stent placement. The tumor extended over approximately one and a

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Fig. 1. Contrast esophagogram in a 77-year-old man performed for obstructive symptoms demonstrates a distal esophageal carcinoma (arrows). Fig. 2. Esophagogram after insertion of a Wallstent demonstrating relief of obstruction. The distal end of the stent is noted to protrude into the stomach (arrowheads). After stent placement there was severe reflux and persistent luminal narrowing by tumor (arrows). Fig. 3. Appearance of the anti-reflux stent after insertion showing free flow of contrast from the esophagus into the stomach. Contrast outlines the plastic sleeve of the antireflux valve (arrows). Fig. 4. Esophagogram with the patient in Trendelenberg position showing a near competent distal esophageal valve allowing for some gastro-esophageal reflux (arrows) potentially preventing the “gas bloat” syndrome.

half vertebral body heights, and involved the gastro-esophageal junction (Fig. 1). The procedure was performed under fluoroscopic guidance and conscious sedation with a combination of midazolam hydrochloride (Roche

Laboratories, Nutley, NJ, USA) and fentanyl citrate (Janssen Pharmaceutica, Titusville, NJ, USA). Local anesthetic 10% lidocaine spray (Xylocaine, Astra, Sodertalje, Sweden) was applied to the mouth and throat.

R.P. Davies et al.: Anti-Reflux Esophageal Stent Salvage

The esophageal stricture was traversed with a 0.035-inch J-wire (Cook, Bloomington, IN, USA) and a selective vertebral angiography catheter (Cordis Europa NV, Roden, The Netherlands) over which a 16 –24-mmdiameter ⫻ 12-cm-long self-expanding partly covered nitinol Wallstent (Schneider-Europe, Bu¨lach, Switzerland) was advanced. The stent was positioned so that the stenotic region was midway along the stent. Balloon dilatation was not performed [2]. The stent expanded almost completely immediately after placement and the distal end of the stent protruded into the gastric lumen beyond the stricture (Fig. 2). Contrast showed free flow from the esophagus to the stomach with no evidence of perforation or any other complication. However one day after stent placement the patient experienced severe retrosternal pain and heartburn. One week later antireflux medication had failed to relieve the symptoms. A Gastrografin (A.G. Schering, Berlin, Germany) swallow demonstrated severe GER extending into the upper third of the esophagus. A 18-mm-diameter ⫻ 10-cm-long Cook anti-reflux Z-stent (Wilson-Cook Medical, Winston-Salem, NC, USA) was then placed coaxially within the in situ Wallstent using the Wilson-Cook Z-stent introducer system. The stent was loaded into the introducer after generous lubrication with silicone, as recommended by the manufacturer. The loaded introducer was then advanced over the guidewire that had been placed in the esophagus. The stent was placed under fluoroscopic guidance and deployed by fixing the inner pusher and slowly withdrawing the outer sheath. The thin polyurethane sleeve was outlined by contrast and shown to protrude into the stomach (Fig. 3). A 24-hr Gastrografin swallow demonstrated that the stent patency and position were satisfactory, with contrast passing freely into the stomach. Occasional mild GER into the lower esophagus was observed in the supine and Trendelenberg positions (Fig. 4). The GER had significantly decreased compared with the contrast examination before the valve stent placement. The patient reported significant symptomatic improvement. A gastric proton pump inhibitor (omeprazole 20 mg bd) was prescribed and the patient was discharged and was followed up clinically. At the 4-month clinical follow-up the patient reported sustained relief of symptomatic GER and no episode of obstruction.

