Accidental portal vein catheterization during pleural drainage catheter insertion: a case report.

BACKGROUND: Iatrogenic portal vein (PV) injuries following pleural drainage catheter (PDC) insertion are rare but life-threatening. This case report emphasizes the importance of prompt recognition and effective interventional radiology (IR) management. CASE PRESENTATION: A 38-year-old Asian male, admitted for a non-ST-segment elevation myocardial infarction, suffered a critical PV injury during PDC insertion, leading to rapid clinical deterioration. The IR team conducted a portogram, retrieved the catheter, and successfully executed an embolization procedure. The patient's recovery, confirmed through imaging and improving liver function tests, enabled discharge with follow-up instructions. CONCLUSIONS: This case highlights the clinical significance of promptly recognizing and effectively managing iatrogenic PV injuries during PDC insertion, with the pivotal role of IR. Collaboration between IR and surgical teams is crucial for optimizing patient outcomes.

An Unusual Presentation of a Rare Combination of Double Moiety and Vaginal Ureter Insertion.

The association between a duplex renal collecting system and ectopic ureter insertion is well-established. Although congenital genitourinary abnormalities are usually detected during childhood, incidentally, or due to underlying symptoms or medical complications, a few cases might not be diagnosed/treated until adulthood. Herein, we present a case of a 43-year-old lady who came to the emergency department with acute left flank pain associated with a burning sensation during micturition for four days. Imaging showed a duplex collecting system, and findings suggestive of obstructive uropathy. The patient underwent an initial trial of left ureteroscopy that was unsuccessful. Therefore, the interventional radiology (IR) department was consulted to perform left percutaneous nephrostomy insertion with antegrade ureteric stenting, where the patient was noted to have ectopic ureter insertion into the anterior wall of the vagina by antegrade ureterogram. The patient underwent ureter re-implantation to save the kidney from further insult.

The predictive value of CTSI scoring system in non-operative management of patients with splenic blunt trauma: The experience of a level 1 trauma center.

Background: The spleen is one of the most injured organs following blunt abdominal trauma. The management options can be either operative or non-operative management (NOM) with either conservative management or splenic artery embolization. The implementation of CT in emergency departments allowed the use of CT imaging as a primary screening tool in early decision-making. Consecutively, new splenic injury scoring systems, such as the CT severity index (CTSI) reported was established. Aim: The main aim of this study is to evaluate the effect of the implementation of CTSI scoring system on the management decision and outcomes in patients with blunt splenic trauma over 8 years in a level 1 trauma center. Methods: This is a retrospective study including all adult patients with primary splenic trauma, having NOM and admitted to our hospital between 2013 and 2021. Results: The analyses were conducted on ninety-nine patients. The average sample age was 32.7 ± 12.3 years old. A total of (63/99) patients had splenic parenchyma injury without splenic vascular injury. There is a statistically significant association between CTSI grade 3 injury and the development of delayed splenic vascular injury (p < 0.05). There is an association between severity of initial CTSI score and the risk of NOM/clinical failure (p = 0.02). Conclusion: Our findings suggest implementing such a system in a level 1 trauma center will further improve the outcome of treatment for splenic blunt trauma. However, CTSI grade 3 is considered an increased risk of NOM failure, and further investigations are necessary to standardize its management.

Efficacy of fusion imaging for immediate post-ablation assessment of malignant liver neoplasms: A systematic review.

BACKGROUND: Percutaneous thermal ablation has become the preferred therapeutic treatment option for liver cancers that cannot be resected. Since ablative zone tissue changes over time, it becomes challenging to determine therapy effectiveness over an extended period. Thus, an immediate post-procedural evaluation of the ablation zone is crucial, as it could influence the need for a second-look treatment or follow-up plan. Assessing treatment response immediately after ablation is essential to attain favorable outcomes. This study examines the efficacy of image fusion strategies immediately post-ablation in liver neoplasms to determine therapeutic response. METHODOLOGY: A comprehensive systematic search using PRISMA methodology was conducted using EMBASE, MEDLINE (via PUBMED), and Cochrane Library Central Registry electronic databases to identify articles that assessed the immediate post-ablation response in malignant hepatic tumors with fusion imaging (FI) systems. The data were retrieved on relevant clinical characteristics, including population demographics, pre-intervention clinical history, lesion characteristics, and intervention type. For the outcome metrics, variables such as average fusion time, intervention metrics, technical success rate, ablative safety margin, supplementary ablation rate, technical efficacy rate, LTP rates, and reported complications were extracted. RESULTS: Twenty-two studies were included for review after fulfilling the study eligibility criteria. FI's immediate technical success rate ranged from 81.3% to 100% in 17/22 studies. In 16/22 studies, the ablative safety margin was assessed immediately after ablation. Supplementary ablation was performed in 9 studies following immediate evaluation by FI. In 15/22 studies, the technical effectiveness rates during the first follow-up varied from 89.3% to 100%. CONCLUSION: Based on the studies included, we found that FI can accurately determine the immediate therapeutic response in liver cancer ablation image fusion and could be a feasible intraprocedural tool for determining short-term post-ablation outcomes in unresectable liver neoplasms. There are some technical challenges that limit the widespread adoption of FI techniques. Large-scale randomized trials are warranted to improve on existing protocols. Future research should emphasize improving FI's technological capabilities and clinical applicability to a broader range of tumor types and ablation procedures.

