Direct sac puncture versus transarterial embolization of type II endoleaks after endovascular abdominal aortic aneurysm repair: Comparison of outcomes.

PURPOSE: Type 2 endoleak (T2EL) is the most common type of endoleak after endovascular abdominal aortic aneurysm repair (EVAR), and increases the risk of aneurysm sac rupture if it persists beyond 6 months. The purpose of this study is to compare the efficacy and safety of direct sac puncture versus transarterial embolization of T2ELs. METHODS: Retrospective review of 42 consecutive T2EL embolization procedures, 19 by DSP and 23 by transarterial technique, between January 2015 and December 2020. Primary outcome was aneurysm sac stability and resolution of endoleak at follow-up imaging. Adverse events (AE) were classified based on the Society of Interventional Radiology (SIR) practice guidelines. RESULTS: Technical success was 94.7% (18/19) in the DSP group and 86.9% (20/23) in the transarterial group (p = 0.32 (-0.77-0.25)). Treatment efficacy was evaluated in 16 patients in the DSP group and 18 patients in the transarterial group who had follow-up imaging ≥6 months after embolization. Mean imaging follow-up was 17.1 ± 11.2 (range, 6-41) months in the DSP group and 26.5 ± 15.4 (range, 6-48) months in the transarterial group (p = 0.06, -19.24-0.37). Treatment efficacy was 75% (12/16) in the DSP group and 33.3% (6/18) in the transarterial group (p = 0.02, 95% CI, 0.09-0.97). There was no procedure-related mortality. Moderate-severe AE occurred in 15.7% (3/19) in the DSP group and 8.7% (2/23) in the transarterial group (p = 0.44, -0.12-0.26). CONCLUSION: In this study, DSP embolization of T2EL was equally safe and more effective than transarterial embolization in achieving aneurysm sac stability and resolution of endoleak.

Performance of clear cell likelihood scores in characterizing solid renal masses at multiparametric MRI: an external validation study.

PURPOSE: The purpose of this study is to evaluate the accuracy and interobserver agreement of ccLS in diagnosing clear cell renal cell carcinoma (ccRCC). METHODS: This retrospective single-center study evaluated consecutive patients with solid renal masses who underwent mpMRI followed by percutaneous biopsy and/or surgical excision between January 2010 and December 2020. Predominantly (> 75%) cystic masses, masses with macroscopic fat and infiltrative masses were excluded. Two abdominal radiologists independently scored each renal mass according to the proposed ccLS algorithm. The diagnostic performance of ccLS categories for ccRCC was calculated using logistic regression modeling. Diagnostic accuracy for predicting ccRCC was calculated using 2 × 2 contingency tables. Interobserver agreement for ccLS was evaluated with Cohen's k statistic. RESULTS: A total of 79 patients (mean age, 63 years ± 12 [SD], 50 men) with 81 renal masses were evaluated. The mean size was 36 mm ± 28 (range 10-160). Of the renal masses included, 44% (36/81) were ccRCC. The area under the receiver operating characteristic curve was 0.87 (95% CI 0.79-0.95). Using ccLS ≥ 4 to diagnose ccRCC, the sensitivity, specificity, and positive predictive value were 93% (95% CI 79, 99), 63% (95% CI 48, 77), and 67% (95% CI 58, 75), respectively. The negative predictive value of ccLS ≤ 2 was 93% (95% CI 64, 99). The proportion of ccRCC by ccLS category 1 to 5 were 10%, 0%, 10%, 57%, and 84%, respectively. Interobserver agreement was moderate (k = 0.47). CONCLUSION: In this study, clear cell likelihood score had moderate interobserver agreement and resulted in 96% negative predictive value in excluding ccRCC.

Late Stent Thrombosis in a Patient with Endovascular Aortic Repair for Blunt Thoracic Aortic Injury.

Blunt thoracic aortic injury (BTAI) is associated with high mortality and morbidity. Thoracic endovascular aortic repair has become the recommended treatment modality given improved short-term results compared to open repair. We present a case of a 19-year-old male who presented with acute paralysis and multiorgan dysfunction from acute TEVAR thrombosis. Systemic thrombolysis, catheter-directed thrombolysis followed by aspiration thrombectomy, and angioplasty were initially successful in restoring perfusion. However, he developed progressive multiorgan failure related to prompt reocclusion within 48 hours. This case is the first to describe thrombolysis and angioplasty as a management strategy for acute TEVAR thrombosis. We also review the literature surrounding this uncommon complication.