Discussion A variety of different stents are available for palliation of malignant esophageal strictures. Late complications related to esophageal stent placement, including tumor ingrowth, ulceration, fistula formation, food impaction, stent migration, twisting and wire fracture, benign hyperplastic obstruction at the stent edges, bleeding and gastro-esophageal reflux, have been described [2, 7, 8]. GER is a common complication and may be seen in 60% of patients [5] where the tumor involves the gastro-esophageal junction or cardia. Endoprostheses with anti-reflux valves have been introduced in order to combat reflux of gastric contents [5, 9]. Stent obstruction by food, however, has been described in stents that use semi-rigid anti-reflux valves (Gianturco-Rosch self-expandable Z stent) [9]. Kocher et al. [5] have described promising results with stents using non-rigid anti-reflux valves (ELLA-CS; Hradec Kralove, Czech Republic). This anti-reflux valve is made of a pliable soft polyurethane sleeve fixed to the distal part of the polyester mesh stent. The valve closes easily under the pressure of the gastric contents thus preventing reflux. Again, due to its pliability, it opens

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easily for the passage of food from the esophagus. The porous polyester mesh allows penetration of gastric gas into the esophagus preventing the ‘gas bloat’ syndrome, which manifests as pain in the epigastrium and the inability to burp. Gastric fluid may, however, also reflux into the esophagus through the mesh and an antacid regimen may be needed in some patients. The Cook anti-reflux Z-stent used in our patient is constructed of a variable number of 2-cm cages, depending on the length of the stent (Fig. 3). When fully expanded the stent assumes a tubular shape 18 mm in diameter and is flared at both ends to allow greater anchoring within the esophageal wall. A small portion of the stent is uncoated at the proximal end to enhance anchoring. The distal end of the stent is equipped with a thin sleeve that is intended to reduce gastric acid reflux into the esophagus. The follow-up contrast swallow in our patient confirmed that the stent design also allowed for some gastro-esophageal reflux potentially preventing the “gas bloat” syndrome, an effect similar to that with the ELLA-CS stent. Our case demonstrates that the anti-reflux stent is effective and can be used as a salvage prosthesis where primary stenting results in severe symptoms of GER. A valved stent may become the device of choice when distal esophageal carcinomas involve the gastroesophageal junction or cardia. Wider clinical experience will establish whether late bolus obstruction or stent displacement can be avoided by the particular design features adopted. References 1. Song HY, Choi KC, Cho BH, Ahan DS, Kim KS (1992) Esophagogastric neoplasms: Palliation with a modified Gianturco stent. Radiology 180: 349 –354 2. Cwikiel W, Stridbeck H, Tranberg KG, von Holstein CS, Hambraues G, Lillo-Gil R, Willen R (1993) Malignant esophageal strictures: Treatment with a self-expanding nitinol stent. Radiology 187:661– 665 3. Winkelbauer FW, Schofl R, Niederle B, Wilding R, Thurner S, Lammer J (1996) Palliative treatment of obstructing esophageal cancer with nitinol stents: Value, safety and long-term results. AJR 166:79 – 84 4. Acunas B, Rozanes I, Akpinar S, Tunaci A, Tunaci M, Acunas G (1996) Palliation of malignant esophageal strictures with self-expanding nitinol stents: Drawbacks and complications. Radiology 199:648 – 652 5. Kocher M, Dlouhy M, Neoral C, Buriankova E, Gryga A, Duda A, Aujesky R (1998) Esophageal stent with anti-reflux valve for tumors involving the cardia: Work in progress. J Vasc Interv Radiol 9:1007– 1010 6. Song HY, Do YS, Han YM, Sung KB, Choi EK, Sohn KH, Kim HR, Kim SH, Min YI (1994) Covered, expandable esophageal metallic stent tubes: Experiences in 19 patients. Radiology 193:689 – 695 7. Cwikiel W, Tranberg K, Cwikiel M, Lillo-Gil R (1998) Malignant dysphagia: Palliation with esophageal stents: Long-term results in 100 patients. Radiology 207:513–518 8. Wagner H, Stinner B, Schwerk W, Hoppe M, Klose KJ (1994) Nitinol prosthesis for the treatment of inoperable malignant esophageal obstruction. J Vasc Interv Radiol 5:899 –904 9. Saxon RR, Barton RE, Katon RM, Petersen BD, Lakin PC, Timmermans H, Uchida B, Keller FS, Rosch J (1995) Treatment of malignant esophageal obstructions with covered metallic Z stents: Long-term results in 52 patients. J Vasc Interv Radiol 6:747–754