Catheter-Directed Thrombolysis in the treatment of acute Portomesenteric Vein Thrombosis after Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Portomesenteric Vein Thrombosis (PMVT) following Laparoscopic Sleeve Gastrectomy (LSG) is an uncommon but potentially debilitating complication. Catheter-Directed Thrombolysis (CDT) has an evolving role in recanalizing the venous flow and preventing thrombus propagation. Therefore, it can be used as an alternative or in combination with systemic anticoagulants in selected patients. We report two trans-hepatic and trans-splenic CDT. The patient's clinical details, radiological findings, safety, and efficacy are reported. CASES PRESENTATION: Two patients presented to the Emergency Department (ED) within 14 days of surgery. The presenting complaints were generally nonspecific. The diagnosis of PMVT was established in both patients based on abdominal Contrast-Enhanced Computed Tomography (CECT). The two patients received a combined therapy of subcutaneous (SC) heparinization and CDT using a trans-hepatic approach in case 1 and a trans-splenic approach in case 2. Subsequent post-procedure venograms and CECT were performed and showed significant thrombus resolution. Both patients received oral anticoagulant therapy upon discharge with a successful overall recovery. CONCLUSION: PMVT is an infrequent and severe post LSG complication. Various approaches for re-establishing the portal venous flow have been described according to the severity of venous thrombosis. This article describes CDT therapy as a safe and effective option for treating PMVT in symptomatic patients.

Rosai-Dorfman Disease of the Spine: A Case Report of a Rare Disease and Review of the Literature.

Rosai-Dorfman disease (also known as sinus histiocytosis with massive lymphadenopathy or Rosai-Dorfman-Destombes disease) is a rare reactive histiocytic disease, classically involving the lymph nodes of the neck, but it can also occur in extranodal sites. Isolated spinal involvement is rare but important to identify as it can mimic malignancy with males being affected more than females. We present a case of a 52-year-old female patient who had breast cancer and was admitted with long-standing anal and sacral pain. The MRI lumbar spine showed a mass concerning for metastasis. CT-guided biopsy results showed sheets of histiocyte-like cells, some of which were positive with S100 and showed emperipolesis along with plasma cells, lymphocytes, and neutrophils. Features were in keeping with Rosai-Dorfman syndrome. The patient responded to steroids. The familiarity with this entity saved the patient from going through the agony of this being considered a metastasis of her primary malignancy.

A lightweight neural network with multiscale feature enhancement for liver CT segmentation.

Segmentation of abdominal Computed Tomography (CT) scan is essential for analyzing, diagnosing, and treating visceral organ diseases (e.g., hepatocellular carcinoma). This paper proposes a novel neural network (Res-PAC-UNet) that employs a fixed-width residual UNet backbone and Pyramid Atrous Convolutions, providing a low disk utilization method for precise liver CT segmentation. The proposed network is trained on medical segmentation decathlon dataset using a modified surface loss function. Additionally, we evaluate its quantitative and qualitative performance; the Res16-PAC-UNet achieves a Dice coefficient of 0.950 ± 0.019 with less than half a million parameters. Alternatively, the Res32-PAC-UNet obtains a Dice coefficient of 0.958 ± 0.015 with an acceptable parameter count of approximately 1.2 million.

Managing Recurrent Rectal Variceal Bleeding Secondary to Portal Hypertension With Liquid Embolics.