Pericarditis Secondary to an Acupuncture Needle Extracted Via a Transjugular Approach.

Acupuncture is generally considered safe; however, cardiac complications can occur. We describe a case of refractory pericarditis requiring transvenous extraction of an acupuncture needle from within the right ventricular cavity. (Level of Difficulty: Intermediate.).

Coaxial guide wire placement in the right adrenal vein for repeated adrenal venous samplings.

PURPOSE: Many adrenal venous sampling (AVS) protocols require repeated samplings before and after adrenocorticotrophic hormone (ACTH) stimulation. Maintaining catheter selectivity in the adrenal vein over time is essential but can be challenging, especially in the short right adrenal vein, where the catheter is often in an unstable position. The aim of our study was to evaluate guide wire insertion into the right adrenal vein catheter to sustain AVS selectivity (adrenal/peripheral cortisol ratio [Ca/Cp]) over time. METHODS: This retrospective investigation was approved by our institutional review board, and informed consent was obtained. A 0.014-inch guide wire was inserted in the right adrenal vein 5F catheter to secure its positioning and to facilitate blood sampling. Plasma cortisol levels from the left and right adrenal veins and left iliac vein were assessed in 117 consecutive patients undergoing bilateral, simultaneous sets of AVS at -5 and 0 min (baseline) and 5, 10, and 15 min after intravenous bolus of 250 µg ACTH (stimulated). Ca/Cp ratios of ≥2 for baseline and >10 for stimulated AVS were considered selective. RESULTS: The first sampling, at time -5 min, was nonselective in 41 of 116 (35.3 %) right and 30 of 116 (25.9 %) left AVSs retained for analysis. In patients with a selective first sampling, 74 of 75 (98.7 %) right and 85 of 86 (98.8 %) left AVSs were selective in all post-ACTH samplings. Right and left selectivity rates were not statistically different (p > 0.87). No complications arose from guide wire insertion. CONCLUSION: Guide wire insertion into the right adrenal vein catheter is safe and effective to maintain AVS selectivity over time.

Rupture signs on computed tomography, treatment, and outcome of abdominal aortic aneurysms.

OBJECTIVES: Abdominal aortic aneurysm (AAA) rupture has a high mortality rate. Although the diagnosis of a ruptured AAA is usually straightforward, detection of impending rupture signs can be more challenging. Early diagnosis of impending AAA rupture can be lifesaving. Furthermore, differentiating between impending and complete rupture has important repercussions on patient management and prognosis. The purpose of this article is to classify and illustrate the entire spectrum of AAA rupture signs and to review current treatment options for ruptured AAAs. METHODS: Using medical illustrations supplemented with computed tomography (CT), this essay showcases the various signs of impending rupture and ruptured AAAs. Endovascular aneurysm repair (EVAR) and open surgical repair are also discussed as treatment options for ruptured AAAs. RESULTS: CT imaging findings of ruptured AAAs can be categorised according to location: intramural, luminal, and extraluminal. Intramural signs generally indicate impending AAA rupture, whereas luminal and extraluminal signs imply complete rupture. EVAR has emerged as an alternative and possibly less morbid method to treat ruptured AAAs. CONCLUSIONS: AAA rupture occurs at the end of a continuum of growth and wall weakening. This review describes the CT imaging findings that may help identify impending rupture prior to complete rupture. TEACHING POINTS: • AAA rupture occurs at the end of a continuum of growth and wall weakening. • Intramural imaging findings indicate impending AAA rupture. • Luminal and extraluminal imaging findings imply complete AAA rupture. • Some imaging findings are not specific to AAA ruptures and can be seen in other pathologies. • EVAR has emerged as an alternative and possibly less morbid method of treating ruptured AAAs.

Inflammatory pseudotumour of the lung.

Inflammatory pseudotumours of the lung are extremely rare. Their pathogenesis is controversial, their diagnosis is often difficult and their clinical behaviour may be unpredictable - ranging from benign to locally invasive, to metastatic in spite of an apparently 'benign' histology. A patient who presented with multiple recurrent lesions in the contralateral lung almost two years after the resection of a large primary tumour of the left upper lobe is reported.