Rectal variceal bleeding is one of the rarer manifestations of portal hypertension caused by chronic liver disease. The management of these varices is very challenging. Our patient had portal vein thrombosis and presented with chronic recurrent rectal bleeding requiring transfusion secondary to rectal varices. The patient was treated from trans-splenic access with liquid embolics (sclerotherapy and glue) without balloon occlusion, leading to the successful cessation of his bleeding. Access hemostasis was achieved using a vascular plug in the access tract. There are no clear guidelines for the management of these patients. If rectal varices cannot be managed by colonoscopy, this approach to embolization with liquid embolic is an excellent minimally invasive alternative.

Balloon-Assisted Percutaneous Thrombin Injection for Treatment of Iatrogenic Left Subclavian Artery Pseudoaneurysm in a Critically Ill COVID-19 Patient.

BACKGROUND: Central venous catheter represents an important tool in the management of critically ill patient. In this report, we described a COVID-19-positive case who had COVID-related complications and iatrogenic left subclavian artery pseudoaneurysm after central venous catheter insertion. Case Presentation. A 58-year-old male patient presented with a high-grade fever, myalgia, and shortness of breath due to COVID-19 infection. He required mechanical ventilation support and hemodialysis. He also developed uneventful deep vein thrombosis and myocardial infarction. As a complication of central line insertion, the patient developed pseudoaneurysm that originated from the subclavian artery with significant bleeding and large hematoma. Balloon-assisted percutaneous thrombin injection was done under ultrasound guidance. The patient was extubated 2 days later with no evidence of flow in the pseudoaneurysm. However, he lost movement in the left arm secondary to the compression of the brachial plexus from the pseudoaneurysm/hematoma, and therefore, 1.5 litres of the hematoma was evacuated in the operating room through a lateral left chest wall incision along the anterior axillary line to relieve the compression over the brachial plexus. The patient declined surgical reconstruction of the brachial plexus, and the flaccid paralysis of the arm did not recover during the follow-up. CONCLUSION: This is a case of unusual complications of COVID infection and iatrogenic left subclavian artery pseudoaneurysm postcentral vein cannulation. Balloon-assisted percutaneous thrombin injection for treatment of left subclavian artery pseudoaneurysm is feasible; however, delayed diagnosis could be associated with long-term or permanent disability.

Alternating Biplanar Fluoroscopy in Percutaneous Nephrostomy to Approach Stones in Patients With Horseshoe Kidney: An Institutional Experience.

This case series aims to evaluate the use of alternating perpendicular biplanar fluoroscopy in percutaneous nephrostomies/percutaneous nephrolithotripsies (PCNs/PCNLs) to approach renal stones in patients with horseshoe kidneys. Between January 2012 and December 2019, PCNs/PCNLs were done for six patients with horseshoe kidneys having renal stones. Skin and renal calyceal entry points were determined by alternating perpendicular biplanar fluoroscopy using a portable C-arm machine in the conventional fluoroscopy unit. The site of renal access, postoperative complications, and residual stones was assessed. The mean age of the patients was 36.8 years. The mean stone size was 6.1 cm (2.1-16.05cm). In five out of six (5/6; 83%) patients, there was one access site. Four patients had their access site through the upper calyx, and one patient had it through the lower calyx. The stone-free rate was four out of six (4/6; 66.6%). One patient had a mild drop in hemoglobin postoperatively. There were no major complications reported. The implementation of alternating biplanar fluoroscopy was found safe and helpful in providing a better appreciation of renal anatomy and stone location in patients with horseshoe kidneys. This technique helps in approaching horseshoe kidney stones in PCN/PCNL without moving the patient or fluoroscopy machine, with a potential decrease in operation time and radiation exposure.

Low back pain in beta thalassemia major revealing sacral extramedullay hematopoeisis: A case report.

Extramedullary hematopoiesis (EMH) is a well-known complication of beta thalassemia major and frequently occurs in typical sites such as liver or spleen. However, when presenting in unusual sites as sacrum, other diagnosis should be excluded by histopathology prior to deciding on treatment plan.

Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding: Descriptive Observational Analysis from a Level 1 Trauma Center.

BACKGROUND: Massive bleeding is a major preventable cause of early death in trauma. It often requires surgical and/or endovascular intervention. We aimed to describe the utilization of angioembolization in patients with abdominal and pelvic traumatic bleeding at a level 1 trauma center. METHODS: We conducted a retrospective analysis for all trauma patients who underwent angioembolization post-traumatic bleeding between January 2012 and April 2018. Patients' data and details of injuries, angiography procedures and outcomes were extracted from the Qatar national trauma registry. RESULTS: A total of 175 trauma patients underwent angioembolization during the study period (103 for solid organ injury, 51 for pelvic injury and 21 for other injuries). The majority were young males. The main cause of injury was blunt trauma in 95.4% of the patients. The most common indication of angioembolization was evident active bleeding on the initial CT scan (contrast pool or blushes). Blood transfusion was needed in two-third of patients. The hepatic injury cases had higher ISS, higher shock index and more blood transfusion. Absorbable particles (Gelfoam) were the most commonly used embolic material. The overall technical and clinical success rate was 93.7% and 95%, respectively, with low rebleeding and complication rates. The hospital and ICU length of stay were 13 and 6 days, respectively. The median injury to intervention time was 320 min while hospital arrival to intervention time was 274 min. The median follow-up time was 215 days. The overall cohort mortality was 15%. CONCLUSION: Angioembolization is an effective intervention to stop bleeding and support nonoperative management for both solid organ injuries and pelvic trauma. It has a high success rate with a careful selection and proper implementation.

Pancreaticoduodenal arcades as salvage route for transarterial embolization of life-threatening hepatic hemorrhage in patients with severe celiac axis stenosis: Case series.

INTRODUCTION: Various transarterial embolotherapies for different hepatic etiologies are performed through the celiac axis (CA). However, this pathway is not always patent due to the extensive stenosis or occlusion of the origin of CA. In such situations, the pancreaticoduodenal arcades (PDAs) catheterization is the main alternative to gain access to the hepatic arteries as demonstrated in clinical studies. PRESENTATION OF CASE: We report two cases of life-threating hepatic hemorrhage indicated for emergency transarterial embolization (TAE). DISCUSSION: The massive hemorrhage was due to spontaneous rupture of hepatocellular carcinoma (HCC) in the first case and due to post liver blunt trauma in the second case. Owing to severe stenosis of the origin of CA, PDAs were used as a salvage alternative route for emergency TAE of hepatic arteries. CONCLUSION: Endovascular management of massive hepatic hemorrhage in cases of inaccessibility to hepatic arteries through CA is a highly challenging situation in which the technical success depends on the operator experience, choice of the material and anatomical knowledge of hepatic arterial collateral supply.

Prospective comparison of freehand and electromagnetic needle tracking for US-guided percutaneous liver biopsy.

PURPOSE: To prospectively compare electromagnetic needle tracking (EMT) and freehand ultrasound (US)-guided liver biopsies. MATERIALS AND METHODS: Among 60 consecutive US-guided liver biopsies performed by staff radiologists (senior operators) and residents (junior operators), 30 were performed freehand and 30 with EMT. Needle placement time, numbers of needle punctures and pullbacks, and subjective scores of procedure difficulty were compared by χ(2) or Student t test. RESULTS: Diagnostic success rates, defined by the procurement of an adequate histopathologic specimen, were 96.6% for freehand biopsy and 100% with EMT. Needle placement time was significantly lower for EMT (mean ± standard deviation, 45.8 s ± 48.1) than for freehand procedures (143.2 s ± 122.1; P < .01). In the freehand group, needle placement times were 179.6 seconds ± 133.3 for junior operators and 106.8 seconds ± 101.3 for senior operators (P = .15). In the EMT group, needle placement times were 49.2 seconds ± 55 for junior operators and 42.5 seconds ± 41.2 for senior operators (P = .53). The number of needle pullbacks was significantly lower for senior operators (1.2 ± 0.80) compared with junior operators (2.4 ± 1.4) in the freehand group (P = .01), with no significant difference (junior, 0.47 ± 0.92; senior, 0.67 ± 0.72; P = .24) in the EMT group. The postprocedural difficulty score was lower in the EMT group (1.5 ± 0.7) than in the freehand group (2.1 ± 1.1; P = .02). Needle placement time and number of needle pullbacks were lower in the EMT group, even after taking into account tumor size and depth and operator experience. CONCLUSIONS: The EMT procedure shortens needle placement time and reduces the number of needle pullbacks needed for redirection, regardless of operator experience.

Cementoplasty of metastases of the proximal femur: is it a safe palliative option?

PURPOSE: Percutaneous cementoplasty has proved very effective for the palliation of pain from bone metastases. However, several studies argue that it should be contraindicated for metastases that are located in the proximal femur because of inadequate bone consolidation. The aim of this study was to evaluate the risk factors for fracture despite performing cementoplasty for metastases of the proximal femur. METHODS: We retrospectively analyzed all consecutive patients who underwent cementoplasty for metastases of the proximal femur who had a high risk for fracture (N = 21) from June 2003 to October 2010. Cementoplasty was performed for preventive consolidation as well as for pain palliation in 16 patients. The risk factors studied were the patient characteristics, the Mirels score, the maximal size and cortical involvement of the lesion, and a history of a previous fracture of the lesser trochanter. RESULTS: The 1-year pathologic fracture rate was 40.6% (seven fractures). The risk of fracture was significantly higher for cortical involvement greater than 30 mm (n = 7/11 vs n = 0/10; P = .0005) and a history of a previous fracture of the lesser trochanter (n = 3/3 vs 4/18; P = .0009). CONCLUSIONS: Percutaneous cementoplasty can be considered for patients with metastases of the proximal femur under certain conditions: cortical involvement less than 30 mm and no history of a fracture of the lesser trochanter. Otherwise, the risk of fracture is too high, and cementoplasty is contraindicated.

Electromagnetic-tracked biopsy under ultrasound guidance: preliminary results.

PURPOSE: This study was designed to evaluate the accuracy and safety of electromagnetic needle tracking for sonographically guided percutaneous liver biopsies. METHODS: We performed 23 consecutive ultrasound-guided liver biopsies for liver nodules with an electromagnetic tracking of the needle. A sensor placed at the tip of a sterile stylet (18G) inserted in a coaxial guiding trocar (16G) used for biopsy was localized in real time relative to the ultrasound imaging plane, thanks to an electromagnetic transmitter and two sensors on the ultrasound probe. This allows for electronic display of the needle tip location and the future needle path overlaid on the real-time ultrasound image. Distance between needle tip position and its electronic display, number of needle punctures, number of needle pull backs for redirection, technical success (needle positioned in the target), diagnostic success (correct histopathology result), procedure time, and complication were evaluated according to lesion sizes, depth and location, operator experience, and "in-plane" or "out-of-plane" needle approach. RESULTS: Electronic display was always within 2 mm from the real position of the needle tip. The technical success rate was 100%. A single needle puncture without repuncture was used in all patients. Pull backs were necessary in six patients (26%) to obtain correct needle placement. The overall diagnostic success rate was 91%. The overall true-positive, true-negative, false-negative, and failure rates of the biopsy were 100% (19/19) 100% (2/2), 0% (0/23), and 9% (2/23). The median total procedure time from the skin puncture to the needle in the target was 30 sec (from 5-60 s). Lesion depth and localizations, operator experience, in-plane or out-of-plane approach did not affect significantly the technical, diagnostic success, or procedure time. Even when the tumor size decreased, the procedure time did not increase. CONCLUSIONS: Electromagnetic-tracked biopsy is accurate to determine needle tip position and allows fast and accurate needle placement in targeted liver nodules.

Percutaneous stabilization of impending pathological fracture of the proximal femur.

OBJECTIVE: Percutaneous osteosynthesis plus cementoplasty (POPC) is a minimally invasive technique that has never been reported before and that we have prospectively evaluated for patients with impending pathological fracture of the proximal femur. METHODS: We performed POPC in 12 patients (3 males, 9 females) with metastasis of the proximal femur with a high risk of fracture (Mirels' score ≥8) between February 2010 and July 2011. Patients were not candidates for standard surgical stabilization. We analyzed the feasibility, duration, and complication of the procedure, the risk of fracture, the decrease in pain (Visual Analog Scale, VAS), and length of stay in hospital. Data were prospectively collected in all patients. RESULTS: The mean Mirels' score was 9.8 ± 1.2 (range, 8-11). The technical success was 100%. POPC was performed under general anesthesia (n = 6) or conscious sedation (n = 6). The mean duration was 110 ± 43 (range, 60-180) minutes. All patients stood up and walked the second day after the procedure. The average length of stay in the hospital was 4 ± 1.6 (range, 2-7) days. We experienced two hematomas in two patients and no thromboembolic complication. For symptomatic patients (n = 8), VAS decreased from 6.5/10 (range, 2-9) before treatment to 1/10 (range, 0-3) 1 month after. No fracture occurred after a median follow-up of 145 (range, 12-608) days. CONCLUSIONS: POPC for impending pathological fracture of the proximal femur seems to be a promising alternative for cancer patients who are not candidates for surgical stabilization. Further studies are required to confirm this preliminary experience.

Arterial embolization as a treatment of chronic edema following free cutaneous flap transfer to the lower limbs.

Persisting chronic edema following postoperative free flap transfer is a common complication. We report 3 cases of successful treatment by selective arterial embolization of the feeding arterial branches without side effect. One session embolization is advocated as a first line treatment of this condition.